English French Notes Complete/Exclude does not exist, AMIE Exam Pension: Claim Folder Loc: ------- Admission data ------- Current Prior ------ Admission date ------- ---- Admitting diagnosis ---- ------- Discharge date ------- ------- Discharge type ------- -------- Bed Service --------- PATIENT LOOKUP Which would you prefer has both Admission and Non Admission information. 0,0,0,2,0^Searching file for existing 7131 requests for 0,0,0,2:2,0^No selection made! Select 1- or '^' to Exit or Return to continue Is this the correct information? Display Admission or Activity information Date Range will allow the user to select the specific dates. All Dates will show the user all possible information. 1,0,0,2,0^There is a 7131 already on file for 0,0,0,1:1,0^Status is Do you want to delete the existing 7131 for this date: Answer YES or No. You may not have two 7131s for the same admission date. Do you want to add a NEW 7131 'YES' to enter a new 7131. 'NO' to search for an existing one. Are you sure you want to edit this 7131 request: 'YES' to edit the 7131 request. 1,0,0,2,0^Unable to add this new record! Enter Patient name: 0,0,0,2:1,1^The following is a list of Admission dates for 0,0,0,2:1,1^The following is a list of activity dates for Stop Code(s) 1,0,0,2:1,0^There is a problem with the Disposition Login information. Contact IRM Disposition Login Date Range For REMOTE SITE (Press RETURN for all sites) : Are you sure you want ALL REMOTE SITES: Enter Y to get all remote sites N for just one BEGINNING date: ENDING date: 1,0,0,2:2,0^Invalid dates! Ending must not be before beginning. 0,0,0,3,0^Notice to MAS on 0,0,0,1,0^There were no new 7131 requests AMIE New Req for 0,0,0,1:3,1^AMIE New Request Report Amie new request rpt CLAIM NO: ACTIVITY DATE: REQUEST DATE: Items Requested: (Not specified) This record was FINALIZED on **Request is incomplete, contact the Regional Office to complete** Record Processing Notes: AMIE 7131 NEW REQUEST REPORT FOR * LONG VERSION * , DIVISION NOT GIVEN , UNABLE TO DETERMINE DIVISION to stop 0,0,0,4:1,0^AMIE 7131 NEW REQUEST REPORT FOR **Long Version** UNABLE TO DETERMINE VARO 7131 NEW REQUEST REPORT FOR * SHORT VERSION * ACT/ADM DATE DOCUMENT TYPE: ** REGIONAL OFFICE MUST EDIT THE INCOMPLETE REQUEST LISTED ABOVE ** Select version Long ACTIVITY DATE You have no user number. 21-DAY CERTIFICATE TEXT ENTRY/EDITING This record is now released. DVBA 21-DAY CERT CLERK You do not have the proper key to use this option. Wrong request type ! This is an ACTIVITY DATE request, not ADMISSION DATE. This request has already been FINALIZED and the text may not be changed. No 21-day certificate has been requested for this Veteran. This Veteran has a 21-day certificate requested but it has not yet been processed. This certificate has been released to the RO but has not been printed. and has already been printed. but the status is unknown. Admit date: DVBA RELEASE 21-DAY CERT Ok to release this 21-day certificate text Enter Y to go ahead and release this certificate to the RO or N to be able to make corrections and release later. 7131 Report Requesting Select Report: initially mark the report as 'YES'. If the number is selected again then it will be changed to 'NO' or vice versa Vet already discharged - you cannot request Notice of Discharge. Cannot select 'Notice of Discharge', 'Hospital Summary', 'Certificate (21-day)', or 'Admission Report' for an activity date. The patient has no Claim Folder Location in the Patient File. Notice of Discharge would not be returned. The patient's Claim Folder Location has no Station Number in file #4. Please check the Claim Folder Location and its entry in file #4. 21 Day Certificate would not be returned. 1,0,0,2,0^You have not selected any reports for this 7131 request 0,0,0,1:2,0^or have selected number 4 but not entered any remarks. );29Routing Location;.5;23/// Do you want to file this request AMIE SITE PARAMETER EDITING Enter SITE NAME: VARO REPORT FOR PENSION SPECIAL AMIE PENSION/A&A REPORT REGIONAL OFFICE SPECIAL REPORT FOR A&A AND PENSION This report prints only Veterans receiving A&A or Pension. Do you want (A)&A or (P)ension ? Must be either A for A&A or P for Pension or or [RETURN] to escape. (NOT COMPLETE) Enter E to end, to EXIT or RETURN to continue Sort by Regional Office number Enter Y to sort by the Regional Office number you select or enter N to get ALL Regional Offices reported. Regional Office number: Must be 1-3 numbers. The entry of future dates is NOT allowed. Invalid date sequence. Beginning date must be before the ending date. Admission date: Finalized Activity date: You have no division code. Please contact the site manager. Your division code is invalid. Your division has no station number defined in the INSTITUTION file. Please consult IRM to request a unique station number for your division. DVBA;ADVB;DVBB;ADVB Are you sure you want to DELETE the existing 7131 for this date and log a NEW one Enter Y to delete the finalized 7131 request