Attachment R - Outpt Dept Pt Record Form 010616

Attachment R – Outpatient Department Patient Record Form

SAMPLE
NATIONAL HOSPITAL CARE SURVEY – AMBULATORY COMPONENT

OUTPATIENT 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 SSSSNSSN

PATIENT_SSN / ENTER_SSN

Patient’s Control #

PTCTRLNUM /ENTER_PTCTRLNUM EEEEENTER_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

Hospital location where visit occurred

HOSP_LOC

Date of Visit

Sex SEX

1 Female – Is patient pregnant?

PREG

1 Yes – Specify gestation

GESTWK

week

2 No

2 Male

Ethnicity ETHNIC

1 Hispanic or Latino

2 Not Hispanic or Latino

Race – Mark (X) all that apply. MULTIRACE1-5

Expected source(s) of payment for this visit – Mark (X) all that apply.

PAY_SOURCE1-8

1 Private insurance

2 Medicare

3 Medicaid or CHIP or other state-based program

4 Workers’ compensation

5 Self-pay

6 No charge/Charity

7 Other

8 Unknown

Tobacco use

USETOBAC

1 Not current

EVERTOBAC

1 Never

2 Former

3 Unknownr

2 Current

3 Unknown

Month

Day

Year

1 White

2 Black or African
American

3 Asian

4 Native Hawaiian or
Other Pacific Islander

5 American Indian or Alaska Native

VDATE

2

0

1

Date of Birth

Month

Day

Year

BDATE

Age AGE/AGET

BIOMETRICS/VITAL SIGNS

Height

HTFT

ft

HTINCG

in

OR

HTCM

cm

Weight

WTLBCG

lb

WTOZ

oz

OR

WTKG

kg

WTGM

gm

Temperature

TEMP

Blood pressure

Systolic		Diastolic
BPSYS	/	BPDIAS

Enter 998 for P, Palp, Dopp, or Doppler

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.

Major reason for this visit MAJOR

1 New problem (<3 mos. onset)

2 Chronic problem, routine

3 Chronic problem, flare-up

4 Preventive care (e.g., routine, prenatal, well-baby, screening, insurance, general exams)

5 Pre-surgery/procedure

6 Post-surgery/procedure

7 Surgery/procedure

First:

1. VRFV1 / VRFV1_LKUP

Other:

2. VRFV2 / VRFV2_LKUP

Other:

3. VRFV3 / VRFV3_LKUP

Other:

4. VRFV4 / VRFV4_LKUP

Other:

5. VRFV5 / VRFV5_LKUP

INJURY/TRAUMA/OVERDOSE/POISONING/ADVERSE EFFECT

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

1 Yes, injury/trauma INJURY

2 Yes,overdose/poisoning

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

Skip ro Cause

4 No

5 Unknown

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

4 Not applicable

Is this injury/trauma or overdose/poisoning intentional?

INTENTO

1 Yes, intentional suicide attempt/ self-harm

2 Yes, intentional harm by another person (e.g., assault, poisoning)

3 No, unintentional (e.g., accidental)

4 Intent unclear

Cause of injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment— Describe the place and circumstances that preceded the injury/trauma, overdose/poisoning, or adverse effect.

Examples:

1. Injury/Trauma (e.g., patient fell while walking down stairs at home and sprained her ankle; patient was bitten by a spider)

2. Overdose/Poisoning (e.g., child was given adult cold/cough medicine and became lethargic; child swallowed large amount of liquid cleanser and began vomiting)

3. Adverse effect (e.g., patient developed a rash on his arm 2 days after taking penicillin for an ear infection)

(1)

VCAUSE / VCAUSEDROPDOWN

(2)

VCAUSE2 / VCAUSEDROPDOWN2

(3)

VCAUSE3 / VCAUSEDROPDOWN3

(4)

VCAUSE4 / VCAUSEDROPDOWN4

(5)

VCAUSE5 / VCAUSEDROPDOWN5

CONTINUITY OF CARE

Is this clinic the patient’s primary care provider? PRIMCARE

1 Yes

2 No

3 Unknown

Was patient referred for this visit? REFER

1 Yes

2 No

3 Unknown

Has the patient been seen in this clinic before? SENBEFOR

1 Yes, established patient

How many past visits in the last 12 months?

