CMS-P-0015A Fac2017R79US

2017 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE
INTERVIEW)
(04) FINAL REFUSAL

(01) US1PRE - US1PRECT
(02) USEND - USENDCT
(03) US1PRE - US1PRECT)
(04) USEND - USENDCT

USE OF HEALTH SERVICES SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF
SEASON= ALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.

BOX USBEG

CONREFFN

USCONREF

routing

code one

IF USDISP = 1/ConsentRequired OR USDISP = 4/InitialRefusal, GO TO USCONREF - CONREFFN.
ELSE GO TO US1PRE - US1PRECT.

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

This series of questions is about the health care services that (SP) may have received between (US
REFERENCE START DATE) and (US REFERENCE END DATE) while (he/she) resided in (FACILITY).

US1PRECT

US1PRE

code one

[The questions include any services that (he/she) received outside this (facility/home), as well as care from any (01) CONTINUE
(02) CONSENT REQUIRED
providers who saw (him/her) here. The kinds of services I will be asking about include physician care, dental
care, mental health services, various kinds of therapies, and care from other kinds of health care providers. I (03) INITIAL REFUSAL
will be asking about the type of provider and the frequency or duration of the services. Please do not include
care while (he/she) was an overnight inpatient in an acute care hospital.]

(01) US1 - OUTMDVST
(02) USEND - USENDCT
(03) USEND - USENDCT

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) US3 - INMDVST
(01) US2 - OUTMDFRQ
(-8) US3 - INMDVST
(-9) US3 - INMDVST

OUTMDVST

US1

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE) while a resident in this
(facility/home), did (SP) see a medical doctor of any kind, outside the (facility/home), excluding mental health
therapy provided by a psychiatrist?

OUTMDFRQ

US2

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she)
see doctors outside this (facility/home)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US3 – INMDVST
(-8) US3 – INMDVST
(-9) US3 – INMDVST

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a medical
doctor of any kind, here, in this (facility/home), excluding mental health therapy provided by a psychiatrist?

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

(00) US6PRE - US6PRECT
(01) US5A - ANYMDFRQ
(-8) US3A - US3ACT
(-9) US6PRE - US6PRECT

(01) Continue

(01) BOX USEND

INMDVST

US3

Please tell me the name and title of someone in (FACILITY) who could give me that information.

US3ACT

US3A

code one

Thank you for your time, those are all the questions I have for you. Right now I need to continue with
[PERSON NAMED] to complete these questions.
PRESS "CTRL/R" TO ADD A PERSON TO THE PERSON ROSTER.
PRESS "1" TO CONTINUE.

ANYMDFRQ

US6PRECT

US5A

US6PRE

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she)
see any doctor here?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US6PRE - US6PRECT
(-8) US6PRE - US6PRECT
(-9) US6PRE - US6PRECT

code one

The following questions are about services used both inside and outside this (facility/home). We are only
interested in services (SP) received while residing in (FACILITY).
PRESS "1" TO CONTINUE.

(01) Continue

(01) US6 - DENTVST

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

(00) US8 - MENTLVST
(01) US7 - DENTFRQ
(-8) US8 - MENTLVST
(-9) US8 - MENTLVST

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US8 - MENTLVST
(-8) US8 - MENTLVST
(-9) US8 - MENTLVST

DENTVST

US6

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a dentist,
dental surgeon, dental assistant, or any other professional for dental care?

DENTFRQ

US7

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she)
see a dentist, dental surgeon, dental assistant, or any other professional for dental care?

yes/no

(00) NO
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a psychiatrist (01) YES
or any other mental health care professional either inside or outside this (facility/home)?
(-8) Don't Know
(-9) Refused

MENTLVST

US8

(00) US12 - PHYSTHPY
(01) US9 - PSYCHTYP
(-8) US12 - PHYSTHPY
(-9) US12 - PHYSTHPY

Page 1 of 5

2017 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description

Code List

What type of mental health specialist did (he/she) see?

