| [604] | 1 | English French Notes Complete/Exclude
|
|---|
| 2 | Discharged From :
|
|---|
| 3 | Room-Bed :
|
|---|
| 4 | REGISTRATION STATUS :
|
|---|
| 5 | VA SCI STATUS :
|
|---|
| 6 | PRIMARY CARE PROVIDER :
|
|---|
| 7 | SCI LEVEL :
|
|---|
| 8 | Etiology Onset Other
|
|---|
| 9 | Recipients of this message:
|
|---|
| 10 | notice for
|
|---|
| 11 | SPNTXT(
|
|---|
| 12 | :INPT START;
|
|---|
| 13 | :INPT GOAL;
|
|---|
| 14 | :INPT INTERIM;
|
|---|
| 15 | :INPT REHAB FINISH;
|
|---|
| 16 | :INPT FOLLOW-UP (END);
|
|---|
| 17 | Enter 1 for an INPT START outcome
|
|---|
| 18 | Enter 2 for an INPT GOAL outcome
|
|---|
| 19 | Enter 3 for an INPT INTERIM outcome
|
|---|
| 20 | Enter 4 for an INPT REHAB FINISH outcome
|
|---|
| 21 | Enter 5 for an INPT FOLLOW-UP (END) outcome
|
|---|
| 22 | Enter 6 for UNKNOWN if the score type is not known
|
|---|
| 23 | 1:OUTPT START;
|
|---|
| 24 | 2:OUTPT GOAL;
|
|---|
| 25 | 3:OUTPT INTERIM;
|
|---|
| 26 | 4:OUTPT REHAB FINISH;
|
|---|
| 27 | 5:OUTPT FOLLOW-UP (END);
|
|---|
| 28 | Enter 1 for an OUTPT START outcome
|
|---|
| 29 | Enter 2 for an OUTPT GOAL outcome
|
|---|
| 30 | Enter 3 for an OUTPT INTERIM outcome
|
|---|
| 31 | Enter 4 for an OUTPT REHAB FINISH outcome
|
|---|
| 32 | Enter 5 for an OUTPT FOLLOW-UP (END) outcome
|
|---|
| 33 | 1:CC ADMIT;
|
|---|
| 34 | 2:CC GOAL;
|
|---|
| 35 | 3:CC INTERIM;
|
|---|
| 36 | 4:CC DISCHARGE;
|
|---|
| 37 | 5:CC OUTPT;
|
|---|
| 38 | Enter 1 for an CC ADMIT outcome
|
|---|
| 39 | Enter 2 for an CC GOAL outcome
|
|---|
| 40 | Enter 3 for an CC INTERIM outcome
|
|---|
| 41 | Enter 4 for an CC DISCHARGE outcome
|
|---|
| 42 | Enter 5 for an CC OUTPT outcome
|
|---|
| 43 | Select the Score Type for this outcome
|
|---|
| 44 | Annual Evaluation
|
|---|
| 45 | Continuum of Care
|
|---|
| 46 | NO CARE TYPE
|
|---|
| 47 | Enter a New Record Date:
|
|---|
| 48 | Do you wish to close this episode of care
|
|---|
| 49 | Enter Yes to close this episode or No to leave it open.
|
|---|
| 50 | Current INPATIENT Episode of Care
|
|---|
| 51 | Previous INPATIENT Episode(s) of Care
|
|---|
| 52 | No care start date is on file for this patient !
|
|---|
| 53 | You need to add an Outcome to the current episode and select
|
|---|
| 54 | a Score Type of INPT FOLLOW-UP (END).
|
|---|
| 55 | There are no INPATIENT episodes of care on file.
|
|---|
| 56 | (An ASIA should be entered first if an episode is created.)
|
|---|
| 57 | Would you like to create an episode of care
|
|---|
| 58 | Would you like to create a new episode of care
|
|---|
| 59 | Enter a Y to create a new INPATIENT episode.
|
|---|
| 60 | Enter a N or just Return to return to the last episode
|
|---|
| 61 | Current OUTPATIENT Episode of Care
|
|---|
| 62 | Previous OUTPATIENT Episode(s) of Care
|
|---|
| 63 | a Score Type of OUTPT FOLLOW-UP (END).
