English French Notes Complete/Exclude | (specify type): | | * HIV-1/HIV-2 combination EIA . | | * If HIV laboratory tests were not documented, Yes No Unk.| | * HIV-1 Western blot/IFA ...... | | is HIV diagnosis documented by a physician? | | * Other HIV antibody test ..... | | * If yes, provide date of documentation by physician | 3. IMMUNOLOGIC LAB TESTS: | | * HIV-2 Western blot .......... | | At or closest to current diagnostic status Mo. Yr. | | 2. POSITIVE HIV DETECTION TEST: (Record earliest test) | * CD4 Count ........... | * HIV culture ..................................... % | * HIV antigen test ................................ | First <200 uL or <14% | | * HIV PCR, DNA or RNA probe ....................... ================================================= VIII. CLINICAL STATUS ====================================================== | CLINICAL YES NO | ENTER DATE PATIENT Asymptomatic Mo. Yr. Symptomatic Mo. Yr. | | RECORD REVIEWED | | | WAS DIAGNOSED AS: (including acute retroviral syndrome and | | | persistant generalized lymphadenopathy): (not AIDS): | Initial Initial | Initial Initial | | Diagnosis Date | Diagnosis Date | | AIDS INDICATOR DISEASES Def. Pres. Mo. Yr. | AIDS INDICATOR DISEASES Def. Pres. Mo. Yr. | |Candidiasis, bronchi, trachea, or lungs | Lymphoma, Burkitt's (or equivalent term) | Lymphoma, Immunoblastic (or equivalent | |Carcinoma, invasive cervical | |Coccidioidomycosis, disseminated or |Lymphoma, primary in brain | Mycobacterium avium complex or | M. kansasii, disseminated or | |Cryptosporidiosis, chronic intestinal | extrapulmonary | | (> 1 month duration) | |Cytomegalovirus disease (other than in |M. tuberculosis, disseminated | | liver, spleen or nodes) | or extrapulmonary * | |Cytomegalovirus retinitis (with loss of |Mycobacterium, of other species or | unidentified species, disseminated | |HIV encephalopathy | | or extrapulmonary | |Herpes simplex: chronic ulcer(s) (>1 mo. |Pneumocystis carinii pneumonia | | duration); or bronchitis, pneumonitis, |Penumonia, recurrent in 12 mo. period | | or esophagitis | Progressive multifocal | |Histoplasmosis, disseminated or | leukoencephalopathy | Salmonella septicemia, recurrent | |Isosporiasis, chronic intestinal (>1 mo. |Toxoplasmosis of brain | |Wasting Syndrome due to HIV | | Def.=definitive diagnosis Pres.=presumptive diagnosis | * RVCT CASE NO.: _______________ | | * If HIV tests were not positive or were not done, does this patient have | | an immunodeficiency that would disqualify him/her from the AIDS case definition | | Has this patient been informed of his/her HIV infection? | | Unk. | This patient is receiving or | | This patient's partners will be notified about their HIV exposure and counseled by: | * HIV related medical services | | Health department | | Unknown | * Substance abuse treatment services | | This patient received or is receiving: | This patient has been enrolled at: | This patient's medical treatment is | | * Anti-retroviral Yes No Unk. | Clinical Trial Clinic | PRIMARILY reimbursed by: | | Private ins/HMO | | No coverage | | Other public funds | | Yes No Unk. | | | * PCP prophylaxis | | Unknown | trial/government program | | FOR WOMEN: *This patient is receiving or has been referred for gynecological or obstetrical services: . | | *Is this patient currently pregnant? ....................................................... | | *Has this patient delivered live born infants? ... | |Yes (If delivered after 1977, provide birth | information below for the most recent birth) | | CHILD'S DATE OF BIRTH: | Hospital of Birth: | Child's Soundex: | Child's State