Cms-p-0015a Mcbs

Medicare Current Beneficiary Survey

Section Specifications for HSF

Round 69

HEALTH STATUS (FACILITY)

Created on 5/9/2014 6:10:55 PM

BOX HSBEG

Box Instructions

IF HSDISP = 1/ConsentRequired OR HSDISP = 4/InitialRefusal, GO TO HSCONREF - CONREFFN.

ELSE GO TO HSPRE - HSPRECT.

HSCONREF Code 1

Question Text

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS
FOR THIS SECTION.

Field 1: CONREFFN

Field 1 Routing

Value	Label	Route
1	CONSENT OBTAINED (CONTINUE INTERVIEW)	HSPRE - HSPRECT
2	FINAL CONSENT DENIED	HSFINSCR2 - FINSCRN2
3	REFUSAL CONVERTED (CONTINUE INTERVIEW)	HSPRE - HSPRECT
4	FINAL REFUSAL	HSFINSCR2 - FINSCRN2

HSPRE Code 1

Question Text

THIS SCREEN BEGINS THE HEALTH STATUS SECTION FOR (SP).

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

Field 1: HSPRECT

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA1
2	CONSENT REQUIRED	HSFINSCR2 - FINSCRN2
3	INITIAL REFUSAL	HSFINSCR2 - FINSCRN2

BOX HA1

Box Instructions

IF ONLY TIME 2, GO TO BOX HAT2BEG.

ELSE IF FACR.HAINTFLG <> 1/Indicated , GO TO HA1PRE1 - HA1PRE1C.

ELSE GO TO HA1PRE2 - HA1PRE2C.

HA1PRE1 Code 1

Question Text

The next questions are about (SP)'s health status on or around (HS REF DATE). We have found that much of the data we are collecting is usually located in the resident's full Minimum Data Set (MDS) assessments, the Quarterly Review forms, and other medical chart notes. Please take a moment to locate the records now and confirm they are the records closest to (HS REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA1PRE1C

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA1PRE2 - HA1PRE2C

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HAINTFLG	FACR.HAINTFLG = 1/Indicated.

HA1PRE2 Code 1

Question Text

The following questions are about (SP)'s health status on or around (HS REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA1PRE2C

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA2

Other Programming Instructions

Report Display

Display report above question text.
Display all stays where STAY.XSTPLAC <> 000 that were reported for this SP in
chronological order by start date of the stay.
Report header: STAY TIMELINE
Report layout:
Column 1, header="Place Name", display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM = STAY.XSTPLAC.
Column 2, header="Start Date", display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month, day
year format.
Column 3, header="End Date", display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month, day
year format.
Column 4, header="Stay Type", display STAY.STAYCLAS.

BOX HA2

Box Instructions

IF BASELINE INTERVIEW OR (CORE AND NO MDS AT PREVIOUS HS) GO TO HA1 - RECHAVE.

ELSE IF CORE AND SP HAD A MDS AT LAST HS APPLICATION ADMINISTERED FOR THIS SP, GO TO HA2 - RECFORMS.

Variable Name	Assignment Instructions
HSMCDFLG	If HSMCDFLG = EMPTY, then HSMCDFLG = 0/NotIndicated

HA1 Yes/No

Question Text

Do you have (SP)'s medical records for the (admission) period on or around (HS REF DATE)?

Field 1: RECHAVE

Field 1 Routing

Value	Label	Route
0	NO	HA1B - HSCONTN1
1	YES	BOX HA2A
	Don't Know	HA1B - HSCONTN1
	Refused	HA9PREB - HA9PRBC

HA1B Code 1

Question Text

Is there someone else I should speak with, or do the records exist elsewhere?

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE MEDICAL RECORDS?

Field 1: HSCONTN1

Field 1 Routing

Value	Label	Route
0	NO, RETURN TO NAVIGATE SCREEN	BOX HCEND
1	YES, CONTINUE WITHOUT MEDICAL RECORDS	HA9PREB - HA9PRBC

BOX HA2A

Box Instructions

GO TO HA2 - RECFORMS.

HA2 Yes/No

Question Text

[The last MDS form we collected was dated (LAST MDS DATE).]

Do (SP)'s medical records contain (a full./another) MDS assessment (or Quarterly Review) form dated [on or around [HSREFDATE)/after (LAST MDS DATE)].

[A MDS for on or around (HS REF DATE) is preferable.]

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: RECFORMS

Field 1 Routing

Value	Label	Route
0	NO	HA2B1 - HSCONTN2
1	YES	BOX HA3

HA2B1 Code 1

Question Text

Is there someone else I should speak with, or do the records exist elsewhere?

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS FORMS?

Field 1: HSCONTN2

Field 1 Routing

Value	Label	Route
0	NO, RETURN TO NAVIGATE SCREEN	BOX HCEND
1	YES, CONTINUE WITHOUT MDS	HA9PREB - HA9PRBC

BOX HA3

Box Instructions

GO TO HA3A - ASSESDT1.

Other Programming Instructions

Background Variable Assignments

CFRBEG:
If PreloadSP.LASTVAD <> EMPTY then CFRBEG = PreloadSP.LASTVAD + 1 day.
Else if PreloadSP.LASTHTYP = B and year portion of RAD + 15 days >= (PreloadSP.BEGCY - 1 year) then CFRBEG = RAD + 15.
Else if PreloadSP.LASTHTYP = T or C and year portion of RAD + 120 days = MAXYR then CFRBEG = RAD + 120.
Else if SP is CFR then CFRBEG = 5/1/MAXYR.

Variable Name	Assignment Instructions
MAXYR	If current round = 63, 64 then MAXYR= 12. Else if current round = 65-67 then MAXYR = 13. Else if current round = 68-70 then MAXYR = 14. Else if current round = 71-73 then MAXYR = 15. Else if current round = 74-76 then MAXYR = 16, etc.
MAXEND	If (SP is SSM or SP is CFR) and RHREFEND > 12/31/MAXYR then MAXEND = 12/31/MAXYR. Else MAXEND = RHREFEND.
HSBEG	If SP is SSM2 or SP is CFC or SP is FFC or SP is FCF then HSBEG = RAD - 7 days. Else if SP is SSM1 then HSBEG = 5/1/MAXYR. Else if SP is CFR then HSBEG = CFRBEG.
HSEND	If (SP is SSM2 or SP is CFC or SP if FFC or SP is FCF) and RAD + 14 days < MAXEND then HSEND = RAD + 14 days. Else HSEND = MAXEND.
HSTOT	HSTOT = 0

HA3A Date

Question Text

[What is the assessment date on the full MDS assessment that was completed for (SP) on or around (HS REF DATE)/What is the assessment date on the full MDS assessment that was completed for (SP) at admission, that is, on or around (HS REF DATE)/What is the assessment date on the full MDS assessment or Quarterly Review that was completed for (SP) closest to (HS REF DATE) after (HA3A DISPLAY DATE/LAST HS REF DATE)/What is the assessment date on that form]?

ENTER DATE IN "MM DD YY" FORMAT.

(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)

Field 1: ASSESDT1

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA4
	Don't Know	BOX HA4
	Refused	BOX HA4

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HSTOT	HSTOT = HSTOT + 1
FORMNUM	HSFORM[HSTOT].FORMNUM = HSTOT
FORMRNDC	HSFORM[HSTOT].FORMRNDC = current round
HA3AFLG	HA3AFLG = 1/Indicated.

Design Notes

Abbreviations:
BCVAD = Baseline Closest Valid Assessment Date
BL = Baseline
CCVAD = Core Closest Valid Assessment Date
DOI = Date of Interview
DOB = Date of Birth
FAD = First Admission Date
HS = Health Status
RAD = Recent Admission Date
TCVAD = Time 2 Closest Valid Assessment Date
DOD = Date of Death

HA3A - ASSESDT1, FORMTYPE, FORMNUM, FORMRNDC, HSVALID AND HA7B - ASSESDT2 should be stored in HSFORM[15] array. Each pass through HA3A-ASSESDT1 or HA7B-ASSESDT2 should fill an element of the array.

BOX HA4

Box Instructions

IF HA3A - ASSESDT1 = DK, RF AND FIRST TIME AT HA3A - ASSESDT1, GO TO HA9PREB - HA9PRBC.

ELSE, GO TO BOX HA5.

Variable Name	Assignment Instructions
LASTASSESSDATE	LASTASSESSDATE = HA3A - ASSESDT1
HSVALID	If HA3A - ASSESDT1 <> DK, RF and HA3A - ASSESDT1 >= HSBEG and HA3A - ASSESDT1 <= HSEND, then HSFORM[HSTOT].HSVALID = 1/Indicated. Else HSFORM[HSTOT].HSVALID = EMPTY.

BOX HA5

Box Instructions

IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3A - ASSESDT1 IS VALID, SET A FLAG AND GO TO BOX HA6.

ELSE GO TO HA5 - CLOSFORM.

BOX HA6

Box Instructions

OBTAIN STATE NAME FROM FACILITY'S ADDRESS. IF STATE NAME IS MS OR SD, GO TO BOX HA7.

ELSE, GO TO HA4 - FORMTYPE1.

Variable Name	Assignment Instructions
EVERFULL	If State Name is MS or SD, EVERFULL = 1/Indicated.
FORMTYPE	If State Name is MS or SD, HSFORM[HSTOT].FORMTYPE = 1/FullMDS

HA4 Code 1

Question Text

Please tell me if the form with the assessment date of (LAST ASSESSMENT DATE) is a full MDS or a quarterly review.

Field 1: FORMTYPE1

Field 1 Routing

Value	Label	Route
0	QUARTERLY REVIEW	BOX HA7
1	FULL MDS	BOX HA7
	Don't Know	BOX HA7
	Refused	BOX HA7

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
EVERFULL	If HA4 - FORMTYPE1 = 1/FullMDS, then EVERFULL = 1/Indicated.
FORMTYPE	HSFORM[HSTOT].FORMTYPE = HA4 - FORMTYPE1.

BOX HA7

Box Instructions

IF MOST RECENT ASSESSMENT DATE IS COMPLETE THEN COMPARE WITH HS REF DATE. IF NUMBER OF DAYS BETWEEN ASSESSMENT DATE AND HS REF DATE MORE THAN +/- 7, OR IF HA3A - ASSESDT1 IS DK OR RF, GO TO HA5 - CLOSFORM.

ELSE, GO TO BOX HA9AA.

HA5 Yes/No

Question Text

Besides the form you just told me about, does (SP)'s medical record contain any other (full) MDS form (or Quarterly Review form) dated closer to (HS REF DATE)?

Field 1: CLOSFORM

Field 1 Routing

Value	Label	Route
0	NO	BOX HA8
1	YES	BOX HA8
	Don't Know	BOX HA8
	Refused	BOX HA8

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
LASTASSESSDATE	LASTASSESSDATE = HA3A - ASSESDT1

BOX HA8

Box Instructions

IF HA5 - CLOSFORM = 1/Yes, GO TO HA3A - ASSESDT1.

ELSE, GO TO BOX HA9AA.

BOX HA9AA

Box Instructions

IF HSTOT = 1 AND FORMTYPE = DK, RF, OR EMPTY, GO TO HA9PREB - HA9PRBC.

ELSE GO TO BOX HA9BB.

Variable Name	Assignment Instructions
HSSORTARRY	If HSTOT > 1, then HSSORTARRAY = HSFORM array sorted by dates closest to HS REF DATE (+ or - days).
CLOSESTFULL	If HSTOT > 1 and EVERFULL = 1/Indicated, then CLOSESTFULL = FORMNUM of the first element of HSSORTARRAY where FORMTYPE = 1/FullMDS. Else CLOSESTFULL = EMPTY.

BOX HA9BB

Box Instructions

GO TO BOX HA9CC.

Variable Name	Assignment Instructions
CCVAD	If PERS.HSCREF <> EMPTY then PERS.CCVAD = HA3A - ASSESDT1 of HSSORTARRAY[1].
BCVAD	If PERS.HS1REF <> EMPTY then PERS.BCVAD = HA3A - ASSESDT1 of HSSORTARRAY[1].
CVATYPE	If HSSORTARRAY[1].FORMTYPE = 1/FullMDS, DK or RF then CVATYPE = 1/FullMDS. Else CVATYPE = 0/QuarterlyReview.
XPRIMARY	XPRIMARY = FORMNUM of HSSORTARRAY[1].
XBACKUP	If CVATYPE = 0/QuarterlyReview and CLOSESTFULL <> EMPTY then XBACKUP = CLOSESTFULL.
XBACKUPDATE	If XBACKUP <> EMPTY then XBACKUPDATE = HA3A - ASSESDT1 of FORMNUM = XBACKUP

BOX HA9CC

Box Instructions

IF CVATYPE = 1/FulllMDS, GO TO HA6 - FORMREAS.

ELSE IF CVATYPE = 0/QuarterlyReview AND XBACKUP = EMPTY, GO TO HA7A - RECMDS.

ELSE GO TO HA7C - MDSINT1.

Other Programming Instructions

Background Variable Assignments

HSEDATE:
If SP is SSM:
Then if RHREFEND < 1/14/BEGCY, HSEDATE = REFEND.
Else HSEDATE = 1/14/BEGCY.
Else if SP is CFC:
Then if RHREFEND < RAD + 30 days, HSEDATE = RHREFEND.
Else HSEDATE = RAD + 30 days.
Else if SP is FFC or SP is FCF:
Then if RHREFEND < RAD + 14 days, then HSEDATE = RHREFEND.
Else HSEDATE = RAD + 14 days.
Else if SP is CFR then HSEDATE = MAXEND.

Variable Name	Assignment Instructions
HSBDATE	If SP is SSM1 then HSBDATE = 1/1/MAXYR. Else if SP is SSM2 or SP is CFC then HSBDATE = RAD - 30 days. Else if SP is FCF or SP is FFC then HSBDATE = RAD. Else HSBDATE = CFRBEG.
HSBDATE2	If SP is SSM1 then HSBDATE2 = 1/1/MAXYR. Else if SP is SSM2 or SP is CFC then HSBDATE2 = RAD - 30 days. Else if SP is FFC or FCF then HSBDATE2 = RAD. Else HSBDATE2 = CRFBEG.

HA6 Code 1

Question Text

What was the primary reason for the assessment on the full MDS assessment dated (BCVAD/CCVAD)?

Field 1: FORMREAS

Field 1 Routing

Value	Label	Route
1	ADMISSION	HA7C - MDSINT1
2	ANNUAL	HA7C - MDSINT1
3	SIGNIFICANT CHANGE IN STATUS	HA7C - MDSINT1
91	OTHER	HA6 - FORMREOS
	Don't Know	HA7C - MDSINT1
	Refused	HA7C - MDSINT1

Field 2: FORMREOS

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	HA7C - MDSINT1

HA7A Yes/No

Question Text

Does (SP)'s medical record contain a full MDS assessment dated between (HS DATE RANGE)?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: RECMDS

Field 1 Routing

Value	Label	Route
0	NO	HA7C - MDSINT1
1	YES	HA7B - ASSESDT2
	Don't Know	HA7C - MDSINT1
	Refused	HA7C - MDSINT1

HA7B Date

Question Text

What is the date of the full MDS assessment closest to (HS REF DATE)?

IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.

Field 1: ASSESDT2

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA10
	Don't Know	BOX HA10
	Refused	BOX HA10

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HSTOT	HSTOT = HSTOT+1
FORMRNDC	HSFORM[HSTOT].FORMRNDC = current round
FORMNUM	HSFORM[HSTOT].FORMNUM = HSTOT
HSVALID	If HA7B - ASSESDT2 <> DK, RF and HA7B - ASSESDT2 >= HSBDATE2 and HA7B - ASSESDT2 <= HSEDATE, then HSFORM[HSTOT].HSVALID = 1/Indicated. Else HSFORM[HSTOT].HSVALID = EMPTY.

BOX HA10

Box Instructions

GO TO HA7C - MDSINT1.

Variable Name	Assignment Instructions
XBACKUP	If HSFORM[HSTOT].HSVALID = 1/Indicated, then XBACKUP = HSTOT. Else XBACKUP = EMPTY.
XBACKUPDATE	If XBACKUP <> EMPTY, then XBACKUPDATE = HA7B - ASSESDT2. Else XBACKUPDATE = EMPTY.

HA7C Code 1

Question Text

Please refer to the (FORM TYPE) with the assessment date of (CLOSEST VALID ASSESSMENT DATE) when answering the following questions. [If the information is not found on the Quarterly Review, (please refer to the full MDS form with the assessment date of (BACKUP MDS ASSESSMENT DATE)/please refer to (SP)'s medical record) to answer the questions.]

PRESS "1" TO CONTINUE.

Field 1: MDSINT1

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA19A

BOX HA19A

Box Instructions

IF BASELINE INTERVIEW, GO TO BOX HA22B.

ELSE, GO TO HA11B - COMATOSE.

BOX HA22B

Box Instructions

IF ((PERS.INCAID = EMPTY OR (PERS.INCAID = 1 AND PERS.ICAIDNM = DK, RF, OR EMPTY)) AND PERS.CAIDECO <> 0/No OR 2/Pending) OR HSMCDFLG = 1/Indicated, GO TO HA44PREB - HA44PRBC.

ELSE, GO TO HA9PREB - HA9PRBC.

HA44PREB Code 1

Question Text

This next section asks for (SP)'s Medicaid number as recorded on the MDS assessment form.

PRESS "1" TO CONTINUE.

Field 1: HA44PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA47B - HCAIDNUM

HA47B Text

Question Text

Please read me (SP)'s [(PREFERRED NAME FOR MEDICAID)/MEDICAID] ID number from the MDS assessment form.

IF NO MEDICAID NUMBER, ENTER 96.

Field 1: HCAIDNUM

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	HA48B - HCAIDVER
	Don't Know	HA9PREB - HA9PRBC
	Refused	HA9PREB - HA9PRBC

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HCAIDNM	PERS.HCAIDNM = HA47B - HCAIDNUM
MCAIDFLG	If HA47B - HCAIDNUM = 96 or RF, then PERS.MCAIDFLG = 1/RForNWK. Else if HA47B - HCAIDNUM = DK, then PERS.MCAIDFLG = 2/NumIsDK
HSMCDFLG	HSMCDFLG = 1/Indicated

HA48B Yes/No

Question Text

I'd like to verify the [(PREFERRED NAME FOR MEDICAID)/MEDICAID] ID number that I have recorded. I have entered (MEDICAID NUMBER). Is this correct?

