Cms-p-0015a Mcbs

Emergency Room Utilization (ERQ)
Variable Name
MR Screen Name

Question type

Question text/description

ERPROBE

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you gone/has (SP) gone/did (SP) go] to a hospital emergency
room for medical care?

ER1

Code list
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]

PROVIDER_ER

ER2

roster

Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]

(01) continuous answer
(-8) Don't Know
(-9) Refused
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
PROVNAME

ER2

verbatim
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL]
NAME:

GROUPNAM

ER2
BOX ER1

VAPLACE

ER3

BOX ER1B

verbatim

GROUP:

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ER3 - VAPLACE.
ELSE GO TO BOX ER1B.

yes/no

Is (PROVIDER NAME) a Department of Veterans Affairs, or V.A., facility?

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ER3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ER3B - HMOREFER.
ELSE GO TO ER4 - EVENT_ER.

HMOASSOC

ER3A

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

ER3B

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Emergency Room Utilization (ERQ)
Variable Name
MR Screen Name

Question type

EVENT_ER

roster

ERADD

ER4

ER4B

Question text/description
When did [you/(SP)] go to the emergency room at (PROVIDER NAME)?
Please tell me all the dates [since REFERENCE DATE/UTILDATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE SAMPLE PERSON SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
HAVE ALL DATES BEEN ENTERED?

choose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.

NAVIGATOR

ER4_IN

instance navigator
[DISPLAY ALL EVENTS ADDED AT ER6]
[EVENT DATE, PROVIDER]

ERADMIT

ER6

yes/no

[Were you/Was (SP)] admitted to (PROVIDER NAME) from the emergency room?

PRESMDCN

ER7

yes/no

During [your/(SP’s)] visit to the emergency room, were any medicines prescribed for [you/(SP)]?

PRESFILL

ERPMMEDS

ER8

yes/no

BOX ER3A

routing

ER8A

no entry

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHETHER OR
NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE
MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
ER8A - ERPMMEDS.
ELSE GO TO ER9 - MEDICINE_ER.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]

Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
(01) continuous answer

MEDICINE_ER
(MED for R71)

ER9

roster

Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.

[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

Emergency Room Utilization (ERQ)
Variable Name
MR Screen Name
PMEDNAME
ER9
PMSTRUNI
ER9

Question type
verbatim
verbatim

ADDP

roster

ER9B

Question text/description
NAME:
STRENGTH:
MEDICATIONS FILLED DURING THIS VISIT
[DISPLAY ALL MEDICINES ADDED AT MED]
GO TO ER4_IN - NAVIGATOR.

BOX ER4

routing
[LOOP THROUGH ALL DETAILED QUESTIONS FOR EACH EVENT BEFORE CONTINUING TO ER10]

ERMORE

ER10

yes/no

BOX ER5

routing

BOX ER6

routing

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to the emergency room at this or
any other hospital?
IF FALL ROUND AND ((SP REPORTED AN EMERGENCY ROOM VISIT AT ER2) AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED)), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX ER6.
GO TO NEXT SECTION

Code list

(01) ADD ANOTHER
(02) ALL DONE
(01) ADD ANOTHER
(02) ALL DONE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused