| 02 |
Oxygen Saturation *DEPRECATED but in intake* |
Oxygen Saturation |
Numeric Value: 0 to 100 |
| 02SA |
Oxygen Saturation |
Oxygen Saturation |
No Validations |
| 24UA |
24 hour urine albumin |
24 hour urine albumin |
Numeric Value greater than or equal to 0 |
| 24UR |
24-hr Urine cr clearance & albuminuria |
Renal 24-hr Urine cr clearance & albuminuria |
Numeric Value: 0 to 50 |
| 5DAA |
5 Day Adherence if ON ART |
5 Day Adherence if ON ART |
Numeric Value: 0 to 100 |
| A1C |
A1C |
A1C |
Numeric Value: 0 to 50 |
| AACP |
Asthma Action Plan |
Asthma Action Plan |
Yes/No/NA |
| ABO |
Blood Group |
ABO RhD blood type group |
No Validations |
| ACOS |
Asthma Coping Strategies |
Asthma Coping Strategies |
Yes/No/NA |
| ACR |
Alb creat ratio |
ACR |
Numeric Value: 0 to 300 |
| ACS |
Acute Conronary Syndrome |
Acute Conronary Syndrome |
Yes/No/NA |
| AEDR |
Asthma Education Referral |
Asthma Education Referral |
Yes/No/NA |
| AELV |
Exacerbations since last visit requiring clincal evaluation |
Exacerbations since last visit requiring clincal evaluation |
Yes/No/NA |
| AENC |
Asthma Environmental Control |
Asthma Environmental Control |
Yes/No/NA |
| AFP |
AFP |
Alpha Fetoprotein |
Numeric Value: 0 to 300 |
| AHGM |
Anit-hypoglycemic Medication |
Anit-hypoglycemic Medication |
Yes/No/NA |
| AIDU |
Active Intravenous Drug Use |
Active Intravenous Drug Use |
Yes/No/NA |
| ALB |
Albumin |
Serum Albumin |
Numeric Value: 0 to 300 |
| ALB |
Albumin |
Albumin |
Numeric Value: 0 to 300 |
| ALC |
Alcohol |
Alcohol |
Yes/No/NA |
| ALP |
ALP |
Alkaline Phosphatase |
Numeric Value greater than or equal to 0 |
| ALP |
Alk Phos |
Alk Phosphatase |
Numeric Value: 0 to 300 |
| ALPA |
Asthma Limits Physical Activity |
Asthma Limits Physical Activity |
Yes/No/X |
| ALPA |
Asthma Limits Physical Activity |
Asthma Limits Physical Activity |
No Validations |
| ALT |
ALT |
ALT |
Numeric Value: 0 to 300 |
| ANA |
ANA |
Antinuclear Antibodies |
pos or neg |
| Ang |
Angina |
Angina |
Yes/No/NA |
| ANR |
Asthma Needs Reliever |
Asthma Needs Reliever |
Numeric Value greater than or equal to 0 |
| ANSY |
Asthma Night Time Symtoms |
Asthma Night Time Symtoms |
Numeric Value greater than or equal to 0 |
| AORA |
ACE-I OR ARB |
ACE-I OR ARB |
Yes/No/NA |
| APOB |
APO B |
Apolipoprotein B |
Numeric Value greater than or equal to 0 |
| ARAD |
Review Asthma Definition |
Review Asthma Definition |
Yes/No/NA |
| ARDT |
Asthma Review Device Technique optimal |
Asthma Review Device Technique optimal |
Yes/No/NA |
| ARMA |
Asthma Review Med Adherence |
Asthma Review Med Adherence |
Yes/No/NA |
| ASAU |
ASA Use |
ASA Use |
Yes/No/NA |
| ASPR |
Asthma Specialist Referral |
Asthma Specialist Referral |
Yes/No/NA |
| AST |
AST |
AST |
Numeric Value: 0 to 100 |
| ASTA |
Asthma Trigger Avoidance |
Asthma Trigger Avoidance |
Yes/No/NA |
| ASWA |
Asthma Absence School Work |
Asthma Absence School Work |
Yes/No/NA |
| ASYM |
Asthma Symptoms |
Asthma Symptoms |
Numeric Value greater than or equal to 0 |
| BCTR |
Birth Control |
Birth Control |
Yes/No/NA |
| BG |
Blood Glucose |
Blood Glucose |
Yes/No/NA |
| BILC |
Bili conj |
Conjugated Bilirubin |
Numeric Value: 0 to 300 |
| BILI |
