Emergency Department Patient Record Form Changes 2015

Attachment M - ED PRF Changes 2015.docx

National Hospital Ambulatory Medical Care Survey

Emergency Department Patient Record Form Changes 2015

OMB: 0920-0278

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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?

  1. Yes, injury

  2. Yes, poisoning

  3. Yes, adverse effect of medical/surgical care or adverse effect of medicinal drug

  4. No

  5. Unknown


New

  • Is this visit related to an injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment?

  1. Yes, injury/trauma

  2. Yes, overdose/poisoning

  3. Yes, adverse effect of medical or surgical treatment or adverse effect of medicinal drug

  4. No

  5. Unknown


Old

  • Did this injury or poisoning occur within 72 hours priors to the date and time of this visit?

  1. Yes

  2. No

  3. Unknown

  4. 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?

  1. Yes

  2. No

  3. Unknown

  4. Not applicable


Old

  • Is this injury or poisoning intentional or unintentional?

        1. Intentional

        2. Unintentional (e.g., accidental)

        3. Intent unclear


New

  • Is this injury/trauma, overdose/ poisoning, or adverse effect intentional or unintentional?

  1. Intentional

  2. Unintentional (e.g., accidental)

  3. Intent unclear



New

  • Was the intent of the injury:

  1. Suicide attempt with intent to die

  2. Intentional self-harm without intent to die

  3. Unclear if suicide attempt or intentional self-harm without intent to die

  4. 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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