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 |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |