Attachment V - OPD PRF Changes 010616

Attachment V: OPD PRF Changes

Changes to 2016 Outpatient Department Patient Record Form (PRF)

Proposed changes are indicated in RED.

• Modified-Patient Information Questions (OPD &ASL combined)

“Patient Information” Section
Modified-Where visit occurred
CLIN_LOC (OPD) and PROC_LOC (ASL):
Old OPD clinic where visit occurred Procedure location where procedure was performed	New Hospital location where visit occurred

Deleted-Last menstrual period (LMP)
LMP:
Old Last menstrual period – Month, day, year	New Last menstrual period – Month, day, year

Modified-Checkbox list of Expected source(s) of payment for this visit
PAY_SOURCE:
Old Private insurance Medicare Medicaid or CHIP Worker’s compensation Self-pay No charge/Charity Other Unknown	New Private insurance Medicare Medicaid or CHIP or other state-based program Workers’ compensation Self-pay No charge/Charity Other Unknown

• Modified-Tobacco use (OPD)

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

• Deleted-Vital Signs – Temperature Type (OPD)

“Biometrics/Vital Signs” Section
TTEMP:
Old Celsius and Fahrenheit	New Celsius and Fahrenheit

• Modified-Reason for Visit Questions (OPD)

“Reason for Visit” Section
VRFV1-3: VRFV1-5:
Old Patient’s complaint(s), symptoms(s). or other reason(s) for this visit – Use patient’s own words if provided. If there are more than 3 reasons, enter the first 3 documented in the chart. Allow up to 3 lines of Reason for visit verbatim and look-up		New 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. Allow up to 5 lines of Reason for visit verbatim and look-up table entries.
MAJOR:
Old Major reason for this visit checkboxes New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Pre/Post surgery Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)	New Major reason for this visit checkboxes New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams) Pre-surgery/procedure Post-surgery/procedure Surgery/Procedure

• Modified-Injury/Poisoning/Adverse Effect Questions (OPD)

“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? Yes, injury/trauma Yes, poisoning Yes, adverse effect of medical or surgical treatment 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/surgical treatment or adverse effect of a medicinal drug No Unknown
	INJURY72:
Old …	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? 1-Yes 2-No 3-Unknown 4-Not applicable
INTENTO:
Is this injury/poisoning unintentional or intentional? Unintentional Intentional Unknown	New Is this injury/trauma or overdose/poisoning intentional or unintentional? Yes, intentional self-harm/suicide attempt Yes, intentional harm by another person (e.g., assault, poisoning) No, unintentional (e.g., accidental) Intent unclear
	VCAUSE1-5:
Old …	Add new question to allow up to 5 lines of causes of injury verbatim and look-up table entries: “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.”

• Modified-Diagnosis Verbatim and Look-up Table (OPD &ASL combined)

“Provider’s Diagnosis For This Visit” Section
VDIAG1-3:	VDIAG1-5:
Old: As specifically as possible, list diagnoses related to this visit including chronic conditions. Allow up to 3 diagnoses verbatim and Look-up table entries	New: As specifically as possible, list diagnoses related to this visit including chronic conditions. List primary diagnosis first. Allow up to 5 diagnoses verbatim and look-up table entries

• Added-Optional ICD-10-CM diagnosis codes (OPD &ASL combined)

VDIAG1-3_CODE: VDIAG1-5_CODE:
Old …	New Allow entry of ICD-10-CM diagnosis and V codes

• Modified-Checkbox list of patient’s underlying chronic conditions (OPD &ASL combined)

“Conditions” Section
PATIENT_HAVE (OPD) and OTH_DIAG (ASL) combined:
Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.
Old	New
Airway problem	Airway problem
---	Alcohol abuse, misuse, or dependence
---	Alzheimer's disease/Dementia
Arthritis	Arthritis
Asthma	Asthma
Cancer	Cancer
Cardiac surgery history	Cardiac surgery history
Cerebrovascular disease/History of stroke or transient ischemic attack (TIA)	Cerebrovascular disease/History of stroke (CVA) or transient ischemic attack (TIA)
Chronic renal failure	Chronic kidney disease (CKD)
Chronic obstructive pulmonary disease (COPD)	Chronic obstructive pulmonary disease (COPD)
Congestive heart failure	Congestive heart failure (CHF)
Coronary heart disease (CAD) (on ASL) Ischemic heart disease (IHD) ( on OPD)	Coronary heart disease (CAD), ischemic heart disease (IHD), or history of myocardial infarction (MI)
Depression	Depression
Diabetes	Diabetes mellitus (DM), Type I
Diabetes	Diabetes mellitus (DM), Type II
Diabetes	Diabetes mellitus (DM), Type Unspecified
Chronic renal failure	End-stage renal disease (ESRD)
---	History of pulmonary embolism (PE), deep vein thrombosis (DVT), or venous thromboembolism (VTE)
---	HIV Infection/AIDS
Hyperlipidemia	Hyperlipidemia
Hypertension	Hypertension
Obesity (on OPD) Morbid obesity (on ASL)	Obesity
Obstructive sleep apnea (OSA) (on ASL)	Obstructive sleep apnea (OSA)
Osteoporosis	Osteoporosis
---	Substance abuse, misuse, or dependence
None of the above or not documented	None of the above or not documented

