name: Agrobacterium radiobacter or Agrobacterium tumefaciens


name: Acute prosthetic tricuspid valve regurgitation


name: Biopsy of lymph node using ultrasound guidance


name: MRI of lower limb for arthroplasty planning


name: History of stromal sarcoma of endometrium


name: Mycobacterium fortuitum or Mycobacterium peregrinum


name: Supervision of high risk pregnancy with history of previous molar pregnancy


name: Injection of sclerosing agent into pseudoaneurysm using fluoroscopic guidance with contrast


name: Deprecated Gestational age indicator [CDC.CS]


name: How intense was your pain at its worse in the past 7D


name: How intense was your average pain in the past 7D


name: Disability information & assistance needed panel


name: Do you have difficulty communicating, reading, or do you have limited proficiency in English


name: Because of a physical, mental, or emotional condition, do you have difficulty doing errands such as visiting a doctor's office or shopping


name: Do you have difficulty walking or climbing stairs


name: Are you blind or do you have difficulty seeing


name: Are you deaf or do you have difficulty hearing


name: Malonylcarnitine (C3-DC)+3-Hydroxybutyrylcarnitine (C4-OH)/Decanoylcarnitine (C10)


name: Congenital syphilis case classification section


name: Congenital syphilis case investigation and report panel


name: Congenital syphilis case classification status


name: Syphilis treatment was given & treatment description


name: Leukocyte count or protein test was performed on CSF & test findings


name: CSF Venereal Disease Research Laboratory test was performed & test findings


name: Long bone x-rays were performed and consistent with congenital syphilis


name: Darkfield exam, DFA, or special stain was performed & test findings


name: Mother had appropriate serologic response following syphilis treatment


name: Amount of benzathine penicillin treatment


name: When mother received first dose of benzathine penicillin


name: Date of first syphilis treatment during pregnancy


name: Surveillance stage of syphilis during pregnancy


name: Clinical stage of syphilis during pregnancy


name: Non-treponemal or treponemal test was performed at delivery


name: Non-treponemal or treponemal test was performed at 28-32 weeks gestation


name: Non-treponemal or treponemal test was performed at first prenatal visit


name: ERBB2 gene duplication associated observations panel


name: Metabolic disorder therapy monitoring panel


name: Vacuum dust collection contaminant panel


name: Immunoglobulin light chains & heavy chains panel


name: Soluble fms-like tyrosine kinase-1 & placental growth factor panel


name: Soluble fms-like tyrosine kinase-1/placental growth factor


name: Vital signs, weight, height, head circumference, oximetry, BMI, & BSA panel


name: Best description of the event or unsafe condition


name: Device involved in patient safety event or unsafe condition


name: At the time of the event, the device was placed within the patient's tissue


name: Event resulted in the device being removed


name: Device intended for single use was involved in the event or unsafe condition


name: Device intended for single use was reused in the event or unsafe condition


name: Medication or other substance was involved


name: Health information technology device was involved


name: Best characterization of health information technology device


name: Administrative or billing system component


name: Electronic health record system component


name: Circumstances involving the health information technology device in the event or unsafe condition


name: Problem that resulted from the equipment or device function problem


name: Ergonomics or human &or device interface issue


name: Influenza virus B Victoria & Yamagata lineage RNA panel


name: NADH cytochrome C reductase/Citrate synthase


name: Succinate cytochrome C reductase/Citrate synthase


name: Coenzyme Q cytochrome C reductase/Citrate synthase


name: Tryptophan-related indole profiling panel


name: Delta aminolevulinate, porphobilinogen and creatinine panel


name: Autopsy or histological placental examination results were used


name: Medical examiner or coroner was contacted


name: Wholesale drug distributors and third-party logistics facility registration


name: Transferrin receptor.soluble/log Ferritin index


name: Additional details of event or unsafe condition


name: Action that prevented the near miss incident from reaching the patient


name: Contributing factors for event were known


name: Event was a National Quality Forum (NQF) serious reportable event


name: National Quality Forum (NQF) serious reportable event


name: Anticipated duration of harm to the patient


name: Increased length of stay due to incident


name: Description of patient safety event or unsafe condition


name: Location of patient safety event or unsafe condition


name: Categories associated with patient safety event or unsafe condition


name: Perinatal incident that affected a neonate


name: Incisional biopsy of other than primary site; needle biopsy


name: Unknown if any cancer-directed surgery performed; date unkno


name: Incisional biopsy of other than primary site,Needle biopsy of other than primary site,Aspiration biopsy of other than primary site


name: Schedule conflicted with my exercise session


name: Patient was never an inpatient at the reporting hospital


name: Twenty-eighth of twenty-eight or more primaries


name: Patient did not participate in screening program related to


name: Baltic Republic(s), NOS (Baltic States, NOS)


name: Other types of physical activity not mentioned


name: Maritime Provinces (New Brunsw, Newfound, Nova Scotia, PE)


name: Affective symptoms predominate although psychotic symptoms may also occur.


name: Product container (e.g. juice box, pop can or bottle)


name: Yes, less than half of the wall surfaces


name: Cleaning solutions, including household cleaners and chemicals


name: Lack of motivation or energy to do things


name: Too old - cannot complete the series because the latest age for receiving dose has passed.


name: I am often unable to respond to questions without extreme effort


name: I regularly eat more often and/or greater amounts of food than usual


name: non-infant: Oriented and appropriate speech; non-verbal infant: Coos and babbles


name: Adult: Localization of painful stimulation; infant or child: Withdraws to touch


name: State-sponsored health plan (if available, display state plan name)


name: Can walk on their own without using walking aids, but needs to hold the handrail when going up or down stairs


name: Deep vein thrombosis of lower extremities during or following a procedure within 60 days


name: No guardian or legally authorized representative available


name: Yes, but have periods now due to female hormones


name: Able to independently take the correct medication and proper dosage at the correct times.


name: Normal vision: sees adequately in most situations, can see medication labels, newsprint.


name: Screening not done due to parental refusal


name: Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)


name: Adequate - sees fine detail, such as regular print in newspapers/books


name: Very loud can be heard in adjacent rooms


name: More than 3 years, but not more than 5 years ago


name: Newborn given surfactant replacement therapy


name: Consistent with active infectious syphilis


name: Behavior continuously present does not fluctuate.


name: Out of range requiring further dried blood spot testing for at least one condition


name: Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.


name: Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)


name: Nausea, dehydration, malnutrition, constipation, impaction


name: Intravenous or infusion therapy (excludes TPN)


name: EXTENSIVE ASSISTANCE--Resident received weight bearing assistance while walking


name: Activity occurred only once or twice - activity did occur but only once or twice


name: Behavior present over last 7 days appears different from resident's usual functioning (e.g., new onset or worsening)


name: ADEQUATE- sees fine detail, including regular print in newspaper/books


name: Private/co-private provider or company/business


name: Currently being treated and transferred in with treatment records from within system.


name: Medical-influenza-like Illness/ upper respiratory infection


name: Morphology (Morph--Type&Behav ICD-O-3 [521] converted from (Morph--Type&Behav ICD-O-2 [419] with review


name: Urban, adjacent to metropolitan area, 20,000 population or more


name: Moans or whimpers; occasional complaint; occasional verbal outburst or grunt; or parent-identified vocalization


name: Mobility greater than 1 mm in a single lateral direction or depressible in the socket.


name: Auto v. pedestrian/bicyclist thrown, run over, or > 20 MPH impact


name: Regularly (an attack once a month on average)


name: Co-worker, boss/superior, or subordinate from a previous firm


name: Radiation therapy administered, but number of treatment days


name: Colorectal malignancy confirmed histologically (exclude carcinoma in situ)


name: Immunotherapy was recommended by the physician, but was refused by patient/family member/guardian


name: Category/Stage III: Full thickness skin loss


name: Arthroplasty/hemiarthroplasty (femoral head replacement)


name: Gas: from underground pipes serving the neighborhood


name: 16 to 25 cigarettes per day (about 1 pack)


name: immediate reconstruction with implant/prosthesis


name: Immunotherapy was recommended, but it is unknown if it was administered


name: Byelorus (Byelorussian SSR, White Russia)


name: Adult: General withdrawal in response to painful stimulation; infant or child: Withdraws to pain


name: No verbal response (>2 yrs); no vocal response (<=2 yrs)


name: Yes, with aqueous or procaine penicillin for 10 days


name: Response could not be determined from available non-treponemal titer information


name: No, inappropriate response: evidence of treatment failure or reinfection


name: No organisms found that can be detected by panel


name: Unable to analyze specimen due to laboratory accident


name: Specimen unsatisfactory due to delay in transit


name: Specimen submitted on expired filter paper


name: Serial number on filter paper does not match serial number on patient information form


name: Demographic information on filter paper does not match electronically submitted information


name: Demographic information is incomplete or invalid


name: Epidural or spinal anesthesia during labor


name: Fetal intolerance of labor such that one or more of the following actions was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery


name: Moderate/heavy meconium staining of the amniotic fluid


name: Clinical chorioamnionitis diagnosed during labor or maternal temperature >38°C (100.4°F)


name: Antibiotics received by the mother during labor


name: Steroids (glucocorticoids) for fetal lung maturation received by the mother prior to delivery


name: Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)


name: Seizure or serious neurologic dysfunction


name: Antibiotics received by the newborn for suspected neonatal sepsis


name: Assisted ventilation required for more than six hours


name: Assisted ventilation required immediately following delivery


name: Died during labor, after first assessment


name: Dead at time of first assessment, labor ongoing


name: Dead at time of first assessment, no labor ongoing


name: Unplanned operating room procedure following delivery


name: Fertility-enhancing drugs, Artificial insemination or Intrauterine insemination


name: May be infectious syphilis if no previous history of syphilis


name: May represent a biological false positive


name: Person from a country endemic for yaws, pinta or bejel


name: No serological evidence of current or past infection


name: Attempted but unsuccessful - technical fail


name: Infant being monitored or treated for non-CCHD condition


name: Diagnostic testing begun in lieu of screening based on clinical suspicion for CCHD


name: Parental refusal for reasons other than religious beliefs


name: Parental refusal based on religious beliefs


name: Medically unstable and inappropriate for screen


name: Suspected Deep Tissue Injury - depth unknown


name: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown


name: Category/Stage IV: Full thickness tissue loss


name: Category/Stage I: Non-blanchable erythema


name: None of the above listed infections were present and/or treated during this pregnancy


name: Normal (Smooth, firm, nail plate attached)


name: Arteriovenous graft combined with a catheter


name: Arteriovenous graft only (with 2 needles)


name: Arteriovenous fistula combined with a catheter


name: Arteriovenous fistula combined with an AV graft


name: Arteriovenous fistula only (with 2 needles)


name: Emergency response (primary response area)


name: Advanced emergency medical technician (AEMT)


name: Other airway device placement confirmation


name: Direct re-visualization of tube in place


name: National Renal Administrators Association-NRAA


name: Hemodialysis - temporary, uncuffed catheter


name: Therapeutic diet (e.g., low salt, diabetic, low cholesterol)


name: Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)


name: Feeding tube - nasogastric or abdominal (PEG)


name: Yes, not on physician-prescribed weight-gain regimen


name: Intellectual disability (mental retardation in federal regulation)


name: Kt/V (peritoneal dialysis adequacy index)


name: General/medical unit or floor - 6 or more pts per nurse


name: Step-down/intermediate unit - 3-6 pts per nurse


name: Critical care/intensive care unit - 1-2 pts per nurse


name: Unknown if pregnant within the past year


name: Not pregnant, but pregnant 43 days to 1 year before death


name: Not pregnant, but pregnant within 42 days of death


name: Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.


name: Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.


name: Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.


name: Mental retardation-developmental (MR/DD) disability facility


name: You don't take this medication because you don't want to


name: You don't understand why you need this medicine


name: You don't think the medicine is helping you


name: No, access not present, or present and not maturing


name: Following hemodialysis (HD) or peritoneal dialysis (PD) access failure


name: Skilled nursing facility (SNF)/Long term care


name: Thyroid treatment (including propylthiouracil (PTU), methimazole (Tapazole), or past treatment with radioactive iodine (I-131))


name: Packed red blood cell (PRBC) transfusion


name: Lactose free formula (including soy or hydrolyzed)


name: Positive level known from law enforcement or hospital record


name: Alcohol containers/paraphernalia at scene


name: Help out when you are short of money by giving or loaning you money


name: Give you suggestions when you have a problem


name: Tell you they care about what happens to you


name: Listen to you when you were feeling down or upset


name: He/she went to school, but R doesn't know what level


name: Professional training beyond a four-year college or university


name: Went to a business, trade, or vocational school after high school


name: Went to a business, trade, or vocational school instead of high school


name: More than eighth grade, but did not graduate from high school


name: Return of spontaneous circulation (pulse or BP noted)


name: Psychiatric problem/abnormal behavior/suicide attempt


name: Industrial accident/inaccessible incident/other entrapments (non-vehicle)


name: Exposure-needle stick without body fluid injection


name: Exposure-needle stick with body fluid injection


name: Exposure-body fluid contact with mucosal surface


name: Exposure-body fluid contact with intact skin


name: Exposure-body fluid contact to broken skin


name: Patient refused evaluation/care (without transport)


name: Patient treated, released (per protocol)


name: Standby-public safety, fire, or EMS operational support provided


name: Patient treated, transported by private vehicle


name: Patient treated, transported by law enforcement


name: Patient treated, transferred care to another EMS professional


name: Patient refused evaluation/care (with transport)


name: Patient evaluated, no treatment/transport required


name: Medical-ventricular tachycardia (with pulse)


name: Medical-supraventricular tachycardia (including atrial fibrillation)


name: Medical-ST-elevation myocardial infarction (STEMI)


name: Medical-respiratory distress/asthma/COPD/reactive airway disease


name: General-universal patient care/initial patient contact


name: Cardiac arrest- ventricular fibrillation/pulseless ventricular tachycardia


name: Cardiac arrest- pulseless electrical activity


name: Airway-Rapid Sequence Induction (RSI-Paralytic)


name: No contraindications to thrombolytic Use


name: Possible contraindications to thrombolytic Use


name: Definite contraindications to thrombolytic use


name: Miami Emergency Neurologic Deficit Exam (MEND)


name: Family/guardian request DNR (but no documentation)


name: Other healthcare advanced directive form


name: Unattended or unsupervised (including minors)


name: Physical barrier (unable to access patient)


name: Yes, sustained for 20 consecutive minutes


name: Compressions-external thumper type device


name: Compressions-external plunger type device


name: Other EMS professional - not part of dispatched response


name: Yes, after any EMS arrival (includes Transport EMS & Medical First Responders)


name: Yes, prior to any EMS arrival (includes Transport EMS & Medical First Responders)


name: Airbag deployed other (knee, airbelt, etc.)


name: Riding on vehicle exterior (non-trailing unit)


name: Passenger in unenclosed passenger or cargo area (non-trailing unit such as a pickup, etc.)


name: Passenger in other enclosed passenger or cargo area (non-trailing unit such as a bus, etc.)


name: Third row-left side (or motorcycle passenger)


name: Second seat-left side (or motorcycle passenger)


name: Front seat-left side (or motorcycle driver)


name: Crash vehicle telemetry data (AACN) consistent with high risk of injury


name: Crash intrusion: > 12 in. occupant site; > 18 in. any site


name: Crash ejection (partial or complete) from vehicle


name: Crash death in same passenger compartment


name: Fall children: > 10 ft. or 2-3 times the height of the child


name: Fall adults: > 20 ft. (one story is equal to 10 ft.)


name: Two or more proximal long-bone fractures


name: Penetrating injury to head, neck, torso, and extremities proximal to elbow and knee


name: Respiratory rate < 10 or >29 or (<20 in infant < one year)


name: Dead without resuscitation efforts (black)


name: Yes, unknown if pre-arrival instructions given


name: Technical failure (computer, phone etc.)


name: Less than 1 tablet a week (but more than one each month)


name: Rarely (less than one attack every 3 months)


name: Sporadically (between 4 and 10 times a year)


name: One of my relatives has already participated in this investigation


name: As far as I know, none of my relatives has already participated in this investigation


name: I have no idea about the cause of my hearing problem


name: Indirect relationship (known via someone else)


name: Someone known because he/she provides a service to me or my family


name: Someone from the same association, club or group


name: Person working for another firm, but known through work relations


name: Gastrointestinal bleeding that required hospitalization or a transfusion


name: Other malignancy confirmed histologicaly or cytologically


name: Colorectal malignancy diagnosed by clinical examination only


name: Colorectal malignancy confirmed cytologically


name: No malignancy and no diagnostic/staging procedures performed


name: Upper GI evaluation - endoscopic/radiographic


name: PreoperatIve carcinoembryonic antigen (CEA)


name: Intravenous pyelography (IVP)/excretory urography


name: Motor vehicle accident or fall from greater than standing height


name: Pathologic fracture-usually associated with cancer in bone


name: Fall from more than standing height, but NOT on stairs


name: Open reduction internal fixation (ORIF or pinning)


name: Reactive. Results suggest evidence of current or recent infection with Typhus Fever Group. If current infection is suspected, please collect a convalescent specimen at least 2 weeks after the acute.


name: Reactive. Results suggest evidence of current or recent infection with Spotted Fever Group. If current infection is suspected, please collect a convalescent specimen at least 2 weeks after the acute.


name: Nonreactive. Results suggest no evidence of infection. If current infection is suspected, please collect a convalescent specimen at least 2 weeks after the acute.


