Name	Value
NAME	WV REFUSAL-DISPLAY-1
DATA DICTIONARY NUMBER	790.1
FIELD	FIELD ORDER: 1 CAPTION: * * * ADD/EDIT A REFUSAL * * * FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 1,22 FIELD ORDER: 6.5 CAPTION: Br Tx Fac: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 6,50 FIELD ORDER: 2.2 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$NAME^WVUTL1(WVDFN)_"("_$$AGE^WVUTL1(WVDFN)_")"_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 3,15 FIELD ORDER: 3.2 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$CMGR^WVUTL1(WVDFN)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 4,15 FIELD ORDER: 5.3 CAPTION: Cx Tx Need : FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 5,1 FIELD ORDER: 5.4 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$CNEED^WVUTL1(WVDFN,1)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 5,15 FIELD ORDER: 4.3 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$PAPRG^WVUTL1(WVDFN,1)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 4,61 FIELD ORDER: 2 CAPTION: Patient Name: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 3,1 FIELD ORDER: 2.8 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$SSN^WVUTL1(WVDFN)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 3,61 FIELD ORDER: 6.4 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$BNEED^WVUTL1(WVDFN,1)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 6,15 FIELD ORDER: 20 CAPTION: -------------------------------------------------------------------------------- FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 10,1 FIELD ORDER: 19 CAPTION: !M EXECUTABLE CAPTION: S Y=$$EDC^WVUTL1(WVDFN) FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 9,1 FIELD ORDER: 17 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$S($$DES^WVUTL1(WVDFN)="YES":"DES DAUGHTER",1:"") FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 9,61 FIELD ORDER: 21 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$FACIL^WVUTL1A(WVDFN,"C")_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 5,61 FIELD ORDER: 22 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$FACIL^WVUTL1A(WVDFN,"B")_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 6,61 FIELD ORDER: 23 CAPTION: MST : FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 8,1 FIELD ORDER: 3 CAPTION: Case Manager: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 4,1 FIELD ORDER: 24 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$MST^WVUTL1A(WVDFN)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 8,15 FIELD ORDER: 25 CAPTION: Veteran: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 7,52 FIELD ORDER: 26 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$VET^WVUTL1A(WVDFN)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 7,61 FIELD ORDER: 27 CAPTION: Elig Code : FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 7,1 FIELD ORDER: 28 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$P($$ELIG^WVUTL9(WVDFN),U,2)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 7,15 FIELD ORDER: 23.1 CAPTION: CST: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 8,56 FIELD ORDER: 23.2 CAPTION: !M EXECUTABLE CAPTION: S Y=IOINHI_$$CST^WVUTL1A(WVDFN)_IOINORM FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 8,61 FIELD ORDER: 5 CAPTION: !M EXECUTABLE CAPTION: S Y="PAP Regimen:" FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 4,48 FIELD ORDER: 6 CAPTION: Br Tx Need : FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 6,1 FIELD ORDER: 2.5 CAPTION: SSN: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 3,56 FIELD ORDER: 4.5 CAPTION: Cx Tx Fac: FIELD TYPE: CAPTION ONLY CAPTION COORDINATE: 5,50

WV REFUSAL-DISPLAY-1 (263) BLOCK (.404)