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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 4 - Staff Services/Special Programs

Chapter 3 - Program Analysis Reports And Statistics


Title Section
Ambulatory Patient Care Services 4-3.1
    Purpose 4-3.1A
    Use of the "Ambulatory Patient Care Report" System 4-3.1B
    Definitions 4-3.1C
    General Instructions 4-3.1D
    Specific Instructions and Guidelines 4-3.1E
      Immunizations 4-3.1E.1
      Immunization Register System 4-3.1E.2
      Tuberculosis Reporting 4-3.1E.3
      Maternal Health, and Family Planning Activities 4-3.1E.4
      Accident, Trauma, and Adverse Effects 4-3.1E.5
      Optional Field 4-3.1E.6
      Reporting on New Cases of Communicable Diseases 4-3.1E.7
      Diagnostic Services Requested 4-3.1E.8
      Minor Surgical Procedures 4-3.1E.9
Disposition 4-3.1E.10
Responsibilities 4-3.1E.11
Ambulatory Patient Care Master Form 4-3.1F
    Purpose 4-3.1F.1
    Responsibilities 4-3.1F.2
    Instructions for Patient Care Master Form 4-3.1F.3
Grouped Services Report Form 4-3.1G
      Purpose 4-3.1G.1
      Responsibilities 4-3.1G.2
      Instructions for Grouped Services Report Form 4-3.1G.3
      Specific Instructions 4-3.1G.4

Appendix/Exhibit Description
Appendix I Definitions of External Cause of Injury Terms
Appendix II Write-In Notifiable Disease List
Appendix III Ambulatory Patient Care Report Diagnostic Code List Compared w/ ICDA Detailed List (8th Revision)
Appendix IV Ambulatory Patient Care Report Format Titles and Frequency of Reporting
Exhibit 4-3.1B.1 Ambulatory Patient Care Report, Form HSM-406 (Rev. 7-73)
Exhibit 4-3.1F.2a Ambulatory Patient Care Master Form, HSM-405
Exhibit 4-3.1G.2a Grouped Services Report, Form HSM-407 (Rev. 7-73)


4-3.1  AMBULATORY PATIENT CARE SERVICES (OUTPATIENT)

  1. Purpose

    This section establishes Indian Health Service policy, procedures, and scope of reporting on outpatient medical services provided to Indian and Alaska Native people or others and will be known as "Ambulatory Patient Care Reporting."

  2. Use of "Ambulatory Patient Care Report" System

    All health service staff in IHS facilities (hospital, health center, school health center, health station and satellite field locations) shall maintain this Ambulatory Health information system, as described herein, to effectively manage their operation.

    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.)

    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:

      1. During a field clinic or nursing conference where a member of Nursing Services (see above) is the "primary" provider of service.  In addition, Nursing Services should complete one "CHA Daily Service Report" form noting the type of activity as "clinic" and the "time spent" in the clinic.

    6. Nursing Services (includes Public Health Nursing, School Nursing, and Clinic Nursing except hospital outpatient) will not utilize the "Ambulatory Patient Care Report“ form in the following circumstance:

      1. Specific referral from physician to Nursing Services personnel (see above) for a home visit.  (This fits the criteria of an Ambulatory Patient Care visit; however, it is an exception to the rule.)  Fill out a Nursing Services "CHA Daily Service Report" form only.

    7. Social Services and Mental Health staff will report all of their activity on the "Social Services and Mental Health Services Report“ form and will not utilize the "Ambulatory Patient Care Report“ form for reporting purposes.  The “Social Services and Mental Health Report" form is also required to be completed by all consultants where fees are paid for out of the Mental Health budget activity.  The separation of Social Services and Mental Health reporting from ambulatory patient care reporting is a temporary measure and an attempt will be made in the future to incorporate both reporting systems into one.

    8. The "Ambulatory Patient Care Report“ form shall be completed in accordance with detailed instructions commencing with Part 4-3.1D.

    9. Completed "Ambulatory Patient Care Report" forms shall be submitted by the Health Records Department or alternate each work day to the designated Area Office accompanied by an "Ambulatory Patient Care Master Form“, HSM-405.  (Refer to Part 4-3,lF.)

  3. Definitions

    1. Ambulatory Patient Care Visit - Any person or his representative who receives a health related service provided by the Indian Health Service, either from a physician or under a physician's orders, and a notation is made in his health record, regardless of who performs the service, and regardless of where the service is rendered.

