Att. S. ASC Instruction Booklet

Form Approved: OMB No. 0920-0278; Expiration Date 09/30/2010
U.S. DEPARTMENT OF COMMERCE

NHAMCS-126

Economics and Statistics Administration

(10/2008)

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

NATIONAL CENTER FOR HEALTH STATISTICS
CENTERS FOR DISEASE CONTROL AND PREVENTION

2009 NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY

Ambulatory Surgery Center
Instruction Booklet

Reporting Period
Data Collection Begins:

Data Collection Ends:

On the first day of data collection, begin completing Patient Record forms with the
_____ patient listed on the log for that day.
Select every _____ patient listed on the log during the rest of the reporting period.

Table of Contents
Page
SECTION I

IDENTIFICATION AND GENERAL INSTRUCTIONS/
INFORMATION ................................................................................................. 1

SECTION II

INTRODUCTION................................................................................................ 2
Purpose and Background...................................................................................... 2
Scope .................................................................................................................... 2
Study Roles........................................................................................................... 3
Data Uses.............................................................................................................. 3
Authorization and Assurance of Confidentiality................................................... 4
NHAMCS Participant Web Page …………………………................................. 4

SECTION III

SAMPLING ......................................................................................................... 5
Overview .............................................................................................................. 5
Listing Patient Visits ............................................................................................ 5
Eligible Visits ....................................................................................................... 6
Sampling Procedures ............................................................................................ 6

SECTION IV

COMPLETING PATIENT RECORD FORMS ................................................... 7
Organizing Visit Sampling and Data Collection................................................... 7
Completing the Patient Record Form ................................................................... 8
Item-by-Item Instructions and Definitions for Completing the
ASC Patient Record Form .................................................................................... 9

EXHIBIT A

ENDORSEMENT LETTER FROM THE SURGEON
GENERAL’S OFFICE ......................................................................................E-1

EXHIBIT B

ENDORSEMENT LETTER FROM THE FEDERATION
OF AMERICAN HOSPITALS .........................................................................E-2

EXHIBIT C

ENDORSEMENT LETTER FROM THE AMERICAN
COLLEGE OF SURGEONS.............................................................................E-3

EXHIBIT D

ENDORSEMENT LETTER FROM THE AMERICAN
HEALTH INFORMATION MANAGEMENT ASSOCIATION .....................E-4

EXHIBIT E

ENDORSEMENT LETTER FROM THE AMERICAN
ACADEMY OF OPHTHALMOLOGY............................................................E-5

EXHIBIT F

ENDORSEMENT LETTER FROM THE SOCIETY
FOR AMBULATORY ANESTHESIA.............................................................E-6

EXHIBIT G

ILLUSTRATIVE USES OF AMBULATORY SURGERY
CENTER DATA ...............................................................................................E-7

EXHIBIT H

OPTIONAL PATIENT LOG FORM (EXAMPLE)..........................................E-8

EXHIBIT I

ASC PATIENT RECORD FORM ....................................................................E-9

EXHIBIT J

NHAMCS Participant Web Page www.cdc.gov/nhamcs.................................E-10

SECTION I

IDENTIFICATION AND GENERAL INSTRUCTIONS/INFORMATION

A.

Ambulatory Surgery Center (ASC) name or description

B.

Sampling

C.

1.

LISTING PATIENT VISITS - Keep daily lists of all patient visits beginning at midnight on the
first date of the reporting period (provided on the cover of this booklet) and continuing through
the last date of the reporting period (also provided on the cover). For additional information on
how and who to list, refer to page 5 - "Listing Patient Visits" and page 6 - "Eligible Visits".

2.

SELECTION OF PATIENT VISITS - Select a sample of patient visits following the
instructions on the cover of this booklet. (See page 6 - "Sampling Procedures" for additional
information on sampling patient visits.)

Patient Record Form Numbers
1.

Folio Number:

4
Additional Folio Number:

4

D.

2.

Contact the field representative when additional pads of Patient Record forms are needed. DO
NOT USE A PAD THAT HAS BEEN ASSIGNED TO ANOTHER UNIT.

3.

Check the Patient Record forms to make sure that they are blue.

4.

Instructions - General instructions for completing Patient Record forms are on
page 8. Instructions for the individual items begin on page 9. Job Aids for completing the
Patient Record forms are found in the NHAMCS-250, Job Aid Booklet.

Field Representative Information

E.

