Att G1- 2021 NAMCS PRF

Attachment G2: 2021 NAMCS PRF

NAMCS-73
(11-10-2020)

Form Approved: OMB No. 0920-0234
Expiration date: 05/31/2022

SAMPLE

National Ambulatory Medical Care Survey
2021 PATIENT RECORD
Notice – CDC estimates the average public reporting burden for this collection of information as 1 minute per response, including the time for reviewing
instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-0234).
Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals,
a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in
identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C.
242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018
(Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject
to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

PATIENT INFORMATION
Patient medical record No.

1
2

Date of visit
Month
Day

3

Year

Sex

202

1

ZIP Code Enter "1" if homeless.

Date of birth
Month
Day

Expected source(s) of
payment for THIS VISIT –
Mark (X) all that apply.

Ethnicity
Age

Year
2

Years
Months
Days

1
2

Hispanic or Latino
Not Hispanic or Latino

1
2

Private insurance
Medicare
Medicaid or CHIP or
other state-based
program
Workers’ compensation
Self-pay
No charge/Charity
Other
Unknown

1

Race – Mark (X) all that
apply.
Female – Is patient pregnant?
White
1
1
Yes – Specify gestation –
Gestation week refers to the
Black or African
2
number of weeks plus 2 that the
American
offspring has spent developing
Asian
3
in the uterus
Native Hawaiian or
4
Other Pacific Islander
2
No
American Indian
5
Male
or Alaska Native

Tobacco use

2
3

4
5
6
7
8

Not current
Current

Prior tobacco use
1
Never
Former
2
Unknown
3

BIOMETRICS/VITAL SIGNS
Blood pressure – If multiple measurements
are taken, record the last measurement.

Temperature
Height

Weight

in

ft
OR
cm

lb
OR

oz

kg

gm

1

˚C
˚F

2

Systolic

Diastolic

/

REASON FOR VISIT
List the first 5 reasons for visit (i.e., symptoms, problems, issues, concerns of the patient)
in the order in which they appear. Start with the chief complaint and then move to the
patient history for additional reasons.
(1) Most important
(2) Other
(3) Other

Major reason for this visit
New problem (<3 mos. onset)
1
2
Chronic problem, routine
3
Chronic problem, flare-up
4
Pre-surgery
Post-surgery
5
Preventive care (e.g., routine prenatal, well-baby,
6
screening, insurance, general exams)

(4) Other
(5) Other

INJURY
Is this visit related to an injury/trauma,
overdose/poisoning, or adverse effect
of medical/surgical treatment?
1
Yes, injury/trauma
2
Yes, overdose/poisoning
Yes, adverse effect of medical or
3
surgical treatment or adverse effect of
medicinal drug
No
4
5
Unknown SKIP to Continuity of Care

}

Did the injury/trauma,
overdose/poisoning or adverse
effect occur within 72 hours
prior to the date and time of
this visit?
Yes
1
2
No
Don’t Know
3

Is this injury/trauma
or overdose/poisoning
intentional
or unintentional?
Intentional
1
2
Unintentional (e.g.,
accidental)
3
Intent unclear

}

For adverse effect SKIP to Cause

What was the intent of the
injury/trauma or overdose/poisoning?
Suicide attempt with intent to die
1
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,
poisoning, or adverse effect. Examples: 1 – Injury/Trauma (for example, patient fell while walking down stairs at home and sprained her ankle; patient was bitten by a spider);
2 – Overdose/Poisoning (for example, 4 year old child was given adult cold/cough medication and became lethargic; child swallowed large amount of liquid cleanser and
began vomiting); 3 – Adverse effect (for example, patient developed a rash on his arm 2 days after taking penicillin for an ear infection)

DIAGNOSIS

CONTINUITY OF CARE
Is the sampled provider the
patient’s primary care provider?
1
Yes – SKIP to
No
2
Don’t Know
3
Was patient referred for this
visit?
3
Don’t Know
1
Yes
2
No

}

Has the patient been seen in this practice
before?
Yes, established patient –
1
How many past visits to this practice
in the last 12 months? (Exclude this visit.)

2

Visits
No, new patient

As specifically as possible, list diagnoses related
to this visit including chronic conditions.
(1) Primary diagnosis
(2) Other
(3) Other
(4) Other
(5) Other

Regardless of the diagnoses previously entered, does the patient now have –
Mark (X) all that apply.
Alcohol misuse, abuse
Chronic obstructive
30
11
20
History of pulmonary embolism
or dependence
pulmonary disease (COPD)
(PE) or deep vein thrombosis
(DVT), or venous
12
Alzheimer’s disease/Dementia 21
Congestive heart failure (CHF)
thromboembolism (VTE)
22
Coronary artery disease (CAD),
Arthritis
13
31
HIV Infection/AIDS
ischemic heart disease (IHD) or
Asthma
14
history of myocardial infarction (MI) 32
Hyperlipidemia
15
Attention deficit disorder
23
Depression
Hypertension
33
(ADD)/Attention deficit
Diabetes mellitus (DM), Type 1
hyperactivity disorder (ADHD) 24
Obesity
34
25
Diabetes mellitus (DM), Type 2
16
Autism spectrum disorder
35
Obstructive sleep apnea (OSA)
Diabetes mellitus (DM), Type
26
17
Cancer
36
Osteoporosis
unspecified
Cerebrovascular disease/History
18
37
Substance abuse or
27
End-stage renal disease (ESRD)
of stroke (CVA) or transient
dependence
ischemic attack (TIA)
Hepatitis B
28
None of the above
38
19
Chronic kidney disease (CKD)
29
Hepatitis C

