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

Medicare Current Beneficiary Survey (MCBS)

Attachment 4 Questionnaire Comprehensive Format Section by SectionOP_05.01.0000

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

OMB: 0938-0568

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OP1

OP1

Page Order # :

Design Screen Type:

Yes/No

Fields:	

Field 1:

OPPROBE

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 the outpatient department or the
outpatient clinic at any hospital for medical care?

Int. Instr II:
INPUT FIELDS / ROUTING

10:56:41 AM Friday, March 06, 2009	

Page 1 of 52

OP1
( OPQ1020 )

OPPROBE

Field1:
Cheshire Name:
Item Text display:

HRND.OPPROBE
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


FieldSize:

Min Value:

Max Value:

Mask:


1

No
No


Number Label
1 Yes

Route
OP2 - PROVIDER_OP ( OPQ1030 )

2

English text: YES
No

3

English text: NO
IndicatedYesByDataPrep

BOX OP7 - (OPQ1505 )

DO NOT DISPLAY. DATA EDITING ONLY.
English text: INDICATED YES BY DATAPREP
Attribute
Don't know

Route
BOX OP7 - (OPQ1505 )

Refusal

BOX OP7 - (OPQ1505 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

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

10:56:44 AM Friday, March 06, 2009

Page 2 of 52

OP1
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

DESIGN NOTES

10:56:44 AM Friday, March 06, 2009

Page 3 of 52

OP2

OP2

Page Order # :

Design Screen Type:

Roster

Fields:	

Field 1:

PROVIDER_OP

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 Hospital '
Display as ' Edit a Hospital '

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
10:56:45 AM Friday, March 06, 2009	

Page 4 of 52

OP2
PROVIDER_OP

Field1:

( OPQ1030 )

PROV.PROVNAME

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

String
TProvPick4

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

1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

4

Route
BOX OP1 - (OPQ1050 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PROV:

PROV key = PROV.PROVBASE + PROV.PROVNUM

PROV.PROVNUM = Number of Provider selected at OP2.

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 = 4/OutpatientHospital.


SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

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

provider.


10:56:45 AM Friday, March 06, 2009

Page 5 of 52

BOX OP1

BOX OP1

Page Order # :

40

BOX INSTRUCTIONS
( OPQ1050 )	

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 OP3 VAPLACE ( OPQ1060 ).
ELSE GO TO BOX OP1B - (OPQ1070 ).

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

10:56:45 AM Friday, March 06, 2009	

Page 6 of 52

OP3

OP3

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 the name of the 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 (HOSPITAL NAME) a Department of Veterans Affairs, or V.A.,

facility?

Int. Instr II:
INPUT FIELDS / ROUTING

10:56:47 AM Friday, March 06, 2009	

Page 7 of 52

OP3
VAPLACE

Field1:
Cheshire Name:

( OPQ1060 )

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 OP1B - (OPQ1070 )

English text: YES
No

BOX OP1B - (OPQ1070 )

English text: NO
Attribute
Don't know

Route
BOX OP1B - (OPQ1070 )

Refusal

BOX OP1B - (OPQ1070 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:56:49 AM Friday, March 06, 2009

Page 8 of 52

BOX OP1B

BOX OP1B

10:56:49 AM Friday, March 06, 2009

Page Order # :

60


Page 9 of 52


BOX OP1B
BOX INSTRUCTIONS
( OPQ1070 )	

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 OP3A - HMOASSOC (
OPQ1080 ).
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 OP3B - HMOREFER ( OPQ1090 ).
ELSE GO TO OP4 - EVENT_OP ( OPQ1130 ).

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 OP1B is routed to OP3A ­
HMOASSOC. If we have already asked this question about this provider,
and the provider responded to HMOASSOC=No, DK or RF, BOX OP1B is
routed to OP3B, skipping OP3A, 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 OP1B routes directly to OP4, collects
outpatient stays, skipping OP3A and OP3B.

