| 1 | English French Notes Complete/Exclude
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| 2 | options found under the Operations Menu. If you want to display a two screen
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| 3 | overview of this case, enter '2'.
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| 4 | To delete this case from your records,
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| 5 | enter '3'. Please note that deleting a case will remove EVERYTHING pertaining
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| 6 | to this operative procedure.
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| 7 | List of Surgery Risk Assessments
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| 8 | 1. List of Incomplete Assessments
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| 9 | 2. List of Completed Assessments
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| 10 | 3. List of Transmitted Assessments
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| 11 | 4. List of Non-Assessed Major Surgical Cases
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| 12 | 5. List of All Major Surgical Cases
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| 13 | 6. List of All Surgical Cases
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| 14 | 7. List of Completed/Transmitted Assessments Missing Information
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| 15 | Select the Number of the Report Desired:
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| 16 | This report is designed to print to your terminal screen or a printer. When
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| 17 | using a printer, a 132 column format is used.
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| 18 | Print the List of Assessments to which Device:
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| 19 | Select the number corresponding to the type of report you want to print.
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| 20 | Print by Surgical Specialty ? YES//
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| 21 | Enter <RET> to print the report by surgical specialty, or 'N' to print
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| 22 | the report listing all surgical cases.
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| 23 | Print report for ALL specialties ? YES//
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| 24 | Enter <RET> to print the report for all surgical specialties, or 'N' to
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| 25 | print the report for a specific surgical specialty.
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| 26 | Print the Report for which Surgical Specialty:
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| 27 | ALL SURGICAL CASES BY SURGICAL SPECIALTY
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| 28 | ALL SURGICAL CASES
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| 29 | TRANSMITTED RISK ASSESSMENTS
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| 30 | TRANSMISSION DATE
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| 31 | Preoperative Information
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| 32 | Preoperative Laboratory Information
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| 33 | want to edit. Examples of proper responses are listed below.
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| 34 | Are you sure you want to delete all information
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| 35 | ANESTHESIA SERVICE
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| 36 | ANESTHESIA AMIS
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| 37 | DATE REVIEWED:
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| 38 | ANESTHETICS ADMINISTERED BY PRINCIPAL TECHNIQUE USED
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| 39 | TOTAL NO OF ANES- | | | | | |
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| 40 | THETICS ADMINISTERED | GENERAL | MAC | SPINAL | EPIDURAL | OTHER | LOCAL
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| 41 | Anesthesia AMIS
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| 42 | ANESTHETICS FOR PROCEDURES ADMINISTERED BY:
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| 43 | ** ANESTHETICS FOR DIAG. & THERA. PROCEDURES ADMINISTERED BY:
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| 44 | ANESTHESIOLOGIST | NURSE ANESTHETIST | OTHER
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| 45 | ** ANESTHESIOLOGIST | NURSE ANESTHETIST | OTHER
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| 46 | NUMBER OF | NO. OF | NUMBER OF | NO. OF | NUMBER OF | NO. OF
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| 47 | ** NUMBER OF | NO. OF | NUMBER OF | NO. OF | NUMBER OF | NO. OF
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| 48 | ANESTHETICS| DEATHS | ANESTHETICS | DEATHS | ANESTHETICS| DEATHS
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| 49 | DEATHS WITHIN 24 HOURS OF INDUCTION OF ANESTHETIC
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| 50 | TOTAL NUMBER
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| 51 | OF DEATHS
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| 52 | No operations exist for this patient. Assessment cannot be entered.
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| 53 | Enter the number of the desired operation
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| 54 | ' to enter a new case.
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| 55 | This case is currently flagged as meeting Risk Assessment exclusion criteria.
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| 56 | Are you sure that you want to create a Risk Assessment for this surgical
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| 57 | Enter 'YES' to create an assessment for this surgical case, or 'NO' to quit
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| 58 | Select Operation, or enter <RET> to continue listing Procedures:
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| 59 | An operation must be selected !
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| 60 | The following information is required for the Anesthesia AMIS and for Risk
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| 61 | Assessment.
