Files > RAD/NUC MED REPORTS

name

RAD/NUC MED REPORTS

number

74

location

^RARPT(

description

This file contains the reports for registered exams. These reports are usually first dictated by the interpreting physician before being entered by the transcriptionist. The Radiology/Nuclear Medicine software includes an HL7 interface to support report entry using voice recognition systems. The data in this file has three basic sections: I. Demographic information about the file - patient, date reported, date entered etc. II. Text Data - clinical history, report and impression III. Computed Fields that obtain data from patient's exam record - technician, procedure etc. The computed fields can be a very efficent way to do File Man prints and searches of exam record data, as opposed to doing prints and searches through the 'RAD/NUC MED PATIENT' file. Data Storage ------------ The data for the 'RAD/NUC MED REPORTS file is stored in the ^RARPT( global. This global is very volatile and should be journaled. It should also be translated if the operating system supports this function. Because of the large amount of disk space the report text will demand of the system, the module has a 'Purge Data' function that will allow the site manager to delete the 'REPORT TEXT' and 'CLINCIAL HISTORY' fields on a periodic basis. It is up to the computer site manager and the imaging coordinator to determine how long this data will remain on-line. The 'IMPRESSION' text will not be purged. In the future, the module will also have an archive function. Input Templates --------------- The following is a list of input templates used by the package and the entry in the OPTIONS file (#19) that uses the template: Compiled Name Routine Description; Option(s) ---- -------- ---------------------- RA REPORT EDIT ^RACTWR* Used to enter/edit reports and associated information into this file; RA RPTENTRY RA VERIFY ^RACTVR* Used to indicate a report has been verified; REPORT ONLY RA BATCHVERIFY, RA RPTVERIFY RA PRE-VERIFY REPORT EDIT Used to edit reports and associated information in this file. Does not allow report verification; RA RESIDENT PRE-VERIFY RA PRE-VERIFY REPORT ONLY Used to pre-verify reports; RA RESIDENT PRE-VERIFY If any modifications to these input templates are needed for local purposes, then great care should be taken not to degrade any branching logic in the template. Print Templates --------------- Compiled Name Routine Description; Option(s) ----- -------- ---------------------- RA REPORT ^RACTRT Prints the status of verified reports only. PRINT STATUS Includes date verified, routing queue, date printed, printed by ward/clinic. RA RPTDISTPRINTSTATUS Sort Templates -------------- The package does not use any sort templates associated with this file.

