Att. R. OPD Instruction Booklet

Form Approved: OMB No. 0920-0278
U.S. DEPARTMENT OF COMMERCE

NHAMCS-123
(10/2008)

Economics and Statistics Administration

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

Outpatient Department Clinic
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
OPD Patient Record Form......................................................................... 9

EXHIBIT A

ENDORSEMENT LETTER FROM THE ACEP ................................. E-1

EXHIBIT B

ENDORSEMENT LETTER FROM THE SAEM ................................ E-2

EXHIBIT C

ENDORSEMENT LETTER FROM THE ENA ................................... E-3

EXHIBIT D

ENDORSEMENT LETTER FROM THE ACOEP .............................. E-4

EXHIBIT E

ENDORSEMENT LETTER FROM THE SURGEON
GENERAL’S OFFICE.......................................................................... E-5

EXHIBIT F

ENDORSEMENT LETTER FROM THE FEDERATION
OF AMERICAN HOSPITALS ............................................................. E-6

EXHIBIT G

ILLUSTRATIVE USES OF NHAMCS OPD DATA........................... E-7

EXHIBIT H

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

EXHIBIT I

OPD 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.

Clinic 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:

2
Additional Folio Number:

2

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 lavender.

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.

Other Contact

Name

Name

_______________________________

_______________________________

Phone Number

Phone Number

_______________________________

_______________________________
1

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, and hospital-based 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. This need is further accentuated by
the increasing efforts at cost containment, the rapidly aging population, the growing number of persons
without health insurance, and the introduction of new technologies. The American College of Emergency
Physicians, Society for Academic Emergency Medicine, Emergency Nurses Association, American
College of Osteopathic Emergency Physicians, Surgeon General’s Office, and Federation of American
Hospitals 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 medical care services from year to year. Eligible hospitals consist of nonfederal, short-stay, 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 and outpatient
departments and ambulatory surgery centers through the National Hospital Ambulatory Medical Care
Survey will complement the study of physician office-based ambulatory care. The uses of OPD data are
shown in EXHIBIT G on page E-7. The list of data users is quite extensive and includes medical
associations, universities and medical schools, government agencies, and broadcast and print media.

3

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, clinics, 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, clinics, 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. Within the hospital,
ambulatory units are selected. In large outpatient departments (containing more than 5 clinics), statistical
sampling methods are also used to select a sample of up to 12 of these clinics. In each of the selected
outpatient clinics, a sample of patient visits is chosen.
Keeping respondent burden and survey costs as low as possible are always important considerations 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 clinics 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. If clinic sampling is necessary for the outpatient department,
Census Bureau staff will select these units. However, the responsibility for sampling patient visits within
the selected clinics 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 150 to 200 visits from the outpatient department. The sampled
visits in the outpatient department are spread over the selected clinics, if the hospital has multiple clinics.
The number of visits sampled for each clinic is dependent on the clinic'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 arrival
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." 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 or e-mail messages calls from patients; and
visits by persons currently admitted as inpatients to any other health care facility on the
premises, that is, the sample hospital.

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. For visits with a disposition
of “No show/Left without being seen,” do NOT write “VOID” on the top margin of the Patient Record
form as these forms are keyed. 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 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 H on page E-8 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. The “Take Every” 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 OPD Patient Record form is a one-page form consisting of 12 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 the outpatient department of average size will complete approximately 150 to 200
Patient Record forms during the reporting period. If multiple clinics exist within the outpatient
department, forms are distributed among the various clinics.
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 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 clinic 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 clinic 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 OPD Patient Record form consists of two sections separated by a perforated line. (See EXHIBIT I on
page E-9 for an example of the OPD 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 2) printed on both sections of the form. The field
representative will give you this identification number when requesting information.
The bottom section of the OPD form consists of 12 brief items designed to collect data on the patient's
demographic characteristics, reason for visit, diagnosis, 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 outpatient department clinic receives a folio containing a pad of Patient Record forms specifically
assigned to that clinic. An ample supply of forms is included in the event that some are damaged or
destroyed, or the clinic sees a much higher volume of patient visits than expected. Should the supply of
forms for this clinic 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 ambulatory surgery centers in this hospital. Check
the Patient Record forms to make sure that they are lavender and have "Outpatient Department"
printed at the top.

8

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

1.

PATIENT INFORMATION

ITEM 1a.

DATE OF VISIT

Record the month, day, and 2-digit year of arrival 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, 06/26/2007 for
June 26, 2007. In the rare event 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 OPD 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

All other persons.