name: Skin-type VI: black skin, black hair, black eyes


name: Skin-type V: brown skin, black hair, black eyes


name: Skin-type IV: olive skin, dark-brown hair, brown eyes


name: Skin-type III: deep skin, brown hair, light to medium eye color


name: Skin-type II: fair skin, blond or light-brown hair, light eyes (blue or green), usual sunburn


name: Skin-type I: very fair skin, blond or red hair, light eyes (blue or green), never tan and always sunburn after sun exposure


name: Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour


name: Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour


name: Grade 2: definite osteophytes, definite narrowing of joint space


name: Grade 1: doubtful narrowing of joint space and possible osteophytic lipping


name: Acquired immunodeficiency syndrome, AIDS, or HIV positive


name: Low blood counts, anemia, low white blood cell count, or low platelet count


name: Pain for more than a few days when taking deep breath, pleurisy


name: Arthritis or rheumatism for more than 3 months


name: Prominent rash on cheeks for more than 1 month


name: Eastern Cooperative Oncology Group Performance Status ECOG101 Standardized Character Result 0


name: Instructor does not offer me any encouragement


name: Felt self-conscious about my appearance when I exercised


name: Didn't like the particular activity program that I was involved in


name: Difficult to get to the exercise location


name: Weather was very bad - hot, humid, rainy, cold


name: Apartments or condos of more than 12 stories


name: Mix of single-family residences and townhouses, row houses, apartments, or condos


name: Townhouses, row houses, apartments, or condos of two-three stories


name: Spent without very much physical activity


name: Engaged in a regular program of physical fitness five or more times per week


name: Engaged in a regular program of physical fitness involving some kind of heavy physical activity at least three times per week


name: Three times per week, on the average, I engaged in some moderate activity


name: Most weekends I was able to get outdoors for some light exercise


name: Spent most of the day doing hard physical labor


name: Spent most of the day lifting or carrying heavy objects


name: Spent most of the day walking or using my hands and arms


name: Spent most of the day sitting or standing


name: Participant took off; did not replace or restart correctly


name: Leisure time - visiting friends,movies,dining out etc


name: Play basketball, soccer, or racquetball, not on sidelines


name: Walk Leisurely for Exercise or Pleasure Question


name: Walk to do errands - to store or taking children to school


name: Walk Fast or Briskly for Exercise Question


name: Work on Car, Truck, Lawn Mower, or Other Machinery Question


name: Play Cards, Bingo, or Board Games with Other People Question


name: Attend a concert, movie, lecture, or sport event


name: Play golf, carrying or pulling your equipment


name: Woodworking, needlework, drawing, or other arts and craft


name: Dance - such a square, folk,line,ballroom


name: Attend Church or Take Part in Church Activities Question


name: Stationary exercise machines - cycle, ski machine, stairclimber, treadmill


name: Karate - judo, martial arts, self defense


name: Sitting around-chatting with friends, on the phone


name: Participant unable to understand instructions


name: Participant could not hold position unassisted


name: Unable to test/exclusion/didn't understand


name: No - solution not consumed in 10 minutes


name: Received cancer chemotherapy in the last 3 weeks


name: Diaphragm with or without jelly or cream


name: Morning after pills or emergency contraception


name: Natural family planning or safe period by temperature or cervical mucus test


name: Masked or fixed faces with severe or complete loss of facial expression; lips parted one fourth inch or more


name: Moderate hypomimia; lips parted some of time


name: Slight but definitely abnormal diminution of facial expression


name: Minimal hypomimia, could be normal Poker Face


name: Marked impairment, difficult to understand


name: Monotone, slurred but understandable; moderately impaired


name: Slight loss of expression, diction, and/or volume


name: Marked, but full range of motion easily achieved


name: Slight or detectable only when activated by mirror or other movements


name: Single; has never married or lived as married


name: Are you married, have you ever been married or lived with the same partner for at least six months?


name: Continuous chronic illness with deterioration


name: Multiple episodes with partial recovery between


name: Multiple episodes with good recovery between


name: Inpatient treatment (any duration) has been received, or no functioning at all in major life role for more than two days, or active psychotic symptoms such as delusions or hallucinations have occurred.


name: Evidence of objective functional impairment in major life role with definite reduction in productivity and/or criticism about functioning or performance has been received


name: Subjective impairment only (at work, school, family or social functioning)


name: No response to neuroleptics, never been psychotic, or never taken neuroleptics


name: Psychotic and affective symptoms are balanced, with neither group of symptoms dominating the overall course of the illness.


name: Psychotic symptoms dominate the clinical picture although occasional affective disturbance may also occur.


name: Present most of the time in a one month period or longer


name: Present less than one month or duration unspecified


name: Present at least two weeks or if lasted < one week but hospitalized for affective disorder


name: Gain of at least 10+ lbs (5 kg) in less than 1 year


name: Gain of at least 2+ lbs (1 kg) per week for 3 or more weeks or 5 to 9 lbs (2.5 to 4.5 kg) in less than 3 weeks


name: Gain of at least 1+ lb (0.5 kg) per week for 3 or more weeks or 4 lbs (2 kg) in less than 3 weeks


name: Loss of at least 10+ lbs (5 kg) in less than 1 year


name: Loss of at least 2+ lbs (1 kg) per week for 3 or more weeks or 5 to 9 lbs (2.5 to 4.5 kg) in less than 3 weeks


name: Loss of at least 1+ lb (0.5 kg) per week for 3 or more weeks or 4 lbs (2 kg) in less than 3 weeks


name: Suicidal ideation present at least one month


name: Suicidal ideation present at least two weeks


name: Increase in libido for at least one week


name: Family history of psychiatric disorder other than schizophrenia


name: Employed at onset (includes full time students and homemakers)


name: Insidious onset over period greater than six months


name: Gradual onset over period up to six months


name: Moderately acute onset definable within one month


name: Abrupt onset definable within hours or days


name: Combined sources including structured interview


name: Take more drugs such as sedatives, anxiolytics, stimulants


name: Can be exhausting or irritating for others


name: More impatient or get irritable more easily


name: Make more jokes or puns when I am talking


name: More flirtatious or am more sexually active


name: More interested in sex, or have increased sexual desire


name: Want to meet or actually do meet more people


name: Wear more colorful and more extravagant clothes or make-up


name: Take more risks in my daily life, my work, or other activities


name: Tend to drive faster or take more risks when driving


name: More sociable, make more phone calls, go out more


name: Taking part or speaking in a meeting or class


name: Talking to people because you might have nothing to say or might sound foolish


name: Eating or drinking where someone could watch you


name: Being in a public place like a department store


name: Seeing blood, getting a shot or injection, seeing a dentist, or going to a hospital


name: Snakes, birds, rats, bugs, or other animals


name: Being in a closed space like a cave, tunnel, elevator, or airplane


name: Heights, storms, thunder, lightning, or being in still water, like a swimming pool or lakes


name: Difficulty keeping your mind on what you were doing


name: Tightness, pain, or discomfort in your chest or stomach


name: Trouble seeing both sides or straight ahead


name: Trouble seeing to the left, but not to right


name: Trouble seeing to the right, but not to left


name: Started in one part and spread to another


name: Trouble in both eyes seeing to both sides or straight ahead


name: Trouble in both eyes seeing to the right


name: Lightheadedness, dizziness, or loss of balance


name: 4+, 4, or 4- on intrinsics or finger extensors


name: Reduced up to and may include elbow/knee


name: Unable to do buttons or zippers but can write


name: Marked flexion with extreme abnormality of posture


name: Other disturbances - children, pets, etc


name: Errors or accidents at work or while driving


name: Social problems or poor work/school performance


name: Attention, concentration or memory problems


name: Always works nights, sleeps during the day


name: Stroke, cerebral hemorrhage, or brain attack


name: Last Smoked a Cigarette Less than One Year Ago


name: At times, I am unable to stay seated and need to pace around


name: I have impulses to move about and am quite restless


name: I'm often fidgety, wringing my hands, or need to shift how I am sitting


name: It takes me several seconds to respond to most questions and I'm sure my thinking is slowed.


name: I find that my thinking is slowed down or my voice sounds dull or flat


name: I think, speak, and move at my usual rate of speed


name: I really cannot carry out most of my usual daily activities because I just don't have the energy


name: I have to make a big effort to start or finish my usual daily activities (for example,shopping, homework, cooking or going to work)


name: There is no change in my usual level of energy.


name: I have virtually no interest in formerly pursued activities


name: I find I have interest in only one or two of my formerly pursued activities


name: I notice that I am less interested in people or activities


name: There is no change from usual in how interested I am in other people or activities.


name: I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life


name: I think of suicide or death several times a week for several minutes


name: I feel that life is empty or wonder if it's worth living


name: I think almost constantly about major and minor defects in myself


name: I largely believe that I cause problems for others


name: I see myself as equally worthwhile and deserving as other people


name: I cannot concentrate well enough to read or cannot make even minor decisions


name: Most of the time, I struggle to focus my attention or to make decisions.


