United States Health Information Knowledgebase

 

Patient Information Form (PIF)


Form ID: F2
Form Name: Patient Information Form (PIF)
Version: 1.2
Form Short Name: PIF
Synonym: PIF
Definition: The Patient Information Form (PIF) is used to collect demographic information as well as additional information about the impact of the event on a patient (e.g., level of harm, unplanned interventions). It supplements the HERF in cases where an incident is being reported.
Setting: Hospitals, including outpatient pharmacies and outpatient departments located within the hospital
Language: U.S. English
Guide For Use: Use this form only if you are reporting an incident. (When reporting a perinatal incident that affected a mother and a neonate, complete a PIF for the mother and a separate PIF for the neonate.)
When multiple patients are involved in an event, a separate event report should be completed for each patient. These reports can subsequently be linked at the local level.
The PIF contains information that is, or may be, identifiable to the patient, reporter, provider, and facility. This information may be transmitted to a PSO as patient safety work product, but it is confidential and prohibited from disclosure as delineated in the Statute and Regulations. It may not be transmitted to the NPSD.
Comments: None defined at this time
Description Of Change: Not Applicable
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE45 Patient age 1 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE48 Hispanic or Latino descent 2 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE51 Patient race 3 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE54 Principal diagnosis code at discharge 4 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE63 Rescue intervention attempted 5 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE66 Documented type of rescue intervention(s) 6 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE55 Extent of harm 7 Hospital Version 1.2 04/03/2012 - -
DE59 Anticipated harm duration 8 Hospital Version 1.2 04/03/2012 - -
DE60 Timing of harm assessment 9 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE69 Increased length of stay 10 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE72 Family or guardian notified 11 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
Effective Date: 04/01/2012
Until Date: - -
Update Date: 04/24/2013
Submitting Organization: Agency for Healthcare Research and Quality (AHRQ)
Date of Submission: - -
Responsible Organization: Agency for Healthcare Research and Quality (AHRQ)
Creator: Amy Helwig, MD, MS
Data Steward: Agency for Healthcare Research and Quality
References: Not Applicable
Administrative Status: Final
Administrative Status Date: 01/24/2014
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