National Ambulatory Medical Care Survey Panel 2011

Attachment F: National Ambulatory Medical Care Survey 2011 Panel-NAMCS 1
OMB No. 0920-0234: Expiration date 07/31/2012
NOTICE - Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time f or reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of info rmation. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently val id OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this b urden to: CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).
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 w ill 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 Ser vice Act (42 USC 242m) and the
Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

1. Physican’s address:

NAMCS-1

FORM
(11-19-2010)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

ACTING AS DATA COLLECTION AGENT FOR THE

RECORD ON CONTROL CARD

NATIONAL CENTER FOR HEALTH STATISTICS

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL AMBULATORY
MEDICAL CARE SURVEY
2011 PANEL
2. Physician’s telephone and FAX numbers (Area code and number)
Office
1

Telephone

RECORD ON CONTROL CARD

FAX

RECORD ON CONTROL CARD

Office Telephone
2
FAX

RECORD ON CONTROL CARD
RECORD ON CONTROL CARD

3. Progress Record
Activity

Date Completed

FR Code

Notes

Telephone Screener
Induction Interview
Patient Record Forms Completed
Final Disposition and Summary
Section I – TELEPHONE SCREENER

4. Record of telephone calls
Call

Date

Time

Results

1
2
3
4
5
6
7
8
9
USCENSUSBUREAU

RECORD ON
CONTROL CARD

FR INSTRUCTION

If interview is with a CHC provider, start with Section II on page 7, but remember
to complete the office hours on page 5. If CHC provider refuses to complete the
survey, obtain answers to item 13 in Section I, on page 6.

5a. Has the physician moved out of the United States?
1
2

Yes – SKIP to CHECK ITEM A on page 6
No

b. Is the physician retired or deceased?
1
2

Yes – SKIP to CHECK ITEM A on page 6
No

6. Introduction
Hello, Dr. . . ., I am (Your name). I’m calling for the Centers for Disease Control and
Prevention regarding their study of ambulatory care. You should have received a letter
from the Director of the National Center for Health Statistics, explaining the study. (Pause)
You’ve probably also received a letter from the Census Bureau. We are acting as data
collection agents for the study.
IF DOCTOR DOES NOT REMEMBER NCHS LETTER; THE LETTER STATES:
The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS)
is conducting the National Ambulat ory Medical Care Survey (NAMCS). This annual s tudy, which
has been in the field sinc e 1973, c ollects information about the lar ge portion of ambulatory care
provided by physicians and mid-level providers throughout the United States . Research utilizing
the NAMCS helps t o inform physicians, health c are researchers, and p olicy makers about the
changing characteristics of ambulatory health c are in this c ountry. The information that will be
requested includes data ab out the patien t visit (e.g., demographics, diagnoses, services, and
treatments), physician practice characteristics (e.g., practice type), and the use o f electronic
medical records.
Many organizations and leader s in the health c are community, including those pr oviding the
enclosed letter of endorsement, have expressed their supp ort and join me in ur ging your participation in this meaningful s tudy. You will be ask ed to complete a onepage ques tionnaire on a
sample of about 30 patien t encounters during a r andomly assigned one- week reporting period.
Additionally, there is a shor t interview (approximately 30 minutes) with y ou about the natur e of
your practice. Participation is v oluntary, and y ou or y our staff may refuse to answer any question
or may stop participating at an y time without penalt y or loss o f benefits. The following are some
key points about the sur vey:
• Data collection for the NAMCS is authoriz ed by Section 306 o f the Public Health Ser vice Act
(Title 42, U.S. Code, 242k).
• All information collected will be held in the s trictest confidence according to Section 308(d) o f
the Public Health Ser vice Act (42, U.S. Code, 242m(d)) and the Con fidential Information
Protection and Statis tical Efficiency Act (Title 5 o f PL 107-347). T his information will be used
for statistical purposes only. No patien t names, social securit y numbers, or addr esses are
collected.
• This study conforms to the Priv acy Rule as mandated b y HIPAA, because disclosure of
patient data is permit ted for public health purp oses, the NCHS Resear ch Ethics Review Board
has approved NAMCS.
• U.S. Census Bur eau employees, who adminis ter the s tudy, have taken an oath t o abide b y
Title 13, U.S. Code, Section 9, which r equires them t o keep all in formation about your practice
and patients confidential.
A representative of the Census Bur eau, acting as our agen t, will be c alling you to schedule
anappointment regarding the de tails of your participation. If y ou have any questions regarding
your participation, please call a NAMCS representative at (800) 392–2862. A dditional information on the sur vey may be ob tained by visiting the NAMCS par ticipant Web site at
www.cdc.gov/namcs. We greatly appreciate your cooperation.

Page 2

FORM NAMCS-1 (11-19-2010)

Section I – TELEPHONE SCREENER – Continued

7. Specialty
a. Your specialty is _______________________________ ,
1

is that right?

2

Yes – SKIP to item 7c
No

Edit

b. What is your specialty (including general
practice)?
(Name of specialty)
Code
Refer to the NAMCS-21, pages 3 and 4 for codes.

FR INSTRUCTION

Do not classify cases solely on the basis of specialty. Complete all items on the NAMCS-1 and
have the physician fill out PRFs if appropriate. If the physician’s specialty is listed as eligible to
complete item 14, as determined in Appendix E of the NAMCS-26 Instruction Booklet, please
check the "Yes" box on the front of the 2011 Patient Record folio. If physician’s specialty makes
them ineligible, check "No." In both instances, please inform the physician/staff of their eligibility
before leaving the office.

c. What is your ethnicity?

1
2

d. What is your race?
Mark (X) one or more.

1
2
3
4
5

8.

Which of the following categories best
describes your professional activity –
patient care, research, teaching,
administration, or something else?

1
2
3
4
5

9a. Do you directly care for any ambulatory
patients in your work?

