MEPS-HC Survey Instrument

PATIENT LABEL

DIAGNOSES CONTINUATION SHEET
FOR
HOSPITALS FOR REFERENCE YEAR 2005

A4a. I need the diagnoses for (this visit/these visits). I would
prefer the ICD-9 codes (or the DSM-4 codes), if they
are available.
[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]

CODE
|__| _____________

DESCRIPTION
___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__|__|

|__| _____________

___________________

USE ONLY

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

OFFICE

A4b. Which of these was the principal diagnosis?

IF ONLY ONE DIAGNOSIS, GO TO B5a.
IF MORE THAN ONE DIAGNOSIS:
„ CHECK BOX FOR PRINCIPAL
DIAGNOSIS
„ CIRCLE '-8' IF PRINCIPAL
DIAGNOSIS NOT KNOWN............... -8

M:\7690\7690.19.04\MPC 2005\Forms\HOSP\Hosp A4a.doc - 1/26/2006 - 11:34 AM - LA