Patient No. | | Mo. Day Yr. | | | | | | | __________ | | | | | | | | | | | | | Definitive Presumptive ** NO DATE ** Diseases Currently Selected: Start Date for Period: End Date for Period: END CAN NOT BE BEFORE START MORE THAN 180 DAYS OF DATA IS TOO MUCH TO TRANSMIT. TRY A SHORTER DATE RANGE. IMMUNOLOGY DATA. *NEW PATIENT* Monthly, Quarterly, Semi-Annually, Yearly, Fiscal Yearly, User Selectable Select date range type: Enter the first few letters of one of the choices listed below. Please enter a month and year MONTH OF Enter Quarter Period and FY you wish Semi-Annual range to end with Enter Quarter and Year: Enter Quarter Period in this format: 2nd quarter 1988 would be 2-88, 2/88, 2 88 Enter Quarter 1 to 4 only QUARTER FY SEMI-ANNUAL PERIOD ENDING FISCAL Enter a 2 or 4 digit FISCAL YEAR YEAR Enter beginning and ending dates for the desired time period: Ending Date: PERIOD FROM Range selected: ***** Patient has a DATE OF DEATH, setting it to 2 **** **** Patient has an ICR DATE OF DEATH ENTERED, setting status to DEAD **** Do you want to enter an ICR DATE OF DEATH (Y/N) ? ***** PATIENT FILE has NO date of death entered, AND IMR DATE OF DEATH FIELD HAS NO DATE ***** ***** You must choose 1 or 9 ***** Enter Coded SSN I will now search the database to decode the SSN... please wait The coded number you entered is either not listed in your local ICR or was typed incorrectly. Please check that you entered the coded SSN correctly. *** NO TRANSLATION FOUND FOR THIS PATIENT *** Coded SSN: Patient's id in the Immunology Case Study file: Coded Date of Birth: Patient's number in the Patient file: BE ABSOLUTELY SURE BEFORE USING THIS OPTION -- IT WILL DELETE ALL DATA FOR THE SPECIFIED INDIVIDUAL FROM THE IMMUNOLOGY CASE FILE ARE YOU ABSOLUTELY SURE? N// IMRTEXT( IMMUNOLOGY DATA Do you want to Enter/Edit CDC form data now This patient must be entered into the Immunology Case Study file using The Enter/Edit option first. Is this patient REALLY supposed to be in your database (Y/N)? Are you sure, should be in your database (Y/N)? Sending the past 365 days of data to the HIV National Database.. Select *SECURE* ALLOWABLE PRINTERS (Field 7) from ICR Site Parameters File: Select one of the valid devices IMR*2.0*23 Please install IMR*2*23 first. ICR v2.1 Installation halted. File Access YOU HAVE INSUFFICIENT SECURITY TO ACCESS THIS OPTION SEE YOUR IMMUNOLOGY COORDINATOR FOR THE PROPER KEYS IMR ACCESS VIOLATION NOTICE IMR ACCESS VIOLATION BY IMR - IMMUNOLOGY UNATHORIZED ACCESS ATTEMPT An attempt was made to invoke IMR functionality by a person who does not have the neccessary Security Keys. Details of this attempt are as follows: Violator's Name: Time: VIOLATION: ACCESS WAS ATTEMPTED BUT NOT GAINED Removing Unused Data Dictionary Fields... Deleting Unused Routines... Deleting Unused Data... Removing Unused Options... IMRO REPORTS MENU IMRO BY DX IMRO BY NAME IMRO DELETE IMRO ENTER IMRO MASTER IMRO NO DX IMRO TRANSMIT Populating Data Fields in File 158... 44)=DATE OF HIV+ (CAT 2) STATUS Populating new NLF ENTRY field in File 158.9... Removing unused File 158.96 dictionary and data... Queuing the IMR REGISTRY DATA option to run immediately... Rescheduling the IMR REGISTRY DATA option... IMR REGISTRY DATA IMMUNOLOGY.VA.GOV Deleting unused input templates... IMR LPOINTER IMR PPOINTER Adding VIRAL LOAD entry to File 158.95... VIRAL LOAD ICR-RX ARCHIVE DATE SEARCH Holders of KEYS for 'IMR' Package as of: KEY HOLDERS: UNKNOWN USER # Deleting the field definitions... The definitions have been deleted. Unknown error ( CD4 or T4 (ACTUAL LEVEL) CD4 or T4 (PERCENTAGE) ** SORRY NO LABORATORY