Attachment F_Electronic Health Record (EHR) Variable List

Attachment F_Electronic Health Record (EHR) Variable List.xlsx

National Ambulatory Medical Care Survey (NAMCS)

Attachment F_Electronic Health Record (EHR) Variable List

OMB: 0920-0234

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Data Item Xpath Section CDA Template Comments
Patient First Given Name /ClinicalDocument/recordTarget/patientRole/patient/name/given (Header) National Health Care Surveys (V2)
Patient Second Given Name (midde name) /ClinicalDocument/recordTarget/patientRole/patient/name/given[2] (Header) National Health Care Surveys (V2)
Patient Surname (last name) /ClinicalDocument/recordTarget/patientRole/patient/name/family (Header) National Health Care Surveys (V2)
Patient Generational Suffix (eg Jr, Sr) /ClinicalDocument/recordTarget/patientRole/patient/name/suffix (Header) National Health Care Surveys (V2)
Patient Address 1 /ClinicalDocument/recordTarget/patientRole/addr/streetAddressLine (Header) National Health Care Surveys (V2)
Patient Address 2 /ClinicalDocument/recordTarget/patientRole/addr/streetAddressLine (Header) National Health Care Surveys (V2)
Patient City /ClinicalDocument/recordTarget/patientRole/addr/city (Header) National Health Care Surveys (V2)
Patient State /ClinicalDocument/recordTarget/patientRole/addr/state (Header) National Health Care Surveys (V2)
Patient Zip /ClinicalDocument/recordTarget/patientRole/addr/postalCode (Header) National Health Care Surveys (V2)
Patient SSN /ClinicalDocument/recordTarget/patientRole/id[@root="2.16.840.1.113883.4.1"] (Header) National Health Care Surveys (V2)
Patient Medicare number /ClinicalDocument/recordTarget/patientRole/id[@root="2.16.840.1.113883.4.572"] (Header) National Health Care Surveys (V2)
Patient's medical record number /ClinicalDocument/recordTarget/patientRole/id (Header) National Health Care Surveys (V2)
Patient Date of Birth /ClinicalDocument/recordTarget/patientRole/patient/birthTime (Header) National Health Care Surveys (V2)
Patient Sex /ClinicalDocument/recordTarget/patientRole/patient/administrativeGenderCode (Header) National Health Care Surveys (V2)
Patient Race /ClinicalDocument/recordTarget/patientRole/patient/raceCode (Header) National Health Care Surveys (V2)
Patient Ethnicity /ClinicalDocument/recordTarget/patientRole/patient/ethnicGroupCode (Header) National Health Care Surveys (V2)
Patient Marital Status /ClinicalDocument/recordTarget/patientRole/patient/maritalStatusCode (Header) National Health Care Surveys (V2)
Patient Residence Type //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.25"]/value Patient Information Section (V3) Patient Residence Observation
Type of clinic/location where visit occurred (family practice, cardiology, etc.) /ClinicalDocument/componentOf/encompassingEncounter/location/healthCareFacility/code (Header) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3)
Has patient been seen in clinic/location before //act[templateId/@root="2.16.840.1.113883.10.20.34.3.9"]/code[@code="108220007"][@codeSystem="2.16.840.1.113883.6.96"] Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/New Patient Act
If yes, how many visits in previous 12 months (excluding this visit) //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.26"]/value Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Number of Visits in the Last 12 Months Value contains the number of visits
NPI of physicians /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/id/@extension (Header) National Health Care Surveys (V2)
Types of care providers seen (including attending, resident, intern, N.P., P. A., consulting, specialist(s), Nurse, mental health providers, social workers) /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/code (Header) National Health Care Surveys (V2)
Anesthesia Provider Type /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/code (Header) National Health Care Surveys (V2) Will be a code representing an anesthesia provider
Seen by PCP /ClinicalDocument/documentationOf/serviceEvent/performer/functionCode[@code="PP"][@codeSystem="2.16.840.1.113883.12.443"] (Header) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V2)
Source of referral //reference/externalDocument/code[@code="57113-1"] Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Clinical Note and External Document Reference
Encounter Number /ClinicalDocument/componentOf/encompassingEncounter/id (Header) National Health Care Surveys (V2)
Date/Time of admission/visit/arrival /ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/low (Header) National Health Care Surveys (V2)
Date/Time of departure/discharge /ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/high (Header) National Health Care Surveys (V2)
Expected source(s) of payment //act[templateId/@root="2.16.840.1.113883.10.20.22.4.129"]/entryRelationship/act/code Payment Sources Section Planned Coverage
Is this visit for a new problem, chronic problem (routine or flare-up), preventive care, pre-/post-surgery, surgery/procedure //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.7"]/value Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Major Reason for Visit
Initial or follow-up visit? //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.32"][templateId/@extension="2015-04-01"]/value Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Episode of Care Observation (V2)
Discharge disposition /ClinicalDocument/componentOf/encompassingEncounter/dischargeDispositionCode
(Header) National Health Care Surveys (V2)
Did someone attempt to follow-up with this patient within 24-hours after this surgery //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.42"][templateId/@extension="2015-04-01"]/value Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Procedure Follow-Up Attempt Observation
If follow-up attempt was made, what was learned? //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.43"][templateId/@extension="2015-04-01"]/value Outpatient Encounters Section (V3) Current Outpatient Visit (V3)/Procedure Follow-Up Attempt Observation/
Follow-up Attempt Outcome Observation

Reason for Visit (Patient) //section[templateId/@root="2.16.840.1.113883.10.20.34.2.14"][templateId/@extension="2016-07-01"]/text Reasons for Visit Section (V2)
Free text
Reason for Visit (Patient) //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.41"][templateId/@extension="2015-04-01"]/code Reasons for Visit Section (V2) Patient's Reason for Visit Observation Coded
Diagnosis //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Problem/Diagnosis/Symptom/Condition Observation (V2)
Primary Diagnosis //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.6"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Primary Diagnosis Observation (V2)
Active Problems Any of the Admission Diagnosis, Diagnosis or Primary Diagnosis where there is no effectiveTime/high Problems Section (V3) Admission Diagnosis Observation
Problem/Diagnosis/Symptom/Condition Observation (V2)
Primary Diagnosis Observation (V2)

Problems the patient has (all others besides asthma) (Co-morbid conditions) //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Problem/Diagnosis/Symptom/Condition Observation (V2)
Adverse effect of medical treatment //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.14"]/value Problems Section (V3) Adverse Effect of Medical Treatment
Lab Tests - Test Name //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@displayName Results Section (Entries Optional) Result Observation (V2)
Lab Tests - Test Code //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@code Results Section (Entries Optional) Result Observation (V2)
Lab Tests - Test Datetime //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/effectiveTime Results Section (Entries Optional) Result Observation (V2)
Lab Test - Quantitative Result //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/value Results Section (Entries Optional) Result Observation (V2)
Lab Test - Qualitative Result //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/interpretationCode Results Section (Entries Optional) Result Observation (V2)
Provided: Examinations //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code Services and Procedures Section Provided Service Observation
Provided: Blood Tests //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code Services and Procedures Section Provided Service Observation
Provided: Imaging Services //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code Services and Procedures Section Provided Service Observation
Provided: Other tests and Procedures (except Excision of tissue, biopsy) //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code Services and Procedures Section Provided Service Act
Provided: Excision of tissue, biopsy //procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.12"]/code Services and Procedures Section Provided Service Procedure
Provided: Non-medication Tx //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code Services and Procedures Section Provided Service Act
Provided: Health Education/Counselling //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code Services and Procedures Section Provided Service Act
Ordered: Examinations //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code Services and Procedures Section Ordered Service Observation
Ordered: Blood Tests //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code Services and Procedures Section Ordered Service Observation
Ordered: Imaging Services //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code Services and Procedures Section Ordered Service Observation
Ordered: Other tests and Procedures (except Excision of tissue, biopsy) //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code Services and Procedures Section Ordered Service Act
Ordered: Excision of tissue, biopsy //procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.11"]/code Services and Procedures Section Ordered Service Procedure
Ordered: Non-medication Tx //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code Services and Procedures Section Ordered Service Act
Ordered: Health Education/Counselling //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code Services and Procedures Section Ordered Service Act
Procedures using CPT and HCPCS CODES //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code
OR
//observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code
OR
//procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.12"]/code
Services and Procedures Section Provided Service Act
OR
Provided Service Observation
OR
Provided Service Procedure
Choose one of the CDA Templates depending on the type of procedure (i.e. Act, Observation, or Procedure). See template descriptions in IG for details.
Supplied/Administered Medication //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.16"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code Medications Section Medication Activity (V2) Continued medication: substanceAdministration/effectiveTime/low < encounter date
