study_idtextStudy ID110y
f0r_doitextResident Screening Datedate_mdyy
f0r_ra_iddropdownResearch Assistant ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
f0r_prim_raradioPrimary Research Nurse1, M (1) | 2, H (2)[f0r_ra_id] = '3' or [f0r_ra_id] = '4' or [f0r_ra_id] = '5'
f0r_facility_nametextFacility Nameyy
f0r_facility_idsqlFacility IDSELECT master.value value, concat(site_name.value, ' (', master.value, ')') label FROM redcap_data master INNER JOIN redcap_data site_name ON site_name.project_id = master.project_id AND site_name.record = master.record AND site_name.event_id = master.event_id AND site_name.field_name = 'fs_site_name' WHERE master.project_id = 41 AND master.field_name = 'fs_facility_id' order by convert(master.value, unsigned integer)y
f0r_scrng_unit_idtextUnit IDyy
f0r_scrn_res_rmtextRoom numberyy
f0r_res_l_nametextResident Last NameLast nameyy
f0r_res_f_nametextResident First NameFirst nameyy
f0r_res_genderradioResident gender1, Male (0) | 2, Female (1)y
f0r_res_agecalcResident ageround(datediff([f0r_doi],[f0r_res_dob],"y","mdy"))calculated age of resident at interview
f0r_gds7_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Global Deterioration = 7 if:
1. Verbal skills: All meaningful verbal abilities are lost. Frequently no speech at all. There may be only grunting, meaningless repetitive sounds or occasional words or phrases which do not make sense.
2. Function: Incontinent of urine and require considerable assistance for eating and toileting
3. Psychomotor skills: Unable to walk or require considerable assistance to ambulate or transfer. "The brain appears to no longer be able to tell the body what to do.[f0r_res_age] >= 65
f0r_gds7radioGlobal deterioration scale=7?0, No (ineligible) (0) | 1, Yes (1)[f0r_res_age] >= 65y
f0r_doatextDate of Resident's nursing home admissiondate_mdy[f0r_res_age] >= 65 and [f0r_gds7] = '1'y
f0r_lngth_staycalcLength of nursing home stayround(datediff([f0r_doi],[f0r_doa],"d","mdy"),2)calculated based on date of admission and date of screening[f0r_res_age] >= 65 and [f0r_gds7] = '1'y
f0r_prim_caus_cog_impradioPrimary cause of cognitive impairment0, Dementia (Any cause) (0) | 1, Acute stroke (ineligible) (1) | 2, Head trauma (ineligible) (2) | 3, Psychiatric illness (ineligible) (3) | 4, Brain tumor or other malignancy (ineligible) (4) | 5, Other (ineligible) (5)[f0r_gds7] = '1' and [f0r_lngth_stay] >= 30y
f0r_other_descriptext"Other" primary cause of cognitive impairment[f0r_prim_caus_cog_imp] = '5'
f0r_res_comaradioResident in coma?0, No (0) | 1, Yes (1)Is resident in a coma?[f0r_prim_caus_cog_imp] = '0'y
f0r_proxyradioProxy appointed?0, No (0) | 1, Yes (1)Has a proxy been appointed?[f0r_prim_caus_cog_imp] = '0' and [f0r_res_coma] = '0'y
f0r_res_eligible_y_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Resident IS ELIGIBLE to participate in the EVINCE study.
Please continue to collect proxy information in the following form (form0c).Click yest to indicate that resident IS eligible[f0r_res_age] >= 65.0 and [f0r_gds7] = '1' and [f0r_lngth_stay] >= 30.0 and [f0r_prim_caus_cog_imp] = '0' and [f0r_res_coma] = '0' and [f0r_proxy] = '1'
f0r_res_eligible_n_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Resident IS NOT ELIGIBLE to participate in the EVINCE study.
Stop data collection here.Resident IS eligible[f0r_res_age] < 65.0 or [f0r_gds7] = '0' or [f0r_lngth_stay] < 30.0 or [f0r_prim_caus_cog_imp] = '1' or [f0r_prim_caus_cog_imp] = '2' or [f0r_prim_caus_cog_imp] = '3' or [f0r_prim_caus_cog_imp] = '4' or [f0r_prim_caus_cog_imp] = '5' or [f0r_res_coma] = '1' or [f0r_proxy] = '0'
f0r_res_eligibilityyesnoIs Resident eligible to participate in the EVINCE study?Click yest to indicate that resident IS eligibley
f0c_ra_iddropdownRA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)
f0c_contact_inf_datetextContact info datedate_mdy
f0c_prxy_nametextProxy nameyy
f0c_prxy_strt_adrstextProxy street addressy
f0c_prxy_citytextProxy cityy
f0c_prxy_statetextProxy Statey
f0c_prxy_zipcodetextProxy Zipcodezipcodey
f0c_prxy_homephonetextProxy home phonephoney
f0c_prxy_workphonetextProxy work phonephoney
f0c_prxy_cellphonetextProxy cell phonephoney
f0c_prxy_emailtextProxy emailemaily
f0c_prxy_relationshipradioProxy's relationship to resident1, Spouse (1) | 2, Son or daughter (2) | 3, Grandson or granddaughter (3) | 4, Sibling (4) | 5, Niece or nephew (5) | 6, Legal guardian (6) | 7, Other (7)
f0c_prxy_othertextProxy relationship otherDefine the proxy's relationship to resident[f0c_prxy_relationship] = '7'y
f0c_prxy_cntc_notestextContact Field Notes
f0p_study_assigncalc<div style="font-size:12pt">Study assignment( function(){ $(document).data("url","https://ifar-edc.hsl.harvard.edu/redcap/api/"); $(document).data("params", { format : "xml", type : "flat", content : "record", token : "13ECC561A5932D67B9D0F660624213E1", fields: "fs_site_r_assign", records: [resident_eligibili_arm_1][f0r_facility_id] }); $(document).data("response", $.ajax( { type: "POST", url: $(document).data("url"), async: false, data: $(document).data("params"), dataType: "xml" } ).responseXML); return $($(document).data("response")).find("fs_site_r_assign").text() } )();
f0p_re_consentdescriptive<div style="background:#FFFF78;font-size:12pt">Previously consented then changed to Ineligible.
Please be aware that you have spoken with this proxy before and received consent for their participation in the study, but as the eligibility status changed, the dyad was removed from study and is now being re-screened/recruited.[proxy_eligibility_arm_1][f0p_prxy_consent] = '1' and [resident_eligibili_arm_1][f99_dyad_status] = '0'
f0p_doitext<div style="font-size:12pt">Proxy Screening datedate_mdyy
f0p_researcherdropdown<div style="font-size:12pt">RA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) | 6, Angelo (6)
f0p_prxy_cntctedradio<div style="font-size:12pt">
Proxy Contacted?0, No (0) | 1, Yes (1) | 2, Yes but resident no longer eligible (2)y
f0p_prxy_res_ineligradio<div style="font-size:12pt">
Reason resident no longer eligible1, Resident is dead or actively dying (1) | 2, Resident is not longer in the facility (2) | 3, Resident is in coma (3)[f0p_prxy_cntcted] = '2'y
f0p_prxy_refusesradio<div style="font-size:12pt">
Proxy Refuses prior to eligibility conversation0, No (0) | 1, Yes (1)[f0p_prxy_cntcted] = '1'y
f0p_proxy_ddescriptive<div style="font-size:12pt">
Person named in the chart as proxy is the health care proxy/decision maker for the resident?[f0p_prxy_refuses] = '0'
f0p_prxy_validationradio<div style="font-size:12pt">
Is Person the Proxy?0, No (0) | 1, Yes (1)[f0p_prxy_refuses] = '0'y
f0p_wrong_contact_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Ask person for contact information on actual proxy. Update/correct contact information on form0c, and follow-up with new proxy/contact. DO NOT SAVE THIS RECORD[f0p_prxy_validation] = '0'
f0p_prxy_englishradio<div style="font-size:12pt">
Proxy speaks english?0, No (0) | 1, Yes (1)[f0p_prxy_validation] = '1'y
f0p_d1_ddescriptive<div style="background:#FFFF99;font-size:12pt">
We would like to include you and (resident) in the EVINCE study. Participating in this study will involve one year of quarterly phone calls, and one initial face to face visit. Our research staff can drive to meet with you within a 60 mile radius of Boston. Would this be possible given your residence or practice of visiting with (resident)?
Can you meet with someone from our research team in person within 2 weeks of this phone call? [f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1'
f0p_prxy_can_meetradio<div style="font-size:12pt">
Proxy can meet0, No (0) | 1, Yes (1)[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1'y
f0p_prxy_eligible_y_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Proxy IS ELIGIBLE to particpate in EVINCEClick on YES to indicate that proxy IS eligible to participate[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1' and [f0p_prxy_can_meet] = '1'
f0p_prxy_eligible_n_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Proxy is NOT ELIGIBLE to participate in EVINCE. Click on no to indicate that proxy is NOT eligible to participate[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '0' or [f0p_prxy_can_meet] = '0'
f0p_prxy_eligibleradio<div style="font-size:12pt">
Is proxy eligible?0, No (0) | 1, Yes (1)Fill in to trigger appropriate follow-up[f0p_prxy_validation] = '1'y
f0p_not_elig_end_ddescriptive<div style="font-size:12pt">
Please save this record and end data collection here.[f0p_prxy_eligible] = '0'
f0p_consent_2_ddescriptive<div style="background:#FFFF99;font-size:12pt">
CONSENT FORM FOR RESEARCH PARTICIPATION
Study title: Improving Nursing home Care in End-stage dementia
Principal Investigator: Susan L. Mitchell MD, MPH/Angelo Volandes MD, MPH
Primary Affiliation: Hebrew SeniorLife/Massachusetts General Hospital
Co-Investigators: Michele Shaffer, PhD; Laura Hanson MD, MPH
About this Consent Form
Please read this form carefully. This form provides important information about participating in a research study. As a research participant, you have the right to take your time in making decisions about participating in this research and you are encouraged to discuss your decision with your family and your doctor. If you have any questions about the research or any part of this form, please ask us. If you decide to take part in this research, you will be asked to provide your consent over the phone. The research team member will record your decision on his/her form. You may want to sign and date your own copy of this consent form to keep for your records.
What you should know about a Research Study
Participation in research is voluntary, which means that it is something for which you volunteer. It is your choice to participate in the study, or to decline participation. If you choose to participate now, you may change your mind and stop participating at a later date. Refusal to participate or withdrawal of participation will not result in any penalty or loss of benefits to which you are otherwise entitled.
STUDY PURPOSE
You are being asked to participate in a research study entitled Improving Nursing home Care in End-stage dementia which is being conducted by Drs. Susan Mitchell and Angelo Volandes. Making sure that patients with late-stage dementia get the type of medical treatments that they would want to receive is an important health care concern. The purpose of this study is to learn the best way to help decision-makers for these patients, such as yourself, make these decisions. These are common decisions made by decisions-makers for people with advanced dementia that can influence the resident's quality and length of life. The nursing home where [RESIDENT] lives has already been assigned to use the usual practices provided in the facility to understand and determine your choices for his/her care. We anticipate that about 400 nursing home residents with advanced dementia and their health care proxies will participate in this study.
SPONSORSHIP
This study is being funded or sponsored by the National Institutes of Health.
PROCEDURES:
The study will take place over the next 12 months. If you agree to participate, the following procedures will be performed:
1. At the beginning of the study and every 3 months, we will review [RESIDENT's] nursing home medical record to collect information about his/her health and the care he/she has received. While we hope [RESIDENT's] stays well during the study, if he/she passes away, the chart will also be reviewed within 14 days of death. Basic demographic data will be collected at the beginning of the study, such as age, gender, and the date of the nursing home admission. At each follow-up assessment, the chart will be reviewed to learn about the [RESIDENT]'s health status, care he or she has received, and decisions made about that care.
2. At the beginning of the study only, we will spend a few minutes asking [RESIDENT's] nurse about his/her cognitive and self-care abilities.
3. At the beginning of the study only, we will spend five minutes asking [RESIDENT] some questions to evaluate his/her thinking abilities.
4. Within the next two weeks, a member of our research team will meet with you in-person for about 20 minutes or less. You can choose to have this meeting at a time of your convenience either in a quiet room at the [RESIDENT's] nursing home or in your home. At the interview we will ask questions about decisions you may have made about the type of care you think [RESIDENT] should receive and discussions you have had with nursing home care providers about these decisions.
5. We would also like to interview you on the telephone every 3 months after the start of the study for a maximum of 12 months. These interviews will take about 20 minutes or less. We will ask questions about decisions you may have made about [RESIDENT]'s care and discussions you have had with nursing home care providers about these decisions. All interviews will be conducted at your convenience.
RISKS
There are minimal risks associated with this study. The majority of the patient's information will be obtained from the medical record and the nurse. In our experience, it is unlikely he or she will become bothered during the one-time 5-minute testing of his or her thinking, however if he or she is bothered, the testing will stop. While unlikely, you may experience discomfort from answering some of the questions during the interviews. You can refuse answering the questions at any time. You may become fatigued from the length of the interview, in which case we can reschedule another session.
IN CASE OF INJURY
While injury is unlikely in this research, if injury does occur while participating in the research, we will offer you or [Resident] the care needed to treat any injury that directly results from taking part in this research study. If you think you or [Resident] have been injured or have experienced a medical problem as a result of taking part in this research study, tell the person in charge of the study as soon as possible. The researcher's name and phone number are listed at the end of this consent form You will be informed of any significant new findings developed during the course of this research, which may relate to your willingness to continue participation.
BENEFITS
There are no direct benefits to you or [RESIDENT] from participation in this study, however others may benefit from the knowledge gained in connection with your participation.
ALTERNATIVE TREATMENTS
There are no treatments in this study. The alternative to participating in this study is not to participate.
CONFIDENTIALITY
All personal information obtained in the study, will be kept confidential, and this information will only be available to the research staff and the HSL Institutional Review Board. The records identifying your name and the [RESIDENT's] will be kept confidential and, to the extent permitted by the applicable laws and/or regulations, will not be made publicly available. The results of the study will only be published or presented as group data. No individual participants will be identified. Data forms will be identified with a unique study number and kept locked in the study office.
COMPENSATION
For your participation in this study, you will be given a $10 gift card to CVS at the time of your in-person interview.
COSTS
There are no costs to you for participating in this study.
STUDY WITHDRAWAL
Your and [RESIDENT's] participation in this research is completely voluntary. If you chose not to participate or withdraw from the study, you or [RESIDENT] will incur no penalty or loss of usual benefits. You may withdraw your consent and discontinue participation at any time without affecting you or the [RESIDENT'S] health care or other services you or [RESIDENT] may be receiving. If you choose to take part in the study, you have the right to stop at any time. Your or [RESIDENT's] participation in this research project may be terminated if the study is determined to be inappropriate or potentially harmful for you or him/her.
AUTHORIZATION FOR USE AND DISCLOSURE OF [RESIDENT'S] PROTECTED HEALTH INFORMATION
As part of this study, we will be collecting and sharing information about you and [Resident] with others. Please review this section carefully as it contains information about the federal privacy rules and the use of Protected Health Information.
Protected Health Information (PHI)
By agreeing to this informed consent document, you are allowing the investigators and other authorized personnel to use (internally at HSL) and disclose (to people and organizations outside the HSL workforce identified in this consent) health information about [RESIDENT]. This may include information about you and [RESIDENT] that already exists such as: the [RESIDENT's] medical record, your demographic information (gender and age) as well as any new information generated as part of this study through nurse interviews and telephone interviews that we may ask you or [RESIDENT] to undergo. This is the [RESIDENT's] Protected Health Information.
People/Groups at HSL Who Will Use Protected Health Information
[RESIDENT's] Protected Health Information may be shared with the investigators listed on this consent form as well as the supporting research team (i.e. research assistants, statisticians, data managers, laboratory personnel, administrative assistants). [RESIDENT's] Protected Health Information may also be shared with the Institutional Review Board of Hebrew SeniorLife as it is responsible for reviewing studies for the protection of the research subjects.
People/Groups Outside of HSL with Whom [RESIDENT'S] Protected Health Information Will Be Shared
We will take care to maintain confidentiality and privacy about you and [RESIDENT's] Protected Health Information. We may share [RESIDENT's] Protected Health Information with the following groups so that they may carry out their duties related to this study:
• The sponsor of this study, the National Institutes of Health, and their clinical research organizations
• The other hospitals and medical centers taking part in this study including: Massachusetts General Hospital and Seattle Children's Research Institute and research collaborators at those institutions
• Statisticians and other data monitors not affiliated with HSL: Seattle Children's Research Institute, Data Safety and Monitoring Board
• Your or [RESIDENT's] health insurance company
• The Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS), the National Institutes of Health (NIH), and the Office for Human Research Protections (OHRP)
Those who receive [RESIDENT's] Protected Health Information may make further disclosures to others. If they do, your information may no longer be covered by the federal privacy regulations.
Why We Are Using and Sharing [RESIDENT'S] Protected Health Information:
The main reason for using and sharing [RESIDENT's] Protected Health Information is to conduct and oversee the research as described in this Informed Consent Document. We also shall use and share [RESIDENT's] Protected Health Information to ensure that the research meets legal, and institutional requirements and to conduct public health activities.
No Expiration Date - Right to Withdraw Authorization
Your authorization for the use and disclosure of [RESIDENT's] Protected Health Information in this Study shall never expire. However, you may withdraw your authorization for the use and disclosure of [RESIDENT's] Protected Health Information at any time by notifying the Principal Investigator in writing. If you would like to take back your authorization so that [RESIDENT's] Protected Health Information can no longer be used in this study, please send a letter notifying the Principal Investigator of your withdrawal of your authorization to Susan L. Mitchell MD, MPH at 1200 Centre Street, Boston, MA 02131. Please be aware that the investigators in this study will not be required to destroy or retrieve any of [Resident's] Protected Health Information that has already been used or disclosed before the Principal Investigator receives your letter.
Right to Access and Copy Your PHI
If you wish to review or copy [RESIDENT's] Protected Health Information, you may do so after the completion or termination of the study by sending a letter to the Principal Investigator requesting a copy of it. You may not be allowed to inspect or copy [RESIDENT's] Protected Health Information until this Study is completed or terminated.
Notice of Privacy Practices
In addition to agreeing to participate in this study, you may also be asked to sign an HSL Acknowledgement Received Notice of Privacy Practices form to acknowledge that you have received the HSL Notice of Privacy Practices.
QUESTIONS
If you have any questions regarding this research or your or [RESIDENT's] participation in it, either now or at any time in the future, please feel free to ask.
• You may obtain further information about your and [RESIDENT's] rights as a research participant or if you have any research concerns, please contact Madhuri Reddy, MD, MSc, Chair, HSL Institutional Review Board (IRB) at (617) 678-7592.
• If you have any questions about your or [RESIDENT's] role in the research study, or if any; problems arise as a result of your or [RESIDENT's] participation in this study, including research-related injuries, please contact the principal investigator, Susan L. Mitchell MD, MPH at Hebrew SeniorLife, 1200 Centre Street, Boston, at (617) 971-5326 immediately.
Do you have any additional questions?
SIGNATURE
I attest that I have fully explained the above information to [RESIDENT's HEALTH CARE PROXY name], answered any questions to his/her satisfaction, and sent him/her a copy of this form. I attest that the health care proxy gave consent to participate and to allow ______________________________ [RESIDENT] to participate in this research study.
________________________________ Signature of Research Associate
________________________________ Printed Name
________________________________ Date
[f0p_study_assign] = '2' and [f0p_prxy_eligible] = '1'
f0p_consent_1_ddescriptive<div style="background:#FFFF99;font-size:12pt">
CONSENT FORM FOR RESEARCH PARTICIPATION
Study title: Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE)
Principal Investigator: Susan L. Mitchell MD, MPH/Angelo Volandes MD, MPH
Primary Affiliation: Hebrew SeniorLife/Massachusetts General Hospital
Co-Investigators: Michele Shaffer, PhD; Laura Hanson MD, MPH
About this Consent Form
Please read this form carefully. This form provides important information about participating in a research study. As a research participant, you have the right to take your time in making decisions about participating in this research and you are encouraged to discuss your decision with your family and your doctor. If you have any questions about the research or any part of this form, please ask us. If you decide to take part in this research, you will be asked to provide your consent over the phone. The research team member will record your decision on his/her form. You may want to sign and date your own copy of this consent form to keep for your records.
What you should know about a Research Study
Participation in research is voluntary, which means that it is something for which you volunteer. It is your choice to participate in the study, or to decline participation. If you choose to participate now, you may change your mind and stop participating at a later date. Refusal to participate or withdrawal of participation will not result in any penalty or loss of benefits to which you are otherwise entitled.
STUDY PURPOSE
You are being asked to participate in a research study entitled Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE) which is being conducted by Drs. Susan Mitchell and Angelo Volandes. Making sure that patients with late-stage dementia get the type of medical treatments that their family and health care providers feel they would want to receive is an important health care concern. The purpose of this study is to learn the best way to help decision-makers, such as yourself, make these decisions. These are common decisions made by decisions-makers for people with advanced dementia that can influence the resident's quality and length of life.
The nursing home where [RESIDENT] lives has already been assigned to use the video to help you understand and determine your choices for his/her care. We anticipate that about 400 nursing home residents with advanced dementia and their health care proxies will participate in this study.
STUDY FUNDING AND DISCLOSURE OF ANY SPECIAL INTERESTS OF THE RESEARCHERS
This study is being funded or sponsored by the National Institutes of Health. Dr. Volandes, along with other medical professionals, developed the video used in this research. Dr. Volandes is the President of the Nous Foundation, a not-for-profit organization that aims to improve patient communication with video support tools. Dr. Volandes does not receive a salary or have any equity or financial arrangements with the nonprofit. Dr. Volandes' wife is the Executive Director and receives a salary from the Foundation.
PROCEDURES:
The study will take place over the next 12 months. If you agree to participate, the following procedures will be performed:
1. At the beginning of the study and every 3 months, we will review [RESIDENT's] nursing home medical record to collect information about his/her health and the care he/she has received. While we hope [RESIDENT's] stays well during the study, if he/she passes away, the chart will also be reviewed within 14 days of death. Basic demographic data will be collected at the beginning of the study, such as age, gender, and the date of the nursing home admission. At each follow-up assessment, the chart will be reviewed to learn about the [RESIDENT]'s health status, care he or she has received, and decisions made about that care.
2. At the beginning of the study only, we will spend a few minutes asking [RESIDENT's] nurse about his/her cognitive and self-care abilities.
3. At the beginning of the study only, we will spend five minutes asking [RESIDENT] some questions to evaluate his/her thinking abilities.
4. Within the next two weeks, a member of our research team will meet with you in-person for about 40 minutes or less. You can choose to have this meeting at a time of your convenience either in a quiet room at the [RESIDENT's] nursing home or in your home. The following steps will occur at this meeting:
a. For about 20 minutes or less, we will ask questions about decisions you may have made about the type of care you wish [RESIDENT] to receive and discussions you have had with nursing home care providers about these decisions.
b. We will show you a 12-minute video on a laptop computer that describes different types of care options available to patients with late-stage dementia.
c. After viewing the video, for about 10 minutes or less, we will ask you questions about the type of care you wish [RESIDENT] to receive, similar to the questions you were asked before viewing the video.
d. After the in-person interview, we will place a paper in [RESIDENT'S] chart and/or email this document to his/her primary care team that describes the type of care you wish him/her to receive as you stated to us during our interview. This document is only meant as information for the [RESIDENT'S] nursing home providers. We will NOT write any medical orders in [RESIDENT'S] chart. If want your wishes to be part of [RESIDENT'S] care, you would need to speak directly with his/her doctor.
5. We would also like to interview you on the telephone every 3 months after the start of the study for a maximum of 12 months. These interviews will take about 20 minutes or less. We will ask questions about decisions you may have made about [RESIDENT]'s care and discussions you have had with nursing home care providers about these decisions. All interviews will be conducted at your convenience.
RISKS
There are minimal risks associated with this study. The majority of the patient's information will be obtained from the medical record and the nurse. In our experience, it is unlikely he or she will become bothered during the one-time 5-minute testing of his or her thinking, however if he or she is bothered, the testing will stop. While unlikely, you may experience discomfort from viewing the video or answering some of the questions during the interviews. You can refuse to continue watching the video or answering the questions at any time. You may become fatigued from the length of the interview, in which case we can reschedule another session.
IN CASE OF INJURY
While injury is unlikely in this research, if injury does occur while participating in the research, we will offer you or [Resident] the care needed to treat any injury that directly results from taking part in this research study. If you think you or [Resident] have been injured or have experienced a medical problem as a result of taking part in this research study, tell the person in charge of the study as soon as possible. The researcher's name and phone number are listed at the end of this consent form. You will be informed of any significant new findings developed during the course of this research, which may relate to your willingness to continue participation.
BENEFITS
There are no direct benefits to you or [RESIDENT] from participation in this study, however others may benefit from the knowledge gained in connection with your participation.
ALTERNATIVE TREATMENTS
There are no treatments in this study. The alternative to participating in this study is not to participate.
CONFIDENTIALITY
All personal information obtained in the study, will be kept confidential, and this information will only be available to the research staff and the HSL Institutional Review Board. The records identifying your name and the [RESIDENT's] will be kept confidential and, to the extent permitted by the applicable laws and/or regulations, will not be made publicly available. The results of the study will only be published or presented as group data. No individual participants will be identified. Data forms will be identified with a unique study number and kept locked in the study office.
COMPENSATION
For your participation in this study, you will be given a $10 gift card to CVS at the time of your in-person interview.
COSTS
There are no costs to you for participating in this study.
STUDY WITHDRAWAL
Your and [RESIDENT's] participation in this research is completely voluntary. If you chose not to participate or withdraw from the study, you or [RESIDENT] will incur no penalty or loss of usual benefits. You may withdraw your consent and discontinue participation at any time without affecting you or the [RESIDENT'S] health care or other services you or [RESIDENT] may be receiving. If you choose to take part in the study, you have the right to stop at any time. Your or [RESIDENT's] participation in this research project may be terminated if the study is determined to be inappropriate or potentially harmful for you or him/her.
AUTHORIZATION FOR USE AND DISCLOSURE OF [RESIDENT'S] PROTECTED HEALTH INFORMATION
As part of this study, we will be collecting and sharing information about you and [Resident] with others. Please review this section carefully as it contains information about the federal privacy rules and the use of Protected Health Information.
PROTECTED HEALTH INFORMATION (PHI)
By agreeing to this informed consent document, you are allowing the investigators and other authorized personnel to use (internally at HSL) and disclose (to people and organizations outside the HSL workforce identified in this consent) health information about [RESIDENT]. This may include information that already exists such as: the [RESIDENT's] medical record, your demographic information (gender and age) as well as any new information generated as part of this study through nurse interviews and your interviews that we may ask you or [RESIDENT] to undergo. This is [RESIDENT's] Protected Health Information.
People/Groups at HSL Who Will Use Protected Health Information
[RESIDENT's] Protected Health Information may be shared with the investigators listed on this consent form as well as the supporting research team (i.e. research assistants, statisticians, data managers, laboratory personnel, administrative assistants). [RESIDENT's] Protected Health Information may also be shared with the Institutional Review Board of Hebrew SeniorLife as it is responsible for reviewing studies for the protection of the research subjects.
People/Groups Outside of HSL with Whom Protected Health Information Will Be Shared
We will take care to maintain confidentiality and privacy about you and [RESIDENT's] Protected Health Information. We may share [RESIDENT's] Protected Health Information with the following groups so that they may carry out their duties related to this study:
• The sponsor of this study, the National Institutes of Health, and their clinical research organizations
• The other hospitals and medical centers taking part in this study including: Massachusetts General Hospital and Seattle Children's Research Institute and research collaborators at those institutions
• Statisticians and other data monitors not affiliated with HSL: Seattle Children's Research Institute, Data Safety and Monitoring Board.
• Your or [RESIDENT's] health insurance company
• The Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS), the National Institutes of Health (NIH), and the Office for Human Research Protections (OHRP)
Those who receive [RESIDENT's] Protected Health Information may make further disclosures to others. If they do, this information may no longer be covered by the federal privacy regulations.
Why We Are Using and Sharing [Resident's] Protected Health Information
The main reason for using and sharing [RESIDENT's] Protected Health Information is to conduct and oversee the research as described in this Informed Consent Document. We also shall use and share [RESIDENT's] Protected Health Information to ensure that the research meets legal, and institutional requirements and to conduct public health activities.
No Expiration Date - Right to Withdraw Authorization
Your authorization for the use and disclosure of [RESIDENT's] Protected Health Information in this Study shall never expire. However, you may withdraw your authorization for the use and disclosure of [RESIDENT's] Protected Health Information at any time by notifying the Principal Investigator in writing. If you would like to take back your authorization so that [RESIDENT's] Protected Health Information can no longer be used in this study, please send a letter notifying the Principal Investigator of your withdrawal of your authorization to Susan L. Mitchell MD, MPH at 1200 Centre Street, Boston, MA 02131. Please be aware that the investigators in this study will not be required to destroy or retrieve any of [RESIDENT's] Protected Health Information that has already been used or disclosed before the Principal Investigator receives your letter.
Right to Access and Copy Your PHI
If you wish to review or copy [RESIDENT's] Protected Health Information, you may do so after the completion or termination of the study by sending a letter to the Principal Investigator requesting a copy of it. You may not be allowed to inspect or copy [RESIDENT's] Protected Health Information until this Study is completed or terminated.
Notice of Privacy Practices
In addition to agreeing to participate in this study, you may also be asked to sign an HSL Acknowledgement Received Notice of Privacy Practices form to acknowledge that you have received the HSL Notice of Privacy Practices.
QUESTIONS
If you have any questions regarding this research or your or [RESIDENT's] participation in it, either now or at any time in the future, please feel free to ask.
• You may obtain further information about your and [RESIDENT's] rights as a research participant or if you have any research concerns, please contact Madhuri Reddy, MD, MSc, Chair, HSL Institutional Review Board (IRB) at (617) 678-7592.
• If you have any questions about your or [RESIDENT's] role in the research study, or if any; problems arise as a result of your or [RESIDENT's] participation in this study, including research-related injuries, please contact the principal investigator, Susan L. Mitchell MD, MPH at Hebrew SeniorLife, 1200 Centre Street, Boston) at (617)971-5326 immediately.
Do you have any additional questions?
SIGNATURE
I attest that I have fully explained the above information to [RESIDENT's HEALTH CARE PROXY name], answered any questions to his/her satisfaction, and sent him/her a copy of this form. I attest that the health care proxy gave consent to participate and to allow ______________________________ [RESIDENT] to participate in this research study.
________________________________ Signature of Research Associate
________________________________ Printed Name
________________________________ Date
[f0p_study_assign] = '1' and [f0p_prxy_eligible] = '1'
f0p_cnsnt_rdradio<div style="font-size:12pt">
Consent Read?0, No (0) | 1, Yes (1)[f0p_prxy_eligible] = '1'y
f0p_datetext<div style="font-size:12pt">
Date Consent Readdate_mdy[f0p_cnsnt_rd] = '1'
f0p_prxy_consentradio<div style="font-size:12pt">
Proxy consent to participate0, No (0) | 1, Yes (1)[f0p_cnsnt_rd] = '1'y
f0p_cnsnt_datetext<div style="font-size:12pt">
Consent Datedate_mdy[f0p_prxy_consent] = '1'y
f0p_descript_n_ddescriptive<div style="background:#FFFF99;font-size:12pt">
If Proxy REFUSES to participate, continue with "non-participation" questions that follow[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'
f0p_descript_y_ddescriptive<div style="background:#FFFF99;font-size:12pt">
"Thank you" for your time and cooperation with this study.
L Klein, one of our research assistants, will be contacting you in the near future to set up a meeting with you.
Please feel free to call me with any questions or concerns at any time. Thank you[f0p_prxy_consent] = '1'
f0p_not_recruited_ddescriptive<div style="font-size:12pt">
Why was the resident not recruited?[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'
f0p_reason_not_recrtradio<div style="font-size:12pt">Reason resident not recruited1, Proxy refuses (1) | 2, Physician refuses (2) | 3, Resident change in med status (3) | 4, Other (4)[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'y
f0p_prxy_no_reascheckbox<div style="font-size:12pt">Reasons for proxy's refusal to consent1, Proxy concerned about proxy's privacy (1) | 2, Proxy concerned about resident's privacy (2) | 3, Proxy feels it is too burdensome (3) | 4, Proxy not interested (4) | 5, Other (5)[f0p_reason_not_recrt] = '1'y
f0p_reason_for_no_ddescriptive<div style="font-size:12pt">
Document other reason for proxy's refusal to participate in the study[f0p_prxy_no_reas(5)] = '1'
f0p_prxy_no_reas_othnotes<div style="font-size:12pt">Other Reasons for proxy refusal to consentExplain other reason for no proxy consent[f0p_prxy_no_reas(5)] = '1'y
f0p_explain_other_ddescriptive<div style="font-size:12pt">
Explain resident's change in medical status that prohibits participation in study[f0p_reason_not_recrt] = '3'
f0p_res_status_changenotes<div style="font-size:12pt">Change in resident medical status[f0p_reason_not_recrt] = '3'
f0p_no_recrt_othnotes<div style="font-size:12pt">Other reason for not being recruitedExplain other reason for no recruitment[f0p_reason_not_recrt] = '4'
f0p_res_inf_ref_ddescriptive<div style="background:#FFFF99;font-size:12pt">
RESIDENT INFORMATION
Thank you.
I understand that you do not wish to participate in this study, but it would be very helpful to us to know a little more information about the resident. Would you mind if we asked a few questions about him/her? You may refuse to answer any of the questions (Leave blank if HCP refuses all questions)[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'
f0p_prxy_cnt1radio<div style="font-size:12pt">Do you mind a few questions about resident?0, No (continue survey) (0) | 1, Yes (end survey there) (1)[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'y
f0p_prxy_cnt_y_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you for your time.
I am now going to ask you a few questions about the resident.
Continue with questions below.[f0p_prxy_cnt1] = '0'
f0p_prxy_cnt_n_ddescriptive<div style="background:#FFFF99;font-size:12pt">
I understand. Thank you for your time.
End survey here.[f0p_prxy_cnt1] = '1'
f0p_res_ethnicityradio<div style="font-size:12pt">Resident Ethnicity1, American Indian/Alaskan native (1) | 2, Asian (2) | 3, Native Hawaiian or other Pacific Islander (3) | 4, Black/African American (4) | 5, White (5) | 6, Other (6) | 888, Refused (888)[f0p_prxy_cnt1] = '0'
f0p_res_ethnic_othertext<div style="font-size:12pt">
Resident Ethnicity Other[f0p_res_ethnicity] = '6'y
f0p_res_raceradio<div style="font-size:12pt">Resident Racial Group1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 888, Refused (888)[f0p_prxy_cnt1] = '0'y
f0p_non_part_prxy_ddescriptive<div style="background:#FFFF99;font-size:12pt">
PROXY INFORMATION
We would like to ask you similar questions about yourself.
You may refuse to answer any or the questions.
(Leave blank if Proxy refuses all questions or if unable to speak with Proxy)[f0p_prxy_cnt1] = '0'
f0p_prxy_cnt2radio<div style="font-size:12pt">Do you mind a few questions about yourself?0, No (continue survey) (0) | 1, Yes (end survey there) (1)[f0p_prxy_cnt1] = '0'y
f0p_prxy_cnt2_y_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you.
(Continue with survey)[f0p_prxy_cnt2] = '0'
f0p_prxy_cnt2_n_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you for your time.
