Form NHAMCS 100 (ED) NHAMCS 100 (ED) ED Patient Record Form

NHAMCS-100(ED), (Cover, Page 2, and back cover), Pantone 479, 40% tone

Sun.
Total

NHAMCS-100(ED)

(6-5-2008)

USCENSUSBUREAU

FORM

No. of
records
filled

No. of
records
filled

Tues. Wed.

Thur.

Patient.

Fri.

Day

Sat.

Sun.

Centers for Disease Control and Prevention
National Center for Health Statistics

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

ACTING AS DATA COLLECTION AGENT FOR

U.S. CENSUS BUREAU

Economics and Statistics Administration

U. S. DEPARTMENT OF COMMERCE
AN

Total

V ICES U
SA
SER

Notice – Public reporting burden for this collection of information is estimated to average 6 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta,
GA 30333, ATTN: PRA (0920-0278).

Dates
W
E
E No. of
K patient
visits
4

Dates
W
E
E No. of
K patient
visits
2

Mon.

TO

Month

H EALT H & H
UM
OF
NT

E

NHAMCS-100(ED), (Cover, Page 2, and back cover), Solid Black

Sat.

No. of
records
filled

Fri.

No. of
records
filled

Thur.

Dates
W
E
E
K No. of
patient
3 visits

Tues. Wed.

Day

Patient. Take every

FROM:

Month

Please return the whole Folio with both the completed
and blank forms at the completion of the survey period.
Thank you!

Start with the

REPORTING
PERIOD

Dates
W
E
E
K No. of
patient
1 visits

Mon.

Ambulatory Unit Number

Hospital ID

2009 Emergency Department
Patient Record Folio

National Hospital
Ambulatory Medical
Care Survey

CENTERS FOR DISEASE CONTROL
AND PREVENTION

Form Approved: OMB No. 0920-0278

DEPAR
TM

2009 ED
TAKE EVERY:

Phone Number

Name

In case of questions or difficulty, please call the Field
Representative collect:

FORM NHAMCS-100(ED) (5-8-2008)

FIELD REP

DISPOSITION As each Patient Record is completed, place the combined form
(Patient Log and Patient Record) in the pocket of the kit. At the end
OF
of each day scan all forms to be sure they are properly completed,
MATERIALS
verify that the total number of completed Patient Records equals
the number appearing on the last completed Patient Record.
Check pages of the Patient Log against other record(s) (e.g.,
appointment book, billing records) to assure that every patient visit
was recorded on the Patient Log. At the end of the period, detach
patient’s name, place all Patient Records and all unused materials
in the postage paid envelope provided and mail to the interviewer.
(DO NOT RETURN THE DETACHED PAGES OF THE PATIENT
RECORD THAT CONTAIN THE PATIENT’S NAME).

2. A visit is a direct, personal exchange between an ambulatory
patient and a physician or hospital staff under a physician’s
supervision for the purpose of seeking care and rendering
personal health services.

1. An ambulatory patient is an individual presenting for personal
health services, not currently admitted to any health care
institution on the premises. Include patients the physician
sees; and patients the physician does not see but who receive
care from a physician assistant, nurse, nurse practitioner, etc.
Exclude persons who visit only for administrative reasons,
such as to complete an insurance form; patients who do not
seek care or services (e.g., pick up a prescription or leave a
specimen); persons currently admitted as inpatients to the
hospital (nursing home patients should be included,
however); and telephone contacts with patients.

DEFINITIONS For purposes of this study:

Please refer to the NHAMCS-122 Instruction Book for
more detailed information on the sampling pattern.

The START WITH designates the FIRST PATIENT for whom a
patient record should be completed. The TAKE EVERY designates
every patient thereafter for whom a patient record should be
completed. For example, for a Start With of 2 and Take Every of 3,
a patient record will be completed for the second patient listed on
the emergency department Sign-In Sheet and every third patient
listed thereafter (e.g., 2, 5, 8, etc.). It is essential that the Take
Every Number is extended each day from one Sign-In Sheet to
another. For example, If your emergency department uses a new
Sign-In Sheet each day, then the Take Every Number has to be
extended from the last patient visit selected on Monday to the new
list on Tuesday. If a single Sign-In Sheet is used the entire
reporting period, then the Take Every simply needs to be extended
as new patient names are added to the list.

START WITH:

Follow the Sampling Pattern below to determine for which visit(s) a
Patient Record should be completed.

PATIENT
RECORD

through Sunday,

Record the name of every patient seen during the Reporting
Period on a Sign-In Sheet maintained in each area of the
emergency department. Record each patient in the order
registered by your receptionist or seen by the provider. If two or
more patients are seen during a single provider visit, the patients
should be listed in the sequence registered or the sequence
seen. It is important to record every patient visit including those
not seen by the provider but attended to by the staff. Patients
who visit more than once during the reporting period should be
recorded on the Sign-In Sheet at each visit.

Monday,

Your reporting dates are:

PATIENT
SIGN-IN
SHEET

REPORTING
DATES

See card in pocket for instructions on how to complete
Patient Record.

GENERAL INSTRUCTIONS

Form Approved OMB No. 0920-0278

NHAMCS-100(ED)

U.S. DEPARTMENT OF COMMERCE

FORM
(6-5-2008)

Economics and Statistics Administration

U.S. CENSUS BUREAU

PATIENT RECORD NO.:

ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

PATIENT’S NAME:

NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2009 EMERGENCY DEPARTMENT PATIENT RECORD
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 persons engaged in and for the purpose of the survey and will not be disclosed or released to other persons or used
for any other purpose without consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act
(42 USC 242m).
(Provider: Detach and keep)

✗

Please keep (X) marks inside of boxes ➜

✗ Incorrect

Correct

1. PATIENT INFORMATION
a. Date and time of visit
Month

c. Date of birth
Month
Day

b. ZIP Code
Day

Time

p.m.

a.m.

Military

Year

:

(1) Arrival
Seen by
(2) MD/DO/PA/NP

d. Patient residence
Private residence
1
Nursing home
2
Homeless
3
4
Other
Unknown
5

:
:

(3) ED discharge

e. Sex
f. Ethnicity
Female
1
1
Hispanic
or Latino
Male
2
2
Not
Hispanic
or Latino

g. Race – Mark (X) one or more.
h. Arrival by ambulance i. Expected source(s) of payment for this visit – Mark (X) all that apply.
Native Hawaiian or
White
Other
4
Worker’s compensation
7
1
4
1
Private insurance
1
Yes
Other Pacific Islander
2
2
Medicare
5
Self-pay
Unknown
Black or
8
No
2
African American 5
American Indian or
3
Medicaid/SCHIP
6
No charge/Charity
Unknown
3
Alaska Native
Asian

2. TRIAGE
a. Initial vital
signs

(1) Temperature
˚C
˚F

(4) Blood pressure
Systolic

(3) Respiratory rate
b. Immediacy with which
patient should be seen
per
No triage
6
Immediate
1
minute
Unknown
1-14 minutes
7
2
(7) Glasgow
15-60 minutes
3
Coma scale
Oz (two)
>1 hour-2 hours
4
Unknown
>2 hours-24 hours
5

(2) Heart rate

(5) Pulse oximetry
Diastolic

1

/

%

2

Yes
No

3
3

3. PREVIOUS CARE
Yes
a. Has patient been –
(1) seen in this ED within
1
the last 72 hours? . .
(2) discharged from any
hospital within the
1
last 7 days? . . . . . .
b. How many times has patient
been seen in this ED within
the last 12 months? . . . .

c. Presenting
level of pain
None
1
Mild
2
Moderate
3
Severe
4
Unknown
5

per
minute
(6) On Oz

4. REASON FOR VISIT
No Unknown
2

2

3

b. Episode of
care

a. Patient’s complaint(s), symptom(s), or other reason(s) for this
visit Use patient’s own words.
(1) Most important:

3

1

(2) Other:

2

(3) Other:

3

Initial visit
for problem
Follow-up visit
for problem
Unknown

3

5. INJURY/POISONING/ADVERSE EFFECT
a. Is this visit
related to an
injury, poisoning,
or adverse effect
of medical
treatment?
1
Yes
2
No – SKIP to
item 6.

b. Is this injury/
poisoning
intentional?
1
2
3
4

c. Cause of injury, poisoning, or adverse effect – Describe the place and events that preceded the injury,
poisoning, or adverse effect (e.g., allergy to penicillin, bee sting, pedestrian hit by car driven by drunk driver, spouse
beaten with fists by spouse, heroin overdose, infected shunt, etc.).

