PHYSICIAN EXAMINATION PROCEDURES MANUAL

[Pages:325]National Health

and Nutrition

Examination Survey

PHYSICIAN EXAMINATION PROCEDURES

MANUAL

January 2003

TABLE OF CONTENTS

Chapter 1

2

Page

OVERVIEW OF THE NATIONAL HEALTH AND NUTRITION

EXAMINATION SURVEY ............................................................................ 1-1

1.1 History of the National Health and Nutrition Examination

Programs .............................................................................................

1.2 Overview of the Current NHANES ....................................................

1-1

1-3

1.2.1 Data Collection.................................................................... 1-4

1.3 Sample Selection................................................................................. 1-6

1.4 Field Organization for NHANES ....................................................... 1-7

1.5 Exams and Interviews in the Mobile Examination Center (MEC) ..... 1-10

1.5.1 1.5.2 1.5.3 1.5.4 1.5.5 1.5.6

Exam Sessions..................................................................... Exam Team Responsibilities............................................... Examination Components ................................................... Sample Person Remuneration ............................................. Report of Exam Findings .................................................... Dry Run Day .......................................................................

1-10

1-12

1-13

1-17

1-17

1-19

1.6 Integrated Survey Information System (ISIS) .................................... 1.7 Confidentiality and Professional Ethics..............................................

1-19

1-19

OVERVIEW OF PHYSICIAN'S EXAMINATION....................................... 2-1

2.1 Medical Policy Regarding the Examination ....................................... 2-1

2.2 The Role of the Physician in NHANES.............................................. 2-2

2.2.1 Presence in MEC during MEC Examinations..................... 2-2

2.2.2 Response to Medical Emergencies...................................... 2-2

2.2.3 Maintenance of Emergency Equipment and Supplies......... 2-3

2.3 Physicians' Examination..................................................................... 2-3

2.3.1 2.3.2

2.3.3 2.3.4

Measurement of Blood Pressure and Pulse ......................... Review for Exclusion and Inclusion of Cardiovascular

Fitness Treadmill Testing.................................................... Counseling for STD and HIV ............................................. Referrals ..............................................................................

2-3

2-4

2-4

2-4

2.4 Maintenance of Physician's Examination Room ................................ 2-4

iii

TABLE OF CONTENTS (continued)

Chapter 3

4

Page

EQUIPMENT AND SUPPLIES...................................................................... 3-1

3.1 Description of Equipment................................................................... 3.2 Sphygmomanometer ...........................................................................

3-1

3-1

3.2.1 3.2.2 3.2.3

The Baumanometer? Calibrated Manometer ..................... Calibrated? V-Lok? Cuff .................................................. LittmanTM Classic II S.E. Stethoscope ................................

3-1

3-2

3-3

3.3 Maintenance of Equipment ................................................................. 3-3

3.3.1 3.3.2 3.3.3

Mercury Sphygmomanometer............................................. Littman Stethoscope............................................................ Blood Pressure Cuffs...........................................................

3-3

3-4

3-5

3.4 Mercury Spills or Leaks...................................................................... 3-5

PHYSICIAN PROTOCOL .............................................................................. 4-1

4.1 General Overview ............................................................................... 4.2 Blood Pressure, Heart Rate, and Pulse Measurements .......................

4-1

4-1

4.2.1 4.2.2 4.2.3

SPs Included for Blood Pressure, Heart Rate, and Pulse

Measurements ..................................................................... SPs Excluded from Blood Pressure, Heart Rate, and

Pulse Measurements............................................................ Procedures for Measuring Blood Pressures, Heart Rates,

and Pulses............................................................................

4-2

4-2

4-2

4.3 SP Exclusion from Cardiovascular Fitness Examination (CV

Fitness)................................................................................................

4-11

4.3.1 Conditions for Exclusion from Cardiovascular Fitness

Testing.................................................................................

4-12

4.4 Sexually Transmitted Diseases (STD), Human Immunodeficiency

Virus (HIV) and Bacterial Vaginosis (BV) ........................................

4-14

4.4.1 4.4.2

Guidelines Affecting STD, HIV and BV Test Result

Reporting............................................................................. Informing SPs of STD, HIV and BV Results......................

4-15

4-16

iv

Chapter 5

TABLE OF CONTENTS (continued)

4.5 Vaginal Swabs ....................................................................................

4.5.1 Instructing the SP for Vaginal Swabs .................................

4.6 Prostate Specific Antigen Testing.......................................................

4.6.1 Physician Script for PSA..................................................... 4.6.2 Introduction to Exclusion Questions ...................................

4.7 Data Entry Screens..............................................................................

4.7.1 4.7.2 4.7.3 4.7.4 4.7.5

4.7.6 4.7.7 4.7.8 4.7.9

4.7.10

4.7.11 4.7.12 4.7.13 4.7.14 4.7.15 4.7.16 4.7.17 4.7.18 4.7.19 4.7.20 4.7.21

Reviewing SP Medications from Household Interview ...... Reviewing SP History ......................................................... Child Heart Rate, Pulse ....................................................... Blood Pressure Data Entry .................................................. Exclusion from CV Fitness Based on Pulse and

Irregular Beats..................................................................... Blood Pressure Measurement Screens ................................ Blood Pressure Edit Limits ................................................. Blood Pressure Component Status and Comments ............. Exclusion from CV Fitness Based on Systolic Blood

Pressure ............................................................................... Exclusion from CV Fitness Based on Diastolic Blood

Pressure ............................................................................... Shared Exclusion Questions................................................ CV Safety Exclusion Questions .......................................... CV Exclusion Status ........................................................... STD and HIV Discussion of Tests and Obtaining Results.. Physician Look-up Table .................................................... Pausing an Examination ...................................................... Room Log ........................................................................... Session Preview .................................................................. SP Examinations ................................................................. End of Section ..................................................................... Close Examination Button ..................................................

REFERRALS...................................................................................................

5.1 Medical Referrals................................................................................ 5.2 Referral Levels....................................................................................

5.2.1 5.2.2 5.2.3

Level 1 Referrals ................................................................. Level 2 Referrals ................................................................. Level 3 Referrals .................................................................

Page

4-17

4-18

4-20

4-20

4-21

4-22

4-22

4-27

4-29

4-32

4-34

4-40

4-48

4-49

4-51

4-52

4-54

4-63

4-85

4-88

4-96

4-98

4-99

4-100

4-101

4-103

4-104

5-1

5-1

5-1

5-2

5-2

5-2

v

TABLE OF CONTENTS (continued)

Chapter

Page

5.3 Basis for Referral ................................................................................ 5-3

5.3.1 5.3.2 5.3.3 5.3.4 5.3.5

Examination Data Related Referrals ................................... Blood Pressure Referrals ? Adults ...................................... Blood Pressure Referrals ? Children................................... Lower Extremity Disease (LED) Referrals ......................... Laboratory Values...............................................................

5-3

5-5

5-8

5-9

5-11

5.4 Observation Referrals ......................................................................... 5.5 Mental Health Observation Referrals .................................................

5-15

5-15

5.5.1 5.5.2 5.5.3 5.5.4 5.5.5 5.5.6

MEC Interviewer Process ................................................... MEC Interviewers ............................................................... MEC Physician.................................................................... Suicide................................................................................. Homicidal Ideations/Threats ............................................... Child Abuse.........................................................................

5-15

5-16

5-16

5-17

5-17

5-18

5.6 Sessions Requiring Review ................................................................ 5.7 Data Entry Screens for Referrals ........................................................

5-18

5-20

5.7.1 5.7.2 5.7.3 5.7.4 5.7.5 5.7.6 5.7.7 5.7.8 5.7.9 5.7.10 5.7.11 5.7.12 5.7.13 5.7.14 5.7.15 5.7.16 5.7.17 5.7.18 5.7.19

Review Menu ...................................................................... Review Box......................................................................... Review Other Sessions........................................................ Sessions Requiring Review................................................. Referral Review Screen....................................................... Selecting SP for Detailed Referral Review ......................... ISIS Message....................................................................... NHANES Release Form for SPs Refusing Referrals.......... Review in Box for Pregnancy Details ................................. Review in Box for CBC Details.......................................... Review in Box ? Blood Pressure Details ............................ Review in Box- LED Details .............................................. Review in Box ? Observations Details ............................... Observation Referrals.......................................................... Referral Letter ..................................................................... Local Physician Pickup ....................................................... Referral Address Information.............................................. Referral Letter Review ........................................................ Referral Letter .....................................................................

5-20

5-21

5-21

5-23

5-24

5-25

5-28

5-29

5-30

5-32

5-34

5-36

5-37

5-37

5-40

5-41

5-42

5-43

5-44

vi

TABLE OF CONTENTS (continued)

Chapter 6

7

SAFETY ISSUES AND EMERGENCY PROCEDURES..............................

6.1 Safety in the Mobile Exam Center (MEC) .........................................

6.1.1 6.1.2 6.1.3

Elderly Sample Persons....................................................... Sample Persons in Wheelchairs .......................................... Children in the MEC ...........................................................

6.2 Safety Precautions...............................................................................

6.2.1 6.2.2 6.2.3

Mobile Exam Center Preparation........................................ Mobile Examination Staff Preparation................................ On-Site Preparations at Each Stand ....................................

6.3 Reporting SP Problems to the MEC Physician................................... 6.4 Medical Management and Referrals ...................................................

6.4.1 Medical Referrals ................................................................ 6.4.2 Medical Management..........................................................

6.5 Emergency Procedures .......................................................................

6.5.1 Medical Emergencies Overview .........................................

6.6 Psychiatric/Behavioral Problem Procedures....................................... 6.7 Natural Disaster Procedures................................................................

6.7.1 Disaster Prior to an Examination Session ........................... 6.7.2 Disaster During an Examination Session ............................

DOCUMENTATION OF INCIDENTS AND EMERGENCIES....................

7.1 Incident Forms ....................................................................................

7.1.1 Incident Report Hard-Copy Form .......................................

7.2 Emergency Forms ...............................................................................

7.2.1 Emergency Report Hard-Copy Form ..................................

Page

6-1

6-1

6-1

6-2

6-2

6-3

6-3

6-3

6-4

6-4

6-5

6-5

6-6

6-9

6-9

6-17

6-18

6-18

6-18

7-1

7-1

7-9

7-10

7-13

vii

TABLE OF CONTENTS (continued)

Chapter 8

PHYSICIAN EQUIPMENT QUALITY CONTROL......................................

8.1 Equipment and Room Set Up Checks.................................................

8.1.1 8.1.2 8.1.3

Daily .................................................................................... Weekly ................................................................................ Stand....................................................................................

8.2 Data Entry Screens for QC on Equipment..........................................

Page

8-1

8-1

8-1

8-2

8-2

8-2

Appendix

A B C D E F G H

List of Appendixes

Child Blood Pressure Values ........................................................................... Child Blood Pressure References..................................................................... Adult Blood Pressure Reference Table............................................................ Exclusions Based on Medications ................................................................... Exclusions Based on Medical Conditions........................................................ Hospitalization Exclusion from CV Fitness .................................................... Cardiovascular Safety and Exclusion Questions ............................................. STD Information Sheets and Role Plays .........................................................

A-1

B-1

C-1

D-1

E-1

F-1

G-1

H-1

Table

4-1 5-1 5-2 5-3

List of Tables

Arm circumference and acceptable cuff size ................................................... 4-4

Table of referral levels ..................................................................................... 5-3

Referral levels for adult blood pressure ........................................................... 5-6

Blood pressure referral levels, category, and action required.......................... 5-6

viii

TABLE OF CONTENTS (continued)

Table

List of Tables (continued) Page

5-4

Table of blood pressure referral comments ..................................................... 5-7

5-5

Reference ranges for complete blood count..................................................... 5-14

List of Exhibits

Exhibit

1-1

Floor plan of the MEC ..................................................................................... 1-11

1-2

MEC exams and rooms.................................................................................... 1-11

1-3

Examination components................................................................................. 1-14

4-1

Reminder form to get STD and HIV results .................................................... 4-17

4-2

Cardiovascular Medication Review ................................................................. 4-23

4-3

CV review for exclusion medication, screen 1 ................................................ 4-24

4-4

CV review for medication exclusion, screen 2 ................................................ 4-25

4-5

CV review for exclusion medication, screen 3 ................................................ 4-26

4-6

Review menu to select SP History................................................................... 4-27

4-7

SP History selections ....................................................................................... 4-28

4-8

Child heart rate/pulse ....................................................................................... 4-29

4-9

Child heart rate: Required data entry ............................................................... 4-30

4-10

Component status for child heart rate/pulse..................................................... 4-31

4-11

Default blood pressure screen.......................................................................... 4-32

4-12

Blood pressure cuff size................................................................................... 4-33

4-13

Irregular rhythm exclusion from CV Fitness ................................................... 4-34

ix

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