CMS-P-0015A Use of Health Services Section Specifications

2023 MCBS Facility Instrument

Variable Name

US-Use of Health Services

MR Screen Name 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

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

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

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

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

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

(01) US48-OUTMDTEL
(-8) US48-OUTMDTEL
(-9) US48-OUTMDTEL

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

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

(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

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

(01) US49 - ANYMDTEL
(-8) US49 - ANYMDTEL
(-9) US49 - ANYMDTEL

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

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

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
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 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.]
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

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?
Please include telehealth visits.
[IF NEEDED: Telehealth visits include visits by telephone or video.]

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)?
Were any of these telehealth visits?

OUTMDTEL

INMDVST

US48

US3

yes/no

yes/no

[IF NEEDED: Telehealth visits include visits by telephone or video.]
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?
Please include telehealth visits.
[IF NEEDED: Telehealth visits include visits by telephone or video.]
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?
Were any of these telehealth visits?

ANYMDTEL

US49

yes/no

US6PRECT

US6PRE

code one

[IF NEEDED: Telehealth visits include visits by telephone or video.]

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).
(01) Continue
PRESS "1" TO CONTINUE.

(01) US6 - DENTVST

Page 1 of 7

2023 MCBS Facility Instrument

Variable Name

DENTVST

US-Use of Health Services

MR Screen Name Question Type

US6

yes/no

Question Text/Description
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?
Please include telehealth visits.
[IF NEEDED: Telehealth visits include visits by telephone or video.]

DENTFRQ

DENTTEL

MENTLVST

US7

US50

US8

Numeric

yes/no

yes/no

Code List

Routing

(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.]
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she) see a
(-8) Don't Know
dentist, dental surgeon, dental assistant, or any other professional for dental care?
(-9) Refused

(01) US50 - DENTTEL
(-8) US50 - DENTTEL
(-9) US50 - DENTTEL

Were any of these telehealth visits?

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

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

(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

[IF NEEDED: Telehealth visits include visits by telephone or video.]
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)?
Please include telehealth visits.
[IF NEEDED: Telehealth visits include visits by telephone or video.]
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.

LCSOWSES

US10A

Numeric

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

LCSOWTYP

US11A

code one

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

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

(01) US51 - LSCOWTEL
(02) US51 - LSCOWTEL
(03) US51 - LSCOWTEL

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

(00) BOX US10B
(01) BOX US10B
(-8) BOX US10B
(-9) BOX US10B

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

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

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

(01) US52 - PSCNUTEL
(02) US52 - PSCNUTEL
(03) US52 - PSCNUTEL

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

(00) BOX US10C
(01) BOX US10C
(-8) BOX US10C
(-9) BOX US10C

Were any of these telehealth visits?
LSCOWTEL

US51

yes/no

BOX US10B

routing

PSCNUSES

US10B

PSCNUTYP

US11B

PSCNUTEL

code one

[IF NEEDED: Telehealth visits include visits by telephone or video.]
IF US9-PSYCHTYP INCLUDES 2/PsychiatricNurse, GO TO US10B - PSCNUSES.
ELSE GO TO BOX US10C.

Were any of these telehealth visits?

US52

yes/no

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) US53 - PSSOWTEL
(02) US53 - PSSOWTEL
(03) US53 - PSSOWTEL

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

(00) BOX US10D
(01) BOX US10D
(-8) BOX US10D
(-9) BOX US10D

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Were any of these telehealth visits?
PSSOWTEL

US53

yes/no

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Page 2 of 7

2023 MCBS Facility Instrument

Variable Name

US-Use of Health Services

MR Screen Name Question Type

Question Text/Description

BOX US10D

routing

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

PSCIASES

US10D

Numeric

PSCIATYP

US11D

code one

Code List

Routing

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

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

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

(01) US54 - PSCIATEL
(02) US54 - PSCIATEL
(03) US54 - PSCIATEL

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

(00) BOX US10E
(01) BOX US10E
(-8) BOX US10E
(-9) BOX US10E

Were any of these telehealth visits?
PSCIATEL

US54

yes/no

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) US55 - PSCOLTEL
(02) US55 - PSCOLTEL
(03) US55 - PSCOLTEL

