Att J - NHCS Ambulatory Pretest ED PRF

Attachment J - NHCS ED Patient Record form (04/10/2012)

Ambulatory Care Pretest, National Hospital Care Survey

OMB No. 0920-xxxx Exp. Date

Assurance of confidentiality - All information which would permit idenitification 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).

1. PATIENT INFORMATION

Patient's name

Patient's SS#

Patient's Control number

Patient's residential address: Street City State

Patient's medical record number

Medicare health insurance benefit/claim number

National Provider Identifier (NPI) - Attending

National Provider Identifier (NPI) - Operating

a. Date and Time of Visit

c.

ZIP Code

d.

Date of Birth

Date

Time

Month Day Year

Month Day Year

(1)

Date of arrival

Age

Enter time period

1 Years 2 Months 3 Days

(2)

Seen by MD/DO/PA/NP

b.

Patient Residence

e.

Sex

f.

Ethnicity

1

Private residence

1

Female

1

Hispanic or Latino

(3)

ED Departure, if released (i.e., patients who do not have a disposition of admit to hospital, admit to observation unit, or transfer)

2

Institution

2

Male

2

Not Hispanic or Latino

Nursing home

Supportive housing/Group home

Jail/Prison

Other

3

Homeless/Homeless shelter

4

Other

5

Unknown

g.

Race

h.

Mode of Arrival

i.

Expected source(s) of payment for this visit

1

White

1

Ambulance

Mark all that apply.

2

Black or African American

2

Police transport

Private insurance

3

Asian

3

Other

TRICARE

4

Native Hawaiian or Other Pacific Islander

4

Unknown

5

American Indian or Alaska Native

Medicare

Medicaid or CHIP

Worker's compensation

Self-pay

No charge/Charity

Other

Unknown

2. TRIAGE

a.

Initial vital

(1)

Temperature

(2)

Heart rate/Pulse

(3)

Respiratory rate

b.

Triage level

signs

Celsius

per

beats

breaths

(1-5 , 0= No triage, 9= Unknown)

Fahrenheit

998= P, PALP, DOPP, DOPPLER

per

minute

per minute

minute

(4)

Blood pressure

Blood pressure

(5)

Pulse oximetry

(6)

On oxygen at arrival

c.

Pain scale

Systolic

Diastolic

1

Yes

3

Unknown

(0-10, 99= Unknown)

%

2

No

998= P, PALP, DOPP, DOPPLER

3. PREVIOUS CARE

a.

Was patient seen in this ED in the last 72 hours and discharged?

Yes

No

Unknown

1

2

3

4. REASON FOR VISIT

a.

Enter the patient's presenting complaint(s), symptom(s), or other reason(s) for this visit in the

b.

Episode of care

patient's own words. Enter the "most important" complaint/symptom/reason first. Enter 0 for None/No more.

(1)

Most important:

Look-up 1

1

Initial visit to this ED for problem

Source of principal reason for visit

1 In patient's own words 2 Other 3 Unknown

(2)

Other:

Look-up 2

2

Follow-up visit to this ED for problem

(3)

Other:

Look-up 3

3

Unknown

(4)

Other:

Look-up 4

5. INJURY/OVERDOSE/POISONING/ADVERSE EFFECT

a. Is this visit related to an injury, overdose, poisoning, or adverse effect of medical or surgical treatment?

b. Is this injury/overdose/poisoning intentional?

c. Cause of injury, poisoning by drug or non-drug toxin, drug-induced illness, or adverse effect - Describe the place and events that preceded the injury (e.g., pedestrian struck by car driven on highway by drunk driver - for motor vehicle crash, indicate if it occurred on the street or highway versus a driveway or parking lot); poisoning by drug (e.g., injected heroin at nightclub restroom and overdosed) or non-drug toxin (e.g., child swallowed bleach at home); or adverse effect (e.g., developed swelling of the throat after taking Celebrex). Enter the primary cause on the first line, followed by the contributing causes. Up to 5 causes may be entered. (Will add dropdown menu.)

