Form #3 Form #3 Medical Office Information Form

M

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

edical Office Information Form

To be completed by a single office point-of-contact for each medical office submitting data to the Medical Office Survey on Patient Safety Culture Comparative Database

Instructions: Please provide the following information, which will be used to produce descriptive statistics and analyze data in aggregate collected with the Medical Office Survey on Patient Safety. Please refer to the Data Use Agreement for assurances regarding the confidentiality and use of this data at http://www.ahrq.gov/qual/mosurvey11/mosopsdua.pdf. If you need assistance in answering any of the questions, please email DatabasesOnSafetyCulture@ahrq.hhs.gov

Name of Office Point-of-Contact: (First) (Last)

Job Title:

Name of Office:

Office Mailing Address: (Street)

(City) (State) (Zip code) _______

POC Phone:_________________ Fax: _______________

Email: ___________________

1. Which best describes the majority ownership of this medical office/practice?

₁ Provider(s) and/or Physician(s)

₂ University or Academic Medical Institution

₃ Hospital or health system

₄ Community health center

₅ Other, please specify:

2. Total Number of Employees asked to complete the survey? _______

2. What was the mode used to administer the survey?

₁ Paper only

₂ Web only

₃ Mixed mode (paper and web)

2. When did your medical office finish its administration of the Medical Office Survey on Patient Safety Culture?

_________month _________year

5. What is the total number of providers (MDs, DOs, PAs, NPs, etc.) working in this medical office location during a typical week?

_________total number of providers working during a typical week

6. To what extent has this medical office implemented the following electronic (computer-based) tools? (By implemented, we mean the office has the tool capability and is using it.)

	Not implemented & no plans to implement in the next 12 months ▼	Not implemented but implementation planned in the next 12 months ▼	Implementation in process (only partial implementation) ▼	Fully implemented ▼
a) Electronic appointment scheduling	1	2	3	4
b) Electronic ordering of medications (with pharmacies capable of processing electronic orders)	1	2	3	4
c) Electronic ordering of tests, imaging, or procedures (with test/‌imaging centers capable of processing electronic orders)	1	2	3	4
d) Electronic access to your patients’ test or imaging results	1	2	3	4
e) Electronic medical/health records (EMR/EHR)	1	2	3	4

7. Check the type of specialty(s) practiced by all providers in your medical office. By providers, we mean physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications.

(Mark all that apply)

	1. Allergy/Immunology		19. Nephrology
	2. Anesthesiology		20. Neurology
	3. Cardiology		21. Nuclear Medicine
	4. Child & Adolescent Psychiatry		22. OB/GYN or GYN
	5. Dermatology		23. Ophthalmology
	6. Diagnostic Radiology		24. Orthopedics
	7. Emergency Medicine		25. Otolaryngology
	8. Endocrinology/Metabolism		26. Pathology – Anatomic/Clinical
	9. Family Practice/Family Medicine		27. Pediatrics
	10. Forensic Pathology		28. Physical Medicine & Rehabilitation
	11. Gastroenterology		29. Psychiatry
	12. General Practice		30. Public Health & Rehabilitation
	13. General Preventive Medicine		31. Pulmonary Medicine
	14. General Surgery		32. Radiology
	15. Geriatrics		33. Rheumatology
	16. Hematology/Oncology		34. Surgery (All)
	17. Internal Medicine		35. Urology
	18. Medical Genetics		36. Vascular Medicine
			37. Other specialties

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