MSH|^~\&|ADM|ARH|||201911221257||ADT^A08|4111508|D|2.2|||AL|NE
EVN|A08|20191122||||
PID|1|FHATVIG0002185|AB00007243|AB7218|EDMTEST^ROBYN||19970320|F|||1^^Surrey^BC^V3V 9V9|||||||AB000038/18|
PV1|1|I|AB-1BAKER^AB1B-B105^2|EL|||DELAPAZO^De La PazTEST^OliverTEST^^^^^^^^^^XX||CHENGN^CHENG^NOK^CIS^^^^^^^^^XX|ACE||||||||IN|||||||||||||||||||||ARH|||||201804061052|
PV2||W^Ward|TESTING ERROR
OBX|1|ST|1010.1^WEIGHT^CPT4||54.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||163.0||||||F
OBX|3|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20180403||||||F
OBX|4|CE|ADM IDSOUR^SOURCE OF ID^ADM||NONE^None||||||F
OBX|5|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|6|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|7|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|8|TX|AcDAIL0003^Current RASS goal^ADM||0||||||F
OBX|9|TX|AdADMRSN00^Reason for admission^ADM||TEST TEST TEST TEST||||||F
OBX|10|TX|AdALERGI00^ID and allergy band(s) applied^ADM||Y||||||F
OBX|11|TX|AdEDCC0000^Chief Complaint^ADM||testing||||||F
OBX|12|CE|AdINSM0000^Information source^ADM||1^Patient~3^Family||||||F
OBX|13|TX|AdINTNEE00^Interpreter needed^ADM||Y||||||F
OBX|14|TX|CaCWMSSF10^CWMS satisfactory to all limbs^ADM||Y||||||F
OBX|15|CE|CaHS000200^Heart sounds quality^ADM||1^Normal||||||F
OBX|16|CE|CaHS000700^Heart sounds audible^ADM||1^S1~3^S2||||||F
OBX|17|TX|CaTELERQ00^Cardiac monitoring required^ADM||Y||||||F
OBX|18|CE|GiAB000400^Abdomen description^ADM||1^Flat~6^Taut||||||F
OBX|19|CE|GiABPALP04^Abdominal palpation^ADM||2^Tender||||||F
OBX|20|TX|GiDUTUPH01^pH duodenal tube^ADM||5.0||||||F
OBX|21|CE|GiETDEDE00^Enteral feeding tube delivery service^ADM||1^Gravity||||||F
OBX|22|CE|GiETSYST00^Enteral feeding tube system^ADM||1^Open||||||F
OBX|23|CE|GiGICOMP00^Gastrointestinal complaints^ADM||1^None||||||F
OBX|24|TX|GiNICUPH01^pH gastric tube^ADM||3.0||||||F
OBX|25|CE|GuURCMR100^Urinary complaints^ADM||1^None||||||F
OBX|26|CE|GuURCMR300^Genitalia complaints^ADM||1^None||||||F
OBX|27|CE|HxHCDMAD01^Healthcare decision making advanced directives^ADM||1^Living Will||||||F
OBX|28|TX|HxIMMUTD00^Immunizations up to date^ADM||N||||||F
OBX|29|TX|HxSPTCHX00^Summary of patient's clinical history^ADM||test||||||F
OBX|30|TX|HxTABCU000^Tobacco use current use^ADM||Y||||||F
OBX|31|TX|HxTSDMR001^Surrogate healthcare decision maker/TSDM required^ADM||N||||||F
OBX|32|CE|HxVACUTD00^Tetanus immunization up to date^ADM||1^Up To Date||||||F
OBX|33|TX|InMMHYD010^Hydration status^ADM||re||||||F
OBX|34|CE|InPED00400^Peripheral skin appearance^ADM||1^Normal||||||F
OBX|35|CE|InPED00600^Central skin temperature^ADM||2^Warm||||||F
OBX|36|CE|InSKIAPP01^Skin appearance^ADM||1^Normal||||||F
OBX|37|CE|InSKIMOI01^Skin moisture^ADM||1^Dry||||||F
OBX|38|CE|InSKITEM00^Skin temperature^ADM||1^Hot||||||F
OBX|39|CE|InWNDCOM50^Integumentary complaints^ADM||1^None||||||F
OBX|40|CE|MoFALRSK00^Falls risk factors^ADM||1^History of falls||||||F
OBX|41|CE|MsCS000000^Cervical spine concerns identified^ADM||1^None||||||F
OBX|42|TX|MsCS000301^Cervical spine on arrival comments^ADM||re||||||F
OBX|43|TX|MsCS000500^C-spine immobilized prior to arrival^ADM||Y||||||F
OBX|44|CE|MsCS000600^C-spine management^ADM||1^None||||||F
OBX|45|TX|MsMSKCR400^Musculoskeletal concerns identified^ADM||N||||||F
OBX|46|CE|Ne00000200^Behaviour^ADM||8^Calm||||||F
OBX|47|TX|NeAGITAT00^Agitation comments^ADM||TEST||||||F
OBX|48|CE|NeGCSEYE03^Glasgow Coma Scale Eye Opening^ADM||1^4- Spontaneous||||||F
OBX|49|CE|NeGCSMOT03^Glasgow Coma Scale Motor Response^ADM||1^6- Obeys commands||||||F
OBX|50|TX|NeGCSSCR01^GCS score^ADM||15||||||F
OBX|51|CE|NeGCSVER03^Glasgow Coma Scale Verbal Response^ADM||1^5- Oriented||||||F
OBX|52|TX|NeGLBLGU00^Glucometer blood glucose^ADM||5.0||||||F
OBX|53|CE|NeICDSCC01^ICDSC altered level of consciousness^ADM||1^1||||||F
OBX|54|CE|NeICDSCD01^ICDSC disorientation^ADM||0^0||||||F
OBX|55|CE|NeICDSCF01^ICDSC symptom fluctuation^ADM||1^1||||||F
OBX|56|CE|NeICDSCH01^ICDSC hallucination, delusion or psychosis^ADM||1^1||||||F
OBX|57|CE|NeICDSCI01^ICDSC inattention^ADM||0^0||||||F
OBX|58|CE|NeICDSCP01^ICDSC psychomotor agitation or retardation^ADM||0^0||||||F
OBX|59|TX|NeICDSCR00^ICDSC score^ADM||4||||||F
OBX|60|CE|NeICDSCS01^ICDSC inappropriate speech or mood^ADM||1^1||||||F
OBX|61|CE|NeICDSCW03^ICDSC sleep/wake cycle disturbance^ADM||0^0||||||F
OBX|62|CE|NeLECONS00^Level of consciousness^ADM||1^Alert||||||F
OBX|63|CE|NeNEFND000^Neurological findings^ADM||1^Headache||||||F
OBX|64|CE|NeORIENT00^Oriented^ADM||1^To person~2^To place~3^To time||||||F
OBX|65|CE|NePURXNL00^Pupil reaction to light^ADM||1^Brisk||||||F
OBX|66|CE|NePUSHPE00^Pupil shape^ADM||1^Round||||||F
OBX|67|CE|NePUSIDE00^Pupil side^ADM||2^Right||||||F
OBX|68|CE|NeRASS0000^RASS score^ADM||3^+2 Agitated||||||F
OBX|69|CE|NmGCSCEO00^Eye opening^ADM||2^2 - To pain||||||F
OBX|70|CE|NmGCSCMR00^Motor response^ADM||1^6 - Obeys commands||||||F
OBX|71|TX|NmGCSCTS00^Modified GCS Child score^ADM||13||||||F
OBX|72|CE|NmGCSCVR00^Verbal response^ADM||1^5 - Oriented/Appropriate||||||F
OBX|73|CE|NmGCSIEO00^Eye opening^ADM||1^4 - Spontaneous||||||F
OBX|74|CE|NmGCSIMR00^Motor response^ADM||1^6 - Spontaneous||||||F
OBX|75|TX|NmGCSITS00^Modified GCS Infant score^ADM||15||||||F
OBX|76|CE|NmGCSIVR00^Verbal response^ADM||1^5 - Coos, babbles||||||F
OBX|77|TX|NmMR001400^Motor strength satisfactory^ADM||Y||||||F
OBX|78|CE|Nu00000301^Enteral nutrition hold reasons^ADM||1^Medication||||||F
OBX|79|TX|NuEN000200^Enteral nutrition hold date^ADM||20180319||||||F
OBX|80|TX|NuEN000300^Enteral nutrition hold time^ADM||1434||||||F
OBX|81|CE|NuENDELI00^Enteral nutrition delivery schedule^ADM||1^Continuous||||||F
OBX|82|CE|NuENFLUS01^Feeding tube flush type^ADM||1^Water||||||F
OBX|83|CE|OEISO^Infection Control:^ADM||D^Droplet||||||F
OBX|84|TX|OhEDIT0000^Reason for edit^ADM||none||||||F
OBX|85|CE|PaANTYPE00^Analgesic infusion type^ADM||1^Fentanyl||||||F
OBX|86|TX|PaCOMMEN00^Pain comments^ADM||TEST||||||F
OBX|87|CE|PaCPOTBO00^CPOT body movements^ADM||1^0-Absence or normal||||||F
OBX|88|CE|PaCPOTFA00^CPOT facial expression^ADM||2^1-Tense||||||F
OBX|89|CE|PaCPOTMU00^CPOT muscle tension^ADM||1^0-Relaxed||||||F
OBX|90|TX|PaCPOTSC00^CPOT score^ADM||1||||||F
OBX|91|CE|PaCPOTVV00^CPOT compliance with the ventilator or vocalization^ADM||2^0-Talking/No sound||||||F
OBX|92|CE|PaLOCBDS02^Location^ADM||31^Breast||||||F
OBX|93|CE|PaPAIASS00^Pain assessment^ADM||1^Pain not reported||||||F
OBX|94|CE|PaPAINAS00^Pain assessed^ADM||1^At rest||||||F
OBX|95|CE|PaPALOCM00^Pain location modifier^ADM||2^Right||||||F
OBX|96|CE|PaPASCLE00^Pain scale used^ADM||1^Numeric||||||F
OBX|97|TX|PaPASCRE01^Pain score^ADM||6.00||||||F
OBX|98|TX|PhAN000100^Analgesic bolus given^ADM||Y||||||F
OBX|99|TX|PsCAREDA00^Date of care conference^ADM||20180320||||||F
OBX|100|TX|PsCARETI00^Time of care conference^ADM||1429||||||F
OBX|101|TX|PsCC000000^Individuals present^ADM||hjdoisalh||||||F
OBX|102|TX|PsCC000100^Information shared^ADM||dsa||||||F
OBX|103|TX|PsCC000200^Plans discussed^ADM||cxas||||||F
OBX|104|TX|PsCC000300^Follow-up actions required^ADM||cdsa||||||F
OBX|105|TX|PsCLB00000^Communication language barrier^ADM||Y||||||F
OBX|106|TX|PsFID00000^Family information dependants^ADM||FSDA||||||F
OBX|107|CE|PsFIMS0001^Family information marital status^ADM||1^Single||||||F
OBX|108|CE|PsSU000000^Substance use^ADM||1^Alcohol||||||F
OBX|109|TX|ReAENTRY00^Air entry adequate throughout^ADM||Y||||||F
OBX|110|CE|ReAW000200^Airway findings^ADM||1^Maintains own and clear||||||F
OBX|111|CE|ReAW000300^Airway interventions^ADM||1^Oral suction||||||F
OBX|112|TX|ReAW000360^Airway on arrival comments^ADM||re||||||F
OBX|113|CE|ReAW000500^Airway patency/protection^ADM||1^Maintains own airway||||||F
OBX|114|TX|ReAW000560^Airway patency/protection comments^ADM||fsjkla||||||F
OBX|115|CE|ReAW000570^Airway significant findings^ADM||1^Stridor||||||F
OBX|116|CE|ReAW000600^Artificial airway in situ^ADM||1^Oropharyngeal airway||||||F
OBX|117|TX|ReAW000690^Artificial airway in situ on assessment^ADM||Y||||||F
OBX|118|TX|ReBCLEAR00^Breath sounds clear throughout^ADM||Y||||||F
OBX|119|CE|ReBROA0000^Breathing status on arrival^ADM||1^Spontaneous||||||F
OBX|120|TX|ReMEDGIV00^Inhalers/Nebulizers given^ADM||Y||||||F
OBX|121|CE|ReNRDISI03^Respiratory distress indicators^ADM||1^Accessory muscle use||||||F
OBX|122|TX|ReOXTHAP00^Oxygen therapy applied^ADM||N||||||F
OBX|123|TX|RePRAMIN00^Pediatric Respiratory Assessment Measure initiated^ADM||Y||||||F
OBX|124|CE|ReRECHEX01^Chest expansion^ADM||1^Symmetrical||||||F
OBX|125|CE|ReRPNM0000^Respiratory pattern^ADM||1^Normal||||||F
OBX|126|CE|RpDE000100^Delivery type^ADM||5^Caesarean elective||||||F
OBX|127|CE|RpFR000100^Female reproductive complaints^ADM||1^None||||||F
OBX|128|CE|SpCYTOPR00^Cytotoxic precautions required^ADM||1^None||||||F
OBX|129|CE|SpIPRATI02^Isolation precautions rationale suspected/confirmed^ADM||12^Bed bugs||||||F
OBX|130|TX|SpPERSA100^Is anyone hurting/threatening you or making you feel afraid^ADM||N||||||F
OBX|131|TX|SpRIREQU00^Reverse isolation required^ADM||N||||||F
OBX|132|TX|TR.CC^History of Chief Complaint^ADM||test||||||F
OBX|133|TX|VS.WTKG.2^Weight (Kg)^ADM||2.200||||||F
OBX|134|CE|VsHRRHYM00^Heart rate rhythm^ADM||1^Regular||||||F
OBX|135|CE|VsHRRHYM02^Pulse rhythm^ADM||1^Regular||||||F
OBX|136|TX|VsHTCM0100^Current height^ADM||163.0||||||F
OBX|137|CE|VsRESP0001^Respiratory effort^ADM||1^Non-laboured||||||F
OBX|138|TX|VsRESP0100^Oxygen applied^ADM||Y||||||F
OBX|139|TX|VsWT000100^Current weight^ADM||33.000||||||F
OBX|140|TX|VsWT000101^Current Weight^ADM||54.000||||||F
OBX|141|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||54000.000||||||F
OBX|142|CE|VsWTSRC000^Weight source^ADM||1^Stated||||||F
ZFD|||CAMPBELLR^CampbellTEST^ReneTEST^^^^^^DOC||DELAPAZO^De La PazTEST^OliverTEST^^^^^^DOC|DELAPAZO^De La PazTEST^OliverTEST^^^^^^DOC||CHENGN^CHENG^NOK^CIS^^^^^DOC|
ZFH|LUMED|201804060807|||||

MSH|^~\&|ADM|ARH|||201911221257||ADT^A08|4111509|D|2.2|||AL|NE
EVN|A08|20191122||||
PID|1|FHATVIG0000154|AB00006631|AB6632|ITSTEST^ZINCOCHROMITE||19800202|M|||789 10TH AVENUE^^HOPE^BC^V7V 8V8|||||||AB000036/17|9876588163
PV1|1|I|AB-1BAKER^AB1B-B105^1|EL|||OEDOCM^Oedoc^Marytrain^^^^MD^^^^^^XX||CHENGN^CHENG^NOK^CIS^^^^^^^^^XX|MEDS||||||||IN|||||||||||||||||||||ARH|||||201707251402|
PV2||W^Ward|DIZZINESS
OBX|1|ST|1010.1^WEIGHT^CPT4||75.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||170.0||||||F
OBX|3|CE|ADM CCI1^CCI#1^ADM||AVB^AVB-Agressive/Violent Beh||||||F
OBX|4|TX|ADM CCI2^CCI#2^ADM||||||||F
OBX|5|TX|ADM CCI3^CCI#3^ADM||||||||F
OBX|6|TX|ADM CCI4^ARO - Antibiotic Resistant Organisms^ADM||||||||F
OBX|7|TX|ADM CCI5^DNA - Do Not Acknowledge^ADM||||||||F
OBX|8|TX|ADM CCI6^AVB - Aggressive/Violent Behaviour^ADM||||||||F
OBX|9|TX|ADM CCI7^MDR - Multiple Drug Resistant Organisms^ADM||||||||F
OBX|10|TX|ADM CCI7a^          **or**^ADM||||||||F
OBX|11|TX|ADM CCICO1^Comments:^ADM||||||||F
OBX|12|TX|ADM CCICO2^:^ADM||||||||F
OBX|13|TX|ADM CCICO3^:^ADM||||||||F
OBX|14|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20170416||||||F
OBX|15|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCSOP^BC Services \T\ Other Photo||||||F
OBX|16|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|17|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|18|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|19|CE|AcFTTYPE00^Footwear type^ADM||1^Non slip socks||||||F
OBX|20|CE|AcHEHT0000^Home environment - housing type^ADM||1^House||||||F
OBX|21|CE|AcHEHT0M00^Home environment - housing type^ADM||2^Bungalow with basement||||||F
OBX|22|CE|AcHOCNPR00^Housing considerations prior to admission^ADM||3^Pets at home||||||F
OBX|23|TX|AcHOCOMM00^Housing prior to admission comments^ADM||Patient got evicted.||||||F
OBX|24|TX|AcHYGCOMM0^Personal care comments^ADM||test||||||F
OBX|25|TX|AcLIVOTH00^Living with others prior to admission^ADM||N||||||F
OBX|26|TX|AcPTSHOWE0^Patient showered^ADM||Y||||||F
OBX|27|TX|AcTOASST02^Toileting assistance^ADM||||||||F
OBX|28|CE|AcTOEQ0000^Equipment used for toileting^ADM||4^Toilet grab bars||||||F
OBX|29|TX|Ad00002000^Two patient identifiers checked^ADM||N||||||F
OBX|30|TX|AdAC000100^Accompanied by other^ADM||wife||||||F
OBX|31|TX|AdADMDAT01^Admission date^ADM||20190505||||||F
OBX|32|CE|AdADMFRO01^Admitted from^ADM||1^Emergency||||||F
OBX|33|TX|AdADMIPB00^Any travel to India Pakistan or Bangladesh in last 12 months^ADM||Y||||||F
OBX|34|TX|AdADMOUT01^Any healthcare encounter outside Canada in last 12 months^ADM||Y||||||F
OBX|35|TX|AdADMRSN00^Reason for admission^ADM||Depression with SI||||||F
OBX|36|TX|AdADMSIX00^Admitted to care area in the last 6 months^ADM||N||||||F
OBX|37|TX|AdADMTIM00^Admission time^ADM||1600||||||F
OBX|38|TX|AdADMTRA00^Name of other unit/site^ADM||smh||||||F
OBX|39|TX|AdAGMDFO00^Against medical advice form signed^ADM||Y||||||F
OBX|40|TX|AdALLERB00^Allergy band checked^ADM||Y||||||F
OBX|41|TX|AdALLERR00^Allergies reviewed^ADM||Y||||||F
OBX|42|TX|AdAMA00000^Left hospital without any notification^ADM||Y||||||F
OBX|43|CE|AdARRMOD00^Mode of arrival^ADM||1^Stretcher||||||F
OBX|44|TX|AdBIRTH010^Expected date of delivery^ADM||20180622||||||F
OBX|45|CE|AdCSUM0000^Community supports utilized prior to admission^ADM||1^None||||||F
OBX|46|TX|AdDCCOMP00^Discharge plan complete^ADM||Y||||||F
OBX|47|CE|AdDISCHA00^Destination^ADM||1^Home||||||F
OBX|48|TX|AdESTDDC03^Reason EDD changed comments^ADM||No change.||||||F
OBX|49|TX|AdESTDTD00^Estimated date of discharge^ADM||20190824||||||F
OBX|50|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity||||||F
OBX|51|TX|AdFUAPCO04^Services and appointments arranged comments^ADM||services arranged other||||||F
OBX|52|TX|AdHXALLE00^Hx of unexplained allergic reaction during medical procedure^ADM||Y||||||F
OBX|53|TX|AdHXCOND00^History of presenting condition^ADM||Patient ran away from parent's home. Relationship of 5 years recently~ended. Patient drinking excessively.||||||F
OBX|54|TX|AdHXITCH00^Hx of itchiness/swelling post dental, rectal or pelvic exam^ADM||Y||||||F
OBX|55|CE|AdHXRUBB00^Hx of sensitivity to materials containing rubber^ADM||7^Erasers||||||F
OBX|56|TX|AdHXSBIF00^Hx of Spina Bifida^ADM||Y||||||F
OBX|57|TX|AdINPSNT00^Inpatient referral(s) sent to other^ADM||intpatient other||||||F
