The Master Data Model for Veteran Care

Developer Documentation » VDM » Tiu_Document-8925

Tiu Document (8925)

This file stores textual information for the clinical record database. Though it is designed to initially accommodate Progress Notes, Consult Reports, and Discharge Summaries, it is intended to be sufficiently flexible to accommodate textual reports or provider narrative of any length or type, and to potentially accommodate such data transmitted from remote sites, which may be excluded from the corresponding local DHCP Package databases (e.g., Operative Reports, Radiology Reports, Pathology Reports, etc.) to avoid confusion with local workload.

Global: ^TIU(8925,

Domain: Documents

Properties

Label/Field Name Field # Description Datatype Attributes Range
Document Type
  document_type
.01 This field points to the Tiu Document Definition file, whose entry defines
the components of the document and various parameters for the document’s
behavior.
POINTER INDEXED
REQUIRED
Tiu_Document_Definition-8925_1
Patient
  patient
.02 This field contains a pointer to the patient file. POINTER INDEXED Patient_ihs-9000001
Visit
  visit
.03   POINTER INDEXED Visit-9000010
Parent Document Type
  parent_document_type
.04 This field points to the immediate parent class or document type to which the
current record belongs. For example, when the current document has the type
SOAP - GENERAL NOTE, this field will point to PROGRESS NOTE, as the parent
class to which SOAP Notes belong, whereas, if the current record is a
SUBJECTIVE component, then this field will point to SOAP - GENERAL NOTE as
the parent document type to which the component belongs.
POINTER   Tiu_Document_Definition-8925_1
Status
  status
.05 This field is intended to accommodate the status of a given report. POINTER   Tiu_Status-8925_6
Parent
  parent
.06 In the event that the current report is an addendum or replacement, or is
a component of a report, this field points to the original report.
POINTER INDEXED Tiu_Document-8925
Episode Begin Date/time
  episode_begin_date_time
.07 This is the date/time at which the treatment episode associated with this
document was initiated (e.g., Amission date/time for a discharge summary,
Visit date/time for a clinic note, Transfer date/time for an interim
summary). Time is optional.
DATE-TIME    
Episode End Date/time
  episode_end_date_time
.08 This is the ending date/time for the treatment episode associated with
this document (e.g., . Time is optional.
DATE-TIME    
Urgency
  urgency
.09 This is the urgency with which the report should be completed. ENUMERATION   priority: P
routine: R
Line Count
  line_count
.1 This is the number of characters in the document (blank lines excluded),
divided by the CHARACTERS PER LINE parameter defined by your site.
STRING    
Credit Stop Code On Completion
  credit_stop_code_on_completion
.11 This boolean field indicates whether the stop code associated with a new
visit should be credited when the note is completed.
BOOLEAN   false: 0
true: 1
Mark Disch Dt For Correction
  mark_disch_dt_for_correction
.12 This boolean field identfies those discharge summaries which were filed
prior to actual discharge of the patient for the nightly background
process to back-fill with corrected discharge dates.
BOOLEAN INDEXED true: 1
Visit Type
  visit_type
.13 This field is used to identify the type of visit information related to
the current document. The value is determined during processing and is
entered by the program. It is used in the generation of a cross-reference
to identify available documents for specified visits.
STRING    
Report Text
  report_text
2 This is a word processing field that contains the report text. STRING    
Edit Text Buffer
  edit_text_buffer
3 This field provides a temporary holding place for the body of a report to
prevent inadvertant record deletion or corruption in a manner independent
of the user’s preferred editor.
STRING    
Entry Date/time
  entry_date_time
1201 This is the date/time at which the document was originally entered into
the database.
DATE-TIME INDEXED  
Author/dictator
  author_dictator
1202
This is the person who composed or dictated the document.
POINTER INDEXED New_Person-200
Clinic
  clinic
1203 This is the stop code to which the document is to be credited (e.g., if the
document is a progress note documenting an encounter which took place in the
Admitting/Screening Clinic, then select the corresponding stop code, etc.).
POINTER   Clinic_Stop-40_7
Expected Signer
  expected_signer
1204 This is the person who is expected to enter the first-line signature for
the document. Ordinarily, this would be the author. One case in which
this would differ would be in the case of a Discharge Summary, when the
author’s signature is NOT required. Then, the attending physician would
be the expected signer.
POINTER   New_Person-200
Hospital Location
  hospital_location
1205 This is the location (WARD or CLINIC) associated with the document. POINTER   Hospital_Location-44
Service Credit Stop
  service_credit_stop
1206 This is the attending physician of record, who is ultimately responsible
for the care of the patient, and the accurate documentation of the care
episode.
POINTER   Clinic_Stop-40_7
Secondary Visit
  secondary_visit
1207   POINTER   Visit-9000010
Expected Cosigner
  expected_cosigner
1208   POINTER INDEXED New_Person-200
Attending Physician
  attending_physician
1209   POINTER   New_Person-200
Order Number
  order_number
1210 This is the Order which was acted on to produce the result reported in the
current document.
POINTER   Order-100
Visit Location
  visit_location
1211 This is the location at which the visit/admission occurred. As distinct
from the HOSPITAL LOCATION field, which represents the location at the time
the document was written, this is the location for the visit/admission with
which the note is associated.
POINTER   Hospital_Location-44
Division
  division
1212 This field contains the institution associated with the document. It is
extracted from the document’s hospital location if known; otherwise it is
extracted from the user’s log-on division.
POINTER   Institution-4
Reference Date
  reference_date
1301 This is the Date (and time) by which the clinician will reference the
document. For Progress Notes, this will likely be the date of the
provider’s encounter with the patient. For Discharge Summaries, it will
correspond to the Discharge Date of the Admission referenced in the
document. (If there is no Discharge Date when dictated, it will
correspond to the dictation date of the record instead.)
In all cases, this is the date by which the document will be referenced
and sorted.
DATE-TIME INDEXED  
Entered By
  entered_by
1302   POINTER INDEXED New_Person-200
Capture Method
  capture_method
1303   ENUMERATION   remote procedure: R
copy: O
converted: C
direct: D
upload: U
Release Date/time
  release_date_time
1304   DATE-TIME INDEXED  
Verification Date/time
  verification_date_time
1305   DATE-TIME    
Verified By
  verified_by
1306   POINTER   New_Person-200
Dictation Date
  dictation_date
1307 This is the date (and time) on which the document was dictated by its
author. In the event that a document originates by dictation, we recommend
that the REFERENCE DATE for the document be defaulted to dictation date, as
the author will be able to identify the document by the date on which s/he
dictated it.
DATE-TIME    
Suspense Date/time
  suspense_date_time
1308 This is the date (and time) on which the document will be removed from
public view. It is currently used only for Patient Postings, although it
may be generalized for use with other document types, if appropriate.
DATE-TIME    
Patient Movement Record
  patient_movement_record
1401   POINTER   Patient_Movement-405
Treating Specialty
  treating_specialty
1402   POINTER INDEXED Facility_Treating_Specialty-45_7
Irt Record
  irt_record
1403   POINTER   Incomplete_Records-393
Service
  service
1404   POINTER INDEXED Service_section-49
Requesting Package Reference
  requesting_package_reference
1405 This field allows a linkage to be maintained between the TIU Document and
the DHCP Package for which it was generated.
POINTER INDEXED Request_consultation-123
Surgery-130
Retracted Original
  retracted_original
1406 This self-refering pointer identifies the original document which was
retracted in error to produce this record.
POINTER   Tiu_Document-8925
Signature Date/time
  signature_date_time
1501   DATE-TIME    
Signed By
  signed_by
1502   POINTER   New_Person-200
Signature Block Name
  signature_block_name
1503   STRING    
Signature Block Title
  signature_block_title
1504 This is the encrypted signature block title of the person who signed the
document.
STRING    
Signature Mode
  signature_mode
1505 This is the mode by which the signature was obtained (i.e., either
electronic or chart).
ENUMERATION   electronic: E
chart: C
Cosignature Needed
