Freestanding Ambulatory Surgery Centers Form

National Hospital Ambulatory Medical Care Survey

Attachment B - 2010 NHAMCS-101(FS)

Freestanding ASC Induction Form

OMB: 0920-0278

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0278 can be found here:

Document [pdf]

Download: pdf | pdf

Form Approved: OMB No. 0920-0278; Expiration date 08/31/2012

NOTES

NOTICE – Public reporting burden of this collection of information is estimated to average 90 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 Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held
confidential, will be used for statistical purposes 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(FS)
(12-10-2009)

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
FREESTANDING AMBULATORY SURGERY CENTERS
2010 PANEL

2a. ASC administrator contact information

b. ASC contact information

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
Section I – TELEPHONE SCREENER

3. Field representative

4. Record of telephone calls

information

Call

Date

Time

Results

FR Code
Telephone screener

1
FR Code

ASC induction
3

5. Final outcome of ASC screening
1

Appointment
Day

Date

Noninterview – Complete Sections V and VI on page 19.

NOTES

Page 20

FORM NHAMCS-FS (12-10-2009)

Time

USCENSUSBUREAU

a.m.
p.m.

During your initial call to the ASC, 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 V – DISPOSITION AND SUMMARY

Section I – TELEPHONE SCREENER – Continued
Part A. INTRODUCTION

AMBULATORY UNIT CHECKLIST

Good (morning/afternoon) . . ., my name is (Your name). I am calling for the Centers for Disease
Control and Prevention concerning their study of ambulatory surgery in freestanding ambulatory
surgery centers and in hospitals. 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 U.S. 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 ASC. Is the correct
name (Read name from Control Card)?

1
2

16a. How many ambulatory surgery locations were
selected for sample?
Enter 0 if no ambulatory surgery locations were
selected for sample.
Did you complete an Ambulatory Unit
Record for each log/list?

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

Number of ambulatory surgery locations
1
2

b. Number of ASC Patient Record Forms completed

RECORD ON CONTROL CARD

17.

FINAL DISPOSITION

Number of ASC PRFs
1
2

b. Is your ASC located at (Read address from
Control Card)?

1
2

Yes
No – Enter ASC location

3
4

Number and street

RECORD ON CONTROL CARD
City State ZIP Code

c. Is this also the mailing address?

1
2

18a. At what point in the interview did the

Yes
No – Enter correct mailing address

refusal/breakoff occur?
Mark (X) appropriate box(es)

RECORD ON CONTROL CARD

2
3

b. By whom?

1
2
3

(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.

c. Was the refusal by telephone or in person?

Part B. VERIFICATION OF ELIGIBILITY
INTRODUCTION
STATEMENT B1

City State ZIP Code

The National Center for Health Statistics of the Centers for Disease Control
and Prevention is conducting an annual study of ambulatory care. The study
began data collection in 1992. Beginning in 2010, freestanding ASCs are being
included in the study. CDC has contracted with the U.S. Census Bureau to
collect the data. (Name of ASC) has been selected to participate
in the study. I am calling to arrange an appointment to discuss your
participation. The study is authorized under the Public Health Service Act and
the information will be held strictly confidential. Participation is voluntary.

All eligible units completed
END interview
Patient Record Forms
Some eligible units completed
Patient Record Forms
GO to item 18
ASC refused
ASC closed
END interview
ASC ineligible

}

Section VI – NONINTERVIEW

Number and street

STATEMENT A

Yes
No – Explain

1
2

During the telephone screening
During the ASC induction
After the ASC induction, but prior to assigned
reporting period
During the assigned reporting period
ASC administrator
ASC director
Approval board or official
Other ASC official
Telephone
In person

d. What reason was given?

Before discussing the details, I would like to verify our basic information about
(Name of ASC) to be sure we have correctly included this ASC in the study.

8a. Is ambulatory (outpatient) surgery or
ambulatory diagnostic or therapeutic
procedures currently performed in this facility?

1
2

Yes
No – SKIP to CHECK ITEM B on page 4.

NOTE: Do not ask item 8b if facility is an eye
surgery center.

b. In this study we are excluding facilities that
are exclusively family planning clinics,
birthing centers, abortion clinics, podiatry
centers or dentistry centers.

