1 | English French Notes Complete/Exclude
|
---|
2 | 8. Other Procedures CPT Code:
|
---|
3 | 9. Preoperative Risk Factors:
|
---|
4 | 10. Cardiac Surgery to Non-VA Facility:
|
---|
5 | Select Operative Risk Summary Information to Edit:
|
---|
6 | 2. Enter the corresponding number to update the information in a particular
|
---|
7 | field. (For example, enter '3' to update Surgical Priority)
|
---|
8 | 3. Enter two numbers separated by a ':' to enter a range of information.
|
---|
9 | (For example, enter '1:2' to update Physician's Preoperative Estimate of
|
---|
10 | Mortality and ASA Classification.)
|
---|
11 | Enter/Edit Patient Resource Data
|
---|
12 | 1. Capture Information from PIMS Records
|
---|
13 | 2. Enter, Edit, or Review Information
|
---|
14 | Enter '1' if you want to capture patient information from PIMS
|
---|
15 | records. Enter '2' if you want to enter, edit, or review patient
|
---|
16 | other information on this screen.
|
---|
17 | No Study
|
---|
18 | Unable to determine
|
---|
19 | Remains intubated at 30 days
|
---|
20 | Remains in ICU at 30 days
|
---|
21 | Are you sure you want to retrieve information from PIMS records ?
|
---|
22 | 4. Enter 'N' or 'NO' to enter negative response for all items.
|
---|
23 | 5. Enter '@' to delete information from all items.
|
---|
24 | To identify the date and time the patient was discharged from intensive
|
---|
25 | care following surgery, see the following list of patient movements
|
---|
26 | that occurred during the inpatient stay associated with this surgery.
|
---|
27 | CABG Distal Anastomoses
|
---|
28 | 14. Cardiac Transplant:
|
---|
29 | 1. Number with Vein:
|
---|
30 | 15. Electrophysiologic Procedure:
|
---|
31 | 2. Number with IMA:
|
---|
32 | 16. Misc. Cardiac Procedures:
|
---|
33 | 3. Number with Radial Artery:
|
---|
34 | A. ASD Repair:
|
---|
35 | 4. Number with Other Artery:
|
---|
36 | B. VSD Repair:
|
---|
37 | 5. Number with Other Conduit:
|
---|
38 | C. Myxoma Resection:
|
---|
39 | D. Foreign Body Removal:
|
---|
40 | 6. Aortic Valve Replacement:
|
---|
41 | E. Myectomy for IHSS:
|
---|
42 | 7. Mitral Valve Replacement:
|
---|
43 | 8. Tricuspid Valve Replacement:
|
---|
44 | G. Other Tumor Resection:
|
---|
45 | 9. Valve Repair:
|
---|
46 | H. Other Procedure(s):
|
---|
47 | 10. LV Aneurysmectomy:
|
---|
48 | 17. Minimally Invasive Procedure:
|
---|
49 | 11. Great Vessel Repair (Req CPB):
|
---|
50 | 18. Batista Procedure:
|
---|
51 | 12. Total Ischemic Time:
|
---|
52 | 19. Incision Type:
|
---|
53 | 13. Total CPB Time:
|
---|
54 | 20. Convert Off Pump to CPB:
|
---|
55 | * Other Procedures List:
|
---|
56 | Miscellaneous Cardiac Procedures
|
---|
57 | Sure you want to delete all Misc. Cardiac Procedures information ?
