Sample ER Patient Record Form

Attachment Q – Emergency Department Patient Record Form

SAMPLE
NATIONAL HOSPITAL CARE SURVEY – AMBULATORY COMPONENT

EMERGENCY DEPARTMENT PATIENT RECORD

2014

OMB No. 0920-0212; Expiration date XX/XX/20XX

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’s name:

PATIENT_NAME

Patient’s SSN

PATIENT_SSN/ ENTER_SSN

Patient’s Control #

PTCTRLNUM, ENTER_PTCTRLNUM

Patient’s address RESIDENCE:Street

PT_STRET, PT_STRET2

City

PT_CITY

State

PT_ST

Zip Code

PATZIP

Patient’s medical record #

PTMEDRECNUM/ENTER_PTMEDRECNUM

Medicare health insurance benefit/claim #

MEDHLTHINSBEN /ENTER_MEDHLTHINSBEN

NPI–Attending

NPI_ATTEND / ENTER_NPI_ATTEND

NPI–Operating

NPI_OPERATING / ENTER_NPI_OPERATING

Date of Visit

Time

a.m.

p.m.

Mil.

Mode of arrival ARRIVE

1 Ambulance

2 Police transport

3 Other

4 Unknown

Was patient transferred from another hospital or freestanding emergency/urgent care facility? AMBTRANSFER

1 Yes

2 No

3 Unknown

Expected source(s) of payment for this visit. Mark (X) all that apply. PAY_SOURCE1-7

1 Private insurance

2 TRICARE

3 Medicare

4 Medicaid or CHIP or other state-based program

5 Workers’ compensation

6 Self-pay

7 No charge/charity

8 Other

9 Unknown

Arrival

- -

Mm VDATE dd yy

: A_TIME

Provider (physician/APRN/PA) contact

- -

mmTSDATEdd yy

: TS_TIME

ED Departure

- -

mmEDDATEdd yy

: ED_TIME

Patient Residence RESIDNCE

1 Private residence

2 Institution

Indicate the type of

institution REST_INST

1 Nursing home

2 Supportive housing/
Group home

3 Jail/Prison

4 Other

3 Homeless/Homeless shelter

4 Other

5 Unknown

Date of Birth BDATE

Month		Day		Year

Age AGE / AGET

Sex SEX

1 Female

2 Male

Ethnicity ETHNIC

1 Hispanic or Latino

2 Not Hispanic or Latino

Race – Mark (X) all that apply.

1 White MULTIRACE1-5

2 Black or African American

3 Asian

4 Native Hawaiian or Other Pacific Islander

5 American Indian or Alaska Native

TRIAGE

PREVIOUS CARE

Initial vital signs

Was patient seen in this ED in the last 72 hours and discharged? SEEN72

1 Yes

2 No

3 Unknown

Temperature

TEMP

Heart rate/Pulse

PULSE

beats per minute

998 = DOPP, DOPPLER

Respiratory rate

RESPR

breaths per minute

Blood pressure

BPSYS

Systolic

BPDIAS

Diastolic

998= P, PALP, DOPP, DOPPLER

Pulse oximetry

POPCT

Percent

Triage level (1-5)

IMMED

Enter 0 if No triage

Enter 99 if Unknown

Pain scale (0-10)

PAIN

Enter 99 if Unknown

REASON FOR VISIT

List the first 5 reasons for visit (i.e., complaint(s), symptom(s), problem(s), concern(s) 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. (Enter 0 for None/No more.) For each reason, use the lookup list to code the entry.

(1) Most important: VRFV1/ VRFV_LKUP1______________________________________________________

Source of first complaint, symptom, reason for visit.

Mark (X) all that apply SOURCE_RFV

Did alcohol cause or contribute to this visit? Alcohol6

Mark (X) all that apply.