Bilirubin |
Total Bilirubin |
Numeric Value greater than or equal to 0 |
| BILT |
Bilirubin |
Total Bilirubin |
Numeric Value: 0 to 300 |
| BILU |
Bili unconj |
Unconjugated Bilirubin |
Numeric Value: 0 to 300 |
| BMED |
Blood Pressure Medication Changes |
BP Med Changes |
Yes/No/NA |
| BMI |
Body Mass Index |
BMI |
Numeric Value: 0 to 100 |
| BP |
BP |
Blood Pressure |
Blood Pressure |
| BPI |
Brief Pain Index -Short Form |
Brief Pain Index -Short Form |
Numeric Value: 0 to 300 |
| BPII |
BPI Pain Interference |
BPI Pain Interference |
Numeric Value: 0 to 10 |
| BPIS |
BPI Pain Severity |
BPI Pain Severity |
Numeric Value: 0 to 10 |
| BTFT |
Brush teeth with fluoride toothpaste and floss |
NULL |
Yes/No/NA |
| BUN |
BUN |
Blood Urea Nitrogen |
Numeric Value greater than or equal to 0 |
| BZD |
Urine Test Benzodiazepine |
Urine Toxicology Test: Benzodiazepine |
pos or neg |
| C125 |
CA 125 |
CA 125 |
Numeric Value greater than or equal to 0 |
| C153 |
CA 15-3 |
CA 15-3 |
Numeric Value greater than or equal to 0 |
| C199 |
CA 19-9 |
CA 19-9 |
Numeric Value greater than or equal to 0 |
| C3 |
C3 |
Complement component 3 |
Numeric Value greater than or equal to 0 |
| CA |
Calcium |
Calcium |
Numeric Value greater than or equal to 0 |
| CANB |
Urine Test Cannabis |
Urine Toxicology Test: Cannabis |
pos or neg |
| CASA |
Consider ASA |
Consider ASA |
Yes/No/NA |
| CAVD |
Calcium and Vitamin D |
NULL |
Review |
| CD4 |
CD4 |
CD4 |
Numeric Value greater than or equal to 0 |
| CD4P |
CD4 Percent |
CD4 Percent |
Numeric Value: 0 to 100 |
| CDMP |
Attended CDM Self Management Program |
Attended CDM Self Management Program |
Yes/No/NA |
| CEA |
CEA |
CEA |
Numeric Value greater than or equal to 0 |
| CEDE |
Education Exercise |
Education Exercise |
Yes/No/NA |
| CEDM |
Education Patient Meds |
Education Patient Meds |
Yes/No/NA |
| CEDS |
Education Salt fluid |
Education Salt fluid |
Yes/No/NA |
| CEDW |
Education Daily Weight Monitoring |
Education Daily Weight Monitoring |
Yes/No/NA |
| CERV |
ER visits for HF |
ER visits for HF |
Numeric Value: 0 to 10 |
| CGSD |
Collaborative Goal Setting |
Collaborative Goal Setting |
Yes/No/NA |
| CHLM |
CHLM |
Chlamydia |
pos or neg |
| CIMF |
Child Immunization recall |
Child Immunization Follow up |
No Validations |
| CK |
CK |
Creatinine Kinase |
Numeric Value greater than or equal to 0 |
| Clpl |
Chloride |
Chloride |
Numeric Value: 0 to 300 |
| Clpl |
Cl |
Plasma Chloride |
Numeric Value: 0 to 300 |
| CMBS |
Coombs |
Coombs |
pos or neg |
| CMVI |
CMV IgG |
CMV IgG |
Yes/No/NA |
| CODC |
COD Classification |
COD Classification |
No Validations |
| COGA |
Cognitive Assessment |
NULL |
Yes/No/NA |
| COPE |
Provide COP Education Materials |
Provide COP Education Materials |
Yes/No/NA |
| COPM |
Review COP Med use and Side effects |
Review COP Med use and Side effects |
Yes/No/NA |
| COPS |
COP Specialist Referral |
COP Specialist Referral |
Yes/No/NA |
| COUM |
Warfarin Weekly Dose |
WarfarinDose |
Numeric Value: 0 to 300 |
| CRCL |
Creatinine Clearance |
Creatinine Clearance |
Numeric Value: 0 to 300 |
| CRP |
CRP |
C reactive protein |
Numeric Value greater than or equal to 0 |
| CVD |
CVD |
Cerebrovascular disease |
Yes/No/NA |
| CXR |
CXR |
CXR |
Yes/No/NA |
| DARB |
ACE AARB |
ACE AARB |
Yes/No/NA |
| DEPR |
Depression |
Depression |
Yes/No/NA |
| DESM |
Dental Exam Every 6 Months |
Dental Exam Every 6 Months |
Yes/No/NA |
| DiaC |
Diabetes Counseling Given |
Diabetes Counseling Given |
Yes/No/NA |
| DIER |
Diet and Exercise |
Diet and Exercise |
Yes/No/NA |
| DIET |
Diet |
Diet |
Yes/No/NA |
| DIFB |
Impaired FB |
Impaired FB |
Yes/No/NA |
| DIG |
Digoxin |
Digoxin Level |
Numeric Value greater than or equal to 0 |
| DIGT |
Impaired GT |
Impaired Glucose Tolerance |
Yes/No/NA |
| DIL |
Dilantin |
Dilantin (Phenytoin) level |
Numeric Value greater than or equal to 0 |
| DILY |
Dentist in the last year |
NULL |
Yes/No/NA |
| DM |
DM |
Diabetes |
Yes/No/NA |
| DMED |
Diabetes Medication Changes |
DM Med Changes |
Yes/No/NA |
| DMME |
Diabetes Education |
Diabetes Education |
Yes/No/NA |
| DMOE |
Daily Morphine Equivalent |
Daily Morphine Equivalent |
No Validations |
| DMSM |
Diabetes Self Management Goals |
Diabetes Self Management Goals |
Yes/No/NA |
| DNFS |
DN4 Questionnaire |
DN4 Questionnaire |
Numeric Value: 0 to 10 |
| DOLE |
Date of last Exacerbation |
Date of last Exacerbation |
Date |
| DpSc |
Depression Screen |
Feeling Sad, blue or depressed for 2 weeks or more |
Yes/No/NA |
| DRCO |
Drug Coverage |
Drug Coverage |
Yes/No/NA |
| DRPW |
Drinks per Week |
Drinks per Week |
Numeric Value: 0 to 300 |
| DT1 |
Type I |
Diabetes Type 1 |
Yes/No/NA |
| DT2 |
Type II |
Diabetes Type 2 |
Yes/No/NA |
| DTYP |
Diabetes Type |
Diabetes Type |
Integer: 1 to 3 |
| ECG |
ECG |
ECG |
Yes/No/NA |
| ECHK |
Do you have your eyes regularly checked? |
NULL |
Yes/No/NA |
| EDC |
EDC |
Expected Date of Confinement |
Date |
| EDDD |
Education Diabetes |
Education Diabetes |
Yes/No/NA |
| EDF |
EDF |
Erectile Dysfunction |
Yes/No/NA |
| EDGI |
Autonomic Neuropathy |
Autonomic Neuropathy |
Yes/No/NA |
| EDND |
Education Nutrition Diabetes |
Education Nutrition Diabetes |
Yes/No/NA |
| EDNL |
Education Nutrition Lipids |
Education Nutrition Lipids |
Yes/No/NA |
| EGFR |
EGFR |
EGFR |
Numeric Value: 0 to 100 |
| ENA |
ENA |
Extractable Nuclear Antigens |
No Validations |
| EPR |
Exacerbation plan in place or reviewed |
Exacerbation plan in place or reviewed |
Yes/No/NA |
| ESR |
ESR |
Erythrocyte sedimentation rate |
Numeric Value greater than or equal to 0 |
| EXE |
Exercise |
Exercise |
Yes/No/NA |
| ExeC |
Exercise Counseling Given |
Exercise Counseling Given |
Yes/No/NA |
| Exer |
Exercise |
Exercise |
Numeric Value greater than or equal to 0 |
| EYEE |
Dilated Eye Exam |
Eye Exam |
Yes/No/NA |
| FAHS |
Risk of Falling |
Risk of Falling |
Yes/No/NA |
| FAMR |
Family/Relationships |
NULL |
Review |
| FAS |
Folic Acid supplementation |
NULL |
Yes/No/NA |
| FBPC |
2 hr PC BG |
2 hr PC BG |
Numeric Value: 0 to 50 |
| FBS |
FBS |
Glucose FBS |
Numeric Value: 0 to 50 |
| FEET |
FEET |
Feet Check skin |
Yes/No/NA |
| Fer |
Ferritin |
Ferritin |
Numeric Value greater than or equal to 0 |
| FEV1 |
Forced Expiratory Volume 1 Second |
Forced Expiratory Volume 1 Second |
Numeric Value greater than or equal to 0 |
| FGLC |
Fasting Glucose meter , lab comparison |
Fasting glucose meter, lab comparison |
Yes/No/NA |
| FICO |
Financial Concerns |
Financial Concerns |
Yes/No/NA |
| FIT |
FIT |
Fecal Immunochemical Test |
pos or neg |
| FLUF |
Flu Recall |
Flu Recall Documentation |
No Validations |
| FOBF |
FOBT prevention recall |
FOBT Immunization Follow up |
No Validations |
| FOBT |
FOBT |
Fecal Occult Blood |
pos or neg |
| FRAM |
Framingham 10 year CAD |
Framingham 10 year CAD |
No Validations |
| FT3 |
FT3 |
Free T3 |
Numeric Value greater than or equal to 0 |
| FT4 |
FT4 |
Free T4 |
Numeric Value greater than or equal to 0 |
| FTE |
Foot Exam |
Foot Exam |
Yes/No/NA |
| FTEx |
Foot Exam: Significant Pathology |
Significant Pathology |
Yes/No/NA |
| FTIn |
Foot Exam: Infection |
Infection |
Yes/No/NA |
| FTIs |
Foot Exam: Ischemia |
Ischemia |
Yes/No/NA |
| FTLS |
Foot Exam Test loss of Sensation |
Foot Exam Loss of Sensation |
Yes/No/NA |
| FTNe |
Foot Exam: Neuropathy |
Neuropathy |
Yes/No/NA |
| FTOt |
Foot Exam: Other Vascular abnomality |
Other Vascular abnomality |
Yes/No/NA |
| FTRe |
Foot Exam: Referral made |
Referral made |
Yes/No/NA |
| FTST |
Free Testost |
Free Testost |
Numeric Value greater than or equal to 0 |
| FTUl |
Foot Exam: Ulcer |
Ulcer |
Yes/No/NA |
| FUPP |
Assessment/Follow-up plans |
NULL |
Review |
| G |
Gravida |
Gravida |
Numeric Value: 0 to 50 |
| G6PD |
G6PD |
G6PD |
Yes/No/NA |
| GAD7 |
GAD 7 score |
GAD 7 score |
Numeric Value: 0 to 100 |
| GBS |
GBS |
Group B Strep |
pos or neg |
| GC |
Gonococcus |
Gonococcus |
pos or neg |
| GCT |
50g Glucose Challenge |
1h 50g Glucose Challenge |
Numeric Value: 0 to 100 |
| GGT |
GGT |
Gamma-glutamyl transferase |
Numeric Value greater than or equal to 0 |
| GT1 |
75g OGTT 1h |
1h 75g Glucose Tolerance Test |
Numeric Value: 0 to 100 |
| GT2 |
75g OGTT 2h |
2h 75g Glucose Tolerance Test |
Numeric Value: 0 to 100 |
| GWS |
General Withdrawal Symptoms |
Methadone Induction Phase Assessment: General Withdrawal Symptoms - Doctor's detailed notes in comment |
No Validations |
| Hb |
Hb |
Hb |
Numeric Value: 0 to 300 |
| HBEB |
AntiHBeAg |
AntiHBeAg |
pos or neg |
| HBEG |
HBeAg |
HBeAg |
pos or neg |
| HBVD |
HBV DNA |
HBV DNA |
pos or neg |
| Hchl |
Hypercholesterolemia |
Hypercholesterolemia |
Yes/No/NA |
| HCO3 |
Bicarbonate |
Bicarbonate |
Numeric Value: 0 to 100 |
| HCON |
Do you have any hearing concerns? |
NULL |
Yes/No/NA |
| HDL |
HDL |
High Density Lipid |
Numeric Value: 0 to 10 |
| HEAD |
Head circumference |
Head circumference |
Numeric Value: 0 to 100 |
| HFCG |
HF Collaorative Goal Setting |
HF Collaorative Goal Setting |
Yes/No/NA |
| HFCS |
HF Self Management Challenge |
HF Self Management Challenge |
Yes/No/NA |
| HFMD |
HF Mod Risk Factor Diabetes |
HF Mod Risk Factor Diabetes |
Yes/No/NA |
| HFMH |
HF Mod Risk Factor Hyperlipidemia |
HF Mod Risk Factor Hyperlipidemia |
Yes/No/NA |
| HFMO |
HF Mod Risk Factor Overweight |
HF Mod Risk Factor Overweight |
Yes/No/NA |
| HFMS |
HF Mod Risk Factor Smoking |
HF Mod Risk Factor Smoking |
Yes/No/NA |
| HFMT |
HF Mod Risk Factor Hypertension |
HF Mod Risk Factor Hypertension |
Yes/No/NA |
| HIP |
Hip Circ. |
Hip Circumference |
Numeric Value greater than or equal to 0 |
| HIVG |
