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Global: ^SRF

Package: Surgery

Global: ^SRF


Information

FileMan FileNo FileMan Filename Package
130 SURGERY Surgery

Description

Directly Accessed By Routines, Total: 460

Package Total Routines
Surgery 422 SR00109    SR100UTL    SR103UTL    SR153UTL    SR158UTL    SR160UTL    SR166UTL    SR175UTL
SR47UTL    SR48DIS    SR54UTL    SR61UTL    SR62UTL    SR68UTL0    SR81UTL    SR83UTL
SR88UTL    SR93UTL    SR95UTL    SRBL    SRBLOOD    SREQUEST    SREQUEST-ICD10    SRHLORU
SRHLUI    SRHLUO    SRHLUO1    SRHLUO2    SRHLUO3    SRHLUO4C    SRHLVORU    SRHLVUO
SRHLVUO1    SRHLVUO2    SRHLVZQR    SRHLVZSQ    SRHLZQR    SRO1L    SRO1L1    SRO3P90
SROA30    SROA38A    SROABCH    SROACAR1    SROACAT    SROACC0    SROACC1    SROACC2
SROACC3    SROACC4    SROACC5    SROACC6    SROACCM    SROACL1    SROACL2    SROACLN
SROACMP    SROACMP1    SROACOD    SROACOM    SROACOM1    SROACOP    SROACPM    SROACPM1
SROACPM2    SROACR1    SROACR2    SROACTH    SROACTH1    SROADEL    SROADOC    SROADOC1
SROADX    SROADX1    SROADX2    SROAERR    SROAEX    SROAL1    SROAL11    SROAL2
SROAL21    SROALC    SROALCP    SROALCS    SROALCSP    SROALEC    SROALEN    SROALET
SROALL    SROALLP    SROALLS    SROALLSP    SROALM    SROALMN    SROALN1    SROALN3
SROALNC    SROALNO    SROALSL    SROALSS    SROALSSP    SROALST    SROALSTP    SROALT
SROALTP    SROALTS    SROALTSP    SROAMAN    SROAMIS    SROANEST    SROANEW    SROANIN
SROANP    SROANR    SROANR0    SROANR1    SROANT    SROANTP    SROANTS    SROANTSP
SROAO    SROAOP    SROAOP1    SROAOPS    SROAOSET    SROAOTH    SROAOUT    SROAPAS
SROAPCA    SROAPCA1    SROAPCA2    SROAPCA3    SROAPCA4    SROAPIMS    SROAPR1A    SROAPRE
SROAPRE1    SROAPRE2    SROAPRT1    SROAPRT2    SROAPRT3    SROAPRT4    SROAPRT5    SROAPRT6
SROAPRT7    SROAPS1    SROAPS2    SROAR1    SROAR2    SROARET    SROARPT    SROASITE
SROASS    SROASS1    SROASSE    SROASSN    SROASSP    SROAT0P    SROAT1P    SROAT2P
SROATCM    SROATCM1    SROATCM2    SROATCM3    SROATM1    SROATM2    SROATM3    SROATM4
SROATMIT    SROATMN1    SROATMNO    SROATT0    SROATT1    SROATT2    SROAUTL    SROAUTL0
SROAUTL1    SROAUTL2    SROAUTL3    SROAUTL4    SROAUTLC    SROAWL1    SROAX    SROBLOD
SROCAN0    SROCANUP    SROCCAT    SROCD    SROCD0    SROCD1    SROCD2    SROCD3
SROCD4    SROCDX    SROCDX1    SROCL1    SROCMP    SROCMPED    SROCMPL    SROCMPS
SROCNR1    SROCNR2    SROCOM    SROCOMP    SROCON    SROCON1    SROCPT    SROCPT0
SROCVER    SRODATE    SRODELA    SRODIS0    SRODLA1    SRODLA2    SRODLT0    SRODPT
SRODTH    SROERR    SROERR0    SROERR1    SROERR2    SROERRPO    SROES    SROESAD
SROESAD1    SROESAR0    SROESARA    SROESHL    SROESL    SROESNR0    SROESNR2    SROESNRA
SROESPR    SROESTV    SROESUTL    SROESX    SROESX0    SROESXA    SROESXP    SROGMTS
SROGMTS0    SROGTSR    SROHIS    SROICD    SROICDGT    SROICU1    SROICU2    SROINQ
SROIRR    SROKRET    SROLOCK    SROMED    SROMENU    SROMOD    SROMOD0    SROMORT
SRONAN1    SRONASS    SRONBCH    SRONEW    SRONIN    SRONON    SRONOP    SRONOP1
SRONOR2    SRONOR3    SRONOR4    SRONOR5    SRONOR7    SRONOR8    SRONP    SRONP0
SRONP1    SRONP2    SRONPEN    SRONRPT    SRONRPT0    SRONRPT1    SRONRPT2    SRONRPT3
SRONRPT4    SRONUR1    SRONUR2    SRONXR    SROP    SROP1    SROPAC0    SROPAC1
SROPACT    SROPCE    SROPCE0    SROPCE0A    SROPCE0B    SROPCE1    SROPCEP    SROPCEU
SROPCEU0    SROPCEX    SROPDEL    SROPECS    SROPECS1    SROPER    SROPFSS    SROPLIST
SROPLSTS    SROPPC    SROPRI    SROPRI1    SROPRI2    SROPRIN    SROPRPT    SROPS
SROPS1    SROPSEL    SROPSN    SROQ0A    SROQ30D    SROQADM    SROQD    SROQD0
SROQD1    SROQIDP    SROQIDP0    SROQL    SROQN    SRORAT1    SRORAT2    SROREA1
SROREA2    SROREQ1    SROREQ2    SROREQ3    SROREQ4    SROREST    SRORESV    SRORET
SRORTRN    SRORUT0    SROSCH    SROSCH1    SROSCH2    SROSNR1    SROSNR2    SROSPC1
SROSPLG    SROSPLG1    SROSPLG2    SROSPSS    SROSRPT    SROSUR    SROSUR1    SROSUR2
SROTHER    SROTIUD    SROTRIG    SROTRPT0    SROUNV1    SROUNV2    SROUTC    SROUTL
SROUTL0    SROUTL1    SROVAR    SROVER    SROVER1    SROVER2    SROVER3    SROWC1
SROWC2    SROWC3    SROWRQ    SROWRQ1    SROXR1    SROXR2    SROXR4    SROXRET
SRSAVG    SRSAVL1    SRSCAN    SRSCAN0    SRSCAN1    SRSCAN2    SRSCD    SRSCDS
SRSCDS1    SRSCDW    SRSCDW1    SRSCHAP    SRSCHC1    SRSCHCA    SRSCHD1    SRSCHD2
SRSCHDA    SRSCHED-UNREQUESTED    SRSCHK    SRSCHUN    SRSCHUN1    SRSCHUP    SRSCOR    SRSCPT1
SRSCPT2    SRSCRAP    SRSDT    SRSPUT0    SRSRBS    SRSRBS1    SRSRBW    SRSRBW1
SRSREQ    SRSREQUT    SRSRQST    SRSRQST1    SRSTCH    SRSUP1    SRSUPC    SRSUPRQ
SRSUTL    SRSUTL2    SRSWL5    SRSWLST    SRTOVRF    SRTPNEW    
Lab Service 6 LRAPKLG    LRAPKLG1    LRBLPCSS    LROSPLG    LROSPLG1    LROSPLG2    
Text Integration Utility 5 TIU215F    TIU215R    TIUHL7P3    TIUPUTS    TIUPUTSX    
DSS Extracts 4 ECX325CV    ECXSURG    ECXSURG1    ECXUSUR1    
Health Summary 4 GMTSPL    GMTSPOST    GMTSROB    GMTSROE    
Imaging 3 MAGGSQI    MAGGTIA2    MAGGTSR    
Automated Medical Information Exchange 2 DVBAB89    DVBASRP1    
Order Entry Results Reporting 2 ORDV04A    ORMEVNT1    
Inpatient Medications 1 PSJPDCLA    
Interim Management Support 1 ECTDSUR    
Occurrence Screen 1 QAOC107    
Virtual Patient Record 1 VPRSDA    

Accessed By FileMan Db Calls, Total: 72

Package Total Routines
Surgery 59 SR100UTL    SR3189P    SRO1L1    SROACAT    SROACL2    SROACOM    SROACOM1    SROACPM
SROACPM0    SROACPM1    SROACR2    SROACTH1    SROADEL    SROAEX    SROALEN    SROALMN
SROAMAN    SROANEST    SROAOP    SROAOP2    SROAOUT    SROAPM    SROAPRE    SROAPS1
SROARPT    SROAUTL    SROAUTL3    SROAUTLC    SROCMPED    SROCMPL    SROESNR0    SROESTV
SROGMTS    SROMED    SRONASS    SRONEW    SRONIN    SRONOP1    SRONP2    SROPCE0
SROPDEL    SROPER    SROPRIO    SROPRIT    SROUTC    SROVER1    SROVER3    SROWC
SROWC2    SRSCAN2    SRSCHC1    SRSCHCC    SRSCHDC    SRSCHUN    SRSCONR    SRSCRAP
SRSIND    SRSRQST    SRSTCH    
Virtual Patient Record 3 VPRDJ07    VPRDSR    VPRSDA    
Enterprise Health Management Platform 2 HMPDJ07    HMPDSR    
Health Summary 2 GMTSROB    GMTSROE    
DSS Extracts 1 ECXSURG    
IFCAP 1 PRCPCRPL    
Lab Service 1 LRUEPR    
National Health Information Network 1 NHINVSR    
Order Entry Results Reporting 1 ORWSR    
VistA Integration Adapter 1 VIABRPC4    

Pointed To By FileMan Files, Total: 8

Package Total FileMan Files
Surgery 4 SURGERY(#130)[357879#130.3513(.01)#130.43(.01)]    SURGERY SITE PARAMETERS(#133)[#133.028(.01)]    SURGERY PROCEDURE/DIAGNOSIS CODES(#136)[.01]    SURGERY TRANSPLANT ASSESSMENTS(#139.5)[2]    
IFCAP 1 INTERNAL DISTRIBUTION ORDER/ADJ.(#445.3)[130]    
Integrated Billing 1 PFSS ACCOUNT(#375)[14.01]    
Order Entry Results Reporting 1 OE/RR PATIENT EVENT(#100.2)[14]    
Text Integration Utility 1 TIU DOCUMENT(#8925)[1405]    

Pointer To FileMan Files, Total: 44

Package Total FileMan Files
Surgery 27 SURGERY(#130)[357879#130.3513(.01)#130.43(.01)]    SURGERY TRANSPORTATION DEVICES(#131.01)[.1125]    SPECIAL INSTRUMENTS(#131.02)[#130.0683(.01)]    SPECIAL SUPPLIES(#131.04)[#130.0682(.01)]    PHARMACY ITEMS(#131.06)[#130.0684(.01)]    SPECIAL EQUIPMENT(#131.3)[#130.25(.01)]    PLANNED IMPLANT(#131.5)[#130.0681(.01)]    SURGERY DISPOSITION(#131.6)[.43.46.79]
PROSTHESIS(#131.9)[#130.01(.01)]    SURGERY POSITION(#132)[.54#130.065(.01)]    RESTRAINTS AND POSITIONAL AIDS(#132.05)[#130.31(.01)]    SURGICAL DELAY(#132.4)[#130.042(.01)]    ASA CLASS(#132.8)[1.13]    ATTENDING CODES(#132.9)[.166]    ANESTHESIA SUPERVISOR CODES(#132.95)[.345]    MONITORS(#133.4)[#130.41(.01)]    IRRIGATION(#133.6)[#130.08(.01)]    SURGERY REPLACEMENT FLUIDS(#133.7)[#130.04(.01)]    SURGERY CANCELLATION REASON(#135)[18]    SKIN PREP AGENTS(#135.1)[.1758]    SKIN INTEGRITY(#135.2)[.07.76]    PATIENT MOOD(#135.3)[.19.81]    PATIENT CONSCIOUSNESS(#135.4)[.196.821]    PERIOPERATIVE OCCURRENCE CATEGORY(#136.5)[#130.0126(5)#130.053(5)#130.13(3)#130.22(5)]    LOCAL SURGICAL SPECIALTY(#137.45)[.04]    ELECTROGROUND POSITIONS(#138)[.556]    OPERATING ROOM(#131.7)[.02]    
Kernel 3 INSTITUTION(#4)[50]    STATE(#5)[#130.03(3)]    NEW PERSON(#200)[.12.14.15.16.164.167.168.18.31.32.33.34.522.525.57.691.09945474861636970123124272.1639657659751753#130.01(10)#130.0129(3)#130.013(1)#130.02(2)#130.03(6)#130.06(35)#130.06(39)#130.23(.01)#130.28(.01)#130.31(1)#130.34(2)#130.34(3)#130.36(.01)#130.39(2)#130.41(3)]    
CPT HCPCS Codes 2 CPT MODIFIER(#81.3)[#130.028(.01)#130.164(.01)]    CPT(#81)[27#130.16(3)]    
Registration 2 SPECIALTY(#42.4)[454]    PATIENT(#2)[.01]    
DRG Grouper 1 ICD DIAGNOSIS(#80)[32.566253286343344392489#130.13(4)#130.17(3)#130.18(3)#130.22(6)]    
Event Capture 1 MEDICAL SPECIALTY(#723)[125]    
Imaging 1 IMAGE(#2005)[#130.02005(.01)]    
Integrated Billing 1 PFSS ACCOUNT(#375)[500]    
Lab Service 1 TOPOGRAPHY FIELD(#61)[#130.49(.01)]    
Order Entry Results Reporting 1 ORDER(#100)[100]    
PCE Patient Care Encounter 1 VISIT(#9000010)[.015]    
Pharmacy Data Management 1 DRUG(#50)[#130.33(.01)#130.47(.01)#130.48(.01)]
Scheduling 1 HOSPITAL LOCATION(#44)[.021119]    
Text Integration Utility 1 TIU DOCUMENT(#8925)[1000100110021003]    

Fields, Total: 760

Field # Name Loc Type Details
.01 PATIENT 0;1 POINTER TO PATIENT FILE (#2)
************************REQUIRED FIELD************************
PATIENT(#2)

  • LAST EDITED:  AUG 23, 2016
  • DESCRIPTION:  This is the name of the patient.
  • DELETE TEST:  1,0)= I 1 D EN^DDIOL("Deletion from this file is not allowed !!",,"!!,?2")
  • CROSS-REFERENCE:  130^B
    1)= S ^SRF("B",$E(X,1,30),DA)=""
    2)= K ^SRF("B",$E(X,1,30),DA)
  • CROSS-REFERENCE:  130^ARET^MUMPS
    1)= Q
    2)= D ^SROKRET
    The ARET cross reference on the PATIENT field removes returns to surgery that are defined for other cases when a case is deleted. In addition, the ARET cross reference includes logic to remove AL and AUD nodes (on case
    deletion) that may exist because of the reverse set and kill logic on the AL and AUD cross references.
  • RECORD INDEXES:  ADT (#1417), ARS (#1418)
.011 HOSPITAL ADMISSION STATUS 0;12 SET
  • 'I' FOR INPATIENT;
  • 'O' FOR OUTPATIENT;
  • '1' FOR SAME DAY;
  • '2' FOR ADMISSION;
  • '3' FOR HOSPITALIZED;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter the code corresponding to the hospital admission status on the calendar day of surgery.
  • DESCRIPTION:  Definition Revised (2015): This field indicates the patient's acute hospital admission status on the calendar day of surgery. Enter "1" or "S" if the operation was same day (the patient was not admitted); "2" or "A" if the
    patient was admitted on the calendar day of surgery; or "3" or "H" if the patient was already hospitalized on the calendar day prior to surgery. Observation is considered outpatient care, not related to an inpatient
    admission, therefore entered as "1" or "S".
  • SCREEN:  S DIC("S")="I Y"
  • EXPLANATION:  Screen prevents selection of retired codes.
  • CROSS-REFERENCE:  130^APCE5^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • RECORD INDEXES:  AD (#196)
.013 PLANNED ADMISSION STATUS 0;26 SET
  • '1' FOR SAME DAY;
  • '2' FOR ADMITTED;
  • '3' FOR HOSPITALIZED;

  • LAST EDITED:  MAY 22, 2015
  • HELP-PROMPT:  Enter the code corresponding to the planned admission status for this surgical case.
  • DESCRIPTION:  This field indicates the patient's planned hospital admission status for the calendar day of surgery.
    Enter "1" or "S" if the operation is planned as SAME day (the patient will not be admitted). Enter" 2" or "A" if the patient will be ADMITTED on the calendar day of surgery. Enter "3" or "H" if the patient will already be
    HOSPITALIZED on the calendar day prior to the date of surgery.
.015 VISIT 0;15 POINTER TO VISIT FILE (#9000010) VISIT(#9000010)

  • LAST EDITED:  SEP 17, 1996
  • HELP-PROMPT:  Enter the visit associated with this occasion of service.
  • DESCRIPTION:  
    This is the visit associated with this case.
  • CROSS-REFERENCE:  130^AV
    1)= S ^SRF("AV",$E(X,1,30),DA)=""
    2)= K ^SRF("AV",$E(X,1,30),DA)
    This is a regular cross reference to be used for sorting.
  • CROSS-REFERENCE:  130^AA^MUMPS
    1)= D ADD^AUPNVSIT
    2)= D SUB^AUPNVSIT
    This MUMPS cross reference maintains the dependency count for this visit in the VISIT file.
.0155 CLASSIFICATION ENTERED (Y/N) 0;20 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  OCT 01, 1996
  • HELP-PROMPT:  Enter YES if classification information has been entered (as appropriate).
  • DESCRIPTION:  This field indicates whether or not classification items have been addressed. This field is used by the software to decide whether to allow the user a choice to update classification information. If the field is NO or
    null, it will not permit a choice if the site parameter to enter classification information is turned on.
.016 SERVICE CONNECTED 0;16 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating a service connected problem, enter YES.
  • DESCRIPTION:  
    This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a service connected problem. This information may be passed to the VISIT file (#9000010) for use by PCE.
  • CROSS-REFERENCE:  130^APCE16^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.017 AGENT ORANGE EXPOSURE 0;17 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating an agent orange exposure problem, enter YES.
  • DESCRIPTION:  This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Agent Orange Exposure. This information may be passed to the VISIT file (#9000010) for use
    by PCE.
  • CROSS-REFERENCE:  130^APCE17^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.018 IONIZING RADIATION EXPOSURE 0;18 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating an Ionizing Radiation Exposure problem, enter YES.
  • DESCRIPTION:  This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Ionizing Radiation Exposure. This information may be passed to the VISIT file (#9000010)
    for use by PCE.
  • CROSS-REFERENCE:  130^APCE18^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.019 SOUTHWEST ASIA CONDITIONS 0;19 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  JUL 26, 2006
  • HELP-PROMPT:  If this case is treating a SW Asia problem, enter YES.
  • DESCRIPTION:  
    This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem related to service in SW Asia. This information may be passed to the VISIT file (#9000010) for use by PCE.
  • CROSS-REFERENCE:  130^APCE19^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.02 OP ROOM PROCEDURE PERFORMED 0;2 POINTER TO OPERATING ROOM FILE (#131.7) OPERATING ROOM(#131.7)

  • INPUT TRANSFORM:  S DIC("S")="I $$ORDIV^SROUTL0(+Y,$G(SRSITE(""DIV""))),('$P(^SRS(+Y,0),U,6))" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the name of the operating room where the principal operation is performed.
  • DESCRIPTION:  
    This is the name of the operating room where the principal operation is performed for this patient. It can be selected by entering the name or abbreviation of the operating room.
  • SCREEN:  S DIC("S")="I $$ORDIV^SROUTL0(+Y,$G(SRSITE(""DIV""))),('$P(^SRS(+Y,0),U,6))"
  • EXPLANATION:  Screen limits selection to active operating rooms for the division.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AOR^MUMPS
    1)= I $P(^SRF(DA,0),"^",9)'="" S ^SRF("AOR",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)=""
    2)= K ^SRF("AOR",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)
    The AOR cross reference on the OPERATING ROOM field is used in various reports when sorting by operating room.
  • CROSS-REFERENCE:  130^AM3^MUMPS
    1)= D AM3^SROXR2
    2)= D KILLAM3^SROXR2
    The AM3 cross reference on the OPERATING ROOM field updates the AMM cross reference when the OPERATING ROOM is edited if the case has been scheduled.
  • CROSS-REFERENCE:  130^APCE20^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • RECORD INDEXES:  AD (#196)
.021 ASSOCIATED CLINIC 0;21 POINTER TO HOSPITAL LOCATION FILE (#44) HOSPITAL LOCATION(#44)

  • INPUT TRANSFORM:  S DIC("S")="I $$HL^SROUTL0(Y,$G(SRSITE(""DIV""))),$$CLINIC^SROUTL(Y,$S($D(DA):DA,1:""""))" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the clinic associated with this case.
  • DESCRIPTION:  
    This is the clinic associated with this surgical case or non-OR procedure. The entry made in this field will be used as the location of the encounter for PCE.
  • SCREEN:  S DIC("S")="I $$HL^SROUTL0(Y,$G(SRSITE(""DIV""))),$$CLINIC^SROUTL(Y,$S($D(DA):DA,1:""""))"
  • EXPLANATION:  Select active, count clinic at the user's division.
  • CROSS-REFERENCE:  130^APCE21^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.022 MILITARY SEXUAL TRAUMA 0;22 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating a problem related to Military Sexual Trauma, enter YES.
  • DESCRIPTION:  This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Military Sexual Trauma. This information may be passed to the VISIT file (#9000010) for use
    by PCE.
  • CROSS-REFERENCE:  130^APCE22^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.023 HEAD AND/OR NECK CANCER 0;23 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating a problem related to Head and/or Neck Cancer, enter YES.
  • DESCRIPTION:  This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Head and/or Neck Cancer. This information may be passed to the VISIT file (#9000010) for
    use by PCE.
  • CROSS-REFERENCE:  130^APCE23^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.024 COMBAT VET 0;24 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  If this case is treating a problem related to Combat, enter YES.
  • DESCRIPTION:  
    This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Combat. This information may be passed to the VISIT file (#9000010) for use by PCE.
  • CROSS-REFERENCE:  130^APCE27^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.026 PROJ 112/SHAD 0;25 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  NOV 17, 2005
  • HELP-PROMPT:  If this case is treating a problem related to PROJ 112/SHAD, enter YES.
  • DESCRIPTION:  
    This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to PROJ 112/SHAD. This information may be passed to the VISIT file (#9000010) for use by PCE.
  • CROSS-REFERENCE:  130^APCE28^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
.03 MAJOR/MINOR 0;3 SET
  • 'J' FOR MAJOR;
  • 'N' FOR MINOR;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.03 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the code corresponding to the case type.
  • DESCRIPTION:  Definition Revised (2004): Major - Any operation performed under general, spinal, or epidural
    anesthesia plus all inguinal herniorrhaphies, carotid
    endarterectomies, parathyroidectomies, thyroidectomies, breast
    lumpectomies, or endovascular AAA repairs regardless of
    anesthesia administered.
    Minor - All operations not designated as Major.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.035 CASE SCHEDULE TYPE 0;10 SET
  • 'EM' FOR EMERGENCY;
  • 'EL' FOR ELECTIVE;
  • 'A' FOR ADD ON (NON-EMERGENT);
  • 'S' FOR STANDBY;
  • 'U' FOR URGENT;

  • INPUT TRANSFORM:  I $D(DA) D EM^SROAUTLC I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.035 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter code describing how the case is scheduled.
  • DESCRIPTION:  This is the code describing how this case was scheduled. It is important that this field is entered. The Scheduler may use this field when updating the schedule due to cancellations or insertions.
    Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related
    preoperative symptomatology. Answer EMERGENCY if the surgeon and anesthesiologist report the case as emergent
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AP^MUMPS
    1)= D NOW^SROAUTLC
    2)= D KNOW^SROAUTLC
    This cross reference stuffs the current date/time into the Date/Time of Cardiac Surgical Priority field (414.1).
.037 CASE SCHEDULE ORDER 0;11 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>35!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.037 D ^SROCON Q
  • LAST EDITED:  JAN 31, 1991
  • HELP-PROMPT:  Enter the sequence when more than one patient is scheduled by a surgeon or service on the same date, i.e. 1ST, 2ND or 3RD.
  • DESCRIPTION:  This is the sequence in which the surgeon expects to do the case if he or she has more than one case scheduled for this day. This field is optional, but is very useful to the person scheduling cases if the surgeon has
    more than one case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.04 SURGERY SPECIALTY 0;4 POINTER TO LOCAL SURGICAL SPECIALTY FILE (#137.45)
************************REQUIRED FIELD************************
LOCAL SURGICAL SPECIALTY(#137.45)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  NOV 30, 2010
  • HELP-PROMPT:  Enter the assigned surgical specialty, or section, of the surgeon.
  • DESCRIPTION:  Definition Revised (2007): This is the surgical specialty credited for doing this operative procedure. Many reports, including the Annual Report of Surgical Procedures, are sorted by the surgical specialty. This field
    should be entered prior to completion of this case. (If you enter '?' in the surgical package, it will display the entire local surgical specialty list and a copy of the national list can be found in the Operations
    Manual.)
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • CROSS-REFERENCE:  130^ASP^MUMPS
    1)= I $P(^SRF(DA,0),"^",9)'="" S ^SRF("ASP",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)=DA
    2)= K ^SRF("ASP",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)
    The ASP cross reference on the SURGERY SPECIALTY field is used by various reports to sort by the surgical specialty and within surgical specialty by date of operation.
  • CROSS-REFERENCE:  130^APCE3^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • RECORD INDEXES:  AD (#196)
.05 PREOPERATIVE INFECTION 0;5 SET
  • 'C' FOR CLEAN;
  • 'D' FOR CONTAMINATED;
  • 'S' FOR SPECIAL CONSIDERATIONS;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter the code corresponding to the wound classification, for scheduling purposes.
  • DESCRIPTION:  Enter the letter code C for clean, D for contaminated, or S for infections that require special considerations (type in the first few letters of any word). This information allows the scheduling manager to determine how
    much time is needed between operations for sanitizing a room. "Special considerations" is for infections that have local or national requirements for special room cleaning (e.g., CJD, VRE, MRSA).
.07 PREOP SKIN INTEG 0;7 POINTER TO SKIN INTEGRITY FILE (#135.2) SKIN INTEGRITY(#135.2)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.07 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the preoperative assessment of the patient's skin integrity upon arrival to the operating room.
  • DESCRIPTION:  This is the preoperative assessment of the patient's skin integrity upon arrival to the operating room. The information entered will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.08 PREOP SKIN COLOR 0;8 SET
  • 'A' FOR ASHEN;
  • 'LBR' FOR LIGHT BROWN;
  • 'DBR' FOR DARK BROWN;
  • 'PI' FOR PINK;
  • 'PA' FOR PALE;
  • 'F' FOR FLUSHED;
  • 'M' FOR MOTTLED;
  • 'C' FOR CYANOTIC;
  • 'I' FOR ICTERIC;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.08 D ^SROCON Q
  • LAST EDITED:  AUG 22, 1990
  • HELP-PROMPT:  Enter the code corresponding to the preoperative assessment of the patient's skin color upon arrival to the operating room.
  • DESCRIPTION:  This is the code corresponding to the preoperative assessment of the patient's skin color upon arrival to the operating room. If entered, this information will appear on the Nurse Intraoperative Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.09 DATE OF OPERATION 0;9 DATE
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  S %DT="ETX" D ^%DT S X=Y K:Y<1 X I $D(X) D SCH^SRODATE
  • LAST EDITED:  MAR 10, 2017
  • HELP-PROMPT:  Enter the date that the principal operation was performed. The patient may have more than principal operation (and operative record) on the same day.
  • DESCRIPTION:  
    This is the date that the case was performed. The date of operation must be entered for all cases.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
    TRIGGERED by the TIME PAT IN OR field of the SURGERY File
    TRIGGERED by the DATE OF PROCEDURE field of the SURGERY File
  • CROSS-REFERENCE:  130^AC^MUMPS
    1)= S ^SRF("AC",X,DA)=$P(^SRF(DA,0),"^")
    2)= K ^SRF("AC",X,DA)
    The AC cross reference on the DATE OF OPERATION field is used to sort entries by date of operation for reports.
  • CROSS-REFERENCE:  130^ASP1^MUMPS
    1)= D SP^SROXR1
    2)= D KSP^SROXR1
    The ASP1 cross reference on the DATE OF OPERATION field updates the ASP and the AOR cross references when the date of operation is changed.
  • CROSS-REFERENCE:  130^AR^MUMPS
    1)= D AR^SROXR1
    2)= D KAR^SROXR1
    The AR cross reference on the DATE OF OPERATION field is used to sort and display requested cases. This cross reference is created when a case is requested or when the request date is changed. Upon scheduling the
    request, the AR cross reference for the case is deleted.
  • FIELD INDEX:  AES8 (#386) MUMPS IR ACTION
    Short Descr: Update TIU when Date of Operation is changed.
    Description: This cross-reference is responsible for updating the REFERENCE DATE field (#1301) in the TIU DOCUMENT file (#8925) for all Reports when the DATE OF OPERATION field (#9) in the SURGERY file (#130) is edited.
    Set Logic: D AES8^SROESX0 Q
    Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
    Kill Logic: Q
    X(1): DATE OF OPERATION (130,.09) (forwards)
  • FIELD INDEX:  AK (#412) MUMPS IR ACTION
    Short Descr: PFSS field monitor flag.
    Description: This cross-reference will be checked before sending a notification to the PFSS after editing the Date Of Operation field.
    Set Logic: I ($P(X1(1),".")'=$P(X2(1),"."))&(X2(1)'="") S ^TMP("SRPFSS",$J)="" Q
    Set Cond: Q
    Kill Logic: I ($P(X1(1),".")'=$P(X2(1),"."))&(X1(1)'="") S ^TMP("SRPFSS",$J)="" Q
    Kill Cond: Q
    X(1): DATE OF OPERATION (130,.09) (forwards)
  • RECORD INDEXES:  AD (#196), ADT (#1417)
.11 TRANS TO OR BY .1;1 POINTER TO SURGERY TRANSPORTATION DEVICES FILE (#131.01) SURGERY TRANSPORTATION DEVICES(#131.01)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.11 D ^SROCON Q
  • LAST EDITED:  JUN 02, 1992
  • HELP-PROMPT:  Enter the transporting device, or method, used to deliver the patient to the operating room.
  • DESCRIPTION:  This is the method or device used to deliver the patient to the operating room. This field is optional, but may be useful for documentation of the case.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.111 OR CIRC SUPPORT 19;0 POINTER Multiple #130.28 130.28

  • DESCRIPTION:  This is information about the nurses with circulating role responsibilities.
  • INDEXED BY:  OR CIRC SUPPORT (AES7)
.112 OR SCRUB SUPPORT 23;0 POINTER Multiple #130.36 130.36

  • DESCRIPTION:  This is information about the person with scrub role responsibilities.
.12 HAIR REMOVAL BY .1;2 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.12"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
  • LAST EDITED:  APR 03, 2006
  • HELP-PROMPT:  If the patient had hair removed for the procedure, enter the name of the person responsible for removing the patient's hair. This field may be restricted based on locally defined keys.
  • DESCRIPTION:  
    This is the person responsible for removing the patient's hair in preparation for the operative procedure (if necessary).
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.12"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  This field may be restricted based on locally defined keys.
.13 RESTR & POSITION AIDS 20;0 POINTER Multiple #130.31 130.31

  • DESCRIPTION:  This is information related to restraints and positioning aids used during this operative procedure.
.14 PRIMARY SURGEON .1;4 POINTER TO NEW PERSON FILE (#200)
************************REQUIRED FIELD************************
NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.14"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the name of the privileged person who performs the major portion of the principal operation.
  • DESCRIPTION:  This is the name of the person performing the major portion of the principal operative procedure. This field is required as part of the Operation Report.
    This field may be restricted by locally determined keys so that only people with the appropriate keys can be entered.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.14"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries into this field may be restricted based on locally selected keys.
  • AUDIT:  YES, ALWAYS
  • CROSS-REFERENCE:  130^ASR^MUMPS
    1)= D STAFF^SROXR1
    2)= D KSTAFF^SROXR1
    The ASR cross reference on the SURGEON field is used to update the STAFF/RESIDENT field when a surgeon is entered.
  • CROSS-REFERENCE:  130^APCE1^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • CROSS-REFERENCE:  130^ATT^MUMPS
    1)= D ATT^SROXR1
    2)= D KATT^SROXR1
    This cross reference updates the ATTEND SURG field with the SURGEON if the SURGERY RESIDENTS (Y/N) site parameter is NO.
  • FIELD INDEX:  AES1 (#380) MUMPS ACTION
    Short Descr: Update TIU when surgeon is changed.
    Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Operation Report when the surgeon is edited.
    Set Logic: D SET^SROESX0
    Set Cond: S X=X1(1)'=X2(1)
    Kill Logic: Q
    Kill Cond: S X=0
    X(1): PRIMARY SURGEON (130,.14) (forwards)
  • RECORD INDEXES:  AD (#196)
.15 FIRST ASST .1;5 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.15"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person assisting the surgeon during the major portion of the principal operation.
  • DESCRIPTION:  
    This is the name of the person assisting the surgeon during the operative procedure. The information entered here appears on the Operation Report and Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.15"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally defined keys.
.16 SECOND ASST .1;6 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.16"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person assisting the surgeon.
  • DESCRIPTION:  This is the name of the second person assisting the surgeon during the operative procedure. If entered, this information appears on the Operation Report and Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.16"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.164 ATTENDING SURGEON .1;13 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.164"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the name of the attending staff surgeon. This is required when the surgeon is in training status.
  • DESCRIPTION:  
    This is the name of the attending staff surgeon responsible for this case. This information appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.164"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
  • DELETE TEST:  1,0)= I 1 D EN^DDIOL("The ATTEND SURGEON can't be deleted.",,"!!,?2")
  • CROSS-REFERENCE:  130^APCE4^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • FIELD INDEX:  AES3 (#382) MUMPS ACTION
    Short Descr: Update TIU when attending surgeon is changed.
    Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Operation Report when the attending surgeon is edited.
    Set Logic: D SET1^SROESX0
    Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
    Kill Logic: D SET1^SROESX0
    Kill Cond: S X=X2(1)=""
    X(1): ATTENDING SURGEON (130,.164) (forwards)
  • RECORD INDEXES:  AD (#196)
.165 *ATTENDING CODE - NOT USED .1;16 SET
  • '0' FOR LEVEL 0. ATTENDING DOING THE OPERATION;
  • '1' FOR LEVEL 1. ATTENDING IN O.R. ASSISTING THE RESIDENT;
  • '2' FOR LEVEL 2. ATTENDING IN O.R., NOT SCRUBBED;
  • '3' FOR LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATELY AVAILABLE;

  • LAST EDITED:  JUN 18, 2004
  • HELP-PROMPT:  Enter the code corresponding to the highest level of supervision provided by the attending staff surgeon.
  • DESCRIPTION:  NOTE: This field is replaced by the new ATTENDING CODE field (#.166).
    This is the code corresponding to the highest level of supervision provided by the attending staff surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative Report, and Attending
    Surgeon Report.
    0 The staff practitioner performs the case but may be assisted by
    a resident.
    1 The supervising practitioner is physically present in the
    operative or procedural suite and directly involved in the
    procedure. The resident performs major portions of the procedure.
    2 The supervising practitioner is physically present in the
    operative or procedural suite and immediately available for
    consultation. The supervising practitioner may observe and
    provide direction. The resident performs the procedure
    3 The supervising practitioner is not physically present in the
    operative or procedural suite, but is in the facility or on the
    VA campus. The supervising practitioner is immediately available
    for resident supervision or consultation as needed. Local policy,
    as approved by the VISN Academic Affiliations Officer, should
    define the standard for "availability" of the supervising
    practitioner. NOTE: The service chief and chief of staff
    are responsible for periodically reviewing cases done under
    Level 3 supervision.
    WRITE AUTHORITY: ^
    UNEDITABLE
.166 ATTENDING/RES SUP CODE .1;10 POINTER TO ATTENDING CODES FILE (#132.9) ATTENDING CODES(#132.9)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the code corresponding to the highest level of supervision provided by the attending staff surgeon.
  • DESCRIPTION:  
    This is the code corresponding to the highest level of resident supervision provided by the attending staff surgeon for this case.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
.167 PERFUSIONIST .1;19 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.167"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person operating the cardio-pulmonary or organ perfusion apparatus.
  • DESCRIPTION:  This is the name of the person operating the cardio-pulmonary or organ perfusion apparatus. Although not required, this information may be valuable in documenting the case. If entered, it will appear on the Nurse
    Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.167"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.168 ASST PERFUSIONIST .1;20 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.168"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person assisting the perfusionist.
  • DESCRIPTION:  This is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.168"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.175 SKIN PREP AGENTS .1;7 POINTER TO SKIN PREP AGENTS FILE (#135.1) SKIN PREP AGENTS(#135.1)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.175 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the name of the skin prep agent used to wash and prepare the operative site.
  • DESCRIPTION:  This is the type of agent used to wash and prepare the operative site. If entered, this information appears on the Nurse Intraoperative Report and is useful in documenting the case.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.18 SKIN PREPPED BY (1) .1;8 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.18"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person performing the preop skin preparation.
  • DESCRIPTION:  This is the name of the person responsible for applying the agent used to wash and prepare the operative site. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.18"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.19 PREOP MOOD .1;9 POINTER TO PATIENT MOOD FILE (#135.3) PATIENT MOOD(#135.3)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.19 D ^SROCON Q
  • LAST EDITED:  JUN 02, 1992
  • HELP-PROMPT:  Enter the code corresponding to the preoperative assessment of the patient's emotional status upon arrival to the operating room.
  • DESCRIPTION:  This is the preoperative assessment of the patient's emotional status upon arrival to the operating room. It may be useful in the documentation of the case. If entered, this information will appear on the Nurse
    Intraoperative Report.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.195 PREOP CONVERSE .1;14 SET
  • 'TC' FOR TALKS CONSTANTLY;
  • 'IC' FOR INITIATES CONVERSATION;
  • 'RQ' FOR RESPONDS TO QUESTIONS;
  • 'NA' FOR NOT ANSWER QUESTIONS;
  • 'A' FOR APHASIC;
  • 'D' FOR DYSPHASIC;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.195 D ^SROCON Q
  • LAST EDITED:  AUG 22, 1990
  • HELP-PROMPT:  Enter the code corresponding to the preoperative assessment of the patient's demonstrated verbal responses upon arrival to the operating room.
  • DESCRIPTION:  This is the preoperative assessment of the patient's demonstrated verbal responses upon arrival to the operating room. Although optional, this field may be valuable in documenting this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.196 PREOP CONSCIOUS .1;15 POINTER TO PATIENT CONSCIOUSNESS FILE (#135.4) PATIENT CONSCIOUSNESS(#135.4)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.196 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the preoperative assessment of the patient's level of consciousness upon arrival to the operating room.
  • DESCRIPTION:  This is the preoperative assessment of the patient's level of consciousness upon arrival to the operating room. Although optional, this information may be useful in documenting the case.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.202 NURSE PRESENT TIME .2;7 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(D0,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.202 D ^SROCON Q
  • LAST EDITED:  AUG 22, 1990
  • HELP-PROMPT:  Enter the date/time that the nurse was present in the operating room.
  • DESCRIPTION:  
    This is the date and time that the nurse was present in the operating room. Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.203 TIME PAT IN HOLD AREA .2;15 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(DA,0),U,9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X) S %DT="ETX" D ^%DT S X=Y K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.203 D ^SROCON Q
  • LAST EDITED:  DEC 09, 1993
  • HELP-PROMPT:  Enter the date/time that the patient arrived in the holding area.
  • DESCRIPTION:  This is the date and time that the patient arrived in the holding area. Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.204 ANES AVAIL TIME .2;8 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA),0),U,9),1,7) D TIME^SROVAR S %DT="TX" D ^%DT S X=Y K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.204 D ^SROCON Q
  • LAST EDITED:  MAY 20, 1993
  • HELP-PROMPT:  Enter the date/time that the anesthetist is available to service the patient.
  • DESCRIPTION:  This is the date and time that the anesthetist is available to service the patient. Although optional, this information is useful for evaluating operation delays.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.205 TIME PAT IN OR .2;10 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.205 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the date/time that the patient was transported into the operating room.
  • DESCRIPTION:  This is the date and time that the patient was transported into the operation room. Times entered without a date will be converted to the date of operation at that time.
    Definition Revised (2004): Patient in Room (PIR): Time when patient enters the OR/PR.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  ^^TRIGGER^130^.09
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X K Y S X=DIV S X=DIV S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X K Y X ^DD(130,.205,1,1,2.1) X ^DD(130,.205,1,1,2.4)
    2.1)= S X=DIV S X=X,Y(1)=X S X=1,Y(2)=X S X=7,X=$E(Y(1),Y(2),X)
    2.4)= S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
    CREATE VALUE)= TIME PAT IN OR
    DELETE VALUE)= $E(OLD TIME PAT IN OR,1,7)
    FIELD)= DATE OF OPERATION
    This trigger on the TIME PAT IN OR field updates the DATE OF OPERATION field with the date/time the patient went into the operating room.
  • CROSS-REFERENCE:  130^APCE6^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • CROSS-REFERENCE:  130^AD^MUMPS
    1)= D VALIDAT^SROCVER
    2)= Q
    This MUMPS cross-reference on the TIME PAT IN OR field is used to invoke the CPT and ICD-9 codes revalidation checks in routine ^SROCVER.
  • CROSS-REFERENCE:  130^AOE^MUMPS
    1)= I $L($T(OR1^ORMEVNT1)) D OR1^ORMEVNT1(DA,X)
    2)= I $L($T(OR2^ORMEVNT1)) D OR2^ORMEVNT1(DA)
    This MUMPS cross reference allows the CPRS to automatic discontinue or release orders when the patient enters the OR.
.206 SURG PRESENT TIME .2;9 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
  • LAST EDITED:  SEP 24, 1987
  • HELP-PROMPT:  Enter the time that the authorized surgeon is available to begin the operation.
  • DESCRIPTION:  This is the date and time that the surgeon is available to begin the operative procedure. Although not mandatory, this information is useful for evaluating hospital delays.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.21 ANES CARE START TIME .2;1 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(D0,0),U,9),1,7) D TIME^SROVAR S %DT="ETX" D ^%DT S X=Y K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.21 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the time a member of the Anesthesia staff begins preparing the patient for surgery in the O.R. suite.
  • DESCRIPTION:  This is the date and time that the anesthesia care began. It is required as part of the anesthesia report. The definition of what constitutes the time anesthesia care begins may vary depending on local anesthesia policy.
    Non-Cardiac Definition Revised(2004): Anesthesia Start (AS): Time when a member of the anesthesia team begins preparing the patient for an anesthetic.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AF^MUMPS
    1)= Q:'$D(SRTN)!('$D(SRSITE("IV")))!('$D(DT)) I SRSITE("IV") D IV^SROXR1
    2)= Q
    The AF MUMPS cross reference on this field is responsible for canceling current IV orders for a patient undergoing a surgical or non-OR procedure if the site parameter is set to allow cancellation of IV orders.
    This cross reference compares the time entered in the ANES CARE START TIME field with the current time. If the difference is more than 24 hours, order cancellation is not allowed. If the difference is more than 1 hour, but
    not more than 24 hours, the user is warned that a considerable amount of time has passed since the start of the operation or procedure. Finally, if order cancellation is allowed, the user is prompted to cancel current IV
    orders or not. If the user chooses to cancel IV orders, the Surgery software calls DCOR^PSIVACT.
.213 ANES CARE TIME BLOCK 50;0 DATE Multiple #130.213 130.213

  • DESCRIPTION:  
    This is the date and time for which anesthesia care is provided.
.214 ANES CARE BILLABLE TIME FLAG .2;17 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  SEP 05, 2003
  • HELP-PROMPT:  "Yes" indicates all anesthesia care time has been entered. "No" indicates time entry is not complete.
  • DESCRIPTION:  This field is a flag that indicates all anesthesia care time has been entered for a case. It is used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered. "No" indicates time entry
    is not complete.
.215 INDUCTION COMPLETE .2;11 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=1,SR130="ANES CARE START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.215 D ^SROCON Q
  • LAST EDITED:  JAN 09, 1998
  • HELP-PROMPT:  Enter the time that the anesthetist declares the patient ready for the start of the surgical procedure.
  • DESCRIPTION:  This is the date and time that the anesthetist declares the patient ready for the start of the operative procedure. Although optional, this information may be useful in management studies.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.218 ANES CARE BILLABLE TIME COMPUTED

  • MUMPS CODE:  S X=$$BILLTIME^SROANEST
  • ALGORITHM:  S X=$$BILLTIME^SROANEST
  • LAST EDITED:  MAR 11, 2004
  • DESCRIPTION:  
    This is the total anesthesia care billable time in minutes. It is calculated from all time intervals entered in the multiple anesthesia start and end time fields..
.22 TIME OPERATION BEGAN .2;2 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
  • LAST EDITED:  JAN 03, 2011
  • HELP-PROMPT:  Enter the time of the start of the surgical procedure. Exclude the skin prep time.
  • DESCRIPTION:  This is the date and time that the operation began. The definition of this time is usually 'knife fall', but may vary according to local surgery service protocol.
    Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure).
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.23 TIME OPERATION ENDS .2;3 DATE

  • INPUT TRANSFORM:  N SRN,SRP,SR130 S SRN=.2,SRP=2,SR130="TIME OPERATION BEGAN" D TERM^SROVAR K:Y<1 X
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the time wherein all surgical procedures related to this operation are complete.
  • DESCRIPTION:  Definition Revised (2004): Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all
    dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, indicate the time the patient was pronounced
    dead.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.232 TIME PAT OUT OR .2;12 DATE

  • INPUT TRANSFORM:  N SRN,SRP,SR130,SRFLD S SRN=.2,SRP=10,SR130="TIME PAT IN OR" D TERM^SROVAR K:Y<1 X I $D(X) D ATT^SROUTL1 I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.232 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the time that the patient is taken from the operating room, i.e. 7:45, 0745, 745, T@7:45, JAN 1@745 ...
  • DESCRIPTION:  This is the date and time that the patient is taken from the operating room. Times entered without a date will be converted to the date of operation at that time. This information is very significant for operating room
    management studies.
    Definition Revised (2011): Indicate the time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element.
  • DELETE TEST:  1,0)= I $$DEL^SROESX(DA,"1,2") D EN^DDIOL("The TIME PAT OUT OR can't be deleted. This case has one or more operative",,"!!,?2") D EN^DDIOL("reports associated with it.",,"!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AH^MUMPS
    1)= I $D(^SRF(DA,14)),'$D(^(15)) S %X="^SRF(DA,14,",%Y="^SRF(DA,15," D %XY^%RCR S ^(0)="^130.18A"_U_$P(^SRF(DA,15,0),U,3,4) K %X,%Y
    2)= Q
    The AH cross reference on the TIME PAT OUT OR field moves the OTHER PREOP DIAGNOSIS information into the OTHER POSTOP DIAGS subfile when the TIME PAT OUT OR is entered.
  • CROSS-REFERENCE:  130^AM1^MUMPS
    1)= D AM1^SROXR2
    2)= Q
    The AM1 cross reference on the TIME PAT OUT OR field is responsible for removing the AMM cross reference for the case and for updating the scheduling display graph. In addition, if the case is a requested case, the AR
    cross reference is removed if it still exists.
  • CROSS-REFERENCE:  130^APCE7^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • CROSS-REFERENCE:  130^AQ^MUMPS
    1)= D AQ^SROXR4
    2)= D KAQ^SROXR4
    This MUMPS cross reference is used by the transmission process to the national database.
  • FIELD INDEX:  AES (#379) MUMPS ACTION
    Short Descr: Create/delete stub entries in TIU for nurse/operation reports.
    Description: This cross reference is responsible for creating stub entries in TIU for the nurse intraoperative report and the operation report when the TIME PAT OUT OR field (#.232) is entered. It is also responsible for deleting the
    stub entries in TIU for these same reports, if unsigned, when the TIME PAT OUT OR field (#.232) is deleted. No action occurs if the value in the TIME PATOUT OR field (#.232) is modified.
    Set Logic: D AES^SROESX
    Set Cond: S X=X1(1)=""
    Kill Logic: D KAES^SROESX
    Kill Cond: S X=X2(1)=""
    X(1): TIME PAT OUT OR (130,.232) (forwards)
.234 OR CLEAN START TIME .2;13 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=12,SR130="TIME PAT OUT OR" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.234 D ^SROCON Q
  • LAST EDITED:  JAN 09, 1998
  • HELP-PROMPT:  Enter the date/time when the 'end of case' cleaning, or terminal cleaning began.
  • DESCRIPTION:  This is the date and time when the 'end of case' or terminal cleaning began. Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.236 OR CLEAN END TIME .2;14 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=13,SR130="OR CLEAN START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.236 D ^SROCON Q
  • LAST EDITED:  JAN 09, 1998
  • HELP-PROMPT:  Enter the date/time when the 'end of case' or terminal cleaning ended.
  • DESCRIPTION:  This is the date and time when the 'end of case' or terminal cleaning ended. Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.24 ANES CARE END TIME .2;4 DATE

  • INPUT TRANSFORM:  N SRN,SRP,SR130,SRFLD S SRN=.2,SRP=1,SR130="ANES CARE START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.24 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the time that the anesthesia staff transfers care to other care providers.
  • DESCRIPTION:  This is the date and time that anesthesia care ends. Its definition may vary according to local anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered without a date will be
    converted to the date of the operation at that time.
    Non-Cardiac Definition Revised (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU).
  • DELETE TEST:  1,0)= I $$DEL^SROESX(DA,"4") D EN^DDIOL("The ANES CARE END TIME field cannot be deleted. This case has an",,"!!,?2") D EN^DDIOL("Anesthesia Report associated with it.",,"!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • FIELD INDEX:  AESA (#387) MUMPS ACTION
    Short Descr: Create/delete stub entries in TIU for anesthesia report.
    Description: This cross reference is responsible for creating a stub entry in TIU for the anesthesia report when the ANES CARE END TIME field (#.24) is entered. It is also responsible for deleting the stub entry in TIU for this
    report, if unsigned, when the ANES CARE END TIME field (#.24) is deleted. No action occurs if the value in the ANES CARE END TIME field (#.24) is modified.
    Set Logic: D AESA^SROESXA
    Set Cond: S X=X1(1)=""
    Kill Logic: D KAESA^SROESXA
    Kill Cond: S X=X2(1)=""
    X(1): ANES CARE END TIME (130,.24) (forwards)
.25 BLOOD LOSS (ML) .2;5 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.25 D ^SROCON Q
  • LAST EDITED:  MAY 14, 1992
  • HELP-PROMPT:  Enter the number of milliliters (0-100000) of blood estimated to be lost during the procedure (EBL).
  • DESCRIPTION:  This is the number of milliliters (0-100000) of blood estimated to be lost during the operative procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.255 TOTAL URINE OUTPUT (ML) .2;16 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.255 D ^SROCON Q
  • LAST EDITED:  AUG 22, 1990
  • HELP-PROMPT:  Enter the number of milliliters (0-100000) of urine output during the operative procedure. (If measured)
  • DESCRIPTION:  This is the total number of milliliters (0-100000) of urine output during the operative procedure. If entered, this information appears on the Nurse Intraoperative Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.27 REPLACEMENT FLUID TYPE 4;0 POINTER Multiple #130.04 130.04

  • DESCRIPTION:  
    This is information related to the replacement fluid given intravascularly during the operative procedure.
.28 GENERAL COMMENTS 5;0 WORD-PROCESSING #130.05

  • DESCRIPTION:  These are general comments about the operative procedure. Any information not provided for elsewhere can be entered here.
.29 NURSING CARE COMMENTS 7;0 WORD-PROCESSING #130.07

  • DESCRIPTION:  
    These are comments on this case required for documentation on the Nurse Intraoperative Report.
.293 MONITORS 27;0 POINTER Multiple #130.41 130.41

  • DESCRIPTION:  This is information related to invasive or non-invasive monitors used during this case.
.31 PRINC ANESTHETIST .3;1 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.31"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 07, 2002
  • HELP-PROMPT:  This may be the anesthesiologist or CRNA (or surgeon, if local)
  • DESCRIPTION:  This is the name of the principal anesthesiologist or CRNA (or surgeon, if local anesthesia). This information is extremely important for the Anesthesia Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.31"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
  • CROSS-REFERENCE:  130^ANES^MUMPS
    1)= D ANES^SROXR1
    2)= D KANES^SROXR1
    The ANES cross reference on the PRINC ANESTHETIST field updates the ANESTHETIST CATEGORY field when a principal anesthetist is entered.
  • FIELD INDEX:  AES5 (#384) MUMPS ACTION
    Short Descr: Update TIU when principal anesthetist is changed.
    Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Anesthesia Report when the principal anesthetist is edited.
    Set Logic: D SET2^SROESX0
    Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
    Kill Logic: D SET2^SROESX0
    Kill Cond: S X=X2(1)=""
    X(1): PRINC ANESTHETIST (130,.31) (forwards)
.32 RELIEF ANESTHETIST .3;2 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.32"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the relief anesthetist (if applicable)
  • DESCRIPTION:  This is the name of the anesthetist relieving the principal anesthetist, if applicable. If entered, this information appears on the Anesthesia Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.32"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.33 ASST ANESTHETIST .3;3 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.33"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the assistant to the principal anesthetist.
  • DESCRIPTION:  This is the name of the person assisting the principal anesthetist. If entered, this information appears on the Anesthesia Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.33"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.34 ANESTHESIOLOGIST SUPVR .3;4 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.34"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 07, 2002
  • HELP-PROMPT:  Enter the name of the anesthesiology staff supervisor.
  • DESCRIPTION:  This is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal anesthetist is in a training
    status, or CRNA.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.34"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
  • FIELD INDEX:  AES6 (#385) MUMPS ACTION
    Short Descr: UPdate TIU when anesthesiologist supervisor is changed.
    Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Anesthesia Report when the anesthesiologist supervisor
    is edited.
    Set Logic: D SET3^SROESX0
    Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
    Kill Logic: D SET3^SROESX0
    Kill Cond: S X=X2(1)=""
    X(1): ANESTHESIOLOGIST SUPVR (130,.34) (forwards)
.345 ANES SUPERVISE CODE .3;6 POINTER TO ANESTHESIA SUPERVISOR CODES FILE (#132.95) ANESTHESIA SUPERVISOR CODES(#132.95)

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.345 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the code corresponding to the highest level of supervision of the anesthesiology staff supervisor.
  • DESCRIPTION:  This is the code corresponding to the highest level of supervision of the anesthesiology staff supervisor. This information appears on the Anesthesia Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.3511 ANES PERSONALLY PERFORMED .2;19 SET
  • '0' FOR NO;
  • '1' FOR YES;

  • LAST EDITED:  SEP 08, 2003
  • HELP-PROMPT:  Choose from: Y YES N NO
  • DESCRIPTION:  
    Answer yes only if the anesthesiologist personally performed the entire anesthesia procedure.
  • TECHNICAL DESCR:  
    Did the anesthesiologist personally perform the anesthesia care? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = No.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.3512 NUM OF CONCURRENT ANES CASES .2;20 NUMBER

  • INPUT TRANSFORM:  K:X<1!(X>9) X
  • LAST EDITED:  SEP 04, 2003
  • HELP-PROMPT:  Enter the total number of concurrent anesthesia procedures to this anesthesia care including this care.
  • DESCRIPTION:  Including this case, enter the number of cases that the anesthesiologist supervised where the time of the anesthesia care overlapped with this care. This field is required to support billing for the care and is critical
    for accurate coding of the primary anesthesia procedure. Enter a zero if the anesthesiologist personally performed the care. Enter 1 if the principal anesthetist was not an anesthesiologist and was medically directed by
    an anesthesiologist.
  • TECHNICAL DESCR:  
    Total number of concurrent cases the anesthesiologist supervised during this care? This field can contain only one digit.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.3513 ANES CONCURRENT CASES 55;0 POINTER Multiple #130.3513 130.3513

  • DESCRIPTION:  
    This field is for information only and is not required. It will assist in correcting potential errors if a start or end time is edited since other cases could be affected by the edit.
  • TECHNICAL DESCR:  
    This field lists the concurrent anesthesia cases to this case by the SURGERY case number.
.3514 ANES MEDICALLY DIRECTED .2;22 SET
  • '0' FOR NO;
  • '1' FOR YES;

  • LAST EDITED:  SEP 08, 2003
  • HELP-PROMPT:  Choose from Y YES N NO
  • DESCRIPTION:  
    If the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist supervised the care. Answering no indicates that the anesthetist was unsupervised.
  • TECHNICAL DESCR:  
    Was the CRNA medically directed by an anesthesiologist during this care? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = NO.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.3515 ANES PHYSICIAN AVAILABLE .2;23 SET
  • '0' FOR NO;
  • '1' FOR YES;

  • LAST EDITED:  SEP 08, 2003
  • HELP-PROMPT:  Choose from Y YES N NO
  • DESCRIPTION:  
    If the anesthetist was a resident, answer yes if the teaching physician was present during all key portions of the procedure and immediately available during the entire procedure.
  • TECHNICAL DESCR:  Was the teaching physician present during all key portions of the procedure and immediately available during the entire procedure? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes
    stores/translates 1 = YES and 0 = NO.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.36 MIN INTRAOP TEMPERATURE (C) .3;7 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X I $D(X),$D(DA),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.36 D ^SROCON Q
  • LAST EDITED:  JAN 03, 1995
  • HELP-PROMPT:  Type a Number between 0 and 50, 1 Decimal Digit
  • DESCRIPTION:  This is the lowest temperature of the patient during the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.37 ANESTHESIA TECHNIQUE 6;0 SET Multiple #130.06 130.06

  • LAST EDITED:  MAR 15, 2007
  • DESCRIPTION:  This is information about the anesthesia technique used during this case.
.375 MEDICATIONS 22;0 POINTER Multiple #130.33 130.33

  • DESCRIPTION:  
    This is information about medication for this case.
.39 IRRIGATION 26;0 POINTER Multiple #130.08 130.08

  • DESCRIPTION:  This is information related to the irrigation solution.
.42 OTHER PROCEDURES 13;0 Multiple #130.16 130.16

  • LAST EDITED:  DEC 06, 1991
  • DESCRIPTION:  This is information related to procedures performed in addition to the principal procedure.
  • INDEXED BY:  OTHER PROCEDURE & PLANNED OTHER PROC CPT CODE (AC)
.43 PLANNED POSTOP CARE .4;3 POINTER TO SURGERY DISPOSITION FILE (#131.6) SURGERY DISPOSITION(#131.6)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3),($P(^(0),U,2)'=""OBS""),($P(^(0),U,2)'=""M"")" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
  • LAST EDITED:  FEB 13, 2014
  • HELP-PROMPT:  Enter the planned postop care disposition for this patient.
  • DESCRIPTION:  This is the code corresponding to the location of care after the patient leaves the operating room and/or the post-anesthesia care unit.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3),($P(^(0),U,2)'=""OBS""),($P(^(0),U,2)'=""M"")"
  • EXPLANATION:  Screen prevents selection of inactive file entries.
  • CROSS-REFERENCE:  130^AI^MUMPS
    1)= I $S('$D(^SRF(DA,.7)):1,$P(^(.7),U,9)="":1,1:0) S $P(^SRF(DA,.7),U,9)=X
    2)= Q
    The AI cross reference on the REQ POSTOP CARE field stuffs the requested post-operative care entry into the PACU DISPOSITION field.
.44 OR SET-UP TIME .4;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.44 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a number between 0 and 999.
  • DESCRIPTION:  This is the number of minutes (0-999) necessary to prepare the operating room for the admission of the patient for the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.46 OP DISPOSITION .4;6 POINTER TO SURGERY DISPOSITION FILE (#131.6) SURGERY DISPOSITION(#131.6)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
  • LAST EDITED:  AUG 21, 2014
  • HELP-PROMPT:  Enter the destination of the patient from the OR and PACU.
  • DESCRIPTION:  
    This is the destination of the patient upon transfer from OR staff care.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive file entries.
.47 PROSTHESIS INSTALLED 1;0 POINTER Multiple #130.01 130.01

  • DESCRIPTION:  This is information related to the prosthesis used for this operative procedure.
.48 TIME TOURNIQUET APPLIED 2;0 DATE Multiple #130.02 130.02

  • LAST EDITED:  JAN 11, 1993
  • DESCRIPTION:  This is information related to the application of a tourniquet.
.52 FINAL COUNTS VERIFY CORRECT .5;1 SET
  • 'Y' FOR CORRECT;
  • 'N' FOR INCORRECT;
  • 'U' FOR UNKNOWN;

  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This is the code corresponding to the status of the final count at the end of the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.522 VERIFIER .5;12 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  DEC 05, 1991
  • HELP-PROMPT:  Enter the name of the verifier.
  • DESCRIPTION:  This is the person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure.
.523 *INST CNT CORRECT .5;10 SET
  • 'Y' FOR CORRECT;
  • 'N' FOR INCORRECT;
  • 'U' FOR UNKNOWN;

  • LAST EDITED:  DEC 29, 1987
  • DESCRIPTION:  Enter the code corresponding to the status of the final instrument count at the end of the surgical procedure.
    This field is marked for deletion.
.525 INST CNT VERF BY .5;11 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  DEC 05, 1991
  • HELP-PROMPT:  Enter the name of the person accountable for the verification of the final instrument count.
  • DESCRIPTION:  This is the name of the person accountable for verification of the final instrument count.
.54 *SURGERY POSITION .5;3 POINTER TO SURGERY POSITION FILE (#132) SURGERY POSITION(#132)

  • LAST EDITED:  OCT 23, 1991
  • HELP-PROMPT:  Enter the position of the patient during the surgery procedure.
  • DESCRIPTION:  This field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.
.55 ELECTROGROUND POSITION .5;4 POINTER TO ELECTROGROUND POSITIONS FILE (#138) ELECTROGROUND POSITIONS(#138)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.55 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the area of placement of the dispersive electrode pad.
  • DESCRIPTION:  This is the code corresponding to the area of placement of the dispersive electrode pad.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.56 FOLEY CATHETER SIZE .5;5 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.56 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 100.
  • DESCRIPTION:  This is the size of the Foley catheter.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.57 FOLEY CATHETER INSERTED BY .5;6 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.57"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person accountable for the insertion of the Foley catheter.
  • DESCRIPTION:  This is the name of the person accountable for insertion of the Foley catheter. Although this information is optional, it may be useful in documentation of this case.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.57"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.61 PREOP TEMPERATURE .6;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>200)!(X<0)!(X?.E1"."2N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.61 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a number between 0 and 200.
  • DESCRIPTION:  This is the most recent ward-recorded temperature of the patient prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.615 PREOP WEIGHT (Kg) .6;10 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>500)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.615 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 500.
  • DESCRIPTION:  This is the most recent ward-recorded weight of the patient prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.62 PREOPERATIVE HEART RATE .6;2 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.62 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 300.
  • DESCRIPTION:  This is the most recent ward-recorded heart rate of the patient prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.63 PREOP BLOOD PRESSURE .6;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.63 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the most recent ward recorded blood pressure of the patient prior to transport to the operating room.
  • DESCRIPTION:  This is the most recent ward recorded blood pressure of the patient prior to transport to the operating room. Although optional, this information may be useful for documentation of this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.64 PREOP RESPIRATORY RATE .6;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>200)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.64 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 200.
  • DESCRIPTION:  this is the most recent ward-recorded respiratory rate of the patient prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.65 FINAL ANESTHESIA TEMP (C) .6;5 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>45)!(X<4)!(X?.E1"."2N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.65 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 4 and 45.
  • DESCRIPTION:  This is the temperature, in degrees centigrade, at the time of the end of anesthesia care.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.66 POSTOP PULSE .6;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.66 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 300.
  • DESCRIPTION:  This is the pulse rate of the patient upon admission to the care area immediately after the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.67 POSTOP BP .6;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.67 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the patient's blood pressure upon admission to the care area immediately after the surgical procedure.
  • DESCRIPTION:  This is the patient's blood pressure upon admission to the care area immediately after the surgical procedure. Although this information is optional, it may be useful in documentation of this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.68 POSTOP RESP .6;8 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.68 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 300.
  • DESCRIPTION:  This is the respiratory rate of the patient upon admission to the care area immediately after the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.69 TIME-OUT DOCUMENT COMPLETED BY .6;9 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,.69"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
  • LAST EDITED:  AUG 20, 2014
  • HELP-PROMPT:  Enter the person confirming that there is valid consent.
  • DESCRIPTION:  
    VASQIP Definition (2014): This is the name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,.69"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
.72 OTHER PREOP DIAGNOSIS 14;0 Multiple #130.17 130.17

  • DESCRIPTION:  This is information related to any diagnosis in addition to the principal preoperative diagnosis.
.74 OTHER POSTOP DIAGS 15;0 Multiple #130.18 130.18

  • LAST EDITED:  OCT 26, 1992
  • DESCRIPTION:  This is information related to any postoperative diagnosis in addition to the principal postoperative diagnosis.
.75 ELECTROCAUTERY UNIT .7;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<2) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.75 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Your answer must be 2-50 characters in length.
  • DESCRIPTION:  This is information identifying the electrosurgical unit utilized during the operative procedure. The information may include, but is not limited to, unit number, ground pad lot number and/or expiration date, coag
    setting, cut setting, blend-BI:Setting and Bipolar BP:Setting. Examples:
    Electrocautery Unit: #7 HP206 COAG:50 CUT:50 BI:1
    Electrocautery Unit: DAISY:18% or DAISY BP:18%
    Electrocautery Unit: VL#2 EXP 3/20/91 COAG:30 CUT:20 BI:2 #2 BP:20
    (VL-VALLEYLAB)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.757 THERMAL UNIT 21;0 Multiple #130.32 130.32

  • DESCRIPTION:  This is information related to the temperature controlling device.
.76 POSTOP SKIN INTEG .7;6 POINTER TO SKIN INTEGRITY FILE (#135.2) SKIN INTEGRITY(#135.2)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.76 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the assessment of the patient's skin integrity after the surgical procedure.
  • DESCRIPTION:  This is the code corresponding to the assessment of the patient's skin integrity after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.77 POSTOP SKIN COLOR .7;7 SET
  • 'A' FOR ASHEN;
  • 'LBR' FOR LIGHT BROWN;
  • 'DBR' FOR DEEP BROWN;
  • 'PI' FOR PINK;
  • 'PA' FOR PALE;
  • 'F' FOR FLUSHED;
  • 'C' FOR CYANOTIC;
  • 'I' FOR ICTERIC;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.77 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the code corresponding to the patient's skin color.
  • DESCRIPTION:  This is the code corresponding to the patient's skin color after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.79 PACU DISPOSITION .7;9 POINTER TO SURGERY DISPOSITION FILE (#131.6) SURGERY DISPOSITION(#131.6)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(DA),$D(X),$P($G(^SRF(DA,"CON")),"^") S SRFLD=.79 D ^SROCON
  • LAST EDITED:  SEP 22, 1994
  • HELP-PROMPT:  Enter the destination of the patient immediately after release from the post-anesthesia care unit.
  • DESCRIPTION:  This is the code corresponding to the destination of the patient immediately after release from the post-anesthesia care unit.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive file entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.81 POSTOP MOOD .8;1 POINTER TO PATIENT MOOD FILE (#135.3) PATIENT MOOD(#135.3)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.81 D ^SROCON Q
  • LAST EDITED:  JUN 02, 1992
  • HELP-PROMPT:  Enter the code corresponding to the assessment of the patient's mood following the surgical procedure.
  • DESCRIPTION:  This is the code corresponding to the assessment of the patient's mood following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.82 POSTOP CONVERS .8;2 SET
  • 'TC' FOR TALKS CONSTANTLY;
  • 'IC' FOR INITIATES CONVERSATION;
  • 'RQ' FOR RESPONDS TO QUESTIONS;
  • 'NA' FOR NOT ANSWER QUESTIONS;
  • 'A' FOR APHASIC;
  • 'D' FOR DYSPHASIC;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.82 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This is the code corresponding to the assessment of the patient's demonstrated verbal responses at the completion of the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.821 POSTOP CONSCIOUS .8;10 POINTER TO PATIENT CONSCIOUSNESS FILE (#135.4) PATIENT CONSCIOUSNESS(#135.4)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.821 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the assessment of the patient's level of consciousness after the surgical procedure.
  • DESCRIPTION:  This is the code corresponding to the assessment of the patient's level of consciousness following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.84 END PULSE .8;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.84 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 300.
  • DESCRIPTION:  This is the patient's pulse rate at the end of the operative procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.85 END BP .8;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.85 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter blood pressure systolic/diastolic.
  • DESCRIPTION:  This is the patient's systolic/diastolic blood pressure at the end of the operative procedure. Although optional, this information may be useful in documentation of this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.86 END RESP .8;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>200)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.86 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a whole number between 0 and 200.
  • DESCRIPTION:  This is the patient's rate of respiration at the end of the operative procedure. This information may be useful in documentation of this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.875 PACKING .8;11 SET
  • 'V' FOR VASOLINE;
  • 'I' FOR IODOFORM;
  • 'P' FOR PLAIN;
  • 'B' FOR BETADINE;
  • 'D' FOR DENTALPACKS;
  • 'O' FOR OTHER;
  • 'N' FOR NONE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.875 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This is the code corresponding to the type of packing placed during the procedure that will remain in place when the patient is discharged from the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.971 PATIENT EDUCATION/ASSESSMENT .97;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;
  • 'U' FOR UNKNOWN;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.971 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether preoperative patient education and assessment, with documentation of a care plan, were completed during the perioperative care of the patient.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.972 CONSENT SIG&WIT .97;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.972 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether there is a properly signed and witnessed operative consent present in the patient's medical record.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.973 BATH & SHAMPOO .97;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.973 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates if the patient's preoperatively prescribed bath and shampoo were completed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.974 REC&XRAY READY .97;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INCOMPLETE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.974 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient's x-rays and records are complete.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.975 ENEMA(S) IF ORD .97;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.975 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the administration of preoperative enema(s) were completed, if ordered.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.976 NPO AS ORD/CLIN MID .97;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.976 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether NPO orders were completed prior to the operative procedure as ordered by the surgeon.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.977 *CLERK CHN DAYS BEFORE .97;7 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  APR 20, 1984
  • HELP-PROMPT:  Enter a whole number between 0 and 100000.
  • DESCRIPTION:  
    This field is not being used and is marked for deletion.
.981 *VERFIFY ID TAG SSN .98;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • LAST EDITED:  APR 18, 1984
  • DESCRIPTION:  This indicates whether the identification bracelet and social security number verification was completed, legal and correct.
    This field has been marked for deletion.
.9811 CARE PLAN IN CHART .98;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9811 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the nursing care plan is present on the patient's medical record prior to transport of the patient into the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.9812 ADDRESS PLATE .98;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9812 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates if the patient's address plate is present on the patient's medical record prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.9813 PATIENT VOIDED .98;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9813 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient voided prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.9814 PREOP MED&RAIL UP .98;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9814 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether preoperative medication was administered and the side rails of the bed were placed in the 'up' position.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.9815 *CLERK CHN DATE PROCEDURE .98;14 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  APR 20, 1984
  • HELP-PROMPT:  Enter a whole number between 0 and 100000.
  • DESCRIPTION:  This field has been marked for deletion. It should not be used.
.982 PROSTHESIS REM .98;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.982 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether prosthetics (dentures, jewelry, hair pieces) have been removed prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.983 CIG, MATCH & VAL REM .98;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.983 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient's tobacco products, matches and valuables have been removed from his or her possession prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.984 VALUABLES SECURED .98;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.984 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient's valuables have been secured according to hospital policy.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.985 ORAL HYGIENE .98;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.985 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient's oral hygiene was completed prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.986 FRESHLY SHAVED .98;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.986 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient's facial hair was freshly shaved prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.987 CLEAN DRESSING .98;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.987 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates if all appropriate wounds have had clean dressings applied prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.988 CLEAN HOSP CLOTH .98;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.988 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient has clean hospital clothing prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.989 LEVIN TUBE/CATH .98;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.989 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether a Levin tube/catheter is present prior to transport to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.991 U/A IN 48 HRS .99;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.991 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient has had a urinalysis within 48 hours prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.9911 *CLERK CHN REC FOR MAJ SURG .99;10 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  APR 20, 1984
  • HELP-PROMPT:  Enter a whole number between 0 and 100000.
  • DESCRIPTION:  This field has been marked for deletion. It should not be used.
.992 CBC IN 48 HRS .99;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.992 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient has had a CBC within 48 hours prior to being transported to the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.993 BLOOD TYPE&XMATCH .99;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.993 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether the patient has had blood typing and crossmatching done.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.994 *BLEEDING & PTT TIME IN 48 HRS .99;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • LAST EDITED:  APR 18, 1984
  • DESCRIPTION:  This indicates whether the patient has had bleed and PTT time within 48 hours prior to being transported to the operating room.
    This field has been marked for deletion in the next version of the Surgery package.
.995 *BUN IN 7 DAYS .99;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • LAST EDITED:  APR 18, 1984
  • DESCRIPTION:  This indicates whether the patient has had a BUN within 7 days prior to being transported to the operating room.
    This field has been marked for deletion in the next version of the Surgery package.
.996 *BLOOD SUGAR IN 7 DAYS .99;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.996 D ^SROCON Q
  • LAST EDITED:  OCT 26, 1992
  • DESCRIPTION:  This field determines whether the patient has had a blood sugar test within the last 7 days. This field has been marked for deletion in the next release of the Surgery software.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.997 *SEROLOGY REPORT .99;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • LAST EDITED:  APR 18, 1984
  • DESCRIPTION:  This field has been marked for deletion. It should not be used.
.998 CHEST XRAY IN 7 DAYS .99;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.998 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This field determines whether the patient has had a chest x-ray within the last seven days.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.999 EKG IN 24 HRS .99;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'I' FOR INAPPLICABLE;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.999 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This field determines whether the patient has had an EKG within the last 24 hours.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.01 REQ ANESTHESIA TECHNIQUE 1.0;1 SET
  • 'L' FOR LOCAL;
  • 'S' FOR SPINAL;
  • 'B' FOR BLOCK;
  • 'G' FOR GENERAL;
  • 'C' FOR CHOICE;
  • 'MAC' FOR MONITORED ANESTHESIA CARE;
  • 'E' FOR EPIDURAL;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.01 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the surgeon's choice for proposed surgery.
  • DESCRIPTION:  This is the surgeon's choice of anesthesia for the proposed operative procedure. This information will appear on the Schedule of Operations.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.02 REQ FROZ SECT 1.0;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.02 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates whether laboratory support is needed to perform frozen section diagnostic tests during the operative procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.03 REQ PREOP X-RAY 1.0;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.03 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Your answer must be 1 to 50 characters in length.
  • DESCRIPTION:  These are the types of preop x-ray films and reports required for delivery to the operating room prior to the surgical procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.035 INTRAOPERATIVE X-RAYS 1.0;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'C' FOR C-ARM;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.035 D ^SROCON Q
  • LAST EDITED:  APR 19, 1993
  • DESCRIPTION:  This indicates if radiology personnel is needed in the operating room for intraoperative radiologic procedures.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.04 REQ PHOTO 1.0;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.04 D ^SROCON Q
  • LAST EDITED:  NOV 16, 1992
  • DESCRIPTION:  This indicates whether Medical Media personnel need to be present in the operating room to obtain photographs during the operative procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.05 REQ BLOOD KIND 11;0 Multiple #130.14 130.14

  • DESCRIPTION:  This is information related to the blood product required during this operative procedure.
1.052 REQ BLOOD AVAIL 1.0;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.052 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter 'Y' if the blood components are available as requested.
  • DESCRIPTION:  This indicates whether the requested blood components are available.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.09 WOUND CLASSIFICATION 1.0;8 SET
  • 'C' FOR CLEAN;
  • 'CC' FOR CLEAN/CONTAMINATED;
  • 'D' FOR CONTAMINATED;
  • 'I' FOR DIRTY/INFECTED;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=1.09 D ^SROCON Q
  • LAST EDITED:  JUN 22, 2015
  • HELP-PROMPT:  Enter the code corresponding to the classification of the wound in relationship to the contamination and increasing risk of infection at the time of completion of the surgical procedure.
  • DESCRIPTION:  Definition Revised (2007): Indicate whether the wound has been classified by the primary surgeon as:
    >> Class 1 - Clean (C): Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed
    drainage. Surgical incisional wounds that occur with nonpenetrating (eg blunt) trauma should be included in this category if they meet the criteria.
    [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.]
    Examples:
    - Exploratory laparotomy
    - Mastectomy or breast reduction
    - Neck dissection
    - Nonpenetrating blunt trauma
    - Thyroidectomy
    - Total hip replacement
    - Vascular operations (e.g. AAA, AV fistula, CEA, aortoiliac bypass)
    - Hernia repair
    - CABG, AVR
    - Craniotomy, majority neurosurgery
    - Pleura biopsy
    - Sternotomy
    - Abdominoplasty
    - Bone anchored hearing aids (BAHA)
    - Penile prosthesis placement
    - Dupuytren's release, finger
    - Liposuction
    - Carpal tunnel release
    - Hydrocele repair
    >> Class 2 - Clean/Contaminated (CC): Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract,
    appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered.
    (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.)
    Examples:
    - Bronchoscopy
    - Routine appendectomy
    - Cholecystectomy (e.g., any approach)
    - Laryngectomy
    - Small bowel resection
    - Oropharynx entered
    - GYN procedures
    - Vagina entered
    - Whipple pancreaticoduodenectomy
    - Pulmonary resection
    - Transurethral resection of prostate
    - Head & Neck cancer operations (e.g., oropharynx)
    - Sigmoid colectomy
    - Minor break in technique
    - Gastrointestinal or respiratory tract entered without significant
    spillage
    - Genitourinary tract entered in absence of infected urine
    >> Class 3 - Contaminated (D): Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and
    incisions in which acute, nonpurulent inflammation is encountered are included in this category.
    Examples:
    - Appendectomy for gangrenous appendicitis
    - Bile spillage during cholecystectomy
    - Diverticulitis
    - Laparotomy for penetrating injury with intestinal spillage
    - Entrance of genitourinary or biliary tracts in presence of infected
    urine or bile
    - Necrotic tissue without evidence of purulent drainage (e.g. dry
    gangrene)
    >> Class 4 - Dirty/Infected (I): Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing
    postoperative infection were present in the surgical field before the procedure.
    (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.)
    Examples:
    - Excision and drainage of abscess
    - Myringotomy for otitismedia
    - Perforated bowel
    - Peritonitis (abdominal exploration for acute bacterial peritonitis)
    - Acute bacterial inflammation, without pus
    - Transection of 'clean' tissue for the purpose of surgical access to
    a collection of pus
    - Traumatic wound with foreign bodies, fecal contamination, or delayed
    treatment, or all of these; or from dirty source
  • SCREEN:  S DIC("S")="N SRZ S SRZ=1 S:(Y=""C""&($$WOND^SROUTL1(Y))) SRZ=0 I SRZ"
  • EXPLANATION:  Screen "CLEAN" if planned CPT matches one of the CPTs that cannot be classified as clean.
1.098 DATE/TIME OR REQUEST MADE 1.0;11 DATE

  • INPUT TRANSFORM:  S %DT="ETX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  SEP 05, 1990
  • DESCRIPTION:  This is the date and time that the operation request was made. This information is automatically entered at the time of request. If the request date is changed, this field will be updated to reflect the new date/time
    requested.
    UNEDITABLE
1.099 SURG SCHED PERSON 1.0;10 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  DEC 05, 1991
  • DESCRIPTION:  This is the name of the person requesting or scheduling this operative procedure.
1.11 PAC(U) ADMIT SCORE 1.1;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.11 D ^SROCON Q
  • LAST EDITED:  MAR 22, 1996
  • HELP-PROMPT:  Enter a number between 0 and 100, 2 decimal digits.
  • DESCRIPTION:  This is the objective evaluation numerical score of the patient upon admission to the post anesthesia care unit.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.12 PAC(U) DISCH SCORE 1.1;2 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.12 D ^SROCON Q
  • LAST EDITED:  MAR 22, 1996
  • HELP-PROMPT:  Enter a number between 0 and 100, 2 decimal digits. Use the objective discharge criteria score.
  • DESCRIPTION:  This is the objective evaluation numeric score of the patient at discharge from the post anesthesia care unit.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.13 ASA CLASS 1.1;3 POINTER TO ASA CLASS FILE (#132.8) ASA CLASS(#132.8)

  • INPUT TRANSFORM:  I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=1.13 D ^SROCON Q
  • OUTPUT TRANSFORM:  S Y=$S(Y["E":$P(^SRO(132.8,$E(Y)+6,0),"^",2),Y:$P(^SRO(132.8,Y,0),"^",2),Y="N":$P(^SRO(132.8,13,0),"^",2),1:Y)
  • LAST EDITED:  JUN 28, 2010
  • HELP-PROMPT:  Select ASA code: Number followed by 'E' if Emergency.
  • DESCRIPTION:  VASQIP Definition (2010): Record the American Society of Anesthesiology (ASA) Physical Status Classification of the patient's present physical condition on a scale from 1-6 as it appears on the anesthesia record. Most
    likely there will be a 2nd assessment of the ASA class prior to anesthesia induction. If this is available, report this most recent assessment. The definitions are:
    ASA 1 - A normal healthy patient
    ASA 2 - A patient with mild systemic disease
    ASA 3 - A patient with severe systemic disease
    ASA 4 - A patient with severe systemic disease that is a constant
    threat to life
    ASA 5 - A moribund patient who is not expected to survive without
    the operation
    ASA 6 - A declared brain-dead patient whose organs are being
    removed for donor purposes
    ASA 6 cases should be excluded.
    Classification numbers followed by an 'E' indicate an emergency.
    Select N for NONE ASSIGNED if no ASA Class is assigned for this patient.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.14 INTRAOPERATIVE OCCURRENCES 10;0 Multiple #130.13 130.13

  • LAST EDITED:  MAR 30, 1992
  • DESCRIPTION:  This is information related to any intraoperative occurrences. If there are no occurrences, leave this field blank. 'NONE' is not an acceptable answer.
1.145 RETURNED TO SURGERY 29;0 POINTER Multiple #130.43 130.43

  • DESCRIPTION:  This is information related to the patient's return to surgery within 30 days of a prior operative procedure.
1.15 SURGEON'S DICTATION 12;0 WORD-PROCESSING #130.15

  • DESCRIPTION:  This is the Surgeon's dictated operation note.
1.16 POSTOP OCCURRENCE 16;0 Multiple #130.22 130.22

  • DESCRIPTION:  This is information related to postoperative occurrences.
1.17 ADMIT PAC(U) TIME 1.1;7 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=12,SR130="TIME PAT OUT OR" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.17 D ^SROCON Q
  • LAST EDITED:  JAN 09, 1998
  • DESCRIPTION:  This is the date/time that the patient was admitted to the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.18 PAC(U) DISCH TIME 1.1;8 DATE

  • INPUT TRANSFORM:  N SRN,SRP,SR130,SRFLD S SRN=1.1,SRP=7,SR130="ADMIT PAC(U) TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.18 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • DESCRIPTION:  This is the date/time that the patient is discharged from the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.
    Non-Cardiac Definition Revised (2004): Discharge from Post-Anesthesia Care Unit (DPACU): Time patient is transported out of PACU.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.19 POSTOP ANES NOTE DATE 1.1;9 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=3,SR130="TIME OPERATION ENDS" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.19 D ^SROCON Q
  • LAST EDITED:  OCT 23, 2000
  • DESCRIPTION:  This is the date and time that the postoperative note is written in the patient's chart. Times entered without a date will be converted to the date of operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
1.2 POSTOP ANES NOTE 48;0 WORD-PROCESSING #130.1

  • DESCRIPTION:  
    This is the postoperative anesthesia note for this patient.
1.21 OPERATION TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.21,9.2) S X1=Y(130,1.21,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.21,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.21,1),U,3),Y(130,1.21,2)=X S X=$P(Y(130,1.21,1),U,2)
  • ALGORITHM:  MINUTES(TIME OPERATION ENDS,TIME OPERATION BEGAN)
  • LAST EDITED:  SEP 26, 1991
  • DESCRIPTION:  This is the number of minutes between the operation start and end times.
1.22 ANESTH INDUCT TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.22,9.2) S X1=Y(130,1.22,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.22,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.22,1),U,11),Y(130,1.22,2)=X S X=$P(Y(130,1.22,1),U,1)
  • ALGORITHM:  MINUTES(INDUCTION COMPLETE,ANES CARE START TIME)
  • DESCRIPTION:  This is the total number of minutes between the anesthesia care start and induction complete times.
1.23 ANES CARE TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.23,9.2) S X1=Y(130,1.23,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.23,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.23,1),U,4),Y(130,1.23,2)=X S X=$P(Y(130,1.23,1),U,1)
  • ALGORITHM:  MINUTES(ANES CARE END TIME,ANES CARE START TIME)
  • LAST EDITED:  NOV 20, 1984
  • DESCRIPTION:  This is the number of minutes between the anesthesia care start time and anesthesia care end time.
1.24 PATIENT IN OR TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.24,9.2) S X1=Y(130,1.24,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.24,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.24,1),U,12),Y(130,1.24,2)=X S X=$P(Y(130,1.24,1),U,10)
  • ALGORITHM:  MINUTES(TIME PAT OUT OR,TIME PAT IN OR)
  • DESCRIPTION:  This is the number of minutes the patient was in the operating room.
1.25 OR CLEAN UP TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.25,9.2) S X1=Y(130,1.25,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.25,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.25,1),U,14),Y(130,1.25,2)=X S X=$P(Y(130,1.25,1),U,13)
  • ALGORITHM:  MINUTES(OR CLEAN END TIME,OR CLEAN START TIME)
  • DESCRIPTION:  This is the number of minutes between the OR clean up start time and OR clean up end time.
1.26 PAC(U) TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,1.26,9.2) S X1=Y(130,1.26,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,1.26,1)=$S($D(^SRF(D0,1.1)):^(1.1),1:"") S X=$P(Y(130,1.26,1),U,8),Y(130,1.26,2)=X S X=$P(Y(130,1.26,1),U,7)
  • ALGORITHM:  MINUTES(PAC(U) DISCH TIME,ADMIT PAC(U) TIME)
  • DESCRIPTION:  This is the number of minutes the patient spent in the PAC(U).
4 SKIN PREPPED BY (2) .1;12 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,4"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the second person performing the preop skin preparation, if appropriate.
  • DESCRIPTION:  This is the name of a second person performing skin preparation, if applicable. When entered, this information appears on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,4"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
5 SKIN PREPPED BY (3) .1;17 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,5"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person performing the preop skin preparation.
  • DESCRIPTION:  This is the name of the third person performing the preoperative skin preparation. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,5"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locallly selected keys.
6 ELECTROGROUND POSITION (2) .5;13 POINTER TO ELECTROGROUND POSITIONS FILE (#138) ELECTROGROUND POSITIONS(#138)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=6 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the code corresponding to the placement of the second dispersive electrode pad.
  • DESCRIPTION:  This is the code corresponding to the placement of the second dispersive electrode pad.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
7 DRESSING CONDITION 31;1 SET
  • 'D' FOR DRY;
  • 'S' FOR SEROSANGUINOUS;
  • 'SA' FOR SANGUINOUS;
  • 'N' FOR NO DRESSING;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=7 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter the status of the drainage on the dressing.
  • DESCRIPTION:  This is the status of the drainage on the dressing. Although optional, this information may be useful in documentation of this case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
8 SECOND SKIN PREP AGENT 31;2 POINTER TO SKIN PREP AGENTS FILE (#135.1) SKIN PREP AGENTS(#135.1)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=8 D ^SROCON Q
  • LAST EDITED:  JUN 03, 1992
  • HELP-PROMPT:  Enter the name of the 2ND antimicrobial agent used to wash and prepare the operative site.
  • DESCRIPTION:  This is the name of the SECOND antimicrobial agent used to wash and prepare the operative site. Although optional, this information may be useful in documentation of the case.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
9 TIME NURSE OUT OF OR 31;3 DATE

  • INPUT TRANSFORM:  S SRN=.2,SRP=7,SR130="NURSE PRESENT TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=9 D ^SROCON Q
  • LAST EDITED:  JAN 09, 1998
  • DESCRIPTION:  This is the date and time that the circulating nurse completed duties for the operative procedure and left the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
10 SCHEDULED START TIME 31;4 DATE

  • INPUT TRANSFORM:  S %DT="ETR" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 28, 2011
  • HELP-PROMPT:  Enter the Scheduled Start Time.
  • DESCRIPTION:  This is the date and time that this operative procedure is scheduled to begin.
  • CROSS-REFERENCE:  130^AM2^MUMPS
    1)= D AM2^SROXR2
    2)= D KILLAM2^SROXR2
    The AM2 cross reference on the SCHEDULED START TIME field resets the AMM cross reference for the case when the scheduled start time is edited.
  • CROSS-REFERENCE:  ^^TRIGGER^130^614
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,3)="" I X S X=DIV S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,3),X=X S DIU=X K Y S X=DIV S X=DIV,X=$P(X,".",1) X ^DD(13
    0,10,1,2,1.4)
    1.4)= S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,3)=DIV,DIH=130,DIG=614 D ^DICR
    2)= Q
    CREATE CONDITION)= #614=""
    CREATE VALUE)= DATE(SCHEDULED START TIME)
    DELETE VALUE)= NO EFFECT
    FIELD)= #614
    If the SCHEDULED START TIME field (#10) is set for the first time, then the ORIGINAL SCHEDULED DATE field (#614) will be set.
  • CROSS-REFERENCE:  ^^TRIGGER^130^617
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,6),X=X S DIU=X K Y S X=DIV S X=DIV,X=$P(X,".",1) S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,6)=DIV,DIH=130,DIG=617 D ^DICR
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,6),X=X S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,6)=DIV,DIH=130,DIG=617 D ^DICR
    CREATE VALUE)= DATE(SCHEDULED START TIME)
    DELETE VALUE)= @
    FIELD)= #617
    This trigger is responsible for updating the SCHEDULED DATE field (#617) whenever the SCHEDULED START TIME field (#10) is updated.
  • RECORD INDEXES:  AD (#196)
11 SCHEDULED END TIME 31;5 DATE

  • INPUT TRANSFORM:  S %DT="ETR" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  NOV 22, 2002
  • DESCRIPTION:  This is the date and time that this operative procedure is scheduled to end.
  • CROSS-REFERENCE:  130^AMM^MUMPS
    1)= D AMM^SROXR2
    2)= D KILLAMM^SROXR2
    The AMM cross reference on the SCHEDULED END TIME field sets the AMM cross reference for the case if the operating room and the scheduled start time are defined.
  • RECORD INDEXES:  AD (#196)
12 IN OR TO ANES START COMPUTED

  • MUMPS CODE:  X ^DD(130,12,9.2) S X1=Y(130,12,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,12,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,12,1),U,1),Y(130,12,2)=X S X=$P(Y(130,12,1),U,10)
  • ALGORITHM:  MINUTES(ANES CARE START TIME,TIME PAT IN OR)
  • DESCRIPTION:  This is the number of minutes between the time anesthesia care began and time that the patient left the operating room.
13 ANES START TO OP START COMPUTED

  • MUMPS CODE:  X ^DD(130,13,9.2) S X1=Y(130,13,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,13,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,13,1),U,2),Y(130,13,2)=X S X=$P(Y(130,13,1),U,1)
  • ALGORITHM:  MINUTES(TIME OPERATION BEGAN,ANES CARE START TIME)
  • DESCRIPTION:  This is the number of minutes between the time that anesthesia care started and time that the operation began.
14 IN OR TO OP START TIME COMPUTED

  • MUMPS CODE:  X ^DD(130,14,9.2) S X1=Y(130,14,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
    9.2 = S Y(130,14,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,14,1),U,2),Y(130,14,2)=X S X=$P(Y(130,14,1),U,10)
  • ALGORITHM:  MINUTES(TIME OPERATION BEGAN,TIME PAT IN OR)
  • DESCRIPTION:  This is the time between the time the patient enters the operating room to the operation start time.
15 DATE/TIME OF DICTATION 31;6 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  DEC 13, 1993
  • DESCRIPTION:  This is the date and time that dictation of the operative summary was completed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
17 CANCEL DATE 30;1 DATE

  • INPUT TRANSFORM:  S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  AUG 20, 1992
  • HELP-PROMPT:  Enter the date and time on which this case was cancelled.
  • DESCRIPTION:  This is the date and time that the operative procedure was canceled.
17.5 CANCELLATION TIMEFRAME 30;5 SET
  • '1' FOR SURGERY CANCELLED <48 HRS BEFORE SCHEDULED SURGERY;
  • '2' FOR SURGERY CANCELLED >48 HRS BEFORE SCHEDULED SURGERY;

