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Sub-Field: 90.01

Package: Mental Health

MEDICAL RECORD(#90)-->90.01

Sub-Field: 90.01


Information

Parent File Name Number Package
MEDICAL RECORD(#90) PHY 90.01 Mental Health

Details

Field # Name Loc Type Details
.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)
.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.
.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.
.04 TEMP. 0;4 NUMBER
************************REQUIRED FIELD************************

  • 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).
.05 PULSE 0;5 FREE TEXT
************************REQUIRED FIELD************************

  • 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.
.06 B.P. 0;6 FREE TEXT
************************REQUIRED FIELD************************

  • 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.
.07 RESPS. 0;7 NUMBER
************************REQUIRED FIELD************************

  • 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.
.9 GENERAL APPEARANCE .8;1 FREE TEXT
************************REQUIRED FIELD************************

  • 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
29 EXAMINER 0;10 POINTER TO NEW PERSON FILE (#200)
************************REQUIRED FIELD************************
NEW PERSON(#200)

  • 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.
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.
31 INITIAL IMPRESSION 20;0 WORD-PROCESSING #90.03

  • DESCRIPTION:  
    Examiner's initial impression.
  • DESCRIPTION:  
    Examiner's initial impression of the patient's condition.
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.
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.
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.
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