      If a patient is referred to another organized clinic for consultation this should be counted as a second visit and another form prepared; if the consultation takes place in the same clinic in which the patient was originally seen and on the same day, this should not be counted as a second visit.  In the case of a second visit to another clinic on the same day, a second form should be stapled to the first form and completed from Item 10 down, as appropriate.

    2. Type of Clinic - Clinic visits shall be classified as to the specific type of clinic conducted during prescheduled hours.

      1. Any patient attending a prescheduled clinic shall be coded to that clinic regardless of their health condition.  For example:  A diabetic patient seen in GYN clinic shall be classified "GYN".

      2. All patients seen outside of regular clinic hours shall be classified in type "Other"; patients seen at 10 o'clock at night, or anytime after regularly scheduled clinic hours, shall be classified in type "Other".

    3. Grouped Services - A clinic held for the performance of any preventive or screening health service(s) for a group of individuals, regardless of its location, the number in the group, or professionals in attendance.  Instructions for completing the "Grouped Services Report" form appear in Part 4-3.1G.

    4. Parent Facility - A parent facility is the facility within a service unit where the majority of the staff are stationed or the facility that provides the administrative and technical assistance to the satellite facilities.  The parent facility is normally the hospital or major health center within a service unit.  In some instances, there may be more than one parent facility within a service unit.  An example of this would be two hospitals in a large service unit each providing the services mentioned above to several satellite facilities.

  4. General Instructions for "Ambulatory Patient Care Report" Form, HSM-406 (Rev. 7-73)

    1. This form is for use beginning July 1, 1973 and is to be prepared by all health professionals (including all consultants except those paid by mental health), as listed in Section XV, Service Rendered By, IHS Standard Code Book, and whose service meets the following definition:

      Any Person or his representative who receives a health related service provided by the Indian Health Service, either from a physician or under a physician's orders, and a notation is made in his health record, regardless of who performs the service, and regardless of where the service is rendered.

    2. The criteria for utilization of the "Ambulatory Patient Care Report" form is as follows:

      1. Physical presence of patient or his representative.

      2. MD provided or MD ordered.

      3. Health related service.

      4. Health record pulled and notation made.

      5. Provided by IHS.

    3. All clinic nursing personnel will complete the "Ambulatory Patient Care Report" form when the service they provide within a facility fits the definition of an "Ambulatory Patient Care Visit".

    4. Nursing Services (includes Public Health Nursing, School Nursing, and Clinic Nursing except hospital outpatient) will utilize the "ambulatory Patient Care Report" form as follows:

      1. During a field clinic or nursing conference where a member of Nursing Services (see above) is the "primary" provider of service.  In addition, Nursing Services should complete one "CHA Daily Service Report" form noting the type of activity as "clinic" and the "time spent" in the clinic.

    5. Nursing Services (includes Public Health Nursing, School Nursing, and Clinic Nursing except hospital outpatient) will not utilize the "Ambulatory Patient Care Report" form in the following circumstance:

      1. Specific referral from physician to Nursing Services personnel (see above) for a home visit.  (This fits the criteria of an Ambulatory Patient Care Visit; however, is an exception to the rule.)  Fill out a Nursing Services "CM Daily Service Report" form only.

    6. Social Services and Mental Health staff will report allof their activity on the "Social Services and Mental Health Services Report" form and will not utilize the "Ambulatory Patient Care Report" form for reporting purposes.  The "Social Services and Mental Health Report" form is also required to be completed by all consultants where fees are paid for out of the Mental Health budget activity.  The separation of Social Services and Mental Health reporting from ambulatory patient care reporting is a temporary measure and an attempt will be made in the future to incorporate both reporting systems into one.

    7. The "Ambulatory Patient Care Report" form must be completed for each pharmacy visit, providing the patient was not first seen by a physician during that particular visit.  The Ambulatory Patient Care visit must meet all of the criteria for utilization of the form, i.e., physical presence of patient or his representative, physician ordered or physician provided ("Over The Counter" medications are considered to be under physician's standing orders), a health related service, the health record is pulled and notation made, and provided by Indian Health Service.  In order to standardize the completion of the "Ambulatory Patient Care Report" form for pharmacy visits, the following guidelines are provided:

      1. 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.

      2. 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".

      3. 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.

      4. 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".

      5. 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 injury, 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 patient’s health record.

      • Drugs without prescription provided an entry is made in the patient’s 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.

    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.

    12. ONLY ONE DIGIT MAY BE PLACED IN A BOX - DO NOT PUT TWO DIGITS IN A SINGLE BOX.

  5. Specific Instructions and Guidelines for Completing the Individual Items on "Ambulatory Patient Care Report" Form, HSM-406 (Rev. 7-731)

    Item 1: 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

    Code - Description

    Blank MD
    01 General (seeing any and all patient's)
    02 Cardiac
    03 Chest and TB
    04 Crippled Children
    05 Dermatology
    06 Diabetic
    07 ENT
    08 Family Planning
    09 Grouped Services 1/
    10 GYN
    11 Home Care
    12 Immunization
    13 Internal Medicine
    14 Mental Health (Psychiatry)
    15 Obesity
    16 Obstetrics
    17 Ophthalmology
    18 Optometry
    19 Orthopedic
    20 Pediatric
    21 Rehabilitation
    22 School
    23 Surgical
    24 Well Child
    25 Other 2/
    26 High Risk 3/
    27 General Preventive 4/
    28 Family Practice
    29 Plastic Surgery
    30 Emergency Medicine 5/
    31 Hypersensitive
    32 Postpartum
    33 Inhalation Therapy
    34 Physical Therapy
    35 Audiology
    36 W.I.C. (Women, Infant, Children)
    37 Neurology
    38 Rheumatology
    39 Pharmacy
    40 Infant Stimulation

    1/ Use this code number only when an "Ambulatory Patient Care Report" form is prepared for an Indian or Alaska Native patient found with abnormal findings in a "Grouped Services" Clinic.

    2/ Include any "organized specialty" clinic not identified above in addition to all patients who are seen outside of regularly scheduled clinic hours.

    3/ Code can be used for any type of "high risk" clinics conducted.

    4/ This type of clinic may be used for preventive clinics without restrictions to age of patients.

    5/ Use only when the facility has an area designated as an emergency room.  All emergency patients seen in this area should be coded 30 in this field.

    Item 11: Services Rendered By - The first box is reserved for the physician or the non-MD health provider who exercises "primary“ or "independent judgment" in managing the patient's health problems during that specific visit.  The additional three sets of boxes are reserved for 0.2 code numbers of "other providers" of care who see the patient during that visit and make additional significant decisions regarding the care of the health problem.  If appropriate, the "primary provider" and three "other providers" could be recorded during one patient visit provided their health services meet the above criteria.

    The "primary provider" of the health service will be responsible for recording a "Problem or Clinical Impression" ad completing Item 32 - Diagnostic Services Requested and Item 34 - Disposition.  "Other Providers" will record only their specific code number in Item 11.

    The primary, or first box, will always be reserved for the physician if he has been involved in the visit.  If left blank, it will be assumed that an MD has seen the patient.  In the event that an MD is not involved in the visit, the primary box will contain the code number of the health provider who makes the major decisions in managing the patient's problem(s).

    Examples of how this section may be completed are as follows:

    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.

    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__]

    SERVICES RENDERED BY

    Code Description
    01 Clinic RN
    02 Environmental Health
    03 Health Aide
    04 Health Educator
    05 Licensed Practical Nurse
    06 Medical or Psychiatric Social Worker
    07 Nutritionalist
    08 Optometrist
    09 Pharmacist
    10 Physical Therapist
    11 Physician Asst. (Comm. Hlth Medic)
    12 Psychologist
    13 Public Health Nurse
    14 School Nurse
    15 Other
    16 Pediatric Nurse Practitioner
    17 Nurse Midwife
    18 Contract Physician
    19 Mental Health Technician
    20 Medical Student
    21 Nurse Practitioner
    22 Nurse Assistant
    23 Laboratory Technician
    24 Contract Optometrist
    25 Contract Podiatrist
    26 Inhalation Specialist
    27 Student Nurse
    28 Audiologist
    29 Dietician
    30 Pharmacy Practitioner
    31 Optometric Assistant
    32 Contract PH Nurse
    33 Podiatrist
    34 Tribal/Contract Nutritionalist
    35 Outreach Worker
    36 Eye Care Specialist
    37 Family Planning Counselor
    38 EMT, Paramedic, Ambulance Attendant
    39 Speech Therapist
    40 Contract OB/GYN

    This item shall be completed by professionals, other than a physician, who provide the "primary" or "other" health related service.

    1. Immunizations

      1. Immunization levels of young children are a good indicator of how successful IHS staff are with well child supervision.

      2. 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.

      3. This automated data processing system may replace the facility immunization registers that are maintained in a useful condition.

      4. 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.

    2. Immunization Register System

      Purpose:

      To collect information throughout the Indian Health Service on the number and type of immunizations given by age group, see Table 1Q.  In addition, the Indian Health Service will have the capacity to correlate immunizations by provider and community of residence.  All facilities will complete Item 12, "Active Immunizations".

      For those service units where individuals can be identified by registration numbers and where immunizations are given mainly by Indian Health Service, Tables l.R, “Immunization Levels" by service unit and l.S, "Listing of Individuals Whose Immunizations Are Not Current" by service unit, will form the basis for the service unit Immunization Register.  Each Area Director will determine the service units that are to receive Tables l.R and l.S, thereby participating in the Immunization Register.

      The register system will be limited to children under two years of age.

      For those service units participating in the immunization register:

      1. 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.)

      2. 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.

      3. 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.

      4. 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.

      5. 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.

      6. 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.

      7. 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.

    3. Tuberculosis Reporting

      1. Purpose

        This section of the "Ambulatory Patient Care Report" form is to supplement tuberculosis reporting at all IHS facilities and does not eliminate or affect any State or IHS tuberculosis registers already in existence.  The IHS "Tuberculosis Control Manual" dated July 1970, shall be used throughout the Indian Health Service to provide uniform and current procedures, terminology and records in the control of tuberculosis, "Tuberculosis Reporting" on the "Ambulatory Patient Care Report" form was designed for the following purposes:

        1. To record all diagnoses related to tuberculosis or tuberculosis control by "first visit" or "revisit" (per episode).

        2. To provide information about tuberculin skin testing, such as:

          1. Reason for doing tuberculin skin testing.

          2. Results of tuberculin skin testing:  size of induration for PPD if positive; negative or positive for Tine.

          3. Tuberculin skin testing information, when correlated with other information (sex, age, community of residence, etc.) will provide valuable epidemiologic information for the identification and management of tuberculosis as a health problem.

        3. To provide information about the use of INH as a tuberculosis prophylactic method:

          1. To identify all positive tuberculin skin test reactors or convertors who have completed one year of INH prophylaxis.

          2. To establish a register, by IHS unit number, of all persons who are currently taking prophylactic INH.

      2. Responsibility

        Each Area Director will determine whether the INH Prophylactic Register system will be used within his Area and how it will be done.  Areas not using the INH Prophylactic Register will be limited in data to be retrieved.  The utilization of a service unit unique numbering system would make the register system more workable and meaningful at the service unit level.

      3. Limitations

        Annual PPD skin testing of school population which is accomplished with a report system (such as HSM-304) that meets Area and Headquarters needs may be utilized in lieu of the individual "Ambulatory Patient Care Report" form.

      4. Specific Instructions for Completing Items 13 Through 16

        Item 13: Skin Test Result - To be completed only when the tuberculin skin test is read.  This section should be used only when the final result of the tuberculin skin test is determined, and a decision made based on this result.  If the result is uncertain, and the test is repeated, do not enter the uncertain result.  If a tuberculin skin test is positive, indicate the appropriate Diagnosis in Item 16.

        Item 14: Purpose - Indicate the reason the tuberculin skin test was done.

        1. Routine - That done as part of a routine physical examination, no real suspicion of disease.

        2. Contact - Person known to have been in contact with a tuberculosis patient, and being skin tested for that purpose.

        3. Suspect - Person who is suspected of being infected with tuberculosis and the tuberculin skin test is done for diagnostic reasons.

        4. School - To be marked when the "Ambulatory Patient Care Report" form is used to record results of routine tuberculin skin testing surveys in schools.

      Item 15: Prophylaxis

      1. 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.

      2. Start - Mark when INH prophylaxis is initially prescribed.

      3. Continue - Mark when a patient is currently taking INH and is to continue.

      4. Discontinue - To be used for patients who discontinue the drug before one year has been completed by personal choice, drug intolerance, etc.

      5. 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.

      6. 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.

