English	French	Notes	Complete/Exclude
history and all appropriate laboratory studies.			
Note: 			
A. Medical history 			
a. Removal of, complete/imcomplete (if incomplete,			
state if pregnancy is prevented) -			
b. Prolapse of, complete through vulva/imcomplete -			
c. Displacement of; also identify adhesions and irregular			
a. Removal of both -			
b. Removal of one with or without partial removal			
of the other -			
c. Atrophy of one or both ovaries, complete -			
3. Rectal and rectovaginal; identify any surgical complications			
of pregnancy -			
4. If a malignant process has been present within the past year,			
give the date of the last surgical, radiation or chemical			
5. If a tubercular or other mycobacterial infection has been treated			
within the past year, give the date of inactivity -			
6. Has a voluntary sterilization procedure been performed? -			
OTHER GENITOURINARY			
In original claims, particularly pension cases, and in			
reopened claims in which the evidence on hand at the time			
the examination request is prepared does not establish the			
exact diagnosis, the nature of the disability will generally			
be expressed in the most general terms, usually in the veteran's			
own words (e.g. 			
kidney condition			
bladder problem			
can't hold water			
, etc).  In such cases it is			
the responsibility of the general medical examiner to conduct			
or order to be conducted such special examinations as may be			
necessary, both to diagnose the underlying disorder, and			
to provide the information that the rating board must have to			
apply the examiner's findings to the rating schedule.  Once			
a definitive diagnosis is established, the examiner need only to			
report history, clinical findings, and laboratory tests for			
evaluation purposes.  Complications and/or medical side effects			
should always be reported, even when not specifically requested.			
A. Medical History:  No medical history for this exam			
E. Diagnostic/clinical test results:			
For GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED			
Type of Exam: GYNECOLOGICAL, NOT ELSEWHERE CLASSIFIED			
HYPERTHYROIDISM, THYROID ADENOMA			
1.  Mental assessment -			
2.  Muscular weakness -			
3.  Loss of weight -			
4.  Thyroid enlargement -			
7.  Disease in remission or demonstrably active -			
8.  Marked disfigurement (including appearance and texture			
of thyroidectomy scar, if present) -			
9.  Continuous medication required -			
2.  Nervous, cardiovascular, or gastrointestinal symptoms -			
4.  Mental assessment -			
5.  Continuous medication required -			
For HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED			
Type of Exam: HEMATOLOGICAL, NOT ELSEWHERE CLASSIFIED			
HEMATOLOGIC DISORDERS-LYMPHATIC			
As with other disorders, a careful history and complete			
physical examination are of first importance in hematologic			
disorders.  However, laboratory evaluation is often necessary			
for a definitive diagnosis.			
1. State whether the disease is currently active or in remission and			
if in remission, whether maintenance chemotherapy is required -			
2. Describe frequency and duration of acute attacks -			
3. Describe the state of general health between acute attacks -			
4. If the veteran is, or has been receiving chemotherapy, X-Ray or			
surgical treatment for Hodgkin's disease or other form of lymphoma,			
give date of last treatment -			
5. If veteran has been treated for any tuberculous adenitis (or			
adenitis due to any other mycobacterial infection) and the disease			
is currently inactive, give date the inactivity was first shown -			
Invalid Patient name or DFN			
Invalid Segment Type			
Not a valid DHCP user number.			
Invalid Patient ID, No SSN			
Invalid Patient ID, Wrong SSN Format			
Invalid Patient Identifier			
Ambiguous Patient identifier			
No 2507 request on file for this Patient			
Invalid Patient identifier			
No Exams or Open Exams on file for this Patient			
No Electronic Signature code present, updating cannot be allowed.			
Missing PID Segment			
Incorrect PID Segment indicator			
Internal Patient ID Missing			
Patient Name Invalid			
Patient SSN Invalid			
Incorrect Patient Identifier			
Invalid SSN			
Missing OBR Segment			
Missing Universal Identifier			
Missing Exam Type			
Missing Report Date			
Request No longer Exists			
Status of Request will not allow for down loading			
Exam No longer Exists			
Exam status not open, no down loading allow* ed			
Bad electronic signature code.			
Electronic signature codes do not match, no down loading allowed			
Invalid OBX Segment			
Results added but request and exam status not updated.			
