Att 9_Medical Record Abstraction Data Elements

Attachment 9

MMP Medical Record Abstraction Data Elements

Medical Monitoring Project

0920-0740

MMP 2015 MEDICAL RECORD ABSTRACTION DATA ELEMENTS

DEMOGRAPHICS

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
absid_mra	Abstractor ID	Abstractor ID
facid_mra*	Facility ID: (Eight digits: Project Area + facility ID)	Facility ID
facloc_mra*	Facility Location	Facility Location
rwfund_mra	Does facility receive Ryan White funding	Ryan White Funded Facility
spstart_mra	Start of Observation	Surveillance period start date
spend_mra	End of Observation	Surveillance period end date
death_mra	Did the participant die during the 2 year observation period?	Patient died
dobmo_mra	Date of birth (Month)	Date of birth (Month)
dobyr_mra	Date of birth (Year)	Date of birth (Year)
gender_mra	Gender	Gender
racend_mra	Not documented	Race not documented
aian_mra	American Indian/Alaska Native	Race American Indian/Alaska Native
asian_mra	Asian	Race Asian
black_mra	Black/African American	Race Black/African American
nhpi_mra	Native Hawaiian/Other Pacific Islander	Race native Hawaiian/other Pacific Islander
white_mra	White	Race White
ethnic_mra	Hispanic/Latino ethnicity or Spanish origin:	Hispanic/Latino ethnicity or Spanish Origin
reimbnd_mra	Not documented	Insurance not documented
reimbadap_mra	AIDS Drug Assistance Program (ADAP)	Insurance ADAP
reimbmc_mra	Medicare	Insurance Medicare
reimbmd_mra	Medicaid	Insurance Medicaid
reimbrw_mra	Ryan White	Insurance Ryan White
reimbtri_mra	Tricare or Champus	Insurance Tricare or Champus
reimbva_mra	Veterans administration coverage	Insurance VA coverage
reimbpvt_mra	Private insurance	Private insurance
reimbsp_mra	None/self-pay	Insurance none/self-pay
reimbpub_mra	City, County, State or other publicly funded	Insurance city, county, state, publicly funded
reimboth_mra	Other insurance	Other insurance
reimbothde_mra	Other insurance description	Other insurance description
hivdateyn_mra	Is the date of first HIV diagnosis documented in the medical record?	Date of HIV diagnosis documented
firsthiv_mra	Date of first HIV diagnosis	Date of HIV diagnosis
_firsthiv_ind_mra		Date of HIV diagnosis indicator
cd4lowest_mra	Lowest CD4 count since HIV diagnosis	Lowest CD4 count
cd4lowestd_nd_mra	Date of lowest CD4 count not documented	Date of lowest CD4 count not documented
cd4lowestd_mra	Date of lowest CD4 count	Date of lowest CD4 count
_cd4lowestd_ind_mra		Date of lowest CD4 count indicator
cd4lowestsrc_mra	What is the source of the lowest CD4 count?	Source of lowest CD4 count
dthdatend_mra	Date of death not documented	Date of death not documented
dthdate_mra	Date of death	Date of death
_dthdate_ind_mra		Date of death indicator

ENCOUNTERS

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
vis_date_mra	Encounter date	Outpatient encounter date
visitloc_mra	Where did the encounter take place?	Place of medical encounter
visitprv_mra	With whom did the encounter take place?	Person with whom medical encounter occurred
hivprvyn_mra	Did the encounter take place with a known HIV provider?	Encounter with known HIV provider
oprvyn_mra	Did the encounter take place with a non-HIV provider?	Encounter with non-HIV provider
oprvtyp_mra	If yes, specify provider type	Non-HIV provider type
othprvothde_mra	Other provider description	Other non-HIV provider description
vital_mra	Were any vital signs documented during the encounter?	Vital signs documented during encounter
physf_mra	One or more physical exam findings documented during visit encounter	Physical exam documented during encounter
arvrx_mra	Antiretroviral therapy prescribed, refilled or continued during visit encounter	ARVs prescribed, refilled or continued during encounter
weightnd_mra	Weight not documented	Weight not documented
weight_mra	Weight	Weight
weightunit_mra	Weight units	Weight units
heightnd_mra	Height not documented	Height not documented
height_ft_mra	Height (feet)	Height (feet)
height_in_mra	Height (inches)	Height (inches)
bpnd_mra	Blood pressure not documented	Blood pressure not documented
bpsys_mra	Systolic blood pressure (mmHg)	Systolic blood pressure
bpdia_mra	Diastolic blood pressure (mmHg)	Diastolic blood pressure

