| 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:
|
|---|
| 151 | G. Tumor Involving CNS:
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|---|
| 152 | I. Preoperative Sepsis:
|
|---|
| 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:
|
|---|
| 160 | CPT CODE - OPERATION
|
|---|
| 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
|
|---|
| 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//
|
|---|
| 171 | Enter 'YES' to change the status of this return from
|
|---|
| 172 | Enter 'NO' to leave the information unchanged.
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|---|
| 173 | SRSITE(
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|---|
| 174 | MEDICAL RECORD | ANESTHESIA REPORT
|
|---|
| 175 | ANESTHETIST'S SIG:
|
|---|
| 176 | Preop Status:
|
|---|
| 177 | Operating Room:
|
|---|
| 178 | Principal Operation:
|
|---|
| 179 | Anesthesia Technique(s):
|
|---|
| 180 | Agents:
|
|---|
| 181 | MONITORED ANESTHESIA CARE
|
|---|
| 182 | Intubated:
|
|---|
| 183 | Approach:
|
|---|
| 184 | Laryngoscope Type:
|
|---|
| 185 | Laryngoscope Size:
|
|---|
| 186 | Stylet Used:
|
|---|
| 187 | Lidocaine Topical:
|
|---|
| 188 | Lidocaine IV:
|
|---|
| 189 | Tube Type:
|
|---|
| 190 | Tube Size:
|
|---|
| 191 | Trauma:
|
|---|
| 192 | Extubated In:
|
|---|
| 193 | Extubated By:
|
|---|
| 194 | Reintubated within 8 Hours: YES
|
|---|
| 195 | Heat, Moisture Exchanger Used: YES
|
|---|
| 196 | Bacteria Filter in Circuit: YES
|
|---|
| 197 | Continuous:
|
|---|
| 198 | Baricity:
|
|---|
| 199 | Puncture Site:
|
|---|
| 200 | Needle Size:
|
|---|
| 201 | Modifiers: -
|
|---|
| 202 | -
|
|---|
| 203 | Other:
|
|---|
| 204 | Medications:
|
|---|
| 205 | Anesthesia Start:
|
|---|
| 206 | Anesthesia Stop:
|
|---|
| 207 | Anesthetist:
|
|---|
| 208 | Relief Anesth:
|
|---|
| 209 | Anesthesiologist:
|
|---|
| 210 | Attending Code:
|
|---|
| 211 | Assistant Anesth:
|
|---|
| 212 | Min Intraoperative Temp:
|
|---|
| 213 | Monitors:
|
|---|
| 214 | Blood Replacement Fluids:
|
|---|
| 215 | Intraoperative Blood Loss:
|
|---|
| 216 | Urine Output:
|
|---|
| 217 | Operation Disposition:
|
|---|
| 218 | PAC(U) Admit Score:
|
|---|
| 219 | PAC(U) Discharge Score:
|
|---|
| 220 | Postop Anesthesia Note:
|
|---|
| 221 | Intraoperative Complications:
|
|---|
| 222 | Postoperative Complications:
|
|---|
| 223 | Applied By:
|
|---|
| 224 | Installed:
|
|---|
| 225 | Source ID:
|
|---|
| 226 | VA ID:
|
|---|
| 227 | Ordered By:
|
|---|
| 228 | Admin By:
|
|---|
| 229 | Medication Comments:
|
|---|
| 230 | Agents:
|
|---|
| 231 | General Comments:
|
|---|
| 232 | Dural Puncture:
|
|---|
| 233 | Catheter Removed By:
|
|---|
| 234 | Date/Time Catheter Removed:
|
|---|
| 235 | Block Site:
|
|---|
| 236 | Needle Length:
|
|---|
| 237 | Needle Gauge:
|
|---|
| 238 | . ---- CREATE NEW ASSESSMENT
|
|---|
| 239 | There are no Surgery Risk Assessments entered for
|
|---|
| 240 | Press RETURN to continue.
|
|---|
| 241 | Select Surgical Case:
|
|---|
| 242 | Enter the number of the desired assessment.
|
|---|
| 243 | ' to create an
|
|---|
| 244 | assessment for another surgical case.
