Attachment L - Pretest Patient Abstraction Form

Attachment L Pretest HDS Patient Abstract Form

PATIENT ABSTRACT – NATIONAL HOSPITAL DISCHARGE SURVEY

A. STUDY-SPECIFIC INFORMATION

Hospital Number ____ ____ ____ ____	2. HDS Number ____ ____ ____ ____		3. Sampling Stratum 1 = Observation 2 = Normal Newborn 6 = All Non-Statified 3 = AMI 9 = Inpatient, Other 4 = End-of-Life
4. Medical Record Number:		5. Discharge Date : MM __ __ DD __ __YY__ __

B. INFORMATION THAT IS REQUESTED ON THE UB-04 CLAIM FORM

6. Patient Name (FL08, line 2b)

_________________________________________________ Last

__________________________ First

__________________________ Middle Name or Initial

7. Patient Street Address (FL09, line 1a):

8. City (FL09, line 2b)

9. State (FL09, line 2c) __ __ If in US, complete items 9 and 10, but skip item 11

ZIP (FL09, line 2d) __ __ __ __ __ - __ __ __ __

11. Country Code (FL09, line 2e) __ __

12a. Birth Date (FL10) MM __ __ DD__ __ YYYY __ __ __ __ (Only if DOB is unavailable from the UB-04 or Medical Record Face Sheet, record age) 12b. Age : ___ ___ ___ Units:  Years  Months  Days

13. Sex (FL11) M = Male F = Female U = Unknown

14. Admission Date (FL12) MM __ __ DD__ __ YY __ __ (If the complete admission date is unavailable from the UB-04, record based on the Medical Record Face Sheet.)

15. Admission Type (FL14) 1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn 5 = Trauma 6-8 = Reserved for assignment by NUBC 9 = Info Not Available

16. Admission Point of Origin (FL15) : Select Only One 1 = Non-Health Care Facility Point of Origin A = Reserved for assignment by NUBC 2 = Clinic B = Transfer from another home health agency 3 = Reserved for assignment by NUBC C = Readmission to same home health agency 4 = Transfer from a hospital (different facility) D = Transfer from one distinct unit of the hospital to another distinct 5 = Transfer from a SNF or ICF unit of the same hospital resulting in a separate claim to payer 6 = Transfer from another health care facility E = Transfers from ambulatory surgery center 7 = Emergency Room F = Transfer from hospice and is under a hospice plan of care or 8 = Court / Law Enforcement enrolled in a hospice program 9 = Information not available G-Z = Reserved for assignment by NUBC Newborn Code Structure 1-4 = Reserved for assignment by NUBC 5 = Born inside this hospital 6 = Born outside this hospital 7-9 = Reserved for assignment by the NUBC

17. Discharge Status (FL17) : Select Only One Code 1 = Discharge to home or self care 42 = Expired – Place Unknown 2 = Discharge / transferred to short term general 43 = Discharge / transferred to Federal Health Care Facility hosp for inpt care 44-49 = Reserved for assignment by the NUBC 3 = Discharge / transferred to SNF 50 = Hospice - home 4 = Discharge / transferred to ICF 51 = Hospice – Medical Facility 5 = Discharge / transferred to a designated Cancer Center or Children’s Hospital 52-60 = Reserved for assignment by the NUBC 6 = Discharge / transferred to home under care of organized 61 = Discharge / transferred to a hospital-based Medicare home health service organization Approved swing bed 7 = Left AMA or discontinued care 62 = Discharge / transferred to an IRF including Rehabilitation Distinct Part Units of a Hospital 8 = Reserved for assignment by the NUBC 63 = Discharge / transferred to a Medicare Certified LTCH 9 = Admitted as an Inpt to this hospital 64 = Discharge / transferred to a Nursing Facility Certified under 10-19 = Reserved for assignment by the NUBC Medicaid but not Certified under Medicare 20 = Expired 65 = Discharge/ transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital 21-29 = Reserved for assignment by the NUBC 66 = Discharge/ transferred to a CAH 30 = Still Patient 67-69 = Reserved for assignment by the NUBC 31-39 = Reserved for assignment by the NUBC 70 = Discharged /transferred to another Type of Health Care 40 = Expired at Home Institution not Defined Elsewhere in the Code List 41 = Expired in Medical Facility 71-99 = Reserved for assignment by the NUBC

18. Units/Charges allocated to select revenue codes:

Revenue Code (FL42)

Revenue Code Description

# Days (FL46)

Total Charges ($) (FL47)

