NHAMCS-101 National Hospital AmbulatoryMedical Care Survey -- 2009

Form Approved OMB No. 0920-0278

NOTES

NOTICE –Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).
Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held
confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or
released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act
(42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

1. Label

NHAMCS-101
(7-11-2008)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

NATIONAL CENTER FOR HEALTH STATISTICS
CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2009 PANEL

2a. Hospital contact information

b. ED contact information

Name

Name

Title

RECORD ON
CONTROL CARD

Telephone number
(Area code and number)
FAX number

Title
Telephone number
(Area code and number)

RECORD ON
CONTROL CARD

FAX number

c. OPD contact information

d. ASC contact information
Name

Name
Title

RECORD ON
CONTROL CARD
RECORD ON
CONTROL CARD

Telephone number
(Area code and number)
FAX number

Title
Telephone number
(Area code and number)

RECORD ON
CONTROL CARD

FAX number

Section I – TELEPHONE SCREENER

3. Field representative

4. Record of telephone calls

information

Call

Date

Time

Results

FR Code

Telephone screener
Hospital induction
ED induction
OPD induction
ASC induction

1
FR Code
2
FR Code

3

FR Code

4

FR Code

5
6

5. Final outcome of hospital screening
1

Appointment
Day

2

Page 24

FORM NHAMCS-101 (7-11-2008)

Date

Time

a.m.
p.m.

Noninterview – Complete sections VI and VII, beginning on page 21.

USCENSUSBUREAU

During your initial call to the hospital, attempt to speak to
the contact person. If the contact person is not available
at this time, determine when he/she can be reached and
call again at the designated time. If, after several
attempts, you are still unable to talk to the contact or
have determined the contact is no longer an appropriate
respondent, begin the interview with a representative of
the contact person or new contact, as appropriate.

Section I – TELEPHONE SCREENER – Continued

NOTES

Part A. INTRODUCTION
Good (morning/afternoon) . . ., my name is (Your name). I am calling for the Centers for Disease
Control and Prevention concerning their study of hospital outpatient and emergency
departments and hospital-based ambulatory surgery centers. You should have received a
letter from Dr. Edward J. Sondik, the director of the National Center for Health Statistics,
describing the study. (Pause) You’ve probably also received a letter from the Census Bureau,
which is collecting the data for the study.

6. Did you receive the letter(s)?
(If "No" or "DK," offer to send or deliver another copy)

1
2
3

7a. Let me verify that I have the correct name
and address for your hospital. Is the correct
name (Read name from control card.)?

1
2

Yes – SKIP to STATEMENT A
No
Don’t know
Yes
No – Enter correct name

RECORD ON CONTROL CARD
b. Is your hospital located at (Read address from
control card.)?

1
2

Yes
No – Enter hospital location

Number and street

RECORD ON CONTROL CARD
City State ZIP Code

c. Is this also the mailing address?

1
2

Yes
No – Enter correct mailing address

Number and street

RECORD ON CONTROL CARD
City State ZIP Code
STATEMENT
A

(Although you have not received the letter), I’d like to briefly explain
the study to you at this time and answer any questions about it.

NOTES

Page 2

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 23

Section I – TELEPHONE SCREENER – Continued

Section VII – NONINTERVIEW

18. Where did the nonresponse occur?

Hospital – Ask item 19
Emergency service area(s)
SKIP to item 20
Clinic(s)
ASC

1

}

2

Mark (X) boxes 2, 3, and 4 if applicable.

3
4

19. What is the reason the hospital did not

}

Hospital closed
END INTERVIEW
Hospital not eligible
Hospital refused – SKIP to item 20
Other – Specify

1

participate in this study?

2
3
4

Part B. VERIFICATION OF ELIGIBILITY
CHECK
ITEM A

1
2

This hospital was in a previous panel – Read INTRODUCTION STATEMENT B1
This hospital is being asked to participate in the study for the FIRST time – Read INTRODUCTION
STATEMENT B2

INTRODUCTION
STATEMENT B1

Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included your
hospital in the study. First, concerning licensing:

END INTERVIEW

20a. At what point in the interview

ED

Hospital

did the refusal/breakoff occur?
Mark (X) appropriate box(es)
(1) During the telephone
screening

OPD

ASC

INTRODUCTION
STATEMENT B2

1

(2) During the hospital induction
(3) During the ED/OPD/ASC
induction
(4) After the ED/OPD/ASC
induction, but prior to
assigned reporting period
(5) During the assigned
reporting period

The National Center for Health Statistics of the Centers for Disease
Control and Prevention is continuing its annual study of hospital-based
ambulatory care. We contacted your hospital previously regarding
participation. Collecting data on an annual basis in hospitals, such as
your own, is necessary to keep updated information on the status of
ambulatory care provided in the hospital environment.