REFERENCE IN PLACE ** SORRY, HIV COORDINATOR HAS NOT SET UP LAB LINKS Local ICR Demographics by Category Do you want to check for entries in the ICR file without CATEGORY data Do you want a list of patients with MISSING data elements Local ICR Demographics By Category Patients Seen During LIVING ALIVE & DECEASED DECEASED PATIENTS IN THE FILE HIV+ HIV+TC AIDS-3 Checking for entries in the ICR file without CATEGORY data. None found. in the IMMUNOLOGY CASE REGISTRY file with NO CATEGORY indicated -- DO YOU WANT TO SEE THE LIST Missing Categories ALIVE (or unknown) GAY OR BISEXUAL MAN IV DRUG USER GAY OR BISEXUAL DRUG USER RECV'D TRANSFUSION/TRANSPLANT WORK-HEALTH/CLINICAL ADULT, CONFIRMED OTHER RISK UNSPECIFIED ELIGIBILITY UNSPECIFIED POS SEEN AS OUTPATIENT SEEN AS INPATIENT SEEN IN LABORATORY PRESCRIPTION(S) FILLED Print Data by CATEGORY as well as totals Answer YES to get separate listings of utilization by HIV CATEGORY as well as the total population. Selected IP/OP Activty SD*5.3*131 NO SC ID NO SC NO ID NO BS How many of the highest users do you want identified ? 0// Enter the number, 0 or greater of the individuals with the highest utilization of pharmacy fills and/or cost you wish listed NO CATEGORY DEFINED^HIV+^HIV+ (CD4<500)^AIDS-3^AIDS TOTAL HIV+ (ALL CATEGORIES) POPULATION FOR THE PERIOD SELECTED OUTPATIENT ACTIVITY A 'stop' is credited for each entry of a stop code, while a 'visit' is split among each stop credited on a given date. Thus, a single visit with two stop codes credited will show as 0.5 visit for each stop code. A total of 1.00 visit is given for out patient activity on a given date. Totals: patients for NOT IDENTIFIED OCCURRENCES OF NO STOP CODE ID ADD/EDIT STOP CODE SCHEDULED VISIT INPATIENT AND OUTPATIENT ACTIVITY STOP CODES SELECTED INPATIENT ACTIVITY stays and days of inpatient care Median Length of Stay (MLOS): Average Length of Stay (ALOS): OCCURRENCES OF NO BEDSECTION ID HIGHEST UTILIZATION OF VISITS HIGHEST NUMBER OF STAYS HIGHEST NUMBER OF DAYS moved in: PTF entry: Number of Days Patients Not Seen Enter the number of days you want to check if any patient has not been seen Immunology Followup List FOLLOW UP REPORT PATIENTS AT RISK OF LOSS TO FOLLOW UP NOT SEEN IN OVER Local Registry List - ICR Patients Select Type of Patients List New Patients added to the registry during this time (Y/N)? N// Do you want the list sorted by Category (Y/N)? N// Do you want the list sorted by Reimbursement Level (Y/N)? N// List Immunology Patients ***NO PATIENTS FOUND IN DATE RANGE*** REGISTRY LIST REIM LEV Minimum number of results reported for a test to be listed This number (1 or greater) is used to keep from showing long lists of infrequent tests by setting a minimum number of results for display Selected LAB Activity Enter the number, 0 or greater, of the individuals with the highest utilization of laboratory orders you wish listed LABORATORY UTILIZATION DATA Totals: orders placed ( results reported) during this period for These include different entries from LAB TEST file placed for in file, not included above # OF DIFFERENT LAB TESTS Max # Results Reported Per Patient (# patients) ***This report will give you a list of your local lab links.*** List Local Lab Links LOCAL LAB LINKS Local Name >>>>> Please wait. Searching for Viral Load & CD4 Values..... Type of Test **NO DATA FOUND** Summary Utilization Data Answer YES to sort by HIV CATEGORY. Immunology Summary Utilization Data Select Facility Source of Information Sending Request Message to the National Registry... #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################