Attachment U: Changes to 2014 Emergency Department Patient Record Form (PRF)
Proposed changes are indicated in RED.
Modified-Patient Information Questions –Dates and Times
“Patient Information” Section |
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TSDATE, TS_TIME, EDDATE, ED_TIME: |
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Old
|
New
|
|
New
|
Added-Transferred from another hospital or urgent care center
Old
|
New AMBTRANSFER: |
… |
Add new question on point of origin:
If ARRIVE=Ambulance, then ask, Was patient transferred from another hospital or freestanding emergency/urgent care center?
|
Modified-Checkbox list of Expected source(s) of payment for this visit
“Patient Information” Section |
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PAY_SOURCE: |
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Old
|
New
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Deleted-Triage – Temperature Type and On oxygen at arrival
“Triage” Section |
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TTEMP: |
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Old Celsius and Fahrenheit |
New
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ONO2: |
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Old Answer list O2: On oxygen at arrival?
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New
|
Modified and added-Reason for Visit Questions
“Reason for Visit” Section |
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VRFV1-3: |
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Old
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New
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SOURCE_RFV: Old What is the source of the most important reason for visit? 1-In patient’s own words 2-Other 3-Unknown |
New Source of the first complaint, symptom, reason for visit 1- 2-Other 3-Unknown |
Old (Only asked, if DRUGS_CONTRIBUTED=1 Yes) Was alcohol involved? 1-Yes 2-No 3-Not documented
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ALCOHOL6: New Did alcohol cause or contribute to this visit? 1-Yes, patient’s own use 2-Yes, other person’s use 3-No 4-Unknown |
|
SUBETOH: |
… |
New
Mark (X) all that apply. 1-Yes, alcohol abuse/misuse/dependence: 1-History of alcohol abuse/misuse/dependence 2-Currently abusing alcohol 2-Yes, other substance abuse/misuse/dependence: 1-History of other substance abuse/misuse/dependence 2- Other substance seeking behavior 3-Currently abusing other substance(s)
3 -Yes, other specify ________________ 4- No 5 - Unknown |
Modified and added-Injury/Overdose/Poisoning/Adverse Effect Questions
“Injury/Trauma/Overdose/Poisoning/Adverse Effect” Section |
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INJURY: |
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Old Is this visit related to an injury, overdose, poisoning, or adverse effect of medical or surgical treatment? 1-No 2-Yes, injury/trauma 3-Yes, poisoning (non-drug toxic substance) 4- Yes, poisoning (drug-induced overdose) Medication Illicit substance Unknown 5-Yes, adverse effect of medical or surgical treatment Medication involved No medication involved 6-Unknown
|
New Is this visit related to an injury/trauma, overdose/ poisoning, or adverse effect of medical/surgical treatment? 1-No 2-Yes,
injury 3-Yes, poisoning (non-drug toxic substance) 4- Yes, poisoning (drug-induced overdose) 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 medicinal drug Was medication involved? 1-Yes 2-No 3-Unknown 6-Unknown
|
|
INJURY72: |
Old
… |
New Add new question on recent timing of injury:
1-Yes 2-No 3-Unknown 4-Not applicable |
INTENT: |
|
Old Is this injury/overdose/poisoning intentional? 1-Yes, intentional a-Self-inflicted Suicide attempt Self-harm or suicide gesture b-Intentional harm by another person 2-No, unintentional (e.g., accidental) 3-Unknown intent
|
New Is this injury/trauma or overdose/poisoning intentional? 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 |
VCAUSE: |
|
Old Cause of injury, poisoning by drug or non-drug toxin, drug-induced illness, or adverse effect |
