DSD Interval Survey - Region 4 Genetics Collaborative by jizhen1947

VIEWS: 12 PAGES: 21

									                                                                    DSD INTERVAL SURVEY




                                                                             Answer                                                                     Units (for
Condition              New Measure                       New Category                                       Measure Answer
                                                                              Type                                                                      value box)



                                                                                         Active, Inactive - Deceased, Inactive - Lost to follow up,
  DSD                                                                                    Inactive - Moved to another State participating in IBEM-IS,
                                                                                         Inactive - Moved to another State not participating in IBEM-
                                                                                         IS, Inactive -Refused follow up, Inactive - Treatment deemed
            Follow up status                         Demographics           Pick List    not necessary


  DSD
            Is patient followed by >1 endocrine
            center?                                  Demographics           Pick List    Missing/unknown data, yes, no


  DSD       If patient is followed by >1 endocrine
            center note which endocrine centers in
            which states                             Demographics           Free Text

            If patient is followed by >1 endocrine
  DSD       center, did patient grant permission to
            share data via IBEM-IS between treating
            endocrine centers?                      Demographics            Pick List    Missing/unknown data, N/A, Yes, No


  DSD
            If deceased, date of death (if N/A enter
            01/01/1901)                              Demographics           Date Field




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                                                                            DSD INTERVAL SURVEY




                                                                                     Answer                                                              Units (for
Condition               New Measure                           New Category                                          Measure Answer
                                                                                      Type                                                               value box)



  DSD

            Does patient have gynecomastia?             Past Health History         Pick List   Missing/unknown data, N/A - patient is female, Yes, No


  DSD       Change in size of clitoris since the last
            outpatient endocrine visit (enter 99999 if
            N/A or unknown)                            Past Health History          Decimal                                                              (cm)


  DSD
            Has patient had urogenital surgery done                                             Missing/unknown data, N/A - urogenital surgery not
            since the last outpatient endocrine visit? Past Health History          Pick List   indicated, yes (complete Urogenital Survey), no


  DSD       Testicular length at time of this
            outpatient visit (enter length as left
            testicle, right testicle), enter 99999 if N/A Past Health History       Free Text                                                            (cm)


  DSD       Testicular volume at time of this
            outpatient visit (enter volume as left
            testicle, right testicle), enter 99999 if N/A Past Health History       Free Text                                                            (mL)


  DSD
            Tanner Stage of pubic hair development
            at time of this outpatient visit       Past Health History              Pick List   Missing/unknown data, not assessed, I, II, III, IV, V



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                                                                        DSD INTERVAL SURVEY




                                                                                 Answer                                                                      Units (for
Condition              New Measure                        New Category                                           Measure Answer
                                                                                  Type                                                                       value box)



  DSD
            Tanner Stage of breast development at
            time of this outpatient visit         Past Health History           Pick List    Missing/unknown data, not assessed, I, II, III, IV, V


  DSD       Number of menstrual periods since the
            last outpatient endocrine visit (enter
            99999 if N/A or unknown)               Past Health History          Integer


  DSD
            Bone age at time of this outpatient visit                                                                                                        (years,
            (enter 99999 if N/A)                      Imaging Studies           Integer                                                                      months)



                                                                                            Missing/unknown data, no, yes-abnormal-evidence of
  DSD                                                                                       adrenal rests, yes-genitogram-WNL, yes-genitogram-Abn,
                                                                                            yes-pelvic ultrasound-WNL, yes-pelvic ultrasound-Abn, yes-
                                                                                            renal ultrasound-WNL, yes-renal ultrasound-Abn, yes-
            Renal/pelvic/genital imaging done since                                         testicular ultrasound-WNL, yes-testicular ultrasound-Abn, yes-
            last outpatient endocrine visit?        Imaging Studies             Check boxes VCUG-WNL, yes-VCUG-Abn


  DSD
            If abnormal pelvic ultrasound results,
            explain finding (enter 99999 if N/A)     Imaging Studies            Free Text




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                                                                         DSD INTERVAL SURVEY




                                                                                  Answer                                                                Units (for
Condition              New Measure                         New Category                                         Measure Answer
                                                                                   Type                                                                 value box)



  DSD                                                                                        Missing/unknown data, N/A - patient is female, not done,
            Testicular ultrasound results since the                                          normal, abnormal,other (if abnormal or other go to next
            last outpatient endocrine visit           Imaging Studies            Pick List   question and explain)


