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