| 1 | English French Notes Complete/Exclude
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| 2 | | (specify type):
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| 3 | |
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| 4 | | * HIV-1/HIV-2 combination EIA . |
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| 5 | | * If HIV laboratory tests were not documented, Yes No Unk.|
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| 6 | | * HIV-1 Western blot/IFA ...... |
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| 7 | | is HIV diagnosis documented by a physician? |
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| 8 | | * Other HIV antibody test ..... |
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| 9 | | * If yes, provide date of documentation by physician
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| 10 | | 3. IMMUNOLOGIC LAB TESTS: |
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| 11 | | * HIV-2 Western blot .......... |
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| 12 | | At or closest to current diagnostic status Mo. Yr. |
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| 13 | | 2. POSITIVE HIV DETECTION TEST: (Record earliest test) | * CD4 Count ...........
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| 14 | | * HIV culture .....................................
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| 15 | %
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| 16 | | * HIV antigen test ................................
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| 17 | | First <200 uL or <14% |
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| 18 | | * HIV PCR, DNA or RNA probe .......................
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| 19 | ================================================= VIII. CLINICAL STATUS ======================================================
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| 20 | | CLINICAL YES NO | ENTER DATE PATIENT Asymptomatic Mo. Yr. Symptomatic Mo. Yr. |
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| 21 | | RECORD REVIEWED |
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| 22 | | | WAS DIAGNOSED AS: (including acute retroviral syndrome and |
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| 23 | | | persistant generalized lymphadenopathy):
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| 24 | (not AIDS):
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| 25 | | Initial Initial | Initial Initial |
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| 26 | | Diagnosis Date | Diagnosis Date |
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| 27 | | AIDS INDICATOR DISEASES Def. Pres. Mo. Yr. | AIDS INDICATOR DISEASES Def. Pres. Mo. Yr. |
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| 28 | |Candidiasis, bronchi, trachea, or lungs |
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| 29 | Lymphoma, Burkitt's (or equivalent term) |
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| 30 | Lymphoma, Immunoblastic (or equivalent |
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| 31 | |Carcinoma, invasive cervical |
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| 32 | |Coccidioidomycosis, disseminated or |Lymphoma, primary in brain |
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| 33 | Mycobacterium avium complex or |
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| 34 | M. kansasii, disseminated or |
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| 35 | |Cryptosporidiosis, chronic intestinal | extrapulmonary |
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| 36 | | (> 1 month duration) |
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| 37 | |Cytomegalovirus disease (other than in |M. tuberculosis, disseminated |
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| 38 | | liver, spleen or nodes) |
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| 39 | or extrapulmonary * |
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| 40 | |Cytomegalovirus retinitis (with loss of |Mycobacterium, of other species or |
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| 41 | unidentified species, disseminated |
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| 42 | |HIV encephalopathy |
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| 43 | | or extrapulmonary |
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| 44 | |Herpes simplex: chronic ulcer(s) (>1 mo. |Pneumocystis carinii pneumonia |
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| 45 | | duration); or bronchitis, pneumonitis, |Penumonia, recurrent in 12 mo. period |
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| 46 | | or esophagitis |
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| 47 | Progressive multifocal |
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| 48 | |Histoplasmosis, disseminated or | leukoencephalopathy |
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| 49 | Salmonella septicemia, recurrent |
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| 50 | |Isosporiasis, chronic intestinal (>1 mo. |Toxoplasmosis of brain |
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| 51 | |Wasting Syndrome due to HIV |
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| 52 | | Def.=definitive diagnosis Pres.=presumptive diagnosis | * RVCT CASE NO.: _______________ |
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| 53 | | * If HIV tests were not positive or were not done, does this patient have |
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| 54 | | an immunodeficiency that would disqualify him/her from the AIDS case definition |
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| 55 | | Has this patient been informed of his/her HIV infection? |
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| 56 | | Unk. | This patient is receiving or |
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| 57 | | This patient's partners will be notified about their HIV exposure and counseled by: | * HIV related medical services |
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| 58 | | Health department |
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| 59 | | Unknown | * Substance abuse treatment services |
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| 60 | | This patient received or is receiving: | This patient has been enrolled at: | This patient's medical treatment is |
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| 61 | | * Anti-retroviral Yes No Unk. | Clinical Trial Clinic | PRIMARILY reimbursed by: |
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| 62 | | Private ins/HMO |
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| 63 | | No coverage |
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| 64 | | Other public funds |
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| 65 | | Yes No Unk. | |
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| 66 | | * PCP prophylaxis |
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| 67 | | Unknown | trial/government program |
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| 68 | | FOR WOMEN: *This patient is receiving or has been referred for gynecological or obstetrical services: . |
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| 69 | | *Is this patient currently pregnant? ....................................................... |
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| 70 | | *Has this patient delivered live born infants? ... |
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| 71 | |Yes (If delivered after 1977, provide birth |
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| 72 | information below for the most recent birth) |
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| 73 | | CHILD'S DATE OF BIRTH: | Hospital of Birth:
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| 74 | | Child's Soundex: | Child's State Patient No. |
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| 75 | | Mo. Day Yr. | | | | | | | __________ | | | | | | | | | | | | |
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| 76 | Definitive
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| 77 | Presumptive
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| 78 | ** NO DATE **
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| 79 | Diseases Currently Selected:
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| 80 | Start Date for Period:
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| 81 | End Date for Period:
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| 82 | END CAN NOT BE BEFORE START
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| 83 | MORE THAN 180 DAYS OF DATA IS TOO MUCH TO TRANSMIT.
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| 84 | TRY A SHORTER DATE RANGE.
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| 85 | IMMUNOLOGY DATA.
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| 86 | *NEW PATIENT*
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| 87 | Monthly, Quarterly, Semi-Annually, Yearly, Fiscal Yearly, User Selectable
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| 88 | Select date range type:
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| 89 | Enter the first few letters of one of the choices listed below.
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| 90 | Please enter a month and year
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| 91 | MONTH OF
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| 92 | Enter Quarter Period and FY you wish Semi-Annual range to end with
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| 93 | Enter Quarter and Year:
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| 94 | Enter Quarter Period in this format: 2nd quarter 1988 would be 2-88, 2/88, 2 88
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| 95 | Enter Quarter 1 to 4 only
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| 96 | QUARTER FY
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| 97 | SEMI-ANNUAL PERIOD ENDING
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| 98 | FISCAL
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| 99 | Enter a 2 or 4 digit
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| 100 | FISCAL YEAR
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| 101 | YEAR
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| 102 | Enter beginning and ending dates for the desired time period:
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| 103 | Ending Date:
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| 104 | PERIOD FROM
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| 105 | Range selected:
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| 106 | ***** Patient has a DATE OF DEATH, setting it to 2 ****
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| 107 | **** Patient has an ICR DATE OF DEATH ENTERED, setting status to DEAD ****
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| 108 | Do you want to enter an ICR DATE OF DEATH (Y/N) ?
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| 109 | ***** PATIENT FILE has NO date of death entered,
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| 110 | AND IMR DATE OF DEATH FIELD HAS NO DATE *****
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| 111 | ***** You must choose 1 or 9 *****
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| 112 | Enter Coded SSN
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| 113 | I will now search the database to decode the SSN... please wait
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| 114 | The coded number you entered is either not listed in your local ICR
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| 115 | or was typed incorrectly. Please check that you entered the coded SSN
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| 116 | correctly. *** NO TRANSLATION FOUND FOR THIS PATIENT ***
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| 117 | Coded SSN:
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| 118 | Patient's id in the Immunology Case Study file:
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| 119 | Coded Date of Birth:
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| 120 | Patient's number in the Patient file:
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| 121 | BE ABSOLUTELY SURE BEFORE USING THIS OPTION -- IT WILL DELETE ALL DATA
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| 122 | FOR THE SPECIFIED INDIVIDUAL FROM THE IMMUNOLOGY CASE FILE
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| 123 | ARE YOU ABSOLUTELY SURE? N//
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| 124 | IMRTEXT(
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| 125 | IMMUNOLOGY DATA
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| 126 | Do you want to Enter/Edit CDC form data now
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| 127 | This patient must be entered into the Immunology Case Study file using
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| 128 | The Enter/Edit option first.
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| 129 | Is this patient REALLY supposed to be in your database (Y/N)?
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| 130 | Are you sure,
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| 131 | should be
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| 132 | in your database (Y/N)?
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| 133 | Sending the past 365 days of data to the HIV National Database..
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| 134 | Select *SECURE* ALLOWABLE PRINTERS (Field 7) from ICR Site Parameters File:
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| 135 | Select one of the valid devices
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| 136 | IMR*2.0*23
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| 137 | Please install IMR*2*23 first. ICR v2.1 Installation halted.
