ºÚÁϳԹÏÍø Data Collection Form,,,,,,,,,,,,,,
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Hospital,"[HOSPITAL ID, ie. NCR-34]",,,,,Chapter,,,Month/Yr,"[MMM-yy, ie. Feb-20]",No.of Discharges,[ie. 15],,
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No.,Patient Initial,Type of patient (Old/ New),Sex (M/F),Weight (kg.),Date of birth (mm/dd/yyyy),Date admitted (mm/dd/yyyy),Date discharged (mm/dd/yyyy),Outcome (Discharged/ Died),Primary diagnosis,ICD No.,Secondary Diagnosis,ICD No.,Tertiary Diagnosis,ICD No.