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BOX_01
IF HOSPITAL STAY DISCHARGE DATE IS ‘95’ (STILL IN
HOSPITAL) [OR IF ROUND 5, CODE ‘95’ INDICATES
‘STILL IN HOSPITAL’ AND ‘RELEASED IN 2009’], DO
NOT ASK THE HOSPITAL STAY (HS) SECTION OR THE
CHARGE/PAYMENT (CP) SECTION FOR THIS EVENT.
(WE WILL FOLLOW UP WITH THESE EVENTS NEXT ROUND.
IF ROUND 5, WE WILL OBTAIN NECESSARY INFORMATION
DURING MPS FOLLOW-UP.)
IF THE MONTH OR DAY OR YEAR FOR THE HOSPITAL STAY
ADMIT DATE OR DISCHARGE DATE IS ‘-7’ (REFUSED) OR
‘-8’ (DON’T KNOW), CONTINUE WITH HS01
OTHERWISE, GO TO HS02
HS01
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
How many nights did {you/{PERSON}} stay in {PROVIDER}?
[Enter Number of Nights] ............... {HS02}
REF ................................... -7 {HS02}
DK .................................... -8 {HS02}
SOFT RANGE CHECK: 1 TO 30.
HS02
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Did this hospital stay begin with a visit to an
emergency room?
YES .................................... 1 {HS03}
NO ..................................... 2 {HS03}
REF ................................... -7 {HS03}
DK .................................... -8 {HS03}
HELP AVAILABLE FOR DEFINITION OF EMERGENCY ROOM.
IF CODED ‘1’ (YES), DISPLAY THE FOLLOWING
MESSAGE: "PLEASE BE SURE YOU HAVE ENTERED THIS
EMERGENCY ROOM VISIT FOR THIS PERSON."
HS03
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Was this hospital stay related to any specific health
condition
or were any conditions discovered during this stay?
YES .................................... 1 {HS04}
NO ..................................... 2 {HS05}
REF ................................... -7 {HS05}
DK .................................... -8 {HS05}
HS04
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
What conditions were discovered or led {you/{PERSON}}
to enter
the hospital?
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.
ROSTER DETAILS:
Title: PERS-COND-1
COL #1 HEADER: MEDICAL CONDITION
INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION
(COND.CONDNAM)
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON-MEDICAL-CONDITIONS-
ROSTER FOR SELECTION AND ADDITION OF ONE OR MANY
MEDICAL CONDITIONS ASSOCIATED WITH THIS EVENT
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. MULTIPLE ADD ALLOWED.
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
ROSTER FILTER:
DISPLAY ALL CONDITIONS ON PERSON’S ROSTER;
DISPLAY ALL.
HS05
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
SHOW CARD HS-1.
Please look at this card and tell me which category best
describes the reason {you/{PERSON}} entered {PROVIDER}
on {ADMIT
DATE}.
IF NECESSARY, PROBE: What was the main reason
{you/he/she}
entered {PROVIDER}?
OPERATION OR SURGICAL PROCEDURE ........ 1 {HS06AA}
TREATMENT OR THERAPY, NOT INCLUDING
SURGERY .............................. 2 {HS06}
DIAGNOSTIC TESTS ONLY .................. 3 {HS06}
GIVE BIRTH TO A BABY - NORMAL OR
CAESAREAN SECTION (MOTHER) ........... 4 {HS06}
TO BE BORN (BABY) ...................... 5 {HS06}
PREGNANCY-RELATED COMPLICATIONS ........ 6 {HS06}
OTHER ................................. 91 {HS06}
REF ................................... -7 {HS06}
DK .................................... -8 {HS06}
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
ALLOW CODE ‘4’ (GIVE BIRTH TO A BABY) AND CODE ‘6’
(PREGNANCY-RELATED COMPLICATIONS) ONLY IF PERSON
IS FEMALE. ALLOW CODE ‘5’ (TO BE BORN) ONLY IF
PERSON IS < OR = 1 YEAR OLD (OR AGE CATEGORY 1).
IF CODED ‘4’ (GIVE BIRTH TO A BABY), DISPLAY THE
FOLLOWING MESSAGE IN RED: "PLEASE BE SURE YOU
HAVE ALSO ENTERED A HOSPITAL STAY EVENT FOR THE
BABY." IF CODED ‘5’ (TO BE BORN), DISPLAY THE
FOLLOWING MESSAGE IN RED: "PLEASE BE SURE YOU
HAVE ALSO ENTERED A HOSPITAL STAY EVENT FOR THE
MOTHER."
IF HS05 IS CODED ‘1’ (OPERATION OR SURGICAL
PROCEDURE), AUTOMATICALLY CODE HS06 AS ‘1’ (YES)
BY CAPI
HS06
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Were any operations or surgical procedures performed
on
{you/{PERSON}} during this stay?
YES .................................... 1 {HS06AA}
NO ..................................... 2 {HS06AA}
REF ................................... -7 {HS06AA}
DK .................................... -8 {HS06AA}
HELP AVAILABLE FOR DEFINITION OF OPERATIONS/SURGICAL
PROCEDURES.
HS06AA
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Did {you/{PERSON} spend any time in an intensive or
critical care
unit (ICU) during this stay?
YES .................................... 1 {BOX_01A}
NO ..................................... 2 {BOX_01A}
REF ................................... -7 {BOX_01A}
DK .................................... -8 {BOX_01A}
HELP AVAILABLE FOR DEFINITION OF ICU.
BOX_01A
IF HS05 IS CODED ‘4’ (GIVE BIRTH TO A BABY),
CONTINUE WITH HS06A
OTHERWISE, GO TO HS08
HS06A
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
What kind of delivery did {you/{PERSON}} have? Was it
a vaginal
delivery or caesarean section?
VAGINAL DELIVERY ....................... 1 {HS06B}
CAESAREAN SECTION ...................... 2 {HS06B}
REF ................................... -7 {HS06B}
DK .................................... -8 {HS06B}
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
HS06B
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Did {you/{PERSON}} receive an epidural or a 'spinal'
for pain?
YES .................................... 1 {HS08}
NO ..................................... 2 {HS08}
REF ................................... -7 {HS08}
DK .................................... -8 {HS08}
HELP AVAILABLE FOR DEFINITION OF EPIDURAL/SPINAL.
HS07
OMITTED.
HS08
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
At the time {you/{PERSON}} {were/was} discharged,
were any medicines
prescribed for {you/him/her}? Please do not include
medications
received while {you/he/she} {were/was} a patient in
the hospital.
YES .................................... 1 {HS09}
NO ..................................... 2 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}
HELP AVAILABLE FOR DEFINITION OF PRESCRIBED MEDICINE.
HS09
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
PROVIDER......} {ADM-DT}
{DIS-DT}
Please tell me the names of the prescribed medicines
from this
stay that were filled.
PROBE: Any other prescribed medicines from this stay
that were
filled?
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
DISPLAY ‘ADD MEDICINE’ AS AN OPTION ON THIS SCREEN
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 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
MEDICINES ADDED AT THE SECCTION AS LONG AS CAPI
HAS NOT YET CREATED THE LINK BETWEEN THIS
MEDICINE AND THE EVENT.
3. EDIT DISALLOWED.
4. ANY MEDICINE ADDED TO THE ROSTER SHOULD BE
FLAGGED AS ‘CREATED’ THIS ROUND. ANY MEDICINE
SELECTED AT THE ROSTER SHOULD BE FLAGGED AS
‘SELECTED’ THIS ROUND. THIS FLAGGING SHOULD
OCCUR AT EACH PERSON’S-PRESCRIBED-MEDICINES-
ROSTER THROUGHOUT THE INSTRUMENT (UNLESS
OTHERWISE SPECIFIED), THE FIRST TIME THE
MEDICINE IS ADDED OR SELECTED DURING THE ROUND.
FOR EXAMPLE, IF IT IS ROUND 1, ALL MEDICINES ON
THE ROSTER WOULD HAVE THE FLAG ‘CREATED –
ROUND 1’. IF A MEDICINE IS CREATED IN HS, BUT
SELECTED IN MV, ALL DURING ROUND 1, IT WOULD
ONLY HAVE THE FLAG ‘CREATED – ROUND 1’. THUS,
FOR ANY ONE ROUND, A MEDICINE CAN BE FLAGGED
ONLY AS EITHER ‘CREATED’ OR ‘SELECTED’. IF IT
IS ROUND 2 AND A MEDICINE THAT WAS CREATED IN
ROUND 1 IS SELECTED, IT SHOULD BE FLAGGED AS
‘SELECTED – ROUND 2’. THIS FLAG IS IN ADDITION
TO THE ORIGINAL ‘CREATED – ROUND 1’ FLAG.
5. WHEN A MEDICINE FROM A PREVIOUS ROUND IS
SELECTED, A NEW EVENT IS CREATED SINCE IT
INVOLVES A NEW PURCHASE OF THE MEDICINE. A NEW
PURCHASE REQUIRES ASKING CP AND THE PHARMACY.
THE REASON FOR INCLUDING ALL OF THE PRESCRIBED
MEDICINES ON THE ROSTER IS SIMPLY TO AVOID THE
INTERVIEWER HAVING TO TYPE THEM IN AGAIN (IF
THE PERSON IS GETTING REFILLS OF THE SAME
MEDICINE EVERY ROUND).
ROSTER FILTER:
DISPLAY ALL MEDICINES ON PERSON’S ROSTER;
NO FILTER.
HS10
OMITTED.
HS11
OMITTED.
LOOP_01
OMITTED.
BOX_02
OMITTED.
BOX_03
OMITTED.
HS12
OMITTED.
END_LP01
OMITTED.
BOX_04
IF THE CHARGE/PAYMENT (CP) SECTION FOR THIS
HOSPITAL STAY IS NOT COMPLETED, ASK THE CHARGE/
PAYMENT (CP) SECTION.
OTHERWISE, GO TO THE EVENT DRIVER (ED) SECTION.
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