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pdf2007 Thoracic Follow-up 6 Month Changes for OMB Clearance
SECTION
FIELD
MODIFICATION/ADDITION
RATIONALE
A 6-month follow-up reporting period
will be added for thoracic transplant
recipients.
Recipient
Information
Patient Status
Name
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Date of birth
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
SSN
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Gender
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
HIC
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Transplant Date
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Previous Follow-up
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Previous Patient
Status Date
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
Transplant
Discharge Date
This data will be populated from
previously entered data.
The additional reporting period is to determine member
specific performance.
State of Permanent
Residence
The additional reporting period is to determine member
specific performance.
ZIP Code
The additional reporting period is to determine member
specific performance.
Date last seen,
retransplanted or
death
The additional reporting period is to determine member
specific performance.
Page 1 of 2
4/2/2007
2007 Thoracic Follow-up 6 Month Changes for OMB Clearance
SECTION
Clinical
Information
FIELD
MODIFICATION/ADDITION
RATIONALE
Patient Status
The additional reporting period is to determine member
specific performance.
Primary Cause of
Death
The additional reporting period is to determine member
specific performance.
Contributory Cause
of Death
The additional reporting period is to determine member
specific performance.
Contributory Cause
of Death
The additional reporting period is to determine member
specific performance.
Graft status
The additional reporting period is to determine member
specific performance.
Date of graft failure
The additional reporting period is to determine member
specific performance.
Primary cause of
graft failure
The additional reporting period is to determine member
specific performance.
New
For pediatric recipients 2 years old or
younger and status 1 at listing and
received a heart with incompatible
ABO and death or graft failure is
reported and 6 month follow-up add:
Current B titer and sample date when
ABO is A, Current A titer and sample
date when ABO is B and Current titer
A, sample date, Current titer B and
sample date when ABO is O.
Page 2 of 2
4/2/2007
Additional data necessary to develop transplant policies.
| File Type | application/pdf |
| File Title | FORM |
| Author | pugham |
| File Modified | 2007-04-02 |
| File Created | 2007-04-02 |