1. |
Each physician, nurse, and/or other paramedical staff member, who is-primary provider of a health related service, shall be responsible for recording the ambulatory health services provided to the patient upon which the statistical count will be based. See Exhibit 4-3.1B.l for sample copy of form HSM-406 (Rev. 7-73).
|
2. |
The report form shall be used to record physician or physician-ordered services at IHS facilities, it patient's home and at other locations, except for "Grouped Services". (Refer to Part 4-3.1D.l.)
|
3. |
Indians and Alaska Natives
only who were screened in
"Grouped Services" and found to have specific abnormal findings shall be reported on an individual "Ambulatory Patient Care Report" form. (Refer to Part 4-3.1G.)
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4. |
The "Ambulatory Patient Care Report" Form HSM-406
(Rev. 7-73) is not to be used if there is not a patient care activity
which is identifiable by a problem or clinical impression listed on the
reverse of the form or accidental injury, tuberculosis, or prenatal care
on front of the form. Family planning visits, immunization visits, and visits to pharmacist, if condition for which the medication dispensed is unknown shall diagnosis on the APC
form.
|
5. |
Nursing Services (includes Public Health Nursing, School Nursing, and Clinic Nursing except hospital outpatient) will utilize the "Ambulatory Patient Care Report" form as follows:
|
a. |
When the pharmacist is the primary provider of a health related service, such as, medications provided "Over The Counter" and refills of original prescriptions, he should record his "Provider" code number in Item 11 and indicate in Items 16, 21, or 31 the condition for which the medication is being dispensed and mark "first visit" or "revisit" as appropriate.
|
b. |
If a patient obtains several Over The Counter" medications for a current problem without first seeing a physician, record your *'Provider" code number in Item 11, code no more than two major diagnoses, and mark as "first visit".
|
c. |
If a patient obtains one or more "Over The Counter" medications for a potential future problem, record your "Provider" code number in Item 11. No diagnosis is necessary.
|
d. |
If a patient obtains one or more refills,, record
your "Provider" code number in Item 11, code the diagnosis for which the
medication was originally obtained and mark as "revisit".
|
e. |
If a patient comes to your facility with a prescription from a contract physician (without first seeing an IHS physician), record your "Provider" code number in Item 11; and if the condition for which the medication is being dispensed is unknown, a diagnosis code is not necessary.
|
8. |
To help clarify when a form is needed the following examples are cited:
Prepare a form for persons who come for:
Any. in jury, illness or a related medical condition.
Postoperative followup.
Health services and are admitted to inpatient services.
Renewal of a prescription provided an entry is made in the patients health
record.
Drugs without prescription provided an entry is made in the patients
health record.
Health services but leave before services can be given.
Prenatal care.
Examination, pre-school.
Examination, pre-employment.
Well baby checkup.
Immunization.
Postnatal care of mother. General physicals. Followup for tuberculosis.
Conditions which students at
IHS School Health Center have for which they are seen individually by the nurse or a physician.
Do not prepare a form for persons who come to:
See a patient hospitalized. Accompany sick person.
Arrange for transportation to another facility.
Obtain dental services
Receive counseling neither ordered nor provided by a physician.
Newborn in hospital transferred to pediatrics.
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9. |
It is suggested that only black or blue ballpoint or felt tip pens be used on the form.
|
10. |
Make all entries and cross marks (+) or (x) neat and legible to facilitate the keytaping process.
|
11. |
The first ten Items and Item 25 on the form are to be completed by Health Records Department at facilities or an alternate under other circumstances. The Provider of the health related services is to complete the balance of the items, namely Items 11 through 24 and 26 through 34 as appropriate.
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12. |
ONLY ONE DIGIT MAY BE PLACED IN A BOX - DO NOT PUT TWO DIGITS IN A SINGLE BOX.
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Item I. |
This space is to record patient identification
information by use of an imprinter card.
ITEM NUMBERS 2 THROUGH 8 ON THE "AMBULATORY-PATIENT CARE REPORT" FORM SHALL BE LEFT BLANK IF AN IMPRINTER CARD IS USED.
|
Item 2 |
IHS Unit Number - Enter the patient's "Medical Record Chart"
number at that facility. Prefix the number with "O" if necessary to
complete a six-digit field. If a patient does not have an IHS Unit
Number at hospitals and health centers, one should be assigned and
recorded at this time. At other locations the item may be left blank
if it is too inconvenient to obtain.
|
Item 3 |
Social Security Number - Enter the patient's nine-digit social security number if he has been assigned one. NOTE: If patient does not have a social security number, he should be encouraged to apply for one at the time of this visit.
|
Item 4 |
Date of Birth - Enter patient's, date of birth with two digits for month, day and year; example - January 8, 1973, enter 01-08-73. If unknown, enter zero's for month and day and calculate year of birth from physician's estimate of patient's age. Do not leave blank If year only is known that should be entered in appropriate boxes; example - 00-00-94.
|
Item 5 |
Sex - Mark appropriate box.
|
Item 6 |
Tribe Code - Enter the patient's tribal code. Refer to
IHS Standard Code Book, Section XVIII, Tribe. Use the code number designating the tribe of which patient considers himself a member. If tribe is not listed, use classification "Other" code number 998; Non-Indian, use 000; Unknown, use 999.
|
Item 7 |
Optional - This three-digit field is for use as prescribed
by each Area Office.
|
Item 8 |
Community of Residence Code - This is a seven-digit code
identifying the patient's present residence by community, county,
and state. Refer to IHS Standard Code Book, Section V. (For
students in boarding schools use community of the school).
|
Item 9 |
Time of Arrival - Complete for each patient. Designate one
of the four time periods in which patient presented himself for medical
care.
|
Item 10 |
Type of Clinic Code - Enter the appropriate clinic code number
from list below: (Refer to definition in Part 4-3.1C.2)
TYPE OF ORGANIZED CLINIC SCHEDULED
|
(1) |
A physician sees a diabetic patient and refers the patient to the Nutritionist/Dietitian. Since the physician is the "primary provider", the first two boxes would be left blank; however, the Nutritionist/ Dietitian would indicate her code (07) in the second set of boxes since she would be discussing and making recommendations about diet 'and weight control.
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(2) |
A physician sees a new mother in prenatal/postpartum clinic and refers the mother to a Public Health Nurse l or Clinic Nurse for additional instructions about her care and/or care of her infant. Since the physician is the "primary provider", the first two boxes would be left blank; however, the PHN or Clinic Nurse would insert her code number (13 or 01 respectively) in the second set of boxes.
|
(3) |
If a physician sees a patient first and orders a prescription, the "primary provider" box would be left blank and the pharmacist would insert his code number (09) in the second set of boxes
only if he provides specific instruction and consultation about the use of the medication. If no instructions or consultation are provided by the pharmacist, he would not insert his code number as an "other provider".
|
(4) |
Laboratory and X-ray services do not meet the preceding criteria of "making significant decisions" regarding the care of the health problem.
The discipline(s) (if not a physician) providing the "primary" or "other" health related service to a patient during a particular visit shall be identified by entering his
appropriate code number from the list below. It is not intended as a workload statistic or a measure of the total activity of that particular discipline and should be restricted only to patient care activities.
For activities other than patient care this form should not be used.
An individual brought to the facility by
ambulance will be coded 38 in the fourth provider box. This code
cannot be used in the first three boxes of this item. The use of this
code is to determine the provision of care for emergency patients. An
example, is as follows: A patient was brought to the emergency room by
ambulance, treated at the scene or enroute by an EMT or a Paramedic or an
ambulance attendant and was seen by an IHS physician in the emergency room.
The coding is as follows:
Primary Provider
Other Providers
[____[____]
[____[____]
[____[____]
[_3__[_8__] |
a. |
Immunization levels of young children are a good indicator of how successful IHS staff are with well child supervision.
|
b. |
An automated data processing system was used to establish an immunization register for children born after June 30, 1970, and immunization workload data will be maintained by the age at which an immunization is given. This will enable the Indian Health Service to follow individuals, starting July 1, 1970. with infants, and to roughly ascertain community immunization levels. For both the register and the workload data, the same input information.- on the Ambulatory Patient Care Report" form - is 811 that is needed. Since infants and toddlers are rarely immunized in mass clinics, the use of the recommended "Grouped Services report will not interfere with this use of immunization data.
|
c. |
This automated data processing system may replace the facility immunization registers that are maintained in a useful condition.
|
d. |
The immunization section (Item 12, a, b, c) on the "Ambulatory Patient Care Report form is to be completed for
active immunizations
only. Passive immunizations such a's diphtheria antitoxin, tetanus antitoxin, gamma globulin, or shots for a specific disease condition should not be recorded in this section. For the above conditions mark
only the correct diagnosis or condition on the "Ambulatory Patient Care Report" form for which the passive immunization or shot was given. For example: AFC code 824 is to be marked for all "contact/carrier of infectious diseases'.'; shots for respiratory allergy, asthma and hay fever" should be recorded under APC code 305.
|
Item 12 |
Active Immunizations - This section is to be completed each time an active immunization is given.
|
Item 12.a |
Vaccines Given This Visit,- Indicate the type of immunization given. When giving the combined measles-rubella-mumps vaccine each component of the vaccine is to, be indicated. Passive
immunization with immune globulins, is not to be indicated.
|
Item 12.b |
Are All Immunizations Current For This Patient's
Age- This section must be completed
each time an active immunization is given and recorded in Item 12.a. Indicate immunization level by marking either "Yes" or "No". The immunization status must be obtained from the patient's health record and compared to age of patient.
|
Item 12.c |
Register Correction
- This section is to be completed only when making corrections in the Immunization Register".
Box 1 - Delete from this facility's register Mark if individual is to be deleted from the Immunization Register. An Ambulatory Patient Care Report form deleting an individual from the Register should show only the IHS Unit Number (Item 2) and this box marked. Forms deleting individuals from the Immunization Register will not be counted as visits for workload purposes.
Box 2 - Correct this IHS Unit Number - This box is to be marked onlv when correcting an erroneous IHS Unit Number which is in the Immunization Register. An Ambulatory Patient Care Report form correcting an erroneous IHS Unit Number should show the erroneous IHS Unit Number (Item 2), this box marked, and the correct IHS Unit Number in Item 25. Forms submitted for correcting erroneous IHS Unit Numbers in the Immunization Register will not be. counted as visits for workload purposes.
|
a. |
The computer will store information on
immunizations by individual, starting with children born after June 30,
1970. The individual will be identified by IHS Unit Number at the
"parent" facility. (See 4-3.1C.4
for definition.)
|
b. |
For individuals born
before July 1, 1970, the computer will not store information on immunizations, Immunizations will
be analyzed for workload by age groups only.
|
c. |
Children will be entered into the immunization module whenever they are delivered in an IHS facility or make their initial Ambulatory Patient Care visit to the "parent" facility, or when they receive their initial immunization at a facility other than the "parent" facility.
|
d. |
The child will be identified to the computer by ,his IHS Unit Number at the "parent" facility. When a child is immunized at a facility
other than the "parent" facility, his IHS Unit Number at the "parent" facility will have to be entered on the "Ambulatory Patient Care Report" form in Item 25.
|
e. |
The computer will determine failure to immunize by comparing the number of each immunization (series) to the child's current age. The following chart shows the immunizations that a child should have received by certain key ages. This is not intended to be a recommended immunization schedule:
By this age - -
- - should have had
4 mo.
DTP#1 OPV#1
6 mo.
DTP#2
8 mo.
DTP#3 OPV#2
12 mo.
Measles and Rubella
22 mo.
DTP#4 OPV#3
The age groupings shown above are the lower limits for determining immunization status, Consequently, an infant will be entered into the Register System in accordance with "d" above; however, their immunization status will not be considered until they are four months of age.
|
f. |
Quarterly, the computer will print out a listing of IHS Unit Numbers, only of those children whose immunizations are not current. The service unit will review the list. Immunizations given to bring a child up to the proper
immunization status for his age will be reported as is routinely done.
|
g. |
Corrections will be submitted on the "Ambulatory Patient Care Report" form. Either Item 1 or Item 2 should be completed in the usual manner - in addition, for:
|
(1) |
Immunizations given but not reported,
complete the balance of the Ambulatory Patient Care Report" form as for
reporting any immunization, or if the child is immunized according to his
age as listed in Part 4-3.1E.2e simply place a mark in
Box 1 in Item 12.b.
|
(2) |
Removing a patient from the Immunization Register because of death or other reason, place a mark in Box 1 of Item 12.c Register Correction.
|
(3) |
Correcting a wrong' IHS Unit Number, place a mark in Box 2 in Item 12.c Register Correction. Record the erroneous IHS Unit Number in Item 2 and the
correct IHS Unit Number in Item 25.
|
(4) |
Procedure for updating immunization register without recording APC visit: Insert patient's IHS unit number in Item 2; indicate "Yes" in Item 12.b; indicate "Correct This IHS Unit Number" in Item 12.c; insert the
same IHS unit number in Item 25 which also appears in Item 2. An APC form completed in this manner will not be counted as a visit and the immunization register will be updated according to the patient's age.
|
a. |
One Year of INH Completed - Patients already known to be tuberculin skin test positive and who are also known to have completed one year of INH, should be entered once into the system by marking this box. This box should also be marked when a patient completes one year of INH after July 1, 1973.
|
b. |
Start - Mark when INH prophylaxis is initially prescribed.
|
c. |
Continue - Mark when a patient is currently taking INH and is to continue.
|
d. |
Discontinue
- To be used for patients who discontinue the drug before one year has been completed--by personal choice, drug intolerance, etc.
|
e. |
The remaining two boxes are used to indicate the number of months that will elapse before the patient is to return for refill of INH or checkup. When these two boxes are completed, the appropriate diagnosis in Item 16
must also be indicated.
|
f. |
For a patient whose parent facility IHS unit number is different from the one appearing on the top of the form (Item 1 if addressograph card used, or Item 2 - IHS unit number) the correct parent facility IHS unit number should be entered in Item 25 - IHS Unit Number at Parent Facility.
|
(1) |
Family Planning and Prenatal Items 17-24 shall be completed when appropriate.
Visits exclusively for Family Planning purposes shall not have a Diagnosis recorded
in Item 31. If a female patient receives a Family Planning service plus services for health related problems, diagnoses for the health related problems shall be recorded in Items 16, 26, or 31. If a diagnosis is recorded in Item 16, two additional diagnoses may be
recorded in either Items 26 or 31.
|
(2) |
1st Prenatal Visit - Complete Items 17, 18, 19, 20 and mark Item 21, Prenatal Care, Code Number 480 as "First Visit". (For EACH pregnancy, the patient's
first visit
for medical care considered as a "First Visit" regardless of where seen and fiscal year.)
|
(3) |
Prenatal Revisits - Complete Item 18 and
mark Item 21, Prenatal Care, Code Number 480, as "Revisit".
|
(4) |
Family Planning: New Case - Complete Items 17, 18, 19, 22, 23, 24, and 25 if appropriate. Also Items 16, 26, or 31 if a service for another health related problem is provided. If not, no diagnosis is required.
|
(5) |
Family Planning: Revisit - Complete Items 22, 23, 24, and 25 if appropriate. Also Items 16, 26 or 31 if a service for another health related problem is provided. If not, no diagnosis is required.
|
Item 17 |
Marital Status - A woman is to be tallied as married if she considers herself to be married. Appropriate question would be "Are you presently married?" The term "Married" should be interpreted to include married, separated and common law and term "Not Married" interpreted to include "single, widows and divorced". Complete for "First Prenatal" visits and family planning "New Cases" only.
|
Item 18 |
Gravida - Total number of times a patient has been pregnant, whether intra- or extrauterine, multiple or single, regardless of length of gestation. Appropriate question, "How many times have you been pregnant? Does that include miscarriages or babies that were born dead? Does that include your present pregnancy (for prenatal patients)?" Prefix two-digit field with a "0" if less than 10.
|
Item 19 |
Number of Living Children - Number of children, now alive, who were borne by the patient regardless of age or place of residence of the children. Appropriate question, "How many of your own children are now alive?" Prefix two-digit field with a "0" if less than 10.
|
Item 20 |
Trimester of FIRST Prenatal Visit - Record as 1, 2, or 3 trimester.
When this section is completed, Item 21, Prenatal Care, Code 480,
must be marked as "First Visit".
|
Item 21 |
Diagnosis
- Mark accordingly as to "First Visit" or Revisit, A prenatal patient should be counted as a "First Visit the
first time she receives prenatal care
during the current pregnancy regardless of where she received the service. If a prenatal patient received prenatal care during the previous fiscal year at another IHS facility or through contract services, she should be counted as a prenatal "Revisit".
|
Item 22 |
Method of Family Planning Service - Methods l-Oral, 2-IUD, 3-Rhythm, 4-Other, are self-explanatory.
