2016 Outpatient Department Patient Record Form

Attachment G: Outpatient Department Patient Record

SAMPLE
NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2016 OUTPATIENT 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 (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
Date of Visit
Mont
h

Day
VDAT
E

Sex SEX
1
Female – Is patient
pregnant?
PREG
1
Yes – Specify
gestation
week
GESTWK

Year

2 0 1

Date of Birth
Month

Day

Year

BDATE

2

Age AGE/AGET

1
2
3

Zip Code

PATIENT_NUMBER

2
No
Male

Ethnicity ETHNIC
1
Hispanic or Latino
2
Not Hispanic or Latino

Years
Months
Days

PATZIP

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

MULTIRACE

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 statebased
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

BIOMETRICS/VITAL SIGNS
Height

Weight
HTFT ft

HTINCG

in

Temperature

WTLBCG

OR
HTCM

lb

WTOZ

oz

TEMP

Blood pressure
Systolic
BPSYS

Diastolic

/

BPDIAS

OR
cm

WTKG

kg

WTGM

gm

REASON FOR VISIT
List the first 5 reasons for visit (i.e., complaint(s), symptom(s), problem(s), concern(s) of Major reason for this visit MAJOR
the patient in the order in which they appear. Start with the chief complaint and then move
1
New problem (<3 mos. onset)
to the patient history or history of present illness (HPI) for additional reasons.
2
Chronic problem, routine
First:
1. VRFV1 / VRFV1_LKUP
3
Chronic problem, flare-up
4
Pre-surgery
Other: 2. VRFV2 / VRFV2_LKUP
5
Post-surgery
Other: 3. VRFV3 / VRFV3_LKUP
6
Preventive care (e.g., routine, prenatal,
well-baby, screening, insurance,
Other: 4. VRFV4 / VRFV4_LKUP
general
exams)
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)
(1
)VCAUSE

CONTINUITY OF CARE
Is this clinic the patient’s primary care provider? PRIMCARE

Has the patient been seen in this clinic before? SENBEFOR

1
2
3

1

Yes
No
Unknown
Was patient referred for this visit? REFER
1
Yes
2
No
3
Unknown

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.
Primar 1
y: .
2
Other:
.
3
Other:
.
4
Other:
.
5
Other:
.

VDIAG1 / VDIAG1_LKUP
VDIAG2 / VDIAG2_LKUP
VDIAG3 / VDIAG3_LKUP
VDIAG4 / VDIAG4_LKUP
VDIAG5 / VDIAG5_LKUP

CONDITIONS

Regardless of the diagnoses previously entered, does the patient now have – Mark (X) all that apply. PATIENT_HAVE
1
Alcohol misuse, abuse, or dependence
6
Autism spectrum disorder
16
Diabetes mellitus (DM), Type
2
Alzheimer’s disease/Dementia
unspecified
7
Cancer
3
Arthritis
17
End-stage renal disease (ESRD)
8
Cerebrovascular
4
Asthma
disease/History of stroke (CVA) 18
Hepatits B
or transient ischemic attack
Asthma severity:
Asthma control:
19
Hepatits C
(TIA)
ASTH_SEV
ASTH_CON
20
History of pulmonary embolism
Intermittent
Well controlled
9
Chronic kidney disease (CKD)
(PE), deep vein thrombosis (DVT),
Mild persistent
Not well controlled
10
Chronic obstructive pulmonary
or venous thromboembolism (VTE)
Moderate
Very poorly
disease (COPD)
21
HIV infection/AIDS
persistent
controlled
11
Congestive heart failure (CHF) 22
Hyperlipidemia
Other – Specify

Severe
persistent
Other – Specify

12

None recorded

ASTH_SEV_SP

5

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

ASTH_CON_SP

13
14
15

None recorded
Attention
deficit
disorder
(ADD)/
Attention
deficit
hyperactivity
disorder
(ADHD)

23
24
25
26
27
25

Hypertension
Obesity
Obstructive sleep apnea (OSA)
Osteoporosis
Substance abuse or dependence
None of the above

8SERVICES
Enter all examinations/screenings, laboratory tests, imaging, procedures,treatment,health education/counseling,and other services not listed
ORDERED OR PROVIDED. DIAG_SERVICE
Laboratory Tests
(cont.)

Laboratory Tests (cont.)

Procedures (cont.)

Treatments (cont.)

