STANDARD DATA DICTIONARY #45.9 -- PAF FILE 3/24/25 PAGE 1
STORED IN ^DG(45.9, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 5.3)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
-----------------------------------------------------------------------------------------------------------------------------------
This file contains data that is tranmitted to the Austin DPC as part of the RUG-II program. Data contained in this file relates to
patients that were (or are) housed on an intermediate care or nursing home care ward. It pertains to the patient's level of care
and needs from the nursing professionals. This data is in turn used for reimbursement. Data should be edited through menu options
on the RUG-II menu, not through VA FileMan options.
Questions asked on this form mimic those on VA form 10-0064a (the Long Term Care Patient Assessment Instrument).
DD ACCESS: @
RD ACCESS: d
WR ACCESS: D
DEL ACCESS: D
LAYGO ACCESS: D
IDENTIFIED BY: ASSESSMENT DATE (#2)[R], ASSESSMENT PURPOSE (#6)[R]
"WR": D WR^DGRUGC
CROSS
REFERENCED BY: ASSESSMENT DATE(AA), DATE OF ADMISSION/TRANSFER IN(AC), ASSESSMENT DATE(AD), ASSESSMENT DATE(AP),
RUG-II GROUP(AR), RECORD STATUS(AS), DATE OF ADMISSION/TRANSFER IN(AT), NAME(B), TRANSMISSION DATE(T)
45.9,.001 NUMBER NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: MAR 24, 1987
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 1 AND 99999999
DESCRIPTION:
This field contains an internal entry number as created by VA FileMan.
45.9,.01 NAME 0;1 POINTER TO PATIENT FILE (#2) (Required)
INPUT TRANSFORM: S DIC("S")="I $D(DFN),DFN=Y" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: APR 22, 1988
DESCRIPTION:
This field contains the name of the long-term care patient for which this assessment was completed.
SCREEN: S DIC("S")="I $D(DFN),DFN=Y"
EXPLANATION: <<>>
UNEDITABLE
CROSS-REFERENCE: 45.9^B
1)= S ^DG(45.9,"B",$E(X,1,30),DA)=""
2)= K ^DG(45.9,"B",$E(X,1,30),DA)
45.9,2 ASSESSMENT DATE 0;2 DATE (Required)
INPUT TRANSFORM: S %DT="EXP",%DT(0)="-0" D ^%DT K %DT S X=Y K:Y<1 X I $D(X) D ASD^DGRUGC1 K %
LAST EDITED: MAR 01, 1989
DESCRIPTION: Enter the month,day and year the assessment is completed. The date must be after the date of
admission/transfer in.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 45.9^AD^MUMPS
1)= S L=+^DG(45.9,DA,0) I L>0 S ^DG(45.9,"AD",L,X,DA)=""
2)= S L=+^DG(45.9,DA,0) I L>0 K ^DG(45.9,"AD",L,X,DA)
CROSS-REFERENCE: 45.9^AA
1)= S ^DG(45.9,"AA",$E(X,1,30),DA)=""
2)= K ^DG(45.9,"AA",$E(X,1,30),DA)
CROSS-REFERENCE: 45.9^AP^MUMPS
1)= S L=$P(^DG(45.9,DA,0),"^",6) I L>0 S ^DG(45.9,"AP",L,X,DA)=""
2)= S L=$P(^DG(45.9,DA,0),"^",6) I L>0 K ^DG(45.9,"AP",L,X,DA)
45.9,3 SSN 0;3 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>9!($L(X)<9) X
LAST EDITED: NOV 14, 1986
HELP-PROMPT: ANSWER MUST BE 9 CHARACTERS IN LENGTH
DESCRIPTION: This field contains the patient's SSN. This data is added automatically when the patient
assessment is created either through a RUG background job or through the 'Create a PAI' option.
45.9,4 SEX 0;4 SET
'M' FOR MALE;
'F' FOR FEMALE;
DESCRIPTION: This field contains the patient's sex. This data is added automatically when the patient
assessment record is created either through a RUG background job or the 'Create a PAI' option.
45.9,5 YEAR OF BIRTH 0;5 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<1800)!(X?.E1"."1N.N) X
LAST EDITED: MAR 09, 1998
HELP-PROMPT: Enter the patient's 4-digit Year of Birth.
DESCRIPTION: This field contains the year in which this patient was born. This data is added automatically when
the patient's assessment record is created either through a RUG background job or the 'Create a
PAI' menu option.
