Core Data Set Requirements; Notice DEPARTMENT OF HEALTH AND HUMAN SERVICES
Federal RegisterJan 20, 1994
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FOR FURTHER INFORMATION CONTACT:Richard Church, telephone (301) 443-
0750 or Anthony D'Angelo, telephone (301) 443-1180. (These are not toll
free numbers.) Copies of the forms referenced as being contained in
Appendix A may be obtained by contacting Anthony D'Angelo, Indian
Health Service, room 6-41, 5600 Fishers Lane, Rockville, Maryland
20857.
SUPPLEMENTARY INFORMATION: The Indian Health Service (IHS) has
established a set of core program data elements that all IHS programs
and facilities are required to submit for the IHS National data base.
These core data requirements are necessary for good management
purposes and to fulfill Congressional and other mandatory reporting
requirements. The core data requirements were developed by a joint IHS
and Tribal Representative Work Group over a period of seven months. Two
meetings were held-December 1988 and June 1989. The participants
included 11 IHS personnel, 8 tribal personnel, and 9 persons
representing the various IHS information systems. The efforts of the
working group were a major step toward reconciling the differences in
data priorities between the IHS and providers and ensuring the
development of a core data set that has beneficial uses and reasonable
costs.
The core data set requirements were published in the Federal
Register on August 7, 1990, as an IHS proposal with an opportunity to
comment. The core data set requirements were revised based on the
comments received and published as a final notice in the Federal
Register of January 22, 1992, 57 FR 2642. The Community Health
Representative Information System (CHRIS) reporting requirements as
published in 57 FR 2642 were corrected to reflect the latest version of
the CHRIS and published in the Federal Register of September 15, 1992,
57 FR 42588. This revision has been consolidated with the January 22,
1992 publication and is reprinted in this issue of the Federal Register
for the convenience of those reviewing the notice of proposed
rulemaking for Public Law 93-638, the Indian Self-Determination Act.
The core data requirements are a subset of the data that are
already being collected locally by IHS providers in order to manage
effective health service programs. The data are used to define current
health status (e.g., prevalance of diabetes); to identify problems
requiring attention (e.g., high number of facility visits related to
accidents); and to evaluate effectiveness of intervention programs
(e.g., reduced infant deaths related to increased prenatal care). The
core data set is needed for the following purposes:
Quality assurance;
Epidemiology;
Problem identification;
Identification of population in need;
Resource management/allocation;
Budget support and justification;
Facilities and program planning; and
National billing.
Specifically, the elements of the core data set are derived from
those elements already embodied within the following IHS information
systems:
Patient Registration System
Ambulatory Patient Care (APC) System
Direct Inpatient Care System
Contract Health Services Inpatient System
Contract Health Services Outpatient System
Dental Reporting System
Pharmacy System
Environmental Health Activity Reporting and Facility Data System
Mental Health and Social Services Reporting System
Alcoholism Treatment Guidance System (ATGS)/Chemical Dependency
Management Information System (CDMIS)
Community Health Representative Information System (CHRIS)
Community Health Activity Reporting System
Health Education Resource Management System (HERMS)
Nutrition and Dietetic's Program Activities Reporting System
Clinical Laboratory Workload Reporting System
Urban Indian Health Common Reporting
Fluoridation Reporting Data System
Each of the above systems has its own manual. This notice
consolidates and summarizes the data submission formats, edits and
schedules from these existing information systems. The core data set
reduces the total number of data elements required from the IHS health
care providers and the frequency of reporting, for certain elements,
has been reduced from monthly to quarterly. Moreover, for activities-
type reporting, data need only be reported for a sample of the services
provided.
The IHS wants to use the social security number (SSN) as the unique
patient identifier in the IHS National data base. Patients may
voluntarily disclose their SSN to health care providers after being
informed of: (1) The purposes of collecting the SSN (for uniquely
identifying patient records, reducing duplicative counting of cases of
a disease, improving patient and health program management, and third
party billing); (2) refusal will not result in denial of services; and
(3) the provider must submit the SSN to IHS. If the health care
provider is unable to obtain the SSN, then there is no longer a
requirement, as indicated in the initial CDSR notice, that it submit a
9-digit substitute SSN for the patient. However, it is still required
that the chronological health record number (HRN) be submitted for
every patient.
There are some data that need to be reported by IHS providers,
contractors, and grantees to IHS headquarters in order to participate
in special funds established through federal legislation or
Congressional appropriations language. There is no mandate that
providers, contractors, or grantees submit such data, but they need to
do so to be eligible to receive the funds. Examples of such special
programs are the Contract Health Services Catastrophic Health Emergency
Fund and Deferred Services.
Information collected in accordance with the core data set
requirements, which identifies individual patients provided health
care, is included in the IHS system of records titled: 09-17-0001,
Health and Medical Records Systems, HHS/IHS/OHP (Federal Register,
November 22, 1988, pages 47348-47353). These records are to be afforded
safeguard protections as required by the Privacy Act of 1974 (5 U.S.C.
552a). These safeguards are described in general terms in the system of
records notice for system 09-17-0001. In addition, information supplied
by staff of health care facilities established to provide alcohol or
drug abuse treatment are to be protected under the safeguard provisions
of the Confidentiality of Alcohol and Drug Abuse Patient Records
regulations, 42 CFR part 2. These were last published in the Federal
Register, June 9, 1987, pages 21796-21814.
As required, program reporting requirements will be submitted to
OMB for clearance pursuant to the Paperwork Reduction Act. Not all of
the program reporting requirements will need to be submitted to OMB for
clearance. The following have already received OMB approval:
Contract Health Services Inpatient System (Indian Health Service,
Hospital, Dental and Other Contract Health Service Reports, OMB
Approval No. 0917-0002)
Contract Health Services Outpatient System (Indian Health Service,
Hospital, Dental and Other Contract Health Service Reports, OMB
Approval No. 0917-0002)
Community Health Representative Information System (IHS Community
Health Representative Activity Reporting Sample, OMB Approval No. 0917-
0010)
Urban Indian Health Common Reporting (Common Reporting Requirements for
Urban Indian Health Programs, OMB Approval No. 0917-0007)
The following reporting requirements are totally exempt from the
OMB approval process because the information collected by them is used
to properly treat clinical disorders of patients:
Ambulatory Patient Care System
Direct Inpatient Care System
The remaining program reporting requirements either are not covered
or only partially covered by the ``clinical'' exemption. Therefore, OMB
clearance will be sought for the applicable portions, as noted below,
of these information systems:
Patient Registration System (portion dealing with third party
eligibility status)
Dental Reporting System (portion dealing with non-clinical activities
reporting)
Pharmacy System (all)
Environmental Health Activity Reporting and Facility Data System (all)
Mental Health and Social Services Reporting System (all)
Chemical Dependency Management Information System (portion dealing with
non-clinical activities reporting)
Community Health Activity Reporting System (all)
Health Education Resource Management System (all)
Nutrition and Dietetic's Program Activities Reporting System (all)
Clinical Laboratory Workload Reporting System (all)
Fluoridation Reporting System (all)
As long as their own data collection and reporting system provides
for the timely submission of accurate and complete data meeting the
core data set requirements, the IHS contractors and grantees will not
be required to use the collection and reporting system used by IHS. The
contractor/grantee data system must meet the requirements of the
Security Act of 1987, Pub. L. 100-275, which are also applicable to the
IHS directly operated programs. The IHS will provide technical
assistance to tribal contractors and grantees to convert their data
into the formats and appropriate transmission media required for IHS
data collection and reporting.
All data will, unless otherwise agreed upon, be sent to the
Division of Data Processing Services (DDPS) in Albuquerque through the
appropriate Area Office. Each IHS Area will establish its own
procedures for reporting data and will monitor compliance with
reporting requirements consistent with applicable laws, regulations,
policies, and grant and contract instruments. Contractors and grantees
are responsible for correcting problems regarding incomplete and
inaccurate data.
Contractors and grantees may use IHS forms or collect the required
data in any manner consistent with their operations. The submission of
these data must meet the format and data requirements of the IHS
information systems.
Core Data Set Requirements for the Following IHS Information
Systems
A. Patient Registration System
1. Reporting Requirements
a. Data on new patients, or changes to previously registered
patients, is submitted at least quarterly through the appropriate Area
Office to the Division of Data Processing Services (DDPS) in
Albuquerque. Data must be submitted monthly for central billing
purposes.
b. Data must be received by the DDPS by the 1st of the month to
ensure it being included in the next month's registration reports.
c. The IHS maintains a complete registration data base for each
Area on the IHS central computer at DDPS. The types of activity that
are reported include:
(1) Registration of new patients.
(2) Changes in any of the required registration fields (i.e. name,
residence) for a patient.
(3) Deletion of an entire patient record. (This would only be done
when the patient is registered in error, or is registered twice at the
same facility under two different health record numbers).
(4) Delete and merge to another health record number. This is done
when a patient is registered twice at two different facilities, and you
wish to merge the two records together by deleting one and merging the
data to the second number indicated.
Normally the last two activities will only be performed by the
registration data base administrator at the Area Office.
2. Record Formats
New patient data, or modifications to patient data, are submitted
in a 310 character record as shown at the end of this section.
Generally data from different facilities will be given different batch
numbers to facilitate error correction, since all errors are listed by
batch number, but this is not required.
Transactions to delete a patient record entirely, or delete a
patient and merge the data into another health record number, require a
different format, as shown at the end of this section. For these
transactions, a separate batch header is submitted followed by any
number of delete/merge transactions. The patient ID number used for
these transactions is not the normal health record number, but the
unique patient ID used in the centralized registration system. This
number consists of three alpha codes indicating the Area, SU and
facility followed by six numerics.
The delete/merge transactions must have a different batch number
than other transactions, and the individual delete/merge transactions
must immediately follow the delete/merge header. However, regular
batches and delete/merge batches can be combined on the same tape.
Samples of the IHS patient registration forms are included in
Appendix A.
3. Transmission Media
Registration records should be sent by the Area to DDPS on nine
track, unlabeled EBCDIC tapes, at 1600 or 6250 bits per inch (BPI).
Records should be blocked at 10 records per block. The Area Office and
the contractor will need to determine how the data will be transmitted
from the contractor to the Area.
4. RPMS Facility Registration System
An ANSI MUMPS facility registration system is available to any
covered contractor that wishes to implement it. This system provides
the capability of generating the transactions described above
automatically, and creating a tape cartridge (or transaction file for
transmission by telecommunications) to be sent to DDPS for all new and/
or modified patients.
Registration Format New And/Or Modified Transactions
----------------------------------------------------------------------------------------------------------------
Position Field Edits Required fields
----------------------------------------------------------------------------------------------------------------
1-4............. BATCH NUMBER.................... Numeric, Right Justified..................
5-10............ FACILITY CODE................... Area-SU-Facility Code. Must be in IHS X
5-6 Area Code Facility Table.
7-8 Service Unit Code
9-10 Facility Code
11-16........... HEALTH RECORD NUMBER............ Numeric, Right Justified.................. X
17-58........... PATIENT NAME.................... See Note 1. Last and First Name. Data must X
17-36 LAST be left justified.
37-47 FIRST
48-58 MIDDLE
59-60........... CLASSIFICATION CODE............. Numeric, Right Justified. Codes must be in
range 01-20
61-67........... DATE OF BIRTH................... Must be less than current date. Month not X
61-62 MONTH greater than 12, day not greater than 31.
63-64 DAY
65-67 Year
(Last three digits)
68.............. SEX............................. M or 1 for Male; F or 2 for Female........ X
69-77........... SOCIAL SECURITY NUMBER.......... Numeric, Right Justified.................. X
78-80........... TRIBE OF MEMBERSHIP CODE........ Numeric, Right Justified. Must be valid X
code in IHS Tribe Table.
81.............. BLOOD QUANTUM................... Numeric................................... X
82-113.......... FATHER'S NAME................... See Note 1
82-101 LAST
102-112 FIRST
113 MIDDLE INITIAL
114-120......... COMMUNITY OF RESIDENCE.......... Community-County-State Code, must be in X
114-116 COMMUNITY CODE IHS Community Table.
117-118 COUNTY CODE
119-120 STATE CODE
121-176......... MAILING ADDRESSES
121-150 STREET/BOX NUMBER....... Alpha-Numeric. If submitted, town and
state also required
151-165 TOWN.................... Alphabetic, left justified. If submitted,
state also required
166-167 STATE................... Alphabetic. Required if town submitted
168-176 ZIP..................... Numeric, right justified
177-208......... MOTHER'S NAME................... See Note 1
209-214......... DATE OF DEATH (MM/DD/YY)........ Same Edit as Date of Birth................ X*
215-235......... MEDICARE A If central billing, all fields required... X
215 ELIGIBLE.................... Y or N (N will delete an authorization
previously submitted).
216-224 ENROLLMENT NUMBER....... Numeric, all digits required
225-229 ENROLLMENT SUFFIX....... Alphanumeric, left justified. Must be
valid code in Medicare suffix table
230-235 DATE OF ELIGIBILITY (MM/ Month and Year Required. Standard Date
DD/YY). Edit
236-256......... MEDICARE B...................... Same as Medicare A........................ X
257-277......... MEDICARE AB..................... Same as Medicare A........................ X
278-298......... MEDICAID........................ If central billing, all fields required
278 ELIGIBLE.................... Y or N (N will delete an authorization X
previously submitted).
279-287 ELIGIBILITY NUMBER...... No Edit
288-292 SUFFIX.................. No Edit
293-298 DATE OF ELIGIBILITY (MM/ Month and Year Required. Standard Date
DD/YY). Edit
299............. VETERAN (VA) ELIGIBLE........... Y, N or Blank............................. X
300............. BLUE CROSS...................... Y, N or Blank
301............. OTHER INSURANCE................. Y, N or Blank............................. X
302............. CHS ELIGIBILITY................. Y, N or Blank
303............. PATIENT ASSIGNMENT/RELEASE Y, N or Blank. Required to initiate
SIGNATURE ON FILE. billing Medicare
304............. ADD/MODIFY CODE................. 1--New Patient
2--Modification
305-310......... RELEASE DATE (MM/DD/YY)......... Standard Date Edit. Required for billing
----------------------------------------------------------------------------------------------------------------
Note 1: ALL NAME FIELDS MUST BE ALPHABETIC WITH THE FOLLOWING SPECIAL CHARACTERS ALLOWED:
ONE SET OF LEFT AND RIGHT PARENTHESES IMBEDDED IN NAME.
ONE OCCURRENCE OF AN APOSTROPHE.
TWO OCCURRENCES OF A PERIOD.
FIVE OCCURRENCES OF A DASH, OR HYPHEN.
NO LOWER CASE.
*As available.
Registration Format Delete/Merge Transactions
[Header Record]
------------------------------------------------------------------------
Position Field Description Required
------------------------------------------------------------------------
1-3.............. IDENTIFIER....... THREE VERTICAL BARS X
(HEX
``4F''CHARACTERS).
4-5.............. AREA CODE........ STANDARD AREA CODE OF X
THE REGISTRATION DATA
BASE.
6-11............. AREA/SU/FAC CODE. AREA, SERVICE UNIT, X
FACILITY CODE OF THE
SUBMITTING FACILITY.
12-17............ AREA/SU/FAC OF CODE PREFIX FOR HEALTH X
HEALTH REC NO. RECORD NUMBERS BEING
USED. NORMALLY
DUPLICATE OF
POSITIONS 6-11.
