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e9bb1e2 | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 | ########################################################################## # Copyright: (c) 2013 Mayo Foundation for Medical Education and # Research (MFMER). All rights reserved. MAYO, MAYO CLINIC, and the # triple-shield Mayo logo are trademarks and service marks of MFMER. # # Except as contained in the copyright notice above, or as used to identify # MFMER as the author of this software, the trade names, trademarks, service # marks, or product names of the copyright holder shall not be used in # advertising, promotion or otherwise in connection with this software without # prior written authorization of the copyright holder. # # Licensed under the Apache License, Version 2.0 (the "License"); # you may not use this file except in compliance with the License. # You may obtain a copy of the License at # # http://www.apache.org/licenses/LICENSE-2.0 # # Unless required by applicable law or agreed to in writing, software # distributed under the License is distributed on an "AS IS" BASIS, # WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. # See the License for the specific language governing permissions and # limitations under the License. ################################################################################ # Adopt SecTag 20100 20100 Revision_History 20101 20101 Referral_Source 20102 20102 Chief_Complaint___Reason_for_Visit 20103 20103 History_of_Present_Illness 20104 20104 Current_Medications 20105 20105 Allergies 20106 20106 System_Reviews 20107 20107 Past_Medical___Surgical_History 20108 20108 Social_History 20109 20109 Family_History 20110 20110 Vital_Signs 20111 20111 Physical_Examination 20112 20112 Impression___Report___Plan 20113 20113 Diagnosis 20114 20114 Administrative 20115 20115 Special_Instructions 20116 20116 Advance_Directives 20117 20117 Service_Contributors 20118 20118 Immunizations 20119 20119 Admission_Findings_Test_Results 20120 20120 Problem_Oriented_Hosp__Course__I_O_P_ 20121 20121 Final_Physical_Examination 20122 20122 Adverse_Reactions 20123 20123 Diet___Nutrition 20124 20124 Discharge_Condition 20125 20125 Condition_at_Discharge 20126 20126 Ongoing_Care_Orders 20127 20127 Admission_Physical_Exam 20128 20128 Ongoing_Care 20129 20129 Follow_Up_Agreements 20130 20130 PFH_and_CVI_Dates 20132 20132 Findings_Procedures_Surgeries 20133 20133 Admission_Medications 20134 20134 Discharge_Activity 20135 20135 Anticipated_Problems_and_Suggested_Interventions 20136 20136 Post_op_services_related_to_Surgical_Procedure 20137 20137 EMTALA_Statement 20138 20138 Patient_Education 20139 20139 Principle_Diagnosis 20140 20140 Secondary_Diagnoses 20141 20141 Final_Pathology_Diagnosis 20142 20142 Supervisor_Present 20143 20143 Pre_Procedure_Information 20144 20144 Procedure_Information 20145 20145 Subjective 20146 20146 Labs 20147 20147 Wound 20148 20148 Informed_Consent 20149 20149 Post_Procedure_Film 20150 20150 Patient_Disposition 20151 20151 Specimens_Removed 20152 20152 Findings 20153 20153 Primary_Surgeon_s_ 20154 20154 Assistants 20155 20155 Complications 20156 20156 Drains 20157 20157 Anesthesia 20158 20158 Fluids 20159 20159 Estimated_Blood_Loss 20160 20160 Prescriptions 20161 20161 Follow_Up_Letter 20162 20162 May_Return_to_Work 20163 20163 Instructions_to_Include 20164 20164 Procedure_Performed_and_Description 20165 20165 Post_Procedure_Diagnosis 20166 20166 Reason_for_Transfer 20167 20167 Condition_at_Transfer 20168 20168 Summary_of_Care 20169 20169 Physician_Attestation 20170 20170 Brief_Hospital_Course 20172 20172 Condition_at_Discharge__v2_ 20173 20173 Discharge_Disposition__v2_ 20174 20174 Contact_Information 20175 20175 Service_Contributor__v2_ 20176 20176 Instructions_for_continuing_care 20178 20178 Consults 20179 20179 Radiological_Review 20180 20180 unknown 20181 20181 unknown 20182 20182 unknown 20183 20183 unknown 20184 20184 unknown 20185 20185 unknown 20186 20186 unknown 20187 20187 DC_Instruct 113290 113290 HISTORY/CLINICAL_HISTORY 187823 187823 FINDINGS/MEASUREMENTS 187831 187831 RECOMMENDATIONS 187856 187856 INDICATIONS/HISTORY 188342 188342 COMPARISON/CONTRAST/COMPARISON_STUDY 190058 190058 IMPRESSIONS/RESULTS 551077 551077 COMMENTS/ADDENDUM 551085 551085 CLINICAL_INFORMATION/REFERRING_PHYSICIAN 551093 551093 COMPLICATIONS 551101 551101 CONCLUSIONS/INTERPRETATION 551119 551119 EXAM/TECHNIQUE/PROTOCOL/PROCEDURE 551127 551127 SUMMARY/ASSESSMENT 642934 642934 INFORMED_CONSENT 99998 99998 DOCUMENT_HEADER 99999 99999 FULL_DOCUMENT_TEXT R20102 R20102 INDICATIONS_FOR_SONOGRAPHY R20112 R20112 OBSERVATIONS R20113 R20113 DX R20132 R20132 FINDINGS R20181 R20181 EXAM_INFORMATION R20182 R20182 ELECTRONICALLY_SIGNED_BY |