Data Dictionary Element Name Available choices for this data element Definition Investigators please note: In CDW? In i2b2? y n Diagnosis, Procedure, and Visit Information: Visit ID Unique identifier for the patient visit Medical Record Number Diagnosis coding system (Current: ICD9), (2015: ICD10) Diagnosis code The schema or version of coding system (eg. ICD9 or ICD10) This field can be requested if a patient has consented to be contacted y for research; or with IRB approval. Currently only ICD9 is used. In 2015, historical ICD9 and current y ICD10 available. The 3-to-5 digit code used to specify the diagnosis n y y y y y y n There are 4 choices. ADMDX DISDX Sequential ordering of the diagnoses done in a single hospital visit Type of diagnosis: admitting, discharge, intermediate Admitting diagnosis Discharge diagnosis INTDX Intermediate diagnosis DX Diagnosis not specified as admission, discharge or intermediate When a diagnosis is not specified by the hospital as admitting or discharge diagnosis, then it is labeled generically. Diagnosis date Months, dates, and years are available. The date of the diagnosis. Months, dates, and years are available. y y; shifted Procedure coding system ICD9, ICD10 The schema or version it is (eg. ICD9 or ICD10). Currently only ICD9 is used. In 2015, historical ICD9 and current ICD10 available. y y Diagnosis Sequence Type of diagnosis Procedure code The 3-to-5 digit code used to specify the procedure. Sequential ordering of procedures done in a single hospital visit. The date on which a procedure was started. The date on which a procedure was completed. Procedure sequence Procedure start date Procedure end date Institution Length of stay Days Active, complete, null Active Complete Null Visit class --(Referred to as Encounter Type in i2b2) The diagnosis that is the reason they were admitted. The diagnosis at time of discharge. Diagnoses that are given in the interim while the doctor is ruling out a condition. This diagnosis would either be ruled out or would be finalized. ***This data element is being evaluated further. Greenville Health System, Palmetto Health, Medical The institution where the patient visit took place. University of South Carolina Visit start date Visit end date Units for length of stay Visit status ***This data element is being evaluated further. Inpatient, outpatient, emergency Inpatient Outpatient Emergency The date on which a visit was started. The date on which a visit was ended. The length of time that a patient stayed in the hospital; This variable is not calculated by HSSC; it is submitted by the see associated units. hospitals. The time measure associated with length of stay. Describes whether a visit is ongoing or has ended. Active = The patient has not been discharged yet. Complete = The patient has been discharged. Null = A planned visit that was cancelled before the We do not differentiate between cancelled and no-show. patient was admitted. The 3 broad patient classes are inpatient, outpatient, and emergency An inpatient encounter is a hospital stay that spans more than one day. An outpatient encounter. Observation visits or stays less than 24 hours are included in this category. An unplanned visit to an emergency department. 7/8/2014 y y y y y y y; shifted y; shifted y y y y y; shifted y; shifted y n y y n n y y Data Dictionary Element Name Available choices for this data element Definition Investigators please note: In CDW? In i2b2? Visit type -- (Referred to as Encounter Subtype in i2b2) There are 11 codes. Indicates with more detail the type of visit. Please see the Encounter Subtype code sheet. y y The date the patient was registered at the hospital. y y; shifted The date the patient was sent home (or elsewhere) from the hospital. y y; shifted Admission date Discharge date Months, dates, and years are available Months, dates, and years are available Age at visit The patient's age in years on the date of the visit. Admission type There are 7 codes. Admission source There are 16 codes. Accomodation code There are 13 codes Discharge location There are 21 codes. Financial class group COMM, SELF, GOVT, OTHR COMM SELF GOVT OTHR Hospital service area or group There are 42 codes. Readmission indicator 1, 0 Patient's Personal and Demographic Information: Patient's first name Patient's middle name Patient's last name Patient's title or prefix Patient's suffix Patient's date of birth