OBX|58|CE|AdINPTRF00^Inpatient referral(s) sent to^ADM||9^Recreation therapist~12^Respiratory therapist~18^Social worker~21^Wound care/ostomy nurse||||||F
OBX|59|TX|AdINTNEE00^Interpreter needed^ADM||Y||||||F
OBX|60|CE|AdLITUBE01^Lines/Tubes in situ^ADM||5^Enteral feeding tube~7^Arterial line~9^ETT||||||F
OBX|61|TX|AdNAMEBN00^Name band on^ADM||N||||||F
OBX|62|TX|AdODISPC00^Other discharge planning comments^ADM||May22: Continue with medication trial.~May18: Patient experiencing side effects with current medication. Started~on new medication today.||||||F
OBX|63|CE|AdOTPREF01^Outpatient/Community referral(s) sent to^ADM||15^Nurse practitioner~18^Geriatrician~24^SLP~27^Palliative care||||||F
OBX|64|TX|AdOTPSNT00^Outpatient/Community referral(s) sent to other^ADM||outpatient other||||||F
OBX|65|TX|AdOTRERF00^Reason for referral^ADM||xxx||||||F
OBX|66|TX|AdPLACEC00^Lines/Tubes placement confirmed with physician^ADM||N||||||F
OBX|67|TX|AdPRLANG00^Primary language spoken^ADM||German||||||F
OBX|68|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||N||||||F
OBX|69|TX|AdPTFAMY00^Patient/Family goals for discharge^ADM||patient fam goal||||||F
OBX|70|TX|AdRECPDB00^Disharge barriers identified by recreational therapist^ADM||discharge barriers||||||F
OBX|71|TX|AdRECPDE00^Problem details^ADM||problem details 3||||||F
OBX|72|TX|AdRECPGD00^Goal target date^ADM||20190925||||||F
OBX|73|TX|AdRECPGO00^Goal^ADM||goal 3||||||F
OBX|74|CE|AdRECPGS00^Goal status^ADM||3^Met||||||F
OBX|75|CE|AdRECPID00^Problem identified^ADM||5^Social awareness||||||F
OBX|76|TX|AdRECPIN00^1. Intervention to address problem^ADM||int 1 prob 3||||||F
OBX|77|TX|AdRECPIN01^2. Intervention to address problem^ADM||int 2 pr 3||||||F
OBX|78|TX|AdRECPIN02^3. Intervention to address problem^ADM||int3||||||F
OBX|79|TX|AdRECPIN03^4. Intervention to address problem^ADM||int4||||||F
OBX|80|TX|AdRECPIN04^5. Intervention to address problem^ADM||int5||||||F
OBX|81|TX|AdREPREF00^Report received^ADM||text||||||F
OBX|82|TX|AdREPRFR01^Report received from^ADM||dr||||||F
OBX|83|CE|AdSERVAR00^Services arranged^ADM||1^None required||||||F
OBX|84|TX|AdSITUOT00^Lines/Tubes in situ other^ADM||PICC||||||F
OBX|85|TX|AdSLATEX01^Suspected latex allergy^ADM||Y||||||F
OBX|86|TX|AdSTRECO01^Reason EDD changed other^ADM||EDD other||||||F
OBX|87|TX|AdTWPAID01^Two patient identifiers checked^ADM||Y||||||F
OBX|88|CE|Ca00000000^Pre-existing pain concerns^ADM||1^No concerns identified~3^Care plan initiated||||||F
OBX|89|CE|Ca00000001^Pre-existing medication concerns^ADM||1^No concerns identified||||||F
OBX|90|CE|Ca00000002^Pre-existing nutrition/hydration concerns^ADM||1^No concerns identified||||||F
OBX|91|CE|Ca00000003^Pre-existing bowel/bladder concerns^ADM||1^No concerns identified||||||F
OBX|92|CE|Ca00000004^Pre-existing cognitive concerns^ADM||2^Concerns identified~3^Care plan initiated||||||F
OBX|93|CE|Ca00000005^Pre-existing mobility concerns^ADM||1^No concerns identified||||||F
OBX|94|CE|Ca00000100^Right radial pulse^ADM||3^+1||||||F
OBX|95|CE|Ca00000200^Right ulnar pulse^ADM||6^+4||||||F
OBX|96|CE|Ca00000400^Left radial pulse^ADM||2^0||||||F
OBX|97|CE|Ca00000500^Left ulnar pulse^ADM||5^+3||||||F
OBX|98|CE|Ca00000700^Right dorsalis pedis pulse^ADM||5^+3||||||F
OBX|99|CE|Ca00000800^Right post tibial pulse^ADM||3^+1||||||F
OBX|100|CE|Ca00000900^Right popliteal pulse^ADM||2^0||||||F
OBX|101|CE|Ca00001000^Left dorsalis pedis pulse^ADM||2^0||||||F
OBX|102|CE|Ca00001100^Left post tibial pulse^ADM||2^0||||||F
OBX|103|CE|Ca00001200^Left popliteal pulse^ADM||2^0||||||F
OBX|104|CE|Ca00001300^Right femoral pulse^ADM||2^0||||||F
OBX|105|CE|Ca00001400^Left femoral pulse^ADM||2^0||||||F
OBX|106|TX|CaCA000400^Cardiac rhythm RR segment^ADM||722||||||F
OBX|107|CE|CaCAARIN00^Investigations done^ADM||1^Blood work||||||F
OBX|108|CE|CaCAARIT00^Cardiac interventions^ADM||5^Code blue called||||||F
OBX|109|TX|CaCAMODD00^Date cardiac monitoring discontinued^ADM||20180115||||||F
OBX|110|CE|CaCARHEC00^Cardiac rhythm ectopy^ADM||6^Trigeminal||||||F
OBX|111|CE|CaCRFOLE01^Capillary refill left foot^ADM||1^Less than 3 seconds||||||F
OBX|112|CE|CaCRFORI01^Capillary refill right foot^ADM||1^Less than 3 seconds||||||F
OBX|113|CE|CaCRHALE00^Capillary refill left hand^ADM||1^Less than 3 seconds||||||F
OBX|114|CE|CaCRHARI00^Capillary refill right hand^ADM||1^Less than 3 seconds||||||F
OBX|115|TX|CaCV000100^Central venous pressure^ADM||6||||||F
OBX|116|CE|CaCYANOS00^Cyanosis^ADM||1^None||||||F
OBX|117|CE|CaEDEMA000^Edema^ADM||2^Present||||||F
OBX|118|CE|CaHS000200^Heart sounds quality^ADM||1^Normal||||||F
OBX|119|TX|CaHS000300^Heart sounds murmur^ADM||N||||||F
OBX|120|CE|CaHS000400^Heart sounds murmur^ADM||1^Systole||||||F
OBX|121|TX|CaHS000500^Heart sounds rub^ADM||N||||||F
OBX|122|TX|CaHS000600^Heart sounds mechanical valve click^ADM||N||||||F
OBX|123|CE|CaHS000700^Heart sounds audible^ADM||1^S1~3^S2||||||F
OBX|124|CE|CaPACETY50^Pacemaker type^ADM||2^Transvenous||||||F
OBX|125|TX|CaPLDATE00^PIV Insertion date^ADM||20190426||||||F
OBX|126|CE|CaPULEDP00^Pulses left dorsalis pedis^ADM||2^+1||||||F
OBX|127|CE|CaPULEFE00^Pulses left femoral^ADM||3^+2||||||F
OBX|128|CE|CaPULEPT00^Pulses left post tibial^ADM||3^+2||||||F
OBX|129|CE|CaTRPSPD00^Pacing dependence^ADM||1^None at all||||||F
OBX|130|TX|CaVTCOAG00^VTE prevention anticoagulant ordered^ADM||N||||||F
OBX|131|CE|CaVTCOMP02^VTE prevention sequential compression device in use^ADM||1^None||||||F
OBX|132|CE|CaVTSTOC01^VTE prevention antiembolic stockings in use^ADM||1^None||||||F
OBX|133|CE|CmCTRIAL00^Compensatory strategies trialled^ADM||6^Smaller bolus size~16^Cyclic ingestion||||||F
OBX|134|CE|CoNOVECO00^Nonverbal communication^ADM||1^Not interacting||||||F
OBX|135|TX|Gi00000600^Maintaining baseline stool pattern^ADM||N||||||F
OBX|136|CE|Gi00001500^Gastrointestinal assessment^ADM||1^Within defined parameters||||||F
OBX|137|CE|Gi00001700^Genitourinary assessment^ADM||1^Within defined parameters||||||F
OBX|138|TX|GiABAPGE00^Abdominal general appearance^ADM||Scar on left side, 5cm in length||||||F
OBX|139|CE|GiABPALP02^Abdominal palpation^ADM||1^Soft||||||F
OBX|140|CE|GiABSHAP00^Abdominal shape^ADM||1^Flat||||||F
OBX|141|CE|GiBMAMT200^Bowel movement amount^ADM||2^Medium (240 mL)||||||F
OBX|142|CE|GiBMAMT201^Bowel movement amount^ADM||7^Small||||||F
OBX|143|CE|GiBMCOLO01^Bowel movement colour^ADM||1^Brown||||||F
OBX|144|TX|GiBMINCO00^Bowel movement incontinence^ADM||||||||F
OBX|145|CE|GiBMINTE01^Bowel movement level of intervention^ADM||3^Bowel protocol given||||||F
OBX|146|TX|GiBMMETH01^Bowel movement method^ADM||||||||F
OBX|147|TX|GiBO000301^Last bowel movement date as reported by patient^ADM||20191112||||||F
OBX|148|TX|GiBO000302^Last bowel movement date as reported by patient^ADM||20180620||||||F
OBX|149|CE|GiBOFLAT00^Bowel flatus present^ADM||1^Absent||||||F
OBX|150|CE|GiBS000100^Bowel sounds frequency^ADM||1^Active||||||F
OBX|151|CE|GiBSACTI01^Bowel sounds active in all four quadrants^ADM||1^Yes||||||F
OBX|152|TX|GiCONSTI00^Patient experiencing constipation^ADM||N||||||F
OBX|153|TX|GiDIARRH00^Patient experiencing diarrhea^ADM||Y||||||F
OBX|154|TX|GiNAUSVO00^Patient experiencing nausea/vomiting^ADM||N||||||F
OBX|155|CE|GiOSASST00^Ostomy assistance provided by^ADM||2^Nurse||||||F
OBX|156|CE|GiOSCARE00^Ostomy care^ADM||1^Dependent||||||F
OBX|157|CE|GiOSFLAN00^Ostomy flange/pouch style^ADM||1^Drainable pouch||||||F
OBX|158|CE|GiOSMUMA00^Ostomy mucocutaneous margin^ADM||1^Approximated||||||F
OBX|159|CE|GiOSPSSK00^Ostomy peristomal skin^ADM||1^Intact||||||F
OBX|160|CE|GiOSREAS00^Ostomy reason for flange/pouch change^ADM||1^Patient education||||||F
OBX|161|TX|GiRTINSI00^Rectal tube in situ^ADM||N||||||F
OBX|162|CE|GiRTRETU01^Rectal tube returns^ADM||4^None||||||F
OBX|163|TX|GiVOMGAG00^Patient vomiting/gagging^ADM||N||||||F
OBX|164|TX|GuBDSVA000^Bladder scan volume^ADM||300||||||F
OBX|165|CE|GuBDUTIS00^Urinary tract infection signs and symptoms^ADM||2^Fever above 38~5^Dysuria||||||F
OBX|166|CE|GuUDGLUC00^Urine dipstick glucose^ADM||5^+4||||||F
OBX|167|CE|GuUDKT0000^Urine dipstick ketones^ADM||2^+1||||||F
OBX|168|CE|GuUDLEUK00^Urine dipstick leukocytes^ADM||2^+1||||||F
OBX|169|CE|GuUDNIT000^Urine dipstick nitrites^ADM||1^Negative||||||F
OBX|170|CE|GuUDPROT00^Urine dipstick protein^ADM||1^Negative||||||F
OBX|171|CE|GuUR000600^Urine blood^ADM||5^+4||||||F
OBX|172|CE|GuURCOL001^Urine colour^ADM||5^Brown||||||F
OBX|173|TX|GuURPH0000^Urine pH^ADM||7.0||||||F
OBX|174|CE|HeBOLUSP00^Bolus preparation^ADM||2^Prolonged manipulation~5^Insufficient manipulation~8^Minimal/No lingual mvt||||||F
OBX|175|CE|HeBOLUSR00^Bolus retrieval^ADM||3^Reduced labial closure||||||F
OBX|176|CE|HeCO000100^Verbal communication^ADM||7^Aphasic||||||F
OBX|177|CE|HeSL003300^Oral trials feeding^ADM||2^Partial assist||||||F
OBX|178|CE|HeSL003500^Oral trials positioning^ADM||1^Upright in bed||||||F
OBX|179|CE|HeSL004604^Oral residue^ADM||2^Residue Rt lateral sulcus||||||F
OBX|180|TX|HeSL004800^Pharyngeal phase nasal regurgitation^ADM||N||||||F
OBX|181|CE|HeSL004902^Pharyngeal phase swallow initiation^ADM||1^No obvious impairment||||||F
OBX|182|CE|HeSL005301^Signs consistent with esophageal dysphagia or reflux^ADM||1^Dysphagia w/solids alone||||||F
OBX|183|CE|HeSL005502^Swallowing assessment mealtime behaviours observed^ADM||1^Functional||||||F
OBX|184|CE|HeSL013800^Secretions management^ADM||6^Drooling from left side||||||F
OBX|185|CE|HeSL018600^Bolus control^ADM||3^Anterior loss right||||||F
OBX|186|CE|HeSL020202^Oral transfer^ADM||2^Suspected impairment||||||F
OBX|187|TX|HeSL036100^Pre-trials suctioning provided^ADM||N||||||F
OBX|188|CE|HeSL041000^Textures/Consistencies dyed blue/green^ADM||3^Honey thick by cup||||||F
OBX|189|CE|HeSLP06001^Throat clear strength^ADM||3^Weak||||||F
OBX|190|CE|HeSLPTCT00^Textures/Consistencies trialled^ADM||3^Honey thick by cup||||||F
OBX|191|CE|HeVO000100^Voice quality^ADM||6^Weak||||||F
OBX|192|TX|Hx486PRO00^Pre-admission screening questionnaire provided^ADM||Y||||||F
OBX|193|TX|HxMEDREC00^Medication reconciliation form present^ADM||Y||||||F
OBX|194|TX|HxMRSAMD00^MRSA/MDRO swabs completed^ADM||Y||||||F
OBX|195|TX|HxSPTCHX00^Summary of patient's clinical history^ADM||history of depression and anxiety||||||F
OBX|196|TX|HxSPTCHX01^Pertinent clinical history^ADM||none||||||F
OBX|197|TX|HxSPTFHX00^Summary of patient's family history^ADM||father has hx of substance use||||||F
OBX|198|TX|HxVIOL0000^Current violent or homicidal ideation^ADM||||||||F
OBX|199|TX|HxVIOL0010^Violent or homicidal ideation details^ADM||||||||F
OBX|200|CE|InBSACTV00^Braden Scale activity^ADM||3^3-Walks occasionally||||||F
OBX|201|CE|InBSFRSH00^Braden Scale friction and shear^ADM||1^1-Problem||||||F
OBX|202|CE|InBSMOBI01^Braden Scale mobility^ADM||1^1-Completely immobile||||||F
OBX|203|CE|InBSMOIS00^Braden Scale moisture^ADM||3^3-Occasionally moist||||||F
OBX|204|CE|InBSNUTR00^Braden Scale nutrition^ADM||1^1-Very poor||||||F
OBX|205|TX|InBSRISK01^Braden Scale risk level^ADM||Moderate||||||F
OBX|206|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||13||||||F
OBX|207|CE|InBSSPER00^Braden Scale sensory perception^ADM||4^4-No impairment||||||F
OBX|208|CE|InEDEMAS00^Edema severity^ADM||3^+3||||||F
OBX|209|CE|InEDEMLB01^Edema location^ADM||5^Lips||||||F
OBX|210|CE|InEDEMLM00^Edema location modifier^ADM||1^Bilateral||||||F
OBX|211|CE|InEDEMTP00^Edema type^ADM||2^Non-pitting||||||F
OBX|212|TX|InINDRES00^Dressing dry and intact^ADM||N||||||F
OBX|213|CE|InISGR0000^infiltration Scale Grade^ADM||5^+4||||||F
OBX|214|CE|InSA000600^Skin condition^ADM||1^Intact~2^Open||||||F
OBX|215|CE|InSKGNTM00^Generalized skin temperature^ADM||1^Hot||||||F
OBX|216|CE|InSKIAPP00^Skin appearance^ADM||1^Normal||||||F
OBX|217|CE|InSKIDES00^Skin description^ADM||12^Bruised||||||F
OBX|218|CE|InSKIMOD01^Skin and wound modifier^ADM||1^Left~10^Lateral||||||F
OBX|219|CE|InSKIMOI00^Skin moisture^ADM||2^Clammy||||||F
OBX|220|CE|InSKITEM00^Skin temperature^ADM||2^Warm||||||F
OBX|221|CE|InWOULOC01^Skin or wound location^ADM||1^Head||||||F
OBX|222|TX|IoNICUIN30^Intake, IV Amount^ADM||100.00||||||F
OBX|223|TX|IoSOLUMA00^Solution^ADM||medication||||||F
OBX|224|CE|IvIN000600^Glycemic management sample source^ADM||1^Capillary||||||F
OBX|225|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|226|CE|IvPIVLOC00^Location^ADM||4^Wrist PIV||||||F
OBX|227|CE|IvPL000700^Initial management^ADM||1^Infusion||||||F
OBX|228|CE|IvPS000100^Phlebitis scale grade^ADM||3^+2||||||F
OBX|229|TX|IvRATE0000^Rate^ADM||100.00||||||F
OBX|230|TX|IvSIZE0000^Size^ADM||20||||||F
OBX|231|CE|MHTHNKTD00^Take Home Naloxone kit dispensed^ADM||03^Not applicable||||||F
OBX|232|TX|Mh00000100^Speech rate^ADM||||||||F
OBX|233|TX|MhACTIVC00^Current activity^ADM||sleeping||||||F
OBX|234|CE|MhAD000100^Admission status^ADM||2^Involuntary||||||F
OBX|235|CE|MhADLEGS02^Legal status^ADM||1^No legal issues||||||F
OBX|236|TX|MhADLIVP00^Living with others prior to admission^ADM||N||||||F
OBX|237|CE|MhADRGSR00^Aware drug screen may be required upon return^ADM||01^Yes||||||F
OBX|238|CE|MhAFFECT01^Affect^ADM||1^Appropriate||||||F
OBX|239|CE|MhAGGRRF00^Aggression/Harm to others: Risk factors^ADM||01^Not at risk||||||F
OBX|240|CE|MhAGGRSK00^Aggression risk^ADM||01^Low||||||F
OBX|241|CE|MhAPPPAD00^Appetite prior to admission^ADM||1^No concerns identified||||||F
OBX|242|TX|MhAPPTMD00^Appointments made^ADM||Appt with on April 26||||||F
OBX|243|CE|MhAWOLRK00^Wandering/AWOL risk^ADM||01^Low||||||F
OBX|244|TX|MhAXPLIC00^Initial Psychiatric Liaison Intake Assessment complete^ADM||Y||||||F
OBX|245|CE|MhBELCKR00^Aware belongings will be checked upon return^ADM||01^Yes||||||F
OBX|246|CE|MhBHBEHA00^Behaviour^ADM||1^Relaxed||||||F
OBX|247|TX|MhBHEYEC01^Eye contact^ADM||||||||F
OBX|248|TX|MhBHPMAO00^Psychomotor activity^ADM||||||||F
OBX|249|CE|MhBOWAID00^Bowel protocol/aids given^ADM||02^Meds per bowel protocol||||||F
OBX|250|TX|MhCAREAC00^Other care activity comments^ADM||test||||||F
OBX|251|CE|MhCLINRF00^Clinical conditions: Risk factors^ADM||03^Chronic pain||||||F
OBX|252|CE|MhCMAIAG01^Cursing or verbal aggression^ADM||7^3-Once or twice a week||||||F
OBX|253|CE|MhCMAIBT01^Biting^ADM||5^5-Once or twice a day||||||F
OBX|254|TX|MhCMAICM01^CMAI-Long Comments^ADM||pt bx continues to be difficult to manage||||||F