1
2

Yes – SKIP to CHECK ITEM B on page 4.
No

Is (Name of facility) exclusively one of these?

9. Is this facility currently licensed by the state?

1
2

Page 2

e. Was conversion attempted?

Yes
No

1
2

FORM NHAMCS-101(FS) (12-10-2009)

Yes
No
Page 19

Section I – TELEPHONE SCREENER – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section H – FINAL DISPOSITION
1. FINAL DISPOSITION

Part B. VERIFICATION OF ELIGIBILITY

10. It is important for us to determine whether

Ambulatory unit
1

Participated
Patients seen, Continue to Item 2
a
b
No patients seen

Refused

Closed
a
Temporary
b
Permanent

Ineligible
a
AU not under auspices of ASC
Only ancillary services provided
b
c
AU classified as out-of-scope
d
Other – Specify

}

or not your facility operates under the
license or Provider of Services (POS)
number of a parent facility.

a. Does your ASC operate under the license of
a parent facility?

b. Does your ASC operate under the Provider
of Services (POS) number of a parent
facility?

END

CHECK
ITEM A
1

1
2

Yes
No
Yes
No

Refer to items 10a and 10b.
Is "Yes" marked in ANY of these items?

Yes – What is the name and address of your parent facility?
Parent facility name
Number and street

2. Who completed the patient record forms?
Mark (X) all that apply

1
2
3
4

City State ZIP Code

ASC staff
FR – abstraction DURING reporting period
FR – abstraction AFTER reporting period
Other – Specify

Thank you for your time and assistance. We may contact you again in a few days
regarding participation in this study. Terminate telephone call.
FR
NOTE
2

NOTES

RECORD ON CONTROL CARD

11.

If after contacting your RO you find that the ASC is eligible, continue with item 11.
If the ASC is not eligible, go to CHECK ITEM B on page 4 and mark checkbox 4.

No – GO to item 11.
Is this facility owned, operated, or managed
by –

A hospital
One or more physicians
Health maintenance organization
Another health care provider
A health care corporation that owns multiple
health care facilities (e.g., HCA or Health South)
Other

Yes – What is the specialty?

Yes
No

1
2
3
4
5

12.

Is the ambulatory (outpatient) surgery
performed here primarily one specialty?

SKIP to CHECK ITEM B on page 4.

13.

Is the ambulatory (outpatient) surgery
performed here multi-specialty?

NOTES

Page 18

FORM NHAMCS-101(FS) (12-10-2009)

Page 3

Section I – TELEPHONE SCREENER – Continued
CHECK
ITEM B

1
2
3
4

CHECK
ITEM
B-1

Section IV – AMBULATORY UNIT RECORD – Continued

ASC meets eligibility requirements (item 8 is YES) – SKIP to Check Item B-1
ASC is ineligible because it does not perform ambulatory surgery (item 8a is NO) – Go to
CLOSING STATEMENT B1 below.
ASC is ineligible because specialty is out-of-scope (item 8b is YES) – Go to
CLOSING STATEMENT B2 below.
ASC is ineligible because it operates under a parent facility that is on the sampling frame (Item
10a is YES) – Complete Section V on page 19.

ASC refused
1
2

Yes – SKIP to item a
No – SKIP to Part C. STUDY DESCRIPTION on page 5

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

Section D – VERIFICATION OF ESTIMATED VISITS
Verify with ASC director BEFORE data collection begins
(and records have been pulled).
1. According to our information, about
(number from B-3) patient visits are
expected during the reporting period. Do
you agree with this estimate?

2. About how many visits do you expect during the

Revised estimate

reporting period,
Eligible ASC?
1
2

Yes –
No

expected visits

Determine if new Take Every and Random Start
numbers must be calculated for this ASC.
3a. Divide the revised estimate by the original
estimate from B-3.

CLOSING
STATEMENT
B2

1
2

Thank you. . ., but it seems that our information was incorrect. Since (Name of
ASC)’s specialty is out-of-scope for our study, it should not have been chosen
for our study. Thank you very much for your cooperation. Terminate telephone call
and complete Section V on page 19.

