| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | name(+) | 0;1 | POINTER | 2 | B | This field gives the name of this rad/nuc med patient. The system obtains this information from the main 'PATIENT' file (#2). It is not stored in the 'RAD/NUC MED PATIENT' file (#70). ALLOWABLE WAYS TO ENTER PATIENT NAME: ------------------------------------ -Patient's last name (to reduce typing errors, enter only first few letters of last name) -Last 4 digits of patient's Social Security Number -First letter of patient's last name and last 4 digits of patient's Social Security Number. |
| 1.1 | reason for study(+) | .1;1 | FREE TEXT | The reason for the study is often a short patient history summarizing the condition of the patient and giving background information as to why the study has been initiated. | ||
| 2 | procedure | 0;2 | POINTER | 71 | This field points to the 'RAD/NUC MED PROCEDURES' file (#71) to indicate the Imaging procedure associated with this request. ALLOWABLE WAYS TO ENTER THE RADIOLOGY/NUCLEAR MEDICINE PROCEDURE FOR THIS REQUEST: ----------------------------------------------------------------- -Name of procedure -CPT Code -Site specific synonym | |
| 3 | type of imaging | 0;3 | POINTER | 79.2 | This field points to the 'IMAGING TYPE' file (#79.2) to indicate the type of imaging used for this rad/nuc med request. It is filled in by the system with the appropriate type of imaging (i.e. GENERAL RADIOLOGY, NUCLEAR MEDICINE, ULTRASOUND, CT SCAN, MAGNETIC RESONANCE IMAGING, VASCULAR LAB, etc.). For example, when a General Radiology procedure is chosen, this field is filled in with 'GENERAL RADIOLOGY'. | |
| 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 request. It is used to compile various 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, 'E' for EMPLOYEE, and 'R' for RESEARCH. | |
| 5 | request status | 0;5 | SET OF CODES | 1:DISCONTINUED 2:COMPLETE 3:HOLD 5:PENDING 6:ACTIVE 8:SCHEDULED 11:UNRELEASED | This field is a set type field. The statuses in this field should correspond in name and number to those in the OE/RR 'ORDER STATUS' file (#100.01). | |
| 6 | request urgency | 0;6 | SET OF CODES | 1:STAT 2:URGENT 9:ROUTINE | This field value defaults to 'ROUTINE', when entering a new request for an imaging exam. Available Urgencies are: ROUTINE, URGENT and STAT. | |
| 7 | order | 0;7 | POINTER | 100 | This field points to the Order Entry/Results Reporting (OE/RR) 'ORDER' File (#100). This field will only contain data if the OE/RR Package is running and the Radiology/Nuclear Medicine package is available through OE/RR. | |
| 8 | approving rad/nuc med phys | 0;8 | POINTER | 200 | This field points to the 'NEW PERSON' file (#200) to indicate the name of the radiology or nuclear medicine physician who approved this order. Procedures which require an approving physician are site specific. | |
| 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 the imaging service for this 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 this patient to the imaging service for this exam. | ||
| 10 | reason | 0;10 | POINTER | 75.2 | This field points to the 'RAD/NUC MED REASON' file (#75.2) to indicate the reason a request is placed in the 'HOLD' or 'CANCELLED' status. | |
| 11 | original request changed | 0;11 | BOOLEAN | y:YES n:NO | This field contains a value to indicate if the information contained in the original request was changed by Rad/Nuc Med Service. Available values are: 'Y' for 'Yes' and 'N' for 'NO". This field is populated when the request moves to a 'complete' status. If the procedure on the request is a 'parent' procedure, this field will always be set to 'yes' since it is not the parent procedure that is actually performed. | |
| 12 | pre-op scheduled date/time | 0;12 | DATE-TIME | This field contains the date/time if a patient has a pre-op scheduled. | ||
| 13 | pregnant(+) | 0;13 | SET OF CODES | y:YES n:NO u:UNKNOWN | This field contains a value to indicate if the patient is pregnant. Available values are 'Y' for 'Yes' and 'N' for 'No'. If 'Yes', a warning message is displayed to the receptionist when this patient is registered for the procedure requested. | |
| 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 | user entering request | 0;15 | POINTER | 200 | This field points to the 'NEW PERSON' file (#200) to indicate the person entering the request into the rad/nuc med system. It is filled in by the system from information the user entered at sign-on. | |
| 16 | request entered date/time | 0;16 | DATE-TIME | This field contains the date and time the request was entered into the system. | ||
| 17 | past visit date/time | 0;17 | DATE-TIME | This field contains the date and time of the patient's last recorded visit to the Radiology/Nuclear Medicine Service. | ||
| 18 | last activity date/time | 0;18 | DATE-TIME | AO | This field contains the date and time the last action was taken on this request. | |
