MRA data structure

Attachment 6

MMP Medical Record Abstraction Data Structure

Medical Monitoring Project

0920-0740

MMP 2018 MEDICAL RECORD ABSTRACTION DATA STRUCTURE

DEMOGRAPHICS

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
absid_mra	Abstractor ID	Abstractor ID	1	1
facid_mra*	Facility ID: (Eight digits: Project Area + facility ID)	Facility ID	1	1
facloc_mra*	Facility Location	Facility Location	1	1
rwfund_mra	Does facility receive Ryan White funding	Ryan White Funded Facility	1	1
spstart_mra	Start of Observation	Surveillance period start date	1	1
spend_mra	End of Observation	Surveillance period end date	1	1
death_mra	Did the participant die during the 2 year observation period?	Patient died	1	1
dobmo_mra	Date of birth (Month)	Date of birth (Month)	1	1
dobyr_mra	Date of birth (Year)	Date of birth (Year)	1	1
gender_mra	Gender	Gender	1	1
racend_mra	Not documented	Race not documented	1	1
aian_mra	American Indian/Alaska Native	Race American Indian/Alaska Native	1	1
asian_mra	Asian	Race Asian	1	1
black_mra	Black/African American	Race Black/African American	1	1
nhpi_mra	Native Hawaiian/Other Pacific Islander	Race native Hawaiian/other Pacific Islander	1	1
white_mra	White	Race White	1	1
ethnic_mra	Hispanic/Latino ethnicity or Spanish origin:	Hispanic/Latino ethnicity or Spanish Origin	1	1
reimbnd_mra	Not documented	Insurance not documented	1	1
reimbadap_mra	AIDS Drug Assistance Program (ADAP)	Insurance ADAP	1	1
reimbmc_mra	Medicare	Insurance Medicare	1	1
reimbmd_mra	Medicaid	Insurance Medicaid	1	1
reimbrw_mra	Ryan White	Insurance Ryan White	1	1
reimbtri_mra	Tricare or Champus	Insurance Tricare or Champus	1	1
reimbva_mra	Veterans administration coverage	Insurance VA coverage	1	1
reimbpvt_mra	Private insurance	Private insurance	1	1
reimbsp_mra	None/self-pay	Insurance none/self-pay	1	1
reimbpub_mra	City, County, State or other publicly funded	Insurance city, county, state, publicly funded	1	1
reimboth_mra	Other insurance	Other insurance	1	1
reimbothde_mra	Other insurance description	Other insurance description	1	1
hivdateyn_mra	Is the date of first HIV diagnosis documented in the medical record?	Date of HIV diagnosis documented	1	1
firsthiv_mra	Date of first HIV diagnosis	Date of HIV diagnosis	1	1
_firsthiv_ind_mra		Date of HIV diagnosis indicator	1	1

ENCOUNTERS

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
vis_date_mra	Encounter date	Outpatient encounter date	1	1
visitloc_mra	Where did the encounter take place?	Place of medical encounter	1	1
visitprv_mra	With whom did the encounter take place?	Person with whom medical encounter occurred	1	1
hivprvyn_mra	Did the encounter take place with a known HIV provider?	Encounter with known HIV provider	1	1
oprvyn_mra	Did the encounter take place with a non-HIV provider?	Encounter with non-HIV provider	1	1
oprvtyp_mra	If yes, specify provider type	Non-HIV provider type	1	1
othprvothde_mra	Other provider description	Other non-HIV provider description	1	1
vital_mra	Were any vital signs documented during the encounter?	Vital signs documented during encounter	1	1
weightnd_mra	Weight not documented	Weight not documented	1	1
weight_mra	Weight	Weight	1	1
weightunit_mra	Weight units	Weight units	1	1
heightnd_mra	Height not documented	Height not documented	1	1
height_ft_mra	Height (feet)	Height (feet)	1	1
height_in_mra	Height (inches)	Height (inches)	1	1
bpnd_mra	Blood pressure not documented	Blood pressure not documented	1	1
bpsys_mra	Systolic blood pressure (mmHg)	Systolic blood pressure	1	1
bpdia_mra	Diastolic blood pressure (mmHg)	Diastolic blood pressure	1	1

