Class Surgery

Each entry in the SURGERY file contains information regarding a surgery case made up of an operative procedure, or multiple operative procedures for a patient. The file includes the information necessary for creating the Nurses' Intraoperative Report, Operation Report, and Anesthesia Report

Attributes
*attendingCodeNotUsed *attendingCodeNotUsed

NOTE: This field is replaced by the new ATTENDING CODE field (#.166). This is the code corresponding to the highest level of supervision provided by the attending staff surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report. 0 The staff practitioner performs the case but may be assisted by a resident. 1 The supervising practitioner is physically present in the operative or procedural suite and directly involved in the procedure. The resident performs major portions of the procedure. 2 The supervising practitioner is physically present in the operative or procedural suite and immediately available for consultation. The supervising practitioner may observe and provide direction. The resident performs the procedure 3 The supervising practitioner is not physically present in the operative or procedural suite, but is in the facility or on the VA campus. The supervising practitioner is immediately available for resident supervision or consultation as needed. Local policy, as approved by the VISN Academic Affiliations Officer, should define the standard for "availability" of the supervising practitioner. NOTE: The service chief and chief of staff are responsible for periodically reviewing cases done under Level 3 supervision.

*bleeding&PttTimeIn48Hrs *bleeding&PttTimeIn48Hrs

This indicates whether the patient has had bleed and PTT time within 48 hours prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.

*bloodSugarIn7Days *bloodSugarIn7Days

This field determines whether the patient has had a blood sugar test within the last 7 days. This field has been marked for deletion in the next release of the Surgery software.

*bunIn7Days *bunIn7Days

This indicates whether the patient has had a BUN within 7 days prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.

Integer *clerkChnDateProcedure *clerkChnDateProcedure

This field has been marked for deletion. It should not be used.

Integer *clerkChnDaysBefore *clerkChnDaysBefore

This field is not being used and is marked for deletion.

Integer *clerkChnRecForMajSurg *clerkChnRecForMajSurg

This field has been marked for deletion. It should not be used.

*instCntCorrect *instCntCorrect

Enter the code corresponding to the status of the final instrument count at the end of the surgical procedure. This field is marked for deletion.

*mazeProcedure *mazeProcedure

CICSP Definition (2004): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt atrial conduction pathways often associated with atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (YES/NO).

*procedureCompleted *procedureCompleted

This indicates whether the principal operative procedure was completed. This field has been marked for deletion.

*serologyReport *serologyReport

This field has been marked for deletion. It should not be used.

*surgeryPosition *surgeryPosition

This field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.

*verfifyIdTagSsn *verfifyIdTagSsn

This indicates whether the identification bracelet and social security number verification was completed, legal and correct. This field has been marked for deletion.

30DayPostopStatusList 30DayPostopStatus 30DayPostopStatus

This is the patient's status 30 days postoperatively. Please select one of the following categories. 1. Discharged alive to home, nursing home, rehabilitation, or psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your VAMC facility in the ICU, on a medical-surgical floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of another VAMC facility from your VAMC without going home 5. Patient was discharged home, but was readmitted to any hospital within 30 days postoperatively due to a postoperative complication as confirmed by the Chief Surgical Resident, Principle Investigator, or Chief of Surgery. If the patient was readmitted due to a postoperative complication, please enter the information in the outcome section of the assessment.

SurgeryHistoryList absentPeripheralPulses absentPeripheralPulses

This determines whether the patient has been diagnosed on the physical examination to have absent femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as present or absent in the remaining limb.

Boolean activeEndocarditis activeEndocarditis

CICSP Definition (2004): Indicate if the patient is being treated with antibiotics for active infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery. Endocarditis is defined as two or more blood cultures positive for the same organism, usually with evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of positive blood cultures, there should be clear evidence of valve infection and/or destruction by ultrasound or direct observation at surgery with subsequent histologic confirmation.

SurgeryHistoryList activeHepatitis activeHepatitis

This determines whether the patient has active hepatitis. Active Hepatitis is defined as an active inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral hepatitis documented by positive serologies (A,B, or C) and recent excessive alcohol intake, or drug induced hepatitis.

SurgeryHistoryList acuteRenalFailure acuteRenalFailure

NSQIP Definition (2007): In a patient who did not require dialysis preoperatively, worsening of renal dysfunction postoperatively requiring hemodialysis, peritoneal dialysis, hemofiltration, hemodiafiltration or ultrafiltration. TIP: If the patient refuses dialysis the answer is Yes to this variable, because he/she did require dialysis. CICSP Definition (2004): Indicate if the patient developed new renal failure requiring dialysis or experienced an exacerbation of preoperative renal failure requiring initiation of dialysis (not on dialysis preoperatively) within 30 days postoperatively. (Dialysis includes continuous venous to venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis [CVAHD], and peritoneal. It does not include ultrafiltration.)

SurgeryPreopCompletedList addressPlate addressPlate

This indicates if the patient's address plate is present on the patient's medical record prior to transport to the operating room.

String admissionTransferDate admissionTransferDate

NSQIP Definition (2004): If the patient was not initially admitted to the surgical service, the date and time of transfer to surgical service for this surgical episode will be entered from the PIMS package. Enter 'NA' if this date is not applicable, e.g. outpatient not admitted or observed.

Datetime admitPacUTime admitPacUTime

This is the date/time that the patient was admitted to the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.

Boolean agentOrangeExposure agentOrangeExposure

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Agent Orange Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.

AirwayIndexList airwayIndex airwayIndex

This field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being least difficult and 5 being most difficult. The value of this field is based on a computed performance index using the oral-pharyngeal (OP) class and the mandibular space (MS). Performance index = 2.5 x OP - MS length (converted to centimeters) Airway Index ------------ 1 - Performance Index less than 0 2 - Performance index greater than 0 and less than 2 3 - Performance index greater than 2 and less than 3 4 - Performance index greater than 3 and less than 4 5 - Performance index greater than 4

Datetime anesAvailTime anesAvailTime

This is the date and time that the anesthetist is available to service the patient. Although optional, this information is useful for evaluating operation delays.

anesCareBillableTime anesCareBillableTime

This is the total anesthesia care billable time in minutes. It is calculated from all time intervals entered in the multiple anesthesia start and end time fields..

Boolean anesCareBillableTimeFlag anesCareBillableTimeFlag

This field is a flag that indicates all anesthesia care time has been entered for a case. It is used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered. "No" indicates time entry is not complete.

Datetime anesCareEndTime anesCareEndTime

This is the date and time that anesthesia care ends. Its definition may vary according to local anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered without a date will be converted to the date of the operation at that time. NSQIP Definition (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU).

Datetime anesCareStartTime anesCareStartTime

This is the date and time that the anesthesia care began. It is required as part of the anesthesia report. The definition of what constitutes the time anesthesia care begins may vary depending on local anesthesia policy. NSQIP Definition (2004): Anesthesia Start (AS): Time when a member of the anesthesia team begins preparing the patient for an anesthetic.

anesCareTime anesCareTime

This is the number of minutes between the anesthesia care start time and anesthesia care end time.

«File 130.213» AnesCareTimeBlock anesCareTimeBlock anesCareTimeBlock
«File 130» Surgery anesConcurrentCases anesConcurrentCases
Boolean anesMedicallyDirected anesMedicallyDirected

If the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist supervised the care. Answering no indicates that the anesthetist was unsupervised.

Boolean anesPersonallyPerformed anesPersonallyPerformed

Answer yes only if the anesthesiologist personally performed the entire anesthesia procedure.

Boolean anesPhysicianAvailable anesPhysicianAvailable

If the anesthetist was a resident, answer yes if the teaching physician was present during all key portions of the procedure and immediately available during the entire procedure.

anesStartToOpStart anesStartToOpStart

This is the number of minutes between the time that anesthesia care started and time that the operation began.

«File 132.95» AnesthesiaSupervisorCodes anesSuperviseCode anesSuperviseCode
«File 130.06» AnethesiaTechnique anesthesiaTechnique anesthesiaTechnique
«File 200» NewPerson anesthesiologistSupvr anesthesiologistSupvr

This is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal anesthetist is in a training status, or CRNA.

AnesthetistCategoryList anesthetistCategory anesthetistCategory

This field holds the category of the principal anesthetist which is used on the Anesthesia AMIS report to enumerate the number of anesthetics administered by each category.

anesthInductTime anesthInductTime

This is the total number of minutes between the anesthesia care start and induction complete times.

AnginaList angina angina

This determines whether the patient has angina. Angina is defined as pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia usually precipitated by exertion or emotion and relieved by rest or nitroglycerine. The Canadian Cardiovascular Society (CCS) classification is now the most commonly used method to record severity of angina. Record according to the most severe angina in the 14 days before surgery: I - Ordinary physical activity, such as walking or climbing stairs does not cause angina. Angina may occur with strenuous or rapid or prolonged exertion at work or recreation. II - There is slight limitation of ordinary activity. Angina may occur with walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, or climbing more than one flight of stairs under normal conditions at a normal pace. III - There is marked limitation of ordinary physical activity. Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace. IV - There is inability to carry on any physical activity without discomfort. Angina may be present at rest.

SurgeryHistoryList anginaOneMonthPrior anginaOneMonthPrior

NSQIP Definition (2004): Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. Documentation in the chart by the physician should state 'angina' or 'anginal equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had angina at any time within 30 days prior to surgery.

AorticStenosisList aorticStenosis aorticStenosis

CICSP Definition (2007): Indicate the severity of any aortic stenosis documented. This question should be answered using either the left ventricular angiogram (hemodynamic cath data) or the cardiac ultrasound examination. Numbers may be converted to describe the severity of the aortic stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Both transvalvular gradient and estimated valve orifice area are used to assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is obtained by converting the velocity of blood flow across the valve measured by the Doppler principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the descriptive categories. Indicate the one most appropriate response: None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow velocity is stated to be normal (< 1.0 M/sec). Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice area is 1.7 - 2.5 cm2 Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the valve orifice area is 1.0 -1.6 cm2 Severe - The mean pressure gradient is > 50 mm Hg and/or the valve orifice area is < 1.0 cm2 NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.

String aorticSystolicPressure aorticSystolicPressure

CICSP Definition (2004): Indicate the patient's aortic systolic pressure measured prior to left ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic pressure was not measured, entering "NS" for "No Study/Unknown" is also allowed.

ValveProcedureList aorticValveProcedure aorticValveProcedure

VASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other

«File 132.8» AsaClass asaClass asaClass
SurgeryHistoryList ascites ascites

VASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within 30 days prior to the operation. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).

Boolean asdRepair asdRepair

This determines if there was a procedure performed to repair an atrial septal defect.

«File 200» NewPerson assessmentCompletedBy assessmentCompletedBy

This is the name of the person who completed this surgery risk assessment.

AssessmentStatusList assessmentStatus assessmentStatus

This is the current status of the surgery risk assessment. When creating a new assessment, the status will automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this field will be updated to 'COMPLETED'. After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.

AssessmentTypeList assessmentType assessmentType

This determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.

«File 44» HospitalLocation associatedClinic associatedClinic
«File 200» NewPerson asstAnesthetist asstAnesthetist

This is the name of the person assisting the principal anesthetist. If entered, this information appears on the Anesthesia Report.

«File 200» NewPerson asstPerfusionist asstPerfusionist

This is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case.

«File 132.9» AttendingCodes attendingCode attendingCode
«File 200» NewPerson attendProvider attendProvider

This is the name of the attending staff provider responsible for this case. This information appears on several reports.

«File 200» NewPerson attendSurg attendSurg

This is the name of the attending staff surgeon responsible for this case. This information appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.

SurgeryPreopCompletedList bathAndShampoo bathAndShampoo

This indicates if the patient's preoperatively prescribed bath and shampoo were completed.

Boolean batistaProcedureUsedYN batistaProcedureUsedYN

Was the Batista procedure used, Yes or No?

SurgeryHistoryList bleedingDisorders bleedingDisorders

VASQIP Definition (2010): Any condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K deficiency, hemophilias, thrombocytopenia, chronic anticoagulation therapy that has not been discontinued prior to surgery). Do not include the patient on chronic aspirin therapy. Lab values should not be used to determine this variable except in the case of platelet counts for determining thrombocytopenia. Use whatever the low range number is for your facility to make this determination. Anything less than your local low range should be considered thrombocytopenia. Please refer to the VASQIP Definitions for a table of medications that impact the patient's risk for bleeding. Please utilize the associated time frames for discontinuation of medication not lab values to determine your answer to this variable. The time frames are up to and including the day or hour listed. If there is no documentation of discontinuation of medication, answer 'yes' for bleeding disorder.

Integer bloodLossMl bloodLossMl

This is the number of milliliters (0-100000) of blood estimated to be lost during the operative procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.

SurgeryPreopCompletedList bloodTypeAndXmatch bloodTypeAndXmatch

This indicates whether the patient has had blood typing and crossmatching done.

String bnp bnp

VASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.

String bnpDate bnpDate

VASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter "NS" for No Study if the BNP test was not performed.

Boolean bridgeToTransplantDevice bridgeToTransplantDevice

CICSP Definition (2006): Indicate if patient received a mechanical support device (excluding IABP) as a bridge to cardiac transplant during the same admission as the transplant procedure; or patient received the device as destination therapy (does not intend to have a cardiac transplant), either with or without placing the patient on cardiopulmonary bypass.

«File 130.09» BriefClinHistory briefClinHistory briefClinHistory
Datetime cancelDate cancelDate

This is the date and time that the operative procedure was canceled.

Boolean cancellationAvoidable cancellationAvoidable

This field contains a set of codes used to flag a cancellation as being avoidable or unavoidable. It is used when determining the percentage of avoidable cancellations.

«File 200» NewPerson cancelledBy cancelledBy

This is the name of the person who cancelled this surgical case. This information is automatically entered when a case is cancelled.

«File 135» SurgeryCancellationReason cancelReason cancelReason
SurgeryHistoryList cardiacArrestReqCpr cardiacArrestReqCpr

CICSP Definition (2004): Indicate if there was any cardiac arrest requiring external or open cardiopulmonary resuscitation (CPR) occurring in the operating room, ICU, ward, or out-of-hospital after the chest had been completely closed and within 30 days of surgery. (YES/NO) If patient had cardiac arrest requiring CPR, indicate whether the arrest occurred intraoperatively or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while patient was in the operating room - postoperatively: occurring after patient left the operating room NSQIP Definition (2006): The absence of cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support. Patients with AICDs that fire but the patient does not lose consciousness should be excluded.

Datetime cardiacCatheterizationDate cardiacCatheterizationDate

Record the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS if unknown or not applicable.

SurgeryHistoryList cardiacOccurrences cardiacOccurrences

This determines whether the patient has had any postoperative cardiac occurrences. Cardiac occurrences are defined as difficulties encountered involving the cardiac system.

String cardiacResourceDataComments cardiacResourceDataComments

CICSP Definition (2006): Indicate additional comments related to this case prior to transmission to Denver by the SCNR/Data Manager (limit 130 characters).

String cardiacRiskPreopComments cardiacRiskPreopComments

CICSP Definition (2006): Indicate in the comment field any preoperative patient risk factors (not previously entered above) that may contribute to this patient's risk of operative mortality. (The maximum length of this field is 130 characters.)

CardiacSurgicalPriorityList cardiacSurgicalPriority cardiacSurgicalPriority

If this is a cardiac procedure, this is the surgical priority reflecting the patient's cardiovascular condition at the time of transport to the operating room: 1. Elective - Patient placed on elective schedule with surgery usually performed > 72 hours following catheterization. 2. Urgent - Clinical condition mandates prompt surgery usually within 12 to 72 hours of catheterization (patients clinically stable on a circulatory support system should be included in this category). 3. 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. 4. 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 immediate surgery within hours of the cardiac catheterization. 5. 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).

BooleanUnknown cardiacSurgPerformedNonVa cardiacSurgPerformedNonVa

CICSP Definition (2004): Indicate whether the patient's cardiac surgery was performed in a non-VA facility through a contracted arrangement, even if part of the post-surgical care is provided at the VA. A "contract" facility is one established to be an affiliate with the VA medical center, and it is most typically a University Hospital. In rare cases a "contract" facility may be a community hospital when there is no University affiliate for the VAMC. By contrast, a "fee-basis" patient surgery should not be indicated as a "contract" facility. Typically, a "fee-basis" establishment is an agreement by the VA Chief of Staff to out-source a patient to a community hospital. That hospital then bills the Chief of Staff for care rendered on the patient. CICSP does not wish to capture the patient data on the "fee-basis" patients. If the patient is not entered into VISTA, send a paper form to Denver for hand-entry, unless your facility contracts-out a majority of its cases. Enter "NS" if funding for the procedure is not known. The default is to NO if a response is not entered.

Boolean cardiacTransplant cardiacTransplant

CICSP Definition (2006): Indicate if an orthotopic or heterotopic transplant was performed at this procedure either with or without placing the patient on cardiopulmonary bypass. (YES/NO) Heart-lung transplant should be listed under "Other cardiac procedures."

SurgeryHistoryList cardiacYN cardiacYN

This determines whether the patient has a history of cardiac illnesses.

Boolean cardiomegaly cardiomegaly

CICSP Definition (2004): Indicate if the patient has generalized cardiac enlargement of any or all of the cardiac chambers by standard or portable chest x-ray within 30 days preceding surgery.

SurgeryPreopCompletedList carePlanInChart carePlanInChart

This indicates whether the nursing care plan is present on the patient's medical record prior to transport of the patient into the operating room.

String caseScheduleOrder caseScheduleOrder

This is the sequence in which the surgeon expects to do the case if he or she has more than one case scheduled for this day. This field is optional, but is very useful to the person scheduling cases if the surgeon has more than one case.

CaseScheduleTypeList caseScheduleType caseScheduleType

This is the code describing how this case was scheduled. It is important that this field is entered. The Scheduler may use this field when updating the schedule due to cancellations or insertions. NSQIP Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related preoperative symptomatology. Answer EMERGENCY if the surgeon and anesthesiologist report the case as emergent

Boolean caseVerification caseVerification

This indicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon.

SurgeryPreopCompletedList cbcIn48Hrs cbcIn48Hrs

This indicates whether the patient has had a CBC within 48 hours prior to being transported to the operating room.

«File 130.013» CellSaver cellSaver cellSaver
SurgeryHistoryList centralNervousSystemYN centralNervousSystemYN

This determines whether the patient has a history of illness related to the central nervous system (CNS).

Boolean cerebralVascularDisease cerebralVascularDisease

This determines whether the patient has disease of the arteries to the head manifested by previous stroke (cerebral vascular accident), and/or transient ischemic attack (TIA), and/or prior surgical repair (e.g. carotid endarterectomy), and/or greater than or equal to 50% obstruction of luminal diameter documented by contrast angiography or duplex ultrasound examination.

SurgeryHistoryList chemotherapyInLast30Days chemotherapyInLast30Days

NSQIP Definition (2007): Enter "YES" if the patient had any chemotherapy treatment for cancer in the 30 days prior to surgery. Chemotherapy may include, but is not restricted to, oral and parenteral treatment with chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma. Do not count if treatment consists solely of hormonal therapy. (See Operations Manual for list of chemotherapeutic agents.) Chemotherapy treatment must be for malignancy.

SurgeryPreopCompletedList chestXrayIn7Days chestXrayIn7Days

This field determines whether the patient has had a chest x-ray within the last seven days.

SurgeryHistoryList chfWithinOneMonth chfWithinOneMonth

NSQIP Definition (2004): Congestive Heart Failure is the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure. Only newly diagnosed CHF within the previous 30 days or a diagnosis of chronic CHF with new signs or symptoms in the 30 days prior to surgery fulfills this definition. Common manifestations are: - Abnormal limitation in exercise tolerance due to dyspnea or fatigue - Orthopnea (dyspnea on lying supine) - Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea) - Increased jugular venous pressure - Pulmonary rales on physical examination - Cardiomegaly - Pulmonary vascular engorgement Should be noted in the medical record as CHF, congestive heart failure, or pulmonary edema.

SurgeryPreopCompletedList cigMatchAndValRem cigMatchAndValRem

This indicates whether the patient's tobacco products, matches and valuables have been removed from his or her possession prior to being transported to the operating room.

String circumflexStenosis circumflexStenosis

CICSP Definition (2004): Indicate the most severe percent stenosis in the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for bypass grafting. Both the anatomy and nomenclature for describing the circumflex coronary artery can be confusing -- in part, because of the marked variability from patient to patient. The true circumflex lies in the groove separating the left atrium from the left ventricle (A-V groove) for a variable distance following its origination from the left main coronary artery. Typically, it gives-off one or more branches that leave the A-V groove to supply the posterior-lateral free wall of the left ventricle. These are known as marginal branches. A few patients have a branch to the posterior-lateral free wall of the left ventricle arising exactly at the bifurcation of the left main coronary artery into the left anterior descending coronary artery and the circumflex coronary artery. Strictly speaking, this vessel is neither a diagonal branch of the left anterior descending coronary artery nor a marginal branch of the circumflex coronary artery. This is often called the "ramus intermedius" or "trifurcation branch". If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.

Boolean classificationEnteredYN classificationEnteredYN

This field indicates whether or not classification items have been addressed. This field is used by the software to decide whether to allow the user a choice to update classification information. If the field is NO or null, it will not permit a choice if the site parameter to enter classification information is turned on.

SurgeryPreopCompletedList cleanDressing cleanDressing

This indicates if all appropriate wounds have had clean dressings applied prior to transport to the operating room.

SurgeryPreopCompletedList cleanHospCloth cleanHospCloth

This indicates whether the patient has clean hospital clothing prior to being transported to the operating room.

SurgeryHistoryList clostridiumDifficileColitis clostridiumDifficileColitis

NSQIP Definition (2008): C. difficile-associated disease occurs when the normal intestinal flora is altered, allowing C. difficile to flourish in the intestinal tract and produce a toxin that causes a watery diarrhea. C. difficile diarrhea is confirmed by the presence of a toxin in a stool specimen. Answer yes only if you have a positive culture for C. difficile and/or a toxin assay and diagnosis of C. difficile documented in the chart.

SurgeryHistoryList cnsOccurrences cnsOccurrences

This determines whether the patient has had any postoperative central nervous system (CNS) occurrences. These occurrences are defined as difficulties related to the brain and spinal cord, with their nerves and end-organs that control voluntary acts.

«File 200» NewPerson codingVerifier codingVerifier

This is the person who last updated procedure and/or diagnosis descriptions and/or codes for this case using the Update/Verify Procedure/Diagnosis Codes [SRCODING EDIT] option. This field is updated automatically by the option when information is changed.

SurgeryHistoryList coma coma

NSQIP Definition (2004): Patient is unconscious, postures to painful stimuli, or is unresponsive to all stimuli entering surgery. This does not include drug-induced coma.

SurgeryHistoryList coma24HoursPostop coma24HoursPostop

NSQIP Definition (2006): Patient is unconscious, postures to painful stimuli, or is unresponsive to all stimuli (exclude transient disorientation or psychosis) for greater than 24 hours during postoperative hospitalization. Do not include drug-induced coma (e.g. Propofol drips, etc.) CICSP Definition (2006): Indicate if postoperatively within 30 days of surgery there was a significantly decreased level of consciousness (exclude transient disorientation or psychosis) for greater than or equal to 24 hours as evidenced by lack of response to deep, painful stimuli.

Boolean combatVet combatVet

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Combat. This information may be passed to the VISIT file (#9000010) for use by PCE.

«File 130» Surgery concurrentCase concurrentCase
CongestiveHeartFailureList congestiveHeartFailure congestiveHeartFailure

CICSP Definition (2007): Indicate whether the patient has congestive heart failure if the patient chart or patient self-report indicates a history of congestive heart failure within the 30 days before surgery. Congestive heart failure is defined as the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure. Common manifestations are identified: From the history: 1) Abnormal limitation in exercise tolerance due to dyspnea, fatigue or angina. 2) Orthopnea (dyspnea on lying supine). 3) Paroxysmal nocturnal dyspnea (PND) - awakening from sleep with dyspnea which is relieved by assuming an upright posture). From the physical examination: 4) Increased jugular venous pressure. 5) Pulmonary rales on physical examination. From the chest x-ray: 6) Cardiomegaly, and 7) Pulmonary vascular engorgement. The New York Heart Association functional classification is commonly used as a subjective assessment of the severity of congestive heart failure. If none of the above manifestations have been present, or congestive heart failure is not mentioned as an active problem in the 30 days before surgery, indicate Class I. Any mention of above manifestations requires the indication of a stage other than Class I. Indicate the one most appropriate response: Class I - cardiac disease, but no symptoms of abnormal fatigue, dyspnea or angina. Class II - slight limitation of physical activity by fatigue, dyspnea, or angina. The patient gets unusual fatigue, dyspnea, and/or angina only upon performing more strenuous activities, such as climbing two or more flights of stairs without stopping. Class III - marked limitation of physical activity by fatigue, dyspnea, or angina. The patient gets unusual fatigue, dyspnea, and/or angina upon performing ordinary activities, such as walking several blocks or climbing a flight of stairs. Class IV - symptoms at rest and/or inability to carry out any physical activity without symptoms of fatigue, dyspnea or angina. The patient has symptoms of unusual fatigue, dyspnea, and/or angina at rest or when performing minimal activity, such as walking across the room.

SurgeryPreopCompletedList consentSigAndWit consentSigAndWit

This indicates whether there is a properly signed and witnessed operative consent present in the patient's medical record.

ConvertFromOffPumpToCpbList convertFromOffPumpToCpb convertFromOffPumpToCpb

CICSP Definition (2004): Indicate whether patient was converted from off cardiopulmonary bypass assistance to on cardiopulmonary bypass during the cardiac surgical procedure. Indicate the one appropriate response: No - There was no conversion that occurred for the off-pump case performed (i.e., the off-pump case remained off-pump throughout the operation). N/A - The procedure was NOT an off-pump case (i.e., procedure began on-pump and remained on- pump throughout the case). [The default will be set to N/A.] Yes, planned - The procedure was begun as an off-pump procedure but changed to on-pump for any length of time; the change was planned due to decision made prior to operation to perform some vessels off-pump and some on-pump in order to minimize total CPB time. Yes, unplanned - The procedure was begun as an off-pump procedure but changed to on-pump for any length of time; the change was unplanned and determined in the operating room due to inability to safely perform revascularization. NS/Unknown - If documentation is not sufficient to answer, entering "NS" for "No Study/Unknown" is also allowed.

Integer coronariesWithStenosis coronariesWithStenosis

This is the category corresponding to the number of major coronaries with stenosis greater than or equal to 50%. The categories are as follows. 0 - no stenosis in any coronary artery greater than or equal to 50% (exclude diagonals) 1 - one or more stenoses greater than or equal to 50% in the left anterior descending (does not include diagonals) or, circumflex (circumflex includes the marginal branches and ramus intermedius), or the right (right includes the posterior descending even if a branch of the circumflex) 2 - Stenoses greater than or equal to 50% in the left main coronary artery, or the left anterior descending (does not include diagonals) and the right (right includes the posterior descending even if a branch of the circumflex), or the left anterior descending (does not include diagonals) and circumflex (circumflex includes the marginals and ramus intermedius), or the circumflex (circumflex includes the marginals and ramus intermedius) and the right (right includes the posterior descending even if a branch of the circumflex) 3 - Stenoses greater than or equal to 50% in the left anterior descending (does not include diagonals) and the circumflex (circumflex includes the marginals and ramus intermedius) and right (right includes the posterior descending even if a branch of the circumflex) or left main and right (right includes the posterior descending even if a branch of the circumflex)

«File 200» NewPerson countVerifier countVerifier

This is the name of the person responsible for verifying the final sponge, sharps and instrument counts.

Boolean cptOnNurseReport cptOnNurseReport

This field reflects the content of the CPT ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time an automatic addendum is made to the report to determine whether the CPT codes should appear on the report.

Boolean createRiskAssessment createRiskAssessment

This determines whether a risk assessment will be created for this surgical case. If answered 'NO', the information will automatically be completed so that the information will be transmitted without any additional intervention.

CrossmatchScreenAutologousList crossmatchScreenAutologous crossmatchScreenAutologous

This determines whether the requested blood will be typed and crossmatched, screened, or autologous.

«File 130.064» Cultures cultures cultures
Boolean currentDigoxinUse currentDigoxinUse

This determines whether the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin, ect.) within the two weeks prior to surgery.

Boolean currentDiureticUse currentDiureticUse

This determines whether the patient has used any diuretic preparation within the two weeks prior to surgery.

SurgeryHistoryList currentlyOnDialysis currentlyOnDialysis

NSQIP Definition (2006): Acute or chronic renal failure requiring periodic peritoneal dialysis, hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration within 2 weeks prior to surgery.

SurgeryHistoryList currentPneumonia currentPneumonia

NSQIP Definition (2007): Report patients with evidence of pneumonia at the time the patient is brought to the OR. Patients with pneumonia must meet ONE of the following two criteria: Criterion 1. Rales or dullness to percussion on physical examination of chest AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolate from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy OR Criterion 2. Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolated from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy d. Isolation of virus or detection of viral antigen in respiratory secretions e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen f. Histopathologic evidence of pneumonia

SurgeryHistoryList currentSmoker currentSmoker

NSQIP Definition (2006): If the patient has smoked cigarettes in the year prior to admission for surgery enter YES. Do not include patients who smoke cigars or pipes or use chewing tobacco.

CurrentSmokerCardiacList currentSmokerCardiac currentSmokerCardiac

CICSP Definition (2006): Indicate the patient's smoking status from information from the patient, or the chart, that best describes the patient's use of tobacco in any form (pipe, cigar, cigarette, tobacco chew). If more than one representation is found, please record according to the most conservative (most recent) quit date: 1 = never a smoker 2 = smoking within two weeks prior to surgery 3 = smoking within 2 weeks to 3 months prior to surgery 4 = remote smoker (more than 3 months prior to surgery)

SurgeryHistoryList cvaStrokeNoNeuroDeficit cvaStrokeNoNeuroDeficit

NSQIP Definition (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with neurologic deficit(s) lasting at least 30 minutes, but no current residual neurologic dysfunction or deficit.

SurgeryHistoryList cvaStrokeWithNeuroDeficit cvaStrokeWithNeuroDeficit

NSQIP Definition (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with persistent residual motor, sensory, or cognitive dysfunction. (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory). If the neurological deficit is hemiplegia/hemiparesis, also enter YES to Hemiplegia/Hemiparesis in addition to CVA/Stroke.

Datetime dateAssessmentCompleted dateAssessmentCompleted

This is the date that the Assessment was completed. This field will be updated if the assessment was transmitted in error.

String dateOfDeath dateOfDeath

If the patient has died, this is the date/time of death.

Datetime dateOfLastTransmission dateOfLastTransmission

This is the date of the retransmission if this risk assessment has been retransmitted to the national database. An assessment can be updated and retransmitted within 14 days of the original transmission date. If there was no retransmission of this assessment, this is the date of the original transmission.

Datetime dateOfOperation dateOfOperation

This is the date that the case was performed. The date of operation must be entered for all cases.

Datetime dateOfProcedure dateOfProcedure

This is the date that the non-OR procedure was performed. The date of procedure must be entered for all non-OR cases.

Datetime dateOfTranscription dateOfTranscription

This is the date and time that transcription of the operative summary was completed.

Datetime dateTimeOfDictation dateTimeOfDictation

This is the date and time that dictation of the operative summary was completed.

Datetime dateTimeOrRequestMade dateTimeOrRequestMade

This is the date and time that the operation request was made. This information is automatically entered at the time of request. If the request date is changed, this field will be updated to reflect the new date/time requested.

Datetime dateTransmitted dateTransmitted

This is the date (or date/time) that this surgery risk assessment was transmitted.

DeathUnrelatedRelatedList deathUnrelatedRelated deathUnrelatedRelated

This indicates if death was unrelated to this surgery.

SurgeryHistoryList deepIncisionalSsi deepIncisionalSsi

NSQIP Definition (2004): Deep Incision SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and infection involved deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following: - Purulent drainage from the deep incision but not from the organ/space component of the surgical site. - A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38 C), localized pain, or tenderness, unless site is culture-negative. - An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination. - Diagnosis of a deep incision SSI by a surgeon or attending physician. Note: - Report infection that involves both superficial and deep incision sites as deep incisional SSI. - Report an organ/space SSI that drains through the incision as a deep incisional SSI.

«File 130.042» DelayCause delayCause delayCause
String deviceS deviceS

This field documents devices used in this procedure that are not documented elsewhere.

DiabetesList diabetes diabetes

NSQIP Definition (2004): Diabetes mellitus is a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. Report the treatment regimen of the patient's chronic, long-term management. Do not include a patient if diabetes is controlled by diet alone. No: No diagnosis of diabetes or diabetes controlled by diet alone Oral: A diagnosis of diabetes requiring therapy with an oral hypoglycemic agent (see list of oral hypoglycemic agents in Operations Manual) Insulin: A diagnosis of diabetes requiring daily insulin therapy (see list of insulin therapy agents in Operations Manual)

DiabetesCardiacList diabetesCardiac diabetesCardiac

CICSP Definition (2006): Indicate if the patient has diabetes treated with diet, oral, and/or insulin therapy. Diabetes is defined as a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin therapy. Indicate the one most appropriate response. No - no diagnosis of diabetes. Diet - a diagnosis of diabetes that is controlled by diet alone in the two weeks preceding surgery (the only prescribed treatment has been diabetic relief). Oral - a diagnosis of diabetes requiring therapy with an oral hypoglycemic agent in the two weeks preceding surgery. Insulin - a diagnosis of diabetes requiring daily insulin therapy in the two weeks preceding surgery.

«File 200» NewPerson diagnosticResultsConfirmBy diagnosticResultsConfirmBy

This is the name of the person responsible for verifying that the essential diagnostic procedure requirements, as per medical center policy, are available.

Boolean diagnosticTherapeuticYN diagnosticTherapeuticYN

This indicates if the anesthesia technique is an anesthesia diagnostic/ therapeutic procedure.

Boolean dictatedSummaryExpected dictatedSummaryExpected

This field indicates if the provider will dictate a summary of this procedure to be electronically signed. Enter YES if a dictated summary is expected. Enter NO or leave blank if no summary is expected.

«File 131.01» SurgeryTransportationDevices dischargedVia dischargedVia

This is the code corresponding to the mode of transport used to move the patient from the care area.

String dischargeTransferDate dischargeTransferDate

NSQIP Definition (2004): The date and time of the patient's discharge or transfer from the surgical or medical service to a chronic care setting. i.e., spinal cord injury unit, psychiatric facility or psychiatric unit, nursing home care unit or facility, or intermediate medicine. Acute care beds must be established locally with the assistance of your station IRM service.

SurgeryHistoryList disseminatedCancerYN disseminatedCancerYN

VASQIP Definition (2010): Disseminated cancer: Patients who have cancer known to be present prior to the start of surgery that: (1) Has spread to one site or more sites in addition to the primary site AND (2) In whom the presence of multiple metastases indicates the cancer is widespread, fulminant, or near terminal. Other terms describing disseminated cancer include "diffuse," "widely metastatic," "widespread," or "carcinomatosis", or AJCC "Stage IV" cancer. Common sites of metastases include major organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You may use the National Cancer Institute as a reference in determining whether a patient has AJCC Stage IV cancer, when the TNM information is the only information documented. Refer to the following website for assistance with translating TNM values with AJCC staging: http://www.cancer.gov/cancertopics/pdq/adulttreatment Examples: - A patient with a primary breast cancer with positive nodes in the axilla does NOT qualify for this definition. The tumor has spread to a site other than the primary site, but does not have widespread metastases. A patient with primary breast cancer with positive nodes in the axilla AND liver metastases does qualify, because the tumor has spread to the axilla and other major organs. - A patient with colon cancer and no positive nodes or distant metastases does NOT qualify. A patient with colon cancer and several local lymph nodes positive for tumor, but no other evidence of metastatic disease does NOT qualify. A patient with colon cancer with liver metastases and/or peritoneal seeding with tumor does qualify. - A patient with adenocarcinoma of the prostate confined to the capsule does NOT qualify. A patient with prostate cancer that extends through the capsule of the prostate only does NOT qualify. A patient with prostate cancer with bony metastases DOES qualify. Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.

«File 4» Institution division division
SurgeryHistoryList dnrStatus dnrStatus

NSQIP Definition (2004): If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the only condition under which a DNR order is official in the VA in the 30 days prior to this surgery], enter "YES". If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the patient, enter "YES". Answer "NO" if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order.

String dressing dressing

These are the dressing(s) used for this case. Although optional, this information may be useful in documentation of this case.

DressingConditionList dressingCondition dressingCondition

This is the status of the drainage on the dressing. Although optional, this information may be useful in documentation of this case.

SurgeryHistoryList drugAddiction drugAddiction

This determines whether this patient has a history of recreational or narcotic substance abuse. There is no time limit on this data element.

String dTPatientDischFromIcu dTPatientDischFromIcu

VASQIP Definition (2010): This is the first date and time of the discharge from the intensive care unit (ICU). ICU is usually a surgical unit (SICU), although it may also include a post-anesthesia recovery unit off the operating room. It may also be a general ICU in which medical patients are also managed (MICU, CCU). This will always be the unit into which the patient goes immediately after surgery and is stabilized, ventilated and ultimately extubated. Do not include lower acuity units where the patient goes subsequently (i.e. stepdown, transitional care, telemetry, etc.). Do not include subsequent readmissions to the ICU. RI - The patient remains in ICU at 30 days after surgery.

String dTPatientExtubated dTPatientExtubated

CICSP Definition (2008): Indicate the date that the endotracheal tube is pulled for the first time after surgery. If a tracheostomy is performed to replace an oral intubation tube, intubation is considered continuous so the patient has not been extubated as long as the patient continues to require ventilator support. If the patient dies while intubated, indicate the date of death for this data element. Indicate "extubated prior to leaving the OR" in the Resource Comment if patient is extubated prior to leaving the OR. RI - The patient remains intubated and on ventilator at 30 days after surgery.

SurgeryHistoryList dvtThrombophlebitis dvtThrombophlebitis

VASQIP Definition (2010): The identification of a new blood clot or thrombus within the deep venous system, which may be coupled with inflammation. This diagnosis is confirmed by a duplex, venogram, CT scan or other imaging modality. The patient must be treated with therapeutic anticoagulation therapy, and/or placement of a vena cava filter or clipping of the vena cava or recommended for such.

Boolean dynamedNotified dynamedNotified

YES indicates at least one notification has been sent to DynaMed by way of the CoreFLS interface. A null value or zero indicates no notification has been sent. The first notification sent to DynaMed will be a NEW APPOINTMENT notification. Subsequent notifications will be for edit, cancel or delete notifications, as appropriate.

