| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | case number | 0;1 | NUMERIC | B | This field contains the computer generated case number of this Imaging exam. The case number is used to quickly track and call up the exam as it is processed through the Rad/Nuc Med system. The case numbers are generated by the system in sequential order. NOTE: Case numbers are not allowed to exceed 99,999. | |
| 1.1 | radiation absorbed dose | 1;1 | POINTER | 70.3 | This field references the radiation absorbed record associated with this study. Please refer to the Radiology/Nuclear Medicine User Manual for information concerning the modalities involved in the radiation absorbed dose collection. | |
| 2 | procedure | 0;2 | POINTER | 71 | AP | This field points to the 'RAD/NUC MED PROCEDURES' file (#71) to indicate the Imaging procedure associated with this case number. ALLOWABLE WAYS TO ENTER THE IMAGING PROCEDURE FOR THIS CASE NUMBER: --------------------------------------------------------------------- -Name of procedure -CPT Code -Site specific synonym |
| 3 | exam status(+) | 0;3 | POINTER | 72 | This field points to the 'EXAMINATION STATUS' file (#72) to indicate the current status of this Imaging exam. The status is determined and updated by the system according to the information entered during the various data entry processes. | |
| 3.5 | reason for cancellation | 0;23 | POINTER | 75.2 | This is the reason this exam was cancelled. | |
| 4 | category of exam(+) | 0;4 | SET OF CODES | I:INPATIENT O:OUTPATIENT C:CONTRACT S:SHARING E:EMPLOYEE R:RESEARCH | This field contains the exam category associated with this case number. It is used to compile workload statistics and various management reports (i.e. AMIS and RCS14-4). Available exam categories are: 'I' for INPATIENT, 'O' for OUTPATIENT, 'C' for CONTRACT, 'S' for SHARING, 'E' for EMPLOYEE, and 'R' for RESEARCH. When the 'category of exam' is asked during the exam registration process, the default value asked is the value in the 'usual category' field. Of course, if the patient is an inpatient, the default value will always be 'inpatient'. An inpatient may have a 'category of exam' of 'contract', 'sharing', or 'research' for its associated case number if the exam procedure is not directly related with their hospital stay. (i.e. An inpatient who has an imaging exam performed for research purposes.) | |
| 6 | ward | 0;6 | POINTER | 42 | This field points to the 'WARD LOCATION' file (#42) to indicate the name of the hospital ward where the inpatient was admitted at the time the Radiology/Nuclear Med exam was performed. This field is filled in by the system from information entered by the ADT system and is updated at the time the exam report is first printed. | |
| 7 | service | 0;7 | POINTER | 49 | This field is used for Rad/Nuc Med patients who are inpatients. It points to the 'HOSPITAL SERVICE' file (#49) to indicate the name of the service treating the patient and is filled in by the system from information entered by the ADT system. | |
| 8 | principal clinic | 0;8 | POINTER | 44 | This field is used for exams with a 'category of exam' of 'outpatient' or 'employee'. It points to the 'HOSPITAL LOCATION' file (#44) to indicate the name of the principle clinic that referred the patient to Radiology/Nuclear Medicine for the exam. If the appropriate Report Distribution Queue is active, the report for this exam will automatically be placed in the queue for this clinic, or in the current ward if the patient is admitted before the report is verified. | |
| 9 | contract/sharing source | 0;9 | POINTER | 34 | This field is used for exams with a 'category of exam' of 'contract' or 'sharing'. It points to the 'CONTRACT/SHARING AGREEMENTS' file (#34) to indicate the name of the contract or sharing agreement that referred this patient to Radiology/Nuclear Medicine for the exam. | |
| 9.5 | research source | R;1 | FREE TEXT | This field is used for exams with a 'category of exam' of 'research'. This field contains the name (3-40 characters) of the research source that referred the patient to Radiology/Nuclear Medicine for the exam. | ||
| 10 | contrast media used | 0;10 | BOOLEAN | Y:YES N:NO | This field contains a value to indicate if a contrast medium was, or if contrast media were used during this Rad/Nuc Med exam. Available values are: 'Y' for YES and 'N' for NO. If the Rad/Nuc Med procedure does not involve the use of a contrast, the field is automatically filled in with NO by the system but the user is prompted with this question. Conversely, if the Rad/Nuc Med procedure does not involve the use of a contrast, the field is automatically filled in with NO by the system but the user is prompted with this question. | |
| 11 | imaging order | 0;11 | POINTER | 75.1 | AO | This field points to the 'RAD/NUC MED ORDERS' File (#75.1). It contains the order associated with this exam. This field will only contain data if the exam has an 'ACTIVE' order associated with it. When orders are purged, the pointer in this field is also purged. |
| 12 | primary interpreting resident | 0;12 | POINTER | 200 | This field points to the 'NEW PERSON' file (#200) to indicate the name of the primary interpreting resident who read the films of this exam. If interpreting staff is required to review this resident's results, then the 'primary interpreting staff' field must also be filled in. Primary Interpreting Resident must be classified as an interpreting resident, and must have access to at least one imaging location that matches the imaging type of the exam. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete. | |
| 13 | primary diagnostic code | 0;13 | POINTER | 78.3 | This field is used at sites that decide to enter diagnostic codes for exams, as designated in the Examination Status file parameters. It points to a short diagnostic code in the 'DIAGNOSTIC CODES' file (#78.3) to indicate the primary diagnostic code associated with this exam. If filled in, this field can be used in the search criteria for database searches. For example, the database can be searched for all 'normal' chest procedures performed during a specific time period. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete. | |
| 13.1 | secondary diagnostic code | DX;0 | MULTIPLE | 70.14 | This field contains additional Diagnostic Codes for this Rad/Nuc Med exam. | |
| 14 | requesting physician(+) | 0;14 | POINTER | 200 | This field points to the 'NEW PERSON' file (#200) to indicate the name of the person who requested this Rad/Nuc Med exam. This person is not always a physician. (i.e. A nurse might request the exam.) | |
| 15 | primary interpreting staff | 0;15 | POINTER | 200 | This field points to the 'NEW PERSON' file (#200) to indicate the name of the primary staff who interpreted the images. Primary Staff must have Rad/Nuc Med personnel classification of 'staff', and must have access to at least one imaging location of the same imaging type as the exam. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete. | |
| 16 | complication | 0;16 | POINTER | 78.1 | This field points to the 'COMPLICATION TYPES' file (#78.1) to indicate if this patient experienced any complication during the exam procedure. (i.e. Reaction to Contrast Medium) If a reaction to the contrast medium did occur, then the system triggers the addition of contrast media as an allergen in the Adverse Reaction Tracking (ART) package without leaving the Radiology/Nuclear Medicine option. | |
| 16.5 | complication text | COMP;1 | FREE TEXT | This field is used to give a brief explanation (4-100 characters) to describe the exam complication. The text entered will appear on the Complications Report, and under the 'Comment' caption in the detailed exam view of the Profile of Rad/Nuc Med Exams. | ||
| 17 | report text | 0;17 | POINTER | 74 | This field points to the 'RAD/NUC MED REPORTS' file (#74) to indicate the report text associated with this exam. It is filled in by the system and is not seen by the user. | |
| 18 | primary camera/equip/rm | 0;18 | POINTER | 78.6 | This field points to the 'CAMERA/EQUIP/RM' file (#78.6) for the name of the primary camera/equipment/room where the imaging exam was performed. Usually there is only one camera/equipment/room per procedure. Depending on the requirements set up in the 'EXAMINATION STATUS' file (#72), it may be necessary for this field to be filled in before the 'exam status' can be considered complete. | |
| 19 | bedsection | 0;19 | POINTER | 42.4 | This field points to the 'SPECIALTY' file (#42.4) to indicate the name of the bedsection of Rad/Nuc Med patients who are inpatients. This field is filled in by the system from information entered by the ADT system. | |
| 20 | diagnostic print date | 0;20 | DATE-TIME | If any diagnostic code associated with this exam requires immediate notification of the physican, this field is filled in with the date that this exam appeared on the 'Abnormal Exam Report'. The report prints a warning indicating abnormal results of the Rad/Nuc Med exam. The report is used by Radiology/Nuclear Medicine to help make sure that the physican is notified of the results of the abnormal exam. The date is filled in on this field when this report is printed so the next time the report is printed this exam will not appear again. This field is filled in by the system and is not seen by the user. | ||
| 21 | requested date | 0;21 | DATE-TIME | This field contains the date the Rad/Nuc Med exam was requested. Depending on the site's specifications, this field may or may not be asked of the transcriptionist. By default, it is populated automatically, at the time an exam is registered, with the Request date in the Rad/Nuc Med Order file. | ||
| 22 | requesting location | 0;22 | POINTER | 44 | This field points to the 'HOSPITAL LOCATION' file (#44) to indicate the name of the hospital location that is requesting the exam. By default, it is populated automatically, using data from the Rad/Nuc Med Orders file, at the time an exam is registered. | |
| 23 | clinic stop recorded? | 0;24 | BOOLEAN | Y:YES | This field contains a YES when clinic stop information has been entered in the Scheduling Visits file for this exam. | |
| 25 | member of set | 0;25 | SET OF CODES | 1:Yes,separate reports 2:Yes,combined report | This field is automatically populated by the system. If this case was registered as a 'descendant' of a 'parent' procedure, the field value is set to '1' if all cases in the set are to have separate reports '2' if all cases in the set are to be combined into one report. All cases belonging to a 'parent' are created from the same order. The system must check all members of the set of descendants to determine the new order status whenever the exam status changes on any member. | |
| 26 | credit method | 0;26 | SET OF CODES | 0:Regular Credit 1:Interpretation Only 2:No Credit 3:Technical Component Only | This field indicates the type of credit this location receives for examinations. This field is populated automatically by the system at the time an exam is registered based on the Credit Method entered for the Imaging Location where the exam is registered. If only the interpretation was done at this facility, code 1 should be used. If the exam was performed at this facility, but the interpretation was done elsewhere, code 3 should be used. If both the exam and interpretation were done at this facility, code 0 should be used. If the entire exam was done outside the facility and exam data is being entered for the purposes of record-keeping only, code 2 should be used. | |