name: I occasionally feel indecisive or find that my attention wanders


name: There is no change in my usual capacity to concentrate or make decisions.


name: I feel as if I've had a slight weight gain


name: I feel as if I've had a slight weight loss


name: I feel driven to overeat both at mealtime and between meals


name: I feel a need to eat more frequently than usual


name: I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat


name: I eat much less than usual and only with personal effort


name: I eat somewhat less often or lesser amounts of food than usual


name: There is no change in my usual appetite.


name: I sleep longer than 12 hours in a 24-hour period including naps


name: I sleep no longer than 12 hours in a 24-hour period including naps


name: I sleep no longer than 10 hours in a 24-hour period including naps


name: I sleep no longer than 7-8 hours/night, without napping during the day


name: I awaken at least one hour before I need to, and can't go back to sleep


name: I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually


name: More than half the time, I awaken no more than 30 minutes before I need to get up


name: Most of the time, I awaken no more than 30 minutes before I need to get up


name: I awaken more than once a night and stay awake for 20 minutes or more, more than half the time


name: I wake up at least once a night, but I go back to sleep easily


name: I have a restless, light sleep with a few brief awakenings each night


name: Never take longer than 30 minutes to fall asleep


name: I take more than 60 minutes to fall asleep, more than half the time


name: I take at least 30 minutes to fall asleep, more than half the time


name: I take at least 30 minutes to fall asleep, less than half the time


name: Negatively (concerned, annoyed, irritated, critical)


name: Repeatedly shows periods of ups and downs


name: Large-amplitude (>2 cm), violent, jerky tremor resulting in difficulty completing the task due to spilling or inability to hold a pen to paper


name: Tremor is of moderate amplitude (1-2 cm) and usually present; it is clearly oscillatory


name: Low-amplitude/barely perceivable tremor or intermittent tremor


name: Prescription medicine for depression or anxiety


name: Prescription medicine for seizures, epilepsy, or fits


name: Prescription medicine (other than water pill) for high blood pressure


name: Water pill or prescription diuretic for high blood pressure


name: Take both prescription and non-prescription medications


name: Working ability or activity severely impaired


name: Working ability or activity impaired to some degree


name: Numbness of lips, tongue, fingers, or legs before the headache starts


name: Seeing shimmering lights, circles, other shapes, or colors before the eyes, before the headache starts


name: Pain-free intervals of days or weeks between severe headache attacks


name: Stopped doing this for other reasons or not interested in doing this


name: Stopped doing this because of your eyesight


name: Prescription or non-prescription sunglasses


name: I have never felt sexually attracted to anyone at all


name: Mostly to males, and at least once to a female


name: About equally often to females and to males


name: Mostly to females, and at least once to a male


name: I didn't have 4 drinks or more in 1 sitting


name: Blank but applicable/cannot be determined


name: About Equally Satisfied and Dissatisfied


name: Tubal ligation (tubes tied) or female sterilization


name: More than one year but less than ten years


name: The hair is like that of a man. It has spread out to the legs.


name: The hair is as dark and curly as that of a man, but it hasn't spread out to the legs.


name: The hair is darker and more curled. It has spread out and thinly covers a bigger area.


name: The penis, scrotum and testes are the size and shape of a man's.


name: The penis is longer and wider. The head of the penis is bigger, the scrotum is a darker color and bigger. The testes are bigger.


name: The penis has grown longer, the testes have grown and dropped lower.


name: The penis is a little bit bigger. The scrotum has dropped and the skin of the scrotum has changed. The testes are bigger.


name: The size and shape of the testes, scrotum (the sac holding the testes) and penis are about the same as when you were younger.


name: The hair is like that of an adult woman. It also covers the same area as that of an adult woman. The hair usually forms a triangular pattern as it spreads out to the legs.


name: The hair is now as dark, curly, and coarse as that of an adult woman. However, the area that the hair covers is not as large as that of an adult woman. The hair has not spread out to the legs.


name: The hair is darker in this stage. It is coarser and more curled. It has spread out and thinly covers a bigger area.


name: There is a little long, lightly colored hair. This hair may be straight or a little curly


name: This is the mature adult stage. The breasts are fully developed. Only the nipple sticks out in this stage. The areola has moved back in the general shape of the breast.


name: The areola and the nipple make up a mound that sticks up above the shape of the breast. (note: this stage may not happen at all for some teenagers. Some teenagers develop from stage 3 to stage 5 with no stage 4.).


name: The areola and the breast are both larger than in stage 2. The areola does not stick out away from the breast.


name: This is the breast bud stage. In this stage the nipple is raised more than in stage 1. The breast is a small mound. The dark area around the nipple (areola) is larger than in stage 1.


name: The nipple is raised a little in this stage. The rest of the breast is still flat.


name: It stops me doing everything I would like to do


name: It stops me doing most of the things I would like to do


name: It stops me doing one or two things I would like to do


name: It does not stop me doing anything I would like to do


name: My chest trouble interferes with my work or made me change my work


name: My chest trouble does not affect my work


name: My chest trouble made me stop work altogether


name: 0.5 = Very, very slight (just noticeable)


name: Permanent root tip is present but a restorative replacement is present


name: Tooth present, condition cannot be assessed


name: Permanent root tip is present but no restorative replacement is present


name: Missing due to other causes but replaced by a removable restoration


name: Missing due to dental disease but replaced by a removable restoration


name: Missing due to other causes but replaced by a fixed restoration


name: Missing due to dental disease but replaced by a fixed restoration


name: Missing due to other causes (orthodontic/traumatic or other non-disease)


name: Missing due to dental disease (caries/periodontal disease)


name: Sound permanent tooth (no decay or filling on any surface)


name: Confluent pitting of the enamel surface exists


name: Both discrete pitting and staining of the intact enamel exist


name: Discrete pitting of the enamel exists, unaccompanied by evidence of staining of intact enamel


name: Enamel shows staining in conjunction with any of the preceding levels of fluorosis


name: Parchment-white fluorosis totals at least two-thirds of the visible surface


name: Parchment-white fluorosis totals at least one-third of the visible surface, but less than two-thirds


name: Enamel shows definite evidence of fluorosis


name: Crown (short call for both primary and permanent teeth)


name: Other flavored milk (e.g., strawberry, vanilla)


name: Dull, aching pain across your face or cheek


name: Pain in the jaw joint or in front of the ear


name: Chewing tobacco, such as Redman®, Levi Garrett® or Beechnut® at least 20 times


name: Snuff, such as Skoal®, Skoal Bandit® or Copenhagen® at least 20 times


name: Went for treatment of a condition that dentist discovered at earlier check-up or examination


name: Something was wrong, bothering or hurting {me/sample person}


name: Was called in by the dentist for check-up, examination or cleaning


name: Went in on own for check-up, examination or cleaning


name: More than 2 years, but not more than 3 years ago


name: More than 1 year, but not more than 2 years ago


name: More than 6 months, but not more than 1 year ago


name: Not applicable (full dentures, upper and lower - FDUL)


name: A = Yes, but unknown if complete or incomplete


name: My child has a snack in the middle of the night


name: My child has a bottle in the middle of the night


name: Diet soda pop or other sugar-free beverages


name: Regular soda pop or other sugared beverages


name: Only occasionally at bedtimes, including naps


name: During In social settings such as bars, restaurants, bowling alleys, bingo halls, and friends' home


name: Yes, regularly (daily for at least 2 months)


name: Never took regularly or did not stop use


name: Naproxen, ketoprofen or other non-steroidal


name: No, did not see a health professional in past 12 months


name: Nicotine nasal spray, inhaler, lozenge, or tablet


name: No, not thinking of quitting In next 6 months


name: Yes, plan to stop within next 6 months, but not within next 30 days


name: Colonoscopy, sigmoidoscopy, or barium enema


name: Yes, but I am no longer taking estrogens


name: Yes, and I am currently taking estrogens


name: Wall-papering, at least half of the wall area


name: Wall-papering, less than half of the wall area


name: Painting, at least half of the wall area


name: Painting, less than half of the wall area


name: Broiling, smoking, grilling or frying outside the house


name: Broiling, smoking, grilling or frying inside the house


name: Paints or solvents, paint thinners and removers, typewriter corrective fluids


name: Hobbies like woodworking or refinishing furniture


name: Have a marked increase or decrease in appetite, that is, have a significant change from your normal level


name: Feel nervous, tense, restless or irritable


name: See, hear, or feel things that weren't really there


name: Think that people were plotting to harm you (paranoid)


name: Have gooseflesh, goose bumps, or get chills


name: Feel slowed down, like you could hardly move


name: Have strong desire or craving for this drug


name: Having trouble concentrating or having such trouble thinking clearly


name: Decreased contact with friends or family


name: Stimulants, for example, preludin, benzedrine, methedrine, ritalin, uppers, or speed


name: More than 12 months ago but within the past 3 years


name: More than 30 days ago but within the past 12 months


name: More than 35 cigarettes per day (about 2 packs or more)


name: 26 to 35 cigarettes per day (about 1 1/2 packs)


name: 6 to 15 cigarettes per day (about 1/2 pack)


name: Hearing, seeing, or smelling things that weren't really there


name: Feeling paranoid or suspicious of people


name: Feeling jumpy or easily startled or nervous


name: Feeling depressed or uninterested in things


name: Memory problems even when you weren't drinking


name: Single service plan (e.g. dental, vision, prescriptions)


name: Military health care (tricare/VA, Champ-VA)


name: SCHIP (CHIP/Children's health insurance program)


name: Medicaid (if available, display plan name)


name: Professional school degree (example: MD, DDS, DVM, JD)


name: Associate degree: occupational, technical, or vocational program


name: Outside the United States - Print U.S. Territory (e.g., Puerto Rico, U.S. Virgin Islands, Guam) or name of foreign country, etc.


