文档介绍：Medical Record Abstractor: Abstract data for anization’s selected measures with the measure code name (I-PN-4) designated in the left hand column under each data element question.
病历摘录者:为医院所选择的策略摘录数据,包括每个数据元素问题下左栏中所指定策略编码( I-PN-4)。
Hospital Name医院名称:
+Plus symbol indicates required administrative data field加号表示所需的行政数据区
+Patient Identifier Number
患者识别号
+Admission Date入院日期
_______/_______/________
Day 日 month 月 year 年
+Discharge Date 出院日期
/ /
Day日 month月 year 年
***别
Admitting Physician Code/Number
入院医生编码/号码
Attending Physician Code/Number
主治医生编码/号码
Principal Procedure Surgeon’s Code/Number
主要手术医师编码/号码
+Principal/Main Diagnosis or ICD Code
主要诊断/国际疾病分类编码
Present on Admission Diagnosis or ICD Codes
入院诊断/国际疾病分类编码
+Other Diagnosis or ICD Codes
其他诊断/国际疾病分类编码
Principal Procedure or ICD Code
主要处置/国际疾病分类编码
Principal Procedure Date
主要处置日期
+Other Procedure or ICD Codes
其他处置/国际疾病分类编码
After the case data abstraction and data flow pleted, circle the assigned Measure Category Assignment (MCA) Letter for each measure as guided by the allowable answer value “STOP” text:
完成病案数据抽象化及数据流后,随着许可的回答数值“STOP”文本的指引,圈出每个策略指定的策略类型赋值字母:
EXAMPLE: If answered No, STOP I-PN-4 data abstraction = case NOT in Measure Population =B
例:如回答NO,停止I-PN-4的数据抽象化=病案不在策略人群中=B
If there is no text prompt instructing you to STOP, continue data collection.
如果没有文本提示指示停止,继续收集每个策略的数据。
What is the date the patient was admitted to
acute inpatient care?: Admission Date
患者收治入紧急住院治疗的日期是?:入院日期
(I-PN-4)
/ /
Day 日(01 – 31)
Month月(01 – 12)
YYYY年(2010 – current year当前年份)
Does this case have a principal diagnosis of:
此病案是否有以下主要诊断
Pneumonia OR肺炎或
Septicemia or Respiratory Failure with an “other” diagnosis of pneumonia? ICD Principal Diagnosis Code国际疾病分类主要诊断编码
败血症或有“其他”肺炎诊断的呼吸衰竭?
(I-PN-4)
(Appendix A, Table PN, Table Septicemia, Table
Respiratory Failure)
附录A,,,
Yes是
No否
If answered No, STOP data abstraction for I-PN-4 = cas