Kurzweil			
Results added and exam status updated but request status not updated.			
Record currently accessed by another user			
Exam currently being accessed by another user			
 HEMATOLOGIC DISORDERS - BLOOD			
disorders; however, laboratory evaluation is often necessary			
HAND, THUMB, AND FINGERS			
The hand should be evaluated as a unit intricately adapted			
for grasping, pushing, pulling, twisting, probing, writing,			
touching, and expression.  Do not designate fingers numerically;			
use thumb, index, 			
middle, ring and little.  Specify which hand is			
involved and state whether the individual is right or left-handed.			
Designate the joints as wrist, MP (metacarpophalangeal), PIP,			
(proximal interphalangeal) or DIP (distal interphalangeal).			
Designate phalanges as proximal, middle or distal.			
1. Anatomical defects -			
2. Functional defects (motion of thumb and fingers should be described			
as to how near, in inches, the tip of thumb can approximate the			
fingers, or how near the tips of fingers can 			
approximate the median			
transverse fold of the palm.) -			
3. Grasping objects (strength and dexterity) -			
Loss of range of motion of the hip will be recorded from			
the anatomical position (0 degrees) varying from 125 degrees			
in flexion to 30 degrees in extension, from 25 degrees in			
adduction to 45 degrees 			
in abduction, and from 60 degrees in			
external rotation to 40 degrees in internal rotation.  To gain			
a true picure of hip flexion, i.e. movement between the pelvis			
and femur in the hip joint, the opposide thigh should be			
extended to minimize motion between the pelvis and spine.			
1. Describe movements of the thigh as it may rotate			
in a circular manner about the femoral head in the 			
acetabulum.  Discuss any pain, tenderness, weakness			
and fatigue on standing and any unusual motions on 			
ORIGINAL SC			
ORIGINAL NSC			
INSUFFICIENT EXAM			
PENDING, REPORTED			
PENDING SCHEDULED			
RELEASED TO RO, NOT PRINTED			
COMPLETED, PRINTED BY RO			
CANCELLED BY MAS			
CANCELLED BY RO			
NEW, TRANSFERRED IN			
COMPLETED, TRANSFERRED OUT			
There should be at least three blood pressure readings			
in the sitting position spaced throughout the examination.			
At times it may be necessary to recall the veteran on			
subsequent days to obtain readings which are most			
representative of the true blood pressure.			
1. Blood pressure readings:			
3. Enlarged heart confirmation -			
4. Apex beat beyond midclavicular line -			
1.  Marked weight loss -			
3.  Decalcification of bones -			
4.  High blood calcium -			
5.  High urinary calcium -			
Total 2507 requests received for date range:			
Total insufficient 2507 requests received for date range:			
Total insufficient 2507 requests cancelled by RO for date range:			
% of insufficient requests per total requests received:			
% of uncancelled insufficient requests per total requests received:			
Total 2507 exams received for date range:			
Total insufficient 2507 exams received for date range:			
Total insufficient 2507 exams cancelled by RO for date range:			
% of insufficient exams per total exams received:			
% of uncancelled insufficient exams per total exams received:			
Summary of insufficient exams per Reason			
Reason			
Num			
Exams without insufficient reason indicated			
Summary Insufficient Exam Report for 			
For Date Range: 			
You have not selected Insufficient reasons to report.			
This is required to print the Detailed report.			
You have not selected Exams to report.			
  Enter 'No' to print only those reasons previously			
   selected, 'Yes' to select all reasons existing			
   on currently entered exams.			
 You have selected to report all insufficient reasons.			
 Is this correct? 			
  Enter 'No' to print only those exams previously			
   selected, 'Yes' to select all exams			
 You have selected to report all AMIE exams.			
0,15,0,1,0^Detailed Insufficient Exam Report			
0,15,0,1,1^Detailed Insufficient Exam Report			
0,11,0,2,0^For Date Range: 			
Exam request of 			
 to correct insufficiency was cancelled on 			
Exam Dt			
Claim #			
Insufficient Reason Selection			
  Enter '^' to end Reason Selection			
  'Return' to select all Insufficient Reasons			
  Enter Insufficient Reason: ALL//			
AMIE Exam Selection			
  Enter '^' to end Exam Selection			
  'Return' to select all AMIE Exams			
  Enter Exam: ALL//			
JOINTS (ORTHOPEDIC)			
Do not use negative values to indicate inability to achieve			
full extension.  The anatomical position is the reference			
position EXCEPT with the regard to rotation of the shoulder			
and pronation/supination 			
of the forearm (see fig. 2.1 and 2.2			
of the Physician's Guide).  To give uniformity in describing			
limitation of motion or ankylosis of a joint, THE USE OF A			
GONIOMETER IS REQUIRED.			
3. Other impairment of knee: subluxation or lateral instability;			
non-union, with loose motion; malunion -			
4. Range of motion (complete chart below)-			
Note: Enter joint names in blanks under numbers below.  If more			
than four joints are involved, please extend your dictation in the			
same format.			
------------------ JOINT EXAMINED -------------------			
Range of:			
Flexion			
Extension			
Rotation			
Abduction			
Adduction			
Pronation			
Supination			
Deviation (radial)			
Deviation (ulnar)			
Plantar Flexion			
Dorsiflexion			
Compensation and Pension Exam for JOINTS for 			
Reprint Lab/X-Ray Results for C&P Exams			
C&P lab/radiology print			
DIC*			
Was 			
 scheduled to rebook a previous appointment			
Enter NO to indicate this appointment is the first time the exam is scheduled.			
Enter YES to indicate this appointment is a rebook of an existing appointment			
  for the exam.			
(If YES, you will be asked to select the appointment being rebooked.)			
You have not selected an appointment link which to modify with the selected			
 appointment.  If the desired appointment was not displayed for selection,			
 it must first be added as a new link to the 2507 request.  You may then 			
 modify the link as you have attempted here.			
You have not selected a C&P appointment to link the request to.			
This is required before further processing with the AMIE link			
 management option.			
Hit Return to continue or '^' to STOP.			
You have selected a veteran that does not have C&P appointments			
 to link to this request.  This is required before further processing with 			
 the AMIE link management option.			
You have selected a C&P appointment that is Currently Linked to the request.			
(NOTE: *CL) If you want to remove this link, see your supervisor.			
Do you want to REMOVE this link			
Enter YES to remove this appointment from the 2507.			
Enter NO leave this appointment associated with the 2507.			
If you enter YES incorrectly, you will need to use this tool to relink the			
 appointment to the request.			
No appointments are currently linked to this 2507 request.			
You will need to create a link to the cancelled appointment			
 before proceding with the link to this appointment.			
Hit Return to continue with appointment display.			
VETERAN CANCELLATION			
VETERAN REQ APPT DATE			
AMIE/C&P Appointment Link Management			
As a Supervisor, you may remove 2507 appointment links			
Can't jump again until you close another screen.			
CAN'T JUMP FROM AN OVERVIEW			
DVBCVIEW,			
Invalid division			
C & P Request Entry for			
C & P Request Veteran Selection			
Vet is an INPATIENT, on ward 			
Want to continue			
Enter Y to proceed with the request or N to go			
back and re-select.			
   ... Timed out!  			
Select action:			
 Press [RETURN] to continue, or enter E to edit or X to cancel:  Continue// 			
 NOT allowed here			
[RETURN] will continue to exam selection, E will allow			
editing of what you have entered and X will DELETE			
the entire request			
Do you want to change the request this insufficient is linked to? 			
Enter Yes to change the link and No to keep the current link			
Must be the RETURN key, X, or E 			
Request DELETED.			
0,0,0,1,0^You must either select a request to link or enter the 2507 Processing Time.			
0,0,0,1,0^Enter 0 if you don't know the processing time of the original request.			
Use ? to see a list of exams available for selection.			
0,0,0,1,0^NOTE:  This request has a priority of Insufficient without a link			
0,8,0,1:1,0^to a completed request.			
0,0,0,1:2,0^Use care to select the proper exam(s) to return as insufficient.			
Enter Y to go back and select exams or N to DELETE the entire request			
as well as any exams selected.			
You have selected these exams:			
Enter Y to go ahead and log the selected exams or N to modify the list.			
Please enter any remarks for this request:			
Exam addition error ! 			
) on File 31...Notify IRM 			
Selections 			
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