# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | patient(+) | 0;1 | POINTER | 2 | B | This field points to the Patient file. A patient must exist in the patient file before an entry can be made in this file. |
.02 | registration date | 0;2 | DATE-TIME | C | This date is automatically entered when a patient is added to this file. This field may not be changed. | |
.03 | registration status(+) | 0;3 | SET OF CODES | 0:NOT SCD 1:SCD - CURRENTLY SERVED 2:SCD - NOT CURRENTLY SERVED X:EXPIRED | AD | SCD - CURRENTLY SERVED designates a patient to be a true SCD patient who is seen at the facility on a continuing basis. SCD - NOT CURRENTLY SERVED designates a patient to be a true SCD patient who is not being seen at the facility on a continuing basis. NOT SCD designates a patient who is not a true SCD patient. |
.05 | date of last review | 0;5 | DATE-TIME | This is the date this file was last edited. | ||
.06 | last updated by | 0;6 | POINTER | 200 | This field contains the name of the last user to edit this record. This field is automatically updated whenever an edit is performed. | |
1.1 | sci network | 1;1 | BOOLEAN | 1:YES 0:NO | When SCI NETWORK is Yes, the patient is (or was, if expired) being clinically treated and followed for an SCD condition within the SCI Hub and Spoke system and is either being offered or referred for annual rehab evaluations. | |
2.1 | sci level | 2;1 | POINTER | 154.01 | This is a pointer to the SCD NLOI Category file. | |
2.2 | ms subtype | 2;2 | SET OF CODES | UN:UNKNOWN RR:RELAPSING-REMITTING PP:PRIMARY PROGRESSIVE SP:SECONDARY PROGRESSIVE PR:PROGRESSIVE RELAPSING | MS Subtype field. | |
2.4 | describe cause other | 2;4 | FREE TEXT | If the cause of injury is listed as 'other', you may enter a description of the cause here. | ||
2.5 | describe other body part | 2;5 | FREE TEXT | If other body part affected is answered 'yes', you may enter a description of the part of the body affected here. | ||
2.6 | va sci status | 2;6 | SET OF CODES | 1:PARAPLEGIA-TRAUMATIC 2:QUADRIPLEGIA-TRAUMATIC 3:PARAPLEGIA-NONTRAUMATIC 4:QUADRIPLEGIA-NONTRAUMATIC X:NOT APPLICABLE | This field is used to describe the patient's level and type of injury. | |
3.1 | received most medical care | 3;1 | SET OF CODES | 1:VA ONLY 2:MOSTLY VA/SOME NON-VA 3:HALF VA/HALF NON-VA 4:SOME VA/MOSTLY NON-VA 5:NON-VA ONLY 6:DID NOT SEE DOCTOR/NURSE LAST 5 YRS | Where does the patient receive most of his medical care? Is most of the care at a VA or Non-VA facility? | |
3.2 | primary care vamc | 3;2 | POINTER | 4 | Where does the patient receive most of his medical care? | |
3.3 | annual rehab vamc | 3;3 | POINTER | 4 | At what facility did the patient receive his annual rehab eval? | |
3.4 | additional care vamc | 3;4 | POINTER | 4 | Where did the patient receive additional care? | |
3.5 | non-va care | 3;5 | FREE TEXT | The Non-VA site that gave the patient care. | ||
4 | etiology | E;0 | MULTIPLE | 154.004 | ||
5.01 | cause of injury | 5;1 | POINTER | 154.03 | If the patient has a spinal cord injury, enter the patient's cause of injury. | |
5.02 | had brain injury? | 5;2 | BOOLEAN | 0:NO 1:YES | If the patient had a spinal cord injury, did he also have a head injury at the same time? | |
5.03 | had amputation? | 5;3 | BOOLEAN | 0:NO 1:YES | Has the patient ever had an amputation. | |
5.04 | memory/thinking affected | 5;4 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if the patient's memory/thinking are affected. | |
5.05 | eyes affected | 5;5 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if the patient's eyes are affected. | |
5.06 | one arm affected | 5;6 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if one of the patient's arms is affected. | |
5.07 | one leg affected | 5;7 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if one of the patient's legs is affected. | |
5.08 | both arms affected | 5;8 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if both of the patient's arms are affected. | |
5.09 | both legs affected | 5;9 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if both of the patient's legs are affected. | |
