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.
.01document type(+)0;1POINTER8925.1BThis field points to the Tiu Document Definition file, whose entry defines the components of the document and various parameters for the document's behavior.
.02patient0;2POINTER9000001CThis field contains a pointer to the patient file.
.04parent document type0;4POINTER8925.1This 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.
.05status0;5POINTER8925.6This field is intended to accommodate the status of a given report.
.06parent0;6POINTER8925DADIn 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.
.07episode begin date/time0;7DATE-TIMEThis 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.
.08episode end date/time0;8DATE-TIMEThis is the ending date/time for the treatment episode associated with this document (e.g., . Time is optional.
.09urgency0;9SET OF CODESP:priority
This is the urgency with which the report should be completed.
.1line count0;10FREE TEXTThis is the number of characters in the document (blank lines excluded), divided by the CHARACTERS PER LINE parameter defined by your site.
.11credit stop code on completion0;11BOOLEAN1:YES
This boolean field indicates whether the stop code associated with a new visit should be credited when the note is completed.
.12mark disch dt for correction0;12BOOLEAN1:YES
FIXThis 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.
.13visit type0;13FREE TEXTThis 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.
2report textTEXT;0WORD-PROCESSINGThis is a word processing field that contains the report text.
3edit text bufferTEMP;0WORD-PROCESSINGThis 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.
1201entry date/time12;1DATE-TIMEFThis is the date/time at which the document was originally entered into the database.
1202author/dictator12;2POINTER200CA This is the person who composed or dictated the document.
1203clinic12;3POINTER40.7This 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.).
1204expected signer12;4POINTER200This 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.
1205hospital location12;5POINTER44This is the location (WARD or CLINIC) associated with the document.
1206service credit stop12;6POINTER40.7This is the attending physician of record, who is ultimately responsible for the care of the patient, and the accurate documentation of the care episode.
1207secondary visit12;7POINTER9000010
1208expected cosigner12;8POINTER200CS
1209attending physician12;9POINTER200
1210order number12;10POINTER100This is the Order which was acted on to produce the result reported in the current document.
1211visit location12;11POINTER44This 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.
1212division12;12POINTER4This 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.
1301reference date13;1DATE-TIMEDThis 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.
1302entered by13;2POINTER200TC
1303capture method13;3SET OF CODESD:direct
R:remote procedure
1304release date/time13;4DATE-TIMEE
1305verification date/time13;5DATE-TIME
1306verified by13;6POINTER200
1307dictation date13;7DATE-TIMEThis 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.
1308suspense date/time13;8DATE-TIMEThis 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.
1401patient movement record14;1POINTER405
1402treating specialty14;2POINTER45.7TS
1403irt record14;3POINTER393
1405requesting package reference14;5VARIABLE-POINTER123, 130GThis field allows a linkage to be maintained between the TIU Document and the DHCP Package for which it was generated.
1406retracted original14;6POINTER8925This self-refering pointer identifies the original document which was retracted in error to produce this record.
1407prf flag actionCOMPUTEDPRF 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.
1501signature date/time15;1DATE-TIME
1502signed by15;2POINTER200
1503signature block name15;3FREE TEXT
1504signature block title15;4FREE TEXTThis is the encrypted signature block title of the person who signed the document.
1505signature mode15;5SET OF CODESE:electronic
This is the mode by which the signature was obtained (i.e., either electronic or chart).
1506cosignature needed15;6BOOLEAN1:YES
This boolean flag indicates to the system whether or not a cosignature is needed.
1507cosignature date/time15;7DATE-TIMEThis is the date/time at which cosignature was obtained.
1508cosigned by15;8POINTER200
1509cosignature block name15;9FREE TEXT
1510cosignature block title15;10FREE TEXT
1511cosignature mode15;11SET OF CODESE:electronic
1512marked signed on chart by15;12POINTER200This 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.
1513marked cosigned on chart by15;13POINTER200This is the user who marked a given document as 'cosigned on chart.'
1601amendment date/time16;1DATE-TIME
1602amended by16;2POINTER200
1603amendment signed16;3DATE-TIME
1604amendment sign block name16;4FREE TEXTThis is the signature block name of the person who amended the document.
1605amendment sign block title16;5FREE TEXT
1606administrative closure date16;6DATE-TIME
1607admin closure sig block name16;7FREE TEXT
1608admin closure sig block title16;8FREE TEXT
1609archive/purge date/time16;9DATE-TIME
1610deleted by16;10POINTER200This is the person who deleted the document per the Privacy Act.
1611deletion date16;11DATE-TIMEThis is the date/(time optional) at which the document was deleted per the Privacy Act.
1612reason for deletion16;12SET OF CODESP:privacy act
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.
1613administrative closure mode16;13SET OF CODESM: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.
1701subject (optional description)17;1FREE TEXTThis freetext field is used to help you find documents by subject (i.e., consider the subject a "key word" of sorts.
1801vbc line count18;1NUMERICA 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.
2101id parent21;1POINTER8925GDADApplies 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.
15001visit id150;1FREE TEXTVIDUnique 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.
70201procedure summary code702;1SET OF CODES1:Normal
5:Machine Resulted
This field contains the summary code for this procedure once it is complete. 'Machine Resulted' is the initial, default code.
70202date/time performed702;2DATE-TIMEThis field contains the Date/Time when the procedure was performed.
89261vha enterprise standard titleCOMPUTEDThis computed field allows calls to FileMan Utilities (e.g. DIQ) to resolve the VHA ENTERPRISE STANDARD TITLE to which the local title is mapped.

Referenced by 15 types

  1. PRF ASSIGNMENT HISTORY (26.14) -- tiu pn link
  2. REQUEST/CONSULTATION (123) -- tiu result narrative
  3. SURGERY (130) -- tiu operative summary, tiu nurse intraop report, tiu procedure report (non-or), tiu anesthesia report
  4. CAPRI TEMPLATES (396.17) -- tiu document
  5. 2507 EXAM (396.4) -- tiu document id
  6. CP TRANSACTION (702) -- tiu note
  7. CP_TRANSACTION_TIU_HISTORY (702.001) -- tiu_note_id
  9. NUPA CARE PLANS (1927.4) -- latest dnr note
  10. IMAGE SERIES (2005.63) -- tiu note reference
  11. TIU DOCUMENT (8925) -- parent, retracted original, id parent
  12. TIU AUDIT TRAIL (8925.5) -- tiu document name, id parent
  13. TIU MULTIPLE SIGNATURE (8925.7) -- tiu document number
  14. TIU PROBLEM LINK (8925.9) -- document
  15. TIU EXTERNAL DATA LINK (8925.91) -- document