Mark as appropriate.
Methods 5 and 6 - Infertility Services and Surgical Sterilization, can be marked for both males and females. Surgical Sterilization should be marked for a male at the time the vasectomy is performed. "Surgical Sterilization" for a female should be marked the
first time the 'female patient is seen, as an outpatient in an IHS facility, without regard to reason for visit. The patient may be returning either for post-operative care relating to surgical sterilization or another health condition. This will automatically remove female patients from the family planning register.
|
Item 23 |
Status of Family Planning Service
|
(1) |
Any woman who has never before received family planning services anywhere.
|
(2) |
First time a patient receives family planning services through IHS direct care, regardless of whether she has in the past used, or is presently using, contraceptives provided by other than IHS.
|
(3) |
If a patient receives the first family planning services on hospital inpatient care, the next outpatient family planning service is considered as a NEW CASE.
|
(4) |
Women who were started on contraceptives through contract health services are to be considered as new patients the first time they receive contraceptives from IHS direct services.
A patient is NOT a NEW CASE if she comes to an IHS facility, for the first time, and receives direct care services on family planning from an Indian Health Service physician but she has received previously, contraceptive services in another Indian Health Service facility. In this situation the physician will check this patient as "Restart" or "Continued" as the case may be.
|
(1) |
A woman using oral contraceptives was seen
on l/20/73 and has a return appointment. for 4/20/73. At the end of the
April reporting period she has failed to show. The April report will enter
her in the “overdue appointment“ column. If by the end of July she still
has not returned, she will appear in the July report as a dropout with the
date last seen 1/20/73 and the dropout date listed as 4/20/73.
|
(2) |
A woman who had an IUD inserted 4/12/73 was to return for a recheck on 5/12/73. If she had not returned by the end of May, she would be listed in the May report as overdue. The June, July, August, September, and October reports will also list her as overdue if she fails to return for family planning service. If by the end of November she has still failed to return, she will be listed in the November report as a dropout. The date last seen will be 4/12/73 and the dropout date will be 5/12/73.
Woman-Months
- How to determine the number of woman-months on birth control during the fiscal year (applicable only to oral contraceptives and IUDs).
It is the sum of the months each case has practiced birth control during the fisca1 year by method of contraception. For new cases - from the date entering the service to the first discontinuance in the fiscal year or change to other method or the end of the fiscal year. For cases who discontinued birth control but restarted the services during the fiscal year, from the day of restarting the services to the next discontinuance or change to other method or end of fiscal year. For patients who changed method during fiscal year -from day of change to the new method to first discontinuance or other change of method or end of fiscal year.
The data will not be available until six months after end of fiscal year due to waiting period for oral contraceptive and IUD dropouts.
In order to obtain round figures for months on birth control it is suggested to count as a complete month the number of days of the first month on contraception, and not to count the portion of the month in which the patient was dropped out of the
program. Or better, to count as one month portions of month 16 days and above; and not to count portions of a month of 15 days and less.
|
a. |
Accident, Trauma, and Adverse Effects, Items 26-29 shall be completed when appropriate.
|
b. |
Item 26 - Nature of Injury shall be marked when appropriate.
|
c. |
If a patient has health conditions in addition to an injury, they may be recorded by appropriate marks in Items 16 (Tuberculosis), 21 (Prenatal Care), or 31 (Problems or Clinical Impressions). If one diagnosis is recorded in Item 26, only one additional diagnosis may be recorded in Item 31, plus diagnoses, if appropriate, in Items 16 and 21.
|
d. |
If Item 26 (Nature of Injury) is marked as "First Visit", Items 27, 28, and 29
must be completed. it is marked "Revisit", Items 27, 28, and 29 shall be left blank.
|
e. |
Specific Instructions for Completing Items 26-29.
|
Item 26 |
Nature of Injury (Problems or Clinical Impressions)
- For each diagnosis marked under "Nature of Injury" either "First Visit" or "Revisit" for this episode must be indicated.
|
Item 27 |
External Cause of Injury
- This item shall be completed only when Item 26,
Nature of Injury, is marked as "First Visit". Mark the appropriate box
which best describes the cause of the accident.
|
Item 28 |
Place of Injury - This item shall be completed only when Item 26, Nature of Injury, is marked as
"First Visit". Mark the appropriate box which best describes the
place of injury.
|
Item 29 |
Was Accident Related to Alcohol? - This item shall be completed
each time a diagnosis is marked as a "First Visit" in Item 26. Mark the appropriate box l=Yes, 2=No. A determination
must be made by the "Primary Provider of Service" whether alcohol was involved by either party in the situation which resulted in the patient's accident or trauma injury.
|
a. |
A daily record of communicable diseases shall be maintained by all IHS hospitals, health centers, and health stations based upon those reported by the attending physicians on the front and reverse sides of the Ambulatory Patient Care Report", HSM-406 (Rev. 7-73).
|
b. |
The
weekly and individual prescribed reports for physicians and health facilities shall be completed by the Health Records Departments and forwarded to the local and state health officers in accordance with respective state requirements.
|
c. |
The appropriate clerical personnel shall assist the Service Unit Director, or attending physician, in the completion of the "Report of Disease Outbreak", HSM-133 (formerly PHS-767).
|
d. |
When indicated by the occurrence of outbreaks, epidemics or unusual occurrence of communicable disease, the "Report of Disease Outbreak" forms shall be completed and forwarded to the Area Office in accordance with instructions issued in IHS Circular No. 69-2, dated March 17, 1969.
|
a. |
The physician, nurse, pharmacist, or other para-medical personnel who provides the
primary medical
service may record, by a checkmark, the two most significant diagnoses or conditions of the patient in Items 26 (Nature of Injury) and 31 (Problems or Clinical Impressions) in addition to one diagnosis each in Items 16 (Tuberculosis Reporting) and 21 (Prenatal Care) if appropriate.
|
b. |
For each diagnosis,
either "First Visit" or "Revisit" -for this- episode of disease or condition must be checkmarked without regard to implementation of the current system or the fiscal year.
Acute diseases such as strep throat, otitis media, URI, etc., the "first visit" is always the first time the patient received medical care for this specific condition regardless of where he was seen, i.e., IHS facility or contract. All followup visits should be marked as "revisits" for that specific condition. It is the physician's judgment and the time lapse since the patient was last seen for a specific acute condition, that will determine whether an acute case is a "First Visit" or "Revisit".
In the case of episodic chronic diseases the physician will have to decide if the fact of a new episode is more important, as with reactivated TB which would be a "First Visit", or if the continuing disease process is more important as would be a reactivation of rheumatoid arthritis, which would be a "Revisit" if previously treated for rheumatoid arthritis.
|
c. |
Do not mark more than two diagnoses or conditions in Items 26 (Nature of Injury) and 31 (Problems or Clinical Impressions). The keytape operator will enter only the first two- -
diagnoses marked regardless of their significance.
|
d. |
Because State communicable disease reporting comprises more entities than could be
listed, only the more common are included in the section for Infective and Parasitic Diseases. Refer to Appendix II of this manual for a "WRITE-IN NOTIFIABLE DISEASE LIST".
When indicated by the occurrence of one of those diseases, the physician will "write-in" the entity in the space provided. A patient with such a condition is expected to receive special processing and will be individually identified to the Health Records personnel.
They will manually record the identifying numerical code number and in addition, prepare special reporting forms for submission to State Health Departments, through local State channels if applicable.
|
e. |
Refer to Appendix III of this manual for the "Ambulatory Patient Care Report Diagnostic Code List Compared with the ICDA Detailed List (8th Revision)".
|
f. |
If there are further questions as to what diagnosis falls in an "Ambulatory Patient Care Report" diagnosis, refer to the codes in the International Classification of Disease, Adapted, Eighth Revision.. (PHS Publication No. 1693.)
|
g. |
The following explanation of specific codes appearing in the "Supplemental" category are intended as an aid in marking the appropriate diagnoses:
|
(a) |
APC recode 818 is equivalent to ICDA code YO0.5, Well Baby and Child Care, and should be checked when an infant or child (under 15 years of age) visits the clinic for relatively comprehensive preventive health services, including assessment of health, growth and development, counseling, anticipatory guidance, teaching, tests for routine health surveillance and immunizations. Visits for just immunizations, routine tests (i.e., urinalysis, hematocrit, etc.), vitamin prescriptions, or incomplete examinations are not comprehensive enough to be considered well child care. This type of visit should be checked as APC recode 819-Other Preventive Health Services.
|
(b) |
The new APC code 819, Other Preventive Health Services, includes ICDA codes YOO.l, YO0.4, Y00.6, and Y02. It should be checked for visits where various types of preventive services are provided for both children and adults. Such services include immunizations I (passive and active), examinations of specific organ systems, prescriptions for vitamins and other examinations.
|
(c) |
Complete physical examinations for school entrance, welfare, Civil Service, etc., are to be coded to APC code 821, Physical Examination.
|
a. |
Health Records Department personnel, or alternate (after hours, or at satellite clinics or home visits) shall be responsible for pulling the health record and initiating an "Ambulatory Patient Care Report" form HSM-406 (Rev. 7-73), and completing Items 1 through 10 at the time a patient registers and requests medical care.
|
b. |
The provider of the medical service shall be responsible for completing the balance of the Items, except Item 25 which will
only be completed by Health Records personnel, or alternate, when needed.
|
c. |
The Health Records Department shall have the responsibility of spot checking documents returned from the outpatient department for completeness and adequacy of recording by the provider of medical services. If omissions or inconsistencies are found, they will be brought to the attention of the responsible person for immediate correction and proper recording in the future.
|
d. |
No prepared copies of the "Ambulatory Patient Care Report" form HSM-406 (Rev. 7-73) should be retained at a facility.
|
a. |
The Health Records Department of the facility is responsible for initiating the "Ambulatory Patient Care Master
Form". (See Exhibit 4-3.1F.2a for sample copy of form HSM-405.)
|
b. |
At satellite facility clinics whoever is responsible for patient records will be responsible for preparation of the "Ambulatory Patient Care Master Form". They will also be responsible for the transmittal of forms to the hospital or health center facility Health Records Department for forwarding to the Area Office. A notice of action required in the form of a special note must be provided with each separate Master Form utilized for individuals who must be identified at the parent facility in Item 25 by the IHS unit record number. Each Area has the option of not utilizing the Service Unit unique numbering system if they so desire.
|
c. |
The Health Records Department of the hospital, health center, school health center, or health station will be responsible for submission of the forms on a daily basis to the Area Office for keytaping unless otherwise directed. Each working day Tuesday through Friday the forms for the previous day will be dispatched; on Monday the forms for Friday, Saturday and Sunday, separately
labeled, will be dispatched together. Numerous regular and on-request reports are by "Day of Week". For this reason, it is very important to maintain control and submit forms on a daily basis, i.e., from midnight of one day to midnight of the following day. DO NOT submit Saturday and Sunday forms in one batch At small stations (Service Unit locations which have only 50-60 or less forms every day) the submission may be every second or third day, provided a-uniform pattern is established which will evenly distribute the data processing workload.
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d. |
"Ambulatory Patient Care Report" personnel when providing services
forms utilized by professional at patient's home shall be included with the reporting facility document's without any special identification other than a clinic code number "11" in Item 10. In other words,' a special "Ambulatory Patient Care Master Form" is
not required for home visits; provided by a physician.
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a. |
This form is to be initiated by the Health Records Department at all hospitals, health centers, and school health centers or by whomever is handling the patient records at satellite facility clinics.
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b. |
A Master Form, HSM-405,
must be prepared for
each different combination of service locations and dates.
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c. |
If Area Office accepts the option to utilize the Service Unit unique numbering system, a separate Master Form. HSM-405, shall be prepared at satellite field clinics for individuals who must be identified by their IHS unit record number at the parent facility in Item 25, namely, (1) family planning patients, (2) children born after June 30, 1470 who receive immunizations, and (3) INH
Prophylaxis register.
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d. |
The Area, Service Unit, and Service Location codes are that of the location where the patient receives the service. The date and day is the time of the service. "Ambulatory Patient Care Report" forms for physician home visits shall be included with the facility Master Form. Refer to IHS Standard Code Book; Section VIII, for the Service Location codes which must be uniformly used.
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e. |
A Master Form, HSM-405, must be the top form of any group of "Ambulatory Patient Care Report" forms submitted. Be sure that each Master Form is in its proper location in the package. Master Form data will be key taped into every "Ambulatory Patient Care Report" appearing under the Master Form until a new Master Form appears in the form pack. Secure the group of forms together by rubber bands or string.
