MEPS-HC Survey Instrument

39 - AS (BETA).pdf

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

MEPS-HC Survey Instrument

OMB: 0935-0118

Document [pdf]
Download: pdf | pdf
PATIENT LABEL

DIAGNOSES CONTINUATION SHEET
FOR
OFFICE-BASED PROVIDERS FOR REFERENCE YEAR 2005

B4a. I need the diagnoses for (this visit/these visits). I would
prefer the ICD-9 codes (or the DSM-4 codes), if they
are available.
[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]

CODE
|__| _____________

DESCRIPTION
___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__|__|
OFFICE

B4b. Which of these was the principal diagnosis?

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

|__| _____________

___________________

IF ONLY ONE DIAGNOSIS, GO TO B5a.
IF MORE THAN ONE DIAGNOSIS:
„ CHECK BOX FOR PRINCIPAL
DIAGNOSIS
„ CIRCLE '-8' IF PRINCIPAL
DIAGNOSIS NOT KNOWN............... -8

M:\7690\7690.19.04\MPC 2005\Forms\OB\OB B4ab ContSheet.doc - 1/26/2006 - 11:51 AM - cg

USE
ONLY


File Typeapplication/pdf
File Title.....MEDICAL EVENT FORM
AuthorDiane Triplett
File Modified2006-01-26
File Created2006-01-26

© 2024 OMB.report | Privacy Policy