Survey Text

2022
2021
2020
2019
2018
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2022

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2021

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2020

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2019

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2018
Survey form view entire document:  text  image
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:
Multiple select allowed.
Multiple add allowed.
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.
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.
HH80 (HH1045)
BLAISE NAME: HHCondRoster
Context Header: 
(PERSON'S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE PROVIDER......) (EVN-MO)
Question Text:
What health condition led (you/(PERSON)) to receive home health care services from (someone from) (PROVIDER) during (VISIT MONTH)?
PROBE: Any other health condition?
ENTER ALL THAT APPLY.
CTRL-A: ADD
CTRL-E: EDIT
CTRL-D: DELETE
HELP: F1
Responses: 
(MEDICAL CONDITION) 1 1 HH90 (HH1085)
(MEDICAL CONDITION) 2 2 HH90 (HH1085)
(MEDICAL CONDITION) 3 3 HH90 (HH1085)
(MEDICAL CONDITION) 4 4 HH90 (HH1085)
(MEDICAL CONDITION)N 5 HH90 (HH1085)
Programmer Instructions: 
Roster Behavior:
Multiple select allowed.
Multiple add allowed.
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.
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's-Medical-Conditions Roster for the selection and/or addition of one or more 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.
Display ?someone from? if provider is flagged as ?AGENCY?.
HS40 (HS1020)
BLAISE NAME: IPCondRoster
Context Header:
(PERSON?S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE PROVIDER......) (ADM-DT)
(DIS-DT)
Question Text:
What conditions were discovered or led (you/(PERSON)) to enter the hospital?
PROBE: Any other condition?
ENTER ALL THAT APPLY.
CTRL-A: ADD
CTRL-E: EDIT
CTRL-D: DELETE
HELP: F1
Responses: 
(MEDICAL CONDITION) 1 1 HS50 (HS1025)
(MEDICAL CONDITION) 2 2 HS50 (HS1025)
(MEDICAL CONDITION) 3 3 HS50 (HS1025)
(MEDICAL CONDITION) 4 4 HS50 (HS1025)
(MEDICAL CONDITION)N 5 HS50 (HS1025)
Programmer Instructions: 
Roster behavior:
Multiple select allowed.
Multiple add allowed.
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.
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:
This item displays person-medical-conditions-roster for selection and addition of one or many medical conditions associated with this event. Display name of medical condition (COND.CONDNAM)
Roster filter:
Display all conditions on person's roster; display all.
MV70 (MV1050)
BLAISE NAME: MVCondRoster
Context Header: 
(PERSON?S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE PROVIDER) - (DOC OR DEPT) (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 MV80 (MV1055)
(MEDICAL CONDITION) 2 2 MV80 (MV1055)
(MEDICAL CONDITION) 3 3 MV80 (MV1055)
(MEDICAL CONDITION) 4 4 MV80 (MV1055)
(MEDICAL CONDITION)N 5 MV80 (MV1055)
Programmer Instructions: 
Roster behavior:
Multiple select allowed.
Multiple add allowed.
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.
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 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.
OP60 (OP1040)
BLAISE NAME: OPCondRoster
Context Header: 
(PERSON'S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE PROVIDER)-(DOC OR DEPT) (EVN-DT)
Question Text:
What conditions were discovered or led (you/ (PERSON)) to make this visit?
PROBE: Any other condition?
ENTER ALL THAT APPLY
CRTL-A:ADD
CRTL-E:EDIT
CRTL-D:DELETE
HELP: F1
Responses: 
(MEDICAL CONDITION) 1 1 OP70 (OP1050)
(MEDICAL CONDITION) 2 2 OP70 (OP1050)
(MEDICAL CONDITION) 3 3 OP70 (OP1050)
(MEDICAL CONDITION) 4 4 OP70 (OP1050)
(MEDICAL CONDITION)N 5 OP70 (OP1050)
Programmer Instructions: 
Roster behavior:
Multiple select allowed.
Multiple add allowed.
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.
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 Allow
Roster definition:
Display the Person-Medical-Conditions-Roster for 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.
PM120 (PM1200)
BLAISE NAME: PmedCondRoster
Context Header: 
(PERSON'S FIRST MIDDLE AND LAST NAME) (NAME OF PRESCRIPTION MEDICINE.) (STR-DT) (END-DT)
Question Text:
(Now, let's talk about (MEDICINE).)
What health problem is (MEDICINE) prescribed for?
PROBE: Any other health problems?
ENTER ALL THAT APPLY
CTRL-A: ADD
CTRL-E: EDIT
CTRL-D: DELETE
HELP:F1
Responses: 
(MEDICAL CONDITION) 1 1 BOX_60 (PM1210)
(MEDICAL CONDITION) 2 2 BOX_60 (PM1210)
(MEDICAL CONDITION) 3 3 BOX_60 (PM1210)
(MEDICAL CONDITION) 4 4 BOX_60 (PM1210)
(MEDICAL CONDITION)N 5 BOX_60 (PM1210)
Programmer Instructions: 
Roster Behavior:
Multiple select allowed. Selection should not impact the round flag of the condition.
Multiple add allowed. Interviewer should record condition name.
Limited delete allowed. Interviewer may delete a condition added at this item as long as CAPI has not created a link between this condition and an event. If a condition, added in PMed section, is never linked to an event, that condition can be deleted until a link is made between the condition and the medicine. The link between condition and the medicine is created at END_LP10 (the end of the cycle for the medicine being asked about).
Limited edit allowed. Interviewer may edit a condition name added at this item as long as CAPI has not created a link between this condition and an event. If a condition, added in PMed section, is never linked to an event, that condition can be edited until a link is made between the condition and the medicine. The link between the condition and the medicine is created at END_LP10 (the end of the cycle for the medicine being asked about).
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 medicine.
Roster Filter:
Display all conditions on person's roster; no filter.
Display 'Now let's talk about (MEDICINE).' if this is the first question presented in LOOP_10, otherwise, use a null display.

Priority Condition Enumeration (PE) Section