| 1 | English French Notes Complete/Exclude
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| 2 | collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including
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| 3 | suggestions for reducing this burden to VA Clearance Officer (045A4), 810 Vermont Avenue, NW, Washington, DC 20420.
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| 4 | PRIVACY ACT NOTICE: The information requested on this form is solicited under authority of Title 38, U.S.C., Sections 710, 1712
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| 5 | and 1722. It is being collected to enable us to determine your eligibility for medical benefits, identify your medical records,
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| 6 | and provide basic data for your treatment. Additional information, such as medical history, may be solicited during the course of
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| 7 | your medical evaluation or treatment. The income and eligibility information you supply may be verified through a computer
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| 8 | matching program at any time and information may be disclosed outside VA as permitted by law; possible disclosures include
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| 9 | those described in the
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| 10 | routine uses
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| 11 | identified in the VA system of records 24VA136, Patient Medical Records-VA, published
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| 12 | in the Federal Register in accordance with the Privacy Act of 1974. These
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| 13 | include disclosures: in response
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| 14 | to court subpoenas; to epidemiological and other research facilities for research purposes; in connection with collections
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| 15 | of amounts owed to the United States; to the Department of Justice for use in litigation; to other Federal agencies in connection
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| 16 | with their employment determinations, investigations, or issuance of licenses or benefits; to report apparent law violations to
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| 17 | other Federal, State or local agencies charged with law enforcement responsibilities; in response to an official request from a
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| 18 | criminal or civil law enforcement governmental agency charged with the protection of public health or safety; to the Internal
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| 19 | Revenue Service to verify unearned income, collect amounts owed VA, and to report as income debts that are waived, compromised or
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| 20 | otherwise forgiven; to the Social Security Administration to verify earned income and employment data; to notify State licensing
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| 21 | boards and Federal agencies of the health care practices of health care providers; to non-VA health care providers; to non-VA
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| 22 | health care providers of facilities when the patient is referred for medical care at VA expense; to private sector organizations
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| 23 | for the purpose of obtaining accreditation or approval rating for the health care facility; to non-VA nursing homes for
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| 24 | preadmission screening; or, to contractors to perform the services covered by the contract. Disclosure is voluntary, however,
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| 25 | failure to furnish the information will result in our inability to process your request and serve your medical needs.
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| 26 | Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.
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| 27 | Disclosure of the Social Security number(s) of those for whom benefits are claimed is requested under the authority of
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| 28 | Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veteran's benefits,
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| 29 | in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for
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| 30 | other purposes where authorized by both Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where
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| 31 | required by another statute.
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| 32 | STREET ADDRESS [LINE 1]
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| 33 | STREET ADDRESS [LINE 2]
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| 34 | K-ADDRESS SAME AS PATIENT'S?
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| 35 | K-STREET ADDRESS [LINE 1]
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| 36 | K-STREET ADDRESS [LINE 2]
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| 37 | K-STREET ADDRESS [LINE 3]
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| 38 | FXa
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| 39 | K-PHONE NUMBER
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| 40 | K-WORK PHONE NUMBER
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| 41 | E-EMER. CONTACT SAME AS NOK?
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| 42 | E-RELATIONSHIP TO PATIENT
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| 43 | E-STREET ADDRESS [LINE 1]
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| 44 | E-STREET ADDRESS [LINE 2]
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| 45 | E-STREET ADDRESS [LINE 3]
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| 46 | E-PHONE NUMBER
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| 47 | E-WORK PHONE NUMBER
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| 48 | SERVICE BRANCH [LAST]
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| 49 | DIC(23,
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| 50 | SERVICE NUMBER [LAST]
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| 51 | CURRENT PH INDICATOR
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| 52 | CURRENT PURPLE HEART STATUS
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| 53 | 1:PENDING;2:IN PROCESS;3:CONFIRMED;
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| 54 | PH DIVISION
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| 55 | CURRENT PURPLE HEART REMARKS
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| 56 | 1:UNACCEPTABLE DOCUMENTATION;2:NO DOCUMENTATION REC'D;3:ENTERED IN ERROR;4:UNSUPPORTED PURPLE HEART;5:VAMC;6:UNDELIVERABLE MAIL;
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| 57 | ENVIRONMENTAL CONTAMINANTS?
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| 58 | DISABILITY RET. FROM MILITARY?