DyspneaList dyspnea dyspnea

NSQIP Definition (2007): The patient describes difficult, painful, or labored breathing. Dyspnea may be symptomatic of numerous disorders that interfere with adequate ventilation or perfusion of the blood with oxygen. The dyspneic patient is subjectively aware of difficulty with breathing. Select one of the following categories that best indicates the patient's subjective experience coupled with your objective assessment: (1) No dyspnea (2) Dyspnea upon moderate exertion (e.g., is unable to climb one flight of stairs without shortness of breath) (3) Dyspnea at rest (e.g., cannot complete a sentence without needing to take a breath) The time frame is at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's dyspnea status worsens prior to surgery, report the most severe.

SurgeryPreopCompletedList ekgIn24Hrs ekgIn24Hrs

This field determines whether the patient has had an EKG within the last 24 hours.

String electrocauteryUnit electrocauteryUnit

This is information identifying the electrosurgical unit utilized during the operative procedure. The information may include, but is not limited to, unit number, ground pad lot number and/or expiration date, coag setting, cut setting, blend-BI:Setting and Bipolar BP:Setting. Examples: Electrocautery Unit: #7 HP206 COAG:50 CUT:50 BI:1 Electrocautery Unit: DAISY:18% or DAISY BP:18% Electrocautery Unit: VL#2 EXP 3/20/91 COAG:30 CUT:20 BI:2 #2 BP:20 (VL-VALLEYLAB)

«File 138» ElectrogroundPositions electrogroundPosition electrogroundPosition
«File 138» ElectrogroundPositions electrogroundPosition2 electrogroundPosition2

This is the code corresponding to the placement of the second dispersive electrode pad.

Boolean electrophysiologicProcedure electrophysiologicProcedure

This determines whether any procedure was performed with cardiopulmonary bypass to correct an electrophysiologic disturbance, such as resection of bypass tract(s) for WPW or endocardial resection for ventricular tachycardia. (This does not include implantation of automatic internal cardiac defibrillator AICD)

EmploymentStatusPreoperativeList employmentStatusPreoperative employmentStatusPreoperative

Employment status preoperatively is to be defined in the broad sense of regularly performed work activity with remuneration.

String endBp endBp

This is the patient's systolic/diastolic blood pressure at the end of the operative procedure. Although optional, this information may be useful in documentation of this case.

Boolean endocarditis endocarditis

CICSP Definition (2004) Indicate if the chart documents that active endocarditis was present within 30 days postoperatively. Endocarditis is defined as any postoperative intracardiac infection (usually on a valve) documented by two or more positive blood cultures with the same organism, and/or development of vegetations and valve destruction seen by echo or repeat surgery, and/or histologic evidence of infection at repeat surgery or autopsy. Patients with preoperative endocarditis who have the above evidence of persistent infection should be included.

Boolean endovascularRepair endovascularRepair

VASQIP Definition (2010): Indicate if the patient had an endovascular repair of the descending thoracic aorta, ascending aorta, and/or aortic arch (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with or without involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, with or without cardiopulmonary bypass. To include in CICSP, an attending cardiothoracic surgeon must have been present and involved in the procedure. It is typically done under general anesthesia and may be performed in the operating room or interventional radiology operating area.

Integer endPulse endPulse

This is the patient's pulse rate at the end of the operative procedure.

Integer endResp endResp

This is the patient's rate of respiration at the end of the operative procedure. This information may be useful in documentation of this case.

SurgeryPreopCompletedList enemaSIfOrd enemaSIfOrd

This indicates whether the administration of preoperative enema(s) were completed, if ordered.

SurgeryHistoryList esophagealVarices esophagealVarices

NSQIP Definition (2004): Esophageal varices are engorged collateral veins in the esophagus that bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal pressure results in esophageal varices that are most frequently demonstrated by direct visualization at esophagoscopy. Esophageal varices must be present preoperatively and must be documented on a recent EGD or CT scan performed within 6 months prior to the surgical procedure.

String estimatedCaseLength estimatedCaseLength

This is the amount of time estimated to perform this operative procedure. Your answer should be in the format of "HOURS:MINUTES". For example, if the procedure will last 2 and 1/2 hours, your answer would be 2:30.

Integer estimateOfMortality estimateOfMortality

CICSP Definition (2006): This is the physician's (cardiologist or cardiac surgeon) subjective estimate of operative mortality based on the assessment of the total clinical picture. (To avoid bias introduced by knowledge of outcome, this must be completed preoperatively. Do not calculate from the computer program provided to you.)

String estimateOfMortality,Date estimateOfMortality,Date

This is the date and time that the estimate of mortality information was collected.

String esuCoagRange esuCoagRange

This is the power setting range on the Electrosurgical Unit during coagulation. This information is optional, but may be useful in documenting the case.

String esuCuttingRange esuCuttingRange

This is the power setting range on the Electrosurgical Unit during cutting. This information is optional, but may be useful in documenting the case.

SurgeryHistoryList etoh2DrinksDay etoh2DrinksDay

NSQIP Definition (2004): The patient admits to drinking >2 ounces of hard liquor or more than two 12 oz. cans of beer or more than two 6 oz. glasses of wine per day in the two weeks prior to admission. If the patient is a "binge drinker" divide out the numbers of drinks during the binge by seven days, and then apply the definition.

String fev1 fev1

This is the forced expiratory volume in one second from the most recent pulmonary function test prior to surgery. Enter 'NS' if there has been no pulmonary function tests in the preceding year.

Integer finalAnesthesiaTempC finalAnesthesiaTempC

This is the temperature, in degrees centigrade, at the time of the end of anesthesia care.

FinalCountsVerifyCorrectList finalCountsVerifyCorrect finalCountsVerifyCorrect

This is the code corresponding to the status of the final count at the end of the surgical procedure.

«File 200» NewPerson firstAsst firstAsst

This is the name of the person assisting the surgeon during the operative procedure. The information entered here appears on the Operation Report and Nurse Intraoperative Report.

«File 200» NewPerson foleyCatheterInsertedBy foleyCatheterInsertedBy

This is the name of the person accountable for insertion of the Foley catheter. Although this information is optional, it may be useful in documentation of this case.

Integer foleyCatheterSize foleyCatheterSize

This is the size of the Foley catheter.

Boolean foreignBodyRemoval foreignBodyRemoval

This determines whether a procedure was performed to remove any foreign body (e.g. bullet or catheter fragment) from the heart with the aid of cardiopulmonary bypass.

SurgeryPreopCompletedList freshlyShaved freshlyShaved

This indicates whether the patient's facial hair was freshly shaved prior to being transported to the operating room.

FunctionalHealthStatusList functionalHealthStatus functionalHealthStatus

VASQIP Definition (2010): Indicate the appropriate term that describes the level of self-care demonstrated by the patient that summarizes his/her status during the two weeks before surgery: Independent - The patient is independent in activities of daily living (bathing, toilet, eating, dressing, transfer and continence); he/she does not require the assistance of nursing care, equipment, or devices. This would include a patient who is able to function independently with a limb prosthesis. Partially dependent - The patient is partially dependent. He/she requires the use of equipment or devices coupled with assistance from another person for some activities of daily living. Any patient coming from a nursing home setting who is not totally dependent is described by this category. Any patient who requires dialysis for kidney failure or requires chronic oxygen therapy yet maintains independent functions, is considered partially dependent. Totally dependent - The patient is totally dependent and cannot perform ANY activities of daily living on his/her own. For example, this may include a patient in an ICU/floor, who is totally dependent on nursing care, or a dependent nursing home patient. All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs in the same manner as the non-psychiatric patient. For instance, if a patient with schizophrenia is able to care for himself without the assistance of nursing care, he/she is considered independent.

Integer gastricOutput gastricOutput

This is the gastric output during the operative procedure. It is recorded in cc's, and appears on the Nurse Intraoperative Report.

SurgeryHistoryList gastrointestinalYN gastrointestinalYN

This determines whether the patient has a history of gastrointestinal problems such as esophageal varices.

«File 130.05» GeneralComments generalComments generalComments
Boolean generalYN generalYN

This determines whether the patient has any general medical problems, such as diabetes, dyspnea, or alcohol related illnesses.

SurgeryHistoryList graftProsthesisFlapFailure graftProsthesisFlapFailure

NSQIP Definition (2004): Mechanical failure of an extracardiac graft/or prosthesis including myocutaneous flaps and skin grafts requiring return to the operating room, interventional radiology, or a balloon angioplasty.

Boolean greatVesselRepairYN greatVesselRepairYN

CICSP Definition (2006): Indicate if patient had a thoracic great vessel open repair of the aorta (ascending, transverse, and/or descending) or other great vessels, with or without cardiopulmonary bypass, with or without aortic valve replacement, CABG, or other procedure but excluding an endovascular repair of the descending thoracic aorta.

«File 200» NewPerson hairRemovalBy hairRemovalBy
«File 130.0508» HairRemovalComments hairRemovalComments hairRemovalComments
HairRemovalMethodList hairRemovalMethod hairRemovalMethod

This is the method used to remove hair prior to surgery. Shaving is not a preferred method for hair removal. If SHAVING is selected, a comment must be entered in the HAIR REMOVAL COMMENTS field explaining why SHAVING was used. If OTHER is selected, comments must be entered explaining the method used.

String hdlCardiac hdlCardiac

CICSP Definition (2006): Indicate the HDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.

String hdlDate hdlDate

CICSP Definition (2006): Indicate the date that the preoperative HDL value was assessed. Enter "NS" for No Study if the HDL test was not performed.

Boolean headAndOrNeckCancer headAndOrNeckCancer

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Head and/or Neck Cancer. This information may be passed to the VISIT file (#9000010) for use by PCE.

String height height

VASQIP Definition (2010): Height: Report the patient's most recent height before surgery documented in the medical record in either inches (25 to 86 in) or centimeters (63 to 218 cm). If you are entering the patient's height in centimeters, enter 'C' after the number of centimeters. Your answer should be in one of the following two formats. 68 (representing inches) 173C (representing centimeters) The software pulls the most recent height measurement, regardless of when it was taken. The date of the measurement returned by the capture process is displayed on the data input screen.

Datetime heightMeasurementDate heightMeasurementDate

This is the date of the patient's height measurement. This date is taken from the VITALS software.

SurgeryHistoryList hemiplegiaHemiparesisYN hemiplegiaHemiparesisYN

NSQIP Definition (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of one side of the body. Enter YES if the patient has hemiplegia/hemiparesis (that has not recovered or been rehabilitated) upon arrival to the OR. Enter YES if there is hemiplegia or hemiparesis associated with a CVA/Stroke also.

String hemoglobinA1c hemoglobinA1c

CICSP Definition (2006)/NSQIP (2007): Indicate the Hemoglobin A1c result (%) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.

String hemoglobinA1c,Date hemoglobinA1c,Date

CICSP Definition (2006)/NSQIP (2007): Indicate the date that the preoperative Hemoglobin A1c value was assessed. Enter "NS" for No Study if the Hemoglobin A1c test was not performed.

SurgeryHistoryList hepatobiliaryYN hepatobiliaryYN

This determines whether the patient has a history of hepatobiliary illnesses.

SurgeryHistoryList hepatomegaly hepatomegaly

This determines whether the patient has the presence of hepatomegaly. Hepatomegaly is defined as enlargement of the liver indicated usually by palpation of the lower border of the liver below the right costal margin or a liver span greater than 10 cm. Hepatomegaly may be noted in acute hepatitis, fatty infiltration, passive congestion, and early biliary obstruction. It is usually noted by the physician under the abdominal portion of the H&P.

Datetime highAnionGapDate highAnionGapDate

This is the date that the highest postoperative Anion Gap was recorded.

Datetime highCpkDate highCpkDate

This is the date that the highest CPK result was recorded.

Datetime highCpkMbDate highCpkMbDate

This is the date that the highest CPK-MB Band result was recorded.

String highestAnionGap highestAnionGap

This is the result of the highest postoperative anion gap recorded. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestCpk highestCpk

This is the highest result of a postoperative CPK test for the patient selected. Data input must be 1 to 6 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestCpkMb highestCpkMb

This is the highest result of a postoperative CP-MB Band for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer highestGlucose highestGlucose

This is the highest result of a postoperative glucose test for the patient selected.

String highestPotassium highestPotassium

This is the highest result of a potassium test for the selected patient. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestSerumCreatinine highestSerumCreatinine

This is the highest postoperative serum creatinine result for the selected patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestSerumSodium highestSerumSodium

This is the highest result of a postoperative serum sodium test for the selected patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestSerumTroponinI highestSerumTroponinI

This is the result of the highest postoperative serum cardiac troponin I test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestSerumTroponinT highestSerumTroponinT

This is the result of the highest postoperative serum cardiac troponin T test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestTotalBilirubin highestTotalBilirubin

This is the highest postoperative total bilirubin result recorded for this patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String highestWbc highestWbc

This is the highest postoperative WBC for the patient selected. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime highestWbcDate highestWbcDate

This is the date that the highest WBC was recorded.

Datetime highGlucoseDate highGlucoseDate

This is the date that the highest Glucose result was recorded.

Datetime highPotassiumDate highPotassiumDate

This is the date that the highest Potassium result was recorded.

Datetime highSerumCreatinineDate highSerumCreatinineDate

This is the date that the highest Serum Creatinine result was recorded.

Datetime highSerumSodiumDate highSerumSodiumDate

This is the date that the highest Serum Sodium result was recorded.

Datetime highSerumTroponinIDate highSerumTroponinIDate

This is the date that the highest postop serum troponin I was performed.

Datetime highSerumTroponinTDate highSerumTroponinTDate

This is the date that the highest postop serum troponin T was performed.

Datetime highTotalBilirubinDate highTotalBilirubinDate

This is the date that the highest Total Bilirubin was recorded.

Boolean historyOfCopd historyOfCopd

VASQIP Definition (2010): History of severe COPD: Chronic obstructive pulmonary disease (such as emphysema and/or chronic bronchitis) requires a diagnosis of COPD and one or more of the following: - Functional disability from COPD (e.g., dyspnea, inability to perform ADLs) - Hospitalization in the past for treatment of COPD - Requires chronic bronchodilator therapy with oral or inhaled agents - An FEV1 of <75% of predicted on pulmonary function testing Do not include patients whose only pulmonary disease is acute asthma, an acute and chronic inflammatory disease of the airways resulting in bronchospasm. Do not include patients with diffuse interstitial fibrosis or sarcoidosis. CICSP Definition (2004): Indicate if the patient has chronic obstructive pulmonary disease (COPD) resulting in functional disability, and/or hospitalization, and/or requiring chronic bronchodilator therapy, and/or an FEV1 of less than 75% of predicted.

SurgeryHistoryList historyOfMi historyOfMi

NSQIP Definition (2004): The history of a non-Q wave or a Q wave infarct in the six months prior to surgery as diagnosed in the patient's medical record.

SurgeryHistoryList historyOfTias historyOfTias

NSQIP Definition (2004): Transient ischemic attacks (TIAs) are focal neurologic deficits (e.g. numbness of an arm or amaurosis fugax) of sudden onset and brief duration (usually <30 minutes), which usually reflect dysfunction in a cerebral vascular distribution. These attacks may be recurrent and, at times, may precede a stroke.

HomelessList homeless homeless

CICSP Definition (2004): If the patient indicates he/she does not have a fixed dwelling, indicate the person's status as homeless.

String hospitalAdmissionDate hospitalAdmissionDate

NSQIP Definition (2004): The date and time of admission to this VAMC as found in the PIMS package. If the patient was admitted directly to surgery and then admitted to the hospital, use the date of surgery as the date of admission. Enter NA if this date is not applicable. CICSP Definition (2004) Indicate the date and time of the hospital admission associated with this surgical case. Entering NA for "NOT APPLICABLE" is not allowed.

String hospitalDischargeDate hospitalDischargeDate

NSQIP Definition (2004): The date and time of discharge as pulled from the PIMS package. Enter NA if this date is not applicable. CICSP Definition (2004) Indicate the date of the hospital discharge associated with this surgical case. Patients transferred to a referring facility should be indicated as discharged from current admission. Patients transferred to the psychiatric unit or any chronic care facility located at the VA facility (e.g., a nursing home) should be indicated as discharged from current admission at the date and time of the transfer to this different facility. (Do not indicate the date of data input, unless the patient was actually discharged on this same date.) Patients who remain as inpatients for reasons other than for post-open heart procedures should continue to be followed until discharged (including the rehabilitation service) even if the cardiothoracic team discharges the patient from their service or would discharge the patient home. If the patient remains in the hospital and/or has subsequent surgeries, indicate such in the "resource data comments" section.

Boolean hypertension hypertension

CICSP Definition (2004): Indicate if the patient has a documented history of hypertension with or without current treatment of antihypertensive medication(s). If a diuretic agent is prescribed to treat hypertension, indicate Yes for both the hypertension and the diuretic questions. (YES/NO).

SurgeryHistoryList hypertensionRequiringMeds hypertensionRequiringMeds

NSQIP Definition (2004): The patient has a persistent elevation of systolic blood pressure >140 mm Hg or a diastolic blood pressure >90 mm Hg or requires an antihypertensive treatment (e.g., diuretics, beta blockers, ACE inhibitors, calcium channel blockers) at the time the patient is being considered as a candidate for surgery which should be no longer than 30 days prior to surgery. Hypertension must be documented in the patient's chart.

Boolean icd9OnNurseReport icd9OnNurseReport

This field reflects the content of the ICD-9 ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time an automatic addendum is made to the report to determine whether the ICD-9 codes should appear on the report.

SurgeryHistoryList ileusBowelObstruction ileusBowelObstruction

This determines whether the patient has prolonged ileus or bowel obstruction. Ileus is obstruction of the intestines from a variety of causes including mechanical obstruction, peritonitis, adhesions, or post surgically as a result of functional dysmotility by the bowel. Bowel obstruction is any hindrance to the passage of the intestinal contents. Prolonged ileus or obstruction is defined as persisting longer than 5 days postoperatively.

«File 2005» Image2005 image image
«File 130.083» ImagingConfirmedComments imagingConfirmedComments imagingConfirmedComments
Datetime imagTimestamp imagTimestamp

This field is updated whenever the PREOPERATIVE IMAGING CONFIRMED field (#72) is entered or changed.

