Attachment U - ED PRF Changes 010616

Attachment U: Changes to 2014 Emergency Department Patient Record Form (PRF)

Proposed changes are indicated in RED.

• Modified-Patient Information Questions –Dates and Times

“Patient Information” Section
TSDATE, TS_TIME, EDDATE, ED_TIME:
Old Seen by MD/DO/PA/NP	New Provider (physician/APRN/PA) contact
ED departure, if released or transferred (i.e., patients who do not have a disposition of admit to hospital or admit to observation unit)	New ED departure

• Added-Transferred from another hospital or urgent care center

Old	New AMBTRANSFER:
…	Add new question on point of origin: If ARRIVE=Ambulance, then ask, Was patient transferred from another hospital or freestanding emergency/urgent care center? Yes No Unknown

• Modified-Checkbox list of Expected source(s) of payment for this visit

“Patient Information” Section
PAY_SOURCE:
Old Private insurance TRICARE Medicare Medicaid or CHIP Workers’ compensation Self-pay No charge/Charity Other Unknown	New Private insurance TRICARE Medicare Medicaid or CHIP or other state-based program Workers’ compensation Self-pay No charge/Charity Other Unknown

• Deleted-Triage – Temperature Type and On oxygen at arrival

“Triage” Section
TTEMP:
Old Celsius and Fahrenheit	New Celsius and Fahrenheit

ONO2:
Old Answer list O2: On oxygen at arrival? Yes No Unknown	New O2: On oxygen at arrival? Yes No Unknown

• Modified and added-Reason for Visit Questions

“Reason for Visit” Section
VRFV1-3:
Old Patient’s complaint(s), symptoms(s). or other reason(s) for this visit – Use patient’s own words Allow up to 3 lines of Reason for visit verbatim and look-up	New List the first 5 reasons for visit (i.e., complaints, symptoms, problems, concerns 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. Allow up to 5 lines of Reason for visit verbatim and look-up
SOURCE_RFV: Old What is the source of the most important reason for visit? 1-In patient’s own words 2-Other 3-Unknown	New Source of the first complaint, symptom, reason for visit 1-In pPatient ’s own words 2-Other 3-Unknown

Old (Only asked, if DRUGS_CONTRIBUTED=1 Yes) Was alcohol involved? 1-Yes 2-No 3-Not documented	ALCOHOL6: New Did alcohol cause or contribute to this visit? 1-Yes, patient’s own use 2-Yes, other person’s use 3-No 4-Unknown
	SUBETOH:
…	New 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. 1-Yes, alcohol abuse/misuse/dependence: 1-History of alcohol abuse/misuse/dependence 2-Currently abusing alcohol 2-Yes, other substance abuse/misuse/dependence: 1-History of other substance abuse/misuse/dependence 2- Other substance seeking behavior 3-Currently abusing other substance(s) 3 -Yes, other specify ________________ 4- No 5 - Unknown

• Modified and added-Injury/Overdose/Poisoning/Adverse Effect Questions

“Injury/Trauma/Overdose/Poisoning/Adverse Effect” Section
INJURY:
Old Is this visit related to an injury, overdose, poisoning, or adverse effect of medical or surgical treatment? 1-No 2-Yes, injury/trauma 3-Yes, poisoning (non-drug toxic substance) 4- Yes, poisoning (drug-induced overdose) Medication Illicit substance Unknown 5-Yes, adverse effect of medical or surgical treatment Medication involved No medication involved 6-Unknown	New Is this visit related to an injury/trauma, overdose/ poisoning, or adverse effect of medical/surgical treatment? 1-No 2-Yes, injury/trauma 3-Yes, poisoning (non-drug toxic substance) 4- Yes, poisoning (drug-induced overdose) 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 medicinal drug Was medication involved? 1-Yes 2-No 3-Unknown 6-Unknown
	INJURY72:
Old …	New Add new question on recent timing of injury: If INJURY=Yes, then ask, 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
INTENT:
Old Is this injury/overdose/poisoning intentional? 1-Yes, intentional a-Self-inflicted Suicide attempt Self-harm or suicide gesture b-Intentional harm by another person 2-No, unintentional (e.g., accidental) 3-Unknown intent	New Is this injury/trauma or overdose/poisoning intentional? 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
VCAUSE:
Old Cause of injury, poisoning by drug or non-drug toxin, drug-induced illness, or adverse effect	New Cause of injury/trauma; overdose/poisoning by drug or non-drug toxic substance; drug-induced illness, or adverse effect of medical/surgical treatment …Describe the place and circumstances that preceded the injury/trauma, overdose/ poisoning, or adverse effect.

• Modified-Substances Involved Question and Checkbox

“Substances Involved“ Section
CONFIRMEDBYTOXD:
Old	New
For each substance listed, mark if confirmed by toxicology report	For each substance listed, mark if confirmed by toxicology or blood test report.

PT_TOOK:
Mark all that apply.
Old	New
Own prescription/OTC medication or dietary supplement	Own prescription/OTC medication or dietary supplement
Prescription medication not prescribed for patient	Prescription medication not prescribed for patient
Prescription/OTC medication as prescribed or according to directions	Prescription/OTC medication as prescribed or according to directions
Too much of a prescription/OTC medication or dietary supplement	Too much of a prescription/OTC medication or dietary supplement
Illicit drug(s)	Illicit drug(s)
Alcohol only, under 21	Alcohol only, under 21
…	Alcohol in combination with other substances
Not documented	Not documented

• Modified and added-Diagnosis

“Diagnosis” Section
VDIAG1-20_CODE:
Old As specifically as possible, list diagnoses related to this visit including chronic conditions.	New As specifically as possible, list diagnoses related to this visit including chronic conditions. List primary diagnosis first.
Old …	New Allow entry of ICD-10-CM diagnosis and V codes

