Medical Abstract National Hospital Discharge Survey
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1
2OMB No. 0920-0212
HDS-1
U.S. DEPARTMENT OF COMMERCE
FORM
(3-20-2008)
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
Notice – All information which would permit identification of an individual or an
NATIONAL CENTER FOR HEALTH STATISTICS
establishment will be held confidential, will be used only by persons engaged in and
for the purposes of the survey, and will not be disclosed or released to other persons
or used for any other purpose. Public reporting burden of this collection of information
is estimated to average 4 minutes per response, including the time for reviewing
MEDICAL ABSTRACT
instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may
NATIONAL HOSPITAL
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. Send comments
regarding this burden estimate or any other aspect of this collection of information,
DISCHARGE SURVEY
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0212).
A. PATIENT IDENTIFICATION
Month
Day
Year
–
–
1. Hospital number
4. Date of admission
–
–
2. HDS number
5. Date of discharge
3.
(Item deleted)
6. Residence ZIP Code
B. PATIENT CHARACTERISTICS
7. Date of birth
11. Race – Mark all that apply
Month
Day
Year
White
Other – Specify
1
6
–
–
Black or
2
African American
8. Age – Complete
Units
{
American Indian
3
Years
1
only if date of
or Alaska Native
birth not given
Months
2
Asian
4
Days
3
Native Hawaiian
5
Not stated
7
or Other Pacific
9. Sex – Mark (X) one
Islander
Male
Female
Not stated
1
2
3
12. Marital status – Mark (X) one
10. Ethnicity – Mark (X) one
Married
Widowed
Separated
1
3
5
Hispanic
Not Hispanic
Not stated
1
2
3
or Latino
or Latino
Single
Divorced
Not stated
2
4
6
C. ADMINISTRATIVE INFORMATION
13. Type of Admission – Mark (X) one
16. Expected source(s) of payment
Other
Principal
additional
Emergency
Elective
Items not available/
1
3
5
sources
unknown
Urgent
Newborn
2
4
Mark
Mark all
one only
that
14. Source of Admission – Mark (X) one
apply
1. Worker’s
Physician referral
Emergency room
1
7
compensation
Clinical referral
Court/Law enforcement
2
8
2. Medicare
HMO referral
Other – Specify
3
9
3. Medicaid
Transfer from a hospital
4
4. Other government payments
Transfer from SNF
5
5. Blue Cross/Blue Shield
Transfer from other
Item not available
6
10
6. HMO/PPO
health facility
7. Other private or
15. Status/Disposition of patient – Mark (X) appropriate box(es)
commercial insurance
Status
Disposition
8. Self pay
9. No charge
Alive
a.
Routine discharge/discharged home
1
10. Other –Specify
b.
Left against medical advice
c.
Discharged, transferred to another
short-term hospital
d.
Discharged, transferred to
long-term care institution
e.
Other disposition/not stated
Died
2
Status not stated
No source of payment indicated
3
(Over)
HDS-1 (Back) Base copy, solid black ink
HDS-1 (front) overlay, Blue Pantone 277, 20% and 100%
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