PCNASP Post-Hospital Transition of Care Data Elements

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Post-Hospital Transition of Care Data Elements

Public reporting of this collection of information is estimated to average 30 minutes/hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

1	Hospital Discharge Date	<DschDate>	Patient's date of hospital discharge	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
2	Date of follow-up	<FUDate>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY
3	Follow-up Method	<FUType>		Numeric # = 1-digit	1 = Phone; 2 = In home; 3 = Other
4	Informant	<Informnt>	Who provided responses to this follow-up?	Numeric # = 1-digit	1 = Patient; 2 = Familiy Member; 3 = Other Lay Caregiver; 4 = Home Health Aide; 5 = Other;
5	Post-Discharge Appointment	<DApptYN>	Was appointment made prior to discharge?	Numeric # = 1-digit	1 = Yes; 0 = No
		<DAppKept>	If yes, was appointment kept or pending?	Numeric # = 1-digit	1 = Kept; 2 = Pending;
		<DAppPend>	If no, has an appointment been scheduled since discharge?	Numeric # = 1-digit	1 = Yes; 0 = No
		<DAppType>	Who did patient see or will see?	Numeric # = 1-digit	1 = Neurologist; 2 = Primary Care Physician; 3 = Other;
6	Patient Location	<CurrLoc>	Where is the patient at the time of follow-up?	Numeric # = 1-digit	1 = Home; 2 = Nursing home or long-term care; 3 = Rehabilitation Hospital; 4 = Acute Care Hospital; 5 = Died
7	ED Visits	<EDYN>	Has patient been seen in ED since discharge?	Numeric # = 1-digit	1 = Yes; 0 = No; 2 = Not sure
		<EDNum>	How many ED visits since discharge?	Numeric # = 1-digit	1 = 1; 2 = 2; 3 = 3 or more; 4 = unknown or not sure
		<EDDate>	If yes, Date of first ED visit	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<EDReasn>	If yes, Reason for first ED visit	_________________	Text. 75 characters
		<EDDispn>	Was patient admitted to hospital or discharge to home?	Numeric # = 1-digit	1 = Discharged to home; 0 = Admitted to hospital
8	Readmissions	< ReAd>	Has patient been readmitted to a hospital since discharge?	Numeric # = 1-digit	1 = Yes; 0 = No; 2 = Not sure	This is a readmission to an acute care hospital. It could be the same hospital or another acute care hospital
		<ReAdNum>	How many readmissions since discharge?	Numeric # = 1-digit	1 = 1; 2 = 2; 3 = 3 or more; 4 = unknown or not sure
		<ReAdDate.	If yes, date of first readmission	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<ReAdWhy>	If yes, reason for first readmission	_________________	Text. 75 characters
		<ReAd30D>	Readmitted within 30 days of discharge?	Numeric # = 1-digit	1 = Yes; 0 = No; 2 = Not sure
9	Complications	<DCFalls>>	Falls	Numeric # = 1-digit	1 = Yes; 0 = No	Default = 0
		<MedPrblm>	Medication problem
		<DCPneum>>	Pneumonia
		<DCUTI>	Urinary tract infection
		<DCVTE>	Venous thromboembolic event
10	Death	<DthDate>	If patient died, date of death	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<DthCause>	If patient died, cause of death	Numeric # = 1-digit	1 = cerebrovascular; 2 = cardiovascular; 3 = other; 4 = unknown
		<Dth30Day>	Died within 30 days of discharge?	Numeric # = 1-digit	1 = Yes; 0 = No
11	Tobacco	<CurrTobac>	If patient was a smoker before stroke, have they smoked tobacco since discharge?	Numeric # = 1-digit	1 = Yes; 0 = No
		<SmkMeds>	If patient was a smoker before stroke, are they using any medications to help stop smoking?	Numeric # = 1-digit	1 = Yes; 0 = No
12	Blood Pressure	<BPMonitr>	Has patient been monitoring their blood pressure at home?	Numeric # = 1-digit	1 = Yes; 0 = No
		<BPSys>	If yes, most recent systolic blood pressure	Numeric # = 3-digit		mm Hg; Suggested range 50-250
		<BPDia>	If yes, most recent diastolic blood pressure	Numeric # = 3-digit		mm Hg; Suggested range 30-150
		<BPReport>	Have they reported their blood pressure to their health care provider since discharge?	Numeric # = 1-digit	1 = Yes; 0 = No
		<BPUsual>	Is this blood pressure usual for you?	Numeric # = 1-digit	1 = Yes; 0 = No
13	Medications Prescribed at Discharge	<DCBPMed>	Antihypertensive	Numeric # = 1-digit	1 = Yes; 0 = No
		<DCStatn>	Statin
		<DCDiab>	Antidiabetic agent
		<DCAsprn>	Aspirin or other antiplatelet
		<DCACoag>	Anticoagulant
14	Medications Currently Taking	<BPMedNow>	Antihypertensive	Numeric # = 1-digit	1 = Yes; 0 = No
		<StatnNow>	Statin
		<DiabNow>	Antidiabetic agent
		<AsprnNow>	Aspirin or other antiplatelet
		<ACoagNow>	Anticoagulant
		<StopMeds>	Have you stopped any medications since you were discharged?	Numeric # = 1-digit	1 = Yes; 0 = No
			If yes, which meds?
		<StopBP>	Antihypertensive	Numeric # = 1-digit	0= No; 1 = Yes - side effects; 2 = Yes - cost; 3 = Yes - no transportation; 4 = Yes - Dr. told them to stop; 5 = Yes - forget to take them; 6 =Yes - Other
		<StopStn>	Statin	Numeric # = 1-digit
		<StopDiab>	Antidiabetic agent	Numeric # = 1-digit
		<StopASA>	Aspirin or other antiplatelet	Numeric # = 1-digit
		<StopCoag>	Anticoagulant	Numeric # = 1-digit
15	Rehabilitation	<Rehab>	Is patient receiving rehabilitation	Numeric # = 1-digit	1 = Outpatient; 2 = In the home; 3 = Inpatient; 4 = Was at discharge but stopped; 0 = No
16	Symptoms	<mRS30Day>	What is the level of the patient's disability? This is the 30-day modified Rankin Scale score	Numeric # = 1-digit	0 = No symptoms; 1 = Some symptoms but able to carry out all usual duties and activities; 2 = Some disability, unable to carry out all previous activities, but able to look after own affairs without assistance; 3 = Moderate disability; requiring some help, but able to walk without assistance; 4 = Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance; 5 = Severe disability; bedridden, incontinent, and requiring constant nursing care and attention.