Att 9_Medical Record Abstraction Data Elements

Att 9_MMP MRA Data Structure 2015.docx

Medical Monitoring Project

Att 9_Medical Record Abstraction Data Elements

OMB: 0920-0740

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Attachment 9

MMP Medical Record Abstraction Data Elements

Medical Monitoring Project

0920-0740



MMP 2015 MEDICAL RECORD ABSTRACTION DATA ELEMENTS

DEMOGRAPHICS

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

absid_mra

Abstractor ID

Abstractor ID

facid_mra*

Facility ID: (Eight digits: Project Area + facility ID)

Facility ID

facloc_mra*

Facility Location

Facility Location

rwfund_mra

Does facility receive Ryan White funding

Ryan White Funded Facility

spstart_mra

Start of Observation

Surveillance period start date

spend_mra

End of Observation

Surveillance period end date

death_mra

Did the participant die during the 2 year observation period?

Patient died

dobmo_mra

Date of birth (Month)

Date of birth (Month)

dobyr_mra

Date of birth (Year)

Date of birth (Year)

gender_mra

Gender

Gender

racend_mra

Not documented

Race not documented

aian_mra

American Indian/Alaska Native

Race American Indian/Alaska Native

asian_mra

Asian

Race Asian

black_mra

Black/African American

Race Black/African American

nhpi_mra

Native Hawaiian/Other Pacific Islander

Race native Hawaiian/other Pacific Islander

white_mra

White

Race White

ethnic_mra

Hispanic/Latino ethnicity or Spanish origin:

Hispanic/Latino ethnicity or Spanish Origin

reimbnd_mra

Not documented

Insurance not documented

reimbadap_mra

AIDS Drug Assistance Program (ADAP)

Insurance ADAP

reimbmc_mra

Medicare

Insurance Medicare

reimbmd_mra

Medicaid

Insurance Medicaid

reimbrw_mra

Ryan White

Insurance Ryan White

reimbtri_mra

Tricare or Champus

Insurance Tricare or Champus

reimbva_mra

Veterans administration coverage

Insurance VA coverage

reimbpvt_mra

Private insurance

Private insurance

reimbsp_mra

None/self-pay

Insurance none/self-pay

reimbpub_mra

City, County, State or other publicly funded

Insurance city, county, state, publicly funded

reimboth_mra

Other insurance

Other insurance

reimbothde_mra

Other insurance description

Other insurance description

hivdateyn_mra

Is the date of first HIV diagnosis documented in the medical record?

Date of HIV diagnosis documented

firsthiv_mra

Date of first HIV diagnosis

Date of HIV diagnosis

_firsthiv_ind_mra

 

Date of HIV diagnosis indicator

cd4lowest_mra

Lowest CD4 count since HIV diagnosis

Lowest CD4 count

cd4lowestd_nd_mra

Date of lowest CD4 count not documented

Date of lowest CD4 count not documented

cd4lowestd_mra

Date of lowest CD4 count

Date of lowest CD4 count

_cd4lowestd_ind_mra

 

Date of lowest CD4 count indicator

cd4lowestsrc_mra

What is the source of the lowest CD4 count?

Source of lowest CD4 count

dthdatend_mra

Date of death not documented

Date of death not documented

dthdate_mra

Date of death

Date of death

_dthdate_ind_mra

 

Date of death indicator



ENCOUNTERS

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

vis_date_mra

Encounter date

Outpatient encounter date

visitloc_mra

Where did the encounter take place?

Place of medical encounter

visitprv_mra

With whom did the encounter take place?

Person with whom medical encounter occurred

hivprvyn_mra

Did the encounter take place with a known HIV provider?

Encounter with known HIV provider

oprvyn_mra

Did the encounter take place with a non-HIV provider?

Encounter with non-HIV provider

oprvtyp_mra

If yes, specify provider type

Non-HIV provider type

othprvothde_mra

Other provider description

Other non-HIV provider description

vital_mra

Were any vital signs documented during the encounter?