9

Latino

10

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 Alaska 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 (X) 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.

3 Medicaid/SCHIP

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).

11

Expected
Source(s) of
Payment

Definition

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
copayment 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, post-operative visits included in a surgical fee, and
pregnancy visits included in a flat fee charged for the entire pregnancy).
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. TOBACCO USE
Tobacco use is defined as smoking cigarettes/cigars, using snuff, or chewing tobacco. Mark “Not
current” if the patient does not currently use tobacco. Mark “Current” if the patient uses tobacco.
Mark “Unknown” if it cannot be determined whether the patient currently uses or does not use
tobacco.

2.

INJURY/POISONING/ADVERSE EFFECT

ITEM 2. IS THIS VISIT RELATED TO ANY OF THE FOLLOWING?
If ANY PART of this visit was related to an injury or poisoning or adverse effect of medical or
surgical care (e.g., unintentional cut during a surgical procedure, foreign object left in body during
procedure) or an adverse effect of a medicinal drug, then mark the appropriate box. The
injury/poisoning/adverse effect does not need to be recent. It can include those visits for follow-up
of previously treated injuries and visits for flare-ups of problems due to old injuries. This item not
only includes injuries or poisonings, but also adverse effects of medical treatment or surgical
12

procedures. Include any prescription or over-the-counter medication involved in an adverse drug
event (e.g., allergies, overdose, medication error, drug interactions).
Injury/Poisoning/
Definition
Adverse effect

3.

1 Unintentional
injury/poisoning

Visit related to an injury or poisoning that was unintentional, such as an
insect bite.

2 Intentional
injury/poisoning

Visit was related to an injury or poisoning that was intentional, such as a
suicide attempt or assault.

3 Injury/poisoning –
unknown intent

Visit related to an injury or poisoning, but the intent is unknown.

4 Adverse effect of
medical/surgical
care or adverse
effect of medicinal
drug

Visit due to adverse reactions to drugs, adverse effects of medical
treatment or surgical procedures.

5 None of the above

Visit not related to an injury, poisoning, or adverse effect of medical or
surgical care or an adverse effect of a medicinal drug.

REASON FOR VISIT

ITEM 3. PATIENT’S COMPLAINT(S), SYMPTOM(S), OR OTHER REASON(S) FOR THIS
VISIT (use patient’s own words)
Enter the patient's complaint(s), symptom(s), or other reason(s) for this visit in the patient's own
words. Space has been allotted for the “most important” and two “other” complaints, symptoms, and
reasons as indicated below.
(1) Most important
(2) Other
(3) Other
The Most Important reason should be entered in (1). Space is available for two other reasons in (2)
and (3). By “most important” we mean the problem or symptom which in the physician's judgment
was most responsible for the patient making this visit. Since we are interested only in the patient's
most important complaints/ symptoms/ reasons, it is not necessary to record more than three.
This is one of the most important items on the Patient Record form. No similar data on OPD visits
are available in any other survey and there is tremendous interest in the findings. Please take the
time to be sure you understand what is wanted--especially the following three points:
♦

We want the patient's principal complaint(s), symptom(s), or other reason(s) in the patient’s
own words. The physician may recognize right away, or may find out after the examination,
13

♦

♦

that the real problem is something entirely different. In item 3 we are interested in how the
patient defines the reason for the visit (e.g., “cramps after eating,” or “fell and twisted my
ankle”).
The item refers to the patient’s complaint, symptom, or other reason for this visit. Conceivably,
the patient may be undergoing a course of treatment for a serious illness, but if his/her principal
reason for this visit is a cut finger or a twisted ankle, then that is the information we want.
There will be visits by patients for reasons other than some complaint or symptom. Examples
might be well baby check-up or routine prenatal care. In such cases, simply record the reason
for the visit.

Reminder: If the reason for a patient's visit is to pay a bill, ask the physician to complete an
insurance form, or drop off a specimen, then the patient is not eligible for the sample. A Patient
Record form should not be completed for this patient.

4.

CONTINUITY OF CARE

ITEM 4a.

IS THIS CLINIC THE PATIENT’S PRIMARY CARE PROVIDER?

