DOCUMENTS AND COMMITTEE REPORTS Series 4 

Number 16 

PROPE~~OF‘E d 

PUBLICATIONS BRANCH 

ED\TORIAL LIBRARY 

AmbulatoryMedicalCare 

Records: 

UniformMinimum 

BasicData Set 

A Reportof the


United States National Committee


on Vital and Health Statistics


DHEW Publication No. (HRA) 75-1453 

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE , 

Public Health Service 

Health Resources Administration 

National Center for Health Statistics 

Rockville, Md. August 1974 
Library of CongrassCataloging in Publication Data 

Main entry under titIe: 

Ambulatory medical care records: uniform minimum basic data set; final report. 

(Vital and health statistics. Documents and committee reports, series 4, no. 16) 

(DHEW publication no. (HRA) 75-1453) 

Supt. of Dots. no.: HE 20.6209: 4/6. 

Report prepmed by Consultants selected by the U.S. National Committee on Vital and 

Health Statistics. 

Includes bibliographical references. 

1. Medical records. I. United States. National Committee on Vital and Health 

Statistics. II. Series: United States. National Center for Health Statistics. Vital and health 

statistics. Series 4: Documents and committee reports, no. 15. III. Series: United States. 

Dept. of Health, Education, and Welfare. DHEW publication no. (HRA) 75-1453. [DNLM: 

1. Ambulatory care. 2. Medical record. W2A N148vd. no. 16 1974] 

HA37.U1693 no. 15 [R864] 312’.0973s [651.5] 74-6288 ISBN O-8406-0016-X 

For eale by the Superintendent of Docnments, U.S. Government Prfntiig OfIlce, Waehfngton, D.C. 20402-Price 60cents 
NATIONAL CENTER FOR HEALTH STATISTICS 

EDWARD B. PEF .{IN, Ph.D., Director 

PHILIP S. LAWRENCE, SC.D,, Deputy Director


JACOB J. FELDMAN, ActitzgAswciate Director for Arwly.sis


GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System


ELIJAH L. WHITE, Associate IXrectorfor Data Systems


IAWO M. MORIYAMA, Ph. D., Associizte Director for International Statistics


EDWARD E MIN’I’Y, ASSOCLZ’: J lirectorfor kfanagemenf


ROBERT A. ISRAEL, Associate Director for Operations


QUENTIN R. REMEIN, Associate Director for Program Development


PHILIP S. LAWRENCE, SC.D., Acting. 1 ~ciate Director for Research


ALICE HAYWOOD, Information Officer 

Vital and Health Statistics-Series4-No. 16 

DHEW Publication iio. (HRA) 75-1453 

Libra~ of Congress Catalog Card i%mber 74-6288 
FOREWORD


This report has been prepared by a group of consultants on 

ambulatory medical care records, under the auspices of the U.S. 

National Committee on Vital and Health Statistics. It sets forth and 

defines the minimum set of items of information that should be ‘ 

entered uniformly in the records of all ambulatory medical care, 

regardless of the setting in which the care is delivered. It also specifies classifications of the information that would be recorded for 

most of the items in the set. 

In selecting and defining this minimum basic data set, the consultants were guided by two types of purposes that are served by the 

maintenance of ambulat xy medical care records: (1) the improvement of ambulatory patient care; and (2) a variety of management, 

planning, educational, and research uses that can be carried out’ only 

when data have been abstracted from records and analyzed. Although the consultants’ decisions on items to be included in tl-w data 

set were influenced by the data needs for the second type of purposes, they have not specified the subset “of the items on which data 

would need to be abstracted, assembled for groups of patients, and 

analyzed to serve any particular purpose. 

Abraham M. Lilienfeld, M.D.


Chairman


U.S. National Committee on


Vital and Health Statistics 
U.S. NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS 

Chairman Executive Secretary 

LILIENFELD, Abraham M., M.D. 1974 MORIYAMA, Iwao M., Ph.D. 

Professor and Chairman Associate Director for International 

Department of Epidemiology Statistics 

School of Hygiene and Public Health National Center for Health Statistics 

The Johns Hopkins University Health Resources Administration, DHEW 

Baltimore, Maryland 21205 . Rockville, Maryland 20852 

Members 

COOPER, E. Leon, M.D. 1976 PETERSON, Osler L., M.D. 1974 

Executive Director Professor, Department of Preventive 

National Medical Association Medicine 

Foundation, Inc. Harvard Medical School 

1150 17th Street, N.W. Boston, Massachusetts 02115 

Washington, D.C. 20002 

POWERS, Mary G., Ph.D. 1976 

Chairman, Department of Sociology and 

FRAZIER, Todd M. 1975 Anthropology 

Assistant Director Fordham University 

Harvard Center for Community Health Bronx, New York 10458 

and Medical Care 

643 Huntington Avenue RICE, Dorothy P., Mrs. 1975 

Boston, Massachusetts 02115 Deputy Assistant Commissioner 

Office of Research and Statistics 

GOLDSMITH, John ‘... M.D. 

Medical Epidemiol ,gist 

1977 Social Security Administration, DHEW 

1875 Connecticut Avenue, N.W. 

Epidemiological Studies Laboratory Washington, D.C. 20009


California 

2151 Berkeley Way 

Berkeley, California 94704 Head, Medical Statistics Section 

Mayo Clinic 

100 First Street, S.W. 

HUXTABLE, Deane L. 1974 Rochester, Minnesota 55901 

State Registrar and D :ector 

Bureau of Vital Records and VENABLE, John Heinz, M.D. 1974 

Health Statistics Acting Director 

Virginia State Department of Health Community Environment Management 

Richmond, Virginia 23208 Center for Disease Control, DHEW 

1600 Clifton Road 

Atlanta, Georgia 30333 

KJELSBERG, Marcus O.: Ph.D. 1977 

Associate Professor an~ Director PERRIN, Edward B., Ph.D., ex officio 

Division of Biometry Director, National Center for Health 

School of Public Health Statistics 

State Department of Health TAYLOR, William F., Ph.D. 1976


1226 Mayo Memorial Building Health Resources Administration, DHEW 

Minneapolis, Minnesota 55455 Rockville, Maryland 20852 

iv 
CONSULTANTS ON AMBULATORY MEDICAL CARE RECORDS 

BERRY, William


Acting Director


Office of Program Implementation


Office of Program Operation, ASH, DHEW


Roclwille, Maryland 20852


COONEY, James P., Jr., Ph.D.


Associate Director


Hospital Research and Educational Trust


840 North Lake Shore Drive


Chicago, Illinois 60611


DEDMON, Robert E., M.D.


President


Twin City Clinic


211 North Commercial Street


Numah, Wisconsin 54956


DENSEN, Paul M., SC.D. 

Director, Harvard Center for Community 

Health and Medical Care 

643 Huntington Avenue 

Boston, Massachusetts 20115


ERVIN, Theodore R.