10:56:49 AM Friday, March 06, 2009	

Page 10 of 52

OP3A

OP3A

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 the name of the 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:

10:56:50 AM Friday, March 06, 2009	

Page 11 of 52

OP3A
Int. Instr I:
Is (HOSPITAL 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:

( OPQ1080 )

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
OP4 - EVENT_OP ( OPQ1130 )

English text: YES
No

OP3B - HMOREFER ( OPQ1090 )

English text: NO
Attribute
Don't know

Route
OP3B - HMOREFER ( OPQ1090 )

Refusal

OP3B - HMOREFER ( OPQ1090 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

10:56:53 AM Friday, March 06, 2009

Deleted plans that are not valid for displays or checks =

Page 12 of 52

OP3A
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

10:56:53 AM Friday, March 06, 2009

Page 13 of 52

OP3B

OP3B

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 the name of the 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:

10:56:55 AM Friday, March 06, 2009	

Page 14 of 52

OP3B
Int. Instr I:
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?

Question Text:
Int. Instr II:

INPUT FIELDS / ROUTING


HMOREFER

Field1:
Cheshire Name:

( OPQ1090 )

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
OP4 - EVENT_OP ( OPQ1130 )

English text: YES
No

OP3D - NOGOHMO ( OPQ1100 )

English text: NO
Attribute
Don't know

Route
OP4 - EVENT_OP ( OPQ1130 )

Refusal

OP4 - EVENT_OP ( OPQ1130 )

BACKGROUND VARIABLE ASSIGNMENTS
OP3B - HMOREFER is an EVENT level detail. The response to OP3B - HMOREFER
needs to be copied to EVNT.HMOREFER for each OP Event added at OP4.

SOFT EDIT CHECKS

HARD EDIT CHECKS

10:56:58 AM Friday, March 06, 2009

Page 15 of 52

OP3B
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.


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

10:56:58 AM Friday, March 06, 2009

Page 16 of 52

OP3D

OP3D

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:
10:57:00 AM Friday, March 06, 2009

Page 17 of 52

OP3D
Question Text:

What is the most important reason [you/(SP)] did not go to a hospital
outpatient department associated with [READ MANAGED CARE
PLAN NAME(S) BELOW] or a hospital outpatient department 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

10:57:05 AM Friday, March 06, 2009

Page 18 of 52

OP3D
NOGOHMO

Field1:
Cheshire Name:
Item Text display:

( OPQ1100 )

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
OP4 - EVENT_OP ( OPQ1130 )

English text: PLAN DOES NOT COVER THE SERVICE SP WANTED
DifficultyDelayGettingService
OP4 - EVENT_OP ( OPQ1130 )

4

English text: DIFFICULTY OR DELAY IN GETTING SERVICES
SPProviderPreference
OP4 - EVENT_OP ( OPQ1130 )
English text: SP PROVIDER PREFERENCE
ServiceCoverdbyOtherInsurance
OP4 - EVENT_OP ( OPQ1130 )

5

English text: THIS SERVICE WAS COVERED BY OTHER INSURANCE SP HAS
NotinManagedCareTimeofEvent
OP4 - EVENT_OP ( OPQ1130 )

6

English text: NOT IN A MANAGED CARE PLAN AT TIME OF EVENT
NoChoiceMedEmergency
OP4 - EVENT_OP ( OPQ1130 )

3

91

English text: NO CHOICE - MEDICAL EMERGENCY OR OUT OF SERVICE AREA
Other
OP3D - NOGOHMOS ( OPQ1110 )
English text: OTHER

Attribute
Don't know

Route
OP4 - EVENT_OP ( OPQ1130 )

Refusal

OP4 - EVENT_OP ( OPQ1130 )

10:57:12 AM Friday, March 06, 2009

Page 19 of 52

OP3D
NOGOHMOS

Field2:
Cheshire Name:

( OPQ1110 )

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
OP4 - EVENT_OP ( OPQ1130 )

BACKGROUND VARIABLE ASSIGNMENTS
OP3D - NOGOHMO and NOGOHMOS are EVENT level details. The response to OP3D ­
NOGOHMO and NOGOHMOS needs to be copied to EVNT.NOGOHMO and
EVNT.NOGOHMOS for each OP Event added at OP4.

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.

