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.
|Label/Field Name||Field #||Description||Datatype||Attributes||Range|
||.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
||.02||This field contains a pointer to the patient file.||POINTER||INDEXED||Patient_ihs-9000001|
|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.
||.05||This field is intended to accommodate the status of a given report.||POINTER||Tiu_Status-8925_6|
||.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.
|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.
|Episode End Date/time
||.08||This is the ending date/time for the treatment episode associated with
this document (e.g., . Time is optional.
||.09||This is the urgency with which the report should be completed.||ENUMERATION||priority: P
||.1||This is the number of characters in the document (blank lines excluded),
divided by the CHARACTERS PER LINE parameter defined by your site.
|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.
|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.
||.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.
||2||This is a word processing field that contains the report text.||STRING|
|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.
||1201||This is the date/time at which the document was originally entered into
This is the person who composed or dictated the document.
||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.).
||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.
||1205||This is the location (WARD or CLINIC) associated with the document.||POINTER||Hospital_Location-44|
|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
||1210||This is the Order which was acted on to produce the result reported in the
||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.
||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.
||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
||1303||ENUMERATION||remote procedure: R
||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
||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.
|Patient Movement Record
|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.
||1406||This self-refering pointer identifies the original document which was
retracted in error to produce this record.
|Signature Block Name
|Signature Block Title
||1504||This is the encrypted signature block title of the person who signed the
||1505||This is the mode by which the signature was obtained (i.e., either
electronic or chart).
||1506||This boolean flag indicates to the system whether or not a cosignature is
||1507||This is the date/time at which cosignature was obtained.||DATE-TIME|
|Cosignature Block Name
|Cosignature Block Title
|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.
|Marked Cosigned On Chart By
||1513||This is the user who marked a given document as ‘cosigned on chart.’||POINTER||New_Person-200|
|Amendment Sign Block Name
||1604||This is the signature block name of the person who amended the document.||STRING|
|Amendment Sign Block Title
|Administrative Closure Date
|Admin Closure Sig Block Name
|Admin Closure Sig Block Title
||1610||This is the person who deleted the document per the Privacy Act.||POINTER||New_Person-200|
||1611||This is the date/(time optional) at which the document was deleted per the
|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.
privacy act: P
|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.
scanned document: S
|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.
|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
||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.
||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.
|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
||70202||This field contains the Date/Time when the procedure was performed.||DATE-TIME|
Document generated on August 31st 2017, 2:55:41 pm