Emergency Room (ER) Section
ER01
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
Did (PERSON) see a medical doctor during this particular visit?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 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 (PERSON) received during the visit to
(PROVIDER) emergency room on (VISIT DATE)?
DIAGNOSIS OR TREATMENT ................. 1
EMERGENCY (E.G., ACCIDENT OR INJURY) ... 2
PSYCHOTHERAPY OR MENTAL HEALTH
COUNSELING ............................. 3
FOLLOW-UP OR POST-OPERATIVE VISIT ...... 4
IMMUNIZATIONS OR SHOTS ................. 5
MATERNITY CARE (PRE/POSTNATAL). ........ 6
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
| IF CODED ‘6’ (MATERNITY CARE (PRE/POSTNATAL)), |
| 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
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 (PERSON) to make
this visit? PROBE: Any other condition?
IF CONDITION IS ALREADY LISTED, ASK: Is this the same (NAME
OF CONDITION) that we have already talked about before?
IF SAME EPISODE OF CONDITION, SELECT ENTRY ON ROSTER.
IF NEW EPISODE OF CONDITION, ADD TO ROSTER.
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S |
| MEDICAL-CONDITIONS-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT A CONDITION(S) ALREADY |
| LISTED ON THE ROSTER. DOING SO SHOULD NOT |
| IMPACT THE ROUND FLAG OF THE CONDITION. |
| 2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF|
| CONDITIONS AT THE ROSTER QUESTIONS (I.E., NO |
| LIMIT TO THE NUMBER OF CONDITIONS). AS |
| CONDITIONS ARE ENTERED, THEY SHOULD BE FLAGGED |
| WITH THE NUMBER OF THE ROUND IN WHICH THEY WERE|
| FIRST CREATED. THIS ROUND FLAG WILL BE USED |
| LATER IN THE INTERVIEW TO DETERMINE WHICH |
| QUESTIONS SHOULD BE ASKED. |
| 3. INTERVIEWER SHOULD BE ABLE TO DELETE CONDITION |
| THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS|
| USED. THAT IS, AS LONG AS THE INTERVIEWER HAS |
| NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO |
| DELETE A CONDITION ENTERED IN ERROR. IF DELETE|
| IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED |
| (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY |
| THE FOLLOWING ERROR MESSAGE: ‘DELETE ALLOWED |
| ONLY WHEN CONDITION IS FIRST ENTERED.’ |
----------------------------------------------------
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 (PERSON) have during this visit?
CODE ‘95’ IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 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) AS ENTRIES IN |
| THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE |
| CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY |
| ORDER. CODE ‘95’ WILL NOT APPEAR AS A RESPONSE |
| CATEGORY ON THE SCREEN. |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CODED ‘95’ (NO SERVICES RECEIVED), |
| NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF |
| A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING |
| MESSAGE: ‘INVALID RESPONSE. PRESS ENTER ON A |
| BLANK FIELD.’ |
----------------------------------------------------
----------------------------------------------------
| WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY |
| FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY |
| ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING|
| ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR |
| THIS DISPLAY: |
| |
| CODE ‘1’ = ‘LAB’ |
| CODE ‘2’ = ‘ULTRA’ |
| CODE ‘3’ = ‘XRAY’ |
| CODE ‘4’ = ‘MAMMO’ |
| CODE ‘5’ = ‘MRI’ |
| CODE ‘6’ = ‘EKG’ |
| CODE ‘7’ = ‘EEG’ |
| CODE ‘8’ = ‘VACIN’ |
| CODE ‘9’ = ‘ANEST’ |
| CODE ‘10’= ‘OTHER’ |
| CODE ‘95’= ‘NONE’ |
----------------------------------------------------
----------------------------------------------------
| NOTE: ‘OTHER DIAGNOSTIC TESTS’ AND ‘NO SERVICES |
| RECEIVED’ ARE NOT DISPLAYED ON SHOW CARD. |
----------------------------------------------------
ER06
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
Was a surgical procedure performed on (PERSON) during this
visit?
YES .................................... 1
NO ..................................... 2 {ER08}
REF ................................... -7 {ER08}
DK .................................... -8 {ER08}
PRESS F1 FOR DEFINITION OF SURGICAL PROCEDURE.
ER07
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
What was the name of the main surgical procedure?
CLEANING OR MEDICAL TREATMENT OF
WOUND, INFECTION, OR BURN ............ 1
STITCHES (WOUND SUTURE) ................ 2
SURGICAL SETTING OF BROKEN BONE
(FRACTURE REDUCTION) ................. 3
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
ER08
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
During this visit, were any medicines prescribed for (PERSON)?