name: In the United States - Print name of state


name: Can walk on their own without using walking aids, and can go up or down stairs without needing to hold the handrail.


name: Can stand on their own and only walks using a walking aid (such as a walker, rollator, crutches, canes, etc.)


name: Can walk on their own without using a walking aid, but has difficulty walking long distances or on uneven surfaces.


name: Can walk on their own using a walking aid (such as a walker, rollator, crutches, canes, etc.)


name: Has difficulty sitting on their own and controlling their head and body posture in most positions


name: Can walk on their own without using a walking aid, including fairly long distances, outdoors and on uneven surfaces.


name: Can sit on their own but does not stand or walk without significant support and adult supervision.


name: Can sit on own and moves by walking without a walking aid.


name: Can sit on own and usually moves by walking with a walking aid.


name: Can sit on own and walk short distances with a walking aid (such as a walker, rollator, crutches, canes, etc.)


name: Can sit on own when placed on the floor and can move within a room


name: Has difficulty controlling head and trunk posture in most positions


name: Cooked cereals (such as oatmeal, cream of wheat, grits)


name: Cereals with some bran or fiber (such as Cheerios®, Raisin Bran®, Shredded Wheat®, Total®, Wheaties®, 40% Bran flakes®, Granola, Grape Nuts®, Muselix®, etc.)


name: Cereals with little bran or fiber (such as Corn Flakes®, Honey Nut Cheerios®, Froot Loops®, Rice Krispies®, Kix®, Frosted Flakes®, Special K®, Cap'n Crunch®, Blueberry Morning®, Product 19®, etc.)


name: All bran cereals (such as All Bran®, Fiber One®, 100% Bran®, or Bran Buds®)


name: Patient record does not state whether a surgical procedure of the primary site was performed and no information is available. Death certificate only.


name: No surgical procedure of primary site at this facility. Diagnosed at autopsy.


name: No proper value is applicable in this context (e.g., no subsequent therapy)


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown if any subsequent therapy)


name: A valid date value is provided in item Subsq RX 2nd Course Date [1660], or the date was not expected to have been transmitted


name: No proper value is applicable in this context (e.g., no surgical procedure was performed; autopsy only case).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., surgery of the primary site was performed but the date is unknown).


name: No proper value is applicable in this context (e.g., no radiation therapy administered; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown whether any radiation therapy administered).


name: Information is not available at this time, but it is expected that it will be available later (e.g., radiation therapy is planned as part of the first course of therapy, but had not been started at the time of the most recent follow-up).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., radiation therapy administered but date is unknown).


name: No proper value is applicable in this context (e.g., no other treatment administered; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g, unknown if other therapy administered).


name: A valid date value is provided in item RX Date-Other [1250], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., other therapy administered but the date is unknown).


name: No proper value is applicable in this context (e.g., no hormone therapy administered; autopsy only cases).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown if any hormone therapy administered).


name: Information is not available at this time, but it is expected that it will be available later (e.g., hormone therapy is planned as part of the first course of therapy, but had not been started at the time of the most recent follow-up).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., hormone therapy administered but date is unknown).


name: No proper value is applicable in this context (e.g., no diagnostic or staging procedure performed; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g, unknown if any diagnostic or staging procedure performed).


name: A valid date value is provided in item RX Date-DX/Stg Proc [1280], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., diagnostic or staging procedure performed but date is unknown).


name: No proper value is applicable in this context (e.g., no chemotherapy administered; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown if chemotherapy administered).


name: Information is not available at this time, but it is expected that it will be available later (e.g., chemotherapy is planned as part of the first course of therapy, but had not been started at the time of the most recent follow-up).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., chemotherapy administered but date is unknown).


name: No proper value is applicable in this context (e.g., no immunotherapy administered; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g, unknown if immunotherapy administered).


name: Information is not available at this time, but it is expected that it will be available later (e.g., immune therapy is planned as part of the first course of therapy, but had not been started at the time of the most recent follow-up).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., immunotherapy administered but date is unknown).


name: No proper value is applicable in this context (e.g., no surgical treatment of the primary site was performed; autopsy only case).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown whether surgical treatment was performed).


name: A valid date value is provided in item RX Date-Surgical Disch [3180], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., surgical treatment performed but the date of discharge is unknown).


name: No proper value is applicable in this context (e.g., radiation therapy was not administered; diagnosed at autopsy).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown if radiation therapy administered).


name: Information is not available at this time, but it is expected that it will be available later (e.g., radiation was administered and was ongoing at the time of most recent follow-up).


name: A valid date value is provided in item RX Date-Radiation Ended [3220], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., date radiation ended is unknown).


name: No proper value is applicable in this context (e.g., no surgical resection of the primary site was performed and for cases diagnosed at autopsy).


name: No information whatsoever can be inferred from this exceptional value (e.g., unknown if any surgical procedure of the primary site was performed).


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., surgical procedure of the primary site was performed but the date is unknown).


name: Lymph-vascular Invasion Not Present (absent)/Not Identified


name: Unknown if patient was an inpatient (only used for consolidated cases)


name: Not a two, three or four grade system; unknown


name: Neoadjuvant therapy was not administered as part of the first course of therapy


name: Neoadjuvant therapy was administered as part of the first course of therapy


name: No proper value is applicable in this context (e.g., single tumor; information on multiple tumors not collected/not applicable for this site).


name: A valid date value is provided in item Date Multiple Tumors [445], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., patient was diagnosed with multiple tumors and the date is unknown).


name: A valid date value is provided in item Date of Last Contact [1750], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., date of last contact is unknown).


name: A valid date value is provided in item Date of Inpatient Disch [600], or the date was not expected to have been transmitted.


name: No proper value is applicable in this context (e.g., patient was never an inpatient at the reporting facility).


name: No information whatsoever can be inferred from this exceptional value (e.g, unknown if patient was an inpatient).


name: A valid date value is provided in item Date of Inpatient Adm [590], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known. This event occurred, but the date is unknown (e.g., the patient was an inpatient but the date is unknown).


name: A valid date value is provided in item Date of Diagnosis [390], or the date was not expected to have been transmitted


name: A proper value is applicable but not known. (e.g., date of diagnosis is unknown)


name: No proper value is applicable in this context (e.g. patient is alive)


name: No information whatsoever can be inferred from this exceptional value (e.g, patient is not known to be deceased)


name: A valid date value is provided in item Date of Death-Canada [1755], or the date was not expected to have been transmitted


name: A proper value is applicable but not known (e.g., date of death is unknown)


name: A valid date value is provided in item Date of Birth [240], or the date was not expected to have been transmitted


name: A proper value is applicable but not known (i.e., birth date is unknown)


name: No proper value is applicable in this context (e.g., autopsy only case)


name: No information whatsoever can be inferred from this exceptional value (e.g, unknown whether treatment was administered)


name: A valid date value is provided in item Date of 1st Crs RX [1270], or the date was not expected to have been transmitted


name: A proper value is applicable but not known (e.g., treatment administered but date is unknown)


name: A valid date value is provided in item Date of 1st Contact [580], or the date was not expected to have been transmitted


name: A proper value is applicable but not known (e.g., date of 1st contact is unknown)


name: No proper value is applicable in this context. (e.g., accessioned based on ambiguous terminology only [Code 1 in data item Ambiguous Terminology DX]; not applicable, initial diagnosis made by unambiguous terminology [Code 0 in data item Ambiguous Terminol


name: No information whatsoever can be inferred from this exceptional value. (e.g., unknown if the diagnosis was initially based on ambiguous terminology).


name: A valid date value is provided in item Date of Conclusive DX [443], or the date was not expected to have been transmitted.


name: A proper value is applicable but not known (e.g., the initial ambiguous diagnosis was followed by a conclusive term, but the date of the conclusive term is unknown).


