Data Dictionary

PATIENT

File Number: 2

File Description:

The PATIENT file contains all the patients followed by the medical center/ Outpatient clinic. At a minimum each patient entry must have a NAME, DATE OF BIRTH and SOCIAL SECURITY NUMBER. In order to add a new patient to the PATIENT file the user must also indicate whether or not the patient is requesting to receive care as a VETERAN of the U.S. Armed Forces and specify the TYPE of patient being added to the system. For the most part the information contained in this file is demographic in nature, i.e., address, employment, service history, etc., however data concerning admissions, appointments,etc., is also stored in this file. The ADMISSION sub-field is scheduled to be moved into the new PATIENT MOVEMENT file by the end of calendar year 1989. Care should be used when removing a patient from the PATIENT file since virtually all other DHCP modules do utilize data from this file. Of the many fields in the file you will note that many are preceeded by an asterisk. Those fields are scheduled to be removed from the file due to either lack of use or replacement by another field/file in the next release.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 Enter the applicant's name in 'Last,First Middle' format between 3-50 characters. Do not use numerics or lowercase alphabetic characters. With the exception of the comma, period, space, hyphen, dash and apostrophe punctuation characters should be avoided.

Free Text
SEX .02 Enter 'M' if this applicant is a male, or 'F' if female.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MALE
  • Code : F
    Stands For: FEMALE
  • Code : U
    Stands For: UNKNOWN
DATE OF BIRTH .03 Enter the patient's DATE OF BIRTH which must be later than 12/31/1870. DATE OF BIRTH cannot be a date after the beneficiary 'Ineligible Date' or a date after the 'Enrollment Application Date'.

Date/Time
AGE .033 A computer field which, based on today's date (or the patient's date of death, if applicable) and the patient's date of birth, will arrive at his/her age.

Computed
MARITAL STATUS .05 Select from the available listing this applicant's current marital status.

Pointer
PointerTo:
fileName:
MARITAL STATUS
fileNumber:
11
RACE .06 This field is no longer being populated and the values that are on file were collected prior to installation of patch DG*5.3*415.

Pointer
PointerTo:
fileName:
RACE
fileNumber:
10
OCCUPATION .07 If applicable, enter this applicant's current occupation [1-30 characters].

Free Text
RELIGIOUS PREFERENCE .08 Select from the available listing the religious preference of this applicant.

Pointer
PointerTo:
fileName:
RELIGION
fileNumber:
13
DUPLICATE STATUS .081 This field is currently not being utilized. It will be active when Patient Merge/Purge options are available to the user. Duplicate Status field will be defined at that time. |

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO UNRESOLVED DUPLICATES
  • Code : 1
    Stands For: CHECK DUPLICATE RECORDS FILE
PATIENT MERGED TO .082 This field is currently not being utilized. It will be active when Patient Merge/Purge options are available to the user. Patient Merged To: field will be defined at that time. |

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
CHECK FOR DUPLICATE .083 This field is currently not being utilized. It will be active when Patient Merge/Purge options are available to the user. Check for Duplicate field will be defined at that time. |

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
SOCIAL SECURITY NUMBER .09 Answer with the individual's social security number. Answer must be 9 numbers in length. The SSN will be sent to the SSA for verification. This will be displayed next to the SSN. Once an SSN has received a status of Verified, it is locked from user updating and a "VERIFIED" will be displayed by the SSN field. Only the Identity Management Data QUality Team are able to change a beneficiary's (veteran/non veteran) SSN. If an Invalid per SSA status is received for the SSN, then an "INVALID" will appear next to the invalid SSN of the individual. Facilities should make every effort to obtain the accurate SSN from the individual for any invalid or pseudo SSN entry. If a valid SSN is not known, then a "P" will be entered at the SSN prompt for the system to automatically assign a Pseudo-SSN. If a Pseudo SSN is entered, a Reason for entering it will be required.

Free Text
TERMINAL DIGIT OF SSN .0901 This is a computed field which returns the terminal digit value of the patient's social security number. This value is computed to be the last 2 digits of the social security number concatenated with the sixth and seventh digits of the social security number concatenated with the forth and fifth pieces of the social security number concatenated with the first 3 digits of the social security number.

Computed
1U4N .0905 This is a computed field used to display the first character of the patient's last name concatenated with the last four digits of the patient's social security number. This combination of characters can be used to look-up a patient in DHCP.

Computed
PSEUDO SSN REASON .0906 This field is used to document the reason the individual was assigned a pseudo SSN. Based on your selection, the Pseudo SSN Report (Patient) option located in the Registration Menu can provide you a current report of the reasons entered at this prompt. The following reasons are available for selection: Refused to Provide - use this reason when the individual was asked for his/her SSN and refused to provide the number. SSN Unknown/Follow-up required - use this reason when the individual is not available to ask/answer the request for SSN. The facility should initiate Follow-up activity to obtain the SSN. No SSN Assigned - use this reason when the individual has not been assigned an SSN. This generally applies to spouse or dependents of veterans who are not US citizens and infrequently, non-citizen beneficiaries.

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REFUSED TO PROVIDE
  • Code : S
    Stands For: SSN UNKNOWN/FOLLOW-UP REQUIRED
  • Code : N
    Stands For: NO SSN ASSIGNED
SSN VERIFICATION STATUS .0907 This field designates whether or not the SSN has been verified. This field will be received in the HL7 record. It is not editable by the user. Once the SSN is verified by the SSA, it is no longer editable.

Set of Codes
Set of Codes:
  • Code : 4
    Stands For: VERIFIED
  • Code : 2
    Stands For: INVALID
REMARKS .091 If so desired, you may enter a short remark about this applicant between 3-60 characters. The remark entered should be significant and tact should be exercised since this field is viewable to virtually all other users who have the ability to 'call up' a patient for any purpose.

Free Text
PLACE OF BIRTH [CITY] .092 Enter the city in which this applicant was born (or foreign country if born outside the U.S.) [2-20 characters].

Free Text
PLACE OF BIRTH [STATE] .093 If the applicant was born within the U.S. select from the available listing the state in which s/he was born.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
WHO ENTERED PATIENT .096 The name of the user who first entered this applicant into the patient file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE ENTERED INTO FILE .097 This field stores the date this patient was initially stored into the PATIENT file. This is filled in automatically once a patient is successfully added to the database.

Date/Time
HOW WAS PATIENT ENTERED? .098 How was the patient entered into the system.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: 10-10T REGISTRATION
  • Code : 99
    Stands For: MANUAL DOWNTIME
WARD LOCATION .1 The ward location on which this patient is currently residing if an inpatient [2-30 characters].

Free Text
ROOM-BED .101 If desired, for this inpatient, enter the room and bed indicator to which s/he is assigned in 'ROOM-BED' format.

Free Text
CURRENT MOVEMENT .102 This field contains the internal entry number of the PATIENT MOVEMENT file denoting the most recent movement for an inpatient. This field is only stored for current inpatients. It must NOT be edited as this could affect the integrity of many options within MAS and other packages. When displaying this field, the date/time of the most recent movement will display.

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
TREATING SPECIALTY .103 From the available listing choose the treating specialty to which this inpatient is currently assigned.

Pointer
PointerTo:
fileName:
FACILITY TREATING SPECIALTY
fileNumber:
45.7
PROVIDER .104 From the available listing select the provider who is currently treating this patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ATTENDING PHYSICIAN .1041 This field contains the attending physician currently responsible for the care of this patient. This field is maintained automatically for all inpatients and must not be edited. Once a patient is discharged, the data in this field is removed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CURRENT ADMISSION .105 This field contains the internal entry number of the PATIENT MOVEMENT file denoting the current admission for an inpatient. This field is only stored for current inpatients. It must NOT be edited as this could affect the integrity of many options within MAS and other DHCP packages. When displaying this field, the date/time of the current admission will be displayed.

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
LAST DMMS EPISODE NUMBER .106 This field was added at the request of the DMMS package developed at the Birmingham ISC. It will be utilized in a future release of that package.

Numeric
LODGER WARD LOCATION .107 The ward on which the patient currently resides if the patient is a lodger.

Free Text
CURRENT ROOM .108 This field contains a pointer to the ROOM-BED file denoting the current room-bed in which this inpatient resides. This field is filled in only for inpatients. It must NOT be edited as editing could adversely affect the operation of the MAS package as well as other DHCP packages. This field is filled in automatically by the module.

Pointer
PointerTo:
fileName:
ROOM-BED
fileNumber:
405.4
EXCLUDE FROM FACILITY DIR .109 Denotes whether or not the patient wished to be excluded from the Facility Directory for current admission. This field is only stored for current inpatients. It must NOT be edited as this could affect the integrity of many options within PIMS and other packages.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
STREET ADDRESS [LINE 1] .111 Enter the first line of this applicant's residence street address [3-35 characters].

Free Text
ZIP+4 .1112 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789).

Free Text
STREET ADDRESS [LINE 2] .112 Enter the second line of this applicant's residence street address [3-30 characters] if the space provided in 'street address' was not sufficient.

Free Text
STREET ADDRESS [LINE 3] .113 Enter the third line of this applicant's residence street address [3-30 characters] if the space provided in 'street address' and 'street address 2' was not sufficient.

Free Text
CITY .114 Enter the city in which this applicant resides [2-15 characters]. If the space provided is not sufficient please abbreviate the city to the best of your ability.

Free Text
STATE .115 From the available listing choose the state in which this applicant resides.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP CODE .116 Enter the zip code [5 numerics] for the city in which this applicant resides.

Free Text
COUNTY .117 If a state of residence is entered select from the available listing the county in which this applicant resides. If no state (or a non-state) is entered no selection is possible.

Numeric
PROVINCE .1171 Enter a Province if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 20 characters in length.

Free Text
POSTAL CODE .1172 Enter with patient's postal code if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 10 characters in length.

Free Text
COUNTRY .1173 Enter the country where the patient's permanent address is located. If entering an Army/Air Force Post Office (APO) or a Fleet Post Office (FPO) address select United States as the country.

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
ADDRESS CHANGE DT/TM .118 This field will hold the date and time of the last Address Update.

Date/Time
ADDRESS CHANGE SOURCE .119 This field will hold the source of the Last address change.

Set of Codes
Set of Codes:
  • Code : HEC
    Stands For: HEC
  • Code : VAMC
    Stands For: VAMC
  • Code : HBSC
    Stands For: HBSC
  • Code : NCOA
    Stands For: NCOA
  • Code : BVA
    Stands For: BVA
  • Code : VAINS
    Stands For: VAINS
  • Code : USPS
    Stands For: USPS
  • Code : LACS
    Stands For: LACS
  • Code : VOA
    Stands For: VOA
ADDRESS CHANGE SITE .12 This field will hold the Site that last changed this patient's address. This field is only populated when the Address Source is listed as VAMC.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
BAD ADDRESS INDICATOR .121 The Bad Address Indicator field applies to the address at which the patient resides. This field should be set as follows (if applicable): "UNDELIVERABLE" - Bad Address based on returned mail. "HOMELESS" - Patient is known to be homeless. "OTHER" - Other Bad Address Reason Setting this field will prevent a Bad Address from being shared with HEC and other VAMC facilities. It will also be used to block Means Test Renewal Letters from being sent. Once the Bad Address Indicator is set, incoming "newer" addresses will automatically remove the Bad Address Indicator, and allow the "updated" address to be transmitted to HEC and other VAMC facilities.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: UNDELIVERABLE
  • Code : 2
    Stands For: HOMELESS
  • Code : 3
    Stands For: OTHER
  • Code : 4
    Stands For: ADDRESS NOT FOUND
TEMPORARY ADDRESS ACTIVE? .12105 Enter 'Y' if you wish to enter a temporary address for this applicant at this time, or 'N' if not. A 'NO' response will cause the temporary address 'Start Date' and 'End Date' fields to be automatically deleted while all other temporary address data will remain on file for future use.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TEMPORARY STREET [LINE 1] .1211 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the first line of the temporary street address for this applicant [2-30 characters] otherwise nothing may be entered. This field cannot be deleted as long as the need for a temporary address is indicated.

Free Text
TEMPORARY ADDRESS COUNTY .12111 If a state is entered for the temporary residence, enter the county in which that residence resides. If a state does not exist for the temporary address, a county can not be entered.

Numeric
TEMPORARY ZIP+4 .12112 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789).

Free Text
TEMPORARY ADDRESS CHANGE DT/TM .12113 This field will hold the date and time of the last Temporary Address Update.

Date/Time
TEMPORARY ADDRESS CHANGE SITE .12114 This field will hold the Site that last changed this patient's temporary address.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
TEMPORARY STREET [LINE 2] .1212 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the second line of the temporary street address [2-30 characters], if necessary, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Free Text
TEMPORARY STREET [LINE 3] .1213 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the third line of the temporary street address [2-30 characters], if necessary, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Free Text
TEMPORARY CITY .1214 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the city in which the temporary address lies [2-30 characters], otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Free Text
TEMPORARY STATE .1215 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES select from the available listing the state in which the temporary address lies, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
TEMPORARY ZIP CODE .1216 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the zip code assigned to the temporary city [5 numerics], otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Free Text
TEMPORARY ADDRESS START DATE .1217 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the date on which the applicant will commence being contacted at the temporary address indicated, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Date/Time
TEMPORARY ADDRESS END DATE .1218 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the date as of which the applicant will no longer be contacted at that temporary address, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Date/Time
TEMPORARY PHONE NUMBER .1219 If the WANT TO ENTER A TEMPORARY ADDRESS prompt is answered YES enter the telephone number at which the applicant can be contacted [4-20 characters] during his/her absence from permanent residence, otherwise nothing may be entered. This field may not be deleted as long as the need for a temporary address is indicated.

Free Text
ADDRESS CHANGE USER .122 The name of the user who has changed this patient's primary address.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TEMPORARY ADDRESS PROVINCE .1221 Enter a Province if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 20 characters in length.

Free Text
TEMPORARY ADDRESS POSTAL CODE .1222 Enter with patient's postal code if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 10 characters in length.

Free Text
TEMPORARY ADDRESS COUNTRY .1223 Enter the country where the patient's temporary address is located. If entering an Army/Air Force Post Office (APO) or a Fleet Post Office (FPO) address select United States as the country.

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
PHONE NUMBER [RESIDENCE] .131 Enter the telephone number [4-20 characters] to this applicant's place of residence.

Free Text
CELLULAR NUMBER CHANGE SOURCE .1311 This field will hold the source of the last Cellular number change.

Set of Codes
Set of Codes:
  • Code : HEC
    Stands For: HEC
  • Code : VAMC
    Stands For: VAMC
  • Code : HBSC
    Stands For: HBSC
  • Code : VOA
    Stands For: VOA
CELLULAR NUMBER CHANGE SITE .13111 This field will hold the site that last changed this patient's Cellular number. This field is only populated when the Cellular Number Change Source is listed as VAMC.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
PAGER NUMBER CHANGE DT/TM .1312 This field will contain the date and time of the last Pager number update.

Date/Time
PAGER NUMBER CHANGE SOURCE .1313 This field will hold the source of the last Pager number change.

Set of Codes
Set of Codes:
  • Code : HEC
    Stands For: HEC
  • Code : VAMC
    Stands For: VAMC
  • Code : HBSC
    Stands For: HBSC
  • Code : VOA
    Stands For: VOA
PAGER NUMBER CHANGE SITE .1314 This field will hold the site that last changed this patient's Pager number. This field is only populated when the Pager Number Change Source is listed as VAMC.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CONFIDENTIAL PHONE NUMBER .1315 If the 'Confidential Address Active' prompt is answered YES, enter the telephone number of the confidential address at which the patient is located [4-20 characters].

Free Text
PHONE NUMBER [WORK] .132 Enter the office phone number [4-20 characters] where this applicant can be reached while employed, if employed.

Free Text
RESIDENCE NUMBER CHANGE DT/TM .1321 This field will contain the date and time of the last Residence phone number update.

Date/Time
RESIDENCE NUMBER CHANGE SOURCE .1322 This field will hold the source of the last Residence phone number change.

Set of Codes
Set of Codes:
  • Code : HEC
    Stands For: HEC
  • Code : VAMC
    Stands For: VAMC
  • Code : HBSC
    Stands For: HBSC
  • Code : VOA
    Stands For: VOA
RESIDENCE NUMBER CHANGE SITE .1323 This field will hold the site that last changed this patient's Residence phone number. This field is only populated when the Residence Number Change Source is listed as VAMC.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
EMAIL ADDRESS .133

Free Text
PHONE NUMBER [CELLULAR] .134 Enter the telephone number [4-20 characters] to the applicant's mobile phone.

Free Text
PAGER NUMBER .135 Enter the applicant's pager number [4-20 characters].

Free Text
EMAIL ADDRESS CHANGE DT/TM .136 This field will contain the date and time of the last EMAIL address update.

Date/Time
EMAIL ADDRESS CHANGE SOURCE .137 This field will hold the source of the last EMAIL address change.

Set of Codes
Set of Codes:
  • Code : HEC
    Stands For: HEC
  • Code : VAMC
    Stands For: VAMC
  • Code : HBSC
    Stands For: HBSC
  • Code : VOA
    Stands For: VOA
EMAIL ADDRESS CHANGE SITE .138 This field will hold the site that last changed this patient's EMAIL address. This field is only populated when the EMAIL Address Source is listed as VAMC.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CELLULAR NUMBER CHANGE DT/TM .139 This field will contain the date and time of the last Cellular number update.

Date/Time
CURRENT MEANS TEST STATUS .14 This field is computed by the system. It contains the current means test status for a patient.

Pointer
PointerTo:
fileName:
MEANS TEST STATUS
fileNumber:
408.32
CONFIDENTIAL ADDRESS CATEGORY .141 This is a multiple valued field containing the confidential address categories for this applicant.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CONFIDENTIAL ADDRESS CATEGORY .01 If the 'Confidential Address Active' prompt is answered YES, select the confidential address category for this applicant's confidential communications.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ELIGIBILITY/ENROLLMENT
  • Code : 2
    Stands For: APPOINTMENT/SCHEDULING
  • Code : 3
    Stands For: COPAYMENTS/VETERAN BILLING
  • Code : 4
    Stands For: MEDICAL RECORDS
  • Code : 5
    Stands For: ALL OTHERS
CONFIDENTIAL CATEGORY ACTIVE 1 If the applicant's confidential communications for this category should be sent to the confidential address, Confidential Category Active field should be set to yes. If not, select N or No.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CONFIDENTIAL ADDRESS ACTIVE? .14105 Enter 'Y' if you wish to enter a confidential address for this applicant at this time. A 'NO' response will cause the Confidential Start Date and Confidential End Date fields to be automatically deleted while other confidential address information will remain on file for future use.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CONFIDENTIAL STREET [LINE 1] .1411 If the 'Confidential Address Active' prompt is answered YES, the user will be prompted for the first line of the confidential street address. This field cannot be deleted as long as the need for a confidential address is indicated.

Free Text
CONFIDENTIAL ADDRESS COUNTY .14111 If the 'Confidential Address Active' prompt is answered YES, enter the county for the applicant's confidential address.

Numeric
CONFIDENTIAL ADDR CHANGE DT/TM .14112 This field will hold the date and time of the last Confidential Address Update. Any change to the following Confidential Address fields will trigger an update: Confidential Street [Line 1], Confidential Street [Line 2], Confidential Street [Line 3], Confidential Address City, Confidential Address State, Confidential Address Zip Code, Confidential Start Date, Confidential End Date, Confidential Address Active?, Confidential Address County, Confidential Addr Province, Confidential Addr Postal Code, Confidential Addr Country and Confidential Phone Number

Date/Time
CONFIDENTIAL ADDR CHANGE SITE .14113 This field will hold the Site that last changed this patient's confidential address.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CONFIDENTIAL ADDR PROVINCE .14114 Enter a Province if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 20 characters in length.

Free Text
CONFIDENTIAL ADDR POSTAL CODE .14115 Enter with patient's postal code if the patient has provided one for his/her foreign address. The entry can be alphanumeric and up to 10 characters in length.

Free Text
CONFIDENTIAL ADDR COUNTRY .14116 Enter the country where the patient's confidential address is located. If entering an Army/Air Force Post Office (APO) or a Fleet Post Office (FPO) address select United States as the country.

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
CONFIDENTIAL STREET [LINE 2] .1412 If the 'Confidential Address Active' prompt is answered YES, the user will be prompted for the second line of the confidential street address [2-30 characters]. The second line of the street address is optional and may be left blank.

Free Text
CONFIDENTIAL STREET [LINE 3] .1413 If the 'Confidential Address Active' prompt is answered YES, the user will be prompted for the third line of the confidential street address. The third line of the street address is optional and may be left blank.

Free Text
CONFIDENTIAL ADDRESS CITY .1414 If the 'Confidential Address Active' prompt is answered YES, enter the confidential address city for this applicant [2-30 characters]. This field may not be deleted as long as the need for a confidential address is indicated.

Free Text
CONFIDENTIAL ADDRESS STATE .1415 If the 'Confidential Address Active' prompt is answered YES, the user will be asked to select the confidential address state from the available listing. This field may not be deleted as long as the need for a confidential address is indicated.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
CONFIDENTIAL ADDRESS ZIP CODE .1416 If the 'Confidential Address Active' prompt is answered YES, the user will be asked to enter the zip code assigned to the city for the confidential address. This field may not be deleted as long as the need for a confidential address is indicated.

Free Text
CONFIDENTIAL START DATE .1417 If the 'Confidential Address Active' prompt is answered YES, enter the date to begin contacting the applicant at the confidential address.

Date/Time
CONFIDENTIAL END DATE .1418 If the 'Confidential Address Active' prompt is answered YES, enter the date the applicant will no longer be contacted at this address.

Date/Time
INELIGIBLE DATE .152 If this applicant is ineligible for treatment enter the effective date. Only users who hold the designated security key may enter/edit this field. The Ineligible Date cannot be prior to the beneficiary Date of Birth.

Date/Time
MISSING PERSON DATE .153 This field contains the date this patient was initially listed as missing.

Date/Time
MISSING OR INELIGIBLE .16 This is a word processing field to contain information on the patient's ineligibility or information about this missing patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MISSING OR INELIGIBLE .01 This is a word processing field to contain information on the patient's ineligibility or information about this missing patient.

Word Processing
INELIGIBLE TWX SOURCE .1651 Choose from the available listing the source of the TWX which informed you that this applicant was ineligible for treatment. An ineligible date must be specified in order to enter/edit this field and the user must hold the designated security key. This field may not be deleted as long as an ineligible date is on file.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: VAMC
  • Code : 2
    Stands For: REGIONAL OFFICE
  • Code : 3
    Stands For: RPC
INELIGIBLE TWX CITY .1653 Enter the city from which the TWX which informed you this applicant was ineligible for treatment originated [3-30 characters]. An ineligible date must be specified in order to enter/edit this field and the user must hold the designated security key. This field may not be deleted as long as an ineligible date is on file.

Free Text
INELIGIBLE TWX STATE .1654 Enter the state from which the TWX which informed you this applicant was ineligible for treatment originated. An ineligible date must be specified in order to enter/edit this field and the user must hold the designated security key. This field may not be deleted as long as an ineligible date is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
INELIGIBLE VARO DECISION .1656 Enter the VARO decision concerning this applicant's ineligibility [between 3-75 characters]. An ineligible date must be specified in order to enter/edit this field and the user must hold the designated security key. This field may not be deleted as long as an ineligible date is on file.

Free Text
MISSING PERSON TWX SOURCE .1657 If this patient is missing, enter the source of the TWX that originally listed the patient as missing.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: VAMC
  • Code : 2
    Stands For: REGIONAL OFFICE
  • Code : 3
    Stands For: RPC
MISSING PERSON TWX CITY .1658 If this patient is missing, enter the city where the TWX reporting the patient as missing was originated.

Free Text
MISSING PERSON TWX STATE .1659 If this patient is missing, enter the state where the TWX reporting the patient as missing was originated.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
FEE HOSPITAL I.D. .172 This field is not used by any DHCP packages and has been *'d for deletion with the release of MAS v5.2. It will be removed in a future release of MAS.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: ISSUED
  • Code : C
    Stands For: CANCELLED
EMERGENCY RESPONSE INDICATOR .181 Enter the appropriate ER Indicator to identify patients from impacted zip code areas designated by FEMA.

Set of Codes
Set of Codes:
  • Code : K
    Stands For: HURRICANE KATRINA
DIVISION .19 Division of inpatient location

Computed
K-WORK PHONE NUMBER .21011 If the person designated as next of kin for this patient is employed, enter the phone number at which the NOK can be reached while at work.

Free Text
PRIMARY NOK CHANGE DATE/TIME .21012 This field will hold the date and time of the last Primary Next of Kin Update.

Date/Time
K-NAME OF PRIMARY NOK .211 Enter the primary next of kin's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
K2-WORK PHONE NUMBER .211011 If the person designated as secondary next of kin for this patient is employed, enter the phone number that individual can be reached at while at work.

Free Text
SECONDARY NOK CHANGE DATE/TIME .211012 This field will hold the date and time of the last Secondary Next of Kin Update. Any change to the following Secondary Next of Kin fields will trigger an update: K2-Name Of Secondary NOK, K2-Relationship To Patient, K2-Street Address [Line 1], K2-Street Address [Line 2], K2-Street Address [Line 3], K2-City, K2-State, K2-Zip Code, K2-Phone Number, K2-Address Same As Patient's? and K2-Work Phone Number

Date/Time
K-RELATIONSHIP TO PATIENT .212 If a primary next-of-kin is specified enter the relationship of that person to the applicant [1-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-ADDRESS SAME AS PATIENT'S? .2125 Enter 'Y' if the next-of-kin should be contacted at the same address and phone number as the applicant, otherwise enter 'N'.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
K-STREET ADDRESS [LINE 1] .213 If a primary next-of-kin is specified enter the first line of that person's street address [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-STREET ADDRESS [LINE 2] .214 If a primary next-of-kin is specified enter the second line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-STREET ADDRESS [LINE 3] .215 If a primary next-of-kin is specified enter the third line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-CITY .216 If a primary next-of-kin is specified enter the city in which that person resides [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-STATE .217 If a primary next-of-kin is specified select from the available listing the state in which that person resides, otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
K-ZIP CODE .218 If a primary next-of-kin is specified enter the zip code [5 numerics] in which his/her city lies, otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K-PHONE NUMBER .219 If a primary next-of-kin is specified enter that person's telephone number [4-20 characters], otherwise nothing may be entered. This field cannot be deleted as long as a 'next of kin' name is on file.

Free Text
K2-NAME OF SECONDARY NOK .2191 Enter the secondary next of kin's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
K2-RELATIONSHIP TO PATIENT .2192 If a secondary next-of-kin is specified enter the relationship of that person to the applicant [1-30 characters]. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-ADDRESS SAME AS PATIENT'S? .21925 Enter 'Y' if the secondary NOK should be contacted at the same address and phone number as the applicant, otherwise enter 'N'.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
K2-STREET ADDRESS [LINE 1] .2193 If a secondary NOK is specified enter the first line of that person's street address [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-STREET ADDRESS [LINE 2] .2194 If a secondary NOK is specified enter the second line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-STREET ADDRESS [LINE 3] .2195 If a secondary NOK is specified enter the third line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-CITY .2196 If a secondary NOK is specified enter the city in which that person resides [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-STATE .2197 If a secondary NOK is specified select from the available listing the state in which that person resides, otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
K2-ZIP CODE .2198 If a secondary NOK is specified enter the zip code for the city in which that person resides [5 numerics], otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
K2-PHONE NUMBER .2199 If a secondary NOK is specified enter the telephone number at which that person may be reached [3-20 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary NOK is on file.

Free Text
E-ZIP+4 .2201 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the Emergency Contact Address.

Free Text
D-ZIP+4 .2202 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the designee for personal effects' address.

Free Text
K2-ZIP+4 .2203 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the secondary next-of-kin's address.

Free Text
E2-ZIP+4 .2204 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the secondary emergency contact's address.

Free Text
EMPLOYER ZIP+4 .2205 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the patient employer's address.

Free Text
SPOUSE'S EMP ZIP+4 .2206 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the spouse's employer's address.

Free Text
K-ZIP+4 .2207 Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789). This is related to the primary emergency contact's address.

Free Text
FATHER'S NAME .2401 Enter the father's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
MOTHER'S NAME .2402 Enter the mother's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
MOTHER'S MAIDEN NAME .2403 Enter the mother's maiden name in 'LAST,FIRST MIDDLE SUFFIX' format. Entry of the LAST name only is permitted and the comma may be omitted. If the response contains no comma, one will be appended to the value. Including the comma, the value must be at least 3 characters in length.

Free Text
SPOUSE'S EMPLOYER NAME .251 For this married applicant (marital status must be married) enter the name of his/her spouse's employer [3-20 characters].

Free Text
SPOUSE'S OCCUPATION .2514 If this patient's spouse is currently employed, enter the spouse's occupation here. Otherwise, leave this field blank.

Free Text
SPOUSE'S EMPLOYMENT STATUS .2515 Choose from the available list the choice that most correctly indicates the current employment status for this patient's spouse.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EMPLOYED FULL TIME
  • Code : 2
    Stands For: EMPLOYED PART TIME
  • Code : 3
    Stands For: NOT EMPLOYED
  • Code : 4
    Stands For: SELF EMPLYED
  • Code : 5
    Stands For: RETIRED
  • Code : 6
    Stands For: ACTIVE MILITARY DUTY
  • Code : 9
    Stands For: UNKNOWN
SPOUSE'S RETIREMENT DATE .2516 For this veteran applicant's spouse, enter the date s/he retired from her/his place of employment.

Date/Time
SPOUSE'S EMP STREET [LINE 1] .252 If applicant is married and a spouse's employer name has been entered enter the first line of the spouse's employer's street address [3-35 characters, otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
SPOUSE'S EMP STREET [LINE 2] .253 If applicant is married and a spouse's employer name has been entered enter the second line of the spouse's employer's street address [3-35 characters, if necessary, otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
SPOUSE'S EMP STREET [LINE 3] .254 If applicant is married and a spouse's employer name has been entered enter the third line of the spouse's employer's street address [3-35 characters, if necessary, otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
SPOUSE'S EMPLOYER'S CITY .255 If applicant is married and a spouse's employer name has been entered enter the spouse's employer city [2-20 characters], otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
SPOUSE'S EMPLOYER'S STATE .256 If applicant is married and a spouse's employer name has been entered select from the available listing the spouse's employer's state. This field may not be deleted as long as a spouse's employer's name is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
SPOUSE'S EMP ZIP CODE .257 If applicant is married and spouse's employer name has been entered enter the spouse's employer zip code [5 numerics], otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
SPOUSE'S EMP PHONE NUMBER .258 If applicant is married and spouse's employer name has been entered enter the spouse's employer telephone number [4-20 characters], otherwise nothing may be entered. This field may not be deleted as long as a spouse's employer's name is on file.

Free Text
ZIP+4 (CIVIL) .290012 Enter the zip code of the address where the person responsible for handling this patient's funds resides. Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789).

Free Text
ZIP+4 (VA) .29013 If this patient has a VA guardian responsible for handling the patient's funds, enter the guardian's zip code here. Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789).

Free Text
DATE RULED INCOMPETENT (VA) .291 Enter the date this patient was ruled to be incompetent to handle his VA funds. The Date Ruled Incompetent cannot be after the Date of Death.

Date/Time
INSTITUTION (VA) .2911 Enter the VA facility or institution responsible for this patient's VA funds.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
GUARDIAN (VA) .2912 Enter the name of the VA representative responsible for this patient's funds.

Free Text
RELATIONSHIP (VA) .2913 Enter the relationship to the patient of the VA representative responsible for handling this patient's funds.

Free Text
STREET ADDRESS 1 (VA) .2914 Enter the first line of the street address of the VA representative responsible for handling this patient's funds.

Free Text
STREET ADDRESS 2 (VA) .2915 Enter the second line of the street address of the VA representative responsible for handling this patient's funds.

Free Text
CITY (VA) .2916 Enter the city in which the person reponsible for handling this patient's funds resides.

Free Text
STATE (VA) .2917 Enter the state in which the person responsible for handling this patient's funds resides.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP (VA) .2918 If this patient has a VA guardian responsible for handling the patient's funds, enter the guardian's zip code here.

Free Text
PHONE (VA) .2919 If this patient has a VA guardian responsible for handling the patient's funds, enter the guardian's phone number here.

Free Text
DATE RULED INCOMPETENT (CIVIL) .292 If this patient was ruled incompetent to handle his funds, enter the date he was ruled incompetent. The Date Ruled Incompetent cannot be after the Date of Death.

Date/Time
INSTITUTION (CIVIL) .2921 If this patient has been ruled incompetant to handle his financial matters, enter the instituition reponsible for handling the funds on the patient's behalf.

Free Text
GUARDIAN (CIVIL) .2922 If this patient has been ruled incompetant to handle his financial matters, enter the name of the individual responsible for handling the funds on the patient's behalf.

Free Text
RELATIONSHIP (CIVIL) .2923 If this patient has been ruled incompetant to handle his financial funds, and someone else is responsible for handling the funds, enter the relationship of that person to the patient.

Free Text
STREET ADDRESS 1 (CIVIL) .2924 Enter the first line of the street address of the person responsible for handling this patient's funds.

Free Text
STREET ADDRESS 2 (CIVIL) .2925 Enter the second line of the street address of the person responsible for handling this patient's funds.

Free Text
CITY (CIVIL) .2926 Enter the city in which the person responsible for this patient's funds resides.

Free Text
STATE (CIVIL) .2927 Enter the state in which the person responsible for handling this patient's funds resides.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP (CIVIL) .2928 Enter the zip code of the address where the person responsible for handling this patient's funds resides.

Free Text
PHONE (CIVIL) .2929 If this patient has been ruled incompetant to handle his money and another person has been assigned to handle the patient's financial matters, enter that person's phone number here.

Free Text
RATED INCOMPETENT? .293 This field was originated for the use of AMIE (Automated Medical Information Exchange). One will receive from DVB the information on whether the patient was rated incompetent by the VA. This may differ from the date rated incompetent field in the patient file.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SERVICE CONNECTED? .301 Enter 'Y' if this applicant is service connected, 'N' if not. Applicants identified as being non-veterans cannot be entered as service connected. Once eligibility has been verified only users holding the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SC AWARD DATE .3012 This field contains the effective date of service connection, based on the VBA decision. This can be obtained either through HINQ or the award letter.

Date/Time
P&T EFFECTIVE DATE .3013 Enter the Effective Date the patient was awarded P&T disability status by VARO. This field is optional (not required). But if entered, the date needs to be a precise date, i.e. a day, month and year MUST be included. P&T Effective Date can not be a date prior to the Veteran's 'Date of Birth', a future date, or a date after the Veteran's 'Date of Death'.

Date/Time
EFF. DATE COMBINED SC% EVAL. .3014 Data will be filed automatically from HL7 message from the HEC. This is the date that the combined Service Connected Disability % was awarded.

Date/Time
SERVICE CONNECTED PERCENTAGE .302 If this applicant is service connected (SERVICE CONNECTED prompt must be answered YES) enter the service connected percentage [a number between 0-100]. Once eligibility has been verified only users who hold the designated security key may enter/edit this field. Field may not be deleted as long as service connection is indicated.

Numeric
RECEIVING VA DISABILITY? .3025 For this veteran applicant enter 'Y' if s/he is in receipt of a disability payment, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF VA DISABILITY .303 For this veteran applicant who is in receipt of disability payment (RECEIPT OF DISABILITY PAYMENT prompt must be answered YES) enter the amount received [a number between 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. Any dollar amomount on file cannot be deleted as long as receipt of disability payment is indicated. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
P&T .304 This field will contain YES if the patient is determined to be permanently and totally disabled by VARO due to a service connected condition. Answering "YES" will prompt you to enter a P&T Effective Date.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
UNEMPLOYABLE .305 Is this patient rated unemployable by the VARO due to a service connected condition?

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
MONETARY BEN. VERIFY DATE .306 Once monetary benefits, and amounts, are verified enter the date of verification. All monetary benefits data fields will become uneditable to any user who does not hold the designated security key once the benefits are verified. Only users who hold the designated security key may enter/edit this field.

Date/Time
INELIGIBLE REASON .307 If this applicant is ineligible for treatment enter the reason [not to exceed 40 characters]. An ineligible date must be specified in order to enter/edit this field and the user must hold the designated security key. This field may not be deleted as long as an ineligible date is on file.

Free Text
AGENCY/ALLIED COUNTRY .309 For this applicant whose eligibility code is either 'OTHER FEDERAL AGENCY' or 'ALLIED VETERAN' select from the available listing the federal agency or allied country, as appropriate, which best classifies this applicant.

Pointer
PointerTo:
fileName:
OTHER FEDERAL AGENCY
fileNumber:
35
*CATEGORY OF BENEFICIARY .31 This field is no longer used by the MAS package. It was previously updated via a cross-reference on the CATEGORY OF BENEFICIARY field in the PTF file. In a prior release of MAS, the use of category of beneficiary was discontinued and period of service is now solely used. In a future release of MAS, this field will be removed along with the ACB cross-reference on the PATIENT file and the cross-reference in the PTF file which sets this data.

Pointer
PointerTo:
fileName:
CATEGORY OF BENEFICIARY
fileNumber:
45.82
EMPLOYER NAME .3111 If employment status is indicated and is not unemployed enter the employer name [1-30 characters], otherwise nothing may be entered.

Free Text
EMPLOYMENT STATUS .31115 Enter the patient's current employment status. Choose from the available choices.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EMPLOYED FULL TIME
  • Code : 2
    Stands For: EMPLOYED PART TIME
  • Code : 3
    Stands For: NOT EMPLOYED
  • Code : 4
    Stands For: SELF EMPLOYED
  • Code : 5
    Stands For: RETIRED
  • Code : 6
    Stands For: ACTIVE MILITARY DUTY
  • Code : 9
    Stands For: UNKNOWN
DATE OF RETIREMENT .31116 For this veteran applicant, enter the date s/he retired from her/his place of employment.

Date/Time
GOVERNMENT AGENCY .3112 If this patient is currently employed by a government agency, respond yes to this question. If the patient is employed by the private sector or currently is unemployed, respond no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
EMPLOYER STREET [LINE 1] .3113 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the first line of the employer street address [1-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
EMPLOYER STREET [LINE 2] .3114 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the second line of the employer street address [1-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
EMPLOYER STREET [LINE 3] .3115 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the third line of the employer street address [1-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
EMPLOYER CITY .3116 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the employer city [1-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
EMPLOYER STATE .3117 If employment status is indicated, applicant is not unemployed and an employer name is entered select from the available listing the employer state, otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
EMPLOYER ZIP CODE .3118 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the employer zip code [5 numerics], otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
EMPLOYER PHONE NUMBER .3119 If employment status is indicated, applicant is not unemployed and an employer name is entered enter the employer telephone number [3-20 characters], otherwise nothing may be entered. This field cannot be deleted as long as an employer name is on file.

Free Text
*CLAIM FOLDER LOCATION .312 For this veteran applicant enter, if applicable, the location of his/her VA claim folder [2-40 characters].

Free Text
INSURANCE TYPE .3121 From the available listing enter the type of insurance under which this applicant is covered regardless of who holds the policy.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INSURANCE TYPE .01 Choose from the available listing the name(s) of the insurance company(ies) under which this applicant is covered.

Pointer
PointerTo:
fileName:
INSURANCE COMPANY
fileNumber:
36
GROUP PLAN .18 Select the plan under which this patient is covered by the specified insurance company. If this is a group plan then there may already be an entry for this plan that you may select. Or, you may add a new plan. If this is an individual plan then it will be associated with only this patient.

Pointer
PointerTo:
fileName:
GROUP INSURANCE PLAN
fileNumber:
355.3
COORDINATION OF BENEFITS .2

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PRIMARY
  • Code : 2
    Stands For: SECONDARY
  • Code : 3
    Stands For: TERTIARY
*SUBSCRIBER ID 1 Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card. This field is scheduled for deletion in May 2015.

Free Text
DATE ENTERED 1.01 This is the date this entry was added. It will be created by the system whenever a new policy is added. Entries created prior the installation of IB v2.0 will not have an entry in this field.

Date/Time
ENTERED BY 1.02 This the user who added this entry. It will be entered by the system whenever a new policy is added. Entries created prior the installation of IB v2.0 will not have an entry in this field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE LAST VERIFIED 1.03 Insurance coverage is generally verified by calling the insurer and requesting an explanation of benefits. When coverage has been verified the person verifying the coverage should use the options to verify the coverage in VISTA. This is the date that this policy for this patient was last verified with the insurance company. It is important to update the verification date regularly so that other users will know how current the information in VISTA is.

Date/Time
VERIFIED BY 1.04 This is the user that last contacted the insurance company to verify the policy. It is updated by using the appropriate DHCP options. It is important to update the verification date and user so that other users will know the insurance policy information is current.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE LAST EDITED 1.05 This is the date this policy was last edited. This field is updated by the computer whenever anyone edits this patient's policy information.

Date/Time
LAST EDITED BY 1.06 This is the user that last edited the policy. This field is updated by the computer whenever anyone edits this patients policy information.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
*COMMENT - PATIENT POLICY 1.08 This is a place to record a short comment about this patients policy. It is specific to this patient and to this policy. The answer must be 3 to 80 characters.

Free Text
SOURCE OF INFORMATION 1.09 Enter the last source of this information. If the insurance information was obtained by patient interview, then enter interview, etc. If the information was initially or previously obtained by one source but updated by another source, then enter the most recent source of the information. The data in this field will be initially set to INTERVIEW with IB v2. The data may be passed to Accounts Receivable and/or the MCCR NDB. If this field is being edited through the use of the pre-registration software, the default for this field will be set to PRE-REGISTRATION.

Pointer
PointerTo:
fileName:
SOURCE OF INFORMATION
fileNumber:
355.12
DATE OF SOURCE OF INFORMATION 1.1

Date/Time
COMMENT - SUBSCRIBER POLICY 1.18 This sub-file (#2.342 COMMENT - SUBSCRIBER POLICY) will contain the Subscriber's Policy Comments, the Date and Time the Subscriber's Policy Comments was entered, and the User's ID that entered the Subscriber's Policy comments.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT DATE/TIME .01 The date/time that the user entered the subscriber's policy comment.

Date/Time
LAST EDITED BY .02 This is the local user ID of the person that entered the Subscriber's Policy comment.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT .03 This field contains a specific comment about this Subscriber's Policy. The comment must be between 3 and 245 characters in length.

Free Text
*GROUP NUMBER 2 Enter any other appropriate number which identifies this policy, i.e., group number/code, under which this applicant is covered. Answer must be between 1 and 17 characters. This field is moved to the HEALTH INSURANCE POLICY file (355.3) beginning with IB v2.0. It will be deleted with the first release 18 months after the release of IB V2.

Free Text
SEND BILL TO EMPLOYER 2.01 If the employer of the person who holds this policy requires that they pre-processed for the insurance policy then enter 'YES'. You will then be allowed to enter the company name and address that these bills should be sent to. The bills will then automatically use this address. If the employer does not require this, or unknown, enter 'NO'. The bills will then be sent to the insurance company. If the policy is held by other than the patient then this will not be the patient's employer but the employer of the person who is insured.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SUBSCRIBER'S EMPLOYER NAME 2.015 This is the name of the employer that will appear on the UB-04 if the bills should be sent to the employer for pre-processing.

Free Text
EMPLOYER CLAIMS STREET ADDRESS 2.02 This is the street address of the employer who should receive claims to be pre-processed before the are forwarded to the insurance carrier. The answer should be 3 to 30 characters.

Free Text
EMPLOY CLAIM ST ADDRESS LINE 2 2.03 This is line 2 of the street address for employers who pre-process insurance claims before they are forwarded to the insurance carrier for processing. Answer must be 3-30 characters.

Free Text
EMPLOY CLAIM ST ADDRESS LINE 3 2.04 This is line 3 of the street address for employers who pre-process insurance claims before they are forwarded to the insurance carrier for processing. Answer must be 3-30 characters.

Free Text
EMPLOYER CLAIMS CITY 2.05 If the employer of the person who holds this policy pre-processes insurance claims prior to forwarding to the insurance carrier enter the city that claim should be sent to. This will be printed on the claim form. Answer must be 3 to 20 characters.

Free Text
EMPLOYER CLAIMS STATE 2.06 If the employer of the person who holds this policy pre-processes insurance claims prior to forwarding to the insurance carrier enter the state that the claim should be sent to. This will be printed on the claim form. Answer must be 3 to 20 characters.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
EMPLOYER CLAIMS ZIP CODE 2.07 Enter the zip code of the mailing address for this employer. Answer with either the 5 digit zip code (format 12345) or with the 9 digit zip code (in format 123456789 or 12345-6789).

Free Text
EMPLOYER CLAIMS PHONE 2.08 Enter the phone number of the employer. This should be the phone number of the person to contact regarding insurance claims.

Free Text
ESGHP 2.1 Enter 'Yes' if this policy is part of a plan that is sponsored or provided by the insured's current or past employer.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
EMPLOYMENT STATUS 2.11 If this is an Employer Sponsored Group Health Plan then this should be the employment status of the insured with the employer that sponsors the plan.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: FULL TIME
  • Code : 2
    Stands For: PART TIME
  • Code : 3
    Stands For: NOT EMPLOYED
  • Code : 4
    Stands For: SELF EMPLOYED
  • Code : 5
    Stands For: RETIRED
  • Code : 6
    Stands For: ACTIVE MILITARY
  • Code : 9
    Stands For: UNKNOWN
RETIREMENT DATE 2.12 If this is an Employer Sponsored Group Health Plan then this should be the date the insured retired from the employer that sponsors the plan.

Date/Time
INSURANCE EXPIRATION DATE 3 If this insurance policy under which this applicant is covered expires on a specified date enter that date, otherwise, leave this field blank.

Date/Time
INSURED'S DOB 3.01 The field is used to store the date of birth of the insured person. The field value may be printed in block 11a of the CMS-1500 claim form. This is a required field for billing ChampUS patients.

Date/Time
INSURED'S BRANCH 3.02 This field may be used to store the service branch of the insured person. The field will be used primarily for CHAMPUS policies, where the subscriber, or sponsor, may be an active duty member of the military. The field value may be printed in block 11b of the CMS-1500 claim form.

Pointer
PointerTo:
fileName:
BRANCH OF SERVICE
fileNumber:
23
INSURED'S RANK 3.03 This field contains the insured person's military rank. The field will be used primarily for CHAMPUS policies, where the subscriber, or sponsor, may be an active duty member of the military. The field value may be printed in block 11c of the CMS-1500 claim form.

Free Text
POLICY NOT BILLABLE 3.04 This field is used primarily for CHAMPUS policies. If the patient is covered under CHAMPUS, but it is known that claims should never be submitted to the CHAMPUS Fiscal Intermediary, then entering YES in this field will cause Pharmacy claims to the FI not to be created.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
INSURED'S SSN 3.05 This field contains the policyholder's social security number, if it is different than the Subscriber ID. For CHAMPUS policies, this value may be automatically inserted into this field from the PATIENT (#2) or SPONSOR PERSON (#355.82) files.

Free Text
INSURED'S STREET 1 3.06 This field contains the first street address of the policyholder.

Free Text
INSURED'S STREET 2 3.07 This field contains the second line of the street address of the policyholder.

Free Text
INSURED'S CITY 3.08 This field contains the city of the policyholder.

Free Text
INSURED'S STATE 3.09 This field contains the state of the policyholder.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
INSURED'S ZIP 3.1 This field contains the zip code of the policyholder.

Free Text
INSURED'S PHONE 3.11 This field contains the phone number of the policyholder.

Free Text
INSURED'S SEX 3.12 This field is used in insurance billing to help verify the policy coverage when the bill is submitted to the carrier. If the patient is the policy holder, this value should match the patient's sex. If the patient's spouse or other relative is the policy holder, the appropriate value should be determined and entered.

Set of Codes
Set of Codes:
  • Code : F
    Stands For: FEMALE
  • Code : M
    Stands For: MALE
INSURED'S COUNTRY 3.13 This field contains the country code of the policyholder.

Free Text
INSURED'S COUNTRY SUBDIVISION 3.14 This field contains the country subdivision code of the policyholder.

Free Text
PRIMARY CARE PROVIDER 4.01 This is the patient's Primary Care Provider within their managed care network that may refer the patient to the VA.

Free Text
PRIMARY PROVIDER PHONE 4.02 This is the phone number of the Primary Care Provider that may refer the patient to the VA.

Free Text
PT. RELATIONSHIP - HIPAA 4.03 Enter the code which best describes the patient's relationship to the person who holds this policy (or insured).

Set of Codes
Set of Codes:
  • Code : 01
    Stands For: SPOUSE
  • Code : 18
    Stands For: SELF
  • Code : 19
    Stands For: CHILD
  • Code : 20
    Stands For: EMPLOYEE
  • Code : 29
    Stands For: SIGNIFICANT OTHER
  • Code : 32
    Stands For: MOTHER
  • Code : 33
    Stands For: FATHER
  • Code : 39
    Stands For: ORGAN DONOR
  • Code : 41
    Stands For: INJURED PLAINTIFF
  • Code : 53
    Stands For: LIFE PARTNER
  • Code : G8
    Stands For: OTHER RELATIONSHIP
EIV AUTO-UPDATE 4.04 Flag that determines how the last update to INSURANCE TYPE sub-file was done. Value of "YES" means that data was last updated via eIV auto-update, value of "NO" means that data was last updated via other means.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PHARMACY RELATIONSHIP CODE 4.05 This is the relationship of the patient to the cardholder. Code Description ---- ----------- 0 Not Specified 1 Cardholder - The individual that is enrolled in and receives benefits from a health plan 2 Spouse - Patient is the husband/wife/partner of the cardholder 3 Child - Patient is a child of the cardholder 4 Other - Relationship to cardholder is not precise

Pointer
PointerTo:
fileName:
BPS NCPDP PATIENT RELATIONSHIP CODE
fileNumber:
9002313.19
PHARMACY PERSON CODE 4.06 This is the code that is assigned by the payer to identify the patient. The payer may use a unique person code to identify each specific person on the pharmacy insurance policy. This code may also describe the patient's relationship to the cardholder. Enrollment Standard Examples: 001 = Cardholder 002 = Spouse 003 - 999 = Dependents and Others (including second spouses, etc.)

Free Text
PATIENT ID 5.01 This is the patient's primary ID number for this insurance company. Enter this field when the patient and the subscriber are different and the patient has been given a unique ID number. If issued by this payer, the number should be present on the patient's insurance card. This data will print in box 8a on the UB-04 for institutional claims when the patient and the subscriber are different.

Free Text
SUBSCRIBER'S SEC QUALIFIER(1) 5.02 Enter the subscriber secondary ID qualifier# 1. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
SUBSCRIBER'S SEC ID(1) 5.03 Enter the subscriber's secondary ID #1. You may enter up to 3 secondary ID's and qualifiers.

Free Text
SUBSCRIBER'S SEC QUALIFIER(2) 5.04 Enter the subscriber secondary ID qualifier# 2. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
SUBSCRIBER'S SEC ID(2) 5.05 Enter the subscriber's secondary ID #2. You may enter up to 3 secondary ID's and qualifiers.

Free Text
SUBSCRIBER'S SEC QUALIFIER(3) 5.06 Enter the subscriber secondary ID qualifier# 3. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
SUBSCRIBER'S SEC ID(3) 5.07 Enter the subscriber's secondary ID #3. You may enter up to 3 secondary ID's and qualifiers.

Free Text
PATIENT'S SEC QUALIFIER(1) 5.08 Enter the patient secondary ID qualifier# 1. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
PATIENT'S SECONDARY ID(1) 5.09 Enter the patient secondary ID #1. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different.

Free Text
PATIENT'S SEC QUALIFIER(2) 5.1 Enter the patient secondary ID qualifier# 2. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
PATIENT'S SECONDARY ID(2) 5.11 Enter the patient secondary ID #2. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different.

Free Text
PATIENT'S SEC QUALIFIER(3) 5.12 Enter the patient secondary ID qualifier# 3. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare.

Set of Codes
Set of Codes:
  • Code : 23
    Stands For: Client Number
  • Code : IG
    Stands For: Insurance Policy Number
  • Code : SY
    Stands For: Social Security Number
PATIENT'S SECONDARY ID(3) 5.13 Enter the patient secondary ID #3. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different.

Free Text
WHOSE INSURANCE 6 Enter 'v' if this insurance policy is held by the veteran (applicant), 's' if the veteran is married and the spouse holds the policy, or 'o' if someone other than the veteran or his/her spouse hold the policy, i.e., employer.

Set of Codes
Set of Codes:
  • Code : v
    Stands For: VETERAN
  • Code : s
    Stands For: SPOUSE
  • Code : o
    Stands For: OTHER
NAME OF INSURED 7.01 Enter the name of the individual for which this insurance policy was issued. If the patient and the insurance subscriber are the same, then this field will be defaulted from the patient name field. The name must contain a comma and be entered in Last,First format.

Free Text
SUBSCRIBER ID 7.02 Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card.

Free Text
EFFECTIVE DATE OF POLICY 8 Enter the date that this insurance policy initially went into effect (the date the patient acquired this policy).

Date/Time
REQUESTED SERVICE DATE 8.01 This is the Eligibility/Service Date that is received on the eIV Response message. If it is not present on the Response message then this is the Eligibility Date that was sent on the Inquiry message.

Date/Time
REQUESTED SERVICE TYPE 8.02 This is the Service Type that is received on the Response message.

Pointer
PointerTo:
fileName:
X12 271 SERVICE TYPE
fileNumber:
365.013
GROUP REFERENCE INFORMATION 9 Subscriber/Dependent additional identification data.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 This field contains a sequential number generated at the time a record is stored in the subfile.

Numeric
REFERENCE ID (GROUP) .02 Subscriber Supplemental Identifier.

Free Text
REF ID QUALIFIER (GROUP) .03 Describes the type of reference ID at the REFERENCE ID (GROUP) (#.02) field.

Pointer
PointerTo:
fileName:
X12 271 REFERENCE IDENTIFICATION
fileNumber:
365.028
DESCRIPTION .04 A free-form description to clarify the Reference ID in the REFERENCE ID (GROUP) (#.02) field. It will be populated with the Plan, Group or Plan Network Name.

Free Text
GROUP PROVIDER INFO 10 Entries in this sub-file identify the characteristics of a provider.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 This field contains a sequential number generated at the time a record is stored in the subfile.

Numeric
PROVIDER CODE .02 Code that identifies the type of provider (e.g., "AD" for Admitting).

Pointer
PointerTo:
fileName:
X12 271 PROVIDER CODE
fileNumber:
365.024
PROV REFERENCE ID .03 Provider specialty type identifier.

Free Text
HEALTH CARE CODE INFORMATION 11 To supply information related to the delivery of health care.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 This field contains a sequential number generated at the time a record is stored in the subfile.

Numeric
DIAGNOSIS CODE .02 Diagnosis Code sent by the payer in response to the insurance eligibility inquiry.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
DIAGNOSIS CODE QUALIFIER .03 Diagnosis Type Code identifying a specific industry code list ICD-9 or ICD-10.

Free Text
PRIMARY OR SECONDARY? .04 This field indicates whether the code in the DIAGNOSIS CODE (#.02) field is a primary or secondary diagnosis.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PRIMARY
  • Code : S
    Stands For: SECONDARY
MILITARY INFO STATUS CODE 12.01 Code to indicate the status of the military information sent by the payer.

Pointer
PointerTo:
fileName:
X12 271 MILITARY PERSONNEL INFO STATUS CODE
fileNumber:
365.039
MILITARY EMPLOYMENT STATUS 12.02 Code showing the general military employment status of an employee/claimant.

Pointer
PointerTo:
fileName:
X12 271 MILITARY EMPLOYMENT STATUS CODE
fileNumber:
365.046
MILITARY GOVT AFFILIATION CODE 12.03 Code specifying the military service affiliation.

Pointer
PointerTo:
fileName:
X12 271 MILITARY GOVT SERVICE AFFILIATION
fileNumber:
365.041
MILITARY PERSONNEL DESCRIPTION 12.04 This field further identifies the exact military unit.

Free Text
MILITARY SERVICE RANK CODE 12.05 Code specifying the military service rank.

Pointer
PointerTo:
fileName:
X12 271 MILITARY SERVICE RANK
fileNumber:
365.042
DATE TIME PERIOD FORMAT QUAL 12.06 Code qualifier indicating the date format, time format, or date and time format respective of the DATE TIME PERIOD field (#12.07).

Pointer
PointerTo:
fileName:
X12 271 DATE FORMAT QUALIFIER
fileNumber:
365.032
DATE TIME PERIOD 12.07 Expression of a date or range of dates that indicates the date span of military service.

Free Text
*GROUP NAME 15 If this insurance policy is a group policy, enter the name of the group. This field is moved to the HEALTH INSURANCE POLICY file (355.3) beginning with IB v2.0. It will be deleted with the first release 18 months after the release of IB V2.

Free Text
PT. RELATIONSHIP TO INSURED 16 Select the relationship code that describes the relationship this patient has to the holder of this insurance policy. If the policy belongs to the patient enter '01' for patient. If the policy belongs to the spouse enter '02' for spouse, etc.

Set of Codes
Set of Codes:
  • Code : 01
    Stands For: PATIENT
  • Code : 02
    Stands For: SPOUSE
  • Code : 03
    Stands For: NATURAL CHILD
  • Code : 08
    Stands For: EMPLOYEE
  • Code : 09
    Stands For: DO NOT USE
  • Code : 11
    Stands For: ORGAN DONOR
  • Code : 15
    Stands For: INJURED PLANTIFF
  • Code : 18
    Stands For: DO NOT USE
  • Code : 32
    Stands For: MOTHER
  • Code : 33
    Stands For: FATHER
  • Code : 34
    Stands For: SIGNIFICANT OTHER
  • Code : 35
    Stands For: LIFE PARTNER
  • Code : 36
    Stands For: OTHER RELATIONSHIP
*NAME OF INSURED 17 Enter the name of the individual for which this insurance policy was issued. If the patient and the insurance subscriber are the same, then this field will be defaulted from the patient name field. The name must contain a comma and be entered in Last,First format. This field is scheduled for deletion in May 2015.

Free Text
NEW GROUP NAME 20 This computed field will yield the Group Name from file# 355.3 based on the current Group Plan in field# .18.

Computed
NEW GROUP NUMBER 21 This computed field will yield the Group Number from file# 355.3 based on the current Group Plan in field# .18.

Computed
ELIGIBILITY/BENEFIT 60 This multiple contains all of the eligibility and benefit data for a specific insured person returned from the Payer.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EB NUMBER .01 This is a sequential number corresponding to the Set-ID for all of the eligibility/benefit (X.12 EB segments) segments coming into VISTA.

Numeric
ELIGIBILITY/BENEFIT INFO .02 This field contains a code identifying the eligibility status of the individual or the benefit returned by the Payer.

Pointer
PointerTo:
fileName:
X12 271 ELIGIBILITY/BENEFIT
fileNumber:
365.011
COVERAGE LEVEL .03 This field identifies the level of coverage of benefits.

Pointer
PointerTo:
fileName:
X12 271 COVERAGE LEVEL
fileNumber:
365.012
*SERVICE TYPE .04 This field is a code identifying the classification of service.

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PointerTo:
fileName:
X12 271 SERVICE TYPE
fileNumber:
365.013
INSURANCE TYPE .05 This is a code identifying the type of insurance policy within a specific insurance program.

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PointerTo:
fileName:
X12 271 INSURANCE TYPE
fileNumber:
365.014
PLAN COVERAGE DESCRIPTION .06 This code is a description or number that identifies the plan or coverage.

Free Text
TIME PERIOD QUALIFIER .07 This is a code for the time period category that determines for how long the benefits are available.

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PointerTo:
fileName:
X12 271 TIME PERIOD QUALIFIER
fileNumber:
365.015
MONETARY AMOUNT .08 This field is populated if eligibility or benefit must be qualified by a monetary amount.

Free Text
PERCENT .09 This field is used if eligibility or benefit must be qualified by a percentage.

Numeric
QUANTITY QUALIFIER .1 This field is used to identify the type of units that are being conveyed in the QUANTITY field (#.11).

Pointer
PointerTo:
fileName:
X12 271 QUANTITY QUALIFIER
fileNumber:
365.016
QUANTITY .11 This field number is used for the quantity value as qualified by the QUANTITY QUALIFIER field.

Free Text
AUTHORIZATION/CERTIFICATION .12 This field indicates that an authorization or certification is required per plan provisions.

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PointerTo:
fileName:
X12 271 YES/NO RESPONSE CODE
fileNumber:
365.033
IN PLAN .13 This field indicates the plan network indicator. A YES value indicates the benefits identified are considered In-Plan-Network. A NO value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network.

Pointer
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fileName:
X12 271 YES/NO RESPONSE CODE
fileNumber:
365.033
PROCEDURE CODING METHOD 1.01 Two character code describing procedure coding method.

Pointer
PointerTo:
fileName:
X12 271 PROCEDURE CODING METHOD
fileNumber:
365.035
PROCEDURE CODE 1.02 Identification code for the procedure.

Free Text
PROCEDURE MODIFIER 1 1.03 Identifies special circumstances related to the procedure; first modifier.

Free Text
PROCEDURE MODIFIER 2 1.04 Identifies special circumstances related to the procedure; second modifier.

Free Text
PROCEDURE MODIFIER 3 1.05 Identifies special circumstances related to the procedure; third modifier.

Free Text
PROCEDURE MODIFIER 4 1.06 Identifies special circumstances related to the procedure; fourth modifier.

Free Text
NOTES 2 This field contains any additional text about the eligibility benefit information. It is transcribed from X.12 271 MSG segments.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
NOTES .01 This field contains any additional text about the eligibility benefit information. It is transcribed from X.12 271 MSG segments.

Word Processing
ENTITY ID CODE 3.01 X12 Entity Identifier Code.

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fileName:
X12 271 ENTITY IDENTIFIER CODE
fileNumber:
365.022
ENTITY TYPE 3.02 Entity Type Qualifier.

Pointer
PointerTo:
fileName:
X12 271 ENTITY TYPE QUALIFIER
fileNumber:
365.043
NAME 3.03 Name of person or organization.

Free Text
ENTITY ID 3.04 Entity identifier.

Free Text
ENTITY ID QUALIFIER 3.05 Code designating the system/method used for Identification.

Pointer
PointerTo:
fileName:
X12 271 IDENTIFICATION QUALIFIER
fileNumber:
365.023
ENTITY RELATIONSHIP CODE 3.06 Benefit Related Entity's relationship to the patient.

Pointer
PointerTo:
fileName:
X12 271 ENTITY RELATIONSHIP CODE
fileNumber:
365.031
ADDRESS LINE 1 4.01 Entity address, line 1.

Free Text
ADDRESS LINE 2 4.02 Entity address, line 2.

Free Text
CITY 4.03 Entity address, city.

Free Text
STATE 4.04 Entity address, state or province code.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP 4.05 Entity address, zip or postal code.

Free Text
COUNTRY CODE 4.06 Entity address, country code.

Free Text
LOCATION 4.07 Entity address, location identifier.

Free Text
LOCATION QUALIFIER 4.08 Entity address, location qualifier.

Pointer
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fileName:
X12 271 LOCATION QUALIFER
fileNumber:
365.034
SUBDIVISION CODE 4.09 Entity address, country subdivision code.

Free Text
PROVIDER CODE 5.01 Code identifying the type of provider.

Pointer
PointerTo:
fileName:
X12 271 PROVIDER CODE
fileNumber:
365.024
REFERENCE ID 5.02 Reference identifier.

Free Text
REFERENCE ID QUALIFIER 5.03 Reference identifier type.

Pointer
PointerTo:
fileName:
X12 271 REFERENCE IDENTIFICATION
fileNumber:
365.028
CONTACT INFORMATION 6 This multiple contains contact information for an eligibility/benefit entity.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 Sequential entry number.

Numeric
NAME .02 Name of the contact.

Free Text
*COMMUNICATION NUMBER .03 Phone, fax, email, etc. This field is scheduled for deletion in May 2015.

Free Text
COMMUNICATION QUALIFIER .04 Code describing type of communication number.

Pointer
PointerTo:
fileName:
X12 271 CONTACT QUALIFIER
fileNumber:
365.021
COMMUNICATION NUMBER 1 Phone, fax, email, URL

Free Text
HEALTHCARE SERVICES DELIVERY 7 Healthcare services delivery multiple.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 Sequential entry number.

Numeric
BENEFIT QUANTITY .02 Numeric value of benefit quantity as qualified by QUANTITY QUALIFIER field.

Numeric
QUANTITY QUALIFIER .03 Benefit quantity qualifier.

Pointer
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fileName:
X12 271 QUANTITY QUALIFIER
fileNumber:
365.016
SAMPLE SELECTION MODULUS .04 Sampling frequency in terms of a modulus of the Unit of Measure. Qualified by UNITS OF MEASUREMENT field.

Free Text
UNITS OF MEASUREMENT .05 Units of measurement for frequency of the benefits.

Pointer
PointerTo:
fileName:
X12 271 UNITS OF MEASUREMENT
fileNumber:
365.029
TIME PERIODS .06 Number of time periods as qualified by TIME PERIOD QUALIFIER field.

Numeric
TIME PERIOD QUALIFIER .07 Code that defines a time period.

Pointer
PointerTo:
fileName:
X12 271 TIME PERIOD QUALIFIER
fileNumber:
365.015
DELIVERY FREQUENCY .08 Code that defines frequency of deliveries.

Pointer
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fileName:
X12 271 DELIVERY FREQUENCY CODE
fileNumber:
365.025
DELIVERY PATTERN .09 Code that defines pattern of deliveries.

Pointer
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fileName:
X12 271 DELIVERY PATTERN
fileNumber:
365.036
SUBSCRIBER DATES 8 Subscriber dates multiple.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 Sequential number of ZSD segment.

Numeric
DATE .02 Date or range of dates.

Free Text
DATE QUALIFIER .03 Code describing the type of date.

Pointer
PointerTo:
fileName:
X12 271 DATE QUALIFIER
fileNumber:
365.026
DATE FORMAT .04 Format of the date representation.

Pointer
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fileName:
X12 271 DATE FORMAT QUALIFIER
fileNumber:
365.032
SUBSCRIBER ADDITIONAL INFO 9 Additional subscriber information multiple.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 Sequential number of ZII segment.

Numeric
PLACE OF SERVICE .02 Place of service code.

Pointer
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fileName:
PLACE OF SERVICE
fileNumber:
353.1
DIAGNOSIS .03 Diagnosis code.

Pointer
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fileName:
ICD DIAGNOSIS
fileNumber:
80
QUALIFIER .04 Additional information qualifier.

Pointer
PointerTo:
fileName:
X12 271 CODE LIST QUALIFIER
fileNumber:
365.044
NATURE OF INJURY CODE .05 Code that represents the nature of the patient injury.

Pointer
PointerTo:
fileName:
X12 271 NATURE OF INJURY CODES
fileNumber:
365.045
NATURE OF INJURY CATEGORY .06 Specifies the situation or category to which the code applies.

Free Text
NATURE OF INJURY TEXT .07 Describes the injured body part or parts.

Free Text
SUBSCRIBER REFERENCE ID 10 Subscriber reference id multiple.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEQUENCE .01 Sequential number of ZRF segment.

Numeric
REFERENCE ID .02 Reference id value.

Free Text
REFERENCE ID QUALIFIER .03 Code describing the type of reference id.

Pointer
PointerTo:
fileName:
X12 271 REFERENCE IDENTIFICATION
fileNumber:
365.028
DESCRIPTION .04 Short description of reference id.

Free Text
SERVICE TYPES 11

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SERVICE TYPES .01 This is a service type code returned from an eligibility inquiry.

Pointer
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fileName:
X12 271 SERVICE TYPE
fileNumber:
365.013
CLAIM NUMBER .313 If the applicant is a veteran enter his/her claim number as 7-8 numerics or by entering the characters 'SS' if his/her claim number is the same as his/her social security number. Once eligibility has been verified only users who hold the designated security key may enter/edit this field.

Free Text
CLAIM FOLDER LOCATION .314 This is the location of the patient's claim folder. It must be an entry in the INSTITUTION File. Valid facility types: RO (Regional Office) RO&IC (Regional Office and Insurance Center) RO-OC (Regional Office - Outpatient Clinic) RPC (Record Processing Center) M&ROC (Medical and Regional Office Center) M&ROC (M&RO) (Medical and Regional Office Center)

Pointer
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fileName:
INSTITUTION
fileNumber:
4
COVERED BY HEALTH INSURANCE? .3192 Enter 'Y' if this applicant is covered by a health insurance policy regardless of who holds policy (applicant, spouse, employer, etc.), 'N' if s/he isn't covered by any policy, or 'U' if unknown.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
VIETNAM SERVICE INDICATED? .32101 For this veteran applicant enter 'Y' if s/he actually served in the Republic of Vietnam, 'N' if not, or 'U' if unknown. Once the service record has been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AGENT ORANGE EXPOS. INDICATED? .32102 For this veteran applicant enter 'Y' if s/he was exposed to the chemical agent orange, 'N' if not, or 'U' if unknown. Exposure cannot be claimed unless the Period of Service (field .323) is answered VIETNAM ERA, which entails those serving in the Korean DMZ between January 1, 1968 and December 31, 1969 or Vietnam. Once the service record has been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
RADIATION EXPOSURE INDICATED? .32103 Enter 'Y' if the veteran was exposed to ionizing radiation 1) at a nuclear device testing site (e.g. the Pacific Islands, NM or NV) or 2) as a POW or while serving in Hiroshima and/or Nagasaki, Japan from August 6, 1945 through July 1, 1946, or 3) served at Department of Energy plants at Paducah, KY, Portsmouth, OH or the K25 area at Oak Ridge, TN for at least 250 days before February 1, 1992 or 4) served at Longshot, Milrow, or Cannikin underground nuclear tests at Amchitka Island, AK prior to January 1, 1974. Veterans exposed by method #3 or #4 are not eligible for copay exemption or enrollment in priority 6 based on their IR exposure. Enter 'N' if not exposed or 'U' if unknown. Once the record has been verified only HEC users may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
VIETNAM FROM DATE .32104 For this veteran applicant who served in the Republic of Vietnam (DID YOU SERVE IN VIETNAM prompt must be answered YES) enter the date on which service in vietnam commenced [between February 28, 1961 and May 7, 1975]. Once the service record is verified only users who hold the designated security key may enter/edit this field. As long as Vietnam service is indicated this date may not be deleted.

Date/Time
VIETNAM TO DATE .32105 For this veteran applicant who served in the Republic of Vietnam (DID YOU SERVE IN VIETNAM prompt must be answered YES) enter the date on which service in Vietnam ended [between February 28, 1961 and May 7, 1975]. Once the service record is verified only user who hold the designated security key may enter/edit this field. As long as Vietnam service is indicated this date may not be deleted.

Date/Time
AGENT ORANGE REGISTRATION DATE .32107 For this veteran applicant who was exposed to agent orange (EXPOSED TO AGENT ORANGE prompt must be answered YES) enter the date registered. Once the service record is verified only users who hold the designated security key may enter/edit this field. As long as agent orange exposure is indicated this field may not be deleted.

Date/Time
AGENT ORANGE REPORTED TO C.O. .32108 Enter the date on which this patient's claim of exposure to Agent Orange was initially reported to VA Central Office.

Date/Time
AGENT ORANGE EXAM DATE .32109 For this veteran applicant who was exposed to agent orange (EXPOSED TO AGENT ORANGE prompt must be answered YES) enter the date s/he was examined for this exposure, if any. Once the service record is verified only users who hold the designated security key may enter/edit this field. As long as agent orange exposure is indicated this field may not be deleted.

Date/Time
AGENT ORANGE REGISTRATION # .3211 For this veteran applicant who was exposed to agent orange (EXPOSED TO AGENT ORANGE prompt must be answered YES) enter the registration number assigned [a number between 1-999999]. Once the service record has been verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as agent orange exposure is indicated.

Numeric
RADIATION REGISTRATION DATE .32111 For this veteran applicant who was exposed to ionizing radiation (WERE YOU EXPOSED TO RADIATION prompt must be answered YES) enter the date registered. Once the service record is verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as ionizing radiation exposure is indicated.

Date/Time
PROJ 112/SHAD .32115

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RADIATION EXPOSURE METHOD .3212 This field represents the method by which the exposure to ionizing radiation occurred.

Set of Codes
Set of Codes:
  • Code : 2
    Stands For: HIROSHIMA/NAGASAKI
  • Code : 3
    Stands For: ATMOSPHERIC NUCLEAR TESTING
  • Code : 4
    Stands For: H/N AND ATMOSPHERIC TESTING
  • Code : 5
    Stands For: UNDERGROUND NUCLEAR TESTING
  • Code : 6
    Stands For: EXPOSURE AT NUCLEAR FACILITY
  • Code : 7
    Stands For: OTHER
AGENT ORANGE EXPOSURE LOCATION .3213 For this veteran applicant who was exposed to agent orange (EXPOSED TO AGENT ORANGE prompt must be answered YES) enter the location where the exposure occurred. Once the service record has been verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as agent orange exposure is indicated.

Set of Codes
Set of Codes:
  • Code : K
    Stands For: KOREAN DMZ
  • Code : V
    Stands For: VIETNAM
  • Code : O
    Stands For: OTHER
FILIPINO VETERAN PROOF .3214 Enter in this field the documentation that was provided in order to establish US citizenship, lawful permanent US residency, and/or VA Compensation at full-dollar rate for a Filipino Veteran (i.e., a veteran whose Branch of Service is F. Commonwealth, F. Guerilla, or F. Scouts New)

Set of Codes
Set of Codes:
  • Code : PP
    Stands For: US PASSPORT
  • Code : BC
    Stands For: US BIRTH CERTIFICATE
  • Code : BA
    Stands For: REPORT OF BIRTH ABROAD OF US CITIZEN
  • Code : NA
    Stands For: VERIFICATION OF NATURALIZATION
  • Code : PR
    Stands For: VERIFICATION OF PERMANENT RESIDENCY
  • Code : VA
    Stands For: VA COMPENSATION AT FULL DOLLAR RATE
  • Code : NO
    Stands For: NO PROOF
SERVICE [OEF OR OIF] .3215 This contains the information relating to the deployment of the patient to a conflict location for the operations Iraqi and Enduring Freedom (OIF, OEF respectively). It also includes records of conflict that can be identified as being EITHER OIF OR OEF, but the specific location cannot be determined.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOCATION OF SERVICE .01 This is the operation in which the patient was in combat during the specified time period.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: OIF
  • Code : 2
    Stands For: OEF
  • Code : 3
    Stands For: UNKNOWN OEF/OIF
OEF/OIF FROM DATE .02 If the service indicated is OEF or UNKNOWN OEF/OIF, this date must be on or after 9/01/2001 and the end date must be after 9/11/2001. If the service indicated is OIF, this date must be on or after 3/01/2003 and the end date must be after 3/19/2003. The meaning of this date depends on where the information was obtained from. If the data came from the VIS, Environmental Medicine or FHIE systems, this is the start date of military pay for the assignment to the OEF/OIF operation. If it came from any other source, it is the date the patient was actually deployed to the OEF/OIF area.

Date/Time
OEF/OIF TO DATE .03 If the service indicated is OEF or UNKNOWN OEF/OIF, this date must be on or after 9/11/2001. If the service indicated is OIF, this date must be on or after 3/19/2003. The meaning of this date depends on where the information was obtained from. If the data came from the VIS, Environmental Medicine or FHIE systems, this is the military pay end date for the assignment to the OEF/OIF operation. If it came from any other source, it is the date the patient actually left the OEF/OIF area.

Date/Time
DATA LOCKED .04 This is a flag that indicates the data is 'locked' at the site and can't be changed or deleted. This flag is set to 1 if the source of the data is the HEC system.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
RECORDED DATE/TIME .05 This is a time stamp for when the data was last added/updated.

Date/Time
ENTERED BY SITE .06 This is the facility where the data was originally entered. If the data's source was not from a facility, it will be assumed to be generated from HEC (CEV) and this field will be blank.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
MILITARY SERVICE EPISODE .3216 This contains the definitive military service episode history for the patient and is updated from the Health Eligibility Center (HEC) system. HEC is the authoritative source for this data and it may not be edited in VistA except to add new episodes.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SERVICE ENTRY DATE .01 For this veteran applicant, enter the date s/he commenced this episode of military service. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their first day of active duty for the episode. If the military service episode has been sent from the Health Eligibility Center (HEC), the data will be locked and cannot be edited or deleted.

Date/Time
SERVICE SEPARATION DATE .02 For this veteran applicant, enter the date s/he ended this episode of military service. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their last day of active duty for this episode. If the military service episode has been sent from the Health Eligibility Center (HEC), the data will be locked and cannot be edited or deleted.

Date/Time
SERVICE BRANCH .03 Enter the service branch for this episode of military service. If the military service episode has been sent from the Health Eligibility Center (HEC), the data will be locked and cannot be edited or deleted.

Pointer
PointerTo:
fileName:
BRANCH OF SERVICE
fileNumber:
23
SERVICE COMPONENT .04 For this veteran applicant, enter the military service component for this episode of military service. If the military service episode has been sent from the Health Eligibility Center (HEC), the data will be locked and cannot be edited or deleted. NATIONAL GUARD IS ONLY VALID FOR BRANCH OF SERVICE ARMY AND AIR FORCE.

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REGULAR
  • Code : V
    Stands For: ACTIVATED RESERVE
  • Code : G
    Stands For: ACTIVATED NG
SERVICE NUMBER .05 Enter the service number for this episode of military service.

Free Text
SERVICE DISCHARGE TYPE .06 For this veteran applicant, select from the available list the discharge type which s/he received for this episode of military service. If the military service episode has been sent from the Health Eligibility Center (HEC), the data will be locked and cannot be edited or deleted.

Pointer
PointerTo:
fileName:
TYPE OF DISCHARGE
fileNumber:
25
DATA LOCKED .07 When a military service episode is sent from HEC, the Data Locked field will be set to '1' (YES). The data in the military service episode can no longer be changed or deleted.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SERVICE VERIFICATION DATE .322 Once the service record has been verified enter the date of verification. All service record data will become uneditable to any user who does not hold the designated security key once the service record is verified. Only users who hold the designated security key may enter/edit this field.

Date/Time
PERSIAN GULF SERVICE? .32201 If this patient served in the Persian Gulf during the war (anytime after August 2, 1990), enter yes here. If the patient did not serve in the Persian Gulf during this timeframe, enter no. Enter unknown if this information could not be obtained from the patient.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
PERSIAN GULF FROM DATE .322011 If this patient served in the Persian Gulf during the war (PERSIAN GULF SERVICE? is answered YES), respond with the date the patient began serving there. The date must be on or after August 2, 1990.

Date/Time
PERSIAN GULF TO DATE .322012 If this patient served in the Persian Gulf during the war, enter the date the patient's service in that region ended. The date must be after the date selected as PERSIAN GULF FROM DATE which must be on or after August 2, 1990.

Date/Time
SOUTHWEST ASIA CONDITIONS? .322013 Enter "Y" if veteran claims need for care of conditions related to service in SW Asia. Enter "N" if veteran did not serve in SW Asia or does not claim need for care of conditions related to service in SW Asia. Enter "U" when veteran served in SW Asia, but is unsure of whether conditions may be related to that service. SW Asia Theater of operations is defined as: Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
SW ASIA COND REGISTRATION DATE .322014 This is the date on which the patient registered for being exposed to Conditions related to service in SW Asia. This date must be after 8/1/1990.

Date/Time
SW ASIA COND EXAM DATE .322015 This is the date on which an examination for exposure to Conditions related to service in SW Asia was performed on the patient.

Date/Time
SOMALIA SERVICE INDICATED? .322016 If this patient served in the Somalia, enter yes here. If the patient did not serve in Somalia, enter no. Enter unknown if this information could not be obtained from the patient.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
SOMALIA FROM DATE .322017 If this patient served in Somalia (SOMALIA SERVICE INDICATED? is answered YES), enter the date this patient's service in Somalia began. This date must be on or after September 28, 1992.

Date/Time
SOMALIA TO DATE .322018 This is the last date of service in Somalia. This date must be on or after September 28, 1992.

Date/Time
YUGOSLAVIA SERVICE INDICATED? .322019 Field stores code indicating if patient served in the Yugolslavia Conflict.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
YUGOSLAVIA FROM DATE .32202 Enter the date that service in the Yugoslavia Conflict began for this patient. Earliest possible date is 6/22/1992.

Date/Time
YUGOSLAVIA TO DATE .322021 The date service in the Yugoslavia Conflict ended for this patient.

Date/Time
LEBANON SERVICE INDICATED? .3221 Did this patient serve in Lebanon between the dates of August 23, 1982 and February 26, 1984?

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
LEBANON FROM DATE .3222 For this veteran applicant who served in Lebanon, enter the date which the applicant's service in Lebanon began. The date must be on or after October 1, 1983. .

Date/Time
LEBANON TO DATE .3223 For this patient, enter the date the patient's service in Lebanon ended. The 'LEBANON SERVICE INDICATED?' field must be answered yes and the date in this field must be after October 1, 1983.

Date/Time
GRENADA SERVICE INDICATED? .3224 Enter yes if this patient served in Grenada between the dates of October 23, 1983 and November 21, 1983.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
GRENADA FROM DATE .3225 Enter the date which this patient began service in Grenada. The 'GRENADA SERVICE INDICATED?' field must be answered YES and the date entered here must be between October 23, 1983 and November 21, 1983.

Date/Time
GRENADA TO DATE .3226 Enter the date which this patient's service in Grenada ended. The 'GRENADA SERVICE INDICATED?' field must be yes and this date must be between October 23, 1983 and November 21, 1983.

Date/Time
PANAMA SERVICE INDICATED? .3227 Respond yes if this patient served in Panama between the dates of December 20, 1989 and January 31, 1990. Enter no if the patient did not serve in Panama during this timeframe. Otherwise, enter unknown if this information could not be obtained from the patient.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
PANAMA FROM DATE .3228 If this patient served in Panama (PANAMA SERVICE INDICATED? is answered YES), enter the date this patient's service in Panama began. The date must be between December 20, 1989 and January 31, 1990.

Date/Time
PANAMA TO DATE .3229 If this patient served during the conflict in Panama (PANAMA SERVICE INDICATED? is YES), enter the date the patient's service there ended. The date must be between December 20, 1989 and January 31, 1990.

Date/Time
PERIOD OF SERVICE .323 From the available listing select the period of service which best classifies this applicant. The selections displayed are limited based on the eligibility code which must have been entered in order to select a period of service. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Pointer
PointerTo:
fileName:
PERIOD OF SERVICE
fileNumber:
21
SERVICE DISCHARGE TYPE [LAST] .324 For this veteran applicant select from the available listing the discharge type which s/he received for his/her most recent episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Pointer
PointerTo:
fileName:
TYPE OF DISCHARGE
fileNumber:
25
SERVICE BRANCH [LAST] .325 For this veteran applicant select from the available listing the branch of service served in during his/her most recent episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Pointer
PointerTo:
fileName:
BRANCH OF SERVICE
fileNumber:
23
SERVICE ENTRY DATE [LAST] .326 For this veteran applicant enter the date s/he commenced his/her most recent episode of military service. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their first day of active duty for the episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Date/Time
SERVICE SEPARATION DATE [LAST] .327 For this veteran applicant enter the date s/he ended his/her most recent episode of military service. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their last day of active duty for this episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Date/Time
SERVICE NUMBER [LAST] .328 For this veteran applicant enter the service number assigned during his/her most recent episode of military service as either 1-15 characters or enter 'SS' if the social security number and service number are the same. Once the service record has been verified only those users who hold the designated security key may enter/edit this field.

Free Text
SERVICE SECOND EPISODE? .3285 For this veteran applicant enter 'Y' if s/he has more than one episode of military service, or 'N' if not. Once the service record is verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SERVICE DISCHARGE TYPE [NTL] .329 For this veteran applicant who has at least two episodes of military service (ANY OTHER PERIODS OF SERVICE prompt must be answered YES) select from the available listing the type of discharge received from his/her next to last episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than one episode of military service is indicated.

Pointer
PointerTo:
fileName:
TYPE OF DISCHARGE
fileNumber:
25
SERVICE BRANCH [NTL] .3291 For this veteran applicant who has at least two episodes of military service (ANY OTHER PERIODS OF SERVICE prompt must be answered YES) select from the available listing the branch of service s/he served in during his/her next to last episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than one episode of military service is indicated.

Pointer
PointerTo:
fileName:
BRANCH OF SERVICE
fileNumber:
23
SERVICE COMPONENT [LAST] .32911 For this veteran applicant enter the military service component for his/her most recent episode of military service. Once the service record has been verified only those users who hold the designated security key may enter/edit this field. NATIONAL GUARD IS ONLY VALID FOR BRANCH OF SERVICE ARMY AND AIR FORCE.

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REGULAR
  • Code : V
    Stands For: ACTIVATED RESERVE
  • Code : G
    Stands For: ACTIVATED NG
SERVICE COMPONENT [NTL] .32912 For this veteran applicant who has at least two episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) enter the military service component for the next to last episode of service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated. NATIONAL GUARD IS ONLY VALID FOR BRANCH OF SERVICE ARMY AND AIR FORCE.

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REGULAR
  • Code : V
    Stands For: ACTIVATED RESERVE
  • Code : G
    Stands For: ACTIVATED NG
SERVICE COMPONENT [NNTL] .32913 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) enter the military service component for the third most recent episode of service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated. NATIONAL GUARD IS ONLY VALID FOR BRANCH OF SERVICE ARMY AND AIR FORCE.

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REGULAR
  • Code : V
    Stands For: ACTIVATED RESERVE
  • Code : G
    Stands For: ACTIVATED NG
SERVICE ENTRY DATE [NTL] .3292 For this veteran applicant who has at least two episodes of military service (ANY OTHER PERIODS OF SERVICE prompt must be answered YES) enter the date on which the next to last episode of service commenced. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their first day of active duty for the episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than one episode of military service is indicated.

Date/Time
SERVICE SEPARATION DATE [NTL] .3293 For this veteran applicant who has at least two episodes of military service (ANY OTHER PERIODS OF SERVICE prompt must be answered YES) enter the date on which the next to last episode of service ended. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their last day of active duty for this episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than one episode of military service is indicated.

Date/Time
SERVICE NUMBER [NTL] .3294 For this veteran applicant who has at least two episodes of military service (ANY OTHER PERIODS OF SERVICE prompt must be answered YES) enter the service number assigned to that next to last episode of service [1-15 characters]. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than one episode of military service is indicated.

Free Text
SERVICE THIRD EPISODE? .32945 Enter 'Y' if this veteran applicant has at least three episodes of military service, or 'N' if not. The ANY OTHER PERIODS OF SERVICE prompt must be answered YES in order to enter a third episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SERVICE DISCHARGE TYPE [NNTL] .3295 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) select from the available listing the discharge type received from the third most recent episode of military service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated.

Pointer
PointerTo:
fileName:
TYPE OF DISCHARGE
fileNumber:
25
SERVICE BRANCH [NNTL] .3296 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) select from the available listing the service branch served in during his/her third most recent episode of service. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated.

Pointer
PointerTo:
fileName:
BRANCH OF SERVICE
fileNumber:
23
SERVICE ENTRY DATE [NNTL] .3297 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) enter the date on which the third most recent episode of service commenced. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their first day of active duty for the episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated.

Date/Time
SERVICE SEPARATION DATE [NNTL] .3298 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) enter the date on which the third most recent episode of service ended. If the military service component is ACTIVATED NATIONAL GUARD or ACTIVATED RESERVE, the period entered should be the period of activation, so this date is their last day of active duty for this episode. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated.

Date/Time
SERVICE NUMBER [NNTL] .3299 For this veteran applicant who has at least three episodes of military service (ANOTHER PERIOD OF SERVICE prompt must be answered YES) enter the service number assigned for the third most recent episode of service [1-15 characters]. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as more than two episodes of military service are indicated.

Free Text
E-WORK PHONE NUMBER .33011 If the emergency contact for this patient is employed, enter the phone number at which this individual may be reached while at work.

Free Text
E-CONTACT CHANGE DATE/TIME .33012 This field will hold the date and time of the last Emergency Contact Update. Any change to the following Emergency Contact fields will trigger an update: E-Name, E-Relationship To Patient, E-Street Address [Line 1], E-Street Address [Line 2], E-Street Address [Line 3], E-City, E-State, E-Zip Code, E-Phone Number, E-Emer. Contact Same As NOK? and E-Work Phone Number

Date/Time
E-EMER. CONTACT SAME AS NOK? .3305 If a primary NOK is defined enter 'Y' if that person is also the primary emergency contact, otherwise enter 'N' for no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
E-NAME .331 Enter the name of the primary person to be contacted in the event of an emergency for this applicant [3-35 characters].

Free Text
E2-WORK PHONE NUMBER .331011 If the person designated as the secondary emergency contact is employed, enter the person's work phone number.

Free Text
E2-NAME OF SECONDARY CONTACT .3311 Enter the secondary emergency contact's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
E2-CONTACT CHANGE DATE/TIME .33112 This field will hold the date and time of the last Secondary Emergency Contact Update. Any change to the following Secondary Emergency Contact fields will trigger an update: E2-Name Of Secondary Contact, E2-Relationship To Patient, E2-Street Address [Line 1], E2-Street Address [Line 2], E2-Street Address [Line 3], E2-City, E2-State, E2-Zip Code, E2-Phone Number and E2-Work Phone Number

Date/Time
E2-RELATIONSHIP TO PATIENT .3312 If a secondary emergency contact is specified enter the relationship of that person to the applicant [2-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-STREET ADDRESS [LINE 1] .3313 If a secondary emergency contact is specified enter the first line of that person's street address [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-STREET ADDRESS [LINE 2] .3314 If a secondary emergency contact is specified enter the second line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-STREET ADDRESS [LINE 3] .3315 If a secondary emergency contact is specified enter the third line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-CITY .3316 If a secondary emergency contact is specified enter the city in which that person resides [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-STATE .3317 If a secondary emergency contact is specified select from the available listing the state in which that person resides, otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
E2-ZIP CODE .3318 If a secondary emergency contact is specified enter the zip code for the city in which s/he resides [5 numerics], otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E2-PHONE NUMBER .3319 If a secondary emergency contact is specified enter the telephone number at which that person may be reached [3-20 characters], otherwise nothing may be entered. This field cannot be deleted as long as a secondary emergency contact is on file.

Free Text
E-RELATIONSHIP TO PATIENT .332 If a primary emergency contact is specified enter the relationship of that person to the applicant [3-35 characters], otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-STREET ADDRESS [LINE 1] .333 If a primary emergency contact is specified enter the first line of that person's street address [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-STREET ADDRESS [LINE 2] .334 If a primary emergency contact is specified enter the second line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-STREET ADDRESS [LINE 3] .335 If a primary emergency contact is specified enter the third line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-CITY .336 If a primary emergency contact is specified enter the city in which that person resides [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-STATE .337 If a primary emergency contact is specified select from the available listing the state in which that person resides, otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
E-ZIP CODE .338 If a primary emergency contact is specified enter the zip code for the city in which s/he resides [5 numerics], otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
E-PHONE NUMBER .339 If a primary emergency contact is specified enter the telephone number [3-20 characters] at which that person may be reached, otherwise nothing may be entered. This field cannot be deleted as long as a primary emergency contact is on file.

Free Text
D-WORK PHONE NUMBER .34011 If the person designated to receive the patient's personal effects is employed, enter the phone number at which that person may be reached while at work.

Free Text
D-DESIGNEE SAME AS NOK? .3405 If a primary NOK is defined enter 'Y' if that person is also the designee appointed by the applicant, otherwise enter 'N' for no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
D-NAME OF DESIGNEE .341 Enter the designee's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-35 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
DESIGNEE CHANGE DATE/TIME .3412 This field will hold the date and time of the last Designee Update. Any change to the following Designee fields will trigger an update: D-Name Of Designee, D-Relationship To Patient, D-Street Address [Line 1], D-Street Address [Line 2], D-Street Address [Line 3], D-City, D-State, D-Zip Code, D-Phone Number, D-Designee Same As Nok?, D-Work Phone Number

Date/Time
D-RELATIONSHIP TO PATIENT .342 If a designee is specified enter the relationship of that person to the applicant [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-STREET ADDRESS [LINE 1] .343 If a designee is specified enter the first line of that person's street address [3-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-STREET ADDRESS [LINE 2] .344 If a designee is specified enter the second line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-STREET ADDRESS [LINE 3] .345 If a designee is specified enter the third line of that person's street address [3-30 characters], if necessary, otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-CITY .346 If a designee is specified enter the city in which that person resides [1-30 characters], otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-STATE .347 If a designee is specified select from the available listing the state in which that person resides. This field cannot be deleted as long as a designee is on file.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
D-ZIP CODE .348 If a designee is specified enter the zip code for the city in which s/he resides [5 numerics], otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
D-PHONE NUMBER .349 If a designee is specified enter the telephone number at which that person may be reached [3-20 characters], otherwise nothing may be entered. This field cannot be deleted as long as a designee is on file.

Free Text
DATE OF DEATH .351 Enter the date the patient died. Date needs to be a precise date, i.e. a day, month, and year MUST be included. Date of Death can not be prior to P&T Effective Date Date Ruled Incompetent (Civil and VA) Date of Birth

Date/Time
DEATH ENTERED BY .352 This field records the date a patient's death was initially entered into the DHCP system. This field is created automatically by the MAS module when a date of death is entered either through the 'Death Entry' option or through the 'Discharge a Patient' option.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SOURCE OF NOTIFICATION .353 This is a set of codes that represents who/what notified the VA of the Date of Death.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INPATIENT AT VAMC
  • Code : 2
    Stands For: NON-VA MEDICAL FACILITY
  • Code : 3
    Stands For: DEATH CERTIFICATE ON FILE
  • Code : 4
    Stands For: VBA
  • Code : 5
    Stands For: VA INSURANCE
  • Code : 6
    Stands For: SSA
  • Code : 7
    Stands For: NCA
  • Code : 8
    Stands For: NEXT OF KIN/FAMILY/FRIEND
  • Code : 9
    Stands For: OTHER
DATE OF DEATH LAST UPDATED .354 This is a date/time value that represents the date/time the date of death field (.351) was last modified/entered/deleted.

Date/Time
LAST EDITED BY .355 This is the local user ID of the person that last made a modification to the date of death (.351) field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COLLATERAL SPONSOR'S NAME .3601 If this patient is a collateral responsible for picking up medications or information regarding another patient, that patient's name should be entered here. This sponsor must be a veteran and must exist in the patient file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
MILITARY DISABILITY RETIREMENT .3602

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DISCHARGE DUE TO DISABILITY .3603

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PRIMARY ELIGIBILITY CODE .361 Select from the available listing the appropriate eligibility code for this applicant. For non-veteran applicants a wide variety of choices are available. For veteran applicants the choices are screened [in the following order] dependent on the responses to other prompts: 1. If the SERVICE CONNECTED prompt (field .301) is answered YES only the following two choices are available: a. If the SERVICE CONNECTED PERCENTAGE prompt (field .302) entered is 50% or greater 'SERVICE CONNECTED 50% TO 100%' can be selected. b. Otherwise, the percentage is assumed to be less than 50% and only 'SC, LESS THAN 50%' may be entered. 2. If the response to the WERE YOU A PRISONER OF WAR field (# .525) is YES and the veteran is not service connected, you must select PRISONER OF WAR as the eligibility code. 3. If the response to the CURRENT PH INDICATOR field (#.531) is YES and the veteran is not service connected and is not a Prisoner of War, you must select PURPLE HEART RECIPIENT as the eligibility code. 4. If the veteran is receiving VA benefits, but does not meet the criteria in items 1 and 2 above, then the following choices may be presented for selection: If RECEIVING A&A BENEFITS is answered YES, the eligibility code AID & ATTENDANCE may be selected. If the RECEIVING HOUSEBOUND BENEFITS is answered YES ,the eligibility code HOUSEBOUND may be selected. If the above two prompts were answered NO, but the RECEIVING A VA PENSION prompt was answered YES, only the NSC, VA PENSION prompt may be selected. 5. If none of the above pertain to this veteran, then the NSC eligibility will be available for selection. ** Dependent on the birthdate of the applicant, the following two eligibility codes may be displayed along with those shown in items 3 through 5 above: WORLD WAR I and MEXICAN BORDER WAR. These would display for veterans not meeting the criteria in items 1 and 2, but whose date of birth is prior to 1907.

Pointer
PointerTo:
fileName:
ELIGIBILITY CODE
fileNumber:
8
ELIGIBILITY STATUS .3611 Select from the available listing the appropriate eligibility status for this applicant. Only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PENDING VERIFICATION
  • Code : R
    Stands For: PENDING RE-VERIFICATION
  • Code : V
    Stands For: VERIFIED
ELIGIBILITY STATUS DATE .3612 Enter the effective date of the eligibility status (ELIG STATUS prompt). Only users who hold the designated security key may enter/edit this field.

Date/Time
ELIGIBILITY VERIF. SOURCE .3613 This field is used to restrict site ability to edit certain data elements when HEC has verified eligibility data.

Set of Codes
Set of Codes:
  • Code : H
    Stands For: HEC
  • Code : V
    Stands For: VISTA
ELIGIBILITY INTERIM RESPONSE .3614 If an interim response has been received concerning this applicant's eligibility status enter the date received. Only users who hold the designated security key may enter/edit this field.

Date/Time
ELIGIBILITY VERIF. METHOD .3615 Enter the method in which the eligibility for this applicant was verified [between 2-50 characters]. Only users who hold the designated security key may enter/edit this field.

Free Text
ELIGIBILITY STATUS ENTERED BY .3616 When eligibility is verified (ELIG STATUS="VERIFIED") the name of the user who certified the verification.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
USER ENROLLEE VALID THROUGH .3617 This field contains the Fiscal Year that the veteran's User Enrollee Status is valid through. This field is populated by the system, no user input is required.

Date/Time
USER ENROLLEE SITE .3618 This field contains the Site that determined the User Enrollee information for the Veteran. This field is populated by the system, no user input is required.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
DISABILITY RET. FROM MILITARY? .362

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES, RECEIVING MILITARY RETIREMENT
  • Code : 2
    Stands For: YES, RECEIVING MILITARY RETIREMENT IN LIEU OF VA COMPENSATION
  • Code : 3
    Stands For: UNKNOWN
RECEIVING A&A BENEFITS? .36205 For this veteran applicant enter 'Y' if s/he is on A&A, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF AID & ATTENDANCE .3621 For this veteran applicant who is receiving A&A benefits (ARE YOU IN RECEIPT OF A&A prompt must be answered YES) enter the amount received [numeric 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. Any dollar amount on file cannot be deleted as long as receipt of A&A benefits is indicated. f you wish to enter a monthly amount either preceed or follow the dollar figure with an asterisk and I'll multiply it out for you.

Numeric
RECEIVING HOUSEBOUND BENEFITS? .36215 For this veteran applicant enter 'Y' if s/he is housebound, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF HOUSEBOUND .3622 For this veteran applicant who is housebound (ARE YOU IN RECEIPT OF HB BENEFITS prompt must be answered YES) enter the amount received [a number between 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as receipt of housebound benefits is indicated. If you wish to enter a monthly amount either preceed of follow it with an asterisk and I'll multiply it out for you.

Numeric
RECEIVING SOCIAL SECURITY? .36225 For this veteran applicant enter 'Y' is s/he is in receipt of social security benefits, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
*AMOUNT OF SOCIAL SECURITY .3623 For this veteran applicant who is in receipt of social security insurance (IN RECEIPT OF SOCIAL SECURITY prompt must be answered YES) enter the amount received [a number between 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. This field may not be deleted as long as receipt of social security benefits is indicated. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
RECEIVING A VA PENSION? .36235 For this veteran applicant enter 'Y' if s/he is in receipt of a pension from the Dept of Veterans Affairs, 'N' if not, or 'U' if unknown. Answering "yes" will prompt you to enter a Pension Award Effective Date and Pension Award Reason. Once monetary benefits have been verified only users holding the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF VA PENSION .3624 For this veteran applicant who is in receipt of a pension from the Dept of Veterans Affairs (ARE YOU RECEIVING A VA PENSION prompt must be answered YES) enter the amount received [a number between 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. This field may not be deleted as long as receipt of VA pension is indicated. If you wish to enter a monthly amount either precede or follow it with an asterisk and I'll multiply it out for you.

Numeric
*AMOUNT OF MILITARY RETIREMENT .3625 For this veteran who is in receipt of military retirement (IN RECEIPT OF MILIT RETIREMENT prompt must be answered YES) enter the amount received [a number between 0-99999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as receipt of military retirement is indicated. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
RECEIVING MILITARY RETIREMENT? .36255 For this veteran applicant enter 'Y' if s/he receives a military retirement, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF GI INSURANCE .3626 For this veteran applicant who does have GI insurance (DO YOU HAVE GI INSURANCE prompt must be answered YES) enter the amount received [a number between 1 and 999999]. Once monetary benefits are verified only users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as the veteran is identified as holding GI insurance. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
GI INSURANCE POLICY? .36265 For this veteran applicant enter 'Y' if s/he has GI insurance, 'N' if not, or 'U' if unknown. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF SSI .3627 For this veteran applicant enter the dollar amount of social security insurance s/he receives [a number between 1-99999]. Leave blank if none received. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
RECEIVING SUP. SECURITY (SSI)? .36275 This field contains a yes or no reponse indicating whether this patient receives supplemental social security insurance. This field is being *'d for deletion and will be removed in a future release of MAS. This data is no longer updated by the MAS package.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
AMOUNT OF OTHER RETIREMENT .3628 For this veteran applicant enter the amount of other retirement s/he is in receipt of [a number between 1-99999]. Leave blank if none received. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiple it out for you.

Numeric
TYPE OF OTHER RETIREMENT .36285 For this veteran applicant choose from the available list the type of other retirement s/he is in receipt of, if any. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : B
    Stands For: BLACK LUNG
  • Code : M
    Stands For: MILITARY
  • Code : C
    Stands For: CIVIL
  • Code : R
    Stands For: RAILROAD
  • Code : O
    Stands For: OTHER
  • Code : X
    Stands For: COMBINATIONS OF TYPES
AMOUNT OF OTHER INCOME .3629 For this veteran applicant enter the amount of other personal income s/he is in receipt of [a number between 1-999999]. Leave blank if none. Once monetary benefits have been verified only users who hold the designated security key may enter/edit this field. If you wish to enter a monthly amount either preceed or follow it with an asterisk and I'll multiply it out for you.

Numeric
TOTAL ANNUAL VA CHECK AMOUNT .36295 If this applicant is receiving A&A, Housebound, Pension, and/or Disability payments from the VA (at least one of the YES/NO questions relating to the above must be answered YES), enter the annual amount received (0-99999). Once monetary benefits are verified, only users who hold the designated security key may enter/edit this field. This field may not be deleted as long as recipt of VA funds is indicated by one of the four fields related to A&A, Housebound, Pension, and Disability. If you wish to enter a monthly amount either precede or follow it with an asterisk and I'll multiply it out for you.

Numeric
PRIMARY LONG ID .363 This field contains the patient's long ID associated with the patient's PRIMARY ELIGIBILITY CODE. For most patients this is the Social Security Number. No user input is needed for this field. It is automatically updated when the PRIMARY ELIGIBILITY CODE field is entered and edited.

Free Text
PRIMARY SHORT ID .364 This field contains the patient's short ID associated with the patient's PRIMARY ELIGIBILITY CODE. For most patients this is the last four digits of the Social Security Number. No user input is needed for this field. It is automatically updated when the PRIMARY ELIGIBILITY CODE field is entered and edited.

Free Text
SERVICE DENTAL INJURY? .368 For this veteran applicant enter 'Y' if a dental injury was incurred while serving in the U.S. Armed Forces, or 'N' if not. Once the service record is verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SERVICE TEETH EXTRACTED? .369 For this veteran applicant enter 'Y' if teeth were extracted while serving in the U.S. Armed Forces, or 'N' if not. Once the service record is verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DATE OF DENTAL TREATMENT .37 For this veteran applicant who either incurred a dental injury (DENTAL INJURY IN SERVICE prompt must be answered YES) or had teeth extracted (TEETH EXTRACTED IN SERVICE prompt must be answered YES) while serving in the U.S. Armed Forces enter the date of dental treatment received. Once the service record is verified only users who hold the designated security key may enter/edit this field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE OF DENTAL TREATMENT .01

Date/Time
CONDITION 2 Enter the patient's condition on the date in which they received dental treatment. Also enter the place of treatment and from whom the treatment was received. This field allows entry of 3-100 characters.

Free Text
DATE CONDITION FIRST NOTICED 3 Enter the date the patient states s/he first noticed this dental condition.

Date/Time
RATED DISABILITIES (VA) .3721 From the available listing choose and enter conditions for which the applicant has been verified as being service connected. Only users who hold the designated security key may enter/edit this field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RATED DISABILITIES (VA) .01 From the available listing choose and enter conditions for which the applicant has been verified as being service connected.

Pointer
PointerTo:
fileName:
DISABILITY CONDITION
fileNumber:
31
DISABILITY % 2 Enter the percentage at which the VA rated this disability for this patient. Only users who hold the designated security key may enter/edit this field.

Numeric
SERVICE CONNECTED 3 Enter whether or not this rated disability was rated as service connected. Only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
EXTREMITY AFFECTED 4

Set of Codes
Set of Codes:
  • Code : BL
    Stands For: BOTH LOWER
  • Code : BU
    Stands For: BOTH UPPER
  • Code : RL
    Stands For: RIGHT LOWER
  • Code : RU
    Stands For: RIGHT UPPER
  • Code : LL
    Stands For: LEFT LOWER
  • Code : LU
    Stands For: LEFT UPPER
ORIGINAL EFFECTIVE DATE 5 Data will be stuffed from messages from the HEC. This field indicates the first date that this disability was evaluated.

Date/Time
CURRENT EFFECTIVE DATE 6 Data will be stuffed from messages from the HEC. This field indicates the most recent date that this disability was evaluated.

Date/Time
SERVICE CONNECTED CONDITIONS .3731 Enter conditions as stated by applicant for which s/he claims service connection [1-30 characters].

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SERVICE CONNECTED CONDITIONS .01 Enter conditions as stated by applicant for which s/he claims service connection.

Free Text
PERCENTAGE .02 Enter the percentage that the patient states this disability was rated at.

Numeric
ELIGIBLE FOR MEDICAID? .381 Enter yes if this patient is eligible to receive medicaid coverage. Otherwise, answer no.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DATE MEDICAID LAST ASKED .382 Enter the date/time the 'ELIGIBLE FOR MEDICAID' question was last asked of this veteran. This data must be asked on a yearly basis as it affects the requirement for a means test (a negative response results in a means test not being required). This field will be stored automatically by the MAS module when editing data on registration or load/edit screen 7. It will not appear for editing.

Date/Time
MEDICAID NUMBER .383 This is the patient's assigned MEDICAID number.

Free Text
PENSION AWARD EFFECTIVE DATE .3851 It is the Effective Date that the patient was awarded VA Pension Entitlement of Original Award by VBA. This field is optional. But if entered, must be a precise date (Month/Day/Year) (00/00/0000). This date cannot be a future date. This date also cannot be before the veteran's 16th birthday.

Date/Time
PENSION AWARD REASON .3852 Enter the Pension Award Reason only if VA Pension (#.36235) field is equal to "Yes". VistA users are only allowed to enter a Pension Award Reason of "Original Award" (106). This field is optional. If Pension Award Reason is entered, an Award Date must be entered.

Pointer
PointerTo:
fileName:
PENSION AWARD REASONS
fileNumber:
27.18
PENSION TERMINATED DATE .3853 The date that the Pension was terminated. The Pension Terminated Date is not editable.

Date/Time
PENSION TERMINATED REASON 1 .3854 The first Reason for the Pension Termination. This field is not editable.

Pointer
PointerTo:
fileName:
PENSION AWARD REASONS
fileNumber:
27.18
PENSION TERMINATED REASON 2 .3855 The second Reason for the Pension Termination. This field is not editable.

Pointer
PointerTo:
fileName:
PENSION AWARD REASONS
fileNumber:
27.18
PENSION TERMINATED REASON 3 .3856 The third Reason for the Pension Termination. This field is not editable.

Pointer
PointerTo:
fileName:
PENSION AWARD REASONS
fileNumber:
27.18
PENSION TERMINATED REASON 4 .3857 The fourth Reason for the Pension Termination. This field is not editable.

Pointer
PointerTo:
fileName:
PENSION AWARD REASONS
fileNumber:
27.18
CLASS II DENTAL INDICATOR .3858

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DENTAL APPL DUE BEFORE DATE .3859

Date/Time
PENSION INDICATOR LOCK .386 This field is used to restrict the site's ability to edit the Pension Indicator field 'RECEIVING A VA PENSION?'(#.36253) field. Once an incoming message is received from ESR with any Pension Data, the Pension Indicator field becomes 'display only' and is not editable by the VistA user.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PENSION AWARD LOCK .3861 This field is used to restrict the site's ability to edit the Pension Award fields 'PENSION AWARD EFFECTIVE DATE'(#.3851) field and 'PENSION AWARD REASON'(#.3852) field. Once an incoming message is received from ESR with a 'PENSION AWARD EFFECTIVE DATE'(#.3851) field and with a 'PENSION AWARD REASON' (#.3852) field of 'ORIGINAL AWARD', or with a 'PENSION TERMINATED REASON'(#.3854,#.3855, #.3856 or #.3857) field that does not have a NULL value, then the 'PENSION AWARD EFFECTIVE DATE' (#.3851) field and 'PENSION AWARD REASON' (#.3852) field become 'display only' and are not editable by the VistA user.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
VETERAN CATASTROPHICALLY DISABLED? .39 This field states whether or not the patient is a veteran who has been determined to meet the criteria for CATASTROPHICALLY DISABLED.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DECIDED BY .391 The name of the VA staff physician who made the determination that the patient was catastrophically disabled.

Free Text
DATE OF DECISION .392 The date the catastrophic disability determination was made.

Date/Time
FACILITY MAKING DETERMINATION .393 The VAMC that made the catastrophic disability determination.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
REVIEW DATE .394 The date that a review to determine Catastrophic Disability was made. This review may be a medical record review or physical exam review.

Date/Time
METHOD OF DETERMINATION .395 Added in order to document the review method of how the decision to assign a CD status was determined. Determination may be made by reviewing the veteran's medical record or by performing a physical examination of the veteran. In the future, the capability to fully automate the record review process will be added to the system.

Set of Codes
Set of Codes:
  • Code : 2
    Stands For: MEDICAL RECORD REVIEW
  • Code : 3
    Stands For: PHYSICAL EXAMINATION
DATE VETERAN REQUESTED CD EVAL .3951

Date/Time
DATE FACILITY INITIATED REVIEW .3952

Date/Time
DATE VETERAN WAS NOTIFIED .3953

Date/Time
CD STATUS DIAGNOSES .396

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CD STATUS DIAGNOSES .01 Veterans having one of the following diagnoses shall be determined catastrophically disabled.

Pointer
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fileName:
CATASTROPHIC DISABILITY REASONS
fileNumber:
27.17
CD STATUS PROCEDURES .397

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CD STATUS PROCEDURES .01 The veteran shall be determined Catastrophically Disabled if he/she has two of the following procedures (ICD-9 Procedure Codes 84.03 through 84.19) and/or certain CPT Codes provided the two procedures were not on the same limb.

Pointer
PointerTo:
fileName:
CATASTROPHIC DISABILITY REASONS
fileNumber:
27.17
AFFECTED EXTREMITY 1

Set of Codes
Set of Codes:
  • Code : RUE
    Stands For: Right Upper Extremity
  • Code : LUE
    Stands For: Left Upper Extremity
  • Code : RLE
    Stands For: Right Lower Extremity
  • Code : LLE
    Stands For: Left Lower Extremity
CD STATUS CONDITIONS .398

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CD STATUS CONDITIONS .01 The veteran shall be determined Catastrophically Disabled if he/she has one of the following conditions: - Dependent in three or more ADLs, with at least three of the dependencies being permanent, using the Katz Scale. - A score of 10 or lower using the Folstein Mini-Mental State Examination. - A score of 2 or lower on at least 4 of the 13 motor items using the Functional Independence Measure (FIM) - A score of 30 or lower using the Global Assessment of Functions in (GAF)

Pointer
PointerTo:
fileName:
CATASTROPHIC DISABILITY REASONS
fileNumber:
27.17
SCORE 1 NOTE: This field does not always contain the veteran's raw test score. Sometimes you must enter specific information about the score that may apply to the determination of Catastrophic Disability. See the help text above for more details.

Numeric
PERMANENT INDICATOR 2

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PERMANENT
  • Code : 2
    Stands For: NOT PERMANENT
  • Code : 3
    Stands For: UNKNOWN
CD HISTORY DATE .399

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CD HISTORY DATE .01 This sub-file stores the history of the PATIENT's Catastrophic Disability Eligibility information.

Date/Time
VETERAN CATASTROPHICALLY DISABLED? .39

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DECIDED BY .391 Captures a historical value of DECIDED BY (#.391) field in PATIENT file.

Free Text
DATE OF DECISION .392 Captures historical value of PATIENT field #.392 DATE OF DECISION.

Date/Time
FACILITY MAKING DETERMINATION .393 Captures a historical value of the FACILITY MAKING DETERMINATION field (#.393) of the PATIENT file.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
REVIEW DATE .394 Captures a historical value of the PATIENT file's REVIEW DATE field (#.394).

Date/Time
METHOD OF DETERMINATION .395 This sub-field stores the historical value of the PATIENT file's METHOD OF DETERMINATION field (#.395).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: AUTOMATED RECORD REVIEW
  • Code : 2
    Stands For: MEDICAL RECORD REVIEW
  • Code : 3
    Stands For: PHYSICAL EXAMINATION
DATE VETERAN REQUESTED CD EVAL .3951

Date/Time
DATE FACILITY INITIATED REVIEW .3952

Date/Time
DATE VETERAN WAS NOTIFIED .3953

Date/Time
CD REASON .396

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CD REASON .01 This sub-field will contain pointers to the CD REASONS file (#27.17), as well as the supporting data stored in the CD STATUS DIAGNOSES (#.396), PROCEDURES (#.397) and CONDITIONS (#.398) fields.

Pointer
PointerTo:
fileName:
CATASTROPHIC DISABILITY REASONS
fileNumber:
27.17
AFFECTED EXTREMITY 1 Stores the historical value of the AFFECTED EXTREMITY sub-field (#1) in the CD STATUS PROCEDURES (#.397) of the PATIENT file (#2).

Set of Codes
Set of Codes:
  • Code : RUE
    Stands For: RIGHT UPPER EXTREMITY
  • Code : LUE
    Stands For: LEFT UPPER EXTREMITY
  • Code : RLE
    Stands For: RIGHT LOWER EXTREMITY
  • Code : LLE
    Stands For: LEFT LOWER EXTREMITY
SCORE 2 This field stores a historical value for the SCORE subfield (#1) of the CD STATUS CONDITIONS field (#.398) of the PATIENT file (#2).

Numeric
PERMANENT INDICATOR 3 This subfield stores a historical value of the PERMANENT INDICATOR subfield (#2) of the CD STATUS CONDITIONS field (#.398) of the PATIENT file (#2).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PERMANENT
  • Code : 2
    Stands For: NOT PERMANENT
  • Code : 3
    Stands For: UNKNOWN
POW STATUS INDICATED? .525 For this veteran applicant enter 'Y' if s/he was confined as a prisoner of war, 'N' if not, or 'U' if unknown. Once the POW Status is verified by the HEC, it is no longer editable.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
POW CONFINEMENT LOCATION .526 For this veteran applicant who was confined as a prisoner of war (WERE YOU A PRISONER OF WAR prompt must be answered YES) enter the war during which confined. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as applicant is identified as a former POW.

Pointer
PointerTo:
fileName:
POW PERIOD
fileNumber:
22
POW FROM DATE .527 For this veteran applicant who was confined as a prisoner of war (WERE YOU A PRISONER OF WAR prompt must be answered YES) enter the date on which confinement commenced. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as applicant is identified as a former POW.

Date/Time
POW TO DATE .528 For this veteran applicant who was confined as a prisoner of war (WERE YOU A PRISONER OF WAR prompt must be answered YES) enter the date on which confinement ended. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as applicant is identified as a former POW.

Date/Time
POW STATUS VERIFIED .529 This field contains the date/time that the POW status was received from HEC. Once the POW status has been received from HEC, it can no longer be edited by the site.

Date/Time
COMBAT SERVICE INDICATED? .5291 For this veteran applicant enter 'Y' if s/he served in a combat zone, or 'N' if not. Once the service record is verified only users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
COMBAT SERVICE LOCATION .5292 For this veteran applicant who served in a combat zone (IN COMBAT prompt must be answered YES) enter the zone in which s/he served. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as combat service is indicated.

Pointer
PointerTo:
fileName:
POW PERIOD
fileNumber:
22
COMBAT FROM DATE .5293 For this veteran who served in a combat zone (IN COMBAT prompt must be answered YES) enter the date on which combat service commenced. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as combat service is indicated.

Date/Time
COMBAT TO DATE .5294 For this veteran who served in a combat zone (IN COMBAT prompt must be answered YES) enter the date on which combat service ended. Once the service record is verified only those users who hold the designated security key may enter/edit this field. This field cannot be deleted as long as combat service is indicated.

Date/Time
COMBAT VETERAN END DATE .5295 This field represents the last day for combat vet eligibility. This field will only be populated by cross-reference when the veteran's combat vet eligibility has been determined. This value will remain after the combat vet eligibility period has expired.

Date/Time
CV DATE EDITED .5296 The CV DATE EDITED field will be stuffed with the current date whenever the COMBAT VET END DATE field (.5295) is changed.

Date/Time
CURRENT PH INDICATOR .531 This field can be entered by the local site if currently null. Subsequent editing can be done only by the HEC. A response of 'Yes' can be entered only if the patient is a veteran,

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CURRENT PURPLE HEART STATUS .532 This field cannot be edited locally. If Current Purple Heart Indicator is set to 'Yes' by the local site, a Current Purple Heart Status of 'Pending' will be stuffed into the field. Other editing or updating is done by the HEC.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PENDING
  • Code : 2
    Stands For: IN PROCESS
  • Code : 3
    Stands For: CONFIRMED
CURRENT PURPLE HEART REMARKS .533 This field cannot be edited locally. If Current Purple Heart Indicator isset to 'No' by the local site, a Current Purple Heart Remarks of 'VAMC' will be stuffed into the field. Other editing or updating is done by the HEC.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: UNACCEPTABLE DOCUMENTATION
  • Code : 2
    Stands For: NO DOCUMENTATION REC'D
  • Code : 3
    Stands For: ENTERED IN ERROR
  • Code : 4
    Stands For: UNSUPPORTED PURPLE HEART
  • Code : 5
    Stands For: VAMC
  • Code : 6
    Stands For: UNDELIVERABLE MAIL
PH DIVISION .535 When site enters a value for CURRENT PH Indicator, a prompt for PH Division will appear. This field will point to the INSTITUTION file (#4), and will hold the division where the PH request was initiated.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CURRENT MOH INDICATOR .541 This field cannot be edited in VistA. It is set by the Z11 Upload from HEC. A response of 'YES' or 'NO' is indicated only if the patient is a veteran.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TEST PATIENT INDICATOR .6

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ALIAS 1 If this applicant is known by any name other than that entered in the NAME field enter that/those other name(s) here. Any entry to this field will be cross-referenced and the applicant may be called up using this alias.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ALIAS .01 Enter the alias name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-50 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
ALIAS SSN 1 If the patient was also known under a name other than that listed in the NAME field of the PATIENT file, enter the social security number used when the patient used this alias.

Free Text
ALIAS COMPONENTS 100.03

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
NAME COMPONENTS 1.01

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
K-NAME COMPONENTS 1.02

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
K2-NAME COMPONENTS 1.03

Pointer
PointerTo:
fileName:
NAME COMPONENTS
fileNumber:
20
FATHER'S NAME COMPONENTS 1.04

Pointer
PointerTo:
fileName:
NAME COMPONENTS
fileNumber:
20
MOTHER'S NAME COMPONENTS 1.05

Pointer
PointerTo:
fileName:
NAME COMPONENTS
fileNumber:
20
MOTHERS MAIDEN NAME COMPONENTS 1.06

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
E-NAME COMPONENTS 1.07

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
E2-NAME COMPONENTS 1.08

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
D-NAME COMPONENTS 1.09

Pointer
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fileName:
NAME COMPONENTS
fileNumber:
20
RACE INFORMATION 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RACE INFORMATION .01 Patient's race

Pointer
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fileName:
RACE
fileNumber:
10
METHOD OF COLLECTION .02 Method used to collect patient's race

Pointer
PointerTo:
fileName:
RACE AND ETHNICITY COLLECTION METHOD
fileNumber:
10.3
ENROLLMENT CLINIC 3 This multiple field contains the data relating to clinic enrollments for this patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENROLLMENT CLINIC .01

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ENROLLMENT DATA 1 This multiple contains the pertinant data relating to this patients enrollment in this clinic. Data contained in this multiple includes the date the patient was enrolled, the date of discharge from the clinic and whether the patient was seen on an outpatient or ambulatory care basis.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE OF ENROLLMENT .01 Enter the date this patient was initially enrolled in this clinic.

Date/Time
OPT OR AC 1 Enter O if the patient is being seen by this clinic on an outpatient basis. Enter A if the patient is being seen for ambulatory care.

Set of Codes
Set of Codes:
  • Code : O
    Stands For: OPT
  • Code : A
    Stands For: AC
SERVICE 2 This is a computed field which returns the service of the clinic in which this patient is (was) enrolled.

Computed
DATE OF DISCHARGE 3 This field contains the date this patient was discharged from this clinic.

Date/Time
REASON FOR DISCHARGE 4 If the patient has been discharged from this clinic, this field contains the reason the patient was discharged. This is a free text field which allows up to 80 characters to be entered.

Free Text
REVIEW DATE 5 Enter the date on which this patients enrollment in this particular clinic was last reviewed.

Date/Time
CURRENT STATUS 2 This field will contain 'I' for inactive if this patient is no longer enrolled in this clinic (patient has been discharged from the clinic).

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INACTIVE
ETHNICITY INFORMATION 6

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ETHNICITY INFORMATION .01 Patient's ethnicity

Pointer
PointerTo:
fileName:
ETHNICITY
fileNumber:
10.2
METHOD OF COLLECTION .02 Method used to collect patient's ethnicity

Pointer
PointerTo:
fileName:
RACE AND ETHNICITY COLLECTION METHOD
fileNumber:
10.3
CURRENT ENROLLMENT 27.01 The patient's current enrollment.

Pointer
PointerTo:
fileName:
PATIENT ENROLLMENT
fileNumber:
27.11
PREFERRED FACILITY 27.02 The facility that the patient chooses to designate as his preferred location for care. The facility must have one of the following facility types: CBOC (Community Based Outpatient Clinic) HCS (Health Care System) HEALTHCARE (VA Boston Health Care System) M&ROC (Medical and Regional Office Center) MOC (Mobile Outpatient Clinic) MORC (Mobile Outreach Clinic) NETWORK (VA Healthcare Network Upstate NY) NHC (Nursing Home Care) OC (Outpatient Clinic - Independent) OCMC (Outpatient Clinic - Subordinate) OCS (Outpatient Clinic Substation) OPC (Out Patient Clinic) ORC (Outreach Clinic) RO-OC (Regional Office - Outpatient Clinic) SATELLITE (Satellite Outpatient Clinic) SOC (Satellite Outpatient Clinic) VAMC (VA Medical Center) VANPH (Neural Psychiatric Hospital) VA ROSEBERG (VA Roseburg Health Care System)

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
SOURCE DESIGNATION 27.03 Source designation contains the value of the place the Preferred Facility field (#27.02) was assigned for the patient. Source designation is automatically assigned by the system. The VistA system can only assign a Preferred Facility if the current Source Designation is VistA or Primary Care Provider (PCP) Inactive.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VISTA
  • Code : E
    Stands For: ESR
  • Code : PA
    Stands For: PCP ACTIVE
  • Code : PI
    Stands For: PCP INACTIVE
*REACTIONS 53

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
*HEIGHT(cm) 57.1

Numeric
*WEIGHT(kg) 57.2

Numeric
SPINAL CORD INJURY 57.4 If this patient does not have a spinal cord injury, enter X for not applicable in this field. Otherwise, if the patient does have a spinal cord injury, choose from the other available choices the one

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PARAPLEGIA-TRAUMATIC
  • Code : 2
    Stands For: QUADRIPLEGIA-TRAUMATIC
  • Code : 3
    Stands For: PARAPLEGIA-NONTRAUMATIC
  • Code : 4
    Stands For: QUADRIPLEGIA-NONTRAUMATIC
  • Code : X
    Stands For: NOT APPLICABLE
LABORATORY REFERENCE 63 This field contains the internal entry number of this patient in the LAB DATA file. This data is entered and maintained by the laboratory package and must NOT be edited under any circumstances. Editing of this data could cause severe repercussions in the laboratory package.

Pointer
PointerTo:
fileName:
LAB DATA
fileNumber:
63
LAB REFERRAL REF 67 This field contains the pointer reference to the Referral file of the Laboratory Package. This field is set by the laboratory accessioning software and should not be edited. Changing of this pointer will result IN misidentification of patients that could have dire medical repercussions.

Pointer
PointerTo:
fileName:
REFERRAL PATIENT
fileNumber:
67
CNH CURRENT 148 This field is used to denote when a patient is currently in a contract nursing home. Answer yes if the patient is in a contract nursing home currently. Otherwise, answer no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DENTAL CLASSIFICATION 220 For Dental Package

Pointer
PointerTo:
fileName:
DENTAL CLASSIFICATION
fileNumber:
220.2
DENTAL ELIGIBILITY EXPIRATION 220.1 For Dental Eligibility

Date/Time
PATIENT ELIGIBILITIES 361 This multiple contains all eligibilities under which this patient can receive care. This includes his primary eligibility and all other eligibilities he may have.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ELIGIBILITY .01 Enter all eligibilities under which this patient may receive care. The patients primary eligibility as well as all other eligibilities he is entitled to is stored in this multiple.

Pointer
PointerTo:
fileName:
ELIGIBILITY CODE
fileNumber:
8
LONG ID .03 This field contains the patient's long ID associated with the patient's ELIGIBILITY. For most eligibilities this is the Social Security Number. This field is triggered by the 'ELIGILBILTY(#.01)' field. It is user defined only if this eligibility's id format allows this user interaction as indicated by the 'PROMPT USER FOR ID?(#.02)' field of the 'IDENTIFICATION FORMAT(#8.1)' file.

Free Text
SHORT ID .04 This field contains the patient's short ID associated with the patient's ELIGIBILITY. For most eligibilities, this is the last four digits of the Social Security Number. This field is uneditable and triggered by the 'LONG ID(#.03)' field.

Free Text
TYPE 391 Enter the patient type for this patient. This is selectable from the distributed entries in the TYPE OF PATIENT file. The type selected should be the primary one selectable. For example, if the patient is both an NSC veteran and an employee, the patient type should be NSC VETERAN, not employee. This field is used by the registration screen processor to determine which screens will be editable for this patient. The selection of which screens can be viewed for which types of patients can be made through the 'Patient Type Update' option.

Pointer
PointerTo:
fileName:
TYPE OF PATIENT
fileNumber:
391
CONDITION 401.3 Enter 'S' if the patient is seriouslly ill and should be displayed on the Seriouslly Ill Roster. Enter '@' to delete patient from seriouslly ill status.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: SERIOUSLY ILL
DATE ENTERED ON SI LIST 401.4 Enter the date the patient was placed on the Seriouslly Ill list.

Date/Time
*CURRENT PC PRACTITIONER 404.01 This field stores the patient's Current Primary Care Practitioner.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
*CURRENT PC TEAM 404.02 This field contains the patients's Primary Care Team.

Pointer
PointerTo:
fileName:
TEAM
fileNumber:
404.51
PH DATE/TIME UPDATED 534

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PH DATE/TIME UPDATED .01 This field is automatically stuffed with the current date and time whenever the Purple Heart data is updated. This may be done initially by the local site, then subsequently by HEC.

Date/Time
PH? 1 Field will be stuffed with the CURRENT PURPLE HEART INDICATOR at the date/time of the update.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PH STATUS 2 Field will be stuffed with CURRENT PURPLE HEART STATUS (if any) at date/time of the update.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PENDING
  • Code : 2
    Stands For: IN PROCESS
  • Code : 3
    Stands For: CONFIRMED
PH REMARKS 3 Field will be stuffed with CURRENT PURPLE HEART REMARKS field, if any, at time of update.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: UNACCEPTABLE DOCUMENTATION
  • Code : 2
    Stands For: NO DOCUMENTATION REC'D
  • Code : 3
    Stands For: ENTERED IN ERROR
  • Code : 4
    Stands For: UNSUPPORTED PURPLE HEART
  • Code : 5
    Stands For: VAMC
  • Code : 6
    Stands For: UNDELIVERABLE MAIL
PH USER 4 Field will be stuffed with the user who updated PH information. If local user, then the value will be the free text user name from the NEW PERSON file. If updated by the HEC, then the value will be "HEC User".

Free Text
INTEGRATION CONTROL NUMBER 991.01 Machine to machine identifier for a patient.

Numeric
ICN CHECKSUM 991.02 This checksum is the calculated checksum for the Integration Control Number. It verifies the integrity of the ICN.

Free Text
COORDINATING MASTER OF RECORD 991.03 The coordinating site for the patient.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
LOCALLY ASSIGNED ICN 991.04 DESIGNATES THAT THE ICN BELONGING TO THIS PATIENT IS LOCAL

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
SUBSCRIPTION CONTROL NUMBER 991.05 This field points to a list of subscribers to this patient's data. For example, see details of the MPI/PD messaging implementation. The subscriber list is specific to this patient. Do not change the subscription control number without remembering to update the current subscriber list in file 774 (SUBSCRIPTION CONTROL). Use only documented API calls to create a new subscription control number for a patient.

Pointer
PointerTo:
fileName:
SUBSCRIPTION CONTROL
fileNumber:
774
CMOR ACTIVITY SCORE 991.06 This score is used to determine the Coordinating Master of Record.

Numeric
SCORE CALCULATION DATE 991.07 This is the last date that the CMOR ACTIVITY SCORE was calculated at this site.

Date/Time
TEMPORARY ID NUMBER 991.08 The Department of Defense (DoD) Defense Eligibility Enrollment Reporting System (DEERS) uses a Temporary Identification Number for individuals (e.g., babies) who do not have or have not provided a Social Security Number (SSN) when the record is added to DEERS. It is used for military dependents only. This DoD TEMPORARY ID NUMBER will be used by the Master Veteran Index to support the linking of patient records across VA and DoD.

Free Text
FOREIGN ID NUMBER 991.09 The Department of Defense (DoD) Defense Eligibility Enrollment Reporting System (DEERS) uses a Foreign Identification Number for foreign military and foreign nationals when the record is added to DEERS. This DoD FOREIGN ID NUMBER will be used by the Master Veteran Index to support the linking of patient records without a given Social Security Number (SSN) across VA and DoD.

Free Text
ICN HISTORY 992

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ICN HISTORY .01 ICN History, to track changes in Integration Control Number for each patient. This will be used by mumps code to perform lookups when ICN can't be found to see if it was used previously.

Numeric
ICN CHECKSUM 1 ICN Checksum for ICN entered in multiple.

Numeric
CMOR 2 CMOR at the time of the ICN change.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
DATE/TIME OF CHANGE 3 Date/Time of change to the ICN.

Date/Time
CMOR HISTORY 993

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CMOR HISTORY .01 Primary Care site for patient at time of change.

Numeric
CMOR ACTIVITY SCORE 1 CMOR score at time of change.

Numeric
CMOR SCORE CALCULATION DATE 2 Date CMOR score was last calculated at time of change.

Date/Time
CMOR CHANGE DATE 3 Date CMOR was changed.

Date/Time
MULTIPLE BIRTH INDICATOR 994 The MULTIPLE BIRTH INDICATOR will designate whether or not the patient is part of a multiple birth (i.e. to identify twins, etc.).

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NO
  • Code : Y
    Stands For: *MULTIPLE BIRTH*
ABSENCE DIVISION 999 Computed field used in Absence list. For programmers only.

Computed
INPATIENT WARD 999.1 For use in historical inpatient list. For programmers only

Computed
LAST MEANS TEST 999.2

Computed
DISPOSITION LOG-IN DATE/TIME 1000 The date/time at which this applicant applied for medical benefits, e.g., was registered for care using the 'Registration' option of ADT. This multiple contains information on each registration entered for this patient including the date of registration, date of disposition, and type of disposition.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOG IN DATE/TIME .01 The date/time the patient was registered using the 'Register a Patient' option in ADT should be entered into this field. Registrations must be entered using the ADT module and should not be entered or edited using VA FileMan options.

Date/Time
10-10T REGISTRATION .2 Was the patient registered using the 10-10T

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
STATUS 1 ter the appropriate code indicating the status of the patient's visit. Enter 0 if this patient had a 1010 visit (application for care). Enter 1 if the patient's visit was not scheduled. Enter 2 if no exam was needed. This data is used by the AMIS 400 series reports.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: 10/10 VISIT
  • Code : 1
    Stands For: UNSCHEDULED
  • Code : 2
    Stands For: APPLICATION WITHOUT EXAM
TYPE OF BENEFIT APPLIED FOR 2 Enter the type of care this patient has applied for whether it be inpatient (dom, hospital, or nursing home) or outpatient (dental, or non-dental).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: HOSPITAL
  • Code : 2
    Stands For: DOMICILIARY
  • Code : 3
    Stands For: OUTPATIENT MEDICAL
  • Code : 4
    Stands For: OUTPATIENT DENTAL
  • Code : 5
    Stands For: NURSING HOME CARE
TYPE OF CARE APPLIED FOR 2.1 Enter the type of care that the patient is requesting service for. If the patient will be receiving treatment for plastic surgery, dental care, sterilization, or pregnancy, enter that choice. Otherwise, enter all other.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DENTAL
  • Code : 2
    Stands For: PLASTIC SURGERY
  • Code : 3
    Stands For: STERILIZATION
  • Code : 4
    Stands For: PREGNANCY
  • Code : 5
    Stands For: ALL OTHER
FACILITY APPLYING TO 3 Enter the facility (division) at which this patient will be receiving care. This is a pointer to the MEDICAL CENTER DIVISION file.

Pointer
PointerTo:
fileName:
MEDICAL CENTER DIVISION
fileNumber:
40.8
WHO ENTERED 10/10 4 The user who entered the registration (1010 application) for this patient will automatically be stored in this field. This field can be used for tracking purposes. It should NOT be edited.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOG OUT DATE TIME 5 Enter in this field the date/time the patient was dispositioned.

Date/Time
DISPOSITION 6 Enter the type of disposition this patient had. Choose from the available list whether the patient was scheduled for a future appointment, admitted to your facility or another facility, or was released from care without exam, for example. Many other choices also exist.

Pointer
PointerTo:
fileName:
DISPOSITION
fileNumber:
37
REASON FOR LATE DISPOSITION 8 As part of the 'MAS Parameter Entry/Edit' option, a site can determine how may hours must elapse before a disposition is considered to be entered late. If the time between the registration (log-in) date/time and the disposition (log-out) date/time is found to be more than the number of hours specified in the MAS parameters, the user will be prompted with a reason for the late disposition. This is a pointer to the DISPOSITION LATE REASON file.

Pointer
PointerTo:
fileName:
DISPOSITION LATE REASON
fileNumber:
30
WHO DISPOSITIONED 9 When a user dispositions a patient, the name of the user will automatically be entered into this field. This field can be used for tracking purposes at the site and should not be edited.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DESCRIPTION OF INCIDENT 10 If the patient was injured in an accident, a brief description (from 3-250 characters) should be entered detailing what caused the injury.

Free Text
*ELIGIBLE FOR MEDICAID 12 If this patient is eligible for medicaid, enter yes in this field. Otherwise, entere no. This field is used for billing purposes.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
REGISTRATION ELIGIBILITY CODE 13 When a patient is registered, the user registering the patient will be asked for the patient's eligibility under which they are receiving care. The default will be the primary eligibility code. However, if the patient also has other entitled eligibilities (employee, for example), one of the other eligibilities may also be entered.

Pointer
PointerTo:
fileName:
ELIGIBILITY CODE
fileNumber:
8
ELIG VERIFIED AT REGISTRATION 14 If the eligibility was verified at the time of registration, this field will be YES. Otherwise, it will be NO.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SC AT REGISTRATION 15 If the patient being registered was SC (as determined by the SERVICE CONNECTED? field on screen 7 of registration) at the time this application was entered, YES will be stuffed into this field. Otherwise NO will be filled in here.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SC% AT REGISTRATION 16 If the patient was service connected at the time of this registration (as determined by the SERVICE CONNECTED? field on registration screen 7), the service connected percentage should be entered here. The default value will be the percentage entered on registration screen 7.

Numeric
AMIS 420 SEGMENT 17 The AMIS 400 series reports are generated based on data in the DISPOSITION LOG-IN DATE/TIME multiple. When an application is dispositioned, it is deterined by the module which AMIS segment (401-420) this registration should fall into. This information is created automatically by the MAS module.

Pointer
PointerTo:
fileName:
AMIS SEGMENT
fileNumber:
391.1
OUTPATIENT ENCOUNTER 18

Pointer
PointerTo:
fileName:
OUTPATIENT ENCOUNTER
fileNumber:
409.68
ENCOUNTER CONVERSION STATUS 19 This field indicates whether or not this disposition was converted during the ACRP Database Conversion (SD*5.3*211). The field is set to '1' after the disposition has been converted by the conversion software.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT CONVERTED
  • Code : 1
    Stands For: CONVERTED
NEED RELATED TO OCCUPATION 20 If the need for care is related to an injury or condition acquired while the patient was performing work-related duties, yes should be entered here. Otherwise, no should be entered.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
WORKMEN'S COMP CLAIM FILED 21 If the injury or condition for which this patient is being treated occurred while performing duties necessary for his/her job and the patient entered a workmen's compensation claim for this injury or condition, enter yes here. Otherwise, enter no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
WORKMEN'S COMP CLAIM NUMBER 22 If this patient is being seen for an injury or condition s/he received while performing work related duties and s/he filed a claim with workmen's compensation, enter the claim number here. Otherwise, leave this field blank.

Free Text
NEED RELATED TO AN ACCIDENT 23 If the injury or condition for which this patient is being treated was the result of an accident, enter yes here. Otherwise, answer no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
INJURY CAUSED BY 24 If the reason this patient is being seen at the medical center is due to an injury sustained, enter what caused the injury. Otherwise, leave this field blank.

Free Text
INJURING PARTIES INSURANCE 25 If the reason this patient is being seen at this medical center is due to an injury sustained and there is a liable party, enter that party's insurance policy number. Otherwise, leave this field blank.

Pointer
PointerTo:
fileName:
INSURANCE COMPANY
fileNumber:
36
FILED AGAINST INJURING PARTY 26 If this patient is being seen is due to an injury resulting from another person's negligence, enter yes here if a claim has been filed against the other party's insurance company. Otherwise, answer no.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
ATTORNEY'S NAME 30 Enter the attorney's name in 'LAST,FIRST MIDDLE SUFFIX' format. This value must be 3-30 characters in length and may contain only uppercase alpha characters, spaces, apostrophes, hyphens and one comma. All other characters and parenthetical text will be removed.

Free Text
A-ADDRESS 1 31 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the first line the street address for the attorney.

Free Text
A-ADDRESS 2 32 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the second line of the street address for the attorney.

Free Text
A-ADDRESS 3 33 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the third line of the street address for the attorney.

Free Text
A-CITY 34 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the city where the attorney practices.

Free Text
A-STATE 35 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the the state where the attorney practices.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
A-ZIP CODE 36 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the zip code of the attorney's address.

Free Text
A-PHONE 37 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the the attorney's business phone number.

Free Text
A-ZIP+4 38 If the patient is being treated for an injury sustained due to the negligence of another and the patient has an attorney covering the incident, enter the zip code of the attorney's address. Answer with either the 5 digit format (e.g. 12345) or the nine digit format (e.g. 12345-6789 or 123456789).

Free Text
ACTIVE 50 If this registration is currently active (not dispostioned) a 1 will be stored in this field. Otherwise, the field should be left blank.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ACTIVE
PROGRAMMERS USE 99 Used to speed reporting in Multidivisional Facilities. Fileman can not sort by same field twice

Computed
ATTORNEY'S NAME COMPONENTS 100.21

Pointer
PointerTo:
fileName:
NAME COMPONENTS
fileNumber:
20
ODS AT REGISTRATION? 11500.01 Enter yes if this patient was an ODS patient at the time of this registration. Otherwise, respond no. this registration. Otherwise, respond no.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ODS REGISTRATION ENTRY 11500.02 Enter the entry in the ODS REGISTRATIONS file which corresponds to this registration.

Pointer
PointerTo:
fileName:
fileNumber:
11500.4
RECEIVED VA CARE PREVIOUSLY? 1010.15 Enter 'Y' if this veteran has previously received care in another VA facility, otherwise enter 'N'.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
MOST RECENT DATE OF CARE 1010.151 If this veteran has previously received care in another VA facility enter the date of care in that facility.

Date/Time
APPOINTMENT REQUEST DATE 1010.1511 This field contains the date the VA enrolling a patient for the first time was notified that the patient requests an appointment with a provider.

Date/Time
MOST RECENT LOCATION OF CARE 1010.152 If this veteran have previously received care in another VA facility select from the available listing the name of the facility (or facility number) in which care was rendered most recently.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
2ND MOST RECENT DATE OF CARE 1010.153 If this applicant has received care in more than one other VA facility enter the date of care received in the next to most recent facility.

Date/Time
2ND MOST RECENT LOCATION 1010.154 If this veteran has received care in more than one other VA facility select from the available listing the name of the facility (or facility number) in which the next to most recent care was received.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
MOST RECENT 1010EZ 1010.156 This field was added via patch DG*5.3*597, distributed with EAS*1.0*51. The purpose of this field is to link the PATIENT file record with the Veteran's latest 1010EZ Application to this site. The 1010EZ data is retained in 1010EZ HOLDING File (#712). The internal entry number to file #712 is stored in the MOST RECENT 1010EZ field.

Pointer
PointerTo:
fileName:
1010EZ HOLDING
fileNumber:
712
COMBAT INDICATED ON 1010EZ 1010.157 This field was added via patch DG*5.3*597, distributed with EAS*1.0*51. The purpose of this field is to store within the PATIENT file the applicant's answer to the 1010EZ question: DID YOU SERVE IN COMBAT AFTER 11/11/1998? This field may contain any of the following: 0 for "NO" 1 for "YES" null (i.e., not answered)

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DISABILITY DISCHARGE ON 1010EZ 1010.158 This field was added via patch DG*5.3*597, distributed with EAS*1.0*51. The purpose of this field is to store within the PATIENT file the applicant's answer to the 1010EZ question: WAS DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED OR AGGRAVATED IN THE LINE OF DUTY? This field may contain any of the following: 0 for "NO" 1 for "YES" null (i.e., not answered)

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
APPOINTMENT REQUEST ON 1010EZ 1010.159 Enter a 'Y' if the veteran applicant has requested an appointment with a VA doctor or provider and wants to be seen as soon as one becomes available. Enter a 'N' if the veteran applicant has not requested an appointment. This question may ONLY be entered ONCE for the veteran. The answer to this question CANNOT be changed after the initial entry.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
APPOINTMENT REQUEST STATUS 1010.161 This field is the status of the veteran's new appointment requested. This field is entered by the user through the new enrollee appointment request option.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CANCELLED
  • Code : E
    Stands For: EWL
  • Code : F
    Stands For: FILLED
  • Code : I
    Stands For: IN PROCESS/VETERAN CONTACTED
DATE STATUS LAST EDITED 1010.162 This is the date appointment request status was last edited. This field is updated by the computer whenever anyone edits the status information.

Date/Time
APPOINTMENT REQUEST COMMENT 1010.163 This field is entered by the user through the new enrollee appointment request option.

Free Text
DATE COMMENT LAST EDITED 1010.164 This is the date appointment request comment was last edited. This field is updated by the computer whenever anyone edits the comment information.

Date/Time
FUGITIVE FELON FLAG 1100.01 This field is in support of Pub. L. 107-103, section 505, and is used to flag a patient who has a fugitive felon warrant outstanding. This information will be provided to the appropriate personnel to enter. Access to this field requires the DGFFP ACCESS key. This field should not be updated directly, but should be entered through the appropriate Fugitive Felon Program options.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
FFF ENTERED BY 1100.02 This field contains the user who entered the current Fugtitive Felon Flag for this patient. It is automatically entered when the FUGITIVE FELON FLAG field (#1100.01) is entered.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FFF DATE ENTERED 1100.03 Date/Time the FUGITIVE FELON FLAG field (#1100.01) was entered. This field is automatically set when the FUGITIVE FELON FLAG field (#1100.01) is set.

Date/Time
FFF REMOVED BY 1100.04 This field contains the user who removed the current Fugitive Felon Flag for this patient. It is automatically entered when the FUGITIVE FELON FLAG field (#1100.01) is deleted.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FFF DATE REMOVED 1100.05 Date/Time the FUGITIVE FELON FLAG Field (#1100.01) was removed. This field is automatically set when the FUGITIVE FELON FLAG field (#1100.01) is deleted.

Date/Time
FFF REMOVAL REMARKS 1100.09 If the FFF flag has been cleared for this patient, this field contains a short reason as to why the flag was cleared. This is a free text field which allows up to 80 characters to be entered.

Free Text
APPOINTMENT 1900 This multiple contains information on appointments this patient has had or is scheduled to have. This information includes the date/time of the appointment, the clinic, and the reason for the appointment.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLINIC .01

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
TELEPHONE OF CLINIC .02 This is a computed field which returns the telephone number for the clinic at which this patient has an appointment. This information is stored in the HOSPITAL LOCATION file.

Computed
STATUS 3 This field contains the current status of the patient's appointment. If the field is blank, it means the appointment has not been no-showed or cancelled and the patient was not an inpatient at the time of the appointment. This field is set automatically by the scheduling module and must NOT be edited.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NO-SHOW
  • Code : C
    Stands For: CANCELLED BY CLINIC
  • Code : NA
    Stands For: NO-SHOW & AUTO RE-BOOK
  • Code : CA
    Stands For: CANCELLED BY CLINIC & AUTO RE-BOOK
  • Code : I
    Stands For: INPATIENT APPOINTMENT
  • Code : PC
    Stands For: CANCELLED BY PATIENT
  • Code : PCA
    Stands For: CANCELLED BY PATIENT & AUTO-REBOOK
  • Code : NT
    Stands For: NO ACTION TAKEN
REAL APPOINTMENT 4 This is a computed field which determines whether the appointment is considered real (kept). This field checks to see that the status is null (this means the appointment is not no-showed or cancelled and the patient was not an inpatient at the time of the appointment).

Computed
LAB DATE/TIME 5 If this patient is scheduled for laboratory tests in conjunction with this appointment, enter the date/time the patient should report to the lab for these tests.

Date/Time
X-RAY DATE/TIME 6 If this patient is scheduled for x-rays in conjunction with this appointment, enter the date/time the patient should report to radiology for these x-rays.

Date/Time
EKG DATE/TIME 7 If this patient is scheduled for EKG tests in conjuction with this clinic appointment, enter the date/time the patient should report for these tests.

Date/Time
ROUTING SLIP PRINTED 8 If a routing sheet was printed for this appointment, this field will contain a yes. Otherwise this field will contain a no. This is created automatically by the scheduling module.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
ROUTING SLIP PRINT DATE 8.5 If a routing sheet was printed for this visit, the date it was printed will be stored here. This is stored automatically by the MAS module.

Date/Time
PURPOSE OF VISIT 9 Choose from the list of available choices the reason this patient has this clinic appointment. Enter 1010 if this patient was sent to the clinic after a 1010 application (registration). Enter C&P if this patient is being seen for a comp and pension exam. Enter scheduled visit if this patient is being seen for a previously scheduled appointment or unsched. visit if the patient is a walk-in.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: C&P
  • Code : 2
    Stands For: 10-10
  • Code : 3
    Stands For: SCHEDULED VISIT
  • Code : 4
    Stands For: UNSCHED. VISIT
APPOINTMENT TYPE 9.5 Enter from the available choices the type of appointment this patient is scheduled for. This is a pointer to the APPOINTMENT TYPE file.

Pointer
PointerTo:
fileName:
APPOINTMENT TYPE
fileNumber:
409.1
SPECIAL SURVEY DISPOSITION 10 If this patinet is claiming exposure to agent orange or ionizing radiation, enter the special survey disposition, indicating whether his treatment was related to that exposure, here.

Numeric
NUMBER OF COLLATERAL SEEN 11 If this patient is a collateral, enter the number assigned to that collateral.

Numeric
AUTO-REBOOKED APPT. DATE/TIME 12 If this appointment was cancelled and automatically rebooked for a future date, this field will contain the date/time for which this appointment was rescheduled. This field is created automatically by the scheduling module and should not be edited.

Date/Time
COLLATERAL VISIT 13 If this patient was seen as a collateral for another patient, enter YES in this field. Otherwise, enter NO.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
NO-SHOW/CANCELLED BY 14 If this appointment was listed as a no-show and was that no-show was subsequently cancelled, this field will contain the user that cancelled the no-show. This field is set automatically by the MAS module and should not be edited.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
NO-SHOW/CANCEL DATE/TIME 15 If this appointment was listed as a no-show and that no-show was subsequently cancelled, this field will contain the date/time the no-show was cancelled. This field is set automatically by the scheduling module and should not be edited.

Date/Time
CANCELLATION REASON 16 If this appointment was cancelled, this field will contain the reason the appointment was cancelled. Choose from the available entries in the CANCELLATION REASONS file.

Pointer
PointerTo:
fileName:
CANCELLATION REASONS
fileNumber:
409.2
CANCELLATION REMARKS 17 If this appointment was cancelled, additional remarks as to the reason the appointment was cancelled can be entered. This is optional.

Free Text
APPT. CANCELLED 18 Field is set when user cancels another appointment set at the same time in another clinic for the same patient. This field reflects the clinic in which the patient had a scheduled appointment which was cancelled to set this appointment.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DATA ENTRY CLERK 19 This field contains the name of the user that entered the appointment into the scheduling system. This field is created automatically by the scheduling module and should not be edited.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE APPT. MADE 20 This field contains the date the appointment was entered into sheduling system. This field is creatd automatically by the scheduling module and should not be edited.

Date/Time
OUTPATIENT ENCOUNTER 21

Pointer
PointerTo:
fileName:
OUTPATIENT ENCOUNTER
fileNumber:
409.68
ENCOUNTER FORMS PRINTED 22 Used by the Print Manager to indicate that it has printed the encounter forms and other reports required by the division and clinic for the appointment.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ENCOUNTER FORMS AS ADD-ONS 23 Used by the Print Manager to indicate that it has printed the encounter forms and other reports required by the division and clinic for the appointment and they were printed as an add-on.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ENCOUNTER CONVERSION STATUS 23.1 This field indicates whether or not this appointment was converted during the ACRP Database Conversion (SD*5.3*211). The field is set to '1' after the appointment has been converted by the conversion software.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT CONVERTED
  • Code : 1
    Stands For: CONVERTED
APPOINTMENT TYPE SUB-CATEGORY 24 This field contains the sub-category associated with this appoitment.

Pointer
PointerTo:
fileName:
SHARING AGREEMENT SUB-CATEGORY
fileNumber:
35.2
SCHEDULING REQUEST TYPE 25

Set of Codes
Set of Codes:
  • Code : N
    Stands For: 'NEXT AVAILABLE' APPT.
  • Code : C
    Stands For: OTHER THAN 'NEXT AVA.' (CLINICIAN REQ.)
  • Code : P
    Stands For: OTHER THAN 'NEXT AVA.' (PATIENT REQ.)
  • Code : W
    Stands For: WALKIN APPT.
  • Code : M
    Stands For: MULTIPLE APPT. BOOKING
  • Code : A
    Stands For: AUTO REBOOK
  • Code : O
    Stands For: OTHER THAN 'NEXT AVA.' APPT.
NEXT AVA. APPT. INDICATOR 26

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT INDICATED TO BE A 'NEXT AVA.' APPT.
  • Code : 1
    Stands For: 'NEXT AVA.' APPT. INDICATED BY USER
  • Code : 2
    Stands For: 'NEXT AVA.' APPT. INDICATED BY CALCULATION
  • Code : 3
    Stands For: 'NEXT AVA.' APPT. INDICATED BY USER & CALCULATION
DESIRED DATE OF APPOINTMENT 27

Date/Time
FOLLOW-UP VISIT 28

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
CURRENT STATUS 100 This computed field determines the current status for the appointment. The difference between this field and the STATUS field is that appointments with a blank STATUS are further defined in this CURRENT STATUS field. Appointments with a blank STATUS may have a CURRENT STATUS of any one of the following: o FUTURE o NO ACTION TAKEN o CHECKED IN o CHECKED OUT o NON-COUNT

Computed
VETERAN (Y/N)? 1901 Enter 'Y' if this applicant is over 17 years of age and is a veteran, 'N' if not. If applicant is under 17 years of age and is a veteran only those users holding the designated security may identify him/her as a veteran. Once eligibility is verified only those users who hold the designated security key may enter/edit this field.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
ARCHIVED DATA 1903 This multiple is not presently used by the MAS module. Archiving capabilities for the patient file are not yet available. This multiple was distributed in 1987, but the archiving routines were not distributed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATA TYPE .01 This field identifies the type of data that was archived

Set of Codes
Set of Codes:
  • Code : DE
    Stands For: CLINIC ENROLLMENT
  • Code : S
    Stands For: APPOINTMENT
  • Code : SSD
    Stands For: SPECIAL SURVEY DISP
DATE OF ARCHIVE 1 This multiple contains data pertaining to each specific archive (the date, the beginning and ending archiving dates, and the tape numbers).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE OF ARCHIVE .01 Enter the date/time the archiving utility was run. This field is not currently used. The archiving software was not distributed.

Date/Time
TAPE # 1 Enter the sequential number of the tape on which this archiving data was put.

Free Text
BEGIN ARCHIVE DATE 2 Enter the date the user chose to begin the scheduling archive.

Date/Time
END ARCHIVE DATE 3 Enter the ending date the user chose for the scheduling archive.

Date/Time
NUMBER OF RECORDS ARCHIVED 4 The number of records archived. This is created automatically by the software. This software has not been released and this field is not presently used in DHCP.

Numeric
VTS PATIENT FLAG 3000 This field indicates whether or not the patient is or wants to be part of the Veteran Transportation Service (VTS).

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
INITIAL ODS TREATMENT RECEIVED 11500.01 Enter the date/time this patient was initially entered as ODS. This field will automatically be created when ODS is selected as the PERIOD OF SERVICE for this patient.

Date/Time
RECALLED TO ACTIVE DUTY 11500.02 Was this operation desert shield patient recalled to active duty? If so select from national guard or reserves. If not, answer no.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: NATIONAL GUARD
  • Code : 2
    Stands For: RESERVES
RANK 11500.03 Enter the grade/rank of this operation desert shield patient.

Pointer
PointerTo:
fileName:
fileNumber:
25002.1
ENTERPRISE PATIENT IDENTIFIER 21400

Free Text
BIRTH DATE/TIME 21400.03 DATE/TIME of Birth - Used to support the Vitals Signs reference ranges for newborns where age needs to be calculated down to the hours for newborns.

Date/Time
DISPLAY AGE 21400.033

Computed
PATIENT'S HOME PHONE COMMENT 21400.131

Free Text
PT'S BUSINESS PHONE COMMENT 21400.132

Free Text
K-EMAIL OF NOK 21400.211

Free Text
K-PHONE NUMBER [CELLULAR] 21400.2115

Free Text
K2-PHONE NUMBER [CELLULAR] 21400.2116

Free Text
K2-EMAIL OF NOK 21400.2117

Free Text
NOK PHONE COMMENT 21400.219

Free Text
K-PREFIX FOR NOK 21400.221

Free Text
K-SUFFIX FOR NOK 21400.222

Free Text
K-DEGREE FOR NOK 21400.223

Free Text
MOTHER'S MAIDEN NAME PREFIX 21400.24031

Free Text
MOTHER'S MAIDEN NAME SUFFIX 21400.24032

Free Text
MOTHER'S MAIDEN NAME DEGREE 21400.24033

Free Text
PREFIX FOR GUARDIAN (CIVIL) 21400.290013

Free Text
SUFFIX FOR GUARDIAN (CIVIL) 21400.290014

Free Text
DEGREE FOR GUARDIAN (CIVIL) 21400.290015

Free Text
PHONE COMMENT (CIVIL) 21400.290016

Free Text
INSTITUTION EMAIL (CIVIL) 21400.290017

Free Text
INSTITUTION COUNTRY (CIVIL) 21400.290018

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
INST ADDRESS TYPE CODE (CIVIL) 21400.290019

Free Text
INST NAME TYPE CODE (CIVIL) 21400.290021

Free Text
ASSIGN AUTH NAMESPACE (CIVIL) 21400.290022

Free Text
ASSIGN AUTH UID (CIVIL) 21400.290023

Free Text
ASSIGN AUTH UID TYPE (CIVIL) 21400.290024

Free Text
ORG ID (CIVIL) 21400.290025

Free Text
ORG ID TYPE CODE (CIVIL) 21400.290026

Free Text
PRELIMINARY CAUSE OF DEATH 21400.356

Free Text
ANONYMIZED 21400.666

Free Text
DIVISIONAL MRNS 21400.98

Computed
ID 21400.99

Computed
CONFIDENTIAL COMM PREFERENCE 21401.01 CONFIDENTIAL COMMUMICATIONS PREFERENCE

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EMAIL
  • Code : L
    Stands For: LETTER
  • Code : P
    Stands For: PHONE
FINANCIAL CLASS 21401.02

Free Text
SEXUAL ORIENTATION 21402.1

Pointer
PointerTo:
fileName:
MSC SEXUAL ORIENTATION
fileNumber:
21402.1
MSC GENDER IDENTITY 21402.2

Pointer
PointerTo:
fileName:
MSC GENDER IDENTITY
fileNumber:
21402.2
ADMITTING DIAGNOSIS 21405.1

Computed
ADMITTING PHYSICIAN 21405.8

Computed
PREVIOUS ADDRESS 21411

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE ADDR BECAME INACTIVE .01

Date/Time
PREVIOUS STREET ADDR [LINE 1] .111

Free Text
PREVIOUS ZIP+4 .1112

Free Text
PREVIOUS STREET ADDR [LINE 2] .112

Free Text
PREVIOUS STREET ADDR [LINE 3] .113

Free Text
PREVIOUS CITY .114

Free Text
PREVIOUS STATE .115

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
PREVIOUS ZIP CODE .116

Free Text
PREVIOUS PROVINCE .1171

Free Text
PREVIOUS POSTAL CODE .1172

Free Text
PREVIOUS COUNTRY .1173

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
LANGUAGES ENTRY DATE 21486

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LANGUAGES ENTRY DATE .01

Date/Time
PRIMARY LANGUAGE .02

Pointer
PointerTo:
fileName:
LANGUAGES
fileNumber:
9999999.99
INTERPRETER REQUIRED .03

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
PREFERRED LANGUAGE .04

Pointer
PointerTo:
fileName:
LANGUAGES
fileNumber:
9999999.99
ENGLISH PROFICIENCY .06

Set of Codes
Set of Codes:
  • Code : VW
    Stands For: VERY WELL
  • Code : W
    Stands For: WELL
  • Code : NW
    Stands For: NOT WELL
  • Code : NA
    Stands For: NOT AT ALL
BIRTH ORDER 21491 When a patient was delivered as part of a multiple-birth, this field identifies which baby (in sequence).

Numeric
MSC HL7 NAME 21499 Name as it comes in from ADT filer, PID.5 field. Filer will change carats '^' to pipes '|' and make it all caps.

Free Text
ACCOUNT NUMBERS 29320.8

Computed
NETWORK IDENTIFIER 537025 This field holds the synonym values from the Network Health Exchange Authorized Site file indicating where a particular patient has been found to have data.

Free Text

MERGE IMAGES

File Number: 15.4

File Description:

File 15.4 stores an image of the pairs of entries in files that were merged immediately prior to the actual merge. In addition, there is also a record of the locations of pointer values that were changed during the merge process.


Fields:

Name Number Description Data Type Field Specific Data
MERGED FROM .01 This field contains a variable pointer reference to the location in the primary merge file of the entry which was merged into another entry.

Variable Pointer
MERGED TO .02 This field contains a variable pointer reference to the entry in the primary file for the merge, into which the entry indicated by the MERGED FROM (#.01) field was merged.

Variable Pointer
DATE MERGED .03 This field indicates the date on which the entry indicated by the MERGED FROM (#.01) field was merged into the entry indicated by the MERGED TO (#.02) field.

Date/Time
FROM FILE# 1 This field specifies a file for which a data image was recorded for the entry specified by the MERGED FROM (#.01) field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FROM FILE# .01 This field specifies a file for which a data image was recorded for the entry specified by the MERGED FROM (#.01) field in the parent file (MERGE IMAGES, 15.4).

Pointer
PointerTo:
fileName:
FILE
fileNumber:
1
IEN IN FILE .02 This is the internal entry number (IEN) associated with the MERGED FROM (#.01 field in file 15.4) entry in the current file (FROM FILE#, #.01). While this is normally the same as the IEN of the entry indicated by MERGED FROM, there are some files which are not associated by DINUMed values and for which the IEN is different. This field contains the proper IEN for the entry in the current file (FROM FILE#, #.01).

Numeric
GLOBAL DATA 1 This multiple field contains the global nodes (lacking the beginning '^') for the MERGED FROM entry in the current file (FROM FILE#, #.01). The global prior to the merge can be reconstructed by setting the value in field #1.01 of the subfile into the global location specified by the data in the current field (#.01). If there is no field #1.01 associated with a global location, the value was NULL.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GLOBAL NODE .01 This field contains global node (lacking the beginning '^') for the MERGED FROM entry in the current file (FROM FILE#, #.01). The global prior to the merge can be reconstructed by setting the value in field #1.01 into the global location specified by the data inthe current field (#.01). If there is no field #1.01 associated with a global location, the value was NULL.

Free Text
DATA VALUE 1.01 This field contains the data value associated with the global location specified in GLOBAL NODE (#.01). If there is no data in the current field, then the value associated with the global was NULL.

Free Text
TO FILE# 2 This field specifies a file for which a data image was recorded for the entry specified by the MERGED TO (#.02) field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TO FILE# .01 This field specifies a file for which a data image was recorded for the entry specified by the MERGED TO (#.02 ) field in the parent file (MERGE IMAGES, 15.4).

