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