Hospital Induction Form

National Hospital Ambulatory Medical Care Survey

Attachment A - 2010 NHAMCS-101

Hospital Induction Form

OMB: 0920-0278

⚠️ Notice: This form may be outdated.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

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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 60 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
(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
2010 PANEL

2a. Hospital contact information

b. ED 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

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

1
FR Code

Hospital induction

ED induction

OPD induction

ASC induction

2
FR Code

FR Code

5
6

5. Final outcome of hospital screening
1

Appointment
Day

Page 24

FORM NHAMCS-101 (12-10-2009)

Date

Time

a.m.
p.m.

Noninterview – Complete Sections VI and VII, beginning on page 22.

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

Section VII – NONINTERVIEW

19a. At what point in the interview

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 U.S. Census
Bureau, which is collecting the data for the study.

6. Did you receive the letter(s)?
(If "No" or "Don’t know," offer to send or deliver
another copy.)

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
3

1
2

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

Control Card)?

1
2

(1) During the telephone
screening
(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

(1) Hospital administrator

(3) Approval board or official

RECORD ON CONTROL CARD
1

(4) Other hospital official

City State ZIP Code

ASC

(2) ED/OPD/ASC director

Yes
No – Enter hospital location

Number and street

c. Is this also the mailing address?

OPD

b. By whom?

RECORD ON CONTROL CARD
b. Is your hospital located at (Read address from

Hospital

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

Specify

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.

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

5
6

Telephone
In person

5
6

Telephone
In person

5
6

Telephone
In person

5
6

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

NOTES

d. Was conversion attempted?

Hospital
1
2

Page 2

FORM NHAMCS-101 (12-10-2009)

Yes
No

ED
1
2

Yes
No

OPD
1
2

Yes
No

ASC
1
2

Yes
No
Page 23

Section I – TELEPHONE SCREENER – Continued

Section VI – DISPOSITION AND SUMMARY
AMBULATORY UNIT CHECKLIST
• COMPLETE 16a FOR EMERGENCY
DEPARTMENT ONLY
16a. How many emergency service areas
were selected for sample?

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

Number of ESAs

Enter 0 if no ESAs were selected for sample.
Did you include a NHAMCS-101(U)
for each?

Yes
No – Explain

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:

• COMPLETE 16b FOR OUTPATIENT
DEPARTMENT ONLY

b. How many clinics were selected for sample?

Number of Clinics

INTRODUCTION
STATEMENT B2

Enter 0 if no clinics were selected for sample.
Did you include a NHAMCS-101(U)
for each?

• COMPLETE 16c FOR AMBULATORY
SURGERY CENTER ONLY
c. How many ambulatory surgery locations were
selected for sample?
Enter 0 if no ambulatory surgery locations were
selected for sample.
Did you include a NHAMCS-101(U)
for each log/list?

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.

1
2

Yes
No – Explain

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 U.S. Census Bureau to collect the data. (Name of
hospital) has been selected to participate in the study. 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:

Number of ambulatory surgery locations

8a. Is this facility a licensed hospital?

1
2

b. Is this hospital nonprofit, government, or

Yes
No – Explain

proprietary?
2

Number of ED PRFs

e. Number of OPD Patient Record Forms completed

Number of OPD PRFs

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

d. Is this a teaching hospital?
f. Number of ASC Patient Record Forms completed

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

Yes
No
Unknown

17.

FINAL DISPOSITION

1
2
3
4
5

18.

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 18
Patient Record Forms
Hospital refused
Hospital closed
END interview
Hospital ineligible

}

Entire ED refused
Entire OPD refused
Entire ASC refused
Some ESAs refused
Some clinics refused
Some ambulatory surgery locations refused

2
3

1
2

Number of ASC PRFs

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

1
2
3
4

f. Does YOUR hospital have its own medical
records department that is separate from
that of the OTHER hospital?

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

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

FORMS COMPLETED

d. Number of ED Patient Record Forms completed

Yes
No – SKIP to CHECK ITEM B on page 4

1
2
3

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

}

Yes
No
Unknown

Hospital name
Number and street
City State

RECORD ON
CONTROL CARD

ZIP Code

FR NOTE – If one or more responses are marked in 18, complete Section VII,
NONINTERVIEW on page 23. If no responses marked, END INTERVIEW.
Page 22

FORM NHAMCS-101 (12-10-2009)

Page 3

Section VI –SURGERY
DISPOSITION
ANDDESCRIPTION
SUMMARY
Section V – AMBULATORY
CENTER
– Continued

Section I – TELEPHONE SCREENER – Continued

(3) Orders for prescriptions? . . . . . . . . . . . . . . . . . . .

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

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

b. Does this OPD include physician services?

1
2

c. Does this hospital have locations that
perform ambulatory surgery?
Read the following statement.
ASC locations include a general or main
operating room, dedicated ambulatory
surgery room, satellite operating room,
cystoscopy room, endoscopy room, cardiac
catheterization lab, laser procedures room,
or a pain block room.

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

}

Yes
SKIP to item 10a
No

1
2
3

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

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

Yes
No – SKIP to item 10c

(b) Are out of range levels highlighted?

(6) Viewing imaging results? . . . . . . . . . . . . . . . . . . .
(7) Reminders for guideline-based interventions

Yes
No
Unknown

or screening tests? . . . . . . . . . . . . . . . . . . . . . . . .

(8) Electronic reporting to immunization registries?
i. At your ASC, if orders for prescriptions or lab tests
are submitted electronically, who submits them?

3
4
5

1
1

1
2
3
4

}

Skip to 15h6 Skip to 15h6 Skip to 15h6

Yes
No

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) . . . . . . . . . . . .

Skip to 15h5 Skip to 15h5 Skip to 15h5

Level I
3
Level III
5
Other/unknown
Level II
Level IV or V 6 None
4
See page 29 of the NHAMCS-124 for definitions

Mark (X) all that apply.

CHECK
ITEM B

CHECK
ITEM
B-1

Yes – SKIP to item 9c
No

If Yes, ask – (a) Are results incorporated in EMR/EHR?
1

Skip to 15h4 Skip to 15h4 Skip to 15h4

(4) Orders for lab tests? . . . . . . . . . . . . . . . . . . . . . . .
1

5
6

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 on page 5.
Hospital is ineligible because it has NEITHER an ED nor OPD nor ASC (items 9a, 9b,
10a, 10b, and/or 10c are NO) – Go to CLOSING STATEMENT B2 on page 5.

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Other
Prescriptions and lab test orders
not submitted electronically
Unknown

NOTES

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

1
2

Eligible ED?
1
2

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

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.

Yes –
No

expected visits

Eligible ASC?
1
2

Yes –
No

expected visits

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

OPD visits
last year

ASC visits
last year

Go to Section VII, NONINTERVIEW on page 23.
Page 4

FORM NHAMCS-101 (12-10-2009)

Page 21

Section I – TELEPHONE SCREENER – Continued

Section V – AMBULATORY SURGERY CENTER DESCRIPTION – Continued

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
on the previous page.)

2
3

d. Would you or your IT staff be able to
generate one list of outpatient surgery
cases for some of these locations?
Record the name and telephone number of the IT
contact on the Control Card.
Give a copy of the "Single Sampling List
Instructions" to the IT contact.
FR
NOTE

}

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
NHAMCS-101(U), Section B, for each AU.
No – Continue with item 15e.

1
2

RECORD ON

Now I would like to ask you some questions about your ASC.
electronically (electronic billing)?

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

1
2

1
2
3
4

Yes, all electronic
Yes, part paper and
part electronic

1
3
4
5
6

g. Does your ASC have plans for installing a
new EMR/EHR system within the next 18
months?

No
Unknown

}

Year

Mark (X) only one box.

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 the
EMR/EHR system?
(2) What is the name of your current
EMR/EHR system?

1
2
3
4

Allscripts
Cerner
eClinicalWorks
Eclipsys
Epic
eMDs

7
8
9
10
11

GE Centricity
Greenway
Medical
HealthPort
McKesson
NextGen

12
13
14
15
16

Praxis
Practice One
Sage Intergy
Other
Unknown

following computerized capabilities. Does your
ASC have a computerized system for: Mark (X) only
one box per row.

(1) Patient history and demographic information? .

Yes
1

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

1
1

Yes, but
turned off
or
not used
2

No
3

Unknown
4

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)?
Page 20

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 and ambulatory surgery centers
(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 and 246 free-standing ambulatory surgery centers
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits

CHECK
ITEM
B-2

Skip to 15h2 Skip to 15h2 Skip to 15h2
If Yes, ask – (a) Does this include a patient problem list?

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

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.

Yes
No
Maybe
Unknown

h. Indicate whether your ASC has each of the

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
Section VI on page 22.

CLOSING
STATEMENT
B2

Part C. STUDY DESCRIPTION

IT Contact name

CONTROL CARD
Telephone number
(Area code and number)
If multiple logs were combined into one list, then assign the same AU number to each location and record in
column (c) on page 19.

e. Does your ASC submit CLAIMS

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
Section VI on page 22.

