B - Changes to Patient Record Form

Attachment B

Changes to 2014 NAMCS Patient Record Form (PRF)

Proposed changes are indicated in RED.

• Modified-Expected source(s) of payment for this visit

Old Answer list Private insurance Medicare Medicaid or CHIP Worker’s compensation Self-pay No charge/Charity Other Unknown

New Answer list Private insurance Medicare Medicaid or CHIP or other state-based program Workers’ compensation Self-pay No charge/Charity Other Unknown

• Modified-Tobacco use

Old Answer list Not current Current Unknown

New Answer list Not current Never Former Current Unknown

• Modified-Reason for Visit Questions

“Reason for Visit” Section
Old Allow up to 3 lines of Reason for visit verbatim and look-up	New Allow up to 5 lines of Reason for visit verbatim and look-up
Major reason for this visit checkboxes New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Pre/Post surgery Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)	Major reason for this visit checkboxes New problem (<3 mos. onset) Chronic problem, routine Chronic problem, flare-up Pre-surgery Post-surgery Preventive care (e.g., routine prenatal, well-baby, screening, insurance, general exams)

• Modified-Injury/Poisoning/Adverse Effect Questions

“Injury/Poisoning/Adverse Effect” Section
Old INJURY: Is this visit related to an injury, poisoning, or adverse effect of medical treatment? Yes, injury/trauma Yes, poisoning Yes, adverse effect of medical treatment No Unknown	New INJURY: Is this visit related to an injury, poisoning, or adverse effect of medical treatment? Yes, injury/trauma Yes, poisoning Yes, adverse effect of medical/surgical care or adverse effect of medicinal drug No Unknown
	Add new question on recent timing of injury: If INJURY=Yes, then ask, Did the injury or poisoning occur within 72 hours prior to the date and time of this visit?
Is this injury/poisoning unintentional or intentional? Unintentional Intentional Unknown	Is this injury/overdose/poisoning intentional or unintentional? Intentional Unintentional (e.g., accidental) Intent unclear
	Add new question for verbatim cause of injury narrative: “Cause of injury, poisoning, or adverse effect” verbatim

• Modified-Diagnosis Verbatim and Look-up Table

Old: Allow up to 3 diagnoses verbatim and Look-up table entries

New: Allow up to 5 diagnoses verbatim and look-up table entries

• Modified-Checkbox list of patient’s underlying chronic conditions

Regardless of the diagnoses previously entered, does the patient now have -
Mark all that apply.
Old	New
---	Alcohol misuse, abuse, or dependence
---	Substance abuse or dependence
---	Alzheimer's disease/Dementia
Arthritis	Arthritis
Asthma	Asthma
Cancer	Cancer
Cerebrovascular disease/History of stroke or transient ischemic attack (TIA)	Cerebrovascular disease/stroke (CVA) or transient ischemic attack (TIA)
Chronic obstructive pulmonary disease (COPD)	Chronic obstructive pulmonary disease (COPD)
Chronic renal failure	Chronic kidney disease (CKD)
Chronic renal failure	End-stage renal disease (ESRD)
Congestive heart failure	Congestive heart failure (CHF)
Depression	Depression
Diabetes	Diabetes mellitus (DM) If checked, then ask sub-categories for Type I & Type II.
---	History of pulmonary embolism (PE) or deep vein thrombosis (DVT)
---	HIV Infection/AIDS
Hyperlipidemia	Hyperlipidemia
Hypertension	Hypertension
Ischemic heart disease	Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI)
Obesity	Obesity
---	Obstructive sleep apnea (OSA)
Osteoporosis	Osteoporosis
None of the above	None of the above

• Modified-Services Ordered or Provided

Enter all examinations, laboratory tests, imaging, other procedures or other treatment and health education or counseling ORDERED or PROVIDED.

• NONE

Examinations/Screenings:

• Alcohol misuse screening (includes AUDIT, MAST, CAGE, T-ACE)

• Breast

• Depression screening

• Domestic violence screening

• Foot

• General physical exam (DELETE)

• Neurologic

• Pelvic

• Rectal

• Retinal/ Eye Exam

• Skin

• Substance abuse screening (includes NIDA/NM ASSIST, CAGE-AID, DAST-10)

Blood tests: Laboratory tests:

• Basic metabolic panel

• CBC

• Chlamydia test

• Comprehensive metabolic panel

• Creatinine /Renal function panel

• Culture

  • Blood

  • Throat

  • Urine

  • Other

• Glucose, serum

• Gonorrhea test

• HbA1c (Glycohemoglobin)

• Hepatitis testing/Hepatitis panel

• HIV test (NEW LOCATION)

• HPV DNA test (NEW LOCATION)

• Lipid profile

• Liver enzymes/Hepatic function panel

• PAP test (NEW LOCATION)

• Pregnancy/HCG test (NEW LOCATION)

• PSA (prostate specific antigen)

• Rapid strep test

• TSH/Thyroid panel

• Urinalysis (NEW LOCATION)

• Vitamin D test

Imaging:

• Bone mineral density

• CT scan

• Echocardiogram

• Ultrasound

• Mammography

• MRI

• X-ray

Other tests and procedures: Procedures:

• Audiometry

• Biopsy

• Cardiac stress test

• Colonoscopy

• Cryosurgery (cryotherapy)/ Destruction of tissue

• EKG/ECG

• Electroencephalogram (EEG)

• Electromyogram (EMG)

• Excision of tissue

• Fetal monitoring

• Peak flow

• Sigmoidoscopy

• Spirometry

• Tonometry

• Tuberculosis skin testing/PPD

• Upper gastrointestinal endoscopy/EGD

Non-medication treatment: Treatments:

• Cast/splint/wrap

• Complementary and alternative medicine (CAM)

• Durable medical equipment

• Home health care

• Mental health counseling, excluding psychotherapy

• Occupational therapy

• Physical therapy

• Psychotherapy

• Radiation therapy

• Wound care

Health education/Counseling:

• Alcohol abuse counseling

• Asthma

• Asthma action plan given to patient

• Diabetes education

• Diet/Nutrition

• Exercise

• Family planning/Contraception

• Genetic counseling

• Growth/Development

• Injury prevention

• STD prevention

• Stress management

• Substance abuse counseling

• Tobacco use/Exposure

• Weight reduction

Other services not listed:

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Other service - Specify__________________________________________

• Modified-Medications and Immunizations

Old: Allow up to 10 drug entries (verbatim and look-up table)

New: Allow up to 30 drug entries (verbatim and look-up table)

• Modified-Time spent with physician

Old: Time spent with physician

New: Estimated time spent with physician

• Modified-Visit disposition

Old Mark (X) all that apply. Refer to other physician Return at specified time Refer to ER/Admit to hospital Other

New Mark (X) all that apply Return to referring physician Refer to other physician Return at specified time-less than 1 week Return at specified time-1 week to less than 2 months Return at specified time-2 months or greater Return as needed (p.r.n.) Return to ER/Admit to hospital Other

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