name: Pattern consistent with IBD: Ulcerative colitis


name: Pattern consistent with IBD: Crohn's disease


name: Cardiac procedure such as coronary artery bypass graft (CABG) or angioplasty


name: Possible fatal coronary heart disease (CHD) (no known non-atherosclerotic cause, and death certificate underlying cause: 120-25, 146, 151.6, R96 or R98-99)


name: Definite fatal coronary heart disease (CHD) (no known non-atherosclerotic cause, and one or both of the following: chest pain within 72 hours of death or a history of chronic ischemic heart disease)


name: Definite fatal myocardial infaction (MI) (no known non-artherosclerotic cause and definite myocardial infarction within 4 weeks of death)


name: Unknown because death certificate unavailable (skip to end)


name: Non-cardiovascular disease (specify) (skip to end)


name: Other cardiovascular disease, not defined above (specify) (complete question 12 only)


name: Atherosclerotic disease other than coronary disease or stroke (specify) (complete question 12 only)


name: Atherosclerotic coronary heart disease (complete questions 10, 11 and 12 only)


name: Nursing Home, Skilled Nursing Facility (SNF), or Extended Care Facility (ECF)


name: Emergency Room (not dead on arrival - DOA)


name: At least 4 hours, but less than 12 hours


name: At least 12 hours, but less than 24 hours


name: Diagnosis of deep vein thrombosis (DVT) based on >= 1 deep vein thrombosis (DVT) criteria in question 1.3 (link to Form 126 in Source section below) plus signs and symptoms suggestive of pulmonary embolism (PE) (e.g., acute chest pain, dyspnea, ....)


name: Positive findings on pulmonary angiogram or spiral CAT scan (CT)


name: High probability orn ventilation-perfusion lung scan (exclude moderate, intermediate, or low probability on ventilation-perfusion lung scan)


name: Deep vein thrombosis of lower extremities not resulting from a procedure within 60 days


name: Physician's office/private medical practitioner


name: Positive findings on doppler duplex, ultrasound, sonogram, or other non-invasive test examination


name: Positive findings using a impedance plethysmography


name: Hospital discharge summary with a diagnosis of deep vein thrombosis


name: Pulmonary embolism during or following a procedure within 60 days


name: Pulmonary embolism not resulting from a procedure within 60 days


name: Evolution of ST-Depression/Inversion alone


name: Evolution of ST-T Elevation with or without Q-Wave


name: Don't know if he or she had a heart attack


name: In utero infection(s) such as herpes, rubella, syphilis, and toxoplasmosis


name: Hyperbilirubinemia with exchange transfusion


name: Aminoglycoside administration for more than 5 days


name: Discharge to community determined to be not feasible


name: Discharge to community determined to be feasible


name: Indicators of pain or possible pain observed daily


name: Indicators of pain or possible pain observed 3 to 4 days


name: Indicators of pain or possible pain observed 1 to 2 days


name: Discharge assessment - return anticipated


name: Discharge assessment - return not anticipated


name: No sample collected due to parental refusal


name: Subsequent screen - for clarification of initial results (not by law or protocol)


name: Subsequent screen - required by protocol


name: Testing of this specimen indicates more than one source of blood is present on the filter paper card


name: Specimen quantity insufficient because blood did not completely fill specimen circles


name: Specimen quantity insufficient due to incomplete saturation (blood did not soak through paper)


name: Specimen received in sealed plastic container


name: Specimen appears diluted, discolored or contaminated


name: Meconium ileus or other bowel obstruction


name: Systemic antibiotics before newborn screening


name: Infant in NICU at time of specimen collection


name: Any blood product transfusion (including ECLS/ECMO)


name: Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)


name: Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA)


name: Frailty indicators, e.g., weight loss, self-reported exhaustion


name: History of falls (2 or more falls - or any fall with an injury - in the past year)


name: Multiple hospitalizations (2 or more) in the past 12 months


name: Recent decline in mental, emotional, or behavioral status


name: Unable to take medication unless administered by another person.


name: Able to take medication(s) at the correct times if given reminders by another person at the appropriate times


name: Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.


name: Unable to take injectable medication unless administered by another person.


name: Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection


name: Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.


name: Patient transferred to a non-institutional hospice


name: Patient remained in the community (with formal assistive services)


name: Patient remained in the community (without formal assistive services)


name: GI bleeding, obstruction, constipation, impaction


name: Cardiac dysrhythmia (irregular heartbeat)


name: Yes, used hospital emergency department WITH hospital admission


name: Yes, used hospital emergency department WITHOUT hospital admission


name: Assistance needed, but no caregiver(s) available


name: Unclear if caregiver(s) will provide assistance


name: Caregiver(s) not likely to provide assistance


name: Caregiver(s) need training/ supportive services to provide assistance


name: Caregiver(s) currently provide assistance


name: Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications


name: No clinically significant medication issues identified since the previous OASIS assessment


name: Yes, and it does not indicate a risk for falls.


name: No multi-factor falls risk assessment conducted.


name: Able to independently plan and prepare all light meals for self or reheat delivered meals; or Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past.


name: Able to feed self independently but requires: (a) meal set-up; OR (b) intermittent assistance or supervision from another person; OR (c) a liquid, pureed or ground meat diet.


name: Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.


name: With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.


name: Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device).


name: Able to bear weight and pivot during the transfer process but unable to transfer self.


name: Able to transfer with minimal human assistance or with use of an assistive device.


name: Patient depends entirely upon another person to maintain toileting hygiene.


name: Someone must help the patient to maintain toileting hygiene and/or adjust clothing.


name: Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.


name: Able to manage toileting hygiene and clothing management without assistance.


name: When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.


name: Able to get to and from the toilet and transfer independently with or without a device.


name: Unable to effectively participate in bathing and is totally bathed by another person.


name: Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person.


name: Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode.


name: Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.


name: Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.


name: With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower.


name: Able to bathe self in shower or tub independently, including getting in and out of tub/shower.


name: Yes, patient was screened with a different standardized, validated assessment and the patient does not meet criteria for further evaluation for depression.


name: Yes, patient was screened with a different standardized, validated assessment and the patient meets criteria for further evaluation for depression.


name: Yes, patient was screened using the PHQ-2© scale.


name: Obtained change in care plan orders (for example, increased monitoring by agency, change in visit frequency, telehealth, etc.)


name: Patient education or other clinical interventions


name: Implemented physician-ordered patient-specific established parameters for treatment


name: Patient advised to get emergency treatment (for example, call 911 or go to emergency room)


name: Patient's physician (or other primary care practitioner) contacted the same day


name: Patient does not have diagnosis of heart failure


name: Continuous / Bi-level positive airway pressure


name: Surgical wound known but not observable due to non-removable dressing/device


name: Yes, patient has at least one observable surgical wound


name: Stasis ulcer known but not observable due to non-removable dressing


name: Yes, patient has one or more (observable) stasis ulcers


name: No observable pressure ulcer or unhealed pressure ulcer


name: No non-epithelialized Stage II pressure ulcers are present at discharge


name: Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified: __ __ /__ __ /____ __ __


name: Was present at the most recent SOC/ROC assessment


name: Patient has pain that does not interfere with activity or movement


name: Yes, and it does not indicate severe pain


name: Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (for example, speech is nonsensical or unintelligible).


name: Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single words or short phrases.


name: Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.


name: Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in word choice, grammar or speech intelligibility; needs minimal prompting or assistance).


name: Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand


name: Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand


name: Severely Impaired: Absence of useful hearing


name: Mildly to Moderately Impaired: Difficulty hearing in some environments or speaker may need to increase volume or speak distinctly


name: Adequate: hears normal conversation without difficulty.


name: Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path, and the surrounding layout; can count fingers at arm's length.


name: Not indicated; patient does not meet age/condition guidelines for PPV


name: Not indicated; patient does not meet age/condition guidelines for influenza vaccine


name: Assessed and determined to have medical contraindication(s)


name: Received from your agency previously during this year's flu season


name: Received from another health care provider (e.g., physician)


name: Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season.


name: The patient's situation is unknown or unclear.


name: The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.


name: The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient's age).


name: The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient's age).


name: Not Applicable: No Medicare case mix group to be defined by this assessment.


name: Medicare (HMO/managed care/Advantage plan)


name: Screen is out of range for at least one condition


name: Screen is indeterminate for at least one condition


name: Screen is borderline for at least one condition


name: All screening is in range for the conditions tested


name: Initial GCS has legitimate values without interventions such as intubation and sedation


name: Nursing home not OMBRA and not PPS assessment


name: Nursing home discharge coupled with EMCA


name: Nursing home quarterly assessment coupled with PPS assessment


name: Nursing home comprehensive assessment coupled with PPS assessment


name: No family or significant other available


name: If not resident, family, or significant other, then guardian or legally authorized representative


name: If not resident, then family or significant other


name: Resident not in facility during this year's flu season


name: Inability to obtain vaccine due to declared shortage


name: Combat Exposure Scale CES0104 Original Result - 26-50%


name: Neither federal nor state required submission


name: State but not federal required submission (FOR NURSING HOMES ONLY)


name: Yes, not on physician-prescribed weight-loss regimen


name: Yes, on physician-prescribed weight-loss regimen


name: Not rated, patient had an ostomy or did not have a bowel movement for the entire 7 days


name: Always incontinent (no episodes of continent bowel movements)


name: Occasionally incontinent (one episode of bowel incontinence)


name: Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days


name: Always incontinent (no episodes of continent voiding)


name: Frequently incontinent (7 or more episodes of urinary incontinence, but with at least one episode of continent voiding)


name: Occasionally incontinent (less than 7 episodes of incontinence)


name: Unable to determine or trial in progress


name: Not steady, only able to stabilize with staff assistance


name: Not steady, but able to stabilize without staff assistance


name: Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other)


name: No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other)


name: Interview could not be completed by resident or family/significant other (No response to 3 or more items)


name: Family or significant other (close friend or other representative)


name: No (resident is rarely/never understood and family/significant other not available)


name: Behavior of this type occurred 1 to 3 days


name: Behavior present, fluctuates (comes and goes, changes in severity)


name: SEVERELY IMPAIRED-never/rarely made decisions


name: Moderately impaired - decisions poor; cues/supervision required


name: MODIFIED INDEPENDENCE-some difficulty in new situations only


name: Yes (resident was unable to complete interview)


name: No (resident was able to complete interview)


name: No (resident is rarely/never understood)


name: SEVERELY IMPAIRED- no vision or sees only light color, or shapes; eyes do not appear to follow objects


name: HIGHLY IMPAIRED-object identification in question, but eyes appear to follow objects


name: MODERATELY IMPAIRED- limited vision; not able to see newspaper headlines, but can identify objects


name: Sometimes understands - responds adequately to simple, direct communication only


name: Usually understands - misses some part/intent of message but comprehends most conversation


name: Sometimes understood - ability is limited to making concrete requests


name: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time


name: Unclear speech - slurred or mumbled words


name: CLEAR SPEECH- distinct, intelligible words


name: HIGHLY IMPAIRED-absence of useful hearing


name: Moderate difficulty - speaker has to increase volume and speak distinctly


name: Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)


name: Adequate - no difficulty in normal conversation, social interaction, listening to TV


name: Community (private home/apt., board/care, assisted living, group home)


name: Both Start and End of therapy assessment


name: Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)


name: Significant correction of prior quarterly assessment


name: Significant correction to prior comprehensive assessment


name: Not performed, medical exclusion - not indicated


name: Distortion Product Otoacoustic Emissions


name: Other Asian, including Asian , NOS and Oriental, NOS


name: American Indian, Aleutian, or Eskimo (includes all indigenous populations of the Western hemisphere)


name: Patient does not answer or is unable to respond


name: Behavior present, fluctuates (e.g., comes and goes, changes in severity).


name: Yes, after cueing (a piece of furniture)


name: Community based residence (e.g., assisted living residence, group home, adult foster care)


name: Long-term care facility (e.g., nursing home)


name: Community residential setting (e.g., private home, assisted living, group home, adult foster care)


name: Family/support (e.g., family could not pick patient up)


name: Services, equipment or medications not available (e.g., home health care, durable medical equipment, IV medications)


name: CG will need training and/or other supportive services


name: Unclear from patient; no confirmation from caregiver


name: Less than daily but more often than weekly


name: Intermittently and predictably during the day or night


name: Weekly or less (e.g., requires help with grocery shopping or errands, etc.)


name: Inpatient rehabilitation hospital or unit (IRF)


name: Other community-based residential setting (e.g., assisted living residents, group home, adult foster care)


name: Other (e.g., shelter, jail, no known address)


name: The patient (or surrogate) has made a decision to forgo resuscitation which is documented in the medical record.


name: The patient has designated a decision-maker (if the patient is unable to make decisions) which is documented in the medical record.


name: The patient's situation is unknown or unclear to the respondent.


name: The patient is temporarily facing high health risks but likely to return to being stable without risk for serious complications and death (beyond those typical of the patient's age).


name: The patient is stable with no risk for serious complications and death (beyond those typical of the patient's age).


name: The patient has serious progressive conditions that could lead to death within a year.


name: Not attempted due to environmental constraints


name: With moderate exertion (e.g., while dressing, using commode or bedpan, walking between rooms)


name: Severe, with evidence the patient is struggling to breathe at rest


name: Fully weight-bearing: No clinician ordered restrictions


name: Not fully weight-bearing: Patient has clinician ordered restrictions


name: Adequate: Hears normal conversation and TV without difficulty


name: Severely Impaired: No vision or object identification questionable


name: Mildly to Moderately Impaired: Can identify objects; may see large print


name: Frequently exhibits difficulty with expressing needs and ideas


name: Expresses complex messages without difficulty and with speech that is clear and easy to understand


name: Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear


name: Rarely/Never expresses self or speech is very difficult to understand.


name: Understands: clear comprehension without cues or repetitions.


name: Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance.


name: Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency.


name: Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety.


name: Holding food in mouth/cheeks or residual food in mouth after meals


name: Coughing or choking during meals or when swallowing medications


name: Complaints of difficulty or pain with swallowing


name: Loss of liquids/solids from mouth when eating or drinking


name: Not applicable (e.g., indwelling catheter)


name: Incontinence daily (at least once a day)


name: No urine/bowel output (e.g., renal failure)


name: Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw)


name: Vocal complaints of pain (e.g., that hurts, ouch, stop)


name: Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement)


name: Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning)


name: None of these signs observed or documented


name: That he or she is in a hospital, nursing home, or home


name: Yes, indicated by high risk by formal assessment (e.g., on Braden or Norton tools) or the patient has a stage I or greater ulcer, a scar over a bony prominence, or a non-removable dressing, device, or cast.


name: Left Ventricular Assistive Device (LVAD)


name: IV Vaso-actors (e.g., pressors, dilators, medication for pulmonary edema)


name: Indwelling Bowel Catheter Management System


name: High O2 Concentration Delivery System with FiO2 > 40%


name: Controlled Parenteral Analgesia - Peripheral


name: Controlled Parenteral Analgesia - Epidural


name: Complex Wound Management with positioning and skin separation/traction that requires at least two persons or extensive & complex wound management by one person


name: Complex External Fixators (e.g., Ilizarov)


name: Multiple Types of IV Antibiotic Administration


name: Specialty Surface or Bed (i.e., air fluidized, bariatric, low air loss, or rotation bed)


name: Other Major Treatments, e.g. isolation, hypothermia blanket


name: Other government (e.g., TRICARE, VA, etc.)


name: Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.


name: Dependent - A helper completed the activity for the patient.


name: Needed partial assistance - Patient needed partial assistance from another person to complete activities.


name: Insufficient space to accommodate extra equipment (e.g., hospital bed, vent equipment).


name: Stairs leading from inside to outside of living setting.


name: Stairs inside the living setting that must be used by patient (e.g., to get to toileting, sleeping, eating areas).


name: Narrow or obstructed doorways for patients using wheelchairs or walkers.


name: Independent - Patient completes the activity by themself with no assistance from a helper.


name: Dependent - Helper does all of the effort. Patient does none of the effort to complete the task.


name: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.


name: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.


name: Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.


name: Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.


name: Discharged prior to completing initial assessment


name: Out of range requiring deferred follow-up for at least one condition


name: Specimen unsatisfactory for at least one condition


name: Out of range requiring immediate second-tier testing for at least one condition


name: No (Includes situations in which there was no source or when the source(s) did not provide a statement regarding the claimant's physical capacities.)


name: limited in lower extremities (describe nature and degree)


name: limited in upper extremities (describe nature and degree)


name: Unlimited, other than as shown for lift and/or carry


name: must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in 6.)


name: Less than about 6 hours in an 8-hour workday


name: medically required hand-held assistive device is necessary for ambulation


name: No evidence of limitation in this category


name: UNABLE to transfer self but is able to bear weight and pivot during the transfer process.


name: Unable to transfer self and is unable to bear weight or pivot when transferred by another person.


name: Transfers with minimal human assistance or with use of an assistive device.


name: Bedfast, unable to transfer but is able to turn and position self in bed.


name: Bedfast, unable to transfer and is unable to turn and position self.


name: When reminded, assisted, or supervised by another person, able to get to and from the toilet.


name: Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.


name: Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).


name: Able to get to and from the toilet independently with or without a device.


name: With the use of devices, is able to bathe self in shower or tub independently.


name: UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.


name: Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in/out of shower/tub, OR c) for washing difficult to reach areas.


name: Able to bathe self in SHOWER OR TUB independently.


name: Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.


name: Patient depends entirely upon another person to dress lower body.


name: Able to obtain, put on, and remove clothing and shoes without assistance.


name: Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.


name: Someone must help the patient put on upper body clothing.


name: Patient depends entirely upon another person to dress the upper body.


name: Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.


name: Able to dress upper body without assistance if clothing is laid out or handed to the patient.


name: Someone must assist the patient to groom self.


name: Patient depends entirely upon someone else for grooming needs.


name: Grooming utensils must be placed within reach before able to complete grooming activities.


