OPD Patient Record - 11/29/2010

National Hospital Ambulatory Medical Care Survey

nhamcs100opd

OPD Patient Record 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⚠️ Notice: This form may be outdated.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

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

Draft 9 (9-22-2010)

NHAMCS-100(OPD)

(9-22-2010)

NHAMCS-100(OPD), (Cover, Page 2, and back cover), Pantone 463U, 10% and 100%, tone

USCENSUSBUREAU

FORM

No. of
records
filled

Mon.

Thur.

Patient.

Tues. Wed.

Month

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

Total

VICES • U
SA
SER
AN

Notice – Public reporting burden for this collection of information is estimated to average 9 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 Information Collection Review Office, 1600 Clifton Road, MS
D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).

W
E
E No. of
K patient
visits
4

W
E
E No. of
K patient
visits
2

Total

Dates

Sun.

Dates

Sat.

No. of
records
filled

Fri.

No. of
records
filled

Thur.

Day

Patient. Take every

Dates
W
E
E
K No. of
patient
3 visits

Tues. Wed.

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

2011 Outpatient Department
Patient Record Folio

National Hospital
Ambulatory Medical
Care Survey

CENTERS FOR DISEASE CONTROL
AND PREVENTION

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

HEALTH & H
UM
OF
NT

DEPAR
TM
E

2011 OPD
TAKE EVERY

Phone Number

Name

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

FORM NHAMCS-100(OPD) (9-22-2010)

FIELD REP

DISPOSITION As each Patient Record is completed, place it in the pocket of the
OF
folio. At the end of each day, review all forms to be sure they are
MATERIALS
properly completed, verify that the total number of completed
Patient Records equals the number appearing on the last
completed Patient Record. At the end of the Reporting Period,
detach patient’s name, return all Patient Records and all unused
materials to the field representative as arranged. (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 member 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);
and telephone/e-mail contacts with patients.

DEFINITIONS For purposes of this study:

Please refer to the NHAMCS-123 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 clinic 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 clinic 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 during the entire Reporting Period,
then the Take Every Number 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 by your clinic. Record each patient
in the order registered by the 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 the provider 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; Expiration date 08/31/2012

NHAMCS-100(OPD)

U.S. DEPARTMENT OF COMMERCE

FORM
(9-22-2010)

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
2011 OUTPATIENT 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 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).
(Provider: Detach and keep upper portion)
Please keep (X) marks inside of boxes ➜

✗

✗ Incorrect

Correct

2. INJURY/POISONING/
ADVERSE EFFECT

1. PATIENT INFORMATION
d. Sex

a. Date of visit
Month

Day

Year

Female

g. Expected source(s) of payment
for this visit – Mark (X) all that apply.
1
Private insurance
2
Medicare
3
Medicaid or CHIP
4
Worker’s compensation
5
Self-pay
6
No charge/Charity
7
Other
8
Unknown
h. Tobacco use
Not current
1
Unknown
3
Current
2

Male

e. Ethnicity
1
Hispanic or Latino
Not Hispanic or Latino
2

1
b. ZIP Code

f. Race – Mark (X) one or more.
White
1
2
Black or African American
Asian
3
Native Hawaiian or
4
Other Pacific Islander
American Indian or Alaska Native
5

c. Date of birth
Month Day
Year

3. REASON FOR VISIT

Is this visit related to any
of the following?
1

Unintentional injury/poisoning

Intentional injury/poisoning

Injury/poisoning –
unknown intent

Adverse effect of medical/
surgical care or adverse
effect of medicinal drug

None of the above

4. CONTINUITY OF CARE

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

1
2
3

(2) Other:

b. Has the patient been seen
in this clinic before?

a. Is this clinic the
patient’s primary
care provider?

1
1

Yes –SKIP to item 4b.
No
Unknown

}

Yes, established patient –
How many past visits
in the last 12 months?
Exclude this visit.

