[604] | 1 | English French Notes Complete/Exclude
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| 2 | ENVIRONMENT CHECK:
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| 3 | Before initialization, this routine will verify whether the
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| 4 | package file entries have been converted to the NEW PERSON file.
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| 5 | OK, there aren't any unconverted pointers.
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| 6 | Hit <RETURN> to continue
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| 7 | OK, stopping the installation here..nothing changed!
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| 8 | *
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| 9 | * This pre-initialization routine will
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| 10 | DATA DICTIONARIES
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| 11 | the data) for the *
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| 12 | * following files: *
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| 13 | * 690 (MEDICAL PATIENT) *
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| 14 | * 691.1 (CARDIAC CATHETERIZATION) *
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| 15 | * 697.5 (MEDICAL DIAGNOSIS/ICD CODES) *
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| 16 | * 699.6 (DIAG/THERAP INTERVENT) *
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| 17 | save any local modifications to the *
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| 18 | * data dictionaries for these files before *
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| 19 | * proceeding with this routine. *
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| 20 | * (See the Installation Guide for instructions.) *
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| 21 | * Any changes not saved will be
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| 22 | LOST!
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| 23 | *
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| 24 | to abort the installation here, or RETURN to continue
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| 25 | DATA DICTIONARIES
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| 26 | for the following *
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| 27 | * 697.3 (MEDICINE SCREEN) *
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| 28 | * data dictionaries and data for this file *
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| 29 | * before proceeding with this routine. *
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| 30 | DIAGNOSIS ENTRY
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| 31 | Do you wish to enter this diagnosis as the primary diagnosis
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| 32 | Enter Primary Diagnosis (1-
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| 33 | Enter Number of Diagnosis That You Wish to Use as Primary Diagnosis
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| 34 | Hit Return if you do not wish to enter any of above
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| 35 | Enter Number of Secondary Diagnosis or 'ALL' to enter all:
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| 36 | Enter Number of Diagnosis from above list or enter 'ALL' for All Diagnoses to be entered as a secondary diagnosis.
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| 37 | Possible
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| 38 | Diagnoses are:
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| 39 | NON-ENDO
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| 40 | Select Patient Name or Date/Time of Appointment:
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| 41 | INSERTION OF STENT
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| 42 | DILATION BY SAVARY BOUGIE
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| 43 | GASTROSTOMY TUBE INSERTED
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| 44 | JEJUNOSTOMY TUBE INSERTED
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| 45 | HEATER PROBE COAGULATION
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| 46 | ENTER DATE/TIME OF CONSULT:
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| 47 | Enter Date/Time of Procedure:
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| 48 | PERSONAL HISTORY INFORMATION
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| 49 | History of Bleeding Disorder:
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| 50 | Valvular Heart Disease:
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| 51 | Glaucoma:
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| 52 | History Comments:
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| 53 | Do you wish to edit the Personal History Information
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| 54 | The valid Anatomy locations are:
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| 55 | * END * Press return to continue:
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| 56 | Enter Date/Time of Non-Endoscopic Procedure:
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| 57 | Allergies/Adverse Reactions:
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| 58 | MCAR(690,
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| 59 | GENERIC EDIT
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| 60 | GEN.IMPL.
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| 61 | GENERATOR IMPLANT
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| 62 | V-LEAD IMP
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| 63 | VENTRICAL LEAD IMPLANT
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| 64 | A-LEAD IMP
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| 65 | ATRIAL LEAD IMPLANT
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| 66 | DEMOGRAPHIC INFORMATION *** SCREEN EDIT ***
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| 67 | PROCEDURES *** SCREEN EDIT ***
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| 68 | Enter patient name, or date and time:
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| 69 | Select Patient or Date/Time of Endoscopic Procedure:
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| 70 | Select Patient or Date/Time of Non-Endoscopic Procedure:
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| 71 | Select Patient or Date/Time of Consultation:
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| 72 | NON-ENDOSCOPIC
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| 73 | MC*
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| 74 | SYMPTOM:
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| 75 | Type of Cough:
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| 76 | Duration:
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| 77 | Location of Pneumonia:
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| 78 | Dates:
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| 79 | SURVEILLANCE:
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| 80 | DISEASE FOLLOWUP:
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| 81 | FOLLOWUP DEVICE/THERAPY:
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| 82 | INDICATED THERAPY:
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| 83 | EGD SIMPLE PRIMARY EXAM
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| 84 | LAB OR XRAY
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| 85 | OCCULT BLOOD
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| 86 | SPECIMEN COLLECTION
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| 87 | Preparation Diet:
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| 88 | CLEAR LIQUIDS
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| 89 | Diet Comment:
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| 90 | Enemas:
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| 91 | Bowel Preparation:
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| 92 | Pneumoperitoneum Gas:
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| 93 | Pressure Control:
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| 94 | Stent Type:
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| 95 | Stent Size:
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| 96 | Stent Length (mm):
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| 97 | Sphincterotome Used:
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| 98 | Incision Size:
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| 99 | SAVARY BOUGIE DIAMETER
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| 100 | HEATER PROBE DURATION
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| 101 | HEATER PROBE POWER
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| 102 | HEMATOLOGY REPORT
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| 103 | Hematology Report
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| 104 | NOT INPATIENT
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| 105 | Press return to continue, '^' to escape:
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| 106 | ,MCY:DTIME S:'$T MCY=U S:MCY=U DN=0,MCOUT=1 D:DN HEAD^MCARP K MCY
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| 107 | Methanol
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| 108 | Ethanol
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| 109 | Formalin
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| 110 | GROSS DESCRIPTION: The specimen consisted of
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| 111 | mm, submitted in
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| 112 | This specimen is submitted for decalcification in EDTA.