  DSD
            If abnormal testicular ultrasound results,
            explain finding (enter 99999 if N/A)       Imaging Studies           Free Text


  DSD
            If abnormal genitogram results, explain
            finding (enter 99999 if N/A)            Imaging Studies              Free Text


  DSD
            Length of urogenital sinus from
            genitogram (enter 99999 if N/A)           Imaging Studies            Decimal                                                                (cm)


  DSD       If patient has a urogenital sinus, what is
            the confluence of the urogenital sinus
            with the vagina?                           Imaging Studies           Pick List   Missing/unknown data, N/A, low, high




                                                                               Page 4
                                                                          DSD INTERVAL SURVEY




                                                                                   Answer                                                                      Units (for
Condition               New Measure                        New Category                                            Measure Answer
                                                                                    Type                                                                       value box)




  DSD                                                                                         Missing/unknown data, no, yes-abnormal-evidence of
                                                                                              adrenal rests, yes-abdominal CT-WNL, yes-abdominal CT-
            Abdominal imaging done since last                                                 Abn, yes-abdominal MRI-WNL, yes-abdominal MRI-Abn, yes-
            outpatient endocrine visit?              Imaging Studies              Check boxes abdominal ultrasound-WNL, yes-abdominal ultrasound-Abn


  DSD                                                                                         Missing/unknown data, no, yes-bone age-WNL, yes-bone
            Musculoskeletal imaging done since last                                           age-Abn, yes-bone x-rays-WNL, yes-bone x-rays-Abn, yes-
            outpatient endocrine visit?             Imaging Studies               Check boxes dexa scan-WNL, yes-dexa scan-Abn


  DSD
            Evidence of osteopenia/osteoporosis at
            time of this outpatient visit          Imaging Studies                Pick List    Missing/unknown data, yes, no

            Other imaging (indicate type of imaging
  DSD       and if WNL or Abn) done since last
            outpatient endocrine visit (enter 99999 if
            N/A)                                       Imaging Studies            Free Text




                                                                                              Missing/unknown data, no abnormal labs, no labs done, yes -
  DSD                                                                                         electrolyte abnormalities, yes -abnormal chromosomes, yes-
                                                                                              abnormal DSD specific molecular testing, yes -electrolyte
            Lab abnormalities at time of this                                                 abnormalities, yes-elevated liver function tests, yes-hormonal
            outpatient visit                         Laboratory Studies           Check boxes abnormality, yes - other (go to next question and explain)



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                                                                             DSD INTERVAL SURVEY




                                                                                      Answer                                                                 Units (for
Condition               New Measure                          New Category                                          Measure Answer
                                                                                       Type                                                                  value box)



  DSD
            Other lab abnormalities at time of this
            outpatient visit (enter 99999 if N/A)       Laboratory Studies           Free Text


  DSD
            LH level at time of this outpatient visit
            (enter 99999 if N/A or unknown)             Laboratory Studies           Decimal                                                                 (IU/L)


  DSD
            FSH level at time of this outpatient visit
            (enter 99999 if N/A or unknown)            Laboratory Studies            Decimal                                                                 (IU/L)


  DSD       Serum testosterone (T) level at time of
            this outpatient endocrine visit (enter
            99999 if N/A)                               Laboratory Studies           Integer                                                                 (ng/dL)



  DSD                                                                                            Missing/unknown data, no, yes - abnormal: compound
                                                                                                 heterozygote, yes - abnormal: homozygote, yes - abnormal:
            Molecular testing: Common or targeted                                                simple heterozygote, yes - alteration(s) of unknown
            mutation panel done at this visit?    Laboratory Studies                 Pick List   significance detected, yes but no mutations were detected




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                                                                         DSD INTERVAL SURVEY




                                                                                  Answer                                                                  Units (for
Condition                New Measure                      New Category                                           Measure Answer
                                                                                   Type                                                                   value box)




                                                                                             Missing/unknown data, no, yes - abnormal: compound
  DSD                                                                                        heterozygote, yes - abnormal: presumed compound
                                                                                             heterozygote 2nd mutation not identified, yes - abnormal:
                                                                                             homozygote, yes - abnormal: simple heterozygote, yes -
            Molecular testing: Full sequencing done                                          alteration(s) of unknown significance detected, yes but no
            at this visit?                          Laboratory Studies           Pick List   mutations were detected


  DSD

            Is patient sexually active?              Sexual History              Pick List   Missing/unknown data, yes, no