18............... NOT USED.........
19-22............ BATCH NUMBER..... NUMERIC, RIGHT X
JUSTIFIED.
23-25............ NO FORMS......... NUMBER OF TRANSACTIONS X
IN THE BATCH.
26-31............ DATE............. DATE SUBMITTED X
(YYMMDD).
32-34............ INITIALS OF OPTIONAL..............
REQUESTOR.
35-60............ COMMENTS......... OPTIONAL--FOR LOCAL
USE.
61-80............ NOT USED ........
------------------------------------------------------------------------
Registration Format Delete/Merge Transactions
[Transaction Record]
------------------------------------------------------------------------
Position Field Description Required
------------------------------------------------------------------------
1................ IDENTIFIER....... A ``?'' IN POSITION 1. X
2-4.............. INITIALS & SEX... INITIALS (LAST, FIRST) X
AND SEX OF PATIENT TO
BE DELETED.
5-13............. PATIENT ID....... PATIENT ID TO BE X
DELETED. (THREE ALPHA
AND SIX NUMERICS).
THIS IS THE
CENTRALIZED
REGISTRATION UNIQUE
ID NUMBER.
14-15............ TRANSACTION TYPE. ``99''................ X
16............... NOT USED.........
17-22............ DATE............. DATE SUBMITTED X
(YYMMDD).
23-25............ ASTERISKS........ ``***''............... X
26-34............ PATIENT ID....... PATIENT ID TO WHICH X
DATA IS TO BE MERGED.
35............... MOVE DEMOGRAPHIC. FLAG TO INDICATE X
WHETHER TO MOVE
DEMOGRAPHIC DATA FROM
DELETED RECORD, OR TO
RETAIN DEMOGRAPHIC
DATA OF THE RECORD TO
WHICH MOVED. ``1''
INDICATES TO RETAIN
DEMOGRAPHIC DATA OF
DELETED RECORD, ``2''
TO RETAIN DATA OF
RECEIVING RECORD.
36-37............ FACILITY......... FACILITY CODE X
SUBMITTING FORM.
38-67............ SUBMITTED BY..... NAME OF PERSON X
SUBMITTING FORM.
------------------------------------------------------------------------
TO DELETE A PATIENT, POSITIONS 1-25 ARE REQUIRED. TO DELETE AND MERGE TO
A NEW PATIENT, POSITIONS 1-37 ARE REQUIRED.
B. Ambulatory Patient Care System (APC)
1. Reporting Requirement
a. An Ambulatory Patient Care (APC) record is required for an
encounter between a patient and health care provider in an organized
clinic within an IHS facility (including covered contractors) where
service resulting from the encounter is not part of an inpatient stay.
The patient or his/her representative (representative only to pick up
prescription) must be physically present at the time of service. Also,
a note must be written in the medical record by a licensed,
credentialled or other provider qualified by the medical staff or
facility administrator.
b. Part 4, chapter 3, section 1 of the Indian Health Manual,
provides complete definitions and procedures for reporting into the APC
system. The definition of an APC visit given in 1a above is somewhat
different and supersedes the definition in the IHS Manual. The IHS
Manual will be changed to reflect the new definition.
c. Each Area will define procedures for collecting APC data and
creating automated records in the format described in the next section.
Options include:
(1) Key-entry of forms at the Area.
(2) Key-entry of forms by a contractor.
(3) Key-entry at the local facility with an RPMS ANSI MUMPS data
entry system.
d. Records will be consolidated at the Area level and forwarded at
least quarterly to the Division of Data Processing Services (DDPS) at
Albuquerque by the 15th of the month. Data must be submitted monthly
for central billing purposes.
2. Record Formats
a. The APC record contains individual patient encounter
information. Each record is 200 characters in length.
b. The format of the APC record is shown at the end of this
section.
c. A sample of the IHS APC form is included in Appendix A.
3. Transmission Media
a. APC records for each Area are generally mailed to DDPS on nine
track unlabeled, unblocked EBCDIC tape. The Area Office and the
contractor will need to determine how the data will be transmitted from
the contractor to the Area.
4. RPMS APC Data Entry System
a. There is available an RPMS ANSI MUMPS APC data entry program
which allows for records to be keyed locally, transmitted to the Area,
and fowarded from the Area to DDPS by telecommunications.
5. Community Health Aide Program
a. An Ambulatory Patient Care (APC) or equivalent record is
required for an encounter between a community health aide and a
patient.
b. The format of the required record is shown at the end of this
section. A sample of the IHS APC form is included in Appendix A.
c. The Alaska Area Office and the contractor will need to determine
how the required data will be collected and transmitted to the Area.
Direct Outpatient System Record\1\
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
1-2.......... Record Code. Always ``15''................... X
3-4.......... Area Code.................................... X
5-6.......... Service Unit Code............................ X
7-8.......... Service Location Code (Facility Code)........ X
9-14......... Date of Service (MMDDYY)..................... X
15........... Day of Week (Sunday=1, Saturday=7)
16-21........ Patient Health Record Number................. X
22-30........ Social Security Number....................... X
31-36........ Date of Birth (MMDDYY)....................... X
37........... Sex.......................................... X
38-40........ Tribe of Membership Code..................... X
41-43........ Optional Code (Area options)
44-50........ Community of Residence
44-46Community Code.......................... X
47-48County Code............................. X
49-50State Code.............................. X
51........... Time of Day Code; ``1'' 8AM-Noon; ``2'' Noon-
5PM; ``3'' 5PM-10PM; ``4'' 10PM-8AM
52-53........ Type of Clinic (IHS Table)
54-61........ Service Rendered by (Discipline Code)
54-55Primary Provider Discipline............. X
56-57Other Provider Discipline...............
58-59Other Provider Discipline...............
60-61Other Provider Discipline...............
62-71........ Immunizations Given.......................... X
621 for Tetanus Toxin
632 for DT
643 for DPT
654 for Polio
665 for Measles
676 for Rubella
687 for Small Pox
698 for Mumps
709 for Influenza
710 for Other
72........... All Immunizations Current (1 yes; 2 no)...... X
73........... Immunization Register Update
74........... Skin Test Result
``1'' PPD 0-4M; ``2'' PPD 5-9MM;
``3'' PPD 10-19M; ``4'' PPD 20+MM;
``5'' TINE NEG.; ``6'' TINE POS
75........... Purpose of Skin Test
``1'' Routine; ``2'' Contact;
``3'' Suspect; ``4'' School
76........... INH Prophylaxis
``1'' 1 Year Completed; ``2'' Start
``3'' Continue; ``4'' Discontinue
77-78........ Next TB Appointment in months
79-82........ TB Diagnosis
79``1'' 1st visit, ``2'' revisit
80-82Three digit APC code (005-012)
83-93........ Maternal Health and Family Planning
83Marital Status (1 Married; 2 Not Married)
84-85Gravida
86-87Number of Living Children
88Trimester of 1st Prenatal Visit
89``1'' 1st visit for prenatal care
``2'' revisit for prenatal care
94-96........ Not Used
97-102....... IHS Unit No at Parent Facility
103-107...... Accidents (required for 1st visits of APC
codes 700-792).
103-104Cause of Accident (01-19)............. X\2\
105-106Place (01-12) X\2\
107Alcohol related (1 yes; 2 no) X\2\
108-113...... Area optional code
114-117...... APC Codes for Injury
114``1'' 1st visit; ``2'' revisit
115-117APC Code X\2\
118-121...... APC Codes for Other Problems/Clinical Imp
118``1'' 1st visit, ``2'' revisit
119-121APC code X\2\
122-132...... Diagnostic Services Requested
122``0'' or blank for none
123``1'' for Urinalysis
124``2'' for Hematology
125``3'' for Chemistry
126``4'' for Bacteriology
127``5'' for Serology
128``6'' for Pap
129``7'' for ECG/EKG
130``8'' for Other
131``1'' for X-Ray-Chest
132``2'' for Other X-ray
133.......... Minor Surgical Procedures (``1'' if yes)..... X\2\
134.......... Disposition Code
``1''Return by appointment
``2''Return PRN
``3'' Admit to IHS Hospital
``4'' Admit to non-IHS Hospital
``5'' Refer for OP Consultation--IHS
``6''Refer for OP Consultation--non-IHS
``7''Did not Answer
135-139...... CPT4/HCPCX Code 1............................ X\2\
140-144...... CPT4/HCPCX Code 2............................ X\2\
145-149...... CPT4/HCPCX Code 3............................ X\2\
150-154...... CPT4/HCPCX Code 4............................ X\2\
155-159...... CPT4/HCPCX Code 5............................ X\2\
160-166...... Unused
167-176...... Specific provider codes
177-181...... ICD-9-CM Code 1.............................. X\2\
182-186...... ICD-9-CM Code 2.............................. X\2\
187.......... Unused
188-191...... Surgical Procedure (ICD-9-CM Code)........... X\2\
192-200...... Unused, except for some Area-specific fields
------------------------------------------------------------------------
\1\Not all patient identification data elements will need to be reported
on every record in a fully integrated information system.
\2\If appropriate.
C. Direct Inpatient Care System (INP)
1. Reporting Requirement
a. A direct Inpatient Clinical Brief is required for any person who
is admitted to an Indian Health Service facility or a facility operated
by a covered contractor.
b. Part 4, chapter 3, section 2 of the Indian Health Manual
provides complete definition and procedures for reporting into the
Direct Inpatient System.
c. Each Area will define procedures for collecting Inpatient data
and creating automated records on the format described in the next
section. Options include:
(1) Key-entry of forms at the Area.
(2) Key-entry of forms by a contractor.
(3) Key-entry at the local facility with an RPMS ANSI MUMPS data
entry system.
d. Records will be consolidated at the Area level and forwarded at
least quarterly to the Division of Data Processing Services (DDPS) at
Albuquerque by the 15th of the month. Data must be submitted monthly
for central billing purposes.
2. Record Formats
a. The record format for the Direct Inpatient Clinical Record
Brief, is shown at the end of this section. Each record is 160
characters in length.
b. A sample of the IHS Clinical Record Brief is included in
appendix A.
3. Transmission Media
a. Clinical Record Brief for each Area are generally mailed to DDPS
on nine-track unlabeled, unblocked EBCDIC tape. The Area Office and the
tribal contractor will need to determine how the data will be
transmitted from the contractor to the Area.
4. RPMS Data Entry System
a. There is an RPMS ANSI MUMPS facility based Direct Inpatient data
entry program which allows for records to be keyed locally, transmitted
to the Area, and forwarded from the Area to DDPS by telecommunications.
Direct Inpatient Clinical Record Brief\1\
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
1-2........... Record Code. Always ``18''.................. X
3-8........... Patient Health Record Number................ X
9-17.......... Social Security Number...................... X
18-23......... Date of Birth (MMDDYY)...................... X
24............ Sex......................................... X
25-27......... Tribe of Membership Code.................... X
28-30......... Optional Code (Area Options)................
31-37......... Community of Residence...................... ..........
.............. 31-33Community Code......................... X
.............. 34-35County Code............................ X
.............. 36-37State Code............................. X
38-39......... Classification Code......................... ..........
40-41......... Area Code................................... X
42-43......... Service Unit Code........................... X
44-45......... Facility Code............................... X
46............ Admission Code.............................. X
47-48......... Clinical Service Admitted to Code........... ..........
49-54......... Admission Date (MMDDYY)..................... X
55-60......... Disposition Date (MMDDYY)................... X
61-63......... Number Hospital Days........................ ..........
64-67......... Third Party Payers.......................... ..........
.............. 64Medicaid..................................
.............. 65Medicare..................................
.............. 66VA........................................
.............. 67Other.....................................
68............ Unused...................................... ..........
69-73......... ICD Code 1 (Principal Diagnosis)............ X
74............ Hospital Acquired ``1''..................... X\2\
75-79......... ICD Code 2.................................. X\2\
80............ Hospital Acquired ``1''..................... X\2\
81-85......... ICD Code 3.................................. X\2\
86............ Hospital Acquired ``1''..................... X\2\
87-91......... ICD Code 4.................................. X\2\
92............ Hospital Acquired ``1''..................... X\2\
93-97......... ICD Code 5.................................. X\2\
98............ Hospital Acquired ``1''..................... X\2\
99-103........ ICD Code 6.................................. X\2\
104........... Hospital Acquired ``1''..................... X\2\
105-108....... 1st ICD Operation Code...................... X\2\
109........... Diagnosis Number (Appropriate Code)......... ..........
110........... Infection ``1'' If checked.................. X\2\
111-114....... Operating Physician Code.................... ..........
115-118....... 2nd ICD Operation Code...................... X\2\
119........... Diagnosis Number (Appropriate Code)......... ..........
120........... Infection ``1'' If checked.................. X\2\
121-124....... 3rd ICD Operation Code...................... X\2\
125........... Diagnosis Number (Appropriate Code)......... ..........
126........... Infection ``1'' If checked.................. X\2\
127........... Disposition Code (1-7)...................... X
128-133....... Facility Transferred to Code................ ..........
134-135....... Clinical Service Discharged from............ ..........
136-137....... Number of Consultations..................... ..........
138-141....... Accident Code (No Leading ``E'') (E800-E999) X\2\
142-143....... Accident Place Code......................... X\2\
144-148....... Cause of Death (ICD Code)................... X\2\
149-152....... Attending Physician Code.................... ..........
153........... Nurse-Midwifery Code........................ ..........
154-160....... Unused...................................... ..........
161-170....... Operating Physician EIN..................... X\2\
171-180....... Attending Physician EIN..................... X
------------------------------------------------------------------------
\1\Not all patient identification data elements will need to be reported
on every record in a fully integrated information system.
\2\If appropriate.
D. Contract Health Services (CHS) Inpatient System (CHI)
1. Reporting Requirement
a. A Contract Health Service Purchase/Delivery Order for Hospital
Services Rendered (HRSA-43) is required for all hospital inpatient care
provided to Indian and Alaska Native patients in contract community
facilities. This includes CHS administered by covered contractors.
b. Part 4, chapter 3, section 3 of the Indian Health Service Manual
provides complete definition and procedures for reporting into the
Contract Inpatient System.
c. Each Area will define procedures for collecting Contract
Inpatient data and creating automated records in the format described
in the next section. Options include:
(1) Key-entry forms at the Area.
(2) Key-entry forms by a contractor.
(3) Key-entry at the local facility with an RPMS ANSI MUMPS data
entry system.
d. Records will be consolidated at the Area level and forwarded at
least quarterly to the Division of Data Processing Services (DDPS) by
the 5th of the month.
2. Record Formats
a. There is only one record format for the Contract Health Service
Purchase/Delivery Order for Hospital Services Rendered as shown at the
end of this section. Each record is 185 characters in length.
b. A sample of the IHS Contract Health Service Purchase/Delivery
Order for Hospital Services Rendered is included in appendix A. Since
this is a government purchase order form, it is recommended that a
similar form in terms of data elements be developed for use by tribal
contractors.
3. Transmission Media
a. Contract Inpatient Authorizations are generally mailed to DDPS
on nine-track unlabeled, unblocked EBCDIC tape. The Area Office and the
contractor will need to determine how the data will be transmitted from
the contractor to the Area.
4. RPMS Data Entry System
a. There is an RPMS ANSI MUMPS Contract Inpatient data entry
program which allows for records to be keyed locally, transmitted to
the Area and forwarded from the Area to DDPS by telecommunications.
