English French Notes Complete/Exclude Discharged From : Room-Bed : REGISTRATION STATUS : VA SCI STATUS : PRIMARY CARE PROVIDER : SCI LEVEL : Etiology Onset Other Recipients of this message: notice for SPNTXT( :INPT START; :INPT GOAL; :INPT INTERIM; :INPT REHAB FINISH; :INPT FOLLOW-UP (END); Enter 1 for an INPT START outcome Enter 2 for an INPT GOAL outcome Enter 3 for an INPT INTERIM outcome Enter 4 for an INPT REHAB FINISH outcome Enter 5 for an INPT FOLLOW-UP (END) outcome Enter 6 for UNKNOWN if the score type is not known 1:OUTPT START; 2:OUTPT GOAL; 3:OUTPT INTERIM; 4:OUTPT REHAB FINISH; 5:OUTPT FOLLOW-UP (END); Enter 1 for an OUTPT START outcome Enter 2 for an OUTPT GOAL outcome Enter 3 for an OUTPT INTERIM outcome Enter 4 for an OUTPT REHAB FINISH outcome Enter 5 for an OUTPT FOLLOW-UP (END) outcome 1:CC ADMIT; 2:CC GOAL; 3:CC INTERIM; 4:CC DISCHARGE; 5:CC OUTPT; Enter 1 for an CC ADMIT outcome Enter 2 for an CC GOAL outcome Enter 3 for an CC INTERIM outcome Enter 4 for an CC DISCHARGE outcome Enter 5 for an CC OUTPT outcome Select the Score Type for this outcome Annual Evaluation Continuum of Care NO CARE TYPE Enter a New Record Date: Do you wish to close this episode of care Enter Yes to close this episode or No to leave it open. Current INPATIENT Episode of Care Previous INPATIENT Episode(s) of Care No care start date is on file for this patient ! You need to add an Outcome to the current episode and select a Score Type of INPT FOLLOW-UP (END). There are no INPATIENT episodes of care on file. (An ASIA should be entered first if an episode is created.) Would you like to create an episode of care Would you like to create a new episode of care Enter a Y to create a new INPATIENT episode. Enter a N or just Return to return to the last episode Current OUTPATIENT Episode of Care Previous OUTPATIENT Episode(s) of Care a Score Type of OUTPT FOLLOW-UP (END). There are no OUTPATIENT episodes of care on file. Enter a Y to create a new OUTPATIENT episode. Previous INPATIENT Episode of Care Previous OUTPATIENT Episode of Care Date Opened to view/edit an episode of care, '^' to exit press Return to see the next group Enter a number within the range allowed. Selected number is outside the range. ANNUAL EVALUATIONS CONTINUUM OF CARE There are no Previous episodes for this patient EDSS: Episodes of care Outcomes on file. (An ASIA should be entered first if you add outcomes.) to view/edit an outcome, '^' to exit, or to see the next group to Add a new outcome Enter a number within the range allowed, or one of the designated keys. Aa^ Care Start Date: End Date:

to view/edit a Previous episode of care to Create a new episode of care AaPpCc^ AaPp^ Aa0^ ******** Patient NOT Expired ******** This is to alert you that a patient marked as 'Expired' in the SCD Registry is alive according to MAS records. Notify your hospital's MAS personnel -- it is possible that the patient is indeed deceased, but Date of Death was not entered into pt's VA record. However, if this patient is truely alive, please update his Registration Status field in the SCD Registry. Patient ----> PT DEATH: MAS RECORD vs. SCD RECORD SCD REGISTRY SPNARR( G.SPNL SCD COORDINATOR ******** Patient NOT Deceased ******** in the PATIENT file has been corrected to 'NOT deceased'. Please check this patient's record in the SCD Registry to ensure the Registration Status field is updated. Patient's name is ----> Patient's SSN is ----> UPDATE REGISTRATION STATUS - SCI PATIENT The date of death for been deleted from the patient file. The Registration Status needs to be up-dated in the Spinal Cord Registry. Date of death deleted for Please stand by while your Registry is updated. Thank you!! The number of days cannot exceed Pt not in SCD Registry! No etiology on file. Enter a START date: Option aborted! Enter a ENDING date: Patients with future Appointments No Clinic on File **** No Data for this report. **** Patients in the Registry only Patients marked as SCI but not in the Registry Combined report -- Pts in Registry AND Pts marked as SCI but not in Registry Listing appointments from Appointment date Reg TEMP ADM No Outcomes on file. You can add one if you wish. Not on the list.. Not on the list Score type: Goal Interim EDSS Score: Self Reported Functional Measure Clinician Reported FIM CHART/FAM/DIENNER/DUSOI ASIA Score MS module (Kurtzke/EDSS) Select 1 through or A to add a new record or ^ to quit. Or Return to see the next group. ;8:Multiple Sclerosis Select the Record Type for this outcome Enter 1 to enter/edit a Self Report of Function score. Enter 2 to enter/edit a FIM score. Enter 3 to enter/edit an ASIA score. Enter 4 to enter/edit a CHART score. Enter 5 to enter/edit a FAM score. Enter 6 to enter/edit a DIENER score. Enter 7 to enter/edit a DUSOI score. Enter 8 to enter/edit a Multiple Sclerosis score. Choose either 1,2,3,4,5,6,7 Enter a New Record Date : The screen-based entry process has failed!! .03///SCD - CURRENTLY SERVED (Computed from incomplete data) (No data or invalid data found) Motor FIM