Hospital Induction Form - 11/29/2010

Form Approved: OMB No. 0920-0278; Expiration date 08/31/2012
NOTICE – Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the 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 currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
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).

1. Label

NHAMCS-101
(11-2-2010)

U.S. DEPARTMENT OF COMMERCE
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

NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2011 PANEL

2a. Hospital contact information

b. ED contact information

Name

Name

Title

RECORD ON
CONTROL CARD

Telephone number
(Area code and number)
FAX number

Title
Telephone number
(Area code and number)

RECORD ON
CONTROL CARD

FAX number

c. OPD contact information

d. Ambulatory surgery contact information
Name

Name
Title

RECORD ON
CONTROL CARD
RECORD ON
CONTROL CARD

Telephone number
(Area code and number)
FAX number

Title
Telephone number
(Area code and number)

RECORD ON
CONTROL CARD

FAX number

Section I – TELEPHONE SCREENER

3. Field representative

4. Record of telephone calls
Call
Date
Time

information

Results

FR Code
Telephone screener

1
FR Code

Hospital induction

ED induction

OPD induction
Ambulatory surgery
induction

2
FR Code

3

FR Code

4

FR Code

5
6

5. Final outcome of hospital screening
1

Appointment
Day

2

Date

Time

a.m.
p.m.

Noninterview – Complete Sections VI and VII, beginning on page 23.

USCENSUSBUREAU

During your initial call to the hospital, attempt to speak to
the contact person. If the contact person is not available
at this time, determine when he/she can be reached and
call again at the designated time. If, after several
attempts, you are still unable to talk to the contact or
have determined the contact is no longer an appropriate
respondent, begin the interview with a representative of
the contact person or new contact, as appropriate.

Section I – TELEPHONE SCREENER – Continued
Part A. INTRODUCTION
Good (morning/afternoon) . . ., my name is (Your name). I am calling for the Centers for Disease
Control and Prevention concerning their study of hospital outpatient and emergency
departments and hospital-based ambulatory surgery locations. You should have received a
letter from Dr. Edward J. Sondik, the director of the National Center for Health Statistics,
describing the study. (Pause) You’ve probably also received a letter from the U.S. Census
Bureau, which is collecting the data for the study.

6. Did you receive the letter(s)?
(If "No" or "Don’t know," offer to send or deliver
another copy.)

7a. Let me verify that I have the correct name
and address for your hospital. Is the correct
name (Read name from Control Card)?

1
2
3

1
2

Yes – SKIP to STATEMENT A
No
Don’t know
Yes
No – Enter correct name

RECORD ON CONTROL CARD
b. Is your hospital located at (Read address from
Control Card)?

1
2

Yes
No – Enter hospital location

Number and street

RECORD ON CONTROL CARD
City State ZIP Code

c. Is this also the mailing address?

1
2

Yes
No – Enter correct mailing address

Number and street

RECORD ON CONTROL CARD
City State ZIP Code
STATEMENT
A

(Although you have not received the letter,) I’d like to briefly explain
the study to you at this time and answer any questions about it.

NOTES

Page 2

FORM NHAMCS-101 (11-2-2010)

Section I – TELEPHONE SCREENER – Continued
Part B. VERIFICATION OF ELIGIBILITY
CHECK
ITEM A

1
2

This hospital was in a previous panel – Read INTRODUCTION STATEMENT B1
This hospital is being asked to participate in the study for the FIRST time – Read INTRODUCTION
STATEMENT B2

INTRODUCTION
STATEMENT B1

The National Center for Health Statistics of the Centers for Disease
Control and Prevention is continuing its annual study of hospital-based
ambulatory care. We contacted your hospital previously regarding
participation. Collecting data on an annual basis in hospitals, such as
your own, is necessary to keep updated information on the status of
ambulatory care provided in the hospital environment.
Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included your
hospital in the study. First, concerning licensing:

INTRODUCTION
STATEMENT B2

The National Center for Health Statistics of the Centers for Disease
Control and Prevention is conducting an annual study of hospital-based
ambulatory care. The study began data collection in 1992. They have
contracted with the U.S. Census Bureau to collect the data. (Name of
hospital) has been selected to participate in the study. The study is
authorized under the Public Health Service Act and the information will
be held strictly confidential. Participation is voluntary.
Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included this hospital
in the study. First, concerning licensing:

8a. Is this facility a licensed hospital?

1
2

b. Is this hospital nonprofit, government, or

1

proprietary?
2

c. Is this hospital owned, operated, or
managed by a health care corporation that
owns multiple health care facilities (e.g.,
HCA or Health South)?

d. Is this a teaching hospital?

separated from any OTHER hospital in the
past 2 years?

Proprietary (includes individually or privately
owned, partnership or corporation)

1

Yes
No
Unknown

2
3

1

1
2
3
4

f. Does YOUR hospital have its own medical
records department that is separate from
that of the OTHER hospital?

g. What is the name and address of this
OTHER hospital?

Nonprofit (includes church-related, nonprofit
corporation, other nonprofit ownership)
State or local government (includes state, county, city,
city-county, hospital district or authority)

3

2

e. Has this hospital either merged with or

Yes
No – SKIP to CHECK ITEM B on page 4

1
2
3

Yes
No
Yes, merged
Yes, separated
No
SKIP to item 9a on page 4
Unknown

}

Yes
No
Unknown

Hospital name
Number and street
City State

FORM NHAMCS-101 (11-2-2010)

RECORD ON
CONTROL CARD

ZIP Code

Page 3

Section I – TELEPHONE SCREENER – Continued
Part B. VERIFICATION OF ELIGIBILITY

9a. Does this hospital provide emergency
services that are staffed 24 HOURS each day
either here at this hospital or elsewhere?

b. Does this hospital operate any emergency
service areas that are not staffed 24
HOURS each day?

c. What is the trauma level rating of this
hospital?

1
2

1
2

1
2

10a. Does this hospital operate an organized
outpatient department either at this
hospital or elsewhere?

b. Does this OPD include physician services?

1
2
1
2

c. Does this hospital have locations that
perform ambulatory surgery?
Read the following statement.
Ambulatory surgery locations include a
general or main operating room, dedicated
ambulatory surgery room, satellite operating
room, cystoscopy room, endoscopy room,
cardiac catheterization lab, laser procedures
room, or a pain block room.
CHECK
ITEM B

2
3

Yes
No
Level I
3
Level III
5
Other/unknown
Level II
Level IV or V 6 None
4
See page 29 of the NHAMCS-124 for definitions
Yes
No – SKIP to item 10c
Yes
No
Yes
No
Unknown

Mark (X) all that apply.
1
2

3
4
5

CHECK
ITEM
B-1

1

Yes
No

ED meets eligibility requirements (item 9a is YES) . . . . . . . . . . . .
OPD meets eligibility requirements (item 9a is NO
and item 9b is YES, or items 10a and b are YES) . . . . . . . . . . . .

}

SKIP to CHECK ITEM B-1

Ambulatory surgery location meets eligibility requirements
(item 10c is YES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital is ineligible because it is not licensed (item 8a is NO) – Go to CLOSING
STATEMENT B1 on page 5.
Hospital is ineligible because it has NEITHER an ED nor OPD nor ambulatory surgery location
(items 9a, 9b, 10a, 10b, and/or 10c are NO) – Go to CLOSING STATEMENT B2 on page 5.

Hospital refused
1
Yes – SKIP to item a
No – SKIP to Part C. STUDY DESCRIPTION on page 5
2
a. Determine whether hospital has an eligible ED and if so,
inquire as to how many visits are expected during the
reporting period.

Eligible ED?
1
2

b. Determine whether hospital has an eligible OPD and if
so, inquire as to how many visits are expected during
the reporting period.

expected visits

Eligible OPD?
1
2

c. Determine whether hospital has an eligible ambulatory
surgery location and if so, inquire as to how many visits
are expected during the reporting period.

Yes –
No

Yes –
No

expected visits

Eligible Ambulatory surgery location?
1
2

Yes –
No

expected visits

d. If unable to determine expected visits for the assigned reporting period, obtain the number of
visits to the department last year.
ED visits
last year

OPD visits
last year

Ambulatory surgery
visits last year

Go to Section VII, NONINTERVIEW on page 24.
Page 4

FORM NHAMCS-101 (11-2-2010)

Section I – TELEPHONE SCREENER – Continued
Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) is not a licensed hospital it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
Section VI on page 23.

CLOSING
STATEMENT
B1

Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) does not have 24-hour emergency services, outpatient clinics, or
ambulatory surgery centers, it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
Section VI on page 23.

CLOSING
STATEMENT
B2

Part C. STUDY DESCRIPTION
Thank you. Now I would like to provide you with further information on the study.
INSTRUCTIONS
Provide the administrator or other hospital representative with a brief description of the study.
Cover following points –
(1) The NHAMCS is the only source of national data on health care provided in hospital emergency and
outpatient departments and ambulatory surgery locations
(2) NHAMCS is endorsed by the:
• American College of Emergency Physicians
• Emergency Nurses Association
• Society for Academic Emergency Medicine
• American College of Osteopathic Emergency Physicians
• Federation of American Hospitals
• Ambulatory Surgery Center Association
• American College of Surgeons
• American Health Information Management Association
• American Academy of Ophthalmology
• Society for Ambulatory Anesthesia
(3) Nationwide sample of about 600 hospitals and 246 free-standing ambulatory surgery centers
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits
As one of the hospitals that has been selected for the study, your contribution will be of
great value in producing reliable, national data on ambulatory care.
CHECK
ITEM
B-2

Hospital MERGED with or SEPARATED from another in the past two years? (Item 8e is YES.)
1
2

Yes – Go to CLOSING STATEMENT C1 below.
No – Go to CLOSING STATEMENT C2 below.

CLOSING
STATEMENT
C1

Since your hospital has merged or separated within the last 2 years, I need to
get further instructions from the Centers for Disease Control and Prevention
(CDC) on how to proceed. I will call you back within a week and let you know
which parts of your hospital will be in the survey. Thank you for your
cooperation! Telephone your Regional Office to report the Hospital Name and ID Number.

CLOSING
STATEMENT
C2

I would like to arrange to meet with you so that I can better present the details
of the study. Is there a convenient time within the next week or so that I could
meet with you or your representative?
Thank you . . . for your cooperation. I am looking forward to our meeting. Record
day, date and time of appointment in item 5, page 1; and terminate telephone call.

NOTES

FORM NHAMCS-101 (10-18-2010)

Page 5

Section II – INDUCTION INTERVIEW
Part A. INTRODUCTION
I would like to begin with a brief review of the background for this study.

INSTRUCTIONS
Provide the administrator or other hospital representative with a brief introduction to the study
and a general overview of procedures.
Cover the following points –
(1) NHAMCS is a sister survey of the National Ambulatory Medical Care Survey (NAMCS). NAMCS
collects data on visits to physicians in office-based practices
(2) NAMCS and NHAMCS are sponsored by the National Center for Health Statistics of the
Centers for Disease Control and Prevention
(3) NAMCS and NHAMCS data are used extensively by health care organizations, health services
planners, researchers, and educators
(4) Annually, there are almost 200 million visits to hospital emergency and outpatient departments
and 20 million visits to hospital-based ambulatory surgery locations
(5) The U.S. Census Bureau is the data collection agent for the study
(6) The study is authorized by Title 42, U.S. Code, Section 242k
(7) Participation is voluntary
(8) Any identifiable information will be held confidential and will be used only 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 facility. 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 of up to $250,000, or both if he or she
willfully discloses ANY identifiable information about you, your hospital and its patients
(9) NO patients’ names or identifiers are collected
(10) The study was approved by the NCHS Research Ethics Review Board or IRB
(11) Data from the study will be used only in statistical summaries
(12) NHAMCS covers hospital facilities on and off hospital grounds
(13) NHAMCS covers care provided by or under the direct supervision of a physician
(14) NHAMCS excludes office-based physicians (these are covered under the NAMCS)
(15) NHAMCS excludes visits to clinics where only ancillary services are provided, e.g., X-ray,
laboratories, and pharmacies, and where physician services are not provided, e.g., physical,
speech, and occupational therapy, and dental and podiatry clinics
(16) NHAMCS excludes the following types of ambulatory surgery locations: dentistry, podiatry,
abortion, birth center, family planning, and small procedures
(17) Only a 4-week data collection period
(18) On average, sample of approximately 100 ED, 150 to 200 OPD, and 100 ambulatory surgery
visits per hospital
SHOW PATIENT RECORD FORMS
(19) Form takes only 6 to 9 minutes to complete
(20) Forms are to be completed by hospital staff at their convenience
(21) Portion containing patient’s name or other identifying information is removed before collecting
Page 6

