Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

ER1

ER1

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ERPROBE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP is deceased or institutionalized, display "did (SP) go".
Else if proxy interview, display "has (SP) gone".
Else display "have you gone".

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
gone/has (SP) gone/did (SP) go] to a hospital emergency room for
medical care?

Int. Instr II:
INPUT FIELDS / ROUTING

12:46:58 PM Monday, November 03, 2008

Page 1 of 48

ER1
ERPROBE

Field1:
Cheshire Name:
Item Text display:

( ERQ1020 )

HRND.ERPROBE
Do not display response option 3/IndicatedYesByDataprep.

Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TProbe

1

No
No

Number Label
1 Yes

FieldSize:

Min Value:

Max Value:

Mask:

Route
ER2 - PROVIDER_ER ( ERQ1030 )

2

English text: YES
No

3

English text: NO
IndicatedYesByDataPrep

BOX ER6 - (ERQ1365 )

DO NOT DISPLAY.

DATA EDITING ONLY.

English text: INDICATED YES BY DATAPREP
Attribute
Don't know

Route
BOX ER6 - (ERQ1365 )

Refusal

BOX ER6 - (ERQ1365 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:00 PM Monday, November 03, 2008

Page 2 of 48

ER2

ER2

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PROVIDER_ER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Provider Roster

Roster Type:

Single Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

30

Display as ' Add a Provider '
Display as ' Edit a Provider '

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "(to which hospital)" in parenthesis.

Multi Field display:

Roster/Grid Instructions:

Display all Providers except for Providers where
PROV.PROVNUM=01 and 02, which are reserved for PM and OM
events.
Display in order of entry.

Roster/Grid display:

COL #

HEADER

1

Provider Name

INSTRUCTIONS
Display PROV.PROVNAME

Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Where did [you/(SP)] go (to which hospital)?

Int. Instr II:

SELECT OR ADD ONLY ONE HOSPITAL.

INPUT FIELDS / ROUTING
12:47:01 PM Monday, November 03, 2008

Page 3 of 48

ER2

Field1:
Cheshire Name:

PROVIDER_ER

( ERQ1030 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TProvPick4
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

4

Route
BOX ER1 - (ERQ1040 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PROV:

PROV key = PROV.PROVBASE + PROV.PROVNUM

PROV.PROVNUM = Number of Provider selected at ER2.

If Provider added at Provider Roster, see PROVIDER ROSTER POP-UP specifications for

pop-up window programming instructions.

Variables populated in Provider Roster Pop-Up Window:

PROV.PROVNUM
PROV.PROVRNDC
PROV.PROVNAME

Provider number

Round number

Provider name

If Provider added, set provider type as instructed below:

PROVTYPE

PROV.PROVTYPE=2/EmergencyRoom.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
Begin Loop 1: Probe for one provider, collect all event dates for this

provider.

12:47:01 PM Monday, November 03, 2008

Page 4 of 48

BOX ER1

BOX ER1

Page Order # :

40

BOX INSTRUCTIONS
( ERQ1040 )

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A.
IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ER3 ­
VAPLACE ( ERQ1050 ).
ELSE GO TO BOX ER1B - (ERQ1060 ).

ASSIGNMENTS

TECHNICAL NOTES
423

SPReceivedCaretThruV
A

SP reported receiving health care services through V.A.in
the current or any previous round =
There is an HRND where HRND.HRNDRND = current
round and HRND.VACOVER = 1/Yes.
HRND.VACOVER is set at BOX HI20 or collected at HI36.

127

ProviderVAUnknown

If Provider is associated with V.A. is unknown =
PROV.VAPLACE = empty.

DESIGN NOTES

12:47:01 PM Monday, November 03, 2008

Page 5 of 48

ER3

ER3

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

VAPLACE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

50

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of hospital, PROV.PROVNAME, currently being
asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Is (PROVIDER NAME) a Department of Veterans Affairs, or V.A.,

facility?

Int. Instr II:
INPUT FIELDS / ROUTING

12:47:03 PM Monday, November 03, 2008

Page 6 of 48

ER3
VAPLACE

Field1:
Cheshire Name:

( ERQ1050 )

PROV.VAPLACE

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX ER1B - (ERQ1060 )

English text: YES
No

BOX ER1B - (ERQ1060 )

English text: NO
Attribute
Don't know

Route
BOX ER1B - (ERQ1060 )

Refusal

BOX ER1B - (ERQ1060 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:05 PM Monday, November 03, 2008

Page 7 of 48

BOX ER1B

BOX ER1B

12:47:05 PM Monday, November 03, 2008

Page Order # :

60

Page 8 of 48

BOX ER1B
BOX INSTRUCTIONS
( ERQ1060 )

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH A
MANAGED CARE PLAN IS UNKNOWN), GO TO ER3A - HMOASSOC (
ERQ1070 ).
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED
WITH A MANAGED CARE PLAN), GO TO ER3B - HMOREFER ( ERQ1080 ).
ELSE GO TO ER4 - EVENT_ER ( ERQ1120 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

2

ManagedCarePlan

SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.

128

ProviderHMOUnknown

If Provider is associated with a Managed Care plan is
unknown =
PROV.HMOASSOC=empty.

130

ProviderNotHMO

Provider is not associated with a Managed Care plan =
PROV.HMOASSOC=2/No, DK, or RF.

129

ProviderAssocHMO

Provider is associated with a Managed Care plan =
PROV.HMOASSOC=1/Yes.

DESIGN NOTES
If the SP belongs to a managed care plan (HMO), we ask each provider
selected/added if the provider is associated with an HMO. This question,
which is asked throughout utilization and cost series, is only asked once
in the study for each provider. The response is never updated. (this
design may change in the future).
If the SP belongs to an HMO, and we have not asked this question for this
provider, HMOASSOC=empty, BOX ER1B is routed to ER3A ­
HMOASSOC. If we have already asked this question about this provider,
and the provider responded to HMOASSOC=No, DK or RF, BOX ER1B is
routed to ER3B, skipping ER3A, to determine if the SP was referred to
this provider by their HMO.
If SP does not belong to an HMO or this provider already reported being
associated with the HMO, BOX ER1B routes directly to ER4, collect
emergency room visits, skipping ER3A and ER3B.

12:47:05 PM Monday, November 03, 2008

Page 9 of 48

ER3A

ER3A

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HMOASSOC

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

70

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of hospital, PROV.PROVNAME, currently being
asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

Display all managed care plans SP was covered by anytime during
the current round.
Display managed care plan name(s) below question text.
Display plans in the following order: Medicare Managed Care plans,
Medicaid Managed Care plans, and Private Managed Care plans. If
there is more than one plan for any specific plan type, display in
order of entry.
Column 1, header = "MANAGED CARE PLANS".

Column 1, display= If Medicaid Managed Care Plan, display

"Medicaid Managed Care Plan".

Else display health insurance plan name "(PLAN NAME) Managed

Care Plan".

TEXT:
Context Header:

12:47:06 PM Monday, November 03, 2008

Page 10 of 48

ER3A
Int. Instr I:
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?

Question Text:
Int. Instr II:

INPUT FIELDS / ROUTING

HMOASSOC

Field1:
Cheshire Name:

( ERQ1070 )

PROV.HMOASSOC

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER4 - EVENT_ER ( ERQ1120 )

English text: YES
No

ER3B - HMOREFER ( ERQ1080 )

English text: NO
Attribute
Don't know

Route
ER3B - HMOREFER ( ERQ1080 )

Refusal

ER3B - HMOREFER ( ERQ1080 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

12:47:09 PM Monday, November 03, 2008

Deleted plans that are not valid for displays or checks =

Page 11 of 48

ER3A
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
2

ManagedCarePlan

SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.

107

PlanIsMCaidHMO

SP is covered by a Medicaid Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.MCAIDHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.

111

PlanIsMCareHMO

SP is covered by a Medicare Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.

112

PlanIsPrivateHMO

SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.

106

HIPlanName

Health Insurance Plan Roster is stored on PLAN.
Plan name = PLAN.PLNAME.

