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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