  • LAST EDITED:  MAR 03, 2014
  • HELP-PROMPT:  Select the response that appropriately fits the cancellation timeframe.
  • DESCRIPTION:  
    VASQIP Definition (2014): This indicates when the surgery was cancelled; either less than 48 hours prior to the scheduled surgery time or more than 48 hours prior to the scheduled surgery time.
18 PRIMARY CANCEL REASON 31;8 POINTER TO SURGERY CANCELLATION REASON FILE (#135) SURGERY CANCELLATION REASON(#135)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,4)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the reason why this scheduled case was cancelled.
  • DESCRIPTION:  VASQIP Definition (2014): This is the reason that this surgical case was cancelled. List of valid reasons:
    1) Patient Related Issue (e.g., patient did not follow pre-surgery
    instructions, patient chooses to cancel for any reason) 2) Environmental Issue (OR availability impacted by e.g., air
    handling, electrical outage, emergency construction, flood, tornado,
    blizzard, hurricane causing OR hospital closure. If due to staff
    availability, use #3) 3) Staff Issue (e.g., unavailable surgeon, anesthesia or nursing
    staff; no documented consent, provider cancels due to change in
    patient treatment plan) 4) Patient Health Status (Provider cancels due to change in patient
    health status) 5) More clinically urgent/emergent case superseded this scheduled
    case 6) Scheduling Issues Not Created By An Emergency Case (previous case
    overtime, case delayed, double booked, general time constraints,
    administrative scheduling error) 7) Unavailable Bed 8) Unavailable Equipment [excluding RME] (e.g.,
    vendor, c-arm, implant, malfunctioning equipment) 9) Unavailable Reusable Medical Equipment (RME) (includes defective
    packaging, damaged instruments or failure of Sterile Processing
    Services [SPS] to provide reprocessed equipment in a timely manner) 10) Patient scheduled into an earlier date for surgery.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,4)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^ACAN^MUMPS
    1)= D CAN^SROXR4
    2)= D KCAN^SROXR4
    The ACAN cross reference on the CANCEL REASON field functions to stuff for the CANCEL REASON the default CANCELLATION AVOIDABLE (Y or N) as defined in the SURGERY CANCELLATION REASON file. It also stuffs the CANCELLED BY
    field with the user if not already defined.
18.5 CASE ABORTED 30;6 SET
  • '1' FOR NO;
  • '2' FOR YES-PRE ANESTHESIA;
  • '3' FOR YES-POST ANESTHESIA;

  • LAST EDITED:  JUN 08, 2015
  • HELP-PROMPT:  Enter Case Aborted flag.
  • DESCRIPTION:  Any medication or intervention, other than a peripheral IV, performed by anesthesia is considered post-anesthesia. This includes any anesthesia or intervention performed by anesthesia staff in the preoperative holding
    area.
19 CANCELLATION COMMENTS 30;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
  • LAST EDITED:  APR 20, 2011
  • HELP-PROMPT:  Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    This is the cancellation comments field. If "OTHER" is selected for the CANCEL REASON field (#18), the user will be prompted to enter a comment in this field.
20 DIAGNOSTIC/THERAPEUTIC (Y/N) 31;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=20 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This indicates if the anesthesia technique is an anesthesia diagnostic/ therapeutic procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
21 WAIT TIME START 31;11 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  AUG 28, 2007
  • HELP-PROMPT:  This is the start of the patient's "wait" for Surgery.
  • DESCRIPTION:  
    This is start of the patient's "wait" for Surgery. Typically, this is the date that the patient was notified that Surgery is needed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
22 TUBES AND DRAINS 3;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=22 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Answer must be 1 to 80 characters in length.
  • DESCRIPTION:  This is the type and placement of tubes and drains during the operative process.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
23 REFERRING PHYSICIAN 18;0 Multiple #130.03 130.03

  • DESCRIPTION:  This is information related to the referring physician.
24 LOCK CASE LOCK;1 SET
  • '1' FOR LOCKED;
  • '0' FOR UNLOCKED;

  • LAST EDITED:  MAR 12, 1992
  • HELP-PROMPT:  This field will be equal to 1 if the case has been completed and locked, or 0 if it is still open.
  • DESCRIPTION:  This indicates whether this case has been completed and locked. Locked cases can only be edited if unlocked by the Chief of Surgery or his or her designee.
  • CROSS-REFERENCE:  130^AL^MUMPS
    1)= K ^SRF("AL",DA)
    2)= S ^SRF("AL",DA)=""
    The AL cross reference on the LOCK CASE field uses reverse set and kill logic to flag cases that have been locked, then unlocked. The cross reference for the case is set when the field is deleted and is killed when the
    field is set.
25 DISCHARGED VIA .7;4 POINTER TO SURGERY TRANSPORTATION DEVICES FILE (#131.01) SURGERY TRANSPORTATION DEVICES(#131.01)

  • INPUT TRANSFORM:  S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=25 D ^SROCON Q
  • LAST EDITED:  JUN 02, 1992
  • HELP-PROMPT:  Enter the mode of transport used to take patient from the care area.
  • DESCRIPTION:  This is the code corresponding to the mode of transport used to move the patient from the care area.
  • SCREEN:  S DIC("S")="I '$P(^(0),U,3)"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
26 PRINCIPAL PROCEDURE OP;1 FREE TEXT
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:$L(X)>135!($L(X)<3) X D:$D(X) PROC^SROPROC,PCPTASO^SROADX2(0) K:$G(X)="" X
  • LAST EDITED:  JAN 03, 2011
  • HELP-PROMPT:  Your answer must be 3-135 characters in length and must not contain an up-arrow (^).
  • DESCRIPTION:  This is the name of the principal procedure for this case. All cases must have a principal procedure.
    The principal procedure must be 3 to 135 characters in length. The procedure name must not contain a semicolon (;), an at-sign (@), an up- arrow (^) or control characters. If the procedure name is longer than 30
    characters, it must contain at least one space in every 31 characters of length. If a comma is being used to separate information, a space should follow the comma.
    Non-Cardiac Definition Revised (2004): The most complex of all the procedures by the primary operating team during this trip to the operating room. Your answer must be at least 3 characters in length. Do not enter an
    additional procedure if it is covered by a single CPT code. (Note that a single CPT code can cover more than one procedure, e.g., cholecystectomy and common bile duct exploration have a single CPT code). Additional
    procedures requiring separate CPT codes and/or concurrent procedures will be entered separately below. An exploratory laparotomy should be entered as the principal operative procedure only when no other procedure eligible
    for assessment has been performed in that particular surgical case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • RECORD INDEXES:  AD (#196)
27 PLANNED PRIN PROCEDURE CODE OP;2 POINTER TO CPT FILE (#81) CPT(#81)

  • INPUT TRANSFORM:  D IN^SROCPT S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA):DA,1:""""),+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X K:'$$CHK^SROCPT($G(X)) X D PCPTASO^SROADX2(1) K:$G(X)="" X
  • OUTPUT TRANSFORM:  D DISPLAY^SROCPT
  • LAST EDITED:  JUN 22, 2015
  • HELP-PROMPT:  Enter the planned CPT code for the principal procedure.
  • DESCRIPTION:  This is the Current Procedural Terminology (CPT) code corresponding with the planned principal procedure. A CPT modifier on the CPT code may be included by appending the modifier to the CPT code separated by a hyphen in
    the format "XXXXX-YY" where "XXXXX" is the five character CPT code and "YY" is the two character CPT modifier.
  • SCREEN:  S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA):DA,1:""""),+Y)"
  • EXPLANATION:  Screen out Inactive Codes
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^ACPT^MUMPS
    1)= D SPRIN^SROMOD
    2)= D KPRIN^SROMOD
    This MUMPS cross reference provides for updating CPT modifiers for the principal procedure code. CPT modifiers for the PRINCIPAL PROCEDURE CODE field (#27) are stored in the PRIN. PROCEDURE CPT MODIFIER field (#.01) of
    the PRIN. PROCEDURE CPT MODIFIER multiple field (#28) in SURGERY file (#130).
    After selecting a CPT code, this cross reference prompts the user for a CPT modifier. If a CPT modifier was entered concatenated with a hyphen to the CPT code, this CPT modifier is displayed as a default modifier. Upon
    entering a CPT modifier, the user is prompted for another CPT modifier until the user makes a null entry. CPT modifier input is controlled by the input transform on the PRIN. PROCEDURE CPT MODIFIER field (#28). At the CPT
    modifier prompt, the user may to enter a question mark (?) to see a list of CPT modifiers already entered and a list of acceptable CPT modifiers to choose from. If the user selects a modifier already entered, the user may
    change or delete the modifier. If a user enters a new CPT code, replacing a previously entered CPT code, KILL logic on the ACPT cross reference deletes any previously entered CPT modifiers for the old CPT code before the
    SET logic prompts the user to enter CPT modifiers for the new CPT code.
  • RECORD INDEXES:  AD (#196)
27.5 PRIN ASSOC DIAGNOSIS PADX;0 Multiple #130.275 130.275

  • LAST EDITED:  FEB 27, 2004
  • DESCRIPTION:  
    This Surgery sub-file is used to store the Procedure/Diagnosis association data.
28 PRIN. PROCEDURE CPT MODIFIER OPMOD;0 POINTER Multiple #130.028 130.028

  • LAST EDITED:  FEB 23, 1999
  • INDEXED BY:  PRIN. PROCEDURE CPT MODIFIER (AC)
29 *PROCEDURE COMPLETED OP;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 17, 1987
  • DESCRIPTION:  This indicates whether the principal operative procedure was completed.
    This field has been marked for deletion.
30 OTHER SCRUBBED ASSISTANTS 28;0 POINTER Multiple #130.23 130.23

  • DESCRIPTION:  This is information about other persons in the operating room in addition to those already listed as scrubbed.
31 OTHER PERSONS IN OR 32;0 Multiple #130.24 130.24

  • DESCRIPTION:  This is information related to other persons, not scrubbed or otherwise identified, present in the operating room.
32 PRINCIPAL PRE-OP DIAGNOSIS 33;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0)
  • LAST EDITED:  OCT 06, 2003
  • HELP-PROMPT:  Your answer must be 1 to 40 characters in length.
  • DESCRIPTION:  
    This is the preoperative diagnosis for which the surgical procedure is being performed.
  • DELETE TEST:  1,0)= I 1 D EN^DDIOL("The PRINCIPAL PRE-OP DIAGNOSIS can't be deleted.",,"!!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  ^^TRIGGER^130^34
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,34)):^(34),1:"") S X=$P(Y(1),U,1),X=X S DIU=X K Y S X=DIV S X=DIV X ^DD(130,32,1,1,1.4)
    1.4)= S DIH=$S($D(^SRF(DIV(0),34)):^(34),1:""),DIV=X S %=$P(DIH,U,2,999),DIU=$P(DIH,U,1),^(34)=DIV_$S(%]"":U_%,1:""),DIH=130,DIG=34 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,34)):^(34),1:"") S X=$P(Y(1),U,1),X=X S DIU=X K Y X ^DD(130,32,1,1,2.1) X ^DD(130,32,1,1,2.4)
    2.1)= S X=DIV S Y(1)=$S($D(^SRF(D0,33)):^(33),1:"") S X=$P(Y(1),U,1)
    2.4)= S DIH=$S($D(^SRF(DIV(0),34)):^(34),1:""),DIV=X S %=$P(DIH,U,2,999),DIU=$P(DIH,U,1),^(34)=DIV_$S(%]"":U_%,1:""),DIH=130,DIG=34 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
    CREATE VALUE)= PRINCIPAL PRE
    DELETE VALUE)= PRINCIPAL PRE
    FIELD)= PRINCIPAL PO
    This trigger on the PRINCIPAL PRE-OP DIAGNOSIS field stuffs the PRINCIPAL POST-OP DIAGNOSIS field with what is entered as the PRINCIPAL PRE-OP DIAGNOSIS.
  • CROSS-REFERENCE:  130^DADX1^MUMPS
    1)= Q
    2)= D DELASOC^SROADX2
    This cross reference removes associations from diagnosis being deleted.
32.5 PRIN PRE-OP ICD DIAGNOSIS CODE 34;3 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • LAST EDITED:  MAR 11, 2014
  • HELP-PROMPT:  Enter the ICD Diagnosis code for the principal Pre-OP diagnosis.
  • DESCRIPTION:  
    This is the principal Pre-OP ICD diagnosis code. It should be entered for all cases.
  • SCREEN:  S DIC("S")="I $P(^(0),""^"",9)'=1"
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AM^MUMPS
    1)= S $P(^SRF(DA,34),"^",2)=X
    2)= Q
    This cross reference stuffs the current value of the PRIN PRE-OP ICD DIAGNOSIS CODE field (#32.5) into the PRIN DIAGNOSIS CODE field (#66).
33 PRINCIPAL DIAGNOSIS 33;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0) K:$G(X)="" X
  • LAST EDITED:  OCT 06, 2003
  • HELP-PROMPT:  Answer must be 1-40 characters in length.
  • DESCRIPTION:  
    This is the principal diagnosis for which the non-OR procedure is being performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^PADX1^MUMPS
    1)= Q
    2)= D PRINASOD^SROADX2
    THIS CROSS REFERENCE REMOVES ASSOCIATIONS TO PROCEDURES UPON EDITS OR DELETES OF THE DIAGNOSIS.
34 PRINCIPAL POST-OP DIAG 34;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0) K:$G(X)="" X
  • LAST EDITED:  OCT 06, 2003
  • HELP-PROMPT:  Your answer must be 1 to 40 characters in length.
  • DESCRIPTION:  
    This is the principal postoperative diagnosis.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
    TRIGGERED by the PRINCIPAL PRE-OP DIAGNOSIS field of the SURGERY File
35 CONCURRENT CASE CON;1 POINTER TO SURGERY FILE (#130) SURGERY(#130)

  • LAST EDITED:  MAR 24, 2011
  • DESCRIPTION:  Definition Revised (2004): An additional operative procedure performed by a different surgical team (i.e., a different specialty/service) under the same anesthetic which has a CPT code different from that of the Principal
    Operative Procedure (e.g., fixation of a femur fracture in a patient undergoing a laparotomy for trauma). This field should be verified and, if need be, edited postoperatively by the Nurse Reviewer in accordance with the
    official operating room log.
  • RECORD INDEXES:  AD (#196)
36 REQUESTED REQ;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  DEC 15, 1987
  • HELP-PROMPT:  Enter '1' if this case has been requested.
  • DESCRIPTION:  This indicates whether this case was requested.
37 ESTIMATED CASE LENGTH .4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>7!($L(X)<1)!'(X?.N1":"2N)!($P(X,":",2)>59) X
  • LAST EDITED:  OCT 02, 1992
  • HELP-PROMPT:  Enter the estimated amount of time to perform this procedure.
  • DESCRIPTION:  This is the amount of time estimated to perform this operative procedure. Your answer should be in the format of "HOURS:MINUTES". For example, if the procedure will last 2 and 1/2 hours, your answer would be 2:30.
  • TECHNICAL DESCR:  
    This field may be stuffed with an answer by using the routine ^SRSAVG. The routine ^SRSAVG calculates the average length of time based on information from previous cases using the surgical specialty and CPT Code.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
38 REQUEST BLOOD AVAILABILITY 0;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  DEC 30, 1991
  • HELP-PROMPT:  Enter 'YES' if you want to request blood for this procedure.
  • DESCRIPTION:  This determines whether blood will be requested for this surgical procedure. Enter 'YES' if blood will be requested. Otherwise, enter 'NO'.
  • TECHNICAL DESCR:  This field determines whether blood will be requested. If answered 'YES', you will then be prompted for the fields CROSSMATCH, SCREEN, OR AUTOLOGOUS, and REQUESTED BLOOD KIND.
39 DATE OF TRANSCRIPTION 31;7 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 14, 1988
  • DESCRIPTION:  This is the date and time that transcription of the operative summary was completed.
40 CROSSMATCH, SCREEN, AUTOLOGOUS 0;13 SET
  • 'T' FOR TYPE & CROSSMATCH;
  • 'S' FOR SCREEN;
  • 'A' FOR AUTOLOGOUS;

  • LAST EDITED:  DEC 30, 1991
  • HELP-PROMPT:  Enter whether the blood requested is type and crossmatched, screened, or autologous.
  • DESCRIPTION:  This determines whether the requested blood will be typed and crossmatched, screened, or autologous.
  • TECHNICAL DESCR:  This will determine whether the requested blood is screened, type and crossmatched, or autologous. If Typed and crossmsatched, you will then be prompted for the requested blood kind and units.
41 DRESSING 35;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>100!($L(X)<1) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the dressing(s) used for this case. Answer must be 1-100 characters in length.
  • DESCRIPTION:  
    These are the dressing(s) used for this case. Although optional, this information may be useful in documentation of this case.
42 DELAY CAUSE 17;0 POINTER Multiple #130.042 130.042

  • DESCRIPTION:  This is information related to the reason why this case did not begin at its scheduled start time.
43 CASE VERIFICATION VER;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 14, 1988
  • DESCRIPTION:  This indicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon.
44 SPONGE FINAL COUNT CORRECT 25;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO, SEE NURSING CARE COMMENTS;
  • 'N/A' FOR NOT APPLICABLE;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  SEP 11, 2014
  • HELP-PROMPT:  Enter 'Y' if the final sponge count is correct.
  • DESCRIPTION:  
    This indicates whether the sponge final count was correct. If entered, this information will appear on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="I Y'=""N/A"""
  • EXPLANATION:  Screen prevents selection of inactive code.
  • RECORD INDEXES:  AO (#402)
45 SHARPS FINAL COUNT CORRECT 25;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO, SEE NURSING CARE COMMENTS;
  • 'N/A' FOR NOT APPLICABLE;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  SEP 11, 2014
  • HELP-PROMPT:  Enter 'Y' if the final sharps count is correct.
  • DESCRIPTION:  This indicates whether the sharps final count was correct. If entered, this information will appear on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital
    policy.
  • SCREEN:  S DIC("S")="I Y'=""N/A"""
  • EXPLANATION:  Screen prevents selection of inactive code.
  • RECORD INDEXES:  AO (#402)
46 INSTRUMENT FINAL COUNT CORRECT 25;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO, SEE NURSING CARE COMMENTS;
  • 'N/A' FOR NOT APPLICABLE;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  SEP 11, 2014
  • HELP-PROMPT:  Enter 'Y' if the instrument final count is correct.
  • DESCRIPTION:  This indicates whether the instrument final count was correct for this case. This information appears on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital
    policy.
  • SCREEN:  S DIC("S")="I Y'=""N/A"""
  • EXPLANATION:  Screen prevents selection of inactive code.
  • RECORD INDEXES:  AO (#402)
47 SPONGE, SHARPS, & INST COUNTER 25;4 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,47"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person doing the final counts.
  • DESCRIPTION:  This is the name of the person doing the final count of sponges, sharps and instruments. If entered, this information appears on the Nurse Intraoperative Report.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,47"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
48 COUNT VERIFIER 25;5 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,48"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person verifying the final counts.
  • DESCRIPTION:  This is the name of the person responsible for verifying the final sponge, sharps and instrument counts.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,48"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
49 SPECIMENS 9;0 WORD-PROCESSING #130.049

  • DESCRIPTION:  These are the names of specimens sent to the lab for analysis.
50 DIVISION 8;1 POINTER TO INSTITUTION FILE (#4) INSTITUTION(#4)

  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  This is the name of the institution credited for performing this operative procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
51 PREOP ATTENDING CONCURRENCE 24;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  
    This field serves as a flag that the attending has concurred with the preoperative workup.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
52 POSTOP ATTENDING CONCURRENCE 24;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 23, 1990
  • DESCRIPTION:  
    This field serves as a flag that the attending concurs with the postoperative workup.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
53 NON-OPERATIVE OCCURRENCES 36;0 Multiple #130.053 130.053

  • LAST EDITED:  FEB 26, 1995
  • DESCRIPTION:  These are occurrences that are not related to a surgical procedure. If there are not any non-operative occurrences, leave this field blank. Do not enter 'NO' or 'NONE'.
54 OCCURRENCE/NO PROCEDURE 37;1 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  NOV 18, 1988
  • DESCRIPTION:  This indicates that this case was a occurrence, not related to a surgical procedure.
  • CROSS-REFERENCE:  130^ANON^MUMPS
    1)= S ^SRF("ANON",$P(^SRF(DA,0),"^"),DA)=""
    2)= K ^SRF("ANON",$P(^SRF(DA,0),"^"),DA)
    The ANON cross reference on the OCCURRENCE/NO PROCEDURE field is used to flag cases that have non-operative occurrences entered.
55 INDICATIONS FOR OPERATIONS 40;0 WORD-PROCESSING #130.055

  • DESCRIPTION:  This is a brief statement of the indications for this operative procedure. The information you enter here prints automatically as the first part of the operative summary.
56 PRE-ADMISSION TESTING 35;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=56 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Answer 'YES' if pre-admission testing was complete.
  • DESCRIPTION:  This indicates whether pre-admission testing was complete. It will be reflected on the Schedule of Operations for outpatients.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
57 ESU COAG RANGE .7;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=57 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
  • DESCRIPTION:  This is the power setting range on the Electrosurgical Unit during coagulation. This information is optional, but may be useful in documenting the case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
58 ESU CUTTING RANGE .7;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=58 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Answer must be 1-30 characters in length.
  • DESCRIPTION:  This is the power setting range on the Electrosurgical Unit during cutting. This information is optional, but may be useful in documenting the case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
59 OPERATIVE FINDINGS 38;0 WORD-PROCESSING #130.059

  • DESCRIPTION:  This field contains a brief description of the operative findings which appears on the Tissue Examination Report.
60 BRIEF CLIN HISTORY 39;0 WORD-PROCESSING #130.09

  • DESCRIPTION:  This field contains a brief clinical history for this patient. It will appear on the Tissue Examination Report.
61 DIAGNOSTIC RESULTS CONFIRM BY .6;11 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,61"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  NOV 06, 1992
  • HELP-PROMPT:  Enter the name of the person verifying diagnostic procedure requirements.
  • DESCRIPTION:  This is the name of the person responsible for verifying that the essential diagnostic procedure requirements, as per medical center policy, are available.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,61"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
62 GASTRIC OUTPUT .2;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=62 D ^SROCON Q
  • LAST EDITED:  AUG 23, 1990
  • HELP-PROMPT:  Enter a Number between 0 and 9999, 0 Decimal Digits.
  • DESCRIPTION:  This is the gastric output during the operative procedure. It is recorded in cc's, and appears on the Nurse Intraoperative Report.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
63 IV STARTED BY .3;5 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,63"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the Person who Started the IV.
  • DESCRIPTION:  This is the name of the person that started the IV for this operative procedure.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,63"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
64 CULTURES 41;0 WORD-PROCESSING #130.064

  • DESCRIPTION:  These are the names of cultures sent to the laboratory for examination.
65 SURGERY POSITION 42;0 POINTER Multiple #130.065 130.065

  • DESCRIPTION:  This is the position in which the patient is placed for this operative procedure. This information will appear on the Nurse Intraoperative Report.
66 PLANNED PRIN DIAGNOSIS CODE 34;2 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA):DA,$G(SRTN):SRTN,1:""))
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$OUT^SROICD(Y)
  • LAST EDITED:  JUL 28, 2014
  • HELP-PROMPT:  Enter the planned ICD Diagnosis code for the principal diagnosis.
  • DESCRIPTION:  
    This is the planned principal postoperative ICD diagnosis code assigned by the clinician.
  • DELETE TEST:  1,0)= I 1 D EN^DDIOL("The PRIN DIAGNOSIS CODE can't be deleted.",,"!!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^PADX1^MUMPS
    1)= Q
    2)= D PRINASOD^SROADX2
    This MUMPS cross reference removes associations to procedures upon edits or deletes of the diagnosis.
67 CANCELLATION AVOIDABLE 30;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  OCT 09, 1991
  • HELP-PROMPT:  Enter 'YES' if this cancellation was avoidable, or 'NO' if it was unavoidable.
  • DESCRIPTION:  This field contains a set of codes used to flag a cancellation as being avoidable or unavoidable. It is used when determining the percentage of avoidable cancellations.
68 SCHEDULED PROCEDURE SP;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>135!($L(X)<1) X
  • LAST EDITED:  DEC 13, 1990
  • HELP-PROMPT:  Your answer must be 1-135 characters in length.
  • DESCRIPTION:  This field contains the scheduled (or original) principal procedure for this case. It will be compared to the actual procedure completed.
69 CODING VERIFIER VER;2 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  OCT 24, 2011
  • HELP-PROMPT:  Enter the name of the person entering the CPT and ICD codes for this case.
  • DESCRIPTION:  This is the person who last updated procedure and/or diagnosis descriptions and/or codes for this case using the Update/Verify Procedure/Diagnosis Codes [SRCODING EDIT] option. This field is updated automatically by the
    option when information is changed.
70 CANCELLED BY 30;3 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  DEC 05, 1991
  • HELP-PROMPT:  Enter the name of the person who cancelled this operative procedure.
  • DESCRIPTION:  This is the name of the person who cancelled this surgical case. This information is automatically entered when a case is cancelled.
71 TIME OUT VERIFIED VER;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO (see TIME OUT VERIFIED COMMENTS);

  • LAST EDITED:  JUL 23, 2004
  • HELP-PROMPT:  Enter YES if the "Time Out" verification process was completed prior to the start of the procedure.
  • DESCRIPTION:  This field refers to the completion of a "Time Out" verification process prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location
    of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider.
    This practice is further defined by local hospital policy.
    If entered "NO", a justification should be documented in the Time Out Verified Comments.
  • CROSS-REFERENCE:  130^AIN^MUMPS
    1)= D IN^SRENSCS
    2)= Q
    This MUMPS cross reference maintains the associated comment field if this field is answered with "NO".
  • FIELD INDEX:  AG (#376) MUMPS IR ACTION
    Short Descr: Timestamp fields update
    Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
    Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    X(1): TIME OUT VERIFIED (130,71) (forwards)
    X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
    X(3): MARKED SITE CONFIRMED (130,73) (forwards)
72 PREOPERATIVE IMAGING CONFIRMED VER;4 SET
  • 'Y' FOR YES;
  • 'I' FOR IMAGING NOT REQUIRED FOR THIS PROCEDURE;
  • 'N' FOR NO - IMAGING REQUIRED BUT NOT VIEWED (see IMAGING CONFIRMED COMMENTS);

  • LAST EDITED:  JUL 22, 2004
  • HELP-PROMPT:  Enter YES if the imaging data was confirmed, "I" if there was no imaging required, or "NO" if the image was not viewed.
  • DESCRIPTION:  This field refers to the completion of the verification process for the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and
    verified by two members of the operating team prior to the start of the procedure.
    This practice is further defined by local hospital policy.
    If entered "NO", a justification should be documented in the Imaging Confirmed Comments.
  • CROSS-REFERENCE:  130^AIN^MUMPS
    1)= D IN^SRENSCS
    2)= Q
    This MUMPS cross reference maintains the associated comment field if this field is answered with "NO".
  • FIELD INDEX:  AG (#376) MUMPS IR ACTION
    Short Descr: Timestamp fields update
    Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
    Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    X(1): TIME OUT VERIFIED (130,71) (forwards)
    X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
    X(3): MARKED SITE CONFIRMED (130,73) (forwards)
73 MARKED SITE CONFIRMED VER;5 SET
  • 'Y' FOR YES;
  • 'M' FOR MARKING NOT REQUIRED FOR THIS PROCEDURE;
  • 'N' FOR NO - MARKING REQUIRED BUT NOT DONE (see MARKED SITE COMMENTS);

  • LAST EDITED:  JUL 22, 2004
  • HELP-PROMPT:  Enter YES if the "Marked Site" confirmation process was completed prior to the start of the procedure.
  • DESCRIPTION:  The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. See applicable VHA Handbooks and Directives for further
    information and guidance.
    If entered "NO", a justification should be documented in the Marked Site Comments.
  • CROSS-REFERENCE:  130^AIN^MUMPS
    1)= D IN^SRENSCS
    2)= Q
    This MUMPS cross reference maintains the associated comment field if this field is answered with "NO".
  • FIELD INDEX:  AG (#376) MUMPS IR ACTION
    Short Descr: Timestamp fields update
    Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
    Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
    Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
    X(1): TIME OUT VERIFIED (130,71) (forwards)
    X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
    X(3): MARKED SITE CONFIRMED (130,73) (forwards)
74 TIME-OUT COMPLETED .6;12 DATE

  • INPUT TRANSFORM:  D TIME^SROUTL K:Y<1!(X'[".") X
  • LAST EDITED:  SEP 25, 2014
  • HELP-PROMPT:  Enter the time the Time-Out was completed.
  • DESCRIPTION:  
    VASQIP Definition (2014): This indicates the actual time when the entire Time-Out process was completed by the OR team. It will be documented using Military Time format.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
75 TOV TIMESTAMP VERD;3 DATE

  • INPUT TRANSFORM:  S %DT="EST" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  FEB 04, 2004
  • HELP-PROMPT:  (No range limit on date)
  • DESCRIPTION:  
    This field is updated whenever the TIME OUT VERIFIED field (#71) is entered or changed.
    WRITE AUTHORITY: ^
    UNEDITABLE
76 IMAG TIMESTAMP VERD;4 DATE

  • INPUT TRANSFORM:  S %DT="EST" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  FEB 04, 2004
  • HELP-PROMPT:  (No range limit on date)
  • DESCRIPTION:  
    This field is updated whenever the PREOPERATIVE IMAGING CONFIRMED field (#72) is entered or changed.
    WRITE AUTHORITY: ^
    UNEDITABLE
77 SITE MARK TIMESTAMP VERD;5 DATE

  • INPUT TRANSFORM:  S %DT="EST" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  FEB 04, 2004
  • HELP-PROMPT:  (No range limit on date)
  • DESCRIPTION:  
    This field is updated whenever the MARKED SITE CONFIRMED field (#73) is entered or changed.
    WRITE AUTHORITY: ^
    UNEDITABLE
78 PREVIOUSLY SCHEDULED CASE SP;2 POINTER TO SURGERY FILE (#130) SURGERY(#130)

  • LAST EDITED:  AUG 10, 2011
  • HELP-PROMPT:  Enter the previously scheduled, now cancelled, case.
  • DESCRIPTION:  
    This field identifies the previously scheduled case that was cancelled and replaced by this case.
79 RESCHEDULED CASE SP;3 POINTER TO SURGERY FILE (#130) SURGERY(#130)

  • LAST EDITED:  AUG 12, 2011
  • HELP-PROMPT:  Enter the replacement case to be scheduled later.
  • DESCRIPTION:  
    This field identifies the new surgery case that will be scheduled later to replace this cancelled case.
80 SPD COMMENTS 80;0 WORD-PROCESSING #130.8

  • DESCRIPTION:  
    This word-processing field contains any information for SPD that cannot be entered elsewhere. These comments will be sent to SPD via the Surgery/CoreFLS interface.
81 DYNAMED NOTIFIED 31;10 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  NOV 27, 2002
  • HELP-PROMPT:  Enter YES if notification has been sent to DynaMed.
  • DESCRIPTION:  YES indicates at least one notification has been sent to DynaMed by way of the CoreFLS interface. A null value or zero indicates no notification has been sent. The first notification sent to DynaMed will be a NEW
    APPOINTMENT notification. Subsequent notifications will be for edit, cancel or delete notifications, as appropriate.
82 TIME OUT VERIFIED COMMENTS 82;0 WORD-PROCESSING #130.082

  • LAST EDITED:  APR 29, 2004
  • DESCRIPTION:  
    This word-processing field contains comments related to the TIME OUT VERIFIED field. The information entered in this field clarifies entry that is entered as "NO".
83 IMAGING CONFIRMED COMMENTS 83;0 WORD-PROCESSING #130.083

  • DESCRIPTION:  
    This word-processing field contains comments related to the PREOPERATIVE IMAGING CONFIRMED field. The information entered in this field clarifies entry that is entered as "NO".
84 MARKED SITE COMMENTS 84;0 WORD-PROCESSING #130.084

  • LAST EDITED:  APR 28, 2004
  • DESCRIPTION:  
    This word-processing field contains comments related to the MARKED SITE CONFIRMED field. The information entered in this field clarifies entry that is entered as "NO".
85 CHECKLIST COMMENT 51;0 WORD-PROCESSING #130.085

  • LAST EDITED:  FEB 16, 2011
  • DESCRIPTION:  This field is a comment that is required if any of the listed below fields for the Time Out Verified Utilizing Checklist had a response of "No".
    - CONFIRM PATIENT IDENTITY (#600)
    - PROCEDURE TO BE PERFORMED (#601)
    - VALID CONSENT FORM (#603)
    - CONFIRM PATIENT POSITION (#604)
    - CORRECT MEDICAL IMPLANTS (#607)
    - ANTIBIOTIC PROPHYLAXIS (#608)
    - APPROPRIATE DVT PROPHYLAXIS (#609)
    - BLOOD AVAILABILITY (#610)
    - AVAILABILITY OF SPECIAL EQUIP (#611)
    - SITE OF PROCEDURE (#602)
    - MARKED SITE CONFIRMED (#605)
    - REOPERATIVE IMAGES CONFIRMED (#606)
100 ORDER NUMBER 0;14 POINTER TO ORDER FILE (#100) ORDER(#100)

  • LAST EDITED:  FEB 28, 1992
  • HELP-PROMPT:  Enter the Order number for ues within the OE/RR module.
  • DESCRIPTION:  This is the pointer to the ORDER file (100). It will be created when a case is requested.
  • TECHNICAL DESCR:  This is the pointer to the ORDER file (100). It is contained in the 14th piece of the zero node.
101 STAFF/RESIDENT .1;3 SET
  • 'R' FOR RESIDENT;
  • 'S' FOR STAFF;

  • LAST EDITED:  APR 15, 1992
  • HELP-PROMPT:  Enter 'R' if the surgeon for this case was a resident, or 'S' if the surgeon was staff.
  • DESCRIPTION:  This determines whether the surgeon was a resident or staff. It will be used for categorizing procedures in the Annual Report of Surgical Procedures.
  • TECHNICAL DESCR:  This field is automatically entered based on the SR STAFF SURGEON security key.
102 REASON FOR NO ASSESSMENT RA;7 SET
  • '0' FOR NON-SURGEON CASE;
  • '1' FOR ANESTHESIA TYPE;
  • '2' FOR EXCEEDS MAX ASSMNTS;
  • '3' FOR EXCEEDS MAX TURPS;
  • '4' FOR INCLSN CRTA NOT MET;
  • '5' FOR PREVIOUS CASE;
  • '6' FOR 10% RULE;
  • '7' FOR PRIOR INDEX PROC;
  • '8' FOR CONCURRENT CASE;
  • '9' FOR EXCEEDS MAX HERNIAS;
  • 'A' FOR ABORTED;

  • LAST EDITED:  AUG 24, 2015
  • HELP-PROMPT:  Enter the reason why no assessment was done on this surgical case.
  • DESCRIPTION:  VASQIP Definition (2015): This is the reason why no assessment was entered for this particular surgical case. It should be entered if any VASQIP CPT-eligible procedure was excluded from the risk assessment module.
    0 - Non-surgeon performed the procedure
    2 - Number of surgical cases entered into the Surgical Package
    exceeded 36 over an 8 day time frame
    3 - Number of TURPs or TURBTs exceeded 5 cases over an 8 day time
    frame
    4 - Surgical case does not meet inclusion criteria (VASQIP excluded
    case, CPT code, ASA 6)
    6 - 10% Rule: Surgical Quality Nurse can exclude up to 10%
    non-mandatory cases in a 12 month calendar year
    8 - Case was a concurrent case, secondary to an assessed primary case
    9 - Number of hernias exceeded 5 cases over an 8 day time frame
    A - Aborted: case was cancelled after the patient entered the operating
    room prior to incision
  • SCREEN:  S DIC("S")="I ""157""'[Y"
  • EXPLANATION:  Screen prevents selection of inactive codes.
103 ANESTHETIST CATEGORY .3;8 SET
  • 'A' FOR ANESTHESIOLOGIST;
  • 'N' FOR NURSE ANESTHETIST;
  • 'O' FOR OTHER;

  • LAST EDITED:  NOV 05, 1992
  • HELP-PROMPT:  Enter the code corresponding to the category of the principal anesthetist for this case.
  • DESCRIPTION:  This field holds the category of the principal anesthetist which is used on the Anesthesia AMIS report to enumerate the number of anesthetics administered by each category.
118 NON-OR PROCEDURE NON;1 SET
  • 'Y' FOR YES;

  • LAST EDITED:  JAN 22, 1992
  • HELP-PROMPT:  Enter 'YES' is this case is a non-OR procedure.
  • DESCRIPTION:  
    This field is a flag signifying this case is a non-OR surgical procedure.
  • CROSS-REFERENCE:  130^ANOR^MUMPS
    1)= S ^SRF("ANOR",$P(^SRF(DA,0),"^"),DA)=""
    2)= K ^SRF("ANOR",$P(^SRF(DA,0),"^"),DA)
    The ANOR cross reference on the NON-OR PROCEDURE field is used to flag cases as non-O.R. procedures.
119 NON-OR LOCATION NON;2 POINTER TO HOSPITAL LOCATION FILE (#44) HOSPITAL LOCATION(#44)

  • INPUT TRANSFORM:  S DIC("S")="I $$NONORDIV^SROUTL0(DA,+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the non-OR location (file 44) where this procedure was performed.
  • DESCRIPTION:  
    This is the location (file 44) where this non-OR procedure was performed.
  • SCREEN:  S DIC("S")="I $$NONORDIV^SROUTL0(DA,+Y)"
  • EXPLANATION:  This screen checks inactivation and reactivation dates as well as the institution field for multi-division hospitals.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^APCE9^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
120 DATE OF PROCEDURE NON;3 DATE
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  S %DT="ETX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  SEP 19, 1997
  • HELP-PROMPT:  Enter the date that the non-OR procedure was performed.
  • DESCRIPTION:  
    This is the date that the non-OR procedure was performed. The date of procedure must be entered for all non-OR cases.
  • CROSS-REFERENCE:  ^^TRIGGER^130^.09
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X K Y S X=DIV S X=DIV S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X K Y S X="" S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
    CREATE VALUE)= DATE OF PROCEDURE
    DELETE VALUE)= @
    FIELD)= DATE OF OPERATION
    This trigger on the DATE OF PROCEDURE field is used to update the DATE OF OPERATION field when the date of procedure is entered or edited. The DATE OF PROCEDURE field is used with non-O.R. procedures, and the DATE OF
    OPERATION field is updated to assist in sorting cases for reports.
121 TIME PROCEDURE BEGAN NON;4 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(DA,"NON"),U,3),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the time of the start of the non-OR procedure.
  • DESCRIPTION:  
    This is the date and time that the non-OR procedure began.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AST^MUMPS
    1)= D AST^SRONXR
    2)= D KILLAST^SRONXR
    The AST cross reference on the TIME PROCEDURE BEGAN field updates the ANES CARE START TIME if the non-O.R. procedure is an Anesthesiology procedure, that is, if the case is assigned to the Anesthesiology Medical Specialty.
  • CROSS-REFERENCE:  130^APCE10^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • CROSS-REFERENCE:  130^ADA^MUMPS
    1)= D VALIDAT^SROCVER
    2)= Q
    This MUMPS cross-reference on the TIME PROCEDURE BEGAN field is used to invoke the CPT and ICD-9 codes revalidation checks in routine ^SROCVER.
122 TIME PROCEDURE ENDED NON;5 DATE

  • INPUT TRANSFORM:  S SRN="NON",SRP=4,SR130="TIME PROCEDURE BEGAN" D TERM^SROVAR K:Y<1 X I $D(X) D ATTP^SROUTL1
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the time that the non-OR procedure was completed.
  • DESCRIPTION:  
    This is the date and time that all the procedures for this non-OR case are complete.
  • DELETE TEST:  1,0)= I $$DEL^SROESX(DA,"3") D EN^DDIOL("The TIME PROCEDURE ENDED field can't be deleted. This case has a Procedure Report associated with it.",,"!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AND^MUMPS
    1)= D AND^SRONXR
    2)= D KILLAND^SRONXR
    The AND cross reference on the TIME PROCEDURE ENDED field updates the ANES CARE END TIME if the non-O.R. procedure is assigned to the Anesthesiology Medical Specialty.
  • CROSS-REFERENCE:  130^APCE11^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • RECORD INDEXES:  AESP (#388)
123 PROVIDER NON;6 POINTER TO NEW PERSON FILE (#200)
************************REQUIRED FIELD************************
NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,123"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the name of the privileged person who performs the major portion of the principle procedure.
  • DESCRIPTION:  
    This is the person who performs the major portion of the principal non-OR procedure. This field is required for several reports.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,123"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
  • CROSS-REFERENCE:  130^APCE12^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • CROSS-REFERENCE:  130^ATTP^MUMPS
    1)= D ATTP^SROXR1
    2)= D KATTP^SROXR1
    This cross reference updates the ATTEND PROVIDER field with the PROVIDER if the SURGERY RESIDENTS (Y/N) site parameter is NO.
  • FIELD INDEX:  AES2 (#381) MUMPS ACTION
    Short Descr: Update TIU when provider is changed.
    Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Procedure Report (Non-OR) when the provider is edited.
    Set Logic: D SET^SROESX0
    Set Cond: S X=X1(1)'=X2(1)
    Kill Logic: Q
    Kill Cond: S X=0
    X(1): PROVIDER (130,123) (forwards)
124 ATTEND PROVIDER NON;7 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130,124"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  MAY 31, 2005
  • HELP-PROMPT:  Enter the name of the attending staff provider. This is required when the provider is in training status.
  • DESCRIPTION:  
    This is the name of the attending staff provider responsible for this case. This information appears on several reports.
  • SCREEN:  S DIC("S")="S RESTRICT=""130,124"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  This field contains a screen which may be used to restrict entries based on locally defined keys.
  • DELETE TEST:  1,0)= I $P($G(^SRF(DA,"NON")),"^",5) D EN^DDIOL("The Attending Provider cannot be deleted on a completed non-OR procedure! ",,"!!,?2")
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^APCE13^MUMPS
    1)= D APCE^SROPCEX
    2)= Q
    This MUMPS cross reference updates PCE.
  • FIELD INDEX:  AES4 (#383) MUMPS ACTION
    Short Descr: Update TIU when attending provider is changed.
    Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Procedure Report (Non-OR) when the attending provider
    is edited.
    Set Logic: D SET1^SROESX0
    Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
    Kill Logic: D SET1^SROESX0
    Kill Cond: S X=X2(1)=""
    X(1): ATTEND PROVIDER (130,124) (forwards)
125 MEDICAL SPECIALTY NON;8 POINTER TO MEDICAL SPECIALTY FILE (#723)
************************REQUIRED FIELD************************
MEDICAL SPECIALTY(#723)

  • LAST EDITED:  MAR 03, 1993
  • HELP-PROMPT:  Enter the assigned medical specialty of the provider.
  • DESCRIPTION:  This is the medical specialty credited for doing this non-OR procedure.
    Many reports are sorted by the medical specialty. This field should be
    entered prior to completion of this non-OR procedure.
126 PROCEDURE OCCURRENCE 43;0 Multiple #130.0126 130.0126

  • DESCRIPTION:  This is a occurrence that is related to a non-O.R. procedure. If there are not any non-O.R. procedure occurrences, this field should be left blank. Do not enter 'NO' or 'NONE'.
127 SEQUENTIAL COMPRESSION DEVICE .7;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 22, 1992
  • HELP-PROMPT:  Enter 'YES' if a sequential compression device was used.
  • DESCRIPTION:  This determines whether a sequential compression device was used.
128 LASER TYPE .7;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  SEP 25, 1992
  • HELP-PROMPT:  Your answer must be 1-30 characters in length.
  • DESCRIPTION:  This determines whether a laser was used during this procedure. If applicable, enter the type of laser used during this surgical procedure.
129 LASER UNIT 44;0 Multiple #130.0129 130.0129

  • DESCRIPTION:  
    These are the laser units, if any, used during this procedure.
130 CELL SAVER 45;0 Multiple #130.013 130.013

  • DESCRIPTION:  
    These are the cell savers, if any, used during this procedure.
131 DEVICE(S) 46;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>70!($L(X)<1) X
  • LAST EDITED:  SEP 05, 2000
  • HELP-PROMPT:  Answer must be 1-70 characters in length.
  • DESCRIPTION:  
    This field documents devices used in this procedure that are not documented elsewhere.
135 LASER PERFORMED 56;0 Multiple #130.11 130.11

  • DESCRIPTION:  
    This is information related to the laser performed, if any, used during this procedure.
136 SPINAL LEVEL 1.1;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the spinal level of the planned procedure. Answer must be 1-50 characters in length.
  • DESCRIPTION:  
    This is the spinal level(s) of the planned procedure as free text, for example L1 or L1-L2.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
200 OPERATIONS THIS ADMISSION 200;51 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS" X=NYUK K NYUK
  • LAST EDITED:  SEP 12, 1991
  • HELP-PROMPT:  Enter the total number of operations prior to the index procedure for this hospital admission.
  • DESCRIPTION:  This is the total number of surgical procedures, prior to the index or principal operation, which required the patient to be taken to the operating room for any type of surgical intervention during this hospital admission.
    Include all procedures whether or not they are part of the inclusion/exclusion criteria.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
201 REDO PROCEDURE 200;53 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 03, 1995
  • HELP-PROMPT:  If this was a return to surgery to re-do a procedure, enter 'YES'.
  • DESCRIPTION:  
    This determines whether the principal operative procedure was a reoperation in the same anatomic location for the same purpose as the first operation regardless of the length of time from the original surgical date.
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen limits selection to Phase III choices.
202 *CURRENT SMOKER 200;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 12, 2011
  • HELP-PROMPT:  Enter the code (YES or NO) describing the patient's status as a smoker prior to surgery.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Non-Cardiac Definition Revised (2006): If the patient has smoked cigarettes in the year prior to admission for surgery enter YES. Do not include patients who smoke cigars or pipes or use chewing tobacco.
202.1 PACK/YEARS 208;9 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>200)!(X<0)!(X?.E1"."2N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Type a Number between 0 and 200, 1 Decimal Digit.
  • DESCRIPTION:  Definition Revised (2004): If the patient has ever been a smoker, enter the total number of pack/years of smoking for this patient. Pack-years are defined as the number of packs of cigarettes smoked per day times the
    number of years the patient has smoked. If the patient has never been a smoker, enter "0". If pack-years are >200, just enter 200. If smoking history cannot be determined, enter "NS". The possible range for number of
    pack-years is 0 to 200. If the chart documents differing values for pack year cigarette history, or ranges for either packs/day or number of years patient has smoked, select the highest value documented, unless you are
    confident in a particular documenter's assessment (e.g., preoperative anesthesia evaluation often includes a more accurate assessment of this value because of the impact it may have on the patient's response to
    anesthesia).
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
203 HISTORY OF COPD 200;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 12, 2015
  • HELP-PROMPT:  Enter 'YES' if the patient has a defined condition of COPD.
  • DESCRIPTION:  VASQIP Definition (2015): Chronic obstructive pulmonary disease (such as emphysema and/or chronic bronchitis) resulting in any one or more of the following in the 30 days preoperative:
    -Functional disability from COPD (e.g., dyspnea, inability to
    perform ADLs)
    -Hospitalization in the past for treatment of COPD
    -Requires chronic bronchodilator therapy with oral or inhaled agents
    -An FEV1 prior to bronchodilator treatment, of <75% of predicted on
    pulmonary function testing
    Do not include patients whose only pulmonary disease is acute asthma, an acute and chronic inflammatory disease of the airways resulting in bronchospasm. Do not include patients with diffuse interstitial fibrosis or
    sarcoidosis.
    Choose from: Y YES N NO
204 VENTILATOR DEPENDENT 200;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient was dependent on a ventilator at any time within the 48 hours prior to surgery.
  • DESCRIPTION:  
    Definition Revised (2004): A preoperative patient requiring ventilator-assisted respirations at any time during the 48 hours preceding surgery. This does not include the treatment of sleep apnea with CPAP.
205 PRIOR MI 206;14 SET
  • '0' FOR NO;
  • '1' FOR YES, < OR EQUAL 7 DAYS PREOP;
  • '2' FOR YES, >7 DAYS AND <6 MONTHS PREOP;
  • '3' FOR UNKNOWN;
  • '4' FOR YES, >6 MONTHS PREOP;
  • '5' FOR UNKNOWN;

