Form unnumbered Att. I. Freestanding ASC Induction Form

National Hospital Ambulatory Medical Care Survey

NHAMCS2010 Attachment I - NHAMCS-101FS

Freestanding ASC Induction Form

OMB: 0920-0278

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0278 can be found here:

Document [pdf]

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Form Approved: OMB No. 0920-0278
NOTICE – Public reporting burden of this collection of information is estimated to average 90 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).

NOTES

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(FS)
(4-9-2009)

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
FREE–STANDING AMBULATORY SURGERY CENTERS
2010 PANEL

2a. ASC administrator contact information

b. ASC contact information

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
Section I – TELEPHONE SCREENER

3. Field representative

4. Record of telephone calls

information

Call

Date

Time

Results

FR Code
Telephone screener

1
FR Code

ASC induction
3

5. Final outcome of ASC screening
1

Appointment
Day

Date

Noninterview – Complete sections V and VI on page 19.

NOTES

Page 20

FORM NHAMCS-FS (4-9-2009)

Time

USCENSUSBUREAU

a.m.
p.m.

During your initial call to the ASC, 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 V – DISPOSITION AND SUMMARY

Section I – TELEPHONE SCREENER – Continued
Part A. INTRODUCTION

AMBULATORY UNIT CHECKLIST

Good (morning/afternoon) . . ., my name is (Your name). I am calling for the Centers for Disease
Control and Prevention concerning their study of ambulatory surgery in free-standing ambulatory
surgery centers and in hospitals. 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.

16a. How many ASCs were selected for sample?
Enter 0 if no ASCs were selected for sample.
Did you include a NHAMCS-101(U)
for each?

Number of ASCs
Yes
No – Explain

1
2

6. Did you receive the letter(s)?
(If "No" or "DK," offer to send or deliver another copy.)

1
2
3

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

1
2

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

b. Number of ASC Patient Record Forms completed

RECORD ON CONTROL CARD

17a. FINAL DISPOSITION

Number of ASC PRFs
All eligible units completed
END interview
Patient Record Forms
Some eligible units completed
GO to Item 17b
Patient Record Forms
ASC refused
Complete Section VI,
ASC closed
NONINTERVIEW
ASC ineligible

}
}

1
2

b. Is your ASC located at (Read address from
Control Card)?

1
2

Yes
No – Enter ASC location

}

3
4

Number and street

RECORD ON CONTROL CARD
City State ZIP Code

c. Is this also the mailing address?

b. NATURE OF REFUSAL

Yes
No – Enter correct mailing address

FR NOTE – If one or more responses are marked in 17b, complete Section VI,
NONINTERVIEW. If no responses marked, END INTERVIEW.
Section VI – NONINTERVIEW

Number and street

RECORD ON CONTROL CARD
City State ZIP Code
STATEMENT A

Mark (X) all that apply.
1

Entire ASC refused
Some ASCs refused

18. What is the reason the ASC did not
participate in this study?

1
2
3

(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.

}

ASC closed
END INTERVIEW
ASC not eligible
ASC refused – SKIP to Item 19a
Other – Specify

Part B. VERIFICATION OF ELIGIBILITY
INTRODUCTION
STATEMENT B1

The National Center for Health Statistics of the Centers for Disease Control
and Prevention is conducting an annual study of ambulatory care. The study
began data collection in 1992. Beginning in 2010, free-standing ASCs are
being included in the study. CDC has contracted with the U.S. Census Bureau
to collect the data. (Name of ASC) has been selected to participate
in the study. I am calling to arrange an appointment to discuss your
participation. 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 ASC) to be sure we have correctly included this ASC in the study.

8a. Is ambulatory (outpatient) surgery or
ambulatory diagnostic or therapeutic
procedures currently performed in this facility?

1
2

are exclusively family planning clinics,
birthing centers, abortion clinics, podiatry
centers or dentistry centers.

19a. At what point in the interview did the
refusal/breakoff occur?
Mark (X) appropriate box(es)

1
2
3
4

b. By whom?

1
2

Yes
No – SKIP to CHECK ITEM B on page 4.