      Item 16: Diagnosis - All persons seen for tuberculosis, who were tuberculin skin tested because of "contact" or "suspect" (Item l&Purpose) or who are currently on INH prophylaxis, must have the appropriate diagnosis checked as to "first visit" or "revisit" (episode).

      When a diagnosis related to tuberculosis is marked, you may still record another diagnosis in Item 21 (Prenatal Care) and an additional two diagnoses in either Item 26 (Nature of Injury ) on the front of the form or Item 31 (Problems or Clinical Impressions) on the reverse.

    4. Maternal Health and Family Planning Activities

      1. Purpose

        To establish a new method of reporting maternal health and family planning activities.

        1. The provision of a computerized register system of data which will assist service unit personnel with:

          1. Clinical management of patients who desire to utilize family planning methods.

          2. Evaluation of family planning program progress and effect.

        2. The provision of data which allows IHS program evaluation at all administrative levels and to answer management questions from persons working in programs other than IHS programs.

      2. General

        The family planning activities reporting system is a computerized register system.  As such, the individual must be identified to the computer by identifying number.

        IHS, in pretesting, was successful in using the patient's health record number at the parent facility.  When a patient is provided with family planning services at a satellite facility where the patient's IHS unit number is not available, the "Ambulatory Patient Care Report" form goes back to the parent facility where the Health Records Clerk enters the health record number.  If the patient has never been seen at the parent facility, she is assigned a new number at the parent facility.

        Each Area Director will determine whether the Family Planning Register System will be used within his Area and how it will be done.  Areas not using the Family Planning Register will be limited in data to be retrieved.  The utilization of a service unit unique numbering system would make the register system more workable and meaningful at the service unit level.

      3. Responsibilities

        1. The physician providing maternal health care or initiating, providing maintenance, or discontinuing family planning services of any type for a patient is responsible for the completion of the Maternal Health and Family Planning section of the "Ambulatory Patient Care Report", HSM-406 (Rev. 7-73).

        2. Upon receipt of the completed Form HSM-406 (Rev. 7-73), at IHS direct care facilities, the pharmacist (or in some facilities another employee who serves this function) may issue the device or medication which has been prescribed for that patient.  Each form should be checked by the pharmacist or alternate for accuracy and completeness.

        3. The pharmacist will forward the APC forms each working day to the respective Health Records Department for inclusion in that day's ambulatory care activity and submission to Area for keytaping.

      4. Definitions Related to Family Planning

        1. Family Planning Services - Includes women whom the Indian Health Service have actually provided oral contraceptives or an IUD, or given instructions in use of the diaphragm, or rhythm method, other contraceptive method or consultation or service for infertility.  These services do not include women who were counseled about family planning but not provided with contraceptives, nor do they include women provided with estrogen and/or progesterone therapy for brief periods of time for purposes other than contraception.  Family Planning Services include cases where men receive infertility counseling or surgical sterilization but exclude men provided with condoms.  Only one box should be marked under "Method".

      5. Specific Instructions for Completing Items 17 Through 24

        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. New Case - This system is developed for Indian Health Service direct care.  A new case is:

        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.

      2. Restart - This is a patient who is restarted on a method of family planning after having discontinued contraception, for any reason, if previous family planning services were provided by the Indian Health Service's direct care program.  It includes:

        1. Women having a new IUD inserted regardless of length of time that previous IUD has been out.

        2. Women on oral contraceptives who have not taken the pill for more than two weeks.

        3. Women who discontinued contraception for a pregnancy and are now restarting contraception.

      3. Continue - A patient continuing uninterrupted the method of contraception indicated in Item 22, or a change of "method" in this visit without interrupting contraception, or who comes for further counseling on the rhythm method or about infertility.

      4. Discontinued - Make a check mark in Box 4 "Discontinued" if the visit is for discontinuing contraceptive practices for any reason except for the patient being pregnant.  If the patient stops contraception because of pregnancy, the physician will check Box 5, "Discontinued Due to Pregnancy".

        If the visit is for changing from one method of contraception to another without interruption of birth control this is not a case for discontinuation, and the physician will check in Item 22 the new "method "she is changing to, and he will also check "Continue" in Item 23.

        The following are pertinent examples:

        1. A woman having an IUD removed so that she may become pregnant will have no information checked in Items 17-21.  Item 22 will have IUD marked, and Item 23 will have "Discontinued" marked.  Item 24 will be left blank.  This is a typical case of discontinuation.

