CMS-P-0015A Use of Health Services

2019 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
providers who saw (him/her) here. The kinds of services I will be asking about include physician care, dental
(02) CONSENT REQUIRED
care, mental health services, various kinds of therapies, and care from other kinds of health care providers. I will
(03) INITIAL REFUSAL
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

INMDVST

US3

Page 1 of 10

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX USEND

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

US5A

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

US6PRECT

US6PRE

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

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?

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

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

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a psychiatrist
or any other mental health care professional either inside or outside this (facility/home)?

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

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

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

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

(01) [Continuous Answer]

(01) BOX US10A

MENTLVST

US8

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

US9

code all

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

PSYCHOS

US9

verbatim

OTHER (SPECIFY)

BOX US10A

routing

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

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2019 MCBS Facility Instrument

US-Use of Health Services

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

LCSOWSES

US10A

Numeric

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a licensed clinical social worker?
(-9) Refused

LCSOWTYP

US11A

code one

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

BOX US10B

routing

IF US9-PSYCHTYP INCLUDES 2/PsychiatricNurse, GO TO US10B - PSCNUSES.
ELSE GO TO BOX US10C.

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

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a psychiatric nurse?
(-9) Refused

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

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a psychiatric social worker?
(-9) Refused

PSSOWTYP

US11C

code one

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

BOX US10D

routing

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

US10D

Numeric

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a psychiatrist?
(-9) Refused

PSCIASES

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

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

Routing

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

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

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

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

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

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

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

Page 3 of 10

2019 MCBS Facility Instrument

US-Use of Health Services

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

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

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a psychologist?
(-9) Refused

PSCOLTYP

US11E

code one

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

BOX US10F

routing

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

PSOTRSES

US10F

Numeric

(01) [Continuous answer.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did
(-8) Don't Know
(he/she) have to a (OTHER MENTAL HEALTH SPECIALIST)?
(-9) Refused

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

(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

PHYSTHPY

US12

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".

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

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

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

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

Page 4 of 10

2019 MCBS Facility Instrument

Variable Name

PHTPYFRQ

PODRTHPY

EDHBSERV

EDUORHAB

EDHABFRQ

MR Screen Name

US14

US22A

US23

US24

US-Use of Health Services

Question Type

Question Text/Description

Code List

code one

(01) LESS THAN 1 WEEK
(02) 1 TO 3 WEEKS
(03) 4 TO 8 WEEKS
SHOW CARD US2
(04) MORE THAN 8 WEEKS BUT NOT THE
Now look at this card. Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how
WHOLE TIME
long a period was therapy provided?
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused

Routing

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

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE) was (SP) seen by a podiatrist
(either inside or outside this (facility/home))?

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

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

yes/no

Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) receive educational
(00) NO
or habilitational services (either inside or outside this (facility/home))?
(01) YES
(-8) Don't Know
[PROBE: "Habilitational services" include training in daily living skills, self care, and so on, in a structured
(-9) Refused
program.]

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

code one

Were those services educational, habilitational, or both?

(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

US25

code one

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?

BOX US2

routing

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

Page 5 of 10

2019 MCBS Facility Instrument

Variable Name

HABFRQ

OTHCPROV

MR Screen Name

US27

US29

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

code one

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

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

yes/no

SHOW CARD US3 FOR PROMPTING AS NEEDED.
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) receive care from
any other licensed or certified health care provider (either inside or outside this (facility/home))?
PRESS F1 FOR "ANY OTHER PROVIDER" CLARIFICATION.

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

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

(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

TYPHCPRV

US30

code all

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

(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

TYPPRVOS

US30

verbatim

OTHER (SPECIFY)

(01) [Continuous Answer]

(01) US31PRE - US31PRCT

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

US31PRCT

US31PRE

PRESS "1" TO CONTINUE.

ERVISITS

US32

yes/no

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)?

