B - Changes to Patient Record Form

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Attachment B

Changes to 2014 NAMCS 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

    • Modified-Tobacco use

Old Answer list
    • Not current
    • Current
    • Unknown

New Answer list
    • Not current
        ◦ Never
        ◦ Former
    • Current
    • 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
    • Major reason for this visit checkboxes
    1. New problem (<3 mos. onset)
    2. Chronic problem, routine
    3. Chronic problem, flare-up
    4. Pre/Post surgery
    5. Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)

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


    • 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?
    1. Yes, injury/trauma
    2. Yes, poisoning
    3. Yes, adverse effect of medical treatment
    4. No
    5. Unknown

New

    • INJURY: Is this visit related to an injury, poisoning, or adverse effect of medical treatment?
    1. Yes, injury/trauma
    2. Yes, poisoning
    3. Yes, adverse effect of medical/surgical care or adverse effect of medicinal drug
    4. No
    5. 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?

    • Is this injury/poisoning unintentional or intentional?
    1. Unintentional
    2. Intentional
    3. Unknown

    • Is this injury/overdose/poisoning intentional or unintentional?
                1. Intentional
                2. Unintentional (e.g., accidental)
                3. Intent unclear


Add new question for verbatim cause of injury narrative:
            ▪ “Cause of injury, poisoning, or adverse effect” verbatim

    • Modified-Diagnosis Verbatim and Look-up Table

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

Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.

Old
New
---
Alcohol misuse, abuse, or dependence
---
Substance abuse or dependence
---
Alzheimer's disease/Dementia
Arthritis
Arthritis
Asthma
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)
Chronic renal failure
Chronic kidney disease (CKD)
Chronic renal failure
End-stage renal disease (ESRD)
Congestive heart failure
Congestive heart failure (CHF)
Depression
Depression
Diabetes
Diabetes mellitus (DM)

If checked, then ask sub-categories for Type I & Type II.
---
History of pulmonary embolism (PE) or deep vein thrombosis (DVT)
---
HIV Infection/AIDS
Hyperlipidemia
Hyperlipidemia
Hypertension
Hypertension
Ischemic heart disease
Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI)
Obesity
Obesity
---
Obstructive sleep apnea (OSA)
Osteoporosis
Osteoporosis
None of the above
None of the above









    • Modified-Services Ordered or Provided

Enter all examinations, laboratory tests, imaging, other procedures or other treatment and health education or counseling ORDERED or PROVIDED.

    • NONE

Examinations/Screenings:
    • Alcohol misuse screening (includes AUDIT, MAST, CAGE, T-ACE)
    • Breast
    • Depression screening
    • Domestic violence screening 
    • Foot
    •  General physical exam (DELETE)
    • Neurologic
    • Pelvic
    • Rectal
    • Retinal/ Eye Exam
    • Skin
    • Substance abuse screening (includes NIDA/NM ASSIST, CAGE-AID, DAST-10) 

Blood tests: Laboratory tests:
    • Basic metabolic panel 
    • CBC
    • Chlamydia test 
    • Comprehensive metabolic panel 
    • Creatinine /Renal function panel 
    • Culture 
        ◦ Blood
        ◦ Throat 
        ◦ Urine
        ◦ Other
    • Glucose, serum 
    • Gonorrhea test 
    • HbA1c (Glycohemoglobin)
    • Hepatitis testing/Hepatitis panel 
    • HIV test (NEW LOCATION)
    • HPV DNA test (NEW LOCATION)
    • Lipid profile
    • Liver enzymes/Hepatic function panel 
    • PAP test (NEW LOCATION)
    • Pregnancy/HCG test (NEW LOCATION)
    • PSA (prostate specific antigen)
    • Rapid strep test
    • TSH/Thyroid panel 
    • Urinalysis (NEW LOCATION)
    • Vitamin D test 

Imaging:
    • Bone mineral density
    • CT scan
    • Echocardiogram
    • Ultrasound 
    • Mammography
    • MRI
    • X-ray

Other tests and procedures: Procedures:
    • Audiometry
    • Biopsy
    • Cardiac stress test
    • Colonoscopy
    • Cryosurgery (cryotherapy)/ Destruction of tissue 
    • EKG/ECG
    • Electroencephalogram (EEG)
    • Electromyogram (EMG)
    • Excision of tissue
    • Fetal monitoring
    • Peak flow
    • Sigmoidoscopy
    • Spirometry
    • Tonometry
    • Tuberculosis skin testing/PPD 
    • Upper gastrointestinal endoscopy/EGD 

Non-medication treatment: Treatments:
    • Cast/splint/wrap
    • Complementary and alternative medicine (CAM)
    • Durable medical equipment
    • Home health care
    • Mental health counseling, excluding psychotherapy
    • Occupational therapy 
    • Physical therapy
    • Psychotherapy
    • Radiation therapy
    • Wound care

Health education/Counseling: 
    • Alcohol abuse counseling 
    • Asthma
    • Asthma action plan given to patient
    • Diabetes education 
    • Diet/Nutrition
    • Exercise
    • Family planning/Contraception
    • Genetic counseling 
    • Growth/Development
    • Injury prevention
    • STD prevention
    • Stress management
    • Substance abuse counseling 
    • Tobacco use/Exposure
    • Weight reduction

Other services not listed:
    • Other service - Specify__________________________________________
    • Other service - Specify__________________________________________
    • Other service - Specify__________________________________________
    • Other service - Specify__________________________________________
    • Other service - Specify__________________________________________

    • Modified-Medications and Immunizations

Old: Allow up to 10 drug entries (verbatim and look-up table)

New: Allow up to 30 drug entries (verbatim and look-up table)


    • Modified-Time spent with physician

Old: Time spent with physician
New: Estimated time spent with physician


    • Modified-Visit disposition

Old
    • Mark (X) all that apply.
    1. Refer to other physician
    2. Return at specified time
    3. Refer to ER/Admit to hospital
    4. Other

New
    • Mark (X) all that apply
    1. Return to referring physician
    2. Refer to other physician
    3. Return at specified time-less than 1 week
    4. Return at specified time-1 week to less than 2 months
    5. Return at specified time-2 months or greater
    6. Return as needed (p.r.n.)
    7. Return to ER/Admit to hospital
    8. Other