5.1 | other body part affected | 5;10 | BOOLEAN | 0:NO 1:YES | Spinal cord injury or disease can affect different areas of the body. Answer yes if another part of the patient's body is affected. If you answer yes, a free text description may be entered. | |
5.11 | extent of movement | 5;11 | SET OF CODES | 1:FULL USEFUL MOVEMENT 2:SOME USEFUL MOVEMENT 3:NO USEFUL MOVEMENT | Sometimes spinal cord injury or disease causes loss of movement in the arms or legs. If the patient has any loss of movement in the body part affected, enter it here. | |
5.12 | extent of feeling | 5;12 | SET OF CODES | 1:FULL FEELING 2:SOME FEELING 3:NO FEELING | Sometimes spinal cord injury or disease causes loss of feeling in the arms or legs. If the patient has any loss of feeling in the body parts affected, enter it here. | |
5.13 | bowel affected | 5;13 | BOOLEAN | 0:NO 1:YES | ||
5.14 | bladder affected | 5;14 | BOOLEAN | 0:NO 1:YES | ||
6.09 | extent of sci | 6;9 | SET OF CODES | C:COMPLETE I:INCOMPLETE | C (complete) means that the neurological level of injury is complete and I (incomplete) means that the neurological level of injury is not complete. | |
7 | annual rehab eval offered | REHAB;0 | MULTIPLE | 154.07 | ||
8.1 | primary care provider | CARE;1 | POINTER | 200 | ENTER THE VA PRIMARY CARE PROVIDER FOR THIS PATIENT. | |
8.2 | sci/scd coordinator | CARE;2 | POINTER | 200 | Enter the SCD-Registry Coordinator at your site. | |
8.3 | referral source | CARE;3 | SET OF CODES | 1:OTHER VA 2:COMMUNITY HOSPITAL 3:NURSING HOME 4:PVA 5:SELF 6:DEPARTMENT OF DEFENSE 7:NON-VA CARE 8:OTHER | ||
8.4 | referral va | CARE;4 | POINTER | 4 | Enter the referring VA Medical Center. | |
8.6 | initial rehab site | CARE;6 | SET OF CODES | 1:COMMUNITY HOSPITAL 2:VA FACILITY WITH SCI CENTER 3:VA FACILITY WITHOUT SCI CENTER 4:OTHER | ||
8.8 | init rehab discharge date | CARE;8 | DATE-TIME | Enter the date that the patient was discharged from the inital rehab center. | ||
10.1 | bowel care reimbursment | BCR;1 | BOOLEAN | 1:YES 0:NO | Is patient in Bowel Care Reimbursment program. | |
10.2 | bcr date certified | BCR;2 | DATE-TIME | Enter the date of Bowel Care Reimbursment Certification. | ||
10.3 | bcr provider | BCR;3 | FREE TEXT | Enter the certified provider Bowel Care Reimbursment. | ||
11 | remarks | REM;1 | FREE TEXT | |||
12 | division | 4;0 | MULTIPLE | 154.012 | ||
999.01 | ssn | COMPUTED | This is the patient's SSN from the Patient file (#2). | |||
999.02 | dob | COMPUTED | This is the patient's date of birth from the Patient file (#2). | |||
999.025 | age | COMPUTED | ||||
999.03 | sensory/motor loss | COMPUTED | The 'Loss of Movement' and 'Loss of Feeling' fields are used to compute the patient's Completeness of Injury. The possible values for this field are shown below. DON'T KNOW NONE INCOMPLETE MOTOR INCOMPLETE SENSORY COMPLETE MOTOR COMPLETE SENSORY INCOMPLETE SENSORY AND MOTOR COMPLETE SENSORY AND INCOMPLETE MOTOR INCOMPLETE SENSORY AND COMPLETE MOTOR COMPLETE SENSORY AND MOTOR | |||
999.04 | classification of paralysis | COMPUTED | The 'One Arm Affected', 'One Leg Affected', 'Both Arms Affected', and 'Both Legs Affected' fields are used to compute the patient's Extent of Paralysis. The possible values for this field are shown below. DON'T KNOW MONOPLEGIA HEMIPLEGIA PARAPLEGIA TETRAPLEGIA | |||
999.05 | type of injury | COMPUTED | This computed field uses the data in the Date of Onset multiple to determine the patient's type of injury. Possible values returned by this field are: 'TRAUMATIC', 'NON-TRAUMATIC', 'UNKNOWN', and 'INDETERMINATE'. Combinations of these values may also be returned for patients with more than one type of injury, e.g., 'TRAUMATIC, NON-TRAUMATIC'. | |||
999.06 | last annual rehab eval offered | COMPUTED | ||||
999.07 | last annual rehab eval rcd | COMPUTED | ||||
999.08 | last annual rehab eval due | COMPUTED | ||||
999.09 | date of death | COMPUTED | ||||
999.095 | enrollment priority | COMPUTED | ||||
1000 | on fly admissions | 1000;0 | MULTIPLE | 154.02 |
Not Referenced