Pointer
PointerTo:
fileName:
FILE
fileNumber:
1
IEN IN FILE .02 This is the internal entry number (IEN) associated with the MERGED TO (#.02 field in file 15.4) entry in the current file (TO FILE#, #.01). While this is normally the same as the IEN of the entry indicated by MERGED TO, there are some files which are not associated by DINUMed values and for which the IEN is different. This field contains the proper IEN for the entry in the current file (TO FILE#, .01).

Numeric
GLOBAL DATA 1 This multiple field contains the global nodes (lacking the beginning '^') for the MERGED TO entry in the current file (TO FILE#, #.01). The global prior to the merge can be reconstructed by setting the value in field #1.01 of the subfile into the global location specified by the data in the current field (#.01). If there is no field #1.01 associated with a global location, the value was NULL.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GLOBAL NODE .01 This field contains a global node (lacking the beginning'^') for the MERGED TO entry in the current file (TO FILE#, #.01). The global prior to the merge can be reconstructed by setting the value in field #1.01 of the subfile into the global location specified by the data in the current field (#.01). If there is no field #1.01 associated with a global location, the value was NULL.

Free Text
DATA VALUE 1.01 This field contains the data value associated with the global location specified in GLOBAL NODE (#.01). If there is no data in the current field, then the value associated with the global was NULL.

Free Text
POINTERS CHANGED 3 This multiple field contains data on locations where a pointer value was changed. The #.01 field contains the information which would be specified as subscripts in the array passed in a call to FILE^DIE. The array subscripts are separated by a ';', and are in the form FILE;IENS;FIELD. The value which was present before the data was changed is stored in field #1.01.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
POINTERS CHANGED .01 This field contains data on a location where a pointer value was changed. The #.01 field contains the information which would be specified as subscripts in the array passed in a call to FILE^DIE. The array subscripts are separated by a ';', and are in the form FILE;IENS;FIELD. The value which was present before the data was changed is stored in field #1.01.

Free Text
ORIGINAL VALUE 1.01 This field contains the pointer value which was present at the location specified by the #.01 field, prior to the value being changed during the merge.

Free Text

MAS PARAMETERS

File Number: 43

File Description:

This file contains the site specific parameters which are used by the Admission, Discharge and Transfer (ADT) modules. The parameters are set by using the 'DGPAR' routine or the 'ADT Parameters' menu option. The parameters are used to identify such things as your facility hemodialysis unit, your admission/discharge/transfer types, your divisions (if multi-division facility) and the devices to which you desire your 10-10's, routing slips, etc., printed to. The ADT parameters must be set prior to running ADT.


Fields:

Name Number Description Data Type Field Specific Data
ONE .01 'One' designates the 'one' MAS Parameter. There can only be one set of parameters.

Numeric
HEMODIALYSIS WARD 3 Does your facility have a Hemodialysis Ward?

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
SYSTEM TIMEOUT 4 Enter number of seconds to wait for user to respond to prompts (at least 10 seconds). Enter 99999 if you wish no system timeout.

Numeric
DAYS TO MAINTAIN G&L CORR 5.5 Enter the number of days you want to save G&L corrections in the system (between 14 and 365); corrections older than this number are deleted by the system when G&L Auto-Recalculation runs. Leave blank if you wish to maintain the complete file. Up to 90 days is recommended.

Numeric
TIME FOR LATE DISPOSITION 6 Enter the number of hours you want an active registration to remain open before the disposition is considered late (between 0 and 240).

Numeric
SUPPLEMENTAL 10/10 7 Do you wish Supplemental 10-10 to be printed wtih 10-10?

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DO NOT PRINT WITH 10 10
  • Code : 0
    Stands For: PRINT WITH 10 10
PRINT DRUG PROFILES WITH 10-10 8 Do you wish to have printing of drug profiles prompted with 10-10 printing?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DEFAULT PTF MESSAGE PRINTER 9 If you answered YES to the 'PRINT PTF MESSAGES?' prompt select the default device to which these message should print. This device will be used in cases where a specific device is not entered for the individual facility/division using the 'DEVICE SELECTION' option of the SYSTEM DEFINITION MENU.

Free Text
PRINT PTF MESSAGES? 9.5 Enter '1' if you wish to print PTF messages upon admission, change of treating specialty or deletion of admission, treating specialty transfer, discharge or 501 movement. Enter '0' if you DO NOT wish PTF messages to print.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
AUTOMATIC PTF MESSAGES? 9.6 This field indicates whether the site wants to automatically generate PTF messages as part of normal ADT processing. If 'YES' than entries into the PTF MESSAGE file will occur. If 'NO' than no PTF messages will be generated during ADT activities.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
EARLIEST DATE FOR G&L 10 Enter the earliest date for G&L to be run on. The day previous to this will be used for ward bed status data initialization.

Date/Time
MULTIDIVISION MED CENTER? 11 Is your facility multi-divisional?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MEDICAL CENTER NAME 12 Enter name of primary facility for which you are defining parameters.

Pointer
PointerTo:
fileName:
MEDICAL CENTER DIVISION
fileNumber:
40.8
AFFILIATED 13 Is your facility affiliated with a teaching facility?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
  • Code : 2
    Stands For: INTERMEDIATE
*HONEYWELL SITE 14 This field is currently unused by the MAS package and will be deleted in a future release of MAS. It was previously used to determine whether the honeywell software should be utilized or not.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
NURSING HOME WARDS? 15 Does your site have nursing home wards?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DOMICILIARY WARDS? 16 Does your medical center have domiciliary wards?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
USE HINQ INQUIRY? 17 Determines if HINQ inquiry can be made on registration.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
EMBOSSERS ON-LINE 18 Do you wish to have embossing of data card prompted during registration options?

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
USE CLOSEST PRINTER 19 Do you wish closest printer to be default for 10-10s, routing slips and pharmacy profiles?

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DEFAULT CODE SHEET PRINTER 25 If a 'Default Code Sheet Printer' is defined, AMIS code sheets can be generated when AMIS(s) are generated. The Code Sheets created will be printed on the default printer.

Free Text
VIEW CHECK OUT INFO DEFAULT 32 During the editing of a disposition, should the user default answer be 'Yes' or 'No' to the following prompt: 'Do you wish to see the check out screen?'

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DAYS TO MAINTAIN SENSITIVITY 33 Enter number of days for which sensitivity data must be maintained on line before purging is permitted.

Numeric
SHOW STATUS SCREEN 34 Do you want the MAS Status Screen to be displayed to users upon entering the ADT Menu?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
CONSISTENCY CHECKER ON? 37 Do you wish to turn on the automatic Consistency Checker? If YES, data will be checked in accordance with parameters set through the Determine Consistencies to Check/Don't Check option of the Consistency Supervisor Menu.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ABBREVIATED PATIENT INQUIRY? 38 Do you wish an abbreviated patient inquiry to be displayed through the Patient Inquiry Option? An abbreviated inquiry will include the following: name, SSN, date of birth, address, temporary address, means test status, eligibility status, admission and appointment enrollment information. Items such as religion, claim number and period of service will be excluded.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ASK DEVICE IN REGISTRATION 39 Answering YES will force the DEVICE: prompt at the beginning of registration the first time through and will set the 1010, routing sheet, and profile printer to this device. This takes precedence over all devices defined as default printers or closet printer.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RUN CO-PAY SOFTWARE? 41 This will prevent the Co-Pay menus and routines from being invoked by the Registration software.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PRINT HEALTH SUMMARY? 42 By answering 'YES' the user will be prompted to print a Health Summary at the end of the Registration process and during the 10/10 Print without New Registration option. NOTE: Unless HEALTH SUMMARY v2.5 patch #3 (or higher) has been loaded the user will not be prompted to print a Health Summary.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DEFAULT HEALTH SUMMARY 43 When the user is prompted to print a Health Summary type in Registration, this field contains the default. NOTE: Unless the MAS PARAMETER, 'PRINT HEALTH SUMMARY?', has been answered 'YES', this has no effect.

Pointer
PointerTo:
fileName:
VA HEALTH SUMMARY TYPE
fileNumber:
142
CHOICE OF DRUG PROFILE TYPE? 44 If YES is entered for the PRINT DRUG PROFILES WITH 10-10 field, answering YES to this field will offer the user a choice between the Action and Informational Drug Profiles. Note: Unless the PRINT DRUG PROFILES WITH 10-10 has been answered 'YES', this field will have no effect.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DEFAULT TYPE OF DRUG PROFILE 45 This field is irrelevant unless the PRINT DRUG PROFILES WITH 10-10 field has been answered 'YES'. If the user has a choice of Drug Profiles (when CHOICE OF DRUG PROFILE TYPE? is YES) this field defines the default. If the user does not have a choice of Drug Profiles, this field defines the type of Drug Profile (Action or Informational).

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTION
  • Code : I
    Stands For: INFORMATIONAL
DAYS TO UPDATE MEDICAID 46 After this number of days without updating the DATE MEDICAID LAST ASKED field an inconsistency will be created. The default is 365 days.

Numeric
PRINT ENCOUNTER FORM AT REG. 47 Answering "YES" will have the prompt Print Encounter Form be asked at Registration. If the encounter form is said to be printed, the clinic(s) to print the encounter forms will be asked.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DEFAULT EF PRINTER 48 This field contains the name of the default printer that will print encounter forms at registration.

Free Text
G&L STARTED 50 The date/time the Gains and Losses Sheet was started by a user through the ADT Outputs menu option.

Date/Time
RECALC STARTED 52 The date/time G&L recalculation was started. A user would recalc a G&L for past dates normally.

Date/Time
RECALC UP TO 53 Date G&L recalculation has reached cleared when recalc is finished.

Date/Time
ZTSK(RECALC) 54 The task number of the G&L recalculation job running.

Numeric
SCHEDULED(RECALC) 55 The date/time the G&L recalculation is scheduled to run. It is a nightly background job usually set to run sometime after midnight each day.

Date/Time
CPU(RECALC) 56 CPU recalc was started from

Free Text
AUTO RECALC LAST STARTED 57 The date/time that Auto Recalc was last started for the G&L stats.

Date/Time
CPU(AUTO RECALC) 58 CPU which last ran auto recalc

Free Text
AUTO RECALC FINISHED 59

Date/Time
AUTO RECALC BACK TO 60 When the G&L Auto Recalc last ran, this is the date it went back to for recalculation of the stats.

Date/Time
G&L LAST RUN 61 Time G&L was run last.

Date/Time
REGISTRATION TEMPLATE (LOCAL) 70 A site may need to capture certain registration data in a format other than that of the distributed registration screens. It may do so by creating a local registration screen (through a FileMan template) specifying that data in the PATIENT file they wish to capture. The template name should be specified at this prompt. This screen will then be prompted during the registration or load/edit process at the end of the other registration screens.

Pointer
PointerTo:
fileName:
INPUT TEMPLATE
fileNumber:
.402
USE HIGH INTENSITY ON SCREENS? 76 Should high intensity be used for those options in MAS which allow it? This feature works in conjunction with the Registration and MCCR screens to signify to users that data which may/may not be edited. Under certain circumstances some screens or individual data groups may only be edited by selected users. When this feature is turned on, those screens and/or data group numbers which a specific user may edit will be 'highlighted' on their terminal but not 'highlighted' to those users who may not edit the screens/data groups.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
EXCLUDE WHICH TERMINAL TYPES? 77 If the USE HIGH INTENSITY ON SCREENS field has been set to YES, you may wish to exclude it from being used on certain terminal types. If so, at this prompt you should specify the terminal type(s) which should not use high intensity. This field allows you to specify multiple terminal types. You will be returned to it repeatedly until no more entries are made.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXCLUDE WHICH TERMINAL TYPES? .01 If the USE HIGH INTENSITY ON SCREENS field has been set to YES, you may wish to exclude it from being used on certain terminal types. If so, at this prompt you should specify the terminal types(s) which should not use high intensity. This field allows you to specify multiple terminal types. You will be returned to it repeatedly until no more entries are made.

Pointer
PointerTo:
fileName:
TERMINAL TYPE
fileNumber:
3.2
CONSISTENCY PURGE STARTED 80 The date the purging of the INCONSISTENT DATA file was started.

Date/Time
CONSISTENCY PURGE LAST RAN 81 The date the INCONSISTENT DATA purge last completed.

Date/Time
CONSISTENCY REBUILD STARTED 82 The date the INCONSISTENT DATA file was started rebuilding.

Date/Time
CONSISTENCY REBUILD LAST RAN 83 The date the INCONSISTENT DATA file last completed rebuilding.

Date/Time
CONSISTENCY UPDATE STARTED 84 The date updating of existing data in the INCONSISTENT DATA file was last started.

Date/Time
CONSISTENCY UPDATE LAST RAN 85 The date updating of existing data in the INCONSISTENT DATA file last completed running.

Date/Time
OVERDUE ABSENCE SEARCH DATE 86 Date the overdue absence list was run. An overdue absence list produces those veterans who have been placed on either AA<96 hrs. or AA and have not returned on the date entered as their return date.

Date/Time
PROVIDER CONVERSION 90 This Multiple will contain parameters used for the conversion of MAS files from file 3, 6, and 16 to file 200.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER CONVERSION .01 The data in this field indicates which file is being processed.

Numeric
START TIME .02 The date/time in this field indicates the start time for the conversion.

Date/Time
END TIME .03 The date/time in this field indicates the completion time for the provider conversion.

Date/Time
CURRENT ENTRY .04 The field contains the IFN of the current entry being processed.

Numeric
NODE .05 The data in this field indicates on which node the data that requires conversion can be found.

Free Text
FILE CONVERTED .06 The field indicates if the file has been converted.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TOTAL ENTRIES CONVERTED .07 The field contains the total number of entries converted during the provider conversion.

Numeric
MULITPLE ENTRY .08 This field is used to identify which multiple entry is being converted.

Free Text
SEQUENCE .09 This field is used to identify the current record being processed.

Numeric
PRE CONVERSION POINTER .1 The data in this field is the pointer value prior to the conversion.

Free Text
PROVIDER CONVERSION LOG 91 This field contains a list of all entries that failed to be converted during the Provider Conversion. The contents of this field will be used to generate a Mailman message at the end of the

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER CONVERSION LOG .01

Word Processing
SCHEDULING VERSION 205 This is the Version number of the currently loaded Scheduling DHCP software.

Numeric
SCHEDULING ARCHIVE DATE 210 This field contains the dates, status, and summary information for the Scheduling archive process.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SCHEDULING ARCHIVE DATE .01

Date/Time
CURRENT STATUS MESSAGE 1 This message may be displayed to inform the user of the status of the scheduling archive process associated with the archive date.

Free Text
CURRENT STATUS FLAG 2 This is the status of the current step of the scheduling archive process and controls which steps of the archive process are valid to run at any point: 0 = No archive has yet been done * Archive extract step may be run * 1 = Archive extract has been started 2 = Scheduling extract step is complete * Archive extract step may be re-run * * Copy data to tape step may be run * 3 = Copy to tape has been started 4 = Copy to tape is complete * Copy to tape step may be re-run * * Archive extract step may be re-run * * Compare of tape for validity step may be run * 5 = Compare of data for validity of tape has been started 6 = Compare of data for validity of tape is complete * Compare of data for validity step may be re-run * * Copy to tape step may be re-run * * Archive extract step may be re-run * * Deletion of archived data and the archive file on disk may be run * 7 = Deletion of archived data and the archive file on disk has been started 8 = Deletion of archived data and archive file on disk is complete (This completes the archive process) * Deletion of archived data and archive file on disk may be re-run * (If any data still exists) * Scheduling extract step may be run *

Free Text
BEGIN DATE OF ARCHIVE 3 This is the date chosen as the earliest date for which the data should be archived for this execution of the archive process.

Date/Time
END DATE OF ARCHIVE 4 This is the date chosen as the latest date for which the data should be archived for this execution of the archive process.

Date/Time
TAPE # 5 This is the tape # or #'s used to hold the archived data for this execution of the archive process.

Free Text
# OF RECORDS ARCHIVED 6 This field contains the total # of each type of record archived for this execution of the archive process.

Free Text
APPT SEARCH THRESHOLD 212 Enter the number of days in the past that the 'Appointment Management' option should initially search for appointments. When the user selects a patient, this parameter will automatically be used to search that many days in the past for appointments. When a clinic is selected, this number will be used to calculate the default beginning date. The user is prompted for a beginning and ending date when a clinic is selected. If this field is not entered, then the system will use 2 days.

Numeric
PATIENT OR CLINIC 213 This field definition is used by the 'Appointment Management' option. The option obtains a patient or clinic when using the FileMan Reader. This field is specified in the Reader call. No data needs to be set in this field.

Variable Pointer
APPT. UPDATE MAIL GROUP 215 This is the name of the Mail Group which should be notified whenever the Appointment Status Update job has been completed.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
NPCDB MAIL GROUP 216 This is the name of the Mail Group which should be notified whenever the nightly NPCDB job has been completed.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
LATE ACTIVITY MAIL GROUP 217 This is the name of the Mail Group which should be notified whenever there is late entry/edit of NPCDB related information. 'Late entry' is defined as information entered after the workload close out date has passed. For example, if an appointment is made after the close out date has passed for the appointment date then the members of this mail group will receive a message.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
DATE CHECK OUT REQUIRED 223 This field indicates the date the site must start checking out appointments, stop code additions (add/edits) and registrations (1010 and unscheduled). Once v5.3 is released then this date will be Oct. 1, 1993. However, for alpha and beta testing, this date needs to be set before 10/1/93.

Date/Time
ALLOW UP-ARROW OUT OF CLASS. 224 Enter 'YES' to allow users to up-arrow out of the classification questions. The classification questions are required for workload credit. Allowing the user to exit without answering these questions could result in additional work at a later time to track down the record and determine the answer to these questions.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
API ERRORS MAIL GROUP 226 This field is used to indicate which Mail Group should receive any notifications produced by the Outpatient API. Field 'API NOTIFICATIONS TO PROCESS (#227)' indicates the type of notifications should result in a MailMan message.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
API NOTIFICATIONS TO PROCESS 227 This field indicates which notification messages from the Outpatient API should be sent to the appropriate Mail Group. The Mail Group is specified in the 'API ERROR MAIL GROUP (#226)' field. Possible answers are the following: ERRORS - send just error notifications WARNINGS & ERRORS - send warning and error notifications NONE - do not send any notifications Error Definition: ----------------- Before an event is processed, the data passed to the API is analyzed. If any problems are found that cause the event processing not to occur then the problem is reported back to the calling application as 'errors'. An example of an 'error' would be an invalid DFN number for a patient. Warning Definition: ------------------- During the processing of an event, certain data passed to the API can be found to be inappropriate or inaccurate but was not crucial to the processing of the event. These types of problems are reported back to the calling application as 'warnings'. An example of a 'warning' would be Agent Orange(AO) exposure information passed for an encounter that did not require AO information.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: ERRORS ONLY
  • Code : WE
    Stands For: WARNINGS & ERRORS
  • Code : N
    Stands For: NONE
MEANS TEST DATA 250 Enter in this field the year of the means test income category thresholds, property threshold and child income exclusion. These figures are released annually. They are effective on January 1st and are applied to the previous year income.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MEANS TEST DATA .01 Enter in this field the year of the means test income category thresholds, property threshold and child income exclusion. These figures are released annually. They are effective on January 1st and are applied to the previous year income.

Date/Time
MT COPAY EXEMPT VET INCOME 2 Enter in this field the threshold for MT COPAY EXEMPT. This amount represents the income level for the previous calendar year. This amount plus any additional amounts for dependents represents the income level under which the veteran will be placed in MT COPAY EXEMPT.

Numeric
MT COPAY EXEMPT 1ST DEP INCOME 3 Enter in this field the first dependent income increment. This amount represents the additional amount of income for the first dependent for this category.

Numeric
MT COPAY EXEMPT INCOME PER DEP 4 Enter in this field the income increment for each dependent after the first. This amount represents the additional amount of income for each dependent after the first for this category.

Numeric
CAT B VET INCOME 5 Enter in this field the threshold for Category B. This amount represents the income level for the previous calendar year. This amount plus any additional amounts for dependents represents the income level under which the veteran will be placed in Catefory B.

Numeric
CAT B FIRST DEPENDENT INCOME 6 Enter in this field the first dependent income increment. This amount represents the additional amount of income for the first dependent for this category.

Numeric
CAT B INCOME PER DEPENDENT 7 Enter in this field the income increment for each dependent after the first. This amount represents the additional amount of income for each dependent after the first for this category.

Numeric
THRESHOLD PROPERTY 8 Enter in this field the property threshold. This amount represents the property threshold for the previous celendar year. If the veteran's total income plus total net worth exceeds the property threshold, the case can be sent to adjudication. In adjudication the case is reviewed for Category C consideration. Note, this only applies to veteran's whose income places them in a 'mandatory' category of care.

Numeric
*MEDICARE DEDUCTIBLE 9 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Dollar amount Medicare allows for a deductible for eligible beneficiaries. VA charges are based on this deductible for veterans falling into Category C.

Numeric
*OUTPATIENT FEE 10 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for an outpatient visit to a VA facility.

Numeric
*MEDICINE (1 DAY) 11 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Medicine ward at a VA facility.

Numeric
*SURGERY (1 DAY) 12 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Surgical ward at a VA facility.

Numeric
*SPINAL CORD INJURY (1 DAY) 13 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Spinal Cord Injury ward at a VA facility.

Numeric
*PSYCHIATRY (1 DAY) 14 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Psychiatry ward at a VA facility.

Numeric
*VA NHCU(1 DAY) 15 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in a Nursing Home Care Unit at a VA facility.

Numeric
*DOM (1 DAY) 16 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in a Domiciliary ward at a VA facility.

Numeric
CHILD INCOME EXCLUSION 17 Enter in this field the child income exclusion. This amount represents the income exclusion for each child for the previous calendar year.

Numeric
*CARE COSTS 251 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Costs by treating Service charged by the VA for care received at a VA facility.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
*EFFECTIVE DATE .01 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Effective date of the treating Service charges

Date/Time
*OPT FEE 2 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for an outpatient visit at a VA facility.

Numeric
*MEDICINE (1 DAY) 3 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Medicine ward at a VA facility.

Numeric
*SURGERY (1 DAY) 4 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Surgical ward at a VA facility.

Numeric
*SPINAL CORD INJURY (1 DAY) 5 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Spinal Cord Injury ward at a VA facility.

Numeric
*PSYCHIATRY (1 DAY) 6 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Psychiatry ward at a VA facility.

Numeric
*VA NHCU (1 DAY) 7 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in a VA Nursing Home Care Unit.

Numeric
*INTERMEDIATE CARE (1 DAY) 8 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in an Intermediate Care ward at a VA facility.

Numeric
*REHAB MEDICINE 9 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in a Rehabilitation Medicine ward at a VA facility.

Numeric
*BLIND REHAB 10 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay in a Blind Rehabilitation ward at a VA facility.

Numeric
*NEUROLOGY 11 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a one-day stay on a Neurology ward at a VA facility.

Numeric
*ALCOHOL & DRUG TREATMENT 12 This data is now stored in Integrated Billing. This field to be deleted with the next release of MAS after 5.2. Charge for a hospital stay in an Alcohol & Drug Treatment program at a VA facility.

Numeric
FISCAL YEAR 300 Fiscal Year that inpatient and outpatient costs at a VA facility are in effect.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FISCAL YEAR .01 Fiscal Year that specific inpatient and outpatient costs at a VA facility are in effect.

Date/Time
$ PER WWU 1 Dollar amount per each Weighted Work Unit.

Numeric
COST FOR 1 DAY LOS 2 Charge/cost for a one day length of stay in a VA hospital.

Numeric
CENSUS PER DIEM COST 3 The value assigned to per diem (per day) cost for census patients.

Numeric
HIGH OUTLIER COST PER DAY 4 Value assigned to a high outlier or hospital stay beyond the expected number of days for a specific condition based on national statistics for a period of one day.

Numeric
CURRENT PIVOT ENTRY 391.701 This is the current entry number in the ADT/HL7 Pivot file. Only the application should edit this field.

Numeric
SEND PIMS HL7 V2.2 MESSAGES 391.7012 This field tells the software whether to stop sending the PIMS HL7 messages. If set to 0 or stop no PIMS HL7 messages will be fired from the event drivers, DDs, or registration options.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND
  • Code : 0
    Stands For: STOP
SEND PIMS HL7 V2.3 MESSAGES 391.7013 This field tells the software whether to stop sending the PIMS HL7 v2.3 messages. If set to 0 or stop no PIMS HL7 v2.3 messages will be fired from the event drivers, DDs, or registration options.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND
  • Code : 0
    Stands For: STOP
  • Code : 2
    Stands For: SUSPEND
CREATE MFU FOR RAI MDS 391.7014

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PIVOT FILE DAYS TO RETAIN 391.702 The number of days worth of data to retain in the ADT/HL7 PIVOT file (#391.71) when the Purge PIMS HL7 PIVOT File option [VAFH PIVOT PURGE] is run. Example: If this field is set to 100, then entries in file #391.71 which are older than TODAY-100 days will be purged. If nothing is entered in this field, then a default value of 547 days will be used. (547 days is approximately 18 months.)

Numeric
RAI INTEGRATED SITE 391.705 This field will indicate whether the site has integrated it's RAI/MDS COTS databases or not and to what level. If the field is null, then the site has not integrated.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT INTEGRATED
  • Code : 1
    Stands For: INTEGRATED, SINGLE DB
  • Code : 2
    Stands For: INTEGRATED, MULTIPLE DB
IRT BACKGROUND JOB LAST RUN 401 This field contains the date/time of the last run of the IRT Background Job.

Date/Time
DEATH GROUP 500 Select the name of the mailgroup which should be notified whenever a patient expires. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
NEW PATIENT GROUP 501 Select the name of the mailgroup which should be notified whenever a new patient is added to the patient file. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
NAME CHANGE GROUP 502 Select the name of the mailgroup which should be notified whenever the spelling of an existing patients name is changed. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
SSN CHANGE GROUP 503 Select the name of the mailgroup which should be notified whenever the social security number of an existing patient is changed. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
UNVERIFIED ADMIT GROUP 504 Select the name of the mailgroup to be notified along with the user, whenever a veteran is admitted for whom eligibility has not been verified, or for patients admitted with verified eligibility who have either future scheduled admissions or waiting list entries. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
INCONSISTENCY EDIT GROUP 505 Select the name of the mailgroup which should be notified whenever inconsistencies are found in a patients database that can not be corrected by the user because of edit restrictions, i.e., not holding the 'DG ELIGIBILITY' security key for verified data. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
NON-VETERAN ADMIT GROUP 506 Select the name of the mailgroup which should be notified whenever a non-veteran is admitted to the facility. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
OVERDUE ABSENCES GROUP 507 Select the name of the mailgroup which should be notified whenever the G&L is run and the user elects to search for patients who are overdue from returning from Authorized/Unauthorized absence and pass. If no mailgroup is select no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
PATIENT DELETED GROUP 508 Select the name of the mailgroup which should be notified whenever a patient is DELETED from the database (PATIENT file). If no local mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
SENSITIVE REC ACCESSED GROUP 509 Select the name of the mailgroup which should be notified whenever a sensitive record is accessed. If no mailgroup is selected no notification will be made however the access will still be recorded.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
SENSITIVITY REMOVED GROUP 510 Select the name of the mailgroup which should be notified whenever the status of a previously identified sensitive record is changed to non-sensitive. If no mailgroup is selected no notification will be made.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
AUTO RECALC GROUP 511

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
MEANS TEST REQUIRED GROUP 512 Enter the name of the mail group that will receive the message stating a means test is required when an appointment is made.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
IRT SHORT FORM LIST GROUP 513 Select the name of the mailgroup which should be notified whenever the IRT Background Job is run, options: (IRT Update Std. Deficiencies and IRT Update Std. Def. Background Job), to receive a list of patients that have been discharged less than 48 hours from their admission (Short Form).. If no mailgroup is selected no bulletin will be generated.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
AMIS 420 STARTED 600 Date/time generation was started for the AMIS 420.

Date/Time
AMIS 420 LAST COMPLETED 601 Date/time AMIS 420 generation was last completed.

Date/Time
AMIS 420 TASK NUMBER 602 System task number assigned to the job for the AMIS 420 generation.

Numeric
AMIS 420 STARTED BY 603 Person/user that ran the generation for the AMIS 420.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AMIS 420 RUNNING 604 Date/time the AMIS 420 is currently running.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PERIOD CHECKED 605 Month and year the MAS Parameters file was checked/edited.

Free Text
RUG BACKGROUND JOB LAST RUN 700 Date/time Resource Utilization Grouper (RUG) background job was last run.

Date/Time
RUG17 CONVERSION DATE 701 Date the RUGs were converted to RUG17 methodology.

Date/Time
BT CERTIFYING OFFICIAL 720 This will be used to print on the 70-3542d form, if the site decides that they want to have a set name printed all the time. If it is left blank then the user's name, followed by DESIGNEE OF CERTIFYING OFFICIAL will be printed instead of the set name of the certifying official.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BT OTHER EXPENSES ASKED 721 This field will be used to determine whether the "MEALS & LODGING" and "FERRY, BRIDGES, ETC." questions are asked in the Beneficiary Travel Claim Enter/Edit Option.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
USE TEMPORARY ADDRESS 722 Do you want the patient's temporary address to be used on scheduling letters if one is provided in the PATIENT file?

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COREFLS ACTIVE 723 This entry determines whether the Bene Travel package prompts for coreFLS vendor (ACTIVE - YES) or FMS vendor (ACTIVE - NO).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ROUTINE 800 A list of all routines distributed with the MAS DHCP software package.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ROUTINE .01 A list of all routines distributed with the MAS DHCP software package.

Free Text
DISTRIBUTED SIZE 2 Size of each routine when distributed for use by running integrity checker value.

Free Text
*NAME OF UB82 SIGNER 900 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*TITLE OF UB82 SIGNER 901 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*CAN REVIEWER AUTHORIZE? 902 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
*REMARK TO APPEAR ON EACH UB82 903 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*FEDERAL TAX NUMBER 904 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*BLUE CROSS/SHIELD PROVIDER # 905 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*UB82 CANCELLATION MAILGROUP 906 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
*BILLING SUPERVISOR NAME 907 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
*UB82 DISAPPROVED MAILGROUP 908 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Pointer
PointerTo:
fileName:
MAIL GROUP
fileNumber:
3.8
*PRINT '001' FOR TOTAL CHARGES 909 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
*CAN INITIATOR REVIEW? 910 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
*AGENT CASHIER MAIL SYMBOL 911 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*AGENT CASHIER STREET ADDRESS 912 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*AGENT CASHIER CITY 913 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*AGENT CASHIER STATE 914 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
*AGENT CASHIER ZIP CODE 915 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*AGENT CASHIER PHONE NUMBER 916 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*UB-82 INITIALIZATION NUMBER 917 This field is no longer used in determining bill numbers.

Free Text
*UB-82 BILL NUMBER ASSIGNMENT 918 Obsolete field no longer used.

Free Text
*MAS SERVICE POINTER 919 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Pointer
PointerTo:
fileName:
SERVICE/SECTION
fileNumber:
49
*CANCELLATION REMARK FOR FISCA 920 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Free Text
*CAN CLERK ENTER NON-PTF CODES 921 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release of MAS after 5.2. Answering Yes to this parameter will also allow billing clerks to enter CPT and HCPCS codes into the billing record as well as ICD Diagnosis and Procedure codes that are not in the corresponding PTF record.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
*ASK HINQ IN MCCR 922 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
*USE OP CPT SCREEN 923 This field has been moved to the IB SITE PARAMETER file. To be deleted with the next release after MAS 5.2.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
*LAST MEANS TEST CONVERTED 926 Restartable entry point for means test conversion; last patient converted This is a temporary field used during the means test conversion, only. Field will be deleted in the following release, MAS 5.3.

Numeric
*DATE MT CONVERSION STARTED 927 Date means test conversion started. This is a temporary field used during the means test conversion, only. Field will be deleted in the following release, MAS 5.3.

Date/Time
*DATE MT CONVERSION COMPLETED 928 Date means test conversion completed. This is a temporary field used during the means test conversion, only. Field will be deleted in the following release, MAS 5.3.

Date/Time
VERSION 999 The version number assigned to the MAS software package currently installed in the system.

Numeric
G&L INITIALIZATION DATE 1000.01 Please enter the date on which you wish to initialize your Gains & Losses Sheet and Bed Status Report. The date selected must be on or after October 1, 1990. Bed Status statistics will be calculated from this date only.

Date/Time
SSN FORMAT 1000.02 The Gains & Losses Sheet allows printing only the last four numbers of the patient's Social Security Number or the entire number. Please determine how you'd like this number to appear on your G&L.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: WHOLE SSN
  • Code : 6
    Stands For: LAST FOUR
MEANS TEST DISPLAY 1000.03 This G&L is designed to display current Means Test Status (where applicable) if you wish. Simply respond YES to this prompt in order to display this data on your daily Gains and Losses Sheet.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PATIENT'S TREATING SPECIALTY 1000.04 The This field is used for the purpose of determining whether or not you wish for the exact Treating Specialty to which a patient is assigned to display on the G&L whenever a movement is displayed. The information will appear immediately to the right of the assigned ward location.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SHOW
  • Code : 0
    Stands For: DON'T SHOW
TWO/THREE COLUMN DISPLAY 1000.05 Please select whether you wish the patient listing (G&L) to display names in a two or three column format. Certain transaction types, i.e., Transfers in/out, will always appear as a single column output regardless, however, this feature may reduce the amount of paper required to generate this listing.

Set of Codes
Set of Codes:
  • Code : 2
    Stands For: TWO
  • Code : 3
    Stands For: THREE
SHOW NON-MOVEMENTS ON G&L 1000.06 Answer YES should you wish for non-movements, i.e., Treating Specialty Change to appear on the G&L otherwise answer NO.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RECALCULATE FROM 1000.07 Please enter the date from which you wish to recalculate totals which must be on or after the G&L Initialization Date. The purpose of this parameter is to allow you the flexibility to maintain an "old" initialization date without the worry that a correction entered say, for five years ago, cause a recalculation process to commence which may take days to complete. It is strongly suggested that recalculation always be accomplished for, at a minumum, the current fiscal reporting year.

Date/Time
COUNT VIETNAM VETS REMAINING 1000.08 Answer YES if you wish to calculate vietnam era veteran's remaining at the end of each day. If you choose to do so the length of processing time may be increased up to 20 minutes per day. Please note that this information is no longer reported on any AMIS Segment.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COUNT OVER 65'S REMAINING 1000.09 Answer YES to the following prompt if you wish to calculate patient's over 65 years in age remaining at the end of each census date. If you choose to do so processing time for recalculation may be increased up to 30 minutes per date. Please note that this information is no longer reported on any AMIS Segment.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DEFAULT TREATING SPECIALTY 1000.1 Once the system starts collecting Treating Specialty statistics it will be necessary to capture those data where a Treating Specialty may not have been assigned to a particular patient. Please respond to to this field with the DEFAULT Treating Specialty to which you want these statistical data associated. Perhaps one might want to create a Treating Specialty called UNKNOWN, UNDEFINED, etc., and utilize this.

Pointer
PointerTo:
fileName:
FACILITY TREATING SPECIALTY
fileNumber:
45.7
TSR INITIALIZATION DATE 1000.11 Enter the date on which you wish to initialize your Treating Specialty Report. The date selected must be on or after October 1, 1992. The Treating Specialty Report census statistics will be calculated from this date.

Date/Time
PRE-REGISTRATION SORT 1100.01 This entry determines the sort order of the call list display

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PATIENT NAME
  • Code : S
    Stands For: MEDICAL SERVICE
DAYS BETWEEN CALLS 1100.02 This field will be used to determine how many days from the latest DATE CHANGED Field, #1, in PRE-REGISTRATION AUDIT File, #41.41, before the patient will be added to the call list again. If the patient has another appointment within x number of days of the date in the DATE CHANGED field, he will not be added.

Numeric
BACKGROUND JOB FUNCTION 1100.03 Preregistration nightly background job. This field determines which actions the background job performs when run. Delete removes all entries from the call list. Purge removes only the called patients from the call list. Nothing tells the background job to leave the call list alone. Add, just adds entries to the call list, without removing any.

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DELETE ALL ENTRIES
  • Code : P
    Stands For: DELETE CALLED PATIENTS
  • Code : DA
    Stands For: DELETE ENTRIES AND ADD NEW
  • Code : PA
    Stands For: DELETE CALLED PATIENTS AND ADD NEW
  • Code : AO
    Stands For: ADD NEW ENTRIES ONLY
  • Code : N
    Stands For: NOTHING
DAYS TO MAINTAIN LOG 1100.04 This field is the number of days to maintain entries in the PRE-REGISTRATION CALL LOG File, #41.43. All entries before this limit will be purged.

Numeric
DAYS TO PULL APPOINTMENT 1100.05 This field sets the number of days in advance to look for appointments to pull patients for.

Numeric
RUN FOR WEEKEND 1100.06 If this field is 'Y'es, then the background job will run and add on weekends.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
CLINIC EXCLUSION 1110

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLINIC EXCLUSION .01 Clinics in this list will be not be check for patient appointments when adding new patient entries to the call list.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ELIGIBILITY EXCLUSION 1120

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ELIGIBILITY EXCLUSION .01 Patients with these eligibility's will not be added to the call list when new patient entries are being added.

Pointer
PointerTo:
fileName:
ELIGIBILITY CODE
fileNumber:
8
RESTRICT PATIENT RECORD ACCESS 1201 If this parameter is set to 1 and the user does not hold the DG RECORD ACCESS security key, they will not be allowed to access their own PATIENT (#2) file record.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PURPLE HEART SORT 1202 This field should be edited if the local site wants the daily tasked Purple Heart Status Report to be sorted in 'A'scending order by the number of days since the last status update. By default, the report will sort by descending order.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ASCENDING
  • Code : D
    Stands For: DESCENDING
NET WORTH CALCULATION 1203 This field is used as a flag to indicate the method to use in determining the veteran's net worth. If the Net Worth Calculation = "YES" then net worth is equal to the veteran's assets minus debts. If the Net Worth Calculation = "NO" then net worth is equal to assets plus income minus debts.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
VFA START DATE 1205 The date, January 1,2013, that the Veteran Financial Assessment(VFA) project becomes operational. A Primary Means Test(MT) on file less than or equal to 1 year old as of the VFA Start Date shall not expire. Otherwise, MTs older than 1 year shall be considered expired and a new MT shall be required.

Date/Time
AO STA EXP DATE 1301 If populated, this field will be used as the expiration date for the Special Treatment Authority (STA) for Agent Orange (AO) Veterans with an AO exposure location of Vietnam. New enrollments of AO Veterans with an exposure location of Vietnam and no additional eligibility factors will no longer be enrolled as a Priority Group 6 if the enrollment date is greater than the expiration date.

Date/Time
SWAC STA EXP DATE 1302 If populated, this field will be used as the expiration date for the Special Treatment Authority (STA) for Southwest Asia Condition (SWAC) Veterans. New enrollments of SWAC Veterans and no additional eligibility factors will no longer be enrolled as a Priority Group 6 if the enrollment date is greater than the expiration date.

Date/Time

PTF

File Number: 45

File Description:

This file contains all PTF information generated from admissions, treating specialty transfers, and PTF screen edits.


Fields:

Name Number Description Data Type Field Specific Data
PATIENT .01 This field contains a pointer to the patient file (#2). This is the patient that the PTF data has been entered for.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ADMISSION DATE 2 This is the date of admission described by the PTF record.

Date/Time
INTERNAL ADMISSION # 2.1 IFN assigned to the admission date/time for this particular record.

Computed
WARD AT DISCHARGE 2.2 This field contains the ward at the time of discharge.

Computed
FACILITY 3 Facility from which this veteran was discharged.

Numeric
FEE BASIS 4 This field indicated if the PTF record is a FEE basis record. A '1' in this field indicates a FEE basis record.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: FEE BASIS
SUFFIX 5 This field contains the suffix of the medical center if not indicated in the facility number.

Free Text
STATUS 6 This field indicates the current status of the PTF record.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: Open
  • Code : 1
    Stands For: Closed
  • Code : 2
    Stands For: Released
  • Code : 3
    Stands For: Transmitted
CLOSED OUT BY 7 This field contains a pointer to the New Person File. The field indicates who closed out the PTF record.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLOSE OUT FILE 7.1 File reference containing all PTF records that have been closed out.

Pointer
PointerTo:
fileName:
PTF CLOSE OUT
fileNumber:
45.84
CLOSE OUT DATE 7.2 This field contains the date the PTF record was closed out.

Computed
RELEASE DATE 7.3 This field contains the date the PTF record was released.

Computed
TRANSMISSION DATE 7.4 This field contains the date the PTF record was transmitted.

Computed
FIRST CLOSED OUT AT 8 This field contains the date the PTF record was first closed out.

Date/Time
DRG 9 This field contains the DGR for the espisode of care described by the PTF record.

Computed
MEANS TEST INDICATOR 10 This field contains the Means Test Indicator.

Set of Codes
Set of Codes:
  • Code : AS
    Stands For: SERVICE CONNECTED
  • Code : AN
    Stands For: NSC MT COPAY EXEMPT
  • Code : B
    Stands For: CAT B
  • Code : C
    Stands For: MT COPAY REQUIRED
  • Code : N
    Stands For: NON VET
  • Code : X
    Stands For: NOT APPLICABLE
  • Code : U
    Stands For: NOT DONE/COMPLETED
  • Code : G
    Stands For: GMT COPAY REQUIRED
TYPE OF RECORD 11 This field indicates what type of record this is represents. As of 8/90 there are only two types, PTF and census. It is important to note that before MAS v4.7 this field did not exist and all records were PTF records. If sites have developed reports, they will need to screen on this field for the PTF record. (A PTF record has an internal value of 1 and a census record has a value of 2.)

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PTF
  • Code : 2
    Stands For: CENSUS
CORRESPONDING PTF RECORD 12 This field is only filled in for census type of records. It points to the PTF record that was used to create the census record. A census record is an extract of information from the parent PTF record for activities that occurred during the census time period.

Pointer
PointerTo:
fileName:
PTF
fileNumber:
45
CENSUS DATE 13 This field is only filled in for census records and it points back to a PTF CENSUS DATE file entry.

Pointer
PointerTo:
fileName:
PTF CENSUS DATE
fileNumber:
45.86
SOURCE OF ADMISSION 20 This field contains the source of admission of the veteran, or where he was admitted to the hospital from, i.e. community, other facility, etc.

Pointer
PointerTo:
fileName:
SOURCE OF ADMISSION
fileNumber:
45.1
ADMITTING ELIGIBILITY 20.1 This field contains the Admitting Eligibility associated with this inpatient stay.

Pointer
PointerTo:
fileName:
ELIGIBILITY CODE
fileNumber:
8
*TRANSFERING FACILITY 21 Old version no longer used

Pointer
PointerTo:
fileName:
PTF TRANSFERRING FACILITY
fileNumber:
45.2
TRANSFERRING FACILITY 21.1 Facility number of the facility that the veteran was transferred to the hospital from.

Numeric
TRANSFERRING SUFFIX 21.2 The suffix assigned to the facility (if applicable) the veteran was transferred to the hospital from, i.e. 9AA = Nursing Home.

Free Text
SOURCE OF PAYMENT 22 The field contains the source of payment for this patient for Non-VA hospitals only.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CONTRACT-PUBLIC&PRIV
  • Code : 2
    Stands For: SHARING
  • Code : 3
    Stands For: CONTRACT-MILT&FED AGENCY
  • Code : 4
    Stands For: PAID UNAUTH
CATEGORY OF BENEFICIARY 23 Category of beneficiary. This field through cross reference sets Category of beneficiary field in patient file which is used for Amis 358

Pointer
PointerTo:
fileName:
CATEGORY OF BENEFICIARY
fileNumber:
45.82
CPT RECORD DATE/TIME 30

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CPT RECORD DATE/TIME .01

Date/Time
REFERRING OR ORDERING PROVIDER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RENDERING PROVIDER .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRIMARY DIAGNOSIS .04 Enter the Diagnosis that should appear first in box 21 of the HCFA 1500 insurance form.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
RENDERING LOCATION .05 Enter the location in file 44 where services were furnished. The name of the facility and address must be entered in file 4 and pointed to by file 44.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
VISIT NUMBER .06 This is a pointer to the Visit File (9000010) in PCE. A visit will be generated for each CPT procedure entry.

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
DATA TO PCE FLAG .07 Set by the PTF system to indiacte if the data in the PTF 810 screen has been sent to the PCE system. It is reset to 0 if the data is edited, after the data in PCE is deleted.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT SENT
  • Code : 1
    Stands For: SENT TO PCE
DELETE FLAG .09 This field flags deleted records so they do not appear on the 801 Screens Not Sent to PCE report.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: Valid subfile record
  • Code : 1
    Stands For: All CPT Transactions have been deleted
401 40 Multiple containing information on the PTF 401 screen relating to surgical procedures and operations.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SURGERY/PROCEDURE DATE .01 Date/time surgery or procedure was performed.

Date/Time
SURGICAL SPECIALTY 3 This field contains the surgical specialty for this espisode of care.

Pointer
PointerTo:
fileName:
SURGICAL SPECIALTY
fileNumber:
45.3
CATEGORY OF CHIEF SURG 4 This field indicates the category of the chief surgeon. The choices are defined as a set of codes.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VA TEAM
  • Code : M
    Stands For: MIXED VA&NON-VA
  • Code : N
    Stands For: NON VA
  • Code : 1
    Stands For: STAFF,FT
  • Code : 2
    Stands For: STAFF, PT
  • Code : 3
    Stands For: CONSULTANT
  • Code : 4
    Stands For: ATTENDING
  • Code : 5
    Stands For: FEE BASIS
  • Code : 6
    Stands For: RESIDENT
  • Code : 7
    Stands For: OTHER(INCLUDES INTERNS)
CATEGORY OF FIRST ASSISTANT 5 This field indicates the category of the first assistant.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: STAFF, FT
  • Code : 2
    Stands For: STAFF, PT
  • Code : 3
    Stands For: CONSULTANT
  • Code : 4
    Stands For: ATTENDING
  • Code : 5
    Stands For: FEE BASIS
  • Code : 6
    Stands For: RESIDENT
  • Code : 7
    Stands For: OTHER (INCLUDES INTERN)
  • Code : 8
    Stands For: NO ASSISTANT
PRINCIPAL ANESTHETIC TECHNIQUE 6 This field indicates the principal anesthetic technique used during the operation/procedure.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NONE
  • Code : 1
    Stands For: INHALATION(OPEN DROP)
  • Code : 2
    Stands For: INHALATION(CIRCLE ABSORBER)
  • Code : 3
    Stands For: INTRAVENOUS
  • Code : 4
    Stands For: INFILTRATION
  • Code : 5
    Stands For: FIELD BLOCK
  • Code : 6
    Stands For: NERVE BLOCK
  • Code : 7
    Stands For: SPINAL
  • Code : 8
    Stands For: EPIDURAL
  • Code : 9
    Stands For: TOPICAL
  • Code : R
    Stands For: RECTAL
  • Code : X
    Stands For: OTHER
SOURCE OF PAYMENT 7 This field indicates the source of payment for patients operated on in a Non-VA facility and returned to a VA facility within a 24-hr period.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CONTRACT
  • Code : 2
    Stands For: SHARING
OPERATION CODE 1 8 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation or procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
OPERATION CODE 2 9 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation of procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
OPERATION CODE 3 10 This field conatins a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation or procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
OPERATION CODE 4 11 This field conatins a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation or procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
OPERATION CODE 5 12 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation or procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
KIDNEY SOURCE 300.01 This field will indicate where the transplant organ was received from.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Live Donor
  • Code : 2
    Stands For: Cadaver
PROCEDURE 1 45.01 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE 2 45.02 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating an operation or procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE 3 45.03 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE 4 45.04 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE 5 45.05 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
501 50 501 movements

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MOVEMENT RECORD .01 This field contains the movement number for this episode of care.

Numeric
LOSING SPECIALTY 2 This field contains the losing bedsection for this movement.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
LEAVE DAYS 3 This field contains the total number of days this patient was on leave (authorized absence) from his stay in this bedsection.

Numeric
PASS DAYS 4 This field contains the total number of days this patient was on pass (authorized absence <92 hrs) from his bedsection during his stay.

Numeric
ICD 1 5 This field contains the diagnosis responsible for the greatest length of stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 2 6 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 3 7 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 4 8 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 5 9 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
MOVEMENT DATE 10 This field contains the date/time of the movement for this episode of care.

Date/Time
ICD 6 11 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 7 12 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 8 13 This field contains a diagnosis for the patient's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 9 14 This field contains diagnosis for the patients's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
ICD 10 15 This field contains a diagnosis for the patients's stay in this bedsection.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SPECIALTY CDR 16 This field contains the CDR for the specialty for which the patient was being treated.

Numeric
TRANSMIT FLAG 17 This flag can be set to stop transmission of a 501 during PTF and census transmission. This flag is only used when there are more than 25 PTF movements. Austin can only accept 25 or less. If no data is in this field then transmission does occur.

Set of Codes
Set of Codes:
  • Code : n
    Stands For: NO, DO NOT TRANSMIT
  • Code : y
    Stands For: YES, TRANSMIT
TREATED FOR SC CONDITION 18 This field indicates if patient care was related to a SC disability.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 2
    Stands For: NO
TRANSFER DRG 20 This field contains the DRG if there was a service transfer.

Pointer
PointerTo:
fileName:
DRG
fileNumber:
80.2
LOSING SERVICE 21 This field contains the losing service for this episode of care.

Free Text
TRANSFER DATE 22 This field contain the transfer date into this service.

Date/Time
LOS IN SERVICE 23 This field contains the total length of stay for the patient.

Numeric
PROVIDER 24 This field contains the provider for this episode of care for the patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CUMULATIVE LOS 25 This field contains the total length of stay minus pass and leave days.

Numeric
TREATED FOR AO CONDITION 26 This field indicates if the patient care was related to Agent Orange exposure.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATED FOR IR CONDITION 27

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
EXPOSED TO SW ASIA CONDITIONS 28

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR MST 29 Identifies whether treatment was for Military Sexual Trauma.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR HEAD/NECK CA 30 Identifies whether treatment was for Head and/or Neck Cancer.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
POTENTIALLY RELATED TO COMBAT 31 Indicate if the inpatient stay at this location is related to military service in combat and not from cause other than military service in combat operations (congenital, developmental, pre-service existing conditions, or conditions having specific and well-established etiology that began after military combat service, i.e., bone fractures occurring after separation date, commond colds, etc). This information can only be entered if the patient has CV status in Registration.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR SHAD 32 Identifies whether treatment was for Project 112/SHAD. Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SUICIDE/SELF INFLICT INDICATOR 300.02 This field will indicate if the suicide was attempted or accomplished or if a self inflicted injury occurred.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Attempted Suicide
  • Code : 2
    Stands For: Accomplished Suicide
  • Code : 3
    Stands For: Self Inflicted Injury
LEGIONNAIRE'S DISEASE 300.03 This field will indicated if the patient was treated for Legionnaire's Disease.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Yes
  • Code : 2
    Stands For: No
SUBSTANCE ABUSE 300.04 Select type of substance abused by the patient.

Pointer
PointerTo:
fileName:
PTF ABUSED SUBSTANCE
fileNumber:
45.61
PSYCHIATRY CLASS. SEVERITY 300.05 This field is an overall rating indicating maximal stress.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: INADEQUATE INFO OR NO CHANGE
  • Code : 1
    Stands For: NONE
  • Code : 2
    Stands For: MILD
  • Code : 3
    Stands For: MODERATE
  • Code : 4
    Stands For: SEVERE
  • Code : 5
    Stands For: EXTREME
  • Code : 6
    Stands For: CATASTROPHIC
CURRENT PSYCH CLASS ASSESS 300.06 CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH

Numeric
HIGH LEVEL PSYCH CLASS 300.07 CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OR HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH

Numeric
601 60 601 movements.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROCEDURE DATE .01 Enter the date of the procedure.

Date/Time
SPECIALTY 1 Treating specialty for which this 601 movement was associated.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
DIALYSIS TYPE 2 If applicable, the PTF designated dialysis type of care received during this episode of care.

Pointer
PointerTo:
fileName:
PTF DIALYSIS TYPE
fileNumber:
45.4
NUMBER OF DIALYSIS TREATMENTS 3 Total number of dialysis treatments received during this episode of care.

Numeric
PROCEDURE CODE 1 4 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure was performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE CODE 2 5 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure was performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE CODE 3 6 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure was performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE CODE 4 7 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure was performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
PROCEDURE CODE 5 8 This field contains a pointer to the ICD OPERATION/PROCEDURE File (#80.1) indicating a procedure was performed during this episode of care.

Pointer
PointerTo:
fileName:
ICD OPERATION/PROCEDURE
fileNumber:
80.1
DISCHARGE DATE 70 For census records, this field holds the census date associated with the record, not the admission's discharge date.

Date/Time
DISCHARGE SPECIALTY 71 This field contains the bedsection this patient was discharged from.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
TYPE OF DISPOSITION 72 This field contains the type of disposition for this patient for this episode of care.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: REGULAR
  • Code : 2
    Stands For: NBC OR WHILE ASIH
  • Code : 3
    Stands For: EXPIRATION 6 MONTH LIMIT
  • Code : 4
    Stands For: IRREGULAR
  • Code : 5
    Stands For: TRANSFER
  • Code : 6
    Stands For: DEATH WITH AUTOPSY
  • Code : 7
    Stands For: DEATH WITHOUT AUTOPSY
DISCHARGE STATUS 72.1 This field contains the discharge status for the patient during this episode of care.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: BED OCCUPANT
  • Code : 2
    Stands For: ON PASS
  • Code : 3
    Stands For: ON LEAVE
  • Code : 4
    Stands For: ASIH
OUTPATIENT TREATMENT 73 This field indicates if the veteran was referred for outpatient treatment following an episode of hospital care.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 3
    Stands For: NO
VA AUSPICES 74 If outpatient care indicated, is it under VA auspices? Is the VA paying for this care or is the veteran being seen at a VA facility?

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 2
    Stands For: NO
PLACE OF DISPOSITION 75 Enter place of disposition..where is the veteran being discharged to?

Pointer
PointerTo:
fileName:
PLACE OF DISPOSITION
fileNumber:
45.6
*RECEIVING FACILITY 76 Discontinued after version 3.3

Pointer
PointerTo:
fileName:
PTF TRANSFERRING FACILITY
fileNumber:
45.2
RECEIVING FACILITY 76.1 Facility number of the facility that the veteran is being transferred to from hospital.

Numeric
RECEIVING SUFFIX 76.2 Suffix of receiving facility, i.e. 9AA for nursing home.

Free Text
ASIH DAYS 77 Number of days patient was Absent Sick in Hospital during this episode of care (pertains to NHCU/DOM patients only).

Numeric
C&P STATUS 78 Compensation and Pension status (synoymous with eligibility).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: COMP/SC COND >10%
  • Code : 2
    Stands For: NON-COMP/SC COND<10%
  • Code : 3
    Stands For: COMP/SC (+10%) NO MED CARE
  • Code : 4
    Stands For: NON-COMP(-10%) SC NO MED CARE-VA PENSION
  • Code : 5
    Stands For: VA PENSION-NO SC COND
  • Code : 6
    Stands For: NON-COMP(-10%) SC NO MED CARE NO PENSION
  • Code : 7
    Stands For: NO PENSION-NO SC
  • Code : 8
    Stands For: NON-VET
PRINCIPAL DIAGNOSIS 79 This field contains the diagnosis responsible for the patient's greatest length of stay.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
PROVIDER 79.1 The primary physician responsible for this patient's episode of care.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SECONDARY DIAGNOSIS 1 79.16 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 2 79.17 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 3 79.18 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the caluculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 4 79.19 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
PROVIDER SSN 79.2 Social Security number of primary care physician.

Computed
SECONDARY DIAGNOSIS 5 79.201 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 6 79.21 This field conatins a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 7 79.22 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 8 79.23 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 9 79.24 This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 10 79.241 This field contains a diagnosis for the patient during this episode of care.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 11 79.242 This field contains a diagnosis for the patient during this episode of care.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 12 79.243 This field contains a diagnosis for the patient during this episode of care.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DIAGNOSIS 13 79.244

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
TREATED FOR SC CONDITION 79.25

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 2
    Stands For: NO
TREATED FOR AO CONDITION 79.26

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATED FOR IR CONDITION 79.27

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
EXPOSED TO SW ASIA CONDITIONS 79.28

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR MST 79.29 Was the treatment related to Military Sexual Trauma.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR HEAD/NECK CA 79.3 Was the treatment related to Head and/or Neck Cancer.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
POTENTIALLY RELATED TO COMBAT 79.31 Indicate if inpatient stay at this location may be related to military service in combat and not from cause other than military service in combat operations (congenital, developmental, pre-service existing conditions, or conditions having specific and well-established etiology that began after military combat service, i.e. bone fractures occuring after separation date, common colds, etc). This information is copied from the movement records.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
TREATMENT FOR SHAD 79.32 Was the treatment related to Project 112/SHAD. Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PRINCIPAL DIAGNOSIS pre 1986 80 This field contains the diagnosis responsible for the patient being admitted to the medical center. This field is not used in the calculation of the DRG. This field is no longer used.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
TERMINAL DIGIT 99 Computed field to determine the last four digits of the SSN

Computed
CODING CLERK 100 Multiple contains information on the coding clerk who worked on the PTF record for this episode of care.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CODING CLERK .01 Coding clerk who worked on the PTF record for this episode of care (closing it out).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INCOME 101.07 This field contains the patient's income as reported for the MEANS TEST if applicable or the income is calculated from fields in the PATIENT file (#2).

Numeric
CENSUS YEAR 200 Multiple containing information on the census year

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CENSUS YEAR .01 Fiscal Year that the patient census was conducted.

Date/Time
DATE TRANSMITTED 2 Date/time the census record for an episode of care was transmitted.

Date/Time
MESSAGE 3 E-mail message received by transmitting clerk that record was indeed transmitted.

Pointer
PointerTo:
fileName:
MESSAGE
fileNumber:
3.9
KIDNEY SOURCE 300.01 This field will indicate where the transplanted organ was received from.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Live Donor
  • Code : 2
    Stands For: Cadaver
SUICIDE/SELF INFLICT INDICATOR 300.02 This field will indicated if a suicide was attempted or accomplished.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Attempted Suicide
  • Code : 2
    Stands For: Accomplished Suicide
  • Code : 3
    Stands For: Self Inflicted Injury
LEGIONNAIRE'S DISEASE 300.03 This field will indicated the patient was treated for Legionnaire's Disease.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Yes
  • Code : 2
    Stands For: No
SUBSTANCE ABUSE 300.04 Select type of substance abused by the patient.

Pointer
PointerTo:
fileName:
PTF ABUSED SUBSTANCE
fileNumber:
45.61
PSYCHIATRY CLASS. SEVERITY 300.05 Enter a one-digit rating from 0 (inadequate information/unchanged) through 6 (catastrophic). This field contains a rating indicating maximal stress.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: INADEQUATE INFORMATION OR NO CHANGE IN CONDITION
  • Code : 1
    Stands For: NONE
  • Code : 2
    Stands For: MILD
  • Code : 3
    Stands For: MODERATE
  • Code : 4
    Stands For: SEVERE
  • Code : 5
    Stands For: EXTREME
  • Code : 6
    Stands For: CATASTROPHIC
CURRENT FUNCTIONAL ASSESSMENT 300.06 CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OR HURTING SELF OR OTHER OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH

Numeric
HIGH LEVEL PSYCH CLASS 300.07 CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH

Numeric
535 535 This multiple contains all the ward specialty movements of a patient that occur during the admission. If a patient changed wards but the specialty of the two wards are the same then no entry in this multiple is created.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PHYSICAL MOVEMENT .01 Computed generated movement number(1,2,3, etc.)

Numeric
LOSING WARD SPECIALTY 2 Specialty of the ward losing the patient.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
LEAVE DAYS 3 Number of leave days accumulated during movement.

Numeric
PASS DAYS 4 Number of pass days accumulated during movement.

Numeric
LOSING WARD 6 Name of the losing ward.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
DISCHARGE MOVEMENT 7 This field indicates whether this movement is the final movement (ie. discharge) for the admission.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MOVEMENT DATE 10 This field holds the date and time of the movement.

Date/Time
LOSING WARD CDR 16 This field contains the CDR number for the losing ward.

Numeric
TRANSMIT FLAG 17 This flag can be set to stop transmission of a 535 during PTF and census transmission. This flag is only used when there are more than 25 535 movements. Austin can only accept 25 or less. If no data is in this field then transmission does occur.

Set of Codes
Set of Codes:
  • Code : n
    Stands For: NO, DO NOT TRANSMIT
  • Code : y
    Stands For: YES, TRANSMIT

PTF MESSAGE

File Number: 45.5

File Description:

Message generated by changes in bedsection and diagnosis to be reviewed by PTF coders


Fields:

Name Number Description Data Type Field Specific Data
NUMBER .01 This field contains the message number. The message number corresponds to the entry number in the file.

Numeric
PATIENT 1 This is a pointer to the patient, in the Ptaient File (#2), for whom the message is for.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ENTRY CLERK 2 This field contains a pointer to the New Person File (#200) indicating which clerk logged this message into the system.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTRY DATE/TIME 3 This field contains the date/time this message was entered into the system.

Date/Time
PRINT DATE/TIME 4 This field contains the date/time this message was first printed in MAS.

Date/Time
MESSAGE 10 This field contains the PTF Message for the patient. Messages are created for the patient by DHCP and can be entered through the 'Enter PTF Message' option.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MESSAGE .01

Word Processing

CENSUS WORKFILE

File Number: 45.85

File Description:

This file is a work file of patients who were inpatients as of 11:59pm on acensus date. File entries are created by the Regenerate Census Workfile option of the Census module. The file is used to produce the Census Status Report. Without this workfile, it would be necessary to search all admissions in order to compile this report. This file eliminates that processing.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field contains the name of the inpatient.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ADMISSION DATE .02 This field contains the admission date and time associated with this workfile entry.

Date/Time
ADMISSION ENTRY .03 This field contains the internal entry number to the patient's admission multiple. This number represent the admission entry that caused this workfile entry to be created.

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
CENSUS DATE .04 This field contains the CENSUS DATE that the workfile entry is associated. Note that an admission can be associated with more than one census record but each workfile entry is associated with only one census record. As an example, a patient who was a continuous inpatient from 8/1/91 to 11/1/92 would have census records for the 9/30/91 and 9/30/92 censuses. This admission would have two workfile entries.

Pointer
PointerTo:
fileName:
PTF CENSUS DATE
fileNumber:
45.86
DISCHARGE DATE .05 This field contains the discharge date and time associated with this workfile entry.

Date/Time
WARD ON CENSUS DATE .06 This field contains the ward that the patient was on as of 11:59 of the CENSUS DATE.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
PTF NUMBER .12 This field contains the PTF record that is assoicated with this workfile entry.

Pointer
PointerTo:
fileName:
PTF
fileNumber:
45
CENSUS STATUS 101 This computed field will display/print the census status associated with the admission and CENSUS DATE for this workfile entry. Possible statuses are: Open Closed Released Transmitted

Computed
CENSUS RECORD NUMBER 103 This computed field displays/prints the census record number associated with the admission and CENSUS DATE for this workfile entry.

Computed

PTF TRANSACTION REQUEST LOG

File Number: 45.87

File Description:

This file is a log of special PTF transactions submitted to Austin. The following PTF transactions are logged in this file: o N099 for PTF record deletion o N150 for RPO of a specific admission o N151 for RPO of all admissions at a VAMC


Fields:

Name Number Description Data Type Field Specific Data
DATE INITIATED .01 This field contains the date and time the user initially submitted the transaction.

Date/Time
USER .02 This field contains the user name who submitted the transaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
MAIL MSG # .03 This field contains the Mailman message number which contains the transaction that was sent to Austin. that was sent to Austin.

Pointer
PointerTo:
fileName:
MESSAGE
fileNumber:
3.9
BLOCK .04 This field contains the transaction type for the request. For example, it can contain the following: o N099 for PTF record deletion o N150 for RPO of a specific admission at a VAMC o N151 for RPO of all admissions at a VAMC

Free Text
SSN .05 Enter the Social Security Number(SSN) of the patient for which you desire information.

Free Text
ADMISSION DATE/TIME .06 Enter the date/time of an admission for the patient(SSN) selected.

Date/Time
ADMITTING FACILITY/SUFFIX .07 This field contains the facility number and suffix of the VAMC that has admitted the patient in the past. This field is filled in by the user when sending a N150 transaction.

Free Text
REQUESTING FACILITY/SUFFIX .08 This field contains the facility number and the suffix of the VAMC requesting information.

Free Text
PATIENT .09 This field contains the patient associated with the transaction submitted. However, it is not required. If filled in then the SSN field will automatically be updated with the patient's SSN, as it appears in the PATIENT file. If the user has an SSN of a patient not in the site's PATIENT file, the user can enter that SSN directly into the SSN field.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ADMITTING INSTITUTION .1 This field allows the user to select the VAMC from which admission information is desired. This field is optional but if filled in, the VAMC's station number, as it appears in the INSTITUTION file, will be stuffed into the ADMITTING FACILITY/SUFFIX field as a default.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4

IV STATS

File Number: 50.8

File Description:

This file contains information concerning the IV workload of the pharmacy. The file is updated each time the Compile IV Stats option is run and the data stored is used as the basis for the IV AMIS report.


Fields:

Name Number Description Data Type Field Specific Data
IV ROOM .01 Looks at the IV Room file.

Pointer
PointerTo:
fileName:
IV ROOM
fileNumber:
59.5
LAST COMPILATION .2 This is the date when the IV STATS file was last successfully compiled. When an IV cost report is run, this date is displayed on the user's screen. If the last compilation date is more than one day in the past, a message is printed warning the user that the cost data may not be accurate.

Date/Time
PATIENT 1 Identifies patients which have statistical information in the IV STATS file (50.8).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01 This field is the holding file for IV STATS that are to be counted. When a COUNTED IV label is run, this field is updated by the computer. Pertinent information about the 'COUNTED IV LABEL' is saved and will be compiled later by a job that is automatically queued to run at 1 AM in the morning. All IV STATS can be compiled immediately by running the 'COMPILE IV STATS' option in the supervisor menu. The 'COMPILE IV STATS' option should not be used regularly, since it is very CPU intensive and is automatically run each day.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
TRANSACTION NUMBER 1 This number is the transaction number in "hold" status until stats are compiled.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TRANSACTION NUMBER .01 This number is the transaction number in "hold" status until stats are compiled.

Numeric
ORDER NUMBER 1 Order Number for the order on "hold"

Numeric
STATUS 2 Status of the order on "hold",1 for Dispensed, 2 for returned and 3 for destroyed, 4 for canceled.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DISPENSED
  • Code : 2
    Stands For: RETURNED
  • Code : 3
    Stands For: DESTROYED
  • Code : 4
    Stands For: CANCELED
DATE OF TRANSACTION 3 The date of the transaction in "hold".

Date/Time
NUMBER OF ORDERS 4 Number of orders on "hold" status.

Numeric
WARD 5 Identifies the ward associated with this transaction.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
DRUG WITH NO COST 6 When compiling IV Statistics, if an order is found which contains a drug that has no cost data entered, the file number (either 52.6 or 52.7) and the print name of that drug is placed in this field. A mail message is then sent to all users holding the "PSJI MGR" security key (excluding IRM staff), identifying the drug missing cost data, and whether it is an additive or a solution. The dispensing information is not added to the statistics file until the cost has been entered.

Free Text
DATE 2 Date of order (the statistics file stores the entries in date order). the IV package.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE .01 Date of order (the statistics file stores the entries in date order).

Date/Time
WARD 1 Ward for which statistics have been gathered (looks at Ward Location File (#42)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
WARD .01 Ward for which statistics have been gathered (looks at ward location file (#42).

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
IVPB DISPENSED 1 IV Piggybacks dispensed for this ward.

Numeric
LVP DISPENSED 2 Large Volume Admixtures administered for this ward.

Numeric
HYPERAL DISPENSED 3 Hyperals administered for this ward.

Numeric
WARD RETURNS 4 Ward for which IV products were returned. Pointer to WARD LOCATION file (42).

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
WARD RETURNS (IVPB) 5 Ward for which IV IVPBs (IV Piggybacks) returned for the specified ward and date.

Numeric
WARD RETURNS (LVP) 6 This is the number of LVPs (Large Volume Parenterals) returned for the specified ward and date.

Numeric
WARD RETURNS (HYPERAL) 7 This is the number of Hyperals returned for the specified ward and date.

Numeric
WARD DESTROYED 8 Ward for which IV products were destroyed. file (42).

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
WARD DESTROYED (IVPB) 9 This is the number of IVPBs (IV piggybacks) destroyed for the specified ward and date.

Numeric
WARD DESTROYED (LVP) 10 This is the number of LVPs (large volume parenterals) destroyed for the specified ward and date.

Numeric
WARD DESTROYED (HYPERAL) 11 This is the number of hyperals returned for the specified ward and date.

Numeric
SYRINGE DISPENSED 12 This is the number of syringes dispensed for the specified ward and date.

Numeric
CHEMOTHERAPY DISPENSED 13 This is the number of chemotherapy IVs dispensed for the specified ward and date.

Numeric
WARD RETURNS (CHEMO) 14 This is the number of chemotherapy IVs returned for the specified ward and date.

Numeric
WARD RETURNS (SYRINGE) 15 This is the number of syringe IVs returned for the specified ward and date.

Numeric
WARD DESTROYED (SYRINGE) 16 This is the number of syringe IVs which were destroyed for the specified ward and date.

Numeric
WARD DESTROYED (CHEMO) 17 This is the number of chemotherapy IVs returned for the specified ward and date.

Numeric
WARD CANCELED (IVPB) 18 This is the number of IVPBs (IV piggybacks) which were canceled for the specified ward and date.

Numeric
WARD CANCELED (LVP) 19 This is the number of LVPs (large volume parenterals) which were cancelled for the specified ward and date.

Numeric
WARD CANCELED (HYPERAL) 20 This is the number of hyperals which were cancelled for the specified ward and date.

Numeric
WARD CANCELED (SYRINGE) 21 This is the number of syringe IVs which were cancelled for the specified ward and date.

Numeric
WARD CANCELED (CHEMO) 22 This is the number of chemotherapy IVs which were cancelled for the specified ward and shift.

Numeric
IV DRUG 2 IV drug administered.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IV DRUG .01 IV drug administered.

Free Text
DISPENSED UNITS (IV DRUG) 1 Number of units dispensed for this drug.

Numeric
RETURNED UNITS (IV DRUG) 2 Number of units returned for this drug.

Numeric
DESTROYED UNITS (IV DRUG) 3 This is the number of units destroyed from this ward of the selected drug on this date.

Numeric
AVERAGE DRUG COST PER UNIT 4 Average cost of drug per unit. This information is taken from the additive or solution file (whichever is appropriate).

Numeric
DRUG UNIT 5 Unit of measure. This is used in calculating cost of drug.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ML
  • Code : 2
    Stands For: LITER
  • Code : 3
    Stands For: MCG
  • Code : 4
    Stands For: MG
  • Code : 5
    Stands For: GM
  • Code : 6
    Stands For: UNITS
  • Code : 7
    Stands For: IU
  • Code : 8
    Stands For: MEQ
  • Code : 9
    Stands For: MM
  • Code : 10
    Stands For: MU
  • Code : 11
    Stands For: THOUU
  • Code : 12
    Stands For: MG-PE
  • Code : 13
    Stands For: NANOGRAM
TYPE 6 Indicates whether drug is additive or solution.

Set of Codes
Set of Codes:
  • Code : 52.6
    Stands For: IV ADDITVE
  • Code : 52.7
    Stands For: IV SOLUTION
DISPENSING OCCURRENCES 7 Number of times drug was dispensed (or number of bags hung).

Numeric
PATIENT 8 These fields specify how many units of the IV drug were dispensed, returned, canceled, or destroyed, for each patient who was to receive this drug.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01 Patient to whom IV was administered.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DISPENSED UNITS (PATIENT) 1 Number of units patient was administered

Numeric
RETURNED UNITS (PATIENT) 2 Units returned to Pharmacy and not administered to patient.

Numeric
DESTROYED UNITS (PATIENT) 3 Units destroyed by pharmacy and not administered to patient.

Numeric
WARD PTR 4 Ward in which IV drug was administered.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
CANCELED UNITS (PATIENT) 5 This is the number of units of the IV drug for this patient which were cancelled on the selected date.

Numeric
PROVIDER 9 These fields specify how many units of the IV drug selected were dispensed, returned, canceled, or destroyed, for each physician prescribing this drug.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER .01 Person who authorized the IV order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DISPENSED UNITS (PROVIDER) 1 Number of units dispensed for provider's order.

Numeric
RETURNED UNITS (PROVIDER) 2 Units returned to the Pharmacy and not administered to the patient.

Numeric
DESTROYED UNITS (PROVIDER) 3 Number of units destroyed by the pharmacy and not administered to the patient

Numeric
CANCELED UNITS (PROVIDER) 4 This is the number of units of the IV drug which were cancelled for the specified provider on the selected date.

Numeric
WARD 10 These fields specify how many units of the selected IV drug were dispensed, returned, canceled, or destroyed, for each ward housing patients who were to receive this drug.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
WARD .01 Ward in which IV drug was administered.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
TYPE 1 This contains information concerning each type of IV ordered for the selected ward, IV drug, and date.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TYPE .01 Type of IV administered: 'P' for piggyback, 'H' for hyperal and 'A' for admixture 'S' for syringe, 'C' for chemotherapy.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PIGGYBACK
  • Code : H
    Stands For: HYPERAL
  • Code : A
    Stands For: ADMIXTURE
  • Code : S
    Stands For: SYRINGE
  • Code : C
    Stands For: CHEMOTHERAPY
DISPENSED UNITS 1 Units dispensed for this type IV.

Numeric
RETURNED UNITS 2 Units for this type IV returned to pharmacy and not administered to the patient.

Numeric
DESTROYED UNITS 3 Units for this type IV destroyed by the Pharmacy and not administered to the patient.

Numeric
DISPENSING OCCURRENCES 4 This is the number of times this type of IV was dispensed for the ward, drug, and date selected.

Numeric
RETURNED OCCURRENCES 5 This is the number of times this type of IV was returned for the ward, drug, and date selected.

Numeric
DESTROYED OCCURRENCES 6 This is the number of times this type of IV was destroyed for the ward, drug, and date selected.

Numeric
CANCELLED UNITS 7 This is the number of units of this type which were cancelled for the ward, drug, and date selected.

Numeric
CANCELLED OCCURRENCES 8 This is the number of times an order of this type was cancelled for the ward, drug, and date selected.

Numeric
DISPENSED UNITS (WARD) 2 Units dispensed for this ward.

Numeric
RETURNED UNITS (WARD) 3 This is the number of units of the specified drug returned from the selected ward on this date.

Numeric
DESTROYED UNITS (WARD) 4 This is the number of units destroyed for this ward and drug on the selected date.

Numeric
CANCELED UNITS 5 This is the number of units cancelled for this ward and drug on the selected date.

Numeric
RETURNED OCCURRENCES 11 This is the number of times an order for the specified drug was destroyed on the selected date.

Numeric
DESTROYED OCCURRENCES 12 This is the number of times an order for the specified drug was destroyed on the selected date.

Numeric
CANCELLED OCCURRENCES 13 This is the number of times an order for the specified drug was cancelled on the selected date.

Numeric
CANCELLED UNITS (IV DRUG) 14 This is the number of units of an IV drug which were cancelled on the date selected.

Numeric

PRESCRIPTION

File Number: 52

File Description:

Contains all outpatient RX data used by the outpatient pharmacy package. As the above indicates, this is the hub of the outpatient system. It will easily be the largest pharmacy file in time and is pointed to very heavily. Deletion of an entry in this file must be handled VERY carefully and is not allowed if refills have been issued. Of particular interest is that essentially all the history pertaining to a particular Rx is contained in each Rx entry.


Fields:

Name Number Description Data Type Field Specific Data
RX # .01 This is the prescription number.

Free Text
ISSUE DATE 1 Date when doctor wrote prescription.

Date/Time
PATIENT 2 The patient receiving treatment.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PATIENT STATUS 3 This field is used to show the status of the patient at the time the medication was filled.

Pointer
PointerTo:
fileName:
RX PATIENT STATUS
fileNumber:
53
PROVIDER 4 Doctor who wrote the prescription.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLINIC 5 Clinic where treatment was given and prescription was written.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DRUG 6 The actual medication.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
TRADE NAME 6.5 Free Text that, if it exists, will replace the DRUG name on the RX label.

Free Text
QTY 7 This field is used to show the amount of medication that was dispensed.

Numeric
DAYS SUPPLY 8 Enter a whole number between 1 and 90. The maximum upper limit is 90, but may be lower based on the maximum specified for this patient status. This parameter is defined in the RX PATIENT STATUS file.

Numeric
# OF REFILLS 9 The number of refills allowed per prescription.

Numeric
SIG 10 Enter the medication instruction for this prescription. Entries should be no longer than 200 total characters, including spaces, with no one set of characters longer than 32 characters in length.

Free Text
OERR SIG 10.1 This field is used to determined if the original medication instructions was accepted. This field for all Rxs entered prior v7 will be null or no. This field is uneditable.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SIG1 10.2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SIG1 .01 This holds a Sig from OERR.

Free Text
SIG1 1

Free Text
ORDER CONVERTED 10.3 This field is used to indicate V7 order conversion complete to OERR. It's also used to indicate the updating of CPRS on expiration of the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ORDER CONVERTED
  • Code : 2
    Stands For: EXPIRATION TO CPRS
COPIES 10.6 The number of copies made of the label for the prescription.

Numeric
MAIL/WINDOW 11 Indicates if the medication will be picked up or mailed to the patient.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MAIL
  • Code : W
    Stands For: WINDOW
REMARKS 12 Any additional comments.

Free Text
ADMINISTERED IN CLINIC 14 This indicates if the medication was administered in a clinic instead of being dispensed to the patient.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ENTERED BY 16 This field will show who requested the rx.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
UNIT PRICE OF DRUG 17 Price per dispense unit.

Numeric
DIVISION 20 Tells which Outpatient Pharmacy Division filled the prescription.

Pointer
PointerTo:
fileName:
OUTPATIENT SITE
fileNumber:
59
LOGIN DATE 21 The date the prescription was entered.

Date/Time
FILL DATE 22 The date the prescription was filled.

Date/Time
PHARMACIST 23 This field is used to identify the pharmacist that filled the medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOT # 24 The vendor code for this product. It is required to be on the label if the medication is sent to a nursing home.

Free Text
DISPENSED DATE 25 This field will be used to show the actual date the medication was dispensed.

Date/Time
EXPIRATION DATE 26 The date the medication expires. This is required to be put on the labels of medication sent to a nursing home.

Date/Time
CANCEL DATE 26.1 This date is used to indicate when the medication was cancelled.

Date/Time
NDC 27 This field is used for the National Drug Code.

Free Text
MANUFACTURER 28 This field is used to enter the manufacturer of the drug issued.

Free Text
DRUG EXPIRATION DATE 29 This date is used to show the expiration date of the medication. The date reflects the manufacturer's expiration date, not the date the Rx can no longer be filled.

Date/Time
GENERIC PROVIDER 30 This field is used to to show a generic provider. A generic provider is a provider of care to the patient outside of the VA.

Free Text
RELEASED DATE/TIME 31 This field is used to show the actual date and time the medication was released for inventory purposes and copay billing if applicable.

Date/Time
LABEL DATE/TIME 32 This sub-file is used to indicate when labels are printed for this prescription.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LABEL DATE/TIME .01 This field is used to track when the label was printed for this RX.

Date/Time
RX REFERENCE 1 This field is used to indicate the prescription fill number.

Numeric
LABEL COMMENT 2 This field is used for comments about the printed label.

Free Text
PRINTED BY 3 This field is used to show the person who printed the medication label.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WARNING LABEL TYPE 4 This field describes the type drug warning that printed. This field will be populated only if a drug warning label is printed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DRUG INTERACTION
  • Code : 2
    Stands For: DRUG ALLERGY
DEVICE 5 This filed is used to show which printer the label printed on.

Free Text
FDA MED GUIDE FILENAME 35 This field contains the filename of the FDA Medication Guide for the drug in this prescription at the time the label for the specific fill was printed.

Free Text
RETURNED TO STOCK 32.1 This field is used to show when and if the medication was returned to stock because the patient did not pick up the meds or it was not mailed.

Date/Time
REPRINT 32.2 This field is used to determined if the original fill was reprinted after being returned to stock. If fill was returned to stock and reprinted this fill will be re-released.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: REPRINTED
BINGO WAIT TIME 32.3 This field reflects, in minutes, the total wait time for bingo board purposes.

Numeric
SEVERITY 33 This field is used to store the significant drug interactions encountered by technicians during new/renew order entry. The data will be stored in the form of a string, i.e., 23,43,201. Each number will represent the drug/drug interaction found in file #56. Data is not added directly by FileMan.

Free Text
AFFECTED MEDICATION 34 This field is used to store the active medication pointer values that is considered to be drug interactions.

Free Text
DRUG ALLERGY INDICATION 34.1 This field is used to indicate if a drug allergy event occured.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DRUG ALLERGY INGREDIENTS 34.11 This sub-file is used to store drug ingredients of a possible drug allergy and/or an adverse reaction to the medication dispensed in a Rx.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INGREDIENTS .01 This field is used to store igredients of a possible drug allergy/adverse reaction to a medication.

Free Text
METHOD OF PICK-UP 35 Enter any special instructions that should appear on mailing address portion of the label, specifing where, or when the RX(s) should be picked up.

Free Text
ARCHIVED 36 This field is used to indicate if the Rx has been archived. Once the Rx is marked to be archived and then actually saved to the archived device should this field be populated. This will later be used to determine if the Rx can be purged.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ARCHIVED
MEDICATION ROUTES 37 This subfile contains possible medication routes from OERR, from the Medication Instructions (SIG) or both.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MEDICATION ROUTES .01 This field contain possible medication routes.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
SCHEDULES 37.1 This sub-file contains possible schedules from OERR, Medication Instructions or both.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SCHEDULES .01 This field contains possible shedules from OERR, Medication Instruction or both.

Free Text
FINISHING PERSON 38 This field is used to indicate the person who finished the order in Pharmacy.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FILLING PERSON 38.1 The name of the pharmacist who scanned the barcode before filling the medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHECKING PHARMACIST 38.2 The name of the pharmacist that checked the medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FINISH DATE/TIME 38.3 Date/time prescription is finished.

Date/Time
PROVIDER COMMENTS 39 This field stores any provider comments that are passed to Pharmacy from CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER COMMENTS .01

Word Processing
PHARMACY INSTRUCTIONS 39.1 This field contains Pharmacy Instructions passed to Pharmacy from CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PHARMACY INSTRUCTIONS .01

Word Processing
PHARMACY ORDERABLE ITEM 39.2 This is the Pharmacy Orderable Item associated with the drug. This data should not be entered by using File Manager. If the Rx does not have a Pharmacy Orderable Item entered check the drug for the RX. If the drug is missing an orderable item match the drug not the Rx. Only matching the Rx will cause problems when renewing the Rx.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
PLACER ORDER # 39.3 This is the CPRS entry number for this order.

Numeric
PREVIOUS ORDER # 39.4 This field is used to indicate rx number renewed from

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
FORWARD ORDER # 39.5 This field is used to stored the pointer to the rx that was renewed.

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
ACTIVITY LOG 40 Activity Log.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ACTIVITY LOG .01 Date when activity occured.

Date/Time
REASON .02 What was done that caused activity to happen.

Set of Codes
Set of Codes:
  • Code : H
    Stands For: HOLD
  • Code : U
    Stands For: UNHOLD
  • Code : C
    Stands For: DISCONTINUED
  • Code : E
    Stands For: EDIT
  • Code : L
    Stands For: RENEWED
  • Code : P
    Stands For: PARTIAL
  • Code : R
    Stands For: REINSTATE
  • Code : W
    Stands For: REPRINT
  • Code : S
    Stands For: SUSPENDED
  • Code : I
    Stands For: RETURNED
  • Code : V
    Stands For: INTERVENTION
  • Code : D
    Stands For: DELETED
  • Code : A
    Stands For: DRUG INTERACTION
  • Code : B
    Stands For: PROCESSED
  • Code : X
    Stands For: INTERFACE
  • Code : G
    Stands For: PT INST
  • Code : K
    Stands For: PKI/DEA
  • Code : N
    Stands For: DISP COMP
  • Code : M
    Stands For: ECME
  • Code : Z
    Stands For: REISSUE
INITIATOR OF ACTIVITY .03 The name of the person entering an activity is entered.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RX REFERENCE .04 This field is used to indicate which fill the activity took place.

Numeric
COMMENT .05 Any additional comments.

Free Text
FIELD EDITED 1 This field is used to indicate any editing to a data field of a presciption. This field will contain the name of the field edited.

Free Text
OLD VALUE 2 This field is used to show the old value of an edited field.

Free Text
NEW VALUE 3 This field is ued to show the new value of an edited field of a RX.

Free Text
OTHER COMMENTS 4

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER COMMENTS .01 This field will be used to store original front door medication instructions for Pre-POE Rxs.

Free Text
DEVICE 9999999.01 This field is used to show which printer the label printed on.

Free Text
TYPE 9999999.02

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PRINTED
  • Code : R
    Stands For: REPRINTED
  • Code : T
    Stands For: TRANSMITTED
  • Code : X
    Stands For: RETRANSMITTED
  • Code : F
    Stands For: FAILED TO TRANSMIT
  • Code : U
    Stands For: UPDATE
WAS THE PATIENT COUNSELED 41 This field indicates whether or not the patient received counseling about the prescription.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
WAS COUNSELING UNDERSTOOD 42 This field indicates whether or not the patient understood the counseling on the prescription, if the patient was counseled.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
TITRATION DOSE RX 45.1 This is the Titration Dose Rx from which the corresponding Maintenance Dose Rx originated.

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
MAINTENANCE DOSE RX 45.2 This is the Maintenance Dose Rx that was created from the corresponding Titration Dose Rx.

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
TITRATION RX FLAG 45.3 This flag indicates whether the prescription is being dispensed as a Titration Dose. It is intended to identify a Titration Dose Rx without a corresponding Maintenance Dose Rx.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
REFILL 52 This is the date the prescription is refilled.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REFILL DATE .01 This is the date the prescription is refilled.

Date/Time
QTY 1

Numeric
DAYS SUPPLY 1.1 This field is used to show days of supply of refill.

Numeric
CURRENT UNIT PRICE OF DRUG 1.2 This field is used to show the current unit cost of the drug at time of refill.

Numeric
MAIL/WINDOW 2 This field contains 'M' if the refill is to be mailed to the patient and 'W' if the refill is to be picked up at the pharmacy window.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MAIL
  • Code : W
    Stands For: WINDOW
REMARKS 3 This field contains comments as deemed necessary by the pharmacy staff.

Free Text
PHARMACIST NAME 4 This field contains the name of the pharmacist responsible for this Rx.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOT # 5 This field contains the lot # of the prescription.

Free Text
CLERK CODE 6 This field contains the NEW PERSON File entry number of the clerk.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOGIN DATE 7 This is the date the refill request was entered.

Date/Time
DIVISION 8 This field contains the Pharmacy Division associated with this Rx.

Pointer
PointerTo:
fileName:
OUTPATIENT SITE
fileNumber:
59
IB NUMBER 9 This field contains the internal entry number of the pointer to the Integrated Billing Action file (#350).

Pointer
PointerTo:
fileName:
INTEGRATED BILLING ACTION
fileNumber:
350
COPAY EXCEEDING CAP 9.1 This field contains the internal entry number of the pointer to the IB COPAY TRANSACTIONS file (#354.71). There will only be data in this field if this Rx's copay exceeded the annual copay cap.

Pointer
PointerTo:
fileName:
IB COPAY TRANSACTIONS
fileNumber:
354.71
DISPENSED DATE 10.1 This field is used to show date/time the medication was placed into packaging.

Date/Time
NDC 11 This field is used for the National Drug Code for the issued drug.

Free Text
MANUFACTURER 12 This field is used to show the manufacturer of the drug issued.

Free Text
DRUG EXPIRATION DATE 13 This field is used to show the date that the medication expires for this refill.

Date/Time
RETURNED TO STOCK 14 This field is used to indicate when and if the medication was returned to inventory due to the prescription not being picked up or mailed to the patient.

Date/Time
PROVIDER 15 This field is used to show the current provider seeing the patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
GENERIC PROVIDER 16 This field is used to show a provider outside of the medical center.

Free Text
RELEASED DATE/TIME 17 This field is used to show the date/time the medication was released for inventory purposes and copay billing if applicable.

Date/Time
BINGO WAIT TIME 18 This field specifies, in minutes, the total wait time for bingo board purposes.

Numeric
FILLING PERSON 19 The name of the person who scanned the barcode before refilling the medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHECKING PHARMACIST 20 The name of the pharmacist that checked the medication refill request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PFSS ACCOUNT REFERENCE 21 This is a reference number to an external medical billing system Account Number for the purposes of uniquely identifying prescription charges for 1st or 3rd party billing.

Pointer
PointerTo:
fileName:
PFSS ACCOUNT
fileNumber:
375
PFSS CHARGE ID 22 This is another unique identifier required when prescription charge messages are passed to the external billing system.

Numeric
ADMINISTERED IN CLINIC 23 This indicates if the medication was administered in a clinic instead of being dispensed to the patient.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DAW CODE 81 Dispensed As Written code. This information is used for NCPDP electronic claim transmission to third party payers (insurance companies).

Free Text
RE-TRANSMIT FLAG 82 This field is used to indicate that a claim should be electronically re-transmitted to the 3rd party insurance. It will be primarily used by CMOP and local mail prescriptions.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DATE NDC VALIDATED 83 This field contains the date and time that the NDC was validated prior to release of the prescription fill.

Date/Time
NDC VALIDATED BY 84 This field contains the user ID of the person who validated the NDC prior to release of the prescription fill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BILLING ELIGIBILITY INDICATOR 85 This field is set when a prescription is third party insurance billable and will contain T for TRICARE, V for VETERAN or C for CHAMPVA.

Set of Codes
Set of Codes:
  • Code : T
    Stands For: TRICARE
  • Code : V
    Stands For: VETERAN
  • Code : C
    Stands For: CHAMPVA
EPHARMACY SUSPENSE HOLD DATE 86 This field is defined when a host reject error is received as a result of an ePharmacy claims submission. The prescription fill will be held on suspense until the next day.

Date/Time
REQUESTING PROVIDER 9999999.01 This field is used to show the EHR provider that requested a refill for the patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BENCHMARK UNIT PRICE OF DRUG 9999999.06

Numeric
PCC REFILL LINK 9999999.11

Pointer
PointerTo:
fileName:
fileNumber:
9000010.14
REFILL PRICING OVERRIDE 9999999.15 This field points to the ABSP NCPCP 5.1 PRICING OVERRIDE file used by Point of Sale to populate needed fields within the pricing segment.

Pointer
PointerTo:
fileName:
fileNumber:
9002313.478
REFILL DIAGNOSIS CODE POINTER 9999999.17

Pointer
PointerTo:
fileName:
fileNumber:
9002313.491
PRIORITY 9999999.18

Set of Codes
Set of Codes:
  • Code : S
    Stands For: RUSH
  • Code : W
    Stands For: WAITING
  • Code : T
    Stands For: TELEPHONE
  • Code : R
    Stands For: REFILL BY MAIL
  • Code : N
    Stands For: NOT WAITING
REJECT INFO 52.25

Subfile
subfile:
Name Number Description Data Type Field Specific Data
NCPDP REJECT CODE .01 NCPDP Reject Code that indicates the reason for the claim rejection for this prescription.

Free Text
DATE/TIME DETECTED 1 Date/Time when the reject was detected by Outpatient Pharmacy.

Date/Time
PAYER MESSAGE 2 Message from the 3r party payer regarding the rejection of the claim.

Free Text
REASON 3 Reason why the claim is being rejected by the 3rd party payer.

Free Text
PHARMACIST 4 Pharmacist using the application when the reject was detected.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FILL NUMBER 5 This field is used to indicate which fill the reject is related to.

Numeric
GROUP NAME 6 This is the patient's insurance group name.

Free Text
PLAN CONTACT 7 This is the patient's insurance company contact information.

Free Text
PLAN PREVIOUS FILL DATE 8 In case of a REFILL TOO SOON reject (#79) and the payer returns the last date the prescription was filled, it will be stored on this field.

Date/Time
STATUS 9 This field indicates whether the reject is OPEN/UNRESOLVED or CLOSED/RESOLVED.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: OPEN/UNRESOLVED
  • Code : 1
    Stands For: CLOSED/RESOLVED
CLOSED DATE/TIME 10 Date/Time when the reject was marked CLOSED/RESOLVED.

Date/Time
CLOSED BY 11 User responsible for marking the reject CLOSED/RESOLVED.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLOSE REASON 12 This field indicates the reason for marking the reject CLOSED/RESOLVED.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CLAIM RE-SUBMITTED
  • Code : 2
    Stands For: RX ON HOLD
  • Code : 3
    Stands For: RX SUSPENDED
  • Code : 4
    Stands For: RX RETURNED TO STOCK
  • Code : 5
    Stands For: RX DELETED
  • Code : 6
    Stands For: IGNORED - NO RESUBMISSION
  • Code : 7
    Stands For: RX DISCONTINUED
  • Code : 8
    Stands For: RX EDITED
  • Code : 99
    Stands For: OTHER
CLOSE COMMENTS 13 User entered comments.

Free Text
REASON FOR SERVICE CODE 14 NCPDP field indicating the resason for service code. See NCPDP REASON FOR SERVICE CODE file (#9002313.23) for possible values.

Free Text
PROFESSIONAL SERVICE CODE 15 NCPDP field indicating the professional service code. See NCPDP PROFESSIONAL SERVICE CODE file (#9002313.21) for possible values.

Free Text
RESPONSE ID 16 This field is used to make sure the reject is recorded only once.

Numeric
OTHER REJECTS 17 List of other reject codes that were returned at the same time.

Free Text
DUR TEXT 18 In case of a DUR reject (#88) the 3rd party payer returns an explanation of the DUR (Drug Usability Review).

Free Text
RESULT OF SERVICE CODE 19 NCPDP field indicating the result of service code. See NCPDP RESULT OF SERVICE CODE file (#9002313.22) for possible values.

Free Text
INSURANCE NAME 20 Patient's insurance company name.

Free Text
GROUP NUMBER 21 Patient's insurance group number.

Free Text
CARDHOLDER ID 22 ID number assigned to Cardholder/Subscriber.

Free Text
RE-OPENED 23 This flag indicates that the user has manually re-opened another reject and this one was created.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
CLARIFICATION CODE 24 This field contains up to 3 NCPDP Clarification Codes for the reject. Clarification codes are copied from the CODE (#.01) field of the BPS NCPDP CLARIFICATION CODES (#9002313.25) file.

Free Text
PRIOR AUTHORIZATION TYPE 25 This is the Prior Authorization Type that will be sent to ECME and placed in NCPDP field 461-EU (Prior Authorization Type) on the NCPDP claim that is sent to the third-party payer.

Numeric
PRIOR AUTHORIZATION NUMBER 26 NCPDP Prior Authorization Number. This field may be left blank if the claim does not require a number.

Numeric
COORDINATION OF BENEFITS 27 This field contains the Coordination of Benefits indicator for the third party insurance rejection for the fill.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PRIMARY
  • Code : 2
    Stands For: SECONDARY
  • Code : 3
    Stands For: TERTIARY
DUR ADD MSG TEXT 28 In case of a DUR reject (#88) the 3rd party payer may return additional text in the DUR Additional Message NCPDP field (570-NS).

Free Text
BIN 29 Card Issuer ID or Bank ID Number used for network routing.

Free Text
RRR FLAG 30 The Reject Resolution Required (RRR) Flag is used to indicate that priority action is required to resolve the rejected ECME claim in the Third Party Rejects Worklist. The flag is used only for Veteran Eligibility claims where the value of the claim is at or above a site specified threshold. RRR rejects are displayed in a separate 'Reject Resolution Required' section of the Third Party Rejects Worklist.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RRR DOLLAR THRESHOLD 31 This is the value of the 'DOLLAR THRESHOLD' (#.02) field of the RESOLUTION REQUIRED REJ CODE (#52.865) subfile of the EPHARMACY SITE PARAMETERS (#52.86) file. It is the dollar threshold value at the time of the prescription processing through the ePharmacy system in which the reject was flagged as a Resolution Required Reject code.

Numeric
RRR GROSS AMOUNT DUE 32 If this rejection is flagged as a Reject Resolution Required reject, then this field is the gross amount due of the prescription. The value is copied from the GROSS AMOUNT DUE (#902.15) field of the PATIENT INSURANCE MULTIPLE (#9002313.59902) subfile of the BPS TRANSACTION (#9002313.59) file.

Numeric
INSURANCE COMPANY 33 This is the IEN of the INSURANCE COMPANY (#36) file. It is a 'soft' pointer as Insurance companies may be deleted if there are no bills assigned to them.

Numeric
COMMENTS 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME .01 Reject comment

Date/Time
USER 1 The user who makes the comment.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENTS 2 Reject comment.

Free Text
PARTIAL DATE 60 This sub-file is used to store data on partial prescriptions filled.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PARTIAL DATE .01 This is the date the partial was made.

Date/Time
MAIL/WINDOW .02 This field tells whether the medication was picked up or mailed to the patient.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MAIL
  • Code : W
    Stands For: WINDOW
REMARKS .03 These are any additional comments.

Free Text
QTY .04 This field is used to show the amount of medication that was dispensed.

Numeric
DAYS SUPPLY .041 This field is used to indicate the days of supply for partial RX fill.

Numeric
CURRENT UNIT PRICE OF DRUG .042 This field is used to show current unit cost of the drug at time of fill.

Numeric
PHARMACIST NAME .05 This is the name of the pharmacist.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOT # .06 This field shows the vendor's lot number.

Free Text
CLERK CODE .07 This is the user number of the clerk that keyed in the prescription.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOGIN DATE .08 This is the date that the prescription was entered.

Date/Time
DIVISION .09 This field contains the Pharmacy Division associated with this RX.

Pointer
PointerTo:
fileName:
OUTPATIENT SITE
fileNumber:
59
NDC 1 This field is used to show the National Drug Code of the drug issued.

Free Text
MANUFACTURER 2 This field is used to store the name of the manufacturer of the drug being dispensed.

Free Text
RETURNED TO STOCK 5 This field is used to show when and if the medication in the prescription was returned to inventory due to not being picked up or mailed.

Date/Time
PROVIDER 6 This field is used to show the provider that is currently seeing the patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
GENERIC PROVIDER 7 This field is used to show if there is a provider outside of the medical center providing care to the patient.

Free Text
DISPENSED DATE 7.5 This field is used to indicate the date the partial medication was dispensed.

Date/Time
RELEASED DATE/TIME 8 This field is used to show the date the medication was released.

Date/Time
BINGO WAIT TIME 9 This field specifies, in minutes, the total wait time for bingo board purposes.

Numeric
FILLING PERSON 10 The name of the person who scanned the barcode before dispensing a partial medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHECKING PHARMACIST 11 The name of the pharmacist that checked the partial medication request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DRUG EXPIRATION DATE 12 This field is used to show the date that the medication expires for this partial fill.

Date/Time
RETURN TO STOCK LOG 70 This sub-file contains a record for each fill returned to stock for the prescription.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RETURN TO STOCK DATE/TIME .01 This is the date/time the prescription fill was returned to stock.

Date/Time
FILL NUMBER 1 This is the prescription fill number that was returned to stock (e.g., "0" for the original fill, "1" for refill 1, "2" for refill 2, ...). For partial fills, the letter "P" is appended to the fill number (e.g., "P1" for partial fill 1, "P2", for partial fill 2, ...).

Free Text
FILL DATE 2 This is the date the prescription was filled.

Date/Time
QUANTITY 3 This is the quantity of medication dispensed for the fill.

Numeric
DAYS SUPPLY 4 This is the number of days of supply dispensed with the fill.

Numeric
UNIT PRICE OF DRUG 5 This is the current unit cost of the drug at the time of fill in US dollars.

Numeric
MAIL/WINDOW 6 This field contains 'M' if the fill was mailed to the patient and 'W' if the fill was picked up at the pharmacy window.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MAIL
  • Code : W
    Stands For: WINDOW
REMARKS 7 This is the comment entered by pharmacy staff for the fill.

Free Text
PHARMACIST 8 This is the pharmacist who filled the prescription.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOT # 9 This is the lot # of the dispense drug used for the fill.

Free Text
CLERK 10 This is the clerk for the fill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LOGIN DATE 11 This is the date the refill record was created.

Date/Time
DIVISION 12 This is the pharmacy division that dispensed the prescription fill.

Pointer
PointerTo:
fileName:
OUTPATIENT SITE
fileNumber:
59
IB NUMBER 13 This is the Integrated Billing action associated with the fill.

Pointer
PointerTo:
fileName:
INTEGRATED BILLING ACTION
fileNumber:
350
COPAY EXCEEDING CAP 14 This is the Integrated Billing Copay Transaction entry. It indicates the fill's copay exceeded the annual copay cap.

Pointer
PointerTo:
fileName:
IB COPAY TRANSACTIONS
fileNumber:
354.71
DISPENSED DATE 15 This is the date the medication was placed into the package.

Date/Time
NDC 16 This is the National Drug Code for the fill.

Free Text
MANUFACTURER 17 This is the name of the manufacturer of the dispense drug in the fill.

Free Text
DRUG EXPIRATION DATE 18 This date is used to show the expiration date of the medication. The date reflects the manufacturer's expiration date, not the date the Rx can no longer be filled.

Date/Time
PROVIDER 19 This is the provider seeing the patient at the time of this fill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ADMINISTERED IN CLINIC 20 This indicates whether the fill was administered in clinic or not.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
RELEASED DATE/TIME 21 This is the date/time the fill was released.

Date/Time
GENERIC PROVIDER 22 This is a provider outside the medical center who provided care to the patient.

Free Text
BINGO BOARD WAIT TIME 23 This field specifies, in minutes, the total wait time for bingo board purposes.

Numeric
FILLING PERSON 24 This is the person who scanned the barcode before filling the prescription.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHECKING PHARMACIST 25 This is the pharmacist who checked the medication.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PFSS ACCOUNT REFERENCE 26 This is a reference number to an external medical billing system Account Number for the purposes of uniquely identifying prescription charges for 1st or 3rd party billing.

Pointer
PointerTo:
fileName:
PFSS ACCOUNT
fileNumber:
375
PFSS CHARGE ID 27 This is another unique identifier required when prescription charge messages are passed to the external billing system.

Numeric
DAW CODE 28 This is the Dispensed As Written code for the fill. This information is used for NCPDP electronic claim transmission to third party payers (insurance companies).

Numeric
DATE/TIME NDC VALIDATED 29 This is the date/time the NDC was validated prior to release of the prescription fill.

Date/Time
NDC VALIDATED BY 30 This is the user who validated the NDC for the fill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BILLING ELIGIBILITY INDICATOR 31 This is the billing eligibility indicator used to bill insurance companies for the fill.

Set of Codes
Set of Codes:
  • Code : T
    Stands For: TRICARE
  • Code : V
    Stands For: VETERAN
  • Code : C
    Stands For: CHAMPVA
EPHARMACY SUSPENSE HOLD DATE 32 This is the date until when the fill should be held on suspense.

Date/Time
DAW CODE 81 Dispensed As Written code. This information is used for electronic claim transmission to third party payers (insurance companies).

Free Text
RE-TRANSMIT FLAG 82 This field is used to indicate that a claim should be electronically re-transmitted to the 3rd party insurance. It will be primarily used by CMOP and local mail prescriptions.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DATE NDC VALIDATED 83 This field contains the date and time that the NDC was validated prior to release of the prescription fill.

Date/Time
NDC VALIDATED BY 84 This field will contain the user ID of the person who validated the NDC prior to release of the prescription fill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BILLING ELIGIBILITY INDICATOR 85 This field is set when a prescription is third party insurance billable and will contain T for TRICARE, V for VETERAN or C for CHAMPVA.

Set of Codes
Set of Codes:
  • Code : T
    Stands For: TRICARE
  • Code : V
    Stands For: VETERAN
  • Code : C
    Stands For: CHAMPVA
EPHARMACY SUSPENSE HOLD DATE 86 This field is defined when a host reject error is received as a result of an ePharmacy claims submission. The prescription fill will be held on suspense until the next day.

Date/Time
HOLD REASON 99 This field tells why the prescription was put on hold.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INSUFFICIENT QTY IN STOCK
  • Code : 2
    Stands For: DRUG-DRUG INTERACTION
  • Code : 4
    Stands For: PROVIDER TO BE CONTACTED
  • Code : 6
    Stands For: ADVERSE DRUG REACTION
  • Code : 7
    Stands For: BAD ADDRESS
  • Code : 8
    Stands For: PER PATIENT REQUEST
  • Code : 9
    Stands For: CONSULT/PRIOR APPROVAL NEEDED
  • Code : 98
    Stands For: OTHER/TECH (NON-CLINICAL)
  • Code : 99
    Stands For: OTHER/RPH (CLINICAL)
HOLD COMMENTS 99.1 This field is used to enter brief comments on why the medication was placed on 'Hold' status.

Free Text
HOLD DATE 99.2 This field is used to indicate the date that a prescription was placed on hold.

Date/Time
STATUS 100 This field represents the current status of the prescription.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: ACTIVE
  • Code : 1
    Stands For: NON-VERIFIED
  • Code : 2
    Stands For: REFILL
  • Code : 3
    Stands For: HOLD
  • Code : 4
    Stands For: DRUG INTERACTIONS
  • Code : 5
    Stands For: SUSPENDED
  • Code : 10
    Stands For: DONE
  • Code : 11
    Stands For: EXPIRED
  • Code : 12
    Stands For: DISCONTINUED
  • Code : 13
    Stands For: DELETED
  • Code : 14
    Stands For: DISCONTINUED BY PROVIDER
  • Code : 15
    Stands For: DISCONTINUED (EDIT)
  • Code : 16
    Stands For: PROVIDER HOLD
  • Code : 9
    Stands For: PRINTED/FAXED
DISCONTINUE TYPE 100.1 This field is used to distinguish what type of external discontinue action occurred.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: HOSPITAL ADMISSION
  • Code : 2
    Stands For: EDITED BY PROVIDER
LAST DISPENSED DATE 101 This field contains the last fill date.

Date/Time
NEXT POSSIBLE FILL 102 This field contains the next possible fill date.

Date/Time
PRIOR FILL DATE 102.1 This field is used to indicate the last date the prescription was filled. The dates in this field will be the date of the last renew from a previous rx, and any subsequent fills.

Date/Time
PENDING NEXT POSSIBLE FILLDATE 102.2 This field is to contain the next possible filldate if the Rx was discontinued prior to the original label printing. If the Rx is reinstated this date will be restored to field 102 (next possbile filldate).

Date/Time
NEW DRUG 103 This field is used to enter a new drug.

Free Text
VERIFYING PHARMACIST 104 This field is used to show the pharmacist that verified the prescription

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COPAY TRANSACTION TYPE 105 This field contains the internal entry number of the pointer to the IB Action Type file (#350.1).

Pointer
PointerTo:
fileName:
IB ACTION TYPE
fileNumber:
350.1
IB NUMBER 106 This field contains the internal entry number of the pointer to the Integrated Billing Action file (#350).

Pointer
PointerTo:
fileName:
INTEGRATED BILLING ACTION
fileNumber:
350
COPAY TYPE AUDIT 106.5 This field serves as an audit of the original copay status. It is not changed or reset if the orignal status is changed.

Free Text
COPAY EXCEEDING CAP 106.6 This field contains the internal entry number of the pointer to the IB COPAY TRANSACTIONS file (#354.71). There will only be data in this field if this Rx's copay exceeded the annual copay cap.

Pointer
PointerTo:
fileName:
IB COPAY TRANSACTIONS
fileNumber:
354.71
COPAY ACTIVITY LOG 107

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COPAY ACTIVITY LOG .01 This is the date when activity occurred.

Date/Time
REASON 1 What was done to cause the copay activity to occur. 'A' will indicate that the Annual Copay Cap was reached for a patient when this prescription was released. 'R' will indicate that the prescription's copay status was reset due to a patient eligibility, copay exemption status change, etc. 'I' will indicate that a copay change was initiated by the Integrated Billing application and not through the release function. 'C' is for cancellation of existing copay charges. 'E' is copay edited, e.g. the Days Supply is changed.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ANNUAL CAP REACHED
  • Code : R
    Stands For: RESET COPAY STATUS
  • Code : I
    Stands For: IB-INITIATED CHARGE
  • Code : C
    Stands For: REMOVE COPAY CHARGE
  • Code : E
    Stands For: RX EDIT
INITIATOR OF COPAY ACTIVITY 2 The name of the person responsible for the copay activity.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RX REFERENCE 3 This field is used to indicate which fill corresponds to the copay activity. .

Numeric
COMMENT 4 Additional information will be entered here to detail why the copay activity occurred.

Free Text
OLD VALUE 5 This field is used to show the old copay status value for the prescription if the reason for the copay activity is set to 'R' 'Reset Copay Status'.

Free Text
NEW VALUE 6 This field is used to show the new copay status value for the prescription if the reason for the copay activity is set to 'R' 'Reset Copay Status'.

Free Text
DELETION COMMENTS 108 This field is used to enter comments on why a prescription was marked as deleted.

Free Text
COSIGNING PHYSICIAN 109 This field identifies the cosigning physician for prescriptions written by a provider for whom a counter signature is required, for example a nurse practitioner.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TYPE OF RX 110 This field is used to indicate if the rx dispensed is a partial or normal process rx. If partial medication was dispensed this will be equal to the entry number else the field will be equal to zero.

Numeric
POE RX 111 This field shall be set whenever a new/renew prescription is entered after the Pharmacy Ordering Enhancements software for Outpatient Pharmacy has been installed. This field will set to 1 for all pre-POE Rxs during the install of PSO*7*46.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ORIGINAL QTY 112 This field will hold the quantity that was filled for the original fill of the Rx.

Numeric
MEDICATION INSTRUCTIONS 113 This sub-file will contain the dispense units per dosage ordered, dosage ordered, units, noun, duration and conjunction fields.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DOSAGE ORDERED .01 This is a single dose of medication the patient will receive for this Rx order.

Free Text
DISPENSE UNITS PER DOSE 1 This is the number of Units (tablets, capsules, etc.) to be dispensed as a dose for this order.

Numeric
UNITS 2 Unit of measure. Pointer to the Drug Units file (50.607).

Pointer
PointerTo:
fileName:
DRUG UNITS
fileNumber:
50.607
NOUN 3 These are the nouns that are associated with this Dosage form. It will be used by the Outpatient Pharmacy software to build a SIG for an OE/RR order.

Free Text
DURATION 4 This is the length of time that a medication order should be given. If you enter a numeric value, Days will be assumed. You may also enter a numeric value followed by a letter. The letters can be entered as 'M' for Minutes, 'H' for Hours, 'D' for Days, 'W' for Weeks, 'L' for Months. THIS IS NOT DAYS SUPPLY!

Free Text
CONJUNCTION 5 This code is used to help build a Possible Sig for a complex medication dose. This code usually expands to an "and", a "then", or an "except".

Set of Codes
Set of Codes:
  • Code : A
    Stands For: AND
  • Code : T
    Stands For: THEN
  • Code : X
    Stands For: EXCEPT
ROUTE 6 This is how the medication is taken, applied, or used.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
SCHEDULE 7 This field is used to tell the patient how often the medication is to be used.

Free Text
VERB 8 This verb will be used to describe how the medication will be taken/used.

Free Text
OTHER LANGUAGE DOSAGE 9 This is a single dose of medication the patient will receive for this Rx order. Data should be entered into the field when the patient has another language preference and there is a free-text of a local dosage entered.

Free Text
PATIENT INSTRUCTIONS 114 The text in this field shall be used for the Patient Instructions in the Outpatient Pharmacy package when entering orders, if the Dispense Drug selected is matched to a Pharmacy Orderable Item with patient instructions.

Free Text
OTHER PATIENT INSTRUCTIONS 114.1 This field will be used to store the Other Language Patient Instructions when added.

Free Text
EXPANDED PATIENT INSTRUCTIONS 115

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXPANDED PATIENT INSTRUCTIONS .01 This field will store the expanded patient instructions that are stored in the patient instruction field (#114) or the expanded patient instructions from CPRS.

Word Processing
SERVICE CONNECTED 116 During Outpatient Pharmacy order entry, a pharmacist may be asked if the medication being prescribed is for a service connected condition. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MILITARY SEXUAL TRAUMA 117 During Outpatient Pharmacy order entry, if a veteran has been identified as having been treated for Military Sexual Trauma, the pharmacist may be asked to identify whether or not the medication prescribed is being used to treat a condition related to Military Sexual Trauma. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
AGENT ORANGE EXPOSURE 118 During Outpatient Pharmacy order entry, if a veteran has been identified as having been exposed to Agent Orange during Vietnam service, the pharmacist may be asked to identify whether or not the medication prescribed is being used to treat a condition due to this exposure. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
IONIZING RADIATION EXPOSURE 119 During Outpatient Pharmacy order entry, if a veteran has been identified as having been exposed to ionizing radiation during military service, the pharmacist may be asked to identify whether or not the medication prescribed is being used to treat a condition due to this exposure. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SOUTHWEST ASIA CONDITIONS 120 During Outpatient Pharmacy order entry, if a veteran has been identified as having been exposed to Southwest Asia Conditions (formerly referred to as Environmental Contaminants), the pharmacist may be asked to identify whether or not the medication prescribed is being used to treat a condition due to this exposure. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DDSTATUS 120.01 This field will hold the status of the prescription at the time a date of death was entered.

Free Text
DATE OF DEATH HISTORY 120.02 This field will be used to take a snapshot of the Rx at the time it was discontinued due to a date of death being entered for the patient. This data will be used to restore the Rx to the state before the date of death was entered.

Free Text
HEAD AND/OR NECK CANCER 121 During Outpatient Pharmacy order entry, if a veteran has been identified as having been treated for Head and/or Neck Cancer due to nose or throat radium treatments while in the military, the pharmacist may be asked to identify whether or not the medication prescribed is being used to treat this condition. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription when a prescription fill is being released, or as the default for the question upon renewal of the prescription through CPRS or Outpatient Pharmacy.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COMBAT VETERAN 122 During Outpatient Pharmacy order entry, a pharmacist may be asked if the medication being prescribed is for a condition related to Combat Services while in the military. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROJ 112/SHAD 122.01 During Outpatient Pharmacy order entry, a pharmacist may be asked if the medication being prescribed is for a condition related to PROJ 112/SHAD while in the military. This field will store the pharmacist's response to this question. The value in this field will be used to evaluate whether or not a copay should be applied to the prescription. This value will also be used as a default should this question be raised again during the life of the prescription.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
EXTERNAL PLACER ORDER NUMBER 123 This field represents the external system order number of this order. This field will only be populated if this order was originally received from an external system into Vista.

Free Text
EXTERNAL APPLICATION 124 This field represents the name of the external system from where the external order was received.

Free Text
PFSS ACCOUNT REFERENCE 125 This is a reference number to an external medical billing system Account Number for the purposes of uniquely identifying prescription charges for 1st or 3rd party billing.

Pointer
PointerTo:
fileName:
PFSS ACCOUNT
fileNumber:
375
PFSS CHARGE ID 126 This is another unique identifier required when prescription charge messages are passed to the external billing system.

Numeric
LAST DISPENSED DATE HOLDER 127 This field is a holder for the last dispensed date.

Date/Time
TPB RX 201 If this field is set to 'Yes', that indicates that this prescription has been created as part of the Transitional Pharmacy Benefit project. This field is controlled by the software.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
CLOZAPINE DOSAGE (MG/DAY) 301 This is the total daily dosage of clozapine if this prescription is for the drug clozapine. This is used only for clozapine.

Numeric
WBC RESULTS 302 This is the results of the WBC test which was used to authorize the clozapine prescription. This will exist only for clozapine prescriptions.

Numeric
DATE OF WBC TEST 303 This is the date of the WBC test which authorized the clozapine prescription. It is used only for clozapine prescriptions.

Date/Time
ANC RESULTS 304 This is the results of the ANC test that was used to authorize the clozapine prescription. This will exist only for clozapine prescriptions.

Numeric
SIGNATURE STATUS 310 Digital Signature status indicator.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BACKDOOR SIGNATURE STATUS 311 This field indicates whether a controlled substance order, schedule (I-V), was not digitally signed but entered via backdoor.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
CMOP EVENT 400

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TRANSMISSION NUMBER .01 This the number of the transmission which contained this prescription.

Pointer
PointerTo:
fileName:
CMOP TRANSMISSION
fileNumber:
550.2
SEQUENCE # 1 This is the message number of the Rx when it was transmitted to the CMOP.

Numeric
RX INDICATOR 2 This is the fill number of the Rx. A '0' indicates that it was an original fill.

Numeric
STATUS 3 The current status of the prescription fill for the Consolidated Mail Outpatient Pharmacy. A status of Transmitted means that the Rx has been transmitted to the CMOP for processing. A status of Dispensed means that the Rx has been filled and mailed by the CMOP. A status of Retransmitted means that the original transmission with this Rx had to be retransmitted to the CMOP. A status of Not Dispensed means that the vendor system was not able to fill the Rx. If the status is Not Dispensed, the reason will be in the Reason field.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: TRANSMITTED
  • Code : 1
    Stands For: DISPENSED
  • Code : 2
    Stands For: RETRANSMITTED
  • Code : 3
    Stands For: NOT DISPENSED
NDC RECEIVED 4 The National Drug Code (NDC) returned for this prescription.

Free Text
CANCELLED DATE/TIME 5 This is the date and time the Rx was cancelled at the CMOP. If cancelled, the Rx was not filled.

Date/Time
RESUBMIT STATUS 6 This field is used to track whether this fill has been resubmitted to the CMOP. If the field contains "yes" then the fill has been resubmitted and cannot be resubmitted again.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CANCELLED REASON 8 This is the free text reason the Rx was not filled at the CMOP.

Free Text
DATE SHIPPED 9 The date/time the prescription was shipped to the patient from the CMOP.

Date/Time
CARRIER 10 The carrier responsible for shipping the prescription to the patient.

Free Text
PACKAGE ID 11 A unique identification code assigned by the non-DHCP system for tracking the prescription shipment.

Free Text
NDC SENT 12 The National Drug Code (NDC) sent for this prescription.

Free Text
FDA MED GUIDE FILENAME 35 This field contains the filename of the FDA Medication Guide for the drug in this prescription at the time the fill was transmitted to CMOP.

Free Text
LOT/EXP 401

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOT/EXP .01 The lot number used to fill this prescription.

Free Text
EXPIRATION DATE 1 The expiration date of the lot number for this prescription.

Date/Time
RX INDICATOR 2 The fill number for this prescription. A '0' indicates the original fill.

Numeric
NON FORMULARY XML 21400

Subfile
subfile:
Name Number Description Data Type Field Specific Data
NON FORMULARY XML .01

Word Processing
DISPLAY DRUG 21401

Computed
ORDERED BY 21410.01

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SUPERVISING PHYSICIAN 21410.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PARENT ORDER 21410.03 Parent order from NewCrop

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
ICD DIAGNOSIS 52311

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ICD DIAGNOSIS .01 Diagnoses (up to nine) assigned for this prescription by the Ordering Provider.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
AGENT ORANGE 1 This field is used to direclty identify the corresponding ICD-9 code in the .01 field as related to Agent Orange for 3rd party billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
IONIZING RADIATION 2 This field is used to directly identify the corresponding ICD-9 code in the .01 field as IONIZING RADIATION related for 3rd party billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SERVICE CONNECTION 3 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Service Connection for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SOUTHWEST ASIA CONDITIONS 4 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Southwest Asia Conditions for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MILITARY SEXUAL TRAUMA 5 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Military Sexual Trauma for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HEAD AND/OR NECK CANCER 6 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Head and/or Neck Cancer for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COMBAT VETERAN 7 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Combat Veteran for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROJ 112/SHAD 8 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to PROJ 112/SHAD for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PHARMACYFULLINFO 214010 NEWCROP Pharmacy Information

Free Text
NEWCROP LOCATION 214018

Computed
NEWCROP TRANSACTION DATE/TIME 214019

Computed
ERX FIELDS 214020

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ERX FIELDS .01

Free Text
VALUE .02

Free Text
HOSPITAL COVERAGE 521011 This field is used to compute hospital coverage from MAS.

Computed
CHRONIC MEDICATION 9999999.02

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
BENCHMARK UNIT PRICE OF DRUG 9999999.06

Numeric
PRICING OVERRIDE 9999999.15 This field points to the ABSP NCPCP 5.1 PRICING OVERRIDE file used by Point of Sale to populate needed fields within the pricing segment.

Pointer
PointerTo:
fileName:
fileNumber:
9002313.478
DIAGNOSIS CODE POINTER 9999999.17

Pointer
PointerTo:
fileName:
fileNumber:
9002313.491
SIGN OR SYMPTOM 9999999.21

Free Text
INDICATION CODE 9999999.22

Free Text
AUTOFINISHED 9999999.23

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ELECTRONIC PHARMACY 9999999.24

Pointer
PointerTo:
fileName:
APSP PHARMACY LIST
fileNumber:
9009033.9
SUBSTITUTION 9999999.25

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: ALLOWED
  • Code : 1
    Stands For: NOT ALLOWED
  • Code : 2
    Stands For: ALLOWED-PATIENT
  • Code : 3
    Stands For: ALLOWED-PHARMACIST
  • Code : 4
    Stands For: ALLOWED-NOT IN STOCK
  • Code : 5
    Stands For: ALLOWED-BDD AS GENERIC
  • Code : 7
    Stands For: NOT ALLOWED-BDM BY LAW
  • Code : 8
    Stands For: ALLOWED-GENERIC NOT AVAIL
CASH DUE 9999999.26

Numeric
PRV STREET ADDRESS 1 9999999.31 Holds the first line of the provider's street address at the time of precription creation.

Free Text
PRV STREET ADDRESS 2 9999999.32 Holds the second line of the provider's street address at the time of precription creation.

Free Text
PRV STREET ADDRESS 3 9999999.33 Holds the third line of the provider's street address at the time of precription creation.

Free Text
PRV CITY 9999999.34 Holds the provider's city at the time of precription creation.

Free Text
PRV STATE 9999999.35 Holds the provider's state at the time of precription creation.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
PRV ZIP CODE 9999999.36 Holds the provider's zip code at the time of precription creation.

Free Text
DEA_VA_USPHS 9999999.37

Free Text
PRIORITY 9999999.38

Set of Codes
Set of Codes:
  • Code : S
    Stands For: RUSH
  • Code : W
    Stands For: WAITING
  • Code : T
    Stands For: TELEPHONE
  • Code : R
    Stands For: REFILL BY MAIL
  • Code : N
    Stands For: NOT WAITING

PENDING OUTPATIENT ORDERS

File Number: 52.41

File Description:

This file holds pending orders transmitted from the OE/RR package. All orders in this file must be processed by pharmacy service, they should be finished or rejected.


Fields:

Name Number Description Data Type Field Specific Data
PLACER NUMBER .01 This field contains the internal number of the order from the ORDER file (#100), representing the corresponding Computerized Patient Record System (CPRS) order to this pending Outpatient Pharmacy order. This field also acts as a temporary holding place for any external system order number, for orders received from any external system. An external system order number will only be stored here temporarily, until the CPRS order number is received to replace the external system order number.

Free Text
PATIENT 1 This is the pointer to the Patient file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PATIENT LOCATION 1.1 This is the pointer to the Hospital Location file.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ORDER TYPE 2 This field describes the status of the Pending order.

Set of Codes
Set of Codes:
  • Code : NW
    Stands For: NEW ORDER
  • Code : HD
    Stands For: HOLD
  • Code : RNW
    Stands For: RENEW
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
  • Code : DC
    Stands For: DISCONTINUED
  • Code : RF
    Stands For: REFILL REQUEST
QUANTITY TIMING SUB-FILE 3 This sub-file is used to store the quantity timing field from the ORC segment from CPRS. The components are used to build a Possible Sig for the finish process in Pharmacy.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
QUANTITY/FORM .01 This fields usually contains the amount to be given as entered through CPRS. It can also possibly contain the Dose Form of the medication.

Free Text
SCHEDULE 1 This is the schedule for the medication, as entered through CPRS.

Free Text
DURATION 2 This is the duration that the medication is to be given for, as entered through CPRS.

Free Text
START DATE/TIME 3 This is the start date/time of the medication.

Date/Time
END DATE/TIME 4 This is the end date/time of the medication.

Date/Time
CONJUNCTION 6 This is a code passed to Pharmacy from CPRS to help build a Possible Sig for a complex medication dose. This code usually expands to an "and", a "then", or an "except".

Set of Codes
Set of Codes:
  • Code : S
    Stands For: THEN
  • Code : A
    Stands For: AND
  • Code : X
    Stands For: EXCEPT
SEQUENCING 7 This field contains any special sequencing instructions for the medication.

Free Text
DOSAGE ORDERED 8 This is a single dose of medication the patient will receive for this prescription order.

Free Text
DISPENSE UNITS PER DOSE 9 This field represents the number of dispense units the patient will receive for a single dose of the medication.

Numeric
MED ROUTE 10 This is the Med Route that the medication is to be administered by.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
UNITS 11 This is the unit of measure associated with the Dosage ordered. It is a pointer to the DRUG UNITS File (#50.607).

Pointer
PointerTo:
fileName:
DRUG UNITS
fileNumber:
50.607
NOUN 12 This is the noun that is associated with this dosing sequence for this pending order. It will be used to build the Possible SIG for orders that are entered through CPRS.

Free Text
VERB 13 This verb will be used to describe how the medication is taken/used.

Free Text
ENTERED BY 4 This is the person who entered the order in CPRS, pointer to the New Person file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROVIDER 5 This is the provider for the order, pointer to the New Person file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EFFECTIVE DATE 6 This is the date the order goes into effect.

Date/Time
NATURE OF ORDER 7 This is the Nature of the order, as it is entered through CPRS.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONE
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: PROVIDER ENTERED
PHARMACY ORDERABLE ITEM 8 This is the Pharmacy Orderable Item for the order, as entered through CPRS.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
PROVIDER COMMENTS 9 This field contains any Provider comments that may have been entered through CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER COMMENTS .01

Word Processing
PHARMACY INSTRUCTIONS 10 This field contains any special instructions for the Pharmacist, as entered through CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PHARMACY INSTRUCTIONS .01

Word Processing
DRUG 11 This is the pointer to the Drug file entry that is associated with the Pharmacy Orderable Item. Not all orders will have a Drug when received from CPRS, but upon finishing the order, a Drug must be entered.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
QTY 12 This shows the amount of the medication to be dispensed.

Numeric
# OF REFILLS 13 The number of refills allowed for this order.

Numeric
LOGIN DATE 15 This is the date that the order was received from CPRS.

Date/Time
MED ROUTE 16 This is the Med Route that the medication is to be administered by.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
SERVICE CONNECTED 17 This indicates whether the order is for a service connected or non-service connected condition.

Free Text
ORDERS CHECKS 18 This is a multiple for the order checks passed to Pharmacy from CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER CHECK NARRATIVE .01 This is the text which describes the order check.

Free Text
OVERRIDING PROVIDER 1 This is the Provider that has seen the order check in the CPRS package.

Free Text
OVERRIDING REASON 2 This is the reason given by the Provider to override the order check.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OVERRIDING REASON .01

Word Processing
PICKUP ROUTING 19 This is how the medication is to be given to the patient.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MAIL
  • Code : W
    Stands For: WINDOW
  • Code : C
    Stands For: ADMINISTERED IN CLINIC
Rx REFILL REQUEST 21 This field will be used to indicate the Rx number for refill request from CPRS.

Numeric
REASON ORDER CREATED 22 This shows why the order was created in CPRS.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEWAL
  • Code : E
    Stands For: EDIT
  • Code : F
    Stands For: REFILL
PREVIOUS ORDER # 22.1 This field will store the pointer value to the Rx that is being Renewed.

Numeric
COMMENTS 23 This field contains any comments associated with the order.

Free Text
DISPENSING INSTRUCTIONS 24 Dispensing instruction for the medication.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPENSING INSTRUCTIONS .01 This is the possible Sig that is created based upon the information from the Quantity Timing fields of this order.

Free Text
PRIORITY 25 This field is used to indicate the urgency of the order.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: STAT
  • Code : E
    Stands For: EMERGENCY
  • Code : R
    Stands For: ROUTINE
POSSIBLE FILLDATE 26 This field will be used to display the effective date of a discharge med or pass med.

Date/Time
DATE/TIME FLAGGED 33 This is the date/time when this order was flagged.

Date/Time
FLAGGED BY 34 This is the user who flagged this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON FOR FLAG 35

Free Text
DATE/TIME UNFLAGGED 36 This is the date/time this order was unflagged.

Date/Time
UNFLAGGED BY 37 This is the user who unflagged this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON FOR UNFLAG 38 This is the reason for unflagging this order, usually a response to the reason for flag.

Free Text
RELATED INSTITUTION 100 This is the Institution that the order was issued from.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
DAYS SUPPLY 101 Enter a whole number between 1 and 90. The maximum upper limit is 90, but may be lower based on the maximum specified for this patient status. This parameter is defined in the RX PATIENT STATUS File (#53).

Numeric
FLAG 102 This field shall designate whether or not a prescription has been flagged for follow up with a provider.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Flagged
PRE-POE ORDER 103 This field will be used to identify pending orders entered before the installation of the Pharmacy Order Enhancement patch. PSO*7*46.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PATIENT INSTRUCTIONS 104 The text in this field shall be used for the Patient Instructions in the Outpatient Pharmacy package when entering orders, if the Dispense Drug selected is matched to a Pharmacy Orderable Item with patient instructions.

Free Text
PATIENT INSTRUCTIONS FLAG 104.1 This field will be used to indicate for the provider wanted the patient instructions included in the SIG.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
EXPANDED PATIENT INSTRUCTIONS 105

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXPANDED PATIENT INSTRUCTIONS .01 This field will store the expanded patient instructions that are stored in the patient instruction field (#114) or the expanded patient instructions from CPRS.

Word Processing
MILITARY SEXUAL TRAUMA 106 During CPRS order entry, if a veteran has been identified as having been treated for Military Sexual Trauma, the clinician will be asked to identify whether or not the outpatient medication order being prescribed is being used to treat a condition related to Military Sexual Trauma. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
AGENT ORANGE EXPOSURE 107 During CPRS order entry, if a veteran has been identified as having been exposed to Agent Orange during Vietnam service, the clinician will be asked to identify whether or not the outpatient medication order prescribed is being used to treat a condition due to this exposure. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
IONIZING RADIATION EXPOSURE 108 During CPRS order entry, if a veteran has been identified as having been exposed to ionizing radiation during military service, the clinician will be asked to identify whether or not the outpatient medication order prescribed is being used to treat a condition due to this exposure. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SOUTHWEST ASIA CONDITIONS 109 During CPRS order entry, if a veteran has been identified as having been exposed to Southwest Asia Conditions during the Persian Gulf War, the clinician will be asked to identify whether or not the outpatient medication order prescribed is being used to treat a condition due to this exposure. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HEAD AND/OR NECK CANCER 110 During CPRS order entry, if a veteran has been identified as having been treated for Head and/or Neck Cancer due to nose or throat radium treatments while in the military, the clinician will be asked to identify whether or not the outpatient medication order prescribed is being used to treat this condition. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COMBAT VETERAN 110.1 During CPRS order entry, if a veteran has been identified as having been treated for a condition related to Combat Services, the clinician will be asked to identify whether or not the outpatient medication order being prescribed is being used to treat a condition related to Combat Services. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROJ 112/SHAD 110.2 During CPRS order entry, if a veteran has been identified as having been treated for a condition related to PROJ 112/SHAD, the clinician will be asked to identify whether or not the outpatient medication order being prescribed is being used to treat a condition related to PROJ 112/SHAD. This field will store the response that was entered for this question. This value will be used as the default value for the same prompt presented to the pharmacist when finishing the medication order that was entered through CPRS.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DDSTATUS 111 This field will hold the status of the pending order at the time a date of death was entered.

Free Text
EXTERNAL PLACER ORDER NUMBER 114 This field represents the external system order number of this order. This field will only be populated if this order was originally received from an external system into Vista.

Free Text
EXTERNAL SYSTEM ORDER REPLACED 115 This field will be set to 1 by the software when an external system order number is successfully replaced by a Computerized Patient Record System (CPRS) order number.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
EXTERNAL APPLICATION 116 This field represents the name of the external system from where the external order was received.

Free Text
SIGNATURE STATUS 117 Digital Signature status indicator.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DRUG INCLUDED 118 This field indicates CPRS included the dispense drug as part of the hash calculation for digitally signed orders.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DIRECTIONS FOR USE 120 This multiple contains the raw HL7 dosage data as sent from CPRS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DIRECTIONS FOR USE .01 This field contains the raw HL7 dosage data as sent from CPRS and will be used to validate the integrity (hash count) against the CPRS digitally signed orders.

Free Text
DIAGNOSIS 311 This multiple is used to store up to eight ICD-9 codes per prescription with the first always being the primary diagnosis code and subsequent ones being secondary diagnosis codes. Also stored in this multiple are all of the Service Connection (SC) and Environmental Indicators (EI) that directly relate to each ICD-9 code. These SC/EI's are passed from CPRS in this manner. This ICD-9/SC/EI relationship is necessary for 3rd Party Billing. Current Copay functionality deals only with SC<50% and only stores EI's when with this is true or not overridden in some way. The new SC/EI fields allow for Outpatient Pharmacy to know if a prescription is SC 0-100%, to know all EI's that apply, and to know how they relate to the ICD-9 code without affecting Copay functionality.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DIAGNOSIS .01 This multiple field will store 8 diagnosis codes. The first code is considered the primary diagnosis and the last seven are secondary diagnosis codes.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
AGENT ORANGE 1 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Agent Orange for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
IONIZING RADIATION 2 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Ionizing Radiation for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SERVICE CONNECTION 3 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Service Connection for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SOUTHWEST ASIA CONDITIONS 4 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Southwest Asia Conditions for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MILITARY SEXUAL TRAUMA 5 This field is used to directly identify the corresponding ICD-9 code in the .01 field as releated to Military Sexual Trauma for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HEAD AND/OR NECK CANCER 6 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Head and/or Neck Cancer for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COMBAT VETERAN 7 This field is used to directly identify the corresponding ICD-9 code in the .01 field as related to Combat Veteran for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROJ 112/SHAD 8 This field is used directly to identify the corresponding ICD-9 code in the .01 field as related to PROJ 112/SHAD for 3rd Party Billing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES

PHARMACY ARCHIVE

File Number: 52.8

File Description:

This file is used to identify prescriptions that have been archived away. The archived prescriptions may have been also deleted from the Prescription file (#52).


Fields:

Name Number Description Data Type Field Specific Data
RX # .01 Pointer to the PRESCRIPTION file

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
PATIENT # 1 This field is used for the name of the patient.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2

NON-VERIFIED ORDERS

File Number: 53.1

File Description:

Unit Dose Pharmacy orders are initially entered into this file.


Fields:

Name Number Description Data Type Field Specific Data
ORDER NUMBER .01 This is a reference number for this order.

Numeric
PRIORITY .24 This field contains the priority of the order that was received from OERR.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: STAT
  • Code : A
    Stands For: ASAP
  • Code : R
    Stands For: ROUTINE
  • Code : P
    Stands For: PREOP
  • Code : T
    Stands For: TIMING CRITICAL
  • Code : D
    Stands For: DONE
NUMBER .25 (Not currently used.)

Numeric
PATIENT NAME .5 This is the patient for which the medication has been ordered.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROVIDER 1 This field should contain the prescribing physician's name.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DISPENSE DRUG 2 This is the medication ordered for the patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPENSE DRUG .01 This is the medication that will actually be dispensed for this order. An order may have more than one dispense drug.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
UNITS PER DOSE .02 This is the number of UNITS (tablets, capsules, etc.) to be dispensed as a DOSE for this order. The literals '1/2' and '1/4' may be entered. If there is no entry, it is assumed to be ONE (1). ** PLEASE NOTE ** If a doctor prescribes 30 ml's of a medication that is usually dispensed and administered as 60 ml's, the correct UNITS PER DOSE would be 1/2 (or .5), NOT 30 ml's. (30 ml's would be entered into the DOSAGE ORDERED field.) If the UNITS PER DOSE ordered is a variable amount (1-2 tab.), it is suggested that the maximum amount be entered into this field and the amount ordered noted either in the DOSAGE ORDERED or SPECIAL INSTRUCTIONS fields.

Numeric
INACTIVE DATE .03 This is the date that this dispense drug will no longer be dispensed for this order. Once an order becomes active, dispense drugs cannot be deleted.

Date/Time
MED ROUTE 3 This is the route of administration for this medication. (If a corresponding abbreviation is found for this route in the MEDICATION ROUTES file, this package will print that abbreviation on it's reports.)

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
TYPE 4 This identifies the type of medication ordered.

Set of Codes
Set of Codes:
  • Code : U
    Stands For: UNIT DOSE
  • Code : I
    Stands For: INPATIENT
  • Code : F
    Stands For: FLUID
  • Code : H
    Stands For: HYPERAL
SELF MED 5 This should contain a `1' (or `YES') if this medication is to be administered by the patient to himself.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HOSPITAL SUPPLIED SELF MED 6 This should contain a `1' (or `YES') if this medication is to be a `SELF MED' and this site's pharmacy is to supply the medication. This is only asked if the user enters `YES' (or `1') to the SELF MED prompt. If the SELF MED field is ever edited to show `NO' (or `0'), this is automatically deleted.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SCHEDULE TYPE 7 This describes the type of schedule for the dispensing of the medication(s) that make up the order. PRE-OP orders are usually considered to be ON-CALL orders, and orders dispensed as MUTLI-DOSE CONTAINERS are usually considered to be FILL ON REQUEST orders.

Set of Codes
Set of Codes:
  • Code : O
    Stands For: ONE-TIME
  • Code : P
    Stands For: PRN
  • Code : C
    Stands For: CONTINUOUS
  • Code : R
    Stands For: FILL on REQUEST
  • Code : OC
    Stands For: ON CALL
SPECIAL INSTRUCTIONS 8 This is any special instructions (using abbreviations whenever possible) needed for this order. This would include the physician's reason for ordering a PRN. The abbreviations and expansions from the MEDICATION INSTRUCTIONS file are utilized.

Free Text
RENEWAL 9 (Not currently used.)

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
START DATE/TIME 10 This is the date and time the order is to begin. This package initially assigns the START DATE/TIME to the closest administration time or next admin. time or NOW depends on the value of the DEFAULT START DATE CALCULATION field in the INPATIENT WARD PARAMETERS file. START DATE/TIME may not be entered prior to 7 days from the order's LOGIN DATE.

Date/Time
DAY LIMIT 11 This is the number of days that this order will last.

Numeric
DOSE LIMIT 12 This is the number of times the medication is to be administered.

Numeric
*UNITS PER DOSE 13 This is now for use only by the package. Units per Dose is now associated with each dispense drug.

Numeric
*PRE-EXCHANGE UNITS 14 This is the number of actual units needed for this order until the next cart exchange.

Numeric
RENEWAL USER 15 This is the user who renewed this order, or marked this order to be renewed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
VERIFYING NURSE 16 This is the nurse who verifies the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY NURSE 17 This is the date the order was verified by the nurse.

Date/Time
VERIFYING PHARMACIST 18 This is the pharmacist who verified the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY PHARMACIST 19 This is the date the order was verified by the pharmacist.

Date/Time
PHYSICIAN 20 This is the physician who signed off on the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY PHYSICIAN 21 This is the date the physician signed off on the order.

Date/Time
CLERK 22 This is the user who entered the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE ENTERED BY CLERK 23 This is the date (to the second) that the order was entered.

Date/Time
SOLUTION 24 (Not currently used.)

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
STOP DATE/TIME 25 This is the date and time the order will automatically expire. This package initially assigns a default STOP DATE/TIME, depending on the SITE PARAMETERS.

Date/Time
SCHEDULE 26 This is the frequency (ONLY) with which the doses are to be administered. Several forms of entry are acceptable, such as Q6H, 09-12-15, STAT, QOD, and MO-WE-FR@AD (where MO-WE-FR are days of the week, and AD is the admin times). The schedule will show on the MAR, labels, etc. No more than TWO spaces (Q3H 4, TID PC PRN, or Q4H PRN) in the schedule are acceptable. If the letters PRN are found as part of the schedule, no admin times will print on the MAR or labels, and the PICK LIST will always show a count of zero (0). Avoid using notation such as W/F (with food) or WM (with meals)in the schedule as it may cause erroneous calculations. That information should be entered into the SPECIAL INSTRUCTIONS. When using the MO-WE-FR@AD schedule, please remember that this type of schedule will not work properly without the "@" character and at least one admin time, and that at least the first two letters of each weekday entered is needed.

Free Text
ORDER DATE 27 This is the date the medication was ordered.

Date/Time
LOG-IN DATE 27.1 This is the date (to the second) the ordered was entered.

Date/Time
STATUS 28 This is the status of the order.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTIVE
  • Code : D
    Stands For: DISCONTINUED
  • Code : I
    Stands For: INCOMPLETE
  • Code : N
    Stands For: NON-VERIFIED
  • Code : U
    Stands For: UNRELEASED
  • Code : P
    Stands For: PENDING
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
DATE RENEWAL MARKED 29 This is the date the order was marked to be renewed.

Date/Time
MARKED CANCELLED 30 This is an internal flag showing that the order has been marked to be cancelled.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
MARKED CANCELLED USER 31 This is the user who marked the order to be cancelled.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INACTIVE DATE/TIME 32 This is the original stop date of the order, and is updated when the order is cancelled.

Date/Time
DOSES CALLED FOR 33 This is the total amount of the medication to be dispensed as calculated by the package.

Numeric
DOSES ACTUALLY DISPENSED 34 This is the amount of the medication actually dispensed as entered by the pharmacist.

Numeric
RETURNS 35 This is the number of doses returned of this medication from the patient's cassette upon the termination of this order.

Numeric
TOTAL RETURNS 36 This is the total amount of returns for this order.

Numeric
TOTAL UNITS DISPENSED 37 This is the total amount dispensed for this order, including PRE-EXCHANGE NEEDS and EXTRA UNITS DISPENSED.

Computed
DATE MARKED CANCELLED 38 This is the date that the order was marked for cancellation.

Date/Time
ADMIN TIMES 39 This is the set of administration times for this order.

Free Text
COMMENTS 40 This is any remarks needed for this order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This is a word processing field that is purely informational. This field only shows on the expanded view on a order.

Word Processing
FREQUENCY (in minutes) 41 This is either a code or the number of minutes between the administration times for the order.

Free Text
TRANSFER 42 This is an internal flag set if the order was cancelled due to the patient being transferred.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PV FLAG 43 This is an internal flag set if the order was ever verified by a pharmacist.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
LABEL DATE 44 This is the date the last label record was created for this order.

Date/Time
LABEL REASON 45 This is the last activity to take place on the order that created a label record.

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DISCONTINUED
  • Code : E
    Stands For: EDITED
  • Code : N
    Stands For: NEW
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
NEW ORDER NO. 46 When an order is first made active, the new order number (from ^PS(55)) is stored in this field. (Not currently used.)

Numeric
SIG 47 This is the provider's exact instructions for this order's medication and its administration.

Free Text
PURGE FLAG 48 This is an internal flag set when the order is due to be purged (deleted).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ORDER TO BE PURGED
ORDERS FILE ENTRY 49 This is the pointer value of the corresponding entry in the Orders file (100) when the order is entered through the OE/RR process.

Free Text
LAST WARD 50 This is the last ward the patient was located when the order expired or was discontinued. This is automatically updated by the Unit Dose package when the package finds that the patient is first admitted or when the patient is found to have been transferred. This allows any returns that are entered to be credited to the correct ward.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
LABEL CREATOR 51 This is the user who took the action that created the label for this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WARD FOR AUTO-CANCEL LABEL 52 This is the ward the patient was on before the transfer or discharge that created the label occurred.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
IV TYPE 53 Type of IV - "A" for Admixture, "C" for Chemotherapy, "H" for Hyperal, "P" for Piggyback, and "S" for Syringe.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : C
    Stands For: CHEMOTHERAPY
  • Code : H
    Stands For: HYPERAL
  • Code : P
    Stands For: PIGGYBACK
  • Code : S
    Stands For: SYRINGE
CHEMOTHERAPY TYPE 54 A chemotherapy IV order may be one of three type: admixture, piggyback, or syringe. The type of chemotherapy IV must be identified as one of these types, so the system will know what kinds of questions to ask in order to properly complete this order.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : P
    Stands For: PIGGYBACK
  • Code : S
    Stands For: SYRINGE
SYRINGE SIZE 55 Enter the size of the syringe which is to be used to administer this IV.

Free Text
INTERMITTENT SYRINGE 56 A syringe IV order may be continuous or intermittent. If a syringe type is continuous (not intermittent), the same order entry procedure will be followed as if a hyperal or admixture is being entered. If a syringe order is to be intermittent, the same order entry method as the piggyback type will be followed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ADDITIVE 57 The additive in the IV. This looks at the IV ADDITIVES file (52.6).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVE .01 The additive selected as part of the IV order. This entry is a pointer to the ADDITIVES file (52.6).

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
STRENGTH 1 "STRENGTH" is the amount of an additive to be used in the manufacturing of the IV order. NOTE! You will be expected to use the strength units that were previously defined within the IV ADDITIVE file (52.6) for each additive. For example, if the DRUG UNITS field of the IV ADDITIVES file specifies the units for ampicillin to be in grams, it would be incorrect to enter 500 for a half-gram dose. Enter 0.5 instead.

Free Text
BOTTLE 2 This is the bottle number (or numbers, separated by commas) in which this additive will be included for this IV order. If this field is blank, it means that the additive will be included in all bottles.

Free Text
SOLUTION 58 Solution in the IV. Points to the IV SOLUTIONS file (52.7).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTION .01 The solution entered as part of the specified IV order.

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
VOLUME 1 The volume of this solution in MLs. Only numeric values may be entered in this field. The total volume of the IV order is sum of solution's volumes.

Free Text
INFUSION RATE 59 The rate at which the IV is to be administered. This value, together with the total volume of the hyperal or the admixture type, is used to determine the time covered by one bag; hence the system can predict the bags needed during a specified time of coverage. This field is free text for IVPB's. For LVP's you must enter a number representing the infusion rate. You may also specify the # of bags per day needed, which will become the default number of LABELS PER DAY. Example. 125 = 125 ml/hr (IV system will calculate bags needed per day) 125@2 = 125 ml/hr with 2 labels per day TITRATE@1 = TITRATE with 1 label per day. The format of this field is either a number only or [FREE TEXT@NUMBER OF LABELS PER DAY]. Note: If an administration time(s) is defined, the number of labels will reflect the administration time(s) for the IVPB type orders. For example: One administration time of 12:00 is specified. The infusion rate is entered as 125@3. Only 1 label will print.

Free Text
SCHEDULE INTERVAL 60 Interval (in minutes) between administrations of the IV order.

Numeric
ATZERO 61 If an IV order is intermittent and a schedule was entered in the form SCHEDULE@0. Notice there are no spaces in the input. When a schedule is entered in this form, this field is set to 1. This causes the order to be printed on the Ward and Manufacturing lists with 0 doses due. Scheduled labels for the order will not be printed unless the Ward list is updated before printing scheduled labels. This is a "print on demand" function similar to entering INFUSION RATE@0 for continuous orders.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PRINT PB'S ON DEMAND
IV ROOM 62 IV room where IV bag was prepared for administration.

Pointer
PointerTo:
fileName:
IV ROOM
fileNumber:
59.5
REMARKS 63 This is not displayed on IV labels, but is printed on some IV reports.

Free Text
OTHER PRINT INFO 64 For use by Pharmacy to print additional information on IV labels and reports.

Free Text
PROVIDER COMMENTS 66 This is used to store any additional information the provider needs to pass along to pharmacy or ward personnel when an order is entered through OE/RR.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER COMMENTS .01 This is used to store an additional information the provider needs to pass along to pharmacy or ward personnel when an order is entered/edited through OE/RR.

Word Processing
PREVIOUS ORDER NUMBER 68 When an order is created from an active order, the old number (from ^PS(55)) is stored in this field.

Numeric
*PRIMARY DRUG 101 This is the primary drug associated with the order. If the order is a unit dose order all dispensed drugs entered must be matched to the order's primary drug. If the order is an IV order at least one of the additives or solutions entered must match the primary drug.

Pointer
PointerTo:
fileName:
PRIMARY DRUG
fileNumber:
50.3
*DOSAGE ORDERED 102 This is the amount of the medication the patient is to receive as one dose for this order. This should be an amount with a unit of measure, such '500MG' or '50CC'. THIS SHOULD NOT BE THE NUMBER OF TABLETS, ETC.

Free Text
REASON ORDER CREATED 103 This is used to show the method used to create this order.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEWAL
  • Code : E
    Stands For: EDIT
PREVIOUS ORDER 104 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the previous order.

Free Text
FOLLOWING ORDER 105 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the order created.

Free Text
*NATURE OF ORDER 106 This is the method the provider used to communicate to the user to enter (or take any other action) the order.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONED
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: PROVIDER ENTERED
REASON FOR FOLLOWING ORDER 107 If the order has been edited or renewed, this will contain the code corresponding to the action taken.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EDIT
  • Code : R
    Stands For: RENEWAL
ORDERABLE ITEM 108 This identifies the Orderable Item associated with the order. If the order contains multiple dispense drugs, or a single dispense drug requiring multiple units/dose, the Orderable Item and Dosage Ordered fields will be displayed.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
DOSAGE ORDERED 109 This is the amount of the medication the patient is to receive as one dose for this order. This should be an amount with a unit of measure, such as '500mg' or '50CC'. THIS SHOULD NOT BE THE NUMBER OF TABLETS, ETC.

Free Text
NATURE OF ORDER 110 This is the method the provider used to communicate the order to the user to enter (or take any other action on) the order.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONED
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: ELECTRONICALLY ENTERED
  • Code : I
    Stands For: POLICY
  • Code : S
    Stands For: SERVICE CORRECTION
  • Code : D
    Stands For: DUPLICATE
INSTRUCTIONS 111

Free Text
ORDER CHECKS 112

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER CHECK NARRATIVE .01 This field will contain the narrative portion of the OBX segment sent from OE/RR when an order check occurs.

Free Text
OVERRIDING PROVIDER 1 This field will contain the name of the provider who over-rode the order check. It comes as a part of the OBX segment from OE/RR.

Free Text
OVERRIDING REASON 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OVERRIDING REASON .01

Word Processing
CLINIC 113 Entry must be a clinic. Depending on the condition, INACTIVATE and REACTIVATE dates may exist.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
LAST RENEW 114 This multiple contains the data that relates to the renewal of an order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LAST RENEW .01 This is the date/time the order was renewed.

Date/Time
RENEWED BY 1 This is the person who renewed the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS PROVIDER 2 This is the name of the provider responsible for the prior order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS STOP DATE/TIME 3 This is the stop date/time of the prior order.

Date/Time
REQUESTED START DATE/TIME 115 This is the Date/Time the provider is requesting that this order start.

Date/Time
DURATION 116 This is the length of time in days the provider requests that this order last.

Free Text
REQUESTED STOP DATE/TIME 117 This is the Date/Time the provider is requesting that this order stop.

Date/Time
UD/IV PROMPT 118 This field will be used during the finishing process to determine if the user should be prompted whether they wish to finish the order as an IV or Unit Dose order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ACTIVITY LOG 119 This is a record of the actions that have taken place on the order.Actions include EDIT, RENEWAL, CANCELLATION, and FINISH. Stored with the action is the date and time the action took place and the user who took the action. If the action is an edit, the data in the field edited prior to the edit is also stored.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE .01 This is the date and time the activity took place.

Date/Time
USER 1 This is the user taking the action on the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ACTION 2 This is the activity that has taken place on the order.

Pointer
PointerTo:
fileName:
ACTIVITY LOG REASON
fileNumber:
53.3
FIELD 3 This is the field that was changed due to the activity.

Free Text
OLD DATA 4 This is the previous data that was in the field that was changed.

Free Text
DOSE 120 This is the numeric dosage for the order. It will be combined with the UNIT field to show the dosage ordered. For a dosage of 325MG, 325 would be stored here.

Numeric
UNIT 121 This is the field which contains the unit for the numeric dosage. The combination of these two fields gives you the dosage ordered for this order. For a dosage of 325MG, MG would be stored here.

Free Text
SI FLAG 122 This flag controls whether the user administering this order in BCMA will have the Special Instructions displayed in a pop-up box.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
OPI FLAG 123 This flag controls whether the user administering this order in BCMA will have the Other Print Info displayed in a pop-up box.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
FLAGGED 124 This indicates that this order has been flagged for clarification.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ORDERS FILE PARENT ORDER 125 This is the parent of a CPRS order that may have a parent/child relationship in CPRS

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
APPOINTMENT DATE/TIME 126 This is the date and time of the appointment this order is being placed for.

Date/Time
REQUESTED IV LIMITATION 127 This is the length of time to administer, or the total volume to administer, for IV fluid orders. The value may be in ML or CC for milliliters, L for liters, D for days, or H for hours.

Free Text
IV TYPE CATEGORY 128 This field contains the category of the order's IV TYPE. The IV TYPE CATEGORY will be "C" (Continuous) for orders with an IV TYPE of Admixture, Hyperal, Non-Intermittent Syringe, or Chemotherapy with a CHEMOTHERAPY TYPE of Admixture, Hyperal, or Non-Intermittent Syringe. The IV TYPE CATEGORY will be "I" (Intermittent) for orders with an IV TYPE of Piggyback, Intermittent Syringe, or Chemotherapy with a CHEMOTHERAPY TYPE of Piggyback or Intermittent Syringe.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INTERMITTENT
  • Code : C
    Stands For: CONTINUOUS
MOST RECENT FLAG COMMENT 129

Free Text
INTERVENTION 130 Interventions logged during Inpatient Order Entry in response to drug-drug or drug-allergy order checks. Only interventions associated with a specific Inpatient Order will be stored with that order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION .01 Pharmacy Interventions logged during Inpatient Order Entry in response to or drug-allergy order checks. Only interventions associated with a specific Inpatient Order will be stored with that order.

Pointer
PointerTo:
fileName:
APSP INTERVENTION
fileNumber:
9009032.4
ACCEPTED DATE/TIME 1 The Date/Time the Intervention is logged in Inpatient Order Entry.

Date/Time
LABELS PER DAY 131 The number of IV labels needed each day. If populated, this value will override the system-calculated number of labels.

Numeric
SPECIAL INSTRUCTIONS (LONG) 135 This is any special instructions needed for this order. This would include the physician's reason for ordering a PRN.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SPECIAL INSTRUCTIONS (LONG) .01 This is any special instructions (using abbreviations whenever possible) needed for this order. This would include the physician's reason for ordering a PRN. The abbreviations and expansions from the MEDICATION INSTRUCTIONS file are utilized.

Word Processing
OTHER PRINT INFO (LONG) 136 For use by Pharmacy to print additional information on IV labels and reports. This is very similar to the REMARKS (#.1) field in the IV (#100) multiple of the PHARMACY PATIENT (#55) file, except OTHER PRINT INFO is shown on the label and the IV REPORTS.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER PRINT INFO (LONG) .01 For use by Pharmacy to print additional information on IV labels and reports. This field is very similar to the REMARKS field except that OTHER INFO is shown on the label and the IV REPORTS.

Word Processing
EDITED STOP DATE 21425

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ALTERNATE DRUG 21434

Pointer
PointerTo:
fileName:
ALTERNATE DRUG COST
fileNumber:
21434
ALTERNATE COST 21434.1

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
TOTAL VOLUME 21437 For IV LABEL ENHANCEMENT artf10691

Numeric
BEYOND USE DAYS 9999999.01 This field contains the number of days to add to the date the label is printed to determine the expiration date for the IV.

Numeric

BCMA MISSING DOSE REQUEST

File Number: 53.68

File Description:

Contains the missing dose requests from the ward that are sent to pharmacy. This file may be purged as needed by VA Fileman.


Fields:

Name Number Description Data Type Field Specific Data
REQUEST NUMBER .01 Contains a system generated unique request number for each missing dose request entered.

Free Text
DATE/TIME ENTERED .02 Automatically stuffed at record creation time with a value of NOW.

Date/Time
ENTERED BY .03 Automatically stuffed at record creation time with the current value of DUZ.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DIVISION .04 Automatically stuffed at record creation time with the current value of DUZ(2).

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
SENT TO MAILGROUP .05 Once submitted this field contains the Mail group the request was sent to.

Free Text
PRINTED ON DEVICE .06 If printing is enabled this contains the printer that the request printed on.

Free Text
STATUS .07 Status of the request as Closed or Unresolved.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: CLOSED
  • Code : 1
    Stands For: UNRESOLVED
PATIENT .11 Pointer to the PATIENT file (#2) of the patient missing the medication.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
WARD LOCATION .12 Pointer to the WARD LOCATION file (#42) with the selected ward for the report.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
DRUG REQUESTED .13 Pointer to DRUG file (#50) with the medication needed.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
DOSE NEEDED .14 Free text description of the dosage needed.

Free Text
REASON NEEDED .15 Set of codes containing the reason a medication is missing.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DROPPED
  • Code : 2
    Stands For: EMPTY PACKAGE
  • Code : 3
    Stands For: NOT AVAILABLE
  • Code : 4
    Stands For: WRONG DOSE/DRUG DELIVERED
  • Code : 5
    Stands For: PACKAGE CONTENTS DAMAGED
  • Code : 6
    Stands For: PACKAGE INTEGRITY DAMAGED
  • Code : 7
    Stands For: BARCODE/IEN ILLEGIBLE
ADMINISTRATION DATE/TIME .16 Date/Time the medication is to be administered.

Date/Time
NEEDED BY DATE/TIME .17 Date/Time the medication will be needed to meet the next administration.

Date/Time
ROOM/BED .18 The room/bed of the patient when the request is entered.

Pointer
PointerTo:
fileName:
ROOM-BED
fileNumber:
405.4
SCHEDULE .19

Free Text
DOSE DELIVERED .21 Was a dose delivered to complete this missing med request. (y/n)

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
DOSE DELIVERED BY .22 Pointer to NEW PERSON file (#200) with the user who resolved the request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DELIVERY TIME .23 Date/Time the medication was delivered/resolved.

Date/Time
PHARMACY REASON NEEDED .24 Set of coded for resolution reason.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: WS/FILL ON REQUEST
  • Code : 2
    Stands For: FOUND IN DRAWER
  • Code : 3
    Stands For: PHARMACIST ERROR
  • Code : 4
    Stands For: EXPIRED/NO ORDER
  • Code : 5
    Stands For: ATC ERROR
  • Code : 6
    Stands For: NOT ENOUGH PRNS
  • Code : 7
    Stands For: TECHNICIAN ERROR
  • Code : 8
    Stands For: PRE-EXCHANGE DOSE
  • Code : 9
    Stands For: PATIENT TRANSFERRED
  • Code : 10
    Stands For: NURSE ADMIN ERROR
  • Code : 11
    Stands For: ROBOT ERROR
  • Code : 12
    Stands For: RESEND
UNIQUE ID .25 This is the unique ID number of an IV bag, which is generated from Inpatient Medications.

Free Text
ADDITIVES .26 Pointer to the additives file. Filled in automatically with the ordered additives when a missing dose is submitted.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVES .01 Pointer to the additives file. Filled in automatically with the ordered additives when a missing dose is submitted.

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
SOLUTIONS .27 Pointer to the SOLUTIONS file. Filled in automatically with the ordered additives when a missing dose is submitted.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTIONS .01 Pointer to the SOLUTIONS file. Filled in automatically with the ordered additives when a missing dose is submitted.

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
CLINIC 1 Pointer to the HOSPITAL LOCATION file (#44) for the selected clinic for the report.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44

BCMA MEDICATION VARIANCE LOG

File Number: 53.78

File Description:

Contains all variances occurring during the medication passes. This file may *NOT* be purged.


Fields:

Name Number Description Data Type Field Specific Data
PATIENT NAME .01 Pointer to the patient file (#2) of the patient in the variance log.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ROOM AND BED .02 Room and bed location of the patient at the time of the variance.

Free Text
USER .03 User passing meds during the variance.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME OF OCCURRENCE .04 Date/time of the variance.

Date/Time
EVENT .05 Set of codes describing the variance.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: WRONG MED
  • Code : 2
    Stands For: EARLY/LATE DOSE
  • Code : 3
    Stands For: LATE PRN EFFECT
ADMINISTRATION TIME VARIANCE .06 If the variance was an early or late event this field store the number of minutes early (<1) or minutes late (>1) of the event.

Numeric
DRUG SCANNED .07 Pointer to the drug file of the medication that was scanned for this variance.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
MED LOG PTR .08 Pointer to the BCMA MEDICATION LOG (#53.79) for this event.

Pointer
PointerTo:
fileName:
BCMA MEDICATION LOG
fileNumber:
53.79
WARD LOCATION .09 The ward location where the patient is located when a Medication Variance is logged.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42

BCMA MEDICATION LOG

File Number: 53.79

File Description:

Contains all medication passes. This file may *NOT* be purged. Due to the size of this file Re-Indexing is also not recommended unless directed by customer support.


Fields:

Name Number Description Data Type Field Specific Data
PATIENT NAME .01 This field contains a pointer to the PATIENT File (#2) and is the patient that received the medication.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PATIENT LOCATION .02 Free text room-bed and ward location of the patient for Inpatient Medication orders or Clinic Name for Clinic orders at the time of the med pass.

Free Text
PATIENT DIVISION .03 Division of the ward that this patient was on during the med pass.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
ENTERED DATE/TIME .04 Date and time the med pass was filed. Defaults to NOW on record creation.

Date/Time
ENTERED BY .05 Pointer to the NEW PERSON file (#200). Contains the user passing meds.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ACTION DATE/TIME .06 Fileman Date/Time containing the actual time the med was administered.