DESIGN NOTES

12:47:09 PM Monday, November 03, 2008

Page 12 of 48

ER3B

ER3B

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HMOREFER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

80

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of hospital, PROV.PROVNAME, currently being
asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

Display all managed care plans SP was covered by anytime during
the current round.
Display managed care plan name(s) below question text.
Display plans in the following order: Medicare Managed Care plans,
Medicaid Managed Care plans, and Private Managed Care plans. If
there is more than one plan for any specific plan type, display in
order of entry.
Column 1, header = "MANAGED CARE PLANS".

Column 1, display= If Medicaid Managed Care Plan, display

"Medicaid Managed Care Plan".

Else display health insurance plan name "(PLAN NAME) Managed

Care Plan".

TEXT:
Context Header:

12:47:10 PM Monday, November 03, 2008

Page 13 of 48

ER3B
Int. Instr I:
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?

Question Text:
Int. Instr II:

INPUT FIELDS / ROUTING

HMOREFER

Field1:
Cheshire Name:

( ERQ1080 )

EVNT.HMOREFER

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER4 - EVENT_ER ( ERQ1120 )

English text: YES
No

ER3D - NOGOHMO ( ERQ1090 )

English text: NO
Attribute
Don't know

Route
ER4 - EVENT_ER ( ERQ1120 )

Refusal

ER4 - EVENT_ER ( ERQ1120 )

BACKGROUND VARIABLE ASSIGNMENTS
ER3B - HMOREFER is an EVENT level detail. The response to ER3B - HMOREFER
needs to be copied to EVNT.HMOREFER for each ER Event added at ER4.

SOFT EDIT CHECKS

HARD EDIT CHECKS

12:47:13 PM Monday, November 03, 2008

Page 14 of 48

ER3B
TECHNICAL NOTES

DESIGN NOTES

12:47:13 PM Monday, November 03, 2008

Page 15 of 48

ER3D

ER3D

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

NOGOHMO

Field 2:

NOGOHMOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

91

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

Display managed care plan name(s) below question text.

Display plans in the following order: Medicare Managed Care plans,

Medicaid Managed Care plans, and Private Managed Care plans. If

there is more than one plan for any specific plan type, display in

order of entry.

Column 1, header = "MANAGED CARE PLANS".

Column 1, display = If Medicaid Managed Care Plan, display

"Medicaid Managed Care Plan".

Else display health insurance plan name "(PLAN NAME) Managed

Care Plan".

TEXT:
Context Header:
Int. Instr I:
12:47:16 PM Monday, November 03, 2008

Page 16 of 48

ER3D
Question Text:

What is the most important reason [you/(SP)] did not go to an
emergency room associated with [READ MANAGED CARE PLAN
NAME(S) BELOW] or an emergency room that [READ MANAGED
CARE PLAN NAME(S) BELOW] would refer [you/(SP)] to?

Int. Instr II:

SCROLL DOWN TO SEE RESPONSE CATEGORIES.

INPUT FIELDS / ROUTING

12:47:21 PM Monday, November 03, 2008

Page 17 of 48

ER3D
NOGOHMO

Field1:
Cheshire Name:
Item Text display:

( ERQ1090 )

EVNT.NOGOHMO
Display responses in one column.

Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
Tnogohmo
1
No
No

Number Label
1 PlanNotCoverService
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER4 - EVENT_ER ( ERQ1120 )

English text: PLAN DOES NOT COVER THE SERVICE SP WANTED
DifficultyDelayGettingService
ER4 - EVENT_ER ( ERQ1120 )

4

English text: DIFFICULTY OR DELAY IN GETTING SERVICES
SPProviderPreference
ER4 - EVENT_ER ( ERQ1120 )
English text: SP PROVIDER PREFERENCE
ServiceCoverdbyOtherInsurance
ER4 - EVENT_ER ( ERQ1120 )

5

English text: THIS SERVICE WAS COVERED BY OTHER INSURANCE SP HAS
NotinManagedCareTimeofEvent
ER4 - EVENT_ER ( ERQ1120 )

6

English text: NOT IN A MANAGED CARE PLAN AT TIME OF EVENT
NoChoiceMedEmergency
ER4 - EVENT_ER ( ERQ1120 )