2

3

3

3

3

4

4

4

4

5

5

5

5

The National Center for Health Statistics of the Centers for Disease
Control and Prevention is conducting an annual study of hospital-based
ambulatory care. The study began data collection in 1992. They have
contracted with the Census Bureau to collect the data. (Name of hospital)
has been selected to participate in the study. I am calling to arrange an
appointment to discuss this hospital’s participation. The study is
authorized under the Public Health Service Act and the information will
be held strictly confidential. Participation is voluntary.
Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included this hospital
in the study. First, concerning licensing:

8a. Is this facility a licensed hospital?

1
2

b. By whom?

b. Is this hospital voluntary non-profit,

(1) Hospital administrator

1

1

1

1

2

2

2

3

3

3

1

government, or proprietary?
2

(2) ED/OPD/ASC director
(3) Approval board or official

3

(4) Other hospital official

4

4

4

4

Specify

Specify

Specify

Specify

c. Is this hospital owned, operated, or
managed by a health care corporation that
owns multiple health care facilities (eg.,
HCA or Health South)?

d. Is this a teaching hospital?
5
6

Telephone
In person

Telephone
In person

5
6

Telephone
In person

5
6

Telephone
In person

5
6

e. Has this hospital either merged with or
separated from any OTHER hospital in the
past 2 years?

c. What reason was given? Please specify hospital, ED, OPD, or ASC (from item 20a) before recording responses.

Proprietary (includes individually or privately
owned, partnership or corporation)

1

Yes
No
Unknown

2
3

1

records department that is separate from
that of the OTHER hospital?

g. What is the name and address of this
OTHER hospital?

d. Was conversion attempted?

Hospital

ED

OPD

1
2
3
4

f. Does YOUR hospital have its own medical

Nonprofit (includes church-related, nonprofit
corporation, other nonprofit ownership)
State or local government (includes state, county, city,
city-county, hospital district or authority)

3

2

(5) Was the refusal by
telephone or in person?

Yes
No – SKIP to CHECK ITEM B on page 4

1
2
3

Yes
No
Yes, merged
Yes, separated
No
SKIP to item 9 on page 4
Unknown

}

Yes
No
Unknown

Hospital name
Number and street

ASC

City State
1
2

Page 22

Yes
No

1
2

Yes
No

1
2

Yes
No

1
2

RECORD ON
CONTROL CARD

ZIP Code

Yes
No

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 3

Section VI – DISPOSITION AND SUMMARY

Section I – TELEPHONE SCREENER – Continued

AMBULATORY UNIT CHECKLIST

Part B. VERIFICATION OF ELIGIBILITY

9a. Does this hospital provide emergency
services that are staffed 24 HOURS each day
either here at this hospital or elsewhere?

b. Does this hospital operate any emergency
service areas that are not staffed 24
HOURS each day?

c. What is the trauma level rating of this
hospital?

1
2

1
2

1
2

10a. Does this hospital operate an organized
outpatient department either at this
hospital or elsewhere?

b. Does this OPD include physician services?

1
2

1
2

Yes
No

1
2

3
4
5

Level I
Level II

Level III
Level IV or V

3
4

5
6

Other/unknown
None

Did you include a NHAMCS-101(U)
for each?

1
2

• COMPLETE 16b FOR OUTPATIENT
DEPARTMENT ONLY

Yes
No

b. How many clinics were selected for sample?

Number of Clinics

Enter 0 if no clinics were selected for sample.

}

Did you include a NHAMCS-101(U)
for each?
SKIP to CHECK ITEM B-1

ASC meets eligibility requirements (item 10c is YES) . . . . . . . . . .
Hospital is ineligible because it is not licensed (item 8a is NO) – Go to CLOSING
STATEMENT B1 below.
Hospital is ineligible because it has NEITHER an ED nor OPD nor ASC (items 9a, 9b,
10a, 10c, and/or 10b are NO) – Go to CLOSING STATEMENT B2 below.

Yes – SKIP to item a
No – SKIP to Part C. STUDY DESCRIPTION on page 5
2
a. Determine whether hospital has an eligible ED and if so,
inquire as to how many visits are expected during the
reporting period.

Did you include a NHAMCS-101(U)
for each?

1

b. Determine whether hospital has an eligible OPD and if
so, inquire as to how many visits are expected during
the reporting period.

2

Yes
No – Explain

Number of ASCs
1
2

Yes
No – Explain

Eligible ED?
1

Yes –
No

expected visits

Eligible OPD?
1
2

c. Determine whether hospital has an eligible ASC and if
so, inquire as to how many visits are expected during
the reporting period.

1

• COMPLETE 16c FOR AMBULATORY
SURGERY CENTER ONLY
c. How many ASC areas were selected for sample?
Enter 0 if no ASCs were selected for sample.

Hospital refused

2

Yes –
No

expected visits

Eligible OPD?
1
2

Yes –
No

expected visits

FORMS COMPLETED

d. Number of ED Patient Record Forms completed

Number of ED PRFs

e. Number of OPD Patient Record Forms completed

Number of OPD PRFs

f. Number of ASC Patient Record Forms completed

Number of ASC PRFs

17a. FINAL DISPOSITION

d. If unable to determine expected visits for the assigned reporting period, obtain the number of
visits to the department last year.
OPD visits
last year

1
2

ASC visits
last year

3
4
5

NOTES

b. NATURE OF REFUSAL
Mark (X) all that apply.

1
2
3
4
5
6

All eligible units completed
END interview
Patient Record Forms
Some eligible units completed
GO to Item 17b
Patient Record Forms
Hospital refused
Complete Section VII,
Hospital closed
NONINTERVIEW on page 22
Hospital ineligible

}
}

}

Entire ED refused
Entire OPD refused
Entire ASC refused
Some ESAs refused
Some clinics refused
Some ASCs refused

FR NOTE – If one or more responses are marked in 17b, complete Section VII,
NONINTERVIEW on page 22 If no responses marked, END INTERVIEW.

Go to Section VII, NONINTERVIEW on page 22.
Page 4

Yes
No – Explain

Yes
No – SKIP to CHECK ITEM B

ED meets eligibility requirements (item 9a is YES) . . . . . . . . . . . .
OPD meets eligibility requirements (item 9a is NO
and item 9b is YES, or items 10a and b are YES) . . . . . . . . . . . . .

ED visits
last year

Number of ESAs

Enter 0 if no ESAs were selected for sample.

Mark (X) all that apply.

CHECK
ITEM B

CHECK
ITEM
B-1

• COMPLETE 16a FOR EMERGENCY
DEPARTMENT ONLY
16a. How many emergency service areas
were selected for sample?

Yes – SKIP to item 9c
No

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 21

Section I – TELEPHONE SCREENER – Continued

Section V – AMBULATORY SURGERY CENTER DESCRIPTION – Continued
Now I would like to ask you some questions about your ASC.

15c. Does your ASC use ELECTRONIC MEDICAL
RECORDS (EMR) (not including billing
records)?

Yes, all electronic
Yes, part paper and part electronic
No
Unknown

1
2
3
4

Yes

d. Does your ASC have a computerized

No

Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) is not a licensed hospital it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
sections VI and VII beginning on page 21.

CLOSING
STATEMENT
B1

Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) does not have 24-hour emergency services, outpatient clinics, or
ambulatory surgery centers, it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
sections VI and VII beginning on page 21.

CLOSING
STATEMENT
B2

Unknown

Turned off

system for –
(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?

1

2

3

4

1

2

3

4

Thank you. Now I would like to provide you with further information on the study.

(2) Orders for prescriptions?
1

If "Yes," ask –

Part C. STUDY DESCRIPTION

2

3

4

INSTRUCTIONS
Provide the administrator or other hospital representative with a brief description of the study.
Cover following points –
(1) The NHAMCS is the only source of national data on health care provided in hospital emergency and
outpatient departments

(a) Are there warnings of
drug interactions or
contraindications
provided?

1

2

3

4

(b) Are prescriptions sent
electronically to
the pharmacy?

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

(3) Orders for tests?
If "Yes," ask – Are orders sent
electronically?
(4) Viewing of lab results?
If "Yes," ask – Are out of range levels
highlighted?
(5) Viewing of imaging results?
If "Yes," ask – Can electronic images be
viewed?

(2) NHAMCS is endorsed by the:
• American College of Emergency Physicians
• Emergency Nurses Association
• Society for Academic Emergency Medicine
• American College of Osteopathic Emergency Physicians
• Federation of American Hospitals
• Ambulatory Surgery Center Association
• American College of Surgeons
• American Health Information Management Association
• American Academy of Ophthalmology
• Society for Ambulatory Anesthesia
(3) Nationwide sample of about 600 hospitals
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits
As one of the hospitals that has been selected for the study, your contribution will be of
great value in producing reliable, national data on ambulatory care.

