EXAMPLE PATIENT DEMOGRAPHICS QUESTIONNAIRE-Self-Administered
Target Audience: Patients and their Families
Purpose: This questionnaire is to be self-administered by patients or their families, and asks for information on patient race, ethnicity, and language abilities and preferences.
Instructions for Use: The sample questionnaire was designed to follow the most current recommendations regarding accurate self-reported patient race and ethnicity as set forth by the Institute of Medicine (IOM), while maintaining categories and rules for rolling up categories that are consistent with current state reporting requirements (questions 1, 2, and 4). For ethnicity, race, and language, facilities may use more granular categories for their specific patient populations.
Guidelines for Rolling Up Categories to Match Current Reporting Requirements
Facilities may choose to collect more detailed race and ethnicity information from patients than OSHPDâs current reporting categories, according to their patient population and needs. In these instances, responses need to be rolled-up into one of the existing reporting categories. The sample questionnaire questions are more granular than current OSHPD reporting requirements.
Racial and Ethnic Categories
ETHNICITY: Respondents are asked to indicate whether they are Hispanic, Latino, or Spanish Origin or not. Patients who answer "Yes" are asked to specify their place(s) of origin.
RACE: Five racial categories are available on the form. Patients who choose one or more racial category will be asked which race they most identify with.
White - Person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American - Person having origins in any of the black racial groups of Africa; includes terms such as "Haitian" or "Negro."
American Indian or Alaska Native - Person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian* - Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander* - Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
* The reporting requirements for the OSHPD Emergency Department (ED) and Ambulatory Surgery (AS) databases differ from Inpatient (IP) admissions. For ED and AS visits, Asians and Pacific Islanders are reported as separate categories, while for IP admissions, they are reported as a combined category. If an admitted patient self-identifies as "Native Hawaiian or Other Pacific Islander", the hospital or clinic would report that patient's race as the combined "Asian/Pacific Islander" to OSHPD. In the ED and AS databases, this patient's race should be reported as "Pacific Islander".
PRINCIPAL LANGUAGE This refers to the language that a person usually or regularly uses, and most closely corresponds with Question #4 below. It is the language that a person is most conversant in and, if non-English speaking, the language for which he/she would need an interpreter.
We want to make sure that all of our patients get the best care possible. We would like you to tell us your racial and ethnic background so that we can review the best treatment that our patients can receive and make sure that everyone of every background gets the highest quality of care. It is also important that we know your preferred spoken language so that you and your healthcare team can have good communication.
We will keep this information private and will update it in your medical record. Your answers are confidential. You need not answer any question you prefer not to answer.
You have been provided a list of Frequently Asked Questions to help answer any questions that you may have about this form. Our registration staff members are happy to answer your questions.
Internet Citation: Patient Demographics Questionnaire-Self Administered Healthcare Cost and Utilization Project (HCUP). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/ca15.jsp. |
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Last modified 10/29/14 |