1 Yes, patient’s own use

2 Yes, other person’s use

3 No

4 Unknown

1 Patient

2 Other

3 Unknown

(2) Other

VRFV2/ VRFV_LKUP2

(3) Other

VRFV3/ VRFV_LKUP3

(4) Other

VRFV4/ VRFV_LKUP4

(5) Other

VRFV5/ VRFV_LKUP5

Was alcohol or other substance abuse/misuse/dependence documented in the medical record for this visit? Other substances include illicit drugs, inhalants, prescription or OTC medications, or dietary supplements. Mark (X) all that apply SUBETOH

Episode of care EPISODE

1 Initial visit to this ED for problem

2 Follow-up visit to this ED for problem

3 Unknown

1 Yes, alcohol abuse/misuse/dependence ALCOHOL_TYPE

1. History of alcohol abuse/misuse/dependence

2. Currently abusing alcohol

2 Yes, other substance abuse/misuse/dependence

1. History of other substance OTHSUB_TYPE

abuse/misuse/dependence

2. Other substance seeking behavior

3. Currently abusing other substance(s)

3 Yes, other specify SUBETHOH_SP

4 No

5 Unknown

INJURY/TRAUMA/OVERDOSE/POISONING/ADVERSE EFFECT

Is this visit related to an injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment? INJURY 1 No, SKIP to SUBSTANCES INVOLVED 2 Yes, injury/trauma 3 Yes, poisoning (non-drug toxic substance) 4 Yes, poisoning (drug-induced overdose) Indicate the kind of drug(s) involved: POISON 1. Medication 2. Illicit substance 3. Both medication and illicit substance 4. Unknown 5 Yes, adverse effect of medical/surgical treatment or adverse effect of a medicinal drug Was medication involved? ADVERSE Skip to Cause of injury/overdose/poisoning/adverse effect 1. Yes 2. No 3. Unknown 6. Unknown (skip to substances involved)

Did the injury/trauma or overdose/ poisoning occur within 72 hours prior to the date and time of this visit? INJURY72 1 Yes 2 No 3 Unknown

Is this injury/trauma or overdose/poisoning intentional? INTENT 1 Yes, intentional - suicide attempt 2 Yes, intentional - self-harm (intentional self-directed harm without intent to die) 3 Yes, intentional – unclear if suicide attempt or self-harm 4 Yes, intentional harm by another person (e.g., assault, poisoning) 5 No, unintentional (e.g., accidental) 6 Unclear if intentional or unintentional

Cause of injury/trauma; overdose/poisoning by drug or non-drug toxic substance; or adverse effect of medical/surgical treatment – Describe the place and circumstances that preceded the injury/trauma, overdose/poisoning, or adverse effect. The following are examples of each: injury (e.g., pedestrian struck by car driven on a highway by drunk driver— indicate location of occurrence, e.g., street, highway, driveway, parking lot);overdose/poisoning by drug (e.g., patient injected heroin in nightclub restroom and overdosed); non-drug toxic substance (e.g., child swallowed bleach at home); adverse effect (e.g., patient developed swelling of the throat after taking their medication). Enter the primary cause on the first line, followed by the contributing causes. Up to 5 causes may be entered.

(1)

VCAUSE / VCAUSEDROPDOWN / TRANSLOC

(2)

VCAUSE2 / VCAUSEDROPDOWN2 / TRANSLOC2

(3)

VCAUSE3 / VCAUSEDROPDOWN3 / TRANSLOC3

(4)

VCAUSE4 / VCAUSEDROPDOWN4 / TRANSLOC4

(5)

VCAUSE5 / VCAUSEDROPDOWN5 / TRANSLOC5

SUBSTANCES INVOLVED

Did any substance(s) (e.g., illicit drugs, inhalants, prescription or OTC medications, dietary supplement) cause or contribute to this visit? OR The patient is under 21 and alcohol is the only drug related to the visit. DRUGS_CONTRIBUTED 1 Yes 2 No, SKIP to DIAGNOSIS 3 Unknown, SKIP to DIAGNOSIS

Enter substances that caused or contributed to the ED visit. Type in the substance name exactly as you see in the patient’s chart. Enter all substances that caused or contributed to the ED visit. Record substances as specifically as possible. The brand name is preferred over generic name preferred over chemical name. Do not record the same substance by two different names unless it was administered/taken in two different ways. Do not record current medications unrelated to the visit. Up to 16 substances may be entered.

