| 1 | English French Notes Complete/Exclude
|
|---|
| 2 | C. Pulmonary Embolism
|
|---|
| 3 | C. Peripheral Nerve Injury
|
|---|
| 4 | D. On Ventilator >48 Hours
|
|---|
| 5 | Cardiac Occurrences Total Other Occurrences Total
|
|---|
| 6 | A. Cardiac Arrest Req. CPR
|
|---|
| 7 | A. Ileus/Bowel Obstruction
|
|---|
| 8 | B. Myocardial Infarction
|
|---|
| 9 | D. Low Cardiac Output >6 Hrs.
|
|---|
| 10 | F. Repeat Card-Pul Bypass
|
|---|
| 11 | E. Systemic Sepsis
|
|---|
| 12 | F. Reoperation for Bleeding
|
|---|
| 13 | Clean Wound Infection Rate:
|
|---|
| 14 | Report of Missing Quarterly Report Data
|
|---|
| 15 | For surgical cases with an entry in the TIME PAT IN OR field and that are not
|
|---|
| 16 | aborted, this option generates a report of cases missing any of the following
|
|---|
| 17 | pieces of information used by the Quarterly Report:
|
|---|
| 18 | In/Out-Patient Status
|
|---|
| 19 | Major/Minor
|
|---|
| 20 | Case Schedule Type
|
|---|
| 21 | Attending Code
|
|---|
| 22 | Time Pat Out OR
|
|---|
| 23 | Wound Classification
|
|---|
| 24 | ASA Class
|
|---|
| 25 | CPT Code (Principal)
|
|---|
| 26 | CPT Code (Other)
|
|---|
| 27 | Report of Missing Data for Quarterly Report
|
|---|
| 28 | TOTAL CASES MISSING DATA:
|
|---|
| 29 | MISSING ITEMS
|
|---|
| 30 | MISSING ITEMS CODES: A-IN/OUT-PATIENT STATUS, B-MAJOR/MINOR, C-CASE SCHEDULE TYPE, D-ATTENDING CODE,
|
|---|
| 31 | E-TIME PAT OUT OR, F-WOUND CLASSIFICATION, G-ASA CLASS, H-CPT CODE (PRINCIPAL), I-CPT CODE (OTHER)
|
|---|
| 32 | QUARTERLY REPORT TRANSMISSION
|
|---|
| 33 | The Quarterly Report for quarter #
|
|---|
| 34 | transmitted to the central database of Surgical Service, VHA Headquarters.
|
|---|
| 35 | Queue report to run at what date/time ?
|
|---|
| 36 | Enter/Edit Information for which Operating Room ?
|
|---|
| 37 | CANCELLATION RATE FOR SCHEDULED CASES:
|
|---|
| 38 | AVOIDABLE CANCELLATION RATE FOR SCHEDULED CASES:
|
|---|
| 39 | AVOIDABLE CANCELLATION RATE FOR CANCELLED CASES:
|
|---|
| 40 | TOTAL SCHEDULED SURGICAL CASES:
|
|---|
| 41 | TOTAL CANCELLATIONS
|
|---|
| 42 | ZZNO REASON ENTERED
|
|---|
| 43 | CANCELLATION RATE REPORT
|
|---|
| 44 | CANCELLATION REASON
|
|---|
| 45 | TOTAL CANCELS
|
|---|
| 46 | TOTAL AVOIDABLE
|
|---|
| 47 | TOTAL SURGICAL CASES SCHEDULED FOR
|
|---|
| 48 | CANCELLATION RATE REPORT, SPECIALTY SUMMARY
|
|---|
| 49 | PERCENT AVOIDABLE CANCELLATIONS
|
|---|
| 50 | SCHEDULED CASES CANCELLED CASES
|
|---|
| 51 | TOTAL DELAY REASONS
|
|---|
| 52 | Enter RETURN to continue displaying the delay reasons for the entire
|
|---|
| 53 | medical center.