(Result)

Original estimate

Complete Sections V and VI on page 19.
CLOSING
STATEMENT
B1

Revised estimate

b. Is the result of (a) between 0.7 and 1.3?

Thank you . . ., but it seems that our information was incorrect. Since (Name of
ASC) does not perform ambulatory surgery, it should not have been chosen for
our study. Thank you very much for your cooperation. Terminate telephone call and
complete Section V on page 19.

Yes – SKIP to section G
No

b. If unable to determine expected visits for the assigned reporting period, obtain the number of
visits to the facility last year.
ASC visits
last year

Yes – SKIP to section G
No

New Take Every

2. Calculate new Random Start, using the next available
row on the label affixed to the back of the
NHAMCS-101(FS).

New Random Start

NOTES
Section G – PATIENT RECORD FORM INFORMATION
1. Enter the range of Patient Record Forms that were ACTUALLY used by the unit.
FIRST FOLIO

FROM:

TO:

SECOND FOLIO

FROM:

TO:

THIRD FOLIO

FROM:

TO:

NOTES

Page 4

FORM NHAMCS-101(FS) (12-10-2009)

Page 17

Section IV – AMBULATORY UNIT RECORD

Section I – TELEPHONE SCREENER – Continued

COMPLETE FOR EACH AMBULATORY UNIT SELECTED

Part C. STUDY DESCRIPTION

Section A – AMBULATORY UNIT INFORMATION

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

a. Mark (X) specialty —
GEN

MULTI

OPH

ORTHO

PLASTIC

PAIN

OTHER

INSTRUCTIONS
Provide the administrator or other facility representative with a brief description of the study.

3
b. AU No.
of
Total AU’s sampled within the ASC

Cover following points –
(1) The NHAMCS is the only source of national data on health care provided in hospital emergency and
outpatient departments and ambulatory surgery centers.

Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASCs

1. Take every number

2. Random start number
3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

From:
To:
7. Numerator

9. What was the total number of patient
visits to this AU from (dates specified in
B5)?(Refer to patient logs, etc. Ask if
necessary.DO NOT LEAVE TOTAL
BLANK. BE AS COMPLETE AND
ACCURATE AS POSSIBLE.)

Week 1
/

–

/
8. Denominator

1
–

1.00

NUMBER OF VISITS
Week 3

Week 2
/

–

Week 4

–

TOTAL

(2) NHAMCS is endorsed by the:
• Ambulatory Surgery Center Association
• American College of Surgeons
• American Health Information Management Association
• American Academy of Ophthalmology
• Society for Ambulatory Anesthesia
• American College of Emergency Physicians
• Emergency Nurses Association
• Society for Academic Emergency Medicine
• American College of Osteopathic Emergency Physicians
(3) Nationwide sample of about 600 hospitals and 246 freestanding ambulatory surgery centers.

(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits

10. How many patient record forms were
filled out for this AU?

Week 1

NUMBER OF FORMS
Week 2
Week 3

11. Was this Ambulatory Unit Record completed for multiple ambulatory
surgery locations that were combined in a single list?

Yes

Week 4

TOTAL

No, this Ambulatory Unit
Record is for a single
ambulatory surgery location

Section C – ASC INFORMATION AND LOGS

As one of the ASC’s that has been selected for the study, your contribution will be of
great value in producing reliable, national data on ambulatory surgery.
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? 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 phone call.

NOTES

1. What are the usual operating hours of this unit?
Day(s)

Time

(a)

(b)
FROM

Monday
FROM

Tuesday
FROM

Wednesday
FROM

Thursday

a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FROM

Hours vary

(c)

(d)

(e)

a.m.
p.m.

TO
a.m.
p.m.

FROM

Mark (X) ONLY one
Not open

FROM

Saturday

Page 16

a.m.
p.m.

Friday

Sunday

Open 24 hours

a.m.
p.m.

FORM NHAMCS-101(FS) (12-10-2009)

Page 5

Section IV – AMBULATORY UNIT RECORD – Continued

Section II – INDUCTION INTERVIEW

Section H – FINAL DISPOSITION

Part A. INTRODUCTION
1. FINAL DISPOSITION
I would like to begin with a brief review of the background for this study.