New medication:
substanceAdministration/effectiveTime/low >= encounter date
Ordered Medication //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.42"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code Medications Section Planned Medication Activity (V2) Continued medication: substanceAdministration/effectiveTime/low < encounter date
New medication:
substanceAdministration/effectiveTime/low >= encounter date
Type(s) of Anesthesia administered //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.16"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code Medications Section Medication Activity (V2) Code would be a type of anesthesia
Supplied/Administered Immunization //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.52"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code Immunizations Section Immunization Activity (V2) Continued immunization: substanceAdministration/effectiveTime/low < encounter date
New immunization:
substanceAdministration/effectiveTime/low >= encounter date
Ordered Immunization //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.120"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code Immunizations Section Planned Immunization Activity (V2) Continued medication: substanceAdministration/effectiveTime/low < encounter date
New medication:
substanceAdministration/effectiveTime/low >= encounter date
Tobacco Use //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.85"][templateId/@extension="2014-06-09"]/value Patient Information Section (V3) Tobacco Use (V2)
Smoking Status //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.78"][templateId/@extension="2014-06-09"]/value Patient Information Section (V3) Smoking Status - Meaningful Use (V2)
Is Female Pregnant //observation[templateId/@root="2.16.840.1.113883.10.20.15.3.8"]/value Patient Information Section (V3) Pregnancy Observation
Estimated Date of Delivery //observation[templateId/@root="2.16.840.1.113883.10.20.15.3.1"]/value Patient Information Section (V3) Estimated Date of Delivery
Patient Asthmatic //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Problem/Diagnosis/Symptom/Condition Observation (V2)
Vital sign - Height //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8302-2"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) value/@value=<numeric value>
value/@unit=<unit of measurement>
Vital sign - Weight //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="3141-9"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) value/@value=<numeric value>
value/@unit=<unit of measurement>
Vital sign - Temperature //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8310-5"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) value/@value=<numeric value>
value/@unit=<unit of measurement>
Vital sign - Blood Pressure - Systolic //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8480-6"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) value/@value=<numeric value>
value/@unit=<unit of measurement>
Vital sign - Blood Pressure - Diastolic //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8462-4"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) value/@value=<numeric value>
value/@unit=<unit of measurement>
Vital sign - others //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"]/code
//observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"]/value
Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) code contains the vital sign being measured
value contains the measurement
value/@value=<numeric value>
value/@unit=<unit of measurement>
Temperature on arrival and last taken //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8310-5"]/value Vital Signs Section (entries required) (V2) Vital Sign Observation (V2) Use date to get the two values
Historical Labs //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@displayName Results Section (Entries Optional) Result Observation (V2) Use date to get historical labs
If injury, intentionality //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.17"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Injury or Poisoning Observation (V2)
If injury, cause //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.17"][templateId/@extension="2015-04-01"]/entryRelationship/observation[templateId/@root="2.16.840.1.113883.10.20.34.3.27"]/value Problems Section (V3) Injury or Poisoning Observation (V2)/Cause of Injury, Poisoning or Adverse Effect
Symptoms(s) present during or after surgery/procedure //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value Problems Section (V3) Problem/Diagnosis/Symptom/Condition Observation (V2) Use date to find inclusion in this set
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