MSH|^~\&|ADM|ARH|||201910171106||ADT^A08|4082281|D|2.2|||AL|NE
EVN|A08|201910171106||||
PID|1|FHATVIG0005809|AB00007595|AB7624|PCSTEST^CDUB|CDUB|20180924|F|||1134 RICHARD ST^^NEW WESTMINSTER^BC^V1V 2V2|||||||AB000604/18|
PV1|1|I|AB-4CHEAM^AB4C-C4033^1|NB|||ZTESTDOC^ZTESTDOC^IM/IT^Use ONLY^^^^^^^^^XX|||NEWB||||||||IN|||||||||||||||||||||ARH|||||201809240752|
PV2||W^Ward|NEWBORN
OBX|1|ST|1010.1^WEIGHT^CPT4||88.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||176.0||||||F
OBX|3|CE|Ac00000700^Upper body washing support provided^ADM||3^Set-up||||||F
OBX|4|CE|Ac00000900^Mouth care support provided^ADM||3^Set-up||||||F
OBX|5|CE|Ac00001000^Grooming support provided^ADM||3^Set-up||||||F
OBX|6|CE|Ac00001100^Toileting hygiene ability^ADM||3^Set-up||||||F
OBX|7|CE|Ac00003700^Lower body washing support provided^ADM||3^Set-up||||||F
OBX|8|CE|AcADLWAT00^Wash type performed^ADM||1^Full bed bath||||||F
OBX|9|CE|AcCL000301^Mouth care completed^ADM||1^Before meal or snack||||||F
OBX|10|TX|AcCL000310^Mouth care completed other^ADM||mouth care other||||||F
OBX|11|CE|AcMOCAPE00^Mouth care performed^ADM||1^Oral suction~2^Antibacterial oral rinse~7^Teeth brushing||||||F
OBX|12|CE|AcMOCARE03^Mouth care assistance^ADM||2^Supervision||||||F
OBX|13|TX|Ad00001900^Other admission and clinical history comments^ADM||test||||||F
OBX|14|TX|Ad00002000^Two patient identifiers checked^ADM||Y||||||F
OBX|15|TX|Ad00002900^Personal aids present^ADM||Y||||||F
OBX|16|TX|Ad00003000^Communication difficulties^ADM||Y||||||F
OBX|17|TX|AdAC000100^Accompanied by other^ADM||test||||||F
OBX|18|TX|AdADMDAT01^Admission date^ADM||20191018||||||F
OBX|19|CE|AdADMFRO01^Admitted from^ADM||3^Other unit||||||F
OBX|20|TX|AdADMRSN00^Reason for admission^ADM||test||||||F
OBX|21|TX|AdADMTIM00^Admission time^ADM||2200||||||F
OBX|22|TX|AdADMTRA00^Name of other unit/site^ADM||test||||||F
OBX|23|TX|AdALLERR00^Allergies reviewed^ADM||Y||||||F
OBX|24|CE|AdARRMOD00^Mode of arrival^ADM||1^Stretcher||||||F
OBX|25|TX|AdDCBSLP00^Discharge barriers identified by speech language pathologist^ADM||discharge barriers identified by SLP||||||F
OBX|26|TX|AdDCCOMP00^Discharge plan complete^ADM||Y||||||F
OBX|27|TX|AdDIETY000^Diet type other^ADM||test||||||F
OBX|28|TX|AdEDADLO00^Other care activity comments^ADM||test||||||F
OBX|29|TX|AdESTDTD00^Estimated date of discharge^ADM||20190830||||||F
OBX|30|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity||||||F
OBX|31|TX|AdFUAPCO04^Services and appointments arranged comments^ADM||services and appointments arranged comments||||||F
OBX|32|TX|AdHXCOND00^History of presenting condition^ADM||test~ ~test||||||F
OBX|33|TX|AdINFNAM00^Name of information source^ADM||test||||||F
OBX|34|TX|AdINFOTH00^Information source other^ADM||test||||||F
OBX|35|TX|AdINPSNT00^Inpatient referral(s) sent to other^ADM||inpatient referrals other||||||F
OBX|36|CE|AdINPTRF00^Inpatient referral(s) sent to^ADM||12^Respiratory therapist||||||F
OBX|37|CE|AdINPTRF01^Inpatient referral(s) sent to^ADM||2^Home health liaison||||||F
OBX|38|CE|AdNICOT000^History of nicotine use^ADM||1^None||||||F
