ASC Patient Record Form - 5/2011

Sun.
Total

NHAMCS-100(ASC)

(3-29-2011)

NHAMCS-100(ASC), (Cover, Page 2, and back cover), Pantone Orange 1505U, 40% & 100% tone

USCENSUSBUREAU

FORM

No. of
records
filled

No. of
records
filled

Tues. Wed.

Thur.

Patient.

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

AN

Total

V ICES U
SA
SER

Notice – Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewin g the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of in formation
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).

Dates
W
E
E No. of
K patient
visits
4

Dates
W
E
E No. of
K patient
visits
2

Mon.

TO:

Month

H EALT H & H
UM
OF
NT

E

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

Sat.

No. of
records
filled

Fri.

No. of
records
filled

Thur.

Dates
W
E
E
K No. of
patient
3 visits

Tues. Wed.

Day

Patient. Take every

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

2012 Ambulatory Surgery
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

DEPAR
TM

2012 ASC
TAKE EVERY:

Phone Number

Name

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

FORM NHAMCS-100(ASC) (3-29-2011)

FIELD REP

DISPOSITION As each Patient Record is completed, place it in the pocket of the
folio. At the end of each day, review 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 the patient’s name, and 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
surgery patient and a physician or facility staff under a
physician’s supervision for the purpose of seeking ambulatory
(outpatient) surgery.

1. An ambulatory surgery patient is an individual presenting for one
or more previously scheduled outpatient surgical or diagnostic
procedure(s). 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-126 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 ambulatory surgery center 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 ambulatory surgery center
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 ambulatory (outpatient) surgery
patient seen during the Reporting Period on one or more Sign-In
Sheets maintained by the inscope ambulatory surgery locations.
Record each patient in the order registered by your receptionist
or seen by the provider. 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,

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(ASC)

U.S. DEPARTMENT OF COMMERCE

FORM
(3-29-2011)

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 HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2012 AMBULATORY SURGERY 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 nec essary 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 ➜

✗

Correct

✗ Incorrect
1. PATIENT INFORMATION

a. Date of visit
Day

Month

Year

1

b. ZIP Code

c. Date of birth
Month Day
Year

d. Sex
Female

1

2

Male

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

f. Race – Mark (X) all that apply. h. Time
White
1
Month
2
Black or African American
(1) Time into
Asian
3
operating
room . . . .
Native Hawaiian or
4
Other Pacific Islander
Month
American Indian or
5
Alaska Native
(2) Time surgery
began . . .
g. Expected source(s) of
payment for this visit –
Month
Mark (X) all that apply.
(3) Time surgery
1
Private insurance
ended . . .
2
Medicare
3
Medicaid or CHIP
Month
(4) Time out of
4
Worker’s compensation
operating
5
Self-pay
room . . . .
6
No charge/Charity
7
Month
Other
(5) Time into
8
Unknown
postoperative
care . . . .
(6) Time out
Month
of
postoperative
care . . . .

Year

Day

1

Time

1
1
1
1
1

Time

a.m. p.m. Military

Time

a.m. p.m. Military

:

Year

Day

a.m. p.m. Military

:

Year

Day

Time

:

Year

Day

a.m. p.m. Military

:

Year

Day

a.m. p.m. Military

:

Year

Day

Time

Time

a.m. p.m. Military

:

2. SURGICAL DIAGNOSIS
Optional –
ICD-9-CM Code

a. As specifically as possible, list all diagnoses related to this surgery or procedure.

•

Primary: 1.

Other:

2.

Other:

3.

Other:

4.

Other:

5.

•
•
•
•

b. Other diagnoses that could impact this surgery – Mark (X) all that apply.
1
2
3
4

Airway problem
Asthma
Cardiac surgery history
Cerebrovascular disease/History of
stroke or transient ischemic attack
(TIA)

5
6
7
8
9

Chronic obstructive pulmonary disease (COPD)
Congestive heart failure (CHF)
Coronary artery disease (CAD)
Diabetes
Hypertension

10
11
12
13

Morbid obesity
Obstructive sleep apnea
Renal failure
Other

3. PROCEDURE(S)
As specifically as possible, list all diagnostic and surgical procedures
performed during this visit.
NONE

2.

