[604] | 1 | English French Notes Complete/Exclude
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| 2 | history and all appropriate laboratory studies.
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| 3 | Note:
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| 4 | A. Medical history
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| 5 | a. Removal of, complete/imcomplete (if incomplete,
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| 6 | state if pregnancy is prevented) -
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| 7 | b. Prolapse of, complete through vulva/imcomplete -
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| 8 | c. Displacement of; also identify adhesions and irregular
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| 9 | a. Removal of both -
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| 10 | b. Removal of one with or without partial removal
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| 11 | of the other -
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| 12 | c. Atrophy of one or both ovaries, complete -
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| 13 | 3. Rectal and rectovaginal; identify any surgical complications
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| 14 | of pregnancy -
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| 15 | 4. If a malignant process has been present within the past year,
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| 16 | give the date of the last surgical, radiation or chemical
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| 17 | 5. If a tubercular or other mycobacterial infection has been treated
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| 18 | within the past year, give the date of inactivity -
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| 19 | 6. Has a voluntary sterilization procedure been performed? -
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| 20 | OTHER GENITOURINARY
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| 21 | In original claims, particularly pension cases, and in
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| 22 | reopened claims in which the evidence on hand at the time
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| 23 | the examination request is prepared does not establish the
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| 24 | exact diagnosis, the nature of the disability will generally
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| 25 | be expressed in the most general terms, usually in the veteran's
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| 26 | own words (e.g.
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| 27 | kidney condition
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| 28 | bladder problem
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| 29 | can't hold water
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| 30 | , etc). In such cases it is
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| 31 | the responsibility of the general medical examiner to conduct
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| 32 | or order to be conducted such special examinations as may be
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| 33 | necessary, both to diagnose the underlying disorder, and
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| 34 | to provide the information that the rating board must have to
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| 35 | apply the examiner's findings to the rating schedule. Once
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| 36 | a definitive diagnosis is established, the examiner need only to
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| 37 | report history, clinical findings, and laboratory tests for
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| 38 | evaluation purposes. Complications and/or medical side effects
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| 39 | should always be reported, even when not specifically requested.
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| 40 | A. Medical History: No medical history for this exam
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| 41 | E. Diagnostic/clinical test results:
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| 42 | For GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 43 | Type of Exam: GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 44 | HYPERTHYROIDISM, THYROID ADENOMA
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| 45 | 1. Mental assessment -
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| 46 | 2. Muscular weakness -
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| 47 | 3. Loss of weight -
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| 48 | 4. Thyroid enlargement -
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| 49 | 7. Disease in remission or demonstrably active -
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| 50 | 8. Marked disfigurement (including appearance and texture
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| 51 | of thyroidectomy scar, if present) -
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| 52 | 9. Continuous medication required -
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| 53 | 2. Nervous, cardiovascular, or gastrointestinal symptoms -
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| 54 | 4. Mental assessment -
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| 55 | 5. Continuous medication required -
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| 56 | For HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 57 | Type of Exam: HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 58 | HEMATOLOGIC DISORDERS-LYMPHATIC
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| 59 | As with other disorders, a careful history and complete
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| 60 | physical examination are of first importance in hematologic
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| 61 | disorders. However, laboratory evaluation is often necessary
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| 62 | for a definitive diagnosis.
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| 63 | 1. State whether the disease is currently active or in remission and
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| 64 | if in remission, whether maintenance chemotherapy is required -
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| 65 | 2. Describe frequency and duration of acute attacks -
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| 66 | 3. Describe the state of general health between acute attacks -
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| 67 | 4. If the veteran is, or has been receiving chemotherapy, X-Ray or
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| 68 | surgical treatment for Hodgkin's disease or other form of lymphoma,
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| 69 | give date of last treatment -
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| 70 | 5. If veteran has been treated for any tuberculous adenitis (or
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| 71 | adenitis due to any other mycobacterial infection) and the disease
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| 72 | is currently inactive, give date the inactivity was first shown -
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| 73 | Invalid Patient name or DFN
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| 74 | Invalid Segment Type
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| 75 | Not a valid DHCP user number.