HOSPITALIZATION

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
hospyn_mra	Was the patient hospitalized during the observation period?	Participant hospitalized
inpadmitnd_mra	Inpatient admission date not documented	Inpatient admission date not documented
inpadmit_mra	Inpatient admission date	Inpatient admission date
_inpadmit_ind_mra		Inpatient admission date indicator
inpdischnd_mra	Inpatient discharge date not documented	Inpatient discharge date not documented
inpdisch_mra	Inpatient discharge date	Inpatient discharge date
_inpdisch_ind_mra		Inpatient discharge date indicator
inpdiag_mra	Diagnosis	Discharge Diagnosis
inpdiagothde_mra	Diagnosis other description	Other discharge diagnosis description
_inpdiagrt_mra		Diagnosis root code
_inpnum_mra		Hospitalization number

DIAGNOSES

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
dxrefsoo_mra	Beginning of month 1 (start of observation period)	Beginning of month 1 (start of observation period)
dxref7mo_mra	Beginning of month 7	Beginning of month 7
dxref13mo_mra	Beginning of month 13	Beginning of month 13
dxref19mo_mra	Beginning of month 19	Beginning of month 19
dxrefeoo_mra	End of month 24 (end of observation period)	End of month 24 (end of observation period)
dx_mra	Diagnosis	Diagnosis
dxothde_mra	Other description	Diagnosis Other description
_dxrt_mra		Diagnosis root code
_coddx_mra	Diagnosis at death	From COD file
_diagdx_mra	Diagnosis from Diagnosis file	From Diagnosis file
dx6mobs_mra	Started or ongoing in first 6 months	Diagnosis first 6 months
dx12mobs_mra	Started or ongoing 7-12 months	Diagnosis 7-12 months
dx18mobs_mra	Started or ongoing 13-18 months	Diagnosis 13-18 months
dx24mobs_mra	Started or ongoing 19-24 months	Diagnosis 19-24 months
dthcodsrc_mra	Source of cause of death information	Source of cause of death info
codsrcothde_mra	Specify other source:	Other source of cause of death info

MEDICATIONS

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
txrefsoo_mra	Beginning of month 1 (start of observation period)	Beginning of month 1 (start of observation period)
txref7mo_mra	Beginning of month 7	Beginning of month 7
txref13mo_mra	Beginning of month 13	Beginning of month 13
txref19mo_mra	Beginning of month 19	Beginning of month 19
txrefeoo_mra	End of month 24 (end of observation period)	End of month 24 (end of observation period)
tx_mra	Medication	Medication
txothde_mra	Other medication description	Other medication description
_txrt_mra		Medication root code
txroute_mra	Medication route	Medication route
txrouteoth_mra	Other route description	Other medication route description
txfreq_mra	Frequency (for ARVs only)	ARV Frequency
txfreqothde_mra	Other ARV frequency description Other frequency (specify)	Other ARV frequency description
tx6mobs_mra	Started or ongoing in first 6 months	Medication first 6 months
tx12mobs_mra	Started or ongoing 7-12 months	Medication 7-12 months
tx18mobs_mra	Started or ongoing 13-18 months	Medication 13-18 months
tx24mobs_mra	Started or ongoing 19-24 months	Medication 19-24 months