| 27 | visit | 0;27 | POINTER | 9000010 | AVSIT | This field links the examination of a patient to a specific visit. |
| 29 | dosage ticket printed? | 0;29 | BOOLEAN | 1:Yes | This field indicates if a dosage ticket has been printed for each radiopharmaceutical associated with this examination. Once this process has completed for a particular exam status, all further status updates will not print dosage tickets. If an examination is cancelled, the dosage ticket field is cleared. Only if the exam is re-registered will the dosage ticket again print for the examination. | |
| 30 | hl7 examined msg sent? | 0;30 | BOOLEAN | Y:Yes | ||
| 31 | site accession number(+) | 0;31 | FREE TEXT | The SITE ACCESSION NUMBER is generated by the VistA Radiology/Nuclear Medicine application. SITE ACCESSION NUMBER is a Free Text data type between 12-16 characters in length. It is created by appending a three-character site identifier to the accession number. This field allows other applications to "look up" an exam record based on a site specific accession number. Example: site id-mmddyy-case # In the example the dash "-" is the delimiter. | ||
| 32 | pregnancy screen | 0;32 | SET OF CODES | y:Patient answered yes n:Patient answered no u:Patient is unable to answer or is unsure | This field tracks the answer given by the patient when asked if she is pregnant at the time of the exam. | |
| 40 | purged date | PURGE;1 | DATE-TIME | This field contains the last purge date associated with this exam. | ||
| 45 | prevent purge | NOPURGE;1 | SET OF CODES | n:NO PURGE o:OK TO PURGE | If this field is set to 'NO PURGE' then the data for this exam will not be purged or archived, nor will the report associated with this exam be purged or archived. | |
| 46 | reason for not purging | NOPURSN;0 | MULTIPLE | 70.346 | This field indicates why the examination should not be purged. | |
| 50 | film size | F;0 | MULTIPLE | 70.04 | This is a multiple field containing the sizes of the films used and films wasted during this exam. | |
| 60 | secondary interpreting staff | SSR;0 | MULTIPLE | 70.11 | This multiple tracks additional Staff who have interpreted the images of an exam. | |
| 70 | secondary interpret'g resident | SRR;0 | MULTIPLE | 70.09 | This multiple tracks additional Interpreting Residents who interpreted the images of an exam. | |
| 75 | exam status times | T;0 | MULTIPLE | 70.05 | This is a multiple field containing a log of when the exam status was changed from one status to another. Depending on how the system parameters are set up, this field may or may not be filled in. Because the mass override process will degrade system performance by slowing the system down, it should be run at specified times only. (i.e. one week per quarter) | |
| 80 | pregnancy screen comment | PCOMM;E1,240 | FREE TEXT | This field allows comments to be collected by the individual administering the exam regarding the patient's answer to the Pregnancy Screen question. | ||
| 81 | study instance uid | SIUID;E1,240 | FREE TEXT | This field will store the Study Instance UID. The Study Instance UID is a unique key that associates the images to a particular study, and thus is required in messages sent to the PACS. An Imaging API will be used to generate the Study Instance UID and the Study Instance UID will be sent in specific v2.4 HL7 event messages (when an order is registered, an exam cancelled, or when an exam reaches the Examined status). This will allow Vista Radiology to send event transactions to a commercial PACS directly, bypassing the Vista DICOM Text Gateway. | ||
| 100 | activity log | L;0 | MULTIPLE | 70.07 | This is a multiple field containing a log of actions that have been taken on this exam record during processing of this exam. Use the function that allows you to View Exam by Case No. within the Exam Entry/Edit menu to view this activity log. | |
| 125 | procedure modifiers | M;0 | MULTIPLE | 70.1 | This multiple field is used to give the imaging modifiers that are associated with this exam. | |
| 135 | cpt modifiers | CMOD;0 | MULTIPLE | 70.3135 | ||
| 175 | technologist | TC;0 | MULTIPLE | 70.12 | This multiple field is used to give the names of technologists who performed this exam. Depending on the site's specifications, this field may or may not be filled in. | |
| 200 | medications | RX;0 | MULTIPLE | 70.15 | ||
| 225 | contrast media | CM;0 | MULTIPLE | 70.3225 | ||
| 250 | contrast media activity log | AUD;0 | MULTIPLE | 70.16 | ||
| 400 | clinical history for exam | H;0 | WORD-PROCESSING | This field may contain a written clinical history of the patient as well as instructions to the interpreting physician . For example, the instructions might be to interpret the images to rule out the possibility of a patient having a certain disease. This field is used as the 'Clinical History' that appears on the printed report for each exam associated with this visit. | ||
| 500 | nuclear med data | 0;28 | POINTER | 70.2 | Radiopharmaceutical data may be automatically entered, if it exists on the procedure file. It is also editable during case edit options and may be configured for editing during status tracking. |
Error: Invalid Global File Type: 70.03