|
|---|
| 64 | There are no OUTPATIENT episodes of care on file.
|
|---|
| 65 | Enter a Y to create a new OUTPATIENT episode.
|
|---|
| 66 | Previous INPATIENT Episode of Care
|
|---|
| 67 | Previous OUTPATIENT Episode of Care
|
|---|
| 68 | Date Opened
|
|---|
| 69 | to view/edit an episode of care, '^' to exit
|
|---|
| 70 | press Return to see the next group
|
|---|
| 71 | Enter a number within the range allowed.
|
|---|
| 72 | Selected number is outside the range.
|
|---|
| 73 | ANNUAL EVALUATIONS
|
|---|
| 74 | CONTINUUM OF CARE
|
|---|
| 75 | There are no Previous episodes for this patient
|
|---|
| 76 | EDSS:
|
|---|
| 77 | Episodes of care
|
|---|
| 78 | Outcomes on file.
|
|---|
| 79 | (An ASIA should be entered first if you add outcomes.)
|
|---|
| 80 | to view/edit an outcome, '^' to exit, or
|
|---|
| 81 | <Return> to see the next group
|
|---|
| 82 | <A> to Add a new outcome
|
|---|
| 83 | Enter a number within the range allowed, or one of the designated keys.
|
|---|
| 84 | Aa^
|
|---|
| 85 | Care Start Date:
|
|---|
| 86 | End Date:
|
|---|
| 87 | <P> to view/edit a Previous episode of care
|
|---|
| 88 | <C> to Create a new episode of care
|
|---|
| 89 | AaPpCc^
|
|---|
| 90 | AaPp^
|
|---|
| 91 | Aa0^
|
|---|
| 92 | ******** Patient NOT Expired ********
|
|---|
| 93 | This is to alert you that a patient marked as 'Expired'
|
|---|
| 94 | in the SCD Registry is alive according to MAS records.
|
|---|
| 95 | Notify your hospital's MAS personnel -- it is possible
|
|---|
| 96 | that the patient is indeed deceased, but Date of Death
|
|---|
| 97 | was not entered into pt's VA record.
|
|---|
| 98 | However, if this patient is truely alive, please update
|
|---|
| 99 | his Registration Status field in the SCD Registry.
|
|---|
| 100 | Patient ---->
|
|---|
| 101 | PT DEATH: MAS RECORD vs. SCD RECORD
|
|---|
| 102 | SCD REGISTRY
|
|---|
| 103 | SPNARR(
|
|---|
| 104 | G.SPNL SCD COORDINATOR
|
|---|
| 105 | ******** Patient NOT Deceased ********
|
|---|
| 106 | in the PATIENT file has been corrected to 'NOT deceased'.
|
|---|
| 107 | Please check this patient's record in the SCD Registry to
|
|---|
| 108 | ensure the Registration Status field is updated.
|
|---|
| 109 | Patient's name is ---->
|
|---|
| 110 | Patient's SSN is ---->
|
|---|
| 111 | UPDATE REGISTRATION STATUS - SCI PATIENT
|
|---|
| 112 | The date of death for
|
|---|
| 113 | been deleted from the patient file.
|
|---|
| 114 | The Registration Status needs to be up-dated in the
|
|---|
| 115 | Spinal Cord Registry.
|
|---|
| 116 | Date of death deleted for
|
|---|
| 117 | Please stand by while your Registry is updated.
|
|---|
| 118 | Thank you!!
|
|---|
| 119 | The number of days cannot exceed
|
|---|
| 120 | Pt not in SCD Registry!
|
|---|
| 121 | No etiology on file.
|
|---|
| 122 | Enter a START date:
|
|---|
| 123 | Option aborted!