  cosignature_needed
1506 This boolean flag indicates to the system whether or not a cosignature is
needed.
BOOLEAN   false: 0
true: 1
Cosignature Date/time
  cosignature_date_time
1507 This is the date/time at which cosignature was obtained. DATE-TIME    
Cosigned By
  cosigned_by
1508   POINTER   New_Person-200
Cosignature Block Name
  cosignature_block_name
1509   STRING    
Cosignature Block Title
  cosignature_block_title
1510   STRING    
Cosignature Mode
  cosignature_mode
1511   ENUMERATION   electronic: E
chart: C
Marked Signed On Chart By
  marked_signed_on_chart_by
1512 This is the identity of the person who marked a given document ‘signed on
chart,’ indicating that a ‘wet’ signature of the chart copy had been obtained.
POINTER   New_Person-200
Marked Cosigned On Chart By
  marked_cosigned_on_chart_by
1513 This is the user who marked a given document as ‘cosigned on chart.’ POINTER   New_Person-200
Amendment Date/time
  amendment_date_time
1601   DATE-TIME    
Amended By
  amended_by
1602   POINTER   New_Person-200
Amendment Signed
  amendment_signed
1603   DATE-TIME    
Amendment Sign Block Name
  amendment_sign_block_name
1604 This is the signature block name of the person who amended the document. STRING    
Amendment Sign Block Title
  amendment_sign_block_title
1605   STRING    
Administrative Closure Date
  administrative_closure_date
1606   DATE-TIME    
Admin Closure Sig Block Name
  admin_closure_sig_block_name
1607   STRING    
Admin Closure Sig Block Title
  admin_closure_sig_block_title
1608   STRING    
Archive/purge Date/time
  archive_purge_date_time
1609   DATE-TIME    
Deleted By
  deleted_by
1610 This is the person who deleted the document per the Privacy Act. POINTER   New_Person-200
Deletion Date
  deletion_date
1611 This is the date/(time optional) at which the document was deleted per the
Privacy Act.
DATE-TIME    
Reason For Deletion
  reason_for_deletion
1612 This is the reason for which the document was deleted, either: Privacy
Act, as invoked by the patient; or Administrative Action, where the note
needed to be removed, following signature, for administrative reasons.
ENUMERATION   administrative: A
privacy act: P
Administrative Closure Mode
  administrative_closure_mode
1613 This indicates whether the document was closed manually by an
administrative person (in order to satisfy authentication
requirements), or automatically by scanning a paper document
bearing the signature of the patient (e.g., Consents, Advanced
Directives, etc.) and not requiring the signature of an author.
ENUMERATION   manual: M
scanned document: S
Subject (optional Description)
  subject_optional_description
1701 This freetext field is used to help you find documents by subject (i.e.,
consider the subject a “key word” of sorts.
STRING    
Vbc Line Count
  vbc_line_count
1801 A VBC Line is defined as the total number of characters you can see with
the naked eye, divided by 65. It includes any character contained within a
header or footer. Spaces, carriage returns, and hidden format
instructions, such as bold, underline, text boxes, printer configurations,
spell check, etc., are not counted in the total character count. A VBC
Line is calculated by counting all visual characters and simply dividing
the total number of characters by 65 to arrive at the number of defined
lines.
NUMERIC    
Id Parent
  id_parent
2101 Applies to ID (interdisciplinary) notes only. The ID PARENT is the note
this note is attached to, making this note an entry in an ID note.

A note with an ID PARENT is referred to as an ID child note. ID parent
notes and ID child notes are both file entries in file 8925.

The entries of an interdisciplinary note consist of the first entry, which
is also the ID PARENT of the ID note, followed by the ID children.
POINTER INDEXED Tiu_Document-8925
Visit Id
  visit_id
15001 Unique Visit Identifier for use by CIRN. The value of this field should
ONLY be modified by virtue of a change to the Visit (.03) field.
STRING INDEXED  
Procedure Summary Code
  procedure_summary_code
70201 This field contains the summary code for this procedure once it is
complete. ‘Machine Resulted’ is the initial, default code.
ENUMERATION   Machine Resulted: 5
Abnormal: 2
Incomplete: 4
Borderline: 3
Normal: 1
Date/time Performed
  date_time_performed
70202 This field contains the Date/Time when the procedure was performed. DATE-TIME    

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