2016 Emergency Department Patient Record Form

Attachment F: Emergency Department Patient Record

SAMPLE
NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2016 EMERGENCY DEPARTMENT 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 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 (09200278).

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 medical record
number

PATIENT_NUMBER

Zip Code
Date of Visit
-

Arrival

Mm VDATE dd

First provider
(physician/APRN/PA) contact

Patient Residence RESIDNCE
1
Private residence
2
Nursing home
3
Homeless/Homeless
shelter
4
Other
5
Unknown
Date of Birth BDATE
Month

Day

Year

Age AGE / AGET

1
2
3

mmTSDATEdd
mmEDDATEdd
Sex SEX
1
Female
2
Male

Time

a.m.

-

:

A_TIME

-

:

TS_TIME

-

:

ED_TIME

p.m.

Mil.

yy
yy
-

ED Departure

PATZIP

yy
Arrival by ambulance
ARRIVE
1
Yes
2
No
3
Unknown

Ethnicity ETHNIC
1
Hispanic or Latino
2
Not Hispanic or Latino
Race – Mark (X) all that apply.
1
White MULTIRACE
2
Black or African American
3
Asian
4
Native Hawaiian or Other
Pacific Islander
5
American Indian or Alaska
Native

Was patient transferred
from another hospital or
freestanding
emergency/urgent care
facility? AMBTRANSFER
1
Yes
2
No
3
Unknown

Expected source(s) of payment for this
visit. Mark (X) all that apply.
PAY_SOURCE
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

Years
Months
Days

TRIAGE
Initial vital signs
Temperature Heart rate/Pulse Respiratory rate
TEMP

PULSE

RESPR

beats per minute
998 = DOPP,
DOPPLER

breaths per minute

Pulse oximetry
POPCT

PREVIOUS CARE
Blood Pressure
Systolic
Diastolic
BPSYS

Triage level (1-5)
IMMED

/

BPDIAS

Was patient seen in this ED
in the last 72 hours?
SEEN72

1
Yes
2
No
3
Unknown
Pain scale (0-10)
PAIN

Enter 0 if No triage
Enter 99 if Unknown

(%)

Enter 99 if Unknown

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. (Enter 0 for None/No
more.) For each reason, use the lookup list to code the entry.

Episode of care EPISODE
1
2

3
(1) Most
important:

VRFV1/VRFV1_LKUP

(2) Other:

VRFV1/VRFV1_LKUP

(3) Other:

VRFV1/VRFV1_LKUP

(4) Other:

VRFV1/VRFV1_LKUP

(5) Other:

VRFV1/VRFV1_LKUP

Initial visit to this ED for problem
Follow-up visit to this ED for
problem
Unknown

INJURY/TRAUMA/OVERDOSE/POISONING/ADVERSE EFFECT
Is this visit related to an injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment? INJURY
1
2
3
4
5

Yes, injury/trauma
Yes, poisoning/overdose
Yes, adverse effect of medical or surgical
treatment or adverse effect of medicinal drug
No
Unknown

Did the injury/trauma or overdose/poisoning or adverse
effect occur within 72 hours prior to the date and time of
this visit?
INJURY72
1
2
3

Yes
No
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 or 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 by drug or non-drug toxic substance; or adverse effect of medical/surgical treatment –
Describe the place and circumstances that preceded the injury/trauma, overdose/poisoning, or adverse effect. The following are examples of each:
injury (e.g., pedestrian struck by car driven on a highway by drunk driver— indicate location of occurrence, e.g., street, highway, driveway, parking
lot); overdose/poisoning by drug (e.g., patient injected heroin in nightclub restroom and overdosed); non-drug toxic substance (e.g., child swallowed
bleach at home); adverse effect (e.g., patient developed swelling of the throat after taking their medication). Enter the primary cause on the first line,
followed by the contributing causes. Up to 5 causes may be entered.
(1)

VCAUSE

DIAGNOSIS
As specifically as possible, list all diagnoses related to this visit, including chronic conditions.
List primary diagnosis first.

ICD-9-CM
Code

Primary diagnosis:

VDIAG1 / VDIA1G_LKUP

DIAG1

(2)

Other:

VDIAG2 / VDIAG2_LKUP

DIAG2

(3)

Other:

VDIAG3 / VDIAG3_LKUP

DIAG3

(4)

Other:

VDIAG4 / VDIAG4_LKUP

DIAG4

(5)

Other:

VDIAG5 / VDIAG5_LKUP

DIAG5

(1)

Regardless of the diagnoses previously entered, does the patient now have: Mark (X) all that apply.
PAT_HAVE
1
Alcohol abuse, misuse, or dependence
13
Diabetes mellitus (DM) – Type unspecified
2

Alzheimer’s disease/Dementia

14

3

Asthma

4

Cancer

15
History of pulmonary embolism (PE), deep vein thrombosis (DVT),
or venous thromboembolism (VTE)

5

Cerebrovascular disease/History of stroke (CVA) or transient 16
ischemic attack (TIA)
17

Hyperlipidemia

6

Chronic kidney disease (CKD)

18

Hypertension

7

Chronic obstructive pulmonary disease (COPD)

19

Obesity

8

Congestive heart failure (CHF)

20

Obstructive sleep apnea (OSA)

9

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

21

Osteoporosis

22

Substance abuse or dependence

10

Depression

23

None of the above

11

Diabetes mellitus (DM) – Type I

12

Diabetes mellitus (DM) – Type II

End-stage renal disease (ESRD)

HIV infection/AIDS

DIAGNOSTIC SERVICES
Mark (X) all ORDERED or PROVIDED at this visit. DIAG_SERVICES1-34
1

