$TXT Created by at DEV.DEV.DOMAIN.EXT (KIDS) on Wednesday, 01/17/18 at 14:04 ============================================================================= Run Date: MAR 14, 2018 Designation: MD*1*48 Package : MD - CLINICAL PROCEDURES Priority: Mandatory Version : 1 SEQ #41 Status: Released Compliance Date: APR 14, 2018 ============================================================================= Associated patches: (v)MD*1*53 <<= must be installed BEFORE `MD*1*48' Subject: CP FLOWSHEET TERMINOLOGY ADD/MODIFY TERMS Category: - Routine - Other Description: ============ This patch will correct the following issue: The Clinical Procedures (CP) Terminology TERM file (#704.101) contains terms used during data entry/display in CP Flowsheet. The Office of Informatics and Analytics - Applied Informatics Services (AIS) Terminology Review Group submitted a spreadsheet requesting additions or updates of Terms. ASSOCIATED CA/SDM TICKETS: ========================== R11574655FY17 - BL: Clinical Procedures Flowsheet (CPFS) terminology. Submittin... 1 of 12 R11645406FY17 - BL: Group 2 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11645787FY17 - BL: Group 3 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11645938FY17 - BL: Group 4 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11646348FY17 - BL: Group 5 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11646436FY17 - BL: Group 6 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11646691FY17 - BL: Group 7 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11646862FY17 - BL: Group 8 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11646969FY17 - BL: Group 9 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11647068FY17 - BL: Group 10 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11647165FY17 - BL: Group 11 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 R11647241FY17 - BL: Group 12 of 12 of Modified/New Clinical Procedures Flowsheet Terms for Patch MD*1*48 ASSOCIATED NSR(S): ================== N/A PARTICIPATING TEST SITES: ========================= Huntington VA Medical Center VA Greater Los Angeles Healthcare System Problem: -------- The Clinical Procedures (CP) Terminology TERM file (#704.101) contains terms used during data entry/display in CP Flowsheet. The Office of Informatics and Analytics - Applied Informatics Services (AIS) Terminology Review Group submitted a spreadsheet requesting additions or updates of Terms. The following list documents the approved changes for R11574655FY17 Group #1 (Mod) ABDOMEN BOWEL SOUNDS (Mod) ADL - ACTIVITIES OF DAILY LIVING (Mod) ADL - ACTIVITIES OF DAILY LIVING (Mod) ADL - BED MOBILITY (Mod) ADL - EMOTIONAL SUPPORT (Mod) ADL - OTHER ACTIVITY (Mod) ADL - REPOSITION (Mod) ADL - VISITORS (Mod) ADL- ORAL CARE (Mod) Affect (Mod) AIRWAY ARTIFICIAL TYPE (Mod) ALARMS (Add) ALLEN TEST (Mod) ARM BAND - ALLERGIES The following list documents the approved changes for R11645406FY17 Group #2 (Mod) ARM BAND - BLOOD TRANSFUSION IV (Mod) ARM BAND - DNR (Mod) ARM BAND - ELOPMENT (Mod) ARM BAND - HIGH FALL RISK (Mod) ARM BAND - PERSONAL MEDICAL ALERT (Mod) ARM BAND - WANDERER (Mod) ARM BANDS PRESENT (Mod) ARTERIAL LINE ALARMS ON (Mod) ARTERIAL LINE CIRCULATION ASSESSED (Mod) ARTERIAL LINE SITE CARE (Mod) ARTERIAL LINE WAVEFORM (Mod) Behavior (Mod) BEHAVIOR CURRENT LOCATION (Mod) BiPAP Expiratory Pressure (Mod) BiPAP Inspiratory Pressure The following list documents the approved changes for R11645787FY17 Group #3 (Add) Body Movement (change to Motor Activity/Posture) (Add) Bowel Elimination (Mod) Breath Sounds (Mod) Cardiac Bruit (Mod) Cardiac Thrill (Add) CAUTI Prevention: Maintenance (Mod) CAUTI: terms - change CAUTI: to CAUTI PREVENTION: CAUTI: ALTERNATIVES ATTEMPTED PRIOR TO CATH CAUTI: CATHETER IN PLACE CAUTI: INDICATIONS CAUTI: INSERTION REQUIREMENTS (Mod) CENTRAL LINE SIZE FRENCH (Mod) CENTRAL LINE INSERTION MARK (Mod) CENTRAL LINE SIZE GAUGE (Mod) CENTRAL VENOUS PRESSURE (Mod) CHEST TUBE DRAINAGE SUCTION TYPE (Mod) CHEST TUBE SUCTION (CM H20) (Mod) Circumference/Girth The following list documents the approved changes for R11645938FY17 Group #4 (Mod) CLOSE OBSERVATION