HOSPITALIZATION

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
hospyn_mra	Was the patient hospitalized during the observation period?	Participant hospitalized	1	1
inpadmitnd_mra	Inpatient admission date not documented	Inpatient admission date not documented	1	1
inpadmit_mra	Inpatient admission date	Inpatient admission date	1	1
_inpadmit_ind_mra		Inpatient admission date indicator	1	1
inpdischnd_mra	Inpatient discharge date not documented	Inpatient discharge date not documented	1	1
inpdisch_mra	Inpatient discharge date	Inpatient discharge date	1	1
_inpdisch_ind_mra		Inpatient discharge date indicator	1	1
inpdiag_mra	Diagnosis	Discharge Diagnosis	1	1
inpdiagothde_mra	Diagnosis other description	Other discharge diagnosis description	1	1
_inpdiagrt_mra		Diagnosis root code	1	1
_inpnum_mra		Hospitalization number	1	1

DIAGNOSES

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
dxrefsoo_mra	Beginning of month 1 (start of observation period)	Beginning of month 1 (start of observation period)	1	1
dxref13mo_mra	Beginning of month 13	Beginning of month 13	1	1
dxrefeoo_mra	End of month 24 (end of observation period)	End of month 24 (end of observation period)	1	1
dx_mra	Diagnosis	Diagnosis	1	1
dxothde_mra	Other description	Diagnosis Other description	1	1
_dxrt_mra		Diagnosis root code	1	1
_coddx_mra	Diagnosis at death	From COD file	1	1
_diagdx_mra	Diagnosis from Diagnosis file	From Diagnosis file	1	1
dx6mobs_mra	Started or ongoing in first 6 months	Diagnosis first 6 months	1	1
dx12mobs_mra	Started or ongoing 7-12 months	Diagnosis 7-12 months	1	1
dx18mobs_mra	Started or ongoing 13-18 months	Diagnosis 13-18 months	1	1
dx24mobs_mra	Started or ongoing 19-24 months	Diagnosis 19-24 months	1	1
dthcodsrc_mra	Source of cause of death information	Source of cause of death info	1	1
codsrcothde_mra	Specify other source:	Other source of cause of death info	1	1

MEDICATIONS

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
txrefsoo_mra	Beginning of month 1 (start of observation period)	Beginning of month 1 (start of observation period)	1	1
txref13mo_mra	Beginning of month 13	Beginning of month 13	1	1
txrefeoo_mra	End of month 24 (end of observation period)	End of month 24 (end of observation period)	1	1
tx_mra	Medication	Medication	1	1
txothde_mra	Other medication description	Other medication description	1	1
_txrt_mra		Medication root code	1	1
txroute_mra	Medication route	Medication route	1	1
txrouteoth_mra	Other route description	Other medication route description	1	1
txfreq_mra	Frequency (for ARVs only)	ARV Frequency	1	1
txfreqothde_mra	Other ARV frequency description Other frequency (specify)	Other ARV frequency description	1	1
tx6mobs_mra	Started or ongoing in first 6 months	Medication first 6 months	1	1
tx12mobs_mra	Started or ongoing 7-12 months	Medication 7-12 months	1	1
tx18mobs_mra	Started or ongoing 13-18 months	Medication 13-18 months	1	1
tx24mobs_mra	Started or ongoing 19-24 months	Medication 19-24 months	1	1

PROPHYLAXIS

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
macrefsoo_mra	Beginning of month 1 (start of observation period)	MAC start of observation period	1	1
macref13mo_mra	Beginning of month 13	MAC beginning of month 13	1	1
macrefeoo_mra	End of month 24 (end of observation period)	MAC end of month 24	1	1
macpx_mra	MAC prophylaxis administered?	MAC prophylaxis administered?	1	1
macpxtx_mra	MAC medication	MAC medication	1	1
macpxtxothde_mra	Other description	MAC medication other description	1	1
mac6mobs_mra	Started or ongoing in first 6 months	MAC Started or ongoing in first 6 months	1	1
mac12mobs_mra	Started or ongoing 7-12 months	MAC Started or ongoing 7-12 months	1	1
mac18mobs_mra	Started or ongoing 13-18 months	MAC Started or ongoing 13-18 months	1	1
mac24mobs_mra	Started or ongoing 19-24 months	MAC Started or ongoing 19-24 months	1	1
pcprefsoo_mra	Beginning of month 1 (start of observation period)	PCP start of observation period	1	1
pcpref7mo_mra	Beginning of month 7	PCP beginning of month 7	1	1
pcpref13mo_mra	Beginning of month 13	PCP beginning of month 13	1	1
pcpref19mo_mra	Beginning of month 19	PCP beginning of month 19	1	1
pcprefeoo_mra	End of month 24 (end of observation period)	PCP end of month 24	1	1
pcppx_mra	PCP prophylaxis administered?	PCP prophylaxis administered?	1	1
pcppxtx_mra	PCP medication	PCP medication	1	1
pcppxtxothde_mra	Other description	PCP medication other description	1	1
pcp6mobs_mra	Started or ongoing in first 6 months	PCP Started or ongoing in first 6 months	1	1
pcp12mobs_mra	Started or ongoing 7-12 months	PCP Started or ongoing 7-12 months	1	1
pcp18mobs_mra	Started or ongoing 13-18 months	PCP Started or ongoing 13-18 months	1	1
pcp24mobs_mra	Started or ongoing 19-24 months	PCP Started or ongoing 19-24 months	1	1
flurefsoo_mra	Start of observation period	Flu start of observation period	1	1
flurefyr2_mra	Beginning of year 2	Flu beginning of year 2	1	1
flurefeoo_mra	End of observation period	Flu end of observation period	1	1
flupx_mra	Influenza vaccination administered?	Influenza vaccination administered?	1	1
fluyr1_mra	Administered during first year of obs period?	Flu vaccine administered year 1	1	1
fludate1_mra	If yes, what date was the influenza vaccine administered in year 1 of the observation period?	Flu vaccine date year 1	1	1
_fludate1_ind_mra		Flu vaccine date year 1 indicator	1	1
fluyr2_mra	Administered during second year of obs period?	Flu vaccine administered year 2	1	1
fludate2_mra	If yes, what date was the influenza vaccine administered in year 2 of the observation period?	Flu vaccine date year 2	1	1
_fludate2_ind_mra		Flu vaccine date year 2 indicator	1	1

PROCEDURE

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
procdate_mra	Date of procedure	Date of procedure	1	1
_procdate_ind_mra		Date of procedure indicator	1	1
proc_mra	Procedure	Procedure	1	1
procothde_mra	Specify details	Procedure other details	1	1

