English French Notes Complete/Exclude ENVIRONMENT CHECK: Before initialization, this routine will verify whether the package file entries have been converted to the NEW PERSON file. OK, there aren't any unconverted pointers. Hit to continue OK, stopping the installation here..nothing changed! * * This pre-initialization routine will DATA DICTIONARIES the data) for the * * following files: * * 690 (MEDICAL PATIENT) * * 691.1 (CARDIAC CATHETERIZATION) * * 697.5 (MEDICAL DIAGNOSIS/ICD CODES) * * 699.6 (DIAG/THERAP INTERVENT) * save any local modifications to the * * data dictionaries for these files before * * proceeding with this routine. * * (See the Installation Guide for instructions.) * * Any changes not saved will be LOST! * to abort the installation here, or RETURN to continue DATA DICTIONARIES for the following * * 697.3 (MEDICINE SCREEN) * * data dictionaries and data for this file * * before proceeding with this routine. * DIAGNOSIS ENTRY Do you wish to enter this diagnosis as the primary diagnosis Enter Primary Diagnosis (1- Enter Number of Diagnosis That You Wish to Use as Primary Diagnosis Hit Return if you do not wish to enter any of above Enter Number of Secondary Diagnosis or 'ALL' to enter all: Enter Number of Diagnosis from above list or enter 'ALL' for All Diagnoses to be entered as a secondary diagnosis. Possible Diagnoses are: NON-ENDO Select Patient Name or Date/Time of Appointment: INSERTION OF STENT DILATION BY SAVARY BOUGIE GASTROSTOMY TUBE INSERTED JEJUNOSTOMY TUBE INSERTED HEATER PROBE COAGULATION ENTER DATE/TIME OF CONSULT: Enter Date/Time of Procedure: PERSONAL HISTORY INFORMATION History of Bleeding Disorder: Valvular Heart Disease: Glaucoma: History Comments: Do you wish to edit the Personal History Information The valid Anatomy locations are: * END * Press return to continue: Enter Date/Time of Non-Endoscopic Procedure: Allergies/Adverse Reactions: MCAR(690, GENERIC EDIT GEN.IMPL. GENERATOR IMPLANT V-LEAD IMP VENTRICAL LEAD IMPLANT A-LEAD IMP ATRIAL LEAD IMPLANT DEMOGRAPHIC INFORMATION *** SCREEN EDIT *** PROCEDURES *** SCREEN EDIT *** Enter patient name, or date and time: Select Patient or Date/Time of Endoscopic Procedure: Select Patient or Date/Time of Non-Endoscopic Procedure: Select Patient or Date/Time of Consultation: NON-ENDOSCOPIC MC* SYMPTOM: Type of Cough: Duration: Location of Pneumonia: Dates: SURVEILLANCE: DISEASE FOLLOWUP: FOLLOWUP DEVICE/THERAPY: INDICATED THERAPY: EGD SIMPLE PRIMARY EXAM LAB OR XRAY OCCULT BLOOD SPECIMEN COLLECTION Preparation Diet: CLEAR LIQUIDS Diet Comment: Enemas: Bowel Preparation: Pneumoperitoneum Gas: Pressure Control: Stent Type: Stent Size: Stent Length (mm): Sphincterotome Used: Incision Size: SAVARY BOUGIE DIAMETER HEATER PROBE DURATION HEATER PROBE POWER HEMATOLOGY REPORT Hematology Report NOT INPATIENT Press return to continue, '^' to escape: ,MCY:DTIME S:'$T MCY=U S:MCY=U DN=0,MCOUT=1 D:DN HEAD^MCARP K MCY Methanol Ethanol Formalin GROSS DESCRIPTION: The specimen consisted