Name

Name

_______________________________

_______________________________

Phone Number

Phone Number

_______________________________

_______________________________

1

Other Contact

SECTION II

INTRODUCTION

Purpose and Background
Every year in the United States, there are approximately 235 million visits made to hospital emergency and
outpatient departments, including ambulatory surgery centers. However, adequate data on the hospital
component of ambulatory medical care did not exist until the initiation of the National Hospital
Ambulatory Medical Care Survey (NHAMCS) by the Centers for Disease Control and Prevention’s (CDC)
National Center for Health Statistics (NCHS) in December 1991. This study is the principal source of
information on the utilization of hospital emergency departments (EDs), outpatient departments (OPDs),
and hospital-based ambulatory surgery centers (ASCs) which were added to NHAMCS in 2009.
Moreover, it is the only source of nationally representative estimates on the demographic characteristics of
outpatients, diagnoses, diagnostic services, medication therapy, and the patterns of use of emergency and
outpatient services in hospitals which differ in size, location, and ownership. Data collected through this
study are essential to plan health services, improve medical education, and determine health care workforce
needs.
The study of hospital-based ambulatory care is one of several health care studies sponsored by the CDC’s
National Center for Health Statistics. The National Hospital Ambulatory Medical Care Survey
complements the National Ambulatory Medical Care Survey which collects data on patient visits to
physicians in office-based practices. The hospital study is now bridging the gap which existed in coverage
of ambulatory care data and is further expanding its uses to include hospital-based ambulatory surgery
centers. This need is further accentuated by the increasing efforts at cost containment, the rapidly aging
population, the growing number of persons without health insurance, the introduction of new technologies,
and the shift from hospital inpatient to outpatient surgery. The Federation of American Hospitals, Surgeon
General’s Office, American College of Surgeons, American Health Information Management Association,
American Academy of Ophthalmology, and Society for Ambulatory Anesthesia have endorsed this study.
Letters of endorsement are provided in Exhibits A, B, C, D, E, and F, on pages E-1 to E-6.

Scope
An annual sample of approximately 480 hospitals across the country is selected for participation in the
National Hospital Ambulatory Medical Care Survey. Each hospital collects data for a specified 4-week
period in the survey year. These hospitals are revisited in subsequent years to measure changes in the
public's use of ambulatory care services from year to year. Eligible hospitals consist of non-federal, shortstay, and general hospitals with emergency service areas and/or outpatient clinics and/or ambulatory
surgery centers.
The study includes a sample of ambulatory units, that is, emergency service areas, outpatient clinics, and
ambulatory surgery centers, within each hospital. Medical care must be provided by or under the direct
supervision of a physician for the unit to be considered eligible. Dental clinics, physical, speech, and
occupational therapy, podiatry, optometry, social work, and other clinics where physician services are not
typically provided are not included. Ancillary services, such as pharmacy, diagnostic x-ray, or radiation
therapy are also excluded from the study. Private practice offices and facilities that might have some
association with the hospital, but are not considered hospital clinics are ineligible.

2

Study Roles
The National Center for Health Statistics has contracted with the U.S. Census Bureau to implement the
data collection activities for the National Hospital Ambulatory Medical Care Survey. Trained Census
Bureau field representatives will:



contact selected hospitals to screen them for eligibility and arrange an appointment with the
hospital administrator or other designated representative to further discuss the study;




assist the hospital as requested in obtaining the necessary approval for participation in the study;




obtain basic information on the hospital's emergency and outpatient departments and
ambulatory surgery centers, and select the ambulatory care units to be included in the data
collection;




show hospital staff how to select a sample of patient visits and record the data; and




monitor the data collection procedures during the reporting period.

We are asking the hospital staff to do the following two activities:




select a sample of patient visits during a specific 4-week reporting period following the specific
sampling guidelines provided; and




complete a one-page form for each selected visit.

A Census Bureau field representative will visit each week to resolve any problems with sampling patient
visits or completing Patient Record forms, and to collect any forms already completed. If any problems
arise, or assistance is otherwise needed between these weekly visits, contact the field representative or
other contact (as listed in items D and E on page 1) immediately.

Data Uses
As mentioned earlier, the information collected on patient visits to hospital emergency, outpatient
departments and ambulatory surgery centers through the National Hospital Ambulatory Medical Care
Survey will complement the study of office-based ambulatory care and the study of inpatient care. When
combined with surgical data from the National Hospital Discharge Survey (NHDS), the ambulatory
surgery center data collected here complements the inpatient surgery data obtained through the NHDS, and
expands the coverage of the National Health Care Surveys. The uses of data from the National Survey of
Ambulatory Surgery (NSAS) conducted in 1994-1996 and again in 2006 are shown in EXHIBIT G on
page E-7. The list of data users includes health care facilities, universities and medical schools, and
government agencies.