1
2
3

b. PROBE: We include as ambulatory patients,
any patients coming to see you for personal
health services who are not currently on
the premises. Does your work include any
such individuals?

c. Do you work as an employee or a contractor
in a federally operated patient care setting
or in a hospital emergency or outpatient
department?

d. In addition to working in a federally patient
care setting, hospital emerency or
outpatient department, do you also see any
ambulatory patients in another setting?
FORM NAMCS-1 (11-19-2010)

Edit

1
2

1
2

1
2

Hispanic or Latino
Not Hispanic or Latino
White
Black/African-American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaska Native
Patient care
Research
Teaching
Administration
Something else – Specify

Yes – SKIP to item 9c
No – does not give direct care [9b PROBE]
No longer in practice – SKIP to item 11 on page 4
Yes, cares for ambulatory patients
No, does not give direct care – Determine
reason, then read item 11 on page 4
Yes
No – SKIP to item 10a on page 4
Yes
No – SKIP to item 11 on page 4

If "Yes" to item 9d, all of the following questions
are concerned with the private patients.
Page 3

Section I – TELEPHONE SCREENER – Continued

10a. We have your address as (Read address shown

1

in item 1). Is that the correct address for your
office?

b. What is the (correct) address and telephone

2

Yes – SKIP to item 12
No, incorrect address – Ask item 10b

}

Number and street

number of your office?

RECORD ON CONTROL CARD
City

RECORD ON CONTROL CARD
State

ZIP Code

RECORD ON CONTROL CARD
Telephone (Area code and number)

RECORD ON CONTROL CARD

11.

Thank you, Dr. . . ., but I believe that since you do not (see any ambulatory
patients/practice any longer), our questions would not be appropriate for you. I
appreciate your time and interest. (Go to Check Item A on page 6.)

12.

I would like to arrange an appointment with you within the next week or so to discuss
the study. It will take about 30 minutes. What would be a good time for you, before
Friday,________________(last Friday before the assigned reporting week)?
Weekday

Month

Day

Year

SKIP to
item 12

Time
a.m.
p.m.

Verify office location, if appropriate:

RECORD ON CONTROL CARD
Physician refused to participate – Go to the top of page 6.

Thank you, Dr. . . . I’ll see you then. (Go to Check Item A on the bottom of page 6.)
NOTES

Page 4

FORM NAMCS-1 (11-19-2010)

Section I – TELEPHONE SCREENER – Continued

FR,
PLEASE
READ
BEFORE
CONTINUING

FR Instruction – If you have made it to this point, it appears the physician will be
cooperative. Please remember to show the physician the Data Use Agreement and
remind them they need to keep this document for six years. If the physician or their
staff are unwilling to complete the Patient Record forms themselves and request you to
abstract the information, please remember that an Accounting Document must be
placed in each of the medical records from which information has been abstracted. This
document must also be kept for six years. If necessary, please show the physician the
IRB approval.

PROVIDER’S OFFICE SCHEDULE

FR
INSTRUCTION
Monday

Please complete the office schedule for the week the provider is in sample.

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

A.M.

P.M.

Office
No.
NOTES

FORM NAMCS-1 (11-19-2010)

Page 5

Section I – TELEPHONE SCREENER – Continued

FR, PLEASE READ
BEFORE CONTINUING

FR Instruction – COMPLETE QUESTIONS BELOW FOR ALL IN-SCOPE PHYSICIANS
WHO HAVE REFUSED TO PARTICIPATE.

I appreciate that you choose not to participate in the study, but I would like to ask a few
short questions about your practice so we can make sure responding physicians do not differ
from nonresponding physicians.

13a. At how many different office locations, do you
see ambulatory patients? Do not include
settings such as EDs, outpatient departments,
surgicenters, and Federal clinincs.

Number of
office locations
Number of weeks

b. In a typical year, about how many weeks do
you NOT see ambulatory patients (e.g.,
conferences, vacations, etc.)?

c. You typically see patients fewer than half
the weeks in each year. Is that correct?

d. You typically see patients all 52 weeks of
the year. Is that correct?

1
2

1
2

e. During your last normal week of practice,

If > 26 weeks, ask item 13c.
If = 0, SKIP to item 13d.
If 1 to 26 weeks,
SKIP to item 13e.
Yes – SKIP to item 13e.
No – Please explain
SKIP to
item 13e

}

Yes
No – Please explain

Number of
patient visits

how many patient visits did you have at all
office locations?
f. During your last normal week of practice,
how many hours of direct patient care did
you provide?

Number of
weekly hours

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

g. At the office location where you see the most

Number of physicians

ambulatory patients:
(1) How many physicians are associated with
you?

If number of other physicians
is 0, SKIP to item 13g(3).

(2) Is this a single- or multi-specialty group
practice?

1

(3) Are you a full- or part-owner, employee, or
an independent contractor?

1

2

2
3

(4) Who owns the practice?

1
2
3

REFER TO FLASHCARD B.

4
5
6
7

Owner – Automatically mark "Physician or
physician group" in item 13g(4)
Employee
Contractor
Physician or physician group
HMO
Community Health Center
Medical/Academic health center
Other hospital
Other health care corporation
Other – Specify

Final outcome of screening
1
Appointment MADE or Physician unavailable during reporting period – Go to Section II, page 7
2
Inscope, but REFUSED –Complete item 13, then go to Section III, page 19
3
Out-of-Scope/Other –Go to Section III, page 19
Edit

➤ CHECK ITEM A MUST BE COMPLETED BEFORE CONTINUING
Page 6

➤

CHECK ITEM A

Multi-specialty practice
Single-specialty practice

FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW
Before we begin, I would like to give you a little background about this study.
Systematic information about the characteristics and problems of the people who consult providers
in their offices is essential for medical researchers, educators, and others who are concerned with
medical education, manpower needs, and the changing nature of health care delivery.
In response to the demand for this information, the Centers for Disease Control and Prevention, in
close consultation with representatives of the medical profession, developed the National
Ambulatory Medical Care Survey.
Your part in the study is very simple, carefully designed, and should not take much of your time. It
consists of your participation during a specified 7-day period. During that time, you would supply a
minimal amount of information about patients you see.
Now, before we get to the actual procedures, I have some questions to ask you about your practice.
The answers you give will be used only for classification and analysis. Of course, ALL information you
provide for this study will be held in strict confidence.
Number of locations

14a. Overall, at how many office locations, do you see
ambulatory patients? Do not include settings such
as EDs, outpatient departments, surgicenters, and
Federal clinics.