OBX|255|CE|MhCMAICO01^Complaining^ADM||7^3-Once or twice a week||||||F
OBX|256|TX|MhCMAICP01^CMAI-Long completion^ADM||Incomplete||||||F
OBX|257|CE|MhCMAIDR01^Inappropriate dress or disrobing^ADM||2^4-Several times a week||||||F
OBX|258|CE|MhCMAIEA01^Eating/drinking inappropriate substance^ADM||2^4-Several times a week||||||F
OBX|259|CE|MhCMAIEA02^Eating/Drinking inappropriate substance^ADM||7^3-Once or twice a week||||||F
OBX|260|CE|MhCMAIFL01^Intentional falling^ADM||1^1-Never||||||F
OBX|261|CE|MhCMAIGR01^Grabbing onto people^ADM||5^5-Once or twice a day||||||F
OBX|262|CE|MhCMAIHI01^Hiding things^ADM||7^3-Once or twice a week||||||F
OBX|263|CE|MhCMAIHN01^Handling things inappropriately^ADM||1^1-Never||||||F
OBX|264|CE|MhCMAIHO01^Hoarding things^ADM||7^3-Once or twice a week||||||F
OBX|265|TX|MhCMAIHT01^Hitting (including self)^ADM||||||||F
OBX|266|CE|MhCMAIHU01^Hurting self or others^ADM||2^4-Several times a week||||||F
OBX|267|CE|MhCMAIKC01^Kicking^ADM||5^5-Once or twice a day||||||F
OBX|268|CE|MhCMAING01^Negativism^ADM||7^3-Once or twice a week||||||F
OBX|269|CE|MhCMAINO01^Strange noises (weird laughter or crying)^ADM||7^3-Once or twice a week||||||F
OBX|270|CE|MhCMAIPL01^Trying to get to a different place^ADM||1^1-Never||||||F
OBX|271|CE|MhCMAIPS01^Pushing^ADM||5^5-Once or twice a day||||||F
OBX|272|CE|MhCMAIQS01^Repetitive sentences or questions^ADM||7^3-Once or twice a week||||||F
OBX|273|CE|MhCMAIRE01^Performing repetitive mannerisms^ADM||7^3-Once or twice a week||||||F
OBX|274|CE|MhCMAIRS01^General restlessness^ADM||7^3-Once or twice a week||||||F
OBX|275|CE|MhCMAISC01^Scratching^ADM||2^4-Several times a week||||||F
OBX|276|CE|MhCMAISP01^Spitting^ADM||2^4-Several times a week||||||F
OBX|277|CE|MhCMAISR01^Screaming^ADM||7^3-Once or twice a week||||||F
OBX|278|CE|MhCMAISX01^Making physical sexual advances^ADM||2^4-Several times a week||||||F
OBX|279|CE|MhCMAITH01^Throwing things^ADM||2^4-Several times a week||||||F
OBX|280|CE|MhCMAITR01^Tearing things or destroying property^ADM||2^4-Several times a week||||||F
OBX|281|CE|MhCMAITT01^Constant unwarranted request for attention or help^ADM||4^2-Less than once a week||||||F
OBX|282|CE|MhCMAITT02^Constant unwarranted request for attention or help^ADM||7^3-Once or twice a week||||||F
OBX|283|CE|MhCMAIVX01^Making verbal sexual advances^ADM||7^3-Once or twice a week||||||F
OBX|284|CE|MhCMAIWN01^Pace, aimless wandering^ADM||2^4-Several times a week||||||F
OBX|285|CE|MhCOATTS01^Attention/Concentration^ADM||1^Good||||||F
OBX|286|CE|MhCOGIMP00^Cognitively impaired^ADM||02^No||||||F
OBX|287|CE|MhCOINSI01^Insight^ADM||2^Partial||||||F
OBX|288|CE|MhCOJUDG01^Judgement^ADM||1^Good||||||F
OBX|289|CE|MhCOMEMO01^Memory^ADM||1^Immediate/Recall intact||||||F
OBX|290|CE|MhCOORIE01^Oriented to^ADM||2^Person||||||F
OBX|291|TX|MhCPPAXO00^Other care providers present during assessment^ADM||N||||||F
OBX|292|CE|MhDAGGBH00^Currently demonstrating aggressive behaviour^ADM||02^No||||||F
OBX|293|TX|MhDENTUR00^Dentures^ADM||N||||||F
OBX|294|CE|MhDISPOS00^Disposition^ADM||9^Admit to psychiatry||||||F
OBX|295|TX|MhDXTEST00^Diagnostic tests^ADM||cxray tomorrow||||||F
OBX|296|TX|MhECTPRE00^Pre-ECT comments^ADM||||||||F
OBX|297|TX|MhECTTXN00^ECT treatment number^ADM||1||||||F
OBX|298|TX|MhECTVIT00^Vital signs taken prior to ECT^ADM||Y||||||F
OBX|299|CE|MhEDLEVC00^Highest level of education completed^ADM||2^Secondary||||||F
OBX|300|TX|MhEDPHAD00^Assessed by ED Physician date^ADM||20180411||||||F
OBX|301|TX|MhEDPHAN00^Assessed by ED Physician name^ADM||dr.o||||||F
OBX|302|TX|MhEDPHAT00^Assessed by ED Physician time^ADM||0900||||||F
OBX|303|TX|MhEDPMHA00^Patient brought under Section 28^ADM||N||||||F
OBX|304|CE|MhEDPSER00^Reason for visit^ADM||12^Suicidal ideation||||||F
OBX|305|CE|MhEDPSRS00^Referral source^ADM||04^Mental health centre||||||F
OBX|306|TX|MhEDPSYI00^Assessment date^ADM||20180411||||||F
OBX|307|TX|MhEDPSYI01^Patient admitted prior to assessment^ADM||N||||||F
OBX|308|TX|MhEDPSYI02^Repeat patient^ADM||N||||||F
OBX|309|TX|MhEDPSYT00^Assessment time^ADM||1121||||||F
OBX|310|TX|MhELIMAC00^Elimination comments^ADM||test||||||F
OBX|311|TX|MhELIMBO00^Bowel concerns identified^ADM||Y||||||F
OBX|312|TX|MhELIMTL00^Independent with toileting^ADM||Y||||||F
OBX|313|TX|MhELIMUC00^Urinary concerns identified^ADM||N||||||F
OBX|314|CE|MhELOPRF00^Elopement: Risk factors^ADM||01^Not at risk||||||F
OBX|315|TX|MhESAFFE02^Affect other^ADM||||||||F
OBX|316|TX|MhESMOOD04^Mood^ADM||pt stated he was feeling really depressed.||||||F
OBX|317|CE|MhETOHT000^Alcohol type used^ADM||1^Beer||||||F
OBX|318|CE|MhEXPSYC00^Experiencing psychosis^ADM||02^No||||||F
OBX|319|CE|MhEXSHSO00^Expressing any thoughts of harm to self or others^ADM||02^No||||||F
OBX|320|TX|MhEYECOL00^Eye colour^ADM||brown||||||F
OBX|321|CE|MhFALLPA00^Recent falls prior to admission^ADM||1^No concerns identified||||||F
OBX|322|TX|MhFALLRK00^Fall risk^ADM||N||||||F
OBX|323|CE|MhFOLLUP00^Follow-up recommendations^ADM||4^Mental health services||||||F
OBX|324|TX|MhFUNMDC00^Functional status/medical considerations comments^ADM||chronic pain||||||F
OBX|325|TX|MhGENCON00^General concerns identified^ADM||no concerns||||||F
OBX|326|TX|MhGLACON00^Glasses/Contacts^ADM||N||||||F
OBX|327|TX|MhHAIRCO00^Hair colour^ADM||blonde||||||F
OBX|328|TX|MhHEARAD00^Hearing aid^ADM||N||||||F
OBX|329|TX|MhHXABUS00^History of vulnerability to abuse^ADM||N||||||F
OBX|330|TX|MhHXADLS00^History of unable to perform activities of daily living^ADM||N||||||F
OBX|331|TX|MhHXDEPR00^Hx depression^ADM||Y||||||F
OBX|332|TX|MhHXDOMV00^Hx domestic violence^ADM||N||||||F
OBX|333|TX|MhHXELOA00^Hx elopement attempt^ADM||N||||||F
OBX|334|TX|MhHXELOP00^Hx elopement^ADM||N||||||F
OBX|335|TX|MhHXFALL00^Hx falls^ADM||N||||||F
OBX|336|TX|MhHXFIRE00^Hx fire setting behaviour^ADM||N||||||F
OBX|337|TX|MhHXFRTX00^History of forensic treatment^ADM||N||||||F
OBX|338|TX|MhHXFVBH00^Hx family violent behaviour^ADM||N||||||F
OBX|339|TX|MhHXONEG00^Hx neglect^ADM||N||||||F
OBX|340|TX|MhHXPDDO00^History of personality disorder^ADM||N||||||F
OBX|341|TX|MhHXPSYD00^Hx psychotic disorder^ADM||N||||||F
OBX|342|TX|MhHXSEIZ00^Hx seizures^ADM||N||||||F
OBX|343|TX|MhHXSUIA00^Hx suicide attempt^ADM||N||||||F
OBX|344|TX|MhHXSUID00^Hx suicidal ideation^ADM||Y||||||F
OBX|345|TX|MhHXSUIF00^Hx family suicide^ADM||N||||||F
OBX|346|TX|MhHXVBEH00^Hx violent behaviour^ADM||N||||||F
OBX|347|TX|MhIMPFOR00^Impression/Formulation^ADM||patient to be admitted to inpatient unit||||||F
OBX|348|CE|MhINCSOU00^Source(s) of income^ADM||1^Employment income||||||F
OBX|349|CE|MhINFOSC00^Information source^ADM||1^Patient||||||F
OBX|350|CE|MhINSTRP00^Instructions provided^ADM||03^Not applicable||||||F
OBX|351|TX|MhITEINS01^Inspected all items brought in and checked for sharps^ADM||N||||||F
OBX|352|TX|MhLOBCO001^Level of observation comments^ADM||test||||||F
OBX|353|CE|MhLOBMT001^Level of observation maintained^ADM||0^Constant||||||F
OBX|354|TX|MhLVEADD00^Address^ADM||Home||||||F
OBX|355|CE|MhMCSIAJ01^There have been family adjustments^ADM||2^Yes sometimes||||||F
OBX|356|CE|MhMCSIBH01^Some behaviour is upsetting^ADM||3^No||||||F
OBX|357|CE|MhMCSICG01^Caregiving is inconvenient^ADM||3^No||||||F
OBX|358|CE|MhMCSICH01^Upset they have changed from their former self^ADM||2^Yes sometimes||||||F
OBX|359|TX|MhMCSICM01^Caregiver Strain Comments^ADM||test test test||||||F
OBX|360|CE|MhMCSICN01^Caregiving is confining^ADM||3^No||||||F
OBX|361|CE|MhMCSIDT01^There have been other demands on my time^ADM||1^Yes on a regular basis||||||F
OBX|362|CE|MhMCSIEM01^There have been emotional adjustments^ADM||2^Yes sometimes||||||F
OBX|363|CE|MhMCSIFS01^Caregiving is a financial strain^ADM||1^Yes on a regular basis||||||F
OBX|364|CE|MhMCSIOV01^I feel completely overwhelmed^ADM||2^Yes sometimes||||||F
OBX|365|CE|MhMCSIPL01^There have been changes in personal plans^ADM||1^Yes on a regular basis||||||F
OBX|366|CE|MhMCSIPS01^Caregiving is a physical strain^ADM||2^Yes sometimes||||||F
OBX|367|CE|MhMCSISL01^My sleep is disturbed^ADM||2^Yes sometimes||||||F
OBX|368|TX|MhMCSITL01^Total Score^ADM||13||||||F
OBX|369|CE|MhMCSIWO01^There have been work adjustments^ADM||2^Yes sometimes||||||F
OBX|370|CE|MhMEDAD001^Medication adherence^ADM||01^No concerns identified||||||F
OBX|371|CE|MhMEDCPA00^Medical considerations prior to admission^ADM||3^Pain||||||F
OBX|372|CE|MhMEDIRF00^Medical instability: Risk factors^ADM||01^Not at risk||||||F
OBX|373|CE|MhMEDSEF00^Medication side effects^ADM||1^No concerns identified||||||F
OBX|374|TX|MhMHCER000^Certification and MHSU programs/services comments^ADM||patient already followed by mental health team, linked with case manager||||||F
OBX|375|TX|MhMHINCM00^Current mental health team case manager^ADM||Susan (604-321-7698)||||||F
OBX|376|TX|MhMHINVP00^Current mental health team psychiatrist^ADM||Dr. Lu (604-541-6745)||||||F
OBX|377|TX|MhMHINVT00^Currently involved with mental health team^ADM||N||||||F
OBX|378|TX|MhMHSPAD01^Mental health services utilized prior to admission other^ADM||intake appt with Abbotsford Mental Health||||||F
OBX|379|CE|MhMHSPAD02^Mental health services utilized prior to admission^ADM||08^Mental health centre||||||F
OBX|380|CE|MhMSEAS015^Thought process^ADM||1^Organized||||||F
OBX|381|TX|MhMSEAS022^Thought process other^ADM||||||||F
OBX|382|TX|MhMSEATT01^Attitude^ADM||||||||F
OBX|383|CE|MhMSECHG00^Showing any significant change in mental status^ADM||02^No||||||F
OBX|384|CE|MhMSECOM00^Mental status assessment completed^ADM||01^Pre-ECT||||||F
OBX|385|TX|MhMSEGAP02^General appearance^ADM||adsfdsaf||||||F
OBX|386|TX|MhMSETPE00^Thoughts and perception comments^ADM||||||||F
OBX|387|TX|MhMUNICP00^Municipality^ADM||Abbotsford||||||F
OBX|388|TX|MhNOSUPP00^Name of supervising person^ADM||Jane, Mother||||||F
OBX|389|TX|MhOTHCON00^Other contacts^ADM||Brad, Father (778-634-8582)||||||F
OBX|390|TX|MhOTINT003^Referral method^ADM||xx||||||F
OBX|391|TX|MhPAINPR00^Pain present^ADM||N||||||F
OBX|392|TX|MhPATAPN00^Patient's alternate phone number^ADM||N/A||||||F
OBX|393|TX|MhPATMPN00^Patient's main phone number^ADM||604-123-4444||||||F
OBX|394|CE|MhPERDIS00^Perceptual disturbances^ADM||4^Illusions||||||F
OBX|395|CE|MhPLINPA00^Pleasure and interest prior to admission^ADM||2^Concerns identified||||||F
OBX|396|TX|MhPORTUN01^Oriented to unit and/or provided orientation pamphlet^ADM||N||||||F
OBX|397|TX|MhPSYAXD00^Assessed by Psychiatrist date^ADM||20180411||||||F
OBX|398|TX|MhPSYAXN00^Assessed by Psychiatrist name^ADM||dr. g||||||F
OBX|399|TX|MhPSYAXT00^Assessed by Psychiatrist time^ADM||1200||||||F
OBX|400|TX|MhPSYCON00^Consulted with Psychiatrist^ADM||Y||||||F
OBX|401|CE|MhPTBELC00^Patient belongings checked^ADM||01^Yes||||||F
OBX|402|CE|MhPTSUAC00^Patient/Supervising person aware they may contact unit^ADM||01^Yes||||||F
OBX|403|CE|MhPTSUAR00^Patient/Supervising person aware they may return anytime^ADM||01^Yes||||||F
OBX|404|CE|MhPXMEDD00^Prescribed medication dispensed with dosing information^ADM||01^Yes||||||F
OBX|405|TX|MhRCTCOM00^RecT comments^ADM||Agrees to attend groups tomorrow||||||F
OBX|406|TX|MhRIGHT005^Using hospital grounds^ADM||Y||||||F
OBX|407|TX|MhRTUNIT00^Time patient returned to unit^ADM||||||||F
OBX|408|CE|MhRXMEDT00^All prescribed medications taken^ADM||01^Yes||||||F
OBX|409|CE|MhSAFEIN01^Emergency department safety interventions^ADM||1^Certified by physician||||||F
OBX|410|TX|MhSCTATT00^Scars/Tattoos^ADM||N||||||F
OBX|411|TX|MhSFCARE00^Independent with personal care^ADM||Y||||||F
OBX|412|TX|MhSIPROT05^Protective factors^ADM||||||||F
OBX|413|CE|MhSIRISK02^Suicide risk level/Degree of risk^ADM||1^No (forseeable) risk||||||F
OBX|414|TX|MhSIRISK04^Suicidal ideation: Assessment confidence^ADM||||||||F
OBX|415|CE|MhSLPATP00^Sleep pattern prior to admission^ADM||2^Concerns identified||||||F
OBX|416|CE|MhSNVURF00^Self neglect/Vulnerability: Risk factors^ADM||01^Not at risk||||||F
OBX|417|CE|MhSOCSRF00^Social situations: Risk factors^ADM||09^Separation/Divorce||||||F
OBX|418|TX|MhSPAMOT01^Speech amount^ADM||||||||F
OBX|419|TX|MhSPTONE05^Speech tone^ADM||||||||F
OBX|420|TX|MhSPVOLU01^Speech volume^ADM||||||||F
OBX|421|TX|MhSSACHE00^Signs and symptoms of headache/muscle soreness present^ADM||||||||F
OBX|422|CE|MhSUBUSS00^Substance use suspected^ADM||01^Yes||||||F
OBX|423|CE|MhSUDRSO00^Supervised urine drug screen obtained^ADM||01^Yes||||||F
OBX|424|CE|MhSUICRF00^Suicide/Self harm: Risk factors^ADM||02^Passive suicidal ideation||||||F
OBX|425|TX|MhSUIDC001^Current suicidal ideation^ADM||||||||F
OBX|426|TX|MhSUIDCH01^Suicidal ideation: Changeability^ADM||||||||F
OBX|427|TX|MhSUIDIL01^Suicidal ideation: Intent and lethality^ADM||||||||F
OBX|428|TX|MhSUPAPN00^Supervising person's alternative phone number^ADM||N/A||||||F
OBX|429|TX|MhSUPMPN00^Supervising person's main phone number^ADM||778-444-7896||||||F
OBX|430|CE|MhSUPWHC01^Previous alcohol withdrawal^ADM||2^No||||||F
OBX|431|CE|MhSUPWSZ01^Previous alcohol withdrawal seizures^ADM||2^No||||||F
OBX|432|TX|MhSUSS0011^Alcohol amount consumed^ADM||states he drink a few beers casually on the weekends||||||F
OBX|433|CE|MhSUSS0027^Alcohol use^ADM||3^Currently using||||||F
OBX|434|CE|MhSUSS0028^Drug use^ADM||1^Does not use||||||F
OBX|435|CE|MhSUSS0034^Tobacco/Nicotine use^ADM||1^Does not use||||||F
OBX|436|CE|MhTHNKRT00^Take Home Naloxone kit returned^ADM||03^Not applicable||||||F
OBX|437|CE|MhTHNKUP00^Take Home Naloxone kit used by patient^ADM||03^Not applicable||||||F
OBX|438|TX|MhTLCLOTH0^Clothing description prior to departure^ADM||Black sweater, dark blue jeans, white shoes.||||||F
OBX|439|TX|MhTLCOMS01^Other therapeutic leave comments^ADM||Patient remains on leave. No contact made to unit.||||||F
OBX|440|TX|MhTLDOPD01^Date of departure^ADM||20180427||||||F
OBX|441|TX|MhTLEDPR01^Expected date of return^ADM||20180430||||||F
OBX|442|TX|MhTLETPR01^Expected time of return^ADM||1000||||||F
OBX|443|CE|MhTLGOLM02^Goals of leave met according to patient^ADM||01^Yes||||||F
OBX|444|CE|MhTLGOLM03^Goals of leave met according to supervising person^ADM||01^Yes||||||F
OBX|445|TX|MhTLRETD01^Date of return^ADM||20180430||||||F
OBX|446|TX|MhTLRETT01^Time of return^ADM||1000||||||F
OBX|447|CE|MhTLSIGN02^Signed in on form^ADM||01^Yes||||||F