(End survey)[f0p_prxy_cnt2] = '1'
f0p_prxy_dobtext<div style="font-size:12pt">
Proxy birthdatedate_mdy[f0p_prxy_cnt2] = '0'y
f0p_prxy_gndrradio<div style="font-size:12pt">Proxy gender1, Male | 2, Female[f0p_prxy_cnt2] = '0'
f0p_prxy_eductnradio<div style="font-size:12pt">Proxy education1, No schooling (1) | 2, Less than or equal to 8th grade (2) | 3, Between 9th and 11th grade (3) | 4, Graduated high school (4) | 5, Technical or trade school (5) | 6, Some college (6) | 7, Bachelor's degree (7) | 8, Graduate degree (8) | 888, Refused to answer (888)What is the highest grade or year of school you have completed? (Don't read options, just ask question)[f0p_prxy_cnt2] = '0'
f0p_thank_you_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you for your time. [f0p_prxy_cnt2] = '0'
f1_doi<div style="background:#FFFF99;font-size:12pt"> BASELINE RESIDENT INTAKE ASSESSMENTtextResident Baseline Datedate_mdyy
f1_ra_iddropdownRA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
f1_base_unit_idtextUnit IDyy
f1_base_res_rmtextRoom numberyy
f1_res_spcl_untradioResident in Certified Alzheimer's Unit?0, No (0) | 1, Yes (1)Is the resident currently being cared for in a special care unit for dementia?y
f1_res_race<div style="background:#FFFF99;font-size:12pt"> Chart Review: DEMOGRAPHICSradioResident Racial Group1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 999, Not available (999)y
f1_res_ethnicradioResident Ethnicity1, American Indian/Alaskan native (1) | 2, Asian (2) | 3, Native Hawaiian or other Pacific Islander (3) | 4, Black/African American (4) | 5, White (5) | 6, Other (6) | 999, Unknown (999)y
f1_res_ethnic_othtextResident Ethnicity Other[f1_res_ethnic] = '6'y
f1_res_eduradioResident Highest education1, No schooling (1) | 2, Less than or equal to 8th grade (2) | 3, Between 9th and 11th grade (3) | 4, Graduated high school (4) | 5, Technical or trade school (5) | 6, Some college (6) | 7, Bachelor's degree (7) | 8, Graduate degree (8) | 888, Refused to answer (888) | 999, Do not know (999)What was the highest grade or year of school the resident completed? (from MDS)y
f1_res_prim_langradioResident primary language1, English (1) | 2, Spanish (2) | 3, French (3) | 4, Russian (4) | 5, Portuguese (5) | 6, Lituanian (6) | 7, Italian (7) | 8, Greek (8) | 9, Other (9) | 10, Chinese (10) | 999, Do not know (999)What is the resident primary language? (from MDS)y
f1_res_prim_lang_othtextResident primary language (other)What is the resident primary language? (from MDS)[f1_res_prim_lang] = '9'y
f1_res_rel_bkgrndradioResident religious background1, Protestant (1) | 2, Catholic (2) | 3, Jewish (3) | 4, Muslim (4) | 5, Other (5) | 999, Unknown (999)What is the resident's religious background?y
f1_res_rel_bkgrnd_othtextResident religious background (other)What is the resident religious background, if other?[f1_res_rel_bkgrnd] = '5'y
f1_res_mar_statradioResident Marital Status1, Married/with Partner (1) | 2, Widowed (not remarried) (2) | 3, Divorced or separated (not remarried) (3) | 4, Never married (4) | 999, Not Available (999)What is the resident's marital status?y
f1_res_dmtia_cause<div style="background:#FFFF99;font-size:12pt"> Chart Review: RESIDENT'S MEDICAL STATUScheckboxUnderlying Cause of Residents Dementia1, Alcoholic dementia (1) | 2, Alzheimer's disease (2) | 3, Vascular dementia due to stroke or multiple infarcts (3) | 4, Lewy Body disease (4) | 5, Parkinson's disease (5) | 6, Pick's disease (6) | 7, Other (7)Please check the underlying cause/causes of resident's dementiay
f1_res_dmtia_cause_othtextUnderlying Cause of Residents Dementia (other)Please specify other cause of dementia[f1_res_dmtia_cause(7)] = '1'y
f1_bellsplsy<div style="background:#FFFF99;font-size:12pt"> Other Neurological conditions (do not include organic brain syndrome, delirium, chronic confusional state)radioBell's Palsy0, No (0) | 1, Yes (1)yneurological_conditions
f1_meningiomaradioMeningioma (left occipital, extra axial)0, No (0) | 1, Yes (1)yneurological_conditions
f1_migrainesradioMigraines0, No (0) | 1, Yes (1)yneurological_conditions
f1_msradioMultiple sclerosis0, No (0) | 1, Yes (1)yneurological_conditions
f1_neuropathyradioNeuropathy0, No (0) | 1, Yes (1)yneurological_conditions
f1_obs_hydroradioOstructive hydrocephalus, normal pressure hydrocephalus, NPH0, No (0) | 1, Yes (1)yneurological_conditions
f1_parkinsonsradioParkinson's0, No (0) | 1, Yes (1)yneurological_conditions
f1_periph_neuropradioPeripheral neuropathy0, No (0) | 1, Yes (1)yneurological_conditions
f1_polioradioPolio0, No (0) | 1, Yes (1)yneurological_conditions
f1_seiz_disradioSeizure disorder0, No (0) | 1, Yes (1)yneurological_conditions
f1_strokeradioStroke0, No (0) | 1, Yes (1)yneurological_conditions
f1_sub_hemaradioSubdural hematoma0, No (0) | 1, Yes (1)yneurological_conditions
f1_syncoperadioSyncope0, No (0) | 1, Yes (1)yneurological_conditions
f1_trdv_dsknradioTardive dyskinesia0, No (0) | 1, Yes (1)yneurological_conditions
f1_tremorsradioTremors0, No (0) | 1, Yes (1)yneurological_conditions
f1_neuro_othradioOther neurological condition0, No (0) | 1, Yes (1)yneurological_conditions
f1_neuro_oth_nametextName of other Neurological condition[f1_neuro_oth] = '1'y
f1_ab_aort_anrsm<div style="background:#FFFF99;font-size:12pt"> Cardiovascular conditionsradioAbdominal or aortic aneurysm0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_arrythmiaradioArrythmia (including atrial fibrillation)0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_chfradioCongestive Heart Failure0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_cadradioCoronary artery disease0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_dvtradioDeep vein thrombosis (DVT)0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_hypertensionradioHypertension0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_orth_hyporadioOrthostatic hypotension0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_pacemakerradioPacemaker0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_pvdradioPeripheral vascular disease0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_vhdradioValvular heart disease0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_vasculitisradioVasculitis0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_cardio_othradioOther cardiovascular condition0, No (0) | 1, Yes (1)ycardiovascular_conditions
f1_cardio_oth_nametextName of other cardiovascular condition[f1_cardio_oth] = '1'y
f1_thyroid<div style="background:#FFFF99;font-size:12pt"> Endocrine/MetabolicradioAny thyroid illness0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_crfradioChronic renal failure0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_diabetesradioDiabetes mellitus0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_hyperpararadioHyperparathyroidism0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_lip_disradioLipid disorder0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_osteoporosisradioOsteoporosis0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_endomet_othradioOther Endocrine or Metabolic0, No (0) | 1, Yes (1)yendocrine_metabolic
f1_endomet_oth_nametextName other Endocrine or Metobolic [f1_endomet_oth] = '1'y
f1_a_cncr_brst<div style="background:#FFFF99;font-size:12pt"> MALIGNANCY [Any malignancy that is CURRENTLY contributing to the resident's health status (do not include postmastectomy if no active breast cancer, do not include skin cancer unless metastatic melanoma)]radioBreast Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_colorecradioColorectal Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_giradioGI cancer (other than colorectal)0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_kdnyradioKidney Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_lngradioLung Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_prstradioProstate Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_utrnradioUterine Cancer0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_othradioOther active malignancy0, No (0) | 1, Yes (1)yactive_malignancy
f1_a_cncr_oth_nametextName other active malignancy[f1_a_cncr_oth] = '1'y
f1_i_cncr_brst<div style="background:#FFFF99;font-size:12pt"> Inactive MalignancyradioInactive Breast Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_colorecradioInactive Colorectal Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_giradioInactive GI cancer (other than colorectal)0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_kdnyradioInactive Kidney Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_lngradioInactive Lung Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_prstradioInactive Prostate Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_utrnradioInactive Uterine Cancer0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_othradioOther inactive malignancy0, No (0) | 1, Yes (1)yinactive_malignancy
f1_i_cncr_oth_nametextName other inactive malignancy[f1_i_cncr_oth] = '1'y
f1_anxiety<div style="background:#FFFF99;font-size:12pt"> Psychiatric IllnessesradioAnxiety0, No 0) | 1, Yes (1)ypsyciatric
f1_bipolarradioBipolar0, No 0) | 1, Yes (1)ypsyciatric
f1_depressionradioDepression0, No 0) | 1, Yes (1)ypsyciatric
f1_ocdradioObsessive Compulsive0, No 0) | 1, Yes (1)ypsyciatric
f1_psychoticradioPsychotic behavior (includes hallucinations and fixed delusions)0, No 0) | 1, Yes (1)ypsyciatric
f1_schiz_affectradioSchizoaffective0, No 0) | 1, Yes (1)ypsyciatric
f1_schizoradioSchizophrenia0, No 0) | 1, Yes (1)ypsyciatric
f1_psych_othradioOther major psychiatric condition0, No 0) | 1, Yes (1)ypsyciatric
f1_psych_oth_nametextName other major psychiatric condition[f1_psych_oth] = '1'y
f1_asthma<div style="background:#FFFF99;font-size:12pt"> PULMONARY [Do not code pneumonia or any derivative of pneumonia as a pulmonary disease, or positive PPD]radioAsthma0, No (0) | 1, Yes (1)ypulmonary
f1_chrnc_plrl_efsnradio(Chronic) pleural effusion0, No (0) | 1, Yes (1)ypulmonary
f1_emphsma_copdradioEmphysema or chronic obstructive lung disease (COPD)0, No (0) | 1, Yes (1)ypulmonary
f1_pulm_embradioPulmonary embolus0, No (0) | 1, Yes (1)ypulmonary
f1_pulm_fibrradioPulmonary fibrosis0, No (0) | 1, Yes (1)ypulmonary
f1_pulm_othradioOther major pulmonary condition0, No (0) | 1, Yes (1)ypulmonary
f1_pulm_oth_nametextName other major pulmonary condition[f1_pulm_oth] = '1'y
f1_btd<div style="background:#FFFF99;font-size:12pt"> Digestive systemradioBilary tract disease0, No (0) | 1, Yes (1)ydigestive_system
f1_celiacradioCeliac disease0, No (0) | 1, Yes (1)ydigestive_system
f1_chrnc_lvrradioChronic liver disease0, No (0) | 1, Yes (1)ydigestive_system
f1_chrnc_pcrtsradioChronic pancreatitis0, No (0) | 1, Yes (1)ydigestive_system
f1_diverticradioDiverticular disease0, No (0) | 1, Yes (1)ydigestive_system
f1_dysphagiaradioDysphagia0, No (0) | 1, Yes (1)ydigestive_system
f1_gerdradioGastroesophageal reflux disease (GERD)0, No (0) | 1, Yes (1)ydigestive_system
f1_gi_bldradioGI bleed0, No (0) | 1, Yes (1)ydigestive_system
f1_peptic_ulcradioPeptic ulcer disease0, No (0) | 1, Yes (1)ydigestive_system
f1_sml_bwl_obstradioSmall bowel obstruction0, No (0) | 1, Yes (1)ydigestive_system
f1_dgstv_othradioOther Digestive Disorder0, No (0) | 1, Yes (1)ydigestive_system
f1_dgstv_oth_nametextName other Digestive Disorder[f1_dgstv_oth] = '1'y
f1_anemia<div style="background:#FFFF99;font-size:12pt"> Blood disordersradioAnemia0, No (0) | 1, Yes (1)yblood_disorders
f1_b12_defradioB12 deficiency0, No (0) | 1, Yes (1)yblood_disorders
f1_myelodysradioMyelodysplasia0, No (0) | 1, Yes (1)yblood_disorders
f1_polycythradioPolycythemia0, No (0) | 1, Yes (1)yblood_disorders
f1_thrombocysradioThrombocystosis0, No (0) | 1, Yes (1)yblood_disorders
f1_thrombocytradioThrombocytopenia0, No (0) | 1, Yes (1)yblood_disorders
f1_wldnstrmsradioWaldenstrom's macroglobulinemia0, No (0) | 1, Yes (1)yblood_disorders
f1_bld_othradioOther blood disorders0, No (0) | 1, Yes (1)yblood_disorders
f1_bld_oth_nametextName other blood disorders[f1_bld_oth] = '1'y
f1_arthritis<div style="background:#FFFF99;font-size:12pt"> MusculoskeletalradioArthritis (any type or locations)0, No (0) | 1, Yes (1)ymusculoskeletal
f1_lmbr_crv_stnradioLumbar or cervical stenosis0, No (0) | 1, Yes (1)ymusculoskeletal
f1_pagetsradioPaget's disease0, No (0) | 1, Yes (1)ymusculoskeletal
f1_ply_rheumradioPolymyalgia rheumatica0, No (0) | 1, Yes (1)ymusculoskeletal
f1_sciaticaradioSciatica0, No (0) | 1, Yes (1)ymusculoskeletal
f1_msclt_othradioOther musculoskeletal0, No (0) | 1, Yes (1)ymusculoskeletal
f1_msclt_oth_nametextName other musculoskeletal[f1_msclt_oth] = '1'y
f1_hearing<div style="background:#FFFF99;font-size:12pt"> SensoryradioHearing disorder0, No (0) | 1, Yes (1)ysensory
f1_visionradioVision disorder0, No (0) | 1, Yes (1)ysensory
f1_sens_othradioOther sensory disorder0, No (0) | 1, Yes (1)ysensory
f1_sens_oth_nametextName other sensory disorder[f1_sens_oth] = '1'y
f1_mrsa<div style="background:#FFFF99;font-size:12pt"> InfectionsradioMRSA0, No (0) | 1, Yes (1)yinfections
f1_vreradioVRE0, No (0) | 1, Yes (1)yinfections
f1_maj_med_oth<div style="background:#FFFF99;font-size:12pt"> OTHER (code other major medical conditions but NOT current infections)radioOther major medical conditioins0, Not in chart (0) | 1, Yes (1)(excluding current infections)y
f1_maj_med_oth_nametextName other major medical conditions(excluding current infections)[f1_maj_med_oth] = '1'y
f1_prv_surgcheckboxAll previous surgeries1, No previous (1) | 2, Hip repair (2) | 3, Other ortho (3) | 4, Cardiovascular (4) | 5, Cateract (5) | 6, Craniotomy (6) | 7, GI (7) | 8, Lobectomy/partial lung resection (8) | 9, Mastectomy (9) | 10, Thyroidectomy (10) | 11, Urogynecological (11) | 12, Other (12) | 999, Not available (999)y
f1_surg_othtextOther previous surgeries[f1_prv_surg(12)] = '1'y
f1_living_will<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: ADVANCE DIRECTIVES (as documented in chart)radioLiving Will 0, No (0) | 1, Yes (1)As documented in charty
f1_lvng_will_spfcscheckboxLiving Will Requests 1, Attempt all life-prolonging measures (1) | 2, DNR (do not resuscitate) (2) | 3, DNI (3) | 4, DNH (or any clearly written directive not to hospitalize) (4) | 5, No tube-feeding (5) | 6, No heroic measures (6)As documented in chart[f1_living_will] = '1'y
f1_dnr_m<div style="background:#FFFF99;font-size:12pt"> Current Advance DirectivesradioDNR0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_dni_mradioDNI0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_dnh_mradioDNH or other clear documentation of decision to avoid hospital transfer0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_no_tube_mradioNo feeding tube0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_no_iv_hydr_mradioNo IV hydration0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_no_iv_antib_mradioNo intravenous antibiotics (oral or intramuscular still ok)0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_no_im_antib_mradioNo intramuscular antibiotics (oral still ok)0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_no_oral_antib_mradioNo oral antibiotics0, DOES NOT have this directive (0) | 1, DOES have this directive (1)ycurrent_advance_directives
f1_doc_disc_ddescriptiveIs there documentation of a discussion between a nursing home primary care provider and the proxy regarding the goals of the residents medical care DURING THE PAST 3 MONTHS (or since admission in nursing home < 90 days)?
f1_doc_disc_gocradioDocumented Discussion of Goals of Medical Care0, No (0) | 1, Yes (1)y
f1_discuss_prvdrcheckboxProvider/s that had documented goals of care discussions with Proxy1, Physician (1) | 2, Nurse (2) | 3, Social Worker (3) | 4, Nurse practitioner (4) | 5, Physician assistant (5) | 6, Administrator (6) | 7, Physical therapist (7) | 8, Other (8)Which provider/s had the discussion with the proxy? (check all that apply)[f1_doc_disc_goc] = '1'y
f1_discuss_prvdr_othtextOther provider with documented goals of care discussions with proxyWhich provider/s had the discussion with the proxy? (check all that apply)[f1_doc_disc_goc] = '1' and [f1_discuss_prvdr(8)] = '1'y
f1_doc_goals_descript_ddescriptivePlease elaborate on discussion details [f1_doc_disc_goc] = '1'
f1_doc_goalsnotesDocumented discussions about the goals of care[f1_doc_disc_goc] = '1'
f1_peg_tube<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: TREATMENTSradioResident CURRENTLY have PEG (or J) tube?0, No (0) | 1, Yes (1)Does the resident currently have a PEG (or J) tube?y
f1_peg_date_availradioDate PEG placed avail?0, No (0) | 1, Yes (1)[f1_peg_tube] = '1'y
f1_peg_date_intextDate PEG tube inserteddate_mdy[f1_peg_tube] = '1' and [f1_peg_date_avail] = '1'y
f1_peg_in_howradioHow was PEG tube placed? 1, Outpatient procedure (came/went in same day) (1) | 2, Hospital admission (2) | 3, Other (3) | 999, Don't know (999)[f1_peg_tube] = '1'y
f1_peg_in_othtextPEG placement, other [f1_peg_in_how] = '3'y
f1_catheter_ddescriptiveHas the resident had an indwelling bladder catheter DURING THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)?
f1_catheterradioIndwelling bladder Catheter?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f1_date_cath_ddescriptiveFor how many days did the resident have an indwelling bladder catheter IN THE PAST 3 MONTHS (OR SINCE ADMISSION, IF IN THE NURSING HOME FOR LESS THAN 90 DAYS)?
Code 999 for "don't know"[f1_catheter] = '1'
f1_cath_daystextIndwelling Catheter days integer0999[f1_catheter] = '1'y
f1_periph_iv_acc_ddescriptiveHas the resident had peripheral intravenous access or therapy IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)
f1_peri_intra_therradioPeripheral intravenous access or therapy?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f1_peri_intra_days_ddescriptiveFor how many days of peripheral intravenous access or therapy did the resident have IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)
Code 999 for "don't know"[f1_peri_intra_ther] = '1'
f1_peri_intra_daystextDays of peripheral IV Days of peripheral IV access or therapy did the resident have in past 3 months (or since admission if in NH < 90 days)?integer0999[f1_peri_intra_ther] = '1'y
f1_vent_ddescriptiveHas the resident been on a ventilator IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)
f1_ventradioVentilator (past 3 months)?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f1_vent_days_ddescriptiveFor how many days was the resident on a ventilator IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)
Code 999 for "don't know"[f1_vent] = '1'
f1_vent_daystextVentilator (# days in past 3 months)?integer0999[f1_vent] = '1'y
f1_venipunct_num_d<div style="background:#FFFF99;font-size:12pt"> Chart Review: INVESTIGATIONSdescriptiveOver the PAST 3 MONTHS, (OR SINCE ADMISSION IF IN NH < 3 MONTHS), How many venipunctures were done ? (each blood draw means a separate venipuncture)
f1_venipunct_numtextVenipunctures (total # in past 3 months)?integer0999y
f1_hosp_dets_d<div style="background:#FFFF99;font-size:12pt"> Chart Review: HEALTH SERVICES UTILIZATIONdescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all hospital admissions OVER THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) in the following section.
(Do not double count for the same admission e.g. ER then overnight is recorded under hospital admission)
f1_hosp_adm_numtextHospital Admissions (total # in past 3 months)?How many hospital admissions in past 3 months (or since admission if in NH < 90 days)?integer093y
f1_hosp1_admit_datetextHospital 1 Admission Datedate_mdy[f1_hosp_adm_num] >= 1y
f1_hosp1_dischg_datetextHospital 1 Discharge Datedate_mdy[f1_hosp_adm_num] >= 1y
f1_hosp1_prim_diagdropdownHospital 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 1y
f1_hosp1_prim_diag_othtextHospital 1 Primary Diag Other[f1_hosp_adm_num] >= 1 and [f1_hosp1_prim_diag] = '109' or [f1_hosp1_prim_diag] = '202' or [f1_hosp1_prim_diag] = '1901'y
f1_hosp1_scnd_diagdropdownHospital 1 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 1
f1_hosp1_scnd_diag_othtextHospital 1 Secondary Diag Other[f1_hosp_adm_num] >= 1 and [f1_hosp1_scnd_diag] = '109' or [f1_hosp1_scnd_diag] = '202' or [f1_hosp1_scnd_diag] = '1901'y
f1_hosp2_admit_datetextHospital 2 Admission Datedate_mdy[f1_hosp_adm_num] >= 2y
f1_hosp2_dischg_datetextHospital 2 Discharge Datedate_mdy[f1_hosp_adm_num] >= 2y
f1_hosp2_prim_diagdropdownHospital 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 2y
f1_hosp2_prim_diag_othtextHospital 2 Primary Diag Other[f1_hosp_adm_num] >= 2 and [f1_hosp2_prim_diag] = '109' or [f1_hosp2_prim_diag] = '202' or [f1_hosp2_prim_diag] = '1901'y
f1_hosp2_scnd_diagdropdownHospital 2 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 2y
f1_hosp2_scnd_diag_othtextHospital 2 Secondary Diag Other[f1_hosp_adm_num] >= 2 and [f1_hosp2_scnd_diag] = '109' or [f1_hosp2_scnd_diag] = '202' or [f1_hosp2_scnd_diag] = '1901'y
f1_hosp3_admit_datetextHospital 3 Admission Datedate_mdy[f1_hosp_adm_num] >= 3y
f1_hosp3_dischg_datetextHospital 3 Discharge Datedate_mdy[f1_hosp_adm_num] >= 3y
f1_hosp3_prim_diagdropdownHospital 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 3y
f1_hosp3_prim_diag_othtextHospital 3 Primary Diagnosis, Other[f1_hosp_adm_num] >= 3 and [f1_hosp3_prim_diag] = '109' or [f1_hosp3_prim_diag] = '202' or [f1_hosp3_prim_diag] = '1901'y
f1_hosp3_scnd_diagdropdownHospital 3 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 3y
f1_hosp3_scnd_diag_othtextHospital 3 Secondary Diagnosis, Other[f1_hosp_adm_num] >= 3 and [f1_hosp3_scnd_diag] = '109' or [f1_hosp3_scnd_diag] = '202' or [f1_hosp3_scnd_diag] = '1901'y
f1_hosp4_admit_datetextHospital 4 Admission Datedate_mdy[f1_hosp_adm_num] >= 4y
f1_hosp4_dischg_datetextHospital 4 Discharge Datedate_mdy[f1_hosp_adm_num] >= 4y
f1_hosp4_prim_diagdropdownHospital 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 4y
f1_hosp4_prim_diag_othtextHospital 4 Primary Diag Other[f1_hosp_adm_num] >= 4 and [f1_hosp4_prim_diag] = '109' or [f1_hosp4_prim_diag] = '202' or [f1_hosp4_prim_diag] = '1901'y
f1_hosp4_scnd_diagdropdownHospital 4 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 4y
f1_hosp4_scnd_diag_othtextHospital 4 Secondary Diag Other[f1_hosp_adm_num] >= 4 and [f1_hosp4_scnd_diag] = '109' or [f1_hosp4_scnd_diag] = '202' or [f1_hosp4_scnd_diag] = '1901'y
f1_hosp5_admit_datetextHospital 5 Admission Datedate_mdy[f1_hosp_adm_num] >= 5y
f1_hosp5_dischg_datetextHospital 5 Discharge Datedate_mdy[f1_hosp_adm_num] >= 5y
f1_hosp5_prim_diagdropdownHospital 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 5y
f1_hosp5_prim_diag_othtextHospital 5 Primary Diag Other[f1_hosp_adm_num] >= 5 and [f1_hosp5_prim_diag] = '109' or [f1_hosp5_prim_diag] = '202' or [f1_hosp5_prim_diag] = '1901'y
f1_hosp5_scnd_diagdropdownHospital 5 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_hosp_adm_num] >= 5y
f1_hosp5_scnd_diag_othtextHospital 5 Secondary Diag Other[f1_hosp_adm_num] >= 5 and [f1_hosp5_scnd_diag] = '109' or [f1_hosp5_scnd_diag] = '202' or [f1_hosp5_scnd_diag] = '1901'y
f1_er_info_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all Emergency Room Visits (WITHOUT HOSPITALIZATION) OVER THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) in the section below
f1_er_adm_numtextEmergency Room Visits (total # in past 3 months)?How many ER visits in past 3 months (or since admission if in NH < 90 days)?number093y
f1_er1_datetextER Visit 1 Datedate_mdy[f1_er_adm_num] >= 1y
f1_er1_prim_diagdropdownER Visit 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_er_adm_num] >= 1y
f1_er1_prim_diag_othtextER Visit 1 Primary Diag, other[f1_er_adm_num] >= 1 and [f1_er1_prim_diag] = '109' or [f1_er1_prim_diag] = '202' or [f1_er1_prim_diag] = '1901'y
f1_er2_datetextER Visit 2 Datedate_mdy[f1_er_adm_num] >= 2y
f1_er2_prim_diagdropdownER Visit 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_er_adm_num] >= 2y
f1_er2_prim_diag_othtextER Visit 2 Prim diag, other[f1_er_adm_num] >= 2 and [f1_er2_prim_diag] = '109' or [f1_er2_prim_diag] = '202' or [f1_er2_prim_diag] = '1901'y
f1_er3_datetextER Visit 3 Datedate_mdy[f1_er_adm_num] >= 3y
f1_er3_prim_diagdropdownER Visit 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_er_adm_num] >= 3y
f1_er3_prim_diag_othtextER Visit 3 Prim diag, other[f1_er_adm_num] >= 3 and [f1_er3_prim_diag] = '109' or [f1_er3_prim_diag] = '202' or [f1_er3_prim_diag] = '1901'y
f1_er4_datetextER Visit 4 Datedate_mdy[f1_er_adm_num] >= 4y
f1_er4_prim_diagdropdownER Visit 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_er_adm_num] >= 4y
f1_er4_prim_diag_othtextER Visit 4 Prim diag, other[f1_er_adm_num] >= 4 and [f1_er4_prim_diag] = '109' or [f1_er4_prim_diag] = '202' or [f1_er4_prim_diag] = '1901'y
f1_er5_datetextER Visit 5 Datedate_mdy[f1_er_adm_num] >= 5y
f1_er5_prim_diagdropdownER Visit 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_er_adm_num] >= 5y
f1_er5_prim_diag_othtextER Visit 5 Prim diag, other[f1_er_adm_num] >= 5 and [f1_er5_prim_diag] = '109' or [f1_er5_prim_diag] = '202' or [f1_er5_prim_diag] = '1901'y
f1_icu_info_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all ICU Admissions OVER THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) in the section below
f1_icu_adm_numtextICU Admissions (total # in past 3 months)?How many ICU visits in past 3 months (or since admission if in NH < 90 days)?integer093y
f1_icu1_admit_datetextICU 1 Admission Datedate_mdy[f1_icu_adm_num] >= 1y
f1_icu1_dischg_datetextICU 1 Discharge Datedate_mdy[f1_icu_adm_num] >= 1y
f1_icu1_prim_diagdropdownICU 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_icu_adm_num] >= 1y
f1_icu1_prim_diag_othtextICU 1 Primary Diag, other[f1_icu_adm_num] >= 1 and [f1_icu1_prim_diag] = '109' or [f1_icu1_prim_diag] = '202' or [f1_icu1_prim_diag] = '1901'y
f1_icu2_admit_datetextICU 2 Admission Datedate_mdy[f1_icu_adm_num] >= 2y
f1_icu2_dischg_datetextICU 2 Discharge Datedate_mdy[f1_icu_adm_num] >= 2y
f1_icu2_prim_diagdropdownICU 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_icu_adm_num] >= 2y
f1_icu2_prim_diag_othtextICU 2 Primary Diag, other[f1_icu_adm_num] >= 2 and [f1_icu2_prim_diag] = '109' or [f1_icu2_prim_diag] = '202' or [f1_icu2_prim_diag] = '1901'y
f1_icu3_admit_datetextICU 3 Admission Datedate_mdy[f1_icu_adm_num] >= 3y
f1_icu3_dischg_datetextICU 3 Discharge Datedate_mdy[f1_icu_adm_num] >= 3y
f1_icu3_prim_diagdropdownICU 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f1_icu_adm_num] >= 3y
f1_icu3_prim_diag_othtextICU 3 Primary Diag, other[f1_icu_adm_num] >= 3 and [f1_icu3_prim_diag] = '109' or [f1_icu3_prim_diag] = '202' or [f1_icu3_prim_diag] = '1901'y
f1_hospice_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all Hospice utilization in the section below
f1_hospice_currentradioResident Currently on Hospice?0, No (0) | 1, Yes (1) | 999, Don't know (999)Is the resident currently on hospice?y
f1_hospice_start_datetextInitial Date Hospice Services StartedWhat was the initial date hospice services were started?date_mdy[f1_hospice_current] = '1'y
f1_provider_invlv_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe involvement with care providers in the section below
f1_np_pa_part_prim_ca_ddescriptiveDoes a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident?
f1_np_pa_part_prim_careradioNP or PA Participate in Primary Care?0, No (0) | 1, Yes (1)y
f1_doc_md_vsts_ddescriptiveHow many DOCUMENTED primary care physician or physician extender visits have there been to the resident OVER THE LAST 3 MONTHS (OR SINCE ADMISSION IF NH STAY LESS THAN 90 DAYS) (must be documentation that MD actually saw the resident)
f1_md_visits_numtext# of MD visits (last 3 months)number093y
f1_np_or_pa_visits_numtext# of NP or PA visits (last 3 months)number093y
f1_sentinal_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: SENTINAL EVENTSdescriptive<div style="background:#FFFF99;font-size:12pt">
IN PRIOR 90 DAYS (OR SINCE ADMISSION IF IN NH LESS THAN 90 DAYS) describe any NEW MAJOR MEDICAL ILLNESSES that significantly altered the resident's health status such as; hip fracture, stroke, myocardial infarction, major GI bleen, new diagnosis of cancer (other than localized skin cancer).
f1_sent_numtextNumber Sentinal EventsNumber of sentinal events since last assessmentinteger0999y
f1_sentinal_1dropdownSentinal Event 11, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 1y
f1_sent_1_othtextSentinal 1 other[f1_sentinal_1] = '11' and [f1_sent_num] >= 1y
f1_sentinal1_datetextSentinal 1 datedate_mdy[f1_sent_num] >= 1y
f1_sentinal_2dropdownSentinal Event 21, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 2y
f1_sent_2_othtextSentinal 2 other[f1_sent_num] >= 2 and [f1_sentinal_2] = '11'y
f1_sentinal2_datetextSentinal 2 datedate_mdy[f1_sent_num] >= 2y
f1_sentinal_3dropdownSentinal Event 31, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 3y
f1_sent_3_othtextSentinal 3 Other[f1_sent_num] >= 3 and [f1_sentinal_3] = '11'y
f1_sentinal3_datetextSentinal 3 datedate_mdy[f1_sent_num] >= 3y
f1_sentinal_4dropdownSentinal Event 41, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 4y
f1_sent_4_othtextSentinal 4 Other[f1_sent_num] >= 4 and [f1_sentinal_4] = '11'y
f1_sentinal4_datetextSentinal 4 datedate_mdy[f1_sent_num] >= 4y
f1_sentinal_5dropdownSentinal Event 51, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 5y
f1_sent_5_othtextSentinal 5 other[f1_sent_num] >= 5 and [f1_sentinal_5] = '11'y
f1_sentinal5_datetextSentinal 5 datedate_mdy[f1_sent_num] >= 5y
f1_sentinal_6dropdownSentinal Event 61, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 6y
f1_sent_6_othtextSentinal 6 other[f1_sent_num] >= 6 and [f1_sentinal_6] = '11'y
f1_sentinal6_datetextSentinal 6 datedate_mdy[f1_sent_num] >= 6y
f1_sentinal_7dropdownSentinal Event 71, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f1_sent_num] >= 7y
f1_sent_7_othtextSentinal 7 other[f1_sent_num] >= 7 and [f1_sentinal_7] = '11'y
f1_sentinal7_datetextSentinal 7 datedate_mdy[f1_sent_num] >= 7y
f1_end_chart_review_ddescriptive<div style="background:#FFFF99;font-size:12pt">
END OF CHART REVIEW. OPEN NEXT FORM TO COMPLETE NURSING INTERVIEW
f1_bans_d<div style="background:#FFFF99;font-size:12pt"> NURSING INTERVIEW: BEDFORD ALZHEIMER NURSING SEVERITY SCALE (BANS)descriptive<div style="background:#FFFF99;font-size:12pt">
Please check the appropriate response below that best describes the resident on an average day OVER THE LAST 3 MONTHS.
f1_bans_dressingradioBANS Scale - Dressing1, Usually is independent (1) | 2, Requires minimal assistance (2) | 3, Requires moderate assistance (3) | 4, Totally dependent (4) | 999, Don't know (999)y
f1_bans_sleepingradioBANS Scale - Sleeping1, Usually has a regular sleep-wake cycle (1) | 2, Sometimes has a regular sleep-wake cycle (2) | 3, Frequently exhibits irregular sleep-wake cycle (3) | 4, Severely disrupted sleep-wake cycle (4) | 999, Don't know (999)y
f1_bans_speechradioBANS Scale - Speech1, Completely intact ability to speak (1) | 2, Somewhat decreased ability to speak (2) | 3, Moderately decreased ability to speak (3) | 4, Totaly mute (4) | 999, Don't know (999)y
f1_bans_eatingradioBANS Scale - Eating1, Eats independently (1) | 2, Requires miminal assistance and/or coaxing (2) | 3, Requires moderate assistance and/or coaxing (3) | 4, Completely dependent (4) | 999, Don't know (999)y
f1_bans_mobilityradioBANS Scale - Mobility1, Always able to walk independently (1) | 2, Sometimes able to walk independently (2) | 3, Able to walk only with help (3) | 4, Unable to walk even with help (4) | 999, Don't know (999)y
f1_bans_musclesradioBANS Scale - Muscles1, Very flexible and has full joint motion (1) | 2, Somewhat flexible with some joint motion impairment (2) | 3, Somewhat rigid (3) | 4, Contracted (4) | 999, Don't know (999)y
f1_bans_eye_contactradioBANS Scale - Eye contact1, Eye contact is maintained (1) | 2, Eye contact is usually maintained (2) | 3, Eye contact is rarely maintained (3) | 4, Never maintains eye contact (4) | 999, Don't know (999)y
f1_end_nurse_interview_ddescriptive<div style="background:#FFFF99;font-size:12pt">
END OF NURSING INTERVIEW
f1_tsi_d<div style="background:#FFFF99;font-size:12pt"> RESIDENT EXAMINATION: TEST FOR SEVERE IMPAIRMENT (TSI)descriptive<div style="background:#FFFF99;font-size:12pt">
Please ask the resident to complete the following tasks ---read the prompts/requests above the data entry field
f1_m_comb_d<div style="background:#FFFF99;font-size:12pt"> MOTOR PERFORMANCE descriptive<div style="font-size:12pt">
"Show me how you would use this comb"
f1_m_combradio<div style="font-size:12pt">Ability to use comb0, No (0) | 1, Yes (1)y
f1_m_top_pen_ddescriptive<div style="font-size:12pt">Can you put the top on the pen?"Can you put the top on the pen?"
f1_m_top_penradio<div style="font-size:12pt">Put top on pen0, No (0) | 1, Yes (1)y
f1_m_write_name_ddescriptive<div style="font-size:12pt">Please write your name"Can you write your name?"
f1_m_write_nameradio<div style="font-size:12pt">Write name0, No (0) | 1, Yes (1)y
f1_lc_point_d<div style="background:#FFFF99;font-size:12pt"> LANGUAGE COMPREHENSIONdescriptive<div style="font-size:12pt">Please point to your ear"Point to your ear"
f1_lc_pointradio<div style="font-size:12pt">Point to ear0, No (0) | 1, Yes (1)y
f1_lc_close_eyes_ddescriptive<div style="font-size:12pt">Please close your eyes"Close your eyes"
f1_lc_close_eyesradio<div style="font-size:12pt">Close eyes0, No (0) | 1, Yes (1)y
f1_lc_show_rpen_ddescriptive<div style="font-size:12pt">Please show me the red pen
f1_lc_show_rpenradio<div style="font-size:12pt">Show red pen0, No (0) | 1, Yes (1)y
f1_lc_show_gpen_ddescriptive<div style="font-size:12pt">Please show me the green pen"Show me the green pen"
f1_lc_show_gpenradio<div style="font-size:12pt">Show green pen0, No (0) | 1, Yes (1)y
f1_lp_names_nose_d<div style="background:#FFFF99;font-size:12pt"> LANGUAGE PRODUCTIONdescriptive<div style="font-size:12pt">"What is this called?" (point to nose)
f1_lp_names_noseradio<div style="font-size:12pt">Names nose0, No (0) | 1, Yes (1)y
f1_lp_names_gpen_ddescriptive<div style="font-size:12pt">"What color is this?" (show green pen)
f1_lp_names_gpenradio<div style="font-size:12pt">Names green pen0, No (0) | 1, Yes (1)y
f1_lp_names_rpen_ddescriptive<div style="font-size:12pt">"What color is this?" (show red pen)
f1_lp_names_rpenradio<div style="font-size:12pt">Names red pen0, No (0) | 1, Yes (1)y
f1_lp_names_key_ddescriptive<div style="font-size:12pt">"What is this called?" (show key)
f1_lp_names_keyradio<div style="font-size:12pt">Names key0, No (0) | 1, Yes (1)y
f1_mi_ids_open_hand_d<div style="background:#FFFF99;font-size:12pt"> MEMORY -- IMMEDIATE Put a paper clip in a hand so resident can see itdescriptive<div style="font-size:12pt">WITH BOTH HANDS OPEN, "Which hand is the clip in?"
f1_mi_ids_open_handradio<div style="font-size:12pt">Picks hand-hands open0, No (0) | 1, Yes (1)y
f1_mi_ids_clsd_hand_ddescriptive<div style="font-size:12pt">WITH BOTH HANDS CLOSED, "Which hand is the clip in?"
f1_mi_ids_clsd_handradio<div style="font-size:12pt">Picks hand-hands closed0, No (0) | 1, Yes (1)y
f1_mi_ids_hdn_hand_ddescriptive<div style="font-size:12pt">MOVE HANDS AROUND BACK, "Which hand is the clip in?"
f1_mi_ids_hdn_handradio<div style="font-size:12pt">Picks hand-behind back0, No (0) | 1, Yes (1)y
f1_gn_counts_ears_d<div style="background:#FFFF99;font-size:12pt"> GENERAL KNOWLEDGEdescriptive<div style="font-size:12pt">"How many ears do I have?"
f1_gn_counts_earsradio<div style="font-size:12pt">Counts ears0, No (0) | 1, Yes (1)y
f1_gn_counts_ten_ddescriptive<div style="font-size:12pt">"Count my fingers" or "Count to 10"
f1_gn_counts_tenradio<div style="font-size:12pt">Counts to ten0, No (0) | 1, Yes (1)y
f1_gn_wks_year_ddescriptive<div style="font-size:12pt">"How many weeks are there are in a year?"
f1_gn_wks_yearradio<div style="font-size:12pt">Knows "Weeks in a year"0, No, (0) | 1, Yes, (1)y
f1_gn_sings_bday_ddescriptive<div style="font-size:12pt">"I am going to sing a song, if you know the words, sing along with me" (sing happy birthday)
f1_gn_sings_bdayradio<div style="font-size:12pt">Sings Happy B-day0, No (0) | 1, Yes (1)y
f1_c_pen_dif_d<div style="background:#FFFF99;font-size:12pt"> CONCEPTUALIZATIONdescriptive<div style="font-size:12pt">Show 2 large paperclips and one pen, "Which of these are different from the other?"
f1_c_pen_difradio<div style="font-size:12pt">IDs different object_pen0, No (0) | 1, Yes (1)y
f1_c_pen_sort_ddescriptive<div style="font-size:12pt">Show 2 red pens and 1 green pen. "Put this pen next to the pen that is the same color"
f1_c_pen_sortradio<div style="font-size:12pt">Sorts colored pens0, No (0) | 1, Yes (1)y
f1_c_predicts_hand_ddescriptive<div style="font-size:12pt">Moving one large paperclip from one hand to the other. " Watch me move the paperclip. Which hand will I put it in next?"
f1_c_predicts_handradio<div style="font-size:12pt">Predicts clip hand0, No (0) | 1, Yes (1)y
f1_md_ids_thread_d<div style="background:#FFFF99;font-size:12pt"> MEMORY-DELAYED descriptive <div style="font-size:12pt">Show key, thread, paperclip. "Which of these have I not done something with while you were with me?"
f1_md_ids_threadradio<div style="font-size:12pt">IDs unused thread0, No (0) | 1, Yes (1)y
f1_motor_perf_ddescriptive<div style="background:#FFFF99;font-size:12pt">
MOTOR PERFORMANCE
f1_mp_handshake_ddescriptive<div style="font-size:12pt">Extend hand to shake hands. "Thank you for spending time with me."
f1_mp_handshakeradio<div style="font-size:12pt">Shakes hand0, No (0) | 1, Yes (1)y
f1_tsi_score_ddescriptive<div style="background:#FFFF99;font-size:12pt">
The TSI score below reflects the results from the above items.
f1_tsi_scorecalc<div style="font-size:12pt">TSI Scoresum([f1_m_comb],[f1_m_top_pen],[f1_m_write_name],[f1_lc_point],[f1_lc_close_eyes],[f1_lc_show_rpen],[f1_lc_show_gpen],[f1_lp_names_nose],[f1_lp_names_gpen],[f1_lp_names_rpen],[f1_lp_names_key],[f1_mi_ids_open_hand],[f1_mi_ids_clsd_hand],[f1_mi_ids_hdn_hand],[f1_gn_counts_ears],[f1_gn_counts_ten],[f1_gn_wks_year],[f1_gn_sings_bday],[f1_c_pen_dif],[f1_c_pen_sort],[f1_c_predicts_hand],[f1_md_ids_thread],[f1_mp_handshake])
f1_tsi_instruction_ddescriptive<div style="background:#FFFF99;font-size:12pt">
If the TSI is greater than or equal to 11, please review this case with the unit nurse to validate eligibility GDS score of 7.
If the nurse indicates that the resident DOES NOT have a GDS score of 7, the resident is INELIGIBLE and must be removed from the study. Please notify research team.[f1_tsi_score] >= 11
f1_gds_validradio<div style="font-size:12pt">GDS=7 validated? 0, No (resident ineligible) (0) | 1, Yes (resident eligible) (1)[f1_tsi_score] >= 11y
f1_end_r_baseline_ddescriptive<div style="background:#FFFF99;font-size:12pt">
End of Resident Baseline data collection
f2_doi<div style="background:#FFFF99;font-size:12pt"> QUARTERLY RESIDENT ASSESSMENTtextResident Quarterly Datedate_mdyy
f2_ra_iddropdownRA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
f2_quart_unit_idtextUnit IDy
f2_quart_res_rmtextRoom numberyy
f2_res_spcl_untradioResident in Certified Alzheimer's Unit?0, No (0) | 1, Yes (1)Is the resident currently being cared for in a special care unit for dementia?y
f2_dnr_m<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: ADVANCE DIRECTIVES (as documented in chart)radioDNR0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_dni_mradioDNI0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_dnh_mradioDNH or other clear documentation of decision to avoid hospital transfer0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_no_tube_mradioNo feeding tube0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_no_iv_hydr_mradioNo IV hydration0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_no_iv_antib_mradioNo intravenous antibiotics (oral or intramuscular still ok)0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_no_im_antib_mradioNo intramuscular antibiotics (oral still ok)0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_no_oral_antib_mradioNo oral antibiotics0, Does not have this directive (0) | 1, Does have this directive (1)ycurrent_advance_directives_quarterly
f2_dnr_newradioDNR new since last assessment?0, No (0) | 1, Yes (1)[f2_dnr_m] = '1'y
f2_dnr_datetextDNR order datedate_mdy[f2_dnr_new] = '1'y
f2_dni_newradioDNI new since last assessment?0, No (0) | 1, Yes (1)[f2_dni_m] = '1'y
f2_dni_datetextDNI order datedate_mdy[f2_dni_new] = '1'y
f2_dnh_newradioDNH new since last assessment?0, No (0) | 1, Yes (1)[f2_dnh_m] = '1'y
f2_dnh_datetextDNH order datedate_mdy[f2_dnh_new] = '1'y
f2_no_tube_newradioNo feeding tube new since last assessment?0, No (0) | 1, Yes (1)[f2_no_tube_m] = '1'y
f2_no_tube_datetextNo feeding tube datedate_mdy[f2_no_tube_new] = '1'y
f2_no_iv_hydr_newradioNo IV hydration new since last assessment?0, No (0) | 1, Yes (1)[f2_no_iv_hydr_m] = '1'y
f2_no_iv_hydr_datetextNo IV hydration datedate_mdy[f2_no_iv_hydr_new] = '1'y
f2_no_iv_antib_newradioNo IV antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f2_no_iv_antib_m] = '1'y
f2_no_iv_antib_datetextNo IV antibiotic (oral or intramuscular still ok) datedate_mdy[f2_no_iv_antib_new] = '1'y
f2_no_im_antib_newradioNo intramuscular antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f2_no_im_antib_m] = '1'y
f2_no_im_antib_datetextNo intramuscular antibiotics date date_mdy[f2_no_im_antib_new] = '1'y
f2_no_oral_antib_newradioNo oral antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f2_no_oral_antib_m] = '1'y
f2_no_oral_antib_datetextNo oral antibiotics datedate_mdy[f2_no_oral_antib_new] = '1'y
f2_doc_disc_ddescriptiveIs there documentation of a discussion between a nursing home primary care provider and the proxy regarding the goals of the residents medical care SINCE LAST ASSESSMENT?
f2_doc_disc_gocradioDocumented Discussion of Goals of Medical Care0, No (0) | 1, Yes (1)y
f2_discuss_prvdrcheckboxProvider/s that had documented goals of care discussions with Proxy1, Physician (1) | 2, Nurse (2) | 3, Social Worker (3) | 4, Nurse practitioner (4) | 5, Physician assistant (5) | 6, Administrator (6) | 7, Physical therapist (7) | 8, Other (8)Which provider/s had the discussion with the proxy? (check all that apply)[f2_doc_disc_goc] = '1'y
f2_discuss_prvdr_othtextOther provider with documented goals of care discussions with proxyWhich provider/s had the discussion with the proxy? (check all that apply)[f2_doc_disc_goc] = '1' and [f2_discuss_prvdr(8)] = '1'y
f2_doc_goals_descript_ddescriptivePlease elaborate on discussion details below[f2_doc_disc_goc] = '1'
f2_doc_goalsnotesDocumented discussions about the goals of care[f2_doc_disc_goc] = '1'
f2_peg_tube<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: TREATMENTSradioResident currently have PEG (or J) tube?0, No (0) | 1, Yes (1)Does the resident currently have a PEG (or J) tube?y
f2_n_peg_date_ddescriptiveIf PEG tube is new SINCE LAST ASSESSMENT, what was the date it was placed?[f2_peg_tube] = '1'
f2_peg_newradioPEG tube new?0, no (0) | 1, yes (1) | 999, don't know (999)[f2_peg_tube] = '1'y
f2_peg_date_intextDate PEG tube inserteddate_mdy[f2_peg_new] = '1'y
f2_peg_in_howradioHow was PEG tube placed? 1, Outpatient procedure (came/went in same day) (1) | 2, Hospital admission (2) | 3, Other (3) | 999, Don't know (999)[f2_peg_tube] = '1'y
f2_peg_in_othtextPEG placement, other [f2_peg_in_how] = '3'y
f2_catheter_ddescriptiveHas the resident had an indwelling bladder catheter SINCE LAST ASSESSMENT?
f2_catheterradioIndwelling bladder Catheter?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f2_date_cath_ddescriptiveFor how many days did the resident have an indwelling bladder catheter SINCE LAST ASSESSMENT?
Code 999 for "don't know"[f2_catheter] = '1'
f2_cath_daystextIndwelling Catheter days integer0999[f2_catheter] = '1'y
f2_periph_iv_acc_ddescriptiveHas the resident had peripheral intravenous access or therapy SINCE LAST ASSESSMENT
f2_peri_intra_therradioPeripheral intravenous access or therapy?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f2_peri_intra_days_ddescriptiveFor how many days of peripheral intravenous access or therapy did the resident have SINCE LAST ASSESSMENT?
Code 999 for "Don't know"[f2_peri_intra_ther] = '1'
f2_peri_intra_daystextDays of peripheral IV Days of peripheral IV access or therapy did the resident have in past 3 months (or since admission if in NH < 90 days)?integer0999[f2_peri_intra_ther] = '1'y
f2_vent_ddescriptiveHas the resident been on a ventilator SINCE LAST ASSESSMENT?
f2_ventradioVentilator (past 3 months)?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f2_vent_days_ddescriptiveFor how many days was the resident on a ventilator SINCE LAST ASSESSMENT?
Code 999 for "Don't know"[f2_vent] = '1'
f2_vent_daystextVentilator (# days in past 3 months)?integer0999[f2_vent] = '1'y
f2_venipunct_num_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: INVESTIGATIONSdescriptiveSINCE LAST ASSESSMENT, how many venipunctures were done? (Each blood draw means a separate venipuncture)
f2_venipunct_numtextVenipunctures (total # in past 3 months)?integer0999y
f2_hosp_dets_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: HEALTH SERVICES UTILIZATIONdescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all hospital admissions SINCE LAST ASSESSMENT in the following section
(Do not double count for the same admission, e.g. ER then overnight is recorded under hospital admission)
f2_hosp_adm_numtextNumber Hospital Admissions (since last assessment)?How many hospital admissions in past 3 months (or since admission if in NH < 90 days)?integer093y
f2_hosp1_admit_datetextHospital 1 Admission Datedate_mdy[f2_hosp_adm_num] >= 1y
f2_hosp1_dischg_datetextHospital 1 Discharge Datedate_mdy[f2_hosp_adm_num] >= 1y
f2_hosp1_prim_diagdropdownHospital 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 1y
f2_hosp1_prim_diag_othtextHospital 1 Primary Diag Other[f2_hosp_adm_num] >= 1 and [f2_hosp1_prim_diag] = '109' or [f2_hosp1_prim_diag] = '202' or [f2_hosp1_prim_diag] = '1901'y
f2_hosp1_scnd_diagdropdownHospital 1 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 1y
f2_hosp1_scnd_diag_othtextHospital 1 Secondary Diag Other[f2_hosp_adm_num] >= 1 and [f2_hosp1_scnd_diag] = '109' or [f2_hosp1_scnd_diag] = '202' or [f2_hosp1_scnd_diag] = '1901'y
f2_hosp2_admit_datetextHospital 2 Admission Datedate_mdy[f2_hosp_adm_num] >= 2y
f2_hosp2_dischg_datetextHospital 2 Discharge Datedate_mdy[f2_hosp_adm_num] >= 2y
f2_hosp2_prim_diagdropdownHospital 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 2y
f2_hosp2_prim_diag_othtextHospital 2 Primary Diag Other[f2_hosp_adm_num] >= 2 and [f2_hosp2_prim_diag] = '109' or [f2_hosp2_prim_diag] = '202' or [f2_hosp2_prim_diag] = '1901'y
f2_hosp2_scnd_diagdropdownHospital 2 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 2y
f2_hosp2_scnd_diag_othtextHospital 2 Secondary Diag Other[f2_hosp_adm_num] >= 2 and [f2_hosp2_scnd_diag] = '109' or [f2_hosp2_scnd_diag] = '202' or [f2_hosp2_scnd_diag] = '1901'y
f2_hosp3_admit_datetextHospital 3 Admission Datedate_mdy[f2_hosp_adm_num] >= 3y
f2_hosp3_dischg_datetextHospital 3 Discharge Datedate_mdy[f2_hosp_adm_num] >= 3y
f2_hosp3_prim_diagdropdownHospital 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 3y
f2_hosp3_prim_diag_othtextHospital 3 Primary Diagnosis, Other[f2_hosp_adm_num] >= 3 and [f2_hosp3_prim_diag] = '109' or [f2_hosp3_prim_diag] = '202' or [f2_hosp3_prim_diag] = '1901'y
f2_hosp3_scnd_diagdropdownHospital 3 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 3y
f2_hosp3_scnd_diag_othtextHospital 3 Secondary Diagnosis, Other[f2_hosp_adm_num] >= 3 and [f2_hosp3_scnd_diag] = '109' or [f2_hosp3_scnd_diag] = '202' or [f2_hosp3_scnd_diag] = '1901'y
f2_hosp4_admit_datetextHospital 4 Admission Datedate_mdy[f2_hosp_adm_num] >= 4y
f2_hosp4_dischg_datetextHospital 4 Discharge Datedate_mdy[f2_hosp_adm_num] >= 4y
f2_hosp4_prim_diagdropdownHospital 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 4y
f2_hosp4_prim_diag_othtextHospital 4 Primary Diag Other[f2_hosp_adm_num] >= 4 and [f2_hosp4_prim_diag] = '109' or [f2_hosp4_prim_diag] = '202' or [f2_hosp4_prim_diag] = '1901'y
f2_hosp4_scnd_diagdropdownHospital 4 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 4y
f2_hosp4_scnd_diag_othtextHospital 4 Secondary Diag Other[f2_hosp_adm_num] >= 4 and [f2_hosp4_scnd_diag] = '109' or [f2_hosp4_scnd_diag] = '202' or [f2_hosp4_scnd_diag] = '1901'y
f2_hosp5_admit_datetextHospital 5 Admission Datedate_mdy[f2_hosp_adm_num] >= 5y
f2_hosp5_dischg_datetextHospital 5 Discharge Datedate_mdy[f2_hosp_adm_num] >= 5y
f2_hosp5_prim_diagdropdownHospital 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 5y
f2_hosp5_prim_diag_othtextHospital 5 Primary Diag Other[f2_hosp_adm_num] >= 5 and [f2_hosp5_prim_diag] = '109' or [f2_hosp5_prim_diag] = '202' or [f2_hosp5_prim_diag] = '1901'y
f2_hosp5_scnd_diagdropdownHospital 5 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_hosp_adm_num] >= 5y
f2_hosp5_scnd_diag_othtextHospital 5 Secondary Diag Other[f2_hosp_adm_num] >= 5 and [f2_hosp5_scnd_diag] = '109' or [f2_hosp5_scnd_diag] = '202' or [f2_hosp5_scnd_diag] = '1901'y
f2_er_infodescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all Emergency Room Visits WITHOUT HOSPITALIZATION, SINCE LAST ASSESSMENT in the section below.
f2_er_adm_numtextNumber ER Visits (since last assessment)?How many ER visits in past 3 months (or since admission if in NH < 90 days)?integer093y
f2_er1_datetextER Visit 1 Datedate_mdy[f2_er_adm_num] >= 1y
f2_er1_prim_diagdropdownER Visit 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_er_adm_num] >= 1y
f2_er1_prim_diag_othtextER Visit 1 Primary Diag, other[f2_er_adm_num] >= 1 and [f2_er1_prim_diag] = '109' or [f2_er1_prim_diag] = '202' or [f2_er1_prim_diag] = '1901'y
f2_er2_datetextER Visit 2 Datedate_mdy[f2_er_adm_num] >= 2y
f2_er2_prim_diagdropdownER Visit 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_er_adm_num] >= 2y
f2_er2_prim_diag_othtextER Visit 2 Prim diag, other[f2_er_adm_num] >= 2 and [f2_er2_prim_diag] = '109' or [f2_er2_prim_diag] = '202' or [f2_er2_prim_diag] = '1901'y
f2_er3_datetextER Visit 3 Datedate_mdy[f2_er_adm_num] >= 3y
f2_er3_prim_diagdropdownER Visit 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_er_adm_num] >= 3y
f2_er3_prim_diag_othtextER Visit 3 Prim diag, other[f2_er_adm_num] >= 3 and [f2_er3_prim_diag] = '109' or [f2_er3_prim_diag] = '202' or [f2_er3_prim_diag] = '1901'y
f2_er4_datetextER Visit 4 Datedate_mdy[f2_er_adm_num] >= 4y
f2_er4_prim_diagdropdownER Visit 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_er_adm_num] >= 4y
f2_er4_prim_diag_othtextER Visit 4 Prim diag, other[f2_er_adm_num] >= 4 and [f2_er4_prim_diag] = '109' or [f2_er4_prim_diag] = '202' or [f2_er4_prim_diag] = '1901'y
f2_er5_datetextER Visit 5 Datedate_mdy[f2_er_adm_num] >= 5y
f2_er5_prim_diagdropdownER Visit 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_er_adm_num] >= 5y
f2_er5_prim_diag_othtextER Visit 5 Prim diag, other[f2_er_adm_num] >= 5 and [f2_er5_prim_diag] = '109' or [f2_er5_prim_diag] = '202' or [f2_er5_prim_diag] = '1901'y
f2_icu_info_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all ICU Admissions SINCE LAST ASSESSMENT, in the section below.
f2_icu_adm_numtextNumber ICU Admissions (since last assessment)?How many ICU visits in past 3 months (or since admission if in NH < 90 days)?integer093y
f2_icu1_admit_datetextICU 1 Admission Datedate_mdy[f2_icu_adm_num] >= 1y
f2_icu1_dischg_datetextICU 1 Discharge Datedate_mdy[f2_icu_adm_num] >= 1y
f2_icu1_prim_diagdropdownICU 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_icu_adm_num] >= 1y
f2_icu1_prim_diag_othtextICU 1 Primary Diag, other[f2_icu_adm_num] >= 1 and [f2_icu1_prim_diag] = '109' or [f2_icu1_prim_diag] = '202' or [f2_icu1_prim_diag] = '1901'y
f2_icu2_admit_datetextICU 2 Admission Datedate_mdy[f2_icu_adm_num] >= 2y
f2_icu2_dischg_datetextICU 2 Discharge Datedate_mdy[f2_icu_adm_num] >= 2y
f2_icu2_prim_diagdropdownICU 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_icu_adm_num] >= 2y
f2_icu2_prim_diag_othtextICU 2 Primary Diag, other[f2_icu_adm_num] >= 2 and [f2_icu2_prim_diag] = '109' or [f2_icu2_prim_diag] = '202' or [f2_icu2_prim_diag] = '1901'y
f2_icu3_admit_datetextICU 3 Admission Datedate_mdy[f2_icu_adm_num] >= 3y
f2_icu3_dischg_datetextICU 3 Discharge Datedate_mdy[f2_icu_adm_num] >= 3y
f2_icu3_prim_diagdropdownICU 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f2_icu_adm_num] >= 3y
f2_icu3_prim_diag_othtextICU 3 Primary Diag, other[f2_icu_adm_num] >= 3 and [f2_icu3_prim_diag] = '109' or [f2_icu3_prim_diag] = '202' or [f2_icu3_prim_diag] = '1901'y
f2_hospice_ddescriptiveHas resident been on hospice SINCE LAST ASSESSMENT?
f2_hospiceradioResident on Hospice0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f2_hospice_start_datetextInitial Date Hospice Services StartedWhat was the initial date hospice services were started?date_mdy[f2_hospice] = '1'y
f2_hospice_num_days_ddescriptiveWhat is the total number of days the resident was enrolled in Hospice SINCE LAST ASSESSMENT?What was the initial date hospice services were started?[f2_hospice] = '1'
f2_hospice_num_daystextNumber hospice daysinteger[f2_hospice] = '1'y
f2_hospice_dschrg_ddescriptiveWas the resident discharged from hospice SINCE LAST ASSESSMENT?What was the initial date hospice services were started?
f2_hospice_dschrgradioDischarged from hospice?0, No (no) | 1, Yes (yes) | 999, Don't knowWhat was the initial date hospice services were started?y
f2_hospice_dschrg_datetextDate Hospice dischargeWhat was the initial date hospice services were started?date_mdy[f2_hospice_dschrg] = '1'y
f2_provider_invlv_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe involvement with care providers in the section below
f2_np_pa_part_prim_ca_ddescriptiveDoes a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident?
f2_np_pa_part_prim_careradioNP or PA Participate in Primary Care?0, No (0) | 1, Yes (1)y
f2_doc_md_vsts_ddescriptiveHow many documented primary care physician or physician extender visits have there been to the resident SINCE LAST ASSESSMENT? (must be documented that provider actually saw the resident)
f2_md_visits_numtext# of MD visits (last 3 months)number093y
f2_np_or_pa_visits_numtext# of NP or PA visits (last 3 months)number093y
f2_sentinal_events_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: SENTINAL EVENTS SINCE LAST ASSESSMENTdescriptive<div style="background:#FFFF99;font-size:12pt">
SINCE LAST ASSESSMENT, describe any NEW MAJOR MEDICAL ILLNESS that significantly altered the resident's health status such as: hip fracture, stroke, myocardial infarction, major GI bleed, new diagnosis of cancer (other than localized skin cancer).
f2_sent_numtextNumber Sentinal EventsNumber of sentinal events since last assessmentinteger07y
f2_sentinal_1dropdownSentinal Event 11, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 1y
f2_sent_1_othtextSentinal 1 other[f2_sentinal_1] = '11' and [f2_sent_num] >= 1y
f2_sentinal1_datetextSentinal 1 datedate_mdy[f2_sent_num] >= 1y
f2_sentinal_2dropdownSentinal Event 21, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 2y
f2_sent_2_othtextSentinal 2 other[f2_sent_num] >= 2 and [f2_sentinal_2] = '11'y
f2_sentinal2_datetextSentinal 2 datedate_mdy[f2_sent_num] >= 2y
f2_sentinal_3dropdownSentinal Event 31, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 3y
f2_sent_3_othtextSentinal 3 Other[f2_sent_num] >= 3 and [f2_sentinal_3] = '11'y
f2_sentinal3_datetextSentinal 3 datedate_mdy[f2_sent_num] >= 3y
f2_sentinal_4dropdownSentinal Event 41, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 4y
f2_sent_4_othtextSentinal 4 Other[f2_sent_num] >= 4 and [f2_sentinal_4] = '11'y
f2_sentinal4_datetextSentinal 4 datedate_mdy[f2_sent_num] >= 4y
f2_sentinal_5dropdownSentinal Event 51, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 5y
f2_sent_5_othtextSentinal 5 other[f2_sent_num] >= 5 and [f2_sentinal_5] = '11'y
f2_sentinal5_datetextSentinal 5 datedate_mdy[f2_sent_num] >= 5y
f2_sentinal_6dropdownSentinal Event 61, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 6y
f2_sent_6_othtextSentinal 6 other[f2_sent_num] >= 6 and [f2_sentinal_6] = '11'y
f2_sentinal6_datetextSentinal 6 datedate_mdy[f2_sent_num] >= 6y
f2_sentinal_7dropdownSentinal Event 71, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f2_sent_num] >= 7y
f2_sent_7_othtextSentinal 7 other[f2_sent_num] >= 7 and [f2_sentinal_7] = '11'y
f2_sentinal7_datetextSentinal 7 datedate_mdy[f2_sent_num] >= 7y
f2_end_chart_review_ddescriptive<div style="background:#FFFF99;font-size:12pt">
END OF CHART REVIEW.
f3_doi<div style="background:#FFFF99;font-size:12pt"> RESIDENT DEATH ASSESSMENTtextResident Death Chart Review Datedate_mdyy
f3_ra_iddropdownRA ID1, M (1) | 2, H (2)y
f3_death_unittextUnit numberyy
f3_death_res_rmtextRoom numberyy
f3_death_facts_ddescriptiveDeath Facts
f3_death_datetextDeath datedate_mdyy
f3_death_siteradioSite of death1, Nursing home (1) | 2, Hospital-ward bed (2) | 3, Hospital- ICU (3) | 4, Hospital-Emergency room (4) | 5, Sub-acute unit (SNF) (5) | 6, Other (6) | 999, Unknown (999)y
f3_death_site_othtextSite of death, otheralpha_only[f3_death_site] = '5'y
f3_nh_end_days_ddescriptiveHow many days of the LAST 7 DAYS (0-7) OF LIFE was the resident cared for at the nursing home?
