MSH|^~\&|ADM|ARH|||201911141010||ADT^A08|4104700|D|2.2|||AL|NE
EVN|A08|201911141010||||
PID|1|FHATVIG0012397||AB8261|EDMTEST^TESTING||19731113|F||||||||||AB000661/19|
PV1|1|P|AB.ER|||||||||||||||ER|||||||||||||||||||||ARH|||||201911131446|
PV2|||TEST
OBX|1|ST|1010.1^WEIGHT^CPT4||4.000||||||F
OBX|2|TX|AdADMRSN00^Reason for admission^ADM||TESTING||||||F
OBX|3|TX|AdALLERB00^Allergy band checked^ADM||N||||||F
OBX|4|TX|AdALLERG00^Allergy band applied^ADM||TESTING||||||F
OBX|5|TX|AdALLERR00^Allergies reviewed^ADM||N||||||F
OBX|6|TX|AdCULREQ01^Cultural/Spiritual considerations^ADM||Y||||||F
OBX|7|TX|AdDUEDAT00^Pregnancy due date^ADM||20191114||||||F
OBX|8|TX|AdEDCC0000^Chief Complaint^ADM||TESTING||||||F
OBX|9|TX|AdENACOM00^Other initial assessment comments^ADM||TESTING||||||F
OBX|10|TX|AdHXALLE00^Hx of unexplained allergic reaction during medical procedure^ADM||N||||||F
OBX|11|TX|AdHXITCH00^Hx of itchiness/swelling post dental, rectal or pelvic exam^ADM||N||||||F
OBX|12|CE|AdHXRUBB00^Hx of sensitivity to materials containing rubber^ADM||1^Rubber gloves~2^Condoms~3^Rubber~4^Halloween masks~5^Balloons~6^Diaphragms~7^Erasers~8^Soccer balls~9^Elastic bandages~10^Rubber bands||||||F
OBX|13|TX|AdHXRUBO00^Hx of sensitivity to materials containing rubber other^ADM||TESTING||||||F
OBX|14|TX|AdHXSBIF00^Hx of Spina Bifida^ADM||N||||||F
OBX|15|TX|AdID000000^ID band applied^ADM||Y||||||F
OBX|16|TX|AdINFOTH00^Information source other^ADM||TESTING||||||F
OBX|17|CE|AdINSM0000^Information source^ADM||1^Patient~3^Family||||||F
OBX|18|TX|AdINTNEE00^Interpreter needed^ADM||N||||||F
OBX|19|TX|AdNAMEBN00^Name band on^ADM||N||||||F
OBX|20|TX|AdNICOTI31^Nicotine use^ADM||N||||||F
OBX|21|TX|AdNICUA141^Other PIV comments^ADM||TESTING||||||F
OBX|22|TX|AdPTAMOC10^Mobility and falls prior to admission^ADM||TESTING||||||F
OBX|23|TX|AdSLATEX01^Suspected latex allergy^ADM||Y||||||F
OBX|24|CE|Ca00000000^Pre-existing pain concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|25|CE|Ca00000001^Pre-existing medication concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|26|CE|Ca00000002^Pre-existing nutrition/hydration concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|27|CE|Ca00000003^Pre-existing bowel/bladder concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|28|CE|Ca00000004^Pre-existing cognitive concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|29|CE|Ca00000005^Pre-existing mobility concerns^ADM||1^No concerns identified~2^Concerns identified~3^Care plan initiated||||||F
OBX|30|TX|Ca00000006^Pre-existing concerns comments^ADM||TESTING||||||F
OBX|31|TX|CaBL000400^Bleeding findings and interventions^ADM||TESTING||||||F
OBX|32|CE|CaCA000100^Capillary refill^ADM||1^Less than 3 seconds||||||F
OBX|33|CE|CaCA000352^Electrocardiogram rhythm^ADM||1^Sinus rhythm||||||F
OBX|34|TX|CaCAVASC00^Other cardiovascular comments^ADM||TESTING||||||F
OBX|35|TX|CaCWMSSF10^CWMS satisfactory to all limbs^ADM||Y||||||F