OBX|448|CE|MhTLSIOU02^Signed out on form^ADM||01^Yes||||||F
OBX|449|TX|MhTLTOPD01^Time of departure^ADM||1000||||||F
OBX|450|CE|MhTLTYPE01^Type of leave^ADM||1^Accompanied||||||F
OBX|451|CE|MhTPCONT02^Thought content^ADM||1^No problem identified||||||F
OBX|452|CE|MhTXMGPL00^Intervention method/services provided^ADM||3^Inpatient care||||||F
OBX|453|CE|MhUNITPN00^Unit phone number provided^ADM||01^Yes||||||F
OBX|454|TX|MhUPSACC01^Communication^ADM||10||||||F
OBX|455|TX|MhUPSACM01^Comment^ADM||lots of comments.  lots of comments.  lots of comments.  lots of comments.~ lots of comments.  lots of comments.  lots of comments.  lots of~comments.  lots of comments.  lots of comments.  lots of comments.  lots~of comments.  lots of comments.  vvlots of comments.  lots of comments.~lots of comments.  lots of comments.  lots of comments.  lots of comments.~ vvlots of comments.  lots of comments.  lots of comments.  lots of~comments.  vlots of comments.  lots of comments.  lots of comments.  vlots~of comments.  lots of comments.  lots of comments.  vvlots of comments.~lots of comments.  vvlots of comments.  lots of comments.  vvvlots of~comments.  lots of comments.  vlots of comments.  lots of comments.  lots~of comments.  vvlots of comments.  lots of comments.  v||||||F
OBX|456|TX|MhUPSAFN01^Finance^ADM||2||||||F
OBX|457|TX|MhUPSAPL01^Comprehension and Planning^ADM||3||||||F
OBX|458|TX|MhUPSAPL02^Comprehension and planning^ADM||20||||||F
OBX|459|TX|MhUPSASK01^Household Skills^ADM||20||||||F
OBX|460|TX|MhUPSASK02^Household skills^ADM||12||||||F
OBX|461|TX|MhUPSATL01^Total Score^ADM||53 Patient unlikely able to live independently||||||F
OBX|462|TX|MhUPSATL02^Total score^ADM||49||||||F
OBX|463|TX|MhUPSATR01^Transportation^ADM||5||||||F
OBX|464|TX|MhVERDIR00^Able to follow verbal direction^ADM||Y||||||F
OBX|465|TX|MhVITALR00^Vital signs taken upon return^ADM||||||||F
OBX|466|CE|MoAIDUSE00^Aid used for independent ambulation^ADM||1^Standard walker||||||F
OBX|467|CE|MoAMASTN02^Assistance required for ambulation^ADM||2^Supervision||||||F
OBX|468|CE|MoAMBABI00^Ambulation ability^ADM||2^Independent with aid||||||F
OBX|469|TX|MoAMBIND00^Independent with ambulation^ADM||N||||||F
OBX|470|TX|MoAMCMTS00^Ambulation comment^ADM||indepedent with walker||||||F
OBX|471|CE|MoAMMBAD00^Mobility aid used for ambulation^ADM||1^Standard walker||||||F
OBX|472|CE|MoAMRMWD00^Ambulation^ADM||1^Within room||||||F
OBX|473|CE|MoFALPRE00^Fall prevention strategy^ADM||4^Hip protectors||||||F
OBX|474|CE|MoPOBDPO01^Bed position^ADM||1^Flat||||||F
OBX|475|TX|NUOTCMST00^Outcome status^ADM||Partially met||||||F
OBX|476|CE|NeCATLOC02^Altered level of consciousness^ADM||2^Yes||||||F
OBX|477|CE|NeCDIFFA01^Difficulty focusing attention^ADM||2^Yes||||||F
OBX|478|CE|NeCDIOFS02^Diagnosis of delirium suggested^ADM||2^Yes||||||F
OBX|479|TX|NeCDIORE00^CAM assessment^ADM||Complete||||||F
OBX|480|CE|NeCEACMS01^Evidence of acute change in mental status from baseline^ADM||1^No||||||F
OBX|481|CE|NeCFBDPD01^Fluctuating behaviour during the past day^ADM||2^Yes||||||F
OBX|482|TX|NeCIDG0000^CIWA-Ar dose given^ADM||2.00||||||F
OBX|483|TX|NeCIRE0002^CIWA-Ar Alcohol Withdrawal Score^ADM||22||||||F
OBX|484|CE|NeCIRG0000^CIWA-Ar route given^ADM||1^Oral||||||F
OBX|485|CE|NeCIWA1000^Headache, fullness in head^ADM||2^2||||||F
OBX|486|CE|NeCIWAA100^Nausea and vomiting^ADM||7^5||||||F
OBX|487|CE|NeCIWAA200^Tremor^ADM||2^2||||||F
OBX|488|CE|NeCIWAA300^Paroxysmal sweats^ADM||6^3||||||F
OBX|489|CE|NeCIWAA400^Anxiety^ADM||6^3||||||F
OBX|490|CE|NeCIWAA500^Agitation^ADM||2^2||||||F
OBX|491|CE|NeCIWAA600^Orientation^ADM||2^1||||||F
OBX|492|CE|NeCIWAA700^Tactile disturbances^ADM||2^2||||||F
OBX|493|CE|NeCIWAA800^Auditory disturbances^ADM||2^2||||||F
OBX|494|CE|NeCIWAA900^Visual disturbances^ADM||1^0||||||F
OBX|495|CE|NeCSPDSI01^Speech disorganized or incoherent^ADM||1^No||||||F
OBX|496|CE|NeGCSEYE03^Glasgow Coma Scale Eye Opening^ADM||1^4- Spontaneous||||||F
OBX|497|CE|NeGCSMOT03^Glasgow Coma Scale Motor Response^ADM||1^6- Obeys commands||||||F
OBX|498|TX|NeGCSSCR01^GCS score^ADM||15||||||F
OBX|499|CE|NeGCSVER03^Glasgow Coma Scale Verbal Response^ADM||1^5- Oriented||||||F
OBX|500|TX|NeGLBLGU00^Glucometer blood glucose^ADM||13||||||F
OBX|501|CE|NeLECONS00^Level of consciousness^ADM||1^Alert||||||F
OBX|502|CE|NeNV001002^Left popliteal pulse^ADM||3^+2||||||F
OBX|503|CE|NeORIENT01^Oriented to^ADM||1^All domains||||||F
OBX|504|CE|NePARAMR00^Neurological and cognition defined parameters^ADM||2^Significant findings||||||F
OBX|505|CE|NePOSC0000^POSS score^ADM||1^1 - Awake and alert||||||F
OBX|506|CE|NeRFCRNL00^Corneal reflex left^ADM||2^Absent||||||F
OBX|507|CE|NmLEGST100^Leg strength right^ADM||3^Weak||||||F
OBX|508|TX|Nu00000200^Oral nutrition amount of meal consumed comments^ADM||test 2||||||F
OBX|509|CE|NuBRAMCO01^Breakfast amount consumed^ADM||3^75%||||||F
OBX|510|CE|NuBRAMCO02^Breakfast amount consumed^ADM||01^0%||||||F
OBX|511|CE|NuDIAMCO01^Dinner amount consumed^ADM||2^50%||||||F
OBX|512|CE|NuDIAMCO02^Dinner amount consumed^ADM||01^0%||||||F
OBX|513|CE|NuFANURO00^Nutrition route^ADM||1^Oral nutrition||||||F
OBX|514|CE|NuFEEASS01^Feeding assistance^ADM||1^Unassisted||||||F
OBX|515|TX|NuGLROUT00^Glucometer result out of range^ADM||yes||||||F
OBX|516|CE|NuLUAMCO01^Lunch amount consumed^ADM||2^50%||||||F
OBX|517|CE|NuLUAMCO02^Lunch amount consumed^ADM||01^0%||||||F
OBX|518|TX|NuNICUF370^Intake, Oral Amount^ADM||25.0||||||F
OBX|519|TX|NuNM000100^Nothing by mouth^ADM||Y||||||F
OBX|520|TX|NuNPOPAT00^Patient currently NPO^ADM||N||||||F
OBX|521|TX|NuONSOOT00^Oral nutrition food source other^ADM||test||||||F
OBX|522|CE|NuONSOUR00^Oral nutrition food source^ADM||1^Hospital~2^Family or friends||||||F
OBX|523|TX|NuORTCOM00^Other ORT comments^ADM||ddfsfsf~dfsf~sfsflewi.cf~sdfwerfv~eflcvks~cfwsfek~dsfesfe~sfdvsef||||||F
OBX|524|TX|NuORTSCH00^Schedule^ADM||50 ml daily||||||F
OBX|525|TX|NuORTTIC00^Time ORT completed^ADM||1500||||||F
OBX|526|TX|NuORTTII00^Time ORT initiated^ADM||1300||||||F
OBX|527|TX|NuOSTOOL00^Output - stool^ADM||20.00||||||F
OBX|528|TX|NuOURINE00^Output - urine^ADM||13.00||||||F
OBX|529|CE|NuPPOSBR00^Patient's position during breakfast^ADM||1^High fowlers||||||F
OBX|530|CE|NuPPOSDI00^Patient's position during dinner^ADM||1^High fowlers||||||F
OBX|531|CE|NuPPOSLU01^Patient's position during lunch^ADM||1^High fowlers||||||F
OBX|532|TX|NuSNAMCO01^Snack amount consumed^ADM||0||||||F
OBX|533|CE|NuSNAMCO02^Snack amount consumed^ADM||01^0%||||||F
OBX|534|TX|OEDIAG^Diagnosis:^ADM||Major Depressive D/O||||||F
OBX|535|CE|OEISO^Infection Control:^ADM||CP^Contact Plus||||||F
OBX|536|TX|OTOTCMST00^Outcome status^ADM||In progress||||||F
OBX|537|TX|OhCO000201^Method of collection^ADM||||||||F
OBX|538|TX|OhEDIT0000^Reason for edit^ADM||edit||||||F
OBX|539|CE|OhIN000300^Information source^ADM||7^Friend~15^Significant other||||||F
OBX|540|CE|OhINFOSR00^Information source if reported^ADM||1^Patient||||||F
OBX|541|TX|OhNAMORG01^Name of organization or profession consulted^ADM||infection prevention||||||F
OBX|542|TX|OhSPECDL01^Laboratory delivery method^ADM||||||||F
OBX|543|TX|OhSPECRE01^Specimen reason^ADM||||||||F
OBX|544|TX|OhSPECTP01^Specimen type^ADM||||||||F
OBX|545|TX|OtPDGLUC00^Glucometer frequency^ADM||ac meals||||||F
OBX|546|TX|OtPDOLWO00^Other lab work^ADM||cbc tomorrow||||||F
OBX|547|TX|OtPDPCCN00^PCC notes^ADM||Med changes in the next week as per Psychiatrist||||||F
OBX|548|TX|OtPDRAPI00^Restrictions and privileges^ADM||May 10: 4hr unaccomp. passes~May 7: 2hr pass w/ dad, increased to level 3 obs||||||F
OBX|549|TX|OtPDSEON00^1^ADM||Needs doctor's note for work, note left for psychiatrist May 16||||||F
OBX|550|TX|OtPDSETH00^3^ADM||||||||F
OBX|551|TX|OtPDSETW00^2^ADM||TB Test to read May 18||||||F
OBX|552|TX|OtPDSSUM00^Shift summary^ADM||May 17 Dx: Pt AWOL'd~ ~May 16 Nx: stable mood, no bx management issues attended groups, denies any~homicidal ideation, attended adls, has pass tomorrow for 2 hours with dad.~ ~May 16 Dx: admitted from ER at 1000hrs, labile mood, admits to command~hallucinations, denies any intent, 48/6 completed, has fasting lab work in~the am.||||||F
OBX|553|TX|OtPDVSIG00^Vital signs frequency^ADM||BID||||||F
OBX|554|TX|PTNOTES1^PT Notes:^ADM||ZA;LKDJA;FLK||||||F
OBX|555|TX|PTNOTES2^:^ADM||A;LSDJKFA;L||||||F
OBX|556|TX|PaCOMMEN00^Pain comments^ADM||Mildly decreased pain||||||F
OBX|557|CE|PaFREQ0000^Pain frequency^ADM||2^With movement||||||F
OBX|558|CE|PaLOCBDS01^Location^ADM||6^Arm||||||F
OBX|559|CE|PaLOCBDS02^Location^ADM||15^Back||||||F
OBX|560|TX|PaPAGOAL02^Pain goal^ADM||3/10||||||F
OBX|561|CE|PaPAIASS00^Pain assessment^ADM||2^Pain reported||||||F
OBX|562|CE|PaPALOCM00^Pain location modifier^ADM||2^Right~4^Lower||||||F
OBX|563|CE|PaPANVBA00^Pain non-verbal behaviours^ADM||10^Guarding~20^Refusing to mobilize||||||F
OBX|564|CE|PaPAQUAL01^Pain quality^ADM||1^Sharp~5^Burning~7^Electric shock||||||F
OBX|565|TX|PaPARADI00^Pain radiating^ADM||Y||||||F
OBX|566|TX|PaPARADL00^Pain radiating location^ADM||right leg||||||F
OBX|567|CE|PaPASCL000^Pain scale used^ADM||1^Numeric||||||F
OBX|568|TX|PaPASCRE01^Pain score^ADM||8.00||||||F
OBX|569|TX|PaPATIME00^Time of pain onset^ADM||1620||||||F
OBX|570|CE|PaPATYPE00^Pain type of onset^ADM||1^Gradual||||||F
OBX|571|CE|PaPNMGTT00^Pain management techniques^ADM||1^Medication~2^Ice pack~5^Positioning~9^Rest||||||F
OBX|572|TX|PdOOTCOM01^OT comments^ADM||Agrees to attend OT groups tomorrow, receptive to discussing pain~management techniques||||||F
OBX|573|TX|PdOSWCOM01^SW comments^ADM||Pt currently living alone, liaised with ex-girlfriend and she is agreeable~to take patients dog to her home to be taken care of.||||||F
OBX|574|TX|PsCLB00000^Communication language barrier^ADM||N||||||F
OBX|575|CE|PsCLCONS00^Special considerations^ADM||5^Extended/Repeat admit~12^Energy level||||||F
OBX|576|CE|PsCLHOSP00^Reactions to hospitalization/Illness^ADM||2^Separation difficulties||||||F
OBX|577|TX|PsCLIFAM00^Clinical update provided to visitor(s)^ADM||N||||||F
OBX|578|CE|PsCLINTE00^Interventions^ADM||2^Developmental play~6^Emotional support~7^Relaxation/Pain mgmt~8^Procedural preparation||||||F
OBX|579|CE|PsCLIRCO00^Consent obtained for child life involvement^ADM||2^No||||||F
OBX|580|CE|PsFIMS0001^Family information marital status^ADM||1^Single||||||F
OBX|581|CE|PsHAMSWB00^14. Behavior at interview^ADM||1^Not present (0)||||||F
OBX|582|CE|PsHAMSWC00^9. Cardiovascular symptoms^ADM||1^Not present (0)||||||F
OBX|583|CE|PsHAMSWD00^6. Depressed mood^ADM||1^Not present (0)||||||F
OBX|584|CE|PsHAMSWG00^11. Gastrointestinal symptoms^ADM||1^Not present (0)||||||F
OBX|585|CE|PsHAMSWN00^13. Autonomic symptoms^ADM||1^Not present (0)||||||F
OBX|586|CE|PsHAMSWO00^8. Somatic (sensory)^ADM||1^Not present (0)||||||F
OBX|587|CE|PsHAMSWR00^10. Respiratory symptoms^ADM||1^Not present (0)||||||F
OBX|588|CE|PsHAMSWS00^7. Somatic (muscular)^ADM||1^Not present (0)||||||F
OBX|589|TX|PsHAMSWT00^HAM-A Result^ADM||Incomplete||||||F
OBX|590|CE|PsHAMSWU00^12. Genitourinary symptoms^ADM||1^Not present (0)||||||F
OBX|591|CE|PsHD000004^1. Depressed mood^ADM||1^Absent (0)||||||F
OBX|592|CE|PsHD000101^2. Feelings of guilt^ADM||1^Absent (0)||||||F
OBX|593|CE|PsHD000201^3. Suicide^ADM||1^Absent (0)||||||F
OBX|594|CE|PsHD000301^4. Insomnia early^ADM||1^No difficulty (0)||||||F
OBX|595|CE|PsHD000401^5. Insomnia middle^ADM||1^No difficulty (0)||||||F
OBX|596|CE|PsHD000501^6. Insomnia late^ADM||1^No difficulty (0)||||||F
OBX|597|CE|PsHD000601^7. Work and activities^ADM||1^No difficulty (0)||||||F
OBX|598|CE|PsHD000701^8. Retardation: Psychomotor^ADM||1^Normal (0)||||||F
OBX|599|CE|PsHD000801^9. Agitation^ADM||1^None (0)||||||F
OBX|600|CE|PsHD000901^10. Anxiety (psychological)^ADM||1^No difficulty (0)||||||F
OBX|601|CE|PsHD001002^11. Anxiety (somatic)^ADM||1^Absent (0)||||||F
OBX|602|CE|PsHD001101^12. Somatic symptoms (gastrointestinal)^ADM||1^None (0)||||||F
OBX|603|CE|PsHD001202^13. Somatic symptoms (general)^ADM||1^None (0)||||||F
OBX|604|CE|PsHD001301^14. Genital symptoms^ADM||1^Absent (0)||||||F
OBX|605|CE|PsHD001401^15. Hypochondriasis^ADM||1^Not present (0)||||||F
OBX|606|CE|PsHD001501^16. Loss of weight^ADM||1^No weight loss (0)||||||F
OBX|607|CE|PsHD001601^17. Insight^ADM||3^Denies (2)||||||F
OBX|608|TX|PsHD001702^HAM-D score^ADM||Incomplete||||||F
OBX|609|CE|PsHD001801^18. Diurnal variation^ADM||1^No variation (0)||||||F
OBX|610|CE|PsHD001901^19. Depersonalization and derealisation^ADM||2^Mild (1)||||||F
OBX|611|CE|PsHD002001^20. Paranoid symptoms^ADM||2^Suspicious (1)||||||F
OBX|612|CE|PsHD002101^21. Obsessional and compulsive symptoms^ADM||2^Mild (1)||||||F
OBX|613|CE|PsSECONT00^Professional/Service contacts^ADM||13^School based services||||||F
OBX|614|TX|PsSTAND190^Primary contact person^ADM||I am the primary contact person||||||F
OBX|615|TX|PsSTAND191^Primary contact person^ADM||Bob||||||F
OBX|616|CE|PsSWEMPL02^Employment^ADM||6^Part-time||||||F
OBX|617|TX|PsSWPUIN00^Purpose of social work involvement^ADM||AGADSFASDF||||||F
OBX|618|TX|PsSWSTDC00^Dependents comments^ADM||has 2 kids 1 7 yr old and 1 3 yr old||||||F
OBX|619|CE|PsSWSTST02^Citizenship status^ADM||1^Canadian citizen||||||F
OBX|620|CE|ReCGSTGH00^Cough strength^ADM||3^Weak||||||F
OBX|621|CE|ReCOLMET01^Secretions collection method^ADM||1^Closed/Inline suction||||||F
OBX|622|CE|ReDO000100^Digital occlusion reason for trial failure^ADM||1^Patient anxiety~3^Change in heart rate||||||F
OBX|623|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||1^Room air||||||F
OBX|624|CE|ReSCAMNT00^Secretions amount^ADM||2^Small||||||F
OBX|625|CE|ReSCCOLR00^Secretions colour^ADM||2^White||||||F
OBX|626|CE|ReSCDESC02^Secretions description^ADM||1^Mucoid~6^Purulent||||||F
OBX|627|CE|ReSV000100^Speaking valve reason for trial failure^ADM||3^Change in heart rate~4^Change in blood pressure||||||F
OBX|628|TX|ReTRCORO00^Digital occlusion trial length^ADM||2||||||F
OBX|629|CE|ReTRCUST00^Tracheostomy cuff status^ADM||2^Cuff down||||||F
OBX|630|TX|ReTRSVTL00^Speaking valve trial length^ADM||30||||||F
OBX|631|CE|ReTRTUSI02^Tracheostomy tube size^ADM||2^5.0 mm||||||F
OBX|632|CE|ReTRTYP00^Tracheostomy type^ADM||2^Cuffless~4^Extra length proximal||||||F
OBX|633|TX|RpPBREAS00^Patient breastfeeding^ADM||N||||||F
OBX|634|TX|SWNOTES1^SW Notes:^ADM||...||||||F