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| 113 | Part of the specimen is fixed and submitted for processing in plastic.
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| 114 | BIOPSY COMMENTS:
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| 115 | Report Released for Printing.
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| 116 | ----------------------------------ATRIAL STUDY----------------------------------
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| 117 | PREMEDICATION:
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| 118 | ENTRY SITE:
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| 119 | RECORDING SITE:
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| 120 | ATRIAL THRESHOLD (mA):
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| 121 | CONDUCTION TIMES
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| 122 | SINUS NODE FUNCTION STUDIES
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| 123 | PA (NL 20-40 MSEC):
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| 124 | SACT (NL 80 +/- 40 MSEC):
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| 125 | AH (NL 60-120 MSEC):
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| 126 | CSART (NL 260+/- 95 MSEC):
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| 127 | HV (NL 35-55 MSEC):
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| 128 | ATRIAL EXTRA STIMULUS TECHNIQUE (VALUES BELOW IN MSEC)
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| 129 | DRIVE CYCLE LENGTH:
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| 130 | AERP:
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| 131 | AVERP:
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| 132 | HPERP:
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| 133 | AFRP:
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| 134 | AVFRP:
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| 135 | HPFRP:
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| 136 | ARRP:
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| 137 | AVRRP:
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| 138 | HPRRP:
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| 139 | INCREMENTAL ATRIAL PACING
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| 140 | MAXIMUM 1:1 CONDUCTION:
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| 141 | WENCKE CYCLE LENGTH:
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| 142 | TACHYCARDIA WINDOW:
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| 143 | RATE:
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| 144 | MORPHOLOGY:
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| 145 | CONDUCTION:
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| 146 | ARRHYTHMIA:
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| 147 | SHORTEST R-R A FIB:
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| 148 | SHORTEST R-R POST ISPUREL:
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| 149 | LOCATION OF TRACT:
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| 150 | ANTEGRADE ERP
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| 151 | RETROGRADE ERP
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| 152 | BYPASS TRACT:
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| 153 | BYPASS ISUPREL:
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| 154 | ATRIAL CYCLE LENGTH (MSEC):
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| 155 | VENT CYCLE LENGTH (MSEC):
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| 156 | QRS DURATION:
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| 157 | QRS AXIS:
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| 158 | QT:
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| 159 | QTC:
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| 160 | RYHTHM:
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| 161 | INTERPRETATION:
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| 162 | DISCHARGE DATE:
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| 163 | MEDICATIONS ON DISCHARGE:
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| 164 | WARD/CLINIC:
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| 165 | REF HOSP OR PHYS:
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| 166 | CATH NO:
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| 167 | HT IN:
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| 168 | WT LBS:
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| 169 | PROCEDURES:
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| 170 | HISTORY:
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| 171 | SYMPTOMS INCLUDED:
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| 172 | RISK FACTORS:
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| 173 | HEART MEDS:
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| 174 | PHYSICAL:
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| 175 | PREMEDICATIONS:
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| 176 | VASCULAR ACCESS:
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| 177 | CATHETERS:
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| 178 | TYPE AND SIZE
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| 179 | RIGHT HEART
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| 180 | LEFT HEART
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| 181 | RIGHT CORONARY
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| 182 | LEFT CORONARY
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| 183 | FLOURO TIME:
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| 184 | OTHER PROCEDURE AND COMMENT:
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| 185 | TECH COMMENTS:
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| 186 | INTERVENTION:
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| 187 | PRESSURES:
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| 188 | RA A:
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| 189 | PCW A:
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| 190 | AO S:
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| 191 | RV S:
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| 192 | LA A:
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| 193 | LV S:
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| 194 | PRE A:
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| 195 | PA S:
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| 196 | (POST DYE)
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| 197 | SATURATIONS:
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| 198 | RA:
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| 199 | PA:
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| 200 | LV:
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| 201 | IVC:
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| 202 | RV:
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| 203 | LA:
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| 204 | SVC:
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| 205 | OUTPUT AND INDEX
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| 206 | ASSUMED FICK
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| 207 | A V AREA (CM SQ):
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| 208 | RIGHT CORONARY ARTERY:
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| 209 | FROM:
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| 210 | TO:
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| 211 | LEFT MAIN CA:
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| 212 | LAD:
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| 213 | CIRCUMFLEX:
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| 214 | BYPASS GRAFTS ?:
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| 215 | DISTAL ANASTOMOSIS:
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| 216 | WALL MOTION:
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| 217 | EJECTION FRACTION:
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| 218 | MITRAL REGURGITATION:
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| 219 | COMPLICATIONS:
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| 220 | IMPRESSION:
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| 221 | CONCLUSION:
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| 222 | PLAN:
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| 223 | CARDIOLOGY FELLOW:
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| 224 | CARDIOLOGY FELLOW (2nd):
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| 225 | CARDIOLOGY STAFF:
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| 226 | CARDIOLOGY STAFF (2nd):
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| 227 | TEST RESULTS:
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| 228 | % FRACT SHORT:
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| 229 | LV MASS:
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| 230 | EF:
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| 231 | mm Hg
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| 232 | FINDINGS:
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| 233 | DIAGNOSIS(ES):
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| 234 | OTHER CONCLUSIONS:
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| 235 | CARDIOLOGY ATTENDING:
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| 236 | CARDIOLOGY FELLOW:
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| 237 | PROCEDURE SUMMARY:
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| 238 | ARRHYTHMIA DIAGNOSIS:
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| 239 | CARDIAC DIAGNOSIS:
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| 240 | REASON FOR STUDY:
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| 241 | SYMPTOMS:
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| 242 | HX:
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| 243 | RHYTHM:
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| 244 | RESPONSE TO ATROPINE:
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| 245 | RESPONSE TO EXERCISE:
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| 246 | RESPONSE TO CAROTID MASSAGE:
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| 247 | HEART MEDICATIONS:
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| 248 | SVT TYPE:
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| 249 | INTERPRETATION:
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| 250 | FOLLOW UP:
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| 251 | CARDIOLOGY FELLOW (2ND)
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| 252 | Endoscopist:
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| 253 | FELLOW:
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| 254 | 2ND FELLOW:
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| 255 | Liver Biopsy:
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| 256 | Bleeding Disorder:
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| 257 | Allergies:
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| 258 | Comments:
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| 259 | COMMENT:
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| 260 | Where Performed:
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| 261 | Start - End:
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| 262 | Instrument:
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| 263 | Insertion Depth:
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| 264 | Medications Used:
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| 265 | Technique:
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| 266 | Results:
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| 267 | Disposition:
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| 268 | Primary:
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| 269 | Supplement:
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| 270 | Instructions:
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| 271 | PHYSICIANS' SIGNATURE ____________________________________
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| 272 | Provider/Physician:
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| 273 | Consultation Type:
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| 274 | Subjective:
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| 275 | Objective:
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| 276 | Assessment:
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| 277 | Planned:
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| 278 | Indication Comment:
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| 279 | Procedure Summary:
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| 280 | INDICATION:
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| 281 | MEDICATIONS:
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| 282 | PROVIDER/PHYSICIAN:
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| 283 | TECHNIQUE:
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| 284 | SUBJECTIVE:
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| 285 | OBJECTIVE:
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| 286 | ASSESSMENT/FINDINGS:
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| 287 | PLAN:
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| 288 | SUMMARY:
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| 289 | PROCEDURE SUMMARY:
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| 290 | Consulting Doctor:
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| 291 | Consultation Type:
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| 292 | Subjective:
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| 293 | Allergies/Adverse Reactions:
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| 294 | Urgency:
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| 295 | Instrument:
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| 296 | Physician:
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| 297 | Follow-up Date:
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| 298 | REVIEWED BY:
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| 299 | HOURS:
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| 300 | MALFUNCTIONS:
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| 301 | HEART RATE
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| 302 | TOTAL BEATS
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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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