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Illustrative table shells: Pre and Post Discharge Patient Questionnaires |
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Pre-Discharge Patient Questionnaire |
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Post-Discharge Patient Questionnaire 14/30/60 |
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Baseline |
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14 day followup |
30 day followup |
60 day followup |
Pre-Question(s) |
Variable |
Value |
Number |
Percent |
95% CI |
Post-Question(s) |
Number |
Percent |
95% CI |
Number |
Percent |
95% CI |
Number |
Percent |
95% CI |
1 |
Health Status |
Excellent |
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17 |
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Very Good |
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Good |
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Fair |
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Poor |
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13-17 |
ADLS |
0 |
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29-33 |
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1-2 |
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3+ |
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18-22 |
IADLS |
0 |
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34-38 |
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1-2 |
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3+ |
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23 |
Personal Care Assistance |
Yes |
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39 |
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24 |
Number of falls |
0 |
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12 |
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1 |
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2+ |
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25 |
Number of injury falls |
0 |
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NA |
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1 |
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2+ |
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NA |
Number of falls limit activity |
0 |
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13 |
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1 |
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2+ |
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NA |
Number of falls doctor visit |
0 |
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14 |
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1 |
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2+ |
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NA |
Number of falls ED visit |
0 |
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15 |
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1 |
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2+ |
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NA |
Number of falls hospitalizatoin |
0 |
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16 |
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1 |
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2+ |
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27 |
Who has talked to you about falling |
Doctor |
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40/43 |
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Pharmacist |
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Nurse |
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Another Healthcare Provider |
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Family Member or Caregiver |
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Other |
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No one has talked to me |
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NA |
Who has talked to you about medications |
Doctor |
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41 |
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Pharmacist |
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Nurse |
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Another Healthcare Provider |
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Family Member or Caregiver |
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Other |
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No one has talked to me |
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32 |
Alcohol drinks per week |
Non-drinker |
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Drinker but doesn't binge |
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50 |
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Binge drinker |
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34 |
Condition causing pain |
Yes |
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52 |
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35 |
Days with pain |
I have had pain, but on less than half of the days |
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53 |
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I have had pain on more than half of the days but not every day |
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I have had every day, but not all the time |
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I have had pain all day, every day, without break |
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39 |
Pain relief interventions |
Yoga, stretching, or range of motion exercises |
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57 |
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Massage or chiropractic |
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Acupuncture or cupping |
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Meditation or cognitive behavioral therapy |
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Prayer |
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Marijuana or THC-containing, smoked, edible or vaporized system |
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40 |
Regularly take pain medications |
Yes |
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58 |
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41 |
Medications for pain |
Over the counter medications such as Motrin or Tylenol |
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59 |
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Prescription non-steroidal medications (NSAIDS) like ibuprofen or naproxen |
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Prescription for short acting opioid medications like oxycodone, Percocet, or Vicodin |
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Prescription long acting opioid medications like OxyContin, Methadone, or MSContin |
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Medications for nerve pain, such as gabapentin, or baclofen |
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Marijuana or THC-containing, smoked, edible or vaporized system |
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42 |
Length of time taken |
Less than a week |
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60 |
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More than a week less than a month |
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More than a month |
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43 |
Tried to decrease |
Yes |
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NA |
Seen Primary Doctor since discharge |
Yes |
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1 |
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NA |
Planned? |
Planned |
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2 |
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Problem |
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NA |
Post-discharge Hospital Visits |
Yes |
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3 |
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NA |
Post-discharge ED Visits |
Yes |
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4 |
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NA |
Heart attack |
Yes |
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5 |
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NA |
Stroke |
Yes |
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6 |
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NA |
Blood clot in leg/calf |
Yes |
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7 |
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NA |
Blood clot in lung |
Yes |
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8 |
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NA |
UTI |
Yes |
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9 |
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NA |
Pneumonia |
Yes |
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10 |
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NA |
fall |
Yes |
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11 |
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NA |
Recommended fall interventions |
Physical Therapy |
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42 |
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Occupational Therapy |
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Exercise Programs (or yoga or Tai Chi) |
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Visiting an Eye Dr. |
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Visiting a Foot Dr. |
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Medication Changes |
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None |
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NA |
Recommended fall interventions-post-discharge |
Physical Therapy |
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44 |
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Occupational Therapy |
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Exercise Programs (or yoga or Tai Chi) |
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Visiting an Eye Dr. |
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Visiting a Foot Dr. |
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Medication Changes |
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None |
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NA |
Physical Therapy Sessions |
None |
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45 |
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One |
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Two |
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Three |
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More than 3 |
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NA |
Occupational Therapy sessions |
None |
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46 |
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One |
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Two |
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Three |
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More than 3 |