  • LAST EDITED:  MAY 13, 2015
  • HELP-PROMPT:  Enter the category that most accurately reflects the patient's most recent Myocardial Infarction.
  • DESCRIPTION:  Definition Revised (2015): Indicate the patient's most recent history of myocardial infarction within 6 months prior to surgery as diagnosed in his or her medical records. Select the one appropriate response:
    0. No 1. Yes, < or equal to 7 days prior to surgery 2. Yes, > 7 days and < 6 months prior to surgery 4. Yes, > 6 months prior to surgery 5. Unknown
  • SCREEN:  S DIC("S")="I Y'=3"
  • EXPLANATION:  Screen prevents selection of retired codes.
206 VASCULAR (Y/N) 200;40 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has any vascular problems or disease.
  • DESCRIPTION:  This determines whether the patient has any vascular problems.
207 *CONGESTIVE HEART FAILURE 206;19 SET
  • 'N' FOR NONE;
  • 'I' FOR CARDIAC DISEASE, NO SYMPTOMS;
  • 'II' FOR SLIGHT LIMITATION;
  • 'III' FOR MARKED LIMITATION;
  • 'IV' FOR SYMPTOMS AT REST;
  • 'U' FOR UNKNOWN;

  • LAST EDITED:  JUN 22, 2015
  • HELP-PROMPT:  Enter the NYHA Class associated with the severity of Congestive Heart Failure in the 30 days preceding surgery.
  • DESCRIPTION:  Definition Revised (2014): The New York Heart Association (NYHA) functional classification is used as a subjective assessment of the severity of congestive heart failure. Indicate whether the patient has congestive heart
    failure if the patient chart or patient self-report indicates a history of congestive heart failure or any mention of symptomatic manifestations in the NYHA Classification within the 30 days before surgery. Indicate the
    one most appropriate response:
    None - no congestive heart failure. Class I - cardiac disease, no symptoms of abnormal fatigue, dyspnea,
    or angina. Class II - slight limitation of physical activity by fatigue, dyspnea,
    or angina. The patient gets unusual fatigue, dyspnea, and/or
    angina only upon performing more strenuous activities, such as
    climbing two or more flights of stairs without stopping. Class III - marked limitation of physical activity by fatigue, dyspnea,
    or angina. The patient gets unusual fatigue, dyspnea, and/or
    angina upon performing ordinary activities, such as walking
    several blocks or climbing a flight of stairs. Class IV - symptoms at rest and/or inability to carry out any
    physical activity without symptoms of fatigue, dyspnea or angina.
    The patient has symptoms of unusual fatigue, dyspnea, and/or
    angina at rest or when performing minimal activity, such as
    walking across the room. Unknown - Unknown
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
208 *HYPERTENSION REQUIRING MEDS 200;36 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 16, 2014
  • HELP-PROMPT:  Enter 'YES' if the patient has a history of hypertension requiring medications.
  • DESCRIPTION:  Definition Revised (2004): The patient has a persistent elevation of systolic blood pressure >140 mm Hg or a diastolic blood pressure >90 mm Hg or requires an antihypertensive treatment (e.g., diuretics, beta blockers, ACE
    inhibitors, calcium channel blockers) at the time the patient is being considered as a candidate for surgery which should be no longer than 30 days prior to surgery. Hypertension must be documented in the patient's chart.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
209 CARDIOMEGALY 206;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 20, 2004
  • HELP-PROMPT:  Enter 'YES' if there is cardiac enlargement on chest x-ray.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate if the patient has generalized cardiac enlargement of any or all of the cardiac chambers by standard or portable chest x-ray within 30 days preceding surgery.
210 CENTRAL NERVOUS SYSTEM (Y/N) 200;18 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of illnesses related to the central nervous system.
  • DESCRIPTION:  This determines whether the patient has a history of illness related to the central nervous system (CNS).
211 CURRENTLY ON DIALYSIS 200;39 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 17, 2006
  • HELP-PROMPT:  Enter YES if the patient is currently on dialysis.
  • DESCRIPTION:  
    Definition Revised (2006): Acute or chronic renal failure requiring periodic peritoneal dialysis, hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration within 2 weeks prior to surgery.
212 ASCITES 200;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient has the presence of fluid accumulation in the peritoneal cavity.
  • DESCRIPTION:  VASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within 30 days prior to the
    operation. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).
213 ESOPHAGEAL VARICES 200;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 06, 2015
  • HELP-PROMPT:  Enter 'YES' if this patient has esophageal varices.
  • DESCRIPTION:  Definition Revised (2015): Esophageal varices are engorged collateral veins in the esophagus that bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal pressure results in
    esophageal varices that are most frequently demonstrated by direct visualization at esophagoscopy. Esophageal varices must be present preoperatively and must be documented on a recent EGD, MRI or CT scan performed within 6
    months prior to the surgical procedure.
    Choose from: Y- YES N- NO NS- NO STUDY
214 PGY OF PRIMARY SURGEON 200;52 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>12)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  MAR 12, 2004
  • HELP-PROMPT:  Enter the post graduate year of the surgeon, or '0' for a staff surgeon.
  • DESCRIPTION:  Definition Revised (2004): Enter the number of surgical residency postgraduate years of the primary surgeon (1-12). Enter 0 if the primary surgeon is a staff/attending surgeon and not a surgical resident or fellow. PGYs
    greater than 12 should be reported as '12'.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
215 WEIGHT LOSS > 10% 200;48 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the body weight loss is more than 10% in the 6 months prior to surgery.
  • DESCRIPTION:  Definition Revised (2007): A >10% decrease in body weight in the six month interval immediately preceding surgery as manifested by serial weights in the chart, as reported by the patient, or as evidenced by change in
    clothing size or severe cachexia. Exclude patients who have intentionally lost weight as part of a weight reduction program.
216 BLEEDING DISORDERS 200;49 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter YES if the patient has a history of a bleeding disorder.
  • DESCRIPTION:  VASQIP Definition (2014): Bleeding (coagulation) disorder is a condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K deficiency, hemophilia, von
    Willebrand disease). Answer YES if the patient has a documented bleeding (coagulation) disorder that is either chronic or acute.
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
217 TRANSFUSION > 4 RBC UNITS 200;50 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient required a transfusion of more than 4 units in 72 hours prior to surgery.
  • DESCRIPTION:  
    Definition Revised (2004): Preoperative loss of blood necessitating a minimum of 5 units of whole blood/packed red cells transfused during the 72 hours prior to surgery including any blood transfused in the emergency room.
218 OPEN WOUND 200;46 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has an open wound with or without infection.
  • DESCRIPTION:  Definition Revised (2007): Evidence of an open wound that communicates to the air by direct exposure, with or without cellulitis or purulent exudate. This does not include osteomyelitis or localized abscesses. The wound
    must communicate to the air by direct exposure. Report mandible fractures under this preoperative variable.
218.1 PREOPERATIVE SEPSIS 206;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NONE;
  • '1' FOR SIRS;
  • '2' FOR SEPSIS;
  • '3' FOR SEPTIC SHOCK;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 09, 2014
  • HELP-PROMPT:  Enter the patient's septic status in the 48 hours prior to surgery.
  • DESCRIPTION:  Definition Revised (2014): 2. Sepsis is the systematic response to infection.
    Answer YES if both of the following criteria are met:
    a) Clinical documentation of infection (such as wound with
    purulent drainage, ruptured bowel with free air, etc.); or a
    positive culture from any site thought to be causative; or
    specialized laboratory evidence of causative infection (such
    as viral DNA in blood).
    AND
    b) The presence of two or more of the following systemic responses:
    - Temperature > 38 degrees C or < 36 degrees C
    - HR > 90 beats/minute
    - RR > 20 breaths /minute or PaCO2 < 32 mmHg
    - WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature
    neutrophils ("bands")
    3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it
    is associated with organ and/or circulatory dysfunction.
    Terminology such as Severe Sepsis/Septic Shock/Refractory Septic
    Shock and Multiple Organ Dysfunction Syndrome (MODS) all fall
    into this category.
    Answer YES if the definition of SEPSIS is present AND there is
    documented organ and/or circulatory dysfunction defined by one or
    more of the following:
    - Areas of acutely mottled skin not related to peripheral vascular
    disease
    - Capillary refilling requires three seconds or longer not
    related to peripheral vascular disease
    - Urine output <0.5 mL/kg for at least one hour, or renal
    replacement therapy
    - Lactate >2 mmol/L
    - Abrupt change in mental status
    - Abnormal EEG findings
    - Platelet count < 100,000 platelets/mL
    - Disseminated intravascular coagulation (DIC)
    - Acute lung injury or acute respiratory distress syndrome (ARDS)
    - New cardiac dysfunction as defined by ECHO or direct measurement
    of the cardiac index
    - An arterial systolic blood pressure (SBP) of <=90 mm Hg or a mean
    arterial pressure (MAP) <=70 mm Hg for at least 1 hour despite
    adequate fluid resuscitation, adequate intravascular volume
    status, or the need for vasopressors to maintain SBP >= 90 mm
    Hg or MAP >=70 mm Hg.
  • SCREEN:  S DIC("S")="I ""N23""[Y"
  • EXPLANATION:  Screen prevents selection of retired codes.
219 PREOPERATIVE HEMOGLOBIN 201;20 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>7!($L(X)<1) X I $D(X) S SRCICSP=1 D NUM^SROAL21
  • LAST EDITED:  APR 15, 2011
  • HELP-PROMPT:  Your answer must be 1-7 characters in length.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate the patient's hemoglobin result (g/dl) preoperatively evaluated closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No Study/Unknown" is not allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
220 *PREVIOUS PCI 200;32 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 15, 2014
  • HELP-PROMPT:  Enter 'Y' if this patient has undergone a percutaneous coronary intervention (PCI).
  • DESCRIPTION:  Definition Revised (2007): The patient has undergone or has had an attempt at percutaneous coronary intervention at any time. This includes either balloon dilatation or stent placement. This does not include valvuloplasty
    procedures.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
221 PREOPERATIVE CPK 201;6 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>6000)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the result of the preoperative CPK test. Your answer should be between 0 and 6000.
  • DESCRIPTION:  This is the result of the preoperative creatinine phosphokinase (CPK) test.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
222 PREOPERATIVE MB BAND 201;7 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the result of the preoperative MB band.
  • DESCRIPTION:  This is the value of the preoperative methyline blue (MB) band. Your answer must be between 0 and 50.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
223 PREOPERATIVE SERUM CREATININE 201;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) N SRCICSP S SRCICSP=1 D NUM^SROAL21
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  Definition Revised (2011): This is the serum creatinine result (mg/dl) most closely preceding surgery - not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters in length which may include a
    prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for non-cardiac case assessments.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
224 PREOPERATIVE BUN 201;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 09, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative Blood Urea Nitrogen (BUN) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for
    "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
225 PREOPERATIVE SERUM ALBUMIN 201;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JAN 19, 2011
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  Definition Revised (2011): This is the serum albumin result (g/dl) most closely preceding surgery - not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters in length which may include a
    prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for non-cardiac case assessments.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
226 PREOPERATIVE SGPT 201;10 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the result of the preoperative SGPT test. Your answer should be between 0 and 1000.
  • DESCRIPTION:  This is the result of the preoperative serum glutamic pyruvic transaminase (SGPT) test.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
227 PREOPERATIVE SGOT 201;11 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative serum glutamic oxaloacetic (SGOT) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
228 PREOPERATIVE TOTAL BILIRUBIN 201;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative total bilirubin test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study"
    is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
229 PREOPERATIVE ALK PHOSPHATASE 201;12 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative alkaline phosphatase test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No
    Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
230 PREOPERATIVE WBC 201;13 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the result of the preoperative white blood count (WBC). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No
    Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
231 PREOPERATIVE PLATELET COUNT 201;15 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative platelet count. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also
    allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
232 PREOPERATIVE PT 201;17 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the result of the preoperative prothombin time (PT). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study"
    is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
233 PREOPERATIVE PTT 201;16 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative partial thromboplastin time (PTT). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for
    "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
234 PREOPERATIVE HEMATOCRIT 201;14 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the result of the preoperative hematocrit test. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is
    also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
235 ASSESSMENT STATUS RA;1 SET
  • 'I' FOR INCOMPLETE;
  • 'C' FOR COMPLETE;
  • 'T' FOR TRANSMITTED;
  • 'N' FOR NO ASSESSMENT;

  • LAST EDITED:  MAR 10, 2017
  • HELP-PROMPT:  Enter the current status of this surgery risk assessment.
  • DESCRIPTION:  This is the current status of the surgery risk assessment. When creating a new assessment, the status will automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this field will be updated to
    'COMPLETED'. After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.
  • RECORD INDEXES:  ARS (#1418)
236 HEIGHT 206;1 FREE TEXT

  • INPUT TRANSFORM:  K:+X>300!(+X<0) X D H^SROAMEAS
  • OUTPUT TRANSFORM:  S Y=$S(Y["C":+Y_" CENTIMETERS",+Y:Y_" INCHES",1:Y)
  • LAST EDITED:  JUN 29, 2010
  • HELP-PROMPT:  Enter the patient's height.
  • DESCRIPTION:  VASQIP Definition (2010): Height: Report the patient's most recent height before surgery documented in the medical record in either inches (25 to 86 in) or centimeters (63 to 218 cm). If you are entering the patient's
    height in centimeters, enter 'C' after the number of centimeters.
    Your answer should be in one of the following two formats.
    68 (representing inches)
    173C (representing centimeters)
    The software pulls the most recent height measurement, regardless of when it was taken. The date of the measurement returned by the capture process is displayed on the data input screen.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  ^^TRIGGER^130^236.1
    1)= Q
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,7),X=X S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,7)=DIV,DIH=130,DIG=236.1 D ^DICR
    CREATE VALUE)= NO EFFECT
    DELETE VALUE)= @
    FIELD)= HEIGHT MEASUREMENT DATE
236.1 HEIGHT MEASUREMENT DATE 200.1;7 DATE

  • INPUT TRANSFORM:  S %DT="EX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  NOV 27, 2007
  • HELP-PROMPT:  Enter the date of the height measurement.
  • DESCRIPTION:  
    This is the date of the patient's height measurement. This date is taken from the VITALS software.
  • NOTES:  TRIGGERED by the HEIGHT field of the SURGERY File
237 WEIGHT 206;2 FREE TEXT

  • INPUT TRANSFORM:  K:+X>999!(+X<0) X D W^SROAMEAS
  • OUTPUT TRANSFORM:  S Y=$S(Y["K":+Y_" KILOGRAMS",+Y:Y_" LBS.",1:Y)
  • LAST EDITED:  JUL 09, 2010
  • HELP-PROMPT:  Enter the patient's weight most closely preceding surgery.
  • DESCRIPTION:  VASQIP Definition (2010): Weight: Report the patient's most recent weight before surgery documented in the medical record in either pounds (50 to 999 lbs) or kilograms (23 to 453 kg). If you are entering the patient's
    weight in kilograms, enter 'K' after the number of kilograms. The software pulls the latest value up to 30 days prior to surgery. If no value is found in the Vitals software, the nurse reviewer must enter the value
    manually.
    Your answer should be in one of the following formats.
    178 (weight in pounds)
    80K (weight in Kilograms)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
237.1 PREOPERATIVE SLEEP APNEA 200.1;8 SET
  • '1' FOR NONE - LEVEL 1;
  • '2' FOR SUSPICION OF SLEEP APNEA - LEVEL 2;
  • '3' FOR SLEEP APNEA CONFIRMED - LEVEL 3;

  • OUTPUT TRANSFORM:  S Y=$S(Y=1:"LEVEL 1",Y=2:"LEVEL 2",Y=3:"LEVEL 3",1:"")
  • LAST EDITED:  JAN 17, 2014
  • HELP-PROMPT:  Identify whether the Patient has sleep apnea preoperatively.
  • DESCRIPTION:  VASQIP Definition (2014): Sleep Apnea is a disorder of respiration whereby the individual has hypoxic and/or apneic periods during sleep due to prolapse or flaccidity of oropharyngeal structures, which improves with
    positive airway pressure (i.e., CPAP or BIPAP). Select one of the following categories that best indicates the patient's level of sleep apnea.
    Level 1 = None: No diagnosis or suspicion of Sleep Apnea Level 2 = Suspicion of Sleep Apnea: No sleep study has been done,
    however the patient has TWO or MORE of the following risk
    factors for Sleep Apnea:
    a) Obesity (BMI > 35)
    b) Thick neck (men > 17 inches, women > 16 inches)
    c) Snoring, loud or frequent
    d) Observed apneas (partner/roommate reported observing
    obstruction episodes during sleep)
    e) Frequent arousals from sleep or choking during sleep
    f) Daytime somnolence
    g) Patient reports diagnosis of sleep apnea even if sleep
    study results are not in the medical record Level 3 = Sleep Apnea: Sleep apnea confirmed by Sleep Study OR
    patient currently uses CPAP/BIPAP at home.
    Answer Options:
    - None
    - Suspicion of Sleep Apnea
    - Sleep Apnea Confirmed
238 DNR STATUS 200;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient has requested not to be resuscitated.
  • DESCRIPTION:  Definition Revised (2004): If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the
    only condition under which a DNR order is official in the VA in the 30 days prior to this surgery], enter "YES". If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the
    patient, enter "YES". Answer "NO" if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official
    order.
239 PREOPERATIVE HEMOGLOBIN, DATE 202;20 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date preop Hemoglobin was performed.
  • DESCRIPTION:  
    This is the date that the preoperative hemoglobin test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
240 *FUNCTIONAL HEALTH STATUS 200;8 SET
  • '1' FOR INDEPENDENT;
  • '2' FOR PARTIALLY DEPENDENT;
  • '3' FOR TOTALLY DEPENDENT;
  • '4' FOR UNKNOWN;

  • LAST EDITED:  JUN 24, 2015
  • HELP-PROMPT:  Enter the level of self care that summarizes the patient's status prior to surgery.
  • DESCRIPTION:  VASQIP Definition (2011): This is a question that focuses on the patient's abilities to perform activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are defined as 'the activities
    usually performed in the course of a normal day in a person's life'. ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level of self-care for activities of daily living
    demonstrated by this patient at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's status changes prior to surgery, that change
    should be reflected in your assessment. For this time point, report the level of functional health status as defined by the following criteria.
    (1) Independent: The patient does not require assistance from another person for any activities of daily living. This includes a person who is able to function independently with prosthetics, equipment, or devices.
    (2) Partially dependent: The patient requires some assistance from another person for activities of daily living. This includes a person who utilizes prosthetics, equipment, or devices but still requires some assistance
    from another person for ADLs.
    (3) Totally dependent: The patient requires total assistance for all activities of daily living.
    (4) Unknown: If unable to ascertain the functional status.
    All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with schizophrenia is able to
    care for him/herself without the assistance of nursing care, he/she is considered independent.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
241 PULMONARY (Y/N) 200;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of pulmonary illnesses.
  • DESCRIPTION:  
    This determines whether the patient has a history of pulmonary illnesses.
242 CARDIAC (Y/N) 200;30 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of cardiac illnesses.
  • DESCRIPTION:  This determines whether the patient has a history of cardiac illnesses.
243 RENAL (Y/N) 200;37 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of renal illnesses.
  • DESCRIPTION:  This determines whether the patient has a history of renal illnesses.
244 HEPATOBILIARY (Y/N) 200;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 22, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of hepatobiliary illnesses.
  • DESCRIPTION:  This determines whether the patient has a history of hepatobiliary illnesses.
245 NUTRITIONAL/IMMUNE/OTHER 200;44 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has a history of general/nutritional/immune illness.
  • DESCRIPTION:  This determines whether the patient has a history of illness related to nutrition, immune deficiencies or other general deficiencies.
246 ETOH > 2 DRINKS/DAY 200;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient admits to having greater than two drinks per day within the two weeks prior to admission.
  • DESCRIPTION:  Definition Revised (2004): The patient admits to drinking >2 ounces of hard liquor or more than two 12 oz. cans of beer or more than two 6 oz. glasses of wine per day in the two weeks prior to admission. If the patient is
    a "binge drinker" divide out the numbers of drinks during the binge by seven days, and then apply the definition.
247 LENGTH OF POST-OP STAY 205;1 FREE TEXT

  • INPUT TRANSFORM:  S:X="NA"!(X="na") X="NA" Q:X="NA" K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  JUL 28, 2004
  • HELP-PROMPT:  Enter the total number of days this patient remained in the hospital after his or her operation. Enter NA if LENGTH OF POST-OP STAY is not applicable.
  • DESCRIPTION:  Definition Revised (2004): The software will automatically calculate the total number of days that the patient stayed in the acute care services of the medical center. The number of days should include the day after
    surgery and the date of discharge or transfer to intermediate or chronic care facilities.
    Enter NA if LENGTH OF POST-OP STAY is not applicable.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
248 SUPERFICIAL INCISIONAL SSI 205;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if this patient had a superficial incisional surgical site infection.
  • DESCRIPTION:  Definition Revised (2004): Superficial incisional SSI is an infection that occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the
    following:
    - Purulent drainage, with or without laboratory confirmation, from the
    superficial incision.
    - Organisms isolated from an aseptically obtained culture of fluid or
    tissue from the superficial incision.
    - At least one of the following signs or symptoms of infection: pain
    or tenderness, localized swelling, redness, or heat and superficial
    incision is deliberately opened by the surgeon, unless incision is
    culture-negative.
    - Diagnosis of superficial incisional SSI by the surgeon or attending
    physician.
    Do not report the following conditions as SSI:
    - Stitch abscess (minimal inflammation and discharge confined to the
    points of suture penetration).
    - Infected burn wound.
    - Incisional SSI that extends into the fascial and muscle layers (see
    deep incisional SSI).
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
249 DEEP INCISIONAL SSI 205;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAY 13, 2015
  • HELP-PROMPT:  Enter YES if this patient had a deep incisional surgical site infection.
  • DESCRIPTION:  Definition Revised (2015): Deep Incisional SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and infection involved deep soft tissues (e.g., fascial
    and muscle layers) of the incision and at least one of the following:
    - Purulent drainage from the deep incision but not from the
    organ/space component of the surgical site.
    - A deep incision spontaneously dehisces or is deliberately opened by
    a surgeon when the patient has at least one of the following signs
    or symptoms: fever (>38 C), localized pain, or tenderness, unless
    site is culture-negative.
    - An abscess or other evidence of infection involving the deep
    incision is found on direct examination, during reoperation, or by
    histopathologic or radiologic examination.
    - Diagnosis of a deep incision SSI by a surgeon or attending
    physician.
    NOTE: Please consult with the operating surgeon for assignment of organ/space vs. deep wound infection occurrences.
250 SYSTEMIC SEPSIS 205;35 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has been diagnosed as having postoperative systemic sepsis.
  • DESCRIPTION:  Definition Revised (2007): Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. Please report the most significant
    level using the criteria below:
    1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults. This
    syndrome is clinically recognized by the presence of two or more of the following:
    - Temp >38 degrees C or <36 degrees C
    - HR >90 bpm
    - RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa)
    - WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band)
    forms
    - Anion gap acidosis: this is defined by either:
    [Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is
    greater than 16, then an anion gap acidosis is present.
    or
    Na - [Cl + HCO3 (or serum CO2)]. If this number is greater
    than 12, then an anion gap acidosis is present.
    and one of the following:
    - positive blood culture
    - clinical documentation of purulence or positive culture from any
    site thought to be causative
    2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND
    documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension,
    requirement of inotropic or vasopressor agents.
    * For the patient that had sepsis preoperatively, worsening of any of the above signs postoperatively would be reported as a postoperative sepsis.
    Examples:
    A patient comes into the emergency room with signs of sepsis - WBC 31, Temperature 104. CT shows an abdominal abscess. He is given antibiotics and is then taken emergently to the OR to drain the abscess. He receives
    antibiotics intraoperatively. Postoperatively his WBC and Temperature are trending down.
    POD#1 WBC 24, Temp 102
    POD#2 WBC 14, Temp 100
    POD#3 WBC 10, Temp 99 This patient does not have postoperative sepsis as his WBC and Temperature are improving each postoperative day.
    Patient comes into the ER with s/s of sepsis - WBC 31, Temp 104. CT shows an abdominal abscess. He is given antibiotics and is taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively.
    Postoperatively his WBC and Temp are as follows:
    POD#1 WBC 28, Temp 103
    POD#2 WBC 24, Temp 102.6
    POD#3 WBC 22, Temp 102
    POD#4 WBC 21, Temp 101.6
    POD#5 WBC 30, Temp 104 This patient does have postoperative sepsis because on postoperative day #5, his WBC and Temperature increase. The patient is having worsening of the defined signs of sepsis.
251 PNEUMONIA 205;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 18, 2004
  • HELP-PROMPT:  Enter YES if the patient has a postoperative occurrence of pneumonia.
  • DESCRIPTION:  Definition Revised (2007): Inflammation of the lungs caused primarily by bacteria, viruses, and/or chemical irritants, usually manifested by chills, fever, pain in the chest, cough, purulent, bloody sputum. Enter YES if
    the patient has pneumonia meeting the definition of pneumonia below AND pneumonia not present preoperatively.
    Pneumonia must meet one of the following TWO criteria:
    Criterion 1.
    Rales or dullness to percussion on physical examination of chest AND
    any of the following:
    a. New onset of purulent sputum or change in character of sputum
    b. Organism isolate from blood culture
    c. Isolation of pathogen from specimen obtained by transtracheal
    aspirate, bronchial brushing, or biopsy
    OR
    Criterion 2.
    Chest radiographic examination shows new or progressive infiltrate,
    consolidation, cavitation, or pleural effusion AND any of the
    following:
    a. New onset of purulent sputum or change in character of sputum
    b. Organism isolated from blood culture
    c. Isolation of pathogen from specimen obtained by transtracheal
    aspirate, bronchial brushing, or biopsy
    d. Isolation of virus or detection of viral antigen in respiratory
    secretions
    e. Diagnostic single antibody titer (IgM) or fourfold increase in
    paired serum samples (IgG) for pathogen
    f. Histopathologic evidence of pneumonia
    *If pneumonia was present preoperatively and resolved postoperatively and a new pneumonia is identified within 30 days after surgery, the following criteria must be met in order to report as a postoperative pneumonia
    occurrence:
    - Patient must have completed the antibiotic course for the
    previous pneumonia.
    - Patient must have evidence of a clear chest x-ray after the
    previous pneumonia and prior to the new pneumonia.
    - There must be evidence of a new isolate of micro-organism on
    culture.
252 PULMONARY EMBOLISM 205;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has had a postoperative pulmonary embolism.
  • DESCRIPTION:  Definition Revised (2007): Lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous
    system. Enter "YES" if the patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram or positive Spiral CT exam. Treatment usually consists
    of:
    - Initiation of anticoagulation therapy
    - Placement of mechanical interruption (e.g. Greenfield Filter), for
    patients in whom anticoagulation is contraindicated or already
    instituted.
253 OTHER RESPIRATORY OCCURRENCE 205;14 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",$G(DA))
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
  • LAST EDITED:  MAR 18, 2013
  • HELP-PROMPT:  Enter the ICD Diagnosis code related to the postoperative respiratory occurrence.
  • DESCRIPTION:  
    Definition Revised (2004): Enter any other respiratory occurrences that you feel to be significant and that are not covered by the predefined respiratory occurrence categories. Enter the ICD-CM code for this entry.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
254 ACUTE RENAL FAILURE 205;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 08, 2011
  • HELP-PROMPT:  Enter YES if the patient has acute renal failure.
  • DESCRIPTION:  VASQIP Definition (2011): Indicate if the patient developed new renal failure requiring renal replacement therapy or experienced an exacerbation of preoperative renal failure requiring initiation of renal replacement
    therapy (not on renal replacement therapy preoperatively) within 30 days postoperatively. Renal replacement therapy is defined as venous to venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis [CVAHD],
    peritoneal dialysis, hemofiltration, hemodiafiltration or ultrafiltration.
    TIP: If the patient refuses dialysis, report as an occurrence because he/she did require dialysis.
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
255 URINARY TRACT INFECTION 205;18 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has a postoperative urinary tract infection.
  • DESCRIPTION:  Definition Revised (2004): Postoperative symptomatic urinary tract infection must meet one of the following TWO criteria:
    1. One of the following: fever (>38 degrees C), urgency, frequency,
    dysuria, or suprapubic tenderness AND a urine culture of >100,000
    colonies/ml urine with no more than two species of organisms
    OR
    2. Two of the following: fever (>38 degrees C), urgency, frequency,
    dysuria, or suprapubic tenderness AND any of the following:
    - Dipstick test positive for leukocyte esterase and/or nitrate
    - Pyuria (>10 WBCs/cc or >3 WBC/hpf of unspun urine)
    - Organisms seen on Gram stain of unspun urine
    - Two urine cultures with repeated isolation of the same uropathogen
    with >100 colonies/ml urine in non-voided specimen
    - Urine culture with <100,000 colonies/ml urine of single
    uropathogen in patient being treated with appropriate
    antimicrobial therapy
    - Physician's diagnosis
    - Physician institutes appropriate antimicrobial therapy
256 STROKE/CVA 205;21 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 22, 2011
  • HELP-PROMPT:  Enter status of Stroke/CVA.
  • DESCRIPTION:  VASQIP Definitions (2011): Indicate if the patient developed a new neurologic deficit with onset immediately post-operatively or occurring within the 30 days after surgery. Neurologic deficits are defined as an embolic,
    thrombotic, or hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory).
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
257 POSTOP BLEEDING/TRANSFUSIONS 205;32 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient had bleeding requiring >4 units PRBC's or whole blood within 72 hours postoperatively.
  • DESCRIPTION:  Definition Revised (2004): Any transfusion (including autologous) of packed red blood cells or whole blood given from the time the patient leaves the operating room up to and including 72 hours postoperatively. Enter YES
    for five or more units of packed red blood cell units in the postoperative period including hanging blood from the OR that is finished outside of the OR. If the patient receives shed blood, autologous blood, cell saver
    blood or pleurovac postoperatively, this is counted if greater than four units. The blood may be given for any reason.
258 MYOCARDIAL INFARCTION 205;27 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 09, 2014
  • HELP-PROMPT:  Enter YES if the patient has had a myocardial infarction.
  • DESCRIPTION:  VASQIP Definition (2014): Indicate the presence of a peri-operative MI that occurs either intraoperatively or postoperatively within 30 days: The term acute MI should be used when there is evidence of myocardial necrosis
    in a clinical setting consistent with acute myocardial ischemia. Under these conditions any ONE of the following criteria meets the diagnosis for MI:
    1. Detection of a rise and/or fall of cardiac biomarker values
    [preferably cardiac troponin (cTn)] with at least one value above
    the 99th percentile Upper Reference Limit (URL) AND at least one
    of the following:
    a. Symptoms suggestive of myocardial ischemia
    b. New or presumed new significant ST-segment-T wave (ST-T) changes
    c. New left bundle branch block (LBBB).
    d. Development of pathological Q waves in the ECG
    e. Imaging evidence of new loss of viable myocardium
    f. New regional wall motion abnormality
    g. Identification of an intracoronary thrombus by angiography or
    autopsy 2. Cardiac death with symptoms suggestive of myocardial ischemia and
    presumed new ischemic ECG changes or new LBBB, but death occurred
    before cardiac biomarkers were obtained, or before cardiac
    biomarker values would be increased.
    3. Percutaneous coronary intervention (PCI) related MI is arbitrarily
    defined by elevation of cTn values (>5x 99th percentile URL) in
    patients with normal baseline values (<99th percentile URL) or a
    rise of cTn values >20% if the baseline values are elevated and
    are stable or falling,
    AND at least one of the following:
    a. Symptoms suggestive of myocardial ischemia
    b. Presumed new ischemic ECG changes
    c. Angiographic findings consistent with a procedural complication
    d. Imaging evidence of new loss of viable myocardium
    e. New regional wall motion abnormality
    4. Stent thrombosis associated with MI when detected by coronary
    angiography or autopsy in the setting of myocardial ischemia and
    with a rise and/or fall of cardiac biomarker values with at least
    one value above the 99th percentile URL.
    5. Coronary artery bypass grafting (CABG) related MI is arbitrarily
    defined by elevation of cardiac biomarker values (>10x 99th
    percentile URL) in patients with normal baseline cTn values
    (<99th percentile URL),
    AND at least one of the following
    a. Development of pathological Q waves in the ECG
    b. New LBBB
    c. Angiographic documented new graft or new native coronary
    artery occlusion
    d. Imaging evidence of new loss of viable myocardium
    e. New regional wall motion abnormality
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
259 PULMONARY EDEMA 205;28 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has postoperative pulmonary edema requiring IV diuretic therapy.
  • DESCRIPTION:  
    This determines whether the patient has developed postoperative distress requiring treatment and diagnosis of CHF or pulmonary edema or Adult Respiratory Distress Syndrome.
260 DATE TRANSMITTED RA;4 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  NOV 05, 2007
  • HELP-PROMPT:  Enter the Date that this Assessment was transmitted.
  • DESCRIPTION:  This is the date (or date/time) that this surgery risk assessment was transmitted.
  • CROSS-REFERENCE:  130^AT1^MUMPS
    1)= D AT1^SROXR4
    2)= D KAT1^SROXR4
    This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases by the DATE TRANSMITTED field.
260.1 DATE OF LAST TRANSMISSION RA;8 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  NOV 05, 2007
  • DESCRIPTION:  This is the date of the retransmission if this risk assessment has been retransmitted to the national database. An assessment can be updated and retransmitted within 14 days of the original transmission date. If there was
    no retransmission of this assessment, this is the date of the original transmission.
  • CROSS-REFERENCE:  130^AT^MUMPS
    1)= D AT^SROXR4
    2)= D KAT^SROXR4
    This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases by the DATE OF LAST TRANSMISSION field.
261 GRAFT/PROSTHESIS/FLAP FAILURE 205;33 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter YES if the patient has had a postoperative graft, flap, or prosthesis failure.
  • DESCRIPTION:  Definition Revised (2015): An extracardiac graft (including myocutaneous flaps or skin grafts) or prosthesis (including stents, mesh) is considered to have failed when it requires additional intervention via return to the
    operating room or interventional radiology. Failures include those caused by an infectious process or a mechanical issue.
262 RETURN TO OR WITHIN 30 DAYS 205;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient had a return to the operating room within 30 days of this surgery.
  • DESCRIPTION:  Definition Revised (2004): Returns to the operating room include all surgical procedures that required the patient to be taken to the surgical operating room for intervention of any kind will automatically be entered by
    the software.
263 DVT/THROMBOPHLEBITIS 205;34 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 07, 2014
  • HELP-PROMPT:  Enter YES if the patient has postoperative DVT/Thrombophlebitis.
  • DESCRIPTION:  VASQIP Definition (2014): The identification of a new blood clot or thrombus within the deep venous system of an extremity, which may be coupled with inflammation. This does not include intra-parenchymal clots of solid
    organs or free intra-peritoneal clots. This diagnosis is confirmed by a duplex, venogram, CT scan or other imaging modality. The patient must be treated with or have documented recommendation for: therapeutic
    anti-coagulation therapy OR placement of a vena cava filter OR clipping of the vena cava.
264 *CEREBRAL VASCULAR DISEASE 206;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 18, 2011
  • HELP-PROMPT:  Enter 'YES' if this patient has disease of the arteries to the head.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    This determines whether the patient has disease of the arteries to the head manifested by previous stroke (cerebral vascular accident), and/or transient ischemic attack (TIA), and/or prior surgical repair (e.g. carotid
    endarterectomy), and/or greater than or equal to 50% obstruction of luminal diameter documented by contrast angiography or duplex ultrasound examination.
265 PERIPHERAL ARTERIAL DISEASE 206;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • '1' FOR NO;
  • '2' FOR YES-W/O ANGI,REVASC,or AMPUT;
  • '3' FOR YES-W HX ANGI,REVASC,or AMPUT;
  • '4' FOR UNKNOWN;

  • LAST EDITED:  MAY 12, 2015
  • HELP-PROMPT:  Select appropriate response from 1 to 3.
  • DESCRIPTION:  VASQIP Definition (2015): Indicate if the patient has peripheral arterial disease (previously "peripheral vascular disease"), defined as disease of the arteries of the extremities. Peripheral arterial disease, most
    commonly identified in the legs but on occasion in the arms, is manifested by at least one of the following: exertional claudication, ischemic rest pain, ischemic ulcers or gangrene, prior revascularization procedure(s) on
    vessels or amputation of one or more extremity for arterial occlusive disease, absent or diminished pulses in legs, or invasive (i.e. angiographic) or non-invasive (i.e. ultrasound) evidence of non-iatrogenic peripheral
    arterial obstruction greater than or equal to 50% of luminal diameter.
    Indicate the one appropriate response:
    1. No
    2. Yes, without angioplasty, revascularization, or amputation
    procedure
    3. Yes, with any history of angioplasty, or revascularization, or
    amputation procedure, regardless of laterality
  • SCREEN:  S DIC("S")="I ""123""[Y"
  • EXPLANATION:  Screen prevents selection of inactive entries.
266 *PREVIOUS CARDIAC SURGERY 200;33 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 08, 2014
  • HELP-PROMPT:  Enter 'YES' if this patient has had a previous cardiac surgery.
  • DESCRIPTION:  Definition Revised (2006): Any major cardiac surgical procedure (performed either as an 'off-pump' repair or utilizing cardiopulmonary bypass). This includes coronary artery bypass graft surgery, valve replacement or
    repair, repair of atrial or ventricular septal defects, great thoracic vessel repair, cardiac transplant, left ventricular aneurysmectomy, insertion of left ventricular assist devices, etc. Do not include pacemaker
    insertions or automatic implantable cardioverter-defibrillator (AICD) insertions.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
267 ANGINA SEVERITY 206;18 SET
  • 'N' FOR NONE;
  • 'I' FOR CLASS I;
  • 'II' FOR CLASS II;
  • 'III' FOR CLASS III;
  • 'IV' FOR CLASS IV;
  • 'U' FOR UNKNOWN;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the CCS classification associated with the severity of angina in the 14 days preceding surgery.
  • DESCRIPTION:  VASQIP Definition (2014): Indicate whether the patient has angina, defined as pain or discomfort between the diaphragm and mandible resulting from myocardial ischemia, usually precipitated by exertion or emotion and
    relieved by rest or nitroglycerin. The Canadian Cardiovascular Society (CCS) classification is used to record severity of angina. Indicate the one appropriate response, according to the most severe angina in the 30 days
    prior to surgery:
    None - No angina Class I - Ordinary physical activity, such as walking or climbing
    stairs does not cause angina. Angina may occur with
    strenuous or rapid or prolonged exertion at work or
    recreation. Class II - There is slight limitation of ordinary activity.
    Angina may occur with walking or climbing stairs rapidly,
    walking uphill, walking or stair climbing after meals or
    in the cold, in the wind, or under emotional stress, or
    walking more than two blocks on the level, or climbing more
    than one flight of stairs under normal conditions at a
    normal pace. Class III - There is marked limitation of ordinary physical activity.
    Angina may occur after walking one or two blocks on the
    level or climbing one flight of stairs under normal
    conditions at a normal pace. Class IV - There is inability to carry on any physical activity
    without discomfort. Angina may be present at rest. Unknown - Unknown
268 HEPATOMEGALY 200;14 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 19, 1991
  • HELP-PROMPT:  Enter 'YES' if the physician has noted the presence of hepatomegaly in his History and Physical.
  • DESCRIPTION:  This determines whether the patient has the presence of hepatomegaly. Hepatomegaly is defined as enlargement of the liver indicated usually by palpation of the lower border of the liver below the right costal margin or a
    liver span greater than 10 cm. Hepatomegaly may be noted in acute hepatitis, fatty infiltration, passive congestion, and early biliary obstruction. It is usually noted by the physician under the abdominal portion of the
    H&P.
269 PREGNANCY 200.1;3 SET
  • 'NO' FOR NO;
  • 'NA' FOR NOT APPLICABLE;
  • 'Y' FOR YES;

  • LAST EDITED:  FEB 14, 2007
  • HELP-PROMPT:  Enter the preoperative pregnancy status of this patient.
  • DESCRIPTION:  Definition Revised (2007): Pregnancy is the process by which a woman carries a developing fetus in her uterus, beginning at conception and ending in birth, miscarriage or abortion. Answer Yes if there is documentation in
    the patient's medical record that the patient is currently pregnant.
270 PREOPERATIVE SERUM SODIUM 201;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative serum sodium test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is
    also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
271 PREOPERATIVE POTASSIUM 201;2 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>8)!(X<1.5)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 28, 1991
  • HELP-PROMPT:  Enter the result of the preoperative potassium test. Your answer must be between 1.5 and 8.0.
  • DESCRIPTION:  This is the result of the preoperative potassium test.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
272 DATE ASSESSMENT COMPLETED RA;5 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  FEB 21, 1992
  • DESCRIPTION:  This is the date that the Assessment was completed. This field will be updated if the assessment was transmitted in error.
272.1 ASSESSMENT COMPLETED BY RA;9 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  MAY 05, 2010
  • HELP-PROMPT:  Enter the name of the person who completed the assessment.
  • DESCRIPTION:  
    This is the name of the person who completed this surgery risk assessment.
273 PREOPERATIVE GLUCOSE 201;3 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>1200)!(X<20)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the result of the preoperative glucose test. Your answer should be between 20 and 1200.
  • DESCRIPTION:  This is the result of the preoperative glucose test.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
274 HIGHEST SERUM SODIUM 203;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the highest result of a postoperative serum sodium test for the selected patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">".
    Entering "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
275 HIGHEST POTASSIUM 203;3 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  This is the highest result of a potassium test for the selected patient. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for
    "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
276 HIGHEST GLUCOSE 203;5 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>1200)!(X<20)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the highest postoperative glucose result. Your answer should be between 20 and 1200.
  • DESCRIPTION:  This is the highest result of a postoperative glucose test for the patient selected.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
277 HIGHEST SERUM CREATININE 203;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the highest postoperative serum creatinine result for the selected patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
278 HIGHEST CPK 203;7 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  This is the highest result of a postoperative CPK test for the patient selected. Data input must be 1 to 6 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
279 HIGHEST CPK-MB 203;8 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the highest result of a postoperative CP-MB Band for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS"
    for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
280 HIGHEST TOTAL BILIRUBIN 203;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the highest postoperative total bilirubin result recorded for this patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
281 HIGHEST WBC 203;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the highest postoperative WBC for the patient selected. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No
    Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
282 LOWEST SERUM ALBUMIN 203;11 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the highest postoperative serum albumin test result. Your answer must be between 0 and 50.
  • DESCRIPTION:  This is the lowest postoperative serum albumin result for the patient selected.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
283 LOWEST HEMATOCRIT 203;12 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the lowest postoperative hematocrit result recorded for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS"
    for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
284 ASSESSMENT TYPE RA;2 SET
  • 'C' FOR CARDIAC;
  • 'N' FOR NON-CARDIAC;

