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
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