| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | accession#(+) | 0;1 | FREE TEXT | B | This is the record number assigned by the Women's Health package. It is composed of the procedure's abbreviated code, a four digit year and a sequential number. | |
| .02 | patient(+) | 0;2 | POINTER | 790 | C | This field contains the name of the patient associated with the procedure. Pointer to the WV Patient (#790) file. |
| .04 | procedure(+) | 0;4 | POINTER | 790.2 | APCD | This field stores the name of the procedure performed on the patient. Pointer to the WV Procedure (#790.1) file. |
| .05 | results/diagnosis | 0;5 | POINTER | 790.31 | This field stores the main result or diagnosis of the patient's procedure. Pointer to the WV Results/Diagnosis (#790.31) file. | |
| .06 | sec result/diagnosis | 0;6 | POINTER | 790.31 | This field stores a secondary outcome/diagnosis associated with the procedure. Pointer to the WV Results/Diagnosis (#790.31) file. | |
| .07 | provider | 0;7 | POINTER | 200 | This field stores the name of the clinician who ordered and/or performed this procedure. | |
| .08 | hpv | 0;8 | BOOLEAN | 1:YES 0:NO | This field is used to document the presence or absence of the Human Papilloma Virus (HPV) in the cytology reports. | |
| .09 | mam unilateral: left or right | 0;9 | SET OF CODES | l:LEFT r:RIGHT | Select left or right for this unilateral mammogram. | |
| .1 | health care facility | 0;10 | POINTER | 4 | This field identifies the name of the health care facility where this procedure was performed. | |
| .11 | ward/clinic/location | 0;11 | POINTER | 44 | This field contains the name of the ward, clinic, or location where the procedure was performed. | |
| .12 | date of procedure | 0;12 | DATE-TIME | D | This field identifies the date on which the procedure was performed. Dates in the future may not be entered. | |
| .13 | complete by (date) | 0;13 | DATE-TIME | This field contains the date used to determine that this procedure record is delinquent when a close status has not been entered in the record. | ||
| .14 | status | 0;14 | SET OF CODES | o:OPEN c:CLOSED | S | This field contains the status (set of codes: O = Open, C = Closed). The value of this field is used in the Program Snapshot reports and the Browse Patients with Needs Past Due report. |
| .15 | radiology mam case# | 0;15 | FREE TEXT | E | This field stores the VISTA Radiology/Nuclear Medicine case# for this mammogram procedure when the Women's Health package automatically imports radiology procedures. | |
| .16 | processed y/n? | 0;16 | BOOLEAN | 0:NO 1:YES | This field indicates if the procedure result was entered via a Clinical Reminder. Answer YES to indicate the procedure result was entered by a Clinical Reminder. Answer NO if the procedure result was not entered by a Clinical Reminder. | |
| .18 | entering user | 0;18 | POINTER | 200 | This field stores the name of the person initially creating this record. | |
| .19 | date first entered | 0;19 | DATE-TIME | ADE | This field stores the date on which this procedure record was first entered. | |
| .2 | satisfactory exam | 0;20 | BOOLEAN | 1:YES 0:NO | This field documents that the procedure or gynecologic exam was satisfactorily performed without any impediments. Set of codes (1 = Yes, 0 = No). | |
| .21 | t-zone seen entirely | 0;21 | BOOLEAN | 1:YES 0:NO | This field documents (set of codes: 1 = Yes, 0 = No) that the T-Zone in the colposcopy/biopsy procedure was adequately visualized. | |
| .22 | lesion outside canal | 0;22 | BOOLEAN | 1:YES 0:NO | This field documents (set of codes: 1 = Yes, 0 = No) that the lesion seen during the procedure was outside the canal. | |
| .23 | multifocal | 0;23 | BOOLEAN | 1:YES 0:NO | This field documents (set of codes: 1 = Yes, 0 = No) that the lesion seen during the procedure was multifocal (as opposed to unifocal). | |
| .24 | number of quadrants | 0;24 | NUMERIC | This field contains a number (0-4) that identifies the number of quadrants occupied by the lesion. | ||