New Cause
of injury/trauma;
overdose/poisoning
by drug or non-drug toxic substance;
|
Modified-Substances Involved Question and Checkbox
“Substances Involved“ Section |
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CONFIRMEDBYTOXD: |
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Old |
New |
For each substance listed, mark if confirmed by toxicology report |
For each substance listed, mark if confirmed by toxicology or blood test report. |
PT_TOOK: |
|
Mark all that apply. |
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Old |
New |
Own prescription/OTC medication or dietary supplement |
Own prescription/OTC medication or dietary supplement |
Prescription medication not prescribed for patient |
Prescription medication not prescribed for patient |
Prescription/OTC medication as prescribed or according to directions |
Prescription/OTC medication as prescribed or according to directions |
Too much of a prescription/OTC medication or dietary supplement |
Too much of a prescription/OTC medication or dietary supplement |
Illicit drug(s) |
Illicit drug(s) |
Alcohol only, under 21 |
Alcohol only, under 21 |
… |
Alcohol in combination with other substances |
Not documented |
Not documented |
Modified and added-Diagnosis
“Diagnosis” Section |
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VDIAG1-20_CODE: |
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Old As specifically as possible, list diagnoses related to this visit including chronic conditions. |
New As specifically as possible, list diagnoses related to this visit including chronic conditions. List primary diagnosis first. |
Old … |
New Allow entry of ICD-10-CM diagnosis and V codes |
Modified-Checkbox list of patient’s underlying chronic conditions
“Diagnosis” Section |
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PAT_HAVE: Regardless of the diagnoses previously entered, does the patient now have - |
|
Mark all that apply. |
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Old |
New |
… |
Alcohol abuse, misuse, or dependence |
Dementia |
Alzheimer's disease/Dementia |
--- |
Asthma |
Cancer |
Cancer |
Cerebrovascular disease/History of stroke or transient ischemic attack (TIA) |
Cerebrovascular disease/History of stroke (CVA) or transient ischemic attack (TIA) |
Chronic kidney disease (CKD) |
Chronic kidney disease (CKD) |
Chronic obstructive pulmonary disease (COPD) |
Chronic obstructive pulmonary disease (COPD) |
Congestive heart failure |
Congestive heart failure (CHF) |
Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI) |
Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI) |
Diabetes |
Diabetes mellitus (DM), Type I |
Diabetes |
Diabetes mellitus (DM), Type II |
Diabetes |
Diabetes mellitus (DM), Type unspecified |
--- |
End-stage renal disease (ESRD) |
History of pulmonary embolism or deep vein thrombosis (DVT) |
History
of pulmonary embolism (PE),
|
HIV infection/AIDS |
HIV infection/AIDS |
Hyperlipidemia |
Hyperlipidemia |
Hypertension |
Hypertension |
Mental illness or episode |
Mental illness or episode |
… |
Obesity |
… |
Obstructive sleep apnea (OSA) |
… |
Osteoporosis |
Substance abuse, misuse, or dependence |
Substance abuse, misuse, or dependence |
Not documented |
None of the above |
Modified-Checkbox list of Diagnostics
“Diagnostics” Section |
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DIAG_SERVICES: |
|
Old |
New |
Blood tests: |
|
ABG (arterial blood gases) |
ABG (Arterial blood gases) |
BAC (blood alcohol concentration) |
BAC (Blood alcohol concentration) |
… |
BMP (Basic metabolic panel) |
BNP (brain natriuretic peptide) |
BNP (Brain natriuretic peptide) |
Cardiac enzymes (CE) |
CE (Cardiac enzymes) |
CBC (complete blood count) |
CBC (Complete blood count) |
… |
CMP (Comprehensive metabolic panel) |
BUN/creatinine |
Creatinine/Renal function panel |
Blood culture |
Culture, blood |
… |
Culture, throat |
Urine culture |
Culture, urine |
Wound culture |
Culture, wound |
… |
Culture, other |