CLOSING
STATEMENT
B1

FORM NHAMCS-101 (12-10-2009)

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

FORM NHAMCS-101 (12-10-2009)

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.

Hospital has at least one ambulatory surgery location (Yes in item 10c).
Hospital does not have any ambulatory surgery locations – SKIP to Section VI, DISPOSITION AND
SUMMARY on page 22.

15a. Does this hospital have any satellite
Provide the administrator or other hospital representative with a brief introduction to the study
and a general overview of procedures.

(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

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

Address

RECORD UP TO 3 ON
CONTROL CARD

Telephone number
(Area code and number)

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

FR
NOTE

In-scope locations:
• Laser procedures
• General or main operating room
• Cystoscopy room
room
• Dedicated ambulatory surgery room • Endoscopy room
• Satellite operating room
• Cardiac catheterization • Pain block room
lab
Specialty groups include:
• GEN – General
• MULTI – Multi-specialty

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

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

Name

telephone numbers of the satellite
facilities?

(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 20 million visits to hospital-based ambulatory surgery centers

b. What are the names, addresses, and

Cover the following points –

• GI – Gastroenterology
• OPH – Ophthalmology

• ORTHO – Orthopedics
• PAIN – Pain Block

Out-of-scope locations:
• Dentistry
• Podiatry
• Family planning • Abortion
• Lump and bump • Birth center
procedure rooms
• PLASTIC – Plastic Surgery
• OTHER – Other specialty

INSTRUCTIONS

(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 you, your hospital and its patients

• Only record generic ambulatory surgery location names in column (a) (e.g., ambulatory surgery center, cardiac cath). 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.

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

Line
No.

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

Name of ambulatory surgery location
(Generic)

Specialty
group

AU
number

(a)

(b)

(c)

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

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

(d)

Take
every
number

Random
start
number

(e)

(f)

(13) NHAMCS covers care provided by or under the direct supervision of a physician
(14) NHAMCS excludes office-based physicians (these are covered under the NAMCS)

(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

(16) Only a 4-week data collection period

(17) On average, sample of approximately 100 ED, 150 to 200 OPD, and 100 ASC visits per hospital

SHOW PATIENT RECORD FORMS

(18) Form takes only 6 or 7 minutes to complete

TOTAL

(19) Forms are to be completed by hospital staff at their convenience
(20) Portion containing patient’s name or other identifying information is removed before collecting

Page 6

facilities which perform ambulatory
(outpatient) surgery?

INSTRUCTIONS

FORM NHAMCS-101 (12-10-2009)

CHECK
ITEM F

1
2

Hospital has only 1 ambulatory surgery location – SKIP to Item 15e.
Hospital has more than 1 ambulatory surgery location – Continue with item 15c. Make sure that item 11
is marked on the NHAMCS-101(U), Section B.

FORM NHAMCS-101 (12-10-2009)

Page 19

Section II – INDUCTION INTERVIEW – Continued

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued

14v. Does your OPD have plans for installing a
new EMR/EHR system within the next 18
months?

1
2
3
4

Yes
No
Maybe
Unknown

CHECK
ITEM B-3

w. Please indicate whether your OPD has each of the
computerized capabilities listed below. Does your
OPD 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

Unknown

1
2

CHECK ITEM B = 1 (ED meets eligibility requirements)
CHECK ITEM B = 2 or 3 (ED does NOT meet eligibility requirements) – SKIP to Part B. Survey
Implementation on page 8.

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

11a. How many days in a week are inpatient
elective surgeries scheduled?
3

Number of days

Skip to 14w2 Skip to 14w2 Skip to 14w2
If Yes, ask – (a) Does this include a patient problem list?
(2) Clinical notes? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Skip to 14w3 Skip to 14w3 Skip to 14w3
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? . . . . . . . . . . . . . . . . . . .

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

c. How often are hospital bed census data
available?

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

Read answer categories.

(b) Are out of range levels highlighted?
(6) Viewing imaging results? . . . . . . . . . . . . . . . . . . .

1
1

(8) Electronic reporting to immunization registries?
x. At your OPD, if orders for prescriptions or lab tests
are submitted electronically, who submits them?

1
2
3
4
5
6
7

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Other
Prescriptions and lab test orders
not submitted electronically
Unknown

3
5
7

staff?
A hospitalist is a physician whose primary
professional focus is the general care of hospitalized
patients. He/she may oversee ED patients being
admitted to the hospital.

e. Do the hospitalists on staff at your hospital
admit patients from your ED?