|
|---|
| 124 | Enter a ENDING date:
|
|---|
| 125 | Patients with future Appointments
|
|---|
| 126 | No Clinic on File
|
|---|
| 127 | **** No Data for this report. ****
|
|---|
| 128 | Patients in the Registry only
|
|---|
| 129 | Patients marked as SCI but not in the Registry
|
|---|
| 130 | Combined report -- Pts in Registry AND Pts marked as SCI but not in Registry
|
|---|
| 131 | Listing appointments from
|
|---|
| 132 | Appointment date
|
|---|
| 133 | Reg
|
|---|
| 134 | TEMP ADM
|
|---|
| 135 | No Outcomes on file.
|
|---|
| 136 | You can add one if you wish.
|
|---|
| 137 | Not on the list..
|
|---|
| 138 | Not on the list
|
|---|
| 139 | Score type:
|
|---|
| 140 | Goal
|
|---|
| 141 | Interim
|
|---|
| 142 | EDSS Score:
|
|---|
| 143 | Self Reported Functional Measure
|
|---|
| 144 | Clinician Reported FIM
|
|---|
| 145 | CHART/FAM/DIENNER/DUSOI
|
|---|
| 146 | ASIA Score
|
|---|
| 147 | MS module (Kurtzke/EDSS)
|
|---|
| 148 | Select 1 through
|
|---|
| 149 | or A to add a new record or ^ to quit.
|
|---|
| 150 | Or Return to see the next group.
|
|---|
| 151 | ;8:Multiple Sclerosis
|
|---|
| 152 | Select the Record Type for this outcome
|
|---|
| 153 | Enter 1 to enter/edit a Self Report of Function score.
|
|---|
| 154 | Enter 2 to enter/edit a FIM score.
|
|---|
| 155 | Enter 3 to enter/edit an ASIA score.
|
|---|
| 156 | Enter 4 to enter/edit a CHART score.
|
|---|
| 157 | Enter 5 to enter/edit a FAM score.
|
|---|
| 158 | Enter 6 to enter/edit a DIENER score.
|
|---|
| 159 | Enter 7 to enter/edit a DUSOI score.
|
|---|
| 160 | Enter 8 to enter/edit a Multiple Sclerosis score.
|
|---|
| 161 | Choose either 1,2,3,4,5,6,7
|
|---|
| 162 | Enter a New Record Date :
|
|---|
| 163 | The screen-based entry process has failed!!
|
|---|
| 164 | .03///SCD - CURRENTLY SERVED
|
|---|
| 165 | (Computed from incomplete data)
|
|---|
| 166 | (No data or invalid data found)
|
|---|
| 167 | Motor FIM Score:
|
|---|
| 168 | Cognitive FIM Score:
|
|---|
| 169 | Total FIM Score:
|
|---|
| 170 | Self Report of Function total score:
|
|---|
| 171 | ERROR, unknown record type: '
|
|---|
| 172 | .03///SCD - CURRENTLY SERVED;.04///TRANSMIT
|
|---|
| 173 | Four Level Functional Measure
|
|---|
| 174 | Enter 'A' to create a new record for the selected patient.
|
|---|
| 175 | E:Edit an existing record;
|
|---|
| 176 | Enter 'E' to edit a pre-existing record for the selected patient.
|
|---|
| 177 | Choose either 'A' or 'E'.
|
|---|
| 178 | Enter 'A' to add a record, <RETURN> or '^' to exit.
|
|---|
| 179 | ;.04///TODAY;.04DATE RECORDED
|
|---|
| 180 | Select DATE RECORDED:
|
|---|
| 181 | Checking data for inconsistencies...
|
|---|
| 182 | CAUSE OF INJURY is not 'OTHER', DESCRIBE CAUSE OTHER should be blank.
|
|---|
| 183 | ONE ARM AFFECTED and BOTH ARMS AFFECTED are both answered 'YES'.
|
|---|
| 184 | ONE LEG AFFECTED and BOTH LEGS AFFECTED are both answered 'YES'.
|
|---|
| 185 | OTHER BODY PART AFFECTED is 'NO', DESCRIBE OTHER BODY PART should be blank.
|
|---|
| 186 | HELP DURING LAST 2 WEEKS is 'NO', NUMBER OF HOURS OF HELP should be blank.