| .245 | quadrant locations | 2;16 | FREE TEXT | The location of the affected quadrants. Any of the following abbreviations may be selected: UL,LL,UR,LR. UL - Upper Left quadrant LL - Lower Left quadrant UR - Upper Right quadrant LR - Lower Right quadrant If more than one quadrant is included separate them with a comma, ie: LL, UL,UR will represent the inclusion of 3 of the 4 quadrants. | ||
| .25 | ecc dysplasia | 0;25 | SET OF CODES | y:YES n:NO nd:Not Done i:Insufficient Tissue | This field indicates if ectocervical dysplasia was present, if an insufficient tissue sample was provided, or the sample was not examined for dysplasia. | |
| .26 | ectocervical biopsy | 0;26 | POINTER | 790.31 | This field contains the diagnosis or impression resulting from the cytology examination. Pointer to the WV Results/Diagnosis (#790.31) file. | |
| .27 | margins clear | 0;27 | BOOLEAN | 1:YES 0:NO | This field indicates tissue sample showed no pathology at the margins of the tissue sample. | |
| .28 | std evaluation | 0;28 | POINTER | 790.31 | This field documents the findings after testing for sexually transmitted diseases. Pointer to the WV Results/Diagnosis (#790.31) file. | |
| .29 | impression | 0;29 | POINTER | 790.31 | This field contains the impression of the clinician performing the exam. Pointer to the WV Results/Diagnosis (#790.31) file. | |
| .3 | screening pap | 0;30 | POINTER | 790.1 | This field stores the PAP procedure associated with the follow-up procedure (e.g., colposcopy). Pointer to the WV Procedure (#790.1) file. | |
| .31 | stage at final dx | 0;31 | SET OF CODES | 1:I 2:II 3:III 4:IV 5:S-Local 6:S-Regional 7:S-Distant 8:Unknown | This field is used to document the clinical stage for invasive carcinoma of the cervix. If clinical stage is unknown, enter the summary ('S-') stage. | |
| .32 | date results received | 0;32 | DATE-TIME | Enter the date that the results were received/uploaded from the lab. | ||
| .33 | final dx pap/colp | 0;33 | POINTER | 790.31 | Enter the Final Diagnosis for this PAP/Colp case. | |
| .34 | facility where accessioned | 0;34 | POINTER | 4 | Select the facility where this procedure was accessioned. | |
| .35 | radiology credit method | 0;35 | SET OF CODES | 0:Regular Credit 1:Interpretation Only 2:No credit 3:Technical Component Only | This field is a set of codes that identify if the radiology exam was performed at the facility or elsewhere. This value is automatically entered by the Radiology/NM package when a radiology report is verified and the WH site parameter is set to accept data from the Radiology/NM package. This piece of information will be used for WH reporting requirements to determine how many radiology procedures were performed at the facility and elsewhere. | |
| 1.01 | notes | 1;0 | WORD-PROCESSING | This field allows you to enter word-processing text in which to elaborate further on the results of this patients various tests. | ||
| 2.17 | lab accession# | 2;17 | FREE TEXT | F | This field contains the lab accession number from the LAB DATA file (#63) for the patient, if this procedure entry is a lab test. | |
| 2.18 | lab data file ien | 2;18 | NUMERIC | This field contains the internal entry number of the LAB DATA file (#63) for the patient, if this procedure entry is a lab test. | ||
| 2.19 | lab inverse date/time | 2;19 | FREE TEXT | This field contains the inverse date/time of a lab test from the LAB DATA file (#63) for the patient, if this procedure entry is a lab test. | ||
| 2.2 | lab subscript | 2;20 | FREE TEXT | This field contains a character string that distinguishes the type of lab test performed. The letters "CY" will represent a cytology test and the letters "SP" will represent a surgical pathology test. | ||
| 3.01 | comments | 3;1 | FREE TEXT | You may enter a one-line clinical history note (limited to 78 characters). | ||
| 9 | reports | 9;0 | WORD-PROCESSING | This field is not editable through WH options. The lab or radiology exams related to this procedure are presented here. |