0170

Nursery

0=General

0171

1=Newborn Level 1

0172

2=Newborn Level 2

0173

3=Newborn Level 3

0174

4=Newborn Level 4

0175

5=Reserved

0176

6=Reserved

0177

7=Reserved

0178

8=Reserved

0179

9=Other nursery

0200

Intensive Care

0=General

0201

1=Surgical

0202

2=Medical

0203

3=Pediatric

0204

4=Psychiatric

0205

5=Reserved

0206

6=Intermediate ICU

0207

7=Burn Care

0208

8=Trauma

0209

9=Other Intensive Care

0210

Coronary Care Unit

0=General

0211

1=Myocardial Infarction

0212

2=Pulmonary Care

0213

3=Heart Transplant

0214

4=Intermediate CCU

0215

5=Reserved

0216

6=Reserved

0217

7=Reserved

0218

8=Reserved

0219

9=Other Coronary CCU

0001

Total Charges

.

Instructions: Record up to 18 diagnoses and 4 E-Codes from the UB-04.
Principal Diagnoses
	19a. ICD-9-CM Code (FL67, FL67a-q)	19b. Present at Admission? (8th position of FL67 and FL67a-q)
Prin Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
Oth Dx		Y N U W
20. Admitting Diagnosis (FL69) ___ ___ ___.___ ___ ICD-9-CM
21a. E-Code (FL72, 1a-c)		21 b. Present at Admission? (8th position of FL72, 1a-c)
 No E-codes
E-Code 1		Y N U W
E-Code 2		Y N U W
E-Code 3		Y N U W
Instructions: Record up to 6 procedures.
Principal Procedures (FL 74)  No procedures
	ICD-9-CM		Procedure Date
Prin Px			MM ____ ____ DD ____ ____ YY____ ____
Oth Px			MM ____ ____ DD ____ ____ YY____ ____
Oth Px			MM ____ ____ DD ____ ____ YY____ ____
Oth Px			MM ____ ____ DD ____ ____ YY____ ____
Oth Px			MM ____ ____ DD ____ ____ YY____ ____
Oth Px			MM ____ ____ DD ____ ____ YY____ ____
23. Attending Physician NPI (FL76) __ __ __ __ __ __ __ __ __ __
24. Operating Physician NPI (FL77) __ __ __ __ __ __ __ __ __ __

C. MEDICAL RECORD FACE SHEET INFORMATION

25. Encounter/Visit Number:
(Only ask question #26, if there is not complete data for either or both the admission or discharge dates.) 26. Length of Stay: ___ ___ ___ days
27. Ethnicity  Hispanic  Not Hispanic  Unknown			28. Race: Please Check All That Apply  White  Black/African American  Asian  Native Hawaiian/Other Pacific Islander  American Indian/ Alaska Native  Other: Specify___________  Unknown
29. Expected Source of Payment: Select Only One Per Category				30. Medicare #  Not Documented ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Primary	Other 1	Other 2
 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______	 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______  Not Applicable	 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______  Not Applicable

D. CURRENT EPISODE/HOSPITAL STAY INFORMATION

31.

If NEWBORN (Per item 3 {Sampling Stratum} code 2 “normal newborn” or item 15 {Adm Type} code 5 “newborn”), skip to Question 36.

32. Vital Signs Value On First Presentation on the day of admission Height: __ ft __ __ in OR __ __ __ cm Weight: __ __ __ lbs OR __ __ __ kg		33. Clinical Laboratory Results: Initial Results on the day of admission Hematocrit (Hct): __ __.__% White Cell Count (WBC): __ __ __.__ x1000/µL Platelet Count (Plt): __ __ __ x1000/µL Sodium (Na): __ __ __ mmol/L Potassium (K): __ __.__ mmol/L Urea Nitrogen (BUN): __ __ __ mg/dL Creatinine (Cr): __ __.__ mg/dL
34.	35.

FOR NEWBORNS (Per item 3 {Sampling Stratum} code 2 “normal newborn” or item 15 {Adm Type} code 5 “newborn”),  If not a Newborn, Skip to Question 37

E. PATIENT CLINICAL VARIABLES (Obtained From Medical Records)

36. Birth Statistics

Weight: ___ ___ lbs ___ ___ oz OR ___ ___ ___ ___ gm

Time of Delivery: ___ ___ : ___ ___ AM or PM (circle one)

Maternal Date of Birth: MM ___ ___ DD ___ ___ YY ___ ___

(Only complete Maternal Age if the Maternal date of birth is not available.)

Maternal Age: ___ ___ years

37.	Medications Patient Was Taking Immediately Preceding Admission (Do not Include Medications Only Given in the Emergency Department)
 None  Not applicable (newborn)  Unknown
List up to 20 pre-admit medications
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20.

