Common Patient-Specific Data Elements Found in a Health Care Organization’s Clinical/Financial Information System

• Date of birth

• Gender

• Race and Ethnicity

• Residence

• Marital Status

• Inpatient Admission Date

• Inpatient Discharge Date

• Outpatient Date of Encounter

• Principal Diagnosis for Inpatient

• Primary Diagnosis for Inpatient

• Other Inpatient Diagnoses

• Qualifier for Other Inpatient Diagnoses

• Diagnosis Chiefly Responsible for Outpatient Services

• Other Outpatient Diagnoses

• External Cause of Injury

• Birth Weight of Newborn

• Principal Inpatient Procedure

• Other Inpatient Procedures

• Dates of Inpatient Procedures

• Outpatient Procedures and Services

• Medications Prescribed

• Outpatient Disposition

• Health Care Practitioner Identification (outpatient)

• Attending Physician Identification (inpatient)

• Operating Clinician Identification (inpatient)

• Health Care Practitioner Specialty

• Disposition of Inpatient

• Patient’s Expected Source of Payment

• Total Billed Charges

• Patient’s Stated Reason for Visit or Outpatient Chief Complaint