NONE

Laboratory tests:

14

Culture, other

Imaging:

32

15

D-dimer

30

X-ray
CT scan

Was MRI ordered or provided
with intravenous (IV) contrast
(also written as “with
gadolinium” or “with gado”)?
MRI
1.
Yes

2

ABG (Arterial blood gases)

16

Electrolytes

31

3

BAC (Blood alcohol
concentration)

17

Glucose, serum

18

Lactate

4

BMP (Basic metabolic panel)

5

BNP (Brain natriuretic peptide)

19
Liver enzymes / Hepatic
function panel

6

CBC (Complete blood count)

7

CE (Cardiac enzymes)

What body site was
scanned during the CT
scan? CT_SCAN
Mark (X) all that apply
1.
Abdomen/Pelvis
2.
Chest
3.
Head
4.
Other

20
Prothrombin time
(PT/PTT/INR)
21 Other blood test

8
CMP (Comprehensive
metabolic panel)
9
Creatinine/Renal function panel
10
Culture, blood

Other tests:
22

Cardiac monitor

23

EKG/ECG

Was CT ordered or provided
with intravenous (IV)
contrast? CT_SCANIV

11

Culture, throat

24

HIV test

1.

Yes

12

Culture, urine

25

Influenza test

13

Culture, wound

26

Pregnancy/HCG test

2.
3.

No
Unknown

27

Toxicology screen

28
Urinalysis (UA) or urine
dipstick
29

Other test/service

PROCEDURES
Mark (X) all procedures PROVIDED at this visit. Exclude medications. PROC_PROV
1

NONE

6

CPR

11

Nebulizer therapy

2

BiPAP/CPAP

7

Endotracheal intubation

12

Pelvic exam

3

Bladder catheter

8

Incision & drainage (I&D)

13

Skin adhesives

4

Cast, splint, or wrap

9

IV fluids

14

Suturing/Staples

5

Central line

Lumbar puncture (LP)

15

Other

10

MRI

2.
3.
33

No
Unknown
Ultrasound

Who performed the
ultrasound? ULTRASOUND
1. Emergency physician
2.
3.
34

Other
Unknown
Other Imaging

MEDICATION(S) & IMMUNIZATION(S)
Enter drugs given at this visit or prescribed at ED discharge. Include Rx and OTC drugs,
immunizations, and anesthetics.

Given in
ED

Both given in ED
and Rx at
discharge

Rx at
discharge

(1)

VMED1 VMEDOTH1

GPMED1 →

1

2

3

(2)

VMED2 VMEDOTH2

GPMED2 →

1

2

3

(3)

VMED3 VMEDOTH3

GPMED3 →

1

2

3

(4)

VMED4 VMEDOTH4

GPMED4 →

1

2

3

(5)

VMED5 VMEDOTH5

GPMED5 →

1

2

3

(6)

VMED6 VMEDOTH6

GPMED6 →

1

2

3

(7)

VMED7 VMEDOTH7

GPMED7 →

1

2

3

(8)

VMED8 VMEDOTH8

GPMED8 →

1

2

3

(9)

VMED9 VMEDOTH9

GPMED9 →

1

2

3

VMED10 VMEDOTH10

GPMED10 →

1

2

3

1

2

3

1

2

3

(10)

…

(…)

GPMED30 →

VMED30 VMEDOTH30

(30)

LAST VITAL SIGNS TAKEN
Does the e chart contain vital signs taken after triage
1.
Yes
2.
No
3.
Unknown VITALS2
Temperature

Heart rate/Pulse

Temp2

Respiratory rate

Blood Pressure
Systolic

Pulse2

Respr2

beats per minute
998= DOPP, DOPPLER

breaths per minute

BPSYS2

Diastolic

/

BPDIAS2

PROVIDERS
Mark (X) all providers seen at this visit. PROV_SEEN
1

ED attending physician

4

RN/LPN

7

2

ED resident/Intern

5

Nurse practitioner (NP)

8

Other mental health provider

6

Physician assistant (PA)

9

Other provider

3

Consulting physician

EMT

VISIT DISPOSITION
Mark (X) all that apply. VISIT_DISP
1
2
3
4
5
6

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

7
8
9
home
10
11

DOA
Died in ED
Return/Transfer to nursing
Transfer to psychiatric hospital

12
13
14

Admit to this hospital
Admit to observation
unit then hospitalized
Admit to observation unit then discharged

15

Other

Transfer to other nonpsychiatric hospital

HOSPITAL ADMISSION
Admitted to: ADMIT
1
2
3

Critical care unit
Stepdown unit
Operating room

Date and time of admit order
Month

Day

ADMDATE

Year

2 0

1

Time

a.m.

p.m.

Military

4
5
6
7

Mental health or detox unit
Cardiac catheterization lab
Other bed/unit
Unknown

Date and time of hospital discharge
Month

Day

Year

2

DDATE

Admitting physician: ADMTPHYS
1
Hospitalist
2
Not hospitalist
3
Unknown

0

Time

a.m.

p.m.

Military

1

Hospital discharge status HDSTAT
1
Alive
2
Dead
3
Unknown

OBSERVATION UNIT STAY
Hospital discharge disposition ADISP
1
2
3

Home/Residence
Return/Transfer to
nursing home
Return/Transfer to
jail/prison/law
enforcement

4

5

Transfer to another
facility (not usual
place of residence)
Other

6

Unknown

Date and time of observation unit/ care initiation order
Month

Day

OBINDATE

Year

2

0

Time

a.m.

p.m.

Military

a.m.

p.m.

Military

1

Date and time of observation unit/ care discharge order
Month

Day

OBINDATE

Year

2

0

1

Time