Field 1: HCAIDVER

Field 1 Routing

Value	Label	Route
0	NO	HA47B - HCAIDNUM
1	YES	HA9PREB - HA9PRBC

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
MCAIDFLG	If HA47B - HCAIDNUM <> 96 and HA48B - HCAIDVER = 1/Yes, then PERS.MCAIDFLG = 3/ValidNumber

HA9PREB Code 1

Question Text

Now I have some questions concerning (SP)'s health on or around [(HS REF DATE)/(his/her) admission to the (facility/home)]. [(Please refer to (SP)'s medical record/Since I will be collecting information about (SP) on or around (HS REF DATE) and there is no MDS or Quarterly Review available close to that date, please refer to (SP)'s medical record for the information/Since you do not have a medical record at hand for reference, please think about the information found in (SP)'s medical record) to answer these questions.]

PRESS "1" TO CONTINUE.

Field 1: HA9PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA9B

BOX HA9B

Box Instructions

IF BASELINE INTERVIEW, GO TO HA9B - MENTAL.

ELSE GO TO HA11B - COMATOSE.

HA9B Yes/No

Question Text

Did (SP)'s record indicate any history of mental retardation, mental illness, or developmental disability problems?
Exclude diagnoses of organic brain syndrome, Alzheimer's disease, and related dementia.

Field 1: MENTAL

Field 1 Routing

Value	Label	Route
0	NO	HA11B - COMATOSE
1	YES	HA11B - COMATOSE
	Don't Know	HA11B - COMATOSE
	Refused	HA11B - COMATOSE

HA11B Code 1

Question Text

Was (SP) in a persistent vegetative state with no discernible consciousness on (HS REF DATE)?

Field 1: COMATOSE

Field 1 Routing

Value	Label	Route
0	NO (NOT COMATOSE)	HA16B - HCHECOND
1	YES (COMATOSE)	HA28PREB - HA28PRBC
	Don't Know	HA16B - HCHECOND
	Refused	HA16B - HCHECOND

HA16B Code 1

Question Text

What was the condition of (SP)'s hearing, with a hearing appliance, if used, on or around (HS REF DATE)? Did (she/he) hear adequately, did (she/he) have minimal difficulty, did (she/he) have moderate difficulty, or was (her/his) hearing highly impaired?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HCHECOND

Field 1 Routing

Value	Label	Route
0	HEARS ADEQUATELY	HA17B - HCHEAID
1	HEARS WITH MINIMAL DIFFICULTY	HA17B - HCHEAID
2	HEARS WITH MODERATE DIFFICULTY	HA17B - HCHEAID
3	HEARING HIGHLY IMPAIRED	HA17B - HCHEAID
	Don't Know	HA17B - HCHEAID
	Refused	HA17B - HCHEAID

HA17B Yes/No

Question Text

Did (she/he) have a hearing aid?

Field 1: HCHEAID

Field 1 Routing

Value	Label	Route
0	NO	HA18PREB - HA18PRBC
1	YES	HA18PREB - HA18PRBC
	Don't Know	HA18PREB - HA18PRBC
	Refused	HA18PREB - HA18PRBC

HA18PREB Code 1

Question Text

The next section deals with how (SP) communicated with others and how well (she/he) was understood by others.

PRESS "1" TO CONTINUE.

Field 1: HA18PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA18B - HCUNCOND

HA18B Code 1

Question Text

Which statement best describes how effective (SP) was at making (herself/himself) understood on or around (HS REF DATE)? Was (she/he) always understood, usually understood, sometimes understood, or rarely or never understood?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HCUNCOND

Field 1 Routing

Value	Label	Route
0	UNDERSTOOD	HA19B - HCUNDOTH
1	USUALLY UNDERSTOOD	HA19B - HCUNDOTH
2	SOMETIMES UNDERSTOOD	HA19B - HCUNDOTH
3	RARELY/NEVER UNDERSTOOD	HA19B - HCUNDOTH
	Don't Know	HA19B - HCUNDOTH
	Refused	HA19B - HCUNDOTH

HA19B Code 1

Question Text

Which statement best describes how well (SP) understood others on or around (HS REF DATE)? Did (SP) always understand, usually understand, sometimes understand, or rarely or never understand?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HCUNDOTH

Field 1 Routing

Value	Label	Route
0	UNDERSTAND	HA20PREB - HA20PRBC
1	USUALLY UNDERSTAND	HA20PREB - HA20PRBC
2	SOMETIMES UNDERSTAND	HA20PREB - HA20PRBC
3	RARELY/NEVER UNDERSTAND	HA20PREB - HA20PRBC
	Don't Know	HA20PREB - HA20PRBC
	Refused	HA20PREB - HA20PRBC

HA20PREB Code 1

Question Text

Next is a question concerning (SP)'s vision on or around (HS REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA20PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA20B - VISION

HA20B Code 1

Question Text

Which of the following statements best described (SP)'s ability to see in adequate light with visual aids, if used? Would you say (her/his) vision was adequate, impaired, moderately impaired, highly impaired, or severely impaired?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: VISION

Field 1 Routing

Value	Label	Route
0	ADEQUATE	HA20AB - VISAPPL
1	IMPAIRED	HA20AB - VISAPPL
2	MODERATELY IMPAIRED	HA20AB - VISAPPL
3	HIGHLY IMPAIRED	HA20AB - VISAPPL
4	SEVERELY IMPAIRED	HA20AB - VISAPPL
	Don't Know	HA20AB - VISAPPL
	Refused	HA20AB - VISAPPL

HA20AB Yes/No

Question Text

Does (SP) use a visual appliance such as glasses, contact lenses, or a magnifying glass?

Field 1: VISAPPL

Field 1 Routing

Value	Label	Route
0	NO	HA12AAB - MENTCON
1	YES	HA12AAB - MENTCON
	Don't Know	HA12AAB - MENTCON
	Refused	HA12AAB - MENTCON

HA12AAB Yes/No

Question Text

Should a brief interview for Mental Status (C0200-C0500) be conducted?

Field 1: MENTCON

Field 1 Routing

Value	Label	Route
0	NO	HA12PREB - HA12PRBC
1	YES	HA12AB - MENTSUM
	Don't Know	HA12PREB - HA12PRBC
	Refused	HA12PREB - HA12PRBC

HA12AB Numeric

Question Text

ENTER SUMMARY SCORE (0-15) FROM BIMS.

ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.

Field 1: MENTSUM

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	HA36B - HALLUC
	Don't Know	HA36B - HALLUC
	Refused	HA36B - HALLUC

HA12PREB Code 1

Question Text

The next series of questions deal with (SP)'s memory or recall ability.

PRESS "1" TO CONTINUE.

Field 1: HA12PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA12B - CSMEMST

HA12B Code 1

Question Text

On or around (HS REF DATE), was (SP)'s short-term memory okay, that is, did (she/he) seem or appear to recall things after 5 minutes?

Field 1: CSMEMST

Field 1 Routing

Value	Label	Route
0	MEMORY OK	HA13B - CSMEMLT
1	MEMORY PROBLEM	HA13B - CSMEMLT
	Don't Know	HA13B - CSMEMLT
	Refused	HA13B - CSMEMLT

HA13B Code 1

Question Text

Was (SP)'s long-term memory okay; that is, did (she/he) seem or appear to recall events in the distant past?

Field 1: CSMEMLT

Field 1 Routing

Value	Label	Route
0	MEMORY OK	HA14B - HA14BCOD
1	MEMORY PROBLEM	HA14B - HA14BCOD
	Don't Know	HA14B - HA14BCOD
	Refused	HA14B - HA14BCOD

HA14B Code All

Question Text

On or around (HS REF DATE), was (SP) able to recall…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA14BCOD

Field 1 Routing

Value	Label	Route
1	the current season?	HA15B - CSDECIS
2	the location of (her/his) own room?	HA15B - CSDECIS
3	staff names or faces?	HA15B - CSDECIS
4	the fact that (she/he) was in a nursing home?	HA15B - CSDECIS
96	NONE CHECKED	HA15B - CSDECIS
	Don't Know	HA15B - CSDECIS

HA15B Code 1

Question Text

How skilled was (SP) in making daily decisions? Was (she/he) independent, did (she/he) exhibit modified independence, was (she/he) moderately impaired, or was (she/he) severely impaired?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: CSDECIS

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	HA36B - HALLUC
1	MODIFIED INDEPENDENCE	HA36B - HALLUC
2	MODERATELY IMPAIRED	HA36B - HALLUC
3	SEVERELY IMPAIRED	HA36B - HALLUC
	Don't Know	HA36B - HALLUC
	Refused	HA36B - HALLUC

HA36B Yes/No

Question Text

Did (SP) experience hallucinations on or around (HS REF DATE)?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HALLUC

Field 1 Routing

Value	Label	Route
0	NO	HA35B - DELUS
1	YES	HA35B - DELUS
	Don't Know	HA35B - DELUS
	Refused	HA35B - DELUS

HA35B Yes/No

Question Text

Did (SP) experience delusions on or around (HS REF DATE)?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: DELUS

Field 1 Routing

Value	Label	Route
0	NO	HA21B - BSAYSOT
1	YES	HA21B - BSAYSOT
	Don't Know	HA21B - BSAYSOT
	Refused	HA21B - BSAYSOT

HA21B Code 1

Question Text

How often did the following behavioral problems occur on or around (HS REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSAYSOT

Physical behavior symptoms directed toward others.

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21B - BSVERBOT
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21B - BSVERBOT
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21B - BSVERBOT
3	BEHAVIOR OCCURRED DAILY	HA21B - BSVERBOT
	Don't Know	HA21B - BSVERBOT
	Refused	HA21B - BSVERBOT

Field 2: BSVERBOT

Verbal behavior symptoms directed toward others.

Field 2 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21B - BSNOTOT
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21B - BSNOTOT
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21B - BSNOTOT
3	BEHAVIOR OCCURRED DAILY	HA21B - BSNOTOT
	Don't Know	HA21B - BSNOTOT
	Refused	HA21B - BSNOTOT

Field 3: BSNOTOT

Other behavioral symptoms not directed toward others.

Field 3 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	BOX HA21B
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	BOX HA21B
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	BOX HA21B
3	BEHAVIOR OCCURRED DAILY	BOX HA21B
	Don't Know	BOX HA21B
	Refused	BOX HA21B

BOX HA21B

Box Instructions

IF HA21B - BSAYSOT and HA21B - BSVERBOT and HA21B - BSNOTOT = 0/BehaviorNotExhibited, GO TO HA21CB - BSNOEVAL.

ELSE GO TO HA21AB - BSELFILL.

HA21AB Yes/No

Question Text

Did any of (SP)'s behavior…

Field 1: BSELFILL

put the resident at significant risk for physical illness or injury?

Field 1 Routing

Value	Label	Route
0	NO	HA21AB - BSELFCAR
1	YES	HA21AB - BSELFCAR
	Don't Know	HA21AB - BSELFCAR
	Refused	HA21AB - BSELFCAR

Field 2: BSELFCAR

significantly interfere with the resident's care?

Field 2 Routing

Value	Label	Route
0	NO	HA21AB - BSELFACT
1	YES	HA21AB - BSELFACT
	Don't Know	HA21AB - BSELFACT
	Refused	HA21AB - BSELFACT

Field 3: BSELFACT

significantly interfere with the resident's participation in activities or social interactions?

Field 3 Routing

Value	Label	Route
0	NO	HA21BB - BSOTHILL
1	YES	HA21BB - BSOTHILL
	Don't Know	HA21BB - BSOTHILL
	Refused	HA21BB - BSOTHILL

HA21BB Yes/No

Question Text

Did any of (SP)'s behavior…

Field 1: BSOTHILL

put others at significant risk for physical illness or injury?

Field 1 Routing

Value	Label	Route
0	NO	HA21BB - BSOTHACT
1	YES	HA21BB - BSOTHACT
	Don't Know	HA21BB - BSOTHACT
	Refused	HA21BB - BSOTHACT

Field 2: BSOTHACT

significantly intrude on the privacy or activities of others?

Field 2 Routing

Value	Label	Route
0	NO	HA21BB - BSOTHENV
1	YES	HA21BB - BSOTHENV
	Don't Know	HA21BB - BSOTHENV
	Refused	HA21BB - BSOTHENV

Field 3: BSOTHENV

significantly disrupt care or living environment?

Field 3 Routing

Value	Label	Route
0	NO	HA21CB - BSNOEVAL
1	YES	HA21CB - BSNOEVAL
	Don't Know	HA21CB - BSNOEVAL
	Refused	HA21CB - BSNOEVAL

HA21CB Code 1

Question Text

How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and well-being on or around (HS REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSNOEVAL

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21DB - BSOFTWAN
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21DB - BSOFTWAN
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21DB - BSOFTWAN
3	BEHAVIOR OCCURRED DAILY	HA21DB - BSOFTWAN
	Don't Know	HA21DB - BSOFTWAN
	Refused	HA21DB - BSOFTWAN

HA21DB Code 1

Question Text

How often did (SP) wander on or around (HS REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSOFTWAN

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA22PREB - HA22PRBC
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21EB - BSWDANGR
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21EB - BSWDANGR
3	BEHAVIOR OCCURRED DAILY	HA21EB - BSWDANGR
	Don't Know	HA21EB - BSWDANGR
	Refused	HA21EB - BSWDANGR

HA21EB Yes/No

Question Text

Did any of (SP)'s wandering…

Field 1: BSWDANGR

place the resident at significant risk of getting to a potentially dangerous place?

Field 1 Routing

Value	Label	Route
0	NO	HA21EB - BSWOTACT
1	YES	HA21EB - BSWOTACT
	Don't Know	HA21EB - BSWOTACT
	Refused	HA21EB - BSWOTACT

Field 2: BSWOTACT

significantly intrude on the privacy or activities of others?

Field 2 Routing

Value	Label	Route
0	NO	HA22PREB - HA22PRBC
1	YES	HA22PREB - HA22PRBC
	Don't Know	HA22PREB - HA22PRBC
	Refused	HA22PREB - HA22PRBC

HA22PREB Code 1

Question Text

The next questions are about (SP)'s ability to perform Activities of Daily Living or ADLs, on or around (HS REF DATE).

I will read you a list of activities and would like you to tell me if (SP)'s self-performance was independent, required supervision, required limited assistance, required extensive assistance, was totally dependent, or if the activity did not occur. [By self-performance I mean what (SP) actually did for (himself/herself) and how much help was required by staff members.]

PRESS "1" TO CONTINUE.

Field 1: HA22PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA22B - PFTRNSFR

HA22B Code 1

Question Text

(SHOW CARD HA1)

Please tell me (SP)'s level of self-performance in…

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: PFTRNSFR

transferring (for example, in and out of bed).

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	HA22B - PFLOCOMO
1	SUPERVISION	HA22B - PFLOCOMO
2	LIMITED ASSISTANCE	HA22B - PFLOCOMO
3	EXTENSIVE ASSISTANCE	HA22B - PFLOCOMO
4	TOTAL DEPENDENCE	HA22B - PFLOCOMO
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22B - PFLOCOMO
8	ACTIVITY DID NOT OCCUR	HA22B - PFLOCOMO
	Don't Know	HA22B - PFLOCOMO
	Refused	HA22B - PFLOCOMO

Field 2: PFLOCOMO

locomotion on unit.

Field 2 Routing

Value	Label	Route
0	INDEPENDENT	HA22B - PFDRSSNG
1	SUPERVISION	HA22B - PFDRSSNG
2	LIMITED ASSISTANCE	HA22B - PFDRSSNG
3	EXTENSIVE ASSISTANCE	HA22B - PFDRSSNG
4	TOTAL DEPENDENCE	HA22B - PFDRSSNG
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22B - PFDRSSNG
8	ACTIVITY DID NOT OCCUR	HA22B - PFDRSSNG
	Don't Know	HA22B - PFDRSSNG
	Refused	HA22B - PFDRSSNG

Field 3: PFDRSSNG

dressing.

Field 3 Routing

Value	Label	Route
0	INDEPENDENT	HA22B - PFEATING
1	SUPERVISION	HA22B - PFEATING
2	LIMITED ASSISTANCE	HA22B - PFEATING
3	EXTENSIVE ASSISTANCE	HA22B - PFEATING
4	TOTAL DEPENDENCE	HA22B - PFEATING
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22B - PFEATING
8	ACTIVITY DID NOT OCCUR	HA22B - PFEATING
	Don't Know	HA22B - PFEATING
	Refused	HA22B - PFEATING

Field 4: PFEATING

eating.

Field 4 Routing

Value	Label	Route
0	INDEPENDENT	HA22B - PFTOILET
1	SUPERVISION	HA22B - PFTOILET
2	LIMITED ASSISTANCE	HA22B - PFTOILET
3	EXTENSIVE ASSISTANCE	HA22B - PFTOILET
4	TOTAL DEPENDENCE	HA22B - PFTOILET
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22B - PFTOILET
8	ACTIVITY DID NOT OCCUR	HA22B - PFTOILET
	Don't Know	HA22B - PFTOILET
	Refused	HA22B - PFTOILET

Field 5: PFTOILET

using the toilet.