|
|---|
| 187 | RECEIVED MOST MEDICAL CARE is 'NON-VA ONLY' or 'DID NOT SEE DOCTOR/NURSE
|
|---|
| 188 | LAST 5 YRS', VA MOST USED FOR MEDICAL CARE should be blank.
|
|---|
| 189 | Select the type of record you wish to enter/edit
|
|---|
| 190 | Enter 1 to enter/edit Registration and Health Care Information
|
|---|
| 191 | Enter 2 to enter/edit Outcome Information
|
|---|
| 192 | Enter 3 to enter/edit Clinical Information
|
|---|
| 193 | Enter 4 to Select a NEW Patient
|
|---|
| 194 | Choose either 1,2,3, or 4.
|
|---|
| 195 | Select SCD (SPINAL CORD) REGISTRY PATIENT:
|
|---|
| 196 | Select the type of Functional Status you wish to print
|
|---|
| 197 | Enter 1 to print Self Report of Function scores
|
|---|
| 198 | Enter 2 to print FIM scores
|
|---|
| 199 | Please enter 1 or 2
|
|---|
| 200 | Select the type of FIM score you wish to print
|
|---|
| 201 | Enter 1 to print Motor scores
|
|---|
| 202 | Enter 2 to print Cognitive scores
|
|---|
| 203 | Enter 3 to print Total scores
|
|---|
| 204 | Please enter 1, 2, or 3
|
|---|
| 205 | Enter the beginning date range:
|
|---|
| 206 | Enter the beginning date to search for Functional Status scores
|
|---|
| 207 | Enter the ending date range:
|
|---|
| 208 | Enter the ending date to search for Functional Status scores
|
|---|
| 209 | SCD Functional Status Scores Report
|
|---|
| 210 | SPNFDATA(
|
|---|
| 211 | No data found for this patient
|
|---|
| 212 | Extent & Completeness:
|
|---|
| 213 | Type of Injury:
|
|---|
| 214 | A-EATING G-BLADDER MANAGEMENT M-STAIRS
|
|---|
| 215 | B-GROOMING H-BOWEL MANAGEMENT N-COMPREHENSION
|
|---|
| 216 | C-BATHING I-TRANSFER TO BED/CHAIR O-EXPRESSION
|
|---|
| 217 | D-DRESSING UPPER BODY J-TRANSFER TO TOILET P-SOCIAL INTERACTION
|
|---|
| 218 | E-DRESSING LOWER BODY K-TRANSFER TO TUB/SHOWER Q-PROBLEM SOLVING
|
|---|
| 219 | F-TOILETING L-MOVE AROUND INSIDE YOUR HOUSE R-MEMORY
|
|---|
| 220 | indicates the score is incomplete.
|
|---|
| 221 | EDSS Score:
|
|---|
| 222 | Invalid message format, rest of message ignored.
|
|---|
| 223 | Patient not found:
|
|---|
| 224 | The SCD Registry Veteran Survey Server has encountered the
|
|---|
| 225 | following problems with MailMan server message #
|
|---|
| 226 | the following number of records:
|
|---|
| 227 | SCD Registry records:
|
|---|
| 228 | FIM records:
|
|---|
| 229 | SCD Registry Veteran Survey Server
|
|---|
| 230 | G.SPNZ SCD COORDINATOR
|
|---|
| 231 | NUMBER OF HOURS OF HELP should be blank if
|
|---|
| 232 | HELP DURING LAST 2 WEEKS is answered 'YES'.
|
|---|
| 233 | A Functional Status record already exists for this date.
|
|---|
| 234 | Please change the DATE RECORDED to a different date.
