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Standard Code Book (SCB)  

Health Factors

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1-25 of 97 items displayed
 
  

Code Category Health Factor Code Health Factor Standards Outcome
C020  REPRODUCTIVE PLAN   F130  AMBIVALENT ABOUT TRYING TO CONCEIVE  These health factors support reproductive planning and implement improvement projects around preconception care. This drives education and interventions such as folate intake, counseling and selection of contraception, and tobacco use cessation interventions to improve healthier pregnancies and reduce unwanted pregnancies.  The patient is not sure if they want to become pregnant if female, or father a child if male, or not in the next year. 
C020  REPRODUCTIVE PLAN   F129  NOT TRYING TO CONCEIVE  These health factors support reproductive planning and implement improvement projects around preconception care. This drives education and interventions such as folate intake, counseling and selection of contraception, and tobacco use cessation interventions to improve healthier pregnancies and reduce unwanted pregnancies.  The patient does not want to become pregnant if female, or father a child if male, in the next year. 
C020  REPRODUCTIVE PLAN   F128  TRYING TO CONCEIVE  These health factors support reproductive planning and implement improvement projects around preconception care. This drives education and interventions such as folate intake, counseling and selection of contraception, and tobacco use cessation interventions to improve healthier pregnancies and reduce unwanted pregnancies.  The patient is actively planning and trying to become pregnant if female, or father a child if male, in the next year. 
C019  ELECTRONIC NICOTINE DELIV SYSTEM (ENDS)  F127  NEVER USED ENDS USER  Use this health factor to document if the patient uses an electronic nicotine delivery system (ENDS) (also referred to as vaping or e-cigarettes containing nicotine).  Does not and has never used an electronic nicotine delivery system. 
C019  ELECTRONIC NICOTINE DELIV SYSTEM (ENDS)  F126  PREVIOUS ENDS USER  Use this health factor to document if the patient uses an electronic nicotine delivery system (ENDS) (also referred to as vaping or e-cigarettes containing nicotine).  Has stopped using electronic nicotine delivery systems for six months or more. 
C019  ELECTRONIC NICOTINE DELIV SYSTEM (ENDS)  F125  CESSATION ENDS USER  Use this health factor to document if the patient uses an electronic nicotine delivery system (ENDS) (also referred to as vaping or e-cigarettes containing nicotine).  Is transitioning from a Current electronic nicotine delivery systems user to a ENDS user. The time period between stopping the use of ENDS and the present date is less than six months. 
C019  ELECTRONIC NICOTINE DELIV SYSTEM (ENDS)  F124  CURRENT ENDS USER  Use this health factor to document if the patient uses an electronic nicotine delivery system (ENDS) (also referred to as vaping or e-cigarettes containing nicotine).  Currently uses electronic nicotine delivery systems (ENDS). 
C018  ECOG PERFORMANCE STATUS  F123  ECOG 5 - DEAD  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Dead 
C017  TOBACCO (SMOKING)  F122  LIGHT TOBACCO USER  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 < 10 cigarettes per day. 
C017  TOBACCO (SMOKING)  F121  HEAVY TOBACCO USER  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 = 10 cigarettes per day. 
C009  BARRIERS TO LEARNING  F120  COGNITIVE IMPAIRMENT  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 demonstrates cognitive impairment 
C018  ECOG PERFORMANCE STATUS  F119  ECOG 4 - COMPLETELY DISABLED  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair  
C018  ECOG PERFORMANCE STATUS  F118  ECOG 3 - LIMITED SELF CARE  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 
C018  ECOG PERFORMANCE STATUS  F117  ECOG 2 - UNABLE TO WORK  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 
C018  ECOG PERFORMANCE STATUS  F116  ECOG 1 - SOME RESTRICTION  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 
C018  ECOG PERFORMANCE STATUS  F115  ECOG 0 - ACTIVE  Use the Eastern Cooperative Oncology Group (ECOG) performance status to assess how a patient's disease is progressing, assess how the diseaase affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. 1.Assess the patient's ability to perform daily tasks. 2.Document the result using the associated health factor codes.   Fully active, able to carry on all pre-disease performance without restriction 
C014  OCCUPATION  F114  UNEMPLOYED  Use Occupation to identify various qualities of the patient's occupation that may influence health outcomes. 1. Ask the patient what type of job he or she does. 2. Ask the patient what hours he or she works. 3. Ask the patient if there are any risks involved in his or her work. 4. Document the health factor screening results using the associated health factor codes. More than one health factor can be documented for the patient.  Currently not employed 
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  F112  LOW HEALTH LITERACY  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 demonstrate the ability to obtain, process, and understand basic health information. 
C017  TOBACCO (SMOKING)  F111  SMOKING 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.   Unable to assess the patient’s smoking status (patient may be unconscious or unresponsive). 
C017  TOBACCO (SMOKING)  F110  NEVER SMOKED  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.   Does not and has never smoked tobacco products. 
C017  TOBACCO (SMOKING)  F109  CURRENT SMOKER, SOME DAY  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.) on some days (but not every day) 
C017  TOBACCO (SMOKING)  F108  CURRENT SMOKER, EVERY DAY  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.) every day. 
C016  TOBACCO (SMOKELESS - CHEWING/DIP)  F107  SMOKELESS TOBACCO, STATUS UNKNOWN  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.  Unable to assess the patient's smokeless tobacco use status (they may be unconscious or unresponsive). 
C016  TOBACCO (SMOKELESS - CHEWING/DIP)  F106  NEVER USED SMOKELESS TOBACCO  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.  Does not and has never used smokeless tobacco products. 
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