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| 59 | 0:NO;1:YES, RECEIVING MILITARY RETIREMENT;2:YES, RECEIVING MILITARY RETIREMENT IN LIEU OF VA COMPENSATION;3:UNKNOWN;
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| 60 | DIC(21,
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| 61 | STREET ADDRESS [LINE 3]
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| 62 | PHONE NUMBER [RESIDENCE]
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| 63 | BAD ADDRESS INDICATOR
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| 64 | 1:UNDELIVERABLE;2:HOMELESS;3:OTHER;
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| 65 | K-NAME OF PRIMARY NOK
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| 66 | K-RELATIONSHIP TO PATIENT
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| 67 | CONFIDENTIAL ADDRESS DATA, SCREEN <
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| 68 | UNK. CITY/STATE
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| 69 | SC AWARD DATE
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| 70 | RATED INCOMPETENT?
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| 71 | DATE RULED INCOMPETENT (CIVIL)
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| 72 | DATE RULED INCOMPETENT (VA)
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| 73 | CLAIM FOLDER LOCATION
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| 74 | TOTAL ANNUAL VA CHECK AMOUNT
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| 75 | GI INSURANCE POLICY?
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| 76 | SERVICE CONNECTED CONDITIONS
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| 77 | AMOUNT OF GI INSURANCE
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| 78 | Applicant doesn't have GI Insurance.
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| 79 | AGENCY/ALLIED COUNTRY
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| 80 | DIC(35,
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| 81 | RECALLED TO ACTIVE DUTY
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| 82 | 0:NO;1:NATIONAL GUARD;2:RESERVES;
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| 83 | DIC(25002.1,
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| 84 | Variable DGDR must be defined!
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| 85 | Executing HL7 ADT Messaging (RAI/MDS)
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| 86 | HL7 ADT MESSAGE (RAI/MDS)
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| 87 | VAFH(
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| 88 | From ASIH
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| 89 | Unable to determine wards for transfer cancellation
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| 90 | -1^Server Protocol not found
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| 91 | -1^Unable to build segment list to transmit
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| 92 | -1^An error occurred in one of the segments
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| 93 | RAI/MDS HL7 MESSAGE XMIT
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| 94 | RAI/MDS APPLICATION
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| 95 | DGRU HL7SND
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| 96 | RAI/MDS HL7 ADT ERROR
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| 97 | DGRU RAI ERROR
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| 98 | DGRU-RAI-A03-SERVER
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| 99 | -1^Unable to build segment list
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| 100 | -1^Error while building segment
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| 101 | The field
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| 102 | is missing data.
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| 103 | Service of ward must be the same as bedsection
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| 104 | A RUG-II GROUP CAN NOT BE DETERMINED ON THIS PATIENT
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| 105 | Do you wish to edit now
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| 106 | There are fields missing data for this patient. The PAI will
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| 107 | not be complete until all data is entered. You can
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| 108 | complete the PAI at this time by responding 'Y'es.
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| 109 | RUG-II GROUP:
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| 110 | HIERARCHY GROUP:
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| 111 | HEAVY REHABILITATION
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| 112 | SPECIAL CARE
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| 113 | CLINICAL COMPLEX
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| 114 | ADL SUM:
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| 115 | RUG-II WWUs:
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| 116 | DG RUG CLOSE PAI
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| 117 | Close this record now
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| 118 | If 'TUBE FEEDING' or 'PARENTERAL FEEDING'
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| 119 | is marked 'Y'es then question 'EATING' must be marked '5'.
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| 120 | If 'TUBE FEEDING' and 'PARENTERAL FEEDING'
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| 121 | are marked 'N'o then question 'EATING' must not be marked '5'.
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| 122 | If 'TUBE FEEDING'
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| 123 | is marked 'Y'es then question 'TUBE FEEDING ROUTE' must not be marked '1'.
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| 124 | If 'CHRONIC VENTILATOR DEP. (CVD)' is marked 'N'o then all CVD related
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| 125 | questions must be marked '1'.
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| 126 | For each of the therapy questions,'DAYS PER WEEK' and 'HOURS PER WEEK' must be '0' if level is '1'.
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| 127 | and 'HOURS/MINUTES PER WEEK' must be greater than 29 minutes if level is
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| 128 | greater than '1'.
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| 129 | Can not have more than 10 hours of therapy per day
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| 130 | If 'NASAL OR ENTERIC FEEDING'
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| 131 | if level is greater than '1'.
