Form Hospital Data Abst Hospital Data Abst Hospital Data Abstraction Form

Evaluation of Emergency Department Crisis Center Follow-up

Attachment A_Hospital Data Abstraction Form

Hospital Data Abstraction Form

OMB: 0930-0337

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Hospital Data Abstraction Form

OMB No. XXXX-XXXX

                                                                                                                                Expiration Date: Month Year

Public Burden Statement: 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.  The OMB control number for this project is XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average 2 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.



  1. Patient ID:

  2. Date of ED Admission:

  3. Gender:

  4. Age:

  5. Ethnicity:

  6. Diagnosis Code(s) (ICD-9 or ICD-10): _____________________________

  7. Prior Suicide Attempt(s)? Yes No

7a. If yes, how many? _______

  1. Discharged to:

 Intensive Care Medical or Surgical Ward Inpatient Psychiatric Ward

 Outpatient Psychiatric/MH/BH Treatment Community

 Other (please specify): __________________________________

  1. Prior ED admissions for suicide-related behavior ? Yes No

9a. If yes, how many? _______

9b. For all suicide-related ED admissions within one year prior to the index admission, please provide:

Date of Admission: Diagnosis Code: Discharge Status:

i.

ii.

iii.

  1. Subsequent ED admissions for suicide-related behavior? Yes No

10a. If yes, how many? _______

10b. For all suicide-related ED admissions within one year following the index admission, please provide:

Date of Admission: Diagnosis Code: Discharge Status:

i.

ii.

iii.

  1. Patient accepted referral to crisis center for follow-up? Yes No N/A

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorColumbia University
File Modified0000-00-00
File Created2021-01-29

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