OBX|36|TX|CaCY000000^Skin cyanosis other^ADM||TESTING||||||F
OBX|37|CE|CaEDEMA000^Edema^ADM||2^Present||||||F
OBX|38|TX|CaHS000200^Heart sounds quality^ADM||TESTING||||||F
OBX|39|CE|CaHS000700^Heart sounds audible^ADM||1^S1~3^S2||||||F
OBX|40|TX|CaTELERQ01^Cardiac monitoring required^ADM||N||||||F
OBX|41|CE|GiAB000400^Abdomen description^ADM||1^Flat||||||F
OBX|42|TX|GiAB000500^Abdomen description other^ADM||TESTING||||||F
OBX|43|TX|GiABAPGE00^Abdominal general appearance^ADM||TESTING||||||F
OBX|44|CE|GiABPALP04^Abdominal palpation^ADM||1^Soft||||||F
OBX|45|TX|GiABPAOT00^Abdominal palpation findings other^ADM||TESTING||||||F
OBX|46|TX|GiBO000301^Last bowel movement date as reported by patient^ADM||20191112||||||F
OBX|47|CE|GiBSACTI01^Bowel sounds active in all four quadrants^ADM||1^Yes||||||F
OBX|48|TX|GiCOMMOT00^Other gastrointestinal comments^ADM||TESTING||||||F
OBX|49|TX|GiGICOMO50^Gastrointestinal complaints other^ADM||TESTING||||||F
OBX|50|CE|GiGICOMP00^Gastrointestinal complaints^ADM||1^None||||||F
OBX|51|CE|GiPED00200^Gastrointestinal complaints^ADM||1^None~5^Pain~3^Blood in stool~4^Nausea~2^Constipation~6^Black/Tarry stool~7^Vomiting~8^Bloating~9^Blood in emesis~10^Diarrhea~11^Lack of appetite~12^Rectal foreign body||||||F
OBX|52|CE|GiTOILET00^Toileting method^ADM||1^Toilet||||||F
OBX|53|TX|GiTOILET10^Toileting method other^ADM||TESTING||||||F
OBX|54|TX|GiTOILET20^Toileting concerns^ADM||Y||||||F
OBX|55|TX|GuBDSVA000^Bladder scan volume^ADM||125||||||F
OBX|56|TX|GuCMMNTO00^Other genitourinary comments^ADM||TESTING||||||F
OBX|57|CE|GuRECOMP00^Reproductive complaints^ADM||1^None||||||F
OBX|58|TX|GuRECOMP02^Reproductive complaints other^ADM||TESTING||||||F
OBX|59|TX|GuREPROC00^Other reproductive system comments^ADM||TESTING||||||F
OBX|60|TX|GuUCINS000^Urinary catheter in situ and patent^ADM||Y||||||F
OBX|61|TX|GuUCOTHR00^Other urinary catheter comments^ADM||TESTING||||||F
OBX|62|TX|GuUCRFCO00^Reason for urinary catheter continued use other^ADM||TESTING||||||F
OBX|63|CE|GuUCRFCU00^Reason for urinary catheter continued use^ADM||1^Unrelieved retention||||||F
OBX|64|CE|GuURCMR100^Urinary complaints^ADM||1^None||||||F
OBX|65|TX|GuURCMR200^Urinary complaints other^ADM||TESTING||||||F
OBX|66|CE|HeTR000100^Trachea position^ADM||1^Midline||||||F
OBX|67|TX|Hx486COM00^Pre-admission screening questionnaire completed by^ADM||TESTING||||||F
OBX|68|TX|Hx486PRO00^Pre-admission screening questionnaire provided^ADM||Y||||||F
OBX|69|TX|HxSPTCHX01^Pertinent clinical history^ADM||TESTING||||||F
OBX|70|CE|HxVACUTD00^Tetanus immunization up to date^ADM||3^Unknown||||||F
OBX|71|CE|InEDEMAS00^Edema severity^ADM||1^+1||||||F
OBX|72|TX|InEDEMCM00^Edema comments^ADM||TESTING||||||F
OBX|73|CE|InEDEMLB01^Edema location^ADM||3^Face||||||F
OBX|74|CE|InEDEMLM00^Edema location modifier^ADM||3^Right||||||F
OBX|75|CE|InEDEMTP00^Edema type^ADM||1^Pitting||||||F
OBX|76|TX|InINTELT01^Integumentary complaints comments^ADM||TESTING||||||F
OBX|77|TX|InPED00800^Other circulation comments^ADM||TESTING||||||F