|
|---|
| 245 | You've selected a Cardiac assessment, using a Non-Cardiac Option,
|
|---|
| 246 | You've selected a Non-Cardiac assessment, using a Cardiac Option,
|
|---|
| 247 | 1. Enter Risk Assessment Information
|
|---|
| 248 | 2. Delete Risk Assessment Entry
|
|---|
| 249 | 3. Update Assessment Status to 'COMPLETE'
|
|---|
| 250 | Enter <RET> or '1' to enter or edit information related to this Risk
|
|---|
| 251 | Assessment entry. If you want to delete the Assessment, enter '2'.
|
|---|
| 252 | Enter '3' to update the status of this Assessment to 'COMPLETE'.
|
|---|
| 253 | This assessment has already been transmitted. The information contained
|
|---|
| 254 | in it cannot be altered unless you first change the status to 'INCOMPLETE'.
|
|---|
| 255 | Do you wish to change the status of this assessment to 'INCOMPLETE'
|
|---|
| 256 | ' to create a
|
|---|
| 257 | new risk assessment entry.
|
|---|
| 258 | is not an O.R. surgical procedure.
|
|---|
| 259 | There is no Surgery Risk Assessment entered for Case #
|
|---|
| 260 | Enter YES to batch print all completed or transmitted assessments for a
|
|---|
| 261 | selected date range. Enter NO or press return to print one specific
|
|---|
| 262 | Do you want to batch print assessments for a specific date range ?
|
|---|
| 263 | Convert existing assessments starting with which date ?
|
|---|
| 264 | The SURGERY RISK ASSSESSMENT file (139) still contains entries. Before you
|
|---|
| 265 | enter any additional risk assessment information, all entries in this file
|
|---|
| 266 | should be converted or deleted.
|
|---|
| 267 | The conversion process has been completed. Please review your incomplete
|
|---|
| 268 | The conversion of the
|
|---|
| 269 | Surgery Risk Assessment Module cannot
|
|---|
| 270 | be run until after April 1, 1994. It should only be run after that date
|
|---|
| 271 | if your Surgery files are complete, including complications, CPT codes and
|
|---|
| 272 | anesthesia information since installing Surgery Version 3.0.
|
|---|
| 273 | You must select a starting date to begin the conversion process. All
|
|---|
| 274 | assessments with operation dates prior to the start date will be automatically
|
|---|
| 275 | deleted. The remaining assessments will then be processed for conversion.
|
|---|
| 276 | The SURGERY RISK ASSESSMENT file will now be deleted from your system...
|
|---|
| 277 | This option is used to move the risk assessment data entered through the
|
|---|
| 278 | Surgery Risk Assessment Module into the DHCP Surgery pacakge.
|
|---|
| 279 | The computer will ask you to select a starting date to move the assessments.
|
|---|
| 280 | All assessments with an operation date prior to this start date will be deleted
|
|---|
| 281 | prior to converting the remaining entries. The software will then begin the
|
|---|
| 282 | conversion process. Upon completion of the conversion, there should be no
|
|---|
| 283 | entries in the SURGERY RISK ASSESSMENT file (139). The computer will then
|
|---|
| 284 | remove that file from your system.
|
|---|
| 285 | The conversion process will merge only those data elements that are not already
|
|---|
| 286 | part of the DHCP Surgery database. You should only convert the assessments if
|
|---|
| 287 | the information contained in your surgery database has been kept up to date.
|
|---|
| 288 | The following information will NOT be moved from the
|
|---|
| 289 | Risk Assessment Module:
|
|---|
| 290 | 1. Operative Procedures and CPT Codes
|
|---|
| 291 | 2. Diagnosis Information
|
|---|
| 292 | 4. ASA Classification
|
|---|
| 293 | 5. Anesthesia Technique
|
|---|
| 294 | 6. Concurrent Cases
|
|---|
| 295 | 7. Returns to Surgery
|
|---|
| 296 | All assessments that have been completed, but not transmitted will have their
|
|---|
| 297 | status changed to
|
|---|
| 298 | after they are converted. You should review
|
|---|
| 299 | these assessments to determine if any of the fields which are not merged need
|
|---|
| 300 | The conversion process will begin by deleting all assessments with a date of
|
|---|
| 301 | operation prior to the start date selected and all entries in the SURGERY RISK
|
|---|
| 302 | ASSESSMENT file (139) that have been entered for log purposes only. These
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
