Attachment I
Ambulatory Unit Induction Form
Ambulatory Care Pretest, National Hospital Care Survey
OMB No. 0920-xxxx; Exp. Date:
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). |
START
CENSUS
CAPI
SYSTEM
Ambulatory
Unit Record
(Muliple ASL's were combined into this AU)
CASE
STATUS IS: (New Case/ Call RO - Unable to locate/Interview
Started/etc)
Reference
Period: (Reference period)
Press ALT-F9 to
update AU/contact information
Press ALT-F11 to update AU
schedule
1. Continue
2. Noninterview (Unable to locate, refusal, etc.)
3. Change PRF mode
4. Transmit for reassignment
5. Quit
CHG_PRFMODE
Enter
how the abstractions will be done
(Previously abstractions were to be done by:
1. Remote
2. Non-remote
3. Other
VERIFY_PRFMODE
The mode of PRF will be changed to: (Remote, Non-remote, Other)
If this is not correct, press F1 to back up and change your answer.
1. Enter 1 to Continue
SETUP_INFO
Enter
the following information into the Web system.
AU Name: (facility name)
Respondent's ID: (Case ID)
Select Form Used: (ED/OPD/Ambulatory Surgery)
Reporting Period: (Reporting Period)
Start With: (Start with number)
Take Every: (Take Every Number)
1. Enter
1 to Continue
SETUP_DONE
Have you finished setting up everything and filling out the form for the staff?
1. Yes
2. No
ADMISSIONS_RES
This
AU did not have any hospital admissions because the charts were
unavailable at the time of abstraction.
Are the charts available now?
1. Yes, charts are available now
2. No, charts are still unavailable - continue to followup
3. Missing admissions info - final (No more followup)
LOG105_RES
There
were PRFs with a disposition on "admitted to hospital" that
had missing
hospital discharge
information.
Is that information available
now?
1. Yes, information is available now
2. No, discharge information is still unavailable - continue to followup
3. Missing discharge info - final (No more followup)
UPDATE_PRF
Enter
1 and then press END to go to NEXT_PRF.
At
NEXT_PRF, Enter 1 to update the appropriate PRF(s)
1. Enter 1 to Continue
NONINT_TYPE
Enter the type of noninterview
1.Unable to locate - Call RO
2.Abstraction delayed by facility
3.AU ineligible - not under auspices of hospital or FSASC
4.AU ineligible - only ancillary services provided
5.AU ineligible - care not provided by or under the direct supervision of a physician
6.AU ineligible - AU classified as out of scope
7.AU ineligible - other
8.Closed - Temporary
9.Closed - Permanent
10.Hospital Refused
11.Whole department Refused
12.Potential Refusal - followup required
13.Refused (TRANSMIT)
INTRO_INTERVIEW
DO
NOT READ AS WORDED BELOW
o
Identify yourself - show I.D.
o Ask to speak to:
(AU contact 1's name )
(2nd AU contact Name )
(Press ALT-F9 to
update AU contact information)
o Introduce
survey, as necessary
o Press ALT-F11 to update AU
schedule, if necessary
1.Continue
2.Reluctant Respondent
3.Inconvenient time
4.Other Outcome
PRIMARYCARE
Does this clinic provide predominantly primary care?
1.Yes
2.No
3.Unknown
AGREEEST
According
to our information, about (Original estimated number of visits)
patients visits are expected during the reporting period.
Do you
agree with this estimate?
Reporting Period: (Reference week)
1.Yes
2.No
ESTVISHR
About how many visits do you expect during the reporting period, (Reference week)
NUMTRLEV
How many levels are in this ESA's triage system?
1.Three
2.Four
3.Five
4.Other - Specify
5.Do not conduct nursing triage
NUMTRLEV_SP
Specify
other triage levels
PRFHELP
Who will complete the PRFs?
1.FR
2.Staff
CINFO
Get
a complete listing of all staff that will be assisting in the
data collection activities during the reporting period.
Press ALT-F10 to enter/update
additional staff that will be assisting.
Press ALT-F9 to enter/update main AU contacts
Enter 1 to Continue
HOW_STAFFPRF
How will the staff complete the PRFs?
1. Laptop
2. Own PC
SETUP_INFO
Enter the following information into the Web system.
AU
Name: (facility name)
Respondent's ID: (Case ID)
Select Form Used: (ED/OPD/Ambulatory Surgery)
Reporting Period: (Reporting Period)
Start With: (Start with number)
Take Every: (Take Every Number)
1. Setup Complete
2. Problem, setup later
PATIENT_LOG
Explain
how to complete the Patient Log/Sign-in sheet. Cover the
following points
Include the following:
- List all patients receiving treatment during all hours of operation
during the reporting period.
Exclude the following:
- Persons who visit only to leave a specimen, pick up a prescription
or medication, or other visit
where medical care is not
provided;
- Persons who visit to pay a
bill, complete insurance forms, or for some other
administrative
reason;
- Telephone
calls or e-mail messages from patients;
- Visits by persons currently admitted as inpatients to any other
health care facility on the premises,
that is, the sample
hospital.
THANK
Thank
you for your time and cooperation.
^LAPTOP_ACCOUNT
If
you have any question (Hand
contact your business card)
please feel free to call me.
1. Enter
1 to Continue
2. Start Abstraction Now
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | swann305 |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |