ED PRF sample card 2021

NHAMCS-173
(11-8-2019)

Form Approved: OMB No. 0920-0278
Expiration date: 06/30/2021

SAMPLE

National Hospital Ambulatory Medical Care Survey
2021 EMERGENCY DEPARTMENT 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 NE, MS D-74,
Atlanta, GA 30333; ATTN: PRA (0920-0278).
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)). 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 number
ZIP Code
Date of birth
Month Day
Year

Date and time of visit
Month
Arrival
First provider
(physician/APRN/
PA) contact

Day

a.m. p.m. Military

Time

Year

202

:

202

:

202

:

}

Temperature

1

2

Blood pressure
Diastolic
Systolic

/

˚C
˚F

Heart rate

Pulse oximetry

Ethnicity

1

Private residence 1 Female
Nursing home
Male
2
Homeless/
Homeless shelter
4
Other
5
Unknown
Race – Mark (X) all that apply.
4
White
1
2
Black or African American 5
3
Asian

1

2
3

2

Hispanic
or Latino
Not
Hispanic
or Latino

TRIAGE
Enter "998" for DOPP or DOPPLER. Respiratory rate
Triage level
breaths per
beats per
(1–5)
minute
minute
Enter "0" if no triage.
Enter "9" if unknown.
Was patient seen in this ED within the

%
Percent of oxyhemoglobin saturation;
value is usually between 80–100%.

Age

Years
Months
Days

1
2
3

Native Hawaiian or
Other Pacific Islander
American Indian or
Alaska Native
Expected source(s) of payment for THIS VISIT – Mark (X) all that apply.
1
Private insurance
Workers’ compensation 7 Other
4
2
Medicare
Self-pay
Unknown
8
5
3
Medicaid or CHIP or
6
No charge/Charity
other state-based program

ED departure
Was patient transferred from
Arrival by ambulance
another hospital or urgent care
1
Yes
facility?
2
No
SKIP to Expected
3
Unknown
Unknown source(s) of payment 1 Yes
3
No
Not applicable
2
4
Initial vital signs

Patient residence Sex

last 72 hours?
1

Yes

2

No

3

Pain scale
(0–10)

Enter "99" if
unknown.

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.

Episode of care
1

Initial visit to
this ED
for problem

2

Follow-up visit
to this ED
for problem
Unknown

(1) Most important:
(2) Other:
(3) Other:

3

(4) Other:
(5) Other:

INJURY
Is this visit related to an
Did the injury/trauma,
Is this injury/trauma or
What was the intent of the
injury/trauma, overdose/poisoning, overdose/poisoning, or
overdose/poisoning
injury/trauma or overdose/poisoning?
or adverse effect of
adverse effect occur within
intentional or unintentional? 1 Suicide attempt with intent to die
medical/surgical treatment?
72 hours prior to the date
1
Intentional
Intentional self-harm without intent to die
2
and time of this visit?
1
Yes, injury/trauma
Unintentional (e.g.,
2
Unclear if suicide attempt or intentional
3
2
Yes, overdose/poisoning
1
Yes
accidental)
self-harm without intent to die
3
Yes, adverse effect of medical or
No
2
Intent unclear
3
Intentional harm inflicted by another
4
surgical treatment or adverse effect 3 Unknown
person (e.g., assault, poisoning)
of medicinal drug
Intent unclear
5
No
4
SKIP to Diagnosis
For adverse effect SKIP to Cause
5
Unknown
Cause of injury/trauma, overdose/poisoning, or adverse effect of medical/surgical treatment – Describe the place and circumstances
that preceded the event. 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., 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 (e.g., patient developed a rash on his arm 2 days after taking penicillin for an ear infection)

}

}

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

DIAGNOSIS
Does patient have – Mark (X) all that apply.
1
Alcohol misuse, abuse, or
Diabetes mellitus (DM), Type 1
11
dependence
Diabetes mellitus (DM), Type 2
12
Diabetes mellitus (DM), Type unspecified
13
Alzheimer’s disease/Dementia
2
End-stage renal disease (ESRD)
14
Asthma
3
History of pulmonary embolism (PE),
15
4
Cancer
deep vein thrombosis (DVT), or venous
Cerebrovascular disease/History
5
thromboembolism (VTE)
of stroke (CVA) or transient ischemic
16
HIV infection/AIDS
attack (TIA)
Hyperlipidemia
17
Chronic kidney disease (CKD)
6
18
Hypertension
7
Chronic obstructive pulmonary
Obesity
19
disease (COPD)
20
Obstructive sleep apnea (OSA)
8
Congestive heart failure (CHF)
Osteoporosis
21
9
Coronary artery disease (CAD),
Substance abuse or dependence
22
ischemic heart disease (IHD) or
23
None of the above
history of myocardial infarction (MI)
10
Depression
2019 ED