D-dimer |
D-dimer |
Electrolytes |
Electrolytes |
Glucose |
Glucose, serum |
Lactate |
LDH (Lactate dehydrogenase) |
Liver function tests (LFT) |
Liver enzymes/Hepatic function panel |
Prothrombin time/INR |
Prothrombin time (PT/PTT/INR) |
Other blood test |
Other blood test Enter other blood tests as written:_______ |
Imaging: |
|
Intravenous contrast |
|
CT scan Abdomen/pelvis Chest Head Other |
CT scan What body site was scanned during the CT scan? Abdomen/pelvis Chest Head Other Was CT ordered or provided with intravenous (IV) contrast? Yes No Unknown |
MRI
|
MRI Was MRI ordered or provided with intravenous (IV) contrast (also written as “with gadolinium” or “with gado”)? Yes No Unknown |
Modified-Procedures
“Procedures” Section |
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PROCEDURES: |
|
Old |
New |
NONE |
NONE |
BiPAP/CPAP |
BiPAP/CPAP |
Bladder catheter |
Bladder catheter |
Cast, splint, or wrap |
Cast, splint, or wrap |
Central line |
Central line |
CPR |
CPR |
Endotracheal tube |
Endotracheal tube (ETT) |
Incision & drainage (I&D) |
Incision & drainage (I&D) |
IV fluids |
IV |
Lumbar puncture |
Lumbar puncture (LP) |
Nebulizer therapy |
Nebulizer therapy |
Pelvic exam |
Pelvic exam |
Physical restraint |
Physical restraint |
Psychiatry/Psychology/Substance abuse consult |
Psychiatry/Psychology/Substance abuse consult |
Skin adhesives |
Skin adhesives |
Suturing/Staples |
Suturing/Staples |
Other |
Other |
Modified-Medications and Immunizations
Modified-Last Vital Signs Taken
“Last Vital Signs Taken” Section |
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VITALSD : |
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Old
|
New Does the chart contain vital signs taken after triage? 1-Yes 2-No |
Modified-Checkbox list of Providers
“Providers” Section |
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PROV_SEEN: |
|
Old
|
New NONE |
ED attending physician |
ED attending physician |
ED resident or intern |
ED resident or intern |
Consulting physician (Specialty of consulting physician) |
Consulting physician |
RN/LPN |
RN/LPN |
Nurse practitioner |
Nurse practitioner (NP) |
Physician assistant |
Physician assistant (PA) |
EMT |
EMT |
Psychologist |
Psychologist |
Social worker |
Social worker |
… |
Substance abuse services provider |
Other mental health provider |
Other mental health provider |
Other provider |
Other provider |
Modified- Providers – Checkbox list of Specialty of consulting physician
“Providers” Section |
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PROV_SEEN: |
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Old:
|
New
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Anesthesia |
|
… |
Cardiology |
Critical care |
|
ENT (Otolaryngology) |
ENT (Otolaryngology) |
… |
Gastroenterology |
… |
General/Trauma Surgery |
… |
Geriatrics |
Hematology/Oncology |
|
… |
Neurology |
… |
Neurosurgery |
… |
Obstetrics-Gynecology |
… |
Ophthalmology |
… |
Orthopedic Surgery |
Palliative care |
|
Psychiatry |
Psychiatry |
Other specialty |
Other specialty |
Unknown |
Unknown |
Modified-Checkbox list of Visit Disposition
“Visit Disposition” Section |
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VISIT_DISP: |
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Old Left before triage |
New Left without being seen (LWBS) |
Left after triage |
Left before treatment complete (LBTC) |
Modified-Hospital Admission Dates and Times
“Hospital Admission” Section |
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BR_DATE, BR_TIME: |
|
Old Date and time bed was requested for hospital admission or transfer |
New Admit order |
Modified-Observation Unit Dates and Times
“Observation Unit/Care Stay” Section |
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EDDISDATE, EDDISTIME, OBDATE, OB_TIME: |
|
Old Date and time of ED departure |
New Observation unit/care initiation order |
Date and time of observation unit discharge |
Observation unit/care discharge order |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |