DN01
OMITTED.
DN02
OMITTED.
DN03
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {EVN-DT}
SHOW CARD DN-1.
What type of dental care provider did {you/{PERSON}}
see during this
visit?
PROBE: Any other type of dental care person?
CHECK ALL THAT APPLY.
GENERAL DENTIST ........................ 1 {DN04}
DENTAL HYGIENIST ....................... 2 {DN04}
DENTAL TECHNICIAN ...................... 3 {DN04}
DENTAL SURGEON ......................... 4 {DN04}
ORTHODONTIST ........................... 5 {DN04}
ENDODONTIST ............................ 6 {DN04}
PERIODONTIST ........................... 7 {DN04}
OTHER ................................. 91 {DN04}
REF ................................... -7 {DN04}
DK .................................... -8 {DN04}
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES
AUTOMATICALLY): CAPI DOES NOT ALLOW -7 OR -8 IN
COMBINATION WITH ANY OTHER CODE.
DN04
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {EVN-DT}
SHOW CARD DN-2.
What did {you/{PERSON}} have done during this visit?
PROBE: What else was done?
CHECK ALL THAT APPLY.
*DIAGNOSTIC OR PREVENTATIVE
GENERAL EXAM, CHECKUP OR CONSULTATION .. 1
CLEANING, PROPHYLAXIS, OR POLISHING .... 2
X-RAYS, RADIOGRAPHS, OR BITEWINGS ...... 3
FLUORIDE TREATMENT ..................... 4
SEALANT (PLASTIC COATINGS ON BACK
TEETH) ................................. 5
*RESTORATIVE OR ENDODONTIC
FILLINGS ............................... 6
INLAYS ................................. 7
CROWNS OR CAPS ......................... 8
ROOT CANAL ............................. 9
*PERIODONTIC (GUM TREATMENT)
PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY ............................ 10
PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR) ............................... 11
*ORAL SURGERY
EXTRACTION, TOOTH PULLED ............... 12
IMPLANTS ............................... 13
ABSCESS OR INFECTION TREATMENT ......... 14
OTHER ORAL SURGERY ..................... 15
*PROSTHETICS
FIXED BRIDGES .......................... 16
DENTURES OR REMOVABLE PARTIAL DENTURES . 17
RELINING OR REPAIR OF BRIDGES OR
DENTURES ............................... 18
*ORTHODONTICS
ORTHODONTIA, BRACES, OR RETAINERS ...... 19
*ADDITIONAL PROCEDURES
BOND, WHITEN, OR BLEACH ................ 20
TREATMENT FOR TMD OR TMJ ............... 21
OTHER .................................. 91 {DN04OV}
REF .................................... -7
DK ..................................... -8
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
HEADINGS AND CODE CATEGORIES WILL NOT FIT ON ONE
SCREEN. THEREFORE, HEADINGS WILL ONLY APPEAR ON
HELP SCREEN AND SHOW CARD DN-1. HEADINGS SHOULD
BE ASSOCIATED WITH CODES AS FOLLOWS:
*DIAGNOSTIC OR PREVENTATIVE = CODES 1-5
*RESTORATIVE OR ENDODONTIC = CODES 6-9
*PERIODONTIC (GUM TREATMENT) = CODES 10-11
*ORAL SURGERY = CODES 12-15
*PROSTHETICS = CODES 16-18
*ORTHODONTICS = CODE 19
*ADDITIONAL PROCEDURES = CODES 20-21 AND 91
FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES
AUTOMATICALLY): CAPI DOES NOT ALLOW -7 OR -8 IN
COMBINATION WITH ANY OTHER CODE.
IF CODE ‘91’ (OTHER) ENTERED ALONE OR IN
COMBINATION WITH ANY OTHER CODE, CONTINUE WITH
DN04OV
OTHERWISE, GO TO DN05
DN04OV
OTHER TYPE OF DENTAL CARE:
[Enter Other Specify].................. {DN05}
REF ................................... -7 {DN05}
DK .................................... -8 {DN05}
DN05
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {EVN-DT}
During this visit, were any medicines prescribed for
{you/{PERSON}}? Please include only prescriptions
which were
filled.
YES .................................... 1 {DN06}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
HELP AVAILABLE FOR DEFINITION OF PRESCRIBED MEDICINE.
DN06
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {EVN-DT}
Please tell me the names of the prescriptions from
this
visit that were filled.
PROBE: Any other prescriptions from this visit filled?
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
ROSTER DETAILS:
TITLE: PERSON'S-PRESCRIBED-MEDICINES_1.
COL # 1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY PMED NAME (PMED.PMEDNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON'S-PRESCRIBED-MEDICINES-
ROSTER FOR SELECTION AND ADDITION OF PRESCRIBED
MEDICINES.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT AND ADD ALLOWED.
2. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS
NOT YET CREATED THE LINK BETWEEN THIS PMED AND THE
EVENT.
3. EDIT DISALLOWED.
ROSTER FILTER:
NONE, DISPLAY ALL.
BOX_01
IF THE CHARGE/PAYMENT MODULE HAS NOT BEEN ASKED
FOR THE EVENT-PROVIDER PAIR BEING ASKED ABOUT, GO
TO THE CHARGE/PAYMENT (CP) SECTION.
OTHERWISE, GO TO THE EVENT DRIVER (ED) SECTION.
Return to Top
|