  • LAST EDITED:  MAR 28, 1991
  • DESCRIPTION:  This determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.
  • RECORD INDEXES:  ARS (#1418)
285 ON VENTILATOR >48 HOURS 205;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 01, 2015
  • HELP-PROMPT:  Enter YES if the total duration of ventilator-assisted respiration during the 30 days postoperative was > or = 48 hours.
  • DESCRIPTION:  Definition Revised (2015): Total duration of ventilator-assisted respirations during postoperative hospitalization after leaving the OR was >48 hours. This can occur at any time during the 30-day period postoperatively.
    This time assessment is CUMULATIVE, not necessarily consecutive. Ventilator-assisted respirations can be via endotracheal tube, nasotracheal tube, or tracheostomy tube. This definition also applies if the patient was on
    the ventilator preoperatively and remained on the ventilator postoperatively >48 hours.
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
286 OTHER URINARY TRACT OCCURRENCE 205;19 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
  • LAST EDITED:  FEB 17, 2012
  • HELP-PROMPT:  Enter the ICD Diagnosis code for the postoperative urinary tract occurrence.
  • DESCRIPTION:  
    Definition Revised (2004): Enter any other urinary occurrences which you feel to be significant and that are not covered by the predefined urinary tract occurrence categories. Enter the ICD-CM code for this entry.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
287 PERIPHERAL NERVE INJURY 205;23 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has major peripheral neurological injuries.
  • DESCRIPTION:  Definition Revised (2007): Peripheral nerve damage may result from damage to the nerve fibers, cell body, or myelin sheath during surgery. Peripheral nerve injuries which result in motor deficits only to the cervical
    plexus, brachial plexus, ulnar plexus, lumbar-sacral plexus (sciatic nerve), peroneal nerve, and/or the femoral nerve should be included.
288 PREOPERATIVE CPK, DATE 202;6 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the preoperative CPK test was performed.
  • DESCRIPTION:  This is the date that the preoperative CPK was performed.
289 PREOPERATIVE MB BAND, DATE 202;7 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the preoperative MB Band was performed.
  • DESCRIPTION:  This is the date that the preoperative MB Band was performed.
290 PREOP SERUM CREATININE, DATE 202;4 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Serum Creatinine was performed.
  • DESCRIPTION:  This is the date that the preoperative Serum Creatinine test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
291 PREOPERATIVE BUN, DATE 202;5 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative BUN was performed.
  • DESCRIPTION:  This is the date that the preoperative BUN was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
292 PREOP SERUM ALBUMIN, DATE 202;8 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Serum Albumin was performed.
  • DESCRIPTION:  This is the date that the preoperative Serum Albumin test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
293 SGPT, DATE PERFORMED 202;10 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the preoperative SGPT was performed.
  • DESCRIPTION:  This is the date that the preoperative SGPT was performed.
294 SGOT, DATE PERFORMED 202;11 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative SGOT was performed.
  • DESCRIPTION:  This is the date that the preoperative SGOT was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
295 PREOP TOTAL BILIRUBIN, DATE 202;9 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Total Bilirubin was performed.
  • DESCRIPTION:  This is the date that the preoperative total bilirubin was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
296 PREOP ALK PHOSPHATASE, DATE 202;12 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Alkaline Phosphatase was performed.
  • DESCRIPTION:  This is the date that the preoperative alkaline phosphatase test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
297 PREOPERATIVE WBC, DATE 202;13 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative WBC was performed.
  • DESCRIPTION:  This is the date that the preoperative WBC test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
298 PREOP PLATELET COUNT, DATE 202;15 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Platelet Count was performed.
  • DESCRIPTION:  This is the date that the preoperative platelet count was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
299 PREOPERATIVE PT, DATE 202;17 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative PT was performed.
  • DESCRIPTION:  This is the date that the preoperative PT test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
300 PREOPERATIVE PTT, DATE 202;16 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative PTT was performed.
  • DESCRIPTION:  This is the date that the preoperative PTT test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
301 PREOP HEMATOCRIT, DATE 202;14 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Hematocrit test was performed.
  • DESCRIPTION:  This is the date that the preoperative hematocrit was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
302 PREOPERATIVE GLUCOSE, DATE 202;3 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the preoperative Glucose test was performed.
  • DESCRIPTION:  This is the date that the preoperative glucose test was performed.
303 PREOP POTASSIUM, DATE 202;2 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the preoperative Potassium test was performed.
  • DESCRIPTION:  This is the date that the preoperative potassium test was performed.
304 PREOP SERUM SODIUM, DATE 202;1 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative Serum Sodium test was performed.
  • DESCRIPTION:  This is the date that the preoperative serum sodium test was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
305 HIGH SERUM SODIUM, DATE 204;1 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest Serum Sodium result was recorded.
  • DESCRIPTION:  This is the date that the highest Serum Sodium result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
306 HIGH POTASSIUM, DATE 204;3 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest Potassium result was recorded.
  • DESCRIPTION:  This is the date that the highest Potassium result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
307 HIGH GLUCOSE, DATE 204;5 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the highest Glucose result was recorded.
  • DESCRIPTION:  This is the date that the highest Glucose result was recorded.
308 HIGH SERUM CREATININE, DATE 204;6 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest Serum Creatinine result was recorded.
  • DESCRIPTION:  This is the date that the highest Serum Creatinine result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
309 HIGH CPK, DATE 204;7 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest CPK result was recorded.
  • DESCRIPTION:  This is the date that the highest CPK result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
310 HIGH CPK-MB, DATE 204;8 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest CPK-MB Band result was recorded.
  • DESCRIPTION:  This is the date that the highest CPK-MB Band result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
311 HIGH TOTAL BILIRUBIN, DATE 204;9 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest Total Bilirubin result was recorded.
  • DESCRIPTION:  This is the date that the highest Total Bilirubin was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
312 HIGHEST WBC, DATE 204;10 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest WBC result was recorded.
  • DESCRIPTION:  This is the date that the highest WBC was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
313 LOW SERUM ALBUMIN, DATE 204;11 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • HELP-PROMPT:  Enter the date that the lowest Serum Albumin result was recorded.
  • DESCRIPTION:  This is the date that the lowest Serum Albumin result was recorded.
314 LOW HEMATOCRIT, DATE 204;12 DATE

  • INPUT TRANSFORM:  S %DT="EP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the lowest Hematocrit result was recorded.
  • DESCRIPTION:  This is the date that the lowest Hematocrit result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
315 PREOPERATIVE PT CONTROL 201;19 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>15)!(X<9)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the preoperative PT Control result. Your answer must be between 9 and 15.
  • DESCRIPTION:  This is the result of the preoperative PT control. Your answer must be between 9 and 15.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
316 PREOPERATIVE PTT CONTROL 201;18 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>40)!(X<15)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  JUL 15, 1991
  • HELP-PROMPT:  Enter the preoperative PTT Control result. Your answer must be between 15 and 40.
  • DESCRIPTION:  This is the preoperative PTT control result. Your answer must be between 15 and 40.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
318 RESPIRATORY OCCURRENCES 205;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has had postoperative respiratory occurrences.
  • DESCRIPTION:  This determines whether the patient had postoperative respiratory occurrences. A respiratory occurrence is defined as an impairment to the lungs to perform their ventilatory function. This may be due to impairment of gas
    exchange in the lung or obstruction of the free flow of air to the lung.
319 URINARY TRACT OCCURRENCES 205;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has had postoperative urinary tract occurrences.
  • DESCRIPTION:  This determines whether the patient has had postoperative urinary tract occurrences. Urinary tract occurrences are defined as difficulties related to the organs and ducts participating in the secretion and elimination of
    urine.
320 CNS OCCURRENCES 205;20 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has had any postoperative CNS occurrences.
  • DESCRIPTION:  This determines whether the patient has had any postoperative central nervous system (CNS) occurrences. These occurrences are defined as difficulties related to the brain and spinal cord, with their nerves and end-organs
    that control voluntary acts.
321 CARDIAC OCCURRENCES 205;25 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has had any postoperative cardiac occurrences.
  • DESCRIPTION:  This determines whether the patient has had any postoperative cardiac occurrences. Cardiac occurrences are defined as difficulties encountered involving the cardiac system.
322 OTHER OCCURRENCES 205;30 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has had other occurrences not included in the other occurrence categories.
  • DESCRIPTION:  This determines whether the patient has had postoperative occurrences, such as Graft/Prosthesis Failure or Unplanned Return to OR, not included in any of the other categories.
323 CREATE RISK ASSESSMENT RA;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 24, 1991
  • HELP-PROMPT:  Enter 'YES' if you are going to create a risk assessment for this surgical case.
  • DESCRIPTION:  This determines whether a risk assessment will be created for this surgical case. If answered 'NO', the information will automatically be completed so that the information will be transmitted without any additional
    intervention.
324 DRUG ADDICTION 200;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient admits to recreational or narcotic substance abuse.
  • DESCRIPTION:  This determines whether this patient has a history of recreational or narcotic substance abuse. There is no time limit on this data element.
325 DYSPNEA 200;6 SET
  • '1' FOR NO;
  • '2' FOR MODERATE EXERTION;
  • '3' FOR AT REST;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 20, 2005
  • HELP-PROMPT:  Enter the category that most appropriately applies to this patient.
  • DESCRIPTION:  Definition Revised (2007): The patient describes difficult, painful, or labored breathing. Dyspnea may be symptomatic of numerous disorders that interfere with adequate ventilation or perfusion of the blood with oxygen.
    The dyspneic patient is subjectively aware of difficulty with breathing. Select one of the following categories that best indicates the patient's subjective experience coupled with your objective assessment:
    (1) No dyspnea
    (2) Dyspnea upon moderate exertion (e.g., is unable to climb one
    flight of stairs without shortness of breath)
    (3) Dyspnea at rest (e.g., cannot complete a sentence without needing
    to take a breath)
    The time frame is at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's dyspnea status worsens prior to surgery, report the most
    severe.
326 CURRENT PNEUMONIA 200;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has Pneumonia.
  • DESCRIPTION:  Definition Revised (2007): Report patients with evidence of pneumonia at the time the patient is brought to the OR. Patients with pneumonia must meet ONE of the following two criteria:
    Criterion 1.
    Rales or dullness to percussion on physical examination of chest AND
    any of the following:
    a. New onset of purulent sputum or change in character of sputum
    b. Organism isolate from blood culture
    c. Isolation of pathogen from specimen obtained by transtracheal
    aspirate, bronchial brushing, or biopsy
    OR
    Criterion 2.
    Chest radiographic examination shows new or progressive infiltrate,
    consolidation, cavitation, or pleural effusion AND any of the
    following:
    a. New onset of purulent sputum or change in character of sputum
    b. Organism isolated from blood culture
    c. Isolation of pathogen from specimen obtained by transtracheal
    aspirate, bronchial brushing, or biopsy
    d. Isolation of virus or detection of viral antigen in respiratory
    secretions
    e. Diagnostic single antibody titer (IgM) or fourfold increase in
    paired serum samples (IgG) for pathogen
    f. Histopathologic evidence of pneumonia
327 ACTIVE HEPATITIS 200;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if this patient has active hepatitis.
  • DESCRIPTION:  This determines whether the patient has active hepatitis. Active Hepatitis is defined as an active inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral hepatitis documented by
    positive serologies (A,B, or C) and recent excessive alcohol intake, or drug induced hepatitis.
328 RENAL FAILURE 200;38 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 01, 2004
  • HELP-PROMPT:  Enter YES if the patient has acute renal failure.
  • DESCRIPTION:  Definition Revised (2004): The clinical condition associated with rapid, steadily increasing azotemia (increase in BUN), and a rising creatinine of above 3 mg/dl. Acute renal failure should be noted within 24 hours prior
    to surgery.
329 *REVASCULARIZATION/AMPUTATION 200;41 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 24, 2014
  • HELP-PROMPT:  Enter 'YES' if the patient has a history of revascularization/amputation for PVD.
  • DESCRIPTION:  Definition Revised (2004): Any type of angioplasty or revascularization procedure for atherosclerotic peripheral vascular disease (PVD) (e.g., aorto-femoral, femoral-femoral, femoral-popliteal) or a patient who has had any
    type of amputation procedure for PVD (e.g., toe amputations, transmetatarsal amputations, below the knee or above the knee amputations). Patients who have had amputation for trauma or a resection of abdominal aortic
    aneurysms should not be included.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
330 REST PAIN/GANGRENE (Y/N) 200;42 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient suffers from rest pain/gangrene.
  • DESCRIPTION:  Definition Revised (2007): Rest pain is a more severe form of ischemic pain due to occlusive disease, which occurs at rest and is manifested as a severe, unrelenting pain aggravated by elevation and often preventing sleep.
    Gangrene is a marked skin discoloration and disruption indicative of death and decay of tissues in the extremities due to severe and prolonged ischemia. Include patients with ischemic ulceration and/or tissue loss related
    to peripheral vascular disease. Do not include Fournier's gangrene. Report only if within the 30 days preoperatively.
331 ABSENT PERIPHERAL PULSES 200;43 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has been diagnosed as having absent peripheral pulses.
  • DESCRIPTION:  This determines whether the patient has been diagnosed on the physical examination to have absent femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as present or absent in the
    remaining limb.
332 IMPAIRED SENSORIUM 200;19 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 15, 2015
  • HELP-PROMPT:  Enter YES if this patient has impaired sensorium.
  • DESCRIPTION:  Definition Revised (2015): Patient is acutely confused and/or delirious and responds to verbal and/or mild tactile stimulation. Patients should be noted to have developed an impaired sensorium if they have mental status
    changes, and/or delirium in the context of the current illness. Patients with chronic or long-standing mental status changes secondary to chronic mental illness (e.g., schizophrenia) or chronic dementing illnesses (e.g.,
    multi-infarct dementia, senile dementia of the Alzheimer's type) should not be included. Answer "Yes" if the criteria for this definition applies at any time within 48 hours preop. If the patient develops impaired
    sensorium, then progresses to a coma, and remains in a coma entering surgery, report just coma.
    Choose from: Y YES N NO NS NO STUDY
333 COMA 200;21 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUN 29, 2004
  • HELP-PROMPT:  Enter YES if the patient is in a coma.
  • DESCRIPTION:  
    Definition Revised (2004): Patient is unconscious, postures to painful stimuli, or is unresponsive to all stimuli entering surgery. This does not include drug-induced coma.
334 *HISTORY OF TIA'S 200;25 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 18, 2011
  • HELP-PROMPT:  Enter YES if the patient has a history of TIA's.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2004): Transient ischemic attacks (TIAs) are focal neurologic deficits (e.g. numbness of an arm or amaurosis fugax) of sudden onset and brief duration (usually <30 minutes), which usually reflect
    dysfunction in a cerebral vascular distribution. These attacks may be recurrent and, at times, may precede a stroke.
335 *CVA/STROKE WITH NEURO DEFICIT 200;26 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 18, 2011
  • HELP-PROMPT:  Enter YES if the patient has a history CVA/stroke with residual neurologic deficit.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with persistent residual motor, sensory, or cognitive dysfunction. (e.g., hemiplegia, hemiparesis, aphasia, sensory
    deficit, impaired memory). If the neurological deficit is hemiplegia/hemiparesis, also enter YES to Hemiplegia/Hemiparesis in addition to CVA/Stroke.
336 *CVA/STROKE - NO NEURO DEFICIT 200;27 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 18, 2011
  • HELP-PROMPT:  Enter YES if the patient has a history of CVA/Stroke with no neurologic deficit.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with neurologic deficit(s) lasting at least 30 minutes, but no current residual neurologic dysfunction or deficit.
337 NEURO DEGENERATIVE DISEASE 200;28 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has a neuromuscular degenerative disease.
  • DESCRIPTION:  This determines whether the patient has neuromuscular degenerative disease. It is defined as any of a number of congenital, hereditary, or acquired diseases resulting in chronic neurological deficits. Common examples of
    these diseases include muscular dystrophy, amyotrophic lateral sclerosis (ALS or 'Lou Gerhig's Disease'), multiple sclerosis, and poliomyelitis.
338 DISSEMINATED CANCER (Y/N) 200;45 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has disseminated cancer.
  • DESCRIPTION:  VASQIP Definition (2010): Disseminated cancer: Patients who have cancer known to be present prior to the start of surgery that:
    (1) Has spread to one site or more sites in addition to the primary
    site
    AND
    (2) In whom the presence of multiple metastases indicates the cancer
    is widespread, fulminant, or near terminal. Other terms describing
    disseminated cancer include "diffuse," "widely metastatic,"
    "widespread," or "carcinomatosis", or AJCC "Stage IV" cancer.
    Common sites of metastases include major organs (e.g., brain,
    lung, liver, meninges, abdomen, peritoneum, pleura, and bone).
    You may use the National Cancer Institute as a reference in
    determining whether a patient has AJCC Stage IV cancer, when the
    TNM information is the only information documented. Refer to the
    following website for assistance with translating TNM values with
    AJCC staging:
    http://www.cancer.gov/cancertopics/pdq/adulttreatment
    Examples:
    - A patient with a primary breast cancer with positive nodes in the
    axilla does NOT qualify for this definition. The tumor has spread to
    a site other than the primary site, but does not have widespread
    metastases. A patient with primary breast cancer with positive nodes
    in the axilla AND liver metastases does qualify, because the tumor
    has spread to the axilla and other major organs.
    - A patient with colon cancer and no positive nodes or distant
    metastases does NOT qualify. A patient with colon cancer and several
    local lymph nodes positive for tumor, but no other evidence of
    metastatic disease does NOT qualify. A patient with colon cancer
    with liver metastases and/or peritoneal seeding with tumor does
    qualify.
    - A patient with adenocarcinoma of the prostate confined to the
    capsule does NOT qualify. A patient with prostate cancer that
    extends through the capsule of the prostate only does NOT qualify.
    A patient with prostate cancer with bony metastases DOES qualify.
    Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma or
    Lymphomas that are Stage I-III as disseminated cancer.
338.1 *CHEMOTHERAPY IN LAST 30 DAYS 206;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAY 22, 2015
  • HELP-PROMPT:  Enter YES if patient has undergone chemotherapy in the 30 days prior to surgery.
  • DESCRIPTION:  Definition Revised (2007): Enter "YES" if the patient had any chemotherapy treatment for cancer in the 30 days prior to surgery. Chemotherapy may include, but is not restricted to, oral and parenteral treatment with
    chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma.
    Do not count if treatment consists solely of hormonal therapy. (See Operations Manual for list of chemotherapeutic agents.) Chemotherapy treatment must be for malignancy.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
338.2 RADIOTHERAPY IN LAST 90 DAYS 206;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if patient had radiotherapy in the 90 days prior to surgery.
  • DESCRIPTION:  Definition Revised (2004): Enter "YES" if the patient had any radiotherapy treatment for cancer in the 90 days prior to surgery. If the patient had radiation seeds implanted, count if implantation is within 90 days prior
    to the operation.
338.3 CHEMO FOR MALIG LAST 90 DAYS 204;17 SET
  • '1' FOR NO CHEMO;
  • '2' FOR W/IN 30 DAYS;
  • '3' FOR 31-90 DAYS;

  • LAST EDITED:  MAY 12, 2015
  • HELP-PROMPT:  Enter timeframe of chemotherapy in the 90 days prior to surgery.
  • DESCRIPTION:  Definition Revised (2015): Enter the timeframe of chemotherapy treatment for cancer in the 90 days prior to surgery. Chemotherapy may include, but is not restricted to, oral and parenteral treatment with chemotherapeutic
    agents for malignancies such as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma. Do not include if
    treatment consists solely of hormonal therapy. Chemotherapy treatment must be for malignancy.
339 STEROID USE FOR CHRONIC COND. 200;47 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  APR 02, 2015
  • HELP-PROMPT:  Enter YES if the patient requires oral or parenteral steroid use for a chronic condition.
  • DESCRIPTION:  Definition Revised (2015): Patient has required the regular administration of oral or parenteral corticosteroid medications (e.g., Prednisone, Decadron) in the 30 days prior to admission for a chronic medical condition
    (e.g., COPD, asthma, rheumatologic disease, rheumatoid arthritis, inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally. Do not
    include patients who only receive short course steroids (duration 10 days or less) in the 30 days prior to surgery. (See list of corticosteroids in Operations Manual.)
    Choose from: Y- YES N- NO NS- NO STUDY
340 INTRAOP RBC UNITS TRANSFUSED 200;54 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  JAN 07, 2014
  • HELP-PROMPT:  Enter the number of red blood cells transfused. Your answer should be from 0 to 99.
  • DESCRIPTION:  Definition Revised (2014): Indicate the number of packed or whole red blood cells given during the operative procedure as it appears on the anesthesia record. The amount of blood reinfused from the cell saver should also
    be noted here. The algorithm for cell saver volume to RBC unit determination is:
    0 units - 0-124 cc's
    1 unit - 125 - 375 cc's
    2 units - 376 - 625 cc's
    3 units - 626 - 875 cc's
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
341 30 DAY POSTOP STATUS 205;2 SET
  • '1' FOR DISCHARGED ALIVE;
  • '2' FOR DIED IN HOSPITAL;
  • '3' FOR REMAINS IN VAMC FACILITY;
  • '4' FOR TRANSFERRED TO ANOTHER VAMC;
  • '5' FOR READMITTED;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 14, 1991
  • HELP-PROMPT:  Enter the status of the patient 30 days postoperatively.
  • DESCRIPTION:  This is the patient's status 30 days postoperatively. Please select one of the following categories.
    1. Discharged alive to home, nursing home, rehabilitation, or
    psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your VAMC facility in the ICU, on a medical-surgical
    floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of another VAMC
    facility from your VAMC without going home 5. Patient was discharged home, but was readmitted to any
    hospital within 30 days postoperatively due to a postoperative
    complication as confirmed by the Chief Surgical Resident,
    Principle Investigator, or Chief of Surgery. If the patient
    was readmitted due to a postoperative complication, please
    enter the information in the outcome section of the assessment.
342 DATE OF DEATH 205;3 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EPT" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  MAY 25, 2011
  • HELP-PROMPT:  Enter the date/time that the patient died.
  • DESCRIPTION:  
    If the patient has died, this is the date/time of death.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  ^^TRIGGER^130^342.1
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,205)):^(205),1:"") S X=$P(Y(1),U,41),X=X S DIU=X K Y X ^DD(130,342,1,1,1.1) S DIH=$G(^SRF(DIV(0),205)),DIV=X S $P(^(205),U,41)=DIV,DIH=130,DIG=342.1 D ^DICR
    1.1)= S X=DIV S X=$S(X="NA"!($P($G(^SRF(D0,.2)),U,3)=""):"N",$$FMDIFF^XLFDT(X,$P(^SRF(D0,.2),U,3))>30:"N",1:"Y")
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,205)):^(205),1:"") S X=$P(Y(1),U,41),X=X S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),205)),DIV=X S $P(^(205),U,41)=DIV,DIH=130,DIG=342.1 D ^DICR
    CREATE VALUE)= S X=$S(X="NA"!($P($G(^SRF(D0,.2)),U,3)=""):"N",$$FMDIFF^XLFDT(X,$P(^SRF(D0,.2),U,3))>30:"N",1:"Y")
    DELETE VALUE)= @
    FIELD)= #342.1
    If the number of days between TIME OPERATION ENDS (#.23) and DATE OF DEATH (#342) is less than or equal 30, set 30 DAY DEATH (#342.1) to YES, otherwise, set the 30 DAY DEATH (#342.1) to NO if DATE OF DEATH (#342) is
    greater than 30 or "NA" is entered.
342.1 30 DAY DEATH 205;41 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 12, 2011
  • HELP-PROMPT:  This field indicates whether operative death has occurred within 30 days of surgery.
  • DESCRIPTION:  This field indicates whether operative death has occurred within 30 days of surgery. This field auto populates based on an entry into the DATE OF DEATH field (#342). If Date of Death occurs within 30 days or less of the
    Date of Operation, then this field is automatically updated to "Yes" when the Date of Death is saved. If the Date of Death is greater than 30 days from the Date of Operation or "NA" is entered then this field is
    automatically updated to "No" when the Date of Death is saved.
  • NOTES:  TRIGGERED by the DATE OF DEATH field of the SURGERY File
343 OTHER CNS OCCURRENCE 205;24 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
  • LAST EDITED:  FEB 17, 2012
  • HELP-PROMPT:  Enter the ICD Diagnosis code for any other CNS occurrence.
  • DESCRIPTION:  
    Definition Revised (2004): Enter any other neurologic related occurrences, which you feel to be significant and that are not covered by the predefined CNS occurrence categories. Enter the ICD-CM code for this entry.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
344 OTHER CARDIAC OCCURRENCE 205;29 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
  • LAST EDITED:  JAN 10, 2013
  • HELP-PROMPT:  Enter the ICD Diagnosis code corresponding to the cardiac occurrence.
  • DESCRIPTION:  
    Definition Revised (2004): Enter any other cardiac related surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-CM code for this entry.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
345 ILEUS/BOWEL OBSTRUCTION 205;31 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has a postoperative intestinal obstruction.
  • DESCRIPTION:  This determines whether the patient has prolonged ileus or bowel obstruction. Ileus is obstruction of the intestines from a variety of causes including mechanical obstruction, peritonitis, adhesions, or post surgically as
    a result of functional dysmotility by the bowel. Bowel obstruction is any hindrance to the passage of the intestinal contents. Prolonged ileus or obstruction is defined as persisting longer than 5 days postoperatively.
346 *DIABETES 200;2 SET
  • 'N' FOR NO;
  • 'O' FOR ORAL;
  • 'I' FOR INSULIN;

  • LAST EDITED:  JUL 12, 2011
  • HELP-PROMPT:  Enter the patient's diabetes status.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2004): Diabetes mellitus is a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a
    hyperglycemic/metabolic acidosis. Report the treatment regimen of the patient's chronic, long-term management. Do not include a patient if diabetes is controlled by diet alone.
    No: No diagnosis of diabetes or diabetes controlled by diet alone
    Oral: A diagnosis of diabetes requiring therapy with an oral
    hypoglycemic agent (see list of oral hypoglycemic agents in
    Operations Manual)
    Insulin: A diagnosis of diabetes requiring daily insulin therapy (see
    list of insulin therapy agents in Operations Manual)
347 FEV1 206;5 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>9.9)!(X<0)!(X?.E1"."2N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  MAR 11, 2015
  • HELP-PROMPT:  Enter the FEV1 on the most recent PFT's (0 to 9.9).
  • DESCRIPTION:  Definition revised (2015): This is the forced expiratory volume (in liters) in one second from the most recent pulmonary function test prior to surgery. Identify only a FEV1 value that is pre-bronochodilator treatment.
    Enter 'NS' if there has been no pulmonary function tests in the preceding year.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
348 *PULMONARY RALES 206;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 05, 2015
  • HELP-PROMPT:  Enter 'YES' if the patient has pulmonary rales within the two weeks preceding surgery.
  • DESCRIPTION:  Definition Revised (2004): Indicate if the chart documents rales not clearing with cough (and not due to pneumonic process) heard within two weeks before surgery. Do not include rales that clear with coughing, as these are
    usually due to atelectasis and carry a much more benign connotation. Please note, crackles are another common approach to noting that rales are present.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
349 ACTIVE ENDOCARDITIS 206;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 20, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient is being treated, or has been treated within two weeks prior to surgery, for active endocarditis.
  • DESCRIPTION:  Definition Revised (2004): Indicate if the patient is being treated with antibiotics for active infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery. Endocarditis is defined as two
    or more blood cultures positive for the same organism, usually with evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of positive blood cultures, there should be clear evidence of
    valve infection and/or destruction by ultrasound or direct observation at surgery with subsequent histologic confirmation.
350 *RESTING ST DEPRESSION 206;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 05, 2015
  • HELP-PROMPT:  Enter 'YES' if the patient has defined Resting ST Depression.
  • DESCRIPTION:  This determines whether the patient has a ST-segment depression greater than or equal to 1 mm in any lead on standard resting electrocardiogram (ECG), and/or ECG diagnosis of subendocardial ischemia, left ventricular
    strain, or left ventricular hypertrophy with repolarization abnormality.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
351 *PCI 206;13 SET
  • '1' FOR NONE RECENT;
  • '2' FOR 12-72 HOURS PRIOR TO SURGERY;
  • '0' FOR NONE;
  • '3' FOR <12 hrs;
  • '12' FOR 12 - 72 hrs;
  • '72' FOR >72 hrs - 7 days;
  • '7' FOR >7 days;

  • LAST EDITED:  JAN 15, 2014
  • HELP-PROMPT:  Enter the category that most accurately reflects the patient's Percutaneous Coronary Intervention.
  • DESCRIPTION:  Definition Revised (2004): Indicate whether/when the patient had a percutaneous coronary intervention (PCI) prior to surgery. Previously, this data field was listed as a percutaneous transluminal coronary angiography
    (PTCA) [e.g., balloon angioplasty, directional coronary atherectomy (DCA), transluminal extraction catheter (TEC), stent, rotoblader, etc.] Indicate the one appropriate response, even if the procedure was not fully
    successful.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
  • SCREEN:  S DIC("S")="I ""1,2""'[Y"
  • EXPLANATION:  Screen prevents selection of
352 NUM OF PRIOR HEART SURGERIES 206;15 SET
  • 'Y' FOR YES;
  • '0' FOR NONE;
  • '1' FOR 1;
  • '2' FOR 2;
  • '3' FOR 3;
  • '>' FOR >3;

  • LAST EDITED:  MAR 11, 2004
  • HELP-PROMPT:  Enter number of prior heart surgeries during a separate preceding hospitalization.
  • DESCRIPTION:  Definition Revised (2006): Indicate the number of previous heart surgeries the patient has had upon current admission, by referencing the patient history. The prior heart surgery/ies would have occurred during a separate
    hospitalization (more than 30 days prior to current surgery). Both on and off-pump cardiac surgical procedures should be considered. Count all surgical procedures performed during separate hospital admissions (not the
    number of grafts, and not additional procedures performed during the same admission due to a postoperative occurrence). Indicate the one appropriate response: 0, 1, 2, 3, >3.
  • SCREEN:  S DIC("S")="I ""Y""'[Y"
  • EXPLANATION:  Screen prevents selection of Y code
353 CURRENT DIURETIC USE 206;20 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 27, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient used any diuretic preparation within two weeks of surgery.
  • DESCRIPTION:  This determines whether the patient has used any diuretic preparation within the two weeks prior to surgery.
354 *CURRENT DIGOXIN USE 206;21 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 05, 2015
  • HELP-PROMPT:  Enter 'YES' if the patient used any digitalis preparation within two weeks of surgery.
  • DESCRIPTION:  This determines whether the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin, ect.) within the two weeks prior to surgery.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
355 IV NTG WITHIN 48 HOURS 206;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 23, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient was given nitroglycerin intravenously within 48 hours prior to surgery.
  • DESCRIPTION:  This determines whether the patient was administered nitroglycerin intravenously within 48 hours prior to surgery.
356 PREOPERATIVE USE OF IABP 206;23 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 27, 1991
  • HELP-PROMPT:  Enter 'YES' if an intra-aortic ballon pump (IABP) was used within two weeks prior to surgery.
  • DESCRIPTION:  This determines whether there was any use of an intra-aortic balloon pump (IABP) within the two weeks prior to surgery.
357 LVEDP 206;24 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>60)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the LVEDP measured following the 'a' wave (if present) at catheterization. Your answer must be between 0 and 60.
  • DESCRIPTION:  Definition Revised (2004): Indicate the patient's left ventricular end-diastolic pressure measured following the a-wave (if present) at the cardiac catheterization most recent prior to surgery. If LVEDP was not measured,
    entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
358 AORTIC SYSTOLIC PRESSURE 206;25 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>300)!(X<15)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the aortic systolic pressure (15-300) measured prior to left ventricular angiography most closely preceding surgery.
  • DESCRIPTION:  Definition Revised (2004): Indicate the patient's aortic systolic pressure measured prior to left ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic pressure was not measured,
    entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
359 PA SYSTOLIC PRESSURE 206;26 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>150)!(X<-30)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the patient's PA systolic pressure (-30 to 150).
  • DESCRIPTION:  Definition Revised (2004): For patients having a right heart catheterization, indicate the patient's pulmonary artery (PA) systolic pressure at the catheterization most recent prior to surgery. PA pressures obtained in the
    operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
360 PAW MEAN PRESSURE 206;27 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>80)!(X<-15)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the mean pulmonary artery wedge (PAW) pressure (-15 to 80).
  • DESCRIPTION:  Definition Revised (2004): For patients having a right heart catheterization, indicate the patient's mean pulmonary artery wedge (PAW) [also called pulmonary capillary] pressure or left atrial pressure measured at the
    catheterization most recent prior to surgery. PAW pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart or transseptal
    catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
361 LEFT MAIN STENOSIS 206;28 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the percent (0-100) diameter reduction of the left main coronary artery.
  • DESCRIPTION:  Definition Revised (2004): Indicate the most severe percent diameter reduction of the left main coronary artery, including its most distal portion. If there is no obstruction of the left main coronary artery, indicate
    zero. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
362 CORONARIES WITH STENOSIS 206;29 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>3)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS" X="NS" K NYUK
  • LAST EDITED:  AUG 05, 1991
  • HELP-PROMPT:  Enter the category related to the number of major coronaries with stenosis(es). Your answer should be from 0 to 3.
  • DESCRIPTION:  This is the category corresponding to the number of major coronaries with stenosis greater than or equal to 50%. The categories are as follows.
    0 - no stenosis in any coronary artery greater than or equal to
    50% (exclude diagonals)
    1 - one or more stenoses greater than or equal to 50% in the
    left anterior descending (does not include diagonals)
    or, circumflex (circumflex includes the marginal branches
    and ramus intermedius),
    or the right (right includes the posterior descending even
    if a branch of the circumflex)
    2 - Stenoses greater than or equal to 50% in the
    left main coronary artery,
    or the left anterior descending (does not include diagonals) and
    the right (right includes the posterior descending even if a
    branch of the circumflex),
    or the left anterior descending (does not include diagonals) and
    circumflex (circumflex includes the marginals and ramus intermedius),
    or the circumflex (circumflex includes the marginals and ramus
    intermedius) and the right (right includes the posterior descending
    even if a branch of the circumflex)
    3 - Stenoses greater than or equal to 50% in the
    left anterior descending (does not include diagonals) and the
    circumflex (circumflex includes the marginals and ramus intermedius)
    and right (right includes the posterior descending even if a branch
    of the circumflex)
    or left main and right (right includes the posterior descending
    even if a branch of the circumflex)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
362.1 LAD STENOSIS 206;33 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the percent (0-100) stenosis.
  • DESCRIPTION:  Definition Revised (2004): Indicate the most severe percent stenosis in the left anterior descending coronary artery. Synonyms for this artery include: LAD, AD, and anterior descending (but does not include the diagonals).
    If there is no obstruction of the LAD, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
362.2 RIGHT CORONARY STENOSIS 206;34 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the percent (0-100) stenosis.
  • DESCRIPTION:  Definition Revised (2004): Indicate the most severe percent stenosis in the right coronary artery. Include the proximal third of the posterior descending coronary artery. The right coronary artery initially runs in the
    groove between the right ventricle and right atrium; it usually gives off branches to both the right and left ventricles and the right atrium. The branches to the right atrium (sinus node artery) and right ventricle (conus
    branch and acute marginal branches) are commonly ignored when describing coronary artery disease. However, the right coronary artery is the most common source for the posterior descending coronary artery and often
    gives-off branches to the posterior-lateral free wall of the left ventricle. These are often known as left ventricular extension branches and are considered branches of the circumflex for the coding of severity of coronary
    disease. If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
362.3 CIRCUMFLEX STENOSIS 206;35 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Enter the percent (0-100) stenosis.
  • DESCRIPTION:  Definition Revised (2004): Indicate the most severe percent stenosis in the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for bypass grafting. Both the
    anatomy and nomenclature for describing the circumflex coronary artery can be confusing -- in part, because of the marked variability from patient to patient. The true circumflex lies in the groove separating the left
    atrium from the left ventricle (A-V groove) for a variable distance following its origination from the left main coronary artery. Typically, it gives-off one or more branches that leave the A-V groove to supply the
    posterior-lateral free wall of the left ventricle. These are known as marginal branches. A few patients have a branch to the posterior-lateral free wall of the left ventricle arising exactly at the bifurcation of the left
    main coronary artery into the left anterior descending coronary artery and the circumflex coronary artery. Strictly speaking, this vessel is neither a diagonal branch of the left anterior descending coronary artery nor a
    marginal branch of the circumflex coronary artery. This is often called the "ramus intermedius" or "trifurcation branch". If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No
    Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
363 LV CONTRACTION SCORE 206;30 SET
  • 'I' FOR > OR EQUAL 0.55 NORMAL;
  • 'II' FOR 0.45-0.54 MILD DYSFUNC.;
  • 'III' FOR 0.35-0.44 MOD. DYSFUNC.;
  • 'IIIa' FOR 0.40-0.44 MOD. DYSFUNC. A;
  • 'IIIb' FOR 0.35-0.39 MOD. DYSFUNC. B;
  • 'IV' FOR 0.25-0.34 SEVERE DYSFUNC.;
  • 'V' FOR <0.25 VERY SEVERE DYSFUNC.;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 28, 2004
  • HELP-PROMPT:  Enter the grade that best describes left ventricular function.
  • DESCRIPTION:  Definition Revised (2004): Indicate the left ventricular contraction grade, where the function is assessed from the preoperative contrast ventriculogram, radionuclide angiogram, or 2-D echocardiogram. If ejection fraction
    is available, indicate the corresponding grade; otherwise, indicate the grade that qualitatively reflects left ventricular function. Ejection fraction is defined as the proportion of blood that is ejected during each
    ventricular contraction compared with the total ventricular filling volume. Indicate the one most appropriate response: I - Ejection fraction >= 0.55 or narrative reports indicating normal left ventricular function.
    II - Ejection fraction range from 0.45 to 0.54 or narrative report indicating mild left ventricular dysfunction.
    IIIa - Ejection fraction range from 0.40 to 0.44 or narrative report indicating moderate left ventricular dysfunction. If "moderate" is the only rating available, select this category.
    IIIb - Ejection fraction range from 0.35 to 0.39 or narrative report indicating moderately severe left ventricular dysfunction.
    IV - Ejection fraction range from 0.25 to 0.34 or narrative report indicating severe left ventricular dysfunction.
    V - Ejection fraction < 0.25 or narrative report indicating very severe left ventricular dysfunction.
    NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
  • SCREEN:  S DIC("S")="I Y'=""III"""
  • EXPLANATION:  Screen prevents selection of code III.
364 ESTIMATE OF MORTALITY 206;31 NUMBER

  • INPUT TRANSFORM:  S NYUK=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
  • LAST EDITED:  JAN 25, 2007
  • HELP-PROMPT:  Enter the physician's preoperative estimate of operative mortality.
  • DESCRIPTION:  Definition Revised (2006): This is the physician's (cardiologist or cardiac surgeon) subjective estimate of operative mortality based on the assessment of the total clinical picture. (To avoid bias introduced by knowledge
    of outcome, this must be completed preoperatively. Do not calculate from the computer program provided to you.)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
364.1 ESTIMATE OF MORTALITY, DATE 206;32 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ETXRP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS" D:$D(X) NC^SROAUTL
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  NOV 06, 2007
  • HELP-PROMPT:  Enter the date and time that the estimate of operative mortality was documented.
  • DESCRIPTION:  
    This is the date and time that the estimate of mortality information was collected.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
365 *NUMBER WITH VEIN 207;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  AUG 05, 1991
  • HELP-PROMPT:  Enter the number of CABG distal anastomoses to native coronary arteries with vein.
  • DESCRIPTION:  This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with vein regardless of whether other procedures were performed. Do not leave this information blank. If no coronary
    artery bypass grafts were performed, enter '0'.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
366 *NUMBER WITH IMA 207;2 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  AUG 05, 1991
  • HELP-PROMPT:  Enter the number of CABG distal anastomoses to native coronary arteries with IMA.
  • DESCRIPTION:  This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with internal mammary arteries (IMA) regardless of whether other procedures were performed. Do not leave this field blank.
    If no coronary artery bypass grafts were performed, enter '0'.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
367 *AORTIC VALVE PROCEDURE 207;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NONE;
  • 'M' FOR MECHANICAL;
  • 'S' FOR STENTED BIOPROSTHETIC;
  • 'B' FOR STENTLESS BIOPROSTHETIC;
  • 'H' FOR HOMOGRAFT;
  • 'PR' FOR PRIMARY REPAIR;
  • 'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
  • 'AN' FOR ANNULOPLASTY DEVICE ALONE;
  • 'AU' FOR AUTOGRAFT (ROSS);
  • 'O' FOR OTHER;

  • LAST EDITED:  JUN 14, 2010
  • HELP-PROMPT:  Enter the appropriate aortic valve procedure performed on this patient.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty,
    commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details
    of the replacement valve.) Indicate the one most appropriate procedure:
    * None
    * Mechanical Valve
    * Stented Bioprosthetic Valve
    * Stentless Bioprosthetic Valve
    * Homograft
    * Primary Valve Repair
    * Primary Valve Repair and Annuloplasty Device
    * Annuloplasty Device alone
    * Autograft Procedure (Ross Procedure)
    * Other
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
  • SCREEN:  S DIC("S")="I ""Y""'[Y"
  • EXPLANATION:  Screen prevents selection of inactive code.
368 *MITRAL VALVE PROCEDURE 207;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NONE;
  • 'M' FOR MECHANICAL;
  • 'S' FOR STENTED BIOPROSTHETIC;
  • 'B' FOR STENTLESS BIOPROSTHETIC;
  • 'H' FOR HOMOGRAFT;
  • 'PR' FOR PRIMARY REPAIR;
  • 'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
  • 'AN' FOR ANNULOPLASTY DEVICE ALONE;
  • 'AU' FOR AUTOGRAFT (ROSS);
  • 'O' FOR OTHER;

  • LAST EDITED:  JUN 14, 2010
  • HELP-PROMPT:  Enter the appropriate mitral valve procedure performed on this patient.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate if the patient had a mitral valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty,
    commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details
    of the replacement valve.) Indicate the one most appropriate procedure:
    * None
    * Mechanical Valve
    * Stented Bioprosthetic Valve
    * Stentless Bioprosthetic Valve
    * Homograft
    * Primary Valve Repair
    * Primary Valve Repair and Annuloplasty Device
    * Annuloplasty Device alone
    * Autograft Procedure (Ross Procedure)
    * Other
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
  • SCREEN:  S DIC("S")="I ""Y""'[Y"
  • EXPLANATION:  Screen prevents selection of inactive code.
369 *TRICUSPID VALVE PROCEDURE 207;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NONE;
  • 'M' FOR MECHANICAL;
  • 'S' FOR STENTED BIOPROSTHETIC;
  • 'B' FOR STENTLESS BIOPROSTHETIC;
  • 'H' FOR HOMOGRAFT;
  • 'PR' FOR PRIMARY REPAIR;
  • 'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
  • 'AN' FOR ANNULOPLASTY DEVICE ALONE;
  • 'AU' FOR AUTOGRAFT (ROSS);
  • 'O' FOR OTHER;

  • LAST EDITED:  JUN 14, 2010
  • HELP-PROMPT:  Enter the appropriate tricuspid valve procedure performed on this patient.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate if the patient had a tricuspid valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty,
    commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details
    of the replacement valve.) Indicate the one most appropriate procedure:
    * None
    * Mechanical Valve
    * Stented Bioprosthetic Valve
    * Stentless Bioprosthetic Valve
    * Homograft
    * Primary Valve Repair
    * Primary Valve Repair and Annuloplasty Device
    * Annuloplasty Device alone
    * Autograft Procedure (Ross Procedure)
    * Other
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
  • SCREEN:  S DIC("S")="I ""Y""'[Y"
  • EXPLANATION:  Screen prevents selection of inactive code.
370 VALVE REPAIR 207;6 SET
  • 'Y' FOR YES;
  • '1' FOR AORTIC;
  • '2' FOR MITRAL;
  • '3' FOR TRICUSPID;
  • '4' FOR OTHER/COMBINATION;
  • '5' FOR NONE;

  • LAST EDITED:  MAR 01, 2006
  • HELP-PROMPT:  Indicate whether/where patient had a reparative procedure to a native valve.
  • DESCRIPTION:  Definition Revised (2006): Indicate if the patient has had any reparative procedure to a native valve, either with or without placing the patient on cardiopulmonary bypass. Valve repair is defined as a procedure performed
    on the native valve to relieve stenosis and/or correct regurgitation (annuloplasty, commissurotomy, etc.); the native valve remains in place. Indicate the one appropriate response.
  • SCREEN:  S DIC("S")="I ""Y""'[Y"
  • EXPLANATION:  Screen prevents selection of Y entries.
371 *LV ANEURYSMECTOMY 207;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient had a resection or plication of left ventricular aneurysm with or without additional procedures.
  • DESCRIPTION:  This determines whether the patient had a resection or plication of a left ventricular aneurysm with or without additional procedures.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
372 *GREAT VESSEL REPAIR (Y/N) 207;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAR 14, 2006
  • HELP-PROMPT:  Enter 'YES' if the patient had a primary procedure to repair the aorta or other great vessels.
  • DESCRIPTION:  Definition Revised (2006): Indicate if patient had a thoracic great vessel open repair of the aorta (ascending, transverse, and/or descending) or other great vessels, with or without cardiopulmonary bypass, with or without
    aortic valve replacement, CABG, or other procedure but excluding an endovascular repair of the descending thoracic aorta.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
373 *CARDIAC TRANSPLANT 207;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  FEB 09, 2006
  • HELP-PROMPT:  Enter 'YES' if the patient had a cardiac transplant.
  • DESCRIPTION:  Definition Revised (2006): Indicate if an orthotopic or heterotopic transplant was performed at this procedure either with or without placing the patient on cardiopulmonary bypass. (YES/NO) Heart-lung transplant should
    be listed under "Other cardiac procedures."
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
374 ELECTROPHYSIOLOGIC PROCEDURE 207;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if an electrophysiologic procedure was performed.
  • DESCRIPTION:  This determines whether any procedure was performed with cardiopulmonary bypass to correct an electrophysiologic disturbance, such as resection of bypass tract(s) for WPW or endocardial resection for ventricular
    tachycardia. (This does not include implantation of automatic internal cardiac defibrillator AICD)
375 MISC. CARDIAC PROCEDURES 207;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 05, 1991
  • HELP-PROMPT:  Enter 'YES' if any of the miscellaneous cardiac procedures were performed.
  • DESCRIPTION:  This determines whether there were any miscellaneous cardiac procedures performed.
376 *ASD REPAIR 207;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if there was a repair of an atrial septal defect.
  • DESCRIPTION:  This determines if there was a procedure performed to repair an atrial septal defect.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
377 *MYXOMA RESECTION 207;14 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if there was a resection of an atrial myxoma.
  • DESCRIPTION:  This determines whether a resection of an atrial myxoma was performed.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
378 *MYECTOMY 207;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 24, 2011
  • HELP-PROMPT:  Enter 'YES' if the patient had a myectomy.
  • DESCRIPTION:  
    Definition Revised (2011): Indicate if patient had resection of a portion of the interventricular septum, with or without placing the patient on cardiopulmonary bypass. (YES/NO)
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
379 *OTHER TUMOR RESECTION 207;18 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 29, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient had a resection of any tumor other than atrial myxoma from the heart requiring CPB.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate if patient had resection of any tumor other than atrial myxoma from the heart either with or without placing the patient on cardiopulmonary bypass.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
380 *VSD REPAIR 207;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient had a procedure to repair a ventricular septal defect (VSD).
  • DESCRIPTION:  This determines whether the patient had a procedure performed to repair a ventricular septal defect.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
381 *FOREIGN BODY REMOVAL 207;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient had a procedure to remove any foreign body from the heart.
  • DESCRIPTION:  This determines whether a procedure was performed to remove any foreign body (e.g. bullet or catheter fragment) from the heart with the aid of cardiopulmonary bypass.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
382 *PERICARDIECTOMY 207;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient had a pericardiectomy on CPB.
  • DESCRIPTION:  This determines whether the patient had a resection of the parietal pericardium with the aid of cardiopulmonary bypass. (NOTE: most pericardiectomies are performed without cardiopulmonary bypass)
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
383 OTHER PROCEDURES (Y/N) 207;19 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  FEB 27, 1992
  • HELP-PROMPT:  Enter 'YES' if the patient had any other surgical procedure on the heart and/or great vessels requiring CPB.
  • DESCRIPTION:  This determines whether the patient had any other surgical procedure on the heart and/or great vessels (including AICD placement) requiring cardiopulmonary bypass.
383.1 OTHER CARDIAC PROCEDURES 207.1;1 FREE TEXT