Field 5 Routing

Value	Label	Route
0	INDEPENDENT	HA23B - PFBATHNG
1	SUPERVISION	HA23B - PFBATHNG
2	LIMITED ASSISTANCE	HA23B - PFBATHNG
3	EXTENSIVE ASSISTANCE	HA23B - PFBATHNG
4	TOTAL DEPENDENCE	HA23B - PFBATHNG
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA23B - PFBATHNG
8	ACTIVITY DID NOT OCCUR	HA23B - PFBATHNG
	Don't Know	HA23B - PFBATHNG
	Refused	HA23B - PFBATHNG

HA23B Code 1

Question Text

Again referring to the time on or around (HS REF DATE), what was (SP)'s level of self-performance when bathing: was (she/he) independent, did (she/he) require supervision, require physical help limited to transfer only, require physical help in part of the bathing activity, was (she/he) totally dependent, or did the activity not occur?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: PFBATHNG

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	HA24PREB - HA24PRBC
1	SUPERVISION	HA24PREB - HA24PRBC
2	PHYSICAL HELP LIMITED TO TRANSFER ONLY	HA24PREB - HA24PRBC
3	PHYSICAL HELP IN PART OF BATHING ACTIVITY	HA24PREB - HA24PRBC
4	TOTAL DEPENDENCE	HA24PREB - HA24PRBC
8	ACTIVITY DID NOT OCCUR	HA24PREB - HA24PRBC
	Don't Know	HA24PREB - HA24PRBC
	Refused	HA24PREB - HA24PRBC

HA24PREB Code 1

Question Text

The next questions are about modes of locomotion and appliances or devices (SP) might have used on or around (HS REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA24PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA24B - HA24BCOD

HA24B Code All

Question Text

On or around (HS REF DATE) did (he/she) use…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HA24BCOD

Field 1 Routing

Value	Label	Route
1	a cane or crutch?	BOX HA14B
2	a walker?	BOX HA14B
3	a manual or electric wheelchair?	BOX HA14B
4	a limb prosthesis?	BOX HA14B
96	NONE CHECKED	BOX HA14B
	Don't Know	BOX HA14B

BOX HA14B

Box Instructions

GO TO HA25PREB - HA25PRBC.

HA25PREB Code 1

Question Text

The next questions are about (SP)'s bowel and bladder control on or around (HS REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA25PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA25B - CTBOWELC

HA25B Code 1

Question Text

What was the level of (SP)'s bowel control on or around (HS REF DATE)? Was (she/he) always continent, occasionally incontinent, frequently incontinent, always incontinent, or was (she/he) not rated?

Field 1: CTBOWELC

Field 1 Routing

Value	Label	Route
0	ALWAYS CONTINENT	HA26B - CTBLADDC
1	OCCASIONALLY INCONTINENT	HA26B - CTBLADDC
2	FREQUENTLY INCONTINENT	HA26B - CTBLADDC
3	ALWAYS INCONTINENT	HA26B - CTBLADDC
4	NOT RATED	HA26B - CTBLADDC
	Don't Know	HA26B - CTBLADDC
	Refused	HA26B - CTBLADDC

HA26B Code 1

Question Text

What was the level of (SP)'s bladder control on or around (HS REF DATE)? Was (she/he) always continent, occasionally incontinent, frequently incontinent, always incontinent, or was (she/he) not rated?

Field 1: CTBLADDC

Field 1 Routing

Value	Label	Route
0	ALWAYS CONTINENT	HA28PREB - HA28PRBC
1	OCCASIONALLY INCONTINENT	HA28PREB - HA28PRBC
2	FREQUENTLY INCONTINENT	HA28PREB - HA28PRBC
3	ALWAYS INCONTINENT	HA28PREB - HA28PRBC
4	NOT RATED	HA28PREB - HA28PRBC
	Don't Know	HA28PREB - HA28PRBC
	Refused	HA28PREB - HA28PRBC

HA28PREB Code 1

Question Text

The questions in the next section deal with (SP)'s active diagnoses or conditions during the time on or around (HS REF DATE). [By active I mean those diseases associated with (her/his) ADL status, cognition, behavior, medical treatments, or risk of death on or around (HS REF DATE). Please think about what is in (SP)'s medical record when answering the following questions.]

PRESS "1" TO CONTINUE.

Field 1: HA28PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA28B

BOX HA28B

Box Instructions

IF XPRIMARY <> EMPTY, GO TO HA28B - HA28BCD1.

ELSE GO TO HA28B2 - HA28BCD2.

HA28B Code All

Question Text

What active diseases were checked on (SP)'s MDS assessment?

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA28BCD1

Field 1 Routing

Value	Label	Route
1	ALZHEIMER'S DISEASE	HA29B - HA29BCOD
2	ANEMIA	HA29B - HA29BCOD
3	ANXIETY DISORDER	HA29B - HA29BCOD
4	APHASIA	HA29B - HA29BCOD
5	ARTHRITIS	HA29B - HA29BCOD
6	ASTHMA, COPD, OR CHRONIC LUNG DISEASE	HA29B - HA29BCOD
7	ATRIAL FIBRILLATION OR OTHER DYSRHYTHMIAS	HA29B - HA29BCOD
8	BENIGN PROSTATIC HYPERPLASIA	HA29B - HA29BCOD
9	CANCER	HA29B - HA29BCOD
10	CATARACTS, GLAUCOMA, OR MACULAR DEGENERATION	HA29B - HA29BCOD
11	CEREBRAL PALSY	HA29B - HA29BCOD
12	CEREBROVASCULAR ACCIDENT (CVA), TRANSIENT ISCHEMIC ATTACK (TIA), OR STROKE	HA29B - HA29BCOD
13	CIRRHOSIS	HA29B - HA29BCOD
14	CORONARY ARTERY DISEASE (E.G., ANGINA, MI, AND ASHD)	HA29B - HA29BCOD
15	DEEP VENOUS THROMBOSIS (DVT), PULMONARY EMBOLUS (PE) OR PULMONARY THROMBO-EMBOLISM (PTE)	HA29B - HA29BCOD
16	DEMENTIA, OTHER THAN ALZHEIMER'S	HA29B - HA29BCOD
17	DEPRESSION	HA29B - HA29BCOD
18	DIABETES MELLITUS (E.G., DIABETIC RETINOPATHY, NEPHROPATHY, AND NEUROPATHY)	HA29B - HA29BCOD
19	GASTROESOPHAGEAL REFLUX DISEASE (GERD) OR ULCER	HA29B - HA29BCOD
20	HEART FAILURE (E.G., CONGESTIVE HEART FAILURE (CHF) AND PULMONARY EDEMA)	HA29B - HA29BCOD
21	HEMIPLEGIA/HEMIPARESIS	HA29B - HA29BCOD
22	HIP FRACTURE	HA29B - HA29BCOD
23	HUNTINGTON'S DISEASE	HA29B - HA29BCOD
24	HYPERKALEMIA	HA29B - HA29BCOD
25	HYPERLIPIDEMIA (E.G., HYPERCHOLESTEROLEMIA)	HA29B - HA29BCOD
26	HYPERTENSION	HA29B - HA29BCOD
27	HYPONATREMIA	HA29B - HA29BCOD
28	MALNUTRITION OR AT RISK FOR MALNUTRITION	HA29B - HA29BCOD
29	MANIC DEPRESSION (BIPOLAR DISEASE)	HA29B - HA29BCOD
30	MULTIPLE SCLEROSIS	HA29B - HA29BCOD
31	NEUROGENIC BLADDER	HA29B - HA29BCOD
32	OBSTRUCTIVE UROPATHY	HA29B - HA29BCOD
33	ORTHOSTATIC HYPOTENSION	HA29B - HA29BCOD
34	OSTEOPOROSIS	HA29B - HA29BCOD
35	OTHER FRACTURE	HA29B - HA29BCOD
36	PARAPLEGIA	HA29B - HA29BCOD
37	PARKINSON'S DISEASE	HA29B - HA29BCOD
38	PERIPHERAL VASCULAR DISEASE (PVD) OR PERIPHERAL ARTERIAL DISEASE (PAD)	HA29B - HA29BCOD
39	POST TRAUMATIC STRESS DISORDER (PTSD)	HA29B - HA29BCOD
40	PSYCHOTIC DISORDER (OTHER THAN SCHIZOPHRENIA)	HA29B - HA29BCOD
41	QUADRIPLEGIA	HA29B - HA29BCOD
42	RENAL INSUFFICIENCY, RENAL FAILURE, OR END-STAGE RENAL DISEASE (ESRD)	HA29B - HA29BCOD
43	RESPIRATORY FAILURE	HA29B - HA29BCOD
44	SCHIZOPHRENIA	HA29B - HA29BCOD
45	SEIZURE DISORDER OR EPILEPSY	HA29B - HA29BCOD
46	THYROID DISORDER (E.G., HYPOTHYROIDISM, HYPERTHYROIDISM, AND HASHIMOTO'S THYROIDITIS)	HA29B - HA29BCOD
47	TOURETTE'S SYNDROME	HA29B - HA29BCOD
48	TRAUMATIC BRAIN INJURY	HA29B - HA29BCOD
49	ULCERATIVE COLITIS, CROHN'S DISEASE, OR INFLAMMATORY BOWEL DISEASE	HA29B - HA29BCOD
91	OTHER	HA28B - HA28BOSP
96	NONE OF THE ABOVE	HA29B - HA29BCOD

Field 2: HA28BOSP

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	HA29B - HA29BCOD

HA28B2 Code All

Question Text

SHOW CARD HA3

Look at the following list and tell me what active diseases did (SP) have on or around (HS REF DATE).

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA28BCD2

Field 1 Routing

Value	Label	Route
1	ALZHEIMER'S DISEASE	HA29B - HA29BCOD
2	ANEMIA	HA29B - HA29BCOD
3	ANXIETY DISORDER	HA29B - HA29BCOD
4	APHASIA	HA29B - HA29BCOD
5	ARTHRITIS	HA29B - HA29BCOD
6	ASTHMA, COPD, OR CHRONIC LUNG DISEASE	HA29B - HA29BCOD
7	ATRIAL FIBRILLATION OR OTHER DYSRHYTHMIAS	HA29B - HA29BCOD
8	BENIGN PROSTATIC HYPERPLASIA	HA29B - HA29BCOD
9	CANCER	HA29B - HA29BCOD
10	CATARACTS, GLAUCOMA, OR MACULAR DEGENERATION	HA29B - HA29BCOD
11	CEREBRAL PALSY	HA29B - HA29BCOD
12	CEREBROVASCULAR ACCIDENT (CVA), TRANSIENT ISCHEMIC ATTACK (TIA), OR STROKE	HA29B - HA29BCOD
13	CIRRHOSIS	HA29B - HA29BCOD
14	CORONARY ARTERY DISEASE (E.G., ANGINA, MI, AND ASHD)	HA29B - HA29BCOD
15	DEEP VENOUS THROMBOSIS (DVT), PULMONARY EMBOLUS (PE) OR PULMONARY THROMBO-EMBOLISM (PTE)	HA29B - HA29BCOD
16	DEMENTIA, OTHER THAN ALZHEIMER'S	HA29B - HA29BCOD
17	DEPRESSION	HA29B - HA29BCOD
18	DIABETES MELLITUS (E.G., DIABETIC RETINOPATHY, NEPHROPATHY, AND NEUROPATHY)	HA29B - HA29BCOD
19	GASTROESOPHAGEAL REFLUX DISEASE (GERD) OR ULCER	HA29B - HA29BCOD
20	HEART FAILURE (E.G., CONGESTIVE HEART FAILURE (CHF) AND PULMONARY EDEMA)	HA29B - HA29BCOD
21	HEMIPLEGIA/HEMIPARESIS	HA29B - HA29BCOD
22	HIP FRACTURE	HA29B - HA29BCOD
23	HUNTINGTON'S DISEASE	HA29B - HA29BCOD
24	HYPERKALEMIA	HA29B - HA29BCOD
25	HYPERLIPIDEMIA (E.G., HYPERCHOLESTEROLEMIA)	HA29B - HA29BCOD
26	HYPERTENSION	HA29B - HA29BCOD
27	HYPONATREMIA	HA29B - HA29BCOD
28	MALNUTRITION OR AT RISK FOR MALNUTRITION	HA29B - HA29BCOD
29	MANIC DEPRESSION (BIPOLAR DISEASE)	HA29B - HA29BCOD
30	MULTIPLE SCLEROSIS	HA29B - HA29BCOD
31	NEUROGENIC BLADDER	HA29B - HA29BCOD
32	OBSTRUCTIVE UROPATHY	HA29B - HA29BCOD
33	ORTHOSTATIC HYPOTENSION	HA29B - HA29BCOD
34	OSTEOPOROSIS	HA29B - HA29BCOD
35	OTHER FRACTURE	HA29B - HA29BCOD
36	PARAPLEGIA	HA29B - HA29BCOD
37	PARKINSON'S DISEASE	HA29B - HA29BCOD
38	PERIPHERAL VASCULAR DISEASE (PVD) OR PERIPHERAL ARTERIAL DISEASE (PAD)	HA29B - HA29BCOD
39	POST TRAUMATIC STRESS DISORDER (PTSD)	HA29B - HA29BCOD
40	PSYCHOTIC DISORDER (OTHER THAN SCHIZOPHRENIA)	HA29B - HA29BCOD
41	QUADRIPLEGIA	HA29B - HA29BCOD
42	RENAL INSUFFICIENCY, RENAL FAILURE, OR END-STAGE RENAL DISEASE (ESRD)	HA29B - HA29BCOD
43	RESPIRATORY FAILURE	HA29B - HA29BCOD
44	SCHIZOPHRENIA	HA29B - HA29BCOD
45	SEIZURE DISORDER OR EPILEPSY	HA29B - HA29BCOD
46	THYROID DISORDER (E.G., HYPOTHYROIDISM, HYPERTHYROIDISM, AND HASHIMOTO'S THYROIDITIS)	HA29B - HA29BCOD
47	TOURETTE'S SYNDROME	HA29B - HA29BCOD
48	TRAUMATIC BRAIN INJURY	HA29B - HA29BCOD
49	ULCERATIVE COLITIS, CROHN'S DISEASE, OR INFLAMMATORY BOWEL DISEASE	HA29B - HA29BCOD
91	OTHER	DO NOT DISPLAY.
96	NONE OF THE ABOVE	HA29B - HA29BCOD
	Don't Know	HA29B - HA29BCOD
	Refused	HA29B - HA29BCOD

HA29B Code All

Question Text

(SHOW CARD HA4)

[What active infections were checked on (SP)'s MDS assessment?]
[Look at the following list and tell me what active infections (SP) had on or around (HS REF DATE) according to the medical record notes.]

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA29BCOD

Field 1 Routing

Value	Label	Route
1	MULTIDRUG-RESISTANT ORGANISM (MDRO)	BOX HA15B
2	PNEUMONIA	BOX HA15B
3	SEPTICEMIA	BOX HA15B
4	TUBERCULOSIS	BOX HA15B
5	URINARY TRACT INFECTION IN LAST 30 DAYS	BOX HA15B
6	VIRAL HEPATITIS	BOX HA15B
7	WOUND INFECTION (OTHER THAN FOOT)	BOX HA15B
96	NONE OF THE ABOVE	BOX HA15B

BOX HA15B

Box Instructions

IF XPRIMARY <> EMPTY, GO TO HA30B - OTMDSDIA.

ELSE GO TO BOX HA16B.

HA30B Yes/No

Question Text

Were there any active diagnoses entered on the MDS form in the section for additional active diagnoses?

Field 1: OTMDSDIA

Field 1 Routing

Value	Label	Route
0	NO	BOX HA16B
1	YES	HA31B - HA31BCOD
	Don't Know	BOX HA16B
	Refused	BOX HA16B

HA31B Code All

Question Text

SHOW CARD HA5

What were the diagnoses?

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

ENTER ICD-9 CODES WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.

Field 1: HA31BCOD

Field 1 Routing

Value	Label	Route
1	AGITATION	BOX HA16A1
2	ALCOHOL DEPENDENCY	BOX HA16A1
3	ALLERGIES	BOX HA16A1
4	ANOREXIA	BOX HA16A1
5	AORTIC STENOSIS	BOX HA16A1
6	ATAXIA	BOX HA16A1
7	ATYPICAL PSYCHOSIS	BOX HA16A1
8	BLINDNESS	BOX HA16A1
9	BREAST DISORDERS	BOX HA16A1
10	CATARACTS	DO NOT DISPLAY.
11	CEREBRAL DEGENERATION	BOX HA16A1
12	CLINICAL OBESITY	BOX HA16A1
13	CLOSTRIDIUM DIFFICILE (C.DIFF.)	BOX HA16A1
14	CONJUNCTIVITIS	BOX HA16A1
15	CONSTIPATION	BOX HA16A1
16	DEGENERATIVE JOINT DISEASE	BOX HA16A1
17	DIAPHRAGMATIC HERNIA (HIATAL HERNIA)	BOX HA16A1
18	DIVERTICULA OF COLON	BOX HA16A1
19	DOWN'S SYNDROME	BOX HA16A1
20	DYSPHAGIA (SWALLOWING DIFFICULTIES)	BOX HA16A1
21	EDEMA (OTHER THAN PULMONARY)	BOX HA16A1
22	GASTRITIS/DUODENITIS	BOX HA16A1
23	GASTROENTERITIS, NONINFECTIOUS	BOX HA16A1
24	GASTROINTESTINAL HEMORRHAGE	BOX HA16A1
25	GOUT	BOX HA16A1
26	HEMORRHAGE OF ESOPHAGUS	BOX HA16A1
27	HIV INFECTION	BOX HA16A1
28	HYPERPLASIA OF PROSTATE	BOX HA16A1
29	HYPOPOTASSEMIA/HYPOKALEMIA	BOX HA16A1
30	HYPOTENSION (OTHER THAN ORTHOSTATIC)	BOX HA16A1
31	INSOMNIA	BOX HA16A1
32	KYPHOSIS	BOX HA16A1
33	MISSING LIMB (E.G., AMPUTATION)	BOX HA16A1
34	NONPSYCHOTIC BRAIN SYNDROME	BOX HA16A1
35	ORGANIC BRAIN SYNDROME	BOX HA16A1
36	OSTEOARTHRITIS	BOX HA16A1
37	PATHOLOGICAL BONE FRACTURE	BOX HA16A1
38	RENAL URETERAL DISORDER	BOX HA16A1
39	RESPIRATORY INFECTION	BOX HA16A1
40	SCOLIOSIS	BOX HA16A1
41	SEXUALLY TRANSMITTED DISEASES	BOX HA16A1
42	SPINAL STENOSIS	BOX HA16A1
43	ULCER OF LEG, CHRONIC	BOX HA16A1
44	URINARY RETENTION	BOX HA16A1
45	VERTIGO	BOX HA16A1
91	OTHER DIAGNOSIS 1	BOX HA16A1
92	OTHER DIAGNOSIS 2	BOX HA16A1
93	OTHER DIAGNOSIS 3	BOX HA16A1
94	OTHER DIAGNOSIS 4	BOX HA16A1

BOX HA16A1

Box Instructions

IF HA31B - HA31BCOD INCLUDES 91/Other1, THEN GO TO HA31BO1 - MDCOTH1.

ELSE GO TO BOX HA16A2.

HA31BO1 Text

Question Text

ENTER OTHER DIAGNOSIS 1.

Field 1: MDCOTH1

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA16A2

BOX HA16A2

Box Instructions

IF HA31B - HA31BCOD INCLUDES 92/Other2, THEN GO TO HA31BO2 - MDCOTH2.

ELSE GO TO BOX HA16A3.

HA31BO2 Text

Question Text

ENTER OTHER DIAGNOSIS 2.

Field 1: MDCOTH2

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA16A3

BOX HA16A3

Box Instructions

IF HA31B - HA31BCOD INCLUDES 93/Other3, THEN GO TO HA31BO3 - MDCOTH3.

ELSE GO TO BOX HA16A4.

HA31BO3 Text

Question Text

ENTER OTHER DIAGNOSIS 3.

Field 1: MDCOTH3

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA16A4

BOX HA16A4

Box Instructions

IF HA31B - HA31BCOD INCLUDES 94/Other4, THEN GO TO HA31BO4 - MDCOTH4.

ELSE GO TO BOX HA16B.

HA31BO4 Text

Question Text

ENTER OTHER DIAGNOSIS 4.

Field 1: MDCOTH4

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA16B

BOX HA16B

Box Instructions

IF HA11B - COMATOSE = 1/YesComatose, GO TO BOX HA16AB.

ELSE, GO TO HA34PREB - HA34PRBC.

HA34PREB Code 1

Question Text

The next few items are about the other conditions (SP) may have had on or around (HS REF DATE). (Again, please refer to the MDS.)

PRESS "1" TO CONTINUE.

Field 1: HA34PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA34B - DEHYD

HA34B Yes/No

Question Text

Did (SP) experience dehydration on or around (HS REF DATE)?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: DEHYD

Field 1 Routing

Value	Label	Route
0	NO	HA37AB - HA37ABCO
1	YES	HA37AB - HA37ABCO
	Don't Know	HA37AB - HA37ABCO
	Refused	HA37AB - HA37ABCO

HA37AB Code All

Question Text

On or around (HS REF DATE), did (SP) experience the swallowing problem of…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA37ABCO

Field 1 Routing

Value	Label	Route
1	a loss of liquids or solids from mouth when eating or drinking?	HA37BB - HA37BBCO
2	holding food in mouth or cheeks or residual food in mouth after meals?	HA37BB - HA37BBCO
3	coughing or choking during meals or when swallowing medications?	HA37BB - HA37BBCO
4	complaints of difficulty or pain with swallowing?	HA37BB - HA37BBCO
96	NONE OF THE ABOVE	HA37BB - HA37BBCO

HA37BB Code All

Question Text

On or around (HS REF DATE), did (SP) experience the oral problem of…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA37BBCO

Field 1 Routing

Value	Label	Route
1	broken or loosely fitting full or partial denture?	BOX HA16AB
2	no natural teeth or tooth fragments?	BOX HA16AB
3	abnormal mouth tissue (ulcers, masses, oral lesions)?	BOX HA16AB
4	obvious or likely cavity or broken natural teeth?	BOX HA16AB
5	inflamed or bleeding gums or loose natural teeth?	BOX HA16AB
6	mouth or facial pain, discomfort or difficulty with chewing?	BOX HA16AB
7	UNABLE TO EXAMINE	BOX HA16AB
96	NONE OF THE ABOVE	BOX HA16AB

BOX HA16AB

Box Instructions

IF PERS.PERSRNDC = CURRENT ROUND, OR CURRENT ROUND IS FALL ROUND, GO TO HA38B - HEIGHT.

ELSE, GO TO HA39B - FCWEIGHT.

HA38B Numeric

Question Text

What (is/was) (SP)'s height in inches?

Field 1: HEIGHT

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	HA39B - FCWEIGHT
	Don't Know	HA39B - FCWEIGHT
	Refused	HA39B - FCWEIGHT

HA39B Numeric

Question Text

What was (SP)'s weight on or around (HS REF DATE)?

Field 1: FCWEIGHT

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA17BB
	Don't Know	BOX HA17BB
	Refused	BOX HA17BB

BOX HA17BB

Box Instructions

GO TO HA10B - HA10BCOD.

HA10B Code All

Question Text

(The rest of the health status questionnaire is not from the MDS.)

Now, please tell me which of the following advanced directives were listed in (SP)'s record or chart for the period on or around (HS REF DATE).

Did (SP)'s record indicate…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA10BCOD

Field 1 Routing

Value	Label	Route
1	a Living Will?	HA32 - OTACTDIA
2	instructions not to resuscitate?	HA32 - OTACTDIA
3	instructions not to hospitalize?	HA32 - OTACTDIA
4	restrictions on feeding, medication, or other treatment restrictions?	HA32 - OTACTDIA
96	NONE CHECKED	HA32 - OTACTDIA
	Don't Know	HA32 - OTACTDIA

HA32 Yes/No

Question Text

Can you add any other active diagnoses for (SP) on or around (HS REF DATE) that have not yet been mentioned? Please refer to the medical record including (SP)'s medications chart for (HS REF DATE MONTH).

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: OTACTDIA

Field 1 Routing

Value	Label	Route
0	NO	BOX HA15A
1	YES	HA33 - HA33CODE
	Don't Know	BOX HA15A
	Refused	BOX HA15A

HA33 Code All

Question Text

SHOW CARD HA5

What were the diagnoses?

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

ENTER ICD-9 CODES, IF AVAILABLE, WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.

Field 1: HA33CODE

Field 1 Routing

Value	Label	Route
1	AGITATION	BOX HA15AA1
2	ALCOHOL DEPENDENCY	BOX HA15AA1
3	ALLERGIES	BOX HA15AA1
4	ANOREXIA	BOX HA15AA1
5	AORTIC STENOSIS	BOX HA15AA1
6	ATAXIA	BOX HA15AA1
7	ATYPICAL PSYCHOSIS	BOX HA15AA1
8	BLINDNESS	BOX HA15AA1
9	BREAST DISORDERS	BOX HA15AA1
10	CATARACTS	DO NOT DISPLAY.
11	CEREBRAL DEGENERATION	BOX HA15AA1
12	CLINICAL OBESITY	BOX HA15AA1
13	CLOSTRIDIUM DIFFICILE (C.DIFF.)	BOX HA15AA1
14	CONJUNCTIVITIS	BOX HA15AA1
15	CONSTIPATION	BOX HA15AA1
16	DEGENERATIVE JOINT DISEASE	BOX HA15AA1
17	DIAPHRAGMATIC HERNIA (HIATAL HERNIA)	BOX HA15AA1
18	DIVERTICULA OF COLON	BOX HA15AA1
19	DOWN'S SYNDROME	BOX HA15AA1
20	DYSPHAGIA (SWALLOWING DIFFICULTIES)	BOX HA15AA1
21	EDEMA (OTHER THAN PULMONARY)	BOX HA15AA1
22	GASTRITIS/DUODENITIS	BOX HA15AA1
23	GASTROENTERITIS, NONINFECTIOUS	BOX HA15AA1
24	GASTROINTESTINAL HEMORRHAGE	BOX HA15AA1
25	GOUT	BOX HA15AA1
26	HEMORRHAGE OF ESOPHAGUS	BOX HA15AA1
27	HIV INFECTION	BOX HA15AA1
28	HYPERPLASIA OF PROSTATE	BOX HA15AA1
29	HYPOPOTASSEMIA/HYPOKALEMIA	BOX HA15AA1
30	HYPOTENSION (OTHER THAN ORTHOSTATIC)	BOX HA15AA1
31	INSOMNIA	BOX HA15AA1
32	KYPHOSIS	BOX HA15AA1
33	MISSING LIMB (E.G., AMPUTATION)	BOX HA15AA1
34	NONPSYCHOTIC BRAIN SYNDROME	BOX HA15AA1
35	ORGANIC BRAIN SYNDROME	BOX HA15AA1
36	OSTEOARTHRITIS	BOX HA15AA1
37	PATHOLOGICAL BONE FRACTURE	BOX HA15AA1
38	RENAL URETERAL DISORDER	BOX HA15AA1
39	RESPIRATORY INFECTION	BOX HA15AA1
40	SCOLIOSIS	BOX HA15AA1
41	SEXUALLY TRANSMITTED DISEASES	BOX HA15AA1
42	SPINAL STENOSIS	BOX HA15AA1
43	ULCER OF LEG, CHRONIC	BOX HA15AA1
44	URINARY RETENTION	BOX HA15AA1
45	VERTIGO	BOX HA15AA1
91	OTHER DIAGNOSIS 1	BOX HA15AA1
92	OTHER DIAGNOSIS 2	BOX HA15AA1
93	OTHER DIAGNOSIS 3	BOX HA15AA1
94	OTHER DIAGNOSIS 4	BOX HA15AA1

BOX HA15AA1

Box Instructions

IF HA33 - HA33CODE INCLUDES 91/Other1, THEN GO TO HA33O1 - NMDCOTH1.

ELSE GO TO BOX HA15AA2.

HA33O1 Text

Question Text

ENTER OTHER DIAGNOSIS 1.

Field 1: NMDCOTH1

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA15AA2

BOX HA15AA2

Box Instructions

IF HA33 - HA33CODE INCLUDES 92/Other2, THEN GO TO HA33O2 - NMDCOTH2.

ELSE GO TO BOX HA15AA3.

HA33O2 Text

Question Text

ENTER OTHER DIAGNOSIS 2.

Field 1: NMDCOTH2

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA15AA3

BOX HA15AA3

Box Instructions

IF HA33 - HA33CODE INCLUDES 93/Other3, THEN GO TO HA33O3 - NMDCOTH3.

ELSE GO TO BOX HA15AA4.

HA33O3 Text

Question Text

ENTER OTHER DIAGNOSIS 3.

Field 1: NMDCOTH3

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA15AA4

BOX HA15AA4

Box Instructions

IF HA33 - HA33CODE INCLUDES 94/Other4, THEN GO TO HA33O4 - NMDCOTH4.

ELSE GO TO BOX HA15A.

HA33O4 Text

Question Text

ENTER OTHER DIAGNOSIS 4.

Field 1: NMDCOTH4

OTHER (SPECIFY)

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA15A

BOX HA15A

Box Instructions

IF HA28B - HA28BCD1 OR HA28B2 - HA28BCD2 INCLUDES 9/Cancer, GO TO HA33PRE - HA33PREC.

ELSE, GO TO HA33D - MYOCARD.

HA33PRE Code 1

Question Text

[While you are referring to (SP)'s medical record/(Now)] I have some (additional) questions about the conditions you mentioned earlier. (These questions cannot be found on the MDS).

PRESS "1" TO CONTINUE.

Field 1: HA33PREC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA33B - HA33BCOD

HA33B Code All

Question Text

Please refer to (SP)'s medical record and tell me in what part or parts of the body was the cancer found?

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA33BCOD

Field 1 Routing

Value	Label	Route
1	BLADDER	HA33D - MYOCARD
2	BREAST	HA33D - MYOCARD
3	CERVIX	HA33D - MYOCARD
4	COLON, RECTUM, OR BOWEL	HA33D - MYOCARD
5	LUNG	HA33D - MYOCARD
6	OVARY	HA33D - MYOCARD
7	PROSTATE	HA33D - MYOCARD
8	SKIN	HA33D - MYOCARD
9	STOMACH	HA33D - MYOCARD
10	UTERUS	HA33D - MYOCARD
91	OTHER	HA33B - CNROTHOS

Field 2: CNROTHOS

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	HA33D - MYOCARD

HA33D Yes/No

Question Text

Still referring to the medical record, has (SP) ever had a myocardial infarction or heart attack?

Field 1: MYOCARD

Field 1 Routing

Value	Label	Route
0	NO	HA33E - CATAROP
1	YES	HA33E - CATAROP
	Don't Know	HA33E - CATAROP
	Refused	HA33E - CATAROP

HA33E Yes/No

Question Text

Has (SP) ever had an operation for cataracts?

Field 1: CATAROP

Field 1 Routing

Value	Label	Route
0	NO	BOX HA15F
1	YES	BOX HA15F
	Don't Know	BOX HA15F
	Refused	BOX HA15F

BOX HA15F

Box Instructions

IF CORE OR PreloadSP.CURELAGE >= 65 OR (SP IS CFR OR SP IS FFC OR SP IS FCF OR SP IS CFC), GO TO BOX HA17B.

IF NO CONDITIONS ARE INDICATED, GO TO HA33G - OTHCAUS.

ELSE, GO TO HA33F - CAUSEMCR.

Other Programming Instructions

Design Notes

NO CONDITIONS ARE INDICATED =
HA28B - HA28BCD1 = 96/NoneOfTheAbove or DK, RF, EMPTY and
HA28B2 - HA28BCD2 = 96/NoneOfTheAbove or DK, RF, EMPTY and
HA29B - HA29BCOD = 96/NoneOfTheAbove or DK, RF, EMPTY and
HA30B - OTMDSDIA = 0/No or DK, RF, EMPTY and
HA37AB - HA37ABCO = 96/NoneOfTheAbove or DK, RF, EMPTY and
HA37BB - HA37BBCO = 96/NoneOfTheAbove or DK, RF, EMPTY and
HA32 - OTACTDIA = 0/No or DK, RF, EMPTY and
HA33D - MYOCARD = 0/No or DK, RF, EMPTY and
HA33E - CATAROP = 0/No or DK, RF, EMPTY

HA33F Yes/No

Question Text

You told me that (SP) has had [READ CONDITIONS LISTED BELOW.]


(Was this/Were any of these) the original cause of (SP)'s becoming eligible for Medicare?

Field 1: CAUSEMCR

Field 1 Routing

Value	Label	Route
0	NO	HA33G - OTHCAUS
1	YES	BOX HA15E
	Don't Know	BOX HA17B
	Refused	BOX HA17B

Other Programming Instructions

Report Display

Display report below "[READ CONDITIONS LISTED BELOW.]".

For each medical condition respondent indicated in HA28B-HA33E, display as a separate line in report:
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 1/AlzheimersDisease, display "ALZHEIMER'S DISEASE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 2/ Anemia, display "ANEMIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 3/ AnxietyDisorder, display "ANXIETY DISORDER".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 4/ Aphasia, display "APHASIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 5/ Arthritis, display "ARTHRITIS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 6/ AsthmaCOPD, display "ASTHMA, COPD, OR CHRONIC LUNG DISEASE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 7/ AtrialFibDysrythmias, display "ATRIAL FIBRILLATION OR OTHER DYSRHYTHMIAS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 8/ BenignProstaticHyperplasia, display "BENIGN PROSTATIC HYPERPLASIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 9/ Cancer, display "CANCER".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 10/ CataractsGlaucomaMD, display "CATARACTS, GLAUCOMA, OR MACULAR DEGENERATION".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 11/ CerebralPalsy, display "CEREBRAL PALSY".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 12/ CVATIASStroke, display "CEREBROVASCULAR ACCIDENT (CVA), TRANSIENT ISCHEMIC ATTACH (TIA), OR STROKE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 13/ Cirrhosis, display "CIRRHOSIS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 14/ CAD, display "CORONARY ARTERY DISEASE (E.G., ANGINA, MI, AND ASHD)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 15/ DVTPEPTE, display "DEEP VENOUS THROMBOSIS (DVT), PULMONARY EMBOLUS (PE) OR PULMONARY THROMBO-EMBOLISM (PTE)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 16/ Dementia, display "DEMENTIA, OTHER THAN ALZHEIMER'S".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 17/ Depression, display "DEPRESSION".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 18/ DiabetesMellitus, display "DIABETES MELLITUS (E.G., DIABETIC RETINOPATHY, NEPHROPATHY, AND NEUROPATHY)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 19/ GERDUlcer, display "GASTROESOPHAGEAL REFLUX DISEASE (GERD) OR ULCER".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 20/ HeartFailure, display "HEART FAILURE (E.G., CONGESTIVE HEART FAILURE (CHF) AND PULMONARY EDEMA)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 21/ HemiplegiaHemiparesis, display "HEMIPLEIA/HEMIPARESIS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 22/ HipFracture, display "HIP FRACTURE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 23/ HuntingtonsDisease, display "HUNTINGTON'S DISEASE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 24/ Hyperkalemia, display "HYPERKALEMIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 25/ Hyperlipidemia, display "HYPERLIPIDEMIA (E.G., HYPERCHOLESTEROLEMIA)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 26/ Hypertension, display "HYPERTENSION".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 27/ Hyponatremia, display "HYPONATREMIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 28/ Malnutrition, display "MALNUTRITION OR AT RISK FOR MALNUTRITION".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 29/ ManicDepressionBipolarDisease, display "MANIC DEPRESSION (BIPOLAR DISEASE)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 30/ MultipleSclerosis, display "MULTIPLE SCLEROSIS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 31/ NeurogenicBladder, display "NEUROGENIC BLADDER".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 32/ ObstructiveUropathy, display "OBSTRUCTIVE UROPATHY".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 33/ OrthostaticHypotension, display "ORTHOSTATIC HYPOTENSION".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 34/ Osteoporosis, display "OSTEOPOROSIS".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 35/ OtherFacture, display "OTHER FRACTURE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 36/ Paralegia, display "PARAPLEGIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 37/ ParkinsonsDisease, display "PARKINSON'S DISEASE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 38/ PVDPAD, display "PERIPHERAL VASCULAR DISEASE (PVD) OR PERIPHERAL ARTERIAL DISEASE (PAD)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 39/ PTSD, display "POST TRAUMATIC STRESS DISORDER (PTSD)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 40/ PsychoticDisorder, display "PSYCHOTIC DISORDER (OTHER THAN SCHIZOPHRENIA)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 41/ Quadriplegia, display "QUADRIPLEGIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 42/ RenalInsuficiency, display "RENAL INSUFFICIENCY, RENAL FAILURE, OR END-STAGE RENAL DISEASE (ESRD)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 43/ RespiratoryFailure, display "RESPIRATORY FAILURE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 44/ Schizophrenia, display "SCHIZOPHRENIA".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 45/ SeizureDisorderEpilepsy, display "SEIZURE DISORDER OR EPILEPSY".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 46/ ThyroidDisorder, display "THYROID DISORDER (E.G., HYPOTHYROIDISM, HYPERTHYROIDISM, AND HASHIMOTO'S THYROIDITIS)".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 47/ TourettesSyndrome, display "TOURETTE'S SYNDROME".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 48/ TraumaticBrainInjury, display "TRAUMATIC BRAIN INJURY".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 49/ UlcerativeColitisCrohns, display "ULCERATIVE COLITIS, CROHN'S DISEASE, OR INFLAMMATORY BOWEL DISEASE".
IF HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 91/ Other, display response in HA28B - HA28BOSP.