OBX|635|TX|SWNOTES2^:^ADM||...||||||F
OBX|636|TX|SWOTCMST00^Outcome status^ADM||In progress||||||F
OBX|637|CE|SpHAMSWA00^1. Anxious mood^ADM||1^Not present (0)||||||F
OBX|638|CE|SpHAMSWF00^3. Fears^ADM||1^Not present (0)||||||F
OBX|639|CE|SpHAMSWI00^4. Insomnia^ADM||1^Not present (0)||||||F
OBX|640|CE|SpHAMSWN00^5. Intellectual^ADM||4^Mild (1)||||||F
OBX|641|CE|SpHAMSWT00^2. Tension^ADM||1^Not present (0)||||||F
OBX|642|CE|SpIPRATI02^Isolation precautions rationale suspected/confirmed^ADM||1^Clostridium difficile~2^MRSA~6^Measles~10^Shingles||||||F
OBX|643|CE|SpIPRTYP00^Isolation precautions room type^ADM||2^Single occupancy room||||||F
OBX|644|TX|SpOSPATT01^Observed sleep pattern^ADM||slept||||||F
OBX|645|TX|SpREPSLE00^Reported sleep pattern^ADM||appears to be sleeping||||||F
OBX|646|TX|SpRIREQU00^Reverse isolation required^ADM||Y||||||F
OBX|647|TX|SpSLEAID00^Sleep aid PRN given^ADM||Y||||||F
OBX|648|CE|TeEDFURQ00^Education follow up required^ADM||1^None||||||F
OBX|649|TX|TeEDINTR00^Interpreter utilized^ADM||Y||||||F
OBX|650|CE|TeEDMATP00^Learning materials provided^ADM||1^Handout/Pamphlet||||||F
OBX|651|CE|TeEDMATP01^Learning materials provided^ADM||1^Handout/Pamphlet||||||F
OBX|652|CE|TeEDMETH00^Education method^ADM||2^Lecture/class||||||F
OBX|653|CE|TeEDPRVD00^Education provided to^ADM||3^Family||||||F
OBX|654|CE|TeREDTOP00^COPD education topics^ADM||1^Disease education||||||F
OBX|655|CE|VsBPCFLP01^Blood pressure cuff location^ADM||1^Right arm||||||F
OBX|656|CE|VsBPDEUS00^Device used^ADM||1^Automated cuff||||||F
OBX|657|TX|VsBPDIAO01^Blood pressure diastolic^ADM||80||||||F
OBX|658|TX|VsBPMAPA03^Blood pressure mean arterial pressure^ADM||65||||||F
OBX|659|CE|VsBPPOST02^Patient position^ADM||2^Supine||||||F
OBX|660|TX|VsBPSYSO01^Blood pressure systolic^ADM||110||||||F
OBX|661|TX|VsHRADEL00^Electrical heart rate^ADM||83||||||F
OBX|662|TX|VsHRADLT01^Heart rate^ADM||88||||||F
OBX|663|CE|VsHRLOCA02^Heart rate location^ADM||1^Radial||||||F
OBX|664|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|665|CE|VsHRMETH00^Heart rate method used^ADM||1^Palpation||||||F
OBX|666|CE|VsHRRHYM02^Pulse rhythm^ADM||1^Regular||||||F
OBX|667|TX|VsHTCM0100^Current height^ADM||170.0||||||F
OBX|668|TX|VsOXDRAD01^Oxygen therapy delivery rate^ADM||0||||||F
OBX|669|TX|VsPOOSAD00^Pulse oximetry oxygen saturation^ADM||86||||||F
OBX|670|CE|VsPRLOMO00^Probe location modifier^ADM||1^Right||||||F
OBX|671|CE|VsPROLOC00^Probe location^ADM||1^Finger||||||F
OBX|672|TX|VsPROREP00^Probe repositioned^ADM||N||||||F
OBX|673|CE|VsPULSTR00^Pulse strength on palpation^ADM||2^Moderate||||||F
OBX|674|TX|VsPUOXCO00^Pulse oximetry comment^ADM||Results came 1 minute after.  Oximeter may be broken||||||F
OBX|675|TX|VsRESPAD03^Respiratory rate^ADM||15||||||F
OBX|676|TX|VsSECTEM00^Secondary temperature^ADM||37||||||F
OBX|677|CE|VsSECTES00^Secondary temperature source^ADM||1^Oral||||||F
OBX|678|CE|VsTPSORC01^Temperature source^ADM||4^Axillary||||||F
OBX|679|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|680|TX|VsTPTEMPO2^Temperature^ADM||38.1||||||F
OBX|681|TX|VsVISICO00^Vital Signs comments^ADM||pt did not take her BP meds this am.||||||F
OBX|682|TX|VsWT000101^Current Weight^ADM||75.000||||||F
OBX|683|CE|VsWT000700^Weight measurement method^ADM||1^Standing scale||||||F
OBX|684|CE|VsWT004900^Height or length source^ADM||4^Estimated||||||F
OBX|685|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||75000.000||||||F
OBX|686|TX|z DATE^DATE QUERY FOR TESTING^ADM||20171004||||||F
OBX|687|TX|z PCS MART^QUANTITY TEST QUERY^ADM||80||||||F
OBX|688|CE|zCBrefgrp^referral group response^ADM||1^Home Health~4^SLP||||||F
OBX|689|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
AL1|1|DA|F006001550^codeine|SV|Shortness of Breath   *AL|20171004
ZFD|OEDOCP^Oedoc^Petertrain^^^^MD^50004^DOC|2222 Main Street^^Vancouver^BC^V3V 1Z1|||OEDOCM^Oedoc^Marytrain^^^^MD^50003^DOC|ZTEST^Test Provider^IM/IT^Use Only^^^^500001^DOC||CHENGN^CHENG^NOK^CIS^^^^^DOC|
ZFH|LUMED||||||

MSH|^~\&|ADM|ARH|||201911221258||ADT^A03|4111521|D|2.2|||AL|NE
EVN|A03|201911221258||||201911221258
PID|1|FHATVIG0007686|AB00007880|AB7835|CCNHABOYTE^JANEE||19120110|F|||3988 LAUKITIS MAN^^COURTNEY^BC^V9D 6G0|||||||AB000696/19|9698718969
PV1|1|I|AB-4CHEAMA^AB4CA-4002^2|EL|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^^^^^^XX|||CARD||||||||IN||||||||||||||||||DISCHARGED WITH APPROVAL|||ARH|||||201911221141|201911221258
PV2||W^Ward|CHEST PAIN
OBX|1|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20071121||||||F
OBX|2|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCSWP^BC Services With Photo||||||F
OBX|3|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|4|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|5|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|6|CE|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N^NO||||||F
ZFD|ADMT^ADM^TEST^A GENP^^^^002^DOC|123 ANY STREET^^SURREY^BC^V3H 5N6|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|
ZFH|LUMED||||||

MSH|^~\&|ADM|ARH|||201911221258||ADT^A08|4111530|D|2.2|||AL|NE
EVN|A08|20191122||||
PID|1|FHATVIG0000154|AB00006631|AB6632|ITSTEST^ZINCOCHROMITE||19800202|M|||789 10TH AVENUE^^HOPE^BC^V7V 8V8|||||||AB000036/17|9876588163
PV1|1|I|AB-1BAKER^AB1B-B105^1|EL|||OEDOCM^Oedoc^Marytrain^^^^MD^^^^^^XX|||MEDS||||||||IN|||||||||||||||||||||ARH|||||201707251402|
PV2||W^Ward|DIZZINESS
OBX|1|ST|1010.1^WEIGHT^CPT4||75.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||170.0||||||F
OBX|3|CE|ADM CCI1^CCI#1^ADM||AVB^AVB-Agressive/Violent Beh||||||F
OBX|4|TX|ADM CCI2^CCI#2^ADM||||||||F
OBX|5|TX|ADM CCI3^CCI#3^ADM||||||||F
OBX|6|TX|ADM CCI4^ARO - Antibiotic Resistant Organisms^ADM||||||||F
OBX|7|TX|ADM CCI5^DNA - Do Not Acknowledge^ADM||||||||F
OBX|8|TX|ADM CCI6^AVB - Aggressive/Violent Behaviour^ADM||||||||F
OBX|9|TX|ADM CCI7^MDR - Multiple Drug Resistant Organisms^ADM||||||||F
OBX|10|TX|ADM CCI7a^          **or**^ADM||||||||F
OBX|11|TX|ADM CCICO1^Comments:^ADM||||||||F
OBX|12|TX|ADM CCICO2^:^ADM||||||||F
OBX|13|TX|ADM CCICO3^:^ADM||||||||F
OBX|14|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20170416||||||F
OBX|15|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCSOP^BC Services \T\ Other Photo||||||F
OBX|16|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|17|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|18|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|19|CE|AcFTTYPE00^Footwear type^ADM||1^Non slip socks||||||F
OBX|20|CE|AcHEHT0000^Home environment - housing type^ADM||1^House||||||F
OBX|21|CE|AcHEHT0M00^Home environment - housing type^ADM||2^Bungalow with basement||||||F
OBX|22|CE|AcHOCNPR00^Housing considerations prior to admission^ADM||3^Pets at home||||||F
OBX|23|TX|AcHOCOMM00^Housing prior to admission comments^ADM||Patient got evicted.||||||F
OBX|24|TX|AcHYGCOMM0^Personal care comments^ADM||test||||||F
OBX|25|TX|AcLIVOTH00^Living with others prior to admission^ADM||N||||||F
OBX|26|TX|AcPTSHOWE0^Patient showered^ADM||Y||||||F
OBX|27|TX|AcTOASST02^Toileting assistance^ADM||||||||F
OBX|28|CE|AcTOEQ0000^Equipment used for toileting^ADM||4^Toilet grab bars||||||F
OBX|29|TX|Ad00002000^Two patient identifiers checked^ADM||N||||||F
OBX|30|TX|AdAC000100^Accompanied by other^ADM||wife||||||F
OBX|31|TX|AdADMDAT01^Admission date^ADM||20190505||||||F
OBX|32|CE|AdADMFRO01^Admitted from^ADM||1^Emergency||||||F
OBX|33|TX|AdADMIPB00^Any travel to India Pakistan or Bangladesh in last 12 months^ADM||Y||||||F
OBX|34|TX|AdADMOUT01^Any healthcare encounter outside Canada in last 12 months^ADM||Y||||||F
OBX|35|TX|AdADMRSN00^Reason for admission^ADM||Depression with SI||||||F
OBX|36|TX|AdADMSIX00^Admitted to care area in the last 6 months^ADM||N||||||F
OBX|37|TX|AdADMTIM00^Admission time^ADM||1600||||||F
OBX|38|TX|AdADMTRA00^Name of other unit/site^ADM||smh||||||F
OBX|39|TX|AdAGMDFO00^Against medical advice form signed^ADM||Y||||||F
OBX|40|TX|AdALLERB00^Allergy band checked^ADM||Y||||||F
OBX|41|TX|AdALLERR00^Allergies reviewed^ADM||Y||||||F
OBX|42|TX|AdAMA00000^Left hospital without any notification^ADM||Y||||||F
OBX|43|CE|AdARRMOD00^Mode of arrival^ADM||1^Stretcher||||||F
OBX|44|TX|AdBIRTH010^Expected date of delivery^ADM||20180622||||||F
OBX|45|CE|AdCSUM0000^Community supports utilized prior to admission^ADM||1^None||||||F
OBX|46|TX|AdDCCOMP00^Discharge plan complete^ADM||Y||||||F
OBX|47|CE|AdDISCHA00^Destination^ADM||1^Home||||||F
OBX|48|TX|AdESTDDC03^Reason EDD changed comments^ADM||No change.||||||F
OBX|49|TX|AdESTDTD00^Estimated date of discharge^ADM||20190824||||||F
OBX|50|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity||||||F
OBX|51|TX|AdFUAPCO04^Services and appointments arranged comments^ADM||services arranged other||||||F
OBX|52|TX|AdHXALLE00^Hx of unexplained allergic reaction during medical procedure^ADM||Y||||||F
OBX|53|TX|AdHXCOND00^History of presenting condition^ADM||Patient ran away from parent's home. Relationship of 5 years recently~ended. Patient drinking excessively.||||||F
OBX|54|TX|AdHXITCH00^Hx of itchiness/swelling post dental, rectal or pelvic exam^ADM||Y||||||F
OBX|55|CE|AdHXRUBB00^Hx of sensitivity to materials containing rubber^ADM||7^Erasers||||||F
OBX|56|TX|AdHXSBIF00^Hx of Spina Bifida^ADM||Y||||||F
OBX|57|TX|AdINPSNT00^Inpatient referral(s) sent to other^ADM||intpatient other||||||F
OBX|58|CE|AdINPTRF00^Inpatient referral(s) sent to^ADM||9^Recreation therapist~12^Respiratory therapist~18^Social worker~21^Wound care/ostomy nurse||||||F
OBX|59|TX|AdINTNEE00^Interpreter needed^ADM||Y||||||F
OBX|60|CE|AdLITUBE01^Lines/Tubes in situ^ADM||5^Enteral feeding tube~7^Arterial line~9^ETT||||||F
OBX|61|TX|AdNAMEBN00^Name band on^ADM||N||||||F
OBX|62|TX|AdODISPC00^Other discharge planning comments^ADM||May22: Continue with medication trial.~May18: Patient experiencing side effects with current medication. Started~on new medication today.||||||F
OBX|63|CE|AdOTPREF01^Outpatient/Community referral(s) sent to^ADM||15^Nurse practitioner~18^Geriatrician~24^SLP~27^Palliative care||||||F
OBX|64|TX|AdOTPSNT00^Outpatient/Community referral(s) sent to other^ADM||outpatient other||||||F
OBX|65|TX|AdOTRERF00^Reason for referral^ADM||xxx||||||F
OBX|66|TX|AdPLACEC00^Lines/Tubes placement confirmed with physician^ADM||N||||||F
OBX|67|TX|AdPRLANG00^Primary language spoken^ADM||German||||||F
OBX|68|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||N||||||F
OBX|69|TX|AdPTFAMY00^Patient/Family goals for discharge^ADM||patient fam goal||||||F
OBX|70|TX|AdRECPDB00^Disharge barriers identified by recreational therapist^ADM||discharge barriers||||||F
OBX|71|TX|AdRECPDE00^Problem details^ADM||problem details 3||||||F
OBX|72|TX|AdRECPGD00^Goal target date^ADM||20190925||||||F
OBX|73|TX|AdRECPGO00^Goal^ADM||goal 3||||||F
OBX|74|CE|AdRECPGS00^Goal status^ADM||3^Met||||||F
OBX|75|CE|AdRECPID00^Problem identified^ADM||5^Social awareness||||||F
OBX|76|TX|AdRECPIN00^1. Intervention to address problem^ADM||int 1 prob 3||||||F
OBX|77|TX|AdRECPIN01^2. Intervention to address problem^ADM||int 2 pr 3||||||F
OBX|78|TX|AdRECPIN02^3. Intervention to address problem^ADM||int3||||||F
OBX|79|TX|AdRECPIN03^4. Intervention to address problem^ADM||int4||||||F
OBX|80|TX|AdRECPIN04^5. Intervention to address problem^ADM||int5||||||F
OBX|81|TX|AdREPREF00^Report received^ADM||text||||||F
OBX|82|TX|AdREPRFR01^Report received from^ADM||dr||||||F
OBX|83|CE|AdSERVAR00^Services arranged^ADM||1^None required||||||F
OBX|84|TX|AdSITUOT00^Lines/Tubes in situ other^ADM||PICC||||||F
OBX|85|TX|AdSLATEX01^Suspected latex allergy^ADM||Y||||||F
OBX|86|TX|AdSTRECO01^Reason EDD changed other^ADM||EDD other||||||F
OBX|87|TX|AdTWPAID01^Two patient identifiers checked^ADM||Y||||||F
OBX|88|CE|Ca00000000^Pre-existing pain concerns^ADM||1^No concerns identified~3^Care plan initiated||||||F
OBX|89|CE|Ca00000001^Pre-existing medication concerns^ADM||1^No concerns identified||||||F
OBX|90|CE|Ca00000002^Pre-existing nutrition/hydration concerns^ADM||1^No concerns identified||||||F
OBX|91|CE|Ca00000003^Pre-existing bowel/bladder concerns^ADM||1^No concerns identified||||||F
OBX|92|CE|Ca00000004^Pre-existing cognitive concerns^ADM||2^Concerns identified~3^Care plan initiated||||||F
OBX|93|CE|Ca00000005^Pre-existing mobility concerns^ADM||1^No concerns identified||||||F
OBX|94|CE|Ca00000100^Right radial pulse^ADM||3^+1||||||F
OBX|95|CE|Ca00000200^Right ulnar pulse^ADM||6^+4||||||F
OBX|96|CE|Ca00000400^Left radial pulse^ADM||2^0||||||F
OBX|97|CE|Ca00000500^Left ulnar pulse^ADM||5^+3||||||F
OBX|98|CE|Ca00000700^Right dorsalis pedis pulse^ADM||5^+3||||||F
OBX|99|CE|Ca00000800^Right post tibial pulse^ADM||3^+1||||||F
OBX|100|CE|Ca00000900^Right popliteal pulse^ADM||2^0||||||F
OBX|101|CE|Ca00001000^Left dorsalis pedis pulse^ADM||2^0||||||F
OBX|102|CE|Ca00001100^Left post tibial pulse^ADM||2^0||||||F
OBX|103|CE|Ca00001200^Left popliteal pulse^ADM||2^0||||||F
OBX|104|CE|Ca00001300^Right femoral pulse^ADM||2^0||||||F
OBX|105|CE|Ca00001400^Left femoral pulse^ADM||2^0||||||F
OBX|106|TX|CaCA000400^Cardiac rhythm RR segment^ADM||722||||||F
OBX|107|CE|CaCAARIN00^Investigations done^ADM||1^Blood work||||||F
OBX|108|CE|CaCAARIT00^Cardiac interventions^ADM||5^Code blue called||||||F
OBX|109|TX|CaCAMODD00^Date cardiac monitoring discontinued^ADM||20180115||||||F
OBX|110|CE|CaCARHEC00^Cardiac rhythm ectopy^ADM||6^Trigeminal||||||F
OBX|111|CE|CaCRFOLE01^Capillary refill left foot^ADM||1^Less than 3 seconds||||||F
OBX|112|CE|CaCRFORI01^Capillary refill right foot^ADM||1^Less than 3 seconds||||||F
OBX|113|CE|CaCRHALE00^Capillary refill left hand^ADM||1^Less than 3 seconds||||||F
OBX|114|CE|CaCRHARI00^Capillary refill right hand^ADM||1^Less than 3 seconds||||||F
OBX|115|TX|CaCV000100^Central venous pressure^ADM||6||||||F
OBX|116|CE|CaCYANOS00^Cyanosis^ADM||1^None||||||F
OBX|117|CE|CaEDEMA000^Edema^ADM||2^Present||||||F
OBX|118|CE|CaHS000200^Heart sounds quality^ADM||1^Normal||||||F
OBX|119|TX|CaHS000300^Heart sounds murmur^ADM||N||||||F
OBX|120|CE|CaHS000400^Heart sounds murmur^ADM||1^Systole||||||F
OBX|121|TX|CaHS000500^Heart sounds rub^ADM||N||||||F
OBX|122|TX|CaHS000600^Heart sounds mechanical valve click^ADM||N||||||F
OBX|123|CE|CaHS000700^Heart sounds audible^ADM||1^S1~3^S2||||||F
OBX|124|CE|CaPACETY50^Pacemaker type^ADM||2^Transvenous||||||F
OBX|125|TX|CaPLDATE00^PIV Insertion date^ADM||20190426||||||F
OBX|126|CE|CaPULEDP00^Pulses left dorsalis pedis^ADM||2^+1||||||F
OBX|127|CE|CaPULEFE00^Pulses left femoral^ADM||3^+2||||||F
OBX|128|CE|CaPULEPT00^Pulses left post tibial^ADM||3^+2||||||F
OBX|129|CE|CaTRPSPD00^Pacing dependence^ADM||1^None at all||||||F
OBX|130|TX|CaVTCOAG00^VTE prevention anticoagulant ordered^ADM||N||||||F
OBX|131|CE|CaVTCOMP02^VTE prevention sequential compression device in use^ADM||1^None||||||F
OBX|132|CE|CaVTSTOC01^VTE prevention antiembolic stockings in use^ADM||1^None||||||F
OBX|133|CE|CmCTRIAL00^Compensatory strategies trialled^ADM||6^Smaller bolus size~16^Cyclic ingestion||||||F
OBX|134|CE|CoNOVECO00^Nonverbal communication^ADM||1^Not interacting||||||F
OBX|135|TX|Gi00000600^Maintaining baseline stool pattern^ADM||N||||||F
OBX|136|CE|Gi00001500^Gastrointestinal assessment^ADM||1^Within defined parameters||||||F
OBX|137|CE|Gi00001700^Genitourinary assessment^ADM||1^Within defined parameters||||||F
OBX|138|TX|GiABAPGE00^Abdominal general appearance^ADM||Scar on left side, 5cm in length||||||F
OBX|139|CE|GiABPALP02^Abdominal palpation^ADM||1^Soft||||||F
OBX|140|CE|GiABSHAP00^Abdominal shape^ADM||1^Flat||||||F
OBX|141|CE|GiBMAMT200^Bowel movement amount^ADM||2^Medium (240 mL)||||||F
OBX|142|CE|GiBMAMT201^Bowel movement amount^ADM||7^Small||||||F
OBX|143|CE|GiBMCOLO01^Bowel movement colour^ADM||1^Brown||||||F
OBX|144|TX|GiBMINCO00^Bowel movement incontinence^ADM||||||||F
OBX|145|CE|GiBMINTE01^Bowel movement level of intervention^ADM||3^Bowel protocol given||||||F
OBX|146|TX|GiBMMETH01^Bowel movement method^ADM||||||||F
OBX|147|TX|GiBO000301^Last bowel movement date as reported by patient^ADM||20191112||||||F
OBX|148|TX|GiBO000302^Last bowel movement date as reported by patient^ADM||20180620||||||F
OBX|149|CE|GiBOFLAT00^Bowel flatus present^ADM||1^Absent||||||F
OBX|150|CE|GiBS000100^Bowel sounds frequency^ADM||1^Active||||||F
OBX|151|CE|GiBSACTI01^Bowel sounds active in all four quadrants^ADM||1^Yes||||||F
OBX|152|TX|GiCONSTI00^Patient experiencing constipation^ADM||N||||||F
OBX|153|TX|GiDIARRH00^Patient experiencing diarrhea^ADM||Y||||||F
OBX|154|TX|GiNAUSVO00^Patient experiencing nausea/vomiting^ADM||N||||||F
OBX|155|CE|GiOSASST00^Ostomy assistance provided by^ADM||2^Nurse||||||F
OBX|156|CE|GiOSCARE00^Ostomy care^ADM||1^Dependent||||||F
OBX|157|CE|GiOSFLAN00^Ostomy flange/pouch style^ADM||1^Drainable pouch||||||F
OBX|158|CE|GiOSMUMA00^Ostomy mucocutaneous margin^ADM||1^Approximated||||||F
OBX|159|CE|GiOSPSSK00^Ostomy peristomal skin^ADM||1^Intact||||||F
OBX|160|CE|GiOSREAS00^Ostomy reason for flange/pouch change^ADM||1^Patient education||||||F
OBX|161|TX|GiRTINSI00^Rectal tube in situ^ADM||N||||||F
OBX|162|CE|GiRTRETU01^Rectal tube returns^ADM||4^None||||||F
OBX|163|TX|GiVOMGAG00^Patient vomiting/gagging^ADM||N||||||F
OBX|164|TX|GuBDSVA000^Bladder scan volume^ADM||300||||||F
OBX|165|CE|GuBDUTIS00^Urinary tract infection signs and symptoms^ADM||2^Fever above 38~5^Dysuria||||||F
OBX|166|CE|GuUDGLUC00^Urine dipstick glucose^ADM||5^+4||||||F
OBX|167|CE|GuUDKT0000^Urine dipstick ketones^ADM||2^+1||||||F
OBX|168|CE|GuUDLEUK00^Urine dipstick leukocytes^ADM||2^+1||||||F
OBX|169|CE|GuUDNIT000^Urine dipstick nitrites^ADM||1^Negative||||||F
OBX|170|CE|GuUDPROT00^Urine dipstick protein^ADM||1^Negative||||||F
OBX|171|CE|GuUR000600^Urine blood^ADM||5^+4||||||F
OBX|172|CE|GuURCOL001^Urine colour^ADM||5^Brown||||||F
OBX|173|TX|GuURPH0000^Urine pH^ADM||7.0||||||F
OBX|174|CE|HeBOLUSP00^Bolus preparation^ADM||2^Prolonged manipulation~5^Insufficient manipulation~8^Minimal/No lingual mvt||||||F
OBX|175|CE|HeBOLUSR00^Bolus retrieval^ADM||3^Reduced labial closure||||||F
OBX|176|CE|HeCO000100^Verbal communication^ADM||7^Aphasic||||||F
OBX|177|CE|HeSL003300^Oral trials feeding^ADM||2^Partial assist||||||F
OBX|178|CE|HeSL003500^Oral trials positioning^ADM||1^Upright in bed||||||F
OBX|179|CE|HeSL004604^Oral residue^ADM||2^Residue Rt lateral sulcus||||||F
OBX|180|TX|HeSL004800^Pharyngeal phase nasal regurgitation^ADM||N||||||F
OBX|181|CE|HeSL004902^Pharyngeal phase swallow initiation^ADM||1^No obvious impairment||||||F
OBX|182|CE|HeSL005301^Signs consistent with esophageal dysphagia or reflux^ADM||1^Dysphagia w/solids alone||||||F
OBX|183|CE|HeSL005502^Swallowing assessment mealtime behaviours observed^ADM||1^Functional||||||F
OBX|184|CE|HeSL013800^Secretions management^ADM||6^Drooling from left side||||||F
OBX|185|CE|HeSL018600^Bolus control^ADM||3^Anterior loss right||||||F
OBX|186|CE|HeSL020202^Oral transfer^ADM||2^Suspected impairment||||||F
OBX|187|TX|HeSL036100^Pre-trials suctioning provided^ADM||N||||||F
OBX|188|CE|HeSL041000^Textures/Consistencies dyed blue/green^ADM||3^Honey thick by cup||||||F
OBX|189|CE|HeSLP06001^Throat clear strength^ADM||3^Weak||||||F
OBX|190|CE|HeSLPTCT00^Textures/Consistencies trialled^ADM||3^Honey thick by cup||||||F
OBX|191|CE|HeVO000100^Voice quality^ADM||6^Weak||||||F
OBX|192|TX|Hx486PRO00^Pre-admission screening questionnaire provided^ADM||Y||||||F
OBX|193|TX|HxMEDREC00^Medication reconciliation form present^ADM||Y||||||F
OBX|194|TX|HxMRSAMD00^MRSA/MDRO swabs completed^ADM||Y||||||F
OBX|195|TX|HxSPTCHX00^Summary of patient's clinical history^ADM||history of depression and anxiety||||||F
OBX|196|TX|HxSPTCHX01^Pertinent clinical history^ADM||none||||||F
OBX|197|TX|HxSPTFHX00^Summary of patient's family history^ADM||father has hx of substance use||||||F
OBX|198|TX|HxVIOL0000^Current violent or homicidal ideation^ADM||||||||F
OBX|199|TX|HxVIOL0010^Violent or homicidal ideation details^ADM||||||||F
OBX|200|CE|InBSACTV00^Braden Scale activity^ADM||3^3-Walks occasionally||||||F
OBX|201|CE|InBSFRSH00^Braden Scale friction and shear^ADM||1^1-Problem||||||F
OBX|202|CE|InBSMOBI01^Braden Scale mobility^ADM||1^1-Completely immobile||||||F
OBX|203|CE|InBSMOIS00^Braden Scale moisture^ADM||3^3-Occasionally moist||||||F
OBX|204|CE|InBSNUTR00^Braden Scale nutrition^ADM||1^1-Very poor||||||F
OBX|205|TX|InBSRISK01^Braden Scale risk level^ADM||Moderate||||||F
OBX|206|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||13||||||F
OBX|207|CE|InBSSPER00^Braden Scale sensory perception^ADM||4^4-No impairment||||||F
OBX|208|CE|InEDEMAS00^Edema severity^ADM||3^+3||||||F
OBX|209|CE|InEDEMLB01^Edema location^ADM||5^Lips||||||F
OBX|210|CE|InEDEMLM00^Edema location modifier^ADM||1^Bilateral||||||F
OBX|211|CE|InEDEMTP00^Edema type^ADM||2^Non-pitting||||||F
OBX|212|TX|InINDRES00^Dressing dry and intact^ADM||N||||||F
OBX|213|CE|InISGR0000^infiltration Scale Grade^ADM||5^+4||||||F
OBX|214|CE|InSA000600^Skin condition^ADM||1^Intact~2^Open||||||F
OBX|215|CE|InSKGNTM00^Generalized skin temperature^ADM||1^Hot||||||F
OBX|216|CE|InSKIAPP00^Skin appearance^ADM||1^Normal||||||F
OBX|217|CE|InSKIDES00^Skin description^ADM||12^Bruised||||||F
OBX|218|CE|InSKIMOD01^Skin and wound modifier^ADM||1^Left~10^Lateral||||||F
OBX|219|CE|InSKIMOI00^Skin moisture^ADM||2^Clammy||||||F
OBX|220|CE|InSKITEM00^Skin temperature^ADM||2^Warm||||||F
OBX|221|CE|InWOULOC01^Skin or wound location^ADM||1^Head||||||F
OBX|222|TX|IoNICUIN30^Intake, IV Amount^ADM||100.00||||||F
OBX|223|TX|IoSOLUMA00^Solution^ADM||medication||||||F
OBX|224|CE|IvIN000600^Glycemic management sample source^ADM||1^Capillary||||||F
OBX|225|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|226|CE|IvPIVLOC00^Location^ADM||4^Wrist PIV||||||F
OBX|227|CE|IvPL000700^Initial management^ADM||1^Infusion||||||F
OBX|228|CE|IvPS000100^Phlebitis scale grade^ADM||3^+2||||||F
OBX|229|TX|IvRATE0000^Rate^ADM||100.00||||||F
OBX|230|TX|IvSIZE0000^Size^ADM||20||||||F
OBX|231|CE|MHTHNKTD00^Take Home Naloxone kit dispensed^ADM||03^Not applicable||||||F
OBX|232|TX|Mh00000100^Speech rate^ADM||||||||F
OBX|233|TX|MhACTIVC00^Current activity^ADM||sleeping||||||F
OBX|234|CE|MhAD000100^Admission status^ADM||2^Involuntary||||||F
OBX|235|CE|MhADLEGS02^Legal status^ADM||1^No legal issues||||||F
OBX|236|TX|MhADLIVP00^Living with others prior to admission^ADM||N||||||F
OBX|237|CE|MhADRGSR00^Aware drug screen may be required upon return^ADM||01^Yes||||||F
OBX|238|CE|MhAFFECT01^Affect^ADM||1^Appropriate||||||F
OBX|239|CE|MhAGGRRF00^Aggression/Harm to others: Risk factors^ADM||01^Not at risk||||||F
OBX|240|CE|MhAGGRSK00^Aggression risk^ADM||01^Low||||||F
OBX|241|CE|MhAPPPAD00^Appetite prior to admission^ADM||1^No concerns identified||||||F
OBX|242|TX|MhAPPTMD00^Appointments made^ADM||Appt with on April 26||||||F
OBX|243|CE|MhAWOLRK00^Wandering/AWOL risk^ADM||01^Low||||||F
OBX|244|TX|MhAXPLIC00^Initial Psychiatric Liaison Intake Assessment complete^ADM||Y||||||F
OBX|245|CE|MhBELCKR00^Aware belongings will be checked upon return^ADM||01^Yes||||||F
OBX|246|CE|MhBHBEHA00^Behaviour^ADM||1^Relaxed||||||F
OBX|247|TX|MhBHEYEC01^Eye contact^ADM||||||||F
OBX|248|TX|MhBHPMAO00^Psychomotor activity^ADM||||||||F
OBX|249|CE|MhBOWAID00^Bowel protocol/aids given^ADM||02^Meds per bowel protocol||||||F
OBX|250|TX|MhCAREAC00^Other care activity comments^ADM||test||||||F
OBX|251|CE|MhCLINRF00^Clinical conditions: Risk factors^ADM||03^Chronic pain||||||F
OBX|252|CE|MhCMAIAG01^Cursing or verbal aggression^ADM||7^3-Once or twice a week||||||F
OBX|253|CE|MhCMAIBT01^Biting^ADM||5^5-Once or twice a day||||||F
OBX|254|TX|MhCMAICM01^CMAI-Long Comments^ADM||pt bx continues to be difficult to manage||||||F
OBX|255|CE|MhCMAICO01^Complaining^ADM||7^3-Once or twice a week||||||F
OBX|256|TX|MhCMAICP01^CMAI-Long completion^ADM||Incomplete||||||F
OBX|257|CE|MhCMAIDR01^Inappropriate dress or disrobing^ADM||2^4-Several times a week||||||F
OBX|258|CE|MhCMAIEA01^Eating/drinking inappropriate substance^ADM||2^4-Several times a week||||||F
OBX|259|CE|MhCMAIEA02^Eating/Drinking inappropriate substance^ADM||7^3-Once or twice a week||||||F
OBX|260|CE|MhCMAIFL01^Intentional falling^ADM||1^1-Never||||||F
OBX|261|CE|MhCMAIGR01^Grabbing onto people^ADM||5^5-Once or twice a day||||||F
OBX|262|CE|MhCMAIHI01^Hiding things^ADM||7^3-Once or twice a week||||||F
OBX|263|CE|MhCMAIHN01^Handling things inappropriately^ADM||1^1-Never||||||F
OBX|264|CE|MhCMAIHO01^Hoarding things^ADM||7^3-Once or twice a week||||||F
OBX|265|TX|MhCMAIHT01^Hitting (including self)^ADM||||||||F
OBX|266|CE|MhCMAIHU01^Hurting self or others^ADM||2^4-Several times a week||||||F
OBX|267|CE|MhCMAIKC01^Kicking^ADM||5^5-Once or twice a day||||||F
OBX|268|CE|MhCMAING01^Negativism^ADM||7^3-Once or twice a week||||||F
OBX|269|CE|MhCMAINO01^Strange noises (weird laughter or crying)^ADM||7^3-Once or twice a week||||||F
OBX|270|CE|MhCMAIPL01^Trying to get to a different place^ADM||1^1-Never||||||F
OBX|271|CE|MhCMAIPS01^Pushing^ADM||5^5-Once or twice a day||||||F
OBX|272|CE|MhCMAIQS01^Repetitive sentences or questions^ADM||7^3-Once or twice a week||||||F
OBX|273|CE|MhCMAIRE01^Performing repetitive mannerisms^ADM||7^3-Once or twice a week||||||F
OBX|274|CE|MhCMAIRS01^General restlessness^ADM||7^3-Once or twice a week||||||F
OBX|275|CE|MhCMAISC01^Scratching^ADM||2^4-Several times a week||||||F
OBX|276|CE|MhCMAISP01^Spitting^ADM||2^4-Several times a week||||||F
OBX|277|CE|MhCMAISR01^Screaming^ADM||7^3-Once or twice a week||||||F
OBX|278|CE|MhCMAISX01^Making physical sexual advances^ADM||2^4-Several times a week||||||F
OBX|279|CE|MhCMAITH01^Throwing things^ADM||2^4-Several times a week||||||F
OBX|280|CE|MhCMAITR01^Tearing things or destroying property^ADM||2^4-Several times a week||||||F
OBX|281|CE|MhCMAITT01^Constant unwarranted request for attention or help^ADM||4^2-Less than once a week||||||F
OBX|282|CE|MhCMAITT02^Constant unwarranted request for attention or help^ADM||7^3-Once or twice a week||||||F
OBX|283|CE|MhCMAIVX01^Making verbal sexual advances^ADM||7^3-Once or twice a week||||||F
OBX|284|CE|MhCMAIWN01^Pace, aimless wandering^ADM||2^4-Several times a week||||||F
OBX|285|CE|MhCOATTS01^Attention/Concentration^ADM||1^Good||||||F
OBX|286|CE|MhCOGIMP00^Cognitively impaired^ADM||02^No||||||F
OBX|287|CE|MhCOINSI01^Insight^ADM||2^Partial||||||F
OBX|288|CE|MhCOJUDG01^Judgement^ADM||1^Good||||||F
OBX|289|CE|MhCOMEMO01^Memory^ADM||1^Immediate/Recall intact||||||F
OBX|290|CE|MhCOORIE01^Oriented to^ADM||2^Person||||||F
OBX|291|TX|MhCPPAXO00^Other care providers present during assessment^ADM||N||||||F
OBX|292|CE|MhDAGGBH00^Currently demonstrating aggressive behaviour^ADM||02^No||||||F
OBX|293|TX|MhDENTUR00^Dentures^ADM||N||||||F
OBX|294|CE|MhDISPOS00^Disposition^ADM||9^Admit to psychiatry||||||F
OBX|295|TX|MhDXTEST00^Diagnostic tests^ADM||cxray tomorrow||||||F
OBX|296|TX|MhECTPRE00^Pre-ECT comments^ADM||||||||F
OBX|297|TX|MhECTTXN00^ECT treatment number^ADM||1||||||F
OBX|298|TX|MhECTVIT00^Vital signs taken prior to ECT^ADM||Y||||||F
OBX|299|CE|MhEDLEVC00^Highest level of education completed^ADM||2^Secondary||||||F
OBX|300|TX|MhEDPHAD00^Assessed by ED Physician date^ADM||20180411||||||F
OBX|301|TX|MhEDPHAN00^Assessed by ED Physician name^ADM||dr.o||||||F
OBX|302|TX|MhEDPHAT00^Assessed by ED Physician time^ADM||0900||||||F
OBX|303|TX|MhEDPMHA00^Patient brought under Section 28^ADM||N||||||F
OBX|304|CE|MhEDPSER00^Reason for visit^ADM||12^Suicidal ideation||||||F
OBX|305|CE|MhEDPSRS00^Referral source^ADM||04^Mental health centre||||||F
OBX|306|TX|MhEDPSYI00^Assessment date^ADM||20180411||||||F
OBX|307|TX|MhEDPSYI01^Patient admitted prior to assessment^ADM||N||||||F
OBX|308|TX|MhEDPSYI02^Repeat patient^ADM||N||||||F
OBX|309|TX|MhEDPSYT00^Assessment time^ADM||1121||||||F
OBX|310|TX|MhELIMAC00^Elimination comments^ADM||test||||||F
OBX|311|TX|MhELIMBO00^Bowel concerns identified^ADM||Y||||||F
OBX|312|TX|MhELIMTL00^Independent with toileting^ADM||Y||||||F
OBX|313|TX|MhELIMUC00^Urinary concerns identified^ADM||N||||||F
OBX|314|CE|MhELOPRF00^Elopement: Risk factors^ADM||01^Not at risk||||||F
OBX|315|TX|MhESAFFE02^Affect other^ADM||||||||F
OBX|316|TX|MhESMOOD04^Mood^ADM||pt stated he was feeling really depressed.||||||F
OBX|317|CE|MhETOHT000^Alcohol type used^ADM||1^Beer||||||F
OBX|318|CE|MhEXPSYC00^Experiencing psychosis^ADM||02^No||||||F
OBX|319|CE|MhEXSHSO00^Expressing any thoughts of harm to self or others^ADM||02^No||||||F
OBX|320|TX|MhEYECOL00^Eye colour^ADM||brown||||||F
OBX|321|CE|MhFALLPA00^Recent falls prior to admission^ADM||1^No concerns identified||||||F
OBX|322|TX|MhFALLRK00^Fall risk^ADM||N||||||F
