HC311-UNIT5-IP
MgjZfIu0
caseabstractform.pdf
Acute Care (Inpatient) Case Abstract
ALFRED STATE M EDICAL 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
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Month Day Year (YYYY)
UPIN
. ICD Code
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Month Day Year (YYYY)
UPIN
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ICD Code
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Month Day Year (YYYY)
UPIN
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ICD Code
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Month Day Year (YYYY)
UPIN
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ICD Code
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Month Day Year (YYYY)
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ICD Code
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Month Day Year (YYYY)
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19 Patient’s Expected Payment Source
1 Bl ue 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
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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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