10:57:13 AM Friday, March 06, 2009

Page 20 of 52

OP3D
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

10:57:13 AM Friday, March 06, 2009

Page 21 of 52

OP4

OP4

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

EVENT_OP

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Event Roster Begin Date RV

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 Outpatient Department Visit '
Display as ' Edit Visit '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

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

Multi Field display:

Roster/Grid Instructions:	

Display all Outpatient Hospital Events for this provider that have
been added in the current round where:
EVNT.EVNTDFLG ^= 1/Yes, and
EVNT.EVNTRNDC = current round, and
EVNT.EVNTTYPE = 'OP', and
EVNT.EVNTPROV=PROV.PROVNUM for the provider selected at
OP2.
Display all loaded events as protected rows.
Display in order of entry.

Roster/Grid display:	

10:57:14 AM Friday, March 06, 2009	

COL #

HEADER

INSTRUCTIONS

1

Event Date	

Display EVENT DATE in "Mon DD YYYY"
format.

2

Repeat Visit	

If VISTTYPE=2/RepeatVisit, display "RV".
Else do not display.

3

Times Per Month	

If VISTTYPE=2/RepeatVisit, display
EVNT.RVTIMES.
Else do not display.

Page 22 of 52

OP4
Report display:

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

When did [you/(SP)] go to an outpatient department at (HOSPITAL
NAME)? Please tell me all the dates [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)].

Int. Instr II:

ENTER ALL DATES.

INPUT FIELDS / ROUTING
EVENT_OP

Field1:

( OPQ1130 )

EVNT.EVBEGMM

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

Label Position:


String
TEvntPick135

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


1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


135

Route
OP4_IN - NAVIGATOR ( OPQ1135 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:

EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM

EVNT.EVNTNUM = Number of event selected at OP4.

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

pop-up window programming instructions.

Variables populated in Event Roster Begin Date RV:

EVNT.EVNTNUM
EVNT.EVNTRNDC
EVNT.EVBEGMM
EVNT.EVBEGDD
EVNT.EVBEGYY

Event number

Round

Visit Month

Visit Day

Visit Year


10:57:14 AM Friday, March 06, 2009

Page 23 of 52

OP4
EVNT.VISTTYPE
EVNT.RVTIMES
BASE.LASTEVNT

Type of Visit
# of visits for Repeat Visit
Highest EVNT.EVNTNUM

For each event added at OP4, set Event type, Statement Event type, Event provider
number, and Event details collected at OP3B and OP3D. See detailed instructions below.
EVNTTYPE	

EVNT.EVNTTYPE = 'OP'.

STEVTYPE	

EVNT.STEVTYPE = 6/OP.

EVNTPROV	

EVNT.EVNTPROV=PROV.PROVNUM of hospital
selected at OP2.

HMOREFER	

EVNT.HMOREFER = Response to OP3B HMOREFER.

NOGOHMO	

EVNT.NOGOHMO = Response to OP3D NOGOHMO.

NOGOHMOS	

EVNT.NOGOHMOS = Response to OP3D 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 date check logic in general specifications.

Edit #2:

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

existing OP event date for the provider selected at OP2. If date of

event added at OP4 does not have missing data, EVBEGMM,

EVBEGDD, EVBEGYY ^= DK and EVBEGMM, EVBEGDD,

EVBEGYY ^= RF, then check this date against other OP event dates

for duplicate dates.

The following must be true for the event added at OP4 to be a

duplicate of an existing event:

Both EVNTDFLG ^= 1/Yes.

Both EVNTRNDC=current round.

Both EVNTTYPE=OP.

EVNTPROV matches.

EVBEGMM matches.

If EVBEGDD ^= empty, EVBEGDD matches. 

Else If EVBEGDD = empty, both VISTTYPE=2/RepeatVisit.

EVBEGYY matches.

The date of the event added at OP4 should not match any OP event 

date for the provider selected at OP2.

If not true, display message "INVALID DATE. THIS DATE

MATCHES AN EXISTING OUTPATIENT VISIT TO (HOSPITAL

NAME).

Display instructions: Display hospital name, PROV.PROVNAME,

10:57:14 AM Friday, March 06, 2009	

Page 24 of 52

OP4
selected at OP2.
TECHNICAL NOTES

DESIGN NOTES
Begin Loop 2: Collect all event dates for this provider, loop through details
for each event added at OP4.
OP allows you to select a provider more than once at OP2. If this provider
has already been selected and visits added at OP4 in an earlier loop, the
visits will be displayed at OP4 as protected rows.

10:57:15 AM Friday, March 06, 2009

Page 25 of 52

OP4_IN

OP4_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 OP4.