Date/Time
ACTION BY .07 Pointer to the NEW PERSON file (#200). Contains the user passing meds.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ADMINISTRATION MEDICATION .08 Pointer to ORDERABLE ITEM (#50.7) containing the medication entered for the order.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
ACTION STATUS .09 Status of administration (H:Held,R:Refused,G:Given,N:NOT GIVEN)

Set of Codes
Set of Codes:
  • Code : G
    Stands For: GIVEN
  • Code : H
    Stands For: HELD
  • Code : R
    Stands For: REFUSED
  • Code : N
    Stands For: NOT GIVEN
  • Code : RM
    Stands For: REMOVED
  • Code : I
    Stands For: INFUSING
  • Code : S
    Stands For: STOPPED
  • Code : C
    Stands For: COMPLETED
  • Code : M
    Stands For: MISSING DOSE
ORDER REFERENCE NUMBER .11 Contains the IEN to the actual order in PHARMACY PATIENT (#55) followed by a U for Unit Dose or V for IV

Free Text
ORDER SCHEDULE .12 Contains the schedule type of the order.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CONTINUOUS
  • Code : P
    Stands For: PRN
  • Code : O
    Stands For: ONE-TIME
  • Code : OC
    Stands For: ON-CALL
SCHEDULED ADMINISTRATION TIME .13 If a continuous order this field will contain the actual administration date and time the medication was ordered for.

Date/Time
ORDER ADMINISTRATION VARIANCE .14 If a continuous order this field contains the minutes early (<1) or Late (>1) that the medication was given.

Numeric
ORDER DOSAGE .15 Free text field containing the dosage from the original order.

Free Text
INJECTION SITE .16 Free text field containing the injection site of medication that are injected.

Free Text
PRN REASON .21 Free text field containing the PRN reason for a PRN med being given.

Free Text
PRN EFFECTIVENESS .22 Free text field containing the effectiveness of a PRN medication.

Free Text
PRN EFFECTIVENESS ENTERED BY .23 Pointer to file NEW PERSON (#200) with the IEN of the user logging the PRN effectiveness.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRN EFFECTIVENESS ENTERED AT .24 Date/time the PRN effectiveness was charted.

Date/Time
PRN EFFECTIVENESS MINUTES .25 Number of minutes from administration to the charting of PRN effectiveness.

Numeric
IV UNIQUE ID .26 This is the unique ID number of an IV bag, which is generated from Inpatient Medications.

Free Text
PRN REASON FLAG .27 The PRN REASON FLAG field is to indicate whether the BCMA Med Log file entry is PRN activity and has an associated PRN REASON which has been set to require BCMA user attention or action.

Numeric
WITNESS DATE/TIME .28 Contains the DATE/TIME that this administration of a High Risk/High Alert medication was witnessed.

Date/Time
ADMIN WITNESSED BY .29 Contains the user that was required to Witness the passing of meds due to Drug High Risk/Alert.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT .3 Multiple containing the comments entered for each med pass.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01 Text of comment entered by the user.

Free Text
ENTERED BY .02 Pointer to the NEW PERSON file (#200) of the user making the comment.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED DATE/TIME .03 Date/Time the comment was filed against this entry.

Date/Time
WITNESS COMMENT .31 Comment the witness may want to enter while witnessing an administration for a High Risk/High Alert medication.

Free Text
WITNESS HR ORDER CODE .32 This field contains the highest level of all the High Risk/High Alert drug indicators that were found in the order when this medication was passed.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT HIGH RISK/ALERT
  • Code : 1
    Stands For: HIGH RISK/ALERT-NO WITNESS REQUIRED IN BCMA
  • Code : 2
    Stands For: RECOMMEND WITNESS IN BCMA-HIGH RISK/ALERT
  • Code : 3
    Stands For: WITNESS REQUIRED IN BCMA-HIGH RISK/ALERT
WITNESSED? .33 This field will track whether the Witness was bypassed for a High Risk/High Alert drug during medication passing.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
INFUSION RATE .35 This is the infusion rate for an IV bag, which is passed by Inpatient Medications.

Free Text
DISPENSE DRUG .5

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPENSE DRUG .01 Pointer to the drug file. Contains the actual medication scanned for this entry.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
DOSES ORDERED .02 Number of units from the PHARMACY PATIENT file (#55)

Numeric
DOSES GIVEN .03 Actual number of units given.

Numeric
UNIT OF ADMINISTRATION .04 Unit of administration (i.e. TABLET, ML, VIAL)

Free Text
HIGH RISK/HIGH ALERT .05 High Risk/High Alert indicator for the Orderable Item this disp drug pointed to at the time of administration.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT HIGH RISK/ALERT
  • Code : 1
    Stands For: HIGH RISK/ALERT-NO WITNESS REQUIRED IN BCMA
  • Code : 2
    Stands For: RECOMMEND WITNESS IN BCMA-HIGH RISK/ALERT
  • Code : 3
    Stands For: WITNESS REQUIRED IN BCMA-HIGH RISK/ALERT
ADDITIVES .6

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVES .01 Pointer to the additives file. Filled in automatically with the ordered additives when marked as given.

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
DOSE ORDERED .02 Dosage from the actual IV order.

Free Text
DOSE GIVEN .03 Actual dosing performed by administration clinician.

Free Text
UNIT OF ADMINISTRATION .04 Unit of administration (i.e. ML)

Free Text
HIGH RISK/HIGH ALERT .05 High Risk/High Alert indicator for the Orderable Item this additive pointed to at the time of administration.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT HIGH RISK/ALERT
  • Code : 1
    Stands For: HIGH RISK/ALERT-NO WITNESS REQUIRED IN BCMA
  • Code : 2
    Stands For: RECOMMEND WITNESS IN BCMA-HIGH RISK/ALERT
  • Code : 3
    Stands For: WITNESS REQUIRED IN BCMA-HIGH RISK/ALERT
SOLUTIONS .7

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTIONS .01 Pointer to the SOLUTIONS file.

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
DOSE ORDERED .02 Dosage ordered from the IV Order.

Free Text
DOSES GIVEN .03 Actual amount of medication given.

Free Text
UNIT OF ADMINISTRATION .04 Unit of administration (i.e. ML)

Free Text
HIGH RISK/HIGH ALERT .05 High Risk/High Alert indicator for the Orderable Item this Solution pointed to at the time of administration.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT HIGH RISK/ALERT
  • Code : 1
    Stands For: HIGH RISK/ALERT-NO WITNESS REQUIRED IN BCMA
  • Code : 2
    Stands For: RECOMMEND WITNESS IN BCMA-HIGH RISK/ALERT
  • Code : 3
    Stands For: WITNESS REQUIRED IN BCMA-HIGH RISK/ALERT
AUDIT LOG .9

Subfile
subfile:
Name Number Description Data Type Field Specific Data
AUDIT LOG .01 Date/time of audit being filed.

Date/Time
USER .02 Pointer to the user making the change.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TEXT .03 Description of the change made.

Free Text
ACTION STATUS LOG .04 Action Status that this log entry is tracking.

Free Text
ACTION BY LOG .05 Pointer to the user who was listed as performing the previous action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMPUTED ORDER 21400

Computed
CHARGE BILLED 21497 ADDED FOR CHARGE ON ADMINISTRATION, SO WE CAN LINK AN ADMINISTRATION EVENT TO A CHARGE

Pointer
PointerTo:
fileName:
CHARGE BILLED
fileNumber:
21497

PHARMACY PATIENT

File Number: 55

File Description:

This file holds, for each patient, information that is typically of interest only to the pharmacy. This should be noted when merging patient records and deleting the 'old' record from the patient file. That process does not delete the corresponding pharmacy patient file entry. This file is also shared with inpatient pharmacy and promises to become a very central file to the pharmacy.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This is the name of a patient that has some type of pharmacy order.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
CAP .02 This field is used to indicate if safety caps are to be issued to patient.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: NON-SAFETY
  • Code : 0
    Stands For: SAFETY
MAIL .03 This field is used to: A) Determine whether this patient's Rx's are to be sent to the CMOP, or retained for local distribution. If 2-4 are selected, none of this patient's Rx's will be transmitted to the CMOP. B) Select what the mail priority is. The CMOP choices are limited to (0) REGULAR and (1) CERTIFIED. Local mail may be designated (3) LOCAL - REGULAR or (4) LOCAL - CERTIFIED. The 'DO NOT MAIL' code (2) may be used to ensure that the patient's Rx's are not mailed.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: REGULAR MAIL
  • Code : 1
    Stands For: CERTIFIED MAIL
  • Code : 2
    Stands For: DO NOT MAIL
  • Code : 3
    Stands For: LOCAL - REGULAR MAIL
  • Code : 4
    Stands For: LOCAL - CERTIFIED MAIL
DIALYSIS PATIENT .04 This field is used to indicate if the patient is in dialysis.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MAIL STATUS EXPIRATION DATE .05 This field places a time limit on the 'Do Not Mail', 'Local - Regular Mail' and 'Local - Certified Mail' conditions in the 'MAIL' field. If a date is placed in this field and the software detects that the date the Rx is processed is greater than the date in the field (past the expired date) a default value of 'Regular Mail' will be assumed for the 'MAIL' field. NOTE: The actual value of the 'MAIL' field will not be changed by the software, but can only be modified by a user editing the 'MAIL' field.

Date/Time
FIRST SERVICE DATE .07 This is the login date of the first order for pharmacy services.

Date/Time
ACTUAL/HISTORICAL FLAG .08 The purpose of this field is to indicate whether the FIRST SERVICE DATE field was populated with actual or historical data. Actual indicates the field was populated when the first pharmacy service was filed. Historical indicates the field was populated by the conversion routine.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTUAL
  • Code : H
    Stands For: HISTORICAL
NARRATIVE 1 This is notable information about the patient that pertains to pharmacy.

Free Text
PATIENT STATUS 3 This field is used to indicate a default patient status.

Pointer
PointerTo:
fileName:
RX PATIENT STATUS
fileNumber:
53
COMMUNITY NURSING HOME 40 This field is used to indicate if the patient resides within a community nursing home.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
NURSING HOME CONTRACT 40.1 This field is used to indicate if the patient has a nursing home contract.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
LAST DATE OF CONTRACT 40.2 This field is used to indicate the last date of the nursing home contract.

Date/Time
RESPITE PATIENT START DATE 41 This field is used to indicate the start date of respite care.

Date/Time
RESPITE PATIENT END DATE 41.1 This field is used to indicate the end date of respite care.

Date/Time
ACTIVE SCRIPTS 50 This field is used to indicate active prescriptions.

Computed
PRESCRIPTION PROFILE 52 This sub-file is used to indicate prescription history for this patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PRESCRIPTION PROFILE .01 This field is used to indicate prescription history.

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
DRUG 1 This field is used to indicate the medication for the prescription.

Computed
STATUS 2 This field is used to indicate the status of the prescription.

Computed
ACTIVE 3 The field is boolean in nature, that is, it's value is 1 if the prescription is active, suspended, or on hold.

Computed
RX UPDATE 52.1 This field is used to indicate if the patient's medications have been updated in the CPRS orders file. If the field is 0, nothing has been updated, 1 indicates the initial data movement is complete, and 2 indicates the Backfill to CPRS is complete.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: Nothing updated
  • Code : 1
    Stands For: Data movement complete
  • Code : 2
    Stands For: Backfill complete
NON-VA MEDS 52.2 This is the Non-VA Meds order multiple. It will be used to store the Non-VA Med orders entered through the CPRS application.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDERABLE ITEM .01 This is the orderable item that represents the Non-VA Med being taken by the patient.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
DISPENSE DRUG 1 This is the dispense drug that represents the Non-VA Med being taken by the patient.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
DOSAGE 2 This is the dosage of the Non-VA Med being taken by the patient.

Free Text
MEDICATION ROUTE 3 This is the route of the Non-VA Medication being taken by the patient.

Free Text
SCHEDULE 4 This is the schedule of the Non-VA Medication being taken by the patient.

Free Text
STATUS 5 This is the status of the Non-VA Med order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DISCONTINUED
  • Code : 2
    Stands For: DATE OF DEATH ENTERED
DISCONTINUED DATE 6 This is the date the patient stopped taking the Non-VA Medication.

Date/Time
ORDER NUMBER 7 This is the CPRS order number.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
START DATE 8 This is the date the patient started taking the Non-VA Medication.

Date/Time
ORDER CHECKS 9

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER CHECK NARRATIVE .01 This is the narrative of the order check(s) for the Non-VA Med order.

Free Text
OVERRIDING PROVIDER 1 This is the provider responsible for overriding the order check.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OVERRIDING REASON 2 This is the overriding reason description given by the Provider.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OVERRIDING REASON .01 This is the overriding reason description given by the Provider.

Word Processing
DISCLAIMER 10 This is the multiple for the Non-VA Med Disclaimer (Statement/Explanation).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISCLAIMER .01 This is the multiple for the Non-VA Med Disclaimer (Statement/Explanation)

Word Processing
DOCUMENTED DATE 11 This is the date the Non-VA Med order was entered to the system.

Date/Time
DOCUMENTED BY 12 This is the person responsible for documenting the Non-VA Med order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLINIC 13

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
COMMENTS 14

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This field will store comments enter when placing the Non-VA med order.

Word Processing
LAST DOSE TAKEN DATE/TIME 21401

Date/Time
HOME MEDICATION LIST 21402

Free Text
LOCATION OF MEDICATION 21403

Free Text
REASON FOR HOME MEDICATION 21404

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASON FOR HOME MEDICATION .01

Word Processing
PCC LINK 9999999.11

Pointer
PointerTo:
fileName:
fileNumber:
9000010.14
CLOZAPINE REGISTRATION NUMBER 53 This is the patient's authorization number assigned by national data base.

Free Text
CLOZAPINE STATUS 54 This is the patient's clozapine treatment status.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PRE-TREATMENT
  • Code : A
    Stands For: ACTIVE TREATMENT
  • Code : H
    Stands For: TREATMENT ON HOLD
  • Code : D
    Stands For: DISCONTINUED
DATE OF LAST CLOZAPINE RX 55 This is the date of the patient's last clozapine prescription.

Date/Time
DEMOGRAPHICS SENT 56 This indicates whether patient demographic data has been sent to the national database.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RESPONSIBLE PROVIDER 57 This is the physician responsible for the patient's clozaril treatment.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REGISTRATION DATE 58 This field is used to enter the date of registration.

Date/Time
UNIT DOSE 62 This represents the 'top' of the UNIT DOSE SUB-FILE, where all of a patient's active (and expired & dc'd) UNIT DOSE orders are kept. Although orders are initially entered into ^PS(53.1), the order is transferred into this sub-file (^PSGOT) upon verification.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER NUMBER .01 This is the record number of the order.

Numeric
PRIORITY .24 This field contains the priority of the order that was received from OERR.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: STAT
  • Code : A
    Stands For: ASAP
  • Code : R
    Stands For: ROUTINE
  • Code : P
    Stands For: PREOP
  • Code : T
    Stands For: TIMING CRITICAL
  • Code : D
    Stands For: DONE
ORIGINAL ORDER NUMBER .25 This is the original number of the order from file 53.1.

Numeric
PATIENT NAME .5 This is the patient for which the medication has been ordered.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROVIDER 1 This is the prescribing physician's name.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DISPENSE DRUG 2 This contains the dispense drug(s), and the related information, for this order. The dispense drug is the actual medication dispense by pharmacy for the order. Dispense drugs are obtained from the DRUG file (#50).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPENSE DRUG .01 This is a medication that will actually be dispensed by pharmacy for this order. Each dispense drug of an order must be tied to the primary drug of the order.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
UNITS PER DOSE .02 This is the number of UNITS (tablets, capsules, etc.) to be dispensed as a DOSE for this order. The literals '1/2' and '1/4' may be entered. If there is no entry, it is assumed to be ONE (1). ** PLEASE NOTE ** If a doctor prescribes 30 ml's of a medication that is usually dispensed and administered as 60 ml's, the correct UNITS PER DOSE would be 1/2 (or .5), NOT 30 ml's. (30 ml's would be entered into the DOSAGE ORDERED field.) If the UNITS PER DOSE ordered is a variable amount (1-2 tab.), it is suggested that the maximum amount be entered into this field and the amount ordered noted either in the DOSAGE ORDERED or SPECIAL INSTRUCTIONS fields.

Numeric
INACTIVE DATE .03 This is the date that this dispense drug will no longer be dispensed for this order. Once an order becomes active, dispense drugs cannot be deleted.

Date/Time
TOTAL UNITS DISPENSED .04 This is the total number of units actually dispensed for this order, including any EXTRA UNIT DISPENSED, and PRE-EXCHANGE NEEDS.

Computed
UNITS CALLED FOR .05 This is the total number of units to be dispensed for this medication as calculated by the package.

Numeric
UNITS ACTUALLY DISPENSED .06 This is the number of units of this medication actually dispensed as entered by the pharmacist.

Numeric
TOTAL RETURNS .07 This is the total number units returned for this medication over the life of the order.

Numeric
RETURNS .08 This is the number of units returned of this medication from the patient's cassette upon the termination of this order.

Numeric
PRE-EXCHANGE UNITS .09 This is the number of actual units required for this order until the next cart exchange.

Numeric
TOTAL EXTRA UNITS DISPENSED .1 This is the total number of extra units dispensed for this order over the entire life of the order.

Numeric
EXTRA UNITS DISPENSED .11 This is the number of units dispensed outside of the normal dispensing process (pick list).

Numeric
TOTAL PRE-EXCHANGE UNITS .12 This is the total number of pre-exchange units dispensed over the life of the order.

Numeric
ADM 21400

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ADM
MED ROUTE 3 This is the route of administration for this medication. If a corresponding abbreviation is found for this route in the MEDICATION ROUTES file, that abbreviation is printed on the various reports in this package.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
TYPE 4 This identifies the type of medication ordered.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : C
    Stands For: CHEMOTHERAPY
  • Code : P
    Stands For: PIGGYBACK
  • Code : T
    Stands For: TPN
  • Code : U
    Stands For: UNIT DOSE
SELF MED 5 This should contain a `1' or (`YES') if this medication is to be administered by the patient to himself.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HOSPITAL SUPPLIED SELF MED 6 This should contain a `1' (or `YES') if this medication is to be a `SELF MED' and this site's pharmacy is to supply the medication. This is only asked if the user enters `YES' (or `1') to the SELF MED prompt. If the SELF MED prompt is ever edited to show `NO' (or `0'), this field is automatically deleted.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SCHEDULE TYPE 7 This describes the type of schedule for the dispensing of the medication(s) that make up the order. PRE-OP orders are usually considered to be ON-CALL orders, and orders dispensed as MUTLI-DOSE CONTAINERS are usually considered to be FILL ON REQUEST orders.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CONTINUOUS
  • Code : O
    Stands For: ONE TIME
  • Code : P
    Stands For: PRN
  • Code : R
    Stands For: FILL ON REQUEST
  • Code : OC
    Stands For: ON CALL
SPECIAL INSTRUCTIONS 8 This is any special instructions (using abbreviations whenever possible) needed for this order. This would include the physician's reason for ordering a PRN. This field utilizes the abbreviations and expansions from the MEDICATION INSTRUCTIONS file.

Free Text
ORIGINAL WARD 9 This is the ward where the patient was located when the order was created.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
START DATE/TIME 10 This is the date and time the order is to begin. This package initially assigns the START DATE/TIME to the closest administration time or next admin. time or NOW depends on the value of the DEFAULT START DATE CALCULATION field in the INPATIENT WARD PARAMETERS. START DATE/TIME may not be entered prior to 7 days from the order's LOGIN DATE.

Date/Time
DAY LIMIT 11 This is number of days this order is to last.

Numeric
DOSE LIMIT 12 This is the number of times the medication is to be administered.

Numeric
*UNITS PER DOSE 13 This is the number of UNITS (tablets, capsules, etc.) to be dispensed as a DOSE for this order. The literals '1/2' and '1/4' may be entered. If there is no entry, it is assumed to be ONE (1). ** PLEASE NOTE ** If a doctor prescribes 30 ml's of a medication that is usually dispensed and administered as 60 ml's, the correct UNITS PER DOSE would be 1/2 (or .5), NOT 30 ml's. (30 ml's would be entered into the DOSAGE ORDERED field.) If the UNITS PER DOSE ordered is a variable amount (1-2 tab.), it is suggested that the maximum amount be entered into this field and the amount ordered noted either in the DOSAGE ORDERED or SPECIAL INSTRUCTIONS fields.

Numeric
*PRE-EXCHANGE UNITS 14 This is the number of actual units required for this order until the next cart exchange.

Numeric
COMMENTS 15 This is any remarks or explanations needed for this order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This is a word processing field that is purely informational. This field only shows on the expanded view of the order.

Word Processing
VERIFYING NURSE 16 This is the nurse who verified the order, or the latest action taken on the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY NURSE 17 This is the date the order was verified by the nurse.

Date/Time
VERIFYING PHARMACIST 18 This is the pharmacist who verified the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY PHARMACIST 19 This is the date the order was verified by the pharmacist.

Date/Time
PHYSICIAN 20 This is the physician who signed off on the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY PHYSICIAN 21 This is the date the physician signed off on the order.

Date/Time
CLERK 22 (Not currently used.)

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE ENTERED BY CLERK 23 (Not currently used.)

Date/Time
*SOLUTION 24 (Not currently used.)

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
PREVIOUS STOP DATE/TIME 25 This is used to store the original stop date when it is changed due to the order being cancelled. This allows the order to be reinstated.

Date/Time
SCHEDULE 26 This is the frequency (ONLY) by which the doses are to be administered. Several forms of entry are acceptable, such as Q6H, 09-12-15, STAT, QOD, and MO-WE-FR@AD (where MO-WE-FR are days of the week, and AD is the admin times.) The schedule will show on the MAR, labels, etc. If the letters PRN are found as part of the schedule, no admin times will print on the MAR or labels, and the PICK LIST will always show a count of zero (0). Avoid using notation such as W/F (with food) or WM (with meals) in the schedule as it may cause erroneous calculations. That information should be entered into the SPECIAL INSTRUCTIONS. When using the MO-WE-FR@AD schedule, please remember that this type of schedule will not work properly without the "@" character and at least one admin. time, and that at least the first two letters of each weekday entered is needed.

Free Text
ORDER DATE 27 This is the date the order was entered into the computer. The package enters this date automatically when the order is transcribed.

Date/Time
LOG-IN DATE 27.1 This is the date (to the second) the order was entered.

Date/Time
STATUS 28 This is the status of the order.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTIVE
  • Code : D
    Stands For: DISCONTINUED
  • Code : E
    Stands For: EXPIRED
  • Code : H
    Stands For: HOLD
  • Code : R
    Stands For: RENEWED
  • Code : RE
    Stands For: REINSTATED
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
  • Code : DR
    Stands For: DISCONTINUED (RENEWAL)
ACTIVITY LOG 29 This is a record of the actions that have taken place on the order. Actions include EDIT, RENEWAL and CANCELLATION. Stored with the action is the date and time the action took place and the user who took the action. If the action is an edit, the data in the field edited prior to the edit is also stored.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE .01 This is the date (to the second) that the activity took place.

Date/Time
USER 1 This is the user who effected the activity.

Free Text
ACTION 2 This is the activity that has taken place on the order.

Pointer
PointerTo:
fileName:
ACTIVITY LOG REASON
fileNumber:
53.3
FIELD 3 This is field that was changed due to the activity.

Free Text
OLD DATA 4 This is the previous data that was in the field that was changed.

Free Text
OLD DATA (WORD PROCESSING) 5 This contains the previous data that was in the changed field, if the field being changed is a Word Processing field. The data is captured automatically and is not editable.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OLD DATA (WORD PROCESSING) .01 This contains the previous data that was in the changed field, if the field being changed is a Word Processing field. The data is captured automatically and is not editable.

Word Processing
REASON FOR HOLD 21400

Free Text
*UNITS CALLED FOR 32 This is the total number of units to be dispensed for this medication as calculated by the package.

Numeric
STOP DATE/TIME 34 This is the date and time the order will automatically expire. This package initially calculates a default stop date, depending on the SITE PARAMETERS.

Date/Time
*TOTAL RETURNS 35 This is the total number units returned for this medication over the life of the order.

Numeric
*UNITS ACTUALLY DISPENSED 36 This is the number of units of this medication actually dispensed as entered by the pharmacist.

Numeric
*RETURNS 38 This is the number of units returned of this medication from the patient's cassette upon the termination of this order.

Numeric
*TOTALS UNITS DISPENSED 39 This is the total number of units actually dispensed for this order, including any EXTRA UNIT DISPENSED, and PRE-EXCHANGE NEEDS.

Computed
ADMIN TIMES 41 This is the times of the day the medication is to be administered. This package initially assigns a default set of ADMIN TIMES when a STANDARD SCHEDULE is entered into the SCHEDULE prompt.

Free Text
FREQUENCY (in minutes) 42 This is either a code or the number of minutes between the times the medication is to be administered.

Free Text
RENEWAL 43 This is an internal flag, set when the order is marked to be renewed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
RENEWAL USER 44 This is the user who marked the order to be renewed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE RENEWAL MARKED 45 This is the date this order was renewed or marked for renewal.

Date/Time
MARKED CANCELLED 46 This is an internal flag set when the order is marked for cancellation.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
MARKED CANCELLED USER 47 This is the user who marked the order for cancellation.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE MARKED CANCELLED 48 This is the date that the order was marked for cancellation.

Date/Time
AUTO CANCELLED FLAG 49 This is an internal flag looked at by the UNIT DOSE package to determine if this order was automatically cancelled by the package because the patient was newly admitted, transferred, or discharged (or deceased). If this flag is on (1), the order may be reinstated within 72 hours of its cancellation.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PV FLAG 50 This is an internal flag set whenever a pharmacist verifies the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
NV FLAG 51 This is an internal flag set whenever a nurse verifies the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
LABEL DATE 52 This is the date the last label record was created for the order.

Date/Time
LABEL REASON 53 This is the last activity to take place on the order that created a label record.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EDITED
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEWED
  • Code : D
    Stands For: DISCONTINUED
  • Code : RE
    Stands For: REINSTATED
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
  • Code : H1
    Stands For: ON HOLD
  • Code : H0
    Stands For: OFF OF HOLD
*TOTALS EXTRA UNITS DISPENSED 54 This is the total number of extra units dispensed for this order over the entire life of the order.

Numeric
*EXTRA UNITS DISPENSED 55 This is the number of units dispensed outside of the normal dispensing process (pick list).

Numeric
HOLD FLAG 56 This is an internal number set whenever the order is placed on HOLD, or marked to be placed on hold.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: OFF
  • Code : 1
    Stands For: ON
HOLD USER 57 This is the user who placed the order on hold, or marked the order to be placed on hold.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOLD DATE 58 This is the date the order was placed on hold, or marked to be placed on hold.

Date/Time
HOLD STATUS 59 This is the previous status of the order, updated when the order is placed on HOLD. This allows the return of the previous status when the order is taken off of hold.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTIVE
  • Code : R
    Stands For: RENEWED
  • Code : RE
    Stands For: REINSTATED
OERR HOLD FLAG 59.1 This field is set when the order is placed on hold through the OE/RR package. Orders placed on hold through OE/RR may only be removed from hold through OE/RR.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
OFF HOLD FLAG 60 This is an internal flag set when an order is taken off of hold, or marked to be taken off of hold.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: OFF
  • Code : 1
    Stands For: ON
OFF HOLD USER 61 This is the user who has taken the order off of hold, or marked the order to be taken off of hold.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OFF HOLD DATE 62 This is the date the order was taken off of hold, or marked to taken off of hold.

Date/Time
*TOTAL PRE-EXCHANGE UNITS 63 This is the total number of pre-exchange units dispensed over the life of the order.

Numeric
PURGE FLAG 64 This is an internal flag set when the order is due to be purged (deleted). This is actually the patient's discharge date, to allow the use of the 'AUDDD' x-ref.

Date/Time
*SIG 65 This is the provider's exact instructions for this order's medication and its administration.

Free Text
ORDERS FILE ENTRY 66 This is the pointer value of the corresponding entry in the ORDERS file (100) when the order is entered into OE/RR.

Free Text
MERGED PATIENT 67 If the order is moved from one patient to another, because patients are being merged, there will be data here. The data will be in the form of another patient's internal record number concatenated with either a `T' (if the order has been moved to the other patient), or an `F' (if the came FROM the other patient).

Free Text
LAST WARD 68 This is the last ward the patient was located when the order expired or was discontinued. This is automatically updated by the Unit Dose package when the package finds that the patient is first admitted or when the patient is found to have been transferred. This allows any returns that are entered to be credited to the correct ward.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
'NOT TO BE GIVEN' FLAG 69 This is a flag that may be set for orders that have been discontinued or expired only. If the flag is set, the order cannot be renewed or reinstated. This is to be set only through the package, and not through VA FileMan.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: NOT TO BE GIVEN
ORIGINAL START DATE/TIME 70 This is the original start date/time of the order. An entry is automatically made here the first time the order is renewed.

Date/Time
DISPENSE LOG 71 This is the dispensing record for this order. It contains information such when the drug was dispensed, by whom, and how it was dispensed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPENSE DATE/TIME .01 This is the date (time optional) that units dispensed (or returned) were entered for this order. If the units were dispensed through the pick list, this will be the start date (no time) of the pick list.

Date/Time
DISPENSE DRUG .02 This is the medication that was dispensed (or returned) for this order.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
AMOUNT .03 This is the number of units that were dispensed (or returned) for this order.

Numeric
COST .04 This is the cost of the amount dispensed or returned.

Numeric
HOW .05 This is the method the drug was dispensed for this order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: FROM PICK LIST
  • Code : 2
    Stands For: PRE-EXCHANGE UNITS
  • Code : 3
    Stands For: EXTRA UNITS DISPENSED
  • Code : 4
    Stands For: RETURNS
USER .06 This is the user who entered the amount dispensed for this drug for this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WARD .07 This is the ward the patient was residing on when the dispense amount was entered.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
PROVIDER .08 This is the provider for the order when the amount dispensed was entered.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ADM 21400 From ADM dispense

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ADM
CREDIT AMOUNT 21400.02

Numeric
ZPM LOCATION 21400.03

Free Text
PROVIDER COMMENTS 72 This is any instructions or comments entered by the provider for this order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER COMMENTS .01 This is any instructions or other comments entered by the provider of this order for this order.

Word Processing
*PRIMARY DRUG 101 This is the primary drug associated with the order. If the order is a unit dose order all dispensed drugs entered must be matched to the order's primary drug. If the order is an IV order at least one of the additives or solutions entered must match the primary drug.

Pointer
PointerTo:
fileName:
PRIMARY DRUG
fileNumber:
50.3
*DOSAGE ORDERED 102 This is the amount of the medication the patient is to receive as one dose for this order. This should be an amount with a unit of measure, such '500MG' or '50CC'. THIS SHOULD NOT BE THE NUMBER OF TABLETS, ETC.

Free Text
REASON ORDER CREATED 103 This is used to show the method used to create this order.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEWAL
  • Code : E
    Stands For: EDIT
PREVIOUS ORDER 104 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the previous order.

Free Text
FOLLOWING ORDER 105 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the order created.

Free Text
*NATURE OF ORDER 106 This is the method the provider used to communicate to the user to enter (or take any other action) the order.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONED
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: PROVIDER ENTERED
REASON FOR FOLLOWING ORDER 107 If the order has been edited or renewed, this will contain the code corresponding to the action taken.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EDIT
  • Code : R
    Stands For: RENEWAL
ORDERABLE ITEM 108 This is the Orderable Item associated with the order. If the order is a unit dose order, all dispense drugs entered must be matched to the order's primary drug. If the order is an IV, at lest one of the additives or solutions entered must match the orderable item.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
DOSAGE ORDERED 109 This is the amount of the medication the patient is to receive as one dose for this order. This should be an amount with a unit of measure, such as '500MG' or '50cc'. THIS SHOULD NOT BE THE NUMBER OF TABLETS, ETC.

Free Text
NATURE OF ORDER 110 This is the method the provider used to communicate to the user to enter (or take any other action) on the order.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONED
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: ELECTRONICALLY ENTERED
  • Code : I
    Stands For: POLICY
  • Code : S
    Stands For: SERVICE CORRECTION
  • Code : D
    Stands For: DUPLICATE
INSTRUCTIONS 111

Free Text
LAST RENEW 114

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LAST RENEW .01 This is the date/time the order was renewed.

Date/Time
RENEWED BY 1 This is the person who renewed the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS PROVIDER 2 This is the name of the provider responsible for the prior order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS STOP DATE/TIME 3 This is the stop date/time of the prior order.

Date/Time
PREVIOUS ORDERS FILE ENTRY 4 When an order is being renewed, this is the pointer value of the corresponding entry in the ORDERS file (100), prior to the renewal.

Free Text
DOSE 120 This is the numeric dosage for the order. It will be combined with the UNIT field to show the dosage ordered. For a dosage of 325MG, 325 would be stored here.

Numeric
UNIT 121 This is the field which contains the unit for the numeric dosage. The combination of these two fields gives you the dosage ordered for this order. For the doasge 325MG, MG would be stored here.

Free Text
SI/OPI FLAG 122 This flag controls whether the user administering this order in BCMA will have the Special Instructions displayed in a pop-up box.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
BCMA EXPIRED FLAG 123 This is an internal flag to indicate the order was expired at the request of the Bar Code Medication Administration (BCMA) package. If the flag is set to 1, then BCMA requested Inpatient Medications expire the order. Only orders with the flag set to 1 can be reinstated by a BCMA reinstate request.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
FLAGGED 124 This indicates that this order has been flagged for clarification.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ORDERS FILE PARENT ORDER 125 This is the parent of an order that may have a parent/child relationship in CPRS.

Free Text
REQUESTED DURATION 126 The duration of an order as requested by the ordering clinician in CPRS. The duration is stored as one of the following upper case letters followed by an integer: L - Months W - Weeks D - Days H - Hours M - Minutes S - Seconds Example: D6 = Six days.

Free Text
MOST RECENT FLAG COMMENT 128

Free Text
CLINIC 130 This is the clinic location if this order is for an Outpatient.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
APPOINTMENT DATE/TIME 131 Date and time of the appointment for this clinic location.

Date/Time
INTERVENTION 132 Pointer to Intervention (#9009032.4) file.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION .01

Pointer
PointerTo:
fileName:
APSP INTERVENTION
fileNumber:
9009032.4
INTERVENTION DATE/TIME 1 The Date/Time the Intervention occurred.

Date/Time
SPECIAL INSTRUCTIONS (LONG) 135

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SPECIAL INSTRUCTIONS (LONG) .01

Word Processing
DISPLAY STATUS 136 This field captures how a "Discontinued" action occurred and this code is displayed on the short patient profile if the Stop Date/Time is within the time specified in the Inpatient Ward Parameter file (#59.6) or the Pharmacy System file (#59.7). The "HP" is to display on the profile if the order was placed on hold by provider through CPRS.

Set of Codes
Set of Codes:
  • Code : DF
    Stands For: Discontinued due to edit by a provider through CPRS
  • Code : DP
    Stands For: Discontinued by provider through CPRS
  • Code : DD
    Stands For: Auto discontinued due to death
  • Code : DA
    Stands For: Auto discontinued due to patient movements
  • Code : HP
    Stands For: Placed on hold by provider through CPRS
COMPUTED MAX (MSC) 21400

Computed
ALTERNATE DRUG 21434

Pointer
PointerTo:
fileName:
ALTERNATE DRUG COST
fileNumber:
21434
ALTERNATE COST 21434.1

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
CHARGE ON ADMINISTRATION 21498

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
UD DEFAULT STOP DATE/TIME 62.01 This is date used as a default value for the STOP DATE/TIME of Unit Dose orders during the order entry and renewal processes, if the corresponding site parameter is turned on. The order entry and renewal processes will sometimes change this date.

Date/Time
UD PROVIDER 62.02 This is the latest provider for this patient, used as a default value in order entry.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
UD LAST ADMISSION DATE 62.03 This is the last admission date for this patient.

Date/Time
UD LAST TRANSFER DATE 62.04 This is the last transfer date for this patient.

Date/Time
UD LAST DISCHARGE DATE 62.05 This is the last discharge date for this patient.

Date/Time
UD EXP UP-DATE 62.06 This is a date used to update expired orders. (Internal)

Date/Time
UD HOLD FLAG 62.07 This is an internal flag set when all of the patient's orders have been placed on hold. If '2', all of a patient's Unit Dose AND IV orders were placed on hold automatically by the package.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: ORDERS NOT ON HOLD
  • Code : 1
    Stands For: ORDERS ON HOLD
  • Code : 2
    Stands For: ORDERS AUTOMATICALLY PLACED ON HOLD
UD DISCHARGE FLAG 62.08 This is an internal flag set when a patient is first found to have been discharged. It is set so that Inpatient Meds does not try to cancel the patient's orders every time the patient is accessed while discharged.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PATIENT HAS BEEN DISCHARGED
COMMENTS 62.1 This is used for temporary storage of data by the Unit Dose package. The data is deleted before and after each use!

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This is used for temporary storage of data by the Unit Dose package. The data is deleted before and after each use!

Word Processing
HOLD REASON 62.11 This is an explanation of why this patient's orders are being placed on hold. This explanation will show on the patient's Unit Dose profile.

Free Text
*LAST UD ORDER CONVERTED TO V4 62.16 This is the last Unit Dose order converted for use with version 4 of the Inpatient Medications package. THIS SHOULD NOT BE EDITED. Editing could result in corrupted data and possibly medication administration errors.

Free Text
INPATIENT NARRATIVE 62.2 This field stores the Inpatient pharmacy narrative for the patient.

Free Text
*UD STOP DATE 63 This field is used by the UNIT DOSE PHARMACY package. It is NOT to be entered into anywhere else!

Date/Time
*NO. OF IV ORDERS 99

Computed
IV 100 This subfile contains IV order information for any given patient. A separate IV order file does not exist. This isn't the same design as outpatient pharmacy -- which does contain a separate file for prescriptions.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER NUMBER .01 Order Number for IV drugs administered to this patient.

Numeric
START DATE/TIME .02 This is the date and time the order is to begin. This package initially assigns the START DATE/TIME to the closest administration time or next admin. time or NOW depends on the value of the DEFAULT START DATE CALCULATION field in the WARD PARAMETERS file. START DATE/TIME may not be entered prior to 7 days from the order's LOGIN DATE.

Date/Time
STOP DATE/TIME .03 This is the date and time the order is to end.

Date/Time
TYPE .04 Type of IV - 'A' for Admixture, 'C' for chemotherapy, 'H' for Hyperal, 'P' for Piggyback, and 'S' for Syringe.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : P
    Stands For: PIGGYBACK
  • Code : H
    Stands For: HYPERAL
  • Code : S
    Stands For: SYRINGE
  • Code : C
    Stands For: CHEMOTHERAPY
PROVIDER .06 Person who authorized the prescription.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INFUSION RATE .08 The rate at which the IV is to be administered. This value, together with the total volume of the hyperal or the admixture type, is used to determine the time covered by one bag; hence the system can predict the bags needed during a specified time of coverage. This field is free text for IVPB's. For LVP's you must enter a number representing the infusion rate. You may also specify the # of bags per day needed, which will become the default number of LABELS PER DAY. Example: 125 = 125 ml/hr (IV system will calculate bags needed per day) 125@2 = 125 ml/hr with 2 labels per day TITRATE@1 = TITRATE with 1 label per day The format of this field is either a number only or [FREE TEXT@NUMBER OF LABELS PER DAY]. Note: If an administration time(s) is defined, the number of labels will reflect the administration time(s) for the IVPB type orders. For example: One administration time of 12:00 is specified. The infusion rate is entered as 125@3. Only 1 label will print.

Free Text
SCHEDULE .09 You may enter a standard schedule here or non-standard schedule. If a standard schedule is entered, the doses will be given at the administration time(s). If a non-standard schedule is entered, and no administration times are entered, the doses will be given at time intervals past the start date/time of the IV order. TID = (09-17-21) doses will be given at admin. times. Q5H = (300 minutes) doses will be given every 300 minutes. The format of this field is [SCHEDULEspaceFREETEXTspaceFREETEXT] and 1-70 characters.

Free Text
REMARKS .1 This field is not shown on the IV labels, but is shown on some of the IV reports.

Free Text
ADMINISTRATION TIMES .12 Enter the times that this order will be given separated by a '-'. The administration times have to be entered in ascending order. Each administration time must be at least two characters long or four characters long. Example: '03-07-11-15-19-23' or '0730-1130'. Administration times are REQUIRED for STANDARD schedules but are NOT REQUIRED for NON-STANDARD schedules.

Free Text
LAST FILL .15 Last time the prescription was filled.

Date/Time
LAST QTY FILLED .16 Quantity of last filled prescription.

Numeric
SCHEDULE INTERVAL .17 Interval between administrations of IV

Numeric
LOGIN DATE/TIME .21 This is the date and time the order was entered.

Date/Time
IV ROOM .22 IV room where IV was prepared for administration.

Pointer
PointerTo:
fileName:
IV ROOM
fileNumber:
59.5
*ENTRY CODE .23 This is the user who entered the order into the system.

Free Text
CUMULATIVE DOSES .24 Cumulative doses of IV for patient.

Numeric
ADDITIVE 1 The additive in the IV. This looks at the Additives File (52.6)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVE .01 This is the additive which was selected as part of the IV order. This entry is a pointer to the ADDITIVES file (52.6).

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
STRENGTH .02 'STRENGTH' is the amount of an additive that is used in the manufacturing of the IV order. NOTE! You'll be expected to use the strength units that have been previously defined within the additive file (52.6) for each additive. That is to say, if the additive file expects AMPICILLIN to be dispensed in 'GMS', it would not be correct for you to enter '500' for a half-gram dose -- enter 0.5 instead.

Free Text
BOTTLE .03 This is the bottle number (or numbers, separated by commas) in which this additive will be included for this IV order. If this field is blank, it means that the additive will be included in all bottles.

Free Text
SOLUTION 3 Solution in IV. Looks at the Solutions File (52.7)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTION .01 This is the solution entered as part of the specified IV order.

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
VOLUME 1 This field represents the volume of this solution in MLs. Only a number can be entered into this field. The total volume of an IV ORDER is all the solution's volumes added together.

Free Text
ORIGINAL WARD 9 This is the ward where the patient was located when the order was created.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
VERIFYING NURSE 16 This is the nurse who acknowledged (through OE/RR) the order, or the lates action taken on the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY NURSE 17 This is the date the order was acknowledged (through OE/RR) by the nurse.

Date/Time
OTHER PRINT INFO 31 This field is very similar to the REMARKS field except that OTHER INFO is shown on the label and the IV REPORTS.

Free Text
ACTIVITY LOG 40 This is used to record changes made to the IV order. Information stored includes the date/time of the action, the user who took the action, and any fields changed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ACTIVITY LOG .01 Log in IV activity.

Numeric
TYPE OF ACTIVITY .02 Captures type of activity. Enter one of following set of codes: H for hold, D for Discontinue, U for Unhold, E for Edit, R for Renew, I for Reinstate, AI for auto reinstate, O for On Call, C for Off call, V for Verify, F for Complete, PNRD for Pending/Non-Verified Renewal Discontinued, G for Flagged, or UG for Unflagged.

Set of Codes
Set of Codes:
  • Code : H
    Stands For: HOLD
  • Code : D
    Stands For: DISCONTINUED
  • Code : U
    Stands For: UNHOLD
  • Code : E
    Stands For: EDIT
  • Code : R
    Stands For: RENEW
  • Code : I
    Stands For: REINSTATE
  • Code : O
    Stands For: ON CALL
  • Code : C
    Stands For: OFF CALL
  • Code : V
    Stands For: VERIFY
  • Code : F
    Stands For: COMPLETE
  • Code : AI
    Stands For: AUTO REINSTATE
  • Code : PNRD
    Stands For: PENDING/NON-VERIFIED RENEWAL DISCONTINUED
  • Code : G
    Stands For: FLAGGED
  • Code : UG
    Stands For: UNFLAGGED
ENTRY CODE .03 This is the free text name from the user file of the person who performed the activity on this order.

Free Text
REASON FOR ACTIVITY .04 Reason for activity. This may be a message field.

Free Text
ACTIVITY DATE .05 This is the date in which this action was taken.

Date/Time
USER .06 This is the user who effected the activity.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FIELD CHANGED 1 This is used to record the actual changes made to fields in the IV order. Information stored includes the field name, it's old value, and it's new value.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FIELD CHANGED .01 The name of the field changed.

Free Text
FROM 1 This is the value which the specified field contained before modification.

Free Text
TO 2 Value field was changed to.

Free Text
OTHER PRINT INFO (OLD VALUE) 2 This contains the previous data that was in the OTHER PRINT INFO (LONG) (#154) multiple in the IV (#100) multiple in the PHARMACY PATIENT (#55) file, prior to an edit. The data is captured automatically and is not editable.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER PRINT INFO (OLD VALUE) .01 This contains the previous data that was in the OTHER PRINT INFO (LONG) (#154) multiple in the IV (#100) multiple in the PHARMACY PATIENT (#55) file, prior to an edit. The data is captured automatically and is not editable.

Word Processing
OTHER PRINT INFO (NEW VALUE) 3 This contains the new data in the OTHER PRINT INFO (LONG) (#154) multiple in the IV (#100) multiple in the PHARMACY PATIENT (#55) file, after an edit. The data is captured automatically and is not editable.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER PRINT INFO (NEW VALUE) .01 This contains the new data in the OTHER PRINT INFO (LONG) (#154) multiple in the IV (#100) multiple in the PHARMACY PATIENT (#55) file, after an edit. The data is captured automatically and is not editable.

Word Processing
STATUS 100 Status of order. Enter one of following codes: A for active, H for hold, R for renewed, D for discontinued, E for expired, P for purge, O for on call, N for nonverified.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTIVE
  • Code : H
    Stands For: HOLD
  • Code : R
    Stands For: RENEWED
  • Code : D
    Stands For: DISCONTINUED
  • Code : E
    Stands For: EXPIRED
  • Code : P
    Stands For: PURGE
  • Code : O
    Stands For: ON CALL
  • Code : N
    Stands For: NON VERIFIED
*DOSAGE ORDERED 101 This is the dosage prescribed by the physician.

Free Text
*IV ORDERED 102 This field is used only for orders entered through the OE/RR interface. If a hyperal is ordered, this field will contain "HYPERAL IV ORDER". If an admixture is ordered, it will contain the free text drug name entered, and may be from 1 to 40 characters long. If a piggyback is ordered it will be null, as the drug entered will be an entry in the additives file, and is stored in the ADDITIVES sub-file (55.02) for the order.

Free Text
*SPECIAL INSTRUCTIONS 103 This field contains any special instructions or messages appropriate for this IV order. This field may only be edited when entering an order through the OE/RR package, and will only be displayed when viewing the order until the order has been verified.

Free Text
WARD 104 If the IV is not a outpatient IV, this field will be a pointer to the ward file 42. If the IV is a outpatient IV, this field will contain a .5

Numeric
TOTAL IV'S ADMINISTERED 105 This is the total number of doses of this IV order which have been administered to the patient.

Numeric
CHEMOTHERAPY TYPE 106 A chemotherapy IV order may be one of three types: admixture, piggyback, or syringe. The type of chemotherapy IV must be identified as one of these types, so the system will know what kinds of questions to ask in order to properly complete this order.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : P
    Stands For: PIGGYBACK
  • Code : S
    Stands For: SYRINGE
SYRINGE SIZE 107 Enter the size of the syringe which is to be used to administer this IV.

Free Text
INTERMITTENT SYRINGE 108 A syringe IV order may be continuous or intermittent. If a syringe type is continuous (not intermittent), the same order entry procedure will be followed as if a hyperal or admixture is being entered. If a syringe order is to be intermittent, the same order entry method as the piggback type will be followed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
DC DATE 109 This is the date the IV order selected was discontinued.

Date/Time
ORDERS FILE ENTRY 110 This value matches this IV order to its entry in the Order file.

Free Text
LABEL TRACKING 111 This contains IV label information pertaining to any label action taken for an IV order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LABEL TRACKING .01 This is the internal number of this label tracking event.

Numeric
DATE 1 This is the date the label action was taken.

Date/Time
ACTION 2 This describes what type of label action was taken.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DISPENSED
  • Code : 2
    Stands For: RECYCLED
  • Code : 3
    Stands For: DESTROYED
  • Code : 4
    Stands For: CANCELED
  • Code : 5
    Stands For: SUSPENDED
  • Code : 6
    Stands For: OTHER
USER 3 This identifies who initiated the label action.

Numeric
LABELS 4 This is the number of labels involved in this event.

Numeric
TRACK 5 This identifies the type of option used when labels were printed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INDIVIDUAL LABELS
  • Code : 2
    Stands For: SCHEDULED LABELS
  • Code : 3
    Stands For: SUSPENDED LABELS
  • Code : 4
    Stands For: ORDER ACTION LABELS
  • Code : 5
    Stands For: OTHER
DAILY USAGE 6 This shows if the labels printed during this event were counted toward daily usage and had an entry made in the IV STATS file (50.8).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 2
    Stands For: NO
ERROR 7 This will be defined when recycling, canceling, or destroying IV bags in an IV room different from the one in which the label was dispensed. This is a built in error log and will show on the label tracking log if the error has occurred. The log will tell you the IV room from which the bag was dispensed and the IV room in which the bag was recycled, canceled, or destroyed. An IV bag should always be recycled, canceled, or destroyed in the same IV room from which it was dispensed.

Free Text
ADM 21400

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ADM
CREDIT AMOUNT 21400.02

Free Text
ZPM LOCATION 21400.03

Free Text
ATZERO 112 This field is a 1 or a null. It will be a 1 if the IV order is intermittent and a schedule was entered in the form SCHEDULE@0. Notice the 'NO space' in the input. When I see a schedule entered in this form, I set this field to one. A 1 means that the user wants to see these order on the ward list and manufacturing list with 0 doses due. They will not get scheduled labels for these orders unless they update the ward list first. They can get these labels from individual order print. This is a 'print on demand function' just like entering INFUSION RATE@0 for continuous orders.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PRINT PB'S ON DEMAND
PREVIOUS ORDER 113 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the previous order.

Free Text
FOLLOWING ORDER 114 If an action is taken on an order that causes a new order to be created, this will contain a code identifying the status and location of the new order.

Free Text
PROVIDER COMMENTS 115 This is any comments about the order that the provider needs to pass along to the pharmacy and/or ward personnel.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROVIDER COMMENTS .01 This contains any comments about the order that the provider needs to pass along to pharmacy or ward personnel. This field may only be edited using OE/RR options.

Word Processing
ORIGINAL STOP DATE 116 When an action is taken on an order that causes the order's original stop date to be changed, the original stop date is stored in this field.

Date/Time
*PRIMARY DRUG 117 Used to store the primary drug entered through OE/RR for Inpatient Medication IV orders. If the order entered is an Inpatient Medication IV order, the primary drug is taken from the first additive or solution entered. The primary drug will be displayed for this order type on the OE/RR Review Orders screen and other displays used by the clinician.

Pointer
PointerTo:
fileName:
PRIMARY DRUG
fileNumber:
50.3
*DOSAGE ORDERED 118 This is the dosage ordered (strength) for the primary drug entered for an Inpatient Medication IV order.

Free Text
*MED ROUTE 119 This is the route of administration for this order. This is not required for IV Fluid orders.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
OERR HOLD FLAG 120 If an IV order is placed on hold using OE/RR options, the hold may only be removed using OE/RR options.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
AUTO DC 121 This is used to determine if an order was auto-discontinued due to a patient movement. Only orders that were discontinued in this way may be reinstated by pharmacy. When reinstated, the status will become active, and the original stop date will be used.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
REASON ORDER CREATED 122 This is used to show the method used to create this order. what actions may be taken on the order.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEW
  • Code : E
    Stands For: EDIT
REASON FOR FOLLOWING ORDER 123 This is used to determine the action taken which caused the creation of the following order.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : E
    Stands For: EDIT
  • Code : R
    Stands For: RENEW
MAR LABEL DATE 128 This is the date and time the latest MAR label for this order was created.

Date/Time
MAR LABEL REASON 129 This is the last activity to take place on the order that created a label record.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EDITED
  • Code : N
    Stands For: NEW
  • Code : R
    Stands For: RENEWED
  • Code : D
    Stands For: DISCONTINUED
  • Code : DE
    Stands For: DISCONTINUED (EDIT)
  • Code : H1
    Stands For: ON HOLD
  • Code : H0
    Stands For: OFF HOLD
  • Code : RE
    Stands For: REINSTATED
ORDERABLE ITEM 130 This is the Orderable Item associated with the order. If the order is a unit dose order, all dispense drugs entered must be matched to the order's primary drug. If the order is an IV, at lest one of the additives or solutions entered must match the orderable item.

Pointer
PointerTo:
fileName:
PHARMACY ORDERABLE ITEM
fileNumber:
50.7
DOSAGE ORDERED 131 This is the amount of the medication the patient is to receive as one dose for this order. This should be an amount with a unit of measure, such as '500MG' or '50cc'. THIS SHOULD NOT BE THE NUMBER OF TABLETS, ETC.

Free Text
MED ROUTE 132 This is the route of administration for this order. This is not required for IV Fluid orders.

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
INSTRUCTIONS 133

Free Text
PRIORITY 134 This field contains the priority of the order that was received from OERR.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: STAT
  • Code : A
    Stands For: ASAP
  • Code : R
    Stands For: ROUTINE
  • Code : P
    Stands For: PREOP
  • Code : T
    Stands For: TIMING CRITICAL
  • Code : D
    Stands For: DONE
ENTRY BY 135 This field contains the pointer value for the person entered the IV order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLINIC 136

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
NATURE OF ORDER 137 This is the method the provider used to communicate the order to the user to enter (or take any other action on) the order.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WRITTEN
  • Code : P
    Stands For: TELEPHONED
  • Code : V
    Stands For: VERBAL
  • Code : E
    Stands For: ELECTRONICALLY ENTERED
  • Code : I
    Stands For: POLICY
  • Code : S
    Stands For: SERVICE CORRECTION
  • Code : D
    Stands For: DUPLICATE
LAST RENEW 138

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LAST RENEW .01 This is the date/time the order was renewed.

Date/Time
RENEWED BY 1 This is the name of the person who renewed this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS PROVIDER 2 This is the name of the provider responsible for the prior order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS STOP DATE/TIME 3 This is the stop date/time of the prior order.

Date/Time
PREVIOUS ORDERS FILE ENTRY 4 When an order is being renewed, this is the pointer value of the corresponding entry in the ORDERS file (100), prior to the renewal.

Free Text
APPOINTMENT DATE/TIME 139 Date and time of the appointment for this clinic location.

Date/Time
VERIFYING PHARMACIST 140 This is the pharmacist who verified the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE VERIFIED BY PHARMACIST 141 This is the date/time the order was verified by the pharmacist.

Date/Time
PV FLAG 142 This is an internal flag set whenever a pharmacist verifies the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
NV FLAG 143 This is an internal flag set whenever a nurse verifies the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BCMA STATUS 144 This is the latest BCMA Status for this order.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INFUSING
  • Code : S
    Stands For: STOP
  • Code : H
    Stands For: HELD
  • Code : R
    Stands For: REFUSED
  • Code : C
    Stands For: COMPLETED
  • Code : G
    Stands For: GIVEN
BCMAID 145 This is the unique barcode ID in the format DFN_"V"_ID# ex: 740V1.

Free Text
SI/OPI FLAG 146 This flag controls whether the user administering this order in BCMA will have the Other Print Info displayed in a pop-up box.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
BCMA EXPIRED FLAG 147 This is an internal flag to indicate the order was expired at the request of the Bar Code Medication Administration (BCMA) package. If the flag is set to 1, then BCMA requested Inpatient Medications expire the order. Only orders with the flag set to 1 can be reinstated by a BCMA reinstate request.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
FLAGGED 148 This indicates that this order has been flagged for clarification.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
HOLD FLAG 149 This is a flag set to 1 whenever the order is placed on HOLD or 0 whenever the order is removed from hold.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: OFF HOLD
  • Code : 1
    Stands For: ON HOLD
ORDERS FILE PARENT ORDER 150 This is the parent of an order that may have a parent/child relationship in CPRS.

Free Text
REQUESTED DURATION 151 The duration of an order as requested by the ordering clinician in CPRS. The duration is stored as one of the following upper case letters followed by an integer: L - Months W - Weeks D - Days H - Hours M - Minutes S - Seconds Example: D6 = Six days.

Free Text
REQUESTED IV LIMITATION 152 This is the length of time to administer, or the total volume to administer, for IV fluid orders. The value may be in ML or CC for milliliters, L for liters, D for days, or H for hours.

Free Text
INTERVENTION 153 Pharmacy Interventions associated with the Inpatient order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION .01 This is the Pharmacy Intervention logged in response to order checks that occurred during Inpatient Order Entry.

Pointer
PointerTo:
fileName:
APSP INTERVENTION
fileNumber:
9009032.4
INTERVENTION DATE/TIME 1 The Date/Time the Intervention was logged in response to Order Checks that occurred during Inpatient Order Entry.

Date/Time
OTHER PRINT INFO (LONG) 154

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SPECIAL INSTRUCTIONS (LONG) .01

Word Processing
LABELS PER DAY 155 The number of IV labels needed each day. If populated, this value will override the system-calculated number of labels.

Numeric
DISPLAY STATUS 157 This field captures how a "Discontinued" action occurred and this code is displayed on the short patient profile if the Stop Date/Time is within the time specified in the Inpatient Ward Parameter file (#59.6) or the Pharmacy System file (#59.7). The "HP" is to display on the profile if the order was placed on hold by provider through CPRS.

Set of Codes
Set of Codes:
  • Code : DF
    Stands For: Discontinued due to edit by a provider through CPRS
  • Code : DP
    Stands For: Discontinued by provider through CPRS
  • Code : DD
    Stands For: Auto discontinued due to death
  • Code : DA
    Stands For: Auto discontinued due to patient movements
  • Code : HP
    Stands For: Placed on hold by provider through CPRS
TOTAL VOLUME 21437

Numeric
CHARGE ON ADMINISTRATION 21498

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BEYOND USE DAYS 9999999.01

Numeric
ARCHIVE DATE 101 This sub file is used to indicate archived prescriptions.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ARCHIVE DATE .01 Date patient Rx information was archived.

Date/Time
RX LIST 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RX LIST .01

Free Text
*LAST ADMISSION NUMBER 102 This field is updated by the IV PACKAGE every time action is taken on this particular patient. This piece will have two pieces of information on it. The first piece ('-' is the delimiter) is the current admissions number, and the second piece is the discharge date for this admissions number. This field is used for determining whether or not to DC IV ORDERS due to ADMISSIONS or DISCHARGE.

Free Text
*LAST SERVICE 102.1 This piece is updated by the IV PACKAGE every time this particular patient has any 'IV ACTION'. This piece represents the service of the last ward that this patient was in. It is a set of codes that was taken from the ADT package. This field is used to determine whether or not to DC IV ORDERS due to SERVICE transfer.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MEDICINE
  • Code : S
    Stands For: SURGERY
  • Code : P
    Stands For: PSYCHIATRY
  • Code : NH
    Stands For: NHCU
  • Code : NE
    Stands For: NEUROLOGY
  • Code : I
    Stands For: INTERMIDIATE MED
  • Code : R
    Stands For: REHAB MEDICINE
  • Code : SCI
    Stands For: SPINAL CORD INJURY
  • Code : D
    Stands For: DOMICILLARY
  • Code : B
    Stands For: BLIND REHAB
*LAST INTERWARD TRANSFER 102.2 This field is updated by the IV PACKAGE every time this particular patient has any 'IV ACTION'. This field represents the last INTERWARD TRANSFER NUMBER for the LAST ADMISSION NUMBER. This field is used to determine whether or not to DC IV ORDERS due to WARD TRANSFER. ORDERS due to SERVICE transfer.

Numeric
*LAST IV ORDER CONVERTED (4.0) 103 This is the last IV order for a patient that had it's data converted to the New Person file (200).

Numeric
CONVERSION COMPLETED? 104 This field contains a 1 if the conversion to the patient's orders for version 5.0 has completed. It contains a 2 if the conversion to the patient's orders for Pharmacy Ordering Enhancement (POE) has completed. It contains a 3 if the patient's IV orders existed prior to BCMA V.2.0 has updated the Verifying Pharmacist field.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: VERSION 5
  • Code : 2
    Stands For: POE
  • Code : 3
    Stands For: IV VERIFIED
BCMA ID 105 This is the unique barcode ID in the format DFN_"V"_ID# ex: 740V1.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BCMA ID .01 This is the unique barcode ID in the format DFN_"V"_ID# ex: 740V1.

Free Text
ON .02 This is the order number for this patient that this BCMA ID is currently associated with.

Numeric
BCMA STATUS DATE/TIME 1 This is the Date/Time the action was taken on this label in BCMA.

Date/Time
BCMA STATUS 2 This is the BCMA Status assigned to this label by the BCMA software.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: COMPLETED
  • Code : G
    Stands For: GIVEN
  • Code : H
    Stands For: HELD
  • Code : M
    Stands For: MISSING
  • Code : R
    Stands For: REFUSED
  • Code : S
    Stands For: STOP
  • Code : I
    Stands For: INFUSING
USAGE COUNT 3 This is a flag to tell whether or not this label should be counted as usage, 1 means count, 0 means no count.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO COUNT
  • Code : 1
    Stands For: COUNT
LABEL DATE 4 This is the Date/Time this label was created.

Date/Time
LABEL STATUS 5 This is the status of this label in Inpatient Medications.

Set of Codes
Set of Codes:
  • Code : RP
    Stands For: REPRINTED
  • Code : RC
    Stands For: RECYCLED
  • Code : CA
    Stands For: CANCELLED
  • Code : DT
    Stands For: DESTROYED
BAG # 6 This identifies which bag of the total number of bags for the day this bag is. Ex. 1[4] means 1 of 4 bags that will be used that day.

Free Text
ADDITIVE 7 This multiple contains the additives associated with this IV order in the form of pointers to the IV Additive file (#52.6)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVE .01 The additive in the IV order. This points to the IV Additives file (#52.6).

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
STRENGTH 1 'STRENGTH' is the amount of an additive that is used in the manufacturing of the IV order. NOTE! You'll be expected to use the strength units that have been previously defined within the additive file (52.6) for each additive. That is to say, if the additive file expects AMPICILLIN to be dispensed in 'GMS', it would not be correct for you to enter '500' for a half-gram dose -- enter 0.5 instead.

Free Text
BOTTLE 2 Enter the bottle no.(s) in which this additive will be included in for this IV order.

Free Text
SOLUTION 8 This multiple contains the solutions associated with this IV order in the form of pointers to the IV Solutions file (#52.7)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTION .01 This is the solution in the IV order. This points to the IV Solutions file (#52.7).

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
VOLUME 1 This field represents the volume of this solution in MLs. Only a number can be entered into this field. The total volume of an IV ORDER is all the solution's volumes added together.

Free Text
INVALID DATE/TIME 9 The Date/Time the label became invalid due to a change to the associated order.

Date/Time
OTHER LANGUAGE PREFERENCE 106 This field is used to identify patients who have another language preference for printing medication instructions on bottle labels.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PMI LANGUAGE PREFERENCE 106.1 This field will be used to determine the default language preference for printing the PMI sheets at the CMOPs.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ENGLISH
  • Code : 2
    Stands For: SPANISH
SCRIPTALK ENROLLMENT ACTIVITY 108 This multiple contains the history log information for ScripTalk enrollment activities for a patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SCRIPTALK ENROLLMENT ACTIVITY .01 Date that the patient was enrolled or the enrollment was changed for this patient.

Date/Time
SCRIPTALK PATIENT 1 If the patient is enrolled for ScripTalk, the enrollment status is 1 (Yes).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
INDICATION 2 This field contains the indication for being enrolled for ScripTalk. B=Blind veteran; L=low vision.

Set of Codes
Set of Codes:
  • Code : B
    Stands For: BLIND VETERAN
  • Code : L
    Stands For: LOW VISION
USER 3 This field contains the person who enrolled or updated the enrollment of a ScripTalk patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

DRUG ACCOUNTABILITY TRANSACTION

File Number: 58.81

File Description:

This file contains the data associated with drug accountability transactions. This file is designed to be shared between the Drug Accountability module and the Controlled Substances module. Entries in this file should NOT be edited directly for Controlled Substances use. The CS module contains all appropriate checks for this file's use. Controlled Substances entries will be flagged.


Fields:

Name Number Description Data Type Field Specific Data
TRANSACTION NUMBER .01 The internal entry number for this transaction.

Numeric
TYPE 1 A pointer to the name of this type transaction.

Pointer
PointerTo:
fileName:
DRUG ACCOUNTABILITY TRANSACTION TYPE
fileNumber:
58.84
PHARMACY LOCATION 2 This field contains a pointer to the Pharmacy location in the DRUG ACCOUNTABILITY STATS file (#58.8). The Controlled Substances module will recognize this location as the Narcotic Area of Use (NAOU), usually the pharmacy dispensing site (vault).

Pointer
PointerTo:
fileName:
DRUG ACCOUNTABILITY STATS
fileNumber:
58.8
DATE/TIME 3 The date/time of this transaction. For Controlled Substances dispensing transactions, this is the date/time the pharmacist verified this transaction.

Date/Time
DRUG 4 A pointer to the drug for this transaction.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
QUANTITY 5 The transaction quantity for this drug. If the transaction type is BALANCE ADJUSTMENT, this quantity may be a negative number.

Numeric
TRANSACTOR 6 This field contains a pointer to the name of the person initiating this transaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CONTROL POINT ACTIVITY 7 Posted (Warehouse) Issue activity that created this transaction. This field is a pointer to the CONTROL POINT ACTIVITY file (#410) and will be used mainly for receipt transactions.

Pointer
PointerTo:
fileName:
CONTROL POINT ACTIVITY
fileNumber:
410
PURCHASE ORDER NUMBER 8 The Unposted (Non-Warehouse) Purchase Order from which this transaction was created. This field is a pointer to the PROCUREMENT & ACCOUNTING TRANSACTION file (#442) and will be used mainly for receipt transactions.

Pointer
PointerTo:
fileName:
PROCUREMENT & ACCOUNTING TRANSACTIONS
fileNumber:
442
BALANCE FORWARD 9 The pharmacy dispensing site (vault) inventory balance forward for this drug. This balance is used in listing pharmacy's "Daily Activity Log".

Numeric
ORDER STATUS 10 The processing status for the Controlled Substances order being updated in this transaction. This field is a pointer to the CS ORDER STATUS file (#58.82).

Pointer
PointerTo:
fileName:
CS ORDER STATUS
fileNumber:
58.82
COMPLETION STATUS 11 The completion status for this Controlled Substances order being updated by this transaction. This field is a pointer to the CS COMPLETION STATUS file (#58.83).

Pointer
PointerTo:
fileName:
CS COMPLETION STATUS
fileNumber:
58.83
MANUFACTURER 12 The current manufacturer of this drug.

Free Text
LOT # 13 The current lot # of this drug.

Free Text
EXPIRATION DATE 14 The current expiration date for this drug.

Date/Time
REASON 15 Reason for creating this transaction.

Free Text
PHARMACY DISPENSING # 16 The pharmacy control number to identify and track this Controlled Substances transaction. This number may be manually entered in pharmacy or auto-generated by the CS software.

Free Text
NAOU 17 The NAOU ordering this Controlled Substances drug.

Pointer
PointerTo:
fileName:
DRUG ACCOUNTABILITY STATS
fileNumber:
58.8
DISPENSED BY 18 A pointer to the name of the pharmacist dispensing this drug.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROCESSED DATE/TIME 19 The date/time this transaction was processed. For Controlled Substances dispensing transactions, this is the date/time a pharmacy technician processed this transaction.

Date/Time
ORDER RECEIVED BY 20 A pointer to the name of the person receiving this Controlled Substances drug into the ordering Narcotic Area of Use.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RECEIPT DATE/TIME 21 The date/time this drug was received into the ordering Narcotic Area of Use.

Date/Time
COMPLETION DATE/TIME 22 The date/time this Controlled Substances Green Sheet (VA FORM 10-2638) was reviewed as complete by pharmacy.

Date/Time
FILLED BY 23 A pointer to the name of the pharmacy technician processing this Controlled Substances transaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REQUEST DATE/TIME 24 The date/time the Controlled Substances order request was generated.

Date/Time
ORDERED BY 25 A pointer to the name of the person requesting this Controlled Substances drug.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDERED BY PHARMACY 25.5 A pointer to the name of the pharmacy employee requesting the Controlled Substances order for nursing.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENTS 26 Comments concerning this transaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This field contains the comments for this transaction.

Word Processing
QUANTITY RECEIVED 27 The actual quantity of the drug received by the ordering NAOU.

Numeric
DISCREPANCY UNRESOLVED 28 If the actual quantity of the drug received is different from the actual quantity pharmacy dispensed, then this field is set to "1" or "YES".

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COMPLETED BY NURSE 29 A pointer to the name of the nurse returning the Green Sheet (VA FORM 10-2638) to pharmacy.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMP BY NURSE DATE/TIME 29.5 The date/time this Green Sheet was completed by nursing and ready for pharmacy pickup.

Date/Time
D/T PLACED ON INSP HOLD 29.6 The date/time this Green Sheet was placed on hold for review by the Controlled Substances Inspector.

Date/Time
D/T INSP HOLD REMOVED 29.7 The date/time this Green Sheet was removed from hold by the Controlled Substances inspector.

Date/Time
HOLD REMARKS 29.8 This field contains information concerning the Green Sheet being held for CS inspector's review.

Free Text
RECEIVED BY TECH 30 A pointer to the name of the pharmacy technician receiving this Controlled Substances drug into the NAOU.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PICK UP DATE/TIME 31 The date/time pharmacy picked up the Green Sheet (VA FORM 10-2638) from the NAOU.

Date/Time
PICKED UP BY 32 A pointer to the name of the pharmacy technician picking up the Green Sheet (VA FORM 10-2638) from the NAOU.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMPLETED BY PHARMACIST 33 A pointer to the name of the pharmacist or pharmacy technician completing the Green Sheet (VA FORM 10-2638).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME RET TO STOCK 34 The date/time this drug is being returned to stock.

Date/Time
QUANTITY RET TO STOCK 35 The actual quantity of this drug being returned to stock.

Numeric
REASON RETURNED TO STOCK 36 The reason this drug is being returned to stock.

Free Text
DATE/TIME TURN IN DESTROY 37 The date/time this drug is being turned in for destruction.

Date/Time
QUANTITY TURN IN FOR DESTROY 38 The actual quantity of this drug being turned in for destruction.

Numeric
REASON TURN IN FOR DESTROY 39 The reason this drug is being turned in for destruction.

Free Text
REQUEST # 40 The order request number from the ordering NAOU.

Numeric
BALANCE FWD RET/STK 41 The inventory balance forward for this drug being returned to stock. This balance is used in listing pharmacy's "Daily Activity Log".

Numeric
DEST HOLDING # 47 A pointer to the destruction number for this drug being held for destruction.

Pointer
PointerTo:
fileName:
CS DESTRUCTION
fileNumber:
58.86
EDIT VERIFIED ORDER DATE/TIME 48 The date/time this verified order is being edited.

Date/Time
PHARMACIST EDITING 49 A pointer to name of the pharmacist editing this verified order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
NEW QUANTITY 50 The actual quantity of this drug being dispensed, if quantity is being edited.

Numeric
ADJUSTED BY QUANTITY 51 The difference in the original quantity dispensed and the edited quantity dispensed. The inventory balance will be adjusted by this amount. This quantity may be a negative number.

Numeric
EDIT MFG/LOT/EXP.DATE 52 This field is set to "1" or "YES" if the manufacturer, lot #, or expiration date is being edited on this verified order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Y
  • Code : 0
    Stands For: N
REASON EDITED 53 The reason this verified order is being edited.

Free Text
BAL FWD EDIT VERIFIED ORDER 54 The inventory balance forward for this drug at the time this verified order is being edited. This balance is used in listing pharmacy's "Daily Activity Log".

Numeric
CANCEL VERIFIED ORD DATE/TIME 55 The date/time this verified order is being cancelled.

Date/Time
PHARMACIST CANCELLING 56 A pointer to the name of the pharmacist cancelling this verified order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ADJUSTMENT QUANTITY 57 The actual quantity of the drug for this cancelled order. The drug inventory balance will be increased by this adjustment quantity.

Numeric
REASON CANCELLED 58 The reason this verified order is being cancelled.

Free Text
BAL FWD CANCEL VERIFIED ORD 59 The inventory balance forward for this drug at the time this verified order is being cancelled. This balance is used in listing pharmacy's "Daily Activity Log".

Numeric
RX # 60 A pointer to the outpatient prescription number.

Pointer
PointerTo:
fileName:
PRESCRIPTION
fileNumber:
52
REFILL # 61 If this prescription is a refill, this field will contain the refill number.

Numeric
PRESCRIPTION DATE 62 The fill date for this prescription.

Date/Time
PARTIAL # 63 If this prescription is a partial, this field contains the partial number.

Numeric
OUTPATIENT RX # 63.5 This is the external form of the Outpatient prescription number.

Free Text
RELEASING PHARMACIST 63.6 This field is used to store the pharmacist responsible for the release of an Outpatient prescription in case it is a different person than the transactor.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TRANSFER FROM NAOU DATE/TIME 64 The date/time the Controlled Substances drug was transferred from this NAOU to another NAOU.

Date/Time
TRANSFER FROM NAOU NURSE 65 A pointer to the name of the nurse or pharmacist transferring the Controlled Substances drug from this NAOU to another NAOU.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TRANSFER TO NAOU 66 The NAOU receiving this Controlled Substances drug from another NAOU.

Pointer
PointerTo:
fileName:
DRUG ACCOUNTABILITY STATS
fileNumber:
58.8
TRANSFER TO NAOU DATE/TIME 67 The date/time the Controlled Substances drug was transferred to this NAOU from another NAOU.

Date/Time
TRANSFER TO NAOU NURSE 68 A pointer to the name of the nurse receiving this transferred Controlled Substances drug from another NAOU.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS TRANSACTION # 69 The transaction number of the transferred from NAOU Controlled Substances drug. This is the previous transaction number for this drug.

Pointer
PointerTo:
fileName:
DRUG ACCOUNTABILITY TRANSACTION
fileNumber:
58.81
QUANTITY TRANSFERRED 70 The quantity of this Controlled Substances drug being transferred from an NAOU to another NAOU.

Numeric
PRIME VENDOR INVOICE 71 To allow the entering of a Prime Vendor Invoice number for a receipt. The Integrated Funds Distribution, Control Point Activity, Accounting and Procurement (IFCAP) Purchase Order number may be used all month and there may not be a corresponding IFCAP transaction number for each Prime Vendor receipt.

Free Text
REFERRED REASON 72 When a completed Green Sheet has been referred to a pharmacy supervisor for review, this field may contain comments about the reason.

Free Text
PATIENT 73 This field contains a pointer to the name of the patient receiving this Controlled Substances medication.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
FROM PATIENT ID LIST? 73.5 This field will be "YES" when the patient ID was picked up from the patient ID list.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
NURSE ID 74 This field contains a pointer to the name of the nurse dispensing this Controlled Substances medication.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORIGINAL COUNT 75 This field contains the original count or balance of this drug when loaded into the TRAKKER for medication dispensing on the NAOU.

Numeric
WASTED QUANTITY 76 This field contains the quantity of this Controlled Substances drug that was wasted during dispensing at the NAOU.

Numeric
LIQUID AMOUNT 77 This field contains the liquid quantity of the drug dispensed at the NAOU.

Numeric
SECOND NURSE ID 78 This field contains a pointer to the name of the nurse witnessing this Controlled Substances transaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CORRECT COUNT 79 This field contains the correct count or balance for a Controlled Substances drug on an NAOU.

Numeric
PHARMACIST ID 80 This field contains a pointer to name of the pharmacist inventorying this Controlled Substances drug.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SECOND PHARMACIST ID 81 This field contains a pointer to the name of the pharmacist witnessing this Controlled Substances transaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ACTUAL DATE/TIME 82 This field contains the actual date/time this transaction was performed using the barcode TRAKKER.

Date/Time
CS INSPECTOR 83 This option contains a pointer to the name of the Controlled Substances inspector inventorying this CS drug.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SECOND CS INSPECTOR 84 This field contains a pointer to the name of the Controlled Substances inspector witnessing the inventory of this CS drug.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EMERGENCY 85 A "YES" entry in this field will cause an order to print on the pharmacy emergency order printer and allow for expedited processing.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
CS TRANSACTION 100 This field will be set to "1" or "YES" if this is a Controlled Substances package transaction. This CS flag will be used when purging data within this file.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PRINTED 2320 101 This field is set to "1" or "YES" when this transaction is printed on pharmacy's VA FORM 10-2320 for this drug.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PRINTED 2321 102 This field is set to "1" or "YES" when this transaction is printed on the dispensing/receiving report (in lieu of VA FORM 10-2321). This flag is used in printing this transaction only once on the dispensing/receiving report. A reprint option is provided in the Controlled Substances module for additional copies to be printed.

Date/Time
PRINTED 2638 103 This field is set to "1" or "YES" when a Green Sheet (VA FORM 10- 2638) is printed for this Controlled Substances order. This flag is used in printing this transaction only once. A reprint option is provided in the Controlled Substances module for additional copies to be printed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PRINTED LABEL 104 This field is set to the date/time when the label for this transaction is printed. This flag is used in printing labels only once for this transaction. A reprint label option is provided in the Controlled Substances module for additional labels to be printed.

Date/Time
SPECIALTY 105 For CDR reporting the specialty for the patient is stored at the time each dose is dispensed.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
PRIME VENDOR ORDER NUMBER 106 The PRIME VENDOR ORDER NUMBER field contains the order number on which the drugs were purchased if the drug is not marked as a controlled substance.

Free Text

PBM PATIENT DEMOGRAPHICS

File Number: 59.9

File Description:

This file captures the date, time, and PATIENT DFN when any change occurs in the PATIENT file (#2) on any field captured in the PBM Patient Demographics Extract. Data in this file will be purged monthly for data older than 75 days.


Fields:

Name Number Description Data Type Field Specific Data
EVENT DATE/TIME .01 This field records the date and time when any change occurs in the PATIENT file (#2) on any field captured in the PBM Patient Demographics Extract. These changes are captured by the DG Field Monitor. The data in this field is purged monthly for all data older than 75 days.

Date/Time
PATIENT .02 This field records the PATIENT DFN when any change occurs in the PATIENT file (#2) on any field captured in the PBM Patient Demographics Extract. When the monthly patient demographic extract runs, it will harvest data from the PATIENT file (#2) for the DFNs stored in this field and all data older than 75 days will be purged from this file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2

REFERRAL PATIENT

File Number: 67

File Description:

Referral patients who do not have an SSN or Pseudo-SSN may be added to this file. If the patient HAS an SSN or Pseudo-SSN, they should be in the Patient file! ONLY BILLABLE PATIENTS SHOULD BE ENTERED INTO THIS FILE !


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 Name of patient.

Free Text
SEX .02 Sex of patient.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MALE
  • Code : F
    Stands For: FEMALE
DOB .03 Date of birth of patient.

Date/Time
AGE .033 Computed field.

Computed
MARITAL STATUS .05 This field contains the marital status of the referral patient.

Pointer
PointerTo:
fileName:
MARITAL STATUS
fileNumber:
11
RACE .06

Pointer
PointerTo:
fileName:
RACE
fileNumber:
10
RELIGION .08 This field contains the religious preference of the referral patient.

Pointer
PointerTo:
fileName:
RELIGION
fileNumber:
13
IDENTIFIER .09 Short description of referral.

Free Text
REFERRAL SOURCE .1 Where specimen came from- (ex. Hospital, Physician's office)

Free Text
PROVIDER .104

Free Text
STREET ADDRESS .111 Street part of address of patient.

Free Text
STREET ADDRESS 2 .112 Secondary street address.

Free Text
STREET ADDRESS 3 .113 Tertiary street address.

Free Text
CITY .114 City part of address of patient.

Free Text
STATE .115 State part of address of patient.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP CODE .116 Zip code part of address of patient.

Free Text
PHONE .131 Home phone number of patient.

Free Text
OFFICE PHONE .132 Office (work) phone number of patient.

Free Text
PHONE #3 .133 Other phone number.

Free Text
PHONE #4 .134 Other phone number.

Free Text
DATE OF DEATH .351 Date of death of patient.

Date/Time
PATIENT FILE REF 2 This field contains the pointer to ^DPT( and is used to obtain patient's demographics. LEDI accessioning attempts to find a match in the Patient file (#2) using the PID (Socical Security Number). If a match is found, the patient's demographic information is copied into the REFERRAL PATIENT file fields, NAME, SSN, Date of Birth and sex. The pointer entry stored in this field is used in future lookup for data validation.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
NHE FILE REF 2.2 This field contains the pointer to the VAMC NETWORK PATIENT (#537010) file used to obtain patient's demographics. LEDI accessioning software attempts to find a match in the 537010 file using the PID (SSN). If a match is found, the patient's demographic information is copied into the REFERRAL PATIENT fields NAME,SSN and Date of Birth. The pointer entry stored in this field is used in future lookups to data validation.

Pointer
PointerTo:
fileName:
VAMC NETWORK PATIENT
fileNumber:
537010
Patient Name 3 This field controls the sequence used to lookup of patient's demographic information already stored in either ^DPT( or the ^LRT(67 files. This field is used by LEDI patient accessioning software.

Variable Pointer
LABORATORY REFERENCE 63 Patient's record number in the lab data file.

Pointer
PointerTo:
fileName:
LAB DATA
fileNumber:
63

LAB SECTION PRINT

File Number: 69.2

File Description:

This file used to hold print headers for anatomic path reports and as a temporary holding file for path cumulative, incomplete and complete reports. It may also be used for any accession area file since the NAME (.01) field is a pointer to the accession area file (68).


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 The name of the Lab section print pointed to the Accession file.

Pointer
PointerTo:
fileName:
ACCESSION
fileNumber:
68
ABBREVIATION .02 Abbreviation to the name of the Lab section print

Free Text
REPORT HEADER 1 .03 First header in path report after Post operative Diagnosis. The routine used is LRSPRPT (CY/EM/SP patient report).

Free Text
REPORT HEADER 2 .04 Second header in path report after Post operative Diagnosis. The routine used is LRSPRPT (CY/EM/SP patient report).

Free Text
PRINT SNOMED/ICD CODES .05 If lower case is to be printed for SNOMED and ICD9CM codes enter 1 or LOWER CASE.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: LOWER CASE
  • Code : 0
    Stands For: UPPER CASE
GROSS DESCRIPTION SPACING .06 If double spacing, gross descriptions for anatomic path microscopic examinations will be double spaced, otherwise single spacing will be used.

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DOUBLE
  • Code : S
    Stands For: SINGLE
LINES IN A LABEL .07 The number of lines from the top of one label to the top of the next label. This is used as the default value when printing various labels.

Numeric
ACCESSION PREFIX .08 If accession prefix is entered the path report will have the accession number printed as follows: PREFIX yr accession# Ex. If S entered for the prefix, accession # is 123 and year 87 the path report will print the accession as S87 123 If you want a space after S enter a space after the 'S'. To eliminate the prefix and date delete the entry. (ex. S//@ ).

Free Text
PRINT SF-515 LINES .09 YES- Prints all dashed lines in the SF-515 form NO- Does not print all lines

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
ASK TC CODES .1 Allows coding cases for tissue committee

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: yes
  • Code : 0
    Stands For: no
ROUTINE PROCEDURE 1 .11 Number of times procedure is routinely performed. For EM the number of thick sections made per block.

Numeric
ROUTINE PROCEDURE 2 .12 Number of times routine procedure is performed. For EM the number of grids routinely made per block.

Numeric
REPORT HEADER 3 .13 Third header in path report after Post operative Diagnosis. The routine used is LRSPRPT CY/EM/SP patient report). For surgical pathology this header will be the frozen section report.

Free Text
REPORT HEADER 4 .14 Fourth header in path report after post op dx. The routine used is LRSPRPT. For surgical pathology this header will be the diagnosis field.

Free Text
NEW PG FOR SUPPLEMENTARY RPT .21 If a page feed is wanted before printing the supplementary report a 'YES' is entered.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: yes
  • Code : 0
    Stands For: no
SLIDE LABEL .3 Enter the name of the type of preparation or technique used for specimens.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SLIDE LABEL .01

Free Text
PRINT NAME .02 Enter the actual text you want printed on the slide label.

Free Text
INCOMPLETE REPORTS QUEUE 1 Here are stored the temporary list of specimens logged-in for printing at time of microscopic exam. The report will contain all past specimens with their SNOMED coding in free text form for Surg path, cytopath, and EM. If there are gross descriptions they will be part of the print-out.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LRDFN .01

Numeric
INVERSE DATE 1

Numeric
ACCESSION DATE 2 When specimen was accessioned. Stored in external date format. Usually only the year will be present.

Free Text
COMPLETED REPORTS QUEUE 2 This is a temporary list of final path reports to be printed on demand. Entries automatically are entered when the microscopic diagnoses or supplementary are entered for Surg path, Cytopath or Electron microscopy.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LRDFN .01 This is a temporary list of final path reports to be printed on demand. Entries automatically are entered when the microscopic diagnoses or supplementary are entered for Surg path, Cytopath or Electron microscopy.

Numeric
INVERSE DATE 1

Numeric
ACCESSION DATE 2 When specimen accessioned. Stored in external date format. Usually only the year will be stored.

Free Text
INTERIM REPORT NUMBER 3 This field contains the numeric sequence of this particular interim report.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERIM REPORT NUMBER .01

Numeric
LOCATION 1

Free Text
REPORTS ON DEMAND 4 Name of the report on demand from the Lab Data file

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REPORTS ON DEMAND .01 Pointer to LAB DATA file (#63).

Pointer
PointerTo:
fileName:
LAB DATA
fileNumber:
63
NAME .02

Free Text
SEX .03

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MALE
  • Code : F
    Stands For: FEMALE
DOB .04 Date of Birth.

Date/Time
ID .1 Usually the SSN of the patient.

Free Text
ENTRY NUMBER 5 Entry number to appropriate file

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTRY NUMBER .01

Numeric
PARENT FILE .02

Numeric
NAME .03 Name of the patient.

Free Text
GENERIC LIST 6 Generic label name

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GENERIC LABEL .01 The name of the generic label.

Free Text
ITEM 2 .02 First line of the label.

Free Text
ITEM 3 .03 The second line of the label.

Free Text
ITEM 4 .04 Third line of the label.

Free Text
ITEM 5 .05 The forth line of the label.

Free Text
USER REQUEST LIST 7 Names of users from file 200

Subfile
subfile:
Name Number Description Data Type Field Specific Data
USER .01 Points to the NEW PERSON file (#200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST DATE USED .02 The last date this was printed.

Date/Time
LRDFN 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LRDFN .01 Internal file number in the LAB DATA file (#63).

Pointer
PointerTo:
fileName:
LAB DATA
fileNumber:
63
PATIENT NAME .02 Patient's name.

Free Text
SEX .03

Set of Codes
Set of Codes:
  • Code : F
    Stands For: FEMALE
  • Code : M
    Stands For: MALE
DOB .04 Date of birth.

Date/Time
LOCATION .05

Free Text
VA PATIENT NUMBER .06 If patient is entered in file 2 the internal file number (DFN) for file 2 will appear here.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ID .1

Free Text
PATIENT GROUP 1 To print only a specific group of patients enter that group name here.

Free Text
LAB TEST GROUP 60

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LAB TEST GROUP .01 You can have one or more groups. Each group can have up to 7 tests.

Numeric
TEST 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST .01 Up to 7 tests allowed. The number will determine placement of the test on the display or print.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
FILE 8 Files for temporary lists of entries.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FILE .01 List of selected entries in a file.

Numeric
START DATE .02

Free Text
END DATE .03

Free Text
USER .04 Person who created list of entries

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
FILE ENTRY 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FILE ENTRY NAME .01 Enter the name of the entry in the file (.01 field)

Free Text
ENTRY COMMENT .02 Description to identify the specific entry

Free Text
DATE 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE .01

Date/Time
RELATED TEXT .02

Free Text
MORE RELATED TEXT .03

Free Text
DATE ENTRY PRINTED? .04 If entry was printed then 'YES' should be entered. If entry was not printed then it should not be deleted.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COMMENT 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Free Text
LABELS 9 ID number of label

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LABEL ID .01

Free Text
LINE 1 .02

Free Text
LINE 2 .03

Free Text
LINE 3 .04

Free Text
LINE 4 .05

Free Text
SNOMED & TC CODING 10 Text entered here will appear on the preliminary pathology report after the cum path summary.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SNOMED & TC CODING .01 Text entered here will appear on the preliminary pathology report after the cum path summary.

Word Processing
TOPOGRAPHY CATEGORY 11 SNOMED coded topography categories

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TOPOGRAPHY CATEGORY .01 Provides a default list of topography selections for anatomic pathology searches and reports. For example if 28 is a selection then all SNOMED coded topographies beginning with 28 will be selected.

Free Text
COMMENT .02 Enter a comment associated with the topography category entry.

Free Text
MORPHOLOGY ENTRY 12 SNOMED morphology entries

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MORPHOLOGY ENTRY .01 List of SNOMED morphology entries for various reports are kept here. For cytopathology option [LRAPCYPCT] this is a default list for calculating %normal, atypical, suspicious and malignant cases.

Pointer
PointerTo:
fileName:
MORPHOLOGY FIELD
fileNumber:
61.1
TEST LIST NUMBER 60 The list number for a group of selected lab tests.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST LIST NUMBER .01

Numeric
TEST 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST .01

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
SPECIMEN .02

Pointer
PointerTo:
fileName:
TOPOGRAPHY FIELD
fileNumber:
61
VALUE .03

Free Text
TOPOGRAPHY 61 For entries the most recent results of tests selected below will be displayed or printed. Ex. You may want to know the results of selected chemistries for a patient who has just had a liver biopsy. Topography entered would be LIVER For blood bank the tests entered will be displayed whenever a crossmatch is ordered or when components are displayed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TOPOGRAPHY .01 Enter here the specimen or organ/tissue that will be associated with the preselected tests to be displayed or printed.

Pointer
PointerTo:
fileName:
TOPOGRAPHY FIELD
fileNumber:
61
TEST TO DISPLAY 1 Most recent results, if any, will be displayed for tests selected associated with a specific topography indicated above when that organ or tissue is submitted to anatomic pathology.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST TO DISPLAY .01 Most recent results, if any, will be displayed for tests selected associated with a specimen.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
SPECIMEN .02

Pointer
PointerTo:
fileName:
TOPOGRAPHY FIELD
fileNumber:
61
TEST TO PRINT 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST TO PRINT .01

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
SPECIMEN .02

Pointer
PointerTo:
fileName:
TOPOGRAPHY FIELD
fileNumber:
61
DATA CHANGE DATE 999 Date of the Data change

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATA CHANGE DATE .01 Date the data was changed.

Date/Time
PERSON CHANGING DATA .02

Free Text
DATA ELEMENT .03 Name of the test being edited.

Free Text
OLD VALUE .04 Previous test result.

Free Text
NEW VALUE .05 New test result.

Free Text
FILE .06 File where the data is stored.

Free Text
FILE ENTRY .07 The numeric entry of the file.

Free Text
INTERNAL FILE # .08 The internal number where the data is stored.

Free Text
SUBFILE FIELD NAME 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SUBFILE FIELD NAME .01

Free Text
SUBFILE FIELD ENTRY .02

Free Text
SUBFILE FIELD # .03

Free Text

RAD/NUC MED PATIENT

File Number: 70

File Description:

This file contains imaging information for patients. This file is the focal point of the entire radiology/nuclear medicine module. The file has four basic sections. They are the following: I. General Patient demographics II. Patient demographics that are imaging related III. Registered exam information IV. Outside films registry; where films received from other hospitals are recorded into the system Data Storage ------------ The data for the 'RAD/NUC MED PATIENT' file is stored under the ^RADPT global. This file is very volatile and should be journaled and translated if the operating system supports these two functions. Input Templates --------------- The following is a list of input templates used by the package and the entry in the OPTIONS file (#19) that uses the template: Compiled Name Routine Description; Option(s) ---- -------- ---------------------- RA DIAGNOSTIC BY CASE Used to input interpreting physicians and diagnostic code; RA DIAGCN RA OUTSIDE ADD Add outside films into system; RA ADDEXAM RA OUTSIDE EDIT Edit outside film registry; RA OUTEDIT RA OUTSIDE SUPEROK Indicate outside film to require supervisor 'ok' before returning; RA OUTFLAG RA CANCEL Cancel a registered exam; RA CANCEL RA EXAM EDIT Edit a registered exam; RA EDITCN, RA EDITPT RA LAST PAST VISIT Allows entry of the last visit by a patient to the department before this module was installed; RA PAST RA NO PURGE SPEC IFICATION Indicates no purging of an exam report. RA NOPURGE RA OVERRIDE Exam status is made complete without doing a requirements check; RA OVERRIDE RA REGISTER ^RACTRG* Initial registered exam entry; RA REG RA STATUS CHANGE Status Tracking input; RA STATRACK If any modifications to these input templates are needed for local purposes, then great care should be taken not to degrade any branching logic in the template. Making modifications is not recommended. The following templates contain a large amount of branching and MUMPS code and as a result they are uneditable: - RA REGISTER - RA STATUS CHANGE - RA EXAM EDIT Print Templates --------------- The following is a list of print templates used by the package: Name Description; Option(s) ---- ---------------------- RA DAILY LOG Prints an informational report for all exams for a specified date. RA LOG RA OUTSIDE LIST Prints list of outside films needing to be returned by a specified date; RA OUTSIDERPT Sort Templates -------------- The following is a list of sort templates associated with this file: Name Related Print Template ---- ---------------------- RA DAILY LOG RA DAILY LOG RA OUTSIDE LIST RA OUTSIDE LIST Also, the modification of the other sort templates is not recommended.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field gives the name of this Radiology/Nuclear Medicine patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70). ALLOWABLE WAYS TO ENTER PATIENT NAME: ------------------------------------- -Patient's last name (to reduce typing errors, enter only first few letters of last name) -Last 4 digits of patient's Social Security Number -First letter of patient's last name and last 4 digits of patient's Social Security Number.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATE OF BIRTH .03 This field is computed by the system to be the date of birth of this Radiology/Nuclear Medicine patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70).

Computed
AGE .033 This field is computed by the system to the age of this Radiology/Nuclear Medicine patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70).

Computed
USUAL CATEGORY .04 This field contains a default value used during the exam registration process to indicate the category of exam for this Radiology/Nuclear Medicine patient. Available categories are: 'O' for OUTPATIENT, 'C' for CONTRACT, 'S' for SHARING, 'R' for RESEARCH, and 'E' for EMPLOYEE.

Set of Codes
Set of Codes:
  • Code : O
    Stands For: OUTPATIENT
  • Code : C
    Stands For: CONTRACT
  • Code : S
    Stands For: SHARING
  • Code : R
    Stands For: RESEARCH
  • Code : E
    Stands For: EMPLOYEE
USER WHO ENTERED PATIENT .06 This field points to the 'NEW PERSON' file (#200) to indicate the person who entered this patient into the Radiology/Nuclear Medicine system. It is filled in by the system from information the user entered at sign-on.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SSN .09 This field is computed by the system to the social security number of this Radiology/Nuclear Medicine patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70).

Computed
ELIGIBILITY CODE .361 This field is computed by the system to the eligibility code of this Radiology/Nuclear Medicine patient from information obtained from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70).

Computed
NARRATIVE 1 This field may contain a brief note (up to 250 characters) about this Radiology/Nuclear Medicine patient. It may describe the personality or any unusual characteristic to identify this Radiology/Nuclear Medicine patient.

Free Text
REGISTERED EXAMS 2 This is a multiple field containing information about the patient's registered Radiology/Nuclear Medicine exams.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXAM DATE .01 This field contains the date and also the time of this Imaging exam. The system stores the exam dates in reverse chronological order to produce reports efficiently.

Date/Time
TYPE OF IMAGING 2 This field points to the 'IMAGING TYPE' file (#79.2) to indicate the type of imaging used for this exam. It is filled in by the system with the appropriate system name. For example, when in General Radiology, this field is filled in with 'GENERAL RADIOLOGY'. Examples of other imaging types this field may use are Nuclear Medicine, Nuclear Magnetic Resonance, and Ultrasound.

Pointer
PointerTo:
fileName:
IMAGING TYPE
fileNumber:
79.2
HOSPITAL DIVISION 3 This field points to the 'RAD/NUC MED DIVISION' file (#79) to indicate the name of the hospital division where this imaging exam was performed. Normally, a hospital has only one division however, some medical centers have multiple divisions. This field allows the system to compile statistics by division. This field is filled in by the system from the information the user enters at sign-on.

Pointer
PointerTo:
fileName:
RAD/NUC MED DIVISION
fileNumber:
79
IMAGING LOCATION 4 This field points to the 'IMAGING LOCATIONS' file (#79.1) to indicate the name of the imaging location within the hospital division where the exam was performed. Normally, a hospital has only one imaging location, however, some medical centers have multiple imaging locations within the division. This field is filled in by the system from information the user enters at sign-on.

Pointer
PointerTo:
fileName:
IMAGING LOCATIONS
fileNumber:
79.1
EXAM SET 5 If all the exams under this date/time are considered part of the same set of exams, this field should be answered YES. Exam sets are created when a parent type procedure is registered. Any non-parent type procedures registered at the same time are also considered part of the exam set.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
EXAMINATIONS 50 This is a multiple field containing information on all imaging examinations performed during this patient visit. All exams (cases) within one exam date must be of the same imaging type.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CASE NUMBER .01 This field contains the computer generated case number of this Imaging exam. The case number is used to quickly track and call up the exam as it is processed through the Rad/Nuc Med system. The case numbers are generated by the system in sequential order. NOTE: Case numbers are not allowed to exceed 99,999.

Numeric
PROCEDURE 2 This field points to the 'RAD/NUC MED PROCEDURES' file (#71) to indicate the Imaging procedure associated with this case number. ALLOWABLE WAYS TO ENTER THE IMAGING PROCEDURE FOR THIS CASE NUMBER: --------------------------------------------------------------------- -Name of procedure -CPT Code -Site specific synonym

Pointer
PointerTo:
fileName:
RAD/NUC MED PROCEDURES
fileNumber:
71
EXAM STATUS 3 This field points to the 'EXAMINATION STATUS' file (#72) to indicate the current status of this Imaging exam. The status is determined and updated by the system according to the information entered during the various data entry processes.

Pointer
PointerTo:
fileName:
EXAMINATION STATUS
fileNumber:
72
REASON FOR CANCELLATION 3.5 This is the reason this exam was cancelled.

Pointer
PointerTo:
fileName:
RAD/NUC MED REASON
fileNumber:
75.2
CATEGORY OF EXAM 4 This field contains the exam category associated with this case number. It is used to compile workload statistics and various management reports (i.e. AMIS and RCS14-4). Available exam categories are: 'I' for INPATIENT, 'O' for OUTPATIENT, 'C' for CONTRACT, 'S' for SHARING, 'E' for EMPLOYEE, and 'R' for RESEARCH. When the 'category of exam' is asked during the exam registration process, the default value asked is the value in the 'usual category' field. Of course, if the patient is an inpatient, the default value will always be 'inpatient'. An inpatient may have a 'category of exam' of 'contract', 'sharing', or 'research' for its associated case number if the exam procedure is not directly related with their hospital stay. (i.e. An inpatient who has an imaging exam performed for research purposes.)

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INPATIENT
  • Code : O
    Stands For: OUTPATIENT
  • Code : C
    Stands For: CONTRACT
  • Code : S
    Stands For: SHARING
  • Code : E
    Stands For: EMPLOYEE
  • Code : R
    Stands For: RESEARCH
WARD 6 This field points to the 'WARD LOCATION' file (#42) to indicate the name of the hospital ward where the inpatient was admitted at the time the Radiology/Nuclear Med exam was performed. This field is filled in by the system from information entered by the ADT system and is updated at the time the exam report is first printed.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
SERVICE 7 This field is used for Rad/Nuc Med patients who are inpatients. It points to the 'HOSPITAL SERVICE' file (#49) to indicate the name of the service treating the patient and is filled in by the system from information entered by the ADT system.

Pointer
PointerTo:
fileName:
SERVICE/SECTION
fileNumber:
49
PRINCIPAL CLINIC 8 This field is used for exams with a 'category of exam' of 'outpatient' or 'employee'. It points to the 'HOSPITAL LOCATION' file (#44) to indicate the name of the principle clinic that referred the patient to Radiology/Nuclear Medicine for the exam. If the appropriate Report Distribution Queue is active, the report for this exam will automatically be placed in the queue for this clinic, or in the current ward if the patient is admitted before the report is verified.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
CONTRACT/SHARING SOURCE 9 This field is used for exams with a 'category of exam' of 'contract' or 'sharing'. It points to the 'CONTRACT/SHARING AGREEMENTS' file (#34) to indicate the name of the contract or sharing agreement that referred this patient to Radiology/Nuclear Medicine for the exam.

Pointer
PointerTo:
fileName:
CONTRACT/SHARING AGREEMENTS
fileNumber:
34
RESEARCH SOURCE 9.5 This field is used for exams with a 'category of exam' of 'research'. This field contains the name (3-40 characters) of the research source that referred the patient to Radiology/Nuclear Medicine for the exam.

Free Text
CONTRAST MEDIA USED 10 This field contains a value to indicate if a contrast medium was, or if contrast media were used during this Rad/Nuc Med exam. Available values are: 'Y' for YES and 'N' for NO. If the Rad/Nuc Med procedure does not involve the use of a contrast, the field is automatically filled in with NO by the system but the user is prompted with this question. Conversely, if the Rad/Nuc Med procedure does not involve the use of a contrast, the field is automatically filled in with NO by the system but the user is prompted with this question.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
IMAGING ORDER 11 This field points to the 'RAD/NUC MED ORDERS' File (#75.1). It contains the order associated with this exam. This field will only contain data if the exam has an 'ACTIVE' order associated with it. When orders are purged, the pointer in this field is also purged.

Pointer
PointerTo:
fileName:
RAD/NUC MED ORDERS
fileNumber:
75.1
PRIMARY INTERPRETING RESIDENT 12 This field points to the 'NEW PERSON' file (#200) to indicate the name of the primary interpreting resident who read the films of this exam. If interpreting staff is required to review this resident's results, then the 'primary interpreting staff' field must also be filled in. Primary Interpreting Resident must be classified as an interpreting resident, and must have access to at least one imaging location that matches the imaging type of the exam. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRIMARY DIAGNOSTIC CODE 13 This field is used at sites that decide to enter diagnostic codes for exams, as designated in the Examination Status file parameters. It points to a short diagnostic code in the 'DIAGNOSTIC CODES' file (#78.3) to indicate the primary diagnostic code associated with this exam. If filled in, this field can be used in the search criteria for database searches. For example, the database can be searched for all 'normal' chest procedures performed during a specific time period. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete.

Pointer
PointerTo:
fileName:
DIAGNOSTIC CODES
fileNumber:
78.3
SECONDARY DIAGNOSTIC CODE 13.1 This field contains additional Diagnostic Codes for this Rad/Nuc Med exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SECONDARY DIAGNOSTIC CODE .01 This field is used at sites that decide that diagnostic codes will be asked or required for exams, as designated by the parameters on the Examination Status file. If the primary diagnostic code is entered, the system will also prompt for secondary diagnostic codes. It points to a short diagnostic code in the 'DIAGNOSTIC CODES' file (#78.3) to indicate additional diagnostic codes associated with this exam.

Pointer
PointerTo:
fileName:
DIAGNOSTIC CODES
fileNumber:
78.3
SECONDARY DX PRINT DATE 1 If the secondary diagnostic code associated with this exam requires immediate notification of the physician, this field is filled in with the date that this exam appeared on the 'Abnormal Exam Report'. The report prints a warning indicating abnormal results of the Rad/Nuc Med exam. The report is used by Radiology/Nuclear Medicine to help make sure that the physician is notified of the results of the abnormal exam. The date is filled in on this field when this report is printed so the next time the report is printed this exam will not appear again. This field is filled in by the system and is not seen by the user.

Date/Time
REQUESTING PHYSICIAN 14 This field points to the 'NEW PERSON' file (#200) to indicate the name of the person who requested this Rad/Nuc Med exam. This person is not always a physician. (i.e. A nurse might request the exam.)

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRIMARY INTERPRETING STAFF 15 This field points to the 'NEW PERSON' file (#200) to indicate the name of the primary staff who interpreted the images. Primary Staff must have Rad/Nuc Med personnel classification of 'staff', and must have access to at least one imaging location of the same imaging type as the exam. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMPLICATION 16 This field points to the 'COMPLICATION TYPES' file (#78.1) to indicate if this patient experienced any complication during the exam procedure. (i.e. Reaction to Contrast Medium) If a reaction to the contrast medium did occur, then the system triggers the addition of contrast media as an allergen in the Adverse Reaction Tracking (ART) package without leaving the Radiology/Nuclear Medicine option.

Pointer
PointerTo:
fileName:
COMPLICATION TYPES
fileNumber:
78.1
COMPLICATION TEXT 16.5 This field is used to give a brief explanation (4-100 characters) to describe the exam complication. The text entered will appear on the Complications Report, and under the 'Comment' caption in the detailed exam view of the Profile of Rad/Nuc Med Exams.

Free Text
REPORT TEXT 17 This field points to the 'RAD/NUC MED REPORTS' file (#74) to indicate the report text associated with this exam. It is filled in by the system and is not seen by the user.

Pointer
PointerTo:
fileName:
RAD/NUC MED REPORTS
fileNumber:
74
PRIMARY CAMERA/EQUIP/RM 18 This field points to the 'CAMERA/EQUIP/RM' file (#78.6) for the name of the primary camera/equipment/room where the imaging exam was performed. Usually there is only one camera/equipment/room per procedure. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete.

Pointer
PointerTo:
fileName:
CAMERA/EQUIP/RM
fileNumber:
78.6
BEDSECTION 19 This field points to the 'SPECIALTY' file (#42.4) to indicate the name of the bedsection of Rad/Nuc Med patients who are inpatients. This field is filled in by the system from information entered by the ADT system.

Pointer
PointerTo:
fileName:
SPECIALTY
fileNumber:
42.4
DIAGNOSTIC PRINT DATE 20 If any diagnostic code associated with this exam requires immediate notification of the physican, this field is filled in with the date that this exam appeared on the 'Abnormal Exam Report'. The report prints a warning indicating abnormal results of the Rad/Nuc Med exam. The report is used by Radiology/Nuclear Medicine to help make sure that the physican is notified of the results of the abnormal exam. The date is filled in on this field when this report is printed so the next time the report is printed this exam will not appear again. This field is filled in by the system and is not seen by the user.

Date/Time
REQUESTED DATE 21 This field contains the date the Rad/Nuc Med exam was requested. Depending on the site's specifications, this field may or may not be asked of the transcriptionist. By default, it is populated automatically, at the time an exam is registered, with the Request date in the Rad/Nuc Med Order file.

Date/Time
REQUESTING LOCATION 22 This field points to the 'HOSPITAL LOCATION' file (#44) to indicate the name of the hospital location that is requesting the exam. By default, it is populated automatically, using data from the Rad/Nuc Med Orders file, at the time an exam is registered.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
CLINIC STOP RECORDED? 23 This field contains a YES when clinic stop information has been entered in the Scheduling Visits file for this exam.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
MEMBER OF SET 25 This field is automatically populated by the system. If this case was registered as a 'descendant' of a 'parent' procedure, the field value is set to '1' if all cases in the set are to have separate reports '2' if all cases in the set are to be combined into one report. All cases belonging to a 'parent' are created from the same order. The system must check all members of the set of descendants to determine the new order status whenever the exam status changes on any member.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Yes,separate reports
  • Code : 2
    Stands For: Yes,combined report
CREDIT METHOD 26 This field indicates the type of credit this location receives for examinations. This field is populated automatically by the system at the time an exam is registered based on the Credit Method entered for the Imaging Location where the exam is registered. If only the interpretation was done at this facility, code 1 should be used. If the exam was performed at this facility, but the interpretation was done elsewhere, code 3 should be used. If both the exam and interpretation were done at this facility, code 0 should be used. If the entire exam was done outside the facility and exam data is being entered for the purposes of record-keeping only, code 2 should be used.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: Regular Credit
  • Code : 1
    Stands For: Interpretation Only
  • Code : 2
    Stands For: No Credit
  • Code : 3
    Stands For: Technical Component Only
VISIT 27 This field links the examination of a patient to a specific visit.

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
DOSAGE TICKET PRINTED? 29 This field indicates if a dosage ticket has been printed for each radiopharmaceutical associated with this examination. Once this process has completed for a particular exam status, all further status updates will not print dosage tickets. If an examination is cancelled, the dosage ticket field is cleared. Only if the exam is re-registered will the dosage ticket again print for the examination.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Yes
HL7 EXAMINED MSG SENT? 30

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: Yes
SITE ACCESSION NUMBER 31 The SITE ACCESSION NUMBER is generated by the VistA Radiology/Nuclear Medicine application. SITE ACCESSION NUMBER is a Free Text data type between 12-16 characters in length. It is created by appending a three-character site identifier to the accession number. This field allows other applications to "look up" an exam record based on a site specific accession number. Example: site id-mmddyy-case # In the example the dash "-" is the delimiter.

Free Text
PREGNANCY SCREEN 32 This field tracks the answer given by the patient when asked if she is pregnant at the time of the exam.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: Patient answered yes
  • Code : n
    Stands For: Patient answered no
  • Code : u
    Stands For: Patient is unable to answer or is unsure
PURGED DATE 40 This field contains the last purge date associated with this exam.

Date/Time
PREVENT PURGE 45 If this field is set to 'NO PURGE' then the data for this exam will not be purged or archived, nor will the report associated with this exam be purged or archived.

Set of Codes
Set of Codes:
  • Code : n
    Stands For: NO PURGE
  • Code : o
    Stands For: OK TO PURGE
REASON FOR NOT PURGING 46 This field indicates why the examination should not be purged.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASON FOR NOT PURGING .01 This field indicates why the examination should not be purged.

Set of Codes
Set of Codes:
  • Code : a
    Stands For: Agent Orange Exposure
  • Code : c
    Stands For: Cancer/Tumor Registry
  • Code : e
    Stands For: Employee
  • Code : m
    Stands For: Mammography
  • Code : p
    Stands For: Persian Gulf War
  • Code : r
    Stands For: Radiation Exposure
  • Code : t
    Stands For: Teaching
FILM SIZE 50 This is a multiple field containing the sizes of the films used and films wasted during this exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FILM SIZE .01 This field points to the 'FILM SIZES' file (#78.4) to indicate the size of the film used during the Rad/Nuc Med exam. Users may also enter film sizes that have been wasted during the exam.

Pointer
PointerTo:
fileName:
FILM SIZES
fileNumber:
78.4
AMOUNT(#films or cine ft) 2 This field contains the amount of film (a number between 0 and 999) used or wasted during the Rad/Nuc Med exam. The amount represents either the number of that film size or the number of cine feet of that film size. On the 'Film Usage Report', these two amounts are distinguished from each other.

Numeric
SECONDARY INTERPRETING STAFF 60 This multiple tracks additional Staff who have interpreted the images of an exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SECONDARY INTERPRETING STAFF .01 This field points to the 'NEW PERSON' file (#200) to indicate the names of other interpreting Staff in addition to the Primary Interpreting Staff who interpreted images of this exam. Secondary Interpreting Staff must be classified as 'staff' and must have access to at least one imaging location with an imaging type matching that of the exam.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SECONDARY INTERPRET'G RESIDENT 70 This multiple tracks additional Interpreting Residents who interpreted the images of an exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SECONDARY INTERPRET'G RESIDENT .01 This field points to the "NEW PERSON" file (#200) to indicate the names of other Residents in addition to the Primary Interpreting Resident who interpreted the images of this exam. Secondary Interpreting Residents cannot be the same as the Primary Interpreting Resident, must have resident classification, and must have access to at least one imaging location with an imaging type matching that of the exam.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EXAM STATUS TIMES 75 This is a multiple field containing a log of when the exam status was changed from one status to another. Depending on how the system parameters are set up, this field may or may not be filled in. Because the mass override process will degrade system performance by slowing the system down, it should be run at specified times only. (i.e. one week per quarter)

Subfile
subfile:
Name Number Description Data Type Field Specific Data
STATUS CHANGE DATE/TIME .01 This field contains the date and the time that the exam status was changed. Depending on how the system parameters are set up on site, this field may or may not be filled in. If the system parameter is set up to have this field filled in, then the system allows the user to have the option of filling in this field or having the field filled in by the system.

Date/Time
NEW STATUS 2 This field points to the 'EXAMINATION STATUS' file (#72) to indicate the new exam status.

Pointer
PointerTo:
fileName:
EXAMINATION STATUS
fileNumber:
72
COMPUTER USER 3 This field points to the 'NEW PERSON file (#200) to indicate the person doing the processing at the time the exam status was changed. This field is filled in by the system and is not seen by the user.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREGNANCY SCREEN COMMENT 80 This field allows comments to be collected by the individual administering the exam regarding the patient's answer to the Pregnancy Screen question.

Free Text
STUDY INSTANCE UID 81 This field will store the Study Instance UID. The Study Instance UID is a unique key that associates the images to a particular study, and thus is required in messages sent to the PACS. An Imaging API will be used to generate the Study Instance UID and the Study Instance UID will be sent in specific v2.4 HL7 event messages (when an order is registered, an exam cancelled, or when an exam reaches the Examined status). This will allow Vista Radiology to send event transactions to a commercial PACS directly, bypassing the Vista DICOM Text Gateway.

Free Text
ACTIVITY LOG 100 This is a multiple field containing a log of actions that have been taken on this exam record during processing of this exam. Use the function that allows you to View Exam by Case No. within the Exam Entry/Edit menu to view this activity log.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOG DATE .01 This field contains the date and time that the action was taken on this exam record. This field is filled in by the system.

Date/Time
TYPE OF ACTION 2 This field contains the type of action that was taken on this exam record during processing of this exam.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: EXAM ENTRY
  • Code : C
    Stands For: EDIT BY CASE NO.
  • Code : P
    Stands For: EDIT BY PATIENT
  • Code : D
    Stands For: DIAGNOSIS ENTRY BY CASE NO.
  • Code : S
    Stands For: EXAM STATUS TRACKING
  • Code : X
    Stands For: CANCELLED
  • Code : O
    Stands For: COMPLETE STATUS OVERRIDE
  • Code : U
    Stands For: UPDATE STATUS
  • Code : N
    Stands For: NO PURGING SPECIFIED
COMPUTER USER 3 This field points to the 'NEW PERSON' file (#200) to indicate the person doing the exam processing at the time the action was taken on this exam record.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TECHNOLOGIST COMMENT 4 This field tracks the comments of the Technologist as the exam is edited. Information, pertinent to the editing of the exam, should be entered here.

Free Text
PROCEDURE MODIFIERS 125 This multiple field is used to give the imaging modifiers that are associated with this exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROCEDURE MODIFIERS .01 This field points to the 'PROCEDURE MODIFIERS' file (#71.2) to give details and further describe this exam. Modifier examples include, 'LEFT', 'RIGHT', 'BILATERAL', 'OPERATING ROOM',and 'PORTABLE' exams.

Pointer
PointerTo:
fileName:
PROCEDURE MODIFIERS
fileNumber:
71.2
CPT MODIFIERS 135

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CPT MODIFIERS .01 This field is screened to accept only those CPT Modifiers that agree with this exam's CPT CODE and EXAM DATE. The screen code calls the CPT package to evaluate the "CPT code" and "CPT Modifier" pair.

Pointer
PointerTo:
fileName:
CPT MODIFIER
fileNumber:
81.3
TECHNOLOGIST 175 This multiple field is used to give the names of technologists who performed this exam. Depending on the site's specifications, this field may or may not be filled in.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TECHNOLOGIST .01 This field points to the 'NEW PERSON' file (#200) to indicate the technologists who performed this exam.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
MEDICATIONS 200

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MED ADMINISTERED .01 If any medications were administered to the patient during this exam, they may be recorded here. If medications are associated with a procedure during system set-up, the system will enter them automatically when the procedure is registered.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
MED DOSE 2 Enter the dose and unit of measure for this pharmaceutical. Example: 2 capsules.

Free Text
DATE/TIME MED ADMINISTERED 3 The date and time this dosage was administered should be recorded here.

Date/Time
PERSON WHO ADMINISTERED MED 4 The name of the radiology/nuclear medicine clinician who administered this medication to the patient should be entered here.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CONTRAST MEDIA 225

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CONTRAST MEDIA .01 This field identifies the contrast agent(s) associated with this Rad/Nuc Med exam.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: Ionic Iodinated
  • Code : N
    Stands For: Non-ionic Iodinated
  • Code : L
    Stands For: Gadolinium
  • Code : C
    Stands For: Cholecystographic
  • Code : G
    Stands For: Gastrografin
  • Code : B
    Stands For: Barium
  • Code : M
    Stands For: unspecified contrast media
CONTRAST MEDIA NAME 21401 This field contains a pointer to the MSC RA CONTRAST MEDIA NAME file which will contain the actual contrast media drug.

Pointer
PointerTo:
fileName:
MSC RA CONTRAST MEDIA NAME
fileNumber:
21434.3
DOSE ADMINISTERED 21402 This field contains the amount of contrast media that was administered in ML.

Numeric
DATE/TIME DOSE ADMINISTERED 21403 This field contains the date and time that the dose was administered.

Date/Time
PERSON WHO ADMINISTERED 21404 This field contains the provider ID that administered the contrast media.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
NEEDLE GAUGE 21405 This field contains the gauge of the needle used to administer the contrast media.

Pointer
PointerTo:
fileName:
MSC RA GAUGE OF NEEDLE
fileNumber:
21434.2
ROUTE OF ADMINISTRATION 21406 This field contains the route of administration used to administer the contrast media.

Pointer
PointerTo:
fileName:
ROUTE OF ADMINISTRATION
fileNumber:
71.6
SITE OF ADMINISTRATION 21407 This field contains the site of administration used when this contrast media was administered.

Pointer
PointerTo:
fileName:
SITE OF ADMINISTRATION
fileNumber:
71.7
SITE OF ADMIN TEXT 21407.1

Free Text
FLOW RATE 21408 This is the Flow Rate of the Contrast Media Drug.

Free Text
CONTRAST MEDIA ACTIVITY LOG 250

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME EDITED .01 This field tracks the date/time the contrast medium or media data was edited for this specific Rad/Nuc Med exam.

Date/Time
PRIOR CONTRAST MEDIA VALUE 2 This field tracks the contrast media of the Rad/Nuc Med exam before the edit occurs.

Free Text
USER WHO EDITED CONTRAST 3 This field tracks the person editing the contrast media data for this Rad/Nuc Med exam.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLINICAL HISTORY FOR EXAM 400 This field may contain a written clinical history of the patient as well as instructions to the interpreting physician . For example, the instructions might be to interpret the images to rule out the possibility of a patient having a certain disease. This field is used as the 'Clinical History' that appears on the printed report for each exam associated with this visit.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLINICAL HISTORY FOR EXAM .01 This field contains the patient's clinical history pertinent to the procedure as well as instructions to the physician interpreting the images for the exam. It should explain why the procedure is being requested; for example, to confirm or rule out a disease.

Word Processing
NUCLEAR MED DATA 500 Radiopharmaceutical data may be automatically entered, if it exists on the procedure file. It is also editable during case edit options and may be configured for editing during status tracking.

Pointer
PointerTo:
fileName:
NUC MED EXAM DATA
fileNumber:
70.2
REASON FOR STUDY 21400 The reason for study is often a short patient history summarizing the condition of the patient and giving background information as to why the study has been initiated.

Free Text
OUTSIDE FILMS REGISTRY 50 This is a multiple field containing information about this patient's films obtained from an outside source.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OUTSIDE FILMS REGISTER DATE .01 This field contains the date this patient's films were received from the outside source and registered.

Date/Time
NEEDED BACK DATE 2 This field contains the requested date that the outside source wants this patient's films back on or the date the films are to be sent back.

Date/Time
RETURNED DATE 3 This field contains the date that this patient's outside films were actually returned to the outside source.

Date/Time
SOURCE OF FILMS 4 This field contains the name (3-80 characters) of the source of this patient's outside films. (ie. General Hospital)

Free Text
ASK FOR 'OK' BEFORE RETURNING? 5 This field contains a value to indicate if these outside films require the approval of the supervisor before returning to their source since some films should be kept on file. Available values are: 'Y' for YES and 'N' for NO. If the value is YES, then a flag is set to designate 'OK' needed before return. The activity log can be used to determine who sent the films back. It can be displayed using the 'Inquire' option of File Manager.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
HAS RETURN BEEN OK'ed? 6 This field is used for outside films which are designated as requiring the supervisor's approval before return to the outside source. It contains a 'Y' for YES or 'N' for NO to indicate if these outside films have been approved for return yet.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
REMARKS 20 This field contains a brief comment (2-240 characters) about the outside films. It is used mainly to identify what type the outside film is. (ie. Chest Films)

Free Text
ACTIVITY LOG 100 This is a multiple field containing a log of actions that have been taken on this outside film record. The activity log can be used to resolve any discrepancies. It can be displayed using the 'Inquire' option of File Manager.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOG DATE .01 This field contains the date and the time that the action was taken on this outside film record.

Date/Time
TYPE OF ACTION 2 This field contains the type of action that was performed on this outside film during processing. Available types include: 'A' for ADD FILMS TO REGISTRY, 'S' for INDICATED FILM NEEDS SUPERVISOR'S OK, and 'E' for EDIT REGISTRY.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADD FILMS TO REGISTRY
  • Code : S
    Stands For: INDICATED FILM NEEDS SUPERVISOR'S OK
  • Code : E
    Stands For: EDIT REGISTRY
COMPUTER USER 3 This field points to the 'NEW PERSON' file (#200) to indicate the person doing the processing at the time the action was performed on this outside film.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
IS PATIENT A VETERAN? 1901 This field is computed by the system and indicates whether this patient is a veteran or not. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in this file (#70).

Computed

RAD/NUC MED REPORTS

File Number: 74

File Description:

This file contains the reports for registered exams. These reports are usually first dictated by the interpreting physician before being entered by the transcriptionist. The Radiology/Nuclear Medicine software includes an HL7 interface to support report entry using voice recognition systems. The data in this file has three basic sections: I. Demographic information about the file - patient, date reported, date entered etc. II. Text Data - clinical history, report and impression III. Computed Fields that obtain data from patient's exam record - technician, procedure etc. The computed fields can be a very efficent way to do File Man prints and searches of exam record data, as opposed to doing prints and searches through the 'RAD/NUC MED PATIENT' file. Data Storage ------------ The data for the 'RAD/NUC MED REPORTS file is stored in the ^RARPT( global. This global is very volatile and should be journaled. It should also be translated if the operating system supports this function. Because of the large amount of disk space the report text will demand of the system, the module has a 'Purge Data' function that will allow the site manager to delete the 'REPORT TEXT' and 'CLINCIAL HISTORY' fields on a periodic basis. It is up to the computer site manager and the imaging coordinator to determine how long this data will remain on-line. The 'IMPRESSION' text will not be purged. In the future, the module will also have an archive function. Input Templates --------------- The following is a list of input templates used by the package and the entry in the OPTIONS file (#19) that uses the template: Compiled Name Routine Description; Option(s) ---- -------- ---------------------- RA REPORT EDIT ^RACTWR* Used to enter/edit reports and associated information into this file; RA RPTENTRY RA VERIFY ^RACTVR* Used to indicate a report has been verified; REPORT ONLY RA BATCHVERIFY, RA RPTVERIFY RA PRE-VERIFY REPORT EDIT Used to edit reports and associated information in this file. Does not allow report verification; RA RESIDENT PRE-VERIFY RA PRE-VERIFY REPORT ONLY Used to pre-verify reports; RA RESIDENT PRE-VERIFY If any modifications to these input templates are needed for local purposes, then great care should be taken not to degrade any branching logic in the template. Print Templates --------------- Compiled Name Routine Description; Option(s) ----- -------- ---------------------- RA REPORT ^RACTRT Prints the status of verified reports only. PRINT STATUS Includes date verified, routing queue, date printed, printed by ward/clinic. RA RPTDISTPRINTSTATUS Sort Templates -------------- The package does not use any sort templates associated with this file.


Fields:

Name Number Description Data Type Field Specific Data
DAY-CASE# .01 This field contains the date and case number of the imaging exam associated with this report. The system fills in this field with information obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist. If the Site Specific Accession Number is in use then the 3-digit Site ID is appended to the beginning of the field.

Free Text
PATIENT NAME 2 This field contains the name of the rad/nuc med patient associated with this report. The system fills in this field with data obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
EXAM DATE/TIME 3 This field contains the date and the time of the exam associated with this report. The system fills in this field with data obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist.

Date/Time
CASE NUMBER 4 This field contains the completed case number of the exam associated with this report. The system fills in the data for this field with information obtained from the 'RAD/NUC MED PATIENT' file (#70).

Numeric
OTHER CASE# 4.5

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER CASE# .01 This field contains the date and case number of any other imaging exams associated with this report. If the Site Specific Accession Number is in use then the 3-digit Site ID is appended to the beginning of this field.

Free Text
REPORT STATUS 5 This field contains a value to indicate the status of this report. Valid choices are: 'V' for Verified, 'R' for Released/Not Verified, 'PD' for Problem Draft, 'D' for Draft, 'EF' for Electronically Filed and 'X' for Deleted. 'V' (Verified) status refers to a report that is verified by the interpreting physician and is available for display outside the Rad/Nuc Med Department to appropriate users, such as ward clerks, nurses, and physicians. 'R' (Released/Not Verified) status refers to a report that is not verified by the interpreting physician and is available for display outside the Rad/Nuc Med Department. The 'R' status is allowed only when the parameter that controls this feature, 'Allow Released/Unverified' of the 'RAD/NUC MED DIVISION' file (#79), is set to 'Yes'. Use the 'Display Report' option to view reports with the 'R' status. 'D' (Draft) status or 'PD' (Problem Draft) status refers to a report that is available only for display in the Rad/Nuc Med Department. A statement describing the problem to the interpreting physician is printed at the end of reports with the 'PD' status. 'EF' (Electronically Filed) status refers to a report that is interpreted outside the Rad/Nuc Med Department. The content is not the actual interpreted report, but canned text referring to the outside interpreted report. 'X' (Deleted) status refers to a report that is deleted from a case, but remains in the database though not selectable from any Radiology options.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VERIFIED
  • Code : R
    Stands For: RELEASED/NOT VERIFIED
  • Code : PD
    Stands For: PROBLEM DRAFT
  • Code : D
    Stands For: DRAFT
  • Code : EF
    Stands For: ELECTRONICALLY FILED
  • Code : X
    Stands For: DELETED
DATE REPORT ENTERED 6 This field contains the date and time that the report was entered into the system by the transcriptionist.

Date/Time
VERIFIED DATE 7 As of July, 1985, this field contains the date and the time that it was indicated to the system that the report was verified by the interpreting physician. An option allowing online verification lets the interpreting physician verify the report directly via a CRT. As a result, there will be no discrepency between the date/time the physician verified the report and the date/time it was indicated to the system.

Date/Time
REPORTED DATE 8 This field contains the date that the interpreting physician dictated this report. The transcriptionist enters this date from the dictation tape. If the physician is using a voice recognition system for dictation, this date is entered at the time the report is transmitted to DHCP.

Date/Time
VERIFYING PHYSICIAN 9 This field is a pointer to the 'NEW PERSON file (#200). Only 'staff' or 'resident' interpreting physicians are allowed to be selected. This field contains the name of the interpreting physician who verified the report.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TELERADIOLOGY PHYSICIAN NAME 9.1 This field identifies the name of the teleradiologist who verified (signed) the report.

Free Text
TELERADIOLOGY PHYSICIAN NPI 9.2 This field identified the National Provider ID (NPI) of the teleradiologist who verified (signed) the report.

Free Text
REPORT VERIFIED BY COTS APP 9.3 This field identifies the Commercial Off the Shelf (COTS) application used to dictate and verify a radiology report. Examples of values for this field, though these need not be the only permissible values, are: RA-PSCRIBE-TCP, RA-SCIMAGE-TCP, and RA-TALKLINK-TCP. If the report was dictated through the use of the VistA Radiology/Nuclear Medicine application the field will be null.

Pointer
PointerTo:
fileName:
HL7 APPLICATION PARAMETER
fileNumber:
771
ELECTRONIC SIGNATURE CODE 10 This field is computed by the system to the electronic signature code of the verifying interpreting physician.

Free Text
TRANSCRIPTIONIST 11 Rad/nuc med personnel who entered the report.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE REPORT PRINTED 13 This is the date this report was first printed. Before a report is printed for the first time the patient location is updated, if necessary, in the 'RAD/NUC MED PATIENT' file (#70) at the Examinations multiple.

Date/Time
PRE-VERIFICATION DATE/TIME 14 This is the date and time a report was pre-verified by an Interpreting Resident or Staff.

Date/Time
PRE-VERIFICATION USER 15 This is the Interpreting Resident or Staff Physician who pre-verified the report.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRE-VERIFICATION E-SIG 16 This is the electronic signature code of the Interpreting Resident or Staff who pre-verified this report.

Free Text
STATUS CHANGED TO VERIFIED BY 17 This field will record the individual who is signed on and responsible for the changing the report status to 'verified'.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE INITIAL OUTSIDE RPT ENTRY 18 The system populates this value when the 'Outside Report Entry/Edit' option is used.

Date/Time
PROBLEM STATEMENT 25 This field may contain a note from the transcriptionist to the interpreting physician if any problems were encountered during the transcribing of this report. This message can be between 2 and 240 characters in length and is used to describe the problem. This field is available for use only if the status of the report is 'PD' (problem draft).

Free Text
PURGED DATE 40 This field contains the date and the time that the 'Purge Data' option of the system was last used to purge the clinical history, report text, and the activity log of this report.

Date/Time
NO PURGE INDICATOR 45 If this field is set to 'NO PURGE', then the report will not be purged or archived. This field is set when the corresponding field of the associated exam is set to 'NO PURGE'.

Set of Codes
Set of Codes:
  • Code : n
    Stands For: NO PURGE
  • Code : o
    Stands For: OK TO PURGE
HOSPITAL DIVISION 53 This field is computed by the system to the name of the hospital division where the exam associated with this exam report was performed.

Computed
IMAGING LOCATION 54 This field is computed by the system to the name of the imaging location within the hospital division where the exam associated with this exam report was performed.

Computed
INTERPRETING IMAGING LOCATION 86 This is the imaging location where the interpretation was performed. It is a pointer to the Imaging Location file (#79.1).

Pointer
PointerTo:
fileName:
IMAGING LOCATIONS
fileNumber:
79.1
ACTIVITY LOG 100 This is a multiple field containing a log of actions that have been taken on this report record.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOG DATE .01 This field contains the date and the time that the action was taken on this report record.

Date/Time
TYPE OF ACTION 2 This field contains the type of action that was taken on this report record. Valid choices are: 'I' for Initial Report Transcription, 'E' for Report Edit, 'V' for Verified, 'U' for Report Unverified, 'C' for Digitized Images Collected, 'P' for Pre-Verified, 'F' for Electronically Filed, 'X' for Deleted Report, 'R' for Restored Report & 'Q' for Quit.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INITIAL REPORT TRANSCRIPTION
  • Code : E
    Stands For: REPORT EDIT
  • Code : V
    Stands For: VERIFIED
  • Code : U
    Stands For: REPORT UNVERIFIED
  • Code : C
    Stands For: IMAGES COLLECTED
  • Code : P
    Stands For: PRE-VERIFIED
  • Code : F
    Stands For: ELECTRONICALLY FILED
  • Code : X
    Stands For: DELETED REPORT
  • Code : R
    Stands For: RESTORED REPORT
  • Code : Q
    Stands For: QUIT
COMPUTER USER 3 This field points to the 'NEW PERSON' file and is used to record the user who took an action on this report record.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BEFORE DELETION REPORT STATUS 4 The system populates this value when the report is deleted via the Radiology application.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VERIFIED
  • Code : R
    Stands For: RELEASED/NOT VERIFIED
  • Code : PD
    Stands For: PROBLEM DRAFT
  • Code : D
    Stands For: DRAFT
  • Code : EF
    Stands For: ELECTRONICALLY FILED
BEFORE DELETION PRIM. DX CODE 5 When a report is marked for deletion, its associated Primary Diagnostic Code from subfile 70.03 is copied into this field, prior to deletion from file 70.03.

Pointer
PointerTo:
fileName:
DIAGNOSTIC CODES
fileNumber:
78.3
BEFORE DELETION SEC. DX CODE 6

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BEFORE DELETION SEC. DX CODE .01 When a report is marked for deletion, its associated Secondary Diagnostic Codes from subfile 70.14, if any, are copied into this multiple field, prior to deletion from subfile 70.14.

Pointer
PointerTo:
fileName:
DIAGNOSTIC CODES
fileNumber:
78.3
BEFORE DELETION PRIM. STAFF 7 When a report is marked for deletion, its associated Primary Interpreting Staff from subfile 70.03 is copied into this field, prior to deletion from file 70.03.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BEFORE DELETION SEC. STAFF 8

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BEFORE DELETION SEC. STAFF .01 When a report is marked for deletion, its associated Secondary Interpreting Staff from subfile 70.11, if any, are copied into this multiple field, prior to deletion from subfile 70.11.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BEFORE DELETION PRIM. RESIDENT 9 When a report is marked for deletion, its associated Primary Interpreting Resident from subfile 70.03 is copied into this field, prior to deletion from file 70.03.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BEFORE DELETION SEC. RESIDENT 10

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BEFORE DELETION SEC. RESIDENT .01 When a report is marked for deletion, its associated Secondary Interpreting Resident from subfile 70.09, if any, are copied into this multiple field, prior to deletion from subfile 70.09.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROCEDURE 102 This field is filled in by the system with the name of the rad/nuc med procedure associated with this report.

Computed
EXAM STATUS 103 This field is filled in by the system with the exam status of the exam associated with this report.

Computed
CATEGORY OF EXAM 104 This field is computed by the system to the category of the exam associated with this report.

Computed
WARD 106 This field is computed by the system to the name of the hospital ward where the inpatient associated with this exam report resided at the time this report was first printed.

Computed
SERVICE 107 This field is computed by the system to the name of the service treating the inpatient associated with this exam report.

Computed
PRINCIPAL CLINIC 108 This field is computed by the system to the name of the outpatient clinic that referred the patient associated with this exam report to rad/nuc med for the exam.

Computed
CONTRACT/SHARING SOURCE 109 This field is computed by the system to the name of the contract or sharing agreement that referred the patient associated with this exam report to rad/nuc med.

Computed
RESEARCH SOURCE 109.5 This field is computed by the system to the name of the research source that referred the patient associated with this exam report to rad/nuc med.

Computed
PRIMARY INTERPRETING RESIDENT 112 This field is computed by the system to the name of the primary interpreting resident who interprets the images associated with this exam report.

Computed
PRIMARY DIAGNOSTIC CODE 113 This field is computed by the system to the primary diagnostic code associated with this exam report.

Computed
REQUESTING PHYSICIAN 114 This field is computed by the system to the name of the person who requested the exam associated with this report. This person does not have to be a physician. (ie. It might be a nurse.)

Computed
PRIMARY INTERPRETING STAFF 115 This field is computed by the system to the name of the primary interpreting staff who interprets the images associated with this report.

Computed
COMPLICATION 116 This field is computed by the system to the complication that may have occurred during the exam procedure associated with this exam report.

Computed
PRIMARY CAMERA/EQUIP/RM 118 This field is computed by the system to the name of the primary camera/equip/rm where the exam associated with this exam report was performed.

Computed
BEDSECTION 119 This field is computed by the system to the name of the bedsection of the rad/nuc med inpatient associated with this exam report.

Computed
REPORT TEXT 200 This field contains the report text for the imaging exam. The report text is written by the interpreting physician and may be entered into the system by a transcriptionist. A report may also be entered into DHCP when the interpreting physician uses a voice recognition system. If the interpreting physician requests a standard report, the information in this field is copied from the 'Report Text' field of the 'Standard Reports' file.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REPORT TEXT .01 This field contains the report text for the imaging exam. The report text is provided by the interpreting physician and is entered into the system by a transcriptionist. The report resides in the 'report text' field. The report may also be entered directly by the physician if the physician is using a voice recognition system. If the interpreting physician requests a standard report, the information in this field is copied from the 'report text' field of the 'Standard Reports' file.

Word Processing
IMPRESSION TEXT 300 This field contains the 'impression text' of the rad/nuc med exam associated with this report. The 'impression text' gives a quick summary of the 'report text'. It is written by the interpreting physician and is entered into the system by the transcriptionist. The system will allow the interpreting physician to directly enter this information into the 'impression text' field through a voice recognition system. If the interpreting physician requests a standard report, the information in this field is copied from the 'impression text' field of the 'Standard Reports' file.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IMPRESSION TEXT .01 This field contains the 'impression text' of the rad/nuc med exam associated with this report. The 'impression text' provides a summary of the 'report text' and is entered into the system by the transcriptionist . Voice recognition systems allows the interpreting physician to directly enter this information into the 'impression text' field. If the interpreting physician requests a standard report, the information in this field is copied from the 'impression text' field of the 'Standard reports' file.

Word Processing
ADDITIONAL CLINICAL HISTORY 400 This field may contain a patient's clinical history as well as instructions to the interpreting physician. For example, the instructions might be for the physician to interpret the exam images to rule out the possibility of the patient having a certain disease. The 'additional clinical history' is written by the interpreting physician and is entered into the system by the transcriptionist. Voice Recognition systems allow the interpreting physician to directly enter this information into the 'additional clinical history' field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIONAL CLINICAL HISTORY .01 This field may contain a patient's clinical history as well as instructions to the interpreting physician. The additional clinical history is dictated by the interpreting physician as provided from the request and entered into the system by the transcriptionist. An enhancement of the system, now allows the interpreting physician to directly enter this information into the 'additional clinical history' field using a voice recognition system.

Word Processing
ERROR REPORTS 1000 This multiple subfile contains date-stamped reports that were unverified and amended. The previous verified data that existed before the report was amended is stored here. As a security precaution, these fields are released to the site as uneditable.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME OF RPT SAVE .01 This field will track the date/time of changes to unverified Radiology/Nuclear Medicine reports. If a report is unverified, a skeletal structure of the report prior to amendments will be saved under this date/time.

Date/Time
ERRONEOUS REPORT 2 This field contains the version of a radiology/nuclear medicine report prior to amendments. It is saved at the time the report is unverified. Data retained includes any of the following that existed on the record at the time it was unverified: Procedure/modifiers, Clinical History, Impression, Report Text, Primary and Secondary Diagnostic Codes, Verifier name/date/esig, Pre-verifier name/date/esig, Primary and Secondary Staff and Residents. This data is stored in a subfile that supports multiple occurrences of amendments for one report.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ERRONEOUS REPORT .01 This field contains the version of a radiology/nuclear medicine report prior to amendments. It is saved at the time the report is unverified. Data retained includes any of the following that existed on the record at the time it was unverified: Procedure/modifiers, Clinical History, Impression, Report Text, Primary and Secondary Diagnostic Codes, Verifier name/date/esig, Pre-verifier name/date/esig, Primary and Secondary Staff and Residents. This data is stored in a subfile that supports multiple occurrences of amendments for one report.

Word Processing
IMAGE 2005 This multiple field holds pointer values to the Image file (2005).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IMAGE .01 This field holds the pointer value for an image located in the Image file (2005).

Pointer
PointerTo:
fileName:
IMAGE
fileNumber:
2005

RAD/NUC MED ORDERS

File Number: 75.1

File Description:

This file contains all information pertaining to an imaging order entered for a patient. The file structure like that of the Rad/Nuc Med Patient file in future, will allow the storage of nuclear medicine, nuclear magnetic resonance and other types of imaging data. Data Storage ------------ The data for 'RAD/NUC MED ORDERS' file is stored in the ^RAO(75.1,global.. This file is very volatile and should be journaled and translated if the operating system supports these two functions. Input Templates --------------- The following is a list of input templates used by the package and in the OPTIONS file (#19) that uses the template: Name Routine Description: Option(s) ---- -------- ---------------------- RA ORDER EXAM ^RACTOE* Enter an order for a procedure; RA ORDEREXAM RA QUICK EXAM ^RACTQE* Allows quick entry of one or multiple ORDER exams for a patient. RA ORDEREXAM RA OERR EDIT Edit an unreleased order that was entered through the OE/RR package. Print Templates --------------- There are no print templates associated with this file. Sort Templates -------------- There are no sort templates associated with this file.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field gives the name of this rad/nuc med patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70). ALLOWABLE WAYS TO ENTER PATIENT NAME: ------------------------------------ -Patient's last name (to reduce typing errors, enter only first few letters of last name) -Last 4 digits of patient's Social Security Number -First letter of patient's last name and last 4 digits of patient's Social Security Number.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
REASON FOR STUDY 1.1 The reason for the study is often a short patient history summarizing the condition of the patient and giving background information as to why the study has been initiated.

Free Text
PROCEDURE 2 This field points to the 'RAD/NUC MED PROCEDURES' file (#71) to indicate the Imaging procedure associated with this request. ALLOWABLE WAYS TO ENTER THE RADIOLOGY/NUCLEAR MEDICINE PROCEDURE FOR THIS REQUEST: ----------------------------------------------------------------- -Name of procedure -CPT Code -Site specific synonym

Pointer
PointerTo:
fileName:
RAD/NUC MED PROCEDURES
fileNumber:
71
TYPE OF IMAGING 3 This field points to the 'IMAGING TYPE' file (#79.2) to indicate the type of imaging used for this rad/nuc med request. It is filled in by the system with the appropriate type of imaging (i.e. GENERAL RADIOLOGY, NUCLEAR MEDICINE, ULTRASOUND, CT SCAN, MAGNETIC RESONANCE IMAGING, VASCULAR LAB, etc.). For example, when a General Radiology procedure is chosen, this field is filled in with 'GENERAL RADIOLOGY'.

Pointer
PointerTo:
fileName:
IMAGING TYPE
fileNumber:
79.2
CATEGORY OF EXAM 4 This field contains the exam category associated with this request. It is used to compile various workload statistics and various management reports (i.e. AMIS and RCS14-4). Available exam categories are: 'I' for INPATIENT, 'O' for OUTPATIENT, 'C' for CONTRACT, 'E' for EMPLOYEE, and 'R' for RESEARCH.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INPATIENT
  • Code : O
    Stands For: OUTPATIENT
  • Code : C
    Stands For: CONTRACT
  • Code : S
    Stands For: SHARING
  • Code : E
    Stands For: EMPLOYEE
  • Code : R
    Stands For: RESEARCH
REQUEST STATUS 5 This field is a set type field. The statuses in this field should correspond in name and number to those in the OE/RR 'ORDER STATUS' file (#100.01).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DISCONTINUED
  • Code : 2
    Stands For: COMPLETE
  • Code : 3
    Stands For: HOLD
  • Code : 5
    Stands For: PENDING
  • Code : 6
    Stands For: ACTIVE
  • Code : 8
    Stands For: SCHEDULED
  • Code : 11
    Stands For: UNRELEASED
REQUEST URGENCY 6 This field value defaults to 'ROUTINE', when entering a new request for an imaging exam. Available Urgencies are: ROUTINE, URGENT and STAT.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: STAT
  • Code : 2
    Stands For: URGENT
  • Code : 9
    Stands For: ROUTINE
ORDER 7 This field points to the Order Entry/Results Reporting (OE/RR) 'ORDER' File (#100). This field will only contain data if the OE/RR Package is running and the Radiology/Nuclear Medicine package is available through OE/RR.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
APPROVING RAD/NUC MED PHYS 8 This field points to the 'NEW PERSON' file (#200) to indicate the name of the radiology or nuclear medicine physician who approved this order. Procedures which require an approving physician are site specific.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CONTRACT/SHARING SOURCE 9 This field is used for exams with a 'category of exam' of 'contract' or 'sharing'. It points to the 'CONTRACT/SHARING AGREEMENTS' file (#34) to indicate the name of the contract or sharing agreement that referred this patient to the imaging service for this exam.

Pointer
PointerTo:
fileName:
CONTRACT/SHARING AGREEMENTS
fileNumber:
34
RESEARCH SOURCE 9.5 This field is used for exams with a 'category of exam' of 'research'. This field contains the name (3-40 characters) of the research source that referred this patient to the imaging service for this exam.

Free Text
REASON 10 This field points to the 'RAD/NUC MED REASON' file (#75.2) to indicate the reason a request is placed in the 'HOLD' or 'CANCELLED' status.

Pointer
PointerTo:
fileName:
RAD/NUC MED REASON
fileNumber:
75.2
ORIGINAL REQUEST CHANGED 11 This field contains a value to indicate if the information contained in the original request was changed by Rad/Nuc Med Service. Available values are: 'Y' for 'Yes' and 'N' for 'NO". This field is populated when the request moves to a 'complete' status. If the procedure on the request is a 'parent' procedure, this field will always be set to 'yes' since it is not the parent procedure that is actually performed.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
PRE-OP SCHEDULED DATE/TIME 12 This field contains the date/time if a patient has a pre-op scheduled.

Date/Time
PREGNANT 13 This field contains a value to indicate if the patient is pregnant. Available values are 'Y' for 'Yes' and 'N' for 'No'. If 'Yes', a warning message is displayed to the receptionist when this patient is registered for the procedure requested.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
  • Code : u
    Stands For: UNKNOWN
REQUESTING PHYSICIAN 14 This field points to the 'NEW PERSON' file (#200) to indicate the name of the person who requested this rad/nuc med exam. This person is not always a physician. (i.e. A nurse might request the exam.)

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
USER ENTERING REQUEST 15 This field points to the 'NEW PERSON' file (#200) to indicate the person entering the request into the rad/nuc med system. It is filled in by the system from information the user entered at sign-on.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REQUEST ENTERED DATE/TIME 16 This field contains the date and time the request was entered into the system.

Date/Time
PAST VISIT DATE/TIME 17 This field contains the date and time of the patient's last recorded visit to the Radiology/Nuclear Medicine Service.

Date/Time
LAST ACTIVITY DATE/TIME 18 This field contains the date and time the last action was taken on this request.

Date/Time
MODE OF TRANSPORT 19 This field contains the mode of transport which the patient will require when the exam is performed.

Free Text
IMAGING LOCATION 20 This field points to the 'IMAGING LOCATIONS' file (#79.1) to indicate the name of the imaging location within the hospital division where the rad/nuc med exam is to be performed.

Pointer
PointerTo:
fileName:
IMAGING LOCATIONS
fileNumber:
79.1
DATE DESIRED (Not guaranteed) 21 This field contains the date for which the rad/nuc med exam is requested. This field should not be interpreted as an appointment date.

Date/Time
REQUESTING LOCATION 22 This field points to the 'HOSPITAL LOCATION' file (#44) to indicate the name of the hospital location that is requesting the exam.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
SCHEDULED DATE (TIME optional) 23 This field contains the scheduled date and time of the requested exam.

Date/Time
ISOLATION PROCEDURES 24 This field contains 'YES' if the patient is on isolation procedures at the time the request is submitted, or 'NO' if the patient is not. If the patient is on isolation procedures the following message will be displayed on the request printed in the imaging service location: ** Universal Isolation Precautions **

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
HOLD DESCRIPTION 25 This is a word processing field for entering the reason an order is on hold.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
HOLD DESCRIPTION .01 This is the reason for placing this order on hold.

Word Processing
NATURE OF (NEW) ORDER ACTIVITY 26 This is the Nature of Order Activity for newly entered orders through the Radiology/Nuclear Medicine 'back door' order entry option. This information is needed to clarify which actions should be taken as a result of entering this order. Depending on the facility configuration of the Nature of Order Activity in the OE/RR software, the code entered here may or may not trigger alerts for electronic signatures and chart copy printing.

Set of Codes
Set of Codes:
  • Code : w
    Stands For: WRITTEN
  • Code : v
    Stands For: VERBAL
  • Code : p
    Stands For: TELEPHONED
  • Code : s
    Stands For: SERVICE CORRECTION
  • Code : i
    Stands For: POLICY
  • Code : e
    Stands For: PHYSICIAN ENTERED
CANCEL DESCRIPTION 27 This field indicates the reason a request is placed in the 'CANCELED' status via CPRS (front-door) only. The description matches an entry on file #100.03. If not canceled using CPRS, then this field will be empty and the REASON field (field 10) will be populated instead.

Free Text
REQUEST STATUS TIMES 75 This field is a multiple that contains dates and times the status of the request is changed. The status changes will only be recorded if the Division Parameter 'Track Request Status Changes' is set to 'YES'.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
STATUS CHANGE DATE/TIME .01 This field contains the date and time that the request status was changed.

Date/Time
NEW STATUS 2 This field contains the new status an order is placed into. The available statuses are: 'Discontinued', 'Complete', 'Hold', 'Pending', 'Active', and 'Scheduled'.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DISCONTINUED
  • Code : 2
    Stands For: COMPLETE
  • Code : 3
    Stands For: HOLD
  • Code : 5
    Stands For: PENDING
  • Code : 6
    Stands For: ACTIVE
  • Code : 8
    Stands For: SCHEDULED
  • Code : 11
    Stands For: UNRELEASED
COMPUTER USER 3 This field points to the 'NEW PERSON' file (#200) to indicate the person doing the processing that caused the request status to change.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON 4 This field is a pointer to the 'Radiology Reason' file (#75.2) to indicate the reason a request is placed in the 'Hold' or 'Cancelled' status.

Pointer
PointerTo:
fileName:
RAD/NUC MED REASON
fileNumber:
75.2
PFSS ACCOUNT REFERENCE 90 This field points to the PFSS ACCOUNT file (#375). The value is returned from the GETACCT^IBBAPI, which Radiology silently invokes whenever an order is placed, whether from the Front Door (CPRS) or from the Back Door (Vista Radiology).

Pointer
PointerTo:
fileName:
PFSS ACCOUNT
fileNumber:
375
PRIMARY ORDERING ICD DIAGNOSIS 91 This field contains the Primary ICD Diagnosis responsible for this order.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
PRIMARY DX RELATED TO SC 92 This field will be used to indicate if this order was for treating a VA patient based on a Service Connected related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO AO 93 This field will be used to indicate if this order was for treating a VA patient based on an Agent Orange related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO IR 94 This field will be used to indicate if this order was for treating a VA patient based on an Ionizing Radiation related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO SWAC 95 This field is used to indicate if this order was for treating a VA patient based on a Southwest Asia Conditions related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO MST 96 This field will be used to indicate if this order was for treating a VA patient based on a Military Sexual Trauma related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO HNC 97 This field will be used to indicate if this order was for treating a VA patient based on a Head and Neck cancer (HNC) related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY ORDERING ICD DIAG. 98

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SECONDARY ORDERING ICD DIAG. .01 This field contains a Secondary Diagnosis responsible for this order.

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
SECONDARY DX RELATED TO SC 2 This field will be used to indicate if this order was for treating a VA patient based on a Service Connected related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO AO 3 This field will be used to indicate if this order was for treating a VA patient based on an Agent Orange related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO IR 4 This field will be used to indicate if this order was for treating a VA patient based on an Ionizing Radiation related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO SWAC 5 This field is used to indicate if this order was for treating a VA patient based on a Southwest Asia Conditions related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO MST 6 This field will be used to indicate if this order was for treating a VA patient based on a Military Sexual Trauma related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO HNC 7 This field will be used to indicate if this order was for treating a VA patient based on a Head and Neck cancer (HNC) related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO CV 8 This field will be used to indicate if this order was for treating a VA patient based on a Combat Veteran related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SECONDARY DX RELATED TO SHAD 9 This field is used to indicate if this order was for treating a Shipboard Hazard and Defense related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO CV 99 This field will be used to indicate if this order was for treating a VA patient based on an Combat Veteran related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PRIMARY DX RELATED TO SHAD 100 This field is used to indicate if this order was for treating a VA patient based on a Shipboard Hazard and Defense related problem.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROCEDURE MODIFIERS 125 This multiple field is used to store the rad/nuc med procedure modifiers that are associated with this exam.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROCEDURE MODIFIERS .01 This multiple field is used to provide rad/nuc med procedure modifiers that are associated with this order.

Pointer
PointerTo:
fileName:
PROCEDURE MODIFIERS
fileNumber:
71.2
CLINICAL HISTORY FOR EXAM 400 This field may contain a written clinical history pertinent to the procedure requested, as well as instructions to the interpreting physician. For example, the instructions might be for the interpreting physician to read the exam films to rule out the possibility of a patient having a certain disease. This field is used as the 'Clinical History' that appears on the printed report for each exam associated with this visit.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLINICAL HISTORY FOR EXAM .01 This field may contain a written clinical history pertinent to the procedure ordered as well as instructions to the interpreting physician. For example, the instructions might be for the interpreting physician to read the exam films to rule out the possibilty of the patient having a certain disease. This field is used as the 'Clinical History' that appears on the printed report for each exam associated with this visit.

Word Processing
URL 21400

Free Text
PREGNANCY ACTIVITY 21401

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PREGNANCY ACTIVITY .01 Record of change in pregnancy activity

Date/Time
NEW VALUE .02

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
  • Code : u
    Stands For: UNKNOWN
OLD VALUE .03

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
  • Code : u
    Stands For: UNKNOWN
USER .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT .05

Free Text

ORDER

File Number: 100

File Description:

This is the file of orders/requisitions made for any package through the Order Entry Option (OR).


Fields:

Name Number Description Data Type Field Specific Data
ORDER # .01 This is the internal order number of the file.

Numeric
OBJECT OF ORDER .02 This is the individual object of the order. Depending on the parent file entry, this would be the Patient, Control Point, etc.

Variable Pointer
ORDERABLE ITEMS .1 This multiple contains the items being ordered.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDERABLE ITEM .01 This is the actual item (test, procedure, diet, drug, etc) being ordered from the Orderable Items file.

Pointer
PointerTo:
fileName:
ORDERABLE ITEMS
fileNumber:
101.43
ORDER ACTIONS .8 These are the actions taken on this order, including the signature and verification required to release to the service.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME ORDERED .01 This is the date/time this action was ordered.

Date/Time
ORDER TEXT .1 This is the text of the order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER TEXT .01 This is the text of the order.

Word Processing
EXTERNAL TEXT .2 This is the text of the order stored in external format. DO NOT EDIT THIS FIELD! This field is used to create a Digital Signature. Editing this field will render the Digital Signature invalid and prevent the order from being processed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXTERNAL TEXT .01 This is the text of the order stored in external format. This field is used along with the Digital Signature to validate the integrity of the order. DO NOT MODIFY THE DATA IN THIS FIELD! Changing anything in this field will invalidate the order.

Word Processing
REASON FOR ACTION/REJECT 1 This is the reason returned by the package why this action is being taken or rejected.

Free Text
ACTION 2 This is the action being ordered.

Set of Codes
Set of Codes:
  • Code : NW
    Stands For: NEW
  • Code : DC
    Stands For: DISCONTINUE
  • Code : HD
    Stands For: HOLD
  • Code : RL
    Stands For: RELEASE HOLD
  • Code : XX
    Stands For: CHANGE
  • Code : VA
    Stands For: VALIDATE
  • Code : IP
    Stands For: TRANSFERRED TO IP
  • Code : OP
    Stands For: TRANSFERRED TO OP
PROVIDER 3 This is the requestor of this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SIGNATURE STATUS 4 This is the signature status of the order. Entries with a null value in this field are assumed to have been entered through the back door via specific package order entry options and do not require signature unless so specified by the package.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: ON CHART w/written orders
  • Code : 1
    Stands For: ELECTRONIC
  • Code : 2
    Stands For: NOT SIGNED
  • Code : 3
    Stands For: NOT REQUIRED
  • Code : 4
    Stands For: ON CHART w/printed orders
  • Code : 5
    Stands For: NOT REQUIRED due to cancel/lapse
  • Code : 6
    Stands For: SERVICE CORRECTION to signed order
  • Code : 7
    Stands For: DIGITALLY SIGNED
  • Code : 8
    Stands For: ON PARENT order
SIGNED BY 5 This is the user who entered his/her electronic signature code to authenticate this order. It will be replaced by an encryption of the name and title of the signer, along with a checksum of the order text, as soon as we figure out how to do that. :)

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME SIGNED 6 This is the date/time that the order was electronically signed.

Date/Time
SIGNED ON CHART 7 This is the person who released an order based on a signature in the chart.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
VERIFYING NURSE 8 This is the nurse who acknowledged or verified the accuracy of this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME NURSE VERIFIED 9 This is the date/time that the order was acknowledged or verified by a nurse.

Date/Time
VERIFYING CLERK 10 This is the ward clerk who took off this order, if it was not transmitted directly to the service for action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME CLERK VERIFIED 11 This is the date/time that the ward clerk took off this order.

Date/Time
NATURE OF ORDER 12 This specifies the nature of the order or how it originated.

Pointer
PointerTo:
fileName:
NATURE OF ORDER
fileNumber:
100.02
ENTERED BY 13 This is the user who entered the information about this order into the computer.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TEXT REFERENCE 14 This field contains a reference to the Order Action entry containing the text for this order.

Numeric
RELEASE STATUS 15 This field tracks the status of the request for this action; this is NOT the same as the order status.

Set of Codes
Set of Codes:
  • Code : 11
    Stands For: unreleased
  • Code : 10
    Stands For: pre-release
  • Code : 13
    Stands For: rejected
  • Code : 12
    Stands For: dc/edit
  • Code : 14
    Stands For: lapsed
RELEASE DATE/TIME 16 This is the date/time the order was released to the service for action.

Date/Time
RELEASING PERSON 17 This is the person who released the order to the service for action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHART REVIEWED BY 18 This field contains the name of the user who performed the chart review that included this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME CHART REVIEWED 19 This field contains the date/time that a chart review was performed, that included this order.

Date/Time
DC/HOLD UNTIL 21 This is the date/time the hold was or will be removed from this order; if a future date/time is entered at the time of holding the order, the hold will be automatically removed when this date/time is reached. If this order is reinstated after being cancelled, this is the date/time the cancel status was removed from this order.

Date/Time
DC/HOLD RELEASED BY 22 This is the user who released the cancel or hold on this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DIGITAL SIGNATURE 23 This is the digital signature of the order.

Free Text
DRUG SCHEDULE 24 This is the CS FEDERAL SCHEDULE of the drug as defined in the National Drug file (VA PRODUCT #50.68). Pharmacy package further refines the schedule to: 1 Sch. I Nar. 2 II 2n II Non-Nar. 3 III 3n III Non-Nar. 4 IV 5 V 0 other active drugs

Free Text
DIGITAL SIGNATURE REQUIRED 25 This field is set if a Digital Signature is required.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
FLAGGED 31 This indicates that this order has been flagged.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BULLETIN 32 This is the bulletin sent as a result of flagging this order.

Pointer
PointerTo:
fileName:
MESSAGE
fileNumber:
3.9
DATE/TIME FLAGGED 33 This is the date/time when this order was flagged.

Date/Time
FLAGGED BY 34 This is the user who flagged this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON FOR FLAG 35 This is the reason this order was flagged; it will be included in the bulletin generated, as well as included in the text of this order until this order is unflagged.

Free Text
DATE/TIME UNFLAGGED 36 This is the date/time this order was unflagged.

Date/Time
UNFLAGGED BY 37 This is the user who unflagged this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON FOR UNFLAG 38 This is the reason for unflagging this order, usually a response to the reason for flag.

Free Text
ALERTED PROVIDER 39 This is the user who was alerted to the flag.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WARD COMMENTS 50 This is where ward or clinic comments on orders are stored.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
WARD COMMENTS .01 This field contains additional comments or instructions regarding this order; these will be included in a detailed display of this order, but not transmitted to the ancillary service.

Word Processing
CHART COPY PRINTED 71 This field is set to YES when the chart copy has printed.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
CHART COPY PRINTED WHEN 72 This field stores the date/time the chart copy 1st printed.

Date/Time
CHART COPY PRINTED BY 73 This field contains the person signed on when the chart copy 1st printed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHART COPY PRINTER 74 This is the device that the chart copy was 1st sent to.

Free Text
ADDITIONAL CHART REVIEW 21400

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHART REVIEWED BY .01

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WHEN .02

Date/Time
ADDITIONAL ALERTED PROVIDERS 21401

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIONAL ALERTED PROVIDERS .01

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDER CHECKS .9 This is the list of order checks found for this order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER CHECK .01 This is an order check that was found to be true for this order.

Pointer
PointerTo:
fileName:
ORDER CHECKS
fileNumber:
100.8
CLINICAL DANGER LEVEL .02 This is the clinical danger level associated with this check; checks flagged as 'HIGH' danger level will require a justification for overriding it and releasing the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: HIGH
  • Code : 2
    Stands For: MODERATE
  • Code : 3
    Stands For: LOW
OVERRIDE REASON .04 This is the reason entered by the user as the justification for overriding the order check and releasing the order.

Free Text
OVERRIDDEN BY .05 This is the user who chose to override this order check and entered the reason why.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME OVERRIDDEN .06 This is the date/time when this order check occurred and was overridden.

Date/Time
ORDER CHECK MESSAGE 1 This is the actual text of the order check that was displayed to the user.

Free Text
CURRENT AGENT/PROVIDER 1 This is the person who is responsible for the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DIALOG 2 This is the dialog that created this order.

Variable Pointer
WHO ENTERED 3 This is the USER who entered the information about the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WHEN ENTERED 4 This is the date/time of completion of the initiation of the order.

Date/Time
RESPONSES 4.5 This contains the responses to an order dialog.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ITEM ENTRY .01 This is the internal entry number of the prompt in the Item multiple by which this response was obtained.

Numeric
DIALOG .02 This is a pointer to the dialog prompt, which is in the Order Dialog file as type prompt.

Pointer
PointerTo:
fileName:
ORDER DIALOG
fileNumber:
101.41
INSTANCE .03 In the case of multiple answers for the same item, this identifies the individual instance.

Numeric
ID .04 This field assigns a free text identifier to this response value, for quick access to certain values in this order.

Free Text
VALUE 1 This contains the actual response, unless the value is a word processing type.

Free Text
TEXT 2 This contains responses to items that are a word processing type.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEXT .01

Word Processing
STATUS 5 This is the status of the order.

Pointer
PointerTo:
fileName:
ORDER STATUS
fileNumber:
100.01
ORDER DIAGNOSES 5.1 These are the the diagnoses associated with this order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDER DIAGNOSES .01

Pointer
PointerTo:
fileName:
ICD DIAGNOSIS
fileNumber:
80
EXPRESSION 1

Pointer
PointerTo:
fileName:
EXPRESSIONS
fileNumber:
757.01
PATIENT LOCATION 6 This is the hospital location from which the order originated.

Variable Pointer
ITEM ORDERED 7 This is the variable pointer to the file and item ordered.

