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DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10
DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10
DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10
DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10
DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10
DISCHARGE
Resident ADMITTING PRIMARY
Service Consultant PRIMARY
Date (I, II, III) DIAGNOSIS OUTCOME
NAME AGE SEX or Pay (F, D, N) DIAGNOSIS
Admitted Year (Include Duration)
(S or P)
Level ICD - 10
ICD – 10