(1)

Drug_Name1 / Drug_List1

(2)

Drug_Name2 / Drug_List2

(3-16)

Drug_Name3-16 / Drug_List3-16

For each substance listed, mark if confirmed by toxicology or blood test report. CONFIRMEDBYTOXD1-16 1 Yes 2 No 3 Unknown/Not documented

For each substance listed, mark the route of administration. ROUTE_ADMINISTRATION1-16 1 Oral 2 Injected 3 Inhaled, sniffed, snorted 4 Smoked 5 Transdermal 6 Other 7 Not documented

Patient took: PT_TOOK1-16 Mark (X) all that apply: 1 Own prescription/OTC medication or dietary supplement 2 Prescription medication not prescribed for patient 3 Prescription/OTC medication as prescribed or according to directions 4 Too much of a prescription/OTC medication or dietary supplement 5 Illicit drug(s) 6 Alcohol only, under 21 7 Alcohol in combination with other substances 8 Not documented

DIAGNOSIS

As specifically as possible, list all diagnoses related to this visit, including chronic conditions.

List primary diagnosis first.

ICD-9-CM Code

ICD-10-CM Code

(1)

Primary diagnosis:

VDIAG1 / VDIA1G_LKUP

VDIAG1_Code

VDIAG1_Code10

(2)

Other:

VDIAG2 / VDIAG2_LKUP

VDIAG2_Code

VDIAG2_Code10

(3)

Other:

VDIAG3 / VDIAG3_LKUP

VDIAG3_Code

VDIAG3_Code10

(4)

Other:

VDIAG4 / VDIAG4_LKUP

VDIAG4_Code

VDIAG4_Code10

(5)

Other:

VDIAG5 / VDIAG5_LKUP

VDIAG5_Code

VDIAG5_Code10

(6)

Other:

VDIAG6 / VDIAG6_LKUP

VDIAG6_Code

VDIAG6_Code10

(7)

Other:

VDIAG7 / VDIAG7_LKUP

VDIAG7_Code

VDIAG7_Code10

(8)

Other:

VDIAG8 / VDIAG8_LKUP

VDIAG8_Code

VDIAG8_Code10

(9)

Other:

VDIAG9 / VDIAG9_LKUP

VDIAG9_Code

VDIAG9_Code10

(10-20)

Other:

VDIAG10-20 / VDIAG10-20_LKUP

VDIAG10-20_Code

VDIAG10-20_Code10

Regardless of the diagnoses previously entered, does the patient now have: Mark (X) all that apply. PAT_HAVE1-23
1 Alcohol abuse, misuse, or dependence 2 Alzheimer’s disease/Dementia 3 Asthma 4 Cancer 5 Cerebrovascular disease/History of stroke (CVA) or transient ischemic attack (TIA) 6 Chronic kidney disease (CKD) 7 Chronic obstructive pulmonary disease (COPD) 8 Congestive heart failure (CHF) 9 Coronary artery disease (CAD), ischemic heart disease (IHD), or history of myocardial infarction (MI) 10 Diabetes mellitus (DM) – Type I 11 Diabetes mellitus (DM) – Type II 12 Diabetes mellitus (DM) – Type unspecified 13 End-stage renal disease (ESRD) 14 History of pulmonary embolism (PE), deep vein thrombosis (DVT), or venous thromboembolism (VTE)				15 HIV infection/AIDS 16 Hyperlipidemia 17 Hypertension 18 Mental illness or episode Indicate the mental illness of episode MENTAL1-6 Mark (X) all that apply 1. Bipolar disorder/Manic depression 2. Depression, excluding manic depression 3. Post-traumatic stress disorder (PTSD) 4. Schizophrenia 5. Suicidal ideation 6. Other 19 Obesity 20 Obstructive sleep apnea (OSA) 21 Osteoporosis 22 Substance abuse, misuse, or dependence 23 None of the above
DIAGNOSTICS
Mark (X) all ORDERED or PROVIDED at this visit. DIAG_SERVICES1-34
1 NONE Blood tests: 2 ABG (Arterial blood gases) 3 BAC (Blood alcohol concentration) Enter BAC _BAC_ % 4 BMP (Basic metabolic panel) 5 BNP (Brain natriuretic peptide) 6 CE (Cardiac enzymes) 7 CBC (Complete blood count) 8 CMP (Comprehensive Metabolic panel) 9 Creatinine/renal function panel 10 Culture, blood 11 D-dimer 12 Electrolytes 13 Glucose, serum 14 LDH (Lactate dehydrogenase)		15 Liver enzymes/Hepatic function panel 16 Prothrombin time (PT/PTT/INR) 17 Other blood test Enter other blood tests as written: OTHDIAGSERV Other tests: 18 Culture, throat 19 Culture, urine 20 Culture, wound 21 Culture, other 22 Cardiac monitor 23 EKG/ECG 24 HIV test 25 Influenza test 26 Pregnancy/HCG test 27 Toxicology screen 28 Urinalysis (UA) or urine dipstick 29 Other test/service			Imaging: 30 X-ray 31 CT scan What body site was scanned during the CT scan? CT_SCAN1-4 Mark (X) all that apply 1. Abdomen/pelvis 2. Chest 3. Head 4. Other Was CT ordered or provided with intravenous (IV) contrast? CT_IV 1. Yes 2. No 3. Unknown				32 MRI Was MRI ordered or provided with intravenous (IV) contrast (also written as “with gadolinium” or “with gado”)? MRI_IV 1. Yes 2. No 3. Unknown 33 Ultrasound Who performed the ultrasound? ULTRASOUND 1. Emergency physician 2. Other 3. Unknown 34 Other Imaging
PROCEDURES
Mark all procedures PROVIDED at this visit. Exclude medications. PROCEDURES1-17
1 NONE 2 BiPAP/CPAP 3 Bladder catheter 4 Cast, splint, or wrap 5 Central line 6 CPR			7 Endotracheal tube (ETT) 8 Incision & drainage (I&D) 9 IV 10 Lumbar puncture (LP) 11 Nebulizer therapy 12 Pelvic exam				13 Physical restraint 14 Psychiatry/psychology/ substance abuse consult 15 Skin adhesives 16 Suturing/Staples 17 Other
MEDICATIONS & IMMUNIZATIONS
NOMED=Were any prescription or non-prescription medications given at this visit or prescribed at ED discharge? 1-Yes 2-No Include Rx and OTC medications, immunizations, oxygen, and anesthetics. Enter XXX if medication cannot be found. Enter 0 for No more.						Given in ED		Rx at discharge		Both given in ED and Rx at discharge
(1)	VMED VMEDOTH GPMED →					1		2		3
(2)	VMED2 VMEDOTH2 GPMED2 →					1		2		3
(3)	VMED3 VMEDOTH3 GPMED3 →					1		2		3
(4)	VMED4 VMEDOTH4 GPMED4 →					1		2		3
(5)	VMED5 VMEDOTH5 GPMED5 →					1		2		3
(6)	VMED6 VMEDOTH6 GPMED6 →					1		2		3
(7)	VMED7 VMEDOTH7 GPMED7 →					1		2		3
(8)	VMED8 VMEDOTH8 GPMED8 →					1		2		3
(9)	VMED9 VMEDOTH9 GPMED9 →					1		2		3
(10)	VMED10 VMEDOTH10 GPMED10 →					1		2		3
(11)	VMED11 VMEDOTH11 GPMED11 →					1		2		3
(12-30)	VMED12-30 VMEDOTH12 GPMED12 →					1		2		3