HIV genotype |
HIV genotype |
Yes/No/NA |
| HLA |
HLA B5701 |
HLA B5701 |
Yes/No/NA |
| HpAI |
Hep A IgG |
Hep A IgG |
Yes/No/NA |
| HpBA |
Hep BS Ab |
Hep BS Ab |
Yes/No/NA |
| HPBC |
Hep B CAb |
Hep B CAb |
Yes/No/NA |
| HPBP |
Hep B PCR |
Hep B PCR |
Yes/No/NA |
| HpBS |
Hep BS Ag |
Hep BS Ag |
Yes/No/NA |
| HpCA |
Hep C Ab |
Hep C Ab |
Yes/No/NA |
| HPCG |
Hep C Genotype |
Hep C Genotype |
Numeric Value: 0 to 10 |
| HPCP |
Hep C PCR |
Hep C PCR |
Yes/No/NA |
| HPNP |
Hearing protection/Noise control programs |
NULL |
Yes/No/NA |
| HPYL |
H Pylori |
H Pylori |
pos or neg |
| HR |
P |
Heart Rate |
Numeric Value: 0 to 300 |
| HRMS |
Review med use and side effects |
HTN Review of Medication use and side effects |
No Validations |
| HSMC |
Self Management Challenges |
HTN Self Management Challenges |
No Validations |
| HSMG |
Self Management Goal |
HTN Self Management Goal |
No Validations |
| HT |
HT |
Height |
Numeric Value: 0 to 300 |
| HTN |
HTN |
Hypertension |
Yes/No/NA |
| HYPE |
Hypoglycemic Episodes |
Number of Hypoglycemic Episodes |
Numeric Value: 0 to 50 |
| HYPM |
Hypoglycemic Management |
Hypoglycemic Management |
Yes/No/NA |
| IART |
Currently ON ART |
Currently ON ART |
Yes/No/NA |
| IBPL |
Income below poverty line |
NULL |
Yes/No/NA |
| iDia |
Eye Exam: Diabetic Retinopathy |
Diabetic Retinopathy |
Yes/No/NA |
| iEx |
Eye Exam: Significant Pathology |
Significant Pathology |
Yes/No/NA |
| iHyp |
Eye Exam: Hypertensive Retinopathy |
Hypertensive Retinopathy |
Yes/No/NA |
| INR |
INR |
INR |
Numeric Value: 0 to 300 |
| INSL |
Insulin |
Insulin |
Yes/No/NA |
| iOth |
Eye Exam: Other Vascular Abnomality |
Other Vascular Abnormality |
Yes/No/NA |
| iPTH |
iPTH |
intact Parathyroid Hormone |
Numeric Value greater than or equal to 0 |
| iRef |
Eye Exam: Refferal Made |
Refferal Made |
Yes/No/NA |
| JVPE |
JPV Elevation |
JPV Elevation |
Yes/No/NA |
| KEEL |
Keele Score |
Keele Score |
Numeric Value: 0 to 10 |
| Kpl |
Potassium |
Potassium |
Numeric Value: 0 to 10 |
| LcCt |
Locus of Control Screen |
Feeling lack of control over daily life |
Yes/No/NA |
| LDL |
LDL |
Low Density Lipid |
Numeric Value: 0 to 10 |
| LEFP |
LEFS Pain |
Lower Extremity Functional Scale - Pain |
Numeric Value: 0 to 300 |
| LETH |
Lethargy |
Lethargic |
Yes/No/NA |
| LHAD |
Lung Related Hospital Admission |
Lung Related Hospital Admission |
Yes/No/NA |
| LITH |
Lithium |
Lithium |
Numeric Value greater than or equal to 0 |
| LMED |
Lipid Lowering Medication Changes |
Lipid Med Changes |
Yes/No/NA |
| LMP |
Last Menstral Period |
LMP |
Date |
| LUCR |
Lung Crackles |
Lung Crackles |
Yes/No/NA |
| MACA |
Macroalbuminuria |
Renal Macrobalbumnuria |
Numeric Value: 0 to 50 |
| MACC |
MAC culture |
MAC culture |
Yes/No/NA |
| MAMF |
MAM Recall |
Mammogram Recall Documentation |
No Validations |
| MAMP |
Urine Test Methamphetamine |
Urine Toxicology Test: Methamphetamine |
pos or neg |
| MCCE |
Motivation Counseling Compeleted Exercise |
Motivation Counseling Compeleted Exercise |
Yes/No/NA |
| MCCN |
Motivation Counseling Compeleted Nutrition |
Motivation Counseling Compeleted Nutrition |
Yes/No/NA |
| MCCO |
Motivation Counseling Compeleted Other |
Motivation Counseling Compeleted Other |
Yes/No/NA |
| MCCS |
Motivation Counseling Compeleted Smoking Cessation |
Motivation Counseling Compeleted Smoking Cessation |
Yes/No/NA |
| MCV |
MCV |
Mean corpuscular volume |
Numeric Value greater than or equal to 0 |
| MDD |
Methadone Dose |
Methadone Induction Phase Assessment: Methadone Dose - Dosing Date Number & Patient Comfort Level in comment |
Numeric Value greater than or equal to 0 |
| MedA |
Medication adherence access barriers |
Difficulty affording meds or getting refills ON time |
Yes/No/NA |
| MedG |
Medication adherence general problem |
Any missed days or doses of meds |
Yes/No/NA |
| MedN |
Medication adherence negative beliefs |
Concerns about side effects or medication IS not working |
Yes/No/NA |
| MedR |
Medication adherence recall barriers |
Difficulty remembering to take meds |
Yes/No/NA |
| MG |
Mg |
Magnesium |
Numeric Value greater than or equal to 0 |
| MI |
MI |
MI |
Yes/No/NA |
| Napl |
Sodium |
Sodium |
Numeric Value: 0 to 300 |
| NDIP |
CMCC NDI Pain |
CMCC Neck Disability Index - Pain |
Numeric Value: 0 to 300 |
| NDIS |
CMCC NDI Score |
CMCC Neck Disability Index - Score |
Numeric Value: 0 to 300 |
| NERF |
Neuropathic Features? |
Neuropathic Features? |
Yes/No/Maybe |
| NOSK |
Number of Cigarettes per day |
Smoking |
Numeric Value: 0 to 300 |
| NOVS |
Need for nocturnal ventilated support |
Need for nocturnal ventilated support |
Yes/No/NA |
| NtrC |
Diet/Nutrition Counseling Given |
Diet/Nutrition Counseling Given |
Yes/No/NA |
| NYHA |
NYHA Functional Capacity Classification |
NYHA Functional Capacity Classification |
Integer: 1 to 4 |
| OB A |
OB A *DEPRECATED*
|
OB A |
Numeric Value: 0 to 10 |
| OB G |
OB G *DEPRECATED* |
OB G |
Numeric Value: 0 to 10 |
| OB L |
OB L *DEPRECATED* |
OB L |
Numeric Value: 0 to 10 |
| OB P |
OB P *DEPRECATED* |
OB P |
Numeric Value: 0 to 10 |
| OB T |
OB T *DEPRECATED* |
OB T |
Numeric Value: 0 to 10 |
| OPAB |
Opioid Aberrant Behaviour |
Opioid Aberrant Behaviour |
pos or neg |
| OPAE |
Opioid Adverse Effects |
Opioid Adverse Effects |
pos or neg |
| OPID |
Urine Test Opioids |
Urine Toxicology Test: Opioids |
pos or neg |
| OPUS |
Opioid Urine Drug Screen |
Opioid Urine Drug Screen |
pos or neg |
| ORDU |
Other Recent Drug Use |
Methadone Induction Phase Assessment: Other Recent Drug Use Yes/No - Description in comment |
Yes/No |
| ORSK |
Opioid Risk |
NULL |
Numeric Value: 0 to 50 |
| OSWP |
Oswestry BDI Pain |
Oswestry Back Disability Index - Pain |
Numeric Value: 0 to 300 |
| OSWS |
Oswestry BDI Score |
Oswestry Back Disability Index - Score |
Numeric Value: 0 to 300 |
| OTCO |
Other Concerns |
Other Concerns |
Yes/No/NA |
| OthC |
Other Counseling Given |
Other Counseling Given |
Yes/No/NA |
| OUTR |
Outside Spirometry Referral |
Outside Spirometry Referral |
Yes/No/NA |
| P |
Para |
Para |
Numeric Value: 0 to 50 |
| PANE |
Painful Neuropathy |
Painful Neuropathy |
Yes/No/NA |
| PAPF |
Pap Recall |
Pap Recall Documentation |
No Validations |
| PB19 |
Parvovirus |
Parvovirus B19 |
No Validations |
| PEDE |
Pitting Edema |
Pitting Edema |
Yes/No/NA |
| PEFR |
PEFR value |
PEFR value |
Numeric Value greater than or equal to 0 |
| PHIN |
Pharmacological Intolerance |
Pharmacological Intolerance |
Yes/No/NA |
| PHOS |
Phosphate |
Phosphate |
Numeric Value greater than or equal to 0 |
| PHQ9 |
PHQ 9 score |
PHQ 9 score |
Numeric Value: 0 to 100 |
| PHQS |
PHQ4 Depression Anxiety Score |
PHQ4 Depression Anxiety Score |
Numeric Value: 0 to 50 |
| PIDU |
Previous Intravenous Drug Use |
Previous Intravenous Drug Use |
Yes/No/NA |
| PLT |
Platelets |
Platelets |
Numeric Value greater than or equal to 0 |
| POSK |
Packs of Cigarettes per day |
Smoking |
Numeric Value: 0 to 50 |
| PPD |
PPD |
PPD |
Yes/No/NA |
| PROT |
Protein |
Total Protein Serum |
Numeric Value greater than or equal to 0 |
| PRRF |
Pulmonary Rehabilitation Referral |
Pulmonary Rehabilitation Referral |
Yes/No/NA |
| PSA |
PSA |
Prostatic specific antigen |
Numeric Value greater than or equal to 0 |
| PSPA |
Patient Sets physical Activity Goal |
Patient Sets physical Activity Goal |
Yes/No/NA |
| PSQS |
PSQ3 Sleep Score |
PSQ3 Sleep Score |
Numeric Value: 0 to 300 |
| PSSC |
Psychosocial Screening |
Psychosocial Screening |
Yes/No/NA |
| PsyC |
Psychosocial Counseling Given |
Psychosocial Counseling Given |
Yes/No/NA |
| PTSD |
PC PTSD Trauma Score |
PC PTSD Trauma Score |
Numeric Value: 0 to 10 |
| PULS |
P |
Heart Rate |
Numeric Value: 0 to 300 |
| PVD |
PVD |
Peripheral vascular disease |
Yes/No/NA |
| PXAM |
Physical Exam |
NULL |
Review |
| QDSH |
QuickDASH Score |
Disabilities of the Arm, Shoulder and Hand - Score |
Numeric Value: 0 to 300 |
| RABG |
Recommend ABG |
Recommend ABG |
Yes/No/NA |
| REBG |
Review Blood Glucose Records |
Review Glucose Records |
Yes/No/NA |
| RESP |
RR |
Respiratory Rate |
Numeric Value: 0 to 100 |
| RETI |
Retinopathy |
NULL |
Yes/No/NA |
| RF |
RF |
Rheumatoid Factor |
pos or neg |
| Rh |
Rh |
RhD blood type group |
No Validations |
| RHU |
Recent Heroin Use |
Methadone Induction Phase Assessment: Recent Heroin Use Yes/No - Amount in comment |
Yes/No |
| RPHR |
Review PHR |
Review PHR |
Yes/No/NA |
| RPPT |
Review Pathophysiology, Prognosis, Treatment with Patient |
Review Pathophysiology, Prognosis, Treatment with Patient |
Yes/No/NA |
| RUB |
Rubella |
Rubella titre |
No Validations |
| RVTN |
Revascularization |
Revascularization |
Yes/No/NA |
| SBLT |
Seat belts |
NULL |
Yes/No/NA |
| SCR |
Serum Creatinine |
Creatinine |
Numeric Value greater than or equal to 0 |
| SDET |
Smoke detector that works |
NULL |
Yes/No/NA |
| SDUS |
Street Drug Use |
NULL |
Review |
| SEXF |
Sexual Function |
Sexual Function |
Yes/No/NA |
| SEXH |
Sexual History |
NULL |
Review |
| SHAB |
Sleep Habits |
NULL |
Review |
| SKD |
SKD |
Signs of Kidney Damage |
Yes/No |
| SKST |
Smoking Status |
Smoking Status |
Yes/No/NA |
| SMBG |
Self monitoring BG |
Self Monitoring Blood Glucose |
Yes/No/NA |
| SmCC |
Smoking Cessation Counseling Given |
Smoking Cessation Counseling Given |
Yes/No/NA |
| SMCD |
Self Management Challenges |
Self Management Challenges |
Yes/No/NA |
| SMCP |
Smoking Cessation Program |
Smoking Cessation Program |
No Validations |
| SMCS |
Smoking Cessation |
Smoking Cessation |
Yes/No/NA |
| SMK |
Smoking |
Smoking |
Yes/No/X |
| SmkA |
Smoking Advice |
Advised to Quid |
