STANDARD DATA DICTIONARY #1927.4 -- NUPA CARE PLANS FILE 3/24/25 PAGE 1
STORED IN ^NUPA(1927.4, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 1.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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These are the interdisciplinary care plans that are done by nurses or other medical personnel. Information is uploaded from the
assessment_careplan GUI. Do not edit this file via Fileman.
IDENTIFIED BY: PATIENT (#1)
POINTED TO BY: CARE PLAN field (#.01) of the NUPA CARE PLAN PRESSURE ULCERS File (#1927.401)
CARE PLAN field (#.01) of the NUPA CARE PLAN IVS File (#1927.402)
CARE PLAN field (#.01) of the NUPA CARE PLAN GI/GU DEVICES File (#1927.403)
CARE PLAN field (#.01) of the NUPA CARE PLAN TEXT CHANGE LOG File (#1927.5)
CARE PLAN field (#.01) of the NUPA DISCHARGE PLANNING GOAL COMMENTS File (#1927.6)
CROSS
REFERENCED BY: DATE/TIME ENTERED(B), PATIENT(C)
1927.4,.01 DATE/TIME ENTERED 0;1 DATE (Required)
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 20, 2009
DESCRIPTION:
This is the DATE/TIME ENTERED from the last assessment or reassessment
CROSS-REFERENCE: 1927.4^B
1)= S ^NUPA(1927.4,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,"B",$E(X,1,30),DA)
1927.4,1 PATIENT 0;2 POINTER TO PATIENT FILE (#2)
LAST EDITED: MAR 20, 2009
DESCRIPTION:
This is the PATIENT from the last assessment or reassessment
CROSS-REFERENCE: 1927.4^C
1)= S ^NUPA(1927.4,"C",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,"C",$E(X,1,30),DA)
1927.4,2 ENTERED BY 0;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 20, 2009
DESCRIPTION:
This is the ENTERED BY from the last assessment or reassessment
1927.4,3 GUARDIAN NAME 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION:
This is the patient's legal guardian.
1927.4,4 PRIMARY LANGUAGE 0;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: APR 26, 2011
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the patient's primary language.
1927.4,4.5 ACCOMPLISH BY THIS HOSP 15;0 WORD-PROCESSING #1927.53 (IGNORE "|")
LAST EDITED: OCT 01, 2009
DESCRIPTION: The patient's prior response to question "What does patient hope to accomplish by this
hospitalization".
1927.4,5 CULTURAL PRACTICES 0;6 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
These are any cultural practices that the patient may have that the nurse believes may affect care.
1927.4,5.1 CULTURAL PRACTICES DESCRIPTION 2;0 WORD-PROCESSING #1927.42 (IGNORE "|")
DESCRIPTION:
This is the CULTURAL PRACTICES DESCRIPTION from the last assessment or reassessment
LAST EDITED: MAR 20, 2009
1927.4,6 BLOOD TRANSFUSION CONCERNS 0;7 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 27, 2009
DESCRIPTION:
Any blood tranfusion concerns that patient may have.
1927.4,6.1 BLOOD TRANSFUSION DESCRIPTION 3;0 WORD-PROCESSING #1927.43 (IGNORE "|")
DESCRIPTION:
This is the BLOOD TRANSFUSION DESCRIPTION from the last assessment or reassessment
LAST EDITED: MAR 20, 2009
1927.4,7 ADVANCE DIRECTIVE 0;8 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Does the patient have any advance directives?
1927.4,7.1 ADVANCE DIRECTIVE LOCATION 4;0 WORD-PROCESSING #1927.44 (IGNORE "|")
DESCRIPTION:
This is the ADVANCE DIRECTIVE LOCATION from the last assessment or reassessment
LAST EDITED: MAR 20, 2009
1927.4,8 SPECIAL DIET NEEDS 0;9 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Does the patient have any special diet needs?
1927.4,8.1 SPECIAL DIET NEEDS DESCRIPTION 5;0 WORD-PROCESSING #1927.45 (IGNORE "|")
DESCRIPTION:
This is the SPECIAL DIET NEEDS DESCRIPTION from the last assessment or reassessment
LAST EDITED: MAR 20, 2009
1927.4,10 SUSPECTED VICTIM OF ABUSE/NEGL 0;10 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Does the nurse suspect that the patient is a victim of abuse or neglect?
1927.4,11 ORGAN DONOR 0;11 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Is the patient an organ donor?
1927.4,12 ALLERGY POINTER 1;0 POINTER Multiple #1927.412
DESCRIPTION:
List of the patients allergies as of the moment of the care plan.
1927.412,.01 ALLERGY POINTER 0;1 POINTER TO PATIENT ALLERGIES FILE (#120.8) (Multiply asked)
LAST EDITED: MAR 20, 2009
CROSS-REFERENCE: 1927.412^B
1)= S ^NUPA(1927.4,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),1,"B",$E(X,1,30),DA)
1927.4,13 PRECAUTIONS 0;14 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: NOV 10, 2009
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
MRSA precautions to take around this patient.
1927.4,14 LEVEL OF UNDERSTANDING 0;15 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: FEB 27, 2010
DESCRIPTION:
The level of understanding that a patient has of the education they were just given on MRSA.
1927.4,17 PRECAUTIONS (FLAGS) 6;0 Multiple #1927.417
DESCRIPTION:
Any precauions or flags (local or national) as of the moment of the care plan.
1927.417,.01 PRECAUTIONS (FLAGS) 0;1 FREE TEXT (Multiply asked)
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
CROSS-REFERENCE: 1927.417^B
1)= S ^NUPA(1927.4,DA(1),6,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),6,"B",$E(X,1,30),DA)
1927.4,18 LATEST DNR NOTE 0;12 POINTER TO TIU DOCUMENT FILE (#8925)
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Latest DNR note, if any, on file for this patient.
1927.4,19 WARD 0;13 POINTER TO HOSPITAL LOCATION FILE (#44)
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Ward that the patient was on as of the moment of the care plan.
1927.4,20 ORIENTED 10;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION:
Was the patient oriented to his/her room as of the moment of the care plan.
1927.4,21 ABLE TO ASSESS EDUCATION 10;2 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Was the nurse able to assess the patient's level of education?
1927.4,22 LEARNS BEST BY 10;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
How does the patient learn best? Hearing, seeing, etc.
1927.4,23 EDUCATION PREFERRED 10;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
What kind of education does the patient prefer? Computer based, group classes, etc.
1927.4,24 READINESS TO LEARN 10;5 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: MAR 20, 2009
DESCRIPTION:
What is the patient's readiness to learn? Ready to learn, not ready, sedated, etc.
1927.4,25 BARRIERS TO LEARNING 10;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
Does the patient have any barriers to learning? None, mental status, hearing, etc.
1927.4,25.1 BARRIERS TO LEARNING DESCRIP 11;0 WORD-PROCESSING #1927.46 (IGNORE "|")
DESCRIPTION:
This is the BARRIERS TO LEARNING DESCRIP from the last assessment or reassessment
LAST EDITED: MAR 20, 2009
1927.4,26 KNOWLEDGE OF CURRENT ILLNESS 10;7 SET
'0' FOR NONE;
'1' FOR LIMITED;
'2' FOR EXTENSIVE;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
What is the patient's level of knowledge of his/her illness? None, limited, or extensive.
1927.4,27 EDUCATIONAL INFO PROVIDED 10;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
Was any educational information provided to the patient? BCMA, Managing Your Pain, etc.