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Authorization and Assurance of Confidentiality
The National Center for Health Statistics has authority to collect data concerning the public's use of
physicians' services under Section 306 (b) (1) (F) of the Public Health Service Act (42 USC 242k).
Any identifiable information will be held confidential and will only be used by NCHS staff, contractors, or
agents, only when necessary and with strict controls, and will not be disclosed to anyone else without the
consent of your hospital. By law, every employee as well as every agent has taken an oath and is subject to
a jail term of up to five years, a fine up to $250,000, or both if he or she willfully discloses ANY
identifiable information about your hospital’s patients. Furthermore, the names or any other identifying
information for individual patients are never collected. Assurance of confidentiality is provided to all
respondents according to Section 308 (d) of the Public Health Service Act (42 USC 242m).
The requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule on
health information permits you to make disclosures of protected health information without patient
authorization for (1) public health purposes, or (2) research that has been approved by an Institutional
Review Board, or (3) under a data use agreement with NCHS. There are several things that you must do to
assure compliance with the Privacy Rule including providing a privacy notice to your patients that
indicates that patient information may be disclosed for either research or public health purposes, and a
record that a disclosure of information to CDC for the NHAMCS was made. More specific information
can be obtained about Privacy Rule disclosure requirements on our website mentioned below.
NHAMCS Participant Web Page
The National Center for Health Statistics has a web page devoted to the common questions and concerns of
hospital staff participating in the National Hospital Ambulatory Medical Care Survey. The participant web
site can be accessed by logging on to www.cdc.gov/nhamcs. Refer to EXHIBIT J on page E-10 for the
Table of Contents.

4

SECTION III

SAMPLING

Overview
The hospitals, hospital-based ambulatory surgery centers, and visits chosen for the study are selected by
well-established statistical methods. The sample design is comprised of multiple stages to ensure that the
sample of hospitals, ambulatory surgery centers, and visits selected are representative of those throughout
the United States. The participation of each hospital is crucial, since each hospital in the sample represents
many others in the country. All ambulatory surgery centers in a selected hospital are included in the study.
In each of the ambulatory surgery centers, a sample of patient visits is chosen.
Keeping respondent burden and survey costs as low as possible is always an important consideration when
designing a study. Sampling allows us to make national estimates of the volume and characteristics of
patient visits from a small sample of visits to hospital-based ambulatory surgery centers and hospitals,
while reducing both the cost of the study and the work asked of the hospital staff. However, sampling
procedures must be implemented accurately or large errors will result, adversely affecting the data. The
National Center for Health Statistics selects the hospitals to be used for the study. The responsibility for
sampling patient visits within the selected hospital-based ambulatory surgery centers lies with the hospital
staff. Procedures for selecting patient visits have been designed to be simple and easy to implement.
Census Bureau field representatives will instruct the hospital staff on these procedures.
Patient visits are systematically selected over the 4-week reporting period. The sampling procedures are
designed so that on average, approximately 100 visits are selected from all ambulatory surgery centers
combined. The sampled visits are spread over the ambulatory surgery centers, if the hospital has multiple
ambulatory surgery centers. The number of visits sampled for each ambulatory surgery center is dependent
on the ambulatory surgery center’s patient volume.
Listing Patient Visits
A daily listing of all patient visits must be kept or constructed by each participating unit so that a sample of
visits can be selected using the prescribed methods. The list of patient visits may be taken from an
operating room log or other source of recording patient visits. The order in which the patients are listed is
not important. However, it is crucial to have a complete listing of all patients receiving treatment during
all hours of operation. The list should include those patients who came without previously being
scheduled, but it should exclude persons who canceled appointments or were "no shows," were originally
admitted as inpatients, or were admitted through the emergency department. The Census Bureau field
representative will review the method used for listing patient visits (or constructing patient lists) in each
unit to determine if patient sampling can be done properly. In some instances, the Census Bureau field
representative will provide an Optional Patient Log (EXHIBIT H on page E-8) to assist the ambulatory
unit with visit sampling.
Once visit sampling begins, the order of the names must not change. Sampling procedures require that
each visit be selected at a predetermined interval (for example, every 2nd patient, every 10th patient, every
15th patient, etc.). This is the "Take Every" pattern. If a patient is inserted into the list after sampling has
already been done, the pattern will be off and the visits must be resampled.

5

Eligible Visits
A "visit" is defined as a direct, personal exchange between an ambulatory patient and a physician, or a staff
member acting under the direct supervision of a physician, for the purpose of seeking care and rendering
health services. Visits solely for administrative purposes and visits in which no medical care is provided
are not eligible. The following are types of visits/contacts which should be excluded:

 persons who visit only to leave a specimen, pick up a prescription or medication, or other visit
where medical care is not provided;

 persons who visit to pay a bill, complete insurance forms, or for some other administrative reason;

 telephone calls or e-mail messages from patients; and

 visits by persons currently admitted as inpatients to any other health care facility on the premises,
that is, the sample hospital.

 visits by persons who were originally admitted through the emergency department.

 visits by patients who left the hospital prior to the receipt of anesthesia and/or commencement of
the procedure.
It may be helpful to provide a brief reason for the patient's visit on the patient visit list/log to ensure the
exclusion of these visits from the sample. If you discover that an ineligible visit has been accidentally
included in the sample and a Patient Record form has been completed, write "VOID" in the white space of
the top margin of the Patient Record form to the right of the “Incorrect” box. Do NOT write “VOID”
ACROSS the Patient Record form for any reason.
Sampling Procedures
The 4-week reporting period for this unit is recorded on the cover of this booklet. It includes the date for
beginning data collection, as well as the date for completing data collection. To determine which patient
visit to sample first, refer to the instructions at the bottom of this booklet's cover. The first part of the
instruction directs staff to begin with the patient listed on a specific line number of the list/log on the first
day of data collection. Locate this patient visit on the list and mark the name to indicate that it is the first
patient visit sampled.
To continue sampling, refer once again to the instructions on the cover. Select every nth patient.
Continue counting down the patient list until you arrive at the nth patient name listed. This is the second
patient selected for the sample. This process is repeated to select subsequent patient visits for the sample.
For example, if the sampling instructions indicate that you begin with the 3rd patient listed, and select
every 15th patient, you would select the 3rd, 18th, 33rd and so forth. See EXHIBIT I on page E-9 for an
Optional Patient Log marked with an example of a sampling pattern. Be sure to follow the sampling
pattern given on the cover of this booklet.
After each selection, mark or circle the patient name to indicate its inclusion in the sample, and to indicate
where to begin for sampling the next patient visit. This pattern of selecting every nth patient is called the
“Take Every” pattern. The pattern remains consistent throughout the remainder of the reporting period and
should be followed continuously (from shift to shift, and day to day). Do not start fresh with a new "Start
With" after the end of a shift or day.

6

SECTION IV

COMPLETING PATIENT RECORD FORMS

Organizing Visit Sampling and Data Collection
A Patient Record form is completed for every patient visit selected in the sample during the 4-week
reporting period. The ASC Patient Record form is a one-page form consisting of 9 items which require
only short answers. It should take approximately six minutes to complete each form. These forms will
require even less time to complete as staff become more familiar with the items. The sampling procedures
are designed so that all of the ambulatory surgery centers combined will complete approximately 100
Patient Record forms during the reporting period. If multiple ambulatory surgery centers exist, forms are
distributed among the various ambulatory surgery centers.
The Patient Record forms may be completed either during the patient's visit, immediately after the patient's
visit, at the end of the shift, day, etc., or in some combination of these, whichever is most convenient for
the staff. In some cases, a nurse or clerk may furnish the information for certain items prior to the patient's
visit, leaving the remainder of the items to be completed by the attending health care provider during or
immediately after the visit. In other situations, it may be more convenient to complete all records at the
end of the shift or day by one designated person. Whatever method you choose, it is strongly suggested
that the forms be completed at least on a daily basis. Retrieving the records at a later date may prove to be
difficult and time-consuming. Also, patient information will be fresher in the minds of the staff in case
clarification is needed.
Staff members completing Patient Record forms must be familiar with medical/surgical terms and
procedures since most items on the form are clinical in nature. They must also know where to locate the
information necessary for completing the forms. To ensure that complete coverage is provided for all
shifts and days, the responsibility for data collection may require the participation of several staff. We ask
that each participating hospital-based ASC appoint a Data Coordinator to coordinate the personnel
involved in the study and their activities. The Data Coordinator's responsibilities will include supervising
and/or conducting the selection of the sample visits and the completion of the Patient Record forms.
Prior to the clinic's assigned reporting period, the Census Bureau field representative will meet with the
director of each ambulatory surgery center and discuss the organization of sampling and the process of
completing the Patient Record forms. The director then determines which staff will be needed in the data
collection activities. The Census Bureau field representative will train the staff on sampling and data
collection.

7

Completing the Patient Record Form
The ASC Patient Record form consists of two sections separated by a perforated line. (See EXHIBIT I on
page E-09 for an example of the ASC Patient Record form.) The top section of the form contains two
items of identifying information about the patient - the patient's name and the patient’s medical record
number. It is helpful to enter the information for these items immediately following the selection of the
patient visit into the sample. The top section of the form remains attached to the bottom until the entire
form is completed. To ensure patient confidentiality, hospital staff should detach and keep the top section
before the Patient Record forms are collected by the Census Bureau field representative. The Data
Coordinator should keep this portion of the form for a period of four weeks following the reporting period.
Should the field representative discover missing or unclear information while editing the forms, he or she
may recontact the Data Coordinator to retrieve this information. The top section can be matched to the
bottom by the seven-digit identification number (beginning with 4) printed on both sections of the form.
The field representative will give you this identification number when requesting information.
The bottom section of the ASC form consists of 9 brief items designed to collect data on the patient's
demographic characteristics, diagnosis, procedure, anesthesia, etc. Item-by-item instructions begin on page
9 of these instructions. To ensure patient confidentiality, please do not record any patient identifying
information on the bottom portion of the form.
Each hospital-based ambulatory surgery center receives a folio containing a pad of Patient Record forms
specifically assigned to that center. An ample supply of forms is included in the event that some are
damaged or destroyed, or the hospital-based ASC sees a much higher volume of patient visits than
expected. Should the supply of forms for this ASC run low, please contact the Census Bureau field
representative or other contact provided in items D and E on page 1 of this booklet. Do not borrow
Patient Record forms from other participating emergency service areas, clinics, or ASCs in this
hospital. Check the Patient Record forms to make sure that they are blue and have "Ambulatory
Surgery Center" printed at the top.

8

Item-by-Item Instructions and Definitions for Completing the ASC Patient Record Form

1.

PATIENT INFORMATION

ITEM 1a. DATE OF VISIT
Record the month, day, and 2-digit year of visit in figures, for example, 05/17/09 for May 17,
2009.

ITEM 1b. ZIP CODE
Enter 5-digit ZIP Code from patient’s mailing address.

ITEM 1c. DATE OF BIRTH
Record the month, day, and 4-digit year of the patient's birth in figures, for example, 05/17/2007
for May 17, 2007. In the rare event that the date of birth is unknown, the year of birth should be
estimated as closely as possible.

ITEM 1d. SEX
Check the appropriate category based on observation or your knowledge of the patient or from
information on the medical record.

ITEM 1e. ETHNICITY
Ethnicity refers to a person's national or cultural group. The ASC Patient Record form has two
categories for ethnicity, Hispanic or Latino and Not Hispanic or Latino.
Mark the appropriate category according to your hospital’s usual practice or based on your
knowledge of the patient or from information in the medical record. You are not expected to ask
the patient for this information. If the patient's ethnicity is not known and is not obvious, mark the
box which in your judgment is most appropriate. The definitions of the categories are listed
below. Do not determine the patient’s ethnicity from their last name.
Ethnicity

Definition

1 Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American or
other Spanish culture or origin, regardless of race.

2 Not Hispanic or
Latino

All other persons.

9

ITEM 1f. RACE
Mark all appropriate categories based on observation or your knowledge of the patient or from
information in the medical record. You are not expected to ask the patient for this information. If
the patient's race is not known or not obvious, mark the box(es) which in your judgment is (are)
most appropriate. Do not determine the patient’s race from their last name.

Race

Definition

1 White

A person having origins in any of the original peoples of Europe, the
Middle East or North Africa.

2 Black or African
American

A person having origins in any of the black racial groups of Africa.

3 Asian

A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.

4 Native Hawaiian
or Other Pacific
Islander

A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.

5 American Indian
or Alaskan Native

A person having origins in any of the original peoples of North America,
and who maintains cultural identification through tribal affiliation or
community recognition.

ITEM 1g. EXPECTED SOURCE(S) OF PAYMENT FOR THIS VISIT
Mark ALL appropriate expected source(s) of payment.
Expected
Source(s) of
Payment

Definition

1 Private insurance

Charges paid in-part or in-full by a private insurer (e.g., Blue Cross/Blue
Shield) either directly to the hospital or reimbursed to the patient. Include
charges covered under a private insurance sponsored prepaid plan.

2 Medicare

Charges paid in-part or in-full by a Medicare plan. Includes payments
directly to the hospital as well as payments reimbursed to the patient.
Include charges covered under a Medicare sponsored prepaid plan.

10

Expected
Source(s) of
Payment
3 Medicaid/SCHIP

Definition
Charges paid in-part or in-full by a Medicaid plan. Includes payments
made directly to the hospital as well as payments reimbursed to the
patient. Include charges covered under a Medicaid sponsored prepaid
plan or the State Children’s Health Insurance Program (SCHIP).

4 Worker’s
compensation

Includes programs designed to enable employees injured on the job to
receive financial compensation regardless of fault.

5 Self-pay

Charges, to be paid by the patient or patient’s family, which will not be
reimbursed by a third party. "Self-pay" includes visits for which the
patient is expected to be ultimately responsible for most of the bill, even
though the patient never actually pays it. DO NOT check this box for a
co-payment or deductible.