PROPHYLAXIS

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
macrefsoo_mra	Beginning of month 1 (start of observation period)	MAC start of observation period
macref7mo_mra	Beginning of month 7	MAC beginning of month 7
macref13mo_mra	Beginning of month 13	MAC beginning of month 13
macref19mo_mra	Beginning of month 19	MAC beginning of month 19
macrefeoo_mra	End of month 24 (end of observation period)	MAC end of month 24
macpx_mra	MAC prophylaxis administered?	MAC prophylaxis administered?
macpxtx_mra	MAC medication	MAC medication
macpxtxothde_mra	Other description	MAC medication other description
mac6mobs_mra	Started or ongoing in first 6 months	MAC Started or ongoing in first 6 months
mac12mobs_mra	Started or ongoing 7-12 months	MAC Started or ongoing 7-12 months
mac18mobs_mra	Started or ongoing 13-18 months	MAC Started or ongoing 13-18 months
mac24mobs_mra	Started or ongoing 19-24 months	MAC Started or ongoing 19-24 months
pcprefsoo_mra	Beginning of month 1 (start of observation period)	PCP start of observation period
pcpref7mo_mra	Beginning of month 7	PCP beginning of month 7
pcpref13mo_mra	Beginning of month 13	PCP beginning of month 13
pcpref19mo_mra	Beginning of month 19	PCP beginning of month 19
pcprefeoo_mra	End of month 24 (end of observation period)	PCP end of month 24
pcppx_mra	PCP prophylaxis administered?	PCP prophylaxis administered?
pcppxtx_mra	PCP medication	PCP medication
pcppxtxothde_mra	Other description	PCP medication other description
pcp6mobs_mra	Started or ongoing in first 6 months	PCP Started or ongoing in first 6 months
pcp12mobs_mra	Started or ongoing 7-12 months	PCP Started or ongoing 7-12 months
pcp18mobs_mra	Started or ongoing 13-18 months	PCP Started or ongoing 13-18 months
pcp24mobs_mra	Started or ongoing 19-24 months	PCP Started or ongoing 19-24 months
flurefsoo_mra	Start of observation period	Flu start of observation period
flurefyr2_mra	Beginning of year 2	Flu beginning of year 2
flurefeoo_mra	End of observation period	Flu end of observation period
flupx_mra	Influenza vaccination administered?	Influenza vaccination administered?
fluyr1_mra	Administered during first year of obs period?	Flu vaccine administered year 1
fludate1_mra	If yes, what date was the influenza vaccine administered in year 1 of the observation period?	Flu vaccine date year 1
_fludate1_ind_mra		Flu vaccine date year 1 indicator
fluyr2_mra	Administered during second year of obs period?	Flu vaccine administered year 2
fludate2_mra	If yes, what date was the influenza vaccine administered in year 2 of the observation period?	Flu vaccine date year 2
_fludate2_ind_mra		Flu vaccine date year 2 indicator

PROCEDURE

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
procdate_mra	Date of procedure	Date of procedure
_procdate_ind_mra		Date of procedure indicator
proc_mra	Procedure	Procedure
procothde_mra	Specify details	Procedure other details

PREGNANCY

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
prg_mra	Pregnant during observation period?	Pregnant
prg_num_mra	Number of pregnancies during observation period	Number of pregnancies
prg_out_mra	Outcome of pregnancy:	Outcome of pregnancy:
prgdatend_mra	Date of pregnancy outcome not documented	Date of pregnancy outcome not documented
prgdate_mra	Date of pregnancy outcome	Date of pregnancy outcome
prgdate_ind_mra		Date of pregnancy outcome indicator
prg_meth_mra	Delivery method	Delivery method

