English	French	Notes	Complete/Exclude
   update Current Pneumonia, enter '2C'.)			
4. Enter a range of numbers (1-5) separated by a ':' to enter a range of			
   occurrences.  (For example, enter '2:4' to enter all pulmonary,			
   hepatobiliary, and cardiac information)			
5. Press <RET> to continue to page 2 of this option.			
Pulmonary			
Hepatobiliary			
CENTRAL NERVOUS SYSTEM			
Central Nervous System			
NUTRITIONAL/IMMUNE/OTHER			
Nutritional/Immune/Other			
Deleting all 			
          MINIMAL EXERTION			
                AT REST			
TOTAL DEPENDENT			
PREOPERATIVE INFORMATION			
GENERAL:			
HEPATOBILIARY:			
Diabetes Mellitus:			
Ascites:			
Current Smoker W/I 1 Year:			
Pack/Years:			
ETOH > 2 Drinks/Day:			
CARDIAC:			
Dyspnea:  			
CHF Within 1 Month:			
DNR Status: 			
Functional Status:  			
RENAL:			
Acute Renal Failure:			
PULMONARY:			
Currently on Dialysis:			
Ventilator Dependent:			
History of Severe COPD:			
Current Pneumonia:			
CENTRAL NERVOUS SYSTEM:			
NUTRITIONAL/IMMUNE/OTHER:			
Impaired Sensorium: 			
Disseminated Cancer:			
Coma:			
Open Wound:			
Hemiplegia:			
Steroid Use for Chronic Cond.:			
History of TIAs:			
Weight Loss > 10%:			
CVA/Residual Neuro Deficit:			
Bleeding Disorders:			
CVA/No Neuro Deficit:			
Transfusion > 4 RBC Units:			
Tumor Involving CNS:			
Chemotherapy W/I 30 Days:			
Radiotherapy W/I 90 Days:			
Preoperative Sepsis:			
OPERATIVE INFORMATION			
Surgical Specialty: 			
Principal Operation: 			
PGY of Primary Surgeon: 			
Emergency Case (Y/N): 			
Major or Minor: 			
Wound Classification: 			
ASA Classification: 			
Anesthesia Technique: 			
Airway Trauma: 			
RBC Units Transfused: 			
OPERATION DATE/TIMES INFORMATION			
Date/Time Patient in OR: 			
Date/Time Operation Began: 			
Date/Time Operation Ended: 			
Date/Time Patient Out of OR: 			
Anesthesia Care Start Date/Time: 			
Anesthesia Care End Date/Time: 			
PACU Discharge Date/Time: 			
PREOPERATIVE LABORATORY TEST RESULTS			
Serum Sodium: 			
Serum Creatinine: 			
BUN: 			
Serum Albumin: 			
Total Bilirubin: 			
SGOT: 			
Alkaline Phosphatase: 			
White Blood Count: 			
Hematocrit: 			
Platelet Count: 			
PTT: 			
PT: 			
POSTOPERATIVE LABORATORY RESULTS			
 * Highest Value			
** Lowest Value			
* Serum Sodium: 			
** Serum Sodium: 			
* Serum Creatinine: 			
* CPK-MB Band: 			
* Total Bilirubin: 			
* White Blood Count: 			
OUTCOME INFORMATION			
Postoperative Diagnosis Code (ICD9): 			
Length of Postoperative Hospital Stay: 			
Death Unrelated/Related: 			
Return to OR Within 30 Days: 			
 NO DATE			
PERIOPERATIVE OCCURRENCE INFORMATION			
WOUND OCCURRENCES:			
CNS OCCURRENCES:			
Superficial Infection:			
Deep Wound Infection:			
Coma > 24 Hours:			
Wound Disruption:			
Peripheral Nerve Injury:			
URINARY TRACT OCCURRENCES: 			
CARDIAC OCCURRENCES:			
Renal Insufficiency: 			
Arrest Requiring CPR:			
Myocardial Infarction:			
Urinary Tract Infection:			
RESPIRATORY OCCURRENCES:			
OTHER OCCURRENCES:			
Pneumonia:			
Ileus/Bowel Obstruction:			
Unplanned Intubation:			
Bleeding/Transfusions:			
Pulmonary Embolism:			
Graft/Prosthesis/Flap Failure:			
On Ventilator > 48 Hours:			
DVT/Thrombophlebitis:			
Systemic Sepsis: 			
* indicates Other (ICD9)			
         MINIMAL EXERTION			
               AT REST			
   A. Diabetes Mellitus:			
   B. Current Smoker W/I 1 Year:			
   A. CHF Within 1 Month:			
   F. DNR Status: 			
   G. Functional Status: 			
   A. Acute Renal Failure:			
   B. Currently on Dialysis:			
   A. Ventilator Dependent:			
   B. History of Severe COPD:			
   C. Current Pneumonia:			
1. CENTRAL NERVOUS SYSTEM:			
   A. Impaired Sensorium: 			
   A. Disseminated Cancer:			
   B. Open Wound:			
   C. Steroid Use for Chronic Cond.:			
   D. History of TIAs:			
   D. Weight Loss > 10%:			
   E. CVA/Residual Neuro Deficit:			
   E. Bleeding Disorders:			
   F. CVA/No Neuro Deficit:			
   F. Transfusion > 4 RBC Units:			
   G. Tumor Involving CNS:			
   I. Preoperative Sepsis:			
Annual Report of Surgical Procedures			
Do you want to print the Annual Report of Surgical Procedures for all			
Print the Annual Report for which Specialty ?  			
This report must be run on a printer.  Please select another device.			
ANNUAL REPORT OF SURGICAL PROCEDURES			
  Press RETURN to continue or '^' to quit. 			
TOTAL OPERATIONS:			
CPT CODE - OPERATION			
TOTALS FOR 			
There are no surgical cases entered for 			
within 30 days of this operation.			
RETURNS TO SURGERY			
Select the number corresponding to the return which you want to update, or			
enter RETURN to quit this option.			
CPT MISSING			
This return to surgery is currently defined as 			
 to the case selected.			
Do you want to change this status ? NO// 			
Enter 'YES' to change the status of this return from 			
Enter 'NO' to leave the information unchanged.			
SRSITE(			
MEDICAL RECORD                  |            ANESTHESIA REPORT			
ANESTHETIST'S SIG: 			
Preop Status: 			
Operating Room: 			
Principal Operation:  			
Anesthesia Technique(s): 			
Agents: 			
MONITORED ANESTHESIA CARE			
Intubated: 			
Approach: 			
Laryngoscope Type: 			
Laryngoscope Size: 			
Stylet Used: 			
Lidocaine Topical: 			
Lidocaine IV: 			
Tube Type: 			
Tube Size: 			
Trauma: 			
Extubated In: 			
Extubated By: 			
Reintubated within 8 Hours: YES			
Heat, Moisture Exchanger Used: YES			
Bacteria Filter in Circuit: YES			
Continuous: 			
Baricity: 			
Puncture Site: 			
Needle Size: 			
Modifiers: -			
           -			
Other:  			
Medications:			
Anesthesia Start: 			
Anesthesia Stop: 			
Anesthetist:      			
Relief Anesth:   			
Anesthesiologist: 			
Attending Code:  			
Assistant Anesth: 			
Min Intraoperative Temp: 			
Monitors:			
Blood Replacement Fluids:			
Intraoperative Blood Loss: 			
Urine Output: 			
Operation Disposition: 			
PAC(U) Admit Score: 			
PAC(U) Discharge Score: 			
Postop Anesthesia Note: 			
Intraoperative Complications: 			
Postoperative Complications: 			
Applied By: 			
Installed: 			
Source ID: 			
VA ID:     			
Ordered By: 			
Admin By: 			
Medication Comments: 			
Agents:			
General Comments:			
Dural Puncture: 			
Catheter Removed By: 			
Date/Time Catheter Removed: 			
Block Site: 			
   Needle Length: 			
   Needle Gauge: 			
.   ----     CREATE NEW ASSESSMENT			
There are no Surgery Risk Assessments entered for 			
  Press RETURN to continue.  			
Select Surgical Case: 			
Enter the number of the desired assessment.			
' to create an			
assessment for another surgical case.			
You've selected a Cardiac assessment, using a Non-Cardiac Option,			
You've selected a Non-Cardiac assessment, using a Cardiac Option,			
1. Enter Risk Assessment Information			
2. Delete Risk Assessment Entry			
3. Update Assessment Status to 'COMPLETE'			
Enter <RET> or '1' to enter or edit information related to this Risk 			
Assessment entry.  If you want to delete the Assessment, enter '2'.			
Enter '3' to update the status of this Assessment to 'COMPLETE'.			
This assessment has already been transmitted.  The information contained			
in it cannot be altered unless you first change the status to 'INCOMPLETE'.			
Do you wish to change the status of this assessment to 'INCOMPLETE'			
' to create a			
new risk assessment entry.			
 is not an O.R. surgical procedure.			
There is no Surgery Risk Assessment entered for Case #			
Enter YES to batch print all completed or transmitted assessments for a			
selected date range.  Enter NO or press return to print one specific			
Do you want to batch print assessments for a specific date range ? 			
Convert existing assessments starting with which date ? 			
The SURGERY RISK ASSSESSMENT file (139) still contains entries.  Before you			
enter any additional risk assessment information, all entries in this file 			
should be converted or deleted.			
The conversion process has been completed.  Please review your incomplete			
The conversion of the 			
 Surgery Risk Assessment Module cannot			
be run until after April 1, 1994.  It should only be run after that date			
if your Surgery files are complete, including complications, CPT codes and			
anesthesia information since installing Surgery Version 3.0.			
You must select a starting date to begin the conversion process.  All 			
assessments with operation dates prior to the start date will be automatically			
deleted.  The remaining assessments will then be processed for conversion.			
The SURGERY RISK ASSESSMENT file will now be deleted from your system... 			
This option is used to move the risk assessment data entered through the			
 Surgery Risk Assessment Module into the DHCP Surgery pacakge.			
The computer will ask you to select a starting date to move the assessments.			
All assessments with an operation date prior to this start date will be deleted			
prior to converting the remaining entries.  The software will then begin the 			
conversion process.  Upon completion of the conversion, there should be no			
entries in the SURGERY RISK ASSESSMENT file (139).  The computer will then 			
remove that file from your system.			
The conversion process will merge only those data elements that are not already			
part of the DHCP Surgery database.  You should only convert the assessments if			
the information contained in your surgery database has been kept up to date.			
The following information will NOT be moved from the 			
Risk Assessment Module:			
1. Operative Procedures and CPT Codes			
2. Diagnosis Information			
4. ASA Classification			
5. Anesthesia Technique			
6. Concurrent Cases			
7. Returns to Surgery			
All assessments that have been completed, but not transmitted will have their			
status changed to 			
 after they are converted.  You should review			
these assessments to determine if any of the fields which are not merged need			
The conversion process will begin by deleting all assessments with a date of			
operation prior to the start date selected and all entries in the SURGERY RISK			
ASSESSMENT file (139) that have been entered for log purposes only.  These			
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