| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | case number | 0;1 | FREE TEXT | B | Indicates the case number for this particular incident. | |
| .02 | incident(+) | 0;2 | POINTER | 742.1 | BINC | Indicates the type of incident for this record. |
| .03 | date of incident(+) | 0;3 | DATE-TIME | BDT | Indicates the date of the incident. | |
| .04 | incident location | 0;4 | POINTER | 742.5 | BLOC | Indicates the location of the incident. |
| .05 | incident description | 1;0 | WORD-PROCESSING | Contains the description of the incident. | ||
| .06 | person reporting the incident | 0;5 | POINTER | 200 | Contains the person who reported the incident. | |
| .07 | title of the reporting person | 0;6 | POINTER | 3.1 | Enter the title of the reporting person. | |
| .08 | witnessed | 0;7 | BOOLEAN | 0:NO 1:YES | Contains whether the incident had a witness. | |
| .09 | local case status | 0;8 | SET OF CODES | 0:CLOSED 1:OPEN 2:DELETED 3:QUICK | ACS | Contains the case status for the incident. |
| .1 | va 10-2633 date created | 0;9 | DATE-TIME | Contains the date the form VA 10-2633 was created. | ||
| .11 | va 10-2633 date completed | 0;10 | DATE-TIME | Contains the date the form VA 10-2633 was completed. | ||
| .12 | level of review | 0;11 | SET OF CODES | 1:NONE 2:ADMINISTRATIVE INVESTIGATION 3:OTHER 4:M&M/PEER REVIEW | Contains the type of level of review. | |
| .13 | lr date initiated | 0;12 | DATE-TIME | Contains the date the level of review was initiated. | ||
| .14 | lr date completed | 0;13 | DATE-TIME | Contains the date the level of review was completed. | ||
| .15 | qa type of death | 0;14 | POINTER | 742.14 | ADTH | Contains the reason for the patient's death. |
| .16 | medical center action | 2;0 | MULTIPLE | 742.42 | Contains the action(s) taken by the medical center. | |
| .17 | national case status | 0;15 | SET OF CODES | 0:CLOSED 1:OPEN 2:DELETED 3:QUICK 4:FULL | ANCS | Indicates the case status on the national level. |
| .18 | patient abuse alleged/proven | 0;16 | SET OF CODES | 0:ALLEGED 1:PROVEN | Indicates whether the incident of patient abuse was proven. '1' for a proven case, '0' for an alleged case. | |
| .19 | beneficiary quarterly report | 0;17 | BOOLEAN | 1:YES 0:NO | Indicates whether the Beneficiary Quarterly Report can be generated based on the incident. | |
| .2 | pertinent information | 3;0 | WORD-PROCESSING | Contains any Pertinent Information as it applies to the incident. | ||
| .21 | incident transmitted to database | 0;18 | SET OF CODES | 1:TRANSMITTED 0:NOT TRANSMITTED | This field flags whether an incident has been 'rolled' up to the regional NQABD system. | |
| .22 | level of review (other) | 0;19 | FREE TEXT | Contains the Level of Review type which is not contained in the Level of Review field. | ||
| .23 | incident summary data | 0;21 | BOOLEAN | 1:YES | Denotes whether Incident Data has been used for the Quarterly Summary. | |
| 50 | incident audit trail | 0;20 | POINTER | 740.5 | Files any changes to the QA Incident file to the QA Audit file. | |
| 52 | division | 0;22 | POINTER | 4 |