3

91

English text: NO CHOICE - MEDICAL EMERGENCY OR OUT OF SERVICE AREA
Other
ER3D - NOGOHMOS ( ERQ1100 )
English text: OTHER

Attribute
Don't know

Route
ER4 - EVENT_ER ( ERQ1120 )

Refusal

ER4 - EVENT_ER ( ERQ1120 )

12:47:27 PM Monday, November 03, 2008

Page 18 of 48

ER3D
NOGOHMOS

Field2:
Cheshire Name:

( ERQ1100 )

EVNT.NOGOHMOS

Item Text display:

Display (SPECIFY) in same blue font used for interviewer

instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

String

TOthrspec

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

30

Route
ER4 - EVENT_ER ( ERQ1120 )

BACKGROUND VARIABLE ASSIGNMENTS
ER3D - NOGOHMO and NOGOHMOS are EVENT level details. The response to ER3D NOGOHMO and NOGOHMOS needs to be copied to EVNT.NOGOHMO and
EVNT.NOGOHMOS for each ER Event added at ER4.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

2

ManagedCarePlan

SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.

12:47:28 PM Monday, November 03, 2008

Page 19 of 48

ER3D
107

PlanIsMCaidHMO

SP is covered by a Medicaid Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.MCAIDHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.

111

PlanIsMCareHMO

SP is covered by a Medicare Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.

112

PlanIsPrivateHMO

SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.

106

HIPlanName

Health Insurance Plan Roster is stored on PLAN.
Plan name = PLAN.PLNAME.

DESIGN NOTES

12:47:28 PM Monday, November 03, 2008

Page 20 of 48

ER4

ER4

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

EVENT_ER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Event Roster Begin Date

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

110

Display as ' Add an Emergency Room visit '
Display as ' Edit a Visit '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of hospital, PROV.PROVNAME, currently being
asked about.

Multi Field display:

Roster/Grid Instructions:

Display all Emergency Room visits for this provider that have been
added in the current round where:
EVNT.EVNTDFLG ^= 1/Yes, and
EVNT.EVNTRNDC=current round, and
EVNT.EVNTTYPE = 'ER', and
EVNT.EVNTPROV = PROV.PROVNUM for the provider selected at
ER2.
Display all loaded events as protected rows.
Display in order of entry.

Roster/Grid display:

COL #
1

HEADER
Event Date

INSTRUCTIONS
Display EVENT DATE in "Mon DD YYYY"
format.

Report display:

TEXT:
Context Header:
12:47:29 PM Monday, November 03, 2008

Page 21 of 48

ER4
Int. Instr I:
When did [you/(SP)] go to the emergency room at (PROVIDER
NAME)?

Question Text:

Please tell me all the dates [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
ENTER ALL DATES.

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

EVENT_ER

( ERQ1120 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TEvntPick135
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

135

Route
ER4_IN - NAVIGATOR ( ERQ1125 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:

EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM

EVNT.EVNTNUM = Number of event selected at ER4.

For Event(s) added, see EVENT ROSTER BEGIN DATE POP-UP specifications for pop-up

window programming instructions.

Variables populated in Event Roster Begin Date:

EVNT.EVNTNUM
EVNT.EVNTRNDC
EVNT.EVBEGMM
EVNT.EVBEGDD
EVNT.EVBEGYY
BASE.LASTEVNT

Event number

Round

Visit Month

Visit Day

Visit Year

Highest EVNT.EVNTNUM.

For each event added at ER4, set Event type, Statement Event type, Event provider

number, and Event details collected at ER3B and ER3D. See detailed instructions below.

12:47:30 PM Monday, November 03, 2008

Page 22 of 48

ER4
EVNTTYPE

EVNT.EVNTTYPE='ER'.

STEVTYPE

EVNT.STEVTYPE=4/ER.

EVNTPROV

EVNT.EVNTPROV=PROV.PROVNUM of provider

selected at ER2.

HMOREFER

EVNT.HMOREFER = Repsonse to ER3B -

HMOREFER.

NOGOHMO

EVNT.NOGOHMO = Response to ER3D -

NOGOHMO.

NOGOHMOS

EVNT.NOGOHMOS = Response to ER3D NOGOHMOS.

SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1:

Date of event, EVBEGMM/EVBEGDD/EVBEGYY, must be on or

between (REFERENCE DATE) and (TODAY/DATE OF

DEATH/DATE OF INSTITUTIONALIZATION). If not true, display

message "INVALID DATE. DATE MUST BE ON OR BETWEEN

(REFERENCE DATE) AND (TODAY/DATE OF DEATH/DATE OF

INSTITUTIONALIZATION)".

See general specifications for date check logic.

Edit #2:

Date of event, EVBEGMM/EVBEGDD/EVBEGYY, cannot match an

existing ER event date for the provider selected at ER2.

If date of event added at ER4 does not have missing data,

EVBEGMM, EVBEGDD, EVBEGYY ^= DK and EVBEGMM,

EVBEGDD, EVBEGYY ^= RF, then check this date against other ER

events for duplicate dates.

The following must be true for the event added at ER4 to be a

duplicate of an existing ER event:

Both EVNTDFLG ^= 1/Yes.

Both EVNTRNDC=current round.

Both EVNTTYPE=ER.

EVNTPROV matches.

EVBEGMM matches.

EVBEGDD matches.

EVBEGYY matches.

The date of the event added at ER4 should not match any other ER

event date for the provider selected at ER2.

If not true, display message, "THIS DATE HAS ALREADY BEEN

ENTERED. PLEASE VERIFY YOUR RESPONSE".

TECHNICAL NOTES

DESIGN NOTES
Begin Loop 2: Collect all event dates for this provider, loop through details

for each event added at ER4.

ER allows you to select a provider more than once at ER2. If this provider
12:47:30 PM Monday, November 03, 2008

Page 23 of 48

ER4
has already been selected and visits added at ER4 in an earlier loop, the
visits will be displayed at ER4 as protected rows.

12:47:30 PM Monday, November 03, 2008

Page 24 of 48

ER4_IN

ER4_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

115

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display events added at ER4.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

12:47:30 PM Monday, November 03, 2008

Page 25 of 48

ER4_IN
NAVIGATOR

Field1:
Cheshire Name:

( ERQ1125 )

N/A

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER5 - CONDTION_ER ( ERQ1160 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
ER10 - ERMORE ( ERQ1270 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:32 PM Monday, November 03, 2008

Page 26 of 48

ER5

ER5

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

CONDTION_ER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Condition Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

130

Display as ' Add a Condition '
Display as ' Edit a Condition '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display date of emergency room visit currently being asked about.

Multi Field display:

Roster/Grid Instructions:

Display all Conditions.
Display in alphabetical order.

Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

For what condition did [you/(SP)] go to the emergency room on
[EVENT DATE]?

Int. Instr II:

SELECT OR ADD ALL CONDITIONS.

INPUT FIELDS / ROUTING

12:47:33 PM Monday, November 03, 2008

Page 27 of 48

ER5

Field1:
Cheshire Name:

CONDTION_ER

( ERQ1160 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TCondPick135
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

135

Route
BOX ER2A - (ERQ1170 )

BACKGROUND VARIABLE ASSIGNMENTS
Conditions will be collected on COND:

COND key = COND.CONDBASE + COND.CONDNUM

COND.CONDNUM = Number of condition selected at ER5.

If adding a new condition, see CONDITION ROSTER POP-UP specifications for pop-up

window programming instructions.

Variables populated at the Condition Roster:

COND.CONDNUM

COND.CONDRNDC

COND.CONDTION

All Conditions selected at ER5 should be linked to the Emergency Room visit being asked

about. Link Conditions to ER visit on XCON.

XCON key = XCON.XCONBASE + XCON.XCONEVNT + XCON.XCONBAS2 +

XCON.XCONCOND.

For each condition selected at ER5, create an XCON where XCONEVNT=

EVNT.EVNTNUM of Emergency Room visit and XCONCOND = COND.CONDNUM of

Condition. XCONBASE and XCONBAS2 both equal the Cheshire BASE.BASEID. Set

additional XCON variables as specified below.

XCONEVNT

XCON.XCONEVNT = EVNT.EVNTNUM of
Emergency Room visit being asked about.

XCONCOND

XCON.XCONCOND = COND.CONDNUM of
Condition selected at ER5.

XCONRNDC

XCON.XCONRNDC = current round.

SOFT EDIT CHECKS

12:47:33 PM Monday, November 03, 2008

Page 28 of 48

ER5
HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
Called by Box ST22A and Box NS22A if ER visit added in ST and/or NS.

12:47:33 PM Monday, November 03, 2008

Page 29 of 48

BOX ER2A

BOX ER2A

Page Order # :

140

BOX INSTRUCTIONS
( ERQ1170 )

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B - (STQ1700 ).
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B (NSQ1700 ).
ELSE GO TO ER6 - ERADMIT ( ERQ1180 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
If currently administering ST or NS, return to Box ST23B or Box NS23B.

12:47:33 PM Monday, November 03, 2008

Page 30 of 48

ER6

ER6

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ERADMIT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

150

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display date of emergency room visit currently being asked about.

Question display:

Display name of hospital, PROV.PROVNAME, currently being
asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

DATE OF ER VISIT: [VISIT ON EVENT DATE]

Int. Instr I:
Question Text:

[Were you/Was (SP)] admitted to (PROVIDER NAME) from the
emergency room?

Int. Instr II:
INPUT FIELDS / ROUTING

12:47:35 PM Monday, November 03, 2008

Page 31 of 48

ER6
ERADMIT

Field1:
Cheshire Name:

( ERQ1180 )

EVNT.ERADMIT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX ER4 - (ERQ1260 )

English text: YES
No

ER7 - PRESMDCN ( ERQ1200 )

English text: NO
Attribute
Don't know

Route
ER7 - PRESMDCN ( ERQ1200 )

Refusal

ER7 - PRESMDCN ( ERQ1200 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:37 PM Monday, November 03, 2008

Page 32 of 48

ER7

ER7

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

PRESMDCN

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

170

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display date of emergency room visit currently being asked about.

Question display:

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

DATE OF ER VISIT: [VISIT ON EVENT DATE]

Int. Instr I:

Question Text:

During [your/(SP’s)] visit to the emergency room, were any

medicines prescribed for [you/(SP)]?

Int. Instr II:
INPUT FIELDS / ROUTING

12:47:38 PM Monday, November 03, 2008

Page 33 of 48

ER7
PRESMDCN

Field1:
Cheshire Name:

( ERQ1200 )

EVNT.PRESMDCN

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER8 - PRESFILL ( ERQ1210 )

English text: YES
No

BOX ER4 - (ERQ1260 )

English text: NO
Attribute
Don't know

Route
BOX ER4 - (ERQ1260 )

Refusal

BOX ER4 - (ERQ1260 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:40 PM Monday, November 03, 2008

Page 34 of 48

ER8

ER8

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

PRESFILL

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

180

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Were any of the prescriptions filled?

Int. Instr II:

INPUT FIELDS / ROUTING

12:47:42 PM Monday, November 03, 2008

Page 35 of 48

ER8
PRESFILL

Field1:
Cheshire Name:

( ERQ1210 )

EVNT.PRESFILL

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX ER3A - (ERQ1220 )

English text: YES
No

BOX ER4 - (ERQ1260 )

English text: NO
Attribute
Don't know

Route
BOX ER4 - (ERQ1260 )

Refusal

BOX ER4 - (ERQ1260 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:44 PM Monday, November 03, 2008

Page 36 of 48

BOX ER3A

BOX ER3A

Page Order # :

190

BOX INSTRUCTIONS
( ERQ1220 )

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN
ASKED IN THE CURRENT ROUND, GO TO ER8A - ERPMMEDS ( ERQ1230
).
ELSE GO TO ER9 - MEDICINE_ER ( ERQ1240 ).

ASSIGNMENTS

TECHNICAL NOTES
131

PMBottleProbe

Prescription Medicine Bottle probe has been asked in the
current round =
GETPMMEDS=1/Yes.