The primary care provider plans and provides the comprehensive primary health care of the patient.
Mark “Yes” if the health care provided to the patient during this visit was from his/her primary care
provider and skip to item 4b. If the provider seen at this visit was substituting for the primary care
provider, also check “Yes.” Mark “No” if care was not from the primary care provider or
“Unknown” if it is not known.
If “No” or “Unknown” is checked, also indicate whether the patient was referred for this visit by
another health care provider. This item provides an idea of the “flow” of ambulatory patients
from one provider to another. Mark the “Yes,” “No,” or “Unknown” category, as appropriate.
Notice that this item concerns referrals to the sample clinic by a different provider or clinic. The
interest is in referrals for this visit and not in referrals for any prior visit.
Referrals are any visits that are made because of the advice or direction of a clinic or
physician/provider other than the clinic or physician/provider being visited.

ITEM 4b.

HAS THE PATIENT BEEN SEEN IN THIS CLINIC BEFORE?

“Seen” means “provided care for” at any time in the past. Mark “Yes, established patient” if the
patient was seen before by any provider in the clinic. Exclude this visit.
Mark “No, new patient” if the patient has not been seen in the clinic before.

14

If “Yes” is checked, also indicate approximately how many past visits the patient has made to
this clinic within the last 12 months using the write-in box provided. Do not include the current
visit in your total. If you cannot determine how many past visits were made, then mark
“Unknown.” Include all visits to other providers in this clinic.

15

ITEM 4c.

MAJOR REASON FOR THIS VISIT

Mark the major reason for the patient’s current visit. Be sure to check only one of the following
“Major Reasons:”

5.

Problem

Definition

1

New problem (<3
mos. onset)

A visit for a condition, illness, or injury having a relatively
sudden or recent onset (within three months of this visit).

2

Chronic problem,
routine

A visit primarily to receive care or examination for a preexisting chronic condition, illness, or injury (onset of condition
was three months or more before this visit).

3

Chronic problem,
flare-up

A visit primarily due to sudden exacerbation of a pre-existing
chronic condition.

4

Pre-/Post- surgery

A visit scheduled primarily for care required prior to or
following surgery (e.g., pre-surgery tests, removing sutures).

5

Preventive care

General medical examinations and routine periodic
examinations. Includes prenatal and postnatal care, annual
physicals, well-child exams, screening, and insurance
examinations.

PROVIDER'S DIAGNOSIS FOR THIS VISIT

ITEM 5a.

AS SPECIFICALLY AS POSSIBLE, LIST DIAGNOSES RELATED TO THIS
VISIT INCLUDING CHRONIC CONDITIONS.

(1) Primary diagnosis
(2) Other
(3) Other
This is one of the most important items on the Patient Record form. Item 5a(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.
If a patient appears for postoperative care (follow-up visit after surgery), record the postoperative
diagnosis as well as any other. The postoperative diagnosis should be indicated with the letters
“P.O.”

16

Space has been allotted for two “other” diagnoses. In Items 5a(2) and 5a(3) list the diagnosis of
other conditions related to this visit. Include chronic conditions (e.g., hypertension, depression,
etc.), if related to this visit.

17

ITEM 5b.

REGARDLESS OF THE DIAGNOSES WRITTEN IN 5a, DOES PATIENT NOW
HAVE:

The intent of this item is to supplement the diagnosis reported in item 5a(1), 5a(2), and 5a(3). Mark
all of the selected condition(s) regardless of whether it is already reported in item 5a. Even if the
condition is judged to be not clinically significant for this visit, it should still be checked. General
descriptions for each condition are listed below.
Condition

Description

1 Arthritis

Includes those types of rheumatic diseases in which there is an
inflammation involving joints (e.g., osteoarthritis, rheumatoid arthritis,
acute arthritis, juvenile chronic arthritis, hypertrophic arthritis, Lyme
arthritis, and psoriatic arthritis).

2 Asthma

Includes extrinsic, intrinsic, and chronic obstructive asthma.

3 Cancer

Includes any type of cancer (ca), such as, carcinoma, sarcoma, leukemia,
and lymphoma.

4

Cerebrovascular
disease

Includes stroke and transient ischemic attacks (TIAs).

5

Chronic renal
failure

Includes end-stage renal disease (ESRD) and chronic kidney failure due
to diabetes or hypertension.

6

Congestive heart
failure

Congestive heart failure (CHF).

7

COPD

Chronic obstructive pulmonary disease. Includes chronic bronchitis and
emphysema. Excludes asthma.

8

Depression

Includes affective disorders and major depressive disorders, such as
episodes of depressive reaction, psychogenic depression, and reactive
depression.

9

Diabetes

Includes both diabetes mellitus and diabetes insipidus.

