APGAR SCORE. The Apgar score is a system of numerical evaluation that describes the status of the infant at birth, 1 minute, and 5 minutes after birth. A score of zero indicates a severely jeopardized infant; the higher the score, up to a maximum of 10, the better the condition of the infant.

BEDS, different types:

Adult Hospital Bed. A hospital bed immediately available for regular use by an inpatient who is 15 years. of age or older.

Pediatric Bed. A bed immediately available for regular use by a patient, other than newborn, under the age of 15 years. A crib and bassinet maintained for use by other than a newborn infant is considered a pediatric bed.

Newborn Bassinet.  A bed immediately available for regular use by an infant newly born in the hospital.

Newborn infant bassinets placed in maternity patients' rooms should be included in the total count of newborn infant bassinets.

The count of newborn infant bassinets does not include incubators used for the treatment of newborn infants, but days of care shall be included in the count of newborn or pediatric days (as appropriate) during periods of treatment in incubators

Swing Bed. A bed utilized for more than one level of care (e.g., acute, skilled nursing, alcohol rehabilitation).

INPATIENT ADMISSION. The formal acceptance of a patient for inpatient services based on the order (standing, verbal, or written) of a physician or dentist member of the hospital's medical staff.

This involves the occupancy of an adult or pediatric hospital bed or newborn infant bassinet and the maintenance of a hospital chart during the period of observation, care, diagnosis, or treatment.

NOTE: Adults without complaint or sickness who are at the hospital for the benefit of a hospitalized patient or the convenience of the hospital are not considered inpatients.

If, after discharge, an inpatient presents himself for admission at a subsequent time, it is a separate admission.

NEWBORN INFANT. Inpatient service of an infant newly born in the hospital involving the occupancy of a newborn infant bassinet and the maintenance of a hospital chart during the period of care.

Newborn infants are considered to be inpatient admissions but always should be stated separately.

Infants born outside the hospital and admitted to the pediatric nursery should be recorded as regular pediatric inpatient admissions and not as newborn infants, or hospital births.

INPATIENT DISCHARGE. The formal release of an inpatient by the hospital and termination of stay. Since deaths are termination of stay, they are also inpatient discharges, although recorded as a specific type of discharge.

Deaths occurring prior to the decedent's (patient's) arrival within the hospital are not carried on the census as an inpatient admission or discharge. Note: Billing may be done on the basis of emergency service provided but never as inpatient service if patient died in the Emergency Room.

READMISSION.   An inpatient's subsequent admission to the same IHS Hospital.

AGE GROUPING.

CHILD (pediatric). A person (excluding newborn admission) from birth through the age of 14.

Infant--Those under 1 year of age.

Preschool--Those 1 year of age or older but less than 5 years of age.

Other Pediatric--Those 5 years of age or older but less than 15 years of age.

ADULT.  A person who is 15 years of age or older.

PATIENT IN TRANSIT. Patient who must stop over at an IHS Hospital for boarding purposes while enroute to another  designated location. Patients awaiting completion of transportation arrangements either to another hospital or to home. All such individuals admitted as patients and for whom a clinical record is established are "patients" and should be included in the count of patients on the monthly report. It is important that the diagnosis be recorded on the patient's chart.

LIVE BIRTH. The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; the product of such a birth is considered live born. If a child breathes or shows any other evidence of life after complete birth, even though it be only momentary, the birth should be registered as a live birth.

IMMATURE INFANT. A live born infant with a birth weight of 5 l/2 pounds (2,500 grams) or less, or specified as immature. If weight is not specified, a live born infant with a period of gestation of less than 37 weeks, or specified as "premature" by the delivering physician or attending pediatrician, shall be considered as an immature infant for purposes of classification.

FETAL DEATH. A death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. They are divided as follows:

Group I-Less than 20 complete weeks of gestation (early fetal death); 500 grams or less.

Group II--20 complete weeks of gestation, but less than 28 (intermediate fetal death); 501 to 1,000 grams.

Group III--28 complete weeks of gestation and over (late fetal death); 1,001 grams or over.

Group IV--gestation not classifiable in Group I, II, or III.

The definitions of fetal death followed in some States differ from the standard definition, particularly with respect to the minimum period of gestation for which a fetal death report is required.

Fetal deaths are not to be counted as admissions and discharges nor are they to be credited with hospital days.

Fetal death records--certificate, autopsy authorization and protocol--shall be filed within the obstetrical patient's record (Mother's record).

PATIENT DAY.  That period of service rendered to a patient occupying a hospital bed between the census taking hours on 2 successive days. The day of discharge is not counted unless a patient was admitted and discharged on the same day. If a patient is admitted and discharged on the same day, it is counted as one patient day.

DAILY PATIENT LOAD--DAILY CENSUS. The number of inpatients occupying beds in the hospital at a given time.

AVERAGE DAILY CENSUS--AVERAGE DAILY PATIENT LOAD (ADPL). The average number of inpatients occupying beds in the hospital each day for a given period of time. ADPL = [(patients at the census hour prior to beginning of period being averaged by number of admissions for the period minus discharges for the period divided by the number of days in the period)].

