| 1 | English French Notes Complete/Exclude
|
|---|
| 2 | salivary glands
|
|---|
| 3 | range of motion
|
|---|
| 4 | pain or tenderness
|
|---|
| 5 | nipple discharge
|
|---|
| 6 | Musculoskeletal - spine,upper and lower extremeties:
|
|---|
| 7 | mobility, tenderness, pain of spine
|
|---|
| 8 | joint pain
|
|---|
| 9 | joint swelling
|
|---|
| 10 | muscle weakness
|
|---|
| 11 | rheumatic fever
|
|---|
| 12 | shortness of breath
|
|---|
| 13 | pulmonary embolus
|
|---|
| 14 | configuration of thorax
|
|---|
| 15 | respiratiory movements
|
|---|
| 16 | inspiratory breath sounds
|
|---|
| 17 | expiratiory breath sounds
|
|---|
| 18 | heart inpulse
|
|---|
| 19 | chest pain/discomfort
|
|---|
| 20 | paroxysmal nocturnal dyspnea
|
|---|
| 21 | neck veins
|
|---|
| 22 | peripheral veins
|
|---|
| 23 | nausea and vomiting
|
|---|
| 24 | abdominal wall/distention/tenderness
|
|---|
| 25 | food intolerance
|
|---|
| 26 | bowel sounds
|
|---|
| 27 | ventral hernia
|
|---|
| 28 | gastric/marginal/duodenal ulcer
|
|---|
| 29 | urinary infection
|
|---|
| 30 | veneral disease
|
|---|
| 31 | inguinal canal
|
|---|
| 32 | Female:
|
|---|
| 33 | external genitalia
|
|---|
| 34 | abnormal menses
|
|---|
| 35 | vaginal discharge
|
|---|
| 36 | anus and sphincter
|
|---|
| 37 | test for occult blood
|
|---|
| 38 | MENTAL DISORDERS - POW PROTOCOL
|
|---|
| 39 | Physician's Guide Reference: Chapter 14, 17, 20
|
|---|
| 40 | 1. Immediate pre-military events -
|
|---|
| 41 | 2. Events as a POW -
|
|---|
| 42 | traumatic events as a POW, if not elsewhere
|
|---|
| 43 | SOCIAL WORK SURVEY - POW PROTOCOL
|
|---|
| 44 | Physician's Guide Reference: Chapter 17
|
|---|
| 45 | A. Describe the veteran's personal appearance -
|
|---|
| 46 | B. Describe the veteran's personal health -
|
|---|
| 47 | C. Describe the veteran's family adjustment -
|
|---|
| 48 | D. Describe the veteran's community adjustment -
|
|---|
| 49 | E. Describe the veteran's economic adjustment -
|
|---|
| 50 | cranial nerves
|
|---|
| 51 | gait disturbance
|
|---|
| 52 | biceps reflex
|
|---|
| 53 | triceps reflex
|
|---|
| 54 | patellar reflex
|
|---|
| 55 | Achilles reflex
|
|---|
| 56 | plantar response
|
|---|
| 57 | peripheral nerves
|
|---|
| 58 | sensory change
|
|---|
| 59 | loss of consciousness
|
|---|
| 60 | memory change
|
|---|
| 61 | trouble with decisions
|
|---|
| 62 | sleep disturbance
|
|---|
| 63 | crying spells
|
|---|
| 64 | thoughts of suicide
|
|---|
| 65 | difficulty with work
|
|---|
| 66 | loss of appetite
|
|---|
| 67 | trouble with sex life
|
|---|
| 68 | social withdrawal
|
|---|
| 69 | improbable beliefs
|
|---|
| 70 | C. Summary of findings:
|
|---|
| 71 | PRISONER OF WAR PROTOCOL
|
|---|
| 72 | A. Medical history (include childhood and adult illnesses and
|
|---|
| 73 | B. Past history (include civilian and military occupation, military)
|
|---|
| 74 | history including geographic locations and dates, habits
|
|---|
| 75 | such as alcohol, tobacco and drugs, family history):
|
|---|
| 76 | C. System review (comment specifically if positive symptom):
|
|---|
| 77 | weight change
|
|---|
| 78 | fever or chills
|
|---|
| 79 | night sweats
|
|---|
| 80 | irritable bowel syndrome
|
|---|
| 81 | peptic ulcer
|
|---|
| 82 | PYELITIS, NEPHROLITHIASIS, URETEROLITHIASIS,
|
|---|
| 83 | URETERAL STRICTURE AND HYDRONEPHROSIS (GU)
|
|---|
| 84 | 4. Catheter drainage requirement (frequency of need) -
|
|---|
| 85 | RECTUM AND ANUS (DIGESTIVE)
|
|---|
| 86 | Diseases of the rectum, anal canal or perineum must be
|
|---|
| 87 | differentiated as to type.