10 Hyperlipidemia

Includes hyperlipidemia and hypercholesterolemia.

11 Hypertension

Includes essential (primary or idiopathic) and secondary hypertension.

12 Ischemic heart
disease

Includes angina pectoris, coronary atherosclerosis, acute myocardial
infarction, and other forms of ischemic heart disease.

13 Obesity

Includes body weight 20% over the standard optimum weight.

14 Osteoporosis

Reduction in the amount of bone mass, leading to fractures after minimal
trauma.

15 None of the above Mark (X) if none of the conditions above exist
18

6. VITAL SIGNS

(1) Height

Record the patient’s height if measured at this visit and enter the value in
the box indicating the unit of measurement (ft/in or cm). If it was not
measured at this visit and the patient is 21 years of age or over, then review
the chart for the last time that height was recorded and enter that value.

(2) Weight

Record the patient’s weight if measured at this visit and enter the value in
the box indicating the unit of measurement (lb or kg). If it was not
measured at this visit and the patient is 21 years of age or over, then review
the chart for the last time that weight was recorded and enter that value.

(3) Temperature

Record the patient’s initial temperature if measured at this visit. Mark the
appropriate box, indicating the type of measurement (degrees C or F).

(4) Blood pressure

Record the patient’s initial blood pressure if measured at this visit. Enter
the systolic and diastolic values in the appropriate box.

7. DIAGNOSTIC/SCREENING SERVICES

Mark all services that were ordered or provided during this visit for the purpose of
screening (i.e., early detection of health problems in asymptomatic individuals) or diagnosis
(i.e., identification of health problems causing individuals to be symptomatic). EACH
SERVICE ORDERED OR PROVIDED SHOULD BE MARKED. At visits for a complete
physical exam, several tests may be ordered prior to the visit, so that the results can be
reviewed during the visit. Since these services are related to the visit, the appropriate
box(es) should be marked.
Mark the “NONE” box, if no examinations, imaging, blood tests, scope procedures, or other
tests were ordered or provided.
Services meriting special attention are as follows:
Answer
Box
Service

Special Instruction

3

Foot exam

Includes visual inspection, sensory exam, and pulse exam.

6

Retinal exam

Includes ophthalmoscopy, funduscopic exam, and dilated retinal exam

19

Answer
Box
Service

Special Instruction
(DRE).

20

Lipids/
Cholesterol

Include any of the following tests - cholesterol, LDL, HDL, cholesterol/HDL
ratio, triglycerides, coronary risk profile, lipid profile.

23

Scope Procedure Mark (X) for scope procedures ordered or provided. Write in the type of
- Specify
procedure in the space provided.

24

Biopsy - Specify Include any form of open or closed biopsy of lesions or tissues. Specify the
site of the biopsy.

25

Chlamydia test

Only include the following tests if chlamydia is specifically mentioned:
enzyme-linked immunosorbent assay (ELISA, EIA), direct fluorescent
antibody test (DFA), nucleic acid amplification test (NAAT), nucleic acid
hybridization test (DNA probe testing), or chlamydia culture.

28

HPV DNA test

Detects the presence in women of human papillomavirus and is performed
by collecting cells from the cervix.

29

Pap test conventional

Refers to a smear spread on a glass slide and fixed.

30

Pap test - liquid- Refers to a specimen suspended in liquid solution.
based

34

Other exam/
test/service Specify

Mark (X) for services ordered or provided that are not listed. Write in the
service(s) in the space provided.

20

8. HEALTH EDUCATION

Mark all appropriate boxes for any of the following types of health education ordered or provided to
the patient during the visit. Exclude medications.
Health
Education

Definition

1

NONE

No health education was provided.

2

Asthma
education

Information regarding the elimination of allergens that may exacerbate
asthma, or other activities that could lead to an asthma attack, or
instruction on the use of medication, such as an inhaler.

3

Diet/Nutrition

Any topic related to the foods and/or beverages consumed by the patient.
Examples include general dietary guidelines for health promotion and
disease prevention, dietary restrictions to treat or control a specific
medical problem or condition, and dietary instructions related to
medications. Includes referrals to other health professionals, for example,
dietitians and nutritionists.

4

Exercise

Any topics related to the patient's physical conditioning or fitness.
Examples include information aimed at general health promotion and
disease prevention and information given to treat or control a specific
medical condition. Includes referrals to other health and fitness
professionals. Does not include referrals for physical therapy. Physical
therapy ordered or provided at the visit is listed as a separate check box in
item 9.

