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