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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

Standard Code Book (SCB)  

Health Factors

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1-25 of 90 items displayed
 
  

Code Category Health Factor Code Health Factor Standards Outcome
C017  TOBACCO (SMOKING)  F002  CURRENT SMOKER, STATUS UNKNOWN  Use this health factor to document whether the patient smokes tobacco (cigarettes, pipe, or cigars) or has a history of smoking. 1. Ask the patient if he or she smokes tobacco or has smoked tobacco in the past (cigarettes, pipe, or cigars). 2. Ask the patient if he or she smokes tobacco products for cultural or religious purposes. 3. Document the Smoking Assessment factor screening results using the associated health factor codes.   Currently smokes tobacco (cigarettes, cigars, pipe, etc.) but the amount smoked is unknown. 
C016  TOBACCO (SMOKELESS - CHEWING/DIP)  F003  CURRENT SMOKELESS  Use this health factor to document whether the patient uses smokeless tobacco (chewing tobacco, dip) or has a history of using smokeless tobaccco. 1. Ask the patient if he or she uses smokeless tobacco products (Chewing tobacco, snuff, dip, etc.). 2. Document the health factor screening results using the associated health factor codes.  Currently uses smokeless tobacco (chew, dip, snuff, etc.). 
C017  TOBACCO (SMOKING)  F004  PREVIOUS (FORMER) SMOKER  Use this health factor to document whether the patient smokes tobacco (cigarettes, pipe, or cigars) or has a history of smoking. 1. Ask the patient if he or she smokes tobacco or has smoked tobacco in the past (cigarettes, pipe, or cigars). 2. Ask the patient if he or she smokes tobacco products for cultural or religious purposes. 3. Document the Smoking Assessment factor screening results using the associated health factor codes.   Has quit smoking tobacco for six months or more. 
C016  TOBACCO (SMOKELESS - CHEWING/DIP)  F005  PREVIOUS (FORMER) SMOKELESS  Use this health factor to document whether the patient uses smokeless tobacco (chewing tobacco, dip) or has a history of using smokeless tobaccco. 1. Ask the patient if he or she uses smokeless tobacco products (Chewing tobacco, snuff, dip, etc.). 2. Document the health factor screening results using the associated health factor codes.  Has quit smokeless tobacco for six months or more. 
C015  TOBACCO (EXPOSURE)  F006  SMOKER IN HOME  Use this health factor to document whether the patient is exposed to tobacco smoke at home or work. 1. Ask the patient if he or she is exposed to tobacco smoke at work. 2. Ask the patient if anyone uses tobacco products at home. 3. ocument the health factor screening results using the associated health factor codes.   Is exposed to secondhand smoke at home. 
C001  ALCOHOL/DRUG  F018  CAGE 0/4  CAGE is a screening tool for alcohol abuse. It can be modified for drug use by substituting 'drug use' for 'drinking' and replacing the fourth question of 'Do you ever use drugs first thing in the morning' to 'take the edge off'? 1. Ask the patient the following four questions: a.Have you ever felt you out to Cut down on your alcohol intake? b. Have people Annoyed you by criticizing your drinking? c.Have you ever felt bad or Guilty about your drinking? d. Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Note: Two or more 'Yes' answers are considered indicative or probable alcohol dependence. One 'Yes' answer indicates that the patient's alcohol use deserves further evaluation. 2. Document the health factor screening results using the associated health factor codes.   Answers NO to all four questions 
C001  ALCOHOL/DRUG  F019  CAGE 1/4  CAGE is a screening tool for alcohol abuse. It can be modified for drug use by substituting 'drug use' for 'drinking' and replacing the fourth question of 'Do you ever use drugs first thing in the morning' to 'take the edge off'? 1. Ask the patient the following four questions: a.Have you ever felt you out to Cut down on your alcohol intake? b. Have people Annoyed you by criticizing your drinking? c.Have you ever felt bad or Guilty about your drinking? d. Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Note: Two or more 'Yes' answers are considered indicative or probable alcohol dependence. One 'Yes' answer indicates that the patient's alcohol use deserves further evaluation. 2. Document the health factor screening results using the associated health factor codes.   Answers YES to one of the four questions 
C001  ALCOHOL/DRUG  F020  CAGE 2/4  CAGE is a screening tool for alcohol abuse. It can be modified for drug use by substituting 'drug use' for 'drinking' and replacing the fourth question of 'Do you ever use drugs first thing in the morning' to 'take the edge off'? 1. Ask the patient the following four questions: a.Have you ever felt you out to Cut down on your alcohol intake? b. Have people Annoyed you by criticizing your drinking? c.Have you ever felt bad or Guilty about your drinking? d. Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Note: Two or more 'Yes' answers are considered indicative or probable alcohol dependence. One 'Yes' answer indicates that the patient's alcohol use deserves further evaluation. 2. Document the health factor screening results using the associated health factor codes.   Answers YES to two of the four questions 
