Form #3 Form #3 Medical Office Information Form

Medical Office Survey on Patient Safety Culture Comparative Database

Attachment D Medical Office Information Form revised 5-15-2012

Medical Office Information Form

OMB: 0935-0196

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Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

edical Office Information Form

To be completed by a single office point-of-contact for each medical office submitting data to the Medical Office Survey on Patient Safety Culture Comparative Database


Instructions: Please provide the following information, which will be used to produce descriptive statistics and analyze data in aggregate collected with the Medical Office Survey on Patient Safety. Please refer to the Data Use Agreement for assurances regarding the confidentiality and use of this data at http://www.ahrq.gov/qual/mosurvey11/mosopsdua.pdf. If you need assistance in answering any of the questions, please email [email protected]


Name of Office Point-of-Contact: (First) (Last)

Job Title:

Name of Office:

Office Mailing Address: (Street)

(City) (State) (Zip code) _______

POC Phone:_________________ Fax: _______________

Email: ___________________



1. Which best describes the majority ownership of this medical office/practice?

1 Provider(s) and/or Physician(s)

2 University or Academic Medical Institution

3 Hospital or health system

4 Community health center

5 Other, please specify:



  1. Total Number of Employees asked to complete the survey? _______



  1. What was the mode used to administer the survey?

1 Paper only

2 Web only

3 Mixed mode (paper and web)



  1. When did your medical office finish its administration of the Medical Office Survey on Patient Safety Culture?

_________month _________year




5. What is the total number of providers (MDs, DOs, PAs, NPs, etc.) working in this medical office location during a typical week?

_________total number of providers working during a typical week



6. To what extent has this medical office implemented the following electronic (computer-based) tools? (By implemented, we mean the office has the tool capability and is using it.)



Not implemented &

no plans

to implement in the next 12 months

Not implemented but implementation planned in the next 12 months

Implementation in process

(only partial implementation)

Fully implemented

a) Electronic appointment scheduling

1

2

3

4

b) Electronic ordering of medications (with pharmacies capable of processing electronic orders)

1

2

3

4

c) Electronic ordering of tests, imaging, or procedures (with test/imaging centers capable of processing electronic orders)

1

2

3

4

d) Electronic access to your patients’ test or imaging results

1

2

3

4

e) Electronic medical/health
records (EMR/EHR)

1

2

3

4






7. Check the type of specialty(s) practiced by all providers in your medical office. By providers, we mean physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications.

(Mark all that apply)


1. Allergy/Immunology

19. Nephrology

2. Anesthesiology

20. Neurology

3. Cardiology

21. Nuclear Medicine

4. Child & Adolescent Psychiatry

22. OB/GYN or GYN

5. Dermatology

23. Ophthalmology

6. Diagnostic Radiology

24. Orthopedics

7. Emergency Medicine

25. Otolaryngology

8. Endocrinology/Metabolism

26. Pathology – Anatomic/Clinical

9. Family Practice/Family Medicine

27. Pediatrics

10. Forensic Pathology

28. Physical Medicine & Rehabilitation

11. Gastroenterology

29. Psychiatry

12. General Practice

30. Public Health & Rehabilitation

13. General Preventive Medicine

31. Pulmonary Medicine

14. General Surgery

32. Radiology

15. Geriatrics

33. Rheumatology

16. Hematology/Oncology

34. Surgery (All)

17. Internal Medicine

35. Urology

18. Medical Genetics

36. Vascular Medicine



37. Other specialties


5


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAppendix B
AuthorJoann Sorra
File Modified0000-00-00
File Created2021-01-31

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