FORM NHAMCS-101 (11-2-2010)

Section II – INDUCTION INTERVIEW – Continued
CHECK
ITEM B-3

1
2

CHECK ITEM B = 1 (ED meets eligibility requirements)
ED does NOT meet eligibility requirements (no in item 9a) – SKIP to Part B.
Survey Implementation on page 8.

Now I would like to ask you a few more
questions about your hospital.

11a. How many days in a week are inpatient
elective surgeries scheduled?
Number of days

b. Does your hospital have a bed coordinator,
sometimes referred to as a bed czar?

1

Unknown

1

Yes
No
Unknown

2
3

c. How often are hospital bed census data
available?
Read answer categories.

1
2
3
4
5
6
7

d. Does your hospital have hospitalists on
staff?
A hospitalist is a physician whose primary
professional focus is the general care of hospitalized
patients. He/she may oversee ED patients being
admitted to the hospital.

e. Do the hospitalists on staff at your hospital
admit patients from your ED?

1
2
3

1
2
3

f. Beginning in 2011, Medicare and Medicaid will offer
incentives to facilities that demonstrate
"meaningful use of Health IT". Does your hospital
have plans to apply for Medicare or Medicaid
incentive payments for meaningful use of Health IT?

(1) In which year does your hospital expect to
apply for the meaningful use payments? . . . . .

1
2
3

1
2
3
4

Instantaneously
Every 4 hours
Every 8 hours
Every 12 hours
Every 24 hours
Other
Unknown
Yes
No
Unknown

} SKIP to item 11f

Yes
No
Unknown
Yes, we intend to apply – Go to item 11f(1)
Uncertain whether we will apply SKIP to
Part B on
No, we will not apply
page 8

}

2011
2012
After 2012
Unknown

NOTES

FORM NHAMCS-101 (11-2-2010)

Page 7

Section II – INDUCTION INTERVIEW – Continued
Part B. SURVEY IMPLEMENTATION
As I mentioned earlier, I would like to discuss the plan for conducting the study. This hospital has
been assigned to a 4-week data collection period beginning on Monday, ( _____ / _____ ).
Month

Day

First, I would like to discuss the steps needed to obtain approval for the study.

12. Are there any additional steps needed to obtain permission for the hospital to
participate in the study?
1
2

Page 8

Yes – Specify the necessary steps below
No

FORM NHAMCS-101 (11-2-2010)

Section II – INDUCTION INTERVIEW – Continued

13. Now I would like to make arrangements to
obtain the information needed for sampling.
I will need to (know/verify) how your
(emergency department/(and), outpatient
department/(and), ambulatory surgery
locations) (is/are) organized and obtain an
estimate of the number of patient visits
expected during the 4-week reporting
period. Would you prefer I (get/verify) this
information from you or someone else?

1
2

Respondent – Go to CHECK ITEM C below
Someone else – Specify below
If different respondent(s), arrange to obtain data
today if possible. Otherwise arrange an appointment
with designated person(s). Briefly explain the study to
the new respondent(s). Then proceed with Section III,
Emergency Department Description, Section IV,
Outpatient Department Description, or Section V,
Ambulatory Surgery Location Description as
appropriate. Thank current respondent for his/her
time and cooperation.

Name
Title
Department

Record on
Control Card

Telephone number
Name
Title
Department

Record on
Control Card

Telephone number
Name
Title
Department

Record on
Control Card

Telephone number

CHECK
ITEM C

1

The hospital provides emergency services that are staffed 24 hours each day. (Yes in item 9a) –
GO to Section III, EMERGENCY DEPARTMENT DESCRIPTION on page 10.

2

The hospital DOES NOT provide emergency services that are staffed 24 hours each day. (No in
item 9a) – SKIP to Check Item C-3 on page 14.

NOTES

FORM NHAMCS-101 (11-2-2010)

Page 9

Section III – EMERGENCY DEPARTMENT DESCRIPTION
To develop the sampling plan, I would like to (collect/verify) more specific information about this
hospital’s emergency department.
(1) If the hospital has previously participated, simply verify that the emergency service area(s) (ESA)
listed below is/are still operating in the hospital by –
(a) crossing through any ESAs on the list that no longer exist or are no longer operational in that hospital.
(b) adding the name(s) of any new ESA(s) that has/have been created or has/have become operational in that
hospital. For each new ESA added to the list, be sure to obtain the proper type to be entered in column (b).
(c) obtaining an estimate of visits for each ESA, covering the 4-week reporting period. Enter the estimate in
column (c).
(2) If the hospital has not previously participated, obtain a complete listing of all eligible ESAs along
with their corresponding type and expected number of visits for each ESA during the 4-week
reporting period. Record this information in columns (a), (b), and (c) below.
INSTRUCTION:
• Only record generic ESA names in column (a) (e.g., pediatric emergency department). If the ESA has a
formal/proper name, enter a generic name in (a) and record the Line No. and the formal/proper name on
page 2 of the Control Card.
FR
NOTE
Line
No.

ESA types include:
• General
• Pediatric
• Adult
• Urgent care/Fast track

• Psychiatric
• Other

Emergency service area name
(Generic)

ESA
type

(a)

(b)

Expected No. of visits
from __________ to __________

Take
every
number

Random
start
number

(c)

(d)

(e)

1
2
3
4
5
6
7
8
9
10
TOTAL
INSTRUCTIONS – Complete columns (d) and (e) after developing the sampling plan. See page 2 of
the NHAMCS-124, Sampling and Information Booklet.
Page 10

FORM NHAMCS-101 (11-2-2010)

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
CHECK
ITEM C-1

Is the total number of expected ED visits during the reporting period between
and
1
2
3

?

Yes – SKIP to item 14a
No, it is MORE THAN the range – GO to item a.
No, it is LESS THAN the range – SKIP to item b.
a. Is the number of expected visits to any of the ESAs more than twice the number shown on last year’s
sampling plan?
1

2

Yes, this is correct, visits have increased this year or were too low last year. – Explain

No, the number of visits has not increased dramatically.

✰SKIP to item 14a
b. Is the number of expected visits to any of the ESAs less than half of the number shown on last year’s
sampling plan?
1

Yes, this is correct, visits have decreased this year or were too high last year. – Explain

2

No, the number of visits has not decreased dramatically.

Now I would like to ask you some questions about your ED.

14a. Does your ED submit any CLAIMS
electronically (electronic billing)?

1
2
3

b. Does your ED verify an individual patient’s
insurance eligibility electronically, with
results returned immediately?

1
2
3

c. Does your ED use an electronic MEDICAL
record (EMR) or electronic HEALTH record
(EHR) system? Do not include billing record
systems.

1
2
3
4

Yes
No
Unknown
Yes, with a stand-alone
practice management system
Yes, with an EMR/EHR system
Yes, using another electronic system

Mark (X) only one box.

1
2
3

5
6

d. Does your ED have plans for installing a
new EMR/EHR system within the next 18
months?

1
2
3
4

FORM NHAMCS-101 (11-2-2010)

No
Unknown

}

}

Year

4

If "Other" is marked, specify the name.

5

Yes, all electronic
Yes, part paper and part electronic Go to item 14c(1)
No
Unknown SKIP to item 14d

(1) In which year did your ED install the
EMR/EHR system?
(2) What is the name of your current
EMR/EHR system?

4

Allscripts
Cerner
CHARTCARE
eClinicalWorks
Epic
eMDs

7
8
9
10
11

GE/Centricity
Greenway
Medical
MED3000
NextGen
Sage

14

SOAPware
Practice Fusion
Other

15

Unknown

12
13

Yes
No
Maybe
Unknown
Page 11

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14e. Indicate whether your ED has each of the
following computerized capabilities. Does your
ED have a computerized system for: Mark (X) only
one box per row.

(1) Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes, ask – (a) Does this include a patient problem list?

(2) Recording clinical notes? . . . . . . . . . . . . . . . . . . .

Yes

1

2

Go to
14e(1)(a)

(3) Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . .

2

1

1

(b) Are warnings of drug interactions or
containdications provided?

Skip to
14e(3)
2

1

2

Go to
14e(3)(a)
If Yes, ask – (a) Are prescriptions sent electronically to
the pharmacy?

Skip to
14e(2)
2

1

Go to
14e(2)(a)
If Yes, ask – (a) Do they include a comprehensive list of
the patient’s medications and allergies?

Yes, but
turned off
or
not used

Skip to
14e(4)

No

3

Unknown

4

Skip to
14e(2)
3

Skip to
14e(2)
4

3

4

Skip to
14e(3)
3

Skip to
14e(3)
4

3

4

Skip to
14e(4)

Skip to
14e(4)

1

2

3

4

1

2

3

4

1

2

3

4

(4) Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . .

(5) Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
14e(5)(a)
If Yes, ask – (a) Are orders sent electronically?

Skip to
14e(6)

3

4

Skip to
14e(6)

Skip to
14e(6)

1

2

3

4

1

2

3

4

(6) Providing standard order sets related to a

particular condition or procedure? . . . . . . . . . . .

(7) Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
14e(7)(a)
If Yes, ask – (a) Are results incorporated in EMR/EHR?

Skip to
14e(8)

3

4

Skip to
14e(8)

Skip to
14e(8)

1

2

3

4

(8) Viewing imaging results? . . . . . . . . . . . . . . . . . . .

1

2

3

4

(9) Viewing data on quality of care measures? . . . .

1

2

3

4

1

2

3

4

(10) Electronic reporting to immunization registries?
(11) Public health reporting? . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
14e(11)(a)
If Yes, ask – (a) Are notifiable diseases sent electronically?

Skip to
14e(12)

3

4

Skip to
14e(12)

Skip to
14e(12)

1

2

3

4

each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(13) Exchanging secure messages with patients? . .

1

2

3

4

(14) At your ED, if orders for prescriptions or lab

1

(12) Providing patients with clinical summaries for

tests are submitted electronically, who submits
them?
Mark (X) all that apply.
Page 12

2
3
4

Prescribing practitioner
Other
Prescriptions and lab test orders
not submitted electronically
Unknown
FORM NHAMCS-101 (11-2-2010)

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14f. Does your ED exchange patient clinical
summaries electronically with any other
providers?

1
2
3
4
5

(1) How does your ED electronically send or
receive patient clinical summaries?
Mark (X) all that apply.

1
2
3
4
5
6

g. Does your ED have a physically separate

1

observation or clinical decision unit?

2
3

h. What type of physicians make decisions for

1

patients in this observation or clinical
decision unit?

2

Mark (X) all that apply.

4

i. Are admitted ED patients ever "boarded" for
more than 2 hours in the ED or the
observation unit while waiting for an
inpatient bed?

j. If the ED is critically overloaded, are
admitted ED patients ever "boarded" in
inpatient hallways or in another space
outside the ED?

k. Did your ED go on ambulance diversion in
2010?

(1) What is the total number of hours that
your hospital’s ED was on ambulance
diversion in 2010?

l. Is ambulance diversion actively
managed on a regional level versus
each hospital adopting diversion if and
when it chooses?

m. Does your hospital continue to admit
elective or scheduled surgery cases when
the ED is on ambulance diversion?

3

1
2
3
1
2
3

}

Yes, send summaries only
Go to 14f(1)
Yes, receive summareis only
Yes, send and receive summaries
No
SKIP to item 14g
Unknown

}

Through EMR/EHR vendor
Through hospital-based system
Through Health Information Organization
or state exchange
Through secure email attachment
Other
Unknown
Yes
No
SKIP to item 14i
Unknown

}

ED physicians
Hospitalists
Other physicians
Unknown
Yes
No
Unknown
Yes
No
Unknown

3

Yes – GO to item 14k(1)
No
SKIP to item 14n
Unknown

1

Total number of hours
Data not available

1
2

1
2
3

}

Yes
No
Unknown

3

Yes
No
Unknown

1

Data not available

1
2

n. As of last week, how many standard
treatment spaces did your ED have?
Standard treatment spaces are beds or treatment
spaces specifically designed for ED patients to
receive care, including asthma chairs.

Total number of standard treatment spaces

o. As of last week, how many other
treatment spaces did your ED have?
Other treatment spaces are other locations where
patients might receive care in the ED, including
chairs, stretchers in hallways that may be used
during busy times.

p. In the last two years, has your ED increased
the number of standard treatment spaces?

Total number of other treatment spaces
1

Data not available

1

Yes
No
Unknown

2
3

FORM NHAMCS-101 (11-2-2010)

Page 13

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued

14q. In the last two years, has your ED’s physical
space been expanded?

1
2
3

r. Do you have plans to expand your ED’s
physical space within the next two years?

1
2
3

Yes
No
Unknown
Yes
No
Unknown

s. Does your ED use —
Show flashcard on page 31 of the NHAMCS-124.
Mark (X) only one box.
Yes

No

(1) Bedside registration

1

2

3

(2) Computer-assisted triage

1

2

3

(3) Separate fast track unit for nonurgent care

1

2

3

(4) Separate operating room dedicated to ED patients

1

2

3

(5) Electronic dashboard (i.e., displays updated patient information
and integrates multiple data sources)

1

2

3

(6) Radio frequency identification (RFID) tracking (i.e., shows exact
location of patients, caregivers, and equipment)

1

2

3

(7) Zone nursing (i.e., all of a nurse’s patients are located
in one area)

1

2

3

(8) Pool nurses (i.e., nurses that can be pulled to the ED to respond
to surges in demand)

1

2

3

(9) Full capacity protocol (i.e., allows some admitted patients to
move from the ED to inpatient corridors while awaiting a bed)

1

2

3

CHECK
ITEM C-3

1

2

Unknown

The hospital has an organized outpatient department that provides physician services. (Yes in items 10a
and b) – SKIP to Section IV, OUTPATIENT DEPARTMENT DESCRIPTION on page 15.
The hospital does not have an organized outpatient department that provides physician services. (No
in items 10a or 10b) – SKIP to Section V, AMBULATORY SURGERY LOCATION DESCRIPTION on
page 20.

NOTES

Page 14

FORM NHAMCS-101 (11-2-2010)

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION
To develop the sampling plan, I would like to (collect/verify) more specific information about
this hospital’s outpatient department.
(1) If the hospital has previously participated, simply verify that the clinic(s) listed on page 16 is (are) still operating in
the hospital by –
(a) crossing through any clinics on the list which no longer exist or are no longer operational in that hospital.
(b) adding the name(s) of any new clinic(s) which has/have been created or become operational in that hospital.
For each new clinic added to the list, be sure to obtain the proper specialty code. Remember, include only
ELIGIBLE clinics.
(c) obtaining an estimate of visits for each clinic, covering the 4-week reporting period. Enter the estimate in
column (d).
(d) If this Outpatient Department has more than 5 clinics – FAX the updated list to your regional office.
The regional office will choose the clinics for sample and provide you with the sampling instructions. Upon
receiving the instructions, attach a copy of the completed clinic listing showing sampled clinics, the Take Every
and Random Start numbers, etc., to the NHAMCS-101(C) Control Card.
(2) If the hospital has not previously participated or a clinic list is not attached to NHAMCS-101(C) Control Card,
obtain a complete listing of all eligible outpatient clinics along with their corresponding specialty group code,
and expected number of visits for each clinic during the 4-week reporting period. Record this information in
columns (a), (b), and (d) on the next page.

NOTES

FORM NHAMCS-101 (11-2-2010)

Page 15

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
FR
NOTE

OPD Specialty Groups include:
• GM – General Medicine
• PED – Pediatrics
• SURG – Surgery
• OBG – Obstetrics/Gynecology

• SA – Substance Abuse
• OTHER – Other

INSTRUCTIONS
• Only record generic clinic names in column (a) (e.g., pediatric clinic). If the clinic has a formal/proper name, enter a
generic clinic name in (a) and record the Line No. and the formal/proper name on page 2 of the control card.
• Complete columns (b) and (c) using pages 7 to 17 of the NHAMCS-124, Sampling and Information Booklet.
Complete columns (e) and (f) after developing the sampling plan. See page 4 of the NHAMCS-124 for instructions.

Line
No.

Outpatient department clinic name
(Generic)
(a)

Specialty
group

NHAMCS-124
Specialty
Group Scope

(b)

(c)

1

In-Scope
Out-of-Scope

2

In-Scope
Out-of-Scope

3

In-Scope
Out-of-Scope

4

In-Scope
Out-of-Scope

5

In-Scope
Out-of-Scope

6

In-Scope
Out-of-Scope

7

In-Scope
Out-of-Scope

8

In-Scope
Out-of-Scope

9

In-Scope
Out-of-Scope

10

In-Scope
Out-of-Scope

11

In-Scope
Out-of-Scope

12

In-Scope
Out-of-Scope

13

In-Scope
Out-of-Scope

14

In-Scope
Out-of-Scope

15

In-Scope
Out-of-Scope

Expected No. of visits
from __________ to __________

Take
every
number

Random
start
number

(d)

(e)

(f)

TOTAL

Page 16

FORM NHAMCS-101 (11-2-2010)

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
CHECK
ITEM D

CHECK
ITEM D-1

1
2

At least one OPD Clinic in-scope.
All OPD Clinics out-of-scope – SKIP to Section V, AMBULATORY SURGERY CENTER
DESCRIPTION on page 20.

Is the total number of expected OPD visits during the reporting period between
and
?
Yes – SKIP to item 14t
No, it is MORE THAN the range – GO to item a.
2
3
No, it is LESS THAN the range – SKIP to item c.
a. Compare to previous sampling plan. Are there more clinics this year compared to last year? (If "Yes"
then verify scope and ownership of the new clinics this year, make changes if needed, and then check
one of the following responses.)
1
Yes, this is correct, some clinics have opened or should have been included last year. – List
1

No, the number of clinics has not increased.

2

b. Is the number of expected visits to any of the clinics more than twice the number shown on last year’s
sampling plan?
Yes, this is correct, visits have increased this year or were too low last year. – Explain
1

2

No, the number of visits has not increased dramatically.
✰ SKIP to item 14t

c. Compare to previous sampling plan. Are there fewer clinics this year compared to last year?
Yes, this is correct, some clinics have closed or shouldn’t have been included last year. – List
1

2

No, the number of clinics has not decreased.

d. Is the number of expected visits to any of the clinics less than half of the number shown on last year’s
sampling plan?
1
Yes, this is correct, visits have decreased this year or were too high last year. – Explain

No, the number of visits has not decreased dramatically.
Now I would like to ask you some questions about your OPD.
2

14t. Does your OPD submit any CLAIMS
electronically (electronic billing)?

1
2
3

u. Does your OPD verify an individual patient’s
insurance eligibiltiy electronically, with
results returned immediately?

1
2
3

v. Does your OPD use an electronic MEDICAL
record (EMR) or electronic HEALTH record
(EHR) system? Do not include billing record
systems.

1
2
3
4

(1) In which year did your OPD install the
EMR/EHR system?
(2) What is the name of your current
EMR/EHR system?
Mark (X) only one box.
If "Other " is marked, specifiy the name.
FORM NHAMCS-101 (11-2-2010)

Yes
No
Unknown
Yes, with a stand-alone practice
management system
Yes, with an EMR/EHR system
Yes, using another electronic system

4
5

No
Unknown

Yes, all electronic
Yes, part paper and part electronic Go to item 14v(1)
No
SKIP to item 14w
Unknown

}

}

Year
1
2
3
4
5
6

Allscripts
Cerner
CHARTCARE
eClinicalWorks
Epic
eMDs

7
8
9
10
11

GE/Centricity
Greenway
Medical
MED3000
NextGen
Sage

14

SOAPware
Practice Fusion
Other

15

Unknown

12
13

Page 17

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued

14w. Does your OPD have plans for installing a new
EMR/EHR system within the next 18 months?

1
2
3
4

Yes
No
Maybe
Unknown

x. Indicate whether your OPD has each of the following
computerized capabilities. Does your OPD have a
computerized system for: Mark (X) only one box per row.

Yes

Yes, but
turned off
or
not used

No

Unknown

(1) Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Go to
14x(1)(a)
If Yes, ask – (a) Does this include a patient problem list?

(2) Recording clinical notes? . . . . . . . . . . . . . . . . . . .

1
1

Go to
14x(2)(a)
If Yes, ask – (a) Do they include a comprehensive list of
the patient’s medications and allergies?

(3) Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . .

1
1

Go to
14x(3)(a)
If Yes, ask – (a) Are prescriptions sent electronically to
the pharmacy?
(b) Are warnings of drug interactions or
containdications provided?

2

Skip to
14x(2)
2
2

Skip to
14x(3)
2
2

Skip to
14x(4)

3

4

Skip to
14x(2)
3

Skip to
14x(2)
4

3

4

Skip to
14x(3)
3

Skip to
14x(3)
4

3

4

Skip to
14x(4)

Skip to
14x(4)

1

2

3

4

1

2

3

4

1

2

3

4

(4) Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . .

(5) Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . .

1

Go to
14x(5)(a)
If Yes, ask – (a) Are orders sent electronically?

2

Skip to
14x(6)

3

4

Skip to
14x(6)

Skip to
14x(6)

1

2

3

4

1

2

3

4

(6) Providing standard order sets related to a
particular condition or procedure? . . . . . . . . . . .

(7) Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . .

1

Go to
14x(7)(a)
If Yes, ask – (a) Are results incorporated in EMR/EHR?

2

Skip to
14x(8)

3

4

Skip to
14x(8)

Skip to
14x(8)

1

2

3

4

(8) Viewing imaging results? . . . . . . . . . . . . . . . . . . .

1

2

3

4

(9) Viewing data on quality of care measures? . . .

1

2

3

4

(10) Electronic reporting to immunization registries?

1

2

3

4

(11) Public health reporting? . . . . . . . . . . . . . . . . . . . .

1

Go to
14x(11)(a)
If Yes, ask – (a) Are notifiable diseases sent electronically?

2

Skip to
14x(12)

3

4

Skip to
14x(12)

Skip to
14x(12)

1

2

3

4

each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(13) Exchanging secure messages with patients? .

1

2

3

4

(12) Providing patients with clinical summaries for

Page 18

FORM NHAMCS-101 (11-2-2010)

Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued

(14) At your OPD, if orders for prescriptions or lab
tests are submitted electronically, who
submits them?
Mark (X) all that apply.

1
2
3
4

y. Does your OPD exchange patient clinical summaries
electronically with any other providers?

1
2
3
4
5

(1) How does your OPD electronically send or receive
patient clinical summaries?
Mark (X) all that aplly.

1
2
3
4
5
6

Prescribing practitioner
Other
Prescriptions and lab test orders not
submitted electronically
Unknown

}

Yes, send summaries only
Go to
Yes, receive summaries only
14y(1)
Yes, send and receive summaries
No
SKIP to Check item E
Unknown

}

Through EMR/EHR vendor
Through hospital-based system
Through Health Information Organization
or state exchange
Through secure email attachment
Other
Unknown

NOTES

FORM NHAMCS-101 (11-2-2010)

Page 19

Section V – AMBULATORY SURGERY LOCATION DESCRIPTION
CHECK
ITEM E

1
2

Hospital has at least one ambulatory surgery location (Yes in item 10c).
Hospital does not have any ambulatory surgery locations – SKIP to Section VI, DISPOSITION AND
SUMMARY on page 23.

15a. Does this hospital have any satellite

1

facilities which perform ambulatory
(outpatient) surgery?

2

Yes – Continue with item 15b.
No – SKIP to developing sampling plan

Name

b. What are the names, addresses, and
telephone numbers of the satellite
facilities?

Address

RECORD UP TO 3 ON
CONTROL CARD

Telephone number
(Area code and number)

To develop the sampling plan, I would like to (collect/verify) more specific information about this
hospital’s ambulatory surgery locations.
Obtain an estimate of ambulatory (outpatient) surgery cases for each ambulatory surgery location, covering the 4-week
reporting period. Enter the estimate in column (d) of the listing below.

FR
NOTE

In-scope locations:
• Laser procedures
• General or main operating room
• Cystoscopy room
room
• Dedicated ambulatory surgery room • Endoscopy room
•
• Satellite operating room
• Cardiac catheterization Pain block room
lab
Specialty groups include:
• GEN – General
• MULTI – Multi-specialty

• GI – Gastroenterology
• OPH – Ophthalmology

• ORTHO – Orthopedics
• PAIN – Pain Block

Out-of-scope locations:
• Dentistry
• Podiatry
• Family planning • Abortion
• Small procedures • Birth center
• PLASTIC – Plastic Surgery
• OTHER – Other specialty

INSTRUCTIONS
• Only record generic ambulatory surgery location names in column (a) (e.g., pain block room, cardiac cath lab). If the
ambulatory surgery location has a formal/proper name, enter a generic name in (a) and record the Line No. and the
formal/proper name on page 2 of the Control Card.
• Record the specialty group acronym in column (b).
• Complete columns (e) and (f) after developing the sampling plan. See page 18 of the NHAMCS-124 for instructions.
Line
No.

Name of ambulatory surgery location
(Generic)

Specialty
group

AU
number

(a)

(b)

(c)

Expected No. of ambulatory
(outpatient) surgery cases
from __________ to __________
(d)

Take
every
number

Random
start
number

(e)

(f)

1
2
3
4
5
6
7
8
TOTAL
CHECK
ITEM F
Page 20

1
2

Hospital has only 1 ambulatory surgery location – SKIP to Item 15e.
Hospital has more than 1 ambulatory surgery location – Continue with item 15c.
FORM NHAMCS-101 (11-2-2010)

Section V – AMBULATORY SURGERY LOCATION DESCRIPTION – Continued

15c. Now I have some questions about generating a report for all outpatient surgery patients
for sampling.
Would you or your IT staff be able to
generate a single list of outpatient surgery
cases for the following locations?
(Read each ambulatory surgery location name listed
on the previous page.)

2
3

d. Would you or your IT staff be able to
generate one list of outpatient surgery
cases for some of these locations?
Record the name and telephone number of the IT
contact on the Control Card.
Give a copy of the "Single Sampling List
Instructions" to the IT contact.
FR
NOTE

}

Yes
SKIP to item 15e
No – ONLY 2 LOGS
No – More than 2 logs – Continue with item 15d.

1

Yes
No – Continue with item 15e.

1
2

IT Contact name

RECORD ON

CONTROL CARD
Telephone number
(Area code and number)
If multiple logs were combined into one list, then assign the same AU number to each location and record in
column (c) on page 20.

Now I would like to ask you some questions about your Ambulatory Surgery Location.

e. Does your ambulatory surgery location

1

submit any CLAIMS electronically
(electronic billing)?

2
3

f. Does your ambulatory surgery location

1

verify an individual patient’s insurance
eligibility electronically, with results
returned immediately?

2
3

g. Does your ambulatory surgery location use

1

an electronic MEDICAL record (EMR) or
electronic HEALTH record (EHR) system?
Do not include billing record systems.

2
3
4

Yes
No
Unknown
Yes, with a stand-alone practice
management system
Yes, with an EMR/EHR system
Yes, using another electronic system

5

No
Unknown

Yes, all electronic
Yes, part paper and part electronic Go to item 15g(1)
No
SKIP to item 15h
Unknown

}

}

(1) In which year did your ambulatory
surgery location install the EMR/EHR
system?

Year

(2) What is the name of your current
EMR/EHR system?

1
2

Mark (X) only one box.

3
4

If "Other" is marked, specify the name.

5
6

h. Does your ambulatory surgery location have
plans for installing a new EMR/EHR system
within the next 18 months?

1
2

Allscripts
Cerner
CHARTCARE
eClinicalWorks
Epic
eMDs
Yes
No

location has each of the following computerized
capabilities. Does your ambulatory surgery
location have a computerized system for: Mark (X)
only one box per row.

(1) Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes, ask – (a) Does this include a patient problem list?

(2) Recording clinical notes? . . . . . . . . . . . . . . . . . . . .
If Yes, ask – (a) Do they include a comprehensive list of
the patient’s medications and allergies?

7
8
9
10
11

3
4

i. Indicate whether your ambulatory surgery

FORM NHAMCS-101 (11-2-2010)

4

Yes
1

Go to
15i(1)(a)
1
1

Go to
15i(2)(a)
1

GE/Centricity
Greenway
Medical
MED3000
NextGen
Sage

14

SOAPware
Practice Fusion
Other

15

Unknown

12
13

Maybe
Unknown
Yes, but
turned off
or
not used
2

Skip to
15i(2)
2
2

Skip to
15i(3)
2

No
3

Skip to
15i(2)
3
3

Skip to
15i(3)
3

Unknown
4

Skip to
15i(2)
4
4

Skip to
15i(3)
4

Page 21

Section VI –SURGERY
DISPOSITION
AND SUMMARY
Section V – AMBULATORY
LOCATION
DESCRIPTION – Continued
Yes, but
turned off
or
not used

Yes

(3) Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
15i(3)(a)
If Yes, ask – (a) Are prescriptions sent electronically to
the pharmacy?
(b) Are warnings of drug interactions or
containdications provided?

Skip to
15i(4)

No

Unknown

3

4

Skip to
15i(4)

Skip to
15i(4)

1

2

3

4

1

2

3

4

1

2

3

4

(4) Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . .

(5) Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
15i(5)(a)
If Yes, ask – (a) Are orders sent electronically?

Skip to
15i(6)

3

4

Skip to
15i(6)

Skip to
15i(6)

1

2

3

4

1

2

3

4

(6) Providing standard order sets related to a
particular condition or procedure? . . . . . . . . . . .

(7) Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
15i(7)(a)
If Yes, ask – (a) Are results incorporated in EMR/EHR?

Skip to
15i(8)

3

4

Skip to
15i(8)

Skip to
15i(8)

1

2

3

4

(8) Viewing imaging results? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(9) Viewing data on quality of care measures? . . . .

1

2

3

4

1

2

3

4

(10) Electronic reporting to immunization registries?
(11) Public health reporting? . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
15i(11)(a)
If Yes, ask – (a) Are notifiable diseases sent
electronically?

Skip to
15i(12)

3

4

Skip to
15i(12)

Skip to
15i(12)

1

2

3

4

each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(13) Exchanging secure messages with patients? . .

1

2

3

4

(14) At your ambulatory surgery location, if orders

1

(12) Providing patients with clinical summaries for

for prescriptions or lab tests are submitted
electronically, who submits them?
Mark (X) all that apply.

15j. Does your ambulatory surgery location
exchange patient clinical summaries
electronically with any other providers?

2
3
4
1
2
3
4
5

(1) How does your ambulatory surgery location
electronically send or receive patient clinical
summaries?
Mark (X) all that apply.

1
2
3
4
5
6

Page 22

Prescribing practitioner
Other
Prescriptions and lab test orders
not submitted electronically
Unknown

}

Yes, send summaries only
Go to
Yes, receive summaries only
15j(1)
Yes, send and receive summaries
No
Skip to 16a
Unknown

}

Through EMR/EHR vendor
Through hospital-based system
Through Health Information Organization
or state exchange
Through secure email attachment
Other
Unknown
FORM NHAMCS-101 (11-2-2010)

Section VI – DISPOSITION AND SUMMARY
AMBULATORY UNIT CHECKLIST
• COMPLETE 16a FOR EMERGENCY
DEPARTMENT ONLY
16a. How many emergency service areas
were selected for sample?

Number of ESAs

Enter 0 if no ESAs were selected for sample.
Did you include a NHAMCS-101(U)
for each?

1
2

Yes
No – Explain

• COMPLETE 16b FOR OUTPATIENT
DEPARTMENT ONLY

b. How many clinics were selected for sample?

Number of Clinics

Enter 0 if no clinics were selected for sample.
Did you include a NHAMCS-101(U)
for each?

• COMPLETE 16c FOR AMBULATORY
SURGERY LOCATIONS ONLY
c. How many ambulatory surgery locations were
selected for sample?
Enter 0 if no ambulatory surgery locations were
selected for sample.
Did you include a NHAMCS-101(U)
for each log/list?

1
2

Yes
No – Explain

Number of ambulatory surgery locations
1
2

Yes
No – Explain

FORMS COMPLETED

d. Number of ED Patient Record Forms completed

Number of ED PRFs

e. Number of OPD Patient Record Forms completed

Number of OPD PRFs

f. Number of ambulatory surgery Patient Record
Forms completed

17.

FINAL DISPOSITION

Number of ambulatory surgery PRFs
1
2
3
4
5

18.

NATURE OF REFUSAL
Mark (X) all that apply.

1
2
3
4
5
6

}

All eligible units completed END interview
Patient Record Forms
Some eligible units completed
GO to Item 18
Patient Record Forms
Hospital refused
Hospital closed
END interview
Hospital ineligible

}

}

Entire ED refused
Entire OPD refused
All ambulatory surgery locations refused
Some ESAs refused
Some clinics refused
Some ambulatory surgery locations refused

FR NOTE – If one or more responses are marked in 18, complete Section VII,
NONINTERVIEW on page 24. If no responses marked, END INTERVIEW.
FORM NHAMCS-101 (11-2-2010)

Page 23

Section VII – NONINTERVIEW

19a. At what point in the interview

ED

Hospital

did the refusal/breakoff occur?
Mark (X) appropriate box(es)
(1) During the telephone
screening

OPD

Ambulatory Surgery

1

(2) During the hospital induction
(3) During the ED/OPD/
Ambulatory Surgery induction
(4) After the ED/OPD/
Ambulatory Surgery
induction, but prior to
assigned reporting period
(5) During the assigned
reporting period

2

3

3

3

3

4

4

4

4

5

5

5

5

1

1

1

1

2

2

2

3

3

3

b. By whom?
(1) Hospital administrator
(2) ED/OPD/Ambulatory
Surgery Director
(3) Approval board or official

3

(4) Other hospital official

(5) Was the refusal by
telephone or in person?

5
6

4

4

4

4

Specify

Specify

Specify

Specify

Telephone
In person

5
6

Telephone
In person

5
6

Telephone
In person

5
6

Telephone
In person

c. What reason was given? Please specify if hospital, ED, OPD, or Ambulatory Surgery (from item 19a) before
recording responses.

d. Was conversion attempted?

Hospital
1
2

Page 24

Yes
No

ED
1
2

Yes
No

OPD
1
2

Yes
No

Ambulatory Surgery
1
2

Yes
No

FORM NHAMCS-101 (11-2-2010)

NOTES

FORM NHAMCS-101 (11-2-2010)

Page 25

NOTES

Page 26

FORM NHAMCS-101 (11-2-2010)