Vital signs documented during encounter

physf_mra

One or more physical exam findings documented during visit encounter

Physical exam documented during encounter

arvrx_mra

Antiretroviral therapy prescribed, refilled or continued during visit encounter

ARVs prescribed, refilled or continued during encounter

weightnd_mra

Weight not documented

Weight not documented

weight_mra

Weight

Weight

weightunit_mra

Weight units

Weight units

heightnd_mra

Height not documented

Height not documented

height_ft_mra

Height (feet)

Height (feet)

height_in_mra

Height (inches)

Height (inches)

bpnd_mra

Blood pressure not documented

Blood pressure not documented

bpsys_mra

Systolic blood pressure (mmHg)

Systolic blood pressure

bpdia_mra

Diastolic blood pressure (mmHg)

Diastolic blood pressure







HOSPITALIZATION

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

hospyn_mra

Was the patient hospitalized during the observation period?

Participant hospitalized

inpadmitnd_mra

Inpatient admission date not documented

Inpatient admission date not documented

inpadmit_mra

Inpatient admission date

Inpatient admission date

_inpadmit_ind_mra


Inpatient admission date indicator

inpdischnd_mra

Inpatient discharge date not documented

Inpatient discharge date not documented

inpdisch_mra

Inpatient discharge date

Inpatient discharge date

_inpdisch_ind_mra

 

Inpatient discharge date indicator

inpdiag_mra

Diagnosis

Discharge Diagnosis

inpdiagothde_mra

Diagnosis other description

Other discharge diagnosis description

_inpdiagrt_mra

 

Diagnosis root code

_inpnum_mra

 

Hospitalization number



DIAGNOSES

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

dxrefsoo_mra

Beginning of month 1 (start of observation period)

Beginning of month 1 (start of observation period)

dxref7mo_mra

Beginning of month 7

Beginning of month 7

dxref13mo_mra

Beginning of month 13

Beginning of month 13

dxref19mo_mra

Beginning of month 19

Beginning of month 19

dxrefeoo_mra

End of month 24 (end of observation period)

End of month 24 (end of observation period)

dx_mra

Diagnosis

Diagnosis

dxothde_mra

Other description

Diagnosis Other description

_dxrt_mra

 

Diagnosis root code

_coddx_mra

Diagnosis at death

From COD file

_diagdx_mra

Diagnosis from Diagnosis file

From Diagnosis file

dx6mobs_mra

Started or ongoing in first 6 months

Diagnosis first 6 months

dx12mobs_mra

Started or ongoing 7-12 months

Diagnosis 7-12 months

dx18mobs_mra

Started or ongoing 13-18 months

Diagnosis 13-18 months

dx24mobs_mra

Started or ongoing 19-24 months

Diagnosis 19-24 months

dthcodsrc_mra

Source of cause of death information

Source of cause of death info

codsrcothde_mra

Specify other source:

Other source of cause of death info





MEDICATIONS

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

txrefsoo_mra

Beginning of month 1 (start of observation period)

Beginning of month 1 (start of observation period)

txref7mo_mra

Beginning of month 7

Beginning of month 7

txref13mo_mra

Beginning of month 13

Beginning of month 13

txref19mo_mra

Beginning of month 19

Beginning of month 19

txrefeoo_mra

End of month 24 (end of observation period)

End of month 24 (end of observation period)

tx_mra

Medication

Medication

txothde_mra

Other medication description

Other medication description

_txrt_mra

 

Medication root code

txroute_mra

Medication route

Medication route

txrouteoth_mra

Other route description

Other medication route description

txfreq_mra

Frequency (for ARVs only)

ARV Frequency

txfreqothde_mra

Other ARV frequency description Other frequency (specify)

Other ARV frequency description

tx6mobs_mra

Started or ongoing in first 6 months

Medication first 6 months

tx12mobs_mra

Started or ongoing 7-12 months

Medication 7-12 months

tx18mobs_mra

Started or ongoing 13-18 months

Medication 13-18 months

tx24mobs_mra

Started or ongoing 19-24 months

Medication 19-24 months



PROPHYLAXIS

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

macrefsoo_mra

Beginning of month 1 (start of observation period)

MAC start of observation period

macref7mo_mra

Beginning of month 7

MAC beginning of month 7

macref13mo_mra

Beginning of month 13

MAC beginning of month 13

macref19mo_mra

Beginning of month 19

MAC beginning of month 19

macrefeoo_mra

End of month 24 (end of observation period)

MAC end of month 24

macpx_mra

MAC prophylaxis administered?

