Form 0920-0278 Attachment B - 2016 NHAMCS ED PRF Changes

Attachment B
2016 NHAMCS Emergency Department Patient Record Form (PRF) Changes
Proposed changes are indicated in RED.


Modified-Patient Information Questions –Dates and Times, Patient Residence
“Patient Information” Section
TSDATE, TS_TIME, EDDATE, ED_TIME:
Old
New


Seen by MD/DO/PA/NP





Date and time of ED departure, if released or
transferred

New

RESIDNCE:
Old
1-Private residence
2-Nursing home
3-Homeless
4-Other
5-Unknown




First provider (physician/APRN/PA)
contact

ED departure

New
1-Private residence
2-Nursing home
3-Homeless/Homeless shelter
4-Other
5-Unknown

Modified-Triage – Seen in ED within last 72 hours
“Triage” Section
SEEN72:
Old
Was patient seen in this ED within the last 72 hours
and discharged?



New
Was patient seen in this ED within the last 72
hoursand discharged?

Modified - Injury Question
“Injury” Section
INJURY72:
Old
Did the injury/trauma, overdose/poisoning, or
adverse effect occur within 72 hours prior to the
date and time of this visit?
1-Yes
2-No
3-Unknown
4-Not applicable

New
Did the injury/trauma, overdose/poisoning, or
adverse effect occur within 72 hours prior to
the date and time of this visit?
1-Yes
2-No
3-Unknown
4-Not applicable



Modified-Checkbox list of Diagnostics
“Diagnostics” Section
DIAG_SERVICES:
Old
Blood tests:

New

Arterial blood gases

Arterial blood gases (ABG)

BAC (blood alcohol concentration)

BAC (Blood alcohol concentration)

Basic metabolic panel (BMP)

Basic metabolic panel (BMP)

Laboratory tests:

…

Blood culture
BNP (brain natriuretic peptide)

BNP (Brain natriuretic peptide)

BUN/Creatinine

Creatinine/Renal function panel

Cardiac enzymes

Cardiac enzymes

CBC

CBC

Comprehensive metabolic panel (CMP)

Comprehensive metabolic panel (CMP)

…

Culture, blood

…

Culture, throat

…

Culture, urine

…

Culture, wound

…

Culture, other

D-dimer

D-dimer

Electrolytes

Electrolytes

Glucose

Glucose, serum

Lactate

Lactate

Liver function tests

Liver enzymes/Hepatic function panel

Prothrombin time/INR

Prothrombin time (PT/PTT/INR)

Other blood test

Other blood test
Other tests:

Other tests:

Cardiac monitor

Cardiac monitor

EKG/ECG

EKG/ECG

HIV test

HIV test

Influenza test

Influenza test

Pregnancy/HCG test

Pregnancy/HCG test
…

Throat culture
Toxicology screen

Toxicology screen

Urinalysis (UA)

Urinalysis (UA) or urine dipstick

Urine culture

…

…

Wound culture

…

Other culture
Other test/service

Other test/service
Imaging:



Imaging:

X-ray
CT scan

X-ray
CT scan

MRI

MRI

Ultrasound

Ultrasound

Other imaging

Other imaging

Modified-Procedures
“Procedures” Section
PROCEDURES:
Old
NONE
BiPAP/CPAP
Bladder catheter
Cast, splint, or wrap
Central line
CPR
Endotracheal intubation
Incision & drainage (I&D)
IV fluids
Lumbar puncture
Nebulizer therapy
Pelvic exam
Skin adhesives
Suturing/Staples
Other



New
NONE
BiPAP/CPAP
Bladder catheter
Cast, splint, or wrap
Central line
CPR
Endotracheal intubation
Incision & drainage (I&D)
IV fluids
Lumbar puncture (LP)
Nebulizer therapy
Pelvic exam
Skin adhesives
Suturing/Staples
Other

Modified-Last Vital Signs Taken
“Last Vital Signs Taken” Section
VITALSD :
Old
Were vital signs taken at discharge?
1-Yes
2-No

New: VITALS2
Does the chart contain vital signs taken
after triage?
1-Yes
2-No
All associated variables will also be
changed:
TEMP2 (write-in) Temperature
TTEMP2 (write-in) Celsius or Fahrenheit

PULSE2 (write-in) Heart rate/Pulse beats per
minute 998= DOPP, DOPPLER
RESPR2 (write-in) Respiratory rate breaths
per minute
BPSYS2 (write-in) Blood pressure Systolic
BPDIAS2 (write-in) Blood pressure Diastolic



Modified-Checkbox list of Visit Disposition
“Visit Disposition” Section
VISIT_DISP:
Old
No follow-up planned
Return to ED
Return/Refer to physician/clinic for FU
Left before triage
Left after triage
Left AMA
DOA
Died in ED
Return/Transfer to nursing home
Transfer to psychiatric hospital
Transfer to other hospital
Admit to this hospital
Admit to observation unit then hospitalized
Admit to observation unit then discharged
Other



Old
No follow-up planned
Return to ED
Return/Refer to physician/clinic for FU
Left without being seen (LWBS)
Left before treatment complete (LBTC)
Left AMA
DOA
Died in ED
Return/Transfer to nursing home
Transfer to psychiatric hospital
Transfer to non-psychiatric hospital
Admit to this hospital
Admit to observation unit then hospitalized
Admit to observation unit then discharged
Other

Modified-Observation Unit Dates and Times
“Observation Unit/Care Stay” Section
EDDISDATE, EDDISTIME, OBDATE, OB_TIME:
Old
New: OBINDATE/OBINTIME
Date and time of ED departure
Date and time of observation unit/care
initiation order
Date and time of observation unit discharge
New: OBOUTDATE/OBOUTTIME
Date and time of observation unit/care
discharge order



Deleted and 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
LE_DATE, LE_TIME:
Old
Date and time bed patient actually left the ED or
observation unit

New: ADMDATE/ADMTIME
Date and time of admit order

New
Delete