Other services not listed

Examinations/

34

TSH/Thyroid panel

52

68

85

Screenings

16

35

Urinalysis (UA) or
urine dipstick

Radiation
therapy

Yes

69

Wound care

36

Vitamin D test

No

1

2

NO SERVICES

CMP
(Comprehensive
metabolic panel)

Alcohol misuse
screening
(includes AUDIT,
MAST, CAGE,
T-ACE)

17
18

Culture, blood

3

Breast

19

Culture, throat

4

Depression
screening

20

Culture, urine

21

Culture, other

22

Glucose, serum

5
Domestic
violence
screening
6

Foot

7

Neurologic

8

Pelvic

9

Rectal

Creatinine/Renal
function panel

23

Gonorrhea test

24

HbA1C
(Glycohemoglobi
n)

25

Hepatitis testing/
panel

10

Retinal/Eye

26

HIV test

11

Skin

27

HPV DNA test

28

Lipid profile/panel

29

Liver enzymes/
Hepatic function
panel

30

PAP test

12

Substance abuse
screening
(includes
NIDA/NM
ASSIST,
CAGE-AID,
DAST-10)

31

Pregnancy/HCG
test

Laboratory Tests
13

BMP (Basic
metabolic panel)

32

PSA (prostate
specific antigen)

14

CBC

33

Rapid strep test

15

Chlamydia test

Excision of
tissue

Imaging

53

Fetal monitoring

Health Education/
Counseling

37

Bone mineral
density

54

Peak flow

70

55

Sigmoidoscopy

Alcohol abuse
counseling

38

CT scan

Yes

71

39

Echocardiogram

Asthma
education

No

40

Other ultrasound

72

56

Spirometry

41

Mammography

57

Tonometry

Asthma action
plan given to
patient

42

MRI

58

43

X-ray

Tuberculosis
skin testing/
PPD

Procedures
44

Audiometry

45

Biopsy

59

Yes

Yes

No
46

Cardiac stress test

47

Colonoscopy

48

49

No

Diabetes
education

74

Diet/Nutrition

75

Exercise

76

Family planning/
Contraception

77

Genetic
counseling

78

Growth/
Development

Treatments

Yes

60

Cast/splint/wrap

79

Injury prevention

No

61

Complementary
and alternative
medicine (CAM)

80

STD prevention

81

Stress
management

82

Substance
abuse
counseling

83

Tobacco use/
Exposure

84

Weight reduction

Cryosurgery
(cryotherapy)/
Destruction of
tissue

62

Durable medical
equipment

EKG/ECG

63

Home health
care

Electroencephalog
ram (EEG)

64

Mental health
counseling,
excluding
psychotherapy

50

51

Upper
gastrointestinal
endoscopy
(EGD)

73

Electromyogram
(EMG)
65

Occupational
therapy

66

Physical therapy

67

Psychotherapy

Other service – Specify

OTHER_SP
Other service – Specify

OTHER_SP2
Other service – Specify

OTHER_SP3
Other service – Specify

OTHER_SP4
Other 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,

NCMED

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.

New

(1)
(2)

VMED1 / VMEDOTH1
VMED2 / VMEDOTH2

1
1

2
2

(3)

VMED3 / VMEDOTH3

1

2

Continued

(4)

VMED4 / VMEDOTH4

1

2

(5)

VMED5 / VMEDOTH5

1

2

(5)

VMED6 / VMEDOTH6

1

2

(7)

VMED7 / VMEDOTH7

1

2

VMED8 / VMEDOTH8

1

2

VMED9 / VMEDOTH9

1

2

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

1

2

(8)
(9)
(1030)

PROVIDERS
Mark (X) all providers seen at this visit PROV_SEEN
1
2
3
4

Physician
Physician assistant (PA)
Nurse practitioner (NP)/Midwife (CNM)
RN/LPN

5
6
7

Mental health provider
Other
NONE

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

Return 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

6
7
8
9

Return at unspecified time
Return as needed (p.r.n.)
Refer to ER/Admit to hospital
Other

TESTS
Most recent result

Date of blood draw

Total Cholesterol CHOL

1

Yes

2

None found

CHOLRES

mg/dL

CHOLDATE
mm

dd

High density lipoprotein (HDL) HDL

1
2

Yes

HDLRES

None found

mg/dL

HDLDATE
mm

dd

Low density lipoprotein (LDL) LDL

1

Yes

2

None found

LDLRES

mg/dL

LDLDATE
mm

dd

Triglycerides TGS

1
2

Yes

TGSRES

mg/dL

None found

TGSDATE
mm

dd

HbA1c (Glycohemoglobin) A1C

1
2

Yes

A1CRES

%

None found

A1CDATE
mm

dd

Blood glucose (BG) FBG

1
2

Yes

FBGRES

mg/dL

None found

FBGDATE
mm

dd

Serum creatinine SERUM

1

Yes

2

None found

SERUMRES

SERUMDATE

mg/dL

CPT CODES

mm

dd

2 0 1
yyyy
0
1
2 0 1
yyyy
0
1
2 0 1
yyyy
0
1
2 0 1
yyyy
0
1
2 0 1
yyyy
0
1
2 0 1
yyyy
0
1
2 0 1
yyyy
0
1

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

CPTCODE1

CPTCODE4

CPTCODE7

CPTCODE10

CPTCODE13

CPTCODE16

CPTCODE2

CPTCODE5

CPTCODE8

CPTCODE11

CPTCODE14

CPTCODE17

CPTCODE3

CPTCODE6

CPTCODE9

CPTCODE12

CPTCODE15

CPTCODE18