DESIGN NOTES
Only probe for prescription medicine bottles once during the current
round.
Adding a new TEMP flag, GETPMMEDS. GETPMMEDS is set to 1/Yes
whenever the Prescription Bottle probe is asked during the current
round. This will get set anywhere in utilization or cost series.

12:47:44 PM Monday, November 03, 2008

Page 37 of 48

ER8A

ER8A

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

ERPMMEDS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

200

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "(s)" in "bottle(s), container(s), or bag(s)" in
parenthesis.
If SP has a "current" Medicare Prescription Drug plan or there was a
Medicare Prescription Drug plan "current" at the time of the
previous round interview, then display "Also, please take out
[your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME)
medicine statements....".
Else do not display.
MEDICARE PRESCRIPTION DRUG PLAN NAME =
Display the name of the "current" Medicare Prescription Drug plan.
If it does not exist, display the name of the Medicare Prescription
Drug plan "current" at the time of the previous round interview.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

12:47:45 PM Monday, November 03, 2008

Page 38 of 48

ER8A
Int. Instr I:
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the medicine
name correctly and enter the strength of the medicine. [Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN
NAME) medicine statements, which should have that same
information on them.]

Question Text:

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same
information for all of the medicines [you/(SP)] obtained since the last
interview, if you’d like to get those bottles, too.
Int. Instr II:

INPUT FIELDS / ROUTING

ERPMMEDS

Field1:

( ERQ1230 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER9 - MEDICINE_ER ( ERQ1240 )

English text: CONTINUE
Attribute
Empty

Route
ER9 - MEDICINE_ER ( ERQ1240 )

BACKGROUND VARIABLE ASSIGNMENTS
The question displayed at ER8A is repeated in other utilization sections. Only show this

probe for prescription medicine bottles once during the current round interview.

If ER8A - ERPMMEDS is asked, set flag as instructed below:

GETPMMEDS

Set GETPMMEDS=1/Yes

SOFT EDIT CHECKS

12:47:47 PM Monday, November 03, 2008

Page 39 of 48

ER8A

HARD EDIT CHECKS

TECHNICAL NOTES
342

MPDPCurrent

SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

343

MPDPCurrPrevRnd

Medicare Prescription Drug plan "current" at time of
previous round interview=
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

12:47:47 PM Monday, November 03, 2008

Page 40 of 48

ER9

ER9

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

MEDICINE_ER

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Prescription Medicine Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

210

Display as ' Add a Medicine '
Display as ' Edit a Medicine '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display "CHECK STATEMENT OR MEDICINE BOTTLE FOR
SPELLING." in BOLD.
Display "INCLUDE STRENGTH WITH NAME." in BOLD.

Multi Field display:

Roster/Grid Instructions:

Display all prescription medicines where:
EVNT.EVNTDFLG ^= 1, and
EVNT.EVNTTYPE='PM' .
Display in alphabetical order.

Roster/Grid display:

COL #

HEADER

INSTRUCTIONS

1

Medicine

Display prescription medicine name,
EVNT.PMEDNAME.

2

Strength

Display prescription medicine strength
text field, EVNT.PMSTRUNI.

Report display:

TEXT:
Context Header:

12:47:48 PM Monday, November 03, 2008

Page 41 of 48

ER9
Int. Instr I:
Question Text:

Please tell me the names of these medicines.

Int. Instr II:

ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.

INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

MEDICINE_ER

( ERQ1240 )

EVNT.PMEDNAME

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TEvntPick135
1

No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

135

Route
BOX ER4 - (ERQ1260 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of PM event selected at ER9.
If Prescription Medicine added at Prescription Medicine Roster, see PRESCRIPTION
MEDICINE ROSTER POP-UP specifications for pop-up window programming instructions.
Variables populated at the Prescription Medicine Roster:
EVNT.EVNTNUM
EVNT.EVNTRNDC
EVNT.EVNTTYPE
EVNT.PMEDNAME
EVNT.PMSTRUNI
EVNT.EVNTPROV
BASE.LASTEVNT

Event number
Round number
PM
Prescription Medicine name
Prescription Medicine strength text field
02
Highest EVNT.EVNTNUM

For all Prescription Medicines selected at ER9, create a current round PMRO. Note: a
current round PMRO may already exist for a Prescription Medicine event if it has already
been selected earlier in the interview.

