English	French	Notes	Complete/Exclude
collection of information.  Send comments regarding this burden estimate or any other aspects of this collection, including			
suggestions for reducing this burden to VA Clearance Officer (045A4), 810 Vermont Avenue, NW, Washington, DC 20420.			
PRIVACY ACT NOTICE:  The information requested on this form is solicited under authority of Title 38, U.S.C., Sections 710, 1712			
and 1722.  It is being collected to enable us to determine your eligibility for medical benefits, identify your medical records,			
and provide basic data for your treatment.  Additional information, such as medical history, may be solicited during the course of			
your medical evaluation or treatment.  The income and eligibility information you supply may be verified through a computer			
matching program at any time and information may be disclosed outside VA as permitted by law; possible disclosures include			
those described in the 			
routine uses			
 identified in the VA system of records 24VA136, Patient Medical Records-VA, published			
in the Federal Register in accordance with the Privacy Act of 1974.  These 			
 include disclosures: in response			
to court subpoenas; to epidemiological and other research facilities for research purposes; in connection with collections			
of amounts owed to the United States; to the Department of Justice for use in litigation; to other Federal agencies in connection			
with their employment determinations, investigations, or issuance of licenses or benefits; to report apparent law violations to			
other Federal, State or local agencies charged with law enforcement responsibilities; in response to an official request from a			
criminal or civil law enforcement governmental agency charged with the protection of public health or safety; to the Internal			
Revenue Service to verify unearned income, collect amounts owed VA, and to report as income debts that are waived, compromised or			
otherwise forgiven; to the Social Security Administration to verify earned income and employment data; to notify State licensing			
boards and Federal agencies of the health care practices of health care providers; to non-VA health care providers; to non-VA			
health care providers of facilities when the patient is referred for medical care at VA expense; to private sector organizations			
for the purpose of obtaining accreditation or approval rating for the health care facility; to non-VA nursing homes for			
preadmission screening; or, to contractors to perform the services covered by the contract.  Disclosure is voluntary, however,			
failure to furnish the information will result in our inability to process your request and serve your medical needs.			
Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.			
Disclosure of the Social Security number(s) of those for whom benefits are claimed is requested under the authority of			
Title 38, U.S.C., and is voluntary.  Social Security numbers will be used in the administration of veteran's benefits,			
in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for			
other purposes where authorized by both Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where			
required by another statute.			
STREET ADDRESS [LINE 1]			
STREET ADDRESS [LINE 2]			
K-ADDRESS SAME AS PATIENT'S?			
K-STREET ADDRESS [LINE 1]			
K-STREET ADDRESS [LINE 2]			
K-STREET ADDRESS [LINE 3]			
FXa			
K-PHONE NUMBER			
K-WORK PHONE NUMBER			
E-EMER. CONTACT SAME AS NOK?			
E-RELATIONSHIP TO PATIENT			
E-STREET ADDRESS [LINE 1]			
E-STREET ADDRESS [LINE 2]			
E-STREET ADDRESS [LINE 3]			
E-PHONE NUMBER			
E-WORK PHONE NUMBER			
SERVICE BRANCH [LAST]			
DIC(23,			
SERVICE NUMBER [LAST]			
CURRENT PH INDICATOR			
CURRENT PURPLE HEART STATUS			
1:PENDING;2:IN PROCESS;3:CONFIRMED;			
PH DIVISION			
CURRENT PURPLE HEART REMARKS			
1:UNACCEPTABLE DOCUMENTATION;2:NO DOCUMENTATION REC'D;3:ENTERED IN ERROR;4:UNSUPPORTED PURPLE HEART;5:VAMC;6:UNDELIVERABLE MAIL;			
ENVIRONMENTAL CONTAMINANTS?			
DISABILITY RET. FROM MILITARY?			
0:NO;1:YES, RECEIVING MILITARY RETIREMENT;2:YES, RECEIVING MILITARY RETIREMENT IN LIEU OF VA COMPENSATION;3:UNKNOWN;			
DIC(21,			
STREET ADDRESS [LINE 3]			
PHONE NUMBER [RESIDENCE]			
BAD ADDRESS INDICATOR			
1:UNDELIVERABLE;2:HOMELESS;3:OTHER;			
K-NAME OF PRIMARY NOK			
K-RELATIONSHIP TO PATIENT			
CONFIDENTIAL ADDRESS DATA, SCREEN <			
UNK. CITY/STATE			
SC AWARD DATE			
RATED INCOMPETENT?			
DATE RULED INCOMPETENT (CIVIL)			
DATE RULED INCOMPETENT (VA)			
CLAIM FOLDER LOCATION			
TOTAL ANNUAL VA CHECK AMOUNT			
GI INSURANCE POLICY?			
SERVICE CONNECTED CONDITIONS			
AMOUNT OF GI INSURANCE			
Applicant doesn't have GI Insurance.			