|
|---|
| 88 | 8. Fecal leakage -
|
|---|
| 89 | 9. Frequency of episodes -
|
|---|
| 90 | EDIT C&P STATIC INFORMATION
|
|---|
| 91 | The status of this request is not NEW or PENDING, REPORTED.
|
|---|
| 92 | It cannot, therefore, be modified.
|
|---|
| 93 | Since you have modified the REMARKS section,
|
|---|
| 94 | a new copy of the request will be issued to the
|
|---|
| 95 | medical center tomorrow morning.
|
|---|
| 96 | 1,3,0,2:1,0^Insufficient link info not updated!...Priority restored
|
|---|
| 97 | Invalid user number (DUZ)
|
|---|
| 98 | DVBA C RELEASE 2507
|
|---|
| 99 | You are not authorized to release 2507 requests!!
|
|---|
| 100 | is not complete
|
|---|
| 101 | 2507 Exam Release
|
|---|
| 102 | Please wait while the individual exam statuses are checked.
|
|---|
| 103 | All exams have been completed, please enter the following:
|
|---|
| 104 | Since there are still incomplete exams,
|
|---|
| 105 | this request cannot be released to the RO.
|
|---|
| 106 | Press RETURN or
|
|---|
| 107 | This request is now released.
|
|---|
| 108 | Release NOT COMPLETED !!
|
|---|
| 109 | This request has been cancelled by the RO.
|
|---|
| 110 | This request has been completed and transferred out.
|
|---|
| 111 | This request has been cancelled by MAS.
|
|---|
| 112 | This request has been released to the RO.
|
|---|
| 113 | This request has been printed by the RO.
|
|---|
| 114 | This request is new and has not yet been reported to MAS.
|
|---|
| 115 | COMPENSATION AND PENSION EXAM REQUEST
|
|---|
| 116 | Requested by
|
|---|
| 117 | 0,0,0,2:1,0^** Priority of exam:
|
|---|
| 118 | 0,0,0,0,0^Date original 2507 Reported to MAS:
|
|---|
| 119 | 0,0,0,3:2,0^Selected exams:
|
|---|
| 120 | Current Rated disabilities:
|
|---|
| 121 | General remarks:
|
|---|
| 122 | Unknown division
|
|---|
| 123 | Medical Center Division at
|
|---|
| 124 | *** Transferred from
|
|---|
| 125 | Date Requested:
|
|---|
| 126 | ** Claim folder review will be required **
|
|---|
| 127 | VA Form 21-2507
|
|---|
| 128 | General remarks (continued):
|
|---|
| 129 | No parameters in AMIE site parameter file!
|
|---|
| 130 | New 2507 Request Report for
|
|---|
| 131 | BDTRQ*
|
|---|
| 132 | EDTRQ*
|
|---|
| 133 | New Request Recap Sheet for Run Date
|
|---|
| 134 | C&P Diagnostic Test Order Record
|
|---|
| 135 | Initials
|
|---|
| 136 | Laboratory:
|
|---|
| 137 | Radiology:
|
|---|
| 138 | Other:
|
|---|
| 139 | Missing vet name
|
|---|
| 140 | Manual New C&P Request Printing
|
|---|
| 141 | Do you want just one request
|
|---|
| 142 | Enter Y for only one Vet or N for all Vets.
|
|---|
| 143 | Enter BEGINNING date of request:
|
|---|
| 144 | and ENDING date of request:
|
|---|
| 145 | Ending date is earlier than starting date!
|
|---|
| 146 | New C&P request printing
|
|---|
| 147 | New C&P Requests --
|
|---|
| 148 | There were no new 2507 requests for
|
|---|
| 149 | for division
|
|---|
| 150 | C&P Request Modifications --
|
|---|
| 151 | No modified requests to report.
|
|---|
| 152 | C&P Exams Added --
|
|---|
| 153 | No added exams to report.
|
|---|
| 154 | Date of request:
|
|---|
| 155 | Enter MED CENTER DIVISION:
|
|---|
| 156 | C&P REQUESTS BY DATE RANGE
|
|---|
| 157 | Enter DATE OF REQUEST FROM:
|
|---|
| 158 | Do you want to report by physician
|
|---|
| 159 | Enter <Y> to report by Physician or <N> to report only by date range.