(01) LICENSED CLINICAL SOCIAL WORKER
(02) PSYCHIATRIC NURSE
(03) PSYCHIATRIC SOCIAL WORKER
(04) PSYCHIATRIST
(05) PSYCHOLOGIST
(91) OTHER

[PROBE: Any others?]
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

PSYCHTYP

US9

code all

PSYCHOS

US9

verbatim

OTHER (SPECIFY)

BOX US10A

routing

IF US9-PSYCHTYP INCLUDES 1/LicensedClinicalSocWork, GO TO US10A - LCSOWSES.
ELSE GO TO BOX US10B.

LCSOWSES

US10A

Numeric

LCSOWTYP

US11A

BOX US10B

Routing
(01) BOX US10A
(02) BOX US10A
(03) BOX US10A
(04) BOX US10A
(05) BOX US10A
(91) US9 - PSYCHOS

(01) [Continuous Answer]

(01) BOX US10A

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a licensed clinical social worker?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11A - LCSOWTYP
(-8) US11A - LCSOWTYP
(-9) US11A - LCSOWTYP

code one

Were these individual sessions, group sessions, or some of both?

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) BOX US10B
(02) BOX US10B
(03) BOX US10B

routing

IF US9-PSYCHTYP INCLUDES 2/PsychiatricNurse, GO TO US10B - PSCNUSES.
ELSE GO TO BOX US10C.
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a psychiatric nurse?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11B - PSCNUTYP
(-8) US11B - PSCNUTYP
(-9) US11B - PSCNUTYP

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) BOX US10C
(02) BOX US10C
(03) BOX US10C

PSCNUSES

US10B

PSCNUTYP

US11B

code one

Were these individual sessions, group sessions, or some of both?

BOX US10C

routing

IF US9-PSYCHTYP INCLUDES 3/PsychiatricSocWork, GO TO US10C - PSSOWSES.
ELSE GO TO BOX US10D.

PSSOWSES

US10C

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a psychiatric social worker?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11C - PSSOWTYP
(-8) US11C - PSSOWTYP
(-9) US11C - PSSOWTYP

PSSOWTYP

US11C

code one

Were these individual sessions, group sessions, or some of both?

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) BOX US10D
(02) BOX US10D
(03) BOX US10D

BOX US10D

routing

IF US9-PSYCHTYP INCLUDES 4/Psychiatrist, GO TO US10D - PSCIASES.
ELSE GO TO BOX US10E.

PSCIASES

US10D

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a psychiatrist?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11D - PSCIATYP
(-8) US11D - PSCIATYP
(-9) US11D - PSCIATYP

PSCIATYP

US11D

code one

Were these individual sessions, group sessions, or some of both?

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) BOX US10E
(02) BOX US10E
(03) BOX US10E

BOX US10E

routing

IF US9-PSYCHTYP INCLUDES 5/Psychologist, GO TO US10E - PSCOLSES.
ELSE GO TO BOX US10F.

PSCOLSES

US10E

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a psychologist?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11E - PSCOLTYP
(-8) US11E - PSCOLTYP
(-9) US11E - PSCOLTYP

PSCOLTYP

US11E

code one

Were these individual sessions, group sessions, or some of both?

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) BOX US10F
(02) BOX US10F
(03) BOX US10F

BOX US10F

routing

IF US9-PSYCHTYP INCLUDES 91/Other, GO TO US10F - PSOTRSES.
ELSE GO TO US12 - PHYSTHPY.

PSOTRSES

US10F

Numeric

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits
did (he/she) have to a (OTHER MENTAL HEALTH SPECIALIST)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US11F - PSOTRTYP
(-8) US11F - PSOTRTYP
(-9) US11F - PSOTRTYP

PSOTRTYP

US11F

code one

Were these individual sessions, group sessions, or some of both?

(01) INDIVIDUAL
(02) GROUP
(03) BOTH

(01) US12 - PHYSTHPY
(02) US12 - PHYSTHPY
(03) US12 - PHYSTHPY

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a therapist
such as a physical therapist, speech therapist, I.V. therapist, occupational therapist, or respiratory therapist?