  DSD

            Weight at this visit                     Measurements                Decimal                                                                  (kg)


  DSD

            Height at this visit                     Measurements                Decimal                                                                  (cm)


  DSD

            Head circumference (OFC) at this visit   Measurements                Decimal                                                                  (cm)




                                                                               Page 7
                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                   Units (for
Condition              New Measure                       New Category                                         Measure Answer
                                                                                  Type                                                                    value box)



  DSD
            Is Estrogen (excluding oral
            contraceptive) prescribed?               Pharmacotherapy           Pick list   Missing/unknown data, N/A - male phenotype, yes, no


  DSD       If on Estrogen (excluding oral
            contraceptive), name of product (enter
            99999 if N/A)                            Pharmacotherapy           Free Text


  DSD       If on Estrogen (excluding oral
            contraceptive), dose prescribed (enter
            99999 if N/A)                            Pharmacotherapy           Decimal                                                                    (mg/day)


  DSD
            If on Estrogen (excluding oral                                                 Missing/unknown data, N/A - not prescribed, feeding tube,
            contraceptive), route prescribed?        Pharmacotherapy           Pick List   oral, intradermal patch


  DSD
            If on Estrogen (excluding oral                                                 Missing/unknown data, N/A - not prescribed, once daily every
            contraceptive), frequency prescribed?    Pharmacotherapy           Pick list   day of the month, once daily for 21 days/month, other


  DSD       Patient/primary caregiver reports
            Estrogen (excluding oral contraceptive)
            is taken as prescribed?                 Pharmacotherapy            Pick list   Missing/unknown data, N/A - not prescribed, yes, no



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                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                      Units (for
Condition               New Measure                      New Category                                           Measure Answer
                                                                                  Type                                                                       value box)


            If Estrogen (excluding oral
  CAH       contraceptive) is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy           Free text




                                                                                           Missing/unknown data, N/A - not prescribed,
  DSD
                                                                                           commercial/private insurance, military insurance, none - can't
            Method of payment for Estrogen                                                 afford to fill medication prescription, self-pay, State program
            (excluding oral contraceptive), if                                             (special needs program, MCH block grant), State/Federal
            prescribed                               Pharmacotherapy           Check boxes insurance (Medicaid/Medicare), Other


  DSD
            Is Progesterone (excluding oral
            contraceptive) prescribed?               Pharmacotherapy           Pick list     Missing/unknown data, N/A - female phenotype, yes, no


  DSD       If on Progesterone (excluding oral
            contraceptive), dose prescribed (enter
            99999 if N/A)                            Pharmacotherapy           Decimal                                                                       (mg/day)


  DSD
            If on Progesterone (excluding oral                                             Missing/unknown data, N/A - not prescribed, feeding tube,
            contraceptive), route prescribed?        Pharmacotherapy           Check boxes oral




                                                                             Page 9
                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                      Units (for
Condition              New Measure                       New Category                                           Measure Answer
                                                                                  Type                                                                       value box)



  DSD                                                                                        Missing/unknown data, N/A - not prescribed, once daily every
            If on Progesterone (excluding oral                                               day of the month, once daily for 5 days of the month, once
            contraceptive), frequency prescribed?    Pharmacotherapy           Pick list     daily for 10 days of the month, other


  DSD       Patient/primary caregiver reports
            Progesterone (excluding oral
            contraceptive) is taken as prescribed?   Pharmacotherapy           Pick list     Missing/unknown data, N/A - not prescribed, yes, no

            If Progesterone (excluding oral
  DSD       contraceptive) is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy           Free text



                                                                                           Missing/unknown data, N/A - not prescribed,
  DSD                                                                                      commercial/private insurance, military insurance, none - can't
            Method of payment for Progesterone                                             afford to fill medication prescription, self-pay, State program
            (excluding oral contraceptive), if                                             (special needs program, MCH block grant), State/Federal
            prescribed                               Pharmacotherapy           Check boxes insurance (Medicaid/Medicare), Other


  DSD

            Is oral contraception prescribed?        Pharmacotherapy           Pick list     Missing/unknown data, N/A - male phenotype, yes, no




                                                                             Page 10
                                                                        DSD INTERVAL SURVEY




                                                                                  Answer                                                                   Units (for
Condition               New Measure                      New Category                                          Measure Answer
                                                                                   Type                                                                    value box)



  DSD
            If on oral contraception, name of product
            (enter 99999 if N/A)                      Pharmacotherapy           Free Text


