Patient Registration Form

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ICU Name____________
Patient Registration (Form B)
Date can be completed retrospectively. Head of Bed needs to be observed on Day 1 of data collection and is an OPTIONAL field.
Patient Number corresponds to the Patient Number from Screening Log
Patient
Sex
Age
Hospital
ICU
Admission
Admission
Start of
Presence of
APACHE II
Head of
number
(Male or
(Years)
Admission
Admission
Categories*
Diagnosis*
Mechanical
ARDS
Score#
Bed
Female)
(Date & Time)
(Date &
(medical or
Ventilation in
Elevation
)
elective/emergency
ICU
(Yes or No)
(degrees)
Time
surgical)
(Date & Time)
(0-90)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*Select from taxonomy
# If not available, complete Apache II worksheet (Form C)
Form B Patient Registration: INS08
Revised 1 April 08

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