|
|---|
| 235 | You have entered an INPT REHAB FINISH or INPT FOLLOW/UP (END) or OUTPT
|
|---|
| 236 | REHAB FINISH or OUTPT FOLLOW/UP (END) CHART for a patient who has a recorded
|
|---|
| 237 | INPT GOAL or OUTPT GOAL CHART. Do you want to see a comparison template you
|
|---|
| 238 | can copy and paste into a CPRS progress note
|
|---|
| 239 | Physical
|
|---|
| 240 | Cogntv
|
|---|
| 241 | Mobility
|
|---|
| 242 | Social
|
|---|
| 243 | Econ
|
|---|
| 244 | ***************** COPYRIGHT NOTICE ******************
|
|---|
| 245 | Some material on the following screen is reprinted with permission from
|
|---|
| 246 | the Paralyzed Veterans of America (PVA). Outcomes Following Traumatic
|
|---|
| 247 | Spinal Cord Injury: Clinical Practice Guideline for Health-Care
|
|---|
| 248 | Professionals. Washington, DC: Paralyzed Veterans of America, 1999.
|
|---|
| 249 | the authors and Aspen Publishers, Inc. Spinal Cord Injury: Clinical
|
|---|
| 250 | Outcomes from the Model Systems. Gaithersburg, MD: Aspen Publishers,
|
|---|
| 251 | Inc., 1995.
|
|---|
| 252 | You have entered an INPT START or OUTPT START Diener's SWLS for a patient with
|
|---|
| 253 | level spinal cord injury and ASIA Impairment Scale of
|
|---|
| 254 | Do you want to see a goal setting template you can copy and paste
|
|---|
| 255 | into a CPRS progress note
|
|---|
| 256 | Aor B or C
|
|---|
| 257 | any neurologic
|
|---|
| 258 | | | Diener's SWLS Composite |
|
|---|
| 259 | REHAB FINISH or OUTPT FOLLOW/UP (END) DIENER for a patient who has a recorded
|
|---|
| 260 | INPT GOAL or OUTPT GOAL DIENER. Do you want to see a comparison template you
|
|---|
| 261 | There is no DIENER start Outcome on file.
|
|---|
| 262 | REHAB FINISH or OUTPT FOLLOW/UP (END) FAM for a patient who has a recorded
|
|---|
| 263 | INPT GOAL or OUTPT GOAL FAM. Do you want to see a comparison template you
|
|---|
| 264 | Swallow
|
|---|
| 265 | Car Txfrs
|
|---|
| 266 | Community
|
|---|
| 267 | Speech |
|
|---|
| 268 | Emot
|
|---|
| 269 | Employ
|
|---|
| 270 | Orientation
|
|---|
| 271 | Attn
|
|---|
| 272 | spinal cord injury level and a motor complete ASIA Impairment Scale of
|
|---|
| 273 | . Do you want to see a goal setting template you can copy
|
|---|
| 274 | and paste into a CPRS progress note
|
|---|
| 275 | | | Bwl | Bldr | Trnsfr | Eat | DUB | DLB | Grmng | Bathe | WC Prp |
|
|---|
| 276 | | | Raw FIM Motor Score |
|
|---|
| 277 | REHAB FINISH or OUTPT FOLLOW/UP (END) FIM for a patient who has a recorded
|
|---|
| 278 | INPT GOAL or OUTPT GOAL FIM. Do you want to see a comparison
|
|---|
| 279 | template you can copy and paste into a CPRS progress note
|
|---|
| 280 | Grmmg
|
|---|
| 281 | Bathe
|
|---|
| 282 | Bldr
|
|---|
| 283 | Bwl
|
|---|
| 284 | BCWC Trf
|
|---|
| 285 | Tlt Trf
|
|---|
| 286 | TSh Trf
|
|---|
| 287 | Strs |
|
|---|
| 288 | Compr
|
|---|
| 289 | Expr
|
|---|
| 290 | Soc
|
|---|
| 291 | Prb Slv
|
|---|
| 292 | Mem
|
|---|
| 293 | Mtr
|
|---|
| 294 | Cogn
|
|---|
| 295 | Tot |
|
|---|
| 296 | There is no FIM goal on file !
|
|---|
| 297 | You have entered an INPT REHAB FINISH FIM for a patient with
|
|---|
| 298 | spinal cord injury level and ASIA Impairment Scale of
|
|---|
| 299 | Do you want to see a comparison template you can copy and paste into a CPRS
|
|---|
| 300 | progress note
|
|---|
| 301 | |||Registration OBR
|
|---|
| 302 | |||154 ETIOLOGY DATA|||
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