5

Family
planning/
Contraception

Information given to the patient to assist in conception or intended to help
the patient understand how to prevent conception.

6

Growth/
Development

Any topics related to human growth and development.

7

Injury
prevention

Any topic aimed at minimizing the chances of injury in one’s daily life.
May include issues as diverse as drinking and driving, seat belt use, child
safety, avoidance of injury during various physical activities, and use of
smoke detectors.

8

Stress
management

Information intended to help patients reduce stress through exercise,
biofeedback, yoga, etc. Includes referrals to other health professionals for
the purpose of coping with stress.

21

Health
Education
9

Tobacco use/
Exposure

Definition
Information given to the patient on issues related to tobacco use in any
form, including cigarettes, cigars, snuff, and chewing tobacco, and on the
exposure to tobacco in the form of "secondhand smoke." Includes
information on smoking cessation as well as prevention of tobacco use.
Includes referrals to other health professionals for smoking cessation
programs.

10 Weight
reduction

Information given to the patient to assist in the goal of weight reduction.
Includes referrals to other health professionals for the purpose of weight
reduction.

11 Other

Check if there were other types of health education ordered or provided
that were not listed above.

9. NON-MEDICATION TREATMENT

Mark (X) all non-medication treatments ordered or provided at this visit.
Non-Medication
treatment

Definition

1

NONE

No non-medication treatments were ordered, scheduled, or performed
at this visit.

2

Complementary
alternative
medicine (CAM)

Includes medical interventions neither widely taught in medical
schools nor generally available in physician offices or hospitals (e.g.,
acupuncture, chiropractic, homeopathy, massage, or herbal therapies).

3

Durable medical
equipment

Equipment which can withstand repeated use (i.e., could normally be
rented and used by successive patients); is primarily used to serve a
medical purpose; generally is not useful to a person in the absence of
illness or injury; and is appropriate for use in the patient’s home (e.g.,
cane, crutch, walker, wheelchair).

4

Home health care

Includes services provided to individuals and families in their places of
residence for the purpose of promoting, maintaining, or restoring
health or for maximizing the level of independence while minimizing
the effects of disability and illness (including terminal illness).
Services may include skilled nursing care; help with bathing, using the
toilet, or dressing provided by home health aides; and physical therapy,

22

Non-Medication
treatment

Definition
speech language pathology services, and occupational therapy.

5

Physical therapy

Physical therapy includes treatments using heat, light, sound, or
physical pressure or movement (e.g., ultrasonic, ultraviolet, infrared,
whirlpool, diathermy, cold, or manipulative therapy).

6

Speech/
Occupational
therapy

Speech therapy includes the treatment of defects and disorders of the
voice and of spoken and written communication. Occupational therapy
includes the therapeutic use of work, self-care, and play activities to
increase independent function, enhance development, and prevent
disability.

7

Psychotherapy

All treatments involving the intentional use of verbal techniques to
explore or alter the patient’s emotional life in order to effect symptom
reduction or behavior change.

8

Other mental
health counseling

General advice and counseling about mental health issues and
education about mental disorders. Includes referrals to other mental
health professionals for mental health counseling.

9

Excision of tissue

Includes any excision of tissue. Excludes wound care and biopsy.

10

Wound care

Includes cleaning, debridement, and dressing of burns; repair of
lacerations with skin tape or sutures. Includes removal of foreign
bodies only if a wound exists. If an object is removed from an orifice,
mark (x) the “Other non-surgical procedures” box and specify the
procedure.

11

Cast

Application of a rigid dressing made of plaster or fiberglass molded to
the body while pliable and hardening as it dries, to give firm support.

12

Splint or wrap

Application of a rigid or flexible appliance used to maintain in position
a displaced or moveable part, or to keep in place and protect an injured
part. May also be made of plaster, but is not circumferential.

13

Other non-surgical
procedures Specify

Write-in any non-surgical procedure ordered or performed at this visit
that was not previously recorded.

14

Other surgical
procedures Specify

Write-in any surgical procedure ordered or performed at this visit that
was not previously recorded. Surgical procedures may be simple (e.g.,
insertion of intrauterine contraceptive device) or complex (e.g., cataract
extraction, hernia repair, hip replacement, etc.).