IF HA29B - HA29BCOD includes 1/MultiDrugResistantOrganism, display "MULTIDRUG-RESISTANT ORGANISM (MDRO)".
IF HA29B - HA29BCOD includes 2/Pneumonia, display "PNEUMONIA".
IF HA29B - HA29BCOD includes 3/Septicemia, display "SEPTICEMIA".
IF HA29B - HA29BCOD includes 4/Tuberculosis, display "TUBERCULOSIS".
IF HA29B - HA29BCOD includes 5/ UrinaryTractInfectionInLast30Days, display "URINARY TRACT INFECTION IN LAST 30 DAYS".
IF HA29B - HA29BCOD includes 6/ViralHepatitis, display "VIRAL HEPATITIS".
IF HA29B - HA29BCOD includes 7/WoundInfection, display "WOUND INFECTION (OTHER THAN FOOT)".

IF HA31B - HA31BCOD includes 1/Agitation, display "AGITATION".
IF HA31B - HA31BCOD includes 2/AlcoholDependency, display "ALCOHOL DEPENDENCY".
IF HA31B - HA31BCOD includes 3/Allergies, display "ALLERGIES".
IF HA31B - HA31BCOD includes 4/Anorexia, display "ANOREXIA".
IF HA31B - HA31BCOD includes 5/AorticStenosis, display "AORTIC STENOSIS".
IF HA31B - HA31BCOD includes 6/Ataxia, display "ATAXIA".
IF HA31B - HA31BCOD includes 7/AtypicalPsychosis, display "ATYPICAL PSYCHOSIS".
IF HA31B - HA31BCOD includes 8/Blindness, display "BLINDNESS".
IF HA31B - HA31BCOD includes 9/BreastDisorders, display "BREAST DISORDERS".
IF HA31B - HA31BCOD includes 11/CerebralDegeneration, display "CEREBRAL DEGENERATION".
IF HA31B - HA31BCOD includes 12/ClinicalObesity, display "CLINICAL OBESITY".
IF HA31B - HA31BCOD includes 13/ClostridiumDifficile, display "CLOSTRIDIUM DIFFICILE (C.DIFF.)".
IF HA31B - HA31BCOD includes 14/Conjunctivitis, display "CONJUNCTIVITIS".
IF HA31B - HA31BCOD includes 15/Constipation, display "CONSTIPATION".
IF HA31B - HA31BCOD includes 16/DegenerativeJointDisease, display "DEGENERATIVE JOINT DISEASE".
IF HA31B - HA31BCOD includes 17/DiaphragmaticHernia, display "DIAPHRAGMATIC HERNIA (HIATAL HERNIA)".
IF HA31B - HA31BCOD includes 18/DiverticulaOfColon, display "DIVERTICULA OF COLON".
IF HA31B - HA31BCOD includes 19/DownsSyndrome, display "DOWN'S SYNDROME".
IF HA31B - HA31BCOD includes 20/Dysphagia, display "DYSPHAGIA (SWALLOWING DIFFICULTIES)".
IF HA31B - HA31BCOD includes 21/Edema, display "EDEMA (OTHER THAN PULMONARY)".
IF HA31B - HA31BCOD includes 22/GastritisDuodenitis, display "GASTRITIS/DUODENITIS".
IF HA31B - HA31BCOD includes 23/GastroenteritisNoninfectious, display "GASTROENTERITIS, NONINFECTIOUS".
IF HA31B - HA31BCOD includes 24/GastrointestinalHemorrhage, display "GASTROINTESTINAL HEMORRHAGE".
IF HA31B - HA31BCOD includes 25/Gout, display "GOUT".
IF HA31B - HA31BCOD includes 26/HemorrhageOfEsophagus, display "HEMORRHAGE OF ESOPHAGUS".
IF HA31B - HA31BCOD includes 27/HIVInfection, display "HIV INFECTION".
IF HA31B - HA31BCOD includes 28/HyperplasiaOfProstate, display "HYPERPLASIA OF PROSTATE".
IF HA31B - HA31BCOD includes 29/HypopotassemiaHypokalemia, display "HYPOPOTASSEMIA/HYPOKALEMIA".
IF HA31B - HA31BCOD includes 30/HypotensionOtherThanOrthostatic, display "HYPOTENSION (OTHER THAN ORTHOSTATIC)".
IF HA31B - HA31BCOD includes 31/Insomnia, display "INSOMNIA".
IF HA31B - HA31BCOD includes 32/Kyphosis, display "KYPHOSIS".
IF HA31B - HA31BCOD includes 33/MissingLimb, display "MISSING LIMB (E.G., AMPUTATION)".
IF HA31B - HA31BCOD includes 34/NonpsychoticBrainSyndrome, display "NONPSYCHOTIC BRAIN SYNDROME".
IF HA31B - HA31BCOD includes 35/OrganicBrainSyndrome, display "ORGANIC BRAIN SYNDROME".
IF HA31B - HA31BCOD includes 36/Osteoarthritis, display "OSTEOARTHRITIS".
IF HA31B - HA31BCOD includes 37/PathologicalBoneFracture, display "PATHOLOGICAL BONE FRACTURE".
IF HA31B - HA31BCOD includes 38/RenalUreteralDisorder, display "RENAL URETERAL DISORDER".
IF HA31B - HA31BCOD includes 39/RespiratoryInfection, display "RESPIRATORY INFECTION".
IF HA31B - HA31BCOD includes 40/Scoliosis, display "SCOLIOSIS".
IF HA31B - HA31BCOD includes 41/SexuallyTransmittedDiseases, display "SEXUALLY TRANSMITTED DISEASES".
IF HA31B - HA31BCOD includes 42/SpinalStenosis, display "SPINAL STENOSIS".
IF HA31B - HA31BCOD includes 43/UlcerOfLegChronic, display "ULCER OF LEG, CHRONIC".
IF HA31B - HA31BCOD includes 44/UrinaryRetention, display "URINARY RETENTION".
IF HA31B - HA31BCOD includes 45/Vertigo, display "VERTIGO".
IF HA31B - HA31BCOD includes 91/Other1, display response in HA31BO1 - MDCOTH1.
IF HA31B - HA31BCOD includes 92/Other2, display response in HA31BO2 - MDCOTH2.
IF HA31B - HA31BCOD includes 93/Other3, display response in HA31BO3 - MDCOTH3.
IF HA31B - HA31BCOD includes 94/Other4, display response in HA31BO4 - MDCOTH4.

IF HA33 - HA33CODE includes 1/Agitation, display "AGITATION".
IF HA33 - HA33CODE includes 2/AlcoholDependency, display "ALCOHOL DEPENDENCY".
IF HA33 - HA33CODE includes 3/Allergies, display "ALLERGIES".
IF HA33 - HA33CODE includes 4/Anorexia, display "ANOREXIA".
IF HA33 - HA33CODE includes 5/AorticStenosis, display "AORTIC STENOSIS".
IF HA33 - HA33CODE includes 6/Ataxia, display "ATAXIA".
IF HA33 - HA33CODE includes 7/AtypicalPsychosis, display "ATYPICAL PSYCHOSIS".
IF HA33 - HA33CODE includes 8/Blindness, display "BLINDNESS".
IF HA33 - HA33CODE includes 9/BreastDisorders, display "BREAST DISORDERS".
IF HA33 - HA33CODE includes 11/CerebralDegeneration, display "CEREBRAL DEGENERATION".
IF HA33 - HA33CODE includes 12/ClinicalObesity, display "CLINICAL OBESITY".
IF HA33 - HA33CODE includes 13/ClostridiumDifficile, display "CLOSTRIDIUM DIFFICILE (C.DIFF.)".
IF HA33 - HA33CODE includes 14/Conjunctivitis, display "CONJUNCTIVITIS".
IF HA33 - HA33CODE includes 15/Constipation, display "CONSTIPATION".
IF HA33 - HA33CODE includes 16/DegenerativeJointDisease, display "DEGENERATIVE JOINT DISEASE".
IF HA33 - HA33CODE includes 17/DiaphragmaticHernia, display "DIAPHRAGMATIC HERNIA (HIATAL HERNIA)".
IF HA33 - HA33CODE includes 18/DiverticulaOfColon, display "DIVERTICULA OF COLON".
IF HA33 - HA33CODE includes 19/DownsSyndrome, display "DOWN'S SYNDROME".
IF HA33 - HA33CODE includes 20/Dysphagia, display "DYSPHAGIA (SWALLOWING DIFFICULTIES)".
IF HA33 - HA33CODE includes 21/Edema, display "EDEMA (OTHER THAN PULMONARY)".
IF HA33 - HA33CODE includes 22/GastritisDuodenitis, display "GASTRITIS/DUODENITIS".
IF HA33 - HA33CODE includes 23/GastroenteritisNoninfectious, display "GASTROENTERITIS, NONINFECTIOUS".
IF HA33 - HA33CODE includes 24/GastrointestinalHemorrhage, display "GASTROINTESTINAL HEMORRHAGE".
IF HA33 - HA33CODE includes 25/Gout, display "GOUT".
IF HA33 - HA33CODE includes 26/HemorrhageOfEsophagus, display "HEMORRHAGE OF ESOPHAGUS".
IF HA33 - HA33CODE includes 27/HIVInfection, display "HIV INFECTION".
IF HA33 - HA33CODE includes 28/HyperplasiaOfProstate, display "HYPERPLASIA OF PROSTATE".
IF HA33 - HA33CODE includes 29/HypopotassemiaHypokalemia, display "HYPOPOTASSEMIA/HYPOKALEMIA".
IF HA33 - HA33CODE includes 30/HypotensionOtherThanOrthostatic, display "HYPOTENSION (OTHER THAN ORTHOSTATIC)".
IF HA33 - HA33CODE includes 31/Insomnia, display "INSOMNIA".
IF HA33 - HA33CODE includes 32/Kyphosis, display "KYPHOSIS".
IF HA33 - HA33CODE includes 33/MissingLimb, display "MISSING LIMB (E.G., AMPUTATION)".
IF HA33 - HA33CODE includes 34/NonpsychoticBrainSyndrome, display "NONPSYCHOTIC BRAIN SYNDROME".
IF HA33 - HA33CODE includes 35/OrganicBrainSyndrome, display "ORGANIC BRAIN SYNDROME".
IF HA33 - HA33CODE includes 36/Osteoarthritis, display "OSTEOARTHRITIS".
IF HA33 - HA33CODE includes 37/PathologicalBoneFracture, display "PATHOLOGICAL BONE FRACTURE".
IF HA33 - HA33CODE includes 38/RenalUreteralDisorder, display "RENAL URETERAL DISORDER".
IF HA33 - HA33CODE includes 39/RespiratoryInfection, display "RESPIRATORY INFECTION".
IF HA33 - HA33CODE includes 40/Scoliosis, display "SCOLIOSIS".
IF HA33 - HA33CODE includes 41/SexuallyTransmittedDiseases, display "SEXUALLY TRANSMITTED DISEASES".
IF HA33 - HA33CODE includes 42/SpinalStenosis, display "SPINAL STENOSIS".
IF HA33 - HA33CODE includes 43/UlcerOfLegChronic, display "ULCER OF LEG, CHRONIC".
IF HA33 - HA33CODE includes 44/UrinaryRetention, display "URINARY RETENTION".
IF HA33 - HA33CODE includes 45/Vertigo, display "VERTIGO".
IF HA33 - HA33CODE includes 91/Other1, display response in HA33O1 - NMDCOTH1.
IF HA33 - HA33CODE includes 92/Other2, display response in HA33O2 - NMDCOTH2.
IF HA33 - HA33CODE includes 93/Other3, display response in HA33O3 - NMDCOTH3.
IF HA33 - HA33CODE includes 94/Other4, display response in HA33O4 - NMDCOTH4.

IF HA33B - HA33BCOD includes 1/Bladder, display "BLADDER".
IF HA33B - HA33BCOD includes 2/Breast, display "BREAST".
IF HA33B - HA33BCOD includes 3/Cervix, display "CERVIX".
IF HA33B - HA33BCOD includes 4/ColonRectumBowel, display "COLON, RECTUM, OR BOWEL".
IF HA33B - HA33BCOD includes 5/Lung, display "LUNG".
IF HA33B - HA33BCOD includes 6/Ovary, display "OVARY".
IF HA33B - HA33BCOD includes 7/Prostate, display "PROSTATE".
IF HA33B - HA33BCOD includes 8/Skin, display "SKIN".
IF HA33B - HA33BCOD includes 9/Stomach, display "STOMACH".
IF HA33B - HA33BCOD includes 10/Uterus, display "UTERUS".
IF HA33B - HA33BCOD includes 11/Other, display response in HA33B - CNROTHOS.

IF HA33D - MYOCARD = 1/Yes, display "MYOCARDIAL INFARCTION OR HEART ATTACK".

IF HA33E - CATAROP = 1/Yes, display "CATARACTS".

HA33G Verbatim Text

Question Text

What was the original cause of (SP)'s becoming eligible for Medicare?

RECORD VERBATIM

Field 1: OTHCAUS

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA17B

BOX HA15E

Box Instructions

IF RESPONDENT REPORTED MORE THAN ONE CONDITION IN HA28B-HA33E, GO TO HA33H - HA33HCOD.

ELSE, GO TO BOX HA17B.

Other Programming Instructions

Design Notes

RESPONDENT REPORTED MORE THAN ONE CONDITION IN HA28B-HA33E =

More than one of the following conditions are indicated:
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 1/AlzheimersDisease
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 2/ Anemia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 3/ AnxietyDisorder
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 4/ Aphasia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 5/ Arthritis
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 6/ AsthmaCOPD
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 7/ AtrialFibDysrythmias
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 8/ BenignProstaticHyperplasia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 9/ Cancer
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 10/ CataractsGlaucomaMD
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 11/ CerebralPalsy
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 12/ CVATIASStroke
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 13/ Cirrhosis
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 14/ CAD
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 15/ DVTPEPTE
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 16/ Dementia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 17/ Depression
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 18/ DiabetesMellitus
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 19/ GERDUlcer
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 20/ HeartFailure
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 21/ HemiplegiaHemiparesis
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 22/ HipFracture
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 23/ HuntingtonsDisease
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 24/ Hyperkalemia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 25/ Hyperlipidemia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 26/ Hypertension
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 27/ Hyponatremia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 28/ Malnutrition
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 29/ ManicDepressionBipolarDisease
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 30/ MultipleSclerosis
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 31/ NeurogenicBladder
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 32/ ObstructiveUropathy
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 33/ OrthostaticHypotension
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 34/ Osteoporosis
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 35/ OtherFacture
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 36/ Paralegia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 37/ ParkinsonsDisease
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 38/ PVDPAD
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 39/ PTSD
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 40/ PsychoticDisorder
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 41/ Quadriplegia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 42/ RenalInsuficiency
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 43/ RespiratoryFailure
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 44/ Schizophrenia
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 45/ SeizureDisorderEpilepsy
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 46/ ThyroidDisorder
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 47/ TourettesSyndrome
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 48/ TraumaticBrainInjury
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 49/ UlcerativeColitisCrohns
HA28B - HA28BCD1 or HA28B2 - HA28BCD2 includes 91/ Other

HA29B - HA29BCOD includes 1/MultiDrugResistantOrganism
HA29B - HA29BCOD includes 2/Pneumonia
HA29B - HA29BCOD includes 3/Septicemia
HA29B - HA29BCOD includes 4/Tuberculosis
HA29B - HA29BCOD includes 5/ UrinaryTractInfectionInLast30Days
HA29B - HA29BCOD includes 6/ViralHepatitis
HA29B - HA29BCOD includes 7/WoundInfection

HA31B - HA31BCOD includes 1/Agitation
HA31B - HA31BCOD includes 2/AlcoholDependency
HA31B - HA31BCOD includes 3/Allergies
HA31B - HA31BCOD includes 4/Anorexia
HA31B - HA31BCOD includes 5/AorticStenosis
HA31B - HA31BCOD includes 6/Ataxia
HA31B - HA31BCOD includes 7/AtypicalPsychosis
HA31B - HA31BCOD includes 8/Blindness
HA31B - HA31BCOD includes 9/BreastDisorders
HA31B - HA31BCOD includes 11/CerebralDegeneration
HA31B - HA31BCOD includes 12/ClinicalObesity
HA31B - HA31BCOD includes 13/ClostridiumDifficile
HA31B - HA31BCOD includes 14/Conjunctivitis
HA31B - HA31BCOD includes 15/Constipation
HA31B - HA31BCOD includes 16/DegenerativeJointDisease
HA31B - HA31BCOD includes 17/DiaphragmaticHernia
HA31B - HA31BCOD includes 18/DiverticulaOfColon
HA31B - HA31BCOD includes 19/DownsSyndrome
HA31B - HA31BCOD includes 20/Dysphagia
HA31B - HA31BCOD includes 21/Edema
HA31B - HA31BCOD includes 22/GastritisDuodenitis
HA31B - HA31BCOD includes 23/GastroenteritisNoninfectious
HA31B - HA31BCOD includes 24/GastrointestinalHemorrhage
HA31B - HA31BCOD includes 25/Gout
HA31B - HA31BCOD includes 26/HemorrhageOfEsophagus
HA31B - HA31BCOD includes 27/HIVInfection
HA31B - HA31BCOD includes 28/HyperplasiaOfProstate
HA31B - HA31BCOD includes 29/HypopotassemiaHypokalemia
HA31B - HA31BCOD includes 30/HypotensionOtherThanOrthostatic
HA31B - HA31BCOD includes 31/Insomnia
HA31B - HA31BCOD includes 32/Kyphosis
HA31B - HA31BCOD includes 33/MissingLimb
HA31B - HA31BCOD includes 34/NonpsychoticBrainSyndrome
HA31B - HA31BCOD includes 35/OrganicBrainSyndrome
HA31B - HA31BCOD includes 36/Osteoarthritis
HA31B - HA31BCOD includes 37/PathologicalBoneFracture
HA31B - HA31BCOD includes 38/RenalUreteralDisorder
HA31B - HA31BCOD includes 39/RespiratoryInfection
HA31B - HA31BCOD includes 40/Scoliosis
HA31B - HA31BCOD includes 41/SexuallyTransmittedDiseases
HA31B - HA31BCOD includes 42/SpinalStenosis
HA31B - HA31BCOD includes 43/UlcerOfLegChronic
HA31B - HA31BCOD includes 44/UrinaryRetention
HA31B - HA31BCOD includes 45/Vertigo
HA31B - HA31BCOD includes 91/Other1
HA31B - HA31BCOD includes 92/Other2
HA31B - HA31BCOD includes 93/Other3
HA31B - HA31BCOD includes 94/Other4

