Physician Examination Procedures Manual September 2011 TABLE OF CONTENTS Chapter Page 1 OVERVIEW OF PHYSICIAN EXAMINATION .......................................... 1-1 1.1 The Role of the Physician in NHANES .............................................. 1-1 1.2 Medical Policy Regarding the Examination ....................................... 1-2 1.2.1 Presence in MEC during MEC Examinations ..................... 1-2 1.2.2 Response to Medical Emergencies ...................................... 1-3 1.2.3 Maintenance of Emergency Equipment and Supplies ......... 1-3 1.3 Physician Examination ....................................................................... 1-3 1.4 Maintenance of Physician’s Examination Room ................................ 1-4 2 EQUIPMENT AND SUPPLIES ...................................................................... 2-1 2.1 Description of Equipment & Supplies ................................................ 2-1 2.2 Inventory ............................................................................................. 2-1 2.3 Blood Pressure .................................................................................... 2-1 2.3.1 Blood Pressure Equipment .................................................. 2-2 2.3.2 Blood Pressure Supplies ...................................................... 2-3 2.3.3 Description of Blood Pressure Equipment and Supplies .... 2-3 2.3.4 Blood Pressure Supplies – Description ............................... 2-5 2.3 HPV Supplies ...................................................................................... 2-6 2.4 Office Supplies ................................................................................... 2-6 2.5 Emergency Supplies ........................................................................... 2-6 2.5.1 Emergency Box – Contents ................................................. 2-7 2.6 OSHA Bloodborne Pathogen Exposure Forms ................................... 2-8 2.7 Inventory ............................................................................................. 2-8 2.7.1 Equipment Set Up ............................................................... 2-8 2.7.2 Teardown Procedure ........................................................... 2-9 2.8 Handling Instructions for Mercury Manometers ................................ 2-9 2.8.1 Mercury Safety Considerations ........................................... 2-9 2.8.2 Required Procedure for Handling Spilled or Leaking Mercury ............................................................................... 2-10 3 PHYSICIAN PROTOCOL .............................................................................. 3-1 3.1 Heart Rate, Pulse, and Blood Pressure Measurements ....................... 3-1 iii TABLE OF CONTENTS (continued) Chapter Page 3.1.1 Procedures for Heart Rate, Pulse, and Blood Pressure Measurements ..................................................................... 3-2 3.1.2 Heart Rate Measurements for SPs through Age 4 ............... 3-2 3.1.3 Blood Pressure Premeasurement Procedure ........................ 3-3 3.1.4 Additional Blood Pressure Measurement Guidelines ......... 3-15 3.1.5 Data Entry Screens for Pulse and Blood Pressure ............... 3-18 3.2 Exclusion from Bronchodilator Based on Pulse and Irregular Beats ................................................................................................... 3-25 3.2.1 Blood Pressure Measurement Screens ................................ 3-29 3.2.2 Blood Pressure Edit Limits ................................................. 3-35 3.2.3 Blood Pressure Component Status and Comments ............. 3-36 3.2.4 Exclusion from Bronchodilator Based on Blood Pressure ............................................................................... 3-37 3.3 Shared Exclusion Questions ............................................................... 3-39 3.4 Sexually Transmitted Diseases (STD) and Human Immunodeficiency Virus (HIV) Testing ............................................. 3-47 3.4.1 Guidelines Affecting STD and HIV Test Result Reporting ............................................................................. 3-47 3.4.2 Gaining Cooperation for the HPV Swab ............................. 3-53 3.4.3 Discussing STD & HIV Testing and Instructing the SP How to Obtain Results ................................................... 3-55 3.4.4 Informed Consent Designation in ISIS ............................... 3-60 3.5 The Physicians’ Role in the Pubertal Maturation Interview Informed Consent ............................................................................... 3-65 3.5.1 Procedure for Changing the PM IC Exclusion .................... 3-69 3.6 The Physician Examination Application and Utilities ........................ 3-71 3.6.1 Review Functionalities ........................................................ 3-71 3.6.2 SP History ........................................................................... 3-71 3.6.3 Utilities Menu...................................................................... 3-75 3.7 Report Utility ...................................................................................... 3-79 3.7.1 SP Examinations ................................................................. 3-81 3.7.2 End of Section ..................................................................... 3-82 3.7.3 Close Examination Button .................................................. 3-82 3.7.4 Pausing an Examination ...................................................... 3-83 iv TABLE OF CONTENTS (continued) Chapter Page 4 REFERRALS ................................................................................................... 4-1 4.1 Medical Referrals ................................................................................ 4-1 4.2 Referral Levels .................................................................................... 4-2 4.2.1 Level 1 Referrals ................................................................. 4-3 4.2.2 Level 2 Referrals ................................................................. 4-3 4.2.3 Level 3 Referrals ................................................................. 4-4 4.3 Laboratory Referrals ........................................................................... 4-4 4.3.1 Pregnancy Referral Requirements ....................................... 4-4 4.3.2 Unmarried Minors Pregnancy Referrals ............................. 4-5 4.3.3 Complete Blood Count ........................................................ 4-6 4.4 Blood Pressure Referrals .................................................................... 4-11 4.4.1 Blood Pressure Referrals – Adults ...................................... 4-11 4.4.2 Blood Pressure Referrals – Children ................................... 4-14 4.5 Observation Referrals ......................................................................... 4-15 4.6 Mental Health Observation Referrals ................................................. 4-16 4.6.1 MEC Interviewer Depression Screening ............................. 4-16 4.6.2 Cognitive Functioning Referrals ......................................... 4-19 4.7 Spirometry Referral Evaluation .......................................................... 4-20 4.7.1 Level II Referral Evaluation for Participants with FEV1/FVC% ≤ 50% Predicted ........................................... 4-20 4.7.2 Level II Referral Evaluation for Participants with FEV1/FVC% ≤ Lower Limits of Normal ........................... 4-23 4.8 Physician Application Referral Procedures ........................................ 4-24 4.8.1 Data Entry Screens for Referrals ......................................... 4-25 4.8.2 Review Menu ...................................................................... 4-25 4.8.3 Review Box ......................................................................... 4-26 4.8.4 Review Other Sessions ........................................................ 4-27 4.8.5 Sessions Requiring Review ................................................. 4-27 4.8.6 Referral Review Inbox Screen ............................................ 4-28 4.8.7 Selecting SP for Detailed Referral Review ......................... 4-29 4.8.8 ISIS Message ....................................................................... 4-32 4.8.9 NHANES Release Form for SPs Refusing Referrals .......... 4-33 4.8.10 Review in Box for Pregnancy Details ................................. 4-35 v TABLE OF CONTENTS (continued) Chapter Page 4.8.11 Review in Box for CBC Details .......................................... 4-36 4.8.12 Review in Box – Blood Pressure Details ............................ 4-37 4.9 Observation Referrals ......................................................................... 4-39 4.9.1 Referral Letter ..................................................................... 4-41 4.9.2 Local Physician Pickup ....................................................... 4-42 4.9.3 Referral Address Information ............................................. 4-43 4.9.4 Referral Letter Review ........................................................ 4-44 4.9.5 Referral Letter ..................................................................... 4-45 5 SAFETY ISSUES AND EMERGENCY PROCEDURES .............................. 5-1 5.1 Safety in the Mobile Examination Center (MEC) .............................. 5-1 5.1.1 Elderly Sample Persons ....................................................... 5-1 5.1.2 Sample Persons in Wheelchairs