OBX|39|CE|AdNICOT010^Type of nicotine use^ADM||1^Cigarettes||||||F
OBX|40|TX|AdNICOT020^Type of nicotine use other^ADM||test||||||F
OBX|41|CE|AdNICOT090^Nicotine cessation interventions^ADM||1^Not applicable||||||F
OBX|42|TX|AdNICOT100^Nicotine cessation interventions other^ADM||test||||||F
OBX|43|CE|AdNICOT110^Willingness to quit^ADM||2^Quit in next month||||||F
OBX|44|CE|AdOTPREF01^Outpatient/Community referral(s) sent to^ADM||15^Nurse practitioner||||||F
OBX|45|TX|AdOTPSNT00^Outpatient/Community referral(s) sent to other^ADM||outpatient community referrals other||||||F
OBX|46|TX|AdPRLANG00^Primary language spoken^ADM||test||||||F
OBX|47|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||Y||||||F
OBX|48|CE|AdPTA05600^Diet type prior to admission^ADM||1^General||||||F
OBX|49|TX|AdPTA14000^Sleep pattern prior to admission^ADM||tired||||||F
OBX|50|TX|AdPTFAMY00^Patient/Family goals for discharge^ADM||patient family goal||||||F
OBX|51|CE|AdREPREF00^Report received^ADM||1^In person||||||F
OBX|52|TX|AdSLCPIN00^1. Intervention to address problem^ADM||intervention to address problem 1||||||F
OBX|53|TX|AdSLCPIN01^2. Intervention to address problem^ADM||intervention to address problem 2||||||F
OBX|54|TX|AdSLCPIN02^3. Intervention to address problem^ADM||intervention to address problem 3||||||F
OBX|55|TX|AdSLCPIN03^4. Intervention to address problem^ADM|| intervetion to address problem 4||||||F
OBX|56|TX|AdSLCPIN04^5. Intervention to address problem^ADM||intervention to address problem 5||||||F
OBX|57|TX|AdSLPCPD00^Problem detail^ADM||patient detail 3||||||F
OBX|58|TX|AdSLPCPG00^Goal^ADM||goal||||||F
OBX|59|CE|AdSLPCPI01^Problem identified^ADM||11^Reduced oral intake||||||F
OBX|60|CE|AdSLPCPS00^Goal status^ADM||2^Partially met||||||F
OBX|61|TX|AdSLPCPT00^Goal target date^ADM||20190830||||||F
OBX|62|TX|AdSTRECO01^Reason EDD changed other^ADM||EDD changed other||||||F
OBX|63|TX|Ca00002100^Circulation satisfactory^ADM||Y||||||F
OBX|64|TX|Ca00002200^History of orthostatic hypotension^ADM||N||||||F
OBX|65|CE|CaPARAMR00^Cardiovascular defined parameters^ADM||1^Within defined parameters||||||F
OBX|66|TX|Ec00000000^History of diabetes^ADM||Y||||||F
OBX|67|CE|GiBM000000^Bowel movement method^ADM||1^Toilet||||||F
OBX|68|TX|GiBMINCO00^Bowel movement incontinence^ADM||N||||||F
OBX|69|CE|GiEFT00000^Tube type^ADM||2^Gastrostomy||||||F
OBX|70|CE|GiGT000400^Placement verification method^ADM||1^Gastric pH||||||F
OBX|71|CE|GiGTSITE00^Gastric tube site^ADM||1^Right nare||||||F
OBX|72|CE|GiPARAMR00^Gastrointestinal defined parameters^ADM||1^Within defined parameters||||||F
OBX|73|TX|GuBDINCO00^Bladder incontinence^ADM||N||||||F
OBX|74|CE|GuBDVM0002^Voiding method^ADM||1^Toilet||||||F
OBX|75|CE|GuPARAMR00^Genitourinary defined parameters^ADM||1^Within defined parameters||||||F
OBX|76|CE|HeREAMCC00^Reason mouth care completed^ADM||1^Food debris||||||F
OBX|77|CE|HeSL013100^Oral cavity dentition^ADM||1^Natural||||||F
OBX|78|TX|Hx486COM00^Pre-admission screening questionnaire completed by^ADM||test||||||F