DIAGNOSTIC SERVICES
Diagnostic Services – Mark (X) all Laboratory tests, Other tests,
and Imaging ORDERED or PROVIDED.
32
MRI
1
NONE
Other tests:
Was MRI
Cardiac monitor
22
Laboratory tests:
ordered/provided
EKG/ECG
23
2
Arterial blood gases
with intravenous (IV)
HIV test
(ABG)
24
contrast (also written
3
BAC (Blood alcohol
25
Influenza test
as "with gadolinium"
concentration)
26
Pregnancy/HCG test
or "with gado")?
4
Basic metabolic
27
Toxicology screen
1
Yes
panel (BMP)
28
Urinalysis (UA) or
2
No
5
BNP (brain
urine dipstick
3
Unknown
natriuretic peptide)
Other test/service
29
33
Ultrasound
6
Creatinine/Renal
Who performed
Imaging:
function panel
the ultrasound?
30
X-ray
Cardiac enzymes
7
Emergency
1
31
CT scan
CBC
8
physician
Was CT
Comprehensive
9
Other provider
2
ordered/provided with
metabolic panel (CMP)
intravenous (IV) contrast? 34 Other imaging
10
Culture, blood
Yes
1
Culture, throat
11
No
2
12
Culture, urine
Unknown
3
13
Culture, wound
What body site was
14
Culture, other
scanned during the CT
15
D-dimer
scan? Mark (X) all that
16
Electrolytes
apply.
Glucose, serum
17
Abdomen/Pelvis
1
Lactate
18
Chest
2
Liver enzymes/Hepatic
19
Head
3
function panel
Other
4
20
Prothrombin time
(PT/PTT/INR)
21
Other blood test

MEDICATIONS & IMMUNIZATIONS
List up to 30 drugs given at this visit or prescribed at ED discharge.
Include Rx and OTC drugs, immunizations, and anesthetics.
When given?
Mark (X) all that apply.
Given
in ED

NONE
(1)

1

2

(2)

1

2

(3)

1

2

(4)

1

2

(5)

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

PROCEDURES
Procedures – Mark (X) all PROVIDED at this visit. (Exclude medications.)
11
Nebulizer therapy
1
NONE
6
CPR
2
BiPAP/CPAP
Endotracheal intubation 12 Pelvic exam
7
3
Bladder catheter 8 Incision & drainage (I&D) 13 Skin adhesives
4
Cast, splint, wrap 9 IV fluids
14
Suturing/Staples
5
Central line
15
Other
10
Lumbar puncture (LP)

VITALS AFTER TRIAGE
Does the chart contain vital signs
taken after triage?
1
Yes –
2
No
Temperature
1
˚C
2
˚F
Heart rate Enter "998" for DOPP or
DOPPLER.
beats per minute
Respiratory rate
breaths per minute
Blood pressure
Diastolic
Systolic

Rx at
discharge

(30)

DISPOSITION

PROVIDERS
Mark (X) all providers
seen at this visit.
1
ED attending physician
2
ED resident/Intern
3
Consulting physician
4
RN/LPN
5
Nurse practitioner
6
Physician assistant
7
EMT
8
Other mental
health provider
9
Other

Mark (X) all that apply.
1
2
3
4
5
6
7
8
9
10
11

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

12
13
14
15

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

/
OBSERVATION UNIT STAY
Date and time of observation unit/care discharge order
Month Day
Year
a.m. p.m. Military
Time

Date and time of observation unit/care initiation order
a.m. p.m. Military
Month Day
Year
Time

202
1

202

:

Unknown

:

Unknown

1

HOSPITAL ADMISSION
Complete if the patient was admitted to this hospital at this ED visit. – Mark (X) "Unknown" in each item, if efforts have been exhausted to collect the data.
Admitted to:
1
2
3
4
5
6
7

Critical care unit
Stepdown unit
Operating room
Mental health or detox unit
Cardiac catheterization lab
Other bed/unit
Unknown

Admitting physician
1
Hospitalist
Not hospitalist
2
Unknown
3

Date and time of admit order
Month Day
Year

1

Unknown

Hospital discharge date
Month Day
Year

202
1

Unknown

Principal hospital discharge diagnosis

1

Unknown

Hospital discharge status/disposition

{

1

1
2
3

Alive
Dead
Unknown

NHAMCS-173 (11-8-2019)

2
3
4
5

a.m. p.m. Military

Time

202

Home/Residence
Return/Transfer to nursing home
Transfer to another facility (not usual place of residence)
Other
Unknown

: