Form unnumbered Att. J. Ambulatory Unit Induction Form

Form Approval OMB No. 0920-0278
NOTICE – Public reporting burden of this collection of information is
Economics and Statistics Administration
estimated to average 60 minutes per response, including the time for
U.S. CENSUS BUREAU
reviewing instructions, searching existing data sources, gathering and
ACTING AS DATA COLLECTION AGENT FOR THE
maintaining the data needed, and completing and reviewing the collection of
U.S. Department of Health and Human Services
information. An agency may not conduct or sponsor, and a person is not
Centers for Disease Control and Prevention
National Center for Health Statistics
required to respond to a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or
AMBULATORY UNIT RECORD
any other aspect of this collection of information, including suggestions for
National Hospital Ambulatory Medical Care Survey
reducing this burden to CDC/ATSDR Information Collection Review Office;
1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
2010 Panel
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).

FORM NHAMCS-101(U)
(3-11-2009)

U.S. DEPARTMENT OF COMMERCE

COMPLETE THIS RECORD FOR EACH AMBULATORY UNIT SELECTED
Section A – AMBULATORY UNIT INFORMATION
a. Is this ambulatory unit part of an emergency or outpatient department or ambulatory surgery center?
1

ED – Mark (X) type

2

OPD – Mark (X) specialty

3

ASC – Mark (X) specialty

1

General

2

Adult

1

GM

1

GEN
MULTI

2

2

3

SURG
3
4

Pediatric
3

PED

GI
OPH

Urgent care/Fast track

4

OBG

4
5
6

b. AU No.

Substance Abuse

5

ORTHO
PAIN

c. Hospital number

Psychiatric

5

7
8

6

Other

Other

6

PLASTIC
OTHER

d. Hospital name

of

Total AU’s sampled within the ED or OPD or ASC
1. Enter the name of the (emergency service area/
clinic/ASC).

Name

2. Where is the (emergency service area/
clinic/ASC) located?

Address (Number and street)

City/State

Onsite at hospital
2
Elsewhere – Specify
3. What is the name and telephone number
of the director of the (emergency service
area/clinic/ASC)?

ZIP Code

1

CHECK
ITEM A-1
4.

5.

Telephone (Area code and number)

Is this an OPD Clinic whose specialty is GM or OBG or PED?
Yes, Continue with Item 4
No, Skip to Section B
2
1

Does this clinic predominantly provide
primary care?

CHECK
ITEM A-2

Name

1

Yes

2

No

3

Unknown

Is this an OPD Clinic whose specialty is GM or OBG?
Yes, Continue with Item 5
No, Skip to Section B
2
1
906 Eligibility

Does this clinic offer any type of cervical
cancer screening?

1. Take every number

1

Yes – Leave NHAMCS-906

Unknown

3

Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ENTIRE department/ALL ASCs

2. Random start number
3. Estimated number of visits in this
AU during reporting period

5.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number
From the Sampling Plan: If a sampling plan
is not required, item 6 is the AU No. from Section
A, Item b. Items 7 and 8 are each 1.

USCENSUSBUREAU

No

2

From:

/

To:

/

7. Numerator

/
/
8. Denominator

Section B – SAMPLE INFORMATION – Continued
9. What was the total number of patient
visits to this AU from (dates specified in
B5)?(Refer to patient logs, etc. Ask if
necessary.DO NOT LEAVE TOTAL
BLANK. BE AS COMPLETE AND
ACCURATE AS POSSIBLE.)

Week 1
/

10. How many patient record forms were
filled out for this AU (emergency service
area/clinic/ASC)?

–

/

Week 1

11. Log/list used for Sampling

1

NUMBER OF VISITS
Week 3

Week 2
/

–

/

Week 2

Single log/list

2

/

–

Week 4

/

/

NUMBER OF FORMS
Week 3

–

TOTAL
/

Week 4

TOTAL

Multiple log/list

Section C – EMERGENCY SERVICES/OUTPATIENT CLINIC/ASC INFORMATION AND LOGS
1. What are the usual operating hours of this unit?
Day(s)

Time

(a)

(b)
FROM

a.m.
p.m.