• Modified-Checkbox list of Services (OPD)

“Services” Section
DIAG_SERVICE:

Enter all examinations/screenings, laboratory tests, imaging, procedures, treatments, health education/ counseling and other services not listed ORDERED or PROVIDED.

• NO SERVICES

Examinations/Screenings:

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

• Breast

• Depression screening

• Domestic violence screening

• Foot

• General physical exam

• Neurologic

• Pelvic

• Rectal

• Retinal/Eye Exam

• Skin

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

Blood tests Laboratory tests:

• BMP (Basic metabolic panel)

• CBC

• Chlamydia test

• CMP (Comprehensive metabolic panel)

• Creatinine /Renal function panel

• Culture, blood

• Culture, throat

• Culture, urine

• Culture, other

• Glucose, serum

• Gonorrhea test

• HbA1c (Glycohemoglobin)

• Hepatitis panel

• HIV test

• HPV DNA test

• Lipid profile/panel

• Liver enzymes/Hepatic function panel

• PAP test

• Pregnancy/HCG test

• PSA (prostate specific antigen)

• Rapid strep test

• TSH/Thyroid panel

• Urinalysis

• Vitamin D test

Imaging:

• Bone mineral density

• CT scan

• Echocardiogram

• Other Ultrasound

• Mammography

• MRI

• X-ray

Other tests and procedures: Procedures:

• Audiometry

• Biopsy

• Cardiac stress test

• Colonoscopy

• Cryosurgery (cryotherapy)/ Destruction of tissue

• EKG/ECG

• Electroencephalogram (EEG)

• Electromyogram (EMG)

• Excision of tissue

• Fetal monitoring

• Peak flow

• Sigmoidoscopy

• Spirometry

• Tonometry

• Tuberculosis skin testing/PPD

• Upper gastrointestinal endoscopy (EGD)

Non-medication treatment: Treatments:

• Cast/splint/wrap

• Complementary and alternative medicine (CAM)

• Durable medical equipment

• Home health care

• Mental health counseling, excluding psychotherapy

• Occupational therapy

• Physical therapy

• Psychotherapy

• Radiation therapy

• Wound care

Health education/Counseling:

• Alcohol abuse counseling

• Asthma

• Asthma action plan given to patient

• Diabetes education

• Diet/Nutrition

• Exercise

• Family planning/Contraception

• Genetic counseling

• Growth/Development

• Injury prevention

• STD prevention

• Stress management

• Substance abuse counseling

• Tobacco use/Exposure

• Weight reduction

Other services not listed:

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Modified-Tests (OPD)

“Tests” Section
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 the visit? 1-Yes 2-No	New Was blood for the following laboratory tests drawn on the day of the sampled visit or during the 12 months prior to the visit? 1-Yes 2-No tests found
CHOLDATE-SERUMDATE:
Old Date of Test	New Date of blood draw

• Modified-Medications and Immunizations (OPD)

	“Medication & Immunizations” Section
	NOMED:
	NONE Enter medications that were ordered, supplied, administered, or continued during this visit. Include Rx and OTC medications, immunizations, allergy shots, oxygen, anesthetics, chemotherapy, and dietary supplements. The maximum number of medications that can be entered is 10 on the OPD PRF and 18 on the ASL PRF.	New 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. The maximum number of medications that can be entered is 30.
	VMED, NCMED:
Old: Allow up to 10 drug entries (verbatim and look-up table) 1-New 2-Continued		New: Allow up to 30 drug entries (verbatim and look-up table) 1-New 2-Continued 3-Administered at this visit 4-Unknown

• Deleted-Medications (ASL)

	“Medication(s)” Section
	VMEDA:
Old: Mark all drugs and anesthetics that were administered and whether they were administered preoperatively, intraoperatively, and/or postoperatively. 1-NONE 2-Fentanyl 3-Lidocaine 4-Nitrous oxide 5-Oxygen 6-Pentothal 7-Propofol 8-Versed (Midazolam) 9-Zofran (Ondanestron) 10-Other, specify Preoperatively, Intraoperatively, Postoperatively.		…

• Modified- Procedures (ASL)

“Procedure(s)” Section
VPROC1:
Old As specifically as possible, list all diagnostic and surgical procedures performed during this visit. NONE	New As specifically as possible, list all diagnostic and surgical procedures performed during this visit. NONE Code each procedure using the lookup list. Once all procedures have been entered, enter 0.

• Added-Optional ICD-10-CM procedure codes (ASL)

“Procedure(s)” Section
ICD10CM1:
Old …	New Allow entry of ICD-10-CM procedure codes.

• Modified and Deleted-Procedure times (ASL)

“Procedure(s)” Section
ORIN_DATE, ORIN_TIME, SURB_DATE, SURB_TIME, SURE_DATE, SURE_TIME, OROUT_DATE, OROUT_TIME, POIN_DATE, POIN_TIME, POUT_DATE, POUT_TIME:
Old Date and time into operating room Date and time surgery began Date and time surgery ended Date and time out of operating room Date and time into postoperative care Date and time out of postoperative care	New Date and time into operating room Date and time surgery/procedure began Date and time surgery/procedure ended Date and time out of operating room Date and time into postoperative care Date and time out of postoperative care

• Modified-Anesthesia types (ASL)

“Anesthesia” Section
ANESTH:
Old NONE General IV sedation MAC (Monitored Anesthesia Care) Topical/Local Regional epidural Regional spinal Regional retrobulbar block Regional peribulbar block Other regional block Other Not documented	New NONE General Conscious/IV sedation/MAC (Monitored Anesthesia Care) Local/Topical Regional epidural Regional peribulbar block Regional peripheral nerve Regional retrobulbar block Regional spinal (subarachnoid) Other regional block Other Not applicable - no procedure performed

• Modified-Follow-up Information ASL)

“Follow-up Information” Section
FUSURG:
Old Did someone attempt to follow-up with the patient within 24 hours after the surgery? Yes No Unknown	New Did someone attempt to follow-up with the patient within 24 hours after the surgery? Yes No Unknown Not applicable – No procedure performed
LEARNED:
Old What was learned from this follow-up: Unable to reach patient Patient reported no problems Patient reported problems and sought medical care Patient reported problems and was advised by ASC staff to seek medical care Patient reported problems, but no follow-up medical care was needed Other Unknown	New What was learned from this follow-up: Unable to reach patient Patient reported no medical or surgical problems Patient reported problems and sought medical care Patient reported problems and was advised by staff to seek medical care Patient reported problems, but no follow-up medical care was needed Other Unknown

• Modified-Visit disposition (OPD &ASL combined)

“Visit disposition” Section
VISIT_DISP:
Old OPD Mark (X) all that apply. Refer to other physician Return at specified time Refer to ER/Admit to hospital Other Old ASL Mark (X) all that apply. 1. Routine discharge to customary residence 2. Patient was moved to observation/post-surgical/recovery care area in same facility, i.e., not admitted as an inpatient 3. Admitted to hospital as inpatient 4. Referred to ED 5. Surgery terminated Reason for termination Allergic reaction Unable to intubate Other 6. Procedure cancelled on arrival to ambulatory surgery unit Reason for cancellation Patient not n.p.o. Incomplete or inadequate medical evaluation Surgical issue 7. Other 8. Unknown	New Mark (X) all that apply Admit to hospital as inpatient Discharge to observation status Discharge to post-surgery/recovery area in same facility, i.e., not admitted as an inpatient Move to observation/post-surgical/recovery care area in same hospital, i.e., not admitted as an inpatient Procedure canceled on arrival to clinic/ambulatory surgery location Reason for cancellation Patient not n.p.o. Incomplete or inadequate medical evaluation Surgical issue Other - Specify______________ Unknown Refer to ED Refer to other physician/provider Return to referring physician/provider Return in less than 1 week Return in 1 week to less than 2 months Return in 2 months or greater Return at unspecified time Return as needed (p.r.n.) Routine discharge to customary residence Surgery terminated Reason for termination Allergic reaction Unable to intubate Other Unknown Other Unknown

• Deleted-Lookback module (OPD)

• Deleted-Colorectal cancer screening questions (ASL)

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