Emergency Room (ER) Section

BOX_00 (ER1000)

BOX_10 (ER1001)

ER10 (ER1010)

BLAISE NAME: ERVstCat

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

&ER-1.

Please look at card ER-1 and tell me which category best describes the care {you/{PERSON}} received during the visit to {PROVIDER} emergency room on {VISIT DATE}.

HELP: F1

Responses: DIAGNOSIS OR TREATMENT 1 ER20 (ER1015)

EMERGENCY (E.G., ACCIDENT OR INJURY) 2 ER20 (ER1015)

PSYCHOTHERAPY OR MENTAL HEALTH COUNSELING 3 ER20 (ER1015)

FOLLOW-UP OR POST-OPERATIVE VISIT 4 ER20 (ER1015)

IMMUNIZATIONS OR SHOTS 5 ER20 (ER1015)

{PREGNANCY-RELATED (INCLUDING PRENATAL CARE AND DELIVERY)} 6 ER20 (ER1015)

OTHER 91 ER20 (ER1015)

REFUSED RF ER20 (ER1015)

DON'T KNOW DK ER20 (ER1015)

Display Instructions: Display response option ‘6’ (PREGNANCY-RELATED (INCLUDING PRENATAL CARE AND DELIVERY) ), if person is female and age 15 to 55 inclusive (or age categories 3 to 8).

Otherwise, use a null display.

ER20 (ER1015)

BLAISE NAME: ERSpecCond

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

Was this visit related to any specific health condition or were any conditions discovered during this visit?

Responses: YES 1 ER30 (ER1020)

NO 2 ER40 (ER1023)

REFUSED RF ER40 (ER1023)

DON'T KNOW DK ER40 (ER1023)

Display Instructions:

ER30 (ER1020)

BLAISE NAME: ERCondRoster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

What conditions were discovered or led {you/{PERSON}} to make this visit?

PROBE: Any other condition?

ENTER ALL THAT APPLY.

CTRL-A: ADD

CTRL-E: EDIT

CTRL-D: DELETE

HELP: F1

Responses: {MEDICAL CONDITION} 1 1 ER50 (ER1025)

{MEDICAL CONDITION} 2 2 ER50 (ER1025)

{MEDICAL CONDITION} 3 3 ER50 (ER1025)

{MEDICAL CONDITION} 4 4 ER50 (ER1025)

{MEDICAL CONDITION}N 5 ER50 (ER1025)

Programmer Instructions: Roster behavior:

1. Multiple select allowed.
   
   
2. Multiple add allowed.
   
   
3. Limited delete allowed. Interviewer may delete a condition added at this item until CAPI creates the link between this condition and the event. The link is created when the collection of utilization and/or charge/payment data is complete.
   
   
4. Limited edit allowed. Interviewer may edit a condition name newly added at this item until CAPI creates the link between this condition and the event. The link is created when the collection of utilization and/or charge/payment data is complete.

Display Instructions: Roster 3 - add/edit/delete allowed

Roster definition:

Display the person-medical-conditions-roster for the selection and addition of one or many medical condition(s) associated with this event. Display name of medical condition (COND.CONDNAM)

Roster filter:

Display all conditions on person's roster; no filter.

ER40 (ER1023)

BLAISE NAME: ERSurgProc

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

Was a surgical procedure performed on {you/{PERSON}} during this visit?

HELP: F1

Responses: YES 1 ER50 (ER1025)

NO 2 ER50 (ER1025)

REFUSED RF ER50 (ER1025)

DON'T KNOW DK ER50 (ER1025)

Display Instructions:

ER50 (ER1025)

BLAISE NAME: CodeAllERSvc

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

&ER-2.

Looking at this card, which of these services, if any, did {you/{PERSON}} have during this visit?

ENTER ALL THAT APPLY.