(6) Clinical notes?
If "Yes," ask – Do they include medical
history and follow-up notes?
(7) Reminders for guideline-based
interventions and/or screening tests?
(8) Public health reporting?
If "Yes," ask – Are notifiable diseases
sent electronically?

e. Are there any of the above features of your
system that your ASC does NOT use or has
turned off?

1

2
3

f. Are there plans for installing a new EMR
system or replacing the current system
within the next 3 years?

1
2
3
4

Page 20

Yes – Please specify

FR NOTE – Indicate in item 14d, last column,
any component(s) turned off.
No
Unknown

CHECK
ITEM
B-2

Hospital HAS MERGED with or SEPARATED from another in the past two years? (Item 8e is YES.)
1
2

Yes – Go to CLOSING STATEMENT C1 below.
No – Go to CLOSING STATEMENT C2 below.

CLOSING
STATEMENT
C1

Since your hospital has merged or separated within the last 2 years, I need to
get further instructions from the Centers for Disease Control and Prevention
(CDC) on how to proceed. I will call you back within a week and let you know
which parts of your hospital will be in the survey. Thank you for your
cooperation! Telephone your Regional Office to report the Hospital Name and ID Number.

CLOSING
STATEMENT
C2

I would like to arrange to meet with you so that I can better present the details
of the study. Is there a convenient time within the next week or so that I could
meet with you or your representative?
Thank you . . . for your cooperation. I am looking forward to our meeting. Record
day, date and time of appointment in item 5, page 1; and terminate telephone call.

NOTES

Yes
No
Maybe
Unknown
FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 5

Section II – INDUCTION INTERVIEW

Section V – AMBULATORY SURGERY CENTER DESCRIPTION

Part A. INTRODUCTION

CHECK
ITEM E

1
2

I would like to begin with a brief review of the background for this study.

INSTRUCTIONS
Provide the administrator or other hospital representative with a brief introduction to the study
and a general overview of procedures.

Hospital has at least one ASC.
Hospital does not have any ASCs – SKIP to Section VI, DISPOSITION AND SUMMARY on page 21.

To develop the sampling plan, I would like to (collect/verify) more specific
information about this hospital’s ambulatory surgery center(s).
(1) Obtain an estimate of ambulatory (outpatient) surgery cases for each ASC, covering the
4-week period. Enter the estimate in column (c) of the listing below.
(2) After obtaining the answer to item 15b, mark (X) column (b) of the listing below indicating if
the ASC is included in a single electronic log/list.

Cover the following points –
(1) NHAMCS is an extension of the National Ambulatory Medical Care Survey (NAMCS). The NAMCS
collects data on visits to physicians in office-based practices

FR
NOTE

(2) NAMCS and NHAMCS are sponsored by the National Center for Health
Statistics of the Centers for Disease Control and Prevention
(3) NAMCS and NHAMCS data are used extensively by health services
planners, researchers and educators

ASC locations:
• General or main operating room
• Dedicated ambulatory surgery room
• Satellite operating room

• Cystoscopy room
• Endoscopy room
• Cardiac catheterization lab

• Laser procedures room
• Pain block room

INSTRUCTIONS
• Only record generic ASC names in column (a) (e.g., ambulatory surgery center, cardiac cath). If the ASC has a
formal/proper name, enter a generic ASC name in (a) and record the Line No. and the formal/proper name on page
2 of the control card.
• Complete columns (d) and (e) after developing the sampling plan. See page 18 of the NHAMCS-124
for instructions.

(4) Annually, there are almost 200 million visits to hospital emergency and outpatient departments
and 20 million visits to hospital-based amublatory surgery centers
(5) Census Bureau is acting as the data collection agent for the study
(6) The study is authorized by Title 42, U.S. Code, Section 242k

Line
No.

ASC name
(Generic)

(7) Participation is voluntary

Log included
in single
log/electronic list

Expected No. of ambulatory (outpatient)
surgery cases

Take
every
number

Random
start
number

(d)

(e)

from __________ to __________

(8) All information, including the name of hospital, is held in strict confidence

(a)

(b)

(c)

1

(9) NO patients’ names or identifiers are collected
(10) The study was approved by the NCHS Research Ethics Review Board

2

(11) Data from the study will be used only in statistical summaries

3

(12) NHAMCS covers hospital facilities on and off hospital grounds

4

(13) NHAMCS covers care provided by or under the direct supervision of a physician

5

(14) NHAMCS excludes office-based physicians (these are covered under the NAMCS)

6

(15) NHAMCS excludes visits to clinics where only ancillary services are provided, e.g., X-ray,
laboratories, and pharmacies, and where physician services are not provided, e.g., physical,
speech, and occupational therapy, and dental and podiatry clinics.