Number of weeks

b. In a typical year, about how many weeks do you
NOT see any ambulatory patients (e.g.,

If > 26 weeks ask item 14c.
If = 0, SKIP to item 14d.
If 1 to 26 weeks,
SKIP to item 15a.

conferences, vacations, etc.)?

c. You typically see patients fewer than half the weeks
in each year. Is that correct?

d. You typically see patients all 52 weeks of the year.
Is that correct?

1
2

1
2

Yes – SKIP to item 15a
No – Please explain

}

SKIP to
item 15a

Yes
No – Please explain

15a. This study will be concerned with the AMBULATORY
patients you will see in your office(s) during the week
of Monday,
_______________ through Sunday,_______________.
Are you likely to see any ambulatory patients in your
office(s) during that week?
(For allergists, family practitioners, etc. – if routine
care such as allergy shots, blood pressure checks,
and so forth will be provided by staff in physician’s
absence, mark "Yes.")

1
2

Yes –SKIP to item 16a on page 8
No

b. Why is that? Record verbatim.
(If appropriate, read item 15c below and leave forms with physician. Otherwise, SKIP to item 16a on page 8.)

c. Since it’s very important that we include any ambulatory patients that you might see in your
office during that week, I’ll leave forms with you – just in case your plans change. I’ll check back
with your office just before (Starting date) to make sure, and if necessary I can explain them in
detail then.
Give the doctor the folio and enter the folio number on page 17. Then continue with item 16a on page 8.
FR, PLEASE READ
BEFORE CONTINUING
FORM NAMCS-1 (11-19-2010)

FR Instruction – Even if the physician is not available during the reporting week, continue
with item 16a on page 8.
Page 7

Section II – INDUCTION INTERVIEW – Continued

16a. At what office

16b. Give FLASHCARD A (p. 15 Flashcard Booklet) and ask Looking at this

location(s) will you see
ambulatory patients
during your practice’s
7-day reporting period
Monday,
through Sunday,
__________________ ?
PROBE: Are there any
other office locations at
which you will see
ambulatory patients
during that 7-day
reporting period?
NOTE –
NON-PARTICIPATING
PHYSICIANS: If refusal
(Final=3) or unavailable
(Final=4), record locations
where ambulatory patients
are normally seen.
Office
No.

Office locations
(Enter street address)

1
2
3
4

RECORD ON CONTROL CARD
RECORD ON CONTROL CARD
RECORD ON CONTROL CARD
RECORD ON CONTROL CARD

list, choose ALL of the type(s) of settings that describe each
location where you work. For each location mark all setting types that
apply. For each location, also mark the appropriate "scope" status. If any
even numbered settings are marked, then mark location as out-of-scope.
If FLASHCARD number 3 (free-standing clinic/urgicenter) is
marked, ask –
Is this/that clinic in an institutional setting (#8), in an
industrial outpatient facility (#10), or operated by the Federal
Government (#12)? (If yes – Mark out-of-scope.)
If FLASHCARD number 11 (family planning clinic) is marked, ask –
Is this/that clinic operated by the Federal Government (#12)?
(If yes – Mark out-of-scope.)
If in doubt about any (clinic/facility/institution), PROBE –
(1) Is this/that (clinic/facility/institution) part of a hospital
emergency department or an outpatient department (#2, #4)?
(If yes – Mark out-of-scope.)
(2) Is this/that (clinic/facility/institution) operated by the
Federal Government (#12)? (If yes – Mark out-of-scope.)
Edit

Mark (X)

Circle
FLASHCARD number

Inscope

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Out-ofscope

1

2

1

2

1

2

1

2

FLASHCARD A
(1) Private solo or group practice
(3) Freestanding clinic/urgicenter (not part of
a hospital outpatient department)
(5) Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or ‘look alike’ clinics)
(7) Mental health center
(9) Non-federal Government clinic (e.g., state,
county, city, maternal and child health,
etc.)
(11) Family planning clinic (including Planned
Parenthood)
(13) Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)
(15) Faculty Practice Plan

(2) Hospital emergency department
(4) Hospital outpatient department
(6) Ambulatory surgicenter
(8) Institutional setting (school infirmary,
nursing home, prison)
(10) Industrial outpatient facility
(12) Federal Government operated clinic
(e.g., VA, military, etc.)
(14) Laser vision surgery

16c. Are there other office locations where you NORMALLY would
see patients, even though you will not see any during your 7-day
reporting period? Do not include settings such as EDs,
outpatient departments, surgicenters, and Federal clinics.

1
2

Yes – SKIP to item 16d
No – SKIP to Check Item B

d. Of these locations where you will not be seeing patients during
your 7-day reporting period, how many total office visits did
you have during your last week of practice at these locations?
CHECK ITEM B

1
2

Number of visits

All locations listed in 16a are out-of-scope – Read CLOSING STATEMENT below
All/Some locations listed in 16a are in-scope – Go to item 17a

CLOSING
Thank you, Dr. . . ., your practice is not within the scope of this study.
STATEMENT We appreciate your time and interest. (Terminate interview and complete Sections III and IV on pages 19–21.)
Page 8

FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW – Continued
Ask item 17a ONCE to obtain total for ALL in-scope locations.

17a. During the week of Monday, ____________ through Sunday, ___________ How many days
do you expect to see any ambulatory patients? (Only include days at in-scope locations.)
NOTE – NON-PARTICIPATING PHYSICIANS: If
refusal (Final=3) or unavailable (Final=4), enter the number of
days in a normal week.