Please include only prescriptions which were filled.
YES .................................... 1
NO ..................................... 2 {ER10}
REF ................................... -7 {ER10}
DK .................................... -8 {ER10}
PRESS F1 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?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S- |
| PRESCRIBED-MEDICINES-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT A MEDICINE(S) ALREADY |
| LISTED ON THE ROSTER. |
| 2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF|
| MEDICINES AT THE ROSTER QUESTIONS (I.E., NO |
| LIMIT TO THE NUMBER OF MEDICINES). |
| 3. INTERVIEWER SHOULD BE ABLE TO DELETE A MEDICINE|
| THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS|
| USED. THAT IS, AS LONG AS THE INTERVIEWER HAS |
| NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO |
| DELETE A MEDICINE ENTERED IN ERROR. IF DELETE |
| IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED |
| (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY |
| THE FOLLOWING ERROR MESSAGE: ‘DELETE ALLOWED |
| ONLY WHEN MEDICINE IS FIRST ENTERED.’ |
----------------------------------------------------
ER10
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
Now I would like to ask about the physicians and surgeons who
treated (PERSON) during this emergency room visit. (Have/Has)
(PERSON) seen any of these doctors or surgeons at a place of
practice outside of (PROVIDER)?
YES .................................... 1
NO ..................................... 2 {BOX_03}
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}
--------------------------------------------------------
| NOTE: IN ROUNDS 1 AND 2, THE SECOND SENTENCE OF THE |
| QUESTION WAS WORDED, “Do any of these doctors or |
| surgeons have a place of practice outside of |
| (PROVIDER) where (PERSON) (was/were) seen as a |
| patient?” |
--------------------------------------------------------
ER11
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
Please give me the names of the medical places or private
doctor’s office where (PERSON) saw each of these doctors or
surgeons outside of (PROVIDER).
PRESS ENTER TO CONTINUE.
LOOP_01
=======
----------------------------------------------------
| FOR EACH OF THE FOLLOWING: |
| |
| PROVIDER 1 |
| PROVIDER 2 |
| PROVIDER 3 |
| PROVIDER 4 |
| |
| ASK BOX_01 - END_LP01 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_01 COLLECTS NAMES AND |
| INFORMATION ABOUT EACH SEPARATELY BILLING |
| PROVIDER. THE RESPONSE TO ER12 DETERMINES WHETHER|
| THE LOOP CYCLES AGAIN. IF ER12 IS CODED ‘1’ |
| (YES), THE LOOP CYCLES TO COLLECT THE NEXT |
| SEPARATELY BILLING PROVIDER. IF ER12 IS CODED ‘2’|
| (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW), THE |
| LOOP ENDS. |
----------------------------------------------------
BOX_01
======
----------------------------------------------------
| ASK THE PROVIDER ROSTER (PV) SECTION. |
| AT THE COMPLETION OF THE PROVIDER ROSTER (PV) |
| SECTION, CONTINUE WITH BOX_02 |
----------------------------------------------------
BOX_02
======
----------------------------------------------------
| FOR EACH PROVIDER ADDED OR SELECTED, ADD A PAIR |
| TO THE PERSON’S-EVENT-PROVIDER-PAIRS-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| FLAG EACH PROVIDER ADDED OR SELECTED AS A |
| ‘SEPARATELY BILLING DOCTOR’ RELATED TO THE |
| EMERGENCY ROOM EVENT BEING ASKED ABOUT. |
----------------------------------------------------
ER12
====
{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EVN-DT}
Was there anyone else?
PROBE: Were there any other doctors or surgeons who treated
(PERSON) during the emergency room visit and who (PERSON)
(have/has) seen at a place of practice outside of (PROVIDER)?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| NOTE: IN ROUNDS 1 AND 2 THE PROBE PART OF THE |
| QUESTION WAS WORDED, “...and who have a place of |
| practice outside of (PROVIDER) where (PERSON) |
| (was/were) seen as a patient?” |
----------------------------------------------------
END_LP01
========
----------------------------------------------------
| IF ER12 IS CODED ‘1’ (YES), CYCLE TO COLLECT NEXT |
| SEPARATELY BILLING PROVIDER. |
----------------------------------------------------
----------------------------------------------------
| IF ER12 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’|
| (DON’T KNOW), END LOOP_01 AND CONTINUE WITH BOX_03|
----------------------------------------------------
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 |
----------------------------------------------------
Return to Top