C001  ALCOHOL/DRUG  F021  CAGE 3/4  CAGE is a screening tool for alcohol abuse. It can be modified for drug use by substituting 'drug use' for 'drinking' and replacing the fourth question of 'Do you ever use drugs first thing in the morning' to 'take the edge off'? 1. Ask the patient the following four questions: a.Have you ever felt you out to Cut down on your alcohol intake? b. Have people Annoyed you by criticizing your drinking? c.Have you ever felt bad or Guilty about your drinking? d. Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Note: Two or more 'Yes' answers are considered indicative or probable alcohol dependence. One 'Yes' answer indicates that the patient's alcohol use deserves further evaluation. 2. Document the health factor screening results using the associated health factor codes.   Answers YES to three of the four questions 
C001  ALCOHOL/DRUG  F022  CAGE 4/4  CAGE is a screening tool for alcohol abuse. It can be modified for drug use by substituting 'drug use' for 'drinking' and replacing the fourth question of 'Do you ever use drugs first thing in the morning' to 'take the edge off'? 1. Ask the patient the following four questions: a.Have you ever felt you out to Cut down on your alcohol intake? b. Have people Annoyed you by criticizing your drinking? c.Have you ever felt bad or Guilty about your drinking? d. Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Note: Two or more 'Yes' answers are considered indicative or probable alcohol dependence. One 'Yes' answer indicates that the patient's alcohol use deserves further evaluation. 2. Document the health factor screening results using the associated health factor codes.   Answers YES to all four questions 
C016  TOBACCO (SMOKELESS - CHEWING/DIP)  F023  CESSATION-SMOKELESS  Use this health factor to document whether the patient uses smokeless tobacco (chewing tobacco, dip) or has a history of using smokeless tobaccco. 1. Ask the patient if he or she uses smokeless tobacco products (Chewing tobacco, snuff, dip, etc.). 2. Document the health factor screening results using the associated health factor codes.  Is transitioning from a Current Smokeless tobacco user to a Previous Smokeless tobacco user. The time period between stopping smokeless tobacco and the present date is less than six months. 
C017  TOBACCO (SMOKING)  F024  CESSATION-SMOKER  Use this health factor to document whether the patient smokes tobacco (cigarettes, pipe, or cigars) or has a history of smoking. 1. Ask the patient if he or she smokes tobacco or has smoked tobacco in the past (cigarettes, pipe, or cigars). 2. Ask the patient if he or she smokes tobacco products for cultural or religious purposes. 3. Document the Smoking Assessment factor screening results using the associated health factor codes.   Is transitioning from a Current Smoker to a Previous Smoker. The time period between the stop date and the present date is less than six months. 
C015  TOBACCO (EXPOSURE)  F025  SMOKE FREE HOME  Use this health factor to document whether the patient is exposed to tobacco smoke at home or work. 1. Ask the patient if he or she is exposed to tobacco smoke at work. 2. Ask the patient if anyone uses tobacco products at home. 3. ocument the health factor screening results using the associated health factor codes.   There is no exposure to tobacco smoke at home. 
C003  TB STATUS  F026  TX COMPLETE  Use Tuberculosis treatment status to document TB treatment status in affected patients. 1. Evaluate patient for history of TB or positive PPD test. 2. Determine if the patient has active or a history of infection or exposure. 3. Document health factor screening results using the associated health factor codes.  Patient has completed a course of TB treatment 
C003  TB STATUS  F027  TX INCOMPLETE  Use Tuberculosis treatment status to document TB treatment status in affected patients. 1. Evaluate patient for history of TB or positive PPD test. 2. Determine if the patient has active or a history of infection or exposure. 3. Document health factor screening results using the associated health factor codes.  Patient has not completed a course of TB treatment 
C003  TB STATUS  F028  TX UNKNOWN  Use Tuberculosis treatment status to document TB treatment status in affected patients. 1. Evaluate patient for history of TB or positive PPD test. 2. Determine if the patient has active or a history of infection or exposure. 3. Document health factor screening results using the associated health factor codes.  Status of TB treatment is uncertain 
