2016 Ambulatory Surgery Center Patient Record Form

Attachment H: Ambulatory Surgery Patient Record

SAMPLE
NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2016 AMBULATORY SURGERY PATIENT RECORD
OMB No. 0920-0278; Expiration date 02/28/2018
NOTICE – Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
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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 (0920-0278).
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
PATIENT_NUMBER

Date of Visit VDATE
Month

Day

Sex SEX
1
Female
2
Male

Expected source(s) of
payment for this visit –
Mark (X) all that apply.
PAY_SOURCE1-8

Ethnicity ETHNIC
1
Hispanic or Latino
2
Not Hispanic or Latino

Year

2 0 1
Zip Code PATZIP

Date of Birth BDATE
Month

Day

Year

2 0 1
Age AGE/AGET
1
2
3

Race – Mark (X) all that apply.
MULTIRACE
1
White
2
Black or African
American
3
Asian
4
Native Hawaiian or
Other Pacific Islander
5
American Indian or
Alaska Native

Surgery/Procedure Date and Time
(1) Date/time surgery/procedure began
Month

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

Day

Time SURB_TIME

Year SURB_DATE

a.m. p.m. Mil.

:
(2) Date/time surgery/procedure ended
Month

Day

Time SURE_TIME

Year SURE_DATE

a.m. p.m. Mil.

:

Years
Months
Days

DIAGNOSIS
As specifically as possible, list all diagnoses related to this surgery or procedure.
Primar
1.
y:
Other: 2.

VDIAG1

VDIAG1_LKUP

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. OTH_DIAG
1
2
3
4

Airway problem
Asthma
Cardiac surgery history
Cerebrovascular disease/History of stroke (CVA)
or transient ischemic attack (TIA)

7
8

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

12
13
14
15
16

End-stage renal disease (ESRD)
Hypertension
Obesity
Obstructive sleep apnea (OSA)
None of the above

5
6

Chronic kidney disease (CKD)
Chronic obstructive pulmonary disease (COPD)

9
10
11

Diabetes mellitus (DM), Type I
Diabetes mellitus (DM), Type II
Diabetes mellitus (DM), Type
unspecified

PROCEDURE(S)
As specifically as possible, list all diagnostic and surgical
procedures performed during this visit.

CPT-4 Code

ICD-10-CM Code

Primary: 1. VPROC1 / VPROC1_LKUP

CPTCODE1

ICD10CM1

Other: 2. VPROC2 / VPROC2_ LKUP

CPTCODE2

ICD10CM2

Other: 3. VPROC3 / VPROC3_ LKUP

CPTCODE3

ICD10CM3

Other: 4. VPROC4 / VPROC4_ LKUP

CPTCODE4

ICD10CM4

Other: 5. VPROC5 / VPROC5_ LKUP

CPTCODE5

ICD10CM5

Other: 6. VPROC6 / VPROC6_ LKUP

CPTCODE6

ICD10CM6

CPTCODE7

ICD10CM7

Other: 7. VPROC7 / VPROC7_ LKUP

MEDICATION(S)

Mark (X) all drugs and anesthetics that were administered and whether they were administered preoperatively,
intraoperatively, and/or postoperatively. VMEDA
Preop

Intraop

GPMED

Postop

1

NONE (Skip to Disposition)

2

Fentanyl .............................

1

2

3

3

Lidocaine ............................

1

2

4

Nitrous oxide ......................

1

2

5

Oxygen ...............................

1

2

3

6
7

Pentothal ............................
Propofol ..............................

1
1

2
2

3
3

Preop

Versed (Midazolam) .......................

1

2

3

3

9

Zofran (Ondansetron) .....................

1

2

3

3

10

1

2

3

Other – Specify
(up to 30 drugs
may be entered)

VMED

PROVIDER(S) OF ANESTHESIA

Type(s) of anesthesia administered – Mark (X) all that apply. ANESTH
1
NONE
7
Regional peripheral nerve block
2
General
8
Regional retrobulbar block
Conscious/IV sedation/MAC
3
9
Regional spinal (subarachnoid)
(Monitored Anesthesia Care)
10
Other regional block
Local/Topical
Regional epidural
Regional peribulbar block

11

Other

Anesthesia administered by – Mark (X) all that
apply.
ANESTH_BY
1
2
3
4
5
6

Anesthesiologist
CRNA (Certified Registered Nurse Anesthetist)
Surgeon/Other physician
Resident
Other provider
Unknown

SYMPTOM(S) PRESENT DURING OR AFTER PROCEDURE
Mark (X) all that apply. SYMPTOMS
1
2
3
4
5
6
7
8

Postop

8

ANESTHESIA

4
5
6

Intraop

NONE
Airway problem or aspiration
Arrhythmia – significant
Bleeding (post-operative) – moderate to severe
Hypertension/High blood pressure - >20% change from
baseline
Hypotension/Low blood pressure - >20% change from baseline
Hypoxia
Nausea – moderate to severe

9
10
11
12
13
14

Pain – moderate to severe
Sedation – excessive
Surgical complications – unanticipated
Urinary retention
Vomiting – moderate to severe
Other

DISPOSITION
Mark (X) all that apply. ASCDISP
1

Routine discharge to customary residence

6

Procedure cancelled on arrival to ambulatory surgery
unit/location

2

Discharge to observation status

3

Admitted to hospital as inpatient

4

Referred to ED

Incomplete or inadequate medical evaluation

5

Surgery terminated

Surgical issue

Reason for surgery termination: TERMINATE

Other

Reason for cancellation: CANCELED
Patient not n.p.o./fasting

Unknown

Allergic reaction
Unable to intubate

7

Other

Other

8

Unknown

Unknown

FOLLOW-UP INFORMATION
Did someone attempt to follow-up with the
patient
within 24 hours after the surgery? Mark (X) one
box.

LEARNED
1

FUSURG
1
2
3

What was learned from this follow-up? Mark (X) all that apply.

Yes
No
Unknown

2
3
4

Unable to reach patient

Patient reported no medical or surgical problems
Patient reported medical or surgical problems and sought medical care
Patient reported medical or surgical problems and was advised
by ambulatory surgery staff to seek medical care
5
Patient reported medical or surgical problems, but no follow-up medical care was
needed
6
Other
7
Unknown