STANDARD DATA DICTIONARY #90 -- MEDICAL RECORD FILE 3/24/25 PAGE 1
STORED IN ^MR( *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 5.01)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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PHYSICAL EXAMINATION, DSM-III DIAGNOSES AND OTHER FILES FOR THE MEDICAL RECORD
Fields annotated with an "*" are scheduled for deletion from file.
DD ACCESS: @
RD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
CROSS
REFERENCED BY: NAME(B)
90,.001 NUMBER NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: APR 06, 1984
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 1 AND 99999
DESCRIPTION:
This is the internal file number of the diagnosis.
90,.01 NAME 0;1 POINTER TO PATIENT FILE (#2) (Required)
INPUT TRANSFORM: S DINUM=X Q
LAST EDITED: AUG 30, 1984
DESCRIPTION:
This is the patient's name.
WRITE AUTHORITY: ^
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 90^B
1)= S ^MR("B",$E(X,1,30),DA)=""
2)= K ^MR("B",$E(X,1,30),DA)
90,100 PHY PE;0 DATE Multiple #90.01
DESCRIPTION:
This field contains the results of the physical examination.
90.01,.01 PHY 0;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y,DINUM=9999999-Y K:Y<1 X
HELP-PROMPT: ENTER TODAYS DATE IF A NEW EXAM, ENTER AN EXISTING DATE TO EDIT OR LIST.
DESCRIPTION:
Date of Physical Exam.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 90.01^B
1)= S ^MR(DA(1),"PE","B",X,DA)=""
2)= K ^MR(DA(1),"PE","B",X,DA)
90.01,.02 HEIGHT IN INCHES 0;2 NUMBER
INPUT TRANSFORM: K:X>120!(+X'=X)!(X<30) X
LAST EDITED: FEB 23, 1987
HELP-PROMPT: TYPE A NUMBER BETWEEN 30 AND 120
DESCRIPTION:
Patent's height in inches.
90.01,.03 WEIGHT IN POUNDS 0;3 NUMBER
INPUT TRANSFORM: K:X>400!(+X'=X)!(X<40) X
LAST EDITED: FEB 23, 1987
HELP-PROMPT: TYPE A NUMBER BETWEEN 40 AND 400
DESCRIPTION:
Patient's weight in pounds.
90.01,.04 TEMP. 0;4 NUMBER (Required)
INPUT TRANSFORM: K:X>120!(+X'=X)!(X<60) X
LAST EDITED: FEB 20, 1987
HELP-PROMPT: TYPE A NUMBER BETWEEN 60 AND 120
DESCRIPTION:
Patient's temperature (fahrenheit).
90.01,.05 PULSE 0;5 FREE TEXT (Required)
INPUT TRANSFORM: K:+X>190!(+X<40)!($L(X)>10) X
HELP-PROMPT: TYPE A NUMBER BETWEEN 40 AND 190
DESCRIPTION:
Patient's observed pulse.
90.01,.06 B.P. 0;6 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>7!($L(X)<5)!'(X?2N.N1"/"2N.N) X
HELP-PROMPT: MAXIMUM LENGTH: 7, MINIMUM LENGTH: 5
DESCRIPTION:
Patient's Blood Pressure.
90.01,.07 RESPS. 0;7 NUMBER (Required)
INPUT TRANSFORM: K:(X>60)!(X\1'=X)!(X<5) X
HELP-PROMPT: ENTER RESP. BETWEEN 5 AND 60
DESCRIPTION:
Patient's observed respirations per minute.
90.01,.9 GENERAL APPEARANCE .8;1 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Patient's general appearance.
90.01,2 HEAD .9;1 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
HELP-PROMPT: Enter 'O' for 'Omitted'; 'A' for 'Abnormal'
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,2.9 HEAD AB 1;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of patient's head.
90.01,3 EYES .9;2 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 13, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,3.1 EOM 2;1 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,3.2 PUPIL SIZE 2;2 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,3.3 FUNDI 2;3 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,3.4 RLA 2;4 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,3.9 EYES AB 2;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's eyes.