45.9,6 ASSESSMENT PURPOSE 0;6 SET (Required)
'1' FOR ADMISSION/TRANSFER;
'2' FOR SEMI-ANNUAL CENSUS;
'3' FOR CONTRACT NURSING HOME;
LAST EDITED: APR 16, 1996
DESCRIPTION: Enter "1" if the assessment is being completed within approximately one week after
admission/transfer into the intermediate medicine or nursing home care unit. Enter "2" if the
assessment is completed on patients in bed as of a semi-annual survey date. If semi-annual
assessment date coincides with the day on which an admission/transfer assessment would have been
done, record "2" as the purpose. Enter "3" if the assessment is for a Contract Nursing Home
patient.
UNEDITABLE
45.9,7 DATE OF ADMISSION/TRANSFER IN 0;7 DATE
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 13, 1987
DESCRIPTION: This field will contain the date/time this patient was either admitted to or transferred to a ward
whose service is either intermediate care (I) or nursing home care (NHCU). This date must be
selected from the choices given under the 'Create a PAI' option. It may also be created
automatically by one of the RUG background jobs (the nightly job or the semi-annual job).
CROSS-REFERENCE: 45.9^AT^MUMPS
1)= S L=$P(^DG(45.9,DA,0),"^",6),DFN=+^DG(45.9,DA,0) I L S ^DG(45.9,"AT",L,X,DFN,DA)=""
2)= S L=$P(^DG(45.9,DA,0),"^",6),DFN=+^DG(45.9,DA,0) I L K ^DG(45.9,"AT",L,X,DFN,DA)
CROSS-REFERENCE: 45.9^AC
1)= S ^DG(45.9,"AC",$E(X,1,30),DA)=""
2)= K ^DG(45.9,"AC",$E(X,1,30),DA)
45.9,8 MEDICAL CENTER 0;8 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<100)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 100 AND 999
DESCRIPTION: This field contains the facility's number (3 digit number) and is transmitted to Austin to indicate
which facility transmitted the data.
45.9,9 BED SECTION 0;9 SET
'I' FOR INTERMEDIATE MEDICINE;
'N' FOR NHCU;
DESCRIPTION: This field contains the bedsection under which this patient was treated. Only patients residing on
wards with a service of Intermediate care or Nursing home care are eligible to have a PAF form
completed.
45.9,10 TRACHEOSTOMY CARE/SUCTIONING 0;10 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Care for a tracheostomy, including Daily Self-care patients suctioning. Exclude any
self-care patients who do not need daily staff help.
45.9,11 SUCTIONING-GENERAL(DAILY) 0;11 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Nasal or oral techniques for clearing Daily Any tracheostomy away fluid or secretions.
May be for suctioning a respiratory problem.
45.9,12 OXYGEN(DAILY) 0;12 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Administration of oxygen by nasal Daily Inhalators,oxygen in catheter,mask (nasal or
oronasal), room,but not in use funnel/cone or oxygen tent for conditions
resulting from oxygen deficiency.
45.9,13 RESPIRATORY CARE 0;13 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Care for any portion of the respiratory Daily Suctioning tract,especially the
lungs. This care may include one or more of the following: percussion or cupping,postural drainage,
positive pressure machine,possibly oxygen to administer drugs,etc.
45.9,14 TUBE FEEDING 0;14 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Primary food intake by means of a tube None None.Includes specifically, nasogastric,
nasoduodenal, gastrostomy nasojejunal, esophagostomy, jejunostomy, or
gastrostomy.
45.9,15 PARENTERAL FEEDING 0;15 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Intravenous or subcutaneous route for None None.Gastrostomy the administration of
fluids used to not applicable. maintain fluid,nutritional intake,
electrolyte balance.
45.9,16 WOUND CARE 0;16 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Subcutaneous lesion(s) resulting Care must be Decubiti from surgery,trauma or open
needed for at Stasis ulcers cancerous ulcers. least 3
consecutive Skin tears
weeks. Feeding tubes
45.9,17 CHEMOTHERAPY 0;17 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Treatment of carcinoma through IV None None and/or oral chemical agents,as
ordered by a physician.
45.9,18 TRANSFUSIONS 0;18 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
Introduction of whole blood or blood components directly into the blood stream. None
None
45.9,19 DIALYSIS/APHORESIS 0;19 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
---------------------------------------------------------------------------
The process of removing impurities from None None the blood of persons who have
renal disease. Include within this definition patients receiving aphoresis,that is, any of the
processes used to separate blood components in order to remove known or suspected pathogenic
elements.
45.9,20 RADIATION THERAPY 0;20 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: ---------------------------------------------------------------------------
DEFINITION SPECIFIC
FREQUENCY EXCLUSIONS
--------------------------------------------------------------------------
Treatment of carcinoma by means of None None ionizing radiation.
