National Ambulatory Medical Care Survey 2013 Medical Rec

NOTICE-Public reporting burden of this collection of information is estimated to average 14 minutes per response, including the 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/.ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Attachment B

NAMCS-73
(4-13-2012)

SAMPLE
NATIONAL AMBULATORY MEDICAL CARE SURVEY
2013 2012 PATIENT RECORD

Form Approved: OMB No. 0920-0234; Expiration date 2/28/2013

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 INFORMATION
Patient medical record No.

Sex
1

Date of visit
Month Day

Year

Ethnicity
Female – Is patient pregnant?
1
Yes - Specify gestation
week
OR

201

LMP
Month Day

ZIP Code

Hispanic or Latino
Not Hispanic or Latino

1
2

3
2

4

Male

4

White
Black or African
American
Asian
Native Hawaiian or
Other Pacific Islander
American Indian or
Alaska Native

3

No
Unknown

2

Date of birth
Month Day
Year

3

Race
2

201

1
2

1

Year

Expected source(s) of payment
for this visit – Mark (X) all that apply.

5

5
6
7
8

Private insurance
Medicare
Medicaid or CHIP
Worker’s compensation
Self-pay
No charge/Charity
Other
Unknown

Tobacco use
1
2
3

Not current
Current
Unknown

VITAL SIGNS
Weight

Height
in

ft

OR

Temperature

cm

lb

˚C
˚F

oz

Blood pressure
Systolic

Diastolic

/

OR
kg

gm

REASON FOR VISIT

INJURY/POISONING/ADVERSE EFFECT
Is this visit related to an
injury, poisoning, or adverse
effect of medical
treatment?
1
2
3
4
5

}

DRAFT

Yes, injury/trauma
Yes, poisoning
Yes, adverse effect of
SKIP to
medical treatment
Reason
No
For Visit
Unknown

}

Is this
injury/poisoning
unintentional or
intentional

1

2
3

Unintentional
Intentional
Unknown

5
Patient’s complaint(s), symptom(s), or other reason(s)
for this visit – Use patient’s
own words.

Most
important

(1)

(2) Other

(3) Other

CONTINUITY OF CARE

Are you the patient’s primary care
physician?
Yes – SKIP to
1
No
2
3
Unknown

Has the patient been seen in your practice
before?

1

}

Yes, established patient –
How many past visits in the last 12 months?
Exclude this visit.

Was patient referred for this
visit?
1
2
3

Visits

Yes
No
Unknown

1
2

Major reason for this visit
New problem (<3 mos. onset)
1
2
Chronic problem, routine
Chronic problem, flare-up
3
4
Pre/Post surgery
5
Preventive care (e.g., routine prenatal, well-baby,
screening, insurance, general exams)

Unknown

No, new patient

DIAGNOSIS
As specifically as possible, list diagnoses related to this visit including chronic conditions.
(1) Primary
diagnosis
(2) Other

(3) Other
Regardless of the diagnoses previously entered, does the patient now have – Mark (X) all that apply.
4
Cerebrovascular
3
Cancer
1
Arthritis
disease/History of
2
Asthma
1
In situ
stroke or transient
2
Stage
I
ischemic attack (TIA)
Asthma control:
Asthma severity:
3
Stage II
5
Chronic obstructive
1
Intermittent
1
Well controlled
Stage III
4
pulmonary disease
Mild persistent
2
2
Not well controlled
Stage IV
5
(COPD)
Moderate persistent
Very poorly controlled
3
3
Unknown stage
6
Chronic renal failure
6
Severe persistent
Other – Specify
4
4
Congestive heart
7
Other – Specify
5
Delete cancer
failure

stages

8
9

5
6

None recorded

None recorded

Depression
Diabetes

10
11
12
13
14
15

Hyperlipidemia
Hypertension
Ischemic heart
disease
Obesity
Osteoporosis
None of the above

SERVICES
Enter all examinations, blood tests, imaging, other tests, non-medication treatment and health education ORDERED or PROVIDED.
Other services not listed:
Non-medication
Other tests and
1
NONE
treatment:
procedures:
60
Other service – Specify
42
Cast/splint/wrap
23
Audiometry
Examinations:
43
Complementary
Biopsy
24
and alternative
2
Breast
1
Provided
medicine (CAM)
Depression screening 25
3
Cardiac stress test
Durable medical
44
4
Foot
26
Chlamydia test
equipment
5
General physical exam 27
Colonoscopy
Other service – Specify
61
45
Home health care
6
Neurologic
1
Provided
Mental health
46
7
Pelvic
EKG/ECG
28
counseling, excluding
8
Rectal
Electroencephalogram
29
psychotherapy
(EEG)
9
Retinal
Physical therapy
47
30
Electromyogram
10
Skin
Psychotherapy
48
(EMG)
49
Radiation therapy
Other service – Specify
62
31
Excision of tissue
50
Wound care
Blood tests:
1
Provided
Fetal monitoring
32
11
CBC
Health education/
Glucose
33
HIV test
12
Counseling:
13
HbA1c
HPV DNA test
34
Asthma
51
(Glycohemoglobin)
35
PAP test
Asthma action
1
Lipid profile
14
36
Peak flow
Other service – Specify
63
plan given
PSA (prostate specific 37
15
Pregnancy/HCG test
to patient
antigen)
38
Sigmoidoscopy
52
Diet/Nurtrition
1
Provided
53
Exercise
Imaging:
39
Spirometry
Family planning/
54
16
Bone mineral density
Tonometry
40
Contraception
CT scan
17
Urinalysis
Growth/Development 64 Other service – Specify
55
41
Echocardiogram
18
Injury prevention
56
Insert Checkbox
Other ultrasound
19
57
Stress management
20
Mammography
Tobacco use/Exposure
58
STD
Prevention
21
MRI
Weight reduction
59
22
X-ray

MEDICATIONS & IMMUNIZATIONS

PROVIDERS

Enter drugs that were ordered, supplied, administered or continued during this
visit. Include Rx and OTC drugs, immunizations, allergy shots, oxygen, anesthetics,
chemotherapy, and dietary supplements.

Mark (X) all providers
seen at this visit.
1

NONE

2

Physician
Physician
assistant
Nurse
practitioner/
Midwife
RN/LPN
Mental health
provider
Other
None

TIME SPENT WITH PROVIDER
Minutes

DRAFT
New Continued

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

1

2

1

2

3

4

1

2

5

1

2

6

1

2

7

1

2

1

2

1

2

1

2

1

2

Enter zero if no
provider seen

VISIT DISPOSITION

Mark (X) all that apply.
1
2
3
4

Refer to other physician
Return at specified time
Refer to ER/Admit to hospital
Other

ADD CPT Codes: Please record ALL
CPT or HCPCS Codes associated with
this visit. Include CPT modifier codes if
available.

TESTS
Was blood for the following laboratory tests
drawn on the day of the sampled visit or during
the 12 months prior to the visit?

Most recent result

Date of test (mm/dd/yyyy)

Total Cholesterol

1

1
2

Yes
None found

mg/dL

/ /

mg/dL

/ /

mg/dL

/ /

mg/dL

/ /

%

/ /

mg/dL

/ /

High density lipoprotein (HDL)

2

1
2

Yes
None found

Low density lipoprotein (LDL)

3

1
2

Yes
None found

Triglycerides (TGS)

4

1
2

Yes
None found

HbA1c (Glycohemoglobin)

5

1
2

Yes
None found

Fasting blood glucose (FBG)

6

1
2

Yes
None found

NAMCS-73 (4-13-2012)

ADD #7 Serum creatinine