23

10. MEDICATIONS & IMMUNIZATIONS

If medications or immunizations were ordered, supplied, administered, or continued 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 “laxative,” “cough preparation,” “analgesic,” “antacid,” “birth control pill,” or
“antibiotic.” The one exception is “allergy shot.” If no medication was prescribed, provided, or
continued, then mark the “NONE” box and continue.
Medication, broadly defined, includes the specific name of any:
♦

prescription and over-the-counter medications, anesthetics, hormones, vitamins,
immunizations, allergy shots, and dietary supplements.

♦

medications and immunizations which the physician/provider ordered or provided prior to this
visit and instructs or expects the patient to continue taking regardless of whether a “refill” is
provided at the time of visit.

For each medication, record if it was new or continued.
If more than eight drugs are listed, then record according to the following level of priority:

1. All medications (including OTC drugs)/immunizations associated with the listed
diagnoses
2. All new medications (including OTC drugs)/immunizations, excluding vitamins and
dietary supplements
3. All continued medications (including OTC drugs)/immunizations, excluding vitamins
and dietary supplements
4. Vitamins and dietary supplements

11. PROVIDERS

Mark all providers seen during this visit. If care was provided, at least in part, by a person not
represented in the four categories, mark the “Other” box.
For mental health provider, include psychologists, counselors, social workers, and therapists who
provide mental health counseling. Exclude psychiatrists.

24

12. VISIT DISPOSITION

Mark all that apply.
Visit Disposition

Definition

1

No show/Left without
being seen

The patient made an appointment at the clinic, but did not keep it
or the patient registered at the clinic, but left without being seen
by a health care provider.

2

Refer to other physician

The patient was instructed to consult or seek care from another
physician. The patient may or may not return to this clinic at a
later date.

3

Return at specified time

The patient was told to schedule an appointment or was given an
appointment to return to the clinic at a particular time.

4

Refer to ER/Admit to
hospital

The patient was instructed to go to the emergency
room/department for further evaluation and care immediately or
the patient was admitted as an inpatient in the hospital.

5

Other

Any other disposition not included in the above list.

25

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

26

EXHIBIT A
ENDORSEMENT LETTER FROM ACEP

Ε−1

Ε−2

EXHIBIT B
ENDORSEMENT LETTER FROM THE SAEM

Ε−3

EXHIBIT C
ENDORSEMENT LETTER FROM ENA

Ε−4

EXHIBIT D
ENDORSEMENT LETTER FROM ACOEP

Ε−5

EXHIBIT E
ENDORSEMENT LETTER FROM THE SURGEON GENERAL’S OFFICE

Ε−6

EXHIBIT F
ENDORSEMENT LETTER FROM THE FEDERATION OF AMERICAN HOSPITALS

Ε−7

EXHIBIT G

Ε−8

Illustrative Uses of NHAMCS OPD Data
Health Care Facilities
Long Island Jewish Medical Center

Published article in Clinical Infectious Diseases on
adherence to the Infectious Diseases Society of America
guidelines in the treatment of urinary tract infection.

Kaiser Permanente

Studied the utilization of physician assistants and nurse
practitioners in outpatient departments.
Universities and Medical Schools

Mount Sinai School of Medicine

Published article in Hypertension on gender disparities in
blood pressure control and cardiovascular care at ambulatory
care visits.

University of South Dakota Sanford
School of Medicine

Published article in Annals of Clinical Psychiatry on the use
of atomoxetine for the treatment of ADHD in childhood and
adolescents.

University of Rochester, School of
Medicine and Dentistry

Published article in the Archives of Pediatric and Adolescent
Medicine on national healthcare visit patters of adolescents;
implications for delivery of new adolescent vaccines.
Government Agencies

U.S. Congress

NHAMCS data were used in two reports to Congress – The
National Healthcare Quality Report and the National Health
Disparities Report.

Centers for Disease Control and
Prevention

Requested that a supplement be added to the NHAMCS
OPD to collect information on cervical cancer screening
practices.

Centers for Disease Control and
Prevention

Published article in Arthritis and Rheumatism on annual
ambulatory care visits for pediatric arthritis and other
rheumatological conditions.
Broadcast and Print Media

USA TODAY

Aging population makes for more visits to doctors’ offices
and hospital outpatient departments (8/7/08).

Ε−9

EXHIBIT H
OPTIONAL PATIENT LOG FORM (EXAMPLE)

Ε − 10

EXHIBIT I
OPD PATIENT RECORD FORM

Ε − 11

Ε − 12

EXHIBIT J
NHAMCS PARTICIPANT WEB PAGE

Ε − 13