|
|---|
| 160 | This report uses
|
|---|
| 161 | by Physician
|
|---|
| 162 | by Date Range
|
|---|
| 163 | EXAMINING PHYSICIAN
|
|---|
| 164 | RESPIRATORY MANIFESTATIONS OF DISEASES OF OTHER SYSTEMS
|
|---|
| 165 | An example of this type of exam is extremely unfavorable
|
|---|
| 166 | ankylosis of the thoracic spine that so severely
|
|---|
| 167 | restricts chest excursion that the veteran is dyspneic
|
|---|
| 168 | on minimal exertion OR abdominal tumor interferes with
|
|---|
| 169 | excursion of the diaphragm to such an extent that chronic
|
|---|
| 170 | passive congestion of one lung results.
|
|---|
| 171 | C. Objective findings :
|
|---|
| 172 | 1. Clinical findings -
|
|---|
| 173 | 2. Pulmonary function studies -
|
|---|
| 174 | Since this request has reopened, its status will
|
|---|
| 175 | be PENDING, REPORTED.
|
|---|
| 176 | Be sure to regenerate any exam worksheets that will be needed
|
|---|
| 177 | for this request.
|
|---|
| 178 | Press RETURN to continue
|
|---|
| 179 | Your user number (DUZ) is invalid !
|
|---|
| 180 | Re-open Exams/Requests
|
|---|
| 181 | Status prohibits activity except by supervisors.
|
|---|
| 182 | 1,0,0,2,0^This 2507 was never reported to MAS, it can NOT be reopened.
|
|---|
| 183 | Do you want to reopen the ENTIRE request
|
|---|
| 184 | Enter Y to reopen the ENTIRE request or N to reopen only selected exams.
|
|---|
| 185 | Select EXAM TO REOPEN:
|
|---|
| 186 | Exam name not found in file 396.6 !
|
|---|
| 187 | Already open!
|
|---|
| 188 | reopen error !
|
|---|
| 189 | There are no cancelled or completed exams remaining on this request.
|
|---|
| 190 | Reopen error on
|
|---|
| 191 | Entire exam is now REOPENED.
|
|---|
| 192 | Reopen error !
|
|---|
| 193 | Sending a bulletin to the 2507 REOPENED mail group ...
|
|---|
| 194 | DVBA C 2507 EXAM REOPENED
|
|---|
| 195 | This request has not been released.
|
|---|
| 196 | This reopen will not affect the AMIE AMIS 290.
|
|---|
| 197 | **THIS REOPEN WILL AFFECT THE AMIE AMIS 290**
|
|---|
| 198 | /Affects AMIE AMIS 290
|
|---|
| 199 | G.DVBA C 2507 EXAM REOPENED@
|
|---|
| 200 | I am sending updated information to
|
|---|
| 201 | Select Reprint Option - (D)ate or (V)eteran: D//
|
|---|
| 202 | Must be D or V
|
|---|
| 203 | Do you want just the Lab/X-ray results
|
|---|
| 204 | Enter Y to get just the Lab/X-ray results for the Vet
|
|---|
| 205 | or N to get the entire exam results AND Lab/X-ray.
|
|---|
| 206 | Enter original printing date:
|
|---|
| 207 | Reprinted by the RO or MAS ? >>
|
|---|
| 208 | Must be R for Regional Office or M for MAS.
|
|---|
| 209 | 2507 Final Exam Reprint
|
|---|
| 210 | Single 2507 Final Exam Reprint
|
|---|
| 211 | ** REPRINT OF FINAL **
|
|---|
| 212 | Physician signature: ___________________________________ Date: _____________
|
|---|
| 213 | SCARS, OTHER THAN BURNS (ORTHOPEDIC/DISFIGUREMENT)
|
|---|
| 214 | The type of injury or infection causing the wound or scar,
|
|---|
| 215 | its date, the treatment used and the response to such
|
|---|
| 216 | treatment should be described. Point of entrance and exit of
|
|---|
| 217 | missiles are important
|
|---|
| 218 | in evaluating injuries of nerves, vessels,
|
|---|
| 219 | and muscles. Photographs, if indicated, (see Physician's Guide,
|
|---|
| 220 | Paragraph 1.19) should be submitted.
|
|---|
| 221 | 2. Keloid formation, adherance, herniation -
|
|---|
| 222 | 3. Inflammation, swelling, depression, vascular supply, ulceration -
|
|---|
| 223 | 4. Tender and painful on objective demonstration -
|
|---|
| 224 | 5. Cosmetic effects (submit photographs of all facial
|
|---|
| 225 | and other significant scars) -
|
|---|
| 226 | 6. Limitation of function of part affected -
|
|---|
| 227 | SCHEDULE C&P EXAMS
|
|---|
| 228 | You have no user number !
|
|---|
| 229 | This request has no exams on it and should
|
|---|
| 230 | be completely cancelled.
|
|---|
| 231 | This request has been completely transferred to another site.
