| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | date(+) | 0;1 | DATE-TIME | B | The DATE field contains the encounter date or date and time. | |
| .07 | time spent (minutes)(+) | 0;7 | NUMERIC | The TIME SPENT field is used to record the TOTAL number of minutes that were used during this clinic visit. TIME SPENT is to include direct (e.g., face-to-face) and indirect time (e.g., paperwork, documentation, administration). | ||
| .08 | linked c&p exam | 0;8 | FREE TEXT | ALCP | For C&P exams, the LINKED C&P EXAM field is automatically filled in by the QUASAR package. It provides a means of linking this QUASAR visit with a specific AMIE C&P request. If the visit is not a C&P exam this field is left blank. This field should not be edited manually. | |
| .09 | c and p status | 0;9 | SET OF CODES | 0:NOT A C&P EXAM 1:NOT SIGNED OFF 2:AWAITING ADEQUATION 3:COMPLETE | The C AND P STATUS field indicates the status of the C&P exam (if any). 0 stands for NOT A C&P EXAM, 1 stands for NOT SIGNED OFF, 2 stands for AWAITING ADEQUATION, and 3 stands for COMPLETE. | |
| .25 | *second clincian | 2;5 | POINTER | 509850.3 | If more than one provider was involved in this exam, the name of the SECONDARY PROVIDER should be entered here. In order to enter a provider in this field, the provider must already exist in the A&SP STAFF file (#509850.3) and the ACTIVATION DATE and INACTIVATION DATE must indicate that the selected provider is active on the date of the exam. The SECONDARY PROVIDER field can be left blank. | |
| .27 | *lead role | 2;7 | POINTER | 509850.3 | For visits involving more than one staff member, the LEAD ROLE field is provided to show which staff member played the leading role in the examination. Credit for the visit is always given to the clinician in the LEAD ROLL field. This field can only be entered through the Enter Clinic Visits option. The LEAD ROLE field has been marked for deletion. This field is not used by QUASAR V. 3.0. Eighteen months after the release of QUASAR 3.0, this field can be removed. | |
| 1 | patient name(+) | 0;2 | POINTER | 509850.2 | APT | The PATIENT NAME field contains the name of the patient seen during this clinic visit. In order to enter a patient name into this field, the patient must already exist in the PATIENT file (#2). |
| 1.5 | age on appointment | 0;4 | NUMERIC | The AGE ON APPOINTMENT field is automatically filled in by the QUASAR package. It is triggered by the PATIENT NAME field of the A&SP CLINIC VISIT file (#509850.6). | ||
| 2 | patient eligibility code(+) | 0;3 | FREE TEXT | This is the Primary Eligibility of the patient | ||
| 2.5 | c and p | 0;5 | BOOLEAN | 0:NO 1:YES | The C AND P field contains 0 or NO if this is not a C&P exam. The field contains 1 or YES if this is a C&P exam. WARNING: QUASAR points to the AMIE 2507 REQUEST file (#396.3) to determine if a patient on a given date is a C&P visit. If AUDIO exam is not found in the exam list, QUASAR does not recognize the visit as a C&P visit. The C AND P field can be filled with 1 or YES at the "Is this a C&P exam?" prompt or by entering ^C AND P. This provides you with the AMIE worksheet fields, but the examination is not available for adequation and is not linked to the AMIE system. | |
| 2.6 | clinic location | 0;6 | POINTER | 44 | The CLINIC LOCATION field is a pointer to the HOSPITAL LOCATION file (#44). Clinic location names must match exactly with MAS clinic names set up in DHCP. | |
| 2.7 | secondary provider | 2.7;0 | MULTIPLE | 509850.66 | ||
| 3 | diagnostic code | 1;0 | MULTIPLE | 509850.63 | The DIAGNOSTIC CODE field is a pointer to the A&SP DIAGNOSTIC CONDITION file (#509850.1). | |
| 4 | clinic stop code | 2;1 | SET OF CODES | A:AUDIOLOGY S:SPEECH AT:TELEPHONE AUDIOLOGY ST:TELEPHONE SPEECH | The CLINIC STOP CODE field contains A for Audiology, S for Speech Pathology, AT for an Audiology Telephone visit and ST for Speech Telephone visit. | |
