The Master Data Model for Veteran Care

Developer Documentation » VDM » Problem-9000011

Problem (9000011)

This file contains patient specific problems entered by the various providers of service. The PATIENT NAME field (.02) is a backward pointer to the IHS PATIENT file. This file contains one record for each problem for each patient, therefore, the KEY field (.01) is duplicated. As of March 17, 1986 the FACILITY must be entered prior to the NUMBER. If the NUMBER is entered without previously entering the FACILITY the “AA” index is created with no FACILITY pointer.

Global: ^AUPNPROB(

Domain: Problems

Properties

Label/Field Name Field # Description Datatype Attributes Range
Diagnosis
  diagnosis
.01 This is the ICD coded diagnosis of the narrative entered describing
this problem.
POINTER INDEXED
REQUIRED
Icd_Diagnosis-80
Patient Name
  patient_name
.02 This is the patient for whom this problem has been observed and recorded. POINTER INDEXED
REQUIRED
Patient_ihs-9000001
Date Last Modified
  date_last_modified
.03 This is the last date/time this problem was changed. DATE-TIME REQUIRED  
Class
  class
.04 This flag is used by the IHS Problem List to indicate if this problem
is documented for historical purposes.
ENUMERATION   PERSONAL HISTORY: P
FAMILY HISTORY: F
Provider Narrative
  provider_narrative
.05 This contains the actual text used by the provider to describe this
problem.
POINTER REQUIRED Provider_Narrative-9999999_27
Facility
  facility
.06 This is the facility at which this problem was originally observed and
documented.
POINTER REQUIRED Location-9999999_06
Nmbr
  nmbr
.07 This is a number which, together with the Patient (#.02) and Facility (#.06)
fields, serves as a unique identifier for this problem. Up to 2 decimal
places may be used to indicate that a problem is a result of, or related
to, another problem.
NUMERIC REQUIRED  
Date Entered
  date_entered
.08 This is the date this problem was entered into this file. DATE-TIME REQUIRED  
Status
  status
.12 This is the current activity status of this problem, whether active or
inactive; if more detail is needed, a notation may be filed with this
problem.
ENUMERATION REQUIRED ACTIVE: A
INACTIVE: I
Date Of Onset
  date_of_onset
.13 This is the approximate date this problem appeared, as precisely as known. DATE-TIME    
Problem
  problem
1.01 This field contains the standardized text stored in the Clinical Lexicon
for this problem.
POINTER INDEXED Expressions-757_01
Condition
  condition
1.02 This reflects the current condition of this entry, whether transcribed
by a clerk from the paper chart, entered or verified by a provider,
or marked as removed from the patient’s list.
ENUMERATION   HIDDEN: H
PERMANENT: P
TRANSCRIBED: T
Entered By
  entered_by
1.03 This is the user who actually entered this problem into this file. POINTER   New_Person-200
Recording Provider
  recording_provider
1.04 This is the provider who first recorded this problem, either on the
paper chart or online.
POINTER   New_Person-200
Responsible Provider
  responsible_provider
1.05 This is the provider currently responsible for treating this problem. POINTER   New_Person-200
Service
  service
1.06 This is the service primarily involved in the treatment of this problem;
the DHCP Problem List defaults this field to the service defined in
File #200 for the Recording Provider of this problem, upon entry of the
problem. It may later be used to categorize problems for screening and
sorting.
POINTER   Service_section-49
Date Resolved
  date_resolved
1.07 This is the date this problem was resolved or inactivated, as precisely
as known.
DATE-TIME    
Clinic
  clinic
1.08 This is the clinic in which this patient is being seen for this problem.
The problem list may be screened based on this value, to change one’s
view of the list.
POINTER   Hospital_Location-44
Date Recorded
  date_recorded
1.09 This is the date this problem was originally recorded, either online or
in the paper chart; it may be the same as, or earlier than, the Date
Entered.
DATE-TIME    
Service Connected
  service_connected
1.1 If the patient has service connection on file in the DHCP Patient file #2,
this problem specifically may be flagged as being service connected.
BOOLEAN   false: 0
true: 1
Agent Orange Exposure
  agent_orange_exposure
1.11 If this problem is related to a patient’s exposure to Agent Orange,
it may be flagged here.
BOOLEAN   false: 0
true: 1
Ionizing Radiation Exposure
  ionizing_radiation_exposure
1.12 If this problem is related to a patient’s exposure to ionizing radiation,
it may be flagged here.
BOOLEAN   false: 0
true: 1
Persian Gulf Exposure
  persian_gulf_exposure
1.13 If this problem is related to a patient’s service in the Persian Gulf,
it may be flagged here.
BOOLEAN   false: 0
true: 1
Priority
  priority
1.14 This is a flag to indicate how critical this problem is for this patient;
problems marked as Acute will be flagged on the Problem List display.
ENUMERATION   ACUTE: A
CHRONIC: C
Head And/or Neck Cancer
  head_and_or_neck_cancer
1.15 If this problem is related to the treatment of head and/or neck cancer
associated with nose or throat radium treatments, it may be flagged here.
BOOLEAN   false: 0
true: 1
Military Sexual Trauma
  military_sexual_trauma
1.16 If this problem is related to the treatment of military sexual trauma, it may
be flagged here.
BOOLEAN   false: 0
true: 1
Combat Veteran
  combat_veteran
1.17   BOOLEAN   false: 0
true: 1
Shipboard Hazard & Defense
  shipboard_hazard__defense
1.18   BOOLEAN   false: 0
true: 1
Note Facility
  note_facility
1101 This is the location at which the notes in this multiple originated. OBJECT   Note_Facility-9000011_11
Snomed Ct Concept Code
  snomed_ct_concept_code
80001 A clinical idea to which a unique ConceptID has been assigned in SNOMED
CT. Each Concept is represented by a row in the Concepts Table.
STRING INDEXED  
Snomed Ct Designation Code
  snomed_ct_designation_code
80002 A single SNOMED Concept may have multiple Designations, where a
Designation may be considered an alternate way of expressing the concept.
Synonyms, lexical variants, abbreviations are all different types of
designations. In many cases, a problem (as reported by the patient) and a
finding indicating a problem will share the same concept and concept code
(e.g., abdominal pain), but will have different designation codes (i.e.,
the generic “abdominal pain and “abdominal pain (finding) share the
concept code 21522001, but they have the designation codes 36112013 and
750827015 respectively.
STRING    
Vhat Concept VUID (future)
  vhat_concept_vuid_future
80003 VHA Unique ID (VUID) for the VHAT Concept. A unique meaningless integer
assigned to a corresponding concept VHA wide.

This field is being implemented to allow a more rapidly extensible
vocabulary for VA, while international normative standard coding systems
continue to evolve more slowly. The precise definition of the concept
Polytrauma may prove to be a useful example. Although the term has
become common among US Military and VA physicians to describe a seriously
injured (i.e., Injury Severity Score (ISS) >= 16) soldier with multiple
traumatic injuries, it is not yet available as a coded concept in either
SNOMED CT, ICD-9-CM, or ICD-10-CM. Allowing the definition and deployment
of VHAT Concept/Designation VUID pairs to identify such problems in
advance of their acceptance by the international medical community will
help to provide coded, computable documentation in a much more timely
manner than waiting for inclusion in SNOMED CT or ICD.

When the infrastructure in VA’s Enterprise Terminology Server (ETS) & New
Term Rapid Turn-around (NTRT) service are ready to deploy VHAT Concepts,
this field will allow us to store patient problems encoded with them.
STRING    
Vhat Designation VUID (future)
  vhat_designation_vuid_future
80004 VHA Unique ID (VUID) for the VHAT Designation. A unique meaningless
integer assigned to a corresponding designation VHA wide.

VHAT Concept/Designation Code pairs function in a manner identical to
that of SNOMED CT Concept/Designation Codes (i.e., they support the
unique identification of clinical concepts, along with the many
alternative ways in which a given concept may be expressed).
STRING    
Snomed Ct-to-icd Map Status
  snomed_cttoicd_map_status
80005 This Set of Codes type field is set to PENDING when an unmapped Clinical
Finding is selected as a patient’s problem. It is updated programmatically
to COMPLETE when NTRT deploys a new SNOMED CT to ICD mapping for
the problem in question.

NOTE: THIS FIELD SHOULD NEVER BE UPDATED BY AN END USER.
ENUMERATION   COMPLETED: 2
N/A: 0
PENDING: 1
Unique New Term Requested
  unique_new_term_requested
80101 Indicates whether the user requested a new term during the process of
entering a freetext problem. It should only be populated automatically by
program code.

NOTE: THIS FIELD SHOULD NEVER BE UPDATED BY AN END USER.
ENUMERATION   True: 1
False: 0
Unique Term Request Comment
  unique_term_request_comment
80102 Please provide clarification of the new term request. For example, if the
requested term is an acronym or abbreviation, the comment field
accommodates the fully specified name, etc.
STRING    
Date Of Interest
  date_of_interest
80201 This is the date when the DIAGNOSIS (#.01) and CODING SYSTEM (#80202)
fields were filed or modified. This allows proper resolution of the code,
irrespective of code set versions, etc.
DATE-TIME    
Coding System
  coding_system
80202 This identifies the Coding System to which the Code belongs. It
corresponds to the Coding System Abbreviation in the ICD Coding Systems
File, to optimize internal/external API calls for resolving codes,
independent of their code set version, and to facilitate transition from
ICD-9-CM to ICD-10-CM.

Examples include:

CODING SYS
ABBREV NOMENCLATURE ICD FILE
———————————————
10D ICD-10-CM ICD Diagnosis
ICD ICD-9-CM ICD Diagnosis
STRING    
Mapping Targets
  mapping_targets
80300 This multiple includes mapped expressions: complications, comorbidities,
and compound diagnoses. e.g., the single SNOMED CT concept Diabetic
neuropathy (230572002) is mapped to two ICD-9-CM diagnoses: DIABETES WITH
NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS
UNCONTROLLED (250.60) and POLYNEUROPATHY IN DIABETES (357.2).
OBJECT   Mapping_Targets-9000011_803

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Sub-Files

Note Facility (9000011.11)

ID
Note_Facility-9000011_11

Properties

Label/Field Name Field # Description Datatype Attributes Range
Note Facility
  note_facility
.01 This is the location at which the notes in this multiple originated. POINTER INDEXED
REQUIRED
Location-9999999_06
Note
  note
1101 Each entry in this multiple is a notation appended to a problem for
further clarification or information. Data includes a note number
and status, the date the note was added, the provider who added it,
and the actual text of the note.
OBJECT   Note-9000011_1111

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Note (9000011.1111)

ID
Note-9000011_1111

Properties

Label/Field Name Field # Description Datatype Attributes Range
Note Nmbr
  note_nmbr
.01 This is the unique note identifier. NUMERIC INDEXED
REQUIRED
 
Note Narrative
  note_narrative
.03 Additional comments may be entered here to further describe this problem. STRING REQUIRED  
Status
  status
.04 This flag indicates if this note is currently active. ENUMERATION REQUIRED ACTIVE: A
Date Note Added
  date_note_added
.05 This is the date this note was entered into this file. DATE-TIME    
Author
  author
.06 This is the provider who authored the text of this note. POINTER   New_Person-200

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Mapping Targets (9000011.803)

ID
Mapping_Targets-9000011_803

Properties

Label/Field Name Field # Description Datatype Attributes Range
Code
  code
.01 This is the code in the target coding system to which the problem is
mapped.
STRING INDEXED
REQUIRED
 
Coding System
  coding_system
.02 This identifies the Coding System to which the Code belongs. It
corresponds to the Source Abbreviation in the Coding Systems File, to
optimize calls to the Lexicon and ICD APIs for resolving codes,
independent of their code set version, and to facilitate transition from
ICD-9-CM to ICD-10-CM. Examples include:

SOURCE
ABBREV NOMENCLATURE SOURCE TITLE
————————————————————————–
10D ICD-10-CM International Classification of Diseases, Diagnosis
ICD ICD-9-CM International Classification of Diseases, Diagnosis
STRING    
Code Date
  code_date
.03 This is the date when the code and coding system were filed. This allows
proper resolution of the code, irrespective of code set versions, etc.
DATE-TIME    

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Document generated on August 31st 2017, 2:55:41 pm