LAST VITAL SIGNS TAKEN

Does the chart contain vital signs taken after triage? 1. Yes 2. No → Skip to Providers VitalsD

Temperature TempD

Heart rate/Pulse PulseD beats per minute 998= DOPP, DOPPLER

Respiratory rate ResprD breaths per minute

Blood pressure

BPSysD

Systolic

BPDiasD

Diastolic

998= P, PALP, DOPP, DOPPLER

PROVIDERS

Mark (X) all providers seen at this visit. PROV_SEEN1-11

1

NONE

2

ED attending physician

3

ED resident or Intern

4

Consulting physician

Specialty of consulting physician SPEC_CONPHYS1-12

5

RN/LPN

1 Cardiology

8 Obstetrics-Gynecology

6

Nurse practitioner (NP)

2 ENT (Otolaryngology)

9 Ophthalmology

7

Physician assistant (PA)

3 Gastroenterology

10 Orthopedic Surgery

8

EMT

4 General/Trauma Surgery

11 Psychiatry

9

Psychologist

5 Geriatrics

12 Other specialty

10

Social worker

6 Neurology

13 Unknown

11

Substance abuse services provider

7 Neurosurgery

12

Other mental health provider

13

Other provider

VISIT DISPOSITION

Mark (X) all that apply. VISIT_DISP1-15

1 No follow-up planned 2 Return to ED 3 Return/Refer to physician/clinic for Specify the type of follow-up FOLLOWUP1-3 1. Outpatient mental health treatment 2. Substance abuse treatment 3. Other follow-up 4 Left without being seen (LWBS) 5 Left before treatment complete (LBTC) 1. Left AMA LEFT_AMA 6 DOA 7 Died in ED 8 Return/Transfer to nursing home 9 Return/Transfer to jail/prison/law enforcement

10 Transfer to inpatient behavioral health care facility Was the patient transferred psychiatric inpatient treatment or a substance abuse treatment facility? BHEALTH 1. Psychiatric inpatient treatment Enter the status of the transfer PSYCH_INP 1. Involuntary status 2. Voluntary status 3. Not documented 2. Substance abuse treatment facility 3. Unknown 11 Transfer to other non-psychiatric hospital Indicate the reason for transfer TRANSFER1-5 Mark (X) all that apply 1. Continuity of care/Request by patient, family, or physician 2. Higher level or specialized care needed 3. Pediatric hospital needed 4. Insurance requirement/request 5. Other/Insufficient information available

12 Admit to this hospital 13 Admit to observation unit then hospitalized 14 Admit to observation unit then discharged 15 Other

HOSPITAL ADMISSION

Admitted to: ADMIT 1 Critical care unit 2 Stepdown unit 3 Operating room 4 Mental health or detox unit 5 Cardiac catheterization lab 6 Other bed/unit 7 Unknown

Admit order

Month

Day

Year

Time

a.m.

p.m.

Military

BRDATE

1

: BR_TIME

Admitting physician: ADMITPHYS 1 Hospitalist 2 Not hospitalist 3 Unknown

Hospital discharge date

Month

Day

Year

DDATE

1

Hospital discharge diagnosis

(1) Principal

VHDDIAG

(2) Secondary

VHDDIAG2

Hospital discharge status HDSTAT

Hospital discharge disposition ADISP

1 Alive 2 Dead 3 Unknown

1 Home/Residence 2 Return/Transfer to nursing home 3 Return/Transfer to jail/prison/law enforcement

4 Transfer to another facility (not usual place of residence) 5 Other 6 Unknown

OBSERVATION UNIT STAY

Observation unit/care initiation order

Month

Day

Year

Time

a.m.

p.m.

Military

EDDISDATE

1

:EDDISTIME

Observation unit/care discharge order

Month

Day

Year

Time

a.m.

p.m.

Military

OBDATE

1

: OB_TIME

June 11, 2014