HA33 - HA33CODE includes 1/Agitation
HA33 - HA33CODE includes 2/AlcoholDependency
HA33 - HA33CODE includes 3/Allergies
HA33 - HA33CODE includes 4/Anorexia
HA33 - HA33CODE includes 5/AorticStenosis
HA33 - HA33CODE includes 6/Ataxia
HA33 - HA33CODE includes 7/AtypicalPsychosis
HA33 - HA33CODE includes 8/Blindness
HA33 - HA33CODE includes 9/BreastDisorders
HA33 - HA33CODE includes 11/CerebralDegeneration
HA33 - HA33CODE includes 12/ClinicalObesity
HA33 - HA33CODE includes 13/ClostridiumDifficile
HA33 - HA33CODE includes 14/Conjunctivitis
HA33 - HA33CODE includes 15/Constipation
HA33 - HA33CODE includes 16/DegenerativeJointDisease
HA33 - HA33CODE includes 17/DiaphragmaticHernia
HA33 - HA33CODE includes 18/DiverticulaOfColon
HA33 - HA33CODE includes 19/DownsSyndrome
HA33 - HA33CODE includes 20/Dysphagia
HA33 - HA33CODE includes 21/Edema
HA33 - HA33CODE includes 22/GastritisDuodenitis
HA33 - HA33CODE includes 23/GastroenteritisNoninfectious
HA33 - HA33CODE includes 24/GastrointestinalHemorrhage
HA33 - HA33CODE includes 25/Gout
HA33 - HA33CODE includes 26/HemorrhageOfEsophagus
HA33 - HA33CODE includes 27/HIVInfection
HA33 - HA33CODE includes 28/HyperplasiaOfProstate
HA33 - HA33CODE includes 29/HypopotassemiaHypokalemia
HA33 - HA33CODE includes 30/HypotensionOtherThanOrthostatic
HA33 - HA33CODE includes 31/Insomnia
HA33 - HA33CODE includes 32/Kyphosis
HA33 - HA33CODE includes 33/MissingLimb
HA33 - HA33CODE includes 34/NonpsychoticBrainSyndrome
HA33 - HA33CODE includes 35/OrganicBrainSyndrome
HA33 - HA33CODE includes 36/Osteoarthritis
HA33 - HA33CODE includes 37/PathologicalBoneFracture
HA33 - HA33CODE includes 38/RenalUreteralDisorder
HA33 - HA33CODE includes 39/RespiratoryInfection
HA33 - HA33CODE includes 40/Scoliosis
HA33 - HA33CODE includes 41/SexuallyTransmittedDiseases
HA33 - HA33CODE includes 42/SpinalStenosis
HA33 - HA33CODE includes 43/UlcerOfLegChronic
HA33 - HA33CODE includes 44/UrinaryRetention
HA33 - HA33CODE includes 45/Vertigo
HA33 - HA33CODE includes 91/Other1
HA33 - HA33CODE includes 92/Other2
HA33 - HA33CODE includes 93/Other3
HA33 - HA33CODE includes 94/Other4

HA33B - HA33BCOD includes 1/Bladder
HA33B - HA33BCOD includes 2/Breast
HA33B - HA33BCOD includes 3/Cervix
HA33B - HA33BCOD includes 4/ColonRectumBowel
HA33B - HA33BCOD includes 5/Lung
HA33B - HA33BCOD includes 6/Ovary
HA33B - HA33BCOD includes 7/Prostate
HA33B - HA33BCOD includes 8/Skin
HA33B - HA33BCOD includes 9/Stomach
HA33B - HA33BCOD includes 10/Uterus
HA33B - HA33BCOD includes 11/Other

HA33D - MYOCARD = 1/Yes

HA33E - CATAROP = 1/Yes

HA33H Code All

Question Text

Which of these conditions was a cause of (him/her) becoming eligible for Medicare?

Field 1: HA33HCOD

Field 1 Routing

Value	Label	Route
1	PLEASE SEE ITEM DISPLAY INSTRUCTIONS	BOX HA17B

Other Programming Instructions

Design Notes

Note:
Please build a list of response options (Conditions) based on responses selected/indicated in questions HA28B, HA28B2, HA29B, HA31B, HA33, HA33B, HA33D, and HA33E. Store response option label.hsf

BOX HA17B

Box Instructions

IF SP IS FEMALE, GO TO HA43APRE - HA43APRC.

ELSE GO TO HA43DAPR - HA43DAPC.

HA43APRE Code 1

Question Text

The next items are about procedures (SP) may have had since (CURRENT MONTH AND DAY) a year ago.

PRESS "1" TO CONTINUE.

Field 1: HA43APRC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA43A - MAMMOGR

HA43A Yes/No

Question Text

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a mammogram or breast x-ray?

Field 1: MAMMOGR

Field 1 Routing

Value	Label	Route
0	NO	HA43B - PAPSMEAR
1	YES	HA43B - PAPSMEAR
	Don't Know	HA43B - PAPSMEAR
	Refused	HA43B - PAPSMEAR

HA43B Yes/No

Question Text

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a Pap smear?

Field 1: PAPSMEAR

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17C
1	YES	BOX HA17C
	Don't Know	BOX HA17C
	Refused	BOX HA17C

BOX HA17C

Box Instructions

IF SP IS CFC or SP IS SSM OR ((SP IS FFC OR SP IS FCF) AND PreloadSP.HYSTFLAG <> 1/Indicated), GO TO HA43D - EVERHYST.

ELSE IF PreloadSP.HYSTFLAG = 1/Indicated, GO TO BOX HA17CB.

ELSE, GO TO HA43C - HYSTEREC.

HA43C Yes/No

Question Text

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a hysterectomy?

Field 1: HYSTEREC

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17CB
1	YES	BOX HA17CB
	Don't Know	BOX HA17CB
	Refused	BOX HA17CB

HA43D Yes/No

Question Text

Has (SP) ever had a hysterectomy?

Field 1: EVERHYST

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17CB
1	YES	BOX HA17CB
	Don't Know	BOX HA17CB
	Refused	BOX HA17CB

HA43DAPR Code 1

Question Text

The next items are about procedures (SP) may have had since (MONTH & DAY OF TODAY'S DATE) a year ago.

PRESS "1" TO CONTINUE.

Field 1: HA43DAPC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA43DA - DRECEXAM

HA43DA Yes/No

Question Text

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a digital rectal examination of the prostate?

Field 1: DRECEXAM

Field 1 Routing

Value	Label	Route
0	NO	HA43DB - BLOODPSA
1	YES	HA43DB - BLOODPSA
	Don't Know	HA43DB - BLOODPSA
	Refused	HA43DB - BLOODPSA

HA43DB Yes/No

Question Text

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a blood test for detection of prostate cancer, such as a PSA?

Field 1: BLOODPSA

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17CB
1	YES	BOX HA17CB
	Don't Know	BOX HA17CB
	Refused	BOX HA17CB

BOX HA17CB

Box Instructions

IF FALL ROUND, GO TO HA43DC - FLUSHOT.

ELSE GO TO BOX HA17CA.

HA43DC Yes/No

Question Text

Next, a question or two about shots people take to prevent certain illnesses. Did (SP) have a flu shot for last winter?

[EXPLAIN IF NECESSARY: Did (SP) have a flu shot anytime during the period from September (HS PREVIOUS YEAR) through December (HS PREVIOUS YEAR)?]

Field 1: FLUSHOT

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17CA
1	YES	BOX HA17CA
	Don't Know	BOX HA17CA
	Refused	BOX HA17CA

BOX HA17CA

Box Instructions

IF PreloadSP.PSHOTFLG = 1/Indicated, GO TO HA43E - EVRSMOKE.

ELSE GO TO HA43DD - PNUESHOT.

HA43DD Yes/No

Question Text

Has (SP) ever had a shot for pneumonia?

Field 1: PNUESHOT

Field 1 Routing

Value	Label	Route
0	NO	HA43E - EVRSMOKE
1	YES	HA43E - EVRSMOKE
	Don't Know	HA43E - EVRSMOKE
	Refused	HA43E - EVRSMOKE

HA43E Yes/No

Question Text

The next couple of questions are about smoking. Has (SP) ever smoked cigarettes, cigars, or pipe tobacco?

Field 1: EVRSMOKE

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17D
1	YES	BOX HA17D
	Don't Know	BOX HA17D
	Refused	BOX HA17D

BOX HA17D

Box Instructions

IF HA11B - COMATOSE = 1/YesComatose, GO TO BOX HA23B.

ELSE IF HA43E - EVRSMOKE = 1/Yes AND SP IS ALIVE, GO TO HA43F - NOWSMOKE.

ELSE GO TO HA43GPRE - HA43GPRC.

HA43F Yes/No

Question Text

Does (SP) smoke now?

Field 1: NOWSMOKE

Field 1 Routing

Value	Label	Route
0	NO	HA43GPRE - HA43GPRC
1	YES	HA43GPRE - HA43GPRC
	Don't Know	HA43GPRE - HA43GPRC
	Refused	HA43GPRE - HA43GPRC

HA43GPRE Code 1

Question Text

Now I'm going to ask about how difficult it was, on the average, for (SP) to do certain kinds of activities on or around (HS REF DATE). Please tell me for each activity whether (SP) had no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or was not able to do it.

PRESS "1" TO CONTINUE.

Field 1: HA43GPRC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA43G - IADSTOOP

HA43G Code 1

Question Text

SHOW CARD HA6

On or around (HS REF DATE), how much difficulty, if any, did (SP) have…

Field 1: IADSTOOP

stooping, crouching, or kneeling?

Field 1 Routing

Value	Label	Route
0	NO DIFFICULTY AT ALL	HA43G - IADLIFT
1	A LITTLE DIFFICULTY	HA43G - IADLIFT
2	SOME DIFFICULTY	HA43G - IADLIFT
3	A LOT OF DIFFICULTY	HA43G - IADLIFT
4	NOT ABLE TO DO IT	HA43G - IADLIFT
	Don't Know	HA43G - IADLIFT
	Refused	HA43G - IADLIFT

Field 2: IADLIFT

lifting or carrying objects as heavy as 10 pounds, like a sack of potatoes?

Field 2 Routing

Value	Label	Route
0	NO DIFFICULTY AT ALL	HA43G - IADREACH
1	A LITTLE DIFFICULTY	HA43G - IADREACH
2	SOME DIFFICULTY	HA43G - IADREACH
3	A LOT OF DIFFICULTY	HA43G - IADREACH
4	NOT ABLE TO DO IT	HA43G - IADREACH
	Don't Know	HA43G - IADREACH
	Refused	HA43G - IADREACH

Field 3: IADREACH

reaching or extending arms above shoulder level?

Field 3 Routing

Value	Label	Route
0	NO DIFFICULTY AT ALL	HA43G - IADGRASP
1	A LITTLE DIFFICULTY	HA43G - IADGRASP
2	SOME DIFFICULTY	HA43G - IADGRASP
3	A LOT OF DIFFICULTY	HA43G - IADGRASP
4	NOT ABLE TO DO IT	HA43G - IADGRASP
	Don't Know	HA43G - IADGRASP
	Refused	HA43G - IADGRASP

Field 4: IADGRASP

either writing or handling and grasping small objects?

Field 4 Routing

Value	Label	Route
0	NO DIFFICULTY AT ALL	HA43G - IADWALK
1	A LITTLE DIFFICULTY	HA43G - IADWALK
2	SOME DIFFICULTY	HA43G - IADWALK
3	A LOT OF DIFFICULTY	HA43G - IADWALK
4	NOT ABLE TO DO IT	HA43G - IADWALK
	Don't Know	HA43G - IADWALK
	Refused	HA43G - IADWALK

Field 5: IADWALK

walking a quarter of a mile - that is, about 2 or 3 blocks?

Field 5 Routing

Value	Label	Route
0	NO DIFFICULTY AT ALL	HA43H1 - DIFUSEPH
1	A LITTLE DIFFICULTY	HA43H1 - DIFUSEPH
2	SOME DIFFICULTY	HA43H1 - DIFUSEPH
3	A LOT OF DIFFICULTY	HA43H1 - DIFUSEPH
4	NOT ABLE TO DO IT	HA43H1 - DIFUSEPH
	Don't Know	HA43H1 - DIFUSEPH
	Refused	HA43H1 - DIFUSEPH

HA43H1 Code 1

Question Text

Now I'm going to ask about some everyday activities and whether
(SP) had any difficulty doing them by (himself/herself) because of a
health or physical problem on or around (HS REF DATE).

Did (SP) have any difficulty on or around (HS REF DATE) using the telephone?

Field 1: DIFUSEPH

Field 1 Routing

Value	Label	Route
0	NO	HA43H2 - DIFSHOP
1	YES	HA43H2 - DIFSHOP
3	DOESN'T DO	HA43I1 - REASNOPH
	Don't Know	HA43H2 - DIFSHOP
	Refused	HA43H2 - DIFSHOP

HA43I1 Code 1

Question Text

You said that using the telephone is something that (SP) doesn't do.

Is this because of a health or physical problem?

Field 1: REASNOPH

Field 1 Routing

Value	Label	Route
0	NO	HA43H2 - DIFSHOP
1	YES	HA43H2 - DIFSHOP
	Don't Know	HA43H2 - DIFSHOP
	Refused	HA43H2 - DIFSHOP

HA43H2 Code 1

Question Text

Did (SP) have any difficulty on or around (HS REF DATE) shopping for personal items (such as toilet items or medicines)?

Field 1: DIFSHOP

Field 1 Routing

Value	Label	Route
0	NO	HA43H3 - DIFMONEY
1	YES	HA43H3 - DIFMONEY
3	DOESN'T DO	HA43I2 - REASNOSH
	Don't Know	HA43H3 - DIFMONEY
	Refused	HA43H3 - DIFMONEY

HA43I2 Code 1

Question Text

You said that shopping is something that (SP) doesn't do.

Is this because of a health or physical problem?

Field 1: REASNOSH

Field 1 Routing

Value	Label	Route
0	NO	HA43H3 - DIFMONEY
1	YES	HA43H3 - DIFMONEY
	Don't Know	HA43H3 - DIFMONEY
	Refused	HA43H3 - DIFMONEY

HA43H3 Code 1

Question Text

Did (SP) have any difficulty on or around (HS REF DATE) managing money (like keeping track of money or paying bills)?

Field 1: DIFMONEY

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17F
1	YES	BOX HA17F
3	DOESN'T DO	HA43I3 - REASNOMM
	Don't Know	BOX HA17F
	Refused	BOX HA17F

HA43I3 Code 1

Question Text

You said that managing money is something that (SP) doesn't do.

Is this because of a health or physical problem?

Field 1: REASNOMM

Field 1 Routing

Value	Label	Route
0	NO	BOX HA17F
1	YES	BOX HA17F
	Don't Know	BOX HA17F
	Refused	BOX HA17F

BOX HA17F

Box Instructions

IF SP IS ALIVE, GO TO HA43J - SPHEALTH.

ELSE GO TO BOX HA23B.

HA43J Code 1

Question Text

[Finally, I have a few questions on (SP)'s general health.]

In general, compared to other people of (his/her) age, would you say that (SP)'s health is excellent, very good, good, fair or poor?

Field 1: SPHEALTH

Field 1 Routing

Value	Label	Route
0	EXCELLENT	HA43K - GENHLTH
1	VERY GOOD	HA43K - GENHLTH
2	GOOD	HA43K - GENHLTH
3	FAIR	HA43K - GENHLTH
4	POOR	HA43K - GENHLTH
	Don't Know	HA43K - GENHLTH
	Refused	HA43K - GENHLTH

HA43K Code 1

Question Text

Compared to one year ago, how would you rate (SP)'s health in general now? Would you say (SP)'s health is . . .

Field 1: GENHLTH

Field 1 Routing

Value	Label	Route
0	much better now than one year ago,	HA43L - LIMACTIV
1	somewhat better now than one year ago,	HA43L - LIMACTIV
2	about the same,	HA43L - LIMACTIV
3	somewhat worse now than one year ago, or	HA43L - LIMACTIV
4	much worse now than one year ago?	HA43L - LIMACTIV
	Don't Know	HA43L - LIMACTIV
	Refused	HA43L - LIMACTIV

HA43L Code 1

Question Text

How much of the time during the past month has (SP)'s health limited (his/her) social activities, like visiting with friends or close relatives? Would you say . . .

Field 1: LIMACTIV

Field 1 Routing

Value	Label	Route
0	none of the time,	BOX HA23B
1	some of the time,	BOX HA23B
2	most of the time, or	BOX HA23B
3	all of the time?	BOX HA23B
	Don't Know	BOX HA23B
	Refused	BOX HA23B

BOX HA23B

Box Instructions

IF BQ9-EDLEVELF = DK, RF, OR EMPTY, GO TO HA51B - HEDULEV.

ELSE GO TO BOX HA24.

HA51B Code 1

Question Text

As far as you know, what (is/was) the highest level of schooling (SP) completed?

IF DK, USE CATEGORIES AS PROBES.

Field 1: HEDULEV

Field 1 Routing

Value	Label	Route
1	NO FORMAL SCHOOLING	BOX HA24
2	ELEMENTARY (1ST-8TH GRADES)	BOX HA24
3	SOME HIGH SCHOOL (9TH-12TH GRADES)	BOX HA24
4	COMPLETED HIGH SCHOOL, NO COLLEGE	BOX HA24
5	TECHNICAL OR TRADE SCHOOL	BOX HA24
6	SOME COLLEGE	BOX HA24
7	COLLEGE GRADUATE	BOX HA24
8	GRADUATE DEGREE	BOX HA24
	Don't Know	BOX HA24
	Refused	BOX HA24

BOX HA24

Box Instructions

IF HS2REF <> EMPTY OR DK AND (HS2DOI = EMPTY OR HA1PRE2T2 - HA1PRE2C = 1/Continue), GO TO BOX HAT2BEG.

ELSE GO TO HC2 - DIDABSTR.

Variable Name	Assignment Instructions
HSDISP	If HS2REF <> EMPTY or DK, then HSDISP = 93/Breakoff
HS1DOI	If HS1REF <> EMPTY and HS1DOI = EMPTY, then HS1DOI = today's date
HSCDOI	If HSCREF <> EMPTY and HSCDOI = EMPTY, then HSCDOI = today's date
HSFORMS	If HS2REF = EMPTY or DK and HA2 - RECFORMS = 1/Yes, then PERS. HSFORMS = 1/Indicated. Else PERS.HSFORMS = EMPTY.

HC2 Code 1

Question Text

DID YOU ABSTRACT?

Field 1: DIDABSTR

Field 1 Routing

Value	Label	Route
1	ALL	HC3 - WHYABSTR
2	MAJORITY	HC3 - WHYABSTR
3	HALF	HC3 - WHYABSTR
4	SOME	HC3 - WHYABSTR
5	NONE	BOX HCEND

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HSDISP	HSDISP = 96/Complete

HC3 Code 1

Question Text

WHY DID YOU ABSTRACT?

Field 1: WHYABSTR

Field 1 Routing

Value	Label	Route
1	NO KNOWLEDGEABLE RESPONDENT AVAILABLE	BOX HCEND
2	NO TIME/STAFF BURDEN TOO GREAT	BOX HCEND
3	REFUSAL--UNWILLING TO COOPERATE	BOX HCEND
91	OTHER	HC3 - WHYABSOS

Field 2: WHYABSOS

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HCEND

BOX HCEND

Box Instructions

GO TO HSFINSCR2 - FINSCRN2.

BOX HAT2BEG

Box Instructions

IF FACR.HAINTFLG <> 1/Indicated, GO TO HA1PRE1T2 - HA1PRE1C.

ELSE GO TO HA1PRE2T2 - HA1PRE2C.

HA1PRE1T2 Code 1

Question Text

The next questions are about (SP)'s health status on or around (T2 REF DATE). We have found that much of the data we are collecting is usually located in the resident's (full Minimum Data Set (MDS) assessments, the Quarterly Review forms, and other medical chart notes/medical record). Please take a moment to locate the records now and confirm they are the records closest to (T2 REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA1PRE1C

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA1PRE2T2 - HA1PRE2C

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HAINTFLG	FACR.HAINTFLG = 1/Indicated.

HA1PRE2T2 Code 1

Question Text

[Those are all of the questions we have about (SP)'s health on (HS REF DATE). Now, I would like to ask some questions about (his/her) health at (T2 REF DATE)./The following questions are about (SP)'s health status on or around (T2 REF DATE)].

PRESS "1" TO CONTINUE.

Field 1: HA1PRE2C

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA2T2

Other Programming Instructions

Report Display

Display report above question text.
Display all stays where STAY.XSTPLAC <> 000 that were reported for this SP in
chronological order by start date of the stay.
Report header: STAY TIMELINE
Report layout:
Column 1, header="Place Name", display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM = STAY.XSTPLAC.
Column 2, header="Start Date", display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month, day
year format.
Column 3, header="End Date", display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month, day
year format.
Column 4, header="Stay Type", display STAY.STAYCLAS.

BOX HA2T2

Box Instructions

IF HA2-RECFORMS = 1/Yes OR (HA2-RECFORMS = EMPTY AND Prelaod.HSFORMS = 1/Indicated), GO TO HA2BT2 - RECFORM2.

ELSE IF HS1REF <> EMPTY, GO TO HA9PREBT2 - HA9PRBC.

ELSE GO TO HA1T2 - RECHAVE.

HA1T2 Yes/No

Question Text

Do you have (SP)'s medical records for the period on or around (T2 REF DATE)?

Field 1: RECHAVE

Field 1 Routing

Value	Label	Route
0	NO	HA1BT2 - HSCONTN1
1	YES	BOX HA2AT2
	Don't Know	HA1BT2 - HSCONTN1
	Refused	HA9PREBT2 - HA9PRBC

HA1BT2 Code 1

Question Text

Is there someone else I should speak with, or do the records exist elsewhere?

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE MEDICAL RECORDS?

Field 1: HSCONTN1

Field 1 Routing

Value	Label	Route
0	NO, RETURN TO NAVIGATE SCREEN	BOX HCENDT2
1	YES, CONTINUE WITHOUT MEDICAL RECORDS	HA9PREBT2 - HA9PRBC

BOX HA2AT2

Box Instructions

IF (PLACTYPE = 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF OR 17/RehabilitationFacility) OR FQ.COMPLEXF = 1/Indicated, GO TO HA2T2 - RECFORMS.

ELSE GO TO HA9PREBT2 - HA9PRBC.

HA2T2 Yes/No

Question Text

Do the medical records contain any full MDS assessment or Quarterly Review Forms?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: RECFORMS

Field 1 Routing

Value	Label	Route
0	NO	HA2B1T2 - HSCONTN2
1	YES	HA2BT2 - RECFORM2

HA2B1T2 Code 1

Question Text

Is there someone else I should speak with, or do the records exist elsewhere?

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS FORMS?

Field 1: HSCONTN2

Field 1 Routing

Value	Label	Route
0	NO, RETURN TO NAVIGATE SCREEN	BOX HCENDT2
1	YES, CONTINUE WITHOUT MDS	HA9PREBT2 - HA9PRBC

HA2BT2 Yes/No

Question Text

Do (SP)'s medical records contain (a full/another) MDS assessment or Quarterly Review form dated [after (PreloadSP.PRVHSREF)/after (PreloadSP.LASTVAD)/on or around (T2 REF DATE)/after BCVAD)]?

Field 1: RECFORM2

Field 1 Routing

Value	Label	Route
0	NO	HA2CT2 - HSCONTN3
1	YES	HA3BT2 - ASSESDT1

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
T2BEG	If PERS.BCVAD <> EMPTY then T2BEG = PERS.BCVAD + 1 day. Else if PreloadSP.LASTVAD <> EMPTY then T2BEG = PreloadSP.LASTVAD + 1 day. Else T2BEG = RAD + 14 days.
T2END	If RAD + 150 days > RHREFEND, then T2END = RHREFEND. Else T2END = RAD + 150 days.
T2TOT	T2TOT = 0

HA2CT2 Code 1

Question Text

Is there someone else I should speak with, or do the records exist elsewhere?

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT?

Field 1: HSCONTN3

Field 1 Routing

Value	Label	Route
0	NO, RETURN TO NAVIGATE SCREEN	BOX HCENDT2
1	YES, CONTINUE WITH THIS RESPONDENT	HA9PREBT2 - HA9PRBC

HA3BT2 Date

Question Text

What is the assessment date on the full MDS assessment or Quarterly Review that was completed closest to (T2 REF DATE) for (SP) after [(RAD+14)/BCVAD/PreloadSP.LASTVAD].

ENTER DATE IN "MM DD YY" FORMAT.

(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)

Field 1: ASSESDT1

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA4T2
	Don't Know	BOX HA4T2
	Refused	BOX HA4T2

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
T2TOT	T2TOT = T2TOT + 1
FORMRNDC	T2FORM[T2TOT].FORMRNDC = current round
FORMNUM	T2FORM[T2TOT].FORMNUM = T2TOT

Design Notes

HA3BT2-ASSESDT1, FORMNUM, FORMRNDC, T2VALID, HA4T2 - FORMTYPE, and HA7BT2 - ASSESDT2 should be stored in T2FORM[15] array.

Each pass through HA3BT2 - ASSESDT1 or HA7BT2 - ASSESDT2 should fill an element of the array.

Abbreviations:
BCVAD = Baseline Closest Valid Assessment Date
BL = Baseline
CCVAD = Core Closest Valid Assessment Date
DOI = Date of Interview
DOB = Date of Birth
FAD = First Admission Date
HS = Health Status
RAD = Recent Admission Date
TCVAD = Time 2 Closest Valid Assessment Date
DOD = Date of Death

BOX HA4T2

Box Instructions

IF HA3BT2 - ASSESDT1 = DK, RF AND FIRST TIME AT HA3BT2 - ASSESDT1, GO TO HA9PREBT2 - HA9PRBC.

ELSE GO TO BOX HA5T2.

Variable Name	Assignment Instructions
T2ASSESSDATE	T2ASSESSDATE = HA3BT2 - ASSESDT1
T2VALID	If HA3BT2 - ASSESDT1 <> DK, RF and HA3BT2 - ASSESDT1 >= T2BEG and HA3BT2 - ASSESDT1 <= T2END, then T2FORM[T2TOT].T2VALID = 1/Indicated. Else T2FORM[T2TOT].T2VALID = EMPTY.

BOX HA5T2

Box Instructions

IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3BT2 - ASSESDT1 IS VALID, GO TO BOX HA6T2.

ELSE GO TO HA5T2 - CLOSFORM.

BOX HA6T2

Box Instructions

OBTAIN STATE NAME FROM FACILITY'S ADDRESS. IF STATE NAME IS MS OR SD, GO TO BOX HA7T2.

ELSE GO TO HA4T2 - FORMTYPE1.

Variable Name	Assignment Instructions
EVERFULL	If State Name is MS or SD, EVERFULL = 1/Indicated.
FORMTYPE	If State Name is MS or SD, T2FORM[T2TOT].FORMTYPE = 1/FullMDS.

HA4T2 Code 1

Question Text

Please tell me if the form with the assessment date of (T2 ASSESS DATE) is a full MDS or a quarterly review.

Field 1: FORMTYPE1

Field 1 Routing

Value	Label	Route
0	QUARTERLY REVIEW	BOX HA7T2
1	FULL MDS	BOX HA7T2
	Don't Know	BOX HA7T2
	Refused	BOX HA7T2

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
EVERFULL	If HA4T2 - FORMTYPE1 = 1/FullMDS, then EVERFULL = 1/Indicated
FORMTYPE	T2FORM[T2TOT].FORMTYPE = HA4T2 - FORMTYPE1.

BOX HA7T2

Box Instructions

IF MOST RECENT ASSESSMENT DATE IS COMPLETE THEN COMPARE WITH T2 REF DATE. IF NUMBER OF DAYS BETWEEN ASSESSMENT DATE AND T2 REF DATE MORE THAN +/- 7, GO TO HA5T2 - CLOSFORM.

ELSE GO TO BOX HA9T2A.

HA5T2 Yes/No

Question Text

Besides the form you just told me about, does (SP)'s medical record contain any other MDS form or Quarterly Review form dated closer to (T2 REF DATE)?

Field 1: CLOSFORM

Field 1 Routing

Value	Label	Route
0	NO	BOX HA8T2
1	YES	BOX HA8T2
	Don't Know	BOX HA8T2
	Refused	BOX HA8T2

BOX HA8T2

Box Instructions

IF HA5T2 - CLOSFORM = 1/Yes, GO TO HA3BT2 - ASSESDT1.

ELSE GO TO BOX HA9T2A.

Variable Name	Assignment Instructions

BOX HA9T2A

Box Instructions

IF T2TOT = 1 AND (FORMTYPE = DK, RF, OR EMPTY), GO TO HA9PREBT2 - HA9PRBC.

ELSE GO TO BOX HA9T2B.

Variable Name	Assignment Instructions
T2SORTARRAY	If T2TOT > 1, then T2SORTARRAY = T2FORM array sorted by dates closest to HS2REF (+ or - days)
CLOSESTFULL	If T2TOT > 1 and EVERFULL = 1/Indicated, then CLOSESTFULL = FORMNUM of the first element of T2SORTARRAY where FORMTYPE = 1\FullMDS. Else CLOSESTFULL = EMPTY.

BOX HA9T2B

Box Instructions

GO TO BOX HA9T2C.

Variable Name	Assignment Instructions
TCVAD	PERS.TCVAD = HA3BT2 - ASSESDT1 of T2SORTARRAY[1]
XPRIMARY	XPRIMARY = FORMNUM of T2SORTARRAY[1]
CVATYPE	If T2SORTARRAY[1].FORMTYPE = 1/FullMDS, DK, or RF, then CVATYPE = 1/FullMDS. Else CVATYPE = 0/QuarterlyReview
XBACKUP	If CVATYPE = 0/QuarterlyReview and CLOSESTFULL <> EMPTY, then XBACKUP = CLOSESTFULL
XBACKUPDATE	If XBACKUP <> EMPTY, then XBACKUPDATE = HA3BT2 - ASSESDT1 of FORMNUM = XBACKUP

BOX HA9T2C

Box Instructions

IF CVATYPE = 1/FullMDS, GO TO HA6T2 - FORMREAS.

ELSE IF CVATYPE = 0/QuarterlyReview, AND XBACKUP = EMPTY, GO TO HA7AT2 - RECMDS.

ELSE GO TO HA7CT2 - MDSINT1.

Variable Name	Assignment Instructions
T2BDATE	If BCVAD <> EMPTY, then T2BDATE = BCVAD + 1 day. Else if PreloadSP.LASTVAD <> EMPTY then T2BDATE = PreloadSP.LASTVAD + 1 day. Else T2BDATE = FAD + 15 days.
T2BDATE2	If BCVAD <> EMPTY, then T2BDATE = BCVAD + 1 day. Else if PreloadSP.LASTVAD <> EMPTY then T2BDATE = PreloadSP.LASTVAD + 1 day. Else T2BDATE = RAD + 14 days.
T2EDATE	If RAD + 270 days > RHREFEND, then T2EDATE = RHREFEND. Else T2EDATE = RAD + 270 days.

HA6T2 Code 1

Question Text

What was the primary reason for the assessment on the full MDS assessment dated (TCVAD)?

Field 1: FORMREAS

Field 1 Routing

Value	Label	Route
1	ADMISSION	HA7CT2 - MDSINT1
2	ANNUAL	HA7CT2 - MDSINT1
3	SIGNIFICANT CHANGE IN STATUS	HA7CT2 - MDSINT1
91	OTHER	HA6T2 - FORMREOS
	Don't Know	HA7CT2 - MDSINT1
	Refused	HA7CT2 - MDSINT1

Field 2: FORMREOS

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	HA7CT2 - MDSINT1

HA7AT2 Yes/No

Question Text

Does (SP)'s medical record contain a full MDS assessment dated between (T2 DATE RANGE).

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: RECMDS

Field 1 Routing

Value	Label	Route
0	NO	HA7CT2 - MDSINT1
1	YES	HA7BT2 - ASSESDT2
	Don't Know	HA7CT2 - MDSINT1
	Refused	HA7CT2 - MDSINT1

HA7BT2 Numeric

Question Text

What is the date of the full MDS assessment closest to (T2 REF DATE)?

IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.

Field 1: ASSESDT2

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA10T2
	Don't Know	BOX HA10T2
	Refused	BOX HA10T2

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
T2TOT	T2TOT = T2TOT + 1
FORMRNDC	T2FORM[T2TOT].FORMRNDC = current round
FORMNUM	T2FORM[T2TOT].FORMNUM = T2TOT
T2VALID	If HA7BT2 - ASSESDT2 <> DK, RF and HA7BT2 - ASSESDT2 >= T2BDATE2 and HA7BT2 - ASSESDT2 <= T2EDATE, then T2FORM[T2TOT].T2VALID = 1/Indicated. Else T2FORM[T2TOT].T2VALID = EMPTY.

BOX HA10T2

Box Instructions

GO TO HA7CT2 - MDSINT1.

Variable Name	Assignment Instructions
XBACKUP	If T2FORM[T2TOT].T2VALID = 1/Indicated, then XBACKUP = T2TOT. Else XBACKUP = EMPTY.
XBACKUPDATE	IF XBACKUP <> EMPTY, then XBACKUPDATE = HA7BT2 - ASSESDT2. Else XBACKUPDATE = EMPTY.

HA7CT2 Code 1

Question Text

Please refer to the (FORM TYPE) with the assessment date of (CLOSEST VALID ASSESSMENT DATE) when answering the following questions. [If the information is not found on the Quarterly Review, please refer to the full MDS form with the assessment date of (BACKUP MDS ASSESSMENT DATE)/If the information is not found on the MDS form, please refer to (SP)'s medical record) to answer the questions.]

PRESS "1" TO CONTINUE.

Field 1: MDSINT1

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HA19AT2

BOX HA19AT2

Box Instructions

GO TO HA11BT2 - COMATOSE.

HA9PREBT2 Code 1

Question Text

Now I have some questions concerning (SP)'s health on or around (T2 REF DATE). [Since I will be collecting information about (SP) on or around (T2 REF DATE) and there is no MDS or Quarterly Review available close to that date, please refer to (SP)'s medical record for the information/Since you do not have a medical record at hand for reference, please think about the information found in (SP)'s medical record) to answer these questions.]

PRESS "1" TO CONTINUE.

Field 1: HA9PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA11BT2 - COMATOSE

HA11BT2 Code 1

Question Text

Was (SP) in a persistent vegetative state with no discernible consciousness on (T2 REF DATE)?

