CTO/NOTES

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S X=$$TIU^C9CGMTSOBJ(DFN,3000215,"PSYCH_SUMMARY","CHRONOLOGICAL")


HS OBJECT DISPLAY Jun 16, 2014@09:25:09 Page: 1 of 1 

              Detailed Display for HOSP COURSE SUMM 40-53 OBJ

               HS Object: HOSP COURSE SUMM 40-53 OBJ (TIU)
     Health Summary Type: HOSP COURSE SUMM 40-53 HS
           Report Period:
                 Creator: KING,MATTHEW M

                                 HS Object

                 Print Label: NO         Print Report Date and Time: NO
Print Blank Line after Label: NO       Print Confidentiality Banner: NO
           Customized Header: YES        Print Report Date and Time: NO
Suppress Components w/o Data: YES            Print Component Header: NO
  Print Deceased Information: NO       Print Time-Occurrence Limits: NO
             National Object: NO         Underline Component Header: NO
                                            Blank Line After Header: NO
 Overwrite No Data:



                      HEALTH SUMMARY TYPE INQUIRY

        Type Name:  HOSP COURSE SUMM 40-53 HS
            Title:  HOSPITAL COURSE
            Owner:  KING,MATTHEW M

SUPPRESS PRINT OF COMPONENTS WITHOUT DATA: yes SUPPRESS SENSITIVE PRINT DATA: NO SSN 

                                  Max        Hos  ICD   Pro  CPT

Abb Ord Component Name Occ Time Loc Text Nar Mod Selection

RSPN 5 SUMMARY 40 53W 

                                                                  PSYCH TREATME

NT PROGRESS REVIE


Checking DAVIDTEST (TIU) with Health Summary...

Creating Health Summary Object 'DAVIDTEST (TIU)' 

Select Health Summary Type: DAVIDTEST (HS)

Are you adding 'DAVIDTEST (HS)' as 

   a new HEALTH SUMMARY TYPE (the 339th)?   No// YES

NAME: DAVIDTEST (HS)// TITLE: DAVID-TEST SUPPRESS PRINT OF COMPONENTS WITHOUT DATA: Y yes SUPPRESS SENSITIVE PRINT DATA: 2 NO SSN

Do you wish to copy COMPONENTS from an existing Health Summary Type? YES// NO Select COMPONENT: ?? 


  300001        CRH RAW TEXT SELECTED PN ALL RSPN
  300002        CRH TEXT SELECT PN EQUALS RSPN
  300003        CRH OUTPAT MED 7 DAY    RXOP
  300004        DJW RAW TEXT SELECTED PN ALL RSPN

Select COMPONENT: 300001 CRH RAW TEXT SELECTED PN ALL RSPN SUMMARY ORDER: 5// 5 OCCURRENCE LIMIT:


CHOOSE 1-5: 3 HEALTH SUMMARY COMPONENT (107 entries) Select HEALTH SUMMARY COMPONENT NAME: ? 

Answer with HEALTH SUMMARY COMPONENT NUMBER, or NAME, or ABBREVIATION, or
    DEFAULT HEADER NAME
Do you want the entire 107-Entry HEALTH SUMMARY COMPONENT List? Y  (Yes)
  Choose from:

Select HEALTH SUMMARY COMPONENT NAME: 300001 CRH RAW TEXT SELECTED PN ALL ANOTHER ONE: STANDARD CAPTIONED OUTPUT? Yes// (Yes) Include COMPUTED fields: (N/Y/R/B): NO// BOTH Computed Fields and Record Number 

(IEN)

NUMBER: 300001 NAME: CRH RAW TEXT SELECTED PN ALL 

 PRINT ROUTINE: MAIN;ZMTSPNSL          TIME LIMITS APPLICABLE: yes
 ABBREVIATION: RSPN                    MAXIMUM OCCURRENCES APPLICABLE: yes
 DEFAULT HEADER NAME: Raw Prog Notes

SELECTION FILE: TIU DOCUMENT DEFINITION 

DESCRIPTION:   This component allows for the selection of specific progress
notes by document title.  These progress notes were entered using the Text
Integration Utilities (TIU).  Data presented include:  Progress note date/time
written, title, text of note, and the note's correction text and correction
date/time.

Only those notes which have been signed with an electronic signature or
electronically marked signed on chart will be reported.

Select HEALTH SUMMARY COMPONENT NAME: 300002 CRH TEXT SELECT PN EQUALS ANOTHER ONE: STANDARD CAPTIONED OUTPUT? Yes// (Yes) Include COMPUTED fields: (N/Y/R/B): NO// BOTH Computed Fields and Record Number 

(IEN)

NUMBER: 300002 NAME: CRH TEXT SELECT PN EQUALS 

 PRINT ROUTINE: MAIN;ZMTSPNSL          TIME LIMITS APPLICABLE: yes
 ABBREVIATION: RSPN                    MAXIMUM OCCURRENCES APPLICABLE: yes
 DEFAULT HEADER NAME: Raw Prog Notes

SELECTION FILE: TIU DOCUMENT DEFINITION 

DESCRIPTION:   This component allows for the selection of specific progress
notes by document title.  These progress notes were entered using the Text
Integration Utilities (TIU).  Data presented include:  Progress note date/time
written, title, text of note, and the note's correction text and correction
date/time.

Only those notes which have been signed with an electronic signature or
electronically marked signed on chart will be reported.

NUMBER: 300004 NAME: DJW RAW TEXT SELECTED PN ALL 

 PRINT ROUTINE: MAIN;C9CTOPNS          TIME LIMITS APPLICABLE: yes
 ABBREVIATION: RSPN                    MAXIMUM OCCURRENCES APPLICABLE: yes
 DEFAULT HEADER NAME: Raw Prog Notes

SELECTION FILE: TIU DOCUMENT DEFINITION 

DESCRIPTION:   This component allows for the selection of specific progress
notes by document title.  These progress notes were entered using the Text
Integration Utilities (TIU).  Data presented include:  Progress note date/time
written, title, text of note, and the note's correction text and correction
date/time.

Only those notes which have been signed with an electronic signature or
electronically marked signed on chart will be reported.


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GTM-Production>W ^TIU(8925,21050,0) 1557^1168^2067^6^7^^3121106.0446^^^^^^H GTM-Production>W ^DPT(1168,0) CAMP,CHERYL^F^2591108^^U^^^^063605986^^^^^^80^3121105.135159^^^^1

ORQQCN GET CONSULT

Params ------------------------------------------------------------------ literal 97 literal 1

Results ----------------------------------------------------------------- 3140429.1425^405^187964^66^50^66^3140429.142519^^505^502^^2^10^656;KING,MATTHEW M^^^C^I^^^68^^^3140429 530549^PHYSICAL THERAPY CONSULT RESULT^3140429.1435^ZZADULT, MALE (Z8035)^656;MATTHEW M KING;KING,MATTHEW M^ZZTESTWARD^completed^Adm: 02/11/13;3130211.165105^  ;^97;GMR(123,^0^^^1^

ORQQCN LIST

Params ------------------------------------------------------------------ literal 405 literal literal literal literal

Results ----------------------------------------------------------------- 97^3140429.142519^c^PHYSICAL THERAPY^Consult^^Evaluation and Treatment PHYSICAL THERAPY Cons^187964^C 96^3140415.152501^c^PHYSICAL THERAPY^Consult^^Evaluation and Treatment PHYSICAL THERAPY Cons^179533^C 82^3140220.143048^dc^GASTROENTEROLOGY^COLONOSCOPY^^COLONOSCOPY GASTROENTEROLOGY Proc^146149^P 81^3140220.142021^dc^CARDIOLOGY^Consult^^CARDIOLOGY Cons^146146^C 80^3140220.140709^c^INFECTIOUS DISEASE^Consult^^INFECTIOUS DISEASE Cons^146135^C 71^3140207.132449^dc^OCCUPATIONAL THERAPY^Consult^^OCCUPATIONAL THERAPY Cons^138531^C 70^3140207.130846^dc^GASTROENTEROLOGY^Consult^^GASTROENTEROLOGY Cons^138507^C

ORQQCN DETAIL

Params ------------------------------------------------------------------ literal 97

Results ----------------------------------------------------------------- Current Pat. Status: Inpatient Ward: ZZTESTWARD Primary Eligibility: EHR PATIENT (NOT VERIFIED) Patient Type: NON-VETERAN (OTHER) OEF/OIF: NO

Order Information To Service: PHYSICAL THERAPY From Service: ZZTESTWARD Requesting Provider: KING,MATTHEW M Service is to be rendered on an INPATIENT basis Place: Consultant's choice Urgency: Routine Earliest Appr. Date: Apr 29, 2014 Orderable Item: PHYSICAL THERAPY Consult: Consult Request Reason For Request: This is a routine request to evaluate this patient for fall risk and physical therapy to reduce the risk of falling.

Inter-facility Information This is not an inter-facility consult request.

Status: COMPLETE Last Action: COMPLETE/UPDATE

Facility 

Activity                Date/Time/Zone      Responsible Person  Entered By

CPRS RELEASED ORDER     04/29/14 14:25      KING,MATTHEW M      KING,MATTHEW M
RECEIVED                04/29/14 14:32      KING,MATTHEW M      KING,MATTHEW M
SCHEDULED               04/29/14 14:34      KING,MATTHEW M      KING,MATTHEW M

CNKXNKX NCKCX 

COMPLETE/UPDATE         04/29/14 14:39      KING,MATTHEW M      KING,MATTHEW M

Note: TIME ZONE is local if not indicated 

LOCAL TITLE: PHYSICAL THERAPY CONSULT RESULT

STANDARD TITLE: PHYSICAL THERAPY CONSULT DATE OF NOTE: APR 29, 2014@14:35 ENTRY DATE: APR 29, 2014@14:36:12 

     AUTHOR: KING,MATTHEW M       EXP COSIGNER:                           
    URGENCY:                            STATUS: COMPLETED