AGENCY/ALLIED COUNTRY			
DIC(35,			
RECALLED TO ACTIVE DUTY			
0:NO;1:NATIONAL GUARD;2:RESERVES;			
DIC(25002.1,			
Variable DGDR must be defined!			
Executing HL7 ADT Messaging (RAI/MDS)			
HL7 ADT MESSAGE (RAI/MDS)			
VAFH(			
From ASIH			
Unable to determine wards for transfer cancellation			
-1^Server Protocol not found			
-1^Unable to build segment list to transmit			
-1^An error occurred in one of the segments			
RAI/MDS HL7 MESSAGE XMIT			
RAI/MDS APPLICATION			
DGRU HL7SND			
RAI/MDS HL7 ADT ERROR			
DGRU RAI ERROR			
DGRU-RAI-A03-SERVER			
-1^Unable to build segment list			
-1^Error while building segment			
The field 			
 is missing data.			
Service of ward must be the same as bedsection			
A RUG-II GROUP CAN NOT BE DETERMINED ON THIS PATIENT 			
Do you wish to edit now			
There are fields missing data for this patient. The PAI will			
 not be complete until all data is entered. You can			
 complete the PAI at this time by responding 'Y'es.			
RUG-II GROUP:   			
HIERARCHY GROUP:   			
HEAVY REHABILITATION			
SPECIAL CARE			
CLINICAL COMPLEX			
ADL SUM:   			
RUG-II WWUs:   			
DG RUG CLOSE PAI			
Close this record now			
If 'TUBE FEEDING' or 'PARENTERAL FEEDING' 			
 is marked 'Y'es then question 'EATING' must be marked '5'.			
If 'TUBE FEEDING' and 'PARENTERAL FEEDING' 			
 are marked 'N'o then question 'EATING' must not be marked '5'.			
If 'TUBE FEEDING' 			
 is marked 'Y'es then question 'TUBE FEEDING ROUTE' must not be marked '1'.			
If 'CHRONIC VENTILATOR DEP. (CVD)' is marked 'N'o then all CVD related			
questions must be marked '1'.			
For each of the therapy questions,'DAYS PER WEEK' and 'HOURS PER WEEK' must be '0' if level is '1'.			
and 'HOURS/MINUTES PER WEEK' must be greater than 29 minutes if level is			
greater than '1'.			
Can not have more than 10 hours of therapy per day			
If 'NASAL OR ENTERIC FEEDING' 			
if level is greater than '1'.			
PATIENT ASSESSMENT INSTRUMENTS HAVE BEEN CREATED FOR THE FOLLOWING PATIENTS 			
DUE TO ADMISSION/TRANSFER IN			
DATE OF ADMISSION/TRANSFER IN			
There was an attempt to set up a PAI record on 			
Please verify that this patient's data is accurate and create a PAI record.			
ADT/HL7 MDS COTS UPDATE			
COTS UPDATE			
EVENT-NUM			
VAR-PTR			
-1^Could not find entry in PATIENT file			
DGRU-PATIENT-A08-SERVER			
RAI/MDS HL7 BUILD ERROR			
Select PATIENT ADMISSION: 			
(A)dmission/transfer or (S)emi Annual Census: A//			
A - Assessment purpose is admission transfer			
S - Assessment purpose is semi-annual census			
NEITHER ADMISSION NOR TRANSFERS ARE TO INTERMEDIATE CARE OR NURSING HOME WARDS			
AFTER THE LAST CLOSEOUT			
There is already an admission/transfer assessment created for that			
admission/transfer date			
FBAAV(			
Record Deleted.			
ADMISSION/TRANSFER DATE: 			
ASSESSMENT RECORD CREATED			
THERE ARE NO ADMISSIONS ON FILE FOR THIS PATIENT			
Assessment date: 			
Enter the PAF record to reopen: 			
Ok to reopen			
Enter PAF record to delete: 			
Ok to delete 			
 PAF record 			
Answer YES or NO			
Enter PAF record to close: 			
Ok to close			
ANSWER 'Y'ES OR 'N'O			
 -- ADMISSION DATE			
'^' TO EXIT			
RETURN FOR MORE CHOICES			
There is already a PAF entry for that date.			
Assessment date must be within a month of the semi-annual census date			
The assessment date must not be before the date of admission/transfer in.			
Assessment date can not be changed to after the RUG17 conversion date.  Must remain before 			
Assessment date can not be changed to prior to conversion.  Date must be on or after 			
Can not have more than 59 minutes of therapy			
DG RUG SUPERVISOR			
RUG-II			
This option will send the RUG/PAI data to the Austin DPC.			
REPLY (Y)ES OR (N)O			
Survey purpose: (A)dmission/transfer & CNH or (S)emi-annual? 			