|
|---|
| 54 | REPORT OF DELAY REASONS
|
|---|
| 55 | TOTAL DELAYS FOR
|
|---|
| 56 | Report of Delay Reasons
|
|---|
| 57 | Do you want to print the Report of Delay Reasons for all Surgical
|
|---|
| 58 | Do you want to display the totals for each Surgical Specialty ? YES//
|
|---|
| 59 | Enter RETURN to display the totals for delay reasons for each specialty. If
|
|---|
| 60 | you want to display the totals for all delay reasons for the entire medical
|
|---|
| 61 | Print Requests for which Surgical Specialty ?
|
|---|
| 62 | Print the Requests on which Device:
|
|---|
| 63 | OPERATION REQUESTS
|
|---|
| 64 | OPERATION REQUESTS FOR
|
|---|
| 65 | Press <RET to continue, or '^' to quit:
|
|---|
| 66 | Req. Anesthesia Technique:
|
|---|
| 67 | OPERATION REQUESTS (SHORT FORM)
|
|---|
| 68 | Requested Anesthesia:
|
|---|
| 69 | Concurrent Case #
|
|---|
| 70 | Case Schedule Order:
|
|---|
| 71 | REQUESTS FOR
|
|---|
| 72 | A surgical case has not been entered.
|
|---|
| 73 | Enter/Edit Irrigations or Restraints and Positioning Aids:
|
|---|
| 74 | 2. Restraints and Positioning Aids
|
|---|
| 75 | Type '1' to enter irrigation solutions, or '2' to enter restraints
|
|---|
| 76 | or positioning aids.
|
|---|
| 77 | Restraints and Positioning Aids
|
|---|
| 78 | Operating Room Reservations:
|
|---|
| 79 | Scheduled Start:
|
|---|
| 80 | Scheduled End:
|
|---|
| 81 | Report of Returns to Surgery
|
|---|
| 82 | This report will list cases completed during the date range entered that
|
|---|
| 83 | have had return cases associated with them. It is designed to use a 132
|
|---|
| 84 | column format.
|
|---|
| 85 | REPORT OF RETURNS TO SURGERY
|
|---|
| 86 | RETURNS TO SURGERY:
|
|---|
| 87 | Operating Room Normal Working Hours Report
|
|---|
| 88 | Print normal working hours starting with which date ?
|
|---|
| 89 | Print normal working hours through which date ?
|
|---|
| 90 | The ending date must be more recent than the starting date.
|
|---|
| 91 | Do you want to print the Operating Room Normal Working Hours Report for all
|
|---|
| 92 | operating rooms ? YES//
|
|---|
| 93 | Enter RETURN if you want to print the normal working hours for every operating
|
|---|
| 94 | room, or 'NO' to print the report for one particular room.
|
|---|
| 95 | Print the report for which Operating Room ?
|
|---|
| 96 | O.R. Normal Working Hours Report
|
|---|
| 97 | OPERATING ROOM NORMAL WORKING HOURS
|
|---|
| 98 | ** OPERATING ROOM:
|
|---|
| 99 | The start and end times for each operating room for the above dates have been
|
|---|
| 100 | entered with default start and end times. Do you still want to print the
|
|---|
| 101 | report even though the start and end times might be inaccurate ? NO//
|
|---|
| 102 | Enter RETURN if you want to update the start and end times to accurately
|
|---|
| 103 | reflect utilization, or 'YES' to print the report with the days listed
|
|---|
| 104 | having the default start and end times.
|
|---|
| 105 | The following dates are missing start and end times for all operating rooms.
|
|---|
| 106 | The times will be automatically entered.
|
|---|
| 107 | This date is a holiday, some/all Operating Rooms and Specialties
|
|---|
| 108 | may have been inactivated.
|
|---|
| 109 | Start Times and End Times Entered.
|
|---|
| 110 | The Utilization Report can not be generated with incomplete dates.
|
|---|
| 111 | Press RETURN to exit the option
|
|---|
| 112 | Number of Returns to O.R. Related to Index Procedure:
|
|---|
| 113 | Number of Returns to O.R. Unrelated to Index Procedure:
|
|---|
| 114 | Operating Room Utilization Report
|
|---|
| 115 | Print utilization information starting with which date ?
|
|---|
| 116 | Print utilization information through which date ?
|
|---|
| 117 | Do you want to print the Operating Room Utilization Report for all
|
|---|
| 118 | Enter RETURN if you want to print utilization information for every operating
|
|---|
| 119 | Print the Operating Room Utilization Report on which Device ?
