_id Variable / Field Name Form Name Section Header Field Type Field Label Choices, Calculations, OR Slider Labels Field Note Text Validation Type OR Show Slider Number Text Validation Min Text Validation Max Identifier? Branching Logic (Show field only if...) Required Field? Custom Alignment Question Number (surveys only) Matrix Group Name Matrix Ranking? Field Annotation 1 study_id form_0r_resident_screening "" text Study ID "" "" "" 1 10 "" "" y "" "" "" "" "" 2 f0r_doi form_0r_resident_screening "" text Resident Screening Date "" "" date_mdy "" "" y "" "" "" "" "" 3 f0r_ra_id form_0r_resident_screening "" dropdown Research Assistant ID 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 4 f0r_prim_ra form_0r_resident_screening "" radio Primary Research Nurse 1, M (1) | 2, H (2) "" "" "" [f0r_ra_id] = '3' or [f0r_ra_id] = '4' or [f0r_ra_id] = '5' "" "" "" "" "" "" 5 f0r_facility_name form_0r_resident_screening "" text Facility Name "" "" "" y "" y "" "" "" "" "" 6 f0r_facility_id form_0r_resident_screening "" sql Facility ID SELECT 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 "" "" "" "" "" 7 f0r_scrng_unit_id form_0r_resident_screening "" text Unit ID "" "" "" y "" y "" "" "" "" "" 8 f0r_scrn_res_rm form_0r_resident_screening "" text Room number "" "" "" y "" y "" "" "" "" "" 9 f0r_res_l_name form_0r_resident_screening "" text Resident Last Name "" Last name "" y "" y "" "" "" "" "" 10 f0r_res_f_name form_0r_resident_screening "" text Resident First Name "" First name "" y "" y "" "" "" "" "" 11 f0r_res_gender form_0r_resident_screening "" radio Resident gender 1, Male (0) | 2, Female (1) "" "" "" "" y "" "" "" "" "" 12 f0r_res_age form_0r_resident_screening "" calc Resident age "round(datediff([f0r_doi],[f0r_res_dob],""y"",""mdy""))" calculated age of resident at interview "" "" "" "" "" "" "" "" "" 13 f0r_gds7_d form_0r_resident_screening "" descriptive "
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 "" "" "" "" "" "" 14 f0r_gds7 form_0r_resident_screening "" radio Global deterioration scale=7? 0, No (ineligible) (0) | 1, Yes (1) "" "" "" [f0r_res_age] >= 65 y "" "" "" "" "" 15 f0r_doa form_0r_resident_screening "" text Date of Resident's nursing home admission "" "" date_mdy "" [f0r_res_age] >= 65 and [f0r_gds7] = '1' y "" "" "" "" "" 16 f0r_lngth_stay form_0r_resident_screening "" calc Length of nursing home stay "round(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 "" "" "" "" "" 17 f0r_prim_caus_cog_imp form_0r_resident_screening "" radio Primary cause of cognitive impairment 0, 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] >= 30 y "" "" "" "" "" 18 f0r_other_descrip form_0r_resident_screening "" text """Other"" primary cause of cognitive impairment" "" "" "" "" [f0r_prim_caus_cog_imp] = '5' "" "" "" "" "" "" 19 f0r_res_coma form_0r_resident_screening "" radio Resident in coma? 0, No (0) | 1, Yes (1) Is resident in a coma? "" "" [f0r_prim_caus_cog_imp] = '0' y "" "" "" "" "" 20 f0r_proxy form_0r_resident_screening "" radio Proxy appointed? 0, No (0) | 1, Yes (1) Has a proxy been appointed? "" "" [f0r_prim_caus_cog_imp] = '0' and [f0r_res_coma] = '0' y "" "" "" "" "" 21 f0r_res_eligible_y_d form_0r_resident_screening "" descriptive "
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' "" "" "" "" "" "" 22 f0r_res_eligible_n_d form_0r_resident_screening "" descriptive "
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' "" "" "" "" "" "" 23 f0r_res_eligibility form_0r_resident_screening "" yesno Is Resident eligible to participate in the EVINCE study? "" Click yest to indicate that resident IS eligible "" "" "" y "" "" "" "" "" 24 f0c_ra_id form_0c_proxycontact_information "" dropdown RA ID 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" "" "" "" "" "" "" 25 f0c_contact_inf_date form_0c_proxycontact_information "" text Contact info date "" "" date_mdy "" "" "" "" "" "" "" "" 26 f0c_prxy_name form_0c_proxycontact_information "" text Proxy name "" "" "" y "" y "" "" "" "" "" 27 f0c_prxy_strt_adrs form_0c_proxycontact_information "" text Proxy street address "" "" "" y "" "" "" "" "" "" "" 28 f0c_prxy_city form_0c_proxycontact_information "" text Proxy city "" "" "" y "" "" "" "" "" "" "" 29 f0c_prxy_state form_0c_proxycontact_information "" text Proxy State "" "" "" y "" "" "" "" "" "" "" 30 f0c_prxy_zipcode form_0c_proxycontact_information "" text Proxy Zipcode "" "" zipcode y "" "" "" "" "" "" "" 31 f0c_prxy_homephone form_0c_proxycontact_information "" text Proxy home phone "" "" phone y "" "" "" "" "" "" "" 32 f0c_prxy_workphone form_0c_proxycontact_information "" text Proxy work phone "" "" phone y "" "" "" "" "" "" "" 33 f0c_prxy_cellphone form_0c_proxycontact_information "" text Proxy cell phone "" "" phone y "" "" "" "" "" "" "" 34 f0c_prxy_email form_0c_proxycontact_information "" text Proxy email "" "" email y "" "" "" "" "" "" "" 35 f0c_prxy_relationship form_0c_proxycontact_information "" radio Proxy's relationship to resident 1, 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) "" "" "" "" "" "" "" "" "" "" 36 f0c_prxy_other form_0c_proxycontact_information "" text Proxy relationship other "" Define the proxy's relationship to resident "" "" [f0c_prxy_relationship] = '7' y "" "" "" "" "" 37 f0c_prxy_cntc_notes form_0c_proxycontact_information "" text Contact Field Notes "" "" "" "" "" "" "" "" "" "" "" 38 f0p_study_assign form_0p_proxy_screening_consent "" calc "
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() } )();" "" "" "" "" "" "" "" "" "" "" 39 f0p_re_consent form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 40 f0p_doi form_0p_proxy_screening_consent "" text "
Proxy Screening date" "" "" date_mdy "" "" y "" "" "" "" "" 41 f0p_researcher form_0p_proxy_screening_consent "" dropdown "
RA ID" 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) | 6, Angelo (6) "" "" "" "" "" "" "" "" "" "" 42 f0p_prxy_cntcted form_0p_proxy_screening_consent "" radio "
Proxy Contacted?" 0, No (0) | 1, Yes (1) | 2, Yes but resident no longer eligible (2) "" "" "" "" y "" "" "" "" "" 43 f0p_prxy_res_inelig form_0p_proxy_screening_consent "" radio "
Reason resident no longer eligible" 1, 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 "" "" "" "" "" 44 f0p_prxy_refuses form_0p_proxy_screening_consent "" radio "
Proxy Refuses prior to eligibility conversation" 0, No (0) | 1, Yes (1) "" "" "" [f0p_prxy_cntcted] = '1' y "" "" "" "" "" 45 f0p_proxy_d form_0p_proxy_screening_consent "" descriptive "
Person named in the chart as proxy is the health care proxy/decision maker for the resident?" "" "" "" "" [f0p_prxy_refuses] = '0' "" "" "" "" "" "" 46 f0p_prxy_validation form_0p_proxy_screening_consent "" radio "
Is Person the Proxy?" 0, No (0) | 1, Yes (1) "" "" "" [f0p_prxy_refuses] = '0' y "" "" "" "" "" 47 f0p_wrong_contact_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 48 f0p_prxy_english form_0p_proxy_screening_consent "" radio "
Proxy speaks english?" 0, No (0) | 1, Yes (1) "" "" "" [f0p_prxy_validation] = '1' y "" "" "" "" "" 49 f0p_d1_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 50 f0p_prxy_can_meet form_0p_proxy_screening_consent "" radio "
Proxy can meet" 0, No (0) | 1, Yes (1) "" "" "" [f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1' y "" "" "" "" "" 51 f0p_prxy_eligible_y_d form_0p_proxy_screening_consent "" descriptive "
Proxy IS ELIGIBLE to particpate in EVINCE" "" Click 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' "" "" "" "" "" "" 52 f0p_prxy_eligible_n_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 53 f0p_prxy_eligible form_0p_proxy_screening_consent "" radio "
Is proxy eligible?" 0, No (0) | 1, Yes (1) Fill in to trigger appropriate follow-up "" "" [f0p_prxy_validation] = '1' y "" "" "" "" "" 54 f0p_not_elig_end_d form_0p_proxy_screening_consent "" descriptive "
Please save this record and end data collection here." "" "" "" "" [f0p_prxy_eligible] = '0' "" "" "" "" "" "" 55 f0p_consent_2_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 56 f0p_consent_1_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 57 f0p_cnsnt_rd form_0p_proxy_screening_consent "" radio "
Consent Read?" 0, No (0) | 1, Yes (1) "" "" "" [f0p_prxy_eligible] = '1' y "" "" "" "" "" 58 f0p_date form_0p_proxy_screening_consent "" text "
Date Consent Read" "" "" date_mdy "" [f0p_cnsnt_rd] = '1' "" "" "" "" "" "" 59 f0p_prxy_consent form_0p_proxy_screening_consent "" radio "
Proxy consent to participate" 0, No (0) | 1, Yes (1) "" "" "" [f0p_cnsnt_rd] = '1' y "" "" "" "" "" 60 f0p_cnsnt_date form_0p_proxy_screening_consent "" text "
Consent Date" "" "" date_mdy "" [f0p_prxy_consent] = '1' y "" "" "" "" "" 61 f0p_descript_n_d form_0p_proxy_screening_consent "" descriptive "
If Proxy REFUSES to participate, continue with ""non-participation"" questions that follow" "" "" "" "" [f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0' "" "" "" "" "" "" 62 f0p_descript_y_d form_0p_proxy_screening_consent "" descriptive "
""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' "" "" "" "" "" "" 63 f0p_not_recruited_d form_0p_proxy_screening_consent "" descriptive "
Why was the resident not recruited?" "" "" "" "" [f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0' "" "" "" "" "" "" 64 f0p_reason_not_recrt form_0p_proxy_screening_consent "" radio "
Reason resident not recruited" 1, 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 "" "" "" "" "" 65 f0p_prxy_no_reas form_0p_proxy_screening_consent "" checkbox "
Reasons for proxy's refusal to consent" 1, 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 "" "" "" "" "" 66 f0p_reason_for_no_d form_0p_proxy_screening_consent "" descriptive "
Document other reason for proxy's refusal to participate in the study" "" "" "" "" [f0p_prxy_no_reas(5)] = '1' "" "" "" "" "" "" 67 f0p_prxy_no_reas_oth form_0p_proxy_screening_consent "" notes "
Other Reasons for proxy refusal to consent" "" Explain other reason for no proxy consent "" "" [f0p_prxy_no_reas(5)] = '1' y "" "" "" "" "" 68 f0p_explain_other_d form_0p_proxy_screening_consent "" descriptive "
Explain resident's change in medical status that prohibits participation in study" "" "" "" "" [f0p_reason_not_recrt] = '3' "" "" "" "" "" "" 69 f0p_res_status_change form_0p_proxy_screening_consent "" notes "
Change in resident medical status" "" "" "" "" [f0p_reason_not_recrt] = '3' "" "" "" "" "" "" 70 f0p_no_recrt_oth form_0p_proxy_screening_consent "" notes "
Other reason for not being recruited" "" Explain other reason for no recruitment "" "" [f0p_reason_not_recrt] = '4' "" "" "" "" "" "" 71 f0p_res_inf_ref_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 72 f0p_prxy_cnt1 form_0p_proxy_screening_consent "" radio "
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 "" "" "" "" "" 73 f0p_prxy_cnt_y_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 74 f0p_prxy_cnt_n_d form_0p_proxy_screening_consent "" descriptive "
I understand. Thank you for your time. End survey here." "" "" "" "" [f0p_prxy_cnt1] = '1' "" "" "" "" "" "" 75 f0p_res_ethnicity form_0p_proxy_screening_consent "" radio "
Resident Ethnicity" 1, 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' "" "" "" "" "" "" 76 f0p_res_ethnic_other form_0p_proxy_screening_consent "" text "
Resident Ethnicity Other" "" "" "" "" [f0p_res_ethnicity] = '6' y "" "" "" "" "" 77 f0p_res_race form_0p_proxy_screening_consent "" radio "
Resident Racial Group" 1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 888, Refused (888) "" "" "" [f0p_prxy_cnt1] = '0' y "" "" "" "" "" 78 f0p_non_part_prxy_d form_0p_proxy_screening_consent "" descriptive "
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' "" "" "" "" "" "" 79 f0p_prxy_cnt2 form_0p_proxy_screening_consent "" radio "
Do you mind a few questions about yourself?" 0, No (continue survey) (0) | 1, Yes (end survey there) (1) "" "" "" [f0p_prxy_cnt1] = '0' y "" "" "" "" "" 80 f0p_prxy_cnt2_y_d form_0p_proxy_screening_consent "" descriptive "
Thank you. (Continue with survey)" "" "" "" "" [f0p_prxy_cnt2] = '0' "" "" "" "" "" "" 81 f0p_prxy_cnt2_n_d form_0p_proxy_screening_consent "" descriptive "
Thank you for your time. (End survey)" "" "" "" "" [f0p_prxy_cnt2] = '1' "" "" "" "" "" "" 82 f0p_prxy_dob form_0p_proxy_screening_consent "" text "
Proxy birthdate" "" "" date_mdy "" [f0p_prxy_cnt2] = '0' y "" "" "" "" "" 83 f0p_prxy_gndr form_0p_proxy_screening_consent "" radio "
Proxy gender" 1, Male | 2, Female "" "" "" [f0p_prxy_cnt2] = '0' "" "" "" "" "" "" 84 f0p_prxy_eductn form_0p_proxy_screening_consent "" radio "
Proxy education" 1, 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' "" "" "" "" "" "" 85 f0p_thank_you_d form_0p_proxy_screening_consent "" descriptive "
Thank you for your time. " "" "" "" "" [f0p_prxy_cnt2] = '0' "" "" "" "" "" "" 86 f1_doi form_1a_baseline_demographics "
BASELINE RESIDENT INTAKE ASSESSMENT" text Resident Baseline Date "" "" date_mdy "" "" y "" "" "" "" "" 87 f1_ra_id form_1a_baseline_demographics "" dropdown RA ID 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 88 f1_base_unit_id form_1a_baseline_demographics "" text Unit ID "" "" "" y "" y "" "" "" "" "" 89 f1_base_res_rm form_1a_baseline_demographics "" text Room number "" "" "" y "" y "" "" "" "" "" 90 f1_res_spcl_unt form_1a_baseline_demographics "" radio Resident 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 "" "" "" "" "" 91 f1_res_race form_1a_baseline_demographics "
Chart Review: DEMOGRAPHICS" radio Resident Racial Group 1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 999, Not available (999) "" "" "" "" y "" "" "" "" "" 92 f1_res_ethnic form_1a_baseline_demographics "" radio Resident Ethnicity 1, 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 "" "" "" "" "" 93 f1_res_ethnic_oth form_1a_baseline_demographics "" text Resident Ethnicity Other "" "" "" "" [f1_res_ethnic] = '6' y "" "" "" "" "" 94 f1_res_edu form_1a_baseline_demographics "" radio Resident Highest education 1, 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 "" "" "" "" "" 95 f1_res_prim_lang form_1a_baseline_demographics "" radio Resident primary language 1, 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 "" "" "" "" "" 96 f1_res_prim_lang_oth form_1a_baseline_demographics "" text Resident primary language (other) "" What is the resident primary language? (from MDS) "" "" [f1_res_prim_lang] = '9' y "" "" "" "" "" 97 f1_res_rel_bkgrnd form_1a_baseline_demographics "" radio Resident religious background 1, 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 "" "" "" "" "" 98 f1_res_rel_bkgrnd_oth form_1a_baseline_demographics "" text Resident religious background (other) "" What is the resident religious background, if other? "" "" [f1_res_rel_bkgrnd] = '5' y "" "" "" "" "" 99 f1_res_mar_stat form_1a_baseline_demographics "" radio Resident Marital Status 1, 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 "" "" "" "" "" 100 f1_res_dmtia_cause form_1b_base_chart_review_med_status "
Chart Review: RESIDENT'S MEDICAL STATUS" checkbox Underlying Cause of Residents Dementia 1, 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 dementia "" "" "" y "" "" "" "" "" 101 f1_res_dmtia_cause_oth form_1b_base_chart_review_med_status "" text Underlying Cause of Residents Dementia (other) "" Please specify other cause of dementia "" "" [f1_res_dmtia_cause(7)] = '1' y "" "" "" "" "" 102 f1_bellsplsy form_1b_base_chart_review_med_status "
Other Neurological conditions (do not include organic brain syndrome, delirium, chronic confusional state)" radio Bell's Palsy 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 103 f1_meningioma form_1b_base_chart_review_med_status "" radio Meningioma (left occipital, extra axial) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 104 f1_migraines form_1b_base_chart_review_med_status "" radio Migraines 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 105 f1_ms form_1b_base_chart_review_med_status "" radio Multiple sclerosis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 106 f1_neuropathy form_1b_base_chart_review_med_status "" radio Neuropathy 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 107 f1_obs_hydro form_1b_base_chart_review_med_status "" radio Ostructive hydrocephalus, normal pressure hydrocephalus, NPH 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 108 f1_parkinsons form_1b_base_chart_review_med_status "" radio Parkinson's 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 109 f1_periph_neurop form_1b_base_chart_review_med_status "" radio Peripheral neuropathy 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 110 f1_polio form_1b_base_chart_review_med_status "" radio Polio 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 111 f1_seiz_dis form_1b_base_chart_review_med_status "" radio Seizure disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 112 f1_stroke form_1b_base_chart_review_med_status "" radio Stroke 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 113 f1_sub_hema form_1b_base_chart_review_med_status "" radio Subdural hematoma 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 114 f1_syncope form_1b_base_chart_review_med_status "" radio Syncope 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 115 f1_trdv_dskn form_1b_base_chart_review_med_status "" radio Tardive dyskinesia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 116 f1_tremors form_1b_base_chart_review_med_status "" radio Tremors 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 117 f1_neuro_oth form_1b_base_chart_review_med_status "" radio Other neurological condition 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" neurological_conditions "" "" 118 f1_neuro_oth_name form_1b_base_chart_review_med_status "" text Name of other Neurological condition "" "" "" "" [f1_neuro_oth] = '1' y "" "" "" "" "" 119 f1_ab_aort_anrsm form_1b_base_chart_review_med_status "
Cardiovascular conditions" radio Abdominal or aortic aneurysm 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 120 f1_arrythmia form_1b_base_chart_review_med_status "" radio Arrythmia (including atrial fibrillation) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 121 f1_chf form_1b_base_chart_review_med_status "" radio Congestive Heart Failure 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 122 f1_cad form_1b_base_chart_review_med_status "" radio Coronary artery disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 123 f1_dvt form_1b_base_chart_review_med_status "" radio Deep vein thrombosis (DVT) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 124 f1_hypertension form_1b_base_chart_review_med_status "" radio Hypertension 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 125 f1_orth_hypo form_1b_base_chart_review_med_status "" radio Orthostatic hypotension 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 126 f1_pacemaker form_1b_base_chart_review_med_status "" radio Pacemaker 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 127 f1_pvd form_1b_base_chart_review_med_status "" radio Peripheral vascular disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 128 f1_vhd form_1b_base_chart_review_med_status "" radio Valvular heart disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 129 f1_vasculitis form_1b_base_chart_review_med_status "" radio Vasculitis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 130 f1_cardio_oth form_1b_base_chart_review_med_status "" radio Other cardiovascular condition 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" cardiovascular_conditions "" "" 131 f1_cardio_oth_name form_1b_base_chart_review_med_status "" text Name of other cardiovascular condition "" "" "" "" [f1_cardio_oth] = '1' y "" "" "" "" "" 132 f1_thyroid form_1b_base_chart_review_med_status "
Endocrine/Metabolic" radio Any thyroid illness 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 133 f1_crf form_1b_base_chart_review_med_status "" radio Chronic renal failure 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 134 f1_diabetes form_1b_base_chart_review_med_status "" radio Diabetes mellitus 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 135 f1_hyperpara form_1b_base_chart_review_med_status "" radio Hyperparathyroidism 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 136 f1_lip_dis form_1b_base_chart_review_med_status "" radio Lipid disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 137 f1_osteoporosis form_1b_base_chart_review_med_status "" radio Osteoporosis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 138 f1_endomet_oth form_1b_base_chart_review_med_status "" radio Other Endocrine or Metabolic 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" endocrine_metabolic "" "" 139 f1_endomet_oth_name form_1b_base_chart_review_med_status "" text Name other Endocrine or Metobolic "" "" "" "" [f1_endomet_oth] = '1' y "" "" "" "" "" 140 f1_a_cncr_brst form_1b_base_chart_review_med_status "
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)]" radio Breast Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 141 f1_a_cncr_colorec form_1b_base_chart_review_med_status "" radio Colorectal Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 142 f1_a_cncr_gi form_1b_base_chart_review_med_status "" radio GI cancer (other than colorectal) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 143 f1_a_cncr_kdny form_1b_base_chart_review_med_status "" radio Kidney Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 144 f1_a_cncr_lng form_1b_base_chart_review_med_status "" radio Lung Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 145 f1_a_cncr_prst form_1b_base_chart_review_med_status "" radio Prostate Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 146 f1_a_cncr_utrn form_1b_base_chart_review_med_status "" radio Uterine Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 147 f1_a_cncr_oth form_1b_base_chart_review_med_status "" radio Other active malignancy 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" active_malignancy "" "" 148 f1_a_cncr_oth_name form_1b_base_chart_review_med_status "" text Name other active malignancy "" "" "" "" [f1_a_cncr_oth] = '1' y "" "" "" "" "" 149 f1_i_cncr_brst form_1b_base_chart_review_med_status "
Inactive Malignancy" radio Inactive Breast Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 150 f1_i_cncr_colorec form_1b_base_chart_review_med_status "" radio Inactive Colorectal Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 151 f1_i_cncr_gi form_1b_base_chart_review_med_status "" radio Inactive GI cancer (other than colorectal) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 152 f1_i_cncr_kdny form_1b_base_chart_review_med_status "" radio Inactive Kidney Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 153 f1_i_cncr_lng form_1b_base_chart_review_med_status "" radio Inactive Lung Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 154 f1_i_cncr_prst form_1b_base_chart_review_med_status "" radio Inactive Prostate Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 155 f1_i_cncr_utrn form_1b_base_chart_review_med_status "" radio Inactive Uterine Cancer 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 156 f1_i_cncr_oth form_1b_base_chart_review_med_status "" radio Other inactive malignancy 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" inactive_malignancy "" "" 157 f1_i_cncr_oth_name form_1b_base_chart_review_med_status "" text Name other inactive malignancy "" "" "" "" [f1_i_cncr_oth] = '1' y "" "" "" "" "" 158 f1_anxiety form_1b_base_chart_review_med_status "
Psychiatric Illnesses" radio Anxiety 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 159 f1_bipolar form_1b_base_chart_review_med_status "" radio Bipolar 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 160 f1_depression form_1b_base_chart_review_med_status "" radio Depression 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 161 f1_ocd form_1b_base_chart_review_med_status "" radio Obsessive Compulsive 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 162 f1_psychotic form_1b_base_chart_review_med_status "" radio Psychotic behavior (includes hallucinations and fixed delusions) 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 163 f1_schiz_affect form_1b_base_chart_review_med_status "" radio Schizoaffective 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 164 f1_schizo form_1b_base_chart_review_med_status "" radio Schizophrenia 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 165 f1_psych_oth form_1b_base_chart_review_med_status "" radio Other major psychiatric condition 0, No 0) | 1, Yes (1) "" "" "" "" y "" "" psyciatric "" "" 166 f1_psych_oth_name form_1b_base_chart_review_med_status "" text Name other major psychiatric condition "" "" "" "" [f1_psych_oth] = '1' y "" "" "" "" "" 167 f1_asthma form_1b_base_chart_review_med_status "
PULMONARY [Do not code pneumonia or any derivative of pneumonia as a pulmonary disease, or positive PPD]" radio Asthma 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 168 f1_chrnc_plrl_efsn form_1b_base_chart_review_med_status "" radio (Chronic) pleural effusion 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 169 f1_emphsma_copd form_1b_base_chart_review_med_status "" radio Emphysema or chronic obstructive lung disease (COPD) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 170 f1_pulm_emb form_1b_base_chart_review_med_status "" radio Pulmonary embolus 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 171 f1_pulm_fibr form_1b_base_chart_review_med_status "" radio Pulmonary fibrosis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 172 f1_pulm_oth form_1b_base_chart_review_med_status "" radio Other major pulmonary condition 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" pulmonary "" "" 173 f1_pulm_oth_name form_1b_base_chart_review_med_status "" text Name other major pulmonary condition "" "" "" "" [f1_pulm_oth] = '1' y "" "" "" "" "" 174 f1_btd form_1b_base_chart_review_med_status "
Digestive system" radio Bilary tract disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 175 f1_celiac form_1b_base_chart_review_med_status "" radio Celiac disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 176 f1_chrnc_lvr form_1b_base_chart_review_med_status "" radio Chronic liver disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 177 f1_chrnc_pcrts form_1b_base_chart_review_med_status "" radio Chronic pancreatitis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 178 f1_divertic form_1b_base_chart_review_med_status "" radio Diverticular disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 179 f1_dysphagia form_1b_base_chart_review_med_status "" radio Dysphagia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 180 f1_gerd form_1b_base_chart_review_med_status "" radio Gastroesophageal reflux disease (GERD) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 181 f1_gi_bld form_1b_base_chart_review_med_status "" radio GI bleed 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 182 f1_peptic_ulc form_1b_base_chart_review_med_status "" radio Peptic ulcer disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 183 f1_sml_bwl_obst form_1b_base_chart_review_med_status "" radio Small bowel obstruction 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 184 f1_dgstv_oth form_1b_base_chart_review_med_status "" radio Other Digestive Disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" digestive_system "" "" 185 f1_dgstv_oth_name form_1b_base_chart_review_med_status "" text Name other Digestive Disorder "" "" "" "" [f1_dgstv_oth] = '1' y "" "" "" "" "" 186 f1_anemia form_1b_base_chart_review_med_status "
Blood disorders" radio Anemia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 187 f1_b12_def form_1b_base_chart_review_med_status "" radio B12 deficiency 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 188 f1_myelodys form_1b_base_chart_review_med_status "" radio Myelodysplasia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 189 f1_polycyth form_1b_base_chart_review_med_status "" radio Polycythemia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 190 f1_thrombocys form_1b_base_chart_review_med_status "" radio Thrombocystosis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 191 f1_thrombocyt form_1b_base_chart_review_med_status "" radio Thrombocytopenia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 192 f1_wldnstrms form_1b_base_chart_review_med_status "" radio Waldenstrom's macroglobulinemia 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 193 f1_bld_oth form_1b_base_chart_review_med_status "" radio Other blood disorders 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" blood_disorders "" "" 194 f1_bld_oth_name form_1b_base_chart_review_med_status "" text Name other blood disorders "" "" "" "" [f1_bld_oth] = '1' y "" "" "" "" "" 195 f1_arthritis form_1b_base_chart_review_med_status "
Musculoskeletal" radio Arthritis (any type or locations) 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 196 f1_lmbr_crv_stn form_1b_base_chart_review_med_status "" radio Lumbar or cervical stenosis 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 197 f1_pagets form_1b_base_chart_review_med_status "" radio Paget's disease 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 198 f1_ply_rheum form_1b_base_chart_review_med_status "" radio Polymyalgia rheumatica 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 199 f1_sciatica form_1b_base_chart_review_med_status "" radio Sciatica 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 200 f1_msclt_oth form_1b_base_chart_review_med_status "" radio Other musculoskeletal 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" musculoskeletal "" "" 201 f1_msclt_oth_name form_1b_base_chart_review_med_status "" text Name other musculoskeletal "" "" "" "" [f1_msclt_oth] = '1' y "" "" "" "" "" 202 f1_hearing form_1b_base_chart_review_med_status "
Sensory" radio Hearing disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" sensory "" "" 203 f1_vision form_1b_base_chart_review_med_status "" radio Vision disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" sensory "" "" 204 f1_sens_oth form_1b_base_chart_review_med_status "" radio Other sensory disorder 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" sensory "" "" 205 f1_sens_oth_name form_1b_base_chart_review_med_status "" text Name other sensory disorder "" "" "" "" [f1_sens_oth] = '1' y "" "" "" "" "" 206 f1_mrsa form_1b_base_chart_review_med_status "
Infections" radio MRSA 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" infections "" "" 207 f1_vre form_1b_base_chart_review_med_status "" radio VRE 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" infections "" "" 208 f1_maj_med_oth form_1b_base_chart_review_med_status "
OTHER (code other major medical conditions but NOT current infections)" radio Other major medical conditioins 0, Not in chart (0) | 1, Yes (1) (excluding current infections) "" "" "" y "" "" "" "" "" 209 f1_maj_med_oth_name form_1b_base_chart_review_med_status "" text Name other major medical conditions "" (excluding current infections) "" "" [f1_maj_med_oth] = '1' y "" "" "" "" "" 210 f1_prv_surg form_1b_base_chart_review_med_status "" checkbox All previous surgeries 1, 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 "" "" "" "" "" 211 f1_surg_oth form_1b_base_chart_review_med_status "" text Other previous surgeries "" "" "" "" [f1_prv_surg(12)] = '1' y "" "" "" "" "" 212 f1_living_will form_1c_base_chart_review_adv_directives "
CHART REVIEW: ADVANCE DIRECTIVES (as documented in chart)" radio Living Will 0, No (0) | 1, Yes (1) As documented in chart "" "" "" y "" "" "" "" "" 213 f1_lvng_will_spfcs form_1c_base_chart_review_adv_directives "" checkbox Living 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 "" "" "" "" "" 214 f1_dnr_m form_1c_base_chart_review_adv_directives "
Current Advance Directives" radio DNR 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 215 f1_dni_m form_1c_base_chart_review_adv_directives "" radio DNI 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 216 f1_dnh_m form_1c_base_chart_review_adv_directives "" radio DNH or other clear documentation of decision to avoid hospital transfer 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 217 f1_no_tube_m form_1c_base_chart_review_adv_directives "" radio No feeding tube 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 218 f1_no_iv_hydr_m form_1c_base_chart_review_adv_directives "" radio No IV hydration 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 219 f1_no_iv_antib_m form_1c_base_chart_review_adv_directives "" radio No intravenous antibiotics (oral or intramuscular still ok) 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 220 f1_no_im_antib_m form_1c_base_chart_review_adv_directives "" radio No intramuscular antibiotics (oral still ok) 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 221 f1_no_oral_antib_m form_1c_base_chart_review_adv_directives "" radio No oral antibiotics 0, DOES NOT have this directive (0) | 1, DOES have this directive (1) "" "" "" "" y "" "" current_advance_directives "" "" 222 f1_doc_disc_d form_1c_base_chart_review_adv_directives "" descriptive Is 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)? "" "" "" "" "" "" "" "" "" "" "" 223 f1_doc_disc_goc form_1c_base_chart_review_adv_directives "" radio Documented Discussion of Goals of Medical Care 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 224 f1_discuss_prvdr form_1c_base_chart_review_adv_directives "" checkbox Provider/s that had documented goals of care discussions with Proxy 1, 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 "" "" "" "" "" 225 f1_discuss_prvdr_oth form_1c_base_chart_review_adv_directives "" text Other provider with documented goals of care discussions with proxy "" Which provider/s had the discussion with the proxy? (check all that apply) "" "" [f1_doc_disc_goc] = '1' and [f1_discuss_prvdr(8)] = '1' y "" "" "" "" "" 226 f1_doc_goals_descript_d form_1c_base_chart_review_adv_directives "" descriptive Please elaborate on discussion details "" "" "" "" [f1_doc_disc_goc] = '1' "" "" "" "" "" "" 227 f1_doc_goals form_1c_base_chart_review_adv_directives "" notes Documented discussions about the goals of care "" "" "" "" [f1_doc_disc_goc] = '1' "" "" "" "" "" "" 228 f1_peg_tube form_1d_base_chart_review_trtmntsinv "
CHART REVIEW: TREATMENTS" radio Resident CURRENTLY have PEG (or J) tube? 0, No (0) | 1, Yes (1) Does the resident currently have a PEG (or J) tube? "" "" "" y "" "" "" "" "" 229 f1_peg_date_avail form_1d_base_chart_review_trtmntsinv "" radio Date PEG placed avail? 0, No (0) | 1, Yes (1) "" "" "" [f1_peg_tube] = '1' y "" "" "" "" "" 230 f1_peg_date_in form_1d_base_chart_review_trtmntsinv "" text Date PEG tube inserted "" "" date_mdy "" [f1_peg_tube] = '1' and [f1_peg_date_avail] = '1' y "" "" "" "" "" 231 f1_peg_in_how form_1d_base_chart_review_trtmntsinv "" radio How 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 "" "" "" "" "" 232 f1_peg_in_oth form_1d_base_chart_review_trtmntsinv "" text PEG placement, other "" "" "" "" [f1_peg_in_how] = '3' y "" "" "" "" "" 233 f1_catheter_d form_1d_base_chart_review_trtmntsinv "" descriptive Has the resident had an indwelling bladder catheter DURING THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS)? "" "" "" "" "" "" "" "" "" "" "" 234 f1_catheter form_1d_base_chart_review_trtmntsinv "" radio Indwelling bladder Catheter? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 235 f1_date_cath_d form_1d_base_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 236 f1_cath_days form_1d_base_chart_review_trtmntsinv "" text Indwelling Catheter days "" "" integer 0 999 "" [f1_catheter] = '1' y "" "" "" "" "" 237 f1_periph_iv_acc_d form_1d_base_chart_review_trtmntsinv "" descriptive Has the resident had peripheral intravenous access or therapy IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) "" "" "" "" "" "" "" "" "" "" "" 238 f1_peri_intra_ther form_1d_base_chart_review_trtmntsinv "" radio Peripheral intravenous access or therapy? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 239 f1_peri_intra_days_d form_1d_base_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 240 f1_peri_intra_days form_1d_base_chart_review_trtmntsinv "" text Days 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)? integer 0 999 "" [f1_peri_intra_ther] = '1' y "" "" "" "" "" 241 f1_vent_d form_1d_base_chart_review_trtmntsinv "" descriptive Has the resident been on a ventilator IN THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) "" "" "" "" "" "" "" "" "" "" "" 242 f1_vent form_1d_base_chart_review_trtmntsinv "" radio Ventilator (past 3 months)? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 243 f1_vent_days_d form_1d_base_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 244 f1_vent_days form_1d_base_chart_review_trtmntsinv "" text Ventilator (# days in past 3 months)? "" "" integer 0 999 "" [f1_vent] = '1' y "" "" "" "" "" 245 f1_venipunct_num_d form_1d_base_chart_review_trtmntsinv "
Chart Review: INVESTIGATIONS" descriptive Over the PAST 3 MONTHS, (OR SINCE ADMISSION IF IN NH < 3 MONTHS), How many venipunctures were done ? (each blood draw means a separate venipuncture) "" "" "" "" "" "" "" "" "" "" "" 246 f1_venipunct_num form_1d_base_chart_review_trtmntsinv "" text Venipunctures (total # in past 3 months)? "" "" integer 0 999 "" "" y "" "" "" "" "" 247 f1_hosp_dets_d form_1e_base_chart_review_healthcare_util "
Chart Review: HEALTH SERVICES UTILIZATION" descriptive "
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)" "" "" "" "" "" "" "" "" "" "" "" 248 f1_hosp_adm_num form_1e_base_chart_review_healthcare_util "" text Hospital Admissions (total # in past 3 months)? "" How many hospital admissions in past 3 months (or since admission if in NH < 90 days)? integer 0 93 "" "" y "" "" "" "" "" 249 f1_hosp1_admit_date form_1e_base_chart_review_healthcare_util "" text Hospital 1 Admission Date "" "" date_mdy "" [f1_hosp_adm_num] >= 1 y "" "" "" "" "" 250 f1_hosp1_dischg_date form_1e_base_chart_review_healthcare_util "" text Hospital 1 Discharge Date "" "" date_mdy "" [f1_hosp_adm_num] >= 1 y "" "" "" "" "" 251 f1_hosp1_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 1 Primary Diagnosis 101, 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 y "" "" "" "" "" 252 f1_hosp1_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 253 f1_hosp1_scnd_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 1 Secondary Diagnosis 101, 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 "" "" "" "" "" "" 254 f1_hosp1_scnd_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 255 f1_hosp2_admit_date form_1e_base_chart_review_healthcare_util "" text Hospital 2 Admission Date "" "" date_mdy "" [f1_hosp_adm_num] >= 2 y "" "" "" "" "" 256 f1_hosp2_dischg_date form_1e_base_chart_review_healthcare_util "" text Hospital 2 Discharge Date "" "" date_mdy "" [f1_hosp_adm_num] >= 2 y "" "" "" "" "" 257 f1_hosp2_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 258 f1_hosp2_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 259 f1_hosp2_scnd_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 2 Secondary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 260 f1_hosp2_scnd_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 261 f1_hosp3_admit_date form_1e_base_chart_review_healthcare_util "" text Hospital 3 Admission Date "" "" date_mdy "" [f1_hosp_adm_num] >= 3 y "" "" "" "" "" 262 f1_hosp3_dischg_date form_1e_base_chart_review_healthcare_util "" text Hospital 3 Discharge Date "" "" date_mdy "" [f1_hosp_adm_num] >= 3 y "" "" "" "" "" 263 f1_hosp3_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 264 f1_hosp3_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 265 f1_hosp3_scnd_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 3 Secondary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 266 f1_hosp3_scnd_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 267 f1_hosp4_admit_date form_1e_base_chart_review_healthcare_util "" text Hospital 4 Admission Date "" "" date_mdy "" [f1_hosp_adm_num] >= 4 y "" "" "" "" "" 268 f1_hosp4_dischg_date form_1e_base_chart_review_healthcare_util "" text Hospital 4 Discharge Date "" "" date_mdy "" [f1_hosp_adm_num] >= 4 y "" "" "" "" "" 269 f1_hosp4_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 270 f1_hosp4_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 271 f1_hosp4_scnd_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 4 Secondary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 272 f1_hosp4_scnd_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 273 f1_hosp5_admit_date form_1e_base_chart_review_healthcare_util "" text Hospital 5 Admission Date "" "" date_mdy "" [f1_hosp_adm_num] >= 5 y "" "" "" "" "" 274 f1_hosp5_dischg_date form_1e_base_chart_review_healthcare_util "" text Hospital 5 Discharge Date "" "" date_mdy "" [f1_hosp_adm_num] >= 5 y "" "" "" "" "" 275 f1_hosp5_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 276 f1_hosp5_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 277 f1_hosp5_scnd_diag form_1e_base_chart_review_healthcare_util "" dropdown Hospital 5 Secondary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 278 f1_hosp5_scnd_diag_oth form_1e_base_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 279 f1_er_info_d form_1e_base_chart_review_healthcare_util "" descriptive "
Describe all Emergency Room Visits (WITHOUT HOSPITALIZATION) OVER THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) in the section below" "" "" "" "" "" "" "" "" "" "" "" 280 f1_er_adm_num form_1e_base_chart_review_healthcare_util "" text Emergency Room Visits (total # in past 3 months)? "" How many ER visits in past 3 months (or since admission if in NH < 90 days)? number 0 93 "" "" y "" "" "" "" "" 281 f1_er1_date form_1e_base_chart_review_healthcare_util "" text ER Visit 1 Date "" "" date_mdy "" [f1_er_adm_num] >= 1 y "" "" "" "" "" 282 f1_er1_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ER Visit 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 283 f1_er1_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 284 f1_er2_date form_1e_base_chart_review_healthcare_util "" text ER Visit 2 Date "" "" date_mdy "" [f1_er_adm_num] >= 2 y "" "" "" "" "" 285 f1_er2_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ER Visit 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 286 f1_er2_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 287 f1_er3_date form_1e_base_chart_review_healthcare_util "" text ER Visit 3 Date "" "" date_mdy "" [f1_er_adm_num] >= 3 y "" "" "" "" "" 288 f1_er3_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ER Visit 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 289 f1_er3_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 290 f1_er4_date form_1e_base_chart_review_healthcare_util "" text ER Visit 4 Date "" "" date_mdy "" [f1_er_adm_num] >= 4 y "" "" "" "" "" 291 f1_er4_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ER Visit 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 292 f1_er4_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 293 f1_er5_date form_1e_base_chart_review_healthcare_util "" text ER Visit 5 Date "" "" date_mdy "" [f1_er_adm_num] >= 5 y "" "" "" "" "" 294 f1_er5_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ER Visit 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 295 f1_er5_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 296 f1_icu_info_d form_1e_base_chart_review_healthcare_util "" descriptive "
Describe all ICU Admissions OVER THE PAST 3 MONTHS (OR SINCE ADMISSION IF IN NH < 3 MONTHS) in the section below" "" "" "" "" "" "" "" "" "" "" "" 297 f1_icu_adm_num form_1e_base_chart_review_healthcare_util "" text ICU Admissions (total # in past 3 months)? "" How many ICU visits in past 3 months (or since admission if in NH < 90 days)? integer 0 93 "" "" y "" "" "" "" "" 298 f1_icu1_admit_date form_1e_base_chart_review_healthcare_util "" text ICU 1 Admission Date "" "" date_mdy "" [f1_icu_adm_num] >= 1 y "" "" "" "" "" 299 f1_icu1_dischg_date form_1e_base_chart_review_healthcare_util "" text ICU 1 Discharge Date "" "" date_mdy "" [f1_icu_adm_num] >= 1 y "" "" "" "" "" 300 f1_icu1_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ICU 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 301 f1_icu1_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 302 f1_icu2_admit_date form_1e_base_chart_review_healthcare_util "" text ICU 2 Admission Date "" "" date_mdy "" [f1_icu_adm_num] >= 2 y "" "" "" "" "" 303 f1_icu2_dischg_date form_1e_base_chart_review_healthcare_util "" text ICU 2 Discharge Date "" "" date_mdy "" [f1_icu_adm_num] >= 2 y "" "" "" "" "" 304 f1_icu2_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ICU 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 305 f1_icu2_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 306 f1_icu3_admit_date form_1e_base_chart_review_healthcare_util "" text ICU 3 Admission Date "" "" date_mdy "" [f1_icu_adm_num] >= 3 y "" "" "" "" "" 307 f1_icu3_dischg_date form_1e_base_chart_review_healthcare_util "" text ICU 3 Discharge Date "" "" date_mdy "" [f1_icu_adm_num] >= 3 y "" "" "" "" "" 308 f1_icu3_prim_diag form_1e_base_chart_review_healthcare_util "" dropdown ICU 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 309 f1_icu3_prim_diag_oth form_1e_base_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 310 f1_hospice_d form_1e_base_chart_review_healthcare_util "" descriptive "
Describe all Hospice utilization in the section below" "" "" "" "" "" "" "" "" "" "" "" 311 f1_hospice_current form_1e_base_chart_review_healthcare_util "" radio Resident Currently on Hospice? 0, No (0) | 1, Yes (1) | 999, Don't know (999) Is the resident currently on hospice? "" "" "" y "" "" "" "" "" 312 f1_hospice_start_date form_1e_base_chart_review_healthcare_util "" text Initial Date Hospice Services Started "" What was the initial date hospice services were started? date_mdy "" [f1_hospice_current] = '1' y "" "" "" "" "" 313 f1_provider_invlv_d form_1e_base_chart_review_healthcare_util "" descriptive "
Describe involvement with care providers in the section below" "" "" "" "" "" "" "" "" "" "" "" 314 f1_np_pa_part_prim_ca_d form_1e_base_chart_review_healthcare_util "" descriptive Does a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident? "" "" "" "" "" "" "" "" "" "" "" 315 f1_np_pa_part_prim_care form_1e_base_chart_review_healthcare_util "" radio NP or PA Participate in Primary Care? 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 316 f1_doc_md_vsts_d form_1e_base_chart_review_healthcare_util "" descriptive How 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) "" "" "" "" "" "" "" "" "" "" "" 317 f1_md_visits_num form_1e_base_chart_review_healthcare_util "" text # of MD visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 318 f1_np_or_pa_visits_num form_1e_base_chart_review_healthcare_util "" text # of NP or PA visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 319 f1_sentinal_d form_1f_base_chart_review_sentinal_events "
CHART REVIEW: SENTINAL EVENTS" descriptive "
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)." "" "" "" "" "" "" "" "" "" "" "" 320 f1_sent_num form_1f_base_chart_review_sentinal_events "" text Number Sentinal Events "" Number of sentinal events since last assessment integer 0 999 "" "" y "" "" "" "" "" 321 f1_sentinal_1 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 1 1, 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] >= 1 y "" "" "" "" "" 322 f1_sent_1_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 1 other "" "" "" "" [f1_sentinal_1] = '11' and [f1_sent_num] >= 1 y "" "" "" "" "" 323 f1_sentinal1_date form_1f_base_chart_review_sentinal_events "" text Sentinal 1 date "" "" date_mdy "" [f1_sent_num] >= 1 y "" "" "" "" "" 324 f1_sentinal_2 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 2 1, 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] >= 2 y "" "" "" "" "" 325 f1_sent_2_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 2 other "" "" "" "" [f1_sent_num] >= 2 and [f1_sentinal_2] = '11' y "" "" "" "" "" 326 f1_sentinal2_date form_1f_base_chart_review_sentinal_events "" text Sentinal 2 date "" "" date_mdy "" [f1_sent_num] >= 2 y "" "" "" "" "" 327 f1_sentinal_3 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 3 1, 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] >= 3 y "" "" "" "" "" 328 f1_sent_3_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 3 Other "" "" "" "" [f1_sent_num] >= 3 and [f1_sentinal_3] = '11' y "" "" "" "" "" 329 f1_sentinal3_date form_1f_base_chart_review_sentinal_events "" text Sentinal 3 date "" "" date_mdy "" [f1_sent_num] >= 3 y "" "" "" "" "" 330 f1_sentinal_4 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 4 1, 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] >= 4 y "" "" "" "" "" 331 f1_sent_4_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 4 Other "" "" "" "" [f1_sent_num] >= 4 and [f1_sentinal_4] = '11' y "" "" "" "" "" 332 f1_sentinal4_date form_1f_base_chart_review_sentinal_events "" text Sentinal 4 date "" "" date_mdy "" [f1_sent_num] >= 4 y "" "" "" "" "" 333 f1_sentinal_5 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 5 1, 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] >= 5 y "" "" "" "" "" 334 f1_sent_5_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 5 other "" "" "" "" [f1_sent_num] >= 5 and [f1_sentinal_5] = '11' y "" "" "" "" "" 335 f1_sentinal5_date form_1f_base_chart_review_sentinal_events "" text Sentinal 5 date "" "" date_mdy "" [f1_sent_num] >= 5 y "" "" "" "" "" 336 f1_sentinal_6 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 6 1, 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] >= 6 y "" "" "" "" "" 337 f1_sent_6_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 6 other "" "" "" "" [f1_sent_num] >= 6 and [f1_sentinal_6] = '11' y "" "" "" "" "" 338 f1_sentinal6_date form_1f_base_chart_review_sentinal_events "" text Sentinal 6 date "" "" date_mdy "" [f1_sent_num] >= 6 y "" "" "" "" "" 339 f1_sentinal_7 form_1f_base_chart_review_sentinal_events "" dropdown Sentinal Event 7 1, 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] >= 7 y "" "" "" "" "" 340 f1_sent_7_oth form_1f_base_chart_review_sentinal_events "" text Sentinal 7 other "" "" "" "" [f1_sent_num] >= 7 and [f1_sentinal_7] = '11' y "" "" "" "" "" 341 f1_sentinal7_date form_1f_base_chart_review_sentinal_events "" text Sentinal 7 date "" "" date_mdy "" [f1_sent_num] >= 7 y "" "" "" "" "" 342 f1_end_chart_review_d form_1f_base_chart_review_sentinal_events "" descriptive "
