Patient Activity Report by obn48518


									                                                                                                             ACTIVITY SUMMARY REPORT                                 ADDITIONS:                                                   LOSSES:

                     Network Patient Activity Report                                             Beginning Patient Census                               New ESRD Patient                            Transfer Out For Txp (combine AB)
                                                                                                   # of additions for the month:                               Transfer In                                Transfer Out (combine ABC)

    PROVIDER #                          PROVIDER NAME:                                                # of losses for the month:                                   Restart                                               Discontinue
                                                                                                        # of modality changes:                         Dx After Txp ( A&B)                                                     Death
               REPORTING MONTH:                                    PHONE:                               Ending Patient Census                            Total Additions:                                           Recover Function
                                                                                                                                                                                                                    Lost to Follow Up
    NAME OF PERSON COMPLETING FORM (print clearly):                                                                                                                                                                   TOTAL Losses

        PATIENT INFORMATION                SSN             Date of Birth    Gender    Zip Code               Date                     ADDITIONS           LOSSES               NEUTRAL EVENTS                MODALITY                       Sending/Receiving Facility

                                                                                                                                                     5A=Transfer out
                                                                                                                                                     for Txp in US
                                                                                                                                                     5B=Transfer out
                                                                                                                                                     for Txp outside US
                                                                                                                                   ADDITION:         6A=Transfer out to
                                                                                                                                   1=New ESRD        another ESRD MC                              CURRENT MODALITY OF
                                                                                                                                   patient (2728)    unit                                         PATIENT: (Write in current
                                                                                                                                   2A=Transfer In- 6B=Transfer out to                             Modality)
                                                                                                                                   Patient           prison/other                                 Hemo Modalities
                                                                                                                                   previously in     country                                      In Center Hemo
                                                                                                                                   Medicare Unit     6C=Transfer out-                             Home Hemo
                                                                                                                                   2B=Transfer In - Involuntary                                   Home Assisted Hemo
                                                                                                                                   Patient New to    Discharge                                    In Center - Self
                                                                                                                                   ESRD Registry     7=Discontinue           Neutral Events:      Frequent Dialysis-In Center
                                                                                                                                   3=Restart         8=Death                 11=Modality          Frequent - Home Hemo
      Last Name                                                                                                                    4A=Dialysis After 9=Recover               Change               PD Modalities
______________________                                                                             DATE OF ADDITION,               Transplant in US Function                 15=Interruption in   CAPD                                  Where is the patient going to,
                                                                                                   LOSS, or NEUTRAL                4B = Dialysis     10=Lost to Follow       Service              CCPD                                    or coming from? (ENTER
      First Name                   Social Security                     Gender                      EVENT AT DIALYSIS               After Transplant Up                       16=Resume            In Center IPD                         PROVIDER NUMBER or NAME
                                      Number             Date of Birth (M/F)         ZIP Code          FACILITY                    outside of US                             Service              Home IPD                                 and STATE or Country)








                                                                                                                                                                                                                                               Revised 05/12/05

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