5. Fiscal Intermediary
a. IHS has contracted with a Fiscal Intermediary to perform the
management of that portion of the CHS program administered by the IHS.
Contract Health Service Purchase/Delivery Order for Hospital Services
Rendered*
[HRSA-43]
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
1-2.......................... Record Code. Always ``19''... X
3-9.......................... Authorization Number......... X
10-15........................ Patient Health Record Number. X
16-24........................ Social Security Number....... X
25-30........................ Date of Birth (MMDDYY)....... X
31........................... Sex (1=Male, 2=Female)....... X
32-34........................ Tribe Code................... X
35-37........................ Optional Code (Area Options)
38-44........................ Community of Residence
............................. 38-40 Community Code......... X
............................. 41-42 County Code............ X
............................. 43-44 State Code............. X
45-50........................ Authorizing Facility (Area- X
Service Unit-Facility).
51-52........................ Provider Type................ X
53-62........................ Provider Code (EIN).......... X
63-68........................ Admission Date (MMDDYY)...... X
69-74........................ Discharge Date (MMDDYY)...... X
75-77........................ Total Hospital Days ..........
78........................... Disposition.................. X
79-83........................ ICD Code 1 (Principal X
Diagnosis).
84-88........................ ICD Code 2................... X\1\
89-93........................ ICD Code 3................... X\1\
94-98........................ ICD Code 4................... X\1\
99-103....................... ICD Code 5................... X\1\
104-107...................... ICD Operation Code 1......... X\1\
108-111...................... Unused ..........
112-115...................... ICD Operation Code 2......... X\1\
116-119...................... ICD Operation Code 3......... X\1\
120-124...................... ICD Newborn Diagnosis ..........
125.......................... Newborn Death Indicator
126-129...................... Attending Physician Code
130-133...................... ICD External Cause or Injury. X\1\
134-135...................... Place of Injury.............. X\1\
136-143...................... Charges--to IHS only $ and X
cents.
144.......................... Full/Part Pay (1=Full, X
2=Part).
145-175...................... Unused
176-185...................... Attending Physician EIN...... X
------------------------------------------------------------------------
*Not all patient identification data elements will need to be reported
on every record in a fully integrated information system.
\1\If appropriate.
E. Contract Health Services (CHS) Outpatient System (CHO)
1. Reporting Requirement
a. A Purchase Order for Contract Health Service Other Than Hospital
Inpatient or Dental (HSA-64) is required for all outpatient services to
Indian and Alaska Native patients in contract community facilities.
This includes CHS administered by covered contractors.
b. Part 4, chapter 3, section 3 of the Indian Health Service Manual
provides complete definition and procedures for reporting into the
Contract Outpatient System.
c. Each Area will define procedures for collecting Contracting
Outpatient data and creating automated records in the format described
in the next section. Options include:
(1) Key-entry forms at the Area.
(2) Key-entry forms by a contractor.
(3) Key-entry at the local facility with an RPMS ANSI MUMPS data
entry system.
d. Records will be consolidated at the Area level and forwarded to
the Division of Data Processing Services (DDPS) at least quarterly by
the 5th of the month.
2. Record Formats
a. There is only one record format for the Purchase Order for
Contract Health Service Other Than Hospital Inpatient or Dental as
shown at the end of this section. Each record is 110 characters in
length.
b. A sample of the Purchase Order for Contract Health Service Other
Than Hospital Inpatient or Dental form is included in Appendix A. Since
this is a government purchase order form, it is recommended that a
similar form in terms of data elements be developed for use by tribal
contractors.
3. Transmission Media
a. Contract Outpatient Authorizations are generally mailed to DDPS
on nine track unlabeled, unblocked EBCDIC tapes. The Area Office and
the contractor will need to determine how the data will be transmitted
from the contractor to the Area.
4. RPMS Data Entry System
a. There is an RPMS ANSI MUMPS Contract Outpatient data entry
program which allows for records to be keyed locally, transmitted to
the Area and forwarded from the Area to DDPS by telecommunications.
5. Fiscal Intermediary
a. IHS has contracted with a Fiscal Intermediary to perform the
management of that portion of the CHS program administered by the IHS.
Purchase Order For Contract Health Service Other Than Hospital Inpatient
or Dental*
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
1-2.......... Record Code. Always ``20''................... X
3-9.......... Authorization Number......................... X
10-15........ Patient Health Record Number................. X
16-24........ Social Security Number....................... X
25-30........ Date of Birth (MMDDYY)....................... X
31........... Sex (1=Male, 2=Female)....................... X
32-34........ Tribe Code................................... X
35-37........ Optional Code (Area Options)
38-44........ Community of Residence
............. 38-40 Community Code......................... X
............. 41-42 County Code............................ X
............. 43-44 State Code............................. X
45-50........ Authorizing Facility (Area-Service Unit X
Facility).
51-52........ Provider Type................................ X
53-62........ Provider Code (EIN/SSN)...................... X
63-69........ HSA-43 Authorization Number
70-75........ Date of Service (MMDDYY)..................... X
76........... Unused
77-79........ Outpatient Diagnostic Recode 1............... X\1\
80........... 1st or Revisit Code
81-83........ Outpatient Diagnostic Recode 2............... X\1\
84........... 1st or Revisit Code
85-86........ Number of Visits............................. X\1\
87-92........ Charges...................................... X
93-94........ Immunization 1............................... X\1\
95-96........ Immunization 2............................... X\1\
97-98........ Immunization 3............................... X\1\
99-100....... Immunization 4............................... X\1\
101-102...... Immunization 5............................... X\1\
103-105...... Maternal Health ..........
103-104 Gravida..............................
............. 105 1st Trimester
106.......... Full/Part Pay (1=Full, 2=Part)............... X
107-110...... Surgical Procedure (ICD-9-CM Code)........... X\1\
111-115...... CPT4/HCPCX Procedure Code 1.................. X\1\
116-120...... CPT4/HCPCX Procedure Code 2.................. X\1\
121-125...... CPT4/HCPCX Procedure Code 3.................. X\1\
126-130...... CPT4/HCPCX Procedure Code 4.................. X\1\
131-135...... CPT4/HCPCX Procedure Code 5.................. X\1\
136-150...... Unused
151-155...... ICD-9-CM Code 1.............................. X\1\
156-160...... ICD-9-CM Code 2.............................. X\1\
------------------------------------------------------------------------
*Not all patient identification data elements will need to be reported
on every record in a fully integrated information system.
\1\If appropriate.
F. Dental Services and Needs Reporting System
1. Reporting Requirement:
a. A description of dental services provided will be submitted for
each patient visit to either a (1) direct care facility or a (2)
contract provider. In addition, specified data will be submitted on a
sample basis from oral exams to provide epidemiologic and needs data
for program monitoring or evaluation and for determining resource
requirements. Tribal programs will be included in such a sample with no
greater frequency than once every three years.
b. Dental treatment provided, as well as a recording of number of
patient visits, persons treated, and patients receiving all planned
treatment, will be identified using the standard nomenclature of the
American Dental Association (see list of codes marked F-1) and include
the number of units of each service provided, and for contract dentist,
the fee for each service. These codes are revised periodically by the
ADA. Updated lists of codes will be provided, as available, to both IHS
and Tribal programs.
c. Non-clinical dental health services not reported in the HERMS,
CHRIS, or other components of the IHS Generic Activities Reporting
System (GARS) should be reported using the data elements and the data
record format shown in Figure F-4. This system serves as a supplement
for the IHS Dental Data Reporting System to specify a range of public
health services which cannot be included in the patient record system.
Headquarters requirements can be met with a sampling procedure that
uses one full week of activities per month in accordance with the
sample reporting week schedule to be specified by IHS Headquarters.
There is an RPMS ANSI MUMPS GARS data entry program which allows for
records to be submitted to Area for compilation and forwarding from
Area to DDPS. The dental non-clinical activities database can be
maintained locally or at regional sites at the discretion of program
management. Local programs are responsible to provide the Area Dental
Office with up-to-date dental activity records after the close of each
month. The timing and method of data submission may vary per negotiated
arrangements in each Area; however, each Area Office is responsible to
transmit all available activity records which have not been previously
submitted to the DDPS in Albuquerque as a merged data extract on tape
or via telecommunication within 10 working days after the close of each
quarter of the Fiscal Year.
d. The procedures for collecting the required data for centralized
processing by the IHS Division of Data Processing Services (DDPS) will
be defined by each area program. The options available for key-entering
the data into a computer are:
1. Weekly submission to a key-entry contractor (IHS or Tribal
source) who transmits the data to the IHS.
2. In-house local key entry into RPMS database with submission of
extracted data to area office by the end of each month.
3. Local key-entry into non-RPMS database with the submission of
formatted records to the DDPS by the end of the month.
e. Oral exam records data will be collected periodically among an
adequate number of dental patients of all ages for processing by the
IHS to monitor the oral health status and treatment needs of the
population being served. The protocol for selecting/sampling of
patients and completing examination records is described in Section III
of the Oral Health Program Guide (OHPG) published by the IHS. Where
variation is noted, the latest version of the OHPG takes precedence
over the following instructions. The required data from exams will
include:
1. Tooth status: sound, decayed, recurrent decay, missing, filled,
filled and decayed, sealed, sealed and decayed, unrestorable and needs
extraction (XC, XP, XO, XT (trauma), X (pros.), fractured, replaced,
crowned (cast restoration).
2. Periodontal status: Using the Community Periodontal Index of
Treatment Needs (C.P.I.T.N.) score by specific mouth sextants (UR,
tooth #1-5), UA (#6-11), UL (#12-16), LL (#17-21), LA (#22-27), LR
(#28-32).
3. Treatment Needs--reported using ADA or other codes in Section
III of the OHPG: all teeth needing restoration by number of surfaces
involved, extractions, other surgery, full or partial dentures needed
per arch and possession of existing dentures, endodontic needs, fixed
bridges needed including number of pontics, orthodontic status
(limited, comprehensive, treatment in progress, or completed).
f. Options for collecting and submitting exam data include:
1. Submission of required data directly to the IHS in hard copy
using standard forms (as shown in Appendix A).
2. Submission of data in automated record format from RPMS or non-
RPMS database.
g. Data input forms used by the IHS are included in Appendix A.
Except for the Oral Health Status Form, the use of these forms is not
required, but is highly recommended for use as part of the patient's
record and for data submission. They include: 1.) Patient Service
Record (HRSA-42-1); 2.) Record, Clinic and Doctor Identification (HSA-
42-2); 3.) Services Provided--Dental Progress Notes (HRSA-42-2); 4.)
Purchase Order for and Report of Contract Dental Care (HSA-57) (Since
this is a government purchase order form, it is recommended that a
similar form be developed for use by tribal contractors. The IHS is
testing a simplified form which will combine the HSA-57 and HSA-64. The
final version of the combined form will be made available to tribal
contractors and may be used by tribes also to develop a similar form.);
and 5.) Oral Health Status Form.
2. Format of Data Processing Records:
a. The required automated record format for processing dental
services data is shown at the end of this section.
b. The automated record for non-clinical dental health services/
activities is shown at the end of this section.
c. The automated record for processing oral examination data is
shown at the end of this section.
3. Transmission to DDPS
a. Data will be transmitted to DDPS on a periodic basis as defined
by area policy on an unlabeled EBCDIC tape, blocked 20 records per
block.
b. The cut-off date at DDPS for inclusion in monthly reports is the
5th working day of each month.
c. The Area Office and the contractor will need to determine how
the data will be transmitted from the contractor to the Area.
d. Oral health status data will be transmitted and processed
separately from dental services data.
4. The data elements for dental epidemiology and services are as
follows:
------------------------------------------------------------------------
Data element Required
------------------------------------------------------------------------
Health Status:
Demographics*............................................. X
Health Needs Assessment................................... X
Dental caries (decay) index............................. X
Prosthodontic status.................................... X
Periodontal status...................................... X
Orthodontic status...................................... X
Oral pathology status................................... X
Treatment Required........................................ X
Services Provided:
Patient demographic information*.......................... X
Mode of delivery (direct/contract)........................ X
Date of Visit............................................. X
Provider/Location......................................... X
Cost of Visit (contract only)............................. X
Services Provided:
ADA procedure code...................................... X
Units................................................... X
Cost.................................................... X
------------------------------------------------------------------------
*Not all patient identification data elements will need to be reported
on every record in a fully integrated information system.
Record Layout for Processing Dental Services Data (Used for Both Direct
and Contract Services)
[Input Record Format for Processing Dental Services Data by the IHS Data
Center at Albuquerque]
------------------------------------------------------------------------
Field position
and size Field name, record identification and (data type)
------------------------------------------------------------------------
1............. Type of Patient (I-Indian; O-Non-Indian).
2............. Type of program (D-Direct; K-Contract).
Provider/Locatio
n of encounter
3-4........... Area Code (std. 2-digit numeric).
5-16.......... Dentist ID (Normally 9-digit numeric SSN, either with
hypens or without. If no hyphens, must be left
justified).
17-18......... Service Unit Code (std. 2-digit numeric).
19-20......... Facility Code (std. 2-digit numeric).
Date of Visit
21-22......... Year (numeric).
23-24......... Month (numeric).
25-26......... Day (numeric).
Patient
Identification
27-29......... Age in years. This field or date of birth field
required. (3-digit numeric).
Birthdate/Sex
30-31......... Year (numeric).
32-33......... Month (numeric).
34-35......... Day (numeric).
36............ Sex (M-Male; F-Female).
Social Security
Number
37-39......... Blank.
40-48......... Social Security Number.
Address
49-53......... Zip Code-Optional (numeric).
54-57......... Zip Extension-Optional (numeric).
Third Party
Coverage
58............ Medicaid (Y or blank) Optional.
59............ Commerce (Y or blank) Optional.
60............ Private (Y or blank) Optional.
Total Charge for
Visit
61-65......... Dollar amount up to 5-digits (numeric).
66-67......... Amount in cents (numeric).
Service #1
68-71......... ADA Procedure Code (from standard set of codes).
72-73......... Units (numeric, 1 to 99).
74-78......... Fee (dollar amount only, cents not allowed).
Service #2
79-82......... ADA Procedure Code.
83-84......... Units.
85-89......... Fee.
Service #3
90-93......... ADA Procedure Code.
94-95......... Units.
96-100........ Fee.
Service #4
101-104....... ADA Procedure Code.
105-106....... Units.
107-111....... Fee.
Service #5
112-115....... ADA Procedure Code.
116-117....... Units.
118-122....... Fee.
Service #6
123-126....... ADA Procedure Code.
127-128....... Units.
129-133....... Fee.
Service #7
134-137....... ADA Procedure Code.
138-139....... Units.
140-144....... Fee.
Service #8
145-148....... ADA Procedure Code.
149-150....... Units.
151-155....... Fee.
Service #9
156-159....... ADA Procedure Code.
160-161....... Units.
162-166....... Fee.
Service #10
167-170....... ADA Procedure Code.
171-172....... Units.
173-177....... Fee.
Service #11
178-181....... ADA Procedure Code.
182-183....... Units.
184-188....... Fee.
Service #12
189-192....... ADA Procedure Code.
193-194....... Units.
195-199....... Fee.
Service #13
200-203....... ADA Procedure Code.
204-205....... Units.
206-210....... Fee.