  • INPUT TRANSFORM:  S NYUK=X K:$L(X)>235!($L(X)<3) X S:NYUK="NS" X=NYUK K NYUK
  • LAST EDITED:  MAR 11, 2004
  • HELP-PROMPT:  Answer must be 3-235 characters in length.
  • DESCRIPTION:  
    Definition Revised (2004): This is the free text description of other procedures requiring cardiopulmonary bypass that were performed on this patient at the same time as the primary cardiac procedure.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
384 OPERATIVE DEATH 208;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAR 28, 2006
  • HELP-PROMPT:  Enter 'YES' if the patient died. Enter "??" for the complete definition of OPERATIVE DEATH.
  • DESCRIPTION:  Definition Revised (2006): Indicate if the patient died within the 30 days after surgery in or out of the hospital regardless of cause; or within the index hospitalization regardless of cause; or patient died greater than
    30 days as a direct result of a perioperative occurrence of the surgery (e.g., mediastinitis). ("Discharge" can be noted when the patient leaves the Acute Care arena.)
385 *PERIOPERATIVE MI 208;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 28, 2011
  • HELP-PROMPT:  Enter 'YES' if the patient had a perioperative myocardial infarction.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2011): Indicate the presence of a peri-operative MI as documented by the following criteria:
    0-24 Hours Post-Op
    The CK-MB (or CK if MB not available) must be greater than or
    equal to 5-times the upper limit of normal, with or without new
    Q waves present in two or more contiguous ECG leads. No symptoms
    required.
    >24 Hours Post-Op
    Indicate the presence of a peri-operative MI (> 24 hours post-op)
    as documented by at least one of the following criteria:
    1. Evolutionary ST- segment elevations
    2. Development of new Q-waves in two or more contiguous ECG leads
    3. New or presumably new LBBB pattern on the ECG
    4. The CK-MB (or CK if MB not available) must be greater than or
    equal to 3 times the upper limit of normal.
    Because normal limits of certain blood tests may vary, please check with your lab for normal limits for CK-MB and total CK. Defining Reference Control Values (Upper Limit of Normal): Reference values must be determined in
    each laboratory by studies using specific assays with appropriate quality control, as reported in peer-reviewed journals.
    Acceptable imprecision (coefficient of variation) at the 99th percentile for each assay should be defined as < or = to 10%. Each individual laboratory should confirm the range of reference values in their specific setting.
    This element should not be coded as an adverse event for evolving MI's unless their enzymes peak, fall, and then have a second peak.
386 ENDOCARDITIS 208;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  APR 15, 2011
  • HELP-PROMPT:  Enter 'YES' if the patient has any postoperative intracardiac infection.
  • DESCRIPTION:  Definition Revised (2004): Indicate if the chart documents that active endocarditis was present within 30 days postoperatively. Endocarditis is defined as any postoperative intracardiac infection (usually on a valve)
    documented by two or more positive blood cultures with the same organism, and/or development of vegetations and valve destruction seen by echo or repeat surgery, and/or histologic evidence of infection at repeat surgery or
    autopsy. Patients with preoperative endocarditis who have the above evidence of persistent infection should be included.
387 LOW CARDIAC OUTPUT > 6 HOURS 208;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has low cardiac output for greater than or equal to 6 hours.
  • DESCRIPTION:  This determines whether the patient has had a postoperative cardiac index of less than 2.0 L/min/M2 and/or peripheral manifestations (e.g. oliguria) of low cardiac output present for 6 or more hours following surgery
    requiring inotropic and/or intra-aortic balloon pump support.
388 MEDIASTINITIS 208;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 09, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient has a bacterial infection below the sternum.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate if the patient developed a bacterial infection involving the sternum or deep to the sternum requiring drainage and anti-microbial therapy diagnosed within 30 days after surgery.
389 REOPERATION FOR BLEEDING 208;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAR 06, 2015
  • HELP-PROMPT:  Enter 'YES' if the patient had a re-exploration of the thorax for suspected bleeding.
  • DESCRIPTION:  
    Definition Revised (2015): Indicate if there was any re-exploration of the thorax for suspected bleeding after the patient left the operating room and within 30 days of surgery.
390 *STROKE 208;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 11, 2011
  • HELP-PROMPT:  Enter 'YES' if the patient has any new objective neurologic defect lasting > or = 30 minutes.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Cardiac Definition Revised (2004): Indicate if there was any new objective neurologic deficit lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after surgery.
391 REPEAT CARDIAC SURG PROCEDURE 208;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 12, 2015
  • HELP-PROMPT:  Enter YES if a repeat operation on the heart occurred.
  • DESCRIPTION:  Definition Revised (2014): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or
    within 30 days of the initial operation.
392 OTHER OCCURRENCES (ICD) 205;36 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • OUTPUT TRANSFORM:  NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
  • LAST EDITED:  FEB 17, 2012
  • HELP-PROMPT:  Enter the ICD Diagnosis Code for any other occurrence.
  • DESCRIPTION:  
    Definition Revised (2004): Enter any other surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-CM code for this entry.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
393 RE-TRANSMISSION RA;3 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  AUG 20, 1991
  • HELP-PROMPT:  Enter 1 if this assessment will be re-transmitted.
  • DESCRIPTION:  This determines whether the assessment will be re-transmitted. It will automatically be set to '1' when a transmitted assessment is updated to an INCOMPLETE status to edit and re-transmit.
394 *HISTORY OF MI 200;31 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 07, 2014
  • HELP-PROMPT:  Enter 'YES' if the patient has a history of MI in the 6 months prior to surgery.
  • DESCRIPTION:  
    Definition Revised (2004): The history of a non-Q wave or a Q wave infarct in the six months prior to surgery as diagnosed in the patient's medical record.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
395 *ANGINA ONE MONTH PRIOR 200;34 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 22, 2014
  • HELP-PROMPT:  Enter 'YES' if the patient has had angina within one month prior to surgery.
  • DESCRIPTION:  Definition Revised (2004): Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated
    by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. Documentation in the
    chart by the physician should state 'angina' or 'anginal equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had angina at any time within 30 days prior to surgery.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
396 *CHF WITHIN ONE MONTH 200;35 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 16, 2014
  • HELP-PROMPT:  Enter 'YES' if the patient has had CHF within one month prior to surgery.
  • DESCRIPTION:  Definition Revised (2004): Congestive Heart Failure is the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure.
    Only newly diagnosed CHF within the previous 30 days or a diagnosis of chronic CHF with new signs or symptoms in the 30 days prior to surgery fulfills this definition. Common manifestations are:
    - Abnormal limitation in exercise tolerance due to dyspnea or fatigue
    - Orthopnea (dyspnea on lying supine)
    - Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea)
    - Increased jugular venous pressure
    - Pulmonary rales on physical examination
    - Cardiomegaly
    - Pulmonary vascular engorgement
    Should be noted in the medical record as CHF, congestive heart failure, or pulmonary edema.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
397 SEVERE HEAD TRAUMA (Y/N) 200;20 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  SEP 10, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has sustained severe head trauma.
  • DESCRIPTION:  This determines whether the patient has sustained open or closed trauma to the head from external force, violence, or accident with resulting impairment in neurological function as manifested by motor, sensory, or
    cognitive impairments.
398 QUADRIPLEGIA (Y/N) 200;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  APR 24, 2007
  • HELP-PROMPT:  Enter 'YES' if the patient has total or partial paralysis or paresis of all four extremities.
  • DESCRIPTION:  
    Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of all four extremities.
399 PARAPLEGIA (Y/N) 200;23 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient has total or partial paralysis or paresis of the lower extremities.
  • DESCRIPTION:  
    Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of the lower extremities.
400 HEMIPLEGIA/HEMIPARESIS (Y/N) 200;24 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has total or partial paralysis or paresis on one side of the body.
  • DESCRIPTION:  Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of one side of the body. Enter YES if the patient has
    hemiplegia/hemiparesis (that has not recovered or been rehabilitated) upon arrival to the OR. Enter YES if there is hemiplegia or hemiparesis associated with a CVA/Stroke also.
401 TUMOR INVOLVING CNS (Y/N) 200;29 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has a tumor involving the central nervous system.
  • DESCRIPTION:  Definition Revised (2007): Space-occupying tumor of the brain and spinal cord, which may be benign (e.g., meningiomas, ependymoma, oligodendroglioma) or primary (e.g., astrocytoma, glioma, glioblastoma multiform) or
    secondary malignancies (e.g., metastatic lung, breast, malignant melanoma). Other tumors that may involve the CNS include lymphomas and sarcomas. Answer "YES" even if the tumor was not treated. A patient with metastatic
    cancer with boney mets to spine is a CNS tumor. Answer "NO" if tumor was removed.
402 GENERAL (Y/N) 200;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 12, 1991
  • HELP-PROMPT:  Enter 'YES' if the patient has any general medical problems.
  • DESCRIPTION:  
    This determines whether the patient has any general medical problems, such as diabetes, dyspnea, or alcohol related illnesses.
403 WOUND OCCURRENCES 205;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 26, 1995
  • HELP-PROMPT:  Enter 'YES' if the patient has any postoperative wound occurrences.
  • DESCRIPTION:  
    This determines whether the patient had any postoperative wound occurrences.
404 WOUND DISRUPTION 205;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JAN 07, 2014
  • HELP-PROMPT:  Enter Yes if the patient has postoperative wound disruption.
  • DESCRIPTION:  
    Definition Revised (2014): Separation of the skin and musculofascial layers of a surgical wound (any surgical site whether primary or secondary, e.g. vein harvest incision), which may be partial or complete.
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
405 LOW SERUM SODIUM 203;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the lowest postoperative serum sodium result recorded within 30 days postoperatively. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or
    ">". Entering "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
406 LOW POTASSIUM 203;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>3!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  APR 10, 1997
  • HELP-PROMPT:  Answer must be 1-3 characters in length.
  • DESCRIPTION:  This is the lowest recorded postoperative potassium result. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is
    also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
407 LOW SODIUM, DATE 204;2 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the lowest postoperative serum sodium was recorded.
  • DESCRIPTION:  This is the date that the lowest serum sodium test result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
408 LOW POTASSIUM, DATE 204;4 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the lowest postoperative potassium was recorded.
  • DESCRIPTION:  This is the date that the lowest potassium test result was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
409 RENAL INSUFFICIENCY 205;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient has progressive renal insufficiency.
  • DESCRIPTION:  
    Definition Revised (2004): The reduced capacity of the kidney to perform its function as evidenced by a rise in creatinine of >2 mg/dl from preoperative value, but with no requirement for dialysis.
410 COMA > 24 HOURS POSTOP 205;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  APR 19, 2011
  • HELP-PROMPT:  Enter YES if the patient has significantly impaired level of consciousness > or = 24 hours postoperatively.
  • DESCRIPTION:  Definition Revised (2011): Indicate if either postoperatively or within 30 days of surgery there was a significantly decreased level of consciousness (exclude transient disorientation or psychosis) for greater than or
    equal to 24 hours as evidenced by lack of response to deep, painful stimuli. Do not include drug-induced coma (e.g. Propofol drips, etc.)
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
411 CARDIAC ARREST REQ CPR 205;26 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  APR 28, 2011
  • HELP-PROMPT:  Enter YES if the patient has had postoperative cardiac arrest requiring CPR.
  • DESCRIPTION:  Definition Revised (2011): Indicate if there was any cardiac arrest requiring external or open cardiopulmonary resuscitation (CPR) occurring in the operating room, ICU, ward, or out-of-hospital after the chest had been
    completely closed and within 30 days of surgery. Patients with AICDs that fire but the patient does not lose consciousness should be excluded.
    If patient had cardiac arrest requiring CPR, indicate whether the arrest occurred intraoperatively or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while patient was in the operating
    room - postoperatively: occurring after patient left the operating room.
  • TECHNICAL DESCR:  The user indicates whether cardiac arrest requiring CPR occurred intraoperatively or postoperatively by the menu option selected to record the occurrence. Intraoperative occurrences are recorded in the INTRAOPERATIVE
    OCCURRENCES multiple field (#1.14) in the SURGERY file (#130). Postoperative occurrences are recorded in the POSTOP OCCURRENCE multiple field (#1.16) multiple field (#1.14) in the SURGERY file (#130).
  • SCREEN:  S DIC("S")="I Y'=""NS"""
  • EXPLANATION:  Screen prevents selection of retired code.
412 UNPLANNED INTUBATION (Y/N) 205;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter YES if the patient had an unplanned intubation due to respiratory or cardiac failure.
  • DESCRIPTION:  Definition Revised (2004): Patient required placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress,
    hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated for their surgery, unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated during surgery,
    intubation at any time after their surgery is considered unplanned.
413 TRANSFER STATUS 208;11 SET
  • '1' FOR NOT TRANSFERRED;
  • '2' FOR NON-VAMC ACUTE CARE HOSPITAL;
  • '3' FOR VAMC ACUTE CARE HOSPITAL;
  • '4' FOR NON-VA NURSING/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY;
  • '5' FOR VA NURSING HOME/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY;
  • '6' FOR OTHER;

  • LAST EDITED:  JUL 01, 2004
  • HELP-PROMPT:  Enter the transfer status of this patient upon admission.
  • DESCRIPTION:  Definition Revised (2004): Was the patient transferred directly from another healthcare facility and admitted to this hospital? Please select from the following choices. If the patient was admitted from home, select #1. If
    the patient was transferred from another facility, please select from choices #2-6.
    (1) Not transferred from a health care facility; admitted directly
    from home
    (2) Non-VAMC Acute Care Hospital
    (3) VAMC Acute Care Hospital
    (4) Non-VA Nursing Home/Chronic Care Facility/Spinal Cord Injury
    Unit/Intermediate Care Unit
    (5) VA Nursing Home/Chronic Care Facility/Spinal Cord Injury
    Unit/Intermediate Care Unit
    (6) Other (for example, Domiciliary)
    * If a patient arrives from another hospital's emergency department, report as #1. If you cannot determine what kind of facility, enter "OTHER".
414 CARDIAC SURGICAL PRIORITY 208;12 SET
  • '1' FOR ELECTIVE;
  • '2' FOR URGENT;
  • '3' FOR EMERGENT (ONGOING ISCHEMIA);
  • '4' FOR EMERGENT (HEMODYNAMIC COMPROMISE);
  • '5' FOR EMERGENT (ARREST WITH CPR);

  • LAST EDITED:  JAN 22, 2007
  • HELP-PROMPT:  Enter the surgical priority that most accurately reflects the acuity of patient's cardiovascular condition at the time of transport to the operating room.
  • DESCRIPTION:  If this is a cardiac procedure, this is the surgical priority reflecting the patient's cardiovascular condition at the time of transport to the operating room:
    1. Elective - Patient placed on elective schedule with surgery usually
    performed > 72 hours following catheterization.
    2. Urgent - Clinical condition mandates prompt surgery usually within
    12 to 72 hours of catheterization (patients clinically stable on a
    circulatory support system should be included in this category).
    3. Emergent (ongoing ischemia) - Clinical condition mandates immediate
    surgery usually on day of catheterization because of ischemia
    despite medical therapy, such as intravenous nitroglycerine.
    Ischemia should be manifested as chest pain and/or ST-segment
    depression.
    4. Emergent (hemodynamic compromise) - Persistent hypotension (arterial
    systolic pressure < 80 mm Hg) and/or low cardiac output (cardiac
    index < 2.0 L/min/MxM) despite iontropic and/or mechanical
    circulatory support mandates immediate surgery within hours of the
    cardiac catheterization.
    5. Emergent (arrest with CPR) - Patient is taken to the operating room
    in full cardiac arrest with the circulation supported by
    cardiopulmonary resuscitation (excludes patients being adequately
    perfused by a cardiopulmonary support system).
414.1 SURGICAL PRIORITY, DATE 208;13 DATE

  • INPUT TRANSFORM:  S %DT="ETXRP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 08, 2008
  • HELP-PROMPT:  Enter the date and time that the cardiac surgical priority was documented.
  • DESCRIPTION:  
    This is the date and time that the cardiac surgical priority information was collected.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
415 MITRAL REGURGITATION 206;9 SET
  • '0' FOR NONE;
  • '1' FOR MILD;
  • '2' FOR MODERATE;
  • '3' FOR SEVERE;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  JUL 21, 2004
  • HELP-PROMPT:  Enter the code describing presence/severity of mitral regurgitation.
  • DESCRIPTION:  Definition Revised (2004): Indicate the severity of any mitral regurgitation documented for the patient. This question should be answered using either the left ventricular angiogram or the cardiac ultrasound examination.
    Adjectives used to describe the severity of the mitral regurgitation on the cardiac cath report should be converted to a four-point scale: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe.
    Diagnosis by angiogram:
    =======================
    The following definitions should be used to assess the presence/severity of mitral regurgitation based on the interpretation of the contrast left ventricular angiogram:
    None/Trivial - There is no visible systolic regurgitation across the mitral valve. Trace or trivial notations of mitral regurgitation should be listed as none.
    Mild - Definite contrast can be seen in the left atrium following left ventricular injection, but the left atrium never fills to the same opacity as the left ventricle.
    Moderate - The left atrium fills to the same opacity as the left ventricle over two or more systoles.
    Severe - The left atrium fills to the same opacity as the left ventricle over a single systole.
    NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
    Diagnosis by cardiac ultrasound:
    ================================
    The following definitions are commonly used to assess the presence/severity of mitral regurgitation based on the interpretation of the cardiac ultrasound examination:
    None/Trivial - No regurgitant jet is seen on the Doppler study. Trace or trivial notations of mitral regurgitation should be listed as none.
    Mild - The area of the regurgitant jet is 0 - 4 cm2.
    Moderate - The area of the regurgitant jet is >4 - 8 cm2.
    Severe - The area of the regurgitant jet is greater than 8 cm2 or greater than one third of the total left atrial area.
    NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
416 *NUMBER WITH OTHER CONDUIT 207;20 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  JUL 21, 2004
  • HELP-PROMPT:  Type a Number between 0 and 9, 0 Decimal Digits
  • DESCRIPTION:  Definition Revised (2004): This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other conduit(s) regardless of whether other procedures were performed. Do not leave this
    information blank. If no coronary artery bypass grafts with other conduits were performed, enter '0'.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
417 RACE 208;10 SET
  • '1' FOR HISPANIC, WHITE;
  • '2' FOR HISPANIC, BLACK;
  • '3' FOR AMERICAN INDIAN OR ALASKA NATIVE;
  • '4' FOR BLACK, NOT OF HISPANIC ORIGIN;
  • '5' FOR ASIAN OR PACIFIC ISLANDER;
  • '6' FOR WHITE, NOT OF HISPANIC ORIGIN;
  • '7' FOR UNKNOWN;

  • LAST EDITED:  MAR 06, 1996
  • DESCRIPTION:  
    This is the race of the patient. This is a standard set of codes and should not be edited.
418 HOSPITAL ADMISSION DATE 208;14 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2011
  • HELP-PROMPT:  Enter the date and time of the hospital admission associated with this surgical case.
  • DESCRIPTION:  Definition Revised (2011): The date and time of the hospital admission to this VAMC associated with this surgical case as found in the PIMS package. If the patient was admitted directly to surgery and then admitted to the
    hospital, use the date of surgery as the date of admission. Entering NA for "NOT APPLICABLE" is allowed for non-cardiac surgery patients.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
419 HOSPITAL DISCHARGE DATE 208;15 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  APR 20, 2011
  • HELP-PROMPT:  Enter the date and time of the hospital discharge associated with this surgical case.
  • DESCRIPTION:  Definition Revised (2011): Indicate the date of the hospital discharge associated with this surgical case. Patients transferred to a referring facility should be indicated as discharged from current admission. Patients
    transferred to the psychiatric unit or any chronic care facility located at the VA facility (e.g., a nursing home) should be indicated as discharged from current admission at the date and time of the transfer to this
    different facility. (Do not indicate the date of data input, unless the patient was actually discharged on this same date.)
    Patients who remain as inpatients for reasons other than for post- open heart procedures should continue to be followed until discharged (including the rehabilitation service) even if the cardiothoracic team discharges the
    patient from their service or would discharge the patient home. If the patient remains in the hospital and/or has subsequent surgeries, indicate such in the CARDIAC RESOURCE DATA COMMENTS field (#431.)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
420 ADMISSION/TRANSFER DATE 208;16 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 08, 2008
  • HELP-PROMPT:  Enter the date of transfer to surgical service for this surgical episode or enter NA if this date is not applicable.
  • DESCRIPTION:  Definition Revised (2004): If the patient was not initially admitted to the surgical service, the date and time of transfer to surgical service for this surgical episode will be entered from the PIMS package. Enter 'NA' if
    this date is not applicable, e.g. outpatient not admitted or observed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
421 DISCHARGE/TRANSFER DATE 208;17 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 08, 2008
  • HELP-PROMPT:  Enter date and time of the patient's discharge or transfer from the surgical or medical service to a chronic care setting, or enter NA if this date is not applicable.
  • DESCRIPTION:  Definition Revised (2004): The date and time of the patient's discharge or transfer from the surgical or medical service to a chronic care setting. i.e., spinal cord injury unit, psychiatric facility or psychiatric unit,
    nursing home care unit or facility, or intermediate medicine. Acute care beds must be established locally with the assistance of your station IRM service.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
422 OUT-OF-OR UNPLANNED INTUBATION 205;44 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 29, 2015
  • HELP-PROMPT:  Enter Yes if the patient had Out-Of-OR unplanned intubation within 30 days.
  • DESCRIPTION:  VASQIP Definition (2015): Patient required unplanned placement of an endotracheal tube or other similar breathing tube out of the operating room for ventilator support within 30 days following surgery regardless of cause.
    This definition includes:
    1) patients re-intubated out of the operating room following planned
    extubation and
    2) patients who self-extubate out of the operating room and were not
    immediately re-intubated.
423 CONGESTIVE HEART FAILURE PREOP 207;29 SET
  • '0' FOR N CARD DX, CHF, OR SX;
  • '1' FOR Y CARD DX/CHF, N SX;
  • '2' FOR Y CARD DX/CHF, Y MILD SX;
  • '3' FOR Y CARD DX/CHF, Y MARKED SX;
  • '4' FOR Y CARD DX/CHF, Y SX AT REST;
  • '5' FOR N CARD DX/CHF, SX UNKNOWN;
  • '6' FOR Y CARD DX/CHF, SX UNKNOWN;

  • LAST EDITED:  AUG 25, 2015
  • HELP-PROMPT:  Indicate whether the patient has Congestive Heart Failure in the 30 days prior to surgery.
  • DESCRIPTION:  VASQIP Definition (2015): Indicate whether the patient has congestive heart failure if the patient chart or patient self-report indicates a history of congestive heart failure with one of the following that describes
    symptoms in the 30 days before surgery. Indicate the one most appropriate response:
    0 - Documented history of no cardiac disease or congestive heart
    failure, and no symptoms of abnormal fatigue, dyspnea, or angina. 1 - Documented history of cardiac disease or congestive heart failure;
    no symptoms of abnormal fatigue, dyspnea, or angina. 2 - Documented history of cardiac disease or congestive heart failure;
    slight limitation of physical activity by fatigue, dyspnea, or
    angina.
    The patient gets unusual fatigue, dyspnea, and/or angina only upon
    performing more strenuous activities, such as climbing two or more
    flights of stairs without stopping. 3 - Documented history of cardiac disease or congestive heart failure;
    marked limitation of physical activity by fatigue, dyspnea, or
    angina. The patient gets unusual fatigue, dyspnea, and/or angina
    upon performing ordinary activities, such as walking several blocks
    or climbing a flight of stairs. 4 - Documented history of cardiac disease or congestive heart failure;
    symptoms at rest and/or inability to carry out any physical
    activity without symptoms of fatigue, dyspnea or angina. The
    patient has symptoms of unusual fatigue, dyspnea, and/or angina
    at rest or when performing minimal activity, such as walking across
    the room. 5 - No documented history of cardiac disease or congestive heart
    failure, and symptomatology is unknown (e.g., documentation not
    found or could not be determined with available information) 6 - Documented history of cardiac disease or congestive heart failure,
    and symptomatology is unknown (e.g., documentation not found or
    could not be determined with available information)
430 CARDIAC RISK PREOP COMMENTS 206.1;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>130!($L(X)<1) X
  • LAST EDITED:  FEB 09, 2006
  • HELP-PROMPT:  Answer must be 1-130 characters in length.
  • DESCRIPTION:  Definition Revised (2006): Indicate in the comment field any preoperative patient risk factors (not previously entered above) that may contribute to this patient's risk of operative mortality. (The maximum length of this
    field is 130 characters.)
431 CARDIAC RESOURCE DATA COMMENTS 206.2;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>130!($L(X)<1) X
  • LAST EDITED:  JAN 21, 2014
  • HELP-PROMPT:  Answer must be 1-130 characters in length.
  • DESCRIPTION:  
    Definition Revised (2014): Indicate additional comments related to this case prior to transmission to Denver by the SQN/Data Manager (limit 130 characters).
439 BATISTA PROCEDURE USED (Y/N) 207;23 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 04, 1997
  • HELP-PROMPT:  Enter whether the Batista Procedure was used or not.
  • DESCRIPTION:  
    Was the Batista procedure used, Yes or No?
440 CARDIAC CATHETERIZATION DATE 207;21 DATE

  • INPUT TRANSFORM:  S:X="NS"!(X="ns") X="NS" Q:X="NS" S %DT="ETPX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  SEP 07, 2000
  • HELP-PROMPT:  Enter the date of the cardiac catheterization closest to and prior to the date of operation or enter NS if unknown or not applicable.
  • DESCRIPTION:  
    Record the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS if unknown or not applicable.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
441 MINIMALLY INVASIVE PROC (Y/N) 207;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 17, 1997
  • DESCRIPTION:  
    Was a minimally invasive procedure technique used, Yes or No?
442 EMPLOYMENT STATUS PREOPERATIVE 208;18 SET
  • '1' FOR EMPLOYED FULL TIME;
  • '2' FOR EMPLOYED PART TIME;
  • '3' FOR NOT EMPLOYED;
  • '4' FOR SELF EMPLOYED;
  • '5' FOR RETIRED;
  • '6' FOR ACTIVE MILITARY DUTY;
  • '9' FOR UNKNOWN;

  • LAST EDITED:  OCT 28, 1997
  • HELP-PROMPT:  Enter the patient's employment status preoperatively.
  • DESCRIPTION:  
    Employment status preoperatively is to be defined in the broad sense of regularly performed work activity with remuneration.
443 INTRAOP DISSEMINATED CANCER 200.1;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  FEB 13, 2007
  • HELP-PROMPT:  Enter YES if cancer was found during the operative procedure.
  • DESCRIPTION:  VASQIP Definition (2010): Intraoperative Disseminated Cancer: Patients who have cancer that was found during the operative procedure that:
    (1) Has spread to one site or more sites in addition to the primary
    site
    AND
    (2) In whom the presence of multiple metastases indicates the cancer
    is widespread, fulminant, or near terminal. Other terms describing
    disseminated cancer include "diffuse," "widely metastatic,"
    "widespread," or "carcinomatosis" or AJCC "Stage IV" cancer.
    Common sites of metastases include major organs (e.g., brain,
    lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You
    may use the National Cancer Institute as a reference in
    determining whether a patient has AJCC Stage IV cancer, when the
    TNM information is the only information documented. Refer to the
    following website for assistance with translating TNM values with
    AJCC staging:
    http://www.cancer.gov/cancertopics/pdq/adulttreatment
    Examples:
    - A patient with a primary breast cancer with positive nodes in the
    axilla does NOT qualify for this definition. The tumor has spread
    to a site other than the primary site, but does not have widespread
    metastases. A patient with primary breast cancer with positive
    nodes in the axilla AND liver metastases does qualify, because the
    tumor has spread to the axilla and other major organs.
    - A patient with colon cancer and no positive nodes or distant
    metastases does NOT qualify. A patient with colon cancer and
    several local lymph nodes positive for tumor, but no other evidence
    of metastatic disease does NOT qualify. A patient with colon cancer
    with liver metastases and/or peritoneal seeding with tumor does
    qualify.
    - A patient with adenocarcinoma of the prostate confined to the
    capsule does NOT qualify. A patient with prostate cancer that
    extends through the capsule of the prostate only does NOT qualify. A
    patient with prostate cancer with bony metastases DOES qualify.
    * Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma
    or Lymphomas that are Stage I-III as disseminated cancer.
  • SCREEN:  S DIC("S")="I ""NS""'=Y"
  • EXPLANATION:  Screen prevents selection of inactive code.
444 PREOPERATIVE ANION GAP 203;15 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JAN 27, 2006
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative Anion Gap calculation. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study"
    is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
444.1 PREOP ANION GAP, DATE 204;15 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date the preoperative Anion Gap was recorded.
  • DESCRIPTION:  
    This is the date the preoperative Anion Gap was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
445 HIGHEST ANION GAP 203;16 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JAN 27, 2006
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the highest postoperative anion gap recorded. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No
    Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
445.1 HIGH ANION GAP, DATE 204;16 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest postop Anion Gap was recorded.
  • DESCRIPTION:  
    This is the date that the highest postoperative Anion Gap was recorded.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
446 INTRAOPERATIVE ASCITES 200.1;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 22, 2007
  • HELP-PROMPT:  Enter Yes or No. NS is not allowed.
  • DESCRIPTION:  VASQIP Definition (2010): Intraoperative Ascites: The presence of fluid accumulation in the peritoneal cavity noted during the operative procedure. Documentation should state a history of or active liver disease (e.g.
    jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).
447 CLOSTRIDIUM DIFFICILE COLITIS 205;39 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  NOV 02, 2007
  • HELP-PROMPT:  Enter YES if this patient had postoperative C. difficile colitis.
  • DESCRIPTION:  Definition Revised (2008): C. difficile-associated disease occurs when the normal intestinal flora is altered, allowing C. difficile to flourish in the intestinal tract and produce a toxin that causes a watery diarrhea.
    C. difficile diarrhea is confirmed by the presence of a toxin in a stool specimen. Answer yes only if you have a positive culture for C. difficile and/or a toxin assay and diagnosis of C. difficile documented in the
    chart.
448 POSTOP ATRIAL FIBRILLATION 205;40 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 14, 2010
  • HELP-PROMPT:  Enter YES if the patient had a new onset postoperatively of atrial fibrillation/flutter (AF).
  • DESCRIPTION:  
    VASQIP Definition (2010) Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been present preoperatively.
450 TOTAL ISCHEMIC TIME 206;36 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  OCT 02, 1997
  • HELP-PROMPT:  Type a Number between 0 and 9999, 0 Decimal Digits
  • DESCRIPTION:  
    Record in minutes the duration of time the ascending aorta is totally cross-clamped. Do not include the duration of partial aorta cross-clamp used for sewing the proximal anastomoses.
451 TOTAL CPB TIME 206;37 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  OCT 08, 1997
  • HELP-PROMPT:  Type a Number between 0 and 9999, 0 Decimal Digits
  • DESCRIPTION:  Record in minutes the total cardiopulmonary bypass time. This includes the total duration of full and partial cardiopulmonary bypass from all episodes of cardiopulmonary bypass. This information can generally be found on
    the perfusionist record and/or the anesthesia record.
452 OBSERVATION ADMISSION DATE 208.1;1 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  MAR 12, 2015
  • HELP-PROMPT:  Enter the date and time the patient was admitted for observation or enter NA if this information is not applicable.
  • DESCRIPTION:  Definition Revised (2015): An observation patient is one who presents with a medical condition with a significant degree of instability or disability, and who needs to be monitored, evaluated and assessed for either
    admission to inpatient status or assignment to care in another setting. An observation patient can occupy a special bed set aside for this purpose or may occupy a bed in any unit of a hospital, i.e., urgent care, medical
    unit. These types of patients should be evaluated against standard inpatient criteria. These beds are not designed to be a holding area for Emergency Rooms. The length-of-stay in observation beds will not exceed 47 hours
    and 59 minutes. Following surgery, if the patient was admitted for observation, this is the date and time of admission for observation. If this information is not applicable, enter NA.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
453 OBSERVATION DISCHARGE DATE 208.1;2 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 08, 2008
  • HELP-PROMPT:  Enter the date and time the patient was discharged from observation or enter NA if this information is not applicable.
  • DESCRIPTION:  
    Definition Revised (2004): If the patient was admitted for observation following surgery, this is the date and time of discharge from observation. If this information in not applicable, enter NA.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
454 OBSERVATION TREATING SPECIALTY 208.1;3 POINTER TO SPECIALTY FILE (#42.4) SPECIALTY(#42.4)

  • INPUT TRANSFORM:  S:X="NA"!(X="na") X="NA" Q:X="NA" S DIC("S")="I $P(^DIC(42.4,Y,0),U)[""OBSERVATION""" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  MAR 16, 2004
  • HELP-PROMPT:  Enter the observation treating specialty associated with the admission for observation or enter NA if this information is not applicable.
  • DESCRIPTION:  
    Definition Revised (2004): If the patient was admitted for observation following surgery, this is the observation treating specialty to which the patient was admitted. If this information is not applicable, enter NA.
  • SCREEN:  S DIC("S")="I $P(^DIC(42.4,Y,0),U)[""OBSERVATION"""
  • EXPLANATION:  Screen allows selection of OBSERVATION specialties only.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
455 HIGHEST SERUM TROPONIN I 203;13 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  FEB 09, 1999
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the highest postoperative serum cardiac troponin I test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
455.1 HIGH SERUM TROPONIN I, DATE 204;13 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest postop troponin I was performed.
  • DESCRIPTION:  
    This is the date that the highest postop serum troponin I was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
456 HIGHEST SERUM TROPONIN T 203;14 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  FEB 09, 1999
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the highest postoperative serum cardiac troponin T test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering
    "NS" for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
456.1 HIGH SERUM TROPONIN T, DATE 204;14 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the highest postop troponin T was performed.
  • DESCRIPTION:  
    This is the date that the highest postop serum troponin T was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
457 HDL (CARDIAC) 201;21 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  FEB 22, 2006
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the HDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
457.1 HDL, DATE 202;21 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  This is the date that the HDL was performed and must not be more than 1000 days before surgery.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the date that the preoperative HDL value was assessed. Enter "NS" for No Study if the HDL test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
458 SERUM TRIGLYCERIDE (CARDIAC) 201;22 FREE TEXT

  • INPUT TRANSFORM:  S:X="NS"!(X="ns") X="NS" Q:X="NS" K:$L(X)>6!($L(X)<1) X
  • LAST EDITED:  FEB 22, 2006
  • HELP-PROMPT:  Answer must be 1-6 characters in length
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the Serum Triglyceride result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
458.1 SERUM TRIGLYCERIDE, DATE (CAR) 202;22 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  This is the date that the Serum Triglyceride was performed and must not be more than 1000 days before surgery.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the date that the preoperative Serum Triglyceride value was assessed. Enter "NS" for No Study if the Serum Triglyceride test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
459 SERUM POTASSIUM (CARDIAC) 201;23 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JUN 30, 2004
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate the serum potassium result (mg/L) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
459.1 SERUM POTASSIUM, DATE(CARDIAC) 202;23 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the Serum Potassium was performed.
  • DESCRIPTION:  Definition Revised (2004): Indicate the date that the preoperative Serum Potassium value was assessed. Enter "NS" for No Study if the Serum Potassium test was not performed or was performed more than 90 days before
    surgery.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
460 SERUM BILIRUBIN (CARDIAC) 201;24 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JUN 30, 2004
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate the serum bilirubin result (mg/dl) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
460.1 SERUM BILIRUBIN, DATE (CARD) 202;24 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the Serum Bilirubin was performed.
  • DESCRIPTION:  Definition Revised (2004): Indicate the date that the preoperative Serum Bilirubin value was assessed. Enter "NS" for No Study if the Serum Bilirubin test was not performed or was performed more than 90 days before
    surgery.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
461 LDL (CARDIAC) 201;25 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  MAR 08, 2006
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the LDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
461.1 LDL, DATE (CARDIAC) 202;25 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  This is the date that the LDL was performed and must not be more than 1000 days before surgery.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the date that the preoperative LDL value was assessed. Enter "NS" for No Study if the LDL test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
462 TOTAL CHOLESTEROL (CARDIAC) 201;26 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  FEB 22, 2006
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the Total Cholesterol result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
462.1 TOTAL CHOLESTEROL, DATE 202;26 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  This is the date that the Total Cholesterol was performed and must not be more than 1000 days before surgery.
  • DESCRIPTION:  
    Definition Revised (2006): Indicate the date that the preoperative Total Cholesterol value was assessed. Enter "NS" for No Study if the Cholesterol test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
463 *HYPERTENSION 206;38 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 16, 2014
  • HELP-PROMPT:  Enter YES if there is any indication that the patient has hypertension.
  • DESCRIPTION:  Definition Revised (2004): Indicate if the patient has a documented history of hypertension with or without current treatment of antihypertensive medication(s). If a diuretic agent is prescribed to treat hypertension,
    indicate Yes for both the hypertension and the diuretic questions. (YES/NO).
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
464 *NUMBER WITH RADIAL ARTERY 207;24 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>10)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  JUL 05, 2000
  • HELP-PROMPT:  Enter the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries performed with radial artery(ies).
  • DESCRIPTION:  This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with radial artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the
    appropriate place if no coronary artery bypass grafts were performed with radial artery. Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
465 *NUMBER WITH OTHER ARTERY 207;25 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>10)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  AUG 24, 2000
  • HELP-PROMPT:  Enter the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries performed with other artery(ies).
  • DESCRIPTION:  This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the
    appropriate place if no coronary artery bypass grafts were performed with other artery(ies). Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
466 TRACHEOSTOMY 206;39 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 09, 2004
  • HELP-PROMPT:  Enter YES if a postoperative tracheostomy was performed on this patient.
  • DESCRIPTION:  
    Definition Revised (2004): Indicate if a procedure to cut into the trachea and insert a tube to overcome tracheal obstruction or to facilitate extended mechanical ventilation was performed within 30 days of surgery.
467 NEW MECHANICAL CIRCULATORY 206;40 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 07, 2014
  • HELP-PROMPT:  Enter NO if new mechanical circulatory support was not necessary perioperatively.
  • DESCRIPTION:  
    Definition Revised (2014): Indicate if the patient left the operating room suite with or required post-op placement of a new IABP, ECMO, or VAD for circulatory support within 30 days post-operatively.
468 INCISION TYPE 207;26 SET
  • 'FS' FOR FULL STERNOTOMY;
  • 'FT' FOR FULL THORACOTOMY;
  • 'LP' FOR LIMITED PARASTERNAL APPROACH;
  • 'LS' FOR LIMITED STERNOTOMY;
  • 'LT' FOR LIMITED THORACOTOMY;
  • 'OL' FOR OTHER LIMITED SURG APPROACH;
  • 'NS' FOR NO STUDY/UNKNOWN;

  • LAST EDITED:  SEP 19, 2000
  • HELP-PROMPT:  Select the appropriate description of the incision used for cardiac access.
  • DESCRIPTION:  This describes the incision used for cardiac access, according to the operative report. (Do not include incisions for port access.) Enter NS if incision type is unknown.
    - Limited Sternotomy: The incision cuts through a small portion (less
    than half of the length) of the sternum (the narrow, flat bone in
    the median line of the thorax in the front of the chest).
    - Full Sternotomy: The incision cuts through the entire length of the
    sternum (the narrow, flat bone in the median line of the thorax in
    the front of the chest).
    - Limited Thoracotomy: A small surgical incision through a portion of
    the chest wall, but not along the sternum. For example, an
    anterolateral thoracotomy approach may be used in LIMA to LAD
    grafting.
    - Full Thoracotomy: A larger surgical incision running across the
    chest wall, but not along the sternum. This may be a left
    submammary incision, which requires the resection of the fourth
    costal cartilage and /or deflation of the left lung.
    - Limited Parasternal Approach: The incision cuts beside a small
    portion (less than 0.5 of the length) of the sternum, on a line
    midway between the sternal margin and an imaginary line passing
    through the nipple.
    - Other Limited Surgical Approach: An incision or incision set used to
    visualize the operating field that is not listed above.
469 CONVERT FROM OFF PUMP TO CPB 207;27 SET
  • '1' FOR NO (began off-pump/ stayed off-pump);
  • '2' FOR YES-PLANNED;
  • '3' FOR YES-UNPLANNED;
  • '4' FOR YES-UNKNOWN IF PLANNED;
  • '5' FOR NA (began on-pump/ stayed on-pump);
  • 'NS' FOR NO STUDY/UNKNOWN;

  • LAST EDITED:  DEC 23, 2013
  • HELP-PROMPT:  Was this procedure begun as an off-pump procedure, but changed so that CPB was used for any reason, or any length of time?
  • DESCRIPTION:  Definition Revised (2004): Indicate whether patient was converted from off cardiopulmonary bypass assistance to on cardiopulmonary bypass during the cardiac surgical procedure. Indicate the one appropriate response:
    No - There was no conversion that occurred for the off-pump case
    performed (i.e., the off-pump case remained off-pump throughout
    the operation). NA - The procedure was NOT an off-pump case (i.e., procedure began
    on-pump and remained on- pump throughout the case). [The default
    will be set to N/A.] Yes, planned - The procedure was begun as an off-pump procedure but
    changed to on-pump for any length of time; the change was planned
    due to decision made prior to operation to perform some vessels
    off-pump and some on-pump in order to minimize total CPB time. Yes, unplanned - The procedure was begun as an off-pump procedure but
    changed to on-pump for any length of time; the change was
    unplanned and determined in the operating room due to inability
    to safely perform revascularization. NS/Unknown - If documentation is not sufficient to answer, entering
    "NS" for "No Study/Unknown" is also allowed.
  • SCREEN:  S DIC("S")="I Y'=4&'(Y=1&($P($G(^SRF(DA,206)),""^"",37)))"
  • EXPLANATION:  Screen prevents selection of 4-YES-UNKNOWN IF PLANNED entry and prevents selection of 1-NO (began off-pump/ stayed off-pump) if CPB Time >0.
470 D/T PATIENT EXTUBATED 208;22 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="RI"!(SRX="ri") X="RI"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  DEC 07, 2010
  • HELP-PROMPT:  Enter the exact date and time that the endotracheal tube is pulled for the first time after the surgery.
  • DESCRIPTION:  Definition Revised (2008): Indicate the date that the endotracheal tube is pulled for the first time after surgery. If a tracheostomy is performed to replace an oral intubation tube, intubation is considered continuous so
    the patient has not been extubated as long as the patient continues to require ventilator support. If the patient dies while intubated, indicate the date of death for this data element. Indicate "extubated prior to leaving
    the OR" in the Resource Comment if patient is extubated prior to leaving the OR.
    RI - The patient remains intubated and on ventilator at 30 days after surgery.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
471 D/T PATIENT DISCH FROM ICU 208;23 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="RI"!(SRX="ri") X="RI"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  JUN 10, 2010
  • HELP-PROMPT:  Enter the first date and time of the discharge from the intensive care unit (ICU).
  • DESCRIPTION:  VASQIP Definition (2010): This is the first date and time of the discharge from the intensive care unit (ICU). ICU is usually a surgical unit (SICU), although it may also include a post-anesthesia recovery unit off the
    operating room. It may also be a general ICU in which medical patients are also managed (MICU, CCU). This will always be the unit into which the patient goes immediately after surgery and is stabilized, ventilated and
    ultimately extubated. Do not include lower acuity units where the patient goes subsequently (i.e. stepdown, transitional care, telemetry, etc.). Do not include subsequent readmissions to the ICU.
    RI - The patient remains in ICU at 30 days after surgery.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
472 *CARDIAC SURG PERFORMED NON-VA 206;41 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR UNKNOWN;

  • LAST EDITED:  JAN 14, 2014
  • HELP-PROMPT:  Enter Yes if the surgery was performed at a non-VA facility through a contract arrangement.
  • DESCRIPTION:  Definition Revised (2004): Indicate whether the patient's cardiac surgery was performed in a non-VA facility through a contracted arrangement, even if part of the post-surgical care is provided at the VA. A "contract"
    facility is one established to be an affiliate with the VA medical center, and it is most typically a University Hospital. In rare cases a "contract" facility may be a community hospital when there is no University
    affiliate for the VAMC. By contrast, a "fee-basis" patient surgery should not be indicated as a "contract" facility. Typically, a "fee-basis" establishment is an agreement by the VA Chief of Staff to out-source a patient
    to a community hospital. That hospital then bills the Chief of Staff for care rendered on the patient. VASQIP does not wish to capture the patient data on the "fee-basis" patients. If the patient is not entered into
    VISTA, send a paper form to Denver for hand-entry, unless your facility contracts-out a majority of its cases. Enter "NS" if funding for the procedure is not known. The default is to NO if a response is not entered.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
473 HOMELESS 209;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY/UNKNOWN;

  • LAST EDITED:  APR 01, 2004
  • HELP-PROMPT:  Enter 'YES' if the patient does not have a fixed dwelling.
  • DESCRIPTION:  
    Definition Revised (2004): If the patient indicates he/she does not have a fixed dwelling, indicate the person's status as homeless.
474 PREOP CIRCULATORY DEVICE 209;2 SET
  • 'N' FOR NONE;
  • 'I' FOR IABP;
  • 'V' FOR VAD (includes BIVAD);
  • 'A' FOR ARTIFICIAL HEART;
  • 'O' FOR OTHER;

  • LAST EDITED:  JUN 29, 2010
  • HELP-PROMPT:  Enter the Preoperative use of new mechanical circulatory device within 2 wks of surgery.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate whether there was any use of any device to assist ventricular function at the time the patient presents for surgery (or placed in the OR before anesthesia induction). Indicate the one
    appropriate response:
    None - No New Mechanical Circulatory Device was placed.
    IABP - An intra-aortic balloon pump was placed to assist ventricular
    function.
    VAD - A ventricular assist device (e.g., LVAD, BIVAD) was placed to
    assist ventricular function.
    Artificial Heart - An artificial heart was placed to assist ventricular
    function.
    Other - An other type of Mechanical Circulatory Device was placed.
475 *DIABETES (CARDIAC) 209;3 SET
  • 'N' FOR NO;
  • 'D' FOR DIET;
  • 'O' FOR ORAL;
  • 'I' FOR INSULIN;

  • LAST EDITED:  JUL 12, 2011
  • HELP-PROMPT:  Enter the patient's diabetes status.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Definition Revised (2006): Indicate if the patient has diabetes treated with diet, oral, and/or insulin therapy. Diabetes is defined as a metabolic disorder of the pancreas whereby the individual requires daily dosages of
    exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin therapy. Indicate the one most appropriate
    response. No - no diagnosis of diabetes. Diet - a diagnosis of diabetes that is controlled by diet alone in the two weeks preceding surgery (the only prescribed treatment has been diabetic relief). Oral - a diagnosis of
    diabetes requiring therapy with an oral hypoglycemic agent in the two weeks preceding surgery. Insulin - a diagnosis of diabetes requiring daily insulin therapy in the two weeks preceding surgery.
476 PROCEDURE TYPE 209;4 SET
  • 'C' FOR CATH;
  • 'I' FOR IVUS;
  • 'B' FOR BOTH/COMBINATION;
  • 'NS' FOR NO STUDY/UNKNOWN;

  • LAST EDITED:  JUL 21, 2004
  • HELP-PROMPT:  Enter procedure type, which was used for the cardiac catheterization and/or angiographic data.
  • DESCRIPTION:  Definition Revised (2004): Indicate which test was used for the cardiac catheterization and/or angiographic data. Indicate the one most appropriate response:
    Cath - A diagnostic procedure in which a catheter is introduced into a
    large vein, usually of an arm or leg, and threaded through the
    circulatory system to the heart to determine blood pressure and the
    rate of flow in the vessels and chambers of the heart and the
    identification of abnormal anatomy. IVUS - Intravascular Ultrasound may be used either alone or in
    combination with results from the cardiac catheterization. If used
    alone, indicate IVUS as the only test from which procedure results
    are calculated. Both - If both IVUS and Cath are available and both tests were
    analyzed for the results, indicate Both/Combination. NS - If no cath study is available, entering NS for "No Study/Unknown"
    is also allowed.
477 AORTIC STENOSIS 209;5 SET
  • '0' FOR NONE/TRIVIAL;
  • '1' FOR MILD;
  • '2' FOR MODERATE;
  • '3' FOR SEVERE;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  APR 16, 2007
  • HELP-PROMPT:  Enter severity of aortic stenosis using LV angiogram or cardiac ultrasound.
  • DESCRIPTION:  Definition Revised (2007): Indicate the severity of any aortic stenosis documented. This question should be answered using either the left ventricular angiogram (hemodynamic cath data) or the cardiac ultrasound
    examination. Numbers may be converted to describe the severity of the aortic stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Both transvalvular
    gradient and estimated valve orifice area are used to assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is obtained by converting the velocity of blood flow across the valve
    measured by the Doppler principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an
    adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the descriptive categories. Indicate
    the one most appropriate response:
    None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice
    area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow
    velocity is stated to be normal (< 1.0 M/sec).
    Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice
    area is 1.7 - 2.5 cm2
    Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the
    valve orifice area is 1.0 -1.6 cm2
    Severe - The mean pressure gradient is > 50 mm Hg and/or the valve
    orifice area is < 1.0 cm2
    NS - If no study was performed, entering "NS" for "No Study/Unknown"
    is also allowed.
478 RE-DO LAD STENOSIS 209;6 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Type a number between 0 and 100, 0 Decimal Digits
  • DESCRIPTION:  
    Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the left anterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
479 RE-DO RT CORONARY STENOSIS 209;7 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Type a number between 0 and 100, 0 Decimal Digits
  • DESCRIPTION:  
    Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the right coronary artery or posterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
480 RE-DO CIRCUMFLEX STENOSIS 209;8 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
  • LAST EDITED:  SEP 23, 2005
  • HELP-PROMPT:  Type a number between 0 and 100, 0 Decimal Digits
  • DESCRIPTION:  Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for
    bypass grafting. Entering "NS" for "No Study/Unknown" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
481 BRIDGE TO TRANSPLANT/DEVICE 209;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NONE;
  • 'B' FOR BRIDGE TO TRANSPLANT;
  • 'D' FOR DESTINATION THERAPY;

  • LAST EDITED:  JUN 24, 2015
  • HELP-PROMPT:  Enter the intended use of the mechanical support device implanted during this surgical procedure.
  • DESCRIPTION:  Definition Revised (2015): Indicate the intended use of the mechanical support device implanted during this surgical procedure (excluding IABP) as either a bridge to cardiac transplantation or patient received the device
    as destination therapy (does not intend to have a cardiac transplant), either with or without placing the patient on cardiopulmonary bypass.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182 and was re-activated with patch SR*3*184.
  • SCREEN:  S DIC("S")="I Y'=""Y"""
  • EXPLANATION:  Screen prevents selection of retired codes.
482 *MAZE PROCEDURE 209;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  APR 05, 2006
  • HELP-PROMPT:  Enter Yes if Maze procedure was done.
  • DESCRIPTION:  Definition Revised (2004): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt atrial conduction
    pathways often associated with atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (YES/NO).
483 *TMR 209;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAR 11, 2004
  • HELP-PROMPT:  Enter 'YES' to indicate if patient received a transmyocardial laser procedure (TMR).
  • DESCRIPTION:  Definition Revised (2004): Indicate if patient received a transmyocardial laser procedure (TMR) to make "channels" or small holes directly into the heart muscle, either with or without placing the patient on
    cardiopulmonary bypass. The TMR may be done in combination with a CABG procedure or as a stand-alone procedure.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
484 *OTHER CARDIAC PROCEDURES-LIST 209.1;1 FREE TEXT

  • INPUT TRANSFORM:  S NYUK=X K:$L(X)>60!($L(X)<3) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
  • LAST EDITED:  APR 04, 2006
  • HELP-PROMPT:  Answer must be 3-60 characters in length.
  • DESCRIPTION:  
    Definition Revised (2006): Specify if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
485 PRIOR HEART SURGERY 206;42 FREE TEXT

  • INPUT TRANSFORM:  K:X["""" X I $D(X) K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  FEB 06, 2014
  • HELP-PROMPT:  Answer must be 1-10 characters in length
  • DESCRIPTION:  Definition Revised (2014): Indicate all applicable types of heart surgery performed, either on or off-pump. Indicate all appropriate responses:
    None - Patient has not had a previous cardiac surgery procedure
    CABG-only - Patient has had a previous coronary artery bypass
    graft (CABG-only) procedure
    Valve-only - Patient has had a previous valve-only procedure
    CABG/Valve - Patient has had a previous combination CABG/valve
    procedure
    Other - Patient has had a previous cardiac procedure(s) other
    than CABG and Valve surgery, such as repair of atrial or
    ventricular septal defects, great thoracic vessel repair,
    cardiac transplant, left ventricular aneurysmectomy, insertion
    of ventricular assist devices, total artificial hearts, Maze
    procedures, etc." (Do not include pacemaker
    insertions or automatic implantable cardioverter-defibrillator
    (AICD) insertions; do not include pericardectomy if done off
    pump).
    CABG/Other - Patient has had a previous cardiac surgery that
    included a CABG with a concurrent "Other" cardiac procedure.
    Unknown - Unknown
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
486 GASTROINTESTINAL (Y/N) 200.1;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  DEC 11, 2003
  • HELP-PROMPT:  Enter 'YES' if this patient has a history of gastrointestinal problems.
  • DESCRIPTION:  
    This determines whether the patient has a history of gastrointestinal problems such as esophageal varices.
487 PREOPERATIVE INR 201;27 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  JAN 18, 2004
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  This is the result of the preoperative INR (International Normalized Ratio). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS"
    for "No Study" is also allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
487.1 PREOPERATIVE INR, DATE 202;27 DATE

  • INPUT TRANSFORM:  S %DT="EXP" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  JAN 19, 2007
  • HELP-PROMPT:  Enter the date that the preoperative INR was performed.
  • DESCRIPTION:  
    This is the date that the preoperative INR was performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
488 ORGAN/SPACE SSI 205;37 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NS' FOR NO STUDY;

  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Enter YES if this patient had postoperative organ/space SSI occurrences within 30 days.
  • DESCRIPTION:  Definition Revised (2015): Organ/Space SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (e.g.,
    organs or spaces) , other than the incision, which was opened or manipulated during an operation and at least one of the following:
    - Purulent drainage from a drain that is placed through a stab wound
    into the organ/space.
    - Organisms isolated from an aseptically obtained culture of fluid or
    tissue in the organ/space.
    - An abscess or other evidence of infection involving the organ/space
    that is found on direct examination, during reoperation, or by
    histopathologic or radiologic examination.
    - Diagnosis of an organ/space SSI by a surgeon or attending physician.
    NOTE: Please consult with the operating surgeon for assignment of organ/space vs. deep wound infection occurrences.
489 OTHER WOUND OCCURRENCE 205;38 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",DA)
  • OUTPUT TRANSFORM:  NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
  • LAST EDITED:  FEB 17, 2012
  • HELP-PROMPT:  Enter the ICD Diagnosis code for any other wound occurrence.
  • DESCRIPTION:  Definition Revised (2004): Enter any other wound occurrences that you feel to be significant and that are not covered by the predefined wound occurrence categories. Enter the ICD-CM code for this entry. (Example: Seromas,
    ICD-CM code: 998.13)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
490 *REPEAT VENTILATOR W/IN 30 DAY 209;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  FEB 27, 2014
  • HELP-PROMPT:  Enter Yes if the patient was placed on ventilator support.
  • DESCRIPTION:  Definition Revised (2008): Indicate if the patient was placed on ventilator support postoperatively within 30 days and this repeat ventilator support is related to the index operation (For example, the patient is on the
    ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is discontinued. Later, the patient gets into trouble and mechanical ventilation has to be reinstated.) However, if the patient
    returns to the OR within 30 days and gets extubated immediately after, it is not considered repeat ventilator support.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
491 OTHER NON-CT PROCEDURES 209.2;1 FREE TEXT

  • INPUT TRANSFORM:  S NYUK=X K:$L(X)>245!($L(X)<3) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
  • LAST EDITED:  JUN 29, 2004
  • HELP-PROMPT:  Answer must be 3-245 characters in length.
  • DESCRIPTION:  Definition Revised (2004): If any other procedure - other than cardiothoracic - performed requiring placing the patient on cardiopulmonary bypass, specify details into the comment field. If no other non-CT procedure
    requiring CPB was performed, indicate "NS" for "No Study/Unknown" in the text field.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
492 PREOP FUNCT. HEALTH STATUS 200.1;2 SET
  • '1' FOR INDEPENDENT;
  • '2' FOR PARTIALLY DEPENDENT;
  • '3' FOR TOTALLY DEPENDENT;
  • '4' FOR UNKNOWN;

  • LAST EDITED:  MAY 22, 2015
  • HELP-PROMPT:  Enter the level of self care that summarizes the patient's status prior to surgery.
  • DESCRIPTION:  Definition Revised (2015): This is a question that focuses on the patient's abilities to perform activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are defined as 'the activities
    usually performed in the course of a normal day in a person's life'. ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level of self-care for activities of daily living
    demonstrated by this patient at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's status changes prior to surgery, that change
    should be reflected in your assessment. For this time point, report the level of functional health status as defined by the following criteria.
    (1) Independent: The patient does not require assistance from another
    person for any activities of daily living. This includes a person
    who is able to function independently with prosthetics, equipment,
    or devices.
    (2) Partially dependent: The patient requires some assistance from
    another person for activities of daily living. This includes a
    person who utilizes prosthetics, equipment, or devices but still
    requires some assistance from another person for ADLs.
    (3) Totally dependent: The patient requires assistance for all
    activities of daily living.
  • SCREEN:  S DIC("S")="I Y'=4"
  • EXPLANATION:  Screen prevents selection of retired code.
493 *PULMONARY VALVE PROCEDURE 207;28 SET
  • 'N' FOR NONE;
  • 'M' FOR MECHANICAL;
  • 'S' FOR STENTED BIOPROSTHETIC;
  • 'B' FOR STENTLESS BIOPROSTHETIC;
  • 'H' FOR HOMOGRAFT;
  • 'PR' FOR PRIMARY REPAIR;
  • 'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
  • 'AN' FOR ANNULOPLASTY DEVICE ALONE;
  • 'AU' FOR AUTOGRAFT (ROSS);
  • 'O' FOR OTHER;

  • LAST EDITED:  JUN 14, 2010
  • HELP-PROMPT:  Enter the appropriate pulmonary valve procedure performed on this patient.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate if the patient had a pulmonary valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty,
    commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details
    of the replacement valve.) Indicate the one most appropriate procedure:
    * None
    * Mechanical Valve
    * Stented Bioprosthetic Valve
    * Stentless Bioprosthetic Valve
    * Homograft
    * Primary Valve Repair
    * Primary Valve Repair and Annuloplasty Device
    * Annuloplasty Device alone
    * Autograft Procedure (Ross Procedure)
    * Other
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
500 PFSS ACCOUNT REFERENCE PFSS;1 POINTER TO PFSS ACCOUNT FILE (#375) PFSS ACCOUNT(#375)

  • LAST EDITED:  JUN 08, 2005
  • HELP-PROMPT:  Enter the PFSS Account Reference associated with this case.
  • DESCRIPTION:  
    This is the PFSS Account Reference number by which Surgery will reference an external account number for purposes of attaching charges for 1st or 3rd party billing.
    DELETE AUTHORITY: ^
    WRITE AUTHORITY: ^
502 *OTHER CARDIAC PROCEDURES (Y/N) 209;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAR 20, 2006
  • HELP-PROMPT:  Enter 'YES' if there are other cardiac procedures.
  • DESCRIPTION:  Definition Revised (2006): Indicate if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass
    (YES/NO).
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
504 HEMOGLOBIN A1C 201;28 FREE TEXT

  • INPUT TRANSFORM:  S:X="NS"!(X="ns") X="NS" Q:X="NS" K:$L(X)>6!($L(X)<1) X
  • LAST EDITED:  NOV 30, 2010
  • HELP-PROMPT:  Answer must be 1-6 characters in length.
  • DESCRIPTION:  
    Definition Revised (2006)/(2007): Indicate the Hemoglobin A1c result (%) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
504.1 HEMOGLOBIN A1C, DATE 202.1;1 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  NOV 30, 2010
  • HELP-PROMPT:  This is the date that the Hemoglobin A1c was performed and must not be more than 1000 days before surgery.
  • DESCRIPTION:  
    Definition Revised (2006)/(2007): Indicate the date that the preoperative Hemoglobin A1c value was assessed. Enter "NS" for No Study if the Hemoglobin A1c test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
505 *ENDOVASCULAR REPAIR 207.1;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 22, 2014
  • HELP-PROMPT:  Enter Yes if an endovascular repair of the aorta was done with a cardiothoracic surgeon attending.
  • DESCRIPTION:  VASQIP Definition (2010): Indicate if the patient had an endovascular repair of the descending thoracic aorta, ascending aorta, and/or aortic arch (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural
    hematoma, or traumatic disruption) with or without involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin,
    with or without cardiopulmonary bypass. To include in VASQIP, an attending cardiothoracic surgeon must have been present and involved in the procedure. It is typically done under general anesthesia and may be performed in
    the operating room or interventional radiology operating area.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
506 HAIR REMOVAL METHOD VER;6 SET
  • 'C' FOR CLIPPER;
  • 'D' FOR DEPILATORY;
  • 'N' FOR NO HAIR REMOVED;
  • 'P' FOR PATIENT REMOVED OWN HAIR;
  • 'S' FOR SHAVING;
  • 'U' FOR NOT DOCUMENTED;
  • 'O' FOR OTHER;

  • LAST EDITED:  MAR 23, 2006
  • HELP-PROMPT:  Enter the method used to remove hair prior to Surgery.
  • DESCRIPTION:  This is the method used to remove hair prior to surgery. Shaving is not a preferred method for hair removal. If SHAVING is selected, a comment must be entered in the HAIR REMOVAL COMMENTS field explaining why SHAVING was
    used. If OTHER is selected, comments must be entered explaining the method used.
  • CROSS-REFERENCE:  130^AN^MUMPS
    1)= D HR^SRENSCS
    2)= Q
    This MUMPS cross reference maintains the Hair Removal Comments field if this field is answered with "S".
507 BNP 201;29 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
  • LAST EDITED:  AUG 03, 2010
  • HELP-PROMPT:  Answer must be 1-5 characters in length.
  • DESCRIPTION:  
    VASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
507.1 BNP DATE 202.1;2 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  APR 30, 2010
  • HELP-PROMPT:  This is the date that the BNP was performed.
  • DESCRIPTION:  
    VASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter "NS" for No Study if the BNP test was not performed.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
508 HAIR REMOVAL COMMENTS 49;0 WORD-PROCESSING #130.0508

  • DESCRIPTION:  
    If SHAVING is selected as the hair removal method, a comment must be entered explaining why SHAVING was used. If OTHER is selected as the hair removal method, comments must be entered explaining the method used.
509 PREOP ATRIAL FIBRILLATION 208;19 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 02, 2010
  • HELP-PROMPT:  Indicate whether atrial fibrillation or flutter is present within two weeks of the procedure. (Yes/No)
  • DESCRIPTION:  
    VASQIP Definition (2010): This field indicates whether atrial fibrillation or flutter is present within two weeks of the procedure. Enter YES or NO. Note: NS is not allowed.
510 *CURRENT SMOKER (CARDIAC) 200.1;5 SET
  • '1' FOR NEVER A SMOKER;
  • '2' FOR WITHIN 2 WEEKS OF SURGERY;
  • '3' FOR 2 WEEKS TO 3 MONTHS PRIOR TO SURGERY;
  • '4' FOR >3 MONTHS PRIOR TO SURGERY (REMOTE SMOKER);

  • LAST EDITED:  SEP 01, 2011
  • HELP-PROMPT:  Enter the code describing the patient's status as a smoker prior to surgery.
  • DESCRIPTION:  This field has been flagged as obsolete for VASQIP. It should no longer be used.
    Cardiac Definition Revised (2006): Indicate the patient's smoking status from information from the patient, or the chart, that best describes the patient's use of tobacco in any form (pipe, cigar, cigarette, tobacco chew).
    If more than one representation is found, please record according to the most conservative (most recent) quit date:
    1 = never a smoker 2 = smoking within two weeks prior to surgery 3 = smoking within 2 weeks to 3 months prior to surgery 4 = remote smoker (more than 3 months prior to surgery)
512 *MAZE PROCEDURE 209;14 SET
  • 'N' FOR NO MAZE PERFORMED;
  • 'F' FOR FULL MAZE;
  • 'M' FOR MINI MAZE;

  • LAST EDITED:  JUN 28, 2006
  • HELP-PROMPT:  Enter NO MAZE PERFORMED, FULL MAZE or MINI MAZE.
  • DESCRIPTION:  Definition Revised (2006): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt abnormal atrial
    conduction pathways that cause atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (A Maze does not include an amputation/resection of the atrial appendage as
    an isolated procedure; an intraoperative electrophysiologic mapping procedure; nor any surgical or ablation procedure conducted on the ventricle for control of ventricular arrhythmias.) Indicate the one most appropriate
    response:
    No - No Maze performed
    Full Maze - The procedure is most often performed on-bypass through a median sternotomy. A combination of incisions and thermal (cryo) or radiofrequency ablations of the atrial wall pathways are done, typically including
    amputation/resection of the one or both atrial appendices. The procedure thus creates a "maze" of electrical propogation roots involving the entire atrial myocardium with only one side of entrance (the sinus node) and one
    side of exit (the AV node).
    Mini-Maze - A more limited and simpler procedure than the traditional full maze, the Mini-Maze is based on the finding that in most patients, ectopic foci located in the pulmonary veins are responsible for the initiation
    of atrial fib. Radiofrequency or a cryo-ablation probe is used either inside or outside of the pulmonary vein ostia to destroy the foci. It can be performed with or without resection of the atrial appendage and includes
    no incision or minimal incisions to the left atrium, rather than the extensive atrial surgical procedure conducted for the full Maze. The Mini can be performed on or off bypass through a median sternotomy or performed
    thorascopically to the outside of the pulmonary veins.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*182.
513 SURGERY CONSULT DATE 209;15 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  MAR 03, 2008
  • HELP-PROMPT:  Indicate the date patient first consulted by Surgery Service for the operation.
  • DESCRIPTION:  Indicate the date that the patient was first consulted by Surgery for the operation as typically documented by a note by a member of Surgery Specialty that will perform the procedure (e.g., attending surgeon, fellow,
    nurse). For non-cardiac assessments, enter NA if this date is not applicable or cannot be determined.
    For Cardiothoracic (CT) Surgery, this date is usually on or just after the diagnostic catheterization date.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
515 PRIMARY CAUSE FOR DELAY 209;16 SET
  • 'RL' FOR RESOURCE LIMITATION;
  • 'PH' FOR PATIENT HEALTH;
  • 'PP' FOR PATIENT PREFERENCE;
  • 'O' FOR OTHER;
  • 'NS' FOR NO STUDY/UNKNOWN;
  • 'N' FOR NONE;

  • LAST EDITED:  DEC 17, 2007
  • HELP-PROMPT:  Enter the primary cause for delay if greater than 30 days.
  • DESCRIPTION:  Definition Revised (2008): This field contains the primary cause for delay. If a Cardiac patient's surgery is greater than 30 days from initial VA Cardiothoracic Surgery Consultation (as calculated between the CT CONSULT
    DATE to DATE OF SURGERY), user shall enter cause as defined in the field. If date is less than or equal to 30 days, system shall automatically default entry to None.
    - Resource Limitation: Due to staffing or other facility limitation,
    e.g., OR scheduling, physician availability, ICU bed capacity
    - Patient Health: Due to patient health issue, e.g., vascular consult,
    additional tests
    - Patient Preference: Due to a non-health related patient preference,
    e.g., vacation
    - Other
    - NS/Unknown: Unable to Locate Reason for Delay. Entering "NS" for "No
    Study/Unknown" is also allowed.
    - None
  • SCREEN:  S DIC("S")="I Y'=""N"""
  • EXPLANATION:  Screen prevents selection of NONE.
516 SURGERY CONSULT REQUESTED 209;17 FREE TEXT

  • INPUT TRANSFORM:  N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
  • OUTPUT TRANSFORM:  S Y(0)=Y D DATE^SROAUTL
  • LAST EDITED:  FEB 28, 2008
  • HELP-PROMPT:  This is the date the Surgery Service is requested to consult with the patient.
  • DESCRIPTION:  This is the date that the patient's physician requests that Surgery Service consult with the patient. It is not the date that the consult took place.
    Enter NA if this date is not applicable or cannot be determined.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
517 TOBACCO USE 200.1;9 SET
  • '1' FOR NEVER USED TOBACCO;
  • '2' FOR NO USE IN LAST 12 MOS;
  • '3' FOR CIGARETTES ONLY;
  • '4' FOR OTHER (NO CIGARETTES);
  • '5' FOR CIGARETTES PLUS OTHER;

  • LAST EDITED:  SEP 23, 2011
  • HELP-PROMPT:  Indicate the patient's type of tobacco product used in the 12 months prior to surgery.
  • DESCRIPTION:  VASQIP Definitions (2011): Indicate the patient's type of tobacco product used in the 12 months prior to surgery. Select one:
    1 = Never used tobacco
    2 = No tobacco use in the last 12 months
    3 = Cigarettes only
    4 = Pipe, cigar, snuff, or chewing tobacco only (no cigarettes)
    5 = Cigarettes plus one or more of pipe, cigar, snuff, or chewing
    tobacco
  • CROSS-REFERENCE:  ^^TRIGGER^130^518
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,10),X=X S DIU=X K Y S X=DIV S X=$S(X<3:"NA",1:"") S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,10)=DIV,DIH=130,DIG=518 D ^DI
    CR
    2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,10),X=X S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,10)=DIV,DIH=130,DIG=518 D ^DICR
    CREATE VALUE)= S X=$S(X<3:"NA",1:"")
    DELETE VALUE)= @
    FIELD)= #518
    Trigger to set the TOBACCO USE TIMEFRAME field (#518) to "NA" for NOT APPLICABLE if the TOBACCO USE field (#517) is set to a value less than 3.
518 TOBACCO USE TIMEFRAME 200.1;10 SET
  • '1' FOR WITHIN 2 WEEKS;
  • '2' FOR 2 WKS TO 3 MOS;
  • '3' FOR 3 TO 12 MONTHS;
  • 'NA' FOR NOT APPLICABLE;

  • INPUT TRANSFORM:  D CHK518^SROAPRE1
  • LAST EDITED:  AUG 16, 2011
  • HELP-PROMPT:  Indicate the timeframe of tobacco use prior to surgery.
  • DESCRIPTION:  VASQIP Definitions (2011): If the patient used tobacco products in the 12 months prior to surgery, indicate the timeframe:
    1 = within the 2 weeks prior to surgery
    2 = between 2 weeks and 3 months prior to surgery
    3 = between 3 months and 12 months prior to surgery
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
    TRIGGERED by the TOBACCO USE field of the SURGERY File
519 DIABETES MELLITUS CHRONIC 200.1;11 SET
  • '1' FOR NO;
  • '2' FOR DIET;
  • '3' FOR ORAL +/- NON-INSULIN INJ;
  • '4' FOR INSULIN;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter appropriate code for chronic, long-term Diabetes Mellitus management.
  • DESCRIPTION:  VASQIP Definitions (2015): Indicate the chronic, long-term treatment regimen for patients with a diagnosis of Diabetes Mellitus. Diabetes Mellitus is defined as a metabolic disorder of the pancreas whereby the individual
    requires diet modification, daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin
    therapy.
    No - no diagnosis of diabetes
    Diet - a diagnosis of diabetes that is controlled by diet alone
    Oral +/- Non-Insulin Inj - a diagnosis of diabetes requiring
    therapy with an oral and/or non-insulin injectable
    hypoglycemic agent
    Insulin - a diagnosis of diabetes requiring daily insulin therapy
    Choose from: 1. NO 2. DIET 3. ORAL +/- NON-INSULIN INJ 4. INSULIN
520 DIABETES MELLITUS PREOP MGMT 200.1;12 SET
  • '1' FOR NO;
  • '2' FOR DIET;
  • '3' FOR ORAL +/- NON-INSULIN INJ;
  • '4' FOR INSULIN;

  • LAST EDITED:  APR 30, 2015
  • HELP-PROMPT:  Enter appropriate code for management of Diabetes Mellitus in the two weeks prior to surgery.
  • DESCRIPTION:  VASQIP Definitions (2015): Enter appropriate code for management of Diabetes Mellitus in the two weeks prior to surgery. Diabetes Mellitus is defined as a metabolic disorder of the pancreas whereby the individual requires
    diet modification, daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin therapy.
    No - no diagnosis of diabetes
    Diet - a diagnosis of diabetes that is controlled by diet alone
    Oral +/- Non-Insulin Inj - a diagnosis of diabetes requiring therapy
    with an oral and/or non-insulin injectable hypoglycemic agent
    Insulin - a diagnosis of diabetes requiring daily insulin therapy
    Choose from: 1. NO 2. DIET 3. ORAL +/- NON-INSULIN INJ 4. INSULIN
521 CVD REPAIR/OBSTRUCTION 200.1;13 SET
  • '0' FOR NO CVD;
  • '1' FOR YES - NO SURGICAL REPAIR;
  • '2' FOR YES - PRIOR SURGICAL REPAIR;

  • LAST EDITED:  SEP 23, 2011
  • HELP-PROMPT:  Enter value of 0-2 to indicate CVD.
  • DESCRIPTION:  VASQIP Definitions (2011): Select one of the following if patient has indication of Cerebrovascular Disease (CVD):
    0 = No CVD indication
    1 = Yes, CVD indication by documented obstruction of carotid artery
    luminal diameter greater than or equal to 50% obstruction of the
    carotid artery documented by contrast angiography or duplex
    ultrasound examination which did not result in surgical repair.
    2 = Yes, CVD indication resulting in prior carotid artery surgical
    repair (e.g., carotid endarterectomy or stenting).
522 HISTORY OF CVD 200.1;14 SET
  • '0' FOR NO CVD;
  • '1' FOR HISTORY OF TIA'S;
  • '2' FOR CVA/STROKE - NO NEURO DEFICIT;
  • '3' FOR CVA/STROKE W/ NEURO DEFICIT;

  • LAST EDITED:  SEP 23, 2011
  • HELP-PROMPT:  Enter value of 0-3 to indicate if the patient has history of CVD events.
  • DESCRIPTION:  VASQIP Definitions (2011): Indicate if the patient has a history of cerebrovascular accident by selecting one of the following indications: (If multiple events, select the one with greatest severity.):
    0 = No CVD
    1= History of Transient Ischemic Attacks: Transient ischemic attacks
    (TIAs) are focal neurologic deficits (e.g. numbness of an arm or
    amaurosis fugax) of sudden onset and brief duration (usually <30
    minutes), which usually reflect dysfunction in a cerebral vascular
    distribution.
    These attacks may be recurrent and, at times, may precede a stroke
    2= CVA/Stroke with no neurological deficit: History of
    a cerebrovascular accident (embolic, thrombotic, or hemorrhagic)
    with neurologic deficit(s) lasting at least 30 minutes, but no
    current residual neurologic dysfunction or deficit
    3= CVA/Stroke with neurological deficit: History of a cerebrovascular
    accident (embolic, thrombotic, or hemorrhagic) with persistent
    residual motor, sensory, or cognitive dysfunction. (e.g.,
    hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory)
600 CONFIRM PATIENT IDENTITY VER;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 22, 2011
  • HELP-PROMPT:  Enter YES if the patient identity was confirmed.
  • DESCRIPTION:  This field verifies the patient identity has been confirmed. Your answer should be "Yes" or "No".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
601 PROCEDURE TO BE PERFORMED VER;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 22, 2011
  • HELP-PROMPT:  Enter YES if the procedure to be confirmed was checked.
  • DESCRIPTION:  This field verifies the procedure to be performed has been confirmed. Your answer should be "Yes" or "No".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
602 SITE OF PROCEDURE VER;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 22, 2011
  • HELP-PROMPT:  Enter YES if the confirm site of procedure including laterality was checked.
  • DESCRIPTION:  This field verifies the site of procedure, including laterality, has been confirmed. Your answer should be "Yes" or "No".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
603 CONFIRM VALID CONSENT VER;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • '1' FOR YES, i-MED;
  • '2' FOR YES, PAPER;
  • '3' FOR YES, TELEPHONE;
  • '4' FOR NO, EMERGENCY;
  • '5' FOR NO, NOT EMERGENCY;

  • LAST EDITED:  MAY 23, 2014
  • HELP-PROMPT:  Select the appropriate response from options 1 to 5.
  • DESCRIPTION:  VASQIP Definition (2014): This field verifies that a valid consent form has been confirmed. Your answer should be one of the following:
    1-YES, i-MED
    2-YES, PAPER
    3-YES, TELEPHONE
    4-NO, EMERGENCY
    5-NO, NOT EMERGENCY
    If you answer 4 or 5, you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • SCREEN:  S DIC("S")="I Y"
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • RECORD INDEXES:  AE (#198)
604 CONFIRM PATIENT POSITION VER;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 22, 2011
  • HELP-PROMPT:  Enter YES if patient position was confirmed.
  • DESCRIPTION:  This field verifies that the patient position has been confirmed. Your answer should be "Yes" or "No".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
605 MARKED SITE CONFIRMED VER;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 19, 2014
  • HELP-PROMPT:  Answer YES if the site was physically marked or if arm band was verified instead of marking.
  • DESCRIPTION:  The site must be marked in all cases. If the patient refuses marking, or if the site is inappropriate to marking, such as mucous membranes and other sites not on the skin that cannot be marked using standard methods, then
    wristbands must be used for marked site. See applicable VHA Handbooks and Directives for further information and guidance.
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
606 PREOPERATIVE IMAGES CONFIRMED VER;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  FEB 03, 2014
  • HELP-PROMPT:  Enter "YES" if the imaging data was confirmed, "NA" if there was no imaging required, or "NO" if the image was not viewed.
  • DESCRIPTION:  This field refers to the completion of the verification process for the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and
    verified by two members of the operating team prior to the start of the procedure. This practice is further defined by local hospital policy.
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
607 CORRECT MEDICAL IMPLANTS VER;14 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  FEB 03, 2014
  • HELP-PROMPT:  Enter YES if the correct medical implant(s) confirmed.
  • DESCRIPTION:  This field verifies that the availability of correct medical implant(s) has been confirmed. Your answer should be "Yes", "No" or "NA".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
608 ANTIBIOTIC PROPHYLAXIS VER;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;
  • 'NI' FOR NOT INDICATED;

  • LAST EDITED:  MAY 23, 2014
  • HELP-PROMPT:  Enter YES if the appropriate antibiotic prophylaxis confirmed.
  • DESCRIPTION:  VASQIP Definition (2014): This field verifies that the appropriate antibiotic prophylaxis has been confirmed. Your answer should be "Yes", "No" or "NI".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • SCREEN:  S DIC("S")="I Y'=""NA"""
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • RECORD INDEXES:  AE (#198)
609 APPROPRIATE DVT PROPHYLAXIS VER;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;
  • 'NI' FOR NOT INDICATED;

  • LAST EDITED:  MAY 19, 2014
  • HELP-PROMPT:  Enter YES if the appropriate deep vein thrombosis prophylaxis was confirmed.
  • DESCRIPTION:  VASQIP Definition (2014): This field verifies that the appropriate deep vein thrombosis prophylaxis has been confirmed. Your answer should be "Yes", "No" or "NI".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • SCREEN:  S DIC("S")="I Y'=""NA"""
  • EXPLANATION:  Screen prevents selection of retired codes.
  • RECORD INDEXES:  AE (#198)
610 BLOOD AVAILABILITY VER;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;
  • 'NI' FOR NOT INDICATED;

  • LAST EDITED:  JUL 13, 2015
  • HELP-PROMPT:  Enter YES if Blood is required and is available. Enter NO if Blood is required and not available. Enter NI if Blood not indicated.
  • DESCRIPTION:  VASQIP Definition (2015): This field verifies that the blood availability has been confirmed. Your answer should be "Yes", "No" or "NI". Enter YES if the Blood was required and availability was confirmed. Enter NO if the
    Blood was required and was not available. Enter NI if Blood was NOT INDICATED (not required) for this procedure. If there was a "type and screen" only, indicate NI.
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT field (#85). A 'NO' response confirms that blood was REQUIRED for the procedure but NOT AVAILABLE. Indicate the reason why the blood was
    not available in the comment section. A 'NI' response means that blood was NOT INDICATED for this procedure and should not be noted in the comment section. Choose "NI" in the selection category.
  • SCREEN:  S DIC("S")="I Y'=""NA"""
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • RECORD INDEXES:  AE (#198)
611 AVAILABILITY OF SPECIAL EQUIP VER;18 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  FEB 03, 2014
  • HELP-PROMPT:  Enter YES if the availability of special equipment was confirmed.
  • DESCRIPTION:  This field verifies that the availability of special equipment has been confirmed. Your answer should be "Yes", "No" or "NA".
    If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
  • RECORD INDEXES:  AE (#198)
612 ORIGINAL DESIRED DATE .9;1 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 25, 2011
  • HELP-PROMPT:  Enter the Original Desired Procedure Date.
  • DESCRIPTION:  This field is the original desired date for surgery to occur, as agreed upon by the provider and patient. That agreed upon date is when the patient desires the surgery to occur and when the provider feels it is
    appropriate to schedule the surgery. If the DESIRED PROCEDURE DATE field (#616) is updated, the value of this field will not change.
    WRITE AUTHORITY: ^
613 D/T OF DESIRED PROCEDURE DATE .9;2 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 25, 2011
  • HELP-PROMPT:  Enter the Date/Time of Desired Procedure Date Entry.
  • DESCRIPTION:  
    This field is the Date/Time stamp for when the provider saves the ORIGINAL DESIRED DATE field (#612) for surgical case in the system.
    WRITE AUTHORITY: ^
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
614 ORIGINAL SCHEDULED DATE .9;3 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  MAY 11, 2011
  • HELP-PROMPT:  Enter the Original Scheduled Date.
  • DESCRIPTION:  
    This field is the original scheduled date for surgery to occur, as entered by the OR scheduler.
    WRITE AUTHORITY: ^
  • NOTES:  TRIGGERED by the SCHEDULED START TIME field of the SURGERY File
  • CROSS-REFERENCE:  ^^TRIGGER^130^615
    1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,4),X=X S DIU=X K Y X ^DD(130,614,1,1,1.1) S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,4)=DIV,DIH=130,DIG=615 D ^DICR
    1.1)= S X=DIV N %I,%H,% D NOW^%DTC S X=% S X=X,Y(1)=$G(X) S X=1,Y(2)=$G(X) S X=12,X=$E(Y(1),Y(2),X)
    2)= Q
    CREATE VALUE)= $E(NOW,1,12)
    DELETE VALUE)= NO EFFECT
    FIELD)= #615
    The D/T OF SCHEDULED DATE ENTRY field (#615) is set when the ORIGINAL SCHEDULED DATE field (#614) is set.
615 D/T OF SCHEDULED DATE ENTRY .9;4 DATE

  • INPUT TRANSFORM:  S %DT="ET" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 21, 2011
  • HELP-PROMPT:  Enter the Date/Time of Scheduled Date.
  • DESCRIPTION:  
    This field is the Date/Time stamp for when the OR Scheduler saves the ORIGINAL SCHEDULED DATE field (#614) for the surgical case in the system.
    WRITE AUTHORITY: ^
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
    TRIGGERED by the ORIGINAL SCHEDULED DATE field of the SURGERY File
616 DESIRED PROCEDURE DATE .9;5 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 20, 2011
  • HELP-PROMPT:  Enter the Desired Procedure Date.
  • DESCRIPTION:  This field is the desired date for surgery to occur, as agreed upon by the provider and patient. That agreed upon date is when the patient desires the surgery to occur and when the provider feels it is appropriate to
    schedule the surgery.
617 SCHEDULED DATE .9;6 DATE

  • INPUT TRANSFORM:  S %DT="E" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  APR 20, 2011
  • HELP-PROMPT:  Enter the Scheduled Date.
  • DESCRIPTION:  
    This field is updated with the new date whenever the OR Scheduler modifies the SCHEDULED START TIME field (#10) for the surgical case.
  • NOTES:  TRIGGERED by the SCHEDULED START TIME field of the SURGERY File
618 POSITIVE DRUG SCREENING 200;55 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NA;
  • '1' FOR NOT DONE;
  • '2' FOR NEGATIVE RESULT;
  • '3' FOR POS NOT Rx;
  • '4' FOR POS Rx;

  • LAST EDITED:  JUN 29, 2015
  • HELP-PROMPT:  Select the response that appropriately fits the positive drug screening.
  • DESCRIPTION:  VASQIP Definition (2015): Indicate if any drug (excluding alcohol) screening (e.g., blood or urine) was performed within 2 weeks prior to surgery. If the patient is being prescribed a medication, such as methadone,
    respond with answer options as indicated below. If the drug screen was positive for both a prescribed and non-prescribed drug, select the answer for a substance that was not prescribed.
    1. Not Done - drug screening was not performed
    2. Drug screening was performed and the result was negative
    3. Drug screening was performed and the result was positive for
    substance not prescribed
    4. Drug screening was performed and the result was positive for a
    prescribed substance
  • SCREEN:  S DIC("S")="I Y"
  • EXPLANATION:  Screen prevents selection of inactive entries.
619 IMMED USE-CONTAMINATION 52;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  
    Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of a specialty item (one of a kind) in the OR.
620 IMMED USE-SPS/OR MGT ISSUE 52;2 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  Indicate the number of cycles of Immediate Use Steam Sterilization due to SPS processing and OR management issues (unsterile from SPS, hole in package, available in SPS but not sterilized, not processed in time, missing in
    set, or broken in set).
621 IMMED USE-EMERGENCY CASE 52;3 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  
    Indicate the number of cycles of Immediate Use Steam Sterilization due to an Emergency Case, such as instruments used on previous case.
622 IMMED USE-NO BETTER OPTION 52;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  
    Indicate the number of cycles of Immediate Use Steam Sterilization due to items for which there may be no better option (batteries, radioactive implants (seeds)).
623 IMMED USE-LOANER INSTRUMENT 52;5 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  
    Indicate the number of cycles of Immediate Use Steam Sterilization due to loaner or short notice instrument excluding implants (instrument(s) not available with sufficient time to reprocess completely).
624 IMMED USE-DECONTAMINATION 52;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
  • DESCRIPTION:  
    Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of instruments already in use in OR for any reason not included in tracking.
630 POSSIBLE ITEM RETENTION 25;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 23, 2015
  • HELP-PROMPT:  Answer YES if the surgical field has the potential for leaving behind a sponge, sharp, or instrument.
  • DESCRIPTION:  VASQIP Definition (2015): This field is intended to capture whether the surgical field has the potential for leaving a retained surgical item, including sponge, sharp, or instrument behind. A retained surgical item
    includes instruments, sharps, sponges or any materials used by the surgical team performing the operative procedure. Sharps include surgical needles, aspirating needles, blunt needles, scalpel blades or any items with a
    sharp or pointed edge posing a risk for skin puncture by the surgical team. Sponges include cotton gauze sponges, laparotomy pads, surgical towels or any absorbent materials not intended to remain in the patient's body
    after the surgical procedure is completed.
    Note: This field does not identify that a retained surgical item actually was found or occurred.
633 WOUND SWEEP 25;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter YES to indicate that a wound sweep (e.g., manual exploration) was done. This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
  • DESCRIPTION:  VASQIP Definition (2015): This indicates that a both a visual and manual methodical wound exploration is performed prior to closing the surgical wound to ensure that all surgical items are accounted for and extracted.
    This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect. Note: The microscopic check for a cataract case is the same as the "wound sweep".
635 WOUND SWEEP COMMENTS 53;0 WORD-PROCESSING #130.0635

  • DESCRIPTION:  VASQIP Definition (2014): These are comments related to the reason(s) a wound sweep was or was not performed that may be useful in the documentation of this case and/or subsequent comments related to the wound sweep
    findings.
636 INTRA-OPERATIVE X-RAY 25;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 21, 2014
  • HELP-PROMPT:  Enter YES to indicate that an intraoperative x-ray was done. This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
  • DESCRIPTION:  VASQIP Definition (2014): This indicates that a radiograph of the entire surgical field to rule out a retained surgical item was performed and interpreted by a physician at the completion of the surgical procedure, prior
    to the patient's transfer from the Operating Room. This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
637 INTRA-OPERATIVE X-RAY COMMENTS 54;0 WORD-PROCESSING #130.0637

  • LAST EDITED:  DEC 27, 2013
  • DESCRIPTION:  VASQIP Definition (2014): These are comments related to the reason(s) an intraoperative x-ray was or was not performed that may be useful in the documentation of this case and/or subsequent comments related to the
    radiograph findings.
638 LATERALITY OF PROCEDURE OP;5 SET
  • '1' FOR NA;
  • '2' FOR LEFT;
  • '3' FOR RIGHT;
  • '4' FOR BILATERAL;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter left or right or bilateral when laterality is applicable to the procedure.
  • DESCRIPTION:  
    This indicates that the side of the procedure is identified as either left, right or bilateral, when applicable to the procedure.
639 REPORT GIVEN TO 25;9 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the name of the staff member who received the postoperative report from the OR staff member.
  • DESCRIPTION:  
    This indicates the name of the staff member who received the postoperative report from the OR staff member.
640 PCI 200;56 SET
  • '1' FOR NONE;
  • '2' FOR <12 HRS OF SURG;
  • '3' FOR >12 HRS - 7 DAYS;
  • '4' FOR >7 DAYS;
  • '5' FOR UNKNOWN;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter the category that most accurately reflects the patient's Percutaneous Coronary Intervention.
  • DESCRIPTION:  VASQIP Definition (2014): Indicate the time period of the patient's most recent percutaneous coronary artery intervention (PCI) prior to surgery. This does not include percutaneous valve interventions including
    valvuloplasty and valve replacement. Indicate the one appropriate response, even if the procedure was not fully successful: 1. None - The patient never had a previous PCI. 2. <12 hr of surg - The patient had a PCI less
    than 12 hours prior to
    surgery. 3. >12 hr - 7 days - The patient had a PCI between 12 hours and 7
    days prior to surgery. 4. >7 days - The patient had a PCI more than 7 days prior to surgery. 5. Unknown
641 HYPERTENSION 200;57 SET
  • '1' FOR NO;
  • '2' FOR YES WITHOUT MED;
  • '3' FOR YES WITH MED;
  • '4' FOR UNKNOWN;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter YES if there is any indication that the patient has hypertension.
  • DESCRIPTION:  VASQIP Definition (2014): Indicate if the patient has a documented history of hypertension within the 30 days prior to surgery. Select the one appropriate response: 1. No history of hypertension 2. Yes without medication
    therapy 3. Yes with medication therapy (antihypertensive therapy: diuretics,
    beta blockers, ACE inhibitors, calcium channel blockers, etc.) 4. Unknown
642 BLEEDING RISK DUE TO MED 200;58 SET
  • '1' FOR NO BLEEDING RISK MED;
  • '2' FOR CHRONIC ASPIRIN NOT D'C;
  • '3' FOR BLEEDING RISK MED D'C;
  • '4' FOR BLEEDING RISK MED NOT D'C;
  • 'N' FOR NO BLEEDING RISK FROM MED;
  • 'Y' FOR BLEEDING RISK MED NOT D'C;

  • LAST EDITED:  JUL 16, 2015
  • HELP-PROMPT:  Enter indicator of bleeding risk due to medication.
  • DESCRIPTION:  VASQIP Definition (2015): Bleeding risk due to medication is present if: 1) a patient is on chronic anticoagulation (e.g. a thrombin inhibitor or an antiplatelet agent other than aspirin) and/or an acute anticoagulant or
    thrombolytic agent; AND 2) the agent was not discontinued before surgery in sufficient time for reversal of anticoagulant effect.
    Select the one appropriate response: N - The patient is not on medications that increase bleeding risk OR
    was on meds that increased bleeding risk that were all discontinued
    in sufficient time for reversal prior to surgery Y - The patient was on pre-operative medication(s) that increase
    bleeding risk AND one or more were NOT discontinued in sufficient
    time for reversal prior to surgery
  • SCREEN:  S DIC("S")="I 'Y"
  • EXPLANATION:  Screen prevents selection of inactive entries.
643 ANGINA TIMEFRAME 200;59 SET
  • '1' FOR NO ANGINA;
  • '2' FOR W/N 14 DAY OF SURGERY;
  • '3' FOR W/N 15-30 DAYS OF SURGERY;
  • '4' FOR UNKNOWN;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Indicate time period when the angina was most recently present.
  • DESCRIPTION:  
    VASQIP Definition (2014): Indicate time period when the angina was most recently present: 1. No Angina 2. Within 14 days prior to surgery 3. Within 15-30 days prior to surgery 4. Unknown
644 SYMPTOMATIC UTI 205;42 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 17, 2015
  • HELP-PROMPT:  Enter YES if the patient has any postoperative Symptomatic UTI-Culture occurrences.
  • DESCRIPTION:  Definition Revised (2015): SYMPTOMATIC UTI - CULTURE plus SIGN/SYMPTOM within 1 calendar day of each other: a. UTI Signs/Symptoms: Urg/Freq/Dys
    Yes = Patient has urgency, frequency, or dysuria with no other
    recognized cause
    No = Patient does not complain of urgency, frequency or dysuria OR
    has a catheter in place
    b. UTI Signs/Symptoms: Fever
    Yes = Patient has a fever > 38C at the time of culture or onset
    of symptoms
    No = Patient does not have a fever > 38C at the time of culture
    or onset of signs or symptoms
    c. UTI Signs/Symptoms: Tenderness
    Yes = Patient has suprapubic tenderness, costovertebral angle
    pain or tenderness with no other recognized cause
    No = Patient does not have suprapubic tenderness, costovertebral
    angle pain or tenderness
    d. UTI Culture: (must choose 1 or 2)
    1. Patient has a positive urine culture that is > 10^5 colony-
    forming units (CFU)/ml with no more than 2 species of
    microorganisms
    2. A positive urine culture of >=10^3 and <10^5 colony-forming
    units (CFU)/ml with no more than 2 species of microorganisms
    plus one of the following three items: a) positive dipstick for
    leukocyte esterase and/or nitrate; b) Pyuria (urine specimen
    with > 10 white blood cell [WBC]/mm3 of unspun urine or > 3
    WBC high-power field of spun urine) or c) microorganisms seen
    of Gram's stain of unspun urine
    INDWELLING URETHRAL CATHETER At the time of specimen collection for suspected urinary tract infection during the post-operative 30 day period, answer the following about indwelling urethral catheter:
    I) IN PLACE > 2 calendar days on the day of UTI Signs/Symptoms and UTI Culture sample.
    R) RECENTLY REMOVED, had been in place > 2 calendar days but removed the day of or the day before UTI Signs/Symptoms and UTI Culture sample.
    S) SHORT DURATION, present at the time of UTI Signs/Symptoms and UTI Culture sample but had not been present > 2 calendar days.
    D) DISTANT REMOVAL, placed in the perioperative period and present >2 calendar days, but removed >2 calendar days prior to UTI Signs/Symptoms and UTI Culture sample.
    N) NO CATHETER, did not have an indwelling urethral catheter > 2 calendar days
645 *MECHANICAL VENT W/N 30 DAYS 205;43 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUL 01, 2015
  • HELP-PROMPT:  Enter Yes if the patient was placed on ventilator support.
  • DESCRIPTION:  Definition Revised (2014): Indicate if ventilator support required within 30 days after initial post-operative extubation: If the patient was placed on ventilator support postoperatively for any reason within 30 days AND
    occurred during the same admission in-hospital. (For example, the patient is on the ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is discontinued. Later, the patient gets into
    trouble and mechanical ventilation has to be reinstated.) In patients who were not intubated during surgery, intubation at any time after their surgery is considered an occurrence.
  • TECHNICAL DESCR:  
    This field became obsolete in patch SR*3*184.
647 ORGANS TO BE TRANSPLANTED 63;0 SET Multiple #130.0647 130.0647