• Modified-Checkbox list of patient’s underlying chronic conditions

“Diagnosis” Section
PAT_HAVE: Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.
Old	New
…	Alcohol abuse, misuse, or dependence
Dementia	Alzheimer's disease/Dementia
---	Asthma
Cancer	Cancer
Cerebrovascular disease/History of stroke 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	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)
Diabetes	Diabetes mellitus (DM), Type I
Diabetes	Diabetes mellitus (DM), Type II
Diabetes	Diabetes mellitus (DM), Type unspecified
---	End-stage renal disease (ESRD)
History of pulmonary embolism 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
Mental illness or episode	Mental illness or episode
…	Obesity
…	Obstructive sleep apnea (OSA)
…	Osteoporosis
Substance abuse, misuse, or dependence	Substance abuse, misuse, or dependence
Not documented	None of the above

• Modified-Checkbox list of Diagnostics

“Diagnostics” Section
DIAG_SERVICES:
Old	New
Blood tests:
ABG (arterial blood gases)	ABG (Arterial blood gases)
BAC (blood alcohol concentration)	BAC (Blood alcohol concentration)
…	BMP (Basic metabolic panel)
BNP (brain natriuretic peptide)	BNP (Brain natriuretic peptide)
Cardiac enzymes (CE)	CE (Cardiac enzymes)
CBC (complete blood count)	CBC (Complete blood count)
…	CMP (Comprehensive metabolic panel)
BUN/creatinine	Creatinine/Renal function panel
Blood culture	Culture, blood
…	Culture, throat
Urine culture	Culture, urine
Wound culture	Culture, wound
…	Culture, other
D-dimer	D-dimer
Electrolytes	Electrolytes
Glucose	Glucose, serum
Lactate	LDH (Lactate dehydrogenase)
Liver function tests (LFT)	Liver enzymes/Hepatic function panel
Prothrombin time/INR	Prothrombin time (PT/PTT/INR)
Other blood test	Other blood test Enter other blood tests as written:_______
Imaging:
Intravenous contrast	Intravenous contrast
CT scan Abdomen/pelvis Chest Head Other	CT scan What body site was scanned during the CT scan? Abdomen/pelvis Chest Head Other Was CT ordered or provided with intravenous (IV) contrast? Yes No Unknown
MRI	MRI Was MRI ordered or provided with intravenous (IV) contrast (also written as “with gadolinium” or “with gado”)? Yes No Unknown

• Modified-Procedures

“Procedures” Section
PROCEDURES:
Old	New
NONE	NONE
BiPAP/CPAP	BiPAP/CPAP
Bladder catheter	Bladder catheter
Cast, splint, or wrap	Cast, splint, or wrap
Central line	Central line
CPR	CPR
Endotracheal tube	Endotracheal tube (ETT)
Incision & drainage (I&D)	Incision & drainage (I&D)
IV fluids	IV
Lumbar puncture	Lumbar puncture (LP)
Nebulizer therapy	Nebulizer therapy
Pelvic exam	Pelvic exam
Physical restraint	Physical restraint
Psychiatry/Psychology/Substance abuse consult	Psychiatry/Psychology/Substance abuse consult
Skin adhesives	Skin adhesives
Suturing/Staples	Suturing/Staples
Other	Other

• Modified-Medications and Immunizations

“Medications & Immunizations” Section
VMED:
Old Enter medications given at this visit or prescribed at ED discharge. Include Rx and OTC medications, immunizations, and anesthetics. The maximum number of medications that can be entered is 12.	New 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. The maximum number of medications that can be entered is 30.
GPMED:
Old …	New Both given in ED and Rx at discharge

• Modified-Last Vital Signs Taken

“Last Vital Signs Taken” Section
VITALSD :
Old No vital signs taken at discharge	New Does the chart contain vital signs taken after triage? 1-Yes 2-No

• Modified-Checkbox list of Providers

“Providers” Section
PROV_SEEN:
Old	New NONE
ED attending physician	ED attending physician
ED resident or intern	ED resident or intern
Consulting physician (Specialty of consulting physician)	Consulting physician
RN/LPN	RN/LPN
Nurse practitioner	Nurse practitioner (NP)
Physician assistant	Physician assistant (PA)
EMT	EMT
Psychologist	Psychologist
Social worker	Social worker
…	Substance abuse services provider
Other mental health provider	Other mental health provider
Other provider	Other provider

• Modified- Providers – Checkbox list of Specialty of consulting physician

“Providers” Section
PROV_SEEN:
Old:	New
Anesthesia	Anesthesia
…	Cardiology
Critical care	Critical care
ENT (Otolaryngology)	ENT (Otolaryngology)
…	Gastroenterology
…	General/Trauma Surgery
…	Geriatrics
Hematology/Oncology	Hematology/Oncology
…	Neurology
…	Neurosurgery
…	Obstetrics-Gynecology
…	Ophthalmology
…	Orthopedic Surgery
Palliative care	Palliative care
Psychiatry	Psychiatry
Other specialty	Other specialty
Unknown	Unknown

• Modified-Checkbox list of Visit Disposition

“Visit Disposition” Section
VISIT_DISP:
Old Left before triage	New Left without being seen (LWBS)
Left after triage	Left before treatment complete (LBTC)

• Modified-Hospital Admission Dates and Times

“Hospital Admission” Section
BR_DATE, BR_TIME:
Old Date and time bed was requested for hospital admission or transfer	New Admit order

• Modified-Observation Unit Dates and Times

“Observation Unit/Care Stay” Section
EDDISDATE, EDDISTIME, OBDATE, OB_TIME:
Old Date and time of ED departure	New Observation unit/care initiation order
Date and time of observation unit discharge	Observation unit/care discharge order

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