OBX|78|CE|InSK000150^Skin cyanosis^ADM||1^None||||||F
OBX|79|TX|InSKCOOT00^Other integumentary comments^ADM||TESTING||||||F
OBX|80|TX|InSKIAPO00^Skin appearance other^ADM||TESTING||||||F
OBX|81|CE|InSKIAPP01^Skin appearance^ADM||1^Normal||||||F
OBX|82|CE|InSKICON00^Skin condition^ADM||1^Intact||||||F
OBX|83|TX|InSKIMOI02^Skin moisture^ADM||TESTING||||||F
OBX|84|TX|InSKIN0010^Identified skin issue comments^ADM||TESTING||||||F
OBX|85|CE|InSKIN0020^Skin breakdown prevention strategies in use^ADM||1^Elevate head of bed||||||F
OBX|86|TX|InSKIN0030^Skin breakdown prevention strategies in use other^ADM||TESTING||||||F
OBX|87|TX|InSKITEM00^Skin temperature^ADM||TESTING||||||F
OBX|88|CE|InWNDCOM50^Integumentary complaints^ADM||1^None||||||F
OBX|89|TX|IvINSERT00^Insertion details^ADM||TESTING||||||F
OBX|90|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|91|CE|IvPIVLOC00^Location^ADM||5^Hand PIV||||||F
OBX|92|CE|IvPL000700^Initial management^ADM||1^Infusion||||||F
OBX|93|TX|IvSIZE0000^Size^ADM||21||||||F
OBX|94|CE|MhBEHAV100^Behaviour^ADM||1^Relaxed||||||F
OBX|95|CE|MhMSCON000^Mental status concerns identified^ADM||1^No concerns||||||F
OBX|96|TX|MhMSCON100^Mental status concerns identified other^ADM||TESTING||||||F
OBX|97|TX|MhMSCON200^Mental status on arrival comments^ADM||TESTING||||||F
OBX|98|CE|MoFA000001^Fall prevention strategies^ADM||1^Universal||||||F
OBX|99|TX|MoFA000010^Fall prevention strategies other^ADM||TESTING||||||F
OBX|100|CE|MoFALRSK01^Falls risk factors^ADM||1^None||||||F
OBX|101|CE|MsCS000000^Cervical spine concerns identified^ADM||2^Pain on palpation||||||F
OBX|102|TX|MsCS000100^C-spine concerns identified other^ADM||TESTING||||||F
OBX|103|TX|MsCS000301^Cervical spine on arrival comments^ADM||TESTING||||||F
OBX|104|TX|MsCS000500^C-spine immobilized prior to arrival^ADM||N||||||F
OBX|105|CE|MsCS000600^C-spine management^ADM||1^None||||||F
OBX|106|CE|MsMUSCCO00^Musculoskeletal complaints^ADM||1^None||||||F
OBX|107|TX|MsMUSCLT01^Musculoskeletal complaints comments^ADM||TESTING||||||F
OBX|108|CE|NeARMDRF00^Arm drift present^ADM||1^None||||||F
OBX|109|CE|NeDEL00000^Delirium screen criteria^ADM||1^65 years or older||||||F
OBX|110|TX|NeDEL00100^History obtained from^ADM||TESTING||||||F
OBX|111|TX|NeDELRES00^Delirium screen result^ADM||Complete CAM||||||F
OBX|112|CE|NeGCSEYE03^Glasgow Coma Scale Eye Opening^ADM||1^4- Spontaneous||||||F
OBX|113|CE|NeGCSMOT03^Glasgow Coma Scale Motor Response^ADM||1^6- Obeys commands||||||F
OBX|114|TX|NeGCSSCR01^GCS score^ADM||15||||||F
OBX|115|CE|NeGCSVER03^Glasgow Coma Scale Verbal Response^ADM||1^5- Oriented||||||F
OBX|116|TX|NeGLBLGU00^Glucometer blood glucose^ADM||4.2||||||F
OBX|117|CE|NeLECONS00^Level of consciousness^ADM||1^Alert||||||F
OBX|118|CE|NeLECONS01^Level of consciousness^ADM||1^Alert||||||F
OBX|119|TX|NeNCBEHO00^Neurological complaint behaviour other^ADM||TESTING||||||F
OBX|120|TX|NeNEFI0000^Other neurological findings/complaints^ADM||TESTING||||||F
OBX|121|CE|NeNEFND000^Neurological findings^ADM||1^Headache||||||F
OBX|122|TX|NeNEFND100^Neurological findings other^ADM||TESTING||||||F
OBX|123|CE|NeORIENT01^Oriented to^ADM||1^All domains||||||F
OBX|124|CE|NePUEYED01^Eye deviation^ADM||2^Left||||||F
OBX|125|CE|NePURXNL00^Pupil reaction to light^ADM||1^Brisk||||||F
OBX|126|CE|NePUSHPE00^Pupil shape^ADM||1^Round||||||F
OBX|127|CE|NePUSIDE00^Pupil side^ADM||3^Bilateral||||||F
OBX|128|TX|NePUSIZE00^Pupil size^ADM||4||||||F
OBX|129|CE|NmHNDGR100^Handgrip right^ADM||3^Weak||||||F
OBX|130|CE|NmHNDGR200^Handgrip left^ADM||3^Weak||||||F
OBX|131|CE|NmLEGST100^Leg strength right^ADM||3^Weak||||||F
OBX|132|CE|NmLEGST200^Leg strength left^ADM||3^Weak||||||F
OBX|133|TX|NmMR001400^Motor strength satisfactory^ADM||Y||||||F
OBX|134|TX|NuGLROUT00^Glucometer result out of range^ADM||TESTING||||||F
OBX|135|CE|OEISO^Infection Control:^ADM||S^Standard/Routine||||||F
OBX|136|TX|OhEDIT0000^Reason for edit^ADM||TESTING||||||F
OBX|137|TX|OhMEDREC00^Medication reconciliation form completed^ADM||Y||||||F
OBX|138|TX|OhSYSTEM00^Other ongoing systems assessment comments^ADM||TESTING||||||F
OBX|139|TX|PaCOMMEN00^Pain comments^ADM||TESTING||||||F
OBX|140|CE|PaLOCBDS02^Location^ADM||1^Head||||||F
OBX|141|CE|PaPAIASS00^Pain assessment^ADM||1^Pain not reported||||||F
OBX|142|CE|PaPALOCM00^Pain location modifier^ADM||2^Right||||||F
OBX|143|CE|PaPASCL000^Pain scale used^ADM||1^Numeric||||||F
OBX|144|TX|PaPASCOR00^Pain score^ADM||7||||||F
OBX|145|TX|PsCAGEA103^Felt you ought to cut down on drinking or drug use^ADM||Y||||||F
OBX|146|TX|PsCAGEA203^Been annoyed by people criticizing your drinking or drug use^ADM||Y||||||F
OBX|147|TX|PsCAGEA303^Ever felt bad or guilty about your  drinking or drug use^ADM||Y||||||F
OBX|148|TX|PsCAGEA403^Ever had a drink or used drugs first thing  in the morning^ADM||Y||||||F
OBX|149|TX|PsCAGET004^CAGE-AID total^ADM||4||||||F
OBX|150|TX|PsCLB00000^Communication language barrier^ADM||N||||||F
OBX|151|CE|PsSU000002^Substance use^ADM||1^None||||||F
OBX|152|TX|PsSU000202^Substance use comments^ADM||TESTING||||||F
OBX|153|TX|ReAENTRY00^Air entry adequate throughout^ADM||N||||||F
OBX|154|CE|ReAUAIRE01^Air entry^ADM||3^Absent||||||F
OBX|155|CE|ReAUBTHS02^Breath sounds^ADM||6^Crackles||||||F
OBX|156|CE|ReAULOCT00^Auscultation location^ADM||7^Left lung||||||F
OBX|157|CE|ReAULOMO00^Auscultation location modifier^ADM||1^Anterior~2^Posterior~3^Lateral||||||F
OBX|158|CE|ReAW000200^Airway findings^ADM||1^Maintains own and clear~9^Hoarse voice||||||F
OBX|159|TX|ReAW000250^Airway findings other^ADM||TESTING||||||F
OBX|160|CE|ReAW000300^Airway interventions^ADM||1^Oral suction||||||F
OBX|161|TX|ReAW000350^Airway interventions other^ADM||TESTING||||||F
OBX|162|TX|ReAW000360^Airway on arrival comments^ADM||TESTING||||||F
OBX|163|TX|ReAW000590^Airway assessment comments^ADM||TESTING||||||F
OBX|164|CE|ReAW000600^Artificial airway in situ^ADM||1^Oropharyngeal airway~2^Nasopharyngeal airway~3^Established tracheostomy||||||F
