Outpatient Dept Patient Record Pretest

National Hospital Ambulatory Medical Care Survey

Attachment E - NHAMCS-100(OPD) -rev

Pretests

OMB: 0920-0278

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0278 can be found here:

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Draft 2 (4-15-2011)

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

2012 OPD

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

CENTERS FOR DISEASE CONTROL
AND PREVENTION

REPORTING
DATES

PRETEST

Your reporting dates are:
Monday,

National Hospital
Ambulatory Medical
Care Survey

PATIENT
SIGN-IN
SHEET

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.

PATIENT
RECORD

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

2012 Outpatient Department
Patient Record Folio
Hospital ID

REPORTING
PERIOD

Month

Day

Month

FROM

Day

Patient. Take every

Please refer to the NHAMCS-123 Instruction Book for
more detailed information on the sampling pattern.

Patient.

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

Mon.

Tues. Wed.

Thur.

Fri.

Sat.

Sun.

Mon.

DEFINITIONS For purposes of this study:

Tues. Wed.

Thur.

Fri.

Sat.

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.

Sun.

Total

Dates
W
E
E
K No. of
patient
1 visits

Dates
W
E
E
K No. of
patient
3 visits

No. of
records
filled

Dates

W
E
E No. of
K patient
visits
2

W
E
E No. of
K patient
visits
4

No. of
records
filled

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.
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).

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).

FIELD REP

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

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

(4-15-2011)

USCENSUSBUREAU

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

NHAMCS-100(OPD), (Cover, Page 2, and back cover), Pantone 106, 20% and 100%, tone

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics

HEALTH & H
UM
OF
NT

NHAMCS-100(OPD)

VICES • U
SA
SER
AN

DEPAR
TM
E

ACTING AS DATA COLLECTION AGENT FOR
FORM

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 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.

Ambulatory Unit Number
Start with the

through Sunday,

Phone Number

FORM NHAMCS-100(OPD) (4-15-2011)

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

NHAMCS-100(OPD)

U.S. DEPARTMENT OF COMMERCE

FORM
(4-15-2011)

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 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:

a. Is this clinic the
patient’s primary
care provider?
1
2
3

(2) Other:

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

Yes –SKIP to item 4b.
No
Unknown

(3) Other:

1
1

}

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

c. Major reason for this visit

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

2
3
4
5

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:
b. Regardless of the diagnoses written in 5a, does the patient now have – Mark (X) all that apply.
Cerebrovascular
Cancer
4
3
Arthritis
1
disease/History of
2
Asthma
In situ
1
stroke or transient
Asthma control:
Asthma severity:
Stage I
2
ischemic attack (TIA)
3
Stage II
Well controlled
Intermittent
1
1
5
Chronic renal failure
Stage III
4
2
Not well controlled
2
Mild persistent
6
Congestive heart
5
Stage IV
3
Very poorly controlled
3
Moderate persistent
failure
6
Unknown stage
Other
4
4
Severe persistent
COPD
7
5
Other
8
Depression
Diabetes
9
6

10
11
12
13
14
15

Hyperlipidemia
Hypertension
Ischemic heart
disease
Obesity
Osteoporosis
9
None of the above

None recorded

6. VITAL SIGNS
(2) Weight

(1) Height
ft

(3) Temperature
lb

˚C
˚F

(4) Blood pressure
Systolic
Diastolic

OR
kg

7. SERVICES
Mark (X) all services ordered or provided at this visit.
18
Echocardiogram
1
NONE
Peak flow
36
Diet/Nurtrition
52
Other service – Specify
61
19
Other ultrasound 37
Pregnancy/HCG test
Exercise
53
Examinations:
20
Mammography
Sigmoidoscopy
38
54
Family planning/
2
Breast
21
MRI
Contraception
1
Provided
3
Depression screening
Other service – Specify
62
X-ray
22
Growth/Development
55
39
Spirometry
4
Foot
56
Injury
prevention
Other
tests:
Tonometry
40
5
General medical exam
Stress management
57
23
Audiometry
Urinalysis
41
Neurologic
6
58
Tobacco use/Exposure
24
Biopsy
7
Pelvic
Non-medication treatment:
Other service – Specify
63
Weight reduction
59
1
Provided
8
Rectal
Cast/splint/wrap
42
25
Cardiac stress test 43
Complementary alternative Other services not listed:
9
Retinal
medicine (CAM)
Colonoscopy
26
Other service – Specify
60
10
Skin
Durable medical equipment
44
1
Provided
Other service – Specify
64
Blood tests:
Home health care
45
Chlamydia test
27
11
CBC
Mental health counseling
46
28
EEG
12
Glucose
Physical therapy
47
29
EKG/ECG
13
HgbA1c (glycohemoglobin
Psychotherapy
48
30
EMG
A1C)
Continue on reverse side
Radiation therapy
49
Excision
of
tissue
31
Lipid profile
14
50
Wound
care
1
Provided
15
PSA (prostate specific
Health education:
32
Fetal monitoring
antigen)
Asthma
HIV test
33
51
Imaging:
HPV DNA test
1
34
Asthma action
Bone mineral density
16
plan given
PAP test
35
17
CT scan
to patient
Peak flow
36
NHAMCS-100(OPD) (4-15-2011)

2012 OPD

8.
NONE

9. PROVIDERS

MEDICATIONS & IMMUNIZATIONS

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)

Mark (X) all
providers seen at
this visit.

10. VISIT DISPOSITION
Mark (X) all that apply.
1
2

1
2
3

4
5
6

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

3
4

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

11. 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