Form 5 Adult Discharge Audit Form B: Sampling Strategy

Form Approved

OMB No. 0920-08AB

Exp. Date xx/xx/20xx

Sampling Strategy

(Form B of Adult Discharge Audit)

ICD9s

1. List ICD9 codes that were sampled from: _____________

2. Complete the following summary table:

	Pneumonia
	Total unsampled	% sampled	sampled	Influenza (487)	Charts 4 review
18-49 yrs	number	%	number	number	Number
50-64 yrs	number	%	number	number	Number
65+ yrs	number	%	number	number	Number
Total number of charts reviewed					Sum

CPTs

1. List CPT codes that were sampled from: _____________

2. Complete the following summary table:

	CPTs used
	Total unsampled	% sampled	Charts for review
18-49 yrs	number	%	Number
50-64 yrs	number	%	Number
65+ yrs	number	%	Number
Total number of charts reviewed			Sum

Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-08AB)