Deputy Director


Michigan Department of Public Health


3500 North Logan


Lansing, Michigan 48914


GURALNICK, Lillian


Office of Research and Statistics


Social Security Administration, DHEW


1875 Connecticut Avenue, N.W.


Washington, D.C. 20009


HOERMANN, Siegfried A.


Acting Director, Division of Health


Resources Utilization Statistics 

National Center for Health Statistics 

Health Resources Administration, DHEW 

Rockville, Maryland 20852 

JACKSON, Ckrmault B., Jr., M.D. 

1620 Nix Professional Building 

San Antonio, Texas 78205 

MARTIN, Samuel P., M.D.


Professor of Medicine and Community Medicine


School of Medicine


University of Pennsylvania


Philadelphia, Pennsylvania 19104


McCARTHY, J. Patrick


Deputy Director


Management Systems Division


Medical Services Administration


Social and Rehabilitation Service, DHEW


Washington, D.C. 20201


PEARCE, Nancy D.


Bureau of Health Services Research


Health Resources Administration, DHEW


Rockville, Maryland 20852


SHAPIRO, Sam


Director, Health Services Research and


Development Center 

School of Hygiene and Public Health 

The Johns Hopkins University 

Baltimore, Maryland 21205 

Staff


KRUEGER, Dean E.


Acting Associate Director for Analysis


Division of Analysis


National Center for Health Statistics


Health Resources Administration, DHEW


Rockville, Maryland 20852


WEISS, Noel S., M.D., Dr.P.H.a


Department of Epidemiology and


International Health 

School of Public Health 

University of Washington 

Seattle, Washington 98195 

. 

‘Dr. Noel S. Weiss had primary responsibrlty for the preparation of this report, which reflects the consensus of the Consultants on Ambulatory Medical Care Records. 

v 
Page 

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111 ’””

Summary of Recommendations. . . . . . . . . . . . . . . . . . . . . ...1


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3


ObjectivesandApproach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4


Purposes of Ambulatory Medical Care Data . . . . . . . . . . . . . . . 4


What Is an Ambulatory Medical Care Encounter? . . . . . . . . . . . . 5


Criteria for Inclusion and Classification of Items


inthe Minimum Set.... . . . . . . . . . . . . . . . . . . . ...5


The hlinimum Basic Data Set To Be Entered Into Ambulatory Medical


Care Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..6


The Maintenance of Confidentiality . . . . . . . . . . . . . . . . . . . . . . 10


Uses and Limitations of the Minimum Data Set and Its Relationship 

to an.Ambulatory Care Encounter Form . . . . . . . . . . . . . . . . . . 10


Office and Practice Management . . . . . . . . . . . . . . . . . . . . . 11


Evaluation of Care and Research . . . . . . . . .. . . . . . . . . . . . . 12


Education and Pkmning.
 . .. . . . . . . . . .. . . . . . . . . . . . . . . 12 

Implementation of the Minimum Basic Data Set . . . . . . . . . . . . . . . . 13


Future Revision of the Minimum Basic Data Set . . . . . . . . . . . . . . . . 13


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...14


Appendix 1. Definition of an Ambulatory Care Encounter . . . . . ; . . . . 15


Appendix II. Groups From Whom Opinions Were Solicited Regarding


the Content of This Report.. . . . . . . . . . . . . . . . . . . . . ...16


vii 
AMBULATORY MEDICAL CARE RECORDS: 

UNIFORM MINIMUM BASIC DATA SET 

SUMMARY OF RECOMMENDATIONS 4. Sex 

The Consultants on Ambulatory Medical Male or female 

Care Records, U.S. National Committee on Vital 

and Health Statistics, recommend that the fol- 5. Expected source of payment 

lowing items constitute the minimum basic data Government 

set that should be entered in the records of all 

ambulatory medical care. Providers of ambula- a. Workmen’s compensation 

tory care should feel free to expand this mini- b. Medicare 

mum data set in accordance with their own par- c. Medicaid 

ticular requirements. The set of data that can be d. Civilian Health and Medical Program 

abstracted from the records for a particular pur- of the Uniformed Services 

pose may not include all the items that should e. Other 

be entered into the records. ~ Insurance mechanism 

A. Items that characterize the patient a. Blue Cross 

b. Blue Shield 

1. Patient identification c. Insurance company 

a. Name 

d. Prepaid group practice or health plan 

e. Medical foundation 

Surname, first name, middle initial Self-pay 

b. Identification number No charge (free, charity, special research, 

teaching) A unique number that distinguishes Other 

the patient and his ambulatory medical care record from all others 

B. Items that characterize the provider 

2. Residence 

1. Provider identification 

Patient’s usual residence, to consist of 

street name and number, apartment a. Name


number (if any), city, State, and zip Surname, first name, middle initial


code


b. Identification number 

3.	 Date of birth A unique number that distinguishes 

Month, day, and year the provider from all other providers 

1 
2. Professional address 

Street address, office number (if any), 

city, State, and zip code 

3. Profession 

The profession in which the provider is 

currently engaged 

a. Physician 

Include specialty, if any, as determined by membership in, or eligibility for, specialty board 

b. Dentist 

(Include specialty) 

Nurse 

:. Other (specify) 

C.	 Items that characterize the patient-provider 

encounter 

1. 

2. 

3. 

4. 

5. 

Date of encounter 

Month, day, and year 

Place of encounter 

a. Private office 

b.	 Clinic or health center (any except 

hospital outpatient department) 

c. Hospital outpatient department 

d. Hospital emergency room 

e. Home 

f. Other (specify) 

Reason for encounter 

The patient’s principal problems, complaints, or symptoms on this encounter, 

in the patient’s own words 

Findings 

All history, physical examination, laboratory and other findings pertinent to 

the patient’s reasons for visit or diagnoses, or both, and any other findings 

the provider deems important 

Diagnosis and/or problem 

The provider’s current assessment of the 

patient’s reasons for the encounter and 

all conditions requiring treatment, with 

the principal diagnosis and/or problcm 

listed first. Principal diagnosis and/or 

problem is defined as the health problem 

that is most significant in terms of the 

procedures carried out and the care provided at this encounter. 

6. Services and procedures 

All dia~ostic, therapeutic, and preventive services and procedures (inciuding 

history taking) performed during the 

encounter and those scheduled to be performed before the next encounter 

7. Itemized charges 

All charges to be made by the provider 

for services and procedures performed 

during the encounter or to be performed 

by him or his associates before the next 

encounter 

8. Disposition (one or more) 

The provider’s statement of the next 

step(s) in the ctie of the patient 

No followup planned 

;. Return, time specified 

Return, P.R.N. 

:. Telephone followup 

e. Referred to other provider 

f. Returned to referring provider 

g“ Admit to hospital 

h. Others 

In addition to specifying the data set and 

defining the individual items ;f information that 

should be entered in all records of ambulatory 

medical care, the consultants make the following 

recommendations: 

1. The consultants recognize that the primary purpose of medical care records is to facilitate patient care. Nearly all other purposes to be 

served by entering the uniform minimum basic 

data set in records of ambulatory care require 

that the information be easily retrieved from the 

records so that it can be assembled for all the 

patients of a single provider and aggregated and 

analyzed for groups of providers. The informa2 

I 
tion that identifies and characterizes the provider needs to be recorded only at the time the 

provider begins practice in a particular setting. 

