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WV-DIALOG-0431.txt@ 1344

Last change on this file since 1344 was 604, checked in by George Lilly, 15 years ago
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File size: 11.6 KB

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

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