Page 6 of 10

2019 MCBS Facility Instrument

Variable Name

ERVSTMM

MR Screen Name

US33

US-Use of Health Services

Question Type

grid

Question Text/Description

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?]

Code List

Routing

(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

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.

RETSMDAY

US37

yes/no

(00) NO
[Besides the (health care providers and emergency room/health care providers/emergency room) visits you have
(01) YES
already told me about, did (he/she) ever go to the hospital and return on the same day/Did (he/she) ever go to
(-8) Don't Know
the hospital and return on the same day]?
(-9) Refused

RETSMFRQ

US38

Numeric

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

(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

Page 7 of 10

2019 MCBS Facility Instrument

Variable Name

USEEQUIP

MR Screen Name

US40

US-Use of Health Services

Question Type

code all

Question Text/Description

SHOW CARD US4
Now I'd like to ask you about any kind of supplies, equipment, or other types of medical services (SP) received
other than the ones I've already mentioned. Please look at this first card and tell me what supplies or services
(SP) received between (US REFERENCE START DATE) and (US REFERENCE END DATE).
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

BOX US3

USEEQUI2

US42

routing

code all

MSTURN

US42

US43

Routing

(01) AMBULANCE SERVICE
(02) CLOTH DIAPERS
(03) DIABETIC EQUIPMENT OR SUPPLIES
(04) DISPOSABLE DIAPERS
(05) EQUIPMENT OR SUPPLIES FOR KIDNEY
DIALYSIS
(06) EYE GLASSES OR CONTACT LENSES
(07) HEARING AID OR OTHER
COMMUNICATION DEVICE
(08) ORTHOPEDIC ITEMS
(09) OSTOMY SUPPLIES
(10) OXYGEN
(11) PROSTHESIS
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused

(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

(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
(06) GERI CHAIR
(07) HOSPITAL BED
(08) IV SUPPLIES
(09) NEBULIZER
(10) SPECIAL MATTRESS, CUSHIONS OR
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

(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

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

SHOW CARD US5
Please look at this second card and tell me what medical devices or equipment (he/she) received between (US
REFERENCE START DATE) and (US REFERENCE END DATE).
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

OTHREQOS

Code List

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

Page 8 of 10

2019 MCBS Facility Instrument

Variable Name

MSTUBE

MSRESTR

MSINJECT

MR Screen Name

US43

US43

US43

US-Use of Health Services

Question Type

Question Text/Description

Code List

Routing

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

list

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

(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

(01) US46 – DIDABUS

list

list

OTHMEDNC

US45

code all

(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)
SHOW CARD US6
Now I'd like to ask about any other medically necessary items or provider services (SP) received that we haven't (05) G TUBE USE AND CARE
(06) INCONTINENCE
talked about already. Please look at this last card and tell me what other items or services (he/she) received
(07) IV USE AND CARE
between (US REFERENCE START DATE) and (US REFERENCE END DATE)?
(08) PACEMAKER CHECK
(09) SKIN TREATMENTS FOR
SELECT ALL THAT APPLY.
PREVENTION/TREATMENT OF SKIN ULCERS
SEPARATE RESPONSES BY USING THE SPACEBAR.
(10) SUCTIONING
(91) SOME OTHER KIND OF ITEM OR
SERVICE
(96) NONE OF THE ABOVE
(-8) Don't Know

OTHRSEOS

US45

verbatim

SOME OTHER KIND OF ITEM OR SERVICE (SPECIFY)

(01) [Continuous Answer]

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2019 MCBS Facility Instrument

Variable Name

MR Screen Name

US-Use of Health Services

Question Type

Question Text/Description

TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY
INTO THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE
THE MINIMUM DATA SET (MDS), NURSES NOTES, PHYSICIANS ORDERS, AND/OR OTHER DOCUMENTS
PROVIDED BY THE FACILITY.
DIDABUS

US46

code one
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR
THE AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".

Code List

Routing

(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

DID YOU ABSTRACT?

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

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

Page 10 of 10