MEPS-HC Core Interview

MEPS FAMES P12R5/P13R3/P14R1 Dental Care (DN) Section

December 8, 2008

Dental Care (DN) Section

DN01

====

OMITTED.

DN02

====

OMITTED.

DN03

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{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER......} {EVN-DT}

What type of dental care provider did (PERSON) see during this

visit?

PROBE: Any other type of dental care person?

CHECK ALL THAT APPLY.

GENERAL DENTIST ........................ 1 {DN04}

DENTAL HYGIENIST ....................... 2 {DN04}

DENTAL TECHNICIAN ...................... 3 {DN04}

DENTAL SURGEON ......................... 4 {DN04}

ORTHODONTIST ........................... 5 {DN04}

ENDODONTIST ............................ 6 {DN04}

PERIODONTIST ........................... 7 {DN04}

OTHER ................................. 91 {DN04}

REF ................................... -7 {DN04}

DK .................................... -8 {DN04}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

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| FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES |

| AUTOMATICALLY): CAPI DOES NOT ALLOW -7 OR -8 IN |

| COMBINATION WITH ANY OTHER CODE. |

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DN04

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER......} {EVN-DT}

SHOW CARD DN-1.

What did (PERSON) have done during this visit?

PROBE: What else was done?

CHECK ALL THAT APPLY.

*DIAGNOSTIC OR PREVENTATIVE

GENERAL EXAM, CHECKUP OR CONSULTATION .. 1

CLEANING, PROPHYLAXIS, OR POLISHING .... 2

X-RAYS, RADIOGRAPHS, OR BITEWINGS ...... 3

FLUORIDE TREATMENT ..................... 4

SEALANT (PLASTIC COATINGS ON BACK

TEETH) ................................. 5

*RESTORATIVE OR ENDODONTIC

FILLINGS ............................... 6

INLAYS ................................. 7

CROWNS OR CAPS ......................... 8

ROOT CANAL ............................. 9

*PERIODONTIC (GUM TREATMENT)

PERIODONTAL SCALING, ROOT PLANING, OR

GUM SURGERY ............................ 10

PERIODONTAL RECALL VISIT (PERIODIC OR

REGULAR) ............................... 11

*ORAL SURGERY

EXTRACTION, TOOTH PULLED ............... 12

IMPLANTS ............................... 13

ABSCESS OR INFECTION TREATMENT ......... 14

OTHER ORAL SURGERY ..................... 15

*PROSTHETICS

FIXED BRIDGES .......................... 16

DENTURES OR REMOVABLE PARTIAL DENTURES . 17

RELINING OR REPAIR OF BRIDGES OR

DENTURES ............................... 18

*ORTHODONTICS

ORTHODONTIA, BRACES, OR RETAINERS ...... 19

*ADDITIONAL PROCEDURES

BOND, WHITEN, OR BLEACH ................ 20

TREATMENT FOR TMD OR TMJ ............... 21

OTHER .................................. 91 {DN04OV}

REF .................................... -7

DK ..................................... -8

[Code All That Apply]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

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| HEADINGS AND CODE CATEGORIES WILL NOT FIT ON ONE |

| SCREEN. THEREFORE, HEADINGS WILL ONLY APPEAR ON |

| HELP SCREEN AND SHOW CARD DN-1. HEADINGS SHOULD |

| BE ASSOCIATED WITH CODES AS FOLLOWS: |

| *DIAGNOSTIC OR PREVENTATIVE = CODES 1-5 |

| *RESTORATIVE OR ENDODONTIC = CODES 6-9 |

| *PERIODONTIC (GUM TREATMENT) = CODES 10-11 |

| *ORAL SURGERY = CODES 12-15 |

| *PROSTHETICS = CODES 16-18 |

| *ORTHODONTICS = CODE 19 |

| *ADDITIONAL PROCEDURES = CODES 20-21 AND 91 |

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----------------------------------------------------

| FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES |

| AUTOMATICALLY): CAPI DOES NOT ALLOW -7 OR -8 IN |

| COMBINATION WITH ANY OTHER CODE. |

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| IF CODE ‘91’ (OTHER) ENTERED ALONE OR IN |

| COMBINATION WITH ANY OTHER CODE, CONTINUE WITH |

| DN04OV |

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| OTHERWISE, GO TO DN05 |

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DN04OV

======

OTHER TYPE OF DENTAL CARE:

[Enter Other Specify].................. {DN05}

REF ................................... -7 {DN05}

DK .................................... -8 {DN05}

DN05

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER......} {EVN-DT}

During this visit, were any medicines prescribed for

(PERSON)? Please include only prescriptions which were

filled.

YES .................................... 1 {DN06}

NO ..................................... 2 {BOX_01}

REF ................................... -7 {BOX_01}

DK .................................... -8 {BOX_01}

HELP AVAILABLE FOR DEFINITION OF PRESCRIBED MEDICINE.

DN06

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER......} {EVN-DT}

Please tell me the names of the prescriptions from this

visit that were filled.

PROBE: Any other prescriptions from this visit filled?

[1. Prescribed Medicine]

[2. Prescribed Medicine]

[3. Prescribed Medicine]

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| ROSTER DETAILS: |

| TITLE: PERSON'S-PRESCRIBED-MEDICINES_1. |

| |

| COL # 1 HEADER: PRESCRIBED MEDICINE |

| INSTRUCTIONS: DISPLAY PMED NAME (PMED.PMEDNAME) |

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| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS PERSON'S-PRESCRIBED-MEDICINES- |

| ROSTER FOR SELECTION AND ADDITION OF PRESCRIBED |

| MEDICINES. |

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| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT AND ADD ALLOWED. |

| |

| 2. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE |

| A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS |

| NOT YET CREATED THE LINK BETWEEN THIS PMED AND THE|

| EVENT. |

| |

| 3. EDIT DISALLOWED. |

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| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

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BOX_01

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| IF THE CHARGE/PAYMENT MODULE HAS NOT BEEN ASKED |

| FOR THE EVENT-PROVIDER PAIR BEING ASKED ABOUT, GO |

| TO THE CHARGE/PAYMENT (CP) SECTION. |

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| OTHERWISE, GO TO THE EVENT DRIVER (ED) SECTION. |

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