Field 1: COMATOSE

Field 1 Routing

Value	Label	Route
0	NO (NOT COMATOSE)	HA12AABT2 - MENTCON
1	YES (COMATOSE)	HA39BT2 - FCWEIGHT
	Don't Know	HA12AABT2 - MENTCON
	Refused	HA12AABT2 - MENTCON

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HSDISP	HSDISP = 92/ReadyToInterview

HA12AABT2 Yes/No

Question Text

Should a brief interview for Mental Status (C0200-C0500) be conducted?

Field 1: MENTCON

Field 1 Routing

Value	Label	Route
0	NO	HA12PREBT2 - HA12PRBC
1	YES	HA12ABT2 - MENTSUM
	Don't Know	HA12PREBT2 - HA12PRBC
	Refused	HA12PREBT2 - HA12PRBC

HA12ABT2 Numeric

Question Text

ENTER SUMMARY SCORE (0 -15) FROM BIMS.

ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.

Field 1: MENTSUM

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA13BT2
	Don't Know	BOX HA13BT2
	Refused	BOX HA13BT2

HA12PREBT2 Code 1

Question Text

The next series of questions deal with (SP)'s memory or recall ability.

PRESS "1" TO CONTINUE.

Field 1: HA12PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA12BT2 - CSMEMST

HA12BT2 Code 1

Question Text

On or around (T2 REF DATE), was (SP)'s short-term memory okay, that is, did (he/she) seem or appear to recall things after 5 minutes?

Field 1: CSMEMST

Field 1 Routing

Value	Label	Route
0	MEMORY OK	HA13BT2 - CSMEMLT
1	MEMORY PROBLEM	HA13BT2 - CSMEMLT
	Don't Know	HA13BT2 - CSMEMLT
	Refused	HA13BT2 - CSMEMLT

HA13BT2 Code 1

Question Text

Was (SP)'s long-term memory okay; that is, did (she/he) seem or appear to recall events in the distant past?

Field 1: CSMEMLT

Field 1 Routing

Value	Label	Route
0	MEMORY OK	HA14BT2 - HA14BCOD
1	MEMORY PROBLEM	HA14BT2 - HA14BCOD
	Don't Know	HA14BT2 - HA14BCOD
	Refused	HA14BT2 - HA14BCOD

HA14BT2 Code All

Question Text

On or around (T2 REF DATE), was (SP) able to recall…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Field 1: HA14BCOD

Field 1 Routing

Value	Label	Route
1	the current season?	HA15BT2 - CSDECIS
2	the location of (her/his) own room?	HA15BT2 - CSDECIS
3	staff names or faces?	HA15BT2 - CSDECIS
4	the fact that (she/he) was in a nursing home?	HA15BT2 - CSDECIS
96	NONE CHECKED	HA15BT2 - CSDECIS
	Don't Know	HA15BT2 - CSDECIS

HA15BT2 Code 1

Question Text

How skilled was (SP) in making daily decisions? Was (she/he) independent, did (she/he) exhibit modified independence, was (she/he) moderately impaired, or was (she/he) severely impaired?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: CSDECIS

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	BOX HA13BT2
1	MODIFIED INDEPENDENCE	BOX HA13BT2
2	MODERATELY IMPAIRED	BOX HA13BT2
3	SEVERELY IMPAIRED	BOX HA13BT2
	Don't Know	BOX HA13BT2
	Refused	BOX HA13BT2

BOX HA13BT2

Box Instructions

GO TO HA21BT2 - BSAYSOT.

HA21BT2 Code 1

Question Text

How often did the following behavioral problems occur on or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSAYSOT

Physical behavior symptoms directed toward others.

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21BT2 - BSVERBOT
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21BT2 - BSVERBOT
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21BT2 - BSVERBOT
3	BEHAVIOR OCCURRED DAILY	HA21BT2 - BSVERBOT
	Don't Know	HA21BT2 - BSVERBOT
	Refused	HA21BT2 - BSVERBOT

Field 2: BSVERBOT

Verbal behavior symptoms directed toward others.

Field 2 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21BT2 - BSNOTOT
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21BT2 - BSNOTOT
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21BT2 - BSNOTOT
3	BEHAVIOR OCCURRED DAILY	HA21BT2 - BSNOTOT
	Don't Know	HA21BT2 - BSNOTOT
	Refused	HA21BT2 - BSNOTOT

Field 3: BSNOTOT

Other behavioral symptoms not directed toward others.

Field 3 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	BOX HA21BT2
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	BOX HA21BT2
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	BOX HA21BT2
3	BEHAVIOR OCCURRED DAILY	BOX HA21BT2
	Don't Know	BOX HA21BT2
	Refused	BOX HA21BT2

BOX HA21BT2

Box Instructions

IF HA21BT2 - BSAYSOT and HA21BT2 - BSVERBOT and HA21BT2 - BSNOTOT = 0/BehaviorNotExhibited, GO TO HA21CBT2 - BSNOEVAL.

ELSE GO TO HA21ABT2 - BSELFILL.

HA21ABT2 Yes/No

Question Text

Did any of (SP)'s behavior…

Field 1: BSELFILL

put the resident at significant risk for physical illness or injury?

Field 1 Routing

Value	Label	Route
0	NO	HA21ABT2 - BSELFCAR
1	YES	HA21ABT2 - BSELFCAR
	Don't Know	HA21ABT2 - BSELFCAR
	Refused	HA21ABT2 - BSELFCAR

Field 2: BSELFCAR

significantly interfere with the resident's care?

Field 2 Routing

Value	Label	Route
0	NO	HA21ABT2 - BSELFACT
1	YES	HA21ABT2 - BSELFACT
	Don't Know	HA21ABT2 - BSELFACT
	Refused	HA21ABT2 - BSELFACT

Field 3: BSELFACT

significantly interfere with the resident's participation in activities or social interactions?

Field 3 Routing

Value	Label	Route
0	NO	HA21BBT2 - BSOTHILL
1	YES	HA21BBT2 - BSOTHILL
	Don't Know	HA21BBT2 - BSOTHILL
	Refused	HA21BBT2 - BSOTHILL

HA21BBT2 Yes/No

Question Text

Did any of (SP)'s behavior…

Field 1: BSOTHILL

put others at significant risk for physical illness or injury?

Field 1 Routing

Value	Label	Route
0	NO	HA21BBT2 - BSOTHACT
1	YES	HA21BBT2 - BSOTHACT
	Don't Know	HA21BBT2 - BSOTHACT
	Refused	HA21BBT2 - BSOTHACT

Field 2: BSOTHACT

significantly intrude on the privacy or activities of others?

Field 2 Routing

Value	Label	Route
0	NO	HA21BBT2 - BSOTHENV
1	YES	HA21BBT2 - BSOTHENV
	Don't Know	HA21BBT2 - BSOTHENV
	Refused	HA21BBT2 - BSOTHENV

Field 3: BSOTHENV

significantly disrupt care or living environment?

Field 3 Routing

Value	Label	Route
0	NO	HA21CBT2 - BSNOEVAL
1	YES	HA21CBT2 - BSNOEVAL
	Don't Know	HA21CBT2 - BSNOEVAL
	Refused	HA21CBT2 - BSNOEVAL

HA21CBT2 Code 1

Question Text

How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and well-being on or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSNOEVAL

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA21DBT2 - BSOFTWAN
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21DBT2 - BSOFTWAN
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21DBT2 - BSOFTWAN
3	BEHAVIOR OCCURRED DAILY	HA21DBT2 - BSOFTWAN
	Don't Know	HA21DBT2 - BSOFTWAN
	Refused	HA21DBT2 - BSOFTWAN

HA21DBT2 Code 1

Question Text

How often did (SP) wander on or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?

Field 1: BSOFTWAN

Field 1 Routing

Value	Label	Route
0	BEHAVIOR NOT EXHIBITED	HA22PREBT2 - HA22PRBC
1	BEHAVIOR OCCURRED 1 TO 3 DAYS	HA21EBT2 - BSWDANGR
2	BEHAVIOR OCCURRED 4 TO 6 DAYS	HA21EBT2 - BSWDANGR
3	BEHAVIOR OCCURRED DAILY	HA21EBT2 - BSWDANGR
	Don't Know	HA21EBT2 - BSWDANGR
	Refused	HA21EBT2 - BSWDANGR

HA21EBT2 Yes/No

Question Text

Did any of (SP)'s wandering…

Field 1: BSWDANGR

place the resident at significant risk of getting to a potentially dangerous place?

Field 1 Routing

Value	Label	Route
0	NO	HA21EBT2 - BSWOTACT
1	YES	HA21EBT2 - BSWOTACT
	Don't Know	HA21EBT2 - BSWOTACT
	Refused	HA21EBT2 - BSWOTACT

Field 2: BSWOTACT

significantly intrude on the privacy or activities of others?

Field 2 Routing

Value	Label	Route
0	NO	HA22PREBT2 - HA22PRBC
1	YES	HA22PREBT2 - HA22PRBC
	Don't Know	HA22PREBT2 - HA22PRBC
	Refused	HA22PREBT2 - HA22PRBC

HA22PREBT2 Code 1

Question Text

The next questions are about (SP)'s ability to perform Activities of Daily Living or ADLs, on or around (T2 REF DATE).

I will read you a list of activities and would like you to tell me if (SP)'s self-performance was independent, required supervision, required limited assistance, required extensive assistance, was totally dependent, or if the activity did not occur. [By self-performance I mean what (SP) actually did for (himself/herself) and how much help was required by staff members.]

PRESS "1" TO CONTINUE.

Field 1: HA22PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA22BT2 - PFTRNSFR

HA22BT2 Code 1

Question Text

(SHOW CARD HA1)

Please tell me (SP)'s level of self-performance in…

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: PFTRNSFR

transferring (for example, in and out of bed).

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	HA22BT2 - PFLOCOMO
1	SUPERVISION	HA22BT2 - PFLOCOMO
2	LIMITED ASSISTANCE	HA22BT2 - PFLOCOMO
3	EXTENSIVE ASSISTANCE	HA22BT2 - PFLOCOMO
4	TOTAL DEPENDENCE	HA22BT2 - PFLOCOMO
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22BT2 - PFLOCOMO
8	ACTIVITY DID NOT OCCUR	HA22BT2 - PFLOCOMO
	Don't Know	HA22BT2 - PFLOCOMO
	Refused	HA22BT2 - PFLOCOMO

Field 2: PFLOCOMO

locomotion on unit.

Field 2 Routing

Value	Label	Route
0	INDEPENDENT	HA22BT2 - PFDRSSNG
1	SUPERVISION	HA22BT2 - PFDRSSNG
2	LIMITED ASSISTANCE	HA22BT2 - PFDRSSNG
3	EXTENSIVE ASSISTANCE	HA22BT2 - PFDRSSNG
4	TOTAL DEPENDENCE	HA22BT2 - PFDRSSNG
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22BT2 - PFDRSSNG
8	ACTIVITY DID NOT OCCUR	HA22BT2 - PFDRSSNG
	Don't Know	HA22BT2 - PFDRSSNG
	Refused	HA22BT2 - PFDRSSNG

Field 3: PFDRSSNG

dressing.

Field 3 Routing

Value	Label	Route
0	INDEPENDENT	HA22BT2 - PFEATING
1	SUPERVISION	HA22BT2 - PFEATING
2	LIMITED ASSISTANCE	HA22BT2 - PFEATING
3	EXTENSIVE ASSISTANCE	HA22BT2 - PFEATING
4	TOTAL DEPENDENCE	HA22BT2 - PFEATING
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22BT2 - PFEATING
8	ACTIVITY DID NOT OCCUR	HA22BT2 - PFEATING
	Don't Know	HA22BT2 - PFEATING
	Refused	HA22BT2 - PFEATING

Field 4: PFEATING

eating.

Field 4 Routing

Value	Label	Route
0	INDEPENDENT	HA22BT2 - PFTOILET
1	SUPERVISION	HA22BT2 - PFTOILET
2	LIMITED ASSISTANCE	HA22BT2 - PFTOILET
3	EXTENSIVE ASSISTANCE	HA22BT2 - PFTOILET
4	TOTAL DEPENDENCE	HA22BT2 - PFTOILET
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA22BT2 - PFTOILET
8	ACTIVITY DID NOT OCCUR	HA22BT2 - PFTOILET
	Don't Know	HA22BT2 - PFTOILET
	Refused	HA22BT2 - PFTOILET

Field 5: PFTOILET

using the toilet.

Field 5 Routing

Value	Label	Route
0	INDEPENDENT	HA23BT2 - PFBATHNG
1	SUPERVISION	HA23BT2 - PFBATHNG
2	LIMITED ASSISTANCE	HA23BT2 - PFBATHNG
3	EXTENSIVE ASSISTANCE	HA23BT2 - PFBATHNG
4	TOTAL DEPENDENCE	HA23BT2 - PFBATHNG
7	ACTIVITY OCCURRED ONLY ONCE OR TWICE	HA23BT2 - PFBATHNG
8	ACTIVITY DID NOT OCCUR	HA23BT2 - PFBATHNG
	Don't Know	HA23BT2 - PFBATHNG
	Refused	HA23BT2 - PFBATHNG

HA23BT2 Code 1

Question Text

Again referring to the time on or around (T2 REF DATE), what was (SP)'s level of self-performance when bathing: was (she/he) independent, did (she/he) require supervision, require physical help limited to transfer only, require physical help in part of the bathing activity, was (she/he) totally dependent, or did the activity not occur?

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: PFBATHNG

Field 1 Routing

Value	Label	Route
0	INDEPENDENT	HA24PREBT2 - HA24PRBC
1	SUPERVISION	HA24PREBT2 - HA24PRBC
2	PHYSICAL HELP LIMITED TO TRANSFER ONLY	HA24PREBT2 - HA24PRBC
3	PHYSICAL HELP IN PART OF BATHING ACTIVITY	HA24PREBT2 - HA24PRBC
4	TOTAL DEPENDENCE	HA24PREBT2 - HA24PRBC
8	ACTIVITY DID NOT OCCUR	HA24PREBT2 - HA24PRBC
	Don't Know	HA24PREBT2 - HA24PRBC
	Refused	HA24PREBT2 - HA24PRBC

HA24PREBT2 Code 1

Question Text

The next questions are about modes of locomotion and appliances or devices (SP) might have used on or around (T2 REF DATE).

PRESS "1" TO CONTINUE.

Field 1: HA24PRBC

Field 1 Routing

Value	Label	Route
1	CONTINUE	HA24BT2 - HA24BCOD

HA24BT2 Code All

Question Text

On or around (T2 REF DATE) did (he/she) use…

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Field 1: HA24BCOD

Field 1 Routing

Value	Label	Route
1	a cane or crutch?	BOX HA14BT2
2	a walker?	BOX HA14BT2
3	a manual or electric wheelchair?	BOX HA14BT2
4	a limb prosthesis?	BOX HA14BT2
96	NONE CHECKED	BOX HA14BT2
	Don't Know	BOX HA14BT2

BOX HA14BT2

Box Instructions

GO TO HA39BT2 - FCWEIGHT.

HA39BT2 Numeric

Question Text

What was (SP)'s weight on or around (T2 REF DATE)?

Field 1: FCWEIGHT

Field 1 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HA17BBT2
	Don't Know	BOX HA17BBT2
	Refused	BOX HA17BBT2

BOX HA17BBT2

Box Instructions

GO TO HC2T2 - DIDABSTR.

Variable Name	Assignment Instructions
HSFORMS	If HA2 - RECFORMS = 1/Yes OR HA2T2 - RECFORMS = 1/Yes OR HA2BT2 - RECFORMS = 1/Yes, then PERS.HSFORMS = 1/Indicated.
HS2DOI	If HS2REF <> EMPTY or DK and HS2DOI = EMPTY, then HS2DOI = today's date

HC2T2 Code 1

Question Text

DID YOU ABSTRACT?

Field 1: DIDABSTR

Field 1 Routing

Value	Label	Route
1	ALL	HC3T2 - WHYABSTR
2	MAJORITY	HC3T2 - WHYABSTR
3	HALF	HC3T2 - WHYABSTR
4	SOME	HC3T2 - WHYABSTR
5	NONE	BOX HCENDT2

Other Programming Instructions

Background Variable Assignments

Variable Name	Assignment Instructions
HSDISP	HSDISP = 96/Complete

HC3T2 Code 1

Question Text

WHY DID YOU ABSTRACT?

Field 1: WHYABSTR

Field 1 Routing

Value	Label	Route
1	NO KNOWLEDGEABLE RESPONDENT AVAILABLE	BOX HCENDT2
2	NO TIME/STAFF BURDEN TOO GREAT	BOX HCENDT2
3	REFUSAL--UNWILLING TO COOPERATE	BOX HCENDT2
91	OTHER	HC3T2 - WHYABSOS

Field 2: WHYABSOS

OTHER (SPECIFY)

Field 2 Routing

Value	Label	Route
1	[Continuous answer.]	BOX HCENDT2

BOX HCENDT2

Box Instructions

GO TO HSFINSCR2 - FINSCRN2.

HSFINSCR2 Code 1

Question Text

(RETURN TO NAVIGATOR TO CONTINUE INTERVIEW. THE HEALTH STATUS SECTION WAS NOT COMPLETED./YOU HAVE COMPLETED THE HEALTH STATUS SECTION FOR THIS SP.)

PRESS "1" TO TO CONTINUE.

Field 1: FINSCRN2

Field 1 Routing

Value	Label	Route
1	CONTINUE	HSFINSCR - FINSCRN

HSFINSCR Code 1

Question Text

PRESS "1" TO RETURN TO NAVIGATION SCREEN.

Field 1: FINSCRN

Field 1 Routing

Value	Label	Route
1	CONTINUE	BOX HSEND

Other Programming Instructions

Background Variable Assignments

HSDISP:
If HSPRE-HSPRECT = 2/ConsentRequired, HSDISP = 1/ConsentRequired.
Else if HSPRE-HSPRECT = 3/InitialRefusal, HSDISP = 4/InitialRefusal.
Else if HSCONREF-CONREFFN = 2/FinalConsentDenied, HSDISP = 11/FinalConsentDenied.
Else if HSCONREF-CONREFFN = 4/FinalRefusal, HSDISP = 12/FinalRefusal.

BOX HSEND

Box Instructions

GO TO NAVIGATOR