Score: Cognitive FIM Score: Total FIM Score: Self Report of Function total score: ERROR, unknown record type: ' .03///SCD - CURRENTLY SERVED;.04///TRANSMIT Four Level Functional Measure Enter 'A' to create a new record for the selected patient. E:Edit an existing record; Enter 'E' to edit a pre-existing record for the selected patient. Choose either 'A' or 'E'. Enter 'A' to add a record, or '^' to exit. ;.04///TODAY;.04DATE RECORDED Select DATE RECORDED: Checking data for inconsistencies... CAUSE OF INJURY is not 'OTHER', DESCRIBE CAUSE OTHER should be blank. ONE ARM AFFECTED and BOTH ARMS AFFECTED are both answered 'YES'. ONE LEG AFFECTED and BOTH LEGS AFFECTED are both answered 'YES'. OTHER BODY PART AFFECTED is 'NO', DESCRIBE OTHER BODY PART should be blank. HELP DURING LAST 2 WEEKS is 'NO', NUMBER OF HOURS OF HELP should be blank. RECEIVED MOST MEDICAL CARE is 'NON-VA ONLY' or 'DID NOT SEE DOCTOR/NURSE LAST 5 YRS', VA MOST USED FOR MEDICAL CARE should be blank. Select the type of record you wish to enter/edit Enter 1 to enter/edit Registration and Health Care Information Enter 2 to enter/edit Outcome Information Enter 3 to enter/edit Clinical Information Enter 4 to Select a NEW Patient Choose either 1,2,3, or 4. Select SCD (SPINAL CORD) REGISTRY PATIENT: Select the type of Functional Status you wish to print Enter 1 to print Self Report of Function scores Enter 2 to print FIM scores Please enter 1 or 2 Select the type of FIM score you wish to print Enter 1 to print Motor scores Enter 2 to print Cognitive scores Enter 3 to print Total scores Please enter 1, 2, or 3 Enter the beginning date range: Enter the beginning date to search for Functional Status scores Enter the ending date range: Enter the ending date to search for Functional Status scores SCD Functional Status Scores Report SPNFDATA( No data found for this patient Extent & Completeness: Type of Injury: A-EATING G-BLADDER MANAGEMENT M-STAIRS B-GROOMING H-BOWEL MANAGEMENT N-COMPREHENSION C-BATHING I-TRANSFER TO BED/CHAIR O-EXPRESSION D-DRESSING UPPER BODY J-TRANSFER TO TOILET P-SOCIAL INTERACTION E-DRESSING LOWER BODY K-TRANSFER TO TUB/SHOWER Q-PROBLEM SOLVING F-TOILETING L-MOVE AROUND INSIDE YOUR HOUSE R-MEMORY indicates the score is incomplete. EDSS Score: Invalid message format, rest of message ignored. Patient not found: The SCD Registry Veteran Survey Server has encountered the following problems with MailMan server message # the following number of records: SCD Registry records: FIM records: SCD Registry Veteran Survey Server G.SPNZ SCD COORDINATOR NUMBER OF HOURS OF HELP should be blank if HELP DURING LAST 2 WEEKS is answered 'YES'. A Functional Status record already exists for this date. Please change the DATE RECORDED to a different date. You have entered an INPT REHAB FINISH or INPT FOLLOW/UP (END) or OUTPT REHAB FINISH or OUTPT FOLLOW/UP (END) CHART for a patient who has a recorded INPT GOAL or OUTPT GOAL CHART. Do you want to see a comparison template you can copy and paste into a CPRS progress note Physical Cogntv Mobility Social Econ ***************** COPYRIGHT NOTICE ****************** Some material on the following screen is reprinted with permission from the Paralyzed Veterans of America (PVA). Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America, 1999. the authors and Aspen Publishers, Inc. Spinal Cord Injury: Clinical Outcomes from the Model Systems. Gaithersburg, MD: Aspen Publishers, Inc., 1995. You have entered an INPT START or OUTPT START Diener's SWLS for a patient with level spinal cord injury and ASIA Impairment Scale of Do you want to see a goal setting template you can copy and paste into a CPRS progress note Aor B or C any neurologic | | Diener's SWLS Composite | REHAB FINISH or OUTPT FOLLOW/UP (END) DIENER for a patient who has a recorded INPT GOAL or OUTPT GOAL DIENER. Do you want to see a comparison template you There is no DIENER start Outcome on file. REHAB FINISH or OUTPT FOLLOW/UP (END) FAM for a patient who has a recorded INPT GOAL or OUTPT GOAL FAM. Do you want to see a comparison template you Swallow Car Txfrs Community Speech | Emot Employ Orientation Attn spinal cord injury level and a motor complete ASIA Impairment Scale of . Do you want to see a goal setting template you can copy and paste into a CPRS progress note | | Bwl | Bldr | Trnsfr | Eat | DUB | DLB | Grmng | Bathe | WC Prp | | | Raw FIM Motor Score | REHAB FINISH or OUTPT FOLLOW/UP (END) FIM for a patient who has a recorded INPT GOAL or OUTPT GOAL FIM. Do you want to see a comparison template you can copy and paste into a CPRS progress note Grmmg Bathe Bldr Bwl BCWC Trf Tlt Trf TSh Trf Strs | Compr Expr Soc Prb Slv Mem Mtr Cogn Tot | There is no FIM goal on file ! You have entered an INPT REHAB FINISH FIM for a patient with spinal cord injury level and ASIA Impairment Scale of Do you want to see a comparison template you can copy and paste into a CPRS progress note |||Registration OBR |||154 ETIOLOGY DATA||| #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################