Att I - Patient Record Form changes

Attachment I: National Ambulatory Medical Care Survey 2012: Changes to Patient Record Form

NOTE: Due to automation the following items are entered into the system during the abstraction
process through the PRF module and are not represented by a paper form.
Added items:
Enter patient’s medical record number
Is patient pregnant?

□1
□2

Yes
No

Modifications 2011 version in BLACK, new is in RED:
Zip code: __/__/__/__/__
Zip code: __/__/__/__/__ + __/__/__/__
Enter “1” for zip code if Patient’s homeless (if patient’s zip code is unavailable)

Regardless of the diagnoses written in 5a, does the patient now have – Mark (x) all that apply.
□1
□2
□3
□4
□5
□6
□7

Arthritis
Asthma
Cancer
Cerebrovascular disease/ History
of stroke or transient ischemic
attack (TIA)
Chronic renal failure
Congestive heart failure
COPD

□8
□9
□10
□11
□12
□13
□14
□15

Depression
Diabetes
Hyperlipidemia
Hypertension
Ischemic heart disease
Obesity
Osteoporosis
None of the above

Regardless of the diagnoses written in 5a, does the patient now have – Mark (x) all that apply.
□1
□2

□3

Arthritis
Asthma
Asthma severity:
□1 Intermittent
□2 Mild persistent
□3 Moderate persistent
□4 Severe persistent
□5 Other – Specify _________
□6 None recorded
Asthma control:
□1 Well controlled
□2 Not well controlled
□3 Very poorly controlled
□4 Other – Specify ____
□5 None recorded
Cancer
□1 In situ
□2 Stage I
□3 Stage II

□4 Stage III
□5 Stage IV
□6 Unknown
□4
□5
□6
□7
□8
□9
□10
□11
□12
□13
□14
□15

Cerebrovascular disease/
History of stroke or transient
ischemic attack (TIA)
Chronic obstructive pulmonary
disease (COPD)
Chronic renal failure
Congestive heart failure
Depression
Diabetes
Hyperlipidemia
Hypertension
Ischemic heart disease
Obesity
Osteoporosis
None of the above

Attachment I
The below sections from 2011 (7, 8, and 9) were combined into services section for 2012 (see
red):
7. Diagnostic/Screening Services:
Mark (x) all ordered or provided at visit:
□14 Mammography
□1 NONE
□15 MRI
Examinations:
□16 Other imaging
□2 Breast
Blood tests:
□3 Foot
□17 CBC (complete
□4 Pelvic
blood test
□5 Rectal
□18 Glucose
□6 Retinal
□19 HgbA1c
□7 Skin
(glycohemoglobin)
□8 Depression
□20 Lipids/
Screening
Cholesterol
Imaging:
□21 PSA (prostate
□9 X-ray
specific antigen)
□10 Bone mineral
□22 Other blood test
density
Scope:
□11 CT scan
□23 Scope procedure
□12 Echocardiogram
-- (e.g.,
□13 Other ultrasound

8. Health Education
Mark (x) all ordered or provided at visit:
□7 Injusry
□1 NONE
prevention
□2 Asthma
□8 Stress
education
Management
□3 Diet/Nutritiion
□9 Tobacco use/
□4 Exercise
Exposure
□5 Family planning/
□10 Weight
contraception
reduction
□6 Growth/
□11 Other
Development

9. Non-Medication Treatment
□1 NONE
□2 Complementary and alternative medicine (CAM)
□3 Durable medical equipment
□4 Home health care
□5 Physical Therapy
□6 Radiation Therapy
□7 Speech/ Occupational Therapy
□8 Psychotherapy
□9 Other mental health counseling
□10 Excision of tissue
□11 Wound Care
□12 Cast
□13 Splint or wrap

□24
□25
□26
□27
□28
□29
□30
□31
□32

colonoscopy)
Specify: ____
Bioposy –
Specify____
Chlamydia Test
EKG/ECG
HIV Test
HPV DNA Test
Pap test
Pregnancy/HCG
test
Urinalysis (UA)
Other exam/test
/service:
Specify___

Attachment I
SERVICES
ENTER all examination, blood tests, imaging, other tests, non-medication treatment and
health education ORDERED or PROVIDED.
□1

NO SERVICES

Examinations:
□2 Breast
□3 Depression
screening
□4 Foot
□5 General physical
exam
□6 Neurologic
□7 Pelvic
□8 Rectal
□9 Retinal
□10 Skin
Blood Tests:
□11 CBC
□12 Glucose
□13 HgbA1c
(Glycohemoglobin)
□14 Lipid Profile
□15 PSA (prostate
specific antigen)
Imaging:
□16 Bone mineral
density
□17 CT scan
□18 Echocardiogram
□19 Other ultrasound
□20 Mammography
□21 MRI

□22 X-Ray and
procedures
Other tests and
procedures:
□23 Audiometry
□24 Biopsy
□1 Provided
□25 Cardiac stress test
□26 Chlamydia test
□27 Colonoscopy
□1 Provided
□28 EKG/ECG
□29 Electroencephalogram (EEG)
□30 Electromyogram
(EMG)
□31 Excision of tissue
□32 Fetal monitoring
□33 HIV Test
□34 HPV DNA Test
□35 Pap test
□36 Peak flow
□37 Pregnancy/HCG test
□38 Sigmoidoscopy
□39 Spirometry
□40 Tonometry
□41 Urinalysis
Non-medication
treatment:
□42 Cast/splint/wrap

□43 Complementary
and alternative
medicine (CAM)
□44 Durable medical
equipment
□45 Home health care
□46 Mental health
counseling,
excluding
psychotherapy
□47 Physical Therapy
□48 Psychotherapy
□49 Radiation
□50 Wound Care
Health Education
□51 Asthma education
□52 Diet/Nutritiion
□53 Exercise
□54 Family planning/
contraception
□55 Growth/
Development
□56 Injusry prevention
□57 Stress Management
□58 Tobacco use/
Exposure
□59 Weight reduction
Other
□60 Other