| 1 | English French Notes Complete/Exclude
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| 2 | does not exist, AMIE Exam
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| 3 | Pension:
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| 4 | Claim Folder Loc:
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| 5 | ------- Admission data -------
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| 6 | Current
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| 7 | Prior
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| 8 | ------ Admission date -------
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| 9 | ---- Admitting diagnosis ----
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| 10 | ------- Discharge date -------
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| 11 | ------- Discharge type -------
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| 12 | -------- Bed Service ---------
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| 13 | PATIENT LOOKUP
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| 14 | Which would you prefer
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| 15 | has both Admission and Non Admission information.
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| 16 | 0,0,0,2,0^Searching file for existing 7131 requests for
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| 17 | 0,0,0,2:2,0^No selection made!
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| 18 | Select 1-
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| 19 | or '^' to Exit or Return to continue
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| 20 | Is this the correct information?
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| 21 | Display Admission or Activity information
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| 22 | Date Range will allow the user to select the specific dates.
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| 23 | All Dates will show the user all possible information.
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| 24 | 1,0,0,2,0^There is a 7131 already on file for
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| 25 | 0,0,0,1:1,0^Status is
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| 26 | Do you want to delete the existing 7131 for this date:
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| 27 | Answer YES or No. You may not have two 7131s for the same admission date.
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| 28 | Do you want to add a NEW 7131
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| 29 | 'YES' to enter a new 7131. 'NO' to search for an existing one.
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| 30 | Are you sure you want to edit this 7131 request:
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| 31 | 'YES' to edit the 7131 request.
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| 32 | 1,0,0,2,0^Unable to add this new record!
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| 33 | Enter Patient name:
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| 34 | 0,0,0,2:1,1^The following is a list of Admission dates for
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| 35 | 0,0,0,2:1,1^The following is a list of activity dates for
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| 36 | Stop Code(s)
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| 37 | 1,0,0,2:1,0^There is a problem with the Disposition Login information. Contact IRM
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| 38 | Disposition Login
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| 39 | Date Range
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| 40 | For REMOTE SITE (Press RETURN for all sites) :
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| 41 | Are you sure you want ALL REMOTE SITES:
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| 42 | Enter Y to get all remote sites N for just one
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| 43 | BEGINNING date:
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| 44 | ENDING date:
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| 45 | 1,0,0,2:2,0^Invalid dates! Ending must not be before beginning.
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| 46 | 0,0,0,3,0^Notice to MAS on
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| 47 | 0,0,0,1,0^There were no new 7131 requests
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| 48 | AMIE New Req for
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| 49 | 0,0,0,1:3,1^AMIE New Request Report
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| 50 | Amie new request rpt
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| 51 | CLAIM NO:
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| 52 | ACTIVITY DATE:
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| 53 | REQUEST DATE:
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| 54 | Items Requested:
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| 55 | (Not specified)
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| 56 | This record was FINALIZED on
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| 57 | **Request is incomplete, contact the Regional Office to complete**
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| 58 | Record Processing Notes:
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| 59 | AMIE 7131 NEW REQUEST REPORT FOR
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| 60 | * LONG VERSION *
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| 61 | , DIVISION NOT GIVEN
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| 62 | , UNABLE TO DETERMINE DIVISION
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| 63 | to stop
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| 64 | 0,0,0,4:1,0^AMIE 7131 NEW REQUEST REPORT FOR
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| 65 | **Long Version**
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| 66 | UNABLE TO DETERMINE
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| 67 | VARO 7131 NEW REQUEST REPORT FOR
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| 68 | * SHORT VERSION *
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| 69 | ACT/ADM DATE
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| 70 | DOCUMENT TYPE:
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| 71 | ** REGIONAL OFFICE MUST EDIT THE INCOMPLETE REQUEST LISTED ABOVE **
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| 72 | Select version
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| 73 | Long
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| 74 | ACTIVITY DATE
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| 75 | You have no user number.
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| 76 | 21-DAY CERTIFICATE TEXT ENTRY/EDITING
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| 77 | This record is now released.
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| 78 | DVBA 21-DAY CERT CLERK
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| 79 | You do not have the proper key to use this option.
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| 80 | Wrong request type !
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| 81 | This is an ACTIVITY DATE request, not ADMISSION DATE.
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| 82 | This request has already been FINALIZED and the text may not be changed.
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| 83 | No 21-day certificate has been requested for this Veteran.
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| 84 | This Veteran has a 21-day certificate requested but
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| 85 | it has not yet been processed.
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| 86 | This certificate has been released to the RO
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| 87 | but has not been printed.
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| 88 | and has already been printed.
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| 89 | but the status is unknown.
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| 90 | Admit date:
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| 91 | DVBA RELEASE 21-DAY CERT
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| 92 | Ok to release this 21-day certificate text
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| 93 | Enter Y to go ahead and release this certificate to the RO
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| 94 | or N to be able to make corrections and release later.
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| 95 | 7131 Report Requesting
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| 96 | Select Report:
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| 97 | initially mark the report as 'YES'. If the number is selected again then it
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| 98 | will be changed to 'NO' or vice versa
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| 99 | Vet already discharged - you cannot request Notice of Discharge.
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| 100 | Cannot select 'Notice of Discharge', 'Hospital Summary', 'Certificate (21-day)', or 'Admission Report' for an activity date.
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| 101 | The patient has no Claim Folder Location in the Patient File.
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| 102 | Notice of Discharge would not be returned.
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| 103 | The patient's Claim Folder Location has no Station Number in file #4.
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| 104 | Please check the Claim Folder Location and its entry in file #4.
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| 105 | 21 Day Certificate would not be returned.
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| 106 | 1,0,0,2,0^You have not selected any reports for this 7131 request
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| 107 | 0,0,0,1:2,0^or have selected number 4 but not entered any remarks.
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| 108 | );29Routing Location;.5;23///
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| 109 | Do you want to file this request
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| 110 | AMIE SITE PARAMETER EDITING
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| 111 | Enter SITE NAME:
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| 112 | VARO REPORT
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| 113 | FOR PENSION
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| 114 | SPECIAL
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| 115 | AMIE PENSION/A&A REPORT
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| 116 | REGIONAL OFFICE SPECIAL REPORT
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| 117 | FOR A&A AND PENSION
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| 118 | This report prints only Veterans receiving A&A or Pension.
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| 119 | Do you want (A)&A or (P)ension ?
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| 120 | Must be either A for A&A
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| 121 | or P for Pension or
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| 122 | or [RETURN] to escape.
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| 123 | (NOT COMPLETE)
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| 124 | Enter E to end,
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| 125 | to EXIT or RETURN to continue
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| 126 | Sort by Regional Office number
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| 127 | Enter Y to sort by the Regional Office number you
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| 128 | select or enter N to get ALL Regional Offices reported.
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| 129 | Regional Office number:
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| 130 | Must be 1-3 numbers.
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| 131 | The entry of future dates is NOT allowed.
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| 132 | Invalid date sequence. Beginning date must be before the ending date.
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| 133 | Admission date:
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| 134 | Finalized
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| 135 | Activity date:
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| 136 | You have no division code. Please contact the site manager.
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| 137 | Your division code is invalid.
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| 138 | Your division has no station number defined in the INSTITUTION file.
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| 139 | Please consult IRM to request a unique station number for your division.
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| 140 | DVBA;ADVB;DVBB;ADVB
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| 141 | Are you sure you want to DELETE the existing 7131 for this date
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|---|
| 142 | and log a NEW one
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|---|
| 143 | Enter Y to delete the finalized 7131 request that
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| 144 | exists for this date and log a new one.
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| 145 | Enter N to leave the existing 7131 as is.
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| 146 | Activity or admission date is missing ! Cannot reopen.
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| 147 | You may now enter a new 7131 for this date.
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| 148 | No site parameters have been setup in file 396.1.
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| 149 | Do you want (A)&A, (P)ension, (S)ervice-connected, or AL(L) discharges ? S//
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| 150 | Must be A for A&A, P for Pension, S for Service-connected, or L for All
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| 151 | SERVICE-CONNECTED
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| 152 | DISCHARGE REPORT
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|---|
| 153 | Are you sure you want to delete this request
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|---|
| 154 | 7131 entry deleted.