MAC prophylaxis administered?

macpxtx_mra

MAC medication

MAC medication

macpxtxothde_mra

Other description

MAC medication other description

mac6mobs_mra

Started or ongoing in first 6 months

MAC Started or ongoing in first 6 months

mac12mobs_mra

Started or ongoing 7-12 months

MAC Started or ongoing 7-12 months

mac18mobs_mra

Started or ongoing 13-18 months

MAC Started or ongoing 13-18 months

mac24mobs_mra

Started or ongoing 19-24 months

MAC Started or ongoing 19-24 months

pcprefsoo_mra

Beginning of month 1 (start of observation period)

PCP start of observation period

pcpref7mo_mra

Beginning of month 7

PCP beginning of month 7

pcpref13mo_mra

Beginning of month 13

PCP beginning of month 13

pcpref19mo_mra

Beginning of month 19

PCP beginning of month 19

pcprefeoo_mra

End of month 24 (end of observation period)

PCP end of month 24

pcppx_mra

PCP prophylaxis administered?

PCP prophylaxis administered?

pcppxtx_mra

PCP medication

PCP medication

pcppxtxothde_mra

Other description

PCP medication other description

pcp6mobs_mra

Started or ongoing in first 6 months

PCP Started or ongoing in first 6 months

pcp12mobs_mra

Started or ongoing 7-12 months

PCP Started or ongoing 7-12 months

pcp18mobs_mra

Started or ongoing 13-18 months

PCP Started or ongoing 13-18 months

pcp24mobs_mra

Started or ongoing 19-24 months

PCP Started or ongoing 19-24 months

flurefsoo_mra

Start of observation period

Flu start of observation period

flurefyr2_mra

Beginning of year 2

Flu beginning of year 2

flurefeoo_mra

End of observation period

Flu end of observation period

flupx_mra

Influenza vaccination administered?

Influenza vaccination administered?

fluyr1_mra

Administered during first year of obs period?

Flu vaccine administered year 1

fludate1_mra

If yes, what date was the influenza vaccine administered in year 1 of the observation period?

Flu vaccine date year 1

_fludate1_ind_mra

 

Flu vaccine date year 1 indicator

fluyr2_mra

Administered during second year of obs period?

Flu vaccine administered year 2

fludate2_mra

If yes, what date was the influenza vaccine administered in year 2 of the observation period?

Flu vaccine date year 2

_fludate2_ind_mra

 

Flu vaccine date year 2 indicator



PROCEDURE

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

procdate_mra

Date of procedure

Date of procedure

_procdate_ind_mra

 

Date of procedure indicator

proc_mra

Procedure

Procedure

procothde_mra

Specify details

Procedure other details







PREGNANCY

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

prg_mra

Pregnant during observation period?

Pregnant

prg_num_mra

Number of pregnancies during observation period

Number of pregnancies

prg_out_mra

Outcome of pregnancy:

Outcome of pregnancy:

prgdatend_mra

Date of pregnancy outcome not documented

Date of pregnancy outcome not documented

prgdate_mra

Date of pregnancy outcome

Date of pregnancy outcome

prgdate_ind_mra

 

Date of pregnancy outcome indicator

prg_meth_mra

Delivery method

Delivery method



LABS

Variable

Question

Label

PARID

Participant ID

Participant ID

_SITEID_mra

 

Site ID

hivlab_date_mra

Collection date

HIV lab date

cd4_result_mra

CD4 count result

CD4 result

cd4_unit_mra

CD4 count units

CD4 units

cd4_unoth_mra

Other description

CD4 other units

cd4pct_result_mra

CD4% result

CD4% Result

viral_load_sign_mra

Viral load sign

Viral load sign

viral_load_mra

Viral load result

Viral load result

viral_load_unit_mra

Viral load units

Viral load units

viral_load_unoth_mra

If other, specify

Viral load other units

viral_load_LL_mra

Lower limit of test

Viral load lower limit

viral_load_LL_oth_mra

If other, specify

Viral load other lower limit

viral_load_UL_mra

Upper limit of test

Viral load upper limit

viral_load_UL_oth_mra

If other, specify

Viral load other upper limit

cbc_date_mra

Collection date

CBC lab date

wbc_res_mra

Result

WBC result

wbc_unit_mra

Units

WBC units

wbc_unoth_mra

Description of other units

WBC other units

hgb_res_mra

Result

Hemoglobin result

hgb_unit_mra

Units

Hemoglobin units

hgb_unoth_mra

Description of other units

Hemoglobin other units

plt_res_mra

Result

Platelets result

plt_unit_mra

Units

Platelets units

plt_unoth_mra

Description of other units

Platelets other units

mvc_res_mra

Result (fL)

MCV result

neut_res_mra

Result

Neutrophils result

neut_unit_mra

Units

Neutrophils units

neut_unoth_mra

Description of other units

Neutrophils other units

chem_date_mra

Collection date

Chemistry lab date

fasting_lab_mra

Fasting lab?