|
|---|
| 120 | OPERATING ROOM UTILIZATION REPORT
|
|---|
| 121 | ALL OPERATING ROOMS
|
|---|
| 122 | -
|
|---|
| 123 | PERCENT UTILIZATION
|
|---|
| 124 | NUMBER OF CASES
|
|---|
| 125 | TOTAL OPERATION TIME
|
|---|
| 126 | TIME WORKED OUTSIDE NORMAL HRS
|
|---|
| 127 | (INCLUDING OR MAINTENANCE)
|
|---|
| 128 | TOTAL UTILIZATION FOR
|
|---|
| 129 | ALL ROOMS
|
|---|
| 130 | TOTAL CASES SCHEDULED:
|
|---|
| 131 | No operations scheduled for this date.
|
|---|
| 132 | MONITORED ANES
|
|---|
| 133 | TO BE ADMITTED
|
|---|
| 134 | UNITS NOT ENTERED
|
|---|
| 135 | Print Schedule of Operations for which date ?
|
|---|
| 136 | Schedule will be queued to print at all locations defined in the SURGERY
|
|---|
| 137 | SITE PARAMETERS file....
|
|---|
| 138 | SCHEDULE OF OPERATIONS
|
|---|
| 139 | SIGNATURE OF CHIEF:
|
|---|
| 140 | REQ ANESTHESIA
|
|---|
| 141 | ** Concurrent Case #
|
|---|
| 142 | Do you want to print the schedule at all locations ? NO//
|
|---|
| 143 | Enter RETURN to select a specific printer, or 'YES' to print the Schedule of
|
|---|
| 144 | Operations on all of the printers specified in your SURGERY SITE
|
|---|
| 145 | PARAMETERS file.
|
|---|
| 146 | FROZEN SECTION TESTS REQUIRED
|
|---|
| 147 | PREOPERATIVE XRAYS:
|
|---|
| 148 | INTRAOPERATIVE X-RAYS REQUESTED
|
|---|
| 149 | C-ARM REQUESTED
|
|---|
| 150 | INTRAOPERATIVE X-RAYS REQUESTED
|
|---|
| 151 | C-ARM REQUESTED
|
|---|
| 152 | Scrub Nurse Staffing Report
|
|---|
| 153 | Enter RETURN to print the Scrub Nurse Staffing Report for all nurses, or 'NO'
|
|---|
| 154 | to select a specific person.
|
|---|
| 155 | Print the Report for which Scrub Nurse ?
|
|---|
| 156 | SCRUB NURSE STAFFING REPORT
|
|---|
| 157 | TOTAL CASES WITHOUT SPECIMENS:
|
|---|
| 158 | CASES WITHOUT SPECIMENS
|
|---|
| 159 | OPERATIVE PROCEDURE
|
|---|
| 160 | Report of Cases Without Specimens
|
|---|
| 161 | Do you want the report sorted by Surgical Specialty ? NO//
|
|---|
| 162 | Enter 'YES' to print this report sorted by surgical specialty or enter RETURN
|
|---|
| 163 | Cases Without Specimens
|
|---|
| 164 | Print the Report of Cases Without Specimens for which Specialty ?
