NAMCS-30 Form

Attachment D1: 2014 Patient Record form (NAMCS-30)
NAMCS-73
(3-6-2014)

SAMPLE
NATIONAL AMBULATORY MEDICAL CARE SURVEY
2014 PATIENT RECORD
Form Approved: OMB No. 0920-0234; Expiration date 12/31/2014

NOTICE – Public reporting burden of this collection of information is estimated to average 14 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 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).
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
Age

Years

1

Months

2

Days

3

Sex
Year

201
ZIP Code Enter "1" if homeless

LMP
Month Day

2
3

1

Race – Mark (X) all
that apply.
1
2

4
5

No
Unknown

Hispanic or Latino
Not Hispanic or
Latino

2

3

Year

201

Date of birth
Month Day
Year

1
2

Female – Is patient pregnant?
1
Yes - Specify gestation week – Gestation
week refers to the number of weeks plus 2
that the offspring has spent developing in
the uterus
OR

1

Date of visit
Month Day

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

Ethnicity

Patient medical record No.

3

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

4
5
6
7
8

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

Tobacco use
Never smoker
Former smoker
Current smoker
Unknown

1
2
3
4

Male

2

BIOMETRICS/VITAL SIGNS
Weight

Height
in

ft

OR

cm

Temperature
lb

˚C
˚F

oz

OR
kg

Blood pressure
Systolic

Diastolic

/
If multiple measurements are
taken, record the last
measurement.

gm

REASON FOR VISIT
List the first 5 reasons for visit (i.e., symptoms, problems, issues, concerns of the
patient) in the order in which they appear. Start with the chief complaint and then
move to the patient history for additional reasons.
(1) Most
important
(2) Other
(3) Other

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

(4) Other
(5) Other

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

}

Yes, injury
Yes, poisoning
Yes, adverse effect of medical/surgical
care or adverse effect of medicinal drug
SKIP to Cause of injury, poisoning, or
adverse effect
No
Unknown

1
2
3

Did the injury or poisoning Is this injury or
poisoning intentional
occur within 72 hours
prior to the date and time or unintentional?
of this visit?
1
Intentional
1
Yes
2
Unintentional (e.g.,
2
No
accidental)
3
Unknown
3
Intent
unclear
Not applicable
4

Cause of injury, poisoning, or adverse effect – Describe
the place and circumstances that preceded the injury, poisoning, or
adverse effect. Examples: 1 – Injury (e.g., patient fell while walking
down stairs at home and sprained her ankle; patient was bitten by
a spider); 2 – Poisoning (e.g., 4 year old child was given adult
cold/cough medication and became lethargic; child swallowed large
amount of liquid cleanser and began vomiting); 3 – Adverse effect
(e.g., patient developed a rash on his arm 2 days after taking
penicillin for an ear infection).

}

4
5

DIAGNOSIS

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

}

Was patient referred for this
visit?

Has the patient been seen in this practice
before?
1

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

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

(3) Other
Visits
Yes
(4) Other
No, new patient
2
2
No
3
(5) Other
Unknown
Regardless of the diagnoses previously entered, does the patient now have – Mark (X) all that apply.
7
Chronic kidney disease (CKD) 11
Depression
1
Alcohol misuse, abuse
17
or dependence
8
Chronic obstructive
12
Diabetes mellitus (DM), Type 1
18
2
Alzheimer’s disease/Dementia
pulmonary disease (COPD)
13
Diabetes mellitus (DM), Type 2
19
Arthritis
3
9
Congestive heart failure
Diabetes mellitus (DM), Type
14
20
4
Asthma
(CHF)
unspecified
21
Coronary artery disease (CAD),
10
5
Cancer
15
End-stage renal disease (ESRD)
22
ischemic heart disease (IHD) or 16
Cerebrovascular
6
History of pulmonary embolism
23
history of myocardial infarction
disease/stroke (CVA) or
(PE) or deep vein thrombosis
(MI)
24
transient ischemic attack (TIA)
(DVT)
Asthma severity:
Asthma control:
Well controlled
5
Other – Specify
4
Intermittent
Other – Specify
1
1
Not well controlled
2
2
Mild persistent
Very poorly controlled
3
3
Moderate persistent
4
6
None recorded
5
None recorded
Severe persistent
1

HIV Infection/AIDS
Hyperlipidemia
Hypertension
Obesity
Obstructive sleep apnea (OSA)
Osteoporosis
Substance abuse or dependence
None of the above

