Electronic Medical Record (EMR) - Data Dictionary - Att

Attachment 8

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

EMR Data Dictionary

Public reporting burden of this collection of information is estimated to average 16 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

EMR Data Dictionaries

Appointment Data (from EMR or other electronic system)

Variable Name	Definition	Values
Appt_ID	Number identifying the record	[Number]
PHC_ID	Patient’s PHC study ID	[Short Text]
Appt_Date	The date of the appointment	MM/DD/YYYY
Appt_Time	The time of the appointment	HH:MM AM/PM
Appt_Type	The type of appointment	1 Primary care 2 Lab 3 Other
Appt_Attendance	The status of the appointment	1 Attended 2 Canceled

Clinical Outcomes – Demographics

Variable Name	Definition	Values
ClinicalOutcomes_ID	Number identifying the record.	[Number]
PHC_ID	Patient’s PHC study ID	[Short Text]
Pt_DOB	Patient’s date of birth	MM/DD/YYYY
Pt_BirthSex	Patient’s sex at birth	1 Male 2 Female 3 Unknown
Pt_Gender	Patient’s current gender identity	1 Male 2 Female 3 Transgender Male to Female 4 Transgender Female to Male 5 Other gender identity
Pt_Race	Patient’s racial identity	1 American Indian or Alaska Native 2 Asian 3 Black or African American 4 Native Hawaiian or Other Pacific Islander 5 White 6 More than one race 7 Not reported/Unknown
Pt_Ethnicity	Patient’s ethnic identity	0 Not Hispanic/Latino 1 Hispanic/Latino
Pt_RiskFactor	Patient’s HIV risk factor	1 Men who have sex with men 2 Injection drug user 3 MSM and IDU 4 Hemophilia/coagulation disorder 5 Receipt of transfusion of blood, blood components, or tissue 6 Mother with/at risk for HIV infection (perinatal transmission) 7 Other 8 Undetermined/unknown
Pt_Insurance	Patient’s insurance status	1 Private 2 Medicare 3 Medicaid 4 Other public 5 No insurance 6 Other 7 Unknown/unreported

Clinical Outcomes – STD Testing

Variable Name	Definition	Values
S_Lab_ID	Number identifying the record.	[Number]
PHC_ID	Patient’s PHC study ID	[Short Text]
Lab_Type	The type of STD screening	1 Syphillis 2 Chlamydia 3 Gonorrhea 4 Hepatitis B 5 Hepatitis C 6 Trichomoniasis
Lab_Result	STD screening result	1 Indeterminate 2 Negative 3 Positive 4 Presumptive 9 Unknown OR a numerical value
Lab_Date	Date of STD screening	MM/DD/YYYY

Clinical Outcomes – HIV Lab Results

Variable Name	Definition	Values
H_Lab_ID	Number identifying the record.	[Number]
PHC_ID	Patient’s PHC study ID	[Short Text]
Lab_Date	The date of the HIV lab	MM/DD/YYYY
Lab_Type	The type of HIV lab	1 Viral Load 2 CD4 Cell Count 3 CD4 Cell Percent
Lab_Result	The result of the HIV Lab; units are dependent on lab type: Viral load – copies/mL CD4 cell count – count/mL CD4 cell percent – CD4 cells/all cells	[Number]

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