Service #14
211-214....... ADA Procedure Code.
215-216....... Units.
217-221....... Fee.
Service #15
222-225....... ADA Procedure Code.
226-227....... Units.
228-232....... Fee.
------------------------------------------------------------------------
If more than 15 ADA procedure codes are associated with a visit date,
then a separate (second) input record must be created for processing
purposes.
GARS/Dental Non-Clinical Activity Reporting System Data Record Format
------------------------------------------------------------------------
Position Field name Data type
------------------------------------------------------------------------
1-6.................. REPORTING LOCATION... 6-digit Code (from IHS
standard table of
values).
7-12................. DATE OF ACTIVITY..... mmddyy.
13-21................ PROVIDER ID.......... 9-digit SSN.
22-23................ ACTIVITY TYPE........ 2-digit numeric code from
list of accepted values.
24-25................ TARGET GROUP......... 6-digit alpha/numeric
code, from list of
values, right justified.
26-30................ RELATED OBJECTIVE.... 5-digit alpha code or
blank, right justified.
31-33................ ACTIVITY TIME........ 3-digit numeric to
represent total minutes
(blank accepted).
34-36................ TRAVEL TIME.......... 3-digit numeric to
represent total minutes
(blank accepted).
37-41................ ACTIVITY SETTING..... 3-digit alpha code from
list of values or blank.
42-121............... NARRATIVE COMMENT.... 80 character free text
entry or blank.
------------------------------------------------------------------------
Record Layout for the Oral Health Survey Data
------------------------------------------------------------------------
Position Data field label Data type specification
------------------------------------------------------------------------
1-6.................. LOCATION CODE........ 6 NUMERIC (Accepts values
from a table).
7-12................. EXAM DATE............ 6 NUMERIC DATE IN FORMAT--
mmddyy.
13-18................ PATIENT NUMBER....... 6 NUMERIC RT. JUSTIFY
(fill with lead 0's).
19-24................ DATE OF BIRTH........ 6 NUMERIC DATE IN FORMAT--
mmddyy.
25................... SEX.................. ALPHA CODE--(m or f).
26................... EXAM TYPE............ ALPHA CODE--(d g f).
27................... USER TYPE............ ALPHA CODE--(x r s u).
28................... FLUORIDE HISTORY..... ALPHA CODE--(x nf y n).
29-33................ HEALTH FACTORS....... Key x for each factor
marked except Tobacco.
None, Diabetes, Handicap,
Pregnancy, Tobacco (1, 2,
or 3), or No info.
34-35................ EDENTULISM........... Key x for each arch
(upper, lower) as marked.
#36-444 and 496-775.. TOOTH STATUS DATA.... 1 or 2-DIGIT A/N CODES IN
1-7 DATA FIELDS FOR EACH
OF 28 TEETH and 0-2 A/N
CODES FOR 4 ADDITIONAL
TEETH (#1, 17, 18, 32) AS
FOLLOWS:
36-37................ TOOTH #1 TREATMENT 1st A/N 2-DIGIT CODE.
DATA.
38-39................ ..................... 2nd A/N 2-DIGIT CODE.
40-41................ TOOTH #2 mesial (M).. A/N 2-DIGIT CODE (25
possible entries).
42-43................ occlusal (O)......... A/N 2-DIGIT CODE.
44-45................ distal (D)........... A/N 2-DIGIT CODE.
46-47................ buccal (B)........... A/N 2-DIGIT CODE.
48-49................ lingual (L).......... A/N 2-DIGIT CODE.
50-51................ TREATMENT DATA....... 1st A/N 2-DIGIT CODE (10
possible entries).
52-53................ ..................... 2nd A/N 2-DIGIT CODE.
54-67................ TOOTH #3 (In same
sequence as tooth #2
format).
68-82................ TOOTH #4 (In same
sequence as tooth #2
format).
83-96................ TOOTH #5 (In same
sequence as tooth #2
format).
97-110............... TOOTH #6 (In same
sequence as tooth #2
format).
111-124.............. TOOTH #7 (In same
sequence as tooth #2
format).
125-138.............. TOOTH #8 (In same
sequence as tooth #2
format).
139-152.............. TOOTH #9 (In same
sequence as tooth #2
format).
153-166.............. TOOTH #10 (In same
sequence as tooth #2
format).
167-180.............. TOOTH #11 (In same
sequence as tooth #2
format).
181-194.............. TOOTH #12 (In same
sequence as tooth #2
format).
195-208.............. TOOTH #13 (In same
sequence as tooth #2
format).
209-222.............. TOOTH #14 (In same
sequence as tooth #2
format).
223-236.............. TOOTH #15 (In same
sequence as tooth #2
format).
237-240.............. TOOTH #16 (In same
sequence as tooth #1
format).
241-444.............. Same format as listed
above applies to
each tooth in the
lower arch numbered:
#17 through 32.
445.................. ORAL TRAUMA Tooth #7. NUMERIC (0-5) OR x PER
TOOTH #.
446.................. ORAL TRAUMA Tooth #8. NUMERIC (0-5) OR x PER
TOOTH #.
447.................. ORAL TRAUMA Tooth #9. NUMERIC (0-5) OR x PER
TOOTH #.
448.................. ORAL TRAUMA Tooth #10 NUMERIC (0-5 OR x) PER
TOOTH #.
449.................. ORAL TRAUMA Tooth #23 NUMERIC (0-5 OR x) PER
TOOTH #.
450.................. ORAL TRAUMA Tooth #24 NUMERIC (0-5 OR x) PER
TOOTH #.
451.................. ORAL TRAUMA Tooth #25 NUMERIC (0-5 OR x) PER
TOOTH #.
452.................. ORAL TRAUMA Tooth #26 NUMERIC (0-5 OR x) PER
TOOTH #.
453.................. FLUOROSIS Group I.... NUMERIC (0-4) OR x OR
BLANK.
454.................. FLUOROSIS Group II... NUMERIC (0-4) OR x OR
BLANK.
455.................. CPITN SCORE UR....... NUMERIC (0-6) OR X OR
BLANK.
456.................. CPITN SCORE UA....... NUMERIC (0-6) OR X OR
BLANK.
457.................. CPITN SCORE UL....... NUMERIC (0-6) OR X OR
BLANK.
458.................. CPITN SCORE LR....... NUMERIC (0-6) OR X OR
BLANK.
459.................. CPITN SCORE LA....... NUMERIC (0-6) OR X OR
BLANK.
460.................. CPITN SCORE LL....... NUMERIC (0-6) OR X OR
BLANK.
461.................. LOA SCORE UR......... NUMERIC (0, 3-6) OR X OR
BLANK.
462.................. LOA SCORE UA......... NUMERIC (0, 3-6) OR X OR
BLANK.
463.................. LOA SCORE UL......... NUMERIC (0, 3-6) OR X OR
BLANK.
464.................. LOA SCORE LR......... NUMERIC (0, 3-6) OR X OR
BLANK.
465.................. LOA SCORE LA......... NUMERIC (0, 3-6) OR X OR
BLANK.
466.................. LOA SCORE LL......... NUMERIC (0, 3-6) OR X OR
BLANK.
467.................. PATHOLOGY CODE NONE.. BLANK OR LETTER CODE AS
MARKED.
468.................. PATHOLOGY SUP........ BLANK OR LETTER CODE AS
MARKED.
469.................. PATHOLOGY BL......... BLANK OR LETTER CODE AS
MARKED.
470.................. PATHOLOGY CP......... BLANK OR LETTER CODE AS
MARKED.
471.................. PATHOLOGY HV......... BLANK OR LETTER CODE AS
MARKED.
472.................. PATHOLOGY TBA........ BLANK OR LETTER CODE AS
MARKED.
473.................. PATHOLOGY ST......... BLANK OR NUMERIC (1-3) AS
CIRCLED.
474.................. PROS. POSSESSION BLANK OR ALPHA CODE (N, F
Upper. or P) IF MARKED.
475.................. PROS. POSSESSION BLANK OR ALPHA CODE (N, F
Lower. or P) IF MARKED.
476.................. PROS. NEED Upper..... BLANK OR A/N CODE IF
MARKED (P/F-1, 2, or 3).
477.................. PROS. NEED Lower..... BLANK OR A/N CODE IF
MARKED (P/F-1, 2, or 3).
478.................. ORTHO. STATUS None... BLANK OR X IF MARKED.
479.................. ORTHO. STATUS Minor.. BLANK OR X IF MARKED.
480.................. ORTHO. STATUS Comp... BLANK OR D or S AS MARKED.
481.................. ORTHO. STATUS In tx.. BLANK OR X IF MARKED.
482.................. ORTHO. STATUS BLANK OR X IF MARKED.
Completed.
483-485.............. SPECIAL USE VARIABLE 3 NUMERIC (0-9) OR BLANK.
#1.
486-487.............. SPECIAL USE VARIABLE 2 NUMERIC (0-9) OR BLANK.
#2.
488-489.............. SPECIAL USE VARIABLE 2 NUMERIC (0-9) OR BLANK.
#3.
490.................. DENTURE QUESTION #1.. BLANK OR LETTER CODE (Y N
or U).
491.................. DENTURE QUESTION #2.. BLANK OR X AS MARKED IN A
CODE BLANK (IHS, TRIBAL,
OTHER, or PRIVATE).
492.................. DENTURE QUESTION #3.. BLANK OR a, b, or c AS
MARKED.
493.................. ACCESS QUESTION #1... BLANK OR LETTER CODE (y, n
or u) AS MARKED.
494.................. ACCESS QUESTION #2... BLANK OR NUMERIC (0-60) AS
MARKED.
495.................. ACCESS QUESTION #3... BLANK OR LETTER CODE (y, n
or u) AS MARKED.
496-497.............. TOOTH #4d mesial (M). A/N 2-DIGIT CODE.
498-499.............. occlusal (O)......... A/N 2-DIGIT CODE.
500-501.............. distal (D)........... A/N 2-DIGIT CODE.
502-503.............. buccal (B)........... A/N 2-DIGIT CODE.
504-505.............. lingual (L).......... A/N 2-DIGIT CODE.
506-507.............. TREATMENT DATA....... 1st A/N 2-DIGIT CODE.
508-509.............. ..................... 2nd A/N 2-DIGIT CODE.
510-775.............. TOOTH #5d-20d (in
same sequence as
tooth #4d format) .
------------------------------------------------------------------------
G. Pharmacy System
1. Reporting Requirements
a. Pharmacy quarterly and cumulative workload report. This form
(HSA-91) is required to be completed by the Chief Pharmacist at each
IHS and tribal facility. Raw workload data relating to both inpatient
and outpatient pharmacy activities are collected and compiled using
this form. Raw data are converted to workload units on this form. These
data are entered on the HSA 91 report at the end of each quarter. The
report is completed by the 15th day following the end of the quarter at
which time it is forwarded to the Area Pharmacy Officer (APO). The APO
compiles the Area data and prepares a summary report for submission to
the Pharmacy Program at Headquarters within 30 days after the end of
the quarter.
The data are used for identifying trends, measuring workload and
correlating staffing and space requirements.
b. Monthly report for narcotics and other controlled substances.
This form (HSA-174) is a record of all Schedule II Controlled Substance
usage. It contains a record of the actual physical count of all
Schedule II items at the beginning of the month and the end of the
month. Records at the facility must correlate with the amount
dispensed.
The report is required to be completed monthly and sent to the
facility director with a copy to the APO. It is to be completed by the
10th day following the end of the month.
2. Record Formats
a. A copy of the HSA-91 Pharmacy Quarterly and Cumulative Workload
Report is included in appendix A.
b. A copy of the HSA-74, Monthly Report for Narcotics and Other
Controlled Substances is included in appendix A.
3. Transmission Media
Reports are to be submitted in hardcopy format to the APO.
H. Environmental Health Activity Reporting and Facility Data System
1. Reporting Requirements
a. The Environmental Health Activity Reporting and Facility Data
System (EHAR & FDS) Instruction Manual provides complete instructions
for reporting into the EHAR & FDS.
b. The EHAR & FDS is a microcomputer based system which combines
two previously separate data collection systems. The system is
decentralized to the Area level providing maximum flexibility for Area
environmental health programs. The EHAR section of the new system is
used to collect environmental health activity data. The FDS section is
a tracking system for surveys conducted at specific facilities. For the
EHAR section, Headquarters requirements can be met with a sampling
procedure that uses one full week of activities per month in accordance
with the sample reporting week schedule to be specified by IHS
Headquarters. The FDS section will not utilize sampling; all surveys
conducted at specific facilities will be reported into the system.
c. Each Area, utilizing standard forms and software, will define
procedures for collecting the EHAR & FDS data. Key entry of forms will
occur at the Area level.
2. Record Formats
a. One form is used to update the EHAR & FDS Area Master File.
b. A sample of the EHAR & FDS form is included in appendix A. Each
form consists of 7 records. To eliminate redundant hand coding, data
fields for each of these 7 records contained in record positions 1-14
are entered only once per form. If one of these values changes, a new
form must be started.
c. Fields in the EHAR & FDS system.
------------------------------------------------------------------------
Record
Field position Required
------------------------------------------------------------------------
Area Code....................................... 1-2 X
Service Unit.................................... 3-4 X
Community Code.................................. 5-7 X
Worker Number................................... 8-10 X
Month........................................... 11-12 X
Year............................................ 13-14 X
Service Code.................................... 15-16 X
Category Code................................... 17-18 X
Id Code......................................... 19-21 X
Activity Code................................... 22-24 X
Number Activities............................... 25-32 X
Activity Time................................... 33-40 X
Linkage Code.................................... 41-49 X
Facility Name................................... 50-79 X
------------------------------------------------------------------------
3. Data Transmission
The EHAR & FDS data will be forwarded electronically to the
Division of Environmental Health computer bulletin board in Rockville,
Maryland, on a quarterly basis.
I. Mental Health and Social Services Reporting System (MH & SS)
1. Reporting Requirements
a. Direct patient care is reported on the appropriate direct care
reporting system. The Mental Health and Social Services record is used
to report program related activities as a supplement to patient care
reporting.
2. Record Formats
a. Mental Health or Social Services direct patient care recording
will follow the appropriate procedures noted in prior sections for
Ambulatory Patient Care, Direct Inpatient, Contract Health Services
Outpatient and Contract Health Services Inpatient.
b. The MH & SS record is used as an activities reporting document
to record staff effort. Headquarters requirements can be met with a
sampling procedure that uses one full week of activities per month in
accordance with the sample reporting week schedule to be specified by
IHS Headquarters. The data are to be reported quarterly.
c. The format of the MH & SS record is shown at the end of this
section.
d. A sample of the MH & SS Activity Reporting Form, an activity
code list, and a problem code list are included in Appendix A. A copy
of the instructions for using the MH & SS Activities Reporting Form are
available on request from Headquarters, IHS.
3. Transmission Media
a. Patient care. Mental Health or Social Services direct patient
care recording will follow the appropriate procedures noted in prior
sections for Ambulatory Patient Care, Direct Inpatient, Contract Health
Services Outpatient and Contract Health Services Inpatient.
b. Activities reporting. Activities reports for each Area are
submitted to the Division of Data Processing Services by mail on nine
track unlabeled, unblocked EBCDIC tape or by other methods arranged
between Area and DDPS. Any arrangements between Area and Contractors on
how the data will be submitted at that level will have to conform to
the methods the Area uses to submit data to DDPS.
c. RPMS Generic Activities Reporting System (RPMS-GARS). There is
an RPMS ANSI MUMPS GARS data entry program which allows for records to
be submitted to Area for compilation and forwarding from Area to DDPS.