1

No - SKIP to Item 6

1

Yes, intentional

2

Yes, injury/trauma

(a)

Self-inflicted

3

Yes, poisoning1 (non-drug toxic substance)

(1) Suicide attempt

4

Yes, poisoning (drug-induced overdose)

(2) Self-harm or suicide gesture

(a) Medication

(b) Intentional harm by another person

(b) Illicit substance

(c) Unknown

2

No, unintentional (e.g., accidental)

5

Yes, adverse effect of medical or surgical treatment

3

Unknown intent

(a) Medication involved

(b) No medication involved - SKIP to Item 5c

(c) Unknown

6

Unknown - SKIP to Item 6

6. SUBSTANCES INVOLVED / ROUTE OF ADMINISTRATION

Did any substance(s) (e.g., illicit drugs, inhalants, prescription or OTC medications, dietary supplement) cause or contribute to this visit? 1-Yes 2-No (Skip to item 7) 3-Unknown (Skip to item 7). Enter all substances that caused or contributed to the ED visit. Record substances as specifically as possible (i.e., brand [trade] name preferred over generic name preferred over chemical name, etc.). Do not record the same substance by two different names. Do not record current medications unrelated to the visit.

Mark if confirmed by toxicology report

Enter all that apply; patient took:

Route of Administration

1 - Oral

Own prescription/OTC medication or dietary supplement

2 - Injected

3 - Inhaled, sniffed, snorted

Prescription medication not prescribed for patient

4 - Smoked

Prescription/OTC medication as prescribed or according to directions

5 - Transdermal

6 - Other

Too much of a prescription/OTC medication or dietary supplement

7 - Not documented

Alcohol involved?

Yes

No/Not documented

Illict drug(s)

Not documented

(1)_____________________

(22)___________________________

Will add dropdown menu with DAWN DRV.

7. PROVIDER'S DIAGNOSIS FOR THIS VISIT

a.

As specifically as possible, enter up to 20 diagnoses related to this visit, including chronic conditions. (verbatim and codes)

b.

Does patient have - Mark all that apply.

(1)

Primary diagnosis:

1

Cancer

8

History of heart attack or myocardial infarction (MI)

Look-up 1

2

Cerebrovascular disease/History of stroke or transient ischemic attack (TIA)

9

History of pulmonary embolism (PE) or deep vein thrombosis (DVT)

Will add drop-down menu so that the abstractor is able to record as many diagnoses as recorded by the UB-04 for the pre-test

3

Chronic obstructive pulmonary disease (COPD)

10

HIV infection/AIDS

4

Conditions requiring dialysis

11

Mental illness or episode2

5

Congestive heart failure (CHF)

Bipolar disorder/Manic depression

6

Dementia

Depression, excluding manic depression

7

Diabetes

Schizophrenia

Suicidal ideation

Other

12

Substance abuse, misuse, or dependence

13

Not documented

8. DIAGNOSTIC SERVICES

9. PROCEDURES

Mark all ORDERED or PROVIDED at this visit.

Mark all procedures PROVIDED at this visit. Exclude medications.

1

NONE

Other tests:

Imaging:

1

NONE

Blood tests:

17

EKG/ECG

29

MRI

2

BiPAP/CPAP

2

ABG (Arterial blood gases)

18

HIV test

30

Ultrasound

3

Bladder catheter

3

BAC (Blood alcohol concentration)

19

Influenza test

Performed by:

4

Cast, splint, or wrap

______ %

20

Pregnancy/HCG test

4

Blood culture

21

Toxicology screen

Emergency Physician

5

Central line

5

BNP (brain natriuretic peptide)

22

Urinalysis (UA) or urine dipstick

Other

6

CPR

6

BUN/Creatinine

Unknown

7

Endotracheal incubation

7

Cardiac enzymes (CE)

23

Urine culture

31

Other imaging

8

Incision & drainage

8

CBC (Complete blood count)

24

Wound culture

(I&D)

9

D-dimer

25

Other test/service

9

IV fluids

10

Electrolytes

Imaging:

10

Lumbar puncture

11

Glucose

26

X-ray

11

Nebulizer therapy

12

Lactate

27

Intravenous contrast

12

Pelvic exam

13

Liver function tests (LFT)

28

CT scan

13

Physical restraint

14

Prothrombin time/INR

Abdomen/pelvis

14

Psychiatry/Psychology/Substance abuse consult3

15

Other blood test

Chest

15

Skin adhesives

Other tests:

Head

16

Suturing/Staples

16

Cardiac monitor

Other

17

Other

10. MEDICATIONS & IMMUNIZATIONS

11. PROVIDERS

Enter up to 12 drugs given at this visit or prescribed at ED discharge. Include Rx and OTC drugs, immunizations, and anesthetics.

