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pdf2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
IPQ - INPATIENT UTILIZATION
Question Type
Question Text/Description
Code List
Routing
INPATIENT UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: If INTTYPE in(C008), SP must have ongoing IP event.
PLACEMENT
Administer after ERQ.
BOX IP1
EVENDMM
EVENDDD
IPS1
IPS1
routing
IF THE SP WAS STILL IN A HOSPTIAL AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO IPS1 EVENDMM.
ELSE GO TO BOX IP1AB.
date
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
IPS1 - EVENDDD
date
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
IPS1 - EVENDYY
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
IPS1 - STILLHOSP
(01) SP IS STILL IN HOSPITAL
(-7) Empty
BOX IP1A
EVENDYY
IPS1
date
STILLHOSP
IPS1
date
BOX IP1A
routing
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IPS1, GO TO BOX IP6.
ELSE GO TO IP7 - ANYOPERS.
BOX IP1AB
routing
IF THE SP HAD AT LEAST ONE EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN
THE SP BEING ADMITTED TO A HOSPITAL, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.
BOX IP1AA
routing
CREATE EVENT FOR FIRST/NEXT ER VISIT ADDED WHERE SP WAS ADMITTED TO HOSPITAL
GO TO IP1A - EVENDMM.
(01) [Continuous answer.]
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
(-7) Empty
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
(-8) Don't Know
DATE)?
(-9) Refused
(01) [Continuous answer.]
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
(-7) Empty
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
(-8) Don't Know
DATE)?
(-9) Refused
(01) [Continuous answer.]
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
(-7) Empty
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
(-8) Don't Know
DATE)?
(-9) Refused
EVENDMM
IP1A
date
EVENDDD
IP1A
date
EVENDYY
IP1A
date
STILLHOSP
IP1A
date
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
(01) SP IS STILL IN HOSPITAL
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
(-7) Empty
DATE)?
BOX IP1B
routing
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP1A, GO TO BOX IP5.
ELSE GO TO IP7 - ANYOPERS.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] [admitted to a hospital/admitted
any other time to this or any other hospital] as an inpatient -- either for an overnight stay or for a "same day"
procedure?
IPPROBE
IP1
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
IP1A - EVENDDD
IP1A - EVENDYY
IP1A - STILLHOSP
BOX IP1B
(01) IP2 - PROVIDER_IP
(02) BOX IP6
(03) DO NOT DISPLAY.
DATA EDITING ONLY
Page 1 of 7
2019 MCBS Community Questionnaire
Variable Name
PROVIDER_IP
MR Screen Name
IP2
IPQ - INPATIENT UTILIZATION
Question Type
roster
Question Text/Description
Where [were you/was (SP)] admitted -- to which hospital?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING
AN EVENT WITH THAT PROVIDER
Code List
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
Routing
01-N) BOX IP2
(N+1) IP2-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX IP2.
ELSE IF "ADD ANOTHER" SELECTED, GO TO IP2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE HOSPITAL BELOW
PROVNAME
IP2
verbatim
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
IP2-GROUPNAM
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM
IP2
verbatim
GROUP:
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
BOX IP2
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
CRCTSPL-CRCTSPL
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
CRCTSPL
CRCTSPL
BOX IP2
VAPLACE
IP3
BOX IP2AA
HMOASSOC
HMOREFER
EVBEGMM
IP3A
IP3B
IP4
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
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 IP3 VAPLACE.
ELSE GO TO BOX IP2AA.
yes/no
Is (HOSPITAL 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 IP3A - 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 IP3B - HMOREFER.
ELSE GO TO IP4 - EVBEGMM.
yes/no
yes/no
date
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
Admission Date:
(01) [Continuous Answer]
BOX IP2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX IP2AA
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) IP4 - EVBEGMM
(02) IP3B - HMOREFER
(-8) IP3B - HMOREFER
(-9) IP3B - HMOREFER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
IP4 - EVBEGMM
MM:
IP4 - EVBEGDD
Page 2 of 7
2019 MCBS Community Questionnaire
IPQ - INPATIENT UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
EVBEGDD
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
DD:
IP4 - EVBEGYY
EVBEGYY
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
YY:
IP4 - EVENDMM
EVENDMM
IP4
date
MM:
IP4 - EVENDDD
EVENDDD
IP4
date
YY:
IP4 - EVENDYY
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
Dishcarge Date:
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
EVENDYY
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
STILLHOSP
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
BOX IP2A
routing
IP4_ERR
code 1
BOX IP3
routing
IPOVERLP
IPADD
IP5
ANYOPERS
IP7
yes/no
SPECCOND
IP10
yes/no
BOX IP4A
routing
PRESMDCN
IP13
yes/no
IF INPATIENT ADMISSION AND DISCHARGE DATE OVERLAP AN EXISTING IP STAY, GO TO IP4_ERR IPOVERLP.
ELSE GO TO BOX IP3.
INVALID DATE. THIS DATE OVERLAPS AN EXISTING IP STAY FROM (ADMISSION DATE) TO [(DISCHARGE (01) CORRECT DATES
DATE)/SP STILL IN HOSPITAL].
(02) CONTINUE INTERVIEW
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP4, GO TO BOX IP5.
ELSE GO TO IP5-IPADD
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
Were any operations performed on [you/(SP)] during the hospital stay that was (ADMISSION DATE) to
(01) YES
(DISCHARGE DATE)?
(02) NO
(-8) Don't Know
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths, or any
(-9) Refused
cutting of the skin.]
(01) YES
(02) NO
[Was this visit/Were any of these visits] to the outpatient department for any specific condition?
(-8) Don't Know
(-9) Refused
IPPMMEDS
IP14
yes/no
BOX IP4B
routing
IP14A
no entry
IP4 - STILLHOSP
BOX IP2A
(01) IP4 - EVBEGMM
(02) BOX IP3
(01) IP4-EVBEGMM
(02) IP7 - ANYOPERS
(01) BOX IP4A
(02) IP10 - SPECCOND
(-8) IP10 - SPECCOND
(-9) IP10 - SPECCOND
BOX IP4A
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO IP13 - PRESMDCN.
At the time [you were /(SP) was] discharged, were any medicines prescribed for [you/(SP)]?
Were any of the prescriptions filled?
PRESFILL
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) SP IS STILL IN HOSPITAL
(-7) Empty
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN
IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT
THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) IP14 - PRESFILL
(02) BOX IP5
(-8) BOX IP5
(-9) BOX IP5
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX IP4B
(02) BOX IP5
(-8) BOX IP5
(-9) BOX IP5
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO IP14A - IPPMMEDS.
ELSE GO TO BOX PM2.
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.]
BOX PM2
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
MEDICINE_PM1
MEDICINE_PM1
routing
code one
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
What is the name of the medicine?
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
BOX PM3
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
Page 3 of 7
2019 MCBS Community Questionnaire
Variable Name
IPQ - INPATIENT UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE BOX BELOW.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
lookup
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
STRNNUMBB
MED
numeric
Medicine strength number
STRNUNIT
MED
code one
Medicine Form [MCBS FORM]
Medicine strength unit
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
Page 4 of 7
2019 MCBS Community Questionnaire
IPQ - INPATIENT UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
PMSTRNOS
MED
verbatim
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
PMCOND
PMCONDOS
PMCOND
PMCOND
code one
verbatim
TABNUM
GETNUM
numeric
BOX PM5
routing
TABNUM
numeric
Routing
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
Page 5 of 7
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
IPQ - INPATIENT UTILIZATION
Question Type
Question Text/Description
Code List
Routing
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PMSATVA
PMSATHMO
PMMORE
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATHMO
PM17
BOX IP5
yes/no
yes/no
routing
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
(01) YES
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)] (-9) REFUSED
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
(01) ADD ANOTHER
(02) ALL DONE
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-PMMORE
(01) BOX PM2
(02) BOX IP5
IF ANOTHER IP EVENT WAS ADDED WITH THIS IP PROVIDER, GO TO IP7-ANYOPERS.
ELSE IF ASKING ABOUT ONGOING IP STAY FROM THE PREVIOUS ROUND, GO TO BOX IP1AB.
ELSE IF ASKING ABOUT AN EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN AN
IP STAY, THEN
IF SP HAS ANOTHER EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN AN IP
STAY THAT HAS NOT BEEN ASKED ABOUT, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.
ELSE GO TO IP16 - IPMORE.
Page 6 of 7
2019 MCBS Community Questionnaire
Variable Name
IPMORE
MR Screen Name
IP16
IPQ - INPATIENT UTILIZATION
Question Type
yes/no
Question Text/Description
IF RESPONDENT HAS ALREADY MENTIONED ANOTHER INPATIENT STAY, ENTER “YES” WITHOUT
ASKING. OTHERWISE, ASK:
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you had/has (SP) had/did (SP) have] any other admissions to this or
any other hospital as an inpatient -- either for an overnight stay or for a "same day" procedure?
IF RESPONDENT HAD A SAME DAY PROCEDURE AND IS NOT SURE IF ADMITTED OR NOT, TREAT AS
OUTPATIENT EVENT AND ENTER WHEN YOU GET TO OP UTILIZATION.
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) IP2 - PROVIDER_IP
(02) BOX IP6
(-8) BOX IP6
(-9) BOX IP6
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]
BOX IP6
routing
IF INTTYPE in(C001, C002, C004, C005, C006, C007), GO TO OPQ.
Page 7 of 7
| File Type | application/pdf |
| Author | Shena Patel |
| File Modified | 2019-03-21 |
| File Created | 2019-03-21 |