Files > MEDICAL RECORD

name
MEDICAL RECORD
number
90
location
^MR(
description
PHYSICAL EXAMINATION, DSM-III DIAGNOSES AND OTHER FILES FOR THE MEDICAL RECORD Fields annotated with an "*" are scheduled for deletion from file.
Fields
#NameLocationTypeDetailsIndexDescription
.001number11This is the internal file number of the diagnosis.
.01name(+)0;1POINTER2BThis is the patient's name.
100phyPE;0MULTIPLE90.01This field contains the results of the physical examination. concerning the patient's overall condition associated with the systems identified. The user may enter one of three responses: 1) Within NORMAL Limits; 2) OMITTED; 3) ABNORMAL. If "3" is entered, the user will be asked to describe the abnormality.
101*principal dsm-iii dx dateDX1;1DATE-TIMEThis is the date the principal DSM-II diagnosis was entered.
102*principal dsm-iii diagnosis(+)DX1;2POINTER627This is the DSM-III code for the diagnosis which is the primary reason for treatment.
102.4*x dsm-iii diagnosis date(+)DX1;3DATE-TIMEThis is the date the DSM-III X diagnosis was entered.
102.6*x dsm-iii diagnosis(+)DX1;4POINTER627This is the DSM-III diagnosis accounting for the largest percentage of the length of stay.
103*dsm-iii diagnosisDX;0MULTIPLE90.04This is the code of the DSM-III diagnosis. conform to DSM-III-R criteria. Mandated June 1987.
104*axis 4DXM;1SET OF CODES1:NONE
2:MINIMAL
3:MILD
4:MODERATE
5:SEVERE
6:EXTREME
7:CATASTROPHIC
0:UNSPECIFIED
This is the rating code for severity of psychosicial stressor.
105*axis 4 dateDXM;2DATE-TIMEThis is the date a given psychosocial stressor code is entered.
106*axis 4 byDXM;3POINTER200This is the name of the user entering a given psychosical stressor code.
107*axis 5DXM;4SET OF CODES1:SUPERIOR
2:VERY GOOD
3:GOOD
4:FAIR
5:POOR
6:VERY POOR
7:GROSSLY IMPAIRED
0:UNSPECIFIED
This is the rating code for highest level of adaptive functioning past year.
108*axis 5 dateDXM;5DATE-TIMEThis is the date a given adaptive functioning code is entered.
109*axis 5 byDXM;6POINTER200This is the name of the user entering a given adaptive functioning code.
110*past principal dxPDX;0MULTIPLE90.06This is the past DSM-III diagnosis that was the primary reason for treatment.
111*past x diagnosisXDX;0MULTIPLE90.07This is the past DSM-III code which accounted for the largest percentage of the length of stay.
112*principle icd9 dx dateDX2;1DATE-TIMEThis is the date the principal ICD9 diagnosis was entered.
113*principal icd9 diagnosis(+)DX2;2POINTER80This is the ICD9 code for the diagnosis which is the primary reason for treatment.
113.4*x icd9 diagnosis dateDX2;3DATE-TIMEThis is the date the ICD9 X diagnosis was entered.
113.6*x icd9 diagnosisDX2;4POINTER80This is the ICD9 diagnosis accounting for the largest percentage of the length of stay.
115*icd9 diagnosisPHDX;0MULTIPLE90.1This is the code of the ICD9 diagnosis.
116*past principal icd9 dxPPDX;0MULTIPLE90.16This is the past ICD9 diagnosis that was the primary reason for treatment.
117*past icd9 x diagnosisXPDX;0MULTIPLE90.17This is the past ICD9 diagnosis code which accounted for the largest percentage of length of stay.

Not Referenced