National Health and Nutrition Examination Survey PHYSICIAN EXAMINATION PROCEDURES MANUAL Original January 1999 (Revised August 2000) TABLE OF CONTENTS Chapter Page 1 OVERVIEW OF THE NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY ............................................................................ 1-1 1.1 History of the National Health and Nutrition Examination Programs ............................................................................................. 1-1 1.2 Overview of the Current NHANES .................................................... 1-3 1.2.1 NHANES Pilot and Dress Rehearsal .................................. 1-4 1.2.2 Data Collection for NHANES Main Survey ....................... 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 1.6 Confidentiality and Professional Ethics.............................................. 1-20 2 OVERVIEW OF THE 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 The Physician’s Examination ............................................................. 2-3 2.3.1 Measurement of Blood Pressure and Pulse ......................... 2-3 2.3.2 Review for Exclusion and Inclusion of Cardiovascular Fitness Treadmill Testing.................................................... 2-3 2.3.3 Counseling for STD and HIV ............................................. 2-4 2.3.4 Referrals .............................................................................. 2-4 2.4 Maintenance of Physician’s Examination Room ................................ 2-4 3 EQUIPMENT AND SUPPLIES...................................................................... 3-1 3.1 Description of Equipment ................................................................... 3-1 3.2 Sphygmomanometer ........................................................................... 3-1 3.2.1 The Baumanometer® Calibrated Manometer ..................... 3-1 3.2.2 Calibrated® V-Lok® Cuff .................................................. 3-2 3.2.3 Littman™ Classic II S.E. Stethoscope ................................ 3-3 iii TABLE OF CONTENTS (continued) Chapter Page 3.3 Maintenance of Equipment ................................................................. 3-3 3.3.1 Mercury Sphygmomanometer............................................. 3-3 3.3.2 Littman Stethoscope............................................................ 3-4 3.3.3 Blood Pressure Cuffs........................................................... 3-5 3.4 Mercury Spills or Leaks...................................................................... 3-5 3.4.1 Required Procedure for Handling Spilled or Leaking Mercury ............................................................................... 3-5 4 PHYSICIAN PROTOCOL .............................................................................. 4-1 4.1 General Overview ............................................................................... 4-1 4.2 Blood Pressure, Heart Rate, and Pulse Measurements ....................... 4-1 4.2.1 SPs Included for Blood Pressure, Heart Rate, and Pulse Measurements............................................................ 4-2 4.2.2 SPs Excluded from Blood Pressure, Heart Rate, and Pulse Measurements............................................................ 4-2 4.2.3 Procedures for Measuring Blood Pressures, Heart Rates, and Pulses ................................................................. 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 Disease and Human Immunodeficiency Virus Information (STD and HIV) ..................................................... 4-14 4.4.1 Guidelines Affecting STD and HIV Test Result Reporting............................................................................. 4-15 4.4.2 Informing SPs of STD and HIV Results ............................. 4-16 4.5 Data Entry Screens.............................................................................. 4-17 4.5.1 Reviewing SP Medications from Household Interview ...... 4-18 4.5.2 Reviewing SP History ......................................................... 4-22 4.5.3 Child Heart Rate, Pulse ....................................................... 4-24 4.5.4 Blood Pressure Data Entry .................................................. 4-27 iv TABLE OF CONTENTS (continued) Chapter Page 4.5.5 Exclusion from CV Fitness Based on Pulse and Irregular Beats..................................................................... 4-29 4.5.6 Blood Pressure Measurement Screens ................................ 4-35 4.5.7 Blood Pressure Edit Limits ................................................. 4-42 4.5.8 Blood Pressure Component Status and Comments ............. 4-43 4.5.9 Exclusion from CV Fitness Based on Systolic Blood Pressure ............................................................................... 4-45 4.5.10 Exclusion from CV Fitness Based on Diastolic Blood Pressure ............................................................................... 4-46 4.5.11 Shared Exclusion Questions................................................ 4-48 4.5.12 CV Safety Exclusion Questions .......................................... 4-57 4.5.13 CV Exclusion Status ........................................................... 4-79 4.5.14 STD and HIV Discussion of Tests and Obtaining Results ................................................................................. 4-82 4.5.15 Physician Look-up Table .................................................... 4-90 4.5.16 Pausing an Examination ...................................................... 4-92 4.5.18 Room Log ........................................................................... 4-93 4.5.19 Session Preview .................................................................. 4-94 4.5.20 SP Examinations ................................................................. 4-95 4.5.21 End of Section ..................................................................... 4-97 4.5.22 Close Examination Button .................................................. 4-98 5 REFERRALS................................................................................................... 5-1 5.1 Medical Referrals................................................................................ 5-1 5.2 Referral Levels.................................................................................... 5-1 5.2.1 Level 1 Referrals ................................................................. 5-2 5.2.2 Level 2 Referrals ................................................................. 5-2 5.2.3 Level 3 Referrals ................................................................. 5-2 5.3 Basis for Referral ................................................................................ 5-2 5.3.1 Examination Data Related Referrals ................................... 5-3 5.3.2 Blood Pressure Referrals – Adults ...................................... 5-5 5.3.3 Blood Pressure Referrals – Children ................................... 5-7 5.3.4 Lower Extremity Disease (LED) Referrals ......................... 5-8 5.3.5 Laboratory Values ............................................................... 5-11 5.3.6 Tuberculosis Skin Test Referrals ........................................ 5-14 5.4 Observation Referrals ......................................................................... 5-15 5.5 Sessions Requiring Review ................................................................ 5-15 v TABLE OF CONTENTS (continued) Chapter Page 5.6 Data Entry Screens for Referrals ........................................................ 5-16 5.6.1 Review Menu ...................................................................... 5-17 5.6.2 Review in Box..................................................................... 5-17 5.6.3 Review Other Sessions........................................................ 5-18 5.6.4 Sessions Requiring Review................................................. 5-19 5.6.5 Reviewing all Sessions in Stand ......................................... 5-19 5.6.6 Viewing Home All Day Sessions........................................ 5-20 5.6.7 Sorting Sessions .................................................................. 5-23 5.6.8 Referral Review Screen....................................................... 5-23 5.6.9 ISIS Message....................................................................... 5-25 5.6.10 NHANES Release Form for SPs Refusing Referrals .......... 5-26 5.6.11 Selecting SP for Detailed Referral Review ......................... 5-27 5.6.12 Review in Box for Pregnancy Details ................................. 5-28 5.6.13 Review in Box for CBC Details