|
|---|
| 165 | TOTAL CASES WITHOUT SPECIMENS: 0
|
|---|
| 166 | MEDICAL RECORD OPERATION REPORT PAGE
|
|---|
| 167 | CASE #:
|
|---|
| 168 | PREOPERATIVE DIAGNOSIS:
|
|---|
| 169 | 1ST ASST:
|
|---|
| 170 | 2ND ASST:
|
|---|
| 171 | CASE TYPE:
|
|---|
| 172 | OTHER ASSISTANTS:
|
|---|
| 173 | ATTEND SURG:
|
|---|
| 174 | ATT CODE:
|
|---|
| 175 | ATTEND ANESTH:
|
|---|
| 176 | ANESTHESIA SUPERVISOR CODE:
|
|---|
| 177 | ANESTHETIST:
|
|---|
| 178 | ASST ANES:
|
|---|
| 179 | PERFUSIONIST:
|
|---|
| 180 | ASST PRFST:
|
|---|
| 181 | OR SUPPORT PERSONNEL:
|
|---|
| 182 | ANESTHESIA TECHNIQUE:
|
|---|
| 183 | ANES BEGINS:
|
|---|
| 184 | ANES ENDS:
|
|---|
| 185 | OP BEGINS:
|
|---|
| 186 | OP ENDS:
|
|---|
| 187 | TUBES AND DRAINS:
|
|---|
| 188 | AGENTS:
|
|---|
| 189 | SPONGE AND NEEDLE COUNT VERIFIED AS
|
|---|
| 190 | MATERIAL SENT TO LAB FOR ANALYSIS:
|
|---|
| 191 | SPECIMENS:
|
|---|
| 192 | CULTURES:
|
|---|
| 193 | POST OPERATIVE DIAGNOSIS:
|
|---|
| 194 | MAJOR
|
|---|
| 195 | MINOR
|
|---|
| 196 | OPERATION(S) PERFORMED:
|
|---|
| 197 | DATE/TIME OF DICTATION:
|
|---|
| 198 | DATE/TIME TRANSCRIBED:
|
|---|
| 199 | INDICATIONS FOR OPERATION:
|
|---|
| 200 | SURGEON'S DICTATION:
|
|---|
| 201 | This routine will add the Tissue Examination Report to the Non-O.R.
|
|---|
| 202 | Procedures (Enter/Edit) Menu. It also provides the ability to add the
|
|---|
| 203 | fields BRIEF CLIN HISTORY, OPERATIVE FINDINGS, and SPECIMENS to the
|
|---|
| 204 | SRNON-OR input template.
|
|---|
| 205 | After updating the input template, the TISSUE EXAM/NON O.R. entry in the
|
|---|
| 206 | PACKAGE file will be removed. It was created to provide the template
|
|---|
| 207 | updates and is no longer needed. The PACKAGE file entry SURGERY V3.0
|
|---|
| 208 | PATCH, which was created by an earlier Surgery patch, will be removed
|
|---|
| 209 | also since it, too, is no longer needed.
|
|---|
| 210 | SRONOP-ENTER
|
|---|
| 211 | You are missing the Non-O.R. Procedures (Enter/Edit) Menu. Please contact
|
|---|
| 212 | your local ISC customer service representative for assistance.
|
|---|
| 213 | You are missing the Tissue Examination Report option. Please contact your
|
|---|
| 214 | local ISC customer service representative for assistance.
|
|---|
| 215 | Adding the Tissue Examination Report to Non-O.R. Procedures (Enter/Edit)...
|
|---|
| 216 | This routine provides the ability to overlay the input template SRNON-OR.
|
|---|
| 217 | This template is used within the option
|
|---|
| 218 | Edit Non-O.R. Procedure
|
|---|
| 219 | update Non-O.R. Procedure information.
|
|---|
| 220 | If you have already made local changes to this template, you may opt to
|
|---|
| 221 | bypass this portion of the process and update your input template manually.
|
|---|
| 222 | The fields to be added are SPECIMENS, BRIEF CLIN HISTORY, and OPERATIVE
|
|---|
| 223 | FINDINGS.
|
|---|
| 224 | Do you want to overlay the input template SRNON-OR? YES//
|
|---|
| 225 | . If you need additional help, enter
|
|---|
| 226 | No updates have been made to the SRNON-OR template.
|
|---|
| 227 | Updating the SRNON-OR template.
|
|---|
| 228 | TISSUE EXAM/NON O.R.
|
|---|
| 229 | The update to SRNON-OR is complete.
|
|---|
| 230 | Removing TISSUE EXAM/NON O.R. from the PACKAGE file...
|
|---|
| 231 | SURGERY V3.0 PATCH
|
|---|
| 232 | Removing SURGERY V3.0 PATCH from PACKAGE file...
|
|---|
| 233 | The process is complete. The Tissue Examination Report can now be printed
|
|---|
| 234 | for Non-O.R. Procedures.
|
|---|
| 235 | if you want to overlay the input template SRNON-OR. If you have
|
|---|
| 236 | made local changes to this template, answering
|
|---|
| 237 | will remove them.
