Form HDS-1 (DRAFT) HDS-1 (DRAFT) Medical Abstraction - National Hospital Discharge Survey

DRAFT

OMB No. 0920-0212: Approval Expires 08/31/2008
U.S. DEPARTMENT OF COMMERCE

FORM HDS-1
(10-31-2006)

Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL CENTER FOR HEALTH STATISTICS

Notice – All information which would permit identification of an individual or an
establishment will be held confidential, will be used only by persons engaged in and
for the purposes of the survey, and will not be disclosed or released to other persons
or used for any other purpose. Public reporting burden of this collection of information
is estimated to average 4 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0212).

MEDICAL ABSTRACT
NATIONAL HOSPITAL
DISCHARGE SURVEY

A. PATIENT IDENTIFICATION
Month

1. Hospital number

4. Date of admission

2. HDS number

5. Date of discharge

3. (Item deleted)

6. Residence ZIP Code

Day

Year

–

–

–

–

6

Other – Specify

7

Not stated

B. PATIENT CHARACTERISTICS
7. Date of birth

Month

Day

–
8. Age – Complete
only if date of
birth not given

11. Race – Mark all that apply

Year

1

–
Units

2

{

1
2
3

3

Years
Months
Days

4
5

9. Sex – Mark (X) one
1

Male

Female

2

3

Not stated

12. Marital status – Mark (X) one

10. Ethnicity – Mark (X) one
1

Hispanic
or Latino

Not Hispanic
or Latino

2

White
Black or
African American
American Indian
or Alaska Native
Asian
Native Hawaiian
or Other Pacific
Islander

3

1

Not stated

2

Married
Single

3
4

Widowed
Divorced

5
6

Separated
Not stated

C. ADMINISTRATIVE INFORMATION
13. Type of Admission – Mark (X) one
1
2

Emergency
Urgent

3
4

Elective
Newborn

16. Expected source(s) of payment
5

Items not available/
unknown

Mark
one only

14. Source of Admission – Mark (X) one
1
2
3
4
5
6

Physician referral
Clinical referral
HMO referral
Transfer from a hospital
Transfer from SNF
Transfer from other
health facility

7
8
9

10

Emergency room
Court/Law enforcement
Other – Specify

Item not available

15. Status/Disposition of patient – Mark (X) appropriate box(es)
Status
1

Alive

Disposition
a.
b.
c.
d.

2
3

e.
Died
Status not stated

Routine discharge/discharged home
Left against medical advice
Discharged, transferred to another
short-term hospital
Discharged, transferred to
long-term care institution
Other disposition/not stated

Principal

Other
additional
sources
Mark all
that
apply

1. Worker’s
compensation
2. Medicare
3. Medicaid
4. Other government payments
5. Blue Cross/Blue Shield
6. HMO/PPO
7. Other private or
commercial insurance
8. Self pay
9. No charge
10. Other –Specify

No source of payment indicated
(Over)

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DRAFT
D. MEDICAL INFORMATION
17. Admitting Diagnosis
ICD-9-CM
Code

Description

Admitting diagnosis
18. Final diagnoses (up to 7 diagnoses including E-codes) (Enter ICD-9-CM codes as well as narrative if available.)
Diagnosis

ICD-9-CM
Code

Description

Present on admission

Principal diagnosis

Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 2

Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 3

Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 4

Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 5

Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 6

Yes
No
Unknown
Clinically undetermined
No information on face sheet
Yes
No
Unknown
Clinically undetermined
No information on face sheet

Diagnosis 7

19. Surgical and Diagnostic Procedures (up to 4 procedures) (Enter ICD-9-CM codes as well as narrative if available.)
Procedure

ICD-9-CM
Code

Date of Procedure(s)

Description
Month

Day

Year

Principal procedure
Procedure 2
Procedure 3
Procedure 4
No procedures
Comments

Completed by

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HDS-1 (Back) Base copy, solid black ink

Date

FORM HDS-1 (11-2-2006)

HDS-1 (Back) overlay, Green Pantone 353, 30% and 100% tone.