(Exclude this visit.)

PASTVIS

Visits

Enter F5 if unknown

2 No, new patient

PROVIDER’S DIAGNOSIS FOR THIS VISIT

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

Primary:

1.

VDIAG1 / VDIAG1_LKUP

VDIAG1_Code

VDIAG1_Code10

Other:

2.

VDIAG2 / VDIAG2_LKUP

VDIAG2_Code

VDIAG2_Code10

Other:

3.

VDIAG3 / VDIAG3_LKUP

VDIAG3_Code

VDIAG3_Code10

Other:

4.

VDIAG4 / VDIAG4_LKUP

VDIAG4_Code

VDIAG4_Code10

Other:

5.

VDIAG5 / VDIAG5_LKUP

VDIAG5_Code

VDIAG5_Code10

CONDITIONS

Regardless of the diagnoses previously entered, does the patient now have – Mark (X) all that apply. PATIENT_HAVE1-26

1 Airway problem

2 Alcohol abuse, misuse, or dependence

3 Alzheimer’s disease/Dementia

4 Arthritis

5 Asthma

6 Cancer

7 Cardiac surgery history

8 Cerebrovascular disease/History of stroke (CVA) or transient ischemic attack (TIA)

9 Chronic kidney disease (CKD)

10 Chronic obstructive pulmonary disease (COPD)

11 Congestive heart failure (CHF)

12 Coronary artery disease (CAD), ischemic heart disease (IHD), or history of myocardial infarction (MI)

13 Depression

14 Diabetes mellitus (DM) – Type I

15 Diabetes mellitus (DM) – Type II

16 Diabetes mellitus (DM) – Type unspecified

17 End-stage renal disease (ESRD)

18 History of pulmonary embolism (PE), deep vein thrombosis (DVT), or venous thromboembolism (VTE)

19 HIV infection/AIDS

20 Hyperlipidemia

21 Hypertension

22 Obesity

23 Obstructive sleep apnea (OSA)

24 Osteoporosis

25 Substance abuse, misuse, or dependence

26 None of the above

Asthma severity:

ASTH_SEV

1 Intermittent

2 Mild persistent

3 Moderate persistent

4 Severe persistent

5 Other – Specify

ASTH_SEV_SP

6 None recorded

Asthma control:

ASTH_CON

1 Well controlled

2 Not well controlled

3 Very poorly controlled

4 Other – Specify

ASTH_CON_SP

5 None recorded

SERVICES

Enter all examinations/screenings, laboratory tests, imaging, procedures,treatment,health education/counseling,and other services not listed ORDERED OR PROVIDED. DIAG_SERVICE1-85

1 NO SERVICES

Examinations/

Screenings

2 Alcohol abuse screening (includes AUDIT, MAST, CAGE,
T-ACE)

3 Breast

4 Depression
screening

5 Domestic violence
screening

6 Foot

7 Neurologic

8 Pelvic

9 Rectal

10 Retinal/Eye Exam

11 Skin

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

Laboratory Tests

13 BMP (Basic metabolic panel)

14 CBC

15 Chlamydia test

Laboratory Tests (cont.)

16 CMP (Comprehensive metabolic panel)

17 Creatinine/Renal function panel

18 Culture, blood

19 Culture, throat

20 Culture, urine

21 Culture, other

22 Glucose, serum

23 Gonorrhea test

24 HbA1C (Glycohemoglobin)

25 Hepatitis panel

26 HIV test

27 HPV DNA test

28 Lipid profile/panel

29 Liver enzymes/ Hepatic function panel

30 PAP test

31 Pregnancy/HCG test

32 PSA (prostate specific antigen)

33 Rapid strep test

Laboratory Tests (cont.)

34 TSH/Thyroid panel

35 Urinalysis

36 Vitamin D test

Imaging

37 Bone mineral density

38 CT scan

39 Echocardiogram

40 Ultrasound

41 Mammography

42 MRI

43 X-ray

Procedures

44 Audiometry

45 Biopsy

46 Cardiac stress test

47 Colonoscopy

48 Cryosurgery (cryotherapy)/ Destruction of tissue

49 EKG/ECG

50 Electroencephalogram (EEG)

51 Electromyogram (EMG)

52 Excision of tissue

53 Fetal monitoring

Procedures (cont.)

