########################################################################## # 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