C003  TB STATUS  F029  TX UNTREATED  Use Tuberculosis treatment status to document TB treatment status in affected patients. 1. Evaluate patient for history of TB or positive PPD test. 2. Determine if the patient has active or a history of infection or exposure. 3. Document health factor screening results using the associated health factor codes.  TB has not been treated 
C015  TOBACCO (EXPOSURE)  F031  EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE  Use this health factor to document whether the patient is exposed to tobacco smoke at home or work. 1. Ask the patient if he or she is exposed to tobacco smoke at work. 2. Ask the patient if anyone uses tobacco products at home. 3. ocument the health factor screening results using the associated health factor codes.   Is exposed to secondhand smoke at work or outside the home. 
C005  DIABETES SELF MONITORING  F032  YES  Use Diabetes self-monitoring to document whether patient perform self-monitoring of blood glucose (blood sugar testing) at home. 1. Ask whether the patient checks blood glucose at home. 2. Document the health facotr screening using the associated health factor codes.  Patient performs self-monitoring of blood glucose 
C005  DIABETES SELF MONITORING  F033  NO  Use Diabetes self-monitoring to document whether patient perform self-monitoring of blood glucose (blood sugar testing) at home. 1. Ask whether the patient checks blood glucose at home. 2. Document the health facotr screening using the associated health factor codes.  Patient does not perform self-monitoring of blood glucose 
C005  DIABETES SELF MONITORING  F034  REFUSED  Use Diabetes self-monitoring to document whether patient perform self-monitoring of blood glucose (blood sugar testing) at home. 1. Ask whether the patient checks blood glucose at home. 2. Document the health facotr screening using the associated health factor codes.  Patient refuses to perform self-monitoring of blood glucose 
C017  TOBACCO (SMOKING)  F035  CEREMONIAL USE ONLY  Use this health factor to document whether the patient smokes tobacco (cigarettes, pipe, or cigars) or has a history of smoking. 1. Ask the patient if he or she smokes tobacco or has smoked tobacco in the past (cigarettes, pipe, or cigars). 2. Ask the patient if he or she smokes tobacco products for cultural or religious purposes. 3. Document the Smoking Assessment factor screening results using the associated health factor codes.   Uses tobacco for ceremonial or religious purposes only. 
C008  LEARNING PREFERENCE  F044  TALK  List Learning Preference in the medical record as a health factor. Although a patient may have a predominant way of learning, it is important to use a variety of teaching methods to optimize an educational encounter. Evaluate learning preference whenever it seems necessary. 1. Review the most common styles of adult learning (talking and asking questions, group discussion, videos, reading). 2. Explain that every individual is unique and has his or her own preference(s) in how they receive new information. 3. Ask the patient, or the patient's family, 'How do you learn best?' 4. Document the health factor screening results using the associated health factor codes.  The patient, or the patient’s family, states that talking and asking questions is a preferred style of learning. 
C008  LEARNING PREFERENCE  F045  MEDIA  List Learning Preference in the medical record as a health factor. Although a patient may have a predominant way of learning, it is important to use a variety of teaching methods to optimize an educational encounter. Evaluate learning preference whenever it seems necessary. 1. Review the most common styles of adult learning (talking and asking questions, group discussion, videos, reading). 2. Explain that every individual is unique and has his or her own preference(s) in how they receive new information. 3. Ask the patient, or the patient's family, 'How do you learn best?' 4. Document the health factor screening results using the associated health factor codes.  The patient, or the patient’s family, states that media (kiosk, videos, interactive displays) is a preferred style of learning. 
C008  LEARNING PREFERENCE  F046  SMALL GROUP  List Learning Preference in the medical record as a health factor. Although a patient may have a predominant way of learning, it is important to use a variety of teaching methods to optimize an educational encounter. Evaluate learning preference whenever it seems necessary. 1. Review the most common styles of adult learning (talking and asking questions, group discussion, videos, reading). 2. Explain that every individual is unique and has his or her own preference(s) in how they receive new information. 3. Ask the patient, or the patient's family, 'How do you learn best?' 4. Document the health factor screening results using the associated health factor codes.  The patient, or the patient’s family, states that participating in small groups is a preferred style of learning. 
 90 Record(s)

 
1-25 of 90 items displayed