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| 76 | Invalid Patient ID, No SSN
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| 77 | Invalid Patient ID, Wrong SSN Format
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| 78 | Invalid Patient Identifier
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| 79 | Ambiguous Patient identifier
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| 80 | No 2507 request on file for this Patient
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| 81 | Invalid Patient identifier
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| 82 | No Exams or Open Exams on file for this Patient
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| 83 | No Electronic Signature code present, updating cannot be allowed.
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| 84 | Missing PID Segment
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| 85 | Incorrect PID Segment indicator
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| 86 | Internal Patient ID Missing
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| 87 | Patient Name Invalid
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| 88 | Patient SSN Invalid
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| 89 | Incorrect Patient Identifier
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| 90 | Invalid SSN
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| 91 | Missing OBR Segment
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| 92 | Missing Universal Identifier
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| 93 | Missing Exam Type
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| 94 | Missing Report Date
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| 95 | Request No longer Exists
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| 96 | Status of Request will not allow for down loading
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| 97 | Exam No longer Exists
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| 98 | Exam status not open, no down loading allow* ed
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| 99 | Bad electronic signature code.
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| 100 | Electronic signature codes do not match, no down loading allowed
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| 101 | Invalid OBX Segment
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| 102 | Results added but request and exam status not updated.
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| 103 | Kurzweil
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| 104 | Results added and exam status updated but request status not updated.
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| 105 | Record currently accessed by another user
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| 106 | Exam currently being accessed by another user
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| 107 | HEMATOLOGIC DISORDERS - BLOOD
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| 108 | disorders; however, laboratory evaluation is often necessary
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| 109 | HAND, THUMB, AND FINGERS
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| 110 | The hand should be evaluated as a unit intricately adapted
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| 111 | for grasping, pushing, pulling, twisting, probing, writing,
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| 112 | touching, and expression. Do not designate fingers numerically;
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| 113 | use thumb, index,
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| 114 | middle, ring and little. Specify which hand is
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| 115 | involved and state whether the individual is right or left-handed.
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| 116 | Designate the joints as wrist, MP (metacarpophalangeal), PIP,
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| 117 | (proximal interphalangeal) or DIP (distal interphalangeal).
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| 118 | Designate phalanges as proximal, middle or distal.
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| 119 | 1. Anatomical defects -
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| 120 | 2. Functional defects (motion of thumb and fingers should be described
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| 121 | as to how near, in inches, the tip of thumb can approximate the
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| 122 | fingers, or how near the tips of fingers can
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| 123 | approximate the median
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| 124 | transverse fold of the palm.) -
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| 125 | 3. Grasping objects (strength and dexterity) -
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| 126 | Loss of range of motion of the hip will be recorded from
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| 127 | the anatomical position (0 degrees) varying from 125 degrees
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| 128 | in flexion to 30 degrees in extension, from 25 degrees in
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| 129 | adduction to 45 degrees
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| 130 | in abduction, and from 60 degrees in
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| 131 | external rotation to 40 degrees in internal rotation. To gain
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| 132 | a true picure of hip flexion, i.e. movement between the pelvis
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| 133 | and femur in the hip joint, the opposide thigh should be
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| 134 | extended to minimize motion between the pelvis and spine.
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| 135 | 1. Describe movements of the thigh as it may rotate
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| 136 | in a circular manner about the femoral head in the
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| 137 | acetabulum. Discuss any pain, tenderness, weakness
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| 138 | and fatigue on standing and any unusual motions on
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| 139 | ORIGINAL SC
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| 140 | ORIGINAL NSC
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| 141 | INSUFFICIENT EXAM
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| 142 | PENDING, REPORTED
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| 143 | PENDING SCHEDULED
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| 144 | RELEASED TO RO, NOT PRINTED
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| 145 | COMPLETED, PRINTED BY RO
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| 146 | CANCELLED BY MAS
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| 147 | CANCELLED BY RO
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| 148 | NEW, TRANSFERRED IN
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| 149 | COMPLETED, TRANSFERRED OUT
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| 150 | There should be at least three blood pressure readings
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| 151 | in the sitting position spaced throughout the examination.