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

(00) US22A - PODRTHPY
(01) US13 - PHTPYWKL
(-8) US22A - PODRTHPY
(-9) US22A - PODRTHPY

PHYSTHPY

US12

Page 2 of 5

2017 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description
SHOW CARD US1

PHTPYWKL

US13

code one

Please look at this card and tell me about how often each week therapy was provided.
PRESS F1 FOR INFORMATION ON "ONE-TIME EVALUATION".

PHTPYFRQ

PODRTHPY

US14

US22A

code one

yes/no

SHOW CARD US2
Now look at this card. Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over
how long a period was therapy provided?

Between (US REFERENCE START DATE) and (US REFERENCE END DATE) was (SP) seen by a podiatrist
(either inside or outside this (facility/home))?
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) receive
educational or habilitational services (either inside or outside this (facility/home))?

EDHBSERV

US23

yes/no
[PROBE: "Habilitational services" include training in daily living skills, self care, and so on, in a structured
program.]

EDUORHAB

EDHABFRQ

HABFRQ

OTHCPROV

US24

code one

US25

code one

BOX US2

routing

US27

US29

code one

yes/no

TYPHCPRV

US30

code all

TYPPRVOS

US30

verbatim

Were those services educational, habilitational, or both?

SHOW CARD US2
Please look at this card and tell me, between (US REFERENCE START DATE) and (US REFERENCE END
DATE), over how long a period were these (educational/habilitational) services provided?

Code List

Routing

(01) LESS THAN ONCE A WEEK
(02) ONCE OR TWICE A WEEK
(03) 3 TO 5 TIMES A WEEK
(04) MORE THAN 5 TIMES A WEEK
(05) ONE-TIME EVALUATION
(-8) Don't Know
(-9) Refused

(01) US14 – PHTPYFRQ
(02) US14 – PHTPYFRQ
(03) US14 – PHTPYFRQ
(04) US14 – PHTPYFRQ
(05) US22A - PODRTHPY
(-8) US14 – PHTPYFRQ
(-9) US22A - PODRTHPY

(01) LESS THAN 1 WEEK
(02) 1 TO 3 WEEKS
(03) 4 TO 8 WEEKS
(04) MORE THAN 8 WEEKS BUT NOT THE WHOLE
TIME
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused

(01) US22A - PODRTHPY
(02) US22A - PODRTHPY
(03) US22A - PODRTHPY
(04) US22A - PODRTHPY
(05) US22A - PODRTHPY
(-8) US22A - PODRTHPY
(-9) US22A - PODRTHPY

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

(00) US23 - EDHBSERV
(01) US23 - EDHBSERV
(-8) US23 - EDHBSERV
(-9) US23 - EDHBSERV

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

(00) US29 - OTHCPROV
(01) US24 - EDUORHAB
(-8) US29 - OTHCPROV
(-9) US29 - OTHCPROV

(01) EDUCATIONAL
(02) HABILITATIONAL
(03) BOTH
(-8) Don't Know
(-9) Refused

(01) US25 - EDHABFRQ
(02) US25 - EDHABFRQ
(03) US25 - EDHABFRQ
(-8) US25 - EDHABFRQ
(-9) US29 - OTHCPROV

(01) LESS THAN 1 WEEK
(02) 1 TO 3 WEEKS
(03) 4 TO 8 WEEKS
(04) MORE THAN 8 WEEKS BUT NOT THE WHOLE
TIME
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused

(01) BOX US2
(02) BOX US2
(03) BOX US2
(04) BOX US2
(05) BOX US2
(-8) BOX US2
(-9) BOX US2

IF US24-EDUORHAB = 3/Both, THEN GO TO US27 - HABFRQ.
ELSE GO TO US29 - OTHCPROV.

SHOW CARD US2
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how long a period were
these habilitational services provided?

