308 lines
13 KiB
Plaintext
308 lines
13 KiB
Plaintext
English French Notes Complete/Exclude
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8. Other Procedures CPT Code:
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9. Preoperative Risk Factors:
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10. Cardiac Surgery to Non-VA Facility:
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Select Operative Risk Summary Information to Edit:
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2. Enter the corresponding number to update the information in a particular
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field. (For example, enter '3' to update Surgical Priority)
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3. Enter two numbers separated by a ':' to enter a range of information.
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(For example, enter '1:2' to update Physician's Preoperative Estimate of
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Mortality and ASA Classification.)
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Enter/Edit Patient Resource Data
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1. Capture Information from PIMS Records
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2. Enter, Edit, or Review Information
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Enter '1' if you want to capture patient information from PIMS
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records. Enter '2' if you want to enter, edit, or review patient
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other information on this screen.
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No Study
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Unable to determine
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Remains intubated at 30 days
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Remains in ICU at 30 days
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Are you sure you want to retrieve information from PIMS records ?
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4. Enter 'N' or 'NO' to enter negative response for all items.
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5. Enter '@' to delete information from all items.
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To identify the date and time the patient was discharged from intensive
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care following surgery, see the following list of patient movements
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that occurred during the inpatient stay associated with this surgery.
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CABG Distal Anastomoses
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14. Cardiac Transplant:
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1. Number with Vein:
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15. Electrophysiologic Procedure:
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2. Number with IMA:
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16. Misc. Cardiac Procedures:
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3. Number with Radial Artery:
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A. ASD Repair:
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4. Number with Other Artery:
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B. VSD Repair:
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5. Number with Other Conduit:
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C. Myxoma Resection:
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D. Foreign Body Removal:
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6. Aortic Valve Replacement:
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E. Myectomy for IHSS:
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7. Mitral Valve Replacement:
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8. Tricuspid Valve Replacement:
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G. Other Tumor Resection:
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9. Valve Repair:
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H. Other Procedure(s):
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10. LV Aneurysmectomy:
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17. Minimally Invasive Procedure:
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11. Great Vessel Repair (Req CPB):
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18. Batista Procedure:
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12. Total Ischemic Time:
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19. Incision Type:
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13. Total CPB Time:
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20. Convert Off Pump to CPB:
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* Other Procedures List:
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Miscellaneous Cardiac Procedures
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Sure you want to delete all Misc. Cardiac Procedures information ?
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1. Operative Death:
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2. Date of Death:
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3. Perioperative MI:
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5. Renal Failure Requiring Dialysis:
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6. Low Cardiac Output > or = 6 Hours:
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8. Reoperation for Bleeding:
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9. On Ventilator > or = 48 Hours:
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10. Repeat Cardiopulmonary Bypass:
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13. Cardiac Arrest Requiring CPR:
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PAGE: 2 OF 2
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1. WOUND COMPLICATIONS:
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4. CNS COMPLICATIONS:
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A. Superficial Infection:
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A. Cerebral Vascular Accident:
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B. Deep Wound Infection:
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C. Wound Dehiscence:
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C. Neurological Deficits:
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2. RESPIRATORY COMPLICATIONS:
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5. CARDIAC COMPLICATIONS:
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A. Arrest Requiring CPR:
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B. Unplanned Intubation:
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B. Myocardial Infarction:
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C. Pulmonary Embolism:
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C. Pulmonary Edema:
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D. On Ventilator > 48 Hours:
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3. URINARY TRACT COMPLICATIONS:
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6. OTHER COMPLICATIONS:
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A. Renal Insufficiency:
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A. Ileus/Bowel Obstruction:
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B. Acute Renal Failure:
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C. Urinary Tract Infection:
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C. Graft/Prosthesis Failure:
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E. Systemic Sepsis:
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mm Hg
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2. Aortic Systolic Pressure:
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3. *PA Systolic Pressure:
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4. *PAW Mean Pressure:
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5. Left Main Stenosis:
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6. LAD Stenosis:
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7. Right Coronary Stenosis:
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8. Circumflex Stenosis:
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9. LV Contraction Grade (from contrast
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or radionuclide angiogram or 2D echo):
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10. Mitral Regurgitation:
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II 0.45-0.54 MILD DYSFUNCTION
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III 0.35-0.44 MODERATE DYSFUNCTION
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IIIa 0.40-0.44 MODERATE DYSFUNCTION A
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IIIb
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IIIb 0.35-0.39 MODERATE DYSFUNCTION B
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IV 0.25-0.34 SEVERE DYSFUNCTION
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V <0.25 VERY SEVERE DYSFUNCTION
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NO LV STUDY
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This assessment has already been verified and transmitted. It cannot be
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deleted. If the assessment was transmitted in error, use the option 'Update
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an Assessment Transmitted in Error'.