OBX|323|CE|MhFOLLUP00^Follow-up recommendations^ADM||4^Mental health services||||||F
OBX|324|TX|MhFUNMDC00^Functional status/medical considerations comments^ADM||chronic pain||||||F
OBX|325|TX|MhGENCON00^General concerns identified^ADM||no concerns||||||F
OBX|326|TX|MhGLACON00^Glasses/Contacts^ADM||N||||||F
OBX|327|TX|MhHAIRCO00^Hair colour^ADM||blonde||||||F
OBX|328|TX|MhHEARAD00^Hearing aid^ADM||N||||||F
OBX|329|TX|MhHXABUS00^History of vulnerability to abuse^ADM||N||||||F
OBX|330|TX|MhHXADLS00^History of unable to perform activities of daily living^ADM||N||||||F
OBX|331|TX|MhHXDEPR00^Hx depression^ADM||Y||||||F
OBX|332|TX|MhHXDOMV00^Hx domestic violence^ADM||N||||||F
OBX|333|TX|MhHXELOA00^Hx elopement attempt^ADM||N||||||F
OBX|334|TX|MhHXELOP00^Hx elopement^ADM||N||||||F
OBX|335|TX|MhHXFALL00^Hx falls^ADM||N||||||F
OBX|336|TX|MhHXFIRE00^Hx fire setting behaviour^ADM||N||||||F
OBX|337|TX|MhHXFRTX00^History of forensic treatment^ADM||N||||||F
OBX|338|TX|MhHXFVBH00^Hx family violent behaviour^ADM||N||||||F
OBX|339|TX|MhHXONEG00^Hx neglect^ADM||N||||||F
OBX|340|TX|MhHXPDDO00^History of personality disorder^ADM||N||||||F
OBX|341|TX|MhHXPSYD00^Hx psychotic disorder^ADM||N||||||F
OBX|342|TX|MhHXSEIZ00^Hx seizures^ADM||N||||||F
OBX|343|TX|MhHXSUIA00^Hx suicide attempt^ADM||N||||||F
OBX|344|TX|MhHXSUID00^Hx suicidal ideation^ADM||Y||||||F
OBX|345|TX|MhHXSUIF00^Hx family suicide^ADM||N||||||F
OBX|346|TX|MhHXVBEH00^Hx violent behaviour^ADM||N||||||F
OBX|347|TX|MhIMPFOR00^Impression/Formulation^ADM||patient to be admitted to inpatient unit||||||F
OBX|348|CE|MhINCSOU00^Source(s) of income^ADM||1^Employment income||||||F
OBX|349|CE|MhINFOSC00^Information source^ADM||1^Patient||||||F
OBX|350|CE|MhINSTRP00^Instructions provided^ADM||03^Not applicable||||||F
OBX|351|TX|MhITEINS01^Inspected all items brought in and checked for sharps^ADM||N||||||F
OBX|352|TX|MhLOBCO001^Level of observation comments^ADM||test||||||F
OBX|353|CE|MhLOBMT001^Level of observation maintained^ADM||0^Constant||||||F
OBX|354|TX|MhLVEADD00^Address^ADM||Home||||||F
OBX|355|CE|MhMCSIAJ01^There have been family adjustments^ADM||2^Yes sometimes||||||F
OBX|356|CE|MhMCSIBH01^Some behaviour is upsetting^ADM||3^No||||||F
OBX|357|CE|MhMCSICG01^Caregiving is inconvenient^ADM||3^No||||||F
OBX|358|CE|MhMCSICH01^Upset they have changed from their former self^ADM||2^Yes sometimes||||||F
OBX|359|TX|MhMCSICM01^Caregiver Strain Comments^ADM||test test test||||||F
OBX|360|CE|MhMCSICN01^Caregiving is confining^ADM||3^No||||||F
OBX|361|CE|MhMCSIDT01^There have been other demands on my time^ADM||1^Yes on a regular basis||||||F
OBX|362|CE|MhMCSIEM01^There have been emotional adjustments^ADM||2^Yes sometimes||||||F
OBX|363|CE|MhMCSIFS01^Caregiving is a financial strain^ADM||1^Yes on a regular basis||||||F
OBX|364|CE|MhMCSIOV01^I feel completely overwhelmed^ADM||2^Yes sometimes||||||F
OBX|365|CE|MhMCSIPL01^There have been changes in personal plans^ADM||1^Yes on a regular basis||||||F
OBX|366|CE|MhMCSIPS01^Caregiving is a physical strain^ADM||2^Yes sometimes||||||F
OBX|367|CE|MhMCSISL01^My sleep is disturbed^ADM||2^Yes sometimes||||||F
OBX|368|TX|MhMCSITL01^Total Score^ADM||13||||||F
OBX|369|CE|MhMCSIWO01^There have been work adjustments^ADM||2^Yes sometimes||||||F
OBX|370|CE|MhMEDAD001^Medication adherence^ADM||01^No concerns identified||||||F
OBX|371|CE|MhMEDCPA00^Medical considerations prior to admission^ADM||3^Pain||||||F
OBX|372|CE|MhMEDIRF00^Medical instability: Risk factors^ADM||01^Not at risk||||||F
OBX|373|CE|MhMEDSEF00^Medication side effects^ADM||1^No concerns identified||||||F
OBX|374|TX|MhMHCER000^Certification and MHSU programs/services comments^ADM||patient already followed by mental health team, linked with case manager||||||F
OBX|375|TX|MhMHINCM00^Current mental health team case manager^ADM||Susan (604-321-7698)||||||F
OBX|376|TX|MhMHINVP00^Current mental health team psychiatrist^ADM||Dr. Lu (604-541-6745)||||||F
OBX|377|TX|MhMHINVT00^Currently involved with mental health team^ADM||N||||||F
OBX|378|TX|MhMHSPAD01^Mental health services utilized prior to admission other^ADM||intake appt with Abbotsford Mental Health||||||F
OBX|379|CE|MhMHSPAD02^Mental health services utilized prior to admission^ADM||08^Mental health centre||||||F
OBX|380|CE|MhMSEAS015^Thought process^ADM||1^Organized||||||F
OBX|381|TX|MhMSEAS022^Thought process other^ADM||||||||F
OBX|382|TX|MhMSEATT01^Attitude^ADM||||||||F
OBX|383|CE|MhMSECHG00^Showing any significant change in mental status^ADM||02^No||||||F
OBX|384|CE|MhMSECOM00^Mental status assessment completed^ADM||01^Pre-ECT||||||F
OBX|385|TX|MhMSEGAP02^General appearance^ADM||adsfdsaf||||||F
OBX|386|TX|MhMSETPE00^Thoughts and perception comments^ADM||||||||F
OBX|387|TX|MhMUNICP00^Municipality^ADM||Abbotsford||||||F
OBX|388|TX|MhNOSUPP00^Name of supervising person^ADM||Jane, Mother||||||F
OBX|389|TX|MhOTHCON00^Other contacts^ADM||Brad, Father (778-634-8582)||||||F
OBX|390|TX|MhOTINT003^Referral method^ADM||xx||||||F
OBX|391|TX|MhPAINPR00^Pain present^ADM||N||||||F
OBX|392|TX|MhPATAPN00^Patient's alternate phone number^ADM||N/A||||||F
OBX|393|TX|MhPATMPN00^Patient's main phone number^ADM||604-123-4444||||||F
OBX|394|CE|MhPERDIS00^Perceptual disturbances^ADM||4^Illusions||||||F
OBX|395|CE|MhPLINPA00^Pleasure and interest prior to admission^ADM||2^Concerns identified||||||F
OBX|396|TX|MhPORTUN01^Oriented to unit and/or provided orientation pamphlet^ADM||N||||||F
OBX|397|TX|MhPSYAXD00^Assessed by Psychiatrist date^ADM||20180411||||||F
OBX|398|TX|MhPSYAXN00^Assessed by Psychiatrist name^ADM||dr. g||||||F
OBX|399|TX|MhPSYAXT00^Assessed by Psychiatrist time^ADM||1200||||||F
OBX|400|TX|MhPSYCON00^Consulted with Psychiatrist^ADM||Y||||||F
OBX|401|CE|MhPTBELC00^Patient belongings checked^ADM||01^Yes||||||F
OBX|402|CE|MhPTSUAC00^Patient/Supervising person aware they may contact unit^ADM||01^Yes||||||F
OBX|403|CE|MhPTSUAR00^Patient/Supervising person aware they may return anytime^ADM||01^Yes||||||F
OBX|404|CE|MhPXMEDD00^Prescribed medication dispensed with dosing information^ADM||01^Yes||||||F
OBX|405|TX|MhRCTCOM00^RecT comments^ADM||Agrees to attend groups tomorrow||||||F
OBX|406|TX|MhRIGHT005^Using hospital grounds^ADM||Y||||||F
OBX|407|TX|MhRTUNIT00^Time patient returned to unit^ADM||||||||F
OBX|408|CE|MhRXMEDT00^All prescribed medications taken^ADM||01^Yes||||||F
OBX|409|CE|MhSAFEIN01^Emergency department safety interventions^ADM||1^Certified by physician||||||F
OBX|410|TX|MhSCTATT00^Scars/Tattoos^ADM||N||||||F
OBX|411|TX|MhSFCARE00^Independent with personal care^ADM||Y||||||F
OBX|412|TX|MhSIPROT05^Protective factors^ADM||||||||F
OBX|413|CE|MhSIRISK02^Suicide risk level/Degree of risk^ADM||1^No (forseeable) risk||||||F
OBX|414|TX|MhSIRISK04^Suicidal ideation: Assessment confidence^ADM||||||||F
OBX|415|CE|MhSLPATP00^Sleep pattern prior to admission^ADM||2^Concerns identified||||||F
OBX|416|CE|MhSNVURF00^Self neglect/Vulnerability: Risk factors^ADM||01^Not at risk||||||F
OBX|417|CE|MhSOCSRF00^Social situations: Risk factors^ADM||09^Separation/Divorce||||||F
OBX|418|TX|MhSPAMOT01^Speech amount^ADM||||||||F
OBX|419|TX|MhSPTONE05^Speech tone^ADM||||||||F
OBX|420|TX|MhSPVOLU01^Speech volume^ADM||||||||F
OBX|421|TX|MhSSACHE00^Signs and symptoms of headache/muscle soreness present^ADM||||||||F
OBX|422|CE|MhSUBUSS00^Substance use suspected^ADM||01^Yes||||||F
OBX|423|CE|MhSUDRSO00^Supervised urine drug screen obtained^ADM||01^Yes||||||F
OBX|424|CE|MhSUICRF00^Suicide/Self harm: Risk factors^ADM||02^Passive suicidal ideation||||||F
OBX|425|TX|MhSUIDC001^Current suicidal ideation^ADM||||||||F
OBX|426|TX|MhSUIDCH01^Suicidal ideation: Changeability^ADM||||||||F
OBX|427|TX|MhSUIDIL01^Suicidal ideation: Intent and lethality^ADM||||||||F
OBX|428|TX|MhSUPAPN00^Supervising person's alternative phone number^ADM||N/A||||||F
OBX|429|TX|MhSUPMPN00^Supervising person's main phone number^ADM||778-444-7896||||||F
OBX|430|CE|MhSUPWHC01^Previous alcohol withdrawal^ADM||2^No||||||F
OBX|431|CE|MhSUPWSZ01^Previous alcohol withdrawal seizures^ADM||2^No||||||F
OBX|432|TX|MhSUSS0011^Alcohol amount consumed^ADM||states he drink a few beers casually on the weekends||||||F
OBX|433|CE|MhSUSS0027^Alcohol use^ADM||3^Currently using||||||F
OBX|434|CE|MhSUSS0028^Drug use^ADM||1^Does not use||||||F
OBX|435|CE|MhSUSS0034^Tobacco/Nicotine use^ADM||1^Does not use||||||F
OBX|436|CE|MhTHNKRT00^Take Home Naloxone kit returned^ADM||03^Not applicable||||||F
OBX|437|CE|MhTHNKUP00^Take Home Naloxone kit used by patient^ADM||03^Not applicable||||||F
OBX|438|TX|MhTLCLOTH0^Clothing description prior to departure^ADM||Black sweater, dark blue jeans, white shoes.||||||F
OBX|439|TX|MhTLCOMS01^Other therapeutic leave comments^ADM||Patient remains on leave. No contact made to unit.||||||F
OBX|440|TX|MhTLDOPD01^Date of departure^ADM||20180427||||||F
OBX|441|TX|MhTLEDPR01^Expected date of return^ADM||20180430||||||F
OBX|442|TX|MhTLETPR01^Expected time of return^ADM||1000||||||F
OBX|443|CE|MhTLGOLM02^Goals of leave met according to patient^ADM||01^Yes||||||F
OBX|444|CE|MhTLGOLM03^Goals of leave met according to supervising person^ADM||01^Yes||||||F
OBX|445|TX|MhTLRETD01^Date of return^ADM||20180430||||||F
OBX|446|TX|MhTLRETT01^Time of return^ADM||1000||||||F
OBX|447|CE|MhTLSIGN02^Signed in on form^ADM||01^Yes||||||F
OBX|448|CE|MhTLSIOU02^Signed out on form^ADM||01^Yes||||||F
OBX|449|TX|MhTLTOPD01^Time of departure^ADM||1000||||||F
OBX|450|CE|MhTLTYPE01^Type of leave^ADM||1^Accompanied||||||F
OBX|451|CE|MhTPCONT02^Thought content^ADM||1^No problem identified||||||F
OBX|452|CE|MhTXMGPL00^Intervention method/services provided^ADM||3^Inpatient care||||||F
OBX|453|CE|MhUNITPN00^Unit phone number provided^ADM||01^Yes||||||F
OBX|454|TX|MhUPSACC01^Communication^ADM||10||||||F
OBX|455|TX|MhUPSACM01^Comment^ADM||lots of comments.  lots of comments.  lots of comments.  lots of comments.~ lots of comments.  lots of comments.  lots of comments.  lots of~comments.  lots of comments.  lots of comments.  lots of comments.  lots~of comments.  lots of comments.  vvlots of comments.  lots of comments.~lots of comments.  lots of comments.  lots of comments.  lots of comments.~ vvlots of comments.  lots of comments.  lots of comments.  lots of~comments.  vlots of comments.  lots of comments.  lots of comments.  vlots~of comments.  lots of comments.  lots of comments.  vvlots of comments.~lots of comments.  vvlots of comments.  lots of comments.  vvvlots of~comments.  lots of comments.  vlots of comments.  lots of comments.  lots~of comments.  vvlots of comments.  lots of comments.  v||||||F
OBX|456|TX|MhUPSAFN01^Finance^ADM||2||||||F
OBX|457|TX|MhUPSAPL01^Comprehension and Planning^ADM||3||||||F
OBX|458|TX|MhUPSAPL02^Comprehension and planning^ADM||20||||||F
OBX|459|TX|MhUPSASK01^Household Skills^ADM||20||||||F
OBX|460|TX|MhUPSASK02^Household skills^ADM||12||||||F
OBX|461|TX|MhUPSATL01^Total Score^ADM||53 Patient unlikely able to live independently||||||F
OBX|462|TX|MhUPSATL02^Total score^ADM||49||||||F
OBX|463|TX|MhUPSATR01^Transportation^ADM||5||||||F
OBX|464|TX|MhVERDIR00^Able to follow verbal direction^ADM||Y||||||F
OBX|465|TX|MhVITALR00^Vital signs taken upon return^ADM||||||||F
OBX|466|CE|MoAIDUSE00^Aid used for independent ambulation^ADM||1^Standard walker||||||F
OBX|467|CE|MoAMASTN02^Assistance required for ambulation^ADM||2^Supervision||||||F
OBX|468|CE|MoAMBABI00^Ambulation ability^ADM||2^Independent with aid||||||F
OBX|469|TX|MoAMBIND00^Independent with ambulation^ADM||N||||||F
OBX|470|TX|MoAMCMTS00^Ambulation comment^ADM||indepedent with walker||||||F
OBX|471|CE|MoAMMBAD00^Mobility aid used for ambulation^ADM||1^Standard walker||||||F
OBX|472|CE|MoAMRMWD00^Ambulation^ADM||1^Within room||||||F
OBX|473|CE|MoFALPRE00^Fall prevention strategy^ADM||4^Hip protectors||||||F
OBX|474|CE|MoPOBDPO01^Bed position^ADM||1^Flat||||||F
OBX|475|TX|NUOTCMST00^Outcome status^ADM||Partially met||||||F
OBX|476|CE|NeCATLOC02^Altered level of consciousness^ADM||2^Yes||||||F
OBX|477|CE|NeCDIFFA01^Difficulty focusing attention^ADM||2^Yes||||||F
OBX|478|CE|NeCDIOFS02^Diagnosis of delirium suggested^ADM||2^Yes||||||F
OBX|479|TX|NeCDIORE00^CAM assessment^ADM||Complete||||||F
OBX|480|CE|NeCEACMS01^Evidence of acute change in mental status from baseline^ADM||1^No||||||F
OBX|481|CE|NeCFBDPD01^Fluctuating behaviour during the past day^ADM||2^Yes||||||F
OBX|482|TX|NeCIDG0000^CIWA-Ar dose given^ADM||2.00||||||F
OBX|483|TX|NeCIRE0002^CIWA-Ar Alcohol Withdrawal Score^ADM||22||||||F
OBX|484|CE|NeCIRG0000^CIWA-Ar route given^ADM||1^Oral||||||F
OBX|485|CE|NeCIWA1000^Headache, fullness in head^ADM||2^2||||||F
OBX|486|CE|NeCIWAA100^Nausea and vomiting^ADM||7^5||||||F
OBX|487|CE|NeCIWAA200^Tremor^ADM||2^2||||||F
OBX|488|CE|NeCIWAA300^Paroxysmal sweats^ADM||6^3||||||F
OBX|489|CE|NeCIWAA400^Anxiety^ADM||6^3||||||F
OBX|490|CE|NeCIWAA500^Agitation^ADM||2^2||||||F
OBX|491|CE|NeCIWAA600^Orientation^ADM||2^1||||||F
OBX|492|CE|NeCIWAA700^Tactile disturbances^ADM||2^2||||||F
OBX|493|CE|NeCIWAA800^Auditory disturbances^ADM||2^2||||||F
OBX|494|CE|NeCIWAA900^Visual disturbances^ADM||1^0||||||F
OBX|495|CE|NeCSPDSI01^Speech disorganized or incoherent^ADM||1^No||||||F
OBX|496|CE|NeGCSEYE03^Glasgow Coma Scale Eye Opening^ADM||1^4- Spontaneous||||||F
OBX|497|CE|NeGCSMOT03^Glasgow Coma Scale Motor Response^ADM||1^6- Obeys commands||||||F
OBX|498|TX|NeGCSSCR01^GCS score^ADM||15||||||F
OBX|499|CE|NeGCSVER03^Glasgow Coma Scale Verbal Response^ADM||1^5- Oriented||||||F
OBX|500|TX|NeGLBLGU00^Glucometer blood glucose^ADM||13||||||F
OBX|501|CE|NeLECONS00^Level of consciousness^ADM||1^Alert||||||F
OBX|502|CE|NeNV001002^Left popliteal pulse^ADM||3^+2||||||F
OBX|503|CE|NeORIENT01^Oriented to^ADM||1^All domains||||||F
OBX|504|CE|NePARAMR00^Neurological and cognition defined parameters^ADM||2^Significant findings||||||F
OBX|505|CE|NePOSC0000^POSS score^ADM||1^1 - Awake and alert||||||F
OBX|506|CE|NeRFCRNL00^Corneal reflex left^ADM||2^Absent||||||F
OBX|507|CE|NmLEGST100^Leg strength right^ADM||3^Weak||||||F
OBX|508|TX|Nu00000200^Oral nutrition amount of meal consumed comments^ADM||test 2||||||F
OBX|509|CE|NuBRAMCO01^Breakfast amount consumed^ADM||3^75%||||||F
OBX|510|CE|NuBRAMCO02^Breakfast amount consumed^ADM||01^0%||||||F
