| Description | Short Desc | Field Type | Attribution Type | Length | Primary | Sticky | Mandatory | Prefilled |
| Facility | Facility | Attribution Type | Facility | 50 | Yes | No | Yes | Yes |
| Account No. | Account # | Text | 20 | Yes | No | Yes | No | |
| Patient Name | Pt Name | Text | 50 | No | No | No | No | |
| Physician | Physician | Attribution Type | Physician | 50 | No | No | No | Yes |
| Unit | Unit | Attribution Type | Unit | 50 | No | No | No | Yes |
| Description | Short Desc | Field Type | Attribution Type | Length |
|