name: Able to groom self unaided, with or without the use of assistive devices or adapted methods.


name: During the day and evening, but not constantly


name: Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.


name: Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.


name: Requires assistance and some direction in specific situations (for example, all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.


name: Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.


name: The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen.


name: Patient's ostomy was not related to an inpatient stay and did not necessitate change in medical or treatment regimen.


name: Patient does not have an ostomy for bowel elimination.


name: Very rarely or never has bowel incontinence


name: Patient has ostomy for bowel elimination


name: Hospitalization for URGENT (scheduled within 24 hours of admisson) care


name: Hospitalization for EMERGENT (unscheduled) care


name: Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care


name: Unknown because patient moved to a geographic location not served by this agency


name: Patient transferred to a noninstitutional hospice


name: Patient remained in the community (not in hospital, nursing home, or rehab facility)


name: If someone else sets up equipment, caregiver is able to manage all other aspects.


name: Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.


name: Caregiver manages all tasks related to equipment completely independently.


name: Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).


name: Caregiver is completely dependent on someone else to manage all equipment.


name: Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.


name: Patient manages all tasks related to equipment completely independently.


name: Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.


name: Patient is completely dependent on someone else to manage all equipment.


name: If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient w/prep solns), patient able to manage all other aspects of equipment.


name: UNABLE to take injectable medications unless administered by someone else.


name: Able to take injectable medication at correct times if: a) indiv syringes are prep in advance by another person OR b) given daily reminders.


name: No inhalant/mist medications prescribed.


name: Able to take medication at the correct times if: a) indiv dosages are prep in advance by another person OR b) given daily reminders.


name: UNABLE to take medication unless administered by someone else.


name: Able to take medication(s) at correct times if: a) indiv dosages prep in advance OR b) given daily reminders OR c) uses drug diary or chart.


name: Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.


name: Unable to answer the telephone at all but can listen if assisted with equipment.


name: Able to use a specially adapted telephone (for example, large numbers on the dial, teletype phone for the deaf) and call essential numbers.


name: Able to dial numbers and answer calls appropriately and as desired.


name: Able to answer the telephone only some of the time or is able to carry on only a limited conversation.


name: Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.


name: UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.


name: Needs someone to do all shopping and errands.


name: Needs some assistance: a) By self is able to do only light shopping and carry small packages OR b) UNABLE to go shopping alone


name: a) Able to plan for shopping needs and indep perform shopping tasks OR b) Physically/cognitively/mentally able to take care of shopping


name: Unable to effectively participate in any housekeeping tasks.


name: UNABLE to consistently perform any housekeeping tasks unless assisted by another person throughout the process.


name: Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.


name: Able to perform housekeeping tasks with intermittent assistance or supervision from another person.


name: a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .


name: UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.


name: Able to do only light laundry, (minor hand wash or light loads). Due to physical/cognitive/mental limitations, needs assist with heavy laundry.


name: a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.


name: UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.


name: Able to ride in car only when driven by another person OR able to use bus/handicap van only when assisted/accompanied by another person.


name: Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.


name: Unable to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.


name: Unable to prepare any light meals or reheat any delivered meals.


name: a) Able to indep plan and prep all lt meals for self or reheat delivered meals OR b) Physically/cognitively/mentally able to prepare lt meals.


name: Unable to take in nutrients orally or by tube feeding.


name: Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.


name: Unable to feed self and must be assisted or supervised throughout the meal/snack.


name: Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.


name: Able to feed self independently but requires: a) meal set-up OR b) intermittent aid/supervision OR c) liquid/pureed/ground meat diet.


name: Requires device (e.g., cane, walker) to walk alone OR requires human supervision/assistance to negotiate stairs/steps/uneven surfaces.


name: Chairfast, unable to ambulate but is able to wheel self independently.


name: Chairfast, unable to ambulate and is unable to wheel self.


name: Bedfast, unable to ambulate or be up in a chair.


name: Able to walk only with the supervision or assistance of another person at all times.


name: Able to independently walk on even/uneven surfaces and climb stairs with or without railings (i.e., needs no human assist or assist device).


name: Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or suprapubic)


name: No incontinence or catheter (includes anuria or ostomy for urinary drainage)


name: With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)


name: With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation


name: When walking more than 20 feet, climbing stairs


name: Patient has no pain or pain does not interfere with activity or movement


name: Xpresses simple ideas/needs w/moderate diff (needs prompting or assist, errors in word choice, org. or speech intell). Speaks in phrases/short sentcs.


name: UNABLE to xpress basic needs even w/maximal prompting or assist but is not comatose/unresponsive (e.g., speech is nonsensical/unintelligible).


name: Patient nonresponsive or unable to speak.


name: Min diff in xpressing ideas/needs (may take xtra time, occasional errors in word choice/grammar/speech intelligibility, needs min prompting or assist).


name: Has severe difficulty expressing basic ideas or needs and requires max assistance or guessing by listener. Speech limited to single words or short phrases.


name: Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.


name: W/ min difficulty, able to hear and understand most multi-step instructns and ordinary conversatn. May need occasional repetition, xtra time or louder voice.


name: UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.


name: No observable impairment. Able to hear and understand complex or detailed instructions and extended or abstract conversation.


name: Has severe difficulty hearing and understanding simple greetings and short comments. Requires mult repetitions, restatements, demonstrations, addtl time.


name: Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.


name: Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive.


name: Partially impaired: cannot see medication labels/newsprint, but CAN see obstacles in path, and surrounding layout, can count fingers at arm's length.


name: Friend or neighbor or community or church member


name: Board and care or assisted living facility


name: Life expectancy is greater than 6 months


name: Guarded: minimal improvement in functional status is expected, decline is possible


name: Good: marked improvement in functional status is expected


name: Poor: little or no recovery is expected and/or further decline is imminent


name: Good/Fair: partial to full recovery is expected


name: Transferred to an inpatient facility - patient not discharged from agency


name: Transferred to an inpatient facility - patient discharged from agency


name: Start of care - no further visits planned


name: Resumption of care (after inpatient stay)


name: Discharge from agency - no visits completed after start/resumption of care assessment


name: Wound or tube site infection, deteriorating wound status, new lesion/ulcer


name: Respiratory problems (SOB, infection, obstruction)


name: Exacerbation of CHF, fluid overload, heart failure


name: Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health, homemaker assistnc, transportation assistnc)


name: Yes, assistance or services provided by family or friends


name: Wound infection, deteriorating wound status, new lesion/ulcer


name: Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)


name: Injury caused by fall or accident at home


name: Improper medication administration, medication side effects, toxicity, anaphylaxis


name: Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)


name: Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.


name: None of the above behaviors demonstrated


name: Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions


name: Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)


name: Delusional, hallucinatory, or paranoid behavior


name: None of the above feelings observed or reported


name: Depressed mood (e.g., feeling sad, tearful)


name: Psychosocial support (e.g., socialization, companionship, recreation)


name: IADL assistance (e.g., meds, meals, housekeeping, laundry, phone, shopping, finances)


name: Health care agent, conservator of person, or medical power of attorney


name: Financial agent, power of attorney, or conservator of finance


name: Environmental support (e.g., housing, home maintenance)


name: Advocates or facilitates patient's participation in appropriate medical care


name: ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)


name: Relatives, friends, or neighbors living outside the home


name: Person residing in the home (EXCLUDING paid help)


name: With paid help (other than home care agency staff)


name: Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)


name: No inpatient facility discharge and no change in medical/treatment regimen in past 14 days


name: Memory loss to the extent that supervision required


name: Title programs (e.g., Title III, V, or XX)


name: Other government (e.g., CHAMPUS, VA, etc.)


name: Outpatient department/clinic emergency (includes urgicenter sites)


name: Hospital emergency room (includes 23-hour holding)


name: Doctor's office emergency visit/house call


name: Patient was not discharged from an inpatient facility


name: Not in facility during this year's flu season


name: LIMITED ASSISTANCE--Resident highly involved in walking; received physical help in guided maneuvering of limbs or other nonweight bearing assistance


name: SUPERVISION--Oversight, encouragement or cueing provided


name: Improved-receives fewer supports, needs less restrictive level of care


name: Stage 4. A full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone.


name: Stage 3. A full thickness of skin is lost, exposing the subcutaneous tissues - presents as a deep crater with or without undermining adjacent tissue.


name: Stage 2. A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.


name: Stage 1. A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.


name: Combat Exposure Scale CES0104 Original Result - 51-75%


name: Times when pain is horrible or excruciating


name: INCONTINENT-Had inadequate control BLADDER, multiple daily episodes; BOWEL, all (or almost all) of the time


name: FREQUENTLY INCONTINENT-BLADDER, tended to be incontinent daily, but some control present (e.g., on day shift); BOWEL, 2-3 times a week


name: OCCASIONALLY INCONTINENT-BLADDER, 2 or more times a week but not daily; BOWEL, once a week


name: USUALLY CONTINENT-BLADDER, incontinent episodes once a week or less; BOWEL, less than weekly