Information Collection

Prepare and Submit EHR for Inpatient and Ambulatory

IC 215050 under ICR 201502-0920-011 · OMB 0920-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att W - Quarterly Data Trans of EHR Data.doc	Instruction
Att G - List of Var for EHR Extract of IP Disch.docx EHR Variables - Inpatient Discharges	IC Document
Att H - List of Var for EHR Extract of ED Visits.docx EHR Variables - Emergency Dept	IC Document
Att I - List of Var for EHR Extract of OPD Visits.docx EHR Variables - Outpatient Dept	IC Document

IC Title:

Prepare and Submit EHR for Inpatient and Ambulatory

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att W - Quarterly Data Trans of EHR Data.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EHR Variables - Inpatient Discharges	Att G - List of Var for EHR Extract of IP Disch.docx	02/19/2015
EHR Variables - Emergency Dept	Att H - List of Var for EHR Extract of ED Visits.docx	02/19/2015
EHR Variables - Outpatient Dept	Att I - List of Var for EHR Extract of OPD Visits.docx	02/19/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.