Yes, self inflicted
Yes, assault
No, unintentional
Unknown

6. PROVIDER’S DIAGNOSIS FOR THIS VISIT
a. As specifically
(1) Primary
as possible, list
diagnosis:
diagnoses related
to this visit
(2) Other:
including chronic
conditions.
(3) Other:

b. Does patient now have – Mark (X) all that apply.
4
HIV
Cerebrovascular disease
1
Congestive heart failure
5
Diabetes
2
3
Chronic renal failure
6
None of
the above

7. DIAGNOSTIC/SCREENING SERVICES
Mark (X) all ordered or provided at this visit.
1
NONE
16
Influenza test
Blood tests:
Pregnancy test
17
CBC
2
Toxicology screen
18
3
BUN/Creatinine
19
Urinalysis (UA)
4
Cardiac enzymes
20
Wound culture
Electrolytes
5
21
Other test/service
6
Glucose
Imaging:
Liver function tests 22
7
X-ray
8
Arterial blood gases 23
CT scan
9
Prothrombin time/INR
Head
Blood culture
10
Other than head
BAC (blood alcohol)
11
24
MRI
12
Other blood test
25
Ultrasound
Other tests:
26
Other imaging
13
Cardiac monitor
14
EKG/ECG
15
HIV test

10. PROVIDERS
Mark (X) all providers
seen at this visit.
1
ED attending physician
2
ED resident/Intern
Consulting physician
3
4
RN/LPN
5
Nurse practitioner
6
Physician assistant
EMT
7
Mental health provider
8
Other
9

8. PROCEDURES
Mark (X) all provided
at this visit. Exclude
medications.
1
NONE
2
IV fluids
3
Cast
4
Splint or wrap
5
Suturing
6
Incision & drainage (I&D)
7
Foreign body removal
8
Nebulizer therapy
9
Bladder catheter
10
Pelvic exam
11
Central line
12
CPR
13
Endotracheal intubation
14
Other

2
3
4
5
6
7

Rx at
discharge

(1)

1

2

(2)

1

2

(3)

1

2

(4)

1

2

(5)

1

2

(6)

1

2

(7)

1

2

1

2

(8)

12. VISIT DISPOSITION

Mark (X) all that apply.

1

Given
in ED

NONE

11. LEVEL SERVICE
Mark (X) all that apply.

CPT code

1

1 (99282)
2 (99283)
3 (99284)
4 (99285)
5 (99291)
Critical care (99281)
Unknown

2
3
4
5
6
7
8
9
10
11

NHAMCS-100(ED) (6-3-2008)

9. MEDICATIONS & IMMUNIZATIONS
List up to 8 drugs given at this visit or prescribed at ED discharge.
Include Rx and OTC drugs, immunizations, and anesthetics.

No follow-up planned
12
Return if needed, PRN/appointment
Return/Refer to physician/clinic for FU 13
Left before medical screening exam
14
Left after medical screening exam
Left AMA
DOA
Died in ED
Transfer to psychiatric hospital
Transfer to other hospital
Admit to observation unit, then discharged

}

Admit to observation unit Continue with Item
13 - HOSPITAL
then hospitalized
ADMISSION on
Admit to hospital
reverse side.
Other

2009 ED

13. HOSPITAL ADMISSION
Complete if the patient was admitted to the hospital at this visit. – Mark (X) "Unknown" in each item, if efforts have been exhausted to collect the data.
a. Admitted to:

f. Principal hospital discharge diagnosis

c. Date and time bed was requested for hospital admission

Month
Day
Year
Time
Critical care unit
Stepdown or
2 0
telemetry unit
1
Unknown
Operating room
3
4
Mental health or
d. Date and time of hospital admission
detox unit
Month
Day
Year
Time
Cardiac catheterization
5
lab
2 0
Other bed/unit
6
Unknown
7
b. Admitting physician
e. Hospital discharge date
1

2

1
2
3

Hospitalist
Not hospitalist
Unknown

Month

Day

:

a.m.
p.m.
Military

:

a.m.
p.m.
Military

Year

2 0

1

Unknown

1

Unknown

g. Hospital discharge status/disposition
1
Alive
1
Home/Residence
2
Dead
2
Transferred
3
Unknown
3
Other
4
Unknown

{

If this information is not available at time of abstraction, then complete the Hospital Admission Log.
NHAMCS-100(ED) (6-5-2008)