OBX|79|TX|Hx486PRO00^Pre-admission screening questionnaire provided^ADM||Y||||||F
OBX|80|TX|HxSPTCHX01^Pertinent clinical history^ADM||test||||||F
OBX|81|CE|InPARAMR00^Integumentary defined parameters^ADM||1^Within defined parameters||||||F
OBX|82|CE|MhINFOSC00^Information source^ADM||1^Patient||||||F
OBX|83|TX|MhMRSAMD00^MRSA/MDRO swabs collected^ADM||Y||||||F
OBX|84|CE|Mo00000100^Repositioning support provided^ADM||8^Independent||||||F
OBX|85|CE|Mo00000200^Transfer support provided for bed to chair transfer^ADM||2^Supervision||||||F
OBX|86|CE|Mo00000300^Transfer support provided for chair to bed transfer^ADM||2^Supervision||||||F
OBX|87|CE|Mo00000400^Transfer support provided for toilet transfer^ADM||2^Supervision||||||F
OBX|88|CE|Mo00000500^Ambulation support provided^ADM||2^Supervision||||||F
OBX|89|CE|Mo00000600^Upper body dressing support provided^ADM||3^Set-up||||||F
OBX|90|CE|Mo00000800^Lower body dressing support provided^ADM||3^Set-up||||||F
OBX|91|CE|Mo00001200^Dressing support provided (footwear)^ADM||3^Set-up||||||F
OBX|92|CE|Mo00001300^Wheelchair propulsion^ADM||8^Independent||||||F
OBX|93|CE|Mo00001400^Falls safety equipment set up on admission^ADM||1^Bed alarm||||||F
OBX|94|TX|Mo00001500^Falls safety equipment set up on admission other^ADM||test||||||F
OBX|95|TX|Mo00002100^Falls in hospital^ADM||Y||||||F
OBX|96|TX|Mo00002200^Fall related injuries^ADM||test||||||F
OBX|97|TX|Mo00002400^Current support required for mobility and ADLs^ADM||test||||||F
OBX|98|CE|MoAIDAMB01^Ambulation aid^ADM||10^Walker: 2 wheeled||||||F
OBX|99|CE|MoAIDTRA01^Transfer aid^ADM||10^Walker: 2 wheeled||||||F
OBX|100|CE|MoEQUITR01^Transfer equipment^ADM||2^No equipment used||||||F
OBX|101|CE|MoFA000001^Fall prevention strategies^ADM||1^Universal||||||F
OBX|102|CE|MoMOTYPE00^Mobility type^ADM||2^Bed to chair transfer||||||F
OBX|103|CE|MoMOTYPT00^Mobility type^ADM||6^Ambulation||||||F
OBX|104|CE|MoRECAID02^Recommended aid^ADM||10^Walker: 2 wheeled||||||F
OBX|105|CE|MoRECEQP02^Recommended equipment^ADM||7^Bed rail||||||F
OBX|106|CE|MoSUPPPT01^Recommended support provided^ADM||2^Supervision||||||F
OBX|107|CE|MoSUPPRV01^Recommended support provided^ADM||6^1 person assist||||||F
OBX|108|TX|MoTRANCO00^Transfer comments^ADM||test||||||F
OBX|109|TX|Ne00005500^Pain reported^ADM||Y||||||F
OBX|110|TX|Ne00005600^Orientation checks complete^ADM||Y||||||F
OBX|111|TX|Ne00005700^Orientation comments^ADM||test||||||F
OBX|112|TX|Ne00005800^History of seizure^ADM||Y||||||F
OBX|113|TX|Ne00005900^Date of last seizure^ADM||20191008||||||F
OBX|114|TX|Ne00006000^Seizure history details^ADM||test||||||F
OBX|115|TX|Ne00006100^History of autonomic dysreflexia^ADM||N||||||F
OBX|116|CE|Ne00006200^Impact of pain on performing activities^ADM||1^None||||||F
OBX|117|CE|NeLECONS01^Level of consciousness^ADM||2^Drowsy||||||F
OBX|118|CE|NeORIENT01^Oriented to^ADM||1^All domains||||||F
OBX|119|CE|NePARAMR00^Neurological and cognition defined parameters^ADM||1^Within defined parameters||||||F
OBX|120|TX|NePCAM0100^Procedure type^ADM||blood patch||||||F