1
2
3

1
2

f. Beginning in 2011, Medicare and Medicaid will offer
incentives to facilities that have "meaningful use of
Health IT". Does your hospital have plans to apply
for Medicare or Medicaid incentive payments for
meaningful use of Health IT?

(1) What year does your hospital expect to apply
for the meaningful use payments? . . . . . . . . . .

1
2
3

1
2
3
4

(2) What incentive payment does your hospital
plan to apply for? . . . . . . . . . . . . . . . . . . . . . . . . .

1
2
3

Instantaneously
Every 4 hours
Every 8 hours
Every 12 hours
Every 24 hours
Other
Unknown
Yes
No
Unknown

to Part B. Survey
} SKIP
Implementation on page 8

Yes
No
Unknown
Yes, we intend to apply – Go to item 11f1
Uncertain whether we will apply SKIP to
Part B
No, we will not apply

}

2011
2012
After 2012
Unknown
Medicare
Medicaid
Unknown

NOTES

Page 18

1
2

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

Yes
No
Unknown

d. Does your hospital have hospitalists on

Skip to 14w6 Skip to 14w6 Skip to 14w6
If Yes, ask – (a) Are results incorporated in EMR/EHR?

1
2

Skip to 14w5 Skip to 14w5 Skip to 14w5
If Yes, ask – (a) Are orders sent electronically to the lab?

Unknown

3
1

Skip to 14w4 Skip to 14w4 Skip to 14w4
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? . . . . . . . . . . . . . . . . . . . . . . .

FORM NHAMCS-101 (12-10-2009)

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

CHECK
ITEM D-1

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

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

Is the total number of expected OPD visits during the reporting period between
and
?
Yes – SKIP to 14t on page 18.
No, it is MORE THAN the range – GO to item a.
2
No, it is LESS THAN the range – SKIP to item c.
3
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
Yes, this is correct, some clinics have opened or should have been included last year. – List
1

12. Are there any additional steps needed to obtain permission for the hospital to
participate in the study?
1
Yes – Specify the necessary steps below
No
2

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

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

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?
1

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

No, the number of visits has not decreased dramatically.

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

14t. Does your OPD submit CLAIMS
electronically (electronic billing)?

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

1
2

1
2
3
4

(1) Which year did your OPD install the
EMR/EHR system?
(2) What is the name of your current
EMR/EHR system?
Mark (X) only one box.

1
2
3
4
6

FORM NHAMCS-101 (12-10-2009)

3
4

No
Unknown

Yes, all electronic
Yes, part paper and part electronic Go to item 14u(1)
No
SKIP to item 14v
Unknown

}

Year

Page 8

Yes, all electronic
Yes, part paper and
part electronic

Allscripts
Cerner
eClinicalWorks
Eclipsys
Epic
eMDs

7
8
9
10
11

GE Centricity
Greenway
Medical
HealthPort
McKesson
NextGen

12
13
14
15
16

Praxis
Practice One
Sage Intergy
Other
Unknown
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
Specialty
Group Scope

(b)

(c)

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

In-Scope
Out-of-Scope

Name
Title
Department

Record on
Control Card

Telephone number
Name
Title
Department

Record on
Control Card

Telephone number

CHECK
ITEM C

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.

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 (12-10-2009)

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 has/have been created or has/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.

Line
No.

(2) If the hospital has not previously participated or a clinic list is not attached to NHAMCS-101(C) Control Card,
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.

• Psychiatric
• Other

Emergency service area name
(Generic)

ESA
type

(a)

(b)

(b) adding the name(s) of any new clinic(s) which has/have been created or 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.

(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 the NHAMCS-101(C) Control Card.

• 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

(a) crossing through any clinics on the list which no longer exist or are no longer operational in that hospital.

(c) obtaining an estimate of visits for each clinic, covering the 4-week reporting period. Enter the estimate in
column (d).

INSTRUCTION:

ESA types include:
• General
• Pediatric
• Adult
• Urgent care/Fast track

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 (12-10-2009)

Page 15

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14s. Does your ED use —

CHECK
ITEM C-1

Show flashcard on page 31 of the NHAMCS-124.