7
8

(16) For the first time, we are including ambulatory surgery visits in the survey

TOTAL

(17) Only a 4-week data collection period
(18) On average, sample of approximately 100 ED, 150 to 200 OPD, and 100 ASC visits per hospital
SHOW PATIENT RECORD FORMS

15a. Now I have some questions about generating a report for all outpatient surgery patients
for sampling.
Would you or your IT staff be able to
generate a single list of outpatient surgery
cases for the following locations?
(Read each ASC name listed above.)

(19) Form takes only 6 or 7 minutes to complete
(20) Forms to be completed by hospital staff at their convenience

1
2
3

b. Would you be able to generate one list of

(21) Portion containing patient’s name or other identifying information is removed before collecting

outpatient surgery cases for some of
these locations?

1
2

Page 6

}

Yes
SKIP to item 15c
No – ONLY 2 LOGS
No – More than 2 logs – Continue with item 15b.

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Yes – Which ones? (Mark (X) column (b) in the
listing above next to each log/list mentioned.)
No – Continue with item 15c.
Page 19

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION

Section II – INDUCTION INTERVIEW – Continued

Now I would like to ask you some questions about your OPD.

14t. Does your OPD use ELECTRONIC MEDICAL
RECORDS (EMR) (not including billing
records)?

CHECK
ITEM B3

Yes, all electronic
Yes, part paper and part electronic
No
Unknown

1
2
3
4

Yes

u. Does your OPD have a computerized

No

1
2

CHECK ITEM B = 1 (ED meets eligibility requirements)
CHECK ITEM B = 2, 3, or 4 (ED does NOT meet eligibility requirements) – SKIP to Item 12 on page 8.

Now I would like to ask you a few more
questions about your hospital.

Unknown

Turned off

system for –

11a. How many days in a week are inpatient
elective surgeries scheduled?
Number of days

(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?

1

2

3

4

1

2

3

4

b. Does your hospital have a bed coordinator,
sometimes referred to as a bed czar?

(2) Orders for prescriptions?

Unknown

1

Yes
No
Unknown

2
3

1

If "Yes," ask –

1

2

3

4

c. How often are hospital bed census data

(a) Are there warnings of
drug interactions or
contraindications
provided?

available?
1

(b) Are prescriptions sent
electronically to
the pharmacy?

2

3

4

Read answer categories.

1
2
3
4
5
6

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

7

Instantaneously
Every 4 hours
Every 8 hours
Every 12 hours
Every 24 hours
Other
Unknown

(3) Orders for tests?
If "Yes," ask – Are orders sent
electronically?

NOTES

(4) Viewing of lab results?
If "Yes," ask – Are out of range levels
highlighted?
(5) Viewing of imaging results?
If "Yes," ask – Can electronic images be
viewed?
(6) Clinical notes?
If "Yes," ask – Do they include medical
history and follow-up notes?
(7) Reminders for guideline-based
interventions and/or screening tests?
(8) Public health reporting?
If "Yes," ask – Are notifiable diseases
sent electronically?

v. Are there any of the above features of your
system that your OPD does NOT use or has
turned off?

1

Yes – Please specify

FR NOTE – Indicate in item 14u, last column,
any component(s) turned off.
2
3

w. Are there plans for installing a new EMR
system or replacing the current system
within the next 3 years?

1
2
3
4

Page 18

No
Unknown
Yes
No
Maybe
Unknown
FORM NHAMCS-101 (6-26-2008)

FORM NHAMCS-101 (6-26-2008)

Page 7

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued

Section II – INDUCTION INTERVIEW – Continued
Part B. SURVEY IMPLEMENTATION
As I mentioned earlier, I would like to discuss the plan for conducting the study. This hospital has

CHECK
ITEM D

1
2

been assigned to a 4-week data collection period beginning on Monday, ( _____ / _____ ).
Month

Day

12. Are there any additional steps needed to obtain permission for the hospital to

and
1

participate in the study?
2

Is the total number of expected OPD visits during the reporting period between
CHECK
ITEM D1

First, I would like to discuss the steps needed to obtain approval for the study.

