Form 3 Ambulatory Unit Induction Form

Attachment I

Ambulatory Unit Induction 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).
Notice – Public reporting burden for this collection of information is estimated to average 15 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-xxxx).

START

CENSUS CAPI SYSTEM
                                                              
Ambulatory Unit Record
(Muliple ASL's were combined into this AU)
CASE STATUS IS:  (New Case/ Call RO - Unable to locate/Interview Started/etc)     
     Reference Period:  (Reference period)
Press ALT-F9 to update AU/contact information
Press ALT-F11 to update AU schedule

1. Continue

2. Noninterview (Unable to locate, refusal, etc.)

3. Change PRF mode

4. Transmit for reassignment

5. Quit

CHG_PRFMODE

   Enter how the abstractions will be done
         (Previously abstractions were to be done by:

1. Remote

2. Non-remote

3. Other

VERIFY_PRFMODE

  The mode of PRF will be changed to:   (Remote, Non-remote, Other)

   If this is not correct, press F1 to back up and change your answer.

1. Enter 1 to Continue

SETUP_INFO

  Enter the following information into the Web system.
    
      AU Name:  (facility name)
       Respondent's ID:   (Case ID)
       Select Form Used: (ED/OPD/Ambulatory Surgery)
       Reporting Period:  (Reporting Period)
       Start With:  (Start with number)              
       Take Every:  (Take Every Number)
 1. Enter 1 to Continue

SETUP_DONE

   Have you finished setting up everything and filling out the form for the staff?

1. Yes

2. No

ADMISSIONS_RES

  This AU did not have any hospital admissions because the charts were unavailable at the time of abstraction.
     Are the charts available now?

1. Yes, charts are available now

2. No, charts are still unavailable - continue to followup

3. Missing admissions info - final (No more followup)

LOG105_RES

  There were PRFs with a disposition on "admitted to hospital" that had missing
    hospital discharge information.
    Is that information available now?

1. Yes, information is available now

2. No, discharge information is still unavailable - continue to followup

3. Missing discharge info - final (No more followup)

UPDATE_PRF

  Enter 1 and then press END to go to NEXT_PRF.
    At NEXT_PRF, Enter 1 to update the appropriate PRF(s)

1. Enter 1 to Continue

NONINT_TYPE

  Enter the type of noninterview

1.Unable to locate - Call RO

2.Abstraction delayed by facility

3.AU ineligible - not under auspices of hospital or FSASC

4.AU ineligible - only ancillary services provided

5.AU ineligible - care not provided by or under the direct supervision of a physician

6.AU ineligible - AU classified as out of scope

7.AU ineligible - other

8.Closed - Temporary

9.Closed - Permanent

10.Hospital Refused

11.Whole department Refused

12.Potential Refusal - followup required

13.Refused (TRANSMIT)

INTRO_INTERVIEW

  DO NOT READ AS WORDED BELOW 
              
o  Identify yourself - show I.D.
o  Ask to speak to: 
           (AU contact 1's name )
           (2nd AU contact Name )
    (Press ALT-F9 to update AU contact information) 
o  Introduce survey, as necessary
o  Press ALT-F11 to update AU schedule, if necessary

1.Continue

2.Reluctant Respondent

3.Inconvenient time

4.Other Outcome

PRIMARYCARE

Does this clinic provide predominantly primary care?

1.Yes

2.No

3.Unknown

AGREEEST

According to our information, about (Original estimated number of visits) patients visits are expected during the reporting period.
Do you agree with this estimate?
       Reporting Period:  (Reference week)

1.Yes

2.No

ESTVISHR

About how many visits do you expect during the reporting period, (Reference week)

NUMTRLEV

  How many levels are in this ESA's triage system?

1.Three

2.Four

3.Five

4.Other - Specify

5.Do not conduct nursing triage

NUMTRLEV_SP

  Specify other triage levels

PRFHELP

Who will complete the PRFs?

1.FR

2.Staff

CINFO

    Get a complete listing of all staff that will be assisting in the
     data collection activities during the reporting period.
    
     Press ALT-F10 to enter/update additional staff that will be assisting.
     Press ALT-F9 to enter/update main AU contacts

1. Enter 1 to Continue

HOW_STAFFPRF

  How will the staff complete the PRFs?

1. Laptop

2. Own PC

SETUP_INFO

  Enter the following information into the Web system.

      AU Name:  (facility name)
       Respondent's ID:   (Case ID)
       Select Form Used:  (ED/OPD/Ambulatory Surgery)
       Reporting Period:  (Reporting Period)
       Start With:  (Start with number)             
          Take Every:  (Take Every Number)

1. Setup Complete

2. Problem, setup later

PATIENT_LOG

  Explain how to complete the Patient Log/Sign-in sheet.  Cover the following points

Include the following:
   - List all patients receiving treatment during all hours of operation during the reporting period.
Exclude the following:
     - Persons who visit only to leave a specimen, pick up a prescription or medication, or other visit
where medical care is not provided;
     - Persons who visit to pay a bill, complete insurance forms, or for some other administrative
reason;
     - Telephone calls or e-mail messages from patients;
     - Visits by persons currently admitted as inpatients to any other health care facility on the premises,
that is, the sample hospital.

THANK

Thank you for your time and cooperation.
 ^LAPTOP_ACCOUNT

If you have any question (Hand contact your business card) please feel free to call me.
1. Enter 1 to Continue

2. Start Abstraction Now

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