(code "999" if unknown)
f3_nh_end_daystextNumber last days at NHinteger07y
f3_dnr_m<div style="background:#FFFF99;font-size:12pt"> Advance Directives (as documented in chart) Check the appropriate responses belowradioDNR0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_dni_mradioDNI0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_dnh_mradioDNH or other clear documentation of decision to avoid hospital transfer0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_no_tube_mradioNo feeding tube0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_no_iv_hydr_mradioNo IV hydration0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_no_iv_antib_mradioNo intravenous antibiotics (oral or intramuscular still ok)0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_no_im_antib_mradioNo intramuscular antibiotics (oral still ok)0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_no_oral_antib_mradioNo oral antibiotics0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1)ycurrent_advance_directives_death
f3_dnr_newradioDNR new since last assessment?0, No (0) | 1, Yes (1)[f3_dnr_m] = '1'y
f3_dnr_datetextDNR order datedate_mdy[f3_dnr_new] = '1'y
f3_dni_newradioDNI new since last assessment?0, No (0) | 1, Yes (1)[f3_dni_m] = '1'y
f3_dni_datetextDNI order datedate_mdy[f3_dni_new] = '1'y
f3_dnh_newradioDNH new since last assessment?0, No (0) | 1, Yes (1)[f3_dnh_m] = '1'y
f3_dnh_datetextDNH order datedate_mdy[f3_dnh_new] = '1'y
f3_no_tube_newradioNo feeding tube new since last assessment?0, No (0) | 1, Yes (1)[f3_no_tube_m] = '1'y
f3_no_tube_datetextNo feeding tube datedate_mdy[f3_no_tube_new] = '1'y
f3_no_iv_hydr_newradioNo IV hydration new since last assessment?0, No (0) | 1, Yes (1)[f3_no_iv_hydr_m] = '1'y
f3_no_iv_hydr_datetextNo IV hydration datedate_mdy[f3_no_iv_hydr_new] = '1'y
f3_no_iv_antib_newradioNo IV antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f3_no_iv_antib_m] = '1'y
f3_no_iv_antib_datetextNo IV antibiotic (oral or intramuscular still ok) datedate_mdy[f3_no_iv_antib_new] = '1'y
f3_no_im_antib_newradioNo intramuscular antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f3_no_im_antib_m] = '1'y
f3_no_im_antib_datetextNo intramuscular antibiotics date date_mdy[f3_no_im_antib_new] = '1'y
f3_no_oral_antib_newradioNo oral antibiotics new since last assessment?0, No (0) | 1, Yes (1)[f3_no_oral_antib_m] = '1'y
f3_no_oral_antib_datetextNo oral antibiotics datedate_mdy[f3_no_oral_antib_new] = '1'y
f3_doc_disc_ddescriptiveIs there documentation of a discussion between a nursing home primary care provider and the proxy regarding the goals of the residents medical care SINCE LAST ASSESSMENT?
f3_doc_disc_gocradioDocumented Discussion of Goals of Medical Care0, No (0) | 1, Yes (1)y
f3_discuss_prvdrcheckboxProvider/s that had documented goals of care discussions with Proxy1, Physician (1) | 2, Nurse (2) | 3, Social Worker (3) | 4, Nurse practitioner (4) | 5, Physician assistant (5) | 6, Administrator (6) | 7, Physical therapist (7) | 8, Other (8)Which provider/s had the discussion with the proxy? (check all that apply)[f3_doc_disc_goc] = '1'y
f3_discuss_prvdr_othtextOther provider with documented goals of care discussions with proxy[f3_doc_disc_goc] = '1' and [f3_discuss_prvdr(8)] = '1'y
f3_doc_goals_descript_ddescriptivePlease elaborate on discussion details below[f3_doc_disc_goc] = '1'
f3_doc_goalsnotesDocumented discussions about the goals of care[f3_doc_disc_goc] = '1'
f3_peg_tube<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: TREATMENTSradioDid the resident die with a PEG (or J) tube?0, No (0) | 1, Yes (1) | 999, Unknown (999)Does the resident currently have a PEG (or J) tube?y
f3_peg_newradioPEG tube is new SINCE LAST ASSESSMENT?0, no (0) | 1, yes (1) | 999, don't know (999)[f3_peg_tube] = '1'y
f3_n_peg_date_ddescriptiveIf PEG tube is new SINCE LAST ASSESSMENT, what was the date it was placed?[f3_peg_new] = '1'
f3_peg_date_intextDate PEG tube inserteddate_mdy[f3_peg_new] = '1'y
f3_peg_in_howradioHow was PEG tube placed? 1, Outpatient procedure (came/went in same day) (1) | 2, Hospital admission (2) | 3, Other (3) | 999, Don't know (999)[f3_peg_tube] = '1'y
f3_peg_in_othtextPEG placement, other [f3_peg_in_how] = '3'y
f3_catheter_ddescriptiveHas the resident had an indwelling bladder catheter SINCE LAST ASSESSMENT?
f3_catheterradioIndwelling bladder Catheter?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f3_date_cath_ddescriptiveFor how many days did the resident have an indwelling bladder catheter SINCE LAST ASSESSMENT?
Code 999 for "Don't know"[f3_catheter] = '1'
f3_cath_daystextIndwelling Catheter days integer0999[f3_catheter] = '1'y
f3_date_cath_d2_ddescriptiveFor how many days did the resident have an indwelling bladder catheter DURING LAST 7 DAYS OF LIFE?
Code 999 for "Don't know"[f3_catheter] = '1'
f3_cath_days_finaltextIndwelling Catheter final days integer07[f3_catheter] = '1'y
f3_periph_iv_acc_ddescriptiveHas the resident had peripheral intravenous access or therapy SINCE LAST ASSESSMENT
f3_peri_intra_therradioPeripheral intravenous access or therapy?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f3_peri_intra_days_ddescriptiveFor how many days of peripheral intravenous access or therapy did the resident have SINCE LAST ASSESSMENT?
Code 999 for "Don't know"[f3_peri_intra_ther] = '1'
f3_peri_intra_daystextDays of peripheral IV Days of peripheral IV access or therapy SINCE LAST ASSESSMENTinteger0999[f3_peri_intra_ther] = '1'y
f3_peri_intra_days_d2_ddescriptiveFor how many days of peripheral intravenous access or therapy did the resident have DURING LAST 7 DAYS?
Code 999 for "Don't know"[f3_peri_intra_ther] = '1'
f3_peri_intra_days_finaltextDays peripheral IV, final Days of peripheral IV in last 7 daysinteger07[f3_peri_intra_ther] = '1'y
f3_vent_ddescriptiveHas the resident been on a ventilator SINCE LAST ASSESSMENT?
f3_ventradioVentilator (past 3 months)?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f3_vent_days_ddescriptiveFor how many days was the resident on a ventilator SINCE LAST ASSESSMENT?
Code 999 for "Don't know"[f3_vent] = '1'
f3_vent_daystextVentilator (# days in past 3 months)?integer0999[f3_vent] = '1'y
f3_vent_days_f_ddescriptiveFor how many days was the resident on a ventilator DURING LAST 7 DAYS?
Code 999 for "Don't know"[f3_vent] = '1'
f3_vent_days_finaltextVentilator (# days in last 7 days)?integer07[f3_vent] = '1'y
f3_venipunct_num_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: INVESTIGATIONSdescriptiveSINCE LAST ASSESSMENT, how many venipunctures were done? (Each blood draw means a separate venipuncture)
Code 999 for (Don't know)
f3_venipunct_numtextVenipunctures (total # in past 3 months)?integer0999y
f3_venipunct_num_f_ddescriptiveIN LAST 7 DAYS OF LIFE, how many venipunctures were done? (Each blood draw means a separate venipuncture)
Code 999 for (Don't know)
f3_venipunct_num_ftextVenipunctures (total # in LAST 7 DAYS)integer07y
f3_hosp_dets_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: HEALTH SERVICES UTILIZATIONdescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all hospital admissions SINCE LAST ASSESSMENT in the following section
(Do not double count for the same admission, e.g. ER then overnight is recorded under hospital admission)
f3_hosp_adm_numtextHospital Admissions (since last assessment)?How many hospital admissions SINCE LAST ASSESSMENTinteger093y
f3_hosp1_admit_datetextHospital 1 Admission Datedate_mdy[f3_hosp_adm_num] >= 1y
f3_hosp1_dischg_datetextHospital 1 Discharge Datedate_mdy[f3_hosp_adm_num] >= 1y
f3_hosp1_prim_diagdropdownHospital 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 1y
f3_hosp1_prim_diag_othtextHospital 1 Primary Diag Other[f3_hosp_adm_num] >= 1 and [f3_hosp1_prim_diag] = '109' or [f3_hosp1_prim_diag] = '202' or [f3_hosp1_prim_diag] = '1901'y
f3_hosp1_scnd_diagdropdownHospital 1 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 1y
f3_hosp1_scnd_diag_othtextHospital 1 Secondary Diag Other[f3_hosp_adm_num] >= 1 and [f3_hosp1_scnd_diag] = '109' or [f3_hosp1_scnd_diag] = '202' or [f3_hosp1_scnd_diag] = '1901'y
f3_hosp2_admit_datetextHospital 2 Admission Datedate_mdy[f3_hosp_adm_num] >= 2y
f3_hosp2_dischg_datetextHospital 2 Discharge Datedate_mdy[f3_hosp_adm_num] >= 2y
f3_hosp2_prim_diagdropdownHospital 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 2y
f3_hosp2_prim_diag_othtextHospital 2 Primary Diag Other[f3_hosp_adm_num] >= 2 and [f3_hosp2_prim_diag] = '109' or [f3_hosp2_prim_diag] = '202' or [f3_hosp2_prim_diag] = '1901'y
f3_hosp2_scnd_diagdropdownHospital 2 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 2y
f3_hosp2_scnd_diag_othtextHospital 2 Secondary Diag Other[f3_hosp_adm_num] >= 2 and [f3_hosp2_scnd_diag] = '109' or [f3_hosp2_scnd_diag] = '202' or [f3_hosp2_scnd_diag] = '1901'y
f3_hosp3_admit_datetextHospital 3 Admission Datedate_mdy[f3_hosp_adm_num] >= 3y
f3_hosp3_dischg_datetextHospital 3 Discharge Datedate_mdy[f3_hosp_adm_num] >= 3y
f3_hosp3_prim_diagdropdownHospital 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 3y
f3_hosp3_prim_diag_othtextHospital 3 Primary Diagnosis, Other[f3_hosp_adm_num] >= 3 and [f3_hosp3_prim_diag] = '109' or [f3_hosp3_prim_diag] = '202' or [f3_hosp3_prim_diag] = '1901'y
f3_hosp3_scnd_diagdropdownHospital 3 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 3y
f3_hosp3_scnd_diag_othtextHospital 3 Secondary Diagnosis, Other[f3_hosp_adm_num] >= 3 and [f3_hosp3_scnd_diag] = '109' or [f3_hosp3_scnd_diag] = '202' or [f3_hosp3_scnd_diag] = '1901'y
f3_hosp4_admit_datetextHospital 4 Admission Datedate_mdy[f3_hosp_adm_num] >= 4y
f3_hosp4_dischg_datetextHospital 4 Discharge Datedate_mdy[f3_hosp_adm_num] >= 4y
f3_hosp4_prim_diagdropdownHospital 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 4y
f3_hosp4_prim_diag_othtextHospital 4 Primary Diag Other[f3_hosp_adm_num] >= 4 and [f3_hosp4_prim_diag] = '109' or [f3_hosp4_prim_diag] = '202' or [f3_hosp4_prim_diag] = '1901'y
f3_hosp4_scnd_diagdropdownHospital 4 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 4y
f3_hosp4_scnd_diag_othtextHospital 4 Secondary Diag Other[f3_hosp_adm_num] >= 4 and [f3_hosp4_scnd_diag] = '109' or [f3_hosp4_scnd_diag] = '202' or [f3_hosp4_scnd_diag] = '1901'y
f3_hosp5_admit_datetextHospital 5 Admission Datedate_mdy[f3_hosp_adm_num] >= 5y
f3_hosp5_dischg_datetextHospital 5 Discharge Datedate_mdy[f3_hosp_adm_num] >= 5y
f3_hosp5_prim_diagdropdownHospital 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 5y
f3_hosp5_prim_diag_othtextHospital 5 Primary Diag Other[f3_hosp_adm_num] >= 5 and [f3_hosp5_prim_diag] = '109' or [f3_hosp5_prim_diag] = '202' or [f3_hosp5_prim_diag] = '1901'y
f3_hosp5_scnd_diagdropdownHospital 5 Secondary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_hosp_adm_num] >= 5y
f3_hosp5_scnd_diag_othtextHospital 5 Secondary Diag Other[f3_hosp_adm_num] >= 5 and [f3_hosp5_scnd_diag] = '109' or [f3_hosp5_scnd_diag] = '202' or [f3_hosp5_scnd_diag] = '1901'y
f3_er_infodescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all Emergency Room Visits WITHOUT HOSPITALIZATION, SINCE LAST ASSESSMENT in the section below.
f3_er_adm_numtextNumber ER Visits (since last assessment)?How many ER visits SINCE LAST ASSESSMENTinteger093y
f3_er1_datetextER Visit 1 Datedate_mdy[f3_er_adm_num] >= 1y
f3_er1_prim_diagdropdownER Visit 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_er_adm_num] >= 1y
f3_er1_prim_diag_othtextER Visit 1 Primary Diag, other[f3_er_adm_num] >= 1 and [f3_er1_prim_diag] = '109' or [f3_er1_prim_diag] = '202' or [f3_er1_prim_diag] = '1901'y
f3_er2_datetextER Visit 2 Datedate_mdy[f3_er_adm_num] >= 2y
f3_er2_prim_diagdropdownER Visit 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_er_adm_num] >= 2y
f3_er2_prim_diag_othtextER Visit 2 Prim diag, other[f3_er_adm_num] >= 2 and [f3_er2_prim_diag] = '109' or [f3_er2_prim_diag] = '202' or [f3_er2_prim_diag] = '1901'y
f3_er3_datetextER Visit 3 Datedate_mdy[f3_er_adm_num] >= 3y
f3_er3_prim_diagdropdownER Visit 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_er_adm_num] >= 3y
f3_er3_prim_diag_othtextER Visit 3 Prim diag, other[f3_er_adm_num] >= 3 and [f3_er3_prim_diag] = '109' or [f3_er3_prim_diag] = '202' or [f3_er3_prim_diag] = '1901'y
f3_er4_datetextER Visit 4 Datedate_mdy[f3_er_adm_num] >= 4y
f3_er4_prim_diagdropdownER Visit 4 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_er_adm_num] >= 4y
f3_er4_prim_diag_othtextER Visit 4 Prim diag, other[f3_er_adm_num] >= 4 and [f3_er4_prim_diag] = '109' or [f3_er4_prim_diag] = '202' or [f3_er4_prim_diag] = '1901'y
f3_er5_datetextER Visit 5 Datedate_mdy[f3_er_adm_num] >= 5y
f3_er5_prim_diagdropdownER Visit 5 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_er_adm_num] >= 5y
f3_er5_prim_diag_othtextER Visit 5 Prim diag, other[f3_er_adm_num] >= 5 and [f3_er5_prim_diag] = '109' or [f3_er5_prim_diag] = '202' or [f3_er5_prim_diag] = '1901'y
f3_icu_info_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe all ICU Admissions SINCE LAST ASSESSMENT, in the section below.
f3_icu_adm_numtextNumber ICU Admissions (since last assessment)?How many ICU visits SINCE LAST ASSESSMENTinteger093y
f3_icu1_admit_datetextICU 1 Admission Datedate_mdy[f3_icu_adm_num] >= 1y
f3_icu1_dischg_datetextICU 1 Discharge Datedate_mdy[f3_icu_adm_num] >= 1y
f3_icu1_prim_diagdropdownICU 1 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_icu_adm_num] >= 1y
f3_icu1_prim_diag_othtextICU 1 Primary Diag, other[f3_icu_adm_num] >= 1 and [f3_icu1_prim_diag] = '109' or [f3_icu1_prim_diag] = '202' or [f3_icu1_prim_diag] = '1901'y
f3_icu2_admit_datetextICU 2 Admission Datedate_mdy[f3_icu_adm_num] >= 2y
f3_icu2_dischg_datetextICU 2 Discharge Datedate_mdy[f3_icu_adm_num] >= 2y
f3_icu2_prim_diagdropdownICU 2 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_icu_adm_num] >= 2y
f3_icu2_prim_diag_othtextICU 2 Primary Diag, other[f3_icu_adm_num] >= 2 and [f3_icu2_prim_diag] = '109' or [f3_icu2_prim_diag] = '202' or [f3_icu2_prim_diag] = '1901'y
f3_icu3_admit_datetextICU 3 Admission Datedate_mdy[f3_icu_adm_num] >= 3y
f3_icu3_dischg_datetextICU 3 Discharge Datedate_mdy[f3_icu_adm_num] >= 3y
f3_icu3_prim_diagdropdownICU 3 Primary Diagnosis101, Respiratory tract infection (101) | 102, Skin or soft tissue infection (102) | 103, Urinary tract infection (103) | 104, Ear/Nose/Throat infection (104) | 105, Diarrhea (105) | 106, Febrile episode undocumented source (106) | 107, Sepsis (107) | 108, Dental (108) | 109, Other infection, Specify (109) | 201, Hip fracture (201) | 202, Other fracture (202) | 301, GI bleed (301) | 302, Bowel obstruction (302) | 303, G tube insertion (303) | 304, G tube complication (304) | 305, G tube replacement (305) | 401, Congestive Heart Failure (CHF) (401) | 402, Pacemaker Replacement (402) | 403, Pulmonary Embolism (PE) (403) | 404, Deep Vein Thrombosis (DVT) (404) | 405, Myocardial Infarction (MI) (405) | 406, Chest Pain (406) | 407, Hypotension (407) | 408, Afib (408) | 501, Stroke (501) | 502, Mental status change (502) | 601, Nephrolithiasis (601) | 602, Renal failure (602) | 701, Pain Control (701) | 801, Abrasions/lacerations (801) | 802, Evaluation (802) | 803, Prophylaxis (803) | 901, Respiratory distress (SOB) (901) | 1001, Dehydration (1001) | 1101, Pre-dental (1101) | 1201, Obstructive jaundice (1201) | 1301, Laceration (1301) | 1401, COPD (1401) | 1501, Agitation (1501) | 1601, IV insertion and reinsertion (1601) | 1701, Hypercalcemia (1701) | 1801, Hypoglycemia (1801) | 1901, Other (1901)[f3_icu_adm_num] >= 3y
f3_icu3_prim_diag_othtextICU 3 Primary Diag, other[f3_icu_adm_num] >= 3 and [f3_icu3_prim_diag] = '109' or [f3_icu3_prim_diag] = '202' or [f3_icu3_prim_diag] = '1901'y
f3_hospice_ddescriptiveHas resident been on hospice SINCE LAST ASSESSMENT?
