Table 2.

Sample Entries in the Assessment Instruments

Column Name	Example 1	Example 2	Example 3
Unique name	Prior condition; urinary incontinence	Primary caregiver assistance type	Primary caregiver
Concept	Prior condition.urinary incontinence	Primary caregiver assistance.ADL	Primary caregiver
Relevance	1*	M0350= =1‖ M0350= =2‖ M0350= =3†	1
Action Type	q	q	q‡
Data Type	Number	Number	Number
Validation§
Action phrase	Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: 1-Urinary incontinence	Type of primary caregiver assistance: 1-ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)	Primary caregiver taking lead responsibility for providing or managing the patient's care, etc.
Answer Options	Check|1|Yes‖	Check|1|Yes	List|0|No one person
			|1|Spouse or significant other
			|2|Daughter or son
			|3|Other family member
			|4|Friend or neighbor or community or church member
			|5|Paid help
			|77|Unknown¶

ADL = Activities of Daily Living.

^*A relevance of 1 means that the question is always asked.

^†The question is asked only if the previous question M0350 is checked as “1” or “2” or “3.”

^‡The action type “q” indicates that a question should be asked.

^§None of these items required validation criteria, so that field is blank.

^‖A “Check” indicates answer options are presented in check box format.

^¶A “list” indicates answer options are presented in list box format.