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Editing and Viewing Case Abstracts

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To view or make corrections to a case abstract, from the Medical Records Abstract System, select View/Change Case Abstract. Enter the account number of the patient to view. If the account number entered is not in the case abstract system, it will display “New” next to the patient name. Otherwise, if the account number entered was included in the generation of case abstracts, it will display “Existing” next to the patient name. Any changes that are made here will be over-written if the case abstracts are regenerated, and the prompt is answered YES to clear the abstract file.

 

 

Select Hospital Base Menu > Print Reports > Medical Records > Page2 > Abstracting System #1 > View/Change Case Abstract

 

absracting_pas_case

Figure 9.7 CPHA PAS Case Abstract

 

 

Admit Date, Code: This is the patient’s Admit date and Admit code and will pull from Stay tab on the Registration and ADT screen.

 

Admit Hour, Discharge Hour: This is the hour the patient was admitted and discharged and will pull from Stay tab on the Registration and ADT screen.

 

Discharge Date, Code: This is the patient’s discharge date and discharge code and will pull from Stay tab on the Registration and ADT screen.

 

Expire Codes: There are 5 available spaces in this field, into any of which an asterisk (“*”) may be placed.  The position of the asterisk (“*”) determines the type of Expire Code:

Position 1

Died

Position 2

Autopsy

Position 3

In OR

Position 4

Post Operative

Position 5

Coroner’s Case

 

If a patient has a Discharge Code of 20, the system will automatically pull an asterisk (“*”) to the first position. The other positions must be entered manually.

 

Birth Date: This is the patient’s birth date and will pull from Patient tab on the Registration and ADT screen.

 

Birth Weight: If the patient is a newborn, this is the birth weight and will pull from Clinical tab on the Registration and ADT screen if the patient’s admit date and birth date are the same.

 

Infant Status: 1=Stillborn   2=NB   3=Trans    If the admit date and birth date are the same, the system will pull a 2 in this field. A status of 1 or 3 can be entered in this field if applicable.

 

Sex: This is the patient’s gender. A code of 1 or 2 will automatically pull from Patient tab on the Registration and ADT screen.

1

Male

2

Female

3

Unknown

4

Male Verified

5

Female Verified

 

Race: This is the patient’s race code. If the letter in parenthesis is entered on Patient tab on the Registration and ADT screen, the corresponding number will automatically pull:

1

(W)hite

2

(B)lack

3

(A)sian

4

American (I)ndian

5

(H)ispanic

6

(M)ulti-racial

7

(O)ther

X

(U)nknown

 

Attending Phy: This is the patient’s Attending physician. This pulls from Stay tab on the Registration and ADT screen.

 

Town&Co Code: This code must be entered manually. A facility’s professional health study group supplies this code.

 

Consult Phys: This field will hold three physician numbers and pulls the physicians from the Medical Records Grouper screen. If a physician has a type S loaded for surgeon, that physician will not pull to this field.

 

Amit Diag: This is the patient’s admitting diagnosis and pulls from field 8 of the Medical Records Grouper screen

 

Principal Diag: This is the patient’s principal diagnosis and pulls from field 21 of the Medical Records Grouper screen.

 

Other Diags: This is the patient’s secondary diagnoses and pulls from fields 22 – 30 of the Medical Records Grouper screen.

 

Surgery Date, Phy: The surgery date and physician will pull from field 31, page 2 of the Medical Records Grouper screen. The physician number will pull from fields A – J, page 2 of the Medical Records Grouper screen, depending on what number is loaded in the “Phy” column for the procedure.

 

Principal Proc, Tissue Code: This is the patient’s principal procedure and pulls from field 31, page 2 of the Medical Records Grouper screen. The valid tissue code may be entered in the second part of this field. Valid codes are:

1

NORM

2

ABN

3

MECH

4

GROW

5

DEGEN

6

NO IN

7

INFLA

8

NOMAL

9

MAL

 

Other Procs: These are the patient’s secondary procedures. There are 12 procedure code fields that pull from fields 32-40 of the Medical Records Grouper screen. If the procedure codes are not relating to the principal procedure or another procedure code, then S2, S3 or S4 may be entered at the bottom of the screen and the procedure code(s) can be entered in either field 17 or field 18. When entering S2, S3, or S4, the date and physician will have to be entered for this surgery, along with the principal procedure or other procedure.

 

Locality Code: This is the patient’s zip code. It pulls from Patient tab on the Registration and ADT screen. There must be two spaces before the zip code to create a 7-character field.

 

Hosp Service: This 2-character field must be entered manually.

 

Primary Payor: This is the patient’s primary financial class and pulls the first character of the financial class from Guarantor/Ins tab on the Registration and ADT screen.

 

Second Payor: This is the patient’s secondary financial class and pulls the first character of the financial class from Guarantor/Ins tab on the Registration and ADT screen.

 

Ins. Contract#: This is the patient’s contract number from the primary financial class.

 

City/Cnty Code: This is the patient’s city/county code. It pulls from Patient tab on the Registration and ADT screen.

 

Days in ICU: This 2-character field must be manually entered.

 

Days in CCU: This 2-character field must be manually entered.

 

Days in SCU: This 2-character field must be manually entered.

 

Total charges: This is the total charges on the patient’s account detail at the time of generation. If “Include Adjustments in Total Charges” in the Abstract System Control Record is set to N, any adjustment charges on the patient account will not be included in the Total Charges.

 

Physician Chgs: This is the total of physician charges on the patient’s account detail at the time of generation.