2
3
4

Was patient referred
for this visit?
Yes
1
No
2
Unknown
3

(3) Other:

c. Major reason for this visit

Visits
Unknown

1
2

No, new patient

New problem (<3 mos.
onset)
Chronic problem, routine
Chronic problem, flare-up
Pre/Post surgery
Preventive care (e.g.,
routine prenatal,
well-baby, screening,
insurance, general exams)

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

(2) Other:

(3) Other:

7. DIAGNOSTIC/SCREENING SERVICES

6. VITAL SIGNS
(1) Height
ft

(2) Weight
lb

OR
kg
(3) Temperature

gm
(4) Blood pressure
Systolic
Diastolic

˚C
˚F

b. Regardless of the diagnoses written in 5a, does the patient
now have – Mark (X) all that apply.
10
Hyperlipidemia
5
Arthritis
1
Chronic renal failure
Hypertension
2
11
Asthma
6
Congestive heart
failure
Cancer
3
12
Ischemic heart
disease
COPD
7
Cerebrovascular
4
Obesity
13
disease/History of
8
Depression
stroke or transient
Osteoporosis
14
9
Diabetes
ischemic attack (TIA)
15
None of the above

Other tests:
Mark (X) all ordered or provided at this visit.
Mammography
24
Biopsy –
14
1
NONE
Specify site
MRI
15
Examinations:
16
Other imaging
2
Breast
25
Chlamydia test
Blood tests:
3
Foot
26
EKG/ECG
17
CBC (complete blood count)
4
Pelvic
27
HIV test
Glucose
18
5
Rectal
28
HPV DNA test
HgbA1c
(glycohemoglobin)
19
Retinal
6
29
Pap test
Lipids/Cholesterol
20
7
Skin
Pregnancy/HCG test
30
PSA
(prostate
specific
antigen)
21
8
Depression screening
31
Urinalysis
(UA)
Other
blood
test
22
Imaging:
32
Other exam/test/service - Specify
9
X-ray
Scope:
10
Bone mineral density 23
Scope procedure
11
CT scan
(e.g., colonoscopy) - Specify
12
Echocardiogram
Other ultrasound
13

9. NON-MEDICATION TREATMENT

8. HEALTH EDUCATION

Mark (X) all ordered or provided at this visit.
Mark (X) all ordered or provided at this visit.
1
NONE
8
Psychotherapy
Injury prevention
1
NONE
7
2
Complementary
alternative
9
Other
mental health
Asthma education
2
8
Stress management
medicine (CAM)
counseling
Diet/Nutrition
3
9
Tobacco use/
3
Durable medical equipment
10
Excision of tissue
Exposure
4
Exercise
4
Home health care
11
Wound care
10
Weight reduction
5
Family planning/
5
Physical therapy
12
Cast
Contraception
Other
11
Radiation therapy
6
13
Splint or wrap
6
Growth/Development
Speech/Occupational therapy
7

10. MEDICATIONS & IMMUNIZATIONS
NONE

11. PROVIDERS

Include Rx and OTC drugs, immunizations, allergy shots, oxygen,
anesthetics, chemotherapy, and dietary supplements that were
ordered, supplied, administered or continued during this visit.
New Continued

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

NHAMCS-100(OPD) (9-22-2010)

2011 OPD

Mark (X) all
providers seen at
this visit.
1
2
3

4
5
6

Physician
Physician
assistant
Nurse
practitioner/
Midwife
RN/LPN
Mental health
provider
Other

Procedures:
Other non-surgical procedures –
Specify

Other surgical procedures –
Specify

12. VISIT DISPOSITION
Mark (X) all that apply.
1
2
3
4

Refer to other physician
Return at specified time
Refer to ER/Admit to hospital
Other

Continue on reverse side

§8!!(9¤
2300001

13. LABORATORY TEST RESULTS
Item
number

Were the following laboratory tests drawn
within 12 months of this visit?

(a)

Most recent result

(b)

Date of the most recent result
(mm/dd/yyyy)

(c)

(d)

Total Cholesterol

1
2