f3_hospiceradioResident on Hospice0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f3_hospice_start_datetextInitial Date Hospice Services StartedWhat was the initial date hospice services were started?date_mdy[f3_hospice] = '1'y
f3_hospice_num_days_ddescriptiveWhat is the total number of days the resident was enrolled in Hospice SINCE LAST ASSESSMENT?What was the initial date hospice services were started?[f3_hospice] = '1'
f3_hospice_num_daystextNumber hospice daysinteger[f3_hospice] = '1'y
f3_hospice_last_days_ddescriptiveWhat was the total number of days enrolled in Hospice DURING THE LAST WEEK OF LIFE?What was the initial date hospice services were started?
f3_hospice_last_daystextNumber hospice days of last 7What was the initial date hospice services were started?integer07y
f3_provider_invlv_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Describe involvement with care providers in the section below
f3_np_pa_part_prim_ca_ddescriptiveDoes a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident?
f3_np_pa_part_prim_careradioNP or PA Participate in Primary Care?0, No (0) | 1, Yes (1) | 999, Don't know (999)y
f3_doc_md_vsts_ddescriptiveHow many documented primary care physician or physician extender visits have there been to the resident SINCE LAST ASSESSMENT? (must be documentation that provider actually saw the resident)
f3_md_visits_numtext# of MD visits (last 3 months)number093y
f3_np_or_pa_visits_numtext# of NP or PA visits (last 3 months)number093y
f3_doc_num_nppa_ddescriptiveHow many documented primary care physician or physician extender visits in the nursing home were there to the resident IN THE LAST 7 DAYS (0-7) OF LIFE?
f3_md_visit_num_ftextNumber MD visitsinteger07y
f3_np_or_pa_visits_num_ftextNumber NP or PA visitsinteger07y
f3_sentinal_events_d<div style="background:#FFFF99;font-size:12pt"> CHART REVIEW: SENTINAL EVENTS SINCE LAST ASSESSMENTdescriptive<div style="background:#FFFF99;font-size:12pt">
SINCE LAST ASSESSMENT, describe any NEW MAJOR MEDICAL ILLNESS that significantly altered the resident's health status such as: hip fracture, stroke, myocardial infarction, major GI bleed, new diagnosis of cancer (other than localized skin cancer).
f3_sent_numtextNumber Sentinal EventsNumber of sentinal events since last assessmentinteger07y
f3_sentinal_1dropdownSentinal Event 11, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 1
f3_sent_1_othtextSentinal 1 other[f3_sentinal_1] = '11' and [f3_sent_num] >= 1y
f3_sentinal1_datetextSentinal 1 datedate_mdy[f3_sent_num] >= 1y
f3_sentinal_2dropdownSentinal Event 21, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 2y
f3_sent_2_othtextSentinal 2 other[f3_sent_num] >= 2 and [f3_sentinal_2] = '11'y
f3_sentinal2_datetextSentinal 2 datedate_mdy[f3_sent_num] >= 2y
f3_sentinal_3dropdownSentinal Event 31, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 3y
f3_sent_3_othtextSentinal 3 Other[f3_sent_num] >= 3 and [f3_sentinal_3] = '11'y
f3_sentinal3_datetextSentinal 3 datedate_mdy[f3_sent_num] >= 3y
f3_sentinal_4dropdownSentinal Event 41, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 4y
f3_sent_4_othtextSentinal 4 Other[f3_sent_num] >= 4 and [f3_sentinal_4] = '11'y
f3_sentinal4_datetextSentinal 4 datedate_mdy[f3_sent_num] >= 4y
f3_sentinal_5dropdownSentinal Event 51, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 5y
f3_sent_5_othtextSentinal 5 other[f3_sent_num] >= 5 and [f3_sentinal_5] = '11'y
f3_sentinal5_datetextSentinal 5 datedate_mdy[f3_sent_num] >= 5y
f3_sentinal_6dropdownSentinal Event 61, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 6y
f3_sent_6_othtextSentinal 6 other[f3_sent_num] >= 6 and [f3_sentinal_6] = '11'y
f3_sentinal6_datetextSentinal 6 datedate_mdy[f3_sent_num] >= 6y
f3_sentinal_7dropdownSentinal Event 71, Pneumonia (1) | 2, Hip fracture (2) | 3, Stroke (3) | 4, MI (4) | 5, GI bleed (5) | 6, Cancer (6) | 7, Seizure (7) | 8, Fracture other than hip (8) | 9, Nephroliathiasis (9) | 10, Sepsis (10) | 11, Other (11)[f3_sent_num] >= 7y
f3_sent_7_othtextSentinal 7 other[f3_sent_num] >= 7 and [f3_sentinal_7] = '11'y
f3_sentinal7_datetextSentinal 7 datedate_mdy[f3_sent_num] >= 7y
f3_end_chart_review_ddescriptive<div style="background:#FFFF99;font-size:12pt">
END OF CHART REVIEW.
f4_doitext<div style="font-size:12pt">
Proxy Baseline datedate_mdyy
f4_int_statradio<div style="font-size:12pt">Refused baseline?1, Agrees to do baseline (1) | 2, Refuses baseline (2)
f4_ra_iddropdown<div style="font-size:12pt">
RA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
f4_prxy_d<div style="background:#FFFF99;font-size:12pt"> Begin Proxy Baseline Interviewdescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you for taking the time to answer these questions. The questions I will ask you relate to [resident], your feelings about [his/her] illness and your role as Health Care Proxy.
I will also ask you some questions about yourself. Your responses will be kept confidential. If at any time or for any reason, you feel you do not wish to continue, we will stop. You may also choose not to answer individual questions. However, I hope you will be able to complete the entire survey. I am going to ask you a number of questions.
Some of the questions will be followed by a choice of answers. Please wait until I have read all of the possible responses before chooseing your answer. Do you have any questions before we begin?</div>
f4_prxy_relation_ddescriptive<div style="font-size:12pt">
What is your relation to [resident]?
f4_prxy_relationradio<div style="font-size:12pt">Proxy relation to resident1, Spouse (1) | 2, Son or daughter (2) | 3, Grandson or granddaughter (3) | 4, Sibling (4) | 5, Niece or nephew (5) | 6, Legal guardian (6) | 7, Friend (7) | 8, Cousin (8) | 9, Child-in-law (9) | 10, Godchild (10) | 11, Other (11) | 888, Refused (888)y
f4_prxy_relation_othtext<div style="font-size:12pt">
Proxy relation to resident, other[f4_prxy_relation] = '11'y
f4_live_with_prior_nh_ddescriptive<div style="font-size:12pt">
Did you live with resident prior to NH admission?
f4_live_with_prior_nhradio
<div style="font-size:12pt">Live with prior0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Unknown (999)y
f4_live_le_1hour_nh_ddescriptive<div style="font-size:12pt">
Do you live within a 1-hour car drive from [RESIDENT'S] nursing home?
f4_live_le_1hour_nhradio<div style="font-size:12pt">Within a 1-hour 0, No (0) | 1, Yes (1) | 888, Refused (888)y
f4_num_hrs_visit_res_nh_ddescriptive<div style="font-size:12pt">
Approximately how many hours a week do you currently spend visiting (resident) at the nursing home?
f4_num_hrs_visit_res_nhradio<div style="font-size:12pt">Hours visiting0, None (0) | 1, < 1 hour each week (1) | 2, 1-3 hours each week (2) | 3, 4-7 hours each week (3) | 4, 8-11 hours each week (4) | 5, 12-15 hours each week (5) | 6, > 15 hours each week (6) | 888, Refused (888) | 999, Don't know (999)y
f4_yrs_diag_dement_ddescriptive<div style="font-size:12pt">
To the best of your knowledge, how many years ago did [RESIDENT] receive a diagnosis of dementia?
(code: refusal "888"; don't know "999")
f4_yrs_diag_dementtext<div style="font-size:12pt">
Years diagnosis dementianumber1999y
f4_descript6<div style="background:#FFFF99;font-size:12pt"> ADVANCE CARE PLANNING: I would now like to ask you a few questions about your role as the health care proxy for [RESIDENT]. descriptive<div style="font-size:12pt">
How long have you been the designated health care proxy for (resident)
(code: refusal "888"; don't know "999")
f4_time_hcptext<div style="font-size:12pt">
Time as proxy (years)number1999y
f4_prxy_care_pref_ddescriptive<div style="background:#FFFF99;font-size:12pt">
I am interested in learning about kind of treatments you want the [RESIDENT] to receive. I will briefly describe three general levels of medical care. I will then ask you which level best fits with the type of care you would choose for [RESIDENT].
The 3 three levels are: 1. Intensive medical care, 2. Basic medical care, and 3. Comfort care.
Intensive medical care includes the use of all medical treatments available, such as cardiopulmonary resuscitation or CPR, breathing machines, and feeding tubes. With intensive care, patients are sent to the hospital for serious illnesses and admitted to an intensive care unit or ICU if necessary.
The next level, Basic medical care, includes some, but not all, available medical treatments. Patients choosing basic care may get treated with antibiotics, fluids, or other medicines through a tube placed in a vein, and may be sent to the hospital for sudden illnesses. People choosing basic care want to avoid intensive medical treatments including CPR, breathing machines, tube-feeding or treatment in an ICU.
Finally, with Comfort care, treatments are only used if they help relieve uncomfortable symptoms, for example medications to relieve pain, and oxygen to reduce trouble breathing. People choosing comfort care do not want CPR, breathing machines, tube-feeding or additional fluids or medications given through a tube placed in a vein. With comfort care, hospitalization is avoided unless the hospital is needed to relieve pain, such as to fix a hip fracture.
f4_res_pref_loc_ddescriptive<div style="font-size:12pt">
Which level do you feel fits closest with the type of care you feel [RESIDENT's name] would want to receive: intensive medical care, basic medical care, or comfort care?
f4_res_pref_locradio<div style="font-size:12pt">Level resident would want1, Intensive medical care (1) | 2, Basic medical care (2) | 3, Comfort care (3) | 888, Refused (888) | 999, Unknown (999)y
f4_prvdr_ask_prxy_opin_ddescriptive<div style="font-size:12pt">
Since being in the nursing home, has any health care provider asked your opinion regarding the goals of [RESIDENT's] medical care?
f4_prvdr_ask_prxy_opinradio<div style="font-size:12pt">Provider asked opinion 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f4_prvdr_disc_trtmnts_ddescriptive<div style="font-size:12pt">
Since being in the nursing home, have you discussed the type of medical treatments the [RESIDENT] would want to receive with a health care provider at the nursing home?
f4_prvdr_disc_trtmntsradio<div style="font-size:12pt">Provider Discussion? 0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Don't know (999)y
f4_who_init_discuss_ddescriptive<div style="font-size:12pt">
Who initiated this discussion, you or the health care provider?[f4_prvdr_disc_trtmnts] = '1'
f4_who_init_discussradio<div style="font-size:12pt">Discussion initiator1, Proxy (1) | 2, Provider (2) | 3, Both proxy and provider (3) | 888, Refused (888) | 999, Don't know (999)[f4_prvdr_disc_trtmnts] = '1'y
f4_discuss_prvdr_ddescriptive<div style="font-size:12pt">
Who was the health provider with whom you had this discussion? [f4_prvdr_disc_trtmnts] = '1'
f4_discuss_prvdrcheckbox<div style="font-size:12pt">Which provider discussed? 1, Physician (1) | 2, Nurse practitioner (2) | 3, Physician assistant (3) | 4, Nurse providing direct care (4) | 5, Director of nursing (DON) (5) | 6, Senior administrator (other than DON) (6) | 7, Social worker (7) | 8, Chaplain (8) | 9, Other, specify (9)[f4_prvdr_disc_trtmnts] = '1'y
f4_discuss_prvdr_oth_ddescriptive<div style="font-size:12pt">
Who was the "other" provider with whom you discussed residents goals of care?[f4_discuss_prvdr(9)] = '1'
f4_discuss_prvdr_othtext<div style="font-size:12pt">
Other provider discussion[f4_discuss_prvdr(9)] = '1'y
f4_phys_disc_hlth_prob_ddescriptive<div style="font-size:12pt">
Has any physician ever counseled you about what types of health problems [RESIDENT] may experience in the later stages of dementia?
f4_phys_disc_hlth_probradio<div style="font-size:12pt">Physician counseled 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f4_prxy_undst_future_ddescriptive<div style="font-size:12pt">
Do you believe you have a good understanding of the types of health problems [RESIDENT] may experience in the later stages of dementia?
f4_prxy_undst_futureradio<div style="font-size:12pt">Proxy understanding0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f4_partic_trtmnt_decis_ddescriptive<div style="font-size:12pt">Have you ever participated in treatment decisions for resident?
f4_partic_trtmnt_decisradio<div style="font-size:12pt">Treatment decisions 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f4_res_life_left_ddescriptive<div style="font-size:12pt">
Although I know this may be a difficult question, please do your best to respond. In your opinion, how close do you feel [RESIDENT] is to the end of her/his life?
f4_res_life_leftradio<div style="font-size:12pt">Near to end of life1, < 1 month (1) | 2, 1-6 months (2) | 3, 7-12 months (3) | 4, > 12 months (4) | 888, Refused (888) | 999, Don't know (999)y
f4_undst_res_hlth_wish_ddescriptive<div style="font-size:12pt">
At this time, how confident are you that you understand what the [RESIDENT] would and would not want with respect to his/her health care if he/she could make his/her own decisions.
f4_undst_res_hlth_wishradio<div style="font-size:12pt">Confident of understanding1, Very confident (1) | 2, Somewhat confident (2) | 3, Not confident at all (3) | 888, Refused (888) | 999, Don't know (999)y
f4_prxy_demographicsdescriptive<div style="font-size:12pt">At this time, I would like to ask you a few questions about yourself.
f4_prxy_dobtext<div style="font-size:12pt">
Proxy birthdatedate_mdy
f4_prox_dob_naradioProxy Birthday available?0, DOB not available (refused to answer)(0) | 1, DOB available and recorded (1)[f4_prxy_dob] = ''y
f4_prxy_gndrradio<div style="font-size:12pt">Proxy gender1, Male | 2, Femaley
f4_prxy_eductnradio<div style="font-size:12pt">Proxy education1, No schooling (1) | 2, Less than or equal to 8th grade (2) | 3, Between 9th and 11th grade (3) | 4, Graduated high school (4) | 5, Technical or trade school (5) | 6, Some college (6) | 7, Bachelor's degree (7) | 8, Graduate degree (8) | 888, Refused to answer (888)What is the highest grade or year of school you have completed? (Don't read options, just ask question)y
f4_prxy_raceradio<div style="font-size:12pt">Prxy Racial Group1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 3, Other (3) | 888, Refused (888) | 999, Not available (999)y
f4_prxy_race_othtext<div style="font-size:12pt">Prxy Racial Group, other[f4_prxy_race] = '3'
f4_prxy_ethnicradio<div style="font-size:12pt">Proxy Ethnicity1, American Indian/Alaskan native (1) | 2, Asian (2) | 3, Native Hawaiian or other Pacific Islander (3) | 4, Black/African American (4) | 5, White (5) | 6, Other (6) | 888, Refused (888) | 999, Unknown (999)y
f4_prxy_ethnic_othtext<div style="font-size:12pt">Proxy Ethnicity Other[f4_prxy_ethnic] = '6'y
f4_prxy_prim_langradio<div style="font-size:12pt">Proxy primary language1, English (1) | 2, Spanish (2) | 3, French (3) | 4, Russian (4) | 5, Portuguese (5) | 6, Lithuanian (6) | 7, Italian (7) | 8, Greek (8) | 9, Other (9) | 10, Chinese (10) | 999, Do not know (999)What is the prxyident primary language? (from MDS)y
f4_prxy_prim_lang_othtext<div style="font-size:12pt">Proxy primary language (other)What is the prxyident primary language? (from MDS)[f4_prxy_prim_lang] = '9'y
f4_prxy_rel_bkgrndradio<div style="font-size:12pt">Proxy religious background1, Protestant (1) | 2, Catholic (2) | 3, Jewish (3) | 4, Muslim (4) | 5, No Religion (5) | 6, Orthodox (6) | 7, Other (7) | 888, Refused (888) | 999, Unknown (999)What is the prxyident's religious background?y
f4_prxy_rel_bkgrnd_othtext<div style="font-size:12pt">Proxy religious background (other)What is the prxyident religious background, if other?[f4_prxy_rel_bkgrnd] = '7'y
f4_prxy_rel_impdescriptive<div style="font-size:12pt">How important is faith or spirituality to you?What is the prxyident's religious background?
f4_prxy_rel_how_impradio<div style="font-size:12pt">Importance of Faith1, Very important (1) | 2, Somewhat important (2) | 3, Not at all important (3) | 888, Refused (888) | 999, Unknown (999)y
f4_prxy_mar_statradio<div style="font-size:12pt">Proxy Marital Status1, Married/with Partner (1) | 2, Widowed (not remarried) (2) | 3, Divorced or separated (not remarried) (3) | 4, Never married (4) | 888, Refused (888) | 999, Not Available (999)What is the prxyident's marital status?y
f4_comf_talk_illness_ddescriptive<div style="background:#FFFF99;font-size:12pt">
As we come to the end of these questions, I would like to know your level of comfort with the topic of this interview. How comfortable did you feel talking about [RESIDENT'S] illness? Would you say you were:
Very comfortable, Comfortable, A little uncomfortable, Very uncomfortable
f4_comf_talk_illnessradio<div style="font-size:12pt">Proxy interview comfort1, Very comfortable (1) | 2, Comfortable (2) | 3, A little uncomfortable (3) | 4, Very uncomfortable (4) | 888, Refused (888) | 999, Don't know (999)y
f4_addnl_thoughts_ddescriptive<div style="font-size:12pt">
Do you have any additional thoughts about what we have discussed that you would like to add?
f4_addnl_thoughtsradio<div style="font-size:12pt">Proxy additional thoughts 0, No (0) | 1, Yes (1)y
f4_add_thoughtsnotes<div style="font-size:12pt">Additional thoughts or questions?[f4_addnl_thoughts] = '1'y
f4_proxy_v_ddescriptive<div style="background:#FFFF99;font-size:12pt">
I would now like to show you a 12 minute video that describes the general levels of medical care available for persons for patients with advanced dementia. If you feel uncomfortable or wish to stop the video at any time, plase let me know and I will stop it.