This data element is only displayed in i2b2. It is calculated using the patient's shifted date of birth and the date of the visit. Indicates the circumstances under which an inpatient visit Please see the Admission Type code sheet. began. Indicates where the patient came from before they were Please see the Admission Source code sheet. admitted to the hospital Please see the Accommodation code sheet. Think of "accommodation" as analogous to a hotel accommodation -- what Indicates the type of accommodation where the patient type of room? What features does it have? This information is stayed in the hospital. captured for billing purposes. Indicates where it was planned for the patient to go when Please see the Discharge Disposition code sheet. they were leaving the hospital. The patient's broad category of type of insurance/payment. Commercial health insurance plan Patient does not have health insurance and pays for him or herself Government payor: medicare or medicaid Source of payment that does not fit into the above Military payors are found in other. categories If the patient was admitted to a specialty unit (e.g., CCU), this may be Indicates the medical or surgical service or specialty area a location rather than a provider specialty designation. See location responsible for the patient. specific dictionary for site details. n y; shifted y y; HSSC project y y y y; HSSC project y y y Indicates whether this encounter is a readmission or not. Some hospitals only populate this field if it IS a readmission, and a null y 1=Readmission, 0=Not a readmission. or missing value indicates that the visit is NOT a readmission. Dr., MD, Rev Jr, Sr, I, II, III, IV This field may not be reliable y; HSSC project y; HSSC project y; HSSC project n y y y y y y n n n n n y; shifted y y y y y y y y y n n n n n n n n n We have record of a patient's most recently updated address, as well as the address given on a particular visit. These addresses may be the patient's temporary or "local" address during the visit. Patient's Address Information: Patient's address Patient's address line 2 Patient's address line 3 Patient's country of residence Patient's county of residence Patient's state of residence Patient's city of residence Patient's home phone Patient's work phone 7/8/2014 Data Dictionary Element Name Available choices for this data element Definition Investigators please note: Patient's mobile phone Patient's email address Please see the race code sheet.To understand this value completely, please also select ethnicity. Please see the ethnicity code sheet.To understand this value completely, please also select race. In CDW? y y n n y; HSSC project y; HSSC project y; HSSC project y; HSSC project y; HSSC project Patient's standardized race There are 10 choices. Patient's standardized ethnicity There are 10 choices. Patient's standardized language There are 16 choices. Primary language spoken by the patient. Please see the language code sheet. y Patient's standardized religion There are 37 choices. Patient's indicated religious preference. Please see the religion code sheet. y Patient's standardized marital status There are 6 choices. Patient's marital status. Please see the marital status code sheet. y Patient's age in years. In i2b2 the patient's age is calculated as of the most recent refresh, and using a shifted date of birth. If you are requesting a dataset using y age as a filter, we suggest that you specify a range of BIRTHDATES you want, rather than a range of ages. y; shifted y y; HSSC project y n y n y y y y Patient's age Patient's standardized, administratively assigned gender M, F, Unknown Patient's social security number Patient's administratively assigned gender. Patient's social security number. Patient's date of death month, day, year Patient's date of death, if applicable and known. Patient's vital status Y, N Yes/no indicator of whether the patient is deceased. Patient's military status Active, Retired, Deceased. Indicates whether the person is or has been in the military. 