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| 152 | At times it may be necessary to recall the veteran on
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| 153 | subsequent days to obtain readings which are most
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| 154 | representative of the true blood pressure.
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| 155 | 1. Blood pressure readings:
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| 156 | 3. Enlarged heart confirmation -
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| 157 | 4. Apex beat beyond midclavicular line -
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| 158 | 1. Marked weight loss -
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| 159 | 3. Decalcification of bones -
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| 160 | 4. High blood calcium -
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| 161 | 5. High urinary calcium -
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| 162 | Total 2507 requests received for date range:
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| 163 | Total insufficient 2507 requests received for date range:
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| 164 | Total insufficient 2507 requests cancelled by RO for date range:
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| 165 | % of insufficient requests per total requests received:
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| 166 | % of uncancelled insufficient requests per total requests received:
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| 167 | Total 2507 exams received for date range:
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| 168 | Total insufficient 2507 exams received for date range:
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| 169 | Total insufficient 2507 exams cancelled by RO for date range:
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| 170 | % of insufficient exams per total exams received:
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| 171 | % of uncancelled insufficient exams per total exams received:
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| 172 | Summary of insufficient exams per Reason
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| 173 | Reason
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| 174 | Num
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| 175 | Exams without insufficient reason indicated
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| 176 | Summary Insufficient Exam Report for
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| 177 | For Date Range:
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| 178 | You have not selected Insufficient reasons to report.
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| 179 | This is required to print the Detailed report.
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| 180 | You have not selected Exams to report.
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| 181 | Enter 'No' to print only those reasons previously
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| 182 | selected, 'Yes' to select all reasons existing
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| 183 | on currently entered exams.
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| 184 | You have selected to report all insufficient reasons.
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| 185 | Is this correct?
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| 186 | Enter 'No' to print only those exams previously
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| 187 | selected, 'Yes' to select all exams
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| 188 | You have selected to report all AMIE exams.
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| 189 | 0,15,0,1,0^Detailed Insufficient Exam Report
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| 190 | 0,15,0,1,1^Detailed Insufficient Exam Report
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| 191 | 0,11,0,2,0^For Date Range:
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| 192 | Exam request of
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| 193 | to correct insufficiency was cancelled on
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| 194 | Exam Dt
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| 195 | Claim #
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| 196 | Insufficient Reason Selection
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| 197 | Enter '^' to end Reason Selection
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| 198 | 'Return' to select all Insufficient Reasons
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| 199 | Enter Insufficient Reason: ALL//
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| 200 | AMIE Exam Selection
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| 201 | Enter '^' to end Exam Selection
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| 202 | 'Return' to select all AMIE Exams
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| 203 | Enter Exam: ALL//
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| 204 | JOINTS (ORTHOPEDIC)
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| 205 | Do not use negative values to indicate inability to achieve
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| 206 | full extension. The anatomical position is the reference
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| 207 | position EXCEPT with the regard to rotation of the shoulder
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| 208 | and pronation/supination
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| 209 | of the forearm (see fig. 2.1 and 2.2
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| 210 | of the Physician's Guide). To give uniformity in describing
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| 211 | limitation of motion or ankylosis of a joint, THE USE OF A
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| 212 | GONIOMETER IS REQUIRED.
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| 213 | 3. Other impairment of knee: subluxation or lateral instability;
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| 214 | non-union, with loose motion; malunion -
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| 215 | 4. Range of motion (complete chart below)-
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| 216 | Note: Enter joint names in blanks under numbers below. If more
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| 217 | than four joints are involved, please extend your dictation in the
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| 218 | same format.
