CMS Death Record Review Data Sheet {CMS-726}

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0378 CMS DEATH RECORD REVIEW DATA SHEET Patient Record Number Date of Admission Date of Birth Date of Death Psychiatric Diagnosis Physical Diagnosis Cause of Death Autopsy (Review autopsy report if available) Mortality Board Review (Please note conclusions and recommendations) Was proper treatment provided? Describe below any deficiencies found. According to the Paperwork Reduction Act of 1995, no persons are require d to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0378. The time required to complete this information collection is estimated to average .25 hours (or minutes) per response, including the time to review instructions, search existing data resource s, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions fro imp roving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. FORM CMS-726 (09/94) (OPTIONAL)