LABS

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID	Participant ID	1	1
_SITEID_mra		Site ID	1	1
hivlab_date_mra	Collection date	HIV lab date	1	1
cd4_result_mra	CD4 count result	CD4 result	1	1
cd4_unit_mra	CD4 count units	CD4 units	1	1
cd4_unoth_mra	Other description	CD4 other units	1	1
cd4pct_result_mra	CD4% result	CD4% Result	1	1
viral_load_sign_mra	Viral load sign	Viral load sign	1	1
viral_load_mra	Viral load result	Viral load result	1	1
viral_load_unit_mra	Viral load units	Viral load units	1	1
viral_load_unoth_mra	If other, specify	Viral load other units	1	1
viral_load_LL_mra	Lower limit of test	Viral load lower limit	1	1
viral_load_LL_oth_mra	If other, specify	Viral load other lower limit	1	1
viral_load_UL_mra	Upper limit of test	Viral load upper limit	1	1
viral_load_UL_oth_mra	If other, specify	Viral load other upper limit	1	1
cbc_date_mra	Collection date	CBC lab date	1	1
wbc_res_mra	Result	WBC result	1	1
wbc_unit_mra	Units	WBC units	1	1
wbc_unoth_mra	Description of other units	WBC other units	1	1
hgb_res_mra	Result	Hemoglobin result	1	1
hgb_unit_mra	Units	Hemoglobin units	1	1
hgb_unoth_mra	Description of other units	Hemoglobin other units	1	1
plt_res_mra	Result	Platelets result	1	1
plt_unit_mra	Units	Platelets units	1	1
plt_unoth_mra	Description of other units	Platelets other units	1	1
mvc_res_mra	Result (fL)	MCV result	1	1
neut_res_mra	Result	Neutrophils result	1	1
neut_unit_mra	Units	Neutrophils units	1	1
neut_unoth_mra	Description of other units	Neutrophils other units	1	1
chem_date_mra	Collection date	Chemistry lab date	1	1
fasting_lab_mra	Fasting lab?	Chemistry fasting	1	1
glu_res_mra	Result	Glucose result	1	1
glu_unit_mra	Units	Glucose units	1	1
glu_unoth_mra	Description of other units	Glucose other units	1	1
creat_res_mra	Result	Creatinine result	1	1
creat_unit_mra	Units	Creatinine units	1	1
creat_unoth_mra	Description of other units	Creatinine other units	1	1
calc_res_mra	Result	Calcium result	1	1
calc_unit_mra	Units	Calcium units	1	1
calc_uoth_mra	Description of other units	Calcium other units	1	1
alb_res_mra	Result	Albumin result	1	1
alb_unit_mra	Units	Albumin units	1	1
alb_unoth_mra	Description of other units	Albumin other units	1	1
ast_res_mra	Result	AST (SGOT) result	1	1
ast_unit_mra	Units	AST (SGOT) units	1	1
ast_unoth_mra	Description of other units	AST (SGOT) other units	1	1
alt_res_mra	Result	ALT (SGPT) result	1	1
alt_unit_mra	Units	ALT (SGPT) units	1	1
alt_unoth_mra	Description of other units	ALT (SGPT) other units	1	1
tbili_res_mra	Result	Total bilirubin result	1	1
tbili_unit_mra	Units	Total bilirubin units	1	1
tbili_unoth_mra	Description of other units	Total bilirubin other units	1	1
othchem_date_mra	Collection date	Other chemistry lab date	1	1
hgba1c_res_mra	Result (%)	Hemoglobin A1c result	1	1
vitd_res_mra	Result	Vitamin D result	1	1
vitd_unit_mra	Units	Vitamin D units	1	1
vitd_unoth_mra	Description of other units	Vitamin D other units	1	1
ttest_res_mra	Result	Total testosterone result	1	1
ttest_unit_mra	Units	Total testosterone units	1	1
ttest_unoth_mra	Description of other units	Total testosterone other units	1	1
lipid_date_mra	Collection date	Lipid lab date	1	1
lipid_fast_mra	Fasting lab?	Lipid fasting	1	1
chol_res_mra	Result	Cholesterol result	1	1
chol_unit_mra	Units	Cholesterol units	1	1
chol_unoth_mra	Description of other units	Cholesterol other units	1	1
hdl_res_mra	Result	HDL Cholesterol result	1	1
hdl_unit_mra	Units	HDL Cholesterol units	1	1
hdl_unoth_mra	Description of other units	HDL Cholesterol other units	1	1
ldl_res_mra	Result	LDL Cholesterol result	1	1
ldl_unit_mra	Units	LDL Cholesterol units	1	1
ldl_unoth_mra	Description of other units	LDL Cholesterol other units	1	1
trig_res_mra	Result	Triglycerides result	1	1
trig_unit_mra	Units	Triglycerides units	1	1
trig_unoth_mra	Description of other units	Triglycerides other units	1	1
sero_date_mra	Collection date	Serology lab date	1	1
toxoab_res_mra	Toxoplasma IgG antibody result	Toxoplasmosis IgG result	1	1
hcv_test_mra	Test type	Hepatitis C test	1	1
hcv_qlres_mra	Qualitative test result	Hepatitis C qualitative result	1	1
hcv_und_mra	Quantitative viral load undetectable	Hepatitis C Viral load undetectable	1	1
hcv_sign_mra	Quantitative viral load sign	Hepatitis C Viral load sign	1	1
hcv_qtres_mra	Quantitative viral load result:	Hepatitis C Viral load result	1	1
hcv_unit_mra	Quantitative viral load units	Hepatitis C Viral load units	1	1
hcv_unoth_mra	Description of other units	Hepatitis C Viral load other units	1	1
hcv_UL_mra	Quantitative viral load test upper limit	Hepatitis C Viral load upper limit	1	1
hcv_LL_mra	Quantitative viral load test lower limit	Hepatitis C Viral load lower limit	1	1
hbv_test_mra	Test type	Hepatitis B test	1	1
hbv_qlres_mra	Qualitative test result	Hepatitis B qualitative result	1	1
hbv_qtres_mra	Viral load (DNA) result	Hepatitis B viral load result	1	1
hbv_unit_mra	Viral load (DNA) units	Hepatitis B viral load units	1	1
hbv_unoth_mra	Description of other units	Hepatitis B viral load units other	1	1
hbv_UL_mra	Viral load (DNA) upper limit	Hepatitis B viral load upper limit	1	1
hbv_LL_mra	Viral load (DNA) lower limit	Hepatitis B viral load lower limit	1	1
covdt	Specimen collection date	SARS-CoV-2 lab date		1	1
covtest	Test type	SARS-CoV-2 test type		1	1
covtestothde	Test type, other (description)	SARS-CoV-2 test type, other description		1	1
covsource	Source of specimen	SARS-CoV-2 source		1	1
covsourceothde	Source, other (description)	SARS-CoV-2 source, other (description)		1	1
covresult	Result	SARS-CoV-2 result		1	1
covresultothde	Result, other (description)	SARS-CoV-2 result, other description		1	1
sti_date_mra	Specimen collection date	STI lab date	1	1
gc_source_mra	Source of specimen	Gonorrhea source	1	1
gc_type_mra	Test type	Gonorrhea test type	1	1
gc_res_mra	Result	Gonorrhea result	1	1
ct_source_mra	Source of specimen	Chlamydia source	1	1
ct_type_mra	Test type	Chlamydia test type	1	1
ct_res_mra	Result	Chlamydia result	1	1
syph_source_mra	Source of specimen	Syphilis source	1	1
syph_type_mra	Test type	Syphilis test type	1	1
syph_res_mra	Result	Syphilis result	1	1
syph_titr_mra	Titer result: 1:X	Syphilis titer 1:X	1	1
trich_source_mra	Source of specimen	Trichomonas source	1	1
trich_type_mra	Test type	Trichomonas test type	1	1
trich_res_mra	Result	Trichomonas result	1	1
os_date_mra	Screening date	Mammogram or Pap screening date	1	1
_os_date_ind_mra		Screening date indicator	1	1
pap_source_mra	PAP source	Pap smear source	1	1
pap_result_mra	PAP result	Pap smear result	1	1
pap_othde_mra	Specify other PAP result	Pap result other description	1	1
ppd_yn_mra	Was a PPD placed?	PPD placed	1	1
ppd_read_mra	Was the PPD read?	PPD read	1	1
ppd_date_mra	What date was the PPD read?	PPD reading date	1	1
ppd_datend_mra	Date not documented	PPD reading date not documented	1	1
ppd_res_mra	PPD result	PPD result	1	1
igra_date_mra	Specimen collection date	IGRA lab date	1	1
igra_type_mra	IGRA test type	IGRA test type	1	1
igra_res_mra	IGRA result	IGRA result	1	1
urine_date_mra	Collection date	Urine lab date	1	1
urine_test_mra	Urine test type	Urine test type	1	1
urine_qt_res_mra	Urine test result	Urine quantitative result	1	1
urine_unit_mra	Urine test units	Urine units	1	1
uruint_othde_mra	Description of other units	Urine other units	1	1
uprotqual_mra	Urine protein result (non-numeric)	Urine protein (qual) result	1	1
uproql_othres_mra	Description of other result	Urine protein (qual) other result	1	1
hct_res_mra^	Result (%)	Hematocrit result	1	1
lymph_res_mra^	Result	Lymphocytes result	1	1
monos_res_mra^	Result	Monocytes result	1	1
eos_res_mra^	Result	Eosinophils result	1	1
baso_res_mra^	Result	Basophils result	1	1
			1	1

RESISTANCE

Variable	Question	Label	2018 MRA	2021 MRA	Added in 2021
PARID	Participant ID		1	1
_SITEID_mra		Site ID	1	1
geno_mra	Genotype or virtual phenotype performed?	Is genotype or virtual phenotype performed?	1	1
geno_rpt_mra	Is a genotype or virtual phenotype lab report available in the medical record?	Is genotype or virtual phenotype report available?	1	1
geno_vpheno_mra	Were the results obtained from a genotype or virtual phenotype?	Genotype or virtual phenotype	1	1
geno_adq_mra	Genotype Specimen adequate?	Genotype specimen adequate	1	1
geno_date_mra	Genotype collection date	Genotype collection date	1	1
geno_nrti_mra	NRTI mutations detected	NRTI mutations detected	1	1
geno_nnrti_mra	NNRTI mutations detected	NNRTI mutations detected	1	1
geno_pi_mra	PI mutations detected	PI mutations detected	1	1
geno_in_mra	Integrase mutations detected	Integrase mutations detected	1	1
geno_en_mra	GP41 Envelope mutations detected	GP41 envelope mutations detected	1	1
_geno_mut_mra	Genotype mutations	Genotype mutation	1	1
_geno_mutsrc_mra		Genotype mutation source	1	1