        2. A woman has IUD removed because it is not well tolerated and she is started in the same visit, without interruption, on oral contraceptives.  This is not a case of discontinuation but a change of method.  In this situation Items 17-21 will have no information.  Item 22 will have a check mark on "Oral"; Item 23 will be marked "Continue"; and Item 24 will show the date of next appointment.

      5. Discontinued Due to Pregnancy - This will be marked whenever the patient is discovered to be pregnant.  (At same time Items 17-21 must be marked for 1st prenatal visit.)  It will be marked if a woman has expelled an IUD or whether IUD is still in place.  It will be marked if a woman had been given a supply of oral contraceptives and became pregnant while the supply was available regardless of whether she took the pills as directed.  Example:

        A woman last provided with three months of oral contraceptives on 3/15/73 is seen on 8/l/73.  She is pregnant with LMP on 4/20/73.  Complete Items 17-21, mark Item 22 for Oral, mark Item 23 as Discontinued Due to Pregnancy, leave Item 24 blank, and fill in Item 25 if appropriate.

        Item 24: Next Appointment Will be in [ ] ] Months. (1f three weeks, round off to nearest month.)  Prefix with a "0" if nine months or less.  Any number greater than twelve will be considered as an error and rejected by the computer.

        Item 25: IHS Unit Number at-Parent Facility - When a patient is provided with a specific service at a facility other than parent facility, the form shall go back to the parent IHS facility where the Health Record Clerk enters the IHS Unit Number in Item 25 if different than number in Item 2.  (Enter number to, right side of spaces - prefix with “O”, if necessary, to complete six-digit field.)

        In addition to family planning services, Item 25 should also be used for immunization register, INH prophylaxis register and any other register-type systems.  A unique IHS Unit Number within each service unit would eliminate, to a great extent, the use of this Item.

        1. To delete an erroneous record in the Family Planning Register, complete Item 2, IHS Unit Number, on the “Ambulatory Patient Care Report” form and insert an “X' in Optional Field 30A.  This record will not be counted as an APC visit.

      6. Terms Related to Output Reports

        Overdue Appointment and Dropout (for output report Table 1.L) - A woman who fails to keep an appointment within the reporting period will be considered as missing an appointment.  If she is on oral contraceptives and does not appear for family planning services within the following three reporting periods, she will be considered as a dropout as of the date of her missed appointment.  If she has an IUD and does not appear for family planning services within the six following reporting periods, she will be considered a dropout as of the date of her appointment.  Women using rhythm method and those for infertility control will not be considered, in this part of the system.  Women using “0ther" methods will be considered in the same manner as women on oral contraceptives.  Examples:

        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.

    5. Accident, Trauma, and Adverse Effects

      1. Accident, Trauma, and Adverse Effects, Items 26-29 shall be completed when appropriate.

      2. Item 26 - Nature of Injury shall be marked when appropriate.

      3. 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.

      4. 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.

      5. 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.

    6. Optional Field

      Item 30: Optional Field - Sub-item A, B, and C may be used by Areas or Service Units for whatever special counts they wish to make.  Approval must be obtained through channels (Service Unit Director - Area Director -Director, Indian Health Service), in accordance with provision of IHS Circular No.70-l to use these boxes for a special count.

      Optional Field A is currently being used to delete records already entered into the Family Planning Register.

    7. Reporting on New Cases of Communicable Diseases

      1. 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).

      2. 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.

      3. 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).

      4. 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.

      Item 31: Problems or Clinical Impressions (on reverse side of form) -

      1. 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.

      2. 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.

      3. 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.

      4. 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.

      5. Refer to Appendix III of this manual for the "Ambulatory Patient Care Report Diagnostic Code List Compared with the ICDA Detailed List (8th Revision)".

      6. 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.)

      7. The following explanation of specific codes appearing in the "Supplemental" category are intended as an aid in marking the appropriate diagnoses:

        1. 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.

        2. 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.

        3. Complete physical examinations for school entrance, welfare, Civil Service, etc., are to be coded to APC code 821, Physical Examination.
      8. The Problem or Clinical Impression Code List was intentionally designed to encompass selected broad categories of diseases to provide the most manageable data consistent with the paramount needs in Indian Health.  Professionals should not be disturbed because of this classification without all possible individual listings.

    8. Diagnostic Services Requested

      Item 32: Diagnostic Services Requested: Laboratory Tests Ordered - The physician ordering laboratory tests will so indicate by marking the appropriate boxes (represents type of tests ordered - not those done). If "none" were ordered, mark "None“. There must be a mark in this item for every Ambulatory Patient Care Visit.

      X-ray Ordered - The physician ordering X-rays will so indicate by marking the appropriate box (represents type of X-rays ordered - not those taken).

    9. Minor Surgical Procedures

      Item 33: Minor Surgical Procedures - This item must be marked if minor surgical procedures were performed during the current outpatient visit and the surgical procedure(s) is related to a problem indicated in Items 16, 26, or 31.

    10. Disposition

      Item 34: Disposition - This section must be completed for each patient visit.  The type of disposition shall be indicated by a mark in one of the boxes (l-6) by the "Primary Provider of Service".  (Do NOT neglect to mark Diagnosis in Items 16, 21, 26, and/or 31.)

      Patients who have their health record pulled but do not wait to be seen in the clinic shall be identified by the clinic nurse or alternate by marking BOX 7 "Did Not Answer".  In such cases a Diagnosis in Items 16, 21, 26, or 31 will not be recorded.

      At facilities where patients are given advanced appointments, an "Ambulatory Patient Care Report" form should not be initiated until the patient arrives.

    11. Responsibilities

      1. 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.

      2. 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.

      3. 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.

      4. No prepared copies of the "Ambulatory Patient Care Report" form HSM-406 (Rev. 7-73) should be retained at a facility.

  6. "Ambulatory-Patient Care Master Form", HSM-405

    1. Purpose

      To establish a simplified method of providing identical information for each "Ambulatory Patient Care Report" form without recording it for each patient.

      The provision of Area, Service Unit, Service Location codes and date of service data for the retrieval system with the least amount of manpower.

    2. Responsibilities

      1. 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.)

      2. 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.

      3. 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.

      4. "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.

    3. Instructions for "Ambulatory Patient Care Master Form", HSM-405

      1. 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.

      2. A Master Form, HSM-405, must be prepared for each different combination of service locations and dates.

      3. 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.

      4. 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.

      5. 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.

      6. 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.

      7. 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.

      8. No prepared copies of the Master Form, HSM-405, should be retained at a facility.

  7. Grouped Services Report Form

    1. Purpose

      To establish a method of reporting workload generated by any professional at any location during the performance of the same, or a combination of, preventive or screening health services to a group of people.  (See definition in 4-3.1C.3.)

    2. Responsibilities

      1. The professional in charge of the grouped services clinic, or his alternate, is responsible for the completion of the "Grouped Services Report" form and submission to the respective Health Records Department.  (See Exhibit 4-3.1G.2 for a sample copy of form HSM-407 (Rev. 7-73).)

      2. It shall be the responsibility of the Health Records Department to mail the "Grouped Services Report“ forms to their appropriate Area Office for keytaping.  (The "Grouped Services Report" forms are complete documents and do not require a Master Form.)

    3. Instructions for "Grouped Services Report" Form, HSM-407 (Rev. 7-73)

      1. 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.

      2. 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.

      3. 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.

      4. 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".

      5. The "Grouped Services Report" form is to be prepared by the professional in charge of the clinic, or his delegate.

      6. All entries may be manually written providing they are neat and legible.  Neat and legible entries will facilitate the keytaping process and eliminate errors.

      7. 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:

        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.

        2. Item 7 - "Total Seen" will be used to generate APC Report 1.A.

        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.

    4. Specific Instructions for Completing the Individual Items

      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.

      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.

      Item 3: Clinic Classification - Mark if Grouped Services were "School Related" or "Not School Related".

      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:

      Code Description
      Blank MD
      01 Clinic RN
      02 Environmental Health
      03 Health Aide
      04 Health Educator
      05 Licensed Practical Nurse
      06 Medical or Psychiatric Social Worker
      07 Nutritionalist/Dietician
      08 Optometrist
      09 Pharmacist
      10 Physical Therapist
      11 Physician Assistant
      12 Psychologist
      13 Public Health Nurse
      14 School Nurse
      15 Other
      16 Pediatric Nurse Practitioner
      17 Nurse Midwife
      18 Contract Physician
      19 Mental Health Technician

      Item 5: Recipient Classification - Designate which group is being provided a health-related service - "Indian or Alaska Native" or "Non-Indian".  Single form for each unless Area exercises its option.

