NHDS - Hospital Interview Questionnaire

OMB No. 0920-0212: Approval Expires 8/31/2008

HDS-11

Confidential – All information which would permit identification of an individual or
of an establishment will be held confidential, will be used only by persons engaged
in and for the purposes of the survey, and will not be disclosed or released to other
persons or used for any other purpose.

FORM
(9-9-2005)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. PUBLIC HEALTH SERVICE
NATIONAL CENTER FOR HEALTH STATISTICS

HOSPITAL INTERVIEW
QUESTIONNAIRE
NATIONAL HOSPITAL DISCHARGE
SURVEY
Notice – All information which would permit identification of an individual or an establishment will be held confidential, will be used only by persons
engaged in and for the purposes of the survey, and will not be disclosed or released to other persons or used for any other purpose. Public reporting
burden of this collection of information is estimated to average 2 hours 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 D-74, Atlanta, GA 30333, ATTN: PRA (0920-0212).

Part A – ADMINISTRATIVE OFFICE
1. HOSPITAL CONTACTS
Date
a. NCHS letter and information packet sent
Area code

Number

Date of contact

b. Hospital telephone number

2. APPOINTMENTS
Name and title

Telephone number

Date

Time

a. ADMINISTRATIVE
OFFICE

b. MEDICAL RECORDS
DEPARTMENT

3. The National Hospital Discharge Survey involves the collection of a limited amount of information
from the medical records of a sample of patients discharged from short-stay hospitals. The
information we collect is usually available from the face sheet or discharge summary of the medical
record. There will be about 30 sample discharges each month. This is the type of information we
collect (Show HDS-5 and HDS-1).

4. Did you have a chance to read the letter and information packet sent you concerning this survey?
(If "No," give a copy of letter and information packet for review.)
Before discussing the survey details, I would like to ask a few questions about the hospital.
(Try not to let any discussion keep you from completing the remaining Part A questions.)
Notes

Part A – ADMINISTRATIVE OFFICE – Continued
5.

We have the hospital name and address as (Read label on cover page). Is this correct?
Yes (6)

6.

No – Correct label, then 6

What is the form of ownership?
Government (non federal)
Proprietary (for profit)
Church operated
Nonprofit
Other – Specify

7a. Which one of the following best describes the hospital’s service?
Mark (X) all that apply
Chronic diseases
Rehabilitation
Children’s
Orthopedic
Maternity

General (7b)
Eye, ear, nose, and throat
Alcoholism and other chemical dependency
Other – Specify

Ask for "General" hospitals only, then 8

b. Are any services excluded such as obstetrics or pediatrics?
Yes – What services?

8.

No

How many hospital beds are maintained; that is, staffed for inpatient use,
excluding "newborn" bassinets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Same

Current number

Different – Specify the bed size as of January 1 and the
date and amount of each subsequent change

9a. How many discharges were there last year from the entire hospital,

Discharges

including deaths and newborns?

b. How many live births were there last year?

Estimate
Live births
Estimate

Notes

Page 2

FORM HDS-11 (9-9-2005)

Part A – ADMINISTRATIVE OFFICE – Continued
10a. What was the average length of stay for all patients last year?

Days
Estimate

b. Does this hospital contain more than one unit?
Yes (10c)

No (11)

c. Specify the name of each unit for which separate medical records are kept.
Number of Number of
beds
discharges

Name of unit
(a)

11.

(e)

Sometimes discharge and readmission – Read details, then 12

No (13)

Is computerization of medical records in effect or planned?
Yes – Describe, then 14

14.

(d)

Are patients ever transferred between this hospital and any other hospital without being
discharged?
Yes – Explain, then 13

13.

(c)

In-scope
unit

When a patient moves from one unit, section, or service of this hospital to another unit, section,
or service, is it always recorded as a transfer or are there circumstances under which it would be
recorded as a discharge and readmission?
Always transfer (12)

12.

(b)

Average length
of stay

No (14)

Does this hospital subscribe to a private abstracting service?
Yes – Specify name

No (15)

Notes

FORM HDS-11 (9-9-2005)

Page 3

Part A – ADMINISTRATIVE OFFICE – Continued
15.

Take out the Memorandum of Agreement Form.
per completed abstract.

The National Center for Health Statistics pays
Is this acceptable to you?
Yes – Fill agreement as appropriate

No – Negotiate acceptable rate and
fill agreement as appropriate

Reimbursement Rates – Offer in order of priority:

1. Primary – $3.00 (uniform) up to $5.00 per abstract

3. Printout⎫To be approved

2. Alternate – $50.00 (uniform) up to $200.00 per

4. Other

100 abstracts

⎬by NCHS
⎭

ASK THE ADMINISTRATOR TO SIGN THE MEMORANDUM OF AGREEMENT.
Notes

16.

HOSPITAL PERSONNEL PRESENT DURING INTERVIEW
Name

Title

The rest of my questions concern your medical records department and record keeping practices.
I can go over these now or with your Director of Medical Records, whichever you prefer.
(If leaving, thank the Administrator for his/her cooperation – Go to Part B.)
Page 4

FORM HDS-11 (9-9-2005)

Part B – MEDICAL RECORDS DEPARTMENT
1.