|
---|
58 | 1. Operative Death:
|
---|
59 | 2. Date of Death:
|
---|
60 | 3. Perioperative MI:
|
---|
61 | 5. Renal Failure Requiring Dialysis:
|
---|
62 | 6. Low Cardiac Output > or = 6 Hours:
|
---|
63 | 8. Reoperation for Bleeding:
|
---|
64 | 9. On Ventilator > or = 48 Hours:
|
---|
65 | 10. Repeat Cardiopulmonary Bypass:
|
---|
66 | 13. Cardiac Arrest Requiring CPR:
|
---|
67 | PAGE: 2 OF 2
|
---|
68 | 1. WOUND COMPLICATIONS:
|
---|
69 | 4. CNS COMPLICATIONS:
|
---|
70 | A. Superficial Infection:
|
---|
71 | A. Cerebral Vascular Accident:
|
---|
72 | B. Deep Wound Infection:
|
---|
73 | C. Wound Dehiscence:
|
---|
74 | C. Neurological Deficits:
|
---|
75 | 2. RESPIRATORY COMPLICATIONS:
|
---|
76 | 5. CARDIAC COMPLICATIONS:
|
---|
77 | A. Arrest Requiring CPR:
|
---|
78 | B. Unplanned Intubation:
|
---|
79 | B. Myocardial Infarction:
|
---|
80 | C. Pulmonary Embolism:
|
---|
81 | C. Pulmonary Edema:
|
---|
82 | D. On Ventilator > 48 Hours:
|
---|
83 | 3. URINARY TRACT COMPLICATIONS:
|
---|
84 | 6. OTHER COMPLICATIONS:
|
---|
85 | A. Renal Insufficiency:
|
---|
86 | A. Ileus/Bowel Obstruction:
|
---|
87 | B. Acute Renal Failure:
|
---|
88 | C. Urinary Tract Infection:
|
---|
89 | C. Graft/Prosthesis Failure:
|
---|
90 | E. Systemic Sepsis:
|
---|
91 | mm Hg
|
---|
92 | 2. Aortic Systolic Pressure:
|
---|
93 | 3. *PA Systolic Pressure:
|
---|
94 | 4. *PAW Mean Pressure:
|
---|
95 | 5. Left Main Stenosis:
|
---|
96 | 6. LAD Stenosis:
|
---|
97 | 7. Right Coronary Stenosis:
|
---|
98 | 8. Circumflex Stenosis:
|
---|
99 | 9. LV Contraction Grade (from contrast
|
---|
100 | or radionuclide angiogram or 2D echo):
|
---|
101 | 10. Mitral Regurgitation:
|
---|
102 | II 0.45-0.54 MILD DYSFUNCTION
|
---|
103 | III 0.35-0.44 MODERATE DYSFUNCTION
|
---|
104 | IIIa 0.40-0.44 MODERATE DYSFUNCTION A
|
---|
105 | IIIb
|
---|
106 | IIIb 0.35-0.39 MODERATE DYSFUNCTION B
|
---|
107 | IV 0.25-0.34 SEVERE DYSFUNCTION
|
---|
108 | V <0.25 VERY SEVERE DYSFUNCTION
|
---|
109 | NO LV STUDY
|
---|
110 | This assessment has already been verified and transmitted. It cannot be
|
---|
111 | deleted. If the assessment was transmitted in error, use the option 'Update
|
---|
112 | an Assessment Transmitted in Error'.
|
---|
113 | This assessment has already been verified. It cannot be deleted. If the
|
---|
114 | assessment was verified in error, use the option 'Update an Assessment Verified
|
---|
115 | in Error'.
|
---|
116 | This assessment has a current status of
|
---|
117 | Enter <RET> if this assessment was selected in error and should not be deleted.
|
---|
118 | If you want to delete this assessment, enter 'YES'.
|
---|
119 | Deleting Assessment...
|
---|
120 | 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
|
---|
121 | 5-STAFF CONSULTING IN OR, 6-STAFF AVAILABLE IN OR SUITE, 7-STAFF AVAILABLE IN HOSP./UNIV. COMPLEX
|
---|
122 | 8-STAFF CALLED FOR EMERGENCY, 9-C.R.N.A. INDEPENDENT DUTY MD/DDS SUP.
|
---|
123 | Anesthesia Provider Report
|
---|
124 | Do you want to print the report for all Anesthesia Providers ? YES//
|
---|
125 | Enter RETURN to print the report for all anesthesia providers, or 'NO'
|
---|
126 | to select a specific anesthesia provider.
|
---|
127 | Print the report for which Anesthesia Provider ?
|
---|
128 | ANESTHESIA PROVIDER REPORT
|
---|
129 | SRPRO*
|
---|
130 | ASA CLASS
|
---|
131 | LEVEL OF SUPERVISION
|
---|
132 | RELIEF ANESTH
|
---|
133 | PRINCIPAL TECHNIQUE
|
---|
134 | ELAPSED ANES TIME
|
---|
135 | ASST ANESTH
|
---|
136 | ANESTHESIA AGENT
|
---|
137 | Press RETURN to continue, '^' to quit
|
---|
138 | Are you sure that you want to change the status of this assessment
|
---|
139 | The Assessment Status has been changed to 'INCOMPLETE'.
|
---|
140 | This assessment already has the status, 'INCOMPLETE'.
|
---|
141 | Enter RETURN if the assessment was
|
---|
142 | in error and the status
|
---|
143 | should be changed to 'INCOMPLETE' to allow editing. Otherwise, enter 'NO'.
|
---|
144 | ADD ON TODAY (NONEMERGENT)
|
---|
145 | 1. Exclusion Criteria:
|
---|
146 | 2. Surgical Priority:
|
---|
147 | 3. Surgical Specialty:
|
---|
148 | 4. Principal Operation (CPT):
|
---|
149 | 5. Principal Anesthesia Technique:
|
---|
150 | 6. Major or Minor:
|
---|
151 | Select Excluded Case Information to Edit:
|
---|
152 | 2. Enter a number (1-6) to update the information in that field. (For
|
---|
153 | example, enter '2' to update Surgical Priority)
|
---|
154 | 3. Enter a range of numbers (1-6) separated by a ':' to enter a range of
|
---|
155 | information. (For example, enter '1:2' to update the Exclusion Criteria
|
---|
156 | and Surgical Priority)
|
---|
157 | Reason for not Creating an Assessment
|
---|
158 | This selection loads the most recent lab data for tests performed
|
---|
159 | within 90 days before the operation.
|
---|
160 | Do you want to automatically load preoperative lab data ? YES//
|
---|
161 | Enter <RET> to automatically load preoperative lab data from the patient's lab record, or 'NO' to return to the menu.
|
---|
162 | Lab data NOT loaded.
|
---|
163 | The 'Time the Operation Began' must be entered before continuing.
|
---|
164 | ..Searching lab record for latest preoperative test data....
|
---|
165 | Do you want to enter 'Time the Operation Began' at this time ? YES//
|
---|
166 | The time that the operation began must be entered prior to capturing the
|
---|
167 | preoperative lab data. Enter 'YES' to input 'Time the Operation Began',
|
---|
168 | or 'NO' to return to the menu.
|
---|
169 | ..Moving preoperative lab test data to Surgery Risk Assessment file....
|
---|
170 | This selection loads highest or lowest lab data for tests performed within
|
---|
171 | 30 days after the operation.
|
---|
172 | Do you want to automatically load postoperative lab data ? YES//
|
---|
173 | Enter <RET> to automatically load postoperative lab data from the patient's lab record, or 'NO' to return to the menu.
|
---|
174 | 'Time the Operation Ends' must be entered before continuing.
|
---|
175 | ..Searching lab record for postoperative lab test data....
|
---|
176 | Do you want to enter the time that the operation was completed at
|
---|
177 | this time ? YES//
|
---|
178 | Enter 'YES' to input 'Time the Operation Ends' or
|
---|
179 | 'NO' to return to the menu.
|
---|
180 | ..Moving postoperative lab data to Surgery Risk Assessment file....
|
---|
181 | You must select a surgery risk assessment prior to using this option.
|
---|
182 | Enter/Edit Laboratory Test Results
|
---|
183 | 1. Capture Preoperative Laboratory Information
|
---|
184 | 2. Capture Postoperative Laboratory Information
|
---|
185 | 3. Enter, Edit, or Review Laboratory Test Results
|
---|
186 | Enter '1' if you want to capture preoperative laboratory test results from the
|
---|
187 | DHCP Laboratory records. Enter '2' if you want to capture the postoperative
|
---|
188 | laboratory test results from the DHCP Laboratory records. If you want to
|
---|
189 | enter, edit, or review preoperative and postoperative laboratory test results,
|
---|
190 | If you want to continue listing incomplete assessments, enter <RET>. Enter
|
---|
191 | '^' to return to the menu.
|
---|
192 | COMPLETED RISK ASSESSMENTS
|
---|
193 | ASSESSMENT #
|
---|
194 | OPERATION DATE
|
---|
195 | PRINCIPAL OPERATION
|
---|
196 | ANESTHESIA TECHNIQUE
|
---|
197 | SURGERY SERVICE
|
---|
198 | PRINCIPAL OPERATIVE PROCEDURE
|
---|
199 | DATE COMPLETED
|
---|
200 | ** SURGICAL SPECIALTY:
|
---|
201 | PAGE: 1 OF 2
|
---|
202 | PREOP LABORATORY RESULTS
|
---|
203 | LATEST PREOP LAB RESULTS IN 90 DAYS PRIOR TO SURGERY
|
---|
204 | 1. Serum Sodium:
|
---|
205 | 3. Serum Creatinine:
|
---|
206 | 4. Serum Albumin:
|
---|
207 | 5. Total Bilirubin:
|
---|
208 | 7. Alkaline Phosphatase:
|
---|
209 | 10. Platelet Count:
|
---|
210 | Select Preoperative Laboratory Information to Edit:
|
---|
211 | 2. Enter a number (1-12) to update the information in that field. (For
|
---|
212 | example, enter '2' to update Preoperative BUN)
|
---|
213 | 3. Enter a range of numbers (1-12) separated by a ':' to enter a range of
|
---|
214 | BUN, and Serum Creatinine)
|
---|
215 | Report of Monthly Case Workload Totals
|
---|
216 | This option provides a report of the monthly risk assessment surgical case
|
---|
217 | workload totals for the following categories:
|
---|
218 | 1. All cases performed
|
---|
219 | 2. Excluded cases
|
---|
220 | 3. Assessed cases
|
---|
221 | 4. Non-assessed cases
|
---|
222 | 5. Cardiac cases
|
---|
223 | 6. Non-cardiac cases
|
---|
224 | 7. Assessed cases per day (based on 20 days/month)
|
---|
225 | This report may be printed and/or transmitted to the national database.
|
---|
226 | Compile workload totals for which month and year?
|
---|
227 | Enter the month and year for which to run this report,
|
---|
228 | for example, 'MAY 94', 'MAY 1994', '5/94' or '5 94'.
|
---|
229 | Compile totals for
|
---|
230 | Do you want this report to be transmitted to the central database
|
---|
231 | Enter YES to have this report automatically transmitted to the central
|
---|
232 | database. Enter NO if you do NOT want this report transmitted.
|
---|
233 | Do you also want to print this report
|
---|
234 | Enter NO if you want to have this report transmitted, but do not want to
|
---|
235 | have it printed. Enter YES if you do want to print the report as well as
|
---|
236 | have it transmitted.
|
---|
237 | Print report on which Device:
|
---|
238 | Report of Surgical Case Workload
|
---|
239 | Queue report to run at what date/time?
|
---|
240 | One month ago, you had an operation at the VA Medical Center. We are
|
---|
241 | interested in how you feel. Have you had any health problems since your
|
---|
242 | operation ? We would like to hear from you. Please take a few minutes
|
---|
243 | to answer these questions and return this letter in the self-addressed
|
---|
244 | stamped envelope.
