Section 1: (A) Patient record element/excerpt: (B)

Section 1: (A) Patient record element/excerpt: (B) Page #: (C) Title of form: (D) Related HIT role/responsibility: Date of Birth 1 Inpatient Face Sheet Release of Information ROI – verify data consistency Section 2: (A) Patient record element/excerpt: (B) Page #: (C) Title of form: (D) Related regulatory agency: Section 3: (A) Patient record element/excerpt: (B) Page #: (C) Title of form: (D) Related policy/standard: Section 4: (A) Patient record element/excerpt: (B) Page #: (C) Title of form: (D) Example of index, database, or registry that data could be used for Section 5: (A) Patient record element/excerpt: (B) Page #: (C) Title of form: (D) Who collected/recorded the information? (name and title) Section 6: Criteria/Design Element: Present in form (Yes/No): Explanation: SCIENCE HEALTH SCIENCE NURSING HITT 1301–46Z1

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