NAMCS 2011 Patient Record Folio

National Ambulatory Medical Care Survey

Att G FINAL namcs30

NAMCS-30 Patient Record form (Line 3)

OMB: 0920-0234

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0234 can be found here:

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Attachment G: National Ambulatory Medical Care Survey 2011 Patient Record Folio

Form Approved: OMB No. 0920-0234 Exp. Date 02/28/2013

CENTERS FOR DISEASE CONTROL
AND PREVENTION

National Ambulatory
Medical Care Survey
2011 Patient Record Folio
Physician ID:
FROM

TO
Month

Day

Month

Day

WEEK OF –
Mon.

SURVEY WEEK
Complete a Patient
Record for patient
SW

Tues.

Wed.

Thur.

Fri.

Sat.

Sun.

Total

Number
of patient
visits

and
every

nth
patient thereafter.

Number
of
records
completed
Please return the entire Folio with both the completed and blank
forms at the completion of the survey week. Thank you!

Notice – Public reporting burden for this collection of information is estimated to average 11 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 (0920-0234).

Complete Item 14:

Yes

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

(2-4-2011)

USCENSUSBUREAU

Centers for Disease Control and Prevention
National Center for Health Statistics

V ICES U
SA
SER

H EALT H & H
UM
OF
NT

NAMCS-30

FORM

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

DEPAR
TM

ACTING AS DATA COLLECTION AGENT FOR

GENERAL INSTRUCTIONS
See card in pocket for instructions on how to complete
Patient Record.
REPORTING
DATES

Your reporting dates are:
Monday,

through Sunday,

PATIENT
SIGN-IN
SHEET

Record the name of every patient seen during the Reporting Period
on a Sign-In Sheet maintained by your office. 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.

PATIENT
RECORD

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

TAKE EVERY

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 office 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 office 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.
Please refer to the NAMCS-26 Instruction Book for more
detailed information on the sampling pattern.
DEFINITIONS For purposes of this study:
1. An ambulatory patient is an individual presenting for personal
health services, not currently admitted to any health care
institution on the premises. Include patients the physician
sees; and patients the physician does not see but who receive
care from a physician assistant, nurse, nurse practitioner, etc.
Exclude persons who visit only for administrative reasons,
such as to complete an insurance form; patients who do not
seek care or services (e.g., pick up a prescription or leave a
specimen); persons currently admitted as inpatients to the
hospital (nursing home patients should be included,
however); and telephone/e-mail contacts with patients.
2. A visit is a direct, personal exchange between an ambulatory
patient and a provider or medical staff member under a
provider’s direction for the purpose of seeking care and
rendering personal health services.
3. Offices are premises that providers identify as locations for their
ambulatory practices, customarily including consulting,
examination, or treatment spaces their patients associate with
the particular provider.
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).
FIELD REP

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

Phone Number

FORM NAMCS-30 (2-4-2011)

Form Approved: OMB No. 0920-0234 Exp. Date 02/28/2013

NAMCS-30

U.S. DEPARTMENT OF COMMERCE

FORM
(2-4-2011)

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 AMBULATORY MEDICAL CARE SURVEY
2011 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 the 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

Office Location

2. INJURY/POISONING/
ADVERSE EFFECT

1. PATIENT INFORMATION
d. Sex

a. Date of visit
Month

Day

Year

Male

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

1
b. ZIP Code

c. Date of birth
Month Day

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

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

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 your practice before?

a. Are you the patient’s
primary care
physician/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
1
2

Unknown

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
˚C
˚F

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

gm
(4) Blood pressure
Systolic
Diastolic

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
30
Pregnancy/HCG test
PSA (prostate specific antigen)
8
Depression screening 21
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
Complementary alternative
9
Other mental health
Asthma education
2
8
Stress management 2
medicine (CAM)
counseling
Diet/Nutrition
3
9
Tobacco use/
Durable medical equipment
3
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
6
Radiation therapy
Splint or wrap
6
Growth/Development
7
Speech/Occupational therapy 13

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)

13. TIME SPENT
WITH
PROVIDER

(8)

Minutes

NAMCS-30

Procedures:
Other non-surgical procedures –
Specify

Other surgical procedures –
Specify

12. VISIT DISPOSITION

Mark (X) all providers Mark (X) all that apply.
seen at this visit.
1
Physician
Refer to other physician
1
Physician
2
Return at specified time
2
assistant
3
Refer to ER/Admit to hospital
3
Nurse
practitioner/
4
Other
Midwife
RN/LPN
4
Continue on
Mental health
5
reverse side
provider
Other
6

(1)

NAMCS-30 (2-4-2011)

➥

Enter zero
if no provider seen

14. LABORATORY TEST RESULTS
If the "Complete Item 14" box is checked YES on the front of this folio, please provide the test results requested
below. If neither box is checked, please see Appendix E in the NAMCS-26 Instruction Booklet.
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