(Read if necessary) – The National Hospital Discharge Survey is designed to provide national
statistics on a continuing basis for hospitalizations in short-stay hospitals. it involves the
collection of a limited amount of information from the records of a sample of discharged patients.
Data abstracted from medical records are items usually found on the face sheet or discharge
summary of the medical record. These are the sampling and abstracting forms which will be used.
(Show HDS-5 and HDS-1)
For this survey, we need to determine the information needed to locate the medical records for
the sample cases.

2a. Is the medical record numbering system used in this hospital serial, unit, or some other system?
Serial

Unit

Serial-unit

Other – Describe

b. Does the numbering system include outpatients?
Yes – How can they be identified? – Explain, then 2c

No (2c)

c. Does this numbering system include patients who are admitted and discharged on the same day,
such as for ambulatory surgery, diagnostic testing, dialysis, and so forth?
Yes – Which types of services are included?
How can they be identified from other
inpatients? (Explain, then 3)

No – What listing is maintained for
patients who do not stay
overnight?
(Explain, then 2d)

d. Is there any way to distinguish between the various reasons for these visits, such as for ambulatory
surgery, diagnostic testing, dialysis, or routine outpatient visits?
Yes – How?
No (3a)

Notes

FORM HDS-11 (9-9-2005)

Page 5

Part B – MEDICAL RECORDS DEPARTMENT – Continued
3a. Does a newborn infant get a medical record number?
Yes (3b)

No (3c)

b. Does a newborn infant receive a different number from that of the mother?
Yes (3d)

No (3c)

c. Are there any circumstances in which a (number/different number) is assigned to a newborn,
such as if the baby is transferred to another unit in the hospital or is discharged at a time
different from the mother’s discharge, or is born before the mother is admitted to the hospital?
Yes – Give details, then 3d

No (3c)

d. Is the newborn’s record filed with the mother’s record?
Yes (3e)

No (4)

e. Is there a face sheet for the newborn separate from that of the mother?
Yes

No

Notes

Page 6

FORM HDS-11 (9-9-2005)

Part B – MEDICAL RECORDS DEPARTMENT – Continued
4.

Do all inpatient units of the hospital use the same face sheet?
Yes – Ask for two samples

No – What face sheets are used? – Ask for two
samples of each and explain where used

Transcribe captions exactly as they appear on face sheet.

5a. Under which captions are discharge (final) diagnoses listed?

b. Under which captions are complications listed?

c. Under which captions are surgical and diagnostic procedures listed?

6.

Please state the best source in the medical record to obtain the data for the following items:
(Mark or specify as appropriate)
Item

Face Discharge
Sheet summary

Other(s)
(Specify)

Item not
available

Name of patient
Medical record number
Date of admission
Date of discharge
Residence ZIP Code
Date of birth
Age
Sex
Ethnicity (Hispanic or Latino/
Not Hispanic or Latino)
Race
Marital status (Explain codes)
Type of admission
Source of admission
Discharge status/disposition
Expected sources of payment
Final diagnoses and procedures
Dates of procedures
FORM HDS-11 (9-9-2005)

Page 7

Part B – MEDICAL RECORDS DEPARTMENT – Continued
7.

In order to select the sample, we will need to work with a list of inpatients from this
hospital during a given month. This list must include date of discharge, or admission,
medical record number, and name, if needed to locate records. Would this be a
discharge, admission or other list? Mark (X) the appropriate box(es).
1
2
3

DISCHARGE
ADMISSION
OTHER – Specify

Complete columns below as appropriate.
Mark "X" for each "Yes"
Does it show – ?

Does it use – ?

Does it include – ?

How
long
kept?

Where
kept?

Name of list
Date
Date
of
of
admis- dission charge
(a)

(b)

(c)

MR
No.
(d)

Patient
name
(e)

Sequential
or serial
(f)

Unit

(g)

Only
Out- Same
patient day overnight
patient
(h)

(i)

(j)

Is there any other
discharge,
admission, or
other list?
(Complete all
columns for each
"Yes")
(m)

(k)

(l)

Yes

No

Notes

Page 8

FORM HDS-11 (9-9-2005)

Part B – MEDICAL RECORDS DEPARTMENT – Continued
8.

Are changes ever made to these list(s) other than spelling?
Yes – What king of changes?

No

9a. Is there a specific time period for completing or signing the medical record?
Yes – Specify, then 9b

No (9b)

b. Is there a procedure for completing the record if not signed in (that time/a reasonable time)?
Yes – State procedure, then 10

10.

No (10)

Determine what list(s) will be used for sampling. Enter name(s) and linkage entries required both
here and on the inside front cover of the hospital manual.

Sample from

Linkage entries

11.

HOSPITAL PERSONNEL PRESENT
Name

Title

Notes

FORM HDS-11 (9-9-2005)

Page 9

Notes

Page 10

FORM HDS-11 (9-9-2005)