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This assessment has already been verified. It cannot be deleted. If the
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assessment was verified in error, use the option 'Update an Assessment Verified
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in Error'.
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This assessment has a current status of
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Enter <RET> if this assessment was selected in error and should not be deleted.
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If you want to delete this assessment, enter 'YES'.
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Deleting Assessment...
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SUPERVISOR CODES: 1-STAFF CASE, 2-STAFF ASSISTED BY RESIDENT OR C.R.N.A., 3-STAFF ASSISTING C.R.N.A., 4-STAFF ASSISTING RESIDENT
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5-STAFF CONSULTING IN OR, 6-STAFF AVAILABLE IN OR SUITE, 7-STAFF AVAILABLE IN HOSP./UNIV. COMPLEX
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8-STAFF CALLED FOR EMERGENCY, 9-C.R.N.A. INDEPENDENT DUTY MD/DDS SUP.
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Anesthesia Provider Report
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Do you want to print the report for all Anesthesia Providers ? YES//
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Enter RETURN to print the report for all anesthesia providers, or 'NO'
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to select a specific anesthesia provider.
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Print the report for which Anesthesia Provider ?
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ANESTHESIA PROVIDER REPORT
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SRPRO*
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ASA CLASS
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LEVEL OF SUPERVISION
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RELIEF ANESTH
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PRINCIPAL TECHNIQUE
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ELAPSED ANES TIME
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ASST ANESTH
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ANESTHESIA AGENT
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Press RETURN to continue, '^' to quit
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Are you sure that you want to change the status of this assessment
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The Assessment Status has been changed to 'INCOMPLETE'.
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This assessment already has the status, 'INCOMPLETE'.
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Enter RETURN if the assessment was
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in error and the status
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should be changed to 'INCOMPLETE' to allow editing. Otherwise, enter 'NO'.
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ADD ON TODAY (NONEMERGENT)
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1. Exclusion Criteria:
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2. Surgical Priority:
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3. Surgical Specialty:
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4. Principal Operation (CPT):
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5. Principal Anesthesia Technique:
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6. Major or Minor:
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Select Excluded Case Information to Edit:
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2. Enter a number (1-6) to update the information in that field. (For
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example, enter '2' to update Surgical Priority)
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3. Enter a range of numbers (1-6) separated by a ':' to enter a range of
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information. (For example, enter '1:2' to update the Exclusion Criteria
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and Surgical Priority)
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Reason for not Creating an Assessment
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This selection loads the most recent lab data for tests performed
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within 90 days before the operation.
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Do you want to automatically load preoperative lab data ? YES//
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Enter <RET> to automatically load preoperative lab data from the patient's lab record, or 'NO' to return to the menu.
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Lab data NOT loaded.
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The 'Time the Operation Began' must be entered before continuing.
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..Searching lab record for latest preoperative test data....
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Do you want to enter 'Time the Operation Began' at this time ? YES//
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The time that the operation began must be entered prior to capturing the
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preoperative lab data. Enter 'YES' to input 'Time the Operation Began',
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or 'NO' to return to the menu.
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..Moving preoperative lab test data to Surgery Risk Assessment file....
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This selection loads highest or lowest lab data for tests performed within
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30 days after the operation.
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Do you want to automatically load postoperative lab data ? YES//
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Enter <RET> to automatically load postoperative lab data from the patient's lab record, or 'NO' to return to the menu.
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'Time the Operation Ends' must be entered before continuing.
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..Searching lab record for postoperative lab test data....
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Do you want to enter the time that the operation was completed at
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this time ? YES//
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Enter 'YES' to input 'Time the Operation Ends' or
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'NO' to return to the menu.
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..Moving postoperative lab data to Surgery Risk Assessment file....
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You must select a surgery risk assessment prior to using this option.
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Enter/Edit Laboratory Test Results
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1. Capture Preoperative Laboratory Information
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2. Capture Postoperative Laboratory Information
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3. Enter, Edit, or Review Laboratory Test Results
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Enter '1' if you want to capture preoperative laboratory test results from the
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DHCP Laboratory records. Enter '2' if you want to capture the postoperative
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laboratory test results from the DHCP Laboratory records. If you want to
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enter, edit, or review preoperative and postoperative laboratory test results,
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If you want to continue listing incomplete assessments, enter <RET>. Enter
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'^' to return to the menu.