MENTAL HEALTH AND SOCIAL SERVICES ACTIVITIES REPORTING
[Input Record Data Fields]
------------------------------------------------------------------------
Position Item Content/comment Required
------------------------------------------------------------------------
2-3....... Area...................... Standard IHS Codes.. X
4-5....... Service Unit.............. Standard IHS Codes.. X
6-7....... Facility.................. Standard IHS Codes.. X
8-9....... Discipline................ Program affiliation, X
MH/SS.
10-15..... Date...................... Date of Service-Mo/ X
Da/Yr.
16-18..... Provider.................. Provider identifier. X
19-21..... Location.................. IHS 3-digit code X
(from St/Co/Comm
code list)
identifying
community where
activity took place.
22-23..... Activity.................. Two digit numeric X
code. See attached
Activity Codes.
24-25..... Recipient................. Two digit numeric ..........
code using Six
category field to
designate
categories of
recipients.
26-27..... Primary Purpose........... Two digit numeric X
code. See attached
Problem Codes.
28-29..... Secondary Purpose......... Two digit numeric ..........
code. See attached
Problem Codes
30-31..... Setting Codes............. Two digits ..........
distinguishing up
to ten service
settings.
32-34..... Number Served............. Up to three digits X
to specify Number
of persons served
directly by
reported activity..
35-36..... Age....................... Two digits to show ..........
age in years
37........ Sex....................... M or F ..........
38-40..... Activity Time............. Up to three digits X
showing Time in
minutes.
41-43..... Travel Time............... Up to three digits ..........
to show Time in
minutes
44-45..... Refer: From............... 2-Digit Code ..........
distinguishing up
to 10 referral
sources
46-47..... Refer: To................. Same as ``Refer ..........
From'' Codes
48........ Flag 1.................... Yes/No Field ..........
49........ Flag 2.................... Yes/No Field ..........
50........ Flag 3.................... One digit field ..........
distinguishing up
to five categories
of data
51........ Flag 4.................... One digit field ..........
distinguishing up
to five categories
of data
52-100.... Notes..................... Narrative (up to 48 ..........
alpha characters)
------------------------------------------------------------------------
J. Alcoholism Treatment Guidance System (ATGS)/Chemical Dependency
Management Information System (CDMIS)
1. General Reporting Requirements for ATGS and CDMIS
a. All IHS-funded alcohol/substance abuse programs, including Urban
Programs, will report their activities on either ATGS or CDMIS.
Programs will use ATGS until CDMIS is operational and implemented in
their specific program. ATGS will be discontinued upon implementation
of CDMIS in a program.
b. CDMIS will be beta-tested in fiscal year (FY) 1991, with
implementation beginning in FY 1992 and will be completed as quickly as
funding, logistics, and staffing allow.
2. Reporting Requirement for ATGS
a. An Alcoholism Treatment Guidance System (ATGS) record is
required for each person treated in an IHS alcoholism and substance
abuse treatment program (including covered contractors) until a program
is converted to CDMIS. Patients are usually present at the time of a
service, but services such as multi-disciplinary staffing and family
counseling without the client present are also documented. In addition
to completing the computer form, the provider must also note services
in the progress notes maintained in the treatment chart. Certified
chemical dependency counselors, counselors-in-training, and other
providers qualified by the program director may enter information in
the client record. In addition to treatment services, prevention
services and other staff activities are reported through ATGS.
b. The ATGS Counselor's Resource Manual, October 1983, provides
complete definitions and procedures for reporting in the ATGS system
and client chart.
3. Record Formats for ATGS
a. The formats of the ATGS records are shown at the end of this
section.
b. Samples of ATGS forms are included in appendix A.
4. Transmission Media for ATGS
a. Computer forms are sent by the alcoholism and substance abuse
programs to the appropriate IHS Area Office by the 6th day of the
month. Forms are then batched and mailed to the keytaping contractor,
UNICOR, on or before the 10th of each month. UNICOR key tapes the data
and forwards a tape to the IHS Division of Data Processing Services
(DDPS) in Albuquerque, New Mexico. DDPS produces reports from the tapes
and provides two copies to each IHS Area Office, who in turn
distributes one copy to each program that provided data.
5. New System Under Development
a. Current plans call for a gradual phasing out of the ATGS in
favor of the new Chemical Dependency Management Information System
(CDMIS) beginning in FY 1992 with implementation to proceed as quickly
as funds, logistics, and staffing allow. Final beta testing is to take
place during the last quarter of FY 1991. Once on CDMIS, a program will
discontinue ATGS. There will be two parallel systems operating during
the CDMIS implementation period.
b. The Alcoholism PSG (also known as the CDMIS Committee and the
ATGS Revision Committee) has examined every item of the ATGS and CDMIS,
asking what is the minimum information required by both the Director,
IHS, and the Congress. Drafts have been distributed to tribal programs
through the Area Alcohol Program Coordinators, with comments carefully
considered. Only those items that are being demanded on a regular basis
by the Director, IHS, or the Congress, those items required in law, and
specific items requested by a majority of the tribal programs have been
included in CDMIS.
6. Reporting Requirement for CDMIS
a. The Chemical Dependency Management Information System is an IHS
RPMS application that builds on the Patient Registration module. CDMIS
consists of two forms. CDMIS-1 is patient-specific and is completed
upon initial entry into the program, during treatment, and during a
follow-up phase. Preventive activities are also recorded on this form
for electronic incorporation into the Generic Activities Reporting
System (GARS). CDMIS-2 is an annual staffing, funding, and program
report. Either or both forms may be completed for later entry into the
computer-based system, or the data may be entered directly into the
database. Certified chemical dependency counselors, counselors-in-
training, other approved providers, data entry personnel, and others
certified as qualified by the program director are to complete the
CDMIS forms and/or enter the data into the computer.
b. The CDMIS Program Manual (complete with sub-manuals) scheduled
for completion in June 1991, provides the definitions and procedures
for reporting on the CDMIS.
c. Staff prevention activities from CDMIS-1 will be reported
through GARS. Headquarters requirements can be met with a sampling
procedure that uses one full week of activities per month in accordance
with the sample reporting week schedule to be specified by IHS
Headquarters.
7. Record Formats for ATGS
a. The formats of the CDMIS records are shown at the end of this
section.
b. Samples of CDMIS forms are included in Appendix A.
8. Transmission Media
a. Data will be transmitted electronically (or by computer disk in
those cases where electronic transmission is unreliable as certified by
the Area ISC) to either the servicing Service Unit or Area Office using
an approved IHS extract program. This data will be forwarded by the
Service Unit to the Area Office electronically. The Area Office will
electronically forward the data to the IHS Division of Data Processing
Services (DDPS) in Albuquerque, New Mexico. Data will be forwarded to
the Area Office quarterly by the 7th day of the month following the end
of the quarter. The Area Office will transmit the data to DDPS by the
10th of the month. DDPS produces reports from the data and provides the
copy to the ASAPB and two copies to each IHS Area Office, who, in turn,
distributes one copy to each program that provided data. DDPS also
provides the capability for ASAPB to download data for special reports,
graphing reports, etc. Programs may download their data from the
Service Unit (or Area Office if serviced by the Area Office) to print
local program reports as desired.
b. The Area ISC will, in consultation with the Area Alcohol Program
Coordinator, appropriate service unit personnel, and alcohol program
director, determine whether the program will be serviced by the Service
Unit or by the Area Office.
ATGS Keytaping Instructions
----------------------------------------------------------------------------------------------------------------
Record
Field Name position Location on documents or special instructions
----------------------------------------------------------------------------------------------------------------
FORM NAME: SHORT TERMNO: A
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `00'.
PROGRAM ID...................... 3-8 NUMERIC.
1. CASE NUMBER..................... 9-17 9-11 ALPHANUMERIC, 12-17 NUMERIC.
2. SEX............................. 18 ``1'' IF M, ``2'' IF F.
3. ETHNICITY....................... 19-21 ENTER `1' IF INDIAN, `2' IF ALASKAN, `3' IF OTHER,
RIGHT BLANK FILL UNUSED POSITIONS.
4. TRIBE CODE...................... 22-24 BLANK OF NUMERIC.
5. EMPLOYED........................ 25 ``1'' IF Y, ``2'' IF NO.
6. DEPENDENTS...................... 26 ``1'' IF Y, ``2'' IF NO, OR BLANK.
NUMBER OF....................... 27-28 BLANK OR LEFT-ZERO FILLED NUMERIC.
7. CHILD CARE...................... 29 ``1'' IF Y, ``2'' IF NO, OR BLANK.
8. ALC/DRUG TREATMENT.............. 30 ``1'' IF Y, ``2'' IF NO, OR BLANK.
9. COMPONENT CODES................. 31-32 BLANK OR NUMERIC.
................................ 33-34 BLANK OR NUMERIC.
................................ 35-36 BLANK OR NUMERIC.
10A. ADMIT/DISCHARGE................. 37-38 BLANK OR ENTER NUMBERS CIRCLED.
TOTAL DAYS...................... 39-40 BLANK OR LEFT-ZERO FILLED NUMERIC.
2ND LINE OF 10A................. 41-44 --SEE INSTRUCTIONS FROM RECORD POS. 37-40.
3RD LINE OF 10A................. 45-48 --SEE INSTRUCTIONS FROM RECORD POS. 37-40.
10B. SERVICE CODE.................... 49-50 BLANK OR NUMERIC.
TOTAL HOURS..................... 51-52 BLANK OR LEFT-ZERO FILLED NUMERIC.
2ND LINE OF 10B................. 53-56 --SEE INSTRUCTIONS FROM RECORD POS. 49-52.
3RD LINE OF 10B................. 57-60 --SEE INSTRUCTIONS FROM RECORD POS. 49-52.
11. REFERRAL CODES.................. 61-72 BLANK AND/OR NUMERIC, ENTER 2-DIGIT CODES LEFT TO
RIGHT, RIGHT BLANK FILL ANY UNUSED POSITIONS.
12. PRIMARY PROBLEM................. 73-74 NUMERIC.
STATE FUNDS CODE................ 75-76 BLANK OR NUMERIC.
13. NEW/REOPEN PROGRAM.............. 77 ENTER ``1'' or ``2'' FOR BOX CHECKED.
NEW/REOPEN ATGS................. 78 ENTER ``1'' or ``2'' FOR BOX CHECKED OR BLANK.
14. DISCHARGE....................... 79 ENTER NUMBER OF BOX CHECKED (1-5) OR BLANK.
15 & 16. ................................ -- DO NOT KEYTAPE.
17. STATE ID NUMBER................. 80-88 BLANK OR ALPHANUMERIC.
18. SERVICE MONTH................... 89-90 NUMERIC, LEFT ZERO FILLED.
SERVICE YEAR.................... 91-92 NUMERIC, LEFT ZERO FILLED.
----------------------------------------------------------------------------------------------------------------
FORM NAME: INITIAL CONTACTNO: 1
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `01'.
PROGRAM ID...................... 3-8 NUMERIC.
COMPONENT CODE.................. 9-10 NUMERIC.
CASE NUMBER..................... 11-19 11-13 ALPHANUMERIC, 14-19 NUMERIC.
STAFF CODE...................... 20-21 BLANK OR NUMERIC.
COUNTY CODE..................... 22-24 BLANK OR NUMERIC.
PRIMARY PROBLEM................. 25-26 NUMERIC.
SECONDARY PROBLEM............... 27-28 BLANK OR NUMERIC.
STATE FUNDS CODE................ 29-30 BLANK OR NUMERIC.
STATE CLIENT ID................. 31-39 BLANK OR ALPHANUMERIC.
OPTIONAL CODE C................. 40-41 BLANK OR NUMERIC.
OPTIONAL CODE D................. 42-43 BLANK OR NUMERIC.
1. SEX............................. 44 ``1'' IF M, ``2'' IF F.
2. REFERRED TO PROGRAM............. 45-46 NUMERIC.
3. COURT REFERRAL.................. 47-48 BLANK OR NUMERIC.
4. ETHNICITY....................... 49-54 ENTER NUMBER CORRESPONDING TO BOX CHECKED, RIGHT-
BLANK FILL UNUSED FIELDS, (i.e., IF BOXES 1 & 3
CHECKED ENTER `13').
5. TRIBE CODE...................... 55-57 BLANK OR NUMERIC.
DEGREE OF BLOOD................. 58 BLANK OR NUMERIC.
6. IHS ELIGIBLE.................... 59 ``1'' IF YES, ``2'' IF NO, ``3'' IF NONE AVAILABLE.
7. MARITAL......................... 60 ENTER NUMBER OF FIRST BOX CHECKED.
8. EMPLOYED........................ 61 ``1'' IF YES, ``2'' IF NO.
OCCUPATION...................... 62-63 BLANK OR NUMERIC.
INCOME.......................... 64-68 BLANK OR NUMERIC OR ZEROS.
9. EDUCATION....................... 69-70 ENTER NUMBER CIRCLED, LEFT-ZERO FILLED.
OTHER........................... 71-72 BLANK OR NUMERIC.
10. SKILL DEVELOPMENT............... 73 ``1'' IF YES, ``2'' IF NO.
11. HEALTH INSURANCE................ 74 ``1'' IF YES, ``2'' IF NO.
MEDICARE........................ 75 ``1'' IF YES, ``2'' IF NO.
MEDICAID........................ 76 ``1'' IF YES, ``2'' IF NO.
12. VETERAN......................... 77 ``1'' IF YES, ``2'' IF NO.
13. YEARS DRINKING/DRUG............. 78-79 LEFT ZERO-FILLED NUMERIC.
YEARS HEAVY USE................. 80-81 BLANK OR LEFT ZERO-FILLED NUMERIC.
PREVIOUS TREATMENT.............. 82 ``1'' IF YES, ``2'' IF NO.
PRIOR TREATMENT-IHS............. 83 BLANK OR ``1'' IF YES, ``2'' IF NO, ``3'' IF
UNKNOWN.
14. DEPENDENTS...................... 84 ``1'' IF YES, ``2'' IF NO.
HOW MANY........................ 85-86 BLANK OR NUMERIC.
15. BEEN HOSPITALIZED............... 87 ``1'' IF YES, ``2'' IF NO.
ALCOHOL RELATED................. 88 ``1'' IF YES, ``2'' IF NO, OR BLANK.
ARRESTED........................ 89 ``1'' IF YES, ``2'' IF NO.
DWI............................. 90 ``1'' IF YES, ``2'' IF NO, OR BLANK.
USED ALCOHOL.................... 91 ``1'' IF YES, ``2'' IF NO.
NUMBER OF DAYS.................. 92-93 BLANK OR LEFT-ZERO FILLED NUMERIC.
USED OTHER DRUGS................ 94 ``1'' IF YES, ``2'' IF NO.
NUMBER OF DAYS.................. 95-96 BLANK OR LEFT-ZERO FILLED NUMERIC.
TYPE OF DRUGS CODE.............. 97-98 BLANK OR NUMERIC.
16. ALCOHOL STAGE................... 99 BLANK OR NUMERIC.
PHYSICAL STAGE.................. 100 BLANK OR NUMERIC.
EMOTIONAL STAGE................. 101 BLANK OR NUMERIC.