  • LAST EDITED:  JUN 26, 2015
  • DESCRIPTION:  
    This is information related to the organ(s) that will be transplanted.
648 UNOS NUMBER VER1;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>10!($L(X)<1) X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the UNOS number of the donor. Must be 1-10 characters in length.
  • DESCRIPTION:  
    This is the UNOS identification number of the donor.
649 DONOR SEROLOGY HCV VER1;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the Hepatitis C virus (HCV) status for the transplant donor.
  • DESCRIPTION:  
    This is the Hepatitis C virus (HCV) status for the transplant donor. Enter 'Yes' if positive, 'N' if negative, 'NA' if unknown or not tested.
650 DONOR SEROLOGY HBV VER1;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the Hepatitis B virus (HBV) status for the transplant donor.
  • DESCRIPTION:  
    This is the Hepatitis B virus (HBV) status for the transplant donor. Enter 'Yes' if positive, 'N' if negative, 'NA' if unknown or not tested.
651 DONOR SEROLOGY CMV VER1;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the Cytomegalovirus (CMV) status for the transplant donor.
  • DESCRIPTION:  
    This is the Cytomegalovirus (CMV) status for the transplant donor. Enter 'Yes' if positive, 'N' if negative, 'NA' if unknown or not tested.
652 DONOR SEROLOGY HIV VER1;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Enter the HIV status for the transplant donor.
  • DESCRIPTION:  
    This is the HIV status for the transplant donor. Enter 'Yes' if positive, 'N' if negative, 'NA' if unknown or not tested.
653 DONOR ABO TYPE VER1;7 SET
  • '1' FOR A RH(+);
  • '2' FOR A RH(-);
  • '3' FOR B RH(+);
  • '4' FOR B RH(-);
  • '5' FOR AB RH(+);
  • '6' FOR AB RH(-);
  • '7' FOR O RH(+);
  • '8' FOR O RH(-);

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the ABO Type of the transplant donor.
  • DESCRIPTION:  
    This is the ABO Type of the transplant donor.
654 RECIPIENT ABO TYPE VER1;8 SET
  • '1' FOR A RH(+);
  • '2' FOR A RH(-);
  • '3' FOR B RH(+);
  • '4' FOR B RH(-);
  • '5' FOR AB RH(+);
  • '6' FOR AB RH(-);
  • '7' FOR O RH(+);
  • '8' FOR O RH(-);

  • LAST EDITED:  JUN 25, 2015
  • HELP-PROMPT:  Enter the ABO Type of the transplant recipient.
  • DESCRIPTION:  
    This is the ABO Type of the transplant recipient.
655 BLOOD BANK ABO VERIFICATION VER1;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the blood bank verified the ABO type of the transplant recipient.
  • DESCRIPTION:  
    This field documents whether the blood bank verified the ABO type of the transplant recipient.
656 OR ABO VERIFICATION (Y/N) VER1;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the OR has verified ABO type of transplant recipient.
  • DESCRIPTION:  
    This field documents whether the OR has verified the ABO type of transplant recipient.
657 SURGEON VERIFYING UNET VER1;11 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  MAY 27, 2015
  • HELP-PROMPT:  Enter the name of the Surgeon verifying UNET.
  • DESCRIPTION:  
    Document the transplant surgeon who completed required UNET verification.
658 ORGAN VER PRE-ANESTHESIA VER1;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the organ was verified prior to anesthesia.
  • DESCRIPTION:  
    This field documents whether the organ was verified prior to anesthesia.
659 SURGEON VER DONOR ORG PRE-ANES VER1;13 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter the Name of the Surgeon that verified the organ prior to donor anesthesia.
  • DESCRIPTION:  
    For a live donor case, enter the name of the surgeon who documented the organ to be removed and transplanted, including laterality when applicable.
660 ORGAN VER PRE-TRANSPLANT VER1;14 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the organ was verified prior to transplant.
  • DESCRIPTION:  
    This field documents whether the organ was verified prior to transplant.
661 PALLIATION .1;21 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if the planned surgical procedure was for palliation, either therapeutic or diagnostic.
  • DESCRIPTION:  
    This field indicates whether the procedure was intended for palliation, either therapeutic or diagnostic.
662 IMPAIRED COGNITIVE FUNCTION 210;1 SET
  • '0' FOR NONE-NO IMPAIRMENT;
  • '1' FOR YES-DOCUMENTED HISTORY;
  • '2' FOR YES-DOCUMENTED AND DECLINING;
  • '3' FOR NO DOCUMENTATION;

  • LAST EDITED:  MAY 13, 2015
  • HELP-PROMPT:  Enter selection options for impaired cognitive function
  • DESCRIPTION:  
    Indicate if there is any documented history of memory loss, functional deficits or declining cognitive skills in the 90 days prior to surgery.
663 DONOR VESSEL USAGE VER1;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if donor vessels were used.
  • DESCRIPTION:  
    This field documents if donor vessels were used.
664 DONOR VESSEL UNOS ID 57;0 Multiple #130.0664 130.0664

  • DESCRIPTION:  
    This field documents the UNOS identification number of the vessel(s) donor(s).
665 DONOR VESSEL DISPOSITION VER1;16 SET
  • 'N' FOR NO DONOR VESSELS RECEIVED;
  • 'D' FOR DISCARDED;
  • 'R' FOR RETURNED TO OPO;
  • 'S' FOR STORED;

  • LAST EDITED:  MAR 25, 2015
  • HELP-PROMPT:  Enter disposition of donor vessels.
  • DESCRIPTION:  
    Document disposition of donor vessels.
666 LIVER DISEASE/CIRRHOSIS 210;2 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is a diagnosis of cirrhosis.
  • DESCRIPTION:  
    This field documents whether there are biopsy, imaging, and/or clinical criteria to support diagnosis of cirrhosis.
667 SLEEP APNEA-COMPLIANCE 200.1;15 SET
  • '1' FOR NIGHTLY;
  • '2' FOR > OR EQUAL 4 TIMES A WEEK;
  • '3' FOR < 4 TIMES A WEEK;
  • '4' FOR NOT DOCUMENTED;

  • INPUT TRANSFORM:  D CHK667^SROAPRE
  • LAST EDITED:  JUN 23, 2015
  • HELP-PROMPT:  Enter the level of the patient's reported compliance with sleep apnea treatment.
  • DESCRIPTION:  
    If yes to Level 3 Sleep Apnea, indicate level of patient's reported compliance with treatment.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
668 IMMUNOCOMPROMISED STATE PREOP 210;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'Y' if the patient has received a medication known to suppress immune system function within 30 days prior to operation.
  • DESCRIPTION:  
    This field documents if the patient has received any medication in a dosage known to suppress immune system function within 30 days prior to operation.
669 PULMONARY HTN 210;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if the patient has pulmonary hypertension.
  • DESCRIPTION:  
    This field documents if the patient has pulmonary hypertension documented on invasive or non-invasive cardiac testing.
670 RESIDENCE 30 DAYS PREOP 210;5 SET
  • '1' FOR HOME;
  • '2' FOR ACUTE CARE FACILITY;
  • '3' FOR LONG TERM CARE;
  • '4' FOR HOMELESS;
  • '5' FOR UNKNOWN;

  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Enter the patient's current residence within 30 days prior to surgery.
  • DESCRIPTION:  Describe the current residence of the patient in the 30 days prior to surgery. If multiple answer options apply, select the highest level applicable within the 30 days preoperative.
    1. Home (patient has their own residence or a similar dwelling e.g.
    residence of a family member) 2. Acute Care Facility (patient was transferred to the VA that performed
    the surgery from an acute care facility, VA or non-VA) 3. Long Term Care (patient came from an extended care facility or
    nursing home, VA or non-VA) 4. Homeless (patient does not have a fixed dwelling (homeless) and/or
    came from a supervised public or private shelter or transitional
    housing facility) 5. Unknown
    Note: Answer 4 if the patient lacks a fixed dwelling, including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelters) that provides temporary living
    accommodations, an individual who is a resident in transitional housing facility, or an individual who lives in another individual's/family's home and would otherwise be homeless.
671 AMBULATION DEVICE PREOP 210;6 SET
  • '1' FOR AMBULATES W/OUT ASSISTIVE DEVICE;
  • '2' FOR AMBULATES WITH CANE OR WALKER;
  • '3' FOR USES MANUAL WHEELCHAIR INDEPENDENTLY;
  • '4' FOR DOES NOT AMBULATE OR USE MANUAL WHEELCHAIR INDEPENDENTLY;

  • LAST EDITED:  JUN 23, 2015
  • HELP-PROMPT:  Enter the degree of mechanical assistance, if any, needed for ambulation in the 30 days prior to surgery.
  • DESCRIPTION:  Describe the degree of mechanical assistance, if any, needed for ambulation in the 30 days prior to surgery.
    1. Ambulates without assistive device 2. Ambulates with cane or walker 3. Uses manual wheelchair independently 4. Does not ambulate or use manual wheelchair independently.
    Note: If the patient ambulates with assistance from another individual, select either 1 or 2 as appropriate. If they use a motorized wheelchair only, select 4.
672 NUTRITIONAL SUPPLEMENT PREOP 210;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if the patient received a prescribed nutrition supplement with protein for at least five days prior to surgery.
  • DESCRIPTION:  
    This field documents if the patient received a prescribed nutrition supplement with protein for at least five days prior to surgery.
673 HISTORY OF CANCER DIAGNOSIS 210;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if the patient has a history of any cancer regardless of stage or treatment.
  • DESCRIPTION:  
    This field documents if the patient has a history of any cancer regardless of stage or treatment. For skin cancers include all melanomas and squamous cell cancers with nodal involvement. Exclude basal cell cancer.
674 HX RAD RX PLANNED SURG FIELD 210;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  SEP 14, 2015
  • HELP-PROMPT:  Enter Yes if the patient received therapeutic radiation to the region of the planned surgical field.
  • DESCRIPTION:  
    This field documents if the patient received therapeutic radiation to the region of the planned surgical field.
675 PRIOR INFEC/INFLAM SURG FIELD 210;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if the patient has had an infection or an acute inflammatory process within the 90 days prior to the operation that locally involves the planned surgical field.
  • DESCRIPTION:  
    This field documents if the patient has had an infection or an acute inflammatory process within the 90 days prior to the operation that locally involves the planned surgical field.
676 HX DEEP VEIN THROMBOSIS 210;11 SET
  • '1' FOR NEITHER DVT NOR PE;
  • '2' FOR DVT WITHOUT PE;
  • '3' FOR PE WITHOUT DVT;
  • '4' FOR BOTH DVT AND PE;

  • LAST EDITED:  MAY 13, 2015
  • HELP-PROMPT:  Enter the patient's history of DVT/PE.
  • DESCRIPTION:  
    Indicate diagnosis of deep venous thrombosis and/or pulmonary embolism confirmed by imaging. Do not include DVT or PE that was clinically suspected but not confirmed by imaging.
677 PRIOR SURG SAME OP FIELD 210;12 SET
  • '0' FOR NO PREVIOUS SURGERIES;
  • '1' FOR 1 PREVIOUS SURGERY;
  • '2' FOR 2 PREVIOUS SURGERIES;
  • '3' FOR 3 PREVIOUS SURGERIES;
  • '4' FOR 4 PREVIOUS SURGERIES;
  • '5' FOR 5 PREVIOUS SURGERIES;
  • '6' FOR >5 PREVIOUS SURGERIES;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the number of procedures that the patient has had performed in the same operative field.
  • DESCRIPTION:  
    This field documents the number of procedures that the patient has had performed in the body cavity or surgical field that is to undergo the current procedure.
680 SPECIAL EQUIPMENT 58;0 POINTER Multiple #130.25 130.25

  • DESCRIPTION:  
    This is information related to the Special Equipment's to be used for this operative procedure.
681 PLANNED IMPLANTS 59;0 POINTER Multiple #130.0681 130.0681

  • LAST EDITED:  JUN 26, 2015
  • DESCRIPTION:  
    This is information related to the planned implants device(s) to be used for this operative procedure.
682 SPECIAL SUPPLIES 60;0 POINTER Multiple #130.0682 130.0682

  • DESCRIPTION:  
    This is information related to the Special Supplies to be used for this operative procedure.
683 SPECIAL INSTRUMENTS 61;0 POINTER Multiple #130.0683 130.0683

  • DESCRIPTION:  
    This is information related to the Special Instruments to be used for this operative procedure.
684 PHARMACY ITEMS 62;0 POINTER Multiple #130.0684 130.0684

  • DESCRIPTION:  
    This is information related to the Pharmacy Items to be used for this operative procedure.
685 DC/REL DESTINATION 210;14 SET
  • '1' FOR HOME;
  • '2' FOR ACUTE CARE FACIL VA/NON-VA;
  • '3' FOR EXTENDED CARE FACIL (NON-REHAB);
  • '4' FOR REHABILITATION CENTER;
  • '5' FOR SHELTER/TRANSITIONAL HOUSING;
  • '6' FOR PATIENT DEATH;
  • '7' FOR OTHER;

  • LAST EDITED:  SEP 02, 2015
  • HELP-PROMPT:  Enter the patient's destination after hospital discharge or ambsurg release.
  • DESCRIPTION:  Indicate the patient's initial destination upon discharge from a VA hospital acute care admission or release from an ambulatory surgery or observation location following an assessed surgery.
    1. Home (patient returned to their own residence or to a similar
    setting e.g. residence of a family member), 2. Acute Care Facility (patient was transferred after the inpatient
    surgery to another acute care facility, VA or non-VA, or was
    admitted to acute care after an ambulatory surgery) 3. Extended Care Facility, Non-Rehabilitation (patient returned to or
    entered an extended care facility for a purpose other than
    rehabilitation, VA or non-VA) 4. Rehabilitation Center (patient entered a rehabilitation facility for
    the purpose of postoperative recovery, e.g. physical or occupational
    therapy) 5. Shelter/Transitional Housing (patient does not have a fixed dwelling
    (homeless) and enters a supervised public or private shelter or
    transitional housing facility) 6. Patient Death (patient died during the postoperative admission or at
    the ambulatory surgery center). 7. Other.
686 AORTIC REGURGITATION 211;1 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient has aortic regurgitation documented on invasive or non-invasive cardiac testing.
  • DESCRIPTION:  
    This field documents if the patient has aortic regurgitation documented on invasive or non-invasive cardiac testing.
687 INJURY TO ADJACENT ORGAN 211;2 SET
  • '0' FOR NO;
  • '1' FOR YES, WITH INTERVENTION;
  • '2' FOR YES, WITH NO INTERVENTION REQ;

  • LAST EDITED:  JUN 29, 2015
  • HELP-PROMPT:  Enter the level of intervention required in the event of unintended injury.
  • DESCRIPTION:  This field documents the level of intervention required in the event of an unintended injury to an adjacent organ/structure during the surgical procedure. Choose from the following answer options: 0. No unintended injury
    to an adjacent organ/structure during the
    surgical procedure. 1. Unintended injury to an adjacent organ/structure that resulted
    in an intervention to manage the injury. 2. Unintended injury to an adjacent organ/structure that did not
    require intervention to manage the injury.
688 STOMA COMPLICATIONS 211;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if any condition of a stoma requires surgical intervention within 30 days postoperative.
  • DESCRIPTION:  
    This field document any condition of a stoma which requires surgical intervention/revision within 30 days from date of stoma creation.
689 NON-UNION 211;4 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if surgeon confirms a diagnosis of non-union.
  • DESCRIPTION:  
    This field documents if either there is not complete healing of the involved bony structure by 6 months after surgery or if the surgeon confirms a diagnosis of non-union.
690 IMPLANT INFECTIONS 211;5 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if infection of, in, or surrounding a non-human-derived foreign body occurs.
  • DESCRIPTION:  
    This field documents if infection of, in, or surrounding a non-human-derived foreign body occurs within 365 days following permanent implantation by an invasive procedure in the operating room.
691 CHYLE/LYMPH LEAK 211;6 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Enter 'YES' if there is clinical/imaging diagnosis of leakage from or collection of chyle/lymph.
  • DESCRIPTION:  
    This field documents if there is clinical or imaging diagnosis of leakage from or collection of chyle/lymph in the surgical field region.
692 ANASTOMOTIC LEAK 211;7 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if an anastomosis in the GI, urinary, or respiratory tract does not heal within 30 days.
  • DESCRIPTION:  This field documents if an anastomosis in the GI, urinary, or respiratory tract does not heal as evidenced by infection adjacent to or in the same body cavity OR by development of a fistula within 30 days of the surgical
    procedure.
693 FISTULA 211;8 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if an abnormal connection occurs between a hollow or tubular organ and the body surface.
  • DESCRIPTION:  
    This field documents if an abnormal connection occurs between a hollow or tubular organ and the body surface, or between two hollow or tubular organs within 90 days of the index surgical procedure.
694 NECROTIZING SOFT TISS INFECT 211;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter 'YES' if the surgical procedure is performed to treat necrotizing soft tissue infection.
  • DESCRIPTION:  
    This field documents if the surgical procedure is performed to treat necrotizing soft tissue infection with or without skin, muscle, or fascial necrosis.
695 OTHER BLOOD PRODUCT UNITS 211;10 SET
  • '0' FOR NONE;
  • '1' FOR PLATELETS;
  • '2' FOR FRESH FROZEN PLASMA;
  • '3' FOR PLASMA AND PLATELETS;
  • '4' FOR ANY OTHER COMBINATION;
  • '5' FOR ANY OTHER BLOOD PRODUCT;

  • LAST EDITED:  MAY 19, 2015
  • HELP-PROMPT:  Enter '1, 2, 3, 4, or 5' to indicate the specific blood product(s) that were administered or '0' if none was administered.
  • DESCRIPTION:  Blood products commonly administered in the operating room include platelets and fresh frozen plasma. Answer 1, 2, 3, 4, or 5 to indicate the specific blood product or combination of blood products that were administered
    in the operating room. Answer 0 if no product was administered. Do not include packed red blood cells (PRBCs) or cell saver blood when answering this question, as these are documented separately.
696 PRESSORS USED INTRAOP 211;11 SET
  • '0' FOR NO;
  • '1' FOR YES-BOLUS;
  • '2' FOR YES-CONTINUOUS INFUSION;

  • LAST EDITED:  MAY 19, 2015
  • HELP-PROMPT:  Select the Pressors used with the intent to raise blood pressure in the operating room.
  • DESCRIPTION:  Pressors are medications used with the intent to raise blood pressure. For this variable, a pressor must be administered for the intent of increasing blood pressure while the patient is in the operating room. Enter 0 if
    no medications were administered or if the intent of medicine administration is for reasons other than increasing blood pressure. Enter 1 if one or more pressor medications were administered via bolus. Enter 2 if one or
    more pressor medications were administered via continuous infusion.
697 MITRAL STENOSIS 211;12 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient has mitral stenosis documented.
  • DESCRIPTION:  
    This field documents if patient has mitral stenosis documented on invasive or non-invasive cardiac testing.
698 PCI INTERVENTION 211;13 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient has had prior percutaneous coronary artery intervention.
  • DESCRIPTION:  This field documents if the patient has had prior treatment of coronary artery stenosis or occlusion by catheter-based techniques, such as percutaneous transluminal coronary angioplasty, atherectomy, laser angioplasty, or
    implantation of coronary stents.
699 ATRIAL ARRHYTHMIAS 211;14 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Enter Yes for documented history of atrial arrhythmias.
  • DESCRIPTION:  
    This field documents a history of atrial arrhythmias, including atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, or Wolff-Parkinson-White (WPW) syndrome.
700 HEAD OR NECK CANCER 211;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes for documented history of specific head or neck cancers.
  • DESCRIPTION:  This field documents a history of cancers of the mouth, nose, sinuses, salivary glands, throat OR skin cancers of the head/neck with lymph nodes metastases in the neck. Do not include any skin cancer without lymph node
    involvement.
701 MACULAR DEGENERATION 211;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if there is medical record documentation of the diagnosis for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of the diagnosis for the operative eye.
702 GLAUCOMA 211;17 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if there is medical record documentation of a glaucoma diagnosis for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of a glaucoma diagnosis for the operative eye.
704 HX RETINAL DETACHMENT 211;19 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if there is medical record documentation of a history of retinal detachment for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of a history of retinal detachment for the operative eye.
705 AXIAL LEN/ANTERIOR CHAM DEP 211;20 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if either axial length is > 30 mm or anterior chamber depth is > 6 mm.
  • DESCRIPTION:  
    This field documents if either axial length is > 30 mm or anterior chamber depth is > 6 mm.
706 CORNEAL GUTTAE/FUCHS ENDO 211;21 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is medical record documentation of the diagnosis of corneal guttae/Fuchs endothelial in the operative eye.
  • DESCRIPTION:  
    This field documents the diagnosis of corneal guttae/Fuchs endothelial dystrophy in the operative eye.
707 DIABETIC RETINOPATHY 211;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is medical record documentation of the diagnosis diabetic retinopathy for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of the diagnosis of diabetic retinopathy for the operative eye.
708 COMPLEX CATARACT 211;23 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is medical record documentation of the diagnosis of complex cataract in the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of the diagnosis of complex cataract in the operative eye.
709 STATIN 30 DAYS PREOP 211;24 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient was prescribed and compliant with usage of a statin for 30 days or greater preoperatively.
  • DESCRIPTION:  
    This field documents if the patient was prescribed and compliant with usage of a statin for 30 days or greater preoperatively.
710 IPSILAT CORTICAL EVENT PREOP 211;25 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient was documented to have a history of an ipsilateral cortical event within 180 days prior to surgery.
  • DESCRIPTION:  
    This field documents if the patient was documented to have a history of a cerebrovascular accident, reversible ischemic neurological deficit or a transient ischemic attack within the 180 days prior to surgery.
711 PREOP MODIFIED RANKIN SCORE 211;26 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>5)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the calculated modified Rankin score. Leave blank if not able to calculate.
  • DESCRIPTION:  
    This field documents the calculated modified Rankin score. Leave blank if not able to calculate.
712 CAROTID SUR ANATOMIC HIGH RISK 211;27 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if carotid surgery was previously performed as described in the description.
  • DESCRIPTION:  This field documents if carotid surgery is being performed in a patient with a previously radiated neck, there has been a prior ipsilateral radical neck dissection or carotid surgery, the carotid bifurcation is at C-2 or
    higher, or if there is a bull-like or inextensible neck.
713 BYPASS CRITICAL LIMB ISCHEMIA 211;28 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter Yes if ankle-brachial blood pressure index is less than or equal to 0.4 or if there is ischemic tissue/ulceration due to vascular disease.
  • DESCRIPTION:  
    For lower extremity inflow or leg bypass procedures, enter Yes if ankle-brachial blood pressure index is less than or equal to 0.4 or if there is ischemic tissue/ulceration due to vascular disease.
715 ENDOLEAK AT COMPLETION 211;30 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient has an endoleak at the time of exit from the operating room.
  • DESCRIPTION:  
    This field documents if the patient has an endoleak at the time of exit from the operating room.
716 HIGH HEART RATE 6HRS PREOP 211;31 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>250)!(X<30)!(X?.E1"."1.N) X
  • LAST EDITED:  JUN 04, 2015
  • HELP-PROMPT:  Enter a number from 30-250 with no decimal places.
  • DESCRIPTION:  
    Enter the highest heart rate in beats per minute recorded in the medical record during the 6 hours preceding entry into the operating room.
717 HIGH HEART RATE INTRAOP 211;32 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>250)!(X<30)!(X?.E1"."1.N) X
  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter a number from 30-250 with no decimal places.
  • DESCRIPTION:  
    Enter the highest heart rate in beats per minute recorded in anesthesia records from time of entry to time of exit from the operating room.
718 LOW ARTERIAL PRESS 6HRS PREOP 211;33 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>200)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Enter a number from 0 to 200 with no decimal places.
  • DESCRIPTION:  
    Enter the lowest mean arterial blood pressure recorded in medical records for the 6 hours preceding entry into the operating room.
719 HIGH LACTIC ACID 6HRS PREOP 211;34 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>30)!(X<0)!(X?.E1"."2.N) X
  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Type a number between 0 and 30, 1 decimal digit.
  • DESCRIPTION:  Enter the highest lactic acid (units = mmol/liter) measured from during the 6 hours prior to entry into the operating room. Do not enter a value if arterial pH was not measured in the 6 hours preceding entry into the
    operating room.
720 HIGH LACTIC ACID INTRAOP VERD;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>30)!(X<0)!(X?.E1"."2.N) X
  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Enter a number from 0 to 30 with 1 decimal place.
  • DESCRIPTION:  
    Enter the highest lactic acid (units = mmol/liter) measured from entry into the operating room to exit from the operating room. Do not enter a value if lactic acid was not measured in the operating room.
721 LOWEST PH 6HRS PREOP VERD;7 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>7.6)!(X<6.8)!(X?.E1"."3.N) X
  • LAST EDITED:  JUL 09, 2015
  • HELP-PROMPT:  Enter a number from 6.80 to 7.60 with 3 significant digits use the format X.YZ where must X be 6 or 7 and YZ may be 00-99.
  • DESCRIPTION:  
    Enter the lowest arterial pH obtained during the 6 hours prior to entry into the operating room. Do not enter a value if arterial pH was not measured in the 6 hours preceding entry into the operating room.
722 LOWEST PH INTRAOP 211;35 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>7.6)!(X<6.8)!(X?.E1"."3.N) X
  • LAST EDITED:  MAY 19, 2015
  • HELP-PROMPT:  Enter a number from 6.80 to 7.60 with 3 significant Digits use the format X.YZ where must X be 6 or 7 and YZ may be 00-99.
  • DESCRIPTION:  
    Enter the lowest arterial pH obtained between from entry to and exit from the operation room. Do not enter a value if pH was not measured in the operation room.
723 LOW ARTERIAL PRESS INTRAOP 211;36 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>200)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  MAY 19, 2015
  • HELP-PROMPT:  Type a number between 0 and 200, 0 decimal digits.
  • DESCRIPTION:  
    Enter the lowest mean arterial blood pressure recorded in anesthesia records between entry to and exit from the operating room.
724 OLIGURIA <60CC/2HRS 6HRS PREOP 211;37 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if urine output was less than 60 cc over any two hour period for the 6 hours prior to entry into the operating room.
  • DESCRIPTION:  
    This field documents if urine output was less than 60 cc over any two hour period for the 6 hours prior to entry into the operating room.
725 OLIGURIA URINE OUTPUT INTRAOP 211;38 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if total urine output from room entry to exit was less than 30 cc/hr.
  • DESCRIPTION:  
    This field documents if total urine output from room entry to exit was less than 30 cc/hr.
726 LOWEST BICARBONATE 6HRS PREOP VERD;8 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>40)!(X<0)!(X?.E1"."2.N) X
  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter a number from 0-40 with 1 decimal place.
  • DESCRIPTION:  Enter the lowest bicarbonate measurement (mmol/L) from an electrolyte panel or arterial blood gas obtained during the 6 hours prior to entry into the operating room. Do not enter a value if bicarbonate was not measured in
    the 6 hours preceding entry into the operating room.
727 LOWEST BICARBONATE INTRAOP 211;39 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>40)!(X<0)!(X?.E1"."2.N) X
  • LAST EDITED:  MAY 18, 2015
  • HELP-PROMPT:  Enter a number from 0 to 40 with on decimal place.
  • DESCRIPTION:  Enter the lowest bicarbonate measurement (mmol/L) from an electrolyte panel or arterial blood gas obtained between entry and exit from the operating room. Do not enter a value if bicarbonate was not measured in the
    operating room.
728 UNITS TRANSFUSED 6HRS PREOP 211;40 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  MAY 22, 2015
  • HELP-PROMPT:  Enter a number from 0 to 100.
  • DESCRIPTION:  
    Enter the number of units of packed RBC or whole blood transfused within 6 hours preceding entry into the operating room. Enter 0 if there were no blood transfusions.
729 VASOPRESSOR USAGE AT OR ENTRY 211;41 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter Yes if one or more medications are being continuously infused with intent to increase blood pressure at the time of entry to the operating room.
  • DESCRIPTION:  This field documents if one or more medications are being continuously infused with intent to increase blood pressure at the time of entry to the operating room. Enter No if such medications are being administered
    intermittently or if the intent of medical infusion is for reasons other than increasing blood pressure.
730 CARDIAC ARREST 24HRS PREOP 211;42 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Answer Yes if cardiac arrest occurs within the 24 hours prior to entry into the operating room.
  • DESCRIPTION:  Cardiac arrest is the sudden cessation of cardiac function due to absence of cardiac rhythm or presence of a disordered rhythm that results in loss of effective circulation requiring the initiation of any component of
    basic and/or advanced cardiac life support. Exclude firing of AICD unless the patient becomes unconscious. Answer Yes if cardiac arrest occurs within the 24 hours prior to entry into the operating room.
731 DIC 6HRS PREOP 211;43 SET
  • '1' FOR SCORE <5;
  • '2' FOR SCORE > OR EQUAL 5;

  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Indicate the ISTH score for Disseminated Intravascular Coagulation (DIC) in the 6 hrs preop.
  • DESCRIPTION:  
    This field documents the International Society on Thrombosis and Haemostasis (ISTH) score for Disseminated Intravascular Coagulation (DIC) in the 6 hrs prior to OR start time.
732 HYPOXEMIA W/IN 6HRS PREOP 211;44 SET
  • '1' FOR NOT MEASURED;
  • '2' FOR PAO2/FIO2 < 200 ;
  • '3' FOR PAO2/FIO2 200-249;
  • '4' FOR PAO2/FIO2 250-299;
  • '5' FOR PAO2/FIO2 > 300;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Indicate the PaO2:FiO2 ratio.
  • DESCRIPTION:  
    This field documents the PaO2:FiO2 ratio.
733 ENDOLEAK AT FOLLOW-UP 211;45 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if the patient has an endoleak at the time of surgical follow-up.
  • DESCRIPTION:  
    This field documents if the patient has an endoleak at the time of surgical postoperative follow-up.
734 CARDIAC ARREST INTRAOP 211;46 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  AUG 26, 2015
  • HELP-PROMPT:  Answer Yes if cardiac arrest occurs at any time between entry and exit from the operating room.
  • DESCRIPTION:  Cardiac arrest is the sudden cessation of cardiac function due to absence of cardiac rhythm or presence of a disordered rhythm that results in loss of effective circulation requiring the initiation of any component of
    basic and/or advanced cardiac life support. Exclude firing of AICD unless the patient becomes unconscious. Answer Yes if cardiac arrest occurs at any time between entry to and exit from the operating room.
735 FLOPPY IRIS INTRAOP 211;47 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is medical record documentation of the diagnosis of intraoperative floppy iris for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of the diagnosis of intraoperative floppy iris for the operative eye.
736 PREOP VISUAL ACUITY 211;48 SET
  • '1' FOR 20/20 OR BETTER;
  • '2' FOR > 20/20 - 20/50;
  • '3' FOR > 20/50 - 20/100;
  • '4' FOR > 20/100 - 20/200;
  • '5' FOR > 20/200;
  • '6' FOR HAND MOTION;
  • '7' FOR LIGHT PERCEPTION;
  • '8' FOR NO LIGHT PERCEPTION;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Report best corrected visual acuity for the operative eye within 60 days prior to surgical procedure.
  • DESCRIPTION:  
    This field documents the best corrected visual acuity for the operative eye within 60 days prior to surgical procedure.
737 POSTOP VISUAL ACUITY 211;49 SET
  • '1' FOR 20/20 OR BETTER;
  • '2' FOR > 20/20 - 20/50;
  • '3' FOR > 20/50 - 20/100;
  • '4' FOR > 20/100 - 20/200;
  • '5' FOR > 20/200;
  • '6' FOR HAND MOTION;
  • '7' FOR LIGHT PERCEPTION;
  • '8' FOR NO LIGHT PERCEPTION;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Report best corrected visual acuity for the operative eye within 60 days after the surgical procedure.
  • DESCRIPTION:  
    This field documents the best corrected visual acuity for the operative eye within 60 days after the surgical procedure.
738 ENDOPHTHALMITIS TYPE 211;50 SET
  • '0' FOR NO ENDOPHTHALMITIS;
  • '1' FOR BACTERIAL;
  • '2' FOR TASS;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Select 0, 1, or 2 to indicate the Endophthalmitis Type.
  • DESCRIPTION:  This field documents the appropriate response to indicate the Endophthalmitis Type.
    0- No endophthalmitis 1- Bacterial 2- TASS
739 CYSTOID MACULAR EDEMA 211;51 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes if there is medical record documentation of the diagnosis of cystoid macular edema for the operative eye.
  • DESCRIPTION:  
    This field documents if there is medical record documentation of the diagnosis of cystoid macular edema for the operative eye.
740 DISLOCATION OF OPERATIVE JOINT 211;52 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes for dislocation of a prosthetic joint within 90 days of its implantation regardless of treatment performed.
  • DESCRIPTION:  
    This field documents dislocation of a prosthetic joint within 90 days of its implantation regardless of treatment performed.
741 PERIPROSTHETIC FRACTURES 211;53 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Answer Yes for fracture adjacent to or involving a prosthetic within 90 days of its implantation.
  • DESCRIPTION:  
    This field documents fracture adjacent to or involving a prosthetic within 90 days of its implantation.
742 D/T PAT ARRIVES HOSP DAY SURG 211;54 DATE

  • INPUT TRANSFORM:  S %DT="ETX" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  JUN 10, 2015
  • HELP-PROMPT:  Enter Date/Time patient arrives for day surgery.
  • DESCRIPTION:  
    Date/Time patient arrives for day surgery.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
743 D/T PAT LEAVES HOSP DAY SURG 211;55 DATE

  • INPUT TRANSFORM:  S %DT="ER" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Enter Date/Time patient leaves hospital after day surgery.
  • DESCRIPTION:  
    Date/Time patient leaves hospital after day surgery.
744 KIDNEY DONOR PROFILE INDEX 211;56 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  APR 21, 2015
  • HELP-PROMPT:  Enter the percent (0-100) of the kidney donor profile index.
  • DESCRIPTION:  
    Kidney Donor Profile Index (KDPI).
745 EXPECTED POST TRANSPLANT INDEX 211;57 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  APR 21, 2015
  • HELP-PROMPT:  Enter the percent (0-100) expected post transplant index.
  • DESCRIPTION:  
    Expected Post Transplant Index (EPTI).
746 BLOOD BANK ABO VER COMMENTS VER1;18 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter comments for blood bank verification of ABO type of the transplant recipient.
  • DESCRIPTION:  
    This field is for comments regarding blood bank verification of ABO type of the transplant recipient.
747 D/T BLOOD BANK ABO VERIF VER1;19 DATE

  • INPUT TRANSFORM:  S %DT="ER" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  JUN 30, 2015
  • HELP-PROMPT:  Enter the date and time when the blood bank verified the ABO type of the transplant recipient.
  • DESCRIPTION:  
    Enter the date and time when the blood bank verified the ABO type of the transplant recipient.
748 OR ABO VER COMMENTS VER1;20 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>50!($L(X)<1) X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter comments for verification of ABO type of the transplant recipient in the operating room.
  • DESCRIPTION:  
    This field is for comments on for verification of ABO type of the transplant recipient in the operating room.
749 D/T OR ABO VERIF VER1;21 DATE

  • INPUT TRANSFORM:  S %DT="ETX" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the date and time when the ABO type of the transplant recipient was verified in the operating room.
  • DESCRIPTION:  
    This field documents the date and time when the ABO type of the transplant recipient was verified in the operating room.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
750 UNET VERIF BY SURGEON (Y/N) VER1;22 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the transplant surgeon completed required UNET verification.
  • DESCRIPTION:  
    This field documents whether the transplant surgeon completed required UNET verification.
751 SURGEON VER ORGAN PRE-ANES VER1;23 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the Name of the surgeon who verified the organ prior to anesthesia.
  • DESCRIPTION:  
    This field documents the Name of the surgeon who documented that the labeling of the organ to be transplanted matches associated documentation for the anticipated donor and recipient.
752 DONOR ORG VER PRE-ANES VER1;24 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;
  • 'NA' FOR NOT APPLICABLE;

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter whether the organ to be removed and transplanted, including laterality when applicable, was documented prior to donor anesthesia.
  • DESCRIPTION:  
    This field documents whether the organ to be removed and transplanted, including laterality when applicable, was documented prior to donor anesthesia. For cases not involving live donors, select 'NA' for not applicable.
753 SURGEON VER ORG PRE-TRANSPLANT VER1;25 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  JUN 26, 2015
  • HELP-PROMPT:  Enter the Name of the Surgeon that verified the organ prior to transplant.
  • DESCRIPTION:  
    This field documents the name of the surgeon who documented the organ to be transplanted. For cases where the organ is not transplanted, enter NA.
901 AIRWAY INDEX .3;9 SET
  • '1' FOR 1. INDEX LESS THAN OR EQUAL TO 0;
  • '2' FOR 2. INDEX > 0 AND LESS THAN OR EQUAL TO 2;
  • '3' FOR 3. INDEX > 2 AND LESS THAN OR EQUAL TO 3;
  • '4' FOR 4. INDEX > 3 AND LESS THAN OR EQUAL TO 4;
  • '5' FOR 5. INDEX GREATER THAN 4;

  • LAST EDITED:  MAY 10, 1995
  • HELP-PROMPT:  Do NOT enter a value. This field is computed based on the ORAL-PHARYNGEAL SCORE and the MANDIBULAR SPACE.
  • DESCRIPTION:  This field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being least difficult and 5 being most difficult. The value of this field is based on a computed performance index using the
    oral-pharyngeal (OP) class and the mandibular space (MS).
    Performance index = 2.5 x OP - MS length (converted to centimeters)
    Airway Index
    ------------
    1 - Performance Index less than 0
    2 - Performance index greater than 0 and less than 2
    3 - Performance index greater than 2 and less than 3
    4 - Performance index greater than 3 and less than 4
    5 - Performance index greater than 4
  • SCREEN:  S DIC("S")="I $P(^SRF(DA,.3),U,11)&$P(^SRF(DA,.3),U,12)"
  • EXPLANATION:  Screen checks for OP Score and Mandibular Space.
    UNEDITABLE
901.1 MALLAMPATI SCALE .3;11 SET
  • '1' FOR CLASS 1;
  • '2' FOR CLASS 2;
  • '3' FOR CLASS 3;
  • '4' FOR CLASS 4;

  • INPUT TRANSFORM:  I $P($G(^SRF(DA,"CON")),"^") N SRFLD S SRFLD=901.1 D ^SROCON Q
  • LAST EDITED:  MAR 24, 2011
  • HELP-PROMPT:  Enter the Mallampati Scale class.
  • DESCRIPTION:  Definition Revised (2004): The Mallampati classification relates tongue size to pharyngeal size. This test is performed with the patient in sitting position, the head held in a neutral position, the mouth wide open, and
    the tongue protruding to the maximum. The subsequent classification is assigned based upon the pharyngeal structures that are visible:
    Class I - visualization of the soft palate, fauces, uvula, and
    anterior and posterior pillars. Class II - visualization of the soft palate, fauces, and uvula. Class III - visualization of the soft palate and the base of the uvula. Class IV - soft palate is not visible
    at all.
    The classification assigned by the clinician may vary if the patient is in the supine position (instead of sitting). If the patient phonates, this falsely improves the view. If the patient arches his or her tongue, the
    uvula is falsely obscured. A class I view suggests ease of intubation and correlates with a laryngoscopic view grade I 99 to 100% of the time. Class IV view suggests a poor laryngoscopic view, grade III or IV 100% of the
    time. Refer to the Operations Manual for a visual depiction of the Mallampati Classification.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AOP^MUMPS
    1)= D OP^SROAUTL
    2)= D K901^SROAUTL
    This MUMPS cross reference is used to update the AIRWAY INDEX field (#901) when the MALLAMPATI SCALE field is edited.
901.2 MANDIBULAR SPACE .3;12 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>150)!(X<20)!(X?.E1"."1N.N) X I $D(X),$P($G(^SRF(DA,"CON")),"^") S SRFLD=901.2 D ^SROCON Q
  • LAST EDITED:  FEB 29, 1996
  • HELP-PROMPT:  Enter the mandibular space in millimeters. Type a number between 20 and 150.
  • DESCRIPTION:  In the sitting position with head extended, enter the distance between the inside of the mentum and the top of the thyroid cartilage in millimeters. The mandibular space (MS) and the oral-pharyngeal (OP) score are used in
    figuring a performance index which is translated to the patient's airway index.
    (Performance Index = 2.5 x OP - MS length in cm)
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  130^AMS^MUMPS
    1)= D MS^SROAUTL
    2)= D K901^SROAUTL
    This MUMPS cross reference is used to update the AIRWAY INDEX field (#901) when the MANDIBULAR SPACE field is edited.
903 DEATH UNRELATED/RELATED .4;7 SET
  • 'U' FOR UNRELATED;
  • 'R' FOR RELATED;

  • LAST EDITED:  NOV 06, 1995
  • HELP-PROMPT:  Enter "U" if the death was not related to the Surgical procedure.
  • DESCRIPTION:  
    This indicates if death was unrelated to this surgery.
904 REVIEW OF DEATH COMMENTS 47;0 WORD-PROCESSING #130.0904

  • LAST EDITED:  DEC 15, 1995
  • DESCRIPTION:  
    This word processing field contains comments about the review of death.
905 READY TO TRANSMIT? .4;2 SET
  • 'R' FOR READY;
  • 'T' FOR TRANSMITTED;

  • LAST EDITED:  JAN 23, 1997
  • HELP-PROMPT:  Enter R if ready to transmit or T if already transmitted.
  • DESCRIPTION:  This field is set to R (ready) by a MUMPS cross reference the TIME PAT OUT OR field. When this case is transmitted to the national database at the end of the quarter, this field will be updated to T (transmitted). This
    field serves as a flag that indicates the transmission status of this case.
  • CROSS-REFERENCE:  130^AQ1^MUMPS
    1)= D AQ1^SROXR4
    2)= D KAQ1^SROXR4
    This MUMPS cross reference updates the AQ cross reference list of cases that are are ready to be transmitted to the national database.
1000 TIU OPERATIVE SUMMARY TIU;1 POINTER TO TIU DOCUMENT FILE (#8925) TIU DOCUMENT(#8925)

  • LAST EDITED:  AUG 28, 2000
  • HELP-PROMPT:  Enter the TIU document that holds the operative summary for this case.
  • DESCRIPTION:  
    This is the operative summary for this case stored in TIU.
1001 TIU NURSE INTRAOP REPORT TIU;2 POINTER TO TIU DOCUMENT FILE (#8925) TIU DOCUMENT(#8925)

  • LAST EDITED:  MAY 24, 2002
  • HELP-PROMPT:  Enter the TIU document that holds the Nurse Intraoperative Report for this case.
  • DESCRIPTION:  
    This is the Nurse Intraoperative Report for this case stored in TIU.
1002 TIU PROCEDURE REPORT (NON-OR) TIU;3 POINTER TO TIU DOCUMENT FILE (#8925) TIU DOCUMENT(#8925)

  • LAST EDITED:  OCT 19, 2000
  • HELP-PROMPT:  Enter the TIU document that holds the procedure summary for this non-OR procedure.
  • DESCRIPTION:  
    This is the Procedure Report (Non-OR) for this non-OR procedure.
1003 TIU ANESTHESIA REPORT TIU;4 POINTER TO TIU DOCUMENT FILE (#8925) TIU DOCUMENT(#8925)

  • LAST EDITED:  OCT 19, 2000
  • HELP-PROMPT:  Enter the TIU document that holds the Anesthesia Report for this case.
  • DESCRIPTION:  
    This is the Anesthesia Report for this case.
1004 DICTATED SUMMARY EXPECTED TIU;5 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  FEB 25, 2004
  • HELP-PROMPT:  Enter YES if a summary of this procedure will be dictated.
  • DESCRIPTION:  
    This field indicates if the provider will dictate a summary of this procedure to be electronically signed. Enter YES if a dictated summary is expected. Enter NO or leave blank if no summary is expected.
  • SCREEN:  S DIC("S")="I '$$DEL^SROESX(DA,""3"")"
  • EXPLANATION:  Screen prevents change if a Procedure Report is associated with the case.
  • DELETE TEST:  1,0)= I $$DEL^SROESX(DA,"3") D EN^DDIOL("The DICTATED SUMMARY EXPECTED field cannot be deleted. This case has a",,"!!,?2") D EN^DDIOL("Procedure Report associated with it.",,"!,?2")
  • RECORD INDEXES:  AESP (#388)
1005 CPT ON NURSE REPORT TIU;6 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  OCT 25, 2000
  • HELP-PROMPT:  Enter YES if the CPT ON NURSE INTRAOP site parameter is set to YES, INCLUDE CPT at the time the nurse intraoperative report is signed.
  • DESCRIPTION:  This field reflects the content of the CPT ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time
    an automatic addendum is made to the report to determine whether the CPT codes should appear on the report.
1006 ICD ON NURSE REPORT TIU;7 SET
  • '1' FOR YES;
  • '0' FOR NO;

  • LAST EDITED:  OCT 26, 2011
  • HELP-PROMPT:  Enter YES if the ICD ON NURSE INTRAOP site parameter is set to YES, INCLUDE ICD at the time the nurse intraoperative report is signed.
  • DESCRIPTION:  This field reflects the content of the ICD ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time
    an automatic addendum is made to the report to determine whether the ICD codes should appear on the report.
2005 IMAGE 2005;0 POINTER Multiple #130.02005 130.02005

  • DESCRIPTION:  
    This sub-file contains pointers to images in the Imaging file (#2005) that are related to this case.
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