Chemistry fasting

glu_res_mra

Result

Glucose result

glu_unit_mra

Units

Glucose units

glu_unoth_mra

Description of other units

Glucose other units

creat_res_mra

Result

Creatinine result

creat_unit_mra

Units

Creatinine units

creat_unoth_mra

Description of other units

Creatinine other units

calc_res_mra

Result

Calcium result

calc_unit_mra

Units

Calcium units

calc_uoth_mra

Description of other units

Calcium other units

alb_res_mra

Result

Albumin result

alb_unit_mra

Units

Albumin units

alb_unoth_mra

Description of other units

Albumin other units

ast_res_mra

Result

AST (SGOT) result

ast_unit_mra

Units

AST (SGOT) units

ast_unoth_mra

Description of other units

AST (SGOT) other units

alt_res_mra

Result

ALT (SGPT) result

alt_unit_mra

Units

ALT (SGPT) units

alt_unoth_mra

Description of other units

ALT (SGPT) other units

tbili_res_mra

Result

Total bilirubin result

tbili_unit_mra

Units

Total bilirubin units

tbili_unoth_mra

Description of other units

Total bilirubin other units

othchem_date_mra

Collection date

Other chemistry lab date

hgba1c_res_mra

Result (%)

Hemoglobin A1c result

vitd_res_mra

Result

Vitamin D result

vitd_unit_mra

Units

Vitamin D units

vitd_unoth_mra

Description of other units

Vitamin D other units

pth_res_mra

Result

Parathyroid Hormone result

pth_unit_mra

Units

Parathyroid Hormone units

pth_unoth_mra

Description of other units

Parathyroid Hormone other units

inr_res_mra

Result

International Normalized Ratio

tsh_res_mra

Result

Thyroid stimulating hormone result

tsh_unit_mra

Units

Thyroid stimulating hormone units

tsh_unoth_mra

Description of other units

Thyroid stimulating hormone other units

ttest_res_mra

Result

Total testosterone result

ttest_unit_mra

Units

Total testosterone units

ttest_unoth_mra

Description of other units

Total testosterone other units

lipid_date_mra

Collection date

Lipid lab date

lipid_fast_mra

Fasting lab?

Lipid fasting

chol_res_mra

Result

Cholesterol result

chol_unit_mra

Units

Cholesterol units

chol_unoth_mra

Description of other units

Cholesterol other units

hdl_res_mra

Result

HDL Cholesterol result

hdl_unit_mra

Units

HDL Cholesterol units

hdl_unoth_mra

Description of other units

HDL Cholesterol other units

ldl_res_mra

Result

LDL Cholesterol result

ldl_unit_mra

Units

LDL Cholesterol units

ldl_unoth_mra

Description of other units

LDL Cholesterol other units

trig_res_mra

Result

Triglycerides result

trig_unit_mra

Units

Triglycerides units

trig_unoth_mra

Description of other units

Triglycerides other units

sero_date_mra

Collection date

Serology lab date

toxoab_res_mra

Toxoplasma IgG antibody result

Toxoplasmosis IgG result

hcv_test_mra

Test type

Hepatitis C test

hcv_qlres_mra

Qualitative test result

Hepatitis C qualitative result

hcv_und_mra

Quantitative viral load undetectable

Hepatitis C Viral load undetectable

hcv_sign_mra

Quantitative viral load sign

Hepatitis C Viral load sign

hcv_qtres_mra

Quantitative viral load result:

