Form Cms-726 - Cms Death Record Review Data Sheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0378

CMS DEATH RECORD REVIEW DATA SHEET

Patient Record Number

Date of Admission

Date of Birth

Date of Death

Psychiatric Diagnosis

Physical Diagnosis

Cause of Death

Autopsy

(Review autopsy report if available)

Mortality Board Review

(Please note conclusions and recommendations)

Was proper treatment provided? Describe below any deficiencies found.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB

control number for this information collection is 0938-0378. The time required to complete this information collection is estimated to average .25 hours (or minutes) per response,

including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments

concerning the accuracy of the time estimate(s) or suggestions fro improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,

Baltimore, Maryland 21244-1850.

(OPTIONAL)

FORM CMS-726 (09/94)