of mm, submitted in This specimen is submitted for decalcification in EDTA. Part of the specimen is fixed and submitted for processing in plastic. BIOPSY COMMENTS: Report Released for Printing. ----------------------------------ATRIAL STUDY---------------------------------- PREMEDICATION: ENTRY SITE: RECORDING SITE: ATRIAL THRESHOLD (mA): CONDUCTION TIMES SINUS NODE FUNCTION STUDIES PA (NL 20-40 MSEC): SACT (NL 80 +/- 40 MSEC): AH (NL 60-120 MSEC): CSART (NL 260+/- 95 MSEC): HV (NL 35-55 MSEC): ATRIAL EXTRA STIMULUS TECHNIQUE (VALUES BELOW IN MSEC) DRIVE CYCLE LENGTH: AERP: AVERP: HPERP: AFRP: AVFRP: HPFRP: ARRP: AVRRP: HPRRP: INCREMENTAL ATRIAL PACING MAXIMUM 1:1 CONDUCTION: WENCKE CYCLE LENGTH: TACHYCARDIA WINDOW: RATE: MORPHOLOGY: CONDUCTION: ARRHYTHMIA: SHORTEST R-R A FIB: SHORTEST R-R POST ISPUREL: LOCATION OF TRACT: ANTEGRADE ERP RETROGRADE ERP BYPASS TRACT: BYPASS ISUPREL: ATRIAL CYCLE LENGTH (MSEC): VENT CYCLE LENGTH (MSEC): QRS DURATION: QRS AXIS: QT: QTC: RYHTHM: INTERPRETATION: DISCHARGE DATE: MEDICATIONS ON DISCHARGE: WARD/CLINIC: REF HOSP OR PHYS: CATH NO: HT IN: WT LBS: PROCEDURES: HISTORY: SYMPTOMS INCLUDED: RISK FACTORS: HEART MEDS: PHYSICAL: PREMEDICATIONS: VASCULAR ACCESS: CATHETERS: TYPE AND SIZE RIGHT HEART LEFT HEART RIGHT CORONARY LEFT CORONARY FLOURO TIME: OTHER PROCEDURE AND COMMENT: TECH COMMENTS: INTERVENTION: PRESSURES: RA A: PCW A: AO S: RV S: LA A: LV S: PRE A: PA S: (POST DYE) SATURATIONS: RA: PA: LV: IVC: RV: LA: SVC: OUTPUT AND INDEX ASSUMED FICK A V AREA (CM SQ): RIGHT CORONARY ARTERY: FROM: TO: LEFT MAIN CA: LAD: CIRCUMFLEX: BYPASS GRAFTS ?: DISTAL ANASTOMOSIS: WALL MOTION: EJECTION FRACTION: MITRAL REGURGITATION: COMPLICATIONS: IMPRESSION: CONCLUSION: PLAN: CARDIOLOGY FELLOW: CARDIOLOGY FELLOW (2nd): CARDIOLOGY STAFF: CARDIOLOGY STAFF (2nd): TEST RESULTS: % FRACT SHORT: LV MASS: EF: mm Hg FINDINGS: DIAGNOSIS(ES): OTHER CONCLUSIONS: CARDIOLOGY ATTENDING: CARDIOLOGY FELLOW: PROCEDURE SUMMARY: ARRHYTHMIA DIAGNOSIS: CARDIAC DIAGNOSIS: REASON FOR STUDY: SYMPTOMS: HX: RHYTHM: RESPONSE TO ATROPINE: RESPONSE TO EXERCISE: RESPONSE TO CAROTID MASSAGE: HEART MEDICATIONS: SVT TYPE: INTERPRETATION: FOLLOW UP: CARDIOLOGY FELLOW (2ND) Endoscopist: FELLOW: 2ND FELLOW: Liver Biopsy: Bleeding Disorder: Allergies: Comments: COMMENT: Where Performed: Start - End: Instrument: Insertion Depth: Medications Used: Technique: Results: Disposition: Primary: Supplement: Instructions: PHYSICIANS' SIGNATURE ____________________________________ Provider/Physician: Consultation Type: Subjective: Objective: Assessment: Planned: Indication Comment: Procedure Summary: INDICATION: MEDICATIONS: PROVIDER/PHYSICIAN: TECHNIQUE: SUBJECTIVE: OBJECTIVE: ASSESSMENT/FINDINGS: PLAN: SUMMARY: PROCEDURE SUMMARY: Consulting Doctor: Consultation Type: Subjective: Allergies/Adverse Reactions: Urgency: Instrument: Physician: Follow-up Date: REVIEWED BY: HOURS: MALFUNCTIONS: HEART RATE TOTAL BEATS #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################