OMB 0920-0840 Surv Surveillance Period Summary Form

Attachment 3b

MMP Medical Record Abstraction

Surveillance Period Summary Form

Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2012 Surveillance Period Summary Form (SPSF)

VERSION 7.1.0

O PTIONAL- FOR LOCAL USE ONLY

M MP SPSF v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)

Medical record number:

Patient name:

Physician name:

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control & Prevention

Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2012 Surveillance Period Summary Form (SPSF) v7.1.0

I. ABSTRACTION AND IDENTIFICATION
MMP Participant ID:
Surveillance Period (SP) SP start date: (12 months prior to date of interview OR 1st contact attempt if no interview obtained)			SP end date: (date of interview OR 1st contact attempt if no interview obtained)
Date of abstraction: Abstractor ID: Mo. Day Year
Abstraction Facility ID: (ID of the facility where abstraction is being conducted)
Was the documented care abstracted with this form given at another facility (i.e., outside the Abstraction Facility)?
		Yes Complete information about the “Care” Facility				Enter Care Facility ID or indicate that Care Facility was not documented or was outside jurisdiction: Care Facility ID (ID of the facility where the documented care was provided)
		No Continue to Section II below				Care Facility not documented or outside jurisdiction
II. PATIENT DEMOGRAPHICS
M ost recent height (ft/in) during the SP: Height not documented
Patient’s country of residence during the surveillance period (select ALL that apply): 1 United States 2 Canada 3 Mexico 4 Other, Specify:­­­­ 5 Not documented/Could not be determined from residence address
III. SURVEILLANCE PERIOD SUMMARY FORM SECTIONS – OPTIONAL
Is there documentation of any of the following during the SP? Yes Select all that are documented below. No This form is now complete except for optional section XIII (Remarks).
Type of coverage for medical care or other services Complete section IV.				Pregnancy (females only) Complete section IX.
Provision of other services at this facility Complete section V.				Reported or suspected substance abuse Complete section X.
Screening for tuberculosis (TB), or for cervical or anal cancer Complete section VI.				Death of the patient Complete section XI.
Whether or not hepatitis A, B, A and B, influenza or pneumococcal immunizations were given Complete section VII.				Visits to other facilities for HIV care Complete section XII.
Referrals for other services Complete section VIII.

IV. COVERAGE FOR MEDICAL CARE
Is there documentation of the type of coverage for medical care or other services during the SP? Yes Select all that are documented below, including if the patient had no medical coverage during all or part of the SP (“None/Self-pay”). No
1 AIDS Drug Assistance Program (ADAP) 2 CHAMPUS/Tricare 3 Clinical Trial/Clinical Study 4 Medicaid 5 Medicare	6 None/Self-pay (during all or part of the SP) 7 Private (including HMO/PPO) 8 Prison/Jail 9 Ryan White (excluding ADAP) 10 Veterans Administration
11 Other public insurance, Specify: 12 Other public insurance, Specify: 13 Other insurance, Specify: 14 Other, Specify:
V. OTHER SERVICES
Is there documentation that other services were provided at this facility during the SP? Yes Select all that are documented below. No
1 Case management		09 Nutritional counseling
2 Chemotherapy		10 Physical therapy
3 Dental care		11 Prenatal care
4 Dialysis		12 Receipt of equipment or supplies
5 Education session		13 Substance abuse counseling or treatment
6 Hospice care		14 Support group
7 Mental health counseling or treatment		15 Pharmacist consultation
8 Nursing home care
16 Other, Specify:
17 Other, Specify:
18 Other, Specify:
19 Other, Specify:
20 Other, Specify:
21 Other, Specify:
VI. TUBERCULOSIS (TB), CERVICAL AND ANAL CANCER SCREENING
Is there documentation of screening for tuberculosis (TB), or cervical or anal cancer, during the SP? Yes Enter all that are documented for each screening below. No
Was screening for tuberculosis (TB) performed during the SP? (select one) 1 Yes, screening done Enter all that are documented below 2 No, documented that screening was not done 3 TB screening not documented Date of the most recent tuberculin skin test (TST/PPD/Mantoux) or QuantiFERON test (QFT) during the SP: Date not documented

VI. TUBERCULOSIS (TB), CERVICAL AND ANAL CANCER SCREENING cont’d

Result of the most recent TST/PPD/Mantoux or QFT test during the SP: (enter one for TST/PPD/Mantoux OR one for QFT)

TST/PPD/Mantoux: (enter OR select one) Result in millimeters: 1 Positive, no value reported 2 Negative, no value reported 3 Not read 4 Anergic 5 Not documented

OR

QFT: (select one) 1 QFT positive 2 QFT negative 3 QFT indeterminate 4 Not documented

Was screening for cervical or anal cancer performed during the SP? (select one: Yes, No, or Not documented)

1 Yes – screening done Select all that apply:

2 No – documented that screening was not done

Site

Most Recent Result (select one for each documented site)

1 Cervical

1 Normal

2 Abnormal

3 Indeterminate

4 Not documented

3 Cervical and anal cancer screening not documented

2 Anal

1 Normal

2 Abnormal

3 Indeterminate

4 Not documented

3 Unspecified

1 Normal

2 Abnormal

3 Indeterminate

4 Not documented

VII. HEPATITIS, INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

Is there documentation of whether or not hepatitis A, B, A and B, influenza or pneumococcal immunizations were given during the SP? Yes Enter all that are documented for each vaccine below. No

Was hepatitis A vaccine (Havrix, Vaqta) given during the SP? (select one: Yes, No, or Not documented)

1 Yes

Enter a maximum of 2 documented doses and dates: Dose No. (If documented) Date

Date not documented

2 Yes – but number of doses not documented

_____

3 No – documented that vaccine was not given

Reason vaccine not given: (select one)

_____

Prior vaccination

Patient declined

Previously infected

Not documented

Other, specify

4 Hepatitis A vaccination not documented

Was hepatitis B vaccine (Energix B, Recombivax) given during the SP? (select one: Yes, No, or Not documented)

1 Yes

Enter a maximum of 4 documented doses and dates: Dose No. (If documented) Date

Date not documented

2 Yes – but number of doses not documented

_____

3 No – documented that vaccine was not given

Reason vaccine not given: (select one)

_____

Prior vaccination

Patient declined

Previously infected

Not documented

Other, specify

_____

_____

4 Hepatitis B vaccination not documented

VII. HEPATITIS, INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS cont’d
Was combination hepatitis A and B vaccine (Twinrix) given during the SP? (select one: Yes, No, or Not documented)
1 Yes	Enter a maximum of 4 documented doses and dates: Dose No. (If documented) Date								Date not documented
2 Yes – but number of doses not documented							_____
3 No – documented that vaccine was not given
Reason vaccine not given: (select one)							_____
	Prior vaccination		Patient declined
	Previously infected		Not documented
	Other, specify						_____
							_____
4 Hepatitis A and B vaccination not documented
Was influenza vaccine (flushield, fluzone) given during the SP? (select one: Yes, No, or Not documented)
1 Yes	Enter the date of the most recent dose:						Date	Date not documented
2 No – documented that vaccine was not given
Reason why vaccine not given: (select one)
	Allergy to vaccine components				Patient declined
	Other, specify				Not documented
3 Influenza vaccination not documented
Was pneumococcal vaccine (Pneumovax 23, Pneu-Immune 23) given during the SP? (select one: Yes, No, or Not documented)
1 Yes	Enter the date of the most recent dose:
2 No – documented that vaccine was not given							Date	Date not documented
Reason why vaccine not given: (select one)
	Prior vaccination		Patient declined
	Other, specify		Not documented
3 Pneumococcal vaccination not documented
VIII. REFERRALS
Is there documentation of any of the following referrals during the SP? Yes Select all that are documented below. No
1 Adherence support						8 Intimate partner violence services
2 Case manager services						9 Mental health services
3 Dental care						10 Partner counseling and referral services
4 Financial assistance						11 Reproductive health services
5 Food and housing support services						12 Social worker services
6 HIV prevention counseling services						13 Substance abuse prevention services
7 Home-based care services						14 TB treatment services

IX. PREGNANCIES AND OUTCOMES (FEMALES ONLY)
Is there documentation that the patient was pregnant during the SP? Yes Enter all that are documented for each pregnancy below. No
Number of pregnancies that occurred during the SP: 1 2 3 or more
Outcome of the first pregnancy during the SP: (select one and enter date)
1 Elective abortion
2 Intrauterine fetal death Select one delivery method:		Delivery method for the first pregnancy during the SP:
3 Live birth Select one delivery method:		1 Cesarean section (elective)
4 Spontaneous abortion/miscarriage		2 Cesarean section (not elective)
5 Still pregnant		3 Induced vaginal delivery
6 Not documented		4 Spontaneous vaginal delivery
Date of first outcome: Date not documented		5 Not documented
Outcome of the second pregnancy during the SP: (select one and enter date)
1 Elective abortion
2 Intrauterine fetal death Select one delivery method:	Delivery method for the second pregnancy during the SP:
3 Live birth Select one delivery method:	1 Cesarean section (elective)
4 Spontaneous abortion/miscarriage	2 Cesarean section (not elective)
5 Still pregnant	3 Induced vaginal delivery
6 Not documented	4 Spontaneous vaginal delivery
Date of second outcome: Date not documented	5 Not documented
Outcome of the third pregnancy during the SP: (select one and enter date)
1 Elective abortion
2 Intrauterine fetal death Select one delivery method:	Delivery method for the third pregnancy during the SP:
3 Live birth Select one delivery method:	1 Cesarean section (elective)
4 Spontaneous abortion/miscarriage	2 Cesarean section (not elective)
5 Still pregnant	3 Induced vaginal delivery
6 Not documented	4 Spontaneous vaginal delivery
Date of third outcome: Date not documented	5 Not documented
X. SUBSTANCE ABUSE
Is there documentation of reported or suspected alcohol abuse or other non-prescribed use of substances, including counseling or treatment for alcohol and/or substance use/abuse, during the SP? Yes Enter all that are documented below. No
Alcohol abuse
Is there documentation of alcohol abuse during the SP? Yes No
Other non-prescribed use of substances
Is there evidence of any injection substance use (e.g., track marks) documented during the SP? Yes No

X. SUBSTANCE ABUSE cont’d
Non-prescribed use of substances documented during the SP: (select all that are documented and type of use)
Substance		Type of Use (select all that apply OR select Not documented)
		Injection	Non-Injection	Not documented
1 Amphetamines (other than methamphetamines)
2 Cocaine (other than crack)
3 Crack cocaine
4 Ecstasy (MDMA, X)
5 GHB
6 Hallucinogens such as LSD or mushrooms
7 Heroin
8 Ketamine (Special K)
9 Marijuana
10 Methadone
11 Methamphetamines
12 Painkillers such as Oxycontin, Vicodin or Percocet
13 Poppers (amyl nitrate)
14 Rohypnol
15 Steroids/Hormones
16 Tranquilizers such as Valium, Ativan, or Xanax
17 Viagra, Levitra or Cialis
18 Other, Specify:
1 9 Other, Specify:
2 0 Other, Specify:
21 Substance not specified
XI. MORTALITY DATA
Is there documentation that the patient died during the SP? Yes Enter all that are documented below. No
Date of death during the SP: Date not documented Cause of death: (select one) Accident Suicide Other, Specify:____________________________________________ Homicide Natural Cause not documented
Diagnoses at death: (enter all documented diagnoses) Diagnosis not documented
1.	6.
2.	7.
3.	8.
4.	9.
5.	10.

FOR LOCAL USE ONLY

M MP SPSF v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)

XII. OTHER FACILITIES cont’d
Facility/Provider Name	Contact Information
1. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
2. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
3. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
4. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
5. ___________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:

FOR LOCAL USE ONLY

M MP SPSF v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)

XII. OTHER FACILITIES cont’d
Facility/Provider Name	Contact Information
6. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
7. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
8. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
9. ____________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:
10. ___________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________	Street: ____________________________________________________________________ _____________________________________________________________________ City: ____________________________________________________________________ State: _____ _____ ZIP code: Telephone:

OPTIONAL - FOR LOCAL USE ONLY

M MP SPSF v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)

XIII. REMARKS

Page 17 of 17

OMB 0920-0740 Surveillance Period Summary Form - 11/2011