# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | date/time(+) | 0;1 | DATE-TIME | B | This field identifies the time and date of entry. | |
1 | medical patient(+) | 0;2 | POINTER | 690 | C | This field identifies the medical patient name. |
1.5 | summary(+) | .2;1 | SET OF CODES | N:Normal A:Abnormal T:Technically unsatisfactory ND:Non-Diagnostic | This field summarizes the results of this procedure. | |
2 | procedure(+) | 0;3 | POINTER | 697.2 | This field identifies a pointer to the procedure location file. | |
2.5 | anatomic site(+) | 0;5 | POINTER | 697 | This field identifies a pointer to the anatomy file. | |
3 | ward/clinic | 0;4 | POINTER | 44 | This field identifies the in-house location of the patient. | |
4.1 | biopsy comments | 0;6 | FREE TEXT | This field identifies a free text field, enter any pertinent biopsy comments. | ||
5 | original consult date | 0;7 | DATE-TIME | This field identifies the date of consult. | ||
6.5 | provisional dx remarks | 1;2 | FREE TEXT | This field identifies a free text field, enter provisional DX remarks. | ||
7 | no. cells counted(+) | 4;13 | NUMERIC | This field identifies the number of cells counted. | ||
8 | cellularity | 1;3 | SET OF CODES | N:NORMAL I:INCREASED D:DECREASED | One of a set of descriptors of the occurrance of cellularity. | |
8.1 | cellularity modifier | 1;7 | SET OF CODES | SL:SLIGHTLY MO:MODERATELY SE:SEVERELY MA:MARKEDLY | One of a set of adjectives used to further define cellularity. | |
9 | m:e ratio | 1;4 | FREE TEXT | This field identifies the M:E ratio. | ||
9.5 | iron stores | 1;6 | SET OF CODES | 0:0 1:1+ 2:2+ 3:3+ 4:4+ | From set of positive values. | |
10 | megakaryocytes | 1;5 | SET OF CODES | N:NORMAL I:INCREASED R:REDUCED | This field identifies the megakaryocyte count. | |
10.1 | megakaryocytes modifier | 1;8 | SET OF CODES | SL:SLIGHTLY MO:MODERATELY SE:SEVERLY MA:MARKEDLY | This field identifies the megakaryocyte count modifier. | |
12 | diff(y/n)(+) | 6;1 | BOOLEAN | Y:YES N:NO | This field identifies no. | |
13 | neutrophils | 4;11 | NUMERIC | This field identifies the neutrophil description. | ||
14 | bands | 4;12 | NUMERIC | The number of bands found. | ||
15 | metamyelocytes | 4;14 | NUMERIC | This field identifies the metamyelocyte count field. | ||
16 | myelocytes | 4;15 | NUMERIC | This field identifies the myelocyte count. | ||
17 | promyelocytes | 4;16 | NUMERIC | This field identifies the promyelocyte count field. | ||
18 | myeloblasts | 4;17 | NUMERIC | This field identifies the myeloblast count field. | ||
19 | eosinophils | 4;18 | NUMERIC | Number of eosinophils found. | ||
20 | basophils | 4;19 | NUMERIC | The number of basophils found. | ||
21 | lymphocytes | 4;20 | NUMERIC | The number of lymphocytes found. | ||
22 | orthochromatic normoblasts | 4;1 | NUMERIC | This field identifies the normoblast count filed. | ||
23 | polychromatic normoblasts | 4;2 | NUMERIC | This field identifies the polychromatic normoblast count field. | ||
24 | basophilic normoblasts | 4;3 | NUMERIC | The number of basophilic normoblasts found. | ||
25 | pronormoblasts | 4;4 | NUMERIC | This field identifies the pronormoblast count field. | ||
26 | lymphoblasts | 4;5 | NUMERIC | Number of lymphoblasts found. | ||
27 | plasma cells | 4;6 | NUMERIC | This field identifies the plasma cell count field. | ||
28 | monocytes | 4;7 | NUMERIC | This field identifies the monocyte count field. | ||
29 | histiocytes | 4;8 | NUMERIC | Number of histiocytes found. | ||
30 | other cell type count | 4;9 | NUMERIC | This field identifies the other cell type count field. | ||
31 | other cell type | 4;10 | FREE TEXT | This field identifies the other cell type descriptor. | ||
34 | date performed | 0;8 | DATE-TIME | Documentation of procedure date. | ||
35 | final diagnosis | 8;0 | MULTIPLE | 694.035 | Enter Medical diagnosis from the medical diagnosis/ICD codes file. | |
36 | decalcification of specimen | 9;1 | BOOLEAN | Y:YES N:NO | Did decalcification of the specimen occur? | |
