| [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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