CULTURAL STAGE.................. 102 BLANK OR NUMERIC.
SPIRITUAL STAGE................. 103 BLANK OR NUMERIC.
RECOMMENDED..................... 104 BLANK OR ENTER NUMBER OF FIRST BOX CHECKED.
DIFFERENCE CODE................. 105-106 BLANK OR NUMERIC.
17. ACTUAL PLACEMENT................ 107 ENTER NUMBER OF FIRST BOX CHECKED (1-7).
PLACEMENT TYPE.................. 108 BLANK OR ENTER LETTER OF BOX (A-F).
18. REFERRAL MADE................... 109 BLANK OR ``1'' IF YES, ``2'' IF NO.
REFERRAL CODE................... 110-111 BLANK OR NUMERIC.
REFERRAL CODE................... 112-113 BLANK OR NUMERIC.
19. SPIRITUAL PREFERENCE............ 114-115 BLANK OR NUMERIC.
SPIRITUAL PREFERENCE............ 116-117 BLANK OR NUMERIC.
PRACTICE........................ 118 ``1'' IF REGULAR, ``2'' IF OCCASIONAL, ``3'' IF
NEVER, OR BLANK.
ORIGINAL CONTACT DATE........... 119-124 BLANK OR NUMERIC (MMDDYY FORMAT). AS REQUIRED, LEFT-
ZERO FILL ANY 2-DIGIT FIELD.
DATE FORM COMPLETED............. 125-130 NUMERIC (MMDDYY FORMAT). AS REQUIRED, LEFT-ZERO FILL
ANY 2-DIGIT FIELD.
----------------------------------------------------------------------------------------------------------------
FORM NAME: DISCHARGE REPORTNO: 7
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `07'.
PROGRAM ID...................... 3-8 NUMERIC.
COMPONENT CODE.................. 9-10 NUMERIC.
CASE NUMBER..................... 11-19 11-13 ALPHANUMERIC, 14-19 NUMERIC.
STAFF CODE...................... 20-21 BLANK OR NUMERIC.
COUNTY CODE..................... 22-24 BLANK OR NUMERIC.
PRIMARY PROBLEM................. 25-26 NUMERIC.
STATE FUNDS CODE................ 27-28 BLANK OR NUMERIC.
STATE CLIENT ID................. 29-37 BLANK OR ALPHANUMERIC.
OPTIONAL CODE C................. 38-39 BLANK OR NUMERIC.
OPTIONAL CODE D................. 40-41 BLANK OR NUMERIC.
1. DATE OF ADMISSION............... 42-47 NUMERIC (MMDDYY FORMAT) LEFT-ZERO FILLED EACH 2-
DIGIT FIELD IF NECESSARY.
2. DATE OF DISCHARGE............... 48-53 see instructions for 42-47.
3. DISCHARGE FROM.................. 54 ENTER LETTER OF BOX CHECKED (A-M).
4. SERVICES USED................... 55-60 ENTER FIRST 6 LETTERS LEFT TO RIGHT, RIGHT-BLANK
FILL ANY REMAINING POSITIONS.
5. DISCHARGE REASON................ 61 ENTER LETTER OF FIRST BOX CHECKED.
6. CLIENT GOALS STATUS............. 62 ENTER NUMBER OF BOX CHECKED.
7. ADMISSION STAGES................ 63-67 BLANKS OR ENTER COLUMN OF NUMBERS UNDER ADMISSION.
DISCHARGE STAGES................ 68-72 BLANKS OR ENTER COLUMN OF NUMBERS UNDER DISCHARGE.
8. USING WHAT...................... 73 ENTER ``1'' IF ALCOHOL CIRCLED, ``2'' FOR DRUG,
``3'' FOR SUBSTANCES, ``4'' IF MORE THAN ONE ITEM
CIRCLED.
USING ALC/DRG/SUB............... 74 ``1'' IF YES, ``2'' IF NO, ``3'' IF UNKNOWN.
9. DISCHARGE PLAN NEGOT............ 75 ``1'' IF YES, ``2'' IF NO, OR BLANK.
10. DISCHARGE TO.................... 76 ENTER LETTER CHECKED IN CR* COLUMN.
................................ 77 ENTER LETTER CHECKED IN CD* COLUMN.
DATE FORM COMPLETED............. 78-83 BLANK OR NUMERIC (MMDDYY FORMAT) AS REQUIRED, LEFT
ZERO-FILL EACH 2-DIGIT FIELD.
----------------------------------------------------------------------------------------------------------------
FORM NAME: FOLLOW-UP STATUSNO: 8
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `08'.
PROGRAM ID...................... 3-8 NUMERIC.
COMPONENT CODE.................. 9-10 BLANK OR NUMERIC.
CASE NUMBER..................... 11-19 11-13 ALPHANUMERIC, 14-19 NUMERIC.
STAFF CODE...................... 20-21 BLANK OR NUMERIC.
COUNTY CODE..................... 22-24 BLANK OR NUMERIC.
PRIMARY PROBLEM................. 25-26 NUMERIC.
STATE FUNDS..................... 27-28 BLANK OR NUMERIC.
STATE CLIENT ID................. 29-37 BLANK OR ALPHANUMERIC.
OPTIONAL CODE C................. 38-39 BLANK OR NUMERIC.
OPTIONAL CODE D................. 40-41 BLANK OR NUMERIC.
1. TYPE STATUS REPORT.............. 42 ENTER NUMBER OF BOX CHECKED.
2. MOVED/DIED...................... 43 BLANK OR NUMERIC.
IF QUESTION 2 IS CHECKED, SKIP REST OF RECORD AND
ENTER DATE ON BOTTOM OF FORM (RECORD POSITION 75-
80).
3. CLIENT STATUS................... 44 ENTER LETTER OF BOX CHECKED.
4. CLIENT STAGE.................... 45-49 BLANK OR NUMERIC.
5. EMPLOYED........................ 50 ``1'' IF YES, ``2'' IF NO.
OCCUPATION...................... 51-52 BLANK OR NUMERIC.
INCOME.......................... 53-57 BLANK OR LEFT-ZERO FILLED NUMERIC.
6. SKILL DEV./TRNG................. 58 ``1'' IF YES, ``2'' IF NO.
7. MARITAL......................... 59 ENTER NUMBER OF BOX CHECKED.
8. HOSPITALIZED.................... 60 ``1'' IF YES, ``2'' IF NO.
ALCOHOL RELATED................. 61 ``1'' IF YES, ``2'' IF NO, OR BLANK.
ARRESTED........................ 62 ``1'' IF YES, ``2'' IF NO.
DWI............................. 63 ``1'' IF YES, ``2'' IF NO, OR BLANK.
USED ALCOHOL.................... 64 ``1'' IF YES, ``2'' IF NO.
NUMBER DAYS..................... 65-66 BLANK OR LEFT-ZERO FILLED NUMERIC.
USED OTHER DRUGS................ 67 ``1'' IF YES, ``2'' IF NO.
NUMBER DAYS..................... 68-69 BLANK OR LEFT-ZERO FILLED NUMERIC.
TYPE CODE....................... 70-71 BLANK OR NUMERIC.
9. DAYS LAST DRINK................. 72-74 BLANK OR LEFT-ZERO FILLED NUMERIC OR ``NA''.
DATE FORM COMPLETED............. 75-80 NUMERIC (MMDDYY FORMAT).
LEFT-ZERO FILL EACH TWO-DIGIT FIELD IF NECESSARY.
----------------------------------------------------------------------------------------------------------------
FORM NAME: SERVICES REPORTNO: 9
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `09'.
MONTH........................... 3-4 LEFT-ZERO FILLED NUMERIC.
YEAR............................ 5-6 LEFT-ZERO FILLED NUMERIC.
PROGRAM ID...................... 7-12 NUMERIC.
COMPONENT CODE.................. 13-14 NUMERIC.
CASE NUMBER..................... 15-23 15-17 ALPHANUMERIC, 18-23 NUMERIC.
STAFF CODE...................... 24-25 BLANK OR NUMERIC.
COUNTY CODE..................... 26-28 BLANK OR NUMERIC.
PRIMARY PROBLEM................. 29-30 NUMERIC.
STATE FUNDS CODE................ 31-32 BLANK OR NUMERIC.
STATE CLIENT ID................. 33-41 BLANK OR ALPHANUMERIC.
OPTIONAL CODE C................. 42-43 BLANK OR NUMERIC.
OPTIONAL CODE D................. 44-45 BLANK OR NUMERIC.
1. DAY OF MONTH.................... 46-47 BLANK OR LEFT-ZERO FILLED NUMERIC.
COMPONENT MONTH................. 48-49 BLANK OR NUMERIC.
STAFF CODE...................... 50-51 BLANK OR ALPHANUMERIC.
SERVICE CODE.................... 52-53 BLANK OR NUMERIC.
TOTAL HOURS..................... 54-56 54-55 LEFT-ZERO FILLED NUMERIC, NO DECIMAL POINT.
56 NUMERIC, ZERO-FILL TENTH'S POSITION IF ONLY WHOLE
NUMBER ENTERED.
14 ADDITIONAL LINES OF DATA, 57-210 ENTER EACH 11-DIGIT FIELD DISREGARDING ANY IMBEDDED
SAME FORMAT AS POSITIONS 46-56. BLANK LINE, RIGHT-BLANK FILL UNUSED FIELDS.
2. TREATMENT PLAN NEG.............. 211 ``1'' IF YES, ``2'' IF NO, OR BLANK.
TREATMENT PLAN PROG............. 212 ``1'' IF YES, ``2'' IF NO, OR BLANK.
3. ARRIVE AT AGENCY................ 213 ``1'' IF YES, ``2'' IF NO, OR BLANK.
ACCEPTED FOR SERVICE............ 214 ``1'' IF YES, ``2'' IF NO, OR BLANK.
4. IHS-NEW/REOPEN/CONT............. 215 ``1, 2 OR 3'' FOR NEW, REOPEN OR CONTINUE
RESPECTIVELY OR BLANK.
PROG-NEW/REOPEN/CONT............ 216 ``1, 2 OR 3'' FOR NEW, REOPEN OR CONTINUE
RESPECTIVELY OR BLANK.
COMP.-NEW/REOPEN/CONT........... 217 ``1, 2 OR 3'' FOR NEW, REOPEN OR CONTINUE
RESPECTIVELY OR BLANK.
5. REFERRALS OUT................... 218-223 BLANK &/OR NUMERIC, ENTER 2-DIGIT CODES LEFT TO
RIGHT, RIGHT BLANK FILL ANY UNUSED POSITIONS.
6. STATUS.......................... 224-226 ENTER NUMBERS CIRCLED OR BLANK.
COMPONENT CODE.................. 227-228 BLANK OR NUMERIC.
TOTAL DAYS...................... 229-230 BLANK OR LEFT-ZERO FILLED NUMERIC.
4 ADDITIONAL LINES OF DATA, SAME 231-258 ENTER EACH 9-DIGIT FIELD DISREGARDING ANY IMBEDDED
FORMAT AS POSITIONS 224-230. BLANK LINE, RIGHT-BLANK FILL UNUSED FIELDS.
DATA FORM COMPLETED............. 259-264 BLANK OR NUMERIC (MMDDYY FORMAT) AS REQUIRED, LEFT-
ZERO FILL ANY 2-DIGIT FIELD.
----------------------------------------------------------------------------------------------------------------
FORM NAME: SERVICES REPORT--CONTINUATIONNO: 9A
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 CHARACTERS `OA' (NUMERIC 0).
PAGE............................ 3 NUMERIC.
MONTH........................... 4-5 LEFT-ZERO FILLED NUMERIC.
YEAR............................ 6-7 LEFT-ZERO FILLED NUMERIC.
PROGRAM ID...................... 8-13 NUMERIC.
COMPONENT CODE.................. 14-15 NUMERIC.
CASE NUMBER..................... 16-24 16-18 ALPHANUMERIC, 19-24 NUMERIC.
STAFF CODE...................... 25-26 BLANK OR NUMERIC.
COUNTY CODE..................... 27-29 BLANK OR NUMERIC.
PRIMARY PROBLEM................. 30-31 NUMERIC.
STATE FUNDS CODE................ 32-33 BLANK OR NUMERIC.
STATE CLIENT CODE............... 34-42 BLANK OR ALPHANUMERIC.
OPTIONAL CODE C................. 43-44 BLANK OR NUMERIC.
OPTIONAL CODE D................. 45-46 BLANK OR NUMERIC.
1. DAY OF MONTH.................... 47-48 LEFT-ZERO FILLED NUMERIC.
COMPONENT CODE.................. 49-50 NUMERIC.
STAFF CODE...................... 51-52 BLANK OR ALPHANUMERIC.
SERVICE CODE.................... 53-54 NUMERIC.
TOTAL HOURS..................... 55-57 55-56 LEFT-ZERO FILLED NUMERIC, NO DECIMAL POINT.
57 NUMERIC, ZERO-FILL TENTHS POSITION IF ONLY WHOLE
NUMBER ENTERED.
36 ADDITIONAL LINES OF DATA, 58-475 ENTER EACH 11-DIGIT FIELD DISREGARDING ANY IMBEDDED
SAME FORMAT AS POSITIONS 47-57. BLANK LINE, RIGHT-BLANK FILL UNUSED FIELDS.
----------------------------------------------------------------------------------------------------------------
FORM NAME: ACTIVITY REPORTNO: 10
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC 10.
MONTH........................... 3-4 LEFT-ZERO FILLED NUMERIC.
YEAR............................ 5-6 LEFT-ZERO FILLED NUMERIC.
PROGRAM ID...................... 7-12 NUMERIC.
COMPONENT CODE.................. 13-14 NUMERIC.
STAFF CODE...................... 15-16 NUMERIC.
STAFF TYPE...................... 17 ``1, 2, 3 OR 4'' FOR REG., CHR, VOLUN., OR CETA,
RESPECTIVELY.
DIRECT SERVICE STAFF............ 18 ``1'' IF YES, ``2'' IF NO.
UNDER PREVENTION AND COMMUNITY EDUCATION; (ALL ROWS
EXCEPT BOTTOM ONE).
TYPE SESSION.................... 19-21 LEFT-ZERO FILLED NUMERIC.
TARGET GROUP.................... 22-23 NUMERIC.
NUMBER OF PEOPLE................ 24-27 LEFT-ZERO FILLED NUMERIC.
21 ADDITIONAL LINES OF DATA, 28-216 ENTER EACH 9-DIGIT FIELD DISREGARDING ANY BLANK
SAME FORMAT AS POSITIONS 19-27. LINES, RIGHT-BLANK FILL UNUSED FIELDS.
TOTAL ROW:
CONFERENCE & WORKSHOPS.......... 217-219 FOR ALL REMAINING FIELDS, BLANK OR LEFT-ZERO.
INSERVICE TRAINING.............. 220-222 FILLED NUMERIC NO DECIMAL POINTS.
STAFF MEETINGS.................. 223-225 ALL TOTAL FIELDS ARE THREE DIGITS EXCEPT THOSE NOTED
BELOW:
LEAVE........................... 226-228
SUPERVISION OF STAFF............ 229-231
REPORT TO TRIBAL CNCL........... 232-234
ATGS............................ 235-237
PLANNING & DEVELOPMENT.......... 238-240
GENERAL ADMINISTRATION.......... 241-243
INPATIENT DIRECT HOURS.......... 244-246
OUTPATIENT DIRECT HOURS......... 247-249
PREVENTION-INDIVIDUALS.......... 250-252
TRAVEL DIRECT-CLIENT............ 253-255
TRAVEL INDIRECT................. 256-258
OTHER........................... 259-261
INFORMATION INQUIRIES........... 262-264
CONTACTS FOR INFO............... 265-268 4 DIGIT FIELD.