Monday
FROM

a.m.
p.m.

Tuesday
FROM

a.m.
p.m.

Wednesday
FROM

a.m.
p.m.

Thursday
FROM

a.m.
p.m.

Friday
FROM

a.m.
p.m.

Saturday
FROM

TO

TO

TO

Open 24 hours

Mark (X) ONLY one
Not open

Hours vary

(c)

(d)

(e)

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

a.m.
p.m.

1

2

3

TO

TO

TO

TO
a.m.
p.m.

Sunday

Section D – VERIFICATION OF ESTIMATED VISITS
Verify with ESA/Clinic/ASC director BEFORE data
collection begins (and records have been pulled).
1. According to our information, about
(number from B-3) patient visits are
expected during the reporting period. Do
you agree with this estimate?

1

2. About how many visits do you expect during the

Revised estimate

reporting period,

to

2

Yes – SKIP to section F, page 3
No

?

Determine if new Take Every and Random Start
numbers must be calculated for this ESA/Clinic/ASC.
3a. Divide the revised estimate by the original
estimate from B-3.

Revised estimate
=

=

(Result)

Original estimate
b. Is the result of (a) between 0.7 and 1.3?

1
2

Page 2

Yes – SKIP to section F, page 3
No
FORM NHAMCS-101(U) (3-11-2009)

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ESA/CLINIC/ASC
1. Calculate new Take Every, using the appropriate table
(page 2 or 4) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).

New Take Every

2. Calculate new Random Start, using the next available
row on the label affixed to the back of the
NHAMCS-101.

New Random Start

Section F – DATA COORDINATOR AND HOSPITAL STAFF
Enter the name, title, and telephone number of the data coordinator and hospital staff involved in the data collection.
Line
No.

Name

Title

(a)

(b)

(c)

Telephone number
(d)
Area code

Number

1
2
3
4
Section G – PATIENT RECORD FORM INFORMATION
1. Enter the range of Patient Record Forms that were ACTUALLY used by the unit.
FIRST FOLIO

FROM:

TO:

SECOND FOLIO

FROM:

TO:

THIRD FOLIO

FROM:

TO:

CHECK
ITEM B

This NHAMCS-101(U) is being completed for:
ED – Continue with Item 2
1
OPD
2
SKIP to Section H, page 4
ASC
3

}

2. How many levels are in this ESA’s triage
system?

1
2
3
4
5

3. Of the completed PRF’s in this ESA, how many
had a visit disposition (item 12) of "Admit to
hospital?"

Three
Four
Five
Other – Specify
Do not conduct nursing triage

Number of PRFs with visit
disposition of "Admit to hospital"
If the number of PRFs given above is 0, then return to
the ED for an explanation and write it in the "NOTES"
section below. If an error was found in sampling or
recording the disposition, then make the correction and
note it below.

4. Did you complete a NHAMCS-105, Hospital
Admission Log for any PRFs where the patient
was admitted to the hospital?

1

Yes

2

No

NOTE – On average, about 12 percent of ED visits result in hospital admission; therefore, it would be unusual to have
no PRFs with this disposition during the 4-week reporting period.
FORM NHAMCS-101(U) (3-11-2009)
Page 3

Section H – FINAL DISPOSITION
1. FINAL DISPOSITION

Ambulatory unit
1

Participated
Patients seen, Continue to Item 2
a
b
No patients seen

2

Refused

3

Closed
a
Temporary
b
Permanent

}

4

Ineligible
a
AU not under auspices of hospital
Only ancillary services provided
b
c
Care not provided by or under the direct
supervision of a physician
d
AU classified as out-of-scope
e
Other – Specify

1

Hospital staff
FR – abstraction DURING reporting period
FR – abstraction AFTER reporting period
Other – Specify

SKIP
to
Item 3

2. Who completed the patient record forms?
Mark (X) all that apply

2
3
4

3. DISPOSITION OF NHAMCS-906
Cervical Cancer Screening Supplement
1
2
3

Completed
Refused
Not applicable – Ambulatory unit not eligible for CCSS

NOTES

Page 4

FORM NHAMCS-101(U) (3-11-2009)