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

(00) BOX US10F
(01) BOX US10F
(-8) BOX US10F
(-9) BOX US10F

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Were any of these telehealth visits?
PSCOLTEL

US55

yes/no

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) US56 - PSOTRTEL
(02) US56 - PSOTRTEL
(03) US56 - PSOTRTEL

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

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

(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) US57 - PHTPYTEL
(-8) US14 – PHTPYFRQ
(-9) US57 - PHTPYTEL

(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) US57 - PHTPYTEL
(02) US57 - PHTPYTEL
(03) US57 - PHTPYTEL
(04) US57 - PHTPYTEL
(05) US57 - PHTPYTEL
(-8) US57 - PHTPYTEL
(-9) US57 - PHTPYTEL

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

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

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Were any of these telehealth visits?
PSOTRTEL

PHYSTHPY

US56

US12

yes/no

yes/no

[IF NEEDED: Telehealth visits include visits by telephone or video.]
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?
Please include telehealth visits.
[IF NEEDED: Telehealth visits include visits by telephone or video.]

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

US14

code one

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?

Were any of these telehealth visits?
PHTPYTEL

US57

yes/no

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Page 3 of 7

2023 MCBS Facility Instrument

Variable Name

PODRTHPY

US-Use of Health Services

MR Screen Name Question Type

Question Text/Description

US22A

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

yes/no

Code List

Routing

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

(00) US23 - EDHBSERV
(01) US58 - PODRTEL
(-8) US23 - EDHBSERV
(-9) US23 - EDHBSERV

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

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

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))?
(00) NO
Please include telehealth visits.
(01) YES
(-8) Don't Know
[IF NEEDED: Telehealth visits include visits by telephone or video.]
(-9) Refused
[PROBE: "Habilitational services" include training in daily living skills, self care, and so on, in a structured program.]

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

[IF NEEDED: Telehealth visits include visits by telephone or video.]

PODRTEL

EDHBSERV

EDUORHAB

EDHABFRQ

US58

US23

US24

US25

yes/no

yes/no

Were any of these telehealth visits?
[IF NEEDED: Telehealth visits include visits by telephone or video.]

code one

Were those services educational, habilitational, or both?

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 WHOLE
Please look at this card and tell me, between (US REFERENCE START DATE) and (US REFERENCE END DATE),
TIME
over how long a period were these (educational/habilitational) services provided?
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused
Were any of these telehealth visits?

EDHABTEL

HABFRQ

OTHCPROV

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

US59

yes/no

BOX US2

routing

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

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 WHOLE
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how long a period were these
TIME
habilitational services provided?
(05) ABOUT THE WHOLE TIME
(-8) Don't Know
(-9) Refused

US27

[IF NEEDED: Telehealth visits include visits by telephone or video.]

Were any of these telehealth visits?
HABTEL

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

US60

US29

yes/no

yes/no

[IF NEEDED: Telehealth visits include visits by telephone or video.]

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

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

(01) US25 - EDHABFRQ
(02) US25 - EDHABFRQ
(03) US25 - EDHABFRQ
(-8) US25 - EDHABFRQ
(-9) US59 - EDHABTEL
(01) US59 - EDHABTEL
(02) US59 - EDHABTEL
(03) US59 - EDHABTEL
(04) US59 - EDHABTEL
(05) US59 - EDHABTEL
(-8) US59 - EDHABTEL
(-9) US59 - EDHABTEL
(01) BOX US2
(02) BOX US2
(-8) BOX US2
(-9) BOX US2

(01) US60 - HABTEL
(02) US60 - HABTEL
(03) US60 - HABTEL
(04) US60 - HABTEL
(05) US60 - HABTEL
(-8) US60 - HABTEL
(-9) US60 - HABTEL
(01) US29 - OTHCPROV
(02) US29 - OTHCPROV
(-8) US29 - OTHCPROV
(-9) US29 - OTHCPROV