3
4

NOTE: Do not ask item 8b if facility is an eye
surgery center.

b. In this study we are excluding facilities that

END INTERVIEW

c. Was the refusal by telephone or in person?

1
2

Yes – SKIP to CHECK ITEM B on page 4.
Continue with item 9.

d. What reason was given?

Yes
No

e. Was conversion attempted?

During the telephone screening
During the ASC induction
After the ASC induction, but prior to assigned
reporting period
During the assigned reporting period
ASC administrator
ASC director
Approval board or official
Other ASC official
Telephone
In person

Is (Name of facility) exclusively one of these?

9. Is this facility currently licensed by the state?

1
2

Page 2

1
2

FORM NHAMCS-101(FS) (4-9-2009)

Yes
No
Page 19

Section I – TELEPHONE SCREENER – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section H – FINAL DISPOSITION
1. FINAL DISPOSITION

Part B. VERIFICATION OF ELIGIBILITY

10. It is important for us to determine whether

Ambulatory unit
1

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

Refused

Closed
a
Temporary
b
Permanent
Ineligible
a
AU not under auspices of ASC
b
Only ancillary services provided
c
AU classified as out-of-scope
d
Other – Specify

}

or not your facility operates under the
License or Provider of Services (POS)
number of a parent facility.

a. Does your ASC operate under the license of
a parent facility?

b. Does your ASC operate under the Provider
END

of Services (POS) number of a parent
facility?
CHECK
ITEM A

Refer to items 10a and 10b.
Is "Yes" marked in ANY of these items?

1
2

Yes
No
Yes
No
Yes – What is the name and address of
your parent facility?

Number and street

RECORD ON CONTROL CARD
City State ZIP Code
Thank you for your time and assistance.
We may contact you again in a few days
regarding participation in this study.

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

1
2
3
4

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

11. Is this facility owned, operated, or managed
by –

No – SKIP to CHECK ITEM B on page 4.

A hospital
One or more physicians
Health maintenance organization
Another health care provider
A health care corporation that owns multiple
health care facilities (e.g., HCA or Health South)
Other

Yes – What is the specialty?

Yes
No

2
3
4
5

NOTES
12a. Is the ambulatory (outpatient) surgery
performed here primarily one specialty?

b. Is the ambulatory (outpatient) surgery
performed here multi-specialty?

– SKIP to Item 13

NOTES

Page 18

FORM NHAMCS-101(FS) (4-9-2009)

Page 3

Section I – TELEPHONE SCREENER – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section D – VERIFICATION OF ESTIMATED VISITS

Part B. VERIFICATION OF ELIGIBILITY

13a. Does this facility have any satellite
facilities which perform ambulatory
(outpatient) surgery?

1
2

Yes – Continue with item 13b
No – SKIP to Check Item B

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

Name

Record on
Control Card

Address

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

2. About how many visits do you expect during the

Revised estimate

reporting period,

Name

Record on
Control Card

Name

Record on
Control Card

Address

b. Is the result of (a) between 0.7 and 1.3?
1
2

3
4

CHECK
ITEM
B-1

ASC meets eligibility requirements (item 8 is YES) – SKIP to Check Item B-1
ASC is ineligible because it does not perform ambulatory surgery (item 8 is NO) – Go to
CLOSING STATEMENT B1 on page 5.
ASC is ineligible because it operates under a parent facility that is on the sampling frame – Go to
CLOSING STATEMENT B2 on page 5.
ASC is ineligible because specialty is out-of-scope (item 8b is YES) – Go to
CLOSING STATEMENT B3 on page 5 (item 10a is YES).

Yes – SKIP to item a
No – SKIP to Part C. STUDY DESCRIPTION on page 5

a. Determine whether facility has an eligible ASC and if so,
inquire as to how many visits are expected during the
reporting period.

(Result)

New Take Every

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

New Random Start

Section G – PATIENT RECORD FORM INFORMATION

ASC refused
1

Yes – SKIP to section G
No

1. Calculate new Take Every, using the appropriate table
(page 18) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).

Telephone number

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ASC

Telephone number

Revised estimate
Original estimate

Address

CHECK
ITEM B

Yes – SKIP to section G
No

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

Telephone number

1. Enter the range of Patient Record Forms that were ACTUALLY used by the unit.
FIRST FOLIO

FROM:

TO:

SECOND FOLIO

FROM:

TO:

THIRD FOLIO

FROM:

TO:

NOTES
Eligible ASC?
1
2

Yes –
No

expected visits

b. If unable to determine expected visits for the assigned reporting period, obtain the number of
visits to the facility last year.
ASC visits
last year
Go to Section V, DISPOSITION AND SUMMARY on page 19.
Page 4

FORM NHAMCS-101(FS) (4-9-2009)

Page 17

Section IV – AMBULATORY UNIT RECORD

Section I – TELEPHONE SCREENER – Continued

COMPLETE FOR EACH AMBULATORY UNIT SELECTED
Section A – AMBULATORY UNIT INFORMATION
a. Mark (X) specialty —
GEN

MULTI

OPH

ORTHO

PLASTIC

PAIN

Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASCs
5.

2. Random start number
3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

From:

To:

/
/

7. Numerator

Thank you . . ., but it seems that our information was incorrect. Since (Name of
ASC) does not perform ambulatory surgery, it should not have been chosen for
our study. Thank you very much for your cooperation. Terminate telephone call and
complete Sections V and VI on page 19.

CLOSING
STATEMENT
B2

Thank you. . ., but it seems that our information was incorrect. Since (Name of
ASC) is operated by a parent company, it should not have been chosen for our
study. Thank you very much for your cooperation. Teminate telephone call and
complete Sections V and VI on page 19.

CLOSING
STATEMENT
B3

Thank you. . ., but it seems that our information was incorrect. Since (Name of
ASC)’s specialty is out-of-scope for our study, it should not have been chosen
for our study. Thank you very much for your cooperation. Terminate telephone call
and complete Sections V and VI on page 19.

OTHER

b. AU No.
of
Total AU’s sampled within the ASC

1. Take every number

CLOSING
STATEMENT
B1

Part C. STUDY DESCRIPTION

8. Denominator

Thank you. Now I would like to provide you with further information on the study.
INSTRUCTIONS

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

Week 1
/

10. How many patient record forms were
filled out for this AU?

–

NUMBER OF VISITS
Week 3

Week 2
/

Week 1

–

Week 4

NUMBER OF FORMS
Week 2
Week 3

11. Did this ambulatory unit use a single log/list or a multiple log/list?

–

TOTAL

Single log/list

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 centers.

Week 4

TOTAL

Multiple log/list

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

Time

(a)

(b)
FROM

Monday
FROM

Tuesday
FROM

Wednesday
FROM

Thursday

a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FROM
a.m.
p.m.
FROM

(d)

(e)

(3) Nationwide sample of about 600 hospitals and 250 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 ASC’s that has been selected for the study, your contribution will be of
great value in producing reliable, national data on ambulatory surgery.

a.m.
p.m.

NOTES

a.m.
p.m.

Saturday

Page 16

a.m.
p.m.

Hours vary

(c)

(2) NHAMCS is endorsed by the:
• American College of Surgeons
• American Health Information Management Association
• American Academy of Ophthalmology
• Society for Ambulatory Anesthesia
• American College of Emergency Physicians
• Emergency Nurses Association
• Society for Academic Emergency Medicine
• American College of Osteopathic Emergency Physicians
• Federation of American Hospitals

FROM

Friday

Sunday

Mark (X) ONLY one
Open 24 hours
Not open

Provide the administrator or other facility representative with a brief description of the study.

a.m.
p.m.

FORM NHAMCS-101(FS) (4-9-2009)

Page 5

Section IV – AMBULATORY UNIT RECORD – Continued

Section II – INDUCTION INTERVIEW

Section H – FINAL DISPOSITION

Part A. INTRODUCTION
1. FINAL DISPOSITION
I would like to begin with a brief review of the background for this study.

Ambulatory unit
1

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

Refused

Closed
a
Temporary
b
Permanent

Ineligible
a
AU not under auspices of ASC
b
Only ancillary services provided
c
AU classified as out-of-scope
d
Other – Specify

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

INSTRUCTIONS
Provide the administrator or other facility 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 35 million visits to ambulatory surgery centers, including 15 million visits to freestanding
ambulatory surgery centers

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

(5) The U.S. Census Bureau is acting as 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 your facility and its patients

}

END

NOTES

(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 excludes office-based physicians (these are covered under the NAMCS)
(13) NHAMCS excludes the following types of ASCs: dentistry, podiatry, abortion, lump and bump
procedure rooms, birth center, and family planning.
(14) For the first time, we are including freestanding ambulatory surgery centers in the survey
(15) Only a 4-week data collection period
(16) On average, sample of approximately 100 ED, 150 to 200 OPD, and 100 ASC visits per hospital
and 100 freestanding ASC visits.

SHOW PATIENT RECORD FORM
(17) Form takes only 6 minutes to complete
(18) Forms are to be completed by ASC staff at their convenience
(19) Portion containing patient’s name or other identifying information is removed before collecting
Page 6

FORM NHAMCS-101(FS) (4-9-2009)

Page 15

Section II – INDUCTION INTERVIEW – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section D – VERIFICATION OF ESTIMATED VISITS

As I mentioned earlier, I would like to discuss the plan for conducting the study. This ASC has

2. About how many visits do you expect during the

Revised estimate

reporting period,

Part B. SURVEY IMPLEMENTATION

been assigned to a 4-week data collection period beginning on Monday, ( _____ / _____ ).

Yes – SKIP to section G
No

Month

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

14a. Are there any additional steps needed to obtain permission for the ASC to participate
in the study?

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

Day

Yes – Specify the necessary steps below

Revised estimate
=

(Result)

Original estimate
b. Is the result of (a) between 0.7 and 1.3?
1
2

Yes – SKIP to section G
No

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ASC
1. Calculate new Take Every, using the appropriate table
(page 18) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).
2. Calculate new Random Start, using the next available
row on the label affixed to the back of the
NHAMCS-101(FS).

New Take Every

14b. Now I would like to make arrangements to
obtain the information needed for sampling.
I will need to (know/verify) how your
ambulatory surgery center is 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?

New Random Start

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

FROM:

1
2

TO:

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,
Ambulatory Surgery Center Description as
appropriate. Thank current respondent for his/her
time and cooperation.

Name

SECOND FOLIO

FROM:

TO:
Title

THIRD FOLIO

FROM:

TO:
Department

Record on
Control Card

NOTES
Telephone number
Name
Title
Department

Record on
Control Card

Telephone number

Page 14

FORM NHAMCS-101(FS) (4-9-2009)

Page 7

Section III – AMBULATORY SURGERY CENTER DESCRIPTION
CHECK
ITEM E

1
2

Section IV – AMBULATORY UNIT RECORD
COMPLETE FOR EACH AMBULATORY UNIT SELECTED

Facility has at least one ASC (Yes in item 8a).
Facility does not have any ASCs – SKIP to Section V, DISPOSITION AND SUMMARY on page 19.

15a. Does this facility have any satellite facilities
b. What are the names, addresses, and

a. Mark (X) specialty —

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

which perform ambulatory (outpatient) surgery?

Section A – AMBULATORY UNIT INFORMATION

Name

telephone numbers of the satellite facilities?

RECORD UP TO 3 ON
Address
CONTROL CARD
Telephone number
(Area code and number)
To develop the sampling plan, I would like to (collect/verify) more specific information about this
facility’s ambulatory surgery center(s).
(1) Obtain an estimate of ambulatory (outpatient) surgery cases for each ASC, covering the 4-week reporting period.
Enter the estimate in column (d) of the listing below.
(2) After asking 15c and 15d to determine if the ASC log/list is included in a single or multiple log/list, assign
each ASC an AU number and enter it in column (c).
Out-of-scope locations:
In-scope ASC locations:
•
Laser
procedures
• General or main operating room
• Dentistry
• Podiatry
• Cystoscopy room
room
• Dedicated ambulatory surgery room • Endoscopy room
• Family planning • Abortion
FR
• Cardiac catheterization lab • Pain block room • Lump and bump • Birth center
NOTE • Satellite operating room
procedure rooms
ASC specialty • GEN – General
• GI – Gastroenterology • ORTHO – Orthopedics • PLASTIC – Plastic Surgery
groups include: • MULTI – Multi-specialty • OPH – Ophthalmology • PAIN – Pain Block
• OTHER – Other specialty
INSTRUCTIONS
• Only record generic ASC names in column (a) (e.g., ambulatory surgery center, endoscopy). If the ASC has a formal/proper
name, enter a generic ASC name in (a) and record the Line No. and the formal/proper name on page 2 of the control card.

GEN

MULTI

OPH

ORTHO

PLASTIC

PAIN

OTHER

b. AU No.
of
Total AU’s sampled within the ASC
Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASC

1. Take every number

2. Random start number
3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

Week 1
/

10. How many patient record forms were
filled out for this AU?

–

Week 1

To:

7. Numerator

–

Week 2

8. Denominator

NUMBER OF VISITS
Week 3

Week 2
/

From:

–

Week 4

NUMBER OF FORMS
Week 3

–

TOTAL
/

Week 4

TOTAL

• Complete columns (e) and (f) after developing the sampling plan. See page 18 of the NHAMCS-124 for instructions.
ASC name
(Generic)

Line
No.

Specialty
group

AU
number

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

(a)

(b)

(c)

(d)

Take Random
every
start
number number
(e)

(f)

11. Did this ambulatory unit use a single log/list or a multiple log/list?

Day(s)

Time

(a)

(b)

Monday
3
FROM

Tuesday
TOTAL

FROM

Wednesday
1
2

Facility has only 1 ASC location – SKIP to Item 15e.
Facility has more than 1 ASC location – Continue with item 15c. Make sure that the
"Single log/list" or "Multiple log/list" box is marked in Section IV, A, item 11.

FROM

Thursday

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 ASC name listed above.)

d. Would you or your IT staff be able to
generate one list of outpatient surgery
cases for some of these locations?
Give a copy of the "Single Sampling List
Instructions" to the IT contact.
Page 8

a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FROM
1
2
3

}

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

Yes – Make sure that the "Single log/list" box is
marked in Section IV, A, Item 11.
2
No – Continue with item 15e.
IT Contact name
RECORD ON
Telephone number
CONTROL CARD
(Area code and number)
1

FORM NHAMCS-101(FS) (4-9-2009)

Multiple log/list

1. What are the usual operating hours of this unit?

FROM

CHECK
ITEM F

Single log/list

Section C – ASC INFORMATION AND LOGS

TO
a.m.
p.m.

FROM

Sunday

FORM NHAMCS-101(FS) (4-9-2009)

(d)

(e)

a.m.
p.m.

FROM

Saturday

Hours vary

(c)

a.m.
p.m.

Friday

Mark (X) ONLY one
Open 24 hours
Not open

a.m.
p.m.

Page 13

Section III – AMBULATORY SURGERY CENTER DESCRIPTION – Continued

Section IV – AMBULATORY UNIT RECORD – Continued
Section H – FINAL DISPOSITION
1. FINAL DISPOSITION

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

15e. Does your ASC use ELECTRONIC MEDICAL

Ambulatory unit
1

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

Refused

Closed
a
Temporary
b
Permanent

Ineligible
a
AU not under auspices of ASC
b
Only ancillary services provided
c
AU classified as out-of-scope
d
Other – Specify

}

OR HEALTH RECORDS (EMR/EHR) (not
including billing records)?
Mark only one box.

1
2

Yes, all electronic
Yes, part paper and
part electronic

(7) Reminders for guideline-based
interventions and/or screening tests?

(8) Public health reporting?

(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?
(2) Orders for prescriptions?
If "Yes," ask – (a) Are warnings of drug
interactions or contraindications
provided?
(b) Are prescriptions sent
electronically to the pharmacy?
(3) Orders for tests?

(4) Viewing of lab results?
2. Who completed the patient record forms?
If "Yes," ask – Are out of range levels highlighted?
1
2
3
4

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

(5) Viewing of imaging results?
If "Yes," ask – Can electronic images be viewed?
(6) Clinical notes?
If "Yes," ask – Do they include medical
history and follow-up notes?

NOTES

No
Unknown

If "Yes," ask – Are orders sent electronically?

Mark (X) all that apply

Yes

f. Does your ASC have a computerized system for –

END

If "Yes," ask – Are notifiable diseases sent
electronically?
g. Are there any of the above features of your
system that your ASC does NOT use or has
turned off?

Show flashcard on page 29 of the NHAMCS-124.
2
3

CHECK
ITEM G

Unknown

Turned off

Yes – Please specify

FR NOTE – Indicate in item 15f, last column, any
component(s) turned off.
No
Unknown

The ASC uses ELECTRONIC MEDICAL/HEALTH RECORDS (Yes (all) or Yes (part) in item 15e)
– Continue with item 15h.
The ASC either does not use ELECTRONIC MEDICAL/HEALTH RECORDS or it is unknown (No or
Unknown in item 15e) – SKIP to item 15j.

h. What year did your ASC buy or last upgrade
your EMR/EHR system?

i. Is your ASC’s EMR/EHR system certified by
the Certification Commission for
Healthcare Information Technology"
(CCHIT)?

j. Are there plans for installing a new
EMR/EHR system or replacing the current
system within the next 3 years?
Page 12

FORM NHAMCS-101(FS) (4-9-2009)

Year
1
2
3

1
2

Unknown

Maybe
Unknown

Yes
No
Unknown
Yes
No

Page 9

Section IV – AMBULATORY UNIT RECORD

Section IV – AMBULATORY UNIT RECORD – Continued

COMPLETE FOR EACH AMBULATORY UNIT SELECTED

Section D – VERIFICATION OF ESTIMATED VISITS

Section A – AMBULATORY UNIT INFORMATION
a. Mark (X) specialty —
1

GEN

MULTI

OPH

ORTHO

PLASTIC

PAIN

OTHER

of
b. AU No.
Total AU’s sampled within the ASC
Section B – SAMPLE INFORMATION
4. Total estimated number of visits during reporting
period for ALL operating rooms within the ASC

1. Take every number

2. Random start number
3. Estimated number of visits in this
AU during reporting period
Item 6 is the AU No. from Section A, Item b.
Items 7 and 8 are each 1.

REPORTING
PERIOD
(Month/Day/Year)

6. SU number

From:

To:

2. About how many visits do you expect during the

Revised estimate

reporting period,

/
/

7. Numerator

8. Denominator

Yes – SKIP to section G
No

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

Revised estimate
=

(Result)

Original estimate

Week 1
/

–

NUMBER OF VISITS
Week 3

Week 2
/

–

Week 4

–

TOTAL

b. Is the result of (a) between 0.7 and 1.3?
1
2

Yes – SKIP to section F, page 3
No

Section E – CALCULATE NEW TAKE EVERY AND RANDOM START NUMBERS FOR THIS ASC

10. How many patient record forms were
filled out for this AU?

Week 1

Week 2

11. Did this ambulatory unit use a single log/list or a multiple log/list?

NUMBER OF FORMS
Week 3

Week 4

Single log/list

TOTAL

1. Calculate new Take Every, using the appropriate table
(page 2 or 4) of the NHAMCS-124. (Use the revised
estimate of visits from D-2 and the original total visits
from B-4).

New Take Every

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

New Random Start

Multiple log/list

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

Time

(a)

(b)
FROM

Monday
FROM

Tuesday
FROM

Wednesday
FROM

Thursday

a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FROM

Hours vary

(c)

(d)

(e)

a.m.
p.m.

TO
a.m.
p.m.

FROM

Mark (X) ONLY one
Not open

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

FROM:

TO:

SECOND FOLIO

FROM:

TO:

THIRD FOLIO

FROM:

TO:

NOTES

FROM

Saturday

Page 10

a.m.
p.m.

Friday

Sunday

Open 24 hours

a.m.
p.m.

FORM NHAMCS-101(FS) (4-9-2009)

Page 11

File Type	application/pdf
File Title	nhamcs101fs1_20.g
File Modified	2009-04-13
File Created	2009-04-09