54 Peak flow

55 Sigmoidoscopy

56 Spirometry

57 Tonometry

58 Tuberculosis skin testing/ PPD

59 Upper gastrointestinal endoscopy (EGD)

Treatments

60 Cast/splint/wrap

61 Complementary and alternative medicine (CAM)

62 Durable medical equipment

63 Home health care

64 Mental health counseling, excluding psychotherapy

65 Occupational therapy

66 Physical therapy

67 Psychotherapy

Treatments (cont.)

68 Radiation therapy

69 Wound care

Health Education/ Counseling

70 Alcohol abuse counseling

71 Asthma

72 Asthma action plan given to patient

73 Diabetes education

74 Diet/Nutrition

75 Exercise

76 Family planning/ Contraception

77 Genetic counseling

78 Growth/ Development

79 Injury prevention

80 STD prevention

81 Stress management

82 Substance abuse counseling

83 Tobacco use/ Exposure

84 Weight reduction

Other services not listed

8 5 Other service – Specify

OTHER_SP

O ther service – Specify

OTHER_SP2

O ther service – Specify

OTHER_SP3

O ther service – Specify

OTHER_SP4

O ther service – Specify

OTHER_SP5

TESTS

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

1 Yes

2 No test found

Most recent result

Date of blood draw

Total Cholesterol CHOL

1 Yes

2 No test found

CHOLRES

mg/dL

CHOLDATE				201	0	1
mm		dd		yyyy

High density lipoprotein (HDL) HDL

1 Yes

2 No test found

HDLRES

mg/dL

HDLDATE				201	0	1
mm		dd		yyyy

Low density lipoprotein (LDL) LDL

1 Yes

2 No test found

LDLRES

mg/dL

LDLDATE				201	0	1
mm		dd		yyyy

Triglycerides TGS

1 Yes

2 No test found

TGSRES

mg/dL

TGSDATE				201	0	1
mm		dd		yyyy

HbA1c (Glycohemoglobin) A1C

1 Yes

2 No test found

A1CRES

%

A1CDATE				201	0	1
mm		dd		yyyy

Blood glucose (BG) FBG

1 Yes

2 No test found

FBGRES

mg/dL

FBGDATE				201	0	1
mm		dd		yyyy

Serum creatinine SERUM

1 Yes

2 No test found

SERUMRES

mg/dL

SERUMDATE				201	0	1
mm		dd		yyyy

MEDICATION(S)

NOMED=Were any prescription or non-prescription medications ORDERED or PROVIDED (by any route of administration) at this visit? 1 Yes 2 No Include Rx and OTC medications, immunizations, allergy shots, oxygen, anesthetics, chemotherapy, and dietary supplements that were ordered, supplied, administered, or continued during this visit. Include medications prescribed at a previous visit if the patient was instructed at THIS VISIT to continue with the medication. Enter XXX if medication cannot be found. Enter 0 for No more.

New

NCMED

Continued

Administered
at this visit

(1)

VMED1 / VMEDOTH1

1

2

3

(2)

VMED2 / VMEDOTH2

1

2

3

(3)

VMED3 / VMEDOTH3

1

2

3

(4)

VMED4 / VMEDOTH4

1

2

3

(5)

VMED5 / VMEDOTH5

1

2

3

(5)

VMED6 / VMEDOTH6

1

2

3

(7)

VMED7 / VMEDOTH7

1

2

3

(8)

VMED8 / VMEDOTH8

1

2

3

(9)

VMED9 / VMEDOTH9

1

2

3

(10-30)

VMED10-30 / VMEDOTH10-30

1

2

3

PROVIDERS

Mark (X) all providers seen at this visit PROV_SEEN1-7

1

NONE

5

RN/LPN

2

Physician

6

Mental health provider

3

Physician assistant (PA)

7

Other

4

Nurse practitioner (NP)/Midwife (CNM)

PROCEDURE(S)

As specifically as possible, list all diagnostic and surgical procedures performed during this visit. Code each procedure using the lookup list. Once all procedures have been entered, enter 0.

CPT-4 Code

ICD-9-CM Code

ICD-10-CM Code

Primary:

1. VPROC1 / VPROC1_DD

CPTCODE1

ICD9CM1

ICD10CM1

Other:

2. VPROC2 / VPROC2_DD

CPTCODE2

ICD9CM2

ICD10CM2

Other:

3. VPROC3 / VPROC3_DD

CPTCODE3

ICD9CM3

ICD10CM3

Other:

4. VPROC4 / VPROC4_DD

CPTCODE4

ICD9CM4

ICD10CM4

Other:

5. VPROC5 / VPROC5_DD

CPTCODE5

ICD9CM5

ICD10CM5

Other:

6. VPROC6 / VPROC6_DD

CPTCODE6

ICD9CM6

ICD10CM6

Other:

7. VPROC7 / VPROC7_DD

CPTCODE7

ICD9CM7

ICD10CM7

Month

Day

Year

Time

a.m.

p.m.

Mil.

(1) Date and time surgery/procedure began

SURB_DATE

1

:SURB_TIME

Month

Day

Year

Time

a.m.

p.m.

Mil.

(2) Date and time surgery/procedure ended

SURE_DATE

1

:SURE_TIME

	ANESTHESIA											PROVIDER(S) OF ANESTHESIA
	Type(s) of anesthesia administered – Mark (X) all that apply. ANESTH1-12											Anesthesia administered by – Mark (X) all that apply. ANESTH_BY1-6
	1				NONE	7		Regional peripheral nerve				1	Anesthesiologist
	2				General	8		Regional retrobulbar block				2	CRNA (Certified Registered Nurse Anesthetist)
	3				Conscious/IV sedation/MAC (Monitored Anesthesia Care)	9		Regional spinal (subarachnoid)				3	Surgeon/Other physician
						10		Other regional block				4	Resident
	4				Local/Topical	11		Other				5	Other provider
	5				Regional epidural	12		Not applicable – no procedure performed				6	Unknown
	6				Regional peribulbar block
	SYMPTOM(S) PRESENT DURING OR AFTER PROCEDURE
	Mark (X) all that apply. SYMPTOMS1-15
	1				NONE					9	Pain – moderate to severe
	2				Airway problem or aspiration					10	Sedation – excessive
	3				Arrhythmia – significant					11	Surgical complications – unanticipated
	4				Bleeding (post-operative) – moderate to severe					12	Urinary retention
	5				Hypertension/High blood pressure - >20% change from baseline					13	Vomiting – moderate to severe
	6				Hypotension/Low blood pressure - >20% change from baseline					14	Other
	7				Hypoxia					15	Not applicable – no procedure performed
	8				Nausea – moderate to severe
	FOLLOW-UP INFORMATION
	Did someone attempt to follow-up with the patient within 24 hours after the surgery? Mark (X) one box. FUSURG						What was learned from this follow-up? Mark (X) all that apply. LEARNED
							1 Unable to reach patient
	1				Yes		2 Patient reported no medical or surgical problems
	2				Skip to VISIT_DISP No		3 Patient reported problems and sought medical care
	3				Unknown		4 Patient reported problems and was advised by staff to seek medical care
	4				Not applicable –		5 Patient reported problems, but no follow-up medical care was needed
					No procedure performed		6 Other
							7 Unknown
DISPOSITION
Mark (X) all that apply. VISIT_DISP
1				Admit to hospital					9 Return in less than 1 week 10 Return in 1 week to less than 2 months 11 Return in 2 months or greater 12 Return at unspecified time 13 Return as needed (p.r.n.) 14 Routine discharge to customary residence 15 Surgery terminated Reason for termination: TERMINATE 1 Allergic reaction 2 Unable to intubate 3 Other 4 Unknown 16 Other 17 Unknown
2				Discharge to observation status
3				Discharge to post-surgery/recovery care facility
4				Move to observation/post-surgical/recovery care area in the same hospital, i.e., not admitted as an inpatient
5				Procedure cancelled on arrival to clinic/ambulatory surgery location Reason for cancellation: CANCELED 1 Patient not n.p.o./fasting 2 Incomplete or inadequate medical evaluation 3 Surgical issue 4 Other 5 Unknown Specify: CANCELED_OTHER
6				Refer to ED
7				Refer to other physician/provider
8				Return to referring physician/provider

June 11, 2014