| 4.01 | tone r500(+) | 4;1 | NUMERIC | The TONE R500 field indicates the patient's pure tone threshold at 500Hz. The 500Hz threshold is not currently used for evaluation, but is used in determining whether or not a ratable hearing loss exists. It is not included in the four-frequency average. | ||
| 4.02 | tone r1000(+) | 4;2 | NUMERIC | The TONE R1000 field indicates the pure tone threshold (Right) at 1000Hz for this patient. | ||
| 4.03 | tone r2000(+) | 4;3 | NUMERIC | The TONE R2000 field indicates the pure tone threshold (Right) at 2000Hz for this patient. | ||
| 4.04 | tone r3000(+) | 4;4 | NUMERIC | The TONE R3000 field indicates the pure tone threshold (Right) at 3000Hz for this patient. | ||
| 4.05 | tone r4000(+) | 4;5 | NUMERIC | The TONE R4000 field indicates the pure tone threshold (Right) at 4000Hz for this patient. | ||
| 4.06 | tone r average(+) | 4;6 | NUMERIC | The TONE R AVERAGE field is the average pure tone threshold for this patient's right ear. This indicates the average of the 1000, 2000, 3000 and 4000Hz scores for the right ear. This is a computed field. If the package options are used to enter the 1000 to 4000Hz threshold values, this field is computed and filled in by the QUASAR software. | ||
| 4.07 | tone l500(+) | 4;7 | NUMERIC | The TONE L500 field indicates the patient's pure tone threshold at 500Hz. The 500Hz threshold is not currently used for evaluation, but is used in determining whether or not a ratable hearing loss exists. It is not included in the four-frequency average. | ||
| 4.08 | tone l1000(+) | 4;8 | NUMERIC | The TONE L1000 field indicates the pure tone threshold (Left) at 1000Hz for this patient. | ||
| 4.09 | tone l2000(+) | 4;9 | NUMERIC | The TONE L2000 field indicates the pure tone threshold (Left) at 2000Hz for this patient. | ||
| 4.1 | tone l3000(+) | 4;10 | NUMERIC | The TONE L3000 field indicates the pure tone threshold (Left) at 3000Hz for this patient. | ||
| 4.11 | tone l4000(+) | 4;11 | NUMERIC | The TONE L4000 field indicates the pure tone threshold (Left) at 4000Hz for this patient. | ||
| 4.12 | tone l average(+) | 4;12 | NUMERIC | The TONE L AVERAGE field is the average pure tone threshold for this patient's left ear. This indicates the average of the 1000, 2000, 3000 and 4000Hz scores for the left ear. This is a computed field. If the package options are used to enter the 1000 to 4000Hz threshold values, this field is computed and filled in by the QUASAR software. | ||
| 4.13 | cnc r | 4;13 | NUMERIC | The CNC R field contains the patient's (Right) word recognition score for Maryland CNC material. This score is a percentage between 0 and 100. | ||
| 4.14 | cnc l | 4;14 | NUMERIC | The CNC L field contains the patient's (Left) word recognition score for Maryland CNC material. This score is a percentage between 0 and 100. | ||
| 4.15 | w22 r | 4;15 | NUMERIC | The W22 R field contains the patient's (Right) word recognition score for CID W-22 material. This score is a percentage between 0 and 100. | ||
| 4.16 | w22 l | 4;16 | NUMERIC | The W22 L field contains the patient's (Left) word recognition score for CID W-22 material. This score is a percentage between 0 and 100. | ||
| 4.17 | signature | 4;17 | FREE TEXT | For C&P exams, the SIGNATURE field contains the electronic signature of the audiologist who completed the exam. When the exam is signed, it is released for adequation by the supervisor. Clinicians and adequators must have an electronic signature provided by IRM or selected through the Edit Electronic Signature Code option on the User's Toolbox menu in the user's secondary DHCP menu. The signature field is not displayed for routine exams. | ||
| 4.18 | date signed | 4;18 | DATE-TIME | For C&P exams, the DATE SIGNED field contains the date that the electronic signature was entered, thereby releasing the C&P exam for adequation. The DATE SIGNED field is not displayed for routine exams. | ||
| 4.19 | adequated by | 4;19 | FREE TEXT | The ADEQUATED BY field contains the electronic signature of the audiologist who adequated the clinic visit. Only an adequator designated as a supervisor in the A&SP STAFF file (#509850.3) can adequate a C&P exam for other clinicians. Clinicians may adequate there own C&P exams. Adequators must have an electronic signature provided by IRM or selected through the Edit Electronic Signature Code option on the User's Toolbox menu in the user's secondary DHCP menu. The signature field is not displayed for routine exams. Adequated exams can be printed and/or released to the AMIE package. | ||
| 4.2 | date adequated | 4;20 | DATE-TIME | The DATE ADEQUATED field contains the date that the electronic signature was entered for the adequation of this C&P exam. | ||
| 4.21 | *nu6 r | 4;21 | NUMERIC | The NU6 R field contains the patient's (Right) word recognition score for NU-6 material. This score is a percentage between 0 and 100. The NU6 R field has been marked for deletion. This field is not used by QUASAR V. 2.0. Eighteen months after the release of QUASAR 2.0, this field can be removed. | ||
| 4.22 | *nu6 l | 4;22 | NUMERIC | The NU6 L field contains the patient's (Left) word recognition score for NU-6 material. This score is a percentage between 0 and 100. The NU6 L field has been marked for deletion. This field is not used by QUASAR V. 2.0. Eighteen months after the release of QUASAR 2.0, this field can be removed. | ||
| 4.23 | date of audiometric testing | 4;23 | DATE-TIME | When audiometric data are pulled from a past visit (i.e., testing is not done on the current date), the DATE OF AUDIOMETRIC TESTING field is filled with the date when actual testing was done. | ||
| 4.24 | completer title | 4;24 | FREE TEXT | For C&P exams, the COMPLETER TITLE field contains the title of the audiologist who completed the exam. QUASAR fills in this field from the SIGNATURE BLOCK TITLE in the NEW PERSON file (#200). SIGNATURE BLOCK TITLE can be entered by IRM or through the Edit Electronic Signature Code option on the User's Toolbox menu in the user's secondary DHCP menu. The title field is not displayed for routine exams. | ||
| 4.25 | adequator title | 4;25 | FREE TEXT | For C&P exams, the ADEQUATOR TITLE field contains the title of the audiologist who adequated the clinic visit. QUASAR fills in this field from the SIGNATURE BLOCK TITLE in the NEW PERSON file (#200). SIGNATURE BLOCK TITLE can be entered by IRM or through the Edit Electronic Signature Code option on the User's Toolbox menu in the user's secondary DHCP menu. The title field is not displayed for routine exams. | ||
| 5 | cdr account | 2;2 | POINTER | 509850 | The CDR ACCOUNT field contains the CDR account number to be credited with this clinic visit. | |
| 6 | primary provider | 2;3 | POINTER | 509850.3 | The PRIMARY PROVIDER field contains the name of the primary A&SP Provider who participated in this exam. In order to enter a Provider in this field, the Provider must already exist in the A&SP STAFF file (#509850.3) and the ACTIVATION DATE and INACTIVATION DATE must indicate that the selected Provider is active on the date of the exam. Credit for a clinic visit is always credited to the Primary Provider. If you want credit be given to the SECONDARY PROVIDER or STUDENT, then you should enter ONLY the name of the provider who will get the credit. For example, if a health technician provides care and will get credit for the visit, the health technician's name should be entered in the SECONDARY PROVIDER field. All other fields should be left blank. | |
| 6.5 | pce error | 6.5;0 | MULTIPLE | 509850.65 | This multiple contains any error messages returned by PCE when this visit was transmitted via the Interface to PCE. The multiple contains the name of the field in error, the internal value of the field, the external value of the field (where possible) and the text of the error message. | |
| 7 | student | 2;4 | POINTER | 509850.3 | If a student or trainee participated in this exam, the name of the STUDENT should be entered here. In order to enter a student in this field, the student must already exist in the A&SP STAFF file (#509850.3), be designated as a student, and the ACTIVATION DATE and INACTIVATION DATE must indicate that the selected student is active on the date of the exam. QUASAR assumes that students are supervised 100% of the time. | |
| 8 | *other provider | 2;8 | POINTER | 509850.3 | The OTHER PROVIDER field contains the name of the health technician who participated in this exam. In order to enter a name in this field, the person must already exist in the A&SP STAFF file (#509850.3) and the ACTIVATION DATE and INACTIVATION DATE must indicate that the selected individual is active on the date of the exam. The OTHER PROVIDER field has been marked for deletion. This field is not used by QUASAR V. 3.0. Eighteen months after the release of QUASAR 3.0, this field can be removed. | |
| 9 | *disposition | 2;6 | FREE TEXT | The DISPOSITION field permits you to enter free text data (up to 80 characters). You can code any data in this field such as clinic outcomes, pre and/or post test data, patient satisfaction, or any other numerical data. This data field can be sorted using FileMan in the Tailor-Made A&SP Reports option on the A&SP Reports menu. The DISPOSITION field has been marked for deletion. This field is not used by QUASAR V. 3.0. Eighteen months after the release of QUASAR 3.0, this field can be removed. | ||
| 10 | procedure code | 3;0 | MULTIPLE | 509850.61 | The PROCEDURE CODE field contains CPT-4 procedure codes and modifiers, if any, for this exam. | |
| 15 | event capture procedure | 7;0 | MULTIPLE | 509850.615 | ||
| 20 | service connected(+) | 5;3 | BOOLEAN | 0:NO 1:YES | This prompt allows the user to indicate if the visit is Service Connected or not. If the visit is not Service Connected the user may be prompted for additional information relating to Agent Orange, Radiation and Environmental Contaminants. | |
| 25 | agent orange(+) | 5;4 | BOOLEAN | 0:NO 1:YES | Is this visit related to Agent Orange Exposure. | |
| 30 | radiation(+) | 5;5 | BOOLEAN | 0:NO 1:YES | Is this visit related to Radiation Exposure. | |
| 35 | environmental contaminants(+) | 5;6 | BOOLEAN | 0:NO 1:YES | Is this visit related to Environmental Contaminants exposure. | |
| 40 | head and/or neck cancer(+) | 5;9 | BOOLEAN | 0:NO 1:YES | Indicates whether or not the visit is related to Head and/or Neck Cancer. | |
| 45 | combat related(+) | 5;10 | BOOLEAN | 0:NO 1:YES | Indicates whether or not the visit is related to Combat. | |
| 55 | appointment time(+) | 5;8 | FREE TEXT | Enter the time the visit took place such as 10, 10AM, 10:30, 0100, 0025 etc. You may also enter a time, such as NOON, MIDNIGHT or NOW. Time is REQUIRED in this response. | ||
| 60 | division(+) | 5;1 | POINTER | 40.8 | This is the division at which the visit took place. All clinics are defined as part of a Division. The user may only select a division that has been entered on the A&SP Site Parameters file. | |
| 80 | visit eligibility(+) | 5;2 | POINTER | 8 | Only Eligibilities associated with the visit are valid for entry. | |
| 90 | military sexual trauma(+) | 2;9 | BOOLEAN | 1:YES 0:NO | Indicates whether the patients visit was related to Military Sexual Trauma. | |
| 100 | review of medical records | 100;0 | WORD-PROCESSING | REVIEW OF MEDICAL RECORDS: Indicate whether the C-file was reviewed. If the C-file was not reviewed or was not available for review, the examiner should so state. | ||