SERVICES
Enter all Examinations/Screenings, Laboratory tests, Imaging, Procedures, Treatments, Health education/Counseling, and Other services not
listed ORDERED OR PROVIDED.
1
NO SERVICES
Examinations/Screenings:
28
Lipid profile
Alcohol misuse screening
2
(includes AUDIT, MAST,
29
Liver enzymes/Hepatic
CAGE, T-ACE)
function panel
Breast
3
30
Pap test
Depression screening
4
31
Pregnancy/HCG test
Domestic violence screening 32
5
PSA (prostate specific antigen)
Foot
6
33
Rapid strep test
Neurologic
7
34
TSH/Thyroid panel
8
Pelvic
Urinalysis
35
Rectal
9
36
Vitamin D test
Retinal/Eye Exam
10
Imaging:
11
Skin
37
Bone mineral density
12
Substance abuse screening
CT scan
(includes NIDA/NM ASSIST, 38
Echocardiogram
39
CAGE-AID, DAST-10)
Ultrasound
40
Laboratory tests:
41
Mammography
Basic metabolic panel
13
42
MRI
CBC
14
43
X-ray
Chlamydia test
15
Procedures:
Comprehensive metabolic
16
panel
44
Audiometry
Creatinine/Renal
17
45
Biopsy
function panel
Biopsy provided?
Culture, blood
18
1
Yes
19
Culture, throat
No
2
20
Culture, urine
46
Cardiac stress test
Culture, other
21
47
Colonoscopy
Glucose, serum
22
Colonoscopy provided?
Gonorrhea test
23
1
Yes
HbA1c (Glycohemoglobin)
24
No
2
Hepatitis testing/Hepatitis panel 48
Cryosurgery (cryotherapy)/
25
Destruction of tissue
26
HIV test
EKG/ECG
49
HPV DNA test
27

Health education/Counseling:
Electroencephalogram (EEG)
Electromyogram (EMG)
51
Excision of tissue
52
Excision of tissue provided?
1
Yes
No
2
Fetal monitoring
53
54
Peak flow
55
Sigmoidoscopy
Sigmoidoscopy provided?
1
Yes
No
2
56
Spirometry
57
Tonometry
58
Tuberculosis skin testing/PPD
59
Upper gastrointestinal
endoscopy/EGD
Treatments:
Cast/splint/wrap
60
Complementary and alternative
61
medicine (CAM)
62
Durable medical equipment
Home health care
63
Mental health counseling,
64
excluding psychotherapy
Occupational therapy
65
66
Physical therapy
67
Psychotherapy
Radiation therapy
68
Wound care
69
50

PROVIDERS

MEDICATIONS & IMMUNIZATIONS
Were any prescription or non-prescription drugs ORDERED or PROVIDED (by any
route of administration) at this visit? Include Rx and OTC drugs, immunizations, allergy
shots, oxygen, anesthetics, chemotherapy, and dietary supplements that were ordered, supplied,
administered, or continued during this visit. Include drugs prescribed at a previous visit if the
patient was instructed at THIS VISIT to continue with the medication.
1
Yes
2
No

Mark (X) all providers
seen at this visit.
1
2
3

New Continued

(1)
(2)

1

2

1

2

(3)

1

2

(4)
(5)

1

2

1

2

1

2

1

2

1

2

(30)

Up to 30 medications can be listed.

4
5
6
7

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

Alcohol abuse counseling
Asthma
Asthma action plan given to patient
72
Diabetes education
73
Diet/Nutrition
74
Exercise
75
Family planning/Contraception
76
77
Genetic counseling
78
Growth/Development
79
Injury prevention
80
STD prevention
81
Stress management
82
Substance abuse counseling
83
Tobacco use/Exposure
84
Weight reduction
Other services not listed:
85
Other service – Specify
70
71

Up to 5 other services
can be listed.

TIME SPENT WITH PROVIDER
Minutes

Enter estimated time spent
with sampled provider –
Enter 0 if no provider seen

VISIT DISPOSITION
Mark (X) all that apply.
Return to referring physician
1
Refer to other physician
2
Return in less than 1 week
3
4
Return in 1 week to less than
2 months
5
Return in 2 months or greater
6
Return at unspecified time
7
Return as needed (p.r.n.)
8
Refer to ER/Admit to hospital
9
Other

TESTS

1
2

Was blood for the following laboratory tests
drawn on the day of the sampled visit or during
the 12 months prior to the visit?
Total Cholesterol
Yes
1
2
None found
High density
lipoprotein (HDL)

1
2

3

Low density
lipoprotein (LDL)

1
2

Month

1
2

5

HbA1c (A1C)
(Glycohemoglobin)

1
2

6

Blood glucose (BG)

1
2

Serum creatinine

7

1
2

Day

Month

Day

Month

Day

Day

Year

201

mg/dL
Month

mg/dL

Year

201

%
Month

.

Year

201

mg/dL

Yes
None found

Year

201

mg/dL

.

Year

201
Month

Yes
None found

Yes
None found

Day

mg/dL

Yes
None found

Year

201
Month

Yes
None found

Yes
None found

Day

mg/dL

Triglycerides (TGs)

4

Date of test

Most recent result

Day

Year

201

CPT CODES
Enter Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. Up to 18 CPT codes can be listed.

NAMCS-73 (3-6-2014)