|
|---|
| 238 | If you have made local changes and do not wish to have them removed, you should
|
|---|
| 239 | to this question. Then, using VA FileMan, add the fields
|
|---|
| 240 | SPECIMENS, OPERATIVE FINDINGS, and BRIEF CLIN HISTORY to the SRNON-OR
|
|---|
| 241 | SR STAFF SURGEON
|
|---|
| 242 | Update Information for which Surgeon:
|
|---|
| 243 | Do you want to designate this person as a 'Staff Surgeon' ? YES//
|
|---|
| 244 | Enter 'YES' if this person is a Staff Surgeon, or 'NO' to quit this option.
|
|---|
| 245 | is now designated as a staff surgeon.
|
|---|
| 246 | This person is already designated as a staff surgeon. Do you want to remove
|
|---|
| 247 | that designation ? NO//
|
|---|
| 248 | Enter 'YES' to remove the key used to designate this person as a staff
|
|---|
| 249 | surgeon, or 'NO' to leave this designation unchanged.
|
|---|
| 250 | Removing key designating
|
|---|
| 251 | as a staff surgeon...
|
|---|
| 252 | ** Task Being Stopped at User's Request **
|
|---|
| 253 | Press RETURN to continue, or '^' to quit:.
|
|---|
| 254 | ROLE:
|
|---|
| 255 | OTHER ASSISTANT
|
|---|
| 256 | SURGEON STAFFING REPORT
|
|---|
| 257 | Surgeon Staffing Report
|
|---|
| 258 | Do you want to print this report for an individual surgeon ? YES//
|
|---|
| 259 | Enter RETURN if you would like to print the report for a specific surgeon, or
|
|---|
| 260 | 'NO' to print the report for all surgeons.
|
|---|
| 261 | Print the report for which Surgeon ?
|
|---|
| 262 | A surgical case must be selected prior to using this option.
|
|---|
| 263 | to edit an existing procedure, or 'NEW' to
|
|---|
| 264 | enter another operative procedure:
|
|---|
| 265 | enter an additional operative procedure.
|
|---|
| 266 | ) to edit an existing procedure, or RETURN to continue:
|
|---|
| 267 | to continue listing procedures.
|
|---|
| 268 | OTHER OPERATIVE PROCEDURES
|
|---|
| 269 | There are no additional procedures entered for this case. Do you want to add
|
|---|
| 270 | a new procedure ? YES//
|
|---|
| 271 | Enter 'YES' to add another operative procedure, or 'NO' to return to the
|
|---|
| 272 | previous screen.
|
|---|
| 273 | Other Operative Procedure
|
|---|
| 274 | TISSUE EXAM REPORT
|
|---|
| 275 | (Continue on reverse side)
|
|---|
| 276 | PATHOLOGIST'S SIGNATURE
|
|---|
| 277 | ID #
|
|---|
| 278 | ETHNICITY:
|
|---|
| 279 | REGISTER NO.
|
|---|
| 280 | REPLACEMENT FORM 515
|
|---|
| 281 | Specimen Submitted By:
|
|---|
| 282 | Obtained:
|
|---|
| 283 | SURGERY CASE #
|
|---|
| 284 | Specimen(s):
|
|---|
| 285 | Brief Clinical History:
|
|---|
| 286 | Operative Procedure(s):
|
|---|
| 287 | Operative Findings:
|
|---|
| 288 | Signature and Title
|
|---|
| 289 | Name of Laboratory
|
|---|
| 290 | Accession Number(s)
|
|---|
| 291 | Gross Description, Histologic Examination and Diagnosis
|
|---|
| 292 | Press RETURN to continue or '^' to quit
|
|---|
| 293 | MEDICAL RECORD |
|
|---|
| 294 | TISSUE EXAMINATION
|
|---|
| 295 | Do you want the list for all Surgical Specialties ? YES//
|
|---|
| 296 | Enter RETURN if you would like to list the unverified cases for
|
|---|
| 297 | all Surgical Specialties, or 'NO' to select a specific specialty.
|
|---|
| 298 | Print the List of Unverified Cases to which Printer ?
|
|---|
| 299 | UNVERIFIED CASES
|
|---|
| 300 | * CPT CODE MISSING *
|
|---|
| 301 | List of Unverified Cases for
|
|---|
| 302 | Operation Date
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