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f. |
The "Ambulatory Patient Care Reports" and Master Forms must be submitted to individual Area Offices on a daily work day basis. Each working day Tuesday through Friday the forms for the previous day will be dispatched; on Monday the forms for Friday, Saturday and Sunday, separately
labeled, will be dispatched together. Numerous regular and on-request reports
are by "Day of week". For this reason, it is very important to maintain
control and submit forms on a daily basis, i.e. from midnight of one day
to midnight of the following day. D0 NOT
submit Saturday and Sunday forms in one batch. At small stations (Service Unit locations which have only 50-60 or less forms per day) the submission may be every second or third day, provided a uniform pattern is established which will evenly distribute the data processing workload.
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g. |
If Indian Health Service physicians provide outpatient services in a contract hospital, a Master. Form, HSM-405, must be prepared in accordance with instructions issued by Area Offices.
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h. |
No prepared copies of the Master Form, HSM-405, should be retained at a facility.
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a. |
A "Grouped Service" clinic is identified as a clinic held for the performance of any preventive or screening health service(s) fcr a group of individuals, regardless of its location, the number in the group, or the professionals in attendance.
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b. |
Use of the "Grouped Services Report" form is optional and is provided for use at the discretion of the professional conducting the clinic. Either a "Grouped Services Report" form may be completed or an "Ambulatory Patient Care Report" form for each individual may be filled out depending on which is easier to record and less time-consuming.
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c. |
The "Grouped Services Report" may be used even though all individuals in the group did not receive the 'same services. Item 7, "Total Seen", represents the total number of
individuals
seen at that specific clinic regardless of the services received. All other lines indicate the number of individuals receiving the designated service. In most cases the total number of services rendered will exceed the number of individuals seen.
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d. |
Services provided to "Indian or Alaska Native" and "Non-Indian" shall be separately reported on the "Grouped Services Report" form for each of these two groups. If an Area determines that a count of "Non-Indians" is insignificant, all services may be coded as "Indian or Alaska Native".
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e. |
The "Grouped Services Report" form is to be prepared by the professional in charge of the clinic, or his delegate.
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f. |
All entries may be manually written providing they are neat and legible. Neat and legible entries will facilitate the keytaping process and eliminate errors.
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g. |
The number of individuals who were provided health services at a "Grouped Services" clinic will be counted as part of the total workload for the Indian Health Service facility and Service Unit. An individual "Ambulatory Patient Care Report" form will be used for patients with an abnormal finding only to enter morbidity data into the retrieval system; however, these will not be counted in the total number of visits. On those "Ambulatory Patient Care Report" forms which are used in conjunction with the "Grouped Services Report" forms, in Item
l0, "Type of Clinic", the clinic code number 09 - Grouped Services will be exclusively utilized. Following is a critique of selected items on the "Grouped Services Report" and the output reports affected:
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(1) |
The individual "Ambulatory Patient Care Report" forms (use described above) will not be counted on Report l.A -Ambulatory Patient Care Total Visits, by Primary Provider of Service, Current Month and Cumulative Year to Date, Each Service Location, Service Unit Total and Area Total - in "Total Visit" count; however, the morbidity from the individual APC forms will be recorded in Report l.C -First Visit and Revisits by Problem or Clinical Impression by Age Groups, Each Service Location, Service Unit and Area.
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(2) |
Item 7 - "Total Seen" will be used to generate APC Report 1.A.
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(3) |
Item 8 -"Number Tested or Examined by Age Group" will be
used to generate Report 1.J - Grouped Services by Discipline Rendering Service and Type of Service Performed by Service Unit and Area, and 1-Q - Immunizations Given by Type for Specific Age Groups, Each Service Unit and Area Total.
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Item 1 |
Facility Code - Enter the appropriate
Area, Service Unit and Service Location code number in the spaces
provided. Refer to IHS Standard Code Book, Section VIII, for the Service
Location code which must be
uniformly used.
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Item 2 |
Dates of Service - Enter the date services were rendered with two digits per month, day and year. Example - January 8, 1974, enter as 01-08-74.
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Item 3 |
Clinic Classification
- Mark if Grouped Services were "School Related" or "Not School Related".
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Item 4 |
Services Rendered by Code - Codes to be used are the same as those used on the "Ambulatory Patient Care Report" form. Following is the approved list of disciplines, as they appear in Section XV, Services Rendered By, IHS Standard Code Book:
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