7/8/2014 This data element is available for the purpose of merging with other databases. This may not include death data for a death occurring outside the hospital. This may not include death data for a death occurring outside the hospital. This is reported by the patient. y In i2b2? y Accommodation Code CC ED IC MC NU O OP OT PR SP ST SV WD Description Coronary Care Emergency Department Intensive Care Intermediate Care Nursery Obstetric Outpatient Other Private Special Program Short Term Care Semi-Private Ward Admission Source Code CR ED HR LW NB NF PR PV TA TD TI TN TO TP UNK Description Clinic Referral Emergency Department Hmo Referral Court/Law Newborn Non Health Care Facility Physician Referral Physician Service Transfer - Outpatient Surgery Transfer - Other Hospital Transfer - Within Hospital Transfer - Skilled Nursing Facility Transfer - Other Transfer - Hospice Unknown Admission Type Code E N O R TM U UNK Description Emergency Newborn Obstetric Elective Trauma Urgent Unknown Discharge Disposition Code ADM AHF AHH AHR AIV ALW AMA ANI ATA ATC ATE ATH ATI ATL ATM ATO ATS ATX DAZ DBZ DCZ Description Admitted To Hospital Hospice Facility Hospice Home Routine To Home Or Self Care Home With Home Health And Iv Court / Law Left Against Medical Advice Home With Home Health And No Iv Assisted Living Critical Access Hospital Extended Care Nursing Facility Short Term Hospital Intermediate Care Facility Acute Long Term Care Facility Transfer Mental Health Center Other Facility Skilled Nursing Facility Rehab Facility Died At Home Died In Medical Facility Died Place Unknown Encounter Subtype Code ED IG IO IX OG OO OR OS OT OV TC Description Emergency / Trauma Inpatient General Inpatient Other Inpatient Transfer Outpatient General Outpatient Other Outpatient Series Outpatient Surgery Other Outpatient Service Transitional Care Hospital Service Area or Group Code ADA ALL ALL ANS CAR DEN DER EMS END ENT EYE FMD GIN GYN HOS ICU IDX LTC MED NEP NRU NSU OBS OBV ONC OPD ORS ORT PAL PAT PED POD PSU PSY PUL RAD REC REH RHU SUR UNK URO Description Alcoholdrug Treatment Allergy Allergy Anesthesiology Cardiology Dentistry Dermatology Emergency Medicine Endocrinology Otolaryngology Ophthalmology Family Medicine Gastroenterology Gynecology Hospitalists Intensive Care Infectious Disease Long Term Care Internal Medicine Nephrology Neurology Neuroscience Obstetrics Observation Oncology Outpatient Department Oral Surgery Orthopedic Palliative Care Pathology Pediatrics Podiatry Plastic Surgery Psychiatry Pulmonary Radiology Recovery Rehab Medicine Rheumatology Surgery Unknown Urology Race Code African American American Indian Or Alaska Native Asian Hispanic Or Latino More Than One Race Native Hawaiian Or Other Pacific Other Race Refused Declaration Unknown White Description African American American Indian Or Alaska Native Asian Hispanic Or Latino More Than One Race Native Hawaiian Or Other Pacific Islander Other Race Refused Declaration Unknown White Ethnicity Code African American American Indian Or Alaska Native Asian Indian Hispanic Or Latino More Than One Race Not Hispanic Or Latino Other Race Refused Declaration Unknown White Description African American American Indian Or Alaska Native Asian Indian Hispanic Or Latino More Than One Race Not Hispanic Or Latino Other Race Refused Declaration Unknown White Language Code ARA CHI ENG FRE GER ITA JPN KOR OTH POL POR RUS SGN SOM SPA VIE Description Arabic Chinese English French German Italian Japanese Korean Other Polish Portugese Russian Sign languages Somali Spanish Vietnamese Religion Code African Methodist Episcopal Assembly Of God Baptist Brethren Buddhist Catholic Christian Christian Science Church of Christ Congregational Disciples Of Christ Episcopalian Evangelical Friends (Quakers) Greek Orthodox Independent Jehovah Witnesses Jewish Latter Day Saints Lutheran Methodist Mission Covenant Mormon Moslem Nazarene No Religious Preference Other Religion Pentecostal Presbyterian Protestant, No Denomination Reformed Salvation Army Seventh Day Adventist Sunni (Islam) Unitarian United Church Of Christ Unknown Description African Methodist Episcopal Assembly Of God Baptist Brethren Buddhist Catholic Christian Christian Science Church of Christ Congregational Disciples Of Christ Episcopalian Evangelical Friends (Quakers) Greek Orthodox Independent Jehovah Witnesses Jewish Latter Day Saints Lutheran Methodist Mission Covenant Mormon Moslem Nazarene No Religious Preference Other Religion Pentecostal Presbyterian Protestant, No Denomination Reformed Salvation Army Seventh Day Adventist Sunni (Islam) Unitarian United Church Of Christ Unknown Marital Status Code D T W S L M Description Divorced Domestic partner Widowed Single Legally separated Married
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