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 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 #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################