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| 132 | PATIENT ASSESSMENT INSTRUMENTS HAVE BEEN CREATED FOR THE FOLLOWING PATIENTS
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| 133 | DUE TO ADMISSION/TRANSFER IN
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| 134 | DATE OF ADMISSION/TRANSFER IN
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| 135 | There was an attempt to set up a PAI record on
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| 136 | Please verify that this patient's data is accurate and create a PAI record.
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| 137 | ADT/HL7 MDS COTS UPDATE
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| 138 | COTS UPDATE
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| 139 | EVENT-NUM
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| 140 | VAR-PTR
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| 141 | -1^Could not find entry in PATIENT file
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| 142 | DGRU-PATIENT-A08-SERVER
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| 143 | RAI/MDS HL7 BUILD ERROR
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| 144 | Select PATIENT ADMISSION:
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| 145 | (A)dmission/transfer or (S)emi Annual Census: A//
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| 146 | A - Assessment purpose is admission transfer
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| 147 | S - Assessment purpose is semi-annual census
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| 148 | NEITHER ADMISSION NOR TRANSFERS ARE TO INTERMEDIATE CARE OR NURSING HOME WARDS
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| 149 | AFTER THE LAST CLOSEOUT
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| 150 | There is already an admission/transfer assessment created for that
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| 151 | admission/transfer date
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| 152 | FBAAV(
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| 153 | Record Deleted.
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| 154 | ADMISSION/TRANSFER DATE:
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| 155 | ASSESSMENT RECORD CREATED
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| 156 | THERE ARE NO ADMISSIONS ON FILE FOR THIS PATIENT
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| 157 | Assessment date:
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| 158 | Enter the PAF record to reopen:
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| 159 | Ok to reopen
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| 160 | Enter PAF record to delete:
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| 161 | Ok to delete
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| 162 | PAF record
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| 163 | Answer YES or NO
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| 164 | Enter PAF record to close:
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| 165 | Ok to close
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| 166 | ANSWER 'Y'ES OR 'N'O
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| 167 | -- ADMISSION DATE
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| 168 | '^' TO EXIT
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| 169 | RETURN FOR MORE CHOICES
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| 170 | There is already a PAF entry for that date.
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| 171 | Assessment date must be within a month of the semi-annual census date
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| 172 | The assessment date must not be before the date of admission/transfer in.
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| 173 | Assessment date can not be changed to after the RUG17 conversion date. Must remain before
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| 174 | Assessment date can not be changed to prior to conversion. Date must be on or after
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| 175 | Can not have more than 59 minutes of therapy
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| 176 | DG RUG SUPERVISOR
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| 177 | RUG-II
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| 178 | This option will send the RUG/PAI data to the Austin DPC.
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| 179 | REPLY (Y)ES OR (N)O
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| 180 | Survey purpose: (A)dmission/transfer & CNH or (S)emi-annual?
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| 181 | ASSESSMENT START DATE:
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| 182 | You must have transmission turned on to Q-
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| 183 | and off for Q-
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| 184 | Transmission is presently turned on to:
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| 185 | Transmission is turned on to the wrong queue. Can not proceed at this time.
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| 186 | Enter '^' at the device prompt to leave this option.
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| 187 | Depending on type of survey being transmitted enter
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| 188 | A - Admission/Transfer and CNH PAI Surveys
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| 189 | S - Semi-annual PAI survey
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| 190 | Start date must be within current closeout cycle.
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| 191 | Date must not be before
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| 192 | Can not transmit for future dates
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| 193 | You can not overlap the RUG17 Conversion date.
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| 194 | Dates must both be prior to or after
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| 195 | Enter Yes to continue or No to quit
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| 196 | Enter the Division you want to do Data Seeding for
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| 197 | Select the division you want to load the patient data for into the COTS database.
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| 198 | You have selected:
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| 199 | Station Number :
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| 200 | Enter Yes or No. Yes will select, No will cancel.
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| 201 | RAI/MDS DATA SEED FOR DIVISION
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| 202 | ** The data seed process was not tasked **
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| 203 | The data seed process has been tasked (#
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| 204 | DGRU-RAI-A01-SERVER
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| 205 | Looping through ward
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| 206 | -- Last DFN sent was
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| 207 | Task stopped as requested
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| 208 | Task ran to completion
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| 209 | Enter the patient you want to data seed:
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| 210 | Select the patient you want to load into the COTS database.
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| 211 | You cannot proceed with this patient
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| 212 | You may select another patient or quit.
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| 213 | Enter Yes or No. Yes will select this patient. No will cancel the selection of this patient.
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| 214 | Select another patient?
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| 215 | Enter Yes or No. Yes will allow you to select another patient.