ASSESSMENT START DATE: 			
You must have transmission turned on to Q-			
 and off for Q-			
Transmission is presently turned on to:			
Transmission is turned on to the wrong queue.  Can not proceed at this time.			
Enter '^' at the device prompt to leave this option.			
Depending on type of survey being transmitted enter			
A - Admission/Transfer and CNH PAI Surveys			
S - Semi-annual PAI survey			
Start date must be within current closeout cycle.			
Date must not be before 			
Can not transmit for future dates			
You can not overlap the RUG17 Conversion date.			
Dates must both be prior to or after 			
Enter Yes to continue or No to quit			
Enter the Division you want to do Data Seeding for			
Select the division you want to load the patient data for into the COTS database.			
You have selected: 			
Station Number   : 			
Enter Yes or No.  Yes will select, No will cancel.			
RAI/MDS DATA SEED FOR DIVISION 			
** The data seed process was not tasked **			
The data seed process has been tasked (#			
DGRU-RAI-A01-SERVER			
Looping through ward 			
 -- Last DFN sent was 			
Task stopped as requested			
Task ran to completion			
Enter the patient you want to data seed: 			
Select the patient you want to load into the COTS database.			
You cannot proceed with this patient			
You may select another patient or quit.			
Enter Yes or No. Yes will select this patient. No will cancel the selection of this patient.			
Select another patient? 			
Enter Yes or No. Yes will allow you to select another patient.			
 is not in an RAI ward.			
 is not an active patient in an RAI ward.			
Sending message...			
You are about to enter national fiscal year RUG values.  All entries must be			
completed, otherwise those that you have entered will be deleted.			
Enter fiscal year (4 digits): 			
 WWU value not assigned			
Do you want to enter these values now			
WARNING:  All existing WWU values for fiscal year 			
 will be deleted.  OK to continue			
Enter RUG			
Enter fiscal year (4 digits) from which you want RUG-II WWU values.			
Must not precede 1987.			
Sort by (A)ssessment or (T)ransfer/Admission Date: T//			
A - Date range for the search is by Assessment Date			
T - Date range is by Transfer or admission date			
RUG group			
Enter Category: 			
ALL// 			
  Enter a category or 'return' when all categories			
have been selected			
You have selected output for:			
Assessment			
Transfer/Admission			
 dates between 			
Patients: 			
Divisions for Wards: 			
Wards: 			
CNH Locations: 			
RUG-II Groups: 			
This output requires 132 columns!			
***RUG-II INDEX REPORTS--NO MATCHES FOUND***			
Choose from (H)eavy Rehabilitation, (S)pecial Care, (C)linical Complex			
RUG-II INDEX REPORT			
BY ADMISSION/TRANSFER DATE			
BY ASSESSMENT DATE			
RUN ON: 			
DATE/PURPOSE			
HEAVY REHAB			
CLIN COMPLEX			
CURRENT STATUS:			
** = Absent from ward			
ASSESSMENT PURPOSE:			
S-A = Semi-annual census			
CNH = Contract Nursing Home			
HISTOGRAM FOR			
 ALL LOCATIONS			
FOR PERIOD COVERING: 			
PERCENTAGE OF PATIENTS IN GROUP			
RUG 			
DGRU-RAI-MFU-SERVER			
NURSING UNIT			
ADMISSION/TRANSFER			
SEMI-ANNUAL CENSUS			
CONTRACT NURSING HOME			
INCOMPLETE PATIENT ASSESSMENT INSTRUMENTS			
No location listed in Patient Assessment File for:			
HIT <RETURN> TO CONTINUE			
INCOMPLETE PATIENT ASSESSMENTS			
THERE ARE NO PATIENTS WITH THE STATUS OF INCOMPLETE			
FOR DATE RANGE: 			
  DATE PRINTED: 			
FOR LOCATIONS: 			
ALL Contract Nursing Homes  			
ALL Wards			
     (A)SSESSMENT OR (T)RANSFER/ADMISSION DATE: ASSESSMENT//			
A - Sort by Assessment date range			
T - Sort by Transfer in/Admission date range			
TIME PER WEEK==> DAYS: 			
1 - HEAVY REHABILITATION			
2 - SPECIAL CARE			
3 - CLINICAL COMPLEX			
>>>>PATIENT ASSESSMENT INSTRUMENT<<<<			
RUG-II GROUP: 			
ADL SUM: 			
YEAR OF BIRTH: 			
ASSESSMENT DATE: 			
RUG-II WWUs: 			
ASSESSMENT PURPOSE: 			
2 SEMI-ANNUAL CENSUS			
3 CONTRACT NURSING HOME			
DATE OF ADMISSION/TRANSFER IN: 			
RECORD STATUS: 			
MEDICAL CENTER CODE: 			
BED SECTION: 			
-INTERMEDIATE MED.			
-NURSING HOME CARE			
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