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

10:57:15 AM Friday, March 06, 2009

Page 26 of 52

OP4_IN
NAVIGATOR

Field1:
Cheshire Name:

( OPQ1135 )

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
OP5 - ANYOPERS ( OPQ1160 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
OP15 - OPMORE ( OPQ1330 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:57:17 AM Friday, March 06, 2009

Page 27 of 52

OP5

OP5

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ANYOPERS

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

120

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display date of event for the Outpatient Department visit currently
being asked about.
If event entered as a Repeat Visit then display "any of the".
Else display "the".
If OP5 is being asked for the first time in the current round interview,
display "[Operations include surgery..]" Always display this
sentence in brackets.
Else do not display.

Multi Field display:

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

TEXT:
Context Header:

Int. Instr I:

Question Text:

10:57:18 AM Friday, March 06, 2009

Were any operations or other surgical procedures performed on 

[you/(SP)] during (any of the/the) [VISIT ON EVENT DATE]?
Page 28 of 52

OP5
[Operations include surgery and other surgical procedures like
setting bones, stitching or removing growths, or any cutting of the
skin.]
Int. Instr II:
INPUT FIELDS / ROUTING
( OPQ1160 )

ANYOPERS

Field1:
Cheshire Name:

EVNT.ANYOPERS

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
OP9 - CONDITION_OP ( OPQ1210 )

English text: YES
No

OP8 - SPECCOND ( OPQ1200 )

English text: NO
Attribute
Don't know

Route
OP8 - SPECCOND ( OPQ1200 )

Refusal

OP8 - SPECCOND ( OPQ1200 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
136

NumberRepeatVisits

10:57:21 AM Friday, March 06, 2009

Number of Repeat Visits =
Page 29 of 52

OP5
EVNT.RVTIMES.
135

RepeatVisitEvent

If Event entered as a Repeat Visit =
EVNT.VISTTYPE=2/RepeatVisit.

DESIGN NOTES
OP5 is called by BOX ST22A or BOX NS22A when an Outpatient Hospital
visit has been added. OP collects the event details and returns to the ST or
NS at BOX OP2A.

10:57:21 AM Friday, March 06, 2009

Page 30 of 52

OP8

OP8

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

SPECCOND

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

160

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:	

Display date of event for the Outpatient Department visit currently
being asked about.

Question display:	

If event entered as a Repeat Visit, display "Were any of these visits".
Else display "Was this visit".

Multi Field display:
Display all input fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:	

DATE OF OUTPATIENT DEPARTMENT VISIT: [VISIT ON EVENT
DATE]

Int. Instr I:
Question Text:	

(Was this visit/Were any of these visits) to the outpatient department
for any specific condition?

Int. Instr II:
INPUT FIELDS / ROUTING

10:57:22 AM Friday, March 06, 2009	

Page 31 of 52

OP8
SPECCOND

Field1:
Cheshire Name:

( OPQ1200 )

EVNT.SPECCOND

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
OP9 - CONDITION_OP ( OPQ1210 )

English text: YES
No

BOX OP2A - (OPQ1220 )

English text: NO
Attribute
Don't know

Route
BOX OP2A - (OPQ1220 )

Refusal

BOX OP2A - (OPQ1220 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:57:25 AM Friday, March 06, 2009

Page 32 of 52

OP9

OP9

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

CONDITION_OP

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


170

Display as ' Add a Condition '

Display as ' Edit a Condition '


DISPLAY INSTRUCTIONS:
Context header display:

Display date of event for the Outpatient Department visit currently
being asked about.

Question display:

If OP5 = 1\Yes, then display "What condition required the surgery".
Else display "What was the condition".

Multi Field display:

Roster/Grid Instructions:

Display all Conditions.
Display in alphabetical order.

Roster/Grid display:
Report display:

TEXT:
Context Header:

DATE OF OUTPATIENT DEPARTMENT VISIT: [VISIT ON EVENT
DATE]

Int. Instr I:
Question Text:

(What condition required the surgery/What was the condition)?

Int. Instr II:

SELECT OR ADD ALL CONDITIONS.

INPUT FIELDS / ROUTING

10:57:25 AM Friday, March 06, 2009

Page 33 of 52

OP9

Field1:
Cheshire Name:

CONDITION_OP

( OPQ1210 )

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 OP2A - (OPQ1220 )

BACKGROUND VARIABLE ASSIGNMENTS
Conditions will be collected on COND:

COND key = COND.CONDBASE + COND.CONDNUM

COND.CONDNUM = Number of condition selected at OP9.

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 OP9 should be linked to the Outpatient Department visit being

asked about. Link Conditions to OP visit on XCON.

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

XCON.XCONCOND.

For each condition selected at OP9, create an XCON where XCONEVNT= 

EVNT.EVNTNUM of Outpatient Department 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
Outpatient Deparment visit being asked about.

XCONCOND

XCON.XCONCOND = COND.CONDNUM of
condition selected at OP9.

XCONRNDC

XCON.XCONRNDC = current round.

SOFT EDIT CHECKS

10:57:26 AM Friday, March 06, 2009

Page 34 of 52

OP9
HARD EDIT CHECKS

TECHNICAL NOTES
135

RepeatVisitEvent	

If Event entered as a Repeat Visit =
EVNT.VISTTYPE=2/RepeatVisit.

DESIGN NOTES

10:57:26 AM Friday, March 06, 2009	

Page 35 of 52

BOX OP2A

BOX OP2A

Page Order # :

180

BOX INSTRUCTIONS
( OPQ1220 )	

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B - (STQ1700 ).
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23A (NSQ1695 ).
ELSE GO TO OP10 - PRESMDCN ( OPQ1230 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
If administering ST or NS, return to BOX ST23A or BOX NS23A.

10:57:26 AM Friday, March 06, 2009	

Page 36 of 52

OP10

OP10

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

190

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:	

Display date of event for the Outpatient Department visit currently
being asked about.

Question display:	

If event entered as a Repeat Visit, display "any of these visits".
Else display "this visit".

Multi Field display:

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

TEXT:
Context Header:	

DATE OF OUTPATIENT DEPARTMENT VISIT: [VISIT ON EVENT
DATE]

Int. Instr I:
Question Text:	

During (this visit/any of these visits) to the outpatient department,
were any medicines prescribed for [you/(SP)]?

Int. Instr II:
INPUT FIELDS / ROUTING

10:57:27 AM Friday, March 06, 2009	

Page 37 of 52

OP10
PRESMDCN

Field1:
Cheshire Name:

( OPQ1230 )

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
OP11 - PRESFILL ( OPQ1240 )

English text: YES
No

BOX OP3 - (OPQ1280 )

English text: NO
Attribute
Don't know

Route
BOX OP3 - (OPQ1280 )

Refusal

BOX OP3 - (OPQ1280 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:57:29 AM Friday, March 06, 2009

Page 38 of 52

OP11

OP11

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

200

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


10:57:31 AM Friday, March 06, 2009

Page 39 of 52

OP11
PRESFILL

Field1:
Cheshire Name:

( OPQ1240 )

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 OP2B - (OPQ1250 )

English text: YES
No

BOX OP3 - (OPQ1280 )

English text: NO
Attribute
Don't know

Route
BOX OP3 - (OPQ1280 )

Refusal

BOX OP3 - (OPQ1280 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:57:33 AM Friday, March 06, 2009

Page 40 of 52

BOX OP2B

BOX OP2B

Page Order # :

210

BOX INSTRUCTIONS
( OPQ1250 )	

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN
ASKED IN THE CURRENT ROUND, GO TO OP11A - OPPMMEDS (
OPQ1260 ).
ELSE GO TO OP12 - MEDICINE_OP ( OPQ1270 ).

ASSIGNMENTS

TECHNICAL NOTES
131

PMBottleProbe

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

DESIGN NOTES

10:57:33 AM Friday, March 06, 2009	

Page 41 of 52

OP11A

OP11A

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

OPPMMEDS

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

220

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "(s)" in "bottle(s), container(s), or bag(s)" in

parenthesis.

Display "[IF RESPONDENT HAS BOTTLE, ASK:]" in same blue font

used for interviewer instructions.