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| 216 | is not in an RAI ward.
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| 217 | is not an active patient in an RAI ward.
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| 218 | Sending message...
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| 219 | You are about to enter national fiscal year RUG values. All entries must be
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| 220 | completed, otherwise those that you have entered will be deleted.
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| 221 | Enter fiscal year (4 digits):
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| 222 | WWU value not assigned
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| 223 | Do you want to enter these values now
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| 224 | WARNING: All existing WWU values for fiscal year
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| 225 | will be deleted. OK to continue
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| 226 | Enter RUG
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| 227 | Enter fiscal year (4 digits) from which you want RUG-II WWU values.
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| 228 | Must not precede 1987.
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| 229 | Sort by (A)ssessment or (T)ransfer/Admission Date: T//
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| 230 | A - Date range for the search is by Assessment Date
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| 231 | T - Date range is by Transfer or admission date
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| 232 | RUG group
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| 233 | Enter Category:
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| 234 | ALL//
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| 235 | Enter a category or 'return' when all categories
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| 236 | have been selected
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| 237 | You have selected output for:
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| 238 | Assessment
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| 239 | Transfer/Admission
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| 240 | dates between
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| 241 | Patients:
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| 242 | Divisions for Wards:
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| 243 | Wards:
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| 244 | CNH Locations:
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| 245 | RUG-II Groups:
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| 246 | This output requires 132 columns!
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| 247 | ***RUG-II INDEX REPORTS--NO MATCHES FOUND***
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| 248 | Choose from (H)eavy Rehabilitation, (S)pecial Care, (C)linical Complex
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| 249 | RUG-II INDEX REPORT
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| 250 | BY ADMISSION/TRANSFER DATE
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| 251 | BY ASSESSMENT DATE
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| 252 | RUN ON:
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| 253 | DATE/PURPOSE
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| 254 | HEAVY REHAB
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| 255 | CLIN COMPLEX
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| 256 | CURRENT STATUS:
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| 257 | ** = Absent from ward
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| 258 | ASSESSMENT PURPOSE:
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| 259 | S-A = Semi-annual census
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| 260 | CNH = Contract Nursing Home
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| 261 | HISTOGRAM FOR
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| 262 | ALL LOCATIONS
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| 263 | FOR PERIOD COVERING:
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| 264 | PERCENTAGE OF PATIENTS IN GROUP
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| 265 | RUG
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| 266 | DGRU-RAI-MFU-SERVER
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| 267 | NURSING UNIT
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| 268 | ADMISSION/TRANSFER
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| 269 | SEMI-ANNUAL CENSUS
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| 270 | CONTRACT NURSING HOME
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| 271 | INCOMPLETE PATIENT ASSESSMENT INSTRUMENTS
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| 272 | No location listed in Patient Assessment File for:
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| 273 | HIT <RETURN> TO CONTINUE
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| 274 | INCOMPLETE PATIENT ASSESSMENTS
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| 275 | THERE ARE NO PATIENTS WITH THE STATUS OF INCOMPLETE
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| 276 | FOR DATE RANGE:
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| 277 | DATE PRINTED:
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| 278 | FOR LOCATIONS:
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| 279 | ALL Contract Nursing Homes
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| 280 | ALL Wards
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| 281 | (A)SSESSMENT OR (T)RANSFER/ADMISSION DATE: ASSESSMENT//
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| 282 | A - Sort by Assessment date range
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| 283 | T - Sort by Transfer in/Admission date range
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| 284 | TIME PER WEEK==> DAYS:
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| 285 | 1 - HEAVY REHABILITATION
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| 286 | 2 - SPECIAL CARE
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| 287 | 3 - CLINICAL COMPLEX
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| 288 | >>>>PATIENT ASSESSMENT INSTRUMENT<<<<
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| 289 | RUG-II GROUP:
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| 290 | ADL SUM:
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| 291 | YEAR OF BIRTH:
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| 292 | ASSESSMENT DATE:
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| 293 | RUG-II WWUs:
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| 294 | ASSESSMENT PURPOSE:
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| 295 | 2 SEMI-ANNUAL CENSUS
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| 296 | 3 CONTRACT NURSING HOME
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| 297 | DATE OF ADMISSION/TRANSFER IN:
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| 298 | RECORD STATUS:
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| 299 | MEDICAL CENTER CODE:
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| 300 | BED SECTION:
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| 301 | -INTERMEDIATE MED.
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| 302 | -NURSING HOME CARE
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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