38.	Medications Prescribed at Discharge
 None  Not applicable (patient expired)  Unknown
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20.

F. FINANCIAL AND BILLING RECORD DATA ELEMENTS

39a. Actual Source of Payment

39c. Actual Payment Grand Total (To be generated by the system)

Primary

Other 1

Other 2

 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______

 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______  Not Applicable

 No source indicated  Medicare  Medicaid / SCHIP  Other Gov’t (e.g., CHAMPUS, Tricare, VA)  Private / commercial insurance  Worker’s compensation  Self-pay  No charge  Other: Specify ______  Not Applicable

39b. Actual Payment by Source

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40. Social Security Number  Not Available __X _X_ _X_ - __X __X - ___ ___ ___ ___

INFORMATION FROM OTHER HOSPITAL CARE WITHIN 30 DAYS

41. If the patient was treated at this hospital as an acute inpatient, up 30 days prior to this hospital stay (index admission) or 30 days following discharge, provide the following information about that (those) hospital visit(s). If the patient was seen more than three times before or after this admission, please list the three visits that were closest to this discharge.

	Admission Date	Discharge Date		Principal Diagnosis ICD-9-CM	Principal Procedure ICD-9-CM/CPT-4*
30 days prior to admission Check here if:  None  Not applicable (newborn)  Unknown
Index Admission	____/____/____	____/____/____
1	____/____/____	____/____/____
2	____/____/____	____/____/____
3	____/____/____	____/____/____
30 days post discharge Check here if:  None  Not applicable (patient expired)  Unknown
Index Discharge	____/____/____	____/____/____
1	____/____/____	____/____/____
2	____/____/____	____/____/____
3	____/____/____	____/____/____

* Use most significant CPT procedure for previous observation status admissions.

G. ACUTE MYOCARDIAL INFARCTION SPECIFIC ITEMS (Items 42 – 46 To Be Completed Only for discharges with a sampling stratum code {Item 3} of “3” {AMI}. All others skip to item 47.)

42. Date of First Hospital Contact MM ___ ___ DD ___ ___ YY ___ ___

43. Time of First Hospital Contact ___ ___ : ___ ___ AM or PM (circle one)

44. Troponin Levels  Check here if no Troponin Levels were obtained

Troponin Level

Troponin Type (Check one)

Date MM/DD/YY

Time

Result

Units

ULN

I

T

_ _ : _ _ HH:MM

AM PM Circle one

Troponin #1

/ /

_ _ : _ _

AM PM

Troponin #2

/ /

_ _ : _ _

AM PM

Troponin #3

/ /

_ _ : _ _

AM PM

45. Ischemic Pain Upon Admission  Yes  No  Unknown

46. Elective (Planned) Cardiac Procedure Admission  Yes  No  Unknown

H. END OF LIFE SPECIFIC ITEMS (Items 47 – 50 To Be Completed Only for discharges with a sampling stratum code {Item 3} of “4” {End-of-Life} or a discharge status {Item 17} code of “20”. All others skip to item 51.)

47. Advanced Care Plan on Admission  Yes  No (Skip to question 49)  Don’t Know (Skip to question 49)  No

48. Type of Advanced Care Plan on Admission (Check All That Apply) Comfort Measures Only Order Do Not Resuscitate Order Do Not Intubate Order Health Care Proxy / Durable Power of Attorney / Surrogate Decision Maker Advanced Directive / Living Will / POLST (Physician Orders for Life Sustaining Treatment) or Other State Program  Other

49. Do Not Resuscitate Order (During Hospitalization)  Yes -------> Date of Order: __ __ / __ __/ __ __ M M D D Y Y  No  Don’t Know

50.

I. INFECTIOUS DISEASE ITEMS

INFORMATION FROM THE LABORATORY RECORDS

51. Did this discharge have any positive blood cultures during this inpatient stay?  Yes (Skip to Item 53)  No -------> Do Not Complete Items 52 - 59

53. How many positive blood cultures were recorded during this stay? _________ Number of Positive Blood Cultures

54. Date of first positive culture ____ ____ / ____ ____ / ____ ____ M M D D Y Y

55. Name of first organism corresponding to first positive blood culture. (Select from pathogen code dictionary)

Genus

Species

Organism ID Code (To be generated by the system)

56.

INFORMATION FROM THE MEDICAL CHART

57. Was a central venous catheter in place at any time from [load date of first positive culture – 2 days] through [load date of first positive culture]?  Yes  No

12 Rev 07/06/07