(01) LESS THAN 1 WEEK
(02) 1 TO 3 WEEKS
(03) 4 TO 8 WEEKS
(04) MORE THAN 8 WEEKS BUT NOT THE WHOLE
TIME
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused

SHOW CARD US3 FOR PROMPTING AS NEEDED.
(00) NO
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) receive care from
(01) YES
any other licensed or certified health care provider (either inside or outside this (facility/home))?
(-8) Don't Know
PRESS F1 FOR "ANY OTHER PROVIDER" CLARIFICATION.
(-9) Refused

What kind of provider was that?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

OTHER (SPECIFY)

(01) US29 - OTHCPROV
(02) US29 - OTHCPROV
(03) US29 - OTHCPROV
(04) US29 - OTHCPROV
(05) US29 - OTHCPROV
(-8) US29 - OTHCPROV
(-9) US29 - OTHCPROV

(00) US31PRE - US31PRCT
(01) US30 - TYPHCPRV
(-8) US31PRE - US31PRCT
(-9) US31PRE - US31PRCT

(01) AUDIOLOGIST
(02) DIETICIAN
(03) LABORATORY TECHNICIAN
(04) NURSE PRACTITIONER
(05) OPHTHALMOLOGIST
(06) OPTOMETRIST
(07) PHYSICIAN'S ASSISTANT
(08) RECREATIONAL THERAPIST
(09) REGISTERED NURSE
(10) SOCIAL WORKER
(11) X-RAY TECHNICIAN
(91) OTHER

(01) US31PRE - US31PRCT
(02) US31PRE - US31PRCT
(03) US31PRE - US31PRCT
(04) US31PRE - US31PRCT
(05) US31PRE - US31PRCT
(06) US31PRE - US31PRCT
(07) US31PRE - US31PRCT
(08) US31PRE - US31PRCT
(09) US31PRE - US31PRCT
(10) US31PRE - US31PRCT
(11) US31PRE - US31PRCT
(91) US30 - TYPPRVOS

(01) [Continuous Answer]

(01) US31PRE - US31PRCT

Page 3 of 5

2017 MCBS Facility Instrument

Variable Name

US31PRCT

MR Screen Name

US31PRE

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

code all

The next few questions are about any visits (SP) may have made to a hospital emergency room from (US
REFERENCE START DATE) through (US REFERENCE END DATE). Please do not include visits to the
emergency room that were immediately followed by inpatient hospital stays.

(01) Continue

(01) US32 - ERVISITS

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

(00) US37 - RETSMDAY
(01) US33 - ERVSTMM
(-8) US37 - RETSMDAY
(-9) US37 - RETSMDAY

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US33 - ERVSTDD
(-8) US33 - ERVSTDD
(-9) US33 - ERVSTDD

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) US33 - ERVSTYY
(-8) US33 - ERVSTYY
(-9) US33 - ERVSTYY

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX US33
(-8) BOX US33
(-9) BOX US33

PRESS "1" TO CONTINUE.

ERVISITS

ERVSTMM

US32

US33

yes/no

grid

While (he/she) was in this (facility/home), did (he/she) make any visits to a hospital emergency room between
(US REFERENCE START DATE) and (US REFERENCE END DATE)?
COLLECT ALL ER VISITS.
Please tell me all dates (SP) made a visit to a hospital emergency room between (US REFERENCE START
DATE) and (US REFERENCE END DATE).
[PROBE: Were there any more visits to the ER?]
IF NO MORE DATES, PRESS ENTER TO CONTINUE.

ERVSTDD

US33

grid

COLLECT ALL ER VISITS.
Please tell me all dates (SP) made a visit to a hospital emergency room between (US REFERENCE START
DATE) and (US REFERENCE END DATE).
[PROBE: Were there any more visits to the ER?]
IF NO MORE DATES, PRESS ENTER TO CONTINUE.

ERVSTYY

US33

grid

COLLECT ALL ER VISITS.
Please tell me all dates (SP) made a visit to a hospital emergency room between (US REFERENCE START
DATE) and (US REFERENCE END DATE).
[PROBE: Were there any more visits to the ER?]
IF NO MORE DATES, PRESS ENTER TO CONTINUE.