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| 138 | File Access
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| 139 | YOU HAVE INSUFFICIENT SECURITY TO ACCESS THIS OPTION
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| 140 | SEE YOUR IMMUNOLOGY COORDINATOR FOR THE PROPER KEYS
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| 141 | IMR ACCESS VIOLATION NOTICE
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| 142 | IMR ACCESS VIOLATION BY
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| 143 | IMR - IMMUNOLOGY UNATHORIZED ACCESS ATTEMPT
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| 144 | An attempt was made to invoke IMR functionality by a person who does
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| 145 | not have the neccessary Security Keys. Details of this attempt
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| 146 | are as follows:
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| 147 | Violator's Name:
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| 148 | Time:
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| 149 | VIOLATION:
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| 150 | ACCESS WAS ATTEMPTED BUT NOT GAINED
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| 151 | Removing Unused Data Dictionary Fields...
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| 152 | Deleting Unused Routines...
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| 153 | Deleting Unused Data...
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| 154 | Removing Unused Options...
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| 155 | IMRO REPORTS MENU
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| 156 | IMRO BY DX
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| 157 | IMRO BY NAME
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| 158 | IMRO DELETE
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| 159 | IMRO ENTER
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| 160 | IMRO MASTER
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| 161 | IMRO NO DX
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| 162 | IMRO TRANSMIT
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| 163 | Populating Data Fields in File 158...
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| 164 | 44)=DATE OF HIV+ (CAT 2) STATUS
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| 165 | Populating new NLF ENTRY field in File 158.9...
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| 166 | Removing unused File 158.96 dictionary and data...
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| 167 | Queuing the IMR REGISTRY DATA option to run immediately...
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| 168 | Rescheduling the IMR REGISTRY DATA option...
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| 169 | IMR REGISTRY DATA
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| 170 | IMMUNOLOGY.VA.GOV
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| 171 | Deleting unused input templates...
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| 172 | IMR LPOINTER
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| 173 | IMR PPOINTER
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| 174 | Adding VIRAL LOAD entry to File 158.95...
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| 175 | VIRAL LOAD
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| 176 | ICR-RX ARCHIVE DATE SEARCH
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| 177 | Holders of KEYS for 'IMR' Package as of:
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| 178 | KEY HOLDERS:
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| 179 | UNKNOWN USER #
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| 180 | Deleting the field definitions...
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| 181 | The definitions have been deleted.
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| 182 | Unknown error (
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| 183 | CD4 or T4 (ACTUAL LEVEL)
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| 184 | CD4 or T4 (PERCENTAGE)
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| 185 | ** SORRY NO LABORATORY REFERENCE IN PLACE **
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| 186 | SORRY, HIV COORDINATOR HAS NOT SET UP LAB LINKS
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| 187 | Local ICR Demographics by Category
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| 188 | Do you want to check for entries in the ICR file without CATEGORY data
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| 189 | Do you want a list of patients with MISSING data elements
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| 190 | Local ICR Demographics By Category
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| 191 | Patients Seen During
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| 192 | LIVING
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| 193 | ALIVE & DECEASED
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| 194 | DECEASED
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| 195 | PATIENTS IN THE FILE
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| 196 | HIV+
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| 197 | HIV+TC
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| 198 | AIDS-3
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| 199 | Checking for entries in the ICR file without CATEGORY data.
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| 200 | None found.
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| 201 | in the IMMUNOLOGY CASE REGISTRY file with
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| 202 | NO CATEGORY indicated --
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| 203 | DO YOU WANT TO SEE THE LIST
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| 204 | Missing Categories
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| 205 | ALIVE (or unknown)
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| 206 | GAY OR BISEXUAL MAN
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| 207 | IV DRUG USER
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| 208 | GAY OR BISEXUAL DRUG USER
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| 209 | RECV'D TRANSFUSION/TRANSPLANT
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| 210 | WORK-HEALTH/CLINICAL
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| 211 | ADULT, CONFIRMED OTHER RISK
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| 212 | UNSPECIFIED ELIGIBILITY
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| 213 | UNSPECIFIED POS
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| 214 | SEEN AS OUTPATIENT
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| 215 | SEEN AS INPATIENT
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| 216 | SEEN IN LABORATORY
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| 217 | PRESCRIPTION(S) FILLED
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| 218 | Print Data by CATEGORY as well as totals
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| 219 | Answer YES to get separate listings of utilization by HIV CATEGORY as well as the total population.
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| 220 | Selected IP/OP Activty
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| 221 | SD*5.3*131
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| 222 | NO SC ID
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| 223 | NO SC
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| 224 | NO ID
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| 225 | NO BS
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| 226 | How many of the highest users do you want identified ? 0//
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| 227 | Enter the number, 0 or greater of the individuals with the highest
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| 228 | utilization of pharmacy fills and/or cost you wish listed
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| 229 | NO CATEGORY DEFINED^HIV+^HIV+ (CD4<500)^AIDS-3^AIDS
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| 230 | TOTAL HIV+ (ALL CATEGORIES) POPULATION
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| 231 | FOR THE PERIOD
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| 232 | SELECTED OUTPATIENT ACTIVITY
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| 233 | A 'stop' is credited for each entry of a stop code, while a 'visit' is split
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| 234 | among each stop credited on a given date. Thus, a single visit with two stop
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| 235 | codes credited will show as 0.5 visit for each stop code.
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| 236 | A total of 1.00
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| 237 | visit is given for out patient activity on a given date.
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| 238 | Totals:
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| 239 | patients for
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| 240 | NOT IDENTIFIED
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| 241 | OCCURRENCES OF NO STOP CODE ID
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| 242 | ADD/EDIT STOP CODE
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| 243 | SCHEDULED VISIT
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| 244 | INPATIENT AND OUTPATIENT ACTIVITY
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| 245 | STOP CODES
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| 246 | SELECTED INPATIENT ACTIVITY
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| 247 | stays and
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| 248 | days of inpatient care
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| 249 | Median Length of Stay (MLOS):
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| 250 | Average Length of Stay (ALOS):
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| 251 | OCCURRENCES OF NO BEDSECTION ID
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| 252 | HIGHEST UTILIZATION OF VISITS
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| 253 | HIGHEST NUMBER OF STAYS
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| 254 | HIGHEST NUMBER OF DAYS
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| 255 | moved in:
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| 256 | PTF entry:
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| 257 | Number of Days Patients Not Seen
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| 258 | Enter the number of days you want to check if any patient has not been seen
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| 259 | Immunology Followup List
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| 260 | FOLLOW UP REPORT
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| 261 | PATIENTS AT RISK OF LOSS TO FOLLOW UP
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| 262 | NOT SEEN IN OVER
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| 263 | Local Registry List - ICR Patients
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| 264 | Select Type of Patients
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| 265 | List New Patients added to the registry during this time (Y/N)? N//
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| 266 | Do you want the list sorted by Category (Y/N)? N//
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| 267 | Do you want the list sorted by Reimbursement Level (Y/N)? N//
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| 268 | List Immunology Patients
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| 269 | ***NO PATIENTS FOUND IN DATE RANGE***
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| 270 | REGISTRY LIST
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| 271 | REIM LEV
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| 272 | Minimum number of results reported for a test to be listed
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| 273 | This number (1 or greater) is used to keep from showing long lists of infrequent tests by setting a minimum number of results for display
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| 274 | Selected LAB Activity
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| 275 | Enter the number, 0 or greater, of the individuals with the highest
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| 276 | utilization of laboratory orders you wish listed
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| 277 | LABORATORY UTILIZATION DATA
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| 278 | Totals:
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| 279 | orders placed (
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| 280 | results reported)
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| 281 | during this period for
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| 282 | These include
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| 283 | different entries from LAB TEST file
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| 284 | placed for
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| 285 | in file, not included above
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| 286 | # OF DIFFERENT
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| 287 | LAB TESTS
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| 288 | Max # Results
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| 289 | Reported
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| 290 | Per Patient (# patients)
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| 291 | ***This report will give you a list of your local lab links.***
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| 292 | List Local Lab Links
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| 293 | LOCAL LAB LINKS
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| 294 | Local Name
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| 295 | >>>>> Please wait. Searching for Viral Load & CD4 Values.....
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| 296 | Type of Test
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| 297 | **NO DATA FOUND**
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| 298 | Summary Utilization Data
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| 299 | Answer YES to sort by HIV CATEGORY.
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| 300 | Immunology Summary Utilization Data
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| 301 | Select Facility Source of Information
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| 302 | Sending Request Message to the National Registry...
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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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