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:

10:57:34 AM Friday, March 06, 2009

Page 42 of 52

OP11A
TEXT:
Context Header:
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

OPPMMEDS

Field1:
Cheshire Name:

( OPQ1260 )

TEMP

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
OP12 - MEDICINE_OP ( OPQ1270 )

English text: CONTINUE
Attribute
Empty

Route
OP12 - MEDICINE_OP ( OPQ1270 )

BACKGROUND VARIABLE ASSIGNMENTS
The question displayed at OP11A is repeated in other utilization sections. Only show this

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

If OP11A - OPPMMEDS is asked, set flag as instructed below:

GETPMMEDS

10:57:36 AM Friday, March 06, 2009

Set GETPMMEDS = 1/Yes.


Page 43 of 52

OP11A
SOFT EDIT CHECKS

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

10:57:36 AM Friday, March 06, 2009

Page 44 of 52

OP12

OP12

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

MEDICINE_OP

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

230

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 Medicine events where:
EVNT.EVNTDFLG ^=1/Yes, 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:

10:57:37 AM Friday, March 06, 2009	

Page 45 of 52

OP12
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
MEDICINE_OP

Field1:

( OPQ1270 )

TEMP

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

Label Position:


String
TEvntPick135

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


1

No
No


Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:


135

Route
BOX OP3 - (OPQ1280 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of PM event selected at OP12.
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 OP12, 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.
10:57:38 AM Friday, March 06, 2009

Page 46 of 52

OP12
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 OP12 should be linked to the Outpatient Department
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 OP12, create an XMED where XMEDEVNT =
EVNT.EVNTNUM of Outpatient Department visit being asked about and XMEDEVT2 =
EVNT.EVNTNUM of Prescription Medicine selected at OP12. 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
OP12:
PMROEVNT

PMRO.PMROEVNT = EVNT.EVNTNUM of
prescription medicine selected at OP12.

PMRORND

PMRO.PMRORND = current round.

PMROTYPE

PMRO.PMROTYPE = PM.

XMEDEVNT

XMED.XMEDEVNT = EVNT.EVNTNUM of
Outpatient Department visit being asked about.

XMEDEVT2

XMED.XMEDEVT2 = EVNT.EVNTNUM of
prescription medicine selected at OP12.

XMEDRNDC

XMED.XMEDRNDC = current round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

10:57:38 AM Friday, March 06, 2009

Page 47 of 52

BOX OP3

BOX OP3

Page Order # :

240

BOX INSTRUCTIONS
( OPQ1280 )

GO TO OP4_IN - NAVIGATOR ( OPQ1135 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:57:38 AM Friday, March 06, 2009

Page 48 of 52

OP15

OP15

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

OPMORE

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

290

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 outpatient department at this
or any other hospital for services?

Int. Instr II:
INPUT FIELDS / ROUTING

10:57:39 AM Friday, March 06, 2009

Page 49 of 52

OP15
OPMORE

Field1:
Cheshire Name:

( OPQ1330 )

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
OP2 - PROVIDER_OP ( OPQ1030 )

English text: YES
No

BOX OP6 - (OPQ1340 )

English text: NO
Attribute
Don't know

Route
BOX OP6 - (OPQ1340 )

Refusal

BOX OP6 - (OPQ1340 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
End loop 1: OP15 - OPMORE probes for additional Outpatient Department

visits. OP visits can be fore a new provider or a provider already selected

and asked about. If OPMORE=1/Yes, go to OP2 to select the next provider.


10:57:42 AM Friday, March 06, 2009

Page 50 of 52

BOX OP6

BOX OP6

Page Order # :

300

BOX INSTRUCTIONS
( OPQ1340 )	

IF FALL ROUND AND ((SP REPORTED AN OUTPATIENT DEPARTMENT
VISIT AT OP4) AND (SP IS ALIVE AND NOT INSTITUTIONALIZED)), GO TO
AC9 - OPDREAS ( ACQ1190 ).
ELSE GO TO BOX OP7 - (OPQ1505 ).

ASSIGNMENTS

TECHNICAL NOTES
98

FallRound

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

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.

DESIGN NOTES
Call AC9 if OP event reported.
AC returns at BOX OP7.

10:57:42 AM Friday, March 06, 2009	

Page 51 of 52

BOX OP7

BOX OP7

Page Order # :

380

BOX INSTRUCTIONS
( OPQ1505 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

10:57:42 AM Friday, March 06, 2009

Page 52 of 52


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