308 lines
10 KiB
Plaintext
308 lines
10 KiB
Plaintext
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English French Notes Complete/Exclude
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update Current Pneumonia, enter '2C'.)
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4. Enter a range of numbers (1-5) separated by a ':' to enter a range of
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occurrences. (For example, enter '2:4' to enter all pulmonary,
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hepatobiliary, and cardiac information)
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5. Press <RET> to continue to page 2 of this option.
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Pulmonary
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Hepatobiliary
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CENTRAL NERVOUS SYSTEM
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Central Nervous System
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NUTRITIONAL/IMMUNE/OTHER
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Nutritional/Immune/Other
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Deleting all
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MINIMAL EXERTION
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AT REST
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TOTAL DEPENDENT
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PREOPERATIVE INFORMATION
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GENERAL:
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HEPATOBILIARY:
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Diabetes Mellitus:
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Ascites:
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Current Smoker W/I 1 Year:
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Pack/Years:
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ETOH > 2 Drinks/Day:
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CARDIAC:
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Dyspnea:
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CHF Within 1 Month:
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DNR Status:
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Functional Status:
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RENAL:
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Acute Renal Failure:
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PULMONARY:
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Currently on Dialysis:
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Ventilator Dependent:
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History of Severe COPD:
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Current Pneumonia:
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CENTRAL NERVOUS SYSTEM:
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NUTRITIONAL/IMMUNE/OTHER:
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Impaired Sensorium:
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Disseminated Cancer:
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Coma:
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Open Wound:
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Hemiplegia:
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Steroid Use for Chronic Cond.:
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History of TIAs:
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Weight Loss > 10%:
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CVA/Residual Neuro Deficit:
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Bleeding Disorders:
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CVA/No Neuro Deficit:
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Transfusion > 4 RBC Units:
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Tumor Involving CNS:
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Chemotherapy W/I 30 Days:
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Radiotherapy W/I 90 Days:
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Preoperative Sepsis:
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OPERATIVE INFORMATION
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Surgical Specialty:
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Principal Operation:
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PGY of Primary Surgeon:
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Emergency Case (Y/N):
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Major or Minor:
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Wound Classification:
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ASA Classification:
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Anesthesia Technique:
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Airway Trauma:
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RBC Units Transfused:
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OPERATION DATE/TIMES INFORMATION
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Date/Time Patient in OR:
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Date/Time Operation Began:
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Date/Time Operation Ended:
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Date/Time Patient Out of OR:
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Anesthesia Care Start Date/Time:
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Anesthesia Care End Date/Time:
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PACU Discharge Date/Time:
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PREOPERATIVE LABORATORY TEST RESULTS
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Serum Sodium:
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Serum Creatinine:
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BUN:
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Serum Albumin:
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Total Bilirubin:
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SGOT:
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Alkaline Phosphatase:
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White Blood Count:
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Hematocrit:
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Platelet Count:
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PTT:
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PT:
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POSTOPERATIVE LABORATORY RESULTS
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* Highest Value
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** Lowest Value
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* Serum Sodium:
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** Serum Sodium:
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* Serum Creatinine:
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* CPK-MB Band:
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* Total Bilirubin:
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* White Blood Count:
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OUTCOME INFORMATION
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Postoperative Diagnosis Code (ICD9):
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Length of Postoperative Hospital Stay:
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Death Unrelated/Related:
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Return to OR Within 30 Days:
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NO DATE
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PERIOPERATIVE OCCURRENCE INFORMATION
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WOUND OCCURRENCES:
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CNS OCCURRENCES:
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Superficial Infection:
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Deep Wound Infection:
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Coma > 24 Hours:
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Wound Disruption:
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Peripheral Nerve Injury:
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URINARY TRACT OCCURRENCES:
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CARDIAC OCCURRENCES:
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Renal Insufficiency:
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Arrest Requiring CPR:
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Myocardial Infarction:
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Urinary Tract Infection:
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RESPIRATORY OCCURRENCES:
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OTHER OCCURRENCES:
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Pneumonia:
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Ileus/Bowel Obstruction:
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Unplanned Intubation:
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Bleeding/Transfusions:
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Pulmonary Embolism:
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Graft/Prosthesis/Flap Failure:
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On Ventilator > 48 Hours:
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DVT/Thrombophlebitis:
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Systemic Sepsis:
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* indicates Other (ICD9)
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MINIMAL EXERTION
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AT REST
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A. Diabetes Mellitus:
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B. Current Smoker W/I 1 Year:
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A. CHF Within 1 Month:
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F. DNR Status:
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G. Functional Status:
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A. Acute Renal Failure:
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B. Currently on Dialysis:
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A. Ventilator Dependent:
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B. History of Severe COPD:
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C. Current Pneumonia:
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1. CENTRAL NERVOUS SYSTEM:
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A. Impaired Sensorium:
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A. Disseminated Cancer:
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B. Open Wound:
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C. Steroid Use for Chronic Cond.:
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D. History of TIAs:
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D. Weight Loss > 10%:
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E. CVA/Residual Neuro Deficit:
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E. Bleeding Disorders:
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F. CVA/No Neuro Deficit:
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F. Transfusion > 4 RBC Units:
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G. Tumor Involving CNS:
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I. Preoperative Sepsis:
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Annual Report of Surgical Procedures
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Do you want to print the Annual Report of Surgical Procedures for all
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Print the Annual Report for which Specialty ?
