| [604] | 1 | English French Notes Complete/Exclude
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| 2 | update Current Pneumonia, enter '2C'.)
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| 3 | 4. Enter a range of numbers (1-5) separated by a ':' to enter a range of
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| 4 | occurrences. (For example, enter '2:4' to enter all pulmonary,
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| 5 | hepatobiliary, and cardiac information)
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| 6 | 5. Press <RET> to continue to page 2 of this option.
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| 7 | Pulmonary
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| 8 | Hepatobiliary
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| 9 | CENTRAL NERVOUS SYSTEM
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| 10 | Central Nervous System
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| 11 | NUTRITIONAL/IMMUNE/OTHER
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| 12 | Nutritional/Immune/Other
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| 13 | Deleting all
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| 14 | MINIMAL EXERTION
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| 15 | AT REST
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| 16 | TOTAL DEPENDENT
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| 17 | PREOPERATIVE INFORMATION
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| 18 | GENERAL:
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| 19 | HEPATOBILIARY:
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| 20 | Diabetes Mellitus:
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| 21 | Ascites:
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| 22 | Current Smoker W/I 1 Year:
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| 23 | Pack/Years:
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| 24 | ETOH > 2 Drinks/Day:
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| 25 | CARDIAC:
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| 26 | Dyspnea:
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| 27 | CHF Within 1 Month:
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| 28 | DNR Status:
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| 29 | Functional Status:
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| 30 | RENAL:
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| 31 | Acute Renal Failure:
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| 32 | PULMONARY:
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| 33 | Currently on Dialysis:
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| 34 | Ventilator Dependent:
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| 35 | History of Severe COPD:
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| 36 | Current Pneumonia:
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| 37 | CENTRAL NERVOUS SYSTEM:
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| 38 | NUTRITIONAL/IMMUNE/OTHER:
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| 39 | Impaired Sensorium:
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| 40 | Disseminated Cancer:
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| 41 | Coma:
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| 42 | Open Wound:
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| 43 | Hemiplegia:
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| 44 | Steroid Use for Chronic Cond.:
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| 45 | History of TIAs:
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| 46 | Weight Loss > 10%:
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| 47 | CVA/Residual Neuro Deficit:
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| 48 | Bleeding Disorders:
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| 49 | CVA/No Neuro Deficit:
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| 50 | Transfusion > 4 RBC Units:
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| 51 | Tumor Involving CNS:
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| 52 | Chemotherapy W/I 30 Days:
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| 53 | Radiotherapy W/I 90 Days:
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| 54 | Preoperative Sepsis:
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| 55 | OPERATIVE INFORMATION
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| 56 | Surgical Specialty:
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| 57 | Principal Operation:
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| 58 | PGY of Primary Surgeon:
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| 59 | Emergency Case (Y/N):
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| 60 | Major or Minor:
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| 61 | Wound Classification:
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| 62 | ASA Classification:
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| 63 | Anesthesia Technique:
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| 64 | Airway Trauma:
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| 65 | RBC Units Transfused:
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| 66 | OPERATION DATE/TIMES INFORMATION
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| 67 | Date/Time Patient in OR:
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| 68 | Date/Time Operation Began:
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| 69 | Date/Time Operation Ended:
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| 70 | Date/Time Patient Out of OR:
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| 71 | Anesthesia Care Start Date/Time:
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| 72 | Anesthesia Care End Date/Time:
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| 73 | PACU Discharge Date/Time:
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| 74 | PREOPERATIVE LABORATORY TEST RESULTS
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| 75 | Serum Sodium:
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| 76 | Serum Creatinine:
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| 77 | BUN:
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| 78 | Serum Albumin:
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| 79 | Total Bilirubin:
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| 80 | SGOT:
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| 81 | Alkaline Phosphatase:
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| 82 | White Blood Count:
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| 83 | Hematocrit:
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| 84 | Platelet Count:
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| 85 | PTT:
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| 86 | PT:
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| 87 | POSTOPERATIVE LABORATORY RESULTS
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| 88 | * Highest Value
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| 89 | ** Lowest Value
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| 90 | * Serum Sodium:
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| 91 | ** Serum Sodium:
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| 92 | * Serum Creatinine:
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| 93 | * CPK-MB Band:
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| 94 | * Total Bilirubin:
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| 95 | * White Blood Count:
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| 96 | OUTCOME INFORMATION
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| 97 | Postoperative Diagnosis Code (ICD9):
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| 98 | Length of Postoperative Hospital Stay:
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| 99 | Death Unrelated/Related:
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| 100 | Return to OR Within 30 Days:
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| 101 | NO DATE
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| 102 | PERIOPERATIVE OCCURRENCE INFORMATION
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| 103 | WOUND OCCURRENCES:
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| 104 | CNS OCCURRENCES:
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| 105 | Superficial Infection:
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| 106 | Deep Wound Infection:
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| 107 | Coma > 24 Hours:
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| 108 | Wound Disruption:
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| 109 | Peripheral Nerve Injury:
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| 110 | URINARY TRACT OCCURRENCES:
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| 111 | CARDIAC OCCURRENCES:
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| 112 | Renal Insufficiency:
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| 113 | Arrest Requiring CPR:
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| 114 | Myocardial Infarction:
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| 115 | Urinary Tract Infection:
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| 116 | RESPIRATORY OCCURRENCES:
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| 117 | OTHER OCCURRENCES:
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| 118 | Pneumonia:
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| 119 | Ileus/Bowel Obstruction:
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| 120 | Unplanned Intubation:
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| 121 | Bleeding/Transfusions:
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| 122 | Pulmonary Embolism:
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| 123 | Graft/Prosthesis/Flap Failure:
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| 124 | On Ventilator > 48 Hours:
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| 125 | DVT/Thrombophlebitis:
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| 126 | Systemic Sepsis:
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| 127 | * indicates Other (ICD9)
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| 128 | MINIMAL EXERTION
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| 129 | AT REST
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| 130 | A. Diabetes Mellitus:
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| 131 | B. Current Smoker W/I 1 Year:
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| 132 | A. CHF Within 1 Month:
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| 133 | F. DNR Status:
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| 134 | G. Functional Status:
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| 135 | A. Acute Renal Failure:
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| 136 | B. Currently on Dialysis:
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| 137 | A. Ventilator Dependent:
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| 138 | B. History of Severe COPD:
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| 139 | C. Current Pneumonia:
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| 140 | 1. CENTRAL NERVOUS SYSTEM:
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| 141 | A. Impaired Sensorium:
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| 142 | A. Disseminated Cancer:
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| 143 | B. Open Wound:
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| 144 | C. Steroid Use for Chronic Cond.:
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| 145 | D. History of TIAs:
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| 146 | D. Weight Loss > 10%:
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| 147 | E. CVA/Residual Neuro Deficit:
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| 148 | E. Bleeding Disorders:
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| 149 | F. CVA/No Neuro Deficit:
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| 150 | F. Transfusion > 4 RBC Units:
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| 151 | G. Tumor Involving CNS:
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| 152 | I. Preoperative Sepsis:
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| 153 | Annual Report of Surgical Procedures
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| 154 | Do you want to print the Annual Report of Surgical Procedures for all
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| 155 | Print the Annual Report for which Specialty ?
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| 156 | This report must be run on a printer. Please select another device.
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| 157 | ANNUAL REPORT OF SURGICAL PROCEDURES
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| 158 | Press RETURN to continue or '^' to quit.
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| 159 | TOTAL OPERATIONS:
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| 160 | CPT CODE - OPERATION
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| 161 | TOTALS FOR
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| 162 | There are no surgical cases entered for
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| 163 | within 30 days of this operation.
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| 164 | RETURNS TO SURGERY
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| 165 | Select the number corresponding to the return which you want to update, or
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| 166 | enter RETURN to quit this option.
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| 167 | CPT MISSING
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| 168 | This return to surgery is currently defined as
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| 169 | to the case selected.
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| 170 | Do you want to change this status ? NO//
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| 171 | Enter 'YES' to change the status of this return from
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| 172 | Enter 'NO' to leave the information unchanged.
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| 173 | SRSITE(
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| 174 | MEDICAL RECORD | ANESTHESIA REPORT
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| 175 | ANESTHETIST'S SIG:
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| 176 | Preop Status:
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| 177 | Operating Room:
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| 178 | Principal Operation:
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| 179 | Anesthesia Technique(s):
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| 180 | Agents:
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| 181 | MONITORED ANESTHESIA CARE
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| 182 | Intubated:
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| 183 | Approach:
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| 184 | Laryngoscope Type:
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| 185 | Laryngoscope Size:
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| 186 | Stylet Used:
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| 187 | Lidocaine Topical:
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| 188 | Lidocaine IV:
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| 189 | Tube Type:
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| 190 | Tube Size:
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| 191 | Trauma:
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| 192 | Extubated In:
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| 193 | Extubated By:
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| 194 | Reintubated within 8 Hours: YES
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| 195 | Heat, Moisture Exchanger Used: YES
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| 196 | Bacteria Filter in Circuit: YES
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| 197 | Continuous:
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| 198 | Baricity:
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| 199 | Puncture Site:
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| 200 | Needle Size:
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| 201 | Modifiers: -
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| 202 | -
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| 203 | Other:
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| 204 | Medications:
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| 205 | Anesthesia Start:
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| 206 | Anesthesia Stop:
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| 207 | Anesthetist:
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| 208 | Relief Anesth:
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| 209 | Anesthesiologist:
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| 210 | Attending Code:
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| 211 | Assistant Anesth:
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| 212 | Min Intraoperative Temp:
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| 213 | Monitors:
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| 214 | Blood Replacement Fluids:
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| 215 | Intraoperative Blood Loss:
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| 216 | Urine Output:
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| 217 | Operation Disposition:
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| 218 | PAC(U) Admit Score:
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| 219 | PAC(U) Discharge Score:
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| 220 | Postop Anesthesia Note:
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| 221 | Intraoperative Complications:
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| 222 | Postoperative Complications:
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| 223 | Applied By:
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| 224 | Installed:
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| 225 | Source ID:
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| 226 | VA ID:
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| 227 | Ordered By:
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| 228 | Admin By:
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| 229 | Medication Comments:
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| 230 | Agents:
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| 231 | General Comments:
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| 232 | Dural Puncture:
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| 233 | Catheter Removed By:
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| 234 | Date/Time Catheter Removed:
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| 235 | Block Site:
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| 236 | Needle Length:
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| 237 | Needle Gauge:
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| 238 | . ---- CREATE NEW ASSESSMENT
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| 239 | There are no Surgery Risk Assessments entered for
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| 240 | Press RETURN to continue.
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| 241 | Select Surgical Case:
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| 242 | Enter the number of the desired assessment.
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| 243 | ' to create an
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| 244 | assessment for another surgical case.
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| 245 | You've selected a Cardiac assessment, using a Non-Cardiac Option,
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| 246 | You've selected a Non-Cardiac assessment, using a Cardiac Option,
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| 247 | 1. Enter Risk Assessment Information
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| 248 | 2. Delete Risk Assessment Entry
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| 249 | 3. Update Assessment Status to 'COMPLETE'
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| 250 | Enter <RET> or '1' to enter or edit information related to this Risk
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| 251 | Assessment entry. If you want to delete the Assessment, enter '2'.
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| 252 | Enter '3' to update the status of this Assessment to 'COMPLETE'.
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| 253 | This assessment has already been transmitted. The information contained
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| 254 | in it cannot be altered unless you first change the status to 'INCOMPLETE'.
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| 255 | Do you wish to change the status of this assessment to 'INCOMPLETE'
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| 256 | ' to create a
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| 257 | new risk assessment entry.
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| 258 | is not an O.R. surgical procedure.
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| 259 | There is no Surgery Risk Assessment entered for Case #
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| 260 | Enter YES to batch print all completed or transmitted assessments for a
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| 261 | selected date range. Enter NO or press return to print one specific
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| 262 | Do you want to batch print assessments for a specific date range ?
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| 263 | Convert existing assessments starting with which date ?
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| 264 | The SURGERY RISK ASSSESSMENT file (139) still contains entries. Before you
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| 265 | enter any additional risk assessment information, all entries in this file
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| 266 | should be converted or deleted.
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| 267 | The conversion process has been completed. Please review your incomplete
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| 268 | The conversion of the
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| 269 | Surgery Risk Assessment Module cannot
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| 270 | be run until after April 1, 1994. It should only be run after that date
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| 271 | if your Surgery files are complete, including complications, CPT codes and
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| 272 | anesthesia information since installing Surgery Version 3.0.
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| 273 | You must select a starting date to begin the conversion process. All
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| 274 | assessments with operation dates prior to the start date will be automatically
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| 275 | deleted. The remaining assessments will then be processed for conversion.
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| 276 | The SURGERY RISK ASSESSMENT file will now be deleted from your system...
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| 277 | This option is used to move the risk assessment data entered through the
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| 278 | Surgery Risk Assessment Module into the DHCP Surgery pacakge.
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| 279 | The computer will ask you to select a starting date to move the assessments.
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| 280 | All assessments with an operation date prior to this start date will be deleted
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| 281 | prior to converting the remaining entries. The software will then begin the
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| 282 | conversion process. Upon completion of the conversion, there should be no
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| 283 | entries in the SURGERY RISK ASSESSMENT file (139). The computer will then
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| 284 | remove that file from your system.
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| 285 | The conversion process will merge only those data elements that are not already
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| 286 | part of the DHCP Surgery database. You should only convert the assessments if
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| 287 | the information contained in your surgery database has been kept up to date.
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| 288 | The following information will NOT be moved from the
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| 289 | Risk Assessment Module:
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| 290 | 1. Operative Procedures and CPT Codes
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| 291 | 2. Diagnosis Information
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| 292 | 4. ASA Classification
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| 293 | 5. Anesthesia Technique
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| 294 | 6. Concurrent Cases
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| 295 | 7. Returns to Surgery
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| 296 | All assessments that have been completed, but not transmitted will have their
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| 297 | status changed to
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| 298 | after they are converted. You should review
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| 299 | these assessments to determine if any of the fields which are not merged need
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| 300 | The conversion process will begin by deleting all assessments with a date of
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| 301 | operation prior to the start date selected and all entries in the SURGERY RISK
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| 302 | ASSESSMENT file (139) that have been entered for log purposes only. These
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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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