45.9,21 TUBE FEEDING ROUTE 0;21 SET
'1' FOR 1> N/A - NOT TUBE FED;
'2' FOR 2> NASOGASTRIC;
'3' FOR 3> NASODUODENAL;
'4' FOR 4> NASOJEJUNAL;
'5' FOR 5> ESOPHAGOSTOMY;
'6' FOR 6> JEJUNOSTOMY;
'7' FOR 7> GASTROSTOMY;
LAST EDITED: OCT 30, 1988
DESCRIPTION: Definition: Tube Feeding Routes - Nasogastric - Transnasal route ending in the stomach.
Nasoduodenal - Transnasal route ending in the duodenum (the first part of
the small intestine). Nasojejunal - Transnasal route ending in the jejunum (the
second part of
the small intestine). Esophagostomy - The feeding tube is passed through a
surgically-created
opening in the lower neck region ending in the stomach. Jejunostomy - The
feeding tube passes through a surgically-created
opening in the abdominal region into the jejunum. Gastrostomy - The feeding tube
passes through a surgically-created
opening in the abdominal region into the stomach.
45.9,22 RESERVED1 0;22 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field is reserved for future use. It is left blank to mimic the actual Long Term Care Patient
Assessment Instrument (VA form 10-0064a).
45.9,23 DECUBITUS LEVEL 0;23 SET
'0' FOR NO REDDENED SKIN;
'1' FOR REDDENED SKIN,POTENTIAL BREAKDOWN;
'2' FOR SUPERFICIAL LAYER OF BROKEN OR BLISTERED SKIN;
'3' FOR SUBCUTANEOUS SKIN BROKEN DOWN;
'4' FOR NECROTIC BREAKDOWN;
'5' FOR AT LEVEL 4,DOES NOT FULFILL QUALIFIERS;
DESCRIPTION: For a patient to be coded as level 4, documentation by a licensed clinician
(e.g.,physician,podiatrist,R.N.) must exist which describes the following three components:
1. a description of the patient's decubitus
2. the active treatment plan
3. circumstances or medical condition which led to the decubitus. (An
exception to this documentation can be made for newly admitted
patients whose decubitus developed before admission and involved
unknown causes or circumstances.)
45.9,24 COMATOSE 0;24 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field contains a yes/no response whether or not the patient is comatose. This data should be
obtained from a nurse on the ward where this patient resides.
45.9,25 DEHYDRATION 0;25 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: If this patient suffers from dehydration, enter a YES in this field. Otherwise, respond NO. This
data should be obtained from a nurse on the ward where this patient resides.
45.9,26 INTERNAL BLEEDING 0;26 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: If this patient suffers from internal bleeding, enter a YES in this field. Otherwise, respond NO.
This data should be obtained from a nurse on the ward where this patient resides (or resided).
45.9,27 STASIS ULCER 0;27 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: Open lesion, usually in lower extremities, caused by decreased blood flow from chronic venous
insufficiency.
45.9,28 TERMINALLY ILL 0;28 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,29 RESERVE2 0;29 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,30 RESERVE3 0;30 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,31 RESERVE4 0;31 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,32 QUADRIPLEGIA 0;32 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: Includes both complete and incomplete paralysis of all limbs. (ICD-9-CM 344.0) Does not include
paraplegia or any other forms of paralysis.
45.9,33 MULTIPLE SCLEROSIS 0;33 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: (ICD-9-CM 340) Does not include any other diseases of the central nervous system.
45.9,34 URINARY TRACT INFECTION 0;34 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: Site of infection does not have to be specified. (ICD-9-CM 599.0)
45.9,35 HEMIPLEGIA 0;35 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: Includes both complete and incomplete paralysis of one side of the body regardless of cause.
(ICD-9-CM 342.9)
45.9,36 RESERVE5 0;36 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,37 RESERVE6 0;37 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,38 RESERVE7 0;38 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,39 RESERVE8 0;39 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: MAY 13, 1987
DESCRIPTION: This field has been left unused to follow numbering guidelines on the RUG-II PAF form. Should VACO
MAS or another RUG contact require that fields be added to the form, this field may be used.
45.9,40 EATING 0;40 SET
'1' FOR 1> FEEDS SELF;
'2' FOR 2> INTERMITTENT SUPERVISION;
'3' FOR 3> CONTINUED HELP;
'4' FOR 4> HAND FED;
'5' FOR 5> TUBE FED;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the code which best represents the method under which this patient receives nutritional
intake.
45.9,41 MOBILITY 0;41 SET
'1' FOR 1> WALKS,NO SUPERVISION;
'2' FOR 2> WALKS,INTERMITTENT SUPERVISION;
'3' FOR 3> WALKS,CONSTANT SUPERVISION;
'4' FOR 4> WHEELS,NO SUPERVISION;
'5' FOR 5> WHEELED;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the code which best represents the method under which this patient is transported (or
transports himself) from place to place.
