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UHDDS DATA ELEMENT

Terms in this set (19)

01. Personal Identification
The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution.
02. Date of Birth
Month, day, and year of birth. Capture of the full four-digit year of birth is recommended
03. Sex
Male or female
04. Race and ethnicity
04a. Race
American Indian/Eskimo/Aleut
Asian or Pacific Islander
Black
White
Other Race
Unknown

04b. Ethnicity
Spanish origin/Hispanic
Non-Spanish origin/Non-Hispanic
Unknown
05. Residence
Full address of usual residence
Zip code (nine digits, if available)
Code for foreign residence
06. Hospital identification
A unique institutional number across data collection systems. The Medicare provider number is the preferred hospital identifier
07. Admission date
Month, day, and year of admission
08. Type of admission
Scheduled: Arranged with admissions office at least 24 hours prior to admission
Unscheduled: All other admissions
09. Discharge date
Month, day, and year of discharge
10 &11. Physician identification
.Attending physician
.Operating physician
The Medicare unique physician identification number (UPIN) is the preferred method of identifying the attending physician and operating physician(s) because it is uniform across all data systems.
12. Principal diagnosis
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
13. Other diagnoses
All conditions that coexist at the time of admission or that develop subsequently or that affect the treatment receive and/or the length of stay. Diagnoses that relate to an earlier episode and have no bearing on the current hospital say are to be excluded.
14. Qualifier for other diagnosis
A qualifier is given for each diagnosis coded under "other diagnoses"to indicate whether the onset of the diagnosis preceded or followed admission to the hospital. The option "uncertain is permitted.
15. External cause-of-injury code
The code for the external cause of an injury, poisoning, or adverse effect (commonly referred to as an E code). Hospitals should complete this item, whenever there is a diagnosis of an injury, poisoning, or adverse effect.
16. Birth weight of neonate
The specific birth weight of a newborn, preferably recorded in grams.
17. Procedures and dates
All significant procedures are to be reported. A significant procedure is one that is:
.Surgical in nature, or
.Carries a procedural risk, or
.Carries an anesthetic risk, or
.Requires specialized training.
18. Disposition of the patient
.Discharged to home (excludes those patients referred to home health service
.Discharged to acute care hospital
.Discharged to nursing facility
.Discharged home to be under the care of a home health service (including a hospice)
.Discharged to other healthcare facility
.Left against medical advice
Died
19. Patient's expected source of payment
Primary source
Other sources
20. Total charges
All charges billed by the hospital for this hospitalization. Professional charges for individual patient care by physicians are excluded.
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