Is the total number of expected ED visits during the reporting period between

Mark (X) only one box.

and
Yes

(1) Bedside registration

(2) Computer-assisted triage

(3) Separate fast track unit for nonurgent care

Unknown
3

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

(4) Separate operating room dedicated to ED patients

(5) Electronic dashboard (i.e., displays updated patient information
and integrates multiple data sources)

(6) Radio frequency identification (RFID) tracking (i.e., shows exact
location of patients, caregivers, and equipment)

(7) Zone nursing (i.e., all of a nurse’s patients are located
in one area)

(8) Pool nurses (i.e., nurses that can be pulled to the ED to respond
to surges in demand)

(9) Full capacity protocol (i.e., allows some admitted patients to
move from the ED to inpatient corridors while awaiting a bed)
CHECK
ITEM C-3

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

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?
1

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

No, the number of visits has not decreased dramatically.

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.

NOTES

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

14a. Does your ED submit CLAIMS electronically
(electronic billing)?

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

1
2

1
2
3
4

Yes, all electronic
Yes, part paper and
part electronic

1
3
4
5
6

c. Does your ED have plans for installing a
new EMR/EHR system within the next 18
months?

1
2
3
4

Page 14

FORM NHAMCS-101 (12-10-2009)

No
Unknown

}

Year

Mark (X) only one box.

Yes, all electronic
Yes, part paper and part electronic Go to item 14b(1)
No
SKIP to item 14c
Unknown

(1) Which year did your ED install the
EMR/EHR system?
(2) What is the name of your current
EMR/EHR system?

Allscripts
Cerner
eClinicalWorks
Eclipsys
Epic
eMDs

7
8
9
10
11

GE Centricity
Greenway
Medical
HealthPort
McKesson
NextGen

12
13
14
15
16

Praxis
Practice One
Sage Intergy
Other
Unknown

Yes
No
Maybe
Unknown
Page 11

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14d. Indicate whether your ED has each of the
following computerized capabilities. Does your
ED have a computerized system for: Mark (X) only
one box per row.

(1) Patient history and demographic information? .

Yes

Yes, but
turned off
or
not used

14j. If the ED is critically overloaded, are
No
3

Unknown
4

Skip to 14d2 Skip to 14d2 Skip to 14d2
If Yes, ask – (a) Does this include a patient problem list?

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

Skip to 14d3 Skip to 14d3 Skip to 14d3
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 14d4 Skip to 14d4 Skip to 14d4
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 14d5 Skip to 14d5 Skip to 14d5
If Yes, ask – (a) Are orders sent electronically to the lab?

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

1
1

Skip to 14d6 Skip to 14d6 Skip to 14d6
If Yes, ask – (a) Are results incorporated in EMR/EHR?
(b) Are out of range levels highlighted?

(6) Viewing imaging results? . . . . . . . . . . . . . . . . . . .
(7) Reminders for guideline-based interventions
or screening tests? . . . . . . . . . . . . . . . . . . . . . . . . .

(8) Electronic reporting to immunization registries?
e. At your ED, if orders for prescriptions or lab tests
are submitted electronically, who submits them?

2
3
4
5
6
7

g. Does your ED have a physically separate
observation or clinical decision unit?

1
2
3

h. What type of physicians make decisions for
patients in this observation or clinical
decision unit?

1
2
3
4

i. Are admitted ED patients ever "boarded" for
more than 2 hours in the ED or the observation
unit while waiting for an inpatient bed?
Page 12

1
2
3

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Other
Prescriptions and lab test orders
not submitted electronically
Unknown

1
2
3

(1) What is the total number of hours that
your hospital’s ED was on ambulance
diversion in 2009?
managed on a regional level versus
each hospital adopting diversion if and
when it chooses?

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

1
1
2
3

1
2
3

Yes
No
Unknown
Yes – GO to item (1)
No
SKIP to item 14n
Unknown

}

Total number of hours
Data not available
Yes
No
Unknown
Yes
No
Unknown

n. As of last week, how many standard
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.

Total number of standard treatment spaces
1

Data not available

o. As of last week, how many other
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.

p. In the last two years, has your ED increased

2009?

l. Is ambulance diversion actively
1

k. Did your ED go on ambulance diversion in

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

the number of standard treatment spaces?

Total number of other treatment spaces
1

Data not available

Yes
No
Unknown

2
3

q. In the last two years, has your ED’s physical
space been expanded?

1
2
3

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

1
2
3

Yes
No
Unknown
Yes
No
Unknown

NOTES

Yes
No
SKIP to item 14i
Unknown

}

ED physicians
Hospital lists
Other physicians
Unknown
Yes
No
Unknown
FORM NHAMCS-101 (12-10-2009)

FORM NHAMCS-101 (12-10-2009)

Page 13

File Type	application/pdf
File Title	untitled
File Modified	2009-12-14
File Created	2009-12-14