English French Notes Complete/Exclude entries contain no assessment information. The computer will then automatically merge those assessments for which the patient has only one surgical case and one surgery risk assessment for the date entered in the SURGERY RISK ASSESSMENT file (139). If the patient has more than one surgical case on that date, or if there is not any surgical case entered for the corresponding date in the SURGERY RISK ASSESSMENT file, that assessment will need to be manually matched. Risk Assessment Pre-Conversion: Deleting all entries from the SURGERY RISK ASSESSMENT file (139) which do not contain assessment information or have an operation date prior to the selected start date. NO ASSESS Entries in the SURGERY RISK ASSESSMENT file (139) which were deleted because they contained no assessment information, or had an operation date prior to the selected start date. DATE OF OPERATION: RISK ASSESSMENT ENTRIES NOT CONVERTED, NO ASSESSMENT INFORMATION RISK ASSESSMENT CONVERSION SROA CONVERT The following entries in the SURGERY RISK ASSESSMENT file (139) cannot be converted because the patient has no surgical cases entered in the SURGERY Deleting all Assessments in which the patient entered has no Surgery cases on file Automatically matching Risk Assessment entries with Surgery Cases The following assessments were matched with entries in the SURGERY file (130) based on the patient identifier and date of operation. Do you want to continue with the manual matching process now ? YES// SURGERY CASE NUMBER: SURGERY RISK ASSESSMENT ENTRIES AUTOMATICALLY CONVERTED Enter 'YES' if you want to continue converting assessments manually, or 'NO' ASSESSMENT NUMBER: There were no Surgery cases for within the 60 days before or after the date of operation entered in this assessment. Select the NUMBER corresponding to the Surgery Case that this Assessment matches: Enter the number that corresponds to the Surgery case that this assessment matches. If the assessment does not relate to any of the cases listed above, enter RETURN at the prompt. Are you sure that this is the correct Surgery Case ? YES// Enter 'YES' to convert the assessemnt into the Surgery file, or 'NO' to make another selection. Converting Risk Assessment Information... Do you want to match the Risk Assessment with this Surgical Case ? NO// Enter 'YES' to move the Risk Assessment information into this surgical case, or 'NO' if the information does not relate to this surgical case. Since this assessment cannot be matched to any Surgery case, it must be Enter 'YES' to delete this assessment from the SURGERY RISK ASSESSMENT file (139), or 'NO' to continue matching other assessments. Deleting assessment from SURGERY RISK ASSESSMENT file (139)... Queuing task to delete all SRA options from your system. Delete all SRA options from OPTION file (19) SROA RISK ASSESSMENT This option will self destruct now... 1. ATTENDING IN O.R. 2. ATTENDING IN O.R. SUITE 3. ATTEND NOT PRESENT, BUT AVAILABLE ATTENDING CODE NOT ENTERED POSTOPERATIVE DIAGNOSIS NOT ENTERED There are more cases for the date range selected. If you want to continue listing them, enter RETURN. Enter '^' to exit from this option. ATTENDING SURGEON REPORT 1ST ASST ATTENDING CODE 2ND ASST TOTAL CASES TOTAL CASES FROM 3. ATTENDING NOT PRESENT, BUT AVAILABLE * ATTENDING CODE NOT ENTERED ATTENDING SURGEON CUMULATIVE REPORT Enter RETURN to continue printing the report, or '^' to exit from this option. ATTENDING SURGEON: ZZ There are more cases for the date range listed. If you want to continue Enter RETURN if you want to display the totals for each specialty, or '^' to exit from this report. TOTAL CASES FOR THIS SPECIALTY CARDIAC ASSESSMENT TRANSMISSION COMPLETE RISK ASSESSMENT SCNR The Cardiac Surgery Risk Assessment Transmission was completed at assessment was sent. assessments were sent. OPERATION DATE: NO ICD9 RISK ASSESSMENT TRANSMISSION COMPLETE The Surgery Risk Assessment Transmission was completed at assessment was assessments were G.RISK ASSESSMENT@ISC-CHICAGO.VA.GOV Attending Surgeon Report Do you want to print the report for all Attending Surgeons ? YES// a specific person. Attending Surgeon Reports 1. Attending Surgeon Report 2. Attending Surgeon Cumulative Report 3. Attending Surgeon Report and Attending Surgeon