2014 ASL PRF Changes

Attachment D

Changes to 2014 Ambulatory Surgery 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-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

Does patient have any of the following conditions? (Note: These conditions could impact this surgery or procedure)
Mark all that apply.
Old	New
Airway problem	Airway problem (Add HELP text)
Asthma	Asthma
Cardiac surgery history	Cardiac surgery history (Add HELP text)
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)
Renal failure	Chronic kidney disease (CKD)
Renal failure	End-stage renal disease (ESRD)
Congestive heart failure (CHF)	Congestive heart failure (CHF)
Diabetes	Diabetes mellitus (DM), Type I
Diabetes	Diabetes mellitus (DM), Type II
Diabetes	Diabetes mellitus (DM), Type Unspecified
Hypertension	Hypertension
Coronary artery disease (CAD)	Coronary artery disease (CAD), ischemic heart disease (IHD) or history of myocardial infarction (MI)
Morbid obesity	Obesity
Obstructive sleep apnea	Obstructive sleep apnea (OSA)
None of the above	None of the above

• 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- Disposition

Old Reason for cancellation Patient not n.p.o. Incomplete or inadequate medication evaluation Surgical issue Other

New Reason for cancellation Patient not n.p.o. (fasting) Incomplete or inadequate medication evaluation Surgical issue Other

• Modified- Follow-up information

Old What was learned from this follow-up? Unable to reach patient Patient reported no problems Patient reported problems and sought medical care Patient reported problems and was advised by ASC staff to seek medical care Patient reported problems, but no follow-up medical care was needed Other Unknown

New What was learned from this follow-up? Unable to reach patient Patient reported no problems Patient reported problems and sought medical care Patient reported problems and was advised by ASC ambulatory surgery staff to seek medical care Patient reported problems, but no follow-up medical care was needed Other Unknown

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