1927.4,30 INTERVENTIONS 20;0 POINTER Multiple #1927.47
DESCRIPTION:
Nursing Interventions provided to correct problems that a patient has.
1927.47,.01 INTERVENTIONS 0;1 POINTER TO NUPA ASSESSMENT INTERVENTIONS FILE (#1927.24) (Multiply asked)
LAST EDITED: MAR 20, 2009
CROSS-REFERENCE: 1927.47^B
1)= S ^NUPA(1927.4,DA(1),20,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),20,"B",$E(X,1,30),DA)
1927.47,1 DATE ENTERED 0;2 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 20, 2009
1927.47,2 USER ENTERING 0;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 20, 2009
1927.47,3 OTHER TEXT 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>99!($L(X)<3) X
LAST EDITED: OCT 18, 2011
HELP-PROMPT: Answer must be 3-99 characters in length.
1927.4,31 PROBLEMS 21;0 POINTER Multiple #1927.431
DESCRIPTION:
List of problems that a patient has.
1927.431,.01 PROBLEMS 0;1 POINTER TO NUPA ASSESSMENT PROBLEMS FILE (#1927.2) (Multiply asked)
LAST EDITED: MAR 20, 2009
CROSS-REFERENCE: 1927.431^B
1)= S ^NUPA(1927.4,DA(1),21,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),21,"B",$E(X,1,30),DA)
1927.431,1 DATE ENTERED 0;2 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 20, 2009
1927.431,2 USER ENTERING 0;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 20, 2009
1927.431,3 OTHER TEXT 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: NOV 12, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
1927.431,4 DESIRED OUTCOME 1;0 WORD-PROCESSING #1927.4314 (IGNORE "|")
LAST EDITED: NOV 18, 2009
DESCRIPTION: Used when the Nurse enters an "Other" problem. In this case, they are required to enter a
desired outcome.
1927.4,32 PROBLEM COMMENTS 12;0 WORD-PROCESSING #1927.432 (IGNORE "|")
DESCRIPTION:
Medical comments on the patient's problems.
LAST EDITED: MAR 20, 2009
1927.4,40 DISCH TO HOME WO ADD SERVICES 30;1 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAR 20, 2009
DESCRIPTION:
Should the patient be discharged to his/her home without additional services?
1927.4,41 DP GOALS 30;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: AUG 23, 2011
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
Does the patient need assistance from a Discharge Planning nurse or a Social Worker?
1927.4,41.1 DP GOALS OTHER 1 41;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<3) X
LAST EDITED: AUG 23, 2011
HELP-PROMPT: Answer must be 3-80 characters in length.
DESCRIPTION:
The "Other 1" free text goal entered by the user.
1927.4,41.2 DP GOALS OTHER 2 41;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<3) X
LAST EDITED: AUG 23, 2011
HELP-PROMPT: Answer must be 3-80 characters in length.
DESCRIPTION:
The "Other 2" free text goal entered by the user.
1927.4,41.3 DP GOALS OTHER 3 41;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<3) X
LAST EDITED: AUG 23, 2011
HELP-PROMPT: Answer must be 3-80 characters in length.
DESCRIPTION:
The "Other 3" free text goal entered by the user.
1927.4,42 BRADEN SCORE 30;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>23)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Type a Number between 0 and 23, 0 Decimal Digits
DESCRIPTION:
The patient's Braden Score as of the moment of the care plan.
1927.4,42.5 BRADEN SCORE DATE 30;5 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 18, 2009
DESCRIPTION:
Date that the Braden test was done.
1927.4,43 MORSE SCORE 30;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>150)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAR 20, 2009
HELP-PROMPT: Type a Number between 0 and 150, 0 Decimal Digits
DESCRIPTION:
The patient's Morse Fall score as of the moment of the care plan.
1927.4,43.5 MORSE SCORE DATE 30;6 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 18, 2009
DESCRIPTION:
Date that the Morse Fall test was done.
1927.4,44 FAMILY SUPPORT INVOLVED IN DP 7;0 WORD-PROCESSING #1927.444 (IGNORE "|")
DESCRIPTION:
Does the patient need family support in the planning of his/her discharge?
LAST EDITED: MAR 20, 2009
1927.4,45 DP OBSERVATIONS/COMMENTS 31;0 WORD-PROCESSING #1927.445 (IGNORE "|")
LAST EDITED: SEP 10, 2009
1927.4,50 GENERAL OBSERVATIONS/COMMENTS 13;0 WORD-PROCESSING #1927.48 (IGNORE "|")
DESCRIPTION:
General comments on this care plan.
LAST EDITED: MAR 20, 2009
1927.4,60 PROBLEM EVALUATIONS 8;0 POINTER Multiple #1927.49
DESCRIPTION:
Log of evaluations of the patient's problems.
1927.49,.01 PROBLEM 0;1 POINTER TO NUPA ASSESSMENT PROBLEMS FILE (#1927.2) (Multiply asked)
LAST EDITED: MAR 20, 2009
CROSS-REFERENCE: 1927.49^B
1)= S ^NUPA(1927.4,DA(1),8,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),8,"B",$E(X,1,30),DA)
1927.49,1 EVALUATION 0;2 SET
'N' FOR NO CHANGE/STABLE;
'I' FOR IMPROVING;
'D' FOR DETERIORATING;
'R' FOR RESOLVED;
'U' FOR UNRESOLVED AT DISCHARGE;
LAST EDITED: MAR 20, 2009
1927.49,2 EVAL DATE 0;3 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 20, 2009
1927.49,3 USER ENTERING 0;4 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 20, 2009
1927.4,61 INTERVENTION EVALUATION 9;0 POINTER Multiple #1927.461
DESCRIPTION:
Log of interventions to help the patient's problems.
1927.461,.01 INTERVENTION 0;1 POINTER TO NUPA ASSESSMENT INTERVENTIONS FILE (#1927.24) (Multiply asked)
LAST EDITED: MAR 20, 2009
CROSS-REFERENCE: 1927.461^B
1)= S ^NUPA(1927.4,DA(1),9,"B",$E(X,1,30),DA)=""
2)= K ^NUPA(1927.4,DA(1),9,"B",$E(X,1,30),DA)
1927.461,1 INTERVENTION STATUS 0;2 SET
'CM' FOR COMPLETED;
'D' FOR DISCONTINUED;
'CN' FOR CONTINUE;
'P' FOR PENDING;
LAST EDITED: MAR 20, 2009
1927.461,2 STATUS DATE 0;3 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 20, 2009
1927.461,3 USER ENTERING 0;4 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 20, 2009
1927.4,70 BED TO CHAIR 14;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the BED TO CHAIR from the last assessment or reassessment
1927.4,70.5 BED TO CHAIR STAFF 14;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the BED TO CHAIR STAFF from the last assessment or reassessment
1927.4,71 BED TO STRETCHER 14;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the BED TO STRETCHER from the last assessment or reassessment
1927.4,71.5 BED TO STRETCHER STAFF 14;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the BED TO STRETCHER STAFF from the last assessment or reassessment
1927.4,72 CHAIR TO STRETCHER 14;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the CHAIR TO STRETCHER from the last assessment or reassessment
1927.4,72.5 CHAIR TO STRETCHER STAFF 14;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the CHAIR TO STRETCHER STAFF from the last assessment or reassessment
1927.4,73 REPOS IN BED 14;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the REPOS IN BED from the last assessment or reassessment
1927.4,73.5 REPOS IN BED STAFF 14;8 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the REPOS IN BED STAFF from the last assessment or reassessment
1927.4,74 REPOS IN CHAIR 14;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the REPOS IN CHAIR from the last assessment or reassessment
1927.4,74.5 REPOS IN CHAIR STAFF 14;10 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the REPOS IN CHAIR STAFF from the last assessment or reassessment
1927.4,75 TRANSFER FROM FLOOR 14;11 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the TRANSFER FROM FLOOR from the last assessment or reassessment
1927.4,75.5 TRANSFER FROM FLOOR STAFF 14;12 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 06, 2009
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION:
This is the TRANSFER FROM FLOOR STAFF from the last assessment or reassessment
1927.4,76 SLING TYPE 14;13 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the SLING TYPE from the last assessment or reassessment
1927.4,77 SLING SIZE 14;14 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the SLING SIZE from the last assessment or reassessment
1927.4,100 GEN INFO DONE 100;1 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the General Info tab has been completed.
1927.4,102 RESP DONE 100;3 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Respiratory tab has been completed.
1927.4,103 CV DONE 100;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the CV tab has been completed.
1927.4,104 NEURO DONE 100;5 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Neuro tab has been completed.
1927.4,105 GI DONE 100;6 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the GI tab has been completed.
1927.4,106 GU DONE 100;7 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the GU tab has been completed.
1927.4,107 MS DONE 100;8 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Musculoskeletal tab has been completed.
1927.4,108 SKIN DONE 100;9 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Skin tab has been completed.
1927.4,109 PS DONE 100;10 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Psychosocial tab has been completed.
1927.4,110 MH DONE 100;11 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Mental Health tab has been completed.
1927.4,111 FUNC DONE 100;12 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Functional tab has been completed.
1927.4,112 DP DONE 100;13 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 21, 2009
DESCRIPTION:
Yes/No flag noting if the Discharge Planning tab has been completed.
1927.4,113 REL PRACTICES FOR CHAPLAIN 100;14 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 29, 2009
DESCRIPTION:
This is the REL PRACTICES FOR CHAPLAIN from the last assessment or reassessment
1927.4,114 IMMEDIATE CHAPLAIN VISIT 100;15 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 29, 2009
DESCRIPTION:
This is the IMMEDIATE CHAPLAIN VISIT from the last assessment or reassessment
1927.4,114.1 SHOULD CLERGY BE NOTIFIED 100;22 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the SHOULD CLERGY BE NOTIFIED from the last assessment or reassessment
1927.4,115 RECV INFO ON AD 100;16 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the RECV INFO ON AD from the last assessment or reassessment
1927.4,116 INITIATE OR CHANGE AD 100;17 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 29, 2009
DESCRIPTION:
This is the INITIATE OR CHANGE AD from the last assessment or reassessment
1927.4,117 TEST FOR MRSA BROCHURE GIVEN 100;18 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 29, 2009
DESCRIPTION:
This is the TEST FOR MRSA BROCHURE GIVEN from the last assessment or reassessment
1927.4,117.1 PATIENT AUTHORIZE NARES 100;19 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the PATIENT AUTHORIZE NARES from the last assessment or reassessment
1927.4,117.2 NARES PREFORMED 100;20 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the NARES PREFORMED from the last assessment or reassessment
1927.4,118 INFECTION CONTROL ED PROVIDED 100;21 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the INFECTION CONTROL ED PROVIDED from the last assessment or reassessment
1927.4,120 PAIN LOCATION 1 101;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the PAIN LOCATION 1 from the last assessment or reassessment
1927.4,121 PAIN TYPE 1 101;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Type a Number between 0 and 1, 0 Decimal Digits
DESCRIPTION:
This is the PAIN TYPE 1 from the last assessment or reassessment
1927.4,122 ONSET OF PAIN 1 101;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ONSET OF PAIN 1 from the last assessment or reassessment
1927.4,123 PAIN WORSE 1 101;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN WORSE 1 from the last assessment or reassessment
1927.4,124 PAIN BETTER 1 101;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN BETTER 1 from the last assessment or reassessment
1927.4,125 AREAS OF LIFE 1 101;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the AREAS OF LIFE 1 from the last assessment or reassessment
1927.4,126 PAIN GOAL 1 101;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 21, 2009
HELP-PROMPT: Type a Number between 0 and 10, 0 Decimal Digits
DESCRIPTION:
This is the PAIN GOAL 1 from the last assessment or reassessment
1927.4,127 OTHER PAIN REGION 1 127;0 WORD-PROCESSING #1927.4127 (IGNORE "|")
LAST EDITED: OCT 15, 2011
DESCRIPTION:
The Other Pain Region for the patient's first pain location.
1927.4,130 PAIN LOCATION 2 102;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the PAIN LOCATION 2 from the last assessment or reassessment
1927.4,131 PAIN TYPE 2 102;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 1, 0 Decimal Digits
DESCRIPTION:
This is the PAIN TYPE 2 from the last assessment or reassessment
1927.4,132 ONSET OF PAIN 2 102;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ONSET OF PAIN 2 from the last assessment or reassessment
1927.4,133 PAIN WORSE 2 102;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN WORSE 2 from the last assessment or reassessment
1927.4,134 PAIN BETTER 2 102;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN BETTER 2 from the last assessment or reassessment
1927.4,135 AREAS OF LIFE 2 102;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the AREAS OF LIFE 2 from the last assessment or reassessment
1927.4,136 PAIN GOAL 2 102;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 10, 0 Decimal Digits
DESCRIPTION:
This is the PAIN GOAL 2 from the last assessment or reassessment
1927.4,137 OTHER PAIN REGION 2 137;0 WORD-PROCESSING #1927.4137 (IGNORE "|")
LAST EDITED: OCT 15, 2011
DESCRIPTION:
The Other Pain Region for the patient's second pain location.
1927.4,140 PAIN LOCATION 3 103;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the PAIN LOCATION 3 from the last assessment or reassessment
1927.4,141 PAIN TYPE 3 103;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 1, 0 Decimal Digits
DESCRIPTION:
This is the PAIN TYPE 3 from the last assessment or reassessment
1927.4,142 ONSET OF PAIN 3 103;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the ONSET OF PAIN 3 from the last assessment or reassessment
1927.4,143 PAIN WORSE 3 103;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN WORSE 3 from the last assessment or reassessment
1927.4,144 PAIN BETTER 3 103;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN BETTER 3 from the last assessment or reassessment
1927.4,145 AREAS OF LIFE 3 103;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the AREAS OF LIFE 3 from the last assessment or reassessment
1927.4,146 PAIN GOAL 3 103;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 10, 0 Decimal Digits
DESCRIPTION:
This is the PAIN GOAL 3 from the last assessment or reassessment
1927.4,147 OTHER PAIN REGION 3 147;0 WORD-PROCESSING #1927.4147 (IGNORE "|")
LAST EDITED: OCT 15, 2011
DESCRIPTION:
The Other Pain Region for the patient's third pain location.
1927.4,150 PAIN LOCATION 4 104;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the PAIN LOCATION 4 from the last assessment or reassessment
1927.4,151 PAIN TYPE 4 104;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 1, 0 Decimal Digits
DESCRIPTION:
This is the PAIN TYPE 4 from the last assessment or reassessment
1927.4,152 ONSET OF PAIN 4 104;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ONSET OF PAIN 4 from the last assessment or reassessment
1927.4,153 PAIN WORSE 4 104;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN WORSE 4 from the last assessment or reassessment
1927.4,154 PAIN BETTER 4 104;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN BETTER 4 from the last assessment or reassessment
1927.4,155 AREAS OF LIFE 4 104;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the AREAS OF LIFE 4 from the last assessment or reassessment
1927.4,156 PAIN GOAL 4 104;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 10, 0 Decimal Digits
DESCRIPTION:
This is the PAIN GOAL 4 from the last assessment or reassessment
1927.4,157 OTHER PAIN REGION 4 157;0 WORD-PROCESSING #1927.4157 (IGNORE "|")
LAST EDITED: OCT 15, 2011
DESCRIPTION:
The Other Pain Region for the patient's fourth pain location.
1927.4,160 PAIN LOCATION 5 105;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the PAIN LOCATION 5 from the last assessment or reassessment
1927.4,161 PAIN TYPE 5 105;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 1, 0 Decimal Digits
DESCRIPTION:
This is the PAIN TYPE 5 from the last assessment or reassessment
1927.4,162 ONSET OF PAIN 5 105;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ONSET OF PAIN 5 from the last assessment or reassessment
1927.4,163 PAIN WORSE 5 105;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN WORSE 5 from the last assessment or reassessment
1927.4,164 PAIN BETTER 5 105;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the PAIN BETTER 5 from the last assessment or reassessment
1927.4,165 AREAS OF LIFE 5 105;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>64!($L(X)<1) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Answer must be 1-64 characters in length.
DESCRIPTION:
This is the AREAS OF LIFE 5 from the last assessment or reassessment
1927.4,166 PAIN GOAL 5 105;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 23, 2009
HELP-PROMPT: Type a Number between 0 and 10, 0 Decimal Digits
DESCRIPTION:
This is the PAIN GOAL 5 from the last assessment or reassessment
1927.4,167 OTHER PAIN REGION 5 167;0 WORD-PROCESSING #1927.4167 (IGNORE "|")
LAST EDITED: OCT 15, 2011
DESCRIPTION:
The Other Pain Region for the patient's fifth pain location.
1927.4,170 ABILITY TO READ 170;1 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the ABILITY TO READ from the last assessment or reassessment
1927.4,171 ABILITY TO WRITE 170;2 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 30, 2009
DESCRIPTION:
This is the ABILITY TO WRITE from the last assessment or reassessment
1927.4,172 EDUCATIONAL LEVEL 170;3 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: OCT 01, 2009
DESCRIPTION:
The patient's educational level. Grade school, high school, college, etc.
1927.4,180 PERIPHERAL LINE 1 LOCATION 180;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<3) X
LAST EDITED: AUG 03, 2009
HELP-PROMPT: Answer must be 3-25 characters in length.
DESCRIPTION:
This is the PERIPHERAL LINE 1 LOCATION from the last assessment or reassessment
1927.4,181 PERIPHERAL LINE 1 SIZE 180;2 SET
'16' FOR 16 Gauge;
'18' FOR 18 Gauge;
'20' FOR 20 Gauge;
'22' FOR 22 Gauge;
'O' FOR Other;
LAST EDITED: AUG 03, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 1 SIZE from the last assessment or reassessment
1927.4,182 PERIPHERAL LINE 1 DATE INS 180;3 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 03, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 1 DATE INS from the last assessment or reassessment
1927.4,183 PERIPHERAL LINE 2 LOCATION 180;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<3) X
LAST EDITED: AUG 03, 2009
HELP-PROMPT: Answer must be 3-25 characters in length.
DESCRIPTION:
This is the PERIPHERAL LINE 2 LOCATION from the last assessment or reassessment
1927.4,184 PERIPHERAL LINE 2 SIZE 180;5 SET
'16' FOR 16 Gauge;
'18' FOR 18 Gauge;
'20' FOR 20 Gauge;
'22' FOR 22 Gauge;
'O' FOR Other;
LAST EDITED: AUG 03, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 2 SIZE from the last assessment or reassessment
1927.4,185 PERIPHERAL LINE 2 DATE INS 180;6 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 03, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 2 DATE INS from the last assessment or reassessment
1927.4,186 PERIPHERAL LINE 3 LOCATION 180;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<3) X
LAST EDITED: AUG 03, 2009
HELP-PROMPT: Answer must be 3-25 characters in length.
DESCRIPTION:
This is the PERIPHERAL LINE 3 LOCATION from the last assessment or reassessment
1927.4,187 PERIPHERAL LINE 3 SIZE 180;8 SET
'16' FOR 16 Gauge;
'18' FOR 18 Gauge;
'20' FOR 20 Gauge;
'22' FOR 22 Gauge;
'O' FOR Other;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 3 SIZE from the last assessment or reassessment
1927.4,188 PERIPHERAL LINE 3 DATE INS 180;9 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the PERIPHERAL LINE 3 DATE INS from the last assessment or reassessment
1927.4,190 CENTRAL LINE 1 TYPE 190;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<3) X
LAST EDITED: AUG 04, 2009
HELP-PROMPT: Answer must be 3-40 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 1 TYPE from the last assessment or reassessment
1927.4,190.5 CENTRAL LINE 1 LOCATION 190;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: AUG 04, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 1 LOCATION from the last assessment or reassessment
1927.4,191 CENTRAL LINE 1 DATE INS 190;3 DATE
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 1 DATE INS from the last assessment or reassessment
1927.4,192 CENTRAL LINE 1 IMPREG 190;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 1 IMPREG from the last assessment or reassessment
1927.4,192.5 CENTRAL LINE 1 POWER INJ 190;5 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 1 POWER INJ from the last assessment or reassessment
1927.4,193 CENTRAL LINE 2 TYPE 190;6 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<3) X
LAST EDITED: AUG 04, 2009
HELP-PROMPT: Answer must be 3-40 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 2 TYPE from the last assessment or reassessment
1927.4,193.5 CENTRAL LINE 2 LOCATION 190;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: AUG 04, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 2 LOCATION from the last assessment or reassessment
1927.4,194 CENTRAL LINE 2 DATE INS 190;8 DATE
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 2 DATE INS from the last assessment or reassessment
1927.4,195 CENTRAL LINE 2 IMPREG 190;9 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 2 IMPREG from the last assessment or reassessment
1927.4,195.5 CENTRAL LINE 2 POWER INJ 190;10 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 2 POWER INJ from the last assessment or reassessment
1927.4,196 CENTRAL LINE 3 TYPE 191;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<3) X
LAST EDITED: AUG 07, 2009
HELP-PROMPT: Answer must be 3-40 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 3 TYPE from the last assessment or reassessment
1927.4,196.5 CENTRAL LINE 3 LOCATION 191;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: AUG 07, 2009
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION:
This is the CENTRAL LINE 3 LOCATION from the last assessment or reassessment
1927.4,197 CENTRAL LINE 3 DATE INS 191;3 DATE
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 3 DATE INS from the last assessment or reassessment
1927.4,198 CENTRAL LINE 3 IMPREG 191;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 3 IMPREG from the last assessment or reassessment
1927.4,198.5 CENTRAL LINE 3 POWER INJ 191;5 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 04, 2009
DESCRIPTION:
This is the CENTRAL LINE 3 POWER INJ from the last assessment or reassessment
1927.4,200 TRACH TYPE 200;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 11, 2009
DESCRIPTION:
This is the TRACH TYPE from the last assessment or reassessment
1927.4,201 OTHER TRACH TYPE 201;0 WORD-PROCESSING #1927.4201 (IGNORE "|")
DESCRIPTION:
This is the OTHER TRACH TYPE from the last assessment or reassessment
LAST EDITED: AUG 11, 2009
1927.4,202 TRACH SIZE 202;0 WORD-PROCESSING #1927.4202 (IGNORE "|")
DESCRIPTION:
This is the TRACH SIZE from the last assessment or reassessment
LAST EDITED: AUG 11, 2009
1927.4,203 TOBACCO SCREEN 200;11 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: OCT 01, 2009
DESCRIPTION:
The results of the patient's last tobacco screening.
1927.4,204 RESP HISTORY 200;12 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
Respiratory problems that a patient has had.
1927.4,205 PRODUCTIVE COUGH 200;2 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 27, 2009
DESCRIPTION:
This is the PRODUCTIVE COUGH from the last assessment or reassessment
1927.4,206 CHEST TUBE 1 LOCATION 200;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: AUG 26, 2009
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the CHEST TUBE LOCATION 1 from the last assessment or reassessment
1927.4,206.5 CHEST TUBE 1 DATE INSERTED 200;4 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 19, 2009
DESCRIPTION:
This is the CHEST TUBE 1 DATE INSERTED from the last assessment or reassessment
1927.4,207 CHEST TUBE 2 LOCATION 200;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the CHEST TUBE 2 LOCATION from the last assessment or reassessment
1927.4,207.5 CHEST TUBE 2 DATE INSERTED 200;6 DATE
INPUT TRANSFORM: S %DT="ETR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 19, 2009
DESCRIPTION:
This is the CHEST TUBE 2 DATE INSERTED from the last assessment or reassessment
1927.4,208 CHEST TUBE 3 LOCATION 200;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: AUG 19, 2009
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the CHEST TUBE 3 LOCATION from the last assessment or reassessment
1927.4,208.5 CHEST TUBE 3 DATE INSERTED 200;8 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 19, 2009
DESCRIPTION:
This is the CHEST TUBE 3 DATE INSERTED from the last assessment or reassessment
1927.4,209 CHEST TUBE 4 LOCATION 200;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: AUG 19, 2009
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
This is the CHEST TUBE 4 LOCATION from the last assessment or reassessment
1927.4,209.5 CHEST TUBE 4 DATE INSERTED 200;10 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 19, 2009
DESCRIPTION:
This is the CHEST TUBE 4 DATE INSERTED from the last assessment or reassessment
1927.4,210 EDEMA-RIGHT ARM 210;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-RIGHT ARM from the last assessment or reassessment
1927.4,210.5 EDEMA-LEFT ARM 210;2 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-LEFT ARM from the last assessment or reassessment
1927.4,211 EDEMA-RIGHT HAND 210;3 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-RIGHT HAND from the last assessment or reassessment
1927.4,211.5 EDEMA-LEFT HAND 210;4 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-LEFT HAND from the last assessment or reassessment
1927.4,212 EDEMA-RIGHT LEG 210;5 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-RIGHT LEG from the last assessment or reassessment
1927.4,212.5 EDEMA-LEFT LEG 210;6 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-LEFT LEG from the last assessment or reassessment
1927.4,213 EDEMA-PEDAL RIGHT 210;7 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-PEDAL RIGHT from the last assessment or reassessment
1927.4,213.5 EDEMA-PEDAL LEFT 210;8 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-PEDAL LEFT from the last assessment or reassessment
1927.4,214 EDEMA-FACIAL 210;9 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-FACIAL from the last assessment or reassessment
1927.4,215 EDEMA-PERIORBITAL 210;10 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-PERIORBITAL from the last assessment or reassessment
1927.4,216 EDEMA-SACRAL 210;11 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 13, 2009
DESCRIPTION:
This is the EDEMA-SACRAL from the last assessment or reassessment
1927.4,216.1 EDEMA-RIGHT HIP 210.1;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: JUL 27, 2011
DESCRIPTION:
This is the EDEMA-RIGHT HIP from the last assessment or reassessment
1927.4,216.2 EDEMA-LEFT HIP 210.1;2 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: JUL 27, 2011
DESCRIPTION:
This is the EDEMA-LEFT HIP from the last assessment or reassessment.
1927.4,217 EXTREMITIES 210;12 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<3) X
LAST EDITED: AUG 13, 2009
HELP-PROMPT: Answer must be 3-20 characters in length.
DESCRIPTION:
This is the EXTREMITIES from the last assessment or reassessment
1927.4,217.1 EXTREMITIES COMMENTS 217.1;0 WORD-PROCESSING #1927.59 (IGNORE "|")
LAST EDITED: APR 23, 2011
LAST EDITED: APR 23, 2011
DESCRIPTION:
This field holds the comments that a nurse made regarding the patient's extremeties.
1927.4,218 JUGULAR VENEOUS DISTORTION 210;13 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 18, 2009
DESCRIPTION:
This is the JUGULAR VENEOUS DISTORTION from the last assessment or reassessment
1927.4,218.1 HOMAN'S SIGN 210;14 FREE TEXT
INPUT TRANSFORM: K:$L(X)>32!($L(X)<1) X
LAST EDITED: AUG 26, 2009
HELP-PROMPT: Answer must be 1-32 characters in length.
DESCRIPTION:
This is the HOMAN'S SIGN from the last assessment or reassessment
1927.4,218.2 CARDIAC MONITOR 210;15 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 18, 2009
DESCRIPTION:
This is the CARDIAC MONITOR from the last assessment or reassessment
1927.4,219 CARDIAC RHYTHMS 210;16 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: NOV 06, 2009
DESCRIPTION:
This is the CARDIAC RHYTHMS from the last assessment or reassessment
1927.4,219.5 CV HISTORY 210;17 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
Cardiac problems that this patient has had.
1927.4,219.6 OTHER CV HISTORY 219.6;0 WORD-PROCESSING #1927.58 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION: This field is only filled in if the patient has an "Other" CV History. This is the description
of the other history.
1927.4,220 AUTONOMIC DYSREFLEXIA 220;1 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the AUTONOMIC DYSREFLEXIA from the last assessment or reassessment
1927.4,221 ORIENTATION (MENTATION) 220;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: JUN 29, 2011
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the ORIENTATION (MENTATION) from the last assessment or reassessment
1927.4,222 GLASGOW COMA SCALE SCORE 220;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>15)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 27, 2009
HELP-PROMPT: Type a Number between 0 and 15, 0 Decimal Digits
DESCRIPTION:
This is the GLASGOW COMA SCALE SCORE from the last assessment or reassessment
1927.4,223 MOTOR-RIGHT ARM 220;4 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the MOTOR-RIGHT ARM from the last assessment or reassessment
1927.4,223.1 MOTOR-LEFT ARM 220;5 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the MOTOR-LEFT ARM from the last assessment or reassessment
1927.4,223.2 MOTOR-RIGHT LEG 220;6 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the MOTOR-RIGHT LEG from the last assessment or reassessment
1927.4,223.3 MOTOR-LEFT LEG 220;7 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the MOTOR-LEFT LEG from the last assessment or reassessment
1927.4,224 PUPIL SIZE 220;8 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the PUPIL SIZE from the last assessment or reassessment
1927.4,224.1 RIGHT EYE REACTIVITY 220;9 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the RIGHT EYE REACTIVITY from the last assessment or reassessment
1927.4,224.2 LEFT EYE REACTIVITY 220;10 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the LEFT EYE REACTIVITY from the last assessment or reassessment
1927.4,225 SPEECH/LANGUAGE 220;11 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the SPEECH/LANGUAGE from the last assessment or reassessment
1927.4,226 SENSATIONS 220;12 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the SENSATIONS from the last assessment or reassessment
1927.4,226.5 PRIOR SENSATIONS 226;0 WORD-PROCESSING #1927.51 (IGNORE "|")
DESCRIPTION:
This is the PRIOR SENSATIONS from the last assessment or reassessment
LAST EDITED: AUG 20, 2009
1927.4,227 REQ ASSISTIVE COMM DEVICES 220;13 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the REQ ASSISTIVE COMM DEVICES from the last assessment or reassessment
1927.4,227.5 PRIOR COMMUNICATION DEVICES 227;0 WORD-PROCESSING #1927.52 (IGNORE "|")
DESCRIPTION:
This is the PRIOR COMMUNICATION DEVICES from the last assessment or reassessment
LAST EDITED: AUG 20, 2009
1927.4,228 LENS IMPLANTS 220;14 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 19, 2009
DESCRIPTION:
This is the LENS IMPLANTS from the last assessment or reassessment
1927.4,229 NEURO HISTORY 220;15 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
The neurological problems this patient has had.
1927.4,230 INDWELLING CATHETER SIZE 230;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: OCT 06, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the FOLEY CATHETER SIZE from the last assessment or reassessment
1927.4,230.5 INDWELLING CATHETER DATE INS 230;2 DATE
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 06, 2009
DESCRIPTION:
This is the FOLEY CATHETER DATE INSERTED from the last assessment or reassessment
1927.4,231 ABNORMAL DISCHARGE 230;3 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 20, 2009
DESCRIPTION:
This is the ABNORMAL DISCHARGE from the last assessment or reassessment
1927.4,232 PRIOR PREGNANCY 230;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: AUG 20, 2009
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
This is the PRIOR PREGNANCY from the last assessment or reassessment
1927.4,233 GU HISTORY 230;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>65!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-65 characters in length.
DESCRIPTION:
The GU problems this patient has had.
1927.4,240 ATTITUDE 240;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the ATTITUDE from the last assessment or reassessment
1927.4,240.5 BEHAVIOR 240;2 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the BEHAVIOR from the last assessment or reassessment
1927.4,241 VERBAL ABUSE 240;3 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR DECLINES TO ANSWER;
LAST EDITED: AUG 31, 2009
DESCRIPTION:
This is the VERBAL ABUSE from the last assessment or reassessment
1927.4,241.1 PHYSICAL ABUSE 240;4 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR DECLINES TO ANSWER;
LAST EDITED: AUG 31, 2009
DESCRIPTION:
This is the PHYSICAL ABUSE from the last assessment or reassessment
1927.4,241.2 FINANCIAL ABUSE 240;5 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR DECLINES TO ANSWER;
LAST EDITED: AUG 31, 2009
DESCRIPTION:
This is the FINANCIAL ABUSE from the last assessment or reassessment
1927.4,241.3 RAPE OR SEXUAL ABUSE 240;6 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR DECLINES TO ANSWER;
LAST EDITED: AUG 31, 2009
DESCRIPTION:
This is the RAPE OR SEXUAL ABUSE from the last assessment or reassessment
1927.4,241.4 NEGLECT 240;7 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR DECLINES TO ANSWER;
LAST EDITED: AUG 31, 2009
DESCRIPTION:
This is the NEGLECT from the last assessment or reassessment
1927.4,241.5 NA VERBAL ABUSE 241;11 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: FEB 11, 2010
DESCRIPTION:
This is the nurses judgement of VERBAL ABUSE from the last assessment or reassessment.
1927.4,241.6 NA PHYSICAL ABUSE 241;12 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: FEB 11, 2010
DESCRIPTION:
This is the nurses judgement of PHYSICAL ABUSE from the last assessment or reassessment.
1927.4,241.7 NA NEGLECT 241;13 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: FEB 11, 2010
DESCRIPTION:
This is the nurses judgement of Neglect from the last assessment or reassessment.
1927.4,241.8 NA HOUSEHOLD VICTIMS 241;14 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR UNKNOWN;
LAST EDITED: FEB 12, 2010
DESCRIPTION: This is the nurse's judgement of whether others in the patient's household are victims of abuse or
neglect by the patient.
1927.4,242 THOUGHTS OF HARMING YOURSELF 240;8 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the THOUGHTS OF HARMING YOURSELF from the last assessment or reassessment
1927.4,242.1 PLAN 240;9 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the PLAN from the last assessment or reassessment
1927.4,242.11 PLAN DESCRIPTION 242.11;0 WORD-PROCESSING #1927.63 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION:
This is the description of the patient's plan to harm his/herself.
1927.4,242.2 MEANS AVAILABLE 240;10 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the MEANS AVAILABLE from the last assessment or reassessment
1927.4,242.21 MEANS DESCRIPTION 242.21;0 WORD-PROCESSING #1927.64 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION:
This is the description of the patient's means to harm his/herself.
1927.4,242.3 REHEARSED OR PRACTICED 240;11 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the REHEARSED OR PRACTICED from the last assessment or reassessment
1927.4,242.4 HEARD VOICES 240;12 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the HEARD VOICES from the last assessment or reassessment
1927.4,242.5 TRIED TO HURT YOURSELF 240;13 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the TRIED TO HURT YOURSELF from the last assessment or reassessment
1927.4,242.6 FEELING HOPELESS 240;14 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the FEELING HOPELESS from the last assessment or reassessment
1927.4,243 HAS GUARDIAN 241;1 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the HAS GUARDIAN from the last assessment or reassessment
1927.4,243.01 GUARDIAN NAME 243.01;0 WORD-PROCESSING #1927.66 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is the name of the patient's court-appointed guardian.
1927.4,243.1 LEGALLY COMMITTED 241;2 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the LEGALLY COMMITTED from the last assessment or reassessment
1927.4,243.2 DANGER TO THEMSELF 241;3 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the DANGER TO THEMSELF from the last assessment or reassessment
1927.4,243.3 ON LEGAL OBSERVATION 241;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the ON LEGAL OBSERVATION from the last assessment or reassessment
1927.4,243.4 LACKS COGNITIVE ABILITY 241;5 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the LACKS COGNITIVE ABILITY from the last assessment or reassessment
1927.4,243.5 HISTORY OF ESCAPE 241;6 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the HISTORY OF ESCAPE from the last assessment or reassessment
1927.4,243.51 HISTORY OF ESCAPE FROM WHERE 243.51;0 WORD-PROCESSING #1927.67 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This field specifies where the patient tried to escape or elope from.
1927.4,244 ALCOHOL USE 241;7 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the ALCOHOL USE from the last assessment or reassessment
1927.4,245 USE RECREATIONAL DRUGS 241;8 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the USE RECREATIONAL DRUGS from the last assessment or reassessment
1927.4,246 MEDICAL MARIJUANA CARD 241;9 SET
'1' FOR Yes;
'0' FOR No;
LAST EDITED: DEC 16, 2009
DESCRIPTION:
This is the MEDICAL MARIJUANA CARD from the last assessment or reassessment
1927.4,247 CONTRABAND 241;10 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 09, 2009
DESCRIPTION:
Did the patient bring in contraband?
1927.4,248 PSYCHOSOCIAL HISTORY 240;15 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
Psychosocial prblems this patient has had.
1927.4,250 WHAT MAKES PATIENT UPSET 250;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>99!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-99 characters in length.
DESCRIPTION:
This is the WHAT MAKES PATIENT UPSET from the last assessment or reassessment
1927.4,250.01 OTHER MAKES PATIENT UPSET 250.01;0 WORD-PROCESSING #1927.702 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is the description of the "Other" response to "What things make patient upset".
1927.4,250.1 HOW ACT WHEN LOSE CONTROL 250;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
This is the HOW ACT WHEN LOSE CONTROL from the last assessment or reassessment
1927.4,250.11 OTHER LOSE CONTROL 250.11;0 WORD-PROCESSING #1927.703 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is the description of the "Other" response to "How does patient act when they lose control".
1927.4,250.2 PATIENT CALM THEMSELF 250;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>99!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-99 characters in length.
DESCRIPTION:
This is the PATIENT CALM THEMSELF from the last assessment or reassessment
1927.4,250.21 OTHER CALM THEMSELVES 250.21;0 WORD-PROCESSING #1927.704 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is the description of the "Other" response to "What does patient do to calm him/herself".
1927.4,251 MOOD 251;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
This is the MOOD from the last assessment or reassessment
1927.4,251.01 OTHER MOOD 251.01;0 WORD-PROCESSING #1927.68 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is a description of the patient's "Other" mood, from Mental Health Page 2.
1927.4,251.1 AFFECT 251;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
This is the AFFECT from the last assessment or reassessment
1927.4,251.11 OTHER AFFECT 251.11;0 WORD-PROCESSING #1927.69 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is a description of the patient's "Other" Affect, from Mental Health Page 2.
1927.4,251.2 BEHAVIOR 251;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>99!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-99 characters in length.
DESCRIPTION:
This is the BEHAVIOR from the last assessment or reassessment
1927.4,251.21 OTHER BEHAVIOR 251.21;0 WORD-PROCESSING #1927.7 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is a description of the patient's "Other" behavior, from Mental Health Page 2.
1927.4,252 BEHAVIORAL HEALTH ADVANCED DIR 251;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
This is the BEHAVIORAL HEALTH ADVANCED DIR from the last assessment or reassessment
1927.4,253 NOTIFY IF PLACED IN RESTRAINTS 250;4 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR Patient declines to answer;
'3' FOR Patient unable to answer;
LAST EDITED: OCT 16, 2009
DESCRIPTION:
Should someone be notified if the patient is placed in restraints?
1927.4,253.1 WHO TO NOTIFY IF PLACED IN RES 253.1;0 WORD-PROCESSING #1927.701 (IGNORE "|")
LAST EDITED: APR 26, 2011
DESCRIPTION:
This is who the hospital should notify if the patient must be placed in restraints.
1927.4,254 MH HISTORY 254;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-55 characters in length.
DESCRIPTION:
Prior Mental Health problems this patient has had.
1927.4,254.1 OTHER MH HISTORY 254.1;0 WORD-PROCESSING #1927.65 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION: This field is only filled in if the patient has an "Other" MH History. This is the description
of the other history.
1927.4,255 SO ANGRY TO LOSE CONTROL 254;2 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: APR 26, 2011
DESCRIPTION:
Has the patient ever been so angry as to explode or lose control?
1927.4,256 CALM THEMSELF 254;3 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: APR 26, 2011
DESCRIPTION:
When the patient gets upset, are they able to calm themself?
1927.4,260 LEVEL OF ASSISTANCE 260;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the LEVEL OF ASSISTANCE from the last assessment or reassessment
1927.4,261 LEVEL OF COOPERATION 260;2 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the LEVEL OF COOPERATION from the last assessment or reassessment
1927.4,262 WEIGHT BEARING CAPABILITY 260;3 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: AUG 17, 2009
DESCRIPTION:
This is the WEIGHT BEARING CAPABILITY from the last assessment or reassessment
1927.4,263 BILATERAL UPPER EXT STRENGTH 260;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 23, 2009
DESCRIPTION:
This is the BILATERAL UPPER EXT STRENGTH from the last assessment or reassessment
1927.4,264 APPLIC COND TO AFFECT TRANSFER 260;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>99!($L(X)<1) X
LAST EDITED: AUG 17, 2009
HELP-PROMPT: Answer must be 1-99 characters in length.
DESCRIPTION:
This is the APPLIC COND TO AFFECT TRANSFER from the last assessment or reassessment
1927.4,265 KATZ SCORE 260;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>6)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 27, 2009
HELP-PROMPT: Type a Number between 0 and 6, 0 Decimal Digits
DESCRIPTION:
This is the KATZ SCORE from the last assessment or reassessment
1927.4,266 DECREASE IN INDEPENDENCE 260;7 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: NOV 09, 2009
DESCRIPTION:
Was there a decrease in the patient's level of independence in the last 30 days?
1927.4,267 ASSIST PATIENT WITH 260;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: FEB 12, 2010
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
Functional items that the patient should be assisted with. Ambulating, bathing, etc.
1927.4,270 BOWEL PATTERN 270;1 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: OCT 02, 2009
DESCRIPTION:
The patient's last bowel pattern.
1927.4,271 GI DEVICE TYPES 270;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: OCT 02, 2009
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
Any devices in the patient's GI system.
1927.4,272 SPECIAL FOOD PREFERENCES 270;3 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 02, 2009
DESCRIPTION:
Does the patient have any special food preferences?
1927.4,273 NUTRITION DESCRIPTION 270;4 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: OCT 02, 2009
DESCRIPTION:
How the patient looks, from a nutition point of view.
1927.4,274 APPETITE 270;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: OCT 02, 2009
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
The patient's appetite.
1927.4,275 DYSPHAGIA SCREEN 270;6 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Patient's last Dysphagia screen results (able or not to screen).
1927.4,275.1 TBI 270;7 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Diagnosis of new Traumatic Brain Injury?
1927.4,275.2 MODIFIED TEXTURE DIET 270;8 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Does the patient need a Modified Texture Diet?
1927.4,275.3 UNABLE TO FOLLOW COMMANDS 270;9 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Is the patient unable to follow commands?
1927.4,275.4 WET GURGLY VOICE 270;10 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Does the patient have a wet gurgly voice?
1927.4,275.5 DROOLING WHILE AWAKE 270;11 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Is the patient drooling while they're awake?
1927.4,275.6 TONGUE DEVIATION FROM MIDLINE 270;12 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Is the patient's tongue deviating from midline?
1927.4,276 UNINTENTIONAL WEIGHT LOSS/GAIN 270;13 SET
'1' FOR YES;
'0' FOR NO;
'2' FOR Unknown;
LAST EDITED: OCT 07, 2009
DESCRIPTION:
Did the patient have an unintentional weight loss or gain in the last month?
1927.4,277 GI HISTORY 270;14 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
The GI problems that this patient has had.
1927.4,277.1 GI OTHER HISTORY 277.1;0 WORD-PROCESSING #1927.56 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION: This field is only filled in if the patient has an "Other" GI History. This is the description
of the other history.