Variable Pointer
VEILED 8 This field is set when creating an order to prevent the order from being displayed on the review screen until the order is complete and accepted.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: VEILED
  • Code : 0
    Stands For: UNVEILED
TYPE 8.1 This field is used to determine the type of order that is being processed. Different things happen depending on the order type.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: STANDARD
  • Code : 1
    Stands For: EDIT
  • Code : 2
    Stands For: RENEW
  • Code : 4
    Stands For: HOLD
  • Code : 6
    Stands For: DISCONTINUE
  • Code : B
    Stands For: BCMA
  • Code : C
    Stands For: COPY
  • Code : X
    Stands For: TRANSFER
  • Code : P
    Stands For: PACKAGE
REPLACED ORDER 9 This is the order number of the order which was replaced by this order, either by editing or renewal.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
REPLACEMENT ORDER 9.1 This is the order number of the order that replaces this one, either by edit or renewal.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
PATIENT CLASS 10 This is the patient's inpatient classification for this order; an inpatient may have some orders performed on an outpatient basis.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INPATIENT
  • Code : O
    Stands For: OUTPATIENT
TREATING SPECIALTY 11 This is the TREATING SPECIALTY associated with this order.

Pointer
PointerTo:
fileName:
FACILITY TREATING SPECIALTY
fileNumber:
45.7
PACKAGE 12 This is the package creating the order.

Pointer
PointerTo:
fileName:
PACKAGE
fileNumber:
9.4
COST 13 This is the cost of filling this order.

Numeric
SIGNATURE REQUIRED 14 This is the OR key required to sign this order. If set to 2, only users with the ORES key will be allowed to sign this order; if set to 1, users with either the ORELSE or ORES keys will be allowed to sign. A 0 or "" indicates that no signature is required.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NONE
  • Code : 1
    Stands For: ORELSE
  • Code : 2
    Stands For: ORES
EVENT 15 This is the event that this order's release is/was delayed till.

Pointer
PointerTo:
fileName:
OE/RR PATIENT EVENT
fileNumber:
100.2
PATIENT APPOINTMENT 16 This is the appointment date/time for outpatients and is only entered when inpatient medications are ordered for them.

Date/Time
CHILDREN 20 This field allows a single order or set of orders to be linked to a parent order.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHILDREN .01 These are the orders which compose this entry and have this entry in the Parent field.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
START DATE 21 This is the start date/time of the order.

Date/Time
STOP DATE 22 This is the stop date/time of the order.

Date/Time
TO 23 This is the service to which the order is referred. This is used to determine the display group in which the order appears.

Pointer
PointerTo:
fileName:
DISPLAY GROUP
fileNumber:
100.98
CURRENT ACTION 30 This is the item number of the action in the Order Actions multiple that is currently being carried out on this order; it will be used to build the text for the Current Orders list.

Numeric
DATE OF LAST ACTIVITY 31 This is the date/time the order was last updated.

Date/Time
GRACE DAYS BEFORE PURGE 32 This is the number of days to hold an order from the date of last activity. The order in OE/RR may be purged after this date. The default is 30 days. If a package needs the order retained for a period longer than 30 days, this can be specified when the order is created by setting the variable ORPURG to the appropriate number of days before calling FILE^ORX.

Numeric
PACKAGE REFERENCE 33 This information allows the package to link the order in OR with its more detailed order information in the individual package. It is the package's responsibility to define and determine the structure of this information.

Free Text
ALERT ON RESULTS 35 This field contains the user who requested to be alerted when results for this order become available. Only lab, radiology, and consult orders will generate results.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PARENT 36 This is the parent of an order that may have a parent/child relationship.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
LAPSED DATE/TIME 39 This field will specify when the order was Lapsed. Lapsing takes place in routine ORTSKLPS and is part of the ORMTIME scheduled option.

Date/Time
SERVICE CONNECTED CONDITION 51 When signing orders, the provider may be asked if this order is for treatment of a service-connected condition; his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
MST 52 If a patient has been identified as having been treated for Military Sexual Trauma (MST), then the provider may be asked when signing the order if it is for treatment of a condition related to MST and his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
AGENT ORANGE EXPOSURE 53 If a patient has been identified as having been exposed to Agent Orange (AO) during service in Vietnam, then the provider may be asked when signing the order if it is for treatment of a condition related to AO and his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
IONIZING RADIATION EXPOSURE 54 If a patient has been identified as having been treated for exposure to ionizing radiation (IR) during military service, then the provider may be asked when signing the order if it is for treatment of a condition related to IR and his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SOUTHWEST ASIA CONDITIONS 55 If a patient has been identified as having been treated for exposure to environmental contaminants (EC) during the Persian Gulf War, then the provider may be asked when signing the order if it is for treatment of a condition related to EC and his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
HEAD AND/OR NECK CANCER 56 If a patient has been identified as having been treated for head or neck cancer due to nose or throat radium treatments while in the military, then the provider may be asked when signing the order if it is for treatment of head or neck cancer and his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COMBAT VETERAN 57 When signing orders, the provider may be asked if this order is for treatment of a combat-related condition; his/her response to this question will be stored in this field. Currently this question is only asked for Outpatient Medications, and the response is passed to that package with the new order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SHIPBOARD HAZARD 58

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
NATURE OF DC 61 Orders that are DC'ed because they have been duplicated do not create a DC order, nor is a chart copy or electronic signature notification generated. If this is a CHANGE IN THERAPY, then a DC order is generated that must be signed, and a chart copy of the new DC request is printed.

Pointer
PointerTo:
fileName:
NATURE OF ORDER
fileNumber:
100.02
DC'ed BY 62 This is the person who DC'ed this order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DC DATE/TIME 63 This is the date/time the order was DC'ed.

Date/Time
DC REASON 64 This is the reason this order was DC'ed, i.e. "Patient discharged."

Pointer
PointerTo:
fileName:
ORDER REASON
fileNumber:
100.03
DC REASON TEXT 65 This is the text of the DC reason.

Free Text
COMPLETED 66 This is the date/time the order was marked as complete.

Date/Time
COMPLETED BY 67 This is the person who marked this order as complete.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DC EVENT 68 This is the event that automatically discontinued this order.

Pointer
PointerTo:
fileName:
OE/RR PATIENT EVENT
fileNumber:
100.2
DC ORIGINAL ORDER 69 This field is only accessed by CPRS. This field is set to True if both the original order and the pending renewal order are discontinued. This field is set to False if only the pending renewal order is discontinued. If only the pending renewal order is discontinued, CPRS assigns the original order's status to the status it received from the pharmacy package.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: TRUE
  • Code : 0
    Stands For: FALSE
RESULTS DATE/TIME 71 This field contains the date/time that results became available for this order; only Lab, Radiology, and Consult orders have results.

Date/Time
ABNORMAL RESULTS 72 This field indicates whether the results for this order were abnormal, or outside of normal ranges.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
FINDINGS 73 This field contains the text of any significant findings for the results of this order.

Free Text
BA SERVICE CONNECTED CONDITION 90 When signing orders, the provider may be asked if this order is for treatment of a service-connected condition; his/her response to this question will be stored in this field.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA MILITARY SEXUAL TRAUMA 91

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA AGENT ORANGE EXPOSURE 92

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA IONIZING RADIATION EXPOSURE 93

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA SOUTHWEST ASIA CONDITIONS 94

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA HEAD AND/OR NECK CANCER 95

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
BA COMBAT VETERAN 96

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PFSS ACCOUNT REFERENCE 97 The PFSS Account Reference field stores the PFSS Account Reference associated with the order. The field is a pointer to the PFSS Account Reference file (#375).

Pointer
PointerTo:
fileName:
PFSS ACCOUNT
fileNumber:
375
BA SHIPBOARD HAZARD 98

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COMPUTED DIALOG 21400

Computed
SNOMED TEXT 21401 This is where the SNOMED text will be stored for the MSC OR GTX PROBLEM order dialog.

Free Text
EXTERNAL ORDER NUMBER 21490

Computed
MSC EXTERNAL ORDER SYSTEM 21491

Pointer
PointerTo:
fileName:
MSC EXTERNAL ORDER SYSTEM
fileNumber:
21491
ACCOUNT NUMBER 29320.8

Free Text

OE/RR PATIENT EVENT

File Number: 100.2

File Description:

This file is used by CPRS to track what happened to a patient's orders as a result of an event, such as an MAS movement or returning from the OR.


Fields:

Name Number Description Data Type Field Specific Data
PATIENT .01 This is a pointer to the patient file and is the patient associated with this event.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ACTIVITY 1 This multiple contains a log of actions taken on this event that are relevant to the release or discontinuance of orders.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME OF ACTIVITY .01 This is the actual date and time that the activity occurred.

Date/Time
TYPE OF EVENT ACTIVITY 2 This field is a code indicating the type of activity that occurred. This may be new, edited, re-entered, manually released, deleted or cancelled. An event may also be "lapsed" if it stays unprocessed beyond the time frame defined by the "Lapse in #Days" field of the OE/RR RELEASE EVENTS file #100.5 for this event.

Set of Codes
Set of Codes:
  • Code : NW
    Stands For: NEW
  • Code : ED
    Stands For: EDITED
  • Code : RE
    Stands For: REENTERED
  • Code : MN
    Stands For: MANUALLY RELEASED
  • Code : LP
    Stands For: LAPSED
  • Code : DL
    Stands For: DELETED
  • Code : CA
    Stands For: CANCELLED
USER 3 This field is the user who entered or modified the activity.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EVENT TYPE 4 This field is the type of event that was processed. This could be admission, discharge, transfer, O.R. (surgery), or specialty change.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMISSION
  • Code : T
    Stands For: TRANSFER
  • Code : D
    Stands For: DISCHARGE
  • Code : O
    Stands For: O.R.
  • Code : S
    Stands For: SPECIALTY CHANGE
MAS MOVEMENT TYPE 5 This field is the MAS Movement Type of the activity that was processed, if it was an MAS patient movement.

Pointer
PointerTo:
fileName:
MAS MOVEMENT TYPE
fileNumber:
405.2
TREATING SPECIALTY 6 This field is the treating specialty associated with this activity, if it is an MAS patient movement.

Pointer
PointerTo:
fileName:
FACILITY TREATING SPECIALTY
fileNumber:
45.7
WARD LOCATION 7 This field is the ward location associated with this activity, if it is an MAS patient movement.

Pointer
PointerTo:
fileName:
WARD LOCATION
fileNumber:
42
EVENT 2 This field is a pointer to the OE/RR RELEASE EVENTS file, which defines the conditions under which delayed orders are to be released for this patient event, if delayed orders are related to this event.

Pointer
PointerTo:
fileName:
OE/RR RELEASE EVENTS
fileNumber:
100.5
ADMISSION 3 This field is a pointer to the Admission movement for which this event is valid; this will be the current admission if the patient is an inpatient when delayed orders are written, otherwise the admission movement will be stuffed in when the patient is admitted and the orders released. If the patient is discharged without this event having been processed, it will be retired and any orders still delayed will be lapsed.

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
ORDER 4 This field is a pointer to the doctor's order requesting that this event occur for this patient when delayed orders are written.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
CREATED ON 5 This field is the timestamp of when this event was entered into the file for this patient.

Date/Time
CREATED BY 6 This field is a pointer to the user who entered this event into the file for this patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EVENT DATE/TIME 11 This field is the date and time that this event occurred for this patient; if the event is an MAS movement, this time will be the DATE/TIME from the PATIENT MOVEMENT file which may be slightly different than the actual time that this event was processed by the event driver.

Date/Time
PATIENT MOVEMENT 12 This field is a pointer to the MAS Patient Movement that satisfied this event for this patient; any changes to this movement that alter the conditions of the event will be tracked in the Activity log.

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
AUTO-DC RULE 13 This field is the Auto-DC Rule from file #100.6 that was used to automatically discontinue active orders when this event occurred. Those orders that were dc'd are listed in the Discontinued Orders multiple of this file.

Pointer
PointerTo:
fileName:
OE/RR AUTO-DC RULES
fileNumber:
100.6
SURGERY 14 This field is a pointer to the Surgery case that satisfied this event for this patient when the TIME PAT OUT OR field was entered (for events prior to the instllation of patch SR*3*157) or when the TIME PAT IN OR field was entered (for events after the installation of patch SR*3*157); any changes to this field will be tracked in the Activity log.

Pointer
PointerTo:
fileName:
SURGERY
fileNumber:
130
PARENT 15 This field is a "parent" event, allowing multiple Patient Events to be collected together for release at the same time based on the same criteria; the parent event tracks the release criteria, while each "child" event defines a particular set of orders to be released on that event.

Pointer
PointerTo:
fileName:
OE/RR PATIENT EVENT
fileNumber:
100.2
RELEASED ORDERS 20 This multiple field contains the delayed orders that were released based on the release event defined in the OE/RR RELEASE EVENTS file #100.5 when this event occurred.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RELEASED ORDER .01 This field is a pointer to the Orders file #100 of an order that was released as a result of the event occurring.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
BY ACTION 2 This is the CPRS action that released this order to the service, instead of the specified OE/RR RELEASE EVENT. These orders are tracked here so that they can all be displayed in the "Auto-DC/Release Events" view, including the complete movement data in the Detailed Display.

Set of Codes
Set of Codes:
  • Code : MN
    Stands For: MANUAL RELEASE
  • Code : ES
    Stands For: SIGNATURE
DISCONTINUED ORDERS 30 This multiple contains the orders that were automatically discontinued based on the rules defined in the OE/RR AUTO-DC RULES file #100.6 when this event occurred.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISCONTINUED ORDER .01 This field is the number of the order in the Orders file #100.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
BY PACKAGE 2 This is the VistA package whose protocol on the DGPM MOVEMENT EVENTS driver caused this order to auto-dc, instead of the OE/RR AUTO-DC RULE. These orders are tracked here so that they can all be displayed in the "Auto-DC/Release Events" view, including the complete movement data in the Detailed Display.

Set of Codes
Set of Codes:
  • Code : FH
    Stands For: DIETETICS
  • Code : LR
    Stands For: LABORATORY
  • Code : PS
    Stands For: PHARMACY

DIETETIC ENCOUNTERS

File Number: 115.7

File Description:

This file contains the various dietetic encounters entered by dietetics personnel. It includes patient-related events, such as diet instructions, as well as non-patient-related events such as talks to the community.


Fields:

Name Number Description Data Type Field Specific Data
NUMBER .01 This field contains a sequential number assigned to the encounter and has no meaning.

Numeric
DATE/TIME OF ENCOUNTER 1 This field contains the date and time at which the dietetic encounter took place.

Date/Time
CLINICIAN 2 This field contains a pointer to the clinician who provided the service during the encounter.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENCOUNTER TYPE 3 This field contains a pointer to the Encounter Type file (115.6) indicating the type of encounter.

Pointer
PointerTo:
fileName:
ENCOUNTER TYPES
fileNumber:
115.6
EVENT LOCATION 4 This optional field contains a pointer to the Hospital Location file (44) indicating where the encounter took place.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
INITIAL/FOLLOWUP 5 This field indicates whether the encounter was an initial one of this type or a follow-up.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INITIAL
  • Code : F
    Stands For: FOLLOWUP
TIME UNITS 6 This field contains the number of time units earned by this encounter.

Numeric
GROUP/INDIVIDUAL 7 This field indicates whether the encounter was a group one or an encounter with a single individual.

Set of Codes
Set of Codes:
  • Code : G
    Stands For: GROUP
  • Code : I
    Stands For: INDIVIDUAL
GROUP SIZE 8 This field contains the total number of persons involved, including any collaterals.

Numeric
EVENT COMMENT 10 This field may contain a short comment concerning the event.

Free Text
COMMUNICATIONS OFFICE 11

Pointer
PointerTo:
fileName:
COMMUNICATION OFFICE
fileNumber:
119.73
PATIENT 20 This field is a multiple containing data relating to patients involved in the encounter.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01 This field contains a pointer to the Patient file (2) and indicates a patient involved in the encounter.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
LOCATION 1 This field contains a pointer to the Hospital Location (file 44) for the patient. It is the patient location rather than the event location.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
# COLLATERALS 2 This field contains the number of collaterals seen with the patient.

Numeric
PATIENT COMMENT 3 This field may be used for a patient-specific comment concerning the encounter.

Free Text
ENTERING CLERK 101 This field is a pointer indicating the person making the encounter entry.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE/TIME ENTERED 102 This field contains the date/time the encounter was actually entered.

Date/Time
LAST REVIEW DATE/TIME 103 This is the date/time that the encounter was last reviewed.

Date/Time
REVIEW CLERK 104 This is a pointer to File 200 of the person entering the review.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

GMRV VITAL MEASUREMENT

File Number: 120.5

File Description:

This file contains vital sign information and other measurement data for a patient.


Fields:

Name Number Description Data Type Field Specific Data
DATE/TIME VITALS TAKEN .01 This field contains the date/time this vital/measurement was taken by the care provider.

Date/Time
PATIENT .02 This field contains the name of the patient for whom this vital measurement data was entered. Pointer to the PATIENT (#2) file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VITAL TYPE .03 This field denotes the type of measurement for this record. Pointer to the GMRV VITAL TYPE (#120.51) file.

Pointer
PointerTo:
fileName:
GMRV VITAL TYPE
fileNumber:
120.51
DATE/TIME VITALS ENTERED .04 This field contains the date/time that this record was entered.

Date/Time
HOSPITAL LOCATION .05 This field contains the location where this measurement was taken. Pointer to the HOSPITAL LOCATION (#44) file.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ENTERED BY .06 This field contains the name of the person who edited the file entry. Pointer to the NEW PERSON (#200) file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RATE 1.2 This field contains the numeric value associated with this vital measurement.

Free Text
SUPPLEMENTAL O2 1.4 This field stores the information of the supplemental oxygen as follows: .5-20 l/min (liters/minute) and/or 21-100 % of oxygen concentration For example: 4.5 l/min 40% 4.5 l/min 40 %

Free Text
ENTERED IN ERROR 2 This field indicates that this record was flagged as entered in error.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 3 This field indicates the name of the person responsible for entering the record in error. Pointer to the NEW PERSON (#200) file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 4 This multiple contains a list of reasons for entering a vital measurement in error.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASON ENTERED IN ERROR .01 This field records the reason for entering the data in error.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
QUALIFIER 5 A list of qualifiers associated with this measurement.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
QUALIFIER .01 This field contains the name of the qualifier associated with this measurement.

Pointer
PointerTo:
fileName:
GMRV VITAL QUALIFIER
fileNumber:
120.52
SNOMED CT 2601

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SNOMED CT .01

Free Text
SNOMED PREFERRED TERM .019

Computed
LOINC CODES 2701

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOINC CODES .01

Free Text
LOINC TEXT .019

Computed
ABNORMAL FLAG 21401 This will store the abnormal flag at the time the vital is stored, allowing for reference ranges to be different as a patient ages.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ABNORMAL
  • Code : H
    Stands For: HIGH
  • Code : L
    Stands For: LOW
  • Code : N
    Stands For: NORMAL
REFERENCE RANGE 21402

Free Text
MSC CALC CONTRIBUTORS 21404

Subfile
subfile:
Name Number Description Data Type Field Specific Data
NEW CALC CONTRIBUTORS .01

Pointer
PointerTo:
fileName:
GMRV VITAL MEASUREMENT
fileNumber:
120.5
VITAL TYPE .02

Pointer
PointerTo:
fileName:
GMRV VITAL TYPE
fileNumber:
120.51
VISIT 9000010

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010

ADVERSE REACTION REPORTING

File Number: 120.85

File Description:

This file contains all the data for an Observed Drug reaction.


Fields:

Name Number Description Data Type Field Specific Data
DATE/TIME OF EVENT .01 The date/time that this observed reaction occurred.

Date/Time
PATIENT .02 This field is the patient to whom this observed reaction occurred. This field is a pointer to the Patient file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
RELATED REACTION .03 This is the related reaction in the Patient Allergies (120.8) file for this event.

Pointer
PointerTo:
fileName:
PATIENT ALLERGIES
fileNumber:
120.8
OBSERVER .5 This field is the person who witnessed this reaction.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE REPORTED 1.1 This field is to track when a report is entered into this file.

Date/Time
REPORTING USER 1.2 This field is used to track the user who entered the reaction. It is a pointer to File 200.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REACTIONS 2 A list of signs/symptoms observed for this reaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REACTIONS .01 One sign/symptom observed for this reaction.

Pointer
PointerTo:
fileName:
SIGN/SYMPTOMS
fileNumber:
120.83
OTHER REACTION 1 If this sign/symptom cannot be found in the Sign/Symptoms (120.83) file, then the free text of what the user typed in will be here, and the signs/symptoms of OTHER REACTION will be the value of the REACTIONS field.

Free Text
ENTERED BY 2 The person who entered this reaction into the system.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SUSPECTED AGENT 3 A list of suspected agents for this observed reaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SUSPECTED AGENT .01 This field indicates one of the suspected agents for this observed reaction.

Free Text
DAILY DOSE 1 This field contains the daily dosage for this suspected agent.

Free Text
SIG 1.5 This file contains the SIG code that indicates how this drug is to be given.

Free Text
ROUTE OF ADMINISTRATION 2 This is the route of administration for this suspected agent.

Free Text
INDICATIONS FOR USE 3 This field indicates the reasoning for a particular agent.

Free Text
START DATE OF ADMINISTRATION 4 This field contains the date a patient was first given the suspected agent.

Date/Time
STOP DATE OF ADMINISTRATION 5 This field contains the stop date for a suspected agent.

Date/Time
DURATION OF ADMINISTRATION 6 This field contains the total time the suspected agent was given to a patient.

Computed
MANUFACTURER 7 This field contains the name of the manufacturer of the suspected agent.

Free Text
LOT # 8 This field contains the lot # for a suspected agent.

Free Text
NUMBER OF PREVIOUS DOSES 9 This field contains the total number of doses of this suspected agent that were given to the patient prior to the reaction.

Numeric
LAST FILL DT 10 This field is the date that this agent was last filled.

Date/Time
EXPIRATION DATE 10.1 This is the date that the suspected agent is to expire.

Date/Time
NDC # 10.2 This is the NDC (National Drug Code) of this agent.

Free Text
LIKE QUESTION #1 11 This question determines whether this reaction normally occurs with this reactant. reactant.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKE QUESTION #2 12 This question determines whether administration of the reactant was stopped.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKE QUESTION #3 13 This question determines if the reaction stopped when the administration of the reactant was terminated. the reactant was terminated.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKE QUESTION #4 14 This question determines whether the reactant was readministered.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKE QUESTION #5 15 This question determines whether the reaction could be due to the patient current clinical condition.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKE QUESTION #6 16 This question determines if the reaction reappeared after the reactant was readministered. was readministered.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
LIKELIHOOD 17 If this is an observed drug allergy/adverse reaction, then this is the likelihood that this is an adverse reaction. The data for this field is based on an algorithm used by the FDA.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: REMOTE
  • Code : 2
    Stands For: POSSIBLE
  • Code : 3
    Stands For: PROBABLE
  • Code : 4
    Stands For: HIGHLY PROBABLE
RELEVANT TEST/LAB DATA 4 A list of all the relevant test/lab data for this observed reaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TEST .01 This field contains a particular test/lab data for this observed reaction.

Free Text
RESULTS 1 This field will contain the results for the particular test.

Free Text
COLLECTION D/T 2 This field is the date the sample was collected from the patient.

Date/Time
QUESTION #1 5 This field indicates whether or not a patient has died from this reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #2 6 This field indicates whether or not a patient was treated with a RX drug for this reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #3 7 This field indicates whether or not the reaction caused a life threatening illness.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #4 8 This field indicates whether or not the patient had to visit a doctor or an ER because of this reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #5 9 This field indicates whether this reaction required hospitalization.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
NO. DAY HOSPITALIZED 9.1 This field shows the number of days the patient was hospitalized because of the reaction.

Numeric
QUESTION #6 10 This field indicates if the patient had a prolonged hospitalization because of the reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #7 11 This field indicates whether or not the patient had some sort of permanent disability as a result of this reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #8 12 This field indicates whether the patient recovered from any illness that may have resulted from the reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #9 12.1 This field is to find out if the observed reaction was a Congenital Anomaly.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
QUESTION #10 12.2 This field is to find out if this event required any intervention.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
CONCOMITANT DRUGS 13 A list of all drugs that may have been taken at the time of the reaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CONCOMITANT DRUGS .01 This field contains the drug(s) this patient was taking at the time of the reaction.

Free Text
START DATE OF ADMINISTRATION 1 This field is the date this drug was first given to the patient.

Date/Time
STOP DATE OF ADMINISTRATION 2 This field is the last day the patient was given this drug.

Date/Time
LAST FILL DT 3 This field is the last date that this drug was filled.

Date/Time
SIG 4 This file contains the SIG code that indicates how this drug is to be given.

Free Text
OTHER RELATED HISTORY 14 This field contains any other related event history for this reaction.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER RELATED HISTORY .01 This field is to document other history relating to this reaction.

Word Processing
SEVERITY 14.5 This field indicates the severity of this reaction.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: MILD
  • Code : 2
    Stands For: MODERATE
  • Code : 3
    Stands For: SEVERE
DATE MD NOTIFIED 22 This field contains the date the doctor was notified of this reaction.

Date/Time
FDA QUESTION #1 23 This field determines if the reaction is considered serious.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
FDA QUESTION #2 24 This question determines whether this reaction is related to a new drug.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
FDA QUESTION #3 25 This question determines whether this reaction was an unexpected reaction for this drug.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
FDA QUESTION #4 26 This question determines whether this reaction is related to a therapeutic failure of the drug.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
FDA QUESTION #5 26.1 This field is to track if the reaction was a dose related reaction.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
DATE REPORTED TO FDA 27 This field contains the date on which the FDA was sent the ADR report.

Date/Time
DATE OF PATIENT CONSENT TO MFR 28 This field is the date the patient had given his consent to have the reaction reported to the manufacturer.

Date/Time
DATE SENT TO MFR 29 This is the date when the report was sent to the manufacturer.

Date/Time
*DATE SENT TO RCPM 30 This is the date when the report was sent to the regional offices.

Date/Time
DATE SENT TO VAERS 31 This field is the date when the report was sent to the VAERS.

Date/Time
P&T ACTION FDA REPORT 31.1 This field indicates if the P&T committee determined whether to send the report to FDA.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
P&T ACTION MFR REPORT 31.2 This field tells if the P&T committee determined whether to send the report to the manufacturer.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
*P&T ACTION RCPM REPORT 31.3 This field determines whether or not the P&T committee will send the report to the regional offices.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
P&T ADDENDUM 31.5 List of comments made by the P&T committee.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME ENTERED .01 This is the date/time the comment was entered.

Date/Time
ADDENDUM 1 This is the actual comment that is being added.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDENDUM .01 This field contains the comments that the P&T committee add to this reaction.

Word Processing
REPORTER NAME 43 This field contains the name of the person filling out the reports.

Free Text
REPORTER ADDRESS1 44 Line one of the address of the person filling out the report.

Free Text
REPORTER ADDRESS2 45 Line two of the address of the person filling out the report.

Free Text
REPORTER ADDRESS3 46 Line three of the address of the person filling out the report.

Free Text
REPORTER CITY 47 The city where the person lives who is filling out the report.

Free Text
REPORTER STATE 48 The state where the reporter resides.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
REPORTER ZIP 49 This is the zip code of the person filling out the report.

Free Text
REPORTER PHONE 50 This is the phone number of the person who is filling out the report.

Free Text
RPT QUESTION #1 51 This field determines if the reporter is a health care provider.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
RPT QUESTION #2 52 This field determines if the reporter wants to permit the FDA to inform the manufacturer of his identity.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
OCCUPATION 52.1 This field contains the reporter's current occupation.

Free Text
MANUFACTURER NAME 53 This field is the name of the manufacturer of the reactant.

Free Text
MFR ADDRESS #1 54 This is address line one for the manufacturer.

Free Text
MFR ADDRESS #2 55 This is address line two for the manufacturer.

Free Text
MFR ADDRESS #3 56 This is address line three for the manufacturer.

Free Text
MFR CITY 57 This is the city of the manufacturer.

Free Text
MFR STATE 58 This is the state where the manufacturer is located.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
MFR ZIP 59 This is the Zip Code of the manufacturer.

Free Text
IND/NDA # FOR SUPPORT DRUG 60 This is the IND/NDA # for support drug for the manufacturer.

Free Text
MFR CONTROL # 61 This is the control number used by the manufacturer.

Free Text
DATE RECEIVED BY MFR 62 This is the date the report was received by the manufacturer.

Date/Time
REPORT SOURCE 63 This is the source of the report.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOURCE .01 This is the actual source of the report.

Set of Codes
Set of Codes:
  • Code : f
    Stands For: FOREIGN
  • Code : h
    Stands For: HEALTH PROFESSIONAL
  • Code : s
    Stands For: STUDY
  • Code : l
    Stands For: LITERATURE
  • Code : c
    Stands For: CONSUMER
15 DAY REPORT 64 This field is to determine if the 15 Day Report has been completed.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
REPORT TYPE 65 This is the type of report issued.

Set of Codes
Set of Codes:
  • Code : i
    Stands For: INITIAL
  • Code : f
    Stands For: FOLLOWUP

ADVERSE REACTION ASSESSMENT

File Number: 120.86

File Description:

This file is a listing of all the patients who have been asked about allergies/adverse reactions. It contains a pointer to File 2 (PATIENT), a flag to indicate if the patient has or does not have an Allergy/Adverse Reaction, the person making the assessment and the date/time of the assessment.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This is the patient who has been asked about allergies/adverse reactions.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
REACTION ASSESSMENT 1 This field indicates if the patient has a reaction on file or not.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Yes
  • Code : 0
    Stands For: No
ASSESSING USER 2 This field contains the name of the user who made the last reaction assessment for this patient.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ASSESSMENT DATE/TIME 3 This field contains the date/time of the last reaction assessment for this patient.

Date/Time
UNASSESSABLE 9999999.11

Subfile
subfile:
Name Number Description Data Type Field Specific Data
UNASSESSABLE .01 Multiple to document patients who could not be assessed for allergies

Date/Time
REASON 1

Pointer
PointerTo:
fileName:
BEH ALLERGY VALUES
fileNumber:
90460.05
USER 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RESOLVED 3

Date/Time
RESOLVED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 5

Free Text

REQUEST/CONSULTATION

File Number: 123

File Description:

This file contains consult and request orders originating primarily via the OE/RR ordering process. Once the order exists in this file, receiving service users perform update tracking activities. An audit trail of the update tracking activities is maintained in this file. The only associating of results to a consult or request, for this version, is based on Medicine Package procedure results.


Fields:

Name Number Description Data Type Field Specific Data
FILE ENTRY DATE .01 Date of actual entry of consultation request into the file. Transparent to user.

Date/Time
PATIENT NAME .02 This is the Patient who the consult or request was ordered for. Enter the patient's name, or the last four digits of the SSN.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
OE/RR FILE NUMBER .03 This is the internal entry number of the order in the Orders File (100). The consult sends CPRS information about the consult which is stored in File 100. This is the IEN of the consult in that file.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
PATIENT LOCATION .04 This is the location of the patient when the consult/request order was placed.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ORDERING FACILITY .05 This field contains the number, from file 4, of the institution/hospital that is requesting the consult. This field is mandatory if the consult/ request is being sent to another hospital/institution, so that routing information can be obtained in order to return the results to the sending hospital/institution.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
REMOTE CONSULT FILE ENTRY .06 This is the ^GMR(123, file number of the consult from a foreign database. It is stored here so that when the consult is returned in an HL7 message, it can be located at the sending facility. Also, if the sending facility needs to send updated consult information to the receiving facility, this number will reference the consult number there so that the data can be added/ammended and tracking information can be updated.

Numeric
ROUTING FACILITY .07 This field will contain the INSTITUTION to which communications and updates regarding this request will be routed. If the request is being requested and performed locally, this field will be blank.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
DISPLAY TEXT OF ITEM ORDERED .1 This is the display text of the item ordered. If the order was placed using a quick order, then the Display text is the text from the Order Dialog File. If the order was placed by selecting an Orderable Item, then the text is the Print Name from the Orderable Item file.

Free Text
IFC ROLE .125 This field will define the role of the particular VistA system in the fullfillment of the inter-facility consult. This facilitates proper HL7 message formats. PLACER indicates that this VistA system originated and ordered this request. FILLER indicates that this request was generated at the institution in the ORDERING FACILITY field.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PLACER
  • Code : F
    Stands For: FILLER
REMOTE ORDERING PROVIDER .126 This field contains the name of the requesting provider of an inter-facility consult. This field is only defined on an inter-facility consult on file at a consulting site.

Free Text
IFC REMOTE SERVICE NAME .131 This field holds the name of the service that will perform the Inter- facility Consult at the remote facility.

Free Text
REMOTE REQUESTOR PHONE .132 This field will contain the telephone number of the remote requestor of an inter-facility consult. This will be displayed with the consult and can expedite communication between requesting provider and consultant. This field is derived from the OFFICE PHONE field of the NEW PERSON file.

Free Text
REMOTE REQUESTOR DIG PAGER .133 This field contains the digital pager number of a remote requesting provider if this is an inter-facility consult. This may expedite communication between the requesting provider and the consultant. This data in this field is derived from the DIGITAL PAGER field of the NEW PERSON file.

Free Text
TO SERVICE 1 This is the "TO" service/specialty. This service is responsible for completion of the consult/request.

Pointer
PointerTo:
fileName:
REQUEST SERVICES
fileNumber:
123.5
CLINICAL PROCEDURE 1.01 This field contains the CP DEFINITION that is associated with this request.

Pointer
PointerTo:
fileName:
CP DEFINITION
fileNumber:
702.01
FROM 2 This field represents the location that sent the order to the receiving location.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DATE OF REQUEST 3 This is the date and time the order was released from OE/RR. If the TO service entered the order stub through the Add Order (AD) action, this is the service-specified request date.

Date/Time
PROCEDURE/REQUEST TYPE 4 This is the procedure that was requested via CPRS while ordering.

Variable Pointer
URGENCY 5 This field describes the urgency of the consult. Urgencies are sent in the PROTOCOL File (#101) as: STAT, EMERGENCY, INPATIENT, NEXT AVAILABLE, NOW, ROUTINE, TODAY, WITHIN 24 HOURS, WITHIN 48 HOURS, WITHIN 72 HOURS, WITHIN 1 WEEK, WITHIN 1 MONTH.

Pointer
PointerTo:
fileName:
PROTOCOL
fileNumber:
101
PLACE OF CONSULTATION 6 This is the place where the consultation will take place. Choose from: B - Bedside C - Consultant's Choice E - Emergency Room O - On Call EKG - EKG Lab

Pointer
PointerTo:
fileName:
PROTOCOL
fileNumber:
101
ATTENTION 7 Enter the name of a person you would like to alert about the consult. This person will be sent a notification that a new consult exists. In order for the person to see this type of notification, the person must be set up to receive "New service consult" notifications.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CPRS STATUS 8 This is the current CPRS status of the consult or request order. The Action Types which may be taken from the "Select Action: " prompt update the status in this file as well as in the Orders File (100).

Pointer
PointerTo:
fileName:
ORDER STATUS
fileNumber:
100.01
LAST ACTION TAKEN 9 This is the last Action Type taken that updated the activity tracking audit trail.

Pointer
PointerTo:
fileName:
REQUEST ACTION TYPES
fileNumber:
123.1
SENDING PROVIDER 10 This is the provider who originated the order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RESULT 11 This is a variable pointer used by the GMRC MEDICINE PKG INTERFACE option to associate results in the Medicine Procedure Files with a consult/request order.

Variable Pointer
MODE OF ENTRY 12 When a consult or request is entered by the service, rather than through CPRS order processing, this field will be set to "1" to indicate the Service forced the entry. This forcing means there is no electronic signature related to the order.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SERVICE FORCED ENTRY
REQUEST TYPE 13 This field will indicate whether the order is a consult or procedure request order. Based on this fields value, the Consultation Body Header alters to indicate "Consult Type: " or "Procedure Request: ".

Set of Codes
Set of Codes:
  • Code : C
    Stands For: Consult
  • Code : P
    Stands For: Procedure
SERVICE RENDERED AS IN OR OUT 14 This field allows the ordering person to indicate if the service is to be rendered on an outpatient or inpatient basis. This is to alleviate the confusion if patient is currently an inpatient/outpatient but is just about to be discharged/admitted and become a outpatient/inpatient.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: inpatient
  • Code : O
    Stands For: outpatient
SIGNIFICANT FINDINGS 15 If significant findings are noted in the consult results, then this field may be marked "Yes", and appropriate comments may be entered in the "Comment" field. "Unknown" is the default. "No" may also be specified to indicate the results do not include significant findings.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: yes
  • Code : N
    Stands For: no
  • Code : U
    Stands For: unknown
TIU RESULT NARRATIVE 16 Pointer to the Text Integration Utilities file (#8925) where consult/request results narrative is stored.

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
EARLIEST DATE 17

Date/Time
REASON FOR REQUEST 20 This is the reason for requesting the Consult or Procedure Request.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASON FOR REQUEST .01 This is the reason for requesting the Consult or Procedure Request.

Word Processing
PROVISIONAL DIAGNOSIS 30 This is the Provisional Diagnosis the ordering clinician would specify on the Consult Form 513.

Free Text
PROVISIONAL DIAGNOSIS CODE 30.1 This field is used to store the coded portion of the Provisional Diagnosis if an ICD-9 coded diagnosis is sent via CPRS.

Free Text
REQUEST PROCESSING ACTIVITY 40 Maintains history of processing actions.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME OF ACTION ENTRY .01 This is the actual date and time the activity tracking update was added to the REQUEST PROCESSING ACTIVITY multiple.

Date/Time
REMOTE ENTERING PERSON .21 This is the free text name of the individual that entered this activity at the facility referenced in the ROUTING FACILITY field. This field will only be popluated for activities entered on a remote VistA system for an inter-facility consult.

Free Text
REMOTE RESPONSIBLE PERSON .22 This is the free text name of the individual that is responsible for this activity at the facility referenced in the ROUTING FACILITY field. This field will only be popluated for activities entered on a remote VistA system for an inter-facility consult.

Free Text
REMOTE ACTIVITY TIME ZONE .23 This is the short representation of the time zone in which this activity took place. When an inter-facility consult update message is generated at a remote facility, the current MAILMAN TIME ZONE at that facility is sent with the message and stored in this field.

Free Text
REMOTE RESULT .24 This field will contain a reference to a result stored on a remote VistA system. Result will be in form: ien;source file of result;institution ien where result resides

Free Text
REMOTE DATE/TIME OF FILING .25 This field will hold the date/time this particular activity was filed at the remote facility. This field will be used in conjunction with the DATE/TIME OF ACTUAL ACTIVITY field to detect and reject the filing of duplicate activities.

Date/Time
PREVIOUS REMOTE SERVICE NAME .31 This field holds the name of the service that the inter-facility consult was was directed to at the remote site prior to being forwarded.

Free Text
ACTIVITY 1 This is the activity that is being updated.

Pointer
PointerTo:
fileName:
REQUEST ACTION TYPES
fileNumber:
123.1
DATE/TIME OF ACTUAL ACTIVITY 2 The Date and time the actual activity was done. This may be different than the DATE/TIME OF ACTION ENTRY for certain actions.

Date/Time
WHO'S RESPONSIBLE FOR ACTIVITY 3 The clinician or service person responsible for the activity.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
WHO ENTERED ACTIVITY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 5 A comment may be added here which would be associated with the Action Type selected at the "Select Action: " prompt.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01 This is a word-processing comment which you may add to provide additional information in reference to the Action Type selected at the "Select Action: " prompt.

Word Processing
FORWARDED FROM 6 This is the Service which forwarded the Consult to the new TO SERVICE. It is maintained for an audit trail.

Pointer
PointerTo:
fileName:
REQUEST SERVICES
fileNumber:
123.5
PREVIOUSLY ASSIGNED TO 7 This is the provider who was previously identified in the ATTENTION (#7) field of the REQUEST/CONSULTATION (#123) file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PRINTED TO 8 This is the printer that the CONSULT FORM 513 was printed to upon the orders release from OE/RR or when the Consult/Request order is forwarded from one service to another.

Pointer
PointerTo:
fileName:
DEVICE
fileNumber:
3.5
RESULT 9 This is the result that was updated when this activity occurred.

Variable Pointer
ACTION METHOD 10 The action method will identify how the user performed the action, from a consults menu, Order entry menu, a GUI menu, or a TIU interface.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Consult Actions
  • Code : 2
    Stands For: Order Actions
  • Code : 3
    Stands For: GUI Actions
  • Code : 4
    Stands For: TIU Interface
ASSOCIATED RESULTS 50

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ASSOCIATED RESULTS .01 This multiple allows one or more results to be associated with a consult. This field invokes IA #147

Variable Pointer
REMOTE RESULTS 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REMOTE RESULT DATE .01 This is the date/time that a remote result was added to the record.

Date/Time
REMOTE ASSOCIATED RESULT .02 This is the free text representation of a variable pointer from a remote facility. The facility is referenced in the RESULTING SITE field.

Free Text
RESULTING SITE .03 This field is a pointer to the INSTITUION file and contains the institution that stores the result referenced in the REMOTE ASSOCIATED RESULT FIELD.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
ADMINISTRATIVE 70 This field is set via a trigger on TO SERVICE which will set this field to the value found in the ADMINISTRATIVE field of the REQUEST SERVICES file (#123.5). Requests marked as administrative shall be excluded from the Consults Performance Monitor report [GMRC RPT PERF MONITOR]

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SNOMED CT 9999999.01 SNOMED CT associated with consult type from file 123.5

Free Text
ASSOC PROBLEM 9999999.02 Find the problem associated with this consult entry

Pointer
PointerTo:
fileName:
PROBLEM
fileNumber:
9000011
CLOSED SCT 9999999.11

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLOSED SCT .01

Free Text
ENTERED BY 1

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DT/TIME ENTERED 2

Date/Time

GMRY PATIENT I/O FILE

File Number: 126

File Description:

This file contains a patient's intake and output measurements.


Fields:

Name Number Description Data Type Field Specific Data
PATIENT .01 This field identifies the patient for whom these intake/output measurements pertain. Pointer to the Patient file (#2).

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
INTAKE 1 This field contains the patient's cumulative intake within an interval of time.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTAKE DATE/TIME .01 This field stores the end date/time point for this intake measurement. NO FUTURE DATE/TIME ALLOWED !!!

Date/Time
INTAKE TYPE 1 This field identifies the major intake categories such as PO, TUBE FEEDING etc.

Pointer
PointerTo:
fileName:
GMRY INPUT TYPE
fileNumber:
126.56
INTAKE ITEM 3 This multiple identifies the fluid intake absorbed by the patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTAKE ITEM .01 This field stores the name of the fluid(s) taken by the patient.

Pointer
PointerTo:
fileName:
GMRY INTAKE ITEMS
fileNumber:
126.8
VOLUME 1 This field contains the measurement in milliliters (ml) for the fluid intake item.

Numeric
SPECIFY 2 The user can specify the intake item if the OTHER item is selected.

Free Text
TOTAL AMOUNT 4 This field stores the cumulative intake measurement in milliliters (ml) for this period. Numeric example: 240.

Numeric
COMMENT 5 This field permits the caregiver to describe additional observations. This field will be used in the next version.

Free Text
ENTERED BY 6 This field contains the name of the user who enters this record. Pointer to the New Person file ^VA(200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 7 This field identifies the patient's hospital location. Pointer to the Hospital Location file (#44).

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ORDER 8

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time
OUTPUT 2 This field contains the patient's cumulative output for an interval of time.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OUTPUT DATE/TIME .01 This field stores the end date/time point for this cumulative measurement. NO FUTURE DATE/TIME ALLOWED !!!

Date/Time
OUTPUT TYPE 1 This field identifies the major output categories such as URINE, EMESIS, etc.

Pointer
PointerTo:
fileName:
GMRY OUTPUT TYPE
fileNumber:
126.58
OUTPUT SUBTYPE 2 This field contains subtitle names associated with each major output category, i.e., FOLEY CATHETER and VOIDED for URINE.

Pointer
PointerTo:
fileName:
GMRY OUTPUT SUBTYPE
fileNumber:
126.6
OUTPUT AMOUNT 3 The field stores the cumulative amount of this output period in milliliters (ml). Enter "*" if output amount is unknown.

Free Text
COMMENT 4 This field permits the caregiver to describe additional observations for this output, i.e., color, odor, consistency for drainage. This field will be used in the next version.

Free Text
ENTERED BY 5 This field contains the name of the user who enters this record. Pointer to the New Person file ^VA(200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 6 This field contains the hospital location of the patient. Pointer to the Hospital Location file (#44).

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time
IV 3 This multiple documents all information specific to the starting and discontinuation of an intravenous(IV) fluid on a patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IV START DATE/TIME .01 This field contains the DATE and TIME this IV solution was added or hung.

Date/Time
INFUSION SITE 1 This field contains the IV's location such as LEFT HAND, RIGHT HAND and LEFT ARM, etc. The user is allowed to select from the IV SITE file (#126.7) by entering a number or a combination of numbers. The software then transforms the number(s) into text.

Free Text
SOLUTION 2 This field contains the name of the IV solution or heparin/saline lock. The user can select the active IV orders for this patient from the PHARMACY PATIENT file (#55) or from the NUR IV SOLUTION file (#126.9). If the user selects a heparin/saline lock, the software inserts the data into the IV record.

Free Text
TYPE OF IV 3 This field describes the type of IV: 'H' for hyperal, 'P' for piggyback, 'A' for admixture, 'B' for blood/blood product, 'I' for intralipid, and 'L' for heparin/saline lock.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : P
    Stands For: PIGGYBACK
  • Code : H
    Stands For: HYPERAL
  • Code : B
    Stands For: BLOOD/BLOOD PRODUCTS
  • Code : I
    Stands For: INTRALIPIDS
  • Code : L
    Stands For: HEPARIN/SALINE LOCK
VOLUME 4 This field identifies the total amount of solution in milliliters (ml) in the IV container.

Free Text
IV CATHETER TYPE/SIZE 5 This field stores the name and size of the IV catheter(s).

Free Text
IV STARTED BY 6 This field holds the name of the user who entered the data. Pointer to the NEW PERSON file (#200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 7 This field identifies the hospital location of the patient. Pointer to the Hospital Location file (#44).

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DATE/TIME DC'ED 8 This field holds the DATE/TIME when the IV was discontinued.

Date/Time
DC'ED BY 9 This field stores the name of the person who removes the IV from the patient. Pointer to NEW PERSON file (#200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON FOR DC 10 This field identifies the reason for discontinuing the IV infusion. Text from IV DC'ED REASON file (#126.76).

Free Text
INFUSION RATE 11 This field contains the rate at which the infusion is to take place. Example: 125 = 125 ml/hr.

Numeric
RESTART DATE/TIME 12 This field stores the date/time when a discontinued IV is restarted.

Date/Time
IV INTAKE 13 This multiple contains the parenteral IV fluid intake records for this patient. NO FUTURE DATE/TIME ALLOWED !!!

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IV INTAKE DATE/TIME .01 This field documents the end date/time point for this IV fluid intake period. NO FUTURE DATE/TIME OR DATE/TIME BEFORE THE IV STARTED ALLOWED !!!

Date/Time
AMOUNT LEFT 1 This field contains the amount of solution left in the IV container. Enter "*" if amount of solution absorbed is unknown.

Free Text
IV INTAKE AMOUNT 2 This field contains the amount of IV fluid that the patient has received

Free Text
ENTERED BY 3 This field holds the name of the person who entered the data. Pointer to NEW PERSON file (#200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 4 This field identifies the hospital location of the patient. Pointer to HOSPITAL LOCATION file (#44).

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
COMMENT 9999999.01 Free text comment about IV intake

Free Text
RESTARTED IV 14 This field stores the new IEN for this IV fluid if it is discontinued before infused.

Numeric
IV LINE # 15 This computed field sets the IV LINE # to the D1 value.

Computed
D/T TITER ADJUSTED 16 This field documents the date/time when the rate of intravenous infusion is adjusted.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
D/T TITER ADJUSTED .01 This field documents the date/time when the rate of intravenous infusion is adjusted.

Date/Time
RATE 1 This field contains the rate at which the infusion is to take place. Example: 125 = 125 ml/hr.

Numeric
ADJUSTED BY 2 This field contains the name of the user who enters this record. Pointer to the New Person file ^VA(200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 3

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
COMMENT 4 This field contains any additional comments associated with this infusion rate adjustment.

Free Text
PORT 17 This field contains the name of the lumen associated with the IV catheter for this IV line.

Free Text
IV RATE 18

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME .01

Date/Time
IV RATE .02

Numeric
DOSE .03

Free Text
DOSE RATE .04

Pointer
PointerTo:
fileName:
MSC FLOWSHEETS UNITS
fileNumber:
21406
INFUSE OVER .05

Free Text
ENTERED BY .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ACTION 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ACTION .01

Pointer
PointerTo:
fileName:
ACTIVITY LOG REASON
fileNumber:
53.3
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time
ORDER NUMBER 19

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time
IV MAINTENANCE 4 This multiple records the patient's IV maintenance or care including the IV infusion site care, IV tube change(s) and dressing change(s).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
IV SITE .01 This field contains the IV's location such as LEFT HAND, RIGHT HAND and LEFT ARM, etc. The user is allowed to select from the IV SITE file (#126.7) by entering a number or a combination of numbers. The software then transforms the number(s) into text.

Free Text
MAINTENANCE DATE/TIME 1 This multiple stores the DATE/TIME the IV infusion was performed along with the specific tasks associated with the maintenance.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MAINTENANCE DATE/TIME .01 This field indicates the DATE/TIME the IV care was performed.

Date/Time
SITE DESCRIPTION 1 This field stores the care-giver's observation of the IV infusion site. The user is allowed to select a number or a combination of numbers from the IV SITE DESCRIPTION file (#126.72). The software then transforms the number(s) into text.

Free Text
TUBING CHANGED 2 This field indicates if the IV tubing was changed. Enter "Y" if IV tube has been changed.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: yes
  • Code : N
    Stands For: no
DRESSING CHANGED 3 This field indicates if the dressing was changed. Enter "Y" if dressing has been changed.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: yes
  • Code : N
    Stands For: no
ENTERED BY 4 This field documents the name of the person who gives the nursing care. Pointer to the NEW PERSON file (#200).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SITE DC'ED 5 This field indicates if the IV was discontinued at its insertion point. Enter Y(es) if the IV site was discontinued.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: yes
  • Code : N
    Stands For: no
LINE OF TUBE 6 This field indicates the IEN of the IV.

Numeric
ACTION 7

Pointer
PointerTo:
fileName:
ACTIVITY LOG REASON
fileNumber:
53.3
RATE 8

Numeric
DOSE 9

Free Text
DOSE RATE 10

Pointer
PointerTo:
fileName:
MSC FLOWSHEETS UNITS
fileNumber:
21406
INFUSE OVER 11

Free Text
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time
FLUSH 9999999.01 Documentation if a flush of the IV was done

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
VISIT NUMBER 20

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
ENTERED IN ERROR 21400.01

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ERROR ENTERED BY 21400.02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASON ENTERED IN ERROR 21400.03

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INCORRECT DATE/TIME
  • Code : 2
    Stands For: INCORRECT READING
  • Code : 3
    Stands For: INCORRECT PATIENT
  • Code : 4
    Stands For: INVALID RECORD
ENTERED IN ERROR DATE/TIME 21400.04

Date/Time

SPN ADMISSIONS

File Number: 154.991

File Description:



Fields:

Name Number Description Data Type Field Specific Data
Admission Date/Time .01

Date/Time
IEN 154_1 1

Pointer
PointerTo:
fileName:
OUTCOMES
fileNumber:
154.1
PATIENT 2

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2

VA FORM 10-7078

File Number: 162.4

File Description:

This file contains the information associated with a 7078 authorization. Per VHA Directive 10-93-142, this file definition should not be modified.


Fields:

Name Number Description Data Type Field Specific Data
REFERENCE NUMBER .01 This number is internally generated and tracked by the IFCAP software.

Free Text
USER WHO CANCELLED .013 This field contains the name of the supervisor who cancelled the 7078.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE CANCELLED .014 This field contains the date that a supervisor cancelled the 7078.

Date/Time
FEE PROGRAM .5 This field contains the valid Fee Program associated with this 7078, as defined in the Fee Basis Program file (i.e. Outpatient Medical, Contract Hospital, Community Nursing Home).

Pointer
PointerTo:
fileName:
FEE BASIS PROGRAM
fileNumber:
161.8
VENDOR 1 This is the vendor that is entered in the request/ notification process.

Variable Pointer
VETERAN 2 This is the veteran that was entered in the request/ notification process.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
AUTHORIZATION FROM DATE 3 This is the date that is entered in the 'Authorization From Date' field during the request/notification process.

Date/Time
DATE OF ADMISSION 3.5 This is the date that is entered in the 'Date of Admission' field during the request/notification process.

Date/Time
AUTHORIZATION TO DATE 4 This is the date you determine the VA will no longer cover the veteran.

Date/Time
DATE OF DISCHARGE 4.5 This is the actual date of discharge.

Date/Time
AUTHORITY 5 This field is the Admitting Authority used for the authorization.

Pointer
PointerTo:
fileName:
VA ADMITTING REGULATION
fileNumber:
43.4
ESTIMATED AMOUNT 6 This dollar amount is the best estimate of costs that will be incurred by the veteran. This dollar amount is passed to IFCAP.

Numeric
AUTHORIZED SERVICES 7 This is a word processing field that should contain a statement similar to the following: "Hospitalization and Professional care necessary until the patients condition is stabilized or improved enough to permit transfer without hazard to a VA or other Federal facility for continued treatment." or "Hospitalization and Professional Care".

Subfile
subfile:
Name Number Description Data Type Field Specific Data
AUTHORIZED SERVICES .01

Word Processing
USER ENTERING 8 This is the name of the user that enters the authorization.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
STATUS 9 The status of the 7078/authorization remains 'Incomplete' until a discharge date is entered. At that time the status is updated to complete and a corresponding authorization is built in file 161.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: COMPLETE
  • Code : I
    Stands For: INCOMPLETE
  • Code : DC
    Stands For: CANCELLED
DATE OF ISSUE 10 This is the date the user sets up the 7078.

Date/Time
REASON FOR PENDING DISPOSITION 12 If the status of a 7078 is Incomplete, that is the discharge date has not been entered, the user is prompted with this field. Once the status of the 7078 is Complete this field is set to null.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: FOLLOW-UP/NOT STABLE
  • Code : 2
    Stands For: AWAITING DISCHARGE/TRANSFER
REFERRING PROVIDER 15 The VA physician who made the referral on behalf of the veteran to the non-VA hospital for inpatient health care services.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REFERRING PROVIDER NPI 16

Computed

DENTAL PATIENT

File Number: 220

File Description:

This file contains patient information pertinent to the Dental Service. It points to the Patient file (2).


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 ENTER PATIENT'S NAME IN THIS ORDER: LAST, FIRST

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
APPLICATION FOR CARE STATUS 1

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW PATIENT
  • Code : R
    Stands For: READMISSION/REAPPLICATION
PATIENT CATEGORY 2 ENTER CODE CHOOSE FROM: 01 = EMERGENCY 02 = COMPELLING MEDICAL NEED 03 = EXTENDED CARE 04 = NURSING HOME CARE 05 = DOMICILIARY 06 = SPECIAL PROVISION 07 = PRIORITY 2 08 = PRIORITY 3

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EMERGENCY
  • Code : 2
    Stands For: COMPELLING MEDICAL NEED
  • Code : 3
    Stands For: EXTENDED CARE
  • Code : 4
    Stands For: NURSING HOME CARE
  • Code : 5
    Stands For: DOMICILIARY
  • Code : 6
    Stands For: SPECIAL PROVISION
  • Code : 7
    Stands For: PRIORITY 2
  • Code : 8
    Stands For: PRIORITY 3
DOM/NHCU 3

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DOMICILIARY
  • Code : N
    Stands For: NHCU
DENTISTRY ADJUNCT 4

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
COMPLETE EXAM AFTER SCREENING 5

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DENTAL CARE NEEDED 6

Set of Codes
Set of Codes:
  • Code : R
    Stands For: REGULAR
  • Code : E
    Stands For: EMERGENCY
  • Code : B
    Stands For: BOTH
PREVENTIVE DENTISTRY 7

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INSTRUCTION
  • Code : P
    Stands For: PROPHY
  • Code : T
    Stands For: TOPICAL FLORIDE
ORAL MALIGNANCY DATE 8

Date/Time
PERIAPICAL RADIOGRAPH DATE 9

Date/Time
BITE WING RADIOGRAPH DATE 10

Date/Time
PANOGRAPHIC RADIOGRAPH DATE 11

Date/Time
OTHER RADIOGRAPH DATE 12

Date/Time
EDENTULOUS NO DENTURES 13

Set of Codes
Set of Codes:
  • Code : U
    Stands For: UPPER
  • Code : L
    Stands For: LOWER
  • Code : B
    Stands For: BOTH
EDENTULOUS WITH DENTURES 14

Set of Codes
Set of Codes:
  • Code : U
    Stands For: UPPER
  • Code : L
    Stands For: LOWER
  • Code : B
    Stands For: BOTH
OTHER FINDINGS/REMARKS 47

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER FINDINGS/REMARKS .01

Word Processing
TREATMENT PLAN PREPARED DATE 48

Date/Time
TREATMENT PLAN 49

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TREATMENT PLAN .01

Pointer
PointerTo:
fileName:
DENTAL TYPE OF SERVICE
fileNumber:
220.3
PLANNED DATE 1

Date/Time
COMPLETED DATE 2

Date/Time
MEDICAL REVIEW DATE 50

Date/Time
TREATMENT PLAN # 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TREATMENT PLAN # .01

Numeric
DATE GENERATED .1

Date/Time
RX NEEDED 1

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PROPHYLAXIS APPT'S NEEDED 2 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
PROPH PROVIDER 3

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
PERIODONTAL APPT'S NEEDED 4 Enter "??" for further information concerning this field, or <RETURN> to continue

Numeric
PERIO PROVIDER 5

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
ENDODONTIC APPT'S NEEDED 6 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
ENDO PROVIDER 7

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
RESTORATIVE APPT'S NEEDED 8 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
REST PROVIDER 9

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
SURGICAL APPT'S NEEDED 10 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
SURG PROVIDER 11

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
CROWN/BRIDGE APPT'S NEEDED 12 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
C/B PROVIDER 13

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
REM PROS APPT'S NEEDED 14 Enter "??" for further information concerning this field, or <RETURN> to continue.

Numeric
PROS PROVIDER 15

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
LAST CLASSIFICATION 70.01 This is computer generated. It is the last classification for this patient based upon data filed in file 228.1 for which a transaction was marked as completed or terminated. This valued is stuffed from a cross reference on the dental transaction file, 228.2.

Pointer
PointerTo:
fileName:
DENTAL CLASSIFICATION
fileNumber:
220.2
LAST CLASSIFICATION DATE 70.02 This is computed generated from data entered into file 228.2. This is date of the last classification.

Date/Time
TP CHART NUM 71 This multiple contains data used by the Discus Treatment Planning software. That software sequences transactions by patient per day. Completed transactions have a chart number of 60 or greater. Chart numbers 0-59 indicate treatment plans. The Discus software allows only one completed chart number per day per patient. To sequence the data within a chart number, the Discus software uses the TIME COUNTER field. For each transaction TIME COUNTER must be unique per patient per day. The data in this multiple is computer generated from cross references on file 228.2.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHART NUMBER .01 This multiple tracks the Discus Treatment Planning software chart numbers and time counters. In this software, there is only one chart number per patient per day. In the Discus software, planning transactions are 0-59. Completed transactions are 60 or greater.

Numeric
TIME COUNTER LAST .02 This is computer generated from filing transactions in file 228.2. The Discus treatment planning software uses a field called TIME COUNTER to sequence the transactions for a patient per day. Discus starts the counter with a value of 1000 and increments it by 10 for each transaction. This field records the last TIME COUNTER filed in file 228.2

Numeric

DENTAL TREATMENT (AMIS)

File Number: 221

File Description:

The Treatment file contains all dental treatments for each patient entered by the date of treatment and the provider ID #. This is the core of the dental package where all dental activities are recorded. Entries are usually recorded in this file on a daily basis.


Fields:

Name Number Description Data Type Field Specific Data
DATE .01

Date/Time
STATION.DIVISION .3 This is the three digit station number.

Free Text
PROVIDER NUMBER .4 ENTER IN THIS FIELD THE PROVIDER CODE NUMBER

Free Text
DENTAL PROVIDER .5 This is the dental provider. Names are entered lastname,first name.

Pointer
PointerTo:
fileName:
DENTAL PROVIDER
fileNumber:
220.5
SSN 1

Free Text
DENTAL PATIENT 2

Free Text
PATIENT (POINTER) 3

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PATIENT CATEGORY 4.5 Category 19 includes only priority 1, continued after priority 1 inpatient care. Category 21 includes only priority 2, continued after priority 2 inpatient care. Category 22 includes only priority 3, continued after priority 3 inpatient care and active duty military personnel, military retirees, and CHAMPVA.

Pointer
PointerTo:
fileName:
DENTAL CLASSIFICATION
fileNumber:
220.2
BED SECTION 5

Pointer
PointerTo:
fileName:
DENTAL BED SECTION
fileNumber:
220.4
SCREENING/COMPLETE EXAM 6 SCREENING EXAMINATION The screening examination includes an evaluation of the oral and perioral soft tissues and a visual estimate of dental status without a tooth by tooth charting. Radiographs usually will not be taken, but may be if PROFESSIONALLY DETERMINED to be necessary as for an emergency. A chart review (patient not present at time of review) is also classed as a screening exam. When a chart review is entered the provider must also mark ADMIN PROCEDURE on the screen to avoid a "patient visit" count. Note: Providers must be aware of significant medical problems; therefore, a medical and dental history and/or medical record review must be included. Recall examinations (may be less than six months) would be included in this area. The screening examination is an essential part of the admission physical examination. All INPATIENT screening examinations will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT screening examinations will be placed in Priority 1. COMPLETE EXAMINATION A complete examination includes dental charting on a tooth by tooth basis as well as the comprehensive evaluation of the oral and perioral soft tissues. A head and neck exam is included as an essential portion of the complete examination. A thorough review of the medical chart and medical history with the pertinent medical findings noted on the dental record are included in the complete examination. A complete examination will be accomplished for a patient who is to receive treatment other than emergency care. Complete examinations will be recorded in the appropriate inpatient or outpatient category/priority.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: SCREENING
  • Code : C
    Stands For: COMPLETE
INTERDISCIPLINARY CONSULT 6.2 Count those that were instituted via Form 513 (Consultation Request), a telephone request with following Form 513 and Form 10-10 or 10-10m with progress notes attached. All INPATIENT interdisciplinary consultations will be placed in a Priority 1 category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT interdisciplinary consultations will be placed in a Priority 1 Category.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INTERDISC. CONSULT
EVALUATION 6.4 No more than one evaluation per provider can be counted on the same visit. Evaluations are identified as medical/dental workups, (e.g., periodontal, surgical, endodontic, etc.) on those patients for whom a complete screening examination has already been performed. Evaluations may be in conjunction with review of a medical record, the initiation of an interdisciplinary consultion or with a medical or dental emergency workup on a patient for whom no definitive treatment is delivered. An evaluation made by the staff mentor for trainees at a scheduled treatment visit prior to carrying out a specific treatment procedure is counted as education time. All other INPATIENT evaluations will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All OUTPATIENT evaluations will be placed in a Priority 1 Category.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EVALUATION
PRE AUTH/2ND OPINION EXAM 6.6 A pre-authorization exam is performed on a fee basis patient in order to determine treatment needs prior to authorization of the patient to a fee- for-service provider. A second opinion exam is performed when the original estimate on a fee basis dental case exceeds $500.00.

Set of Codes
Set of Codes:
  • Code : 2
    Stands For: PRE-AUTH/2ND OPINION
SPOT CHECK EXAM 6.7

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: STAFF
  • Code : 3
    Stands For: FEE
SPOT CHECK DISCREPANCY # 6.8 The DISCREPANCY categories are defined as follows: 1 = MINOR discrepancy only 2 = MAJOR discrepancy-- QUALITY ONLY 3 = MAJOR discrepancy- MISREPRESENTATION ONLY

Numeric
ADMIN PROCEDURE 7 An entry should be made in this field when a case, a service or a procedure has been administratively completed or terminated without an actual patient visit (i.e., chart review, telephone call, death, etc.).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ADMIN PROCEDURE
COMPLETIONS/TERMINATIONS 7.1 COMPLETIONS A case is completed when all treatment authorized has been accomplished. Only one count should be taken for a patient during any single period of hospitalization unless the patient is under long term care. In the case of long term care patients, including NHC and Dom patients, a count for a completed case may be taken once in each six months if re-examination indicated need for another episode of care. For outpatients, only one complete case count may be taken per episode of care for which a treatment plan was established, even if there were intervening terminations. If, after an outpatient case has been completed and s/he is eligible for recall, another episode of care may begin with the recall examination if treatment is indicated. Treatment plans will not be segmented for the purpose of multiple completions during an episode of care. For cases administratively completed, also make an entry in the ADMIN PROCEDURE field. TERMINATIONS A case is terminated when an episode of care is interrupted or stopped short of completion of the authorized treatment plan. Examples of this would be the death of a patient, discharge to OPT status, closure of the case due to failed appointments, health reasons, or at the patient's request. For cases administratively terminated, also make an entry in the ADMIN PROCEDURE field.

Set of Codes
Set of Codes:
  • Code : 2
    Stands For: COMPLETION
  • Code : 3
    Stands For: TERMINATION
X-RAYS EXTRAORAL # 8 Enter the number of EXTRAORAL radiographs taken on this patient for panoramic, cephalometric or other extraoral procedures.

Numeric
X-RAYS INTRAORAL # 10 Enter the number of INTRAORAL radiographs taken for this patient for PA, bitewing, occlusal and other intraoral procedures.

Numeric
PROPHY NATURAL DENTITION 11 In special circumstances, when a patient is of such a difficult nature that two or more appointments are needed to complete the prophylaxis,credit for each treatment episode may be recorded. If a patient is on a formal recall status, such as head and neck cancer patients who are being followed after radiation treatment,credit may be taken at each prophylaxis appointment. A prophylaxis will include a complete review of preventive oral disease instructions.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PROPHY DENTURE 12 If a patient had a prophylaxis of natural dentition and a removeable prothesis cleaned on the same visit, an entry can be made for both procedures.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
NEOPLASM CONFIRMED MALIGNANT # 14 Activities surrounding the confirmation should include patient/family counseling and discussion with other hospital services (laboratory, surgery, etc.) for diagnostic interpretation and treatment planning. All confirmed malignant neoplasms on INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All confirmed malignant neoplasms on OUTPATIENTS will be placed in the appropriate Priority 1 Category.

Numeric
NEOPLASM REMOVED # 15 All neoplasms removed for INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All neoplasms removed for OUTPATIENTS will be placed in the appropriate Priority 1 Category.

Numeric
BIOPSY/SMEAR # 16 Enter the number of incisional biopsies (separate lesions) plus the number of cytological smears (one smear per patient) taken. All biopsies and cytological smears performed on INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All biopsies and cytological smears performed on OUTPATIENTS will be placed in the appropriate Priority 1 Category.

Numeric
FRACTURE # 17 For multiple fractures in the same bone (e.g., bilateral condylar or a bilateral combination of body and condyle) count only as one fracture reduction if only one surgical site/procedure was used. The computer generated weighted value includes all post-operative visits. All maxillofacial fractures reduced for INPATIENTS will be placed in a Priority 1 Category. If the inpatient does not fall into Emergency, Extended Care, NHCU, Dom, or Special Provisions, s/he would be placed in the Compelling Medical Need Category. All Maxillofacial fractures reduced for OUTPATIENTS will be placed in the appropriate Priority 1 Category.

Numeric
OTHER SIGNIF. SURG. (CTV) 19 OTHER SIGNIFICANT SURGERY CTV'S 1. Salivary Gland Surgery 16.0 2. Dislocation 3.0 3. Laceration/suturing 6.0 4. Incision and Drainage 4.0 5. Orthognathic Surgery 65.0 6. Frenectomy* 6.0 7. Alveoplasty* (per quadrant) 4.0 8. Exostoses removal* 4.0 9. Apicoectomy 10.0 10. Tooth hemisection, Root amputation* 10.0 11. Vestibuloplasty* Sulcus revision, Ridge extension (W/O skin graft) 12.0 Graft procedure 16.0 12. Endosteal Implants** 9.0 13. All other surgeries 6.0 * These procedures will be reported at one-half of the listed units when done in conjunction with a quadrant of periodontal surgery. ** Requires VAMC Research and Development Committee approval.

Numeric
SURFACES RESTORED # 21 DO NOT record the number of teeth restored or the number of restorations or temporary restorations in this field. They must be recorded under Other Significant Treatment.

Numeric
ROOT CANAL THERAPY # 22

Numeric
PERIODONTAL QUADS (SURGICAL) # 23 A quadrant may have fewer than eight (8) teeth present or treated, that is, a full quadrant of teeth is not required. If two to eight teeth are present in the same arch and any number cross the midline, count as only ONE quadrant. DO NOT INCLUDE SCALING AND CURETTAGE IN THIS AREA EVEN IF LOCAL ANESTHESIA IS USED. If scaling and curettage are done as part of the surgical procedure, do not take additional credit by entering both the periodontal surgery and the scaling. Included in the periodontal surgery is the chart review, local anesthesia, post-operative instructions, treating of complications, suture removal and pack changes. NOTE: ADDITIONAL SURGICAL PROCEDURES, FRENECTOMY, ALVEOPLASTY, EXOSTOSES REMOVAL, TOOTH HEMISECTION, ROOT AMPUTATION, AND/OR VESTIBULOPLASTY, WHICH ARE PERFORMED AT THE TIME OF PERIODONTAL SURGERY ARE ENTERED AS A SEPARATE PROCEDURE UNDER OTHER SIGNIFICANT SURGERY AND ARE WEIGHTED AT ONE-HALF THE LISTED VALUE IF PERFORMED IN THE SAME SURGICAL SITE.

Numeric
PERIO QUADS (ROOT PLANE) # 24 This must not be part of a periodontal surgery procedure performed in the same quadrant on the same visit. A quadrant may have fewer than eight (8) teeth present or treated, that is, a full quadrant of teeth is not required. If two to eight teeth are present in the same arch and any number cross the midline, count as only ONE quadrant. If nine or more teeth are present in the same arch, count as two quadrants. DO NOT COUNT AS QUADRANTS OF ROOT PLANING AND CURETTAGE A PROPHYLAXIS PERFORMED BY A DENTIST, EFDA, OR HYGIENIST. That is, do not count a supragingival scaling (such as using a cavitron alone) and polishing as a curettage.

Numeric
PATIENT ED. (CTV) 25 Enter the weighted value of preventive dentistry instructions. DO NOT LIST THE NUMBER OF MINUTES. These instructions may be given by any provider. However, NO CREDIT IS RECORDED AT THE SAME APPOINTMENT when a prophylaxis or another treatment procedure is being accomplished by the same provider (an increase in CTV credits recognizes time spent for patient instruction during other scheduled treatment procedures). The main pupose of this field is to record a specific appointment scheduled for a single patient or for a group training session to provide oral hygiene instructions, diet counseling, plaque scoring, etc. For an individual patient, enter the service code, a weighted value of three (3), and the patient's name for each instructional session. For a group session, enter the service code, a weighted value of four (4), and the word "GROUP" in place of a patient's name for all instructional sessions. All group instructions will be entered under the appropriate patient category for the majority of the group in attendance. The patient category determination for individual instructional sessions will be reported the same as for other services provided for that individual. Preventive Dentistry instructions presented for employees are recorded as education/training time.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NONE
  • Code : 3
    Stands For: INDIVIDUAL
  • Code : 4
    Stands For: GROUP
INDIVIDUAL CROWNS # 27 The crowns cemented are not part of a fixed prosthesis. Included in this field are all types of permanent crowns such as, 3/4, porcelain fused to metal, porcelain jacket, full gold, etc. Temporary crowns are NOT to be counted in this field.

Numeric
POST & CORES # 28 Enter a post/core or overdenture coping regardless of whether that tooth will have a crown as part of a fixed prosthesis or have an individual crown placed on it. This field includes all types of posts/cores (i.e., cast, pre-prepared types, and/or threaded systems).

Numeric
FIXED PARTIALS (ABUT) # 29 Temporary bridges for this treatment episode are NOT counted in this field. This category includes all types of fixed prostheses with the exception of Acid Etched, Resin Bonded Retainers. These types of prostheses are recorded under Splints and Special Procedures.

Numeric
FIXED PARTIALS (PONT ONLY) # 30 PONTIC UNITS of temporary bridges for this treatment episode are NOT counted in this field. This field includes all types of fixed prostheses except Acid Etched, Resin Bonded Retainers. These are reported under SPLINTS AND SPECIAL PROCEDURES.

Numeric
REMOVABLE PARTIALS # 31 Acrylic R.P.D.'s may be counted here ONLY if the clasp assembly contains definitive occlusal rests. Transitional (temporary) tissue supported partials are counted in the SPLINTS AND SPECIAL PROCEDURES field. R.P.D. relines or rebases are counted under OTHER SIGNIFICANT TREATMENT.

Numeric
COMPLETE DENTURES # 32 All COMPLETE DENTURES are counted at the time of insertion or disposition of the dentures. Complete Denture relines or rebases are to be credited under the field OTHER SIGNIFICANT TREATMENT.

Numeric
PROSTHETIC REPAIR # 33 Each repair is counted at the time of delivery to the patient or other disposition. Fixed prostheses with broken facings which have been repaired are reported in the Other Significant Treatment section. If the patient does not come to the clinic for the prosthetic repair, an entry must be made in the Admin Procedure field.

Numeric
SPLINTS & SPEC. PROCS. (CTV) 34 WEIGHTED VALUES (CTV'S) 1. Periodontal or trauma splinting, orthodontic bands and/or brackets 1.0/tooth 2. Flouride carriers (custom) 3.0/patient 3. Facial moulage 9.0 4. Tissue borne partial prosth. 12.0 5. Oral hygiene aids for handicapped pts. 9.0 6. Acrylic cranial plate 18.0 7. Mandibular guidance appliance 36.0 8. Radiation stent 12.0 9. Surgical stent or night guard 9.0 10. Dynamic bite opening device 36.0 11. Intraoral obturator (includes basic prosthesis) 50.0 12. Speech aid prosthesis (includes basic prosthesis) 50.0 13. Palatal lift prosthesis (includes basic prosthesis) 50.0 14. Stock occular prosthesis 50.0 15. Ear prosthesis 50.0 16. Custom occular prosthesis 75.0 17. Facial prosthesis 75.0 18. Resin bonded retainers 3.0/unit 19. Orthodontic appliance adjustment 2.0/visit

Numeric
EXTRACTIONS # 35 These extractions are considered as simple extractions since no flap was necessary for surgical exposure to extract the tooth or root. Flaps in conjuction with an alveoplasty do not indicate a surgical extraction. This entry includes all post-operative care and instructions.

Numeric
SURGICAL EXTRACTIONS # 36 This includes any type of impaction or an erupted tooth for which an intentional flap is required. This entry includes all post-operative care and instructions.

Numeric
OTHER SIGNIFICANT TREAT (CTV) 37 WEIGHTED VALUES (CTV's) 1. Blood pressure recording 1.0/patient. 2. Topical flouride treatment 2.0/patient. 3. Drug injection (not local anesthetic) 1.0/patient. 4. Prescription writing (Pharmacy) 1.0/patient. 5. Temporary restoration 2.0/patient. 6. Nitrous oxide sedation 2.0/patient. 7. Complete or partial denture adj. (not constructed by treating clinic during this episode of care.) 2.0/patient. 8. Occulusal equilibration (not isolated adjustments) 2.0/quadrant. 9. Recementation of crown 2.0 10. Recementation of fixed bridge 3.0 11. Crown or bridge facing repair or recementation 3.0 12. Tissue conditioning or chairside reline 3.0/visit 13. Temporary crown (not constructed by treating clinic during this episode of care.) 3.0 14. Temporary bridge (not constructed by treating clinic during this episode of care.) 6.0 15. Bleaching of teeth 4.0/visit 16. Attachments (intra or extra coronal, semi-precision or precision) 5.0/attach. 17. Full mouth periodontal charting 6.0/patient. 18. I.V. sedation/medication 6.0/patient. 19. Dental admissions (no O.R.) 9.0/patient. 20. Reline or rebase of a complete or partial denture 12.0/unit

Numeric
OPERATING ROOM 38 These cases will not be credited to a resident provider. They must be credited to a dental staff provider or a dental consultant or attending.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
FACTOR (NOT USED) 39

Numeric
CHANGE/DELETE 40

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CHANGE
  • Code : D
    Stands For: DELETE
RELEASED BY 60

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE RELEASED 61

Date/Time

AR DEBTOR

File Number: 340

File Description:

This file should **NOT** be edited directly by FileMan. By editing this file directly data corruption can occur. This file holds information pertaining to debtor accounts. A debtor can be an insurance company, patient, person, institution, or vendor. Per VHA Directive 10-93-142, this file definition should not be modified.


Fields:

Name Number Description Data Type Field Specific Data
DEBTOR .01 This field contains the debtor to which this account belongs to. An account can belong to an insurance company, vendor, institution, person, or patient. Accounts can be set up for Medical Care Cost Recovery charges and also for non-benefit debts, such as: Employee bills, Ex-employee bills, and Vendor bills.

Variable Pointer
PATIENT STATEMENT DETAIL .02 This field is used to determine the amount of detail to be displayed on the patient statement for RX Copay charges. A site can define brief or detailed information for each patient to be displayed on the statement. Brief information consists only of the RX # and Fill date, while the expanded information consists of much more (Physician, drug name, etc.).

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: USE SITE DEFAULT
  • Code : 1
    Stands For: BRIEF
  • Code : 2
    Stands For: EXPANDED
STATEMENT DAY .03 A statement day is assigned to all types of debtors, except insurance companies. A statement day is the day that a patient statement is generated or a follow-up letter is generated for non-benefit debts. The AR package will hold 'notifications' from being sent until the debtors 'statement day' arrives. This allows all activity since the previous statement to print and update the debtor on the account activity. Patient statement days never change, but Institution, Person, and Vendor statement days are changed by the AR software. When these type debtors have a new active bill, the date the new active bill is created becomes their 'statement day'. This statement day remains in effect until no active bills exist for the debtor, at which time the statement day is 'deleted'. Insurance companies are notified based on a bill-specific date. Since insurance companies have much more activity, they are notified on a constant basis depending on each individual bill 'due-date'.

Numeric
RECEIVABLE CODE .05 This field identifies the type of of debtor

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: DEFAULT
  • Code : 1
    Stands For: FEDERAL
  • Code : 2
    Stands For: NON-FEDERAL
  • Code : 3
    Stands For: OWCP
VENDOR LINK .06 This field is used to link a vendor from file 440 to a debtor that is not a vendor debtor. It is used to get the vendor ID to send to FMS on Billing Documents (BDs).

Pointer
PointerTo:
fileName:
VENDOR
fileNumber:
440
ACCT. PROCESSED (KATRINA) .08 This field will be set by the software whenever a debtor is processed for a possible refund of payments made to interest and/or administrative charges that were charged inappropriately during the Hurricane Katrina emergency period. A '1' in this field indicates that the account was already processed and should not be processed again.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
COPAY CHARGES CANCELLED? .09 This field is used to flag debtors, who were affected by Hurricane Katrina, who had copay charges from 8/29/05 through 2/28/06 cancelled by patch PRCA*4.5*241.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
LAST DATE ACCT CHARGED ADMIN .12 This field is used to track the last date the account was charged an administrative charge.

Date/Time
STREET ADDRESS #1 1.01 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the first address field on patient statements and profiles.

Free Text
STREET ADDRESS #2 1.02 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the second address field on patient statements and profiles.

Free Text
STREET ADDRESS #3 1.03 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the third address field on patient statements and profiles.

Free Text
CITY 1.04 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the city field on patient statements and profiles.

Free Text
STATE 1.05 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the state address field on patient statements and profiles.

Pointer
PointerTo:
fileName:
STATE
fileNumber:
5
ZIP CODE 1.06 For patients, the MCCR/Fiscal staff can enter a 'billing address' that will over-ride the address fields in the patient file. This is necessary for patients that may be incompetent and may need to have a separate billing address from their home address. Once the MAS package supports 'billing addresses', then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the Zip Code address field on patient statements and profiles.

Free Text
PHONE NUMBER 1.07 For patients, the MCCR/Fiscal staff can enter a "billing phone number" that will over-ride the address fields in the Patient file. This is necessary for patients that may be incompetent and may need to have a separate phone number from their home phone number. Once the MAS package supports "billing phone numbers", then the AR software will incorporate this functionality from the MAS package. This field will be displayed as the phone number on the patient account profiles and bill profiles.

Free Text
FOREIGN COUNTRY CODE 1.08 This field will be used for foreign addresses where the state is a foreign country.

Free Text
ADDRESS UNKNOWN 1.09 This field will indicate whether the address is unknown or not.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
COMMENT 2 This field should contain any necessary "general" comments about the debtor. This information will be displayed at the top of the Account Profile.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01 This field should contain any necessary "general" comments about the debtor. This information will be displayed at the top of the Account Profile. This field could, for example, contain a message to remind the agent cashier to remind the patient of an important message.

Word Processing
ACCOUNT AT DMC? 3.01 This field will contain a '1' if this account has been referred to the Debt Management Center (DMC). It will be automatically set by the AR software upon creation of the DMC Master Record.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ACCOUNT FORWARDED TO DMC
DATE SENT TO DMC 3.02 This is the date the DMC Master Record was created and transmitted.

Date/Time
DMC DISCOVERY DATE 3.03 This is the date bill established of the oldest bill referred to DMC.

Date/Time
CURRENT TOTAL AT DMC 3.05 This is the current amount of the debt that has been referred to DMC. This field will be updated by the DMC weekly transmission.

Numeric
CURRENT PRINCIPAL AT DMC 3.06 This is the current principal amount of the debt that has been referred to DMC. This field will be updated by the DMC weekly transmission.

Numeric
CURRENT INTEREST AT DMC 3.07 This is the current interest amount of the debt that has been referred to DMC. This field will be updated by the DMC weekly transmission.

Numeric
CURRENT ADMIN AT DMC 3.08 This is the current admin amount of the debt that has been referred to DMC. This field will be updated by the DMC weekly transmission.

Numeric
LESSER WITHHOLDING AMOUNT 3.09 This field is used to enter a lesser withholding amount for DMC (Debt Management Center). Currently, when a debtor is identified for withholding by DMC, the full amount that the debtor holds is withheld. An amount in this field will allow the DMC to take a lesser amount monthly until the full debt is paid.

Numeric
SITE DELETION FLAG 3.1 This field will be sent whenever a site deletes a debtor from DMC. When the weekly updates encounters this flag, a '0' balance code sheet will be sent to DMC to delete the debtor from their files. However, the debtor could be resent with the next master record run.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DELETED BY SITE
ORIGINAL TOP TIN 4.01 This is the SSN or Tax ID number sent to TOP on the original referral document.

Free Text
ORIGINAL TOP DEBTOR NAME 4.02 This is the name as sent on the original TOP referral document.

Free Text
CURRENT TOP DEBT AMOUNT 4.03

Numeric
ALIAS TOP TIN 4.04 This field contains the most current "Alias" TIN sent to TOP.

Free Text
ALIAS TOP NAME 4.05 This field contains the most current "Alias" name sent to TOP

Free Text
TOP DELINQUENCY DATE 4.06 This is the date of the oldest active bill currently sent to TOP. This is initially entered upon creation of the master documents and may be changed during the creation of the update documents.The date in this field is placed on Recertification and Refund/ Refund Reversal documents.

Date/Time
TOP DEBTOR ADDRESS, LINE 1 5.01 This contains the 1st line of the current debtor address transmitted to TOP.

Free Text
TOP DEBTOR ADDRESS, LINE 2 5.02 This contains the 2nd line of the current debtor address transmitted to TOP.

Free Text
TOP DEBTOR ADDRESS, CITY 5.03 This contains the city included in the current debtor address transmitted to TOP.

Free Text
TOP DEBTOR ADDRESS, STATE 5.04 This field is a pointer to the State file. It includes the state from the current address sent to TOP.

Free Text
TOP DEBTOR ADDRESS, ZIP CODE 5.05 This contains the Zip Code included in the current debtor address transmitted to TOP.

Free Text
DATE DEBTOR REFERRED TO TOP 6.01 This contains the date the account was 1st referred to TOP.

Date/Time
STOP TOP REFERRAL FLAG 6.02 This flag is set whenver a 'Stop TOP Referral' is entered by the user through the menu option RCTOP STOP REFERRAL.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: STOP TOP REFERRAL FLAG SET
STOP TOP REFERRAL EFF. DATE 6.03 This field contains a date, for which bills generated after, are eligible for TOP referral.

Date/Time
STOP TOP REFERRAL REASON 6.04 This field contains a code ,detailing the reason TOP referral was stopped.

Set of Codes
Set of Codes:
  • Code : W
    Stands For: WAIVER
  • Code : B
    Stands For: BANKRUPTCY
  • Code : N
    Stands For: NOT FORWARDED BY AAC
  • Code : O
    Stands For: OTHER
  • Code : R
    Stands For: REJECTED BY TOP
STOP TOP REFERRAL COMMENT 6.05 This field must be answered whenever a reason of 'Other' is entered for stopping TOP referral.

Free Text
TOP REFERRAL HOLD DATE 6.06 This field contains the date the Vendor or Ex-Employee referral will be forwarded to TOP by the AAC.

Date/Time
CURRENT TOP TRACE NUMBER 6.07 This is the number assigned by TOP to the last payment from the debtor.

Free Text
TCSP RECALL FLAG 7.02 The flag that marks this debtor for recall from Cross-Servicing together with all of the debts at Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: TCSP RECALL FLAG SET
TCSP RECALL DATE 7.03 The date that the Cross-Servicing recall record was sent to Cross-Servicing.

Date/Time
TCSP RECALL REASON 7.04 The reason that the debtor is being recalled from Cross-Servicing. Select from: '03' for bankruptcy, '05' for debtor is disabled with inability to pay, '06' for debtor is deceased.

Set of Codes
Set of Codes:
  • Code : 03
    Stands For: BANKRUPTCY WITH AUTOMATIC STAY
  • Code : 05
    Stands For: DEBTOR IS DISABLED WITH INABILITY TO PAY
  • Code : 06
    Stands For: DEBTOR IS DECEASED
DATE DEBTOR REFERRED TO TCSP 7.05 The date that the debtor was first referred to Cross-Servicing.

Date/Time
SSN 110 This field is used to display the SSN of patient and persons on AR reports or local reports.

Computed
LARGE PRINT NEEDED ON STMT 111 This field will identify 1st party debtors requiring statements with large print.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO

AR DATA QUEUE

File Number: 348.4

File Description:

This file contains bill entries which based upon certain criteria have been triggered into this file. These bill entries are used to export data information for CBO to the Boston Allocation Resource Center (ARC).


Fields:

Name Number Description Data Type Field Specific Data
BATCH NUMBER .01 The Batch Number is a sequential counter distinguishing each batch of data to be transmitted

Numeric
BATCH DATE .02 This field will contain the date for which the batch is generated.

Date/Time
STATUS .03 This field contains the status of the batch. 'Pending' will indicate that the batch is ready for the nightly process. 'Transmitted' will indicate that the batch has been sent to the Vitria server but no completed acknowledgement has been received. If the batch is still at the status of 'Transmitted' the next night, it will be sent to Vitria. 'Completed' will indicate that the batch has been successfully received and processed on the Vitria server and records may now be available for purging.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PENDING
  • Code : T
    Stands For: TRANSMITTED
  • Code : C
    Stands For: COMPLETED
BATCH TYPE .04 This field contains the type of data contained in this batch.

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DAILY
  • Code : H
    Stands For: HISTORICAL
  • Code : A
    Stands For: ACTIVE
  • Code : R
    Stands For: DEPOSITS/RECEIPTS
  • Code : C
    Stands For: CURRENT FY
  • Code : E
    Stands For: FY 05
  • Code : P
    Stands For: PRE-REGISTRATION
  • Code : B
    Stands For: BUFFER
  • Code : I
    Stands For: IB COPAY
BATCH SEQUENCE NUMBER .05 This field contains the sequence number of the batch where there may be more than one batch transmitted in the daily transmission.

Numeric
TOTAL BATCH SEQUENCE NUMBER .06 This field contains the total number of batches in a daily transmission.

Numeric
NUMBER OF RECORDS .07 This field will contain the number of records contained in this batch.

Numeric
ACK RECEIVED DATE/TIME .08 This field will contain the date and time that the successful acknowledgement was received from the Vitria server.

Date/Time
ARC ACK RECEIVED DATE/TIME .09 This field contains the date and time that the Boston Allocation Resource Center sent back an acknowledgement that the data was loaded succesfully.

Date/Time
COPAY MONTH/YEAR .1 If this batch is a Co-Pay Transmission, ("I" batch type), this field will hold the month/year that the transmission is for.

Date/Time
BILL NUMBER 1.01

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BILL NUMBER .01 This field will contain the IEN of the bill who was triggered to be processed for this BATCH DATE. This field will be DINUM'd so there will not be any duplicates.

Pointer
PointerTo:
fileName:
ACCOUNTS RECEIVABLE
fileNumber:
430
PATIENT .02 This is the patient associated with the bill.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
AR BATCH PAYMENT 2.01

Subfile
subfile:
Name Number Description Data Type Field Specific Data
AR BATCH PAYMENT .01 This field will contain any batch payments for a specific date. It will be used to transmit information to the Boston Allocation Resource Center or re-transmit as needed.

Pointer
PointerTo:
fileName:
AR BATCH PAYMENT
fileNumber:
344
COPAY PATIENT 3.01

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COPAY PATIENT .01 If this transmission is a Co-Pay transmission ("P" batch type), this field will contain the IEN of the patient whose data will be transmitted. This field will be DINUMed, so there are no duplicates. This field is populated from routine RCXVDC10.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PRE-REGISTRATION MONTH/YEAR 4 If this batch is a Pre-registration transmission, ("P" batch type), this field will hold the month/year that the transmission is for.

Date/Time
INSURANCE BUFFER MONTH/YEAR 5 If this batch is a Buffer file transmission, ("B" batch type), this field will hold the month/year that the transmission is for.

Date/Time

AMIE REPORT

File Number: 396.2

File Description:

File to hold various parameters for specialized reporting in the A.M.I.E. package. Information is deleted as soon as possible. (This file is used specifically when generating and printing Notices of Discharge.)


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 Name of the Patient.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
7132 ADMISSION DATE 1 This field holds the date of admission for a veteran. It is used when printing Notices of Discharge.

Date/Time
7132 ADMISSION POINTER 2 Pointer to the Patient Movement file.

Numeric
7132 STATUS 3 The print status of the Notice of Discharge Record.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PRINTED
  • Code : R
    Stands For: READY TO PRINT
7132 ROUTING LOCATION 3.5 Holds the Patient File Claim Folder Location from which a Notice of Discharge was generated for the patient.

Free Text
DATE 7132 PRINTED 4 This field contains the date the Notice of Discharge was originally printed.

Date/Time
7132 PRINTED BY 5 Indicates the name of the person who originally printed the Notice of Discharge.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

2507 REQUEST

File Number: 396.3

File Description:

Holds all 2507 requests generated from Regional Office users.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field contains the name of the veteran for whom you are requesting a 2507 exam.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
REQUEST DATE 1 This field contains the date the 2507 request was entered.

Date/Time
REGIONAL OFFICE NUMBER 2 This field contains the name of the regional office that entered the request.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
REQUESTER 3 This field contains the name of the regional office employee who entered the 2507 request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE REPORTED TO MAS 4 This is the date the request was reported (printed) to MAS. It can only be set one time, at the first printing. Future prints or reprints of the same request will not alter the "starting" date. This date is the basis for when the clock begins for both the RO and MAS. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
DATE SCHEDULING COMPLETED 5 This field contains the date scheduling of the 2507 request was completed through the AMIE option. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
DATE COMPLETED 6 This field contains the date the entire 2507 request was completed.

Date/Time
PRIORITY OF EXAM 9 This field contains the status of the 2507 exam to be conducted.

Set of Codes
Set of Codes:
  • Code : T
    Stands For: TERMINAL
  • Code : P
    Stands For: POW
  • Code : OS
    Stands For: ORIGINAL SC
  • Code : ON
    Stands For: ORIGINAL NSC
  • Code : I
    Stands For: INCREASE
  • Code : R
    Stands For: REVIEW
  • Code : OTR
    Stands For: OTHER
  • Code : E
    Stands For: INSUFFICIENT EXAM
  • Code : AO
    Stands For: AGENT ORANGE
  • Code : BDD
    Stands For: BEN DELIV AT DISCHG
  • Code : DCS
    Stands For: DES CLAIMED COND BY SVCMBR
  • Code : DFD
    Stands For: DES FIT-FOR-DUTY
  • Code : QS
    Stands For: QUICK START
OTHER DISABILITIES [Line 1] 10 This field contains other known disabilities or those stated by the veteran.

Free Text
OTHER DISABILITIES [Line 2] 10.1 This field contains other known disabilities or those stated by the veteran.

Free Text
OTHER DISABILITIES [Line 3] 10.2 This field contains other known disabilities or those stated by the veteran.

Free Text
TRANSCRIPTION DATE 11 This field contains the date/time transcription was completed.

Date/Time
DATE APPROVED 12 This field contains the date/time exam results were approved.

Date/Time
DATE RELEASED 13 This field contains the date/time the 2507 request was released to the regional office for printing. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
RELEASED BY 14 This field contains the name of the MAS employee who released the request to the regional office.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE PRINTED BY THE RO 15 This field contains the date/time the examination results were printed by the regional office.

Date/Time
PRINTED BY 16 This field contains the name of the regional office employee who printed the examination results.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REQUEST STATUS 17 This field contains the request status of the 2507 exam request.

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NEW
  • Code : P
    Stands For: PENDING, REPORTED
  • Code : S
    Stands For: PENDING, SCHEDULED
  • Code : R
    Stands For: RELEASED TO RO, NOT PRINTED
  • Code : C
    Stands For: COMPLETED, PRINTED BY RO
  • Code : X
    Stands For: CANCELLED BY MAS
  • Code : RX
    Stands For: CANCELLED BY RO
  • Code : T
    Stands For: TRANSCRIBED
  • Code : NT
    Stands For: NEW, TRANSFERRED IN
  • Code : CT
    Stands For: COMPLETED, TRANSFERRED OUT
ELAPSED TIME 18 This field contains the computation of TODAY - DATE REPORTED TO MAS.

Computed
CANCELLATION DATE 19 This field contains the date/time the entire request was cancelled. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
CANCELLED BY 20 This field contains the name of the employee who cancelled the entire request.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLAIM FOLDER REQUIRED? 21 This field indicates whether or not a claim folder is required for this request.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
OTHER DOCUMENTS REQUIRED? 22 This field indicates whether or not a document will be able to be printed at the regional office. If YES, the regional office will not be prompted to print the document when it is released by the Medical Center.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
REMARKS 23 This field contains the remarks that are entered for a 2507 request.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REMARKS .01

Word Processing
LAST EXAM ADD DATE 23.3 This field contains the last date an exam was added to this request.

Date/Time
LAST PERSON TO ADD EXAM 23.4 This field contains the name of the last person to add an exam to this request after it was originally entered by the RO.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REMARKS MODIFICATION DATE 23.5 This field contains the date the REMARKS field was last modified.

Date/Time
REMARKS MODIFIED BY 23.6 This field contains the name of the employee who last modified the REMARKS field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ROUTING LOCATION 24 This field contains the station name or number of the site which will be responsible for this request.

Pointer
PointerTo:
fileName:
MEDICAL CENTER DIVISION
fileNumber:
40.8
APPROVED BY 25 This field contains the name of the employee who approved the examination results.

Free Text
APPROVAL DATE/TIME 26 This field contains the date/time the exam was approved.

Date/Time
*EXAM 27 Data moved to File #396.4; field starred for deletion.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
*EXAM .01 Data moved to File #396.4; field starred for deletion.

Pointer
PointerTo:
fileName:
AMIE EXAM
fileNumber:
396.6
*WORKSHEET PRINTED? .5 Data moved to File #396.4; field starred for deletion.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
*STATUS 1 Data moved to File #396.4; field starred for deletion.

Set of Codes
Set of Codes:
  • Code : O
    Stands For: OPEN
  • Code : C
    Stands For: COMPLETED
  • Code : X
    Stands For: CANCELLED BY MAS
  • Code : RX
    Stands For: CANCELLED BY RO
  • Code : T
    Stands For: TRANSFERRED OUT
*CANCELLATION REASON 2 Data moved to File #396.4; field starred for deletion.

Pointer
PointerTo:
fileName:
2507 CANCELLATION REASON
fileNumber:
396.5
*EXAM CANCELLED BY 2.3 Data moved to File #396.4; field starred for deletion.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
*EXAM CANCELLATION DATE/TIME 2.5 Data moved to File #396.4; field starred for deletion.

Date/Time
*DATE OF EXAM 3 Data moved to File #396.4; field starred for deletion.

Date/Time
*EXAMINING PHYSICIAN 4 Data moved to File #396.4; field starred for deletion.

Free Text
*IS THIS A FEE EXAM? 5 Data moved to File #396.4; field starred for deletion.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
*EXAM PLACE 6 Data moved to File #396.4; field starred for deletion.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CLINIC
  • Code : F
    Stands For: FEE LOCATION
  • Code : O
    Stands For: OTHER STATION
*RESULTS 7 Data moved to File #396.4; field starred for deletion.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RESULTS .01

Word Processing
*TRANSFERRED OUT TO 8 Data moved to File #396.4; field starred for deletion.

Pointer
PointerTo:
fileName:
DOMAIN
fileNumber:
4.2
*TRANSFERRED OUT BY 8.5 Data moved to File #396.4; field starred for deletion.

Free Text
*DATE TRANSFERRED OUT 9 Data moved to File #396.4; field starred for deletion.

Date/Time
*DATE TRANSFERRED IN 10 Data moved to File #396.4; field starred for deletion.

Date/Time
*DATE RETURNED TO OWNER SITE 11 Data moved to File #396.4; field starred for deletion.

Date/Time
RETURNED TO OWNER SITE BY 27.5 This field contains the name of the employee who returned the transferred request to the owner site.

Free Text
OWNER DOMAIN 28 For transferred-in requests, this field contains the domain of the site which owns the request.

Pointer
PointerTo:
fileName:
DOMAIN
fileNumber:
4.2
LAST RATING EXAM DATE 29 This field contains the date of the last rating exam.

Date/Time
ORIGINAL REQUEST POINTER 30 This field contains a number which is used to point to the original request at the original site.

Numeric
TRANSFERRED TO ANOTHER SITE? 31 This field is set to YES if either the entire request or individual exams on it have been transferred to another site.

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
DATE TRANSFERRED TO OTHER SITE 32 This is the date the owner site transferred this request to another site. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
DATE TRANSFRD IN FRM REM SITE 33 This field contains the date this transferred in request was received from the owner site. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
DATE ALL TRANSFERS RETURNED 34 A request may be transferred to multiple sites. This field represents the date the last transfer on the request was received back at the owner site. Only after this date is set will the request be counted on the AMIS 290. This field is used as part of the implementation of a Nationally Controlled Procedure (AMIS 290). Per VHA Directive 10-93-142, the information contained in this field is not to be changed as the results of local (site) modifications.

Date/Time
ORIGINAL 2507 REQUEST 44 This field is a pointer to the insufficient request this 2507 was entered for.

Pointer
PointerTo:
fileName:
2507 REQUEST
fileNumber:
396.3
ORIGINAL 2507 PROCESSING TIME 45 This field contains the processing time of the original request the insufficient request was entered for.

Numeric

PATIENT APPOINTMENT INFO LOG

File Number: 409.6

File Description:

The Patient Appointment Information Transmission (PAIT) log is maintained in this file. Log entries are added when appointment information is transmitted to the Austin Automation Center via HL7 messages. File entries are deleted automatically when HL7 acknowledgments are received.


Fields:

Name Number Description Data Type Field Specific Data
RUN DATE .01 The date the extract started running at the site. Extracts are run as Taskman background jobs.

Date/Time
TASK ID 1 The Taskman task ID number. When the extract is run the Taskman ID of the process is stored in this field.

Free Text
LAST BATCH # OF THIS RUN 1.1 This is the the Message Conrol ID of MSH segment in the latest created HL7 batch. When the extract is run an HL7 batch is created that may contain up to 5000 individual messages.

Numeric
LAST SCANNED DATE 1.2 This field represents an appointment creation date that was completely scanned as the last one with this transmission.

Date/Time
# OF APPOINTMENTS 1.3 This is the number of appointments corresponding to individual MSG segments sent with this transmission.

Numeric
# OF BATCHES 1.4 This is the number of batches generated during the run.

Numeric
TRANSMISSION FINISHED 1.5

Date/Time
PATIENT 2 The multiple field that records key elements of the patient appointment extract.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01 This subfield will hold the pointer to the Patient file to identify a name of each patient whose appointment information is being transmitted.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
APPT DATE 1 This is the date/timen the appointment was scheduled for by the scheduling package. This date and the appointment creation date is used in the patient wait time calculation.

Date/Time
HL7 MESSAGE ID 2 This field represents the HL7 message number. The message number is used in conjunction with incoming HL7 acknowledgement messages to identify the original extract message. This message # corresponds to the Message Control ID in MSG segment. Each message # corresponds to a unique batch # and that relation is identified in the Batch Tracking multiple (#3) where it is represented as the MESSAGE CONTROL ID field (#.03).

Free Text
HL7 SEQUENCE ID 3 This number corresponds to a location of this nessage within the Batch #.

Free Text
RETENTION FLAG 4 This flag will determine if the entry is to remain in the file to be transmitted on the subsequent run. Also it may indicate that another entry was created because of 'S' - sending as final or 'R' - resending because of rejection.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES - to be sent when 'Final'
  • Code : N
    Stands For: NO - was sent as 'Final'
  • Code : S
    Stands For: SENT as 'Final' with another entry
  • Code : R
    Stands For: RESENT - because of rejection
EVENT REASON 5 Event reason code as it is files into SCH.6 segment of HL7 message.

Set of Codes
Set of Codes:
  • Code : CI
    Stands For: Check-in
  • Code : NS
    Stands For: No Show
  • Code : CC
    Stands For: Canceled by Clinic
  • Code : CP
    Stands For: Canceled by Patient
  • Code : COE
    Stands For: Checked out by Encounter
  • Code : NM
    Stands For: No Match
  • Code : CO
    Stands For: Checked-out
  • Code : CT
    Stands For: Canceled Terminated
DATE APPT MADE 6 This is the date when an appointment was created.

Date/Time
ERROR MESSAGE 7 If the Error Flag as 'R' or numeric error code is entered it means that that appointment has to be resent with its current status. A new entry will be created.

Pointer
PointerTo:
fileName:
PCMM HL7 ERROR CODE
fileNumber:
404.472
APPOINTMENT TYPE 8 This field records a descriptive code of the appointment type and it implements the Event Reason as the appointment identifier.

Set of Codes
Set of Codes:
  • Code : AR
    Stands For: Action Required
  • Code : NAT
    Stands For: No Action Taken
  • Code : F
    Stands For: Future
  • Code : NC
    Stands For: Non Count
  • Code : I
    Stands For: Inpatient
  • Code : NCF
    Stands For: Non Count Future
  • Code : ABK
    Stands For: Auto Rebook
  • Code : RS
    Stands For: Rescheduled
  • Code : O
    Stands For: Outpatient
  • Code : RSN
    Stands For: Rescheduled Non Count
CLINIC 9

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
BATCH TRACKING 3

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BATCH CONTROL ID .01 This fields corresponds to the Batch Control ID from the BSH segment.

Free Text
BATCH CREATE DATE/TIME .02 The date/time HL7 packages creates the batch message.

Date/Time
MESSAGE CONTROL ID .03 This fields corresponds to the Message Control ID from MSH segment.

Free Text
APPLICATION ACK DATE/TIME .04 This is the date/time Vista HL7 receives the application acknowledgement from the Vista Interface Engine.

Date/Time
APPLICATION ACK TYPE .05

Set of Codes
Set of Codes:
  • Code : AA
    Stands For: APPLICATION ACCEPT
  • Code : AE
    Stands For: APPLICATION ERROR
  • Code : AR
    Stands For: APPLICATION REJECT
  • Code : MR
    Stands For: MANUAL REJECTION

ACCOUNTS RECEIVABLE

File Number: 430

File Description:

This is the main file of the Accounts Receivable system. It holds a permanent record, by bill number, of the receivable. DO NOT USE FILEMAN TO EDIT THIS FILE DIRECTLY! Using FileMan will compromise system integrity. Use the AR menu options. Per VHA Directive 10-93-142, this file definition should not be modified.


Fields:

Name Number Description Data Type Field Specific Data
BILL NO. .01 This is the unique bill number assigned to this billing episode. New bill numbers consist of 7 characters, preceded by station number if multi-divisional (Example: 662-K000001). Bill numbers for bills that have been cancelled in Integrated Billing (IB) during the process of correcting errors in the original bill add an additional 3 characters, a hyphen and an incremental number (Example: 662-K000001-01).

Free Text
LAST INTEREST CHARGE DATE .11 This field stores the last date interest was charged to this bill.

Date/Time
LAST ADMIN CHARGE DATE .12 This field stores the last date an administrative charge was applied to this bill.

Date/Time
LAST PENALTY CHARGE DATE .13 This field stores the last date penalty charges were added to this bill.

Date/Time
FISCAL YEAR 1 A single bill can have activity that spreads over more than one fiscal year. This multiple field holds a record of each year's appropriation symbol, PAT reference number, original amount, etc.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FISCAL YEAR .01 This is the 2-digit code representing the Fiscal Year, for instance, 89 stands for Fiscal Year 1989. Bills may have data for more than one Fiscal year.

Free Text
CURR.PRIN.BAL. 1 This is the current principal balance for the Fiscal Year.

Numeric
PAT REF NO. 2 ***This field is obsolete with version 4.5 and will be deleted with an upcoming cleanup patch.

Free Text
APPROPRIATION SYMBOL 3 This is the accounting symbol that represents the annual appropriation for this bill.

Free Text
ALD CODE 4 This is a pointer to the ALD Code File (Appropriation/Limitation/Department). New entries are not allowed.

Pointer
PointerTo:
fileName:
PRCD FUND/APPROPRIATION CODE
fileNumber:
420.3
CALM CODE DONE 5 This is a set of codes, indicating whether or not a CALM code sheet has been completed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: NOT DONE
  • Code : 2
    Stands For: DONE
FY ORIGINAL AMOUNT 7 This is the original amount of the charges for this Fiscal Year.

Numeric
CATEGORY 2 This is the bill's Category - a pointer to the Category File (Means Test, Vendor, Employee, Tort, etc.).

Pointer
PointerTo:
fileName:
ACCOUNTS RECEIVABLE CATEGORY
fileNumber:
430.2
ORIGINAL AMOUNT 3 This is the original dollar amount of the bill.

Numeric
GL NO. 4 This is the General Ledger Number for the ALD CODE assigned to this bill.

Free Text
BILL RESULTING FROM 4.5 The cause of the debt. This field points to the AR Debt List File which contains brief statements describing the source of the bills that are used on the debt collection letters. The type of entry selected must be compatible with the bill's category type.

Pointer
PointerTo:
fileName:
AR DEBT LIST
fileNumber:
430.6
PATIENT 7 This is a pointer to the Patient File. Adding new patients is NOT ALLOWED through this option.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
CURRENT STATUS 8

Pointer
PointerTo:
fileName:
ACCOUNTS RECEIVABLE TRANS.TYPE
fileNumber:
430.3
DEBTOR 9 This field points to the Debtor File, which in turn is a variable pointer to other files. This allows automatic look-up of debtors based on the category of the bill. Adding new entries to the other files may not be allowed.

Pointer
PointerTo:
fileName:
AR DEBTOR
fileNumber:
340
DATE BILL PREPARED 10 The date the bill was prepared. Time is not allowed.

Date/Time
CURRENT BALANCE 11 This field computes the current balance of the account.

Computed
SITE 12 This is a pointer to the Admin. Activity Site Parameter File. Adding new entries is allowed.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
AGENT CASHIER 13 This field is an inactive field and used to point to the AR SITE PARAMETER file (430.5) in AR v3.7.

Pointer
PointerTo:
fileName:
AR GROUP
fileNumber:
342.1
ACCOUNT RECEIVABLE SECTION 13.1 This field is inactive and use to point to the AR SITE PARAMETER file (430.5) in AR v3.7.

Pointer
PointerTo:
fileName:
AR GROUP
fileNumber:
342.1
DATE STATUS UPDATED 14

Date/Time
STATUS REMARK 15 An optional field that holds a brief remark regarding the status, reason for change in status, etc. 3-45 characters.

Free Text
TYPE OF CARE 15.1 This is a pointer to the AR category file. This entry should be 'NURSING HOME CARE', 'OUTPATIENT CARE' or 'HOSPITAL CARE'. Adding new entries is not allowed.

Pointer
PointerTo:
fileName:
ACCOUNTS RECEIVABLE CATEGORY
fileNumber:
430.2
DATE CALM DONE 16 The date the PAT reference number was assigned and the CALM code sheet was done.

Date/Time
STATUS UPDATED BY 17 This is a pointer to the New Person File. It extracts the name of the person making a change to the bill's status. Adding new entries is not allowed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
APPROPRIATION SYMBOL 18 This is a free-text field holding the appropriation symbol. 7-10 characters.

Free Text
SECONDARY INSURANCE CARRIER 19 This is a pointer to the Insurance Company File. Adding new entries is not allowed.

Pointer
PointerTo:
fileName:
INSURANCE COMPANY
fileNumber:
36
TERTIARY INSURANCE CARRIER 19.1 This is a pointer to the Insurance Company File. Adding new entries is not allowed.

Pointer
PointerTo:
fileName:
INSURANCE COMPANY
fileNumber:
36
SEGMENT 20.1 This is the number of the billing category's AMIS reporting segment.

Numeric
HOLD LETTER DATE 21 This is the date a hold is/was placed on follow-up letters for this account.

Date/Time
HOLD LETTER REASON 22 This is the reason a hold was placed on sending follow-up letters. Select from the list of choices.

Set of Codes
Set of Codes:
  • Code : L
    Stands For: PERSONAL LETTER
  • Code : P
    Stands For: PHONE CALL
  • Code : V
    Stands For: PERSONAL VISIT
  • Code : O
    Stands For: OTHERS
HOLD LETTER COMMENTS 23 This field allows the user to enter expanded comments on the reason for holding follow-up letters.

Free Text
DATE RETURNED TO SERVICE 31 This is the date a bill was returned to the originating service.

Date/Time
RETURNED BY 32 This is the user from the New Person File who returned the bill to the originating service. Adding a new Person is not allowed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AMENDED DATE 33 This is the date this bill was amended.

Date/Time
AMENDED BY 34 This is the user from the New Person File who amended this bill. Adding a new Person is not allowed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AMENDED AMOUNT 35 This is the dollar value of the amendment. It can be a positive or negative figure.

Numeric
FISCAL COMMENTS (RETURN) 36 This text field holds Fiscal service comments regarding the return of a bill.

Free Text
SERVICE COMMENTS (AMEND) 37 This text field holds the Service's comments regarding the amendment of a bill.

Free Text
REPAYMENT PLAN DATE 41 This is the date a repayment plan was established.

Date/Time
DAY OF MON. PAYMENT DUE 42 This is the day of the month that payments are due according to the repayment plan.

Numeric
REPAYMENT AMOUNT DUE 43 This is the monthly payment amount agreed upon in the repayment plan.

Numeric
NUMBER OF PAYMENTS 44 This is the number of payments agreed upon in the repayment plan.

Numeric
REPAYMENT DUE DATES 51 This multiple field holds information about each payment received during the repayment plan.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REPAYMENT DUE DATES .01 This is the date a payment is due.

Date/Time
PAYMENT RECEIVED 1 This indicates whether or not a payment was received.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SEND STATEMENT 2 This indicates whether or not a statement of account was mailed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
PAYMENT DATA 4 This is the AR transaction for this repayment date.

Pointer
PointerTo:
fileName:
AR TRANSACTION
fileNumber:
433
DATE SENT PAYMENT STATEMENT 5 This is the date the statement was sent to the debtor.

Date/Time
DATE ACCOUNT ACTIVATED 60

Date/Time
LETTER1 61 This is the date the first debt collection letter was sent to the debtor.

Date/Time
LETTER2 62 This is the date the second debt collection letter was sent to the debtor.

Date/Time
LETTER3 63 This is the date the third debt collection letter was sent to the debtor.

Date/Time
REFERRAL DATE 64 This is the date the account was referred to the Regional Counsel or the Department of Justice for collection.

Date/Time
REFERRAL CODE 65 This field indicates where an account was referred to.

Set of Codes
Set of Codes:
  • Code : RC
    Stands For: REGIONAL COUNSEL
  • Code : DOJ
    Stands For: DEPT.OF JUSTICE
  • Code : DC
    Stands For: REGIONAL COUNSEL
REFERRAL AMOUNT 66 This is the account balance that was referred.

Numeric
LAST INT/ADM CHARGE DATE 67 This is the most recent date that Interest/Administrative costs were charged to the account.

Date/Time
LETTER4 68 This is the date the fourth debt collection letter was sent to the debtor.

Date/Time
LAST LETTER DATE 68.1 This is the date of the most recent debt collection letter.

Date/Time
RE-REFERRAL DATE 68.2 This is the date the account was re-referred to the Regional Counsel or Department of Justice.

Date/Time
RETURNED DATE BY RC/DOJ 68.3 This is the date a referred account was returned by the Regional Counsel or Department of Justice.

Date/Time
REFERRAL DATE TO COWC 68.4 This is the date the account was referred to the DVB Committee on Waivers and Compromise.

Date/Time
REFERRED AMOUNT TO COWC 68.5 This is the balance of an account referred to the DVB Committee on Waivers and Compromise.

Numeric
IRS OFFSET LETTER 68.6 This field stores the last date an IRS Offset letter was printed that contained the amount due from the bill.

Date/Time
DATE FORWARDED TO IRS 68.7 This is the date the receivable was forwarded to the IRS.

Date/Time
IRS PRINCIPAL BALANCE 68.8 This is the principal balance of the receivable forwarded to the IRS.

Numeric
IRS INTEREST BALANCE 68.9 This is the Interest Balance forwarded to the IRS.

Numeric
IRS ADMIN. BALANCE 68.91 This is the Administrative Balance forwarded to the IRS.

Numeric
ORIGINAL IRS LETTER AMOUNT 68.92 This is the Original Amount of the bill forwarded to the IRS.

Numeric
ORIGINAL IRS OFFSET AMOUNT 68.93 This is the Original IRS Offset Amount.

Numeric
REFERRAL REASON CODE 68.94 This is a code for the transmission to Regional Counsel to let them know the reason for the referral. This is required for the transmission.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: LITIGATION ISSUES
  • Code : 2
    Stands For: VET NOT RESP FOR COST OF CARE
  • Code : 3
    Stands For: REFUSAL TO PAY GOV HOSPITAL
  • Code : 4
    Stands For: VETERAN PAID DIRECTLY
  • Code : 5
    Stands For: MCCR REF WITH RC CONSENT
REFERRAL COMMENT 68.95 Enter specific information on the account pertaining to the reason for referral; date, time of call and contact person the staff spoke with at the Regional Counsel.

Free Text
OVER LETTER3 69 This field computes the length of time since the third debt collection letter was mailed.

Computed
DELINQUENT DAYS 70 This field computes the number of days an account is delinquent by subtracting the date of the first debt collection letter from the current date.

Computed
PRINCIPAL BALANCE 71 This field is set to the original amount when a new bill is established.

Numeric
INTEREST BALANCE 72 This is the balance due for interest charges on this bill.

Numeric
ADMINISTRATIVE COST BALANCE 73 This is the balance due for administrative costs on this bill.

Numeric
MARSHAL FEE 74 This is the amount of the Marshal Fee included in this bill.

Numeric
COURT COST 75 This is the amount of court costs included in this bill.

Numeric
TOTAL PAID PRINCIPAL 77 This is the total amount received toward this bill's principal balance.

Numeric
TOTAL PAID INTEREST 78 This is the total amount received toward this bill's interest charges.

Numeric
TOTAL PAID ADMINISTRATIVE COST 79 This is the total amount received toward this bill's administrative cost charges.

Numeric
TOTAL PAID MARSHAL FEE 79.1 This is the total amount received toward this bill's Marshal Fee.

Numeric
OUTSTANDING PB 79.12 This is the total outstanding principal balance for this debtor's account.

Numeric
OUTSTANDING IB 79.13 This is the total outstanding principal interest balance for this debtor's account.

Numeric
OUTSTANDING AB 79.14 This is the total outstanding administrative cost charges for this debtor's account.

Numeric
OUTSTANDING MF 79.15 This is the total outstanding marshal's fee for this debtor's account.

Numeric
OUTSTANDING CC 79.16 This is the total outstanding court cost for this debtor's account.

Numeric
EXCESS PAYMENT AMOUNT 79.17 This field stores the amount of a patient's excess payment.

Numeric
REFUNDED AMOUNT 79.18 This field stores the dollar amount that has been refunded to the patient.

Numeric
REFUNDED DATE 79.19 This field stores the date the refund was made.

Date/Time
TOTAL PAID COURT COST 79.2 This is the total amount received toward this bill's court costs.

Numeric
REFUNDED BY 79.21 This field stores the name of the person who approved the refund. It is a pointer to the New Person File.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
IRS LOCATION COST 81 This is the amount charged to the bill for an IRS locator search.

Numeric
CREDIT REP. COST 82 This is the amount charged to the bill for a credit report locator check.

Numeric
DMV LOCATION COST 83 This is the amount charged to the bill for a state agency/department of motor vehicles locator search.

Numeric
DMV LOCATION CHECK 83.1 This flag indicates whether or not a state agency/department of motor vehicles locator check was done.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CONSUMER REP. AGENCY COST 84 This is the amount charged to the bill for a consumer rep. agency locator search.

Numeric
POSTAL LOCATION COST 85 This is the amount charged to the bill for a US Postal Service locator search.

Numeric
ABLE TO PAY 86 This flag indicates whether or not the debtor is able to pay this bill.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
ABLE TO LOCATE 87 This flag indicates whether or not the debtor could be located.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
POSTAL LOC.DATE SENT 88 This is the date a request to locate the debtor was sent to the US Postal Service.

Date/Time
POSTAL LOC.DATE RECEIVED 89 This is the date a reply was received to the Postal locator request.

Date/Time
IRS ABLE TO LOCATE 89.1 This flag indicates whether or not the IRS was able to locate the debtor.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
IRS LOC. DATE SENT 89.2 This is the date a request to locate the debtor was sent to the IRS.

Date/Time
IRS LOC. DATE RECEIVED 89.3 This is the date a reply was received to the IRS locator request.

Date/Time
CREDIT REP. ABLE TO PAY 89.4 This flag indicates whether or not the credit report says the debtor is able to pay the bill.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
CREDIT REPT. DATE SENT 89.5 This is the date a request for a credit report was sent.

Date/Time
CREDIT REP. DATE RECEIVED 89.6 This is the date the requested credit report was received.

Date/Time
PATIENT FOLDER REVIEWED 89.7 This flag indicates whether or not the debtor's Patient Folder was reviewed for locator information.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DATE FOLDER REVIEWED 89.8 This is the date the debtor's Patient Folder was reviewed.

Date/Time
APPROVED BY (FISCAL) 90 This is the person in Fiscal who approved the bill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AR ELECTRONIC SIGNATURE 91

Free Text
AR DATE SIGNED 92 This is the date the bill was signed in Fiscal.

Date/Time
AR APPR.OFFICIAL'S TITLE 93 This is the approving official's title.

Free Text
APPROVED BY (BILLING) 94 This is the person who approved the bill in the Service or Section.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS STATUS 95 This is the former status of the bill if it has been changed.

Pointer
PointerTo:
fileName:
ACCOUNTS RECEIVABLE TRANS.TYPE
fileNumber:
430.3
APPROVED DATE (SERVICE) 96 This is the date the bill was approved in the Service or Section.

Date/Time
PROCESSED BY (SERVICE) 97 This is the person in the Service or Section who processed the bill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENTS 98 This word processing field allows the AR Clerk or Supervisor to add optional comments at the time the bill is audited.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01 This word processing field allows the AR Clerk or Supervisor to add a comment at the time the bill is audited.

Word Processing
FORM TYPE 100 This response indicates the type of form for the bill. (1080, 1081 or 1114).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: 1081
  • Code : 2
    Stands For: 1080
  • Code : 3
    Stands For: 1114
SERVICE 101 This is the Service or Section that originated the bill.

Pointer
PointerTo:
fileName:
SERVICE/SECTION
fileNumber:
49
VOUCHER NUMBER 104 This is the billing Service/Section's voucher number. It is used on the 1080, 1081 and 1114 bill forms.

Free Text
DESCRIPTION 106 This is a description of the bill.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE OF CHARGES .01 This is the date that the charges were incurred.

Date/Time
DESCRIPTION OF CHARGES 2 This is a description of the individual charges on the bill.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01 This is a description of the individual charges on the bill.

Word Processing
QUANTITY (UNITS) 3 If the total amount of charges is computed using units of issue, then this is the number of units that are being billed.

Numeric
UNIT COST 4 This is the billing cost of a single unit of issue.

Numeric
UNIT 5 This is the unit of issue -- EA, BX, DZ, etc.

Pointer
PointerTo:
fileName:
UNIT OF ISSUE
fileNumber:
420.5
TOTAL AMOUNT 6 This total is computed by multiplying the number of units by the cost per unit.

Numeric
ORDER NO. 7 If the Service or Section has an order number associated with this bill it is entered here.

Free Text
BILLING AGENCY 107 This is the billing agency from the AR Site Parameter file.

Pointer
PointerTo:
fileName:
AR GROUP
fileNumber:
342.1
AGENCY LOCATION CODE (ALC) 108 This is the Agency Location Code.

Free Text
DOCUMENT NUMBER 110 This is the Document Number used on the 1081 bill form.

Numeric
APPROVING OFFICIAL (SERVICE) 111 This is the person in the Service or Section who approved the bill.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ELECTRONIC SIGNATURE 112

Free Text
DATE SIGNED (APPROVED) 113 This is the date the bill was approved in the Service or Section.

Date/Time
APPR. OFFICIAL'S TITLE 114 This is the title of the person who approved the bill in the Service or Section.

Free Text
DATE SENT TO DMC 121 This is the date that the bill was first sent to the Debt Management Center.

Date/Time
DMC PRINCIPAL BALANCE 122 This is the current principal balance for the bill that is at the Debt Management Center.

Numeric
DMC INTEREST BALANCE 123 This is the current interest balance for the bill that is at the Debt Management Center.

Numeric
DMC ADMIN BALANCE 124 This is the current administrative cost balance for the bill that is at the Debt Management Center.

Numeric
DMC Debt Valid 125 If the field value is NULL the nightly DMC job will prevent the debt from being referred to DMC when the debtor is SC 50% to 100% or in Receipt of a VA Pension. It will then set this field value to PENDING so the users will know this is what occurred. If a user sets this field value to YES and the debt meets all criteria to be sent to DMC it will be referred to DMC even if the debtor is SC 50% to 100% or in Receipt of a VA Pension. If a user sets this value to NO the debt will not be referred to DMC. Users should only interactively be able to set the value to YES or NO. PENDING is reserved for the nightly DMC job.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : P
    Stands For: PENDING
DMC Debt Valid Edited By 126 This is a pointer to the New Person File. It extracts the name of the last person making a change to the DMC Debt Valid field. Adding new entries to the New Person File is not allowed.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DMC Debt Valid Edited Date 127 This is the Date and Time a user last edited the DMC Debt Valid Field.

Date/Time
MEDICARE CONT. ADJUSTMENT 131 This field will reflect the Medicare contractual adjustment for a bill.

Numeric
MEDICARE UNREIMBURSABLE 132 This field will reflect the Medicare Unreimbursable Expense for a bill.

Numeric
DATE BILL REFERRED TO TOP 141 This field contains the date that the bill was originally referred to TOP.

Date/Time
TOP REFUND STATUS 142 This field contains the current status of a TOP refund.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: REFUND
  • Code : 2
    Stands For: REFUND TRANSMITTED
  • Code : 3
    Stands For: REVERSAL
  • Code : 4
    Stands For: REVERSAL TRANSMITTED
TOP TRACE NUMBER 143 This field contains the trace number attached to the refund.

Free Text
TOP REFUND YEAR 144 This field contains the calendar year for which the refund is granted.

Free Text
DATE BILL REFERRED TO TCSP 151 The date that the debt was referred to Cross Servicing.

Date/Time
TCSP RECALL FLAG 152 The flag that marks this debt for recall record creation from Cross-Servicing when the AR nightly background job is run.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CROSS-SERVICING RECALL SET
TCSP RECALL EFF. DATE 153 The date that the recall flag is set for the debt.

Date/Time
TCSP RECALL REASON 154 The reason that the debt is being recalled from Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : 01
    Stands For: DEBT REFERRED IN ERROR
  • Code : 07
    Stands For: AGENCY IS FORGIVING DEBT
  • Code : 08
    Stands For: AGENCY CAN COLLECT THROUGH INTERNAL OFFSET
  • Code : 15
    Stands For: DEBTOR WAS INCORRECTLY ASSOCIATED WITH THE DEBT
  • Code : 03
    Stands For: BANKRUPTCY
  • Code : 05
    Stands For: DEBTOR DISABLED
  • Code : 06
    Stands For: DEBTOR DECEASED
RECALL AMOUNT 155 The amount of the debt being recalled from Cross-Servicing.

Numeric
STOP TCSP REFERRAL FLAG 157 The flag that stops further Cross-Servicing activity for this debt.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: STOP TCSP REFERRAL SET
STOP TCSP REFERRAL EFF. DATE 158 The date that the stop flag was set for the debt.

Date/Time
STOP TCSP REFERRAL REASON 159 The reason that the debt is being stopped for further Cross-Servicing activity. Select from 'B' for bankruptcy, 'W' for waiver, 'O' for other, and 'R' for rejected by Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : B
    Stands For: BANKRUPTCY
  • Code : W
    Stands For: WAIVER
  • Code : O
    Stands For: OTHER
  • Code : R
    Stands For: REJECTED BY CROSS-SERVICING
STOP TCSP REFERRAL COMMENT 159.1 Type a comment to support the reason that a stop flag has been set for this debt. A comment is required in the case of 'Other' as a reason code.

Free Text
TCSP CASE RECALL FLAG 159.2 The flag that marks this case for recall record creation from Cross-Servicing when the AR nightly background job is run.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CROSS-SERVICING CASE RECALL SET
TCSP CASE RECALL EFF. DATE 159.3 The date that the recall flag is set for the case.

Date/Time
TCSP CASE RECALL REASON 159.4 The reason that the case is being recalled from Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : 15
    Stands For: DEBTOR WAS INCORRECTLY ASSOCIATED WITH THE DEBT
TCSP GENDER 159.5 The Debtor's gender, 'M' for Male or 'F' for Female.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MALE
  • Code : F
    Stands For: FEMALE
TCSP TIN 161 The SSN sent on the Cross-Servicing debtor record.

Free Text
TCSP DEBTOR NAME 162 The debtor name sent on the Cross-Servicing record.

Free Text
TCSP DELINQUENCY DATE 163 The date that the bill became active. The debt is referred to Cross-Servicing when the debt is 120 days old counted from the delinquency date.

Date/Time
TCSP DEBTOR ADDRESS, LINE 1 164 The street address line 1 from the Patient file (#2)

Free Text
TCSP DEBTOR ADDRESS, LINE 2 165 The street address line 2 from the Patient file (#2).

Free Text
TCSP DEBTOR ADDRESS, CITY 166 The city from the Patient file (#2).

Free Text
TCSP DEBTOR ADDRESS, STATE 167 The state from the Patient file (#2).

Free Text
TCSP DEBTOR ZIP CODE 168 The zip code from the Patient file (#2).

Free Text
ORIGINAL TCSP AMOUNT 169 The original amount referred to Cross-Servicing.

Numeric
CURRENT TCSP AMOUNT 169.1 The current debt amount at Cross-Servicing.

Numeric
TCSP DEBTOR PHONE 169.2 The residence phone number from the Patient file (#2).

Free Text
TCSP COUNTRY CODE 169.3 The country code from the Patient file (#2).

Pointer
PointerTo:
fileName:
COUNTRY CODE
fileNumber:
779.004
TCSP DOB 169.4 The patient date of birth.

Date/Time
CS DECREASE ADJ TRANS NUMBER 171 The transaction numbers in the AR Transaction file (#433) for transactions to be included in a 5B record to be sent to Cross-Servicing.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CS DECREASE ADJ TRANS NUMBER .01 The transaction number in the AR Transaction file (#433) for transactions to be included in a 5B record to be sent to Cross-Servicing.

Pointer
PointerTo:
fileName:
AR TRANSACTION
fileNumber:
433
SEND TCSP RECORD 5B 1 The flag that marks this transaction to be sent to Cross-Servicing in a 5B record when the AR nightly background job is run.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
REJECT DATE 172 The dates that the Cross-Servicing record was received and processed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REJECT DATE .01 The date that the Cross-Servicing record was received and processed.

Date/Time
REJECT SOURCE 1 The source of the Cross-Servicing reject records.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: AITC
  • Code : D
    Stands For: DMC
  • Code : T
    Stands For: TREASURY
REJECT REASON1 2 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON2 3 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON3 4 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON4 5 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON5 6 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON6 7 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON7 8 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON8 9 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
REJECT REASON9 10 The error code that applies to this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI ERROR CODES
fileNumber:
348.5
RECORD TYPE 11 The record type that is associated with this Cross-Servicing reject record.

Pointer
PointerTo:
fileName:
TCS IAI RECORD TYPES
fileNumber:
348.7
RECORD ACTION CODE 12 The action code of this Cross-Servicing record.

Pointer
PointerTo:
fileName:
TCS IAI ACTION CODES
fileNumber:
348.6
REJECT BATCH ID 13 This is the AITC Reject File Batch Control ID which in the format YDOYnnnn where Y=last digit of year, DOY=day of year, nnnn=seq Batch number (i.e. 42910001)

Numeric
REJECT MM MSG NO. 14 The MailMan message number associated with this Cross-Servicing reject record.

Numeric
DUE PROCESS NOTIFICATION FLAG 173 This flag is set during the install post initialization to identify this bill as requiring a Due Process notification when and if the current balance equals or exceeds $25.00.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES, CHECK FOR DPN
DUE PROCESS REQUEST DATE 174 The date that the request was made to AITC to send a Due Process Notification letter to the patient.

Date/Time
DUE PROCESS LETTER PRINT DATE 175 The date that the Due Process Notification letter was printed by AITC.

Date/Time
DUE PROCESS REFERRAL DATE 176 The date that the bill was referred to Cross-Servicing.

Date/Time
DUE PROCESS ERROR DATE 177 The date that the error codes were returned for the Due Process Notification letter request to AITC.

Date/Time
DUE PROCESS ERROR CODES 178 The error codes returned by AITC for the Due Process Notification file sent to AITC requesting that a Due Process Notification letter be sent to the patient.

Free Text
SEND TCSP RECORD 1 191 The flag set by the unprocessable file to request that a record 1 be sent for this debt.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND 1 ACTION U
SEND TCSP RECORD 2 192 The flag set by the unprocessable file to request that a record 2 be sent for this debt.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND 2 ACTION U
SEND TCSP RECORD 2A 193 The flag set by the unprocessable file to request that a record 2A be sent for this debt.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND 2A ACTION U
SEND TCSP RECORD 2C 194 The flag set by the unprocessable file to request that a record 2C be sent for this debt.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SEND 2C ACTION A
STOP INTEREST ADMIN CALC 199.2 The flag to stop interest and admin calculation for debts referred to Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
RECEIVABLE CODE 200 Identifies bill as Federal/Non-federal.

Computed
TYPE OF BILL 200.2 This is the type of bill code from the UB-82 bill form.

Free Text
BEGINNING BUDGET FY 201 Beginning Fiscal Year of accounting FUND.

Free Text
ENDING BUDGET FY 202 Ending Fiscal Year of accounting FUND.

Free Text
FUND 203 FMS Accounting FUND.

Free Text
ADMIN OFFICE 204 Administrative Office code used by FMS.

Set of Codes
Set of Codes:
  • Code : 10
    Stands For: VHA
  • Code : 20
    Stands For: VBA
  • Code : 30
    Stands For: NCS
ORGANIZATIONAL CTRL POINT 205 FMS accounting field.

Free Text
FCP/PROJ 206 FMS accounting field.

Free Text
INSURED NAME 239 This is the individual in whose name the insurance is carried.

Free Text
INSURED SEX 240 This is the insured individual's sex.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MALE
  • Code : F
    Stands For: FEMALE
  • Code : U
    Stands For: UNKNOWN
PT RELATIONSHIP 241 This is the two-digit code for the relationship between the insured individual and the patient. It comes from the UB-82 bill form.

Free Text
CERT SSN HIC ID NO. 242 This is the Certificate/Social Security Number/Health Insurance Claim/Identification Number from the UB-82 bill form.

Free Text
GROUP NAME 243 This is the name of the group through which the insurance is provided.

Free Text
GROUP NUMBER 244 This is the identification number of the group providing insurance.

Free Text
EMPLOYEE INFORMATION DATA 245 This is the employee information data code from the UB-82 bill form.

Free Text
EMPLOYMENT STATUS CODE 246 This is the employment status code from the UB-82 bill form.

Free Text
EMPLOYER NAME 247 This is the employer's name from the UB-82 bill form.

Free Text
EMPLOYEE ID NUMBER 248 This is the employee's identification number from the UB-82 bill form.

Free Text
EMPLOYER LOCATION 249 This is the employer's location from the UB-82 bill form.

Free Text
CONTROL POINT 250 IFCAP control point.

Free Text
COST CENTER 251 This field is required for spending transactions and is used to record expenditure of funds by various organizations within DVA.

Free Text
SUB COST CENTER 252 This code is a further breakdown of the Cost Center.

Free Text
BOC (SUB ACCOUNT) 253 This code is equivalent to the CALM subaccount. Required for spending transactions and is used to determine the budget operating expense account to effect.

Free Text
SUB BOC 254 This code is a further breakdown of the Budget Object Code.

Free Text
REVENUE SOURCE 255 This code is required for revenue transactions. It is used to group collected revenue and to determine whether the revenue will credit actual reimbursement receivables for the associated fund.

Pointer
PointerTo:
fileName:
REVENUE SOURCE CODE
fileNumber:
347.3
RSC (CALC FOR ACCRUED BILLS) 255.1 This field was added with patch PRCA*4.5*90. This field is used to store the calculated revenue source code for bills which are accrued. It is calculated and set in the field by the routine RCXFMSUR.

Free Text
SUB-REV SOURCE 256 This code is a further breakdown of the Revenue Source Code.

Free Text
STATION 257 FMS accounting station number.

Free Text
FEDERAL/NON-FEDERAL/EMPLOYEE 258 FMS accounting field to identify type of bill.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: FEDERAL
  • Code : 1
    Stands For: NON-FEDERAL
  • Code : 2
    Stands For: EMPLOYEE
REFUND/REIBURSMENT 259 Identifies bill category for FMS

Set of Codes
Set of Codes:
  • Code : 01
    Stands For: REFUND
  • Code : 02
    Stands For: REIMBURSEMENT
  • Code : 3
    Stands For: SF REIBURSMENT
  • Code : 4
    Stands For: SF REFUND
  • Code : 24
    Stands For: INELIG. HEALTH
  • Code : 09
    Stands For: GENERAL FUND
  • Code : 20
    Stands For: EMPLOYEE
  • Code : 50
    Stands For: TORT FEASOR
SAT STATION 260 This field is the Satellite station number

Free Text
JOB NUMBER 261 FMS accounting element.

Free Text
XPROGAM 262 FMS accounting element.

Free Text
REPORTING CATEGORY 263 FMS accounting element.

Free Text
FMS LINE NUMBER 264 This field contains the line number assigned to an FMS billing document. This field will only be populated if the line number is different than 001. Line number 001 is the default line number (for null entries).

Free Text
VENDOR ID 265 This field contains the vendor ID that was sent on the billing document.

Free Text
FMS TRANSMISSION DATE 266 This field contains the date this document was transmitted to FMS.

Date/Time
RETURNED DATE 301 The returned date field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Date/Time
RETURN REASON CODE 302 The returned reason code field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Pointer
PointerTo:
fileName:
AR RETURN REASON CODE
fileNumber:
430.5
COMPROMISE INDICATOR 303 The compromise indicator field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
COMPROMISE AMOUNT 304 The compromise amount field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Numeric
CLOSED DATE 305 The closed date field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Date/Time
BANKRUPTCY DATE 306 The bankruptcy date field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Date/Time
DATE OF DEATH 307 The date of death field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Date/Time
DATE OF DISSOLUTION 308 The date of dissolution field on the reconciliation file for records returned by Treasury from Cross-Servicing.

Date/Time

MH ADMINISTRATIONS

File Number: 601.84

File Description:

The MH ADMINISTRATIONS file (#601.84) contains the data collected during the administration of a specified instrument from the MH TESTS AND SURVEYS file (#601.71) given to a patient at a specific date and time. For each administration of a specified instrument from the MH TESTS AND SURVEYS file (#601.71) there will be an entry in this file. An entry in this file does not store the results of the instrument's administration but is an index to the instrument's administration. The entry indicates whether the instrument has been completed, who ordered the instrument, how many questions were answered and if the test has been electronically signed.


Fields:

Name Number Description Data Type Field Specific Data
ADMINISTRATION NUMBER .01 This is the unique identifier for this administration record. It is the IEN.

Numeric
PATIENT 1 Pointer to the NAME field (#.01) of the PATIENT file (#2). This specifies the patient attached to this specific administration.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
INSTRUMENT NAME 2 A pointer to NAME field (#.01) of the MH TESTS AND SURVEYS file (#601.71), it specifies a particular instrument.

Pointer
PointerTo:
fileName:
MH TESTS AND SURVEYS
fileNumber:
601.71
DATE GIVEN 3 This is the date the patient started the instrument.

Date/Time
DATE SAVED 4 Date last edited, ie last time test was worked on for this administration.

Date/Time
ORDERED BY 5 User who ordered the test.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ADMINISTERED BY 6 Clerk who actually entered the information or started the patient in front of the computer.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SIGNED 7 Has administration been signed by the orderer or administrator.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: Yes
  • Code : N
    Stands For: No
IS COMPLETE 8 Boolean specifying if test is complete.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: Yes
  • Code : N
    Stands For: No
NUMBER OF QUESTIONS ANSWERED 9 The number of answers entered. If less than in MH Instrument CONTENT for this instrument, it is incomplete.

Numeric
COMMENTS 10 Place for orderer or administrator to make free text comments.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENTS .01

Word Processing
TRANSMISSION STATUS 11 Used to indicate success or failure in transmission to the Mental Health National DataBase.

Set of Codes
Set of Codes:
  • Code : S
    Stands For: Successfully added to db
  • Code : T
    Stands For: Transmitted, not yet added
  • Code : E
    Stands For: Error
TRANSMISSION TIME 12 Time of last transmission status.

Date/Time
LOCATION 13 Associates an administration to a Hospital Location. Pointer to the NAME field (#.01) of the HOPSITAL LOCATION file (#44).

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44

MH CR SCRATCH

File Number: 601.94

File Description:

This file is used as temporary storage space for the interface between the MHA3 DLL and Clinical Reminders. The data in this file cannot be entered manually and is managed by the MHA3 DLL. Data in this file is routinely purged. The data in this file is transferred to files MH Administrations 601.84 and MH Answers 601.85 and then deleted when the Clinical Reminder is completed.


Fields:

Name Number Description Data Type Field Specific Data
ID NUMBER .01 This is a unique number identifying this entry. It is the same as the internal .001 DINUM. You may enter 'New' and the correct number will automatically be assgined.

Numeric
PATIENT 1 The field specifies the patient (File #2) about which the current data applies. This is the DFN that is associated with the Instrument Results.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
RESPONSE DATE 2 Date/Time of responses given via the reminder.

Date/Time
INSTRUMENT 3 Instrument from MHA3 file 601.71 that is the basis of the clinical reminder.

Pointer
PointerTo:
fileName:
MH TESTS AND SURVEYS
fileNumber:
601.71
QUESTION 4 Question number from file 601.72 MH Questions. This is the question being asked as part of the specified instrument on which the Clinical Reminder is based.

Pointer
PointerTo:
fileName:
MH QUESTIONS
fileNumber:
601.72
ANSWER 5 This is the MH Choice selected as the answer. This is the answer to the question in field 4.

Pointer
PointerTo:
fileName:
MH CHOICES
fileNumber:
601.75
LEGACY VALUE 6 The MH Choices file contains the individual selections possible in a multiple choice question. Examples are Yes or No, True or False, 1. Abraham Lincoln, 2. George Washington, 3. George W. Bush or 4. Richard Nixon. For instruments first defined in the legacy system MH INSTRUMENT file (#601), 1-3 characters are specified for a multiple choice answer. If George Washington was the choice selected the legacy value would be 2. Choices are pointed to by the MH CHOICETYPES file (#601.751) which is a collection of choices. Choices are referenced in the MH ANSWERS file (#601.85) as a pointer to the full response. Please remember this field is automatically entered by the MHA3 DLL and Clinical reminders. No user input is allowed.

Free Text
IS MULTIPLE CHOICE 7 Yes if Question is of Multiple choice type.

Set of Codes
Set of Codes:
  • Code : YES
    Stands For: Yes
  • Code : NO
    Stands For: NO
USER 8 This is the person who entered the clinical reminder.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ANSWER TEXT 9 Full text of the free text answer. Only populated if the question specified in field 4 is listed as free text in the MH Questions file (601.72).

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ANSWER TEXT .01

Word Processing
HANDLE 10 Enter the Unique identifier of the windows session; formally called the Handle. This is the Windows identification of the process calling the MHA3 DLL.

Free Text

MH CLINICAL FILE

File Number: 615

File Description:

File stores data produced from the Problem List Option of the Mental Health System. Exported with data.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This name points to the Patient file. It is the name of the patient for whom the problem list is being made. To search data bases, or to print out problem lists by ward or clinic, use the 'Problist' name.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROBLEM 1 This is the name of the problem category used in the Mental Health package.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROBLEM .01 Problem, pointing to the 'Problem' file is the title of the problem selected for the 'Problist' patient.

Pointer
PointerTo:
fileName:
PROBLEM
fileNumber:
620
SPECIFY OTHER PROBLEM 1 This is free text describing a problem 'Other' not found covered by the other specific problems in the 'Problem' file. Only one 'Specify Other Problem' entry may be made. Multiple entries may be made in the 'Specify Other Indicator' field.

Free Text
PRIORITY 2 This determines the order in which the Problem is presented to the user and printed. It is used in the critical item screen and problem list printouts.

Numeric
ONSET DATE 3 Date of problem onset. Requested when a problem is entered.

Date/Time
RECORDED DATE 4 Date problem was recorded. Mandatory, time of day important.

Date/Time
STAFF 5 Person entering problem on the list. Points to New Person file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SCREEN 6 This is the alphabetical key which associates a problem with its indicators.

Free Text
PROBLEM INDICATOR 7 This is the problem indicator selected by the staff for that problem.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROBLEM INDICATOR .01

Pointer
PointerTo:
fileName:
INDICATOR
fileNumber:
625
SPECIFY OTHER INDICATOR 1 This free text entry allows adding another indicator not found in the pre-set list associated with that problem.

Free Text
STAFF 2 Person entering the indicator.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INDICATOR DATE 3 Date problem indicator was entered.

Date/Time
STATUS DATE 8 Date that problem's status (Active, Inactive, Resolved, Reformulated) was added.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME OF PROBLEM STATUS .01 DATE PROBLEM STATUS WAS ENTERED OR CHANGED

Date/Time
STATUS 1 Indicates status (e.g., Active, Inactive, Reformulated, Resolved) of the problem.

Set of Codes
Set of Codes:
  • Code : AC
    Stands For: active
  • Code : IN
    Stands For: inactive
  • Code : RA
    Stands For: reactived
  • Code : RF
    Stands For: reformulated
  • Code : RS
    Stands For: resolved
  • Code : RA
    Stands For: ra (reactivated)
  • Code : RF
    Stands For: rf (reformulated)
  • Code : RS
    Stands For: rs (resolved)
REFORMULATE TO 2 Problem name to which an existing problem has been reformulated.

Set of Codes
Set of Codes:
  • Code : DSM
    Stands For: dsm (DSM-III-R) diagnosis
  • Code : ICD
    Stands For: icd (ICD9) diagnosis
  • Code : EP
    Stands For: existing problem
  • Code : NP
    Stands For: new problem
  • Code : OT
    Stands For: other problem
  • Code : EP
    Stands For: ep (existing problem)
  • Code : NP
    Stands For: np (new problem)
  • Code : OT
    Stands For: op (other problem)
REFORMULATION 3 This number reflects the number of the problem, the DSM3 number or ICD9 number to which the old problem has been reformulated.

Numeric
STAFF 4 Person who has entered or changed the problem status.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

SECLUSION/RESTRAINT

File Number: 615.2

File Description:

Contain information required for the processing of management reports for Seclusion/Restraint.


Fields:

Name Number Description Data Type Field Specific Data
FILE ENTRY DATE .01 Actual date/time of entry of transaction into file. This field is transparent to the user.

Date/Time
NAME .02 Name (DFN) of patient placed under seclusion and/or restraint for this episode.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATE/TIME APPLIED .03 Date/time seclusion and/or restraint actually applied to patient.

Date/Time
WARD .04 Ward (hospital location) seclusion/restraint occurred.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
NAME OF NURSE PRESENT .05 Supervisory nurse responsible for carrying out of seclusion/restraint action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
NURSING SHIFT .06 Nursing shift during which seclusion/restraint episode commenced.

Pointer
PointerTo:
fileName:
NURS TOUR OF DUTY
fileNumber:
211.6
PATIENT SEARCHED .08 Question as to whether or not a patient was searched for possible harmful objects on his/her person.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SEARCH COMMENT .09 If a patient was not searched, a reason must be given as to why the procedure was not done.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SEARCH COMMENT .01

Word Processing
INITIAL TRANSCRIBER 4 Person placing information into file. TRANSPARENT TO USER.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TYPE OF SECLUSION/RESTRAINT 5 Manner in which seclusion/restraint is performed.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TYPE OF SECLUSION/RESTRAINT .01

Pointer
PointerTo:
fileName:
S/R CATEGORY
fileNumber:
615.6
ATTEMPTED ALTERNATIVES 6 Different clinical strategies employed prior to placing patient into seclusion/restraint.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ATTEMPTED ALTERNATIVES .01

Pointer
PointerTo:
fileName:
S/R ALTERNATIVES
fileNumber:
615.8
RESULTS 1 Supplemental narrative regarding patient's actions.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RESULTS .01

Word Processing
DIAGNOSIS 7 The diagnosis may be an actual DSM diagnosis selected from the PTF file or it may be a perceived diagnosis by caretaker.

Free Text
REASONS FOR S/R 10 A reason for the seclusion/restraint action.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASONS FOR S/R .01 Select from the list of possible reasons that necessitated the seclusion/restraint action.

Pointer
PointerTo:
fileName:
S/R REASONS
fileNumber:
615.5
DESCRIBE CIRCUMSTANCES 1 A brief narrative describing the circumstances which necessitated the seclusion/restraint action.

Free Text
MEDICATIONS 15 A list of medications given to the patient during this seclusion/restraint episode.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MEDICATIONS .01

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
BEHAVIOR REQUIRED FOR RELEASE 20 Actions required on the part of the patient prior to release from seclusion/restraint.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
BEHAVIOR REQUIRED FOR RELEASE .01

Pointer
PointerTo:
fileName:
S/R RELEASE CRITERIA
fileNumber:
615.7
ORDERED BY 25 Caretaker responsible for initiating the seclusion/restraint action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDER TYPE 26 Method by which the seclusion/restraint order was conveyed by the responsible caretaker to appropriate personnel.

Set of Codes
Set of Codes:
  • Code : w
    Stands For: WRITTEN
  • Code : e
    Stands For: EMERGENCY
  • Code : p
    Stands For: PHONE
DATE/TIME OF ORDER 27 Date and time the order was written, phoned or the situation required emergency action.

Date/Time
DATE ORDER CHANGED 28 Field will only contain data when the order is altered. It indicates the date and time the order was changed. TRANSPARENT TO USER.

Date/Time
GENERAL COMMENTS 30 Additional comments concerning this seclusion/restraint episode.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GENERAL COMMENTS .01

Word Processing
RELEASE ORDERED BY 40 Caretaker ordering cessation of seclusion/restraint order.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PERSONNEL EFFECTING RELEASE 41 Personnel actually performing release of patient from seclusion/restraint.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TIME REMOVED 42 Actual date/time release was performed.

Date/Time
RELEASE TRANSCRIBER 43 Person entering release information into file. TRANSPARENT TO USER.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RELEASE FILED 44 Date/time release information placed in file. TRANSPARENT TO USER.

Date/Time
CIRCUMSTANCES/FURTHER ACTIONS 45 Narrative concerning release action and possible follow-up care.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CIRCUMSTANCES/FURTHER ACTIONS .01

Word Processing
REVIEWED BY 50 Personnel, in authority, reviewing action.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ACTION 51 Decision of the reviewer as to whether or not action taken was appropriate.

Set of Codes
Set of Codes:
  • Code : A
    Stands For: APPROPRIATE
  • Code : I
    Stands For: INAPPROPRIATE
  • Code : O
    Stands For: OTHER (See Reviewer's Comments)
ACTUAL DATE OF REVIEW 52 Actual date/time review was made by personnel.

Date/Time
REVIEW TRANSCRIBER 53 Personnel entering review into file. TRANSPARENT TO USER.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REVIEW FILED 54 Actual date/time review entered into file by transcriber.

Date/Time
REVIEWER'S COMMENTS 55 Narrative of additional comments provided by the reviewer.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REVIEWER'S COMMENTS .01

Word Processing
OBSERVATION CHECK TIME 60 A history of observations performed during a single patient episode.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHECK TIME .01 Actual date/time observation made.

Date/Time
PERSONNEL OBSERVING 1 Caretaker performing observation.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OBSERVATION TRANSCRIBER 2 Personnel entering observation information into file. TRANSPARENT TO USER.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OBSERVATION FILED 3 Date/time observation actually placed in file.

Date/Time
OBSERVATION CODE 4 A listing of codes used to describe patient's actions during time of observation.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OBSERVATION CODE .01

Pointer
PointerTo:
fileName:
S/R OBSERVATION CHECKLIST
fileNumber:
615.9
COMMENT 1 Supplemental narrative regarding patient's actions.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing

DIAGNOSTIC RESULTS - MENTAL HEALTH

File Number: 627.8

File Description:

File contains the results of the Diagnosis Option in the Mental Health System. "AC" Xref - DFN, Inverse Date, Dx, Status, IFN. Used to list dx as Active, Inactive, etc. "AE" Xref - Type (DSM or ICD DIAGNOSIS), DFN, System Dte, Dx, DFN. Used for reference. "AF" Xref - DFN, Inverse Date, DX, IFN. Used for historical listing. "AG" Xref - Type (DSM or ICD DIAGNOSIS), DFN, Dx, IFN. Used for listing duplicate diagnoses.


Fields:

Name Number Description Data Type Field Specific Data
FILE ENTRY DATE .01 Date/time patient data entered into file. Transparent to user.

Date/Time
PATIENT NAME .02 Patient name. Set through the routine, ^YSLRP.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATE/TIME OF DIAGNOSIS .03 Date and time of diagnosis as indicated by person formulating the dx.

Date/Time
DIAGNOSIS BY .04 Person responsible for dx. Not necessarily the transcriber.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TRANSCRIBER .05 Person entering data into the file. Transparent to user.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DIAGNOSIS 1 The diagnosis is a condition which may be responsible for the evaluation or admission to clinical care.

Variable Pointer
STATUS (V/P/R/I/N/RU) 5 This is a SET of codes defining the status of the diagnosis.

Set of Codes
Set of Codes:
  • Code : v
    Stands For: VERIFIED
  • Code : p
    Stands For: PROVISIONAL
  • Code : r
    Stands For: REFORMULATED
  • Code : i
    Stands For: INACTIVE
  • Code : n
    Stands For: NOT FOUND
  • Code : ru
    Stands For: RULE OUT
CONDITION 7 States whether a dx is clinically active or inactive. (Active is based on the status of verified or provisional. All others are considered inactive.)

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ACTIVE
  • Code : I
    Stands For: INACTIVATED
INACTIVATED DATE 8 When a dx status changes from active to inactive, this flags is set. This permits the system to show only truly active dx while maintaining a history of the dx's status.

Date/Time
STATUS CHANGED 9 Indicates if this dx's status has been changes from Active to Inactive.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
DXLS 10 This is the diagnosis accounting for the largest % of length of stay for an admission. There may only be ONE DXLS (DSM or ICD DIAGNOSIS) per admission. This information may not be the same as that stored in the Patient Treatment Folder (PTF).

Set of Codes
Set of Codes:
  • Code : y
    Stands For: YES
  • Code : n
    Stands For: NO
  • Code : c
    Stands For: CHANGED
MODIFIERS 50 Modifiers further clarify the diagnosis. They are entered in accordance with the DSM-IV Manual.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MODIFIER .01 Each dx has a modifier or group of modifiers to further define itself.

Pointer
PointerTo:
fileName:
DSM MODIFIERS
fileNumber:
627.9
NUMBER OF ANSWER 1 Stores the response made by the responsible party to the modifier.

Free Text
STANDS FOR 2 Actual narrative of modifier. Stored to speed printout of lists and reports.

Free Text
PSYCHOSOCIAL STRESSOR 60 A stressor frequently plays a precipitating role in a disorder or it may also be a consequence of the person's psychopathology.

Free Text
SEVERITY CODE 61 Axis 4 provides a scale, the Severity of Psychosocial Stressors Scale, for coding overall severity of a psychosocial stressor or multiple psychosocial stressors that have occurred in the year preceding the current evaluation.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: NONE
  • Code : 2
    Stands For: MILD
  • Code : 3
    Stands For: MODERATE
  • Code : 4
    Stands For: SEVERE
  • Code : 5
    Stands For: EXTREME
  • Code : 6
    Stands For: CATASTROPHIC
  • Code : 0
    Stands For: INADEQUATE INFORMATION/NO CHANGE IN CONDITION
AXIS 5 65 Axis 5 permits the clinician to indicate his/her overall judgment of a person's psychological, social and occupation functioning on a scale, the Global Assessment of Functioning (GAF Scale), that assesses mental illness.

Numeric
PATIENT TYPE 66 Patient Type indicates that the patient is either an 'I'n-Patient or 'O'ut-Patient.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: In-Patient
  • Code : O
    Stands For: Out-Patient
COMMENT 80 This is additional comments describing this diagnosis.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing

MEDICAL PATIENT

File Number: 690

File Description:

This file stores medicine patients' DINUM to the PATIENT file and also keeps a cross-reference of procedures done on a patient.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field identifies the medical patient's name followed by his/her first name followed by a space and his/her middle initial and a period.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
LIVER BIOPSY 1 This field identifies if a liver biopsy has been done.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
ALLERGIES 2 This field identifies if the patient has allergies.

Computed
HISTORY OF BLEEDING DISORDER 3 This field identifies if the patient has a history of bleeding disorder.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
VALVULAR HEART DISEASE 4 This field identifies if the patient has a valvular heart disease.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
GLAUCOMA 5 This field identifies if the patient has glaucoma.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
HISTORY COMMENTS 6 This field identifies a free text field. Enter any pertinent history comments.

Free Text
PACING INDICATION 7 This field defines the medical rationale for electronic cardiac regulation.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PACING INDICATION .01 This field defines the medical rationale for electronic cardiac regulation.

Pointer
PointerTo:
fileName:
INDICATION
fileNumber:
694.1
RISK FACTOR (PACE) 8 This field indicates the conditions for which electronic cardiac regulation is a hazard for this patient.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
RISK FACTOR (PACE) .01 This field defines the conditions which make electronic cardiac regulation a particular hazard for this patient.

Pointer
PointerTo:
fileName:
PAST HISTORY AND RISK FACTOR
fileNumber:
695.4
DATE RISK FACTOR REPORTED 1 This 'date format' field documents the realization of a hazard.

Date/Time
PSC STATUS 9 This field indicates the Pacemaker Surveillance Center Status.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EAST PSC FOLLOW-UP
  • Code : 2
    Stands For: ARTIFICIAL
  • Code : 3
    Stands For: DEAD
  • Code : 4
    Stands For: REGISTRY ONLY
  • Code : 5
    Stands For: EXPLANT TEST ONLY
  • Code : 6
    Stands For: EXPLANTED,NO REPLACEMENT
  • Code : 7
    Stands For: WEST PSC FOLLOW-UP
  • Code : 8
    Stands For: LOST TO FOLLOW-UP
INDICATION FOR FILE CLOSURE 10 This field identifies the reason for the file to be closed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: DEATH
  • Code : 2
    Stands For: LOST TO FOLLOW-UP
  • Code : 3
    Stands For: PACEMAKER REMOVAL
  • Code : 4
    Stands For: DISCHARGE FOR ANOTHER REASON
CAUSE OF DEATH 11 This field identifies the cause of death.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: RELATED TO PACEMAKER
  • Code : 2
    Stands For: RELATED TO ELECTRODE
  • Code : 3
    Stands For: CARDIAC-UNRELATED TO PACEMAKER
  • Code : 4
    Stands For: NON-CARDIAC-UNRELATED TO PACEMAKER
  • Code : 5
    Stands For: CAUSE UNKNOWN
SUDDENNESS OF DEATH 12 This field identifies the reason for the sudden death.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: SUDDEN-WITHIN ONE HOUR OF SYMPTOMS
  • Code : 2
    Stands For: NON-SUDDEN
  • Code : 3
    Stands For: UNKNOWN
DATE OF FILE CLOSURE 13 This field identifies the date when the file is closed.

Date/Time
DISCHARGE (PACEMAKER) REASON 14 This field identifies the rationale for the release of the patient.

Free Text
TRANSMITTED PACEMAKER REPORTS 15 This field contains the date of each report.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE REPORT TRANSMITTED .01 This field stores the date (or date/time) of reports transmitted to national pacemaker center. It is set from the routine MCARPCS4.

Date/Time
DATE OF INITIAL IMPLANT 16 This field identifies the date of implant.

Date/Time
TELEPHONE FOLLOWUP PROVIDED BY 17 This field identifies the location for a follow-up visit.

Set of Codes
Set of Codes:
  • Code : E
    Stands For: VA EASTERN PACEMAKER SURVEILLANCE CENTER
  • Code : W
    Stands For: VA WESTERN PACEMAKER SURVEILLANCE CENTER
  • Code : L
    Stands For: LOCAL VAMC
REASON FOR FILE CLOSURE 18 This field identifies an extended explanation for the file to be closed.

Free Text

WV PATIENT

File Number: 790

File Description:

This file contains the names of patient's tracked by the Women's Health application. Patient names may be either manually entered by a case manager or loaded through the Automatically Load Patients [WV AUTOLOAD PATIENTS] option. Other data stored in this file can be categorized as demographic, administrative, and clinical information. The clinical data reflects current breast and cervical treatment needs, pregnancy information, breast and cervical treatment regimes, family history of breast cancer and DES, name of facility responsible for breast and treatment needs, and personal history of sexual trauma. Information specific to the results of breast and cervical exams and procedures are stored in the WV Procedure (#790.1) file. Administrative data is limited to the name of the current case manager, the date of first encounter, and the date the patient record was inactivated.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field contains the patient's name. It is a pointer to the Patient (#2) file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
MAILING ADDRESS-STREET .02 The street mailing address of this patient. This is computed from data in the Patient file.

Computed
MAILING ADDRESS-CITY .03 The city mailing address for this patient. This information in this field is obtained from the Patient file.

Computed
MAILING ADDRESS-STATE .04 The State portion of this patient's mailing address, obtained from the Patient file.

Computed
MAILING ADDRESS-ZIP .05 The zip code portion of this patient's mailing address is obtained from the Patient file.

Computed
SSN# .06 This computed field gathers the patient's social security number from the Patient file.

Computed
CASE MANAGER .1 This field contains the name of the person who is currently managing the women's health care needs of this patient.

Pointer
PointerTo:
fileName:
WV CASE MANAGER
fileNumber:
790.01
CX TX NEED .11 This field contains the name of the current or next cervical procedure or treatment need scheduled for this patient.

Pointer
PointerTo:
fileName:
WV CERVICAL TX NEED
fileNumber:
790.5
CX TX NEED DUE DATE .12 This field contains the date when this cervical procedure or treatment need should be completed.

Date/Time
CURRENTLY PREGNANT .13 This field contains information on the pregnancy status of the patient. The status is a set of codes: 1 = Yes if this patient is currently pregnant, 0 = No, if not. When the pregnanacy status is unknown, the field is blank.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
EDC .14 This field stores the patient's delivery date or estimated date of confinement (EDC).

Date/Time
DES DAUGHTER .15 This field indicates if this patient's mother took diethylstilbestrol (DES) when she was pregnant with this patient.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
  • Code : 9
    Stands For: UNKNOWN
PAP REGIMEN .16 This field stores the current PAP regimen for the patient.

Pointer
PointerTo:
fileName:
WV PAP REGIMEN
fileNumber:
790.03
PAP REGIMEN START DATE .17 This field stores a date on which the patient began or will begin her current PAP regimen.

Date/Time
BR TX NEED .18 This field contains the name of the the current or next breast study procedure needed for this patient.

Pointer
PointerTo:
fileName:
WV BREAST TX NEED
fileNumber:
790.51
BR TX NEED DUE DATE .19 This field contains the date by which the breast treatment procedure should be completed.

Date/Time
DATE OF FIRST ENCOUNTER .21 This field contains the date of the patient's first clinic visit. Although a date is automatically stuffed when the Automatically Load Patients [WV AUTOLOAD PATIENTS] option is run, the information can be edited through the Edit/Print Patient Case Data option.

Date/Time
REFERRAL SOURCE .22 This field stores information on who referred the patient or how the patient found out about the womens health care services at the facility. This field points to entries in the WV Referral Source (#790.07) file.

Pointer
PointerTo:
fileName:
WV REFERRAL SOURCE
fileNumber:
790.07
FAMILY HX OF BR CA .23 This field identifies if the patient or the patient's relatives have had breast cancer. The information may be selected from a set of codes to indicate unknown, personal history, no family history, a 2nd degree relative (cousin, aunt, grandmother), a 1st degree relative (mother OR sister) or multiple 1st degree relatives (mother AND sister).

