Fillable Printable Admission and Coding Information
Fillable Printable Admission and Coding Information
Admission and Coding Information
ADMISSION AND CODING INFORMATION
For use of this form, see AR 40-400; the proponent agency is OTSG
19. TRAUMA
10. LENGTH OF SERVICE12. SOCIAL SECURITY NUMBER
18. MOS
1. REPORTING MTF
3. REGISTER NUMBER
2. MTF LOCATION
NAME (Last, First, Middle Initial)
5. SEX4. PAY GRADE
6. DATE OF BIRTH (Y Y Y Y M M D D)
9. ETHNIC8. RACE7. AGE AT ADMISSION
RELIGION
1
23
4
567
8
910
11
12
131415
161718
19202122232425262728293031
323334
ETS11. FMP
3536373839404142434445
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
46
HOUR OF
ADMISSION
BRANCH / CORPS
14. FLYING STATUS
474849
15. BENEFICIARY CATEGORY
505152535455565758596061
16. ZIP CODE OF RESIDENCE
17. UNIT LOCATION (State or
62636465666768697071
PREV. ADMISSION
YEAR
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR
72
WARD
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
NAME AND LOCATION OF MEDICAL TREATMENT FACILITYTELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
7374
22. MTF TRANSFERRED TO
757677787980
23. DATE OF DISPOSITION (Y Y Y Y M M D D)
818283848586
24.
8990
25. MTF TRANSFERRED FROM
939495969798
26. DATE THIS ADMISSION (Y Y Y Y M M D D)
99100101102103104
27. LOCATION OF OCCURRENCE
107108
28. MTF OF INITIAL ADMISSION
109110111112113114
29. DATE INITIAL ADMISSION (Y Y Y Y M M D D)
115116117118119120
9192
FOR LOCAL USE
ADMITTING OFFICER (Signature, as required)
SIGNATURE OF ADMITTING CLERK
APD LC v1.02ES
DA FORM 2985, MAR 2000
EDITION OF MAR 89 IS OBSOLETE
Country Code)
ADMISSION
CLINIC SVC - ADMITTING
(Battle Casualty Only)
A
(State or
Country
Code.)
BACK-
GROUND
8788
105106
121122
ADMISSION AND CODING INFORMATION
46. THIRD PROCEDURE
44. FIRST PROCEDURE (Principal Diagnosis)
49. SIXTH PROCEDURE
50. SEVENTH PROCEDURE
30. AGE AT DISP31. AUTOPSY32. UNDERLYING CAUSE33. RESIDUAL DISABILITY34. DO NOT USE - DATA FILLER #135. CAUSE OF INJURY
38. THIRD DIAGNOSIS37. SECOND DIAGNOSIS
36. FIRST DIAGNOSIS (Principal Diagnosis)
41. SIXTH DIAGNOSIS40. FIFTH DIAGNOSIS39. FOURTH DIAGNOSIS
43. EIGHTH DIAGNOSIS42. SEVENTH DIAGNOSIS
45. SECOND PROCEDURE
48. FIFTH PROCEDURE47. FOURTH PROCEDURE
51.
EIGHTH PROCEDURE
52. NUMBER OF DIAGNOSTIC FIELDS53. NUMBER OF PROCEDURAL FIELDS55. BLOOD USAGE54. PRIMARY PROVIDER
PAGE 2, DA FORM 2985, MAR 2000
APD LC v1.02ES
123124125126127128129130131132133134135136137138139140141142
143144145146147148149150151152153154155156157158159160161162163 1648165166
191192193194195196197198199200201202203204205206
167168169170171172173174175176177178179180181182183184185186187188189190
207208209210211212213214215216217218219220221222223224225226227228229230
255256257258259260261262263264265266267268269270
231232233234235236237238239240241242243244245246247248249250251252253254
271272273274275276277278
OF DEATH / SEPY / N
CONTAINING CODESCONTAINING CODESSPECIALTY CODE Y / N
FOR LOCAL USE
ADMISSION AND CODING INFORMATION
REGISTER NUMBER
PAGE 3, DA FORM 2985, MAR 2000
APD LC v1.02ES
REPORTING MTF
56. TOTAL SICK DAYS (All Facilities)
57. BED DAYS THIS MTF58. BED DAYS OTHER FED MTFS59. BED DAYS CIV. HOSPITALS
60. BASSINET DAYS (Neonatal)
61. QUARTER DAYS62. MEDICAL HOLDING DAYS63. COOPERATIVE CARE DAYS64. CONVALESCENT LEAVE DAYS65. SUPPLEMENTAL CARE DAYS
66. OTHER DAYS67. TOTAL SICK DAYS - THIS MTF68. BED DAYS - ICU69. BED DAYS - ADMITTING
70. CLINIC SERVICE (Second)
71. BED DAYS SECOND CLINIC SERVICE
72. CLINIC SERVICE (Third)
73. BED DAYS THIRD CLINIC SERVICE74. CLINIC SERVICE DISPOSITION75. BED DAYS DISPOSITION CLINIC
76. CONVALESCENT LEAVE RECOM-77. PATIENT ACUITY - DAYS I78. PATIENT ACUITY - DAYS II79. PATIENT ACUITY - DAYS III80. PATIENT ACUITY - DAYS IV
81. PATIENT ACUITY - DAYS V82. PATIENT ACUITY - DAYS VI
83. DO NOT USE THIS SPACE
84. TYPE RECORD
A
279280281282283284285286287288289290291292293294295296297298299
304305306307300301302303308309310311312313314315316317318319
320321322323324325326327329330331332333334335336
CLINIC
SERVICE
337338339340
341342343344345346347348349350351352353354355356357358359360
361362363
SERVICE
MENDED
364365366367368369370371372373374375376377378379
380381382383384385386387388389390391392393394395396397398399
328