REASON FOR PRECAUTION (Mod) CODE STATUS (Mod) CPAP (Add) DIALYSIS BLOOD FLOW RATE (originally submitted as Blood Flow) (Mod) DIET (Mod) DRAIN SUCTION CM H2O (Mod) EDEMA AMOUNT (Mod) EDEMA SEVERITY (Mod) EKG LEAD (Add) EKG Wave Descriptions (Mod) ENTERAL NUTRITION TYPE (Add) Eye Contact (Add) Fecal Incontinence Device Assessment (Add) Fecal Incontinent Device Care (Mod) Fingerstick Glucose The following list documents the approved changes for R11646348FY17 Group #5 (Mod) FOOT STRENGTH (Add) Gait Assessment (Mod) Gastric pH (Mod) Gastric Residual Amount Discarded (Mod) Gastric Residual Not Discarded (Add) WNL: GASTROINTESTINAL (Mod) GCS - Eye Opening (Mod) GCS - Motor Response (Mod) GCS - Verbal Response (Mod) GCS -Total (Add) WNL: GENITAL URINARY SYSTEM (Mod) GI Symptoms (Mod) GI Tube Placement Confirmation (Mod) GI Tube Size (Mod) GU Catheter Size The following list documents the approved changes for R11646436FY17 Group #6 (Mod) GU Catheter Type (Mod) HAND GRIP (Mod) Height (Add) Hygiene (Mod) IABP Assisted Systolic Pressure (Add) IV Dose Rate - mcg/kg/min - DO NOT CHECK TOTAL OR SUBTOTALS (Mod) IV FLOW RATE - ml/kg/TIME - DO NOT CHECK TOTAL OR SUBTOTALS (Mod) LOWER LIMB EXTREMITIES STRENGTH (Mod) Lower Limb Extremities Strength (Add) Behavioral Health - Motor Activity (Add) Behavioral Health - Thought Process (Add) Mental Status (Add) Metal Implant/Shrapnel (Mod) MONITORING CAMERA The following list documents the approved changes for R11646691FY17 Group #7 (Mod) MORSE: SCORE TOTAL (Mod) MOTOR ACTIVITY/POSTURE (Add) WNL: Muscular (Mod) Need for fluids/toileting assessed (Mod) Nose Size (Add) Observation Status (Mod) ORTHOTICS (Mod) Output - Do Not check Total or Subtotals (Mod) Output - Drain (Mod) Output - Stool (Mod) PA CATHETER INSERTION MARK (Mod) PA CATHETER SIZE (Mod) PACEMAKER CAPTURE (Mod) PAIN CHARACTER (Add) Pain Control The following list documents the approved changes for R11646862FY17 Group #8 (Mod) Pain Goal (Mod) Pain Level (Mod) PAIN NON-VERBAL CUES (Mod) PAIN RELIEVING FACTOR INTERVENTION (Add) Pain Scale Used (Add) Pain Type (Mod) PAINAD TOTAL (Add) Patient Safety Rounds completed (Add) PCA : 2nd verifier (Add) PCA: Ability to report pain and use PCA without requiring clues? (Add) PCA: AOX3 for PCA use? (Add) PCA: Continuous Rate (Add) PCA: Loading Dose Given (Add) PCA: Medication Ordered (Mod) PCA: Mode The following list documents the approved changes for R11646969FY17 Group #9 (Add) PCA: Ordered Dose Range (Add) PCA: Oriented to person, place, and time? (Add) PCA: RASS Score +1, 0, -1? (Add) PCA: Respiratory Pattern (Add) PCA: Risk for respiratory depression assessed? (Add) PCA: RR 11/min or greater? (Add) PCA: Ordered Profile (Mod) PCA: Side Effects (Mod) PEAK INSPIRATORY PRESSURE (Mod) PR INTERVAL (Add) PRECAUTIONS (Add) Precautions - Spinal (Mod) Restraint Criteria (Mod) Restraint Education Type (Mod) RESTRAINT EVAL - ALT. MEASURES ATTEMPTED The following list documents the approved changes for R11647068FY17 Group #10 (Mod) RESTRAINT EVAL - MENTAL (Mod) RESTRAINT EVAL - SKIN INTEGRETY (Mod) RESTRAINT LEAST RESTRICTIVE MEASURES (Mod) RESTRAINT MENTAL ASSESSMENT (Mod) Restraint Safety Care (Add) Rounding (Mod) Seizure Duration (Mod) Sensation Foot (Mod) Sensation Hand (Mod) Sensation Lower Extremity (Mod) Sensation Upper Extremity (Mod) SEWS - AGITATION (Mod) SEWS - ANXIETY (Mod) SEWS - DISORIENTATION NAME PLACE (Mod) SEWS - HALLUCINATION ANY The following list documents the approved changes for R11647165FY17 Group #11 (Mod) SEWS - HALLUCINATION AUDITORY ONLY (Mod) SEWS - NAME ONLY (Mod) SEWS - NAUSEA (Add) SEWS - ORIENTATION (Mod) SEWS - SWEATING (Mod) SEWS - TOTAL (Mod) SEWS - TREMOR (Mod) SEWS - VITAL SIGNS (Add) Speech (Mod) Stool Number of Stools (Mod) TRACTION WEIGHT - DO NOT (Mod) UPPER LIMB EXTREMITIES STRENGTH (Mod) Urine Characteristics (Mod) URINE NUMBER VOIDS The following list documents the approved changes for R11647241FY17 Group #12 (Mod) URINE VOIDING METHOD (Add) VERIFY TIME RANGE (Mod) STOOL COLOR (Mod) STOOL CHARACTERISTICS (Mod) PASERO OPIOID-INDUCED SEDATION SCALE (POSS) Resolution ----------- The above Additions/Updates will be made to the CP Terminology TERM File (#704.101). The details of each of these terms is in the Clinical Observation (CliO) Terminology Dictionary And Clinical Data Model Documentation that is listed below. Software and Documentation Retrieval Instructions: ---------------------------------------------------- Software being released as a host file and/or documentation describing the new functionality introduced by this patch are available. The preferred method is to retrieve files from download.vista.domain.ext. This transmits the files from the first available server. Sites may also elect to retrieve files directly from a specific server. Sites may retrieve the software and/or documentation directly using Secure File Transfer Protocol (SFTP) from the ANONYMOUS.SOFTWARE directory at the following OI Field Offices: Hines: ftp.domain.ext Salt Lake City: ftp.domain.ext File Name: Description: Protocol: ========== ============ ========= MD1_0P48TERM.PDF CliO Terminology Dictionary Binary And Clinical Data Model Documentation can also be found on the VA Software Documentation Library at: http://www4.domain.ext/vdl/ INSTALLATION INSTRUCTIONS: ========================== If installed during the normal workday, it is recommended that the Clinical Procedures users be off the system. Other VISTA users will not be affected. Install Time - less than 5 minutes (unless otherwise indicated) 1. Load Transport Global --------------------- Choose the PackMan message containing this patch and invoke the INSTALL/CHECK MESSAGE PackMan option. 2. Start Up KIDS ------------- Start up the Kernel Installation and Distribution System Menu [XPD MAIN]: Edits and Distribution ... Utilities ... Installation ... Select Kernel Installation & Distribution System Option: INStallation --- Load a Distribution Print Transport Global Compare Transport Global to Current System Verify Checksums in Transport Global Install Package(s) Restart Install of Package(s) Unload a Distribution Backup a Transport Global 3. Select Installation Option: --------------------------- NOTE: The following are OPTIONAL - (When prompted for the INSTALL NAME, enter MD*1.0*48): a. Backup a Transport Global - This option will create a backup message of any routines exported with this patch. It will not backup any other changes such as DD's or templates. b. Compare Transport Global to Current System - This option will allow you to view all changes that will be made when this patch is installed. It compares all components of this patch (routines, DD's, templates, etc.). c. Verify Checksums in Transport Global - This option will allow you to ensure the integrity of the routines that are in the transport global. 4. Select Installation Option: Install Package(s) --------------------------------------------------- **This is the step to start the installation of this KIDS patch: a. Choose the Install Package(s) option to start the patch install. b. When prompted 'Want KIDS to INHIBIT LOGONs during the install? NO//' answer NO c. When prompted 'Want to DISABLE Scheduled Options, Menu Options, and Protocols? NO//' answer NO NOTE: Post-Init routine MDTERMX can be deleted after the patch has completed the installation. Back-out/Rollback Strategy: ==================== In the event of a catastrophic failure, the Facility CIO may make the decision to back-out the patch. This patch involves data modifications. A rollback would need to be implemented. To rollback, please re-install patch MD*1.0*53 Routine Information: ==================== The second line of each of these routines now looks like: ;;1.0;CLINICAL PROCEDURES;**[Patch List]**;Aug 2, 2012;Build 5 The checksums below are new checksums, and can be checked with CHECK1^XTSUMBLD. Routine Name: MDTERMX Before: B4314808 After: B4314808 **48** ============================================================================= User Information: Entered By : Date Entered : NOV 22, 2016 Completed By: Date Completed: MAR 14, 2018 Released By : Date Released : MAR 14, 2018 ============================================================================= Packman Mail Message: ===================== $END TXT