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 SERVICE 12. 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
2 3
4
5 6 7
8
9 10
11
12
13 14 15
16 17 18
19 20 21 22 23 24 25 26 27 28 29 30 31
32 33 34
ETS 11. FMP
35 36 37 38 39 40 41 42 43 44 45
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
46
HOUR OF
ADMISSION
BRANCH / CORPS
14. FLYING STATUS
47 48 49
15. BENEFICIARY CATEGORY
50 51 52 53 54 55 56 57 58 59 60 61
16. ZIP CODE OF RESIDENCE
17. UNIT LOCATION (State or
62 63 64 65 66 67 68 69 70 71
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 FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
73 74
22. MTF TRANSFERRED TO
75 76 77 78 79 80
23. DATE OF DISPOSITION (Y Y Y Y M M D D)
81 82 83 84 85 86
24.
89 90
25. MTF TRANSFERRED FROM
93 94 95 96 97 98
26. DATE THIS ADMISSION (Y Y Y Y M M D D)
99 100 101 102 103 104
27. LOCATION OF OCCURRENCE
107 108
28. MTF OF INITIAL ADMISSION
109 110 111 112 113 114
29. DATE INITIAL ADMISSION (Y Y Y Y M M D D)
115 116 117 118 119 120
91 92
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EDITION OF MAR 89 IS OBSOLETE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
87 88
105 106
121 122
ADMISSION AND CODING INFORMATION
46. THIRD PROCEDURE
44. FIRST PROCEDURE (Principal Diagnosis)
49. SIXTH PROCEDURE
50. SEVENTH PROCEDURE
30. AGE AT DISP 31. AUTOPSY 32. UNDERLYING CAUSE 33. RESIDUAL DISABILITY 34. DO NOT USE - DATA FILLER #1 35. 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 FIELDS 53. NUMBER OF PROCEDURAL FIELDS 55. BLOOD USAGE54. PRIMARY PROVIDER
PAGE 2, DA FORM 2985, MAR 2000
APD LC v1.02ES
123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142
143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 1648 165 166
191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206
167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190
207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230
255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270
231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254
271 272 273 274 275 276 277 278
OF DEATH / SEPY / N
CONTAINING CODES CONTAINING CODES SPECIALTY 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 MTF 58. BED DAYS OTHER FED MTFS 59. BED DAYS CIV. HOSPITALS
60. BASSINET DAYS (Neonatal)
61. QUARTER DAYS 62. MEDICAL HOLDING DAYS 63. COOPERATIVE CARE DAYS 64. CONVALESCENT LEAVE DAYS 65. SUPPLEMENTAL CARE DAYS
66. OTHER DAYS 67. TOTAL SICK DAYS - THIS MTF 68. BED DAYS - ICU 69. BED DAYS - ADMITTING
70. CLINIC SERVICE (Second)
71. BED DAYS SECOND CLINIC SERVICE
72. CLINIC SERVICE (Third)
73. BED DAYS THIRD CLINIC SERVICE 74. CLINIC SERVICE DISPOSITION 75. BED DAYS DISPOSITION CLINIC
76. CONVALESCENT LEAVE RECOM- 77. PATIENT ACUITY - DAYS I 78. PATIENT ACUITY - DAYS II 79. PATIENT ACUITY - DAYS III 80. PATIENT ACUITY - DAYS IV
81. PATIENT ACUITY - DAYS V 82. PATIENT ACUITY - DAYS VI
83. DO NOT USE THIS SPACE
84. TYPE RECORD
A
279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299
304 305 306 307300 301 302 303 308 309 310 311 312 313 314 315 316 317 318 319
320 321 322 323 324 325 326 327 329 330 331 332 333 334 335 336
CLINIC
SERVICE
337 338 339 340
341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360
361 362 363
SERVICE
MENDED
364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379
380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399
328