90.01,4 EARS .9;3 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 13, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,4.1 HEARING 3;1 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within mormal limits, 2=omitted, 3=abnormal.
90.01,4.2 EXTERNAL MEATUS 3;2 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,4.3 DRUMS 3;3 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,4.9 EARS AB 3;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's ears.
90.01,5 NOSE .9;4 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,5.9 NOSE AB 4;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's nose.
90.01,6 MOUTH .9;5 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,6.9 MOUTH AB 5;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<0) X
LAST EDITED: NOV 04, 1983
HELP-PROMPT: ANSWER MUST BE 0-200 CHARACTERS IN LENGTH
DESCRIPTION:
Abnormalities observed of the patient's mouth.
90.01,7 NECK .9;6 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,7.9 NECK AB 6;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's neck.
90.01,8 CHEST AND BREASTS .9;7 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,8.9 CHEST AB 7;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's chest and/or breast(s).
90.01,9 LUNGS .9;8 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,9.9 LUNGS AB 8;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's lung(s).
90.01,10 HEART .9;9 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,10.9 HEART AB 9;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's heart.
90.01,11 ABDOMEN .9;10 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,11.9 ABDOMEN AB 10;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's abdomen.
90.01,12 GENITALIA .9;11 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 13, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,12.1 TESTES 11;1 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,12.2 EPIDIDYMIDES 11;2 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,12.3 PENIS 11;3 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,12.4 PROSTATE 11;4 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,12.9 GENITALIA AB 11;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's genitalia.
90.01,13 PELVIC .9;12 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,13.9 PELVIC AB 12;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's pelvis/pelvic area.
90.01,14 RECTUM .9;13 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,14.9 RECTUM AB 13;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's rectum.
90.01,15 BACK .9;14 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abmormal.
90.01,15.9 BACK AB 14;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's back.
90.01,16 EXTREMITIES .9;15 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,16.9 EXTREMITIES AB 15;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200 X
LAST EDITED: MAY 23, 1986
HELP-PROMPT: MAXIMUM LENGTH: 200, MINIMUM LENGTH: 1
DESCRIPTION:
Abnormalities observed of the patient's extremities.
90.01,17 NEUROLOGICAL .9;16 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,17.9 NEUROLOGICAL AB 16;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<1) X
HELP-PROMPT: ANSWER MUST BE 1-200 CHARACTERS IN LENGTH
DESCRIPTION:
Patient neurological abnormalities observed.
90.01,18 SKIN .9;17 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,18.9 SKIN AB 17;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<1) X
HELP-PROMPT: ANSWER MUST BE 1-200 CHARACTERS IN LENGTH
DESCRIPTION:
Abnormalities observed of the patient's skin.
90.01,19 LYMPH .9;18 SET
'1' FOR WITHIN NORMAL LIMITS;
'2' FOR OMITTED;
'3' FOR ABNORMAL;
LAST EDITED: SEP 12, 1984
DESCRIPTION:
Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal.
90.01,19.9 LYMPH AB 18;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>200!($L(X)<1) X
HELP-PROMPT: ANSWER MUST BE 1-200 CHARACTERS IN LENGTH
DESCRIPTION:
Abnormalities observed of the patient's lymph system.
90.01,29 EXAMINER 0;10 POINTER TO NEW PERSON FILE (#200) (Required)
LAST EDITED: APR 30, 1985
HELP-PROMPT: ENTER YOUR CODE. CALL COMPUTER SECTION IF YOU DON'T HAVE ONE
DESCRIPTION: Enter the name of the person examining the patient. It is stored internally as a pointer value
to the NEW PERSON file (#200) for the examiner.
90.01,30 COMMENTS 19;0 WORD-PROCESSING #90.02
DESCRIPTION:
Comments relating to the physical exam.
DESCRIPTION:
Comments entered by the examiner relating to the physical exam of the patient.
90.01,31 INITIAL IMPRESSION 20;0 WORD-PROCESSING #90.03
DESCRIPTION:
Examiner's initial impression.
DESCRIPTION:
Examiner's initial impression of the patient's condition.
90.01,32 HEIGHT IN CENTIMETERS 0;8 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<75)!(X?.E1"."1N.N) X
LAST EDITED: FEB 20, 1987
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 75 AND 300
DESCRIPTION:
Patient's height in centimeters.
90.01,33 WEIGHT IN KILOGRAMS 0;9 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>180)!(X<18)!(X?.E1"."1N.N) X
LAST EDITED: FEB 23, 1987
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 18 AND 180
DESCRIPTION:
Patient's weight in kilograms.
90.01,34 TEMPERATURE CENTIGRADE 0;11 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>50)!(X<15)!(X?.E1"."2N.N) X
LAST EDITED: FEB 23, 1987
HELP-PROMPT: TYPE A NUMBER BETWEEN 15 AND 50
DESCRIPTION:
Patient's temperature in centigrades.
90,101 *PRINCIPAL DSM-III DX DATE DX1;1 DATE
PRINCIPAL DSM-III DX DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAY 10, 1984
DESCRIPTION:
This is the date the principal DSM-II diagnosis was entered.
90,102 *PRINCIPAL DSM-III DIAGNOSIS DX1;2 POINTER TO DSM3 FILE (#627) (Required)
PRINCIPAL DSM-III DIAGNOSIS
LAST EDITED: OCT 11, 1984
DESCRIPTION:
This is the DSM-III code for the diagnosis which is the primary reason for treatment.
90,102.4 *X DSM-III DIAGNOSIS DATE DX1;3 DATE (Required)
X DSM-III DIAGNOSIS DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:2990000X) X
LAST EDITED: FEB 24, 1984
HELP-PROMPT: TYPE A DATE BETWEEN 1970 AND 1999
DESCRIPTION:
This is the date the DSM-III X diagnosis was entered.
90,102.6 *X DSM-III DIAGNOSIS DX1;4 POINTER TO DSM3 FILE (#627) (Required)
LAST EDITED: OCT 12, 1984
DESCRIPTION:
This is the DSM-III diagnosis accounting for the largest percentage of the length of stay.
90,103 *DSM-III DIAGNOSIS DX;0 POINTER Multiple #90.04 (Add New Entry without Asking)
DESCRIPTION:
This is the code of the DSM-III diagnosis.
90.04,.001 *NUMBER NUMBER
NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: MAR 01, 1984
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 1 AND 999999999
90.04,.01 *DSM-III DIAGNOSIS 0;1 POINTER TO DSM3 FILE (#627) (Required)
LAST EDITED: OCT 05, 1984
HELP-PROMPT: ENTER DSM-III CODE NUMBER OR ONE MOST DESCRIPTIVE WORD.
CROSS-REFERENCE: 90.04^B
1)= S ^MR(DA(1),"DX","B",$E(X,1,30),DA)=""
2)= K ^MR(DA(1),"DX","B",$E(X,1,30),DA)
90.04,1 *DSM-III QUALIFIER DATE 1;0 DATE Multiple #90.05 (Add New Entry without Asking)
DESCRIPTION: DX entries are qualified with PROVISIONAL, BY HISTORY, VERIFIED, etc. DX qualifier date must be
entered first.
90.05,.01 *DSM-III QUALIFIER DATE 0;1 DATE (Required)
DSM-III QUALIFIER DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:DT65!($L(X)<2) X
LAST EDITED: JAN 19, 1989
HELP-PROMPT: ANSWER MUST BE 2-65 CHARACTERS IN LENGTH
90.05,6 *OLD COMMENT 0;6 FREE TEXT
OLD COMMENT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<2) X
LAST EDITED: FEB 29, 1984
HELP-PROMPT: ANSWER MUST BE 2-80 CHARACTERS IN LENGTH
90.04,2 *STATUS 0;2 SET
STATUS
'A' FOR ACTIVE;
'I' FOR INACTIVE;
'U' FOR UNKNOWN;
LAST EDITED: MAR 01, 1984
90.04,3 *STATUS DATE 0;3 DATE
STATUS DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:2990000X) X
LAST EDITED: FEB 15, 1984
HELP-PROMPT: TYPE A DATE BETWEEN 1980 AND 1999
90,104 *AXIS 4 DXM;1 SET
SEVERITY OF PSYCHOSOCIAL STRESSORS
'1' FOR NONE;
'2' FOR MINIMAL;
'3' FOR MILD;
'4' FOR MODERATE;
'5' FOR SEVERE;
'6' FOR EXTREME;
'7' FOR CATASTROPHIC;
'0' FOR UNSPECIFIED;
LAST EDITED: FEB 24, 1984
DESCRIPTION:
This is the rating code for severity of psychosicial stressor.
CROSS-REFERENCE: ^^TRIGGER^90^105
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^MR(D0,"DXM")):^("DXM"),1:"") S X=$P(Y(1),U,2) S DIU
=X K Y N %I,%H,% D NOW^%DTC S X=X X ^DD(90,104,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"DXM")):^("DXM"),1:""),DIV=X S %=$P(DIH,U,3,999),^("DXM")=$P(DIH,U,1,1
)_U_DIV_$S(%]"":U_%,1:""),DIH=90,DIG=105 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= Q
CREATE VALUE)= TODAY
DELETE VALUE)= NO EFFECT
FIELD)= AXIS 4 DATE
CROSS-REFERENCE: ^^TRIGGER^90^106
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^MR(D0,"DXM")):^("DXM"),1:"") S X=$P(Y(1),U,3) S DIU
=X K Y S X=DUZ X ^DD(90,104,1,2,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"DXM")):^("DXM"),1:""),DIV=X X "F %=0:0 Q:$L($P(DIH,U,2,99)) S DIH=DI
H_U" S %=$P(DIH,U,4,999),^("DXM")=$P(DIH,U,1,2)_U_DIV_$S(%]"":U_%,1:""),DIH=90,DIG=106 D ^DICR:$O(^
DD(DIH,DIG,1,0))>0
2)= Q
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= AXIS 4 BY
90,105 *AXIS 4 DATE DXM;2 DATE
AXIS 4 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:2990000X) X
LAST EDITED: FEB 24, 1984
HELP-PROMPT: TYPE A DATE BETWEEN 1970 AND 1999
DESCRIPTION:
This is the date a given psychosocial stressor code is entered.
NOTES: TRIGGERED by the *AXIS 4 field of the MEDICAL RECORD File
90,106 *AXIS 4 BY DXM;3 POINTER TO NEW PERSON FILE (#200)
AXIS 4 BY
LAST EDITED: APR 25, 1984
DESCRIPTION:
This is the name of the user entering a given psychosical stressor code.
WRITE AUTHORITY: ^
NOTES: TRIGGERED by the *AXIS 4 field of the MEDICAL RECORD File
90,107 *AXIS 5 DXM;4 SET
HIGHEST LEVEL OF ADAPTIVE FUNCTIONING PAST YEAR
'1' FOR SUPERIOR;
'2' FOR VERY GOOD;
'3' FOR GOOD;
'4' FOR FAIR;
'5' FOR POOR;
'6' FOR VERY POOR;
'7' FOR GROSSLY IMPAIRED;
'0' FOR UNSPECIFIED;
LAST EDITED: FEB 24, 1984
DESCRIPTION:
This is the rating code for highest level of adaptive functioning past year.
CROSS-REFERENCE: ^^TRIGGER^90^108
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^MR(D0,"DXM")):^("DXM"),1:"") S X=$P(Y(1),U,5) S DIU
=X K Y N %I,%H,% D NOW^%DTC S X=X X ^DD(90,107,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"DXM")):^("DXM"),1:""),DIV=X X "F %=0:0 Q:$L($P(DIH,U,4,99)) S DIH=DI
H_U" S %=$P(DIH,U,6,999),^("DXM")=$P(DIH,U,1,4)_U_DIV_$S(%]"":U_%,1:""),DIH=90,DIG=108 D ^DICR:$O(^
DD(DIH,DIG,1,0))>0
2)= Q
CREATE VALUE)= TODAY
DELETE VALUE)= NO EFFECT
FIELD)= AXIS 5 D
CROSS-REFERENCE: ^^TRIGGER^90^109
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^MR(D0,"DXM")):^("DXM"),1:"") S X=$P(Y(1),U,6) S DIU
=X K Y S X=DUZ X ^DD(90,107,1,2,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"DXM")):^("DXM"),1:""),DIV=X X "F %=0:0 Q:$L($P(DIH,U,5,99)) S DIH=DI
H_U" S %=$P(DIH,U,7,999),^("DXM")=$P(DIH,U,1,5)_U_DIV_$S(%]"":U_%,1:""),DIH=90,DIG=109 D ^DICR:$O(^
DD(DIH,DIG,1,0))>0
2)= Q
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= AXIS 5 B
90,108 *AXIS 5 DATE DXM;5 DATE
AXIS 5 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:2990000X) X
LAST EDITED: FEB 24, 1984
HELP-PROMPT: TYPE A DATE BETWEEN 1970 AND 1999
DESCRIPTION:
This is the date a given adaptive functioning code is entered.
NOTES: TRIGGERED by the *AXIS 5 field of the MEDICAL RECORD File
90,109 *AXIS 5 BY DXM;6 POINTER TO NEW PERSON FILE (#200)
AXIS 5 BY
LAST EDITED: APR 25, 1984
DESCRIPTION:
This is the name of the user entering a given adaptive functioning code.
WRITE AUTHORITY: ^
NOTES: TRIGGERED by the *AXIS 5 field of the MEDICAL RECORD File
90,110 *PAST PRINCIPAL DX PDX;0 POINTER Multiple #90.06 (Add New Entry without Asking)
DESCRIPTION:
This is the past DSM-III diagnosis that was the primary reason for treatment.
90.06,.01 *PAST PRINCIPAL DX 0;1 POINTER TO DSM3 FILE (#627) (Required)
PAST PRINCIPAL DX
LAST EDITED: OCT 11, 1984
WRITE AUTHORITY: ^
90.06,1 *DATE PAST PRINCIPAL DX 0;2 DATE (Required)
DATE PAST PRINCIPAL DX
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 10, 1984
WRITE AUTHORITY: ^
CROSS-REFERENCE: ^^TRIGGER^90.06^2
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 X ^DD(90.06,1,1,1,9.2) S X=$P($G(^VA(200,+$P(Y
(102),U,3),0)),U) S D1=Y(1) S DIU=X K Y S X=DIV S X=DUZ X ^DD(90.06,1,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"PDX",DIV(1),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,
2,99)) S DIH=DIH_U" S %=$P(DIH,U,4,999),DIU=$P(DIH,U,3),^(0)=$P(DIH,U,1,2)_U_DIV_$S(%]"":U_%,1:"")
,DIH=90.06,DIG=2 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= Q
9.2)= S Y(1)=$S($D(D1):D1,1:"") S X=2841100 K DIC S Y=-1,DIC="^MR(D0,""PDX"",",DIC(0)="NMF" D ^DIC:
D0>0 S D1=+Y,DIV(1)=+Y S Y(102)=$S($D(^MR(D0,"PDX",D1,0)):^(0),1:"")
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= 110:110:DIAGNOSIS BY
90.06,2 *DIAGNOSIS BY 0;3 POINTER TO NEW PERSON FILE (#200) (Required)
DIAGNOSIS BY
LAST EDITED: FEB 29, 1984
WRITE AUTHORITY:^
NOTES: TRIGGERED by the *DATE PAST PRINCIPAL DX field of the *PAST PRINCIPAL DX sub-field of the MEDICAL
RECORD File
90,111 *PAST X DIAGNOSIS XDX;0 POINTER Multiple #90.07 (Add New Entry without Asking)
DESCRIPTION:
This is the past DSM-III code which accounted for the largest percentage of the length of stay.
90.07,.01 *PAST X DIAGNOSIS 0;1 POINTER TO DSM3 FILE (#627) (Required)
PAST X DIAGNOSIS
LAST EDITED: OCT 25, 1984
WRITE AUTHORITY: ^
90.07,1 *PAST X DATE 0;2 DATE (Required)
PAST X DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 10, 1984
WRITE AUTHORITY: ^
CROSS-REFERENCE: ^^TRIGGER^90.07^2
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 X ^DD(90.07,1,1,1,9.2) S X=$P($G(^VA(200,+$P(Y
(102),U,3),0)),U) S D1=Y(1) S DIU=X K Y S X=DIV S X=DUZ X ^DD(90.07,1,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"XDX",DIV(1),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U,
2,99)) S DIH=DIH_U" S %=$P(DIH,U,4,999),DIU=$P(DIH,U,3),^(0)=$P(DIH,U,1,2)_U_DIV_$S(%]"":U_%,1:"")
,DIH=90.07,DIG=2 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= Q
9.2)= S Y(1)=$S($D(D1):D1,1:"") S X=2841101 K DIC S Y=-1,DIC="^MR(D0,""XDX"",",DIC(0)="NMF" D ^DIC:
D0>0 S D1=+Y,DIV(1)=+Y S Y(102)=$S($D(^MR(D0,"XDX",D1,0)):^(0),1:"")
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= 111:111:DIAGNOSIS BY
90.07,2 *DIAGNOSIS BY 0;3 POINTER TO NEW PERSON FILE (#200) (Required)
DIAGNOSIS BY
LAST EDITED: FEB 29, 1984
WRITE AUTHORITY:^
NOTES: TRIGGERED by the *PAST X DATE field of the *PAST X DIAGNOSIS sub-field of the MEDICAL RECORD File
90,112 *PRINCIPLE ICD9 DX DATE DX2;1 DATE
PRINCIPLE ICD9 DX DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 05, 1984
DESCRIPTION:
This is the date the principal ICD9 diagnosis was entered.
90,113 *PRINCIPAL ICD9 DIAGNOSIS DX2;2 POINTER TO ICD DIAGNOSIS FILE (#80) (Required)
PRINCIPAL ICD9 DIAGNOSIS
LAST EDITED: OCT 12, 1984
DESCRIPTION:
This is the ICD9 code for the diagnosis which is the primary reason for treatment.
90,113.4 *X ICD9 DIAGNOSIS DATE DX2;3 DATE
X ICD9 DIAGNOSIS DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 05, 1984
DESCRIPTION:
This is the date the ICD9 X diagnosis was entered.
90,113.6 *X ICD9 DIAGNOSIS DX2;4 POINTER TO ICD DIAGNOSIS FILE (#80)
X ICD9 DIAGNOSIS
LAST EDITED: OCT 12, 1984
DESCRIPTION:
This is the ICD9 diagnosis accounting for the largest percentage of the length of stay.
90,115 *ICD9 DIAGNOSIS PHDX;0 POINTER Multiple #90.1 (Add New Entry without Asking)
DESCRIPTION:
This is the code of the ICD9 diagnosis.
90.1,.001 *NUMBER NUMBER
NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: AUG 28, 1984
HELP-PROMPT: TYPE A WHOLE NUMBER BETWEEN 1 AND 999999999
90.1,.01 *ICD9 DIAGNOSIS 0;1 POINTER TO ICD DIAGNOSIS FILE (#80)
ICD9 DIAGNOSIS
LAST EDITED: AUG 29, 1984
CROSS-REFERENCE: 90.1^B
1)= S ^MR(DA(1),"PHDX","B",$E(X,1,30),DA)=""
2)= K ^MR(DA(1),"PHDX","B",$E(X,1,30),DA)
90.1,1 *ICD9 QUALIFIER DATE 1;0 DATE Multiple #90.11 (Add New Entry without Asking)
DESCRIPTION:
Sets date for entry type, e.g., provisional, verified, etc.
90.11,.01 *ICD9 QUALIFIER DATE 0;1 DATE
ICD9 QUALIFIER DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 29, 1984
DESCRIPTION: Diagnosis entries are qualified by PROVISIONAL, BY HISTORY, VERIFIED, etc. Diagnosis qualifier
date must be entered first.
CROSS-REFERENCE: 90.1^CH^MUMPS
1)= S ^MR(DA(2),"PHDX","CH",9999999-X,DA(1),DA)=""
2)= K ^MR(DA(2),"PHDX","CH",9999999-X,DA(1),DA)
90.11,1 *ICD9 QUALIFIER 0;2 SET (Required)
ICD9 QUALIFIER
'P' FOR PROVISIONAL;
'R' FOR RULE OUT;
'H' FOR BY HISTORY;
'V' FOR VERIFIED;
'N' FOR NOT FOUND;
INPUT TRANSFORM: I $D(V),(X="V"),'V K X W "MUST HAVE CLINICAL PRIVILEGE TO VERIFY" Q
LAST EDITED: FEB 11, 1985
HELP-PROMPT: Diagnosis entries are qualified by PROVISIONAL, VERIFIED, By HISTORY, etc.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
90.11,2 *USER 0;3 POINTER TO NEW PERSON FILE (#200) (Required)
USER
LAST EDITED: AUG 28, 1984
90.11,3 *COMMENT 0;4 FREE TEXT
COMMENT
INPUT TRANSFORM: K:$L(X)>70!($L(X)<3) X
LAST EDITED: AUG 28, 1984
HELP-PROMPT: ANSWER MUST BE 3-70 CHARACTERS IN LENGTH
90.1,2 *STATUS 0;2 SET
STATUS
'A' FOR ACTIVE;
'I' FOR INACTIVE;
'U' FOR UNKNOWN;
LAST EDITED: AUG 28, 1984
90.1,3 *STATUS DATE 0;3 DATE
STATUS DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 28, 1984
90,116 *PAST PRINCIPAL ICD9 DX PPDX;0 POINTER Multiple #90.16 (Add New Entry without Asking)
DESCRIPTION:
This is the past ICD9 diagnosis that was the primary reason for treatment.
90.16,.01 *PAST PRINCIPAL ICD9 DX 0;1 POINTER TO ICD DIAGNOSIS FILE (#80) (Required)
PAST PRINCIPAL ICD9 DX
LAST EDITED: OCT 25, 1984
WRITE AUTHORITY: ^
90.16,1 *DATE PAST PRINCIPAL ICD9 DX 0;2 DATE
DATE PAST PRINCIPAL ICD9 DX
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 10, 1984
WRITE AUTHORITY: ^
CROSS-REFERENCE: ^^TRIGGER^90.16^2
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 X ^DD(90.16,1,1,1,9.2) S X=$P($G(^VA(200,+$P(Y
(102),U,3),0)),U) S D1=Y(1) S DIU=X K Y S X=DIV S X=DUZ X ^DD(90.16,1,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"PPDX",DIV(1),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U
,2,99)) S DIH=DIH_U" S %=$P(DIH,U,4,999),DIU=$P(DIH,U,3),^(0)=$P(DIH,U,1,2)_U_DIV_$S(%]"":U_%,1:""
),DIH=90.16,DIG=2 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= Q
9.2)= S Y(1)=$S($D(D1):D1,1:"") S X=2841106 K DIC S Y=-1,DIC="^MR(D0,""PPDX"",",DIC(0)="NMF" D ^DIC
:D0>0 S D1=+Y,DIV(1)=+Y S Y(102)=$S($D(^MR(D0,"PPDX",D1,0)):^(0),1:"")
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= 116:116:ICD9 DIAGNOSIS BY
90.16,2 *ICD9 DIAGNOSIS BY 0;3 POINTER TO NEW PERSON FILE (#200)
ICD9 DIAGNOSIS BY
LAST EDITED: OCT 05, 1984
WRITE AUTHORITY:^
NOTES: TRIGGERED by the *DATE PAST PRINCIPAL ICD9 DX field of the *PAST PRINCIPAL ICD9 DX sub-field of the
MEDICAL RECORD File
90,117 *PAST ICD9 X DIAGNOSIS XPDX;0 POINTER Multiple #90.17 (Add New Entry without Asking)
DESCRIPTION:
This is the past ICD9 diagnosis code which accounted for the largest percentage of length of stay.