Hepatitis C Viral load result

hcv_unit_mra

Quantitative viral load units

Hepatitis C Viral load units

hcv_unoth_mra

Description of other units

Hepatitis C Viral load other units

hcv_UL_mra

Quantitative viral load test upper limit

Hepatitis C Viral load upper limit

hcv_LL_mra

Quantitative viral load test lower limit

Hepatitis C Viral load lower limit

hbv_test_mra

Test type

Hepatitis B test

hbv_qlres_mra

Qualitative test result

Hepatitis B qualitative result

hbv_qtres_mra

Viral load (DNA) result

Hepatitis B viral load result

hbv_unit_mra

Viral load (DNA) units

Hepatitis B viral load units

hbv_unoth_mra

Description of other units

Hepatitis B viral load units other

hbv_UL_mra

Viral load (DNA) upper limit

Hepatitis B viral load upper limit

hbv_LL_mra

Viral load (DNA) lower limit

Hepatitis B viral load lower limit

sti_date_mra

Specimen collection date

STI lab date

gc_source_mra

Source of specimen

Gonorrhea source

gc_type_mra

Test type

Gonorrhea test type

gc_res_mra

Result

Gonorrhea result

ct_source_mra

Source of specimen

Chlamydia source

ct_type_mra

Test type

Chlamydia test type

ct_res_mra

Result

Chlamydia result

syph_source_mra

Source of specimen

Syphilis source

syph_type_mra

Test type

Syphilis test type

syph_res_mra

Result

Syphilis result

syph_titr_mra

Titer result: 1:X

Syphilis titer 1:X

trich_source_mra

Source of specimen

Trichomonas source

trich_type_mra

Test type

Trichomonas test type

trich_res_mra

Result

Trichomonas result

os_date_mra

Screening date

Mammogram or Pap screening date

_os_date_ind_mra

 

Screening date indicator

mammo_res_mra

Mammogram result

Mammogram result

pap_source_mra

PAP source

Pap smear source

pap_result_mra

PAP result

Pap smear result

pap_othde_mra

Specify other PAP result

Pap result other description

ppd_yn_mra

Was a PPD placed?

PPD placed

ppd_read_mra

Was the PPD read?

PPD read

ppd_date_mra

What date was the PPD read?

PPD reading date

ppd_datend_mra

Date not documented

PPD reading date not documented

ppd_res_mra

PPD result

PPD result

igra_date_mra

Specimen collection date

IGRA lab date

igra_type_mra

IGRA test type

IGRA test type

igra_res_mra

IGRA result

IGRA result

urine_date_mra

Collection date

Urine lab date

urine_test_mra

Urine test type

Urine test type

urine_qt_res_mra

Urine test result

Urine quantitative result

urine_unit_mra

Urine test units

Urine units

uruint_othde_mra

Description of other units

Urine other units

uprotqual_mra

Urine protein result (non-numeric)

Urine protein (qual) result

uproql_othres_mra

Description of other result

Urine protein (qual) other result

hct_res_mra^

Result (%)

Hematocrit result

lymph_res_mra^

Result

Lymphocytes result

monos_res_mra^

Result

Monocytes result

eos_res_mra^

Result

Eosinophils result

baso_res_mra^

Result

Basophils result






RESISTANCE

Variable

Question

Label

PARID

Participant ID

 

_SITEID_mra

 

Site ID

geno_mra

Genotype or virtual phenotype performed?

Is genotype or virtual phenotype performed?

geno_rpt_mra

Is a genotype or virtual phenotype lab report available in the medical record?

Is genotype or virtual phenotype report available?

geno_vpheno_mra

Were the results obtained from a genotype or virtual phenotype?

Genotype or virtual phenotype

geno_adq_mra

Genotype Specimen adequate?

Genotype specimen adequate

geno_date_mra

Genotype collection date

Genotype collection date

geno_nrti_mra

NRTI mutations detected

NRTI mutations detected

geno_nnrti_mra

NNRTI mutations detected

NNRTI mutations detected

geno_pi_mra

PI mutations detected

PI mutations detected

geno_in_mra

Integrase mutations detected

Integrase mutations detected

geno_en_mra

GP41 Envelope mutations detected

GP41 envelope mutations detected

_geno_mut_mra

Genotype mutations

Genotype mutation

_geno_mutsrc_mra

 

Genotype mutation source

pheno_date_mra

Phenotype collection date

Phenotype collection date

pheno_mra

Was a standard phenotype performed (not a virtual phenotype)?

Phenotype performed

trofyn_mra

Tropism assay performed

Tropism performed

trofrpt_mra

Is Tropism assay lab report available in medical record for entry?

Tropism report available

trof_date_mra

Tropism assay collection date

Tropism collection date

trof_rslt_mra

Result

Tropism result





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