Att K OPD PRF

Attachment K

Outpatient Department Patient Record form

Ambulatory Care Pretest, National Hospital Care Survey

OMB No. 0920-xxxx Exp. Date

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).

Patient’s name: ________________________________________________________

Patient’s address: ______________________________________________________ Street

____________________________ City _______ State

Patient’s Social Security number _____________________

Patient’s Control number ____________________________

Medicare health insurance benefit/claim number ___________________________

National Provider Identifier (NPI) - Attending _______________________________

National Provider Identifier (NPI) - Operating _______________________________

The current question on page 8 “Is patient allergic to any medication, e.g., bleeding from aspirin?” will be changed to the following:

Is the patient allergic to any medication?

Yes – Enter up to 3

No or no known allergies

Unknown

Has the patient had any adverse reaction to any medication (e.g., bleeding from aspirin)?

Yes – Enter up to 3

No or no known adverse reactions

Unknown

Lookback

Skipping height through BP systolic screens- simply asks to fill in the number

Total test result screens for each test is the same as cholesterol screen except with different wording to indicate the respective test, so did not copy those in.

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