2011 Pretest NAMCS Patient Record

Attachment T: 2011 Pretest-NAMCS Patient Record Form

For the 2011 pretest, the 2011 NAMCS patient record form (Attachment G) will be used as a survey template for all sampled physicians/CHC providers. The proposed asthma questions highlighted below will be added to the form for the pretest. It is estimated that the addition of the asthma questions will not change the currently approved burden of 9 minutes for the 2011 patient record form.

● In Section 7 (Diagnostic/Screening Services), add the following check-boxes under box #2 Asthma:

 Peak flow

 Spirometry

● In Section 8 (Health Education), under box #2 for asthma education, insert a check-box for “Asthma action plan given to patient”

● In a new section, document whether asthma severity is recorded with the following check-box:

Asthma severity:

 Intermittent

 Mild persistent

Moderate persistent

Severe persistent

Other (specify)___________________

None recorded