English French Notes Complete/Exclude history and all appropriate laboratory studies. Note: A. Medical history a. Removal of, complete/imcomplete (if incomplete, state if pregnancy is prevented) - b. Prolapse of, complete through vulva/imcomplete - c. Displacement of; also identify adhesions and irregular a. Removal of both - b. Removal of one with or without partial removal of the other - c. Atrophy of one or both ovaries, complete - 3. Rectal and rectovaginal; identify any surgical complications of pregnancy - 4. If a malignant process has been present within the past year, give the date of the last surgical, radiation or chemical 5. If a tubercular or other mycobacterial infection has been treated within the past year, give the date of inactivity - 6. Has a voluntary sterilization procedure been performed? - OTHER GENITOURINARY In original claims, particularly pension cases, and in reopened claims in which the evidence on hand at the time the examination request is prepared does not establish the exact diagnosis, the nature of the disability will generally be expressed in the most general terms, usually in the veteran's own words (e.g. kidney condition bladder problem can't hold water , etc). In such cases it is the responsibility of the general medical examiner to conduct or order to be conducted such special examinations as may be necessary, both to diagnose the underlying disorder, and to provide the information that the rating board must have to apply the examiner's findings to the rating schedule. Once a definitive diagnosis is established, the examiner need only to report history, clinical findings, and laboratory tests for evaluation purposes. Complications and/or medical side effects should always be reported, even when not specifically requested. A. Medical History: No medical history for this exam E. Diagnostic/clinical test results: For GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED Type of Exam: GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED HYPERTHYROIDISM, THYROID ADENOMA 1. Mental assessment - 2. Muscular weakness - 3. Loss of weight - 4. Thyroid enlargement - 7. Disease in remission or demonstrably active - 8. Marked disfigurement (including appearance and texture of thyroidectomy scar, if present) - 9. Continuous medication required - 2. Nervous, cardiovascular, or gastrointestinal symptoms - 4. Mental assessment - 5. Continuous medication required - For HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED Type of Exam: HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED HEMATOLOGIC DISORDERS-LYMPHATIC As with other disorders, a careful history and complete physical examination are of first importance in hematologic disorders. However, laboratory evaluation is often necessary for a definitive diagnosis. 1. State whether the disease is currently active or in remission and if in remission, whether maintenance chemotherapy is required - 2. Describe frequency and duration of acute attacks - 3. Describe the state of general health between acute attacks - 4. If the veteran is, or has been receiving chemotherapy, X-Ray or surgical treatment for Hodgkin's disease or other form of lymphoma, give date of last treatment - 5. If veteran has been treated for any tuberculous adenitis (or adenitis due to any other mycobacterial infection) and the disease is currently inactive, give date the inactivity was first shown - Invalid Patient name or DFN Invalid Segment Type Not a valid DHCP user number. Invalid Patient ID, No SSN Invalid Patient ID, Wrong SSN Format Invalid Patient Identifier Ambiguous Patient identifier No 2507 request on file for this Patient Invalid Patient identifier No Exams or Open Exams on file for this Patient No Electronic Signature code present, updating cannot be allowed. Missing PID Segment Incorrect PID Segment indicator Internal Patient ID Missing Patient Name Invalid Patient SSN Invalid Incorrect Patient Identifier Invalid SSN Missing OBR Segment Missing Universal Identifier Missing Exam Type Missing Report Date Request No longer Exists Status of Request will not allow for down loading Exam No longer Exists Exam status not open, no down loading allow* ed Bad electronic signature code. Electronic signature codes do not match, no down loading allowed Invalid OBX Segment Results added but request and exam status not updated. Kurzweil Results added and exam status updated but request status not updated. Record currently accessed by another user Exam currently being accessed by another user HEMATOLOGIC DISORDERS - BLOOD disorders; however, laboratory evaluation is often necessary HAND, THUMB, AND FINGERS The hand should be evaluated as a unit intricately adapted for grasping, pushing, pulling, twisting, probing, writing, touching, and expression. Do not designate fingers numerically; use thumb, index, middle, ring and little. Specify which hand is involved and state whether the individual is right or left-handed. Designate the joints as wrist, MP (metacarpophalangeal), PIP, (proximal interphalangeal) or DIP (distal interphalangeal). Designate phalanges as proximal, middle or distal. 1. Anatomical defects - 2. Functional defects (motion of thumb and fingers should be described as to how near, in inches, the tip of thumb can approximate the fingers, or how near the tips of fingers can approximate the median transverse fold of the palm.) - 3. Grasping objects (strength and dexterity) - Loss of range of motion of the hip will be recorded from the anatomical position (0 degrees) varying from 125 degrees in flexion to 30 degrees in extension, from 25 degrees in adduction to 45 degrees in abduction, and from 60 degrees in external rotation to 40 degrees in internal rotation. To gain a true picure of hip flexion, i.e. movement between the pelvis and femur in the hip joint, the opposide thigh should be extended to minimize motion between the pelvis and spine. 1. Describe movements of the thigh as it may rotate in a circular manner about the femoral head in the acetabulum. Discuss any pain, tenderness, weakness and fatigue on standing and any unusual motions on ORIGINAL SC ORIGINAL NSC INSUFFICIENT EXAM PENDING, REPORTED PENDING SCHEDULED RELEASED TO RO, NOT PRINTED COMPLETED, PRINTED BY RO CANCELLED BY MAS CANCELLED BY RO NEW, TRANSFERRED IN COMPLETED, TRANSFERRED OUT There should be at least three blood pressure readings in the sitting position spaced throughout the examination. At times it may be necessary to recall the veteran on subsequent days to obtain readings which are most representative of the true blood pressure. 