3 survey

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