HELP: F1

Responses: LABORATORY TESTS 1 ER60 (ER1035)

SONOGRAM OR ULTRASOUND 2 ER60 (ER1035)

X-RAYS 3 ER60 (ER1035)

MAMMOGRAM 4 ER60 (ER1035)

MRI OR CATSCAN 5 ER60 (ER1035)

EKG, ECG, OR EEG 6 ER60 (ER1035)

VACCINATION 7 ER60 (ER1035)

NONE OF THESE SERVICES RECEIVED 95 ER60 (ER1035)

REFUSED RF ER60 (ER1035)

DON'T KNOW DK ER60 (ER1035)

Programmer Instructions: Soft Check:

If coded ‘4’ (MAMMOGRAM) and person being asked about is male or is female and < or = 17 years of age (or age categories 1-3), display the following message: “UNLIKELY RESPONSE FOR {MALES/CHILDREN 17 AND YOUNGER}. VERIFY AND RE-ENTER.”

Display ‘MALE’ in error message if person being asked about is a male > 17 years of age (or age categories 4 through 9). Display ‘CHILDREN 17 AND YOUNGER’ in the error message if person being asked about is male or female and < or = 17 years of age (or age categories 1-3).

Allow code '95' (NONE OF THESE SERVICES RECEIVED) , 'RF' (REFUSED), and 'DK' (DON'T KNOW) alone only; these responses may not be selected with any other response.

Note: 'NONE OF THESE SERVICES RECEIVED' is not displayed on show card.

Hard check:

Edit: if coded ‘95’ (NONE OF THESE SERVICES RECEIVED), no other service categories can be coded.

If interviewer selects another code with NONE OF THESE SERVICES RECEIVED, display the following message: "NONE OF THESE SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER OPTIONS. VERIFY AND RE- ENTER."

Display Instructions:

ER60 (ER1035)

BLAISE NAME: ERPmed

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

During this visit, were any medicines prescribed for {you/{PERSON}}? Please include only prescriptions which were filled.

Responses: YES 1 ER70 (ER1040)

NO 2 BOX_20 (ER1045)

REFUSED RF BOX_20 (ER1045)

DON'T KNOW DK BOX_20 (ER1045)

Display Instructions:

ER70 (ER1040)

BLAISE NAME: ERPmedRoster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EVN-DT}

Question Text:

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?

ENTER ALL THAT APPLY.

CTRL-A: ADD

CTRL-E: EDIT

CTRL-D: DELETE

Responses: {PRESCRIBED MEDICINE}1 1 BOX_20 (ER1045)

{PRESCRIBED MEDICINE}2 2 BOX_20 (ER1045)

{PRESCRIBED MEDICINE}3 3 BOX_20 (ER1045)

{PRESCRIBED MEDICINE}4 4 BOX_20 (ER1045)

{PRESCRIBED MEDICINE}N 5 BOX_20 (ER1045)

Programmer Instructions: Roster behavior:

1. Multiple select allowed.
   
   
2. Multiple add allowed.
   
   
3. Limited delete allowed. Interviewer may delete a medicine added at this item until CAPI creates the link between this medicine and the event. The link is created when the collection of utilization and/or charge/payment data is complete.
   
   
4. Limited edit allowed. Interviewer may edit medicines added at this item until CAPI creates the link between this medicine and the event. The link is created when the collection of utilization and/or charge/payment data is complete.

NOTE: In order for the columns to display properly, 35 allowable characters for the medicines will be accepted for display on the roster.

When adding a medicine in the pop-up manipula, a maximum of 60 characters will be allowed.

When the CTRL-D or CTRL-E command is called, the pop-up manipula should display 60 characters for the medicine name.

General flag rules for medicines:

- Round medicine first created (by definition a medicine is selected the same time it is created)

- Question number medicine first created

- Round medicine selected

- Event medicine is linked to (however, this is known by virtue that the medicine was selected at ER70 for this event)

Display Instructions: Roster 3 - add/edit/delete allowed

Roster definition:

This item displays the person's-prescription medicines-roster for selection. Display name of prescribed medicine (DRUG.DRUGNAME).

Roster filter:

Display all medicines on person's roster; no filter.

BOX_20 (ER1045)

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