Acute Care (Inpatient) Case Abstract - Brands Delmar ...€¦ · Acute Care (Inpatient) Case...
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Acute Care (Inpatient) Case Abstract ALFRED STATE MEDICAL CENTER ACUTE CARE (I NPATIENT) CASE ABSTRACT 01 Hospital Number 02 Patient Date of Birth Month Day Year (YYYY) 03 Patient Gender 1 Male 2 Female 3 Other 4 Unknown 04A Race 1 American Indian/Eskimo/Aleut 2 Asian or Pacific Islander 3 Black 4 White 5 Other 6 Unknown 04B Ethnicity 1 Spanish origin/Hispanic 2 Non-Spanish origin/Non-Hispanic 3 Unknown 05A Living Arrangement 1 Alone 2 With spouse 3 With children 4 With parent or guardian 5 With relative other than spouse 6 With nonrelatives 7 Unknown 05B Marital Status 1 Married 2 Single 3 Divorced 4 Separated 5 Unknown 06 Hospital Number 07 Admission Date and Hour Month Day Year (YYYY) Military Time 08 Type of Admission 1 Scheduled 2 Unscheduled 09 Discharge Date and Time Month Day Year (YYYY) Military Time 10 Attending Physician Number 11 Operating Physician Number 12 Principal Diagnosis Code . ICD Code 16 Birth Weight of Neonate Kilograms Date Abstract Completed Month Day Year (YYYY) 17 Procedures, Dates, and Operating Physician UPIN . Month Day Year (YYYY) UPIN 13 Other Diagnosis Code(s) 14 Qualifiers for Other Diagnoses 1 Onset preceded hospital admission 2 Onset followed hospital admission 3 Uncertain whether onset preceded or followed hospital admission . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN 19 Patient’s Expected Payment Source 1 Blue Cross/Blue Shield 2 Other commercial insurance 3 Other liability insurance 4 Medicare 5 Medicaid 6 Workers’ Compensation 7 Self-insured employer plan 8 Health maintenance organization (HMO) 9 TRICARE 10 CHAMPVA 11 Other government payer 12 Self-pay 13 No charge (e.g., charity, special research, teaching) 14 Other 15 External Cause of Injury Codes . ICD E-code . ICD E-code . ICD E-code . ICD E-code . ICD E-code 18 Disposition 1 Discharged to home 2 Discharged to acute care hospital 3 Discharged to nursing facility 4 Discharged home to be under the care of a home health service (including hospice) 5 Discharged to other health care facility 6 Left against medical advice (AMA) 7 Alive, other 8 Died 20 Total Charges $ , .
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Transcript of Acute Care (Inpatient) Case Abstract - Brands Delmar ...€¦ · Acute Care (Inpatient) Case...
Acute Care (Inpatient) Case Abstract
ALFRED STATE MEDICAL CENTER ACUTE CARE (INPATIENT) CASE ABSTRACT
01 Hospital Number
02 Patient Date of Birth
Month Day Year (YYYY)
03 Patient Gender
1 Male 2 Female 3 Other 4 Unknown
04A Race
1 American Indian/Eskimo/Aleut 2 Asian or Pacific Islander 3 Black 4 White 5 Other 6 Unknown
04B Ethnicity
1 Spanish origin/Hispanic 2 Non-Spanish origin/Non-Hispanic 3 Unknown
05A Living Arrangement
1 Alone 2 With spouse 3 With children 4 With parent or guardian 5 With relative other than spouse 6 With nonrelatives 7 Unknown
05B Marital Status
1 Married 2 Single 3 Divorced 4 Separated 5 Unknown
06 Hospital Number
07 Admission Date and Hour
Month Day Year (YYYY)
Military Time
08 Type of Admission
1 Scheduled 2 Unscheduled
09 Discharge Date and Time
Month Day Year (YYYY)
Military Time
10 Attending Physician Number
11 Operating Physician Number
12 Principal Diagnosis Code
. ICD Code
16 Birth Weight of Neonate
Kilograms
Date Abstract Completed
Month Day Year (YYYY)
17 Procedures, Dates, and Operating Physician UPIN
.
Month Day Year (YYYY)
UPIN
13 Other Diagnosis Code(s)
14 Qualifiers for Other Diagnoses
1 Onset preceded hospital admission 2 Onset followed hospital admission 3 Uncertain whether onset preceded or followed hospital admission
.
Month Day Year (YYYY)
UPIN
. ICD Code
.
Month Day Year (YYYY)
UPIN
. ICD Code
.
Month Day Year (YYYY)
UPIN
.
ICD Code
.
Month Day Year (YYYY)
UPIN
.
ICD Code
.
Month Day Year (YYYY)
UPIN
.
ICD Code
.
Month Day Year (YYYY)
UPIN
.
ICD Code
.
Month Day Year (YYYY)
UPIN
19 Patient’s Expected Payment Source
1 Blue Cross/Blue Shield 2 Other commercial insurance 3 Other liability insurance 4 Medicare 5 Medicaid 6 Workers’ Compensation 7 Self-insured employer plan 8 Health maintenance organization (HMO)
9 TRICARE 10 CHAMPVA 11 Other government payer 12 Self-pay 13 No charge (e.g., charity, special research, teaching) 14 Other
15 External Cause of Injury Codes
.
ICD E-code
.
ICD E-code
.
ICD E-code
.
ICD E-code
.
ICD E-code
18 Disposition 1 Discharged to home 2 Discharged to acute care hospital 3 Discharged to nursing facility 4 Discharged home to be under the care of a home health service (including hospice) 5 Discharged to other health care facility 6 Left against medical advice (AMA) 7 Alive, other 8 Died
20 Total Charges
$ , .
Green
Text Box
FIGURE 7-1 CASE ABSTRACT FORM INSTRUCTIONS: Click in the first box at 01 Hospital Number, and enter patient information. Then, Tab to the next box. Print each completed abstract to PDF (using free cutePDF software, available as a download from www.cutepdf.com), saving your file YourLastNameCaseNo.pdf (e.g., GreenCase01.pdf). Send each file created to your instructor as an email attachment for evaluation.
