Hospital And Ambulatory Surgical Center Fax Report Form Page 2
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11patient, provide additional patient information under the narrative portion of the report or on
an additional page. Please indicate:
NAME: The patient’s first and last name.
AGE; SEX; ADMISSION DATE: Enter each for the named patient.
AMBULATORY STATUS: Select the term from Table #1, “Ambulatory Status”, that most
closely describes the patient’s ability to walk.
ADL STATUS: Activities of Daily Living (ADLs) such as eating, dressing or personal
grooming. Select the term from Table #2, “Patient ADL Status”, that most closely
describes the patient’s ability to perform these functions.
COGNITIVE LEVEL: Select the term from Table #3, “Patient Cognitive Status”, that best
describes the patient’s cognitive status at the time of the occurrence.
MENTALLY RETARDED/DEVELOPMENTALLY DISABLED: Indicate whether or not
the patient is mentally retarded or developmentally disabled. If the resident is either, indicate
the name of the Service Coordinator (mentally retarded) or Case Manager (developmentally
disabled) assigned to the patient, if known.
RACE/ETHNICITY: Indicate the Patient’s Race and Ethnicity. Complete the Hispanic
Indicator. The rules for coding race and ethnicity and the Hispanic Indicator are the same
as used by the Division of Health Care Finance and Policy in its inpatient discharge data
submission regulations. See the instructions in the Electronic Records Submission
Specification:
The details are on page 25 of this document.
DPH OCCURRENCE TYPE: For all reports, select the term from Table #4, “Occurrence
Type”, that best describes the occurrence you are reporting. You may select “Other” and
describe what happened in one or two words if none of the examples listed are applicable
to your report.
SERIOUS REPORTABLE EVENT: Indicate whether or not this is a report of a “serious
reportable event” as described in the current National Quality Forum (NQF) list of serious
reportable events (SRE). If it is an SRE, check of the type of SRE on the table on page 2.
For additional information regarding NQF see
TYPE OF HARM: Select the term from Table #5, “Type of Harm”, that best describes the
harm or injury that resulted from the occurrence. You may select “Other” and describe
what happened in one or two words if none of the examples listed are applicable to your
report. Note that harm includes psychological injury as well as physical harm, and
SHOULD NOT BE DESCRIBED AS “NONE” SIMPLY BECAUSE THERE WAS NO
PHYSICAL HARM.
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