| 19 | mode of transport | 0;19 | SET OF CODES | a:AMBULATORY p:PORTABLE s:STRETCHER w:WHEEL CHAIR | This field contains the mode of transport which the patient will require when the exam is performed. Available categories are : AMBULATORY, PORTABLE, STRETCHER and WHEEL CHAIR. | |
| 20 | imaging location | 0;20 | POINTER | 79.1 | This field points to the 'IMAGING LOCATIONS' file (#79.1) to indicate the name of the imaging location within the hospital division where the rad/nuc med exam is to be performed. | |
| 21 | date desired (not guaranteed) | 0;21 | DATE-TIME | This field contains the date for which the rad/nuc med exam is requested. This field should not be interpreted as an appointment date. | ||
| 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. | |
| 23 | scheduled date (time optional) | 0;23 | DATE-TIME | This field contains the scheduled date and time of the requested exam. | ||
| 24 | isolation procedures | 0;24 | BOOLEAN | y:YES n:NO | This field contains 'YES' if the patient is on isolation procedures at the time the request is submitted, or 'NO' if the patient is not. If the patient is on isolation procedures the following message will be displayed on the request printed in the imaging service location: ** Universal Isolation Precautions ** | |
| 25 | hold description | 1;0 | WORD-PROCESSING | This is a word processing field for entering the reason an order is on hold. | ||
| 26 | nature of (new) order activity | 0;26 | SET OF CODES | w:WRITTEN v:VERBAL p:TELEPHONED s:SERVICE CORRECTION i:POLICY e:PHYSICIAN ENTERED | This is the Nature of Order Activity for newly entered orders through the Radiology/Nuclear Medicine 'back door' order entry option. This information is needed to clarify which actions should be taken as a result of entering this order. Depending on the facility configuration of the Nature of Order Activity in the OE/RR software, the code entered here may or may not trigger alerts for electronic signatures and chart copy printing. | |
| 27 | cancel description | 0;27 | FREE TEXT | This field indicates the reason a request is placed in the 'CANCELED' status via CPRS (front-door) only. The description matches an entry on file #100.03. If not canceled using CPRS, then this field will be empty and the REASON field (field 10) will be populated instead. | ||
| 75 | request status times | T;0 | MULTIPLE | 75.12 | This field is a multiple that contains dates and times the status of the request is changed. The status changes will only be recorded if the Division Parameter 'Track Request Status Changes' is set to 'YES'. | |
| 90 | pfss account reference(+) | 0;28 | POINTER | 375 | This field points to the PFSS ACCOUNT file (#375). The value is returned from the GETACCT^IBBAPI, which Radiology silently invokes whenever an order is placed, whether from the Front Door (CPRS) or from the Back Door (Vista Radiology). | |
| 91 | primary ordering icd diagnosis(+) | BA;1 | POINTER | 80 | This field contains the Primary ICD Diagnosis responsible for this order. | |
| 92 | primary dx related to sc | BA;2 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on a Service Connected related problem. | |
| 93 | primary dx related to ao | BA;3 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on an Agent Orange related problem. | |
| 94 | primary dx related to ir | BA;4 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on an Ionizing Radiation related problem. | |
| 95 | primary dx related to swac | BA;5 | BOOLEAN | 0:NO 1:YES | This field is used to indicate if this order was for treating a VA patient based on a Southwest Asia Conditions related problem. | |
| 96 | primary dx related to mst | BA;6 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on a Military Sexual Trauma related problem. | |
| 97 | primary dx related to hnc | BA;7 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on a Head and Neck cancer (HNC) related problem. | |
| 98 | secondary ordering icd diag. | BAS;0 | MULTIPLE | 75.13 | ||
| 99 | primary dx related to cv | BA;8 | BOOLEAN | 0:NO 1:YES | This field will be used to indicate if this order was for treating a VA patient based on an Combat Veteran related problem. | |
| 100 | primary dx related to shad | BA;9 | BOOLEAN | 0:NO 1:YES | This field is used to indicate if this order was for treating a VA patient based on a Shipboard Hazard and Defense related problem. | |
| 125 | procedure modifiers | M;0 | MULTIPLE | 75.1125 | This multiple field is used to store the rad/nuc med procedure modifiers that are associated with this exam. | |
| 400 | clinical history for exam | H;0 | WORD-PROCESSING | This field may contain a written clinical history pertinent to the procedure requested, as well as instructions to the interpreting physician. For example, the instructions might be for the interpreting physician to read the exam films 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. |