Administrative Billing Data Patient Identification and Demographic Information: From UB-04 Data or Medical Record Face Sheet. Note: When you go to enter data on this case, the information below will already be available in the database, if uploaded. This information is used to identify the case for which you need to input abstracted data. Abstraction Information Abstractor Name: Abstraction Date: / / (MM/DD/YYYY) Case Identification Bill Number:* Medical Record Number:* National Provider Medical Provider Identifier:* Identifier (NPI):* Hospital ID: Payment Source * (select all that apply) Medicare: Medicare Other: Medicaid: Other: No insurance/not documented/: Demographic Patient First Name: Patient Last Name: Patient Birthdate: * / / (MM/DD/YYYY) Hispanic Ethnicity or Latino:* Yes No/ Patient HIC Number: Postal Code: * (Note: Patient HIC Number is mandatory only for Medicare patients) Patient Race: * White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Pacific Islander Patient Gender: * Male Female Unknown 2002 2008 Quantros. All Rights Reserved. August 5, 2008 1
Encounter Details Encounter Date:* / / (MM/DD/YYYY) Emergency Department Discharge Status:* Discharged to home care or self care (routine discharge) 01 Discharged/transferred to a short term general hospital for inpatient care 02 Discharged/transferred to SNF with Medicare certification in anticipation of covered skilled care 03 Discharged/transferred to an intermediate care facility (ICF) 04 Discharged/transferred to another type of health care institution not defined elsewhere in this code list 05 Discharged/transferred to home with care of home health service organization in anticipation of covered skill care 06 Left against medical advice or discontinued care 07 Expired 20 Expired in a medical facility (e.g. hospital, SNF, ICF or freestanding hospice) 41 Discharged/transferred to a federal health care facility 43 Hospice - home 50 Hospice - medical facility (certified) providing hospice level of care 51 Discharged/transferred to a hospital-based medicare approved swing bed 61 Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital 62 Discharged/transferred to a medicare certified long term care hospital (LTCH) 63 Discharged/transferred to a nursing facility certified by Medicaid but not by Medicare 64 Discharged/transferred to a psychiatric hospital OR psychiatric distinct part unit of a hospital 65 Discharged/ transferred to a Critical Access Hospital (CAH) 66 Another Type of Health Care Institution not Defined Elsewhere in this Code List 70 Evaluation and Management Codes (Note: Procedure/ E&M code is mandatory, enter one or more E/M Code or CPT Code) E/M Code Documented for this Outpatient Encounter: (Mandatory for AMI and/or Chest Pain Records) CPT Code Documented for this Outpatient Encounter: (Mandatory for Surgical Record) CPT Date: / / (MM/DD/YYYY) Provdier Details Attending MD: Surgeon: Consulting MD: Other MD: 2002 2008 Quantros. All Rights Reserved. August 5, 2008 2
Diagnosis Code Principal Diagnosis Code:* Other Diagnosis Code-1: Other Diagnosis Code-2: Other Diagnosis Code-3: Other Diagnosis Code-4: Other Diagnosis Code-5: Other Diagnosis Code-6: Other Diagnosis Code-7: Other Diagnosis Code-8: Other Diagnosis Code-9: Other Diagnosis Code-10: Other Diagnosis Code-11: Other Diagnosis Code-12: Other Diagnosis Code-13: Other Diagnosis Code-14: Other Diagnosis Code-15: Other Diagnosis Code-16: Other Diagnosis Code-17: 2002 2008 Quantros. All Rights Reserved. August 5, 2008 3
Acute Myocardial Infaraction (AMI) Documentation of ST- segment elevation or left bundle branch block (LBBB) Yes No on the electrocardiogram (ECG) performed closest to emergency department arrival? Did the patient receive fibrinolytic therapy at this emergency department? Yes No Date and Time fibrinolytic therapy was initiated at this emergency department: / / (MM/DD/YYYY) : (24 Hour Military format) Date/Time Documentation the patient was transferred from this facility s emergency department to another facility for acute coronary intervention: Transferred from ED for AC Intervention. Admitted to observation prior to transfer. Transferred from ED for reason other than AC Intervention or Emergency Department Discharge Date and Time: / / (MM/DD/YYYY : (24 Hour Military format) Emergency Department Arrival Time: : (24 Hour Military format) Time Physician /APN/PA documentation of a reason for a delay in initiating fibrinolytic Yes No therapy after patient arrival to the emergency department: Potential contraindications or reasons for not administering fibrinolytic therapy: Documented contraindications/reason Cardiogenic Shock No documented contraindication/reason or Unable to determine () 2002 2008 Quantros. All Rights Reserved. August 5, 2008 4
Chest Pain (CP) Chest Pain presumed to be cardiac in origin: Yes No Aspirin received within 24 hours before emergency department arrival or administered prior to transfer: Yes No Potential contraindications or reasons for not prescribing aspirin: Allergy/Sensitivity to aspirin Documentation of Coumadin/Warfarin prescribed pre-arrival Other documented reasons No documented contraindication/reason or Unable to determine () ECG performed within 1 hour before emergency department arrival or in the ED prior to transfer: Yes No Date and Time of the earliest ECG: / / (MM/DD/YYYY) : 24 Hour Military format) Date/Time Surgery Clinical Trial relevant to the measure:* Yes No Infection during this outpatient encounter prior to surgery:* Yes No Antibiotic Received:* Yes No Antibiotics Antibiotic Name: * Route or Antibiotic:* 2002 2008 Quantros. All Rights Reserved. August 5, 2008 5
Antibiotic Name: * Route or Antibiotic:* (Note: If more space is needed, enter the Antibiotics on a separate sheet.) Antibiotic Timing Was an Antiobiotic initiated (started) within 60 minutes (120 minutes for Vancomycin or Yes No Quniolones) prior to surgical incision?:* Vancomycin (Select all that apply) Documented reason for using Vancomycin Documentation of beta-lactam (penicillin or cephalosporin) allergy: Physician/APN/PA or pharmacist documentation of known infection or colonization with MRSA: Physician/APN/PA or pharmacist documentation of person being high-risk due to acute inpatient hospitalization within the last year: Physician/APN/PA or pharmacist documentation of person being high-risk due to nursing home or extended care facility setting within the last year, prior to admission: 2002 2008 Quantros. All Rights Reserved. August 5, 2008 6
Vancomycin (continued) Physician/APN/PA or pharmacist documentation of increased MRSA rate, either facility wide or operation-specific: Physician/APN/PA or pharmacist documentation of chronic wound care or dialysis: Other Physician/APN/PA or pharamist documented reason: No documented reason/ Unable to determine: Antibiotic Allergy Did the patient have any allergies, sensitivities, or intolerance to beta-lactam/ penicillin: Yes No antibiotic or cephalosporin medications?:* User Defined Data Field 1: Field 2: Field 3: Field 4: Field 5: Field 6: Field 7: Field 8: Field 9: Field 10: Field 11: Field 12: 2002 2008 Quantros. All Rights Reserved. August 5, 2008 7