hosp_conditionapproach

[p.55]

1. Person number ________

Enter month, day, year; if the exact date is not known, obtain the best estimate.
You said that --was in the (hospital/nursing home) during the past year.
2. When did --enter the (hospital/nursing home) (the last time)?

Do not include any nights in interview week. If the exact number is not known, accept the best estimate.
3. How many nights was--in the (hospital/nursing home)?

Complete question 4 from entries in questions 2 and 3 if not clear, ask the questions.
Do not include any nights in interview week
4a. How many of these --nights were during the past 12 months?

b. How many of these --nights were last week or the week before?

c. Was -- still in the (hospital/nursing home) last Sunday night for this hospitalization (stay)?

If medical name not known enter an adequate description. Entry must show cause, kind, and part of body in same detail as required for the condition page.
5a. For what condition did --enter the (hospital/nursing home) do you know the medical name?
For deliver ask: was this a normal deliver? If No ask:What was the matter? Record in condition box.
For newborn ask: was the baby normal at birth? If No ask:What was the matter? Record in condition box.

If name of operations is not known, describe what was done.
6a. Were any operations performed on--during this stay at the (hospital/nursing home)?

b. What was the name of the operation?

c. Any other operations?

Enter the full name of the hospital or nursing home; the street or highway on which it is located and the city and state; if the city is not known, enter the county.
7. What is the name and address of the (hospital/nursing home)?

[p.56]

Ask questions 8-10 for all completed hospitalizations- mark one circle

Ask if "No" marked in question 4c.
8. What was the total amount of the hospital (nursing home) bill for this stay? Do not include any doctor's or surgeon's bills.

9a. Did (will) health insurance pay any part of this bill?

b. What is the name of the insurance plan?

c. Did (will) any other health insurance plan pay part of his hospital (nursing home) bill?

If "Yes" reask 9b
For each health insurance plan named, ask:
d. What was (will be) the amount paid by (name of plan)? ________

Enter total amount paid by health insurance in line A. Enter any amount paid by Social Security Medicare in line B
10a. Who paid (will pay) the (remainder of the) hospital bill? Mark each category mentioned.

b. Did any other person or agency pay any other part of the hospital bill?

c. Who was this? Mark each category mentioned

d. What was the amount paid by--? Enter amount paid opposite appropriate category.

Interviewer: Add amounts entered (include any amount paid by health insurance) and enter in Total box, then mark one of the following boxes.

Ask questions 11-13 if person is 55 years old or over.
Mark one circle

11a. When -- left (name of hospital/nursing home), did he return home or go some other place?

b. What kind of place did -- go to?

Interviewer: If the "Place" in 11b is a hospital, nursing home or a similar place, was a hospital page filled for that stay? Mark one box.

12. After leaving the (hospital/nursing home) how many days did -- have to remain in bed all or most of the day?
Mark entry.

[survey choices not clear]

13. (Altogether) how many days was -- confined to the house after returning home from the (hospital/nursing home)?
Mark entry.

14. Note to interviewer:
If the condition in question 5 or 6 in card A (A-1, A-2) or B (B-1, B-2) or there is "1" or more nights in question 4b, the condition must have a completed condition page. If the condition does not have a condition page, fill one after completing all required hospital pages