1

At least one OPD Clinic in-scope.
All OPD Clinics out-of-scope – SKIP to Section V, AMBULATORY SURGERY CENTER
DESCRIPTION on page 19.

2

Yes – Specify the necessary steps below
No

3

?

Yes – SKIP to 14t on page 18.
No, it is MORE THAN the range – GO to item a
No, it is LESS THAN the range – SKIP to item c
a. Compare to previous sampling plan. Are there more clinics this year compared to last year? (If "Yes"
then verify scope and ownership of the new clinics this year, make changes if needed, and then check
one of the following responses.)
1

2

Yes, this is correct, some clinics have opened or should have been included last year. – List

No, the number of clinics has not increased.

b. Is the number of expected visits to any of the clinics more than twice the number shown on last year’s
sampling plan?
1

Yes, this is correct, visits have increased this year or were too low last year. – Explain

2

No, the number of visits has not increased dramatically.

✰ SKIP to item 14t on page 18

c. Compare to previous sampling plan. Are there fewer clinics this year compared to last year?
1

Yes, this is correct, some clinics have closed or shouldn’t have been included last year. – List

2

No, the number of clinics has not decreased.

d. Is the number of expected visits to any of the clinics less than half of the number shown on last year’s
sampling plan?

Page 8

FORM NHAMCS-101 (7-11-2008)

1

Yes, this is correct, visits have decreased this year or were too high last year. – Explain

2

No, the number of visits has not decreased dramatically.

FORM NHAMCS-101 (7-11-2008)

Page 17

Section II – INDUCTION INTERVIEW – Continued

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
FR
NOTE

OPD Specialty Groups include:
• GM – General Medicine
• PED – Pediatrics
• SURG – Surgery
• OBG – Obstetrics/Gynecology

13. Now I would like to make arrangements to

• SA – Substance Abuse
• OTHER – Other

INSTRUCTIONS
• Only record generic clinic names in column (a) (e.g., pediatric clinic). If the clinic has a formal/proper name, enter a
generic clinic name in (a) and record the Line No. and the formal/proper name on page 2 of the control card.
• Complete columns (b) and (c) using pages 7 to 17 of the NHAMCS-124, Sampling and Information Booklet.
Complete columns (e) and (f) after developing the sampling plan. See page 4 of the NHAMCS-124 for instructions.

Line
No.

Outpatient department clinic name
(Generic)
(a)

Specialty
group

NHAMCS-124
Speciality
Group Scope

(b)

(c)

1

In-Scope
Out-of-Scope

2

In-Scope
Out-of-Scope

3

In-Scope
Out-of-Scope

4

In-Scope
Out-of-Scope

5

In-Scope
Out-of-Scope

6

In-Scope
Out-of-Scope

7

In-Scope
Out-of-Scope

8

In-Scope
Out-of-Scope

9

In-Scope
Out-of-Scope

10

In-Scope
Out-of-Scope

11

In-Scope
Out-of-Scope

12

In-Scope
Out-of-Scope

13

In-Scope
Out-of-Scope

14

In-Scope
Out-of-Scope

15

In-Scope
Out-of-Scope

Expected No. of visits
from __________ to __________

Take
every
number

Random
start
number

(d)

(e)

(f)

obtain the information needed for sampling.
I will need to (know/verify) how your
(emergency department/(and), outpatient
department/(and), ambulatory surgery
center) (is/are) organized and obtain an
estimate of the number of patient visits
expected during the 4-week reporting
period. Would you prefer I (get/verify) this
information from you or someone else?

1
2

Respondent – Go to CHECK ITEM C below
Someone else – Specify below
If different respondent(s), arrange to obtain data
today if possible. Otherwise arrange an appointment
with designated person(s). Briefly explain the study to
the new respondent(s). Then proceed with Section III,
Emergency Department Description, Section IV,
Outpatient Department Description, or Section V,
Ambulatory Surgery Center Description as
appropriate. Thank current respondent for his/her
time and cooperation.

Name
Title
Department

Record on
Control Card

Telephone number
Name
Title
Department

Record on
Control Card

Telephone number

CHECK
ITEM C

1

The hospital provides emergency services that are staffed 24 hours each day. (Yes in item 9a) –
GO to Section III, EMERGENCY DEPARTMENT DESCRIPTION on page 10.

2

The hospital DOES NOT provide emergency services that are staffed 24 hours each day. (No in
item 9a) – SKIP to Section IV, OUTPATIENT DEPARTMENT DESCRIPTION on page 15.