37 | specimen submitted for plastic | 9;2 | BOOLEAN | Y:YES N:NO | This field identifies the specimen submitted for plastic field. | |
38 | provisional dx | 10;0 | MULTIPLE | 694.038 | This field identifies the provisional diagnosis field. | |
39 | release report | 0;9 | BOOLEAN | Y:YES N:NO | This field identifies the release report field. | |
40 | microscopic description | 5;0 | MULTIPLE | 694.01 | This field identifies the microscopic description field. | |
41 | final diagnosis remarks | 3;0 | WORD-PROCESSING | Free text field for diagnostic remarks. | ||
43 | fixative | 6;2 | SET OF CODES | F:Formalin B:B-5 Z:Zenker's C:Carnoy's | This field identifies for BMB only | |
44 | number of pieces | 6;3 | NUMERIC | This field identifies for BMB only | ||
45 | piece 1 | 6;4 | NUMERIC | This field is for BMB only. | ||
46 | piece 2 | 6;5 | NUMERIC | This field is for BMB only | ||
47 | piece 3 | 6;6 | NUMERIC | This field is for BMB only | ||
48 | piece 4 | 6;7 | NUMERIC | This field is for BMB only | ||
49 | piece 5 | 6;8 | NUMERIC | This field is for BMB only | ||
50 | performed by | 1;11 | POINTER | 200 | This field identifies the health care provider who performed this procedure. | |
51 | approved by | 1;9 | POINTER | 200 | This field identifies the health care provider who approved the results. | |
52 | approval date | 1;10 | DATE-TIME | This field identifies the date on which the results were approved. | ||
54 | micro description remarks | 7;0 | WORD-PROCESSING | This field identifies the micro description remark field. | ||
55 | complications | 2;0 | MULTIPLE | 694.055 | Free text field whose purpose is to document procedural difficulties. | |
56 | peripheral blood smear | 11;1 | FREE TEXT | This field documents the results of the peripheral smear. | ||
57 | indication | 12;0 | MULTIPLE | 694.057 | Entry from the indication file. | |
58 | other indication | 13;0 | WORD-PROCESSING | This field identifies the other indication field. | ||
600 | procedure summary(+) | .2;2 | FREE TEXT | This 1-79 character field is produced on the summary of patient procedures. | ||
700 | icd diagnosis | ICD;0 | MULTIPLE | 694.02 | This field contains the ICD Diagnosis(es) for the procedure. | |
701 | primary provider | PROV;1 | POINTER | 200 | This contains the primary provider. It is triggered by another field in the file and is located here to provider a standard provider location for use in transferring data to the PCC. | |
900 | pcc pointer | PCC;1 | POINTER | 9000010 | APCE | This field is used to link the Medicine package results with the PCC Visit File for use by Queryman. |
1000 | orifn | OR;1 | POINTER | 100 | This field contains a pointer to the 'Consult Orders' internal file number, stored in file 100. This field is entered when results are entered in the Medicine package. | |
1001 | gmrco | OR;2 | POINTER | 123 | This field contains a pointer to the internal number of the consult order stored in the REQUEST/CONSULTATION file (123). This field is entered when results are entered in the Medicine package. | |
1500 | entering duz | ES;1 | POINTER | 200 | ||
1501 | cosigner validation code | ES;2 | FREE TEXT | |||
1502 | entering date | ES;3 | DATE-TIME | |||
1503 | verifying duz | ES;4 | POINTER | 200 | ||
1504 | signer validation code | ES;5 | FREE TEXT | |||
1505 | verifier date | ES;6 | DATE-TIME | |||
1506 | release code | ES;7 | SET OF CODES | D:DRAFT PD:PROBLEM DRAFT RV:RELEASE ON-LINE VERIFIED ROV:RELEASE OFF-LINE VERIFIED RNV:RELEASE NOT VERIFIED S:SUPERSEDED SRV:SUPERSEDING RELEASE ON-LINE VERIFIED SROV:SUPERSEDING RELEASE OFF-LINE VERIFIED | ES | |
1507 | date of released | ES;8 | DATE-TIME | |||
1508 | date of verified | ES;9 | DATE-TIME | |||
1509 | superseded | ES;10 | NUMERIC | |||
1510 | superseded by | ES;11 | NUMERIC | |||
1511 | mark for deletion | ES;12 | SET OF CODES | 1:MARK FOR DELETION | ||
1512 | deleter duz | ES;13 | POINTER | 200 | ||
1513 | superseded date | ES;14 | FREE TEXT | |||
1514 | creation date | ES;15 | DATE-TIME | |||
2005 | image | 2005;0 | MULTIPLE | 694.02005 | This field points to an object in the Image File. |