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: no family history
  • Code : 1
    Stands For: 2nd degree relative
  • Code : 2
    Stands For: 1st degree relative
  • Code : 3
    Stands For: >1 1st degree relatives
  • Code : 4
    Stands For: personal history
  • Code : 9
    Stands For: unknown
DATE INACTIVE .24 This field contains the date on which this patient's record became inactive. ANY date (past, present or future) will cause this patient's data to be excluded from all reports that assess treatment needs (i.e., Snapshot of the Program Today report and Browse Patients with Needs Past Due).

Date/Time
BREAST TX FACILITY .25 The name of the facility responsible for performing breast diagnostic procedures for this patient if treatment is performed at another facility. Facility choices are limited to entries in the Institution (#4) file.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CERVICAL TX FACILITY .26 The name of the facility that is responsible for providing the gynecological tests/exams for this patient if treatment is performed at another facility. Facility choices are limited to entries in the Institution (#4) file.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
CST .28 This field indicates if the patient has experienced any sexual trauma (rape, sexual assault, etc.) as a civilian.

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: Yes
  • Code : N
    Stands For: No
  • Code : D
    Stands For: Declined to Answer
  • Code : U
    Stands For: Unknown
NOTES 1.01 This field stores special notes regarding the patient and her health care needs.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
NOTES .01 Enter any special notes regarding the patient

Word Processing
APPOINTMENTS 2 This multiple contains the patient's future appointments.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
APPOINTMENTS .01 This field contains the external date of the appointment concatenated to the name of the clinic. This field value is set by the WVUTL9 routine when a WH user displays/prints a notification letter. If there are no future appointments scheduled, then the value "No Future Appointments" is stored in this field. The future appointments are displayed in the text of the letter only when "|APPOINTMENTS|" (without the quotes) appears in the form letter template.

Free Text
COMPLETE ADDRESS 3 This multiple field contains the patient's complete mailing address.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMPLETE ADDRESS .01 This field contains the patient's complete address (street, city, state and zip code). This information is computed by a call to the ADD^VADPT API and stuffed into this multiple field whenever a notification letter is printed. This address information is displayed in the text of the letter only when "|COMPLETE ADDRESS|" (without the quotes) appears in the form letter template. Example: STREET ADDRESS [LINE 1] <---if there is a value STREET ADDRESS [LINE 2] <---if there is a value STREET ADDRESS [LINE 3] <---if there is a value CITY, STATE ZIP CODE

Free Text

WV LAB TESTS

File Number: 790.08

File Description:

This file is used to store lab test data sent from the LAB DATA file (#63) until such time as a Women's Health package user can determine if the lab test should be entered as a procedure in the WV PROCEDURE file (#790.1). If the lab test is converted into a procedure entry in FILE 790.1, it will be deleted from this file. Also, the Women's Health package user may decide to delete the lab test from this file if it is determined that the lab test is not to be tracked in FILE 790.1.


Fields:

Name Number Description Data Type Field Specific Data
LAB ACCESSION# .01 This field contains the Lab Accession number value from File 63 of the Lab package (e.g., CY 99 1).

Free Text
PATIENT .02 This field contains the name of the patient associated with this lab test.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROVIDER .07 This field contains the requesting provider for the lab test. The source of this value is either the PHYSICIAN field (63.09, .07) or the SURGEON/PHYSICIAN field (63.08, .07) of the LAB DATA file (#63).

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HEALTH CARE FACILITY .1 This field identifies the name of the health care facility where this procedure was performed.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
WARD/CLINIC/LOCATION .11 This field contains the name of the ward, clinic, or location where the procedure was performed.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DATE OF PROCEDURE .12 This field identifies the date on which the procedure was performed. Dates in the future may not be entered.

Date/Time
ENTERING USER .18 This field stores the name of the person initially creating this record.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE FIRST ENTERED .19 This field stores the date on which this procedure record was first entered.

Date/Time
FACILITY WHERE ACESSIONED .34 Select the facility where this procedure was accessioned.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
LAB DATA FILE IEN 2.18 This field contains the internal entry number of the LAB DATA file (#63) for the patient, if this procedure entry is a lab test.

Numeric
LAB INVERSE DATE/TIME 2.19 This field contains the inverse date/time of a lab test from the LAB DATA file (#63) for the patient, if this procedure entry is a lab test.

Free Text
LAB SUBSCRIPT 2.2 This field contains a character string that distinguishes the type of lab test performed. The letters "CY" will represent a cytology test and the letters "SP" will represent a surgical pathology test.

Free Text

PCE PARAMETERS

File Number: 815

File Description:

This file has one entry (1) that contains parameters used by Patient Care Encounter (PCE). The "LM" node is used by the User Inteface (PXCE).


Fields:

Name Number Description Data Type Field Specific Data
ONE .01 There is only "1" parameter similiar to MAS Parameters File.

Numeric
SD/PCE SWITCH OVER DATE .02 This is the date that Scheduling stops asking for Providers, Diagnoses, and Procedures and PCE collects them.

Date/Time
HEALTH SUMMARY START DATE .03 This date will be used to restrict view of PCE data for the following Health Summar components: PCE Immunization, PCE Skin Test, PCE Outpatient Diagnosis, and PCOutpatient Encounter.

Date/Time
PATIENT, CLINIC OR WARD 201 This field definition is used by the PCE Encounter options. The option uses this field with a Fileman Reader call to determine the view to be used in building the display list. It determines if the list will be of a patient and which one or of a clinic/ward and which one. No data should be put in this field.

Variable Pointer
STARTUP VIEW 202 This is the default view for all users. It tells which List the PCE Encounter Data Entry starts up in. If it is "V" the the list is by Visit/Encounter. If it is "A" then the list is of Appointments.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VISIT/ENCOUNTER
  • Code : A
    Stands For: APPOINTMENT
BEGINNING PATIENT DATE OFFSET 203 This is the value that determines the starting date for the list by a patient in PCE Encounter Data Entry. The number is added to today to get the starting day. e.g. If the value is -30 then the starting day is T-30, or 30 days before today. If the valuse is 5 then the starting day is T+5, or 5 days after today. If it is 0 then the starting day will be today.

Numeric
ENDING PATIENT DATE OFFSET 204 This is the value that determines the ending date for the list by a patient in PCE Encounter Data Entry. The number is added to today to get the ending day. e.g. If the value is -30 then the ending day is T-30,or 30 days before today. If the valuse is 5 then the ending day is T+5,or 5 days after today. If it is 0 then the ending day will be today.

Numeric
BEGINNING HOS LOC DATE OFFSET 205 This is the value that determines the starting date for the list by a Clinic/Ward in PCE Encounter Data Entry. The number is added to today to get the starting day. e.g. If the value is -30 then the starting day is T-30,or 30 days before today. If the valuse is 5 then the starting day is T+5,or 5 days after today. If it is 0 then the starting day will be today.

Numeric
ENDING HOS LOC DATE OFFSET 206 This is the value that determines the ending date for the list by a Clinic/Ward in PCE Encounter Data Entry. The number is added to today to get the ending day. e.g. If the value is -30 then the ending day is T-30,or 30 days before today. If the valuse is 5 then the ending day is T+5,or 5 days after today. If it is 0 then the ending day will be today.

Numeric
RETURN WARNINGS 301 This field determines if the Device Interface will return "WARNING"s or not if there are no Procedures for this encounter.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
MULTIPLE PRIMARY DIAGNOSES 302

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: RETURN WARNING
  • Code : 1
    Stands For: RETURN ERROR
NO PRIMARY DIAGNOSIS 303 This field determines if a WARNING or an ERROR will be returned if no primary diagnosis exists for this encounter.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: RETURN WARNING
  • Code : 1
    Stands For: RETURN ERROR
DISPOSITION HOSPITAL LOCATIONS 401

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DISPOSITION HOSPITAL LOCATIONS .01

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
PXPT LOCATION 501 This is the facility's site name. It points to the LOCATION file (#9999999.06) which is DINUMed to the INSTITUTION file (#4). This is the location that patients in the PATIENT/IHS file (#9000001) are associated with.

Pointer
PointerTo:
fileName:
LOCATION
fileNumber:
9999999.06
PXPT LAST PATIENT LOADED 502 This is a field that allows a process to keep track of the last patient that was processed. In case of failure that process can find out where it last completed a process and where to restart at. If process completed then this field is reset to 0. Enter the number of name of the last patient processed.

Free Text
PATCH 9 LAST VISIT PROCESSED 601

Numeric
PATCH 27 LAST DATE PROCESSED 602 This is the date and time of the last visit processed by PCE patch 27. This date starts at the last visit at the time the patch is installed and works backward through the visit tell all visit since 10/1/96 have been processed. If the patch cleanup has finished this will contain the date and time of the first visit of 10/1/96.

Date/Time
DEFAULT REMINDER DISCLAIMER 701 This reminder disclaimer is distributed nationally. This disclaimer is printed at the beginning of the Health Summaries' Clinical Maintenance and Clinical Reminder components, unless your site chooses to create your own reminder disclaimer. If the Site Reminder Disclaimer is defined, the Site Reminder Disclaimer will be used by Health Summary, instead of this Default Reminder Disclaimer.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DEFAULT REMINDER DISCLAIMER .01

Word Processing
SITE REMINDER DISCLAIMER 702

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SITE REMINDER DISCLAIMER .01 This is the site-specified reminder disclaimer to use at the beginning of the Health Summary "Clinical Maintenance" and "Clinical Reminder" components. When this field is blank, the DEFAULT REMINDER DISCLAIMER will be used in the Health Summary.

Word Processing
REPORT ER CLINIC NAMES 801 This multiple is used to define the laboratory test names from the Laboratory Test file that will be used by the PCE Reporting Module to evaluate patient data for critical values. These tests are defined by your IRM personnel or Clinical Coordinator.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ER CLINIC NAME .01 This field will contain the names of all clinics which are considered "Emergency Rooms" to allow the clinic reporting module of the Patient Care Encounter package to monitor caseload activity. Entries should be made either by IRM personnel or the Clinic coordinator.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
REPORT GLUCOSE NAMES 802

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GLUCOSE NAMES .01 This field will contain the names of all BLOOD GLUCOSE assays as they appear in the Laboratory Test (60) file to allow the clinic reporting module of the Patient Care Encounter Package to monitor Quality of Care Markers. Entries should be made either by IRM personnel or the Clinic coordinator.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
REPORT CHOLESTEROL NAMES 803

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHOLESTEROL NAMES .01 This field will contain the names of all TOTAL CHOLESTEROL assays as they appear in the Laboratory Test (60) file to allow the clinic reporting module of the Patient Care Encounter Package to monitor Quality of Care Markers. Entries should be made either by IRM personnel or the Clinic coordinator.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
REPORT LDL CHOLESTEROL NAMES 804

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LDL CHOLESTEROL NAMES .01 This field will contain the names of all LDL CHOLESTEROL assays as they appear in the Laboratory Test (60) file to allow the clinic reporting module of the Patient Care Encounter Package to monitor Quality of Care Markers. Entries should be made either by IRM personnel or the Clinic coordinator.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60
REPORT HBA1C NAMES 805

Subfile
subfile:
Name Number Description Data Type Field Specific Data
HBA1C NAMES .01 This field will contain the names of all HBA1C assays as they appear in the Laboratory Test (60) file to allow the clinic reporting module of the Patient Care Encounter Package to monitor Quality of Care Markers. Entries should be made either by IRM personnel or the Clinic coordinator.

Pointer
PointerTo:
fileName:
LABORATORY TEST
fileNumber:
60

IMAGE

File Number: 2005

File Description:

+---------------------------------------------------------------+ | | | Property of the US Government. | | No permission to copy or redistribute this software is given. | | Use of unreleased versions of this software requires the user | | to execute a written test agreement with the VistA Imaging | | Development Office of the Department of Veterans Affairs, | | telephone (301) 734-0100. | | | | The Food and Drug Administration classifies this software as | | a medical device. As such, it may not be changed in any way. | | Modifications to this software may result in an adulterated | | medical device under 21CFR820, the use of which is considered | | to be a violation of US Federal Statutes. | | | +---------------------------------------------------------------+ This file will contain an entry for every image, image group, waveform, audio file, or waveform generated at your site. It is distributed without data. Objects handled by the VistA Imaging System currently include single images (various resolutions), series of images, scanned documents, motion video, waveforms, and audio files. There is a record in file 2005 for each object, containing the attributes of the object. All fields are automatically stuffed by the Imaging software - there is no user input. Objects handled by the VISTA Imaging System currently include: * Single images (various resolutions) * Series of images * Scanned documents * Waveforms * Motion video * Audio files Each object has a natural language Name (.01); this usually consists of the patient's name, ssn, and object description. Depending on the object type, the object will either have: * A filename and logical location on the network (e.g., single image, graphics). * A multiple field called Object Group, containing entries, which point back to the Image file (e.g., image series or tiled abstract display).


Fields:

Name Number Description Data Type Field Specific Data
OBJECT NAME .01 Each object has a natural language name; this usually consists of the patient name, social security number, and object description. This field is automatically defined by the Imaging software.

Free Text
ACQUISITION SITE .05 The 'origin' location is the location where an image is created. For instance, a site like 'St. Louis' may process images for several other locations, such as Topeka, Wichita and Leavenworth. Any reference to a site identifier will return the name of the primary location. For the purpose of finding the 'origin' of images, the more specific sub-site is needed. This field contains the name of this 'sub-site'.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
EXPORT LOCATION .06 This table contains audit information regarding the export locations of file copies generated by the generic carbon copy (GCC) utility. This utility is used by the Health Eligibility Center functionality.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXPORT LOCATION .01 This is the network location file pointer that successfully received a copy of the file.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
TIMESTAMP 1 This is the date and time that the file was copied to the network location.

Date/Time
EXTENSION 2 This is the file extension that was successfully copied to the network location.

Free Text
FILEREF 1 This field contains the unique image filename of the image stored on the Vista Imaging file servers. It is either 12 or 18 characters long. It contains three elements: the facility's Imaging Namespace, from the Current Namespace field (#.02) of the IMAGING SITE PARAMETERS file (#2006.1), the Image IEN, and padded with zeros if needed, and the extension that indicates the format of the image. Supported formats are stored in the IMAGE FILE TYPES (#2005.021) file. This field is automatically set by the Imaging software.

Free Text
DISK & VOLUME, MAGNETIC 2 This field gives the path for the network location of the stored image (i.e. on which server it resides). After a specified time period during which the image is not viewed, the image is deleted from the magnetic server but remains available upon request from the jukebox. It takes slightly longer to display from the jukebox, but if requested, it is moved back to the server until it is no longer being viewed. This field is set automatically by the Imaging software.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DISK & VOLUME, ABSTRACT 2.1 This field points to the path of the network storage location for the image abstract. An abstract is a miniature copy of the captured image. If the parent image has not been viewed during the specified time period (if there is a jukebox), this file will be deleted along with the parent image file. Should the abstract be requested for viewing, it will be copied back onto the server currently being used to write captured images. This field is automatically set by the Imaging software.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DISK & VOLUME, WORM 2.2 This field is a pointer to the Network Location file giving the jukebox platter where the image is stored (provided there is a jukebox in the Imaging System). If it is a WORM, this file can never be deleted.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
OBJECT TYPE 3 This field is a pointer to the Object Type file (2005.02) which defines the object type of this object, e.g., still image, black & white image, x-ray etc. The image type determines how various actions are performed i.e., how the full resolution image is displayed, or how and when the image abstract is displayed. This field is automatically set by the Imaging software at the time of image capture.

Pointer
PointerTo:
fileName:
OBJECT TYPE
fileNumber:
2005.02
OBJECT GROUP 4 The object group is a multiple field pointing back to the Image file (2005). Only objects with an object type of GROUP have the Object Group field defined. These objects can be thought of as the "parent" of a set of images. Generally, instead of having their own abstract, objects of the GROUP type use the abstract of the first entry in their object group multiple. Sometimes, text will be used in place of the GROUP abstract for speed. Methods for viewing a GROUP object generally allow viewing of all the members of the group, either selectively or altogether. A good example would be a set of thirty CT scan images. Using the Integrated View menu option, the tiled display of image abstracts would contain only one abstract for the group. Selecting the group object for viewing provides the user with a tiled display of the abstracts of the individual CT scan images. The user can then identify individual images for full resolution viewing.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OBJECT GROUP .01 This field points to an entry of the IMAGE file (#2005) that represents an existing (non-deleted) member of this image group.

Pointer
PointerTo:
fileName:
IMAGE
fileNumber:
2005
DICOM SERIES NUM 1

Numeric
DICOM IMAGE NUM 2

Numeric
PATIENT 5 This field is a pointer to the VistA Patient file (#2), and contains the DFN of the patient that the image or object belongs to. The image or object is part of this patient's medical record. This pointer ties the image to the patient and is automatically set by the Imaging software.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROCEDURE 6 This field is an abbreviation for the procedure (e.g., COL for colonoscopy, SUR for surgery, SP for surgical pathology, X-ray for radiology). This field is automatically set by the Imaging software.

Free Text
DATE/TIME IMAGE SAVED 7 This field is the date and time the image was captured. It is automatically stuffed into the file as "NOW". It is not the same as the date and time of the procedure or exam. This field is set automatically by the Imaging software.

Date/Time
IMAGE SAVE BY 8 This field is a pointer to the New Person file and thus equal to the DUZ of the person who logged in to capture the image. It identifies who captured or saved the image and is automatically stuffed into the Image file. An image received via a Multimedia Mail message will not have data in this field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CAPTURE APPLICATION 8.1 Code stored in this field indicates the application that captured this image and created the image entry. This field cannot be edited; it is auto-populated by the "ACA" action index.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: Capture Workstation
  • Code : D
    Stands For: DICOM Gateway
  • Code : I
    Stands For: Import API
  • Code : A
    Stands For: Audit
SUMMARY OBJECT 9 This field is used to indicate whether the image or object is to be used as a summary for a group of objects. For example, in a GROUP of images, normally the abstract of the first object in the group multiple is used for the integrated view display. This field allows the user to select a summary image to be used for this purpose. This field is currently not in use.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SHORT DESCRIPTION 10 This field allows the user to store a brief, one line description with the image or object record. For images associated with patients, this data is appended to the patient's name and SSN to create the .01 field of the Image file. It is also permanently written on the upper left corner of the image to provide visible identification.

Free Text
LONG DESCRIPTION 11 This word processing field allows the user to describe the image at length. The user may only choose to append this long description on selected images - those which are "classic" or "unusual" cases. It can be used to summarize a group of images which have been put together for a conference or consult. It will be used in the future to a greater extent, as options for image capture (independent of VistA packages) are provided.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LONG DESCRIPTION .01

Word Processing
LAST ACCESS DATE 12 This is the date and time the image was last viewed or accessed. Each time an abstract or image is requested for viewing, this field is automatically set with the current date and time. In conjunction with the appropriate site parameter, this field is used for automatic file migration. That is, when an image has not been accessed within the predefined time period, it will be deleted from the magnetic server and will only be accessible from the optical disk jukebox.

Date/Time
IQ 13 This indicates that this image entry has questionable integrity.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DUPE 13.5 This field is to allow screening of images that have duplicate instances in the archive file and the image file. The intent is to prevent purging of these images on the raid until a utility to store this file on the Jukebox is implemented.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
GROUP PARENT 14 This field is used for images that are part of a group, for example a CT exam might contain 30 images. This field contains a pointer back to the Image file (2005), to the object whose type is "GROUP" that points to this object as a member of its group. A pointer to this object will be found in the Object Group multiple of the parent GROUP object.

Pointer
PointerTo:
fileName:
IMAGE
fileNumber:
2005
PROCEDURE/EXAM DATE/TIME 15 This is the date/time of the procedure or the exam. It is obtained from the Parent Data file (i.e. the date/time of the X-ray exam, the Medical Procedure, the time the Laboratory specimen was obtained from the patient, or the date/time of the Surgical procedure). This often is not the same as the date/time the image was captured. In a long surgical procedure the image capture time may be several hours later than the start of the operation. When a lab specimen is collected from a patient, it may be several days before images are captured from the slide. If images are initially stored on an intermediate media such as x-ray film or video tape, the capture time can be long after the procedure time.

Date/Time
PARENT DATA FILE# 16 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Pointer
PointerTo:
fileName:
PARENT DATA FILE
fileNumber:
2005.03
PARENT GLOBAL ROOT D0 17 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
PARENT DATA FILE IMAGE POINTER 18 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
EXPORT REQUEST STATUS 19 This field is used by Multimedia MailMan when an image needs to be sent to another site. The Imaging software sets the field automatically, after checking its status. After the request is carried out, it will be automatically reset.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EXPORT REQUESTED
  • Code : 0
    Stands For: EXPORTED
DELETED BY 30 This is the person who deleted the image. It is a pointer to the new person file. The system uses the DUZ variable to set the field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DELETED DATE 30.1 This is the date the Image was deleted from the Image File.

Date/Time
DELETED REASON 30.2 This is the Reason that the Image was deleted.

Free Text
PACKAGE INDEX 40 This is an abbreviation of the package that the Image is attached to.

Set of Codes
Set of Codes:
  • Code : RAD
    Stands For: RAD
  • Code : LAB
    Stands For: LAB
  • Code : MED
    Stands For: MED
  • Code : NOTE
    Stands For: NOTE
  • Code : CP
    Stands For: CP
  • Code : SUR
    Stands For: SUR
  • Code : PHOTOID
    Stands For: PHOTOID
  • Code : NONE
    Stands For: NONE
  • Code : CONS
    Stands For: CONS
CLASS INDEX 41 The Classification of the Image. CLASS is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR CLASS
fileNumber:
2005.82
TYPE INDEX 42 The TYPE of Image. TYPE is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR TYPES
fileNumber:
2005.83
PROC/EVENT INDEX 43 The PROCEDURE/EVENT of Image. PROCEDURE/EVENT is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR PROCEDURE/EVENT
fileNumber:
2005.85
SPEC/SUBSPEC INDEX 44 The SPECIALTY/SUBSPECIALTY of Image. SPECIALTY/SUBSPECIALTY is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR SPECIALTY/SUBSPECIALTY
fileNumber:
2005.84
ORIGIN INDEX 45 This field indicates whether this image originated inside or outside of VA.

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VA
  • Code : N
    Stands For: NON-VA
  • Code : D
    Stands For: DOD
  • Code : F
    Stands For: FEE
PATH ACCESSION NUMBER 50 This is the Anatomic Pathology accession number - the identifying number for the slide.

Free Text
SPECIMEN DESCRIPTION 51 This is the description given to the specimen in the Lab Data file - the information is carried over and stuffed into the Image file.

Free Text
SPECIMEN# 52 This is the specimen number of the slide given in the Lab Data file.

Numeric
STAIN 53 Free text description of the Histological Stain. It is the stain used in the preparation of the specimen and is chosen by the pathologist from the Histological Stain file list.

Free Text
MICROSCOPIC OBJECTIVE 54 Free text description of the Microscopic Objective selected by the pathologist. It identifies the power of the microscope objective used when capturing the image of the slide.

Free Text
PACS UID 60 This field is used by the VISTA-PACS interface and is the unique (up to) 64 character image identifier of the PACS image.

Free Text
RADIOLOGY REPORT 61 Pointer to Radiology Report file used by the PACS interface to tie the image to the correct radiology report.

Pointer
PointerTo:
fileName:
RAD/NUC MED REPORTS
fileNumber:
74
PACS PROCEDURE 62 This field is used by the VistA-PACS interface and is a backwards pointer to the Radiology Reports file with which this radiological image is associated.

Pointer
PointerTo:
fileName:
RAD/NUC MED PROCEDURES
fileNumber:
71
PARENT GLOBAL ROOT D1 63 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
PARENT ASSOCIATION DATE 64 This is the Date that the Document/Image was associated with the Parent Data File. Field # 16

Date/Time
AUDIT 99 This multiple stores previous values of the record fields (audit trail). See the "AUDIT2", "AUDIT40", and "AUDIT100" cross-references for more details.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01 When a value of an audited field changes, date and time of the change are stored in this field.

Date/Time
FIELD NUMBER .02 Value of this field identifies the audited field that was updated.

Numeric
USER .03 This field identifies the user who modified value of the audited field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OLD INTERNAL VALUE 1 This field stores the previous value of the audited field in internal format.

Free Text
OLD EXTERNAL VALUE 2 If the previous external value of the audited field is different from the internal value stored in the OLD INTERNAL VALUE field (1), then the external value is stored in this field.

Free Text
DESCRIPTIVE CATEGORY 100 This is mainly for Document Imaging, it further describes the type of document image.

Pointer
PointerTo:
fileName:
MAG DESCRIPTIVE CATEGORIES
fileNumber:
2005.81
CLINIC 101 Points to the Hospital location file and will be used mainly for document images. If an image is associated with a patient encounter (visit), this is the clinic they had (will have) the appointment. The appointment date/time is in field #15, PROCEDURE/EXAM DATE/TIME.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
BIG MAGNETIC PATH 102 Full file path description for Image file of .BIG file types. This field will indicate on which magnetic server this file resides.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
BIG JUKEBOX PATH 103 Full file path on jukebox for images of .BIG file extension. This field will indicate whether this file is located on the Jukebox.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
BIG FILE EXTENSION 104 This is the Image File Extension (e.g. DCM, BIG).

Free Text
ROUTING TIMESTAMP 106 This field keeps track of any routing activity.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ROUTING TIMESTAMP .01 This field keeps track of any routing activity. For each time that an image file is transmitted in the context of 'routing', an entry will be added to this multiple that records which type of image file was transmitted (FULL, BIG, ABSTRACT, etcetera), and to which destination (pointer to network location) it was transmitted.

Date/Time
DESTINATION 2 The value of this field is a pointer (into the network location file) that indicated where an image file was sent in the context of automated routing.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
TYPE 3 The value of this field indicates what type of image file was transmitted (FULL, BIG, TEXT, DICOM or ABSTRACT).

Set of Codes
Set of Codes:
  • Code : FULL
    Stands For: Full
  • Code : ABSTRACT
    Stands For: Abstract
  • Code : BIG
    Stands For: Big
  • Code : TEXT
    Stands For: Text
  • Code : DICOM
    Stands For: DICOM
FILENAME 4 The value of this field is the name of the transmitted file as it is at the destination location. This file name contains all directory prefixes and a 'type' suffix.

Free Text
START TRANSMIT 5 The value of this field is a timestamp that indicates the date and time when the transmission of a file started. Together with the value of the field ROUTING TIMESTAMP, which indicates the time when the transmission completed, statistics can be calculated on how long it took to transmit image files.

Date/Time
TIMESTAMP QUEUE ENTRY 6 The value of this field is a timestamp that indicates the date and time when the entry was made into the routing queue. Together with the value of the field START TRANSMIT, which indicates when the transmission started, statistics can be calculated related to wait times in the routing queue.

Date/Time
LOG ENTRY 7 The value of this field is an integer number that indicates the entry in the "permanent" log of all routed copies of the current image (as required by HIPAA). This value is used to record when images are purged from their routed destination.

Numeric
ACQUISITION DEVICE 107

Pointer
PointerTo:
fileName:
ACQUISITION DEVICE
fileNumber:
2006.04
TRACKING ID 108 This field tracks the packages that are using the Import API. It is an ";" (semicolon) delimited free text field. First piece is the Package ID that performed the Import Second piece is the Internal package identifier

Free Text
CREATE METHOD 109 This field holds the command that either has created the image(s) or will dynamically access the Image when called from the Display GUI an example is a DLL provided by a COTS product. When the DLL is called, it generates the image.

Free Text
DOCUMENT DATE 110 Document Images can have a separate date, unlike clinical images that are attached to a procedure, and only procedure date is needed.

Date/Time
ROUTING LOG 111

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESTINATION NAME .01 The value of this field is a string that identifies the location to which the current image has been routed.

Free Text
COPY LOCATION 2 The value of this field is a pointer to the Network Location table (#2005.2). When an image is transmitted using the "copy" method, this field is populated.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DICOM SEND LOCATION 3 The value of this field is a pointer to the DICOM Transmit Destination table (#2006.587). When an image is transmitted using the DICOM Send method, this field is populated.

Pointer
PointerTo:
fileName:
DICOM TRANSMIT DESTINATION
fileNumber:
2006.587
TIMESTAMP TRANSMIT 4 The value of this field is a timestamp that indicates the date and time when the current image was transmitted to the location described in the current record.

Date/Time
TIMESTAMP PURGE 5 The value of this field is a timestamp that indicates the date and time when the copy of the current image was purged from the location that is described in the current record.

Date/Time
FILE NAME 6 The value of this field is a string that represents the name of the (host system) file as it appears at the location to which the image has been copied.

Free Text
FILE TYPE 7 The value of this field is a code for the type of data that is stored in the file that is described in the current record.

Set of Codes
Set of Codes:
  • Code : TXT
    Stands For: Text
  • Code : BIG
    Stands For: Large X-Ray
  • Code : TGA
    Stands For: Targa(TM)
  • Code : ABS
    Stands For: Thumbnail
  • Code : DCM
    Stands For: DICOM
  • Code : DICOM
    Stands For: DICOM
CONTROLLED IMAGE 112 In the Clinical Display application, the abstract of a controlled image is not shown in the Abstracts or Group Abstracts window. A "canned" bitmap is shown in place of the image. It has a text that states that the image is controlled. Controlled images are not displayed until the user explicitly selects the image to be viewed. If the value of this field is 'NO' or the field is empty, then the image is handled "as usual": the actual abstract of the image is shown in the Abstracts and Group Abstracts windows.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
CONTROLLED DATE 112.1 This field indicates date/time of the most recent change of the image controlled status (see the CONTROLLED IMAGE field (112)).

Computed
CONTROLLED BY 112.2 This field references the user who made the most recent change of the image controlled status (see the CONTROLLED IMAGE field (112)).

Computed
STATUS 113 Viewable By default, all images are viewable, and images with no status are considered viewable. Verified A user has viewed the image and verified that the patient identifier and values of index fields are correct for this image. In Progress When capturing image groups, this status will indicate that the images are being added to the group of images. When the process is complete, the status will change to Viewable. Needs Review Indicates that value(s) of the index fields or patient identifier have been found to be incorrect. VistA Imaging Display application will block images with this status from being viewed. The Image Edit utility can be used to modify the incorrect values of the index fields. Deleted Marks the image as deleted.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Viewable
  • Code : 2
    Stands For: QA Reviewed
  • Code : 10
    Stands For: In Progress
  • Code : 11
    Stands For: Needs Review
  • Code : 12
    Stands For: Deleted
STATUS DATE 113.1 This field indicates date/time of the most recent change of the image status (see the STATUS field (113)).

Computed
STATUS BY 113.2 This field references the user who made the most recent change of the image status (see the STATUS field (113)).

Computed
STATUS REASON 113.3 This field indicates the reason for the latest image status change (see the STATUS field (113)).

Pointer
PointerTo:
fileName:
MAG REASON
fileNumber:
2005.88
NUMBER OF PAGES 114 This field stores number of pages in a multi-page document (e.g. multi-page TIFF image).

Numeric
LINKED IMAGE 115.1 This is a pointer to the rescinded image. For example, when an image is rescinded a new image entry is created and the original is deleted. A link is established between the new image and the rescinded image. The value of the field is the rescinded image.

Pointer
PointerTo:
fileName:
IMAGE AUDIT
fileNumber:
2005.1
LINKED TYPE 115.2 This is the type of the image link. For example, when image is rescinded a new image entry is created and the original is deleted. A link is established between the new image and the rescinded image. The value of the LINKED TYPE will be "RESCINDED".

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: RESCINDED
LINKED DATE 115.3 This is the date that the Document/Image was associated with the LINKED IMAGE.

Date/Time
PRESENTATION STATE 210 Image Presentation state data stored below; this is free-text in XML format. Annotations are included in this data.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PS UID .01 This is the presentation state UID for the image.

Free Text
PS DATA 1 Lines of free-text data that describe the presentation state, in XML format.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PS DATA .01 Lines of the PS data stored here.

Word Processing
PS TYPE 2 Indicates the type of presentation state data stored here: Key Image; Interpretation-based; User-specific.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: Interpretation
  • Code : U
    Stands For: User
  • Code : K
    Stands For: Key Image
WHO 3 User who created this presentation state.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TIMESTAMP 4 Date/Time when this PS was created.

Date/Time
DICOM SOP CLASS 251 The value of this field is a pointer. The pointed to record identifies the DICOM SOP Class that was used to acquire this image.

Pointer
PointerTo:
fileName:
DICOM SOP CLASS
fileNumber:
2006.532
NEW SOP INSTANCE UID 252 The value of this field is a string that represents a DICOM UID. The DICOM standard defines the format of a UID: a string containing only digits and periods that does not exceed a length of 64 characters. This field is populated when a corrected version of an image is exported, and the corrections are of such a nature that the image cannot be exported with its original SOP Instance UID. Note that this UID value is assigned by VA software, and thus will always start with the characters "1.2.840.113754.".

Free Text
SERIES UID 253 The value of this field is a DICOM unique identifier for the series to which an image belongs. A DICOM UID looks like a series of digits and periods, is not longer than 64 characters, starts and ends with a digit and never has two consecutive periods.

Free Text
ACCOUNT NUMBER 21401

Pointer
PointerTo:
fileName:
ACCOUNT NUMBER
fileNumber:
29320.8
VISIT 21402

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
REFERENCE DATE 21403

Date/Time
FILE SIZE (KB) 21404 This is the number of KBs of the image file.

Numeric
IMAGE CATEGORY 21405 This field should NOT be edited.

Pointer
PointerTo:
fileName:
MSCMAG CATEGORY
fileNumber:
21416.1
IMAGE CATEGORY TYPE 21406 This field should NEVER be edited by a user. The value of this field is a pointer to the MSCMAG CATEGORY TYPE file.

Pointer
PointerTo:
fileName:
MSCMAG CATEGORY TYPE
fileNumber:
21416.3
EXTERNAL IMAGE ID 21407 RCM's External Image Identifier

Free Text
EXTERNAL IMAGE SOURCE 21408

Free Text
LAST SAVED DATE 21409 The date when the image was last updated; i.e., when the image file in webdav was last written to.

Date/Time
LAST SAVED USER 21410 The IEN of the user who last updated the image in webdav.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

IMAGE AUDIT

File Number: 2005.1

File Description:

+---------------------------------------------------------------+ | | | Property of the US Government. | | No permission to copy or redistribute this software is given. | | Use of unreleased versions of this software requires the user | | to execute a written test agreement with the VistA Imaging | | Development Office of the Department of Veterans Affairs, | | telephone (301) 734-0100. | | | | The Food and Drug Administration classifies this software as | | a medical device. As such, it may not be changed in any way. | | Modifications to this software may result in an adulterated | | medical device under 21CFR820, the use of which is considered | | to be a violation of US Federal Statutes. | | | +---------------------------------------------------------------+ This file holds data from modified image records of the Image file (2005) and serves as an audit trail for modified images. When image deletion takes place, the image is deleted on the server if it is there, the Parent Report file's pointer to the image file is deleted, the data from the Image file is copied over to this file using the same IEN, and the node in the image file is set to null as it can never be used again. The image residing on the WORM drive cannot be deleted, so it can always be retrieved. This file stores the modified image record from the Image file (2005) and serves as an audit trail for modified images. When image deletion takes place: * The image is deleted on the imaging server (if it is there). * The parent report file's pointer to the image file is deleted. * The data from the image file is copied over to this file using the same IEN. * The node is deleted from the image file. The image residing on the WORM drive cannot be deleted, so it can always be retrieved. The field names and definitions are the same as the Image file (#2005).


Fields:

Name Number Description Data Type Field Specific Data
OBJECT NAME .01 Each object has a natural language name; this usually consists of the patient name, social security number, and object description. This field is automatically defined by the Imaging software.

Free Text
ACQUISITION SITE .05 The 'origin' location is the location where an image is created. For instance, a site like 'St. Louis' may process images for several other locations, such as Topeka, Wichita and Leavenworth. Any reference to a site identifier will return the name of the primary location. For the purpose of finding the 'origin' of images, the more specific sub-site is needed. This field contains the name of this 'sub-site'.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
EXPORT LOCATION .06 This table contains audit information regarding the export locations of file copies generated by the generic carbon copy (GCC) utility. This utility is used by the Health Eligibility Center functionality.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EXPORT LOCATION .01 This is the network location file pointer that successfully received a copy of the file.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
TIMESTAMP 1 This is the date and time that the file was copied to the network location.

Date/Time
EXTENSION 2 This is the file extension that was successfully copied to the network location.

Free Text
FILEREF 1 This field contains the unique image filename of the image stored on the magnetic server (and the jukebox if you have one). It is always eight characters in length, starting with the facility's 2 character Imaging namespace, with the remaining six characters ranging from 000001 to 999999. The extensions indicate what type of image it is: .BW for Black and White medium resolution (Cath, Path), .TGA for X-ray, .756 for 16-bit namespace, with the remaining six characters ranging from 000001 to set by the Imaging software.

Free Text
DISK & VOL,MAGNETIC 2 This field gives the path for the network location of the stored image (i.e. on which server it resides). After a specified time period during which the image is not viewed, the image is deleted from the magnetic server but remains available upon request from the jukebox. It takes slightly longer to display from the jukebox, but if requested, it is moved back to the server until it is no longer being viewed. This field is set automatically by the Imaging software.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DISK & VOLUME. - ABSTRACT 2.1 This field points to the path of the network storage location for the Image abstract. An abstract is miniature copy of the captured image. If the parent image has not been viewed during the specified time period (if there is a jukebox), this file will be deleted along with the parent image onto the server currently being used to write captured images. This field is automatically set by the Imaging software.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DISK & VOL.: WORM 2.2 This field is a pointer to the Network location file giving the jukebox platter where the image is stored (provided there is a jukebox in the Imaging System). If the jukebox is a WORM, this file can never be deleted.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
OBJECT TYPE 3 This field is a pointer to the Object Type file (2005.02) which defines the object type of this object, e.g. still image, black & white image, X-ray etc. The image type determines how various actions are performed i.e. how the full resolution image is displayed, or how and when the image abstract is displayed. This field is automatically set by the Imaging software at the time of image capture.

Pointer
PointerTo:
fileName:
OBJECT TYPE
fileNumber:
2005.02
OBJECT GROUP 4 The object group is a multiple field pointing back to the Image file (2005.1). Only objects with an object type of GROUP have the object group field defined. These objects can be thought of as the 'parent' of a set of images. Generally, instead of having their own abstract, objects of the GROUP type use the abstract of the first entry in their object group multiple. Sometimes, text will be used in place of the GROUP abstract for speed. Methods for viewing a GROUP object generally allow viewing of all the members of the group, either selectively or altogether. A good example would be a set of thirty CT scan images. Using the integrated view menu option, the tiled display of image abstracts would contain only one abstract for the group. Selecting the group object for viewing provides the user with a tiled display of the abstracts of the individual CT scan images. The user can then identify individual images for full resolution viewing.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OBJECT GROUP .01 The object group is a multiple field pointing back to the Image file (2005.1). Only objects with an object type of GROUP have the object group field defined. These objects can be thought of as the 'parent' of a set of images. Generally, instead of having their own abstract, objects of the GROUP type use the abstract of the first entry in their object group multiple. Sometimes, text will be used in place of the GROUP abstract for speed. Methods for viewing a GROUP object generally allow viewing of all the members of the group, either selectively or altogether. A good example would be a set of thirty CT scan images. Using the integrated view menu option, the tiled display of image abstracts would contain only one abstract for the group. Selecting the group object for viewing provides the user with a tiled display of the abstracts of the individual CT scan images. The user can then identify individual images for full resolution viewing.

Pointer
PointerTo:
fileName:
IMAGE AUDIT
fileNumber:
2005.1
DICOM SERIES NUM 1

Numeric
DICOM IMAGE NUM 2

Numeric
PATIENT 5 This field is a pointer to the VistA patient file (#2), and contains the DFN of the patient that the image or object belongs to. The image or object is part of this patient's medical record. This pointer ties the image to the patient and is automatically set by the imaging software.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROCEDURE 6 This field is an abbreviation for the procedure e.g COL for colonoscopy, SUR for surgery, SP for surgical pathology, X-ray for radiology . This field is automatically set by the Imaging software.

Free Text
DATE/TIME IMAGE SAVED 7 This field is the date and time the image was captured. It is automatically stuffed into the file as 'NOW'. It is not the same as the date and time of the procedure or exam. This field is set automatically by the Imaging software.

Date/Time
IMAGE SAVE BY 8 This field is a pointer to the New Person file and thus equal to the DUZ of the person who logged in to capture the image. It identifies who captured or saved the image and is automatically stuffed into the image file. An image received via a Multimedia Mail message will not have data in this field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CAPTURE APPLICATION 8.1 Code stored in this field indicates the application that captured this image and created the image entry. This field cannot be edited; it is auto-populated by the "ACA" action index.

Set of Codes
Set of Codes:
  • Code : C
    Stands For: Capture Workstation
  • Code : D
    Stands For: DICOM Gateway
  • Code : I
    Stands For: Import API
SUMMARY OBJECT 9 This field is used to indicate whether the image or object is to be used as a summary for a group of objects. For example, in a GROUP of images, normally the abstract of the first object in the group multiple is used for the integrated view display. This field allows the user to select a summary image to be used for this purpose. This field is currently not in use.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SHORT DESCRIPTION 10 This field allows the user to store a brief, one line description with the image or object record. For images associated with patients, this data is appended to the patient's name and SSN to create the .01 field of the Image file. It is also permanently written on the upper left corner of the image to provide visible identification.

Free Text
LONG DESCRIPTION 11 This word processing field allows the user to describe the image at length. The user may only choose to append this long description on selected images - ones which are 'classic' or 'unusual' cases. It can be used to summarize a group of images which have been put together for a conference or consult. It will be used in the future to a greater extent, as options for image capture independent of VistA package are provided.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LONG DESCRIPTION .01

Word Processing
LAST ACCESS DATE 12 This is the date and time the image was last viewed or accessed. Each time an abstract or image is requested for viewing, this field is automatically set with the current date and time. In conjunction with the appropriate site parameter, this field is used for automatic file migration. That is, when an image has not been accessed within the predefined time period, it will be deleted from the magnetic server and will only be accessible from the optical disk jukebox.

Date/Time
IQ 13 This field is set by various integrity checkers in the Imaging software. This field is set if an entry has questionable integrity.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
DUPE 13.5 This field is to allow screening of images that have duplicate instances in the archive file and the image file. The intent is to prevent purging of these images on the raid until a utility to store this file on the Jukebox is implemented.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
GROUP PARENT 14 This field is used for images that are part of a group, for example a CT exam might contain 30 images. This field contains a pointer back to the image file (2005.1), to the object whose type is "GROUP" that points to this object as a member of its group. A pointer to this object will be found in the Object Group multiple of the parent GROUP object.

Pointer
PointerTo:
fileName:
IMAGE AUDIT
fileNumber:
2005.1
PROCEDURE/EXAM DATE/TIME 15 This is the date/time of the procedure or the exam. It is obtained from the parent data file, i.e. the date/time of the X-ray exam, the Medical Procedure, the time the Laboratory specimen was obtained from the patient, or the date/time of the Surgical procedure. This often is not the same as the date/time the image was captured. In a long surgical procedure the image capture time may be several hours later than the start of the operation. When a lab specimen is collected from a patient, it may be several days before images are captured from the slide. If images are initially stored on an intermediate media such as X-ray film or video tape, the capture time can be long after the procedure time.

Date/Time
PARENT DATA FILE# 16 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Pointer
PointerTo:
fileName:
PARENT DATA FILE
fileNumber:
2005.03
PARENT GLOBAL ROOT D0 17 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
PARENT DATA FILE IMAGE POINTER 18 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
EXPORT REQUEST STATUS 19 This field is used by Multimedia Mailman when an image needs to be sent to another site. The Imaging software sets the field automatically, after checking its status. After the request is carried out, it will be automatically reset.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: EXPORT REQUESTED
  • Code : 0
    Stands For: EXPORTED
DELETED BY 30 This is the person who deleted the image. It is a pointer to the new person file. The system uses the DUZ variable to set the field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DELETED DATE 30.1 This is the date the Image was deleted from the Image File.

Date/Time
DELETED REASON 30.2 This is the Reason that the Image was deleted.

Free Text
PACKAGE INDEX 40 This is an abbreviation of the package that the Image is attached to.

Set of Codes
Set of Codes:
  • Code : RAD
    Stands For: RAD
  • Code : LAB
    Stands For: LAB
  • Code : MED
    Stands For: MED
  • Code : NOTE
    Stands For: NOTE
  • Code : CP
    Stands For: CP
  • Code : SUR
    Stands For: SUR
  • Code : PHOTOID
    Stands For: PHOTOID
  • Code : NONE
    Stands For: NONE
  • Code : CONS
    Stands For: CONS
CLASS INDEX 41 The Classification of the Image. CLASS is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR CLASS
fileNumber:
2005.82
TYPE INDEX 42

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR TYPES
fileNumber:
2005.83
PROC/EVENT INDEX 43 The PROCEDURE/EVENT of Image. PROCEDURE/EVENT is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR PROCEDURE/EVENT
fileNumber:
2005.85
SPEC/SUBSPEC INDEX 44 The SPECIALTY/SUBSPECIALTY of Image. SPECIALTY/SUBSPECIALTY is an index field used for sorting and searching.

Pointer
PointerTo:
fileName:
IMAGE INDEX FOR SPECIALTY/SUBSPECIALTY
fileNumber:
2005.84
ORIGIN INDEX 45 This field indicates whether this image originated inside or outside of the VA

Set of Codes
Set of Codes:
  • Code : V
    Stands For: VA
  • Code : N
    Stands For: NON-VA
PATH ACCESSION NUMBER 50 This is the Anatomic Pathology accession number - the identifying number for the slide.

Free Text
SPECIMEN DESCRIPTION 51 This is the description given to the specimen in the Lab Data file - the information is carried over and stuffed into the Image file.

Free Text
SPECIMEN# 52 This is the specimen number of the slide given in the Lab Data file.

Numeric
STAIN 53 This is a pointer to the Histological Stain file. It is the stain used in the preparation of the specimen and is input by the pathologist.

Free Text
MICROSCOPIC OBJECTIVE 54 This is a pointer to the Microscopic Objective file. It is input by the pathologist and identifies the power of the microscope objective used when capturing the image of the slide.

Free Text
PACS UID 60 This field is used by the VISTA-PACS interface and is the unique (up to) 64 character image identifier of the PACS image.

Free Text
RADIOLOGY REPORT 61 Pointer to radiology report file used by the PACS interface to tie the image to the correct radiology report.

Pointer
PointerTo:
fileName:
RAD/NUC MED REPORTS
fileNumber:
74
PACS PROCEDURE 62 This field is used by the CHCP-PACS interface and is a backward pointer to the Radiology Reports file with which this radiological image is associated.

Pointer
PointerTo:
fileName:
RAD/NUC MED PROCEDURES
fileNumber:
71
PARENT GLOBAL ROOT D1 63 The values of fields 16, 17, 18 and 63 are numbers. These numbers are internal entry numbers. Which field corresponds to which internal entry number is explained below. Together, the values of these fields establish a link back to the entry in the "parent" file, that holds the information that describes why the image was collected. The link to the "parent" information is brought about by the combination of the values of fields 16, 17, and, 18, and optionally also field 63. The value of field 16 is a number that indicates the internal entry number of the "parent file" in the VA-FileMan data dictionary. Common parent files are: File Name ==== ==== 3.9: MAIL MESSAGE 63: AUTOPSY (MICROSCOPIC) 63.02: ELECTRON MICROSCOPY 63.08: SURGICAL PATHOLOGY 63.09: CYTOLOGY 63.2: AUTOPSY (GROSS) 74: RADIOLOGY 130: SURGERY 691: ECHOCARDIOGRAM 691.1: CARDIAC CATHETERIZATION 691.5: ELECTROCARDIOGRAPHY 694: HEMATOLOGY 699: ENDOSCOPY 699.5: GENERIC MEDICINE 8925: TIU The records in each of these "parent" files contain a multiple that itemizes the list of images that belong to that record. The field numbers and fixed indexes for those multiples all have the number 2005. The entries within these multiples all have a field that is a pointer back to the image file. The entries in these multiples identify the various images that belong with the record in question. The various parent files each have their own structure, for instance Type Number Form of Root =========== ============ 1 ^RARPT(D0,2005,D1,0)=image... 2 ^MCAR(699,D0,2005,D1,0)=image... 3 ^LR(D0,"SP",D1,2005,D2,0)=image... Depending on the nature of the file structure of the parent file, the imaging software will need either just the value of D0 (type 1 and type 2) to find the correct entry, or the values of D0 as well as D1 (type 3). The values of the fields in the image file correspond to the values of the indices in the parent file as follows: Type Number Field Number and FileMan Index =========== ============================== 1 field 17 = D0, field 18 = D1 2 field 17 = D0, field 18 = D1 3 field 17 = D0, field 63 = D1, field 18 = D2 In the case of type 3, the value of D0 is equal to the value of LRDFN.

Numeric
AUDIT 99 This multiple stores previous values of the record fields (audit trail). See the "AUDIT2", "AUDIT40", and "AUDIT100" cross-references for more details.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01 When a value of an audited field changes, date and time of the change are stored in this field.

Date/Time
FIELD NUMBER .02 Value of this field identifies the audited field that was updated.

Numeric
USER .03 This field identifies the user who modified value of the audited field.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
OLD INTERNAL VALUE 1 This field stores the previous value of the audited field in internal format.

Free Text
OLD EXTERNAL VALUE 2 If the previous external value of the audited field is different from the internal value stored in the OLD INTERNAL VALUE field (1), then the external value is stored in this field.

Free Text
DESCRIPTIVE CATEGORY 100 This is mainly for Document Imaging, it further describes the type of document image.

Pointer
PointerTo:
fileName:
MAG DESCRIPTIVE CATEGORIES
fileNumber:
2005.81
CLINIC 101 Points to the Hospital location file and will be used mainly for document images. If an image is associated with a patient encounter(visit), this is the clinic they had (will have) the appointment. The appointment date/time is in field #15, PROCEDURE/EXAM DATE/TIME.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
BIG MAGNETIC PATH 102 Full file path description for Image file of .BIG file types. This field will indicate on which magnetic server this file resides.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
BIG JUKEBOX PATH 103 Full file path on jukebox for images of .BIG file extension. This field will indicate whether this file is located on the Jukebox.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
BIG FILE EXTENSION 104 This is the Image File Extension (e.g. DCM, BIG).

Free Text
ROUTING TIMESTAMP 106 This field keeps track of any routing activity.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ROUTING TIMESTAMP .01 This field keeps track of any routing activity. For each time that an image file is transmitted in the context of 'routing', an entry will be added to this multiple that records which type of image file was transmitted (FULL, BIG, ABSTRACT, etcetera), and to which destination (pointer to network location) it was transmitted.

Date/Time
DESTINATION 2 The value of this field is a pointer (into the network location file) that indicated where an image file was sent in the context of automated routing.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
TYPE 3 The value of this field indicates what type of image file was transmitted (FULL, BIG, TEXT, DICOM or ABSTRACT).

Set of Codes
Set of Codes:
  • Code : FULL
    Stands For: Full
  • Code : ABSTRACT
    Stands For: Abstract
  • Code : BIG
    Stands For: Big
  • Code : TEXT
    Stands For: Text
  • Code : DICOM
    Stands For: DICOM
FILENAME 4 The value of this field is the name of the transmitted file as it is at the destination location. This file name contains all directory prefixes and a 'type' suffix.

Free Text
START TRANSMIT 5 The value of this field is a timestamp that indicates the date and time when the transmission of a file started. Together with the value of the field ROUTING TIMESTAMP, which indicates the time when the transmission completed, statistics can be calculated on how long it took to transmit image files.

Date/Time
TIMESTAMP QUEUE ENTRY 6 The value of this field is a timestamp that indicates the date and time when the entry was made into the routing queue. Together with the value of the field START TRANSMIT, which indicates when the transmission started, statistics can be calculated related to wait times in the routing queue.

Date/Time
LOG ENTRY 7 The value of this field is an integer number that indicates the entry in the "permanent" log of all routed copies of the current image (as required by HIPAA). This value is used to record when images are purged from their routed destination.

Numeric
ACQUISITION DEVICE 107

Pointer
PointerTo:
fileName:
ACQUISITION DEVICE
fileNumber:
2006.04
TRACKING ID 108 This field tracks the packages that are using the Import API. It is an ";" (semicolon) delimited free text field. First piece is the Package ID that performed the Import Second piece is the Internal package identifier.

Free Text
CREATE METHOD 109 This field holds the command that either has created the image(s) or will dynamically access the Image when called from the Display GUI an example is a DLL provided by a COTS product. When the DLL is called, it generates the image.

Free Text
DOCUMENT DATE 110 Document Images can have a separate date, unlike clinical images that are attached to a procedure, and only procedure date is needed.

Date/Time
ROUTING LOG 111

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ROUTING LOG .01 The value of this field is a string that identifies the location to which the current image has been routed.

Free Text
COPY LOCATION 2 The value of this field is a pointer to the Network ocation table (#2005.2). When an image is transmitted using the "copy" method, this field is populated.

Pointer
PointerTo:
fileName:
NETWORK LOCATION
fileNumber:
2005.2
DICOM SEND LOCATION 3 The value of this field is a pointer to the DICOM Transmit Destination table (#2006.587). When an image is transmitted using the DICOM Send method, this field is populated.

Pointer
PointerTo:
fileName:
DICOM TRANSMIT DESTINATION
fileNumber:
2006.587
TIMESTAMP TRANSMIT 4 The value of this field is a timestamp that indicates the date and time when the current image was transmitted to the location described in the current record.

Date/Time
TIMESTAMP PURGE 5 The value of this field is a timestamp that indicates the date and time when the copy of the current image was purged from the location that is described in the current record.

Date/Time
FILE NAME 6 The value of this field is a string that represents the name of the (host system) file as it appears at the location to which the image has been copied.

Free Text
FILE TYPE 7 The value of this field is a code for the type of data that is stored in the file that is described in the current record.

Set of Codes
Set of Codes:
  • Code : TXT
    Stands For: Text
  • Code : BIG
    Stands For: Large X-Ray
  • Code : TGA
    Stands For: Targa(TM)
  • Code : ABS
    Stands For: Thumbnail
  • Code : DCM
    Stands For: DICOM
  • Code : DICOM
    Stands For: DICOM
CONTROLLED IMAGE 112 In the Clinical Display application, the abstract of a controlled image is not shown in the Abstracts or Group Abstracts window. A "canned" bitmap is shown in place of the image. It has a text that states that the image is controlled. controlled images are not displayed until the user explicitly selects the image to be viewed. If the value of this field is 'NO' or the field is empty, then the image is handled "as usual": the actual abstract of the image is shown in the Abstracts and Group Abstracts windows.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
CONTROLLED DATE 112.1 This field indicates date/time of the most recent change of the image controlled status (see the CONTROLLED IMAGE field (112)).

Computed
CONTROLLED BY 112.2 This field references the user who made the most recent change of the image controlled status (see the CONTROLLED IMAGE field (112)).

Computed
STATUS 113 Internal value of this field is 12 for all entries of the IMAGE AUDIT file (#2005).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Viewable
  • Code : 2
    Stands For: QA Reviewed
  • Code : 10
    Stands For: In Progress
  • Code : 11
    Stands For: Needs Review
  • Code : 12
    Stands For: Deleted
STATUS DATE 113.1 This field indicates date/time of the most recent change of the image status (see the STATUS field (113)).

Computed
STATUS BY 113.2 This field references the user who made the most recent change of the image status (see the STATUS field (113)).

Computed
STATUS REASON 113.3 This field indicates the reason for the latest image status change (see the STATUS field (113)).

Pointer
PointerTo:
fileName:
MAG REASON
fileNumber:
2005.88
NUMBER OF PAGES 114 This field stores number of pages in a multi-page document (e.g. multi-page TIFF image).

Numeric
LINKED IMAGE 115.1 This is a pointer to the rescinded image. For example, when an image is rescinded a new image entry is created and the original is deleted. A link is established between the new image and the rescinded image. The value of the field is the rescinded image.

Pointer
PointerTo:
fileName:
IMAGE AUDIT
fileNumber:
2005.1
LINKED TYPE 115.2 This is the type of the image link. For example, when image is rescinded a new image entry is created and the original image is deleted. A link is established between the original and the rescinded image. The value of the LINKED TYPE will be "RESCINDED".

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: RESCINDED
LINKED DATE 115.3 This is the date that the Document/Image was associated with the LINKED IMAGE.

Date/Time
DICOM SOP CLASS 251 The value of this field is a pointer. The pointed to record identifies the DICOM SOP Class that was used to acquire this image.

Pointer
PointerTo:
fileName:
DICOM SOP CLASS
fileNumber:
2006.532
NEW SOP INSTANCE UID 252 The value of this field is a string that represents a DICOM UID. The DICOM standard defines the format of a UID: a string containing only digits and periods that does not exceed a length of 64 characters. This field is populated when a corrected version of an image is exported, and the corrections are of such a nature that the image cannot be exported with its original SOP Instance UID. Note that this UID value is assigned by VA software, and thus will always start with the characters "1.2.840.113754.".

Free Text
SERIES UID 253 The value of this field is a DICOM unique identifier for the series to which an image belongs. A DICOM UID looks like a series of digits and periods, is not longer than 64 characters, starts and ends with a digit and never has two consecutive periods.

Free Text
ACCOUNT NUMBER 21401

Pointer
PointerTo:
fileName:
ACCOUNT NUMBER
fileNumber:
29320.8
VISIT 21402

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
REFERENCE DATE 21403

Date/Time
FILE SIZE (KB) 21404

Numeric
IMAGE CATEGORY 21405

Pointer
PointerTo:
fileName:
MSCMAG CATEGORY
fileNumber:
21416.1
IMAGE CATEGORY TYPE 21406

Pointer
PointerTo:
fileName:
MSCMAG CATEGORY TYPE
fileNumber:
21416.3
EXTERNAL IMAGE ID 21407

Free Text
EXTERNAL IMAGE SOURCE 21408

Free Text
LAST SAVED DATE 21409

Date/Time
LAST SAVED USER 21410

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

MSC NA DATASET OBSERVATION

File Number: 21412.57

File Description:



Fields:

Name Number Description Data Type Field Specific Data
PATIENT .01

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
OBSERVATIONS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REFERENCE TIME .01

Date/Time
DATASET .02

Pointer
PointerTo:
fileName:
MSC NA DATASET DEFINITION
fileNumber:
21412.56
DOCUMENT .03

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
ELEMENTS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ELEMENT .01

Pointer
PointerTo:
fileName:
MSC NA DATASET ELEMENT
fileNumber:
21412.58
ENTRY TIME .02

Date/Time
ENTERED BY .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTRY ORDER .04

Free Text
VALUE 1

Free Text
TEXT 2

Free Text
VALUES 3

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ID .01

Free Text
ENTRY ORDER .02

Free Text
FIELDS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FIELD .01

Pointer
PointerTo:
fileName:
MSC NA DATASET FIELD
fileNumber:
21412.59
VALUE .02

Free Text
TEXT 1

Free Text

FHIR IMPORT QUEUE

File Number: 21416.2

File Description:

This file contains the records for FHIR documents that need to be generated and posted. There is a status and a log associated with each record, along with other needed properties. The status will be updated as the document is pending, generated, posted or errored.


Fields:

Name Number Description Data Type Field Specific Data
VISIT .01

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
REQUESTING DUZ .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REQUEST TOKEN .04

Free Text
DOCUMENT TYPE .05

Set of Codes
Set of Codes:
  • Code : CCD
    Stands For: CCD
  • Code : TOC
    Stands For: TRANSITION OF CARE
  • Code : DS
    Stands For: DISCHARGE SUMMARY
  • Code : VSUM
    Stands For: VISIT SUMMARY
STATUS .06

Set of Codes
Set of Codes:
  • Code : PE
    Stands For: PENDING
  • Code : T
    Stands For: TASKED
  • Code : C
    Stands For: CREATED
  • Code : PO
    Stands For: POSTED
  • Code : E
    Stands For: ERROR
RECORD TIMESTAMP .07

Date/Time
COMPLETE TIMESTAMP .08

Date/Time
HISTORY LOG .09

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TIMESTAMP .01

Date/Time
STATUS .02

Set of Codes
Set of Codes:
  • Code : PE
    Stands For: PENDING
  • Code : T
    Stands For: TASKED
  • Code : C
    Stands For: CREATED
  • Code : PO
    Stands For: POSTED
  • Code : E
    Stands For: ERROR
MESSAGE .03

Free Text
ADDITIONAL PARAMS 10

Subfile
subfile:
Name Number Description Data Type Field Specific Data
KEY .01

Free Text
VALUE .02

Free Text

MSCM FHIR PATIENT

File Number: 21416.26

File Description:



Fields:

Name Number Description Data Type Field Specific Data
PATIENT .01

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
ENROLLMENT .02

Set of Codes
Set of Codes:
  • Code : I
    Stands For: OPT-IN
  • Code : O
    Stands For: OPT-OUT
  • Code : B
    Stands For: BLOCKED
EMAIL 1

Free Text

MSCM FHIR VISIT

File Number: 21416.27

File Description:



Fields:

Name Number Description Data Type Field Specific Data
VISIT .01

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
TOKEN .02

Free Text
STATE .03

Free Text
PATIENT .04

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATA 1

Free Text
ACTIONS 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TIMESTAMP .01

Date/Time
ACTION .02

Free Text
USER .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
STATUS .04

Free Text
STATE .05

Free Text
RESPONSE TEXT 1

Free Text
RESPONSE DATA 2

Free Text
PARAMETERS 3

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PARAMETER .01

Free Text
VALUE 1

Free Text
DETAILS 4

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LINE .01

Word Processing

MSECR TRIGGER EVENT

File Number: 21441

File Description:



Fields:

Name Number Description Data Type Field Specific Data
DATE/TIME .01

Date/Time
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VISIT .03

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
SOURCE FILE .04

Pointer
PointerTo:
fileName:
FILE
fileNumber:
1
SOURCE FILE IENS .05

Free Text
CODE 1.1

Free Text
CODING SYSTEM 1.2

Free Text
CODING SYSTEM OID 1.3

Free Text
GROUPING NAME 2.1

Free Text
GROUPING ID 2.2

Free Text
GROUPING OID 2.3

Free Text
GROUPING LIBRARY VERSION 2.4

Free Text
VALUE SET NAME 3.1

Free Text
VALUE SET OID 3.2

Free Text
VALUE SET VERSION 3.3

Free Text
REPORTABLE CONDITION CODE 4.1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REPORTABLE CONDITION CODE .01

Free Text
REPORTABLE CONDITION NAME .02

Free Text
CODING SYSTEM .03

Free Text

MSC ERX RENEWAL

File Number: 21452

File Description:



Fields:

Name Number Description Data Type Field Specific Data
GUID .01

Free Text
PROVIDER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ALERT XQAID .04

Free Text
PATIENT .06

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DOB .07

Date/Time
PATIENT FREE TEXT .08

Free Text
LOCATION 1.01

Free Text
LOCATION ID 1.02

Free Text
PHARMACY 1.03

Free Text
DRUG INFO 1.04

Free Text
RECEIVED DATE/TIME 1.05

Date/Time

MSC PRIMARY CARE PROVIDER

File Number: 21463.2

File Description:



Fields:

Name Number Description Data Type Field Specific Data
PCP ID .01 PCP ID

Numeric
PCP NAME .02 PCP Name

Free Text
FAX NUMBER .03 PCP's Fax number. Must enter full number, including the area code and a 1 at the beginning. Ex. 15555551212 DO NOT enter dashes, nor periods. Only the numbers.

Free Text
MODULE .04 Package to send faxes for: LR = LABORATORY only RA = RADIOLOGY only B = BOTH NOTE: No entry implies B.

Set of Codes
Set of Codes:
  • Code : LR
    Stands For: LABORATORY
  • Code : RA
    Stands For: RADIOLOGY
  • Code : B
    Stands For: BOTH
LAB PATIENT LOCATION .05 PCP's Lab Module preference: I = Only wants Lab Inpatient faxes O = Only wants Lab Outpatient faxes B = Either Lab Inpatient or Outpatient faxes NOTE: No entry implies B.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INPATIENT
  • Code : O
    Stands For: OUTPATIENT
  • Code : B
    Stands For: BOTH
RAD PATIENT LOCATION .06 PCP's Radiology Module Patient Preference: I = Only wants Radiology Inpatient faxes O = Only wants Radiology Outpatient faxes B = Either Radiology Inpatient or Outpatient faxes NOTE: No entry implies B.

Set of Codes
Set of Codes:
  • Code : I
    Stands For: INPATIENT
  • Code : O
    Stands For: OUTPATIENT
  • Code : B
    Stands For: BOTH
OFFICE PHONE .07 PCP's Office Phone Number. This is NOT the fax number.

Free Text
INACTIVATED .08 If this field is set to YES, the PCP will not receive faxes.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
UPDATED .09 Date/Time Entry updated.

Date/Time
NPI .1

Free Text
PATIENT 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01 PCP Patient. Pointer to Patient (#2) file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DIRECT EMAIL 2

Free Text
EMAIL 3

Free Text

MSC VITAL MEASUREMENTS FILE

File Number: 21470

File Description:



Fields:

Name Number Description Data Type Field Specific Data
DATE/TIME RESULTS TAKEN .01 This field contains the date/time this vital/measurement was taken.

Date/Time
PATIENT .02 This field contains the name of the patient for whom the vital measurement data was entered. Pointer to the PATIENT (#2) file.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VITAL TYPE .03 This field denotes the type of measurement for this record. Pointer to the GMRV VITAL TYPE (#120.51) file.

Pointer
PointerTo:
fileName:
GMRV VITAL TYPE
fileNumber:
120.51
DATE/TIME VITALS ENTERED .04 This field contains the date/time that this record was entered.

Date/Time
HOSPITAL LOCATION .05 This field contains the location where this measurement was taken. Pointer to the HOSPITAL LOCATION (#44) file.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ENTERED BY .06 This field contains the name of the person who edited the file entry. Pointer to the NEW PERSON (#200) file.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RATE 1.2 This field contains the numeric value associated with this vital measurement.

Pointer
PointerTo:
fileName:
GMRV VITAL QUALIFIER
fileNumber:
120.52
SUPPLEMENTAL O2 1.4 This field stores the information of the supplemental oxygen as follows: .5-20 l/min (liters/minute) and/or 21-100 % of oxygen concentration For example: 4.5 l/min 40% 4.5 l/min 40 %

Free Text
VITALS 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
VITALS .01

Pointer
PointerTo:
fileName:
GMRV VITAL TYPE
fileNumber:
120.51
HOSPITAL LOCATION .02

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
ENTERED BY .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RATE 1.2

Free Text
SUPPLEMENTAL O2 1.4

Free Text
QUALIFIERS 5

Subfile
subfile:
Name Number Description Data Type Field Specific Data
QUALIFIERS .01

Pointer
PointerTo:
fileName:
GMRV VITAL QUALIFIER
fileNumber:
120.52
SAVED 6

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
LAST SAVED DATE 7

Date/Time
PROCESSED 8

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROCESSED DATE/TIME 9

Date/Time
PROCESSED BY USER 10

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SAVED 6

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
SAVED DATE 7

Date/Time
PROCESSED 8

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
PROCESSED DATE/TIME 9

Date/Time
PROCESSED BY USER 10 User who "looked" at vitals data.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
VISIT 9000010

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010

MSC IMPLANTABLE DEVICES

File Number: 21471

File Description:



Fields:

Name Number Description Data Type Field Specific Data
UDI .01

Free Text
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATE RECORDED .03

Date/Time
RECORDED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DATE OF IMPLANT .05

Date/Time
STATUS .06

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: ACTIVE
  • Code : 1
    Stands For: INACTIVE
  • Code : 2
    Stands For: ENTERED IN ERROR
INACTIVE REASON .07

Free Text
INACTIVE DATE .08

Date/Time
GMDN PT NAME 1.1

Free Text
BRAND NAME 1.2

Free Text
VERSION/MODEL NUMBER 1.3

Free Text
COMPANY NAME 1.4

Free Text
MRI SAFETY INFORMATION 2.1

Free Text
CONTAINS RUBBER? 2.2

Set of Codes
Set of Codes:
  • Code : N
    Stands For: NO
  • Code : Y
    Stands For: YES
SNOMED CT 2601

Free Text
SNOMED CT DESCRIPTION 2602

Free Text

MSCH IV INTEROPERABILITY LOG

File Number: 21478

File Description:



Fields:

Name Number Description Data Type Field Specific Data
MESSAGE/ENTERED DATE/TIME .01

Date/Time
MESSAGE TYPE .02

Set of Codes
Set of Codes:
  • Code : O
    Stands For: OUT
  • Code : I
    Stands For: IN
PATIENT 1.1 The patient involved in the scan event.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
MASTER LOG CODE 1.101 This field is auto-populated when MASTER LOG ENTRY #1.9 is added via cross-ref. Format - 'IV' + Master Log Entry IEN. For example, master log entry = 900, master log code = IV900

Free Text
PUMP CHANNEL 1.11 Pump Channel from pump id/channel

Free Text
PUMP ID 1.12 Pump ID from pump id/channel (w/o channel)

Free Text
IV PUMP ID/CHANNEL 1.2 The pump ID/channel involved in the scan event.

Free Text
PHARMACY ORDER NUMBER 1.3 The order number and type from Patient Pharmacy file with the "V" appended to specify an order type of IV order. For IV orders, the order number is recorded in Patient Pharmacy (File 55) at level: ^PS(55,D0,"IV",D1,0) = (#.01) ORDER NUMBER The order type is at the same level in field #.04, TYPE

Free Text
TAB 1.4 BCMA Tab IVTAB for IV/Admixture 'IVTAB' or PBTAB for Piggyback 'IVP/IVPB' For PSB TRANSACTION rpc and other PSB rpcs

Set of Codes
Set of Codes:
  • Code : IVTAB
    Stands For: IV
  • Code : PBTAB
    Stands For: IVP/IVPB
BAG SEQUENCE 1.5 The sequence of IV bag currently involved in the scan event of that order.

Numeric
LOG STATUS 1.6 The log status involved in the pump event. For example: Scan Pump Set Up Auto-Program Send Auto-Program data to pump Receive message from pump Receive error message from pump

Free Text
USER ID 1.7 The user (DUZ) at the time of the scan event.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INSTITUTION 1.8 Instituion name assigned to where the patient's ward is located or the nurse is logged in for IV pump (DUZ(2)). INSTITUION Field #3 in Hospital Location file

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
MASTER LOG ENTRY 1.9

Pointer
PointerTo:
fileName:
MSCH IV INTEROPERABILITY LOG
fileNumber:
21478
RATE 2.1

Numeric
RATE UNITS 2.2

Free Text
DURATION 2.3

Numeric
DURATION TIME UNIT 2.4

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MINUTES
  • Code : H
    Stands For: HOURS
  • Code : N
    Stands For: NONE
CALCULATED 2.5

Set of Codes
Set of Codes:
  • Code : R
    Stands For: RATE
  • Code : D
    Stands For: DURATION
PATIENT WT IN KG ENTERED 2.6

Numeric
AP ENTERED BY USER 2.7

Set of Codes
Set of Codes:
  • Code : R
    Stands For: RATE
  • Code : D
    Stands For: DURATION
  • Code : B
    Stands For: BOTH
AP DURATION ENTERED 2.8 Duration in hours and minutes entered by user

Free Text
IV TYPE 3.1 IV TYPE - Type field #.04 in IV Subfile #55.01 of Patient Pharmacy file #55

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMIXTURE
  • Code : P
    Stands For: PIGGYBACK
  • Code : H
    Stands For: HYPERAL
  • Code : C
    Stands For: CHEMOTHERAPY
  • Code : S
    Stands For: SYRINGE
ROUTE 3.2 ROUTE - Med Route field #132 in IV Subfile #55.01 of Patient Pharmacy file #55

Pointer
PointerTo:
fileName:
MEDICATION ROUTES
fileNumber:
51.2
FREE TEXT OF INFUSION RATE 3.3 Infusion Rate field #.08 in IV Subfile #55.01 of Patient Pharmacy file #55 Free Text@Number of Labels per day, i.e. 'TITRATE@2' and for this field, it would be stored as 'TITRATE'. See the field description of Infusion Rate field for more info. This field will be displayed in Auto-Program Screen only.

Free Text
FREQUENCY 3.4 Schedule field #.09 in IV Subfile of Patient Pharmacy file #55 This field will be displayed in Auto-Program screen only.

Free Text
DOSE DUE TIME 3.5 BCMA's Scheduled Administration for piggyback orders. This field will be stored in Scheduled Administration Time field #13 in BCMA Medication Log file #53.79 when filed a Bag Log. This field will be displayed in Auto-Program screen only.

Date/Time
PROVIDER COMMENTS 3.6 Other Print Info field #131 in IV Subfile of Patient Pharmacy file #55

Free Text
VOLUME IN ML 3.7 If the order contains a solution, then get Volume field #1 in Solution Subfile #55.11 in IV Subfile #55.01 of Patient Pharmacy file #55 or Volume field #2 in IV Solution file #52.7 of the primary or first solution. If the order doesn't have a solution, then get the IV Interop Volume field #21499.2 in IV Additives file #52.6 of the primary or first additive.

Numeric
ORDER NUMBER 4.01 Order number ien from ORDER FILE ENTRY #110 in IV Subfile #55.01 (integer only)

Free Text
INFUSION RATE ORDERED 4.02 Infusion Rate .08 in IV Subfile #55.01

Free Text
DOSAGE ORDERED 4.03 Dosage Ordered #131 in IV Subfile #55.01

Free Text
ACCOUNT NUMBER 4.04 Account Number #29320.8 in Order file

Free Text
WRONG ADMIN TIME COMMENT 5.01 if select the iv order with outside BCMA Admin Schedule, it displayed the warning message "Wrong time: Admin is ## minutes after the scheduled administration time". The user needs to enter the comment here. This comment will be added to the comment of BCMA Bag Log.

Free Text
ADDITIONAL (PAIN) COMMENT 6.01 Document the pain score if IV order is PRN. This comment will be added to the comment of BCMA Bag Log.

Free Text
AP PROGRAM FIELDS 7.01 Edit fields by user

Free Text
AP COMMENT 8.01 Auto=Program comment entered by user

Free Text
ADDITIVES 10

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ADDITIVE .01 This is the additive which was selected as part of the IV order. This entry is a pointer to the IV ADDITIVES file #52.6.

Pointer
PointerTo:
fileName:
IV ADDITIVES
fileNumber:
52.6
ADDITIVE PRIMARY DRUG .02 This field identifies this drug is a primary drug which has IV Drug ID for IV pump.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
ADDITIVE IV PUMP DRUG ID .03 IV INTEROP DRUG ID field #21499.2 in Drug file #50

Free Text
ADDITIVE PREMIX VOLUME IN ML .04 IV INTEROP VOLUME field #21499.2 in IV Additives file #52.6

Numeric
ADDITIVE RATE UNITS .05 IV INTEROP RATE UNITS Field #21499.4 in Drug file #50 The list of units are located in MSC FLOWSHEETS UNITS file plus 'ml/hr'. (Note: standard rate 'ml/hr' is not in MSC FLOWSHEETS UNITS file #21406)

Free Text
ADDITIVE PREMIX .06 The premix of drug from IV INTEROP PREMIX Field #21499.1 in IV Additives file #52.6

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ADDITIVE STRENGTH .07 STRENGTH field #.02 in IV subfile of Patient Pharmacy file #55

Numeric
ADDITIVE STRENGTH UNIT .08 STRENGTH field .02 in IV subfile of Patient Pharmacy file #55 and also from DRUG UNIT field #2 in IV Additives file #52.6 The following units are: ML (1) LITER (2) MCG (3) MG (4) GM (5) UNITS (6) IU (7) MEQ (8) MM (9) MU (10) THOUU (11) MG-PE (12) NANOGRAM (13) MMOL (14)

Free Text
ADDITIVE WT BASED RATE UNIT .09 IV INTEROP WT BASED RATE UNIT field #21499.5 in Drug file #50

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ADDITIVE GENERIC DRUG .1 GENERIC DRUG field #1 in IV Additives file #52.6

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
ADDITIVE DRUG NAME AND DOSE .11 Additive Drug Name with dose ADDITIVE Field #.01 and STRENGTH Field #.02 of ADDITIVE Subfile #55.02 (in IV Subfile #55.01 of Patient Pharmacy file #55)

Free Text
SOLUTIONS 20

Subfile
subfile:
Name Number Description Data Type Field Specific Data
SOLUTION .01 This is the solution which was selected as part of the IV order. This entry is a pointer to the IV SOLUTION file #52.7.

Pointer
PointerTo:
fileName:
IV SOLUTIONS
fileNumber:
52.7
SOLUTION PRIMARY DRUG .02 This field identifies this drug is a primary drug which has IV Drug ID for IV pump.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
SOLUTION IV PUMP DRUG ID .03 IV INTEROP DRUG ID field #21499.2 in Drug file #50

Free Text
SOLUTION VOLUME IN ML .04 VOLUME field #2 in IV Solution file #52.7

Numeric
SOLUTION RATE UNITS .05 IV INTEROP RATE UNITS Field #21499.4 in Drug file #50 The list of units are located in MSC FLOWSHEETS UNITS file plus 'ml/hr'. (Note: standard rate 'ml/hr' is not in MSC FLOWSHEETS UNITS file #21406)

Free Text
SOLUTION PREMIX .06 PREMIX field #18 in IV Solution file #52.7

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SOLUTION PREMIX STRENGTH .07 IV INTEROP STRENGTH field #21499.1 in IV Solution file #52.7

Numeric
SOLUTION PREMIX STRENGTH UNIT .08 IV INTEROP DRUG UNIT field #21499.2 in IV Solution file #52.7 The following units are: ML (1) LITER (2) MCG (3) MG (4) GM (5) UNITS (6) IU (7) MEQ (8) MM (9) MU (10) THOUU (11) MG-PE (12) NANOGRAM (13) MMOL (14)

Free Text
SOLUTION WT BASED RATE UNIT .09 IV INTEROP WT BASED RATE UNIT field #21499.5 in Drug file #50

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
SOLUTION GENERIC DRUG .1 GENERIC DRUG field #1 in IV Solution file #52.7

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
SOLUTION DRUG NAME AND DOSE .11 Solution Drug Name with dose SOLUTION field #.01 and VOLUME field #.02 of SOLUTIONS subfile #55.11 (in IV Subfile #55.01 of Patient Pharmacy file #55)

Free Text
PRIMARY IV DRUG SUBSCRIPT 30.1

Set of Codes
Set of Codes:
  • Code : IVA
    Stands For: ADDITIVES
  • Code : IVS
    Stands For: SOLUTIONS
PRIMARY IV DRUG IEN 30.2

Numeric
BCMA ADMIN D/T ORIGINAL 40.01 Save original BCMA Admin Schedule d/t or 'PRN' for prn iv orders

Free Text
BCMA ORDER TYPE OF SCHEDULE 40.02 ORDER SCHEDULE field #.12 in BCMA MED LOG file #53.79 for PSB TRANSACTION rpc Based on Frequency field in Patient Pharmacy file

Set of Codes
Set of Codes:
  • Code : C
    Stands For: CONTINUOUS
  • Code : P
    Stands For: PRN
  • Code : O
    Stands For: ONE-TIME
  • Code : OC
    Stands For: ON-CALL
BCMA INJECTION SITE 40.03 INJECTION SITE field #.16 in BCMA MED LOG file #53.79 for PSB TRANSACTION rpc

Free Text
BCMA INSTRUCTOR USER 40.04 For PSB Transaction rpc

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BCMA WITNESS USER 40.05 for PSB TRANSACTION rpc 4 witness fields in BCMA MED LOG file #53.79

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
BCMA WITNESS COMMENT 40.06 for PSB TRANSACTION rpc WITNESS COMMENT field #.31 in BCMA MED LOG file #53.79

Free Text
BCMA WITNESS HR ORDER CODE 40.07 for PSB TRANSACTION rpc WITNESS HR ORDER CODE field #.32 in BCMA MED LOG file #53.79

Free Text
BCMA PRN REASON 40.08 for PSB TRANSACTION rpc PRN REASON field #.21 in BCMA MED LOG file #53.79

Free Text
BCMA PRN FLAG 40.09 for PSB TRANSACTION rpc PRN REASON FLAG field #.27 in BCMA MED LOG file #53.79

Numeric
BCMA MED LOG 50.01 BCMA Med log file #53.79 when creating/updating bag log in BCMA

Pointer
PointerTo:
fileName:
BCMA MEDICATION LOG
fileNumber:
53.79
BCMA IV UNIQUE ID 50.02 IV UNIQUE ID field #.26 in BCMA Med Log file #53.79

Free Text
BCMA BAG ID SELECTED 50.03 Bag ID (BCMA IV Unique ID) that the user scanned the iv bag or "WS" for ward stock

Free Text
PUMP STATUS 80.1

Set of Codes
Set of Codes:
  • Code : S
    Stands For: START
  • Code : P
    Stands For: STOP
  • Code : C
    Stands For: COMPLETE
  • Code : E
    Stands For: ERROR
  • Code : L
    Stands For: CLEAR
  • Code : F
    Stands For: OFF
  • Code : O
    Stands For: ON
HL7 ERROR CODE 80.2 HL7 Error Code from the IV pump via HL7 message

Pointer
PointerTo:
fileName:
MSCH IV INTEROP ERROR MESSAGE
fileNumber:
21478.2
INBOUND LOG 80.3 Log the return message when calling inbound tag to update BCMA Bag Log.

Free Text
HL7 EVENT TYPES 81

Subfile
subfile:
Name Number Description Data Type Field Specific Data
HL7 OBX IDENTIFIER .01

Pointer
PointerTo:
fileName:
MSCH IV INTEROP OBX MAPPING
fileNumber:
21478.1
HL7 OBX VALUE .02

Free Text
HL7 OBX UNITS IDENTIFIER .03 OBX for units

Pointer
PointerTo:
fileName:
MSCH IV INTEROP OBX MAPPING
fileNumber:
21478.1
HL7 OBX UNITS VALUE .04 The value of OBX units if the OBX Units Identifer doesn't exist in file 21478.1.

Free Text

MDTP TREATMENT PLAN

File Number: 21480

File Description:



Fields:

Name Number Description Data Type Field Specific Data
TREATMENT PLAN NAME .01

Free Text
CREATED DATE/TIME 1

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME 3

Date/Time
LAST UPDATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PLAN CLASS 5

Pointer
PointerTo:
fileName:
MDTP PLAN CLASS
fileNumber:
21480.18
ENTERED IN ERROR DATE/TIME 7

Date/Time
ENTERED IN ERROR BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PATIENT 9

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VISIT 10

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
START DATE 11

Date/Time
LOCKED FOR COMPLETION 12

Date/Time
LOCKED FOR COMPLETION BY 13

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
REASSESSMENT FREQUENCY 14

Pointer
PointerTo:
fileName:
MDTP PLAN FREQUENCY
fileNumber:
21480.06
EXPECTED DISCHARGE DATE 17

Date/Time
TYPE 18

Pointer
PointerTo:
fileName:
MDTP PLAN TYPE
fileNumber:
21480.11
NEXT UPDATE DUE 19

Date/Time
CUSTOM LIST 31

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OPTION .01 Option subfile IDs for the MDTP CUSTOM LIST file entry #1.

Pointer
PointerTo:
fileName:
MDTP CUSTOM LIST OPTIONS
fileNumber:
21480.17
CUSTOM LIST HISTORY 32

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CAPTION (AUDIT) .03 This field contains the text from the CAPTION field in file 21480.15 at the time of the Custom List edit.

Free Text
CUSTOM LIST 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OPTION .01

Pointer
PointerTo:
fileName:
MDTP CUSTOM LIST OPTIONS
fileNumber:
21480.17
TEAM 33

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MEMBER .01

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TEAM HISTORY 34

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
MEMBERS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MEMBERS .01

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PATIENT STRENGTHS 35

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT STRENGTH .01

Free Text
PATIENT STRENGTHS HISTORY 36

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PATIENT STRENGTHS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT STRENGTH .01

Free Text
PATIENT CHALLENGES 37

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT CHALLENGE .01

Free Text
PATIENT CHALLENGES HISTORY 38

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PATIENT CHALLENGES 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT CHALLENGE .01

Free Text
PLAN SNAPSHOTS 39

Subfile
subfile:
Name Number Description Data Type Field Specific Data
TIU NOTE .01

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
PLAN SNAPSHOTS HISTORY 40

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
TIU NOTE .03

Free Text
TIU STATUS .04

Pointer
PointerTo:
fileName:
TIU STATUS
fileNumber:
8925.6
MDTP ACTION .05

Set of Codes
Set of Codes:
  • Code : A
    Stands For: Added
  • Code : C
    Stands For: Changed
  • Code : D
    Stands For: Deleted
  • Code : R
    Stands For: Retracted
COMMENTS 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTERED DATE/TIME .01

Date/Time
ENTERED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME .03

Date/Time
LAST UPDATED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME .07

Date/Time
ENTERED IN ERROR BY .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing
HISTORY 43

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHANGED DATE/TIME .01

Date/Time
CHANGED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PREVIOUS COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PREVIOUS COMMENT .01

Word Processing
CATEGORIES 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CATEGORY .01

Free Text
CREATED DATE/TIME 1

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME 3

Date/Time
LAST UPDATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 7

Date/Time
ENTERED IN ERROR BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CATEGORY REFERENCE 9

Pointer
PointerTo:
fileName:
MDTP CATEGORY REF
fileNumber:
21480.09
ASSOCIATED DIAGNOSIS 21

Free Text
COMMENTS 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTERED DATE/TIME .01

Date/Time
ENTERED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME .03

Date/Time
LAST UPDATED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME .07

Date/Time
ENTERED IN ERROR BY .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing
PROBLEMS 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROBLEM .01

Free Text
CREATED DATE/TIME 1

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME 3

Date/Time
LAST UPDATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 7

Date/Time
ENTERED IN ERROR BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROBLEM REFERENCE 9

Pointer
PointerTo:
fileName:
MDTP PROBLEM REF
fileNumber:
21480.05
START DATE 10

Date/Time
STATUS 11

Pointer
PointerTo:
fileName:
MDTP PROBLEM STATUS
fileNumber:
21480.12
AS EVIDENCED BY 21

Subfile
subfile:
Name Number Description Data Type Field Specific Data
AS EVIDENCED BY .01

Word Processing
AS EVIDENCED BY HISTORY 22

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AS EVIDENCED BY 21

Subfile
subfile:
Name Number Description Data Type Field Specific Data
AS EVIDENCED BY .01

Word Processing
COMMENTS 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTERED DATE/TIME .01

Date/Time
ENTERED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME .03

Date/Time
LAST UPDATED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME .07

Date/Time
ENTERED IN ERROR BY .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing
DESCRIPTION 43

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing
DESCRIPTION HISTORY 44

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DESCRIPTION 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing
GOALS 51

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GOAL .01

Free Text
CREATED DATE/TIME 1

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME 3

Date/Time
LAST UPDATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 7

Date/Time
ENTERED IN ERROR BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
START DATE 9

Date/Time
STATUS 10

Pointer
PointerTo:
fileName:
MDTP GOAL STATUS
fileNumber:
21480.13
SHORT/LONG TERM 11

Set of Codes
Set of Codes:
  • Code : S
    Stands For: SHORT TERM
  • Code : L
    Stands For: LONG TERM
PATIENT STATED 12

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
EXPECTED ACHIEVEMENT DATE 13

Date/Time
GOAL REFERENCE 14

Pointer
PointerTo:
fileName:
MDTP GOAL REF
fileNumber:
21480.03
PROGRESS COMMENTS 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTERED DATE/TIME .01

Date/Time
ENTERED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME .03

Date/Time
LAST UPDATED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME .07

Date/Time
ENTERED IN ERROR BY .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROGRESS COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROGRESS COMMENT .01

Word Processing
DESCRIPTION 43

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing
DESCRIPTION HISTORY 44

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DESCRIPTION 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing
CHILD INTERVENTIONS 45

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHILD INTERVENTION .01

Numeric
CHILD INTERVENTION HISTORY 46

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CHILD INTERVENTIONS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CHILD INTERVENTION .01

Numeric
ASSOCIATED INTERVENTIONS 47

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ASSOCIATED INTERVENTION .01 This ASSOCIATED INTERVENTIONS subfile is used when Interventions belong to Problems (option A). This is defined by the ASSOCIATED INTERVENTIONS field (#101) in the MDTP SITE PARAMETERS file defined as 0:PROBLEMS.

Numeric
ASSOCIATED INT HISTORY 48

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ASSOCIATED INTERVENTIONS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ASSOCIATED INTERVENTION .01 ASSOCIATED INTERVENTIONS are Interventions within the PROBLEM that are associated to 'this' Goal. Used when Interventions belong to Problems: The ASSOCIATED INTERVENTIONS field (#101) in the MDTP SITE PARAMETERS file is defined as 0:PROBLEM.

Numeric
INTERVENTIONS 61

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION .01

Free Text
CREATED DATE/TIME 1

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME 3

Date/Time
LAST UPDATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 7

Date/Time
ENTERED IN ERROR BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
INTERVENTION REFERENCE 9

Pointer
PointerTo:
fileName:
MDTP INTERVENTION REF
fileNumber:
21480.04
START DATE 10

Date/Time
DISCIPLINE 11

Pointer
PointerTo:
fileName:
USR CLASS
fileNumber:
8930
FREQUENCY 12

Pointer
PointerTo:
fileName:
MDTP INTERVENTION FREQUENCY
fileNumber:
21480.07
CARE ACTION 13

Pointer
PointerTo:
fileName:
MDTP CARE ACTION
fileNumber:
21480.14
RESPONSIBLE PERSON 14

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PATIENT SPECIFIC FOCUS 21

Free Text
COMMENTS 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ENTERED DATE/TIME .01

Date/Time
ENTERED BY .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
LAST UPDATED DATE/TIME .03

Date/Time
LAST UPDATED BY .04

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME .07

Date/Time
ENTERED IN ERROR BY .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COMMENT 41

Subfile
subfile:
Name Number Description Data Type Field Specific Data
COMMENT .01

Word Processing
DESCRIPTION 43

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing
DESCRIPTION HISTORY 44

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DATE/TIME RECORDED .01

Date/Time
USER .02

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DESCRIPTION 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
DESCRIPTION .01

Word Processing

ZMDTP PLAN

File Number: 21481.01

File Description:



Fields:

Name Number Description Data Type Field Specific Data
NAME .01

Free Text
DFN 2

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VISIT 3

Free Text
ADMISSION DATE 4

Date/Time
ENTRY DATE 5

Date/Time
LAST SIGNED DATE 6

Date/Time
REASSESSMENT FREQUENCY 7

Pointer
PointerTo:
fileName:
ZMDTP FREQUENCY
fileNumber:
21481.06
PLAN TYPE 8

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: INITIAL
  • Code : 2
    Stands For: COMPREHENSIVE
  • Code : 3
    Stands For: UPDATE
  • Code : 4
    Stands For: PROBLEM LIST
STATUS 9

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PENDING
  • Code : 2
    Stands For: SIGNED
  • Code : 3
    Stands For: UPDATED
TEAM 10

Free Text
COMMENTS 11

Free Text
LAST UPDATED DATE 12

Date/Time
NEXT MEETING DATE 13

Computed
START DATE 14

Date/Time

PATIENT CARE PLAN

File Number: 21482.01

File Description:



Fields:

Name Number Description Data Type Field Specific Data
NAME .01

Free Text
PATIENT 2

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
VISIT 3

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
LAST UPDATED DATE 12

Date/Time
LAST UPDATED BY 13

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
START DATE 14

Date/Time
ENTERED IN ERROR BY 17

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 17.5

Date/Time
PLAN VERSIONS 20

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CREATED DATE/TIME .01

Date/Time
CREATED BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PLAN VERSION NAME 3

Free Text
STATUS 5

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PENDING
  • Code : 2
    Stands For: COMPLETED
COMMENTS 6

Free Text
NEXT MEETING DATE 8

Computed
REASSESSMENT FREQUENCY 9

Pointer
PointerTo:
fileName:
PATIENT CARE PLAN FREQUENCY
fileNumber:
21482.06
ENTERED IN ERROR BY 10

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 11

Date/Time
SIGNED DATE/TIME 12

Date/Time
SIGNED BY 13

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROBLEMS 25

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROBLEM NAME .01

Free Text
LAST UPDATED DATE 1

Date/Time
LAST UPDATED BY 1.2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 3

Date/Time
PROBLEM VERSIONS 20

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PROBLEM VERSION NAME .01

Free Text
START DATE 1

Date/Time
STATUS 2

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: ACTIVE
  • Code : 2
    Stands For: INACTIVE
  • Code : 3
    Stands For: RESOLVED
  • Code : 4
    Stands For: CHRONIC
CREATED BY 3

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CREATED DATE/TIME 4

Date/Time
ENTERED IN ERROR BY 5

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 6

Date/Time
LAST UPDATED DATE 7

Date/Time
LAST UPDATED BY 7.2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PROBLEM REFERENCE 8

Pointer
PointerTo:
fileName:
PATIENT CARE PLAN PROBLEM REF
fileNumber:
21482.05
CATEGORY 9

Pointer
PointerTo:
fileName:
PATIENT CARE PLAN PROBLEM CATEGORY
fileNumber:
21482.09
COMMENTS 10

Free Text
GOALS 20

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GOAL NAME .01

Free Text
LAST UPDATED DATE 1

Date/Time
LAST UPDATED BY 1.2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 3

Date/Time
GOAL VERSIONS 10

Subfile
subfile:
Name Number Description Data Type Field Specific Data
GOAL VERSION NAME .01

Free Text
START DATE 1

Date/Time
STATUS 2

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: MET
  • Code : 2
    Stands For: NOT MET
  • Code : 3
    Stands For: OTHER
  • Code : 4
    Stands For: IN PROGRESS
CREATED BY 4

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CREATED DATE/TIME 5

Date/Time
ENTERED IN ERROR BY 6

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 7

Date/Time
COMMENTS 10

Free Text
INTERVENTIONS 25

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION NAME .01

Free Text
LAST UPDATED DATE 1

Date/Time
LAST UPDATED BY 1.2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR BY 2

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 3

Date/Time
INTERVENTION VERSIONS 10

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERVENTION VERSION NAME .01

Free Text
START DATE 1

Date/Time
DISCIPLINE 2

Free Text
FREQUENCY 3

Pointer
PointerTo:
fileName:
PATIENT CARE PLAN FREQUENCY
fileNumber:
21482.06
CARE ACTION 6

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: CONTINUE
  • Code : 2
    Stands For: DISCONTINUE
  • Code : 3
    Stands For: COMPLETED
  • Code : 4
    Stands For: ADD
CREATED BY 8

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CREATED DATE/TIME 9

Date/Time
ENTERED IN ERROR BY 10

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ENTERED IN ERROR DATE/TIME 11

Date/Time
COMMENTS 20

Free Text

XXXMSC EHI EXPORT LOG

File Number: 21517.2

File Description:



Fields:

Name Number Description Data Type Field Specific Data
NAME .01

Free Text
STATUS .02

Set of Codes
Set of Codes:
  • Code : Q
    Stands For: QUEUED
  • Code : P
    Stands For: IN PROGRESS
  • Code : C
    Stands For: COMPLETED
  • Code : E
    Stands For: ERROR
USER .03

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CREATED DATE/TIME .04

Date/Time
LAST UPDATED DATE/TIME .05

Date/Time
COMPLETED DATE/TIME .06

Date/Time
ERROR INFO .07

Free Text
EXPORT PATH 1

Free Text
PATIENT 2

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PATIENT .01

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
STATUS .02

Set of Codes
Set of Codes:
  • Code : Q
    Stands For: QUEUED
  • Code : P
    Stands For: IN PROGRESS
  • Code : C
    Stands For: COMPLETED
  • Code : E
    Stands For: ERROR
CREATED DATE/TIME .04

Date/Time
LAST UPDATED DATE/TIME .05

Date/Time
COMPLETED DATE/TIME .06

Date/Time
ERROR INFO .07

Free Text

PATIENT/IHS

File Number: 9000001

File Description:

This file is IHS's primary patient data file. The NAME (.01) field of this file is a pointer to the VA's patient file (#2). Fields in common between the two dictionaries actually exist only in the VA patient file and are referenced by the IHS patient file as computed fields. All other files containing patient data have backward pointers linking them to this file. The linkage is by patient name and the internal FileMan gener- ated number of the ancillary file is the same number used in this file. All applications developed for the RPMS which require patient data will point to this file.


Fields:

Name Number Description Data Type Field Specific Data
NAME .01 This field points to the Patient file (#2) and has the same internal number as that file. Thus, the patient's name is the Patient file (#2) name.

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
DATE OF LAST UPDATE .16 This field is set by several packages, as well as Registration, indicating that data was changed in the patient file.

Date/Time
POSTAL CODE (NON-US) .46 Postal Code field for addresses outside the U.S.

Free Text
LOCATION OF HOME 1201 This is the directions to get to the patients home.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LOCATION OF HOME .01 This is the directions to get to the patients home.

Word Processing
MAILING ADDRESS-STREET 1602.2

Computed
MAILING ADDRESS-CITY 1603.2

Computed
MAILING ADDRESS-STATE 1604.2

Computed
MAILING ADDRESS-ZIP 1605.2

Computed
FATHERS EMAIL ADDRESS 2901

Free Text
FATHERS PHONE 2902

Free Text
FATHERS CELL PHONE 2903

Free Text
MOTHERS EMAIL ADDRESS 3001

Free Text
MOTHERS PHONE 3002

Free Text
MOTHERS CELL PHONE 3003

Free Text
VAMB ELIGIBLE 3502

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
SEND GENERIC INFORMATION 4001

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PREFERRED REMINDER METHOD 4002

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PHONE
  • Code : E
    Stands For: EMAIL
  • Code : L
    Stands For: LETTER
  • Code : D
    Stands For: DO NOT NOTIFY
HEALTH RECORD NO. 4101 This multiple contains the different health record identifiers by facility. IHS uses a 6 character identifier. The VA uses the social security number which may be up to 10 characters.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
HEALTH RECORD FAC .01 This field is a pointer to the LOCATION file. The internal pointer is forced into the third subscript for the 9000001.41 subfile. This allows easy lookup by health record number for the logged on location (facility). The complete subscript for 9000001.41 will be (DFN,41,facility pointer,0).

Pointer
PointerTo:
fileName:
LOCATION
fileNumber:
9999999.06
MEDICAL RECORD NO. .02

Free Text
DATE INACTIVATED/DELETED .03 This is date that the patients entry was inactivated.

Date/Time
RECORD STATUS .05 This field is used by the IHS Multi-Facility Integration (MFI) package to determine whether to stop integrating data at a facility for a particular patient and location facility.

Set of Codes
Set of Codes:
  • Code : D
    Stands For: DELETED
  • Code : I
    Stands For: INACTIVATED
  • Code : M
    Stands For: MERGED
STOP INTEGRATION .06 This field is used by the Mult-Facility Integration (MFI) package, created by IHS, to indicate this patients data should no longer be integrated by MFI.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
INTERNET ACCESS QUESTION DATE 8101

Subfile
subfile:
Name Number Description Data Type Field Specific Data
INTERNET ACCESS QUESTION DATE .01

Date/Time
CAN YOU ACCESS THE INTERNET .02

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
ACCESS THE WEB FROM .03

Set of Codes
Set of Codes:
  • Code : H
    Stands For: HOME
  • Code : W
    Stands For: WORK
  • Code : S
    Stands For: SCHOOL
  • Code : HC
    Stands For: HEALTH CARE FACILITY
  • Code : L
    Stands For: LIBRARY
  • Code : T
    Stands For: TRIBAL/COMMUNITY CENTER
MIGRANT WORKER QUESTION DATE 8401

Subfile
subfile:
Name Number Description Data Type Field Specific Data
MIGRANT WORKER QUESTION DATE .01

Date/Time
MIGRANT WORKER STATUS .02

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
MIGRANT WORKER TYPE .03

Set of Codes
Set of Codes:
  • Code : M
    Stands For: MIGRANT AGRICULTURAL WORKER
  • Code : S
    Stands For: SEASONAL AGRICULTURAL WORKER
HOMELESS STATUS QUESTION DATE 8501

Subfile
subfile:
Name Number Description Data Type Field Specific Data
HOMELESS STATUS QUESTION DATE .01

Date/Time
HOMELESS STATUS .02

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
HOMELESS TYPE .03

Set of Codes
Set of Codes:
  • Code : H
    Stands For: HOMELESS SHELTER
  • Code : T
    Stands For: TRANSITIONAL
  • Code : D
    Stands For: DOUBLING UP
  • Code : S
    Stands For: STREET
  • Code : O
    Stands For: OTHER
  • Code : U
    Stands For: UNKNOWN
LANGUAGES ENTRY DATE 8601

Subfile
subfile:
Name Number Description Data Type Field Specific Data
LANGUAGES ENTRY DATE .01

Date/Time
PRIMARY LANGUAGE .02

Pointer
PointerTo:
fileName:
LANGUAGES
fileNumber:
9999999.99
INTREPRETER REQUIRED .03

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
  • Code : U
    Stands For: UNKNOWN
PREFERRED LANGUAGE .04

Pointer
PointerTo:
fileName:
LANGUAGES
fileNumber:
9999999.99
ENGLISH PROFICIENCY .06

Set of Codes
Set of Codes:
  • Code : VW
    Stands For: VERY WELL
  • Code : W
    Stands For: WELL
  • Code : NW
    Stands For: NOT WELL
  • Code : NA
    Stands For: NOT AT ALL
HOUSEHOLD INCOME PERIOD 8701

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YEAR
  • Code : M
    Stands For: MONTH
  • Code : W
    Stands For: WEEKLY
  • Code : B
    Stands For: BIWEEKLY
HARD OF HEARING 8702

Set of Codes
Set of Codes:
  • Code : Y
    Stands For: YES
  • Code : N
    Stands For: NO
PHR ACCESS DATE 8801

Subfile
subfile:
Name Number Description Data Type Field Specific Data
PHR ACCESS DATE .01

Date/Time
ACCESS .02

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO

APSP INTERVENTION

File Number: 9009032.4

File Description:

This file is used to enter pharmacy interventions. Interventions in this file are records of occurrences where the pharmacist had to take some sort of action involving a particular prescription or order. A record would record things like the provider involved, why an intervention was necessary, what action was taken by the pharmacists.


Fields:

Name Number Description Data Type Field Specific Data
INTERVENTION DATE .01 This is the date that you recorded the intervention. You can enter any standard FileMan date input. ex. 2/5/90, Feb 5, 1990, etc.

Date/Time
PATIENT .02 You should enter the patient that you are intervening for. You may use any of the normal ways you use to enter a prompt that asks for a patient. Ex. Lastname, Firstname MI. or ID#

Pointer
PointerTo:
fileName:
PATIENT
fileNumber:
2
PROVIDER .03 You should enter the name of the provider that prescribed this medication or treatment that you are intervening on. You may enter the provider's name or the provider's synonym.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
PHARMACIST .04 You should enter the name of the pharmacist making the intervention and who will be doing the follow up with the provider.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DRUG .05 If there is a drug involved in the intervention, enter the name of the drug here. This is a pointer to your local Drug file and you will only be able to enter drugs that are in this file.

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
INSTITUTED BY .06 This field is asking who initially brought up the need for an intervention. You should enter a '?' to see your choices. The choices currently offered include : Pharmacy, Nursing, Provider, Patient or Family, and Other (to catch everybody else).

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: PHARMACY
  • Code : 2
    Stands For: PROVIDER
  • Code : 3
    Stands For: NURSING
  • Code : 4
    Stands For: PATIENT OR FAMILY
  • Code : 5
    Stands For: OTHER
INTERVENTION .07 You are given a selection of 19 different types of interventions. You should enter 1 of the choices. Choices include: Inappropriate Drug, Incorrect Dose, Allergy, etc. If you would like to see a list of all your choices enter a '?' at the prompt. If none of the selections really cover the reason for the intervention you should enter 'Other'.

Pointer
PointerTo:
fileName:
APSP INTERVENTION TYPE
fileNumber:
9009032.3
RECOMMENDATION .08 This is the type of recommendation the pharmacist is going to make to the provider. You can see the list of selections by entering a '?' at the prompt. Just as in previous fields if none of the selections cover the recommendation the pharmacist should enter an 'Other' at the prompt.

Pointer
PointerTo:
fileName:
APSP INTERVENTION RECOMMENDATION
fileNumber:
9009032.5
WAS PROVIDER CONTACTED .09 This field is used to record whether or not a provider was contacted regarding the intervention. In most cases a provider will be contacted but if a pharmacy and a provider have certain agreements about changing orders the provider may not be contacted.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: YES
  • Code : 1
    Stands For: NO
PROVIDER CONTACTED .11 This field is used to record the name of a provider that was contacted if it is different from the provider who wrote the prescription or ordered the treatment. It is a pointer to the New Person file and you should enter the provider here just as you would anyplace else.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
RECOMMENDATION ACCEPTED .12 This field is used to record whether your recommendation was accepted or rejected by the provider.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
AGREE WITH PROVIDER .13 This field is used to record whether you agree with the provider if your recommendation was rejected. This field will only be asked if the user answered 'No' to the Recommendation Accepted field. The pharmacist should answer either 'Yes' or 'No'.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: YES
  • Code : 1
    Stands For: NO
ORIGINATING PACKAGE .14 This field contains information about whether a intervention was originated by the Outpatient Pharmacy or Inpatient Medications software.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: OUTPATIENT
  • Code : 1
    Stands For: INPATIENT
RX # .15 This field contains the prescription number involved in an intervention. This field is filled by the routine called for drug-drug interactions.

Free Text
DIVISION .16 This is the pharmacy division involved in the intervention

Pointer
PointerTo:
fileName:
OUTPATIENT SITE
fileNumber:
59
FINANCIAL COST .17 This field is used to estimate the savings due to this intervention.

Numeric
OTHER FOR INTERVENTION 1100

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER FOR INTERVENTION .01 This field is used when a pharmacist has chosen 'Other' as the entry for the Intervention field. This is a word processing field that the pharmacist can then use to enter a Intervention Type that was not covered by the other selections of the Intervention field. The person making the entry will only be asked this field if they entered 'Other' in the Intervention field.

Word Processing
OTHER FOR RECOMMENDATION 1200 The pharmacist is asked this field only if they have answered the Recommendation field with 'Other'. This is a word-processing field that allows you to enter any recommendation you would like to make that was not covered by the selections in the Recommendation field.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
OTHER FOR RECOMMENDATION .01 This field is used to enter other recommedations if 'Other' is entered as a recommendation.

Word Processing
REASON FOR INTERVENTION 1300 This field is a word-processing field that is used by the pharmacist if they wish to record a more detailed explanation of the intervention.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REASON FOR INTERVENTION .01 This field is used to enter a more detailed explantion of the intervention.

Word Processing
ACTION TAKEN 1400 This word-processing field may be used by the pharmacist to record more detailed information about the action taken with this intervention.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ACTION TAKEN .01 This field is used to enter a more detailed explanation of the action taken.

Word Processing
CLINICAL IMPACT 1500 This word-processing field may be utilized by the pharmacist if they wish to document what they felt the clinical impact of the intervention is.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
CLINICAL IMPACT .01 This field is used by the pharmacist if they want to document what they felt the clinical impact of the intervention is.

Word Processing
FINANCIAL IMPACT 1600 This word processing field may be utilized by the pharmacist if they wish to document some sort of financial impact of the intervention.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
FINANCIAL IMPACT .01 This field is used to to document if some type of financial impact is related to the intervention.

Word Processing

TIU DOCUMENT

File Number: 8925

File Description:

This file stores textual information for the clinical record database. Though it is designed to initially accommodate Progress Notes, Consult Reports, and Discharge Summaries, it is intended to be sufficiently flexible to accommodate textual reports or provider narrative of any length or type, and to potentially accommodate such data transmitted from remote sites, which may be excluded from the corresponding local DHCP Package databases (e.g., Operative Reports, Radiology Reports, Pathology Reports, etc.) to avoid confusion with local workload.


Fields:

Name Number Description Data Type Field Specific Data
DOCUMENT TYPE .01 This field points to the Tiu Document Definition file, whose entry defines the components of the document and various parameters for the document's behavior.

Pointer
PointerTo:
fileName:
TIU DOCUMENT DEFINITION
fileNumber:
8925.1
PATIENT .02 This field contains a pointer to the patient file.

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
VISIT .03

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
PARENT DOCUMENT TYPE .04 This field points to the immediate parent class or document type to which the current record belongs. For example, when the current document has the type SOAP - GENERAL NOTE, this field will point to PROGRESS NOTE, as the parent class to which SOAP Notes belong, whereas, if the current record is a SUBJECTIVE component, then this field will point to SOAP - GENERAL NOTE as the parent document type to which the component belongs.

Pointer
PointerTo:
fileName:
TIU DOCUMENT DEFINITION
fileNumber:
8925.1
STATUS .05 This field is intended to accommodate the status of a given report.

Pointer
PointerTo:
fileName:
TIU STATUS
fileNumber:
8925.6
PARENT .06 In the event that the current report is an addendum or replacement, or is a component of a report, this field points to the original report.

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
EPISODE BEGIN DATE/TIME .07 This is the date/time at which the treatment episode associated with this document was initiated (e.g., Amission date/time for a discharge summary, Visit date/time for a clinic note, Transfer date/time for an interim summary). Time is optional.

Date/Time
EPISODE END DATE/TIME .08 This is the ending date/time for the treatment episode associated with this document (e.g., . Time is optional.

Date/Time
URGENCY .09 This is the urgency with which the report should be completed.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: priority
  • Code : R
    Stands For: routine
LINE COUNT .1 This is the number of characters in the document (blank lines excluded), divided by the CHARACTERS PER LINE parameter defined by your site.

Free Text
CREDIT STOP CODE ON COMPLETION .11 This boolean field indicates whether the stop code associated with a new visit should be credited when the note is completed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
MARK DISCH DT FOR CORRECTION .12 This boolean field identfies those discharge summaries which were filed prior to actual discharge of the patient for the nightly background process to back-fill with corrected discharge dates.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
VISIT TYPE .13 This field is used to identify the type of visit information related to the current document. The value is determined during processing and is entered by the program. It is used in the generation of a cross-reference to identify available documents for specified visits.

Free Text
REPORT TEXT 2 This is a word processing field that contains the report text.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
REPORT TEXT .01

Word Processing
EDIT TEXT BUFFER 3 This field provides a temporary holding place for the body of a report to prevent inadvertant record deletion or corruption in a manner independent of the user's preferred editor.

Subfile
subfile:
Name Number Description Data Type Field Specific Data
EDIT TEXT BUFFER .01

Word Processing
ENTRY DATE/TIME 1201 This is the date/time at which the document was originally entered into the database.

Date/Time
AUTHOR/DICTATOR 1202 This is the person who composed or dictated the document.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CLINIC 1203 This is the stop code to which the document is to be credited (e.g., if the document is a progress note documenting an encounter which took place in the Admitting/Screening Clinic, then select the corresponding stop code, etc.).

Pointer
PointerTo:
fileName:
CLINIC STOP
fileNumber:
40.7
EXPECTED SIGNER 1204 This is the person who is expected to enter the first-line signature for the document. Ordinarily, this would be the author. One case in which this would differ would be in the case of a Discharge Summary, when the author's signature is NOT required. Then, the attending physician would be the expected signer.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
HOSPITAL LOCATION 1205 This is the location (WARD or CLINIC) associated with the document.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
SERVICE CREDIT STOP 1206 This is the attending physician of record, who is ultimately responsible for the care of the patient, and the accurate documentation of the care episode.

Pointer
PointerTo:
fileName:
CLINIC STOP
fileNumber:
40.7
SECONDARY VISIT 1207

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
EXPECTED COSIGNER 1208

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ATTENDING PHYSICIAN 1209

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDER NUMBER 1210 This is the Order which was acted on to produce the result reported in the current document.

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
VISIT LOCATION 1211 This is the location at which the visit/admission occurred. As distinct from the HOSPITAL LOCATION field, which represents the location at the time the document was written, this is the location for the visit/admission with which the note is associated.

Pointer
PointerTo:
fileName:
HOSPITAL LOCATION
fileNumber:
44
DIVISION 1212 This field contains the institution associated with the document. It is extracted from the document's hospital location if known; otherwise it is extracted from the user's log-on division.

Pointer
PointerTo:
fileName:
INSTITUTION
fileNumber:
4
REFERENCE DATE 1301 This is the Date (and time) by which the clinician will reference the document. For Progress Notes, this will likely be the date of the provider's encounter with the patient. For Discharge Summaries, it will correspond to the Discharge Date of the Admission referenced in the document. (If there is no Discharge Date when dictated, it will correspond to the dictation date of the record instead.) In all cases, this is the date by which the document will be referenced and sorted.

Date/Time
ENTERED BY 1302

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
CAPTURE METHOD 1303

Set of Codes
Set of Codes:
  • Code : D
    Stands For: direct
  • Code : U
    Stands For: upload
  • Code : C
    Stands For: converted
  • Code : R
    Stands For: remote procedure
  • Code : O
    Stands For: copy
RELEASE DATE/TIME 1304

Date/Time
VERIFICATION DATE/TIME 1305

Date/Time
VERIFIED BY 1306

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DICTATION DATE 1307 This is the date (and time) on which the document was dictated by its author. In the event that a document originates by dictation, we recommend that the REFERENCE DATE for the document be defaulted to dictation date, as the author will be able to identify the document by the date on which s/he dictated it.

Date/Time
SUSPENSE DATE/TIME 1308 This is the date (and time) on which the document will be removed from public view. It is currently used only for Patient Postings, although it may be generalized for use with other document types, if appropriate.

Date/Time
PATIENT MOVEMENT RECORD 1401

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
TREATING SPECIALTY 1402

Pointer
PointerTo:
fileName:
FACILITY TREATING SPECIALTY
fileNumber:
45.7
IRT RECORD 1403

Pointer
PointerTo:
fileName:
INCOMPLETE RECORDS
fileNumber:
393
SERVICE 1404

Pointer
PointerTo:
fileName:
SERVICE/SECTION
fileNumber:
49
REQUESTING PACKAGE REFERENCE 1405 This field allows a linkage to be maintained between the TIU Document and the DHCP Package for which it was generated.

Variable Pointer
RETRACTED ORIGINAL 1406 This self-refering pointer identifies the original document which was retracted in error to produce this record.

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
PRF FLAG ACTION 1407 PRF FLAG ACTION applies only to Patient Record Flag (PRF) notes. When a new flag is assigned to a given patient, or, after review, another action such as CONTINUE is taken on an existing flag assignment, a note must be written to document the clinical reasons for the action. Upon entry, the note is linked to the action it documents. Field PRF FLAG ACTION refers to this linked action. The field contains the Date of the Action followed by the Name of the Action. Example: 3/3/05 CONTINUE If the PRF note is not linked to a flag action or the linked action date or name cannot be found, the field has value "?". If the note is not a PRF note (a note with a title under Document Class PATIENT RECORD FLAG CAT I or PATIENT RECORD FLAG CAT II), the field has value NA for non-applicable. Technical Note: Flag Actions and their linked note entry numbers are stored in the PRF ASSIGNMENT HISTORY FILE (#26.14). The Date and Action are attributes of the Assignment History entry the note is linked to.

Computed
SIGNATURE DATE/TIME 1501

Date/Time
SIGNED BY 1502

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
SIGNATURE BLOCK NAME 1503

Free Text
SIGNATURE BLOCK TITLE 1504 This is the encrypted signature block title of the person who signed the document.

Free Text
SIGNATURE MODE 1505 This is the mode by which the signature was obtained (i.e., either electronic or chart).

Set of Codes
Set of Codes:
  • Code : E
    Stands For: electronic
  • Code : C
    Stands For: chart
COSIGNATURE NEEDED 1506 This boolean flag indicates to the system whether or not a cosignature is needed.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
  • Code : 0
    Stands For: NO
COSIGNATURE DATE/TIME 1507 This is the date/time at which cosignature was obtained.

Date/Time
COSIGNED BY 1508

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
COSIGNATURE BLOCK NAME 1509

Free Text
COSIGNATURE BLOCK TITLE 1510

Free Text
COSIGNATURE MODE 1511

Set of Codes
Set of Codes:
  • Code : E
    Stands For: electronic
  • Code : C
    Stands For: chart
MARKED SIGNED ON CHART BY 1512 This is the identity of the person who marked a given document 'signed on chart,' indicating that a 'wet' signature of the chart copy had been obtained.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
MARKED COSIGNED ON CHART BY 1513 This is the user who marked a given document as 'cosigned on chart.'

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AMENDMENT DATE/TIME 1601

Date/Time
AMENDED BY 1602

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
AMENDMENT SIGNED 1603

Date/Time
AMENDMENT SIGN BLOCK NAME 1604 This is the signature block name of the person who amended the document.

Free Text
AMENDMENT SIGN BLOCK TITLE 1605

Free Text
ADMINISTRATIVE CLOSURE DATE 1606

Date/Time
ADMIN CLOSURE SIG BLOCK NAME 1607

Free Text
ADMIN CLOSURE SIG BLOCK TITLE 1608

Free Text
ARCHIVE/PURGE DATE/TIME 1609

Date/Time
DELETED BY 1610 This is the person who deleted the document per the Privacy Act.

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
DELETION DATE 1611 This is the date/(time optional) at which the document was deleted per the Privacy Act.

Date/Time
REASON FOR DELETION 1612 This is the reason for which the document was deleted, either: Privacy Act, as invoked by the patient; or Administrative Action, where the note needed to be removed, following signature, for administrative reasons.

Set of Codes
Set of Codes:
  • Code : P
    Stands For: privacy act
  • Code : A
    Stands For: administrative
ADMINISTRATIVE CLOSURE MODE 1613 This indicates whether the document was closed manually by an administrative person (in order to satisfy authentication requirements), or automatically by scanning a paper document bearing the signature of the patient (e.g., Consents, Advanced Directives, etc.) and not requiring the signature of an author.

Set of Codes
Set of Codes:
  • Code : M
    Stands For: manual
  • Code : S
    Stands For: scanned document
SUBJECT (OPTIONAL description) 1701 This freetext field is used to help you find documents by subject (i.e., consider the subject a "key word" of sorts.

Free Text
VBC LINE COUNT 1801 A VBC Line is defined as the total number of characters you can see with the naked eye, divided by 65. It includes any character contained within a header or footer. Spaces, carriage returns, and hidden format instructions, such as bold, underline, text boxes, printer configurations, spell check, etc., are not counted in the total character count. A VBC Line is calculated by counting all visual characters and simply dividing the total number of characters by 65 to arrive at the number of defined lines.

Numeric
ID PARENT 2101 Applies to ID (interdisciplinary) notes only. The ID PARENT is the note this note is attached to, making this note an entry in an ID note. A note with an ID PARENT is referred to as an ID child note. ID parent notes and ID child notes are both file entries in file 8925. The entries of an interdisciplinary note consist of the first entry, which is also the ID PARENT of the ID note, followed by the ID children.

Pointer
PointerTo:
fileName:
TIU DOCUMENT
fileNumber:
8925
VISIT ID 15001 Unique Visit Identifier for use by CIRN. The value of this field should ONLY be modified by virtue of a change to the Visit (.03) field.

Free Text
TRANSCRIBED ORIGINAL DOC ID 21401

Free Text
TRANSCRIBED PARENT DOC ID 21402

Free Text
TRANSCRIPTIONIST 21403

Free Text
COMPLETE CONSULT ON SIGNING? 21404

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
PROCEDURE SUMMARY CODE 70201 This field contains the summary code for this procedure once it is complete. 'Machine Resulted' is the initial, default code.

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: Normal
  • Code : 2
    Stands For: Abnormal
  • Code : 3
    Stands For: Borderline
  • Code : 4
    Stands For: Incomplete
  • Code : 5
    Stands For: Machine Resulted
DATE/TIME PERFORMED 70202 This field contains the Date/Time when the procedure was performed.

Date/Time
VHA ENTERPRISE STANDARD TITLE 89261 This computed field allows calls to FileMan Utilities (e.g. DIQ) to resolve the VHA ENTERPRISE STANDARD TITLE to which the local title is mapped.

Computed

ILC M DRUG

File Number: 19233.2

File Description:



Fields:

Name Number Description Data Type Field Specific Data
NAME .01

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
DATE VENDED .03

Date/Time
ORDER NUMBER .04

Free Text
QUANTITY VENDED .05

Numeric
ORDERED BY .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDER TYPE .07

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PPK
  • Code : O
    Stands For: OBS
  • Code : S
    Stands For: STARTER DOSE

ILC M SUPPLY

File Number: 19233.3

File Description:



Fields:

Name Number Description Data Type Field Specific Data
ITEM .01

Pointer
PointerTo:
fileName:
ITEM MASTER
fileNumber:
441
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
DATE VENDED .03

Date/Time
ORDER NUMBER .04

Free Text
QUANTITY VENDED .05

Numeric
ORDERED BY .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

OMNICELL RECEIVE DRUG

File Number: 19235.2

File Description:



Fields:

Name Number Description Data Type Field Specific Data
NAME .01

Pointer
PointerTo:
fileName:
DRUG
fileNumber:
50
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
DATE VENDED .03

Date/Time
ORDER NUMBER .04

Free Text
QUANTITY VENDED .05

Numeric
ORDERED BY .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
ORDER TYPE .07

Set of Codes
Set of Codes:
  • Code : P
    Stands For: PPK
  • Code : O
    Stands For: OBS
  • Code : S
    Stands For: STARTER DOSE

OMNICELL RECEIVE SUPPLY

File Number: 19235.3

File Description:



Fields:

Name Number Description Data Type Field Specific Data
ITEM .01

Pointer
PointerTo:
fileName:
ITEM MASTER
fileNumber:
441
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
DATE VENDED .03

Date/Time
ORDER NUMBER .04

Free Text
QUANTITY VENDED .05

Numeric
ORDERED BY .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200

MSC MED REC

File Number: 21451

File Description:

Storage of medication reconciliation events.


Fields:

Name Number Description Data Type Field Specific Data
EVENT DATE .01 Date/time of reconciliation. Will be date/time of event.

Date/Time
PATIENT .02

Pointer
PointerTo:
fileName:
PATIENT/IHS
fileNumber:
9000001
TYPE .03

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADMISSION
  • Code : T
    Stands For: TRANSFER
  • Code : D
    Stands For: DISCHARGE
  • Code : O
    Stands For: OUTPATIENT
VISIT .04

Pointer
PointerTo:
fileName:
VISIT
fileNumber:
9000010
PATIENT MOVEMENT .05

Pointer
PointerTo:
fileName:
PATIENT MOVEMENT
fileNumber:
405
PROVIDER .06

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EXPIRED .07

Set of Codes
Set of Codes:
  • Code : 1
    Stands For: YES
NURSE .08

Pointer
PointerTo:
fileName:
NEW PERSON
fileNumber:
200
EXPIRED DATE .09 Date/time of when the MSC MED REC entry was expired by the system based on the number of hours in the MSCE MED REC ADMISSION HOURS or MSCE MED REC DISCHARGE HOURS.

Date/Time
STARTED DATE .1 Date/time of when this MSC MED REC had orders saved.

Date/Time
FINALIZED DATE .11 Date/time of when the PROVIDER has 'Finalized' this MSC MED REC entry.

Date/Time
NO HOME MEDS .12 Field is set to '1' if patient confirmed they are not taking any home medications or '2' if patient was unable to provide home medications.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NOT INDICATED
  • Code : 1
    Stands For: NONE BEING TAKEN
  • Code : 2
    Stands For: UNABLE TO OBTAIN
NO OUTPT MEDS .13 Field is set to "YES" if patient does not have any outpatient medications.

Set of Codes
Set of Codes:
  • Code : 0
    Stands For: NO
  • Code : 1
    Stands For: YES
NURSE COMPLETED DATE .14 Date/time of when the NURSE has 'Completed' this MSC MED REC entry.

Date/Time
ORDERS 1

Subfile
subfile:
Name Number Description Data Type Field Specific Data
ORDERS .01

Pointer
PointerTo:
fileName:
ORDER
fileNumber:
100
ACTION .02

Set of Codes
Set of Codes:
  • Code : A
    Stands For: ADD
  • Code : S
    Stands For: STOP
  • Code : C
    Stands For: CHANGE
  • Code : N
    Stands For: NO CHANGE
  • Code : H
    Stands For: HOLD
  • Code : TIP
    Stands For: TRANSFER TO IP
  • Code : R
    Stands For: RELEASE HOLD
  • Code : X
    Stands For: NO ACTION
TAKING .03

Set of Codes
Set of Codes:
  • Code : T
    Stands For: TAKING
  • Code : N
    Stands For: NOT TAKING
TIME LAST TAKEN .04

Date/Time
NEW MED .05 Indicates whether the order is a new order for the medication reconciliation.

Set of Codes
Set of Codes:
    CHANGELOG 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PERFORMED AT .01

    		Date/Time
    CHANGED FIELD .02 Pointer to file,field of the field where data has been updated. If the field is an order, then it will include the Order #. Example 21451.01,.03;2 to represent ACTION field under the ORDERS multiple for the MSC MED REC order IEN.

    		Free Text
    PERFORMED BY .03 The user who added/changed a field in the MSC MED REC entry.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    OLD VALUE 1 The value of the CHANGED FIELD prior to the add/update.

    		Free Text
    NEW VALUE 2 The value of the CHANGED FIELD after the add/update.

    		Free Text
    COMMENT 3 Comment to explain why No Home Medications is being documented or why the list of medications could not be obtained from the patient.

    		Free Text

    BEH RECONCILIATION

    File Number: 90461.63

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01

    		Date/Time
    PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    SOURCE .03

    		Free Text
    RECONCILIATION COMPLETED .04

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    ALLERGY RECONCILIATION .07 Date Allergy Reconciliation was marked as done.

    		Date/Time
    PROBLEM RECONCILIATION .08 Date Problem Reconciliation was marked as done.

    		Date/Time
    MEDICATION RECONCILIATION .09 Date Medication Reconciliation was marked as done.

    		Date/Time
    IMAGE 1.1

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    HIE OID 1.2

    		Free Text
    HIE EXT 1.3

    		Free Text
    ITEM RECONCILED 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ITEM RECONCILED DATE/TIME .01

    		Date/Time
    RECONCILING PERSON .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ITEM TYPE .03

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALLERGY
    • Code : P
      Stands For: PROBLEM
    • Code : X
      Stands For: PRESCRIPTION
    • Code : N
      Stands For: NON-VA MED
    • Code : U
      Stands For: UNIT DOSE
    • Code : M
      Stands For: MEDICATION
    ID .04

    		Free Text

    MEDICARE ELIGIBLE

    File Number: 9000003

    File Description:

    This file contains information on patients who are eligible for Medicare. The PATIENT NAME field of this file (.01) is a backward pointer to the IHS PATIENT file. A patient must exist in the IHS PATIENT file before data can be added here. Medicare and Railroad Retirement are basically the same. Both are sent to the same Medicare FI. Both are treated the same in regards to plans, filing procedures, and payments. There are minor differences such as benefits provided to Railroad retirees that are different than the traditional Medicare Plan.


    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01 This field points to the NAME field of the PATIENT file. The internal FileMan number for this entry is the same as the internal FileMan number in the PATIENT file. A patient must exist in the PATIENT file before data for that patient can be added to this file.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURER POINTER .02 This field is a pointer to the MEDICARE entry in the INSURER file.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    MEDICARE NUMBER .03

    		Free Text
    SUFFIX .04

    		Pointer
    PointerTo:
    fileName:
    MEDICARE SUFFIX
    fileNumber:
    9999999.32
    MEDICARE SECONDARY PAYER .05

    		Date/Time
    DATE OF LAST UPDATE .07

    		Date/Time
    QMB/SLMB .08 Qualified Medical Beneficiary / Specified Low income Medicare Beneficiary

    		Set of Codes
    Set of Codes:
    • Code : Q
      Stands For: QMB
    • Code : S
      Stands For: SLMB
    • Code : U
      Stands For: UNKNOWN
    • Code : P
      Stands For: PENDING
    • Code : N
      Stands For: NONE
    *IMP MSG FORM MCR SIG OBTAINED .09

    		Date/Time
    PRIMARY CARE PROVIDER .14 Not a required field. Enter the name of the Primary Care Provider for this patient's plan.

    		Free Text
    MEDICARE CARD COPY ON FILE .15

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DATE MEDICARE CC WAS OBTAINED .16 Date Medicare card copy was obtained

    		Date/Time
    ELIGIBILITY 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ELIG. DATE .01

    		Date/Time
    ELIG. END DATE .02

    		Date/Time
    COVERAGE TYPE .03

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : D
      Stands For: D
    PLAN NAME .04

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    MEDICARE NAME .05

    		Free Text
    ID Number .06

    		Free Text
    PERSON CODE .07

    		Free Text
    GENDER .08

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MALE
    • Code : F
      Stands For: FEMALE
    • Code : U
      Stands For: UNKNOWN
    DATE OF BIRTH .09

    		Date/Time
    GROUP NAME .11

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    IMP MSG FORM MCR SIG OBTAINED 1201

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMP MSG FORM MCR SIG OBTAINED .01

    		Date/Time
    ADVANCE BENEFICIARY NOTICE 1301

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ADVANCE BENEFICIARY NOTICE .01 Enter the date that the ABN was signed and filed.

    		Date/Time
    MEDICARE NAME 2101

    		Free Text
    MEDICARE DATE OF BIRTH 2102

    		Date/Time

    POLICY HOLDER

    File Number: 9000003.1

    File Description:

    This file contains the information on the Patient Policy holders used in the 3rd party billing system.


    Fields:

    Name Number Description Data Type Field Specific Data
    NAME OF POLICY HOLDER .01

    		Free Text
    PATIENT POINTER .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURANCE COMPANY .03

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    POLICY NUMBER .04

    		Free Text
    COVERAGE TYPE .05

    		Pointer
    PointerTo:
    fileName:
    COVERAGE TYPE
    fileNumber:
    9999999.65
    GROUP NAME .06

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    POLICY HOLDER'S SEX .08

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MALE
    • Code : F
      Stands For: FEMALE
    • Code : U
      Stands For: UNKNOWN
    HOLDER'S ADDRESS - STREET .09

    		Free Text
    HOLDER'S ADDRESS - CITY .11

    		Free Text
    HOLDER'S ADDRESS - STATE .12

    		Pointer
    PointerTo:
    fileName:
    STATE
    fileNumber:
    5
    HOLDER'S ADDRESS - ZIP .13

    		Free Text
    HOLDER'S TELEPHONE NUMBER .14

    		Free Text
    HOLDER'S EMPLOYMENT STATUS .15

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: FULL-TIME
    • Code : 2
      Stands For: PART-TIME
    • Code : 3
      Stands For: UNEMPLOYED
    • Code : 4
      Stands For: SELF EMPLOYED
    • Code : 5
      Stands For: RETIRED
    • Code : 6
      Stands For: ACTIVE MILITARY DUTY
    • Code : 9
      Stands For: UNKNOWN
    EMPLOYER .16

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.75
    EFFECTIVE DATE .17

    		Date/Time
    EXPIRATION DATE .18

    		Date/Time
    DATE OF BIRTH .19

    		Date/Time
    CARD NAME 2

    		Free Text

    MEDICAID ELIGIBLE

    File Number: 9000004

    File Description:

    This file contains information on patients who are eligible for Medicaid. The PATIENT NAME field of this file (.01) is a backward pointer to the IHS PATIENT file. A patient must exist in the IHS PATIENT file before data can be added here. 1-8-87 This file cannot currently be RE-INDEXED. To do so creates residual "AA" cross-reference entries.


    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01 This field points to the NAME field of the PATIENT file. A patient must exist in the PATIENT file before data for that patient can be added to this file.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURER POINTER .02 This field is a pointer to the MEDICAID entry in the INSURER file.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    MEDICAID NUMBER .03

    		Free Text
    STATE .04

    		Pointer
    PointerTo:
    fileName:
    STATE
    fileNumber:
    5
    NAME OF INSURED .05

    		Free Text
    RELATIONSHIP TO INSURED .06

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    SEX OF INSURED .07

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MALE
    • Code : F
      Stands For: FEMALE
    • Code : U
      Stands For: UNKNOWN
    DATE OF LAST UPDATE .08

    		Date/Time
    POLICY HOLDER .09

    		Pointer
    PointerTo:
    fileName:
    POLICY HOLDER
    fileNumber:
    9000003.1
    PLAN NAME .11

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    RATE CODE .12

    		Free Text
    CASE NUMBER .13

    		Free Text
    PRIMARY CARE PROVIDER .14

    		Free Text
    MEDICAID CARD COPY ON FILE .15

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DATE MCD CC WAS OBTAINED .16

    		Date/Time
    GROUP NAME .17

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    ELIGIBILITY DATES 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ELIG. DATE .01

    		Date/Time
    ELIG. END DATE .02

    		Date/Time
    COVERAGE TYPE .03

    		Free Text
    MEDICAID NAME 2101

    		Free Text
    MEDICAID DATE OF BIRTH 2102

    		Date/Time

    RAILROAD ELIGIBLE

    File Number: 9000005

    File Description:

    This file contains information on patients who are eligible for Railroad. The PATIENT NAME field of this file (.01) is a backward pointer to the IHS PATIENT file. A patient must exist in the IHS PATIENT file before data can be added here. Medicare and Railroad Retirement are basically the same. Both are sent to the same Medicare FI. Both are treated the same in regards to plans, filing procedures, and payments. There are minor differences such as benefits provided to Railroad retirees that are different than the traditional Medicare Plan.


    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01 This field points to the NAME field of the PATIENT file. The internal FileMan number for this entry is the same as the internal FileMan number in the PATIENT file. A patient must exist in the PATIENT file before data for that patient can be added to this file.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURER POINTER .02 This field is a pointer to the RAILROAD RETIREMENT entry in the INSURER file.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    PREFIX .03

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.33
    RAILROAD NUMBER .04

    		Free Text
    DATE OF LAST UPDATE .07

    		Date/Time
    QMB/SLMB .08 Qualified Medical Beneficiary / Specified Low income Medicare Beneficiary

    		Set of Codes
    Set of Codes:
    • Code : Q
      Stands For: QMB
    • Code : S
      Stands For: SLMB
    • Code : U
      Stands For: UNKNOWN
    • Code : P
      Stands For: PENDING
    • Code : N
      Stands For: NONE
    SIGNATURE ON FILE .11

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DATE SIGNATURE WAS OBTAINED .12 Used to indicate the date the MSP was obtained and placed in the chart

    		Date/Time
    PRIMARY CARE PROVIDER .14

    		Free Text
    RR CARD COPY ON FILE .15

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DATE RR CC WAS OBTAINED .16

    		Date/Time
    ELIGIBILITY 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ELIG. DATE .01

    		Date/Time
    ELIG. END DATE .02

    		Date/Time
    COVERAGE TYPE .03

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : D
      Stands For: D
    PLAN NAME .04

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    MEDICARE NAME .05

    		Free Text
    ID Number .06

    		Free Text
    PERSON CODE .07

    		Free Text
    GENDER .08

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MALE
    • Code : F
      Stands For: FEMALE
    • Code : U
      Stands For: UNKNOWN
    DATE OF BIRTH .09

    		Date/Time
    GROUP NAME .11

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    RAILROAD NAME 2101

    		Free Text
    RAILROAD DATE OF BIRTH 2102

    		Date/Time

    PRIVATE INSURANCE ELIGIBLE

    File Number: 9000006

    File Description:

    This file contains information on patients who are eligible for Private Ins. The PATIENT NAME field of this file (.01) is a backward pointer to the IHS PATIENT file. A patient must exist in the IHS PATIENT file before data can be added here.


    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01 This field points to the NAME field of the PATIENT file. The internal FileMan number for this entry is the same as the internal FileMan number in the PATIENT file. A patient must exist in the PATIENT file before data for that patient can be added to this file.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURER 1101 This multi-valued field contains information about each private carrier who is, or has, insured this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INSURER .01 This field is a pointer to the INSURER file. MEDICARE, MEDICAID, and RAILROAD RETIREMENT are not allowed in this file because they are pointed to from files created especially for them. This field is LAYGO.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    *POLICY NUMBER .02

    		Free Text
    *COVERAGE .03

    		Pointer
    PointerTo:
    fileName:
    COVERAGE TYPE
    fileNumber:
    9999999.65
    *NAME OF INSURED .04

    		Free Text
    RELATIONSHIP .05

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    ELIG. DATE .06

    		Date/Time
    ELIG. END DATE .07

    		Date/Time
    POLICY HOLDER .08

    		Pointer
    PointerTo:
    fileName:
    POLICY HOLDER
    fileNumber:
    9000003.1
    VERIFIED COVERAGE DATE .09

    		Date/Time
    VERIFIED BY .11

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PERSON CODE .12

    		Free Text
    PRIMARY CARE PROVIDER .14

    		Free Text
    PI CARD COPY ON FILE .15

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DATE PI CC WAS OBTAINED .16

    		Date/Time
    MEMBER NUMBER 21

    		Free Text

    VAMB ELIGIBLE

    File Number: 9000006.02

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    INSURER 1

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    DATE OF LAST UPDATE 2

    		Date/Time
    VETERAN NAME 3

    		Free Text
    RELATIONSHIP TO VETERAN 4

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    VETERAN VMBP ENROLLMENT NUMBER 5

    		Free Text
    VETERAN DOB 6

    		Date/Time
    VETERAN GENDER 7

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MALE
    • Code : F
      Stands For: FEMALE
    • Code : U
      Stands For: UNKNOWN
    ELIGIBILITY DATES 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ELIG BEGIN DATE .01

    		Date/Time
    ELIG END DATE .02

    		Date/Time
    COVERAGE TYPE .03

    		Pointer
    PointerTo:
    fileName:
    COVERAGE TYPE
    fileNumber:
    9999999.65

    VISIT

    File Number: 9000010

    File Description:

    This file contains a record of all patient visits at health care facilities or by health care providers, including direct outpatient and clinic visits, as well as inpatient encounters with providers of care. All other visit related files, such as purpose of visit (diagnoses), operative procedures, immunizations, examinations, etc. will point to a visit in this file. The records are maintained by date/time of visit, and the patient name field is a pointer to the IHS Patient file, where the patient must exist before data can be added here. Cross References: ("AA",<patient pointer>,<9's-visit date+time>,IEN)=<eligibility pointer> ("AAH",<patient pointer>,<9's-visit date+time>,IEN)="" set conditional SERVICE CATEGORY = Hospitalization ("ABILL",<date visit created>, IEN)="" set conditional to site parameter ("AC",<patient pointer>,IEN)="" ("AD", <parent visit pointer>,IEN)="" ("ADEL",<visit date&time>,IEN)="" set conditional DEPENDENT ENTRY COUNT '> 0 ("AI",IEN)="" set conditional SERVICE CATEGORY = In hospital ("AMRG",<date visit created>,IEN)="" ("APCIS",<date visit created>,IEN)=""


    Fields:

    Name Number Description Data Type Field Specific Data
    VISIT/ADMIT DATE&TIME .01 Type date of visit. Must be between DOB and today. In the VA this reflects the visit appointment and or event date time.

    		Date/Time
    DATE VISIT CREATED .02 Generated when new visit added to subfile. Date visit added to file. Usually stuffed with DT. A date between 1960 and today.

    		Date/Time
    TYPE .03 IHS- The type of visit. Differentiates between various categories of visit types. E.g. A visit provided by contract care funds versus a visit directing provided by IHS. I-IHS, C-Contract, V-VA, O-Other, 6-638 Program.

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: IHS
    • Code : C
      Stands For: CONTRACT
    • Code : T
      Stands For: TRIBAL
    • Code : O
      Stands For: OTHER
    • Code : 6
      Stands For: 638 PROGRAM
    • Code : V
      Stands For: VA
    PATIENT NAME .05 Pointer to the Patient file.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    LOC. OF ENCOUNTER .06 Pointer to the location file. Location where the visit took place. In the VA, the Location file entries will be based on the current entries in the institution file, so this field represents the institution.

    		Pointer
    PointerTo:
    fileName:
    LOCATION
    fileNumber:
    9999999.06
    SERVICE CATEGORY .07

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AMBULATORY
    • Code : H
      Stands For: HOSPITALIZATION
    • Code : I
      Stands For: IN HOSPITAL
    • Code : C
      Stands For: CHART REVIEW
    • Code : T
      Stands For: TELECOMMUNICATIONS
    • Code : N
      Stands For: NOT FOUND
    • Code : S
      Stands For: DAY SURGERY
    • Code : O
      Stands For: OBSERVATION
    • Code : E
      Stands For: EVENT (HISTORICAL)
    • Code : R
      Stands For: NURSING HOME
    • Code : D
      Stands For: DAILY HOSP DATA
    • Code : X
      Stands For: ANCILLARY PACKAGE DAILY
    • Code : M
      Stands For: TELEMEDICINE
    DSS ID .08 Pointer to the Clinic Stop file. Organized clinic in which this visit took place. E.g. Pediatrics, General

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    DEPENDENT ENTRY COUNT .09 IHS- a count of how many "V" file entries are pointing to this visit. If the count is zero, the visit should be deleted. Field is updated by a cross reference in each "V" file that calls routine ADD^AUPNVSIT or SUB^AUPNVSIT.

    		Numeric
    DELETE FLAG .11 Flag set to signify that the visit has been deleted.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: ACTIVE
    • Code : 1
      Stands For: DELETED
    PARENT VISIT LINK .12 The PARENT VISIT LINK field points back to the VISIT file.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    DATE LAST MODIFIED .13 Date on which the visit was last modified. Any time a field in the visit file or a V File is added or deleted, this field is automatically updated with the current date.

    		Date/Time
    CHECK OUT DATE&TIME .18 This field is the date and time the patient checked out for this visit. This field will only store the information temporarily and will be empty.

    		Date/Time
    ELIGIBILITY .21 Defines the patient's eligibility for this visit.

    		Pointer
    PointerTo:
    fileName:
    ELIGIBILITY CODE
    fileNumber:
    8
    HOSPITAL LOCATION .22

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    CREATED BY USER .23 This field contains either the DUZ passed in by the application calling the PCE API ($$DATA2PCE^PXAPI) to create or update the visit, or defaults to the DUZ at the time the entry was created or updated if no DUZ is passed in, or if something other than the API is used to create or update the entry.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    OPTION USED TO CREATE .24 If known, the option under which this visit was created.

    		Pointer
    PointerTo:
    fileName:
    OPTION
    fileNumber:
    19
    PROTOCOL .25 This is the protocol which was used to create this visit.

    		Pointer
    PointerTo:
    fileName:
    PROTOCOL
    fileNumber:
    101
    PFSS ACCOUNT REFERENCE .26 The number by which all VistA applications will reference an external medical billing system account number for purposes of attaching charges for 1st or 3rd party billing.

    		Pointer
    PointerTo:
    fileName:
    PFSS ACCOUNT
    fileNumber:
    375
    GROUP ENCOUNTER? 1115

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DECISION TO ADMIT DT/TIME 1116

    		Date/Time
    OUTSIDE LOCATION 2101 Free text location of service.

    		Free Text
    REASON FOR DELETION 2201

    		Free Text
    WHERE SEEN SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    WHERE SEEN SNOMED CT .01

    		Free Text
    WHERE SEEN PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    FACE TO FACE SNOMED CT 2801

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FACE TO FACE SNOMED CT .01

    		Free Text
    FACE TO FACE PREFERRED TERM .019

    		Computed
    LOOKUP 9999

    		Computed
    VISIT ID 15001

    		Free Text
    PATIENT STATUS IN/OUT 15002 This is an indicator of the patient's status at the time of the visit.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: IN
    • Code : 0
      Stands For: OUT
    ENCOUNTER TYPE 15003 This field notes the primary type of visits, the stop code visit and the occasion of service visit that were manual entered.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PRIMARY
    • Code : O
      Stands For: OCCASION OF SERVICE
    • Code : S
      Stands For: STOP CODE
    • Code : A
      Stands For: ANCILLARY
    • Code : C
      Stands For: CREDIT STOP
    EXTERNAL ACCOUNT NUMBER 21400

    		Free Text
    MSC ADMISSION SOURCE 21404.1

    		Free Text
    MSC NEW PATIENT FLAG 21404.2

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MSC PATIENT TYPE 21405

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PATIENT TYPE DATE .01

    		Date/Time
    MSC PATIENT TYPE .02

    		Pointer
    PointerTo:
    fileName:
    MSC PATIENT TYPES
    fileNumber:
    21405
    MSC DISCHARGE TYPE CODE 21406.1

    		Pointer
    PointerTo:
    fileName:
    MSC PATIENT DISCHARGE CODES
    fileNumber:
    21405.1
    PRIMARY MEDICAL DOCTOR 21415

    		Free Text
    PRIVACY REQUESTED 21487

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIVACY WARNING ACCEPTED 21487.1 This field contains the users who have already viewed and accepted the privacy warning for this visit.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    USER .01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    HL7 VISIT NUMBER 29320.01 This field contains a optional visit identifier supplied by an external system. The value is usually obtained from HL7 segment PV1.19.1, but other sources are possible.

    		Free Text
    SERVICE CONNECTED 80001 This field will be used to indicate if this visit was for treating a VA patient based on a service connected problem.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    AGENT ORANGE EXPOSURE 80002 This field is used to indicate that this visit represents treatment of a VA patient for a problem that is related to Agent Orange Exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    IONIZING RADIATION EXPOSURE 80003 This field is used to indicate that this visit represents treatment of a VA patient for a problem that is related to Ionizing Radiation Exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SW ASIA CONDITIONS 80004 This field is used to indicate that this visit represents treatment of a VA patient for a problem that is related to Southwest Asia Conditions Exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MILITARY SEXUAL TRAUMA 80005 Indicates whether the patient visit was related to their Military Sexual Trauma.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEAD AND/OR NECK CANCER 80006 This field is used to indicate that the visit represents treatment of a VA patient for a problem that is related to Head and/or Neck Cancer.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    COMBAT VETERAN 80007 This field is used to indicate that the visit represents treatment of a VA patient for a problem that is possibly related to combat.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PROJ 112/SHAD 80008 Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SERVICE CONNECTION EDIT FLAG 80011 This field is used to determine if the Service Connection Classification for the Visit can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    AGENT ORANGE EDIT FLAG 80012 This field is used to determine if the Agent Orange Classification for the Visit can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    IONIZING RADIATION EDIT FLAG 80013 This field is used to determine if the Ionizing Radiation classification for the Visit can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    SW ASIA CONDITIONS EDIT FLAG 80014 This field is used to determine if the Southwest Asia Conditions classification for the Visit can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    MST EDIT FLAG 80015 This field is used to determine if the Military Sexual Trauma classification for the Visit can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    HEAD AND NECK CANCER EDIT FLAG 80016 This field is used to determine if the Head and/or Neck Cancer classification can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    COMBAT VETERAN EDIT FLAG 80017 This field is used to determine if the Combat Veteran classification can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    PROJ 112/SHAD EDIT FLAG 80018 This field is used to determine if the PROJ 112/SHAD classification can be edited by the user.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDITABLE
    • Code : 1
      Stands For: NOT EDITABLE
    COMMENTS 81101 A FIELD TO ADD COMMENTS AS THEY PERTAIN TO A VISIT

    		Free Text
    PACKAGE 81202 This is a pointer to the package that wanted the visit created.

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203 This is a pointer to the PCE DATA SOURCE file and is the source that wanted the visit created.

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V MEASUREMENT

    File Number: 9000010.01

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. Measurements, such as weight, height, blood pressure, etc., taken by a health professional at an outpatient encounter, will be stored in this file. The patient name is a pointer to the Patient/IHS file, and the visit is a pointer to the Visit file. Both of these must exist before data can be entered in this record. This file contains one record for each measurement for a patient for each visit; therefore the key field (.01) will be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    TYPE .01 This is the type of measurement being taken on the patient. BP, HT, WT, HC, etc.

    		Pointer
    PointerTo:
    fileName:
    MEASUREMENT TYPE
    fileNumber:
    9999999.07
    PATIENT NAME .02 Patient Name.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 The encounter entry in the Visit file that is associated with this measurement.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    VALUE .04

    		Free Text
    PERCENTILE .05

    		Numeric
    NUMERATOR ON VC/VU .06

    		Numeric
    DATE/TIME VITALS ENTERED .07 This field contains the date/time this vital/measurement was taken by the care provider.

    		Date/Time
    ENTERED BY .08

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPPLEMENTAL O2 1.4 This field stores the information of the supplemental oxygen as follows: .5-20 l/min (liters/minute) and/or 21-100 % of oxygen concentration For example: 4.5 l/min 40% 4.5 l/min 40 %

    		Free Text
    ENTERED IN ERROR 2 This field indicates that this record was flagged as entered in error.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    ERROR ENTERED BY 3 This field indicates the name of the person responsible for entering the record in error. Pointer to the NEW PERSON (#200) file.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REASON ENTERED IN ERROR 4 This multiple contains a list of reasons for entering a vital measurement in error.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REASON ENTERED IN ERROR .01 This multiple contains a list of reasons for entering a vital measurement in error.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: INCORRECT DATE/TIME
    • Code : 2
      Stands For: INCORRECT READING
    • Code : 3
      Stands For: INCORRECT PATIENT
    • Code : 4
      Stands For: INVALID RECORD
    QUALIFIER 5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    QUALIFIER .01

    		Pointer
    PointerTo:
    fileName:
    GMRV VITAL QUALIFIER
    fileNumber:
    120.52
    EVENT DATE & TIME 1201 This is the date and time that the measurement was taken by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time that the provider performed the clinical event. The data may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction that the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the measurment to be done.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who took the measurement at the encounter.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V MEASUREMENT
    fileNumber:
    9000010.01
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any measurment data is being edited from the original entry of data.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    DATA SOURCE 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE Data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's measurement which may be entered by the provider. It may be entered manually via the PCE User Interface.

    		Free Text
    %RW 9999999

    		Computed

    V EYE GLASS

    File Number: 9000010.04

    File Description:

    This file contains eye glass prescription information specific to a par- ticular visit for a particular patient. The VISIT field of this file (.01) is a backward pointer to the VISIT file. This file contains one record for each eye glass prescription for each visit, therefore, the KEY field (.01) may be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    NAME .01

    		Numeric
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    COMMENT 1101

    		Free Text
    EVENT DATE&TIME 1201

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V EYE GLASS
    fileNumber:
    9000010.04
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    READING ONLY 1901

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DRE SPHERE 1902

    		Free Text
    DRE CYLINDER 1903

    		Free Text
    RE AXIS 1904

    		Numeric
    DLE SPHERE 1905

    		Free Text
    DLE CYLINDER 1906

    		Free Text
    LE AXIS 1907

    		Numeric
    READING ADD. R 1908

    		Free Text
    READING ADD. L 1909

    		Free Text
    *EYE SIZE 1910

    		Numeric
    *BRIDGE 1911

    		Numeric
    *TEMPLE 1912

    		Free Text
    PD (NEAR) 1913

    		Numeric
    PD (DISTANCE) 1914

    		Numeric
    RE PRISM H 1915

    		Free Text
    LE PRISM H 1916

    		Free Text
    RE PRISM V 1917

    		Free Text
    LE PRISM V 1918

    		Free Text
    PD (LEFT) 1919

    		Numeric
    PD (RIGHT) 1920

    		Numeric

    V PROVIDER

    File Number: 9000010.06

    File Description:

    This record, along with a purpose of visit, is required for each patient encounter, whether at an IHS, tribal or CHS facility, or at a visit in the home or other field location. It has backward pointers to the IHS Patient file, and the visit file, and data must exist in both of these files for this visit before data can be entered here. There can be multiple providers for a given visit. The primary/secondary field identifies which provider is considered the primary provider for this visit. The provider must exist in the Provider File (#6). data can be entered here. There can be multiple providers for a given visit. The primary/secondary field identifies which provider is considered the primary provider for this visit. The only providers that can be entered in the file, are those providers who have the "AK.PROVIDER" key. In the VA, providers without the security key can be entered in the V-files Encounter Provider field.


    Fields:

    Name Number Description Data Type Field Specific Data
    PROVIDER .01 This is the provider giving patient care at this encounter. The provider must hold the AK.PROVIDER security key. Providers giving care who do not hold the AK.PROVIDER security key may be documented in the Encounter Provider field for each PCE V-file (visit-related file, e.g., V CPT) for the itemized care provided.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    AFF.DISC.CODE .019

    		Computed
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 The encounter entry in the Visit file where the provider gave clinical care to the patient.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    PRIMARY/SECONDARY .04 This field indicates the provider was the primary or secondary care giver for the encounter. The primary provider is usually the physician responsible for the patients care at THIS PARTICULAR encounter, where clinical decisions were being made. The primary provider for this encounter may or may not be the "Primary Care Provider" for this patient for overall care. Secondary providers are those providers, who were also providing care where clinical decisions were being made. This may be nurses, social workers, pharmacists,... There may be more than one "primary" and "secondary" V Provider entries for a particular encounter in the Visit file.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PRIMARY
    • Code : S
      Stands For: SECONDARY
    PROVIDER STATUS .05 A Provider may be furthur identified as the "Attending" provider or an "Operating" provider for the encounter.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ATTENDING
    • Code : O
      Stands For: OPERATING
    • Code : C
      Stands For: CONSULTING
    PERSON CLASS .06 This is the class of the provider at the time of the encounter.

    		Pointer
    PointerTo:
    fileName:
    PERSON CLASS
    fileNumber:
    8932.1
    EVENT DATE AND TIME 1201 This is the date and time the provider had the encounter with the patient. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V PROVIDER
    fileNumber:
    9000010.06
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original provider data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The formt of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_"-"DUZ of the persion who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's provider. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V POV

    File Number: 9000010.07

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. POV is an abbreviation for "Purpose of Visit" (descriptive name used by IHS) or "Problem of Visit" (descriptive name used by VA). The V POV file is used to store clinical data related to the "purpose of visit" or "problem of visit", (POV). This is the provider's definition of what diagnosis to use to represent the patient care given at the visit. The POV entry is not the patient's "Chief Complaint" text. It is the diagnosis as defined by the provider which will have an ICD Diagnosis code related to it to support Clinical needs and additionally support Administrative functions too such as Billing, Workload, and DSS. There should be at least one "purpose of visit" (descriptive name used by IHS) or one "problem of visit" (descriptive name used by the VA) in the V POV file for each patient visit whether it is an inpatient, outpatient or field visit, and regardless of the discipline of the provider (i.e. dental, CHN, mental health, etc.). There is no limit to the number of POV's that can be entered for a patient for a given encounter. At IHS facilities, POV's are generated automatically for this file at time of discharge from the Admission, Discharge and Transfer (ADT) system. POV's are entered in narrative form, and coded automatically to the appropriate ICD9 code. Physician entered narrative which modifies the diagnosis, such as "doubtful, suspect, resolved" are entered by the data entry person in the MODIFIER field. Narrative qualifiers, such as "not healing well", "date of onset", "severe" etc.. are stored in the NARRATIVE QUALIFIER field. STAGE is used only as a local option. The file contains pointers to the IHS Patient file, and visit file, and data must exist in both of these files for this visit before a POV can be entered here. At VA facilities, POV is used as an abbreviation for "Problem of Visit", or the problem treated at the visit. POV's are primarily created for clinic visits from 3 sources: 1) The scheduling checkout process, in which case the information collected about the POV is limited to the ICD Diagnosis code. The provider narrative becomes the ICD narrative from the ICD Diagnosis file. 2) The Encounter Form automated data scanning (AICS package). In this case the provider narrative is the terminology defined by the clinician to represent the diagnosis on the encounter form. The AICS package, or other automated data capture tool, is able to pass the narrative and the ICD Diagnosis. If the problem treated at the visit was a pre-existing problem from the patient's "Problem List", the related problem entry is also stored in the POV record. (The Problem List orientation is not utilized by IHS.) 3) The manual data entry process for encounter form data not collected via automated data capture. This process is the most like the process IHS


    Fields:

    Name Number Description Data Type Field Specific Data
    POV .01 POV is an abbreviation for "Purpose of Visit". Since Purpose of Visit is often confused with "Chief complaint", another abbreviation might better be "Problem of Visit". This is the Provider's conclusion about what was treated at the visit. The Provider should be able to indicate a preferred narrative for what was treated and an ICD Diagnosis code. If the problem treated is from the Problem List, then the problem list entry information can be used for the "Problem of Visit" entry. The provider can alternatively have this information automatically captured via scanned Encounter Forms (e.g., AICS - the VA's Encounter Form Data Capture package). At VA facilites, the ICD Diagnosis is screened by Inactive Code and it must be appropriate for the Patient's age and sex. At IHS facilities, the ICD Diagnosis is screened by Inactive Code, appropriate for the Patient's age and sex, and Not "E" codes.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ICD NARRATIVE .019

    		Computed
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 The encounter entry in the Visit file that is associated with this problem treated. In IHS facilities, this is the date and time the visit actually occurred. In VA facilities, this is the data and time of the clinic appointment for the patient in the Scheduling package, or the date and time the encounter occurred if there was no appointment. By using the appointment date and time, clinic activity can be captured for clinical use as well as be used for billing and workload information by the appropriate VA packages. If the visit was for a walk-in, an appointment should be entered in Scheduling first in order to have the clinical information also be used for the administrative uses. Non-clinic appointment encounters can be entered, but the clinical POV information is not accepted for billing. The patient encounter can be the result of an inpatient encounter. In this case, the ward would be specified as the hospital location in the Visit File.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    PROVIDER NARRATIVE .04 This is the providers text describing the diagnosis that was treated at the visit. The text may contain additional information related specifically to the patient at the time of the visit (e.g, Hypertension, uncontrolled). The providers' narrative may be different from the ICD Diagnosis files description for a code, but should not have a significantly different meaning. The ICD Diagnosis code in the POV (.01) field should be the code that "most closely" represents the providers narrative. In IHS facilities, this narrative is entered by data entry clerks. In VA facilities, this narrative may be entered manually or derived from: 1) the ICD Diagnosis text from the ICD Diagnosis file (Scheduling interface) 2) the text defined on Encounter Forms when defining the most common diagnosis treated for a clinic (AICS or other automated data capture) 3) the Problem list entries' "provider narrative", captured from the Active Problem list being checked off for problems treated at the encounter on an Encounter Form (AICS or other automated data capture).

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    STAGE .05

    		Numeric
    MODIFIER .06 (Optional) This is how a provider may modify the diagnosis or problem treated to reflect the status of the diagnosis as of this visit. Common examples of modifiers are Rule Out, Follow-up, or Status Post.

    		Set of Codes
    Set of Codes:
    • Code : C
      Stands For: CONSIDER
    • Code : D
      Stands For: DOUBTFUL
    • Code : F
      Stands For: FOLLOW UP
    • Code : M
      Stands For: MAYBE, POSSIBLE, PERHAPS
    • Code : O
      Stands For: RULE OUT
    • Code : P
      Stands For: PROBABLE
    • Code : R
      Stands For: RESOLVED
    • Code : S
      Stands For: SUSPECT, SUSPICIOUS
    • Code : T
      Stands For: STATUS POST
    CAUSE OF DX .07

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: HOSPITAL ACQUIRED
    • Code : 2
      Stands For: ALCOHOL RELATED
    • Code : 3
      Stands For: BATTERED CHILD
    • Code : 4
      Stands For: EMPLOYMENT RELATED
    • Code : 5
      Stands For: DOMESTIC VIOLENCE RELATED
    • Code : 6
      Stands For: DRUG RELATED
    FIRST/REVISIT .08

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: FIRST VISIT
    • Code : 2
      Stands For: REVISIT
    EXTERNAL CAUSE .09

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DATE OF ONSET .1

    		Date/Time
    PLACE OF ACCIDENT .11

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: HOME-INSIDE
    • Code : B
      Stands For: HOME-OUTSIDE
    • Code : C
      Stands For: FARM
    • Code : D
      Stands For: SCHOOL
    • Code : E
      Stands For: INDUSTRIAL PREMISES
    • Code : F
      Stands For: RECREATIONAL AREA
    • Code : G
      Stands For: STREET/HIGHWAY
    • Code : H
      Stands For: PUBLIC BUILDING
    • Code : I
      Stands For: RESIDENT INSTITUTION
    • Code : J
      Stands For: HUNTING/FISHING
    • Code : K
      Stands For: OTHER
    • Code : L
      Stands For: UNKNOWN
    PRIMARY/SECONDARY .12 This field represents the clinically pertinent ranking of problems treated. There is no limit on how many POV's may be identified as primary or secondary problems treated at the visit.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PRIMARY
    • Code : S
      Stands For: SECONDARY
    DATE OF INJURY .13 This is the date the injury occurred for the problem being treated. At VA facilities, the date of injury is prompted for when the ICD Diagnosis in the POV field (.01) is for an injury with a code between 800-999.999.

    		Date/Time
    OVERRIDE/ACCEPT .14

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINICAL TERM .15 This field is the clinical lexicon term which most closely represents the provider narrative of the problem treated. At VA facilities: The clinical lexicon is automatically captured via encounter form data capture (AICS package) when the of problem being treated is from the Active Problem List. In the manual data entry process, there is currently no prompt for the clinical term.

    		Pointer
    PointerTo:
    fileName:
    EXPRESSIONS
    fileNumber:
    757.01
    PROBLEM LIST ENTRY .16 This field identifies what Problem List entry is related to the problem treated at the visit.

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    DATE OF ONSET .17 Enter the month, day and year of the onset of this diagnosis. Currently, this is only asked for surgical complication diagnosis codes.

    		Date/Time
    EXTERNAL CAUSE 2 .18

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    EXTERNAL CAUSE 3 .19

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PLACE OF OCCURRENCE .21

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PRESENT ON ADMISSION? .22

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    • Code : W
      Stands For: CLINICALLY UNDETERMINED
    • Code : 1
      Stands For: UNREPORTED/NOT USED
    RETAINED FOREIGN BODY .23

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ICD-9 CODE .24

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ICD-9 CODE NARRATIVE .241

    		Computed
    CAUSE (E-code) .25

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    CAUSE (E-code) #2 .26

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    CAUSE (E-code) #3 .27

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PLACE OF OCCURENCE (E849) .28

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SNOMED CONCEPT ID 1101

    		Free Text
    SNOMED PREFERRED TERM 1101.019

    		Computed
    SNOMED DESCRIPTION ID 1102

    		Free Text
    SNOMED DESC ID PREFERRED TERM 1102.019

    		Computed
    PRIMARY SNOMED 1103

    		Free Text
    PRIMARY SNOMED PREFERRED TERM 1103.019

    		Computed
    EVENT DATE AND TIME 1201 This is the actual date and time of the encounter. This date and time may be different than the visit date and time specified in the Visit file. However it must be within 30 days of the Visit date and Not be a future date. This field is useful for capturing the actual time encounters take place, or when, during the encounter, something happened.