Ambulatory unit
1

Participated
Patients seen, Continue to Item 2
a
b
No patients seen

Refused

Closed
a
Temporary
b
Permanent

Ineligible
a
AU not under auspices of ASC
Only ancillary services provided
b
c
AU classified as out-of-scope
d
Other – Specify

ASC staff
FR – abstraction DURING reporting period
FR – abstraction AFTER reporting period
Other – Specify

INSTRUCTIONS
Provide the administrator or other facility representative with a brief introduction to the study and a
general overview of procedures.
Cover the following points –
(1) NHAMCS is a sister survey of the National Ambulatory Medical Care Survey (NAMCS). NAMCS
collects data on visits to physicians in office-based practices
(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 care organizations, health services planners,
researchers, and educators
(4) Annually, there are almost 200 million visits to hospital emergency and outpatient departments and 35
million visits to ambulatory surgery centers, including 15 million visits to freestanding ambulatory surgery
centers

2. Who completed the patient record forms?
Mark (X) all that apply

(5) The U.S. Census Bureau is the data collection agent for the study

(6) The study is authorized by Title 42, U.S. Code, Section 242k

(7) Participation is voluntary

(8) Any identifiable information will be held confidential and will be used only by NCHS staff, contractors or agents,
only when necessary and with strict controls, and will not be disclosed to anyone else without the consent of
your facility. By law, every employee as well as every agent has taken an oath and is subject to a jail term of
up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information
about your facility and its patients

}

END

NOTES

(9) NO patients’ names or identifiers are collected
(10) The study was approved by the NCHS Research Ethics Review Board or IRB
(11) Data from the study will be used only in statistical summaries
(12) NHAMCS excludes office-based physicians (these are covered under the NAMCS)
(13) NHAMCS excludes the following types of ASCs: dentistry, podiatry, abortion, lump and bump
procedure rooms, birth center, and family planning.
(14) For the first time, we are including freestanding ambulatory surgery centers in the survey
(15) Only a 4-week data collection period
(16) On average, sample of approximately 100 ASC visits per hospital and 100 freestanding ASC visits.

SHOW PATIENT RECORD FORM
(17) Form takes only 6 minutes to complete
(18) Forms are to be completed by ASC staff at their convenience
(19) Portion containing patient’s name or other identifying information is removed before collecting

Page 6

FORM NHAMCS-101(FS) (12-10-2009)

Page 15

Section II – INDUCTION INTERVIEW – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section D – VERIFICATION OF ESTIMATED VISITS

As I mentioned earlier, I would like to discuss the plan for conducting the study. This ASC has

Verify with ASC director BEFORE data collection begins
(and records have been pulled).
1. According to our information, about
(number from B-3) patient visits are
expected during the reporting period. Do
you agree with this estimate?

2. About how many visits do you expect during the

Revised estimate

reporting period,

Part B. SURVEY IMPLEMENTATION

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

Yes – SKIP to section G
No

Month

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

14a. Are there any additional steps needed to obtain permission for the ASC to participate
in the study?
1
Yes – Specify the necessary steps below

Determine if new Take Every and Random Start
numbers must be calculated for this ASC.
3a. Divide the revised estimate by the original
estimate from B-3.

Day

Revised estimate
=

(Result)

Original estimate
b. Is the result of (a) between 0.7 and 1.3?
1
2

Yes – SKIP to section G
No

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ASC
1. Calculate new Take Every, using the appropriate table
(page 19) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).
2. Calculate new Random Start, using the next available
row on the label affixed to the back of the
NHAMCS-101(FS).

New Take Every

14b. Now I would like to make arrangements to
obtain the information needed for sampling.
I will need to (know/verify) how your
ambulatory surgery center is 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?

New Random Start

Section G – PATIENT RECORD FORM INFORMATION
1. Enter the range of Patient Record Forms that were ACTUALLY used by the unit.
FIRST FOLIO

FROM:

1
2

TO:

Respondent
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,
Ambulatory Surgery Center Description as
appropriate. Thank current respondent for his/her
time and cooperation.

