1

MEDICAL RECORD NUMBER

20

2

PATIENT LAST NAME

20

Y

3

PATIENT FIRST NAME

20

Y

4

PATIENT MIDDLE NAME

20

5

ACCOUNT NUMBER

20

Y

6

BIRTH DATE

10

MM/DD/YYYY

7

SEX

1

M or F

8

SOCIAL SECURITY NUMBER

12

999-99-9999

9

VISIT DATE

10

MM/DD/YYYY

10

DISCHARGE DATE

10

MM/DD/YYYY

11

DOCTOR 1 CODE

8

12

DOCTOR 1 NAME

40

13

DOCTOR 2 CODE

8

14

DOCTOR 2 NAME

40

15

PATIENT SERVICE

10

16

LOCATION

20

17

EXTRA

30

18

FACILITY CODE

15

19

DOCTOR 3 CODE

8

20

DOCTOR 3 NAME

40

21

EXTERNAL ID

15

22

PATIENT TYPE

10