45.9,42 TRANSFER 0;42 SET
'1' FOR 1> NO SUPERVISION;
'2' FOR 2> INTERMITTENT SUPERVISION;
'3' FOR 3> ASSISTANCE OF 1 PERSON;
'4' FOR 4> ASSISTANCE OF 2 PEOPLE;
'5' FOR 5> CANNOT GET OUT OF BED;
LAST EDITED: APR 20, 1987
DESCRIPTION:
Enter the code which best represents how this patient is moved.
45.9,43 TOILETING 0;43 SET
'1' FOR 1> NO SUPERVISION;
'2' FOR 2> INTERMITTENT SUPERVISION;
'3' FOR 3> CONTINENT,REQUIRES SUPERVISION;
'4' FOR 4> INCONTINENT,NOT TAKEN TO TOILET;
'5' FOR 5> INCONTINENT,TAKEN TO TOILET;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the code which best represents the manner in which this patient transported to and from the
toilet.
45.9,44 VERBAL DISRUPTION 0;44 SET
'1' FOR 1> NONE IN PAST 4 WEEKS;
'2' FOR 2> 1-3 TIMES IN PAST 4 WEEKS;
'3' FOR 3> SHORT LIVED AT LEAST ONCE A WEEK;
'4' FOR 4> UNPREDICTABLE;
'5' FOR 5> AT LEVEL 4,DOES NOT FULFILL QUALIFIERS;
LAST EDITED: APR 20, 1987
DESCRIPTION: Choose from the available choices, the item that best describes this patient's verbal disruption.
Verbal disruption is considered yelling, baiting, threatening, etc.
45.9,45 PHYSICAL AGGRESSION 0;45 SET
'1' FOR 1> NONE IN PAST 4 WEEKS;
'2' FOR 2> UNPREDICTABLE IN PAST 4 WEEKS;
'3' FOR 3> PREDICTABLE DURING SPECIFIC ROUTINES;
'4' FOR 4> UNPREDICTABLE,AT LEAST ONCE A WEEK;
'5' FOR 5> AT LEVEL 4,DOES NOT FULFILL QUALIFIERS;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter from the available choices, the item that best describes the amount of physical agression
behavior this patient exibits. Physical agression is described as assertive or combative behavior
to self or others with the possibiltity of injury. Examples include hits self, throws objects,
punches, and makes dangerous maneuvers with a wheelchair.
45.9,46 DISRUPTIVE BEHAVIOR 0;46 SET
'1' FOR 1> NONE IN PAST 4 WEEKS;
'2' FOR 2> NOT DISRUPTIVE TO OTHERS;
'3' FOR 3> DISRUPTIVE IN PAST 4 WEEKS;
'4' FOR 4> AT LEAST ONCE A WEEK;
'5' FOR 5> AT LEVEL 4,DOES NOT FULFILL QUALIFIERS;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter from the available choices, the item that best describes the amount of disruptive behavior
this patient exibits. This would include disruptive, infantile, or socially inappropriate behavior
and can be described as childish, repetitive or antisocial physical behavior which creates
disruption with others. Examples include constantly undressing self, stealing, smearing feces, and
sexually displaying oneself to others. Exclude verbal actions and read choices for other
exclusions.
45.9,47 HALLUCINATIONS 0;47 SET
'1' FOR NO;
'2' FOR YES;
'3' FOR YES,BUT DOES NOT FULFILL THE QUALIFIERS;
LAST EDITED: FEB 17, 1991
DESCRIPTION: Enter from the available choices the item that best describes the patient's hallucinations (or lack
thereof). Hallucinations are described as visual, auditory, or tactile perceptions that have no
basis in external reality. In order to be recorded her, the hallucinations must be experienced at
least once per week during the past four weeks.
45.9,48 PHYSICAL THERAPY LEVEL 0;48 SET
'1' FOR 1> DOES NOT RECEIVE;
'2' FOR 2> MAINTENANCE PROGRAM;
'3' FOR 3> RESTORATIVE PROGRAM;
'4' FOR 4> NON-QUALIFYING PROGRAM;
LAST EDITED: FEB 16, 1988
DESCRIPTION: Enter the appropriate code denoting the level of physical therapy that this patient receives. The
following are the choices available:
DOES NOT RECEIVE: patient does not receive physical therapy
MAINTENANCE PROGRAM: patient requires and is currently receiving
physical therapy to help stabilize or slow
functional deteriorization.
RESTORATIVE PROGRAM: patient requires and is currently receiving
physical therapy for four or more consecutive
weeks with a restorative goal.
NON-QUALIFYING PROGRAM: patient requires and receives restorative
therapy, but does not meet the qualifiers
stated in the instructions.
45.9,49 PT DAYS PER WEEK 0;49 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>7)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 7
DESCRIPTION: Enter the number of days a week (0-7) that this patient receives physical therapy. Enter 0 if this
patient does not receive physical therapy (pysical theraphy level was listed as 1).
45.9,49.5 PT HOURS/MINUTES PER WEEK 0;63 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>5059)!(X<0)!(X?.E1"."1N.N) X I $D(X) D HM^DGRUGC1
LAST EDITED: NOV 30, 1988
HELP-PROMPT: Type a Number between 0 and 5059, 0 Decimal Digits
DESCRIPTION: Enter a number 0 through 5059 in the format HHMM. For example, if the patient has received 3 hours
and 30 minutes of therapy per week, enter 330. Enter 30 if the patient received only 30 minutes
per week. Leading zeros should be left off.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
45.9,50 OCCUPATIONAL THERAPY LEVEL 0;50 SET
'1' FOR 1> DOES NOT RECEIVE;
'2' FOR 2> MAINTENANCE PROGRAM;
'3' FOR 3> RESTORATIVE PROGRAM;
'4' FOR 4> NON-QUALIFYING PROGRAM;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the appropriate code denoting the level of occupational therapy that this patient receives.
The following are the choices available:
DOES NOT RECEIVE: patient does not receive occupational therapy.
MAINTENANCE PROGRAM: patient requires and is currently receiving
occupational therapy to help stabilize or slow
functional deteriorization.
RESTORATIVE PROGRAM: patient requires and is currently receiving
occupational therapy for four or more consecutive
weeks with a restorative goal.
NON-QUALIFYING PROGRAM: patient requires and receives restorative
therapy, but does not meet the qualifiers
stated in the instructions.
45.9,51 OT DAYS PER WEEK 0;51 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>7)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 7
DESCRIPTION: Enter the number of days a week (0-7) this patient receives occupational therapy. Enter 0 if this
patient does not receive occupational therapy (occupational therapy level was listed as 1).
45.9,51.5 OT HOURS/MINUTES PER WEEK 0;64 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>5059)!(X<0)!(X?.E1"."1N.N) X I $D(X) D HM^DGRUGC1
LAST EDITED: NOV 30, 1988
HELP-PROMPT: Type a Number between 0 and 5059, 0 Decimal Digits
DESCRIPTION: Enter a number 0 through 5059 in the format HHMM. For example, if the patient has received 3 hours
and 30 minutes of therapy per week, enter 330. Enter 30 if the patient received only 30 minutes
per week. Leading zeros should be left off.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
45.9,52 CORRECTIVE THERAPY LEVEL 0;52 SET
'1' FOR 1> DOES NOT RECEIVE;
'2' FOR 2> MAINTENANCE PROGRAM;
'3' FOR 3> RESTORATIVE PROGRAM;
'4' FOR 4> NON-QUALIFYING PROGRAM;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the appropriate code denoting the level of corrective therapy that this patient receives.
The following are the choices available:
DOES NOT RECEIVE: patient does not receive corrective therapy.
MAINTENANCE PROGRAM: patient requires and is currently receiving
corrective therapy to help stabilize or slow
functional deteriorization.
RESTORATIVE PROGRAM: patient requires and is currently receiving
corrective therapy for four or more consecutive
weeks with a restorative goal.
NON-QUALIFYING PROGRAM: patient requires and receives restorative
therapy, but does not meet the qualifiers
stated in the instructions.
45.9,53 CT DAYS PER WEEK 0;53 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>7)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 7
DESCRIPTION: Enter the number of days a week (0-7) that this patient receives corrective therapy. Enter 0 if
this patient does not receive corrective therapy (corrective therapy level was listed as 1).
45.9,53.5 CT HOURS/MINUTES PER WEEK 0;65 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>5059)!(X<0)!(X?.E1"."1N.N) X I $D(X) D HM^DGRUGC1
LAST EDITED: NOV 30, 1988
HELP-PROMPT: Type a Number between 0 and 5059, 0 Decimal Digits
DESCRIPTION: Enter a number 0 through 5059 in the format HHMM. For example, if the patient has received 3 hours
and 30 minutes of therapy per week, enter 330. Enter 30 if the patient received only 30 minutes
per week. Leading zeros should be left off.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
45.9,54 MANUAL ARTS THERAPY LEVEL 0;54 SET
'1' FOR 1> DOES NOT RECEIVE;
'2' FOR 2> MAINTENANCE PROGRAM;
'3' FOR 3> RESTORATIVE PROGRAM;
'4' FOR 4> NON-QUALIFYING PROGRAM;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the appropriate code denoting the level of manual arts therapy that this patient receives.
The following are the choices available:
DOES NOT RECEIVE: patient does not receive manual arts therapy.
MAINTENANCE PROGRAM: patient requires and is currently receiving
manual arts therapy to help stabilize or slow
functional deteriorization.
RESTORATIVE PROGRAM: patient requires and is currently receiving
manual arts therapy for four or more consecutive
weeks with a restorative goal.
NON-QUALIFYING PROGRAM: patient requires and receives restorative
therapy, but does not meet the qualifiers
stated in the instructions.
45.9,55 MAT DAYS PER WEEK 0;55 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>7)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 7
DESCRIPTION: Enter the number of days a week (0-7) that this patient receives manual arts therapy. Enter 0 if
this patient does not receive manual arts therapy (manual arts therapy level was listed as 1).
45.9,55.5 MAT HOURS/MINUTES PER WEEK 0;66 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>5059)!(X<0)!(X?.E1"."1N.N) X I $D(X) D HM^DGRUGC1
LAST EDITED: NOV 30, 1988
HELP-PROMPT: Type a Number between 0 and 5059, 0 Decimal Digits
DESCRIPTION: Enter a number 0 through 5059 in the format HHMM. For example, if the patient has received 3 hours
and 30 minutes of therapy per week, enter 330. Enter 30 if the patient received only 30 minutes
per week. Leading zeros should be left off.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
45.9,56 EDUCATIONAL THERAPY LEVEL 0;56 SET
'1' FOR 1> DOES NOT RECEIVE;
'2' FOR 2> MAINTENANCE PROGRAM;
'3' FOR 3> RESTORATIVE PROGRAM;
'4' FOR 4> NON-QUALIFYING PROGRAM;
LAST EDITED: APR 20, 1987
DESCRIPTION: Enter the appropriate code denoting the level of educational therapy that this patient receives.
The following are the choices available:
DOES NOT RECEIVE: patient does not receive educational therapy.
MAINTENANCE PROGRAM: patient requires and is currently receiving
educational therapy to help stabilize or slow
functional deteriorization.
RESTORATIVE PROGRAM: patient requires and is currently receiving
educational therapy for four or more consecutive
weeks with a restorative goal.
NON-QUALIFYING PROGRAM: patient requires and receives restorative
therapy, but does not meet the qualifiers
stated in the instructions.
45.9,57 ET DAYS PER WEEK 0;57 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>7)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 7
DESCRIPTION: Enter the number of days a week (0-7) that this patient receives educational therapy. Enter 0 if
this patient does not receive educational therapy (educational therapy level was listed as 1).
45.9,57.5 ET HOURS/MINUTES PER WEEK 0;67 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>5059)!(X<0)!(X?.E1"."1N.N) X I $D(X) D HM^DGRUGC1
LAST EDITED: NOV 30, 1988
HELP-PROMPT: Type a Number between 0 and 5059, 0 Decimal Digits
DESCRIPTION: Enter a number 0 through 5059 in the format HHMM. For example, if the patient has received 3 hours
and 30 minutes of therapy per week, enter 330. Enter 30 if the patient received only 30 minutes
per week. Leading zeros should be left off.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
45.9,58 CHRONIC VENTILATOR DEP. (CVD) 0;58 SET
'2' FOR YES;
'1' FOR NO;
LAST EDITED: OCT 30, 1988
DESCRIPTION: Definition: Chronic ventilator dependent - Patient is, or in the past six months has been,
dependent upon mechanical respiratory support to sustain life. The definition of 'mechanical'
includes either negative or positive pressure ventilators, rocking beds, or pneumobelts.
Specific Frequency: Patients who are currently being supported by a mechanical respirator must
have been supported for at least 6 hours a day for each of the past 30 days. This question should
also be answered 'yes' for any patient who is not now being supported by a mechanical respirator
because of successful weaning attempts but who had been supported for at least 6 hours a day in any
5 of the last 6 months.
Exclusions: Any patient not meeting either of the specific frequency requirements. The term
'mechanical' excludes phrenic nerve pacemakers used to generate breathing through diaphragm
pacemaking.
45.9,59 TIME SINCE BECOMING CVD 0;59 SET
'1' FOR 1> N/A - NOT CVD;
'2' FOR 2> LESS THAN 2 MONTHS;
'3' FOR 3> 2 TO 6 MONTHS;
'4' FOR 4> 6 TO 36 MONTHS;
'5' FOR 5> MORE THAN 36 MONTHS;
LAST EDITED: OCT 30, 1988
DESCRIPTION:
Enter a number 1 through 5 specifying the length of time since the patient has become CVD.