applicationGroups

RA

Fields

#	Name	Location	Type	Details	Index	Description
.01	day-case#(+)	0;1	FREE TEXT		B	This field contains the date and case number of the imaging exam associated with this report. The system fills in this field with information obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist. If the Site Specific Accession Number is in use then the 3-digit Site ID is appended to the beginning of the field.
2	patient name(+)	0;2	POINTER	2	C	This field contains the name of the rad/nuc med patient associated with this report. The system fills in this field with data obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist.
3	exam date/time(+)	0;3	DATE-TIME			This field contains the date and the time of the exam associated with this report. The system fills in this field with data obtained from the 'RAD/NUC MED PATIENT' file (#70) according to the case number selected by the transcriptionist.
4	case number(+)	0;4	NUMERIC			This field contains the completed case number of the exam associated with this report. The system fills in the data for this field with information obtained from the 'RAD/NUC MED PATIENT' file (#70).
4.5	other case#	1;0	MULTIPLE	74.05
5	report status(+)	0;5	SET OF CODES	V:VERIFIED R:RELEASED/NOT VERIFIED PD:PROBLEM DRAFT D:DRAFT EF:ELECTRONICALLY FILED X:DELETED		This field contains a value to indicate the status of this report. Valid choices are: 'V' for Verified, 'R' for Released/Not Verified, 'PD' for Problem Draft, 'D' for Draft, 'EF' for Electronically Filed and 'X' for Deleted. 'V' (Verified) status refers to a report that is verified by the interpreting physician and is available for display outside the Rad/Nuc Med Department to appropriate users, such as ward clerks, nurses, and physicians. 'R' (Released/Not Verified) status refers to a report that is not verified by the interpreting physician and is available for display outside the Rad/Nuc Med Department. The 'R' status is allowed only when the parameter that controls this feature, 'Allow Released/Unverified' of the 'RAD/NUC MED DIVISION' file (#79), is set to 'Yes'. Use the 'Display Report' option to view reports with the 'R' status. 'D' (Draft) status or 'PD' (Problem Draft) status refers to a report that is available only for display in the Rad/Nuc Med Department. A statement describing the problem to the interpreting physician is printed at the end of reports with the 'PD' status. 'EF' (Electronically Filed) status refers to a report that is interpreted outside the Rad/Nuc Med Department. The content is not the actual interpreted report, but canned text referring to the outside interpreted report. 'X' (Deleted) status refers to a report that is deleted from a case, but remains in the database though not selectable from any Radiology options.
6	date report entered	0;6	DATE-TIME			This field contains the date and time that the report was entered into the system by the transcriptionist.
7	verified date	0;7	DATE-TIME			As of July, 1985, this field contains the date and the time that it was indicated to the system that the report was verified by the interpreting physician. An option allowing online verification lets the interpreting physician verify the report directly via a CRT. As a result, there will be no discrepency between the date/time the physician verified the report and the date/time it was indicated to the system.
8	reported date	0;8	DATE-TIME			This field contains the date that the interpreting physician dictated this report. The transcriptionist enters this date from the dictation tape. If the physician is using a voice recognition system for dictation, this date is entered at the time the report is transmitted to DHCP.
9	verifying physician	0;9	POINTER	200		This field is a pointer to the 'NEW PERSON file (#200). Only 'staff' or 'resident' interpreting physicians are allowed to be selected. This field contains the name of the interpreting physician who verified the report.
9.1	teleradiology physician name	TT;1	FREE TEXT			This field identifies the name of the teleradiologist who verified (signed) the report.
9.2	teleradiology physician npi	TT;2	FREE TEXT			This field identified the National Provider ID (NPI) of the teleradiologist who verified (signed) the report.
9.3	report verified by cots app	TT;3	POINTER	771	AC	This field identifies the Commercial Off the Shelf (COTS) application used to dictate and verify a radiology report. Examples of values for this field, though these need not be the only permissible values, are: RA-PSCRIBE-TCP, RA-SCIMAGE-TCP, and RA-TALKLINK-TCP. If the report was dictated through the use of the VistA Radiology/Nuclear Medicine application the field will be null.
10	electronic signature code	0;10	FREE TEXT			This field is computed by the system to the electronic signature code of the verifying interpreting physician.
11	transcriptionist	T;1	POINTER	200		Rad/nuc med personnel who entered the report.
13	date report printed	0;11	DATE-TIME			This is the date this report was first printed. Before a report is printed for the first time the patient location is updated, if necessary, in the 'RAD/NUC MED PATIENT' file (#70) at the Examinations multiple.
14	pre-verification date/time	0;12	DATE-TIME			This is the date and time a report was pre-verified by an Interpreting Resident or Staff.
15	pre-verification user	0;13	POINTER	200		This is the Interpreting Resident or Staff Physician who pre-verified the report.
16	pre-verification e-sig	0;14	FREE TEXT			This is the electronic signature code of the Interpreting Resident or Staff who pre-verified this report.
17	status changed to verified by	0;17	POINTER	200		This field will record the individual who is signed on and responsible for the changing the report status to 'verified'.
18	date initial outside rpt entry	0;18	DATE-TIME			The system populates this value when the 'Outside Report Entry/Edit' option is used.
