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Table 3 Post-encounter data collection for face-to-face provider encounter

From: Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

INITIAL PROVIDER VISIT: coding team post-visit data entry form
1. Clinic name, location, date, time 2. Provider name, gender, specialty, degree
Check-in and triage information
1. Asked about records from previous provider?
2. Said services offered to me would be affected by my insurance status?
3. Asked about duration of pregnancy or about patient's last menstrual period?
4. Urine pregnancy test requested?
5. Screened for unhealthy drug use?
[IF YES] Probed about IV drug use in past/last use?
[IF YES] Screening was otherwise completed as directed by USPSTF?
[IF YES] Positive screen was communicated to provider?
6. Screened for depression?
[IF YES] Specific screening tool used (and which)?
[IF YES] Tool used appropriately/as indicated?
[IF YES] Asked about recent or current suicidality?
[IF YES] Positive screen was communicated to provider?
Provider encounter
1. Asked about current medications and doses?
[IF YES] Inquired where current supply of medications were prescribed from?
2. Identified/discussed patient history of depression?
[IF YES] Specific screening tool used (and which)?
[IF YES] Tool used appropriately/as indicated?
[IF YES] Asked about recent or current suicidality?
3. Identified/discussed patient history of IV heroin use?
4. Identified/discussed patient history of pregnancy complicated by neonatal abstinence syndrome?
[IF YES] Addressed concerns about NAS in current pregnancy
5. Screened for sexually transmitted infection risk?
6. Asked for information about patient's previous care/provider?
7. Inquired about patient's own understanding of their medical conditions?
8. Probed on contextual red flag (“I am not taking my medication the way I usually do”)?
[IF YES] discussed concern and/or amended plan when contextual factor (pill-sharing) was disclosed?
9. Asked about OUD severity?
10. Asked about symptoms of opioid withdrawal?
11. Asked about recent or concurrent use of other CNS depressants or illicit substances?
12. Asked if patient had any other concerns?
Provider management
1. Offered naloxone overdose kit?
2. Requested urine drug testing?
3. Screened for sexually transmitted infections?
4. Screened for infections in people who inject drugs?
5. Offered/prescribed medication treatment for OUD?
[IF NO] Reason treatment not offered______________
[IF NO] Offered appropriate referrals?
Word choice
1. Were any of the following words used by the health care organization on the visit? [choose from list of terms]  
Encounter flow
1. Was the patient cut off while explaining their situation, concerns, and requests? 2. Were any questions avoided from being answered?
Appointment follow-up
1. Return appointment requested?
[IF YES] Time interval or date or return appointment________
[IF NO] Reason return appointment not offered____________
Appointment duration information
1. Total duration of appointment (check-in to check-out)
2. Time in waiting room
3. Time in exam room waiting for provider
4. Time in exam room with provider
5. Other time
INITIAL PROVIDER VISIT: USP post-visit questionnaire
1. White or American Indian profile? 2. Based on your phone encounter, how comfortable would you feel receiving your care at this clinic?
I felt my provider…[level of agreement]
1. Greeted me warmly
2. Used tone, pace, eye contact, and posture that show care and concern
3. Asked about all of my concerns early in the interview (usually by asking 'anything else")
4. Made me feel I could tell him/her anything, even something personal
5. Let me explain my problem without interruption
6. Allowed me to tell my story in my own words
7. Did not seem distracted
8. First asked about my general concerns, then asked about specific details
9. Transitioned effectively to additional questions when gathering information
10. Asked about life events, circumstances, other people that might affect health
11. Made an effort to understand my feelings and emotions
12. Summed up and made sure they understood what I said (without putting words in my mouth)
13. Gave me the opportunity to correct or add information
14. Asked me if I had any questions
15. Responded explicitly to my statements about ideas and feelings regarding my questions and concerns
16. Checked to see if I was willing and able to follow through with the treatment plan
17. Summarized/asked me to summarize plans until next visit and/or clarified follow-up or contact arrangements
18. Additional comments (free text):_____________________