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Burn Center Admission Information

My Name • 777-00003

Patient's first name ⓢ *

Not Known / Not Recorded

Patient's last name ⓢ *

Not Known / Not Recorded

Patient's hospital ID ⓢ *

Not Known / Not Recorded

Patient account number ⓢ *

Not Known / Not Recorded

Emergency Department arrival date *

Not Known / Not Recorded

Emergency Department arrival time *

Not Known / Not Recorded

Admission date *

Not Known / Not Recorded

Admission time *

Not Known / Not Recorded

Admitting MD ⓢ *

Not Known / Not Recorded

Admission type *

Initial admission

Related admission or readmission

Legacy system registry case number *

Not Known / Not Recorded

Admission status *

Unanticipated or unplanned admission

Anticipated or planned admission

Admission source *

Direct from scene of injury

Transfer from an emergency department or ambulatory care center

Transfer from another acute care facility

Admissions from burn center outpatient office/clinic

Admissions from other physician office or clinic

Admission category *

Acute

Non-acute

Admitting service *

Burn

Medicine

Pediatric

Trauma

Plastic Surgery

Other

Transport mode *

Ground ambulance

Helicopter ambulance

Fixed-wing ambulance

Private/Public vehicle/Walk-in

Police

Not known/Not recorded

Other

EMS name/Ambulance company ⓢ *

Not Known / Not Recorded

Hospital transfer / referral *

Not Referred/Transferred From Another Facility

In State but Outside of City/County

Local in City/County Referral

Out of Country

Out of State

Referring hospital/facility name ⓢ *

Not Known / Not Recorded

Referring hospital/facility state *

Referring MD ⓢ *

Not Known / Not Recorded

Injury incident date *

Not Known / Not Recorded

Injury incident time *

Not Known / Not Recorded

Injury details ⓢ *