    		Date/Time
    ORDERING PROVIDER 1202 For consistency, this field was added to each V-file. However, for the V POV, the Ordering Provider does not apply itself well, unless a provider is ordering another provider to treat a problem. Optionally, in the future, this field may be able to represent the provider responsible for the encounter providers work.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC STOP 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who treated the diagnosis at the encounter.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V POV
    fileNumber:
    9000010.07
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SEVERITY 1301

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SEVERITY .01

    		Free Text
    SEVERITY PREFERRED TERM .019

    		Computed
    ENTERED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    EPISODICITY 1401

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EPISODICITY .01

    		Free Text
    EPISODICITY PREFERRED TERM .019

    		Computed
    DATE PASSED TO EXTERNAL 1501

    		Date/Time
    FINDING SITE 1701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FINDING SITE .01

    		Free Text
    CLINICAL COURSE 1801

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CLINICAL COURSE .01

    		Free Text
    CLINICAL COURSE PREFERRED TERM .019

    		Computed
    SERVICE CONNECTED 80001 This field is used in the VA to indicate that this problem treated at this visit was service connected.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    AGENT ORANGE EXPOSURE 80002 This field is used in the VA to indicate that this problem treated at this visit was related to agent orange exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    IONIZING RADIATION EXPOSURE 80003 This field is used in the VA to indicate that this problem treated at this visit was related to ionizing radiation exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PERSIAN GULF EXPOSURE 80004 This field is used in the VA to indicate that this problem treated at this visit was related to Persian Gulf exposure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MILITARY SEXUAL TRAUMA 80005 This field will be used to indicate if this Diagnosis code was related to a Military Sexual Trauma problem.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEAD AND/OR NECK CANCER 80006 This field will be used to indicate if this Diagnosis code was related to Head and/or Neck Cancer

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    COMBAT VETERAN 80007 This field is used to indicate that the visit represents treatment of a VA patient for a problem that is possibly related to combat.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PROJ 112/SHAD 80008 Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any measurement data is being edited from the original entry of data.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102

    		Free Text
    PROVIDER NARRATIVE CATEGORY 80201 This field is the category narrative related to the problem treated.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    COMMENTS 81101

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7
    DATE OF ONSET 9999999.17 Enter the month, day and year of the onset of this diagnosis

    		Date/Time

    V PROCEDURE

    File Number: 9000010.08

    File Description:

    This file contains all operative procedures performed on a patient at an inpatient, outpatient or field visit, either through direct care, tribal program or CHS. Data is generated in this file automatically from the ADT system at time of discharge. Eventually data will also be generated automatically from the CHS/MIS, but this is not being done currently. Data is generally entered in narrative form, and coded to the ICD9 operative procedures automatically. The file contains backward pointers to the IHS Patient file, and visit file, and data must exist in both of these files for this visit before data can be entered here.


    Fields:

    Name Number Description Data Type Field Specific Data
    PROCEDURE .01

    		Pointer
    PointerTo:
    fileName:
    ICD OPERATION/PROCEDURE
    fileNumber:
    80.1
    PROCEDURE NARRATIVE .019

    		Computed
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    PROVIDER NARRATIVE .04

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    DIAGNOSIS .05

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PROCEDURE DATE .06

    		Date/Time
    PRINCIPLE PROCEDURE .07

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    INFECTION .08

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    OVERRIDE/ACCEPT .09

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    OPERATING PROVIDER .11

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ANESTHESIOLOGIST .12

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ELAPSED TIME (ANESTHESIA) .13

    		Numeric
    ANESTHESIA ADMINISTERED .14

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    ASA-PS CLASS .15 ASA-PS CLASS is the American Society of Anesthesiologists-Physical Status classification system based on the presence and severity of disease.

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.85
    CPT CODE .16

    		Pointer
    PointerTo:
    fileName:
    CPT
    fileNumber:
    81
    CPT SHORT NAME .1609

    		Computed
    CPT MODIFIER .17

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.88
    CPT MODIFIER 2 .18

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.88
    ANESTHESIA START DATE/TIME .19

    		Date/Time
    ANESTHESIA STOP DATE/TIME .21

    		Date/Time
    EVENT DATE&TIME 1201

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RENDERING PROVIDER 1205

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V PROCEDURE
    fileNumber:
    9000010.08
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ANCILLARY POV 1213

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE PASSED TO EXTERNAL 1501

    		Date/Time
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED CT PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text

    V IMMUNIZATION

    File Number: 9000010.11

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. This file contains immunizations specific to a particular visit for a particular patient. This file contains one record for each immunization. In the VA, if a CPT code is entered into PCE that represents an immunization, than an immunization will automatically be entered in the V Immunization file. And vice versa, if an immunization is entered into PCE that has a related CPT code, then a V CPT entry will automatically be created with the CPT code for the immunization. The PCE Code Mapping file contains the definitions of what immunization is related to what CPT code, and vice versa.


    Fields:

    Name Number Description Data Type Field Specific Data
    IMMUNIZATION .01 This is the type of immunization that was given to the patient at the encounter.

    		Pointer
    PointerTo:
    fileName:
    IMMUNIZATION
    fileNumber:
    9999999.14
    PATIENT NAME .02 This is the patient who was given the immunization.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter defined in the Visit file that represents when and where the immunization was given.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    SERIES .04 This field allows the provider to specify which series of immunization type was given to the patient.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PARTIALLY COMPLETE
    • Code : C
      Stands For: COMPLETE
    • Code : B
      Stands For: BOOSTER
    • Code : 1
      Stands For: SERIES 1
    • Code : 2
      Stands For: SERIES 2
    • Code : 3
      Stands For: SERIES 3
    • Code : 4
      Stands For: SERIES 4
    • Code : 5
      Stands For: SERIES 5
    • Code : 6
      Stands For: SERIES 6
    • Code : 7
      Stands For: SERIES 7
    • Code : 8
      Stands For: SERIES 8
    LOT .05

    		Pointer
    PointerTo:
    fileName:
    IMMUNIZATION LOT
    fileNumber:
    9999999.41
    REACTION .06 This is the reaction that may have been observed by the provider as a result of the immunization given.

    		Pointer
    PointerTo:
    fileName:
    BI TABLE REACTION
    fileNumber:
    9002084.8
    CONTRAINDICATED .07 This field allows the immunization to be recorded as contraindicated. Reminders will include a check to see if the previous immunization was contraindicated before creating reminders.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES (DO NOT REPEAT THIS VACCINE).
    • Code : 0
      Stands For: NO (OK TO USE IN THE FUTURE)
    DIAGNOSIS .08 This is the diagnosis, from the ICD Diagnosis file, associated with the immunization performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    INJECTION SITE .09

    		Set of Codes
    Set of Codes:
    • Code : LTI
      Stands For: Left Thigh IM
    • Code : LTS
      Stands For: Left Thigh SQ
    • Code : RTI
      Stands For: Right Thigh IM
    • Code : RTS
      Stands For: Right Thigh SQ
    • Code : BTI
      Stands For: Both Thighs IM
    • Code : LDI
      Stands For: Left Deltoid IM
    • Code : LDS
      Stands For: Left Deltoid SQ
    • Code : LAS
      Stands For: Left Arm SQ
    • Code : RDI
      Stands For: Right Deltoid IM
    • Code : RDS
      Stands For: Right Deltoid SQ
    • Code : RAS
      Stands For: Right Arm SQ
    • Code : O
      Stands For: Oral
    • Code : IN
      Stands For: Intranasal
    • Code : LID
      Stands For: Left Arm Intradermal
    • Code : RID
      Stands For: Right Arm Intradermal
    • Code : LB
      Stands For: Left Buttock/Gluteus
    • Code : RB
      Stands For: Right Buttock/Gluteus
    DIAGNOSIS 3 .1 This is the diagnosis, from the ICD Diagnosis file, associated with the immunization performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    VOLUME .11

    		Numeric
    DATE OF VAC INFO STATEMENT .12

    		Date/Time
    CREATED BY V CPT ENTRY .13

    		Numeric
    VAC ELIGIBILITY .14

    		Pointer
    PointerTo:
    fileName:
    BI TABLE ELIGIBILITY CODES
    fileNumber:
    9002084.83
    IMPORT FROM OUTSIDE REGISTRY .15

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: IMPORTED
    • Code : 0
      Stands For: NOT IMPORTED
    • Code : 2
      Stands For: EDITED AFTER IMPORT
    NDC .16

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9002084.95
    ADMINISTRATIVE NOTES 1

    		Free Text
    REMARKS 1101 This is additional comments or remarks related to the immunization given to the patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REMARKS .01 This field can be used to enter comments related to the immunization encounter with the patient.

    		Word Processing
    EVENT DATE AND TIME 1201 This is the date and time the immunization was given. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before of after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 The field can be used to document the provider who ordered the immunization.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ENCOUNTER PROVIDER 1204 This is the provider who gave the immunization.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    USER LAST UPDATE 1214

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    VFC ELIGIBILITY 21405.01

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: Unknown
    • Code : 1
      Stands For: Not Eligible
    • Code : 2
      Stands For: Medicaid
    • Code : 3
      Stands For: Uninsured
    • Code : 4
      Stands For: Am Indian/AK Native
    • Code : 5
      Stands For: Federally Qualified
    • Code : 6
      Stands For: State-specific Elig
    • Code : 7
      Stands For: Local-specific Elig
    INFORMATION SOURCE 21405.02

    		Set of Codes
    Set of Codes:
    • Code : 00
      Stands For: NEW IMMUNIZATION RECORD
    • Code : 01
      Stands For: SOURCE UNSPEC
    • Code : 02
      Stands For: OTHER PROVIDER
    • Code : 03
      Stands For: PARENT WRITTEN RECORD
    • Code : 04
      Stands For: PARENT RECALL
    • Code : 05
      Stands For: OTHER REGISTRY
    • Code : 06
      Stands For: BIRTH CERT
    • Code : 07
      Stands For: SCHOOL RECORD
    • Code : 08
      Stands For: PUBLIC AGENCY
    • Code : 09
      Stands For: PATIENT RECALL
    • Code : 10
      Stands For: FAMILY MEMBER RECALL
    COUNSELLED 21405.03

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    VIS DATES GDTI 21410

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIS .01 VIS = Vaccine Information Sheet. VIS field is a pointer to the MSC IMMUNIZATION VIS file, identifying which VIS was given.

    		Pointer
    PointerTo:
    fileName:
    MSC IMMUNIZATION VIS
    fileNumber:
    21468.1
    VIS FULL CODE 2

    		Computed
    VIS EDITION DATE 3

    		Computed
    VIS PRESENTATION DATE 4 The date the document was presented. Required.

    		Date/Time
    DELETED/ENTERED IN ERROR 21499.1

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: DELETED
    DELETED/EIE DATE 21499.2

    		Date/Time
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original immunization data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entred the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's immunization. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7
    DOSE OVERRIDE 9999999.08

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: @
    • Code : 1
      Stands For: INVALID--BAD STORAGE
    • Code : 2
      Stands For: INVALID--DEFECTIVE
    • Code : 3
      Stands For: INVALID--EXPIRED
    • Code : 4
      Stands For: INVALID--ADMIN ERROR
    • Code : 9
      Stands For: FORCED VALID
    INJECTION SITE 9999999.09

    		Set of Codes
    Set of Codes:
    • Code : LTI
      Stands For: Left Thigh IM
    • Code : LTS
      Stands For: Left Thigh SQ
    • Code : RTI
      Stands For: Right Thigh IM
    • Code : RTS
      Stands For: Right Thigh SQ
    • Code : BTI
      Stands For: Both Thighs IM
    • Code : LDI
      Stands For: Left Deltoid IM
    • Code : LDS
      Stands For: Left Deltoid SQ
    • Code : LAS
      Stands For: Left Arm SQ
    • Code : RDI
      Stands For: Right Deltoid IM
    • Code : RDS
      Stands For: Right Deltoid SQ
    • Code : RAS
      Stands For: Right Arm SQ
    • Code : O
      Stands For: Oral
    • Code : IN
      Stands For: Intranasal
    • Code : LID
      Stands For: Left Arm Intradermal
    • Code : RID
      Stands For: Right Arm Intradermal
    • Code : LB
      Stands For: Left Buttock/Gluteus
    • Code : RB
      Stands For: Right Buttock/Gluteus
    VOLUME 9999999.11

    		Numeric
    DATE OF VAC INFO STATEMENT 9999999.12

    		Date/Time

    V SKIN TEST

    File Number: 9000010.12

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. There will be one record for each type of skin test given to a patient on a given visit. Data must exist for a patient and a visit before data can be entered here. The record is normally created when a skin test is given, and the results, if available, are entered at a later date and matched to the original record. If results are entered and a skin test given does not exist, a new record is created. In the VA, If a CPT code is entered into PCE that represents a skin test, then a skin test entry will automatically be entered into the V Skin Test file. And vice versa, if a skin test is entered into PCE that represents a CPT code, then a CPT entry will automatically be entered into the V CPT file. This supports getting workload credit from clinical activities. The PCE Code Mapping file defines the relationships between Skin Tests and CPT codes.


    Fields:

    Name Number Description Data Type Field Specific Data
    SKIN TEST .01 This is the type of Skin Test that was given to the patient at the encounter.

    		Pointer
    PointerTo:
    fileName:
    SKIN TEST
    fileNumber:
    9999999.28
    PATIENT NAME .02 This is the patient who received the skin test.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter defined in the Visit file that represents when and where the skin test was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    RESULTS .04 This is where a provider can designate the results of the skin test.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: POSITIVE
    • Code : N
      Stands For: NEGATIVE
    • Code : D
      Stands For: DOUBTFUL
    • Code : O
      Stands For: NO TAKE
    READING .05 Enter the value representing the reading of the skin test.

    		Numeric
    DATE READ .06 This is the Date of the Reading.

    		Date/Time
    DIAGNOSIS .08 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    INJECTION SITE .09

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LEFT FOREARM
    • Code : R
      Stands For: RIGHT FOREARM
    DIAGNOSIS 3 .1 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DIAGNOSIS 4 .11 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DIAGNOSIS 5 .12 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DIAGNOSIS 6 .13 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DIAGNOSIS 7 .14 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    DIAGNOSIS 8 .15 This is the diagnosis, from the ICD Diagnosis file, associated with the skin test performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    EVENT DATE AND TIME 1201 This is the date and time the skin test was performed. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the skin test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ENCOUNTER PROVIDER 1204 This is the provider who gave the skin test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original skin test data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically be the PCE filing logic. The formt of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's skin test. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7
    TEST READER 9999999.08

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    INJECTION SITE 9999999.09

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LEFT FOREARM
    • Code : R
      Stands For: RIGHT FOREARM
    VOLUME 9999999.11

    		Numeric

    V EXAM

    File Number: 9000010.13

    File Description:

    This file contains exam information specific to a particular visit for a particular patient. This file contains one record for each exam for each visit.


    Fields:

    Name Number Description Data Type Field Specific Data
    EXAM .01 This is the entry in the Exam file that represents what type of exam was done at the encounter.

    		Pointer
    PointerTo:
    fileName:
    EXAM
    fileNumber:
    9999999.15
    PATIENT NAME .02 This is the patient who received the exam.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    RESULT .04

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : N
      Stands For: NORMAL/NEGATIVE
    • Code : PR
      Stands For: PRESENT
    • Code : PAP
      Stands For: PRESENT AND PAST
    • Code : PA
      Stands For: PAST
    • Code : PO
      Stands For: POSITIVE
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V EXAM
    fileNumber:
    9000010.13
    EXTERNAL KEY 1209

    		Free Text
    ANCILLARY POV 1213

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original exam data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's exam. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V TREATMENT

    File Number: 9000010.15

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. This file contains a record for each treatment provided to a patient on a given patient visit. There will be multiple treatment records for the same treatment (.01) field based on the date on which it was given. Data must exist in the Patient/IHS file and visit file for the patients' visit before data can be entered in the V Treatment file.


    Fields:

    Name Number Description Data Type Field Specific Data
    TREATMENT .01 This is a treatment or service provided which does not map to a CPT code but is clinically useful for patient care management.

    		Pointer
    PointerTo:
    fileName:
    TREATMENT
    fileNumber:
    9999999.17
    PATIENT NAME .02 This is the patient who received this treatment.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter or occasion of service defined in the Visit file that represents when and where the treatment was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    HOW MANY .04 This is the number of times this treatment was given to the patient during the encounter.

    		Numeric
    PROVIDER NARRATIVE .06 This is the provider's preferred text used to represent the treatment provided.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    Event Date and Time 1201 This is the date and time the treatment was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field may be used to document the provider who ordered the treatment.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ENCOUNTER PROVIDER 1204 This is the provider who gave the treatment.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original treatment data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    PROVIDER NARRATIVE CATEGORY 80201 This field is the heading or category used to represent the provider narrative on the scanner form or workstation. It may be useful for understanding how providers are grouping data for use on the encounter form, and may help determine clinical terminology definitions in the future.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    COMMENTS 81101 This is a comment related to the patient's treatment. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V PATIENT ED

    File Number: 9000010.16

    File Description:

    This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. This is the file which stores the patient education given to a patient or his responsible care giver. Data must exist in the Patient/IHS file and Visit file for a patient visit before data can be entered in the V Patient Ed File.


    Fields:

    Name Number Description Data Type Field Specific Data
    TOPIC .01 Pointer to the EDUCATION TOPICS file. education given to the patient.

    		Pointer
    PointerTo:
    fileName:
    EDUCATION TOPICS
    fileNumber:
    9999999.09
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter or occasion of service defined in the Visit file that represents when and where the education was provided.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ICD DIAGNOSIS .04

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ICD TEXT .041

    		Computed
    PROVIDER .05

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LEVEL OF UNDERSTANDING .06 This is the provider's assessment of how well the patient understood the education received.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: POOR
    • Code : 2
      Stands For: FAIR
    • Code : 3
      Stands For: GOOD
    • Code : 4
      Stands For: GROUP-NO ASSESSMENT
    • Code : 5
      Stands For: REFUSED
    INDIVIDUAL/GROUP .07

    		Set of Codes
    Set of Codes:
    • Code : G
      Stands For: GROUP SETTING
    • Code : I
      Stands For: INDIVIDUAL
    LENGTH OF EDUC (MINUTES) .08

    		Numeric
    CPT CODE .09

    		Pointer
    PointerTo:
    fileName:
    CPT
    fileNumber:
    81
    COMMENT .11 This field is to capture narrative text about the patient education given. Will display on the health summary if present.

    		Free Text
    TOPIC CATEGORY .12

    		Pointer
    PointerTo:
    fileName:
    PCC DATA ENTRY EDUC TOPICS
    fileNumber:
    9001002.5
    GOAL CODE .13

    		Set of Codes
    Set of Codes:
    • Code : GS
      Stands For: GOAL SET
    • Code : GM
      Stands For: GOAL MET
    • Code : GNM
      Stands For: GOAL NOT MET
    • Code : GNS
      Stands For: GOAL NOT SET
    GOAL COMMENT .14

    		Free Text
    SUB-TOPIC 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUB-TOPIC .01

    		Free Text
    LEVEL OF UNDERSTANDING .02

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: POOR
    • Code : 2
      Stands For: FAIR
    • Code : 3
      Stands For: GOOD
    • Code : 4
      Stands For: GROUP-NO ASSESSMENT
    • Code : 5
      Stands For: REFUSED
    PROVIDER'S NARRATIVE 1101

    		Free Text
    READINESS TO LEARN 1102

    		Pointer
    PointerTo:
    fileName:
    READINESS TO LEARN
    fileNumber:
    99999.15
    PROBLEM 1103

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    EVENT DATE AND TIME 1201 This is the date and time the education was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the patient education.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the patient education.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V PATIENT ED
    fileNumber:
    9000010.16
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED TOPIC 1301

    		Free Text
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC ODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original exam data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's education. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V CPT

    File Number: 9000010.18

    File Description:

    The V CPT file has been defined for joint use by the Indian Health Service and the Department of Veteran Affairs. This is the file used to store CPT related services performed at a visit. Data must exist for a patient and a visit before data can be entered in the V CPT file. This file is used in the VA to identify procedures that were done to a patient at an encounter or occassion of service. The procedures may have been performed by a primary or secondary provider of patient care. Procedures checked off and scanned from ambulatory care encounter forms are stored here to record that they were done. Results of procedures are not included. This file is restricted to procedures that have a CPT code. The V Treatment file is used to store procedures without CPT codes that do not fit into any other V-file category. The Provider Narrative field represents the preferred text for this procedure as defined by the clinician.


    Fields:

    Name Number Description Data Type Field Specific Data
    CPT .01 This is the entry in the CPT file that most closely represents the clinical procedure done to the patient during the encounter. The preferred text for the procedure performed may be specified in the Provider Narrative field. This field is used for Administrative and Clinical purposes. If a procedure performed is to be billable, the CPT code must be specified here.

    		Pointer
    PointerTo:
    fileName:
    CPT
    fileNumber:
    81
    CPT SHORT NAME .019

    		Computed
    PATIENT NAME .02 This is the patient to whom the procedure was done during the encounter.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter or occasion of service defined in the Visit file that represents when and where the procedure was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    PROVIDER NARRATIVE .04 This is the narrative the provider uses to represent the procedure that was done. The text may be different from the CPT file's procedure name text, but should not have a significantly different meaning. The CPT code in the CPT (.01) field should be the CPT code that "most closely" represents the provider narrative for the procedure done.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    DIAGNOSIS .05 This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PRINCIPAL PROCEDURE .07 This field identifies this procedure as the prinicipal procedure done to the patient at the encounter.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    MODIFIER .08

    		Pointer
    PointerTo:
    fileName:
    CPT MODIFIER
    fileNumber:
    81.3
    MODIFIER 2 .09

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.88
    DIAGNOSIS 3 .1 This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ANESTHESIA ADMINISTERED? .11

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    ASA-PS CLASS .12

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.85
    ANESTHESIA START DATE/TIME .13

    		Date/Time
    ANESTHESIA STOP DATE/TIME .14

    		Date/Time
    ELASPED TIME (ANESTHESIA) .15

    		Numeric
    QUANTITY .16 This is the number of times this procedure was done to the patient during the encounter.

    		Numeric
    ANESTHESIOLOGIST .17

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DEPARTMENT CODE .19 The 3-digit code that defines the service area associated with the charge by the sending application.

    		Free Text
    PFSS CHARGE ID .2 A numeric identifier of not more than 8 digits that uniquely identifies the charge item in the external medical billing system. This data item is referred to as the "PFSS Charge Identifier" within the PFSS project documentation.

    		Numeric
    CPT MODIFIER 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CPT MODIFIER .01 This multiple field points to the CPT MODIFIER file (#81.3). The modifier(s) you select must be valid for the CPT field (#.01).

    		Pointer
    PointerTo:
    fileName:
    CPT MODIFIER
    fileNumber:
    81.3
    NUMBER .02

    		Numeric
    EVENT DATE AND TIME 1201 This is the date and time the procedure was performed. This date and time may be different from the visit data and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provder performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who performed the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RENDERING PROVIDER 1205

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V CPT
    fileNumber:
    9000010.18
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    CHARGE CODE 21400.01

    		Pointer
    PointerTo:
    fileName:
    CHARGE MASTER
    fileNumber:
    21499
    CPT PREFERENCE IENS 21400.11 Points to the associated CPT multiple of the BGO CPT PREFERENCES file (#90362.31). <BGO CPT PREFERENCES id>;<CPT subfile ID>

    		Free Text
    CPT ASSOCIATIONS 21401

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CPT ASSOCIATIONS .01

    		Variable Pointer
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original procedure data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic.. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    PROVIDER NARRATIVE CATEGORY 80201 This field is the heading or category used to represent the provider narrative on the scanner form. It may be useful for understanding how providers are grouping data for use on the encounter form, and may help determine clinical data base definitions in the future.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    COMMENTS 81101 This is a commented related to the procedure performed. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V ACTIVITY TIME

    File Number: 9000010.19

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    ACTIVITY TIME .01

    		Numeric
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    TRAVEL MINUTES .04

    		Numeric
    TOTAL TIME .049

    		Computed
    TIME PATIENT SPENT IN GROUP .05

    		Numeric
    EVENT DATE&TIME 1201

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V ACTIVITY TIME
    fileNumber:
    9000010.19
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER KEY 1210

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    V DIAGNOSTIC PROCEDURE RESULT

    File Number: 9000010.21

    File Description:

    This V file contains the diagnostic procedure ECG SUMMARY. Originally designed to be populated by a link from the VA Medicine package.


    Fields:

    Name Number Description Data Type Field Specific Data
    TYPE .01

    		Pointer
    PointerTo:
    fileName:
    DIAGNOSTIC PROCEDURE RESULT
    fileNumber:
    9999999.68
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    VALUE .04

    		Free Text
    ABNORMAL .05

    		Free Text
    PARAMS .06

    		Free Text
    *PARENT .07

    		Pointer
    PointerTo:
    fileName:
    V DIAGNOSTIC PROCEDURE RESULT
    fileNumber:
    9000010.21
    EVENT DATE&TIME 1201

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V DIAGNOSTIC PROCEDURE RESULT
    fileNumber:
    9000010.21
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ANCILLARY POV 1213

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    V HEALTH FACTORS

    File Number: 9000010.23

    File Description:

    This file has been defined for joint use by the Indian Health Service and the Department of Veteran Affairs. This is the file used for storing patient health factors identified at a visit. Data must exist in the Patient/IHS and Visit file for a patient's visit before data can be entered in the V Health Factor file.


    Fields:

    Name Number Description Data Type Field Specific Data
    HEALTH FACTOR .01 This is the entry in the Health Factor file that most closely represents the patient's health factor status at the encounter for a given health factor category.

    		Pointer
    PointerTo:
    fileName:
    HEALTH FACTORS
    fileNumber:
    9999999.64
    HLTH FACTOR CATEGORY .019

    		Computed
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    LEVEL/SEVERITY .04

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MINIMAL
    • Code : MO
      Stands For: MODERATE
    • Code : H
      Stands For: HEAVY/SEVERE
    PROVIDER .05

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    QUANTITY .06

    		Numeric
    EVENT DATE AND TIME 1201 This is the date and time the health factor was recorded by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the health factor recorded.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who recorded the health factor.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V HEALTH FACTORS
    fileNumber:
    9000010.23
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed
    EDITED 80101 This field is automatically set to 1 if PCE detects that any original health factor data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    AUDIT TRAIL 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's health factor. The provider may enter this manually via the PCE User Interface.

    		Free Text
    VERIFIED 81201

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTRONICALLY SIGNED
    • Code : 2
      Stands For: VERIFIED BY PACKAGE
    PACKAGE 81202

    		Pointer
    PointerTo:
    fileName:
    PACKAGE
    fileNumber:
    9.4
    DATA SOURCE 81203

    		Pointer
    PointerTo:
    fileName:
    PCE DATA SOURCE
    fileNumber:
    839.7

    V EMERGENCY VISIT RECORD

    File Number: 9000010.29

    File Description:

    This file contains exam information specific to a particular visit for a particular patient. This file contains one record for each exam for each visit. for each visit, therefore, the VISIT field (.03) will be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    FORM ID .01 This is the entry in the Exam file that represents what type of exam was done at the encounter.

    		Free Text
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    URGENCY .04

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: RESUSCITATION (1)
    • Code : E
      Stands For: EMERGENT (2)
    • Code : U
      Stands For: URGENT (3)
    • Code : L
      Stands For: LESS URGENT (4)
    • Code : N
      Stands For: ROUTINE (5)
    MEANS OF ARRIVAL .05

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AMBULANCE
    • Code : P
      Stands For: POLICE
    • Code : POV
      Stands For: POV
    • Code : T
      Stands For: TAXI
    • Code : W
      Stands For: WALKED
    • Code : O
      Stands For: OTHER
    • Code : R
      Stands For: AIR
    • Code : M
      Stands For: MEDIVAC FROM VILLAGE
    OTHER MEANS OF ARRIVAL .06

    		Free Text
    ENTERED ER BY .07

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AMBULATORY
    • Code : W
      Stands For: WHEEL CHAIR
    • Code : S
      Stands For: STRETCHER
    • Code : C
      Stands For: CARRIED
    INFORMANT .08

    		Free Text
    NOTIFIED .09

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: RELATIVE
    • Code : P
      Stands For: POLICE
    • Code : C
      Stands For: CORONER
    DISPOSITION OF CARE .11

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ADMIT
    • Code : T
      Stands For: TRANSFER
    • Code : D
      Stands For: DISCHARGE
    • Code : O
      Stands For: OTHER
    • Code : M
      Stands For: MEDIVAC TRANSFER
    • Code : L
      Stands For: LIFEGUARD
    • Code : E
      Stands For: DIED/EXPIRED
    • Code : 1
      Stands For: LEFT AMA
    DISPOSITION IF OTHER .12

    		Free Text
    DEPARTURE DATE&TIME .13

    		Date/Time
    LEFT AREA .14

    		Date/Time
    CONDITION ON DEPARTURE .15

    		Free Text
    TRANSFERRED TO .16

    		Variable Pointer
    TRAUMA LEVEL .17

    		Numeric
    BP AT ARRIVAL 1101

    		Free Text
    BP AT FIRST HOUR 1102

    		Free Text
    BP AT SECOND HOUR 1103

    		Free Text
    BP AT THIRD HOUR 1104

    		Free Text
    PULSE ON ARRIVAL 1105

    		Numeric
    PULSE AT FIRST HOUR 1106

    		Numeric
    PULSE AT SECOND HOUR 1107

    		Numeric
    PULSE AT THIRD HOUR 1108

    		Numeric
    RESPIRATION AT ARRIVAL 1109

    		Numeric
    RESPIRATION AT FIRST HOUR 1110

    		Numeric
    RESPIRATION AT SECOND HOUR 1111

    		Numeric
    RESPIRATION AT THIRD HOUR 1112

    		Numeric
    GCS SCORE ARRIVAL 1113

    		Numeric
    GCS AT 1ST HOUR 1114

    		Numeric
    GCS AT 2ND HOUR 1115

    		Numeric
    GCS AT 3RD HOUR 1116

    		Numeric
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V EMERGENCY VISIT RECORD
    fileNumber:
    9000010.29
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    V NARRATIVE TEXT

    File Number: 9000010.34

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    TEXT TYPE .01 This is the type of narrative.

    		Pointer
    PointerTo:
    fileName:
    NARRATIVE TEXT TYPE
    fileNumber:
    9999999.89
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    TEXT 1100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TEXT .01

    		Word Processing
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V NARRATIVE TEXT
    fileNumber:
    9000010.34
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    V ELDER CARE

    File Number: 9000010.35

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    FORM ID .01

    		Free Text
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    TOILETING .04

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    BATHING .05

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    DRESSING .06

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    TRANSFERS .07

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    FEEDING .08

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    CONTINENCE .09

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    FINANCES .11

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    COOKING .12

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    SHOPPING .13

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    HOUSEWORK/CHORES .14

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    MEDICATIONS .15

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    TRANSPORTATION .16

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INDEPENDENT
    • Code : N
      Stands For: NEEDS HELP
    • Code : T
      Stands For: TOTALLY DEPENDENT
    CHANGE IN FUNCTIONAL STATUS .17

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: SAME
    • Code : I
      Stands For: IMPROVEMENT
    • Code : D
      Stands For: DECLINE
    IS PATIENT A CAREGIVER .18

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V ELDER CARE
    fileNumber:
    9000010.35
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    V TREATMENT CONTRACT

    File Number: 9000010.39

    File Description:

    This file contains exam information specific to a particular visit for a particular patient. This file contains one record for each exam for each visit. for each visit, therefore, the VISIT field (.03) will be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    CONTRACT TYPE .01 This is the entry in the Exam file that represents what type of exam was done at the encounter.

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MENTAL HEALTH
    • Code : P
      Stands For: PAIN
    EXAM CODE .019

    		Computed
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    DATE INITIATED .04

    		Date/Time
    PROVIDER .05

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V TREATMENT CONTRACT
    fileNumber:
    9000010.39
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original exam data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    DATA SOURCE 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's exam. The provider may enter this manually via the PCE User Interface.

    		Free Text

    V ASTHMA

    File Number: 9000010.41

    File Description:

    This file contains exam information specific to a particular visit for a particular patient. This file contains one record for each exam for each visit. for each visit, therefore, the VISIT field (.03) will be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    DUMMY FIELD .01

    		Free Text
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    SEVERITY .04

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: INTERMITTENT
    • Code : 2
      Stands For: MILD PERSISTENT
    • Code : 3
      Stands For: MODERATE PERSISTENT
    • Code : 4
      Stands For: SEVERE PERSISTENT
    FEV 1 .05

    		Numeric
    FEF 25-75 .06

    		Numeric
    PEF/BEST PF .07

    		Numeric
    ETS .08

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    PARTICULATE MATTER .09

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    DUST MITE .11

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    ASTHMA MANAGEMENT PLAN .12

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    CREATED BY VPOV .13

    		Pointer
    PointerTo:
    fileName:
    V POV
    fileNumber:
    9000010.07
    ASTHMA CONTROL .14

    		Set of Codes
    Set of Codes:
    • Code : W
      Stands For: WELL CONTROLLED
    • Code : N
      Stands For: NOT WELL CONTROLLED
    • Code : V
      Stands For: VERY POORLY CONTROLLED
    YELLOW ZONE INSTRUCTIONS 1101

    		Free Text
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V ASTHMA
    fileNumber:
    9000010.41
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RED ZONE INSTRUCTIONS 1301

    		Free Text
    EDITED FLAG 80101 This field is automatically set to 1 if PCE detects that any original exam data is being edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EDITED
    DATA SOURCE 80102 This field is populated automatically by the PCE filing logic. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...

    		Free Text
    COMMENTS 81101 This is a comment related to the patient's exam. The provider may enter this manually via the PCE User Interface.

    		Free Text

    V INFANT FEEDING CHOICES

    File Number: 9000010.44

    File Description:

    Infant feeding choice data is captured in this file. Typically 1 entry per visit.


    Fields:

    Name Number Description Data Type Field Specific Data
    FEEDING CHOICE .01

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EXCLUSIVE BREASTFEEDING
    • Code : 2
      Stands For: MOSTLY BREASTFEEDING
    • Code : 3
      Stands For: 1/2 & 1/2 BREAST AND FORMULA
    • Code : 4
      Stands For: MOSTLY FORMULA
    • Code : 5
      Stands For: FORMULA ONLY
    • Code : 6
      Stands For: MOSTLY BREASTFEEDING, SOME FORMULA
    • Code : 7
      Stands For: MOSTLY FORMULA, SOME BREAST MILK
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    COMMENT 1101

    		Free Text
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V INFANT FEEDING CHOICES
    fileNumber:
    9000010.44
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ANCILLARY POV 1213

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ADDITIONAL SECONDARY FEEDING 1300

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ADDITIONAL SECONDARY FEEDING .01

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MILK
    • Code : 2
      Stands For: FRUIT JUICE
    • Code : 3
      Stands For: CARBONATED DRINK
    • Code : 4
      Stands For: SPORTS DRINK
    • Code : 5
      Stands For: GLUCOSE
    • Code : 6
      Stands For: WATER
    • Code : 7
      Stands For: FORMULA
    • Code : 8
      Stands For: BREAST MILK
    COMMENT .02

    		Free Text
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text
    LOINC TEXT .019

    		Computed

    V UPDATED/REVIEWED

    File Number: 9000010.54

    File Description:

    This file will contain various fields to indicate that a provider reviewed the problem list, medications and/or the allergy list.


    Fields:

    Name Number Description Data Type Field Specific Data
    CLINICAL ACTION .01

    		Pointer
    PointerTo:
    fileName:
    CLINICAL REVIEW ACTION
    fileNumber:
    9999999.101
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    DATE/TIME ENTERED 1.01

    		Date/Time
    ENTERED BY 1.02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DELETED/ENTERED IN ERROR 2.01

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    DELETED/ENTERED IN ERROR BY 2.02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REASON DELETED 2.03

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DUPLICATE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OTHER
    REASON IF OTHER 2.04

    		Free Text
    EVENT DATE AND TIME 1201 Date and time that the assessment was made. May be different than visit timestamp. Date must be precise. Must be within 30 days before or after visit date, but not a future date.

    		Date/Time
    ORDERING PROVIDER 1202 Provider who ordered the assessment

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 Provider that made the assessment

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT ASSESSMENT 1208

    		Pointer
    PointerTo:
    fileName:
    V UPDATED/REVIEWED
    fileNumber:
    9000010.54
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SNOMED CT 2601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED CT PREFERRED TERM .019

    		Computed
    LOINC CODES 2701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOINC CODES .01

    		Free Text

    V CARE PLANNING

    File Number: 9000010.57

    File Description:

    This file contains exam information specific to a particular visit for a particular patient. This file contains one record for each exam for each visit. for each visit, therefore, the VISIT field (.03) will be duplicated.


    Fields:

    Name Number Description Data Type Field Specific Data
    PROBLEM .01 This is the problem to which the care plan is associated. Points to file 9000011.

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03 This is the encounter in the Visit file that represents when and where the exam was done.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    GOAL NOTES 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GOAL NOTE ENTERED BY .01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .02

    		Date/Time
    EVENT DATE/TIME .03

    		Date/Time
    GOAL NOTE TEXT 1100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GOAL NOTE TEXT .01

    		Word Processing
    EVENT DATE AND TIME 1201 This is the date and time the exam was given by the provider. This date and time may be different from the visit date and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provider performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.

    		Date/Time
    ORDERING PROVIDER 1202 This field can be used to document the provider who ordered the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204 This is the provider who gave the exam.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V EXAM
    fileNumber:
    9000010.13
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ANCILLARY POV 1213

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PLAN OF CARE 1301

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLAN OF CARE ENTERED BY .01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .02

    		Date/Time
    EVENT DATE/TIME .03

    		Date/Time
    PLAN OF CARE TEXT 1100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLAN OF CARE TEXT .01

    		Word Processing
    VISIT INSTRUCTIONS ENTERED BY 1401

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VISIT INSTRUCTIONS .01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .02

    		Date/Time
    EVENT DATE/TIME .03

    		Date/Time
    VISIT INSTRUCTIONS TEXT 1100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VISIT INSTRUCTIONS TEXT .01

    		Word Processing
    REFERRAL SNOMED CONCEPT ID 1501

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REFERRAL SNOMED CONCEPT ID .01

    		Free Text
    ENTERED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    EVENT DATE/TIME .04

    		Date/Time
    DISCONTINUED? .05

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    CONSULTS SNOMED CONCEPT ID 1601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CONSULTS SNOMED CONCEPT ID .01

    		Free Text
    ENTERED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    EVENT DATE/TIME .04

    		Date/Time
    DISCONTINUED? .05

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    TREATMENT/REGIMEN SNOMED CT 1701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TREATMENT/REGIMEN SNOMED CT .01

    		Free Text
    ENTERED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    EVENT DATE/TIME .04

    		Date/Time

    V REFERRAL

    File Number: 9000010.59

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    SNOMED CT .01

    		Free Text
    SNOMED PREFERRED TERM .019

    		Computed
    PATIENT NAME .02 Patient Name.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VISIT .03

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    PROBLEM .04

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    DISCONTINUED? .05

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    REFERRAL IEN .06

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    90001
    EVENT DATE & TIME 1201

    		Date/Time
    ORDERING PROVIDER 1202

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLINIC 1203

    		Pointer
    PointerTo:
    fileName:
    CLINIC STOP
    fileNumber:
    40.7
    ENCOUNTER PROVIDER 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARENT 1208

    		Pointer
    PointerTo:
    fileName:
    V MEASUREMENT
    fileNumber:
    9000010.01
    EXTERNAL KEY 1209

    		Free Text
    OUTSIDE PROVIDER NAME 1210

    		Free Text
    ORDERING LOCATION 1215

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    PROBLEM

    File Number: 9000011

    File Description:

    This file contains patient specific problems entered by the various providers of service. The PATIENT NAME field (.02) is a backward pointer to the IHS PATIENT file. This file contains one record for each problem for each patient, therefore, the KEY field (.01) is duplicated. As of March 17, 1986 the FACILITY must be entered prior to the NUMBER. If the NUMBER is entered without previously entering the FACILITY the "AA" index is created with no FACILITY pointer.


    Fields:

    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01 This is the ICD coded diagnosis of the narrative entered describing this problem.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SNOMED CONCEPT PREFERRED TERM .019

    		Computed
    PATIENT NAME .02 This is the patient for whom this problem has been observed and recorded.

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE LAST MODIFIED .03 This is the last date/time this problem was changed.

    		Date/Time
    CLASS .04 This flag is used by the IHS Problem List to indicate if this problem is documented for historical purposes.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PERSONAL HISTORY
    • Code : F
      Stands For: FAMILY HISTORY
    PROVIDER NARRATIVE .05 This contains the actual text used by the provider to describe this problem.

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    FACILITY .06 This is the facility at which this problem was originally observed and documented.

    		Pointer
    PointerTo:
    fileName:
    LOCATION
    fileNumber:
    9999999.06
    NMBR .07 This is a number which, together with the Patient (#.02) and Facility (#.06) fields, serves as a unique identifier for this problem. Up to 2 decimal places may be used to indicate that a problem is a result of, or related to, another problem.

    		Numeric
    DATE ENTERED .08 This is the date this problem was entered into this file.

    		Date/Time
    STATUS .12 This is the current activity status of this problem, if more detail is needed, a notation may be filed with this problem.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ACTIVE
    • Code : I
      Stands For: INACTIVE
    • Code : D
      Stands For: DELETED
    DATE OF ONSET .13 This is the approximate date this problem appeared, as precisely as known.

    		Date/Time
    USER LAST MODIFIED .14

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CLASSIFICATION .15

    		Free Text
    EXTERNAL CAUSE .16

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    EXTERNAL CAUSE 2 .17

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    EXTERNAL CAUSE 3 .18

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PIP .19

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES, ACTIVE IN PIP
    ASSOCIATED WITH .21

    		Free Text
    PROBLEM 1.01 This field contains the standardized text stored in the Clinical Lexicon for this problem.

    		Pointer
    PointerTo:
    fileName:
    EXPRESSIONS
    fileNumber:
    757.01
    CONDITION 1.02 This reflects the current condition of this entry, whether transcribed by a clerk from the paper chart, entered or verified by a provider, or marked as removed from the patient's list.

    		Set of Codes
    Set of Codes:
    • Code : T
      Stands For: TRANSCRIBED
    • Code : P
      Stands For: PERMANENT
    • Code : H
      Stands For: HIDDEN
    ENTERED BY 1.03 This is the user who actually entered this problem into this file.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RECORDING PROVIDER 1.04 This is the provider who first recorded this problem, either on the paper chart or online.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RESPONSIBLE PROVIDER 1.05 This is the provider currently responsible for treating this problem.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SERVICE 1.06 This is the service primarily involved in the treatment of this problem; the DHCP Problem List defaults this field to the service defined in File #200 for the Recording Provider of this problem, upon entry of the problem. It may later be used to categorize problems for screening and sorting.

    		Pointer
    PointerTo:
    fileName:
    SERVICE/SECTION
    fileNumber:
    49
    DATE RESOLVED 1.07 This is the date this problem was resolved or inactivated, as precisely as known.

    		Date/Time
    CLINIC 1.08 This is the clinic in which this patient is being seen for this problem. The problem list may be screened based on this value, to change one's view of the list.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    DATE RECORDED 1.09 This is the date this problem was originally recorded, either online or in the paper chart; it may be the same as, or earlier than, the Date Entered.

    		Date/Time
    SERVICE CONNECTED 1.1 If the patient has service connection on file in the DHCP Patient file #2, this problem specifically may be flagged as being service connected.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    AGENT ORANGE EXPOSURE 1.11 If this problem is related to a patient's exposure to Agent Orange, it may be flagged here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    IONIZING RADIATION EXPOSURE 1.12 If this problem is related to a patient's exposure to ionizing radiation, it may be flagged here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PERSIAN GULF EXPOSURE 1.13 If this problem is related to a patient's service in the Persian Gulf, it may be flagged here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PRIORITY 1.14 This is a flag to indicate how critical this problem is for this patient; problems marked as Acute will be flagged on the Problem List display.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ACUTE
    • Code : C
      Stands For: CHRONIC
    HEAD AND/OR NECK CANCER 1.15 If this problem is related to the treatment of head and/or neck cancer associated with nose or throat radium treatments, it may be flagged here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MILITARY SEXUAL TRAUMA 1.16 If this problem is related to the treatment of military sexual trauma, it may be flagged here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    COMBAT VETERAN 1.17

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SHIPBOARD HAZARD & DEFENSE 1.18

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PROBLEM DELETED BY 2.01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME PROBLEM DELETED 2.02

    		Date/Time
    REASON PROBLEM DELETED 2.03

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DUPLICATE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OTHER
    REASON IF OTHER 2.04

    		Free Text
    NOTE FACILITY 1101 This is the location at which the notes in this multiple originated.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    NOTE FACILITY .01 This is the location at which the notes in this multiple originated.

    		Pointer
    PointerTo:
    fileName:
    LOCATION
    fileNumber:
    9999999.06
    NOTE 1101 Each entry in this multiple is a notation appended to a problem for further clarification or information. Data includes a note number and status, the date the note was added, the provider who added it, and the actual text of the note.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    NOTE NMBR .01 This is the unique note identifier.

    		Numeric
    NOTE NARRATIVE .03 Additional comments may be entered here to further describe this problem.

    		Free Text
    STATUS .04 This flag indicates if this note is currently active.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ACTIVE
    DATE NOTE ADDED .05 This is the date this note was entered into this file.

    		Date/Time
    AUTHOR .06 This is the provider who authored the text of this note.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ENTERED IN ERROR BY .07

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REASON ENTERED IN ERROR .08

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DUPLICATE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OTHER
    ENTERED BY .09

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMMENT IF OTHER EIE 1101

    		Free Text
    ADDITIONAL ICD CODES 1201

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ADDITIONAL ICD CODES .01

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SEVERITY 1301

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SEVERITY .01

    		Free Text
    SEVERITY PREFERRED TERM .019

    		Computed
    ENTERED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    MODIFIED BY .04

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME MODIFIED .05

    		Date/Time
    USE AS POV (VISIT) 1401

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    USE AS POV (VISIT) .01

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    USED FOR INPATIENT 1501

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    USED FOR INPATIENT .01

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    RECONCILLIATION 1601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RECONCILLIATION .01

    		Date/Time
    RECONCILLED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SOURCE .03

    		Free Text
    FINDING SITE 1701

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FINDING SITE .01

    		Free Text
    CLINICAL COURSE 1801

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CLINICAL COURSE .01

    		Free Text
    CLINICAL COURSE PREFERRED TERM .019

    		Computed
    ASSOCIATED WITH PROBLEM 1901

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ASSOCIATED WITH PROBLEM .01

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    SNOMED CT CONCEPT CODE 80001 A clinical idea to which a unique ConceptID has been assigned in SNOMED CT. Each Concept is represented by a row in the Concepts Table.

    		Free Text
    SNOMED CT DESIGNATION CODE 80002 A single SNOMED Concept may have multiple Designations, where a Designation may be considered an alternate way of expressing the concept. Synonyms, lexical variants, abbreviations are all different types of designations. In many cases, a problem (as reported by the patient) and a finding indicating a problem will share the same concept and concept code (e.g., abdominal pain), but will have different designation codes (i.e., the generic "abdominal pain and "abdominal pain (finding) share the concept code 21522001, but they have the designation codes 36112013 and 750827015 respectively.

    		Free Text
    VHAT CONCEPT VUID (FUTURE) 80003 VHA Unique ID (VUID) for the VHAT Concept. A unique meaningless integer assigned to a corresponding concept VHA wide. This field is being implemented to allow a more rapidly extensible vocabulary for VA, while international normative standard coding systems continue to evolve more slowly. The precise definition of the concept Polytrauma may prove to be a useful example. Although the term has become common among US Military and VA physicians to describe a seriously injured (i.e., Injury Severity Score (ISS) >= 16) soldier with multiple traumatic injuries, it is not yet available as a coded concept in either SNOMED CT, ICD-9-CM, or ICD-10-CM. Allowing the definition and deployment of VHAT Concept/Designation VUID pairs to identify such problems in advance of their acceptance by the international medical community will help to provide coded, computable documentation in a much more timely manner than waiting for inclusion in SNOMED CT or ICD. When the infrastructure in VA's Enterprise Terminology Server (ETS) & New Term Rapid Turn-around (NTRT) service are ready to deploy VHAT Concepts, this field will allow us to store patient problems encoded with them.

    		Free Text
    VHAT DESIGNATION VUID (FUTURE) 80004 VHA Unique ID (VUID) for the VHAT Designation. A unique meaningless integer assigned to a corresponding designation VHA wide. VHAT Concept/Designation Code pairs function in a manner identical to that of SNOMED CT Concept/Designation Codes (i.e., they support the unique identification of clinical concepts, along with the many alternative ways in which a given concept may be expressed).

    		Free Text
    SNOMED CT-TO-ICD MAP STATUS 80005 This Set of Codes type field is set to PENDING when an unmapped Clinical Finding is selected as a patient's problem. It is updated programmatically to COMPLETE when NTRT deploys a new SNOMED CT to ICD mapping for the problem in question. NOTE: THIS FIELD SHOULD NEVER BE UPDATED BY AN END USER.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: N/A
    • Code : 1
      Stands For: PENDING
    • Code : 2
      Stands For: COMPLETED
    UNIQUE NEW TERM REQUESTED 80101 Indicates whether the user requested a new term during the process of entering a freetext problem. It should only be populated automatically by program code. NOTE: THIS FIELD SHOULD NEVER BE UPDATED BY AN END USER.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: False
    • Code : 1
      Stands For: True
    UNIQUE TERM REQUEST COMMENT 80102 Please provide clarification of the new term request. For example, if the requested term is an acronym or abbreviation, the comment field accommodates the fully specified name, etc.

    		Free Text
    DATE OF INTEREST 80201 This is the date when the DIAGNOSIS (#.01) and CODING SYSTEM (#80202) fields were filed or modified. This allows proper resolution of the code, irrespective of code set versions, etc.

    		Date/Time
    CODING SYSTEM 80202 This identifies the Coding System to which the Code belongs. It corresponds to the Coding System Abbreviation in the ICD Coding Systems File, to optimize internal/external API calls for resolving codes, independent of their code set version, and to facilitate transition from ICD-9-CM to ICD-10-CM. Examples include: CODING SYS ABBREV NOMENCLATURE ICD FILE --------------------------------------------- 10D ICD-10-CM ICD Diagnosis ICD ICD-9-CM ICD Diagnosis

    		Free Text
    MAPPING TARGETS 80300 This multiple includes mapped expressions: complications, comorbidities, and compound diagnoses. e.g., the single SNOMED CT concept Diabetic neuropathy (230572002) is mapped to two ICD-9-CM diagnoses: DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED (250.60) and POLYNEUROPATHY IN DIABETES (357.2).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CODE .01 This is the code in the target coding system to which the problem is mapped.

    		Free Text
    CODING SYSTEM .02 This identifies the Coding System to which the Code belongs. It corresponds to the Source Abbreviation in the Coding Systems File, to optimize calls to the Lexicon and ICD APIs for resolving codes, independent of their code set version, and to facilitate transition from ICD-9-CM to ICD-10-CM. Examples include: SOURCE ABBREV NOMENCLATURE SOURCE TITLE -------------------------------------------------------------------------- 10D ICD-10-CM International Classification of Diseases, Diagnosis ICD ICD-9-CM International Classification of Diseases, Diagnosis

    		Free Text
    CODE DATE .03 This is the date when the code and coding system were filed. This allows proper resolution of the code, irrespective of code set versions, etc.

    		Date/Time

    PERSONAL HISTORY

    File Number: 9000013

    File Description:

    *** WARNING *** ... The .05 field requires programmer access for delete. The field is optional. Once data is entered it may be changed, but never deleted. The affect of overriding this protection and deleting the field would be to leave a residual entry in the "AA" index pointing to the PERSONAL HISTORY entry from which the field was deleted. The Personal History file contains information on a patient's past health problems that is gathered retroactively at a patient visit. Since the data is the patient's view of his/her problems, not necessarily substantiated by a confirmed physician's diagnosis, the information is stored here rather than in the POV record. There will be a separate record for each health problem for a patient. The file contains backward pointers to the IHS Patient file and visit file, and data must exist in both of these files for the patient and visit before data can be entered here.


    Fields:

    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE NOTED .03

    		Date/Time
    PROVIDER NARRATIVE .04

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    DATE OF ONSET .05

    		Date/Time
    MULTIPLE BIRTH? .06

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    MULTIPLE BIRTH TYPE .07

    		Set of Codes
    Set of Codes:
    • Code : TU
      Stands For: TWIN, UNSPECIFIED
    • Code : IT
      Stands For: IDENTICAL TWIN
    • Code : FT
      Stands For: FRATERNAL TWIN
    • Code : TR
      Stands For: TRIPLET
    • Code : OTH
      Stands For: OTHER MULTIPLE

    FAMILY HISTORY

    File Number: 9000014

    File Description:

    This file contains a history of family health problems for a given patient. These are not the patient's problems, but those of some immediate member of the family. The information is gathered as a result of a patient visit at which the patient provides the history. The file contains backward pointers to the IHS Patient file and visit file, and data must exist in both of these files for the patient and visit before data can be entered here.


    Fields:

    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE NOTED .03

    		Date/Time
    PROVIDER NARRATIVE .04

    		Pointer
    PointerTo:
    fileName:
    PROVIDER NARRATIVE
    fileNumber:
    9999999.27
    DIAGNOSIS ONSET AGE .05

    		Numeric
    *STATUS .06

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LIVING
    • Code : D
      Stands For: DECEASED
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PT REFUSED TO ANSWER
    *RELATIONSHIP .07

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    PROVIDER .08

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RELATION/FAMILY MEMBER .09

    		Pointer
    PointerTo:
    fileName:
    FAMILY HISTORY FAMILY MEMBERS
    fileNumber:
    9000014.1
    AGE AT ONSET .11

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: In Infancy
    • Code : 1
      Stands For: Before age 20
    • Code : 2
      Stands For: At age 20-29
    • Code : 3
      Stands For: At age 30-39
    • Code : 4
      Stands For: At age 40-49
    • Code : 5
      Stands For: At age 50-59
    • Code : 6
      Stands For: 60 and older
    • Code : U
      Stands For: Age Unknown
    DATE LAST MODIFIED .12

    		Date/Time
    SNOMED CT .13

    		Free Text
    SNOMED DESCRIPTION ID .14

    		Free Text
    APPROXIMATE AGE? .15

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES, APPROXIMATE AGE
    • Code : 0
      Stands For: NO
    AGE RANGE MOVED (PATCH) .16 USED ONLY BY POST INIT FOR MU PATCH, FIELD WILL EVENTUALLY BE DELETED

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    ADDITIONAL ICD CODES 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ADDITIONAL ICD CODES .01

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80

    FAMILY HISTORY FAMILY MEMBERS

    File Number: 9000014.1

    File Description:

    Contains 1 entry for each family member for a patient for which family history is documented.


    Fields:

    Name Number Description Data Type Field Specific Data
    RELATIONSHIP .01

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    RELATION DESCRIPTION .03

    		Free Text
    STATUS .04

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LIVING
    • Code : D
      Stands For: DECEASED
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PT REFUSED TO ANSWER
    AGE AT DEATH .05

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: In Infancy
    • Code : 1
      Stands For: Before Age 20
    • Code : 2
      Stands For: At age 20-29
    • Code : 3
      Stands For: At age 30-39
    • Code : 4
      Stands For: At age 40-49
    • Code : 5
      Stands For: At age 50-59
    • Code : 6
      Stands For: 60 and older
    • Code : U
      Stands For: Age Unknown
    CAUSE OF DEATH .06

    		Free Text
    MULTIPLE BIRTH? .07

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    MULTIPLE BIRTH TYPE .08

    		Set of Codes
    Set of Codes:
    • Code : TU
      Stands For: TWIN, UNSPECIFIED
    • Code : IT
      Stands For: IDENTICAL TWIN
    • Code : FT
      Stands For: FRATERNAL TWIN
    • Code : TR
      Stands For: TRIPLET
    • Code : OTH
      Stands For: OTHER MULTIPLE
    DATE UPDATED .09

    		Date/Time
    DATE ADDED .11

    		Date/Time

    REPRODUCTIVE FACTORS

    File Number: 9000017

    File Description:

    This file is used to maintain information on reproductive factors for women of reproductive age. It points to the PATIENT file (9000001) and is DINUM to it. Associated files include PRENATAL (9000002) and OFFSPRING HISTORY (9000012).


    Fields:

    Name Number Description Data Type Field Specific Data
    NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    REPRODUCTIVE HX .019

    		Computed
    *REPRODUCTIVE HISTORY 1

    		Free Text
    *DATE REPRO HX OBTAINED 1.1

    		Date/Time
    LAST MENSTRUAL PERIOD 2

    		Date/Time
    LACTATION STATUS 2.01 Record current lactation status

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NOT LACTATING
    • Code : 1
      Stands For: LACTATING
    • Code : U
      Stands For: UNKNOWN
    DATE LAST LACTATION STATUS UPD 2.02

    		Date/Time
    PROV DOCUMENTED LACT STAT 2.03

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE LMP HX OBTAINED 2.1

    		Date/Time
    CONTRACEPTIVE METHOD 3

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: EDUCATION ONLY
    • Code : 1
      Stands For: ORAL CONTRACEPTIVES
    • Code : 2
      Stands For: IUD
    • Code : 3
      Stands For: SURGICAL STERILIZATION
    • Code : 4
      Stands For: BARRIER METHODS
    • Code : 5
      Stands For: PARTNER STERILIZED
    • Code : 6
      Stands For: NATURAL TECHNIQUES
    • Code : 7
      Stands For: MENOPAUSE
    • Code : 8
      Stands For: NONE
    • Code : 9
      Stands For: OTHER
    • Code : 10
      Stands For: HORMONAL IMPLANT
    • Code : 11
      Stands For: HORMONE INJECTION
    • Code : 12
      Stands For: ABSTINENCE
    CONTRACEPTION BEGUN 3.05

    		Date/Time
    DATE METHOD HX OBTAINED 3.1

    		Date/Time
    *EDC 4

    		Date/Time
    *HOW EDC DETERMINED 4.05

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: UNKNOWN METHOD
    • Code : 1
      Stands For: SONOGRAM
    • Code : 2
      Stands For: DATES
    • Code : 3
      Stands For: CLINICAL PARAMETERS
    DATE EDC DETERMINED 4.1

    		Date/Time
    CURRENTLY PREGNANT 1101

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PT REFUSED TO ANSWER
    CURRENTLY PREGNANT DT UPDATED 1102

    		Date/Time
    TOTAL # PREGNANCIES 1103

    		Numeric
    TOTAL # PREG UPDATED 1104

    		Date/Time
    MULTIPLE BIRTHS 1105

    		Numeric
    MULTIPLE BIRTHS UPDATED 1106

    		Date/Time
    FULL TERM BIRTHS 1107

    		Numeric
    FULL TERM BIRTHS DT UPDATED 1108

    		Date/Time
    PREMATURE BIRTHS 1109

    		Numeric
    PREMATURE BIRTHS DT UPDATED 1110

    		Date/Time
    ECTOPIC PREGNANCIES 1111

    		Numeric
    ECTOPIC DT UPDATED 1112

    		Date/Time
    LIVING CHILDREN 1113

    		Numeric
    LIVING CHILDREN DT UPDATED 1114

    		Date/Time
    MENARCHE AGE 1117

    		Numeric
    MENARCHE AGE DT UPDATED 1118

    		Date/Time
    COITARCHE AGE 1119

    		Numeric
    COITARCHE AGE DT UPDATED 1120

    		Date/Time
    MENOPAUSE ONSET AGE 1121

    		Numeric
    MENOPAUSE DT UPDATED 1122

    		Date/Time
    *SEXUAL TRAUMA HISTORY 1123

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PATIENT REFUSED TO ANSWER
    *SEXUAL TRAUMA DT UPDATED 1124

    		Date/Time
    *MULTIPLE SEXUAL PARTNERS 1125

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PATIENT REFUSED TO ANSWER
    *MULT SEX PART DT UDPATED 1126

    		Date/Time
    DES DAUGHTER? 1127

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : U
      Stands For: UNKNOWN
    • Code : R
      Stands For: PATIENT REFUSED TO ANSWER
    DES DAUGHTER DT UPDATED 1128

    		Date/Time
    DATE REPROD HX UPDATED 1130

    		Date/Time
    ABORTIONS, # INDUCED 1131

    		Numeric
    ABORTIONS, # INDUCED DT UPD 1132

    		Date/Time
    ABORTIONS, # SPONTANEOUS 1133

    		Numeric
    ABORTIONS, # SPONT DT UPD 1134

    		Date/Time
    PROV WHO DOCUMENTED CURR PREG 1135

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDD (LMP) 1302

    		Date/Time
    EDD (LMP) DATE/TIME ENTERED 1303

    		Date/Time
    PROV DOCUMENTING EDD (LMP) 1304

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDD (ULTRASOUND) 1305

    		Date/Time
    DATE/TIME EDD (ULTRA) ENTERED 1306

    		Date/Time
    PROV DOCUMENTED EDD (ULTRA) 1307

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDD (CLINICAL PARAMETERS) 1308

    		Date/Time
    DATE/TIME EDD (CP) ENTERED 1309

    		Date/Time
    PROV DOCUMENTED EDD (CLIN PAR) 1310

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DEFINITIVE EDD 1311

    		Date/Time
    DATE/TIME DEFINITIVE EDD 1312

    		Date/Time
    PROV DOCUMENTED DEFINITIVE EDD 1313

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDD (METHOD UNKNOWN) 1314

    		Date/Time
    DATE EDD (METH UNK) DETERMINED 1315

    		Date/Time
    PROV DETERMINED EDD METH UNK 1316

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDD (LMP) COMMENT 1401

    		Free Text
    EDD (ULTRASOUND) COMMENT 1402

    		Free Text
    EDD (CLIN PARAMETERS) COMMENT 1501

    		Free Text
    DEFINITIVE EDD COMMENT 1502

    		Free Text
    EDD (METHOD UNKNOWN) COMMENT 1601

    		Free Text
    CONTRACEPTIVE METHOD 2101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CONTRACEPTIVE METHOD .01

    		Pointer
    PointerTo:
    fileName:
    CONTRACEPTIVE METHODS
    fileNumber:
    99999.11
    CONTRACEPTION BEGUN .02

    		Date/Time
    CONTRACEPTION ENDED .03

    		Date/Time
    DATE UPDATED .04

    		Date/Time
    REASON DISCONTINUED .05

    		Free Text
    COMMENT .06

    		Free Text
    DELETED BY 1.01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME DELETED 1.02

    		Date/Time
    REASON DELETED 1.03

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DUPLICATE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OTHER
    REASON IF OTHER 1.04

    		Free Text
    TOTAL # PREG DOC BY 21401 This field holds the user that last edited the TOTAL # PREGNANCIES field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MULTIPLE BIRTHS DOC BY 21402 This field holds the user that last edited the MULTIPLE BIRTHS field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FULL TERM BIRTHS DOC BY 21403 This field holds the user that last edited the FULL TERM BIRTHS field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMATURE BIRTHS DOC BY 21404 This field holds the user that last edited the PREMATURE BIRTHS field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ECTOPIC PREG DOC BY 21405 This field holds the user that last edited the ECTOPIC PREGNANCIES field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LIVING CHILDREN DOC BY 21406 This field holds the user that last edited the LIVING CHILDREN field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ABORTIONS, # SPONT DOC BY 21407 This field holds the user that last edited the ABORTIONS, # SPONTANEOUS field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ABORTIONS, # IND DOC BY 21408 This field holds the user that last edited the ABORTIONS, # INDUCED field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAST MENSTRUAL PERIOD DOC BY 21409 This field holds the user that last edited the LAST MENSTRUAL PERIOD field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DES DAUGHTER DOC BY 21410 This field holds the user that last edited the DES DAUGHTER? field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MENARCHE AGE DOC BY 21411 This field holds the user that las edited the MENARCHE AGE field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COITARCHE AGE DOC BY 21412 This field holds teh user that last edited the COITARCHE AGE field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MENOPAUSE ONSET AGE DOC BY 21413 This field holds the user that last edited the MENOPAUSE ONSET AGE field.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    PATIENT REFUSALS FOR SERVICE/NMI

    File Number: 9000022

    File Description:

    This file contains all refusals for patient services. The reason for refusal can be documented.


    Fields:

    Name Number Description Data Type Field Specific Data
    SERVICE TYPE .01

    		Pointer
    PointerTo:
    fileName:
    REFUSAL TYPE
    fileNumber:
    9999999.73
    PATIENT NAME .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE DECLINED/NOT INDICATED .03

    		Date/Time
    SERVICE DESC/PREFERRED TERM .04

    		Free Text
    POINTER FILE .05

    		Pointer
    PointerTo:
    fileName:
    FILE
    fileNumber:
    1
    POINTER VALUE .06

    		Free Text
    REASON NOT DONE .07

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: DECLINED SERVICE
    • Code : N
      Stands For: NOT MEDICALLY INDICATED
    • Code : F
      Stands For: NO RESPONSE TO FOLLOWUP
    • Code : P
      Stands For: PROVIDER DISCONTINUED
    • Code : U
      Stands For: CONSIDERED AND NOT DONE
    • Code : S
      Stands For: SYSTEM REASON
    DATE LAST MODIFIED .08

    		Date/Time
    CONCEPT ID REASON NOT DONE 1.01

    		Free Text
    CONCEPT ID RND FSN 1.019

    		Computed
    DESC ID REASON NOT DONE 1.02

    		Free Text
    COMMENT 1101

    		Free Text
    PROVIDER WHO DOCUMENTED 1204

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED 1216

    		Date/Time
    ENTERED BY 1217

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED 1218

    		Date/Time
    LAST MODIFIED BY 1219

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CONCEPT ID FOR REFUSED SERVICE 1301

    		Free Text
    DESC ID FOR REFUSED SERVICE 1302

    		Free Text
    MSC REFUSED SERVICE CODE 21400.1 This field will allow for virtually ANY code from any coding system that is supported by the Clinical Quality Measures value sets to be refused. It will also support the refusal of an entire Value Set by supplying the OID for that value set.

    		Free Text
    MSC REFUSED SERVICE CODESET 21400.2 This field will hold the official NAME of the Coding System for the code defined in field 21400.1. This name must match the name used in a C0Q VALUE SET CODES definition or be the name "VALUE SET" when an entire value set OID is defined.

    		Free Text
    MSC REFUSED SERVICE DESC 21400.3

    		Free Text

    BIRTH MEASUREMENT

    File Number: 9000024

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    BIRTH WEIGHT LBS .02

    		Numeric
    BIRTH WEIGHT OZS .03

    		Numeric
    APGAR 1 MINUTE .04

    		Numeric
    APGAR 5 MINUTE .05

    		Numeric
    GESTATIONAL AGE WKS .06

    		Numeric
    DELIVERY TYPE .07

    		Free Text
    COMPLICATIONS .08

    		Free Text
    BW GRAMS .09

    		Numeric
    BIRTH ORDER .11

    		Numeric
    FORMULA STARTED .12

    		Free Text
    FORMULA STARTED (DAYS) .13

    		Numeric
    BREAST STOPPED .14

    		Free Text
    BREAST STOPPED (DAYS) .15

    		Numeric
    SOLIDS STARTED .16

    		Free Text
    SOLIDS STARTED (DAYS) .17

    		Numeric
    BIRTH WEIGHT KG .18

    		Numeric
    BIRTH WEIGHT .19

    		Numeric
    MOTHER .21

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    BIRTH LENGTH .22

    		Numeric

    THIRD PARTY LIABILITY

    File Number: 9000041

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE OF INJURY 101 Enter the date the injury occurred.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE OF INJURY .01

    		Date/Time
    INSURER .02 Enter the person's insurance company involved in this incident.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    POLICY NUMBER .03 Enter the policy number.

    		Free Text
    EFFECTIVE DATE .04 Enter the effective date of this coverage.

    		Date/Time
    ENDING DATE .05

    		Date/Time
    GROUP NAME .06

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    RESPONSIBLE PARTY NAME 101 Enter the responsible party's name.

    		Free Text
    RESPONSIBLE PARTY SSN 102 Enter the responsible party's SSN

    		Free Text
    PATIENTS ATTORNEY 103 Enter the patient's attorney.

    		Free Text
    CAUSE OF INJURY 104 Enter the cause of this injury.

    		Free Text
    DESCRIPTION OF INJURY 105 Enter a short description of this injury.

    		Free Text
    NOTES 106 Enter pertinent notes concerning this incident.

    		Free Text
    CLAIM NUMBER 201

    		Free Text
    DATE LAST WORKED 202

    		Date/Time
    DISABILITY START DATE 203

    		Date/Time
    DISABILITY END DATE 204

    		Date/Time
    WORK RETURN AUTH DATE 205

    		Date/Time
    CONTACT INFO 206

    		Free Text

    WORKMAN'S COMPENSATION

    File Number: 9000042

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE OF WC INJURY 1101 Enter the date this work related injury occurred.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE OF WC INJURY .01

    		Date/Time
    DESC OF INJURY .02 Enter as specific as possible a description of the injury.

    		Free Text
    CLAIM FILED .03 Was a claim filed ?

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    CLAIM NUMBER .04 Enter the claim or policy number assigned to this work-related incident. This field is free text up to 15 characters and in some cases mey be the patient's SSN.

    		Free Text
    NAME OF PATIENT'S ATTORNEY .05 Enter the attorney's name the same as you do for the patient's name. 3-30 characters long. ie: LAST,FIRST MIDDLE (NO spaces after comma).

    		Free Text
    PATIENT'S EMPLOYER .06 Enter the employer name of where the patient was employed at the time the injury occurred. The entries are taken from the EMPLOYER file and must exist prior to entry.

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9999999.75
    DATE CASE CLOSED .07 Enter the date this case was closed.

    		Date/Time
    TYPE OF ACCIDENT .08 Describe what caused the injury.

    		Free Text
    CLAIM STATUS .09

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PENDING
    • Code : A
      Stands For: ACTIVE
    • Code : C
      Stands For: CLOSED
    ENTITY .11 Enter the name of the responsible insurer or company.

    		Pointer
    PointerTo:
    fileName:
    INSURER
    fileNumber:
    9999999.18
    GROUP NAME .12

    		Pointer
    PointerTo:
    fileName:
    EMPLOYER GROUP INSURANCE
    fileNumber:
    9999999.77
    EFFECTIVE DATE .13 Enter the effective date of this claim.

    		Date/Time
    EXPIRATION DATE .14 Enter the expiration date of this claim.

    		Date/Time
    NOTES .15 Enter any applicable notes about this claim.

    		Free Text
    DATE LAST WORKED 201

    		Date/Time
    DISABILITY START DATE 202

    		Date/Time
    DISABILITY END DATE 203

    		Date/Time
    WORK RETURN AUTH DATE 204

    		Date/Time
    CONTACT INFO 205

    		Free Text

    GUARANTOR

    File Number: 9000043

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    GUARANTOR 101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GUARANTOR .01

    		Variable Pointer
    REFERENCE NUMBER .02

    		Free Text
    PO NUMBER .03

    		Free Text
    DATE OF BIRTH .04

    		Date/Time
    GENDER .05

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FEMALE
    • Code : M
      Stands For: MALE
    • Code : U
      Stands For: UNKNOWN
    RELATIONSHIP TO GUARANTOR .06

    		Pointer
    PointerTo:
    fileName:
    RELATIONSHIP
    fileNumber:
    9999999.36
    EFFECTIVE DATE 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EFFECTIVE DATE .01

    		Date/Time
    ENDING DATE .02

    		Date/Time

    PATIENT APPLICATIONS

    File Number: 9000045

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE APPLICATION OBTAINED 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE APPLICATION OBTAINED .01

    		Date/Time
    APPLICATION TYPE .02

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9000048
    PERSON RECEIVING APPLICATION .03

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    OVERALL STATUS OF APPLICATION .04

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PENDING
    • Code : A
      Stands For: APPROVED
    • Code : D
      Stands For: DENIED
    • Code : R
      Stands For: RE-SUBMITTED
    • Code : RE
      Stands For: REFUSED
    • Code : F
      Stands For: FOLLOW UP NEEDED
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OVER INCOME
    • Code : S
      Stands For: SCREENING ONLY
    BENEFIT COORDINATOR CASE .05 THIS FILED IS POPULATED BY THE BENEFIT COORDINATORE SCREENS. IT IS NOT TO BE EDITED BY FILEMAN AT ALL. ITS POINTS TO THE BENFIT COORDINATORE CASE FILE.

    		Numeric
    DATE APPLICATION SUBMITTED 110101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE APPLICATION SUBMITTED .01

    		Date/Time
    APPLICATION SUBMITTED VIA .02

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FAX
    • Code : M
      Stands For: MAIL
    • Code : T
      Stands For: TELEPHONE
    • Code : O
      Stands For: ONLINE/INTERNET
    • Code : H
      Stands For: HAND DELIVERED
    REASON FOR SUBMISSION .03

    		Free Text
    SUBMITTED BY .04

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    STATUS DATE 11010101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STATUS DATE .01

    		Date/Time
    STATUS .02

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PENDING
    • Code : A
      Stands For: APPROVED
    • Code : D
      Stands For: DENIED
    • Code : R
      Stands For: RE-SUBMITTED
    • Code : F
      Stands For: FOLLOW UP NEEDED
    • Code : E
      Stands For: ENTERED IN ERROR

    CARE PLAN

    File Number: 9000092

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PROBLEM .01 Pointer to Problem file. Problem for this care plan is being created.

    		Pointer
    PointerTo:
    fileName:
    PROBLEM
    fileNumber:
    9000011
    PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    PROVIDER .03

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TYPE .04

    		Set of Codes
    Set of Codes:
    • Code : G
      Stands For: GOAL
    • Code : P
      Stands For: PLAN OF CARE
    EVENT DATE/TIME .05

    		Date/Time
    DATE/TIME ENTERED .06

    		Date/Time
    SIGNED BY .07

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME SIGNED .08

    		Date/Time
    THIS ONE REPLACES .09

    		Pointer
    PointerTo:
    fileName:
    CARE PLAN
    fileNumber:
    9000092
    STATUS 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STATUS .01

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ACTIVE
    • Code : I
      Stands For: INACTIVE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : R
      Stands For: REPLACED
    • Code : M
      Stands For: MET
    USER WHO ENTERED .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME ENTERED .03

    		Date/Time
    REASON ENTERED IN ERROR .04

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DUPLICATE
    • Code : E
      Stands For: ENTERED IN ERROR
    • Code : O
      Stands For: OTHER
    REASON IF OTHER .05

    		Free Text
    NEW PLAN IF REPLACED .06

    		Pointer
    PointerTo:
    fileName:
    CARE PLAN
    fileNumber:
    9000092
    COMMENT IF INACTIVE 1

    		Free Text
    TEXT OF CARE PLAN 1200

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TEXT OF CARE PLAN .01

    		Word Processing

    PATIENT GOALS

    File Number: 9000093

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    GOAL SETTING .01 This field is set when a goal is first created. Once it is created this field is not editable. If entered in error, goal must be deleted and re-entered.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: GOAL SET
    • Code : N
      Stands For: GOAL NOT SET
    PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE CREATED .03 The date the goal was entered into the computer.

    		Date/Time
    CREATED BY .04 The user who entered this goal into the computer.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED .05 The date/time the goal entry was last modified. This field should be updated with $$NOW^XLFDT everytime the goal is edited. It is triggered and stuffed when a goal is first added.

    		Date/Time
    FACILITY WHERE GOAL SET .06 The facility (Location file entry) where the goal was established. THis is the facility that is monitoring the goal. Will most likely be DUZ(2).

    		Pointer
    PointerTo:
    fileName:
    LOCATION
    fileNumber:
    9999999.06
    GOAL NUMBER .07

    		Numeric
    PROVIDER .08 The provider who is monitoring this goal for this patient.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    GOAL START DATE .09

    		Date/Time
    GOAL FOLLOWUP DATE .1

    		Date/Time
    GOAL STATUS .11

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: GOAL STOPPED
    • Code : ME
      Stands For: GOAL MET
    • Code : MA
      Stands For: MAINTAINING GOAL
    • Code : D
      Stands For: DELETED/ENTERED IN ERROR
    • Code : A
      Stands For: ACTIVE
    USER LAST UPDATE .12

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    GOAL DELETED BY 2.01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME GOAL DELETED 2.02

    		Date/Time
    REASON GOAL DELETED 2.03

    		Set of Codes
    Set of Codes:
    • Code : W
      Stands For: WRONG PATIENT
    • Code : D
      Stands For: DUPLICATE
    • Code : O
      Stands For: OTHER
    REASON IF OTHER 2.04

    		Free Text
    GOAL TYPE 1000

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GOAL TYPE .01

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9001002.4
    GOAL NAME 1101

    		Free Text
    REASON FOR GOAL 1201

    		Free Text
    REVIEW/PROGRESS NOTES 1300

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE REVIEWED .01

    		Date/Time
    REVIEW/PROGRESS NOTE .02

    		Free Text
    STEP FACILITY 2100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STEP FACILITY .01 This is the facility (most likely DUZ(2)) where this step was created.

    		Pointer
    PointerTo:
    fileName:
    LOCATION
    fileNumber:
    9999999.06
    STEP NUMBER 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STEP NUMBER .01

    		Numeric
    CREATED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE CREATED .03

    		Date/Time
    STEP TYPE .04

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    9001002.4
    STEP START DATE .05

    		Date/Time
    STEP FOLLOWUP DATE .06

    		Date/Time
    USER LAST UPDATE .07

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME LAST MODIFIED .08

    		Date/Time
    STEP STATUS .09

    		Set of Codes
    Set of Codes:
    • Code : ME
      Stands For: STEP MET
    • Code : MA
      Stands For: MAINTAINING STEP
    • Code : S
      Stands For: STEP STOPPED
    • Code : A
      Stands For: ACTIVE
    • Code : D
      Stands For: DELETED
    PROVIDER .1

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    STEP DELETED BY 2.01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME STEP DELETED 2.02

    		Date/Time
    REASON STEP DELETED 2.03

    		Set of Codes
    Set of Codes:
    • Code : W
      Stands For: WRONG GOAL
    • Code : D
      Stands For: DUPLICATE
    • Code : O
      Stands For: OTHER
    REASON IF OTHER 2.04

    		Free Text
    STEP TEXT 1101

    		Free Text

    TREATMENT PLAN

    File Number: 9000094

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    TREATMENT PLAN TYPE .01

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    99999.21
    PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DATE INITIATED .03

    		Date/Time
    DURATION .04

    		Free Text
    COMPLETION DATE .05

    		Date/Time
    DIAGNOSIS .06

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    RESPONSIBLE PROVIDER .07

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE LAST UPDATE .08

    		Date/Time
    USER LAST UPDATE .09

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    NEXT REVIEW DATE .11

    		Date/Time
    DATE DISCONTINUED .12

    		Date/Time
    DISCONTINUED BY .13

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REASON DISCONTINUED .14

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    99999.22
    TREATMENT PLAN OTHER .15

    		Free Text
    TEAM MEMBERS 1201

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TEAM MEMBERS .01

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PATIENT STRENGTHS 1301

    		Free Text
    AREA OF FOCUS 1401

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AREA OF FOCUS .01

    		Free Text
    GOALS 1501

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GOALS .01

    		Free Text
    OBJECTIVES 1601

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OBJECTIVES .01

    		Free Text
    NARRATIVE COMMENT 1700

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    NARRATIVE COMMENT .01

    		Word Processing
    REVIEW DATES 1801

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REVIEW DATES .01

    		Date/Time
    REVIEWED BY .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REVIEW COMMENT 1100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REVIEW COMMENT .01

    		Word Processing
    TEAM MEMBERS (OUTSIDE) 1901

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TEAM MEMBERS (OUTSIDE) .01

    		Free Text
    DISCONTINUED COMMENTS 2100

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISCONTINUED COMMENTS .01

    		Word Processing

    BI PATIENT

    File Number: 9002084

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    MAILING ADDRESS-STREET .02

    		Computed
    MAILING ADDRESS-CITY .03

    		Computed
    MAILING ADDRESS-STATE .04

    		Computed
    MAILING ADDRESS-ZIP .05

    		Computed
    CHART# .06

    		Computed
    INACTIVE DATE .08

    		Date/Time
    PARENT OR GUARDIAN .09

    		Free Text
    CASE MANAGER .1

    		Pointer
    PointerTo:
    fileName:
    BI CASE MANAGER
    fileNumber:
    9002084.01
    MOTHERS HBSAG STATUS .11

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: POSITIVE
    • Code : N
      Stands For: NEGATIVE
    • Code : U
      Stands For: UNKNOWN
    MOVED OR TX ELSEWHERE LOCATION .12

    		Free Text
    OTHER INFO .13

    		Free Text
    DATE OF LAST LETTER .14

    		Date/Time
    FORECAST INFLUENZA/PNEUMO .15

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: Normal
    • Code : 1
      Stands For: Influenza
    • Code : 2
      Stands For: Pneumococcal
    • Code : 3
      Stands For: Both, Influ & Pneumo
    • Code : 4
      Stands For: Disregard Risk Factors
    INACTIVE REASON .16

    		Set of Codes
    Set of Codes:
    • Code : m
      Stands For: Moved Elsewhere
    • Code : t
      Stands For: Treatment Elsewhere
    • Code : d
      Stands For: Deceased
    • Code : p
      Stands For: Previously Inactivated
    • Code : n
      Stands For: Never Activated
    • Code : i
      Stands For: Ineligible, non-Ben
    FIRST ENTERED BY USER .2

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE FIRST ENTERED .21

    		Date/Time
    AUTOMATICALLY ACTIVATED .22

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: MANUALLY
    • Code : 1
      Stands For: AUTOMATICALLY
    INACTIVATED BY USER .23

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    IMM/SERVE TEXT 1.01

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMM/SERVE TEXT .01

    		Word Processing
    STATE REGISTRY ID 21401.01

    		Free Text
    SHARING CONSENT INDICATOR 21401.02

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SHARING CONSENT DATE 21401.03

    		Date/Time
    REMINDER/RECALL INDICATOR 21401.04

    		Free Text
    REMINDER/RECALL EFFECTIVE DATE 21401.05

    		Date/Time

    BI PATIENT IMMUNIZATIONS DUE

    File Number: 9002084.1

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    IMMUNIZATION .02

    		Pointer
    PointerTo:
    fileName:
    IMMUNIZATION
    fileNumber:
    9999999.14
    SERIES .03

    		Numeric
    RECOMMENDED DATE DUE .04

    		Date/Time
    DATE PAST DUE .05

    		Date/Time

    BI PATIENT CONTRAINDICATIONS

    File Number: 9002084.11

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    VACCINE .02

    		Pointer
    PointerTo:
    fileName:
    IMMUNIZATION
    fileNumber:
    9999999.14
    REASON FOR CONTRAINDICATION .03

    		Pointer
    PointerTo:
    fileName:
    BI TABLE CONTRA REASON
    fileNumber:
    9002084.81
    DATE NOTED .04

    		Date/Time
    PROVIDER WHO DOCUMENTED 21400

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200

    PT TAXONOMY

    File Number: 9002227

    File Description:

    Stores the patients who have had a purpose of visit that is a member of one of the taxonomies in the TAXONOMY file


    Fields:

    Name Number Description Data Type Field Specific Data
    NAME .01

    		Pointer
    PointerTo:
    fileName:
    TAXONOMY
    fileNumber:
    9002226
    DATE CREATED .02

    		Date/Time
    USER .03

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PATIENT 1101

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PATIENT .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    COUNT .02 Count will be direct set by program. If count gets to zero, the patient will be deleted from the taxonomy.

    		Numeric

    DAY SURGERY

    File Number: 9009012

    File Description:

    This is the main data file for an Ambulatory Surgery program at your facility. It contains basic patient data on the surgery. The clinical data is stored in PCC as ambulatory visits for the day surgery (44) clinic.


    Fields:

    Name Number Description Data Type Field Specific Data
    PATIENT NAME .01

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    DAY SURGERY DATE/TIME 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DAY SURGERY DATE/TIME .01

    		Date/Time
    PROCEDURE 1

    		Free Text
    DIAGNOSIS 1.5

    		Free Text
    WARD LOCATION 2

    		Pointer
    PointerTo:
    fileName:
    WARD LOCATION
    fileNumber:
    42
    ROOM-BED 3

    		Free Text
    SPECIALTY 4

    		Pointer
    PointerTo:
    fileName:
    FACILITY TREATING SPECIALTY
    fileNumber:
    45.7
    PROVIDER 5

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    INTERVIEW COMMENTS 6

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERVIEW COMMENTS .01

    		Word Processing
    RELEASE DATE/TIME 7

    		Date/Time
    LOS 8

    		Computed
    DATE/TIME TO OBSERVATION 9

    		Date/Time
    EXTENDED STAY LOS 10

    		Computed
    PATIENT ADMITTED? 11

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    SURGERY CANCELLED? 12

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    NO-SHOW? 13

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    MEDICAID NUMBER 14

    		Computed
    UNESCORTED? 15

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    POST-OP COMMENTS 16

    		Free Text
    HRCN 2

    		Computed
    COMMUNITY OF RESIDENCE 3

    		Computed

    BLR REFERENCE LAB ORDER/ACCESSION

    File Number: 9009026.3

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    ORDER NUMBER .01

    		Free Text
    ACCESSION NUMBER .02

    		Free Text
    CLIENT ACCOUNT NUMBER .03

    		Free Text
    PATIENT .04

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    BILL TYPE .05

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PATIENT BILL
    • Code : C
      Stands For: CLIENT BILL
    • Code : T
      Stands For: THIRD PARTY BILL
    COLLECTION DATE/TIME .06

    		Date/Time
    RESULT COPIES TO .07 This is used for MU and will be put in OBR-28 of the ORM Order message.

    		Free Text
    DIAGNOSIS 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    INSURER 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AGINS STRING .01

    		Free Text
    ACCESSION NUMBERS 3

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ACCESSION NUMBERS .01

    		Free Text
    ASK AT ORDER QUESTIONS 4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAB TEST .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    ACCESSION .02

    		Free Text
    ASK AT ORDER QUESTION .03

    		Free Text
    ASK AT ORDER RESPONSE .04

    		Free Text
    RESULT CODE .05

    		Free Text

    APSP REFILL REQUESTS

    File Number: 9009033.91

    File Description:



    Fields:

    Name Number Description Data Type Field Specific Data
    MESSAGE ID .01

    		Free Text
    OERR ORDER # .02

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    STATUS .03

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: TO BE PROCESSED
    • Code : 1
      Stands For: PROCESSING
    • Code : 2
      Stands For: PROCESSED - ACCEPTED
    • Code : 3
      Stands For: PROCESSED - DENIED
    • Code : 4
      Stands For: MAPPING - INCOMPLETE
    • Code : 5
      Stands For: PROCESSED - DENIED (NEW RX)
    • Code : 6
      Stands For: MAPPING - COMPLETE
    • Code : 9
      Stands For: ERROR
    MESSAGE DATE/TIME .04

    		Date/Time
    HLO MESSAGE .05

    		Free Text
    RX TO RENEW .06

    		Pointer
    PointerTo:
    fileName:
    PRESCRIPTION
    fileNumber:
    52
    LAST UPDATED .07

    		Date/Time
    ACTIVITY ACTION .08 Holds the user action selected during processing of the order.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ACCEPT
    • Code : 2
      Stands For: ACCEPT W/CHG
    • Code : 3
      Stands For: DENY W/NOTF
    • Code : 4
      Stands For: DENY
    ACTIVITY ACTION USER .09

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RXREFNUMBER .1 Holds the RxReferenceNumber coming from Surescripts.

    		Free Text
    ITEMS MATCHED .11 Field can contain one or more of the following characters. O=Order (PON) P=Patient M=Medication D=Doctor Z=Forces Deny only

    		Free Text
    ORDERABLE ITEM 1.1

    		Pointer
    PointerTo:
    fileName:
    ORDERABLE ITEMS
    fileNumber:
    101.43
    REQUEST CHANGED 1.11 Field is set to yes when the ordering provider is changed from the original provider assigned during the mapping process.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: CHANGED PROVIDER
    • Code : 2
      Stands For: CHANGED MAPPINGS
    DAW 1.12

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PATIENT 1.2

    		Pointer
    PointerTo:
    fileName:
    PATIENT/IHS
    fileNumber:
    9000001
    PROVIDER 1.3

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    QUANTITY 1.4

    		Numeric
    DAYS SUPPLY 1.5

    		Numeric
    HOSPITAL LOCATION 1.6

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    PHARMACY 1.7

    		Pointer
    PointerTo:
    fileName:
    APSP PHARMACY LIST
    fileNumber:
    9009033.9
    DISPENSE MED 1.8

    		Pointer
    PointerTo:
    fileName:
    DRUG
    fileNumber:
    50
    FILL COUNT 1.9

    		Numeric
    MEDICATION INSTRUCTIONS 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    QUANTITY/FORM .01

    		Free Text
    DISPENSE UNITS PER DOSE 1

    		Numeric
    DOSAGE ORDERED 1.1

    		Free Text
    DISPENSE UNITS PER DOSE 1.2

    		Numeric
    UNITS 1.3

    		Pointer
    PointerTo:
    fileName:
    DRUG UNITS
    fileNumber:
    50.607
    NOUN 1.4

    		Free Text
    DURATION 1.5

    		Free Text
    CONJUCTION 1.6

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AND
    • Code : T
      Stands For: THEN
    • Code : X
      Stands For: EXCEPT
    ROUTE 1.7

    		Pointer
    PointerTo:
    fileName:
    MEDICATION ROUTES
    fileNumber:
    51.2
    SCHEDULE 1.8

    		Free Text
    VERB 1.9

    		Free Text
    UNITS 2

    		Pointer
    PointerTo:
    fileName:
    DRUG UNITS
    fileNumber:
    50.607
    NOUN 3

    		Free Text
    DURATION 4

    		Free Text
    CONJUCTION 5

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AND
    • Code : T
      Stands For: THEN
    • Code : X
      Stands For: EXCEPT
    ROUTE 6

    		Pointer
    PointerTo:
    fileName:
    MEDICATION ROUTES
    fileNumber:
    51.2
    SCHEDULE 7

    		Free Text
    VERB 8

    		Free Text
    SIG1 3

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SIG1 .01

    		Free Text
    DENIAL REASON 4

    		Free Text
    PATIENT INSTRUCTIONS 4.1 This field holds the value of field 6 of the HL7 RXO segment.

    		Free Text
    RESPONSES 4.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ITEM ENTRY .01

    		Numeric
    DIALOG .02

    		Pointer
    PointerTo:
    fileName:
    ORDER DIALOG
    fileNumber:
    101.41
    INSTANCE .03 In the case of multiple answers for the same item, this identifies the individual instance.

    		Numeric
    ID .04

    		Free Text
    VALUE 1

    		Free Text
    TEXT 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TEXT .01

    		Word Processing
    HL7 MESSAGE 5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HL7 MESSAGE .01

    		Word Processing
    ACTIVITY DATE/TIME 6

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ACTIVITY DATE/TIME .01

    		Date/Time
    ACTIVITY .02

    		Free Text
    USER .03

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGN OR SYMPTOM 7.1

    		Free Text
    INDICATION CODE 7.2

    		Free Text
    SNOMED CONCEPT ID 7.3

    		Free Text
    RELATED REQUESTS 9

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RELATED REQUESTS .01

    		Pointer
    PointerTo:
    fileName:
    APSP REFILL REQUESTS
    fileNumber:
    9009033.91

    RECORD OF PROS APPLIANCE/REPAIR

    File Number: 660

    File Description:

    This is the main file for prosthetic purchasing transactions. AMIS is calculated from this file based on item issued and disability served. This file is also the permanent record for the patient VAF 10-2319 of items issued to the veteran.


    Fields:

    Name Number Description Data Type Field Specific Data
    ENTRY DATE .01 This is the date that the transaction was entered into the system. It may or may not be the same as the request date.

    		Date/Time
    PATIENT NAME .02 This is the name of the patient that this transaction is for. The name is a pointer to the PROSTHETIC PATIENT file which has the same internal entry number as the main patient database.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETICS PATIENT
    fileNumber:
    665
    REQUEST DATE 1 This field is the date the appliance issue or repair was requested by the patient. It may or may not be the same as the entry date or the delivery date. This depends on how quickly the transactions take place.

    		Date/Time
    TYPE OF TRANSACTION 2 This set of codes will tell what kind of transaction this request is. The possibilities all fall under the VAF 10-7306a listings except for the repair.

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INITIAL ISSUE
    • Code : R
      Stands For: REPLACE
    • Code : S
      Stands For: SPARE
    • Code : X
      Stands For: REPAIR
    • Code : 5
      Stands For: RENTAL
    ITEM 4 This field is a pointer to the master item list of possible appliances. The master list is set up so that appliances fall into groups which are the types of appliances.

    		Pointer
    PointerTo:
    fileName:
    PROS ITEM MASTER
    fileNumber:
    661
    HCPCS 4.1 Health Care Financing Administration Common Procedure Coding System (HCPCS). This field should have the HCPCS code for the Item you are selecting. HCPCS is a uniform method for healthcare providers and medical suppliers to report professional services, procedures and supplies.

    		Pointer
    PointerTo:
    fileName:
    CPT
    fileNumber:
    81
    VENDOR TRACKING NUMBER 4.2 This field is the Vendor's internal unique tracking number. Some of the small vendors are not automated with VISA, and this tracking number is used to reference this transaction. This tracking number is based on the item, and can be as simple as the vendors item number, or elaborate as the vendors transaction number. This data will be used in the reconciliation process.

    		Free Text
    BANK AUTHORIZATION NUMBER 4.3 This six digit number is the authorization number VISA gives to the vendor for guaranteed payment. This number is used in the reconciliation process.

    		Free Text
    PSAS HCPCS 4.5 Standardized Prosthetics HCPCS that points to file 661.1.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETIC HCPCS
    fileNumber:
    661.1
    STOCK ISSUE 4.6 This is a pointer to file #661.6.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETIC INVENTORY TRANSACTION
    fileNumber:
    661.6
    CPT MODIFIER 4.7 CPT Modifiers in a comma delimited format, consistent with the HCFA published manuals.

    		Free Text
    DATE CPT MODIFIER EXTRACTED 4.8 This is the date the patient record extracted for billing. This date is also being used to trigger a mail message to billing if the PSAS HCPCS is edited and changed after the extraction has been ran.

    		Date/Time
    HCPCS-ICD9 CODING FLAG 4.9 This field is used to determine the current code set versioning of a transaction. No errors, number 1. PSAS HCPCS, Not Billiable Item, number 14. ICD9 error, number 12. HCPCS error, number 13. Both ICD9 and HCPCS error, number 132. Both ICD9 error and Not Billiable Item, number 142.

    		Numeric
    CODING FLAG DATE 4.91 This is the date associated with field number 4.9. The date the coding flag was set.

    		Date/Time
    HIGH TECH ITEM 4.92 This is the determination by the Prosthetics Laboratory Technician. 1=YES 0=NO

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    QTY 5 This is the number of units that was issued or repaired for this transaction.

    		Numeric
    SHIP/DEL 6 This is the charge associated with shipping.

    		Numeric
    PICKUP/DEL 6.5 This field is a set of codes to identify pickup/delivery charges on VAF 10-2319.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PICKUP
    • Code : D
      Stands For: DELIVERY
    VENDOR 7 The vendor is a pointer to IFCAP's VENDOR file and is the name of the company from which this appliance was or is to be purchased. The vendor may or may not be the same as the manufacturer. Therefore, manufacturers should also be listed in this file as vendors if you are going to be purchasing directly from the manufacturer.

    		Pointer
    PointerTo:
    fileName:
    VENDOR
    fileNumber:
    440
    STATION 8 The station is the Veterans Affairs site where this transaction is to come to completion. It is the station that is ultimately responsible for the issue and payment for the prosthetic device. This is the station reporting the workload.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    SUSPENSE DATE 8.1 This is suspense date (.01 field) of file (#668).

    		Date/Time
    SUSPENSE STATION 8.11 This refers to the consulting station.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    PCE 8.12 This field is pointer to (Patient Encounter), Visit file (#9000010). When an entry is created in PCE a pointer is being set.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    DATE SENT TO PCE 8.13 This is the date last sent or edited in PCE. If PCE is deleted this field should be deleted.

    		Date/Time
    SUSPENSE STATUS 8.14 This is the suspense status of the patient 2319 record. If the status is complete, a suspense link was established. If the status is incomplete, there is no suspense link to the patient 2319 record.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: INCOMPLETE
    • Code : 1
      Stands For: COMPLETE
    DATE RX WRITTEN 8.2 This is the date the prescription was written as it appears in file #668.

    		Date/Time
    INITIAL ACTION DATE 8.3 This field is the date when an initial action was entered in suspense.

    		Date/Time
    COMPLETION DATE 8.4 This is the date the susepnse was completed as it appears in file #668.

    		Date/Time
    TYPE OF REQUEST 8.5 This field could either be ROUTINE PROSTHETICS, EYEGLASS, CONTACT LENS, OXYGEN, MANUAL NON CPRS or CLOTHING ALLOWANCE.

    		Free Text
    SUSPENSE REQUESTOR 8.6 This is a pointer to file #200, the person requesting the suspense as it appears in file #668.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CONSULT REQUEST SERVICE 8.61 A service/section of a suspense requestor that initiated a consult for Prosthetics item. This free text entry is a service/section name of SERVICE/SECTION file (#49).

    		Free Text
    PROVISIONAL DIAGNOSIS 8.7 This is a free text diagnosis as it appears in suspense file.

    		Free Text
    SUSPENSE ICD9 8.8 This field is a pointer to ICD9 file, #80. This is the code at the time suspense was created.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    CONSULT 8.9 This is a pointer to Consult file #123.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    SERIAL NBR 9 This is the serial number of the issued or repaired appliance. If the serial number is longer than 20 characters, use the FIRST 20 characters.

    		Free Text
    PRODUCT DESCRIPTION 9.1 The manufacture product description to be used for recalls.

    		Free Text
    PRODUCT MODEL 9.2 The manufacture product model number to be used for recalls.

    		Free Text
    DELIVERY DATE 10 This is the date that the appliance was delivered and accepted by the patient. This date, under certain circumstances, may be a date that the appliance was mailed to the patient. It may or may not be the same as the transaction date and/or the request date.

    		Date/Time
    FORM REQUESTED ON 11 The FORM REQUESTED ON is based on current VA regulations. The system makes no checks to be sure that the form entered from the set of codes is within these regulations.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: PSC
    • Code : 2
      Stands For: 2421
    • Code : 3
      Stands For: 2237
    • Code : 4
      Stands For: 2529-3
    • Code : 5
      Stands For: 2529-7
    • Code : 6
      Stands For: 2474
    • Code : 7
      Stands For: 2431
    • Code : 8
      Stands For: 2914
    • Code : 9
      Stands For: OTHER
    • Code : 10
      Stands For: 2520
    • Code : 11
      Stands For: STOCK ISSUE
    • Code : 12
      Stands For: INVENTORY ISSUE
    • Code : 13
      Stands For: HISTORICAL DATA
    • Code : 14
      Stands For: VISA
    • Code : 15
      Stands For: LAB ISSUE-3
    • Code : 16
      Stands For: DALC
    SOURCE 12 This set of codes denotes which two possible sources were used for the acquisition of the appliance. The sources are grouped into either VA sources or commercial sources.

    		Set of Codes
    Set of Codes:
    • Code : V
      Stands For: VA
    • Code : C
      Stands For: COMMERCIAL
    ACTION 13 The action taken on this transaction is noted here. The set of codes is self explanatory; however, the inactive action is used to indicate that the appliance is no longer being followed by VA.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: LOAN
    • Code : 2
      Stands For: CONDEMNED
    • Code : 3
      Stands For: RETURNED
    • Code : 4
      Stands For: INACTIVE
    • Code : 5
      Stands For: LOST
    TOTAL COST 14 This field contains the total cost of the transaction.

    		Numeric
    HISTORICAL DATA 15 If this field contains an asterisk (*), then this transaction has been counted by the AMIS option, or is considered to be a historical transaction.

    		Free Text
    REMARKS 16 A free-text field used to indicate any additional information that is needed for this entry. For Purchasing Transactions this field will contain the remarks for the individual item, and the close-out remarks added together.

    		Free Text
    RETURNED STATUS 17 The status of the appliance upon return to the veteran. This notes what action was taken by the repair depot or station upon the completion of repairs.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: RETURNED
    • Code : 2
      Stands For: CONDEMNED
    • Code : 3
      Stands For: CANCELLED
    • Code : 4
      Stands For: TURNED-IN
    • Code : 5
      Stands For: LOST
    • Code : 6
      Stands For: BROKEN
    RETURN STATUS DATE 17.5 This is the date upon which the return status was determined and carried out if the item was returned to the veteran.

    		Date/Time
    *STATUS FLAG 18 The status of the patient is entered here so the service can determine if the patient is being followed, dropped, transferred, or canceled by this station.

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DECEASED
    • Code : T
      Stands For: TRANSFERRED
    • Code : I
      Stands For: INACTIVE
    PATIENT NOTIFICATION FLAG 19 This field if set to 1 will be used to gather the patient records that need to be re-sent for the daily pull of the Mandatory Patient Notification process.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: RE-SEND
    DELIVERY VERIFICATION DATE 20 This is the date the Veteran indicates on the Notification card that he received the item.

    		Date/Time
    DELIVERY VERIFICATION STATUS 20.1 This is the statement of receipt that the Veteran indicates on the returned Delivery Notification Card.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: RECEIVED
    • Code : 2
      Stands For: NOT RECEIVED
    • Code : 3
      Stands For: DAMAGED or INCOMPLETE
    • Code : 4
      Stands For: RECEIVED not as ORDERED
    • Code : 5
      Stands For: RECEIVED in ERROR
    LOT NUMBER 21 This field stores the lot number of the item being furnished to the patient. Enter the manufacturer's lot number, if known.

    		Free Text
    *PRODUCT LINE 22 Set of codes that contains information for Hearing Aid transactions.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: HEARING AIDS
    • Code : 2
      Stands For: BATTERIES
    • Code : 3
      Stands For: OTHER
    TRANSACTION 23 This is the IFCAP transaction number from VAF 4-1358 or VAF 2237. A temporary Transaction number for a VAF 10-2529-3 may also be entered.

    		Free Text
    DESCRIPTION 24 This is a detailed description of the item/service supplied.

    		Free Text
    DELIVER TO 25 Delivery location that will print on VAF 10-2421 to show the vendor where the item will be delivered.

    		Free Text
    DATE REQUIRED 26 This field stores the date the vendor is required to provide the Item/Service by.

    		Date/Time
    INITIATOR 27 This is the person who created the transaction.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EXTENDED DESCRIPTION 28 This is the extended information from purchasing and also from posting of VAF 2237s.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EXTENDED DESCRIPTION .01 This is the extended information from purchasing and also from posting of VAF 2237s.

    		Word Processing
    INVENTORY POINT 29 This is the inventory point for this transaction and is a pointer to the GENERIC INVENTORY file (#445).

    		Pointer
    PointerTo:
    fileName:
    GENERIC INVENTORY
    fileNumber:
    445
    PRIMARY ICD DIAGNOSIS CODE 30 Pointer to Primary Diagnosis code for order.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    PRIMARY AGENT ORANGE EXPOSURE 30.1 Primary diagnosis is related to Agent Orange exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY IONIZED RADIATION 30.2 Primary diagnosis is related to Ionized Radiation exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY SERVICE-CONNECTED 30.3 Primary diagnosis is related to a Service-Connected condition.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY ENVIRONMENTAL CONT. 30.4 Primary diagnosis is related to Environmental Contaminants exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY MST 30.5 Primary diagnosis is related to Military Sexual Trauma.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY HEAD/NECK CANCER 30.6 Primary diagnosis is related to Head/Neck Cancer.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    PRIMARY COMBAT VET 30.7 Primary diagnosis related to Combat.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ICD DIAGNOSIS CODE 1 31 Pointer to ICD Diagnosis file (#80) for Secondary ICD Diagnosis code 1.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SECONDARY AGENT ORANGE 1 31.1 Secondary diagnosis 1 is related to Agent Orange exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY IONIZED RADIATION 1 31.2 Secondary diagnosis 1 is related to Ionized Radiation exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY SERVICE-CONNECTED 1 31.3 Secondary Diagnosis 1 is related to a Service-Connected condition.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ENVIRONMENTAL CONT 1 31.4 Secondary diagnosis 1 is related to Environmental Contaminants exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY MST 1 31.5 Secondary diagnosis 1 is related to Military Sexual Trauma.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY HEAD/NECK CANCER 1 31.6 Secondary diagnosis 1 is related to Head/Neck cancer.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY COMBAT VET 1 31.7 Secondary diagnosis 1 is related to Combat.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ICD DIAGNOSIS 2 32 Pointer to ICD Diagnosis file (#80) for Secondary ICD diagnosis code 2.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SECONDARY AGENT ORANGE 2 32.1 Secondary diagnosis 2 is related to Agent Orange exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY IONIZED RADIATION 2 32.2 Secondary diagnosis 2 is related to Ionized Radiation exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY SERVICE-CONNECTED 2 32.3 Secondary diagnosis 2 is related to a Service-Connected condition.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ENVIR. CONT. 2 32.4 Secondary diagnosis 2 is related to Environmental Contaminants exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY MST 2 32.5 Secondary diagnosis 2 is related to Military Sexual Trauma.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY HEAD/NECK CANCER 2 32.6 Secondary diagnosis 2 is related to Head/Neck cancer.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY COMBAT VET 2 32.7 Secondary diagnosis 2 is related to Combat.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ICD DIAGNOSIS 3 33 Pointer to ICD Diagnosis file (#80) for Secondary ICD diagnosis code 3.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    SECONDARY AGENT ORANGE 3 33.1 Secondary diagnosis 3 is related to Agent Orange exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY IONIZED RADIATION 3 33.2 Secondary diagnosis 3 is related to Ionized Radiation exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY SERVICE-CONNECTED 3 33.3 Secondary diagnosis 3 is related to a Service-Connected condition.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY ENVIRON. CONT. 3 33.4 Secondary diagnosis 3 is related to Environmental Contaminants exposure.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY MST 3 33.5 Secondary diagnosis 3 is related to Military Sexual Trauma.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY HEAD/NECK CANCER 3 33.6 Secondary diagnosis 3 is related to Head/Neck cancer.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SECONDARY COMBAT VET 3 33.7 Secondary diagnosis 3 is related to Combat.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    OIF/OEF 34 Veteran determined to be OEF/OIF 1 Yes 0 NO.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    USER WHO EDIT 35 User who edited the 2319 record using option ED2. This field will only be populated when the Total Cost field has been changed.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE EDITED 36 This is the date the Total Cost field has been changed using option ED2.

    		Date/Time
    HCPCS/ITEM 37 Enternal entry of an HCPCS concatenated to an enternal entry of an item in file #661.1. Entry for this field is derived from the entry in file 661.2, field #9.

    		Free Text
    HCPCS/ITEM DESCRIPTION 38 This is the description of an Item or Appliance kept by local site in file #661.1, field #20. This field is updated during the STOCK ISSUE options.

    		Free Text
    EXCLUDE/WAIVER 38.1 This field determines if the item is EXCLUDED or Waver off of a National Contract

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: EXCLUDED
    • Code : W
      Stands For: WAIVER
    CONTRACT # 38.7 This field stores the Contract Number.

    		Free Text
    NUMBER OF BIDS 38.8 The number of bids recieved for a particular item.

    		Numeric
    DATE OF SERVICE 39 This is the date when an item is issued to the patient.

    		Date/Time
    REQUESTING STATION 40 This is the station requesting services or appliances.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    TOTAL LABOR HOURS 45 This is the number of hours spent on the job. This field is only populated via routines.

    		Numeric
    TOTAL LABOR COST 46 The total cost of the labor to perform this job.

    		Numeric
    TOTAL MATERIAL COST 47 The total cost of all the materials to perform the job.

    		Numeric
    TOTAL LAB COST 48 The Prosthetic Laboratory Total Cost calculated by AMIS.

    		Numeric
    COMPLETION DATE 50 The date the job was completed.

    		Date/Time
    LAB REMARKS 51 A free-text field used to indicate any additional Laboratory information that is needed for this entry. Since the field is only 40 characters in length, use meaningful abbreviations where possible.

    		Free Text
    AMIS NEW CODE 52 This field is set when AMIS is generated. It is the New Worksheet AMIS code.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    AMIS DATE 60 This field is set when AMIS is generated. This is the date AMIS was run and the item was picked up and counted.

    		Date/Time
    PATIENT CATEGORY 62 This is the Prosthetic Patient Category used for counting AMIS.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: SC/OP
    • Code : 2
      Stands For: SC/IP
    • Code : 3
      Stands For: NSC/IP
    • Code : 4
      Stands For: NSC/OP
    SPECIAL CATEGORY 63 If the patient is NSC/OP, then this field must also be set. SPECIAL CATEGORY is also used in counting AMIS.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: SPECIAL LEGISLATION
    • Code : 2
      Stands For: A&A
    • Code : 3
      Stands For: PHC
    • Code : 4
      Stands For: ELIGIBILITY REFORM
    ADMIN REPAIR AMIS CODE 64 This field will be set when AMIS is generated for the Repair Worksheets.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    AMIS GROUPER 68 This is used in AMIS calculations. This field should never be changed through FileMan!

    		Numeric
    SOURCE OF PROCUREMENT 69 The source from which the Purchasing Agent is ordering the needed equipment. The sources one may choose from are limited.

    		Set of Codes
    Set of Codes:
    • Code : O
      Stands For: ORTHOTIC LAB
    • Code : R
      Stands For: RESTORATION LAB
    • Code : S
      Stands For: SHOE LAST CLINIC
    • Code : W
      Stands For: WHEELCHAIR REPAIR SHOP
    • Code : N
      Stands For: NATIONAL FOOT CENTER
    • Code : D
      Stands For: DENVER DISTRIBUTION CENTER
    RECEIVING STATION 70 This field contains the institution that will receive the VAF 10-2529-3 request for processing.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    WORK ORDER NUMBER 71 Work Order Number (STA-FY-QTR-TYPE OF LAB-NUMBER) for items processed in the Prosthetic Laboratory.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETIC WORK ORDER
    fileNumber:
    664.2
    2529-3 72 VAF 10-2529-3 information will be displayed if the VAF 10-2319 item is associated with a Denver Distribution Center, National Foot Center, or Prosthetics Lab request.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETIC 2529-3
    fileNumber:
    664.1
    FREE TEXT WO # 72.5 This is the actual human readable Work Order Number for NPPD identification purposes.

    		Free Text
    LAB AMIS DATE 73 Last date the Lab AMIS was run.

    		Date/Time
    ORTHOTICS LAB CODE 74 Contains the Orthotic Lab New Code.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    ORTHOTICS LAB REPAIR CODE 75 Contains the Orthotic Lab Repair Code.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    RESTORATION LAB CODE 76 Contains the Restoration Lab New Code.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    RESTORATIONS LAB REPAIR CODE 77 Contains the Restoration Lab Repair Code.

    		Pointer
    PointerTo:
    fileName:
    PROS AMIS CODES
    fileNumber:
    663
    UNIT OF ISSUE 78 This is the unit by which items/services are issued (e.g., each, pair, box, case, etc.).

    		Pointer
    PointerTo:
    fileName:
    UNIT OF ISSUE
    fileNumber:
    420.5
    AMIS FLAG 79 Contains the status if the Item will not count on the Administrative AMIS.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NO ADMIN COUNT
    WORK FOR OTHER STATION 80 Contains the Status if the Job Performed will display as work performed for another station.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    NO ADMIN COUNT 81 This field will be set if the Item will not count on the Administrative AMIS or the Orthotic Laboratory AMIS.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NO COUNT
    NO LAB COUNT 82 Field will be set if there is no AMIS Count for AMIS.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NO COUNT
    BACKLOG DATE 83 This field will contain the date that the entry was created. This entry will be a backlog entry until it has been completed. All backlog data must show up on the Laboratory or Restoration AMIS Count.

    		Date/Time
    HISTORICAL ITEM 89 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    DALC REFERENCE NUMBER 89.1 This is the line level reference number from a DALC purchase order or delivery of item or service.

    		Free Text
    DALC BILL DATE 89.2 This is the Billing Date from the Denver Acquisition and Logistics Center (DALC).

    		Date/Time
    DALC ORDERING STATION 89.3 This is the Ordering station from to the Denver Acquisition and Logistics Center (DALC).

    		Free Text
    HISTORICAL STATION 90 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL VENDOR 91 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL VENDOR PHONE 92 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL STREET ADD 93 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL CITY 94 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL STATE 95 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL ZIP 96 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Free Text
    HISTORICAL RECORD 97 This field is used for the consolidation sites, will contain the data that has been merged from a legacy system. This field is populated by the RMPRJ routine that is not exported.

    		Numeric
    PFSS ACCOUNT REFERENCE 100 This refers to the reference number passed back to Prosthetics application from the PFSS IBB get account process. This field points to PFSS ACCOUNT file (#375).

    		Pointer
    PointerTo:
    fileName:
    PFSS ACCOUNT
    fileNumber:
    375
    PFSS CHARGE ID 101 A unique charge identifier for each charge entity. Prosthetics calls $$GETCHGID^IBBAPI() to obtain a Unique Charge Identifier.

    		Numeric
    LATEST PSAS HCPCS 102 This is the latest PSAS HCPCS code that is held and stored for comparison during the account updates for the PFSS project.

    		Pointer
    PointerTo:
    fileName:
    PROSTHETIC HCPCS
    fileNumber:
    661.1
    LATEST QTY 103 This is the latest QTY that is held and stored for comparison during the account updates for the PFSS project.

    		Numeric
    LATEST TOTAL COST 104 This is the latest Total Cost that is held and stored for comparison during the account updates for the PFSS project.

    		Numeric
    LATEST ORDERING PROVIDER 105 This is the latest attending physician (ordering provider) that is held and stored for comparison during the account updates for the PFSS project.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PFSS ACCOUNT FLAG 106 Flag for ready to process PFSS Account Creation/Pre-Certification. 1 = Ready to process

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: READY TO PROCESS
    PFSS CHARGE FLAG 107 Flag for ready to process PFSS Charge message. 1 = Ready to process

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: READY TO PROCESS

    ECHO

    File Number: 691

    File Description:

    This file stores data on Echo procedures done on a patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the date and time when the echo was taken.

    		Date/Time
    ID .02 Enter any site specific unique identification number for this ECHO test. No need to enter the SSN. SSN is already recorded for this ECHO.

    		Free Text
    SUMMARY .03 This field identifies the result of the echo procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    SYMPTOM .04 This field identifies the medical patients symptoms listed on the procedure request form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 This field identifies the medical patients symptoms listed on the procedure request form.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 This field identifies the medical patient's risk factors listed on the procedure request form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 This field identifies the medical patients risk factors listed on the procedure request form.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    MEDICAL PATIENT 1 This field identifies the medical patient's name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    WT LBS 1.1 This field identifies the medical patient's weight in pounds.

    		Numeric
    SEX 1.15 This code tells the gender of the patient.

    		Computed
    HT IN 1.2 This field identifies the medical patient's height in inches.

    		Numeric
    BODY SURFACE AREA 2 This field identifies the patient's BSA, computed from patient's height and weight.

    		Numeric
    RESTING SYSTOLIC BP 3 This field identifies the patient's resting systolic blood pressure.

    		Numeric
    RESTING DIASTOLIC BP 4 This field identifies the patient's resting diastolic blood pressure.

    		Numeric
    RESTING HEART RATE 5 This field identifies the patient's resting heart rate.

    		Numeric
    RHYTHM 6 This field identifies the patient's current ECG/EKG rhythm.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NSR
    • Code : 2
      Stands For: A-FIB
    • Code : 3
      Stands For: OTHER
    STUDY QUALITY 7 This field identifies the technical quality of the procedure.

    		Numeric
    STUDY TYPE 7.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STUDY TYPE .01 This field is to track/monitor different types of echocardiographic studies.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: TRANSTHORACIC/TRANSCUTANEOUS
    • Code : 2
      Stands For: TEE
    • Code : 3
      Stands For: EXERCISE STRESS
    • Code : 4
      Stands For: PHARMACOLOGIC STRESS
    • Code : 5
      Stands For: INTRA-OPERATIVE
    • Code : 6
      Stands For: CONTRAST
    MED(CARDIOLOGY MEDICATION) 8 This field identifies the medications listed on the medical patient's request form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MED(CARDIOLOGY MEDICATION) .01 This field identifies the medications listed on the medical patients request form.

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This allows the user to enter dosage of medication listed on the medical patient's request form.

    		Free Text
    FREQUENCY 2 This allows the user to enter when/how often (frequency) medication is to be taken.

    		Free Text
    PRE-DX 9 This defines the medical patient's pre-diagnosis listed on the procedure request form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRE-DX .01 This defines the medical patients pre-diagnosis listed on the procedure request form.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: CAD
    • Code : 2
      Stands For: MYOCARDIAL INFARCT
    • Code : 3
      Stands For: VALVULAR DISEASE
    • Code : 4
      Stands For: SBE
    • Code : 5
      Stands For: HTN
    • Code : 6
      Stands For: CARDIOMYOPATHY
    • Code : 7
      Stands For: HCM
    • Code : 8
      Stands For: CHD
    • Code : 9
      Stands For: NORMAL
    • Code : 10
      Stands For: UNKNOWN
    COMMENT 10 This allows the user to make specific comments on a particular field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This allows the user to make specific comments on a particular field.

    		Word Processing
    SEPTUM 11 This allows the user to enter the dimensions of the ventricular septum.

    		Numeric
    POSTERIOR WALL 12 This allows the user to enter the dimensions of the posterior wall.

    		Numeric
    LT. ATRIUM 13 This allows the user to enter the dimensions of the left atrium.

    		Numeric
    AORTIC ROOT 14 This allows the user to enter the dimensions of the aortic root.

    		Numeric
    RT VENTRICLE 15 This allows the user to enter the dimensions of the right ventricle.

    		Numeric
    ANT. RV WALL 16 This allows the user to enter the dimensions of the anterior right ventricular wall.

    		Numeric
    LT. VENT. DIASTOLE 17 This allows the user to enter the internal left ventricular diastolic dimensions.

    		Numeric
    LT. VENT. SYSTOLE 18 This allows the user to enter the internal left ventricular systolic dimensions.

    		Numeric
    % FRACT. SHORTENING 19 This field identifies the computed percent shortening fraction of the left ventricular.

    		Computed
    E-SEPT. 20 This allows the user to enter the E-point of the mitral valve to septum dimensions.

    		Numeric
    LV XS AREA, MIT. SYST. 21

    		Numeric
    LV XS AREA, PAP. MUSC. SYST. 22

    		Numeric
    LV XS AREA, AP. 4-CH SYST. 23

    		Numeric
    LV XS AREA, MIT. DIAST. 24

    		Numeric
    LV XS AREA, PAP. MUSC. DIAST. 25

    		Numeric
    LV XS AREA, AP. 4-CH DIAST. 26

    		Numeric
    % FAS MITRAL LEVEL 27

    		Computed
    % FAS PAP. MUSCLE 28

    		Computed
    % FAS AP. 4-CH VIEW 29

    		Computed
    EDV 30 This allows the user to enter the left ventricular end diastolic volume.

    		Numeric
    ESV 31 This allows the user to enter the left ventricular end systolic volume.

    		Numeric
    ANGIOGRAPHIC CARDIAC OUTPUT 31.1 This field computes the Angiographic Cardiac Output from the Resting Heart Rate (#5), EDV (#30), and ESV (#31). The formula used is: Heart_Rate * ( EDV - ESV ).

    		Computed
    EF 32 This defines the computed left ventricular ejection fraction.

    		Computed
    ESTIMATED EF 32.1 This allows the user to enter the left ventricular ejection fraction.

    		Numeric
    ESTIMATED EF DESCRIPTOR 32.2 This allows the user to enter the estimated ejection fraction descriptor.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : I
      Stands For: INCREASED
    • Code : MIN
      Stands For: MINIMALLY DEPRESSED
    • Code : MOD
      Stands For: MODERATELY DEPRESSED
    • Code : S
      Stands For: SEVERELY DEPRESSED
    LV MASS 32.8

    		Computed
    REGIONAL WALL MOTION 33 This allows the user to enter multiple left ventricular regional wall abnormalities.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REGIONAL WALL MOTION .01 This allows the user to enter multiple left ventricular regional wall abnormalities.

    		Pointer
    PointerTo:
    fileName:
    REGIONAL WALL MOTION
    fileNumber:
    695.1
    MODIFIER 1 This allows the user to choose a descriptive code for type of regional wall abnormalities.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: HYPERKINETIC
    • Code : 2
      Stands For: NORMAL
    • Code : 3
      Stands For: MILDLY HYPOKINETIC
    • Code : 4
      Stands For: HYPOKINETIC
    • Code : 5
      Stands For: AKINETIC
    • Code : 6
      Stands For: DYSKINETIC
    • Code : 7
      Stands For: UNINTERPRETABLE
    DOPPLER 34 This allows the user to enter multiple doppler findings.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DOPPLER .01 This allows the user to enter multiple doppler findings.

    		Set of Codes
    Set of Codes:
    • Code : MR
      Stands For: MITRAL REGURGITATION
    • Code : TR
      Stands For: TRICUSPID REGURGITATION
    • Code : AR
      Stands For: AORTIC REGURGITATION
    • Code : PR
      Stands For: PULMONIC REGURGITATION
    SEVERITY 1 This allows the user to choose a descriptive code for type of doppler finding.

    		Set of Codes
    Set of Codes:
    • Code : MI
      Stands For: MILD
    • Code : MO
      Stands For: MODERATE
    • Code : S
      Stands For: SEVERE
    • Code : TR
      Stands For: TRACE
    • Code : N
      Stands For: NONE
    AORTIC MAX VELOCITY 34.1 This allows the user to enter the calculated aortic maximum velocity.

    		Numeric
    AORTIC MEAN VELOCITY 34.2 This allows the user to enter the calculated mean velocity.

    		Numeric
    AORTIC INTEGRAL 34.3 This allows the user to enter the calculated aortic valve integral.

    		Numeric
    LVOT MAX VELOCITY 34.4 This allows the user to enter the left ventricular outflow tract maximum velocity.

    		Numeric
    LVOT MEAN VELOCITY 34.5 This allows the user to enter the left ventricular outflow tract mean velocity.

    		Numeric
    LVOT INTEGRAL 34.6 This allows the user to enter the left ventricular outflow tract integral.

    		Numeric
    AORTIC MAX PRESSURE GRADIENT 34.7 This defines the computed aortic valve maximum pressure gradient.

    		Computed
    AORTIC MEAN PRESSURE GRADIENT 34.8 This allows the user to enter the aortic valve mean pressure gradient.

    		Numeric
    AORTIC ESTIMATED VALVE ORIFICE 34.9 This allows the user to enter the calculated aortic valve estimated orifice.

    		Numeric
    MITRAL MAX VELOCITY 35 This allows the user to enter the calculated mitral valve maximum velocity.

    		Numeric
    MITRAL MEAN VELOCITY 35.1 This allows the user to enter the mitral valve mean velocity.

    		Numeric
    MITRAL INTEGRAL 35.2 This allows the user to enter the mitral valve calculated integral.

    		Numeric
    MITRAL MAX GRADIENT 35.3 This defines the computed mitral valve maximum gradient.

    		Computed
    MITRAL MEAN GRADIENT 35.4 This allows the user to enter the mitral valve mean gradient.

    		Numeric
    MITRAL P 1/2 35.5 This allows the user to enter the mitral valve P-1/2 time.

    		Numeric
    MITRAL EST VALVE ORIFICE 35.6 This defines the computed mitral valve estimated orifices.

    		Numeric
    COMPUTED MITRAL VALVE ORIFICE 35.65 This defines the computed mitral valve orifices.

    		Computed
    PULMONIC MAX VELOCITY 35.7 This allows the user to enter the calculated pulmonic valve maximum velocity.

    		Numeric
    PULMONIC MEAN VELOCITY 35.8 This allows the user to enter the calculated pulmonic valve mean velocity.

    		Numeric
    PULMONIC INTEGRAL 35.9 This allows the user to enter the calculated pulmonic valve integral.

    		Numeric
    PULMONIC MAX PRESSURE GRADIENT 36 This field identifies the computed pulmonic valve maximum pressure gradient.

    		Computed
    PULMONIC MEAN GRADIENT 36.1 This allows the user to enter the calculated pulmonic valve mean gradient.

    		Numeric
    TRICUS DIAS MAX VEL (m/s) 36.2 This allows the user to enter the calculated tricuspid valve maximum velocity.

    		Numeric
    TRICUSPID MEAN VELOCITY 36.3 This field quantifies the average speed of tricuspid valve flow.

    		Numeric
    TRICUS DIAS MAX PRESS GRAD 36.31 This field is computed

    		Computed
    TRICUS REGURG SYS MAX VEL(m/s) 36.4 This allows the user to enter the calculated tricuspid valve integral.

    		Numeric
    PA SYSTOLIC PRESSURE 36.5 This field identifies is the Pulmonary Artery Wedge Pressure in millimeters of Mercury.

    		Numeric
    TRICUSPID MEAN GRADIENT 36.6 This field identifies the average Tricuspid gradient.

    		Numeric
    FINDINGS 37 This allows the user to enter multiple interpreted echo findings.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FINDINGS .01 This allows the user to enter multiple interpreted echo findings.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DESCRIPTION
    fileNumber:
    693
    DIAGNOSIS 37.5 This allows the user to enter multiple interpreted echo diagnoses.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01 This allows the user to enter multiple interpreted echo diagnosis.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    OTHER CONCLUSION 38 This allows the user to enter additional comments on the findings and diagnosis fields.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER CONCLUSION .01 This allows the user to enter additional comments on the findings and diagnosis fields.

    		Word Processing
    CARDIOLOGY ATTENDING 39 This field identifies the physician who interpreted the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    WARD/CLINIC 40 This allows the user to enter the medical patients location.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    ONSET DATE ATRIAL FIB 41 This allows the user to enter the date of the onset of the patient's atrial fibrillation ECG/EKG rhythm.

    		Date/Time
    DURATION ATRIAL FIB 42 This allows the user to enter the duration of the atrial fibrillation ECG/EKG rhythm.

    		Free Text
    CARDIOLOGY FELLOW 43 This field identifies one of the key members of the clinical staff assigned to follow this patient.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    STUDY PHASE 44

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: PRE-CV
    • Code : 2
      Stands For: POST-CV
    • Code : 3
      Stands For: 1 MON CV
    • Code : 4
      Stands For: 6 MON CV
    CARDIOVERSION DATE 45

    		Date/Time
    RHYTHM 2 46

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: A-FIB
    • Code : 2
      Stands For: A-FLUTTER
    • Code : 3
      Stands For: NSR
    PROCEDURE SUMMARY 600 This allows the user to enter the procedure summary information.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. This field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. This field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC VISIT file for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500 This field contains the provider who enter the information into the database.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETATION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETATION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Date/Time
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric
    IMAGE 2005 This field points to an entry in the image file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This fields points to an object in the Image File.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    CARDIAC CATHETERIZATION

    File Number: 691.1

    File Description:

    THIS FILE STORES THE DATA ON 'CATHERIZATIONS' DONE ON PATIENTS


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This date/time field identifies the catheterization procedure.

    		Date/Time
    ID .02 This field identifies the patient's identification number assigned by the medical facility. In most cases it is the person's social security number.

    		Free Text
    SUMMARY .03 This fields contains the gross evaluation of the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    SYMPTOM .04 This field contains the patient's physical complaints or symptoms.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 This field contains the patient's physical complaints or symptoms.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 This field contains the morbidity factors which this patient is most susceptible to.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 This field contains the morbidity factors which this patient is most susceptible to.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    MEDICAL PATIENT 1 This field identifies the name of the patient followed by a space(optional), followed by the first name, followed by a space, followed by the middle initial.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    WT LBS 1.1 The weight of the patient at the time of the procedure is stored here.

    		Numeric
    HT IN 1.2 The height in inches at the time of the procedure.

    		Numeric
    BODY SURFACE AREA 1.3 This field identifies parameter is calculated by height and weight and stored in square meters.

    		Numeric
    CATH NUMBER 3 This allows the user to enter the cardiac catheterization procedure number.

    		Free Text
    REFERRING PHYSICIAN/AGENCY 4 This allows the user to enter the referring physician/agency/hospital's name.

    		Pointer
    PointerTo:
    fileName:
    REFERRING PHYSICIAN/AGENCY
    fileNumber:
    697.1
    WARD/CLINIC 5 This field identifies the in-house patient address.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    CCL LOG PROCEDURE 6 This allows the user to enter the cardiac catheterization procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CCL LOG PROCEDURE .01 This allows the user to enter the cardiac catheterization procedure.

    		Pointer
    PointerTo:
    fileName:
    CATH PROCEDURE
    fileNumber:
    695.3
    TECH COMMENT 7 This allows the cardiac cath. technician to enter comments pertaining to the procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TECH COMMENT .01 This allows the cardiac cath technician to enter comments pertaining to the procedure.

    		Word Processing
    PROCEDURE 8 This allows the user to enter multiple cardiac cath. procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROCEDURE .01 This allows the user to enter multiple cardiac cath procedure.

    		Pointer
    PointerTo:
    fileName:
    CATH PROCEDURE
    fileNumber:
    695.3
    HISTORY 9 This allows the user to enter a brief medical history.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HISTORY .01 This allows the user to enter a brief medical history.

    		Word Processing
    HEART MEDICATION 11 This field documents the cardiac medicines that the patient is taking at the time of this procedure. (multiple)

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART MEDICATION .01 This field documents the cardiac medicines that the patient is taking at the time of this procedure. (multiple)

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This allows the user to enter dosage of cardiac medicine given.

    		Free Text
    FREQUENCY 2 This allows the user to enter when/number of times (frequency) patient should be given cardiac medicine.

    		Free Text
    PHYSICAL EXAM 12 This allows the user to enter data obtained from medical patient's physical examination.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PHYSICAL EXAM .01 This allows the user to enter a data obtain from medical patient's physical examination.

    		Word Processing
    INDICATION 13 This allows the user to enter multiple pre-cardiac catheterization diagnoses.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INDICATION .01 This allows the user to enter multiple pre-cardiac catheterization diagnosis.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    PREMEDICATION 15 This allows the user to enter multiple pre-cardiac catheterization medications.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMEDICATION .01 This allows the user to enter multiple pre-cardiac catheterization medications.

    		Set of Codes
    Set of Codes:
    • Code : V
      Stands For: DIAZEPAM
    • Code : B
      Stands For: DIPHENHYDRAMINE
    • Code : S
      Stands For: STEROIDS
    • Code : N
      Stands For: NONE
    VASCULAR ACCESS 16 This allows the user to enter multiple cardiac catheterization vascular accesses.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VASCULAR ACCESS .01 This allows the user to enter multiple cardiac catheterization vascular accesses.

    		Set of Codes
    Set of Codes:
    • Code : RFA
      Stands For: RIGHT FEMORAL ARTERY
    • Code : RFV
      Stands For: RIGHT FEMORAL VEIN
    • Code : LFA
      Stands For: LEFT FEMORAL ARTERY
    • Code : LFV
      Stands For: LEFT FEMORAL VEIN
    • Code : RBA
      Stands For: RIGHT BRACHIAL ARTERY
    • Code : RBV
      Stands For: RIGHT BRACHIAL VEIN
    • Code : LBA
      Stands For: LEFT BRACHIAL ARTERY
    • Code : LBV
      Stands For: LEFT BRACHIAL VEIN
    FLUORO TIME 17 This allows the user to enter catheterization fluoroscopy time.

    		Numeric
    USE OF SHEATH 18 This defines the use of a sheath during cardiac catheterization.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ARTERY
    • Code : V
      Stands For: VEIN
    • Code : B
      Stands For: BOTH ARTERY AND VEIN
    • Code : N
      Stands For: NEITHER ARTERY NOR VEIN
    RIGHT HEART CATHETER 19 This allows the user to enter the specific right heart catheter used.

    		Set of Codes
    Set of Codes:
    • Code : C
      Stands For: 7F COURNAND
    • Code : Z
      Stands For: 7F ZUCKER
    • Code : S
      Stands For: 7F SWAN GANZ
    • Code : E
      Stands For: 7F EPPENDORF
    LEFT VENTRICULAR CATHETER 20 This allows the user to enter multiple left ventricular catheters used.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LEFT VENTRICULAR CATHETER .01 This allows the user to enter multiple left ventricular catheters used.

    		Pointer
    PointerTo:
    fileName:
    HEART CATHETER
    fileNumber:
    695.6
    ADEQUATE 1 This allows the user to enter the adequacy of the left ventricular catheter used.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ADEQUATE
    • Code : 2
      Stands For: POOR
    • Code : 3
      Stands For: INADEQUATE
    RIGHT CORONARY CATHETER 21 This allows the user to enter multiple right coronary catheters used.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RIGHT CORONARY CATHETER .01 This allows the user to enter multiple right coronary catheters used.

    		Pointer
    PointerTo:
    fileName:
    HEART CATHETER
    fileNumber:
    695.6
    ADEQUACY OF ENGAGEMENT 1 This allows the user to enter the adequacy of the right coronary catheter used.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ADEQUATE
    • Code : 2
      Stands For: POOR
    • Code : 3
      Stands For: INADEQUATE
    LEFT CORONARY CATHETER 22 This allows the user to enter multiple left coronary catheters used.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LEFT CORONARY CATHETER .01 This allows the user to enter multiple left coronary catheters used.

    		Pointer
    PointerTo:
    fileName:
    HEART CATHETER
    fileNumber:
    695.6
    ADEQUACY OF ENGAGEMENT 1 This allows the user to enter the adequacy of the left coronary catheter used.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ADEQUATE
    • Code : 2
      Stands For: POOR
    • Code : 3
      Stands For: INADEQUATE
    AORTOGRAPHY PROJECTION 23 This field identifies the view of the aortography projection.

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LAO
    • Code : R
      Stands For: RAO
    OTHER PROCEDURE AND COMMENT 24 This allows the user to enter unspecified procedures and comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER PROCEDURE AND COMMENT .01 This allows the user to enter unspecified procedures and comments.

    		Word Processing
    PROTAMINE 25 This allows the user to enter the protamine used during the cardiac catheterization.

    		Free Text
    INTERVENTION 26 This allows the user to enter multiple cardiac catheterization interventions.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERVENTION .01 This allows the user to enter multiple cardiac catheterization interventions.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: BASELINE
    • Code : 2
      Stands For: POST CONTRAST
    • Code : 3
      Stands For: AFTER EXERCISE
    • Code : 4
      Stands For: AFTER DRUGS
    • Code : 9
      Stands For: OTHER
    OTHER INTERVENTION COMMENT .5 This allows the user to enter comments about cardiac catheteriztion interventions used.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER INTERVENTION COMMENT .01 This allows the user to enter comments about cardiac catheterization interventions used.

    		Word Processing
    RA A WAVE 1 This allows the user to enter the right atrial A wave pressure.

    		Numeric
    RA V WAVE 2 This allows the user to enter the right atrial V wave pressure.

    		Numeric
    RA MEAN PRESSURE 3 This field identifies the right atrial mean pressure measured in millimeters of mercury.

    		Numeric
    RA SATURATION 4 This allows the user to enter the amount of oxygen in the right atrial blood sample.

    		Numeric
    RV SYSTOLIC 5 This allows the user to enter the right ventrical systolic pressure.

    		Numeric
    RV DIASTOLIC 6 This allows the user to enter the right ventrical diastolic pressure.

    		Numeric
    RV SATURATION 7 This allows the user to enter the amount of oxygen in the right ventricular blood sample.

    		Numeric
    PA SYSTOLIC 8 This allows the user to enter the pulmonary artery systolic pressure.

    		Numeric
    PA DIASTOLIC 9 This allows the user to enter the pulmonary artery diastolic pressure.

    		Numeric
    PA MEAN 10 This allows the user to enter the pulmonary artery mean pressure in millimeters of mercury.

    		Numeric
    PA SATURATION 11 This allows the user to enter the amount of oxygen found in the pulmonary artery blood sample.

    		Numeric
    PCW A WAVE 12 This allows the user to enter the pulmonary capillary A wave pressure.

    		Numeric
    PCW V WAVE 13 This allows the user to enter the pulmonary capillary V wave pressure.

    		Numeric
    PCW MEAN 14 This allows the user to enter the pulmonary capillary mean pressure.

    		Numeric
    LA A WAVE 15 This allows the user to enter the left atrial A wave pressure.

    		Numeric
    LA V WAVE 16 This allows the user to enter the left atrial V wave pressure.

    		Numeric
    LA MEAN PRESSURE 17 This allows the user to enter the left atrial mean pressure.

    		Numeric
    LA SATURATION 18 This allows the user to enter the amount of oxygen found in the left atrial blood sample.

    		Numeric
    LV PRE A 19 This allows the user to enter the left ventricular pre-wave A pressure.

    		Numeric
    LV END DIASTOLIC (Z) 20 This allows the user to enter the left ventricular end diastolic post contrast.

    		Numeric
    LV SYSTOLIC 21 This allows the user to enter the left ventricular systolic post contrast pressure.

    		Numeric
    LV SATURATION 22 This allows the user to enter the amount of oxygen found in the left ventricular blood sample.

    		Numeric
    LV SYSTOLIC POST CONTRAST 23 This allows the user to enter the left ventricular systolic post contrast pressure.

    		Numeric
    LV PRE A POST CONTRAST 24 This allows the user to enter the left ventricular pre-A wave post contrast.

    		Numeric
    LV END DIAST (Z) POST CONTRAST 25 This allows the user to enter the left ventricular end diastolic post contrast.

    		Numeric
    LV SATURATION POST CONTRAST 26 This allows the user to enter the amount of oxygen found in the left ventricular post contrast blood sample.

    		Numeric
    AORTIC SYSTOLIC 27 This allows the user to enter the aortic systolic pressure.

    		Numeric
    AORTIC DIASTOLIC 28 This allows the user to enter the aortic diastolic pressure.

    		Numeric
    AORTIC MEAN PRESSURE 29 This allows the user to enter the aortic mean pressure measured in millimeters or mercury.

    		Numeric
    AORTIC SATURATION 30 This allows the user to enter the amount of oxygen found in the aortic blood sample.

    		Numeric
    SVC PRESSURE 31 This allows the user to enter the superior vena cava pressure.

    		Numeric
    SVC SATURATION 32 This allows the user to enter the amount of oxygen found in the superior vena cava blood sample.

    		Numeric
    IVC MEAN PRESSURE 33 This allows the user to enter the inferior vena cava mean pressure.

    		Numeric
    IVC SATURATION 34 This allows the user to enter the amount of oxygen found in the inferior vena cava blood sample.

    		Numeric
    C O, ASSUMED FICK, L/MIN 35 This allows the user to enter cardiac output, assuming fick is a method of performing cardiac output.

    		Numeric
    C I, ASS FICK L/MIN/M2 36 This cardiac index is computed from the cardiac output, assuming fick is a method of performing cardiac output.

    		Computed
    C O, INDO GREEN, L/MIN 38 This allows the user to enter cardiac output, assuming indo green is a method of measuring cardiac output.

    		Numeric
    C I, INDO GREEN, L/MIN/M2 39 This field identifies computed from the cardiac output, assuming indo green is a method of measuring cardiac output.

    		Computed
    C O, THERMO, L/MIN 40 This allows the user to enter cardiac output, assuming thermo is a method of measuring cardiac output.

    		Numeric
    C I, THERMO, L/MIN/M2 41 This field identifies computed from the cardiac output, assuming thermo is a method of measuring cardiac output.

    		Computed
    M V AREA, CM2 42 This allows the user to enter the mitral valve area, entered in centimeters squared.

    		Numeric
    M V PEAK GRADIENT 43 This allows the user to enter the mitral valve peak gradient.

    		Numeric
    M V MEAN GRADIENT 44 This allows the user to enter the mitral valve mean gradient.

    		Numeric
    A V AREA, CM2 45 This allows the user to enter the aortic valve area, entered in centimeters squared.

    		Numeric
    A V INDEX, CM2/M2 46 The aortic valve index is calculated from the aortic valve area and the body surface area.

    		Computed
    A V PEAK GRADIENT 47 This allows the user to enter the aortic valve peak gradient.

    		Numeric
    A V MEAN GRADIENT 48 This allows the user to enter the aortic valve mean gradient.

    		Numeric
    SYSTEMIC FLOW 49 This allows the user to enter the systemic flow, the blood flow on the left side of the cardiac system.

    		Numeric
    PULMONARY FLOW 50 This allows the user to enter the pulmonary flow, the blood flow on the right side of the cardiac system.

    		Numeric
    P/S RATIO 51 This field identifies to the pulmonary flow/systemic flow ratio.

    		Numeric
    L-R SHUNT 52 This allows the user to enter the L-R shunt, which refers to the abnormal flow where the interventricular septum or atrial septum is involved. These entries are in millimeters of mercury.

    		Numeric
    R-L SHUNT 53 This allows the user to enter the R-L shunt, which refers to the abnormal flow where the interventricular septum or atrial septum is involved. These entries are in millimeters of mercury.

    		Numeric
    PULM RESIST 54 This field shows the Pulmonary Resistance.

    		Numeric
    SYSTEMIC RESIST 55 This field shows the Systemic Resistance.

    		Numeric
    RCA NORMALITY 27 This allows the user to enter the right coronary artery normality.

    		Pointer
    PointerTo:
    fileName:
    NORMALITY OF CORONARY VESSEL
    fileNumber:
    695.9
    RCA SEGMENT 28 This allows the user to enter multiple right coronary artery segments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RCA SEGMENT .01 This allows the user to enter multiple right coronary artery segments.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    PERCENT NARROWING 1 This allows the user to enter percent narrowing of the RCA segment.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    PERCENT NARROWING NUMBER 1.5 This allow the user tp enter percent narrowing of the RCA segment.

    		Numeric
    MORPHOLOGY 2 This allows the user to enter the lesion morphology.

    		Pointer
    PointerTo:
    fileName:
    LESION MORPHOLOGY
    fileNumber:
    696.2
    RCA DISTAL VESSEL 29 This allows the user to enter the right coronary artery distal vessel.

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY OF DISTAL VESSEL
    fileNumber:
    696.3
    RCA COLLATERAL 30 This allows the user to enter the right coronary artery collateral vessel.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PRESENT
    • Code : N
      Stands For: NOT PRESENT
    RCA ORIGIN OF COLLATERAL 31 This allows the user to enter multiple right coronary artery origins of collateral vessels.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RCA ORIGIN OF COLLATERAL .01 This allows the user to enter multiple right coronary artery origin of collateral vessel.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    RECEIVING VESSEL 1 This allows the user to enter the receiving vessel.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    LEFT MAIN CA NORMALITY 32 This allows the user to enter the left main coronary artery normality.

    		Pointer
    PointerTo:
    fileName:
    NORMALITY OF CORONARY VESSEL
    fileNumber:
    695.9
    LMCA NARROWING 33 This allows the user to enter multiple left main coronary artery narrowings.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LMCA NARROWING .01 This allows the user to enter multiple left main coronary artery narrowing.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    MORPHOLOGY 1 This allows the user to enter lesion morphology.

    		Pointer
    PointerTo:
    fileName:
    LESION MORPHOLOGY
    fileNumber:
    696.2
    LMCA NARROWING # 33.5 This allows the user to enter multiple left main coronary artery narrowings.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LMCA NARROWING # .01 This allows the user to enter a left main coronary artery narrowing.

    		Numeric
    MORPHOLOGY 1 This field describes the the disease process which caused the lumenal occlusion.

    		Pointer
    PointerTo:
    fileName:
    LESION MORPHOLOGY
    fileNumber:
    696.2
    LAD NORMALITY 34 This allows the user to enter the left anterior descending coronary artery normality.

    		Pointer
    PointerTo:
    fileName:
    NORMALITY OF CORONARY VESSEL
    fileNumber:
    695.9
    LAD SEGMENT 35 This allows the user to enter multiple left anterior descending coronary artery segments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAD SEGMENT .01 This allows the user to enter multiple left anterior decending coronary artery segments.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    PERCENT NARROWING 1 This allows the user to enter the percent narrowing of the left anterior descending coronary artery segment.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    PERCENT NARROWING # 1.5 This field represents the fraction of the vessels lumenal space which has been occluded by disease.

    		Numeric
    MORPHOLOGY 2 This allows the user to enter the lesion morphology.

    		Pointer
    PointerTo:
    fileName:
    LESION MORPHOLOGY
    fileNumber:
    696.2
    LAD DISTAL VESSELS 36 This allows the user to enter the left anterior descending distal vessels.

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY OF DISTAL VESSEL
    fileNumber:
    696.3
    LAD COLLATERALS 37 This allows the user to enter left anterior descending collateral vessels.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NONE
    • Code : P
      Stands For: PRESENT
    LAD ORIGIN OF COLLATERALS 38 This allows the user to enter the left anterior descending arterial origin of collaterals (multiple).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAD ORIGIN OF COLLATERALS .01 This allows the user to enter the left anterior descending arterior origin of collaterals (multple).

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    RECEIVING VESSEL 1 This allows the user to enter the receiving vessel.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    CIRCUMFLEX NORMALITY 39 This allows the user to enter the circumflex coronary normality.

    		Pointer
    PointerTo:
    fileName:
    NORMALITY OF CORONARY VESSEL
    fileNumber:
    695.9
    CIRCUMFLEX SEGMENT 40 This allows the user to enter multiple circumflex artery segments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CIRCUMFLEX SEGMENT .01 This allows the user to enter multiple circumflex artery segments.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    PERCENT NARROWING 1 This allows the user to enter the percent narrowing of the circumflex artery segment.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    PERCENT NARROWING # 1.5 This allows the user to enter the percent narrowing of the circumflex artery segment.

    		Numeric
    MORPHOLOGY 2 This allows the user to enter the lesion morphology.

    		Pointer
    PointerTo:
    fileName:
    LESION MORPHOLOGY
    fileNumber:
    696.2
    CIRCUMFLEX DISTAL VESSEL 41 This allows the user to enter circumflex coronary artery distal vessels.

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY OF DISTAL VESSEL
    fileNumber:
    696.3
    CIRCUMFLEX COLLATERALS 42 This allows the user to enter the circumflex coronary artery collaterals.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NONE
    • Code : P
      Stands For: PRESENT
    CIR. ORIGIN OF COLLATERALS 43 This allows the user to enter the origin of circumflex collaterals. (multiple)

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORIGIN OF COLLATERALS .01 This allows the user to enter the origin of circumflex collaterals. (multiple)

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    RECEIVING VESSEL 1 This allows the user to enter the receiving vessel.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    FLUOROSCOPY 44 This allows the user to enter multiple visualizations of calcium noted during the cardiac cath.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FLUOROSCOPY .01 This allows the user to enter multiple visualization of calcium noted during the cardiac cath.

    		Set of Codes
    Set of Codes:
    • Code : AV
      Stands For: CALCIUM IN AREA OF AORTIC VALVE
    • Code : MV
      Stands For: CALCIUM IN AREA OF MITRAL VALVE
    • Code : MA
      Stands For: CALCIUM IN AREA OF MITRAL ANNULUS
    • Code : LC
      Stands For: CALCIUM IN AREA OF LEFT CORONARIES
    • Code : RC
      Stands For: CALCIUM IN AREA OF RIGHT CORONARIES
    • Code : NO
      Stands For: NO CALCIUM NOTED
    DOMINANCE 45 This allows the user to enter the dominant coronary tree.

    		Set of Codes
    Set of Codes:
    • Code : L
      Stands For: LEFT DOMINANCE
    • Code : R
      Stands For: RIGHT DOMINANCE
    • Code : B
      Stands For: BALANCED DOMINANCE
    BYPASS GRAFT? 46 This allows the user to enter the presence of coronary bypass grafts.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NOT PRESENT
    • Code : P
      Stands For: PRESENT
    DISTAL ANASTOMOSIS 47 This allows the user to enter multiple distal anastomosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISTAL ANASTOMOSIS .01 This allows the user to enter multiple distal anastamosis.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    PERCENTAGE LESION 1 This allows the user to enter the percentage lesion of the distal anastamosis.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    PERCENTAGE LESION # 1.5 This allows the user to enter the percentage lesion of the distal anastamosis.

    		Numeric
    LOCATION OF LESION 2 This allows the user to enter the location of the lesion of the distal anastamosis.

    		Pointer
    PointerTo:
    fileName:
    BYPASS GRAFT SEGMENT
    fileNumber:
    696.4
    ANGIOPLASTY SEGMENT 48 This allows the user to enter multiple angioplasty segments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SEGMENT IF ANGIOPLASTY DONE .01 This allows the user to enter multiple angioplasty segments.

    		Pointer
    PointerTo:
    fileName:
    SEGMENT OF CORONARY ARTERIES
    fileNumber:
    696
    STARTING % OBSTRUCTION 1 This allows the user to enter the starting percent obstruction.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    STARTING % OBSTRUCTION # 1.5 This allow the user to enter the starting percent obstruction.

    		Numeric
    RESULTING % OBSTRUCTION 2 This allows the user to enter the resulting percent obstruction.

    		Pointer
    PointerTo:
    fileName:
    PERCENTAGE LESION
    fileNumber:
    696.1
    RESULTING % OBSTRUCTION # 2.5 This allows the user to enter the resulting percent obstruction.

    		Numeric
    STARTING GRADIENT 3 This allows the user to enter the starting gradient.

    		Numeric
    RESULTING GRADIENT 4 This allows the user to enter the resulting gradient.

    		Numeric
    INFLATION PRESSURE IN ATM 5 This allows the user to enter inflation pressure in ATM.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INFLATION PRESSURE .01 This field identifies between 0 and 99

    		Numeric
    INFLATION TIME IN SEC. 1 This allows the user to enter the inflation time in seconds.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INFLATION TIME IN SEC. .01 This allows the user to enter the inflation time in seconds

    		Numeric
    TOTAL INFLATION TIME (SEC) 6 This allows the user to enter the total inflation time in seconds.

    		Numeric
    LEFT VENTRICULOGRAPHY 49 This field identifies the field used to enter the performance of a left ventriculography.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : G
      Stands For: GLOBAL HYPOKINESIS
    • Code : NO
      Stands For: NOT PERFORMED
    LEFT VENTRICULAR WALL MOTION 50 This allows the user to enter multiple LV wall motion normalities.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LEFT VENTRICULAR WALL MOTION .01 This allows the user to enter multiple LV wall motion normality.

    		Pointer
    PointerTo:
    fileName:
    LEFT VENTRICULOGRAPHY
    fileNumber:
    696.5
    DESCRIPTION 1 This allows the user to describe by codes the left ventricular wall motion.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NORMAL
    • Code : 2
      Stands For: HYPOKINETIC
    • Code : 3
      Stands For: AKINETIC
    • Code : 4
      Stands For: DYSKINETIC
    • Code : 5
      Stands For: ANEURYSMAL
    • Code : 6
      Stands For: MILDLY HYPOKINETIC
    • Code : 7
      Stands For: SEVERELY HYPOKINETIC
    MITRAL REGURGITATION 51 This allows the user to enter the presence of mitral regurgitation.

    		Pointer
    PointerTo:
    fileName:
    MITRAL REGURG ON LV GRAM
    fileNumber:
    696.7
    MITRAL REGURGITANT FRACTION 51.5 This allows the user to enter the mitral regurgitation fraction.

    		Numeric
    AORTIC REGURGITANT FRACTION 51.6 This allows the user to enter aortic regurgitant fraction.

    		Numeric
    TOTAL REGURGITANT FRACTION 51.7 This defines the computed total regurgitant fraction.

    		Numeric
    THROMBUS OM LV GRAM 52 This allows the user to enter presence of a LV thrombus.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    LV EJECTION FRACTION 53 This allows the user to enter the calculated LV ejection fraction.

    		Numeric
    AORTOGRAPHY 54 This allows the user to enter the aortography projection.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: 1+
    • Code : 2
      Stands For: 2+
    • Code : 3
      Stands For: 3+
    • Code : 4
      Stands For: 4+
    • Code : 5
      Stands For: 5+
    AORTIC ROOT 55 This allows the user to enter the aortic root dimensions normality.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : D
      Stands For: DILATED
    SINUSES OF VALSALVA 56 This allows the user to enter number of sinuses of valsalva.

    		Set of Codes
    Set of Codes:
    • Code : 2
      Stands For: 2 SINUSES OF VALSALVA
    • Code : 3
      Stands For: 3 SINUSES OF VALSALVA
    BYPASS GRAFTS 57 This allows the user to enter number of coronary bypass grafts.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: ONE
    • Code : 2
      Stands For: TWO
    • Code : 3
      Stands For: THREE
    • Code : 4
      Stands For: FOUR
    • Code : 5
      Stands For: FIVE
    COMPLICATION 58 This allows the user to enter multiple cardiac cath. complications.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMPLICATION .01 This allows the user to enter multiple cardiac cath complication.

    		Pointer
    PointerTo:
    fileName:
    COMPLICATION
    fileNumber:
    696.9
    INTERPRETATION 59 This allows the user to enter the final interpretation of the cardiac cath.

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    CONCLUSION 60 This allows the user to enter specific statements in reference to the cardiac cath.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CONCLUSION .01 This allows the user to enter specific statements inreference to the cardiac cath.

    		Word Processing
    PLAN 61 This allows the user to enter specific statements in reference to the patient's management plan.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLAN .01 This allows the user to enter specific statements inreference to the patients management plan.

    		Word Processing
    CARDIOLOGY FELLOW 62 This allows the user to enter the primary cardiology fellow.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY STAFF 63 This allows the user to enter the primary physician in attendance.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY FELLOW-2ND 64 This allows the user to enter the secondary cardiology fellow.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY STAFF-2ND 65 This allows the user to enter the secondary physician in attendance.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PROCEDURE SUMMARY 600 This field will be displayed in the summary areas of Order Entry/Results Reporting and Health Care Summaries.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02 This field allows the provider to add comments to the diagnostic findings.

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MARKED FOR DELETION 899 This field is used by lookup operations to screen out such records from general access by the electronic medical record. The functionality allows this record to remain in the system for auditing purposes.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARKED FOR DELETION
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC VISIT file for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500 This field identifies the individual who created this version of the record, the last person to edit the entree.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ENTERING ELECTRONIC SIGNATURE 1501 This is the scrambled electronic signature.

    		Free Text
    ENTERING DATE 1502 This is the date and time that the record was entered.

    		Date/Time
    VERIFYING DUZ 1503 This is the New Person file identifier of the person releasing the record. The person entering the electronic signature is captured here.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    VERIFIER ELECTRONIC SIGNATURE 1504 This is the electronic signature of the verifier.

    		Free Text
    VERIFIER DATE 1505 This is the date that the record was verified.

    		Date/Time
    RELEASE CODE 1506 This field controls the release status of the record.

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASE ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASE OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASE NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: SUPERSEDING RELEASE ON-LINE VERIFIED
    • Code : SROV
      Stands For: SUPERSEDING RELEASE OFF-LINE VERIFIED
    DATE OF RELEASED 1507 This is the date that the record was released to the general medical record viewer.

    		Date/Time
    DATE OF VERIFIED 1508 This is the date and time that the procedure was signed electronically.

    		Date/Time
    SUPERSEDED 1509 This indicator controls the process of superseding released records which require addendums or changes. This functionality allows an auditing of information which has been available for the medical record.

    		Numeric
    SUPERSEDED BY 1510 This field directs the flow of supersessions of records.

    		Numeric
    MARKED FOR DELETION 1511 This field allows the record to remain in the database but screened from the medical record.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARKED FOR DELETION
    DELETER DUZ 1512 This field documents the identity of the deleter.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513 This is the date and time that the supersession took place.

    		Free Text
    RECORD CREATATION DATE 1514 This field stores the date the original file entry for this procedure was made.

    		Date/Time
    SUPERSEDED NUMBER 1515 This value documents the sequence number of record revisions.

    		Numeric
    IMAGE 2005 This field points to an entry in the image file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This field points to an entry in the image file.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    RESTING HEART RATE 2006 This field identifies the patient's resting heart rate.

    		Numeric
    END DIASTOLIC VOLUME 2007 This allows the user to enter the left ventricular diastolic volume.

    		Numeric
    END SYSTOLIC VOLUME 2008 This allows the user to enter the left ventricular end systolic volume.

    		Numeric
    CARDIAC OUTPUT 2009 This field computes the Angiographic Cardiac Output from the Resting Heart Rate (#2006), EDV (#2007), and ESV (#2008). The formula used is: Heart_Rate * (EDV - ESV).

    		Computed

    ELECTROCARDIOGRAM (EKG)

    File Number: 691.5

    File Description:

    This file stores data on EKGs done on a patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the specific EKG procedure.

    		Date/Time
    ID .02 This field identifies the patient's identification number assigned by the medical facility. In most cases it is the person's social security number.

    		Free Text
    SUMMARY .03 This field contains the gross evaluation of the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : T
      Stands For: TECHNICALLY UNSATISFACTORY
    SYMPTOM .04 This field contains the patient's physical complaints or symptoms.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 This field contains the patient's physical complaints or symptoms.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    HEART MED .06 This field documents the cardiac medicines that the patient is taking at the time of this procedure (multiple).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART MED .01 This field documents the cardiac medicines that the patient is taking at the time of this procedure (multiple).

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This allows the user to enter in the dosage for the cardiac medicine that the patient is taking at the time of this procedure.

    		Free Text
    FREQUENCY 2 This allows the user to enter the time/number of times the patient is to take the cardiac medicine.

    		Free Text
    WEIGHT (LBS) .07 The weight of the patient at the time of the procedure is stored here.

    		Numeric
    HEIGHT (INCHES) .08 The height of the patient in inches at the time of the procedure.

    		Numeric
    MEDICAL PATIENT 1 This field identifies the patient's last name followed by a comma, followed by a space(optional), followed by the first name, followed by a space, followed by the middle initial.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    TYPE OF EKG 2 This allows the user to enter the type of ECG/EKG.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: STAT RETRIEVAL
    • Code : R
      Stands For: ROUTINE
    • Code : O
      Stands For: ORIGINAL
    VENT. RATE 3 This allows the user to enter the ventricular rate.

    		Numeric
    PR INTERVAL 4 This allows the user to enter ECG/EKG PR interval.

    		Numeric
    QRS DURATION 5 This allows the user to enter the ECG/EKG QRS duration.

    		Numeric
    QT 6 This allows the user to enter the QT interval.

    		Numeric
    QTC 7 This allows the user to enter the QTC interval.

    		Numeric
    P AXIS 8 This allows the user to enter the P axis.

    		Numeric
    R AXIS 9 This allows the user to enter the R axis.

    		Numeric
    T AXIS 10 This allows the user to enter the T axis.

    		Numeric
    CONFIRMATION STATUS 11 This allows the user to enter the ECG/EKG confirmation status.

    		Set of Codes
    Set of Codes:
    • Code : C
      Stands For: CONFIRMED
    • Code : U
      Stands For: UNCONFIRMED
    INTERPRETED BY 12 This allows the user to enter the interpreting physician.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMPARISON STATEMENT 13 This allows the user to enter the ECG/EKG comparison statement.

    		Free Text
    INTERPRETATION CODE (RHYTHM) 14 This allows the user to enter multiple rhythm interpretation codes.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION CODE (RHYTHM) .01 This allows the user to enter multiple rhythm interpretation codes.

    		Pointer
    PointerTo:
    fileName:
    ECG INTERPRETATION
    fileNumber:
    693.3
    CODE MODIFIER 1 This allows the user to describe the interpretation code (rhythm).

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: DEFINITE
    • Code : 2
      Stands For: PROBABLE
    • Code : 3
      Stands For: POSSIBLE
    • Code : 4
      Stands For: BORDERLINE
    • Code : 5
      Stands For: CONSIDER
    • Code : 6
      Stands For: CHANGES OR SERIAL
    INTERPRETATION CODE (CONFIG) 14.1 This allows the user to enter multiple configuration interpretation codes.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION CODE (CONFIG) .01 This allows the user to enter multiple config interpretation codes.

    		Pointer
    PointerTo:
    fileName:
    ECG INTERPRETATION
    fileNumber:
    693.3
    CODE MODIFIER 1 This allows the user to describe the type of interpretation code (config).

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: DEFINITE
    • Code : 2
      Stands For: PROBABLE
    • Code : 3
      Stands For: POSSIBLE
    • Code : 4
      Stands For: BORDERLINE
    • Code : 5
      Stands For: CONSIDER
    • Code : 6
      Stands For: CHANGES OR SERIAL
    INTERPRETATION CODE (PACING) 14.2 This allows the user to enter multiple pacing interpretation codes.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION CODE (PACING) .01 This allows the user to enter multiple pacing interpretation codes.

    		Pointer
    PointerTo:
    fileName:
    ECG INTERPRETATION
    fileNumber:
    693.3
    CODE MODIFIER 1 This allows the user to describe the type of interpretation code (pacing).

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: DEFINITE
    • Code : 2
      Stands For: PROBABLE
    • Code : 3
      Stands For: POSSIBLE
    • Code : 4
      Stands For: BORDERLINE
    • Code : 5
      Stands For: CONSIDER
    • Code : 6
      Stands For: CHANGES OR SERIAL
    DIASTOLIC BP 15 This allows the user to enter the diastolic blood pressure.

    		Numeric
    SYSTOLIC BP 16 This allows the user to enter the systolic blood pressure.

    		Numeric
    COMMENT 17 This allows the user to make specific comments regarding the ECG/EKG.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This allows the user to make specific comments regarding the ECG/EKG.

    		Word Processing
    WARD/CLINIC 18 This field identifies the in-house patient address.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    AUTO-INSTRUMENT DIAGNOSIS 20 This field contains the interpretation of the procedure generated by the instrument(EKG monitor).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTO-INSTRUMENT DIAGNOSIS .01 This field contains the interpretation of the procedure generated by the instrument(EKG monitor).

    		Word Processing
    AUTOMATED INSTRUMENT DATA ? 21 This field stores the last date that the ECG was successfully transferred into DHCP system through the automated interface

    		Date/Time
    PROCEDURE SUMMARY 600 Answer must be 1-79 characters in length. This will appear on the 'Summary of Patient Procedures'.

    		Free Text
    ICD DIAGNOSIS 700 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS subfield which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS subfield which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MARKED FOR DELETION 899

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARKED FOR DELETION
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE STATUS 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    IMAGE 2005 This field points to an entry in the Image File.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This field points to an entry in the Image File.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    HOLTER

    File Number: 691.6

    File Description:

    This file stores data for Holter tests done on a patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    HOOK-UP DATE/TIME .01 This field identifies the specific Holter procedure.