Yes/No/NA |
| SmkC |
Cigarette Smoking Cessation |
Cigarette Smoking Cessation |
Date |
| SmkD |
Daily Packs |
Packs of Cigarets Daily |
No Validations |
| SmkF |
Smoking Followup |
Followup Requested |
Yes/No/NA |
| SmkP |
Cigarette Smoking History |
Cigarette Smoking History |
Numeric Value: 0 to 300 |
| SmkS |
Cigarette Smoking Status |
Cigarette Smoking Status |
Numeric Value: 0 to 100 |
| SODI |
Salt Intake |
Salt Intake |
Yes/No/NA |
| SOHF |
Symptoms of Heart Failure |
Symptoms of Heart Failure |
Yes/No/NA |
| SPIR |
Spirometry |
Spirometry |
Numeric Value greater than or equal to 0 |
| SSEX |
Practicing Safe Sex |
Practicing Safe Sex |
Yes/No/NA |
| SSXC |
Safe Sex Counselling |
NULL |
Review |
| STIS |
STI Screening |
Sexual Transmitted Infections |
Review |
| STRE |
Stress Testing |
Stress Testing |
Yes/No/NA |
| StSc |
Stress Screen |
Several periods of irritability, feeling filled with anxiety, or difficulty sleeping b/c of stress |
Yes/No/NA |
| SUAB |
Substance Use |
Substance Use |
Yes/No/NA |
| SUNP |
Sun protection |
NULL |
Yes/No/NA |
| SUO2 |
Need for supplemental oxygen |
Need for supplemental oxygen |
Yes/No/NA |
| TCHD |
TC/HDL |
LIPIDS TD/HDL |
Numeric Value: 0 to 50 |
| TCHL |
Total Cholestorol |
Total Cholestorol |
Numeric Value: 0 to 10 |
| TDP |
Diabetes Program Patient |
Diabetes Program Patient |
No Validations |
| TEMP |
Temp |
Temperature |
Numeric Value: 0 to 50 |
| TG |
TG |
LIPIDS TG |
Numeric Value: 0 to 50 |
| TOXP |
Toxoplasma IgG |
Toxoplasma IgG |
Yes/No/NA |
| TRIG |
Triglycerides |
Triglycerides |
Numeric Value: 0 to 50 |
| TSAT |
Transferrin Saturation |
Transferrin Saturation |
Numeric Value: 0 to 100 |
| TSH |
TSH |
Thyroid Stimulating Hormone |
Numeric Value: 0 to 100 |
| TUG |
Timed Up and Go |
Timed Up and Go |
Numeric Value greater than or equal to 0 |
| UA |
Urate |
Uric Acid |
Numeric Value: 0 to 300 |
| UACR |
Alb creat ratio |
UACR |
Numeric Value: 0 to 300 |
| UAIP |
UPDATE AIDS defining illness in PMH |
UPDATE AIDS defining illness in PMH |
Yes/No/NA |
| UALB |
Urine alb: creat ratio |
Urine alb: creat ratio |
Numeric Value: 0 to 100 |
| UDUS |
UPDATE Drug Use |
UPDATE Drug Use |
Yes/No/NA |
| Uetc |
Urine Test etc |
Urine Toxicology Test: other substance - name in comment |
pos or neg |
| UHTP |
UPDATE HIV Test History in PMH |
UPDATE HIV Test History in PMH |
Yes/No/NA |
| URBH |
UPDATE Risk Behaviours |
UPDATE Risk Behaviours |
Yes/No/NA |
| URIC |
Uric Acid |
Uric Acid |
Numeric Value greater than or equal to 0 |
| USSH |
UPDATE Sexual Identity in Social History |
UPDATE Sexual Identity in Social History |
Yes/No/NA |
| VB12 |
Vit B12 |
Vitamin B12 |
Numeric Value greater than or equal to 0 |
| VDRL |
VDRL |
VDRL |
Yes/No/NA |
| VLOA |
Viral Load |
Viral Load |
Numeric Value greater than or equal to 0 |
| VZV |
Zoster |
Varicella Zoster |
pos or neg |
| WAIS |
Waist |
Waist |
Numeric Value: 0 to 300 |
| WBC |
WBC |
White Cell Count |
Numeric Value greater than or equal to 0 |
| WC |
Waist Circ. |
Waist Circumference |
No Validations |
| WHR |
Waist:Hip |
Waist Hip Ratio |
Numeric Value: 0 to 10 |
| WKED |
Work/Education |
NULL |
Review |
| WT |
WT |
Weight |
Numeric Value: 0 to 300 |