LABS

Variable	Question	Label
PARID	Participant ID	Participant ID
_SITEID_mra		Site ID
hivlab_date_mra	Collection date	HIV lab date
cd4_result_mra	CD4 count result	CD4 result
cd4_unit_mra	CD4 count units	CD4 units
cd4_unoth_mra	Other description	CD4 other units
cd4pct_result_mra	CD4% result	CD4% Result
viral_load_sign_mra	Viral load sign	Viral load sign
viral_load_mra	Viral load result	Viral load result
viral_load_unit_mra	Viral load units	Viral load units
viral_load_unoth_mra	If other, specify	Viral load other units
viral_load_LL_mra	Lower limit of test	Viral load lower limit
viral_load_LL_oth_mra	If other, specify	Viral load other lower limit
viral_load_UL_mra	Upper limit of test	Viral load upper limit
viral_load_UL_oth_mra	If other, specify	Viral load other upper limit
cbc_date_mra	Collection date	CBC lab date
wbc_res_mra	Result	WBC result
wbc_unit_mra	Units	WBC units
wbc_unoth_mra	Description of other units	WBC other units
hgb_res_mra	Result	Hemoglobin result
hgb_unit_mra	Units	Hemoglobin units
hgb_unoth_mra	Description of other units	Hemoglobin other units
plt_res_mra	Result	Platelets result
plt_unit_mra	Units	Platelets units
plt_unoth_mra	Description of other units	Platelets other units
mvc_res_mra	Result (fL)	MCV result
neut_res_mra	Result	Neutrophils result
neut_unit_mra	Units	Neutrophils units
neut_unoth_mra	Description of other units	Neutrophils other units
chem_date_mra	Collection date	Chemistry lab date
fasting_lab_mra	Fasting lab?	Chemistry fasting
glu_res_mra	Result	Glucose result
glu_unit_mra	Units	Glucose units
glu_unoth_mra	Description of other units	Glucose other units
creat_res_mra	Result	Creatinine result
creat_unit_mra	Units	Creatinine units
creat_unoth_mra	Description of other units	Creatinine other units
calc_res_mra	Result	Calcium result
calc_unit_mra	Units	Calcium units
calc_uoth_mra	Description of other units	Calcium other units
alb_res_mra	Result	Albumin result
alb_unit_mra	Units	Albumin units
alb_unoth_mra	Description of other units	Albumin other units
ast_res_mra	Result	AST (SGOT) result
ast_unit_mra	Units	AST (SGOT) units
ast_unoth_mra	Description of other units	AST (SGOT) other units
alt_res_mra	Result	ALT (SGPT) result
alt_unit_mra	Units	ALT (SGPT) units
alt_unoth_mra	Description of other units	ALT (SGPT) other units
tbili_res_mra	Result	Total bilirubin result
tbili_unit_mra	Units	Total bilirubin units
tbili_unoth_mra	Description of other units	Total bilirubin other units
othchem_date_mra	Collection date	Other chemistry lab date
hgba1c_res_mra	Result (%)	Hemoglobin A1c result
vitd_res_mra	Result	Vitamin D result
vitd_unit_mra	Units	Vitamin D units
vitd_unoth_mra	Description of other units	Vitamin D other units
pth_res_mra	Result	Parathyroid Hormone result
pth_unit_mra	Units	Parathyroid Hormone units
pth_unoth_mra	Description of other units	Parathyroid Hormone other units
inr_res_mra	Result	International Normalized Ratio
tsh_res_mra	Result	Thyroid stimulating hormone result
tsh_unit_mra	Units	Thyroid stimulating hormone units
tsh_unoth_mra	Description of other units	Thyroid stimulating hormone other units
ttest_res_mra	Result	Total testosterone result
ttest_unit_mra	Units	Total testosterone units
ttest_unoth_mra	Description of other units	Total testosterone other units
lipid_date_mra	Collection date	Lipid lab date
lipid_fast_mra	Fasting lab?	Lipid fasting
chol_res_mra	Result	Cholesterol result
chol_unit_mra	Units	Cholesterol units
chol_unoth_mra	Description of other units	Cholesterol other units
hdl_res_mra	Result	HDL Cholesterol result
hdl_unit_mra	Units	HDL Cholesterol units
hdl_unoth_mra	Description of other units	HDL Cholesterol other units
ldl_res_mra	Result	LDL Cholesterol result
ldl_unit_mra	Units	LDL Cholesterol units
ldl_unoth_mra	Description of other units	LDL Cholesterol other units
trig_res_mra	Result	Triglycerides result
trig_unit_mra	Units	Triglycerides units
trig_unoth_mra	Description of other units	Triglycerides other units
sero_date_mra	Collection date	Serology lab date
toxoab_res_mra	Toxoplasma IgG antibody result	Toxoplasmosis IgG result
hcv_test_mra	Test type	Hepatitis C test
hcv_qlres_mra	Qualitative test result	Hepatitis C qualitative result
hcv_und_mra	Quantitative viral load undetectable	Hepatitis C Viral load undetectable
hcv_sign_mra	Quantitative viral load sign	Hepatitis C Viral load sign
hcv_qtres_mra	Quantitative viral load result:	Hepatitis C Viral load result
hcv_unit_mra	Quantitative viral load units	Hepatitis C Viral load units
hcv_unoth_mra	Description of other units	Hepatitis C Viral load other units
hcv_UL_mra	Quantitative viral load test upper limit	Hepatitis C Viral load upper limit
hcv_LL_mra	Quantitative viral load test lower limit	Hepatitis C Viral load lower limit
hbv_test_mra	Test type	Hepatitis B test
hbv_qlres_mra	Qualitative test result	Hepatitis B qualitative result
hbv_qtres_mra	Viral load (DNA) result	Hepatitis B viral load result
hbv_unit_mra	Viral load (DNA) units	Hepatitis B viral load units
hbv_unoth_mra	Description of other units	Hepatitis B viral load units other
hbv_UL_mra	Viral load (DNA) upper limit	Hepatitis B viral load upper limit
hbv_LL_mra	Viral load (DNA) lower limit	Hepatitis B viral load lower limit
sti_date_mra	Specimen collection date	STI lab date
gc_source_mra	Source of specimen	Gonorrhea source
gc_type_mra	Test type	Gonorrhea test type
gc_res_mra	Result	Gonorrhea result
ct_source_mra	Source of specimen	Chlamydia source
ct_type_mra	Test type	Chlamydia test type
ct_res_mra	Result	Chlamydia result
syph_source_mra	Source of specimen	Syphilis source
syph_type_mra	Test type	Syphilis test type
syph_res_mra	Result	Syphilis result
syph_titr_mra	Titer result: 1:X	Syphilis titer 1:X
trich_source_mra	Source of specimen	Trichomonas source
trich_type_mra	Test type	Trichomonas test type
trich_res_mra	Result	Trichomonas result
os_date_mra	Screening date	Mammogram or Pap screening date
_os_date_ind_mra		Screening date indicator
mammo_res_mra	Mammogram result	Mammogram result
pap_source_mra	PAP source	Pap smear source
pap_result_mra	PAP result	Pap smear result
pap_othde_mra	Specify other PAP result	Pap result other description
ppd_yn_mra	Was a PPD placed?	PPD placed
ppd_read_mra	Was the PPD read?	PPD read
ppd_date_mra	What date was the PPD read?	PPD reading date
ppd_datend_mra	Date not documented	PPD reading date not documented
ppd_res_mra	PPD result	PPD result
igra_date_mra	Specimen collection date	IGRA lab date
igra_type_mra	IGRA test type	IGRA test type
igra_res_mra	IGRA result	IGRA result
urine_date_mra	Collection date	Urine lab date
urine_test_mra	Urine test type	Urine test type
urine_qt_res_mra	Urine test result	Urine quantitative result
urine_unit_mra	Urine test units	Urine units
uruint_othde_mra	Description of other units	Urine other units
uprotqual_mra	Urine protein result (non-numeric)	Urine protein (qual) result
uproql_othres_mra	Description of other result	Urine protein (qual) other result
hct_res_mra^	Result (%)	Hematocrit result
lymph_res_mra^	Result	Lymphocytes result
monos_res_mra^	Result	Monocytes result
eos_res_mra^	Result	Eosinophils result
baso_res_mra^	Result	Basophils result