Other:

3.

Other:

4.

Other:

5.

Other:

6.

Other:

7.

Optional –
ICD-9-CM-Codes

•

Primary: 1.
Other:

Optional –
CPT-4 Codes

•
•
•
•
•
•

PLEASE CONTINUE ON THE REVERSE SIDE
NHAMCS-100(ASC) (3-29-2011)

2012 ASC

4. MEDICATION(S) & ANESTHESIA
a. Mark (X) all drugs and anesthetics that were administered and whether they were administered preoperatively,
intraoperatively, and/or postoperatively.
1

NONE – SKIP to item 6.

Preop

2

Fentanyl

. . . . . . . . . . . . . . . . . . . .

1

2

3

3

Midazolam . . . . . . . . . . . . . . . . . . .

1

2

3

4

Nitrous oxide . . . . . . . . . . . . . . . . . .

1

2

3

5

Oxygen . . . . . . . . . . . . . . . . . . . . .

1

2

3

6

Pentathol . . . . . . . . . . . . . . . . . . . .

1

2

3

7

Propofol . . . . . . . . . . . . . . . . . . . . .

1

2

3

8

Zofran . . . . . . . . . . . . . . . . . . . . . .

1

2

3

9

Other – Specify

1

2

3

1

2

3

1

2

3

1

2

3

Intraop

Postop

Other – Specify

10

Other – Specify

11

Other – Specify

12

b. Type(s) of anesthesia listed in 4a – Mark (X) all that apply.
1

NONE – SKIP to item 6.

2

General
IV sedation
MAC (Monitored Anesthesia Care)
Topical/Local

3
4
5

Regional
Epidural
Spinal
Retrobulbar block
Peribulbar block
Other block

6
7
8
9
10

5. PROVIDER(S) OF ANESTHESIA
Anesthesia administered by –
Mark (X) all that apply.

11

Other

6. SYMPTOM(S) PRESENT DURING OR AFTER PROCEDURE
Mark (X) all that apply.
1

NONE

Anesthesiologist

2

2 2

CRNA (Certified Registered Nurse Anesthetist)

3

3 3

Surgeon/Other physician

4 4

Resident

5 5

Unknown

Airway problem or aspiration
Arrhythmia – significant
Bleeding (post-operative) – moder ate
to severe
Hypertension/High blood pr essure –
>20% change fr om baseline
Hypotension/Low blood pressure –
>20% change from baseline

1 1

4
5
6

1
2
3
4
5
6

7

8
9

Routine discharge to customary residence
Discharge to observation status
Discharge to post-surgical/recovery care facility
Admitted to hospital as inpatient
Referred to ED
Surgery terminated
Reason for termination
a
Allergic reaction
Unable to intubate
b
Other
c
Procedure canceled on arriv al to ambulatory
surgery unit
Reason for cancellation
a
Patient not n.p.o.
Incomplete or inadequate medic al evaluation
b
Surgical issue
c
Other
d
Other
Unknown

NHAMCS-100(ASC) (3-29-2011)

8
9
10
11
12
13
14

Hypoxia
Nausea – moderate to severe
Pain – moderate to severe
Sedation – excessive
Surgical complications – unanticipated
Urinary retention
Vomiting – moderate to severe
Other

8. FOLLOW-UP INFORMATION

7. DISPOSITION
Mark (X) one box.

7

a. Did someone attempt to follow-up with the patient within 24 hours
after the surgery?
Mark (X) one box.
1
2
3

Yes – Continue with Item 8b.
No
END – Patient Record complete.
Unknown

}

b. What was learned from this follow-up?
Mark (X) all that apply.
1
2
3
4
5
6
7

Unable to reach patient
Patient reported no problems
Patient reported problems and sought medical care
Patient reported problems and was advised by ASC staff to seek medical care
Patient reported problems, but no follow-up medical care was needed
Other
Unknown