Attachment Q - Emer Dept Pt Record Form 010616

Attachment Q - Emer Dept Pt Record Form 010616.docx

National Hospital Care Survey

Attachment Q - Emer Dept Pt Record Form 010616

OMB: 0920-0212

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Attachment Q – Emergency Department Patient Record Form


SAMPLE
NATIONAL HOSPITAL CARE SURVEY – AMBULATORY COMPONENT

EMERGENCY DEPARTMENT PATIENT RECORD

2016


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

Shape2 Shape1 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

Shape4 Shape3

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

Shape5

VDIAG1_Code





Shape6


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

Shape7 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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleNational Hospital Care Survey Emergency Department Sample Card (Patient Record Form) 2013, Panel 1
SubjectNational Hospital Care Survey Emergency Department Sample Card 2013, Panel 1
AuthorNational Center for Health Statistics
File Modified0000-00-00
File Created2021-01-24

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