Mark all providers seen at this visit.

NONE

Given in ED

Rx at discharge

1

ED attending physician

(1)

1

2

2

ED resident or Intern

(2)

1

2

3

Consulting physician

Specialty of consulting physician

(3)

1

2

4

RN/LPN

1 Anesthesia

(4)

1

2

5

Nurse practitioner

2 Critical care

(5)

1

2

6

Physician assistant

3 ENT (Otolaryngology)

(6)

1

2

7

EMT

4 Hematology/Oncology

(7)

1

2

8

Psychologist

5 Palliative care

(8)

1

2

9

Social worker

6 Psychiatry

(9)_________________________

1

2

10

Other mental health provider

7 Other specialty

(10)________________________

1

2

11

Other provider

8 Unknown

(11) _______________________

1

2

9

Other

7 - Not documented

12. VISIT DISPOSITION

Mark all that apply.

11

Return/Transfer to jail/prison

1

No follow-up planned

12

Transfer to acute 24-hour behavioral health care facility

2

Return to ED

Psychiatric inpatient treatment

3

Return/Refer to physcian/clinic for

Involuntary status

Reason for transfer

Outpatient mental health/

Voluntary status

1 Continuity of care; Request by patient, family, or physician

Substance abuse treatment

Not documented

Other follow-up

Substance abuse treatment facility

2 Higher level or specialized care needed

5

Left before triage

13

Transfer to other non-psychiatric hospital

6

Left after triage

14

Admit to this hospital - SKIP to Item 13

4 Insurance requirement/request

7

Left AMA

15

Admit to observation unit then hospitalized - Skip to item 13

5 Other/Insufficient information available

8

DOA

16

Admit to observation unit then discharged -

SKIP to Item 14

9

Died in ED

17

Other

10

Return/Transfer to nursing home

13. ADMISSION TO THIS HOSPITAL

a.

Admitted to:

c.

Date and time bed was requested for hospital admission or transfer

1

Critical care unit

Date

Time

2

Stepdown unit

3

Operating room

4

Mental health or detox unit4

d. Hospital discharge date

Date and time patient actually left the ED or observation unit

5

Cardiac catheterization lab

Date

Time

6

Other bed/unit

7

Unknown

b.

Admitting physician:

e. Hospital discharge date

Hospital discharge date

1

Hospitalist

Date

2

Not hospitalist

3

Unknown

f.

Hospital discharge diagnosis

1 Unknown

Principal

2

Secondary

g.

Hospital discharge status/disposition

1

Alive

1

Home/Residence

2

Dead - SKIP to END

2

Return/Transfer to nursing home

3

Unknown -SKIP to END

3

Transfer to another facility (not usual place of residence)

4

Return/Transfer to jail/prison

5

Other

6

Unknown

14. OBSERVATION UNIT STAY

a. Date and time of ED discharge

Date

Time

1

Unknown

b. Date and time of observation unit discharge

Date

Time

1

Unknown

Notes:

1 "Poisoning (non-drug toxic substance)" is defined as ingestion (e.g., bleach), inhalation (e.g., carbon monoxide), absorption through the skin (e.g., mercury), or injection of too much of a non-drug toxin (biologic or non-biologic) or other chemical where a harmful effect results. This category does not include any harmful effects from any drug or bacterial illnesses.

2 "Mental illness or episode" includes not only those visits by a patient with a known diagnosis of mental illness (e.g. depression, schizophrenia), but those presenting with psychiatric symptoms not previously manifest or diagnosed (e.g., acute paranoia, hallucinations).

3 "Psychiatry/Psychology/Substance abuse consult" includes terms such as mental health status exam, mental health exam, behavioral health assessment, etc.

4 "Mental health or detox unit" refers to any specialized unit serving patients with mental, psychological, or behavioral health problems and/or addictions or substance use/misuse.