Cumulative Report Select the number corresponding with the desired report(s): Start report for each attending surgeon on a new page ? Do you want the report for all Surgical Specialties ? YES// Enter 'YES' to print this report for all Surgical Specialties, or 'NO' to The Attending Surgeon Report was designed to use a 132 column format. The Attending Surgeon Cumulative Report was designed to use an 80 column format. Print the report on which Device ? Enter '1' if you want to print the Attending Surgeon Report only. If you only want to print the Attending Surgeon Cumulative Report, enter '2'. Enter '3' to print both reports. Print the Report for which Attending Surgeon ? Do you want to view the totals for attending codes only ? NO// Enter RETURN to dispay individual case information and the total number of cases for each code. If you only want to display the totals for the attending This report is designed to use an 80 column format. ZZ ATTENDING NOT ENTERED Enter RETURN to continue with this report, or '^' to quit this option. ZZ SPECIALTY NOT ENTERED This patient had a previous non-cardiac operation on Do you want to duplicate the preoperative information from the earlier assessment in this assessment? Anesthesia Technique Other Procedure CPT Code POSTOP OCCURRENCE DATE Date Noted on (Postop Occurrence) NO ICD9 CODE ENTERED Death Unrelated/Related Enter risk assessment preop information for this patient (Y/N) Will this procedure require cardiopulmonary bypass (Y/N) ? Enter Cardiac Preoperative information 1. Clinical Information 2. Cardiac Catheterization & Angiographic Data 3. Operative Risk Summary Data Enter the number of the selection to be edited. PREOPERATIVE LABORATORY TEST INFORMATION The SURGERY SITE PARAMETERS file indicates this site/division does not use the Cardiac Risk Assessment module. Therefore, this option is not available for use. Enter category of emergency. 1. Emergent (ongoing ischemia) 2. Emergent (hemodynamic compromise) 3. Emergent (arrest with CPR) Enter number (1, 2 or 3): Is this emergency case a cardiac procedure requiring cardiopulmonary This is the category of emergency reflecting the patient's cardiovascular condition at the time of transport to the operating room: 1. Emergent (ongoing ischemia) - Clinical condition mandates immediate surgery usually on day of catheterization because of ischemia despite medical therapy, such as intravenous nitroglycerine. Ischemia should be manifested as chest pain and/or ST-segment depression. 2. Emergent (hemodynamic compromise) - Persistent hypotension (arterial systolic pressure < 80 mm Hg) and/or low cardiac output (cardiac index < 2.0 L/min/MxM) despite iontropic and/or mechanical circulatory support mandates immediates surgery within hours of the cardiac 3. Emergent (arrest with CPR) - Patient is taken to the operating room in full cardiac arrest with the circulation supported by cardiopulmonary resuscitation (excludes patients being adequately perfused by a cardiopulmonary support system). Enter the appropriate number to designate the category of emergency. workload totals which include the following categories: 4. Not logged major cases The second part of this report provides the total number of incomplete assessments remaining for the month selected and the prior 12 months. REPORT OF MONTHLY SURGICAL CASE WORKLOAD TOTAL CASES PERFORMED TOTAL MAJOR CASES TOTAL MINOR CASES CASES MEETING EXCLUSION CRITERIA ANESTHESIA TYPE EXCEEDS MAX. ASSESSMENTS EXCEEDS MAXIMUM TURPS STUDY CRITERIA SCNR WAS ON A/L CONCURRENT CASE EXCEEDS MAXIMUM HERNIAS ASSESSED CASES NOT LOGGED MAJOR CASES CARDIAC CASES NON-CARDIAC CASES ASSESSED CASES PER DAY NUMBER OF INCOMPLETE ASSESSMENTS REMAINING FOR PAST YEAR SURGERY WORKLOAD .13///SAFETY STRAP Request Blood Availability (Y/N) Type and Crossmatch, Screen, or Autologous TYPE & CROSSMATCH REQUESTED BLOOD COMPONENTS: UNITS NOT ENTERED Report of Cancellations NOTE: This report contains all cancelled cases, including those that were cancelled after the patient had entered the operating room. Aborted cases are identified by an '*' next to the procedure name. Do you want to print the report for all Surgical Specialties ? YES// REPORT OF CANCELLATIONS Select An Additional Specialty: NO SPECIALTY ENTERED >> SURGICAL SPECIALTY: CANCEL