Form unnumbered Att. M. ED Patient Record Form

CENTERS FOR DISEASE CONTROL
AND PREVENTION

Form Approved: OMB No. 0920-0278

National Hospital
Ambulatory Medical
Care Survey

REPORTING
PERIOD

FROM:

Month

Day

Patient. Take every

Mon.

TO:

Month

Thur.

Patient.

Tues. Wed.

Day

Fri.

Sat.

Sun.

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

Economics and Statistics Administration
ACTING AS DATA COLLECTION AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

AN

ME

(4-13-2009)

Centers for Disease Control and Prevention
National Center for Health Statistics

V ICES
SER

US
A

Total

2010 Emergency Department
Patient Record Folio
Hospital ID
Ambulatory Unit Number
Start with the

Total

Please return the whole Folio with both the completed
and blank forms at the completion of the survey period.
Thank you!

Sun.

Dates
W
E
E
K No. of
patient
3 visits

Sat.

No. of
records
filled

Fri.

Dates
W
E
E
K No. of
patient
1 visits

Dates

Thur.

No. of
records
filled

W
E
E No. of
K patient
visits

Tues. Wed.

Dates

4

Mon.

W
E
E No. of
K patient
visits

No. of
records
filled

2

NHAMCS-100(ED)

Notice – Public reporting burden for this collection of information is estimated to average 7 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).

No. of
records
filled

FORM

USCENSUSBUREAU

2010 ED
NHAMCS-100(ED), (Cover, Page 1, and back cover), Pantone 385U, 10% and 70% tone

DEPAR
T

NHAMCS-100(ED), (Cover, Page 1, and back cover), Solid Black

H EALT H & H
UM
OF
NT

GENERAL INSTRUCTIONS

Your reporting dates are:

See card in pocket for instructions on how to complete
Patient Record.

REPORTING
DATES

through Sunday,

Record the name of every patient seen during the Reporting
Period on a Sign-In Sheet maintained in each area of the
emergency department. Record each patient in the order
registered by your 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 more than once during the Reporting Period should be
recorded on the Sign-In Sheet at each visit.

Monday,

PATIENT
SIGN-IN
SHEET

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

TAKE EVERY:

PATIENT
RECORD

START WITH:

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 emergency department 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 emergency department 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 NHAMCS-122 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 physician or hospital staff member under a
physician’s supervision for the purpose of seeking care and
rendering personal health services.

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

DISPOSITION As each Patient Record is completed, place it in the pocket of the
folio. At the end of each day, scan all forms to be sure they are
OF
properly completed, verify that the total number of completed
MATERIALS
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

Name

Phone Number

FORM NHAMCS-100(ED) (4-13-2009)

Form Approved: OMB No. 0920-0278

NHAMCS-100(ED)

U.S. DEPARTMENT OF COMMERCE

FORM
(4-13-2009)

Economics and Statistics Administration

PATIENT RECORD NO.:

U.S. CENSUS BUREAU
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
2010 EMERGENCY 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)
Please keep (X) marks inside of boxes ➜

✗

✗ Incorrect

Correct

1. PATIENT INFORMATION
a. Date and time of visit
Month

c. Date of birth
Month
Day

b. ZIP Code
Year

Day

a.m. p.m. Military

Time

Year

:

(1) Arrival
Seen by
(2) MD/DO/PA/NP

d. Patient residence e. Sex
Private residence
1
Female
1
Nursing home
2
Male
2
Homeless
3
4
Other
Unknown
5

:
:

(3) ED discharge

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

g. Race – Mark (X) one or more.
h. Arrival by ambulance i. Expected source(s) of payment for this visit – Mark (X) all that apply.
White
Native Hawaiian or
4
Worker’s compensation
7
Other
1
4
1
Private insurance
1
Yes
Other Pacific Islander
Medicare
2
2
5
Self-pay
Unknown
Black or
8
No
2
African American 5
American Indian or
Medicaid/SCHIP
3
No charge/Charity
6
Unknown
3
Alaska Native
3
Asian

2. TRIAGE
a. Initial vital
signs

(1) Temperature

(2) Heart rate
˚C
˚F

(4) Blood pressure
Systolic

(5) Pulse oximetry
Diastolic

1

/

%

(3) Respiratory rate
b. Triage level
(1–5)
per
minute
(7) Glasgow Coma
No triage
1
Scale (3–15)
Unknown
Unknown
2

2

Yes
No

3

3. PREVIOUS CARE
Yes
a. Has patient been –
(1) seen in this ED within
1
the last 72 hours? . .
(2) discharged from any
hospital within the
1
last 7 days? . . . . . .
b. How many times has patient
been seen in this ED within
the last 12 months? . . . .

c. Pain scale
(0–10)

per
minute
(6) On oxygen

1

Unknown

4. REASON FOR VISIT
No Unknown
2

2

3

3

b. Episode of
care

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

1

(2) Other:

2

(3) Other:

3

Initial visit
for problem
Follow-up visit
for problem
Unknown

3

5. INJURY/POISONING/ADVERSE EFFECT
a. Is this visit
related to an
injury, poisoning,
or adverse effect
of medical
treatment?
1
Yes
2
No – SKIP to
item 6.

b. Is this injury/
poisoning
intentional?
1
2
3
4

c. Cause of injury, poisoning, or adverse effect – Describe the place and events that preceded the injury,
poisoning, or adverse effect (e.g., allergy to penicillin, bee sting, pedestrian hit by car driven by drunk driver, spouse
beaten with fists by spouse, heroin overdose, infected shunt, etc.).