12:47:49 PM Monday, November 03, 2008

Page 42 of 48

ER9
PMRO key = PMRO.PMROBASE + PMRO.PMROEVNT + PMRO.PMRORND.
Create PMRO where PMRO.PMROEVNT = EVNT.EVNTNUM for prescription medicine
selected and PMRO.PMRORND = current round. Set additional PMRO variable as
instructed below.
All prescription medicines selected at ER9 should be linked to the Emergency Room visit
being asked about. Prescription medicine events are linked to other events on XMED.
XMED key = XMED.XMEDBASE + XMED.XMEDEVNT + XMED.XMEDBAS2 +
XMED.XMEDEVT2.
For each medicine selected at ER9, create an XMED where XMEDEVNT =
EVNT.EVNTNUM of Emergency
Room visit being asked about and XMEDEVT2 = EVNT.EVNTNUM of Prescription
Medicine selected at ER9. XMEDBASE and XMEDBAS2 both equal the Cheshire
BASE.BASEID. Set additional XMED variables as specified below.
Set the following PMRO and XMED variables for each prescription medicine selected at
ER9:
PMROEVNT

PMRO.PMROEVNT = EVNT.EVNTNUM of
prescription medicine selected at ER9.

PMRORND

PMRO.PMRORND = current round.

PMROTYPE

PMRO.PMROTYPE = PM.

XMEDEVNT

XMED.XMEDEVNT = EVNT.EVNTNUM of
Emergency Room visit being asked about.

XMEDEVT2

XMED.XMEDEVT2 = EVNT.EVNTNUM of
prescription medicine selected at ER9.

XMEDRNDC

XMED.XMEDRNDC = current round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:47:49 PM Monday, November 03, 2008

Page 43 of 48

BOX ER4

BOX ER4

Page Order # :

220

BOX INSTRUCTIONS
( ERQ1260 )

GO TO ER4_IN - NAVIGATOR ( ERQ1125 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

12:47:49 PM Monday, November 03, 2008

Page 44 of 48

ER10

ER10

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ERMORE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

230

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:
Int. Instr I:
Question Text:

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to the emergency room at this or any
other hospital?

Int. Instr II:
INPUT FIELDS / ROUTING

12:47:50 PM Monday, November 03, 2008

Page 45 of 48

ER10
ERMORE

Field1:
Cheshire Name:

( ERQ1270 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
ER2 - PROVIDER_ER ( ERQ1030 )

English text: YES
No

BOX ER5 - (ERQ1280 )

English text: NO
Attribute
Don't know

Route
BOX ER5 - (ERQ1280 )

Refusal

BOX ER5 - (ERQ1280 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
End Loop 1: ER10 - ERMORE probes for additional Emergency Room
visits. Emergency Room visits can be for a new provider or a provider
already selected and asked about. If ERMORE=1/Yes, go to ER2 to select
the next provider.

12:47:52 PM Monday, November 03, 2008

Page 46 of 48

BOX ER5

BOX ER5

Page Order # :

240

BOX INSTRUCTIONS
( ERQ1280 )

IF FALL ROUND AND ((SP REPORTED AN EMERGENCY ROOM VISIT AT
ER2) AND (SP IS ALIVE AND NOT INSTITUTIONALIZED)), GO TO AC6A EWAITHRS ( ACQ1130 ).
ELSE GO TO BOX ER6 - (ERQ1365 ).

ASSIGNMENTS

TECHNICAL NOTES
59

SPStatus

SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.

98

FallRound

If the remainder of (Current round divided by 3) = 1, then
it is a Fall round.

DESIGN NOTES

12:47:52 PM Monday, November 03, 2008

Page 47 of 48

BOX ER6

BOX ER6

Page Order # :

290

BOX INSTRUCTIONS
( ERQ1365 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

12:47:52 PM Monday, November 03, 2008

Page 48 of 48