The Master Data Model for Veteran Care

Developer Documentation » VDM » Wv_Procedure-790_1

Wv Procedure (790.1)

This file contains the Women Veterans Health’s database of procedures actually performed and the data associated with them.

Global: ^WV(790.1,

Domain: Non-Clinical

Properties

Label/Field Name Field # Description Datatype Attributes Range
Accession#
  accessionnumber
.01 This is the record number assigned by the Women’s Health package. It is
composed of the procedure’s abbreviated code, a four digit year and a
sequential number.
STRING INDEXED
REQUIRED
 
Patient
  patient
.02 This field contains the name of the patient associated with the procedure.
Pointer to the WV Patient (#790) file.
POINTER INDEXED
REQUIRED
Wv_Patient-790
Procedure
  procedure
.04 This field stores the name of the procedure performed on the patient.
Pointer to the WV Procedure (#790.1) file.
POINTER INDEXED
REQUIRED
Wv_Procedure_Type-790_2
Results/diagnosis
  results_diagnosis
.05 This field stores the main result or diagnosis of the patient’s procedure.
Pointer to the WV Results/Diagnosis (#790.31) file.
POINTER   Wv_Results_diagnosis-790_31
Sec Result/diagnosis
  sec_result_diagnosis
.06 This field stores a secondary outcome/diagnosis associated with the
procedure. Pointer to the WV Results/Diagnosis (#790.31) file.
POINTER   Wv_Results_diagnosis-790_31
Provider
  provider
.07 This field stores the name of the clinician who ordered and/or performed
this procedure.
POINTER   New_Person-200
Hpv
  hpv
.08 This field is used to document the presence or absence of the Human
Papilloma Virus (HPV) in the cytology reports.
BOOLEAN   false: 0
true: 1
Mam Unilateral: Left Or Right
  mam_unilateral_left_or_right
.09 Select left or right for this unilateral mammogram. ENUMERATION   RIGHT: r
LEFT: l
Health Care Facility
  health_care_facility
.1 This field identifies the name of the health care facility where this
procedure was performed.
POINTER   Institution-4
Ward/clinic/location
  ward_clinic_location
.11 This field contains the name of the ward, clinic, or location where the
procedure was performed.
POINTER   Hospital_Location-44
Date Of Procedure
  date_of_procedure
.12 This field identifies the date on which the procedure was performed. Dates
in the future may not be entered.
DATE-TIME INDEXED  
Complete By (date)
  complete_by_date
.13 This field contains the date used to determine that this procedure record
is delinquent when a close status has not been entered in the record.
DATE-TIME    
Status
  status
.14 This field contains the status (set of codes: O = Open, C = Closed). The
value of this field is used in the Program Snapshot reports and the Browse
Patients with Needs Past Due report.
ENUMERATION INDEXED OPEN: o
CLOSED: c
Radiology Mam Case#
  radiology_mam_casenumber
.15 This field stores the VISTA Radiology/Nuclear Medicine case# for this
mammogram procedure when the Women’s Health package automatically imports
radiology procedures.
STRING INDEXED  
Processed Y/n?
  processed_y_n
.16 This field indicates if the procedure result was entered via a Clinical
Reminder.

Answer YES to indicate the procedure result was entered by a Clinical
Reminder. Answer NO if the procedure result was not entered by a Clinical
Reminder.
BOOLEAN   false: 1
true: 0
Entering User
  entering_user
.18 This field stores the name of the person initially creating this record. POINTER   New_Person-200
Date First Entered
  date_first_entered
.19 This field stores the date on which this procedure record was first
entered.
DATE-TIME INDEXED  
Satisfactory Exam
  satisfactory_exam
.2 This field documents that the procedure or gynecologic exam was
satisfactorily performed without any impediments. Set of codes (1 = Yes,
0 = No).
BOOLEAN   false: 0
true: 1
T-zone Seen Entirely
  tzone_seen_entirely
.21 This field documents (set of codes: 1 = Yes, 0 = No) that the T-Zone in
the colposcopy/biopsy procedure was adequately visualized.
BOOLEAN   false: 0
true: 1
Lesion Outside Canal
  lesion_outside_canal
.22 This field documents (set of codes: 1 = Yes, 0 = No) that the lesion seen
during the procedure was outside the canal.
BOOLEAN   false: 0
true: 1
Multifocal
  multifocal
.23 This field documents (set of codes: 1 = Yes, 0 = No) that the lesion seen
during the procedure was multifocal (as opposed to unifocal).
BOOLEAN   false: 0
true: 1
Number Of Quadrants
  number_of_quadrants
.24 This field contains a number (0-4) that identifies the number of quadrants
occupied by the lesion.
NUMERIC    
Quadrant Locations
  quadrant_locations
.245
The location of the affected quadrants. Any of the following abbreviations
may be selected: UL,LL,UR,LR.