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COMPLETED RISK ASSESSMENTS
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ASSESSMENT #
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OPERATION DATE
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PRINCIPAL OPERATION
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ANESTHESIA TECHNIQUE
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SURGERY SERVICE
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PRINCIPAL OPERATIVE PROCEDURE
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DATE COMPLETED
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** SURGICAL SPECIALTY:
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PAGE: 1 OF 2
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PREOP LABORATORY RESULTS
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LATEST PREOP LAB RESULTS IN 90 DAYS PRIOR TO SURGERY
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1. Serum Sodium:
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3. Serum Creatinine:
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4. Serum Albumin:
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5. Total Bilirubin:
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7. Alkaline Phosphatase:
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10. Platelet Count:
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Select Preoperative Laboratory Information to Edit:
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2. Enter a number (1-12) to update the information in that field. (For
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example, enter '2' to update Preoperative BUN)
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3. Enter a range of numbers (1-12) separated by a ':' to enter a range of
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BUN, and Serum Creatinine)
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Report of Monthly Case Workload Totals
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This option provides a report of the monthly risk assessment surgical case
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workload totals for the following categories:
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1. All cases performed
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2. Excluded cases
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3. Assessed cases
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4. Non-assessed cases
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5. Cardiac cases
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6. Non-cardiac cases
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7. Assessed cases per day (based on 20 days/month)
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This report may be printed and/or transmitted to the national database.
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Compile workload totals for which month and year?
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Enter the month and year for which to run this report,
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for example, 'MAY 94', 'MAY 1994', '5/94' or '5 94'.
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Compile totals for
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Do you want this report to be transmitted to the central database
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Enter YES to have this report automatically transmitted to the central
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database. Enter NO if you do NOT want this report transmitted.
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Do you also want to print this report
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Enter NO if you want to have this report transmitted, but do not want to
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have it printed. Enter YES if you do want to print the report as well as
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have it transmitted.
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Print report on which Device:
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Report of Surgical Case Workload
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Queue report to run at what date/time?
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One month ago, you had an operation at the VA Medical Center. We are
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interested in how you feel. Have you had any health problems since your
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operation ? We would like to hear from you. Please take a few minutes
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to answer these questions and return this letter in the self-addressed
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stamped envelope.
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Have you been to a hospital or seen a doctor for any reason since your
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If you answered NO, you do not need to answer any more questions. Please
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return this sheet in the self-addressed stamped envelope.
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If you have answered YES, please answer the following questions.
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1) Have you been seen in an outpatient clinic or doctor's office ?
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Why did you go to the clinic or doctor's office ? ________________
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Where ? (name and location) _____________________ Date ? ________
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Who was your doctor ? ____________________________________________
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2) Were you admitted to a hospital ? ___ Yes ___ No
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Why did you go to the hospital ? _________________________________
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Please return this letter whether or not you have had any medical problems.
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Your health and opinion are important to us. Thank You.
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Surgical Clinical Nurse Reviewer
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NO ASSESSMENT
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CPT CODE MISSING
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NON-ASSESSED MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
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ALL MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
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OPERATIVE PROCEDURE(S)
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ASSESSMENT STATUS
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EXCLUSION CRITERIA
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PRINCIPAL CPT CODE
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NON-ASSESSED MAJOR SURGICAL CASES
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ALL MAJOR SURGICAL CASES
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SRA,$J)
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TOTAL MAJOR CASES FOR ALL SPECIALTIES:
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If you want to continue listing assessments, enter <RET>. Enter '^' to
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return to the menu.
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TOTAL CASES FOR ALL SPECIALTIES:
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SURGICAL SPECIALTY:
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COMPLETED/TRANSMITTED ASSESSMENTS MISSING INFORMATION
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NON-CARDIAC
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Missing information:
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OPERATION(S)
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TOTAL FOR ALL SPECIALTIES:
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Select Postoperative Laboratory Information to Edit:
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example, enter '5' to update Highest Serum Creatinine)
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Lowest Serum Sodium, and Highest Potassium)
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POSTOP LAB RESULTS WITHIN 30 DAYS AFTER SURGERY
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1. Highest Serum Sodium:
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2. Lowest Serum Sodium:
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3. Highest Potassium:
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4. Lowest Potassium:
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5. Highest Serum Creatinine:
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6. Highest CPK:
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7. Highest CPK-MB Band:
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8. Highest Total Bilirubin:
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9. Highest WBC:
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10. Lowest Hematocrit:
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11. Highest Troponin I:
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12. Highest Troponin T:
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Select Operation:
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Enter the number corresponding to the surgical case for which you will be
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creating a surgical risk assessment.
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1. Enter Information
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2. Review Information
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3. Delete Surgery Case
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Select Number: 1//
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Enter RETURN or '1' to enter or edit information contained within one of the
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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