Emergency Dept Patient Pretest

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

2012 ED

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

CENTERS FOR DISEASE CONTROL
AND PREVENTION

PRETEST

REPORTING
DATES

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 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.

PATIENT
RECORD

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

2012 Emergency Department
Patient Record Folio
Hospital ID

REPORTING
PERIOD

Month

Day

Month

FROM:

Start with the

START WITH:

Patient. Take every

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 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.

Day

TO:

Ambulatory Unit Number

through Sunday,

Patient.

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

Please refer to the NHAMCS-122 Instruction Book for
more detailed information on the sampling pattern.
DEFINITIONS For purposes of this study:

Mon.

Tues. Wed.

Thur.

Fri.

Sat.

Sun.

Mon.

Tues. Wed.

Thur.

Fri.

Sat.

Total

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

No. of
records
filled

Dates

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.

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.

Dates

W
E
E No. of
K patient
visits
2

W
E
E No. of
K patient
visits
4

No. of
records
filled

No. of
records
filled

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 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 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).

FIELD REP

Name

U.S. DEPARTMENT OF COMMERCE
(4-19-2011)

Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR

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

AN

E

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

NHAMCS-100(ED), (Cover, Page 1, and back cover), Pantone Blue 3135U, 20% and 100% tone

V ICES U
SA
SER

H EALT H & H
UM
OF
NT

NHAMCS-100(ED)

Phone Number
DEPAR
TM

FORM

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

FORM NHAMCS-100(ED) (4-19-2011)

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

NHAMCS-100(ED)

U.S. DEPARTMENT OF COMMERCE

FORM
(4-19-2011)

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 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

1

(1) Arrival

Year

:

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

1

:

(3) ED discharge

1

:

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

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
Other
4
Worker’s compensation
7
1
4
1
Private insurance
1
Yes
Other Pacific Islander
2
Black or
No
2
8
5
Self-pay
Unknown
2
Medicare
African American 5
American Indian or
Unknown
3
6
No charge/Charity
3
Medicaid or CHIP
Alaska Native
3
Asian

2. TRIAGE
a. Initial vital
signs

(1) Temperature

(2) Heart rate
˚C
˚F

(4) Blood pressure
Systolic

(5) Pulse oximetry

(3) Respiratory rate
per
per
minute
minute
(6) On oxygen on arrival

Diastolic

Yes
No

1

/

%

2

3

1

Unknown

3. PREVIOUS CARE
a. Has patient been –
(1) seen in this ED within the
last 72 hours and discharged?
(2) discharged from any
hospital within the
last 30 days? . . . . .
b. How many times has patient
been seen in this ED within
the last 12 months? . . . .

b. Triage level
(1–5)

2

c. Pain scale
(0–10)

Unknown

1

No triage
Unknown

4. REASON FOR VISIT
Yes

No Unknown

1

2

3

1

2

3

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

b. Episode of
care
1

(2) Other:
2

(3) Other:
3

3

Initial visit to
this ED
for problem
Follow-up visit
to this ED
for problem
Unknown

5. INJURY/POISONING/ADVERSE EFFECT
a. Is this visit related to an injury, poisoning,
b. Is this injury/
or adverse effect of medical treatment?
poisoning
Mark (X) all that apply.
intentional?
4
No
1
Yes, injury/trauma
SKIP to
1
Yes, self inflicted
5
Unknown item 6
2
Yes, poisoning
Yes, assault
2
3
Yes, adverse effect
3
No, unintentional
of medical treatment
4
Unknown
– SKIP to 5c

}

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.).

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

b. Does patient have – Mark (X) all that apply.
Cancer
1
7
Dementia
Cerebrovascular disease/
2
8
Diabetes
History of stroke or transient
History of
9
ischemic attack (TIA)
heart attack
3
Chronic lung disease
History of pulmonary
10
4
Congestive heart failure
embolism or deep
vein thrombosis (DVT)
5
Condition requiring dialysis
HIV
6
Current medications includes 11
Coumadin (warfarin)
None of the above
12

7. DIAGNOSTIC SERVICES

8. PROCEDURES

Mark (X) all ordered or provided at this visit.
Mark (X) all provided
at this visit. Exclude
1
NONE
19
Influenza test
medications.
Pregnancy/HCG test
20
Blood tests:
1
NONE
2
Arterial blood gases 21 Toxicology screen
2
BiPAP/CPAP
3
BAC (blood alcohol 22 Urinalysis (UA)
3
Bladder catheter
23
Wound culture
concentration)
4
Cast, splint, wrap
24
Urine
culture
4
Blood culture
5
Central line
BNP (brain
25
Other test/service
5
6
CPR
natriuretic peptide)
Imaging:
7
Endotracheal intubation
6
BUN/Creatinine
X-ray
26
Incision & drainage (I&D)
8
7
Cardiac enzymes
27
Intravenous contrast
9
IV fluids
8
CBC
28
CT scan
Lumber puncture
9
D-dimer
Abdomen/Pelvis 10
11
Nebulizer therapy
10
Electrolytes
Chest
Pelvic exam
12
11
Glucose
Head
13
Suturing/Staples
Lactate
12
Other
14
Liver function tests
Skin adhesives
13
29
MRI
Prothrombin time/INR
Other
15
14
30
Ultrasound
15
Other blood test
Performed by:

Other tests:
16
17
18

Cardiac monitor
EKG/ECG
HIV test
31

NHAMCS-100(ED) (4-19-2011)

Emergency
physician
Radiologist
Other imaging

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.
NONE

Given
in ED

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

2012 ED

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

11. VISIT DISPOSITION
Mark (X) all that apply.
No follow-up planned
Return to ED
Return/Refer to physician/clinic for FU
Left before triage
Left after triage
Left AMA
DOA
Died in ED
Return/Transfer to nursing home
Transfer to psychiatric hospital
Transfer to other hospital

1
2
3
4
5
6
7
8
9
10
11

12
13
14
15

}

Admit to this hospital
Admit to observation unit Continue with Item 12
then hospitalized
Admit to observation unit, then discharged – SKIP
to Item 13
Other

12. 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 or transfer

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

1

:

Unknown

1

d. Date and time patient actually left the ED or observation unit
a.m. p.m. Military
Month
Day
Year
Time

1

:

Unknown

1

b. Admitting physician

Day

e. Hospital discharge date
Month

Hospitalist
Not hospitalist
Unknown

Day

Year

1
1

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.
13. OBSERVATION UNIT STAY

a. Date and time of observation unit discharge
Month

Day

Year

1
1

Unknown

NHAMCS-100(ED) (4-19-2011)

a.m. p.m. Military

Time

: