CMS-P-0015A MCBS Facility Round 46 Prescription Medicines

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

PM. PRESCRIBED MEDICINES
(CORE ONLY)

PM1PRE
The following questions are about all of the medicines prescribed for {SP} in {FACILITY/READ FACILITIES IN
HEADER ABOVE} {in {REFERENCE START MONTH} {between {REFERENCE START MONTH} and
{REFERENCE END MONTH}}.

CURRENT TIMELINE
PLACE NAME
{ }
{ }
{ }
etc.

START DATE
{ }
{ }
{ }

USE ARROW KEYS. TO EXIT, PRESS ESC.

1

END DATE
{ }
{ }
{ }

PLACE TYPE
{ }
{ }
{ }

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

PM1A
{What is the {first/next} month the prescribed medicine chart is available for {SP}/Is the prescribed medicine chart for
{SP} for {REFERENCE DATE} available}?
SELECT ONE.
{REFERENCE DATE 1}
{REFERENCE DATE 2}
{REFERENCE DATE 3}
etc.
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

PM1B
Does the chart show any prescribed medicines administered in {REFERENCE DATE}?
YES..............................................................................................
NO................................................................................................

1
0

(BOX PM4)
(BOX PM0)

PRESS F1 FOR EXPLANATION OF ADMINISTERED.

BOX PM4

If not first time coming to BOX PM4 and there were active medicines in most recent
previous month for which PM data were collected, go to PM8.
Else, go to PM2.

PM2
IN {REFERENCE DATE}:
What was the name of the prescribed medicine administered to {SP}?
TO SELECT/DESELECT PRESS ENTER. IF MEDICINE NOT ON LIST OR TO EXIT, PRESS ESC.
PRESS F1 FOR EXPLANATION OF "ADMINISTERED."

2

PM. PRESCRIBED MEDICINES

BOX PM1

2006 Facility Interview
(Core Only)

If was entered in PM2 without selecting a medicine, go to PM2A;
Else if no form and/or strength exists in the lookup file for PM2, then set a flag and go
to PM3;
Otherwise (a drug name was selected in PM2 and there is at least one combination of
form and strength in the second Redbook file), go to PM2B.

PM2A
IN {REFERENCE DATE}:
What was the name of the prescribed medicine administered to {SP}?
_______________________________________________

(PM3)

PM2B
In what form and strength was {DRUG NAME FROM PM2}?
{CHOICE LIST OF FORM & STRENGTH COMBINATIONS}
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

BOX PM2

If "ADD FORM AND STRENGTH" was selected, go to PM3; else, go to PM5.

3

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

PM3
IN {REFERENCE DATE}:
In what form was {NAME OF MEDICINE FROM PM2/PM2A}?
SELECT ONE.
TABLET/CAPSULE/PILL ............................................................. 1
LIQUID (ORAL) ............................................................................ 2
TOPICAL OINTMENT, CREME, LOTION, DROPS ..................... 3
SUPPOSITORIES........................................................................ 4
INHALANT, AEROSOL/SPRAY USED ORALLY ......................... 5
SHAMPOO, SOAP....................................................................... 6
INJECTION (BODY)..................................................................... 7
INTRAVENOUS (IV) .................................................................... 8
PATCHES .................................................................................... 9
TOPICAL GEL/JELLY .................................................................. 10
POWDER..................................................................................... 11
OTHER (SPECIFY:
).......................... 91
USE ARROW KEYS. TO SELECT OR DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

4

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

MCG (MICROGRAMS) ...............................................................

7

PM4
What was the strength of {NAME OF MEDICINE FROM PM2/PM2A}?
ENTER NUMBER AND SELECT UNIT.
{IF NO STRENGTH SPECIFIED, ENTER 0 IN NUMBER FIELD AND SELECT "NO STRENGTH" IN UNITS. IF
A COMPOUND MEDICINE, ENTER 0 IN NUMBER FIELD AND SELECT "CO" IN UNITS.}
(
)
NUMBER

BOX
PM2A

(
)
UNITS

If PM3 = 8 (INTRAVENOUS), go to PM7.
Else, go to PM5.

PM5
IN {REFERENCE DATE}:
{The next few questions ask about the dosage of {NAME OF MEDICINE} {STRENGTH} {FORM}. {As you know,
dosage has two attributes -- the number of units (pills, injections, patches, and so on) of a particular strength of
medicine to be received at one time and how often this number of units was to be received. First, let me ask about
the number of units.}
What was a single dosage of {NAME OF MEDICINE} {STRENGTH} {FORM}?
IF NO UNIT, ENTER SHIFT/5.
(
)
NUMBER
{PRESS F1 FOR EXPLANATION OF DOSAGE.}

5

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

PM6 omitted.

PM7
{IN {REFERENCE DATE}:}
How often was this dosage of {NAME OF MEDICINE}, {NUMBER}, {STRENGTH}, {FORM} prescribed to be
administered?
SELECT ONE.
QD (1 TIME PER DAY) ................................................................
BID (2 TIMES PER DAY) .............................................................
TID (3 TIMES PER DAY) .............................................................
QID (4 TIMES PER DAY).............................................................
Q__W ( __ TIMES PER WEEK)...................................................
QH (EVERY HOUR).....................................................................
Q4H (EVERY 4 HOURS) .............................................................
Q6H (EVERY 6 HOURS) .............................................................
Q8H (EVERY 8 HOURS) .............................................................
Q12H (EVERY 12 HOURS) .........................................................
Q__H (EVERY __ HOURS) .........................................................
AC (BEFORE MEALS).................................................................
PC (AFTER MEALS)....................................................................
QHS (DAILY AT BED TIME) ........................................................
QOD (EVERY OTHER DAY) .......................................................
PRN (STANDING ORDER, AS NECESSARY) ............................
OTO (ONE TIME ONLY)..............................................................
OTHER (SPECIFY:
) ........................

1
2
3
4
16
5
6
7
8
9
10
11
12
13
14
15
17
91

(PM7b)

(PM7a)

USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

PM7a
EVERY _______ HOURS
(NUMBER)

PM7b
________TIMES PER WEEK
(NUMBER)

6

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

PM8
In {REFERENCE DATE}, what was the total number of times [READ MEDICINES BELOW] was
administered?
COUNT EACH TIME THE DRUG WAS GIVEN ON EACH DAY.
IF DRUG NOT LISTED ON CHART - AS SPECIFIED, PRESS SHIFT/5 IN # OF ITEMS.

# OF
TIMES

DISCONTINUED?
Y=1 N=0

{NAME OF MEDICINE} {NUMBER} {STRENGTH}
{FORM} {DOSAGE}

(

)

(0)

{NAME OF MEDICINE}
{FORM} {DOSAGE}

(

)

(0)

{NUMBER} {STRENGTH}

etc.
USE ARROW KEYS. TO EXIT, PRESS ESC.

PM9
IN {REFERENCE DATE}:
Were any other prescribed medicines administered to {SP}?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

BOX PM4 omitted.

BOX PM5 omitted.

7

1
0
-8
-7

(PM2)
(BOX PM3)
(BOX PM3)
(BOX PM3)

PM. PRESCRIBED MEDICINES

BOX PM3

2006 Facility Interview
(Core Only)

If there are any NUMBER fields in the PM8 Matrix for which the interviewer has not
entered a number, go to PM8 with the cursor residing on the first "empty"
NUMBER FIELD;
Else, go to BOX PM0.

PM10 omitted.

PM11 omitted.

BOX PM0

If no REFERENCE DATEs (months) remaining, go to PM10;
Else go to PM1A.

PM10
DID YOU ABSTRACT?
ALL.........................................................
MAJORITY.............................................
HALF......................................................
SOME ....................................................
NONE.....................................................

1
2
3
4
5

NO KNOWLEDGEABLE RESPONDENT AVAILABLE ...............
NO TIME/STAFF BURDEN TOO GREAT...................................
REFUSAL--UNWILLING TO COOPERATE ................................
OTHER (SPECIFY: _____________________) ........................

1
2
3
91

(PMEND)

PM11
WHY DID YOU ABSTRACT?

PMEND
YOU HAVE COMPLETED THE PRESCRIBED MEDICINES DATA COLLECTION FOR THIS SP.
PRESS ENTER TO RETURN TO NAVIGATION SCREEN.

8

PM. PRESCRIBED MEDICINES

2006 Facility Interview
(Core Only)

9