Acute Care (Inpatient) Case Abstract ALFRED STATE MEDICAL CENTER ACUTE CARE (I NPATIENT) CASE ABSTRACT 01 Hospital Number 02 Patient Date of Birth Month Day Year (YYYY) 03 Patient Gender 1 Male 2 Female 3 Other 4 Unknown 04A Race 1 American Indian/Eskimo/Aleut 2 Asian or Pacific Islander 3 Black 4 White 5 Other 6 Unknown 04B Ethnicity 1 Spanish origin/Hispanic 2 Non-Spanish origin/Non-Hispanic 3 Unknown 05A Living Arrangement 1 Alone 2 With spouse 3 With children 4 With parent or guardian 5 With relative other than spouse 6 With nonrelatives 7 Unknown 05B Marital Status 1 Married 2 Single 3 Divorced 4 Separated 5 Unknown 06 Hospital Number 07 Admission Date and Hour Month Day Year (YYYY) Military Time 08 Type of Admission 1 Scheduled 2 Unscheduled 09 Discharge Date and Time Month Day Year (YYYY) Military Time 10 Attending Physician Number 11 Operating Physician Number 12 Principal Diagnosis Code . ICD Code 16 Birth Weight of Neonate Kilograms Date Abstract Completed Month Day Year (YYYY) 17 Procedures, Dates, and Operating Physician UPIN . Month Day Year (YYYY) UPIN 13 Other Diagnosis Code(s) 14 Qualifiers for Other Diagnoses 1 Onset preceded hospital admission 2 Onset followed hospital admission 3 Uncertain whether onset preceded or followed hospital admission . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN . ICD Code . Month Day Year (YYYY) UPIN 19 Patient’s Expected Payment Source 1 Blue Cross/Blue Shield 2 Other commercial insurance 3 Other liability insurance 4 Medicare 5 Medicaid 6 Workers’ Compensation 7 Self-insured employer plan 8 Health maintenance organization (HMO) 9 TRICARE 10 CHAMPVA 11 Other government payer 12 Self-pay 13 No charge (e.g., charity, special research, teaching) 14 Other 15 External Cause of Injury Codes . ICD E-code . ICD E-code . ICD E-code . ICD E-code . ICD E-code 18 Disposition 1 Discharged to home 2 Discharged to acute care hospital 3 Discharged to nursing facility 4 Discharged home to be under the care of a home health service (including hospice) 5 Discharged to other health care facility 6 Left against medical advice (AMA) 7 Alive, other 8 Died 20 Total Charges $ , .