DATE Update Cancelled Case No cancelled cases exist on this patient. Enter the number of the desired operation. Update Perioperative Occurrences for Individual Patient Attending Surgeon No Date of Operation found ! There are no perioperative occurrences recorded for the selected date range. SURGICAL SPECIALTY NOT ENTERED These reports are This report is designed to use a 132 column format. PERIOPERATIVE OCCURRENCES OCCURRENCE(S) - (DATE) OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH '*' Represents Postoperative Occurrences You do not have the access necessary to delete a case from the file. By deleting this case, all information stored for this occurrence will be removed from the computer. Enter 'YES' to delete this occurrence, or RETURN if you have made a mistake. Occurrence ... 2. Occurrence Category: 3. ICD Diagnosis Code: 4. Treatment Instituted: 5. Outcome to Date: 6. Date Noted: *** INFORMATION ENTERED *** . Occurrence Comments: Select Occurrence Information: Enter the number, or range of numbers you want to edit. Examples of proper 1. Enter 'A' to update all occurrence information. to update a specific occurrence element. (For example, enter '2' to update the occurrence category) 3. Enter a range of numbers separated by a ':' to enter a range of elements. (For example, enter '1:3' to enter occurrence, occurrence category, and ICD diagnosis code) The occurrence selected does not have a corresponding category. A category must be selected at this time, or the occurrence will be deleted. Select Occurrence Category: Enter 'YES' to delete this occurrence from the patient's record. Enter 'NO' to backup and enter a category for this occurrence. NOTE: You are about to enter an occurrence for a patient that has not had an operation during this admission. If this patient has a surgical procedure during the current admission, use the option to enter or edit intraoperative and postoperative occurrences. ENTER A NEW NON-OPERATIVE OCCURRENCE Enter the number of the desired occurrence, or ' ' to enter a new occurrence. Enter or Delete Data ? E// OCCURRENCE IN WHICH THERE WAS NO SURGICAL PROCEDURE DURING THE CURRENT ADMISSION Enter RETURN to select an option used to enter or edit information for this case. If you would like a two screen overview of this operation, enter 'Review'. To delete this surgical case from your records, Enter 'Delete'. Please note that choosing to delete a case will remove EVERYTHING pertaining will be removed from the computer. Select the Date of Occurrence: When entering a new non-operative occurrence, a date MUST be entered. Enter/Edit Intraoperative Postoperative Select a number ( ), or type 'NEW' to enter another occurrence: Select the number corresponding to the occurrence you want to update, or enter 'NEW' to add another occurrence. Occurrences entered for this case. Enter a New Since you have selected one of the 'OTHER' occurrence categories, an ICD Diagnosis Code should be entered for this occurrence. Select ICD Diagnosis Code Circulating Nurse Staffing Report Do you want the report for all nurses ? YES// Enter RETURN to print the Circulating Nurse Staffing Report for all nurses, or 'NO' to select a specific person. Select Circulating Nurse: CIRCULATING NURSE STAFFING REPORT NURSE* SCRUB NURSE CIRC. NURSE TIME IN TIME OUT ELAPSED (MINS) Enter the name of the drug you wish to flag This drug is already flagged for SURGERY. Do you want to remove the flag (Y/N) Do you want to flag this drug for SURGERY (Y/N) ANESTHESIA AGENT^50^.01 Enter the number which corresponds to the case that you want to enter comments. You have entered an invalid number, please select again. Date of Operation: Attending Surgeon: Attending Code: Principal Postop Preop Intraoperative Occurrences: Postoperative Occurrences: Related Returns to Surgery: Press RETURN to list more information, or '^' to leave this option. Outcome: Do you want to store this information in the concurrent case ? YES// There is a concurrent surgical case associated with this procedure. A brief description of that case is listed below. If you answer 'YES', the information you entered for this field will also be stored for the concurrent case. If this information is not pertinent for #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################