3 Primary Care Data Extraction Template

Attachment C: Data Extraction Template

Providing Primary Care and Preventive Medical Services in Ryan White-funded Medical Care Settings: Data Extraction Template

OMB No. 0906-XXXX
Expiration date: XX/XX/201X

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0906- XXXX.  Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

Instructions

Thank you for providing information on the provision of primary and preventative care in your clinic and healthcare system. This information is essential in helping the HIV/AIDS Bureau (HAB) understand the extent to which Ryan White-funded providers are rendering primary and preventative care services to HIV-infected individuals.

We would like to know whether a small subset of your clients received certain primary and preventative care services in a given time period. This process requires you to look up a client's medical record and answer a series of questions about each service. Please complete this form through the following steps:

1. Identify your clinic's HIV-infected clients who received any medical service within 2014

2. Sort those clients by alphabetical order, based on last name

3. Pull up the medical record of every 100th client. In total, you will pull the records of approximately 10 clients.

4. For each client, answer the following questions:

   1. Gender

• Male

• Female

• Transgender

1. Age: __________

2. Race

• White

• Black or African American

• Asian

• Native American/Pacific Islander

• American Indian or Alaskan Native

• Multiple

• Other

• Unknown

1. Ethnicity

• Hispanic/Latino

• Non-Hispanic/Latino

1. Health insurance status

• Private

• Medicare

• Medicaid, CHIP, or other public

• VA Tricare

• HIS

• No insurance

• Multiple

• Other

• Unknown

1. Number of medical visits with the program: ________

1. Through the information provided in the medical record, answer the following questions about each client/service combination (see Table 1 below for the list of services):

   1. What was the date of the latest service?

   2. If referred for care outside of the healthcare system, were screening results provided back to the clinic?

• Not applicable; client received care within our healthcare system

• Not applicable; service not medically indicated based on client's age and gender

• Not applicable; service not medically indicated based on client's risk

• Not applicable; service not medically indicated because client is already seeking treatment for condition

• Not applicable; client did not receive the service for reasons other than stated above

• Yes

• No

• Not sure

3. Was follow up care provided?

• Yes, in our immediate clinic

• Yes, in a separate clinic within the healthcare system

• Yes, referred to a clinic outside the healthcare system

• Not medically indicated; client did not receive the service or test positive for the condition

• No

• Other

• Not sure

Table 1: Questions per Primary and Preventative Care Service

Concept		Recommendations	Please indicate the date of the latest service	If referred for care outside of the healthcare system, were screening results provided back to the clinic?	Was follow up care provided?
1	Breast Cancer Screening (Mammogram)	Every two years; women 50 and older
2	Cervical Cancer Screening	Annual; women 18 and older
3	Diabetes Screening	Annual; adults 18 and older
4	Cholesterol Screening	Annual; adults 18 and older
5	Colorectal Screening (one of the following)
	-- Fecal Occult Blood Test	Annual; adults 50 and older
	-- Sigmoidoscopy	Every 5 years; adults 50 and older
	-- Colonoscopy	Every 10 years; adults 50 and older
6	Smoking Cessation Counseling	Annual; adults 18 and older
7	Behavioral Counseling to Promote a Healthy Diet	Annual; adults 18 and older
8	Depression and Mental Health Screening	Annual; adults 18 and older
9	Alcohol and Substance Use Assessment	Annual; adults 18 and older
10	Hypertension Screening	Annual; adults 18 and older
11	Hepatitis C Screening	Annual; at risk adults 18 and older
12	Syphilis Screening	Annual; adults 18 and older
13	Gonorrhea Screening	Annual; adults 18 and older

3