SESSION CODE.................... 269-271 BLANK.
TARGET GROUP.................... 272-273 BLANK--2 DIGIT FIELD.
PERSONS IN GROUP................ 274-277 4 DIGIT FIELD.
HOURS PREPARATION............... 278-280
HOURS PRESENTATION.............. 281-283
TOTAL HOURS..................... 284-286
----------------------------------------------------------------------------------------------------------------
FORM NAME: ACTIVITY REPORT--CONTINUATIONNO: 10A
----------------------------------------------------------------------------------------------------------------
RECORD TYPE..................... 1-2 NUMERIC `11'.
3-286 THIS RECORD IS IDENTICAL TO FORM NO. 10 EXCEPT THE
RECORD TYPE CODE.
----------------------------------------------------------------------------------------------------------------
Record Format Control List of Fields
[CDMIS Client Demographics]
----------------------------------------------------------------------------------------------------------------
Field name Starts Length Ends Fill logic XS Length logic
----------------------------------------------------------------------------------------------------------------
Program..................................... 1 6 6 Blanks.......... Truncate.
Service Date................................ 7 6 12 Blanks.......... ... Truncate.
Component................................... 13 4 16 Blanks.......... ... Truncate.
Provider.................................... 17 5 21 Blanks.......... ... Truncate.
Contact..................................... 22 2 23 Blanks.......... ... Truncate.
Follow-up Months............................ 24 2 25 Blanks.......... ... Truncate.
Client ID................................... 26 9 34 Blanks.......... ... Truncate.
Client Age RNG.............................. 35 1 35 Blanks.......... ... Truncate.
Client DOB.................................. 36 7 42 Blanks.......... ... Truncate.
Client Tribe................................ 43 3 45 Blanks.......... ... Truncate.
Client Sex.................................. 46 1 46 Blanks.......... ... Truncate.
Client Community............................ 47 7 53 Blanks.......... ... Truncate.
Primary Problem............................. 54 2 55 Zero/Blank...... ... Truncate.
Secondary Problem........................... 56 2 57 Zero/Blank...... ... Truncate.
In Treatment................................ 58 1 58 Blanks.......... ... Truncate.
Alcohol Days................................ 59 3 61 Zero/Blank...... ... Truncate.
Drug Days................................... 62 3 64 Zero/Blank...... ... Truncate.
Drug Combination............................ 65 1 65 Blanks.......... ... Truncate.
Drug Type................................... 66 8 73 Blanks.......... ... Truncate.
Hospital Days............................... 74 3 76 Zero/Blank...... ... Truncate.
Arrests..................................... 77 3 79 Zero/Blank...... ... Truncate.
Alc/Sub Stage............................... 80 1 80 Blanks.......... ... Truncate.
Physical Stage.............................. 81 1 81 Blanks.......... ... Truncate.
Emotional Stage............................. 82 1 82 Blanks.......... ... Truncate.
Social Stage................................ 83 1 83 Blanks.......... ... Truncate.
Cultural Stage.............................. 84 1 84 Blanks.......... ... Truncate.
Behavioral Stage............................ 85 1 85 Blanks.......... ... Truncate.
Recommended Placement....................... 86 4 89 Blanks.......... ... Truncate.
Actual Placement............................ 90 4 93 Blanks.......... ... Truncate.
Difference Reason........................... 94 2 95 Blanks.......... ... Truncate.
Inpatient Days.............................. 96 3 96 Zero/Blank...... ... Truncate.
Goal Attainment............................. 99 1 99 Blanks.......... ... Truncate.
TDC Reason.................................. 100 2 101 Blanks.......... ... Truncate.
Discharge Plan.............................. 102 1 102 Blanks.......... ... Truncate.
----------------------------------------------------------------------------------------------------------------
RECORD FORMAT CONTROL LIST OF FIELDS
[CDMIS Client Services]
----------------------------------------------------------------------------------------------------------------
Field name Starts Length Ends Fill Logic XS Length Logic
----------------------------------------------------------------------------------------------------------------
Program..................................... 1 6 6 Blanks.......... ... Truncate.
Service Date................................ 7 6 12 Blanks.......... ... Truncate.
Component................................... 13 4 16 Blanks.......... ... Truncate.
Provider.................................... 17 5 21 Blanks.......... ... Truncate.
Contact..................................... 22 2 23 Blanks.......... ... Truncate.
Client ID................................... 24 9 32 Blanks.......... ... Truncate.
Client Age Range............................ 33 1 33 Blanks.......... ... Truncate.
Client DOB.................................. 34 7 40 Blanks.......... ... Truncate.
Client Tribe................................ 41 3 43 Blanks.......... ... Truncate.
Client Sex.................................. 44 1 44 Blanks.......... ... Truncate.
Client Community............................ 45 7 51 Blanks.......... ... Truncate.
Record Order................................ 52 2 53 Zeroes.......... ... Truncate.
Service 1................................... 54 9 62 Blanks.......... ... Truncate.
Service 2................................... 63 9 71 Blanks.......... ... Truncate.
Service 3................................... 72 9 80 Blanks.......... ... Truncate.
Service 4................................... 81 9 89 Blanks.......... ... Truncate.
Service 5................................... 90 9 98 Blanks.......... ... Truncate.
Service 6................................... 99 9 107 Blanks.......... ... Truncate.
Service 7................................... 106 9 116 Blanks.......... ... Truncate.
Service 8................................... 117 9 125 Blanks.......... ... Truncate.
Service 9................................... 126 9 134 Blanks.......... ... Truncate.
Service 10.................................. 135 9 143 Blanks.......... ... Truncate.
Service 11.................................. 144 9 152 Blanks.......... ... Truncate.
----------------------------------------------------------------------------------------------------------------
Record Format Control List of Fields
[CDMIS Program]
----------------------------------------------------------------------------------------------------------------
Field name Starts Length Ends Fill logic XS Length logic
----------------------------------------------------------------------------------------------------------------
CDMIS Program............................... 1 6 6 Blanks.......... ... Truncate.
Fiscal Year................................. 7 2 8 Zero/Blank...... ... Truncate.
Director.................................... 9 35 43 Blanks.......... ... Truncate.
Fund CAT1................................... 44 3 46 Blanks.......... ... Truncate.
Fund CAT2................................... 47 3 49 Blanks.......... ... Truncate.
Fund CAT3................................... 50 3 52 Blanks.......... ... Truncate.
Fund CAT4................................... 53 3 55 Blanks.......... ... Truncate.
Staff Total................................. 56 3 58 Zeroes.......... ... Truncate.
IHS Staff................................... 59 3 61 Zeroes.......... ... Truncate.
Male Staff.................................. 62 3 64 Zeroes.......... ... Truncate.
Female Staff................................ 65 3 67 Zeroes.......... ... Truncate.
Indian Staff................................ 68 3 70 Zeroes.......... ... Truncate.
NON Indian Staff............................ 71 3 73 Zeroes.......... ... Truncate.
Salary Average.............................. 74 5 78 Zeroes.......... ... Truncate.
Salary PCT IHS Funded....................... 79 3 81 Zeroes.......... ... Truncate.
IHS Funds Direct............................ 82 10 91 Zeroes.......... ... Truncate.
IHS Funds Indirect.......................... 92 10 101 Zeroes.......... ... Truncate.
IHS Indirect Rate........................... 102 3 104 Zeroes.......... ... Truncate.
Outpatients to See.......................... 105 5 109 Zeroes.......... ... Truncate.
Smoke Free.................................. 110 1 110 Zeroes.......... ... Truncate.
CAC......................................... 111 3 113 Zeroes.......... ... Truncate.
NAC......................................... 114 3 116 Zeroes.......... ... Truncate.
PSY......................................... 117 3 119 Zeroes.......... ... Truncate.
SW.......................................... 120 3 122 Zeroes.......... ... Truncate.
FT.......................................... 123 3 125 Zeroes.......... ... Truncate.
RT.......................................... 126 3 128 Zeroes.......... ... Truncate.
AT.......................................... 129 3 131 Zeroes.......... ... Truncate.
PHY......................................... 132 3 134 Zeroes.......... ... Truncate.
NUR......................................... 135 3 137 Zeroes.......... ... Truncate.
ED.......................................... 138 3 140 Zeroes.......... ... Truncate.
ADM......................................... 141 3 143 Zeroes.......... ... Truncate.
SPT......................................... 144 3 146 Zeroes.......... ... Truncate.
OCC......................................... 147 3 149 Zeroes.......... ... Truncate.
ONC......................................... 150 3 152 Zeroes.......... ... Truncate.
CON......................................... 153 3 155 Zeroes.......... ... Truncate.
VOL......................................... 156 3 158 Zeroes.......... ... Truncate.
STU......................................... 159 3 161 Zeroes.......... ... Truncate.
OTH-CC...................................... 162 3 164 Zeroes.......... ... Truncate.
ADC......................................... 165 3 167 Zeroes.......... ... Truncate.
FT-JD....................................... 168 3 170 Zeroes.......... ... Truncate.
MH.......................................... 171 3 173 Zeroes.......... ... Truncate.
SW-JD....................................... 174 3 176 Zeroes.......... ... Truncate.
ADE......................................... 177 3 179 Zeroes.......... ... Truncate.
RT-JD....................................... 180 3 182 Zeroes.......... ... Truncate.
AT-JD....................................... 183 3 185 Zeroes.......... ... Truncate.
MED......................................... 186 3 188 Zeroes.......... ... Truncate.
ED-JD....................................... 189 3 191 Zeroes.......... ... Truncate.
AFT......................................... 192 3 194 Zeroes.......... ... Truncate.
OC-JD....................................... 195 3 197 Zeroes.......... ... Truncate.
ADM-JD...................................... 198 3 200 Zeroes.......... ... Truncate.
VOL-JD...................................... 201 3 203 Zeroes.......... ... Truncate.
STU-JD...................................... 204 3 206 Zeroes.......... ... Truncate.
OTH-JD...................................... 207 3 209 Zeroes.......... ... Truncate.
NO HS GRAD.................................. 210 3 212 Zeroes.......... ... Truncate.
HS GRAD..................................... 213 3 215 Zeroes.......... ... Truncate.
AART........................................ 216 3 218 Zeroes.......... ... Truncate.
BA/BS....................................... 219 3 221 Zeroes.......... ... Truncate.
MA/MS....................................... 222 3 224 Zeroes.......... ... Truncate.
MD/PHD...................................... 225 3 227 Zeroes.......... ... Truncate.
Other ED LVL................................ 228 3 230 Zeroes.......... ... Truncate.
DTX-Type.................................... 231 1 231 Blanks.......... ... Truncate.
DTX-Fund.................................... 232 1 232 Blanks.......... ... Truncate.
DTX-Beds.................................... 233 2 234 Zero/Blank...... ... Truncate.
OTX-OCC..................................... 235 3 237 Zero/Blank...... ... Truncate.
DTX-IHS..................................... 238 3 240 Zero/Blank...... ... Truncate.
DTX-TOT..................................... 241 3 243 Zero/Blank...... ... Truncate.
PRT-Type.................................... 244 1 244 Blanks.......... ... Truncate.
PRT-Fund.................................... 245 1 245 Blanks.......... ... Truncate.
PRT-Beds.................................... 246 2 247 Zero/Blank...... ... Truncate.
PRT-OCC..................................... 248 3 250 Zero/Blank...... ... Truncate.
PRT-IHS..................................... 251 3 253 Zero/Blank...... ... Truncate.
PRT-TOT..................................... 254 3 256 Zero/Blank...... ... Truncate.
HWH-Type.................................... 257 1 257 Blanks.......... ... Truncate.
HWH-Fund.................................... 258 1 258 Blanks.......... ... Truncate.
HWH-Beds.................................... 259 2 260 Zero/Blank...... ... Truncate.
HWH-OCC..................................... 261 3 263 Zero/Blank...... ... Truncate.
HWH-IHS..................................... 264 3 266 Zero/Blank...... ... Truncate.
HWH-TOT..................................... 267 3 269 Zero/Blank...... ... Truncate.
TLC-Type.................................... 270 1 270 Blanks.......... ... Truncate.
TLC-Fund.................................... 271 1 271 Blanks.......... ... Truncate.
TLC-Beds.................................... 271 2 273 Blanks.......... ... Truncate.
TLC-OCC..................................... 274 3 276 Zero/Blank...... ... Truncate.
TLC-IHS..................................... 277 3 279 Zero/Blank...... ... Truncate.
TLC-TOT..................................... 280 3 282 Zero/Blank...... ... Truncate.
GRH-Type.................................... 283 1 283 Blanks.......... ... Truncate.
GRH-Fund.................................... 284 1 284 Blanks.......... ... Truncate.
GRH-Beds.................................... 285 2 286 Zero/Blank...... ... Truncate.
GRH-OCC..................................... 287 3 289 Zero/Blank...... ... Truncate.
GRH-IHS..................................... 290 3 292 Zero/Blank...... ... Truncate.
GRH-TOT..................................... 293 3 295 Zero/Blank...... ... Truncate.
FGH-Type.................................... 296 1 296 Blanks.......... ... Truncate.
FGH-Fund.................................... 297 1 297 Blanks.......... ... Truncate.
FGH-Beds.................................... 298 2 299 Zero/Blank...... ... Truncate.
FGH-OCC..................................... 300 3 302 Zero/Blank...... ... Truncate.
FGH-IHS..................................... 303 3 305 Zero/Blank...... ... Truncate.
FGH-TOT..................................... 306 3 308 Zero/Blank...... ... Truncate.
TFH-Type.................................... 309 1 309 Blanks.......... ... Truncate.
TFH-Fund.................................... 310 1 310 Blanks.......... ... Truncate.
TFH-Beds.................................... 311 2 312 Zero/Blank...... ... Truncate.
TFH-OCC..................................... 313 3 315 Zero/Blank...... ... Truncate.
TFH-IHS..................................... 316 3 318 Zero/Blank...... ... Truncate.
TFH-TOT..................................... 319 3 321 Zero/Blank...... ... Truncate.
DIC-Type.................................... 322 1 322 Blanks.......... ... Truncate.
DIC-Fund.................................... 323 1 323 Blanks.......... ... Truncate.
DIC-Beds.................................... 324 2 325 Zero/Blank...... ... Truncate.
DIC-OCC..................................... 326 3 328 Zero/Blank...... ... Truncate.
DIC-IHS..................................... 329 3 331 Zero/Blank...... ... Truncate.
DIC-TOT..................................... 332 3 334 Zero/Blank...... ... Truncate.
OPT-Type.................................... 335 1 335 Blanks.......... ... Truncate.
OPT-Fund.................................... 336 1 336 Blanks.......... ... Truncate.
OPT-OCC..................................... 337 3 339 Zero/Blank...... ... Truncate.
OPT-IHS..................................... 340 3 342 Zero/Blank...... ... Truncate.
OPT-TOT..................................... 343 3 345 Zero/Blank...... ... Truncate.
AFT-Type.................................... 346 1 346 Blanks.......... ... Truncate.
