Form 0920-0234 Att D2 2016 NAMCS PRF 122115

Attachment D2: 2016 Patient Record form (NAMCS-30), sample card

SAMPLE
NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT RECORD

2016

OMB No. 0920-0234; Expiration date xx/xx/20xx

NOTICE – Public reporting burden of this collection of information is estimated to average 14 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

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 medical record number

PTMEDRECNUM / ENTER_PTMEDRECNUM

Zip Code

PATZIP

Date of Visit VDATE

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.

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

2 Current

3 Unknown

EVERTOBAC

1 Never

2 Former

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

2

0

1

Date of Birth BDATE

Month

Day

Year

Age AGE/AGET

1 Years

2 Months

3 Days

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

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 or history of present illness (HPI) 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 Pre-surgery

5 Post-surgery

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

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 or surgical
treatment or adverse effect of medicinal drug

4 No

5 Unknown

Did the injury/trauma, overdose/poisoning, or adverse effect 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 or unintentional?

INTENTO

1 Intentional

2 Unintentional (e.g., accidental)

3 Intent unclear

What was the intent of the injury/trauma ot overdose/poisoning?

INTENTYP

1 Suicide attempt with intent to die

2 Intentional self-harm without intent to die

3 Unclear if suicide attempt or intentional self-harm without intent to die

4 Intentional harm inflicted by another person (e.g., assault, poisoning)

5 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)

VCAUSE

CONTINUITY OF CARE

Are you 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 practice 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.

Primary:

1.

VDIAG1 / VDIAG1_LKUP

Other:

2.

VDIAG2 / VDIAG2_LKUP

Other:

3.

VDIAG3 / VDIAG3_LKUP

Other:

4.

VDIAG4 / VDIAG4_LKUP

Other:

5.

VDIAG5 / VDIAG5_LKUP

CONDITIONS

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

1 Alcohol misuse, abuse, or dependence

2 Alzheimer’s disease/Dementia

3 Arthritis

4 Asthma

6 Autism spectrum disorder

7 Cancer

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 Hepatitis B

19 Hepatitis C

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

21 HIV infection/AIDS

22 Hyperlipidemia

23 Hypertension

24 Obesity

25 Obstructive sleep apnea (OSA)

26 Osteoporosis

27 Substance abuse or dependence

28 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

5 Attention deficit disorder (ADD)/ Attention hyperactivity deficit disorder (ADHD)/

Asthma control:

ASTH_CON91 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_SERVICE

1 NO SERVICES

Examinations/

Screenings

2 Alcohol misuse 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

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 testing/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 (UA) or urine dipstick

36 Vitamin D test

Imaging

37 Bone mineral density

38 CT scan

39 Echocardiogram

40 Other 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 misuse counseling

71 Asthma education

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

MEDICATION(S) & IMMUNIZATIONS

NOMED=Were any prescription or non-prescription drugs ORDERED or PROVIDED (by any route of administration) at this visit? 1 Yes 2 No Include Rx and OTC drugs, 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.

NCMED

New

Continued

(1)

VMED1 / VMEDOTH1

1

2

(2)

VMED2 / VMEDOTH2

1

2

(3)

VMED3 / VMEDOTH3

1

2

(4)

VMED4 / VMEDOTH4

1

2

(5)

VMED5 / VMEDOTH5

1

2

(6)

VMED6 / VMEDOTH6

1

2

(7)

VMED7 / VMEDOTH7

1

2

(8)

VMED8 / VMEDOTH8

(9)

VMED9 / VMEDOTH9

1

2

(10-30)

VMED10-30 / VMEDOTH10-30 (Up to 30 drugs can be listed.)

1

2

PROVIDERS

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

1

Physician

5

Mental health provider

2

Physician assistant (PA)

6

Other

3

Nurse practitioner (NP)/Midwife (CNM)

7

NONE

4

RN/LPN

TIME SPENT WITH PROVIDER

Enter estimated time spent with sampled provider. Enter 0 if no provider seen. DURATION

Minutes

VISIT DISPOSITION

Mark (X) all that apply. VISIT_DISP

1

Return to referring physician/provider

6

Return at unspecified time

2

Refer to other physician/provider

7

Return as needed (p.r.n.)

3

Return in less than 1 week

8

Refer to ER/Admit to hospital

4

Return in 1 week to less than 2 months

9

Other

5

Return in 2 months or greater

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

Most recent result

Date of blood draw

Total Cholesterol CHOL

1 Yes

2 None found

CHOLRES

mg/dL

CHOLDATE				201	0	1
mm		dd		yyyy

High density lipoprotein (HDL) HDL

1 Yes

2 None found

HDLRES

mg/dL

HDLDATE				201	0	1
mm		dd		yyyy

Low density lipoprotein (LDL) LDL

1 Yes

2 None found

LDLRES

mg/dL

LDLDATE				201	0	1
mm		dd		yyyy

Triglycerides TGS

1 Yes

2 None found

TGSRES

mg/dL

TGSDATE				201	0	1
mm		dd		yyyy

HbA1c (Glycohemoglobin) A1C

1 Yes

2 None found

A1CRES

%

A1CDATE				201	0	1
mm		dd		yyyy

Blood glucose (BG) FBG

1 Yes

2 None found

FBGRES

mg/dL

FBGDATE				201	0	1
mm		dd		yyyy

Serum creatinine SERUM

1 Yes

2 None found

SERUMRES

mg/dL µmol/L

SERUMDATE				201	0	1
mm		dd		yyyy

CPT CODES

Enter Current Procedure Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. Up to 18 CPT codes can be listed.

CPTCODE1

CPTCODE2

CPTCODE3

CPTCODE4

CPTCODE5

CPTCODE6

CPTCODE7

CPTCODE8

CPTCODE9

CPTCODE10

CPTCODE11

CPTCODE12

CPTCODE13

CPTCODE14

CPTCODE15

CPTCODE16

CPTCODE17

CPTCODE18