Emergency Department Patient Record Form Changes 2015

Attachment M

Changes to 2015 NHAMCS Emergency Department Patient Record Form (PRF)

Proposed changes are indicated in RED; variable names are in [ ].

• Modified-Injury/Poisoning/Adverse Effect Questions [INJURY]

Old 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 No Unknown	New Is this visit related to an injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment? Yes, injury/trauma Yes, overdose/poisoning Yes, adverse effect of medical or surgical treatment or adverse effect of medicinal drug No Unknown
Old Did this injury or poisoning occur within 72 hours priors to the date and time of this visit? Yes No Unknown Not applicable	New Did the injury/trauma, overdose/ poisoning, or adverse effect occur within 72 hours prior to the date and time of this visit? Yes No Unknown Not applicable
Old Is this injury or poisoning intentional or unintentional? Intentional Unintentional (e.g., accidental) Intent unclear	New Is this injury/trauma, overdose/ poisoning, or adverse effect intentional or unintentional? Intentional Unintentional (e.g., accidental) Intent unclear
	New Was the intent of the injury: Suicide attempt with intent to die Intentional self-harm without intent to die Unclear if suicide attempt or intentional self-harm without intent to die Intentional harm inflicted by another person (e.g., assault, poisoning)
Old Cause of injury/trauma, overdose, poisoning, or adverse effect.	New Cause of injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment

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

Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.
Old	New
Alcohol abuse	Alcohol misuse, abuse, or dependence
Alzheimer's disease/Dementia	Alzheimer's disease/Dementia
Asthma	Asthma
Cancer	Cancer
Cerebrovascular disease/stroke (CVA) 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 (CHF)	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)
Depression	Depression
End-stage renal disease (ESRD)	End-stage renal disease (ESRD)
Diabetes mellitus (DM), Type I	Diabetes mellitus (DM), Type I
Diabetes mellitus (DM), Type II	Diabetes mellitus (DM), Type II
Diabetes mellitus (DM), Type Unspecified	Diabetes mellitus (DM), Type Unspecified
History of pulmonary embolism (PE) or deep vein thrombosis (DVT)	History of pulmonary embolism (PE) or deep vein thrombosis (DVT) or venous thromboembolism (VTE)
HIV Infection/AIDS	HIV Infection/AIDS
Hyperlipidemia	Hyperlipidemia
Hypertension	Hypertension
Obesity	Obesity
Obstructive sleep apnea (OSA)	Obstructive sleep apnea (OSA)
Osteoporosis	Osteoporosis
Substance abuse	Substance abuse or dependence
None of the above	None of the above

• Modified-Diagnostic Services Ordered or Provided [DIAG_SERVICES]

Enter all Examinations/Screenings, Laboratory tests, Imaging, Procedures, and Health education/counseling ORDERED or PROVIDED.

• NONE

Blood tests:

• Arterial blood gases

• BAC (blood alcohol concentration)

• Basic metabolic panel (BMP)

• Blood culture

• BNP (brain natriuretic peptide)

• BUN/Creatinine

• Cardiac enzymes

• CBC

• Comprehensive metabolic panel (CMP)

• D-dimer

• Electrolytes

• Glucose

• Lactate

• Liver function tests

• Prothrombin time/INR

• Other blood test

Other tests:

• Cardiac monitor

• EKG/ECG

• HIV test

• Influenza test

• Pregnancy/HCG test

• Throat culture

• Toxicology screen

• Urinalysis

• Urine culture

• Wound culture

• Other culture

• Other test/service

Imaging:

• X-ray

• CT scan
  - Abdomen/Pelvis
  - Chest
  - Head
  - Other
  
  
  

Was CT ordered/provided with intravenous (IV) contrast?
- Yes
- No
- Unknown

• MRI
  Was MRI ordered/provided with intravenous (IV) contrast
  (also written as “with gadolinium” or “with gado”)?
  - Yes
  - No
  - Unknown
  
  
  

• Ultrasound
  Who performed the ultrasound?
  - Emergency physician
  - Other provider
  
  
  

• Other imaging

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