Emergency Room (ER) Section
BOX_00
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| CONTEXT HEADER DISPLAY INSTRUCTIONS: |
| DISPLAY PERS.FULLNAME, PROV.LORPNAME, |
| EVNT.EVNTBEGM, EVNT.EVNTBEGD, EVNT.EVNTBEGY |
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ER01
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{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 {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 (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.
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| 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.’|
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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 (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]
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| DISPLAY ‘ADD CONDITION’ AS AN OPTION ON THIS |
| SCREEN. |
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| GO TO ER05 |
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| ROSTER DETAILS: |
| Title: PERS_COND_1 |
| |
| COL #1 HEADER: MEDICAL CONDITION |
| INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION |
| (COND.CONDNAM) |
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| ROSTER DEFINITION: |
| DISPLAY THE PERSON-MEDICAL-CONDITIONS-ROSTER FOR |
| THE SELECTION AND ADDITION OF ONE OR MANY MEDICAL |
| CONDITION(S) ASSOCIATED WITH THIS EVENT. |
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| 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.” |
| |
| 4. LIMITED EDIT ALLOWED. INTERVIEWER MAY EDIT A |
| CONDITION NAME NEWLY 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 EDIT A CONDITION WHEN |
| EDIT IS NOT ALLOWED, DISPLAY THE FOLLOWING |
| MESSAGE: “EDIT ALLOWED ONLY WHEN CONDITION IS |
| FIRST ENTERED.” |
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| ROSTER FILTER: |
| DISPLAY ALL CONDITIONS ON PERSON’S ROSTER; NO |
| FILTER. |
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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?
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]
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| ALLOW CODE ‘4’ (MAMMOGRAM) ONLY IF PERSON IS |
| FEMALE AND AGE IS > 17 YEARS (OR AGE CATEGORIES 4 |
| THROUGH 9). |
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| 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. |
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| NOTE: ‘OTHER DIAGNOSTIC TESTS’ AND ‘NO SERVICES |
| RECEIVED’ ARE NOT DISPLAYED ON SHOW CARD. |
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| 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.” |
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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 {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 (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]
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| DISPLAY ‘ADD MEDICINE’ AS AN OPTION ON THIS |
| SCREEN. |
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| GO TO BOX_03 |
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| ROSTER DETAILS: |
| TITLE: PERSON'S_PRESCRIBED_MEDICINES_1 |
| |
| COL # 1 HEADER: PRESCRIBED MEDICINE |
| INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE |
| (DRUG.DRUGNAME) |
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| ROSTER DEFINITION: |
| THIS ITEM DISPLAYS THE PERSON'S-PRESCRIPTION- |
| MEDICINES-ROSTER FOR SELECTION. |
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| 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. |
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| ROSTER FILTER: |
| DISPLAY ALL MEDICINES ON PERSON’S ROSTER; NO |
| FILTER. |
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ER10
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OMITTED.
ER11
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OMITTED.
LOOP_01
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OMITTED.
BOX_01
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OMITTED.
BOX_02
======
OMITTED.
ER12
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OMITTED.
END_LP01
========
OMITTED.
BOX_03
======
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| IF THE CHARGE/PAYMENT (CP) SECTION FOR THIS |
| EMERGENCY ROOM EVENT IS NOT COMPLETED, ASK THE |
| CHARGE/PAYMENT (CP) SECTION |
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| OTHERWISE, GO TO THE EVENT DRIVER (ED) SECTION |
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