| Name | Value |
|---|---|
| SERVICE NAME | PROSTHETICS REQUEST |
| PROVISIONAL DX PROMPT | REQUIRE |
| PROVISIONAL DX INPUT | LEXICON |
| OE/RR DISPLAY GROUP | CONSULTS |
| PROTOCOL ACTION MENU BY USERS | GMRCACTM SERVICE ACTION MENU |
| DEFAULT REASON FOR REQUEST |
FOR (INPATIENT) - ESTIMATED DISCHARGE DATE:
=======================================================================
(Describe PROSTHETIC APPLIANCE or REPAIR above LINE)
ISSUING INSTRUCTIONS:
[] VETERAN WILL PICK UP
[] WARD/CLINIC PERSONNEL WILL PICKUP
[] DELIVERY LOCATION
|
| SERVICE USAGE | DISABLED |