|
---|
245 | Have you been to a hospital or seen a doctor for any reason since your
|
---|
246 | If you answered NO, you do not need to answer any more questions. Please
|
---|
247 | return this sheet in the self-addressed stamped envelope.
|
---|
248 | If you have answered YES, please answer the following questions.
|
---|
249 | 1) Have you been seen in an outpatient clinic or doctor's office ?
|
---|
250 | Why did you go to the clinic or doctor's office ? ________________
|
---|
251 | Where ? (name and location) _____________________ Date ? ________
|
---|
252 | Who was your doctor ? ____________________________________________
|
---|
253 | 2) Were you admitted to a hospital ? ___ Yes ___ No
|
---|
254 | Why did you go to the hospital ? _________________________________
|
---|
255 | Please return this letter whether or not you have had any medical problems.
|
---|
256 | Your health and opinion are important to us. Thank You.
|
---|
257 | Surgical Clinical Nurse Reviewer
|
---|
258 | NO ASSESSMENT
|
---|
259 | CPT CODE MISSING
|
---|
260 | NON-ASSESSED MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
|
---|
261 | ALL MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
|
---|
262 | OPERATIVE PROCEDURE(S)
|
---|
263 | ASSESSMENT STATUS
|
---|
264 | EXCLUSION CRITERIA
|
---|
265 | PRINCIPAL CPT CODE
|
---|
266 | NON-ASSESSED MAJOR SURGICAL CASES
|
---|
267 | ALL MAJOR SURGICAL CASES
|
---|
268 | SRA,$J)
|
---|
269 | TOTAL MAJOR CASES FOR ALL SPECIALTIES:
|
---|
270 | If you want to continue listing assessments, enter <RET>. Enter '^' to
|
---|
271 | return to the menu.
|
---|
272 | TOTAL CASES FOR ALL SPECIALTIES:
|
---|
273 | SURGICAL SPECIALTY:
|
---|
274 | COMPLETED/TRANSMITTED ASSESSMENTS MISSING INFORMATION
|
---|
275 | NON-CARDIAC
|
---|
276 | Missing information:
|
---|
277 | OPERATION(S)
|
---|
278 | TOTAL FOR ALL SPECIALTIES:
|
---|
279 | Select Postoperative Laboratory Information to Edit:
|
---|
280 | example, enter '5' to update Highest Serum Creatinine)
|
---|
281 | Lowest Serum Sodium, and Highest Potassium)
|
---|
282 | POSTOP LAB RESULTS WITHIN 30 DAYS AFTER SURGERY
|
---|
283 | 1. Highest Serum Sodium:
|
---|
284 | 2. Lowest Serum Sodium:
|
---|
285 | 3. Highest Potassium:
|
---|
286 | 4. Lowest Potassium:
|
---|
287 | 5. Highest Serum Creatinine:
|
---|
288 | 6. Highest CPK:
|
---|
289 | 7. Highest CPK-MB Band:
|
---|
290 | 8. Highest Total Bilirubin:
|
---|
291 | 9. Highest WBC:
|
---|
292 | 10. Lowest Hematocrit:
|
---|
293 | 11. Highest Troponin I:
|
---|
294 | 12. Highest Troponin T:
|
---|
295 | Select Operation:
|
---|
296 | Enter the number corresponding to the surgical case for which you will be
|
---|
297 | creating a surgical risk assessment.
|
---|
298 | 1. Enter Information
|
---|
299 | 2. Review Information
|
---|
300 | 3. Delete Surgery Case
|
---|
301 | Select Number: 1//
|
---|
302 | Enter RETURN or '1' to enter or edit information contained within one of the
|
---|
303 | #################### #################### ####################
|
---|
304 | #################### #################### ####################
|
---|
305 | #################### #################### ####################
|
---|
306 | #################### #################### ####################
|
---|
307 | #################### #################### ####################
|
---|