SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 2A: INTERVENTION SERVICES FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 2A: Intervention-Services Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 2A: INTERVENTION SERVICES FORM

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Service Date. Enter the numbers representing the date of service in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Visit/Daily Summary. Darken the circle next to "Visit" if this form is being used to record a client visit. Darken the circle next to "Daily Summary" if this form is being used to record a summary of intervention services rendered on the day recorded in "Service Date."

Nursing Home (Fill in bubble if provided today). Darken the circle next to "Adult Group Home" if the services were provided in a group home. Darken the circle next to "Residential Health Care Facility" if the services were provided in a residential health care facility providing housing, food, and some monitoring of the patient’s health. Darken the circle next to "Skilled Nursing Home Facility", such as a facility providing 24-hour nursing, if the services were provided to the client at a skilled nursing home facility.

Type of Visit (CPT Code). In the boxes provided, enter the CPT code for the type of visit. Space is provided for up to seven types of visits. The CPT codes for this section will most likely be in the "Evaluation and Management" section of the CPT guidelines; most codes for type of visit will be in the 99000 range.

Ambulatory Care (Visits today). Darken the circle(s) next to the numbers which indicate the number of ambulatory care visits provided in each of the four categories, "Physician Office: Primary Care," "Physician Office: Specialty Care," "Health Center: Primary Care," "Health Center: Specialty Care." For each category, darken the circle next to "1" if one visit was provided. Darken the circle next to "2" if two visits were provided. Darken the circle next to "3" if three visits were provided. Darken the circle next to "4" if four visits were provided. Darken the circle next to "5" if five visits were provided. Darken the circle next to "6 or more" if six or more visits were provided.

Radiology (CPT Code). In the boxes provided, enter up to six CPT CODES for radiology procedures performed during the period of time covered by this form.

Procedures (CPT Code). In the boxes provided, enter up to five CPT CODES for procedures performed during the period of time covered by this form.

Laboratory (CPT Code). In the boxes provided, enter up to twelve CPT CODES for laboratory procedures performed during the period of time covered by this form.

Homecare (Visits today). Darken the circle(s) next to the numbers which indicate the number of homecare visits provided in each of the three categories, Homemaker, Home Health Aide and/or Visiting Nurse. For each category, darken the circle next to "1" if one visit was provided. Darken the circle next to "2" if two visits were provided. Darken the circle next to "3" if three visits were provided. Darken the circle next to "4" if four visits were provided. Darken the circle next to "5" if five visits were provided. Darken the circle next to "6 or more" if six or more visits were provided.

Dental Care (Visits today). Darken the circle(s) next to the numbers which indicate the number of dental care visits provided in each of the two categories, Emergency Care and/or Routine Care. For each category, darken the circle next to "1" if one visit was provided. Darken the circle next to "2" if two visits were provided. Darken the circle next to "3" if three visits were provided. Darken the circle next to "4" if four visits were provided. Darken the circle next to "5" if five visits were provided. Darken the circle next to "6 or more" if six or more visits were provided.

Emergency Room (Visits today). Darken the circle(s) next to the numbers which indicate the number of emergency room care visits provided in each of the three categories, Urgent Care, Emergency Room and/or Admitted to Hospital. For each category, darken the circle next to "1" if one visit was provided. Darken the circle next to "2" if two visits were provided. Darken the circle next to "3" if three visits were provided. Darken the circle next to "4" if four visits were provided. Darken the circle next to "5" if five visits were provided. Darken the circle next to "6 or more" if six or more visits were provided.

Specialty Medical (all that apply). Darken the circle(s) of all specialty medical services provided. In the boxes provided under Other Specialists, write in specialties not listed.

Inpatient Medical Care (Fill in bubble if provided today). Darken the circle(s) next to the inpatient medical care services provided today. If care was provided in an intensive care unit, darken the circle next to "Intensive Care Unit." If acute care was provided in an inpatient setting, darken the circle next to "Acute Care." If alternative care was provided in an inpatient unit, darken the circle next to "Alternative Care."

(Fill in bubble if provided today). Darken the circle next to "Daycare" if daycare services were provided today. Darken the circle next to "Respite Care" if respite care services were provided. Darken the circle next to "Home Hospice" if home hospice services were provided today. Darken the circle next to "Residential Hospice" if residential hospice services were provided today.

Durable Medical Equipment (charges). Write in to the nearest dollar the amount charged for durable medical equipment. If the amount is less than four digits, please right justify the numbers entered into the boxes provided. For example, if the amount is "$75" you would enter "0075."

Participates in Clinical Trial(s) If the client is participating in a clinical trial or trials, darken this bubble.

Location Darken the bubble next to "Location serves HIV+ clients only," if services are provided in a facility only serving HIV+ clients. Darken the bubble next to "Location provides comprehensive care" if service are provided in a comprehensive care setting.

Services Provided By (all that apply). Darken the circle(s) next to the caregiver(s) who provided services during the period of time covered by this form.

If you are using the short version of this form (the one that is letter-sized and does not include the staff code boxes at the bottom of the page), stop here. If you are using the long version (legal-sized and includes the staff code boxes), please continue. You may use either version of the form.

Staff Codes. Enter the 3-digit code(s) for the person(s) who provided services today. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."