|
|---|
| 232 | Scheduling will not be allowed.
|
|---|
| 233 | Scheduling has been completed for this request as of
|
|---|
| 234 | Only supervisors can change it.
|
|---|
| 235 | Do you want to change
|
|---|
| 236 | Enter Y to be able to change the scheduling information or N to backup.
|
|---|
| 237 | Note: One or more exams on this request have transferred out.
|
|---|
| 238 | Do you want to make an appointment for a clinic
|
|---|
| 239 | Schedule a Clinic Appointment for 2507 Exam
|
|---|
| 240 | Enter Y to make an appointment via ADT/Scheduling or N to skip.
|
|---|
| 241 | Enter Scheduling Information for 2507 Exams
|
|---|
| 242 | Has scheduling for all exams been completed
|
|---|
| 243 | Enter Y if scheduling is completed, N if not.
|
|---|
| 244 | Ok, then please complete the following:
|
|---|
| 245 | Important scheduling information is missing!
|
|---|
| 246 | 2507 file NOT updated!
|
|---|
| 247 | For SKIN, NOT ELSEWHERE CLASSIFIED
|
|---|
| 248 | Type of Exam: SKIN, NOT ELSEWHERE CLASSIFIED
|
|---|
| 249 | SKIN, OTHER THAN SCARS
|
|---|
| 250 | When furnishing the history of the present skin disease
|
|---|
| 251 | include a description of the skin changes, when the disorder
|
|---|
| 252 | first appeared, and the progression of the illness since that
|
|---|
| 253 | time. Note whether
|
|---|
| 254 | remissions or exacerbations occurred
|
|---|
| 255 | and whether they were related to the occupation or treatment.
|
|---|
| 256 | Include the duration of remissions and factors that
|
|---|
| 257 | may have influenced the course of the disorder.
|
|---|
| 258 | B. Subjective complaints:
|
|---|
| 259 | (List the types of complaints such as itching
|
|---|
| 260 | burning, pain and anesthesia. Note whether environmental factors such as
|
|---|
| 261 | temperature or seasonal change affect the severity of the symptoms.)
|
|---|
| 262 | 1. Description of skin disorder -
|
|---|
| 263 | 2. Distribution of skin disorder -
|
|---|
| 264 | 3. Configuration and characteristics of lesions -
|
|---|
| 265 | 4. Nervous manifestations -
|
|---|
| 266 | 5. Attach color photograph if condition is disfiguring.
|
|---|
| 267 | (Note: If current diagnosis differs from the skin condition
|
|---|
| 268 | for which the examination was ordered, then review prior records and
|
|---|
| 269 | express opinion whether current disease is a new problem or original
|
|---|
| 270 | diagnosis was in error.)
|
|---|
| 271 | SENSE OF SMELL
|
|---|
| 272 | Report whether loss is partial or complete and whether it
|
|---|
| 273 | is on an organic or psychiatric basis. If a psychiatric
|
|---|
| 274 | basis is suspected, a special psychiatric examination should
|
|---|
| 275 | be ordered.
|
|---|
| 276 | Substances used for testing olfaction and results (each side of nose
|
|---|
| 277 | should be tested separately):
|
|---|
| 278 | 4. Oil of lemon -
|
|---|
| 279 | 5. Other (state substance) -
|
|---|
| 280 | SPINE (ORTHOPEDIC)
|
|---|
| 281 | Complete description of spinal orthosis, its impact on
|
|---|
| 282 | motion before and after application, and whether the
|
|---|
| 283 | usage is constant or intermittent should be part of the
|
|---|
| 284 | To give uniformity in
|
|---|
| 285 | describing limitation of motion or
|
|---|
| 286 | ankylosis, THE USE OF A GONIOMETER IS REQUIRED. Report
|
|---|
| 287 | each spinal segment separately.
|
|---|
| 288 | 1. Postural abnormalities -
|
|---|
| 289 | 2. Fixed deformity -
|
|---|
| 290 | 3. Musculature of back -
|
|---|
| 291 | 4. Range of motion:
|
|---|
| 292 | a. Forward flexion -
|
|---|
| 293 | b. Backward extension -
|
|---|
| 294 | c. Left lateral flexion -
|
|---|
| 295 | d. Right lateral flexion -
|
|---|
| 296 | e. Rotation to left -
|
|---|
| 297 | f. Rotation to right -
|
|---|
| 298 | 5. Objective evidence of pain on motion -
|
|---|
| 299 | 6. Identify and describe any evidence of neurological involvement -
|
|---|
| 300 | SCARS, BURN
|
|---|
| 301 | When true third degree burn involvement is established,
|
|---|
| 302 | measure and describe all areas of scarring and all secondary
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