END OF CHART REVIEW. OPEN NEXT FORM TO COMPLETE NURSING INTERVIEW" "" "" "" "" "" "" "" "" "" "" "" 343 f1_bans_d form_1g_base_nursing_interview "
NURSING INTERVIEW: BEDFORD ALZHEIMER NURSING SEVERITY SCALE (BANS)" descriptive "
Please check the appropriate response below that best describes the resident on an average day OVER THE LAST 3 MONTHS." "" "" "" "" "" "" "" "" "" "" "" 344 f1_bans_dressing form_1g_base_nursing_interview "" radio BANS Scale - Dressing 1, Usually is independent (1) | 2, Requires minimal assistance (2) | 3, Requires moderate assistance (3) | 4, Totally dependent (4) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 345 f1_bans_sleeping form_1g_base_nursing_interview "" radio BANS Scale - Sleeping 1, 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 "" "" "" "" "" 346 f1_bans_speech form_1g_base_nursing_interview "" radio BANS Scale - Speech 1, 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 "" "" "" "" "" 347 f1_bans_eating form_1g_base_nursing_interview "" radio BANS Scale - Eating 1, 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 "" "" "" "" "" 348 f1_bans_mobility form_1g_base_nursing_interview "" radio BANS Scale - Mobility 1, 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 "" "" "" "" "" 349 f1_bans_muscles form_1g_base_nursing_interview "" radio BANS Scale - Muscles 1, 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 "" "" "" "" "" 350 f1_bans_eye_contact form_1g_base_nursing_interview "" radio BANS Scale - Eye contact 1, 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 "" "" "" "" "" 351 f1_end_nurse_interview_d form_1g_base_nursing_interview "" descriptive "
END OF NURSING INTERVIEW" "" "" "" "" "" "" "" "" "" "" "" 352 f1_tsi_d form_1h_base_tsi "
RESIDENT EXAMINATION: TEST FOR SEVERE IMPAIRMENT (TSI)" descriptive "
Please ask the resident to complete the following tasks ---read the prompts/requests above the data entry field" "" "" "" "" "" "" "" "" "" "" "" 353 f1_m_comb_d form_1h_base_tsi "
MOTOR PERFORMANCE " descriptive "
""Show me how you would use this comb""" "" "" "" "" "" "" "" "" "" "" "" 354 f1_m_comb form_1h_base_tsi "" radio "
Ability to use comb" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 355 f1_m_top_pen_d form_1h_base_tsi "" descriptive "
Can you put the top on the pen?" "" """Can you put the top on the pen?""" "" "" "" "" "" "" "" "" "" 356 f1_m_top_pen form_1h_base_tsi "" radio "
Put top on pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 357 f1_m_write_name_d form_1h_base_tsi "" descriptive "
Please write your name" "" """Can you write your name?""" "" "" "" "" "" "" "" "" "" 358 f1_m_write_name form_1h_base_tsi "" radio "
Write name" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 359 f1_lc_point_d form_1h_base_tsi "
LANGUAGE COMPREHENSION" descriptive "
Please point to your ear" "" """Point to your ear""" "" "" "" "" "" "" "" "" "" 360 f1_lc_point form_1h_base_tsi "" radio "
Point to ear" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 361 f1_lc_close_eyes_d form_1h_base_tsi "" descriptive "
Please close your eyes" "" """Close your eyes""" "" "" "" "" "" "" "" "" "" 362 f1_lc_close_eyes form_1h_base_tsi "" radio "
Close eyes" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 363 f1_lc_show_rpen_d form_1h_base_tsi "" descriptive "
Please show me the red pen" "" "" "" "" "" "" "" "" "" "" "" 364 f1_lc_show_rpen form_1h_base_tsi "" radio "
Show red pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 365 f1_lc_show_gpen_d form_1h_base_tsi "" descriptive "
Please show me the green pen" "" """Show me the green pen""" "" "" "" "" "" "" "" "" "" 366 f1_lc_show_gpen form_1h_base_tsi "" radio "
Show green pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 367 f1_lp_names_nose_d form_1h_base_tsi "
LANGUAGE PRODUCTION" descriptive "
""What is this called?"" (point to nose)" "" "" "" "" "" "" "" "" "" "" "" 368 f1_lp_names_nose form_1h_base_tsi "" radio "
Names nose" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 369 f1_lp_names_gpen_d form_1h_base_tsi "" descriptive "
""What color is this?"" (show green pen) " "" "" "" "" "" "" "" "" "" "" "" 370 f1_lp_names_gpen form_1h_base_tsi "" radio "
Names green pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 371 f1_lp_names_rpen_d form_1h_base_tsi "" descriptive "
""What color is this?"" (show red pen) " "" "" "" "" "" "" "" "" "" "" "" 372 f1_lp_names_rpen form_1h_base_tsi "" radio "
Names red pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 373 f1_lp_names_key_d form_1h_base_tsi "" descriptive "
""What is this called?"" (show key) " "" "" "" "" "" "" "" "" "" "" "" 374 f1_lp_names_key form_1h_base_tsi "" radio "
Names key" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 375 f1_mi_ids_open_hand_d form_1h_base_tsi "
MEMORY -- IMMEDIATE Put a paper clip in a hand so resident can see it" descriptive "
WITH BOTH HANDS OPEN, ""Which hand is the clip in?""" "" "" "" "" "" "" "" "" "" "" "" 376 f1_mi_ids_open_hand form_1h_base_tsi "" radio "
Picks hand-hands open" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 377 f1_mi_ids_clsd_hand_d form_1h_base_tsi "" descriptive "
WITH BOTH HANDS CLOSED, ""Which hand is the clip in?""" "" "" "" "" "" "" "" "" "" "" "" 378 f1_mi_ids_clsd_hand form_1h_base_tsi "" radio "
Picks hand-hands closed" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 379 f1_mi_ids_hdn_hand_d form_1h_base_tsi "" descriptive "
MOVE HANDS AROUND BACK, ""Which hand is the clip in?""" "" "" "" "" "" "" "" "" "" "" "" 380 f1_mi_ids_hdn_hand form_1h_base_tsi "" radio "
Picks hand-behind back" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 381 f1_gn_counts_ears_d form_1h_base_tsi "
GENERAL KNOWLEDGE" descriptive "
""How many ears do I have?""" "" "" "" "" "" "" "" "" "" "" "" 382 f1_gn_counts_ears form_1h_base_tsi "" radio "
Counts ears" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 383 f1_gn_counts_ten_d form_1h_base_tsi "" descriptive "
""Count my fingers"" or ""Count to 10""" "" "" "" "" "" "" "" "" "" "" "" 384 f1_gn_counts_ten form_1h_base_tsi "" radio "
Counts to ten" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 385 f1_gn_wks_year_d form_1h_base_tsi "" descriptive "
""How many weeks are there are in a year?""" "" "" "" "" "" "" "" "" "" "" "" 386 f1_gn_wks_year form_1h_base_tsi "" radio "
Knows ""Weeks in a year""" 0, No, (0) | 1, Yes, (1) "" "" "" "" y "" "" "" "" "" 387 f1_gn_sings_bday_d form_1h_base_tsi "" descriptive "
""I am going to sing a song, if you know the words, sing along with me"" (sing happy birthday)" "" "" "" "" "" "" "" "" "" "" "" 388 f1_gn_sings_bday form_1h_base_tsi "" radio "
Sings Happy B-day" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 389 f1_c_pen_dif_d form_1h_base_tsi "
CONCEPTUALIZATION" descriptive "
Show 2 large paperclips and one pen, ""Which of these are different from the other?""" "" "" "" "" "" "" "" "" "" "" "" 390 f1_c_pen_dif form_1h_base_tsi "" radio "
IDs different object_pen" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 391 f1_c_pen_sort_d form_1h_base_tsi "" descriptive "
Show 2 red pens and 1 green pen. ""Put this pen next to the pen that is the same color""" "" "" "" "" "" "" "" "" "" "" "" 392 f1_c_pen_sort form_1h_base_tsi "" radio "
Sorts colored pens" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 393 f1_c_predicts_hand_d form_1h_base_tsi "" descriptive "
Moving one large paperclip from one hand to the other. "" Watch me move the paperclip. Which hand will I put it in next?""" "" "" "" "" "" "" "" "" "" "" "" 394 f1_c_predicts_hand form_1h_base_tsi "" radio "
Predicts clip hand" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 395 f1_md_ids_thread_d form_1h_base_tsi "
MEMORY-DELAYED " descriptive "
Show key, thread, paperclip. ""Which of these have I not done something with while you were with me?""" "" "" "" "" "" "" "" "" "" "" "" 396 f1_md_ids_thread form_1h_base_tsi "" radio "
IDs unused thread" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 397 f1_motor_perf_d form_1h_base_tsi "" descriptive "
MOTOR PERFORMANCE" "" "" "" "" "" "" "" "" "" "" "" 398 f1_mp_handshake_d form_1h_base_tsi "" descriptive "
Extend hand to shake hands. ""Thank you for spending time with me.""" "" "" "" "" "" "" "" "" "" "" "" 399 f1_mp_handshake form_1h_base_tsi "" radio "
Shakes hand" 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 400 f1_tsi_score_d form_1h_base_tsi "" descriptive "
The TSI score below reflects the results from the above items. " "" "" "" "" "" "" "" "" "" "" "" 401 f1_tsi_score form_1h_base_tsi "" calc "
TSI Score" sum([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]) "" "" "" "" "" "" "" "" "" "" 402 f1_tsi_instruction_d form_1h_base_tsi "" descriptive "
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 "" "" "" "" "" "" 403 f1_gds_valid form_1h_base_tsi "" radio "
GDS=7 validated? " 0, No (resident ineligible) (0) | 1, Yes (resident eligible) (1) "" "" "" [f1_tsi_score] >= 11 y "" "" "" "" "" 404 f1_end_r_baseline_d form_1h_base_tsi "" descriptive "
End of Resident Baseline data collection" "" "" "" "" "" "" "" "" "" "" "" 405 f2_doi form_2a_quarterly_demographics "
QUARTERLY RESIDENT ASSESSMENT" text Resident Quarterly Date "" "" date_mdy "" "" y "" "" "" "" "" 406 f2_ra_id form_2a_quarterly_demographics "" dropdown RA ID 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 407 f2_quart_unit_id form_2a_quarterly_demographics "" text Unit ID "" "" "" y "" "" "" "" "" "" "" 408 f2_quart_res_rm form_2a_quarterly_demographics "" text Room number "" "" "" y "" y "" "" "" "" "" 409 f2_res_spcl_unt form_2a_quarterly_demographics "" radio Resident 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 "" "" "" "" "" 410 f2_dnr_m form_2c_quart_chart_review_adv_directives "
CHART REVIEW: ADVANCE DIRECTIVES (as documented in chart)" radio DNR 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 411 f2_dni_m form_2c_quart_chart_review_adv_directives "" radio DNI 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 412 f2_dnh_m form_2c_quart_chart_review_adv_directives "" radio DNH or other clear documentation of decision to avoid hospital transfer 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 413 f2_no_tube_m form_2c_quart_chart_review_adv_directives "" radio No feeding tube 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 414 f2_no_iv_hydr_m form_2c_quart_chart_review_adv_directives "" radio No IV hydration 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 415 f2_no_iv_antib_m form_2c_quart_chart_review_adv_directives "" radio No intravenous antibiotics (oral or intramuscular still ok) 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 416 f2_no_im_antib_m form_2c_quart_chart_review_adv_directives "" radio No intramuscular antibiotics (oral still ok) 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 417 f2_no_oral_antib_m form_2c_quart_chart_review_adv_directives "" radio No oral antibiotics 0, Does not have this directive (0) | 1, Does have this directive (1) "" "" "" "" y "" "" current_advance_directives_quarterly "" "" 418 f2_dnr_new form_2c_quart_chart_review_adv_directives "" radio DNR new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_dnr_m] = '1' y "" "" "" "" "" 419 f2_dnr_date form_2c_quart_chart_review_adv_directives "" text DNR order date "" "" date_mdy "" [f2_dnr_new] = '1' y "" "" "" "" "" 420 f2_dni_new form_2c_quart_chart_review_adv_directives "" radio DNI new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_dni_m] = '1' y "" "" "" "" "" 421 f2_dni_date form_2c_quart_chart_review_adv_directives "" text DNI order date "" "" date_mdy "" [f2_dni_new] = '1' y "" "" "" "" "" 422 f2_dnh_new form_2c_quart_chart_review_adv_directives "" radio DNH new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_dnh_m] = '1' y "" "" "" "" "" 423 f2_dnh_date form_2c_quart_chart_review_adv_directives "" text DNH order date "" "" date_mdy "" [f2_dnh_new] = '1' y "" "" "" "" "" 424 f2_no_tube_new form_2c_quart_chart_review_adv_directives "" radio No feeding tube new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_no_tube_m] = '1' y "" "" "" "" "" 425 f2_no_tube_date form_2c_quart_chart_review_adv_directives "" text No feeding tube date "" "" date_mdy "" [f2_no_tube_new] = '1' y "" "" "" "" "" 426 f2_no_iv_hydr_new form_2c_quart_chart_review_adv_directives "" radio No IV hydration new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_no_iv_hydr_m] = '1' y "" "" "" "" "" 427 f2_no_iv_hydr_date form_2c_quart_chart_review_adv_directives "" text No IV hydration date "" "" date_mdy "" [f2_no_iv_hydr_new] = '1' y "" "" "" "" "" 428 f2_no_iv_antib_new form_2c_quart_chart_review_adv_directives "" radio No IV antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_no_iv_antib_m] = '1' y "" "" "" "" "" 429 f2_no_iv_antib_date form_2c_quart_chart_review_adv_directives "" text No IV antibiotic (oral or intramuscular still ok) date "" "" date_mdy "" [f2_no_iv_antib_new] = '1' y "" "" "" "" "" 430 f2_no_im_antib_new form_2c_quart_chart_review_adv_directives "" radio No intramuscular antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_no_im_antib_m] = '1' y "" "" "" "" "" 431 f2_no_im_antib_date form_2c_quart_chart_review_adv_directives "" text No intramuscular antibiotics date "" "" date_mdy "" [f2_no_im_antib_new] = '1' y "" "" "" "" "" 432 f2_no_oral_antib_new form_2c_quart_chart_review_adv_directives "" radio No oral antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f2_no_oral_antib_m] = '1' y "" "" "" "" "" 433 f2_no_oral_antib_date form_2c_quart_chart_review_adv_directives "" text No oral antibiotics date "" "" date_mdy "" [f2_no_oral_antib_new] = '1' y "" "" "" "" "" 434 f2_doc_disc_d form_2c_quart_chart_review_adv_directives "" descriptive Is 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? "" "" "" "" "" "" "" "" "" "" "" 435 f2_doc_disc_goc form_2c_quart_chart_review_adv_directives "" radio Documented Discussion of Goals of Medical Care 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 436 f2_discuss_prvdr form_2c_quart_chart_review_adv_directives "" checkbox Provider/s that had documented goals of care discussions with Proxy 1, 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 "" "" "" "" "" 437 f2_discuss_prvdr_oth form_2c_quart_chart_review_adv_directives "" text Other provider with documented goals of care discussions with proxy "" Which provider/s had the discussion with the proxy? (check all that apply) "" "" [f2_doc_disc_goc] = '1' and [f2_discuss_prvdr(8)] = '1' y "" "" "" "" "" 438 f2_doc_goals_descript_d form_2c_quart_chart_review_adv_directives "" descriptive Please elaborate on discussion details below "" "" "" "" [f2_doc_disc_goc] = '1' "" "" "" "" "" "" 439 f2_doc_goals form_2c_quart_chart_review_adv_directives "" notes Documented discussions about the goals of care "" "" "" "" [f2_doc_disc_goc] = '1' "" "" "" "" "" "" 440 f2_peg_tube form_2d_quart_chart_review_trtmntsinv "
CHART REVIEW: TREATMENTS" radio Resident currently have PEG (or J) tube? 0, No (0) | 1, Yes (1) Does the resident currently have a PEG (or J) tube? "" "" "" y "" "" "" "" "" 441 f2_n_peg_date_d form_2d_quart_chart_review_trtmntsinv "" descriptive If PEG tube is new SINCE LAST ASSESSMENT, what was the date it was placed? "" "" "" "" [f2_peg_tube] = '1' "" "" "" "" "" "" 442 f2_peg_new form_2d_quart_chart_review_trtmntsinv "" radio PEG tube new? 0, no (0) | 1, yes (1) | 999, don't know (999) "" "" "" [f2_peg_tube] = '1' y "" "" "" "" "" 443 f2_peg_date_in form_2d_quart_chart_review_trtmntsinv "" text Date PEG tube inserted "" "" date_mdy "" [f2_peg_new] = '1' y "" "" "" "" "" 444 f2_peg_in_how form_2d_quart_chart_review_trtmntsinv "" radio How 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 "" "" "" "" "" 445 f2_peg_in_oth form_2d_quart_chart_review_trtmntsinv "" text PEG placement, other "" "" "" "" [f2_peg_in_how] = '3' y "" "" "" "" "" 446 f2_catheter_d form_2d_quart_chart_review_trtmntsinv "" descriptive Has the resident had an indwelling bladder catheter SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 447 f2_catheter form_2d_quart_chart_review_trtmntsinv "" radio Indwelling bladder Catheter? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 448 f2_date_cath_d form_2d_quart_chart_review_trtmntsinv "" descriptive "For how many days did the resident have an indwelling bladder catheter SINCE LAST ASSESSMENT? Code 999 for ""don't know""" "" "" "" "" [f2_catheter] = '1' "" "" "" "" "" "" 449 f2_cath_days form_2d_quart_chart_review_trtmntsinv "" text Indwelling Catheter days "" "" integer 0 999 "" [f2_catheter] = '1' y "" "" "" "" "" 450 f2_periph_iv_acc_d form_2d_quart_chart_review_trtmntsinv "" descriptive Has the resident had peripheral intravenous access or therapy SINCE LAST ASSESSMENT "" "" "" "" "" "" "" "" "" "" "" 451 f2_peri_intra_ther form_2d_quart_chart_review_trtmntsinv "" radio Peripheral intravenous access or therapy? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 452 f2_peri_intra_days_d form_2d_quart_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 453 f2_peri_intra_days form_2d_quart_chart_review_trtmntsinv "" text Days 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)? integer 0 999 "" [f2_peri_intra_ther] = '1' y "" "" "" "" "" 454 f2_vent_d form_2d_quart_chart_review_trtmntsinv "" descriptive Has the resident been on a ventilator SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 455 f2_vent form_2d_quart_chart_review_trtmntsinv "" radio Ventilator (past 3 months)? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 456 f2_vent_days_d form_2d_quart_chart_review_trtmntsinv "" descriptive "For how many days was the resident on a ventilator SINCE LAST ASSESSMENT? Code 999 for ""Don't know""" "" "" "" "" [f2_vent] = '1' "" "" "" "" "" "" 457 f2_vent_days form_2d_quart_chart_review_trtmntsinv "" text Ventilator (# days in past 3 months)? "" "" integer 0 999 "" [f2_vent] = '1' y "" "" "" "" "" 458 f2_venipunct_num_d form_2d_quart_chart_review_trtmntsinv "
CHART REVIEW: INVESTIGATIONS" descriptive SINCE LAST ASSESSMENT, how many venipunctures were done? (Each blood draw means a separate venipuncture) "" "" "" "" "" "" "" "" "" "" "" 459 f2_venipunct_num form_2d_quart_chart_review_trtmntsinv "" text Venipunctures (total # in past 3 months)? "" "" integer 0 999 "" "" y "" "" "" "" "" 460 f2_hosp_dets_d form_2e_quart_chart_review_healthcare_util "
CHART REVIEW: HEALTH SERVICES UTILIZATION" descriptive "
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)" "" "" "" "" "" "" "" "" "" "" "" 461 f2_hosp_adm_num form_2e_quart_chart_review_healthcare_util "" text Number Hospital Admissions (since last assessment)? "" How many hospital admissions in past 3 months (or since admission if in NH < 90 days)? integer 0 93 "" "" y "" "" "" "" "" 462 f2_hosp1_admit_date form_2e_quart_chart_review_healthcare_util "" text Hospital 1 Admission Date "" "" date_mdy "" [f2_hosp_adm_num] >= 1 y "" "" "" "" "" 463 f2_hosp1_dischg_date form_2e_quart_chart_review_healthcare_util "" text Hospital 1 Discharge Date "" "" date_mdy "" [f2_hosp_adm_num] >= 1 y "" "" "" "" "" 464 f2_hosp1_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 465 f2_hosp1_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 466 f2_hosp1_scnd_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 1 Secondary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 467 f2_hosp1_scnd_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 468 f2_hosp2_admit_date form_2e_quart_chart_review_healthcare_util "" text Hospital 2 Admission Date "" "" date_mdy "" [f2_hosp_adm_num] >= 2 y "" "" "" "" "" 469 f2_hosp2_dischg_date form_2e_quart_chart_review_healthcare_util "" text Hospital 2 Discharge Date "" "" date_mdy "" [f2_hosp_adm_num] >= 2 y "" "" "" "" "" 470 f2_hosp2_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 471 f2_hosp2_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 472 f2_hosp2_scnd_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 2 Secondary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 473 f2_hosp2_scnd_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 474 f2_hosp3_admit_date form_2e_quart_chart_review_healthcare_util "" text Hospital 3 Admission Date "" "" date_mdy "" [f2_hosp_adm_num] >= 3 y "" "" "" "" "" 475 f2_hosp3_dischg_date form_2e_quart_chart_review_healthcare_util "" text Hospital 3 Discharge Date "" "" date_mdy "" [f2_hosp_adm_num] >= 3 y "" "" "" "" "" 476 f2_hosp3_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 477 f2_hosp3_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 478 f2_hosp3_scnd_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 3 Secondary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 479 f2_hosp3_scnd_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 480 f2_hosp4_admit_date form_2e_quart_chart_review_healthcare_util "" text Hospital 4 Admission Date "" "" date_mdy "" [f2_hosp_adm_num] >= 4 y "" "" "" "" "" 481 f2_hosp4_dischg_date form_2e_quart_chart_review_healthcare_util "" text Hospital 4 Discharge Date "" "" date_mdy "" [f2_hosp_adm_num] >= 4 y "" "" "" "" "" 482 f2_hosp4_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 483 f2_hosp4_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 484 f2_hosp4_scnd_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 4 Secondary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 485 f2_hosp4_scnd_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 486 f2_hosp5_admit_date form_2e_quart_chart_review_healthcare_util "" text Hospital 5 Admission Date "" "" date_mdy "" [f2_hosp_adm_num] >= 5 y "" "" "" "" "" 487 f2_hosp5_dischg_date form_2e_quart_chart_review_healthcare_util "" text Hospital 5 Discharge Date "" "" date_mdy "" [f2_hosp_adm_num] >= 5 y "" "" "" "" "" 488 f2_hosp5_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 489 f2_hosp5_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 490 f2_hosp5_scnd_diag form_2e_quart_chart_review_healthcare_util "" dropdown Hospital 5 Secondary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 491 f2_hosp5_scnd_diag_oth form_2e_quart_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 492 f2_er_info form_2e_quart_chart_review_healthcare_util "" descriptive "
Describe all Emergency Room Visits WITHOUT HOSPITALIZATION, SINCE LAST ASSESSMENT in the section below." "" "" "" "" "" "" "" "" "" "" "" 493 f2_er_adm_num form_2e_quart_chart_review_healthcare_util "" text Number ER Visits (since last assessment)? "" How many ER visits in past 3 months (or since admission if in NH < 90 days)? integer 0 93 "" "" y "" "" "" "" "" 494 f2_er1_date form_2e_quart_chart_review_healthcare_util "" text ER Visit 1 Date "" "" date_mdy "" [f2_er_adm_num] >= 1 y "" "" "" "" "" 495 f2_er1_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ER Visit 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 496 f2_er1_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 497 f2_er2_date form_2e_quart_chart_review_healthcare_util "" text ER Visit 2 Date "" "" date_mdy "" [f2_er_adm_num] >= 2 y "" "" "" "" "" 498 f2_er2_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ER Visit 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 499 f2_er2_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 500 f2_er3_date form_2e_quart_chart_review_healthcare_util "" text ER Visit 3 Date "" "" date_mdy "" [f2_er_adm_num] >= 3 y "" "" "" "" "" 501 f2_er3_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ER Visit 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 502 f2_er3_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 503 f2_er4_date form_2e_quart_chart_review_healthcare_util "" text ER Visit 4 Date "" "" date_mdy "" [f2_er_adm_num] >= 4 y "" "" "" "" "" 504 f2_er4_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ER Visit 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 505 f2_er4_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 506 f2_er5_date form_2e_quart_chart_review_healthcare_util "" text ER Visit 5 Date "" "" date_mdy "" [f2_er_adm_num] >= 5 y "" "" "" "" "" 507 f2_er5_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ER Visit 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 508 f2_er5_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 509 f2_icu_info_d form_2e_quart_chart_review_healthcare_util "" descriptive "
Describe all ICU Admissions SINCE LAST ASSESSMENT, in the section below." "" "" "" "" "" "" "" "" "" "" "" 510 f2_icu_adm_num form_2e_quart_chart_review_healthcare_util "" text Number ICU Admissions (since last assessment)? "" How many ICU visits in past 3 months (or since admission if in NH < 90 days)? integer 0 93 "" "" y "" "" "" "" "" 511 f2_icu1_admit_date form_2e_quart_chart_review_healthcare_util "" text ICU 1 Admission Date "" "" date_mdy "" [f2_icu_adm_num] >= 1 y "" "" "" "" "" 512 f2_icu1_dischg_date form_2e_quart_chart_review_healthcare_util "" text ICU 1 Discharge Date "" "" date_mdy "" [f2_icu_adm_num] >= 1 y "" "" "" "" "" 513 f2_icu1_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ICU 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 514 f2_icu1_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 515 f2_icu2_admit_date form_2e_quart_chart_review_healthcare_util "" text ICU 2 Admission Date "" "" date_mdy "" [f2_icu_adm_num] >= 2 y "" "" "" "" "" 516 f2_icu2_dischg_date form_2e_quart_chart_review_healthcare_util "" text ICU 2 Discharge Date "" "" date_mdy "" [f2_icu_adm_num] >= 2 y "" "" "" "" "" 517 f2_icu2_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ICU 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 518 f2_icu2_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 519 f2_icu3_admit_date form_2e_quart_chart_review_healthcare_util "" text ICU 3 Admission Date "" "" date_mdy "" [f2_icu_adm_num] >= 3 y "" "" "" "" "" 520 f2_icu3_dischg_date form_2e_quart_chart_review_healthcare_util "" text ICU 3 Discharge Date "" "" date_mdy "" [f2_icu_adm_num] >= 3 y "" "" "" "" "" 521 f2_icu3_prim_diag form_2e_quart_chart_review_healthcare_util "" dropdown ICU 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 522 f2_icu3_prim_diag_oth form_2e_quart_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 523 f2_hospice_d form_2e_quart_chart_review_healthcare_util "" descriptive Has resident been on hospice SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 524 f2_hospice form_2e_quart_chart_review_healthcare_util "" radio Resident on Hospice 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 525 f2_hospice_start_date form_2e_quart_chart_review_healthcare_util "" text Initial Date Hospice Services Started "" What was the initial date hospice services were started? date_mdy "" [f2_hospice] = '1' y "" "" "" "" "" 526 f2_hospice_num_days_d form_2e_quart_chart_review_healthcare_util "" descriptive What 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' "" "" "" "" "" "" 527 f2_hospice_num_days form_2e_quart_chart_review_healthcare_util "" text Number hospice days "" "" integer "" [f2_hospice] = '1' y "" "" "" "" "" 528 f2_hospice_dschrg_d form_2e_quart_chart_review_healthcare_util "" descriptive Was the resident discharged from hospice SINCE LAST ASSESSMENT? "" What was the initial date hospice services were started? "" "" "" "" "" "" "" "" "" 529 f2_hospice_dschrg form_2e_quart_chart_review_healthcare_util "" radio Discharged from hospice? 0, No (no) | 1, Yes (yes) | 999, Don't know What was the initial date hospice services were started? "" "" "" y "" "" "" "" "" 530 f2_hospice_dschrg_date form_2e_quart_chart_review_healthcare_util "" text Date Hospice discharge "" What was the initial date hospice services were started? date_mdy "" [f2_hospice_dschrg] = '1' y "" "" "" "" "" 531 f2_provider_invlv_d form_2e_quart_chart_review_healthcare_util "" descriptive "
Describe involvement with care providers in the section below" "" "" "" "" "" "" "" "" "" "" "" 532 f2_np_pa_part_prim_ca_d form_2e_quart_chart_review_healthcare_util "" descriptive Does a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident? "" "" "" "" "" "" "" "" "" "" "" 533 f2_np_pa_part_prim_care form_2e_quart_chart_review_healthcare_util "" radio NP or PA Participate in Primary Care? 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 534 f2_doc_md_vsts_d form_2e_quart_chart_review_healthcare_util "" descriptive How 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) "" "" "" "" "" "" "" "" "" "" "" 535 f2_md_visits_num form_2e_quart_chart_review_healthcare_util "" text # of MD visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 536 f2_np_or_pa_visits_num form_2e_quart_chart_review_healthcare_util "" text # of NP or PA visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 537 f2_sentinal_events_d form_2f_quart_chart_review_sentinal_events "
CHART REVIEW: SENTINAL EVENTS SINCE LAST ASSESSMENT" descriptive "
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)." "" "" "" "" "" "" "" "" "" "" "" 538 f2_sent_num form_2f_quart_chart_review_sentinal_events "" text Number Sentinal Events "" Number of sentinal events since last assessment integer 0 7 "" "" y "" "" "" "" "" 539 f2_sentinal_1 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 1 1, 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] >= 1 y "" "" "" "" "" 540 f2_sent_1_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 1 other "" "" "" "" [f2_sentinal_1] = '11' and [f2_sent_num] >= 1 y "" "" "" "" "" 541 f2_sentinal1_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 1 date "" "" date_mdy "" [f2_sent_num] >= 1 y "" "" "" "" "" 542 f2_sentinal_2 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 2 1, 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] >= 2 y "" "" "" "" "" 543 f2_sent_2_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 2 other "" "" "" "" [f2_sent_num] >= 2 and [f2_sentinal_2] = '11' y "" "" "" "" "" 544 f2_sentinal2_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 2 date "" "" date_mdy "" [f2_sent_num] >= 2 y "" "" "" "" "" 545 f2_sentinal_3 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 3 1, 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] >= 3 y "" "" "" "" "" 546 f2_sent_3_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 3 Other "" "" "" "" [f2_sent_num] >= 3 and [f2_sentinal_3] = '11' y "" "" "" "" "" 547 f2_sentinal3_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 3 date "" "" date_mdy "" [f2_sent_num] >= 3 y "" "" "" "" "" 548 f2_sentinal_4 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 4 1, 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] >= 4 y "" "" "" "" "" 549 f2_sent_4_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 4 Other "" "" "" "" [f2_sent_num] >= 4 and [f2_sentinal_4] = '11' y "" "" "" "" "" 550 f2_sentinal4_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 4 date "" "" date_mdy "" [f2_sent_num] >= 4 y "" "" "" "" "" 551 f2_sentinal_5 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 5 1, 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] >= 5 y "" "" "" "" "" 552 f2_sent_5_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 5 other "" "" "" "" [f2_sent_num] >= 5 and [f2_sentinal_5] = '11' y "" "" "" "" "" 553 f2_sentinal5_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 5 date "" "" date_mdy "" [f2_sent_num] >= 5 y "" "" "" "" "" 554 f2_sentinal_6 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 6 1, 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] >= 6 y "" "" "" "" "" 555 f2_sent_6_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 6 other "" "" "" "" [f2_sent_num] >= 6 and [f2_sentinal_6] = '11' y "" "" "" "" "" 556 f2_sentinal6_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 6 date "" "" date_mdy "" [f2_sent_num] >= 6 y "" "" "" "" "" 557 f2_sentinal_7 form_2f_quart_chart_review_sentinal_events "" dropdown Sentinal Event 7 1, 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] >= 7 y "" "" "" "" "" 558 f2_sent_7_oth form_2f_quart_chart_review_sentinal_events "" text Sentinal 7 other "" "" "" "" [f2_sent_num] >= 7 and [f2_sentinal_7] = '11' y "" "" "" "" "" 559 f2_sentinal7_date form_2f_quart_chart_review_sentinal_events "" text Sentinal 7 date "" "" date_mdy "" [f2_sent_num] >= 7 y "" "" "" "" "" 560 f2_end_chart_review_d form_2f_quart_chart_review_sentinal_events "" descriptive "
END OF CHART REVIEW. " "" "" "" "" "" "" "" "" "" "" "" 561 f3_doi form_3c_death_chart_review_adv_directives "
RESIDENT DEATH ASSESSMENT" text Resident Death Chart Review Date "" "" date_mdy "" "" y "" "" "" "" "" 562 f3_ra_id form_3c_death_chart_review_adv_directives "" dropdown RA ID 1, M (1) | 2, H (2) "" "" "" "" y "" "" "" "" "" 563 f3_death_unit form_3c_death_chart_review_adv_directives "" text Unit number "" "" "" y "" y "" "" "" "" "" 564 f3_death_res_rm form_3c_death_chart_review_adv_directives "" text Room number "" "" "" y "" y "" "" "" "" "" 565 f3_death_facts_d form_3c_death_chart_review_adv_directives "" descriptive Death Facts "" "" "" "" "" "" "" "" "" "" "" 566 f3_death_date form_3c_death_chart_review_adv_directives "" text Death date "" "" date_mdy "" "" y "" "" "" "" "" 567 f3_death_site form_3c_death_chart_review_adv_directives "" radio Site of death 1, 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 "" "" "" "" "" 568 f3_death_site_oth form_3c_death_chart_review_adv_directives "" text Site of death, other "" "" alpha_only "" [f3_death_site] = '5' y "" "" "" "" "" 569 f3_nh_end_days_d form_3c_death_chart_review_adv_directives "" descriptive "How many days of the LAST 7 DAYS (0-7) OF LIFE was the resident cared for at the nursing home? (code ""999"" if unknown)" "" "" "" "" "" "" "" "" "" "" "" 570 f3_nh_end_days form_3c_death_chart_review_adv_directives "" text Number last days at NH "" "" integer 0 7 "" "" y "" "" "" "" "" 571 f3_dnr_m form_3c_death_chart_review_adv_directives "
Advance Directives (as documented in chart) Check the appropriate responses below" radio DNR 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 572 f3_dni_m form_3c_death_chart_review_adv_directives "" radio DNI 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 573 f3_dnh_m form_3c_death_chart_review_adv_directives "" radio DNH or other clear documentation of decision to avoid hospital transfer 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 574 f3_no_tube_m form_3c_death_chart_review_adv_directives "" radio No feeding tube 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 575 f3_no_iv_hydr_m form_3c_death_chart_review_adv_directives "" radio No IV hydration 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 576 f3_no_iv_antib_m form_3c_death_chart_review_adv_directives "" radio No 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) "" "" "" "" y "" "" current_advance_directives_death "" "" 577 f3_no_im_antib_m form_3c_death_chart_review_adv_directives "" radio No intramuscular antibiotics (oral still ok) 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 578 f3_no_oral_antib_m form_3c_death_chart_review_adv_directives "" radio No oral antibiotics 0, Did not have this directive when they died (0) | 1, Did have this directive when they died(1) "" "" "" "" y "" "" current_advance_directives_death "" "" 579 f3_dnr_new form_3c_death_chart_review_adv_directives "" radio DNR new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_dnr_m] = '1' y "" "" "" "" "" 580 f3_dnr_date form_3c_death_chart_review_adv_directives "" text DNR order date "" "" date_mdy "" [f3_dnr_new] = '1' y "" "" "" "" "" 581 f3_dni_new form_3c_death_chart_review_adv_directives "" radio DNI new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_dni_m] = '1' y "" "" "" "" "" 582 f3_dni_date form_3c_death_chart_review_adv_directives "" text DNI order date "" "" date_mdy "" [f3_dni_new] = '1' y "" "" "" "" "" 583 f3_dnh_new form_3c_death_chart_review_adv_directives "" radio DNH new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_dnh_m] = '1' y "" "" "" "" "" 584 f3_dnh_date form_3c_death_chart_review_adv_directives "" text DNH order date "" "" date_mdy "" [f3_dnh_new] = '1' y "" "" "" "" "" 585 f3_no_tube_new form_3c_death_chart_review_adv_directives "" radio No feeding tube new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_no_tube_m] = '1' y "" "" "" "" "" 586 f3_no_tube_date form_3c_death_chart_review_adv_directives "" text No feeding tube date "" "" date_mdy "" [f3_no_tube_new] = '1' y "" "" "" "" "" 587 f3_no_iv_hydr_new form_3c_death_chart_review_adv_directives "" radio No IV hydration new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_no_iv_hydr_m] = '1' y "" "" "" "" "" 588 f3_no_iv_hydr_date form_3c_death_chart_review_adv_directives "" text No IV hydration date "" "" date_mdy "" [f3_no_iv_hydr_new] = '1' y "" "" "" "" "" 589 f3_no_iv_antib_new form_3c_death_chart_review_adv_directives "" radio No IV antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_no_iv_antib_m] = '1' y "" "" "" "" "" 590 f3_no_iv_antib_date form_3c_death_chart_review_adv_directives "" text No IV antibiotic (oral or intramuscular still ok) date "" "" date_mdy "" [f3_no_iv_antib_new] = '1' y "" "" "" "" "" 591 f3_no_im_antib_new form_3c_death_chart_review_adv_directives "" radio No intramuscular antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_no_im_antib_m] = '1' y "" "" "" "" "" 592 f3_no_im_antib_date form_3c_death_chart_review_adv_directives "" text No intramuscular antibiotics date "" "" date_mdy "" [f3_no_im_antib_new] = '1' y "" "" "" "" "" 593 f3_no_oral_antib_new form_3c_death_chart_review_adv_directives "" radio No oral antibiotics new since last assessment? 0, No (0) | 1, Yes (1) "" "" "" [f3_no_oral_antib_m] = '1' y "" "" "" "" "" 594 f3_no_oral_antib_date form_3c_death_chart_review_adv_directives "" text No oral antibiotics date "" "" date_mdy "" [f3_no_oral_antib_new] = '1' y "" "" "" "" "" 595 f3_doc_disc_d form_3c_death_chart_review_adv_directives "" descriptive Is 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? "" "" "" "" "" "" "" "" "" "" "" 596 f3_doc_disc_goc form_3c_death_chart_review_adv_directives "" radio Documented Discussion of Goals of Medical Care 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 597 f3_discuss_prvdr form_3c_death_chart_review_adv_directives "" checkbox Provider/s that had documented goals of care discussions with Proxy 1, 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 "" "" "" "" "" 598 f3_discuss_prvdr_oth form_3c_death_chart_review_adv_directives "" text Other provider with documented goals of care discussions with proxy "" "" "" "" [f3_doc_disc_goc] = '1' and [f3_discuss_prvdr(8)] = '1' y "" "" "" "" "" 599 f3_doc_goals_descript_d form_3c_death_chart_review_adv_directives "" descriptive Please elaborate on discussion details below "" "" "" "" [f3_doc_disc_goc] = '1' "" "" "" "" "" "" 600 f3_doc_goals form_3c_death_chart_review_adv_directives "" notes Documented discussions about the goals of care "" "" "" "" [f3_doc_disc_goc] = '1' "" "" "" "" "" "" 601 f3_peg_tube form_3d_death_chart_review_trtmntsinv "
CHART REVIEW: TREATMENTS" radio Did 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 "" "" "" "" "" 602 f3_peg_new form_3d_death_chart_review_trtmntsinv "" radio PEG tube is new SINCE LAST ASSESSMENT? 0, no (0) | 1, yes (1) | 999, don't know (999) "" "" "" [f3_peg_tube] = '1' y "" "" "" "" "" 603 f3_n_peg_date_d form_3d_death_chart_review_trtmntsinv "" descriptive If PEG tube is new SINCE LAST ASSESSMENT, what was the date it was placed? "" "" "" "" [f3_peg_new] = '1' "" "" "" "" "" "" 604 f3_peg_date_in form_3d_death_chart_review_trtmntsinv "" text Date PEG tube inserted "" "" date_mdy "" [f3_peg_new] = '1' y "" "" "" "" "" 605 f3_peg_in_how form_3d_death_chart_review_trtmntsinv "" radio How 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 "" "" "" "" "" 606 f3_peg_in_oth form_3d_death_chart_review_trtmntsinv "" text PEG placement, other "" "" "" "" [f3_peg_in_how] = '3' y "" "" "" "" "" 607 f3_catheter_d form_3d_death_chart_review_trtmntsinv "" descriptive Has the resident had an indwelling bladder catheter SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 608 f3_catheter form_3d_death_chart_review_trtmntsinv "" radio Indwelling bladder Catheter? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 609 f3_date_cath_d form_3d_death_chart_review_trtmntsinv "" descriptive "For how many days did the resident have an indwelling bladder catheter SINCE LAST ASSESSMENT? Code 999 for ""Don't know""" "" "" "" "" [f3_catheter] = '1' "" "" "" "" "" "" 610 f3_cath_days form_3d_death_chart_review_trtmntsinv "" text Indwelling Catheter days "" "" integer 0 999 "" [f3_catheter] = '1' y "" "" "" "" "" 611 f3_date_cath_d2_d form_3d_death_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 612 f3_cath_days_final form_3d_death_chart_review_trtmntsinv "" text Indwelling Catheter final days "" "" integer 0 7 "" [f3_catheter] = '1' y "" "" "" "" "" 613 f3_periph_iv_acc_d form_3d_death_chart_review_trtmntsinv "" descriptive Has the resident had peripheral intravenous access or therapy SINCE LAST ASSESSMENT "" "" "" "" "" "" "" "" "" "" "" 614 f3_peri_intra_ther form_3d_death_chart_review_trtmntsinv "" radio Peripheral intravenous access or therapy? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 615 f3_peri_intra_days_d form_3d_death_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 616 f3_peri_intra_days form_3d_death_chart_review_trtmntsinv "" text Days of peripheral IV "" Days of peripheral IV access or therapy SINCE LAST ASSESSMENT integer 0 999 "" [f3_peri_intra_ther] = '1' y "" "" "" "" "" 617 f3_peri_intra_days_d2_d form_3d_death_chart_review_trtmntsinv "" descriptive "For 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' "" "" "" "" "" "" 618 f3_peri_intra_days_final form_3d_death_chart_review_trtmntsinv "" text Days peripheral IV, final "" Days of peripheral IV in last 7 days integer 0 7 "" [f3_peri_intra_ther] = '1' y "" "" "" "" "" 619 f3_vent_d form_3d_death_chart_review_trtmntsinv "" descriptive Has the resident been on a ventilator SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 620 f3_vent form_3d_death_chart_review_trtmntsinv "" radio Ventilator (past 3 months)? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 621 f3_vent_days_d form_3d_death_chart_review_trtmntsinv "" descriptive "For how many days was the resident on a ventilator SINCE LAST ASSESSMENT? Code 999 for ""Don't know""" "" "" "" "" [f3_vent] = '1' "" "" "" "" "" "" 622 f3_vent_days form_3d_death_chart_review_trtmntsinv "" text Ventilator (# days in past 3 months)? "" "" integer 0 999 "" [f3_vent] = '1' y "" "" "" "" "" 623 f3_vent_days_f_d form_3d_death_chart_review_trtmntsinv "" descriptive "For how many days was the resident on a ventilator DURING LAST 7 DAYS? Code 999 for ""Don't know""" "" "" "" "" [f3_vent] = '1' "" "" "" "" "" "" 624 f3_vent_days_final form_3d_death_chart_review_trtmntsinv "" text Ventilator (# days in last 7 days)? "" "" integer 0 7 "" [f3_vent] = '1' y "" "" "" "" "" 625 f3_venipunct_num_d form_3d_death_chart_review_trtmntsinv "
CHART REVIEW: INVESTIGATIONS" descriptive "SINCE LAST ASSESSMENT, how many venipunctures were done? (Each blood draw means a separate venipuncture) Code 999 for (Don't know)" "" "" "" "" "" "" "" "" "" "" "" 626 f3_venipunct_num form_3d_death_chart_review_trtmntsinv "" text Venipunctures (total # in past 3 months)? "" "" integer 0 999 "" "" y "" "" "" "" "" 627 f3_venipunct_num_f_d form_3d_death_chart_review_trtmntsinv "" descriptive "IN LAST 7 DAYS OF LIFE, how many venipunctures were done? (Each blood draw means a separate venipuncture) Code 999 for (Don't know)" "" "" "" "" "" "" "" "" "" "" "" 628 f3_venipunct_num_f form_3d_death_chart_review_trtmntsinv "" text Venipunctures (total # in LAST 7 DAYS) "" "" integer 0 7 "" "" y "" "" "" "" "" 629 f3_hosp_dets_d form_3e_death_chart_review_healthcare_util "
CHART REVIEW: HEALTH SERVICES UTILIZATION" descriptive "
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)" "" "" "" "" "" "" "" "" "" "" "" 630 f3_hosp_adm_num form_3e_death_chart_review_healthcare_util "" text Hospital Admissions (since last assessment)? "" How many hospital admissions SINCE LAST ASSESSMENT integer 0 93 "" "" y "" "" "" "" "" 631 f3_hosp1_admit_date form_3e_death_chart_review_healthcare_util "" text Hospital 1 Admission Date "" "" date_mdy "" [f3_hosp_adm_num] >= 1 y "" "" "" "" "" 632 f3_hosp1_dischg_date form_3e_death_chart_review_healthcare_util "" text Hospital 1 Discharge Date "" "" date_mdy "" [f3_hosp_adm_num] >= 1 y "" "" "" "" "" 633 f3_hosp1_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 634 f3_hosp1_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 635 f3_hosp1_scnd_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 1 Secondary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 636 f3_hosp1_scnd_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 637 f3_hosp2_admit_date form_3e_death_chart_review_healthcare_util "" text Hospital 2 Admission Date "" "" date_mdy "" [f3_hosp_adm_num] >= 2 y "" "" "" "" "" 638 f3_hosp2_dischg_date form_3e_death_chart_review_healthcare_util "" text Hospital 2 Discharge Date "" "" date_mdy "" [f3_hosp_adm_num] >= 2 y "" "" "" "" "" 639 f3_hosp2_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 640 f3_hosp2_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 641 f3_hosp2_scnd_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 2 Secondary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 642 f3_hosp2_scnd_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 643 f3_hosp3_admit_date form_3e_death_chart_review_healthcare_util "" text Hospital 3 Admission Date "" "" date_mdy "" [f3_hosp_adm_num] >= 3 y "" "" "" "" "" 644 f3_hosp3_dischg_date form_3e_death_chart_review_healthcare_util "" text Hospital 3 Discharge Date "" "" date_mdy "" [f3_hosp_adm_num] >= 3 y "" "" "" "" "" 645 f3_hosp3_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 646 f3_hosp3_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 647 f3_hosp3_scnd_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 3 Secondary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 648 f3_hosp3_scnd_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 649 f3_hosp4_admit_date form_3e_death_chart_review_healthcare_util "" text Hospital 4 Admission Date "" "" date_mdy "" [f3_hosp_adm_num] >= 4 y "" "" "" "" "" 650 f3_hosp4_dischg_date form_3e_death_chart_review_healthcare_util "" text Hospital 4 Discharge Date "" "" date_mdy "" [f3_hosp_adm_num] >= 4 y "" "" "" "" "" 651 f3_hosp4_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 652 f3_hosp4_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 653 f3_hosp4_scnd_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 4 Secondary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 654 f3_hosp4_scnd_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 655 f3_hosp5_admit_date form_3e_death_chart_review_healthcare_util "" text Hospital 5 Admission Date "" "" date_mdy "" [f3_hosp_adm_num] >= 5 y "" "" "" "" "" 656 f3_hosp5_dischg_date form_3e_death_chart_review_healthcare_util "" text Hospital 5 Discharge Date "" "" date_mdy "" [f3_hosp_adm_num] >= 5 y "" "" "" "" "" 657 f3_hosp5_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 658 f3_hosp5_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 659 f3_hosp5_scnd_diag form_3e_death_chart_review_healthcare_util "" dropdown Hospital 5 Secondary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 660 f3_hosp5_scnd_diag_oth form_3e_death_chart_review_healthcare_util "" text Hospital 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 "" "" "" "" "" 661 f3_er_info form_3e_death_chart_review_healthcare_util "" descriptive "