OBX|165|TX|ReAW000700^Artificial airway in situ other^ADM||TESTING||||||F
OBX|166|TX|ReBCLEAR00^Breath sounds clear throughout^ADM||Y||||||F
OBX|167|TX|ReBRESOU00^Breath sounds other^ADM||TESTING||||||F
OBX|168|TX|ReBROA0000^Breathing status on arrival^ADM||TESTING||||||F
OBX|169|CE|ReCGDESC01^Cough description^ADM||2^Congested||||||F
OBX|170|TX|ReCGDESO00^Cough description other^ADM||TESTING||||||F
OBX|171|TX|ReCGPROD00^Cough productive^ADM||Y||||||F
OBX|172|TX|ReFIND0000^Other respiratory findings^ADM||TESTING||||||F
OBX|173|TX|ReMEDGIV00^Inhalers/Nebulizers given^ADM||Y||||||F
OBX|174|CE|ReNRDISI03^Respiratory distress indicators^ADM||1^Accessory muscle use~9^Sitting position altered||||||F
OBX|175|TX|ReOXTHAP00^Oxygen therapy applied^ADM||N||||||F
OBX|176|CE|RePHASE000^Phase^ADM||1^Inspiration||||||F
OBX|177|CE|ReRECHEX01^Chest expansion^ADM||1^Symmetrical||||||F
OBX|178|TX|ReREDISO00^Respiratory distress indicators other^ADM||TESTING||||||F
OBX|179|CE|ReREDPTH00^Respiratory depth^ADM||1^Normal||||||F
OBX|180|TX|ReREPTRN01^Respiratory pattern^ADM||TESTING||||||F
OBX|181|CE|ReRESDIS00^Respiratory distress indicators^ADM||1^Accessory muscle use~2^Audible wheeze~3^Audible stridor~5^Nasal flaring~7^Pursed lip breathing~8^Speaks in short sentences~9^Sitting position altered||||||F
OBX|182|CE|ReRPNM0000^Respiratory pattern^ADM||1^Normal||||||F
OBX|183|TX|ReRTCONS00^Respiratory therapist consulted^ADM||N||||||F
OBX|184|CE|ReSCCOLR00^Secretions colour^ADM||1^Clear||||||F
OBX|185|TX|RpME000100^Date of last menses^ADM||20191114||||||F
OBX|186|TX|RpPBREAS00^Patient breastfeeding^ADM||Y||||||F
OBX|187|CE|RpPRPREG00^Pregnant^ADM||1^Yes||||||F
OBX|188|TX|SpCYTOME00^Receiving cytotoxic medication^ADM||N||||||F
OBX|189|CE|SpCYTOPR00^Cytotoxic precautions required^ADM||1^None||||||F
OBX|190|TX|SpEDSWA101^ARO/MDRO swabs collected^ADM||Y||||||F
OBX|191|TX|SpEDSWAB01^ARO/MDRO swabs required^ADM||Y||||||F
OBX|192|CE|SpIP000000^Isolation precautions rationale suspected/confirmed^ADM||18^HSV||||||F
OBX|193|TX|SpIPROTH00^Isolation precautions rationale suspected/confirmed other^ADM||TESTING||||||F
OBX|194|TX|SpPERSA100^Is anyone hurting/threatening you or making you feel afraid^ADM||N||||||F
OBX|195|TX|SpSAFREF10^Safety referrals made other^ADM||TESTING||||||F
OBX|196|CE|SpSAREFP00^Safety referrals made^ADM||1^Social Worker~4^Police~7^Substance use supports||||||F
OBX|197|TX|SpUPAICM02^Fall prevention comments^ADM||TESTING||||||F
OBX|198|TX|TR.CC^History of Chief Complaint^ADM||TESTING||||||F
OBX|199|TX|VsPU001400^Pulse location^ADM||TESTING||||||F
OBX|200|CE|VsPULSTR10^Pulse strength^ADM||1^Doppler||||||F
OBX|201|TX|VsRESP0001^Respiratory effort^ADM||TESTING||||||F
OBX|202|TX|VsWT000101^Current Weight^ADM||74.000||||||F
OBX|203|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||74000.000||||||F
OBX|204|CE|VsWTSRC000^Weight source^ADM||2^Estimated||||||F
ZFH|LUMED|||NEW|New Patient||

