Hospitalization Form
FORM CODE: HOS
VERSION:A 12/02/09
ID NUMBER:
Contact
Occasion
SEQ #
Administrative Information
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
INSTRUCTIONS: Complete this form for each hospitalization admission.
Requested / Photocopied from Hospital Medical Record
Requested
& Pending
1. Discharge Report ................................................................................. 0
Requested
& Photocopied
Requested
but NA
1
2
Notes:_____________________________________________________________________________
2. All Procedure Reports including CATH, Echo, Stress Test, EPS ........ 0
1
2
Notes:_____________________________________________________________________________
3. Admission EKG ................................................................................... 0
1
2
Notes:_____________________________________________________________________________
4. Discharge EKG .................................................................................... 0
1
2
Notes:_____________________________________________________________________________
5. Cardiac Enzymes (All that were done in-hospital) ................................ 0
1
2
Notes:_____________________________________________________________________________
6. Hemaglobin/Hematocrit (All that were done in-hospital)....................... 0
1
2
Notes:_____________________________________________________________________________
7. Hospitalization summary list w/ ICD-9 codes for diagnosis and
Procedures ........................................................................................ 0
1
2
Notes: ____________________________________________________________________________
Hospitalization Form (HOS)
Page 1 of 4
DISCHARGE DIAGNOSIS
1.
List the number of HOSPITALS related to this HOSPITALIZATION: ______
(2) First Hospital
(a)
Name: _____________________________________________
(b)
Phone # for Medical Records: ( __ __ __ ) __ __ __ - __ __ __ __
(c)
___________________________________________________
(f)
Study Affiliation?:
1Affiliated
2Non-affiliated
(g)
Medical Record #: __________________
(h)
Chart located?: 0 No 1Yes
Street Address Line 1
____________________________________________________
Street Address Line 2
_____________________________
________
________
City/Town
State
Zip Code
(d)
Admission date to first hospital: ____ / ____ / 20___
Month
(e)
Day
(i)
Admission Time (24-hr format): _____ _____
Year
Hour
Minutes
Discharge / transfer date (for non-fatal case) or death: _____ / _____ / 20___
Month
 Check if not applicable and skip to question #5
Day
Year
(3) Second Hospital
(a)
Name: _____________________________________________
(b)
Phone # for Medical Records: ( __ __ __ ) __ __ __ - __ __ __ __
(c)
___________________________________________________
(f)
Study Affiliation?:
1Affiliated
2Non-affiliated
(g)
Medical Record #: __________________
(h)
Chart located?: 0 No 1Yes
Street Address Line 1
____________________________________________________
Street Address Line 2
_____________________________
________
________
City/Town
State
Zip Code
(d)
Admission date to second hospital: ____ / ____ / 20___
Month
(e)
Day
(i)
Admission Time (24-hr format): _____ _____
Year
Hour
Minutes
Discharge / transfer date (for non-fatal case) or death: _____ / _____ / 20___
Month
Hospitalization Form (HOS)
Day
Year
Page 2 of 4
 Check if not applicable and skip to question #5
(4) Third Hospital
(a)
Name: _____________________________________________
(b)
Phone # for Medical Records: ( __ __ __ ) __ __ __ - __ __ __ __
(c)
___________________________________________________
(f)
Study Affiliation?:
1Affiliated
2Non-affiliated
(g)
Medical Record #: __________________
(h)
Chart located?: 0 No 1Yes
Street Address Line 1
____________________________________________________
Street Address Line 2
_____________________________
________
________
City/Town
State
Zip Code
(d)
Admission date to third hospital: ____ / ____ / 20___
Month
(e)
Day
(i)
Admission Time (24-hr format): _____ _____
Year
Hour
Minutes
Discharge / transfer date (for non-fatal case) or death: _____ / _____ / 20___
Month
Day
Year
5. What was the disposition of the patient on discharge from the last hospital?
1 Deceased (If Deceased, complete Death Certificate Form.)
2 Nursing home
3 Rehabilitation hospital
4 Home or other private residence
5 Discharged alive, disposition unknown
6. (Leave blank, and skip to #7 for nonfatal events) Are any causes of death given on the discharge
summary? ............................................................................................ 0 No
1 Yes
Record the cause(s) of death:
a. ________________________________ b. ______________________________
c. _________________________________ d. ______________________________
7. List the hospital discharge diagnoses and codes exactly as they appear on the front sheet of the final
discharge summary.
ICD-9 Codes
a.
b.
c.
d.
e.
Hospitalization Form (HOS)
.
.
.
.
.
Discharge Diagnoses
______________________
______________________
______________________
______________________
______________________
Page 3 of 4
ICD-9 Codes
f.
g.
h.
Discharge Diagnoses
.
.
.
______________________
______________________
______________________
CARDIAC ENZYMES
8. Troponin I Assessment Performed ...............................................
No
Yes
If YES, fill out the following:
8a. Initial Troponin I at First Presentation to Hospital: ___________ ng/mL
8b. Peak Troponin I During Hospitalization: ___________ ng/mL
(peak prior to PCI or CABG if done)
Upper limit of normal of troponin I for the diagnosis of MI at hospital (if not CUMC): ________ng/mL
9. CK Assessment Performed............................................................
No
Yes
No
Yes
If YES, fill out the following:
9a. Initial CK at First Presentation to Hospital: ___________ U/L
9b. Peak CK During Hospitalization: ___________ U/L
(peak prior to PCI or CABG if done)
Upper limit of normal of CK at hospital (if not CUMC): ________U/L
10. CKMB Assessment Performed ....................................................
If YES, fill out the following:
10a. Initial CKMB at First Presentation to Hospital: ___________ U/L
10b. Peak CKMB During Hospitalization: ___________ U/L
(peak prior to PCI or CABG if done)
Upper limit of normal of CKMB at hospital (if not CUMC): ________ U/L
Upper limits of Normal at CUMC:
Cardiac Troponin I
CK-MB
Creatine Kinase (CK)
Hospitalization Form (HOS)
0.39 ng/mL
5.5 ng/mL
Male: 294 U/L
Female: 238 U/L
Page 4 of 4