Table 1

Demographic and Admission Data Elements and Definitions

Element NameElement Definition
Demographics
Unique patient IDPatient ID is a unique number that permanently identifies each patient. Once assigned to a patient, this number can never be changed or reassigned to a different patient. Each time a patient returns to the site, the patient MUST receive the same unique patient identifier.
Sex
  • Indicate the patient's sex at birth as either male or female. Choose 1 of the following:

  • • Male

  • • Female

Date of birthIndicate the patient's date of birth.
Race
  • Indicate the patient's race as determined by the patient or family. Choose 1 of the following:

  • • White

  • • Black or African American

  • • Asian Indian

  • • Chinese

  • • Filipino

  • • Japanese

  • • Korean

  • • Vietnamese

  • • Other Asian

  • • American Indian or Alaska Native

  • • Native Hawaiian

  • • Guamanian or Chamorro

  • • Samoan

  • • Other Pacific Islander

Ethnicity
  • Indicate if the patient is of Hispanic or Latino ethnicity as determined by the patient or family. Hispanic ethnicity includes patient reports of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Choose 1 of the following:

  • • No

  • • Yes

Postal codeIndicate the postal code for the patient's residence. For US ZIP codes, the hyphen is implied. If the patient is determined to not have a permanent residence, then the patient is considered homeless.
Admission/encounter date
  • Indicate the date the patient was admitted as an inpatient to the facility for the current episode of care.

  • For outpatients, note the date (month/day/year) of the encounter (e.g., physician visit, nurse visit, consultation, procedures).

Admission source
  • Indicate the source of the patient's admission as an inpatient to your facility.

  • Choose 1 of the following:

  • • Physician referral: The patient was admitted to this facility on the recommendation of his or her personal physician.

  • • Clinic referral: The patient was admitted to this facility on the recommendation of this facility's clinic physician.

  • • HMO referral: The patient was admitted to this facility on the recommendation of an HMO physician.

  • • Transfer from a hospital (different facility): The patient was admitted to this facility as a hospital transfer from a different acute care facility where he or she was an inpatient.

  • • Transfer from SNF: The patient was admitted to this facility as a transfer from an SNF where he or she was an inpatient.

  • • Transfer from another healthcare facility: The patient was admitted to this facility as a transfer from a healthcare facility other than an acute care facility or an SNF. This includes transfers from nursing homes and long-term care facilities and SNF patients who are at a nonskilled level of care.

  • • ED: The patient was admitted to this facility on the recommendation of this facility's emergency physician.

  • • Court/law enforcement: The patient was admitted to this facility on the direction of a court of law or the request of a law enforcement agency representative.

  • • Information not available: The means by which the patient was admitted to this hospital is not known.

  •  - Transfer from a critical access hospital: The patient was admitted to this facility as a transfer from a critical access hospital where he or she was an inpatient.

  •  - Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer: The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.

Insurance payer
  • Indicate the patient's primary insurance payer for this admission. Choose 1 of the following:

  • • Government: Refers to patients who are covered by government-reimbursed care. In the United States this includes

  •  - Medicare

  •  - Medicaid (including all state or federal Medicaid-type programs)

  •  - Veterans Health Administration

  •  - Department of Defense

  •  - Other federal group (specify)

  • • Commercial: Refers to all indemnity (fee-for-service) carriers and PPOs

  • • HMO: Refers to a HMO characterized by coverage that provides healthcare services for members on a prepaid basis

  • • None: Refers to patients with limited or no health insurance; thus, the patient is the payer regardless of ability to pay. Only mark “None” when “self” or “none” is denoted as the first insurance in the medical record.

Presentation (to healthcare facility) date/timeDate and time the patient first presented to the hospital
Location of first evaluation in EDIndicate if the patient was first evaluated in your facility's ED. This includes traditional ED locations, as well as ED-based chest pain units, clinics, and short-stay CCUs housed in the ED.
Transfer out of ED date/timeIf the patient was first evaluated in your facility's ED, enter the date and time the patient was moved out of the ED, either to another location within your facility or to another acute care center.
Type of admission
  • The categories of type of admission are

  • • Elective (i.e., scheduled >24 h before hospital arrival)

  • • Urgent (i.e., through the ED or directly from a health care provider's office or transferred from another facility)

Admission location
  • The categories of location of a patient at the time of admission to the hospital or observation unit are

  • • CCU/ICU

  • • Step-down unit/monitored bed/cardiac ward

  • • Unmonitored hospital floor

  • • Observation unit/ED chest pain unit

Means of transport of nontransfer patient
  • Indicate the means by which a nontransfer patient was transported to your facility. Choose 1 of the following:

  • • Self/family

  • • Ground-transport ambulance (includes 911 provider, private provider, or hospital based)

  • • Air ambulance (helicopter or fixed wing)

  • • Mobile ICU

  • • Unknown

Prearrival first medical contact date/time
  • Indicate the date and time of prearrival first medical contact, when the patient was first evaluated by either EMS or another healthcare professional before arrival at your facility. This is not the date and time of arrival at your facility.

  • Note: Enter the date and time of first medical contact only for patients who were transported by ambulance (ground or air) or mobile ICU.

Transfer patientIndicate if the patient was transferred directly to your facility from another ED or hospital unit and indicate which.
Means of transport of transfer patient
  • Indicate the means by which the transfer patient was transported to your facility.

  • Choose 1 of the following:

  • • Mobile ICU

  • • Air ambulance (helicopter or fixed wing) transfer from another facility

  • • Ground-transport ambulance transfer from another acute care facility

  •  - 911 Provider

  •  - Hospital based

  •  - Private provider

  •  - Unknown

Arrival at outside hospital date/timeIndicate the date and time the patient arrived at the outside hospital. If unknown, leave blank.
Transfer from outside hospital date/timeIndicate the date and time the patient left the outside facility.
Time points for STEMI patients
  • Indicate the following time points for STEMI patients:

  • • Symptom-onset date/time

  • • EMS dispatch date/time

  •  - If ground or air ambulance, indicate EMS first medical contact date/time

  • • Non-EMS first medical contact date/time

  • • EMS leaving scene date/time

  • • Hospital arrival date/time

  • • First ECG date/time

  • • Catheterization lab activation date/time

CCU indicates coronary care unit; ECG, electrocardiogram; ED, emergency department; EMS, emergency medical services; HMO, health maintenance organization; ICU, intensive care unit; ID, identification; PPO, preferred provider organization; SNF, skilled nursing facility; and STEMI, ST-segment elevation myocardial infarction.