Edit

Estimated Number
of Days

Enter street name or town of in-scope location(s).
Office location No.

NOTE: Keep the location numbers the same as the office numbers in item 16a.

RECORD ON CONTROL CARD

#1

#2

#3

#4

_____

_____

_____

_____

b. During your last normal week of practice,
approximately how many office visit encounters
did you have at each office location?
NOTE: If physician is in group practice, only
include the visits to sampled physician.

Edit

Number
of visits

c. During the week of Monday, ____________ through
Sunday ____________, do you expect to have about
the same number of visits as you saw during
your last normal week in each office taking into
account time off, holidays, and conferences?

Yes . . .
No . . .

1

1

1

1

2

2

2

2

NOTE: Mark (X) response. If answer is "Yes", transcribe
the number in 17b to 17d for that office location. If answer
is "No" then ASK item 17d for that office location.

d. Approximately how many ambulatory visits do
you expect to have at this office location?

e. Tally of estimated number of visits
NOTE: To obtain the total number of estimated visits,
add the estimate for each office location in 17d.

Now, I’m going to ask about your practice at
(in-scope location).

18a. Do you have a solo practice, or are you
associated with other physicians in a
partnership, in a group practice, or in some
other way (at this/that in-scope location)?

Number
of visits

_____

_____

_____

_____

Number of visits
_____
Office Location

#1

#2

#3

#4

Solo . . . . . . . . . . . . . 1
1
1
If Solo, SKIP to item 18d.

1

Nonsolo . . . . . . . . . . 2

2

2

2

b. How many physicians are associated with you
(at this/that in-scope location)?

c. Is this a single- or multi-specialty (group)
practice (at this/that in-scope location)?

FORM NAMCS-1 (11-19-2010)

How many

_____

_____

_____

_____

Multi . . . . . . . . .

1

1

1

1

Single . . . . . . . .

2

2

2

2

Page 9

Section II – INDUCTION INTERVIEW – Continued

18d. How many mid-level providers (i.e., nurse

practitioners, physician assistants, and
nurse midwives) are associated with you
How many
(at this/that in-scope location)?
Are
you
a
fullor
part-owner,
employee,
or
an
e.
Owner . . . . . . . .
independent contractor (at this/that in-scope
Employee . . . . . .
location)? If "Owner" is marked then automatically
Contractor . . . . . .
mark "Physician or physician group" in item 18f.

f. Give FLASHCARD B (p.16 Flashcard Booklet)
and ask:
Who owns the practice (at this/that in-scope
location)?

#2

#3

#4

_____

_____

_____

1

1

1

1

2

2

2

2

3

3

3

3

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

6

6

6

6

7

7

7

7

#1

Office Location

Physician or
physician group . . .
HMO . . . . . . . . . .
Community Health
Center . . . . . . . .
Medical/ Academic
health center . . . .
Other hospital . . .
Other health care corp
Other . . . . . . . . .

_____

g. Does your practice have the ability to

perform any of the following on site (at
this/that in-scope location)?
1. EKG/ECG

1
2
3

2. Lab testing

1
2
3

3. Spirometry

1
2
3

4. Ultrasound

1
2
3

5. X-Ray

1
2
3

h. Do you see patients in the office during the
evening or on weekends?

1
2
3

i. What is your Federal Tax ID at each office
location?

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK

RECORD ON CONTROL CARD

Notes

Page 10

FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW – Continued

19a. During your last normal week of practice,
how many hours of direct patient care did
you provide?

Number of
weekly hours

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

b. During your last normal week of practice,

Number of encounters
per week

about how many encounters of the
following type did you make with patients:
(1) Nursing home visits . . . . . . . . . . . . . . . . . . .
(2) Other home visits . . . . . . . . . . . . . . . . . . . . .
(3) Hospital visits . . . . . . . . . . . . . . . . . . . . . . . .
(4) Telephone consults . . . . . . . . . . . . . . . . . . .
(5) Internet/e-mail consults . . . . . . . . . . . . . . .

Have provider answer items 20–27 for the
in-scope location/practice with the most visits.

20. Does your practice submit any claims
electronically (electronic billing)?

1
2
3

21. Do you or your staff verify an individual

patient’s insurance eligibility electronically,
with results returned immediately?

1
2
3
4
5

22. Does your practice use an electronic medical
record (EMR) or electronic health record
(EHR) system? Do not include billing record
systems.

1
2
3
4

Yes
No
Unknown
Yes, with a stand-alone practice management system
Yes, with an EMR/EHR system
Yes, using another electronic system
No
Unknown

}

a. In which year did your practice install your
EMR/EHR system?

b. What is the name of your practice’s current
EMR/EHR system?
Mark (X) only one box.

Year
1
2
3
4
5
6

23. At your practice, are there plans for installing
a new EMR/EHR system within the next 18
months?

}

Yes, all electronic
Go to Question 22a.
Yes, part paper and part electronic
No
Skip to Question 23.
Unknown

1
2
3
4

Allscripts
Cerner
CHARTCARE
eClinicalWorks
Epic
eMDs

7
8
9
10
11

GE Centricity
Greenway
Medical
MED 3000
NextGen
Sage

14

SOAPware
Practice Fusion
Other

15

Unknown

12
13

Yes
No
Maybe
Unknown

Notes

FORM NAMCS-1 (11-19-2010)

Page 11

Section II – INDUCTION INTERVIEW – Continued

24. Give FLASHCARD G (p.21 Flashcard Booklet): Please
indicate whether your practice has each of the
computerized capabilities listed below. Does your
practice have a computerized system for:
Mark (X) only one per row.

Yes

Yes, but
turned off
or
not used

No

Unknown

a. Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Go to
24a(1)
If Yes, ask – (1) Does this include a patient problem list?
b. Recording clinical notes? . . . . . . . . . . . . . . . . . . . . .

1

c. Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . . . . .

1

4

Skip to
24b

2

Skip to
24c

3

4

3

4

Skip to
24c

Skip to
24c

1

2

3

4

1

2

3

4

Go to
24c(1)
If Yes, ask – (1) Are prescriptions sent electronically to the
pharmacy?

3

Skip to
24b

2

Go to
24b(1)
If Yes, ask – (1) Do they include a comprehensive list of the
patient’s medications and allergies?

2

Skip to
24b

Skip to
24d

Skip to
24d

Skip to
24d

1

2

3

4

1

2

3

4

d. Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . . . . .

1

2

3

4

e. Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(2) Are warnings of drug interactions or
contraindications provided?

Go to
24e(1)

Skip to
24f

Skip to
24f

Skip to
24f

If Yes, ask – (1) Are orders sent electronically?

1

2

3

4

Providing standard order sets related to a
particular condition or procedure? . . . . . . . . . . . . . .

1

2

3

4

g. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

f.

Go to
24g(1)
If Yes, ask – (1) Are results incorporated in EMR/EHR?

Skip to
24h

Skip to
24h

Skip to
24h

1

2

3

4

h. Viewing imaging results? . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

i.

Viewing data on quality of care measures? . . . . . . .

1

2

3

4

j.

Electronic reporting to immunization registries? . .

1

2

3

4

k. Public health reporting? . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
24k(1)

Skip to
24i

3

4

Skip to
24i

Skip to
24i

If Yes, ask – (1) Are notifiable diseases sent electronically?

1

2

3

4

Providing patients with clinical summaries for
each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

m. Exchanging secure messages with patients? . . . . .

1

2

3

4

l.

25. At your practice, if orders for prescriptions or lab
tests are submitted electronically, who submits
them?

1
2
3

Mark all that apply.
4

Page 12

Prescribing practitioner
Other
Prescriptions and lab tes t orders not
submmited electronically
Unknown
FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW – Continued

26. Does your practice exchange patient clinical

1

summaries electronically with any other providers?

2
3
4
5

a. How does your practice electronically send or receive

1

patient clinical summaries?

2
3

Mark all that apply.

4
5

27. Beginning in 2011, Medicare and Medicaid will offer
incentives to practices that demonstrate
"meaningful use of Health IT". Does your practice
have plans to apply for Medicare or Medicaid
incentive payments for meaningful use of Health IT?

1

2

3

a. In which year does your pactice expect to apply for

1

the meaningful use payments?

2
3
4

Yes, send summaries only
Yes, receive summaries only
Yes, send and receive summaries
No
Unknown Skip to question 27

}

}

Go to
Question
26a

Through EMR/EHR vendor
Through hospital-based system
Through Health In formation Organization
or state exchange
Through secure email at tachment
Other/Unknown
Yes, we intend to apply – Go to
Question 27a
Uncertain whether we
Skip to
will apply
question 28a
No, we will no t apply

}

2011
2012
After 2012
Unknown

Give FLASHCARD C (p.17 Flashcard Booklet) and ask
items 28–31 ONCE for ALL in-scope locations.
I would like to ask a few questions about your practice
revenue and contracts with managed care plans.
Percent of patient care
revenue

28a. Roughly, what percent of your patient care revenue
comes from –

(1) Medicare?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(2) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(3) Private insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(5) Other? –(including charity, research, CHAMPUS, VA, etc.)

%
FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.

b. Roughly, how many managed care contracts does
this practice have such as HMOs, PPOs, IPAs, and
point-of-service plans?
If necessary read– Managed care includes any type of
group health plan using financial incentives or
specific controls to encourage utilization of specific
providers associated with the plan.
FR NOTE – Include Medicare managed care and
Medicaid managed care, but not traditional Medicare
and Medicaid. Include any private insurance
managed care plans. Be sure the response is about
contracts and not patients.
Include all the different plans an insurance provider
may have and for which the physician has a contract.
For example, the physician may have a contract for
each of the plans Aetna may offer: a PPO, IPA, and
point-of-service plan. This would equal 3 contracts,
not 1 contract. It may be necessary to obtain
information from the billing office of the practice.
FORM NAMCS-1 (11-19-2010)

1
2
3
4

None – SKIP to item 29
Less than 3
3 to 10
More than 10

Page 13

Section II – INDUCTION INTERVIEW – Continued
Percent of revenue from
c. Roughly, what percentage of the patient care
managed care
revenue received by this practice comes from
(these) managed care contracts?

Edit

%
Percent of patient care
revenue

29. Give FLASHCARD D (p.18 Flashcard Booklet) and ask:
Roughly, what percent of your patient care revenue
comes from each of the following methods of payment?
(1) Usual, customary and reasonable fee-for-service?

%

(2) Discounted fee for service?. . . . . . . . . . . . . . . . . . . .

%

(3) Capitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Case rates (e.g., package pricing/episode
of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(5) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.

3

Yes
No – SKIP to item 31
Don’t know – SKIP to item 31

(a) Capitated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(b) Non-capitated? . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(2) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(3) Medicaid?

1

Yes

2

No

3

Don’t know

(4) Workers compensation? . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(5) Self-pay?

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

No

3

Don’t know

30a. Are you currently accepting "new" patients into your
practice(s) (at in-scope locations)?

1
2

b. From those "new" patients, which of the following

types of payment do you accept (at in-scope locations)?
(1) Private insurance –

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

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

(6) No charge?

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

31a. Roughly, what percent of your daily visits are

%

same day appointments?

b. Does your practice set time aside for same
day appointments?
c. On average, about how long does it take to get
an appointment for a routine medical exam?

1
1
2
3
4
5
6
7

Yes

2

Within 1 week
1–2 weeks
3–4 weeks
1–2 months
3 or more months
Do not provide routine
medical exams
Don’t know

CHECK ITEM C Is provider part of the community health center sample?
1
2

Page 14

Yes – Ask item 32
No – SKIP to FR Instruciton on page 15
FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW – Continued

32. Provider demographics –
a. What is your year of birth?
b. What is your sex?

1 9
1
2

c. Give FLASHCARD E (p.19 Flashcard Booklet) and ask:

1
2

What is your highest medical degree?

