Files > TIU DOCUMENT

name

TIU DOCUMENT

number

8925

location

^TIU(8925,

description

This file stores textual information for the clinical record database. Though it is designed to initially accommodate Progress Notes, Consult Reports, and Discharge Summaries, it is intended to be sufficiently flexible to accommodate textual reports or provider narrative of any length or type, and to potentially accommodate such data transmitted from remote sites, which may be excluded from the corresponding local DHCP Package databases (e.g., Operative Reports, Radiology Reports, Pathology Reports, etc.) to avoid confusion with local workload.

applicationGroups

TIU

Fields

#	Name	Location	Type	Details	Index	Description
.01	document type(+)	0;1	POINTER	8925.1	B	This field points to the Tiu Document Definition file, whose entry defines the components of the document and various parameters for the document's behavior.
.02	patient	0;2	POINTER	9000001	C	This field contains a pointer to the patient file.
.03	visit	0;3	POINTER	9000010	V
.04	parent document type	0;4	POINTER	8925.1		This field points to the immediate parent class or document type to which the current record belongs. For example, when the current document has the type SOAP - GENERAL NOTE, this field will point to PROGRESS NOTE, as the parent class to which SOAP Notes belong, whereas, if the current record is a SUBJECTIVE component, then this field will point to SOAP - GENERAL NOTE as the parent document type to which the component belongs.
.05	status	0;5	POINTER	8925.6		This field is intended to accommodate the status of a given report.
.06	parent	0;6	POINTER	8925	DAD	In the event that the current report is an addendum or replacement, or is a component of a report, this field points to the original report.
.07	episode begin date/time	0;7	DATE-TIME			This is the date/time at which the treatment episode associated with this document was initiated (e.g., Amission date/time for a discharge summary, Visit date/time for a clinic note, Transfer date/time for an interim summary). Time is optional.
.08	episode end date/time	0;8	DATE-TIME			This is the ending date/time for the treatment episode associated with this document (e.g., . Time is optional.
.09	urgency	0;9	SET OF CODES	P:priority R:routine		This is the urgency with which the report should be completed.
.1	line count	0;10	FREE TEXT			This is the number of characters in the document (blank lines excluded), divided by the CHARACTERS PER LINE parameter defined by your site.
.11	credit stop code on completion	0;11	BOOLEAN	1:YES 0:NO		This boolean field indicates whether the stop code associated with a new visit should be credited when the note is completed.
.12	mark disch dt for correction	0;12	BOOLEAN	1:YES	FIX	This boolean field identfies those discharge summaries which were filed prior to actual discharge of the patient for the nightly background process to back-fill with corrected discharge dates.
.13	visit type	0;13	FREE TEXT			This field is used to identify the type of visit information related to the current document. The value is determined during processing and is entered by the program. It is used in the generation of a cross-reference to identify available documents for specified visits.
2	report text	TEXT;0	WORD-PROCESSING			This is a word processing field that contains the report text.
3	edit text buffer	TEMP;0	WORD-PROCESSING			This field provides a temporary holding place for the body of a report to prevent inadvertant record deletion or corruption in a manner independent of the user's preferred editor.
1201	entry date/time	12;1	DATE-TIME		F	This is the date/time at which the document was originally entered into the database.
1202	author/dictator	12;2	POINTER	200	CA	This is the person who composed or dictated the document.
1203	clinic	12;3	POINTER	40.7		This is the stop code to which the document is to be credited (e.g., if the document is a progress note documenting an encounter which took place in the Admitting/Screening Clinic, then select the corresponding stop code, etc.).
1204	expected signer	12;4	POINTER	200		This is the person who is expected to enter the first-line signature for the document. Ordinarily, this would be the author. One case in which this would differ would be in the case of a Discharge Summary, when the author's signature is NOT required. Then, the attending physician would be the expected signer.
1205	hospital location	12;5	POINTER	44		This is the location (WARD or CLINIC) associated with the document.
1206	service credit stop	12;6	POINTER	40.7		This is the attending physician of record, who is ultimately responsible for the care of the patient, and the accurate documentation of the care episode.
1207	secondary visit	12;7	POINTER	9000010
1208	expected cosigner	12;8	POINTER	200	CS
1209	attending physician	12;9	POINTER	200
1210	order number	12;10	POINTER	100		This is the Order which was acted on to produce the result reported in the current document.
1211	visit location	12;11	POINTER	44		This is the location at which the visit/admission occurred. As distinct from the HOSPITAL LOCATION field, which represents the location at the time the document was written, this is the location for the visit/admission with which the note is associated.
1212	division	12;12	POINTER	4		This field contains the institution associated with the document. It is extracted from the document's hospital location if known; otherwise it is extracted from the user's log-on division.
1301	reference date	13;1	DATE-TIME		D	This is the Date (and time) by which the clinician will reference the document. For Progress Notes, this will likely be the date of the provider's encounter with the patient. For Discharge Summaries, it will correspond to the Discharge Date of the Admission referenced in the document. (If there is no Discharge Date when dictated, it will correspond to the dictation date of the record instead.) In all cases, this is the date by which the document will be referenced and sorted.
1302	entered by	13;2	POINTER	200	TC
1303	capture method	13;3	SET OF CODES	D:direct U:upload C:converted R:remote procedure O:copy
1304	release date/time	13;4	DATE-TIME		E
1305	verification date/time	13;5	DATE-TIME
1306	verified by	13;6	POINTER	200
