Form 0920-0278 Attachment C - 2016 NHAMCS OPD PRF Changes

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

Modified-Checkbox list of patient’s underlying chronic conditions
“Conditions” Section
PATIENT_HAVE:
Regardless of the diagnoses previously entered, does the patient now have Mark all that apply.
Old
New
Alcohol misuse, abuse or dependence
Alcohol misuse, abuse or dependence
Alzheimer's disease/Dementia
Alzheimer's disease/Dementia
Arthritis
Arthritis
Asthma
Asthma
Autism spectrum disorder
Autism spectrum disorder
…
Attention deficit disorder (ADD)/ Attention deficit
hyperactivity disorder (ADHD)
Cancer
Cancer
Cardiac surgery history
Cardiac surgery history
Cerebrovascular disease/History of stroke Cerebrovascular disease/History of stroke (CVA) or
(CVA) or transient ischemic attack (TIA) transient ischemic attack (TIA)
Chronic kidney disease (CKD)

Chronic kidney disease (CKD)

Chronic obstructive pulmonary disease
(COPD)
Congestive heart failure (CHF)
Coronary heart disease (CAD), ischemic
heart disease (IHD) or history of
myocardial infarction (MI)
Depression
Diabetes mellitus (DM), Type I

Chronic obstructive pulmonary disease (COPD)

Diabetes mellitus (DM), Type II

Diabetes mellitus (DM), Type II

Diabetes mellitus (DM), Type unspecified

Diabetes mellitus (DM), Type unspecified

End-stage renal disease (ESRD)

End-stage renal disease (ESRD)

Congestive heart failure (CHF)
Coronary heart disease (CAD), ischemic heart disease
(IHD) or history of myocardial infarction (MI)
Depression
Diabetes mellitus (DM), Type I

…

Hepatitis B

…

Hepatitis C

History of pulmonary embolism (PE),
deep vein thrombosis (DVT), or venous
thromboembolism (VTE)
HIV Infection/AIDS
Hyperlipidemia
Hypertension
Obesity
Obstructive sleep apnea (OSA)
Osteoporosis
Substance abuse or dependence
None of the above


History of pulmonary embolism (PE), deep vein
thrombosis (DVT), or venous thromboembolism (VTE)
HIV Infection/AIDS
Hyperlipidemia
Hypertension
Obesity
Obstructive sleep apnea (OSA)
Osteoporosis
Substance abuse or dependence
None of the above

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



Modified-Checkbox list of Diagnostics
“Diagnostics” Section
DIAG_SERVICE:
 NO SERVICES

Examinations/Screenings:
 Alcohol misuse screening (includes AUDIT, MAST, CAGE, T-ACE)
 Breast
 Depression screening
 Domestic violence screening
 Foot
 Neurologic
 Pelvic
 Rectal
 Retinal/Eye
 Skin
 Substance abuse screening (includes NIDA/NM ASSIST, CAGE-AID, DAST-10)

Laboratory tests:
 Basic metabolic panel (BMP)
 CBC
 Chlamydia test
 Comprehensive metabolic panel (CMP)
 Creatinine /Renal function panel
 Culture, blood
 Culture, throat
 Culture, urine
 Culture, other
 Glucose, serum
 Gonorrhea test
 HbA1c (Glycohemoglobin)
 Hepatitis testing/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 (UA) or urine dipstick
 Vitamin D test
Imaging:
 Bone mineral density
 CT scan
 Echocardiogram
 Other ultrasound
 Mammography
 MRI
 X-ray
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)

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 education
 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-Visit disposition
“Visit disposition” Section
VISIT_DISP:
Old
Mark (X) all that apply.
1. Returning to referring physician
2. Refer to other physician
3. Return in less than 1 week
4. Return in 1 week to less than 2
months
5. Return in 2 months or greater
6. Return at unspecified time
7. Return as needed (p.r.n.)
8. Refer to ER/Admit to hospital
9. Other



New
1.
2.
3.
4.
5.
6.
7.
8.
9.

Mark (X) all that apply
Returning to referring physician/provider
Refer to other 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.)
Refer to ER/Admit to hospital
Other

Modified-Tests
“Tests” Section
LAB_TEST:
CHOLDATE-SERUMDATE:
Old
Date of Test

New
Date of blood draw