6 No charge/Charity

Visits for which no fee is charged (e.g., charity, special research or
teaching). Do not include visits paid for as part of a total package (e.g.,
prepaid plan visits and post-operative visits included in a surgical fee).
Mark the box or boxes that indicate how the services were originally paid.

7 Other

Any other sources of payment not covered by the above categories, such
as CHAMPUS, state and local governments, private charitable
organizations, and other liability insurance (e.g., automobile collision
policy coverage).

8 Unknown

The primary source of payment is not known.

ITEM 1h. Time
Record the hour and minutes for each phase of the surgical visit in (1)–(6). For example, enter
01:15 for 1:15 a.m. or 1:15 p.m. Also, check the appropriate box (a.m., p.m., or Military) when
recording the times. It is important that this item be recorded correctly. Please pay special
attention to the a.m., p.m., and Military boxes. Also, cross-check item (1) Time in to operating
room with item (2) ‘Time surgery began’ through item (6) ‘Time out of postoperative care.’ For
example, the time out of postoperative care should be after the time in to operating room.

11

2.

FINAL DIAGNOSIS

As specifically as possible, list diagnoses related to this visit including chronic conditions.
(1) Primary
(2) Other
(3) Other
(4) Other
(5) Other
This is one of the most important items on the Patient Record form. Item 2(1) refers to the
provider’s primary diagnosis for this visit. While the diagnosis may be tentative, provisional, or
definitive, it should represent the provider's best judgment at this time, expressed in acceptable
medical terminology including “problem” terms. If the patient was not seen by a physician, then the
diagnosis by the main health care provider should be recorded.
Space has been allotted for four “other” diagnoses. If the hospital-based ASC coded the diagnoses
using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes
and entered the codes on the face sheet, discharge summary/instructions or operative report, record
these codes. Do not provide ICD-9-CM codes instead of narratives, unless the narratives are not
included in the medical record.

3.

EXTERNAL CAUSE OF INJURY

As specifically as possible, describe the injury that preceded the visit or the adverse effect that
occurred during the visit.
Provide a brief description of the who, what, when, where, and why associated with the injury or the
adverse effects of medical treatment or surgical procedures (e.g., foreign object left in body during
procedure), including adverse drug events (e.g., allergy to penicillin). Refer to page 2 in the
NHAMCS-250, which is a Job Aid designed to assist you with Item 3 of the Patient Record form.
Indicate the place of the injury (e.g., residence, recreation or sports area, street or highway, school,
hospital, public building, or industrial place). Include any post-surgical complications and if it
involved an implant, specify what kind. If safety precautions were taken, describe them (e.g., seat
belt use). Be sure to include the mechanism that caused the injury (e.g., farm equipment, fire,
arsenic, knife, pellet gun). If it was a work-related injury or poisoning, specify the industry of the
patient’s employment (e.g., food service, agricultural, mining, health services, etc.).
Describe in detail the circumstances that caused the injury (e.g., fell off monkey bars, motor vehicle
collision with another car, spouse beaten with fists by spouse). Include information on the role of the
patient associated with the injury (e.g., bicyclist, pedestrian, unrestrained driver or passenger in a
motor vehicle, horseback rider), the specific place of occurrence (e.g., lake, school football field), and
the activity in which the patient was engaged at the time of the injury (e.g., swimming, boating,
playing football).

12

Also include what happened to the patient and identify the mechanism of injury that was immediately
responsible for the injury. In addition, record the underlying or precipitating cause of injury (i.e., the
event or external cause of injury that initiated and led to the mechanism of injury). An example is the
incorrect dilution of fluid in an infusion administered during a surgical procedure. Both the
precipitating or underlying cause (surgical procedure) and the mechanism (incorrect dilution of fluid
in an infusion) would be important to record. It is especially important to record as much detail about
falls and motor vehicle crashes as possible. For fall, indicate what the fall was from (e.g., steps) and
where the patient landed (e.g., pavement). For motor vehicle crash, indicate if it occurred on the
street or highway versus a driveway or parking lot. The National Center for Health Statistics will use
the information collected to classify the cause of the injury using the International Classification of
Diseases, Supplementary Classification of External Causes of Injury and Poisoning codes (ICD-9CM E-Codes).
If the ASC coded the external cause of injury using ICD-9-CM E-Codes and entered the codes on the
face sheet, discharge summary/instructions, or operative report, record these codes. Do not provide
ICD-9-CM E-Codes instead of narratives, unless the narratives are not included in the medical
record.
Mark the “NONE” box, if the procedure is not related to a previous injury or an adverse effect did
not occur during the visit.

4.