OBX|121|TX|NePSC00000^Other procedure comments^ADM||Patient tolerated well and aware to stay flat for 2 hours||||||F
OBX|122|TX|NePSFAPR10^Family present during procedural sedation^ADM||N||||||F
OBX|123|TX|NePSG00000^Procedural sedation given^ADM||N||||||F
OBX|124|CE|NePSPER000^Personnel present during procedural sedation^ADM||2^RN||||||F
OBX|125|TX|Nu00000900^Have you lost wt in the past 6 mo without trying to lose wt?^ADM||Y||||||F
OBX|126|TX|Nu00001000^Have you been eating less than usual for more than a week?^ADM||Y||||||F
OBX|127|TX|Nu00016600^Current fluid order^ADM||1500||||||F
OBX|128|CE|Nu00016700^Current feeding support required^ADM||8^Independent||||||F
OBX|129|CE|NuCMSTHR00^Canadian malnutrition screening tool high nutritional risk^ADM||1^Yes||||||F
OBX|130|CE|NuFANURO00^Nutrition route^ADM||1^Oral nutrition||||||F
OBX|131|TX|Oh00000900^Patient stated rehab goals^ADM||test||||||F
OBX|132|TX|Oh00001000^Reported bedtime^ADM||1500||||||F
OBX|133|TX|Oh00001100^Reported wake time^ADM||0300||||||F
OBX|134|TX|Oh00001200^Number naps during day^ADM||6||||||F
OBX|135|CE|Oh00001300^Reported general health status^ADM||1^Excellent||||||F
OBX|136|CE|Oh00001400^General health status reported by^ADM||1^Patient||||||F
OBX|137|TX|OhEDIT0000^Reason for edit^ADM||reason for edit||||||F
OBX|138|CE|OhINTE0001^Type of interpreter^ADM||1^Interpreter Services||||||F
OBX|139|TX|OhMOSTST00^MOST status reviewed^ADM||Y||||||F
OBX|140|CE|PaPARAMR00^Pain defined parameters^ADM||1^Within defined parameters||||||F
OBX|141|TX|PsCLB00000^Communication language barrier^ADM||Y||||||F
OBX|142|CE|PsSU000002^Substance use^ADM||1^None||||||F
OBX|143|TX|PsSU000200^Substance use comments^ADM||test||||||F
OBX|144|TX|Re00000200^Airway stable^ADM||Y||||||F
OBX|145|TX|Re00000300^Breathing easy^ADM||Y||||||F
OBX|146|TX|ReFRINOX01^Fraction of inspired oxygen (FiO2)^ADM||0.21||||||F
OBX|147|CE|RePARAMR00^Respiratory defined parameters^ADM||1^Within defined parameters||||||F
OBX|148|TX|SpOSPATT01^Observed sleep pattern^ADM||test||||||F
OBX|149|TX|SpPRPERF00^Practitioner performing^ADM||Anethetist||||||F
OBX|150|TX|SpREPSLE00^Reported sleep pattern^ADM||test||||||F
OBX|151|TX|SpSLEAID00^Sleep aid PRN given^ADM||Y||||||F
OBX|152|TX|SpUPAICM02^Fall prevention comments^ADM||test||||||F
OBX|153|TX|TeEDINTR00^Interpreter utilized^ADM||Y||||||F
OBX|154|TX|TeSL001300^Communication SMART goals^ADM||SLP communication SMART goals||||||F
OBX|155|TX|TeSLPCOM00^SLP Dysphagia SMART goals^ADM||SLP Dysphagia SMART goals||||||F
OBX|156|TX|VsHTCM0100^Current height^ADM||176.0||||||F
OBX|157|TX|VsWT000101^Current Weight^ADM||88.000||||||F
OBX|158|CE|VsWT000700^Weight measurement method^ADM||2^Bed scale||||||F
OBX|159|CE|VsWT004900^Height or length source^ADM||1^Measured (head-to-toe)||||||F
OBX|160|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||88000.000||||||F
OBX|161|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
GT1|1||||||||||MO
ZFD|ZTESTDOC^ZTESTDOC^IM/IT^Use ONLY^^^^0^DOC||||ZTESTDOC^ZTESTDOC^IM/IT^Use ONLY^^^^0^DOC|ZTESTDOC^ZTESTDOC^IM/IT^Use ONLY^^^^0^DOC|
ZFH|LUMED||||||