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NA |
Exercise Program |
None |
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47 |
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One |
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Two |
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Three |
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More than 3 |
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NA |
Eye doctor |
None |
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48 |
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One |
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Two |
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Three |
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More than 3 |
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NA |
Foot doctor |
None |
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49 |
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One |
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Two |
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Three |
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More than 3 |
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Number |
Mean(sd) |
95% CI |
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Number |
Mean(sd) |
95% CI |
Number |
Mean(sd) |
95% CI |
Number |
Mean(sd) |
95% CI |
2-5 |
SF-12 Physical Component |
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18-21 |
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6-12 |
SF-12 Mental Component |
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22-28 |
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28 |
Perceived priority of falling |
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NA |
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29 |
Perceived likeliehood of falling |
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NA |
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30 |
Perceived severity of falling |
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NA |
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31 |
Efficacy for preventing falls |
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NA |
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36 |
Pain in the past 6 months (pre) or week (post) |
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54 |
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37 |
Pain interference with life enjoyment |
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55 |
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38 |
Pain interference with general activity |
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56 |
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44-50 |
Opioid Misuse Index |
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61-66 |
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51 |
Open comment |
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67 |
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Illustrative table shells: UCSF Clinical Staff Evaluation Questionnaire |
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Physicians |
Pharmacists |
Nurses |
Question(s) |
Variable |
Value |
Number |
Percent |
95% CI |
Number |
Percent |
95% CI |
Number |
Percent |
95% CI |
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Age |
<30 |
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30-90 |
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40-90 |
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50-64 |
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65+ |
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Gender |
Female |
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Male |
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Other |
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Years in practice |
0-5 |
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6-10 |
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11-15 |
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16-20 |
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> 20 |
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Student, resident, fellow |
Yes |
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DEA registration |
Yes |
|
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|
|
|
|
|
|
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|
Primary unit |
15 |
|
|
|
|
|
|
|
|
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|
14 |
|
|
|
|
|
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|
12 |
|
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|
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|
11 |
|
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|
10 |
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|
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|
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9 |
|
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|
|
|
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8 |
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|
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7 |
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|
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6 |
|
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|
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5 |
|
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|
In the past week, number of times … |
|
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|
|
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|
screened a patient for opioid use disorder |
0 |
|
|
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|
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|
|
|
|
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|
1-3 |
|
|
|
|
|
|
|
|
|
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|
4-6 |
|
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|
|
|
|
|
|
|
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|
7-10 |
|
|
|
|
|
|
|
|
|
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|
>10 |
|
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All |
|
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|
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|
|
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|
|
|
Seeked consultation from pain management for a patient |
0 |
|
|
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|
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|
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|
1-3 |
|
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|
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|
|
|
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|
4-6 |
|
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|
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|
7-10 |
|
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|
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|
|
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|
>10 |
|
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|
All |
|
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|
|
|
|
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|
|
Gave intruction on non-pharmacologic pain treatments |
0 |
|
|
|
|
|
|
|
|
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|
1-3 |
|
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|
|
|
|
|
|
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|
4-6 |
|
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|
|
|
|
|
|
|
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|
7-10 |
|
|
|
|
|
|
|
|
|
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|
>10 |
|
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|
|
|
|
|
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|
All |
|
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|
|
|
|
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|
wrote for discharge opioid prescription |
0 |
|
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|
|
|
|
|
|
|
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|
1-3 |
|
|
|
|
|
|
|
|
|
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|
4-6 |
|
|
|
|
|
|
|
|
|
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|
7-10 |
|
|
|
|
|
|
|
|
|
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|
>10 |
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|
|
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|
|
|
|
All |
|
|
|
|
|
|
|
|
|
|
Gave opioid taper instruction after discharge |
0 |
|
|
|
|
|
|
|
|
|
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|
1-3 |
|
|
|
|
|
|
|
|
|
|
|
4-6 |
|
|
|
|
|
|
|
|
|
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|
7-10 |
|
|
|
|
|
|
|
|
|
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|
>10 |
|
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|
|
|
|
|
|
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|
All |
|
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|
|
|
|
|
|
|
|
Gave non-pharmacologic pain treatment instructions after discharge |
0 |
|
|
|
|
|
|
|
|
|
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|
1-3 |
|
|
|
|
|
|
|
|
|
|
|
4-6 |
|
|
|
|
|
|
|
|
|
|
|
7-10 |
|
|
|
|
|
|
|
|
|
|
|
>10 |
|
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|
|
|
|
|
|
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|
All |
|
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|
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|
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|
|
Illustrative table shell: PCP Post Discharge Survey |
|
|
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|
|
Number |
Percent |
95% CI |
Saw discharged patient |
In the last day |
|
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|
|
In the last 2-5 days |
|
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|
|
In the last 5-10 days |
|
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|
More than 10 days ago |
|
|
|
How Useful … |
|
|
|
|
Information about functional status and rehab goals |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Information about fall risk |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestion about pain referral |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestion about PT/OT referral |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestion about other rehab |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestion about Vitamin D/Cal use |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestion for non-opioid pain meds |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
suggestions for opioid tapering |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
Suggestions for identifying patients at risk of opioid adverse events |
Most useful |
|
|
|
|
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|
Suggestions for non medication therapies |
Not useful |
|
|
|
|
Slightly useful |
|
|
|
|
Somewhat useful |
|
|
|
|
Very useful but not perfect |
|
|
|
|
Most useful |
|
|
|