2014 ED PRF Changes

Attachment C

Changes to 2014 Emergency Department Patient Record Form (PRF)

Proposed changes are indicated in RED.

• Modified-Expected source(s) of payment for this visit

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

New Answer list Private insurance Medicare Medicaid or CHIP or other state-based program Workers’ compensation Self-pay No charge/Charity Other Unknown

• Added-Arrival by ambulance

Old Answer list ARRIVE: Arrival by ambulance? Yes No Unknown	New Answer list ARRIVE: Arrival by ambulance? Yes No Unknown
	Add new question on point of origin: If ARRIVE=Yes, then ask, Was patient transferred from another hospital or urgent care center? [AMBTRANSFER] Yes No Unknown

• Deleted-On oxygen at arrival

“Triage” Section
Old Answer list O2: On oxygen at arrival? Yes No Unknown	New Answer list O2: On oxygen at arrival? Yes No Unknown

• Modified-Reason for Visit Questions

“Reason for Visit” Section
Old Allow up to 3 lines of Reason for visit verbatim and look-up	New Allow up to 5 lines of Reason for visit verbatim and look-up

• Modified-Injury/Poisoning/Adverse Effect Questions

“Injury/Poisoning/Adverse Effect” Section
Old INJURY: Is this visit related to an injury, poisoning, or adverse effect of medical treatment? Yes, injury/trauma Yes, poisoning Yes, adverse effect of medical treatment No Unknown	New INJURY: Is this visit related to an injury, poisoning, or adverse effect of medical treatment? Yes, injury/trauma Yes, poisoning Yes, adverse effect of medical treatment No Unknown
	Add new question on recent timing of injury: If INJURY=Yes, then ask, Did the injury or poisoning occur within 72 hours prior to the date and time of this visit? [INJURY72]

• Modified-Diagnosis Verbatim and Look-up Table

“Diagnosis” Section
Old: Allow up to 3 diagnoses verbatim and Look-up table entries	New: Allow up to 5 diagnoses verbatim and look-up table entries

• Modified-Checkbox list of patient’s underlying chronic conditions

“Diagnosis” Section
Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.
Old	New
---	Alcohol abuse
---	Substance abuse
Dementia	Alzheimer's disease/Dementia
---	Asthma
Cancer	Cancer
Cerebrovascular disease/History of stroke or transient ischemic attack (TIA)	Cerebrovascular disease/stroke (CVA) or transient ischemic attack (TIA)
Chronic obstructive pulmonary disease (COPD)	Chronic obstructive pulmonary disease (COPD)
Condition requiring dialysis	Chronic kidney disease (CKD)
Condition requiring dialysis	End-stage renal disease (ESRD)
Congestive heart failure	Congestive heart failure (CHF)
---	Depression
Diabetes	Diabetes mellitus (DM), Type I
Diabetes	Diabetes mellitus (DM), Type II
Diabetes	Diabetes mellitus (DM), Type Unspecified
History of pulmonary embolism or deep vein thrombosis (DVT)	History of pulmonary embolism (PE) or deep vein thrombosis (DVT)
---	Hyperlipidemia
---	Hypertension
History of heart attack	Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI)

• Modified-Medications and Immunizations

“Medications” Section
Old: Allow up to 10 drug entries (verbatim and look-up table)	New: Allow up to 30 drug entries (verbatim and look-up table)

• Added-Vitals at Discharge (after Medications)

“Vitals at Discharge” Section
Old	New VITALSD – Checkbox for “No vitals taken at discharge” TEMPD (write-in) Temperature TTEMPD (write-in) Celsius or Fahrenheit PULSED (write-in) Heart rate/Pulse beats per minute 998= DOPP, DOPPLER RESPRD (write-in) Respiratory rate breaths per minute BPSYSD (write-in) Blood pressure Systolic BPDIASD (write-in) Blood pressure Diastolic

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