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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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Code Category Health Factor Code Health Factor Standards Outcome
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 
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 
C003  TB STATUS  F105  TX IN PROGRESS  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 is currently receiving TB treatment 
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 
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. 
C008  LEARNING PREFERENCE  F047  READ  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 reading is a preferred style of learning. 
C008  LEARNING PREFERENCE  F048  DO/PRACTICE  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 states that doing or practicing a new skill is the preferred style of learning new information. 
C009  BARRIERS TO LEARNING  F049  NO BARRIERS  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient has no apparent barriers to learning 
C009  BARRIERS TO LEARNING  F050  DOESN'T READ ENGLISH  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient is unable to read English. 
C009  BARRIERS TO LEARNING  F051  INTERPRETER NEEDED  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient does not readily understand spoken English. 
C009  BARRIERS TO LEARNING  F053  VALUES/BELIEFS  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient has values or beliefs that may impact learning; this may also include traditional Native American/Alaska Native values or beliefs that may impact the medical or clinical aspects of healthcare. 
C009  BARRIERS TO LEARNING  F055  FINE MOTOR SKILLS DEFICIT  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient has fine motor skills impairment which can interfere with tasks requiring manual dexterity. 
C009  BARRIERS TO LEARNING  F056  HARD OF HEARING  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient has a problem hearing that can be compensated with increased volume or hearing devices. 
C009  BARRIERS TO LEARNING  F057  DEAF  Barriers to learning are patient specific. They usually are not visit specific, but rather relate to the patient's overall health status. Assess barriers by observation and interview, and then document them to alert other healthcare providers who may provide education. It is important to accommodate and overcome barriers to enhance patient learning. Assess barriers annually or any time the situation warrents assessment. 1. Observe and question the patient for any barriers to learning. a.Visually Impaired - The patient may divert the eyes, squint, or state his or her difficulty seeing. b.Blind - The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is =20/200 or =20 degrees of visual field in the better eye). c.Hard of Hearing - The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device. d. Deaf - The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness. e.Doesn't Read English - Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her. f.Speaks English as a Second Language - The patient speaks English fluently, but may have minor barriers due to differences in primary language. g.Interpreter Needed - The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment. h.Fine Motor Skills Deficit - The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications). i.Dementia - The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia. j.Values or Beliefs - The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care. k.Stressors - The patient may appear distraught, avoid eye contact, or show anger. The emotional stressors may be acute or ongoing. e.g., personal issues (marital/relationship problems, unemployment/financial stress, lack of housing, problems with children/family members) or behavioral issues (mood, anxiety, grief). Emotional stressors are internal while social stressors are external. l.Low Health Literacy - Assessment is made by a low score on a health literacy screening tool or observation. m.Cognitive Impairment - The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment. n.Developmental Delay - (DO NOT USE) The patient may behave younger than actual age. o.Learning Disability - (DO NOT USE) The patient may comment about a learning disability or be diagnosed as such. p.Childhood Development - (DO NOT USE) The pediatric patient is of an age or cognition level that he or she relies on others for care. q.Less than 6th Grade Education - (DO NOT USE) Must assess by asking grade level completed. r.Social Stressors - (DO NOT USE) The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal. 2. Document the health factor screening results using the associated health factor codes.  The patient is deaf and cannot compensate with increased volume or hearing devices. 
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