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| 219 | ------------------ JOINT EXAMINED -------------------
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| 220 | Range of:
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| 221 | Flexion
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| 222 | Extension
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| 223 | Rotation
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| 224 | Abduction
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| 225 | Adduction
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| 226 | Pronation
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| 227 | Supination
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| 228 | Deviation (radial)
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| 229 | Deviation (ulnar)
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| 230 | Plantar Flexion
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| 231 | Dorsiflexion
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| 232 | Compensation and Pension Exam for JOINTS for
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| 233 | Reprint Lab/X-Ray Results for C&P Exams
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| 234 | C&P lab/radiology print
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| 235 | DIC*
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| 236 | Was
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| 237 | scheduled to rebook a previous appointment
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| 238 | Enter NO to indicate this appointment is the first time the exam is scheduled.
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| 239 | Enter YES to indicate this appointment is a rebook of an existing appointment
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| 240 | for the exam.
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| 241 | (If YES, you will be asked to select the appointment being rebooked.)
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| 242 | You have not selected an appointment link which to modify with the selected
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| 243 | appointment. If the desired appointment was not displayed for selection,
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| 244 | it must first be added as a new link to the 2507 request. You may then
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| 245 | modify the link as you have attempted here.
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| 246 | You have not selected a C&P appointment to link the request to.
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| 247 | This is required before further processing with the AMIE link
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| 248 | management option.
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| 249 | Hit Return to continue or '^' to STOP.
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| 250 | You have selected a veteran that does not have C&P appointments
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| 251 | to link to this request. This is required before further processing with
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| 252 | the AMIE link management option.
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| 253 | You have selected a C&P appointment that is Currently Linked to the request.
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| 254 | (NOTE: *CL) If you want to remove this link, see your supervisor.
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| 255 | Do you want to REMOVE this link
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| 256 | Enter YES to remove this appointment from the 2507.
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| 257 | Enter NO leave this appointment associated with the 2507.
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| 258 | If you enter YES incorrectly, you will need to use this tool to relink the
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| 259 | appointment to the request.
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| 260 | No appointments are currently linked to this 2507 request.
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| 261 | You will need to create a link to the cancelled appointment
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| 262 | before proceding with the link to this appointment.
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| 263 | Hit Return to continue with appointment display.
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| 264 | VETERAN CANCELLATION
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| 265 | VETERAN REQ APPT DATE
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| 266 | AMIE/C&P Appointment Link Management
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| 267 | As a Supervisor, you may remove 2507 appointment links
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| 268 | Can't jump again until you close another screen.
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| 269 | CAN'T JUMP FROM AN OVERVIEW
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| 270 | DVBCVIEW,
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| 271 | Invalid division
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| 272 | C & P Request Entry for
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| 273 | C & P Request Veteran Selection
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| 274 | Vet is an INPATIENT, on ward
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| 275 | Want to continue
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| 276 | Enter Y to proceed with the request or N to go
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| 277 | back and re-select.
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| 278 | ... Timed out!
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| 279 | Select action:
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| 280 | Press [RETURN] to continue, or enter E to edit or X to cancel: Continue//
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| 281 | NOT allowed here
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| 282 | [RETURN] will continue to exam selection, E will allow
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| 283 | editing of what you have entered and X will DELETE
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| 284 | the entire request
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| 285 | Do you want to change the request this insufficient is linked to?
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| 286 | Enter Yes to change the link and No to keep the current link
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| 287 | Must be the RETURN key, X, or E
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| 288 | Request DELETED.
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| 289 | 0,0,0,1,0^You must either select a request to link or enter the 2507 Processing Time.
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| 290 | 0,0,0,1,0^Enter 0 if you don't know the processing time of the original request.
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| 291 | Use ? to see a list of exams available for selection.
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| 292 | 0,0,0,1,0^NOTE: This request has a priority of Insufficient without a link
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| 293 | 0,8,0,1:1,0^to a completed request.
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| 294 | 0,0,0,1:2,0^Use care to select the proper exam(s) to return as insufficient.
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| 295 | Enter Y to go back and select exams or N to DELETE the entire request
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| 296 | as well as any exams selected.
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| 297 | You have selected these exams:
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| 298 | Enter Y to go ahead and log the selected exams or N to modify the list.
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| 299 | Please enter any remarks for this request:
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| 300 | Exam addition error !
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| 301 | ) on File 31...Notify IRM
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| 302 | Selections
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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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