  DSD
            If on oral contraception, dose
            prescribed?                              Pharmacotherapy            Decimal                                                                    (mcg/day)


  DSD
            If on oral contraception, route                                                 Missing/unknown data, N/A - not prescribed, feeding tube,
            prescribed?                              Pharmacotherapy            Pick List   oral


  DSD
            If on oral contraception, frequency                                             Missing/unknown data, N/A - not prescribed, once daily every
            prescribed?                              Pharmacotherapy            Pick list   day of the month, once daily for 21days of the month


  DSD
            Patient/primary caregiver reports oral
            contraception is taken as prescribed?    Pharmacotherapy            Pick list   Missing/unknown data, N/A - not prescribed, yes, no


  DSD       If oral contraception is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy            Free text



                                                                              Page 11
                                                                      DSD INTERVAL SURVEY




                                                                                Answer                                                                      Units (for
Condition               New Measure                     New Category                                           Measure Answer
                                                                                 Type                                                                       value box)




                                                                                          Missing/unknown data, N/A - not prescribed,
  DSD                                                                                     commercial/private insurance, military insurance, none - can't
                                                                                          afford to fill medication prescription, self-pay, State program
            Method of payment for oral                                                    (special needs program, MCH block grant), State/Federal
            contraception, if prescribed            Pharmacotherapy           Check boxes insurance (Medicaid/Medicare), Other


  DSD

            Is Testosterone prescribed?             Pharmacotherapy           Pick list     Missing/unknown data, N/A - female phenotype, yes, no


  DSD
            If on Testosterone, dose prescribed
            (enter 99999 if N/A)                    Pharmacotherapy           Decimal                                                                       (mg)


  DSD
                                                                                            Missing/unknown data, N/A - not prescribed, cream, feeding
            If on Testosterone, route prescribed?   Pharmacotherapy           Pick List     tube, gel, oral


  DSD
            If on Testosterone, frequency                                                   Missing/unknown data, N/A - not prescribed, daily,
            prescribed?                             Pharmacotherapy           Pick list     once/month, twice/month, other




                                                                            Page 12
                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                      Units (for
Condition              New Measure                      New Category                                            Measure Answer
                                                                                  Type                                                                       value box)



  DSD
            Patient/primary caregiver reports
            Testosterone is taken as prescribed?   Pharmacotherapy             Pick list     Missing/unknown data, N/A - not prescribed, yes, no


  DSD       If Testosterone is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy           Free text




                                                                                           Missing/unknown data, N/A - not prescribed,
  DSD                                                                                      commercial/private insurance, military insurance, none - can't
                                                                                           afford to fill medication prescription, self-pay, State program
            Method of payment for Testosterone, if                                         (special needs program, MCH block grant), State/Federal
            prescribed                             Pharmacotherapy             Check boxes insurance (Medicaid/Medicare), Other


  DSD

            Are Biphosphanates prescribed?         Pharmacotherapy             Pick list     Missing/unknown data, N/A - not prescribed, yes, no


  DSD
            If Biophosphanates prescribed, name of
            product (enter 99999 if N/A)           Pharmacotherapy             Free Text




                                                                             Page 13
                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                Units (for
Condition              New Measure                      New Category                                           Measure Answer
                                                                                  Type                                                                 value box)



  DSD
            If on Biphosphonates, dose prescribed
            (enter 99999 if N/A)                    Pharmacotherapy            Decimal                                                                 (mg)


  DSD
                                                                                           Missing/unknown data, N/A - not prescribed, feeding tube,
            If on Biphosphonates, route prescribed? Pharmacotherapy            Check boxes oral, IV


  DSD
            If on Biphosphates, frequency
            prescribed?                             Pharmacotherapy            Pick list    Missing/unknown data, N/A - not prescribed, daily


  DSD
            Patient/primary caregiver reports
            Biphosphonates is taken as prescribed? Pharmacotherapy             Pick list    Missing/unknown data, N/A - not prescribed, yes, no


  DSD       If Biphosphonates is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy           Free text




                                                                             Page 14
                                                                          DSD INTERVAL SURVEY




                                                                                   Answer                                                                       Units (for
Condition              New Measure                         New Category                                            Measure Answer
                                                                                    Type                                                                        value box)




                                                                                              Missing/unknown data, N/A - not prescribed,
  DSD                                                                                         commercial/private insurance, military insurance, none - can't
                                                                                              afford to fill medication prescription, self-pay, State program
            Method of payment for Biphosphonates,                                             (special needs program, MCH block grant), State/Federal
            if prescribed                         Pharmacotherapy                 Check boxes insurance (Medicaid/Medicare), Other


  DSD

            Is growth hormone prescribed?            Pharmacotherapy              Pick List     Missing/unknown data, yes, no


  DSD       If growth hormone is prescribed, what
            was patient's age in years at initiation of
            drug (enter 99999 if N/A)                   Pharmacotherapy           Integer                                                                       (years)


  DSD       If growth hormone is prescribed, what is
            the current prescribed dose (enter
            99999 if N/A)                            Pharmacotherapy              Decimal                                                                       (mg/kg/week)


  DSD

            If on growth hormone, route prescribed? Pharmacotherapy               Pick List     Missing/unknown data, N/A - not prescribed, SQ




                                                                                Page 15
                                                                       DSD INTERVAL SURVEY




                                                                                 Answer                                                                      Units (for
Condition              New Measure                      New Category                                            Measure Answer
                                                                                  Type                                                                       value box)



  DSD
            If on growth hormone, frequency
            prescribed?                            Pharmacotherapy             Pick list     Missing/unknown data, N/A - not prescribed, once/day, other


  DSD
            Patient/primary caregiver reports growth
            hormone is taken as prescribed?          Pharmacotherapy           Pick list     Missing/unknown data, N/A - not prescribed, yes, no


  DSD       If growth hormone is not taken as
            prescribed, reason given (enter 99999 if
            N/A)                                     Pharmacotherapy           Free text



                                                                                           Missing/unknown data, N/A - not prescribed,
                                                                                           commercial/private insurance, military insurance, none - can't
  DSD
                                                                                           afford to fill medication prescription, self-pay, State program
                                                                                           (newborn screening funds, special needs program, MCH
            Method of payment for growth hormone,                                          block grant), State/Federal insurance (Medicaid/Medicare),
            if prescribed                         Pharmacotherapy              Check boxes Other




                                                                             Page 16
                                                                      DSD INTERVAL SURVEY




                                                                               Answer                                                                       Units (for
Condition              New Measure                     New Category                                             Measure Answer
                                                                                Type                                                                        value box)




                                                                                          Missing/unknown data, none, Ammonul, analgesics,
                                                                                          antacids, antianxiety, antibiotics,
                                                                                          anticoagulants/thrombolytics, anticonvulsants,
  DSD                                                                                     antidepressants, antiemetics, antifungals, antivirals,
                                                                                          antihistamines, antihypertensives, antiinflammatories,
                                                                                          antipsychotics, antipyretics, bronchodilators, contraceptives -
                                                                                          oral, contraceptives - injection, corticosteroids, diuretics,
            Other medications (see optional DocSite                                       hormones, immunosuppresives, insulin sensitizers, iron,
            detailed medication survey also)        Pharmacotherapy           Check boxes laxatives, manitol, sleeping medications, vitamins, other


  DSD
            Developmental screening occurred at
            this visit?                            Development                Pick List     Missing/unknown data, yes, no


                                                                                          Missing/unknown data, N/A - no developmental screening
  DSD                                                                                     occurred at this visit, Ages and Stages Questionnaire, Ages
                                                                                          and Stages - Social/Emotional Questionnaire, Denver (DDST-
            Developmental screening tool used at                                          II), PEDS Questionnaire, provider history, other standardized
            this visit (if screening was done)     Development                Check boxes screening tool


  DSD
            Developmental milestones achieved at                                            Missing/uknown data, N/A - no developmental screening
            this time?                             Development                Pick List     occurred at this visit, yes, no




                                                                            Page 17
                                                                 DSD INTERVAL SURVEY




                                                                          Answer                                                                     Units (for
Condition              New Measure                     New Category                                      Measure Answer
                                                                           Type                                                                      value box)



                                                                                     Missing/unknown data, cognitive, fine motor, gross motor,
  DSD                                                                                social-emotional, speech-language, N/A - no developmental
            If developmental milestone(s) not                                        screening occurred at this visit, N/A - developmental
            achieved, which one(s) were not                                          screening occurred at this visit and all developmental
            achieved?                              Development           Check boxes milestones were achieved


  DSD       If developmental milestones were not
            achieved, was patient referred for                                        Missing/unknown data, N/A - no developmental screening
            further developmental evaluation?      Development           Pick List    occurred at this visit, yes, no