OBX|511|CE|NuDIAMCO01^Dinner amount consumed^ADM||2^50%||||||F
OBX|512|CE|NuDIAMCO02^Dinner amount consumed^ADM||01^0%||||||F
OBX|513|CE|NuFANURO00^Nutrition route^ADM||1^Oral nutrition||||||F
OBX|514|CE|NuFEEASS01^Feeding assistance^ADM||1^Unassisted||||||F
OBX|515|TX|NuGLROUT00^Glucometer result out of range^ADM||yes||||||F
OBX|516|CE|NuLUAMCO01^Lunch amount consumed^ADM||2^50%||||||F
OBX|517|CE|NuLUAMCO02^Lunch amount consumed^ADM||01^0%||||||F
OBX|518|TX|NuNICUF370^Intake, Oral Amount^ADM||25.0||||||F
OBX|519|TX|NuNM000100^Nothing by mouth^ADM||Y||||||F
OBX|520|TX|NuNPOPAT00^Patient currently NPO^ADM||N||||||F
OBX|521|TX|NuONSOOT00^Oral nutrition food source other^ADM||test||||||F
OBX|522|CE|NuONSOUR00^Oral nutrition food source^ADM||1^Hospital~2^Family or friends||||||F
OBX|523|TX|NuORTCOM00^Other ORT comments^ADM||ddfsfsf~dfsf~sfsflewi.cf~sdfwerfv~eflcvks~cfwsfek~dsfesfe~sfdvsef||||||F
OBX|524|TX|NuORTSCH00^Schedule^ADM||50 ml daily||||||F
OBX|525|TX|NuORTTIC00^Time ORT completed^ADM||1500||||||F
OBX|526|TX|NuORTTII00^Time ORT initiated^ADM||1300||||||F
OBX|527|TX|NuOSTOOL00^Output - stool^ADM||20.00||||||F
OBX|528|TX|NuOURINE00^Output - urine^ADM||13.00||||||F
OBX|529|CE|NuPPOSBR00^Patient's position during breakfast^ADM||1^High fowlers||||||F
OBX|530|CE|NuPPOSDI00^Patient's position during dinner^ADM||1^High fowlers||||||F
OBX|531|CE|NuPPOSLU01^Patient's position during lunch^ADM||1^High fowlers||||||F
OBX|532|TX|NuSNAMCO01^Snack amount consumed^ADM||0||||||F
OBX|533|CE|NuSNAMCO02^Snack amount consumed^ADM||01^0%||||||F
OBX|534|TX|OEDIAG^Diagnosis:^ADM||Major Depressive D/O||||||F
OBX|535|CE|OEISO^Infection Control:^ADM||CP^Contact Plus||||||F
OBX|536|TX|OTOTCMST00^Outcome status^ADM||In progress||||||F
OBX|537|TX|OhCO000201^Method of collection^ADM||||||||F
OBX|538|TX|OhEDIT0000^Reason for edit^ADM||edit||||||F
OBX|539|CE|OhIN000300^Information source^ADM||7^Friend~15^Significant other||||||F
OBX|540|CE|OhINFOSR00^Information source if reported^ADM||1^Patient||||||F
OBX|541|TX|OhNAMORG01^Name of organization or profession consulted^ADM||infection prevention||||||F
OBX|542|TX|OhSPECDL01^Laboratory delivery method^ADM||||||||F
OBX|543|TX|OhSPECRE01^Specimen reason^ADM||||||||F
OBX|544|TX|OhSPECTP01^Specimen type^ADM||||||||F
OBX|545|TX|OtPDGLUC00^Glucometer frequency^ADM||ac meals||||||F
OBX|546|TX|OtPDOLWO00^Other lab work^ADM||cbc tomorrow||||||F
OBX|547|TX|OtPDPCCN00^PCC notes^ADM||Med changes in the next week as per Psychiatrist||||||F
OBX|548|TX|OtPDRAPI00^Restrictions and privileges^ADM||May 10: 4hr unaccomp. passes~May 7: 2hr pass w/ dad, increased to level 3 obs||||||F
OBX|549|TX|OtPDSEON00^1^ADM||Needs doctor's note for work, note left for psychiatrist May 16||||||F
OBX|550|TX|OtPDSETH00^3^ADM||||||||F
OBX|551|TX|OtPDSETW00^2^ADM||TB Test to read May 18||||||F
OBX|552|TX|OtPDSSUM00^Shift summary^ADM||May 17 Dx: Pt AWOL'd~ ~May 16 Nx: stable mood, no bx management issues attended groups, denies any~homicidal ideation, attended adls, has pass tomorrow for 2 hours with dad.~ ~May 16 Dx: admitted from ER at 1000hrs, labile mood, admits to command~hallucinations, denies any intent, 48/6 completed, has fasting lab work in~the am.||||||F
OBX|553|TX|OtPDVSIG00^Vital signs frequency^ADM||BID||||||F
OBX|554|TX|PTNOTES1^PT Notes:^ADM||ZA;LKDJA;FLK||||||F
OBX|555|TX|PTNOTES2^:^ADM||A;LSDJKFA;L||||||F
OBX|556|TX|PaCOMMEN00^Pain comments^ADM||Mildly decreased pain||||||F
OBX|557|CE|PaFREQ0000^Pain frequency^ADM||2^With movement||||||F
OBX|558|CE|PaLOCBDS01^Location^ADM||6^Arm||||||F
OBX|559|CE|PaLOCBDS02^Location^ADM||15^Back||||||F
OBX|560|TX|PaPAGOAL02^Pain goal^ADM||3/10||||||F
OBX|561|CE|PaPAIASS00^Pain assessment^ADM||2^Pain reported||||||F
OBX|562|CE|PaPALOCM00^Pain location modifier^ADM||2^Right~4^Lower||||||F
OBX|563|CE|PaPANVBA00^Pain non-verbal behaviours^ADM||10^Guarding~20^Refusing to mobilize||||||F
OBX|564|CE|PaPAQUAL01^Pain quality^ADM||1^Sharp~5^Burning~7^Electric shock||||||F
OBX|565|TX|PaPARADI00^Pain radiating^ADM||Y||||||F
OBX|566|TX|PaPARADL00^Pain radiating location^ADM||right leg||||||F
OBX|567|CE|PaPASCL000^Pain scale used^ADM||1^Numeric||||||F
OBX|568|TX|PaPASCRE01^Pain score^ADM||8.00||||||F
OBX|569|TX|PaPATIME00^Time of pain onset^ADM||1620||||||F
OBX|570|CE|PaPATYPE00^Pain type of onset^ADM||1^Gradual||||||F
OBX|571|CE|PaPNMGTT00^Pain management techniques^ADM||1^Medication~2^Ice pack~5^Positioning~9^Rest||||||F
OBX|572|TX|PdOOTCOM01^OT comments^ADM||Agrees to attend OT groups tomorrow, receptive to discussing pain~management techniques||||||F
OBX|573|TX|PdOSWCOM01^SW comments^ADM||Pt currently living alone, liaised with ex-girlfriend and she is agreeable~to take patients dog to her home to be taken care of.||||||F
OBX|574|TX|PsCLB00000^Communication language barrier^ADM||N||||||F
OBX|575|CE|PsCLCONS00^Special considerations^ADM||5^Extended/Repeat admit~12^Energy level||||||F
OBX|576|CE|PsCLHOSP00^Reactions to hospitalization/Illness^ADM||2^Separation difficulties||||||F
OBX|577|TX|PsCLIFAM00^Clinical update provided to visitor(s)^ADM||N||||||F
OBX|578|CE|PsCLINTE00^Interventions^ADM||2^Developmental play~6^Emotional support~7^Relaxation/Pain mgmt~8^Procedural preparation||||||F
OBX|579|CE|PsCLIRCO00^Consent obtained for child life involvement^ADM||2^No||||||F
OBX|580|CE|PsFIMS0001^Family information marital status^ADM||1^Single||||||F
OBX|581|CE|PsHAMSWB00^14. Behavior at interview^ADM||1^Not present (0)||||||F
OBX|582|CE|PsHAMSWC00^9. Cardiovascular symptoms^ADM||1^Not present (0)||||||F
OBX|583|CE|PsHAMSWD00^6. Depressed mood^ADM||1^Not present (0)||||||F
OBX|584|CE|PsHAMSWG00^11. Gastrointestinal symptoms^ADM||1^Not present (0)||||||F
OBX|585|CE|PsHAMSWN00^13. Autonomic symptoms^ADM||1^Not present (0)||||||F
OBX|586|CE|PsHAMSWO00^8. Somatic (sensory)^ADM||1^Not present (0)||||||F
OBX|587|CE|PsHAMSWR00^10. Respiratory symptoms^ADM||1^Not present (0)||||||F
OBX|588|CE|PsHAMSWS00^7. Somatic (muscular)^ADM||1^Not present (0)||||||F
OBX|589|TX|PsHAMSWT00^HAM-A Result^ADM||Incomplete||||||F
OBX|590|CE|PsHAMSWU00^12. Genitourinary symptoms^ADM||1^Not present (0)||||||F
OBX|591|CE|PsHD000004^1. Depressed mood^ADM||1^Absent (0)||||||F
OBX|592|CE|PsHD000101^2. Feelings of guilt^ADM||1^Absent (0)||||||F
OBX|593|CE|PsHD000201^3. Suicide^ADM||1^Absent (0)||||||F
OBX|594|CE|PsHD000301^4. Insomnia early^ADM||1^No difficulty (0)||||||F
OBX|595|CE|PsHD000401^5. Insomnia middle^ADM||1^No difficulty (0)||||||F
OBX|596|CE|PsHD000501^6. Insomnia late^ADM||1^No difficulty (0)||||||F
OBX|597|CE|PsHD000601^7. Work and activities^ADM||1^No difficulty (0)||||||F
OBX|598|CE|PsHD000701^8. Retardation: Psychomotor^ADM||1^Normal (0)||||||F
OBX|599|CE|PsHD000801^9. Agitation^ADM||1^None (0)||||||F
OBX|600|CE|PsHD000901^10. Anxiety (psychological)^ADM||1^No difficulty (0)||||||F
OBX|601|CE|PsHD001002^11. Anxiety (somatic)^ADM||1^Absent (0)||||||F
OBX|602|CE|PsHD001101^12. Somatic symptoms (gastrointestinal)^ADM||1^None (0)||||||F
OBX|603|CE|PsHD001202^13. Somatic symptoms (general)^ADM||1^None (0)||||||F
OBX|604|CE|PsHD001301^14. Genital symptoms^ADM||1^Absent (0)||||||F
OBX|605|CE|PsHD001401^15. Hypochondriasis^ADM||1^Not present (0)||||||F
OBX|606|CE|PsHD001501^16. Loss of weight^ADM||1^No weight loss (0)||||||F
OBX|607|CE|PsHD001601^17. Insight^ADM||3^Denies (2)||||||F
OBX|608|TX|PsHD001702^HAM-D score^ADM||Incomplete||||||F
OBX|609|CE|PsHD001801^18. Diurnal variation^ADM||1^No variation (0)||||||F
OBX|610|CE|PsHD001901^19. Depersonalization and derealisation^ADM||2^Mild (1)||||||F
OBX|611|CE|PsHD002001^20. Paranoid symptoms^ADM||2^Suspicious (1)||||||F
OBX|612|CE|PsHD002101^21. Obsessional and compulsive symptoms^ADM||2^Mild (1)||||||F
OBX|613|CE|PsSECONT00^Professional/Service contacts^ADM||13^School based services||||||F
OBX|614|TX|PsSTAND190^Primary contact person^ADM||I am the primary contact person||||||F
OBX|615|TX|PsSTAND191^Primary contact person^ADM||Bob||||||F
OBX|616|CE|PsSWEMPL02^Employment^ADM||6^Part-time||||||F
OBX|617|TX|PsSWPUIN00^Purpose of social work involvement^ADM||AGADSFASDF||||||F
OBX|618|TX|PsSWSTDC00^Dependents comments^ADM||has 2 kids 1 7 yr old and 1 3 yr old||||||F
OBX|619|CE|PsSWSTST02^Citizenship status^ADM||1^Canadian citizen||||||F
OBX|620|CE|ReCGSTGH00^Cough strength^ADM||3^Weak||||||F
OBX|621|CE|ReCOLMET01^Secretions collection method^ADM||1^Closed/Inline suction||||||F
OBX|622|CE|ReDO000100^Digital occlusion reason for trial failure^ADM||1^Patient anxiety~3^Change in heart rate||||||F
OBX|623|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||1^Room air||||||F
OBX|624|CE|ReSCAMNT00^Secretions amount^ADM||2^Small||||||F
OBX|625|CE|ReSCCOLR00^Secretions colour^ADM||2^White||||||F
OBX|626|CE|ReSCDESC02^Secretions description^ADM||1^Mucoid~6^Purulent||||||F
OBX|627|CE|ReSV000100^Speaking valve reason for trial failure^ADM||3^Change in heart rate~4^Change in blood pressure||||||F
OBX|628|TX|ReTRCORO00^Digital occlusion trial length^ADM||2||||||F
OBX|629|CE|ReTRCUST00^Tracheostomy cuff status^ADM||2^Cuff down||||||F
OBX|630|TX|ReTRSVTL00^Speaking valve trial length^ADM||30||||||F
OBX|631|CE|ReTRTUSI02^Tracheostomy tube size^ADM||2^5.0 mm||||||F
OBX|632|CE|ReTRTYP00^Tracheostomy type^ADM||2^Cuffless~4^Extra length proximal||||||F
OBX|633|TX|RpPBREAS00^Patient breastfeeding^ADM||N||||||F
OBX|634|TX|SWNOTES1^SW Notes:^ADM||...||||||F
OBX|635|TX|SWNOTES2^:^ADM||...||||||F
OBX|636|TX|SWOTCMST00^Outcome status^ADM||In progress||||||F
OBX|637|CE|SpHAMSWA00^1. Anxious mood^ADM||1^Not present (0)||||||F
OBX|638|CE|SpHAMSWF00^3. Fears^ADM||1^Not present (0)||||||F
OBX|639|CE|SpHAMSWI00^4. Insomnia^ADM||1^Not present (0)||||||F
OBX|640|CE|SpHAMSWN00^5. Intellectual^ADM||4^Mild (1)||||||F
OBX|641|CE|SpHAMSWT00^2. Tension^ADM||1^Not present (0)||||||F
OBX|642|CE|SpIPRATI02^Isolation precautions rationale suspected/confirmed^ADM||1^Clostridium difficile~2^MRSA~6^Measles~10^Shingles||||||F
OBX|643|CE|SpIPRTYP00^Isolation precautions room type^ADM||2^Single occupancy room||||||F
OBX|644|TX|SpOSPATT01^Observed sleep pattern^ADM||slept||||||F
OBX|645|TX|SpREPSLE00^Reported sleep pattern^ADM||appears to be sleeping||||||F
OBX|646|TX|SpRIREQU00^Reverse isolation required^ADM||Y||||||F
OBX|647|TX|SpSLEAID00^Sleep aid PRN given^ADM||Y||||||F
OBX|648|CE|TeEDFURQ00^Education follow up required^ADM||1^None||||||F
OBX|649|TX|TeEDINTR00^Interpreter utilized^ADM||Y||||||F
OBX|650|CE|TeEDMATP00^Learning materials provided^ADM||1^Handout/Pamphlet||||||F
OBX|651|CE|TeEDMATP01^Learning materials provided^ADM||1^Handout/Pamphlet||||||F
OBX|652|CE|TeEDMETH00^Education method^ADM||2^Lecture/class||||||F
OBX|653|CE|TeEDPRVD00^Education provided to^ADM||3^Family||||||F
OBX|654|CE|TeREDTOP00^COPD education topics^ADM||1^Disease education||||||F
OBX|655|CE|VsBPCFLP01^Blood pressure cuff location^ADM||1^Right arm||||||F
OBX|656|CE|VsBPDEUS00^Device used^ADM||1^Automated cuff||||||F
OBX|657|TX|VsBPDIAO01^Blood pressure diastolic^ADM||80||||||F
OBX|658|TX|VsBPMAPA03^Blood pressure mean arterial pressure^ADM||65||||||F
OBX|659|CE|VsBPPOST02^Patient position^ADM||2^Supine||||||F
OBX|660|TX|VsBPSYSO01^Blood pressure systolic^ADM||110||||||F
OBX|661|TX|VsHRADEL00^Electrical heart rate^ADM||83||||||F
OBX|662|TX|VsHRADLT01^Heart rate^ADM||88||||||F
OBX|663|CE|VsHRLOCA02^Heart rate location^ADM||1^Radial||||||F
OBX|664|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|665|CE|VsHRMETH00^Heart rate method used^ADM||1^Palpation||||||F
OBX|666|CE|VsHRRHYM02^Pulse rhythm^ADM||1^Regular||||||F
OBX|667|TX|VsHTCM0100^Current height^ADM||170.0||||||F
OBX|668|TX|VsOXDRAD01^Oxygen therapy delivery rate^ADM||0||||||F
OBX|669|TX|VsPOOSAD00^Pulse oximetry oxygen saturation^ADM||86||||||F
OBX|670|CE|VsPRLOMO00^Probe location modifier^ADM||1^Right||||||F
OBX|671|CE|VsPROLOC00^Probe location^ADM||1^Finger||||||F
OBX|672|TX|VsPROREP00^Probe repositioned^ADM||N||||||F
OBX|673|CE|VsPULSTR00^Pulse strength on palpation^ADM||2^Moderate||||||F
OBX|674|TX|VsPUOXCO00^Pulse oximetry comment^ADM||Results came 1 minute after.  Oximeter may be broken||||||F
OBX|675|TX|VsRESPAD03^Respiratory rate^ADM||15||||||F
OBX|676|TX|VsSECTEM00^Secondary temperature^ADM||37||||||F
OBX|677|CE|VsSECTES00^Secondary temperature source^ADM||1^Oral||||||F
OBX|678|CE|VsTPSORC01^Temperature source^ADM||4^Axillary||||||F
OBX|679|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|680|TX|VsTPTEMPO2^Temperature^ADM||38.1||||||F
OBX|681|TX|VsVISICO00^Vital Signs comments^ADM||pt did not take her BP meds this am.||||||F
OBX|682|TX|VsWT000101^Current Weight^ADM||75.000||||||F
OBX|683|CE|VsWT000700^Weight measurement method^ADM||1^Standing scale||||||F
OBX|684|CE|VsWT004900^Height or length source^ADM||4^Estimated||||||F
OBX|685|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||75000.000||||||F
OBX|686|TX|z DATE^DATE QUERY FOR TESTING^ADM||20171004||||||F
OBX|687|TX|z PCS MART^QUANTITY TEST QUERY^ADM||80||||||F
OBX|688|CE|zCBrefgrp^referral group response^ADM||1^Home Health~4^SLP||||||F
OBX|689|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
AL1|1|DA|F006001550^codeine|SV|Shortness of Breath   *AL|20171004
ZFD|OEDOCP^Oedoc^Petertrain^^^^MD^50004^DOC|2222 Main Street^^Vancouver^BC^V3V 1Z1|||OEDOCM^Oedoc^Marytrain^^^^MD^50003^DOC|ZTEST^Test Provider^IM/IT^Use Only^^^^500001^DOC|
ZFH|LUMED||||||

MSH|^~\&|ADM|ARH|||201911221259||ADT^A03|4111537|D|2.2|||AL|NE
EVN|A03|201911221259||||201911221258
PID|1|FHATVIG0007390|AB00007817|AB7769|BCHANNEMAN^PLIS|Jenny|19520922|M|||123 Cole Ave^^North Vancouver^BC^V7L 2L7|||||||AB000697/19|9698656171
PV1|1|I|AB-ERIN^ABERIN-01^7|UE|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^^^^^^XX|||CARD||||||||IN||||||||||||||||||DISCHARGED WITH APPROVAL|||ARH|||||201911221145|201911221258
PV2||W^Ward|CHEST PAIN
OBX|1|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||19821117||||||F
OBX|2|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCSWP^BC Services With Photo||||||F
OBX|3|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|4|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|5|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
ZFD|SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|123 ROAD^^SURREY^BC^V2V 0A0|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|
ZFH|LUMED||||||

