Get Icd Registry V3 - Data Collection Form - Leads Only. Generator & Leads Data Collection Form

Filling out the ICD Registry V3 - Data Collection Form is essential for collecting accurate and comprehensive data related to leads in cardiovascular procedures. This guide provides a clear, step-by-step approach to assist users in completing the form accurately and efficiently.

Follow the steps to complete your form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin filling out Section A: Demographics. Enter the last name, first name, middle name, birth date, race, and sex of the patient. If applicable, check all relevant races and indicate if the patient identifies as Hispanic or Latino.
3. Proceed to Section B: Episode of Care (Admission). Record the arrival date and the reason for admission. Indicate the health insurance status and any applicable payment sources.
4. In Section C: History and Risk Factors, indicate whether the patient has a prior cardiovascular implantable electronic device. This includes any previously placed devices.
5. Move to Section F: Procedure Information. Fill in the procedure start and end dates/times, and select the procedure types such as initial generator implant, generator change, or lead only.
6. For Section H: Lead Assessment, fill out the operator’s name and NPI, the lead counter, and the details for each lead, specifying if it is new or existing. Include device ID, serial number, UDI, and lead location.
7. Complete Section I: Discharge. Fill in the discharge date and status, including whether the discharge is to home or other facilities. If applicable, indicate any medications prescribed at discharge.
8. Review all sections for accuracy. Once complete, you can save changes, download, print, or share the form as needed.

Take the next step and complete your document online today.