3
4
5
6

Male
Female

}

MD
Go to item 32d
DO
Nurse practitioner
SKIP to
Physician assistant
FR INSTRUCTION
Nurse midwife
on page 15.
Other

}

d. What is your primary specialty?
Name of specialty

Code

Name of specialty

Code

e. What is your secondary specialty?

f. What is your primary board certification?
Board certification

g. What is your secondary board certification?
Board certification

h. What year did you graduate medical school?
Year

i. Did you graduate from a foreign medical school?

1
2

FR INSTRUCTION

Yes
No

If physician unavailable during reporting period, SKIP to item 34b on page 18.

33a. During the period Monday, ________________ through
Sunday, ________________ will ANYONE be available
to help you fill out the patient record forms for this
study (at in-scope locations)?

1
2

Yes
No – Go to Visit Sampling on page 17

FR NOTE – Explain to the physician that
you would like to review some of the
questions found on the patient record form.

NOTES

FORM NAMCS-1 (11-19-2010)

Page 15

Section II – INDUCTION INTERVIEW – Continued

33b. Who will be helping you at each location? (Below enter the location and person’s name and position.)
Office
No.

NOTE: Keep the location numbers the same as the office numbers in item 16a.
Location
Name
(Enter street name)

Position

1

RECORD ON CONTROL CARD

2

RECORD ON CONTROL CARD

3

RECORD ON CONTROL CARD

4

RECORD ON CONTROL CARD

FR NOTE –Explain to the physician and to anyone helping the physician that you would like to review
some of the questions found on the Patient Record form. Go to page 17.
Visit Sampling
To select a sample of patient visits, the physician’s office will need to know where to start sampling (Start With) and how
to select subsequent patient visits (Take Every).
To determine Take Every (TE) and Start With (SW) numbers follow these instructions. Read down the "Estimated visits
for week" column to the line that corresponds to the total entry in ITEM 17e. Then, read across the "Days physician will
see patients that week" line to the column that corresponds to the entry in ITEM 17a. Circle the appropriate number. This
number is the physician’s Take Every number for all office locations. Then transcribe this number below, and onto the front
of the folio, and to the Patient Visit Worksheet if it is used.
TAKE EVERY NUMBER
Days physician will see patients that week

Estimated Visits for Week

1

2

3

4

5

6

7

0–12 . . . . . . . . . . . . . . . . . . . . . . . .

1

1

1

1

1

1

1

13–24. . . . . . . . . . . . . . . . . . . . . . .

2

1

1

1

1

1

1

25–39. . . . . . . . . . . . . . . . . . . . . . .

3

2

1

1

1

1

1

40–44. . . . . . . . . . . . . . . . . . . . . . .

4

2

2

1

1

1

1

45–49. . . . . . . . . . . . . . . . . . . . . . .

4

2

2

2

2

2

2

50–64. . . . . . . . . . . . . . . . . . . . . . .

5

3

2

2

2

2

2

65–74. . . . . . . . . . . . . . . . . . . . . . .

10

3

2

2

2

2

2

75–89. . . . . . . . . . . . . . . . . . . . . . .

10

4

3

2

2

2

2

90–104 . . . . . . . . . . . . . . . . . . . . .

10

4

3

3

3

3

3

105–114 . . . . . . . . . . . . . . . . . . . .

10

5

3

3

3

3

3

115–129 . . . . . . . . . . . . . . . . . . . .

10

5

4

3

3

3

3

130–134 . . . . . . . . . . . . . . . . . . . .

15

10

4

3

3

3

3

135–154 . . . . . . . . . . . . . . . . . . . .

15

10

4

4

4

4

4

155–174 . . . . . . . . . . . . . . . . . . . .

15

10

5

4

4

4

4

175–194 . . . . . . . . . . . . . . . . . . . .

15

10

5

5

5

5

5

195–209 . . . . . . . . . . . . . . . . . . . .

20

10

10

5

5

5

5

210–219 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

5

5

5

220–254 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

10

10

10

255–319 . . . . . . . . . . . . . . . . . . . .

25

15

10

10

10

10

10

320–364 . . . . . . . . . . . . . . . . . . . .

30

15

10

10

10

10

10

365+ . . . . . . . . . . . . . . . . . . . . . . .

30

30

30

30

30

30

30

Take Every Number
Page 16

FORM NAMCS-1 (11-19-2010)

Section II – INDUCTION INTERVIEW – Continued
START WITH NUMBER
To determine the Start With (SW) number read down
the "If Take Every Number is" column and find the
Take Every Number. The number to the right is the
Start With Number. Transcribe this number onto line at
the right, and to the front of the folio, and to the Patient
Visit Worksheet if it is used.

If the Take
Every Number is:

Then the Start
With Number is:

1
2
3
4
5

Start With Number

10
15
20
25
30
Office number

Edit

Folio Number

OFFICE USE ONLY
Number of PRFs completed

1
2
3
4
Additional folio
for Office #
INSTRUCTIONS
GIVE THE PHYSICIAN A FOLIO AND A COPY OF THE SAMPLE PATIENT RECORD FORM (NAMCS-73),
AND EXPLAIN HOW TO COMPLETE THE FORMS.
Cover the following points —
(1) Who to list/who not to list on the Patient Visit Worksheet found in the back of the NAMCS-26
• List every ambulatory patient visit to all in-scope locations during the reporting period.
• INCLUDE patients the physician doesn’t see but who receive care from an assistant, nurse, nurse
practitioner, physician assistant, etc.
• EXCLUDE patients who do not seek care or services (e.g., they come to pay a bill or leave a specimen).
• EXCLUDE telephone contacts with patients.
(2) Show doctor instruction card in folio pocket and go over Patient Record item by item, paying particular
attention to —
Item 2, Injury/Poisoning/Adverse Effect – If any part of this visit was related to an injury or
poisoning or adverse effect of medical or surgical care or an adverse effect of medicinal drug, then mark
the appropriate box. If this visit was not related to any of these, then mark the last option, "None of the
above."
Item 3, Reason for Visit – To be recorded in patient’s own words. We want the patient’s own
complaint here, not the physician’s diagnosis. If the patient has no complaint, the physician should enter
the reason for the visit.

FORM NAMCS-1 (11-19-2010)

Page 17

Section II – INDUCTION INTERVIEW – Continued
INSTRUCTIONS – Continued
Items 5a(1), Provider’s Primary Diagnosis for this Visit – Can be tentative or provisional or
expressed as a problem. Physician should not record "Rule Out" diagnosis (R.O.). Enter any other
diagnosis related to the visit (e.g., depression, obesity, asthma, etc.) in items 5a(2) and 5a(3).
Items 5b, Chronic Disease Checklist – Mark all chronic diseases that the patient has, regardless
of entry in item 5a. This item supplements the diagnoses reported in item 5a. If none of the conditions
listed apply, then mark "None of the above."
Item 6, Vital Signs – When possible, record specific values for the 4 vital signs. For height and
weight, enter the value on the line next to the type or measurement system used. If height was not
measured at this visit and patient is 21 years of age or over, enter the most recent height recorded.
Item 8, Health Education – Mark all services ordered or provided at this visit.
Item 9, Non-Medication Treatment – Mark and/or list all non-medical treatment including surgical
or non-surgical procedures ordered or provided at this visit.
Item 10, List medication/immunization names – Record up to 8 medications that were ordered,
supplied, administered or told to continue at the visit. Include Rx and OTC medications, immunizations,
allergy shots, anesthetics, chemotherapy, and dietary supplements. Use SPECIFIC BRAND OR
GENERIC DRUG NAMES as entered on prescription or medical records. Do NOT enter broad drug
classes such as "pain medication." Record if the medication/immunization was new or continued.
Item 13, Time Spent with Provider – Best estimate of time spent in face-to-face contact with the
patient and the sampled provider. The answer may be zero (0), if the patient was attended entirely by a
registered nurse or technician and did not see the sampled physician/CHC provider.
Item 14, Laboratory Test Results – If applicable, please make sure provider is aware of items
on back of PRF and completes information about tests drawn within last 12 months. If primary medical
specialty is listed in Appendix E in the NAMCS-26 Instruction Booklet, please complete checkbox on
front of folio. Also, physician should complete Item 14.
(3) Explain to the provider, where appropriate, that the receptionist, nurse, or assistant can list patients on
the Patient Visit Worksheet as they enter the office. They may also complete items 1–4 on the Patient
Record form.
(4) Instruct provider to enter number of patients seen and number of PRF’s completed on front of folio – at
the end of each day.

34a. CLOSING STATEMENT
Thank you for your time and cooperation Dr. . . . I will call you on
Monday,_____________________ to see if (everything is all right/your plans have changed).
If you have any questions (Hand doctor your business card) please feel free to call me. My
telephone number is also written in the folio.

FR INSTRUCTIONS

If applicable, complete Sections III through V before returning
completed materials to office.

34b. CLOSING STATEMENT
Thank you for your time and cooperation Dr. . . . The information you provided will
improve the accuracy of the NAMCS in describing office-based patient care in the
United States.

FR INSTRUCTIONS
Page 18

Complete Sections III through IV before returning completed
materials to office.
FORM NAMCS-1 (11-19-2010)

Section III – NONINTERVIEW

35. What is the reason the provider did not participate in
this study?

1
2
3

Explanations for noninterview codes 6 and 11 –
• Temporarily not practicing –Refers to duration
of 3 months or more

4
5
6
7
8
9

• Unavailable during reporting period –Absence
must be for duration of LESS than 3 months

10

Edit

12

36. Check all that apply to describe provider’s practice or

1

medical activities which define him/her as ineligible or
out-of-scope.

11

2
3
4
5
6
7

37a. At what point in the interview did the refusal/break-off
occur?

1

(Mark (X) one.)

3

2

4
5
6

b. By whom?
(Mark (X) one.)

1
2
3
4
5
6

Refused/Breakoff –SKIP to item 37a
Non-office based
SKIP to item 36
Sees no ambulatory patients
Retired
SKIP to item 40 on page 21
Deceased
Temporarily not practicing –SKIP to item 38 on page 20
Can’t locate
SKIP to item 40 on page 21
Not licensed
Moved out of U.S.A.
Other out-of-scope –SKIP to item 36
Unavailable during reporting period –SKIP to item 38 on
page 20
Moved out of PSU –SKIP to item 39a on page 20

}

}

}

Federally employed
Radiology, anesthesiology or pathology
specialist
Administrator
Work in institutional setting
Work in hospital emergency
department or outpatient department
Work in industrial setting
Other – Specify

}

SKIP to
item 40
page
21

}

During telephone screening
Make sure item 13
has been completed
During induction interview
After induction but prior to assigned
reporting days
At reminder call
During assigned reporting days or
mid-week calls
At follow-up contact
Sampled provider
Sampled provider through nurse
Nurse/Secretary
Receptionist
Office manager/Administrator
Other office staff – Specify

c. What reason was given? (Verbatim)

d. Date refusal/breakoff was reported to supervisor

e. Conversion attempt result

Month

1
2
3

FORM NAMCS-1 (11-8-2010)

Day

Year

}

No conversion attempt
SKIP to item 40 on
Sampled provider refused page 21
Sampled provider agreed to see
Field Representative – Complete Section II
Page 19

Section III – NONINTERVIEW – Continued

}

38. Why is provider unavailable or not in practice?

39a. What is the provider’s new address?

