3 survey

The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)

Attach 14 - Common Hospital Information (CHI) Form

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

OMB: 0925-0491

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Common Hospital Information Form

OMB# 0925-0491

Expiration Date XX/XXXX



FORM CODE: C H I

VERSION: A 11/16/2006

ID NUMBER: CONTACT YEAR:



LAST NAME: INITIALS:



General Instructions:

The Common Hospital Information Form is completed for any hospital record abstraction for CHD or HF.

Q. 1 – 10 are common to both the HRA and the HFA forms.



0 . a. Hospital code number:

0. b. Medical Record Number:


0. c. Date of discharge (for nonfatal case) or death:

Month Day Year








SECTION I: DISCHARGE CODES, TRANSFER STATUS, DEMOGRAPHIC DATA


1.a. Primary admission diagnosis: 1.b. Primary discharge diagnosis:


. .



[Specify if diagnosis is not ICD coded] [Specify if diagnosis is not ICD coded]


_______________________________________ ____________________________________



2. Record the ICD9-CM diagnoses and procedure codes from the hospital discharge index (or Eligibility Form):


a . o.


b. p.


c. q.


d. r.


e. s.


f. t.


g. u.


h. v.


i. w.


j . x.


k . y.


l . z.


m.


n.




3. Sex:

M………Male

F........... Female


4. What is your race?:


White ……………………………………………. W


American Indian or Alaskan Native …… I

Black or African American …………………… B


Asian ………………………………………… A

Native Hawaiian or Other Pacific Islander ... P


Unknown/ not recorded ………………… U

Other ……………………………………………. O

(if other, specify)





4.a. What is your ethnicity?

Hispanic or Latino…………………Y

Not Hispanic or Latino………….. N

Unk……………………………………U


5.a. Does this person have health insurance?

Go to item 6a.

Yes………………… Y

N o………………..… N

Unk………………… U

b. Indicate type of insurance recorded: Yes No Unknown


1. Prepaid insurance or health plan (BC/BS, HMO)


2. Medicare

3. Medicaid

4. Other




6.a. Date of arrival at this hospital (mm-dd-yyyy) :


b. Arrival time at this hospital (24-hr clock) :


7. Did an emergency medical service unit transport the patient to this hospital?

Yes…………………. Y

No………………..… N

Unk………………… U



T ransfer information


8

Go to item 9.

.a. Was the patient transferred from or to another acute care hospital? Yes……………Y

N o…………… N

Unk………….. U



8.b. Was this an in-catchment hospital? Yes……………Y

No…………… N


b.1. Hospital Code: If 96 - 99, specify:

Hospital Name: ____________________________


City and State: _____________________________



8.c. Date of admission to that hospital (mm-dd-yyyy):


Go to item 9.

c.1. Was the patient transferred a second time? Yes No


8.d. Was this an in-catchment hospital? Yes……………Y

No…………… N

d. Hospital Code: If 96 - 99, specify: Hospital Name: ____________________________

City and State: _____________________________


8.e. Date of admission to that hospital (mm-dd-yyyy):









9. List the hospital discharge diagnosis and procedure codes exactly as they appear on the front sheet of the medical record and/or on the discharge summary:


a. n.


b. o.


c. p.


d. q.


e. r.


f. s.


g. t.


h. u.


i. v.


j. w.


k. x.


l. y.


m. z.












ID Label

10. Discharge diagnoses Transcribed (as they

appear on front sheet of medical record

and/or discharge summary)?

Yes (Y)* or No (N)

[If Yes, specify on notelog]

















































SECTION Il: ADMINISTRATIVE INFORMATION


11. Abstractor number:


1 2. Date abstract completed (mm-dd-yyyy):


13. Source of information abstracted:

Medical Record (Paper chart)……………………………. P

Medical Record (Electronic chart) ……………………..E

Medical Record (Both paper and electronic chart)….. B




CHI Version A: 11/16/2006 7 of 7

File Typeapplication/msword
File TitleARIC HOSPITAL ABSTRACTION FORM
AuthorCSCC
Last Modified Bypandeym
File Modified2010-03-15
File Created2010-03-15

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