that exists for this date and log a new one. Enter N to leave the existing 7131 as is. Activity or admission date is missing ! Cannot reopen. You may now enter a new 7131 for this date. No site parameters have been setup in file 396.1. Do you want (A)&A, (P)ension, (S)ervice-connected, or AL(L) discharges ? S// Must be A for A&A, P for Pension, S for Service-connected, or L for All SERVICE-CONNECTED DISCHARGE REPORT Are you sure you want to delete this request 7131 entry deleted. Notice of discharge Hospital Summary Certificate (21-day) Other/Exam (Review Remarks) Special Report Competency Report VA Form 21-2680 Asset Information Admission Report Beginning Date Care Original processing date Adm. Act. 1,0,0,2,0^Record is currently in use! 1,0,0,2:2,0^There is no Admission or Non Admission information for this date range! 1,0,0,2:2,0^You must select a 7131 with Pending reports! Activity Date: 1,0,0,2,0^The admission you selected is an ASIH admission. 0,0,0,1,0^This means the veteran was admitted from a Nursing 0,0,0,1,0^ Home or Domiciliary. It is suggested that you 0,0,0,1,0^ review the veteran's claim folder before requesting 0,0,0,1,0^This parameter can be adjusted to allow the site to keep 2507 requests 0,0,0,1,0^for up to 999 days. The site can not select to retain the requests 0,0,0,1,0^for less than 120 days. Selection of a number of days between 0,0,0,1:2,0^120 and 999 is the allowable response. NOT a stand-alone program ! Eligibility data: Please review previous information entered as well as entering additional REQUIRED information: RSaR RFXaR FXOaR NJ3,0XOaR SERVICE ENTRY DATE [LAST] SERVICE SEPARATION DATE [LAST] Need to edit the information you've just entered Enter Y to go back and correct any errors or you may enter N to proceed. FaR DAYS TO FINALIZED BY Requisition Operator Current Division Notice/Discharge: Hospital Summary: 21-day Certificate: Other/Exam: Special Report: Competency Report: Form 21-2680: Asset Information: Admission Report: OPT Treatment Rpt: Beg Date/Care: REMARKS: NOTICE/DISCHG STATUS P:PENDING;C:COMPLETED; NOTICE/DISCHG COMPLETION DATE EDIT4.5 Completed status must have date. HOSPITAL SUMMARY STATUS HOSP SUMMARY COMPLETION DATE EDIT5.5 (21-DAY) CERTIFICATE STATUS (21-DAY) COMPLETION DATE EDIT6.5 STATUS OF OTHER/EXAM OTHER/EXAM COMPLETION DATE STATUS OF SPECIAL REPORT SPECIAL REPORT COMPLETION DATE STATUS OF COMPETENCY REPORT COMPETENCY RPT COMPLETION DATE STATUS OF VA FORM 21-2680 FORM 21-2680 COMPLETION DATE STATUS OF ASSET INFORMATION ASSET INFO COMPLETION DATE ADMISSION REPORT STATUS ADMISSION RPT COMPLETION DATE EDIT17.4 STATUS OF OPT TREATMENT RPT OPT TREAT RPT COMPLETION DATE STATUS-BEG DATE/CARE (CHAP 17) BEG/DATE/CARE COMPLETION DATE DVBA*2.7*4 - APE x-ref cleanup process APE x-ref cleanup queued...task= DVBA*2.7*4 Start Time of process: Results of search in DA^DFN^Request Date^Exam Type format No bad APE x-refs found! End Time: NOTHING WAS KILLED!! D EN^DVBAYAPE TO HAVE KILLS EXECUTED DVBA*2.7*4 Diagnostic has run Department of Veterans Affairs Abbreviated Full Exam Worksheet ALIMENTARY APPENDAGES (DIGESTIVE) Date of exam: ____________________ Place of exam: ___________________ Type of Exam: Narrative: Detailed description of chronic, active symptomatology in the subjective complaints portion of this or the main examination is critical to the degree of disability assigned for the veteran. A. Medical history: B. Subjective complaints: C. Objective findings: Specific evaluation information required by the rating board (if the information requested is included elsewhere, do not repeat here): 1. Abdominal discomfort - 2. Food intolerance - 5. Degree of pain - 8. Weight loss - 9. Generalized weakness - Diagnostic/clinical test results: Diagnosis: Signature: ______________________________ Date: _________________________ Compensation and Pension Exam for When only pure tone results should be used to evaluate hearing loss, the Chief of the Audiology Clinic should certify that language difficulties or other problems make the use of both pure tone average and speech discrimination A. Audiological history: Pure tone thresholds at indicated frequencies (air conduction): ========== RIGHT EAR ========== + ========== LEFT EAR =========== * The pure tone threshold at 500 Hz is not currently used for evaluation purposes but is used in determining whether or not a ratable hearing loss exists. ** - average of B, C, D, and E Speech recognition score: 1. Maryland CNC word list _______ % right ear _______ % left ear 2. W-22 word list _______ % right ear _______ % left ear (Only if specifically requested by the regional office) Note whether tinnitus is present and if so, indicate the following: Date/circumstance of onset Unilateral vs bilateral Constant vs periodic (indicate frequency) Severity and effect on daily life Veteran account of loudness/pitch Note whether audiologic results indicate an ear or hearing problem #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################