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 |