AFT-Fund.................................... 347 1 347 Blanks.......... ... Truncate.
AFT-OCC..................................... 348 3 350 Zero/Blank...... ... Truncate.
AFT-IHS..................................... 351 3 353 Zero/Blank...... ... Truncate.
AFT-TOT..................................... 354 3 356 Zero/Blank...... ... Truncate.
DIA-Type.................................... 357 1 357 Blanks.......... ... Truncate.
DIA-Fund.................................... 358 1 358 Blanks.......... ... Truncate.
DIA-OCC..................................... 359 3 361 Zero/Blank...... ... Truncate.
DIA-IHS..................................... 362 3 364 Zero/Blank...... ... Truncate.
DIA-TOT..................................... 365 3 367 Zero/Blank...... ... Truncate.
DIB-Type.................................... 368 1 368 Blanks.......... ... Truncate.
DIB-Fund.................................... 369 1 369 Blanks.......... ... Truncate.
DIB-OCC..................................... 370 3 372 Zero/Blank...... ... Truncate.
DIB-IHS..................................... 373 3 375 Zero/Blank...... ... Truncate.
DIB-TOT..................................... 376 3 378 Zero/Blank...... ... Truncate.
PRV-Type.................................... 379 1 379 Blanks.......... ... Truncate.
PRV-Fund.................................... 380 1 380 Blanks.......... ... Truncate.
PRV-OCC..................................... 381 3 383 Zero/Blank...... ... Truncate.
PRV-IHS..................................... 384 3 386 Zero/Blank...... ... Truncate.
PRV-TOT..................................... 387 3 389 Zero/Blank...... ... Truncate.
Address..................................... 390 70 459 Blanks.......... ... Truncate.
City........................................ 460 30 489 Blanks.......... ... Truncate.
State....................................... 490 2 491 Blanks.......... ... Truncate.
ZIP......................................... 492 11 502 Blanks.......... ... Truncate.
Phone....................................... 503 12 514 Blanks.......... ... Truncate.
----------------------------------------------------------------------------------------------------------------
K. Community Health Representative Information System (CHRIS)
1. Reporting Requirement
a. A one line entry is required to be completed on a Community
Health Representative (CHR) Activities Report form for each CHR service
that was provided on the day to which the form applies. If more
services are performed on one day than can be reported on one CHR
Activities form, an additional form(s) should be used and appropriately
numbered. CHR Activities forms are completed during one sample week (a
7-day week) per month in accordance with the CHR sample reporting week
schedule specified by the IHS Headquarters Director of the CHR Program.
b. The CHR Activities Report User Manual provides complete
definitions and procedures for reporting into the Community Health
Representative Information System (CHRIS).
c. Each CHR Program, in cooperation with their respective IHS Area
Office CHR Coordinator, determines procedures for collecting CHR
Activities data and creating automated records in the format described
in the next section. Key-entry of forms options include:
(1) At the CHR Program/Tribal level.
(2) At the Area level.
(3) At the service unit.
(4) By a contractor.
d. CHR Activity forms or automated records are batched by the Area
CHR staff and forwarded to the national CHR Program's data processing
contractor no later than two weeks after the last day of each sample
reporting week. The data processing contractor key enters hard copy
data and consolidates the data with automated records submitted through
the Area Offices. At a future date, automated records will be
consolidated at the Area level and forward to the Division of Data
Processing Services (DDPS) at Albuquerque no later than two weeks after
the last day of each sample reporting week.
2. Record Formats
a. The CHR Activities record contains individual patient encounter
and/or group encounter information. Each record is 61 characters in
length.
b. The proposed format of the CHR Activities record is shown at the
end of this section.
c. A CHR Activities Report form is included in Appendix A.
3. Transmission Media
a. CHR Automated Activities records for each Area are maintained by
the national CHR Program's data processing contractor. In the future,
these data will be generated at the local CHR office, on RPMS Generic
Activity Reporting System (GARS), and will be electronically
transmitted to the Area which will electronically transmit the data to
DDPS.
4. RPMS CHR Data Entry System
a. RPMS ANSI MUMPS CHR data entry program, known as the Generic
Activity Reporting System (GARS) is under development to allow records
to be keyed locally, transmitted to the Area, and forwarded from the
Area to DDPS by telecommunications.
CHR Activities Record
[Note: All Fields are Required Reporting Fields. The record Format for
Local Automated Data Entry Is]
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
A. Header Information
------------------------------------------------------------------------
1-4......... CHR Provider (Last 4 digits of each CHR's All
Social Security Number unless otherwise
instructed by the CHR's supervisor. If more
than one CHR in the same CHR program have
the same last four Social Security Number
digits, a different 4-digit number may be
given by the CHR supervisor to use.).
5........... Blank....................................... ............
6-13........ Program.....................................
6-7......... Area Code...................................
8-9......... Service Unit Code...........................
10-12....... Tribe/Community Code........................
13.......... Blank.......................................
14-22....... Date........................................
14-15....... Month (01-12)...............................
15.......... Blank.......................................
17-18....... Day (01-31).................................
19.......... Blank.......................................
20-21....... Year (last 2 digits of year)................
22.......... Blank.......................................
23-25....... Page........................................
23.......... Specific Report Page........................
24.......... Total Reporting Pages for that day (``Page
______ of ______'' is used to distinguish
between forms when one CHR provides more
services than can be reported on one
reporting form.).
25.......... Blank.......................................
------------------------------------------------------------------------
B. Service Data
------------------------------------------------------------------------
Note: One line is used for each service provided on the day to which the
form applies. If more services are performed on one day than can be
reported on one CHR Activities form, an additional form(s) should be
used and numbered as described above. All spaces should be filled in
with information. If an item does not apply to a particular service,
enter a dash ``--'', not a zero. For additional reporting instructions
consult the CHR Activities Report User Manual.
------------------------------------------------------------------------
26-28....... Line Number (01-20 corresponding to the line All
on the reporting form).
28.......... Blank.......................................
29-31....... Service Code................................
29-30....... Code........................................
31.......... Blank.......................................
01Health Education..........................
02Case Find/Screen..........................
03Case Management--Coordinate...............
04Monitor Patient...........................
05Emergency Care............................
06Patient Care..............................
07Homemaker Services........................
08Transport.................................
09Interpret/Translate.......................
10Other Patient Services....................
11Environmental Services....................
12Administration/Management.................
13Obtain Training...........................
99Leave Time................................
32-34....... Health Area.................................
32-33....... Code........................................
34.......... Blank.......................................
01Diabetes..................................
02Cancer....................................
03Hypertension/Cardio.......................
04HIV/ARC/AIDS..............................
05Communicable Disease......................
06Alcohol/Substance Abuse...................
07Community Injury Control..................
08Health Promotion/Disease Prevention.......
91Other General Medical.....................
92Dental....................................
93Gerontological............................
94Maternal/Child Health.....................
95Mental Health.............................
96Non-Specific..............................
35-36....... Setting.....................................
01Home......................................
02CHR Office................................
03Community.................................
04Hospital/Clinic...........................
05Radio/Telephone...........................
37-40....... Number Served (Leading zero fill)........... All
When a group service is provided, the number
of participants receiving direct service is
to be recorded here. If there is only one
main client, enter a ``1''. A breast
feeding class is an example of services
provided for more than one person. Enter a
dash ``--'' in the box for a service in
which people are not provided for directly,
e.g. Adm/Mgmt service.
41-44....... Minutes Used--Service (Leading zero fill)...
45-48....... Minutes used--Travel (Leading zero fill)....
49.......... Blank.......................................
50-52....... Age.........................................
Two digits for age. If the recipient is less
than 1 year of age use a zero, ``0.'' If no
personal service is given or a group is
served, enter a dash, ``--.''.
53.......... Blank.......................................
54-56....... Sex.........................................
54.......... Blank.......................................
55.......... 1 Male 2 Female.............................
56.......... Blank.......................................
Where service for both males and females is
provided or no direct client service is
involved, enter a dash, ``--.''.
57-59....... Referral From...............................
57-58....... Code........................................
59.......... Blank.......................................
60-61....... Referral To.................................
Referral Codes..............................
--None......................................
01Medical...................................
02Nursing...................................
03Dental....................................
04Eye.......................................
05Social Worker.............................
06Substance Abuse Professional..............
07Other Professional........................
08Technician................................
09Agency/Program............................
10Family/Self/Community.....................
11CHR.......................................
------------------------------------------------------------------------
L. Community Health Activity Reporting System
1. Reporting Requirement
a. A Community Health Activity record is required for all
activities performed by each Public Health Nurse (PHN). These are to
include both direct and indirect patient care contacts and all
administrative and training activities. A CHA record must be completed
on each discrete activity according to the time required for the
activity. Each daily activity sheet should include records to account
for the total time during the day that the PHN was on duty.
b. All reporting requirements and procedures are outlined in the
CHA Reporting System Guide.
c. Each Area will define procedures for getting the data from each
reporting site. All data from each Area will be sent at least quarterly
to the designated UNICORP data entry point.
d. Headquarters requirements can be met with a sampling procedure
that uses one full week of activities per month in accordance with the
sample reporting week schedule to be specified by IHS Headquarters.
There is an RPMS ANSI MUMPS Generic Activities Reporting System (GARS)
data entry program which allows for records to be submitted to Area for
compilation and forwarded from Area to DDPS.
2. Record Formats
a. The CHA record contains data on each discrete activity performed
by a Public Health Nurse. Each record is 82 characters in length.
b. The format of the CHA record is shown at the end of this
section.
c. A sample of the IHS CHA form is included in Appendix A.
3. Transmission Media
a. The CHA records are mailed to DDPS by UNICORP on nine track
unlabeled, unblocked EBCDIC tape.
4. CHA Data Entry System
a. Currently all data is entered onto a data entry sheet. These are
consolidated at the Area level and transmitted to UNICORP for data
entry.
b. A MUMPS based Generic Activities Reporting System is being
developed which will allow service units, contractors and/or Area
Offices to do their own data entry and transmit the data via 9 track
disks or data cartridges to the data center.
Community Health Activity Record Format
------------------------------------------------------------------------
Position Field Required
------------------------------------------------------------------------
1-2......................... Record Code (Always ``14'')
3-8......................... Area/Service Unit/Facility X
Code.
9-10........................ Position Code................. X
11-16....................... Date (MMDDYY)................. X
17-19....................... Community..................... X
20-21....................... Activity...................... X
22-24....................... Primary Purpose Code.......... X
25.......................... First Visit
26.......................... Nursing Diagnosis
27-29....................... Secondary Purpose Code
30.......................... First Visit
31.......................... Nursing Diagnosis
32.......................... Time for Activity (Hour(s))... X
33-34....................... Time for Activity (Minutes)... X
35-37....................... Number Counseled in Clinic/
Number Contacted in Group
Session
38-43....................... Health Record Number (Required
for patient contacts)
44-45....................... Date of Birth (Month)......... X
46-47....................... Date of Birth (Day)........... X
48-49....................... Date of Birth (Year).......... X
50.......................... Sex........................... X
51.......................... Family Status................. X
52.......................... Travel Time (Hour(s))
53-54....................... Travel Time (Minutes)
55-56....................... Total Time (Hours)
57-58....................... Total Time (Minutes)
59-60....................... Leave Taken (Annual--Hours)
61-62....................... Leave Taken (Annual--Minutes)
63-64....................... Leave Taken (Sick--Hours)
65-66....................... Leave Taken (Sick--Minutes)
67-68....................... Leave Taken (Compensatory--
Hours)
69-70....................... Leave Taken (Compensatory--
Minutes)
71-72....................... Leave Taken (Station--Hours)
73-74....................... Leave Taken (Station--Minutes)
75-76....................... Leave Taken (Other--Hours)
77-78....................... Leave Taken (Other--Minutes)
79-80....................... Overtime Worked--Hours
81-82....................... Overtime Worked--Minutes
83-91....................... Social Security Number X
(Required for patient
contacts).
------------------------------------------------------------------------
M. Health Education Resources Management System (HERMS)
1. Reporting Requirements
a. The Indian Health Service Health Education Program developed a
new data system--the Health Education Resources Management System
(HERMS) over three years ago. This system has undergone several field
tests, and all data during these tests have been generated manually by
the field health education staff.
The HERMS includes a daily record encounter and this record system
is required for service unit health education staff. This includes
covered contractors.
b. HERMS forms are due in the Area Health Education Office.
Specific collection procedures will be determined by the Area Health
Education Branch Chief. The Area Office will collect and key-enter all
data. The Area Health Education Office will be required to submit a
quarterly report to the field staff and IHS Headquarters Director of
the Health Education Program.
c. Part 3, Chapter 12 of the Indian Health Service Manual (Health
Education) is currently being revised and will require the HERMS.
d. The HERMS forms are to be completed during one sample week (a 7
day week) per month in accordance with the HERMS reporting week
schedule to be specified by the IHS Headquarters Director of the Health
Education Program.
2. Record Format
a. The format of the HERMS form is shown at the end of this
section.
b. A sample of the IHS HERMS form is included in Appendix A.
3. Reports
The following reports will be generated from the Health Education
Resources Management System (HERMS) to be provided to Headquarters,
Areas, and service unit/tribal health education personnel as required.
Reports To Be Provided:
Report I: Quarterly Summary
Report II: Annual Summary
Report III: Quarterly Cost of Activities by Provider
4. RPMS MUMPS Data Entry System
There is an RPMS ANSI MUMPS Generic Activities Reporting System
(GARS) data entry program which allows for records to be submitted to
Area for compilation and forwarding from Area to the Division of Data
Processing Services.
5. Additional Benefits
This new data system will enable the IHS and tribal programs to
have the ability to collect and generate statistical data to address
the efficiency and effectiveness of health education services, RAM
issues relevant to staff productivity and cost benefit, reporting for
Area and Headquarters requirements, justification and tracking system
for staffing, etc.
Improved control, communication, coordination, and up-to-date
reporting for categorical activities for the Chief, Health Education
Branch, and Chief, Health Education Section, Indian Health Service, is
also anticipated.
6. HERMS Manual
A complete instruction manual for the HERMS is available from the
Area Health Education Office.
HERMS Record Reporting Instructions
----------------------------------------------------------------------------------------------------------------
Position Field Required
----------------------------------------------------------------------------------------------------------------
To Be Determined.......... Ia........... Area Coding is to be numbered according to the IHS X
Standard Code Book.
Ib........... Service Unit/Tribal Program Coding is to be numbered X
according to the IHS Standard Code Book.
Ic........... PROVIDER NO.: This number is assigned by the Area Branch X
Chief.
Id........... FACILITY NO.: Assigned in IHS Standard Code Book. X
Facility is where the Health Education staff member
completes H.E.R.M.S. forms.
Ie........... MONTH: Enter the Month that reports are being submitted X
for workload activities. 01-12.
If........... FISCAL YEAR: Enter the last two digits of the fiscal year X
Ig........... PAGE: Enter the number of forms submitted for the
reporting period, example: page 1 of 3 pages, page 2 of
3, page 3 of 3
Box I........ DATE: List each day's date............................... X
Box II....... TASK MATRIX: The purpose of this column is to identify X
those direct services which are provided in the course
of health education activities. The following tasks are
to be utilized in the task matrix categories: 100
series, Identification of Health Problems and Needs; 200
series, Design Educational Objectives
This text is long and has been trimmed here. Open the source document for the complete record.
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