• Code units of client services.
• Code providers.
• Code purpose of client services.
• Code referrals provided at interventions.
• Code medications ordered or provided.

Content Domain - Types of service provided (outpatient medical, emergency room, HIV testing and counseling, mental health, social supports, etc.), providers (physician, nurse, social worker, psychologist, peer, etc.), purpose of services, referrals made to ancillary services, medications ordered or provided.

Operational Data Items

• Form A: Medical Services - ID Letters/ID Numbers, Site, Sub-Provider, Intake/Service Date, Staff Code, Visit or Daily Summary, Nursing Home days (RHCF or SNF), CPT Code for Type of visit (7), Ambulatory Care visits (Physician Office: Primary Care, Physician Office: Specialty Care, Health Center: Primary Care, Health Center: Specialty Care), Inpatient Medical Care days (Intensive Care Unit, Acute Care, Alternative Care), Dental Care visits (Emergency Care, Routine Care), Emergency Room visits (Urgent Care, Emergency Room, Admitted to Hospital), CPT Codes for Radiology (6), CPT Codes for Procedures (5), CPT Codes for Laboratory (12), Specialty Medical category, Durable Medical Equipment charges, Participates in clinical trials, location serves HIV+ clients only, location provides comprehensive care, Homecare visits (Homemaker, Home Health Aide, Visiting Nurse), Daycare days, Home Hospice days, Residential Hospice days, Services Provided by; Optionally include staff codes.
• Form B: Psychosocial Services - ID Letters/ID Numbers, Site, Sub-Provider, Intake/Service Date, Staff Code, Visit or Daily Summary, HIV Prevention/Intervention Services, Mental Health Services, Group Counseling, Substance Abuse Services, Case Management/Advocacy, Other Services, Topics Discussed, Service Location, Services Provided by; Optionally include staff codes.
• Form C: Medications Ordered or Provided - ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, Ordered or Provided, List of Medications by Generic and Brand Names.

Citations

• 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.
• Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 2B: Intervention-Services Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Usage - Permission is granted for non-commercial use so long as form is not altered, the copyright is not removed, and a proper citation is made to the instrument. Non-commercial use is use by a not-for-profit organization in which the instrument is not sold. If you have questions about appropriate and proper uses, contact The Measurement Group.