complexity of the case, the selection will be a matter of judgment. The cause of
admission diagnosis should be the first diagnosis entry on the Inpatient Treatment
Record Cover Sheet and coded in Field 38 of the Admission and Coding Form.
(3) Recording of operations and special procedures. Date and record all
operations and procedures performed during the current hospitalization, including those
performed prior to transfer into your MTF. Record the principal procedure first,
regardless of the date it was performed. Record only "exchange" and "intrauterine"
transfusions in Item 34.
(4) Residual disability. Leave this field blank.
(5) Special information on death. For cases terminating in death, all
conditions found to have been present during the period of treatment, even though
established after death, must be recorded with the notation "Established postmortem,"
when appropriate. In cases of suicide, homicide, or death by legal execution,
information characterizing the death will be included in addition to the required
(6) Deliveries. The mother's record should include the following:
(a) Presentation of each fetus with indication of live birth or stillbirth
except in case of a delivery by cesarean section. Terminology for recording
presentation of fetus can be found in The Standard Nomenclature of Diseases and
(b) Previous Cesarean section, if any.
(c) Duration of pregnancy in weeks.
(d) The cause of fetal death and birth weight in the case of a stillbirth.
(7) Liveborn infants - additional information. A separate Inpatient Treatment
Record is required for each infant born in the reporting MTF. Record the following on
(a) Whether the infant is a single birth or one of multiple births. If the
latter, indicate also whether all mates were liveborn or if one or more were stillborn.
(b) Gestational age and birth weight. Record birth weight in grams.
(8) Drug overdoses. The Inpatient Treatment Record Cover Sheet on
overdose cases must include all sufficient information to apply the coding principles
outlined in Appendix A. (See principle IV Adverse Effects of Drug and E Codes.)