NOTES

TOTAL

Page 16

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 9

Section III – EMERGENCY DEPARTMENT DESCRIPTION

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION

To develop the sampling plan, I would like to (collect/verify) more specific information about this
hospital’s emergency department.
(1) If the hospital has previously participated, simply verify that the emergency service area(s) (ESA)
listed below is (are) still operating in the hospital by –

(1) If the hospital has previously participated, simply verify that the clinic(s) listed on page 16 is
(are) still operating in the hospital by –

(a) crossing through any ESAs on the list that no longer exist or are no longer operational in that hospital.
(b) adding the name(s) of any new ESA(s) that have been created or have become operational in that hospital.
For each new ESA added to the list, be sure to obtain the proper type to be entered in column (b).
(c) obtaining an estimate of visits for each ESA, covering the 4-week reporting period. Enter the estimate in
column (c).
(2) If the hospital has not previously participated, obtain a complete listing of all eligible ESAs along
with their corresponding type and expected number of visits for each ESA during the 4-week
reporting period. Record this information in columns (a), (b), and (c) below.
INSTRUCTION:
• Only record generic ESA names in column (a) (e.g., pediatric emergency department). If the ESA has a
formal/proper name, enter a generic name in (a) and record the Line No. and the formal/proper name on
page 2 of the control card.
FR
NOTE
Line
No.

ESA types include:
• General
• PED
• Adult
• Urgi-/Fast track

• PSYC
• Trauma

ESA
type

(a)

(b)

(a) crossing through any clinics on the list which no longer exist or are no longer operational
in that hospital.
(b) adding the names of any new clinics which have been created or have become
operational in that hospital. For each new clinic added to the list, be sure to obtain the
proper specialty code. Remember, include only ELIGIBLE clinics.
(c) obtaining an estimate of visits for each clinic, covering the 4-week period. Enter the estimate
in column (c) of the attached listing.
(d) If this Outpatient Department has more than 5 clinics – FAX the updated list to
your regional office. The regional office will choose the clinics for sample and provide you with
the sampling instructions. Upon receiving the instructions, attach a copy of the completed clinic
listing showing sampled clinics, the Take Every and Random Start numbers, etc., to page 15 of
the NHAMCS-101, Questionnaire.
(2) If the hospital has not previously participated or a clinic list is not attached to this 101, obtain a
complete listing of all eligible outpatient clinics along with their corresponding specialty group
code, and expected number of visits for each clinic during the 4-week reporting period.
Record this information in columns (a), (b), and (d) on the next page.

• Other

Emergency service area name
(Generic)

To develop the sampling plan, I would like to (collect/verify) more specific
information about this hospital’s outpatient department.

Expected No. of visits
from __________ to __________

Take
every
number

Random
start
number

(c)

(d)

(e)

NOTES

1
2
3
4
5
6
7
8
9
10
TOTAL
INSTRUCTIONS – Complete columns (d) and (e) after developing the sampling plan. See page 2 of
the NHAMCS-124, Sampling and Information Booklet.
Page 10

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 15

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14q. Which of the following procedures does
your ED use?
Show flashcard on page 27 of the NHAMCS-124.
Mark (X) all that apply.

1
2
3
4
5
6

7
8

10

r. How many levels are in your ED’s nursing
(R.N. and L.P.N.) triage system?

1
2
3
4
5

s. Does your ED admit to hospitalist medicine
specialists, or "hospitalists?"

1
2
3

CHECK
ITEM C-2

1

2

Bedside registration
Computer-assisted triage
Separate fast track unit for nonurgent care
Separate operating room dedicated to ED patients
Electronic dashboard (i.e., displays updated patient
information and integrates multiple data sources)
Radio frequency identification (RFID) tracking (i.e.,
shows exact location of patients, caregivers, and
equipment)
Zone nursing (i.e., all of a nurse’s patients are
located in one area)
"Pool" nurses (i.e., nurses that can be pulled to the
ED to respond to surges in demand)
Full capacity protocol (i.e., allows some admitted
patients to move from the ED to inpatient corridors
while awaiting a bed)
None of the above

Is the total number of expected ED visits during the reporting period between
CHECK
ITEM C-1
and
?
1
2
3

Yes – SKIP to item 14a on page 12
No, it is MORE THAN the range – GO to item a
No, it is LESS THAN the range – SKIP to item b

a. Is the number of expected visits to any of the ESAs more than twice the number shown on last year’s
sampling plan?
1

Three
Four
Five
Other – Specify
Do not conduct nursing triage

2

Yes, this is correct, visits have increased this year or were too low last year. – Explain

No, the number of visits has not increased dramatically.