RESISTANCE

Variable	Question	Label
PARID	Participant ID
_SITEID_mra		Site ID
geno_mra	Genotype or virtual phenotype performed?	Is genotype or virtual phenotype performed?
geno_rpt_mra	Is a genotype or virtual phenotype lab report available in the medical record?	Is genotype or virtual phenotype report available?
geno_vpheno_mra	Were the results obtained from a genotype or virtual phenotype?	Genotype or virtual phenotype
geno_adq_mra	Genotype Specimen adequate?	Genotype specimen adequate
geno_date_mra	Genotype collection date	Genotype collection date
geno_nrti_mra	NRTI mutations detected	NRTI mutations detected
geno_nnrti_mra	NNRTI mutations detected	NNRTI mutations detected
geno_pi_mra	PI mutations detected	PI mutations detected
geno_in_mra	Integrase mutations detected	Integrase mutations detected
geno_en_mra	GP41 Envelope mutations detected	GP41 envelope mutations detected
_geno_mut_mra	Genotype mutations	Genotype mutation
_geno_mutsrc_mra		Genotype mutation source
pheno_date_mra	Phenotype collection date	Phenotype collection date
pheno_mra	Was a standard phenotype performed (not a virtual phenotype)?	Phenotype performed
trofyn_mra	Tropism assay performed	Tropism performed
trofrpt_mra	Is Tropism assay lab report available in medical record for entry?	Tropism report available
trof_date_mra	Tropism assay collection date	Tropism collection date
trof_rslt_mra	Result	Tropism result