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

Page 4 of 7

2023 MCBS Facility Instrument

Variable Name

US-Use of Health Services

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(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) US61 - TYPHCTEL
(02) US61 - TYPHCTEL
(03) US61 - TYPHCTEL
(04) US62 - TYPHCTEL
(05) US61 - TYPHCTEL
(06) US61 - TYPHCTEL
(07) US61 - TYPHCTEL
(08) US61 - TYPHCTEL
(09) US61 - TYPHCTEL
(10) US61 - TYPHCTEL
(11) US61 - TYPHCTEL
(91) US30 - TYPPRVOS

TYPHCPRV

US30

code all

SHOW CARD US3
What kind of provider was that?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

TYPPRVOS

US30

verbatim

OTHER (SPECIFY)

(01) [Continuous Answer]

(01) US62 - TYPHCTEL

Were any of these telehealth visits?

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

(01) US31PRE - US31PRCT
(02) US31PRE - US31PRCT
(-8) US31PRE - US31PRCT
(-9) US31PRE - US31PRCT

(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

TYPHCTEL

US31PRCT

US61

US31PRE

yes/no

code all

[IF NEEDED: Telehealth visits include visits by telephone or video.]

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.
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)
(01) [Continuous answer.]
and (US REFERENCE END DATE).
(-8) Don't Know
[PROBE: Were there any more visits to the ER?]
(-9) Refused

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

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)
(01) [Continuous answer.]
and (US REFERENCE END DATE).
(-8) Don't Know
[PROBE: Were there any more visits to the ER?]
(-9) Refused

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

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)
(01) [Continuous answer.]
and (US REFERENCE END DATE).
(-8) Don't Know
[PROBE: Were there any more visits to the ER?]
(-9) Refused

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

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

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

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

(01) US40 - USEEQUIP
(-8) US40 - USEEQUIP
(-9) US40 - USEEQUIP

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)?

Page 5 of 7

2023 MCBS Facility Instrument

Variable Name

USEEQUIP

USEEQUI2

US-Use of Health Services

MR Screen Name Question Type

Question Text/Description

US40

code all

(01) AMBULANCE SERVICE
(03) DIABETIC EQUIPMENT OR SUPPLIES
(05) EQUIPMENT OR SUPPLIES FOR KIDNEY
DIALYSIS
SHOW CARD US4
(06) EYE GLASSES OR CONTACT LENSES
Now I'd like to ask you about any kind of supplies, equipment, or other types of medical services (SP) received other (07) HEARING AID OR OTHER COMMUNICATION
than the ones I've already mentioned. Please look at this first card and tell me what supplies or services (SP)
DEVICE
received between (US REFERENCE START DATE) and (US REFERENCE END DATE).
(12) INCONTINENCE BRIEFS
(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.

US42

code all

MSTURN

MSTUBE

MSINJECT

US42

US43

US43

US43

verbatim

list

list

list

Routing

(01) BOX US3
(03) BOX US3
(05) BOX US3
(06) BOX US3
(07) BOX US3
(12) 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

SOME OTHER TYPE OF DEVICE OR EQUIPMENT (SPECIFY)

(01) [Continuous Answer]

(01) US43 - MSTURN

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 - 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

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

Page 6 of 7

2023 MCBS Facility Instrument

Variable Name

OTHMEDNC

US-Use of Health Services

MR Screen Name Question Type

US45

code all

Question Text/Description

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

SOME OTHER KIND OF ITEM OR SERVICE (SPECIFY)

Code List

Routing

(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) 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) [Continuous Answer]

(01) US46 – DIDABUS

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
(01)ALL
PROVIDED BY THE FACILITY.
(02) MAJORITY
(03) HALF
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR THE (04) SOME
AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".
(05) NONE

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

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

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

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 7 of 7