| 101 | medical history | 101;0 | WORD-PROCESSING | MEDICAL HISTORY (SUBJECTIVE COMPLAINTS): |NOWRAP| Comment on: 1. Chief Complaint. 2. Situation of greatest difficulty. 3. Pertinent service history. 4. History of military, occupational, and recreational noise exposure. 5. Tinnitus - If present, state: a. date and circumstances of onset b. whether it is unilateral or bilateral c. whether it is recurrent (indicate frequency and duration) d. State the most likely etiology of the tinnitus, and specifically, if hearing loss is present, whether the tinnitus is due to the same etiology (or causative factor) as the hearing loss. | ||
| 102 | physical examination | 102;0 | WORD-PROCESSING | PHYSICAL EXAMINATION (OBJECTIVE FINDINGS): |NOWRAP| 1. Measure pure tone thresholds in decibels at the indicated frequencies (air conduction): ==========RIGHT EAR=============================LEFT EAR=============== A* B C D E ** A* B C D E ** 500 1000 2000 3000 4000 average 500 1000 2000 3000 4000 average *The pure tone threshold at 500 Hz is not used in determining the evaluation but is used in determining whether or not a ratable hearing loss exists. **The average of B, C, D, and E. 2. Speech Recognition Score: Maryland CNC word list ______% right ear _____% left ear 3. When only pure tone results should be used to evaluate hearing loss, the examiner, who must be a state-licensed audiologist, should certify that language difficulties or other problems (specify what the problems are) make the combined use of pure tone average and speech discrimination inappropriate. | ||
| 103 | diagnostic and clinical tests | 103;0 | WORD-PROCESSING | DIAGNOSTIC AND CLINICAL TESTS: |NOWRAP| 1. Report middle-ear status, confirm type of loss, and indicate need for medical follow-up. In cases where there is poor inter-test reliability and/or positive Stenger test results, obtain and report estimates of hearing thresholds using a combination of behavioral testing, Stenger interference levels, and electrophysiological tests. 2. Include results of all diagnostic and clinical tests conducted in the examination report. | ||
| 104 | diagnosis | 104;0 | WORD-PROCESSING | DIAGNOSIS: |NOWRAP| 1. Summary of audiologic test results. Indicate type and degree of hearing loss for the frequency range from 500 to 4000 Hz. For type of loss, indicate whether it is normal, conductive, sensorineural, central, or mixed. For degree, indicate whether it is mild (26-40 dB HL), moderate (41-54 dB HL), moderately-severe (55-69 dB HL), severe (70-89 dB HL), or profound (90+ dB HL). For VA purposes, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hz is 40 dB HL or greater; or when the auditory thresholds for at least three of these frequencies are 26 dB HL or greater; or when speech recognition scores are less than 94%. 2. Note whether, based on audiologic results, medical follow-up is needed for an ear or hearing problem, and whether there is a problem that, if treated, might cause a change in hearing threshold levels. | ||
| 125 | pce visit ien | 6;3 | FREE TEXT | This is the IEN of the PCE visit passed back by the send to PCE processing. | ||
| 135 | last sent to pce | 6;5 | DATE-TIME | The Date/Time that the system last attempted to send this data to PCE. | ||
| 140 | last edited in quasar | 6;7 | DATE-TIME | This date is the date when the visit record was last edited in Quasar. This field is not dependant on the PCE interface being on for the current Division. | ||
| 900 | exception date | 6;6 | DATE-TIME | Set to NOW whenever the system determines that the Visit has become a PCE Exception. Triggered by changes to the PCE Visit IEN field, the LAST SENT TO PCE field and the LAST EDITED IN QUASAR field. NB. This field has been numbered 900 to ensure it is the last field killed when a visit is deleted. |
Not Referenced