Files > V POV

name

V POV

number

9000010.07

location

^AUPNVPOV(

description

This file has been designed for joint use by the Indian Health Service and the Department of Veteran Affairs. POV is an abbreviation for "Purpose of Visit" (descriptive name used by IHS) or "Problem of Visit" (descriptive name used by VA). The V POV file is used to store clinical data related to the "purpose of visit" or "problem of visit", (POV). This is the provider's definition of what diagnosis to use to represent the patient care given at the visit. The POV entry is not the patient's "Chief Complaint" text. It is the diagnosis as defined by the provider which will have an ICD Diagnosis code related to it to support Clinical needs and additionally support Administrative functions too such as Billing, Workload, and DSS. There should be at least one "purpose of visit" (descriptive name used by IHS) or one "problem of visit" (descriptive name used by the VA) in the V POV file for each patient visit whether it is an inpatient, outpatient or field visit, and regardless of the discipline of the provider (i.e. dental, CHN, mental health, etc.). There is no limit to the number of POV's that can be entered for a patient for a given encounter. At IHS facilities, POV's are generated automatically for this file at time of discharge from the Admission, Discharge and Transfer (ADT) system. POV's are entered in narrative form, and coded automatically to the appropriate ICD diagnosis code. Physician entered narrative which modifies diagnosis, such as "doubtful, suspect, resolved" are entered by the data entry person in the MODIFIER field. Narrative qualifiers, such as "not healing well", "date of onset", "severe" etc.. are stored in the NARRATIVE QUALIFIER field. STAGE is used only as a local option. The file contains pointers to the IHS Patient file, and visit file, and data must exist in both of these files for this visit before a POV can be entered here. At VA facilities, POV is used as an abbreviation for "Problem of Visit", or the problem treated at the visit. POV's are primarily created for clinic visits from 3 sources: 1) The scheduling checkout process, in which case the information collected about the POV is limited to the ICD Diagnosis code. The provider narrative becomes the ICD narrative from the ICD Diagnosis file. 2) The Encounter Form automated data scanning (AICS package). In this case the provider narrative is the terminology defined by the clinician to represent the diagnosis on the encounter form. The AICS package, or other automated data capture tool, is able to pass the narrative and the ICD Diagnosis. If the problem treated at the visit was a pre-existing problem from the patient's "Problem List", the related problem entry is also stored in the POV record. (The Problem List orientation is not utilized by IHS.) 3) The manual data entry process for encounter form data not collected via automated data capture. This process is the most like the process IHS

Fields

#	Name	Location	Type	Details	Index	Description
.01	pov(+)	0;1	POINTER	80	B	POV is an abbreviation for "Purpose of Visit". Since Purpose of Visit is often confused with "Chief complaint", another abbreviation might better be "Problem of Visit". This is the Provider's conclusion about what was treated at the visit. The Provider should be able to indicate a preferred narrative for what was treated and an ICD Diagnosis code. If the problem treated is from the Problem List, then the problem list entry information can be used for the "Problem of Visit" entry. The provider can alternatively have this information automatically captured via scanned Encounter Forms (e.g., AICS - the VA's Encounter Form Data Capture package). At VA facilities, the ICD Diagnosis is screened by Inactive Code and it must be appropriate for the Patient's age and sex. At IHS facilities, the ICD Diagnosis is screened by Inactive Code, appropriate for the Patient's age and sex, and Not "E" codes.
.019	icd narrative		COMPUTED			This is the computed diagnosis narrative that is defined in the ICD Diagnosis file for the ICD Diagnosis code identified in the POV (.01) field.
.02	patient name(+)	0;2	POINTER	9000001		This is the patient whose problem or diagnosis was treated.
.03	visit(+)	0;3	POINTER	9000010	AD	The encounter entry in the Visit file that is associated with this problem treated. In IHS facilities, this is the date and time the visit actually occurred. In VA facilities, this is the data and time of the clinic appointment for the patient in the Scheduling package, or the date and time the encounter occurred if there was no appointment. By using the appointment date and time, clinic activity can be captured for clinical use as well as be used for billing and workload information by the appropriate VA packages. If the visit was for a walk-in, an appointment should be entered in Scheduling first in order to have the clinical information also be used for the administrative uses. Non-clinic appointment encounters can be entered, but the clinical POV information is not accepted for billing. The patient encounter can be the result of an inpatient encounter. In this case, the ward would be specified as the hospital location in the Visit File.
.04	provider narrative(+)	0;4	POINTER	9999999.27		This is the providers text describing the diagnosis that was treated at the visit. The text may contain additional information related specifically to the patient at the time of the visit (e.g, Hypertension, uncontrolled). The providers' narrative may be different from the ICD Diagnosis files description for a code, but should not have a significantly different meaning. The ICD Diagnosis code in the POV (.01) field should be the code that "most closely" represents the providers narrative. In IHS facilities, this narrative is entered by data entry clerks. In VA facilities, this narrative may be entered manually or derived from: 1) the ICD Diagnosis text from the ICD Diagnosis file (Scheduling interface) 2) the text defined on Encounter Forms when defining the most common diagnosis treated for a clinic (AICS or other automated data capture) 3) the Problem list entries' "provider narrative", captured from the Active Problem list being checked off for problems treated at the encounter on an Encounter Form (AICS or other automated data capture).
.06	modifier	0;6	SET OF CODES	C:CONSIDER D:DOUBTFUL F:FOLLOW UP M:MAYBE, POSSIBLE, PERHAPS O:RULE OUT P:PROBABLE R:RESOLVED S:SUSPECT, SUSPICIOUS T:STATUS POST		(Optional) This is how a provider may modify the diagnosis or problem treated to reflect the status of the diagnosis as of this visit. Common examples of modifiers are Rule Out, Follow-up, or Status Post.
.12	primary/secondary	0;12	SET OF CODES	P:PRIMARY S:SECONDARY		This field represents the clinically pertinent ranking of problems treated. There is no limit on how many POV's may be identified as primary or secondary problems treated at the visit.
.13	date of injury	0;13	DATE-TIME			This is the date the injury occurred for the problem being treated. At VA facilities, the date of injury is prompted for when the ICD Diagnosis in the POV field (.01) is for an injury with a code between 800-999.999.
.15	clinical term	0;15	POINTER	757.01		This field is the clinical lexicon term which most closely represents the provider narrative of the problem treated. At VA facilities: The clinical lexicon is automatically captured via encounter form data capture (AICS package) when the of problem being treated is from the Active Problem List. In the manual data entry process, there is currently no prompt for the clinical term.
.16	problem list entry	0;16	POINTER	9000011		This field identifies what Problem List entry is related to the problem treated at the visit.
.17	ordering/resulting	0;17	SET OF CODES	O:ORDERING R:RESULTING OR:BOTH O&R		This field identifies a diagnosis as being Ordering, Resulting, or both Ordering and Resulting.
1201	event date and time	12;1	DATE-TIME			This is the actual date and time of the encounter. This date and time may be different than the visit date and time specified in the Visit file. However it must be within 30 days of the Visit date and Not be a future date. This field is useful for capturing the actual time encounters take place, or when, during the encounter, something happened.
1202	ordering provider	12;2	POINTER	200		For consistency, this field was added to each V-file. However, for the V POV, the Ordering Provider does not apply itself well, unless a provider is ordering another provider to treat a problem. Optionally, in the future, this field may be able to represent the provider responsible for the encounter providers work.
1204	encounter provider	12;4	POINTER	200		This is the provider who treated the diagnosis at the encounter.
80001	service connected	800;1	BOOLEAN	1:YES 0:NO		This field is used in the VA to indicate that this problem treated at this visit was service connected.
80002	agent orange exposure	800;2	BOOLEAN	1:YES 0:NO		This field is used in the VA to indicate that this problem treated at this visit was related to agent orange exposure.
80003	ionizing radiation exposure	800;3	BOOLEAN	1:YES 0:NO		This field is used in the VA to indicate that this problem treated at this visit was related to ionizing radiation exposure.
80004	sw asia conditions	800;4	BOOLEAN	1:YES 0:NO		This field is used in the VA to indicate that this problem treated at this visit was related to Southwest Asia Conditions exposure.
80005	military sexual trauma	800;5	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this Diagnosis code was related to a Military Sexual Trauma problem.
80006	head and/or neck cancer	800;6	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this Diagnosis code was related to Head and/or Neck Cancer.
80007	combat veteran	800;7	BOOLEAN	1:YES 0:NO		This field is used to indicate that the visit represents treatment of a VA patient for a problem that is possibly related to combat.
80008	proj 112/shad	800;8	BOOLEAN	1:YES 0:NO		Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests.
80101	edited flag	801;1	SET OF CODES	1:EDITED		This field is automatically set to 1 if PCE detects that any measurement data is being edited from the original entry of data.
80102	audit trail	801;2	FREE TEXT
80201	provider narrative category	802;1	POINTER	9999999.27		This field is the category narrative related to the problem treated.
81101	comments	811;1	FREE TEXT
81201	verified	812;1	SET OF CODES	1:ELECTRONICALLY SIGNED 2:VERIFIED BY PACKAGE
81202	package	812;2	POINTER	9.4
81203	data source	812;3	POINTER	839.7