PROCEDURES

As specifically as possible, list all diagnostic and surgical procedures performed during this
visit.
Abstract the procedures from the face sheet or discharge summary dictated by the surgeon, although
they may be listed on a variety of forms within the medical record. Transcribe the surgeon’s exact
wording for each procedure in the space provided. Report all procedures.
If a primary procedure is specified, enter the surgeon’s exact terminology next to the caption
“Primary” on the Patient Record form. If the surgeon did not enter a primary procedure, record the
first procedure shown as the primary procedure.
Next to “Other,” enter all other procedures listed, using the surgeon’s exact wording. If the ASC
coded these surgical procedures using ICD-9-CM and/or CPT-4 (Current Procedural Terminology, 4th
Revision) and entered the codes on the face sheet, discharge summary/instructions, or operative
report, record these codes. Do not provide codes instead of narratives unless the narratives are
not included in the medical record.

13

5.

MEDICATIONS & ANESTHESIA

ITEM 5a. INCLUDE RX AND OTC DRUGS, ANESTHETICS, AND OXYGEN THAT WERE
ORDERED, SUPPLIED, OR ADMINISTERED DURING THIS VISIT OR AT
DISCHARGE.
If medications or anesthetics were ordered, supplied, or administered at this visit, list up to 8 in
the space provided using either the brand or generic names. Record the exact drug name (brand
or generic) written on any prescription or on the medical record. Do not enter broad drug classes,
such as “anesthetic,” “laxative,” “analgesic,” or “antibiotic.” If no medication or anesthetic was
prescribed or provided, then mark (X) the “NONE” box and continue.
Medication and anesthesia, broadly defined, includes the specific name of any:
♦ prescription and over-the-counter medications, anesthetics, hormones, vitamins,
immunizations, allergy shots, and dietary supplements.
♦ medications which the physician/provider ordered, supplied, or administered during the
visit or at discharge.
For each medication or anesthetic, record if it was administered during the visit or at discharge.
If more than eight drugs were given in the ASC during the visit and/or prescribed at ASC discharge,
then record the medications/anesthetics according to the following priority:
1. All medications (including OTC drugs)/anesthetics associated with the listed diagnoses and/or
procedures.
2. All medications (including OTC drugs)/anesthetics given during the visit
3. All medications (including OTC drugs)/anesthetics prescribed at discharge

ITEM 5b. TYPE(S) OF ANESTHESIA
Record all of the type(s) of anesthesia used during surgery when they are clearly documented in
the record. Mark all that apply.
Type of
Anesthesia

Definition

1 NONE

No medications or anesthesia were ordered, supplied, or administered
during the visit.

2 General

General anesthesia causes the whole body to lose sensation. There are
two ways that general anesthesia is administered. Inhalation is the most
common form of general anesthesia in which the patient inhales gas or
vapor. Another way to administer general anesthesia is intravenously,
where anesthetics are injected directly into a patient’s vein.

14

3 IV sedation

Intravenous sedation.

4 MAC

Monitored Anesthesia Care uses sedatives and other agents, but the
dosage is low enough that patients remain responsive and breathe without
assistance. MAC is often used to supplement local and regional
anesthesia, particularly during simple procedures and minor surgery.

5 Topical/Local

Topical anesthesia numbs only part of the body. Feeling is numbed by
temporarily blocking nerves at or near the site of the operation.

Regional
6 Epidural

Anesthesia is injected into the spine continuously or intermittently over a
period of time.

7 Spinal

Anesthesia is injected into cerebrospinal fluid in a one-time procedure.

8 Retrobulbar block Retrobulbar block is a technique used in eye surgery to immobilize the
muscles around the eye and eliminate pain sensation.

6.

9 Peribulbar block

Peribulbar block is a technique used in eye surgery to immobilize the
muscles around the eye and eliminate pain sensation.

10 Other block

Other type of block, not retrobulbar or peribulbar.

11 Other

Any other type of anesthesia not included in the above list.

PROVIDER(S) OF ANESTHESIA

If there is a clear indication in the medical record of the specialty of the person(s) administering
anesthesia (e.g., anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), surgeon), mark
all that apply. If not indicated, mark “Unknown.”

7.

SYMPTOMS PRESENT DURING OR AFTER SURGERY

Mark all symptoms that were present during or after the procedure(s). Read through the progress
or operative notes of the nurse or physician and the anesthesia notes to determine whether the
patient had any of the symptoms listed.

15

8.

DISPOSITION

Mark the one box that is most appropriate.
Many facilities do not record the patient’s status or disposition on the chart. The information
about the patient’s disposition might be recorded only in the nurse’s or physician’s notes on the
operative report or the discharge summary. In most situations, the patient will be discharged to
their customary residence, but read the notes carefully to determine if the patient was admitted to
the hospital. Mark the appropriate box to indicate the disposition of the patient upon discharge
from the ASC.
Disposition

Definition

1 Routine discharge
to customary
residence

Patient was discharged to his/her normal place of residence, i.e., home,
nursing home, prison, etc.