SKIP to
item 40 on
page 21

Number and street

RECORD ON CONTROL CARD
City, State, ZIP Code

RECORD ON CONTROL CARD
Telephone

RECORD ON CONTROL CARD

b. Name of Field Representative

RO

PSU

Date transferred

RECORD ON CONTROL CARD

Continue
with item
40 on
page 21

NOTES

Page 20

FORM NAMCS-1 (11-19-2010)

Section IV – DISPOSITION AND SUMMARY

40. FINAL DISPOSITION
(a) Eligible physician/provider

41. CASE SUMMARY

}

1

Completed Patient Record forms

2

Out-of-scope (Item 35,
codes 2, 3, 4, 5, 6, 8, 9, or 10)
Refused-Breakoff (Item 35,
code 1)
Unavailable during
reporting period (Item 35,
code 11)
Moved out of PSU (Item 35,
code 12–final)
Can’t locate (Item 35
code 7)

3
4

5
6

1. Number of patient visits
during reporting week . . . . . .

➜

2. Number of days during
reporting week on which
patients were seen . . . . . . . .

End of Interview
–Make certain
all items are
accurately
completed
before returning
materials to the
office.

3. Number of patient record
forms completed . . . . . . . . . .
NOTE – For items 41(1) and 41(3),
see FR instruction below.

(b) Unused CHC NAMCS-1
7

Less than 3 providers sampled

8

Parent CHC Out-of-scope

9

Parent CHC Refused to participate

(c) Transfer cases
Moved out of PSU (Item 35,
code 12 –pending)
Edit

FR,
PLEASE
READ
BEFORE
CONTINUING

Edit

Item 41(1) – Accurate determination of "Number of patient visits during reporting week" is
EXTREMELY IMPORTANT! This count is to include any days the provider may have skipped
or not participated. This information may be obtained from either the office staff or from the PRF
Folio cover. Only inlcude visits to sampled provider and NOT the total number of visits to entire
practice or clinic.
Item 41(3) – If the number of Patient Record forms completed is less than 20 or greater than
40, then explain why in the NOTES section below.
Items 17e and 41(1) – If applicable, record explanation of why items 17e and 41(1) differ
significantly and any other information regarding this case which may help to understand it at a
later date.

Notes

FORM NAMCS-1 (11-19-2010)

Page 21

Section V – PATIENT RECORD FORM CHECK
CHECK ITEM D

1. Who answered the questions in the Physician Induction Interview?
Mark (X) all that apply.
1
Sampled provider
3
Other – Specify
2
Office staff
2. Who completed the Patient Record forms?
Mark (X) all that apply.
1
Sampled provider
4
Other – Specify
2
Office staff
3
FR – abstraction
3. Did the sampled provider accept the Data Use Agreement?
1
Yes
2
No
4. If the FR abstracted the PRFs, were the Accounting Documents placed in each of the medical records
used for abstraction?
1
2

Yes
No – Explain

5. Did sampled provider (or staff) request to see the IRB approval?
1
2

Yes
No

42. Verify that all items on the Patient Record form check list have been answered. DO

NOT call the sampled provider regarding missing information on Patient Record form
unless instructed by your supervisor or the FR Manual.

Mark (X) when completed
Field
Representative
check list
(a)

Office
check
list
(b)

a. Check for missing Patient Record forms (e.g., if the last completed Patient Record

is number 1500051, do you have 1500001 through 1500050). List missing Patient
Record forms in Section VI, Part I of chart.
b. Item 1a – Date of visit recorded on each Patient Record form – If missing,
complete 1 and 2 below.
(1) Determine date of visit by referring to Patient Record forms immediately before
and after. For example, if 1550087 through 1550092 are dated "1/12/2010" and
the date on 1550088 is missing, enter "1/12/2010" in item 1a.
(2) If the exact date of the patient visit cannot be determined, estimate the date
and enter "EST" next to the entry.

c. Items 1–13 –Verify that each of these items has been answered on the Patient

Record form. List missing information in Section VI, Part 3 of chart on page 24. If
applicable make sure item 14, laboratory values, was completed accuraterly.

d. Check the sample provider’s office schedule against the dates on the Patient

Record forms for survey week days with no completed Patient Record
forms. Do the dates on the Patient Record forms include every day during the
survey week that the sample provider’s office scheduled appointments?
Yes

No –List missing days in Section VI, Part 2 of chart on page 23.

NOTES

Page 22

FORM NAMCS-1 (11-19-2010)

Section VI – MISSING INFORMATION CHART
Part 1 — Missing Patient Record Forms

43a. Enter 7-digit Patient Record number(s) for missing forms.

b. Contact provider regarding missing forms. Enter results of missing forms
follow-up below:

Forms/information obtained
Forms/information not obtained – Explain why

Part 2 — Missing Days or Blocks of Time

c. List day(s) and blocks of time not reported, and check with the provider’s office for the reason. (If
patients were seen during day(s)/hours not reported, arrange to obtain missing data. If not possible
to obtain missing data, ask for the number of patients seen during day(s)/hours not reported.)
Not reported
Day(s) Blocks of
time
(a)

(b)

FORM NAMCS-1 (11-19-2010)

Reason

Will physician’s
office provide
missing data?
(Mark X)
(d)

(c)

Yes

No

Number
of
patients
seen
(e)

Page 23

Part 3 — Missing Patient Record Form Items (1–13)

43d. List missing items, and refer to the FR manual for guidelines on retrieving missing information.
Patient Record
number

Item
number(s)

Comments

(b)

(c)

(a)

44. Was provider/office staff contacted for any reason during the editing pr ocess?
Yes

No

45. For all Final = 1 cases, transfer information from front of Patient Record Folio.
FROM

TO
Month

Day

Month

Day

WEEK OF –
SURVEY WEEK
Complete a Patient
Record for patient
SW

Mon.

Tues.

Wed.

Thur.

Fri.

Sat.

Sun.

Total

Number
of patient
visits

and
every

TE

nth
patient thereafter.

Number
of
records
completed

NOTES

Page 24

FORM NAMCS-1 (11-19-2010)