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| 62 | Airway Index:
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| 63 | Would you like to enter additional anesthesia related information ? NO//
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| 64 | If you would like to enter anesthesia information in addition to what is
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| 65 | required for the Anesthesia AMIS, enter 'YES'. Enter RETURN to leave this
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| 66 | ANESTHESIA INFO
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| 67 | List of Anesthetic Procedures
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| 68 | Print List of Anesthetic Procedures for
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| 69 | 1. O.R. Surgical Procedures.
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| 70 | LIST OF ANESTHETIC PROCEDURES
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| 71 | Enter '1' or press <RET> to print the List of Anesthetic Procedures
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| 72 | performed in the OR with a surgical procedure. Enter '2' to print the
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| 73 | List of Anesthetic Procedures performed as or with a Non-OR Procedure.
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| 74 | Enter '3' to print the List of Anesthetic Procedures including both of
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| 75 | the above categories of procedures.
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| 76 | O.R. SURGICAL AND NON-O.R. PROCEDURES
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| 77 | PRIN ANESTHETIST
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| 78 | ANESTH TECHNIQUE
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| 79 | END TIME
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| 80 | ANESTH AGENT
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| 81 | INCOMPLETE RISK ASSESSMENTS
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| 82 | SRECIALTY NOT ENTERED
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| 83 | Select Postoperative Outcome:
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| 84 | 1. Enter 'A' to update all outcome information.
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| 85 | 2. Enter a number (1-3) to update an individual outcome element. (For
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| 86 | example, enter '1' to update all postoperative diagnosis)
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| 87 | 3. Enter a range of numbers (1-3) separated by a ':' to enter a range of
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| 88 | outcomes. (For example, enter '1:3' to enter postoperative diagnosis,
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| 89 | length of postoperative stay, and 30 day postoperative status)
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| 90 | 2. Enter a number (1-13) to update the information in that field. (For
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| 91 | example, enter '2' to update Principal Operation.)
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| 92 | 3. Enter a range of numbers (1-13) separated by a ':' to enter a range of
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| 93 | Principal Operation, and Principal CPT Code.)
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| 94 | Concurrent case information cannot be updated using the Risk Assessment
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| 95 | Module. To update the CPT code of a concurrent case, please use an option
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| 96 | contained within the Operation Menu.
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| 97 | Concurrent Procedure:
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| 98 | Surgeon:
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| 99 | 1. Surgical Specialty:
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| 100 | 2. Principal Operation:
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| 101 | 3. Principal CPT Code:
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| 102 | 4. Other Procedures:
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| 103 | 5. Concurrent Procedure:
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| 104 | 6. PGY of Primary Surgeon:
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| 105 | 7. Surgical Priority:
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| 106 | 8. Wound Classification:
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| 107 | 9. ASA Classification:
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| 108 | 10. Anesthesia Technique:
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| 109 | 11. RBC Units Transfused:
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| 110 | 12. Postop Diagnosis Code (ICD9):
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| 111 | 13. Major or Minor:
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| 112 | 1. Other Procedure (1):
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| 113 | CPT Code:
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| 114 | 2. Other Procedure (2):
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| 115 | 3. Other Procedure (3):
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| 116 | 4. Other Procedure (4):
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| 117 | 5. Other Procedure (5):
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| 118 | Select Other Operative Procedure Information:
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| 119 | 2. Enter a number (1-5) to update one specific procedure. For example,
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| 120 | enter '1' to update Other Procedure (1).
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| 121 | 3. Enter a range of numbers, separated by a ':' to update more than one
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| 122 | procedure. For example, enter '1:2' to enter Other Procedure (1) and
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| 123 | Other Procedure (2).
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| 124 | Other Operative Procedure (
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| 125 | DISCHARGED ALIVE
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| 126 | DIED IN HOSPITAL
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| 127 | REMAINS IN VAMC FACILITY
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| 128 | TRANSFERRED TO ANOTHER VAMC
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| 129 | 1. Postoperative Diagnosis Code (ICD9):
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| 130 | 2. Length of Postoperative Hospital Stay:
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| 131 | 3. 30 Day Postoperative Status:
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| 132 | Other Procedure (
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| 133 | Operation Date:
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| 134 | Ethnicity:
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| 135 | Race:
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| 136 | Transfer Status:
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| 137 | Observation
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| 138 | Hospital Admission Date:
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| 139 | Hospital Discharge Date:
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| 140 | Admitted/Transferred to Surgical Service:
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| 141 | Discharged/Transferred to Chronic Care:
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| 142 | In/Out-Patient Status:
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| 143 | Enter <RET> to continue printing the remaining pages of this assessment, or
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| 144 | '^' to exit this option.
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| 145 | VA CARDIAC RISK ASSESSMENT
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| 146 | VA NON-CARDIAC RISK ASSESSMENT Assessment:
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| 147 | All complications must be entered using the option contained within the
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| 148 | Complications Menu.
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| 149 | VA CARDIAC SURGERY RISK ASSESSMENT PROGRAM
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| 150 | Assessment Number:
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| 151 | Hospital Number:
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| 152 | Cardiac Surgery Performed at Non-VA Facility (but funded by VA):
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| 153 | I. CLINICAL DATA
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| 154 | Gender:
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| 155 | Resting ST Depression:
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| 156 | Functional Status:
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| 157 | PTCI:
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| 158 | Prior MI:
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| 159 | Diabetes:
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| 160 | Prior Heart Surgery:
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| 161 | COPD:
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| 162 | Peripheral Vascular Disease:
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| 163 | FEV1:
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| 164 | Cerebral Vascular Disease:
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| 165 | Cardiomegaly (X-ray):
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| 166 | Angina (use CCS Class):
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| 167 | Pulmonary Rales:
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| 168 | CHF (use NYHA Class):
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| 169 | Current Smoker:
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| 170 | Current Diuretic Use:
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| 171 | Creatinine:
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| 172 | Current Digoxin Use:
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| 173 | Hemoglobin:
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| 174 | IV NTG 48 Hours Preceding Surgery:
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| 175 | Serum Albumin:
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| 176 | Preop Use of IABP:
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| 177 | Active Endocarditis:
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| 178 | Hypertension:
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| 179 | II. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA
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| 180 | Cardiac Catheterization Date:
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| 181 | LVEDP:
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| 182 | Left Main Stenosis:
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| 183 | Aortic Systolic Pressure:
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| 184 | LAD Stenosis:
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| 185 | *PA Systolic Pressure:
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| 186 | Right Coronary Stenosis:
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| 187 | *PAW Mean Pressure:
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| 188 | Circumflex Stenosis:
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| 189 | Mitral Regurgitation:
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| 190 | LV Contraction Grade (from contrast or radionuclide angiogram or 2D Echo):
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| 191 | Ejection Fraction Range
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| 192 | Definition
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| 193 | III. OPERATIVE RISK SUMMARY DATA
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| 194 | (Operation Began:
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| 195 | Physician's Preoperative
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| 196 | (Operation Ended:
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| 197 | Estimate of Operative Mortality:
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| 198 | ASA Classification:
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| 199 | Surgical Priority:
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| 200 | CPT Code Missing
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| 201 | Principal CPT Code:
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| 202 | Other Procedures CPT Codes:
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| 203 | Preoperative Risk Factors:
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| 204 | II 0.45-0.54 MILD DYSFUNCTION
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| 205 | III 0.35-0.44 MODERATE DYSFUNCTION
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| 206 | IIIa 0.40-0.44 MODERATE DYSFUNCTION A
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| 207 | IIIb 0.35-0.39 MODERATE DYSFUNCTION B
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| 208 | IV 0.25-0.34 SEVERE DYSFUNCTION
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| 209 | V <0.25 VERY SEVERE DYSFUNCTION
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| 210 | IV. OPERATIVE DATA
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| 211 | Incision Type:
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| 212 | A. Cardiac Procedures Requiring Cardiopulmonary Bypass
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| 213 | Cardiac Transplant:
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| 214 | Number with Vein:
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| 215 | Electrophysiologic Procedure:
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| 216 | Number with IMA:
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| 217 | Misc. Cardiac Procedures
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| 218 | Number with Radial Artery:
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| 219 | ASD Repair:
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| 220 | Number with Other Artery:
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| 221 | VSD Repair:
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| 222 | Number with Other Conduit:
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| 223 | Myxoma Resection:
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| 224 | Aortic Valve Replacement:
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| 225 | Foreign Body Removal:
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| 226 | Mitral Valve Replacement:
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| 227 | Myectomy for IHSS:
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| 228 | Tricuspid Valve Replacement:
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| 229 | Pericardiectomy:
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| 230 | Valve Repair:
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| 231 | Other Tumor Resection:
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| 232 | LV Aneurysmectomy:
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| 233 | Minimally Invasive Procedure:
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| 234 | Great Vessel Repair (Req CPB):
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| 235 | Batista Procedure:
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| 236 | Total Ischemic Time (minutes):
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| 237 | Other Procedure(s):
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| 238 | Total CPB Time (minutes):
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| 239 | Convert Off Pump to CPB:
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| 240 | B. Operative Death:
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| 241 | Perioperative MI:
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| 242 | Reoperation for Bleeding:
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| 243 | Endocarditis:
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| 244 | On Ventilator > or = 48 Hours:
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| 245 | Renal Failure Requiring Dialysis:
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| 246 | Repeat Cardiopulmonary Bypass:
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| 247 | Low Cardiac Output > or = 6 Hours:
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| 248 | Coma > or = 24 Hours:
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| 249 | Mediastinitis:
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| 250 | Stroke/CVA:
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| 251 | Cardiac Arrest Requiring CPR:
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| 252 | Trachestomy:
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| 253 | Mechanical Circulatory Support:
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| 254 | V. RESOURCE DATA
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| 255 | Time Patient In OR:
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| 256 | Time Patient Out OR:
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| 257 | Date and Time Patient Extubated:
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| 258 | Date and Time Patient Discharged from ICU:
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| 259 | Resource Data Comments:
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| 260 | VI. Socioeconomic Data
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| 261 | Employment Status Preoperatively:
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| 262 | Race/Ethnic:
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| 263 | *** End of report for
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| 264 | VII. Guideline Compliance Indicators: Background Data
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| 265 | Primary care or referral VAMC identification code:
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| 266 | Follow-up VAMC identification code:
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| 267 | VIII. Detailed Laboratory Information - Assessment at Patient Discharge
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| 268 | Note: Laboratory data is collected at the time of assessment completion and
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| 269 | can not be edited by the nurse!!
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| 270 | HDL:
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| 271 | LDL:
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| 272 | Date of HDL:
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| 273 | Date of LDL:
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| 274 | Serum Triglyceride:
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| 275 | Total Cholesterol:
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| 276 | Date of Serum Trig.:
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| 277 | Date of Total Cholesterol:
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| 278 | Serum Potassium:
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| 279 | Date of Serum Potassium:
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| 280 | Serum Bilirubin:
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| 281 | Date of Serum Bilirubin:
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| 282 | IX. Detailed Discharge Information
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| 283 | Discharge ICD-9 Codes:
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| 284 | Discharge Disposition:
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| 285 | MCAR(691.1
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| 286 | Enter/Edit Patient Demographic Information
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| 287 | Enter '1' if you want to capture patient movement information from PIMS
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| 288 | movement and other information on this screen.
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| 289 | The Patient's Race and Ethnicity information cannot be updated through the
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| 290 | Surgery package options.
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| 291 | NOTE: Items 11 and 12 cannot be updated through the surgery package options.
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| 292 | 1. Enter 'A' to update items 1 through 10.
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| 293 | Cardiac
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| 294 | Sure you want to delete all
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| 295 | Select Preoperative Information to Edit:
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| 296 | 2. Enter a number (1-2) to update the information in that group. (For
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| 297 | example, enter '1' to update all Central Nervous System information)
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| 298 | update Impaired Sensorium, enter '1A')
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| 299 | 4. Enter a range of numbers (1-2) separated by a ':' to enter all
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| 300 | Central Nervous System and Nutritional/Immune/Other information.
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| 301 | 2. Enter a number (1-5) to update the information in that group. (For
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| 302 | example, enter '4' to update all cardiac information)
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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