Describe all Emergency Room Visits WITHOUT HOSPITALIZATION, SINCE LAST ASSESSMENT in the section below." "" "" "" "" "" "" "" "" "" "" "" 662 f3_er_adm_num form_3e_death_chart_review_healthcare_util "" text Number ER Visits (since last assessment)? "" How many ER visits SINCE LAST ASSESSMENT integer 0 93 "" "" y "" "" "" "" "" 663 f3_er1_date form_3e_death_chart_review_healthcare_util "" text ER Visit 1 Date "" "" date_mdy "" [f3_er_adm_num] >= 1 y "" "" "" "" "" 664 f3_er1_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ER Visit 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 665 f3_er1_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 666 f3_er2_date form_3e_death_chart_review_healthcare_util "" text ER Visit 2 Date "" "" date_mdy "" [f3_er_adm_num] >= 2 y "" "" "" "" "" 667 f3_er2_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ER Visit 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 668 f3_er2_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 669 f3_er3_date form_3e_death_chart_review_healthcare_util "" text ER Visit 3 Date "" "" date_mdy "" [f3_er_adm_num] >= 3 y "" "" "" "" "" 670 f3_er3_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ER Visit 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 671 f3_er3_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 672 f3_er4_date form_3e_death_chart_review_healthcare_util "" text ER Visit 4 Date "" "" date_mdy "" [f3_er_adm_num] >= 4 y "" "" "" "" "" 673 f3_er4_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ER Visit 4 Primary Diagnosis 101, 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] >= 4 y "" "" "" "" "" 674 f3_er4_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 675 f3_er5_date form_3e_death_chart_review_healthcare_util "" text ER Visit 5 Date "" "" date_mdy "" [f3_er_adm_num] >= 5 y "" "" "" "" "" 676 f3_er5_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ER Visit 5 Primary Diagnosis 101, 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] >= 5 y "" "" "" "" "" 677 f3_er5_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ER 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 "" "" "" "" "" 678 f3_icu_info_d form_3e_death_chart_review_healthcare_util "" descriptive "
Describe all ICU Admissions SINCE LAST ASSESSMENT, in the section below." "" "" "" "" "" "" "" "" "" "" "" 679 f3_icu_adm_num form_3e_death_chart_review_healthcare_util "" text Number ICU Admissions (since last assessment)? "" How many ICU visits SINCE LAST ASSESSMENT integer 0 93 "" "" y "" "" "" "" "" 680 f3_icu1_admit_date form_3e_death_chart_review_healthcare_util "" text ICU 1 Admission Date "" "" date_mdy "" [f3_icu_adm_num] >= 1 y "" "" "" "" "" 681 f3_icu1_dischg_date form_3e_death_chart_review_healthcare_util "" text ICU 1 Discharge Date "" "" date_mdy "" [f3_icu_adm_num] >= 1 y "" "" "" "" "" 682 f3_icu1_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ICU 1 Primary Diagnosis 101, 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] >= 1 y "" "" "" "" "" 683 f3_icu1_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 684 f3_icu2_admit_date form_3e_death_chart_review_healthcare_util "" text ICU 2 Admission Date "" "" date_mdy "" [f3_icu_adm_num] >= 2 y "" "" "" "" "" 685 f3_icu2_dischg_date form_3e_death_chart_review_healthcare_util "" text ICU 2 Discharge Date "" "" date_mdy "" [f3_icu_adm_num] >= 2 y "" "" "" "" "" 686 f3_icu2_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ICU 2 Primary Diagnosis 101, 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] >= 2 y "" "" "" "" "" 687 f3_icu2_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 688 f3_icu3_admit_date form_3e_death_chart_review_healthcare_util "" text ICU 3 Admission Date "" "" date_mdy "" [f3_icu_adm_num] >= 3 y "" "" "" "" "" 689 f3_icu3_dischg_date form_3e_death_chart_review_healthcare_util "" text ICU 3 Discharge Date "" "" date_mdy "" [f3_icu_adm_num] >= 3 y "" "" "" "" "" 690 f3_icu3_prim_diag form_3e_death_chart_review_healthcare_util "" dropdown ICU 3 Primary Diagnosis 101, 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] >= 3 y "" "" "" "" "" 691 f3_icu3_prim_diag_oth form_3e_death_chart_review_healthcare_util "" text ICU 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 "" "" "" "" "" 692 f3_hospice_d form_3e_death_chart_review_healthcare_util "" descriptive Has resident been on hospice SINCE LAST ASSESSMENT? "" "" "" "" "" "" "" "" "" "" "" 693 f3_hospice form_3e_death_chart_review_healthcare_util "" radio Resident on Hospice 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 694 f3_hospice_start_date form_3e_death_chart_review_healthcare_util "" text Initial Date Hospice Services Started "" What was the initial date hospice services were started? date_mdy "" [f3_hospice] = '1' y "" "" "" "" "" 695 f3_hospice_num_days_d form_3e_death_chart_review_healthcare_util "" descriptive What 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' "" "" "" "" "" "" 696 f3_hospice_num_days form_3e_death_chart_review_healthcare_util "" text Number hospice days "" "" integer "" [f3_hospice] = '1' y "" "" "" "" "" 697 f3_hospice_last_days_d form_3e_death_chart_review_healthcare_util "" descriptive What was the total number of days enrolled in Hospice DURING THE LAST WEEK OF LIFE? "" What was the initial date hospice services were started? "" "" "" "" "" "" "" "" "" 698 f3_hospice_last_days form_3e_death_chart_review_healthcare_util "" text Number hospice days of last 7 "" What was the initial date hospice services were started? integer 0 7 "" "" y "" "" "" "" "" 699 f3_provider_invlv_d form_3e_death_chart_review_healthcare_util "" descriptive "
Describe involvement with care providers in the section below" "" "" "" "" "" "" "" "" "" "" "" 700 f3_np_pa_part_prim_ca_d form_3e_death_chart_review_healthcare_util "" descriptive Does a Nurse Practitioner (NP) or Physician's Assistant (PA) participant in the primary care of the resident? "" "" "" "" "" "" "" "" "" "" "" 701 f3_np_pa_part_prim_care form_3e_death_chart_review_healthcare_util "" radio NP or PA Participate in Primary Care? 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 702 f3_doc_md_vsts_d form_3e_death_chart_review_healthcare_util "" descriptive How 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) "" "" "" "" "" "" "" "" "" "" "" 703 f3_md_visits_num form_3e_death_chart_review_healthcare_util "" text # of MD visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 704 f3_np_or_pa_visits_num form_3e_death_chart_review_healthcare_util "" text # of NP or PA visits (last 3 months) "" "" number 0 93 "" "" y "" "" "" "" "" 705 f3_doc_num_nppa_d form_3e_death_chart_review_healthcare_util "" descriptive How 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? "" "" "" "" "" "" "" "" "" "" "" 706 f3_md_visit_num_f form_3e_death_chart_review_healthcare_util "" text Number MD visits "" "" integer 0 7 "" "" y "" "" "" "" "" 707 f3_np_or_pa_visits_num_f form_3e_death_chart_review_healthcare_util "" text Number NP or PA visits "" "" integer 0 7 "" "" y "" "" "" "" "" 708 f3_sentinal_events_d form_3f_death_chart_review_sentinal_events "
CHART REVIEW: SENTINAL EVENTS SINCE LAST ASSESSMENT" descriptive "
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)." "" "" "" "" "" "" "" "" "" "" "" 709 f3_sent_num form_3f_death_chart_review_sentinal_events "" text Number Sentinal Events "" Number of sentinal events since last assessment integer 0 7 "" "" y "" "" "" "" "" 710 f3_sentinal_1 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 1 1, 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 "" "" "" "" "" "" 711 f3_sent_1_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 1 other "" "" "" "" [f3_sentinal_1] = '11' and [f3_sent_num] >= 1 y "" "" "" "" "" 712 f3_sentinal1_date form_3f_death_chart_review_sentinal_events "" text Sentinal 1 date "" "" date_mdy "" [f3_sent_num] >= 1 y "" "" "" "" "" 713 f3_sentinal_2 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 2 1, 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] >= 2 y "" "" "" "" "" 714 f3_sent_2_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 2 other "" "" "" "" [f3_sent_num] >= 2 and [f3_sentinal_2] = '11' y "" "" "" "" "" 715 f3_sentinal2_date form_3f_death_chart_review_sentinal_events "" text Sentinal 2 date "" "" date_mdy "" [f3_sent_num] >= 2 y "" "" "" "" "" 716 f3_sentinal_3 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 3 1, 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] >= 3 y "" "" "" "" "" 717 f3_sent_3_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 3 Other "" "" "" "" [f3_sent_num] >= 3 and [f3_sentinal_3] = '11' y "" "" "" "" "" 718 f3_sentinal3_date form_3f_death_chart_review_sentinal_events "" text Sentinal 3 date "" "" date_mdy "" [f3_sent_num] >= 3 y "" "" "" "" "" 719 f3_sentinal_4 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 4 1, 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] >= 4 y "" "" "" "" "" 720 f3_sent_4_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 4 Other "" "" "" "" [f3_sent_num] >= 4 and [f3_sentinal_4] = '11' y "" "" "" "" "" 721 f3_sentinal4_date form_3f_death_chart_review_sentinal_events "" text Sentinal 4 date "" "" date_mdy "" [f3_sent_num] >= 4 y "" "" "" "" "" 722 f3_sentinal_5 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 5 1, 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] >= 5 y "" "" "" "" "" 723 f3_sent_5_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 5 other "" "" "" "" [f3_sent_num] >= 5 and [f3_sentinal_5] = '11' y "" "" "" "" "" 724 f3_sentinal5_date form_3f_death_chart_review_sentinal_events "" text Sentinal 5 date "" "" date_mdy "" [f3_sent_num] >= 5 y "" "" "" "" "" 725 f3_sentinal_6 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 6 1, 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] >= 6 y "" "" "" "" "" 726 f3_sent_6_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 6 other "" "" "" "" [f3_sent_num] >= 6 and [f3_sentinal_6] = '11' y "" "" "" "" "" 727 f3_sentinal6_date form_3f_death_chart_review_sentinal_events "" text Sentinal 6 date "" "" date_mdy "" [f3_sent_num] >= 6 y "" "" "" "" "" 728 f3_sentinal_7 form_3f_death_chart_review_sentinal_events "" dropdown Sentinal Event 7 1, 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] >= 7 y "" "" "" "" "" 729 f3_sent_7_oth form_3f_death_chart_review_sentinal_events "" text Sentinal 7 other "" "" "" "" [f3_sent_num] >= 7 and [f3_sentinal_7] = '11' y "" "" "" "" "" 730 f3_sentinal7_date form_3f_death_chart_review_sentinal_events "" text Sentinal 7 date "" "" date_mdy "" [f3_sent_num] >= 7 y "" "" "" "" "" 731 f3_end_chart_review_d form_3f_death_chart_review_sentinal_events "" descriptive "
END OF CHART REVIEW. " "" "" "" "" "" "" "" "" "" "" "" 732 f4_doi form_4_proxy_baseline "" text "
Proxy Baseline date" "" "" date_mdy "" "" y "" "" "" "" "" 733 f4_int_stat form_4_proxy_baseline "" radio "
Refused baseline?" 1, Agrees to do baseline (1) | 2, Refuses baseline (2) "" "" "" "" "" "" "" "" "" "" 734 f4_ra_id form_4_proxy_baseline "" dropdown "
RA ID" 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 735 f4_prxy_d form_4_proxy_baseline "
Begin Proxy Baseline Interview" descriptive "
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?
" "" "" "" "" "" "" "" "" "" "" "" 736 f4_prxy_relation_d form_4_proxy_baseline "" descriptive "
What is your relation to [resident]?" "" "" "" "" "" "" "" "" "" "" "" 737 f4_prxy_relation form_4_proxy_baseline "" radio "
Proxy relation to resident" 1, 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 "" "" "" "" "" 738 f4_prxy_relation_oth form_4_proxy_baseline "" text "
Proxy relation to resident, other" "" "" "" "" [f4_prxy_relation] = '11' y "" "" "" "" "" 739 f4_live_with_prior_nh_d form_4_proxy_baseline "" descriptive "
Did you live with resident prior to NH admission?" "" "" "" "" "" "" "" "" "" "" "" 740 f4_live_with_prior_nh form_4_proxy_baseline "" radio "
Live with prior" 0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Unknown (999) "" "" "" "" y "" "" "" "" "" 741 f4_live_le_1hour_nh_d form_4_proxy_baseline "" descriptive "
Do you live within a 1-hour car drive from [RESIDENT'S] nursing home? " "" "" "" "" "" "" "" "" "" "" "" 742 f4_live_le_1hour_nh form_4_proxy_baseline "" radio "
Within a 1-hour " 0, No (0) | 1, Yes (1) | 888, Refused (888) "" "" "" "" y "" "" "" "" "" 743 f4_num_hrs_visit_res_nh_d form_4_proxy_baseline "" descriptive "
Approximately how many hours a week do you currently spend visiting (resident) at the nursing home?" "" "" "" "" "" "" "" "" "" "" "" 744 f4_num_hrs_visit_res_nh form_4_proxy_baseline "" radio "
Hours visiting" 0, 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 "" "" "" "" "" 745 f4_yrs_diag_dement_d form_4_proxy_baseline "" descriptive "
To the best of your knowledge, how many years ago did [RESIDENT] receive a diagnosis of dementia? (code: refusal ""888""; don't know ""999"")" "" "" "" "" "" "" "" "" "" "" "" 746 f4_yrs_diag_dement form_4_proxy_baseline "" text "
Years diagnosis dementia" "" "" number 1 999 "" "" y "" "" "" "" "" 747 f4_descript6 form_4_proxy_baseline "
ADVANCE CARE PLANNING: I would now like to ask you a few questions about your role as the health care proxy for [RESIDENT]. " descriptive "
How long have you been the designated health care proxy for (resident) (code: refusal ""888""; don't know ""999"")" "" "" "" "" "" "" "" "" "" "" "" 748 f4_time_hcp form_4_proxy_baseline "" text "
Time as proxy (years)" "" "" number 1 999 "" "" y "" "" "" "" "" 749 f4_prxy_care_pref_d form_4_proxy_baseline "" descriptive "
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. " "" "" "" "" "" "" "" "" "" "" "" 750 f4_res_pref_loc_d form_4_proxy_baseline "" descriptive "
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?" "" "" "" "" "" "" "" "" "" "" "" 751 f4_res_pref_loc form_4_proxy_baseline "" radio "
Level resident would want" 1, Intensive medical care (1) | 2, Basic medical care (2) | 3, Comfort care (3) | 888, Refused (888) | 999, Unknown (999) "" "" "" "" y "" "" "" "" "" 752 f4_prvdr_ask_prxy_opin_d form_4_proxy_baseline "" descriptive "
Since being in the nursing home, has any health care provider asked your opinion regarding the goals of [RESIDENT's] medical care?" "" "" "" "" "" "" "" "" "" "" "" 753 f4_prvdr_ask_prxy_opin form_4_proxy_baseline "" radio "
Provider asked opinion " 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 754 f4_prvdr_disc_trtmnts_d form_4_proxy_baseline "" descriptive "
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?" "" "" "" "" "" "" "" "" "" "" "" 755 f4_prvdr_disc_trtmnts form_4_proxy_baseline "" radio "
Provider Discussion? " 0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 756 f4_who_init_discuss_d form_4_proxy_baseline "" descriptive "
Who initiated this discussion, you or the health care provider?" "" "" "" "" [f4_prvdr_disc_trtmnts] = '1' "" "" "" "" "" "" 757 f4_who_init_discuss form_4_proxy_baseline "" radio "
Discussion initiator" 1, 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 "" "" "" "" "" 758 f4_discuss_prvdr_d form_4_proxy_baseline "" descriptive "
Who was the health provider with whom you had this discussion? " "" "" "" "" [f4_prvdr_disc_trtmnts] = '1' "" "" "" "" "" "" 759 f4_discuss_prvdr form_4_proxy_baseline "" checkbox "
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 "" "" "" "" "" 760 f4_discuss_prvdr_oth_d form_4_proxy_baseline "" descriptive "
Who was the ""other"" provider with whom you discussed residents goals of care?" "" "" "" "" [f4_discuss_prvdr(9)] = '1' "" "" "" "" "" "" 761 f4_discuss_prvdr_oth form_4_proxy_baseline "" text "
Other provider discussion" "" "" "" "" [f4_discuss_prvdr(9)] = '1' y "" "" "" "" "" 762 f4_phys_disc_hlth_prob_d form_4_proxy_baseline "" descriptive "
Has any physician ever counseled you about what types of health problems [RESIDENT] may experience in the later stages of dementia?" "" "" "" "" "" "" "" "" "" "" "" 763 f4_phys_disc_hlth_prob form_4_proxy_baseline "" radio "
Physician counseled " 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 764 f4_prxy_undst_future_d form_4_proxy_baseline "" descriptive "
Do you believe you have a good understanding of the types of health problems [RESIDENT] may experience in the later stages of dementia?" "" "" "" "" "" "" "" "" "" "" "" 765 f4_prxy_undst_future form_4_proxy_baseline "" radio "
Proxy understanding" 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 766 f4_partic_trtmnt_decis_d form_4_proxy_baseline "" descriptive "
Have you ever participated in treatment decisions for resident?" "" "" "" "" "" "" "" "" "" "" "" 767 f4_partic_trtmnt_decis form_4_proxy_baseline "" radio "
Treatment decisions " 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 768 f4_res_life_left_d form_4_proxy_baseline "" descriptive "
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? " "" "" "" "" "" "" "" "" "" "" "" 769 f4_res_life_left form_4_proxy_baseline "" radio "
Near to end of life" 1, < 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 "" "" "" "" "" 770 f4_undst_res_hlth_wish_d form_4_proxy_baseline "" descriptive "
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." "" "" "" "" "" "" "" "" "" "" "" 771 f4_undst_res_hlth_wish form_4_proxy_baseline "" radio "
