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BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, PROV.LORPNAME,
EVNT.EVNTBEGM, EVNT.EVNTBEGD, EVNT.EVNTBEGY
ER01
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
Did {you/{PERSON}} see a medical doctor during this
particular visit?
YES .................................... 1 {ER02}
NO ..................................... 2 {ER02}
REF ................................... -7 {ER02}
DK .................................... -8 {ER02}
HELP AVAILABLE FOR DEFINITION OF MEDICAL DOCTOR.
ER02
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
SHOW CARD ER-1.
Please look at this card and tell me which category best
describes the care {you/{PERSON}} received during the
visit to
{PROVIDER} emergency room on {VISIT DATE}.
DIAGNOSIS OR TREATMENT ................. 1 {ER03}
EMERGENCY (E.G., ACCIDENT OR INJURY) ... 2 {ER03}
PSYCHOTHERAPY OR MENTAL HEALTH
COUNSELING ............................. 3 {ER03}
FOLLOW-UP OR POST-OPERATIVE VISIT ...... 4 {ER03}
IMMUNIZATIONS OR SHOTS ................. 5 {ER03}
PREGNANCY-RELATED (INCLUDING
PRENATAL CARE AND DELIVERY) ............ 6 {ER03}
OTHER ................................. 91 {ER03}
REF ................................... -7 {ER03}
DK .................................... -8 {ER03}
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
IF CODED ‘6’ (PREGNANCY-RELATED (INCLUDING
PRENATAL CARE AND DELIVERY)), CHECK THAT PERSON IS
FEMALE. IF NOT, DISPLAY THE FOLLOWING MESSAGE:
‘CODE UNAVAILABLE FOR MALES. VERIFY AND RE-ENTER.’
ER03
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
Was this visit related to any specific health
condition or
were any conditions discovered during this visit?
YES .................................... 1 {ER04}
NO ..................................... 2 {ER05}
REF ................................... -7 {ER05}
DK .................................... -8 {ER05}
ER04
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
What conditions were discovered or led {you/{PERSON}}
to make
this visit?
PROBE: Any other condition?
IF CONDITION IS ALREADY LISTED, SELECT ENTRY ON
ROSTER.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
DISPLAY ‘ADD CONDITION’ AS AN OPTION ON THIS
SCREEN.
GO TO ER05
ROSTER DETAILS:
Title: PERS_COND_1
COL #1 HEADER: MEDICAL CONDITION
INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION
(COND.CONDNAM)
ROSTER DEFINITION:
DISPLAY THE PERSON-MEDICAL-CONDITIONS-ROSTER FOR
THE SELECTION AND ADDITION OF ONE OR MANY MEDICAL
CONDITION(S) ASSOCIATED WITH THIS EVENT.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. SELECTION SHOULD NOT
IMPACT THE ROUND FLAG OF THE CONDITION.
2. MULTIPLE ADD ALLOWED. INTERVIEWER SHOULD RECORD
THE CONDITION NAME.
3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A CONDITION ADDED ON THIS SCREEN AS LONG AS
CAPI HAS NOT YET CREATED THE LINK BETWEEN THIS
CONDITION AND THE EVENT. IF THE INTERVIEWER
ATTEMPTS TO DELETE A CONDITION WHEN DELETE IS
NOT ALLOWED, DISPLAY THE FOLLOWING MESSAGE:
"DELETE ALLOWED ONLY WHEN CONDITION IS FIRST
ENTERED."
ROSTER FILTER:
DISPLAY ALL CONDITIONS ON PERSON’S ROSTER; NO
FILTER.
ER05
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
SHOW CARD ER-2.
Looking at this card, which of these services, if any,
did {you/{PERSON}} have during this visit?
CHECK ALL THAT APPLY.
LABORATORY TESTS ....................... 1 {ER06}
SONOGRAM OR ULTRASOUND ................. 2 {ER06}
X-RAYS ................................. 3 {ER06}
MAMMOGRAM .............................. 4 {ER06}
MRI OR CATSCAN ......................... 5 {ER06}
EKG OR ECG ............................. 6 {ER06}
EEG .................................... 7 {ER06}
VACCINATION ............................ 8 {ER06}
ANESTHESIA ............................. 9 {ER06}
OTHER DIAGNOSTIC TEST ................. 10 {ER06}
THROAT SWAB ........................... 11 {ER06}
NO SERVICES RECEIVED .................. 95 {ER06}
REF ................................... -7 {ER06}
DK .................................... -8 {ER06}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
ALLOW CODE ‘4’ (MAMMOGRAM) ONLY IF PERSON IS
FEMALE AND AGE IS > 17 YEARS (OR AGE CATEGORIES 4
THROUGH 9).
ALLOW CODE ‘95’ (NO SERVICES RECEIVED), ‘-7’
(REFUSED), AND ‘-8’ (DON’T KNOW) ALONE ONLY; THESE
RESPONSES MAY NOT BE SELECTED WITH ANY OTHER
RESPONSE.
NOTE: ‘OTHER DIAGNOSTIC TESTS’ AND ‘NO SERVICES
RECEIVED’ ARE NOT DISPLAYED ON SHOW CARD.
HARD CHECK:
EDIT: IF CODED ‘95’ (NO SERVICES RECEIVED),
NO OTHER SERVICE CATEGORIES CAN BE CODED. IF
INTERVIEWER SELECTS ANOTHER CODE WITH ‘NO
SERVICES’, DISPLAY THE FOLLOWING MESSAGE: "NO
SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER
OPTIONS. VERIFY AND RE-ENTER."
NOTE: CODE ‘11’ (THROAT SWAB) IS DISPLAYED ON
THE SCREEN AND ON THE SHOW CARD BETWEEN CODES ‘1’
(LABORATORY TESTS) AND ‘2’ (SONOGRAM OR
ULTRASOUND).
ER06
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER} {EVN-DT}
Was a surgical procedure performed on {you/{PERSON}}
during this
visit?
YES .................................... 1 {ER08}
NO ..................................... 2 {ER08}
REF ................................... -7 {ER08}
DK .................................... -8 {ER08}
HELP AVAILABLE FOR DEFINITION OF SURGICAL PROCEDURE.
ER07
OMITTED.
ER08
{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 {ER09}
NO ..................................... 2 {BOX_03}
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}
HELP AVAILABLE FOR DEFINITION OF PRESCRIBED MEDICINE.
ER09
{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 prescribed medicines from this visit
that were
filled?
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
DISPLAY ‘ADD MEDICINE’ AS AN OPTION ON THIS
SCREEN.
GO TO BOX_03
ROSTER DETAILS:
TITLE: PERSON'S_PRESCRIBED_MEDICINES_1
COL # 1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE
(DRUG.DRUGNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE PERSON'S-PRESCRIPTION-
MEDICINES-ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. MULTIPLE ADD ALLOWED.
3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A MEDICINE ADDED ON THIS SCREEN AS LONG AS
CAPI HAS NOT YET CREATED THE LINK BETWEEN THIS
MEDICINE AND THE EVENT.
4. EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY ALL MEDICINES ON PERSON’S ROSTER; NO
FILTER.
ER10
OMITTED.
ER11
OMITTED.
LOOP_01
OMITTED.
BOX_01
OMITTED.
BOX_02
OMITTED.
ER12
OMITTED.
END_LP01
OMITTED.
BOX_03
IF THE CHARGE/PAYMENT (CP) SECTION FOR THIS
EMERGENCY ROOM EVENT IS NOT COMPLETED, ASK THE
CHARGE/PAYMENT (CP) SECTION
OTHERWISE, GO TO THE EVENT DRIVER (ED) SECTION
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