    		Date/Time
    ID .02 This field identifies the patient's identification number assigned by the medical facility. In most cases it is the person's social security number.

    		Free Text
    SUMMARY .03 This field contains the gross evaluation of the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : T
      Stands For: TECHNICALLY UNSATISFACTORY
    SYMPTOM .04 This field contains the patient's physical complaints or symptoms.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 This field contains the patients physical complaints or symtoms.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    MEDICAL PATIENT 1 This field identifies the patient's last name, followed by a comma, followed by a space(optional), followed by the first name, followed by a space, followed by the middle initial.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    HT IN 2 This field contains the patient's height in inches at the time of the procedure.

    		Numeric
    WT LBS 3 This field contains the weight of the patient at the time of the procedure.

    		Numeric
    REQUESTED BY 4 This field identifies the medical provider who ordered this procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE REQUESTED 5 This field identifies the time/date the procedure was ordered.

    		Date/Time
    REASON FOR STUDY 5.5 This field contains the rationale for ordering this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REASON FOR STUDY .01 This field contains the rationale for ordering this procedure.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: SYNCOPE
    • Code : 2
      Stands For: HX SUDDEN DEATH OR SUSTAINED V-T
    • Code : 3
      Stands For: DOCUMENTED V ECTOPY
    • Code : 4
      Stands For: DOCUMENTED SVT
    • Code : 5
      Stands For: WPW
    • Code : 6
      Stands For: PACEMAKER
    • Code : 7
      Stands For: EFFICACY OF THERAPY
    • Code : 8
      Stands For: LIGHTHEADEDNESS
    • Code : 9
      Stands For: RECENT INFARCT
    OTHER INDICATIONS 5.8 This field identifies field is used to define indications not included in the Reason for Study set.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER INDICATIONS .01 This field identifies field is used to define indications not included in the Reason for Study set.

    		Word Processing
    APPROVED BY 6 This field identifies the medical provider who approved the request for this procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE APPROVED 7 This field is used to document the date of procedure request approval.

    		Date/Time
    APPOINTMENT DATE 8 This field contains the date this procedure is/was scheduled.

    		Date/Time
    HOOK-UP BY 10 This field identifies the medical provider who physically initiated this procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RETURN DATE & TIME 11 This field contains the time/date which the patient is scheduled for return. This date is automatically set to the appointment time/date plus 24 hours by the system.

    		Date/Time
    SCANNED BY 12 This field documents the medical provider who performed the Holter scan.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SCANNED DATE 13 This field documents the date the scanning procedure was performed.

    		Date/Time
    REVIEWED BY 14 This field identifies the medical provider who reviewed this procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REVIEW DATE 15 This field documents the date the review occurred.

    		Date/Time
    PATIENT CATEGORY 16 This field defines either inpatient or outpatient status.

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: INPATIENT
    • Code : O
      Stands For: OUTPATIENT
    WARD/CLINIC 17 This field identifies the in house address of the patient.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    HEART MED 18 This field contains the multiple cardiac medicines that the patient was taking at the time of this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART MED .01 This field identifies the name of the cardiac medication.

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This field contains the amount of drug taken at any given time.

    		Free Text
    FREQUENCY 2 This field contains the rate at which the prescribed dose is given.

    		Free Text
    HOLTER RUN NUMBER 19 This field contains the facility generated procedure number.

    		Numeric
    RECORDER NUMBER 20 This field identifies the recorder used in this procedure.

    		Numeric
    BATTERY NUMBER 21 This field identifies the battery used in this procedure.

    		Numeric
    MALFUNCTIONS 22 This field documents whether any procedure malfunction occurred.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    MALFUNCTION TYPE 23 This free text field provides documentation or comments regarding the malfunction.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MALFUNCTION TYPE .01 This free text field provides documentation or comments regarding the malfunction.

    		Word Processing
    TAPE QUALITY 24 This contains the gross evaluation of the tape quality.

    		Set of Codes
    Set of Codes:
    • Code : G
      Stands For: GOOD
    • Code : P
      Stands For: POOR
    • Code : U
      Stands For: UNREADABLE
    TOTAL HOURS 25 This field documents the length in hours of this procedure.

    		Numeric
    READABLE HOURS 26 This field documents the length in hours of distortion free procedure readings.

    		Numeric
    AVERAGE HR 27 This field contains the average heart rate for the entire Holter session.

    		Numeric
    MAX HR 28 This field identifies documents the greatest heart rate that was monitored during this procedure.

    		Numeric
    TIME MAX HR 29 This field identifies field documents the exact time at which maximum heart rate occurred.

    		Free Text
    MIN HR 30 This field identifies documents the lowest heart rate that was monitored during this procedure.

    		Numeric
    TIME MIN HR 31 This documents the time at which minimum heart rate occurred during this procedure.

    		Free Text
    QRS TOTAL 32 This field identifies is the total number of ventricular complexes generated (monitored) during this procedure.

    		Numeric
    VPBS (VENT) 33 This field identifies is the total number of ventricular ectopic beats monitored during this procedure.

    		Numeric
    VPBS PERCENT (VENT) 34 This field identifies is computed from VPBS(VENT)/QRS TOTAL.

    		Computed
    AVE/HR 35 This field identifies the average rate of premature ventricular ectopy per hour.

    		Numeric
    MAX/HR 36 This field identifies is the maximum number of ventricular ectopy monitored during any hour of this procedure.

    		Numeric
    ISOLATED (VENT) 37 This field identifies is the total number of isolated ventricular ectopy.

    		Numeric
    BIGEMINY (VENT) 38 This field identifies is the total number of ventricular ectopy occurring in a bigeminal pattern during this procedure.

    		Numeric
    COUPLETS (VENT) 39 This field identifies is the total number of ventricular ectopy occurring in a couplet pattern during this procedure.

    		Numeric
    NUM OF RUNS 3 OR MORE (VENT) 40 This field identifies is the total number of occurrences of ventricular ectopy in groups of 3 or more monitored during this procedure.

    		Numeric
    RUNS 100 BPM OR MORE (VENT) 40.5 This field identifies is the total number of occurrences of ventricular tachycardia monitored during this procedure.

    		Numeric
    BEATS IN RUNS (VENT) 41 This field identifies is the total number of ventricular ectopy occurring in groups of 3 or more monitored during this procedure.

    		Numeric
    BEATS LONGEST RUN (VENT) 42 This field identifies is the number of ventricular complexes that occurred in the longest ventricular tachycardia event monitored during this procedure.

    		Numeric
    BEATS FASTEST RUN (VENT) 43 This field identifies is the total number of ventricular ectopy occurring in the fastest run of ventricular ectopy monitored during this procedure.

    		Numeric
    BPM IN FASTEST RUN (VENT) 44 This field identifies is the highest ventricular rate occurring in ectopic runs of 3 or more monitored during this procedure.

    		Numeric
    ATRIAL BEATS TOTAL 45 This field identifies is the sum of all P waves monitored during this procedure.

    		Numeric
    ECTOPICS (ATR) 46 This field identifies is the total number of atrial complexes of non-SA node origin monitored during this procedure.

    		Numeric
    ECTOPICS PERCENT (ATR) 47 This field identifies is computed from ECTOPICS/ATRIAL BEATS TOTAL.

    		Computed
    AV/H (ATR) 48 This field identifies the average rate of supraventricular ectopy per hour.

    		Numeric
    MAX/H (ATR) 49 This field identifies is the maximum number of atrial ectopy monitored during any hour of this procedure.

    		Numeric
    ISOLATED (ATR) 50 This field identifies is the total number of single atrial ectopy monitored during this procedure.

    		Numeric
    COUPLETS (ATR) 50.5 This field is used to quantify the amount of back-to-back PVC's or PVC's occurring in pairs.

    		Numeric
    BLOCKED APC (ATR) 51 This field identifies is the total number of non-conducted atrial ectopy monitored during this procedure.

    		Numeric
    NUM. RUNS SVT (ATR) 52 This field identifies is the total number of occurrences of groups of supraventricular tachycardia monitored during this procedure.

    		Numeric
    BTS IN RUNS (ATR) 53 This field identifies is the average number of atrial ectopy occurring in groups of 3 or more monitored during this procedure.

    		Numeric
    BTS LONGEST RUN (ATR) 54 This field identifies is the total number of supraventricular ectopy in the largest group monitored during this procedure.

    		Numeric
    BTS FASTEST RUN (ATR) 55 This field identifies is the total number of atrial ectopy monitored during the fastest run of atrial tachycardia.

    		Numeric
    BPM FASTEST RUN (ATR) 56 This field identifies is the fastest rate of atrial tachycardia monitored during this procedure(beats/minute).

    		Numeric
    HEART BLOCK 57 This field contains the degree of heart block monitored during this procedure.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABSENT
    • Code : FD
      Stands For: FIRST DEGREE BLOCK
    • Code : MI
      Stands For: MOBITZ I SECOND DEGREE, FREQ, RARE
    • Code : MII
      Stands For: MOBITZ II SECOND DEGREE, FREQ, RARE
    • Code : TD
      Stands For: THIRD DEGREE HEART BLOCK, FREQ, RARE
    PAUSES (SINUS) 58 This field indicates whether sinus pauses were monitored during this procedure.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    LONGEST SINUS PAUSE 59 This field identifies is the length of the longest sinus pause monitored during this procedure in the range of .1 and 10 seconds.

    		Numeric
    PAUSES (VENT) 60 This field indicates the occurrence of ventricular pauses monitored during this procedure.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    LONGEST PAUSE (VENT) 61 This field identifies is the longest occurrence of ventricular pause monitored during this procedure in the range of .1 and 10 seconds.

    		Numeric
    INTERPRETATION 62 This free text field contains the clinical evaluation of the patient's cardiac condition based on the information collected by this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION .01 This free text field contains the clinical evaluation of the patient's cardiac condition based on the information collected by this procedure.

    		Word Processing
    COMMENT 63 This free text field provides an area for the medical provider to remark on the data collected in this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This free text field provides an area for the medical provider to remark on the data collected in this procedure.

    		Word Processing
    ST LEVEL 64 This field identifies is the level of ST segment deviation from baseline monitored during this procedure in the range of 0 and 5 millimeters using 2 decimal digits.

    		Numeric
    ST LEVEL DEP/ELEV 65 This field contains the evaluation of ST segment deviation monitored during this procedure.

    		Set of Codes
    Set of Codes:
    • Code : D-SY
      Stands For: DEPRESSION WITH SYMPTOMS
    • Code : D
      Stands For: DEPRESSION WITHOUT SYMPTOMS
    • Code : E-SY
      Stands For: ELEVATION WITH SYMPTOMS
    • Code : E
      Stands For: ELEVATION WITHOUT SYMPTOMS
    AUTOMATED INSTRUMENT DATA 66 This field stores the last date that the ECG was successfully transferred into the DHCP system through the automated interface.

    		Date/Time
    VENDOR 67 This field is used to identify the Holter System Manufacturer.

    		Free Text
    PROCEDURE SUMMARY 600 This 1-79 character field will be displayed on the Summary of Patient Procedures.

    		Free Text
    ICD DIAGNOSIS 700 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS subfield which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS subfield which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETATION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric

    EXERCISE TOLERANCE TEST

    File Number: 691.7

    File Description:

    This file stores data on Exercise Tolerance Tests done on a patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME OF TEST .01 This field identifies the precise Exercise Tolerance procedure.

    		Date/Time
    ID .02 This field identifies the patient's identification number assigned by the medical facility. In most cases it is the person's social security number.

    		Free Text
    SUMMARY .03 This field contains the gross evaluation of the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : T
      Stands For: TECHNICALLY UNSATISFACTORY
    SYMPTOM .04 This field contains the patient's physical complaints or symptoms.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 This field contains the patient's physical complaints or symtoms.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 This field contains the morbidity factors which this patient is most susceptible to in regards to this procedure.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    MEDICAL PATIENT 1 This field identifies the patient's last name, followed by a comma, followed by a space (optional), followed by the first name, followed by a space, followed by the middle initial.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    DATE/TIME OF APPOINTMENT 2 This date/time field documents the scheduled time for this procedure.

    		Date/Time
    REASON FOR TEST 3 This field documents the rationale of the procedure for this patient.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: Overt or Latent C.H.D.
    • Code : B
      Stands For: Diff. diag. - chest pain etiology
    • Code : C
      Stands For: Determination of functional capacity
    • Code : D
      Stands For: Determination of need for cardiac rehab.
    • Code : E
      Stands For: Research - drug evaluation
    • Code : F
      Stands For: Screening for employm. or ins.
    HEART MED 4 This field (multiple) contains the cardiac medicines that the patient is taking at the time of this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART MED .01 This field (multiple) contains the cardiac medicines that the patient is taking at the time of this procedure.

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This allows the user to enter the dosage of the cardiac medicines that the patient is taking at the time of this procedure.

    		Free Text
    FREQUENCY 2 This allows the user to enter the time/number of times (frequency) the patient takes the cardiac medicine.

    		Free Text
    OTHER MEDICATION 4.5 This field (multiple) contains the non-cardiac medicines that the patient was taking at the time of this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER MEDICATION .01 This field (multiple) contains the non-cardiac medicines that the patient was taking at the time of this procedure.

    		Free Text
    DOSE 1 This allows the user to enter the dosage of non-cardiac medicines that the patient was taking at the time of this procedure.

    		Free Text
    RESTING EKG 5 This field refers to the latest, pre-exercise EKG procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RESTING EKG .01 This field refers to the latest, pre-exercise EKG procedure.

    		Word Processing
    REF. MD 6 This field identifies the referring physician.

    		Free Text
    WT LBS 6.1 This field identifies is the patient's weight in pounds at the time of this procedure.

    		Numeric
    ETT PROTOCOL 7 This field defines the protocol used in this procedure.

    		Set of Codes
    Set of Codes:
    • Code : BR
      Stands For: BRUCE
    • Code : M
      Stands For: MODIFIED BRUCE
    • Code : N
      Stands For: NAUGHTON
    • Code : BA
      Stands For: BALKE
    • Code : L
      Stands For: LEVEL MODIFIED BRUCE
    • Code : S
      Stands For: SPECIAL
    • Code : BL
      Stands For: BLOCKER
    • Code : MN
      Stands For: MODIFIED NAUGHTON
    • Code : BI
      Stands For: BICYCLE ERGOMETRY
    • Code : A
      Stands For: ARM ERGOMETRY
    HYPERVENTILATION 8 This allows the user to enter information about the patient and hyperventilation.

    		Free Text
    RS HR 9 This field identifies the resting/supine heart rate.

    		Numeric
    RS SBP 10 This field identifies the resting/supine systolic blood pressure.

    		Numeric
    RS DBP 11 This field identifies resting/supine Diastolic blood pressure.

    		Numeric
    RS RPP 12 This field identifies a number based on the resting heart rate and resting systolic pressure.

    		Computed
    RU HR 13 This field identifies the resting/upright heart rate.

    		Numeric
    RU SBP 14 This field identifies the resting,upright systolic blood pressure.

    		Numeric
    RU DBP 15 This field identifies the resting/upright diastolic blood pressure.

    		Numeric
    RU RPP 16 This field identifies based on the resting/upright heart rate and systolic pressure.

    		Computed
    RS ST 17 This field identifies the resting/supine ST elevation.

    		Numeric
    RU ST 17.5 This field identifies the resting/upright ST elevation.

    		Numeric
    RS ST SLOPE 18 This field identifies the resting/supine ST slope.

    		Numeric
    RU ST SLOPE 19 This field identifies the resting/upright ST slope.

    		Numeric
    CP TME MIN 20 Enter the minutes portion of the elapsed time, that the chest pain occurred.

    		Numeric
    CP TME SEC 21 Enter the seconds portion of the elapsed time, that the chest pain occurred.

    		Numeric
    CP MODIFIER 21.5 This field qualifies the type of chest pain that the patient experienced.

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DURING EXERCISE
    • Code : A
      Stands For: AFTER EXERCISE
    • Code : C
      Stands For: COMBINED
    CP TIME TOTAL 22 This field is the total time of chest pain in seconds computed from the two fields, CP TIME MIN and CP TIME SEC.

    		Computed
    ONSET CP HR 23 This field identifies the heart rate at the onset of chest pain.

    		Numeric
    ONSET CP SBP 24 This field identifies the systolic blood pressure at the onset of chest pain.

    		Numeric
    ONSET CP DBP 25 This field identifies the diastolic blood pressure at the onset of chest pain.

    		Numeric
    ONSET CP ST 26 This field identifies the ST elevation at the onset of chest pain.

    		Numeric
    ONSET CP ST SLOPE 27 This field identifies the ST slope at the onset of chest pain.

    		Numeric
    ONSET CP RPP 28 This field identifies the RPP at the onset of chest pain.

    		Computed
    PK HR 29 This field identifies the peak heart rate.

    		Numeric
    PK SBP 30 This field identifies the peak systolic blood pressure.

    		Numeric
    PK DBP 31 This field identifies the peak diastolic blood pressure.

    		Numeric
    PK EX MPH 32 This field identifies the peak exercise miles per hour.

    		Numeric
    KILO POND METERS (KPM) 32.1 This field identifies the kilo pond meters.

    		Numeric
    WATTS 32.2 This field identifies the wattage.

    		Numeric
    PK EX GRADE 33 This field identifies the peak exercise grade.

    		Numeric
    METS 34 This field identifies the METS (Metabolic Equivalents-1 MET=3.5ml of O2 resting).

    		Numeric
    PK ST 39 This field identifies the peak ST elevation.

    		Numeric
    PK ST SLOPE 40 This field identifies the peak ST slope.

    		Numeric
    PK RPP 42 This field identifies the peak RPP.

    		Computed
    EX TIME 43 This field identifies the time at which exercise began.

    		Computed
    EX TIME MIN 44 Enter the minutes portion of the elapsed time, that the exercise occurred.

    		Numeric
    EX TIME SEC 45 Enter the seconds portion of the elapsed time, that the exercise occurred.

    		Numeric
    PREDICTED HR 46 This field identifies the predicted heart rate.

    		Computed
    TIME ST - 1 47 This field identifies time of ST-1.

    		Free Text
    % TARGET HR 48 This field identifies the percentage of target heart rate achieved.

    		Computed
    TIME ST - 2 49 This field identifies the time of ST-2.

    		Free Text
    REASON FOR STOPPING 50 This field identifies the rationale for terminating the procedure.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    ARRHYTHMIAS 51 This field identifies the documented cardiac rhythm irregularity.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NONE
    • Code : DP
      Stands For: DEC PVCS
    • Code : IFP
      Stands For: INC FREQ PVCS
    • Code : IGC
      Stands For: INC GRADE, COUPLETS
    • Code : IGT
      Stands For: INC GRADE, TRIPLETS
    • Code : IVT
      Stands For: INC SUST VT (>10)
    OTHER EKG CHANGE 52 This field identifies an irregularity.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER EKG CHANGE .01 This field identifies an irregularity.

    		Word Processing
    HEART RATE RESPONSE 53 This field identifies the heart rate response.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    BLOOD PRESSURE RESPONSE 53.5 This field identifies the blood pressure response.

    		Set of Codes
    Set of Codes:
    • Code : SR
      Stands For: SYSTOLIC ROLL-OVER
    • Code : N
      Stands For: NORMAL
    • Code : H
      Stands For: HYPERTENSIVE
    TIME RETURN BASELINE ST 54 This field identifies the time that the ST segment returned to baseline.

    		Free Text
    INTERPRETATION 55 This field identifies the interpretation field.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    COMMENT 56 This field identifies the comment (word-processing) field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This field identifies the comment (word-processing) field.

    		Word Processing
    EKG TECHNICIAN 57 This field identifies the staff member responsible for hooking up the patient.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ATTN PHYS 58 This field identifies the patient's attending physician.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MPH MOD BRUCE 59 This identifies the MPH MOD BRUCE field (miles/hr of lower intensity standardized exercise test).

    		Computed
    MPH SPECIAL 60 This field identifies the MPH Special field.

    		Computed
    MPH BALKE 62 This field identifies the MPH BALKE field.

    		Computed
    GRADE SPECIAL 65 This field identifies the GRADE SPECIAL field.

    		Computed
    GRADE BALKE 67 This field identifies the GRADE BALKE field.

    		Computed
    WARD/CLINIC 69 This field identifies the in-house patient location.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    COMPLICATIONS 70 This field identifies the complications field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMPLICATIONS .01 This field identifies the complications field.

    		Pointer
    PointerTo:
    fileName:
    COMPLICATION
    fileNumber:
    696.9
    PROCEDURE SUMMARY 600 Answer must be 1-79 characters in length. This will appear on the 'Summary of Patient Procedures.'

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es). There is also a subfield labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es). There is also a subfield labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric

    ELECTROPHYSIOLOGY (EP)

    File Number: 691.8

    File Description:

    Stores (along with ATRIAL STUDY and VENTRICULAR STUDY files) data on Electrophysiologies done on a patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the date and time that the procedure was entered into the database.

    		Date/Time
    ID .02 This field identifies the patient identifier.

    		Free Text
    SUMMARY .03 This field summarizes the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    SYMPTOM .04 These are the clinical signs of disease.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SYMPTOM .01 These are the clinical signs of disease.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    RISK FACTOR .05 These are the conditions which contribute to the overall percentages of disease.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RISK FACTOR .01 These are the conditions which contribute to the overall percentages of disease.

    		Pointer
    PointerTo:
    fileName:
    PAST HISTORY AND RISK FACTOR
    fileNumber:
    695.4
    HEART MEDICATION .9 This field identifies the medication which the patient has been prescribed

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART MEDICATION .01 This field identifies the medication which the patient has been prescribed

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSE 1 This allows the patient to enter dosage of medicine the patient is taking.

    		Free Text
    FREQUENCY 2 This allows the user to enter time/number of times (frequency) patient should take medicine.

    		Free Text
    MEDICAL PATIENT 1 This field identifies the patients last name, followed by a comma, followed by a space(optional), followed by the first name, followed by a space, followed by the middle initial.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    HOSPITAL OF STUDY 3 This field defines the facility performing this procedure.

    		Free Text
    REASON FOR STUDY 4 This field documents the rationale of the procedure for this patient.

    		Free Text
    ARRHYTHMIA DX 5 This field identifies an arrhythmia diagnosis field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ARRHYTHMIA DX .01 This field identifies an arrhythmia diagnosis field.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    CARDIAC DX 6 This field identifies a cardiac diagnosis field.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    HX 7

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HX .01 This field may be used to detail the relevant patient history.

    		Word Processing
    EJECTION FRACTION 8 This field quantifies the cardiac efficiency.

    		Numeric
    EJECTION FRACTION METHOD 9 This field documents the methodology used to determine the ejection fraction.

    		Set of Codes
    Set of Codes:
    • Code : RVG
      Stands For: RVG
    • Code : VENT
      Stands For: VENTRICULOGRAPHY
    • Code : 2-DE
      Stands For: 2D ECHO
    HEART BLOCK 10 This field defines the state of heart block.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HEART BLOCK .01 This field defines the state of heart block.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PROXIMAL BLOCK
    • Code : D
      Stands For: DISTAL (INFRA HIS BLOCK)
    • Code : H
      Stands For: INTRA HIS BLOCK
    UNDERLYING RHYTHM 1 This field identifies describes the rhythm associated with a particular block.

    		Free Text
    RESPONSE TO ATROPINE 2 This field quantifies the response to atropine.

    		Free Text
    RESPONSE TO EXERCISE 3 This field documents the response to exercise.

    		Free Text
    RESPONSE TO CAROTID MASSAGE 4 This field documents the response to carotid massage.

    		Free Text
    CAROTID STIMULATION 11 This field documents the episodes of carotid stimulation.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CAROTID STIMULATION .01 This field documents the episodes of carotid stimulation.

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: RT CAROTID PRESSURE
    • Code : L
      Stands For: LT CAROTID PRESSURE
    • Code : ND
      Stands For: NOT DONE
    LONGEST PAUSE 1 This field describes the longest pause.

    		Numeric
    SVT-TYPE 12 This field defines the SVT-type

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SVT-TYPE .01 This field defines the SVT-type

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: AVNRT
    • Code : 2
      Stands For: ORTHODROMIC AVRT
    • Code : 3
      Stands For: ANTIDROMIC AVRT
    • Code : 4
      Stands For: SNRT
    • Code : 5
      Stands For: IART
    • Code : 6
      Stands For: ATRIAL FLUTTER
    • Code : 7
      Stands For: ATRIAL FIB
    • Code : 8
      Stands For: AUTOMATIC
    INTERPRETATION 13 This field documents the clinical interpretation.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION .01 This field documents the clinical interpretation.

    		Word Processing
    COMMENT 14 This field identifies a word processing comment field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This field identifies a word processing comment field.

    		Word Processing
    FOLLOW UP 15 This field documents follow up care/diagnostics.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FOLLOW UP .01 This field documents follow up care/diagnostics.

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: RECURRENT VT/VF
    • Code : H
      Stands For: REHOSPITALIZATION
    • Code : D
      Stands For: PATIENT DEATH
    • Code : S
      Stands For: SIDE EFFECTS FROM DRUGS
    CARDIOLOGY STAFF 16 This field identifies the participating clinical staff.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY FELLOW 17 This field identifies the participating clinical fellow.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    WARD/CLINIC 18 This field identifies the patient's location.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    CARDIOLOGY STAFF-2ND 19 This field identifies the secondary participating staff member.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY FELLOW-2ND 20 This field identifies the secondary clinical fellow.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DISCHARGE DATE 21

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISCHARGE DATE .01

    		Date/Time
    MEDICATION ON DISCHARGE 1

    		Free Text
    FOLLOW UP 22

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FOLLOW UP .01

    		Set of Codes
    Set of Codes:
    • Code : RE
      Stands For: RECURRENT VT/VF
    • Code : HO
      Stands For: REHOSPITALIZATION
    • Code : DI
      Stands For: PATIENT DEATH
    • Code : SE
      Stands For: SIDE EFFECTS FROM DRUG
    CARDIOLOGY STAFF 24

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CARDIOLOGY FELLOW 25

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PROCEDURE SUMMARY 600 This 1-79 character field is provided as input into the summary of patient procedures.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. This field also contains a subfield labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. This field also contains a subfield labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERFIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETATION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETATION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric

    HEMATOLOGY

    File Number: 694

    File Description:

    Stores results of Bone Marrow Aspirates and Bone Marrow Biopsies.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the time and date of entry.

    		Date/Time
    MEDICAL PATIENT 1 This field identifies the medical patient name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    SUMMARY 1.5 This field summarizes the results of this procedure.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: Normal
    • Code : A
      Stands For: Abnormal
    • Code : T
      Stands For: Technically unsatisfactory
    • Code : ND
      Stands For: Non-Diagnostic
    PROCEDURE 2 This field identifies a pointer to the procedure location file.

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE/SUBSPECIALTY
    fileNumber:
    697.2
    ANATOMIC SITE 2.5 This field identifies a pointer to the anatomy file.

    		Pointer
    PointerTo:
    fileName:
    ANATOMY
    fileNumber:
    697
    WARD/CLINIC 3 This field identifies the in-house location of the patient.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    BIOPSY COMMENTS 4.1 This field identifies a free text field, enter any pertinent biopsy comments.

    		Free Text
    ORIGINAL CONSULT DATE 5 This field identifies the date of consult.

    		Date/Time
    PROVISIONAL DX REMARKS 6.5 This field identifies a free text field, enter provisional DX remarks.

    		Free Text
    NO. CELLS COUNTED 7 This field identifies the number of cells counted.

    		Numeric
    CELLULARITY 8 One of a set of descriptors of the occurrance of cellularity.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : I
      Stands For: INCREASED
    • Code : D
      Stands For: DECREASED
    CELLULARITY MODIFIER 8.1 One of a set of adjectives used to further define cellularity.

    		Set of Codes
    Set of Codes:
    • Code : SL
      Stands For: SLIGHTLY
    • Code : MO
      Stands For: MODERATELY
    • Code : SE
      Stands For: SEVERELY
    • Code : MA
      Stands For: MARKEDLY
    M:E RATIO 9 This field identifies the M:E ratio.

    		Free Text
    IRON STORES 9.5 From set of positive values.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: 0
    • Code : 1
      Stands For: 1+
    • Code : 2
      Stands For: 2+
    • Code : 3
      Stands For: 3+
    • Code : 4
      Stands For: 4+
    MEGAKARYOCYTES 10 This field identifies the megakaryocyte count.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : I
      Stands For: INCREASED
    • Code : R
      Stands For: REDUCED
    MEGAKARYOCYTES MODIFIER 10.1 This field identifies the megakaryocyte count modifier.

    		Set of Codes
    Set of Codes:
    • Code : SL
      Stands For: SLIGHTLY
    • Code : MO
      Stands For: MODERATELY
    • Code : SE
      Stands For: SEVERLY
    • Code : MA
      Stands For: MARKEDLY
    DIFF(Y/N) 12 This field identifies no.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    NEUTROPHILS 13 This field identifies the neutrophil description.

    		Numeric
    BANDS 14 The number of bands found.

    		Numeric
    METAMYELOCYTES 15 This field identifies the metamyelocyte count field.

    		Numeric
    MYELOCYTES 16 This field identifies the myelocyte count.

    		Numeric
    PROMYELOCYTES 17 This field identifies the promyelocyte count field.

    		Numeric
    MYELOBLASTS 18 This field identifies the myeloblast count field.

    		Numeric
    EOSINOPHILS 19 Number of eosinophils found.

    		Numeric
    BASOPHILS 20 The number of basophils found.

    		Numeric
    LYMPHOCYTES 21 The number of lymphocytes found.

    		Numeric
    ORTHOCHROMATIC NORMOBLASTS 22 This field identifies the normoblast count filed.

    		Numeric
    POLYCHROMATIC NORMOBLASTS 23 This field identifies the polychromatic normoblast count field.

    		Numeric
    BASOPHILIC NORMOBLASTS 24 The number of basophilic normoblasts found.

    		Numeric
    PRONORMOBLASTS 25 This field identifies the pronormoblast count field.

    		Numeric
    LYMPHOBLASTS 26 Number of lymphoblasts found.

    		Numeric
    PLASMA CELLS 27 This field identifies the plasma cell count field.

    		Numeric
    MONOCYTES 28 This field identifies the monocyte count field.

    		Numeric
    HISTIOCYTES 29 Number of histiocytes found.

    		Numeric
    OTHER CELL TYPE COUNT 30 This field identifies the other cell type count field.

    		Numeric
    OTHER CELL TYPE 31 This field identifies the other cell type descriptor.

    		Free Text
    DATE PERFORMED 34 Documentation of procedure date.

    		Date/Time
    FINAL DIAGNOSIS 35 Enter Medical diagnosis from the medical diagnosis/ICD codes file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FINAL DIAGNOSIS .01 Enter Medical diagnosis from the medical diagnosis/ICD codes file.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    DECALCIFICATION OF SPECIMEN 36 Did decalcification of the specimen occur?

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    SPECIMEN SUBMITTED FOR PLASTIC 37 This field identifies the specimen submitted for plastic field.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    PROVISIONAL DX 38 This field identifies the provisional diagnosis field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROVISIONAL DX .01 This field identifies the provisional diagnosis field.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    RELEASE REPORT 39 This field identifies the release report field.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    MICROSCOPIC DESCRIPTION 40 This field identifies the microscopic description field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICROSCOPIC DESCRIPTION .01 This field identifies the microscopic description field.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DESCRIPTION
    fileNumber:
    693
    FINAL DIAGNOSIS REMARKS 41 Free text field for diagnostic remarks.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FINAL DIAGNOSIS REMARKS .01 Free text field for diagnostic remarks.

    		Word Processing
    FIXATIVE 43 This field identifies for BMB only

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: Formalin
    • Code : B
      Stands For: B-5
    • Code : Z
      Stands For: Zenker's
    • Code : C
      Stands For: Carnoy's
    NUMBER OF PIECES 44 This field identifies for BMB only

    		Numeric
    PIECE 1 45 This field is for BMB only.

    		Numeric
    PIECE 2 46 This field is for BMB only

    		Numeric
    PIECE 3 47 This field is for BMB only

    		Numeric
    PIECE 4 48 This field is for BMB only

    		Numeric
    PIECE 5 49 This field is for BMB only

    		Numeric
    PERFORMED BY 50 This field identifies the health care provider who performed this procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    APPROVED BY 51 This field identifies the health care provider who approved the results.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    APPROVAL DATE 52 This field identifies the date on which the results were approved.

    		Date/Time
    MICRO DESCRIPTION REMARKS 54 This field identifies the micro description remark field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICRO DESCRIPTION REMARKS .01

    		Word Processing
    COMPLICATIONS 55 Free text field whose purpose is to document procedural difficulties.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMPLICATIONS .01 Free text field whose purpose is to document procedural difficulties.

    		Pointer
    PointerTo:
    fileName:
    COMPLICATION
    fileNumber:
    696.9
    PERIPHERAL BLOOD SMEAR 56 This field documents the results of the peripheral smear.

    		Free Text
    INDICATION 57 Entry from the indication file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INDICATION .01 Entry from the indication file.

    		Pointer
    PointerTo:
    fileName:
    INDICATION
    fileNumber:
    694.1
    OTHER INDICATION 58 This field identifies the other indication field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER INDICATION .01 This field identifies the other indication field.

    		Word Processing
    PROCEDURE SUMMARY 600 This 1-79 character field is produced on the summary of patient procedures.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a sub-field labeled NARRATIVE DIAGNOSIS which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASE ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASE OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASE NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: SUPERSEDING RELEASE ON-LINE VERIFIED
    • Code : SROV
      Stands For: SUPERSEDING RELEASE OFF-LINE VERIFIED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    IMAGE 2005 This field points to an object in the Image File.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This field points to an object in the Image File.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    GENERATOR IMPLANT

    File Number: 698

    File Description:

    This file is used to hold the Generator Implant/Explant data for the Pacemaker portion of the Medicine package.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME OF IMPLANT .01 This allows analysis based on time.

    		Date/Time
    MEDICAL PATIENT 1 Patient's name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    PACEMAKER MODEL 2 This field identifies the device by the manufacturer's production name.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    PACEMAKER MANUFACTURER 3 This field identifies the producer of the pacemaker.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER MANUFACTURER
    fileNumber:
    698.6
    PACEMAKER SERIAL NUMBER 4 This field identifies the specific device.

    		Free Text
    PACING MODE 6 This defines the operation established with the device.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: AAI
    • Code : 2
      Stands For: VVI
    • Code : 3
      Stands For: DDD
    • Code : 4
      Stands For: DVI
    • Code : 5
      Stands For: AAT
    • Code : 6
      Stands For: VVT
    • Code : 7
      Stands For: VAT
    • Code : 8
      Stands For: VDD
    • Code : 9
      Stands For: AOO
    • Code : 10
      Stands For: VOO
    • Code : 11
      Stands For: DOO
    • Code : 12
      Stands For: OTHER
    • Code : 13
      Stands For: VVIR
    OTHER PACING MODE EXPLANATION 6.1 This field permits an explanation of the pacing mode if "OTHER" is chosen at the PACING MODE prompt. It does not apply if anything besides "OTHER" is chosen at the PACING MODE prompt.

    		Free Text
    HOSP WHERE IMPLANT OCCURRED 7 This field identifies the facility where the implant procedure was performed.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    TRANSMITTER MODEL 12 This field identifies the device by the manufacturer's production name.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    TRANSMITTER MANUFACTURER 13 This field identifies the producer of the transmitter.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER MANUFACTURER
    fileNumber:
    698.6
    LEADS (A,V,AV) 14 This describes the placement/type of conductors established.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ATRIAL
    • Code : V
      Stands For: VENTRICULAR
    • Code : AV
      Stands For: BOTH A & V
    IMPLANTATION ETIOLOGY 19 This allows for the storage of historical patient data.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: CONDUCTION TISSUE FIBROSIS
    • Code : 2
      Stands For: ISCHEMIA
    • Code : 3
      Stands For: POST INFARCTION
    • Code : 4
      Stands For: SURGICAL
    • Code : 5
      Stands For: CONGENITAL
    • Code : 6
      Stands For: MYOCARDIOPATHY
    • Code : 7
      Stands For: VALVULAR HEART DISEASE
    • Code : 8
      Stands For: CAROTID SINUS SYNDROME
    • Code : 9
      Stands For: IDIOPATHIC
    • Code : 10
      Stands For: OTHER
    FIRST SCHEDULED F/U VISIT 30 This allows documentation of the primary visit.

    		Date/Time
    NON-MAG RATE AT BEGIN-OF-LIFE 32 This allows documentation of initial rate.

    		Numeric
    MAGNET RATE AT BEGIN-OF-LIFE 34 This allows documentation of initial rate.

    		Numeric
    NON-MAG PULSE WIDTH AT B-O-L 36 This allows documentation of initial width.

    		Numeric
    MAGNET PULSE WIDTH AT B-O-L 38 This allows documentation of initial width.

    		Numeric
    OTHER BEGIN-OF-LIFE INDICATOR 40 This allows other initial documentation.

    		Free Text
    NON-MAG RATE AT END-OF-LIFE 42 This allows documentation of terminal rate.

    		Numeric
    MAGNET RATE AT END-OF-LIFE 44 This allows documentation of terminal rate.

    		Numeric
    NON-MAG PULSE WIDTH AT E-O-L 46 This allows documentation of terminal width.

    		Numeric
    MAGNET PULSE WIDTH AT E-O-L 48 This allows documentation of terminal width.

    		Numeric
    OTHER END-OF-LIFE INDICATOR 50 This allows documentation of other terminal parameters.

    		Free Text
    NO. PULSE GENERATORS 70 This field identifies the sequential value of this generator.

    		Numeric
    DATE OF LAST PREVIOUS IMPLANT 75 This allows documentation of previous implantations.

    		Date/Time
    DATE OF INCIPIENT MALFUNCTION 90 This allows documentation of malfunction date.

    		Date/Time
    PACING FAILURE (EKG) 93 This allows documentation of failures.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PACING FAILURE (EKG) .01 This allows documentation of failures.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: LOSS OF CAPTURE
    • Code : 2
      Stands For: UNDERSENSING
    • Code : 3
      Stands For: OVERSENSING
    • Code : 4
      Stands For: RATE DECREASE
    • Code : 5
      Stands For: RATE INCREASE
    DATE OF FAILURE 1 This allows the user to enter the date of failure.

    		Date/Time
    EXPLANT DATE 96 This allows documentation of generator removal.

    		Date/Time
    REASON FOR GENERATOR CHANGE 99 This allows documentation of change rationale.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    ATTENDING PHYSICIAN 300 This field identifies the name of the Attending Physician for this Generator Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-1st 301 This field identifies the name of a Cardiology Fellow for this Generator Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-2nd 302 This field identifies the name of a second Cardiology Fellow for this Generator Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMMENTS 500 This allows a documentation area of free form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENTS .01 This field identifies the free text documentation area.

    		Word Processing
    PROCEDURE SUMMARY 600 This field identifies a required free text summary of the Generator Implant. This summary (up to 79 characters) will appear on the Summary of Patient Procedures.

    		Free Text
    SUMMARY 601 This field identifies a required summary of the implant (Abnormal,Borderline,Normal). This summary will appear on the Summary of Patient Procedures.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : N
      Stands For: NORMAL
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123

    V LEAD IMPLANT

    File Number: 698.1

    File Description:

    This holds the V Lead Implant/Explant information for Pacemaker.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME OF IMPLANT .01 This field is the date/time that the procedure was entered into the database.

    		Date/Time
    MEDICAL PATIENT 1 This field identifies the field which identifies the patient.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    V LEAD MODEL 2 This field identifies the V Lead Model.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    V LEAD MANUFACTURER 3 This field identifies the V Lead Manufacturer.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER MANUFACTURER
    fileNumber:
    698.6
    V LEAD SERIAL NUMBER 4 This field identifies the V Lead Serial number.

    		Free Text
    V LEAD THRESHOLD IN VOLTS 11 This field identifies the V Lead threshold in Volts.

    		Numeric
    V LEAD THRESHOLD IN mA'S AT .5 12 This field identifies the V lead threshold.

    		Numeric
    V LEAD RESISTANCE (OHMS) AT 5V 13 This field identifies the V lead resistance.

    		Numeric
    R WAVE AMPLITUDE (mV) 14 This field identifies the R wave amplitude.

    		Numeric
    V LEAD PSA USED 15 This field identifies the V Lead PSA used.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    EXPLANT DATE 56 This field identifies the explant date.

    		Date/Time
    V LEAD EXPLANT REASON 57 This field identifies the V lead explant rationale.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    ATTENDING PHYSICIAN 300 This field identifies the name of the Attending Physician for this V-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-1st 301 This field identifies the name of a Cardiology Fellow for this V-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-2nd 302 This field identifies the name of a Second Cardiology Fellow for this V-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMMENTS 500 This field identifies the comment field for this procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENTS .01 This field identifies the comment field for this procedure.

    		Word Processing
    PROCEDURE SUMMARY 600 This 1-79 character field is for display on the medicine procedure summary report.

    		Free Text
    SUMMARY 601 This field identifies the procedure summary.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : N
      Stands For: NORMAL
    ICD DIAGNOSIS 700 This field contains the ICD Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123

    A LEAD IMPLANT

    File Number: 698.2

    File Description:

    This holds the A Lead Implant/Explant information for Pacemaker.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME OF IMPLANT .01 This allows analysis based on time.

    		Date/Time
    MEDICAL PATIENT 1 Patient's name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    A LEAD MODEL 2 This field identifies the device by the manufacturer's production name.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    A LEAD MANUFACTURER 3 This field identifies the producer of the lead.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER MANUFACTURER
    fileNumber:
    698.6
    A LEAD SERIAL NUMBER 4 This field identifies the specific device.

    		Free Text
    A LEAD THRESHOLD IN VOLTS 11 This allows documentation of an initial threshold parameter.

    		Numeric
    A LEAD THRESHOLD IN mA's AT .5 12 This allows documentation of an initial threshold parameter.

    		Numeric
    A LEAD RESISTANCE (OHMS) AT 5V 13 This allows documentation of an initial resistance parameter.

    		Numeric
    P WAVE AMPLITUDE (MV) 14 This allows documentation of the initial amplitude parameter.

    		Numeric
    A LEAD PSA USED 15 This allows documentation of lead implementation.

    		Pointer
    PointerTo:
    fileName:
    PACEMAKER EQUIPMENT
    fileNumber:
    698.4
    EXPLANT DATE 56 This allows documentation of lead removal.

    		Date/Time
    A LEAD EXPLANT REASON 57 This allows documentation of explant rationale.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    ATTENDING PHYSICIAN 300 This field identifies the name of the Attending Physician for this A-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-1st 301 This field identifies the name of a Cardiology Fellow for this A-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW-2nd 302 This field identifies the name of a second Cardiology Fellow for this A-Lead Implant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMMENTS 500 This allows a documentation area of free form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENTS .01 This allows a documentation area of free form.

    		Word Processing
    PROCEDURE SUMMARY 600 This 1-79 character field will be displayed on the medical procedure summary report.

    		Free Text
    SUMMARY 601 This field summarizes the results of the procedure.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : N
      Stands For: NORMAL
    ICD DIAGNOSIS 700 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field identifies the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123

    PACEMAKER SURVEILLANCE

    File Number: 698.3

    File Description:

    This file holds the telephone/clinic follow-up data for Pacemaker.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This allows analysis based on time.

    		Date/Time
    MEDICAL PATIENT 1 Patient's name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    CALLER 2 This field identifies the surveillance operator.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATA GATHERING MODE 3 This defines the surveillance technique.

    		Set of Codes
    Set of Codes:
    • Code : T
      Stands For: TELEPHONE
    • Code : C
      Stands For: CLINIC
    PULSE INTERVAL (MSEC) WO MAG 4 This allows documentation of a current rate parameter.

    		Numeric
    RATE WO MAG 5 This allows documentation of a current rate parameter.

    		Computed
    PULSE INTERVAL (MSEC) W MAG 6 This allows documentation of a current rate parameter.

    		Numeric
    RATE W MAG 7 This allows documentation of a current rate parameter.

    		Computed
    A-V DELAY WO MAG (MSEC) 11 This allows documentation of a current rhythm parameter.

    		Numeric
    A-V DELAY W MAG (MSEC) 12 This allows documentation of a current rhythm parameter.

    		Numeric
    BATTERY VOLTAGE 13 This allows documentation of current power state.

    		Numeric
    RESISTANCE 14 This allows documentation of the current ohms parameter.

    		Numeric
    BASIC RHYTHM 15 This allows documentation of the current rhythm.

    		Pointer
    PointerTo:
    fileName:
    NON-MAGNET ECG RHYTHM
    fileNumber:
    698.9
    PERCENT OF PACED BEATS 16 This allows documentation of the current rate of generator activity.

    		Numeric
    REPROGRAMMED RATE 50 This allows documentation of rate adjustments.

    		Numeric
    REPROG. UPPER RATE LIMIT 51 This allows documentation of a rate adjustment.

    		Numeric
    REPROGRAMMED A-V DELAY (MSECS) 52 This allows documentation of a rhythm adjustment.

    		Numeric
    REPROGRAMMED HYSTERESIS 53 This allows documentation of a hysteresis adjustment.

    		Numeric
    REPROGRAMMED PACING MODE 54 This allows documentation of an adjustment to device operations.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: AAI
    • Code : 2
      Stands For: VVI
    • Code : 3
      Stands For: DDD
    • Code : 4
      Stands For: DVI
    • Code : 5
      Stands For: AAT
    • Code : 6
      Stands For: VVT
    • Code : 7
      Stands For: VAT
    • Code : 8
      Stands For: VDD
    • Code : 9
      Stands For: AOO
    • Code : 10
      Stands For: VOO
    • Code : 11
      Stands For: DOO
    • Code : 12
      Stands For: OTHER
    REASON FOR REPROGRAMMING 55 This allows documentation of the adjustment rationale.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    PULSE WIDTH (ATRIAL-MSEC) 101 This allows documentation of a pulse segment rate parameter.

    		Numeric
    MEASURED A-LEAD AMPLITUDE (MV) 102 This allows documentation of atrial lead voltage.

    		Numeric
    RATIO (T/L) (ATRIAL) 103 This allows documentation of a performance ratio.

    		Numeric
    THRESHOLD WIDTH (ATRIAL) 104 This allows documentation of the atrial threshold parameter.

    		Numeric
    THRESHOLD AMPLITUDE (ATRIAL) 105 This allows documentation of the atrial voltage threshold.

    		Numeric
    CAPTURE (ATRIAL) 106 This allows documentation of atrial capture.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : I
      Stands For: INTERMITTENT
    • Code : U
      Stands For: UNKNOWN
    • Code : NA
      Stands For: NOT APPLICABLE
    SENSE (ATRIAL) 107 This allows documentation of atrial sense.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : I
      Stands For: INTERMITTENT
    • Code : U
      Stands For: UNKNOWN
    • Code : NA
      Stands For: NOT APPLICABLE
    REPR.PULSE WIDTH (ATRIAL-MSEC) 121 This allows documentation of a pulse segment adjustment.

    		Numeric
    REPROG. A-AMPLITUDE (VOLTS) 122 This allows documentation of atrial voltage adjustments.

    		Numeric
    REPR.SENSITIVITY(ATRIAL-VOLTS) 123 This allows documentation of adjustments to atrial sense.

    		Numeric
    REPR.ATRIAL REFRACTORY PERIOD 124 This allows documentation of adjustments to atrial refraction.

    		Numeric
    PULSE WIDTH (VENTRICLE-MSEC) 201 This allows documentation of a pulse segment rate parameter.

    		Numeric
    MEASURED V-LEAD AMPLITUDE (MV) 202 This allows documentation of ventricular lead voltage.

    		Numeric
    RATIO (T/L) (VENTRICLE) 203 This allows documentation of a performance ratio.

    		Numeric
    THRESHOLD WIDTH (VENTRICLE) 204 This allows documentation of the ventricular threshold.

    		Numeric
    THRESHOLD AMPLITUDE (VENT.) 205 This allows documentation of the ventricular voltage threshold.

    		Numeric
    CAPTURE (VENTRICULAR) 206 This allows documentation of ventricular capture.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : I
      Stands For: INTERMITTENT
    • Code : UNK
      Stands For: UNKNOWN
    • Code : NA
      Stands For: NOT APPLICABLE
    SENSE (VENTRICULAR) 207 This allows documentation of ventricular sense.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    • Code : I
      Stands For: INTERMITTENT
    • Code : UNK
      Stands For: UNKNOWN
    • Code : NA
      Stands For: NOT APPLICABLE
    REPR.PULSE WIDTH (VENT-MSEC) 221 This allows documentation of a pulse segment adjustment.

    		Numeric
    REPROGR. V-AMPLITUDE (VOLTS) 222 This allows documentation of ventricular voltage adjustments.

    		Numeric
    REPR.SENSITIVITY (VENTR.-MV) 223 This allows documentation of adjustments to ventricular sense.

    		Numeric
    REPR. VENT. REFRACTORY PERIOD 224 This allows documentation of adjustments to ventricular refraction.

    		Numeric
    ATTENDING PHYSICIAN 300

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FELLOW 301 This field identifies the name of the Cardiology Fellow for this Surveillance Entry.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FOLLOWUP COMMENT 491 This allows a documentation area of free form.

    		Free Text
    FAST OR SLOW CHECK 492 This allows documentation of fast/slow check.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FAST CHECK
    • Code : S
      Stands For: SLOW CHECK
    NEXT FOLLOW-UP DATE 493 This allows documentation of the scheduled follow-up date.

    		Date/Time
    COMMENTS 500 This allows a documentation area of free form.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENTS .01 This allows a documentation area of free form.

    		Word Processing
    PROCEDURE SUMMARY 600 This field identifies a required free-text summary (1 to 79 characters) of the surveillance. This summary will appear on the Summary of Patient Procedures.

    		Free Text
    SUMMARY 601 This field identifies a required summary of the surveillance (Normal, Abnormal, or Borderline). This will appear on the Summary of Patient Procedures.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : N
      Stands For: NORMAL
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123

    ENDOSCOPY/CONSULT

    File Number: 699

    File Description:

    This file holds all Endoscopic procedures as well as GI Non-endoscopic procedures.


    Fields:

    Name Number Description Data Type Field Specific Data
    APPOINTMENT DATE/TIME .01 This field contains the date/time of the Endoscopy procedure.

    		Date/Time
    MEDICAL PATIENT .02 This field identifies the name of the patient under-going the procedure.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    PROCEDURE 1 This field identifies the specific procedure performed, such as colonoscopy.

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE/SUBSPECIALTY
    fileNumber:
    697.2
    INDICATION FOR PROCEDURE 2 This field identifies field stores the reason (s) why the Endoscopic procedure was performed. This field has been broken out for GI Endoscopies into it's individual elements and is no longer asked by the GI edit templates, but continues to be asked for Pulmonary Endoscopies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INDICATION FOR PROCEDURE .01 This contains a specific reason why the procedure was performed.

    		Pointer
    PointerTo:
    fileName:
    INDICATION
    fileNumber:
    694.1
    INDICATED THERAPY 2.1 This field identifies field records the therapeutic manipulations which you believe you may perform at the time of the examination. This does not record the findings of the procedure, but rather the reason for which the procedure is performed. Used as an indication for procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INDICATED THERAPY .01 This field identifies the specific therapeutic manipulation which you believe you may perform at the time of the examination.

    		Pointer
    PointerTo:
    fileName:
    DIAG/THERAP INTERVENT
    fileNumber:
    699.6
    SIGNS AND SYMPTOMS 2.2 This field identifies an indication for procedure that records the specific sign or symptom for performing the procedure. The purpose of this field is to record specific correlation between common symptoms and the Endoscopic Findings.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SIGNS AND SYMPTOMS .01 This field identifies the specific sign or symptom used as an indication for procedure.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    LOCATION OF PAIN 2.3 This field stores the specific location of pain if pain is entered as a sign or symptom. This field has been removed from the input templates for version 2.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOCATION OF PAIN .01 This field identifies the specific location of pain.

    		Pointer
    PointerTo:
    fileName:
    LOCATION OF PAIN/PNEUMONIAS
    fileNumber:
    699.83
    DURATION 1 This field indicates the length of time the pain persists.

    		Free Text
    FREQUENCY 2 This field identifies the frequency of the pain.

    		Free Text
    ABNORMAL BOWEL CONSISTENCY 2.4 This field stores the consistency (alternating, bloody,formed,hard,soft,or watery) for a patient who has the symptom of abnormal bowel habits. This field has been removed from the input templates for version 2.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ALTERNATING
    • Code : 2
      Stands For: BLOODY
    • Code : 3
      Stands For: FORMED
    • Code : 4
      Stands For: HARD
    • Code : 5
      Stands For: SOFT
    • Code : 6
      Stands For: WATERY
    ABNORMAL BOWEL DURATION 2.45 This field stores the length of time the patient has had the abnormal bowel habits. This field has been removed from the input templates for version 2.

    		Free Text
    ABNORMAL BOWEL FREQUENCY 2.46 This field stores the frequency for abnormal bowel habits. This field has been removed from the input templates for version 2.

    		Free Text
    DISEASE FOLLOWUP 2.5 This field refers to the patient who is undergoing repeat procedure for the same (active) disease, such as follow-up on gastric ulcer healing. Used as an indication for procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISEASE FOLLOWUP .01 This field identifies the specific disease or evaluation used as an indication.

    		Pointer
    PointerTo:
    fileName:
    DISEASE EVALUATION
    fileNumber:
    699.84
    FOLLOWUP DEVICE OR THERAPY 2.6 This field records the type of device or therapy, previously performed, which needs follow-up. Used as an indication for procedure.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FOLLOWUP DEVICE OR THERAPY .01 This field identifies the specific type of device or therapy, previously performed, which needs follow-up.

    		Pointer
    PointerTo:
    fileName:
    FOLLOWUP DEVICE/THERAPY
    fileNumber:
    699.85
    SURVEILLANCE 2.7 This field identifies to the asymptomatic patient who is being re-examined because of old disease, such as prior colonic polyps. Used as an indication for procedure for GI Endoscopies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SURVEILLANCE .01 This field identifies the specific surveillance disease used as an indication for procedure.

    		Pointer
    PointerTo:
    fileName:
    SURVEILLANCE
    fileNumber:
    699.86
    PROTOCOL 2.8 This field identifies a mandated endoscopy according to a pre-approved schedule. The name or number of the protocol should be entered here. Used as a GI Endoscopy indication for procedure.

    		Free Text
    EGD SIMPLE PRIMARY EXAM 2.85 This field identifies that a PDGE (Primary Diagnostic Gastrointestinal Endoscopy) was performed in place of an initial screening X-ray, for diagnostic purposes in an outpatient setting.

    		Free Text
    LAB OR XRAY 2.86 This free text field indicates that there is an abnormal X-ray of lab test suggesting the Endoscopy. Used as an indication for procedure for GI Endoscopies.

    		Free Text
    OCCULT BLOOD 2.87 This field identifies a specific indication for procedure. It indicates that Occult Blood in the stool is present. Used for GI Endoscopies.

    		Free Text
    SPECIMEN COLLECTION 2.88 This free text field indicates that the procedure is performed to collect tissue or body fluid to perform other tests. Used as an indication for procedure for GI Endoscopies.

    		Free Text
    INDICATION COMMENT 3 This free text field is used to enhance or add to the specific indications for procedure.

    		Free Text
    INSTRUMENT 4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INSTRUMENT .01

    		Pointer
    PointerTo:
    fileName:
    INSTRUMENT
    fileNumber:
    699.48
    MEDICATION USED 5 This field identifies field records the type of medication administered for the procedure. It also records the dosage of the medication and the route of administration.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MEDICATION USED .01 This field identifies the specific medication administered.

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DRUG DOSE ROUTE 1 This field identifies a set of codes to record the route of administration for GI Endoscopies.

    		Set of Codes
    Set of Codes:
    • Code : IM
      Stands For: INTRAMUSCULAR
    • Code : IV
      Stands For: INTRAVENOUS
    • Code : O
      Stands For: ORAL
    • Code : PV
      Stands For: PARAVARICEAL
    • Code : SM
      Stands For: SUBMUCOSAL
    • Code : SQ
      Stands For: SUBCUTANEOUS
    • Code : T
      Stands For: TOPICAL
    • Code : V
      Stands For: INTRAVARICEAL
    TOTAL DOSE (in mg.) 2 This field identifies the total dosage in milligrams of the medication administered.

    		Numeric
    DRUG DOSE ROUTE-P 3 This field identifies a set of codes to record the route of administration for Pulmonary Endoscopies.

    		Set of Codes
    Set of Codes:
    • Code : SQ
      Stands For: SUBCUTANEOUS
    • Code : IM
      Stands For: INTRAMUSCULAR
    • Code : IV
      Stands For: INTRAVENOUS
    • Code : N/P
      Stands For: NASOPHARYNGEAL
    • Code : LA
      Stands For: LARYNGEAL
    • Code : TR
      Stands For: TRACHEAL
    ENDOSCOPIST 6 This field identifies the name of the provider who performed the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SECOND ENDOSCOPIST 7 This field identifies the name of a second doctor performing the procedure.

    		Free Text
    WHERE PERFORMED 8 This field identifies the hospital location where the procedure was performed.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    WARD/CLINIC 9 This field identifies the in-house location of the patient.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    TIME STARTED 10 This field identifies the time the procedure was begun in 24 hour time, without punctuation. (EX: 0800, 1630, etc.)

    		Free Text
    TIME COMPLETED 11 This field identifies the time the procedure was completed in 24 hour time, without punctuation (Ex: 0800,1630, etc.)

    		Free Text
    URGENCY OF PROCEDURE 12 This field identifies whether the procedure was elective, urgent, or emergency.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ELECTIVE
    • Code : 2
      Stands For: URGENT
    • Code : 3
      Stands For: EMERGENCY
    PNEUMOPERITONEUM GAS 13 This field identifies field contains the type of Pneumoperitoneum Gas used and the method of pressure control for Laparoscopy procedures.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PNEUMOPERITONEUM GAS .01 This field identifies the type of Pneumoperitoneum Gas (Air,CO2,NO2, Other) used.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AIR
    • Code : C
      Stands For: CO2
    • Code : N
      Stands For: NO2
    • Code : O
      Stands For: OTHER
    PRESSURE CONTROL 1 This field identifies whether the pressure was controlled manually or automatically.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: AUTOMATIC
    • Code : M
      Stands For: MANUAL
    PREPARATION DIET 14 This field identifies to the oral intake for preparation of the colon for a colonoscopy.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NO CHANGE
    • Code : 2
      Stands For: CLEAR LIQUIDS
    • Code : 3
      Stands For: SUPPLEMENTS
    • Code : 4
      Stands For: OTHER
    DIET COMMENT 15 This field identifies a comment on the oral intake given for the preparation for a colonscopy.

    		Free Text
    BOWEL PREPARATION 16 This field identifies a multiple field which records commonly used laxative preparations given for a colonoscopy and the route by which it was given.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BOWEL PREPARATION .01 This field indicates the type of laxative preparation given for a colonoscopy.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: BISCODYL
    • Code : 2
      Stands For: CASTER OIL
    • Code : 3
      Stands For: GOLYTELY
    • Code : 4
      Stands For: MAGNESIUM CITRATE
    • Code : 5
      Stands For: NEOLOID
    • Code : 6
      Stands For: OTHER
    • Code : 7
      Stands For: PHOSPHASODA
    ROUTE 1 This field indicates the method (Oral or Rectal) by which the preparation was administered.

    		Set of Codes
    Set of Codes:
    • Code : PO
      Stands For: ORAL
    • Code : PR
      Stands For: RECTAL
    ENEMAS 17 This field records the type of enemas given in preparation for a colonoscopy.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: WATER
    • Code : 2
      Stands For: PHOSPHASODA
    • Code : 3
      Stands For: OTHER
    COMMON BILE DUCT SIZE (mm) 22 This field identifies the size in millimeters of the Common Bile Duct. Used for the ERCP Procedure.

    		Numeric
    PANCREATIC DUCT SIZE (mm) 23 This field identifies the size in millimeters of the pancreatic duct. Used for ERCP procedures.

    		Numeric
    DEPTH OF INSERTION 24 This field indicates the extent of examination irrespective of the findings reported. This is a pointer to the Anatomy file.

    		Pointer
    PointerTo:
    fileName:
    ANATOMY
    fileNumber:
    697
    RESULTS 28 This field is used to record results of the overall procedure. This field is labeled 'Findings' for Pulmonary Endoscopies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RESULTS .01 This field identifies a result of the overall procedure.

    		Pointer
    PointerTo:
    fileName:
    RESULTS
    fileNumber:
    699.81
    POST-PROC INSTRUMENT CLEANSING 29 This field describes how the instruments were cleaned following the procedure. This is used for epidemiologic purposes.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: WASH
    • Code : 2
      Stands For: IMMERSION
    • Code : 3
      Stands For: GAS
    • Code : 4
      Stands For: UNKNOWN
    • Code : 5
      Stands For: OTHER
    COMPLICATIONS 30 This field identifies field indicates any complications encountered during the procedure or resulting from the procedure and the result of the complication.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMPLICATIONS .01 This field identifies any complications encountered during the procedure or as a result of the procedure.

    		Pointer
    PointerTo:
    fileName:
    COMPLICATION
    fileNumber:
    696.9
    COMP. RESULTS 1 This field identifies the result of the complication, ranging from REQUIRED NO THERAPY to RESULTING IN DEATH.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: REQUIRED NO THERAPY
    • Code : 2
      Stands For: REQUIRED TRANSFUSION
    • Code : 3
      Stands For: REQUIRED MEDICAL THERAPY
    • Code : 4
      Stands For: REQUIRED ENDOSCOPIC THERAPY
    • Code : 5
      Stands For: REQUIRED SURGICAL THERAPY
    • Code : 6
      Stands For: RESULTED IN DEATH
    NON-ENDOSCOPIC PROCEDURE 31 This field stores the procedure type for a non-endoscopic GI procedure. It is accessed by entering 'NON-ENDO' at the procedure prompt in the GI Endoscopy Enter/Edit.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    NON-ENDOSCOPIC PROCEDURE .01 This field stores the procedure type for a non-endoscopic GI procedure. It is accessed by entering 'NON-ENDO' at the procedure prompt in the GI Endoscopy Enter/Edit.

    		Pointer
    PointerTo:
    fileName:
    NON-ENDOSCOPIC PROCEDURE
    fileNumber:
    699.88
    CONSULTATION TYPE 31.5 This field indicates the type of consultation requested. Used in the Consult options.

    		Pointer
    PointerTo:
    fileName:
    CONSULTATION TYPE
    fileNumber:
    699.82
    SUBJECTIVE 32 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUBJECTIVE .01 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Word Processing
    OBJECTIVE 33 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OBJECTIVE .01 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Word Processing
    ASSESSMENT 34 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ASSESSMENT .01 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Word Processing
    PLANNED 35 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLANNED .01 This field identifies field is used to enter information in the Consult options and the Non-Endoscopic GI Procedure entry. Both these entries use the SOAP (Subjective, Objective, Assessment, Planned) format.

    		Word Processing
    DISC ID 35.9 This field is not being used at the present time.

    		Free Text
    VIDEO FRAME NUMBER 36 This field is not being used at the present time.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIDEO FRAME NUMBER .01 This field is not being used at the present time.

    		Numeric
    VIDEO/AUDIO FILE NAME 36.5 This field is not being used at the present time.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIDEO/AUDIO FILE NAME .01 This field is not being used at the present time.

    		Free Text
    DATE/TIME ADDED 1 This allows the user to enter the date/time the video/audio file name is added.

    		Date/Time
    DATE/TIME MODIFIED 3 This allows the user to enter the date/time the video/audio file name is modified.

    		Date/Time
    COMMENTS-1 5 This allows the user to enter comments.

    		Free Text
    COMMENTS-2 6 This allows the user to enter comments.

    		Free Text
    COMMENTS-3 7 This allows the user to enter comments.

    		Free Text
    COMMENTS-4 8 This allows the user to enter comments.

    		Free Text
    *RESERVED 37 This free-text field has been superseded by word-processing Field #37.1, DIAGNOSIS/DIAGNOSIS SUPPLEMENT.

    		Free Text
    DIAGNOSIS/DIAGNOSIS SUPPLEMENT 37.1 This field is used in addition to or instead of the diagnosis list generated from the impressions.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DIAGNOSIS/DIAGNOSIS SUPPLEMENT .01

    		Word Processing
    REVISED DIAGNOSIS 38 This field is a free text field used to modify or enhance the primary diagnosis. This field is generally used when there is an unexpected Pathology report.

    		Free Text
    DISPOSITION 39 This field identifies field stores post-encounter dispositions modified by a date and a free text reason.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISPOSITION .01 This field identifies the post-encounter disposition entered.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: VISIT FOLLOW-UP
    • Code : 2
      Stands For: ENDOSCOPY FOLLOW-UP
    • Code : 3
      Stands For: TEST (LAB OR XRAY)
    • Code : 4
      Stands For: CONSULT OTHER SPECIALIST
    • Code : 5
      Stands For: RETURN TO REFERRING MD
    • Code : 6
      Stands For: ADMIT TO HOSPITAL
    • Code : 7
      Stands For: DISCHARGED TO HOME
    • Code : 8
      Stands For: DISCHARGED TO WARD
    • Code : 9
      Stands For: OTHER
    FINAL DISPOSITION DATE 1 This field identifies the date of the disposition. This date may be in the future as in the case of Endoscopy Follow Up entered as the disposition.

    		Date/Time
    REASON 2 This field identifies the reason for the disposition given.

    		Free Text
    PRESCRIPTION GIVEN 40 This field identifies field stores the drug(s) and dosage(s) given as a post- encounter prescription.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRESCRIPTION GIVEN .01 This field identifies the name of the formulary drug given as a post-encounter prescription.

    		Pointer
    PointerTo:
    fileName:
    DRUG
    fileNumber:
    50
    DOSAGE 1 This field identifies the dosage of the prescribed drug.

    		Free Text
    SECONDARY DIAGNOSIS 41 This field identifies one or more diagnoses chosen from the list of impressions minus the diagnosis chosen as the primary diagnosis. Each diagnosis also has a free text impression field linked with it.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SECONDARY DIAGNOSIS .01 This field identifies a diagnosis chosen from the list of impressions entered minus the diagnosis entered as the primary diagnosis.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    SECONDARY DIAGNOSIS IMPRESSION 1 This contains a free text comment regarding the chosen secondary diagnosis.

    		Free Text
    ANATOMY 2 This allows the user to enter the anatomy of the secondary diagnosis. Once this is entered, it may not be edited.

    		Pointer
    PointerTo:
    fileName:
    ANATOMY
    fileNumber:
    697
    LOCATION EVALUATED 50 This field identifies field records the anatomical location evaluated and records findings for the location evaluated.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOCATION EVALUATED .01 This field identifies field records the anatomical location evaluated and records findings for the location evaluated.

    		Pointer
    PointerTo:
    fileName:
    ANATOMY
    fileNumber:
    697
    GROSS 2 This field identifies a descriptor of the findings on the anatomical location.

    		Pointer
    PointerTo:
    fileName:
    GROSS
    fileNumber:
    699.55
    MODIFIER 3 This field identifies a multiple adjective used to modify the Gross descriptor.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MODIFIER .01 This field identifies a specific adjective used to modify the Gross descriptor.

    		Pointer
    PointerTo:
    fileName:
    MODIFIER
    fileNumber:
    699.57
    MEASUREMENT 4 This field identifies the size of the Gross finding (Ex: 4 cm; 4x3 cm; 4 cm high,etc.)

    		Free Text
    TECHNIQUE 5 This field identifies subfield indicates the technique(s) used to evaluate the anatomical location.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TECHNIQUE .01 This field identifies the specific technique used to evaluate the anatomical location.

    		Pointer
    PointerTo:
    fileName:
    DIAG/THERAP INTERVENT
    fileNumber:
    699.6
    IMPRESSION 6 This field identifies findings for the location evaluated. It then is placed on the list of possible diagnoses.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    VIDEO FRAME NUMBER 10 This field identifies is not being used at the present time.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIDEO FRAME NUMBER .01 This field identifies is not being used at the present time.

    		Numeric
    STENT TYPE 11 This field identifies the type of stent used if INSERTION OF STENT is entered as a technique. Used for GI Endoscopies.

    		Pointer
    PointerTo:
    fileName:
    ENDOSCOPIC DEVICE
    fileNumber:
    699.7
    STENT SIZE (FR) 12 This field identifies the size of stent used if INSERTION OF STENT is entered as a technique. Used for GI Endoscopies.

    		Numeric
    STENT LENGTH (mm) 13 This field identifies the length of the stent used in millimeters if INSERTION OF STENT is entered as a technique. Used for GI Endoscopies.

    		Numeric
    SPHINCTEROTOME USED 14 This field identifies the type of sphincterotome used if SPHINCTEROTOMY is entered as a technique. Used for GI Endoscopies.

    		Pointer
    PointerTo:
    fileName:
    ENDOSCOPIC DEVICE
    fileNumber:
    699.7
    INCISION SIZE 15 This field identifies the length of the incision made if SPHINCTEROTOMY is entered as a technique. Used for GI Endoscopies.

    		Numeric
    SAVARY BOUGIE DIAMETER 16 This field identifies the diameter of the savary bougie used if DILATION BY SAVARY BOUGIE is entered as a technique. Used for GI procedures.

    		Free Text
    HEATER PROBE: DURATION 17 This field identifies the length of time a heater probe is used if HEATER PROBE COAGULA- TION is entered as a technique. Used for GI procedures.

    		Free Text
    HEATER PROBE: POWER 18 This field identifies the power of the heater probe used if HEATER PROBE COAGULATION is entered as a technique. Used for GI procedures.

    		Free Text
    GASTROSTOMY TUBE USED 19 This field identifies the specific tube used if GASTROSTOMY TUBE INSERTED is entered as a technique. Used for GI procedures.

    		Pointer
    PointerTo:
    fileName:
    ENDOSCOPIC DEVICE
    fileNumber:
    699.7
    JEJUNOSTOMY TUBE INSERTED 20 This field identifies the specific tube used if JEJUNOSTOMY TUBE INSERTED is entered as a technique. Used for GI procedures.

    		Pointer
    PointerTo:
    fileName:
    ENDOSCOPIC DEVICE
    fileNumber:
    699.7
    FELLOW 200 This field identifies the name of a fellow who assisted on the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SECOND FELLOW 201 This field identifies the name of a second fellow who assisted on the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUMMARY 202 This field indicates whether the Endoscopy was Normal,Abnormal or Incomplete. This required field appears on the Summary of Patient Procedures.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : I
      Stands For: INCOMPLETE EXAMINATION
    INSTRUCTIONS TO PATIENT 203 This field identifies a word processing field which indicates post-procedural instructions given to the patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INSTRUCTIONS TO PATIENT .01 This field identifies a word processing field which indicates post-proceduriall instructions given to the patient.

    		Word Processing
    PRIMARY DIAGNOSIS 204 This field contains a primary diagnosis chosen by the user from the list of impressions entered in the location evaluated field. Once this diagnosis is entered it can not be changed or deleted.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    PRIMARY DIAGNOSIS ANATOMY 204.5 This allows the user to enter the Primary Diagnosis Anatomy. Once this is entered it can not be changed or deleted.

    		Pointer
    PointerTo:
    fileName:
    ANATOMY
    fileNumber:
    697
    PRIMARY DIAGNOSIS IMPRESSION 205 This contains a free text comment regarding the primary diagnosis.

    		Free Text
    COUGH 206 This field stores the type of cough the patient has and the duration of the cough. Used for Pulmonary Endoscopies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TYPE OF COUGH .01 This field identifies the type of cough the patient has. Used in Pulmonary Endoscopy.

    		Pointer
    PointerTo:
    fileName:
    SYMPTOM
    fileNumber:
    695.5
    DURATION 1 This free text subfield indicates the duration of the cough.

    		Free Text
    PNEUMONIA 207 This field identifies field stores the location of pneumonia and the dates during which the pneumonia occurred. This is used as an indication for Pulmonary Endoscopies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LOCATION OF PNEUMONIA .01 This field identifies the anatomical location of the pneumonia.

    		Pointer
    PointerTo:
    fileName:
    LOCATION OF PAIN/PNEUMONIAS
    fileNumber:
    699.83
    DATES 1 This field identifies a range of dates during which the pneumonia occurred and is free text.

    		Free Text
    OTHER FOLLOWUP DEVICE/THERAPY 208 This field identifies a free text field which records the type of device or therapy, previously performed, which needs therapy. This can be used instead of or in addition to the pointed to list.

    		Free Text
    PROCEDURE SUMMARY 600 This field identifies a free text summary of the Endoscopy (up to 79 characters). This required field appears on the Summary of Patient Procedures.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provide a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARKED FOR DELETION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARKED FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    RECORD CREATED 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric
    IMAGE 2005 This field points to an object in the Image File.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This field points to an object in the Image File.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    GENERALIZED PROCEDURE/CONSULT

    File Number: 699.5

    File Description:

    This file stores basic information on procedures in subspecialties for which separate files do not currently exist in the Medicine package.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01

    		Date/Time
    MEDICAL PATIENT .02

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    SUBSPECIALTY .05 Only subspecailty in the PROCEDURE/SUBSPECIALTY file will be chosen.

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE/SUBSPECIALTY
    fileNumber:
    697.2
    PROCEDURE .06 Only procedure in the PROCEDURE/SUBSPECIALTY file will be chosen.

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE/SUBSPECIALTY
    fileNumber:
    697.2
    INDICATION 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INDICATION .01

    		Word Processing
    PROBLEM ORIENTED CONSULT? 2 This field is automatically stuffed if an entry is made though the various Medicine package sub-modules' Problem-Oriented Consult Option.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    OUTPUT-FORMATTED POC 2.01 This field formats the PROBLEM ORIENTED CONSULT? field (#2) for the output report.

    		Computed
    INDICATION COMMENT 3 This field is used in the Problem-Oriented Consult Enter/Edit and Print.

    		Free Text
    MEDICATIONS 5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MEDICATIONS .01

    		Pointer
    PointerTo:
    fileName:
    DRUG
    fileNumber:
    50
    PROVIDER/PHYSICIAN 6

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TECHNIQUE 7

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TECHNIQUE .01

    		Pointer
    PointerTo:
    fileName:
    DIAG/THERAP INTERVENT
    fileNumber:
    699.6
    COMPLICATIONS 30

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMPLICATIONS .01

    		Pointer
    PointerTo:
    fileName:
    COMPLICATION
    fileNumber:
    696.9
    CONSULTATION TYPE 31.5

    		Pointer
    PointerTo:
    fileName:
    CONSULTATION TYPE
    fileNumber:
    699.82
    SUBJECTIVE 32

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUBJECTIVE .01

    		Word Processing
    OBJECTIVE 33

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OBJECTIVE .01

    		Word Processing
    ASSESSMENT/FINDINGS 34

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ASSESSMENT/FINDINGS .01

    		Word Processing
    PLAN 35

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLAN .01

    		Word Processing
    PROCEDURE SUMMARY 600

    		Free Text
    SUMMARY 601

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ABNORMAL
    • Code : N
      Stands For: NORMAL
    • Code : I
      Stands For: INCOMPLETE EXAMINATION
    ICD DIAGNOSIS 700 This field is used to store ICD Diagnosises for retrieval by Queryman. The field consists of an ICD Code Subfield and a Narrative Diagnosis Subfield. The Narrative Diagnosis Subfield is for future use and is not used at the present time.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field is used to store ICD Diagnosises for retrieval by Queryman. The field consists of an ICD Code Subfield and a Narrative Diagnosis Subfield. The Narrative Diagnosis Subfield is for future use and is not used at the present time.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE CODE 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASE ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASE OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASE NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: SUPERSEDING RELEASE ON-LINE VERIFIED
    • Code : SROV
      Stands For: SUPERSEDING RELEASE OFF-LINE VERIFIED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETATION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Date/Time
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric
    IMAGE 2005

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    PULMONARY FUNCTION TESTS

    File Number: 700

    File Description:

    This file stores the data on Pulmonary Function Tests performed on the patient.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the date/time of the Pulmonary Function tests.

    		Date/Time
    SUMMARY .03 This field identifies a brief summary of the PFT for use on the Summary of Patient Procedures and the Health Summary. The Results portion of OERR is expected to trigger off this field in the future.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    • Code : B
      Stands For: BORDERLINE
    • Code : T
      Stands For: TECHNICALLY UNSATISFACTORY
    MEDICAL PATIENT 1 This field identifies the patient's name.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    HEIGHT (CM) 2 This field identifies the Height of the patient in Centimeters.

    		Numeric
    HEIGHT (INCHES.TENTHS) 3 This field identifies the height of the patient in inches and tenths of inches. This value will be converted to Centimeters for the report.

    		Numeric
    WEIGHT (POUNDS.TENTHS) 4 This field identifies the weight of the patients in pounds and tenths of pounds. This value will be converted to Kilograms for the report.

    		Numeric
    WEIGHT (KG) 5 This field identifies the weight of the patient in Kilograms.

    		Numeric
    BAROMETRIC PRESSURE 6 This field identifies the Barometric Pressure in Torr units at the time the PFT was done

    		Numeric
    ROOM TEMPERATURE (CENTIGRADE) 6.5 This field identifies the room temperature in degrees centigrade at the time the PFT was done

    		Numeric
    SMOKER 7 This field tells whether the patient is a smoker or a non-smoker.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    CURRENT BRONCHODILATOR 8 This field tells whether the patient had used a Bronchodilator within 4 hours of the test.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    WARD/CLINIC 9 This field will be a ward if the patient is an inpatient, a clinic if the patient is an outpatient.

    		Pointer
    PointerTo:
    fileName:
    HOSPITAL LOCATION
    fileNumber:
    44
    REFERRING PHYSICIAN 10 This field refers to the Physician who ordered the PFT.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CONSULT DX 11 This field identifies the diagnosis sent to the PFT lab by the Referring Physician.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CONSULT DX .01 This field identifies the diagnosis sent to the PFT lab by the referring physician

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    VOLUME STUDY 17 The subfields of this field hold the Volume Study Data for the PFT.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VOLUME STUDY TYPE .01 This field identifies the type of Volume Study done.

    		Set of Codes
    Set of Codes:
    • Code : B
      Stands For: BODY BOX
    • Code : I
      Stands For: INERT GAS DILUTION
    • Code : N
      Stands For: NITROGEN WASH OUT
    • Code : X
      Stands For: X-RAY PLANIMETRY
    TLC 1 This field identifies the Total Lung Capacity measured.

    		Numeric
    VC 2 This field identifies the measured Vital Capacity.

    		Numeric
    FRC 3 This field identifies the measured Functional Residual Capacity.

    		Numeric
    RV 4 This field identifies the measured Residual Volume.

    		Numeric
    NOTES 6 This field identifies a free text field for entering a note on the current Volume Study.

    		Free Text
    FLOWS STUDY 18 This field identifies stores data of the Flow Study done on the patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FLOWS STUDY .01 This field identifies the type of Flow Study performed.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: STANDARD STUDY
    • Code : B
      Stands For: AFTER BRONCHODILATORS
    • Code : I
      Stands For: AFTER INHALATION CHALLENGE
    • Code : X
      Stands For: AFTER EXERCISE
    FVC 1 This field identifies the measured Forced Vital Capacity.

    		Numeric
    FEV1 2 This field identifies the measured Forced Expired Volume in 1 second

    		Numeric
    PF 3 This field identifies the measured Peak Flow.

    		Numeric
    FEF25-75 4 This field identifies the measured Forced Expired Flow from 25 to 75 percent.

    		Numeric
    FEV1/FVC 5 This computed field is the Forced Expired Volume divided by the Forced Vital capacity.

    		Computed
    MVV 5.5 This field identifies the Maximum Voluntary Ventilation in Liters/Minute

    		Numeric
    NOTES 6 This field identifies allows the entering of a note (up to 60 characters) on this Flow Study.

    		Free Text
    DLCO-SB 19 This field identifies the measured Diffusing Capacity.

    		Numeric
    BLOOD GAS 20 This field is a multiple field which stores the data for the Arterial Blood Gas (ABG) Study.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BLOOD GAS .01 This field identifies the type of Arterial Blood Gas Study done.

    		Set of Codes
    Set of Codes:
    • Code : O
      Stands For: 100% O2 STUDY
    • Code : X
      Stands For: POST EXERCISE
    • Code : S
      Stands For: SUPPLEMENTAL O2 STUDY
    • Code : R
      Stands For: ROOM AIR
    • Code : M
      Stands For: MAXIMUM EXERCISE
    • Code : P
      Stands For: PRE EXERCISE
    HB 1 This field identifies the measured Hemoglobin value.

    		Numeric
    pH 2 This field identifies the measured pH level.

    		Numeric
    pCO2 3 This field identifies the measured Arterial Carbon Dioxide Pressure in mm Mercury.

    		Numeric
    pO2 4 This field identifies the measured Arterial Oxygen Pressure in mm Mercury.

    		Numeric
    O2HB 5 This field identifies the measured Hemoglobin Oxygen

    		Numeric
    COHB 6 This field identifies the measured Carboxyhemoglobin Saturation

    		Numeric
    FiO2 7 This field identifies the fraction of Inspired Oxygen

    		Numeric
    MHB 8 This field identifies the Methemoglobin Saturation

    		Numeric
    NOTES 9 This field identifies allows a 60 character note to be entered on the Arterial Blood Gas study

    		Free Text
    PATIENT TEMPERATURE 10 This allows the user to enter the patient temperature in degrees Centigrade.

    		Numeric
    INTERPRETATION BY 21 This field identifies the provider who interpreted the PFT

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    INTERPRETATION BY .01 This field identifies the provider who interpreted the PFT

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COMP. GEN. VOLUME INTERP. 22

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. GEN. VOLUME INTERP. .01

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    VOLUME INTERPRETATION 22.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VOLUME INTERPRETATION .01

    		Word Processing
    COMP. GEN. FLOWS INTERP. 23

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. GEN. FLOWS INTERP. .01

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    FLOWS INTERPRETATION 23.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FLOWS INTERPRETATION .01

    		Word Processing
    COMP. FLOW VOL. LOOP INTERP. 24

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. FLOW VOL. LOOP INTERP. .01

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    FLOW VOLUME LOOP INTERP. 24.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FLOW VOLUME LOOP INTERP. .01

    		Word Processing
    COMP. GEN. DIFFUSION INTERP. 26

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. GEN. DIFFUSION INTERP. .01

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    DIFFUSION INTERPRETATION 26.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DIFFUSION INTERPRETATION .01

    		Word Processing
    COMP. GEN. ABG INTERP. 27

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. GEN. ABG INTERP. .01

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    PREDICTED VALUE FORMULAS USED 28 This field identifies a pointer to the set of formulas used to calculate predicted values.

    		Pointer
    PointerTo:
    fileName:
    PFT PREDICTED VALUES
    fileNumber:
    700.1
    IMPRESSION 29

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMPRESSION .01

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DESCRIPTION
    fileNumber:
    693
    COMMENTS AND RECOMMENDATIONS 30 This field identifies a word processing field which allows comments and recommendations to be entered by the interpreter.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENTS AND RECOMMENDATIONS .01 This field identifies a word processing field which allows comments and recommendations to be entered by the interpreter.

    		Word Processing
    REVIEWED BY 31 This field identifies the provider who reviewed the PFT.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SPECIAL STUDY 32 This field identifies allows special study data to be entered for this PFT

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIAL STUDY .01 This field identifies the type of special study done: Exercise, Mechanics, Small Airway, or Maximum Pressures.

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: EXERCISE
    • Code : M
      Stands For: MECHANICS
    • Code : S
      Stands For: SMALL AIRWAY
    • Code : P
      Stands For: MAXIMUM PRESSURES
    RESISTANCE,RAW 1 This field identifies the Specific Airway Resistance in cm H2O/Liters per second. Used in the Mechanics Special Study.

    		Numeric
    RESISTANCE,SGAW 2 This field identifies the Specific Airway Conductance in Liters per second/cm H2O. Used in the Mechanics Special Study.

    		Numeric
    COMPLIANCE,CST 3 This field identifies the Static Compliance in Liters/cm H2O. Used in the Mechanics Special Study.

    		Numeric
    COMPLIANCE,CDYN 4 This field identifies the Dynamic Compliance in Liters/cm H2O. Used in the Small Airway Special Study.

    		Numeric
    FEF50 HE-AIR 5 This field identifies the Maximum Expiratory at 50% of Vital Capacity breathing air in Liters/second. Used in the Small Airway Special Study.

    		Numeric
    VISOV 6 This field identifies the Lung Volume at which Helium & Air Flow Tracings meet in Liters. Used in the Small Airway Special Study.

    		Numeric
    CV 7 This field identifies the Closing Volume in Liters. Used in the Small Airway Special Study

    		Numeric
    CC 8 This field identifies the Closing Capacity in Liters. Used in the Small Airway Special Study.

    		Numeric
    VALVE DEAD SPACE 9

    		Numeric
    VEMAX(BTPS) 10 This field identifies the Maximum Expiratory Minute Ventilation at Peak Exercise in ml/beat. Used in the Exercise Special Study.

    		Numeric
    BR 11 This field identifies the Breathing Reserve in Liters. Used in the Exercise Special Study.

    		Numeric
    VD/VT REST 12 This field identifies the Resting Dead Space to Tidal Volume Ratio. Used in the Exercise Special Study.

    		Numeric
    VD/VT MAX 12.3 This field identifies the Maximum Dead Space to Tidal Volume Ratio. Used in the Exercise Special Study.

    		Numeric
    VE/VCO2, AT 12.6 This field identifies the Ventilatory Equivalent for Carbon Dioxide at Anaerobic Threshold. Used in the Exercise Special Study.

    		Numeric
    CV 13

    		Numeric
    VE REST(BTPS) 14 This field identifies the Expiratory Minute Ventilation at Rest in ml/beat. Used in the Exercise Special Study.

    		Numeric
    VO2 REST 15 This field identifies the Oxygen Uptake at Rest in Liters/Minute. Used in the Exercise Special Study.

    		Numeric
    VO2 MAX 16 This field identifies the Oxygen Uptake at Peak Exercise in Liters/Minute. Used in the Exercise Special Study.

    		Numeric
    AT 16.5 This field identifies the Anaerobic Threshold in Liters. Used in the Exercise Special Study.

    		Numeric
    HR REST 17 This field identifies the Heart Rate at Rest. Used in the Exercise Special Study.

    		Numeric
    HR MAX 18 This field identifies the Heart Rate at Peak Exercise in beats/minute. Used in the Exercise Special Study.

    		Numeric
    VO2/HR 18.2 This field identifies the Oxygen Pulse Maximum in milliliters per beat. Used in the Exercise Special Study.

    		Numeric
    BP MAX 18.4 This field identifies the Maximum Blood Pressure. Used in the Exercise Special Study.

    		Free Text
    EKG 18.6 This field identifies whether the EKG was Normal or Abnormal. Used in the Exercise Special Study.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : A
      Stands For: ABNORMAL
    RR REST 19 This field identifies the Respiratory Rate at Rest. Used in the Exercise Special Study.

    		Numeric
    RR MAX 20 This field identifies the Respiratory Rate at Peak Exercise. Used in the Exercise Special Study.

    		Numeric
    W MAX 21 This field identifies the Work Rate in Watts. Used in the Exercise Special Study.

    		Numeric
    WRI/WRT 21.5 This field identifies the Work Rate Increment/Work Rate Time Interval ratio in Watts per minute. Used in the Exercise Special Study.

    		Numeric
    TOTAL TIME 22 This field identifies the Total Time in minutes of Exercise. Used in the Exercise Special Study.

    		Numeric
    HCO3 CHANGE 22.5 This field identifies the change in bicarbonate IN mEq/l. Used in the Exercise Special Study.

    		Numeric
    MAX SPEED 23 This field identifies the Maximum Treadmill Speed in MPH at Peak Exercise. Used in the Exercise Special Study.

    		Numeric
    MAX GRADE 24 This field identifies the Maximum Treadmill Grade at Peak Exercise. Used in the Exercise Special Study.

    		Numeric
    EXERCISE TESTING MODE 28 This field identifies the mode of testing used for an Exercise Special Study.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: TREADMILL
    • Code : 2
      Stands For: BIKE ERGOMETER
    • Code : 3
      Stands For: HAND ERGOMETER
    REASON FOR STOPPING 29 This field identifies the Reason for Stopping an Exercise Special Study. This subfield points to the REASON (MEDICINE) File.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    REASON FOR STOPPING .01 This field identifies the Reason for Stopping of an Exercise Special Study. This subfield points to the MEDICINE (REASON) File.

    		Pointer
    PointerTo:
    fileName:
    REASON (MEDICINE)
    fileNumber:
    695.8
    OTHER REASON FOR STOPPING 30 This field identifies a word-processing field to enter Reason(s) for Stopping for Exercise Special Studies that are not in the REASON (MEDICINE) File.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER REASON FOR STOPPING .01 This field identifies a word-processing field to enter Reason(s) for Stopping for Exercise Special Studies that are not in the REASON (MEDICINE) File.

    		Word Processing
    PIMAX 35 This field identifies the Maximum Inspiratory Pressure in cm H2O. Only element of the Maximum Pressures Special Study.

    		Numeric
    PATIENT EFFORT (SPEC. STUDIES) 39

    		Set of Codes
    Set of Codes:
    • Code : G
      Stands For: GOOD
    • Code : E
      Stands For: EXCELLENT
    • Code : P
      Stands For: POOR
    NOTES 40 This field identifies a 60 character Free Text field which allows the user to enter a note on the Special Study.

    		Free Text
    COMP. GENERATED INTERPRETATION 33 This field identifies stores the Computer Generated Interpretation(s) for the PFT and whether or not the Interpreter accepted the Interpretation.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMP. GENERATED INTERPRETATION .01 This field identifies a computer generated interpretation for the PFT.

    		Pointer
    PointerTo:
    fileName:
    INTERPRETATION
    fileNumber:
    693.2
    ACCEPTED? 1 This field tell whether or not the Interpreter accepted the Computer Generated Interpretation. The Interpretation will appear on the report ONLY IF the Interpreter accepted the Interpretation.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    FREE TEXT INTERPRETATION 33.5 This field identifies a word processing field which allows the Interpreter to enter Interpretation(s) in addition to, or instead of, the Computer Generated Interpretations.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FREE TEXT INTERPRETATION .01 This field identifies a word processing field which allows the Interpreter to enter Interpretation(s) in addition to , or instead of, the Computer Generated Interpretations.

    		Word Processing
    TECHNICIAN 34 This field identifies the Technician who performed the PFT.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    FLOW STUDY MACHINE 35 This field identifies the type of machine used for the Flow Study.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FLOW TURBINE
    • Code : P
      Stands For: PNEUMOTACH
    • Code : A
      Stands For: ANEMOMETER
    • Code : DS
      Stands For: DRY WATER SEAL
    • Code : WS
      Stands For: WATER SEAL
    • Code : W
      Stands For: WEDGE
    DIFFUSING CAPACITY METHOD 37 This field identifies the Method used for the Diffusing Capacity (DLCO) Test.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: SINGLE BREATH
    • Code : 2
      Stands For: STEADY STATE
    USE RACE CORRECTIONS 38 This field allows the user to decide whether certain data should be race corrected. Used for Black or Oriental patients.

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    RACE CORRECTIONS FOR RACE TYPE 38.5 If the 'USE RACE CORRECTIONS' is set to YES and the race value is both BLACK and ASIAN, this field will store which race type the race correction will be for.

    		Set of Codes
    Set of Codes:
    • Code : B
      Stands For: BLACK
    • Code : A
      Stands For: ASIAN
    PATIENT EFFORT 39 This field indicates the patient effort: GOOD, EXCELLENT, or POOR.

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: EXCELLENT
    • Code : G
      Stands For: GOOD
    • Code : P
      Stands For: POOR
    RELEASE REPORT 40

    		Set of Codes
    Set of Codes:
    • Code : Y
      Stands For: YES
    • Code : N
      Stands For: NO
    OTHER REASON FOR STOPPING 41

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OTHER REASON FOR STOPPING .01

    		Word Processing
    PROCEDURE SUMMARY 600 This field identifies a required 79 character summary of the PFT. Will appear on the Summary of Patient Procedures.

    		Free Text
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    ENTERING DUZ 1500

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    COSIGNER VALIDATION CODE 1501

    		Free Text
    ENTERING DATE 1502

    		Date/Time
    VERIFYING DUZ 1503

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SIGNER VALIDATION CODE 1504

    		Free Text
    VERIFIER DATE 1505

    		Date/Time
    RELEASE STATUS 1506

    		Set of Codes
    Set of Codes:
    • Code : D
      Stands For: DRAFT
    • Code : PD
      Stands For: PROBLEM DRAFT
    • Code : RV
      Stands For: RELEASED ON-LINE VERIFIED
    • Code : ROV
      Stands For: RELEASED OFF-LINE VERIFIED
    • Code : RNV
      Stands For: RELEASED NOT VERIFIED
    • Code : S
      Stands For: SUPERSEDED
    • Code : SRV
      Stands For: RELEASED ON-LINE VERIFIED OF SUPERSEDED
    • Code : SROV
      Stands For: RELEASED OFF-LINE VERIFIED OF SUPERSEDED
    DATE OF RELEASED 1507

    		Date/Time
    DATE OF VERIFIED 1508

    		Date/Time
    SUPERSEDED 1509

    		Numeric
    SUPERSEDED BY 1510

    		Numeric
    MARK FOR DELETION 1511

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MARK FOR DELETION
    DELETER DUZ 1512

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPERSEDED DATE 1513

    		Free Text
    CREATION DATE 1514

    		Date/Time
    SUPERSEDED NUMBER 1515

    		Numeric

    RHEUMATOLOGY

    File Number: 701

    File Description:

    This file stores data on Rheumatology visits.


    Fields:

    Name Number Description Data Type Field Specific Data
    DATE/TIME .01 This field identifies the date and time that the data is first entered into the database or when the data was collected.

    		Date/Time
    MEDICAL PATIENT 1 This field identifies the patient in the medicine file.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL PATIENT
    fileNumber:
    690
    SSN 1.1 This field identifies the SSN, which is computed.

    		Computed
    BLURRED VISION 2 Indicates whether the patient experienced blurring of vision in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DIZZINESS 3 Indicates whether the patient experienced dizziness in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DRY EYES 4 Indicates whether the patient experienced dry eyes in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DRY MOUTH 5 Indicates whether the patient experienced dry mouth in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    FEVER 6 Indicates whether the patient experienced fever in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEADACHE 7 Indicates whether the patient experienced headache in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEARING DIFFICULTIES 8 Indicates whether the patient experienced hearing difficulties in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    INCREASED SWEATING 9 Indicates whether the patient experienced increased sweating in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    NIGHT SWEATS 9.1 Indicates whether the condition of NIGHT Sweats exists.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOSS,CHANGE IN TASTE 10 Indicates whether the patient experienced loss, change in taste in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOSS OF HAIR 11 Indicates whether the patient experienced loss of hair in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MOUTH SORES 12 Indicates whether the patient experienced mouth sores in the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    RED,IRRITATED EYES 13 Indicates whether the patient experienced red, irritated eyes over the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    RINGING IN EARS 14 Indicates whether the patient experienced ringing in ears during the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SORE THROAT 15 Indicates whether the patient experienced sore throat during the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    CHEST PAIN/TAKING DEEP BREATH 16 Indicates whether the patient experienced chest pain/ taking deep breath during the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SHORTNESS OF BREATH 17 Indicates whether the patient experienced shortness of breath during the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    WHEEZING(ASTHMA) 18 Indicates whether the patient experienced wheezing during the past 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    BLK/TARRY STOOL(NOT FROM IRON) 19 Indicates whether the patient experienced black/tarry stool (not caused by iron ingestion) during the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LIVER PROBLEMS 19.1 Enter a brief description of liver disease.

    		Free Text
    CONSTIPATION 20 Indicates whether the patient experienced constipation during the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DIARRHEA(FREQUENT,WATERY) 21 Indicates whether the patient experienced diarrhea in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DIFFICULTY SWALLOWING 22 Indicates whether the patient experienced difficulty in swallowing in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    GAS(FLATULENCE) 23 Indicates whether the patient experienced gas in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEARTBURN,INDIGESTION,BELCHING 24 Indicates whether the patient experienced heartburn, indigestion, or belching in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    JAUNDICE 25 Indicates whether the patient experienced jaundice in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOOSE/FREQUENT BOWEL(MILD) 26 Indicates whether the patient experienced loose/ frequent bowel in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOSS OF APPETITE 27 Indicates whether the patient experienced loss of appetite in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PAIN/CRAMPS LOWER ABDOMEN 28 Indicates whether the patient experienced pain/ cramps in the lower abdomen in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PAIN/DISCOMFORT UPPER ABDOMEN 29 Indicates whether the patient experienced pain/ discomfort in the upper abdomen in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    VOMITING 30 Indicates whether the patient experienced vomiting in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    BLOOD IN URINE 31 Indicates whether the patient experienced blood in the urine in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    URINE PROTEIN 31.1 Indicates whether the patient has had a history of urine protein.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    KIDNEY PROBLEMS 31.5 Describes forms of kidney problems in the patient's history.

    		Free Text
    OTHER 31.8 A brief description of a relevant condition which cannot be otherwise noted.

    		Free Text
    BURNING ON URINATION 32 Indicates whether the patient experienced burning on urination in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PREGNANT 33 Indicates whether the patient is pregnant.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    IRREGULAR PERIODS 34 Indicates whether the patient experienced irregular periods in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    STIFF IN THE MORNING HOW LONG 35 Indicates whether the patient experienced stiffness in the morning and how long in the last 6 months.

    		Numeric
    JOINT PAIN 36 Indicates whether the patient experienced joint pain in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    JOINT SWELLING 37 Indicates whether the patient experienced joint swelling in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOW BACK PAIN 38 Indicates whether the patient experienced low back pain in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    MUSCLE PAIN 39 Indicates whether the patient experienced muscle pain in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    NECK PAIN 40 Indicates whether the patient experienced neck pain in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    NIGHT PAIN 41 Indicates whether the patient experienced night pain in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    NUMBNESS OR TINGLING 42 Indicates whether the patient experienced numbness or tingling in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SWELLING OF LEGS 43 Indicates whether the patient experienced swelling of legs in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    WEAKNESS OF MUSCLES 44 Indicates whether the patient experienced weakness of muscles experienced in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DEPRESSION 45 Indicates whether the patient experienced depression in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    INSOMNIA 46 Indicates whether the patient experienced insomnia in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    NERVOUSNESS 47 Indicates whether the patient experienced nervousness in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SEIZURES OR CONVULSION 48 Indicates whether the patient experienced seizures or convulsions in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    TIREDNESS 49 Indicates whether the patient experienced tiredness in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    TROUBLE REMEMBERING/THINKING 50 Indicates whether the patient experienced trouble remembering or thinking in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    EASY BRUISING 51 Indicates whether the patient experienced easy bruising in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    FACIAL SKIN TIGHTENING 52 Indicates whether the patient experienced facial skin tightening in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HIVES OR WELTS 53 Indicates whether the patient experienced hives or welts in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    ITCHING 54 Indicates whether the patient experienced itching in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    RASH 55 Indicates whether the patient experienced a rash in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    RASH OVER CHEEKS 56 Indicates whether the patient experienced rash over cheeks in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SKIN COLOR CHANGE IN FINGER 57 Indicates whether the patient experienced skin color change in finger in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SUN SENSITIVITY 58 Indicates whether the patient experienced sun sensitivity in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DISCHARGE FROM PENIS 59 Indicates whether the patient experienced discharge from the penis in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    IMPOTENCE 60 Indicates whether the patient experienced impotence in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    RASH/ULCERS ON PENIS 61 Indicates whether the patient experienced rash/ ulcers on the penis in the last 6 months.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    HEIGHT 62 Indicates the patient's height in centimeters.

    		Numeric
    WEIGHT 63 Indicates the patient's weight in kilograms.

    		Numeric
    SYSTOLIC PRESSURE 64 Indicates systolic blood pressure in millimeters of mercury.

    		Numeric
    DIASTOLIC PRESSURE 65 Indicates diastolic pressure in millimeters of mercury.

    		Numeric
    PULSE 66 Indicates pulse rate per minute.

    		Numeric
    UVEITIS 67 Indicates the presence of uveitis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    UVEITIS/IRITIS 67.5 Indicates the degree of uveitis/iritis present.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    CONJUNCTIVITIS/EPISCLERITIS 67.7 Indicates the degree of conjunctivitis/episcleritis present.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    CATARACT 68 Indicates the presence of a cataract.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    IRITIS 69 Indicates the presence of iritis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ORAL ULCERS 70 Indicates the patient has oral ulcers.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RALES 71 Indicate the degree of rales.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PLEURAL RUB/CLINICAL PLEURISY 72 Indicates the degree of pleural rub.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PLEURAL EFFUSION 73 Indicates the degree of pleural effusion.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PERICARDIAL RUB/PERICARDITIS 74 Indicates the degree of pericardial rub.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SYSTOLIC MURMUR 75 Indicates the degree of systolic murmur.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    DIASTOLIC MURMUR 76 Indicates the degree of diastolic murmur.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    LYMPH NODE ENLARGEMENT 77 Indicates the degree of lymph node enlargement.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MUSCLE TENDERNESS 78 Indicates the degree of muscle tenderness.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MUSCLE WEAKNESS-DISTAL 79 Indicates the degree of distal muscle weakness.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    HEPATOMEGALY 80 Indicates the degree of hepatomegaly.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SPLENOMEGALY 81 Indicates the degree of splenomegaly.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MUSCLE WEAKNESS-PROXIMAL 82 Indicates the degree of proximal muscle weakness.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MUSCLE ATROPHY 83 Indicates the degree of muscle atrophy.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PSYCHOSIS 84 Indicates the degree of psychosis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ORGANIC BRAIN SYNDROME 85 Indicates the degree of organic brain syndrome.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MOTOR NEUROPATHY 86 Indicates the degree of motor neuropathy.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SENSORY NEUROPATHY 87 Indicates the degree of sensory neuropathy.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    HELIOTROPE EYELIDS 88 Indicates the degree of heliotrope eyelids.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RASH-MALAR 89 Indicates the degree of Rash-Malar.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RASH-SLE,NON-MALAR 89.1 Indicates the degree of rash-sle, non-maler present.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NORMAL
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RASH-OTHER 89.2 Indicates the degree of rash-other present.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PSORIASIS 90 Indicates the degree of psoriasis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RASH-DISCOID 91 Indicates the degree of Rash-Discoid.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    RASH-JRA 92 Indicates the degree of Rash-JRA.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PALPABLE PURPURA 93 Indicates the degree of palpable purpura.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SCLERODACTYLY 94 Indicates the degree of sclerodactyly.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SCLERODERMA-EXTREMITY 95 Indicates the degree of scleroderma of the extremity.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SCLERODERMA-GENERALIZED 96 Indicates the degree of scleroderma, generalized.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MORPHEA 97 Indicates the degree of morphea.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TELANGIECTASIS 98 Indicates the degree of telangiectasis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    CUTANEOUS VASCULTITIS 99 Indicates the degree of cutaneous vasculitis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    PERIUNGAL ERYTHEMA 100 Indicates the degree of periungual erythema.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    KERATODERMIA BLENNORRHAGICA 101 Indicates the degree of keratodermia blennorrhagia.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    KNUCKLE ERYTHEMA 102 Indicates the degree of Knuckle erythema.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    DIGITAL ULCERS 103 Indicates the degree of digital ulcers.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    NAIL PITTING 104 Indicates the degree of nail pitting.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SKIN ULCERS 105 Indicates the degree skin ulcers.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ERYTHEMA NODOSUM 106 Indicates the degree of erythema nodosum.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    CURRENT MEDICATION 107 This field identifies the current medication.

    		Free Text
    PRESCRIBED MEDICATIONS 108 This field identifies the prescribed medications.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRESCRIBED MEDICATIONS .01 This field identifies the prescribed medications.

    		Word Processing
    SYMMETRICAL ARTHRITIS 109 This field identifies No indicates if the patient has symmetrical arthritis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    DACTYLITIS 110 Indicates the degree of impairment of dactylitis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TOPHI 111 This field identifies No indicates if the patient has tophi.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SUB-CUTANEOUS NODULES 112 This field identifies No indicates if the patient has sub-cutaneous nodules.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    SUBCUTANEOUS CALCIFICATIONS 112.5 Indicates the degree of subcutaneous calcifications presently found.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SYNOVIAL (BAKER'S) CYST 113 This field identifies No indicates if the patient has synovial (Baker's) cyst.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    HEEL PAIN 114 Indicates the degree of impairment of heel pain.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TENOSYNOVITIS(TENDON RUBS) 115 Indicates the degree of impairment of tenosynovitis (tendon rubs)

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TEMPORAL ARTERY TENDERNESS 116 Indicates the degree of impairment of temporal artery tenderness.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    COSTOCHONDRITIS 117 Indicates the degree of impairment of costochondritis.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    GRIP STRENGTH-LEFT 118 Indicates left grip strength in millimeters of mercury.

    		Numeric
    GRIP STRENGTH-RIGHT 119 Indicates right grip strength in millimeters of mercury.

    		Numeric
    SCHOBER TEST (10 cm BASE) 120 Indicates the results of the Schober test (with a 10 cm base).

    		Numeric
    CHEST EXPANSION 121 Indicates expansion of chest between 0 and 12 cm.

    		Numeric
    OCCIPUT-WALL 122 Indicates occiput - wall between 0 and 20 cm.

    		Numeric
    FINGER-TO-PALM CREASE-LEFT 123 Indicates left finger-to-palm crease.

    		Numeric
    FINGER-TO-PALM CREASE-RIGHT 124 Indicates right finger-to-palm crease.

    		Numeric
    INTERINCISOR DISTANCE 125 Indicates interincisor distance, between 0 and 60 mm.

    		Numeric
    SCHIRMER TEST 126 Indicates results of Schirmer test, between 0 and 25 mm.

    		Numeric
    WALK TIME (50 FEET) 127 This field identifies the walk time of 50 feet between 6 and 50 seconds.

    		Numeric
    FUNCTIONAL CLASS (ACR) 128 This field identifies the ACR functional class to indicate degree of impairment.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NORMAL
    • Code : 2
      Stands For: ADEQUATE
    • Code : 3
      Stands For: LIMITED
    • Code : 4
      Stands For: INCAPACITATED
    DISEASE SEVERITY-PAT. ESTIMATE 129 This field identifies the Pat. estimate of disease severity.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MB (MUCH BETTER)
    • Code : 2
      Stands For: B (BETTER)
    • Code : 3
      Stands For: S (SAME)
    • Code : 4
      Stands For: W (WORSE)
    • Code : 5
      Stands For: MW (MUCH WORSE)
    FINGERS-DIP LEFT 130 Indicates the degree of impairment of fingers - dip left

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    FINGERS-DIP RIGHT 131 Indicates the degree of impairment of fingers - dip right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    FINGERS-PIP LEFT 132 Indicates the degree of impairment of fingers - pip left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    FINGERS-PIP RIGHT 133 Indicates the degree of impairment of fingers - pip right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MCPS LEFT 134 Indicates the degree of impairment of MCPS LEFT.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MCPS RIGHT 135 Indicates the degree of impairment of MCPS RIGHT.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    1ST CARPOMETACARPAL L 136 Indicates the degree of impairment of first carpometacarpal left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    1ST CARPOMETACARPAL R 137 Indicates the degree of impairment of first carpometacarpal right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    WRIST LEFT 138 Indicates the degree of impairment of wrist left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    WRIST RIGHT 139 Indicates the degree of impairment of wrist right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ELBOW LEFT 140 Indicates the degree of impairment of elbow left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ELBOW RIGHT 141 Indicates the degree of impairment of elbow right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SHOULDER LEFT 142 Indicates the degree of impairment of shoulder left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SHOULDER RIGHT 143 Indicates the degree of impairment of shoulder right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    STERNOCLAVICULAR LEFT 144 Indicates the degree of impairment of sternoclavicular left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    STERNOCLAVICULAR RIGHT 145 Indicates the degree of impairment of sternoclavicular right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TMJ LEFT 146 Indicates the degree of impairment of TMJ left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TMJ RIGHT 147 Indicates the degree of impairment of TMJ right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    HIP LEFT 148 Indicates the degree of impairment of hip left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    HIP RIGHT 149 Indicates the degree of impairment of hip right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    KNEE LEFT 150 Indicates the degree of impairment of knee left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    KNEE RIGHT 151 Indicates the degree of impairment of knee right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ANKLE LEFT 152 Indicates the degree of impairment of ankle left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    ANKLE RIGHT 153 Indicates the degree of impairment of ankle right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MTP LEFT 154 Indicates the degree of impairment of MTP left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MTP RIGHT 155 Indicates the degree of impairment of MTP right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TOES-PIP LEFT 156 Indicates the degree of impairment of toes - PIP left.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    TOES-PIP RIGHT 157 Indicates the degree of impairment of toes - PIP right.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    CERVICAL SPINE 158 Indicates the degree of impairment of cervical spine.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    LUMBAR SPINE 159 Indicates the degree of impairment of lumbar spine.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    COSTOCHONDRAL-LEFT 160 Indicates the degree of costochondral disease(left).

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NORMAL
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    COSTOCHONDRAL-RIGHT 161 Indicates the degree of costochondral disease(right).

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NORMAL
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SACROILIAC-LEFT 162 Indicates the degree of sacroiliac disease(left).

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NORMAL
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    SACROILIAC-RIGHT 163 Indicates the degree of sacroiliac disease(right).

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NORMAL
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    THORACIC SPINE 164 Indicates the degree of Thoracic spine disease.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: MILD
    • Code : 2
      Stands For: MODERATE
    • Code : 3
      Stands For: SEVERE
    MEDICATION 201 These are the patient's current medications.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MEDICATION .01 These are the patients current medications.

    		Pointer
    PointerTo:
    fileName:
    MEDICATION
    fileNumber:
    695
    DOSAGE 1 This allows the user to enter the dosage of the patient's current medications.

    		Free Text
    FREQUENCY 2 This allows the user to enter the time/number of times (frequency) of the patient's current medications.

    		Free Text
    BP-SYSTOLIC 295 This field identifies the patient's systolic blood pressure.

    		Numeric
    BP-DIASTOLIC 296 This field identifies the patient's diastolic blood pressure.

    		Numeric
    DISEASE ACTIVITY COMPOSITE 297 Indicates the patients disease activity composite.

    		Numeric
    DISEASE SEVERITY-PT. ESTIMATE 298 This field identifies the patient's estimate of the disease severity.

    		Numeric
    DISEASE SEVERITY-MD ESTIMATE 299 This field identifies the clinician's estimate of the disease severity.

    		Numeric
    PAINSCAL 300 Indicates the pain scale.

    		Numeric
    DISABILITY INDEX 301 Indicates the disability index.

    		Numeric
    DRESSING AND GROOMING 302 Indicates the level of functionality for dressing and grooming.

    		Numeric
    ARISING 303 Indicates the level of functionality for arising.

    		Numeric
    EATING 304 Indicates the level of functionality for eating.

    		Numeric
    WALK 305 Indicates the level of functionality for walking.

    		Numeric
    HYGIENE 306 Indicates the level of functionality for hygiene.

    		Numeric
    REACH 307 Indicates the level of functionality for reaching.

    		Numeric
    GRIP-ARA 308 Indicates the level of functionality for ARA grip.

    		Numeric
    ACTIVITIES 309 Indicates the level of functionality for activities.

    		Numeric
    OCCUPATION 312 This allows the user to enter occupation from a list of choices.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NONE
    • Code : 1
      Stands For: PROFESSIONAL-TECH
    • Code : 2
      Stands For: FARMERS
    • Code : 3
      Stands For: MANAGERS
    • Code : 4
      Stands For: CLERICAL
    • Code : 5
      Stands For: SALES
    • Code : 7
      Stands For: OPERATIVES
    • Code : 8
      Stands For: SERVICE
    • Code : 9
      Stands For: FARM LABORERS
    • Code : 10
      Stands For: OTHER LABORERS
    CHART TYPE 313 This allows the user to select chart type for the patient.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: HAQ
    • Code : 1
      Stands For: UNMARKED, RDC VI, OR R
    • Code : 2
      Stands For: RDC VIII
    • Code : 3
      Stands For: RDC IX
    • Code : 4
      Stands For: RDC X
    • Code : 5
      Stands For: RDC XI (1985)
    • Code : 6
      Stands For: DEATH INFORMATION
    • Code : 7
      Stands For: DISCHARGE SUMMARY
    OBSERVER 314 The provider who saw the patient.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    VISIT TYPE 315

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: CLINIC (PRIOR RDC X
    • Code : 1
      Stands For: HOSPITAL
    • Code : 2
      Stands For: PHONE
    • Code : 3
      Stands For: MAIL
    • Code : 4
      Stands For: INITIAL-COMP
    • Code : 5
      Stands For: RETURN
    • Code : 6
      Stands For: COMP PT ASSESSOR
    • Code : 7
      Stands For: MAIL-OUTSIDE PHY RECO
    • Code : 8
      Stands For: MAIL-OTHER
    • Code : 9
      Stands For: TLI-RENAL VISIT
    DEC NUMBER 316 Data entry clerk number.

    		Numeric
    VISIT NUMBER 317 This field identifies sequentially numbered.

    		Numeric
    LOST OR DEATH STATUS 318 Is patient dead or lost from the VA files.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: CLINIC ALIVE
    • Code : 1
      Stands For: CLINIC LOST
    • Code : 2
      Stands For: CLINIC DEAD
    DEATH DATE 319 This allows the user to enter the death date of patient.

    		Date/Time
    AUTOPSY AVAILABLE 321 This field identifies enter yes or no if autopsy is available.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    CAUSE OF DEATH 322 This allows user to choose cause of death from list.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: NOT RHEUM DIS
    • Code : 2
      Stands For: RHEUM DIS
    • Code : 3
      Stands For: RHEUM DIS SURGERY
    • Code : 4
      Stands For: RHEUM DIS DRUG TOXICITY
    NOTIFIED BY 326 This allows user to choose notification method by list.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: PHONE
    • Code : 2
      Stands For: LETTER
    • Code : 3
      Stands For: OBITUARY
    • Code : 4
      Stands For: OTHER
    PERSON PROVIDING NOTIFICATION 327 This allows user to enter the person's name who provided the notification, last name first.

    		Free Text
    DEATH NOTIFIED DATE 328 This allows user to enter the date when notified.

    		Date/Time
    DISEASE SEVERITY-PHY. ESTIMATE 329 This allows the user to choose estimate from list.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: MB (MUCH BETTER)
    • Code : 2
      Stands For: B (BETTER)
    • Code : 3
      Stands For: S (SAME)
    • Code : 4
      Stands For: W (WORSE)
    • Code : 5
      Stands For: MW (MUCH WORSE)
    LOW WHITE BLOOD COUNT 350 Indicates the condition of low white blood count.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOW PLATELETS 351 Indicates the condition of low platelet count.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    LOW RED BLOOD COUNT 352 Indicates the condition of low red blood count.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PROCEDURE SUMMARY 600 This allows user to enter a summary of the procedure.

    		Free Text
    SUMMARY 601 This allows user to choose summary code.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NORMAL
    • Code : MI
      Stands For: MILD ABNL
    • Code : MO
      Stands For: MOD ABNL
    • Code : S
      Stands For: SEV ABNL
    QUESTDATE 602 This field identifies the date of the HAQ.

    		Date/Time
    HAQADMIN 603

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: CLINIC INTERVIEW
    • Code : 1
      Stands For: HOSPITAL INTERVIEW
    • Code : 2
      Stands For: TELEPHONE
    • Code : 3
      Stands For: MAIL
    QUESTYPE 604

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: EVERY YEAR
    • Code : 2
      Stands For: EVERY 6 MONTHS
    STUDY STATUS 605 This allows user to choose code of study status.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: ONGOING
    • Code : 1
      Stands For: LOSS OF FUNDS
    • Code : 2
      Stands For: DEAD
    • Code : 3
      Stands For: WITHDRAWN FROM STUDY
    • Code : 4
      Stands For: DX CHANGED
    • Code : 5
      Stands For: NON-PART REFUSED
    • Code : 6
      Stands For: NON-PART NO RESPONSE
    • Code : 7
      Stands For: TEMP OUT OF STUDY
    • Code : 8
      Stands For: STEY RE-ENTRY
    DRUGSTY 606 This field identifies a special field to identify patients who are participating in a drug research study.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: COHORT I
    • Code : 2
      Stands For: COHORT II
    • Code : 3
      Stands For: COHORT III
    • Code : 4
      Stands For: COHORT IV
    • Code : 5
      Stands For: COHORT V
    • Code : 6
      Stands For: COHORT VI
    • Code : 7
      Stands For: COHORT VII
    • Code : 8
      Stands For: COHORT VIII
    QUESTNUM 607

    		Numeric
    PMSVIS 608

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    RISE 609 Summary score of HAQ questions about arising.

    		Numeric
    NAUSEA 610 This allows user to enter yes or no for presence of nausea.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    HISTORY NARRATIVE 611 This allows user to enter a history narrative.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HISTORY NARRATIVE .01 This allows user to enter a history narrative.

    		Word Processing
    END SESSION 612 This allows user to hit the RETURN key to end session.

    		Free Text
    LABORATORY INFO 613 This allows user to enter laboratory information.

    		Pointer
    PointerTo:
    fileName:
    LAB DATA
    fileNumber:
    63
    LAB CHEM 614 This allows user to enter information to the laboratory test file.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    DIAGNOSIS 615 This allows user to enter Diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DIAGNOSIS .01 This allows user to enter Diagnosis.

    		Pointer
    PointerTo:
    fileName:
    MEDICAL DIAGNOSIS/ICD CODES
    fileNumber:
    697.5
    DATE OF SYMPTOM 1 This allows the user to enter the date this diagnosis was made.

    		Date/Time
    ICD DIAGNOSIS 700 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD DIAGNOSIS .01 This field contains the ICD9 Diagnosis(es) for the procedure. The field also contains a NARRATIVE DIAGNOSIS sub-field which will be used in the future.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    NARRATIVE DIAGNOSIS .02

    		Free Text
    PRIMARY PROVIDER 701 This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PCC POINTER 900 This field is used to link the Medicine package results with the PCC Visit File for use by Queryman.

    		Pointer
    PointerTo:
    fileName:
    VISIT
    fileNumber:
    9000010
    ORIFN 1000 This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    GMRCO 1001 This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package.

    		Pointer
    PointerTo:
    fileName:
    REQUEST/CONSULTATION
    fileNumber:
    123
    CREATION DATE 1514

    		Date/Time
    IMAGE 2005 This field points to an entry in the image file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01 This field points to an object in the image file.

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005

    LAB DATA

    File Number: 63

    File Description:

    Patient's laboratory data CROSS REFERENCE DESCRIPTION: ^LR("AEMA",'YEAR SPECIMEN TAKEN','ACCESSION #',LRDFN,'DATE/TIME SPECIMEN TAKEN')="" ^LR("AEM",'DATE/TIME SPECIMEN RECEIVED',LRDFN,'DATE/TIME SPECIMEN TAKEN')="" Similar x-refs exists for SURGICAL PATHOLOGY: "ASPA" and "ASP" CYTOLOGY: "ACYA" and "ACY" AUTOPSY: "AAUA" and "AAU" ^LR("AAU",'AUTOPSY DATE/TIME',LRDFN)="" ^LR("AD",DT,'ORGANISM','ACCESSION'_" ")=LRDFN Set when an organism to be reported to the health department is entered. ^LR(LRDFN,"CH",LRIDT,1,"AC",DUZ,$H)=DATE REPORT COMPLETED^VERIFY PERSON^ COMMENT (DELETED) Set when a comment is deleted from a verified test, used by the routine LRDCOM.


    Fields:

    Name Number Description Data Type Field Specific Data
    LRDFN .01 The internal file number of the "patient" (or other entity)

    		Numeric
    PARENT FILE .02 The file where the name of this entry may be found.

    		Pointer
    PointerTo:
    fileName:
    FILE
    fileNumber:
    1
    NAME .03 The internal file number in the parent file for this entry.

    		Numeric
    DO NOT TRANSFUSE .04 If DO NOT TRANSFUSE is entered then the patient cannot be transfused until the reason for not transfusing a blood component is resolved. The reason can be entered in the BLOOD BANK COMMENTS field.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: DO NOT TRANSFUSE
    • Code : 0
      Stands For: OK TO TRANSFUSE
    ABO GROUP .05 ABO blood group of patient

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : AB
      Stands For: AB
    • Code : O
      Stands For: O
    RH TYPE .06 This is the patient's RH blood type.

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POS
    • Code : NEG
      Stands For: NEG
    RBC ANTIGENS PRESENT(other) .07 Red blood cell antigens present other than ABO and Rho(D).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RBC ANTIGENS PRESENT .01 These are red blood cell antigens present other than ABO and Rho(D).

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    RBC ANTIGENS PRESENT COMMENT .02 This is a comment on the red blood cell antigen present.

    		Free Text
    ANTIBODIES IDENTIFIED .075 These are the patient's identified antibodies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ANTIBODIES IDENTIFIED .01 This is a pointer to an antibody identified on this patient.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    ANTIBODIES IDENTIFIED COMMENT .02 This is a comment on the antibodies identified.

    		Free Text
    BLOOD BANK COMMENTS .076 These are blood bank comments for this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BLOOD BANK COMMENTS .01 These are blood bank comments for this patient.

    		Word Processing
    RBC ANTIGENS ABSENT(other) .08 Red blood cell antigens absent other than ABO & Rho(D).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RBC ANTIGENS ABSENT .01 This is a red blood cell antigen that is absent for this patient.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    RBC ANTIGENS ABSENT COMMENT .02 This is the comment on the absent antigen.

    		Free Text
    BLOOD COMPONENT REQUEST .084 These are blood component requests.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BLOOD COMPONENT REQUEST .01 This is the component requested.

    		Pointer
    PointerTo:
    fileName:
    BLOOD PRODUCT
    fileNumber:
    66
    PRE-OP REQUEST .02 YES indicates this is a pre-operative request.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    REQUEST DATE/TIME .03 This is the date/time of the request.

    		Date/Time
    NUMBER OF UNITS .04 This is the number of units requested.

    		Numeric
    DATE/TIME UNITS WANTED .05 This is the date/time the units are wanted.

    		Date/Time
    PREVIOUS TRANSFUSIONS .06 YES indicates the patient has had previous transfusions.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PREVIOUS TRANSFUSION REACTION .07 YES indicates the patient has had a previous transfusion reaction.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    ENTERING PERSON .08 This is the person entering the request.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REQUESTING PERSON .09 This is the person making the request.

    		Free Text
    UNITS SELECTED FOR XMATCH 1 These are units selected for crossmatch.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    UNIT SELECTED FOR XMATCH .01 This is the unit selected for crossmatch.

    		Pointer
    PointerTo:
    fileName:
    BLOOD INVENTORY
    fileNumber:
    65
    INVERSE SPECIMEN DATE .02 This is 9999999--collection date of the specimen for crossmatch.

    		Numeric
    COMPONENT REQUEST REASON 2.1 If request does not meet acceptable criteria enter the reason why the request should still be completed.

    		Free Text
    APPROVED BY 2.2 This is the person approving the crossmatch request.

    		Free Text
    TREATING SPECIALITY 2.3 This is the treating specialty of the crossmatch request.

    		Pointer
    PointerTo:
    fileName:
    FACILITY TREATING SPECIALTY
    fileNumber:
    45.7
    TRANSFUSION RECORD .085 This is data concerning the patient's transfusion.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TRANSFUSION DATE/TIME .01 This is a reverse chronological order of blood components transfused.

    		Date/Time
    COMPONENT .02 This is the component transfused.

    		Pointer
    PointerTo:
    fileName:
    BLOOD PRODUCT
    fileNumber:
    66
    COMPONENT ID .03 This is the component identification number.

    		Free Text
    ENTERING PERSON .04 This is the person entering information on the transfusion.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ABO .05 ABO group of component

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : AB
      Stands For: AB
    • Code : O
      Stands For: O
    RH .06 Rh type of component

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POSITIVE
    • Code : NEG
      Stands For: NEGATIVE
    UNITS POOLED .07 This is the number of units pooled.

    		Numeric
    TRANSFUSION REACTION .08 YES indicates a transfusion reaction was associated with this transfusion.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DATA ENTERED VIA OLD RECORDS .09 If transfusion data entered in the transfusion record via previous records option then a 'YES' will be entered here.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    VOL(ml) TRANSFUSED .1 Enter in milliliters the volume of the unit transfused

    		Numeric
    TRANSFUSION REACTION TYPE .11 Indicates type of transfusion reaction

    		Pointer
    PointerTo:
    fileName:
    BLOOD BANK UTILITY
    fileNumber:
    65.4
    TRANSFUSION COMMENT 1 These are comments on the transfusion.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TRANSFUSION COMMENT .01 This is a comment on the transfusion.

    		Free Text
    CROSSMATCH COMMENT 2 These are comments on the crossmatch.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CROSSMATCH COMMENT .01 This is a comment on the crossmatch.

    		Free Text
    TRANSFUSION REACTION DATE .086 Transfusion reactions that cannot be assigned to a specific unit are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TRANSFUSION REACTION DATE .01 Transfusion reactions that cannot be assigned to a specific unit are entered here.

    		Date/Time
    TRANSFUSION REACTION TYPE .02 Stores the type of transfusion reaction

    		Pointer
    PointerTo:
    fileName:
    BLOOD BANK UTILITY
    fileNumber:
    65.4
    PERSON ENTERING REACTION .03 Person entering reaction information

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TRANSFUSION REACTION COMMENT 1 Multiple for transfusion reaction comment

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TRANSFUSION REACTION COMMENT .01 Comments related to a transfusion reaction such as suspected component or units

    		Free Text
    HOSPITAL ID .09 Computed field to present the hospital ID from the parent file.

    		Computed
    PAT. INFO. .091 Patient information

    		Free Text
    LOCATION TYPE .092 This field is used for Workload Classification. Other location type is the default answer.

    		Set of Codes
    Set of Codes:
    • Code : C
      Stands For: CLINIC
    • Code : M
      Stands For: MODULE
    • Code : W
      Stands For: WARD
    • Code : Z
      Stands For: OTHER LOCATION
    • Code : N
      Stands For: NON-CLINIC STOP
    • Code : F
      Stands For: FILE AREA
    • Code : I
      Stands For: IMAGING
    • Code : OR
      Stands For: OPERATING ROOM
    REPORT ROUTING (LOCATION) .1 The most current location where a lab procedure was requested.

    		Free Text
    REPORT ROUTING (PROVIDER) .101 The most current requesting person who requested a lab procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CUMULATIVE REPORT PAGES .11 Current temporary (active) page numbers for the cumulative report.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CUMULATIVE REPORT PAGES .01 First ":" piece page number for the cumulative report.

    		Pointer
    PointerTo:
    fileName:
    LAB REPORTS
    fileNumber:
    64.5
    PAGE 1 Second ":" piece page number for the cumulative report.

    		Numeric
    PRODUCING LABORATORY .12 Contains information related to laboratory results which document legal and accreditation required information. It documents the laboratory that produces the lab result value (performing laboratory) in addition to other supporting information such as address of the performing laboratory and the name/title/identifier of the laboratory director of the performing laboratory when required.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAB DATA REFERENCE .01 Contains the global reference in a format similar to a FileMan DA array. It resolves to the section of this file which contains the results that are related to this producing laboratory. It constructed based on the entry's LRDFN, LRSS and LRIDT where LRDFN = internal enter number in file #63 LRSS = related subscript LRIDT = inverse date/time of specimen Autopsy results being one of a kind are created using a value LRSS="AU" LRIDT=0 to maintain the structure of the entries and related index. The structure of the reference is LRDFN,LRSS,LRIDT,1...N related global nodes in the LR global. When reference is to a specific field which shares other fields on the same node then the format used to distinguish separate fields is node;piece position on node. Example microbiology results within MI subscript - 173,MI,6959788.895648,3,1,0 Example microbiology results with MI subscript, 6th piece of 1 node - 356,MI,6919497.888687,1;6

    		Free Text
    INSTITUTION .02 Contains the pointer to the entry in the INSTITUTION file which is related to the laboratory which produced the related laboratory results.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    EXTERNAL PACKAGE REFERENCE .13 Stores information related to various external packages which are related to a laboratory specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAB DATA REFERENCE .01 Contains the global reference in a format similar to a FileMan DA array. It resolves to the section of this file which contains the results that are related to this reference. It constructed based on the entry's LRDFN, LRSS and LRIDT where LRDFN = internal enter number in file #63 LRSS = related subscript LRIDT = inverse date/time of specimen Autopsy results being one of a kind are created using a value LRSS="AU" LRIDT=0 to maintain the structure of the entries and related index. The structure of the reference is LRDFN,LRSS,LRIDT,1...N related global nodes in the LR global. When reference is to a specific field which shares other fields on the same node then the format used to distinguish separate fields is node;piece position on node. Example microbiology results within MI subscript - 173,MI,6959788.895648,3,1,0 Example microbiology results with MI subscript, 6th piece of 1 node - 356,MI,6919497.888687,1;6

    		Free Text
    TYPE OF REFERENCE .02 Stores various references to external data that is related to this laboratory specimen/order/result. This field indicates the type/source of the package reference being stored in the REFERENCE field (#1). Examples can be: 1 - Imaging when there are associated images or other binary documents. 2 - Surgery when there is a related surgical case and a linkage needs to be recorded between the surgical operative report and the laboratory surgical pathology, cytology, or other laboratory report. 3 - Placer order number when the order was received from an external system and a reference/linkage needs to be maintained with the system. 4 - Filler order number when the order was fulfilled by an external system and a reference/linkage needs to be maintained to this system.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: SURGICAL CASE
    • Code : 2
      Stands For: IMAGING RECORD
    • Code : 3
      Stands For: PLACER ORDER NUMBER
    • Code : 4
      Stands For: FILLER ORDER NUMBER
    FILE REFERENCE .03 If the type of external reference stored is one which the laboratory package can establish a pointed-to file relationship then the pointer to that file can be stored here. Examples are pointing to the IMAGING file (#2005) or INSTITUTION file (#4). It can be used in conjunction with type #3/4 when storing an order number and in addition to the order number the institution related to the external order number can also be specified.

    		Variable Pointer
    REFERENCE 1 Stores the actual reference related to the external system. Format is based on the type and handled via software. If type=imaging then the reference provided by the Imaging package will be recorded. If type=surgery then the Surgical Case # or reference to the Surgery Package. If type=placer order then the order identifier received from the placer of the order. If type=filler order then the filler identifier received from the filler of the order.

    		Free Text
    CODE SYSTEM REFERENCE .14 Contains codes from various code systems used to encode this data element.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    LAB DATA REFERENCE .01 Contains the global reference in a format similar to a FileMan DA array. It resolves to the section of this file which contains the results that are related to this reference. It constructed based on the entry's LRDFN, LRSS and LRIDT where LRDFN = internal enter number in file #63 , LRSS = related subscript LRIDT = inverse date/time of specimen Autopsy results being one of a kind are created using a value LRSS="AU" LRIDT=0 to maintain the structure of the entries and related index. The structure of the reference is LRDFN,LRSS,LRIDT,1...N related global nodes in the LR global. When reference is to a specific field which shares other fields on the same node then the format used to distinguish separate fields is node;piece position on node. Example microbiology results within MI subscript - 173,MI,6959788.895648,3,1,0 Example microbiology results with MI subscript, 6th piece of 1 node - 356,MI,6919497.888687,1;6

    		Free Text
    ROLE .02

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ORDER
    • Code : 2
      Stands For: RESULT
    • Code : 3
      Stands For: ANSWER
    • Code : 4
      Stands For: METHODOLOGY
    • Code : 5
      Stands For: WORKLOAD
    • Code : 6
      Stands For: BILLING
    CODE ID .03 The code id value from the code system being stored.

    		Free Text
    CODE TEXT .035 Contains the text associated with the CODE ID.

    		Free Text
    NAME OF CODE SYSTEM .04 Contains the code system name or designated abbreviation used to identify the CODE ID.

    		Free Text
    CODE VERSION .05 This is the version ID for the coding system identified by CODE ID.

    		Free Text
    RELATED ENTRY .06 If the associated code exists in a VistA file then this field will contain a link to the related entry. This field can be blank if the code system does not exist in a related VistA file or the code is contained in a version not supported by a related VistA file.

    		Variable Pointer
    HLA ANTIGENS PRESENT .2 These are HLA antigens associated with this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HLA ANTIGEN PRESENT .01 This is the HLA antigen associated with this patient.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    HLA ANTIGEN PRESENT COMMENT .02 This is a comment about the patient's HLA antigen.

    		Free Text
    HLA ANTIGENS ABSENT .21 These are HLA antigens NOT associated with this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HLA ANTIGENS ABSENT .01 This is the HLA antigen NOT associated with this patient.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    HLA ANTIGEN ABSENT COMMENT .02 This is a comment on the antigen absent for this patient.

    		Free Text
    BLOOD BANK 1 This is blood bank data on this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time the specimen was collected.

    		Date/Time
    DATE REPORT COMPLETED .03 This is the date the report was completed.

    		Date/Time
    ENTERING PERSON .04 This is the person entering the date.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SPECIMEN .05 This is the specimen collected.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE .055 This is the collection sample for the specimen.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    ACCESSION NUMBER .06 This is the blood bank accession.

    		Free Text
    PHYSICIAN .07 This is the requesting provider.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    WARD .08 This is the requesting location.

    		Free Text
    PHLEBOTOMIST .09 This is the person collecting the sample

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE/TIME RECEIVED .1 This is the date/time the sample was received at the blood bank.

    		Date/Time
    ACCESSION LINK .12 This field is used to determine the accession area, accession date and the accession number. The data is stuffed by the accessioning logic. The contents is used by the workload capturing routines. NOTE: THIS FIELD SHOULD NOT BE EDITED MANUALLY, ONLY PROGRAM LOGIC SHOULD SET THIS FIELD.

    		Free Text
    SPECIMEN COMMENT .99 This is a comment on the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIMEN COMMENT .01 This is a comment on the specimen.

    		Free Text
    DIRECT AHG(POLYSPECIFIC) 2.1

    		Free Text
    DIRECT AHG(5 min incub) 2.2

    		Free Text
    DIRECT AHG CC 2.3

    		Free Text
    ANTI-IgG 2.4

    		Free Text
    ANTI-IgG CC 2.5

    		Free Text
    ANTI-COMPLEMENT 2.6

    		Free Text
    ANTI-COMPLEMENT (5 min incub) 2.7

    		Free Text
    ANTI-COMPLEMENT CC 2.8

    		Free Text
    DIRECT AHG INTERPRETATION 2.9 Interpretation of the direct AHG

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: POSITIVE
    • Code : N
      Stands For: NEGATIVE
    • Code : I
      Stands For: INVALID, USE EDTA SPECIMEN
    DIRECT AHG TEST COMMENT 2.91 Any comment on the direct AHG test

    		Free Text
    ELUATE ANTIBODY 3 These are eluate antibodies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ELUATE ANTIBODY .01 This is the eluate antibody.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    SCREEN CELL METHOD 4 These are the screen cell methods.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SCREEN CELL METHOD .01 This is the screen cell method.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: SALINE
    • Code : A
      Stands For: ALBUMIN
    • Code : P
      Stands For: PAPAIN
    • Code : F
      Stands For: FICIN
    • Code : L
      Stands For: LISS
    • Code : H
      Stands For: LISH
    TECHNIQUE .02 This is the screen cell technique.

    		Set of Codes
    Set of Codes:
    • Code : T
      Stands For: TUBE
    • Code : M
      Stands For: MICROPLATE
    • Code : A
      Stands For: AUTOMATED
    SCREEN CELL 1 These are the screen cells.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SCREEN CELL .01 This is the screen cell used.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    SOURCE .02 This is the source of the screen cells.

    		Pointer
    PointerTo:
    fileName:
    BLOOD PRODUCT
    fileNumber:
    66
    INTERPRETATION .03 This is the interpretation of the screen cells.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEGATIVE
    • Code : P
      Stands For: POSITIVE
    IS .04

    		Free Text
    37 C .05

    		Free Text
    AHG .06

    		Free Text
    CONTROL CELL .07

    		Free Text
    ROOM TEMP .08

    		Free Text
    12-18 C .09

    		Free Text
    4 C .1

    		Free Text
    ANTIBODY SCREEN INTERPRETATION 6 If antibodies are present in the patient's serum the antibody screen interpretation will usually be positive.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEG
    • Code : P
      Stands For: POS
    RBC ANTIGEN PRESENT 6.1 Antigens present on RBC's of patient are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RBC ANTIGEN PRESENT .01 Antigens present on RBC's of patient are entered here.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    COMMENT .02 Comment field

    		Free Text
    RBC ANTIGEN ABSENT 6.2 Antigens identified as absent on red blood cells are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RBC ANTIGEN ABSENT .01 Antigens identified as absent on red blood cells are entered here.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    COMMENT .02 Comment field

    		Free Text
    HLA ANTIGEN PRESENT 6.3 HLA antgens present on WBC's are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HLA ANTIGEN PRESENT .01 HLA antigens present on WBC's are entered here.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    COMMENT .02 Comment field

    		Free Text
    HLA ANTIGEN ABSENT 6.4 HLA antigens absent on WBC's are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    HLA ANTIGEN ABSENT .01 HLA antigens absent on WBC's are entered here.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    COMMENT .02 Comment field

    		Free Text
    SERUM ANTIBODY 7 These are the serum antibodies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SERUM ANTIBODY .01 These are the patient's serum antibodies.

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    ANTIBODY COMMENT .02 This is a comment on the antibodies.

    		Free Text
    ANTIBODY SCREEN COMMENT 8 These are antibody screen comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ANTIBODY SCREEN COMMENT .01 This is a comment on the antibody screen.

    		Free Text
    RBC TYPING METHOD 9 These are RBC typing methods.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    RBC TYPING METHOD .01 This is the method used for RBC typing.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: SALINE
    • Code : M
      Stands For: SERUM
    TECHNIQUE .02 This is the technique of RBC typing.

    		Set of Codes
    Set of Codes:
    • Code : S
      Stands For: SLIDE
    • Code : T
      Stands For: TUBE
    • Code : A
      Stands For: AUTOMATED
    • Code : M
      Stands For: MICROPLATE
    ANTISERUM 1 These are the antiserums used for RBC typing.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ANTISERUM .01 This is the antiserum used for RBC typing.

    		Pointer
    PointerTo:
    fileName:
    BLOOD PRODUCT
    fileNumber:
    66
    LOT # .02 This is the lot number of the antiserum.

    		Free Text
    INTERPRETATION .03 This is the patient's antiserum interpretation.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: POSITIVE
    • Code : N
      Stands For: NEGATIVE
    • Code : U
      Stands For: UNCERTAIN
    IS .04

    		Free Text
    37 C .05

    		Free Text
    AHG .06

    		Free Text
    CONTROL CELL .07

    		Free Text
    ROOM TEMP .08

    		Free Text
    12-18 C .09

    		Free Text
    4 C .1

    		Free Text
    ABO INTERPRETATION 10 This is the patient's ABO interpretation.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : O
      Stands For: O
    • Code : AB
      Stands For: AB
    • Code : ND
      Stands For: NOT DONE
    ABO TYPING TECH 10.2 Technologist interpretating ABO typing results

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ABO TESTING COMMENT 10.3 This is a comment on the ABO testing.

    		Free Text
    RH INTERPRETATION 11 This is the patient's Rh interpretation.

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : ND
      Stands For: NOT DONE
    RH TYPING TECH 11.2 Technologist interpretating Rh typing results

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RH TESTING COMMENT 11.3 This is a comment on the Rh testing.

    		Free Text
    PT CELLS+ANTI D (sal) 121

    		Free Text
    PT CELLS+RH CTRL (sal) 122

    		Free Text
    PT CELLS(sal)+ANTI D(hp IS) 123

    		Free Text
    PT CELLS(ser)+ANTI D(hp IS) 124

    		Free Text
    PT CELLS+ANTI D (hp 37) 125

    		Free Text
    PT CELLS+ANTI D (hp AHG) 126

    		Free Text
    PT CELLS+ANTI D SLIDE (hp) 127

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: AGGLUTINATION
    • Code : N
      Stands For: NO AGGLUTINATION
    PT CELLS(sal)+RH CTRL (hp IS) 128

    		Free Text
    PT CELLS(ser)+RH CTRL(hp IS) 129

    		Free Text
    PT CELLS+RH CTRL (hp 37) 129.1

    		Free Text
    PT CELLS+RH CTRL (hp AHG) 129.11

    		Free Text
    PT CELLS+RH CTRL SLIDE (hp) 129.12

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: AGGLUTINATION
    • Code : N
      Stands For: NO AGGLUTINATION
    INTERPRETATION OF RH TESTING 131

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : PDU
      Stands For: RH POS DU POS
    • Code : NDU
      Stands For: RH NEG DU NEG
    RH TEST COMMENT 132

    		Free Text
    PT Cells(sal)+Anti D(mod) IS 133

    		Free Text
    PT Cells(ser)+Anti D(mod) IS 134

    		Free Text
    PT Cells+Anti D(mod) 37 135

    		Free Text
    PT Cells+Anti D(mod) AHG 136

    		Free Text
    PT Cells(sal)+RH Ctrl(sal) IS 138

    		Free Text
    PT Cells(ser)+RH Ctrl(sal) IS 139

    		Free Text
    PT Cells+RH Ctrl(sal) 37 139.1

    		Free Text
    PT Cells+RH Ctrl(sal) AHG 139.11

    		Free Text
    PT CELLS(ser)+ANTI A IS 141

    		Free Text
    PT CELLS(sal)+ANTI A IS 142

    		Free Text
    PT CELLS+ANTI A SLIDE 143

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: AGGLUTINATION
    • Code : N
      Stands For: NO AGGLUTINATION
    PT CELLS(ser)+ANTI B IS 144

    		Free Text
    PT CELLS(sal)+ANTI B IS 145

    		Free Text
    PT CELLS+ANTI B SLIDE 146

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: AGGLUTINATION
    • Code : N
      Stands For: NO AGGLUTINATION
    PT CELLS(ser)+ANTI A,B IS 147

    		Free Text
    PT CELLS(ser)+ANTI A,B (RT) 148

    		Free Text
    PT CELLS(sal)+ANTI A,B (IS) 149

    		Free Text
    PT CELLS(sal)+ANTI A,B (RT) 149.1

    		Free Text
    PT CELLS+ANTI A,B SLIDE 149.11

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: AGGLUTINATION
    • Code : N
      Stands For: NO AGGLUTINATION
    PT SERUM+A1 CELLS 149.12

    		Free Text
    PT SERUM+B CELLS 149.13

    		Free Text
    INTERPRETATION OF ABO TESTING 151

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : AB
      Stands For: AB
    • Code : O
      Stands For: O
    ABO TESTING COMMENT 152

    		Free Text
    INTERPRETATION ABO GROUP(cell) 153 This is the interpretation of the patient's ABO group(cell).

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : O
      Stands For: O
    • Code : AB
      Stands For: AB
    INTERPRETATION ABO GROUP(ser) 154 This is the interpretation of the patient's ABO type.

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : B
      Stands For: B
    • Code : O
      Stands For: O
    • Code : AB
      Stands For: AB
    EM 2 This is patient data from electron microscopy (EM).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time of collection of the EM specimen.

    		Date/Time
    SPECIMEN SUBMITTED BY .011 This is the person submitting the specimen.

    		Free Text
    SPECIMEN .012 These are the specimens submitted for testing.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIMEN .01 This is the specimen submitted for testing.

    		Free Text
    SPECIMEN TOPOGRAPHY .06 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE .07 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    EPON BLOCK 1 Identification of epon block prepared from specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EPON BLOCK .01 Identification of epon block prepared from specimen.

    		Free Text
    DATE/TIME BLOCK PREPARED .02 Date/time epon block prepared. Used for workload recording.

    		Date/Time
    BLOCK COUNTED .03 If block counted for workload a 'YES' is entered.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    EM PROCEDURE 1 EM procedures are recorded here. They are either thick (slides) or thin (grids) sections.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EM PROCEDURE .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SECTIONS PREPARED(#) .02 The number of thick (slides) or thin (grids) sections prepared is kept here.

    		Numeric
    DATE/TIME SECTIONS PREPARED .04 When sections are prepared

    		Date/Time
    DATE/TIME SECTIONS EXAMINED .05 When sections are examined

    		Date/Time
    SECTIONS COUNTED(#) .06 Number of sections counted

    		Numeric
    NEW SECTIONS .07 Sections added since prior preparation time.

    		Numeric
    SECTIONS EXAMINED(#) .08 Number of sections examined

    		Numeric
    NON-CONTROL SLIDES COUNTED .09 Number of non-control slides counted.

    		Numeric
    PRINTS MADE(#) .1 Number of prints made

    		Numeric
    DATE/TIME PRINTS MADE .11 When the prints are made.

    		Date/Time
    PRINTS COUNTED(#) .12 Number of prints counted

    		Numeric
    EXAMINED SECTIONS COUNTED(#) .13 Number of examined sections that were counted.

    		Numeric
    BRIEF CLINICAL HISTORY .013 This is the brief clinical history for this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BRIEF CLINICAL HISTORY .01

    		Word Processing
    PREOPERATIVE DIAGNOSIS .014 This is the pre-operative diagnosis for this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREOPERATIVE DIAGNOSIS .01

    		Word Processing
    OPERATIVE FINDINGS .015 These are the operative findings for this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OPERATIVE FINDINGS .01

    		Word Processing
    POSTOPERATIVE DIAGNOSIS .016 This is the post-operative diagnosis for this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    POSTOPERATIVE DIAGNOSIS .01 This is the post-operative diagnosis for this specimen.

    		Word Processing
    PATHOLOGIST .02 This is the pathologist performing the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RESIDENT OR EMTECH .021 This is the resident pathologist or the EM technologist performing the test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE REPORT COMPLETED .03 This is the date the report was completed.

    		Date/Time
    EM ACC # .06 This is the accession number of the electron microscopy specimen.

    		Free Text
    PHYSICIAN .07 This is the requesting physician.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PATIENT LOCATION .08 This is the requesting location.

    		Free Text
    TYPIST .09 These are the initials of the typist entering the data.

    		Free Text
    DATE/TIME SPECIMEN RECEIVED .1 This is the date/time the specimen was received.

    		Date/Time
    REPORT RELEASE DATE .11 YES indicates the report was released.

    		Date/Time
    RELEASED BY .13 Who released the report

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TC CODE .14 Tissue committee codes The meaning of each code is identified by each site.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    • Code : 4
      Stands For: 4
    • Code : 5
      Stands For: 5
    • Code : 6
      Stands For: 6
    • Code : 7
      Stands For: 7
    • Code : 8
      Stands For: 8
    • Code : 9
      Stands For: 9
    • Code : 0
      Stands For: 0
    ORIGINAL RELEASE DATE .15 If report was modified after release the original release date is kept here.

    		Date/Time
    TIU REFERENCE DATE/TIME - EM .16 This multiple stores TIU information for corresponding SF515 electron microscopy reports that have been electronically signed and stored in TIU. This information is used to access the reports in TIU.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TIU REFERENCE DATE/TIME - EM .01 This is the date and time that the electron microscopy SF515 was stored in TIU. It will match the REFERENCE DATE (#1301) field of the corresponding document in the TIU DOCUMENT (#8925) file.

    		Date/Time
    TIU ENTRY POINTER - EM 1 This field is a pointer to the TIU DOCUMENT (#8925) file. It stores the pointer for an electron microscopy SF515 that has been electronically signed and stored in TIU.

    		Pointer
    PointerTo:
    fileName:
    TIU DOCUMENT
    fileNumber:
    8925
    TIU CHECKSUM 2 This field stores the checksum that is calculated at the time the report version is initially stored in TIU. It will be used for comparison in future print/view requests. A new checksum will be calculated whenever the report version is printed/viewed, and matching checksums are proof that the report version has not been illegally altered.

    		Free Text
    DATE REPORT MODIFIED - EM .17 This is the date the report was modified if it was modified after it was electronically signed/released.

    		Date/Time
    PERSON MODIFYING TEXT .171 Stores the DUZ of the person who modified the report AFTER it was electronically signed/released.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DIAGNOSIS MODIFIED .172 1 = Diagnosis modified AFTER report was electronically signed/released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    UID .31 This is the UID used by the HOST LEDI system for this order/accession. This field is used by LEDI software.

    		Free Text
    ORDERING SITE .32 This field contains the pointer to the INSTITUTION file for the MailMan domain location of the computer system. All LEDI results are returned to the Ordering computer system. Location to send LEDI HL7 result messages. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    COLLECTING SITE .33 This field contains the pointer to the INSTITUTION file for the actual collection site. The ordering site is the MailMan location of the computer system. MailMan domain location and the collecting site may be different. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    HOST UID .34 Each Order/Accession is given a HOST UID. The UID is stored in this location. If LEDI software is used to accession specimens, usually the collecting site's UID is used to track specimens. If the collecting UID conflicts with the HOST system number sequence, the HOST UID will be used instead of the collecting site's UID. This field is used by LEDI software.

    		Free Text
    ORDERING SITE UID .342 This field contains the collecting site's UID for this specimen. This field is used by LEDI software.

    		Free Text
    RELEASING SITE .345 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    ORDERED TEST .35 This subfile contains information about the ordered test(s) for this accession. The .01 field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORDERED TEST .01 The ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Free Text
    ORDERED URGENCY 2 This field contains the urgency for this ordered test.

    		Pointer
    PointerTo:
    fileName:
    URGENCY
    fileNumber:
    62.05
    CPRS ORDER # 3 This field contains the pointer to CPRS ORDER (#100) file. This field is only populated when the original order is placed on the local system.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    LAB ORDER # 4 This field contains the LAB ORDER number for this test. The construct of this free text field is: LR-Lab order number-XXXX - where XXXX is the Julian date.

    		Free Text
    ORDER TYPE 5 This field contains information about how the test order was genera selection must be made from HL7 Table 0065 entries. This field indicates if the ordered test was part of the original order, an add-on, or reflexed per clinical protocol.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    ORDERING PROVIDER LOCAL 6 The pointer to the NEW PERSON file if the original order was placed on the local system. This field will be empty if order is placed via LEDI.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING PROVIDER REMOTE 7 If this test is ordered by a provider from a remote system (not local system), the names containeed in the HL7 message will be stored in this field.

    		Free Text
    SPECIMEN TOPOGRAPHY 8 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE 9 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    DISPOSITION 10 Maintains the disposition of the ordered test. It will be used to value the test disposition in HL7 messaging, specifically OBR-25.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    DISPOSITION DATE/TIME 11 Stores the date and time that a lab user or the system dispositioned this test.

    		Date/Time
    DISPOSITION BY 12 Store the user who entered the disposition of this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAB TEST ORDERED 13 Contains the ordered laboratory test associated with the ordered NLT code.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT TEST 14 If this test is a reflex test this indicates the ordered test that is associated with the reflex test.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT NLT 15 Contains the order NLT code associated with the parent test when the ordered test is a reflex test.

    		Free Text
    DELAYED REPORT COMMENT .97 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DELAYED REPORT COMMENT .01 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Free Text
    COMMENT .99 These are comments on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment on this specimen.

    		Free Text
    GROSS DESCRIPTION 1 This is the gross description of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GROSS DESCRIPTION .01

    		Word Processing
    MICROSCOPIC EXAMINATION 1.1 This is the microscopic examination diagnosis of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICROSCOPIC EXAMINATION .01

    		Word Processing
    SUPPLEMENTARY REPORT 1.2 These are supplementary reports.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT DATE/TIME .01 This is the date and time of the supplementary report.

    		Date/Time
    RELEASE SUPPLEMENTARY REPORT .02 If supplementary report is to be displayed or printed outside of lab the report must be released by entering 'YES'.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: yes
    • Code : 0
      Stands For: no
    RELEASE SUPP REPORT MODIFIED .03 This flag will be set to '1' when a released supplementary report is modified. It is removed when the modified supplementary report is released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DESCRIPTION 1 This is a description of the supplementary report.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    SUPPLEMENTARY REPORT MODIFIED 2 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT MODIFIED .01 This is the date/time in which this supplementary report was modified. It is updated by the software and can only be modified from programmer mode.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the DUZ of the person who modified the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PERSON RELEASING THE SUPP. RPT .03 This is the DUZ of the person who released the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPP REPORT RELEASE DATE/TIME .04 This is the date/time in which this supplementary report was released. It is updated by the software and can only be modified from programmer mode.

    		Date/Time
    PREMODIFICATION TEXT 1 This is the text of the supplementary report as it existed before it was modified. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01 This is the text of the supplementary report as it existed before it was modified. This field is updated by the software and can only be modified from programmer mode.

    		Word Processing
    EM DIAGNOSIS 1.4 Electron microscopy diagnoses are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EM DIAGNOSIS .01

    		Word Processing
    DATE MICROSCOPIC EXAM MODIFIED 4 These are the dates of modification of the microscopic examination/diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE MICROSCOPIC EXAM MODIFIED .01 This is the date of modification of the microscopic examination/diagnosis.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the person making the modification.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the text of the modification.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE DIAGNOSIS MODIFIED 5 This is the date of the modification of the diagnosis field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE DIAGNOSIS MODIFIED .01 This is the date of the modification of the diagnosis field.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the person modifying text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE GROSS DESCRIPTION CHANGED 7 These are the dates of change to the gross description field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE GROSS DESCRIPTION CHANGED .01 Dates of change of the gross description field are stored here.

    		Date/Time
    PERSON MODIFYING TEXT .02 User changing text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    QA CODE 9 Multiple field for Quality Assurance code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    QA CODE .01 The quality assurance code

    		Pointer
    PointerTo:
    fileName:
    LAB DESCRIPTIONS
    fileNumber:
    62.5
    EM ORGAN/TISSUE 10 These are the organ/tissue(s) being examined.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    EM ORGAN/TISSUE .01 This is the organ/tissue(s) being examined.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    FUNCTION 1 These are the functions associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FUNCTION .01 This is the function associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    PROCEDURE 1.5 These are the procedures associated with this organ/tissue.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROCEDURE .01 This is the procedure associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE FIELD
    fileNumber:
    61.5
    RESULT .02 If result of procedure is positive enter '1' or 'P'.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NEG
    • Code : 1
      Stands For: POS
    DISEASE 3 These are the diseases associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISEASE .01 This is the disease associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    DISEASE FIELD
    fileNumber:
    61.4
    MORPHOLOGY 4 These are the morphologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MORPHOLOGY .01 This is the morphology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY FIELD
    fileNumber:
    61.1
    ETIOLOGY 1 These are the etiologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ETIOLOGY .01 This is the etiology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    SPECIAL STUDIES 5 These are special studies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIAL STUDIES .01 This is a special study associated with this organ/tissue(s).

    		Set of Codes
    Set of Codes:
    • Code : I
      Stands For: IMMUNOFLUORESCENCE
    • Code : P
      Stands For: PHOTOGRAPHY
    • Code : C
      Stands For: CONSULTATION
    • Code : L
      Stands For: LIGHT MICROSCOPY
    • Code : IP
      Stands For: IMMUNOPEROXIDASE
    DATE .02 This is the date of the special study.

    		Date/Time
    ID # .03 This is the ID number of the special study.

    		Free Text
    DESCRIPTION 1 This is the description of the special study.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    ICD CODE 80 These are the ICD codes on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ICD CODE .01 This is the ICD code on this specimen.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    IMAGE 2005 Images associated with EM reports are stored in this multiple within the EM field of the Lab Data (#63) file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    CHEM, HEM, TOX, RIA, SER, etc. 4 Multiple field for Chem., Hem., Tox., RIA, Ser., etc. results

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time the specimen was taken.

    		Date/Time
    DATE/TIME OBTAINED INEXACT .02 YES indicates the time the specimen was obtained is inexact.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DATE REPORT COMPLETED .03 This is the date the report was completed.

    		Date/Time
    VERIFY PERSON .04 This is the person verifying the report.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SPECIMEN TYPE .05 This is the specimen type.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    ACCESSION .06 This is the accession for this specimen.

    		Free Text
    *VOLUME .07 No longer used. To be deleted after 1/89.

    		Free Text
    METHOD OR SITE .08 This is the method/site of collection.

    		Free Text
    SUM REPORT NUM. .09 This is the summary report number.

    		Numeric
    REQUESTING PERSON .1 This is the person requesting the test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    REQUESTING LOCATION .11 This is the requesting location.

    		Free Text
    REQUESTING LOC/DIV .111 This is the hospital location or institution ordering this test.

    		Variable Pointer
    ACCESSIONING INSTITUTION .112 This field contains the pointer to the institution where the specimen was accessioned. This field can be blank if LEDI or POC specimen is accessioned. The field will be set if an actual user accepts the specimen.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    NEW PERSON CONVERSION .12 This field is to indicate that this entry has all of the pointers converted to the NEW PERSON file. The use of the NEW PERSON file began with Version 5.2 A number 2 in this field indicates that this entry also contains test normal range data stored. This enhancement is provide by the LEDI auto- instrument upgrade.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: Y
    UID .31 This is the UID used by the HOST LEDI system for this order/accession. This field is used by LEDI software.

    		Free Text
    ORDERING SITE .32 This field contains the pointer to the INSTITUTION file for the MailMan domain location of the computer system. All LEDI results are returned to the Ordering computer system. Location to send LEDI HL7 result messages. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    COLLECTING SITE .33 This field contain the pointer to the INSTITUTION file for the actual collection site. The ordering site is the MailMan location of the computer system. MailMan domain location and the collecting site may be different. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    HOST UID .34 Each Order/Accession is given a HOST UID. The UID is stored in this location. If LEDI software is used to accession specimens, usually the collecting sites UID is used to track specimens. If the collecting UID conflict is the HOST system number sequence, the HOST UID will be used instead of the collecting site's UID. This field is used by LEDI software.

    		Free Text
    ORDERING SITE UID .342 This field contains the collecting sites UID for this specimen. This field is used by LEDI software.

    		Free Text
    RELEASING SITE .345 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    ORDERED TEST .35 This subfile contains information about the ordered test(s) for this accession. The .01 field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORDERED TEST .01 Contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Free Text
    ORDERED URGENCY 2 This field contains the urgency for this ordered test.

    		Pointer
    PointerTo:
    fileName:
    URGENCY
    fileNumber:
    62.05
    CPRS ORDER # 3 This field contains the pointer to CPRS ORDER (#100) file. This field is only populated when the original order is placed on the local system.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    LAB ORDER # 4 This field contains the LAB ORDER number for this test. The construct of this free text field is: LR-Lab order number-XXXX - where XXXX is the Julian date.

    		Free Text
    ORDER TYPE 5 This field contains information about how how the test order was generated. The selection must be made from HL7 Table 0065 entries. This field indicates if the ordered test was part of the original order, an add-on or reflexed per clinical protocol.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    ORDERING PROVIDER LOCAL 6 The pointer to the NEW PERSON file if the original order was placed on the local system. This field will be empty if order is placed via LEDI.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING PROVIDER REMOTE 7 If this test is ordered by a provider from a remote system (not local system); the names contained in the HL7 message will be stored in this field.

    		Free Text
    SPECIMEN TOPOGRAPHY 8 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE 9 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    DISPOSITION 10 Maintains the disposition of the ordered test. It will be used to value the test disposition in HL7 messaging, specifically OBR-25.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    DISPOSITION DATE/TIME 11 Stores the date and time that a lab user or the system dispositioned this test.

    		Date/Time
    DISPOSITION BY 12 Store the user who entered the disposition of this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAB TEST ORDERED 13 Contains the ordered laboratory test associated with the ordered NLT code.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT TEST 14 If this test is a reflex test this indicates the ordered test that is associated with the reflex test.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT NLT 15 Contains the order NLT code associated with the parent test when the ordered test is a reflex test.

    		Free Text
    COMMENT .99 These are the comments on the tests.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment reported with CHEM, HEM, TOX, etc., data.