UL - Upper Left quadrant
LL - Lower Left quadrant
UR - Upper Right quadrant
LR - Lower Right quadrant

If more than one quadrant is included separate them with a comma, ie: LL,
UL,UR will represent the inclusion of 3 of the 4 quadrants.
STRING    
Ecc Dysplasia
  ecc_dysplasia
.25 This field indicates if ectocervical dysplasia was present, if an
insufficient tissue sample was provided, or the sample was not examined
for dysplasia.
ENUMERATION   YES: y
Insufficient Tissue: i
Not Done: nd
NO: n
Ectocervical Biopsy
  ectocervical_biopsy
.26 This field contains the diagnosis or impression resulting from the
cytology examination. Pointer to the WV Results/Diagnosis (#790.31) file.
POINTER   Wv_Results_diagnosis-790_31
Margins Clear
  margins_clear
.27 This field indicates tissue sample showed no pathology at the margins of
the tissue sample.
BOOLEAN   false: 0
true: 1
Std Evaluation
  std_evaluation
.28 This field documents the findings after testing for sexually transmitted
diseases. Pointer to the WV Results/Diagnosis (#790.31) file.
POINTER   Wv_Results_diagnosis-790_31
Impression
  impression
.29 This field contains the impression of the clinician performing the exam.
Pointer to the WV Results/Diagnosis (#790.31) file.
POINTER   Wv_Results_diagnosis-790_31
Screening Pap
  screening_pap
.3 This field stores the PAP procedure associated with the follow-up
procedure (e.g., colposcopy). Pointer to the WV Procedure (#790.1) file.
POINTER   Wv_Procedure-790_1
Stage At Final Dx
  stage_at_final_dx
.31 This field is used to document the clinical stage for invasive carcinoma
of the cervix. If clinical stage is unknown, enter the summary (‘S-‘)
stage.
ENUMERATION   S-Distant: 7
I: 1
Unknown: 8
IV: 4
II: 2
S-Regional: 6
S-Local: 5
III: 3
Date Results Received
  date_results_received
.32 Enter the date that the results were received/uploaded from the lab. DATE-TIME    
Final Dx Pap/colp
  final_dx_pap_colp
.33 Enter the Final Diagnosis for this PAP/Colp case. POINTER   Wv_Results_diagnosis-790_31
Facility Where Accessioned
  facility_where_accessioned
.34 Select the facility where this procedure was accessioned. POINTER   Institution-4
Radiology Credit Method
  radiology_credit_method
.35 This field is a set of codes that identify if the radiology exam was
performed at the facility or elsewhere. This value is automatically
entered by the Radiology/NM package when a radiology report is verified
and the WH site parameter is set to accept data from the Radiology/NM
package.

This piece of information will be used for WH reporting requirements to
determine how many radiology procedures were performed at the facility and
elsewhere.
ENUMERATION   No credit: 2
Regular Credit: 0
Technical Component Only: 3
Interpretation Only: 1
Notes
  notes
1.01 This field allows you to enter word-processing text in which to elaborate
further on the results of this patients various tests.
STRING    
Lab Accession#
  lab_accessionnumber
2.17 This field contains the lab accession number from the LAB DATA file (#63)
for the patient, if this procedure entry is a lab test.
STRING INDEXED  
Lab Data File Ien
  lab_data_file_ien
2.18 This field contains the internal entry number of the LAB DATA file (#63)
for the patient, if this procedure entry is a lab test.
NUMERIC    
Lab Inverse Date/time
  lab_inverse_date_time
2.19 This field contains the inverse date/time of a lab test from the LAB DATA
file (#63) for the patient, if this procedure entry is a lab test.
STRING    
Lab Subscript
  lab_subscript
2.2 This field contains a character string that distinguishes the type of lab
test performed. The letters “CY” will represent a cytology test and the
letters “SP” will represent a surgical pathology test.
STRING    
Comments
  comments
3.01 You may enter a one-line clinical history note (limited to 78 characters). STRING    
Reports
  reports
9 This field is not editable through WH options. The lab or radiology exams
related to this procedure are presented here.
STRING    

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