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This report must be run on a printer. Please select another device.
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ANNUAL REPORT OF SURGICAL PROCEDURES
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Press RETURN to continue or '^' to quit.
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TOTAL OPERATIONS:
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CPT CODE - OPERATION
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TOTALS FOR
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There are no surgical cases entered for
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within 30 days of this operation.
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RETURNS TO SURGERY
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Select the number corresponding to the return which you want to update, or
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enter RETURN to quit this option.
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CPT MISSING
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This return to surgery is currently defined as
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to the case selected.
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Do you want to change this status ? NO//
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Enter 'YES' to change the status of this return from
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Enter 'NO' to leave the information unchanged.
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SRSITE(
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MEDICAL RECORD | ANESTHESIA REPORT
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ANESTHETIST'S SIG:
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Preop Status:
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Operating Room:
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Principal Operation:
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Anesthesia Technique(s):
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Agents:
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MONITORED ANESTHESIA CARE
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Intubated:
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Approach:
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Laryngoscope Type:
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Laryngoscope Size:
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Stylet Used:
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Lidocaine Topical:
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Lidocaine IV:
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Tube Type:
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Tube Size:
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Trauma:
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Extubated In:
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Extubated By:
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Reintubated within 8 Hours: YES
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Heat, Moisture Exchanger Used: YES
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Bacteria Filter in Circuit: YES
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Continuous:
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Baricity:
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Puncture Site:
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Needle Size:
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Modifiers: -
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-
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Other:
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Medications:
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Anesthesia Start:
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Anesthesia Stop:
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Anesthetist:
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Relief Anesth:
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Anesthesiologist:
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Attending Code:
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Assistant Anesth:
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Min Intraoperative Temp:
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Monitors:
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Blood Replacement Fluids:
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Intraoperative Blood Loss:
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Urine Output:
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Operation Disposition:
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PAC(U) Admit Score:
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PAC(U) Discharge Score:
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Postop Anesthesia Note:
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Intraoperative Complications:
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Postoperative Complications:
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Applied By:
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Installed:
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Source ID:
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VA ID:
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Ordered By:
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Admin By:
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Medication Comments:
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Agents:
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General Comments:
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Dural Puncture:
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Catheter Removed By:
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Date/Time Catheter Removed:
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Block Site:
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Needle Length:
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Needle Gauge:
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. ---- CREATE NEW ASSESSMENT
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There are no Surgery Risk Assessments entered for
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Press RETURN to continue.
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Select Surgical Case:
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Enter the number of the desired assessment.
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' to create an
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assessment for another surgical case.
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You've selected a Cardiac assessment, using a Non-Cardiac Option,
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You've selected a Non-Cardiac assessment, using a Cardiac Option,
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1. Enter Risk Assessment Information
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2. Delete Risk Assessment Entry
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3. Update Assessment Status to 'COMPLETE'
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Enter <RET> or '1' to enter or edit information related to this Risk
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Assessment entry. If you want to delete the Assessment, enter '2'.
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Enter '3' to update the status of this Assessment to 'COMPLETE'.
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This assessment has already been transmitted. The information contained
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in it cannot be altered unless you first change the status to 'INCOMPLETE'.
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Do you wish to change the status of this assessment to 'INCOMPLETE'
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' to create a
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new risk assessment entry.
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is not an O.R. surgical procedure.
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There is no Surgery Risk Assessment entered for Case #
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Enter YES to batch print all completed or transmitted assessments for a
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selected date range. Enter NO or press return to print one specific
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Do you want to batch print assessments for a specific date range ?
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Convert existing assessments starting with which date ?
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The SURGERY RISK ASSSESSMENT file (139) still contains entries. Before you
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enter any additional risk assessment information, all entries in this file
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should be converted or deleted.
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The conversion process has been completed. Please review your incomplete
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The conversion of the
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Surgery Risk Assessment Module cannot
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be run until after April 1, 1994. It should only be run after that date
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if your Surgery files are complete, including complications, CPT codes and
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anesthesia information since installing Surgery Version 3.0.
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You must select a starting date to begin the conversion process. All
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assessments with operation dates prior to the start date will be automatically
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deleted. The remaining assessments will then be processed for conversion.
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The SURGERY RISK ASSESSMENT file will now be deleted from your system...
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This option is used to move the risk assessment data entered through the
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Surgery Risk Assessment Module into the DHCP Surgery pacakge.
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The computer will ask you to select a starting date to move the assessments.
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All assessments with an operation date prior to this start date will be deleted
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prior to converting the remaining entries. The software will then begin the
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conversion process. Upon completion of the conversion, there should be no
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entries in the SURGERY RISK ASSESSMENT file (139). The computer will then
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remove that file from your system.
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The conversion process will merge only those data elements that are not already
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part of the DHCP Surgery database. You should only convert the assessments if
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the information contained in your surgery database has been kept up to date.
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The following information will NOT be moved from the
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Risk Assessment Module:
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1. Operative Procedures and CPT Codes
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2. Diagnosis Information
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4. ASA Classification
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5. Anesthesia Technique
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6. Concurrent Cases
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7. Returns to Surgery
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All assessments that have been completed, but not transmitted will have their
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status changed to
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after they are converted. You should review
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these assessments to determine if any of the fields which are not merged need
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The conversion process will begin by deleting all assessments with a date of
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operation prior to the start date selected and all entries in the SURGERY RISK
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ASSESSMENT file (139) that have been entered for log purposes only. These
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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