BOX US33

routing

CREATE NEW EMERGENCY ROOM VISITS FOR EACH DATE ADDED AND GO TO US37 - RETSMDAY.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

RETSMDAY

US37

yes/no

[Besides the (health care providers and emergency room/health care providers/emergency room) visits you
have already told me about, did (he/she) ever go to the hospital and return on the same day/Did (he/she) ever
go to the hospital and return on the same day]?

RETSMFRQ

US38

Numeric

How many times did this happen between (US REFERENCE START DATE) and (US REFERENCE END
DATE)?

US40

code all

(01) AMBULANCE SERVICE
(02) CLOTH DIAPERS
(03) DIABETIC EQUIPMENT OR SUPPLIES
(04) DISPOSABLE DIAPERS
(05) EQUIPMENT OR SUPPLIES FOR KIDNEY
SHOW CARD US4
Now I'd like to ask you about any kind of supplies, equipment, or other types of medical services (SP) received DIALYSIS
other than the ones I've already mentioned. Please look at this first card and tell me what supplies or services (06) EYE GLASSES OR CONTACT LENSES
(07) HEARING AID OR OTHER COMMUNICATION
(SP) received between (US REFERENCE START DATE) and (US REFERENCE END DATE).
DEVICE
(08) ORTHOPEDIC ITEMS
SELECT ALL THAT APPLY.
(09) OSTOMY SUPPLIES
SEPARATE RESPONSES BY USING THE SPACEBAR.
(10) OXYGEN
(11) PROSTHESIS
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused

BOX US3

routing

IF US40-USEEQUIP INCLUDES DK OR RF, GO TO US43 - MSTURN.
ELSE GO TO US42 - USEEQUI2.

USEEQUIP

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) US40 - USEEQUIP
(01) US38 - RETSMFRQ
(-8) US40 - USEEQUIP
(-9) US40 - USEEQUIP
(01) US40 - USEEQUIP
(-8) US40 - USEEQUIP
(-9) US40 - USEEQUIP

(01) BOX US3
(02) BOX US3
(03) BOX US3
(04) BOX US3
(05) BOX US3
(06) BOX US3
(07) BOX US3
(08) BOX US3
(09) BOX US3
(10) BOX US3
(11) BOX US3
(96) BOX US3
(-8) BOX US3
(-9) BOX US3

Page 4 of 5

2017 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

USEEQUI2

US42

code all

(01) BEDSIDE COMMODE
(02) BED PADS (CLOTH OR DISPOSABLE)
(03) CATHETER AND CATHETER SUPPLIES
(04) FEEDING SUPPLIES (INCLUDE PUMPS,
SYRINGES, TUBES)
(05) G TUBE AND SUPPLIES
SHOW CARD US5
(06) GERI CHAIR
Please look at this second card and tell me what medical devices or equipment (he/she) received between (US
(07) HOSPITAL BED
REFERENCE START DATE) and (US REFERENCE END DATE).
(08) IV SUPPLIES
(09) NEBULIZER
SELECT ALL THAT APPLY.
(10) SPECIAL MATTRESS, CUSHIONS OR
SEPARATE RESPONSES BY USING THE SPACEBAR.
MATTRESS PADS (INCLUDING EGG CRATE, AIR)
(11) SUCTION MACHINE AND SUPPLIES
(12) TED HOSE AND SUPPLIES
(13) WHEELCHAIR/WALKER
(91) SOME OTHER TYPE OF DEVICE OR
EQUIPMENT
(96) NONE OF THE ABOVE

OTHREQOS

US42

verbatim

SOME OTHER TYPE OF DEVICE OR EQUIPMENT (SPECIFY)

(01) [Continuous Answer]

(01) US43 - MSTURN

list

Please tell me if (SP) received any of the following medical services. Did (he/she) receive… turning and
positioning?

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

(00) US43 - MSTUBE
(01) US43 - MSTUBE
(-8) US43 - MSTUBE
(-9) US43 - MSTUBE

Please tell me if (SP) received any of the following medical services. Did (he/she) receive… tubefeeding?

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

(00) US43 - MSRESTR
(01) US43 - MSRESTR
(-8) US43 - MSRESTR
(-9) US43 - MSRESTR

Please tell me if (SP) received any of the following medical services. Did (he/she) receive… restraints?

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

(00) US43 – MSINJECT
(01) US43 – MSINJECT
(-8) US43 – MSINJECT
(-9) US43 – MSINJECT

Please tell me if (SP) received any of the following medical services. Did (he/she) receive… injections?

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

(00) US45 - OTHMEDNC
(01) US45 - OTHMEDNC
(-8) US45 - OTHMEDNC
(-9) US45 - OTHMEDNC

MSTURN

MSTUBE

MSRESTR

MSINJECT

OTHMEDNC

US43

US43

US43

US43

US45

list

list

list

code all

SHOW CARD US6
Now I'd like to ask about any other medically necessary items or provider services (SP) received that we
haven't talked about already. Please look at this last card and tell me what other items or services (he/she)
received between (US REFERENCE START DATE) and (US REFERENCE END DATE)?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

OTHRSEOS

DIDABUS

US45

US46

verbatim

code one

(01) APPLYING/CHANGING DRESSINGS INCLUDING
BAND-AIDS
(02) APPLYING/MONITORING HOT PACKS
(03) CATHETERIZATION AND IRRIGATION
(04) FEEDING (WITH SPOON SYRINGE PUMP OR
OTHER DEVICE)
(05) G TUBE USE AND CARE
(06) INCONTINENCE
(07) IV USE AND CARE
(08) PACEMAKER CHECK
(09) SKIN TREATMENTS FOR
PREVENTION/TREATMENT OF SKIN ULCERS
(10) SUCTIONING
(91) SOME OTHER KIND OF ITEM OR SERVICE
(96) NONE OF THE ABOVE
(-8) Don't Know

(01) US43 - MSTURN
(02) US43 - MSTURN
(03) US43 - MSTURN
(04) US43 - MSTURN
(05) US43 - MSTURN
(06) US43 - MSTURN
(07) US43 - MSTURN
(08) US43 - MSTURN
(09) US43 - MSTURN
(10) US43 - MSTURN
(11) US43 - MSTURN
(12) US43 - MSTURN
(13) US43 - MSTURN
(91) US42 - OTHREQOS
(96) US43 - MSTURN

(01) US46 - DIDABUS
(02) US46 - DIDABUS
(03) US46 - DIDABUS
(04) US46 - DIDABUS
(05) US46 - DIDABUS
(06) US46 - DIDABUS
(07) US46 - DIDABUS
(08) US46 - DIDABUS
(09) US46 - DIDABUS
(10) US46 - DIDABUS
(91) US45 - OTHRSEOS
(96) US46 - DIDABUS
(-8) US46 - DIDABUS

SOME OTHER KIND OF ITEM OR SERVICE (SPECIFY)

(01) [Continuous Answer]

(01) US46 – DIDABUS

DID YOU ABSTRACT?

(01)ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE

(01) US47 - WHYABUS
(02) US47 - WHYABUS
(03) US47 - WHYABUS
(04) US47 - WHYABUS
(05) USEND - USENDCT
(01) USEND – USENDCT
(02) USEND – USENDCT
(03) USEND – USENDCT
(91) US47 - WHYABUOS

WHYABUS

US47

code one

WHY DID YOU ABSTRACT

(01) NO KNOWLEDGEABLE RESPONDENT
AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER

WHYABUOS

US47

verbatim

OTHER (SPECIFY)

(01) [Continuous Answer]

(01) USEND - USENDCT

USEND

code one

(YOU HAVE COMPLETED THE USE SECTION FOR THIS SP.)
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) Continue

(01) BOX USEND

BOX USEND

routing

GO TO NAVIGATOR

USENDCT

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