    		Free Text
    PERSON 1 Person making comment

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    GLUCOSE 2

    		Numeric
    UREA NITROGEN 3

    		Numeric
    CREATININE 4

    		Numeric
    SODIUM 5

    		Free Text
    POTASSIUM 6

    		Numeric
    CHLORIDE 7

    		Numeric
    CO2 8

    		Numeric
    CALCIUM 9

    		Numeric
    PO4 10

    		Numeric
    URIC ACID 11

    		Numeric
    CHOLESTEROL 12

    		Numeric
    PROTEIN,TOTAL 13

    		Free Text
    ALBUMIN 14

    		Numeric
    BILIRUBIN,TOTAL 15

    		Numeric
    BILIRUBIN,DIRECT 16

    		Free Text
    ALKALINE PHOSPHATASE 17

    		Numeric
    LDH 18

    		Numeric
    SGOT 19

    		Numeric
    SGPT 20

    		Numeric
    GAMMA-GTP 21

    		Numeric
    QUINIDINE 22

    		Free Text
    DILANTIN 23

    		Free Text
    THEOPHYLLINE 24

    		Numeric
    BARBITURATES 25

    		Free Text
    AMPHETAMINES 26

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    PHENOBARBITAL 27

    		Numeric
    LITHIUM 28

    		Numeric
    MAGNESIUM 29

    		Numeric
    BROMIDE 30

    		Numeric
    COPPER 31

    		Numeric
    ZINC 32

    		Numeric
    ARSENIC 33

    		Free Text
    MERCURY 34

    		Free Text
    LEAD 35

    		Free Text
    ETHANOL 36

    		Free Text
    ACETONE 37

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    N-ACETYL 38

    		Free Text
    ACID PHOSPHATASE 39

    		Numeric
    AMYLASE 40

    		Numeric
    CPK 41

    		Numeric
    LACTIC ACID 42

    		Numeric
    LIPASE 43

    		Numeric
    5' NUCLEOTIDASE 44

    		Numeric
    SALICYLATE 45

    		Numeric
    OSMOLALITY 46

    		Numeric
    TRIGLYCERIDE 47

    		Numeric
    AMMONIA 48

    		Numeric
    ACTH 49

    		Numeric
    ANGIOTENSIN 1 51

    		Numeric
    DESIPRAMINE 52

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    ESTROGEN 53

    		Numeric
    IMI+DES 54

    		Free Text
    GENTAMICIN 55

    		Free Text
    DISOPYRAMIDE 57

    		Free Text
    HGB ELECTROPHORESIS 58

    		Free Text
    PROTEIN ELECTROPHORESIS 59

    		Free Text
    RENIN 60

    		Numeric
    MYELIN BASIC PROTEIN 61

    		Free Text
    DNA 62

    		Free Text
    ALDOLASE 63

    		Numeric
    ALDOSTERONE 64

    		Numeric
    AMITRIPTYLINE 65

    		Free Text
    IMIPRAMINE 66

    		Free Text
    ANTI SMOOTH MUSCLE 67

    		Free Text
    BUTABARBITAL 68

    		Numeric
    C-PEPTIDE 69

    		Numeric
    CANDIDA PRECIPITANS AB TITER 70

    		Numeric
    CERULOPLASMIN 71

    		Numeric
    NORTRIPTYLINE 72

    		Free Text
    11-DEOXYCORTISOL 73

    		Free Text
    PTH (C-TERMINAL) 74

    		Free Text
    PTH (INTACT) 75

    		Numeric
    FSH 76

    		Numeric
    METANEPHRINES, TOT 77

    		Numeric
    GASTRIN 78

    		Numeric
    HETEROPHIL 79

    		Numeric
    HDL 80

    		Numeric
    LH 81

    		Numeric
    MYSOLINE 82

    		Numeric
    PROCAINAMIDE 83

    		Free Text
    PROLACTIN 84

    		Free Text
    TESTOSTERONE 85

    		Numeric
    TEGRETOL 86

    		Free Text
    CATECHOLAMINES 88

    		Numeric
    EPINEPHRINE 89

    		Numeric
    NOREPINEPHRINE 90

    		Numeric
    VMA 91

    		Numeric
    CARBAMAZEPINE 92

    		Numeric
    TOBRAMYCIN 93

    		Free Text
    AMIKACIN 94

    		Numeric
    CHOLINESTERASE 95

    		Numeric
    COMPUTED CREATININE CLEARANCE 96

    		Numeric
    ACETAMINOPHEN 97

    		Numeric
    HYDROXYBUTYRIC DEHYDROGENASE 98

    		Numeric
    AMINOLEVULINIC ACID 99

    		Numeric
    ANTIMONY 100

    		Numeric
    CADMIUM 101

    		Free Text
    CARBON TETRACHLORIDE 102

    		Numeric
    CAROTENE 103

    		Numeric
    CHLORPHENIRAMINE 104

    		Free Text
    CHLORPROMAZINE 105

    		Free Text
    CHROMIUM 106

    		Numeric
    CLONAZEPAM 107

    		Numeric
    COBALT 108

    		Numeric
    COPROPORPHYRIN 109

    		Free Text
    CREATINE 110

    		Numeric
    CRYOFIBRINOGEN 111

    		Free Text
    DIAZEPAM 112

    		Free Text
    25 OH VITAMIN D 113

    		Numeric
    VITAMIN A 114

    		Numeric
    VITAMIN E 115

    		Numeric
    MANGANESE 116

    		Numeric
    SELENIUM 117

    		Numeric
    UROPORPHYRIN 118

    		Free Text
    PROTOPORPHYRIN 119

    		Free Text
    MEPROBAMATE 120

    		Free Text
    CARISOPRODOL 121

    		Free Text
    CODEINE 122

    		Free Text
    PHENACETIN 123

    		Free Text
    1,25-DIHYDROXYVIT D3 124

    		Free Text
    CYSTINE 125

    		Free Text
    RETINOL BINDING PROTEIN 128

    		Free Text
    TRANSTHYRETIN 129

    		Free Text
    ACETYLCHOLINE RCPTR AB TITER 130

    		Free Text
    LDH1 131

    		Free Text
    CPK-MB 132

    		Free Text
    CPK-MB/CPK 133

    		Numeric
    LDH1/LDH 134

    		Numeric
    DOXEPIN 135

    		Free Text
    NORDOXEPIN 136

    		Free Text
    TOT/NDOX 137

    		Free Text
    C1 ESTERASE INHIBIT. 138

    		Free Text
    BUTALBITAL 139

    		Free Text
    NORDIAZEPAM 140

    		Free Text
    VANCOMYCIN 141

    		Free Text
    METHANOL 142

    		Free Text
    ISOPROPANOL 143

    		Free Text
    COCAINE 144

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    PHENYLPROPANOLAMINE 145

    		Free Text
    LIPIDS, TOTAL 146

    		Numeric
    NITROGEN 147

    		Numeric
    HYDROXYPROLINE-TOTAL 148

    		Numeric
    FASTING GTT 149

    		Numeric
    1/2Hr.GTT 150

    		Numeric
    1Hr.GTT 151

    		Numeric
    2Hr.GTT 152

    		Numeric
    3Hr.GTT 153

    		Numeric
    4Hr.GTT 154

    		Numeric
    5Hr.GTT 155

    		Numeric
    PROPRANOLOL 156

    		Numeric
    VITAMIN C 157

    		Numeric
    DOPAMINE 159

    		Free Text
    LIPIDS, QUALITATIVE 160

    		Numeric
    LIPID PHENOTYPE EVAL. 161

    		Free Text
    APPEARANCE 162

    		Free Text
    CHYLOMICRONS 163

    		Free Text
    LIPOPROTEIN, BETA 164

    		Free Text
    LIPOPROTEIN, PRE-BETA 165

    		Free Text
    LIPOPROTEIN, ALPHA 166

    		Free Text
    6Hr.GTT 167

    		Numeric
    KETONES 169

    		Free Text
    SOMATOMEDIN-C 170

    		Numeric
    LIDOCAINE 171

    		Numeric
    IMMUNE COMPLEX-C1Q 172

    		Numeric
    HLA B8 173

    		Free Text
    HLA B27 174

    		Free Text
    HCG BETA, QUANT. 175

    		Free Text
    HCG BETA, SCREEN 176

    		Free Text
    MAPROTILINE-LUDIOMIL 177

    		Numeric
    AMITRIPTYLENE & NORTRIPTYLINE 178

    		Free Text
    IMIPRAMINE & DESIPRAMINE 179

    		Free Text
    DOXEPIN & N-DESMETHYLDOXEPIN 180

    		Free Text
    N-DESMETHYLDOXEPIN 181

    		Free Text
    CIE: CLOSTRIDIUM DIFFICILE 182

    		Free Text
    CIE: GROUP B STREPTOCOCCUS 183

    		Free Text
    CIE: H. INFLUENZA 184

    		Free Text
    CIE: MENINGOCOCCUS 185

    		Free Text
    CIE: PNEUMOCOCCUS 186

    		Free Text
    HOMOVANILLIC ACID 187

    		Free Text
    ANTI-DEOXYRIBONUCLEASE 188

    		Free Text
    IONIZED CALCIUM 189

    		Numeric
    TCA 190

    		Free Text
    FATTY ACIDS, FREE 191

    		Numeric
    ALK PHOSPHATASE, HEAT LABILE 192

    		Numeric
    ALK PHOSPHATASE, HEAT STABLE 193

    		Numeric
    17-HYDROXYCORTICOSTEROIDS 194

    		Free Text
    17-KETOGENIC STEROIDS 195

    		Free Text
    17-KETOSTEROIDS, TOTAL 196

    		Free Text
    A/G RATIO 197

    		Numeric
    ACETALDEHYDE 198

    		Free Text
    ACETAZOLAMIDE 199

    		Free Text
    ACTIVE METABOLITE 200

    		Free Text
    ALPHA-1 FRACTION 201

    		Free Text
    ALPHA-1 GLOBULIN 202

    		Free Text
    ALPHA-2 FRACTION 203

    		Free Text
    ALPHA-2 GLOBULIN 204

    		Free Text
    ALUMINUM 205

    		Free Text
    AMORBARBITAL 209

    		Free Text
    AMOXAPINE 210

    		Free Text
    AMPICILLIN 211

    		Free Text
    ANTIDIURETIC HOR 212

    		Free Text
    ARYLSULFATASE 213

    		Free Text
    BENCE JONES PROTEIN 214

    		Free Text
    BENZENE 215

    		Free Text
    BENZODIAZEPINES 216

    		Free Text
    BERYLLIUM 217

    		Free Text
    BETA 2-MICROGLOB 218

    		Free Text
    BETA FRACTION 219

    		Free Text
    BETA GLOBULIN 220

    		Free Text
    BETA LACTOGLOBULIN 221

    		Free Text
    BISMUTH 222

    		Free Text
    CAFFEINE 224

    		Free Text
    CANNABINOIDS 225

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    CARBON MONOXIDE 226

    		Free Text
    CHLORAL HYDRATE 227

    		Free Text
    CHLORAMPHENICOL 228

    		Free Text
    CHLORAZEPATE 229

    		Free Text
    CHLORDANE 230

    		Free Text
    CHLORDIAZEPOXIDE 231

    		Free Text
    CHLORPROPAMIDE 232

    		Free Text
    CIMETIDINE 233

    		Free Text
    CORTICOSTERONE 234

    		Free Text
    CYANIDE 235

    		Free Text
    DESMETHYLDOXEPIN 236

    		Free Text
    DIELDRIN 237

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    DIMETHADIONE 238

    		Free Text
    DIPHENHYDRAMINE 239

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    DISULFIRAM 240

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    ESTRONE 241

    		Free Text
    ETHCHLORVYNOL 242

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    ETHINAMATE 243

    		Free Text
    ETHOSUXIMIDE 244

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    ETHOTOIN 245

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    ETHYLENE GLYCOL 246

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    ETIOCHOLANOLONE 247

    		Free Text
    FIGLU 249

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    FLUORIDE 250

    		Free Text
    FLUPHENAZINE-PROLIXN 251

    		Free Text
    FLURAZEPAM 252

    		Free Text
    FREE HCL 253

    		Free Text
    FRUCTOSE 254

    		Free Text
    FUROSEMIDE 255

    		Free Text
    G-6-PD,QUANTITATIVE 256

    		Free Text
    GALACTOSEMIA 257

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    GLOBULIN 260

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    GLUTAMINE 261

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    GLUTAMYL TRANSFERASE 262

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    GLUTATHIONE 263

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    GLUTETHIMIDE 264

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    GOLD 265

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    GUANASE 266

    		Free Text
    HEMOGLOBIN A2 BY COLUMN 267

    		Free Text
    HEMOGLOBIN C 268

    		Numeric
    HEMOGLOBIN F 269

    		Numeric
    HEMOGLOBIN S 270

    		Numeric
    HEMOPEXIN 271

    		Free Text
    HEROIN 272

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    HEXOSAMINIDASE 273

    		Free Text
    HISTAMINE 274

    		Free Text
    HOMOCYSTINE 275

    		Free Text
    HOMOGENTISIC ACID 276

    		Free Text
    HYDROXYPROLINE, FREE 277

    		Free Text
    HYPNOTIC/SEDATIVES EVAL. 278

    		Free Text
    INDOLE3 ACETIC ACID 279

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    IODINE, INORGANIC 281

    		Free Text
    IODINE, TOTAL 282

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    ISOCITRIC-DEHYDROGENASE 283

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    ISONIAZID 284

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    KANAMYCIN 285

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    KYNURENIC ACID 286

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    LDH 2 287

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    LDH 3 288

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    LDH 5 289

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    LDH 4 290

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    LDL CHOLESTEROL 291

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    LDL-CHOL CALCULATION 292

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    LDL/HDL RATIO 293

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    LECITHIN/SPHINGOMYELIN RATIO 294

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    LONG ACTING THYROID HORMONE 295

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    LSD 296

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    LYSOZYME 297

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    MACROGLOBULINS 298

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    MARIJUANA SCREEN 299

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    MAUVE SPOT 300

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    MELANIN 301

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    MEPERIDINE 302

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    MEPHOBARBITAL 303

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    MESANTOIN 304

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    METHADONE 306

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    METHAMPHETAMINE 307

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    METHAPYRILENE 308

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    METHAQUALONE 309

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    METHARBITAL 310

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    METHEMALBUMIN 311

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    METHOCARBAMOL 312

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    METHOTREXATE 313

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    METHSUXIMIDE 314

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    METHYLMALONIC ACID 315

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    METHYPRYLON 316

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    MORPHINE 317

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    MUCOPOLYSACCHARIDES 318

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    MYOGLOBIN 319

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    N-DESALKYL FLURAZEPAM 320

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    NAFCILLIN 321

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    NICKEL 322

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    NICOTINE 323

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    NIRVANOL 324

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    NORMETHSUXIMIDE 325

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    OPIATES 326

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    OXALATE 327

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    OXAZEPAM 328

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    OXYCODONE 329

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    PARAMETHADIONE 330

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    PCB-POLYCHLORINATED 331

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    PEMA 332

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    PENTAZOCINE 333

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    PENTOBARBITAL 334

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    PEPSINOGEN 335

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    PEPSINOGEN 1 336

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    PHENCYCLIDINE 337

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    PHENCYCLIDINE (PCP) 338

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    PHENCYCLIDINE (PCP)B 339

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    PHENOL 340

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    PHENOLSULFONPHTHALEIN 341

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    PHENOTHIAZINE 342

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    PHENSUXIMIDE 343

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    PHENYLALANINE 344

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    PHOSPHOLIPIDS 345

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    PHYTANIC ACID 346

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    PRAZEPAM 347

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    PREGNANEDIOL 348

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    PREGNANETRIOL 349

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    PROPOXYPHENE 350

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    PROTRIPTYLINE 351

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    PSEUDOCHOLINESTERASE 352

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    PYRUVATE 353

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    PYRUVATE KINASE SCREEN 354

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    SECOBARBITAL 356

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    SEROTONIN 357

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    STRYCHNINE 358

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    SULFHEMOGLOBIN 359

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    SULFONAMIDES 360

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    TETRACYCLINE 361

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    THALLIUM 363

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    THIAMINE 364

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    THIOCYANATE 365

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    THIOPENTAL 366

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    THIORIDAZINE 367

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    THIORIDAZINE-MELLARIL 368

    		Free Text
    THYROGLOBULIN 369

    		Free Text
    TRANXENE 371

    		Free Text
    TRAZODONE 372

    		Free Text
    TRICYCLICS 373

    		Free Text
    TRIMETHADIONE 374

    		Free Text
    TRYPSIN 375

    		Free Text
    TRYPTAMINE 376

    		Free Text
    VALPROIC ACID 377

    		Numeric
    VASO ACTIVE PEPTIDE 378

    		Free Text
    VITAMIN B-1 379

    		Free Text
    VITAMIN B-2 380

    		Free Text
    VITAMIN B-6 381

    		Free Text
    XANTHURENIC ACID 382

    		Free Text
    XYLOSE ABSORPTION 383

    		Free Text
    WBC 384

    		Numeric
    RBC 385

    		Numeric
    HGB 386

    		Numeric
    HCT 387

    		Numeric
    MCV 388

    		Numeric
    MCH 389

    		Numeric
    MCHC 390

    		Numeric
    RDW 391

    		Numeric
    PLT 392

    		Numeric
    MPV 393

    		Numeric
    SEGS 394

    		Numeric
    BANDS 395

    		Numeric
    LYMPHS 396

    		Numeric
    MONOCYTES 397

    		Numeric
    EOSINO 398

    		Numeric
    BASO 399

    		Numeric
    META 400

    		Numeric
    MYELO 401

    		Numeric
    PROMYELOCYTES 402

    		Numeric
    BLAST 403

    		Numeric
    NRBC/100 WBC 404

    		Numeric
    PLT. (SMEAR EST.) 405

    		Set of Codes
    Set of Codes:
    • Code : Adeq.
      Stands For: ADEQ.
    • Code : Reduced
      Stands For: REDUCED
    • Code : Inc.
      Stands For: INC.
    • Code : Hi Adq
      Stands For: HI ADQ
    • Code : Lo Adq
      Stands For: LO ADQ
    NORMOCYTIC 406

    		Set of Codes
    Set of Codes:
    • Code : Yes
      Stands For: YES
    • Code : No
      Stands For: NO
    NORMOCHROMIC 407

    		Set of Codes
    Set of Codes:
    • Code : Yes
      Stands For: YES
    • Code : No
      Stands For: NO
    ANISOCYTOSIS 408

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    POIKILOCYTOSIS 409

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    MICROCYTOSIS 410

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    MACROCYTOSIS 411

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    POLYCHROMASIA 412

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    HYPOCHROMIA 413

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Few
      Stands For: F
    TARGET CELLS 414

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    DOHLE BODIES 415

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    HOWELL JOLLY BODIES 416

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    PAPPENHEIMER BODIES 417

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    MALARIA FORMS 418

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    MEGAKARYOCYTE 419

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    OVALOCYTES 420

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    TEARDROPS 421

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    SICKLE CELLS 422

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    BURR CELLS 423

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    HELMET CELLS 424

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: F
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    SCHISTOCYTES 425

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    ACANTHOCYTES 426

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    WINTROBE ESR 427

    		Free Text
    RETICULOCYTES 428

    		Free Text
    PROTHROMBIN TIME 430

    		Numeric
    PARTIAL THROMBOPLASTIN TIME 431

    		Free Text
    FIBRINOGEN 432

    		Numeric
    FIBRIN SPLIT PRODUCTS 433

    		Free Text
    BLEEDING TIME 434

    		Numeric
    THROMBIN TIME 435

    		Free Text
    VISCOSITY 436

    		Free Text
    LIQUIFACTION 437

    		Free Text
    ANTITHROMBIN III 438

    		Free Text
    MOTILITY 439

    		Free Text
    SPERM COUNT 440

    		Numeric
    PT CONTROL 441

    		Numeric
    MESOTHELIAL CELLS 442

    		Numeric
    CRYSTALS 443

    		Free Text
    FIO2 (L. OR %) 444

    		Free Text
    HB (HGB) 445

    		Free Text
    %O2HB 446

    		Numeric
    %COHB 447

    		Numeric
    %METHB 448

    		Numeric
    O2CT. 449

    		Numeric
    PH 450

    		Numeric
    PCO2 451

    		Numeric
    PO2 452

    		Numeric
    BASE EXCESS 453

    		Free Text
    BICARBONATE 454

    		Numeric
    CO2CT. 455

    		Numeric
    PT. TEMP 456

    		Numeric
    pH at PT temp 457

    		Numeric
    PCO2 AT PT. TEMP 458

    		Numeric
    PO2 AT PT. TEMP 459

    		Numeric
    PTT CONTROL 460

    		Numeric
    HAM'S TEST 461

    		Free Text
    HEMOGLOBIN A1C 462

    		Free Text
    LE PREP 463

    		Free Text
    OSMOTIC FRAGILITY 464

    		Free Text
    SICKLE CELL PREP 465

    		Free Text
    SUGAR WATER TEST 466

    		Free Text
    SPERM MORPHOLOGY 467

    		Free Text
    NEUTROPHIL 468

    		Numeric
    WESTERGREN ESR 469

    		Free Text
    ERYTHROPOIETIN 470

    		Numeric
    ATYPICAL LYMPHOCYTES 471

    		Numeric
    PLASMA CELLS 472

    		Numeric
    SPHEROCYTES 473

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Occ
      Stands For: O
    • Code : Few
      Stands For: F
    • Code : Neg.
      Stands For: NEG
    BASOPHILIC STIPPLING 474

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    TOXIC GRANULATION 475

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Occ
      Stands For: O
    • Code : Few
      Stands For: F
    • Code : Neg.
      Stands For: NEG
    HYPERSEGMENTED NEUTROPHILS 476

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Occ
      Stands For: O
    • Code : Few
      Stands For: F
    • Code : Neg.
      Stands For: NEG
    SMUDGE CELLS 477

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Occ
      Stands For: O
    • Code : Few
      Stands For: F
    • Code : Neg.
      Stands For: NEG
    NEUTROPHIL MATURITY, MEAN 478

    		Numeric
    NEUTROPHIL MATURITY, STA DEV 479

    		Numeric
    LYMPHOCYTE ATYPIA, MEAN 480

    		Numeric
    LYMPHOCYTE ATYPIA, STA DEV 481

    		Numeric
    TURBIDITY 482

    		Free Text
    COLOR 483

    		Free Text
    FACTOR VII 484

    		Free Text
    FACTOR IX INHIBITOR 485

    		Free Text
    FACTOR XII 486

    		Free Text
    BETHESDA ASY 487

    		Numeric
    MALARIA SMEAR 488

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    TUBE # 489

    		Numeric
    MACROPHAGES 490

    		Numeric
    PLATELET AGGREGATION 491

    		Free Text
    FACTOR VIII ANTIGEN 492

    		Free Text
    FACTOR VIII ACTIVITY 493

    		Numeric
    FACTOR VIII MULTIMER 494

    		Numeric
    FACTOR II INHIBITOR 495

    		Free Text
    FACTOR V INHIBITOR 496

    		Free Text
    FACTOR X INHIBITOR 497

    		Free Text
    FACTOR XI 498

    		Free Text
    FACTOR XIII 499

    		Free Text
    PT WITH MIX 500

    		Free Text
    REPTILASE TIME 501

    		Free Text
    ALTERNATE LYMPHS 502

    		Numeric
    A2 HEMOGLOBIN BY COLUMN 503

    		Free Text
    BONE MARROW 504

    		Free Text
    LUPUS TYPE INHIBITOR 505

    		Free Text
    COLLAGEN TYPE INHIBITOR 506

    		Free Text
    FACTOR VIII INHIBITOR 507

    		Free Text
    FACTOR VII INHIBITOR 508

    		Free Text
    HEM FACTOR IX INHIBITOR 509

    		Free Text
    DRUG INDUCED INHIBITOR 510

    		Free Text
    STYPVEN TIME 511

    		Free Text
    EUGLOBULIN LYSIS TIME 512

    		Free Text
    MUCIN CLOT 513

    		Free Text
    PROTAMINE SULFATE 514

    		Free Text
    HEPARIN 515

    		Free Text
    PLASMINOGEN, ACTIVATED 516

    		Free Text
    PLASMINOGEN, TOTAL 517

    		Free Text
    ADP 518

    		Free Text
    HEM EPINEPHRINE 519

    		Free Text
    ARACHIDONIC ACID 520

    		Free Text
    RISTOCETIN 521

    		Free Text
    VON WILLEBRAND FACTOR 522

    		Free Text
    VON WILLEBRAND (CONTROL) 523

    		Free Text
    PLATELET ADHESION 524

    		Free Text
    ADP COMMENT 525

    		Free Text
    COLLAGEN COMMENT 526

    		Free Text
    EPINEPHRINE COMMENT 527

    		Free Text
    ARACHIDONIC ACID COMMENT 528

    		Free Text
    RISTOCETIN COMMENT 529

    		Free Text
    HEINZ BODY STAIN 530

    		Free Text
    LUPUS TYPE INHIBITOR (CONTROL) 531

    		Free Text
    COLLAGEN TYPE (CONTROL) 532

    		Free Text
    FACTOR VIII (CONTROL) 533

    		Free Text
    FACTOR VII (CONTROL) 534

    		Free Text
    FACTOR V (CONTROL) 535

    		Free Text
    FACTOR II (CONTROL) 536

    		Free Text
    FACTOR IX (CONTROL) 537

    		Free Text
    FACTOR X (CONTROL) 538

    		Free Text
    STYPVEN TIME (CONTROL) 539

    		Free Text
    EUGLOBULIN TIME (CONTROL) 540

    		Free Text
    ALPHA-1-ANTITRYPSIN 541

    		Free Text
    ANTINUCLEAR ANTIBODY 542

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: Negative
    • Code : H
      Stands For: Positive (Homogeneous Pattern)
    • Code : M
      Stands For: Positive (Membranous Pattern)
    • Code : S
      Stands For: Positive (Speckled Pattern)
    • Code : PP
      Stands For: Positive (Peripheral Pattern)
    • Code : P
      Stands For: Positive
    ANTISTREPTOLYSIN SC 543

    		Free Text
    ASO 544

    		Free Text
    C-REACTIVE PROTEIN 545

    		Numeric
    COLD AGGLUTININS 546

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    COMPLEMENT C3 547

    		Free Text
    COMPLEMENT C4 548

    		Free Text
    CRYOGLOBULINS 549

    		Free Text
    FEBRILE AGGLUTINS 550

    		Free Text
    FTA 551

    		Set of Codes
    Set of Codes:
    • Code : R
      Stands For: Reactive
    • Code : WR
      Stands For: Weakly Reactive
    • Code : N
      Stands For: Nonreactive
    HAPTOGLOBIN 552

    		Numeric
    HEPATITIS B SURFACE ANTIGEN 553

    		Free Text
    IMMUNOELECTROPHORESIS 554

    		Free Text
    IMMUNOGLOBULINS 555

    		Free Text
    MONO TEST 556

    		Free Text
    MYCOPLASMA TITER 557

    		Free Text
    RHEUMATOID FACTOR 558

    		Free Text
    RPR,QUAL 559

    		Set of Codes
    Set of Codes:
    • Code : Reactive
      Stands For: Reactive
    • Code : Nonreactive
      Stands For: Nonreactive
    • Code : Weakly Reactive
      Stands For: Weakly Reactive
    STREPTOZYME 560

    		Free Text
    VDRL 561

    		Free Text
    FUNGAL 562

    		Free Text
    ANTI-DNA ANTIBODY 563

    		Free Text
    ANTI-HYALURONIDASE TITER 564

    		Free Text
    ANTI-MICROSOMAL ANTIBODY 565

    		Free Text
    ANTI-MITOCHONDRIAL ANTIBODIES 566

    		Free Text
    ANTI-PARIETAL CELL ANTIBODY 567

    		Free Text
    ANTI-THYROGLOBULIN ANTIBODY 568

    		Free Text
    BRUCELLA AGGLUTINATION 569

    		Free Text
    COMPLEMENT C2 570

    		Numeric
    COMPLEMENT C5 571

    		Numeric
    COMPLEMENT C6 572

    		Numeric
    COMPLEMENT DECAY RATE 573

    		Numeric
    COMPLEMENT TOTAL 574

    		Numeric
    DIBUCAINE NUMBER 575

    		Numeric
    CHLAMYDIA AB TITER 576

    		Numeric
    RUBELLA 577

    		Free Text
    HERPES SIMPLEX,COMMON AG TITER 578

    		Free Text
    CMV 579

    		Free Text
    TOXOPLASMA 580

    		Free Text
    HEPATITIS A ANTIBODY 581

    		Free Text
    HEPATITIS B CORE ANTIBODY 582

    		Free Text
    HEPATITIS B SURFACE ANTIBODY 583

    		Free Text
    HEPATITIS E ANTIBODY 584

    		Free Text
    HEPATITIS E ANTIGEN 585

    		Free Text
    ANTI GLOM BASEMENT MEM 586

    		Free Text
    COMPLEMENT CH50 587

    		Free Text
    BRUCELLA BLOCKING ANTIBODIES 588

    		Free Text
    ADENOVIRUS TITER 589

    		Free Text
    ANTI-DNASE AB 590

    		Free Text
    ANTI-EPIDERMAL AB 591

    		Free Text
    ANTI-MYOCARDIAL AB 592

    		Free Text
    ANTI-RETICULIN 593

    		Free Text
    ANTI-RNP 594

    		Free Text
    ANTI-SKELETAL MUSCLE 595

    		Free Text
    ANTI-STRIATED MUSCLE 596

    		Free Text
    ANTI-THYROID ANTIBODIES GROUP 597

    		Free Text
    ANTICENTROMERE 598

    		Free Text
    ASPERGILLUS AB IMMUNODIFFUSION 599

    		Free Text
    ASPERGILLUS COMPLEMENT TITER 600

    		Free Text
    BLASTOMYCES AB 601

    		Free Text
    BLASTOMYCES COMPLEMENT TITER 602

    		Free Text
    C-1Q COMPLEMENT COMPONENT 603

    		Free Text
    C-1Q IMMUNE COMPLEX 604

    		Free Text
    CANDIDA IMMUNO DIFF 605

    		Free Text
    CRYPTOCOCCUS ANTIGEN 606

    		Free Text
    CYTOMEGALO IFA 607

    		Free Text
    CYTOMEGALOVIRUS 608

    		Free Text
    CYTOPLASMIC AB 609

    		Free Text
    EPSTEIN BARR 610

    		Free Text
    FUNGUS ANTIBODY GROUP 611

    		Free Text
    GROUP B-1 612

    		Free Text
    GROUP B-2 613

    		Free Text
    GROUP B-3 614

    		Free Text
    GROUP B-4 615

    		Free Text
    GROUP B-5 616

    		Free Text
    GROUP B-6 617

    		Free Text
    H. SIMPLEX I 618

    		Free Text
    H. SIMPLEX II 619

    		Free Text
    HETEROPHIL AB DIFFERENTIAL 620

    		Free Text
    HISTONE-REACTIVE AB 621

    		Free Text
    HISTOPLASMA COMPLEMENT TITER 622

    		Free Text
    HISTOPLASMA PRECIPITIN 623

    		Free Text
    HLA-ABC TYPING 624

    		Free Text
    IGA 625

    		Free Text
    IGD 626

    		Free Text
    IGG 627

    		Free Text
    IGG SYNTHESIS RATE 628

    		Free Text
    IGG, ACUTE 629

    		Free Text
    IGG, CONVALESCENT 630

    		Free Text
    IGM 631

    		Free Text
    IGM, ACUTE 632

    		Free Text
    IGM, CONVALESCENT 633

    		Free Text
    INFLUENZA TYPE B (TITER) 634

    		Free Text
    INFLUENZA TYPE C (TITER) 635

    		Free Text
    INSULIN ANTIBODIES 636

    		Free Text
    INSULIN BINDING 637

    		Free Text
    INTRINSIC FACTOR AB 638

    		Free Text
    LATEX FIXATION 639

    		Free Text
    LEGIONELLA AB 640

    		Free Text
    LEPTOSPIRA AGGLT 641

    		Free Text
    MEASLES-RUBEOLA TITER 642

    		Free Text
    MUMPS 643

    		Free Text
    MUMPS SOLUBLE 644

    		Free Text
    MUMPS VIRAL 645

    		Free Text
    PARAINFLUENZA 1 TITER 646

    		Free Text
    PARAINFLUENZA 2 TITER 647

    		Free Text
    PARAINFLUENZA 3 TITER 648

    		Free Text
    PLATELET AB 649

    		Free Text
    POLIO VIRUS 1 650

    		Free Text
    POLIO VIRUS 2 651

    		Free Text
    POLIO VIRUS 3 652

    		Free Text
    PREGNANCY TEST 653

    		Free Text
    RA PRECIPITIN AB 654

    		Free Text
    ROCKY MTN SPOTTED FV. TITER 655

    		Free Text
    RUBELLA TITER 656

    		Free Text
    RUBEOLA 657

    		Free Text
    SALINE TITER 658

    		Free Text
    CYCLOSPORIN 659

    		Free Text
    LEUKOCYTE ALK PHOS SCORE 660

    		Numeric
    SALMONELLA AGGLUTINATION 661

    		Free Text
    SALMONELLA GROUP A 662

    		Free Text
    SALMONELLA GROUP B 663

    		Free Text
    SALMONELLA GROUP C 664

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    SALMONELLA GROUP D 665

    		Free Text
    SALMONELLA GROUP E 666

    		Free Text
    SALMONELLA H ANTIGEN 667

    		Free Text
    SALMONELLA O ANTIGENS 668

    		Free Text
    SCLERODERMA AB 669

    		Free Text
    SEROTYPE 2 670

    		Free Text
    SEROTYPE 4 671

    		Free Text
    SEROTYPE 11 672

    		Free Text
    SEROTYPE 16 673

    		Free Text
    TEICHOIC ACID AB 674

    		Free Text
    TRICHINELLA AGGLUTINATION 675

    		Free Text
    TULAREMIA AGGLUTINATION 676

    		Free Text
    TYPHOID H 677

    		Free Text
    AMOEBIC IHA ANTIBODY 681

    		Free Text
    LYMPHOCHORIOMENINGITIS 682

    		Free Text
    UR COLOR 683

    		Free Text
    DENSITY 684

    		Free Text
    SPECIFIC GRAVITY 685

    		Numeric
    UROBILINOGEN 686

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: SMALL
    • Code : 2+
      Stands For: MODERATE
    • Code : 3+
      Stands For: LARGE
    UR BLOOD 687

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Neg.
      Stands For: NEG
    • Code : Trace
      Stands For: TRACE
    UR BILIRUBIN 688

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Neg.
      Stands For: NEG
    • Code : Trace
      Stands For: TRACE
    UR KETONES 689

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Neg.
      Stands For: NEG
    • Code : Trace
      Stands For: TRACE
    UR GLUCOSE 690

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Neg.
      Stands For: NEG
    • Code : Trace
      Stands For: TRACE
    UR PROTEIN 691

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Neg.
      Stands For: NEG
    • Code : Trace
      Stands For: TRACE
    UR PH 692

    		Numeric
    WBC/HPF 693

    		Free Text
    RBC/HPF 694

    		Free Text
    EPITHELIAL CELLS 695

    		Set of Codes
    Set of Codes:
    • Code : NoneObs
      Stands For: NONEOBS
    • Code : Y
      Stands For:
    BACTERIA 696

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    • Code : Few
      Stands For: FEW
    • Code : NoneObs
      Stands For: NONEOBS
    MUCUS 697

    		Free Text
    URINE CASTS 698

    		Set of Codes
    Set of Codes:
    • Code : NoneObs
      Stands For: NONEOBS
    • Code : Y
      Stands For:
    • Code : Unexamd
      Stands For: UNEXAMD
    URINE CRYSTALS 699

    		Set of Codes
    Set of Codes:
    • Code : NoneObs
      Stands For: NONEOBS
    • Code : Y
      Stands For:
    • Code : Unexamd
      Stands For: UNEXAMD
    WBC/CASTS/LPF 700

    		Free Text
    RBC/CASTS/LPF 701

    		Free Text
    HYALINE/CASTS/LPF 702

    		Free Text
    GRANULAR/CASTS/LPF 703

    		Free Text
    WAXY/CASTS/LPF 704

    		Free Text
    FATTY/CASTS/LPF 705

    		Free Text
    UR YEAST 706

    		Set of Codes
    Set of Codes:
    • Code : Abundnt
      Stands For: ABUNDNT
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : NoneObs
      Stands For: NONEOBS
    • Code : Occ
      Stands For: OCC
    • Code : Rare
      Stands For: RARE
    HEMOSIDERIN 707

    		Free Text
    5HIAA-QUANT 708

    		Free Text
    PORPHOBILINOGEN 709

    		Free Text
    TRICHOMONAS 710

    		Set of Codes
    Set of Codes:
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    • Code : NoneObs
      Stands For: NONEOBS
    AM URATE CRYSTALS 711

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    AM PHOSPHATE CRYSTALS 712

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    TRI PHOSPHATE CRYSTALS 713

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    CA++ OXALATE CRYSTALS 714

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    URIC ACID CRYSTALS 715

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    CYSTINE CRYSTALS 716

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    LEUCINE CRYSTALS 717

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    TYROSINE CRYSTALS 718

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    CHOLESTEROL CRYSTALS 719

    		Set of Codes
    Set of Codes:
    • Code : Rare
      Stands For: RARE
    • Code : Few
      Stands For: FEW
    • Code : Moderat
      Stands For: MODERAT
    • Code : Abundnt
      Stands For: ABUNDNT
    UR GLUCOSE TOLERANCE TEST 720

    		Free Text
    UR FASTING GTT 721

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 1/2Hr.GTT 722

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 1Hr.GTT 723

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 2Hr.GTT 724

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 3Hr.GTT 725

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 4Hr.GTT 726

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 5Hr.GTT 727

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    UR 6Hr.GTT 728

    		Set of Codes
    Set of Codes:
    • Code : Neg.
      Stands For: NEG
    • Code : 1+
      Stands For: 1
    • Code : 2+
      Stands For: 2
    • Code : 3+
      Stands For: 3
    • Code : 4+
      Stands For: 4
    • Code : Trace
      Stands For: T
    RENAL TUBE EPITH 729

    		Free Text
    SPERM 730

    		Free Text
    CALCULUS 731

    		Free Text
    ADDIS COUNT 732

    		Free Text
    REACTION PH 733

    		Free Text
    B 12 734

    		Numeric
    DIGITOXIN 735

    		Free Text
    DIGOXIN 736

    		Numeric
    THYROXINE 737

    		Numeric
    T-3 RESIN UPTAKE 738

    		Free Text
    FREE T4 739

    		Numeric
    FOLATE 740

    		Free Text
    TSH 741

    		Numeric
    INSULIN 742

    		Free Text
    HCG 743

    		Free Text
    FERRITIN 744

    		Numeric
    CORTISOL 745

    		Free Text
    PREGNANCY 746

    		Free Text
    ALPHA-FETOPROTEIN 747

    		Free Text
    TIBC 748

    		Free Text
    UIBC 749

    		Free Text
    IRON 750

    		Numeric
    IRON SATURATION 751

    		Free Text
    GONADOTROPINS 752

    		Free Text
    TRIIODOTHYRONINE 753

    		Free Text
    CEA 754

    		Free Text
    ANDROSTENEDIONE 755

    		Free Text
    CALCITONIN 756

    		Free Text
    CHOLYLGLYCINE 757

    		Free Text
    CHORIONIC GONADOTROPIN 758

    		Free Text
    CYCLIC AMP 759

    		Free Text
    DHEA SULFATE 760

    		Numeric
    DHEA 761

    		Free Text
    DEOXYCORTICOSTERONE 762

    		Free Text
    DIHYDROTESTOSTERONE 763

    		Free Text
    ESTRADIOL, 17-B 764

    		Free Text
    ESTRADIOL RECEPTOR ASSAY 765

    		Free Text
    ESTRIOL 766

    		Free Text
    REV T-3 767

    		Free Text
    TRANSFERRIN 768

    		Free Text
    FREE TRIIODOTHYRONINE 769

    		Free Text
    GROWTH HORMONE 770

    		Free Text
    T-4 BINDING GLOBULIN 771

    		Free Text
    GLUCAGON 772

    		Numeric
    17-HYDROXYPROGESTERONE 773

    		Free Text
    CEA-S, RIA 774

    		Free Text
    ABNORMAL FORMS 775

    		Free Text
    ALTERNATE LYMPHS 2 776

    		Numeric
    SQUAMOUS EPITHELIAL 777

    		Free Text
    RENAL EPITHELIAL 778

    		Free Text
    TRANSITIONAL EPITHELIAL 779

    		Free Text
    OTHER 780

    		Free Text
    Q FEVER (ACUTE) TITER 781

    		Free Text
    Q FEVER (CONV.) TITER 782

    		Free Text
    MICROGLOBULIN 783

    		Free Text
    TOTAL WEIGHT 784

    		Free Text
    OLIGOCLONAL BANDS 785

    		Free Text
    PRESSURE 786

    		Numeric
    %O2 787

    		Numeric
    %CO2 788

    		Numeric
    MISCELLANEOUS 789

    		Free Text
    ANION GAP 790

    		Numeric
    CALCULATED OSMOLALITY 791

    		Numeric
    MALIGNANT CELLS 792

    		Free Text
    VENTRICULAR LINING CELLS 793

    		Numeric
    SYNOVIAL LINING CELLS 794

    		Numeric
    NITRITE, URINE 795

    		Free Text
    LEUKOCYTE ESTERASE, URINE 796

    		Free Text
    VOLUME 797

    		Free Text
    ANTICOAGULANT 798

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: HEPARIN ONLY
    • Code : 2
      Stands For: COUMADIN ONLY
    • Code : 3
      Stands For: HEPARIN & COUMADIN
    • Code : 4
      Stands For: NO ANTICOAGULANTS
    • Code : 5
      Stands For: ANTICOAGULANT NOT INDICATED
    PORPHYRINS-QUAL 799

    		Free Text
    FREE HEMOGLOBIN 800

    		Free Text
    FAST.LTT 801

    		Free Text
    1/2HR.LTT 802

    		Free Text
    1HR.LTT 803

    		Free Text
    2HR.LTT 804

    		Free Text
    3HR.LTT 805

    		Free Text
    INFLUENZA TYPE A (TITER) 806

    		Free Text
    RESP SYNCYTIAL VIRUS TITER 807

    		Free Text
    ECHO,2,3,4,7,8,11 TITER 808

    		Free Text
    ECHO,6,9,16,30 TITER 809

    		Free Text
    ECHO,14,18,20,25,28 TITER 810

    		Free Text
    COXSACKIE A 1-10 TITER 811

    		Free Text
    COXSACKIE B 1-6 TITER 812

    		Free Text
    ARBOVIRUS CALIF TITER 813

    		Free Text
    ARBOVIRUS EEE TITER 814

    		Free Text
    ARBOVIRUS SLE TITER 815

    		Free Text
    ARBOVIRUS WEE TITER 816

    		Free Text
    COLORADO TICK FEVER TITER 817

    		Free Text
    TYPHUS AB TITER 818

    		Free Text
    VARICELLA ZOSTER(VZ) AB TITER 819

    		Free Text
    INFLUENZA A,BANGKOK TITER 820

    		Free Text
    INFLUENZA A,ENGLAND TITER 821

    		Free Text
    INFLUENZA A,PHILLIPINES TITER 822

    		Numeric
    INFLUENZA B,SINGAPORE 823

    		Numeric
    HELPER T CELLS 824

    		Free Text
    SUPPRESSOR T CELLS 825

    		Free Text
    HELPER/SUPPRESSOR T CELL RATIO 826

    		Free Text
    T LYMPHOCYTES 827

    		Free Text
    B LYMPHOCYTES 828

    		Free Text
    SALMONELLA A-O TITER 829

    		Free Text
    SALMONELLA B-O TITER 830

    		Free Text
    SALMONELLA C-O TITER 831

    		Free Text
    SALMONELLA D-O TITER 832

    		Free Text
    SALMONELLA A-H TITER 833

    		Free Text
    SALMONELLA B-H TITER 834

    		Free Text
    SALMONELLA C-H TITER 835

    		Free Text
    SALMONELLA TYPHI-H TITER 836

    		Free Text
    COCCIDIOIDES LPA TITER 837

    		Free Text
    COCCIDIOIDES IDCF TITER 838

    		Free Text
    COCCIDIOIDES CF TITER 839

    		Free Text
    ELAPSED TIME 840

    		Free Text
    NEUTROPHIL, ABSOLUTE 841

    		Numeric
    LYMPHS, ABSOLUTE 842

    		Numeric
    MONOS, ABSOLUTE 843

    		Numeric
    EOSINO, ABSOLUTE 844

    		Numeric
    BASO, ABSOLUTE 845

    		Numeric
    GRANULOCYTES, ABSOLUTE 846

    		Numeric
    BANDS, ABSOLUTE 847

    		Numeric
    SEGS, ABSOLUTE 848

    		Numeric
    PROTEUS OX2 849

    		Free Text
    PROTEUS OXK 850

    		Free Text
    PROTEUS OX19 851

    		Free Text
    HALOPERIDOL 852

    		Free Text
    VITAMIN B-12 853

    		Free Text
    COCCIDIOIDES AB 854

    		Free Text
    COCCIDIOIDES PRECIPITIN 855

    		Free Text
    HISTOPLASMA AB 856

    		Free Text
    GRANULOCYTE, ALTERNATE % 857

    		Numeric
    MONOCYTE, ALTERNATE % 858

    		Numeric
    GRANULOCYTE, ALTERNATE ABS 859

    		Numeric
    MONOCYTE, ALTERNATE ABS 860

    		Numeric
    LYMPHS, ALTERNATE ABS 861

    		Numeric
    UROBILINOGEN, QUANTITATIVE 862

    		Numeric
    BLOOD UREA NITROGEN 1001

    		Numeric
    NA+ 1002

    		Numeric
    CARBON DIOXIDE 1003

    		Numeric
    CREATINE KINASE 1004

    		Numeric
    LACTATE DHYGNASE 1005

    		Numeric
    ALT-SGPT 1006

    		Numeric
    AST-SGOT 1007

    		Numeric
    ALK PHOSPHATASE 1008

    		Numeric
    G G TRANSFERASE 1009

    		Numeric
    BILIRUBIN TOTAL 1010

    		Numeric
    BILIRUBIN DIRECT 1011

    		Numeric
    NEONATAL BILI 1012

    		Numeric
    BILI CONJUGATED 1013

    		Numeric
    TOTAL PROTEIN 1014

    		Numeric
    HDLD CHOLESTEROL 1015

    		Numeric
    LDL DIRECT CHOLESTEROL 1016

    		Numeric
    HF LDL 1017

    		Numeric
    TTL IRON BDG CAPACITY 1018

    		Numeric
    %SAT CAL 1019

    		Numeric
    BUN/CREAT RATIO 1020

    		Numeric
    GLUCOSE METERED 1021

    		Numeric
    OSMO SERUM 1022

    		Numeric
    GLUCOSE FASTING 1023

    		Numeric
    GLU 1/2 1024

    		Numeric
    GLU 1HR 1025

    		Numeric
    GLU 2HR 1026

    		Numeric
    GLU 3HR 1027

    		Numeric
    GLU 4HR 1028

    		Numeric
    GLU 5HR 1029

    		Numeric
    GLU 6HR 1030

    		Numeric
    TOTAL VOLUME 1031

    		Numeric
    HEIGHT 1032

    		Numeric
    WEIGHT 1033

    		Numeric
    BODY SURFACE AREA 1034

    		Numeric
    UR CREATININE RANDOM 1035

    		Numeric
    U CREATININE 24 CAL 1036

    		Numeric
    CREAT CLEARANCE CALCUALTION 1037

    		Numeric
    MICRO ALBUMIN 1038

    		Numeric
    MICROALB/CREAT RATIO 1039

    		Numeric
    U MICROALBUMIN CAL 1040

    		Numeric
    URINE K+ RANDOM 1041

    		Numeric
    U K+24HR CALCULATION 1042

    		Numeric
    U NA+ RANDOM 1043

    		Numeric
    U NA+24HR CAL 1044

    		Numeric
    URINE TOTAL PROTEIN 1045

    		Numeric
    U PROTEIN CALCULATION 1046

    		Numeric
    OSMOLALITY URINE 1047

    		Numeric
    CKMB 1048

    		Numeric
    TROPONIN-I 1049

    		Numeric
    PEPTIDE 1050

    		Numeric
    TRIAGE CKMB 1051

    		Numeric
    TRIAGE MYOGLOBIN 1052

    		Numeric
    TRIAGE TROPONIN 1053

    		Numeric
    ALCOHOL 1054

    		Numeric
    URINE AMPHETAMINES 1055

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE BARBITURATES 1056

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE BENZODIAZEPINES 1057

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE CANNABINOIDS 1058

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE COCAINE 1059

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE OPIATES 1060

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE PCP 1061

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    UR TRCYICS ANTIDEP 1062

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    PHENYTOIN 1063

    		Numeric
    GENTAMICIN TROUGH 1064

    		Numeric
    GENTAMICIN PEAK 1065

    		Numeric
    VANCOMYCIN TROUGH 1066

    		Numeric
    VANCOMYCIN PEAK 1067

    		Numeric
    VANCOMYCIN RANDOM 1068

    		Numeric
    HCG QUANT 1069

    		Numeric
    PROSTATIC SPECIFIC AG 1070

    		Numeric
    T4 1071

    		Numeric
    TOTAL T3 1072

    		Numeric
    FREE T3 1073

    		Numeric
    VITAMIN B12 1074

    		Numeric
    SERUM FOLATE 1075

    		Numeric
    FOLATERI 1076

    		Numeric
    FOLATER CALC 1077

    		Numeric
    CORTISOL AM (0700-0900) 1078

    		Numeric
    CORTISOL PM (1600-1800) 1079

    		Numeric
    CORTISOL (RANDOM) 1080

    		Numeric
    HGBA1C 1081

    		Numeric
    HEP A VIRUS ANTIBODY 1082

    		Set of Codes
    Set of Codes:
    • Code : NONREACT
      Stands For: NONREACT
    • Code : REACTIVE
      Stands For: REACTIVE
    • Code : GZ
      Stands For: GZ
    HEP B SURFACE ANTIGEN 1083

    		Set of Codes
    Set of Codes:
    • Code : NONREACT
      Stands For: NONREACT
    • Code : REACTIVE
      Stands For: REACTIVE
    • Code : RPTREAC
      Stands For: RPTREAC
    HEP C VIRUS ANTIBODY 1084

    		Set of Codes
    Set of Codes:
    • Code : NONREACT
      Stands For: NONREACT
    • Code : REACTIVE
      Stands For: REACTIVE
    • Code : GZ
      Stands For: GZ
    HEP B CORE ANTIBODY 1085

    		Set of Codes
    Set of Codes:
    • Code : NONREACT
      Stands For: NONREACT
    • Code : REACTIVE
      Stands For: REACTIVE
    • Code : GZ
      Stands For: GZ
    HEP B SURFACE AB 1086

    		Set of Codes
    Set of Codes:
    • Code : NONREACT
      Stands For: NONREACT
    • Code : REACTIVE
      Stands For: REACTIVE
    • Code : GZ
      Stands For: GZ
    INDUSTRIAL PSA 1087

    		Numeric
    INDUSTRIAL TSH 1088

    		Numeric
    IND HGBA1C 1089

    		Numeric
    HEALTH FAIR PSA 1090

    		Numeric
    HEALTH FAIR TSH 1091

    		Numeric
    HEALTH FAIR HGBA1C 1092

    		Numeric
    AMPHETAMINE 1093

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    BARBITURATE 1094

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    BENZODIAZEPINE 1095

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    CANNABINOID 1096

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    METHODONE 1097

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    OPIATE 1098

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : QUEST CON
      Stands For: QUEST CON
    INR 1099

    		Numeric
    ACTIVATED PTT 1100

    		Numeric
    FIBRIN DGRD PRODUCTS 1101

    		Set of Codes
    Set of Codes:
    • Code : <10
      Stands For: <10
    • Code : 10-40
      Stands For: 10-40
    • Code : >40
      Stands For: >40
    D DIMER 1102

    		Numeric
    ACTED CLOTTING TIME 1103

    		Free Text
    NRBC 1104

    		Numeric
    RED BLOOD COUNT 1105

    		Numeric
    HEMOGLOBIN 1106

    		Numeric
    HEMATOCRIT 1107

    		Numeric
    PLATELET COUNT 1108

    		Numeric
    MANUAL PLTELET COUNT 1109

    		Numeric
    RBC DIST WDTH 1110

    		Numeric
    MANUAL DIFF 1111

    		Set of Codes
    Set of Codes:
    • Code : PERF
      Stands For: PERF
    • Code : ND
      Stands For: ND
    SEGMTED NEUTROPHILS 1112

    		Numeric
    LYMPHOCYTES 1113

    		Numeric
    MONOCYTE 1114

    		Numeric
    BASOPHILS 1115

    		Numeric
    EOSINOPHILS 1116

    		Numeric
    ATYPICAL LYMPHS 1117

    		Numeric
    METAMYELOCYTES 1118

    		Numeric
    MYELOCYTES 1119

    		Numeric
    BLASTS 1120

    		Numeric
    RBC MORPHOLOGY 1121

    		Set of Codes
    Set of Codes:
    • Code : N/N
      Stands For: N/N
    • Code : ABN
      Stands For: ABN
    HYPERCHROMASIA 1122

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    HYPOCHROMASIA 1123

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    MACROCYTES 1124

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    MICROCYTES 1125

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    SPHEROCYTE 1126

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    CRENATED RBC 1127

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    ELLIPTOCYTES 1128

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    TEAR DROP CELLS 1129

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    TOXIC GRAN 1130

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    DOHLE BODY 1131

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    VACUOLES-WBC 1132

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    DIFF MISC 1133

    		Set of Codes
    Set of Codes:
    • Code : DECPLT
      Stands For: DECPLT
    • Code : INCPLT
      Stands For: INCPLT
    • Code : GIANTPLT
      Stands For: GIANTPLT
    • Code : LARGEPLT
      Stands For: LARGEPLT
    STOMATOCYTES 1134

    		Set of Codes
    Set of Codes:
    • Code : SLT
      Stands For: SLT
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    RETIC 1135

    		Numeric
    PHLEBOTOMY 1136

    		Set of Codes
    Set of Codes:
    • Code : PHLEB100
      Stands For: PHLEB100
    • Code : PHLEB150
      Stands For: PHLEB150
    • Code : PHLEB200
      Stands For: PHLEB200
    • Code : PHLEB250
      Stands For: PHLEB250
    • Code : PHLEB300
      Stands For: PHLEB300
    • Code : PHLEB350
      Stands For: PHLEB350
    • Code : PHLEB400
      Stands For: PHLEB400
    • Code : PHLEB450
      Stands For: PHLEB450
    • Code : PHLEB500
      Stands For: PHLEB500
    ERYTHROCYTE SED RATE 1137

    		Numeric
    EOSINOPHIL SMEAR 1138

    		Numeric
    FETAL HGB SCREEN 1139

    		Set of Codes
    Set of Codes:
    • Code : NEG FH
      Stands For: NEG FH
    • Code : POS FH
      Stands For: POS FH
    EOS CNT 1140

    		Numeric
    EOS CALC 1141

    		Numeric
    BF TYPE 1142

    		Set of Codes
    Set of Codes:
    • Code : AMNIO
      Stands For: AMNIO
    • Code : DIAL
      Stands For: DIAL
    • Code : DRAIN
      Stands For: DRAIN
    • Code : OTHER
      Stands For: OTHER
    • Code : PERITO
      Stands For: PERITO
    • Code : PLEURAL
      Stands For: PLEURAL
    • Code : SYNOV
      Stands For: SYNOV
    BF COLOR 1143

    		Set of Codes
    Set of Codes:
    • Code : BLOODY
      Stands For: BLOODY
    • Code : BROWN
      Stands For: BROWN
    • Code : COLORLESS
      Stands For: COLORLESS
    • Code : GREEN
      Stands For: GREEN
    • Code : OTHER
      Stands For: OTHER
    • Code : PA YELLOW
      Stands For: PA YELLOW
    • Code : PINK
      Stands For: PINK
    • Code : YELLOW
      Stands For: YELLOW
    BF APPEARANCE 1144

    		Set of Codes
    Set of Codes:
    • Code : CLEAR
      Stands For: CLEAR
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    SYNOVIAL VISCOSITY 1145

    		Set of Codes
    Set of Codes:
    • Code : MILKY
      Stands For: MILKY
    • Code : NORMAL
      Stands For: NORMAL
    • Code : PURULENT
      Stands For: PURULENT
    • Code : VISCOUS
      Stands For: VISCOUS
    • Code : WATERY
      Stands For: WATERY
    BF HGB 1146

    		Numeric
    BF HEMATOCRIT 1147

    		Numeric
    BF WBC COUNT 1148

    		Numeric
    BF RBC COUNT 1149

    		Numeric
    BF SEGMTED NUTROPHILS 1150

    		Numeric
    BF LYMPHOCYTES 1151

    		Numeric
    BF MONOCYTES 1152

    		Numeric
    BF OTHER 1153

    		Free Text
    BF CRYSTAL EXAM 1154

    		Set of Codes
    Set of Codes:
    • Code : CRYEXNEG
      Stands For: CRYEXNEG
    • Code : CRYEXPOS
      Stands For: CRYEXPOS
    BF GLUCOSE 1155

    		Numeric
    BF PROTEIN 1156

    		Numeric
    BF LD 1157

    		Numeric
    BF SPECIFIC GRAVITY 1158

    		Numeric
    BF AMY 1159

    		Numeric
    BF ALB 1160

    		Numeric
    CSF TUBE # 1161

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    • Code : 4
      Stands For: 4
    CSF GLUCOSE 1162

    		Numeric
    CSF PROTEIN 1163

    		Numeric
    CSF COLOR 1164

    		Set of Codes
    Set of Codes:
    • Code : COLORLESS
      Stands For: COLORLESS
    • Code : YELLOW
      Stands For: YELLOW
    • Code : RED
      Stands For: RED
    • Code : PINK
      Stands For: PINK
    • Code : PA YELLOW
      Stands For: PA YELLOW
    CSF APPEARANCE 1165

    		Set of Codes
    Set of Codes:
    • Code : CLEAR
      Stands For: CLEAR
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    CSF WBC 1166

    		Numeric
    CSF RBC 1167

    		Numeric
    CSF SEGMTED NEUTPHLS 1168

    		Numeric
    CSF LYMPHOCYTES 1169

    		Numeric
    CSF MONOCYTES 1170

    		Numeric
    CSF OTHER 1171

    		Free Text
    U COLOR 1172

    		Set of Codes
    Set of Codes:
    • Code : YELLOW
      Stands For: YELLOW
    • Code : COLORLESS
      Stands For: COLORLESS
    • Code : STRAW
      Stands For: STRAW
    • Code : LIGHT YELL
      Stands For: LIGHT YELL
    • Code : AMBER
      Stands For: AMBER
    • Code : BROWN
      Stands For: BROWN
    • Code : DK YELLOW
      Stands For: DK YELLOW
    • Code : ORANGE
      Stands For: ORANGE
    • Code : PINK
      Stands For: PINK
    • Code : RED
      Stands For: RED
    U APPEARANCE 1173

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U SPECIFIC GRAVITY 1174

    		Numeric
    U pH 1175

    		Numeric
    U PROTEIN 1176

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U GLUCOSE 1177

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U KETONE 1178

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U BILI 1179

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U BLOOD 1180

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U LEUK 1181

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U NITRITE 1182

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : POS
      Stands For: POS
    U UROBILINOGEN 1183

    		Numeric
    U RBC 1184

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U WBC 1185

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U EPI 1186

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U TRANSITIONAL EPI 1187

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U RENAL TUBULAR 1188

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U MUCUS 1189

    		Set of Codes
    Set of Codes:
    • Code : ABSENT
      Stands For: ABSENT
    • Code : PRESENT
      Stands For: PRESENT
    • Code : LGAMTPRES
      Stands For: LGAMTPRES
    U BACTERIA 1190

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U AMORPH 1191

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    U CAST 1192

    		Free Text
    U HYALINE CASTS 1193

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U WBC CAST 1194

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U RBC CAST 1195

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U GRANULAR CAST 1196

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U CRYSTALS 1197

    		Free Text
    U URIC ACID 1198

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U CALCIUM OXALATE 1199

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U TRIPLE PHOSPHATE 1200

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : 2-5
      Stands For: 2-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    U MISC 1201

    		Set of Codes
    Set of Codes:
    • Code : <10CC
      Stands For: <10CC
    • Code : FALSE COL
      Stands For: FALSE COL
    U SPERM 1202

    		Set of Codes
    Set of Codes:
    • Code : NONM SPERM
      Stands For: NONM SPERM
    • Code : MOT SPERM
      Stands For: MOT SPERM
    • Code : SPERM PRESENT
      Stands For: SPERM PRESENT
    U TRICH 1203

    		Set of Codes
    Set of Codes:
    • Code : RARE
      Stands For: RARE
    • Code : FEW
      Stands For: FEW
    • Code : MOD
      Stands For: MOD
    • Code : MANY
      Stands For: MANY
    U YEAST 1204

    		Set of Codes
    Set of Codes:
    • Code : RARE
      Stands For: RARE
    • Code : FEW
      Stands For: FEW
    • Code : MOD
      Stands For: MOD
    • Code : MANY
      Stands For: MANY
    GASTROCCULT 1205

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    CULTURE IF INDICATED 1206

    		Set of Codes
    Set of Codes:
    • Code : PER
      Stands For: PER
    • Code : NOT PER
      Stands For: NOT PER
    pH 1207

    		Set of Codes
    Set of Codes:
    • Code : PH1
      Stands For: PH1
    • Code : PH2
      Stands For: PH2
    • Code : PH3
      Stands For: PH3
    • Code : PH4
      Stands For: PH4
    • Code : PH5
      Stands For: PH5
    • Code : PH6
      Stands For: PH6
    • Code : PH7
      Stands For: PH7
    • Code : PH>7
      Stands For: PH>7
    WET MOUNT 1208

    		Set of Codes
    Set of Codes:
    • Code : CLUE CELLS
      Stands For: CLUE CELLS
    • Code : NOTRIYT
      Stands For: NOTRIYT
    • Code : NYTCLUE
      Stands For: NYTCLUE
    • Code : TR/NOYST
      Stands For: TR/NOYST
    • Code : TRI/YST
      Stands For: TRI/YST
    • Code : YST/NOTR
      Stands For: YST/NOTR
    POST VAS 1209

    		Set of Codes
    Set of Codes:
    • Code : SPERM PRES
      Stands For: SPERM PRES
    • Code : NO SPERM
      Stands For: NO SPERM
    • Code : NONMSPERM
      Stands For: NONMSPERM
    FERTILITY LIQUEFACTION 1210

    		Set of Codes
    Set of Codes:
    • Code : COMP
      Stands For: COMP
    • Code : INCOMP
      Stands For: INCOMP
    FERTILITY VISCOSITY 1211

    		Set of Codes
    Set of Codes:
    • Code : NORMAL
      Stands For: NORMAL
    • Code : INC
      Stands For: INC
    • Code : DEC
      Stands For: DEC
    FERTILITY VOLUME 1212

    		Numeric
    FERTILITY MOTILITY 1213

    		Set of Codes
    Set of Codes:
    • Code : 10
      Stands For: 10
    • Code : 20
      Stands For: 20
    • Code : 30
      Stands For: 30
    • Code : 40
      Stands For: 40
    • Code : 50
      Stands For: 50
    • Code : 60
      Stands For: 60
    • Code : 70
      Stands For: 70
    • Code : 80
      Stands For: 80
    • Code : 90
      Stands For: 90
    • Code : 100
      Stands For: 100
    FERTILITY VIGOR 1214

    		Set of Codes
    Set of Codes:
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    FERTILITY PH 1215

    		Numeric
    FERTILITY COUNT 1216

    		Numeric
    FERTILITY MORPH 1217

    		Set of Codes
    Set of Codes:
    • Code : 10
      Stands For: 10
    • Code : 20
      Stands For: 20
    • Code : 30
      Stands For: 30
    • Code : 40
      Stands For: 40
    • Code : 50
      Stands For: 50
    • Code : 60
      Stands For: 60
    • Code : 70
      Stands For: 70
    • Code : 80
      Stands For: 80
    • Code : 90
      Stands For: 90
    • Code : 100
      Stands For: 100
    STOOL WBC 1218

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : 0-3
      Stands For: 0-3
    • Code : 3-5
      Stands For: 3-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    STOOL RBC 1219

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : 0-3
      Stands For: 0-3
    • Code : 3-5
      Stands For: 3-5
    • Code : 5-10
      Stands For: 5-10
    • Code : 10-25
      Stands For: 10-25
    • Code : 25-50
      Stands For: 25-50
    • Code : 50-100
      Stands For: 50-100
    • Code : >100
      Stands For: >100
    FECAL FAT SCREEN 1220

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    STOOL PH 1221

    		Numeric
    STOOL RDCNG SBST 1222

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    MEAT FIBERS 1223

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    ANTI-STREPTOLYSIN O 1224

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    • Code : ASO TITER
      Stands For: ASO TITER
    RHMATOID FCT TTR UNORD 1225

    		Free Text
    HCG SCREEN 1226

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    URINE PREGNANCY 1227

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    AMNIOSTAT-PG 1228

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : LO POS
      Stands For: LO POS
    • Code : HI POS
      Stands For: HI POS
    FETAL FIBRONECTIN 1229

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    RAPID STREP 1230

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    RSV ANTIGEN 1231

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    INFLUENZA A AND B AG 1232

    		Set of Codes
    Set of Codes:
    • Code : A+ B=
      Stands For: A+ B=
    • Code : A+ B+
      Stands For: A+ B+
    • Code : A= B+
      Stands For: A= B+
    • Code : A= B=
      Stands For: A= B=
    • Code : INCON/FLU
      Stands For: INCON/FLU
    MONOSPOT 1233

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    CLOSTRIDIUM DIFFICILE 1234

    		Set of Codes
    Set of Codes:
    • Code : AG+ TX+
      Stands For: AG+ TX+
    • Code : AG+ TX=
      Stands For: AG+ TX=
    • Code : AG= TX+
      Stands For: AG= TX+
    • Code : AG= TX=
      Stands For: AG= TX=
    • Code : INCON
      Stands For: INCON
    LAMELLAR BODIES 1235

    		Numeric
    HIV 1236

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : HIV/WB
      Stands For: HIV/WB
    RPR 1237

    		Set of Codes
    Set of Codes:
    • Code : REACT
      Stands For: REACT
    • Code : WK REACT
      Stands For: WK REACT
    • Code : NONREACT
      Stands For: NONREACT
    BLOOD BANK TYPE/RH 1238

    		Set of Codes
    Set of Codes:
    • Code : O NEG
      Stands For: O NEG
    • Code : O POS
      Stands For: O POS
    • Code : A NEG
      Stands For: A NEG
    • Code : A POS
      Stands For: A POS
    • Code : B NEG
      Stands For: B NEG
    • Code : B POS
      Stands For: B POS
    • Code : AB NEG
      Stands For: AB NEG
    • Code : AB POS
      Stands For: AB POS
    BLOOD BANK RH 1239

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    BLOOD BANK AB SCREEN 1240

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    DIRECT COOMBS 1241

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : POS
      Stands For: POS
    FETAL SCREEN 1242

    		Set of Codes
    Set of Codes:
    • Code : 0-2
      Stands For: 0-2
    • Code : >3
      Stands For: >3
    B B RHOGAM VIAL 1243

    		Set of Codes
    Set of Codes:
    • Code : >1 VIALRHO
      Stands For: >1 VIALRHO
    • Code : 1 VIALRHO
      Stands For: 1 VIALRHO
    • Code : PHYSORD
      Stands For: PHYSORD
    TYPE AND CROSS 1244

    		Set of Codes
    Set of Codes:
    • Code : COMP
      Stands For: COMP
    CROSSMATCH 1245

    		Set of Codes
    Set of Codes:
    • Code : COMP
      Stands For: COMP
    ELUTION STUDY 1246

    		Free Text
    AB ID PANEL 1247

    		Free Text
    AB TITER 1248

    		Free Text
    GENETIC SCREEN 1249

    		Set of Codes
    Set of Codes:
    • Code : RGSLAB
      Stands For: RGSLAB
    SOURCE 1250

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: A
    • Code : C
      Stands For: C
    • Code : CORD
      Stands For: CORD
    • Code : O
      Stands For: O
    • Code : P
      Stands For: P
    • Code : U
      Stands For: U
    • Code : V
      Stands For: V
    CPpH 1251

    		Numeric
    TOTAL CO2 1252

    		Numeric
    HCO3 1253

    		Numeric
    O2 SATURATION 1254

    		Numeric
    O2Hb 1255

    		Numeric
    COHb 1256

    		Free Text
    MET Hb 1257

    		Numeric
    O2 CONTENT (ART) 1258

    		Numeric
    FIO2 1259

    		Free Text
    PSV 1260

    		Free Text
    PEEP 1261

    		Free Text
    TIDVOL 1262

    		Free Text
    RATE 1263

    		Free Text
    MODE 1264

    		Free Text
    BIPAPI 1265

    		Free Text
    BIPAPE 1266

    		Free Text
    CPAP 1267

    		Free Text
    SITE 1268

    		Free Text
    RESP RATE 1269

    		Free Text
    BARO PRES 1270

    		Free Text
    ALLEN TEST 1271

    		Free Text
    DRAWN BY 1272

    		Free Text
    TIME COLLECTED 1273

    		Free Text
    RUN BY 1274

    		Free Text
    ANTIGEN SCREEN 1275

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    UBS AG SCREEN/UNIT 1276

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    AUTOTRANSFUSION 1277

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    AUTOLOGOUS WORKUP 1278

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    LEUKO-FREE BKD UNIT 1279

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    CMV TESTING 1280

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    UBS COMPLEX SENDOUT 1281

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    UBS EXTENDED SENDOUT 1282

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    FRESH FROZEN PLASMA 1283

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    FRESH FROZEN THAW 1284

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    IRRADIATION BLOOD 1285

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    IRRADIATION PLATELET 1286

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    MISCELLANEOUS CHARGE 1287

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    CROSS MATCH 1288

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    PLATELET PHERESED 1289

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHG
    RUBELLA IGG 1290

    		Numeric
    OCCULT BLD #1 UNORD 1291

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POS
    • Code : NEG
      Stands For: NEG
    OCCULT BLD #2 UNORD 1292

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POS
    • Code : NEG
      Stands For: NEG
    OCCULT BLD #3 UNORD 1293

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POS
    • Code : NEG
      Stands For: NEG
    CLD AGGTN TTR UNORD 1294

    		Free Text
    PH GASTROCCULT 1295

    		Numeric
    24 HR URINE VOLUME 1296

    		Numeric
    ABSOLUTE CD4 1297

    		Numeric
    AFP TUMOR MARKER 1298

    		Numeric
    ALBUMIN URINE 1299

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DETECTED
      Stands For: NONE DETECTED
    ALPHA 1 1300

    		Numeric
    ALPHA 1 ANTITRYPSIN 1301

    		Numeric
    ALPHA 2 1302

    		Numeric
    ALPHA-1 URINE 1303

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DETECTED
      Stands For: NONE DETECTED
    ALPHA-2 URINE 1304

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DETECTED
      Stands For: NONE DETECTED
    ALUMINUM, SERUM 1305

    		Numeric
    AMPHETAMINES CONF 1306

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    ANA TITER 1307

    		Numeric
    ANCA TITER 1308

    		Free Text
    ANGIO CONVERT ENZ 1309

    		Numeric
    ANTI-NUCLEAR AB IFA 1310

    		Free Text
    ANTI-NUCLEAR AB IGG 1311

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DET
      Stands For: NONE DET
    BETA 1312

    		Numeric
    BETA 2 MICROGLOBIN 1313

    		Numeric
    BETA-URINE 1314

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DETECTED
      Stands For: NONE DETECTED
    BK VIRUS QUAN PCR 1315

    		Numeric
    CALCIUM 24 HR 1316

    		Numeric
    CALCIUM PTH 1317

    		Numeric
    CALCIUM U 1318

    		Numeric
    CANCER ANTIGEN 125 1319

    		Numeric
    CANCER ANTIGEN 27.29 1320

    		Numeric
    CANCER ANTIGEN GI 19-9 1321

    		Numeric
    CANCER BREAST CA15-3 1322

    		Numeric
    CANNABINOIDS CONF 1323

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    CARCINOEMBRYONIC ANT 1324

    		Numeric
    CARDIOLIPIN AB IGA 1325

    		Numeric
    CARDIOLIPIN AB IGG 1326

    		Numeric
    CARDIOLIPIN AB IGM 1327

    		Numeric
    CHLAMYDIA APTIMA 1328

    		Free Text
    CITRIC ACID 24 HR 1329

    		Numeric
    CITRIC ACID U 1330

    		Numeric
    COCAINE CONF 1331

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    COCAINES 1332

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POSITIVE
    • Code : NEG
      Stands For: NEGATIVE
    CREATININE 24 HR 1333

    		Numeric
    CREATININE U 1334

    		Numeric
    CYCLOSPORINE A 1335

    		Numeric
    DRVVT CONFIRMATION 1336

    		Numeric
    DS DNA IGG 1337

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NONE DETECTED
    ELP ALBUMIN 1338

    		Numeric
    ELP TOTAL PROTEIN 1339

    		Numeric
    ESTRADIOL SERUM 1340

    		Numeric
    ESTROGENS FRACT 1341

    		Numeric
    F-ACTIN (SMA) IGG 1342

    		Numeric
    FACTOR V LEIDEN 1343

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    FSH-REF 1344

    		Numeric
    FREE K/L RATIO U 1345

    		Numeric
    FREE KAP LT CH 24 1346

    		Numeric
    FREE KAP LT CH U 1347

    		Numeric
    FREE LAMB LT CH 24 1348

    		Numeric
    FREE LAMB LT CH U 1349

    		Numeric
    GAMMA 1350

    		Numeric
    GAMMA-URINE 1351

    		Set of Codes
    Set of Codes:
    • Code : DETECTED
      Stands For: DETECTED
    • Code : NONE DETECTED
      Stands For: NONE DETECTED
    GC APTIMA 1352

    		Free Text
    GLIA IGA 1353

    		Numeric
    GLIA IGG 1354

    		Numeric
    H PYLORI AB IGM 1355

    		Numeric
    H PYLORI ANTIGEN STL 1356

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    H PYLORI IGA 1357

    		Numeric
    H PYLORI IGG 1358

    		Numeric
    HEMOGLOBIN ABN EVAL 1359

    		Free Text
    HEMOGLOBIN A1 1360

    		Numeric
    HEMOGLOBIN A2 1361

    		Numeric
    HEMOGLOBIN E 1362

    		Numeric
    HEMOGLOBIN OTHER 1363

    		Numeric
    HEP C GENOTYPE 1364

    		Free Text
    HEP C RNA QUNT RT PCR 1365

    		Free Text
    HEPATITIS A TOTAL IGG 1366

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    HERPES SIMPLEX CU 1367

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POSITIVE
    • Code : NEG
      Stands For: NEGATIVE
    HERPES SIMPLEX PCR 1368

    		Set of Codes
    Set of Codes:
    • Code : POS
      Stands For: POSITIVE
    • Code : NEG
      Stands For: NEGATIVE
    HERPES SIMPLEX TYPE 1369

    		Set of Codes
    Set of Codes:
    • Code : HSV TYPE 1
      Stands For: HSV TYPE 1
    • Code : HSV TYPE 2
      Stands For: HSV TYPE 2
    HEX PHOS NEUT RFLX 1370

    		Free Text
    HIV-1RNA UPCR log (cpy/mL) 1371

    		Numeric
    HLA-B27 1372

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    HOMOCYSTEINE 1373

    		Numeric
    IMMUNOFIXATION 1374

    		Free Text
    IMMUNOGLOBULIN A 1375

    		Numeric
    IMMUNOGLOBULIN E 1376

    		Numeric
    IMMUNOGLOBULIN G 1377

    		Numeric
    IMMUNOGLOBULIN M 1378

    		Numeric
    INSULIN, FASTING 1379

    		Numeric
    IONIZED CALCIUM PH 7.4 1380

    		Numeric
    LAMOTRIGINE 1381

    		Numeric
    LEAD, BLOOD VENOUS 1382

    		Free Text
    LEGIONELLA PNEUMO U 1383

    		Free Text
    LUPUS ANTICOAG INTER 1384

    		Free Text
    LUTEINIZING HORMONE 1385

    		Free Text
    MISC. SENDOUT 1386

    		Free Text
    MITOCHONDRIAL M2 IGG 1387

    		Free Text
    MPO/PR3 (ANCA) 1388

    		Free Text
    OPIATES CONF 1389

    		Free Text
    OVA & PARASITE FECAL 1390

    		Free Text
    OXALATE 24 HR 1391

    		Free Text
    OXALATE U 1392

    		Free Text
    PARTIAL THROMBO-LAP 1393

    		Free Text
    PHENCYCLIDINE CONF 1394

    		Free Text
    PHENCYCLIDINES 1395

    		Free Text
    PLATELET NEUTRALIZA 1396

    		Free Text
    PROGESTERONE 1397

    		Free Text
    PROTEIN C FUNCTIONAL 1398

    		Free Text
    PROTEIN C TOTAL 1399

    		Free Text
    PROTEIN S FUNCTIONAL 1400

    		Free Text
    PROTEIN S TOTAL 1401

    		Free Text
    PROTHROMBIN TIME-LAP 1402

    		Free Text
    PT PCR FACTOR II 1403

    		Free Text
    PTH I 1404

    		Free Text
    PTT-D CORRECTION 1405

    		Free Text
    PTT-HEPARIN NEUTRALIZED 1406

    		Free Text
    REPTILASE TIME (PATIENT) 1407

    		Free Text
    RNP (ENA) IGG 1408

    		Free Text
    ROTOVIRUS ANTIGEN 1409

    		Free Text
    RUSSELL VIPER VEN PAT 1410

    		Free Text
    SERINE PROTEASE 3 1411

    		Free Text
    SEX HORMON BIND GLOB 1412

    		Free Text
    SIROLIMUS 1413

    		Free Text
    SMITH (ENA) IGG 1414

    		Free Text
    SMOOTH MUSCLE AB T 1415

    		Free Text
    SSA RO (ENA) IGG 1416

    		Free Text
    SSB LA (ENA ) IGG 1417

    		Free Text
    T3 UPTAKE 1418

    		Free Text
    TACROLIMUS 1419

    		Free Text
    TESTOST ADULT MALE 1420

    		Free Text
    TESTOSTER FR M 1421

    		Free Text
    TESTOSTER FR O 1422

    		Free Text
    TESTOSTERONE % FREE 1423

    		Free Text
    TESTOSTERONE OTHER 1424

    		Free Text
    THYROGLOBULIN ANTIBODY 1425

    		Free Text
    THYROID PEROXIDASE TPO 1426

    		Free Text
    TOTAL PROTEIN URINE 1427

    		Free Text
    TSH 3RD GENERATION 1428

    		Free Text
    TSH RECEPTOR ANTIBODY 1429

    		Free Text
    URIC ACID 24 HR 1430

    		Free Text
    URIC ACID U 1431

    		Free Text
    URINE IFE INTERP 1432

    		Free Text
    VITAMIN D 1 25 DIHYDROX 1433

    		Free Text
    VITAMIN D 25 HYDROXY 1434

    		Free Text
    WEST NILE VIRUS IGG 1435

    		Free Text
    WEST NILE VIRUS IGM 1436

    		Free Text
    VENOUS UNORDERABLE 1437

    		Set of Codes
    Set of Codes:
    • Code : CHG
      Stands For: CHARGE ONLY
    COLLECTION LENGTH 1438

    		Set of Codes
    Set of Codes:
    • Code : RANDOM
      Stands For: RANDOM 24
    • Code : RANDOM 12
      Stands For: RANDOME 12
    • Code : RANDOM 12
      Stands For: RANDOM 12
    SAT CAL 1439

    		Numeric
    CORRECTED WBC 1440

    		Numeric
    U MIC24HR CALCULATION 1441

    		Numeric
    CARDIAC PROFILE 1442

    		Free Text
    CYANOCOBALAMIN 1443

    		Free Text
    TEST DATA NAME 1444

    		Set of Codes
    Set of Codes:
    • Code : SEE
      Stands For: See the NOTES tab for scanned documents
    SODIUM, URINE 67001

    		Numeric
    ROTAVIRUS ANTIGEN 67002

    		Free Text
    BORRELIA IGG 67003

    		Free Text
    BORRELIA IGM 67004

    		Free Text
    ENTEROVIRUS ANTIGEN 67005

    		Free Text
    NEWBORN METABOLIC SCREEN 67006

    		Free Text
    PROSTATE SPECIFIC ANTIGEN 67007

    		Numeric
    PREALBUMIN 67008

    		Numeric
    TEST DATA NAME 2 67009

    		Numeric
    PT/INR 67010

    		Numeric
    GLEASON SCORE 67011

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    • Code : 4
      Stands For: 4
    • Code : 5
      Stands For: 5
    COOMBS 67012

    		Set of Codes
    Set of Codes:
    • Code : NEGATIVE
      Stands For: NEGATIVE
    • Code : POSITIVE
      Stands For: POSITIVE
    EGFR 67013

    		Numeric
    Creatinine Clearance Corr 67014

    		Numeric
    Creatinine Clearance Uncorr 67015

    		Numeric
    Urine Volume 67016

    		Numeric
    Urine Creatinine 67017

    		Numeric
    24 Hr Urine Creatinine 67018

    		Numeric
    CD3+CD4 67019

    		Free Text
    LEAD,BLOOD CAPILLARY 67020

    		Free Text
    HEP C AB SIG/CUT (IMMUNOASSAY) 67021

    		Free Text
    DENGUE VIRUS IgM AB TITER 67022

    		Free Text
    RPR TITER (REAGIN AB) 67023

    		Free Text
    WEST NILE VIRUS IgM AB TITER 67024

    		Free Text
    B. PERTUSSIS DNA PROBE (QUAL) 67025

    		Free Text
    INFLUENZA B RNA (QUAL) 67026

    		Free Text
    M.TUBERCULOSIS COMPLEX rRNA 67027

    		Free Text
    CU BLOOD SO 67028

    		Free Text
    COVID19 67029

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEGATIVE
    • Code : P
      Stands For: POSITIVE
    BLOOD UREA NITROGEN A2 75001

    		Numeric
    BLOOD UREA NITROGEN B1 75002

    		Numeric
    BLOOD URENA NITROGEN 75003

    		Numeric
    BLOOD UREA NITROGEN B2 75004

    		Numeric
    A2 CREATININE 75005

    		Numeric
    B1 CREATININE 75006

    		Numeric
    B2 CREATININE 75007

    		Numeric
    A2 NA 75008

    		Numeric
    B1 NA 75009

    		Numeric
    B2 NA 75010

    		Numeric
    A2 POTASSIUM 75011

    		Numeric
    B1 POTASSIUM 75012

    		Numeric
    B2 POTASSIUM 75013

    		Numeric
    A2 CHLORIDE 75014

    		Numeric
    B1 CHLORIDE 75015

    		Numeric
    B2 CHLORIDE 75016

    		Numeric
    A2 CARBON DIOXIDE 75017

    		Numeric
    B1 CARBON DIOXIDE 75018

    		Numeric
    B2 CARBON DIOXIDE 75019

    		Numeric
    A2 ALT SGPT 75020

    		Numeric
    B1 ALT SGPT 75021

    		Numeric
    B2 ALT SGPT 75022

    		Numeric
    A2 ALBUMIN 75023

    		Numeric
    B1 ALBUMIN 75024

    		Numeric
    B2 ALBUMIN 75025

    		Numeric
    A1 ALK PHOSPHATASE 75026

    		Numeric
    A2 ALK PHSPHATASE 75027

    		Numeric
    B1 ALK PHOSPHATASE 75028

    		Numeric
    B2 ALK PHOSPHATASE 75029

    		Numeric
    A2 AMMONIA 75030

    		Numeric
    B1 AMMONIA 75031

    		Numeric
    B2 AMMONIA 75032

    		Numeric
    A2 AMYLASE 75033

    		Numeric
    B1 AMYLASE 75034

    		Numeric
    B2 AMYLASE 75035

    		Numeric
    A2 ANION GAP 75036

    		Numeric
    B1 ANION GAP 75037

    		Numeric
    B2 ANION GAP 75038

    		Numeric
    A2 AST SGOT 75039

    		Numeric
    B1 AST SGOT 75040

    		Numeric
    B2 AST SGOT 75041

    		Numeric
    A2 BILIRUBIN DIRECT 75042

    		Numeric
    B1 BILIRUBIN DIRECT 75043

    		Numeric
    B2 BILIRUBIN DIRECT 75044

    		Numeric
    A2 NEONATAL BILI 75045

    		Numeric
    B1 BILIRUBIN NEONATAL 75046

    		Numeric
    B2 NEONATAL BILI 75047

    		Numeric
    A2 BILIRUBIN TOTAL 75048

    		Numeric
    B1 BILIRUBIN TOTAL 75049

    		Numeric
    B2 BILIRUBIN TOTAL 75050

    		Numeric
    A2 BUN CREAT RATIO 75051

    		Numeric
    B1 BUN CREAT RATIO 75052

    		Numeric
    B2 BUN CREAT RATIO 75053

    		Numeric
    A2 TOTAL PROTEIN 75054

    		Numeric
    B1 TOTAL PROTEIN 75055

    		Numeric
    B2 TOTAL PROTEIN 75056

    		Numeric
    A2 GLUCOSE 75057

    		Numeric
    B1 GLUCOSE 75058

    		Numeric
    B2 GLUCOSE 75059

    		Numeric
    A2 CALCIUM 75060

    		Numeric
    B1 CALCIUM 75061

    		Numeric
    B2 CALCIUM 75062

    		Numeric
    A2 CHOLESTEROL 75063

    		Numeric
    B1 CHOLESTEROL 75064

    		Numeric
    B2 CHOLESTEROL 75065

    		Numeric
    A2 OSMOLALITY 75066

    		Numeric
    B1 OSMOLALITY 75067

    		Numeric
    B2 OSMOLALITY 75068

    		Numeric
    A2 EGFR 75069

    		Numeric
    B1 EGFR 75070

    		Numeric
    B2 EGFR 75071

    		Numeric
    A2 AG RATIO 75072

    		Numeric
    B1 AG RATIO 75073

    		Numeric
    B2 AG RATIO 75074

    		Numeric
    A2 MAGNESIUM 75075

    		Numeric
    B1 MAGNESIUM 75076

    		Numeric
    B2 MAGNESIUM 75077

    		Numeric
    A2 PO4 75078

    		Numeric
    B1 PO4 75079

    		Numeric
    B2 PO4 75080

    		Numeric
    A2 G G TRANSFERASE 75081

    		Numeric
    B1 G G TRANSFERASE 75082

    		Numeric
    B2 G G TRANSFERASE 75083

    		Numeric
    A2 LIPASE 75084

    		Numeric
    B1 LIPASE 75085

    		Numeric
    B2 LIPASE 75086

    		Numeric
    A2 HEMOGLOBIN 75087

    		Numeric
    B1 HEMOGLOBIN 75088

    		Numeric
    B2 HEMOGLOBIN 75089

    		Numeric
    A2 HEMATOCRIT 75090

    		Numeric
    B1 HEMATOCRIT 75091

    		Numeric
    B2 HEMATOCRIT 75092

    		Numeric
    A2 PLATELET COUNT 75093

    		Numeric
    B1 PLATELET COUNT 75094

    		Numeric
    B2 PLATELET COUNT 75095

    		Numeric
    A2 HGBA1C 75096

    		Numeric
    B1 HGBA1C 75097

    		Numeric
    B2 HGBA1C 75098

    		Numeric
    A2 MCV 75099

    		Numeric
    B1 MCV 75100

    		Numeric
    B2 MCV 75101

    		Numeric
    A2 MCH 75102

    		Numeric
    B1 MCH 75103

    		Numeric
    B2 MCH 75104

    		Numeric
    A1 MCHC 75105

    		Numeric
    B1 MCHC 75106

    		Numeric
    B2 MCHC 75107

    		Numeric
    A2 MCHC 75108

    		Numeric
    A2 RBC DIST WDTH 75109

    		Numeric
    B1 RBC DIST WDTH 75110

    		Numeric
    B2 RBC DIST WDTH 75111

    		Numeric
    A2 SEGMTED NEUTROPHILS 75112

    		Numeric
    B1 SEGMTED NEUTROPHILS 75113

    		Numeric
    B2 SEGMTED NEUTROPHILS 75114

    		Numeric
    A2 LYMPHOCYTES 75115

    		Numeric
    B1 LYMPHOCYTES 75116

    		Numeric
    B2 LYMPHOCYTES 75117

    		Numeric
    A2 MONOCYTE 75118

    		Numeric
    B1 MONOCYTE 75119

    		Numeric
    B2 MONOCYTE 75120

    		Numeric
    A2 EOSINOPHILS 75121

    		Numeric
    B1 EOSINOPHILS 75122

    		Numeric
    B2 EOSINOPHILS 75123

    		Numeric
    A2 BASOPHILS 75124

    		Numeric
    B1 BASOPHILS 75125

    		Numeric
    B2 BASOPHILS 75126

    		Numeric
    A2 NEUTROPHIL ABSOLUTE 75127

    		Numeric
    B1 NEUTROPHIL ABSOLUTE 75128

    		Numeric
    B2 NEUTROPHIL ABSOLUTE 75129

    		Numeric
    A2 LYMPHS ABSOLUTE 75130

    		Numeric
    B1 LYMPHS ABSOLUTE 75131

    		Numeric
    B2 LYMPHS ABSOLUTE 75132

    		Numeric
    A2 MONOS ABSOLUTE 75133

    		Numeric
    B1 MONOS ABSOLUTE 75134

    		Numeric
    B2 MONOS ABSOLUTE 75135

    		Numeric
    A2 EOSINO ABSOLUTE 75136

    		Numeric
    B1 EOSINO ABSOLUTE 75137

    		Numeric
    B2 EOSINO ABSOLUTE 75138

    		Numeric
    A2 BASO ABSOLUTE 75139

    		Numeric
    B1 BASO ABSOLUTE 75140

    		Numeric
    B2 BASO ABSOLUTE 75141

    		Numeric
    A2 RBC MORPHOLOGY 75142

    		Set of Codes
    Set of Codes:
    • Code : N/N
      Stands For: N/N
    • Code : ABN
      Stands For: ABN
    B1 RBC MORPHOLOGY 75143

    		Set of Codes
    Set of Codes:
    • Code : N/N
      Stands For: N/N
    • Code : ABN
      Stands For: ABN
    B2 RBC MORPHOLOGY 75144

    		Set of Codes
    Set of Codes:
    • Code : N/N
      Stands For: N/N
    • Code : ABN
      Stands For: ABN
    A2 MANUAL DIFF 75145

    		Set of Codes
    Set of Codes:
    • Code : PERF
      Stands For: PERF
    • Code : ND
      Stands For: ND
    B1 MANUAL DIFF 75146

    		Set of Codes
    Set of Codes:
    • Code : PERF
      Stands For: PERF
    • Code : ND
      Stands For: ND
    B2 MANUAL DIFF 75147

    		Set of Codes
    Set of Codes:
    • Code : PERF
      Stands For: PERF
    • Code : ND
      Stands For: ND
    A2 WBC 75148

    		Numeric
    B1 WBC 75149

    		Numeric
    B2 WBC 75150

    		Numeric
    A2 RBC 75151

    		Numeric
    B1 RBC 75152

    		Numeric
    B2 RBC 75153

    		Numeric
    A2 D DIMER 75154

    		Numeric
    B1 D DIMER 75155

    		Numeric
    B2 D DIMER 75156

    		Numeric
    A2 INR 75157

    		Numeric
    B1 INR 75158

    		Numeric
    B2 INR 75159

    		Numeric
    A2 PROTHROMBIN TIME 75160

    		Numeric
    B1 PROTHROMBIN TIME 75161

    		Numeric
    B2 PROTHROMBIN TIME 75162

    		Numeric
    A2 PTT CONTROL 75163

    		Numeric
    B1 PTT CONTROL 75164

    		Numeric
    B2 PTT CONTROL 75165

    		Numeric
    A2 ACTIVATED PTT 75166

    		Numeric
    B1 ACTIVATED PTT 75167

    		Numeric
    B2 ACTIVATED PTT 75168

    		Numeric
    A2 CREATININE 24 HR 75169

    		Numeric
    B1 CREATININE 24 HR 75170

    		Numeric
    B2 CREATININE 24 HR 75171

    		Numeric
    A2 CREATININE U 75172

    		Numeric
    B1 CREATININE U 75173

    		Numeric
    B2 CREATININE U 75174

    		Numeric
    A2 Urine Volume 75175

    		Numeric
    B1 Urine Volume 75176

    		Numeric
    B2 Urine Volume 75177

    		Numeric
    A2 Urine Creatinine 75178

    		Numeric
    B1 Urine Creatinine 75179

    		Numeric
    B2 Urine Creatinine 75180

    		Numeric
    A2 24 Hr Urine Creatinine 75181

    		Numeric
    B1 24 Hr Urine Creatinine 75182

    		Numeric
    B2 24 Hr Urine Creatinine 75183

    		Numeric
    A2 Creatinine Clearance Corr 75184

    		Numeric
    B1 Creatinine Clearance Corr 75185

    		Numeric
    B2 Creatinine Clearance Corr 75186

    		Numeric
    A2 Creatinine Clearance Uncorr 75187

    		Numeric
    B1 Creatinine Clearance Uncorr 75188

    		Numeric
    B2 Creatinine Clearance Uncorr 75189

    		Numeric
    A2 TROPONIN 75190

    		Numeric
    B1 TROPONIN 75191

    		Numeric
    B2 TROPONIN 75192

    		Numeric
    EVEROLIMUS 75193

    		Numeric
    A2 EVEROLIMUS 75194

    		Numeric
    B1 EVEROLIMUS 75195

    		Numeric
    B2 EVEROLIMUS 75196

    		Numeric
    A1 U COLOR 75197

    		Set of Codes
    Set of Codes:
    • Code : YELLOW
      Stands For: YELLOW
    • Code : COLORLESS
      Stands For: COLORLESS
    • Code : STRAW
      Stands For: STRAW
    • Code : LIGHT YELLOW
      Stands For: LIGHT YELLOW
    • Code : AMBER
      Stands For: AMBER
    • Code : BROWN
      Stands For: BROWN
    • Code : DK YELLOW
      Stands For: DARK YELLOW
    • Code : ORANGE
      Stands For: ORANGE
    • Code : PINK
      Stands For: PINK
    • Code : RED
      Stands For: RED
    A2 U COLOR 75198

    		Set of Codes
    Set of Codes:
    • Code : YELLOW
      Stands For: YELLOW
    • Code : COLORLESS
      Stands For: COLORLESS
    • Code : STRAW
      Stands For: STRAW
    • Code : LIGHT YELLOW
      Stands For: LIGHT YELLOW
    • Code : AMBER
      Stands For: AMBER
    • Code : BROWN
      Stands For: BROWN
    • Code : DK YELLOW
      Stands For: DARK YELLOW
    • Code : ORANGE
      Stands For: ORANGE
    • Code : PINK
      Stands For: PINK
    • Code : RED
      Stands For: RED
    A1 U APPEARANCE 75199

    		Set of Codes
    Set of Codes:
    • Code : CLEAR
      Stands For: CLEAR
    • Code : CLOUDY
      Stands For: CLOUDY
    A2 U APPEARANCE 75200

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    A1 U SPECIFIC GRAVITY 75201

    		Numeric
    A2 U SPECIFIC GRAVITY 75202

    		Numeric
    A1 U pH 75203

    		Numeric
    A2 U pH 75204

    		Numeric
    A1 U GLUCOSE 75205

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 50
      Stands For: 50
    • Code : 100
      Stands For: 100
    • Code : 150
      Stands For: 150
    • Code : 200
      Stands For: 200
    • Code : >200
      Stands For: >200
    A2 U GLUCOSE 75206

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 50
      Stands For: 50
    • Code : 100
      Stands For: 100
    • Code : 150
      Stands For: 150
    • Code : 200
      Stands For: 200
    • Code : >200
      Stands For: >200
    A1 U KETONES 75207

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEGATIVE
    • Code : TRACE
      Stands For: TRACE
    • Code : 1+
      Stands For: 1+
    • Code : 2+
      Stands For: 2+
    • Code : 3+
      Stands For: 3+
    • Code : 4+
      Stands For: 4+
    A1 U PROTEIN 75208

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 50
      Stands For: 50
    • Code : 100
      Stands For: 100
    • Code : 150
      Stands For: 100
    • Code : 150
      Stands For: 150
    • Code : 200
      Stands For: 200
    • Code : >200
      Stands For: >200
    A2 U PROTEIN 75209

    		Set of Codes
    Set of Codes:
    • Code : NEG
      Stands For: NEG
    • Code : TRACE
      Stands For: TRACE
    • Code : 50
      Stands For: 50
    • Code : 100
      Stands For: 100
    • Code : 150
      Stands For: 150
    • Code : 200
      Stands For: 200
    • Code : >200
      Stands For: >200
    A1 PAP SMEAR THIN PREP 75210

    		Set of Codes
    Set of Codes:
    • Code : NORMAL
      Stands For: NORMAL
    • Code : ABNORMAL
      Stands For: ABNORMAL
    SL ANION GAP 75211

    		Numeric
    SL BUN 75212

    		Numeric
    SL CALCIUM 75213

    		Numeric
    SL C02 75214

    		Numeric
    SL CHLORIDE 75215

    		Numeric
    SL CREATININE 75216

    		Numeric
    SL GLUCOSE 75217

    		Numeric
    SL MAGNESIUM 75218

    		Numeric
    SL OSMO SERUM 75219

    		Numeric
    SL POTASSIUM 75220

    		Numeric
    SL NA 75221

    		Numeric
    A1 COVID19 75222

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEGATIVE
    • Code : P
      Stands For: POSITIVE
    SPECIMEN CONDITION 9999991 Specimen Condition from Reference Lab.

    		Free Text
    RESULT COPIES TO 9999992

    		Free Text
    RELEVANT CLINICAL INFORMATION 9999993

    		Free Text
    RESULTS HANDLING 9999994

    		Free Text
    HL7 MESSAGE 9999995

    		Pointer
    PointerTo:
    fileName:
    LA7 MESSAGE QUEUE
    fileNumber:
    62.49
    RELEASING SITE COUNTY 9999996

    		Free Text
    RELEASING SITE COUNTRY 9999997

    		Pointer
    PointerTo:
    fileName:
    COUNTRY CODE
    fileNumber:
    779.004
    MICROBIOLOGY 5 This is microbiology data associated with this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time of collection of the microbiology specimen.

    		Date/Time
    DATE/TIME OBTAINED INEXACT .02 YES indicates the date/time of collection is inexact.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DATE REPORT COMPLETED .03 This is the date the report was completed.

    		Date/Time
    VERIFY PERSON .04 This is the person verifying the report.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SITE/SPECIMEN .05 This is the site/specimen collected.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE .055 This is the collection sample of the specimen.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    MICROBIOLOGY ACCESSION .06 This is the microbiology accession.

    		Free Text
    PHYSICIAN .07 This is the requesting physician.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    WARD .08 This is the requesting location.

    		Free Text
    AMENDED REPORT .09 YES will indicate that this report has been edited after the report had been verified by a supervisor. This field is set directly by the result entry routine when a previously verified report is edited.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    DATE/TIME RECEIVED .1 This is the date/time the specimen was received.

    		Date/Time
    REQUESTING LOC/DIV .111 Enter the hospital location or institution ordering this test.

    		Variable Pointer
    ACCESSIONING INSTITUTION .112 This field contains the pointer to the institution where the specimen was accessioned. This field can be blank if LEDI or POC specimen is accessioned. The field will be set if an actual user accepts the specimen.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    UID .31 This is the UID used by the HOST LEDI system for this order/accession. This field is used by LEDI software.

    		Free Text
    ORDERING SITE .32 This field contains the pointer to the INSTITUTION file for the Mailman domain location of the computer system. All LEDI results are returned to the Ordering computer system. Location to send LEDI HL7 result messages. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    COLLECTING SITE .33 This field contains the pointer to the INSTITUTION file for the actual collection site. The ordering site is the MailMan location for the computer system. MailMan domain location and the collecting site may be different. This field is used by LEDI.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    HOST UID .34 Each order/accession is given a HOST UID. The UID is stored in this location. If LEDI software is used to accession specimens, usually the collecting sites UID is used to track specimens. If the collecting UID conflicts with the HOST system number sequence, the HOST UID will be used instead of the collecting site's UID. This field is used by LEDI software.

    		Free Text
    ORDERING SITE UID .342 This field contains the collecting sites UID for this specimen. This field is used by LEDI software.

    		Free Text
    RELEASING SITE .345 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    ORDERED TEST .35 This subfile contains information about the ordered test(s) for this accession. The .01 field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORDERED TEST .01 This field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Free Text
    ORDERED URGENCY 2 This field contains the urgency for this ordered test.

    		Pointer
    PointerTo:
    fileName:
    URGENCY
    fileNumber:
    62.05
    CPRS ORDER # 3 This field contains the pointer to CPRS ORDER(#100) file. This field is only populated when the original order is placed on the local system.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    LAB ORDER # 4 This field contains the LAB ORDER number for this test. The construct of this free text field is: LR-Lab order number-XXXX- where XXXX is the Julian date.

    		Free Text
    ORDERED TYPE 5 This field contains information about how the test order was generated. The selection must be made from HL7 0065 entries. This field indicates if the ordered test was part of the original order, an add-on or reflexed per clinical protocol.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    ORDERING PROVIDER LOCAL 6 The pointer to the NEW PERSON file if the original order was placed on the local system. This field will be empty if order is placed via LEDI.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING PROVIDER REMOTE 7 If this test is ordered by a provider from a remote system (not local system), the names contained in the HL7 message will be stored in this field.

    		Free Text
    SPECIMEN TOPOGRAPHY 8 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE 9 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    DISPOSITION 10 Maintains the disposition of the ordered test. It will be used to value the test disposition in HL7 messaging, specifically OBR-25.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    DISPOSITION DATE/TIME 11 Stores the date and time that a lab user or the system dispositioned this test.

    		Date/Time
    DISPOSITION BY 12 Store the user who entered the disposition of this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAB TEST ORDERED 13 Contains the ordered laboratory test associated with the ordered NLT code.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT TEST 14 If this test is a reflex test then indcates the ordered test that is associated with the reflex test.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT NLT 15 Contains the order NLT code associated with the parent test when the ordered test is a reflex test.

    		Free Text
    COMMENT ON SPECIMEN .99 This is a comment on the specimen.

    		Free Text
    PRELIMINARY BACT COMMENT 1 These are preliminary bacteriology comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRELIMINARY BACT COMMENT .01 This is a comment concerning the bacteriology.

    		Free Text
    BACTERIOLOGY TEST(S) 1.5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BACTERIOLOGY TEST(S) .01

    		Free Text
    BACT RPT DATE APPROVED 11 This is the approval date of bacteriology data for this specimen.k

    		Date/Time
    BACT RPT STATUS 11.5 This is the report status of the bacteriology data.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FINAL REPORT
    • Code : P
      Stands For: PRELIMINARY REPORT
    STERILITY CONTROL 11.51 This indicates the sterility control as positive or negative.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEGATIVE
    • Code : P
      Stands For: POSITIVE
    STERILITY RESULTS 11.52 These are results of microbiology sterility testing.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STERILITY RESULTS .01 These are results of microbiology sterility testing.

    		Set of Codes
    Set of Codes:
    • Code : N
      Stands For: NEGATIVE
    • Code : P
      Stands For: POSITIVE
    BACT PERSON 11.55 This is the person entering the bacteriology data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MIC PERSON 11.56 This is the person entering the minimum inhibitory concentration data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    URINE SCREEN 11.57 This indicates the urine screen is positive or negative.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: POSITIVE
    • Code : N
      Stands For: NEGATIVE
    SPUTUM SCREEN 11.58 These are the results of a sputum screen.

    		Free Text
    GRAM STAIN 11.6 These are gram stain results.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GRAM STAIN .01 This is the gram stain result.

    		Free Text
    BACTERIOLOGY SMEAR/PREP 11.7 These are results of a smear/prep in bacteriology.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BACTERIOLOGY SMEAR/PREP .01 This is the result of a smear/prep in bacteriology.

    		Free Text
    ORGANISM 12 These are the organisms reported on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORGANISM .01 This is an organism identified on this specimen.

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    ISOLATE ID .1 The Isolate ID text. Commonly used for HL7 messaging as OBX-4. This should be in the form of 99VA4:x:y

    		Free Text
    QUANTITY 1 This is the quantity of the organism present.

    		Free Text
    SIT #1 1.3

    		Free Text
    SBT #1 1.4

    		Free Text
    DRAW TIME #1 (SIT,SBT) 1.5 This is the draw time of SIT #1 or SBT #1.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PEAK
    • Code : T
      Stands For: TROUGH
    SIT #2 1.6

    		Free Text
    SBT #2 1.7

    		Free Text
    DRAW TIME #2 (SIT,SBT) 1.8 This is the draw time of SIT #2 or SBT #2.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PEAK
    • Code : T
      Stands For: TROUGH
    COMMENT 2 These are comments on this organism.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment on this organism.

    		Free Text
    cntest 2.00214001

    		Free Text
    cntest INTERP 2.002140011

    		Free Text
    cntest SCREEN 2.002140012

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    TEST ANTIBIOTIC 2.006700001

    		Free Text
    TEST ANTIBIOTIC INTERP 2.0067000011

    		Free Text
    TEST ANTIBIOTIC SCREEN 2.0067000012

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NEOMYCIN 5

    		Free Text
    NEOMYCIN INTERP 5.1

    		Free Text
    NEOMYCIN SCREEN 5.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    BACITRACIN 10

    		Free Text
    BACITRACIN INTERP 10.1

    		Free Text
    BACITRACIN SCREEN 10.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    PENICILLIN 15

    		Free Text
    PENICILLIN INTERP 15.1

    		Free Text
    PENICILLIN SCREEN 15.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CLINDAMYCIN 20

    		Free Text
    CLINDAMYCIN INTERP 20.1

    		Free Text
    CLINDAMYCIN SCREEN 20.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    METHICILLIN 25

    		Free Text
    METHICILLIN INTERP 25.1

    		Free Text
    METHICILLIN SCREEN 25.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    VANCOMYCIN 30

    		Free Text
    VANCOMYCIN INTERP 30.1

    		Free Text
    VANCOMYCIN SCREEN 30.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    GENTAMICIN 35

    		Free Text
    GENTAMICIN INTERP 35.1

    		Free Text
    GENTAMICIN SCREEN 35.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CHLORAMPHENICOL 40

    		Free Text
    CHLORAMPHENICOL INTERP 40.1

    		Free Text
    CHLORAMPHENICOL SCREEN 40.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    KANAMYCIN 45

    		Free Text
    KANAMYCIN INTERP 45.1

    		Free Text
    KANAMYCIN SCREEN 45.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFAZOLIN 50

    		Free Text
    CEFAZOLIN INTERP 50.1

    		Free Text
    CEFAZOLIN SCREEN 50.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    TETRACYCLINE 55

    		Free Text
    TETRACYCLINE INTERP 55.1

    		Free Text
    TETRACYCLINE SCREEN 55.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    AMPICILLIN 60

    		Free Text
    AMPICILLIN INTERP 60.1

    		Free Text
    AMPICILLIN SCREEN 60.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CARBENICILLIN 65

    		Free Text
    CARBENICILLIN INTERP 65.1

    		Free Text
    CARBENICILLIN SCREEN 65.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    TOBRAMYCIN 70

    		Free Text
    TOBRAMYCIN INTERP 70.1

    		Free Text
    TOBRAMYCIN SCREEN 70.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    TRIMETHAPRIM/SULFAMETHOXAZOLE 75

    		Free Text
    TRIMETHAPRIM/SULFA INTERP 75.1

    		Free Text
    TRIMETHAPRIM/SULFA SCREEN 75.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    AMIKACIN 80

    		Free Text
    AMIKACIN INTERP 80.1

    		Free Text
    AMIKACIN SCREEN 80.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFAMANDOLE 85

    		Free Text
    CEFAMANDOLE INTERP 85.1

    		Free Text
    CEFAMANDOLE SCREEN 85.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFOXITIN 90

    		Free Text
    CEFOXITIN INTERP 90.1

    		Free Text
    CEFOXITIN SCREEN 90.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFOTAXIME 95

    		Free Text
    CEFOTAXIME INTERP 95.1

    		Free Text
    CEFOTAXIME SCREEN 95.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NITROFURANTOIN 100

    		Free Text
    NITROFURANTOIN INTERP 100.1

    		Free Text
    NITROFURANTOIN SCREEN 100.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    POLYMYXIN B 105

    		Free Text
    POLYMYXIN B INTERP 105.1

    		Free Text
    POLYMYXIN B SCREEN 105.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    ERYTHROMYCIN 110

    		Free Text
    ERYTHROMYCIN INTERP 110.1

    		Free Text
    ERYTHROMYCIN SCREEN 110.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    RIFAMPIN 115

    		Free Text
    RIFAMPIN INTERP 115.1

    		Free Text
    RIFAMPIN SCREEN 115.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NOVOBIOCIN 120

    		Free Text
    NOVOBIOCIN INTERP 120.1

    		Free Text
    NOVOBIOCIN SCREEN 120.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFOPERAZONE 125

    		Free Text
    CEFOPERAZONE INTERP 125.1

    		Free Text
    CEFOPERAZONE SCREEN 125.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    MEZLOCILLIN 130

    		Free Text
    MEZLOCILLIN INTERP 130.1

    		Free Text
    MEZLOCILLIN SCREEN 130.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    MOXALACTAM 135

    		Free Text
    MOXALACTAM INTERP 135.1

    		Free Text
    MOXALACTAM SCREEN 135.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NETILMICIN 140

    		Free Text
    NETILMICIN INTERP 140.1

    		Free Text
    NETILMICIN SCREEN 140.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    PIPERACILLIN 145

    		Free Text
    PIPERACILLIN INTERP 145.1

    		Free Text
    PIPERACILLIN SCREEN 145.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    OXACILLIN 150

    		Free Text
    OXACILLIN INTERP 150.1

    		Free Text
    OXACILLIN SCREEN 150.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    SULFISOXAZOLE 151

    		Free Text
    SULFISOXAZOLE INTERP 151.1

    		Free Text
    SULFISOXAZOLE SCREEN 151.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NAFCILLIN 152

    		Free Text
    NAFCILLIN INTERP 152.1

    		Free Text
    NAFCILLIN SCREEN 152.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    NALIDIXIC ACID 153

    		Free Text
    NALIDIXIC ACID INTERP 153.1

    		Free Text
    NALIDIXIC ACID SCREEN 153.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEPHALOTHIN 154

    		Free Text
    CEPHALOTHIN INTERP 154.1

    		Free Text
    CEPHALOTHIN SCREEN 154.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    COLISTIN 155

    		Free Text
    COLISTIN INTERP 155.1

    		Free Text
    COLISTIN SCREEN 155.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    METRONIDAZOLE 156

    		Free Text
    METRONIDAZOLE INTERP 156.1

    		Free Text
    METRONIDAZOLE SCREEN 156.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFUROXIME 157

    		Free Text
    CEFUROXIME INTERP 157.1

    		Free Text
    CEFUROXIME SCREEN 157.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    CEFTIZOXIME 158

    		Free Text
    CEFTIZOXIME INTERP 158.1

    		Free Text
    CEFTIZOXIME SCREEN 158.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    SPECTINOMYCIN 159

    		Free Text
    SPECTINOMYCIN INTERP 159.1

    		Free Text
    SPECTINOMYCIN SCREEN 159.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    TRIMETHOPRIM 160

    		Free Text
    TRIMETHOPRIM INTERP 160.1

    		Free Text
    TRIMETHOPRIM SCREEN 160.2

    		Set of Codes
    Set of Codes:
    • Code : A
      Stands For: ALWAYS DISPLAY
    • Code : N
      Stands For: NEVER DISPLAY
    • Code : R
      Stands For: RESTRICT DISPLAY
    ANTIBIOTIC 200 These are other antibiotics reported.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ANTIBIOTIC .01 This is a free text entry for another antibiotic.

    		Free Text
    MIC(ug/ml) 1

    		Numeric
    MBC(ug/ml) 2

    		Numeric
    RELEASE DATE 9999901

    		Date/Time
    STATUS 9999902

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FINAL
    • Code : P
      Stands For: PRELIMINARY
    • Code : U
      Stands For: UNKNOWN
    FLAG 9999903

    		Free Text
    SUSCEPTIBILITY 9999904

    		Free Text
    UNITS 9999905

    		Pointer
    PointerTo:
    fileName:
    fileNumber:
    90475.3
    INTP 9999906

    		Free Text
    BACT RPT REMARK 13 These are report remarks on bacteriology data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BACT RPT REMARK .01 This is a report remark on bacteriology data.

    		Free Text
    PARASITE RPT DATE APPROVED 14 This is the approval date of the parasitology data.

    		Date/Time
    PARASITE RPT STATUS 15 This is the approval date of the parasitology data.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FINAL REPORT
    • Code : P
      Stands For: PRELIMINARY REPORT
    PARASITE ENTERING PERSON 15.5 This is the person entering the parasitology data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PARASITOLOGY SMEAR/PREP 15.51 These are the results of a smear/prep in parasitology.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARASITOLOGY SMEAR/PREP .01 This is the result of a smear/prep in parasitology.

    		Free Text
    PARASITE 16 These are the parasites reported on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARASITE .01 This is the parasite identified on this specimen.

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    ISOLATE ID .1 The Isolate ID text. Commonly used for HL7 messaging as OBX-4. This should be in the form of 99VA4:x:y

    		Free Text
    STAGE 1 These are the stages identified with this parasite.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STAGE .01 This is the stage identified with this parasite.

    		Set of Codes
    Set of Codes:
    • Code : T
      Stands For: TROPHOZOITES
    • Code : C
      Stands For: CYSTS
    • Code : E
      Stands For: EGGS
    • Code : L
      Stands For: LARVAE
    • Code : S
      Stands For: SCHIZONTS
    • Code : G
      Stands For: GAMETES
    • Code : M
      Stands For: MICROFILARIA
    • Code : A
      Stands For: ADULTS
    • Code : R
      Stands For: RHABDITIFORM LARVAE
    • Code : F
      Stands For: FILARIFORM LARVAE
    QUANTITY 1 This is the quantity of the parasite present.

    		Free Text
    COMMENT 2 These are the comments on this parasite.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment on this parasite.

    		Free Text
    PARASITE TEST(S) 16.4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARASITE TEST(S) .01

    		Free Text
    PRELIMINARY PARASITE COMMENT 16.5 These are preliminary parasitology comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRELIMINARY PARASITE COMMENT .01 This is a comment on the preliminary parasitology report.

    		Free Text
    PARASITE RPT REMARK 17 These are report remarks on the parasitology data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARASITE RPT REMARK .01

    		Free Text
    MYCOLOGY RPT DATE APPROVED 18 This is the date of approval of the mycology report.

    		Date/Time
    MYCOLOGY RPT STATUS 19 This is the status of the mycology report.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FINAL REPORT
    • Code : P
      Stands For: PRELIMINARY REPORT
    MYC PERSON 19.5 This is the person entering the mycology data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MYCOLOGY SMEAR/PREP 19.6 These are the results of the smear/prep in mycology.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MYCOLOGY SMEAR/PREP .01

    		Free Text
    FUNGUS/YEAST 20 These are the fungus/yeast reported on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FUNGUS/YEAST .01 The fungus/yeast identified on this specimen.

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    ISOLATE ID .1 The Isolate ID text. Commonly used for HL7 messaging as OBX-4. This should be in the form of 99VA4:x:y

    		Free Text
    QUANTITY 1

    		Free Text
    COMMENT 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01

    		Free Text
    MYCOLOGY TEST(S) 20.4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MYCOLOGY TEST(S) .01

    		Free Text
    PRELIMINARY MYCOLOGY COMMENT 20.5 These are preliminary mycology comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRELIMINARY MYCOLOGY COMMENT .01

    		Free Text
    MYCOLOGY RPT REMARK 21 These are report remarks on the mycology data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MYCOLOGY RPT REMARK .01

    		Free Text
    TB RPT DATE APPROVED 22 This is the approval date of mycobacterium data for this specimen.

    		Date/Time
    TB RPT STATUS 23 This is the status of the report.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FINAL REPORT
    • Code : P
      Stands For: PRELIMINARY REPORT
    ACID FAST STAIN 24 This is the acid fast stain result.

    		Set of Codes
    Set of Codes:
    • Code : DP
      Stands For: DIRECT POSITIVE
    • Code : DN
      Stands For: DIRECT NEGATIVE
    • Code : CP
      Stands For: CONCENTRATE POSITIVE
    • Code : CN
      Stands For: CONCENTRATE NEGATIVE
    QUANTITY 25 This is the quantity of the mycobacterium present.

    		Free Text
    TB ENTERING PERSON 25.5 This is the person entering the mycobacterium data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    MYCOBACTERIUM 26 These are the mycobacterium identified with this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MYCOBACTERIUM .01 This is the mycobacterium identified with this specimen.

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    ISOLATE ID .1 The Isolate ID text. Commonly used for HL7 messaging as OBX-4. This should be in the form of 99VA4:x:y

    		Free Text
    QUANTITY 1 This is the quantity of the mycobacterium present.

    		Free Text
    COMMENT 2 These are the comments on the microbacterium data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is the comment on the mycobacterium data.

    		Free Text
    STR 5

    		Free Text
    PAS 10

    		Free Text
    INH 15

    		Free Text
    ETH 20

    		Free Text
    RIF 25

    		Free Text
    KANAMYCIN 30

    		Free Text
    CAPREOMYCIN 35

    		Free Text
    CYCLOSERINE 40

    		Free Text
    ETHIONAMIDE 45

    		Free Text
    PYRAZINAMIDE 50

    		Free Text
    MIOMYCIN 55

    		Free Text
    TB TEST(S) 26.4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TB TEST(S) .01

    		Free Text
    PRELIMINARY TB COMMENT 26.5 These are preliminary TB comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRELIMINARY TB COMMENT .01 This is a preliminary TB comment.

    		Free Text
    TB RPT REMARK 27 These are report remarks on the mycobacterium data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TB RPT REMARK .01 This is a report remark on the mycobacterium data.

    		Free Text
    ANTIBIOTIC LEVEL 28 These are the results of the antibiotic levels.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ANTIBIOTIC(for SERUM LEVEL) .01 This is the result of the antibiotic levels.

    		Free Text
    DRAW TIME 1 This is the collection time of the antibiotic level.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PEAK
    • Code : T
      Stands For: TROUGH
    • Code : R
      Stands For: RANDOM
    CONC(ug/ml) 2 This is the concentration of the result of antibiotic level.

    		Free Text
    IHS RESULT DATE 9999990

    		Date/Time
    IHS REF LAB 9999991

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    VIROLOGY RPT DATE 33 This is the approval date of virology data for this specimen.

    		Date/Time
    VIROLOGY REPORT STATUS 34 This is the report status of virology.

    		Set of Codes
    Set of Codes:
    • Code : P
      Stands For: PRELIMINARY
    • Code : F
      Stands For: FINAL
    VIROLOGY ENTERING PERSON 35 This is the person entering the virology data.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    VIRUS 36 These are the viruses reported on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIRUS .01 This is the virus reported on this specimen.

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    ISOLATE ID .1 The Isolate ID text. Commonly used for HL7 messaging as OBX-4. This should be in the form of 99VA4:x:y

    		Free Text
    VIROLOGY TESTS 36.4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIROLOGY TESTS .01

    		Free Text
    PRELIMINARY VIROLOGY COMMENT 36.5 These are preliminary virology comments.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PRELIMINARY VIROLOGY COMMENT .01 This is a preliminary virology comment.

    		Free Text
    VIROLOGY RPT REMARK 37 These are report remarks for virology.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    VIROLOGY RPT REMARK .01 This is a report remark for virology.

    		Free Text
    NEW PERSON CONVERSION 38 This field is to indicate that this entry has all of the pointers converted to the NEW PERSON file. The use of the NEW PERSON file. began with Version 5.2. The number 2 in this field indicates that the pointers have been converted to NEW PERSON file and normal range information is also being stored with the data.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    MICROBIOLOGY AUDIT 39 The microbiology audit file contains audit data for a given test on an accession.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICROBIOLOGY AUDIT .01 The Date/Time the audit log added this entry.

    		Date/Time
    LREDIT 1 This field contains the date that the test was edited. This is the entry point for the audit trail for this particular test.

    		Date/Time
    LAB TECH 2 This field contains the ID of the lab technician who is editing the results for this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    EDIT TYPE 3 The EDIT TYPE field is used to identify the type of revision being done to the lab test results.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ROUTINE EDIT
    • Code : 2
      Stands For: SUPPLEMENTAL
    • Code : 3
      Stands For: CORRECTION
    EDIT JUSTIFICATION 4 Used by the technician to record the reason the lab data is being revised or modified.

    		Free Text
    LAB AREA 6 Since the audit data is not being stored under each of the lab data file sections, but rather with the individual test results, we want to be able to identify the lab area of the test for reporting purposes without having to do a look-up for that data.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: BACTERIOLOGY
    • Code : 5
      Stands For: PARASITOLOGY
    • Code : 8
      Stands For: MYCOLOGY
    • Code : 11
      Stands For: MYCOBACTERIOLOGY
    • Code : 16
      Stands For: VIROLOGY
    FACILITY 7 This field is used to record the facility at which this test is being edited.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    SPECIMEN CONDITION 9999991 Specimen Condition from Reference Lab.

    		Free Text
    RELEASE DATE 9999993

    		Date/Time
    HL7 MESSAGE 9999994

    		Pointer
    PointerTo:
    fileName:
    LA7 MESSAGE QUEUE
    fileNumber:
    62.49
    RELEASING SITE COUNTY 9999996

    		Free Text
    RELEASING SITE COUNTRY 9999997

    		Pointer
    PointerTo:
    fileName:
    COUNTRY CODE
    fileNumber:
    779.004
    SURGICAL PATHOLOGY 8 This is the surgical pathology for this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time the specimen was taken.

    		Date/Time
    SPECIMEN SUBMITTED BY .011 This is the person submitting the specimen.

    		Free Text
    SPECIMEN .012 These are the specimens submitted.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIMEN .01 This is the specimen submitted.

    		Free Text
    SURGICAL WORKLOAD PROFILE .02 Profile of surgical workload

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    GROSS DESCRIPTION/CUTTING DATE .03 If gross description/cutting of a specimen is performed by a non-physician date and time are entered here.

    		Date/Time
    GROSS DESCRIPTION/CUTTING TYPE .04 Select 1 or 'R' when the gross description and cutting of surgical tissue is performed by a nonphysician (e.g., a pathology assistant) Select 2 or 'E' when extensive gross processing is required by technical assistants in addition to the usual dissection and description (e.g., orientation of a renal biopsy and splitting it for light and electron microscopy, and immunofluorescence) Select 3 or 'T' when technical or clerical staff assist with gross processing.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: ROUTINE GROSS SURGICAL
    • Code : 2
      Stands For: EXTENSIVE GROSS SURGICAL
    • Code : 3
      Stands For: TECHNICAL ASSISTANCE SURGICAL
    GROSS DESCRIPTION COUNTED .05 Whether the gross description is counted for workload

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    SPECIMEN TOPOGRAPHY .06 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE .07 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    PARAFFIN BLOCK 1 This is a list of paraffin blocks prepared from the specimen submitted.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARAFFIN BLOCK ID .01 The identification number on the paraffin block used to make the slides for any stains or procedures.

    		Free Text
    DATE/TIME BLOCK PREPARED .02 Date/time block prepared. Used for workload recording.

    		Date/Time
    BLOCK COUNTED .03 Used for workload recording. If block counted a 'YES' is entered.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    STAIN/PROCEDURE 1 List of tissue stains or procedures performed on the slides cut from the paraffin block.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STAIN/PROCEDURE .01 A tissue stain or procedure performed on a slide cut from a paraffin block.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02 The number of slides for which a specific stain or procedure was performed.

    		Numeric
    CONTROL SLIDES (#) .03 This is the number of control slides prepared.

    		Numeric
    DATE/TIME SLIDES STAINED .04 When slides are stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 When slides are examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07 Number of labels to print

    		Numeric
    NON-CONTROL SLIDES COUNTED .09 Number of non-control slides counted

    		Numeric
    PLASTIC BLOCK 2 These are the plastic blocks set up on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLASTIC BLOCK ID .01 This is the plastic block identification.

    		Free Text
    DATE/TIME BLOCK PREPARED .02 When the block is prepared

    		Date/Time
    BLOCK COUNTED .03

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    PLASTIC STAIN/PROCEDURE 1 These are the plastic stain/procedures performed.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PLASTIC STAIN/PROCEDURE .01 This is the plastic stain or procedure performed.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PLASTIC SLIDES PREPARED (#) .02 This is the number of slides prepared.

    		Numeric
    CONTROL SLIDES (#) .03 This is the number of control slides prepared.

    		Numeric
    DATE/TIME SLIDES STAINED .04 When slides are stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 When slides are examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    FROZEN TISSUE BLOCK 3 This is the list of frozen tissues prepared from the specimen submitted.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FROZEN TISSUE ID .01 This is the identification of frozen tissue.

    		Free Text
    DATE/TIME FROZEN PREPARED .02 When the frozen section is prepared

    		Date/Time
    FROZEN COUNTED .03

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    FROZEN TISSUE BLOCK TYPE .04 Entry indicates if the frozen tissue block is used for rush (rapid) diagnosis or routinely processed (not rush).

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: RUSH
    • Code : 0
      Stands For: NOT RUSH
    STAIN/PROCEDURE 1 These are the stain/procedures performed on this specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STAIN/PROCEDURE .01 This is the stain/procedure performed on this specimen.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02 This is the number of slides prepared.

    		Numeric
    CONTROL SLIDES (#) .03 This is the number of control slides.

    		Numeric
    DATE/TIME SLIDES STAINED .04 When the slides are prepared

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 When the slides are examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    BRIEF CLINICAL HISTORY .013 This is a brief clinical history of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BRIEF CLINICAL HISTORY .01

    		Word Processing
    PREOPERATIVE DIAGNOSIS .014 This is the pre-operative diagnosis of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREOPERATIVE DIAGNOSIS .01

    		Word Processing
    OPERATIVE FINDINGS .015 These are the operative findings of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OPERATIVE FINDINGS .01

    		Word Processing
    POSTOPERATIVE DIAGNOSIS .016

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    POSTOPERATIVE DIAGNOSIS .01

    		Word Processing
    PATHOLOGIST .02 This is the pathologist performing the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    RESIDENT PATHOLOGIST .021 This is the resident pathologist performing the procedure.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE REPORT COMPLETED .03 This is the date the report is completed.

    		Date/Time
    SURGICAL PATH ACC # .06 This is the accession number of the surgical pathology specimen.

    		Free Text
    SURGEON/PHYSICIAN .07 This is the requesting provider.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PATIENT LOCATION .08 This is the requesting location.

    		Free Text
    TYPIST .09 These are the initials of the typist entering the data.

    		Free Text
    DATE/TIME SPECIMEN RECEIVED .1 This is the date/time the specimen was received.

    		Date/Time
    REPORT RELEASE DATE/TIME .11 YES indicates the report was released.

    		Date/Time
    RELEASED BY .13

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TC CODE .14 Tissue committee codes The meaning of each code is identified by each site.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    • Code : 4
      Stands For: 4
    • Code : 5
      Stands For: 5
    • Code : 6
      Stands For: 6
    • Code : 7
      Stands For: 7
    • Code : 8
      Stands For: 8
    • Code : 9
      Stands For: 9
    • Code : 0
      Stands For: 0
    ORIGINAL RELEASE DATE .15 If report was modified after release the original release date is kept here.

    		Date/Time
    TIU REFERENCE DATE/TIME - SP .16 This multiple stores TIU information for corresponding SF515 surgical pathology reports that have been electronically signed and stored in TIU. This information is used to access the reports in TIU.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TIU REFERENCE DATE/TIME - SP .01 This is the date and time that the surgical pathology SF515 was stored in TIU. It will match the REFERENCE DATE (#1301) field of the corresponding document in the TIU DOCUMENT (#8925) file.

    		Date/Time
    TIU ENTRY POINTER - SP 1 This field is a pointer to the TIU DOCUMENT (#8925) file. It stores the pointer for a surgical pathology SF515 that has been electronically signed and stored in TIU.

    		Pointer
    PointerTo:
    fileName:
    TIU DOCUMENT
    fileNumber:
    8925
    TIU CHECKSUM - SP 2 This field stores the checksum that is calculated at the time the report version is initially stored in TIU. It will be used for comparison in future print/view requests. A new checksum will be calculated whenever the report version is printed/viewed, and matching checksums are proof that the report version has not been illegally altered.

    		Free Text
    DATE REPORT MODIFIED - SP .17 This is the date the report was modified if it was modified after it was electronically signed/released.

    		Date/Time
    PERSON MODIFYING TEXT .171 Stores the DUZ of the person who modified the report AFTER it was electronically signed/released.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DIAGNOSIS MODIFIED .172 1 = Diagnosis modified AFTER report was electronically signed/released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    UID .31 This is the UID used by the HOST LEDI system for this order/accession. This field is used by LEDI software.

    		Free Text
    ORDERING SITE .32 This field contains the pointer to the INSTITUTION file for the MailMan domain location of the computer system. All LEDI results are returned to the Ordering computer system. Location to send LEDI HL7 result messages. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    COLLECTING SITE .33 This field contains the pointer to the INSTITUTION file for the actual collection site. The ordering site is the MailMan location of the computer system. MailMan domain location and the collecting site may be different. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    HOST UID .34 Each Order/Accession is given a HOST UID. The UID is stored in this location. If LEDI software is used to accession specimens, usually the collecting sites UID is used to track specimens. If the collecting UID conflicts with the HOST system number sequence, the HOST UID will be used instead of the collecting site's UID. This field is used by LEDI software.

    		Free Text
    ORDERING SITE UID .342 This field contains the collecting site's UID for this specimen. this field is used by LEDI software.

    		Free Text
    RELEASING SITE .345 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    ORDERED TEST .35 This subfile contains information about the ordered test(s) for this accession. The .01 field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORDERED TEST .01 Contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Free Text
    ORDERED URGENCY 2 This field contains the urgency for this ordered test.

    		Pointer
    PointerTo:
    fileName:
    URGENCY
    fileNumber:
    62.05
    CPRS ORDER # 3 This field contains the pointer to CPRS ORDER (#100) file. This field is only populated when the original order is placed on the local system.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    LAB ORDER # 4 This field contains the LAB ORDER number for this test. The construct of this free text field is: LR-Lab order number-XXXX - where XXXX is the Julian date.

    		Free Text
    ORDER TYPE 5 This field contains information about how the test order was generated. The selection must be made from HL7 Table 0065 entries. This field indicates if the ordered test was part of the original order, an add-on or reflexed per clinical protocol.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    ORDERING PROVIDER LOCAL 6 The pointer to the NEW PERSON file if the original order was placed on the local system. This field will be empty if order is placed via LEDI.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING PROVIDER REMOTE 7 If this test is ordered by a provider from a remote system (not local sytem), the names contained in the HL7 message will be stored in this field.

    		Free Text
    SPECIMEN TOPOGRAPHY 8 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE 9 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    DISPOSITION 10 Maintains the disposition of the ordered test. It will be used to value the test disposition in HL7 messaging, specifically OBR-25.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    DISPOSITION DATE/TIME 11 Stores the date and time that a lab user or the system dispositioned this test.

    		Date/Time
    DISPOSITION BY 12 Store the user who entered the disposition of this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAB TEST ORDERED 13 Contains the ordered laboratory test associated with the ordered NLT code.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT TEST 14 If this test is a reflex test this indicates the ordered test that is associated with the reflex test.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT NLT 15 Contains the order NLT code associated with the parent test when the ordered test is a reflex test.

    		Free Text
    DELAYED REPORT COMMENT .97 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DELAYED REPORT COMMENT .01 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Free Text
    COMMENT .99 These are the comments on the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment on the specimen.

    		Free Text
    GROSS DESCRIPTION 1 This is the gross description of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GROSS DESCRIPTION .01

    		Word Processing
    MICROSCOPIC DESCRIPTION 1.1 This is the microscopic examination diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICROSCOPIC DESCRIPTION .01 Microscopic slide examination report is entered here.

    		Word Processing
    SUPPLEMENTARY REPORT 1.2 These are supplementary reports on the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT DATE/TIME .01 This is the date/time of the supplementary report.

    		Date/Time
    RELEASE SUPPLEMENTARY REPORT .02 If supplementary report is to be displayed or printed outside of lab the report must be released by entering 'YES'.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: yes
    • Code : 0
      Stands For: no
    RELEASE SUPP REPORT MODIFIED .03 This flag will be set to '1' when a released supplementary report is modified. It is removed when the modified supplementary report is released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DESCRIPTION 1 This is the description of the supplementary report.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    SUPPLEMENTARY REPORT MODIFIED 2 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT MODIFIED .01 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the DUZ of the person who modified the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PERSON RELEASING THE SUPP. RPT .03 This is the DUZ of the person who released the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPP REPORT RELEASE DATE/TIME .04 This is the date/time in which this supplementary report was released. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Date/Time
    PREMODIFICATION TEXT 1 This is the text of the supplementary report as it existed before it was modified. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01 This is the text of the supplementary report as it existed before it was modified. This field is updated by the software and can only be modified from programmer mode.

    		Word Processing
    FROZEN SECTION 1.3 Frozen section descriptions can optionally be entered in this field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FROZEN SECTION .01

    		Word Processing
    SURGICAL PATH DIAGNOSIS 1.4 Surgical pathology diagnoses are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SURGICAL PATH DIAGNOSIS .01

    		Word Processing
    DATE MICROSCOPIC EXAM MODIFIED 4 These are the dates of modification of the microscopic examination diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE MICROSCOPIC EXAM MODIFIED .01 This is the date of modification of the microscopic examination diagnosis.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the person modifying the text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE DIAGNOSIS MODIFIED 5 These are the dates of modification of the diagnosis field (DD(63.08,1.4))

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE DIAGNOSIS MODIFIED .01

    		Date/Time
    PERSON MODIFYING TEXT .02 User who changes text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE FROZEN SECTION MODIFIED 6 These are the dates of modification of the frozen section field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE FROZEN SECTION MODIFIED .01 These are the dates of modification of the frozen section field.

    		Date/Time
    PERSON MODIFYING TEXT .02 User who changes text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 Text before modification is stored here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE GROSS DESCRIPTION CHANGED 7 These are the dates of modification of the gross description field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE GROSS DESCRIPTION CHANGED .01 These are the dates of modification of the gross description field.

    		Date/Time
    PERSON MODIFYING TEXT .02 User who changes text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    QA CODE 9

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    QA CODE .01

    		Pointer
    PointerTo:
    fileName:
    LAB DESCRIPTIONS
    fileNumber:
    62.5
    ORGAN/TISSUE 10 These are the organ/tissue(s) being examined.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORGAN/TISSUE .01 This is the organ/tissue(s) being examined.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    FUNCTION 1 These are the functions associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FUNCTION .01 This is the function associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    PROCEDURE 1.5 These are the procedures associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROCEDURE .01 This is a procedure associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE FIELD
    fileNumber:
    61.5
    RESULT .02 If result of procedure is positive enter '1' or 'P'.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NEG
    • Code : 1
      Stands For: POS
    WEIGHT (gm) 2 This is the weight of the specimen.

    		Numeric
    DISEASE 3 These are the diseases associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISEASE .01 This is a disease associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    DISEASE FIELD
    fileNumber:
    61.4
    MORPHOLOGY 4 These are the morphologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MORPHOLOGY .01 This is a morphology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY FIELD
    fileNumber:
    61.1
    ETIOLOGY 1 These are the etiologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ETIOLOGY .01 This is an etiology associated with this organ/tissue(s)

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    SPECIAL STUDIES 5 These are special studies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIAL STUDIES .01 This is a special study associated with this organ/tissue(s).

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: ELECTRON MICROSCOPY
    • Code : I
      Stands For: IMMUNOFLUORESCENCE
    • Code : P
      Stands For: PHOTOGRAPHY
    • Code : C
      Stands For: CONSULTATION
    • Code : F
      Stands For: FROZEN SECTION
    • Code : IP
      Stands For: IMMUNOPEROXIDASE
    DATE .02 This is the date of the special studies.

    		Date/Time
    ID # .03 This is the identification number of the special studies.

    		Free Text
    DESCRIPTION 1 This is the description of the special studies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    CPT/ICD DIAGNOSIS 80 These are the ICD diagnoses associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CPT/ICD DIAGNOSIS .01 This is the ICD diagnosis associated with this organ/tissue(s).

    		Variable Pointer
    IMAGE 2005 Images associated with Surgical Pathology reports are stored in this multiple within the Surgical Pathology field of the Lab Data (#63) file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    CYTOPATHOLOGY 9 QCytopathology data associated with this patient.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE/TIME SPECIMEN TAKEN .01 This is the date/time of collection of the specimen.

    		Date/Time
    SPECIMEN SUBMITTED BY .011 This is the person submitting the specimen.

    		Free Text
    SPECIMEN .012 These are the specimens submitted.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIMEN .01 Enter the name of the specimen submitted..

    		Free Text
    WORKLOAD PROFILE .02 The name of a cytology subscripted entry in the lab test file. The entry is composed of accession WKLD codes and one or more cytology procedures associated with specimen processing.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SPECIMEN TOPOGRAPHY .06 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE .07 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    SMEAR PREP 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SMEAR PREP .01

    		Free Text
    STAIN/PROCEDURE 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STAIN/PROCEDURE .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02 The number of slides prepared

    		Numeric
    CONTROL SLIDES (#) .03

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    SLIDES SCREENED (#) .08 Last number of slides screened for workload.

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    CELL BLOCK 2

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CELL BLOCK .01

    		Free Text
    CELL BLOCK STAIN 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CELL BLOCK STAIN .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02

    		Numeric
    CONTROL SLIDES (#) .03

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    SLIDES SCREENED (#) .08 Last number of slides screened for workload.

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    MEMBRANE FILTER 3

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MEMBRANE FILTER .01

    		Free Text
    MEMBRANE FILTER STAIN 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MEMBRANE FILTER STAIN .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02

    		Numeric
    CONTROL SLIDES (#) .03

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    SLIDES SCREENED (#) .08 Last number of slides screened for workload.

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    PREPARED SLIDES 4

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREPARED SLIDES .01

    		Free Text
    PREPARED SLIDES STAIN 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREPARED SLIDES STAIN .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02

    		Numeric
    CONTROL SLIDES (#) .03

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    SLIDES SCREENED (#) .08 Last number of slides screened for workload.

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    CYTOSPIN 5

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CYTOSPIN .01

    		Free Text
    CYTOSPIN STAIN 1

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CYTOSPIN STAIN .01

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02

    		Numeric
    CONTROL SLIDES (#) .03

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07

    		Numeric
    SLIDES SCREENED (#) .08 Last number of slides screened for workload.

    		Numeric
    NON-CONTROL SLIDES COUNTED .09

    		Numeric
    BRIEF CLINICAL HISTORY .013 This is a brief clinical history of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    BRIEF CLINICAL HISTORY .01

    		Word Processing
    PREOPERATIVE DIAGNOSIS .014 This is the pre-operative diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREOPERATIVE DIAGNOSIS .01

    		Word Processing
    OPERATIVE FINDINGS .015 These are the operative findings of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    OPERATIVE FINDINGS .01

    		Word Processing
    POSTOPERATIVE DIAGNOSIS .016 This is the post-operative diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    POSTOPERATIVE DIAGNOSIS .01

    		Word Processing
    PATHOLOGIST/CYTOTECHNOLOGIST .02 This is the pathologist performing the examination.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    CYTOTECH .021 This is the technologist performing the test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DATE REPORT COMPLETED .03 This is the date the report was completed.

    		Date/Time
    CYTOPATH ACC # .06 This is the accession number of the cytopathology specimen.

    		Free Text
    PHYSICIAN .07 This is the requesting provider.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PATIENT LOCATION .08 This is the requesting location.

    		Free Text
    TYPIST .09 These are the initials of the typist entering the cytopathology data.

    		Free Text
    DATE/TIME SPECIMEN RECEIVED .1 This is the date/time the specimen was received.

    		Date/Time
    REVIEWED BY PATHOLOGIST .101 YES identifies that the case has been reviewed by the pathologist.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: yes
    • Code : 0
      Stands For: no
    REPORT RELEASE DATE/TIME .11 Date report was released

    		Date/Time
    RELEASED BY .13 Name of individual who released report

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    TC CODE .14 Tissue committee codes The meaning of each code is identified by each site.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: 1
    • Code : 2
      Stands For: 2
    • Code : 3
      Stands For: 3
    • Code : 4
      Stands For: 4
    • Code : 5
      Stands For: 5
    • Code : 6
      Stands For: 6
    • Code : 7
      Stands For: 7
    • Code : 8
      Stands For: 8
    • Code : 9
      Stands For: 9
    • Code : 0
      Stands For: 0
    ORIGINAL RELEASE DATE .15 If report was modified after release the original release date is kept here.

    		Date/Time
    TIU REFERENCE DATE/TIME - CY .16 This multiple stores TIU information for corresponding SF515 cytopathology reports that have been electronically signed and stored in TIU. This information is used to access the reports in TIU.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TIU REFERENCE DATE/TIME - CY .01 This is the date and time that the cytopathology SF515 was stored in TIU. It will match the REFERENCE DATE (#1301) field of the corresponding document in the TIU DOCUMENT (#8925) file.

    		Date/Time
    TIU ENTRY POINTER - CY 1 This field is a pointer to the TIU DOCUMENT (#8925) file. It stores the pointer for a cytopathology SF515 that has been electronically signed and stored in TIU.

    		Pointer
    PointerTo:
    fileName:
    TIU DOCUMENT
    fileNumber:
    8925
    TIU CHECKSUM - CY 2 This field stores the checksum that is calculated at the time the report version is initially stored in TIU. It will be used for comparison in future print/view requests. A new checksum will be calculated whenever the report version is printed/viewed, and matching checksums are proof that the report version has not been illegally altered.

    		Free Text
    DATE REPORT MODIFIED - CY .17 This is the date the report was modified if it was modified after it was electronically signed/released.

    		Date/Time
    PERSON MODIFYING TEXT .171 Stores the DUZ of the person who modified the report AFTER it was electronically signed/released.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DIAGNOSIS MODIFIED .172 1 = Diagnosis modified AFTER report was electronically signed/released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    UID .31 This is the UID used by the HOST LEDI system for this order/accession. This field is used by LEDI software.

    		Free Text
    ORDERING SITE .32 This field contains the pointer to the INSTITUTION file for the Mailman domain location of the computer system. All LEDI results are returned to the Ordering computer system. Location to send LEDI HL7 result messages. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    COLLECTING SITE .33 This field contains the pointer to the INSTITUTION file for the actual collection site. The ordering site is the MailMan location of the computer system. MailMan domain location and the collecting site may be different. This field is used by LEDI software.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    HOST UID .34 Each Order/Accession is given a HOST UID. The UID is stored in this location. If LEDI software is used to accession specimens, usually the collecting sites UID is used to track specimens. If the collecting UID conflicts with the HOST system number sequence, the HOST UID will be used instead of the collecting site's UID. This field is used by LEDI software.

    		Free Text
    ORDERING SITE UID .342 This field contains the collecting sites UID for this specimen. This field is used by LEDI software.

    		Free Text
    RELEASING SITE .345 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    ORDERED TEST .35 This subfile contains information about the ordered test(s) for this accession. The .01 field contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ORDERED TEST .01 Contains the ordered test NLT code requested by the clinical provider. If this test is a panel, all atomic tests within the panel will be associated with the ordered test using this NLT code.

    		Free Text
    ORDERED URGENCY 2 This field contains the urgency for this ordered test.

    		Pointer
    PointerTo:
    fileName:
    URGENCY
    fileNumber:
    62.05
    CPRS ORDER # 3 This field contains the pointer to CPRS ORDER (#100) file. This field is only populated when the original order is placed on the local system.

    		Pointer
    PointerTo:
    fileName:
    ORDER
    fileNumber:
    100
    LAB ORDER # 4 This field contains the LAB ORDER number for this test. The construct of this free text field is: LR-Lab order number-XXXX - where XXXX is the Julian date.

    		Free Text
    ORDER TYPE 5 This field contains information about how the test order was generated. The selection must be made from HL7 Table 0065 entries. This field indicates if the ordered test was part of the original order, an add-on or reflexed per clinical protocol.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    ORDERING PROVIDER LOCAL 6 The pointer to the NEW PERSON file if the original order was placed on the local system. This field will be empty if order is placed via LEDI.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    ORDERING PROVIDER REMOTE 7 If this test is ordered by a provider from a remote system (not local system), the names contained in the HL7 message will be stored in this field.

    		Free Text
    SPECIMEN TOPOGRAPHY 8 This field contains the topography location for this test.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    COLLECTION SAMPLE 9 This field contains the collection sample for this test.

    		Pointer
    PointerTo:
    fileName:
    COLLECTION SAMPLE
    fileNumber:
    62
    DISPOSITION 10 Maintains the disposition of the ordered test. It will be used to value the test disposition in HL7 messaging, specifically OBR-25.

    		Pointer
    PointerTo:
    fileName:
    LAB ELECTRONIC CODES
    fileNumber:
    64.061
    DISPOSITION DATE/TIME 11 Stores the date and time that a lab user or the system dispositioned this test.

    		Date/Time
    DISPOSITION BY 12 Store the user who entered the disposition of this test.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    LAB TEST ORDERED 13 Contains the ordered laboratory test associated with the ordered NLT code.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT TEST 14 If this test is a reflex test this indicates the ordered test that is associated with the reflex test.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    PARENT NLT 15 Contains the order NLT code associated with the parent test when the ordered test is a reflex test.

    		Free Text
    DELAYED REPORT COMMENT .97 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DELAYED REPORT COMMENT .01 If a report is delayed, reason(s) for delay may be entered here. They will appear on the log book report and the clinician screen display.

    		Free Text
    COMMENT .99 These are comments on the cytopathology data.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    COMMENT .01 This is a comment on the cytopathology data.

    		Free Text
    GROSS DESCRIPTION 1 This is the gross description of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    GROSS DESCRIPTION .01

    		Word Processing
    MICROSCOPIC EXAMINATION 1.1 This is the microscopic examination diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MICROSCOPIC EXAMINATION .01

    		Word Processing
    SUPPLEMENTARY REPORT 1.2 These are the supplementary reports on the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT DATE/TIME .01 This is the date/time of the supplementary report.

    		Date/Time
    RELEASE SUPPLEMENTARY REPORT .02 If supplementary report is to be displayed or printed outside of lab the report must be released by entering 'YES'.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: yes
    • Code : 0
      Stands For: no
    RELEASE SUPP REPORT MODIFIED .03 This flag will be set to '1' when a released supplementary report is modified. It is removed when the modified supplementary report is released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DESCRIPTION 1 This is the description of the supplementary report.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    SUPPLEMENTARY REPORT MODIFIED 2 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT MODIFIED .01 This is the date/time in which this supplementary report was modified. It is updated by the software and can only be modified from programmer mode.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the DUZ of the person who modified the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PERSON RELEASING THE SUPP. RPT .03 This is the DUZ of the person who released the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPP REPORT RELEASE DATE/TIME .04 This is the date/time the supplementay report is released. It is updated by the software and can only be modified from programmer mode.

    		Date/Time
    PREMODIFICATION TEXT 1 This is the text of the supplementary report as it existed before it was modified. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01 This is the text of the supplementary report as it existed before it was modified. This field is updated by the software and can only be modified from programmer mode.

    		Word Processing
    CYTOPATHOLOGY DIAGNOSIS 1.4 Cytopathology diagnoses are entered here.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CYTOPATHOLOGY DIAGNOSIS .01

    		Word Processing
    DATE MICROSCOPIC EXAM MODIFIED 4 These are the dates of the modification of the microscopic examination diagnosis.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE MICROSCOPIC EXAM MODIFIED .01 This is the date of the modification of the microscopic examination diagnosis.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the person modifying text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01 This is the premodification text.

    		Word Processing
    DATE DIAGNOSIS MODIFIED 5 This is the date of the modification of the diagnosis field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE DIAGNOSIS MODIFIED .01 This is the date of the modification of the diagnosis field.

    		Date/Time
    PERSON MODIFYING TEXT .02

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    DATE GROSS DESCRIPTION CHANGED 7 These are the dates of change in the gross description field.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DATE GROSS DESCRIPTION CHANGED .01 These are the dates of change in the gross description field.

    		Date/Time
    PERSON MODIFYING TEXT .02 User who changes text.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PREMODIFICATION TEXT 1 This is the premodification text.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01

    		Word Processing
    QA CODE 9

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    QA CODE .01

    		Pointer
    PointerTo:
    fileName:
    LAB DESCRIPTIONS
    fileNumber:
    62.5
    CYTOPATH ORGAN/TISSUE 10 This is the organ/tissue(s) being examined.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CYTOPATH ORGAN/TISSUE .01

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    FUNCTION 1 These are the functions associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FUNCTION .01 This is the function associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    PROCEDURE 1.5 These are the procedures associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROCEDURE .01 This is the procedure associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE FIELD
    fileNumber:
    61.5
    RESULT .02 If result of procedure is positive enter '1' or 'P'.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NEG
    • Code : 1
      Stands For: POS
    DISEASE 3 These are the diseases associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISEASE .01 This is the disease associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    DISEASE FIELD
    fileNumber:
    61.4
    MORPHOLOGY 4 These are morphologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MORPHOLOGY .01 This is the morphology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY FIELD
    fileNumber:
    61.1
    ETIOLOGY 1 These are the etiologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ETIOLOGY .01 This is an etiology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    SPECIAL STUDIES 5 These are the special studies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIAL STUDIES .01 This is a special study associated with this organ/tissue(s).

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: EM
    • Code : I
      Stands For: IMMUNOFLUORESCENCE
    • Code : P
      Stands For: PHOTOGRAPHY
    • Code : C
      Stands For: CONSULTATION
    • Code : IP
      Stands For: IMMUNOPEROXIDASE
    DATE .02 This is the date of the special study.

    		Date/Time
    ID # .03 This is the identification number of the special study.

    		Free Text
    DESCRIPTION 1 This is the description of the special studies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    CPT/ICD DIAGNOSIS 80 These are the IDC diagnosis of the specimen.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CPT/ICD DIAGNOSIS .01 This is the ICD diagnosis of the specimen.

    		Variable Pointer
    IMAGE 2005 Images associated with Cytopathology reports are stored in this multiple within the Cytopathology field of the Lab Data (#63) file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    AUTOPSY DATE/TIME 11 This is the date/time of the autopsy.

    		Date/Time
    DATE/TIME OF DEATH 12 This is the date/time of death.

    		Computed
    PHYSICIAN 12.1 This is the requesting provider.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    AGE AT DEATH 12.5 This is the age of the patient at the time of death.

    		Free Text
    DATE AUTOPSY REPORT COMPLETED 13 This is the date the autopsy report was completed.

    		Date/Time
    AUTOPSY TYPIST 13.01 The name of the Autopsy typist

    		Free Text
    DATE FINAL AUTOPSY DIAGNOSES 13.1 This is the date the final autopsy diagnoses are completed.

    		Date/Time
    RESIDENT PATHOLOGIST 13.5 This is the resident pathologist.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SENIOR PATHOLOGIST 13.6 This is the senior pathologist.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    AUTOPSY TYPE 13.7 This is the autopsy type.

    		Set of Codes
    Set of Codes:
    • Code : F
      Stands For: FULL AUTOPSY
    • Code : H
      Stands For: HEAD ONLY
    • Code : T
      Stands For: TRUNK ONLY
    • Code : A
      Stands For: ABDOMEN ONLY
    • Code : C
      Stands For: CHEST ONLY
    • Code : O
      Stands For: OTHER LIMITATION
    AUTOPSY ASSISTANT 13.8 If prosector has an assistant enter name of assistant.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    AUTOPSY ACC # 14 This is the number of this autopsy.

    		Free Text
    LOCATION 14.1 This is the requesting location.

    		Free Text
    SERVICE 14.5 This is the service to which this patient was assigned.

    		Set of Codes
    Set of Codes:
    • Code : M
      Stands For: MEDICINE
    • Code : S
      Stands For: SURGERY
    • Code : P
      Stands For: PSYCHIATRY
    • Code : NH
      Stands For: NHCU
    • Code : NE
      Stands For: NEUROLOGY
    • Code : I
      Stands For: INTERMEDIATE MED
    • Code : R
      Stands For: REHAB MEDICINE
    • Code : SCI
      Stands For: SPINAL CORD INJURY
    • Code : D
      Stands For: DOMICILLARY
    • Code : B
      Stands For: BLIND REHAB
    TREATING SPECIALITY AT DEATH 14.6 Name of treating specialty at time of patient's death.

    		Pointer
    PointerTo:
    fileName:
    FACILITY TREATING SPECIALTY
    fileNumber:
    45.7
    AUTOPSY RELEASE DATE/TIME 14.7 Date and time autopsy verified.

    		Date/Time
    AUTOPSY RELEASED BY 14.8 Name of person releasing verified autopsy report.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PROVISIONAL ANAT DX DATE 14.9 Date provisional anatomic diagnoses reported

    		Date/Time
    RELEASING SITE 14.91 This field indicates the site that released the clinical report. This field can be used to determine the information required to correctly indicate the address/location of the laboratory responsible for releasing the report.

    		Pointer
    PointerTo:
    fileName:
    INSTITUTION
    fileNumber:
    4
    BODY HEIGHT (in) 16 Height of body in inches

    		Numeric
    BODY WT (lb) 17 Weight of body in pounds

    		Numeric
    LUNG,RT (gm) 18 Right lung

    		Numeric
    LUNG,LT (gm) 19 Left lung

    		Numeric
    LIVER (gm) 20 Body organ

    		Numeric
    SPLEEN (gm) 21 Body organ

    		Numeric
    KIDNEY,RT (gm) 22 Right kidney

    		Numeric
    KIDNEY,LT (gm) 23 Left kidney

    		Numeric
    HEART (gm) 24 Body organ

    		Numeric
    BRAIN (gm) 25 Body organ

    		Numeric
    PITUITARY GLAND (gm) 25.1 Body organ

    		Numeric
    THYROID GLAND (gm) 25.2 Body organ

    		Numeric
    PARATHYROID, LEFT UPPER (gm) 25.3 Left upper parathyroid

    		Numeric
    PARATHYROID, LEFT LOWER (gm) 25.4 Left lower parathyroid

    		Numeric
    PARATHYROID, RIGHT UPPER (gm) 25.5 Right upper parathyroid

    		Numeric
    PARATHYROID, RIGHT LOWER (gm) 25.6 Right lower parathyroid

    		Numeric
    ADRENAL, LEFT (gm) 25.7 Left adrenal

    		Numeric
    ADRENAL, RIGHT (gm) 25.8 Right adrenal

    		Numeric
    PANCREAS (gm) 25.9 Body organ

    		Numeric
    TESTIS, LEFT (gm) 25.91 Left testis

    		Numeric
    TESTIS, RIGHT (gm) 25.92 Right testis

    		Numeric
    OVARY, LEFT (gm) 25.93 Left ovary

    		Numeric
    OVARY, RIGHT (gm) 25.94 Right ovary

    		Numeric
    TRICUSPID VALVE (cm) 26 Body organ

    		Numeric
    PULMONIC VALVE (cm) 27 Body organ

    		Numeric
    MITRAL VALVE (cm) 28 Body organ

    		Numeric
    AORTIC VALVE (cm) 29 Body organ

    		Numeric
    RIGHT VENTRICLE (cm) 30 Body organ

    		Numeric
    LEFT VENTRICLE (cm) 31 Body organ

    		Numeric
    PLEURAL CAVITY, LEFT (ml) 31.1 Left pleural cavity

    		Numeric
    PLEURAL CAVITY, RIGHT (ml) 31.2 Right pleural cavity

    		Numeric
    PERICARDIAL CAVITY (ml) 31.3 Body organ

    		Numeric
    PERITONEAL CAVITY (ml) 31.4 Body organ

    		Numeric
    AUTOPSY ORGAN/TISSUE 32 These are the organ/tissue(s) examined.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTOPSY ORGAN/TISSUE .01 This is the autopsy organ/tissue(s) being examined.

    		Pointer
    PointerTo:
    fileName:
    TOPOGRAPHY FIELD
    fileNumber:
    61
    FUNCTION 1 These are the functions associated with the organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    FUNCTION .01 This is the function associated with this organ/tissues(s).

    		Pointer
    PointerTo:
    fileName:
    FUNCTION FIELD
    fileNumber:
    61.3
    PROCEDURE 1.5 These are the procedures associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PROCEDURE .01 This is the procedure associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    PROCEDURE FIELD
    fileNumber:
    61.5
    RESULT .02 If result is positive enter '1' or 'P'.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NEG
    • Code : 1
      Stands For: POS
    DISEASE 3 These are the diseases associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DISEASE .01 This is a disease associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    DISEASE FIELD
    fileNumber:
    61.4
    MORPHOLOGY 4 These are the morphologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    MORPHOLOGY .01 This is a morphology associated with this organ/tissue.

    		Pointer
    PointerTo:
    fileName:
    MORPHOLOGY FIELD
    fileNumber:
    61.1
    ETIOLOGY 1 These are the etiologies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ETIOLOGY .01 This is an etiology associated with this organ/tissue(s).

    		Pointer
    PointerTo:
    fileName:
    ETIOLOGY FIELD
    fileNumber:
    61.2
    SPECIAL STUDIES 5 These are special studies associated with this organ/tissue(s).

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SPECIAL STUDIES .01 This is the special study associated with this organ/tissue(s).

    		Set of Codes
    Set of Codes:
    • Code : E
      Stands For: EM
    • Code : I
      Stands For: IMMUNOFLUORESCENCE
    • Code : P
      Stands For: PHOTOGRAPHY
    • Code : C
      Stands For: CONSULTATION
    • Code : F
      Stands For: FROZEN SECTION
    • Code : IP
      Stands For: IMMUNOPEROXIDASE
    DATE .02 This is the date of the special studies.

    		Date/Time
    ID # .03 This is the identification number of the special studies.

    		Free Text
    DESCRIPTION 1 This is the description of the special studies.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01 This is the description of the special studies.

    		Word Processing
    IMAGE (GROSS) 2005 Images associated with Autopsy Organ/Tissue reports are stored in this multiple within the Autopsy Organ/Tissue field of the Lab Data (#63) file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE (GROSS) .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    IMAGE (MICROSCOPIC) 2005.1 Images associated with Autopsy Organ/Tissue reports are stored in this multiple within the Autopsy Organ/Tissue field of the Lab Data (#63) file.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    IMAGE (MICROSCOPIC) .01

    		Pointer
    PointerTo:
    fileName:
    IMAGE
    fileNumber:
    2005
    AUTOPSY COMMENTS 32.1 These are comments on the autopsy.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTOPSY COMMENTS .01 This is a comment on this autopsy.

    		Free Text
    CLINICAL DIAGNOSES 32.2 These are the clinical diagnoses.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    CLINICAL DIAGNOSES .01

    		Word Processing
    PATHOLOGICAL DIAGNOSES 32.3 These are the pathological diagnoses.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PATHOLOGICAL DIAGNOSES .01

    		Word Processing
    AUTOPSY SUPPLEMENTARY REPORT 32.4 Multiple for autopsy supplementary report

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT DATE .01 Date of supplementary autopsy report

    		Date/Time
    RELEASE SUPPLEMENTARY REPORT .02 If the supplementary report is to be displayed or printed outside of lab, the report must be released by entering 'YES'.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: yes
    • Code : 0
      Stands For: no
    RELEASE SUPP REPORT MODIFIED .03 This flag will be set to '1' when a released supplementary report is modified. It is removed when the modified supplementary report is released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    DESCRIPTION 1 Description of the supplementary autopsy

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    DESCRIPTION .01

    		Word Processing
    SUPPLEMENTARY REPORT MODIFIED 2 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    SUPPLEMENTARY REPORT MODIFIED .01 This is the date/time in which this supplementary report was modified. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Date/Time
    PERSON MODIFYING TEXT .02 This is the DUZ of the person who modified the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    PERSON RELEASING THE SUPP. RPT .03 This is the DUZ of the person who released the supplementary report. It is updated by the software and can only be modified from programmer mode.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    SUPP REPORT RELEASE DATE/TIME .04 This is the date/time in which this supplementary report was released. This information is stored for audit trail purposes. It is updated by the software and can only be changed from programmer mode.

    		Date/Time
    PREMODIFICATION TEXT 1 This is the text of the supplementary report as it existed before it was modified. It is updated by the software and can only be modified from programmer mode.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PREMODIFICATION TEXT .01 This is the text of the supplementary report as it existed before it was modified. This field is updated by the software and can only be modified from programmer mode.

    		Word Processing
    AUTOPSY SPECIMEN 33 Autopsy organs and tissues are entered here for block and slide preparation, label printing and workload.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTOPSY SPECIMEN .01 Autopsy organs and tissues are entered here for block and slide preparation, label printing and workload.

    		Free Text
    PARAFFIN BLOCK 1 List of paraffin blocks prepared from autopsy organs/tissues.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    PARAFFIN BLOCK ID .01 The identification number on the paraffin block used to make slides for staining.

    		Free Text
    DATE/TIME BLOCK PREPARED .02 Date/time block prepared. Used for workload recording.

    		Date/Time
    BLOCK COUNTED .03 Used for workload recording.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    STAIN/PROCEDURE 1 List of tissue stains or procedures performed on the slides cut from the paraffin block.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    STAIN/PROCEDURE .01 A tissue stain or procedure performed on a slide cut from a paraffin block.

    		Pointer
    PointerTo:
    fileName:
    LABORATORY TEST
    fileNumber:
    60
    SLIDES PREPARED (#) .02 The number of slides for which a specific stain or procedure was performed.

    		Numeric
    CONTROL SLIDES (#) .03 Number of control slides prepared.

    		Numeric
    DATE/TIME SLIDES STAINED .04 Date slides were stained

    		Date/Time
    DATE/TIME SLIDES EXAMINED .05 Date slides were examined

    		Date/Time
    SLIDES COUNTED (#) .06 Last number of slides counted for workload.

    		Numeric
    LABELS TO PRINT .07 Amount of labels needed to print

    		Numeric
    NON-CONTROL SLIDES COUNTED .09 Number of non-control slides counted

    		Numeric
    AUTOPSY ICD CODE 80 These are the ICD codes on this autopsy.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTOPSY ICD CODE .01 This is the ICD code on this autopsy.

    		Pointer
    PointerTo:
    fileName:
    ICD DIAGNOSIS
    fileNumber:
    80
    MAJOR DIAGNOSTIC DISAGREEMENT 83.1 If major diagnostic disagreements between autopsy and clinical findings enter 'YES' else enter 'NO'.

    		Set of Codes
    Set of Codes:
    • Code : 0
      Stands For: NO
    • Code : 1
      Stands For: YES
    CLINICAL DIAGNOSIS CLARIFIED 83.2 If clinical dx insufficient (ex. intracranial hemorrhage) did autopsy clarify the dx (ex. ruptured aneurysm) ?

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO
    • Code : 2
      Stands For: CONFIRMED
    AUTOPSY QA CODE 99 Multiple for autopsy quality assurance code

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    AUTOPSY QA CODE .01 Quality assurance code for autopsy

    		Pointer
    PointerTo:
    fileName:
    LAB DESCRIPTIONS
    fileNumber:
    62.5
    ARCHIVE REFERENCE 100 These are references to archiving information.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    ARCHIVE REFERENCE .01 This points to the entry in the Laboratory site parameters file 69.9 in the Archive multiple to indicate where data is archived.

    		Numeric
    TIU REFERENCE DATE/TIME - AU 101 This multiple stores TIU information for corresponding SF515 autopsy reports that have been electronically signed and stored in TIU. This information is used to access the reports in TIU.

    		Subfile
    subfile:
    Name Number Description Data Type Field Specific Data
    TIU REFERENCE DATE/TIME - AU .01 This is the date and time that the autopsy SF515 was stored in TIU. It will match the REFERENCE DATE (#1301) field of the corresponding document in the TIU DOCUMENT (#8925) file.

    		Date/Time
    TIU ENTRY POINTER - AU 1 This field is a pointer to the TIU DOCUMENT (#8925) file. It stores the pointer for an autopsy SF515 that has been electronically signed and stored in TIU.

    		Pointer
    PointerTo:
    fileName:
    TIU DOCUMENT
    fileNumber:
    8925
    TIU CHECKSUM 2 This field stores the checksum that is calculated at the time the report version is initially stored in TIU. It will be used for comparison in future print/view requests. A new checksum will be calculated whenever the report version is printed/viewed, and matching checksums are proof that the report version has not been illegally altered.

    		Free Text
    DATE REPORT MODIFIED - AU 102 This is the date the report was modified if it was modified after it was electronically signed/released.

    		Date/Time
    PERSON MODIFYING TEXT 102.1 Stores the DUZ of the person who modified the report AFTER it was electronically signed/released.

    		Pointer
    PointerTo:
    fileName:
    NEW PERSON
    fileNumber:
    200
    DIAGNOSIS MODIFIED 102.2 1 = Diagnosis modified AFTER report was electronically signed/released.

    		Set of Codes
    Set of Codes:
    • Code : 1
      Stands For: YES
    • Code : 0
      Stands For: NO