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| 155 | <Return to continue>
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| 156 | Notice of discharge
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| 157 | Hospital Summary
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|---|
| 158 | Certificate (21-day)
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|---|
| 159 | Other/Exam (Review Remarks)
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|---|
| 160 | Special Report
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| 161 | Competency Report
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|---|
| 162 | VA Form 21-2680
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| 163 | Asset Information
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| 164 | Admission Report
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| 165 | Beginning Date Care
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| 166 | Original processing date
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| 167 | Adm.
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| 168 | Act.
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| 169 | 1,0,0,2,0^Record is currently in use!
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| 170 | 1,0,0,2:2,0^There is no Admission or Non Admission information
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|---|
| 171 | for this date range!
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| 172 | 1,0,0,2:2,0^You must select a 7131 with Pending reports!
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| 173 | Activity Date:
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|---|
| 174 | 1,0,0,2,0^The admission you selected is an ASIH admission.
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| 175 | 0,0,0,1,0^This means the veteran was admitted from a Nursing
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| 176 | 0,0,0,1,0^ Home or Domiciliary. It is suggested that you
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| 177 | 0,0,0,1,0^ review the veteran's claim folder before requesting
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| 178 | 0,0,0,1,0^This parameter can be adjusted to allow the site to keep 2507 requests
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| 179 | 0,0,0,1,0^for up to 999 days. The site can not select to retain the requests
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| 180 | 0,0,0,1,0^for less than 120 days. Selection of a number of days between
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| 181 | 0,0,0,1:2,0^120 and 999 is the allowable response.
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| 182 | NOT a stand-alone program !
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| 183 | Eligibility data:
|
|---|
| 184 | Please review previous information entered as well as
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|---|
| 185 | entering additional REQUIRED information:
|
|---|
| 186 | RSaR
|
|---|
| 187 | RFXaR
|
|---|
| 188 | FXOaR
|
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| 189 | NJ3,0XOaR
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| 190 | SERVICE ENTRY DATE [LAST]
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|---|
| 191 | SERVICE SEPARATION DATE [LAST]
|
|---|
| 192 | Need to edit the information you've just entered
|
|---|
| 193 | Enter Y to go back and correct any errors or
|
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| 194 | you may enter N to proceed.
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| 195 | FaR
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| 196 | DAYS TO
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| 197 | FINALIZED BY
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| 198 | Requisition
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| 199 | Operator
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| 200 | Current Division
|
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| 201 | Notice/Discharge:
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| 202 | Hospital Summary:
|
|---|
| 203 | 21-day Certificate:
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|---|
| 204 | Other/Exam:
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|---|
| 205 | Special Report:
|
|---|
| 206 | Competency Report:
|
|---|
| 207 | Form 21-2680:
|
|---|
| 208 | Asset Information:
|
|---|
| 209 | Admission Report:
|
|---|
| 210 | OPT Treatment Rpt:
|
|---|
| 211 | Beg Date/Care:
|
|---|
| 212 | REMARKS:
|
|---|
| 213 | NOTICE/DISCHG STATUS
|
|---|
| 214 | P:PENDING;C:COMPLETED;
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| 215 | NOTICE/DISCHG COMPLETION DATE
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|---|
| 216 | EDIT4.5
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|---|
| 217 | Completed status must have date.
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|---|
| 218 | HOSPITAL SUMMARY STATUS
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|---|
| 219 | HOSP SUMMARY COMPLETION DATE
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| 220 | EDIT5.5
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| 221 | (21-DAY) CERTIFICATE STATUS
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|---|
| 222 | (21-DAY) COMPLETION DATE
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|---|
| 223 | EDIT6.5
|
|---|
| 224 | STATUS OF OTHER/EXAM
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|---|
| 225 | OTHER/EXAM COMPLETION DATE
|
|---|
| 226 | STATUS OF SPECIAL REPORT
|
|---|
| 227 | SPECIAL REPORT COMPLETION DATE
|
|---|
| 228 | STATUS OF COMPETENCY REPORT
|
|---|
| 229 | COMPETENCY RPT COMPLETION DATE
|
|---|
| 230 | STATUS OF VA FORM 21-2680
|
|---|
| 231 | FORM 21-2680 COMPLETION DATE
|
|---|
| 232 | STATUS OF ASSET INFORMATION
|
|---|
| 233 | ASSET INFO COMPLETION DATE
|
|---|
| 234 | ADMISSION REPORT STATUS
|
|---|
| 235 | ADMISSION RPT COMPLETION DATE
|
|---|
| 236 | EDIT17.4
|
|---|
| 237 | STATUS OF OPT TREATMENT RPT
|
|---|
| 238 | OPT TREAT RPT COMPLETION DATE
|
|---|
| 239 | STATUS-BEG DATE/CARE (CHAP 17)
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|---|
| 240 | BEG/DATE/CARE COMPLETION DATE
|
|---|
| 241 | DVBA*2.7*4 - APE x-ref cleanup process
|
|---|
| 242 | APE x-ref cleanup queued...task=
|
|---|
| 243 | DVBA*2.7*4
|
|---|
| 244 | Start Time of process:
|
|---|
| 245 | Results of search in DA^DFN^Request Date^Exam Type format
|
|---|
| 246 | No bad APE x-refs found!
|
|---|
| 247 | End Time:
|
|---|
| 248 | NOTHING WAS KILLED!! D EN^DVBAYAPE TO HAVE KILLS EXECUTED
|
|---|
| 249 | DVBA*2.7*4
|
|---|
| 250 | Diagnostic
|
|---|
| 251 | has run
|
|---|
| 252 | Department of Veterans Affairs
|
|---|
| 253 | Abbreviated
|
|---|
| 254 | Full
|
|---|
| 255 | Exam Worksheet
|
|---|
| 256 | ALIMENTARY APPENDAGES (DIGESTIVE)
|
|---|
| 257 | Date of exam: ____________________
|
|---|
| 258 | Place of exam: ___________________
|
|---|
| 259 | Type of Exam:
|
|---|
| 260 | Narrative:
|
|---|
| 261 | Detailed description of chronic, active symptomatology in the
|
|---|
| 262 | subjective complaints
|
|---|
| 263 | portion of this or the main examination is
|
|---|
| 264 | critical to the degree of disability assigned for the veteran.
|
|---|
| 265 | A. Medical history:
|
|---|
| 266 | B. Subjective complaints:
|
|---|
| 267 | C. Objective findings:
|
|---|
| 268 | Specific evaluation information required by the rating board
|
|---|
| 269 | (if the information requested is included elsewhere, do not
|
|---|
| 270 | repeat here):
|
|---|
| 271 | 1. Abdominal discomfort -
|
|---|
| 272 | 2. Food intolerance -
|
|---|
| 273 | 5. Degree of pain -
|
|---|
| 274 | 8. Weight loss -
|
|---|
| 275 | 9. Generalized weakness -
|
|---|
| 276 | Diagnostic/clinical test results:
|
|---|
| 277 | Diagnosis:
|
|---|
| 278 | Signature: ______________________________
|
|---|
| 279 | Date: _________________________
|
|---|
| 280 | Compensation and Pension Exam for
|
|---|
| 281 | When only pure tone results should be used to evaluate
|
|---|
| 282 | hearing loss, the Chief of the Audiology Clinic should
|
|---|
| 283 | certify that language difficulties or other problems make
|
|---|
| 284 | the use of both pure tone average and speech discrimination
|
|---|
| 285 | A. Audiological history:
|
|---|
| 286 | Pure tone thresholds at indicated frequencies (air conduction):
|
|---|
| 287 | ========== RIGHT EAR ========== + ========== LEFT EAR ===========
|
|---|
| 288 | * The pure tone threshold at 500 Hz is not currently used for evaluation
|
|---|
| 289 | purposes but is used in determining whether or not a ratable hearing
|
|---|
| 290 | loss exists.
|
|---|
| 291 | ** - average of B, C, D, and E
|
|---|
| 292 | Speech recognition score:
|
|---|
| 293 | 1. Maryland CNC word list _______ % right ear _______ % left ear
|
|---|
| 294 | 2. W-22 word list _______ % right ear _______ % left ear
|
|---|
| 295 | (Only if specifically requested by the regional office)
|
|---|
| 296 | Note whether tinnitus is present and if so, indicate the following:
|
|---|
| 297 | Date/circumstance of onset
|
|---|
| 298 | Unilateral vs bilateral
|
|---|
| 299 | Constant vs periodic (indicate frequency)
|
|---|
| 300 | Severity and effect on daily life
|
|---|
| 301 | Veteran account of loudness/pitch
|
|---|
| 302 | Note whether audiologic results indicate an ear or hearing problem
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