  DSD       Was neuropsychological evaluation
            done since last outpatient endocrine                                      Missing/unknown data, yes (enter available data under
            visit?                                 Development           Pick List    separate Neuropsych Test Results Survey), no

            Overall neuropsychological testing
  DSD       impression (from most recent                                              Missing/unknown data, N/A - no neuropsych evaluation has
            neuropsych                                                                been done on this patient, above average, average, below
            evaluation)                            Development           Pick List    average


  DSD
            Are behavioral concerns suspected at                                      Missing/unknown data, yes (go to next question and explain),
            this time?                             Development           Pick List    no




                                                                       Page 18
                                                                    DSD INTERVAL SURVEY




                                                                              Answer                                                                      Units (for
Condition               New Measure                         New Category                                      Measure Answer
                                                                               Type                                                                       value box)



  DSD
            If behavioral concerns are suspected at
            this time, explain (enter 99999 if N/A) Development              Free Text


                                                                                         Missing/unknown data, N/A - no concerns suspected, yes - to
  DSD       If behavioral concerns are suspected at                                      behavioral pediatrics, yes - to neuropsychologist, yes - to
            this time, was patient referred for                                          psychiatrist, yes - to psychologist, yes - to
            further evaluation?                     Development              Check boxes therapist/counselor, yes - to other


  DSD
            Was patient referred for Special
            Education evaluation at this time?         Education             Pick List    Missing/unknown data, yes, no


  DSD
            Are Special Educational services                                              Missing/unknown data, yes - IEP/IFSP, yes - 504 plan, yes -
            received by this patient currently?        Education             Pick List    other, no


  DSD       Special Educational services are                                              Missing/unknown data, N/A - no Special Ed services are
            received currently: age (in years) child                                      currently received, N/A - patient is >21 years old, <1, >1-2,
            qualified for services?                    Education             Pick List    >2-3, >3-4, >4-5, 6-10, 11-17, 18+




                                                                           Page 19
                                                                         DSD INTERVAL SURVEY




                                                                                  Answer                                                                         Units (for
Condition              New Measure                       New Category                                               Measure Answer
                                                                                   Type                                                                          value box)



                                                                                             Missing/unknown data, N/A (no Special Ed services are
  DSD                                                                                        currently received), cognitive disability, fine motor disability,
                                                                                             gross motor disability, learning disability, social-emotional
            Reason Special Educational services                                              disability, speech-language disability, other health impaired
            are received currently?                 Education                    Check boxes (OHI), other




  DSD                                                                                        Missing/unknown data, commercial/private insurance, military
                                                                                             insurance, none (self-pay), State program (newborn
                                                    Socioeconomic                            screening funds, special needs program, MCH block grant),
            Current insurance status                Status                       Check boxes State/Federal insurance (Medicaid/Medicare), Other



                                                                                             Missing/unknown data, none, audiology,
                                                                                             behavioral/developmental pediatrics, cardiology,
  DSD                                                                                        dermatology, endocrinology, hematology/oncology, home
                                                                                             health care, nephrology, neurology, neuropsychology,
                                                                                             occupational therapy, ophthalmology, orthopedics,
                                                                                             otolaryngology, pulmonology, physical therapy, psychology,
                                                                                             public health nursing, respiratory therapy, speech-language
            Other health services received currently Care Coordination           Check boxes therapy, other




                                                                               Page 20
                                                                          DSD INTERVAL SURVEY




                                                                                   Answer                                                                     Units (for
Condition              New Measure                         New Category                                            Measure Answer
                                                                                    Type                                                                      value box)




                                                                                              Missing/unknown data, none, daycare, family support group
                                                                                              related to this IBEM, family support - other, Medical Home,
  DSD                                                                                         nutritional services (WIC/MAC), personal care attendant
                                                                                              (PCA), preschool, Head Start, respite care, social services -
                                                                                              county, social services - medical, social services -
                                                                                              developmental disability, waivered services (CAC/CADI
            Community resources received currently Care Coordination              Check boxes waiver, other waivers)


                                                                                              Endocrinologist, child and family life specialist, genetic
  DSD                                                                                         counselor, general surgeon, geneticist, neuropsychologist,
                                                                                              nurse, nurse practitioner, OB/GYN, physician assistant,
            Providers seen at this outpatient                                                 psychologist, social worker, urology surgeon, other (go to
            endocrine visit                           Care Coordination           Check boxes next question and explain)


  DSD
            Other providers seen at this outpatient
            endocrine visit                           Care Coordination           Free Text




                                                                                Page 21

								
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