Name

SECOND FOLIO

FROM:

TO:
Title

THIRD FOLIO

FROM:

TO:
Department

Record on
Control Card

NOTES
Telephone number
Name
Title
Department

Record on
Control Card

Telephone number

Page 14

FORM NHAMCS-101(FS) (12-10-2009)

Page 7

Section III – AMBULATORY SURGERY CENTER DESCRIPTION

15a. Does this facility have any satellite facilities

Yes – Continue with item 15b.
No – SKIP to developing sampling plan

which perform ambulatory (outpatient) surgery?

b. What are the names, addresses, and

Section IV – AMBULATORY UNIT RECORD

COMPLETE FOR EACH AMBULATORY UNIT SELECTED
Section A – AMBULATORY UNIT INFORMATION

Name

telephone numbers of the satellite facilities?

RECORD UP TO 3 ON
Address
CONTROL CARD
Telephone number
(Area code and number)
To develop the sampling plan, I would like to (collect/verify) more specific information about this
facility’s ambulatory surgery locations.
Obtain an estimate of ambulatory (outpatient) surgery cases for each ambulatory surgery location, covering
the 4-week reporting period. Enter the estimate in column (d) of the listing below.
Out-of-scope locations:
In-scope locations:
•
Laser
procedures
• General or main operating room
•
• Podiatry
Cystoscopy
room
Dentistry
•
room
Dedicated
ambulatory
surgery
room
Endoscopy
room
•
Family
planning
•
•
• Abortion
FR
Satellite
operating
room
Cardiac
catheterization
lab
Lump
and
bump
•
• Birth center
•
Pain
block
room
•
•
NOTE
procedure rooms
Specialty
• GEN – General
• GI – Gastroenterology • ORTHO – Orthopedics • PLASTIC – Plastic Surgery
groups include: • MULTI – Multi-specialty • OPH – Ophthalmology • PAIN – Pain Block
• OTHER – Other specialty
INSTRUCTIONS
• Only record generic ambulatory surgery location names in column (a) (e.g., ambulatory surgery center, endoscopy). If the
ambulatory surgery location 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.
• Record the specialty group acronym in column (b).
• Complete columns (e) and (f) after developing the sampling plan. See page 18 of the NHAMCS-124 for instructions.
Line
No.

Name of ambulatory surgery location
(Generic)

Specialty
group

AU
number

(a)

(b)

(c)

Expected No. of ambulatory
(outpatient) surgery cases
from __________ to __________

Take Random
every
start
number number

(d)

(e)

(f)

a. Mark (X) specialty —
1

GEN

MULTI

OPH

ORTHO

PLASTIC

PAIN

OTHER

2
of
b. AU No.
Total AU’s sampled within the ASC
Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASC

1. Take every number

2. Random start number
3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

From:

To:

Week 1
/

10. How many patient record forms were
filled out for this AU?

–

Week 1

8. Denominator

–

Week 2

11. Was this Ambulatory Unit Record completed for multiple ambulatory
surgery locations that were combined in a single list?

1.00

NUMBER OF VISITS
Week 3

Week 2
/

7. Numerator

–

Week 4

NUMBER OF FORMS
Week 3

Yes

–

TOTAL
/

Week 4

TOTAL

No, this Ambulatory Unit
Record is for a single
ambulatory surgery location

Section C – ASC INFORMATION AND LOGS
2
1. What are the usual operating hours of this unit?
3
4

Day(s)

Time

(a)

(b)
FROM

TOTAL
CHECK
ITEM F

1
2

Monday

Facility has only 1 ambulatory surgery location – SKIP to Item 15e.
Facility has more than 1 ambulatory surgery location – Continue with item 15c. Make sure that
item 11 is marked on the Ambulatory Unit Record, Section B.

FROM

Tuesday
FROM

15c. 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 ambulatory surgery
location name listed above.)

d. Would you or your IT staff be able to

Wednesday
1
2
3
1

}

Yes
SKIP to item 15e
No – ONLY 2 lists
No – More than 2 lists – Continue with item 15d.
Yes – Make sure that item 11 is marked on the
Ambulatory Unit Record, Section B.
No – Continue with item 15e.

generate one list of outpatient surgery cases
for some of these locations?
2
Record the name and telephone number of the IT
contact on the Conrol Card.
IT Contact name
Give a copy of the "Single Sampling List Instructions" Telephone number
to the IT contact.
(Area code and number)

RECORD ON
CONTROL CARD

FR
If multiple logs can be combined into one list, assign the same AU number to each location whose log is
NOTE included in the list.
Page 8

FORM NHAMCS-101(FS) (12-10-2009)

FROM

Thursday

a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FROM

TO
a.m.
p.m.

FROM

Sunday
FORM NHAMCS-101(FS) (12-10-2009)

(d)

(e)

a.m.
p.m.

FROM

Saturday

Hours vary

(c)

a.m.
p.m.

Friday

Mark (X) ONLY one
Open 24 hours
Not open

a.m.
p.m.

Page 13

Section III – AMBULATORY SURGERY CENTER DESCRIPTION – Continued

Section IV – AMBULATORY UNIT RECORD – Continued

15e. Does your ASC submit CLAIMS

Section H – FINAL DISPOSITION
1. FINAL DISPOSITION

electronically (electronic billing)?

Ambulatory unit
1

Participated
Patients seen, Continue to Item 2
a
b
No patients seen

Refused

Closed
a
Temporary
b
Permanent

Ineligible
a
AU not under auspices of ASC
Only ancillary services provided
b
c
AU classified as out-of-scope
d
Other – Specify

}

f. Does your ASC use an electronic MEDICAL
record (EMR) or electronic HEALTH record
(EHR) system. Do not include billing record
systems.

END

1
2
3
4

(2) What is the name of your current
EMR/EHR system?
Mark (X) only one box.

Mark (X) all that apply

1
2
4
5
6

1
2
3

1
2
3
4

ASC staff
FR – abstraction DURING reporting period
FR – abstraction AFTER reporting period
Other – Specify

No
Unknown

}

Year

new EMR/EHR system within the next 18
months?

Yes, all electronic
Yes, part paper and part electronic Go to item 15f1
No
SKIP to item 15g
Unknown

(1) Which year did your ASC install your
EMR/EHR system?

g. Does your ASC have plans for installing a
2. Who completed the patient record forms?

Yes, all electronic
Yes, part paper and
part electronic

Allscripts
Cerner
eClinicalWorks
Eclipsys
Epic
eMDs

GE Centricity
Greenway
Medical
HealthPort
McKesson
NextGen

7
8
9
10
11

12
13
14
15
16

Praxis
Practice One
Sage Intergy
Other
Unknown

Yes
No
Maybe
Unknown

h. Indicate whether your ASC has each of the
following computerized capabilities. Does the
reporting location have a computerized system
for: Mark (X) only one box per row.

(1) Patient history and demographic information? .

Yes
1

Yes, but
turned off
or
not used
2

No
3

Unknown
4

Skip to 15h2 Skip to 15h2 Skip to 15h2

NOTES

If Yes, ask – (a) Does this include a patient problem list?

(2) Clinical notes? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Skip to 15h3 Skip to 15h3 Skip to 15h3
If Yes, ask – (a) Do they include a list of medications
that the patient is taking?
(b) Do they include a comprehensive list of
the patient’s allergies (including allergies
to medication)?
(3) Orders for prescriptions? . . . . . . . . . . . . . . . . . . .

Skip to 15h4 Skip to 15h4 Skip to 15h4
If Yes, ask – (a) Are warnings of drug interactions or
containdications provided?
(b) Are prescriptions sent electronically to
the pharmacy?

(4) Orders for lab tests? . . . . . . . . . . . . . . . . . . . . . . .

Skip to 15h5 Skip to 15h5 Skip to 15h5
If Yes, ask – (a) Are orders sent electronically to the lab?

(5) Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . .

1
1

Skip to 15h6 Skip to 15h6 Skip to 15h6
If Yes, ask – (a) Are results incorporated in EMR/EHR?
(b) Are out of range levels highlighted?

(6) Viewing imaging results? . . . . . . . . . . . . . . . . . . .
Page 12

FORM NHAMCS-101(FS) (12-10-2009)

Page 9

Section III – AMBULATORY SURGERY CENTER DESCRIPTION – Continued

15h. Continued

Section C – ASC INFORMATION AND LOGS

Yes, but
turned off
or
not used

Yes

Section IV – AMBULATORY UNIT RECORD – Continued

Unknown

(7) Reminders for guideline-based interventions or
screening tests? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(8) Electronic reporting to immunization registries?

i. At your ASC, if orders for prescriptions or lab tests

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Other
Prescriptions and lab test orders
not submitted electronically
Unknown
Yes, we intend to apply – Go to 15j1
Uncertain whether we will apply SKIP to
Section IV
No, we will not apply

2
3
4
5
6
7

j. Beginning in 2011, Medicare and Medicaid will offer

incentives to facilities that have meaningful use of
Health IT". Does your ASC have plans to apply for
Medicare or Medicaid incentive payments for
meaningful use of Health IT?

(1) What year do you expect to apply for the

}

2011
2012
After 2012
Unknown

2
3
4

(2) What incentive payment do you plan to apply

2
3

Section IV – AMBULATORY UNIT RECORD
COMPLETE FOR EACH AMBULATORY UNIT SELECTED

OPH

ORTHO

PLASTIC

PAIN

OTHER

1
b. AU No.
of
Total AU’s sampled within the ASC

1. Take every number

Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASC
5.

3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.
9. What was the total number of patient
visits to this AU from (dates specified in
B5)?(Refer to patient logs, etc. Ask if
necessary.DO NOT LEAVE TOTAL
BLANK. BE AS COMPLETE AND
ACCURATE AS POSSIBLE.)

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

From:
To:
7. Numerator

1
Week 1

Friday
Saturday

(d)

(e)

a.m.
p.m.

FROM

a.m.
p.m.

FROM

a.m.
p.m.

FROM

a.m.
p.m.

FROM

a.m.
p.m.

Wednesday
Thursday

Hours vary

(c)

a.m.
p.m.

FROM

FROM
FROM

2. About how many visits do you expect during the

Revised estimate

Yes – SKIP to section G
No

Determine if new Take Every and Random Start
numbers must be calculated for this ASC.
3a. Divide the revised estimate by the original
estimate from B-3.

Revised estimate
=

–

b. Is the result of (a) between 0.7 and 1.3?
1
2

(Result)

1
–

1.00

–

Week 4

–

Yes – SKIP to section G
No

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ASC

8. Denominator

NUMBER OF VISITS
Week 3

Week 2

TOTAL

1. Calculate new Take Every, using the appropriate table
(page 19) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).

New Take Every

2. Calculate new Random Start, using the next available
row on the label affixed to the back of the
NHAMCS-101(FS).

New Random Start

Section G – PATIENT RECORD FORM INFORMATION

1. Enter the range of Patient Record Forms that were ACTUALLY used by the unit.

Week 1

Week 2

11. Was this Ambulatory Unit Record completed for multiple ambulatory
surgery locations that were combined in a single list?
Page 10

Tuesday

Mark (X) ONLY one
Not open

Original estimate

2. Random start number

10. How many patient record forms were
filled out for this AU?

(b)

reporting period,

Section A – AMBULATORY UNIT INFORMATION
GI

(a)

Open 24 hours

Section D – VERIFICATION OF ESTIMATED VISITS

Medicare
Medicaid
Unknown

......................................

Time

Sunday

meaningful use payments? . . . . . . . . . . . . . . . . . .

a. Mark (X) specialty —
1
GEN
2
MULTI

Day(s)

Monday

are submitted electronically, who submits them?

for?

1. What are the usual operating hours of this unit?

NUMBER OF FORMS
Week 3

Yes

Week 4

TOTAL

No, this Ambulatory Unit
Record is for a single
ambulatory surgery location
FORM NHAMCS-101(FS) (12-10-2009)

FIRST FOLIO

FROM:

TO:

SECOND FOLIO

FROM:

TO:

THIRD FOLIO

FROM:

TO:

FORM NHAMCS-101(FS) (12-10-2009)

Page 11

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