PERCENTAGE OF OCCUPANCY.  The ratio of actual patient days to the maximum patient days possible or bed count days as determined by bed capacity over a given period of time. The IBS, unlike the AHA, figures this based on patient days of care rather than discharge days. Overtime this should make little or no difference.

Percent Occupancy = (patient days of care divided by bed count days times 100 percent)

AVERAGE LENGTH OF STAY. The average number of days of service rendered to each inpatient discharged during a given period.

AMBULATORY PATIENT CARE (APC) ENCOUNTER. An Ambulatory Patient Care record is required for an encounter between a patient and health care provider in an organized clinic within an IHS facility (including covered contractors) where services resulting from the encounter are not part of an inpatient stay. The patient or his/her representative (representative only to pick up prescription) must be physically present at the time of service. Also, a note must be written in the medical record by a licensed, credentialed, or other provider qualified by the medical staff or facility administrator.

FIRST VISIT. The first ambulatory care visit for an episode of care.

REVISIT. The second or subsequent ambulatory care visit for the episode of disease or condition treated.

PRENATAL VISIT. A prenatal patient will be considered once as a "prenatal first visit" during each pregnancy. All other prenatal visits are considered "revisits." Examinations performed within eight weeks following delivery are considered postpartum.

IMMUNIZATION.  The process of rendering a patient immune to a disease.

CATEGORIES OF DEATH:

ANESTHETIC - Death occurring on the operating table and caused by anesthetic agents, not surgical complications.

FETAL - (See number 11 above of this Appendix.)

INFANT DEATH - Infant death is the death of a liveborn infant at any time from the moment of birth to the end of the first year of life.

INSTITUTIONAL OR HOSPITAL DEATH - One occurring in the hospital after admission.

NEONATAL - Infant death occurring in the first 27 days, 23 hours, and 59 minutes of life.

MATERNAL DEATH - Maternal death is the death of any woman, from any cause, while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy.

For world statistical evaluation, it is necessary to divide the 42 days into two periods:

Period I - 1 to 7 days after termination of pregnancy.

Period II - 8 to42 days after termination of pregnancy.

Deaths resulting from abortion are also classified as maternal deaths.

POSTOPERATIVE - Death occurring within the first ten days postoperatively.

EMERGENCY. Any medical condition for which immediate medical attention is necessary to prevent the death or serious impairment of the health of an individual.

HOSPITAL INFECTION. Invasion of the body by pathogenic microorganisms and reaction of the tissue to their presence and to the toxins generated by them, occurring after the patient was admitted to the hospital and under circumstances which should have been prevented by the hospital.

OBSTETRICAL OR PUERPERAL MORBIDITY. A temperature of 100.4 F. (38 C) occurring on any  two of the first 10 days postpartum, exclusive of the first 24 hours, may constitute febrile morbidity. The diagnosis of morbidity should be accompanied by a statement of causative factors when possible.

POSTOPERATIVE INFECTION. Infection occurring in a clean surgical case.

OPERATION. An operation is surgery performed in the operating room. A given operation may consist of several procedures.

POSTMORTEM EXAMINATION, AUTOPSY, NECROPSY. The scientific examination of a body after death to determine the direct, indirect, or contributory causes of death through a study of the physiologic, histologic, and pathologic characteristics of organs and their structure.

STERILIZATION. Any procedure by which an individual is made incapable of reproduction, such as castration, vasectomy, salpingectomy oophorectomy, and hysterectomy.

INTRAHOSPITAL TRANSFER. A change in medical care unit, medical staff unit, or responsible physician, of an inpatient during hospitalization.

MEDICAL CONSULTATION.  The response by one member of the medical staff to a request for consultation by another member of the medical staff, characterized by review of the patient's history, examination of the patient, and completion of a consultation report giving recommendations and/or opinions.

DIAGNOSES.

DIAGNOSIS: A disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care.

ADMITTING DIAGNOSIS: The reason for admission.

PREOPERATIVE DIAGNOSIS: The reason for surgery of the expected findings upon surgery.

POSTOPERATIVE DIAGNOSIS: The clinical findings of the surgery.

PATHOLOGICAL DIAGNOSIS: A description of the morphology, or cellular characteristics, of the tissue removed during surgery.

PRINCIPAL DIAGNOSIS: The condition established after study to be chiefly responsible for occasioning the admission of the patient t the hospital for care.

PRIMARY DIAGNOSIS: The most important or significant condition of a patient in terms of its implications for the patient's health, medical care, and use of hospital resources.

SECONDARY DIAGNOSES: Complications and/or comorbidities.

Complication: A condition arising during the hospitalization that modifies the course of the patient's illness or the medical care required.

Cormorbidity: A condition existing at the time of hospitalization which has potential for affecting the course of illness or medical care provided.

NOTE: Refer to the American Medical Record Association's Glossary of Hospital Terms.