1. Blood pressure readings: 3. Enlarged heart confirmation - 4. Apex beat beyond midclavicular line - 1. Marked weight loss - 3. Decalcification of bones - 4. High blood calcium - 5. High urinary calcium - Total 2507 requests received for date range: Total insufficient 2507 requests received for date range: Total insufficient 2507 requests cancelled by RO for date range: % of insufficient requests per total requests received: % of uncancelled insufficient requests per total requests received: Total 2507 exams received for date range: Total insufficient 2507 exams received for date range: Total insufficient 2507 exams cancelled by RO for date range: % of insufficient exams per total exams received: % of uncancelled insufficient exams per total exams received: Summary of insufficient exams per Reason Reason Num Exams without insufficient reason indicated Summary Insufficient Exam Report for For Date Range: You have not selected Insufficient reasons to report. This is required to print the Detailed report. You have not selected Exams to report. Enter 'No' to print only those reasons previously selected, 'Yes' to select all reasons existing on currently entered exams. You have selected to report all insufficient reasons. Is this correct? Enter 'No' to print only those exams previously selected, 'Yes' to select all exams You have selected to report all AMIE exams. 0,15,0,1,0^Detailed Insufficient Exam Report 0,15,0,1,1^Detailed Insufficient Exam Report 0,11,0,2,0^For Date Range: Exam request of to correct insufficiency was cancelled on Exam Dt Claim # Insufficient Reason Selection Enter '^' to end Reason Selection 'Return' to select all Insufficient Reasons Enter Insufficient Reason: ALL// AMIE Exam Selection Enter '^' to end Exam Selection 'Return' to select all AMIE Exams Enter Exam: ALL// JOINTS (ORTHOPEDIC) Do not use negative values to indicate inability to achieve full extension. The anatomical position is the reference position EXCEPT with the regard to rotation of the shoulder and pronation/supination of the forearm (see fig. 2.1 and 2.2 of the Physician's Guide). To give uniformity in describing limitation of motion or ankylosis of a joint, THE USE OF A GONIOMETER IS REQUIRED. 3. Other impairment of knee: subluxation or lateral instability; non-union, with loose motion; malunion - 4. Range of motion (complete chart below)- Note: Enter joint names in blanks under numbers below. If more than four joints are involved, please extend your dictation in the same format. ------------------ JOINT EXAMINED ------------------- Range of: Flexion Extension Rotation Abduction Adduction Pronation Supination Deviation (radial) Deviation (ulnar) Plantar Flexion Dorsiflexion Compensation and Pension Exam for JOINTS for Reprint Lab/X-Ray Results for C&P Exams C&P lab/radiology print DIC* Was scheduled to rebook a previous appointment Enter NO to indicate this appointment is the first time the exam is scheduled. Enter YES to indicate this appointment is a rebook of an existing appointment for the exam. (If YES, you will be asked to select the appointment being rebooked.) You have not selected an appointment link which to modify with the selected appointment. If the desired appointment was not displayed for selection, it must first be added as a new link to the 2507 request. You may then modify the link as you have attempted here. You have not selected a C&P appointment to link the request to. This is required before further processing with the AMIE link management option. Hit Return to continue or '^' to STOP. You have selected a veteran that does not have C&P appointments to link to this request. This is required before further processing with the AMIE link management option. You have selected a C&P appointment that is Currently Linked to the request. (NOTE: *CL) If you want to remove this link, see your supervisor. Do you want to REMOVE this link Enter YES to remove this appointment from the 2507. Enter NO leave this appointment associated with the 2507. If you enter YES incorrectly, you will need to use this tool to relink the appointment to the request. No appointments are currently linked to this 2507 request. You will need to create a link to the cancelled appointment before proceding with the link to this appointment. Hit Return to continue with appointment display. VETERAN CANCELLATION VETERAN REQ APPT DATE AMIE/C&P Appointment Link Management As a Supervisor, you may remove 2507 appointment links Can't jump again until you close another screen. CAN'T JUMP FROM AN OVERVIEW DVBCVIEW, Invalid division C & P Request Entry for C & P Request Veteran Selection Vet is an INPATIENT, on ward Want to continue Enter Y to proceed with the request or N to go back and re-select. ... Timed out! Select action: Press [RETURN] to continue, or enter E to edit or X to cancel: Continue// NOT allowed here [RETURN] will continue to exam selection, E will allow editing of what you have entered and X will DELETE the entire request Do you want to change the request this insufficient is linked to? Enter Yes to change the link and No to keep the current link Must be the RETURN key, X, or E Request DELETED. 0,0,0,1,0^You must either select a request to link or enter the 2507 Processing Time. 0,0,0,1,0^Enter 0 if you don't know the processing time of the original request. Use ? to see a list of exams available for selection. 0,0,0,1,0^NOTE: This request has a priority of Insufficient without a link 0,8,0,1:1,0^to a completed request. 0,0,0,1:2,0^Use care to select the proper exam(s) to return as insufficient. Enter Y to go back and select exams or N to DELETE the entire request as well as any exams selected. You have selected these exams: Enter Y to go ahead and log the selected exams or N to modify the list. Please enter any remarks for this request: Exam addition error ! ) on File 31...Notify IRM Selections #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################