1307	dictation date	13;7	DATE-TIME			This is the date (and time) on which the document was dictated by its author. In the event that a document originates by dictation, we recommend that the REFERENCE DATE for the document be defaulted to dictation date, as the author will be able to identify the document by the date on which s/he dictated it.
1308	suspense date/time	13;8	DATE-TIME			This is the date (and time) on which the document will be removed from public view. It is currently used only for Patient Postings, although it may be generalized for use with other document types, if appropriate.
1401	patient movement record	14;1	POINTER	405
1402	treating specialty	14;2	POINTER	45.7	TS
1403	irt record	14;3	POINTER	393
1404	service	14;4	POINTER	49	SVC
1405	requesting package reference	14;5	VARIABLE-POINTER	123, 130	G	This field allows a linkage to be maintained between the TIU Document and the DHCP Package for which it was generated.
1406	retracted original	14;6	POINTER	8925		This self-refering pointer identifies the original document which was retracted in error to produce this record.
1407	prf flag action		COMPUTED			PRF FLAG ACTION applies only to Patient Record Flag (PRF) notes. When a new flag is assigned to a given patient, or, after review, another action such as CONTINUE is taken on an existing flag assignment, a note must be written to document the clinical reasons for the action. Upon entry, the note is linked to the action it documents. Field PRF FLAG ACTION refers to this linked action. The field contains the Date of the Action followed by the Name of the Action. Example: 3/3/05 CONTINUE If the PRF note is not linked to a flag action or the linked action date or name cannot be found, the field has value "?". If the note is not a PRF note (a note with a title under Document Class PATIENT RECORD FLAG CAT I or PATIENT RECORD FLAG CAT II), the field has value NA for non-applicable. Technical Note: Flag Actions and their linked note entry numbers are stored in the PRF ASSIGNMENT HISTORY FILE (#26.14). The Date and Action are attributes of the Assignment History entry the note is linked to.
1501	signature date/time	15;1	DATE-TIME
1502	signed by	15;2	POINTER	200
1503	signature block name	15;3	FREE TEXT
1504	signature block title	15;4	FREE TEXT			This is the encrypted signature block title of the person who signed the document.
1505	signature mode	15;5	SET OF CODES	E:electronic C:chart		This is the mode by which the signature was obtained (i.e., either electronic or chart).
1506	cosignature needed	15;6	BOOLEAN	1:YES 0:NO		This boolean flag indicates to the system whether or not a cosignature is needed.
1507	cosignature date/time	15;7	DATE-TIME			This is the date/time at which cosignature was obtained.
1508	cosigned by	15;8	POINTER	200
1509	cosignature block name	15;9	FREE TEXT
1510	cosignature block title	15;10	FREE TEXT
1511	cosignature mode	15;11	SET OF CODES	E:electronic C:chart
1512	marked signed on chart by	15;12	POINTER	200		This is the identity of the person who marked a given document 'signed on chart,' indicating that a 'wet' signature of the chart copy had been obtained.
1513	marked cosigned on chart by	15;13	POINTER	200		This is the user who marked a given document as 'cosigned on chart.'
1601	amendment date/time	16;1	DATE-TIME
1602	amended by	16;2	POINTER	200
1603	amendment signed	16;3	DATE-TIME
1604	amendment sign block name	16;4	FREE TEXT			This is the signature block name of the person who amended the document.
1605	amendment sign block title	16;5	FREE TEXT
1606	administrative closure date	16;6	DATE-TIME
1607	admin closure sig block name	16;7	FREE TEXT
1608	admin closure sig block title	16;8	FREE TEXT
1609	archive/purge date/time	16;9	DATE-TIME
1610	deleted by	16;10	POINTER	200		This is the person who deleted the document per the Privacy Act.
1611	deletion date	16;11	DATE-TIME			This is the date/(time optional) at which the document was deleted per the Privacy Act.
1612	reason for deletion	16;12	SET OF CODES	P:privacy act A:administrative		This is the reason for which the document was deleted, either: Privacy Act, as invoked by the patient; or Administrative Action, where the note needed to be removed, following signature, for administrative reasons.
1613	administrative closure mode	16;13	SET OF CODES	M:manual S:scanned document		This indicates whether the document was closed manually by an administrative person (in order to satisfy authentication requirements), or automatically by scanning a paper document bearing the signature of the patient (e.g., Consents, Advanced Directives, etc.) and not requiring the signature of an author.
1701	subject (optional description)	17;1	FREE TEXT			This freetext field is used to help you find documents by subject (i.e., consider the subject a "key word" of sorts.
1801	vbc line count	18;1	NUMERIC			A VBC Line is defined as the total number of characters you can see with the naked eye, divided by 65. It includes any character contained within a header or footer. Spaces, carriage returns, and hidden format instructions, such as bold, underline, text boxes, printer configurations, spell check, etc., are not counted in the total character count. A VBC Line is calculated by counting all visual characters and simply dividing the total number of characters by 65 to arrive at the number of defined lines.
2101	id parent	21;1	POINTER	8925	GDAD	Applies to ID (interdisciplinary) notes only. The ID PARENT is the note this note is attached to, making this note an entry in an ID note. A note with an ID PARENT is referred to as an ID child note. ID parent notes and ID child notes are both file entries in file 8925. The entries of an interdisciplinary note consist of the first entry, which is also the ID PARENT of the ID note, followed by the ID children.
15001	visit id	150;1	FREE TEXT		VID	Unique Visit Identifier for use by CIRN. The value of this field should ONLY be modified by virtue of a change to the Visit (.03) field.
70201	procedure summary code	702;1	SET OF CODES	1:Normal 2:Abnormal 3:Borderline 4:Incomplete 5:Machine Resulted		This field contains the summary code for this procedure once it is complete. 'Machine Resulted' is the initial, default code.
70202	date/time performed	702;2	DATE-TIME			This field contains the Date/Time when the procedure was performed.
89261	vha enterprise standard title		COMPUTED			This computed field allows calls to FileMan Utilities (e.g. DIQ) to resolve the VHA ENTERPRISE STANDARD TITLE to which the local title is mapped.