Confident of understanding" 1, Very confident (1) | 2, Somewhat confident (2) | 3, Not confident at all (3) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 772 f4_prxy_demographics form_4_proxy_baseline "" descriptive "
At this time, I would like to ask you a few questions about yourself." "" "" "" "" "" "" "" "" "" "" "" 773 f4_prxy_dob form_4_proxy_baseline "" text "
Proxy birthdate" "" "" date_mdy "" "" "" "" "" "" "" "" 774 f4_prox_dob_na form_4_proxy_baseline "" radio Proxy Birthday available? 0, DOB not available (refused to answer)(0) | 1, DOB available and recorded (1) "" "" "" [f4_prxy_dob] = '' y "" "" "" "" "" 775 f4_prxy_gndr form_4_proxy_baseline "" radio "
Proxy gender" 1, Male | 2, Female "" "" "" "" y "" "" "" "" "" 776 f4_prxy_eductn form_4_proxy_baseline "" radio "
Proxy education" 1, 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 "" "" "" "" "" 777 f4_prxy_race form_4_proxy_baseline "" radio "
Prxy Racial Group" 1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 3, Other (3) | 888, Refused (888) | 999, Not available (999) "" "" "" "" y "" "" "" "" "" 778 f4_prxy_race_oth form_4_proxy_baseline "" text "
Prxy Racial Group, other" "" "" "" "" [f4_prxy_race] = '3' "" "" "" "" "" "" 779 f4_prxy_ethnic form_4_proxy_baseline "" radio "
Proxy Ethnicity" 1, 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 "" "" "" "" "" 780 f4_prxy_ethnic_oth form_4_proxy_baseline "" text "
Proxy Ethnicity Other" "" "" "" "" [f4_prxy_ethnic] = '6' y "" "" "" "" "" 781 f4_prxy_prim_lang form_4_proxy_baseline "" radio "
Proxy primary language" 1, 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 "" "" "" "" "" 782 f4_prxy_prim_lang_oth form_4_proxy_baseline "" text "
Proxy primary language (other)" "" What is the prxyident primary language? (from MDS) "" "" [f4_prxy_prim_lang] = '9' y "" "" "" "" "" 783 f4_prxy_rel_bkgrnd form_4_proxy_baseline "" radio "
Proxy religious background" 1, 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 "" "" "" "" "" 784 f4_prxy_rel_bkgrnd_oth form_4_proxy_baseline "" text "
Proxy religious background (other)" "" What is the prxyident religious background, if other? "" "" [f4_prxy_rel_bkgrnd] = '7' y "" "" "" "" "" 785 f4_prxy_rel_imp form_4_proxy_baseline "" descriptive "
How important is faith or spirituality to you?" "" What is the prxyident's religious background? "" "" "" "" "" "" "" "" "" 786 f4_prxy_rel_how_imp form_4_proxy_baseline "" radio "
Importance of Faith" 1, Very important (1) | 2, Somewhat important (2) | 3, Not at all important (3) | 888, Refused (888) | 999, Unknown (999) "" "" "" "" y "" "" "" "" "" 787 f4_prxy_mar_stat form_4_proxy_baseline "" radio "
Proxy Marital Status" 1, 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 "" "" "" "" "" 788 f4_comf_talk_illness_d form_4_proxy_baseline "" descriptive "
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" "" "" "" "" "" "" "" "" "" "" "" 789 f4_comf_talk_illness form_4_proxy_baseline "" radio "
Proxy interview comfort" 1, Very comfortable (1) | 2, Comfortable (2) | 3, A little uncomfortable (3) | 4, Very uncomfortable (4) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 790 f4_addnl_thoughts_d form_4_proxy_baseline "" descriptive "
Do you have any additional thoughts about what we have discussed that you would like to add?" "" "" "" "" "" "" "" "" "" "" "" 791 f4_addnl_thoughts form_4_proxy_baseline "" radio "
Proxy additional thoughts " 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 792 f4_add_thoughts form_4_proxy_baseline "" notes "
Additional thoughts or questions?" "" "" "" "" [f4_addnl_thoughts] = '1' y "" "" "" "" "" 793 f4_proxy_v_d form_4_proxy_baseline "" descriptive "
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 VIDEO" "" Was the video shown to the Proxy? "" "" [proxy_eligibility_arm_1][f0p_study_assign] = '1' "" "" "" "" "" "" 794 f4_video form_4_proxy_baseline "" radio "
Video Shown?" 0, No (0) | 1, Yes (1) Was the video shown to the Proxy? "" "" [proxy_eligibility_arm_1][f0p_study_assign] = '1' y "" "" "" "" "" 795 f4_post_video_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 796 f4_post_video_loc form_4_proxy_baseline "" radio "
Level of care resident would want" 1, 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 "" "" "" "" "" 797 f4_conclusion_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 798 f4_prxy_pstvd_comfort form_4_proxy_baseline "" radio "
Proxy video comfort" 1, 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 "" "" "" "" "" 799 f4_video_helpful_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 800 f4_video_helpful form_4_proxy_baseline "" radio "
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 "" "" "" "" "" 801 f4_video_not_helpful_d form_4_proxy_baseline "" descriptive "
If the video was not helpful, why was it not? (check all that apply)" "" "" "" "" [f4_video_helpful] = '4' "" "" "" "" "" "" 802 f4_video_not_helpful form_4_proxy_baseline "" checkbox "
Video not helpful" 1, 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 "" "" "" "" "" 803 f4_video_not_helpful_oth form_4_proxy_baseline "" text "
Video not helpful, other" "" "" "" "" [f4_video_not_helpful(3)] = '1' y "" "" "" "" "" 804 f4_rec_video_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 805 f4_rec_video form_4_proxy_baseline "" radio "
Recommend video" 1, 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 "" "" "" "" "" 806 f4_prxy_addl_thoughts_d form_4_proxy_baseline "" descriptive "
Do you have any additional thoughts about what we have discussed that you would like to add?" "" "" "" "" [f4_video] = '1' "" "" "" "" "" "" 807 f4_prxy_addl form_4_proxy_baseline "" radio "
Additional thoughts?" 0, No (0) | 1, Yes (1) "" "" "" [f4_video] = '1' y "" "" "" "" "" 808 f4_prxy_addl_thoughts form_4_proxy_baseline "" notes "
Proxy additional thoughts" "" "" "" "" [f4_prxy_addl] = '1' "" "" "" "" "" "" 809 f4_anyquestions_2_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 810 f4_anyquestions_1_d form_4_proxy_baseline "" descriptive "
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' "" "" "" "" "" "" 811 ff_ra_id form_ff_feedback_form "" dropdown "
RA ID" 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 812 ff_feedback_date form_ff_feedback_form "" text "
Feedback date" "" "" date_mdy "" "" y "" "" "" "" "" 813 ff_feedback_d form_ff_feedback_form "" descriptive "
[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" "" "" "" "" "" "" "" "" "" "" "" 814 ff_pref_loc form_ff_feedback_form "" radio "
Preferred Level of Care" 1, Intensive Medical Care (1) | 2, Basic Medical Care (2) | 3, Comfort care (3) | 888, Refused to answer (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 815 ff_feedback_conc_d form_ff_feedback_form "" descriptive "
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 " "" "" "" "" "" "" "" "" "" "" "" 816 f6_int_stat form_6_proxy_quarterly "" dropdown Interview Status 1, Complete (1) | 2, Refused assessment (2) | 3, Cannot contact (3) | 4, Resident Died (4) | 6, HCP drops out (6) | 7, HCP died (7) "" "" "" "" y "" "" "" "" "" 817 f6_keep_res form_6_proxy_quarterly "" radio Can we continue to include [resident] in the study? 0, No (0) | 1, Yes (1) "" "" "" [f6_int_stat] = '6' y "" "" "" "" "" 818 f6_hcp_doi form_6_proxy_quarterly "" text "
Proxy quarterly DOI" "" "" date_mdy "" "" y "" "" "" "" "" 819 f6_ra_id form_6_proxy_quarterly "" dropdown "
RA ID#" 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 820 f6_prxy_quart_intro_d form_6_proxy_quarterly "" descriptive "
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? " "" "" "" "" "" "" "" "" "" "" "" 821 f6_live_le_1hour_nh_d form_6_proxy_quarterly "" descriptive "
Do you live within a 1-hour car drive from [RESIDENT'S] nursing home? " "" "" "" "" "" "" "" "" "" "" "" 822 f6_live_le_1hour_nh form_6_proxy_quarterly "" radio "
Within a 1-hour " 0, No (0) | 1, Yes (1) | 888, refused (888) "" "" "" "" y "" "" "" "" "" 823 f6_num_hrs_visit_res_nh_d form_6_proxy_quarterly "" descriptive "
Approximately how many hours a week do you currently spend visiting (resident) at the nursing home?" "" "" "" "" "" "" "" "" "" "" "" 824 f6_num_hrs_visit_res_nh form_6_proxy_quarterly "" radio "
Hours visiting" 0, 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 "" "" "" "" "" 825 f6_prxy_prf_loc_d form_6_proxy_quarterly "" descriptive "
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. " "" "" "" "" "" "" "" "" "" "" "" 826 f6_res_pref_loc_d form_6_proxy_quarterly "" descriptive "
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?" "" "" "" "" "" "" "" "" "" "" "" 827 f6_res_pref_loc form_6_proxy_quarterly "" radio "
Level resident would want" 1, Intensive medical care (1) | 2, Basic medical care (2) | 3, Comfort care (3) | 888, Refused (888) | 999, Unknown (999) "" "" "" "" y "" "" "" "" "" 828 f6_prvdr_ask_prxy_opin_d form_6_proxy_quarterly "" descriptive "
Since our last interview, has any health care provider asked your opinion regarding the goals of [RESIDENT's] medical care?" "" "" "" "" "" "" "" "" "" "" "" 829 f6_prvdr_ask_prxy_opin form_6_proxy_quarterly "" radio "
Provider asked opinion " 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 830 f6_prvdr_disc_trtmnts_d form_6_proxy_quarterly "" descriptive "
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?" "" "" "" "" "" "" "" "" "" "" "" 831 f6_prvdr_disc_trtmnts form_6_proxy_quarterly "" radio "
Provider Discussion? " 0, No (0) | 1, Yes (1) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 832 f6_who_init_discuss_d form_6_proxy_quarterly "" descriptive "
Who initiated this discussion, you or the health care provider?" "" "" "" "" [f6_prvdr_disc_trtmnts] = '1' "" "" "" "" "" "" 833 f6_who_init_discuss form_6_proxy_quarterly "" radio "
Discussion initiator" 1, 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 "" "" "" "" "" 834 f6_discuss_prvdr_d form_6_proxy_quarterly "" descriptive "
Who was the health provider with whom you had this discussion? " "" "" "" "" [f6_prvdr_disc_trtmnts] = '1' "" "" "" "" "" "" 835 f6_discuss_prvdr form_6_proxy_quarterly "" checkbox "
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 "" "" "" "" "" 836 f6_discuss_prvdr_oth_d form_6_proxy_quarterly "" descriptive "
Who was the ""other"" provider with whom you discussed residents goals of care?" "" "" "" "" [f6_prvdr_disc_trtmnts] = '1' and [f6_discuss_prvdr(9)] = '1' "" "" "" "" "" "" 837 f6_discuss_prvdr_oth form_6_proxy_quarterly "" text "
Other provider discussion" "" "" "" "" [f6_prvdr_disc_trtmnts] = '1' and [f6_discuss_prvdr(9)] = '1' y "" "" "" "" "" 838 f6_partic_trtmnt_decis_d form_6_proxy_quarterly "" descriptive "
Since we last spoke together, have you participated in treatment decisions for resident?" "" "" "" "" "" "" "" "" "" "" "" 839 f6_partic_trtmnt_decis form_6_proxy_quarterly "" radio "
Treatment decisions " 0, No (0) | 1, Yes (1) | 8, Refused (888) | 9, Don't know (999) "" "" "" "" y "" "" "" "" "" 840 f6_res_life_left_d form_6_proxy_quarterly "" descriptive "
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? " "" "" "" "" "" "" "" "" "" "" "" 841 f6_res_life_left form_6_proxy_quarterly "" radio "
Near to end of life" 1, < 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 "" "" "" "" "" 842 f6_undst_res_hlth_wish_d form_6_proxy_quarterly "" descriptive "
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." "" "" "" "" "" "" "" "" "" "" "" 843 f6_undst_res_hlth_wish form_6_proxy_quarterly "" radio "
Confident of understanding" 1, Very confident (1) | 2, Somewhat confident (2) | 3, Not confident at all (3) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 844 f6_comf_talk_illness_d form_6_proxy_quarterly "" descriptive "
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 " "" "" "" "" "" "" "" "" "" "" "" 845 f6_comf_talk_illness form_6_proxy_quarterly "" radio "
Proxy interview comfort" 1, Very comfortable (1) | 2, Comfortable (2) | 3, A little uncomfortable (3) | 4, Very uncomfortable (4) | 888, Refused (888) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 846 f6_addnl_thoughts_d form_6_proxy_quarterly "" descriptive "
Do you have any additional thoughts about what we have discussed that you would like to add?" "" "" "" "" "" "" "" "" "" "" "" 847 f6_addnl_thoughts form_6_proxy_quarterly "" radio "
Proxy additional thoughts " 0, No (0) | 1, Yes (1) "" "" "" "" y "" "" "" "" "" 848 f6_add_thoughts form_6_proxy_quarterly "" notes "
Additional thoughts" "" "" "" y [f6_addnl_thoughts] = '1' y "" "" "" "" "" 849 f6_anyquestions_d form_6_proxy_quarterly "" descriptive "
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." "" "" "" "" "" "" "" "" "" "" "" 850 f6_prxy_questions form_6_proxy_quarterly "" notes "
Further questions? " "" "" "" "" "" "" "" "" "" "" "" 851 fd_ra_id form_d_death_report "" dropdown RA ID 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 852 fd_report_date form_d_death_report "" text Death report date "" "" date_mdy "" "" y "" "" "" "" "" 853 fd_res_death form_d_death_report "" yesno Resident deceased "" "" "" "" "" y "" "" "" "" "" 854 fd_res_death_date form_d_death_report "" text Resident Death Date "" "" date_mdy "" "" y "" "" "" "" "" 855 fd_source_d_notice form_d_death_report "" radio Source of Death Notification 1, Facility (1) | 2, Proxy (2) "" "" "" "" "" "" "" "" "" "" 856 fd_proxy_death form_d_death_report "" yesno Proxy deceased "" "" "" "" "" "" "" "" "" "" "" 857 fd_proxy_death_date form_d_death_report "" text Proxy Death Date "" "" date_mdy "" "" "" "" "" "" "" "" 858 fae_report_date adverse_event "" text "
AE report date" "" "" date_mdy "" "" y "" "" "" "" "" 859 fae_ra_id adverse_event "" dropdown "
RA ID" 1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) "" "" "" "" y "" "" "" "" "" 860 fae_participant_info_d adverse_event "" descriptive "
Participant information" "" "" "" "" "" "" "" "" "" "" "" 861 fae_subject_l_name adverse_event "" text "
Last Name of subject experiencing Adverse Event" "" "" "" "" "" y "" "" "" "" "" 862 fae_subject_f_name adverse_event "" text "
First Name of subject experiencing Adverse Event" "" "" "" "" "" y "" "" "" "" "" 863 fae_prev_ae_d adverse_event "" descriptive "
Has the participant experienced a PRIOR unexpected or serious event while in this study?" "" "" "" "" "" "" "" "" "" "" "" 864 fae_prev_ae adverse_event "" radio "
Prior AE" 0, No (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" "" "" "" "" "" "" 865 fae_prev_ae_date adverse_event "" text "
Prior AE Date" "" "" date_mdy "" "" "" "" "" "" "" "" 866 fae_withdrawn_d adverse_event "" descriptive "
Has the participant been withdrawn from the study?" "" "" "" "" "" "" "" "" "" "" "" 867 fae_withdrawn adverse_event "" radio "
Subject withdrawn?" 0, No, (0) | 1, Yes (1) | 999, Don't know (999) "" "" "" "" "" "" "" "" "" "" 868 fae_withdraw_dets adverse_event "" notes "
Withdraw details" "" "" "" "" "" "" "" "" "" "" "" 869 fae_event_descrip adverse_event "" notes "
Event description" "" "" "" "" "" "" "" "" "" "" "" 870 fae_event_date adverse_event "" text "
Adverse Event date" "" "" date_mdy "" "" y "" "" "" "" "" 871 fae_date_event_reported adverse_event "" text "
Date AE reported to researcher" "" "" date_mdy "" "" y "" "" "" "" "" 872 fae_event_loc adverse_event "" text "
Event location" "" "" "" "" "" y "" "" "" "" "" 873 fae_event_severity adverse_event "" radio "
Severity of event" 1, Mild (1) | 2, Moderate (2) | 3, Serious (3) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 874 fae_event_severity_dets adverse_event "" checkbox "
Serious event detail" 1, 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' "" "" "" "" "" "" 875 fae_intervention_dets adverse_event "" notes "
Required intervention detail" "" "" "" "" [fae_event_severity] = '3' "" "" "" "" "" "" 876 fae_anticipate_d adverse_event "" descriptive "
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." "" "" "" "" "" "" "" "" "" "" "" 877 fae_anticipate adverse_event "" radio "
Event anticipation" 1, Anticipated (1) | 2, Unanticipated (2) | 999, Don't know (999) "" "" "" "" y "" "" "" "" "" 878 fae_event_rel_d adverse_event "" descriptive "
What was the relation of the event to participation in the study?" "" "" "" "" "" "" "" "" "" "" "" 879 fae_event_rel adverse_event "" radio "
AE related to study?" 0, Unrelated (0) | 1, Related (1) | 2, Possibly related (2) | 999, Don't know "" "" "" "" y "" "" "" "" "" 880 fae_event_rel_exp adverse_event "" notes "
Explain relationship to study" "" "" "" "" "" y "" "" "" "" ""