1927.4,278 ABDOMINAL ASSESSMENT 271;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: APR 23, 2011
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
The abdominal assessment on the patient.
1927.4,278.1 OTHER ABDOMINAL ASSESSMENT 278.1;0 WORD-PROCESSING #1927.57 (IGNORE "|")
LAST EDITED: APR 23, 2011
DESCRIPTION: This field is only filled in if the patient has an "Other" abdominal assessment. This is the
description of the abdominal assessment.
1927.4,280 MUSC HISTORY 280;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>65!($L(X)<1) X
LAST EDITED: OCT 08, 2009
HELP-PROMPT: Answer must be 1-65 characters in length.
DESCRIPTION:
The Musculoskeletal history of the patient.
1927.4,280.1 OTHER MUSC HISTORY 280.1;0 WORD-PROCESSING #1927.62 (IGNORE "|")
LAST EDITED: APR 23, 2011
LAST EDITED: APR 23, 2011
DESCRIPTION: This field is only filled in if the patient has an "Other" MS History. This is the description
of the other history.
1927.4,281 RANGE OF MOTION 280;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: OCT 08, 2009
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
The patient's Range of Motion.
1927.4,290 SKIN HISTORY 290;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>65!($L(X)<1) X
LAST EDITED: OCT 08, 2009
HELP-PROMPT: Answer must be 1-65 characters in length.
DESCRIPTION:
The patient's skin history
1927.4,291 SKIN RISK FACTORS 290;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: OCT 08, 2009
HELP-PROMPT: Answer must be 1-55 characters in length.
DESCRIPTION:
The patient's skin risk factors.
1927.4,292 SKIN PATIENT ED PROVIDED 290;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X
LAST EDITED: OCT 08, 2009
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
Was education provided to the patient or caregiver about skin care?
1927.4,293 SKIN BREAKDOWN FACTORS 290;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: NOV 08, 2009
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
The Skin Beakdown Factors that this patient has.
1927.4,300 RESPIRATORY PATTERN 300;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION:
The patient's prior respiratory pattern.
1927.4,301 WORK OF BREATHING 300;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
The patient's prior Work of Breathing.
1927.4,302 CRACKELS/RALES 300;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
The patient's prior Crackles & Rales (breath sounds).
1927.4,302.1 DIMINISHED/DECRASED 300;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
The patient's prior Decreased/Diminshed Breath Sounds.
1927.4,302.2 RHONCHI 300;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
The patient's prior Rhonchi breath sounds.
1927.4,303 SPUTUM AMOUNT 300;6 POINTER TO NUPA COMPONENT ITEMS FILE (#1927.41)
LAST EDITED: NOV 28, 2010
DESCRIPTION:
The patient's prior amount of sputum.
1927.4,303.1 SPUTUM COLOR 300;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
The patient's prior sputum color.
1927.4,303.2 SPUTUM CONSISTENCY 300;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: NOV 28, 2010
HELP-PROMPT: Answer must be 1-25 characters in length.
DESCRIPTION:
The patient's prior sputum consistency.
1927.4,304 CHAPLAIN CONSULT SENT 304;1 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 22, 2011
DESCRIPTION: Was a Chaplain consult sent as part of this care plan from either the Admission Assessment or a
prior reassessment?
1927.4,304.1 DP CONSULT SENT 304;2 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 22, 2011
DESCRIPTION: Was a DP consult sent as part of this care plan from either the Admission Assessment or a prior
reassessment?
1927.4,304.2 NUTRITION CONSULT SENT 304;3 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 22, 2011
DESCRIPTION: Was a Nutrition consult sent as part of this care plan from either the Admission Assessment or a
prior reassessment?
1927.4,304.3 SPEECH CONSULT SENT 304;4 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 22, 2011
DESCRIPTION: Was a Speech consult sent as part of this care plan from either the Admission Assessment or a prior
reassessment?
1927.4,304.4 SOCIAL WORK CONSULT SENT 304;5 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 22, 2011
DESCRIPTION: Was a Social Work consult sent as part of this care plan from either the Admission Assessment or a
prior reassessment?
FILES POINTED TO FIELDS
HOSPITAL LOCATION (#44) WARD (#19)
NEW PERSON (#200) ENTERED BY (#2)
PROBLEMS:USER ENTERING (#2)
INTERVENTION EVALUATION:USER ENTERING (#3)
INTERVENTIONS:USER ENTERING (#2)
PROBLEM EVALUATIONS:USER ENTERING (#3)
NUPA ASSESSMENT INTERVENTIONS
(#1927.24) INTERVENTION EVALUATION:INTERVENTION (#.01)
INTERVENTIONS:INTERVENTIONS (#.01)
NUPA ASSESSMENT PROBLEMS
(#1927.2) PROBLEMS:PROBLEMS (#.01)
PROBLEM EVALUATIONS:PROBLEM (#.01)
NUPA COMPONENT ITEMS (#1927.41) LEVEL OF UNDERSTANDING (#14)
READINESS TO LEARN (#24)
SLING TYPE (#76)
SLING SIZE (#77)
EDUCATIONAL LEVEL (#172)
TRACH TYPE (#200)
TOBACCO SCREEN (#203)
EDEMA-RIGHT ARM (#210)
EDEMA-LEFT ARM (#210.5)
EDEMA-RIGHT HAND (#211)
EDEMA-LEFT HAND (#211.5)
EDEMA-RIGHT LEG (#212)
EDEMA-LEFT LEG (#212.5)
EDEMA-PEDAL RIGHT (#213)
EDEMA-PEDAL LEFT (#213.5)
EDEMA-FACIAL (#214)
EDEMA-PERIORBITAL (#215)
EDEMA-SACRAL (#216)
EDEMA-RIGHT HIP (#216.1)
EDEMA-LEFT HIP (#216.2)
CARDIAC RHYTHMS (#219)
MOTOR-RIGHT ARM (#223)
MOTOR-LEFT ARM (#223.1)
MOTOR-RIGHT LEG (#223.2)
MOTOR-LEFT LEG (#223.3)
PUPIL SIZE (#224)
RIGHT EYE REACTIVITY (#224.1)
LEFT EYE REACTIVITY (#224.2)
SPEECH/LANGUAGE (#225)
ABNORMAL DISCHARGE (#231)
ATTITUDE (#240)
BEHAVIOR (#240.5)
THOUGHTS OF HARMING YOURSELF (#242)
PLAN (#242.1)
MEANS AVAILABLE (#242.2)
REHEARSED OR PRACTICED (#242.3)
HEARD VOICES (#242.4)
TRIED TO HURT YOURSELF (#242.5)
FEELING HOPELESS (#242.6)
ALCOHOL USE (#244)
USE RECREATIONAL DRUGS (#245)
SO ANGRY TO LOSE CONTROL (#255)
CALM THEMSELF (#256)
LEVEL OF ASSISTANCE (#260)
LEVEL OF COOPERATION (#261)
WEIGHT BEARING CAPABILITY (#262)
DECREASE IN INDEPENDENCE (#266)
BOWEL PATTERN (#270)
NUTRITION DESCRIPTION (#273)
DYSPHAGIA SCREEN (#275)
SPUTUM AMOUNT (#303)
PATIENT (#2) PATIENT (#1)
PATIENT ALLERGIES (#120.8) ALLERGY POINTER:ALLERGY POINTER (#.01)
TIU DOCUMENT (#8925) LATEST DNR NOTE (#18)
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