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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
C011  ACTIVITY LEVEL  F084  ACTIVE  Use Activity level to document the average amount of physical activity in which the patient engages. 1. Ask the patient if he or she engages in physical activity. 2. Ask the patient in what activities he or she is engaged. 3. Ask the patient how much time he or she spends engaging in this activity. 4. Document the health factor screening results using the associated health factor codes.  For patients age 18 and over: Engages in 150–299 minutes of physical activity per week (For patients age 6-17: 210-419 minutes) 
C011  ACTIVITY LEVEL  F085  INACTIVE  Use Activity level to document the average amount of physical activity in which the patient engages. 1. Ask the patient if he or she engages in physical activity. 2. Ask the patient in what activities he or she is engaged. 3. Ask the patient how much time he or she spends engaging in this activity. 4. Document the health factor screening results using the associated health factor codes.  Engages in little or no physical activity 
C011  ACTIVITY LEVEL  F086  SOME ACTIVITY  Use Activity level to document the average amount of physical activity in which the patient engages. 1. Ask the patient if he or she engages in physical activity. 2. Ask the patient in what activities he or she is engaged. 3. Ask the patient how much time he or she spends engaging in this activity. 4. Document the health factor screening results using the associated health factor codes.  For patients age 18 and over: Engages in < 150 minutes (approximately 30 minutes four or fewer times a week) of physical activity per week (For patients age 6-17: <210) 
C011  ACTIVITY LEVEL  F087  VERY ACTIVE  Use Activity level to document the average amount of physical activity in which the patient engages. 1. Ask the patient if he or she engages in physical activity. 2. Ask the patient in what activities he or she is engaged. 3. Ask the patient how much time he or she spends engaging in this activity. 4. Document the health factor screening results using the associated health factor codes.  For patients age 18 and over: Engages in 300 or more minutes of physical activity per week to achieve and maintain a healthy body weight and reduce body fat (For patients age 6-17: 420 or more) 
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 
C010  ASTHMA TRIGGERS  F061  DUST MITES  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to dust and dust mites. 
C010  ASTHMA TRIGGERS  F062  COCKROACHES  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to cockroaches. 
C010  ASTHMA TRIGGERS  F063  MOLD  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to mold and/or mildew. 
C010  ASTHMA TRIGGERS  F064  AIR POLLUTANTS  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to air pollutants or when the air quality index is low. 
C010  ASTHMA TRIGGERS  F065  POLLEN  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to pollen or other seasonal triggers. 
C010  ASTHMA TRIGGERS  F066  TOBACCO SMOKE  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exposed to tobacco smoke. 
C010  ASTHMA TRIGGERS  F067  EXERCISE  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when exercising/cold. 
C010  ASTHMA TRIGGERS  F069  CHANGE IN WEATHER  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens with changes in weather such as cold air, high humidity, or heat. 
C010  ASTHMA TRIGGERS  F070  MENSES  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The female patient’s asthma status worsens during menses. 
C010  ASTHMA TRIGGERS  F071  OTHER TRIGGER  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  Use only if no other trigger is appropriate. 
C010  ASTHMA TRIGGERS  F072  STRONG EMOTIONAL EXPRESSION  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  Strong emotional expressions cause worsening of the patient’s asthma status. 
C010  ASTHMA TRIGGERS  F073  VIRAL INFECTION  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  Viral infections worsen the patient’s asthma status. 
C010  ASTHMA TRIGGERS  F113  ANIMAL  1. Ask the patient if exposure to any of the associated health factors worsen asthma symptoms. 2. Document the asthma trigger health factors using the associated health factor codes. When necessary, add multiple health factors (to document that the patient has more than one asthma trigger: mold, dust mites and animals).  The patient’s asthma status worsens when around animals and pets including rodents and birds. 
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. 
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