CLICK ON "SAVE AND CONTINUE" AT THE END OF THIS FORM BEFORE PLAYING VIDEO.
PLAY VIDEOWas the video shown to the Proxy?[proxy_eligibility_arm_1][f0p_study_assign] = '1'
f4_videoradio<div style="font-size:12pt">Video Shown?0, No (0) | 1, Yes (1)Was the video shown to the Proxy?[proxy_eligibility_arm_1][f0p_study_assign] = '1'y
f4_post_video_ddescriptive<div style="font-size:12pt">
After viewing the video, which level of care do you feel fits closest with the type of care you think (resident) would want to receive: Intensive medical care, Basic medical care, or Comfort care?[f4_video] = '1'
f4_post_video_locradio<div style="font-size:12pt">Level of care resident would want1, Intensive medical care (1) | 2, Basic medical care (2) | 3, Comfort care (3) | 888, Refused to aswer (888) | 999, Unsure (999)[f4_video] = '1'y
f4_conclusion_ddescriptive<div style="font-size:12pt">
As we near the end of the interview. I would like to know your level of comfort with the video.
How comfortable did you feel watching the video? Would you say that you were:
Very comfortable, Somewhat comfortable, A little uncomfortable, or Very uncomfortable?[f4_video] = '1'
f4_prxy_pstvd_comfortradio<div style="font-size:12pt">Proxy video comfort1, Very comfortable (1) | 2, Somewhat comfortable (2) | 3, A little uncomfortable (3) | 4, Very uncomfortable (4) | 888, Refused to answer (888) | 999, Don't know (999)[f4_video] = '1'y
f4_video_helpful_ddescriptive<div style="font-size:12pt">
How helpful was the video in making a decision about medical care?
Would you say the video was: Very helpful, Somewhat helpful, A little helpful, or Not helpful?[f4_video] = '1'
f4_video_helpfulradio<div style="font-size:12pt">Video helpful?1, Very helpful (1) | 2, Somewhat helpful (2) | 3, A little helpful (3) | 4, Not helpful (4) | 888, Refused (888) | 999, Don't know (999)[f4_video] = '1'y
f4_video_not_helpful_ddescriptive<div style="font-size:12pt">
If the video was not helpful, why was it not? (check all that apply)[f4_video_helpful] = '4'
f4_video_not_helpfulcheckbox<div style="font-size:12pt">Video not helpful1, Respondent knew what they wanted to do prior to watching the video (1) | 2, Video did not show anything the respondent didn't already know (2) | 3, Other (3)[f4_video_helpful] = '4'y
f4_video_not_helpful_othtext<div style="font-size:12pt">
Video not helpful, other[f4_video_not_helpful(3)] = '1'y
f4_rec_video_ddescriptive<div style="font-size:12pt">
Would you recommend the video to others who are facing a similar decision?
Your choices are: definitely recommend, probably recommend, probably not recommend, and definitely not recommend.[f4_video] = '1'
f4_rec_videoradio<div style="font-size:12pt">Recommend video1, Definitely recommend it (1) | 2, Probably recommend it (2) | 3, Probably not recommend it (3) | 4, Definitely not recommend it (4) | 888, Refused (888) | 999, Don't know (999)[f4_video] = '1'y
f4_prxy_addl_thoughts_ddescriptive<div style="font-size:12pt">
Do you have any additional thoughts about what we have discussed that you would like to add?[f4_video] = '1'
f4_prxy_addlradio<div style="font-size:12pt">Additional thoughts?0, No (0) | 1, Yes (1)[f4_video] = '1'y
f4_prxy_addl_thoughtsnotes<div style="font-size:12pt">Proxy additional thoughts[f4_prxy_addl] = '1'
f4_anyquestions_2_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you, for taking the time to participate in our research efforts. In approximately 3 months, you will be contacted by another research assistant from the EVINCE study who will be asking you questions similar to the ones I asked you today.
Do you have any questions or concerns that I can respond to today?
If you have any questions or issues you would like to discuss with our study team in the future, please call the project manager, R Carroll, who is very happy to discuss the study with you. Her number is: 617-971-5314.
Thank you very much for your time and support in this important study. [proxy_eligibility_arm_1][f0p_study_assign] = '2'
f4_anyquestions_1_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Thank you, for taking the time to participate in our research efforts. As part of the research protocol, we will be communicating your preference to the [resident's] primary care team for their information only; it will not become an order or formal medical directive. That can only be done by the resident's primary care provider after direct discussion with you. Please bear in mind that the video was meant to encourage, not replace direct discussions between you and [resident's] health care providers.
Over the next year, another research assistant from the EVINCE study will be contacting you about every 3 months. Although you will not see the video again, they will be asking you questions similar to the ones I asked you today, including your preferences for the residents' care. However, we will not be giving any further feedback to the [resident's] primary care team after today. So if your preferences for [resident's] care change throughout the course of this study, we encourage you to make those changes known to the care team.
Do you have any questions or concerns that I can respond to today?
If you have any questions or issues you would like to discuss with our study team in the future, please call the project manager, R Carroll, who is very happy to discuss the study with you. Her number is: 617-971-5314.
Thank you very much for your time and support in the EVINCE study. [proxy_eligibility_arm_1][f0p_study_assign] = '1'
ff_ra_iddropdown<div style="font-size:12pt">
RA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
ff_feedback_datetext<div style="font-size:12pt">
Feedback datedate_mdyy
ff_feedback_ddescriptive<div style="background:#FFFF99;font-size:12pt">
[RESIDENT's NAME] is a participant in the EVINCE study. On [DATE OF PROXY INTERVIEW] his/her health care proxy, [NAME OF PROXY] watched a video that described 3 general levels of treatment available to nursing home residents with advanced dementia. After viewing the video the proxy stated which level aligned best with his/her treatment preferences for [RESIDENT]. Below are brief descriptions of the 3 treatment levels presented to the proxies:
Intensive medical care: Includes the use of all medical treatments available, such as cardiopulmonary resuscitation (CPR), ventilators, and feeding tubes. Patients are sent to the hospital for serious illnesses and admitted to an intensive care unit or ICU if necessary.
Basic medical care: May include treatment with antibiotics, intravenous fluids or medications, and hospitalization for new acute illnesses. Basic care does NOT include CPR, ventilators, tube-feeding or treatment in an ICU.
Comfort care: Includes only treatments that are needed to relieve uncomfortable symptoms (e.g., pain medication, oxygen, etc.). Comfort care does NOT include CPR, ventilators, tube-feeding, ICU care, or intravenous/intramuscular fluids or medications. Hospitalization is avoided unless the hospital is needed to relieve discomfort, such as for a hip fracture.
After viewing the video, [RESIDENT's name] proxy stated that the level that is checked off below is his/her preference for [RESIDENTS's] treatment,
The proxy for [RESIDENT] selected the followin
ff_pref_locradio<div style="font-size:12pt">
Preferred Level of Care1, Intensive Medical Care (1) | 2, Basic Medical Care (2) | 3, Comfort care (3) | 888, Refused to answer (888) | 999, Don't know (999)y
ff_feedback_conc_ddescriptive<div style="background:#FFFF99;font-size:12pt">
We are providing this feedback as information only. We have not written any orders or directives in [RESIDENT's] record. We have encouraged [PROXY's name] to discuss his/her wishes for [RESIDENT'S] care with you.
We hope this information is helpful to you in caring for [RESIDENT]. If you have any questions, please contact the Principal Investigators of the EVINCE study.
Susan L. Mitchell MD, MPH, Hebrew Senior Life Institute for Aging Research
1200 Centre Street, Boston, MA. 02131
Tel: 617-971-5326, FAX: 617-971-5339
Email: smitchell@hsl.harvard.edu
MPH Angelo Volandes, MD, MPH, Massachusetts General Hospital
Email: avolandes@partners.org
f6_int_statdropdownInterview Status1, Complete (1) | 2, Refused assessment (2) | 3, Cannot contact (3) | 4, Resident Died (4) | 6, HCP drops out (6) | 7, HCP died (7)y
f6_keep_resradioCan we continue to include [resident] in the study?0, No (0) | 1, Yes (1)[f6_int_stat] = '6'y
f6_hcp_doitext<div style="font-size:12pt">Proxy quarterly DOIdate_mdyy
f6_ra_iddropdown<div style="font-size:12pt">RA ID#1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
f6_prxy_quart_intro_ddescriptive <div style="background:#FFFF99;font-size:12pt">
Thank you for taking the time to answer these questions. The questions I will ask you relate to [RESIDENT], your feelings about [his/her] illness and your role as Health Care Proxy (HCP). I will also ask you some questions about yourself.
Your responses will be kept confidential. If at any time or for any reason, you feel you do not wish to continue, we will stop. You may also choose not to answer individual questions. However, I hope you will be able to complete the entire survey. I am going to ask you a number of questions.
Some of the questions will be followed by a choice of answers. Please wait until I have read all the possible responses before choosing your answer. Do you have any questions before we begin?
f6_live_le_1hour_nh_ddescriptive<div style="font-size:12pt">Do you live within a 1-hour car drive from [RESIDENT'S] nursing home?
f6_live_le_1hour_nhradio<div style="font-size:12pt">Within a 1-hour 0, No (0) | 1, Yes (1) | 888, refused (888)y
f6_num_hrs_visit_res_nh_ddescriptive<div style="font-size:12pt">Approximately how many hours a week do you currently spend visiting (resident) at the nursing home?
f6_num_hrs_visit_res_nhradio<div style="font-size:12pt">Hours visiting0, None (0) | 1, < 1 hour each week (1) | 2, 1-3 hours each week (2) | 3, 4-7 hours each week (3) | 4, 8-11 hours each week (4) | 5, 12-15 hours each week (5) | 6, > 15 hours each week (6) | 888, Refused (888) | 999, Don't know (999)y
f6_prxy_prf_loc_ddescriptive<div style="background:#FFFF99;font-size:12pt">
I am interested in learning about kind of treatments you want the [RESIDENT] to receive. I will briefly describe three general levels of medical care. I will then ask you which level best fits with the type of care you would choose for [RESIDENT].
The 3 three levels are: 1. Intensive medical care, 2. Basic medical care, and 3. Comfort care.
Intensive medical care includes the use of all medical treatments available, such as cardiopulmonary resuscitation or CPR, breathing machines, and feeding tubes. With intensive care, patients are sent to the hospital for serious illnesses and admitted to an intensive care unit or ICU if necessary.
The next level, Basic medical care, includes some, but not all, available medical treatments. Patients choosing basic care may get treated with antibiotics, fluids, or other medicines through a tube placed in a vein, and may be sent to the hospital for sudden illnesses. People choosing basic care want to avoid intensive medical treatments including CPR, breathing machines, tube-feeding or treatment in an ICU.
With the next level, Comfort care, treatments are only used if they help relieve uncomfortable symptoms, for example medications to relieve pain, and oxygen to reduce trouble breathing. People choosing comfort care do not want CPR, breathing machines, tube-feeding or additional fluids or medications given through a tube placed in a vein. With comfort care, hospitalization is avoided unless the hospital is needed to relieve pain, such as to fix a hip fracture.
f6_res_pref_loc_ddescriptive<div style="font-size:12pt">
Which level do you feel fits closest with the type of care you feel [RESIDENT's name] would want to receive: intensive medical care, basic medical care, or comfort care?
f6_res_pref_locradio<div style="font-size:12pt">Level resident would want1, Intensive medical care (1) | 2, Basic medical care (2) | 3, Comfort care (3) | 888, Refused (888) | 999, Unknown (999)y
f6_prvdr_ask_prxy_opin_ddescriptive<div style="font-size:12pt">
Since our last interview, has any health care provider asked your opinion regarding the goals of [RESIDENT's] medical care?
f6_prvdr_ask_prxy_opinradio<div style="font-size:12pt">Provider asked opinion 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f6_prvdr_disc_trtmnts_ddescriptive<div style="font-size:12pt">
Since our last interview, have you discussed the type of medical treatments the [RESIDENT] would want to receive with a health care provider at the nursing home?
f6_prvdr_disc_trtmntsradio<div style="font-size:12pt">Provider Discussion? 0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Don't know (999)y
f6_who_init_discuss_ddescriptive<div style="font-size:12pt">
Who initiated this discussion, you or the health care provider?[f6_prvdr_disc_trtmnts] = '1'
f6_who_init_discussradio<div style="font-size:12pt">Discussion initiator1, Proxy (1) | 2, Provider (2) | 3, Both proxy and provider (3) | 888, Refused (888) | 999, Don't know (999)[f6_prvdr_disc_trtmnts] = '1'y
f6_discuss_prvdr_ddescriptive<div style="font-size:12pt">
Who was the health provider with whom you had this discussion? [f6_prvdr_disc_trtmnts] = '1'
f6_discuss_prvdrcheckbox<div style="font-size:12pt">Which provider discussed? 1, Physician (1) | 2, Nurse practitioner (2) | 3, Physician assistant (3) | 4, Nurse providing direct care (4) | 5, Director of nursing (DON) (5) | 6, Senior administrator (other than DON) (6) | 7, Social worker (7) | 8, Chaplain (8) | 9, Other, specify (9)[f6_prvdr_disc_trtmnts] = '1'y
f6_discuss_prvdr_oth_ddescriptive<div style="font-size:12pt">
Who was the "other" provider with whom you discussed residents goals of care?[f6_prvdr_disc_trtmnts] = '1' and [f6_discuss_prvdr(9)] = '1'
f6_discuss_prvdr_othtext<div style="font-size:12pt">
Other provider discussion[f6_prvdr_disc_trtmnts] = '1' and [f6_discuss_prvdr(9)] = '1'y
f6_partic_trtmnt_decis_ddescriptive<div style="font-size:12pt">
Since we last spoke together, have you participated in treatment decisions for resident?
f6_partic_trtmnt_decisradio<div style="font-size:12pt">Treatment decisions 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999)y
f6_res_life_left_ddescriptive<div style="font-size:12pt">
Although I know this may be a difficult question, please do your best to respond. In your opinion, how close do you feel [RESIDENT] is to the end of her/his life?
f6_res_life_leftradio<div style="font-size:12pt">Near to end of life1, < 1 month (1) | 2, 1-6 months (2) | 3, 7-12 months (3) | 4, > 12 months (4) | 888, Refused (888) | 999, Don't know (999)y
f6_undst_res_hlth_wish_ddescriptive<div style="font-size:12pt">
At this time, how confident are you that you understand what the [RESIDENT] would and would not want with respect to his/her health care if he/she could make his/her own decisions.
f6_undst_res_hlth_wishradio<div style="font-size:12pt">Confident of understanding1, Very confident (1) | 2, Somewhat confident (2) | 3, Not confident at all (3) | 888, Refused (888) | 999, Don't know (999)y
f6_comf_talk_illness_ddescriptive<div style="font-size:12pt">
As we come to the end of questions, I would like to know your level of comfort with the topic of this interview. How comfortable did you feel talking about [RESIDENT'S] illness? Would you say you were:
Very comfortable, Comfortable, A little uncomfortable, Very uncomfortable
f6_comf_talk_illnessradio<div style="font-size:12pt">Proxy interview comfort1, Very comfortable (1) | 2, Comfortable (2) | 3, A little uncomfortable (3) | 4, Very uncomfortable (4) | 888, Refused (888) | 999, Don't know (999)y
f6_addnl_thoughts_ddescriptive<div style="font-size:12pt">
Do you have any additional thoughts about what we have discussed that you would like to add?
f6_addnl_thoughtsradio<div style="font-size:12pt">Proxy additional thoughts 0, No (0) | 1, Yes (1)y
f6_add_thoughtsnotes<div style="font-size:12pt">Additional thoughtsy[f6_addnl_thoughts] = '1'y
f6_anyquestions_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Do you have any further questions?
Please feel free to contact me if any additional questions or concerns arise.
My telephone # is:_______________. I thank you very much for your time.
f6_prxy_questionsnotes<div style="font-size:12pt">Further questions?
fd_ra_iddropdownRA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
fd_report_datetextDeath report datedate_mdyy
fd_res_deathyesnoResident deceasedy
fd_res_death_datetextResident Death Datedate_mdyy
fd_source_d_noticeradioSource of Death Notification1, Facility (1) | 2, Proxy (2)
fd_proxy_deathyesnoProxy deceased
fd_proxy_death_datetextProxy Death Datedate_mdy
fae_report_datetext<div style="font-size:12pt">
AE report datedate_mdyy
fae_ra_iddropdown<div style="font-size:12pt">
RA ID1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)y
fae_participant_info_ddescriptive<div style="font-size:12pt">
Participant information
fae_subject_l_nametext<div style="font-size:12pt">
Last Name of subject experiencing Adverse Eventy
fae_subject_f_nametext<div style="font-size:12pt">
First Name of subject experiencing Adverse Eventy
fae_prev_ae_ddescriptive<div style="font-size:12pt">
Has the participant experienced a PRIOR unexpected or serious event while in this study?
fae_prev_aeradio<div style="font-size:12pt">
Prior AE0, No (0) | 1, Yes (1) | 999, Don't know (999)
fae_prev_ae_datetext<div style="font-size:12pt">
Prior AE Datedate_mdy
fae_withdrawn_ddescriptive<div style="font-size:12pt">
Has the participant been withdrawn from the study?
fae_withdrawnradio<div style="font-size:12pt">
Subject withdrawn?0, No, (0) | 1, Yes (1) | 999, Don't know (999)
fae_withdraw_detsnotes<div style="font-size:12pt">
Withdraw details
fae_event_descripnotes<div style="font-size:12pt">
Event description
fae_event_datetext<div style="font-size:12pt">
Adverse Event datedate_mdyy
fae_date_event_reportedtext<div style="font-size:12pt">
Date AE reported to researcherdate_mdyy
fae_event_loctext<div style="font-size:12pt">
Event locationy
fae_event_severityradio<div style="font-size:12pt">
Severity of event1, Mild (1) | 2, Moderate (2) | 3, Serious (3) | 999, Don't know (999)y
fae_event_severity_detscheckbox<div style="font-size:12pt">
Serious event detail1, Hospitalization or its prolongation (1) | 2, Persistent/significant disability/incapacity (2) | 3, Life-threatening (3) | 4, Death (4) | 5, Required intervention (5)[fae_event_severity] = '3'
fae_intervention_detsnotes<div style="font-size:12pt">
Required intervention detail[fae_event_severity] = '3'
fae_anticipate_ddescriptive<div style="background:#FFFF99;font-size:12pt">
Was the event anticipated/expected (foreseeable risk or side effect, or progression of disease or condition) or UNANTICIPATED/UNEXPECTED (not foreseeable risk or side effect, or not consistent with participant's health)?
(DUE TO SENSITIVE NATURE OF THE MATERIAL, TEARING UP BY THE PROXY CAN BE EXPECTED AND IS NOT DEEMPED TO BE A REFLECTION OF DISTRESS)
Anticipated Adverse Events include:
1. Observation by the trained research assistant of what they assess to be severe proxy distress while watching the intervention video or during the interview.
2. The proxy asks for the video or discussion surrounding goals of care to be stopped, due to related distress.
3. The proxy leaves the room during the video or discussion due to related distress.
fae_anticipateradio<div style="font-size:12pt">
Event anticipation1, Anticipated (1) | 2, Unanticipated (2) | 999, Don't know (999)y
fae_event_rel_ddescriptive<div style="font-size:12pt">
What was the relation of the event to participation in the study?
fae_event_relradio<div style="font-size:12pt">
AE related to study?0, Unrelated (0) | 1, Related (1) | 2, Possibly related (2) | 999, Don't knowy
fae_event_rel_expnotes<div style="font-size:12pt">
Explain relationship to studyy