Form unnumbered Att. O. ASC Patient Record Form

CENTERS FOR DISEASE CONTROL
AND PREVENTION

FROM:

Month

Day
TO:

Month

Thur.

Patient.

Tues. Wed.

Day

Fri.

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

Economics and Statistics Administration
ACTING AS DATA COLLECTION AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Sun.

AN

ME

(1-16-2009)

Centers for Disease Control and Prevention
National Center for Health Statistics

V ICES
SER

US
A

Total

Form Approved: OMB No. 0920-0278; Expiration date 09/30/2010

National Hospital
Ambulatory Medical
Care Survey

REPORTING
PERIOD

Patient. Take every

Mon.

Sat.

2010 Ambulatory Surgery
Center
Patient Record Folio
Hospital ID
Ambulatory Unit Number
Start with the

Total

Please return the whole Folio with both the completed
and blank forms at the completion of the survey period.
Thank you!

Sun.

Dates
W
E
E
K No. of
patient
3 visits

Sat.

No. of
records
filled

Fri.

Dates
W
E
E
K No. of
patient
1 visits

Dates

Thur.

No. of
records
filled

W
E
E No. of
K patient
visits

Tues. Wed.

Dates

4

Mon.

W
E
E No. of
K patient
visits

No. of
records
filled

2

NHAMCS-100(ASC)

Notice – Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road,
MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).

No. of
records
filled

FORM

USCENSUSBUREAU

2010 ASC
NHAMCS-100(ASC), (Cover, Page 2, and back cover), Pantone 534U, 20% & 80% tone

DEPAR
T

NHAMCS-100(ASC), (Cover, Page 2, and back cover), Solid Black

H EALT H & H
UM
OF
NT

GENERAL INSTRUCTIONS

Your reporting dates are:

See card in pocket for instructions on how to complete
Patient Record.

REPORTING
DATES

through Sunday,

Record the name of every patient seen during the Reporting
Period on a Sign-In Sheet maintained in each area of the
ambulatory surgery center. Record each patient in the order
registered by your receptionist or seen by the provider. If two or
more patients are seen during a single provider visit, the patients
should be listed in the sequence registered or the sequence
seen. It is important to record every patient visit including those
not seen by the provider but attended to by the staff. Patients
who visit more than once during the Reporting Period should be
recorded on the Sign-In Sheet at each visit.

Monday,

PATIENT
SIGN-IN
SHEET

Follow the Sampling Pattern below to determine for which visit(s) a
Patient Record should be completed.

TAKE EVERY:

PATIENT
RECORD

START WITH:

The START WITH designates the FIRST PATIENT for whom a
Patient Record should be completed. The TAKE EVERY
designates every patient thereafter for whom a Patient Record
should be completed. For example, for a Start With of 2 and Take
Every of 3, a Patient Record will be completed for the second
patient listed on the ambulatory surgery center Sign-In Sheet and
every third patient listed thereafter (e.g., 2, 5, 8, etc.). It is essential
that the Take Every Number is extended each day from one Sign-In
Sheet to another. For example, if your ambulatory surgery center
uses a new Sign-In Sheet each day, then the Take Every Number
has to be extended from the last patient visit selected on Monday to
the new list on Tuesday. If a single Sign-In Sheet is used during the
entire Reporting Period, then the Take Every Number needs to be
extended as new patient names are added to the list.

Please refer to the NHAMCS-126 Instruction Book for
more detailed information on the sampling pattern.

DEFINITIONS For purposes of this study:

1. An ambulatory patient is an individual presenting for personal
health services, not currently admitted to any health care
institution on the premises. Include patients the physician
sees; and patients the physician does not see but who receive
care from a physician assistant, nurse, nurse practitioner, etc.
Exclude persons who visit only for administrative reasons,
such as to complete an insurance form; patients who do not
seek care or services (e.g., pick up a prescription or leave a
specimen); persons currently admitted as inpatients to the
hospital (nursing home patients should be included,
however); and telephone/e-mail contacts with patients.

2. A visit is a direct, personal exchange between an ambulatory
patient and a physician or hospital staff under a physician’s
supervision for the purpose of seeking care and rendering
personal health services.

In case of questions or difficulty, please call the Field
Representative collect:

DISPOSITION As each Patient Record is completed, place it in the pocket of the
folio. At the end of each day, scan all forms to be sure they are
OF
properly completed, verify that the total number of completed
MATERIALS
Patient Records equals the number appearing on the last
completed Patient Record. At the end of the Reporting Period,
detach patient’s name, return all Patient Records and all unused
materials to the field representative as arranged. (DO NOT
RETURN THE DETACHED PAGES OF THE PATIENT RECORD
THAT CONTAIN THE PATIENT’S NAME).

FIELD REP

Name

Phone Number

FORM NHAMCS-100(ASC) (1-16-2009)

Form Approved: OMB No. 0920-0278; Expiration date 09/30/2010

NHAMCS-100(ASC)

U.S. DEPARTMENT OF COMMERCE

FORM
(1-16-2009)

Economics and Statistics Administration

U.S. CENSUS BUREAU PATIENT RECORD NO.:

ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

PATIENT’S NAME:

NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2010 AMBULATORY SURGERY CENTER PATIENT RECORD
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).
(Provider: Detach and keep upper portion)
Please keep (X) marks inside of boxes ➜

✗

Correct

✗ Incorrect
1. PATIENT INFORMATION

a. Date of visit
Day

Month

Year

b. ZIP Code

f. Race – Mark (X) all that apply.
White
1
2
Black or African American
Asian
3
Native Hawaiian or Other Pacific Islander
4
American Indian or Alaska Native
5

h. Time

:

a.m.
p.m.
Military

:

a.m.
p.m.
Military

:

a.m.
p.m.
Military

(4) Time out of operating room . . . .

:

a.m.
p.m.
Military

(5) Time in to postoperative care . . .

:

a.m.
p.m.
Military

:

a.m.
p.m.
Military

(1) Time in to operating room . . . . .

(2) Time surgery began . . . . . . . .
g. Expected source(s) of payment for this
visit – Mark (X) all that apply.

c. Date of birth
Month Day
Year

1
2
3
4

d. Sex
1

5

Female

2

Male

6
7

e. Ethnicity
Hispanic or Latino
1
Not Hispanic or Latino
2

8

Private insurance
Medicare
Medicaid/SCHIP
Worker’s compensation
Self-pay
No charge/Charity
Other
Unknown

(3) Time surgery ended . . . . . . . .

(6) Time out of postoperative care . .

2. FINAL DIAGNOSIS
Optional –
ICD-9-CM Code

As specifically as possible, list all diagnoses related to this visit.

•
Primary: 1.

•
Other:

2.

Other:

3.

Other:

4.

Other:

5.

•
•
•
3. EXTERNAL CAUSE OF INJURY
As specifically as possible, describe the injury that preceded the visit or adverse effect that occurred during the visit.
NONE
Optional –
E-Code

•
4. PROCEDURE(S)
As specifically as possible, list all diagnostic and surgical procedures
performed during this visit.
NONE

Optional –
CPT-4 Codes

Optional –
ICD-9-CM-Codes

•
Primary: 1.

•
Other:

2.

Other:

3.

Other:

4.

Other:

5.

•
•
•

PLEASE CONTINUE ON THE REVERSE SIDE
NHAMCS-100(ASC) (1-16-2009)

2010 ASC

5. MEDICATION(S) & ANESTHESIA
a. Was oxygen administered during this visit?
Mark (X) one box.
1
2
3

b. List up to 8 anesthetics that were administered during this visit.
NONE

Yes
No
Unknown

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)

c. Type(s) of anesthesia listed in 5b – Mark (X)
all that apply.
1

NONE

2

General
IV sedation
MAC (Monitored Anesthesia Care)
Topical/Local

3
4
5

7
8
9
10
11

Epidural
Spinal
Retrobulbar block
Peribulbar block
Other block

Other

(1)

1

2

(2)

1

2

(3)

1

2

(4)

1

2

(5)

1

2

(6)

1

2

(7)

1

2

(8)

1

2

6. PROVIDER(S) OF ANESTHESIA
Anesthesia administered by – Mark (X) all that apply.
1
2
3
4

During
At
this visit discharge

NONE

Regional
6

d. List up to 8 Rx and OTC drugs that were ordered, supplied, or administered
during this visit or at discharge, exclude anesthetics.

Anesthesiologist
CRNA (Certified Registered Nurse Anesthetist)
Surgeon/Other physician
Unknown

7. SYMPTOM(S) PRESENT DURING OR AFTER PROCEDURE
Mark (X) all that apply.
1

NONE

2

Apnea
Bleeding/Hemorrhage
Difficulty waking up
Dysrhythmia/Arrhythmia
Hypertension/High blood pressure

3
4
5
6

7

1
2
3
4
5
6
7
8

Routine discharge to customary residence
Discharge to observation status
Discharge to post-surgical/recovery care facility
Admitted to hospital as inpatient
Referred to ED
Surgery terminated
Other
Unknown

11
12

a. Did someone attempt to follow-up with the patient within 24 hours
after the surgery?
Mark (X) one box.
1
2
3

Yes – Continue with Item 9b.
No
END – Patient Record complete.
Unknown

}

b. What was learned from this follow-up?
Mark (X) all that apply.
1
2
3
4
5
6
7

NHAMCS-100(ASC) (1-16-2009)

9
10

Hypotension/Low blood pressure
Hypoxia
Incontinence
Nausea
Vomiting
Other

9. FOLLOW-UP INFORMATION

8. DISPOSITION
Mark (X) one box.

8

Unable to reach patient
Patient reported no problems
Patient reported problems and sought medical care
Patient reported problems and was advised by ASC staff to seek medical care
Patient reported problems, but no follow-up medical care was needed
Other
Unknown