45.9,60 WEANING ATTEMPT FREQUENCY 0;60 SET
'1' FOR 1> N/A - NOT CVD;
'2' FOR 2> NO ATTEMPTS IN THE PAST SIX MONTHS;
'3' FOR 3> DAILY ATTEMPTS;
'4' FOR 4> WEEKLY ATTEMPTS;
'5' FOR 5> MONTHLY ATTEMPTS;
LAST EDITED: OCT 30, 1988
DESCRIPTION:
Enter a number 1 through 5 corresponding to the frequency of weaning attempts for this patient.
45.9,61 IS PNP>-20CM AND VC>15ML 0;61 SET
'1' FOR 1> N/A - NOT CVD;
'2' FOR 2> NO;
'3' FOR 3> YES;
'4' FOR 4> NOT MEASURED IN THE LAST 2 MONTHS;
LAST EDITED: OCT 30, 1988
DESCRIPTION: Is peak negative pressure more than -20 cm H2O and vital capacity greater than 15 ml/kg based on
the most recent measurement?
45.9,62 CAUSE FOR RESPIRATORY FAILURE 0;62 SET
'1' FOR 1> N/A - NOT CVD;
'2' FOR 2> COPD;
'3' FOR 3> AMYOTROPHIC LATERAL SCLEROSIS;
'4' FOR 4> STROKE/HEAD INJURY;
'5' FOR 5> SPINAL CORD INJURY;
'6' FOR 6> KYPHOSCOLIOSIS;
'7' FOR 7> 2 OR MORE OF THE ABOVE;
'8' FOR 8> NONE OF THE ABOVE;
'9' FOR 9> UNKNOWN;
LAST EDITED: OCT 30, 1988
DESCRIPTION: Enter primary cause (diagnosis) for the respiratory failure. Note: COPD is chronic obstructive
pulmonary disease.
45.9,70 LOCATION R;1 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
42 1 W n LOCATION
161.2 2 CNH n LOCATION
SCREEN ON FILE 42: S DIC("S")="I '$D(DGCNH),$P(^(0),U,3)]"""",""NHI""[$P(^(0),U,3)"
SCREEN EXPLANATION: Only choose wards whose service is intermediate medicine or nursing home care.
SCREEN ON FILE 161.2: S DIC("S")="I $$SCREEN^DGRUGU1()"
SCREEN EXPLANATION: Only choose an active CNH vendor.
LAST EDITED: APR 17, 1996
DESCRIPTION: Enter the location where this patient was when this patient assessment instrument was completed.
If a ward is selected, it must have a service or either Intermediate medicine or nursing home care.
If a CNH is selected, it must be an active CNH vendor.
45.9,71 RUG-II GROUP R;2 POINTER TO RUG-II FILE (#45.91)
LAST EDITED: MAR 14, 1987
DESCRIPTION: Enter the RUG-II group (1-17) that this patient was categorized into. This field is completed by
the RUG-II software based on the responses to all of the assessment questions. It should not be
altered in any way. Any changes should be made through the appropriate RUG-II menu options.
WRITE AUTHORITY: ^
CROSS-REFERENCE: 45.9^AR^MUMPS
1)= S R=$P(^DG(45.9,DA,0),"^",6),R1=$P(^(0),"^",2) I R,R1 S ^DG(45.9,"AR",X,R,R1,DA)=""
2)= S R=$P(^DG(45.9,DA,0),"^",6),R1=$P(^(0),"^",2) I R,R1 K ^DG(45.9,"AR",X,R,R1,DA)
45.9,72 ADL SUM R;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 04, 1986
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 0 AND 10
DESCRIPTION: The ADL sum is the sum of the numeric codes given for the eating, toileting, and transfer
questions. This sum is computed automatically by the RUG-II software and should not be altered.
Any changes should be made through the appropriate RUG-II menu option. The ADL sum, along with
responses to various questions in the patient assessment instrument, is used to compute the RUG-II
group under which this patient will be placed.
WRITE AUTHORITY: ^
45.9,73 DATE EDITED U;0 DATE Multiple #45.9001 (Add New Entry without Asking)
DESCRIPTION:
This multiple stores the user and dates on which this patient assessment instrument was edited.
WRITE AUTHORITY: ^
45.9001,.01 DATE EDITED 0;1 DATE
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 04, 1986
DESCRIPTION:
Enter the date this patient assessment instrument was edited.
45.9001,1 USER 0;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: OCT 06, 1990
DESCRIPTION:
Enter the name of the user that edited this patient assessment instrument.
45.9,74 CATEGORY R;4 SET
'1' FOR HEAVY REHABILITATION;
'2' FOR SPECIAL CARE;
'3' FOR CLINICAL COMPLEX;
'4' FOR BEHAVIORAL;
'5' FOR PHYSICAL;
LAST EDITED: MAR 09, 1987
DESCRIPTION: This field stores the category under which this patient assessment instrument has been grouped.
The category is determined automatically by the RUG-II module based on responses to various
questions on the assessment form. This field should NOT be altered in any way.
WRITE AUTHORITY: ^
45.9,80 RECORD STATUS C;1 SET
'1' FOR COMPLETED;
'2' FOR CLOSED;
'3' FOR RELEASE;
'4' FOR TRANSMITTED;
'0' FOR OPEN;
'5' FOR INCOMPLETE;
LAST EDITED: MAR 14, 1987
DESCRIPTION: Enter the code that best respresents the status of this record. Statuses are updated automatically
by the RUG-II module and should not be altered except through options on the RUG-II menu. Altering
this data could have negative impacts on the performance of the RUG software including rejections
of records transmitted to Austin.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 45.9^AS
1)= S ^DG(45.9,"AS",$E(X,1,30),DA)=""
2)= K ^DG(45.9,"AS",$E(X,1,30),DA)
CROSS-REFERENCE: ^^TRIGGER^45.9^84
1)= Q
1.4)= S DIH=$S($D(^DG(45.9,DIV(0),"C")):^("C"),1:""),DIV=X X "F %=0:0 Q:$L($P(DIH,U,4,99)) S DIH=D
IH_U" S %=$P(DIH,U,6,999),DIU=$P(DIH,U,5),^("C")=$P(DIH,U,1,4)_U_DIV_$S(%]"":U_%,1:""),DIH=45.9,DIG
=84 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X S X=$S('$D(^DG(45.9,DA,"C")):0,$P(^("C"),U)'=0:0,X=2:1,1
:0) I X S X=DIV S Y(1)=$S($D(^DG(45.9,D0,"C")):^("C"),1:"") S X=$P(Y(1),U,5),X=X S DIU=X K Y S X=DI
V S X=DUZ X ^DD(45.9,80,1,2,2.4)
2.4)= S DIH=$S($D(^DG(45.9,DIV(0),"C")):^("C"),1:""),DIV=X X "F %=0:0 Q:$L($P(DIH,U,4,99)) S DIH=D
IH_U" S %=$P(DIH,U,6,999),DIU=$P(DIH,U,5),^("C")=$P(DIH,U,1,4)_U_DIV_$S(%]"":U_%,1:""),DIH=45.9,DIG
=84 D ^DICR:$N(^DD(DIH,DIG,1,0))>0
CREATE CONDITION)= S X=$S('$D(RMOFLG):0,X=0:1,1:0)
CREATE VALUE)= NO EFFECT
DELETE CONDITION)= S X=$S('$D(^DG(45.9,DA,"C")):0,$P(^("C"),U)'=0:0,X=2:1,1:0)
DELETE VALUE)= S X=DUZ
FIELD)= REO
45.9,81 CLOSE OUT DATE C;2 DATE
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 05, 1986
DESCRIPTION: Enter the date this record was closed. This is the date on which the user chose to close the
record after all assessment questions were answered correctly. This field is updated automatically
by the RUG-II software and should not be altered.
45.9,82 CLOSED OUT BY C;3 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: OCT 06, 1990
DESCRIPTION: This field stores the name of the person who chose to complete this assessment once all questions
on the patient assessment instrument were answered appropriately. This field is updated
automatically by the RUG-II software and should not be altered.
45.9,83 TRANSMISSION DATE C;4 DATE
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 17, 1986
DESCRIPTION: If this patient assessment instrument has been transmitted, this field will indicate the date this
record was transmitted to Austin. The transmission software will automatically update this field.
CROSS-REFERENCE: 45.9^T
1)= S ^DG(45.9,"T",$E(X,1,30),DA)=""
2)= K ^DG(45.9,"T",$E(X,1,30),DA)
45.9,84 REOPENED BY C;5 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: OCT 06, 1990
DESCRIPTION: If this record required reopening after it was closed, this field will contain the name of the
individual that reopened the record. Records which have already been transmitted and need changing
may also be reopened.
NOTES: TRIGGERED by the RECORD STATUS field of the PAF File
FILES POINTED TO FIELDS
FEE BASIS VENDOR (#161.2) LOCATION (#70)
NEW PERSON (#200) CLOSED OUT BY (#82)
REOPENED BY (#84)
DATE EDITED:USER (#1)
PATIENT (#2) NAME (#.01)
RUG-II (#45.91) RUG-II GROUP (#71)
WARD LOCATION (#42) LOCATION (#70)
INPUT TEMPLATE(S):
DGRUG MAR 06, 1998@13:30 USER #0
DGRUG16 OCT 24, 1988 USER #0
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):