Attachment R - Outpt Dept Pt Record Form 010616

Attachment R - Outpt Dept Pt Record Form 010616.docx

National Hospital Care Survey

Attachment R - Outpt Dept Pt Record Form 010616

OMB: 0920-0212

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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

Shape1

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

Shape2

1 Yes

Shape3

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

Shape4 VDIAG1_Code





Shape5

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

Shape6

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

Shape7

5 Other – Specify


ASTH_SEV_SP


6 None recorded

Asthma control:

ASTH_CON

1 Well controlled

2 Not well controlled

3 Very poorly controlled

Shape8

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



Shape9

1 Yes

2 No test found

CHOLRES

mg/dL











CHOLDATE

201

0

1


mm

dd

yyyy



High density lipoprotein (HDL) HDL

Shape10

1 Yes

2 No test found

HDLRES

mg/dL











HDLDATE

201

0

1


mm

dd

yyyy



Low density lipoprotein (LDL) LDL

Shape11

1 Yes

2 No test found

LDLRES

mg/dL











LDLDATE

201

0

1


mm

dd

yyyy



Triglycerides TGS

Shape12

1 Yes

2 No test found

TGSRES

mg/dL











TGSDATE

201

0

1


mm

dd

yyyy



HbA1c (Glycohemoglobin) A1C

Shape13

1 Yes

2 No test found

A1CRES

%











A1CDATE

201

0

1


mm

dd

yyyy



Blood glucose (BG) FBG

Shape14

1 Yes

2 No test found

FBGRES

mg/dL











FBGDATE

201

0

1


mm

dd

yyyy



Serum creatinine SERUM

Shape15

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

Shape16 Administered
at this visit

(1)

VMED1 / VMEDOTH1


1

2

Shape17 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


Shape18

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

Shape19 Shape20

Yes

2 Patient reported no medical or surgical problems


2

Shape21

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


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