Complete if Asthma box is marked.
Asthma 1
Intermittent
severity: 2
Mild persistent
3
Moderate persistent
Severe persistent
4
5
Other – Specify

Asthma
control:

6

None recorded

1
2
3
4

Well controlled
Not well controlled
Very poorly controlled
Other – Specify

5

None recorded

SERVICES
Mark (X) all Examinations/Screenings, Laboratory tests, Diagnostic Imaging, Procedures, Treatments, and Health education/Counseling ORDERED
OR PROVIDED.
NO SERVICES
Examinations/Screenings:
Alcohol misuse screening
12
(includes AUDIT, MAST,
CAGE, T-ACE)
Breast
13
Depression screening
14
Domestic violence screening
15
Foot
16
Neurologic
17
18
Pelvic
Rectal
19
Retinal/Eye
20
21
Skin
22
Substance abuse screening
(includes NIDA/NM ASSIST,
CAGE-AID, DAST-10)
Laboratory tests:
Basic metabolic panel (BMP)
23
CBC
24
Chlamydia test
25
Comprehensive metabolic
26
panel (CMP)
27
Creatinine/Renal
function panel
Culture, blood
28
29
Culture, throat
30
Culture, urine
31
Culture, other
32
Glucose, serum
Gonorrhea test
33
HbA1c (Glycohemoglobin)
34
Hepatitis testing/panel
35
36
HIV test
HPV DNA test
37
11

Lipid profile/panel
39
Liver enzymes/Hepatic
function panel
40
PAP test
41
Pregnancy/HCG test
42
PSA (prostate specific antigen)
43
Rapid strep test
44
TSH/Thyroid panel
Urinalysis (UA) or urine dipstick
45
46
Vitamin D test
Diagnostic Imaging:
47
Bone mineral density
48
CT scan
49
Echocardiogram
Other Ultrasound
50
51
Mammography
52
MRI
53
X-ray
Procedures:
54
Audiometry
55
Biopsy
Biopsy provided?
1
Yes
No
2
56
Cardiac stress test
57
Colonoscopy
Colonoscopy provided?
1
Yes
No
2
Cryosurgery (cryotherapy)/
58
Destruction of tissue
59
EKG/ECG
38

Electroencephalogram (EEG)
Electromyogram (EMG)
61
Excision of tissue
62
Excision of tissue provided?
1
Yes
No
2
Fetal monitoring
63
64
Peak flow
65
Sigmoidoscopy
Sigmoidoscopy provided?
1
Yes
No
2
66
Spirometry
67
Tonometry
68
Tuberculosis skin testing/PPD
69
Upper gastrointestinal
endoscopy/EGD
Upper gastrointestinal
endoscopy/EGD provided?
1
Yes
No
2
Treatments:
Cast/splint/wrap
70
Complementary and alternative
71
medicine (CAM)
72
Durable medical equipment
Home health care
73
Mental health counseling,
74
excluding psychotherapy
75
Occupational therapy
76
Physical therapy
77
Psychotherapy
Radiation therapy
78
Wound care
79
60

PROVIDERS

MEDICATIONS & IMMUNIZATIONS

Were any prescription or non-prescription drugs ORDERED or PROVIDED (by any
Mark (X) all
route of administration) at this visit? Include Rx and OTC drugs, immunizations, allergy
providers seen at
shots, oxygen, anesthetics, chemotherapy, and dietary supplements that were ordered,
this visit.
supplied, administered, or continued during this visit. Include drugs prescribed at a previous
Physician
1
visit if the patient was instructed at THIS VISIT to continue with the medication.
2
Physician
1
Yes
assistant
2
No
Nurse
New Continued 3
List up to 30 drugs.
practitioner/
Midwife
(1)
1
2
4
RN/LPN
(2)
1
2
5
Mental health
(3)
1
2
provider
(4)
6
Other
1
2
7
None
(5)
1
2

(30)

1

2

1

2

1

2

Health education/Counseling:
80
Alcohol abuse counseling
81
Asthma education
Asthma action plan given to patient
82
Diabetes education
83
Diet/Nutrition
84
Exercise
85
Family planning/Contraception
86
87
Genetic counseling
88
Growth/Development
89
Injury prevention
90
STD prevention
91
Stress management
92
Substance abuse counseling
93
Tobacco use/Exposure
94
Weight reduction
Other services not listed:
95
Other service – Specify

Up to 5 other services
can be listed.

TIME SPENT WITH PROVIDER
Enter estimated time spent with
Minutes sampled provider – Enter 0 if
sampled provider not seen. Leave
blank if time spent with sampled
provider is unknown.

VISIT DISPOSITION
Mark (X) all that apply.
1
Return to referring physician/provider
Refer to other physician/provider
2
Return in less than 1 week
3
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

TESTS
Was blood for the following laboratory tests
drawn on the day of the sampled visit or
during the 12 months prior to the visit?
Total Cholesterol
1

1

2

2

High density
lipoprotein (HDL)

1
2

3

Low density
lipoprotein (LDL)

1
2

Triglycerides (TGs)

4

1
2

5

HbA1c
Glycohemoglobin

1
2

6

Blood glucose (BG)

1
2

Serum creatinine

7

1
2

Most recent result

Month

Yes
None found

Day

Month

Day

Month

Day

Month

Day

%
Day

2

mg/dL
μmol/L

Year

20

mg/dL
1

Year

20
Month

.

Year

20

mg/dL

Yes
None found

Year

20

mg/dL

.

Year

20

mg/dL

Yes
None found

Year

20
Month

Yes
None found

Yes
None found

Day

mg/dL

Yes
None found

Yes
None found

Date of blood draw

Month

Day

Year

20

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

NAMCS-73 (11-10-2020)