The information that identifies and characterizes 

the patient should be recorded at the time of the 

first encounter with the provider and needs only 

occasional updating. Information that identifies 

and characterizes the encounter needs to be recorded at each encounter. The consultants recommend that the information be entered in a 

manner that will facilitate its being abstracted 

from the record. 

2. The consultants recommend that the uniform minimum basic data set be accepted by the 

U.S. Department of Health, Education, and Welfare and other Federal agencies that operate or 

finance ambulatory medical care programs; and 

that the Federal agencies foster and promote the 

minimum basic data set for use in all these programs including Medicare, Medicaid, CHAMPUS, 

Children and Youth Projects, family health centers, Public Health Service hospitals, and Professional Standards Review Organizations, and in 

all statistical surveys of ambulatory medical 

care. The consultants further recommend that 

private health care institutions, professional organizations, and insurance carriers accept and 

encourage the use of the data set. 

INTRODUCTION 

htost medical care is delivered in ambulatory 

cam set tings. Ambulatory care includes all care 

to patients who are not assigned inpatient beds. 

According to estimates from the Health Interview Survey, conducted by the National Center 

for Health Statistics, there were 1,017 million 

physician visits in the United States in 1972 (including telephone contacts), an average of 5.0 

pcr person.1 Seventy-three percent of the popukition consulted a physician at least once that 

year. In contrast, there were 28.5 million discharges from short-stay hospitals in 1972, an 

average of 0.14 per person; and 10.6 percent of 

the population were hospitalized at least once. 

Thus despite the fact that hospital inpatients 

generally have more acute medical problems 

(one reason they have been the primary focus of 

medical research and teaching), ambulatory care 

accounts for, in quantitative terms, most of the 

medical profession’s efforts and the majority of 

the population’s contacts with the health care 

system. 

Despite the importance of ambulatory care, 

systematically gathered information concerning 

its characteristics is relatively sparse. Until the 

advent of the National Ambulatory Medical Care 

Survey-initiated in 1973 b y the National Center 

for Health Statistics–only limited data were 

available for the United States as a whole, for 

any region, and for all but a few localities on 

ambulatory patients’ complaints and conditions, 

medical services provided, or the disposition of 

patients. This lack of knowledge resulted largely 

from the inability to obtain pertinent data from 

the records of the providers of care. Items of 

information recorded by the different providers 

about the patient and the visit vary considerably. In addition, even for the items that are 

recorded, it is difficult to make comparisons because of differences in definition and classification. 

At present there are several factors that 

make comparability of information in the records of ambulatory care providers more important than in the past. First, fewer and fewer providers are practicing alone, increasing the need 

for records that are complete and comprehensible to colleagues. Second, a larger part of ambulatory care costs is being paid by third parties, 

who require a uniform set of information on 

which to base payment. Finally, current interest 

in the quality and the cost of medical care (as 

manifested, for example, in the Federal legislation on Professional Standards Review Organizations) z necessitates the development of records 

that can be systematically reviewed and contain 

data that are comparable among providers. 

Against this background, the Conference on 

Ambulatory Medical Care Records was held in 

Chicago in April 1972. It was sponsored by the 

National Center for Health Services Research 

and Development and the National Center for 

Health Statistics in the “Department of Healthj 

Education, and Welfare, and by The Johns 

Hopkins University, with support from the 

Commonwealth Fund. This Conference was patterned after the National Conference on Hospital Discharge Abstract Systems of June 1969, 

which had stimulated considerable interest and 

action in developing more systematic and uni3 
form approaches to the abstracting of hospital 

inpatient data. 

One of the main conclusions of the Conference on Ambulatory Medical Care Records was 

stated as follows:3 

We believe that the first and most important steps now are 

to identify the basic core of data germane to alf [functions 

served by ambulatory care data] and to introduce uniform 

terms, definitions and classifications for this data set. A 

major concern of the Conference is the proliferation of 

different ambulatory medical record and reporting systems 

being introduced by federalfy sponsored health programs, 

by medicaf foundations and institutions, and by commercbd data processing cornpakes. We propose that a minimum 

uniform basic data set form a part of each patient’s medicaf 

record, so that it will be universally avaifable for abstracting, reporting and analysis. 

The Conference requested that the U.S. National 

Committee on Vital and Health Statistics refine 

and develop the uniform minimum basic data set 

to appear in ambulatory medical care records 

and to specify formats for recording information 

for each item in the data set. The present report 

is based on the work of consultants whom the 

U.S. National Committee on Vital aiid Health 

Statistics selected in response to the recommendation of the Conference. 

OBJECTIVES AND APPROACH 

Purposes of Ambulatory Medical Care Data 

The participants in the Conference identified 

eight broad purposes that can be served by a 

uniform minimum set of information on ambulatory medical care:3 

1.	 To assist the physician in caring for his patients and 

managing his practice; 

2.	 To facilitate self-evafuation by the physicism and 

professional review; 

3.	 To provide the medicaf profession with a better 

understanding of the natural histnry of health 

problems, complaints and diseases; 

4.	 To aasist those responsible for the management of 

office practices, clinics, group practices, hospitalbased ambulatory services and other settings where 

ambulatory medical care is provided, in planning 

services, in allocating personnel and other resources, and in monitoring costs; 

5. To assist medical educators in clarifying the objectives of their curricufa for medical personnel and 

health services administrators; 

6.	 To support the efforts of Iocaf, state, and national 

agencies, health departments, medicsd foundations, 

and Regional Medicaf Programs in formulating objectives, plans and policies for improving heakh 

care services; 

7. To serve the needs of private insurance carriers, 

Blue Cross and Blue Shield, the Sociaf Security Administration and related Federal payment programs, and to permit the development of uniform 

insmce claims forms and patient bilfing forms; 

8.	 To provide epidemiologists and other health services ‘investiga~ors with sampling frames for research 

designed to improve the impact of health services. 

The consultants believe that entering a 

standard set of data items into ambulatory medical care records can assistin achieving these purposes. Specification of this set, however, must 

take into account the character of the system in 

which the items will be recorded. Ambulatory 

care records, no matter how simple, will consist 

of three informational components: 

.4.	 Information that identifies and characterizes the patient; 

B.	 Information that identifies and characterizes the provider; 

c.	 Information that identifies and characterizes each encounter between patient 

and provider (see “What Is an Ambulatory Medical Care Encounter?” below 

and appendix I for definition of “encounter”). 

Patient information should be recorded at 

the time of the patient’s first encounter with a 

provider in a particular ambulatory care setting 

and should be kept up to date. Provider information should be recorded when a provider begins 

work in a particular setting and will remain the 

same until the setting or tasks change. Items of 

information that are specific to the patientprovider encounter should be recorded at each 

encounter; they include information on charges 

that may be maintained in a record separate 

from the record of other information on the 

encounter. 

The primary reasoil for maintaining ambulatory medical care records is their value in provid-
ing care to the patient, in the same sense that 

the medical history is of value in making diagnoses and deciding on treatment regimens. Emphasis on preventive health care, the need of 

many patients for care that continues over long 

periods of time, and the fact that many individual patients receive care from two or more providers increase the value of the record in the 

provision of high-quality care. All other purposes to be served by the minimum basic data 

set can be served only if information is systematically recorded, abstracted from the record, and 

summarized. Fortunately many of the items of 

information which should be recorded in the 

interest of facilitating patient care are the same 

items that are needed for the other purposes. 

This fact gives rise to the concept of the uniform 

minimum basic data set. There is no implication 

that the minimum data set comprises all the 

information which providers should enter into 

ambulatory medical care records. 

What Is an Ambulatory Medical Care 

Encounter? 

The consultants think that it is important 

not only to have a uniform set of items recorded 

at each encounter but to define the specific 

circumstances, in which they are to be recorded. 

Borrowing from the Guidelines for Producing 

Uniform Data for Health Care Plans,4 “encounter” has been defined as a face-to-face contact 

between a patient and a provider who, at the 

time of contact, has primary responsibility for 

assessing and treating or managing the condition 

of the patient and who exercises independent 

judgment as to the care of the patient. The 

provider at an encounter can be a physician, 

dentist, nurse, or any other health professional, 

so long as there is face-to-face contact and the 

professional uses independent judgment in the 

care of the patient. Under this definition a 

health professional who carries out a test or 

renders care that is ordered or prescribed by 

another health professional is not a “provider.” 

(The advantages and disadvantages of this particular definition of “encounter” are outlined in 

appendix I.) An ambulatory care encounter is 

simply one in which the patient is neither 

hospitalized nor institutionalized at the time of 

the encounter; some examples of settings in 

which ambulatory care can take place are a 

physician’s office, an outpatient clinic, the 

patient’s home, and a health center. 

Criteria for Inclusion and Classification 

of Items in the Minimum Set 

The minimum set of items was considered to 

be that set which should be present in every 

ambulatory care record. No attempt was made 

to produce a set of items sufficient for all the 

purposes identified by the Conference on Ambulatory Medical Care Records, nor an individual 

optimum set for any single purpose. For example, to care properly for some of his patients, 

the provider of care will need to record considerably more detail than is specified here and 

should feel free to do so in accordance with his 

own particular needs. Nonetheless, the consultants have chosen a set of items that is fairly 

comprehensive and one that will Got in the near 

future be exceeded by parties requesting information from providers regarding the delivery of 

care. It is hoped that with widespread adoptiori 

of this set of items, a reduction of uncertainty 

over future requirements for information from 

providers will be achieved. 

Items considered for inclusion were taken 

from those cited by the Conference on Ambulatory Medical Care Records, as well as from 

suggestions of the consultants. Selection of an 

item was guided by those that were already 

being widely recorded with reasonable accuracy. 

The items were reviewed against the purposes 

that ambulatory care data could serve and, 

depending on the capability of each item to help 

in fulfilling these purposes, were either accepted 

or rejected from the minimum set. 

Each item has been defined. For most items 

a classification of the information to be recorded has been specified. Where appropriate, 

the format matches that used in the Uniform 

Hospital Discharge Data Set5 or the National 

Ambulatory Medical Care Survey. For other 

items, such as“Reason for encounter;’ “Diagnosis 

and/or problem,” and “Services and procedures, ” 

none is suggested, since the choice of a particular scheme depends on which pu~me of ambulatory care data is to be served. The general 

principle followed in selecting classifications is 

that of minimal specificity. Many providers will 

5 
need greater detail for some of the items to 

achieve their immediate purposes; for example, 

under the item “Expected source of payment” if 

the patient’s bill is to be paid by an insurance 

company, the provider would likely wish to 

record the name of the carrier. Nonetheless, 

what the provider does record should be classifiable into the categories shown in this report; in 

the example above, the name of the specific 

company could subsequently be abstracted as 

category “Insurance company” (see Item A, 5). 

THE MINIMUM BASIC DATA SET TO BE 

ENTERED INTO AMBULATORY MEDICAL 

CARE RECORDS 

A. Items that characterize the patient. 

1. Patient Identification 

a.	 iVame. Surname, first name, middle 

initial. 

b.	 Identification number. A unique 

number that distinguishes the patient 

and his ambulatory care record from 

all others. 

Comment: Many patients have multiple encounters within a single provider setting. It is important for 

me dlcal, planning, administrative 

management, and research reasons 

that it be possible to link together 

the records of all such encounters. A 

unit record number system is the 

most effective means of assuring this 

linkage. In this system the patient is 

assigned an identification number at 

the time of the initial encounter, and 

the same number is used in all later 

encounters. 

Many patients encounter multiple 

providers as both ambulatory patients and inpatients. The capability 

for linking records on encounters 

with different ambulatory care providers and with hospital inpatient 

records is important for the same 

reasons cited above. Use of a unique 

identifying number which is permanently assigned to each individual 

would be the most effective method 

of enabling linkage. Such a standard, 

universal number does not exist at 

present. 

It is recommended that wherever 

possible the Social Security Number 

be used for this purpose. If such use 

continues to be consistent with Federal policy, it is expected that use of 

the number to identify medical records will become universal. Not all 

patients have or know their Social 

Security Number, but use of this 

number can be initiated for those 

who do with the expectation of 

substituting the Social Security 

Number for other patient numbers as 

they become available. Use of the 

Social Security Number is now required in medical records when reim 

bursement for care is made from 

Federal funds dir:ctly to the provider, in medical records maintained 

by the Indian Health Service, and in 

hospital records of the Armed Forces 

and Veterans Administration. Its use 

in widespread record linkage in fields 

other than health “ has been costeffective, e.g., for income tax reports 

and drivers licenses. 

Problems which may be encountered 

in use of the Social Security Number 

are similar to those encountered in 

use of other numbering systems. 

These are mainly errors in reporting 

the number. Occasional difficulty in 

correct identification of individuals 

is likely to occur with use of any 

numbering system. Safeguards required to maintain confidentiality of 

patient information are also similar 

to those required with any other 

numbering system. 

The Social Security Number is also 

recommended for use as the provider 

identification number (see Item B, 

lb). 

2.	 Residence. Patient’s usual residence, to 

consist of street name and number, 
3. 

4. 

5, 

apartment number (if any), city, State, 

and zip code. 

Comment: It is recognized that patients 

can have several addresses, all of which 

differ: address of current residence, billing addess, legal address, etc. These 

multiple addresses occur most frequently 

when the potential patient population 

contains college students, military personnel, or visitors to the area. Each of 

these addresses carI be relevant and 

necessary information to the provider; it 

is not the intent of this item to preclude 

inclusion of multiple address information in the record. When more than one 

address is recorded, each should be 

properly and consistently identified. The 

usual or permanent address is the one 

preferred for geographic coding in studies of utilization of services. An example: 

a. Usual or permanent address 

b. Local address (if not usual) 

c.	 Billing address (if not local and 

usual) 

Date of birth. Month, day, year. 

Sex. Male, female. 

Expected source of payment. The following classification, similar tg that recommended in the Uniform Hospital Discharge Data Set,5 is suggested as a 

minimum: 

Government progam 

a. Workmen’s compensation 

b. Medicare 

c. Medicaid 

d.	 Civilian Health and Medical Program 

of the Uniformed Services 

e. Other (specify) 

Insurance mechanism 

E Blue Cross 

Blue Shield 

c. Insurance company 

d. Prepaid group practice or health plan 

e. hledical foundation 

Self-pay 

No charge (free, charity, special research, 

teaching) 

Other (specify) 

B. Items that characterize the provider. 

1.	 Provider identification (for definition of 

“provider,” see prior discussion, “What 

Is an Ambulatory Medical Care Encounter?”). 

a.	 Name. Surname, first name, middle 

initial. 

b.	 Identification number. A unique 

number that distinguishes the provider from all other providers. 

Comment: Several providers may 

render care in the same setting and 

many providers practice in more 

than one setting. An example of the 

latter is the solo practitioner who 

also sees patients in a hospital outpatient department or emergency 

room. Use of a unique number for 

each provider will make it possible to 

distinguish his patients from those of 

another provider in the same setting 

and also to identify all of the patients whom the provider encounters 

in various settings. A single provider 

identification number will also benefit the provider, for it can replace the 

many different numbers with which 

he may currently identify himself in 

different situations. 

It is recommended that providers use 

the Social Security Number to identify themselves in all situations in 

which they have this option, with 

the expectation that in time its use 

will become universal. Many thirdparty payers (e.g., Medicare) now 

require use of the Social Security 

Number for provider identification. 

The Social Security Number is also 

recommended for use as the patient 

identification number (see Item A, 

lb). 

7 
. 

2.	 Professional address. Street address, 

office number (if any), city, State, zip 

code. 

3.	 Profession. That profession in which the 

prcwider is. currently engaged. The following classification is suggested as a 

minimum: 

a. Physician 

Include specialty, if any, as determined by membership in, or elig-ibility for, specialty born-d. 

b. Dentist (Include specialty) 

c. Nurse “ 

d. Other (specify) 

C.	 Items that characterize the patient-provider 

encounter. 

1. Date of encounter. Month, day, year. 

Comment: To assist in allocating personnel and monitoring cost, some larger 

practices,’ consisting of several types of 

providers, may wish also to record the 

time and the duration of the encounter. 

2. Place of encounter. 

;. 

c. 

d. 

e. 

f. 

Private office


Clinic or health center (any except


hospital outpatient department)


Hospital outpatient department


Hospital emergency room


Home


Other (specify)


Comment: The purpose of this item


is to identify the physical location of


the encounter. Encounters that oc­


cur in facilities shared by several


providers should be classified as “pri­


vate office” rather than “clinic or


health center” if payment for care is


made to an individual provider rather


than to an organization of providers.


Group practices and health mainte­


nance organizations in which the


physicians pool their income should


be classified as “clinic or health


center. ”


3.	 Reason for encounter. The patient’s 

principaJ problem(s), complaint(s), or 

symptom(s) at this encounter, in the 

patient’s own words. If more than one 

reason is given, list as first the one most 

important to the patient. 

Comment: The inclusion of this item, 

normally elicited by the provider to help 

him focus on the patient’s concerns, will 

-also be usefil for health services research, for planning, and for studies of 

the natural history of illnesses. By specifying that the reason for visit be recorded in the patient’s words, the provider will be discouraged from substituting his own words, which frequently 

take the form of a diagnosis rather than 

the patient’s statement of symptoms or 

complaints. For example, if the patient 

complains of being short of breath the 

provider would record just that, rather 

than “dyspnea” or a specific diagnosis. 

However, ethnic terms which are not 

generally understood may be translated 

into more familiar laymen’s terms. 

4. Findings. All history, physical examination, laboratory, and other findings pertinent to the patient’s reasons for the 

encounter or diagnoses, and any other 

findings or results of diagnostic procedures which tl-ie provider deems important. 

Comment: To care properly for the 

individual patient, it is essential that 

there be a statement in the record of the 

provider’s findings. The consultants did 

not attempt to spell out the detailed 

content of this area. For certain purposes, such as professional review it may 

be necessary to specify particular items 

that should be included in the record. 

However, this should be a matter of the 

individual provider’s option, at least 

until such time as experience with such 

programs as the Professional Standards 

Review Organizations provides some observations that can be used as guidelines. 

5.	 Diagnosis and/or problem. The provider’s current assessment of the 
patient’s reasons for the encounter and 

all conditions requiring treatment or 

management. Depending on the amount 

and kind of information which the provider has secured about the patient and 

his personal preferences, the diagnoses 

and/or problems may be stated as 

symptoms, problems requiring management, and formal diagnoses. The provider may wish to refer to the systems of 

recording problems or symptoms developed by Weed6 and Hurtado and Greenlick7 as aids to systematic recording. The 

principal diagnosis and/or problem 

should be listed first and is defined as 

the health problem that is most significant in terms of the procedures carried 

out and the care provided at this enccwnter. When possible, the diagnosis should 

be expressed in the nomenclature given 

in Current Medical Information and 

Terminology, though CMIT does not 

include all acceptable diagnostic terms. 

(bn.ment: The consultants concluded 

that most of the purposes of data on 

ambulatory care require the knowledge 

of only those diagnoses and/or problems 

relating to the patient’s reasons for the 

current encounter or for which he receives treatment. It is acknowledged that 

without any specific instructions for 

classification of diagnoses and/or problems the recommended format may not 

prove optimally useful for some purposes. 

6.	 Services and procedures. All diagnostic, 

therapeutic, and preventive services and 

procedures (including history taking) 

performed during the encounter or 

scheduled to be performed before the 

next encounter. . 

Comment: For purposes of professional 

review, planning, clarifying curricula 

objectives, and health services research, 

it is particularly important that the 

services and procedures provided be recorded in as much detail as possible. This 

detail would also enable charges for an 

encounter to be compared meaningfully 

among providers. No particular terminology of services and procedures is .recommended at this time. The consultants 

encourage efforts to develop and evaluate terminologies that are useful to 

providers, third-part y payers, planners, 

and researchers on health services. One 

such effort is the Uniform Medical Procedures Terminology and Code Project 

established by the Assistant Secretary 

for Health, DHEW. Similar developmental activities by other governmental and 

private organizations are essential in arriving at a standard terminology which 

will meet the needs of all interested 

parties. 

7.	 Itemized charges. All charges to be made 

by the provider for services and procedures performed during the encounter or 

to be performed by him or his associates 

before the next encounter. Each charge 

is to be related to a specific service or 

procedure. 

Comment: In those cases where there 

has been cavitation prepayment of services and no fee schedule is associated 

with a specific service, thk item would 

be deleted. 

8.	 Disposition. The provider’s statement of 

the next step(s) in the care of the 

patient. The following classification is 

suggested as a minimum: 

No followup planned 

:. Return, time specified 

c. Return, P.R.N. 

d. Telephone followup 

e. Referred to other provider 

f.	 Returned to referring provider 

Admit to hospital 

i. Other 

Two or more dispositions may-apply for 

some encounters, and all should be 

recorded, e.g., e. Referred to other provider, and either d. Telephone followup 

or b. Return, time specified. 

9 
THE MAINTENANCE OF 

CONFIDENTIALITY 

The President’s Commission on Federal Statistics has formulated two criteria for confidentiality of data supplied by or obtained from 

persons about themselves: 

1. Disclosure of data in a manner that 

would allow public identification of the respondent or would in any way be harmful to 

him is prohibited; and 

2. The data are immune from legal process.g 

Physicians and other providers of health care 

have a long tradition of maintaining the confidentiality of information given to them by 

patients or developed during the provision of 

care, and they allow other persons access to it 

only under certain circumstances. These circumstances include the following: 

1. Specific authorization by the patient to 

supply the information, most commonly to 

third-party payers in support of claims. 

2. Receipt of assurance that information 

released will be held in confidence by the person 

or organization to which the information is 

given. This is frequently the circumstance in 

which one provider supplies information to 

other providers of medical care (confidentiality 

implied) and to research investigators and statistical reporting programs (confidentiality y generally made explicit in a formal statement). 

The items of information in the uniform 

minimum data set should be afforded the same 

safeguards with respect to confidentiality as all 

other items of information in the ambulatory 

medical care record. 

USES AND LIMITATIONS OF THE 

MINIMUM DATA SET AND ITS RELATIONSHIP TO AN AMBULATORY CARE 

ENCOUNTER FORM 

The consultants have chosen, defined, and 

categorized a set of items of information which 

should be entered into ambulatory medical care 

records. This task is distinct from that of 

specifying how information is to be abstracted 

from these records. Indeed, the organization of 

most ambulatory care records does not lend 

itself to easy retrieval of particular items. The 

placement and wording of items varies from 

record to record of a single provider, and even 

more among the records of different providers. 

In considering items of information for 

inclusion in the minimum data set the consultants recognized that they naturally fall into 

groups of items that identify and characterize 

the patient, the provider, and the encounter 

between patient and provider. Because of differences in frequency of recording the three types 

of information, it would be practical for abstracting purposes to enter various items in 

separate parts of the record or to maintain 

separate records. Legal requirements and professional standards for the maintenance and authentication of medical records should be 

observed in recording the information. Abstracting information from the records will be facilitated if the items of data are grouped as shown 

in table A. 

Items of information that are listed for two 

or more records are those needed for identification. 

It is recognized that some of the records 

need not be maintained in certain settings. For 

example, in a prepaid group practice or health 

care plan the patients are not charged for 

services provided, so that a billing record is not 

needed. In the case of a solo practitioner, a 

provider record is not needed and it may be 

desirable to combine the other items of information in a single record. These differences in the 

types of records that are maintained should not 

affect ability to record the minimum data set in 

a uniform manner. 

Abstracting the minimum basic data set 

from the total ambulatory medical care record 

would be greatly simplified if the information 

were entered in a uniform systematic fashion in 

all of the records of a particular provider. There 

are various ways of accomplishing this. One is 

for the provider to enter the items that have 

been identified as pertaining to the encounter 

and those pertaining to the patient in separate, 

labeled parts of the ambulatory care record. 

Another is to have the two sets of information 

entered on separate pieces of paper—an encounter form and a patient form–so that the 

10 
Table A. Items of information “for inclusion in medical records 

Data item 

Provider name


Provider identification no.


Provider address


Provider profession


Patient name


Patient identification no.


Patient residence address


Patient dete of birth


Patient sex


Principal source of payment


Date of encounter


Place of encounter


Reason for encounter


Findings


Diagnoses


Services and procadu res


Charges


Disposition


Provider 

record 

x 

x 

x 

x 

information could be extracted by simply. mak­ . 

ing copies of the forms. Alternately, snapout 

forms with multiple copies could be used. 

There is no intention of prescribing a specific format. It seems wiser at this stage of 

development of ambulatory care information to 

be flexible so that each user can adapt the 

format to his own situation. 

Such a patient form and encounter form 

need not be restricted to the items contained in 

the minimum basic set, but could include other 

items desired by the provider. Information 

systems are being developed and established in 

many ambulatory care settings, each with its 

own set of data items. It is recommended that 

the items in the proposed minimum basic data 

set be the uniform core set of items for all such 

information systems to the extent that they are 

pertinent to the purposes served by the systems. 

The following discussion provides examples 

of how the minimum data set and patient and 

Patient Encounter Billing 

record record record 

x x 

x x 

x x x 

x x x 

x x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

encounter forms can be used together to achieve 

the eight purposes of ambu~tory care data 

defined by the Conference on Ambulatory 

Medical Care Records (see the section “Objectives and Approach”). It is clear that none of 

these purposes can be served without development of methods for extracting the information 

from the records, and that for most of the 

purposes the information so extracted must be 

assembled for groups of providers and analyzed 

in systematic fashion. 

Office and Practice Management 

(Purposes 1,4, and 7) 

The consultants believe that the inclusion of 

a minimum set of items in the ambulatory care 

record and on an encounter fo~ can be of great 

assistance to physicians and other providers of 

health care. The information in the minimum 

11 ‘ 
data set, along with other information which the 

provider wants to record, serves as a basis for 

planning individual patient care, for documenting and evaluating the course of the patient’s. 

illness, and for communication among several 

providers of care to the same patient. If the 

items were placed in machine-readable form and 

a computer were available, the provider could 

easily be given an up-to-date patient profile. 

The data set should simplify the process of 

billing and collecting. fees when there is thirdparty payment. Indeed, the careful organization 

of the encounter form would make it possible to 

relate the service or procedure rendered to the 

appropriate fee schedule. For this process to 

work effectively, however, there must be a 

nomenclature for services and procedures that is 

adhered to by both providers and third-party 

payers. The consultants urge that representatives 

of both groups develop and implement such a 

uniform nomenclature of services and procedures. 

Successful management of a medical practice 

involves control of expenditures, and in all but 

the smallest practices successful control requires 

information on the relative costs of providing 

services under different forms of manpower 

organization. The minimum set of items, available on a copy of an encounter (and claim or 

billing) form, can” serve this internal accounting 

function to a large extent. 

Evaluation of Care and Research 

(Purposes 2,3, and 8) 

Purposes 2, 3, and 8 are grouped because the 

entry of a uniform minimum set of items on 

ambulatory care records can help achieve them 

in the same two ways: it can determine the 

frequency with which specified events occur, 

and can provide a sampling frame from which a 

subset of encounters can be selected for more 

intensive study. 

Evaluation of the quality and costs of health 

care. —It is necessary to have specific criteria in 

order to adequately judge whether the quality or 

cost of care in a particular instance is appropriate. Prominent among such criteria are the 

particular local or regional patterns of delivery 

or charges for care. The presence of a uniform 

set of items in the records of all providers, 

particulady if in a standardized format or 

included on an encounter form, would enable 

such local and regional patterns to be determined quickly and accurately. A further advantage is that the set of all encounters can be easily 

screened for a subset to be more intensively 

reviewed. To identify encounters for which it is 

suspected that care has not been properly given, 

the provider’s records (or more quickly, encounter forms, if available) would be reviewed for 

encounters in which, for example, the “services 

and procedures” or “disposition” were not 

appropriate to the patient’s “reason for encounter,” the provider’s diagnosis, or both. More 

detailed information regarding these suspect 

encounters could then be obtained from the 

patient and the provider in order to make a 

judgment. Similarly, encounters could be 

screened for inappropriate combinations of 

“services and procedures” and “charges,” thus 

providing a tentative identification of instances 

in which charges may have been excessive. 

Study of health care delivery and of the 

natural hktory of dkeases. —The presence of a 

uniform set of items in the records of all 

providers of care in a defined area has the 

potential to describe objectively (1) the frequency and distribution of complaints and 

illnesses for which professional care is sought, 

and (2) the health care providers’ ways of 

dealing with these complaints and illnesses. To 

facilitate the achievement of this potential, the 

set of items should be entered in a standard 

format to enable rapid abstracting. A further 

advantage of a standard format is that subsets of 

encounters can be rapidly screened for those in 

which there were certain symptoms, diagnoses, 

or dispositions, for example, so that these could 

be followed up in detailed studies of specific 

hypotheses. 

Education and Planning (Purposes 5 and 6) 

In order for educators of health professionals to plan curricula around those activities that 

are quantitatively of greatest importance in 

ambulatory care, they need to know the relative 

frequencies of those activities. Areawide health 

planners, to do their job properly, need to know 

the frequency of various professional activities. 

Their needs can be relatively easily met by the 

12

I


incorporation of a uniform set of items in . 

ambulatory care records, once records from a 

representative sample of a defined population 

are made available to them since neither the 

educator nor the planner needs to identify 

specific patients. Again, if the items were to 

appear on a standard encounter form, their task 

would be further simplified. 

IMPLEMENTATION OF THE MINIMUM 

BASIC DATA SET 

The uses of the data set which are summarized in the preceding section and set forth 

clscwhcre in greater details >4 make a convincing 

case for the need for uniform, systematic information cm ambulatory medical care. Increases in 

the proportion of ambulatory services that are 

being paid for by third parties and on a 

cavitation basis, proliferation of different information systems by public and private organizations which pay for care, and the imminent 

establishment of Professional Standards Review 

Organizations to maintain the quality and control the costs of care lend urgency to the 

widespread adoption of the minimum basic data 

Set. 

Development of specific proposals for implementation of the data set are beyond the 

responsibilities of the consultants to the U.S. 

National Committee on Vital and Health Statistics. The consultants feel strongly, however, that 

the various Federal agencies that operate programs providing ambulatory care either directly 

or through financial support to other public and 

private organizations should take the lead, by 

accepting the minimum basic data set and 

fostering and promoting its use wherever possible in all such programs. These include Medicare, 

Medicaid, CHAMPUS, outpatient departments 

of Public Health Service hospitals, Children and 

Youth projects, family and neighborhood health 

centers, clinics of the Indian Health Service and 

the Veterans Administration, and Professional 

Standards Review Organizations. Statistical surveys of ambulatory care by the Social Security 

Administration, Nation@ Center for Health Statistics, the Cooperative Health Statistics System 

and other agencies should employ the data set. 

The consultants also recommend that private 

health care plans, insurance carriers, and professional organizations that influence the activities 

of health care institutions should encourage the 

use of the minimum basic data set in a.11 

ambulatory medical care records. 

FUTURE REVISION OF THE MINIMUM 

BASIC DATA SET 

The data set presented in this report has 

been developed on the basis of expert opinion 

and the limited experience available from various sources in the systematic recording of 

information in ambulatory medical care records. 

Difficulty may be encountered in getting certain 

items recorded with a satisfactory “degree of 

completeness and accuracy; the definitions and 

classifications proposed for individual items may 

not be the most suitable; and some of the items 

of information may not prove to have the 

anticipated value. Experience in using the data 

set as an aid in patient care, for supplying 

evidence in support of individual claims for 

reimbursement, and for providing statistical data 

on ambulatory care for management, community planning, research, and medical education 

may indicate need for modification of the data 

set. 

It would be desirable that field tests of the 

feasibility of recording the data and of their 

utility for the purposes stated earlier be carried 

out before the set is put into large-scale use. The 

need for the data set is urgent, however, and 

probably will not wait for completion of adequate tests. The consultants therefore recommend that (1) agencies such as the National 

Center for Health Statistics and the Bureau of 

Health Services Research undertake as soon as 

possible formal field tests of feasibility and 

utility with respect to the data set as a whole 

and of the individual items, in each of the major 

settings in which ambulatory care is provided; 

(2) agencies that employ the data set before 

completion of the field tests also make provision 

for evaluating the quality, usefulness, and problems encountered in recording of items in the 

data set that are of particular interest to them; 

and (3) after a suitable period of testing and use, 

a representative group be assembled to revise the 

uniform minimum basic data set in the light of 

that experience. 

13 
REFERENCES


lNationd Center for Health Statistics: Current estimates 

from the Health Interview Survey: United States, 1972. Vital 

and Health Statistics. series 10, No. 85. DHEW Pub. No. (HRA) 

74-1512. Heafth Resources Administration. Washington. U.S. 

Government Printing Office, Sept. 1973. 

2U.S. 92d Congress, 2d Session, 1972. Public Law 92-603, 

H.R. 1; An Act to Amend the Social Security Act. Washington, 

D.C., 1972. 

3Ambulatory Care Data: Report of the Conference on 

Ambulatory Medical Care Records. In Mumaghan, J. H., ed. 

Medicaf Care, Vol. 11, No. 2 (suPPI.), 1973. Afso, Philadelphia, 

J. B. Lippincott, 1973. 

4NationaJ Center for Heafth Services Research and Develop 

men~ Guidelines for producing uniform data for health care 

plans. DHEW Pub. No. (HSM) 73-3005. Heafth Services and 

Mental Health Administration. Washington. U.S. Government 

Printing Office, July 1972. 

%ational Center for Health Statistics: Uniform hospitrd 

abstract: Minimum basic data set. Vital and Health Statistics. 

Series 4, No. 14. DHEW Pub. No. (HSM) 73-1451. Heafth 

Services and Mental Health Administration. Washington. U.S. 

Government Printing Office, Dec. 1972. 

6Weed, L. L,; Me&cal Records, Medical Education and 

Patient Care: The Problem-Oriented Record as a Basic Tool. 

Cleveland. Case Western Reserve University Press, 1969. 

7Hurtado, A. V., and Greenhck, M. R.: A dkease classification system for analysis of med]cal care utilisation, with a note 

“ on symptom classification. Health Sero. Res. 6:235-250, 1971. 

8p=sident~s com~ssion on Federal Statistics. Federal 

Statistics. Vol. L Washington, D.C. U.S. Government Printing 

Office, 1971. 
APPENDIX I


DEFINITION OF AN AMBULATORY CARE ENCOUNTER


To obtain information on the totality of 

ambulatory care, the broadest possible definition of “encounter” should be employed, i.e., 

any contact between a patient and the medical 

care system in an ambulatory care setting. For 

the following practical reasons, however, the 

consultants decided not to recommend a definition of this sort: 

1. Medical personnel who deal with the 

patient but who do not use independent judgment in his care (e.g., X-ray or EKG technicians, 

laboratory personnel) generally would not be 

able to complete many of the items in part C 

(encounter items). 

2. Contacts between patient and provider 

that are not face to face, e.g., telephone calls, 

probably would not be recorded uniformly 

among providers. 

3. Surveys that produce data on per capita 

physician utilization exclude certain contacts 

from consideration, e.g., visits to a radiologist 

for diagnostic X-rays. If data from provider’s 

records were to include such contacts, comparisons with the surveys would be difficult to 

interpret and the continuity of utilization statistics might be hampered. 

The consultants recommend instead that 

encounter items be recorded each time there is a 

face-to-face contact between a patient and a 

provider who, at the time of contact, has 

primary responsibility for assessing and treating 

the patient’s condition and who exercises independent judgment as to the care of the patient. 

They also recommend that the provider record 

not orJIy services given at the encounter itself, 

but those scheduled to occur before a subsequent encounter. Completion of the service or 

procedure can be indicated by a note or mark 

adjacent to the original scheduling statement. In 

this way it is hoped that, except for telephone 

calls, most ambulatory care activities will be 

accounted for. Experience will be the judge of 

this particular scheme. The consultants encourage the development of any system that optimizes both the completeness and the reliability 

of recording ambulatory care encounter data. 

Some of the services that would not be 

accounted for under this definition of an encounter are recorded separately, e.g., in X-ray 

logs. If the objective is to account for all services 

rendered, including telephone calls, it is recoin 

mended that those not coming within the 

definition of “encounter” be kept separate so 

that they can be excluded in the interest of 

comparability y. 

15 
APPENDIX II


GROUPS FROM WHOM OPINIONS WERE SOLICITED REGARDING


THE CONTENT OF THIS REPORT


American Academy of Family Physicians 

American Academy of Obstetricians and Gynecologists, The 

American Academy of Pediatrics 

American Association of Foundations for Medical Care 

American Association of Medical Clinics 

American College of Physicians 

American College of Surgeons 

American Hospital Association 

American Medical Association 

American Osteopathic Association 

American Public Health Association 

American Society of Internal Medicine 

Association of American Medical Colleges 

Association of State and Territorial Health 

Officers 

Commission on Professional and Hospital Activities 

Group Health Association of America 

Health Insurance Association of America 

National Ambulance and Medical Services Association 

National Association of Blue Shield Plans 

National Medical Association 

Social Security Administration 

Schools of Public Health 

University of California, School of Public Health 

University of California at Los Angeles, School 

of Public Health 

Columbia University, School of Public Health 

and Administrative Medicine 

Harvard University, School of Public Health 

University of Hawaii, School of Public Health 

The Johns Hopkins University, School of Hygiene and Public Health 

Loma Linda University, School of Public Health 

University of Michigan, School of Public Health 

University of Minnesota, School of Public 

Health 

University of Montreal, School of Public Health 

University of North Carolina, School of Public 

Health 

University of Oklahoma, School of HeaIth 

University of Pittsburgh, Graduate School of 

Public Health 

University of Puerto Rico, School of Public 

Hezdth 

The University of Texas, School of Public 

Health at Houston 

University of Toronto, School of Hygiene 

Tukme University, School of Public Health and 

Tropical Medicine 

University of Washington, School of Public 

Health and Community Medicine 

Yale University, Department of Epidemiology 

and Public Health 

16 
VITAL AND HEALTH STATISTICS PUBLICATION SERIES 

Formerly Public Health Service Publication No. 1000 

Series 1. Programs and collection proceduves.— Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding the data. 

Series 2.	 lku!a evaluation and methods research —Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, contributions to statistical theory. 

Sert”es 3. Analytical studies. —Reports presenting analytical or interpretive studies basedon vital and health 

Series 4. 

Series 10. 

Series 11. 

Series 12. 

Series 13. 

Series 14. 

Series 20. 

Sm”es 21, 

Series 22. 

For a list 

statistics, carrying the analysis further than the expository types of reports in the other series. 

Documents and committee reports. —Final reports of major committees concerned with vital and 

health statistics, and documents such as recommended model vital registration laws and revised 

birth and death certificates. 

Data f?om the Health Interview Swrvev. —Statistics on illness, accidental injuries, disabili~, use 

of hospital, medical, dental, and other services, and other health-related topics, based on data 

collected in a continuing national household interview survey. 

Data from the Health Examination Survey. —Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutional population provide the basis for two types 

of reports: (1) estimates of the medically defined prevalence of specific diseases in the United 

States and the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without 

reference to an explicit finite universe of persons. 

Data from the Institutional Population Surveys —Statistics relating to the health characteristics of 

persons in instinitions, and their medical, nursing, and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

Data from the Hospital Discharge Survey. —Statistics relating to discharged patients in short-stay 

hospitals, based on a sample of patient records in a national sample of hospitals. 

Data on health vesources: manpoww and facilities. —Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health 

occupations, hospitals, nursing homes, and outpatient facilities. 

Data on mortality. -Various statistics on mortality other than as included in regular annual or 

mont~y reports—special analyses by cause of death, age, and other demographic variables, also 

geographic and time series analyses. 

Data on natality, marriage, and divorce. —Various statistics on natality, marriage, and divorce 

other than as included in regular annual or monthly reports+pecial analyses by demographic 

variables, also geographic and time series analyses, studies of fertility. 

lkta from the National Natality and Mortality Surveys. — Statistics on characteristics of births 

and deaths not available from the vital records, based on sample surveys stemming horn these 

records, including such topics as mortality by socioeconomic class, hospital experience in the 

last year of life, medical care during pregnancy, health insurance coverage, etc. 

of titles of reports published in these series, write to: Office of Information 

National Center for Health Statistics 

Public Health Servicer HRA 

Rockville, Md. 20852