✰SKIP to item 14a on page 12

Yes
No
Unknown

b. Is the number of expected visits to any of the ESAs less than half of the number shown on last year’s
sampling plan?

The hospital has an organized outpatient department that provides physician services. (Yes in items 10a
and b) – SKIP to Section IV, OUTPATIENT DEPARTMENT DESCRIPTION on page 15.
The hospital does not have an organized outpatient department that provides physician services. (No in
items 10a or 10b) – SKIP to Section V, AMBULATORY SURGERY CENTER DESCRIPTION on page 19.

1

Yes, this is correct, visits have decreased this year or were too high last year. – Explain

2

No, the number of visits has not decreased dramatically.

NOTES

NOTES

Page 14

FORM NHAMCS-101 (7-11-2008)

FORM NHAMCS-101 (7-11-2008)

Page 11

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
Now I would like to ask you some
questions about your ED.

14a. Does your ED use ELECTRONIC MEDICAL
RECORDS (EMR) (not including billing
records)?

14e. Does your ED have a physically separate
Yes, all electronic
Yes, part paper and part electronic
No
Unknown

1
2
3
4

Yes

b. Does your ED have a computerized system

No

2
3

f. Do ED physicians make decisions for patients

1

in this observation or clinical decision unit?

Unknown

2
3

Turned off

for –

g. Are admitted ED patients ever "boarded" for

(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?

1

2

3

4

1

2

3

4

1

If "Yes," ask – (a) Are there warnings of
drug interactions or
contraindications
provided?

2

1

2

3

3

4

4

If "Yes," ask – Are orders sent
electronically?

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

(4) Viewing of lab results?
If "Yes," ask – Are out of range levels
highlighted?

1

2

3

4

1

2

3

4

(5) Viewing of imaging results?
If "Yes," ask – Can electronic images be
viewed?

1

2

3

4

(6) Clinical notes?
If "Yes," ask – Do they include medical
history and follow-up
notes?
(7) Reminders for guideline-based
interventions and/or screening tests?

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

(8) Public health reporting?
If "Yes," ask – Are notifiable diseases
sent electronically?
1

3

system or replacing the current system
within the next 3 years?

1
2
3

i. What is the total number of hours that your

j. Is ambulance diversion actively
managed on a regional level versus
each hospital adopting diversion if and
when it chooses?

k. Does your hospital continue to admit
elective or scheduled surgery cases when
the ED is on ambulance diversion?

1

1
2
3
4

1
2
3

1
2
3

treatment spaces did your ED have?
Standard treatment spaces are beds or treatment
spaces specifically designed for ED patients to
receive care, including asthma chairs.
treatment spaces did your ED have?
Other treatment spaces are other locations where
patients might receive care in the ED, including
chairs, stretchers in hallways that may be used
during busy times.

n. In the last two years, has your ED increased
the number of standard treatment spaces?

space been expanded?

Yes
No
Unknown
Yes
No
Unknown

Total number of hours
Data not available
ED did not go on ambulance
diversion in 2008 – SKIP to item 14l
Yes
No
Unknown
Yes
No
Unknown

Total number of other treatment spaces

1
2

1
2
3

p. Do you have plans to expand your ED’s
physical space within the next two years?

1
2
3

FORM NHAMCS-101 (7-11-2008)

Part of the ED
Part of the inpatient side of the hospital
Unknown

Total number of standard treatment spaces

3

Yes
No
Maybe
Unknown

}

m. As of last week, how many others

Yes – Please specify
FR NOTE – Indicate in item 14b, last column,
any component(s) turned off.
No
Unknown

Yes
No
SKIP to item 14g
Unknown

l. As of last week, how many standard

o. In the last two years, has your ED’s physical
2

d. Are there plans for installing a new EMR

3

2
1

(3) Orders for tests?

system that your ED does NOT use or has
turned off?

2

admitted ED patients ever "boarded" in
inpatient hallways or in another space
outside the ED?

hospital’s ED was on ambulance diversion
in 2008?

(b) Are prescriptions sent
electronically to
the pharmacy?

c. Are there any of the above features of your

1

more than 2 hours in the ED or the observation
unit while waiting for an inpatient bed?

h. If the ED is critically overloaded, are

(2) Orders for prescriptions?

Page 12

1

observation or clinical decision unit?

FORM NHAMCS-101 (7-11-2008)

Yes
No
Unknown
Yes – SKIP to item 14q
No
Unknown
Yes
No
Unknown

Page 13