25	problem statement	P;E1,240	FREE TEXT			This field may contain a note from the transcriptionist to the interpreting physician if any problems were encountered during the transcribing of this report. This message can be between 2 and 240 characters in length and is used to describe the problem. This field is available for use only if the status of the report is 'PD' (problem draft).
40	purged date	PURGE;1	DATE-TIME			This field contains the date and the time that the 'Purge Data' option of the system was last used to purge the clinical history, report text, and the activity log of this report.
45	no purge indicator	NOPURGE;1	SET OF CODES	n:NO PURGE o:OK TO PURGE		If this field is set to 'NO PURGE', then the report will not be purged or archived. This field is set when the corresponding field of the associated exam is set to 'NO PURGE'.
53	hospital division		COMPUTED			This field is computed by the system to the name of the hospital division where the exam associated with this exam report was performed.
54	imaging location		COMPUTED			This field is computed by the system to the name of the imaging location within the hospital division where the exam associated with this exam report was performed.
86	interpreting imaging location	BA;1	POINTER	79.1		This is the imaging location where the interpretation was performed. It is a pointer to the Imaging Location file (#79.1).
100	activity log	L;0	MULTIPLE	74.01		This is a multiple field containing a log of actions that have been taken on this report record.
102	procedure		COMPUTED			This field is filled in by the system with the name of the rad/nuc med procedure associated with this report.
103	exam status		COMPUTED			This field is filled in by the system with the exam status of the exam associated with this report.
104	category of exam		COMPUTED			This field is computed by the system to the category of the exam associated with this report.
106	ward		COMPUTED			This field is computed by the system to the name of the hospital ward where the inpatient associated with this exam report resided at the time this report was first printed.
107	service		COMPUTED			This field is computed by the system to the name of the service treating the inpatient associated with this exam report.
108	principal clinic		COMPUTED			This field is computed by the system to the name of the outpatient clinic that referred the patient associated with this exam report to rad/nuc med for the exam.
109	contract/sharing source		COMPUTED			This field is computed by the system to the name of the contract or sharing agreement that referred the patient associated with this exam report to rad/nuc med.
109.5	research source		COMPUTED			This field is computed by the system to the name of the research source that referred the patient associated with this exam report to rad/nuc med.
112	primary interpreting resident		COMPUTED			This field is computed by the system to the name of the primary interpreting resident who interprets the images associated with this exam report.
113	primary diagnostic code		COMPUTED			This field is computed by the system to the primary diagnostic code associated with this exam report.
114	requesting physician		COMPUTED			This field is computed by the system to the name of the person who requested the exam associated with this report. This person does not have to be a physician. (ie. It might be a nurse.)
115	primary interpreting staff		COMPUTED			This field is computed by the system to the name of the primary interpreting staff who interprets the images associated with this report.
116	complication		COMPUTED			This field is computed by the system to the complication that may have occurred during the exam procedure associated with this exam report.
118	primary camera/equip/rm		COMPUTED			This field is computed by the system to the name of the primary camera/equip/rm where the exam associated with this exam report was performed.
119	bedsection		COMPUTED			This field is computed by the system to the name of the bedsection of the rad/nuc med inpatient associated with this exam report.
200	report text	R;0	WORD-PROCESSING			This field contains the report text for the imaging exam. The report text is written by the interpreting physician and may be entered into the system by a transcriptionist. A report may also be entered into DHCP when the interpreting physician uses a voice recognition system. If the interpreting physician requests a standard report, the information in this field is copied from the 'Report Text' field of the 'Standard Reports' file.
300	impression text	I;0	WORD-PROCESSING			This field contains the 'impression text' of the rad/nuc med exam associated with this report. The 'impression text' gives a quick summary of the 'report text'. It is written by the interpreting physician and is entered into the system by the transcriptionist. The system will allow the interpreting physician to directly enter this information into the 'impression text' field through a voice recognition system. If the interpreting physician requests a standard report, the information in this field is copied from the 'impression text' field of the 'Standard Reports' file.
400	additional clinical history	H;0	WORD-PROCESSING			This field may contain a patient's clinical history as well as instructions to the interpreting physician. For example, the instructions might be for the physician to interpret the exam images to rule out the possibility of the patient having a certain disease. The 'additional clinical history' is written by the interpreting physician and is entered into the system by the transcriptionist. Voice Recognition systems allow the interpreting physician to directly enter this information into the 'additional clinical history' field.
1000	error reports	ERR;0	MULTIPLE	74.06		This multiple subfile contains date-stamped reports that were unverified and amended. The previous verified data that existed before the report was amended is stored here. As a security precaution, these fields are released to the site as uneditable.
2005	image	2005;0	MULTIPLE	74.02005		This multiple field holds pointer values to the Image file (2005).