Outpatient Department Patient Record Form Changes 2015

Attachment N

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

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

• Remove LMP question from the form [LMP]

• Modified – Tobacco use [USETOBAC/EVERTOBAC]

Old Never Former Current Unknown	New Not current Current Unknown
	New Never Former Unknown

• Modified-Major Reason for this Visit [MAJOR]

Old Answer list New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Pre surgery Post surgery Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)

New Answer list New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Pre-surgery Post-surgery Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)

• 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 misuse, abuse, or dependence	Alcohol misuse, abuse, or dependence
Alzheimer's disease/Dementia	Alzheimer's disease/Dementia
Arthritis	Arthritis
Asthma	Asthma
---	Autism spectrum disorder
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
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
End-stage renal disease (ESRD)	End-stage renal disease (ESRD)
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 or dependence	Substance abuse or dependence
None of the above	None of the above

• Modified-Services Ordered or Provided [DIAG_SERVICE]

Enter all examinations, laboratory tests, imaging, other procedures or other treatment and health education or counseling ORDERED or PROVIDED.

• NO SERVICES

Examinations/Screenings:

• Alcohol misuse screening (includes AUDIT, MAST, CAGE, T-ACE)

• Breast

• Depression screening

• Domestic violence screening

• Foot

• Neurologic

• Pelvic

• Rectal

• Retinal/ Eye Exam

• Skin

• Substance abuse screening (includes NIDA/NM ASSIST, CAGE-AID, DAST-10)

Laboratory tests:

• Basic metabolic panel (BMP)

• CBC

• Chlamydia test

• Comprehensive metabolic panel (CMP)

• Creatinine /Renal function panel

• Culture, blood

• Culture, throat

• Culture, urine

• Culture, other

• Glucose, serum

• Gonorrhea test

• HbA1c (Glycohemoglobin)

• Hepatitis testing/Hepatitis panel

• HIV test

• HPV DNA test

• Lipid profile

• Liver enzymes/Hepatic function panel

• PAP test

• Pregnancy/HCG test

• PSA (prostate specific antigen)

• Rapid strep test

• TSH/Thyroid panel

• Urinalysis

• Vitamin D test

Procedures:

• Audiometry

• Biopsy
  - Provided

• Cardiac stress test

• Colonoscopy
  - Provided

• Cryosurgery (cryotherapy)/ Destruction of tissue

• EKG/ECG

• Electroencephalogram (EEG)

• Electromyogram (EMG)

• Excision of tissue
  - Provided

• Fetal monitoring

• Peak flow

• Sigmoidoscopy
  - Provided

• Spirometry

• Tonometry

• Tuberculosis skin testing/PPD

• Upper gastrointestinal endoscopy/EGD
  - Provided

• Modified- Tests [LAB_TEST]

Old Was blood for the following laboratory tests drawn on the day of the sampled visit or during the 12 months prior to visit? Enter 1 to Continue

New Was blood for the following laboratory tests drawn on the day of the sampled visit or during the 12 months prior to visit? Enter 1 to Continue

• Add CPT codes [CPTCODE]

Old: No CPT codes were collected

New: Allow up to 18 CPT codes

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