      Item 6: Number of Ambulatory Patient Care Report Forms Attached

      1. This space is provided to record the total number of "Ambulatory Patient Care Report" forms for patients with abnormal findings that are attached to this "Grouped Services Report" form.

      2. The "Ambulatory Patient Care Report" form will be completed in accordance with existing instructions.  The following patients are examples of those requiring an individual APC form:

        Example -

        1. Patients with diagnosed notifiable diseases.

        2. Patients with diagnosed morbid conditions.

        3. Children (born after June 30, 1970) who have received immunizations and are to be put on the Immunization Register.  Use of register is optional to each Area.

      3. Abnormal findings from vision or audiometric tests in a mass screening program shall not be reported on an individual "Ambulatory Patient Care Report" form.

        Item 7: Total Seen - The numbers in this section should represent the "Total" number of individuals rendered a health service(s) at this "Grouped Services" session, by total and specific age groups.  Include a count of those patients with an abnormal finding for whom an individual "Ambulatory Patient Care Report" form is provided.  Each individual should be counted only once regardless of the number of health services rendered.

        Item 8: Kind of Services Performed - Each screening test and examination has been assigned a specific code.  It is permissible to report more than one screening test or examination.  Following are the screening tests and examinations with their appropriate code numbers, as indicated on the form:

        Code Test
        23 Vision
        24 Audiometry
        25 Hgb. or Hct.
        26 Urinalysis
        27 Blood Sugar
        28 Tuberculosis Chest X-ray
        29 Serology
        20 Other

        Code Examination
        31 General Physical
        32 Ears
        33 Trachoma
        34 Eyes
        35 Throat
        36 Cardiac
        37 PKC (Phlyctenular keratoconjunctivitis)
        38 Other

        The use of the "General Physical Examination" category excludes the use of any other examination or screening test which is considered as a part of a general physical examination in this particular group, only General Physical (Code "31") should be recorded.

        Item 9: Number Tested or Examined by Age Group

        1. The first two blocks of each line are used to record the code of the screening tests or examinations as outlined in Item 8 above.

        2. The third block of each line is used to indicate whether the individuals examined have "normal" or "abnormal" findings.  Use the codes as indicated on the form: O-Normal and l-Abnormal.

        3. In the blocks under the age groups record the number of individuals who received a specific type of screening test or examination.  Example:  In a vision screening program 100 children, age S-9, were screened by Snellen for visual defects and 45 met referral criteria.  The first two rows in Item 9 would be coded as follows:

          Number Tested or examined by age group

        4. If more space is needed to record the kind of screening tests and examinations, fill out only Item, 9 of a second “Grouped Services Report” form and staple the second form to the first one.

        5. Tuberculin testing for groups -of patients is reported as shown in Item 9. Report tuberculin tests m when read.  If an Area is collecting tuberculin testing data from the “Ambulatory Patient Care Report” system, all individuals with positive tuberculin tests must also be reported on individual “Ambulatory Patient Care Report” forms.  These “Ambulatory Patient Care Report” forms must be completed according to instructions and attached to the “Grouped Services Report” form, If tuberculin reactor rates are to be derived from the “Grouped Services Report” system, it will be mandatory for each form to include the “previous known reactors” in Item 7, “Total Seen” by age groups as well as showing them as positive (Code 221) by age groups in Item 9.  The above procedure is necessary if tuberculin reactor rates are to be compiled from the Data Retrieval System.

          Item 10: Number of Immunizations Provided by Age Group - Record the number of immunizations given for each age group on the appropriate line following the specific type and series of immunization listed.  If children who were born after June 30, 1970, are immunized at a “Grouped Services” clinic and the Area utilizes the Immunization Register system, their service shall be reported on an individual “Ambulatory Patient Care Report” form and entirely excluded from the summary “Grouped Services Report” (Items 6 and 10). All other immunizations given during “Grouped Services” clinics can be reported on this form.

          1. The professional in charge of a “Grouped Services” clinic should submit the completed “Grouped Services Report” form to the facility’s Health Records Department.  They have the responsibility of reviewing it for completeness and adequacy of reporting.  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.

          2. The “Grouped Services Report "form shall be forwarded daily or as completed to the appropriate Area Off ice.

          3. No prepared copies of the “Grouped Services Report” form shall be retained at a facility.

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