90.17,.01 *PAST ICD9 X DIAGNOSIS 0;1 POINTER TO ICD DIAGNOSIS FILE (#80)
PAST ICD9 X DIAGNOSIS
LAST EDITED: OCT 25, 1984
WRITE AUTHORITY: ^
90.17,1 *PAST ICD9 X DATE 0;2 DATE
PAST ICD9 X DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 10, 1984
WRITE AUTHORITY: ^
CROSS-REFERENCE: ^^TRIGGER^90.17^2
1)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 X ^DD(90.17,1,1,1,9.2) S X=$P($G(^VA(200,+$P(Y
(102),U,3),0)),U) S D1=Y(1) S DIU=X K Y S X=DIV S X=DUZ X ^DD(90.17,1,1,1,1.4)
1.4)= S DIH=$S($D(^MR(DIV(0),"XPDX",DIV(1),0)):^(0),1:""),DIV=X I $D(^(0)) X "F %=0:0 Q:$L($P(DIH,U
,2,99)) S DIH=DIH_U" S %=$P(DIH,U,4,999),DIU=$P(DIH,U,3),^(0)=$P(DIH,U,1,2)_U_DIV_$S(%]"":U_%,1:""
),DIH=90.17,DIG=2 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= Q
9.2)= S Y(1)=$S($D(D1):D1,1:"") S X=2841107 K DIC S Y=-1,DIC="^MR(D0,""XPDX"",",DIC(0)="NMF" D ^DIC
:D0>0 S D1=+Y,DIV(1)=+Y S Y(102)=$S($D(^MR(D0,"XPDX",D1,0)):^(0),1:"")
CREATE VALUE)= S X=DUZ
DELETE VALUE)= NO EFFECT
FIELD)= 117:117:ICD9 X DIAGNOSIS BY
90.17,2 *ICD9 X DIAGNOSIS BY 0;3 POINTER TO NEW PERSON FILE (#200)
ICD9 X DIAGNOSIS BY
LAST EDITED: OCT 05, 1984
WRITE AUTHORITY:^
NOTES: TRIGGERED by the *PAST ICD9 X DATE field of the *PAST ICD9 X DIAGNOSIS sub-field of the MEDICAL
RECORD File
FILES POINTED TO FIELDS
DSM3 (#627) *PRINCIPAL DSM-III DIAGNOSIS (#102)
*X DSM-III DIAGNOSIS (#102.6)
*DSM-III DIAGNOSIS:*DSM-III DIAGNOSIS (#.01)
*PAST PRINCIPAL DX:*PAST PRINCIPAL DX (#.01)
*PAST X DIAGNOSIS:*PAST X DIAGNOSIS (#.01)
ICD DIAGNOSIS (#80) *PRINCIPAL ICD9 DIAGNOSIS (#113)
*X ICD9 DIAGNOSIS (#113.6)
*ICD9 DIAGNOSIS:*ICD9 DIAGNOSIS (#.01)
*PAST PRINCIPAL ICD9 DX:*PAST PRINCIPAL ICD9 DX (#.01)
*PAST ICD9 X DIAGNOSIS:*PAST ICD9 X DIAGNOSIS (#.01)
NEW PERSON (#200) *AXIS 4 BY (#106)
*AXIS 5 BY (#109)
PHY:EXAMINER (#29)
*DSM-III QUALIFIER DATE:*ACCESS CODE (#2)
*PAST PRINCIPAL DX:*DIAGNOSIS BY (#2)
*PAST X DIAGNOSIS:*DIAGNOSIS BY (#2)
*ICD9 QUALIFIER DATE:*USER (#2)
*PAST PRINCIPAL ICD9 DX:*ICD9 DIAGNOSIS BY (#2)
*PAST ICD9 X DIAGNOSIS:*ICD9 X DIAGNOSIS BY (#2)
PATIENT (#2) NAME (#.01)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):