Yes, self inflicted
Yes, assault
No, unintentional
Unknown

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

b. Does patient have – Mark (X) all that apply.
4
HIV
1
Cerebrovascular disease/
History of stroke
5
Diabetes
Congestive heart failure
2
6
None of
3
the above
Condition requiring dialysis

7. DIAGNOSTIC/SCREENING SERVICES

8. PROCEDURES

Mark (X) all ordered or provided at this visit.
Mark (X) all provided
at this visit. Exclude
1
NONE
16
Influenza test
Blood tests:
Pregnancy/HCG test medications.
17
CBC
2
1
NONE
Toxicology screen
18
3
BUN/Creatinine
2
IV fluids
19
Urinalysis (UA)
4
Cardiac enzymes
3
Cast
20
Wound culture
Electrolytes
4
5
Splint or wrap
21
Other test/service
6
Glucose
5
Suturing/Staples
Imaging:
Liver function tests 22
7
6
Incision & drainage (I&D)
X-ray
8
Arterial blood gases 23
7
Foreign body removal
CT scan
9
Prothrombin time/INR
8
Nebulizer therapy
Head
Blood culture
10
Other than head
9
Bladder catheter
BAC (blood alcohol)
11
10
24
MRI
Pelvic exam
12
Other blood test
11
Central line
25
Ultrasound
Other tests:
Other imaging
26
12
CPR
13
Cardiac monitor
13
Endotracheal intubation
14
EKG/ECG
14
Other
15
HIV test

10. PROVIDERS
Mark (X) all providers
seen at this visit.
1
ED attending physician
2
ED resident/Intern
Consulting physician
3
4
RN/LPN
5
Nurse practitioner
6
Physician assistant
EMT
7
Mental health provider
8
Other
9

NHAMCS-100(ED) (4-13-2009)

11. SERVICE LEVEL
Mark (X) all that apply.
(CPT code)
1
2
3
4
5
6
7

1 (99281)
2 (99282)
3 (99283)
4 (99284)
5 (99285)
Critical care (99291)
Unknown

9. MEDICATIONS & IMMUNIZATIONS
List up to 8 drugs given at this visit or prescribed at ED discharge.
Include Rx and OTC drugs, immunizations, and anesthetics.
Given
in ED

NONE

Rx at
discharge

(1)

1

2

(2)

1

2

(3)

1

2

(4)

1

2

(5)

1

2

(6)

1

2

(7)

1

2

(8)

1

2

12. VISIT DISPOSITION
Mark (X) all that apply.
1
No follow-up planned
2
Return if needed, PRN/appointment
3
Return/Refer to physician/clinic for FU
4
Left before triage
Left after triage
5
6
Left AMA
7
DOA
Died in ED
8
9
Return/Transfer to nursing home
Transfer to psychiatric hospital
10
11
Transfer to other hospital

12
13
14
15

}

Admit to this hospital
Continue with Item 13
Admit to observation unit on reverse side.
then hospitalized
Admit to observation unit, then discharged – Continue
with Item 14 on reverse side.
Other

2010 ED

13. HOSPITAL ADMISSION
Complete if the patient was admitted to this hospital at this ED visit. – Mark (X) "Unknown" in each item, if efforts have been exhausted to collect the data.
c. Date and time bed was requested for hospital admission

a. Admitted to:
1
2
3
4
5
6
7

Critical care unit
Stepdown unit
Operating room
Mental health or detox unit
Cardiac catheterization lab
Other bed/unit
Unknown

Month

1
2
3

Year

a.m. p.m. Military

Time

:
Unknown

1

d. Date and time patient actually left the ED
Month

Day

Year

a.m. p.m. Military

Time

:
Unknown

1

b. Admitting physician

Day

e. Hospital discharge date
Month

Hospitalist
Not hospitalist
Unknown
1

Day

Year

Unknown

f. Principal hospital discharge diagnosis

1

Unknown

g. Hospital discharge status/disposition
1
Alive
1
Home/Residence
2
Dead
2
Return/Transfer to nursing home
3
Unknown
3
Transfer to another facility (not usual place of residence)
Other
4
5
Unknown

{

▲

If this information is not available at time of abstraction, then complete the Hospital Admission Log.
14. OBSERVATION UNIT STAY

a. Date and time of observation unit discharge
Month

Day

Year

a.m. p.m. Military

Time

:
1

Unknown

NHAMCS-100(ED) (4-13-2009)