PHYSICAL THERAPY EVALUATION

PAST MEDICAL HISTORY:

PATIENT GOALS:

PREVIOUS LEVEL OF FUNCION/SOCIAL ENVIRONMENT (LIVING ARRANGEMENTS, EQUIPMENT, ECT.):

PHYSICAL ASSESSMENT

SPEECH: VISION: HEARING: ROM:


STRENGTH:

TRANSFERS:

BED MOBILITY:

BALANCE: SITTING STATIC DYNAMIC 

        STANDING STATIC      DYNAMIC

GAIT:

SENSATION:

SKIN:

ENDURANCE:

PAIN LEVEL:

BARRIERS TO LEARNING:

ASSESSMENT:

GOALS: independently in 4 weeks

independently in 4 weeks

Patient will ambulate 250 feet independently in 4 weeks 


0 pain  in 4 weeks

ADDITIONAL GOALS:

TREATMENT PLAN:


FREQUENCY/DURATION:

    • PLEASE ADD THE CONSULTING PROVIDER AS AN ADDITIONAL SIGNER TO THIS NOTE**








/es/ MATTHEW M KING, MD Medical Physician Signed: 04/29/2014 14:39

====================================================================
============================== END ===============================

ORQQCN SVC W/SYNONYMS

Params ------------------------------------------------------------------ literal 1 literal 1 literal 1

Results ----------------------------------------------------------------- 1^ALL SERVICES^0^+^1^84 51^CRH EXTERNAL REFERRALS^1^+^1 56^BRACE SHOP^51^^^5286


4^CARDIOLOGY^51^^^85 65^CARDIOVASCULAR SURGERY^51^^^5295 54^DERMATOLOGY^51^^^5284 59^ENDOCRINOLOGY^51^^^5289 5^GASTROENTEROLOGY^51^^^86 57^GYNECOLOGY^51^^^5287 6^HEMATOLOGY^51^^^87 61^INFECTIOUS DISEASE^51^^^5291 52^NEPHROLOGY^51^^^5282 60^NEUROLOGY^51^^^5290 62^NEUROSURGERY^51^^^5292 53^ORTHOPEDICS^51^^^5283 66^OTHER SURGICAL SPECIALTY^51^^^5300 58^OTOLARYNGOLOGY^51^^^5288 64^OUTPATIENT SURGERY^51^^^5294 63^PLASTIC SURGERY^51^^^5293 7^PULMONARY^51^^^90 8^RHEUMATOLOGY^51^^^91 55^UROLOGY^51^^^5285 47^CRH INTERNAL REFERRALS^1^+^1^5281 67^GYN CLINIC (CRH)^47^^^5301 48^OCCUPATIONAL THERAPY^47^^^4471 50^PHYSICAL THERAPY^47^^^4503 65^THORACIC SURGERY <CARDIOVASCULAR SURGERY>^^^S^5295 65^VASCULAR SURGERY <CARDIOVASCULAR SURGERY>^^^S^5295 54^DERM <DERMATOLOGY>^^^S^5284 5^GI <GASTROENTEROLOGY>^^^S^86 53^ORTHO <ORTHOPEDICS>^^^S^5283 58^ENT <OTOLARYNGOLOGY>^^^S^5288 48^OT <OCCUPATIONAL THERAPY>^^^S^4471 50^PT <PHYSICAL THERAPY>^^^S^4503

ORWDCN32 DEF

Params ------------------------------------------------------------------ literal C

Results ----------------------------------------------------------------- ~ShortList ~Inpt Cslt Urgencies i17^EMERGENCY^506 i9^ROUTINE^505 i1^STAT^512 i13^WITHIN 48 HOURS^494 i14^WITHIN 72 HOURS^495 d9^ROUTINE^505 ~Outpt Urgencies i10^NEXT AVAILABLE^496 i9^ROUTINE^505 i1^STAT^512 i11^TODAY^492 i16^WITHIN 1 MONTH^499 i15^WITHIN 1 WEEK^498 i12^WITHIN 24 HOURS^493 i14^WITHIN 72 HOURS^495 d9^ROUTINE^505 ~Inpt Place iB^BEDSIDE^B iC^CONSULTANT'S CHOICE^C dB^BEDSIDE^B ~Outpt Place iC^CONSULTANT'S CHOICE^C iE^EMERGENCY ROOM^E dC^CONSULTANT'S CHOICE^C

ORWDX DLGDEF

Params ------------------------------------------------------------------ literal GMRCOR CONSULT

Results ----------------------------------------------------------------- ORDERABLE^4^2^^^^Cons COMMENT^15^ CLASS^10^ URGENCY^7^4^^ROUTINE PLACE^140^3 PROVIDER^17^ MISC^20^^^^^^^^166~ ITEM^178^1 CODE^166^^^^^^^^^1 EARLIEST^205^

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