Facility staff providing patient lists

Attachment 5 B 2

II. Health Care Data and Insurance Status

Was this visit

This section characterizes the type of the facility that the patient visited. In this project we will abstract medical records from facilities other than the facility from which the patient was selected. These facilities include outpatient facility, inpatient facility, STD clinic, TB clinic, Ob-Gyn clinic, and any other facility from which the patient received care during the surveillance period. This information will also be used to determine the type and frequency of health care visits HIV-infected patients made during the surveillance period.

Did the patient receive any of the following care during this visit or between visits?

Check all that applies after reviewing the medical records to determine whether the patient has received any of the listed types of care during this visit or sometime between the last visit and the current visit. This applies only to events that took place during the surveillance period. If the patient had only one visit during the surveillance period this section will include only care received during that visit. For events that took place between visits enter the information to the visit that occurred after the event. For events that occurred during the SP and before the first visit within the SP enter the information along with the first visit only if you have the exact dates of these events. However, you must try to capture events that occurred after the last visit and before the last date of the SP using the last visit form. Make sure that these events occurred within the SP.

Is there any documentation of visit to other provider/facility between these visits?

Since abstractions will be performed at other facilities from which the patient had received HIV care during the surveillance period, we need to capture information about other facilities visited by the patient during the surveillance period if it is available in the medical records. This information may be documented by the physician and may be available in the history notes usually referred to as history of present illness or HPI. Enter all the available information. If there is not sufficient space, use the Remarks section on the last page of this form. For patients recruited using real time sampling or first list from a multiple list pick-up and whose surveillance period ends at a date that is within the PDP please refer to the additional guidelines at the beginning of this manual. For all patients, start abstraction after the PDP is over.

Type of insurance during this visit

Indicate the type of health insurance that the patient had during this visit by checking the appropriate boxes. If the patient had more than one form of insurance, multiple boxes may be checked. If the patient had a type of health insurance not listed on the form, check "Other" and record the type of insurance in the adjacent field.

If the patient was enrolled in the state AIDS Drug Assistance Program (ADAP) during the current visit, check the appropriate box. It is not necessary to see documentation of specific drugs received through the program if enrollment is documented in the medical record.

Please Note: Ryan White and support from service providers are not types of insurance.