2 Discharge to
observation status

Patient was kept at the facility for up to 72 hours for observation, but was
not considered an inpatient by the facility.

3 Discharge to postsurgical/recovery
care facility

Patient was discharged to an organized recovery care center.

4 Admitted to
hospital as
inpatient

Patient was admitted to the hospital as an inpatient after the ambulatory
surgical procedure was performed. If the patient was ORIGINALLY
admitted as an inpatient, this case is out-of-scope.

5 Referred to ED

Patient was referred to an emergency department.

6 Surgery
terminated

Patient was scheduled for ambulatory surgery, appeared at the designated
time, received anesthesia and/or began the procedure, but the procedure
was terminated prior to completion.

7 Other

Status/disposition of the patient is something other than categories 1-7.

8 Unknown

Patient’s disposition is not indicated.

16

9.

FOLLOW-UP INFORMATION

Information on follow-up of the patient after they are discharged may be found in the discharge
summary/instructions. Most ASCs will contact the patient or the patient’s caregiver within 24
hours after surgery to make sure the patient is recovering as expected and does not have any
problems post-surgery. This phone call should be documented in the patient’s medical record,
typically in the discharge summary/instructions.
If the answer is “No” or “Unknown,” then stop here.

ITEM 9a. DID SOMEONE ATTEMPT TO FOLLOW-UP WITH THE PATIENT WITHIN 24
HOURS AFTER THE SURGERY?
Mark “Yes” if the medical record indicates that someone from the ASC attempted to
contact the patient within 24 hours after the surgery..
If there is no indication that someone attempted to follow-up with the patient within 24
hours after the surgery, mark “No.”
Mark “Unknown” if it cannot be determined whether someone from the ASC attempted to
contact the patient within 24 hours after the surgery.

ITEM 9b. WHAT WAS LEARNED FROM THIS FOLLOW-UP?
Use information in the medical record to complete this item and mark all that apply.
Mark “Unable to reach patient” if the medical record indicates that a message was left on
an answering machine or voicemail and the patient did not return the call.
Mark “Other” if what was learned from the follow-up is something other than categories
1-5.
Mark “Unknown” if what was learned from the follow-up is not indicated.

*All names and examples referenced in this instruction booklet are fictional and in no way represent actual
situations or individuals

17

EXHIBIT A
ENDORSEMENT LETTER FROM THE SURGEON GENERAL’S OFFICE

Ε−1

EXHIBIT B
ENDORSEMENT LETTER FROM THE FEDERATION OF AMERICAN HOSPITALS

Ε−2

EXHIBIT C

Ε−3

ENDORSEMENT LETTER FROM THE AMERICAN COLLEGE OF SURGEONS

Ε−4

EXHIBIT D
ENDORSEMENT LETTER FROM THE AMERICAN HEALTH INFORMATION
MANAGEMENT ASSOCIATION

Ε−5

EXHIBIT E
ENDORSEMENT LETTER FROM THE AMERICAN ACADEMY OF OPHTHALMOLOGY

Ε−6

EXHIBIT F
ENDORSEMENT LETTER FROM THE SOCIETY FOR AMBULATORY ANESTHESIA

Ε−7

EXHIBIT G
Illustrative Uses of National Survey of Ambulatory Surgery Data

VA Greater Los Angeles Health Care
System and the UCLA, Geffen School
of Medicine
Brigham and Women's Hospital, New
York Presbyterian Hospital-Weill
Cornell Medical Center, Mathematica
Policy Research Inc.

University of Iowa and Stanford
University

Health Care Facilities
Examined the impact of the aging population on the demand
for surgical procedures
Examined patient disposition following inguinal hernia repair
surgery

Universities and Medical Schools
Published article in Ambulatory Anesthesia on the relative
frequency of uncommon ambulatory surgery procedures

Wake Forest University and BristolMyers Squibb

Published article in Dermatologic Surgery on the cost of
Nonmelanoma Skin Cancer Treatment

Ohio State University and University of
Pittsburgh

Published article in American Journal of Obstetrics and
Gynecology on ambulatory surgery for urinary incontinence
in women over time.

Centers for Disease Control and
Prevention
Agency for Healthcare Research and
Quality and University of Washington

Government Agencies
Examined the number and rates of tubal sterilization in the
US.
Examined trends in ambulatory lumbar spine surgery

Ε−8

EXHIBIT H
OPTIONAL PATIENT LOG FORM (EXAMPLE)

Ε−9

EXHIBIT I
ASC PATIENT RECORD FORM

Ε − 10

EXHIBIT J
NHAMCS PARTICIPANT WEB PAGE

Ε − 11