SurgeryHistoryList impairedSensorium impairedSensorium

NSQIP Definition (2004): Patient is acutely confused and/or delirious and responds to verbal and/or mild tactile stimulation. Patients should be noted to have developed an impaired sensorium if they have mental status changes, and/or delirium in the context of the current illness. Patients with chronic or long-standing mental status changes secondary to chronic mental illness (e.g., schizophrenia) or chronic dementing illnesses (e.g., multi-infarct dementia, senile dementia of the Alzheimer's type) should not be included. This assessment of the patient's mental status should be within 48 hours prior to the surgical procedure. If the patient develops impaired sensorium, then progresses to a coma, and remains in a coma entering surgery, report just coma. Example: A patient is admitted to the orthopedics service after a fall with a fractured hip. The patient is also noted to be dehydrated and febrile. He is disoriented to place and time and seems confused. His family reports that he has been oriented and alert prior to the fall. This patient has an impaired sensorium on the basis of his confusion and disorientation. Example: A patient is admitted to the general surgical service with biliary sepsis and high spiking fevers. While febrile, the patient is noted by the clinician to be disoriented and confused. This patient has an impaired sensorium. Example: A long-term resident of a VA nursing home with chronic schizophrenia is admitted for an elective hernia repair. He is noted to have long-standing mental status changes and is chronically disoriented to place, time, and person. Although this patient has disorientation, his mental status changes are long-standing, chronic, and unchanged and would not qualify for "impaired sensorium." Note: These examples would apply only if noted within 48 hours prior to surgery

IncisionTypeList incisionType incisionType

This describes the incision used for cardiac access, according to the operative report. (Do not include incisions for port access.) Enter NS if incision type is unknown. - Limited Sternotomy: The incision cuts through a small portion (less than half of the length) of the sternum (the narrow, flat bone in the median line of the thorax in the front of the chest). - Full Sternotomy: The incision cuts through the entire length of the sternum (the narrow, flat bone in the median line of the thorax in the front of the chest). - Limited Thoracotomy: A small surgical incision through a portion of the chest wall, but not along the sternum. For example, an anterolateral thoracotomy approach may be used in LIMA to LAD grafting. - Full Thoracotomy: A larger surgical incision running across the chest wall, but not along the sternum. This may be a left submammary incision, which requires the resection of the fourth costal cartilage and /or deflation of the left lung. - Limited Parasternal Approach: The incision cuts beside a small portion (less than 0.5 of the length) of the sternum, on a line midway between the sternal margin and an imaginary line passing through the nipple. - Other Limited Surgical Approach: An incision or incision set used to visualize the operating field that is not listed above.

«File 130.055» IndicationsForOperations indicationsForOperations indicationsForOperations
Datetime inductionComplete inductionComplete

This is the date and time that the anesthetist declares the patient ready for the start of the operative procedure. Although optional, this information may be useful in management studies.

inOrToAnesStart inOrToAnesStart

This is the number of minutes between the time anesthesia care began and time that the patient left the operating room.

inOrToOpStartTime inOrToOpStartTime

This is the time between the time the patient enters the operating room to the operation start time.

InOutPatientList inOutPatientStatus inOutPatientStatus

NSQIP Definition (2004): This field contains the patient's hospital admission status at the time of surgery. Enter the letter "I" if the patient is an inpatient or the letter "O" if he or she was an outpatient. Please follow your hospital's definition of inpatient and outpatient status.

«File 200» NewPerson instCntVerfBy instCntVerfBy

This is the name of the person accountable for verification of the final instrument count.

SurgeryCountCorrectList instrumentCountCorrectYN instrumentCountCorrectYN

This indicates whether the final instrument count was correct for this case. This information appears on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital policy.

SurgeryHistoryList intraopDisseminatedCancer intraopDisseminatedCancer

VASQIP Definition (2010): Intraoperative Disseminated Cancer: Patients who have cancer that was found during the operative procedure that: (1) Has spread to one site or more sites in addition to the primary site AND (2) In whom the presence of multiple metastases indicates the cancer is widespread, fulminant, or near terminal. Other terms describing disseminated cancer include "diffuse," "widely metastatic," "widespread," or "carcinomatosis" or AJCC "Stage IV" cancer. Common sites of metastases include major organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You may use the National Cancer Institute as a reference in determining whether a patient has AJCC Stage IV cancer, when the TNM information is the only information documented. Refer to the following website for assistance with translating TNM values with AJCC staging: http://www.cancer.gov/cancertopics/pdq/adulttreatment Examples: - A patient with a primary breast cancer with positive nodes in the axilla does NOT qualify for this definition. The tumor has spread to a site other than the primary site, but does not have widespread metastases. A patient with primary breast cancer with positive nodes in the axilla AND liver metastases does qualify, because the tumor has spread to the axilla and other major organs. - A patient with colon cancer and no positive nodes or distant metastases does NOT qualify. A patient with colon cancer and several local lymph nodes positive for tumor, but no other evidence of metastatic disease does NOT qualify. A patient with colon cancer with liver metastases and/or peritoneal seeding with tumor does qualify. - A patient with adenocarcinoma of the prostate confined to the capsule does NOT qualify. A patient with prostate cancer that extends through the capsule of the prostate only does NOT qualify. A patient with prostate cancer with bony metastases DOES qualify. * Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.

Boolean intraoperativeAscites intraoperativeAscites

VASQIP Definition (2010): Intraoperative Ascites: The presence of fluid accumulation in the peritoneal cavity noted during the operative procedure. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).

«File 130.13» IntraoperativeOccurrences intraoperativeOccurrences intraoperativeOccurrences
IntraoperativeXRaysList intraoperativeXRays intraoperativeXRays

This indicates if radiology personnel is needed in the operating room for intraoperative radiologic procedures.

String intraopRbcUnitsTransfused intraopRbcUnitsTransfused

NSQIP Definition (2004): Indicate the number of packed or whole red blood cells given during the operative procedure as it appears on the anesthesia record. The amount of blood reinfused from the cell saver should also be noted here. For a cell saver, every 500 cc's of fluid will equal 1 unit of packed cells. If there is less than 250 cc of fluid, enter 0.

Boolean ionizingRadiationExposure ionizingRadiationExposure

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Ionizing Radiation Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.

«File 130.08» Irrigation130_08 irrigation irrigation
Boolean ivAneurysmectomy ivAneurysmectomy

This determines whether the patient had a resection or plication of a left ventricular aneurysm with or without additional procedures.

IvContractionScoreList ivContractionScore ivContractionScore

CICSP Definition (2004): Indicate the left ventricular contraction grade, where the function is assessed from the preoperative contrast ventriculogram, radionuclide angiogram, or 2-D echocardiogram. If ejection fraction is available, indicate the corresponding grade; otherwise, indicate the grade that qualitatively reflects left ventricular function. Ejection fraction is defined as the proportion of blood that is ejected during each ventricular contraction compared with the total ventricular filling volume. Indicate the one most appropriate response: I - Ejection fraction >= 0.55 or narrative reports indicating normal left ventricular function. II - Ejection fraction range from 0.45 to 0.54 or narrative report indicating mild left ventricular dysfunction. IIIa - Ejection fraction range from 0.40 to 0.44 or narrative report indicating moderate left ventricular dysfunction. If "moderate" is the only rating available, select this category. IIIb - Ejection fraction range from 0.35 to 0.39 or narrative report indicating moderately severe left ventricular dysfunction. IV - Ejection fraction range from 0.25 to 0.34 or narrative report indicating severe left ventricular dysfunction. V - Ejection fraction < 0.25 or narrative report indicating very severe left ventricular dysfunction. NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed.

Boolean ivNtgWithin48Hours ivNtgWithin48Hours

This determines whether the patient was administered nitroglycerin intravenously within 48 hours prior to surgery.

«File 200» NewPerson ivStartedBy ivStartedBy

This is the name of the person that started the IV for this operative procedure.

String ladStenosis ladStenosis

CICSP Definition (2004): Indicate the most severe percent stenosis in the left anterior descending coronary artery. Synonyms for this artery include: LAD, AD, and anterior descending (but does not include the diagonals). If there is no obstruction of the LAD, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.

String laserType laserType

This determines whether a laser was used during this procedure. If applicable, enter the type of laser used during this surgical procedure.

«File 130.0129» LaserUnit laserUnit laserUnit
String ldlCardiac ldlCardiac

CICSP Definition (2006): Indicate the LDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.

String ldlDateCardiac ldlDateCardiac

CICSP Definition (2006): Indicate the date that the preoperative LDL value was assessed. Enter "NS" for No Study if the LDL test was not performed.

String leftMainStenosis leftMainStenosis

CICSP Definition (2004): Indicate the most severe percent diameter reduction of the left main coronary artery, including its most distal portion. If there is no obstruction of the left main coronary artery, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.

String lengthOfPostOpStay lengthOfPostOpStay

NSQIP Definition (2004): The software will automatically calculate the total number of days that the patient stayed in the acute care services of the medical center. The number of days should include the day after surgery and the date of discharge or transfer to intermediate or chronic care facilities. Enter NA if LENGTH OF POST-OP STAY is not applicable.

SurgeryPreopCompletedList levinTubeCath levinTubeCath

This indicates whether a Levin tube/catheter is present prior to transport to the operating room.

LockCaseList lockCase lockCase

This indicates whether this case has been completed and locked. Locked cases can only be edited if unlocked by the Chief of Surgery or his or her designee.

Boolean lowCardiacOutput6Hours lowCardiacOutput6Hours

This determines whether the patient has had a postoperative cardiac index of less than 2.0 L/min/M2 and/or peripheral manifestations (e.g. oliguria) of low cardiac output present for 6 or more hours following surgery requiring inotropic and/or intra-aortic balloon pump support.

String lowestHematocrit lowestHematocrit

This is the lowest postoperative hematocrit result recorded for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer lowestSerumAlbumin lowestSerumAlbumin

This is the lowest postoperative serum albumin result for the patient selected.

Datetime lowHematocritDate lowHematocritDate

This is the date that the lowest Hematocrit result was recorded.

String lowPotassium lowPotassium

This is the lowest recorded postoperative potassium result. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime lowPotassiumDate lowPotassiumDate

This is the date that the lowest potassium test result was recorded.

Datetime lowSerumAlbuminDate lowSerumAlbuminDate

This is the date that the lowest Serum Albumin result was recorded.

String lowSerumSodium lowSerumSodium

This is the lowest postoperative serum sodium result recorded within 30 days postoperatively. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime lowSodiumDate lowSodiumDate

This is the date that the lowest serum sodium test result was recorded.

String lvedp lvedp

CICSP Definition (2004): Indicate the patient's left ventricular end-diastolic pressure measured following the a-wave (if present) at the cardiac catheterization most recent prior to surgery. If LVEDP was not measured, entering "NS" for "No Study/Unknown" is also allowed.

MajorMinorList majorMinor majorMinor

NSQIP Definition (2004): Major - Any operation performed under general, spinal, or epidural anesthesia plus all inguinal herniorrhaphies, carotid endarterectomies, parathyroidectomies, thyroidectomies, breast lumpectomies, or endovascular AAA repairs regardless of anesthesia administered. Minor - All operations not designated as Major.

MallampatiScaleList mallampatiScale mallampatiScale

NSQIP Definition (2004): The Mallampati classification relates tongue size to pharyngeal size. This test is performed with the patient in sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum. The subsequent classification is assigned based upon the pharyngeal structures that are visible: Class I - visualization of the soft palate, fauces, uvula, and anterior and posterior pillars. Class II - visualization of the soft palate, fauces, and uvula. Class III - visualization of the soft palate and the base of the uvula. Class IV - soft palate is not visible at all. The classification assigned by the clinician may vary if the patient is in the supine position (instead of sitting). If the patient phonates, this falsely improves the view. If the patient arches his or her tongue, the uvula is falsely obscured. A class I view suggests ease of intubation and correlates with a laryngoscopic view grade I 99 to 100% of the time. Class IV view suggests a poor laryngoscopic view, grade III or IV 100% of the time. Refer to the Operations Manual for a visual depiction of the Mallampati Classification.

Integer mandibularSpace mandibularSpace

In the sitting position with head extended, enter the distance between the inside of the mentum and the top of the thyroid cartilage in millimeters. The mandibular space (MS) and the oral-pharyngeal (OP) score are used in figuring a performance index which is translated to the patient's airway index. (Performance Index = 2.5 x OP - MS length in cm)

«File 130.084» MarkedSiteComments markedSiteComments markedSiteComments
MarkedSiteConfirmedList markedSiteConfirmed markedSiteConfirmed

The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. See applicable VHA Handbooks and Directives for further information and guidance. If entered "NO", a justification should be documented in the Marked Site Comments.

MazeProcedureList mazeProcedure mazeProcedure

CICSP Definition (2006): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt abnormal atrial conduction pathways that cause atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (A Maze does not include an amputation/resection of the atrial appendage as an isolated procedure; an intraoperative electrophysiologic mapping procedure; nor any surgical or ablation procedure conducted on the ventricle for control of ventricular arrhythmias.) Indicate the one most appropriate response: No - No Maze performed Full Maze - The procedure is most often performed on-bypass through a median sternotomy. A combination of incisions and thermal (cryo) or radiofrequency ablations of the atrial wall pathways are done, typically including amputation/resection of the one or both atrial appendices. The procedure thus creates a "maze" of electrical propogation roots involving the entire atrial myocardium with only one side of entrance (the sinus node) and one side of exit (the AV node). Mini-Maze - A more limited and simpler procedure than the traditional full maze, the Mini-Maze is based on the finding that in most patients, ectopic foci located in the pulmonary veins are responsible for the initiation of atrial fib. Radiofrequency or a cryo-ablation probe is used either inside or outside of the pulmonary vein ostia to destroy the foci. It can be performed with or without resection of the atrial appendage and includes no incision or minimal incisions to the left atrium, rather than the extensive atrial surgical procedure conducted for the full Maze. The Mini can be performed on or off bypass through a median sternotomy or performed thorascopically to the outside of the pulmonary veins.

Boolean mediastinitis mediastinitis

CICSP Definition (2004): Indicate if the patient developed a bacterial infection involving the sternum or deep to the sternum requiring drainage and anti-microbial therapy diagnosed within 30 days after surgery.

«File 723» MedicalSpecialty medicalSpecialty medicalSpecialty
«File 130.33» Medications medications medications
Boolean militarySexualTrauma militarySexualTrauma

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Military Sexual Trauma. This information may be passed to the VISIT file (#9000010) for use by PCE.

Boolean minimallyInvasiveProcYN minimallyInvasiveProcYN

Was a minimally invasive procedure technique used, Yes or No?

Integer minIntraopTemperatureC minIntraopTemperatureC

This is the lowest temperature of the patient during the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.

Boolean miscCardiacProcedures miscCardiacProcedures

This determines whether there were any miscellaneous cardiac procedures performed.

MitralRegurgitationList mitralRegurgitation mitralRegurgitation

CICSP Definition (2004): Indicate the severity of any mitral regurgitation documented for the patient. This question should be answered using either the left ventricular angiogram or the cardiac ultrasound examination. Adjectives used to describe the severity of the mitral regurgitation on the cardiac cath report should be converted to a four-point scale: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Diagnosis by angiogram: ======================= The following definitions should be used to assess the presence/severity of mitral regurgitation based on the interpretation of the contrast left ventricular angiogram: None/Trivial - There is no visible systolic regurgitation across the mitral valve. Trace or trivial notations of mitral regurgitation should be listed as none. Mild - Definite contrast can be seen in the left atrium following left ventricular injection, but the left atrium never fills to the same opacity as the left ventricle. Moderate - The left atrium fills to the same opacity as the left ventricle over two or more systoles. Severe - The left atrium fills to the same opacity as the left ventricle over a single systole. NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed. Diagnosis by cardiac ultrasound: ================================ The following definitions are commonly used to assess the presence/severity of mitral regurgitation based on the interpretation of the cardiac ultrasound examination: None/Trivial - No regurgitant jet is seen on the Doppler study. Trace or trivial notations of mitral regurgitation should be listed as none. Mild - The area of the regurgitant jet is 0 - 4 cm2. Moderate - The area of the regurgitant jet is >4 - 8 cm2. Severe - The area of the regurgitant jet is greater than 8 cm2 or greater than one third of the total left atrial area. NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.

ValveProcedureList mitralValveProcedure mitralValveProcedure

VASQIP Definition (2010): Indicate if the patient had a mitral valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other

«File 130.41» Monitors130_41 monitors monitors
Boolean myectomyForIhss myectomyForIhss

This determines whether the patient had a resection of a portion of the interventricular septum for idiopathic hypertrophic subaortic stenosis (IHSS).

SurgeryHistoryList myocardialInfarction myocardialInfarction

NSQIP Definition (2004): A new transmural acute myocardial infarction occurring during surgery or within 30 days following surgery as manifested by new Q-waves on ECG. Non-Q-wave infarctions should be entered under "OTHER".

Boolean myxomaResection myxomaResection

This determines whether a resection of an atrial myxoma was performed.

SurgeryHistoryList neuroDegenerativeDisease neuroDegenerativeDisease

This determines whether the patient has neuromuscular degenerative disease. It is defined as any of a number of congenital, hereditary, or acquired diseases resulting in chronic neurological deficits. Common examples of these diseases include muscular dystrophy, amyotrophic lateral sclerosis (ALS or 'Lou Gerhig's Disease'), multiple sclerosis, and poliomyelitis.

Boolean newMechanicalCirculatory newMechanicalCirculatory

CICSP Definition (2004): Indicate if the patient left the operating room suite with or required post-op placement of a new IABP, ECMO, or VAD for circulatory support within 30 days perioperatively. A "yes" response is appropriate even if the pump is only used for a short time perioperatively. A "yes" response, however, is only correct if the patient did not enter the operating room with this same mechanical circulatory support, and the device insertion occurred AFTER the induction of anesthesia. If patient had/required new mechanical circulatory support, indicate whether the placement occurred intraoperatively or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while patient was in the operating room. - postoperatively: occurring after patient left the operating room. A "no" response is appropriate if the circulatory support device was placed as a prophylaxis before the induction of anesthesia; however, if it was placed for any reason after the induction of anesthesia, then a "yes" response is appropriate. A "no" response is also appropriate if the primary operation is to insert a ventricular assist device.

«File 130.053» NonOperativeOccurrences nonOperativeOccurrences nonOperativeOccurrences
«File 44» HospitalLocation nonOrLocation nonOrLocation

This is the location (file 44) where this non-OR procedure was performed.

NonOrProcedureList nonOrProcedure nonOrProcedure

This field is a flag signifying this case is a non-OR surgical procedure.

SurgeryPreopCompletedList npoAsOrdClinMid npoAsOrdClinMid

This indicates whether NPO orders were completed prior to the operative procedure as ordered by the surgeon.

Integer numberWithIma numberWithIma

This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with internal mammary arteries (IMA) regardless of whether other procedures were performed. Do not leave this field blank. If no coronary artery bypass grafts were performed, enter '0'.

Integer numberWithOtherArtery numberWithOtherArtery

This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with other artery(ies). Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.

Integer numberWithOtherConduit numberWithOtherConduit

CICSP Definition (2004): This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other conduit(s) regardless of whether other procedures were performed. Do not leave this information blank. If no coronary artery bypass grafts with other conduits were performed, enter '0'.

Integer numberWithRadialArtery numberWithRadialArtery

This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with radial artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with radial artery. Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.

Integer numberWithVein numberWithVein

This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with vein regardless of whether other procedures were performed. Do not leave this information blank. If no coronary artery bypass grafts were performed, enter '0'.

Integer numOfConcurrentAnesCases numOfConcurrentAnesCases

Including this case, enter the number of cases that the anesthesiologist supervised where the time of the anesthesia care overlapped with this care. This field is required to support billing for the care and is critical for accurate coding of the primary anesthesia procedure. Enter a zero if the anesthesiologist personally performed the care. Enter 1 if the principal anesthetist was not an anesthesiologist and was medically directed by an anesthesiologist.

NumOfPriorHeartSurgeriesList numOfPriorHeartSurgeries numOfPriorHeartSurgeries

CICSP Definition (2006): Indicate the number of previous heart surgeries the patient has had upon current admission, by referencing the patient history. The prior heart surgery/ies would have occurred during a separate hospitalization (more than 30 days prior to current surgery). Both on and off-pump cardiac surgical procedures should be considered. Count all surgical procedures performed during separate hospital admissions (not the number of grafts, and not additional procedures performed during the same admission due to a postoperative occurrence). Indicate the one appropriate response: 0, 1, 2, 3, >3.

Datetime nursePresentTime nursePresentTime

This is the date and time that the nurse was present in the operating room. Times entered without a date will be converted to the date of operation at that time.

«File 130.07» NursingCareComments nursingCareComments nursingCareComments
SurgeryHistoryList nutritionalImmuneOther nutritionalImmuneOther

This determines whether the patient has a history of illness related to nutrition, immune deficiencies or other general deficiencies.

String observationAdmissionDate observationAdmissionDate

NSQIP Definition (2004): An observation patient is one who presents with a medical condition with a significant degree of instability or disability, and who needs to be monitored, evaluated and assessed for either admission to inpatient status or assignment to care in another setting. An observation patient can occupy a special bed set aside for this purpose or may occupy a bed in any unit of a hospital, i.e., urgent care, medical unit. These types of patients should be evaluated against standard inpatient criteria. These beds are not designed to be a holding area for Emergency Rooms. The length-of-stay in observation beds will not exceed 23 hours. Following surgery, if the patient was admitted for observation, this is the date and time of admission for observation. If this information is not applicable, enter NA.

String observationDischargeDate observationDischargeDate

NSQIP Definition (2004): If the patient was admitted for observation following surgery, this is the date and time of discharge from observation. If this information in not applicable, enter NA.

«File 42.4» Specialty observationTreatingSpecialty observationTreatingSpecialty
Boolean occurrenceNoProcedure occurrenceNoProcedure

This indicates that this case was a occurrence, not related to a surgical procedure.

SurgeryHistoryList onVentilator48Hours onVentilator48Hours

NSQIP Definition (2004): Total duration of ventilator-assisted respirations during postoperative hospitalization was >48 hours. This can occur at any time during the 30-day period postoperatively. This time assessment is CUMULATIVE, not necessarily consecutive. Ventilator-assisted respirations can be via endotracheal tube, nasotracheal tube, or tracheostomy tube. CICSP Definition (2007): Indicate if the total duration of ventilator-assisted respiration within 30 days post-operatively was greater than or equal to 48 hours.

«File 131.6» SurgeryDisposition opDisposition opDisposition
SurgeryHistoryList openWound openWound

NSQIP Definition (2007): Evidence of an open wound that communicates to the air by direct exposure, with or without cellulitis or purulent exudate. This does not include osteomyelitis or localized abscesses. The wound must communicate to the air by direct exposure. Report mandible fractures under this preoperative variable.

«File 131.7» OperatingRoom131_7 operatingRoom operatingRoom
Integer operationsThisAdmission operationsThisAdmission

This is the total number of surgical procedures, prior to the index or principal operation, which required the patient to be taken to the operating room for any type of surgical intervention during this hospital admission. Include all procedures whether or not they are part of the inclusion/exclusion criteria.

operationTime operationTime

This is the number of minutes between the operation start and end times.

Boolean operativeDeath operativeDeath

CICSP Definition (2006): Indicate if the patient died within the 30 days after surgery in or out of the hospital regardless of cause; or within the index hospitalization regardless of cause; or patient died greater than 30 days as a direct result of a perioperative occurrence of the surgery (e.g., mediastinitis). ("Discharge" can be noted when the patient leaves the Acute Care arena.)

«File 130.059» OperativeFindings operativeFindings operativeFindings
SurgeryPreopCompletedList oralHygiene oralHygiene

This indicates whether the patient's oral hygiene was completed prior to being transported to the operating room.

«File 130.28» OrCircSupport orCircSupport orCircSupport
Datetime orCleanEndTime orCleanEndTime

This is the date and time when the 'end of case' or terminal cleaning ended. Times entered without a date will be converted to the date of operation at that time.

Datetime orCleanStartTime orCleanStartTime

This is the date and time when the 'end of case' or terminal cleaning began. Times entered without a date will be converted to the date of operation at that time.

orCleanUpTime orCleanUpTime

This is the number of minutes between the OR clean up start time and OR clean up end time.

«File 100» Order orderNumber orderNumber
SurgeryHistoryList organSpaceSsi organSpaceSsi

NSQIP Definition (2004): Organ/Space SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation and at least one of the following: - Purulent drainage from a drain that is placed through a stab wound into the organ/space. - Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. - An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination. - Diagnosis of an organ/space SSI by a surgeon or attending physician. Site-Specific Classifications of Organ/Space Surgical Site Infection -------------------------------------------------------------------- Arterial or venous infection Meningitis or ventriculitis Breast abscess or mastitis Myocarditis or pericarditis Disc space Oral cavity (mouth, tongue, or Ear, mastoid gums) Endocarditis Osteomyelitis Endometritis Other infections of the lower Eye, other than conjunctivitis respiratory tract (e.g. abscess Gastrointestinal tract or empyema) Intra-abdominal, not specified Other male or female reproductive elsewhere tract Intracranial, brain abscess or Sinusitis dura Spinal abscess without meningitis Joint or bursa Upper respiratory tract Mediastinitis Vaginal cuff

«File 130.36» OrScrubSupport orScrubSupport orScrubSupport
Integer orSetUpTime orSetUpTime

This is the number of minutes (0-999) necessary to prepare the operating room for the admission of the patient for the surgical procedure.

«File 80» ICDDiagnosis otherCardiacOccurrence otherCardiacOccurrence

NSQIP Definition (2004): Enter any other cardiac related surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-9-CM code for this entry.

String otherCardiacProcedures otherCardiacProcedures

CICSP Definition (2004): This is the free text description of other procedures requiring cardiopulmonary bypass that were performed on this patient at the same time as the primary cardiac procedure.

String otherCardiacProceduresList otherCardiacProceduresList

CICSP Definition (2006): Specify if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass.

Boolean otherCardiacProceduresYN otherCardiacProceduresYN

CICSP Definition (2006): Indicate if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass (YES/NO).

«File 80» ICDDiagnosis otherCnsOccurrence otherCnsOccurrence

NSQIP Definition (2004): Enter any other neurologic related occurrences, which you feel to be significant and that are not covered by the predefined CNS occurrence categories. Enter the ICD-9-CM code for this entry.

String otherNonCtProcedures otherNonCtProcedures

CICSP Definition (2004): If any other procedure - other than cardiothoracic - performed requiring placing the patient on cardiopulmonary bypass, specify details into the comment field. If no other non-CT procedure requiring CPB was performed, indicate "NS" for "No Study/Unknown" in the text field.

SurgeryHistoryList otherOccurrences otherOccurrences

This determines whether the patient has had postoperative occurrences, such as Graft/Prosthesis Failure or Unplanned Return to OR, not included in any of the other categories.

«File 80» ICDDiagnosis otherOccurrencesIcd9 otherOccurrencesIcd9

NSQIP Definition (2004): Enter any other surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-9-CM code for this entry.

«File 130.24» OtherPersonsInOr otherPersonsInOr otherPersonsInOr
«File 130.18» OtherPostopDiags otherPostopDiags otherPostopDiags
«File 130.17» OtherPreopDiagnosis otherPreopDiagnosis otherPreopDiagnosis
«File 130.16» OtherProcedures otherProcedures otherProcedures
Boolean otherProceduresYN otherProceduresYN

This determines whether the patient had any other surgical procedure on the heart and/or great vessels (including AICD placement) requiring cardiopulmonary bypass.

«File 80» ICDDiagnosis otherRespiratoryOccurrence otherRespiratoryOccurrence

NSQIP Definition (2004): Enter any other respiratory occurrences that you feel to be significant and that are not covered by the predefined respiratory occurrence categories. Enter the ICD-9-CM code for this entry.

«File 130.23» OtherScrubbedAssistants otherScrubbedAssistants otherScrubbedAssistants
Boolean otherTumorResection otherTumorResection

CICSP Definition (2004): Indicate if patient had resection of any tumor other than atrial myxoma from the heart either with or without placing the patient on cardiopulmonary bypass.

«File 80» ICDDiagnosis otherUrinaryTractOccurrence otherUrinaryTractOccurrence

NSQIP Definition (2004): Enter any other urinary occurrences which you feel to be significant and that are not covered by the predefined urinary tract occurrence categories. Enter the ICD-9-CM code for this entry.

«File 80» ICDDiagnosis otherWoundOccurrence otherWoundOccurrence

NSQIP Definition (2004): Enter any other wound occurrences that you feel to be significant and that are not covered by the predefined wound occurrence categories. Enter the ICD-9-CM code for this entry. (Example: Seromas, ICD-9-CM code: 998.13)

PackingList packing packing

This is the code corresponding to the type of packing placed during the procedure that will remain in place when the patient is discharged from the operating room.

String packYears packYears

NSQIP Definition (2004): If the patient has ever been a smoker, enter the total number of pack/years of smoking for this patient. Pack-years are defined as the number of packs of cigarettes smoked per day times the number of years the patient has smoked. If the patient has never been a smoker, enter "0". If pack-years are >200, just enter 200. If smoking history cannot be determined, enter "NS". The possible range for number of pack-years is 0 to 200. If the chart documents differing values for pack year cigarette history, or ranges for either packs/day or number of years patient has smoked, select the highest value documented, unless you are confident in a particular documenter's assessment (e.g., preoperative anesthesia evaluation often includes a more accurate assessment of this value because of the impact it may have on the patient's response to anesthesia).

Integer pacUAdmitScore pacUAdmitScore

This is the objective evaluation numerical score of the patient upon admission to the post anesthesia care unit.

Integer pacUDischScore pacUDischScore

This is the objective evaluation numeric score of the patient at discharge from the post anesthesia care unit.

Datetime pacUDischTime pacUDischTime

This is the date/time that the patient is discharged from the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time. NSQIP Definition (2004): Discharge from Post-Anesthesia Care Unit (DPACU): Time patient is transported out of PACU.

«File 131.6» SurgeryDisposition pacuDisposition pacuDisposition

This is the code corresponding to the destination of the patient immediately after release from the post-anesthesia care unit.

pacUTime pacUTime

This is the number of minutes the patient spent in the PAC(U).

SurgeryHistoryList paraplegiaYN paraplegiaYN

NSQIP Definition (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of the lower extremities.

String paSystolicPressure paSystolicPressure

CICSP Definition (2004): For patients having a right heart catheterization, indicate the patient's pulmonary artery (PA) systolic pressure at the catheterization most recent prior to surgery. PA pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.

«File 2» Patient patient patient
PatientEducationAssessmentList patientEducationAssessment patientEducationAssessment

This indicates whether preoperative patient education and assessment, with documentation of a care plan, were completed during the perioperative care of the patient.

patientInOrTime patientInOrTime

This is the number of minutes the patient was in the operating room.

SurgeryPreopCompletedList patientVoided patientVoided

This indicates whether the patient voided prior to being transported to the operating room.

String pawMeanPressure pawMeanPressure

CICSP Definition (2004): For patients having a right heart catheterization, indicate the patient's mean pulmonary artery wedge (PAW) [also called pulmonary capillary] pressure or left atrial pressure measured at the catheterization most recent prior to surgery. PAW pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart or transseptal catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.

PCIList pci pci

CICSP Definition (2004): Indicate whether/when the patient had a percutaneous coronary intervention (PCI) prior to surgery. Previously, this data field was listed as a percutaneous transluminal coronary angiography (PTCA) [e.g., balloon angioplasty, directional coronary atherectomy (DCA), transluminal extraction catheter (TEC), stent, rotoblader, etc.] Indicate the one appropriate response, even if the procedure was not fully successful.

«File 200» NewPerson perfusionist perfusionist

This is the name of the person operating the cardio-pulmonary or organ perfusion apparatus. Although not required, this information may be valuable in documenting the case. If entered, it will appear on the Nurse Intraoperative Report.

Boolean pericardiectomy pericardiectomy

This determines whether the patient had a resection of the parietal pericardium with the aid of cardiopulmonary bypass. (NOTE: most pericardiectomies are performed without cardiopulmonary bypass)

Boolean perioperativeMi perioperativeMi

NSQIP Definition (2004): A new transmural acute myocardial infarction occurring during surgery or within 30 days following surgery as manifested by new Q-waves on ECG. Non-Q-wave infarctions should be entered under "OTHER". CICSP Definition (2007): Indicate the presence of a peri-operative MI if at least one of the following criteria occurs either intraoperatively or postoperatively within 30 days: 1. Evolutionary ST-segment elevations 2. Development of new Q-waves in two or more contiguous ECG leads 3. New or presumably new LBBB pattern on the ECG.

SurgeryHistoryList peripheralNerveInjury peripheralNerveInjury

NSQIP Definition (2007): Peripheral nerve damage may result from damage to the nerve fibers, cell body, or myelin sheath during surgery. Peripheral nerve injuries which result in motor deficits only to the cervical plexus, brachial plexus, ulnar plexus, lumbar-sacral plexus (sciatic nerve), peroneal nerve, and/or the femoral nerve should be included.

Boolean peripheralVascularDisease peripheralVascularDisease

This determines whether the patient has peripheral vascular disease. Peripheral vascular disease is defined as disease of the arteries to legs below bifurcation of aorta manifested by external claudication, and/or ischemic rest pain, and/or prior revascularization procedure(s) on vessels to legs, and/or absent or diminished pulses in legs, and/or angiographic evidence of noniatrogenic peripheral arterial obstruction greater than or equal to 50% of luminal diameter.

«File 375» PFSSAccount pfssAccountReference pfssAccountReference
Integer pgyOfPrimarySurgeon pgyOfPrimarySurgeon

NSQIP Definition (2004): Enter the number of surgical residency postgraduate years of the primary surgeon (1-12). Enter 0 if the primary surgeon is a staff/attending surgeon and not a surgical resident or fellow. PGYs greater than 12 should be reported as '12'.

«File 80» ICDDiagnosis plannedPrinDiagnosisCode plannedPrinDiagnosisCode

This is the planned principal postoperative ICD9 diagnosis code assigned by the clinician.

«File 81» CPT plannedPrinProcedureCode plannedPrinProcedureCode
SurgeryHistoryList pneumonia pneumonia

NSQIP Definition (2007): Inflammation of the lungs caused primarily by bacteria, viruses, and/or chemical irritants, usually manifested by chills, fever, pain in the chest, cough, purulent, bloody sputum. Enter YES if the patient has pneumonia meeting the definition of pneumonia below AND pneumonia not present preoperatively. Pneumonia must meet one of the following TWO criteria: Criterion 1. Rales or dullness to percussion on physical examination of chest AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolate from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy OR Criterion 2. Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolated from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy d. Isolation of virus or detection of viral antigen in respiratory secretions e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen f. Histopathologic evidence of pneumonia *If pneumonia was present preoperatively and resolved postoperatively and a new pneumonia is identified within 30 days after surgery, the following criteria must be met in order to report as a postoperative pneumonia occurrence: - Patient must have completed the antibiotic course for the previous pneumonia. - Patient must have evidence of a clear chest x-ray after the previous pneumonia and prior to the new pneumonia. - There must be evidence of a new isolate of micro-organism on culture.

«File 130.1» PostopAnesNote postopAnesNote postopAnesNote
Datetime postopAnesNoteDate postopAnesNoteDate

This is the date and time that the postoperative note is written in the patient's chart. Times entered without a date will be converted to the date of operation at that time.

Boolean postopAtrialFibrillation postopAtrialFibrillation

VASQIP Definition (2010) Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been present preoperatively.

Boolean postopAttendingConcurrence postopAttendingConcurrence

This field serves as a flag that the attending concurs with the postoperative workup.

SurgeryHistoryList postopBleedingTransfusions postopBleedingTransfusions

NSQIP Definition (2004): Any transfusion (including autologous) of packed red blood cells or whole blood given from the time the patient leaves the operating room up to and including 72 hours postoperatively. Enter YES for five or more units of packed red blood cell units in the postoperative period including hanging blood from the OR that is finished outside of the OR. If the patient receives shed blood, autologous blood, cell saver blood or pleurovac postoperatively, this is counted if greater than four units. The blood may be given for any reason.

String postopBp postopBp

This is the patient's blood pressure upon admission to the care area immediately after the surgical procedure. Although this information is optional, it may be useful in documentation of this case.

«File 135.4» PatientConsciousness postopConscious postopConscious

This is the code corresponding to the assessment of the patient's level of consciousness following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.

PostopConversList postopConvers postopConvers

This is the code corresponding to the assessment of the patient's demonstrated verbal responses at the completion of the surgical procedure.

«File 135.3» PatientMood postopMood postopMood

This is the code corresponding to the assessment of the patient's mood following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.

«File 130.22» PostopOccurrence postopOccurrence postopOccurrence
Integer postopPulse postopPulse

This is the pulse rate of the patient upon admission to the care area immediately after the surgical procedure.

Integer postopResp postopResp

This is the respiratory rate of the patient upon admission to the care area immediately after the surgical procedure.

PostopSkinColorList postopSkinColor postopSkinColor

This is the code corresponding to the patient's skin color after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.

«File 135.2» SkinIntegrity postopSkinInteg postopSkinInteg

This is the code corresponding to the assessment of the patient's skin integrity after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.

Boolean preAdmissionTesting preAdmissionTesting

This indicates whether pre-admission testing was complete. It will be reflected on the Schedule of Operations for outpatients.

PregnancyList pregnancy pregnancy

NSQIP Definition (2007): Pregnancy is the process by which a woman carries a developing fetus in her uterus, beginning at conception and ending in birth, miscarriage or abortion. Answer Yes if there is documentation in the patient's medical record that the patient is currently pregnant.

Datetime preopAlkPhosphataseDate preopAlkPhosphataseDate

This is the date that the preoperative alkaline phosphatase test was performed.

Datetime preopAnionGapDate preopAnionGapDate

This is the date the preoperative Anion Gap was recorded.

Boolean preopAtrialFibrillation preopAtrialFibrillation

VASQIP Definition (2010): This field indicates whether atrial fibrillation or flutter is present within two weeks of the procedure. Enter YES or NO. Note: NS is not allowed.

Boolean preopAttendingConcurrence preopAttendingConcurrence

This field serves as a flag that the attending has concurred with the preoperative workup.

String preopBloodPressure preopBloodPressure

This is the most recent ward recorded blood pressure of the patient prior to transport to the operating room. Although optional, this information may be useful for documentation of this case.

PreopCirculatoryDeviceList preopCirculatoryDevice preopCirculatoryDevice

VASQIP Definition (2010): Indicate whether there was any use of any device to assist ventricular function at the time the patient presents for surgery (or placed in the OR before anesthesia induction). Indicate the one appropriate response: None - No New Mechanical Circulatory Device was placed. IABP - An intra-aortic balloon pump was placed to assist ventricular function. VAD - A ventricular assist device (e.g., LVAD, BIVAD) was placed to assist ventricular function. Artificial Heart - An artificial heart was placed to assist ventricular function. Other - An other type of Mechanical Circulatory Device was placed.

«File 135.4» PatientConsciousness preopConscious preopConscious
PreopConverseList preopConverse preopConverse

This is the preoperative assessment of the patient's demonstrated verbal responses upon arrival to the operating room. Although optional, this field may be valuable in documenting this case.

String preoperativeAlkPhosphatase preoperativeAlkPhosphatase

This is the result of the preoperative alkaline phosphatase test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String preoperativeAnionGap preoperativeAnionGap

This is the result of the preoperative Anion Gap calculation. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String preoperativeBun preoperativeBun

This is the result of the preoperative Blood Urea Nitrogen (BUN) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime preoperativeBunDate preoperativeBunDate

This is the date that the preoperative BUN was performed.

Integer preoperativeCpk preoperativeCpk

This is the result of the preoperative creatinine phosphokinase (CPK) test.

Datetime preoperativeCpkDate preoperativeCpkDate

This is the date that the preoperative CPK was performed.

Integer preoperativeGlucose preoperativeGlucose

This is the result of the preoperative glucose test.

Datetime preoperativeGlucoseDate preoperativeGlucoseDate

This is the date that the preoperative glucose test was performed.

Integer preoperativeHeartRate preoperativeHeartRate

This is the most recent ward-recorded heart rate of the patient prior to transport to the operating room.

String preoperativeHematocrit preoperativeHematocrit

This is the result of the preoperative hematocrit test. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String preoperativeHemoglobin preoperativeHemoglobin

CICSP Definition (2004) Indicate the patient's hemoglobin result (g/dl) preoperatively evaluated closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No Study/Unknown" is not allowed.

Datetime preoperativeHemoglobin,Date preoperativeHemoglobin,Date

This is the date that the preoperative hemoglobin test was performed.

PreoperativeImagingConfirmedList preoperativeImagingConfirmed preoperativeImagingConfirmed

This field refers to the completion of the verification process for the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. This practice is further defined by local hospital policy. If entered "NO", a justification should be documented in the Imaging Confirmed Comments.

String preoperativeInr preoperativeInr

This is the result of the preoperative INR (International Normalized Ratio). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime preoperativeInrDate preoperativeInrDate

This is the date that the preoperative INR was performed.

Integer preoperativeMbBand preoperativeMbBand

This is the value of the preoperative methyline blue (MB) band. Your answer must be between 0 and 50.

Datetime preoperativeMbBandDate preoperativeMbBandDate

This is the date that the preoperative MB Band was performed.

String preoperativePlateletCount preoperativePlateletCount

This is the result of the preoperative platelet count. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer preoperativePotassium preoperativePotassium

This is the result of the preoperative potassium test.

String preoperativePt preoperativePt

This is the result of the preoperative prothombin time (PT). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer preoperativePtControl preoperativePtControl

This is the result of the preoperative PT control. Your answer must be between 9 and 15.

Datetime preoperativePtDate preoperativePtDate

This is the date that the preoperative PT test was performed.

String preoperativePtt preoperativePtt

This is the result of the preoperative partial thromboplastin time (PTT). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer preoperativePttControl preoperativePttControl

This is the preoperative PTT control result. Your answer must be between 15 and 40.

Datetime preoperativePttDate preoperativePttDate

This is the date that the preoperative PTT test was performed.

PreoperativeSepsisList preoperativeSepsis preoperativeSepsis

NSQIP Definition (2007): Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. Please report the most significant level using the criteria below: 1. SIRS (Systemic Inflammatory Response Syndrome): SIRS is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following: - Temp >38 degrees C or <36 degrees C - HR >90 bpm - RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa) - WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms - Anion gap acidosis: this is defined by either: [Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is greater than 16, then an anion gap acidosis is present. or Na - [Cl + HCO3 (or serum CO2)]. If this number is greater than 12, then an anion gap acidosis is present. 2. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS listed above and one of the following: - positive blood culture - clinical documentation of purulence or positive culture from any site thought to be causative 3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents.

String preoperativeSerumAlbumin preoperativeSerumAlbumin

This is the result of the preoperative serum albumin test. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for NSQIP assessments. CICSP Definition (2004) Indicate the patient's serum albumin result (g/dl) preoperatively evaluated closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No Study/Unknown" is also allowed.

String preoperativeSerumCreatinine preoperativeSerumCreatinine

This is the serum creatinine result (mg/dl) most closely preceding surgery. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for NSQIP assessments. CICSP Definition (2004) Indicate the patient's Serum Creatinine result (mg/dl) preoperatively evaluated closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No Study/Unknown" is not allowed.

String preoperativeSerumSodium preoperativeSerumSodium

This is the result of the preoperative serum sodium test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

String preoperativeSgot preoperativeSgot

This is the result of the preoperative serum glutamic oxaloacetic (SGOT) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Integer preoperativeSgpt preoperativeSgpt

This is the result of the preoperative serum glutamic pyruvic transaminase (SGPT) test.

PreoperativeSleepApneaList preoperativeSleepApnea preoperativeSleepApnea

VASQIP Definition (2010): Sleep Apnea is a disorder of respiration whereby the individual has hypoxic and/or apneic periods during sleep due to prolapse or flaccidity of oropharyngeal structures, which improves with positive airway pressure (i.e., CPAP or BIPAP). Select one of the following categories that best indicates the patient's level of sleep apnea. - Level 1 = None: No diagnosis or suspicion of Sleep Apnea - Level 2 = Suspicion of Sleep Apnea: No sleep study has been done, however the patient has TWO or MORE of the following risk factors for Sleep Apnea (Anesthesiology 2006; 104: 1081-1093): a) Obesity (BMI > 35) b) Thick neck (men > 17 inches, women > 16 inches) c) Snoring, loud or frequent d) Observed apneas (partner/roommate reported observing obstruction episodes during sleep) e) Frequent arousals from sleep or choking during sleep f) Daytime somnolence g) Patient reports diagnosis of sleep apnea even if sleep study results are not in the medical record - Level 3 = Sleep Apnea: Sleep apnea confirmed by Sleep Study OR patient currently uses/was prescribed CPAP/BIPAP at home

String preoperativeTotalBilirubin preoperativeTotalBilirubin

This is the result of the preoperative total bilirubin test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Boolean preoperativeUseOfIabp preoperativeUseOfIabp

This determines whether there was any use of an intra-aortic balloon pump (IABP) within the two weeks prior to surgery.

String preoperativeWbc preoperativeWbc

This is the result of the preoperative white blood count (WBC). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.

Datetime preoperativeWbcDate preoperativeWbcDate

This is the date that the preoperative WBC test was performed.

PreopFunctHealthStatusList preopFunctHealthStatus preopFunctHealthStatus

NSQIP Definition (2008): This is a question that focuses on the patient's abilities to perform activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are defined as 'the activities usually performed in the course of a normal day in a person's life'. ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level of self-care for activities of daily living demonstrated by this patient at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's status changes prior to surgery, that change should be reflected in your assessment. For this time point, report the level of functional health status as defined by the following criteria. (1) Independent: The patient does not require assistance from another person for any activities of daily living. This includes a person who is able to function independently with prosthetics, equipment, or devices. (2) Partially dependent: The patient requires some assistance from another person for activities of daily living. This includes a person who utilizes prosthetics, equipment, or devices but still requires some assistance from another person for ADLs. (3) Totally dependent: The patient requires total assistance for all activities of daily living. (4) Unknown: If unable to ascertain the functional status for the time point of 'prior to the current illness' only, report as unknown. All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with schizophrenia is able to care for him/herself without the assistance of nursing care, he/she is considered independent.

Datetime preopHematocritDate preopHematocritDate

This is the date that the preoperative hematocrit was performed.

SurgeryPreopCompletedList preopMedAndRailUp preopMedAndRailUp

This indicates whether preoperative medication was administered and the side rails of the bed were placed in the 'up' position.

«File 135.3» PatientMood preopMood preopMood
Datetime preopPlateletCountDate preopPlateletCountDate

This is the date that the preoperative platelet count was performed.

Datetime preopPotassiumDate preopPotassiumDate

This is the date that the preoperative potassium test was performed.

Integer preopRespiratoryRate preopRespiratoryRate

this is the most recent ward-recorded respiratory rate of the patient prior to transport to the operating room.

Datetime preopSerumAlbuminDate preopSerumAlbuminDate

This is the date that the preoperative Serum Albumin test was performed.

Datetime preopSerumCreatinineDate preopSerumCreatinineDate

This is the date that the preoperative Serum Creatinine test was performed.

Datetime preopSerumSodiumDate preopSerumSodiumDate

This is the date that the preoperative serum sodium test was performed.

PreopSkinColorList preopSkinColor preopSkinColor

This is the code corresponding to the preoperative assessment of the patient's skin color upon arrival to the operating room. If entered, this information will appear on the Nurse Intraoperative Report.

«File 135.2» SkinIntegrity preopSkinInteg preopSkinInteg
Integer preopTemperature preopTemperature

This is the most recent ward-recorded temperature of the patient prior to transport to the operating room.

Datetime preopTotalBilirubinDate preopTotalBilirubinDate

This is the date that the preoperative total bilirubin was performed.

Integer preopWeightKg preopWeightKg

This is the most recent ward-recorded weight of the patient prior to transport to the operating room.

SurgeryHistoryList previousCardiacSurgery previousCardiacSurgery

NSQIP Definition (2006): Any major cardiac surgical procedure (performed either as an 'off-pump' repair or utilizing cardiopulmonary bypass). This includes coronary artery bypass graft surgery, valve replacement or repair, repair of atrial or ventricular septal defects, great thoracic vessel repair, cardiac transplant, left ventricular aneurysmectomy, insertion of left ventricular assist devices, etc. Do not include pacemaker insertions or automatic implantable cardioverter-defibrillator (AICD) insertions.

SurgeryHistoryList previousPci previousPci

NSQIP Definition (2007): The patient has undergone or has had an attempt at percutaneous coronary intervention at any time. This includes either balloon dilatation or stent placement. This does not include valvuloplasty procedures.

PrimaryCauseForDelayList primaryCauseForDelay primaryCauseForDelay

CICSP Definition (2008): This field contains the primary cause for delay. If a Cardiac patient's surgery is greater than 30 days from initial VA Cardiothoracic Surgery Consultation (as calculated between the CT CONSULT DATE to DATE OF SURGERY), user shall enter cause as defined in the field. If date is less than or equal to 30 days, system shall automatically default entry to None. - Resource Limitation: Due to staffing or other facility limitation, e.g., OR scheduling, physician availability, ICU bed capacity - Patient Health: Due to patient health issue, e.g., vascular consult, additional tests - Patient Preference: Due to a non-health related patient preference, e.g., vacation - Other - NS/Unknown: Unable to Locate Reason for Delay. Entering "NS" for "No Study/Unknown" is also allowed. - None

«File 130.275» PrinAssocDiagnosis prinAssocDiagnosis prinAssocDiagnosis
«File 200» NewPerson princAnesthetist princAnesthetist

This is the name of the principal anesthesiologist or CRNA (or surgeon, if local anesthesia). This information is extremely important for the Anesthesia Report.

String principalDiagnosis principalDiagnosis

This is the principal diagnosis for which the non-OR procedure is being performed.

String principalPostOpDiag principalPostOpDiag

This is the principal postoperative diagnosis.

String principalPreOpDiagnosis principalPreOpDiagnosis

This is the preoperative diagnosis for which the surgical procedure is being performed.

String principalProcedure principalProcedure

This is the name of the principal procedure for this case. All cases must have a principal procedure. The principal procedure must be 3 to 135 characters in length. The procedure name must not contain a semicolon (;), an at-sign (@), an up- arrow (^) or control characters. If the procedure name is longer than 30 characters, it must contain at least one space in every 31 characters of length. If a comma is being used to separate information, a space should follow the comma. NSQIP Definition (2004): The most complex of all the procedures by the primary operating team during this trip to the operating room. Your answer must be at least 3 characters in length. Do not enter an additional procedure if it is covered by a single CPT code. (Note that a single CPT code can cover more than one procedure, e.g., cholecystectomy and common bile duct exploration have a single CPT code). Additional procedures requiring separate CPT codes and/or concurrent procedures will be entered separately below. An exploratory laparotomy should be entered as the principal operative procedure only when no other procedure eligible for assessment has been performed in that particular surgical case.

«File 80» ICDDiagnosis prinPreOpIcdDiagnosisCode prinPreOpIcdDiagnosisCode
«File 130.028» PrinProcedureCptModifier prinProcedureCptModifier prinProcedureCptModifier
String priorHeartSurgeries priorHeartSurgeries

CICSP Definition (2004): Indicate all applicable types of heart surgery performed, occurring during a separate hospitalization (more than 30 days prior to current surgery), either on or off-pump. Indicate all appropriate responses: None - Patient has not had a previous cardiac surgery procedure CABG-only - Patient has had a previous coronary artery bypass graft (CABG-only) procedure Valve-only - Patient has had a previous valve-only procedure CABG/valve - Patient has had a previous combination CABG/valve procedure Other - Patient has had a previous cardiac procedure(s) not indicated in this list CABG/other - Patient has had a previous combination CABG/other procedure(s) not indicated in this list

PriorMiList priorMi priorMi

This determines whether the patient has a history of non-Q wave or Q wave myocardial infarction as diagnosed in his or her medical records. Select the appropriate category.

«File 130.0126» ProcedureOccurrence procedureOccurrence procedureOccurrence
ProcedureTypeList procedureType procedureType

CICSP Definition (2004): Indicate which test was used for the cardiac catheterization and/or angiographic data. Indicate the one most appropriate response: Cath - A diagnostic procedure in which a catheter is introduced into a large vein, usually of an arm or leg, and threaded through the circulatory system to the heart to determine blood pressure and the rate of flow in the vessels and chambers of the heart and the identification of abnormal anatomy. IVUS - Intravascular Ultrasound may be used either alone or in combination with results from the cardiac catheterization. If used alone, indicate IVUS as the only test from which procedure results are calculated. Both - If both IVUS and Cath are available and both tests were analyzed for the results, indicate Both/Combination. NS - If no cath study is available, entering NS for "No Study/Unknown" is also allowed.

Boolean proj112Shad proj112Shad

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to PROJ 112/SHAD. This information may be passed to the VISIT file (#9000010) for use by PCE.

«File 130.01» ProsthesisInstalled prosthesisInstalled prosthesisInstalled
SurgeryPreopCompletedList prosthesisRem prosthesisRem

This indicates whether prosthetics (dentures, jewelry, hair pieces) have been removed prior to transport to the operating room.

«File 200» NewPerson provider provider

This is the person who performs the major portion of the principal non-OR procedure. This field is required for several reports.

SurgeryHistoryList pulmonaryEdema pulmonaryEdema

This determines whether the patient has developed postoperative distress requiring treatment and diagnosis of CHF or pulmonary edema or Adult Respiratory Distress Syndrome.

SurgeryHistoryList pulmonaryEmbolism pulmonaryEmbolism

NSQIP Definition (2007): Lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous system. Enter "YES" if the patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram or positive Spiral CT exam. Treatment usually consists of: - Initiation of anticoagulation therapy - Placement of mechanical interruption (e.g. Greenfield Filter), for patients in whom anticoagulation is contraindicated or already instituted.

Boolean pulmonaryRales pulmonaryRales

CICSP Definition (2004): Indicate if the chart documents rales not clearing with cough (and not due to pneumonic process) heard within two weeks before surgery. Do not include rales that clear with coughing, as these are usually due to atelectasis and carry a much more benign connotation. Please note, crackles are another common approach to noting that rales are present.

ValveProcedureList pulmonaryValveProcedure pulmonaryValveProcedure

VASQIP Definition (2010): Indicate if the patient had a pulmonary valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other

SurgeryHistoryList pulmonaryYN pulmonaryYN

This determines whether the patient has a history of pulmonary illnesses.

SurgeryHistoryList quadriplegiaYN quadriplegiaYN

NSQIP Definition (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of all four extremities.

SurgeryRaceList race race

This is the race of the patient. This is a standard set of codes and should not be edited.

SurgeryHistoryList radiotherapyInLast90Days radiotherapyInLast90Days

NSQIP Definition (2004): Enter "YES" if the patient had any radiotherapy treatment for cancer in the 90 days prior to surgery. If the patient had radiation seeds implanted, count if implantation is within 90 days prior to the operation.

ReadyToTransmitList readyToTransmit readyToTransmit

This field is set to R (ready) by a MUMPS cross reference the TIME PAT OUT OR field. When this case is transmitted to the national database at the end of the quarter, this field will be updated to T (transmitted). This field serves as a flag that indicates the transmission status of this case.

ReasonForNoAssessmentList reasonForNoAssessment reasonForNoAssessment

This is the reason why no assessment was entered for this particular surgical case. It should be entered if any major procedure was excluded from the risk assessment module. 0 - Non-surgeon performed the procedure 2 - Number of surgical cases entered into the Surgical Risk Study exceeded 36 over an 8 day time frame 3 - Number of TURPs or TURBTs exceeded 5 cases over an 8 day time frame 4 - Study exclusion criteria prohibits patient entry 6 - Surgical Clinical Nurse Reviewer was on Annual Leave 8 - Case was a concurrent case, secondary to an assessed primary case 9 - Number of hernias exceeded 5 cases over an 8 day time frame

SurgeryPreopCompletedList recAndXrayReady recAndXrayReady

This indicates whether the patient's x-rays and records are complete.

String reDoCircumflexStenosis reDoCircumflexStenosis

CICSP Definition (2004): If a re-do, indicate the most severe percent stenosis in the graft to the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for bypass grafting. Entering "NS" for "No Study/Unknown" is also allowed.

String reDoLadStenosis reDoLadStenosis

CICSP Definition (2004): If a re-do, indicate the most severe percent stenosis in the graft to the left anterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.

SurgeryHistoryList redoProcedure redoProcedure

This determines whether the principal operative procedure was a reoperation in the same anatomic location for the same purpose as the first operation regardless of the length of time from the original surgical date.

String reDoRtCoronaryStenosis reDoRtCoronaryStenosis

CICSP Definition (2004): If a re-do, indicate the most severe percent stenosis in the graft to the right coronary artery or posterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.

«File 130.03» ReferringPhysician referringPhysician referringPhysician
«File 200» NewPerson reliefAnesthetist reliefAnesthetist

This is the name of the anesthetist relieving the principal anesthetist, if applicable. If entered, this information appears on the Anesthesia Report.

SurgeryHistoryList renalFailure renalFailure

NSQIP Definition (2004): The clinical condition associated with rapid, steadily increasing azotemia (increase in BUN), and a rising creatinine of above 3 mg/dl. Acute renal failure should be noted within 24 hours prior to surgery.

SurgeryHistoryList renalInsufficiency renalInsufficiency

NSQIP Definition (2004): The reduced capacity of the kidney to perform its function as evidenced by a rise in creatinine of >2 mg/dl from preoperative value, but with no requirement for dialysis.

SurgeryHistoryList renalYN renalYN

This determines whether the patient has a history of renal illnesses.

Boolean reoperationForBleeding reoperationForBleeding

CICSP Definition (2004): Indicate if there was any re-exploration of the thorax for suspected bleeding within 30 days of surgery.

Boolean repeatCardiacSurgProcedure repeatCardiacSurgProcedure

CICSP Definition (2004): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or within 30 days of the initial operation.

Boolean repeatVentilatorWIn30Days repeatVentilatorWIn30Days

CICSP Definition (2008): Indicate if the patient was placed on ventilator support postoperatively within 30 days and this repeat ventilator support is related to the index operation (For example, the patient is on the ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is discontinued. Later, the patient gets into trouble and mechanical ventilation has to be reinstated.) However, if the patient returns to the OR within 30 days and gets extubated immediately after, it is not considered repeat ventilator support.

«File 130.04» ReplacementFluidType replacementFluidType replacementFluidType
ReqAnesthesiaTechniqueList reqAnesthesiaTechnique reqAnesthesiaTechnique

This is the surgeon's choice of anesthesia for the proposed operative procedure. This information will appear on the Schedule of Operations.

Boolean reqBloodAvail reqBloodAvail

This indicates whether the requested blood components are available.

«File 130.14» ReqBloodKind reqBloodKind reqBloodKind
ReqCleanOrContaminatedList reqCleanOrContaminated reqCleanOrContaminated

This is the description of the wound class for the case. The code entered is used when scheduling the operating room for this procedure.

Boolean reqFrozSect reqFrozSect

This indicates whether laboratory support is needed to perform frozen section diagnostic tests during the operative procedure.

Boolean reqPhoto reqPhoto

This indicates whether Medical Media personnel need to be present in the operating room to obtain photographs during the operative procedure.

«File 131.6» SurgeryDisposition reqPostopCare reqPostopCare
String reqPreopXRay reqPreopXRay

These are the types of preop x-ray films and reports required for delivery to the operating room prior to the surgical procedure.

Boolean requestBloodAvailability requestBloodAvailability

This determines whether blood will be requested for this surgical procedure. Enter 'YES' if blood will be requested. Otherwise, enter 'NO'.

Integer requested requested

This indicates whether this case was requested.

SurgeryHistoryList respiratoryOccurrences respiratoryOccurrences

This determines whether the patient had postoperative respiratory occurrences. A respiratory occurrence is defined as an impairment to the lungs to perform their ventilatory function. This may be due to impairment of gas exchange in the lung or obstruction of the free flow of air to the lung.

Boolean restingStDepression restingStDepression

This determines whether the patient has a ST-segment depression greater than or equal to 1 mm in any lead on standard resting electrocardiogram (ECG), and/or ECG diagnosis of subendocardial ischemia, left ventricular strain, or left ventricular hypertrophy with repolarization abnormality.

SurgeryHistoryList restPainGangreneYN restPainGangreneYN

NSQIP Definition (2007): Rest pain is a more severe form of ischemic pain due to occlusive disease, which occurs at rest and is manifested as a severe, unrelenting pain aggravated by elevation and often preventing sleep. Gangrene is a marked skin discoloration and disruption indicative of death and decay of tissues in the extremities due to severe and prolonged ischemia. Include patients with ischemic ulceration and/or tissue loss related to peripheral vascular disease. Do not include Fournier's gangrene. Report only if within the 30 days preoperatively.

«File 130.31» RestrAndPositionAids restrAndPositionAids restrAndPositionAids
Integer reTransmission reTransmission

This determines whether the assessment will be re-transmitted. It will automatically be set to '1' when a transmitted assessment is updated to an INCOMPLETE status to edit and re-transmit.

«File 130.43» ReturnedToSurgery returnedToSurgery returnedToSurgery
SurgeryHistoryList returnToOrWithin30Days returnToOrWithin30Days

NSQIP Definition (2004): Returns to the operating room include all surgical procedures that required the patient to be taken to the surgical operating room for intervention of any kind will automatically be entered by the software.

SurgeryHistoryList revascularizationAmputation revascularizationAmputation

NSQIP Definition (2004): Any type of angioplasty or revascularization procedure for atherosclerotic peripheral vascular disease (PVD) (e.g., aorto-femoral, femoral-femoral, femoral-popliteal) or a patient who has had any type of amputation procedure for PVD (e.g., toe amputations, transmetatarsal amputations, below the knee or above the knee amputations). Patients who have had amputation for trauma or a resection of abdominal aortic aneurysms should not be included.

«File 130.0904» ReviewOfDeathComments reviewOfDeathComments reviewOfDeathComments
String rightCoronaryStenosis rightCoronaryStenosis

CICSP Definition (2004): Indicate the most severe percent stenosis in the right coronary artery. Include the proximal third of the posterior descending coronary artery. The right coronary artery initially runs in the groove between the right ventricle and right atrium; it usually gives off branches to both the right and left ventricles and the right atrium. The branches to the right atrium (sinus node artery) and right ventricle (conus branch and acute marginal branches) are commonly ignored when describing coronary artery disease. However, the right coronary artery is the most common source for the posterior descending coronary artery and often gives-off branches to the posterior-lateral free wall of the left ventricle. These are often known as left ventricular extension branches and are considered branches of the circumflex for the coding of severity of coronary disease. If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.

Datetime scheduledEndTime scheduledEndTime

This is the date and time that this operative procedure is scheduled to end.

String scheduledProcedure scheduledProcedure

This field contains the scheduled (or original) principal procedure for this case. It will be compared to the actual procedure completed.

Datetime scheduledStartTime scheduledStartTime

This is the date and time that this operative procedure is scheduled to begin.

«File 200» NewPerson secondAsst secondAsst

This is the name of the second person assisting the surgeon during the operative procedure. If entered, this information appears on the Operation Report and Nurse Intraoperative Report.

«File 135.1» SkinPrepAgents secondSkinPrepAgent secondSkinPrepAgent

This is the name of the SECOND antimicrobial agent used to wash and prepare the operative site. Although optional, this information may be useful in documentation of the case.

Boolean sequentialCompressionDevice sequentialCompressionDevice

This determines whether a sequential compression device was used.

String serumBilirubinCardiac serumBilirubinCardiac

CICSP Definition (2004): Indicate the serum bilirubin result (mg/dl) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.

String serumBilirubinDateCard serumBilirubinDateCard

CICSP Definition (2004): Indicate the date that the preoperative Serum Bilirubin value was assessed. Enter "NS" for No Study if the Serum Bilirubin test was not performed or was performed more than 90 days before surgery.

String serumPotassiumCardiac serumPotassiumCardiac

CICSP Definition (2004): Indicate the serum potassium result (mg/L) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.

String serumPotassiumDateCardiac serumPotassiumDateCardiac

CICSP Definition (2004): Indicate the date that the preoperative Serum Potassium value was assessed. Enter "NS" for No Study if the Serum Potassium test was not performed or was performed more than 90 days before surgery.

String serumTriglycerideCardiac serumTriglycerideCardiac

CICSP Definition (2006): Indicate the Serum Triglyceride result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.

String serumTriglycerideDateCar serumTriglycerideDateCar

CICSP Definition (2006): Indicate the date that the preoperative Serum Triglyceride value was assessed. Enter "NS" for No Study if the Serum Triglyceride test was not performed.

Boolean serviceConnected serviceConnected

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a service connected problem. This information may be passed to the VISIT file (#9000010) for use by PCE.

SurgeryHistoryList severeHeadTraumaYN severeHeadTraumaYN

This determines whether the patient has sustained open or closed trauma to the head from external force, violence, or accident with resulting impairment in neurological function as manifested by motor, sensory, or cognitive impairments.

Datetime sgotDatePerformed sgotDatePerformed

This is the date that the preoperative SGOT was performed.

Datetime sgptDatePerformed sgptDatePerformed

This is the date that the preoperative SGPT was performed.

SurgeryCountCorrectList sharpsCountCorrectYN sharpsCountCorrectYN

This indicates whether the final sharps count was correct. If entered, this information will appear on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital policy.

Datetime siteMarkTimestamp siteMarkTimestamp

This field is updated whenever the MARKED SITE CONFIRMED field (#73) is entered or changed.

«File 135.1» SkinPrepAgents skinPrepAgents skinPrepAgents
«File 200» NewPerson skinPreppedBy1 skinPreppedBy1

This is the name of the person responsible for applying the agent used to wash and prepare the operative site. If entered, this information will appear on the Nurse Intraoperative Report.

«File 200» NewPerson skinPreppedBy2 skinPreppedBy2

This is the name of a second person performing skin preparation, if applicable. When entered, this information appears on the Nurse Intraoperative Report.

«File 200» NewPerson skinPreppedBy3 skinPreppedBy3

This is the name of the third person performing the preoperative skin preparation. If entered, this information will appear on the Nurse Intraoperative Report.

Boolean southwestAsiaConditions southwestAsiaConditions

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem related to service in SW Asia. This information may be passed to the VISIT file (#9000010) for use by PCE.

«File 130.8» SpdComments spdComments spdComments
«File 130.049» Specimens specimens specimens
SurgeryCountCorrectList spongeCountCorrectYN spongeCountCorrectYN

This indicates whether the final sponge count was correct. If entered, this information will appear on the Nurse Intraoperative Report.

«File 200» NewPerson spongeSharpsAndInstCounter spongeSharpsAndInstCounter

This is the name of the person doing the final count of sponges, sharps and instruments. If entered, this information appears on the Nurse Intraoperative Report.

StaffResidentList staffResident staffResident

This determines whether the surgeon was a resident or staff. It will be used for categorizing procedures in the Annual Report of Surgical Procedures.

SurgeryHistoryList steroidUseForChronicCond steroidUseForChronicCond

NSQIP Definition (2004): Patient has required the regular administration of oral or parenteral corticosteroid medications (e.g., Prednisone, Decadron) in the 30 days prior to admission for a chronic medical condition (e.g., COPD, asthma, rheumatologic disease, rheumatoid arthritis, inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally. Do not include patients who only receive short course steroids (duration 10 days or less) in the 30 days prior to surgery. (See list of corticosteroids in Operations Manual.)

Boolean stroke stroke

CICSP Definition (2004): Indicate if there was any new objective neurologic deficit lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after surgery.

SurgeryHistoryList strokeCva strokeCva

NSQIP Definition (2004): Patient develops an embolic, thrombotic, or hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory) that persist for 24 or more hours. CICSP Definition (2004): Indicate if there was any new objective neurologic deficit lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after surgery.

SurgeryHistoryList superficialIncisionalSsi superficialIncisionalSsi

NSQIP Definition (2004): Superficial incisional SSI is an infection that occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following: - Purulent drainage, with or without laboratory confirmation, from the superficial incision. - Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. - At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by the surgeon, unless incision is culture-negative. - Diagnosis of superficial incisional SSI by the surgeon or attending physician. Do not report the following conditions as SSI: - Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration). - Infected burn wound. - Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).

«File 200» NewPerson surgeon surgeon
«File 130.15» SurgeonsDictation surgeonsDictation surgeonsDictation
String surgeryConsultDate surgeryConsultDate

Indicate the date that the patient was first consulted by Surgery for the operation as typically documented by a note by a member of Surgery Specialty that will perform the procedure (e.g., attending surgeon, fellow, nurse). For non-cardiac assessments, enter NA if this date is not applicable or cannot be determined. For Cardiothoracic (CT) Surgery, this date is usually on or just after the diagnostic catheterization date.

String surgeryConsultRequested surgeryConsultRequested

This is the date that the patient's physician requests that Surgery Service consult with the patient. It is not the date that the consult took place. Enter NA if this date is not applicable or cannot be determined.

«File 130.065» SurgeryPosition130_065 surgeryPosition surgeryPosition
«File 137.45» LocalSurgicalSpecialty surgerySpecialty surgerySpecialty
Datetime surgicalPriorityDate surgicalPriorityDate

This is the date and time that the cardiac surgical priority information was collected.

Datetime surgPresentTime surgPresentTime

This is the date and time that the surgeon is available to begin the operative procedure. Although not mandatory, this information is useful for evaluating hospital delays.

«File 200» NewPerson surgSchedPerson surgSchedPerson

This is the name of the person requesting or scheduling this operative procedure.

SurgeryHistoryList systemicSepsis systemicSepsis

NSQIP Definition (2007): Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. Please report the most significant level using the criteria below: 1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following: - Temp >38 degrees C or <36 degrees C - HR >90 bpm - RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa) - WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms - Anion gap acidosis: this is defined by either: [Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is greater than 16, then an anion gap acidosis is present. or Na - [Cl + HCO3 (or serum CO2)]. If this number is greater than 12, then an anion gap acidosis is present. and one of the following: - positive blood culture - clinical documentation of purulence or positive culture from any site thought to be causative 2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents. * For the patient that had sepsis preoperatively, worsening of any of the above signs postoperatively would be reported as a postoperative sepsis. Examples: A patient comes into the emergency room with signs of sepsis - WBC 31, Temperature 104. CT shows an abdominal abscess. He is given antibiotics and is then taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively. Postoperatively his WBC and Temperature are trending down. POD#1 WBC 24, Temp 102 POD#2 WBC 14, Temp 100 POD#3 WBC 10, Temp 99 This patient does not have postoperative sepsis as his WBC and Temperature are improving each postoperative day. Patient comes into the ER with s/s of sepsis - WBC 31, Temp 104. CT shows an abdominal abscess. He is given antibiotics and is taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively. Postoperatively his WBC and Temp are as follows: POD#1 WBC 28, Temp 103 POD#2 WBC 24, Temp 102.6 POD#3 WBC 22, Temp 102 POD#4 WBC 21, Temp 101.6 POD#5 WBC 30, Temp 104 This patient does have postoperative sepsis because on postoperative day #5, his WBC and Temperature increase. The patient is having worsening of the defined signs of sepsis.

«File 130.32» Thermal Unit thermalUnit thermalUnit
Datetime timeNurseOutOfOr timeNurseOutOfOr

This is the date and time that the circulating nurse completed duties for the operative procedure and left the operating room.

Datetime timeOperationBegan timeOperationBegan

This is the date and time that the operation began. The definition of this time is usually 'knife fall', but may vary according to local surgery service protocol. NSQIP Definition (2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure).

Datetime timeOperationEnds timeOperationEnds

NSQIP Definition (2004): Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, indicate the time the patient was pronounced dead.

Boolean timeOutVerified timeOutVerified

This field refers to the completion of a "Time Out" verification process prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider. This practice is further defined by local hospital policy. If entered "NO", a justification should be documented in the Time Out Verified Comments.

«File 130.082» TimeOutVerifiedComments timeOutVerifiedComments timeOutVerifiedComments
Datetime timePatInHoldArea timePatInHoldArea

This is the date and time that the patient arrived in the holding area. Times entered without a date will be converted to the date of operation at that time.

Datetime timePatInOr timePatInOr

This is the date and time that the patient was transported into the operation room. Times entered without a date will be converted to the date of operation at that time. NSQIP Definition (2004): Patient in Room (PIR): Time when patient enters the OR/PR.

Datetime timePatOutOr timePatOutOr

This is the date and time that the patient is taken from the operating room. Times entered without a date will be converted to the date of operation at that time. This information is very significant for operating room management studies. NSQIP Definition (2004): Patient Out of Room (POR): Time at which patient leaves OR/PR. CICSP Definition (2004): Indicate the time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element.

Datetime timeProcedureBegan timeProcedureBegan

This is the date and time that the non-OR procedure began.

Datetime timeProcedureEnded timeProcedureEnded

This is the date and time that all the procedures for this non-OR case are complete.

«File 130.02» TimeTourniquetApplied timeTourniquetApplied timeTourniquetApplied
«File 8925» TIUDocument tiuAnesthesiaReport tiuAnesthesiaReport

This is the Anesthesia Report for this case.

«File 8925» TIUDocument tiuNurseIntraopReport tiuNurseIntraopReport

This is the Nurse Intraoperative Report for this case stored in TIU.

«File 8925» TIUDocument tiuOperativeSummary tiuOperativeSummary
«File 8925» TIUDocument tiuProcedureReportNonOr tiuProcedureReportNonOr

This is the Procedure Report (Non-OR) for this non-OR procedure.

Boolean tmr tmr

CICSP Definition (2004): Indicate if patient received a transmyocardial laser procedure (TMR) to make "channels" or small holes directly into the heart muscle, either with or without placing the patient on cardiopulmonary bypass. The TMR may be done in combination with a CABG procedure or as a stand-alone procedure.

String totalCholesterolCardiac totalCholesterolCardiac

CICSP Definition (2006): Indicate the Total Cholesterol result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.

String totalCholesterolDate totalCholesterolDate

CICSP Definition (2006): Indicate the date that the preoperative Total Cholesterol value was assessed. Enter "NS" for No Study if the Cholesterol test was not performed.

Integer totalCpbTime totalCpbTime

Record in minutes the total cardiopulmonary bypass time. This includes the total duration of full and partial cardiopulmonary bypass from all episodes of cardiopulmonary bypass. This information can generally be found on the perfusionist record and/or the anesthesia record.

Integer totalIschemicTime totalIschemicTime

Record in minutes the duration of time the ascending aorta is totally cross-clamped. Do not include the duration of partial aorta cross-clamp used for sewing the proximal anastomoses.

Integer totalUrineOutputMl totalUrineOutputMl

This is the total number of milliliters (0-100000) of urine output during the operative procedure. If entered, this information appears on the Nurse Intraoperative Report.

Datetime tovTimestamp tovTimestamp

This field is updated whenever the TIME OUT VERIFIED field (#71) is entered or changed.

Boolean tracheostomy tracheostomy

CICSP Definition (2004): Indicate if a procedure to cut into the trachea and insert a tube to overcome tracheal obstruction or to facilitate extended mechanical ventilation was performed within 30 days of surgery.

TransferStatusList transferStatus transferStatus

NSQIP Definition (2004): Was the patient transferred directly from another healthcare facility and admitted to this hospital? Please select from the following choices. If the patient was admitted from home, select #1. If the patient was transferred from another facility, please select from choices #2-6. (1) Not transferred from a health care facility; admitted directly from home (2) Non-VAMC Acute Care Hospital (3) VAMC Acute Care Hospital (4) Non-VA Nursing Home/Chronic Care Facility/Spinal Cord Injury Unit/Intermediate Care Unit (5) VA Nursing Home/Chronic Care Facility/Spinal Cord Injury Unit/Intermediate Care Unit (6) Other (for example, Domiciliary) * If a patient arrives from another hospital's emergency department, report as #1. If you cannot determine what kind of facility, enter "OTHER".

SurgeryHistoryList transfusion4RbcUnits transfusion4RbcUnits

NSQIP Definition (2004): Preoperative loss of blood necessitating a minimum of 5 units of whole blood/packed red cells transfused during the 72 hours prior to surgery including any blood transfused in the emergency room.

«File 131.01» SurgeryTransportationDevices transToOrBy transToOrBy
ValveProcedureList tricuspidValveProcedure tricuspidValveProcedure

VASQIP Definition (2010): Indicate if the patient had a tricuspid valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other

String tubesAndDrains tubesAndDrains

This is the type and placement of tubes and drains during the operative process.

SurgeryHistoryList tumorInvolvingCnsYN tumorInvolvingCnsYN

NSQIP Definition (2007): Space-occupying tumor of the brain and spinal cord, which may be benign (e.g., meningiomas, ependymoma, oligodendroglioma) or primary (e.g., astrocytoma, glioma, glioblastoma multiform) or secondary malignancies (e.g., metastatic lung, breast, malignant melanoma). Other tumors that may involve the CNS include lymphomas and sarcomas. Answer "YES" even if the tumor was not treated. A patient with metastatic cancer with boney mets to spine is a CNS tumor. Answer "NO" if tumor was removed.

SurgeryPreopCompletedList uAIn48Hrs uAIn48Hrs

This indicates whether the patient has had a urinalysis within 48 hours prior to being transported to the operating room.

SurgeryHistoryList unplannedIntubationYN unplannedIntubationYN

NSQIP Definition (2004): Patient required placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated for their surgery, unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated during surgery, intubation at any time after their surgery is considered unplanned.

SurgeryHistoryList urinaryTractInfection urinaryTractInfection

NSQIP Definition (2004): Postoperative symptomatic urinary tract infection must meet one of the following TWO criteria: 1. One of the following: fever (>38 degrees C), urgency, frequency, dysuria, or suprapubic tenderness AND a urine culture of >100,000 colonies/ml urine with no more than two species of organisms OR 2. Two of the following: fever (>38 degrees C), urgency, frequency, dysuria, or suprapubic tenderness AND any of the following: - Dipstick test positive for leukocyte esterase and/or nitrate - Pyuria (>10 WBCs/cc or >3 WBC/hpf of unspun urine) - Organisms seen on Gram stain of unspun urine - Two urine cultures with repeated isolation of the same uropathogen with >100 colonies/ml urine in non-voided specimen - Urine culture with <100,000 colonies/ml urine of single uropathogen in patient being treated with appropriate antimicrobial therapy - Physician's diagnosis - Physician institutes appropriate antimicrobial therapy

SurgeryHistoryList urinaryTractOccurrences urinaryTractOccurrences

This determines whether the patient has had postoperative urinary tract occurrences. Urinary tract occurrences are defined as difficulties related to the organs and ducts participating in the secretion and elimination of urine.

«File 200» NewPerson validIdConsentConfirmedBy validIdConsentConfirmedBy

This is the name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record.

SurgeryPreopCompletedList valuablesSecured valuablesSecured

This indicates whether the patient's valuables have been secured according to hospital policy.

ValveRepairList valveRepair valveRepair

CICSP Definition (2006): Indicate if the patient has had any reparative procedure to a native valve, either with or without placing the patient on cardiopulmonary bypass. Valve repair is defined as a procedure performed on the native valve to relieve stenosis and/or correct regurgitation (annuloplasty, commissurotomy, etc.); the native valve remains in place. Indicate the one appropriate response.

SurgeryHistoryList vascularYN vascularYN

This determines whether the patient has any vascular problems.

SurgeryHistoryList ventilatorDependent ventilatorDependent

NSQIP Definition (2004): A preoperative patient requiring ventilator-assisted respirations at any time during the 48 hours preceding surgery. This does not include the treatment of sleep apnea with CPAP.

«File 200» NewPerson verifier verifier

This is the person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure.

«File 9000010» Visit visit visit
Boolean vsdRepair vsdRepair

This determines whether the patient had a procedure performed to repair a ventricular septal defect.

Datetime waitTimeStart waitTimeStart

This is start of the patient's "wait" for Surgery. Typically, this is the date that the patient was notified that Surgery is needed.

String weight weight

VASQIP Definition (2010): Weight: Report the patient's most recent weight before surgery documented in the medical record in either pounds (50 to 999 lbs) or kilograms (23 to 453 kg). If you are entering the patient's weight in kilograms, enter 'K' after the number of kilograms. The software pulls the latest value up to 30 days prior to surgery. If no value is found in the Vitals software, the nurse reviewer must enter the value manually. Your answer should be in one of the following formats. 178 (weight in pounds) 80K (weight in Kilograms)

SurgeryHistoryList weightLoss10Percent weightLoss10Percent

NSQIP Definition (2007): A >10% decrease in body weight in the six month interval immediately preceding surgery as manifested by serial weights in the chart, as reported by the patient, or as evidenced by change in clothing size or severe cachexia. Exclude patients who have intentionally lost weight as part of a weight reduction program.

WoundClassificationList woundClassification woundClassification

NSQIP Definition (2007): Indicate whether the wound has been classified by the primary surgeon as: >> Class 1 - Clean (C): Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed drainage. Surgical incisional wounds that occur with nonpenetrating (eg blunt) trauma should be included in this category if they meet the criteria. [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.] Examples: - Exploratory laparotomy - Mastectomy or breast reduction - Neck dissection - Nonpenetrating blunt trauma - Thyroidectomy - Total hip replacement - Vascular operations (e.g. AAA, AV fistula, CEA, aortoiliac bypass) - Hernia repair - CABG, AVR - Craniotomy, majority neurosurgery - Pleura biopsy - Sternotomy - Abdominoplasty - Bone anchored hearing aids (BAHA) - Penile prosthesis placement - Dupuytren's release, finger - Liposuction - Carpal tunnel release - Hydrocele repair >> Class 2 - Clean/Contaminated (CC): Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered. (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.) Examples: - Bronchoscopy - Routine appendectomy - Cholecystectomy (e.g., any approach) - Laryngectomy - Small bowel resection - Oropharynx entered - GYN procedures - Vagina entered - Whipple pancreaticoduodenectomy - Pulmonary resection - Transurethral resection of prostate - Head & Neck cancer operations (e.g., oropharynx) - Sigmoid colectomy - Minor break in technique - Gastrointestinal or respiratory tract entered without significant spillage - Genitourinary tract entered in absence of infected urine >> Class 3 - Contaminated (D): Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category. Examples: - Appendectomy for gangrenous appendicitis - Bile spillage during cholecystectomy - Diverticulitis - Laparotomy for penetrating injury with intestinal spillage - Entrance of genitourinary or biliary tracts in presence of infected urine or bile - Necrotic tissue without evidence of purulent drainage (e.g. dry gangrene) >> Class 4 - Dirty/Infected (I): Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the surgical field before the procedure. (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.) Examples: - Excision and drainage of abscess - Myringotomy for otitismedia - Perforated bowel - Peritonitis (abdominal exploration for acute bacterial peritonitis) - Acute bacterial inflammation, without pus - Transection of 'clean' tissue for the purpose of surgical access to a collection of pus - Traumatic wound with foreign bodies, fecal contamination, or delayed treatment, or all of these; or from dirty source

SurgeryHistoryList woundDisruption woundDisruption

NSQIP Definition (2004): Separation of the layers of a surgical wound, which may be partial or complete, with disruption of the fascia.

SurgeryHistoryList woundOccurrences woundOccurrences

This determines whether the patient had any postoperative wound occurrences.


Properties:

Alias
businessRule[]
Classifier Behavior
dateAdded12/10/12
dateModified
fileNameSURGERY
fileNumber130
highLevelConcept
informationDomain
Is Abstractfalse
Is Activefalse
Is Leaffalse
KeywordsFile 130
modReason
NameSurgery
Name Expression
NamespaceClasses
note
originalName
Owned Template Signature
OwnerClasses
Owning Template Parameter
PackageClasses
packageNameSURGERY
projectID
Qualified NameHybrid::Surgery::Classes::Surgery
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
Representation
requestedBy
rootClass
StereotypeClassDictionary, VistaClassDictionary
synonym
Template Parameter
VisibilityPublic

Attribute Details

 *attendingCodeNotUsed
Public  *attendingCodeNotUsed

NOTE: This field is replaced by the new ATTENDING CODE field (#.166). This is the code corresponding to the highest level of supervision provided by the attending staff surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report. 0 The staff practitioner performs the case but may be assisted by a resident. 1 The supervising practitioner is physically present in the operative or procedural suite and directly involved in the procedure. The resident performs major portions of the procedure. 2 The supervising practitioner is physically present in the operative or procedural suite and immediately available for consultation. The supervising practitioner may observe and provide direction. The resident performs the procedure 3 The supervising practitioner is not physically present in the operative or procedural suite, but is in the facility or on the VA campus. The supervising practitioner is immediately available for resident supervision or consultation as needed. Local policy, as approved by the VISN Academic Affiliations Officer, should define the standard for "availability" of the supervising practitioner. NOTE: The service chief and chief of staff are responsible for periodically reviewing cases done under Level 3 supervision.

Constraints:
Properties:

absMaxLength67
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*ATTENDING CODE - NOT USED
fieldNumber.165
fileNumber130
formatRule
formatString
generalDescriptionNOTE: This field is replaced by the new ATTENDING CODE field (#.166). This is the code corresponding to the highest level of supervision provided by the attending staff surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report. 0 The staff practitioner performs the case but may be assisted by a resident. 1 The supervising practitioner is physically present in the operative or procedural suite and directly involved in the procedure. The resident performs major portions of the procedure. 2 The supervising practitioner is physically present in the operative or procedural suite and immediately available for consultation. The supervising practitioner may observe and provide direction. The resident performs the procedure 3 The supervising practitioner is not physically present in the operative or procedural suite, but is in the facility or on the VA campus. The supervising practitioner is immediately available for resident supervision or consultation as needed. Local policy, as approved by the VISN Academic Affiliations Officer, should define the standard for "availability" of the supervising practitioner. NOTE: The service chief and chief of staff are responsible for periodically reviewing cases done under Level 3 supervision.
helpTextEnter the code corresponding to the highest level of supervision provided by the attending staff surgeon.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*attendingCodeNotUsed
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsLEVEL 0. ATTENDING DOING THE OPERATION;LEVEL 1. ATTENDING IN O.R. ASSISTING THE RESIDENT;LEVEL 2. ATTENDING IN O.R., NOT SCRUBBED;LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATELY AVAILABLE
permissableValues0;1;2;3
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*attendingCodeNotUsed
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *bleeding&PttTimeIn48Hrs
Public  *bleeding&PttTimeIn48Hrs

This indicates whether the patient has had bleed and PTT time within 48 hours prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*BLEEDING & PTT TIME IN 48 HRS
fieldNumber.994
fileNumber130
formatRule
formatString
generalDescriptionThis indicates whether the patient has had bleed and PTT time within 48 hours prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*bleeding&PttTimeIn48Hrs
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*bleeding&PttTimeIn48Hrs
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *bloodSugarIn7Days
Public  *bloodSugarIn7Days

This field determines whether the patient has had a blood sugar test within the last 7 days. This field has been marked for deletion in the next release of the Surgery software.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*BLOOD SUGAR IN 7 DAYS
fieldNumber.996
fileNumber130
formatRule
formatString
generalDescriptionThis field determines whether the patient has had a blood sugar test within the last 7 days. This field has been marked for deletion in the next release of the Surgery software.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*bloodSugarIn7Days
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*bloodSugarIn7Days
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *bunIn7Days
Public  *bunIn7Days

This indicates whether the patient has had a BUN within 7 days prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*BUN IN 7 DAYS
fieldNumber.995
fileNumber130
formatRule
formatString
generalDescriptionThis indicates whether the patient has had a BUN within 7 days prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*bunIn7Days
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*bunIn7Days
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *clerkChnDateProcedure
Public Integer *clerkChnDateProcedure

This field has been marked for deletion. It should not be used.

Constraints:
Properties:

absMaxLength6
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeNUMERIC
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*CLERK CHN DATE PROCEDURE
fieldNumber.9815
fileNumber130
formatRule
formatString
generalDescriptionThis field has been marked for deletion. It should not be used.
helpTextEnter a whole number between 0 and 100000.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*clerkChnDateProcedure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*clerkChnDateProcedure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeInteger
Upper1
Upper Value(1)
VisibilityPublic


 *clerkChnDaysBefore
Public Integer *clerkChnDaysBefore

This field is not being used and is marked for deletion.

Constraints:
Properties:

absMaxLength6
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeNUMERIC
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*CLERK CHN DAYS BEFORE
fieldNumber.977
fileNumber130
formatRule
formatString
generalDescriptionThis field is not being used and is marked for deletion.
helpTextEnter a whole number between 0 and 100000.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*clerkChnDaysBefore
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*clerkChnDaysBefore
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeInteger
Upper1
Upper Value(1)
VisibilityPublic


 *clerkChnRecForMajSurg
Public Integer *clerkChnRecForMajSurg

This field has been marked for deletion. It should not be used.

Constraints:
Properties:

absMaxLength6
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeNUMERIC
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*CLERK CHN REC FOR MAJ SURG
fieldNumber.9911
fileNumber130
formatRule
formatString
generalDescriptionThis field has been marked for deletion. It should not be used.
helpTextEnter a whole number between 0 and 100000.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*clerkChnRecForMajSurg
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*clerkChnRecForMajSurg
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeInteger
Upper1
Upper Value(1)
VisibilityPublic


 *instCntCorrect
Public  *instCntCorrect

Enter the code corresponding to the status of the final instrument count at the end of the surgical procedure. This field is marked for deletion.

Constraints:
Properties:

absMaxLength9
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*INST CNT CORRECT
fieldNumber.523
fileNumber130
formatRule
formatString
generalDescriptionEnter the code corresponding to the status of the final instrument count at the end of the surgical procedure. This field is marked for deletion.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*instCntCorrect
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsCORRECT;INCORRECT;UNKNOWN
permissableValuesY;N;U
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*instCntCorrect
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *mazeProcedure
Public  *mazeProcedure

CICSP Definition (2004): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt atrial conduction pathways often associated with atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (YES/NO).

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*MAZE PROCEDURE
fieldNumber482
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2004): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt atrial conduction pathways often associated with atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (YES/NO).
helpTextEnter Yes if Maze procedure was done.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*mazeProcedure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*mazeProcedure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *procedureCompleted
Public  *procedureCompleted

This indicates whether the principal operative procedure was completed. This field has been marked for deletion.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*PROCEDURE COMPLETED
fieldNumber29
fileNumber130
formatRule
formatString
generalDescriptionThis indicates whether the principal operative procedure was completed. This field has been marked for deletion.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*procedureCompleted
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*procedureCompleted
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *serologyReport
Public  *serologyReport

This field has been marked for deletion. It should not be used.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*SEROLOGY REPORT
fieldNumber.997
fileNumber130
formatRule
formatString
generalDescriptionThis field has been marked for deletion. It should not be used.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*serologyReport
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*serologyReport
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *surgeryPosition
Public  *surgeryPosition

This field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.

Constraints:
Properties:

absMaxLength45
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*SURGERY POSITION
fieldNumber.54
fileNumber130
formatRule
formatString
generalDescriptionThis field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.
helpTextEnter the position of the patient during the surgery procedure.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsPointer
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*surgeryPosition
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameSURGERY POSITION
pointerFileNumber132
Qualified NameHybrid::Surgery::Classes::Surgery::*surgeryPosition
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 *verfifyIdTagSsn
Public  *verfifyIdTagSsn

This indicates whether the identification bracelet and social security number verification was completed, legal and correct. This field has been marked for deletion.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName*VERFIFY ID TAG SSN
fieldNumber.981
fileNumber130
formatRule
formatString
generalDescriptionThis indicates whether the identification bracelet and social security number verification was completed, legal and correct. This field has been marked for deletion.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
KeywordsEnumeration
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name*verfifyIdTagSsn
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::*verfifyIdTagSsn
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 30DayPostopStatus
Public 30DayPostopStatusList 30DayPostopStatus

This is the patient's status 30 days postoperatively. Please select one of the following categories. 1. Discharged alive to home, nursing home, rehabilitation, or psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your VAMC facility in the ICU, on a medical-surgical floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of another VAMC facility from your VAMC without going home 5. Patient was discharged home, but was readmitted to any hospital within 30 days postoperatively due to a postoperative complication as confirmed by the Chief Surgical Resident, Principle Investigator, or Chief of Surgery. If the patient was readmitted due to a postoperative complication, please enter the information in the outcome section of the assessment.

Constraints:
Properties:

absMaxLength27
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldName30 DAY POSTOP STATUS
fieldNumber341
fileNumber130
formatRule
formatString
generalDescriptionThis is the patient's status 30 days postoperatively. Please select one of the following categories. 1. Discharged alive to home, nursing home, rehabilitation, or psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your VAMC facility in the ICU, on a medical-surgical floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of another VAMC facility from your VAMC without going home 5. Patient was discharged home, but was readmitted to any hospital within 30 days postoperatively due to a postoperative complication as confirmed by the Chief Surgical Resident, Principle Investigator, or Chief of Surgery. If the patient was readmitted due to a postoperative complication, please enter the information in the outcome section of the assessment.
helpTextEnter the status of the patient 30 days postoperatively.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Name30DayPostopStatus
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsDISCHARGED ALIVE;DIED IN HOSPITAL;REMAINS IN VAMC FACILITY;TRANSFERRED TO ANOTHER VAMC;READMITTED;NO STUDY
permissableValues1;2;3;4;5;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::30DayPostopStatus
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type30DayPostopStatusList
Upper1
Upper Value(1)
VisibilityPublic


 absentPeripheralPulses
Public SurgeryHistoryList absentPeripheralPulses

This determines whether the patient has been diagnosed on the physical examination to have absent femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as present or absent in the remaining limb.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameABSENT PERIPHERAL PULSES
fieldNumber331
fileNumber130
formatRule
formatString
generalDescriptionThis determines whether the patient has been diagnosed on the physical examination to have absent femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as present or absent in the remaining limb.
helpTextEnter 'YES' if the patient has been diagnosed as having absent peripheral pulses.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameabsentPeripheralPulses
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::absentPeripheralPulses
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 activeEndocarditis
Public Boolean activeEndocarditis

CICSP Definition (2004): Indicate if the patient is being treated with antibiotics for active infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery. Endocarditis is defined as two or more blood cultures positive for the same organism, usually with evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of positive blood cultures, there should be clear evidence of valve infection and/or destruction by ultrasound or direct observation at surgery with subsequent histologic confirmation.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameACTIVE ENDOCARDITIS
fieldNumber349
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2004): Indicate if the patient is being treated with antibiotics for active infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery. Endocarditis is defined as two or more blood cultures positive for the same organism, usually with evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of positive blood cultures, there should be clear evidence of valve infection and/or destruction by ultrasound or direct observation at surgery with subsequent histologic confirmation.
helpTextEnter 'YES' if the patient is being treated, or has been treated within two weeks prior to surgery, for active endocarditis.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameactiveEndocarditis
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::activeEndocarditis
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 activeHepatitis
Public SurgeryHistoryList activeHepatitis

This determines whether the patient has active hepatitis. Active Hepatitis is defined as an active inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral hepatitis documented by positive serologies (A,B, or C) and recent excessive alcohol intake, or drug induced hepatitis.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameACTIVE HEPATITIS
fieldNumber327
fileNumber130
formatRule
formatString
generalDescriptionThis determines whether the patient has active hepatitis. Active Hepatitis is defined as an active inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral hepatitis documented by positive serologies (A,B, or C) and recent excessive alcohol intake, or drug induced hepatitis.
helpTextEnter 'YES' if this patient has active hepatitis.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameactiveHepatitis
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::activeHepatitis
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 acuteRenalFailure
Public SurgeryHistoryList acuteRenalFailure

NSQIP Definition (2007): In a patient who did not require dialysis preoperatively, worsening of renal dysfunction postoperatively requiring hemodialysis, peritoneal dialysis, hemofiltration, hemodiafiltration or ultrafiltration. TIP: If the patient refuses dialysis the answer is Yes to this variable, because he/she did require dialysis. CICSP Definition (2004): Indicate if the patient developed new renal failure requiring dialysis or experienced an exacerbation of preoperative renal failure requiring initiation of dialysis (not on dialysis preoperatively) within 30 days postoperatively. (Dialysis includes continuous venous to venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis [CVAHD], and peritoneal. It does not include ultrafiltration.)

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameACUTE RENAL FAILURE
fieldNumber254
fileNumber130
formatRule
formatString
generalDescriptionNSQIP Definition (2007): In a patient who did not require dialysis preoperatively, worsening of renal dysfunction postoperatively requiring hemodialysis, peritoneal dialysis, hemofiltration, hemodiafiltration or ultrafiltration. TIP: If the patient refuses dialysis the answer is Yes to this variable, because he/she did require dialysis. CICSP Definition (2004): Indicate if the patient developed new renal failure requiring dialysis or experienced an exacerbation of preoperative renal failure requiring initiation of dialysis (not on dialysis preoperatively) within 30 days postoperatively. (Dialysis includes continuous venous to venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis [CVAHD], and peritoneal. It does not include ultrafiltration.)
helpTextEnter YES if the patient has renal failure requiring the initiation of dialysis postoperatively.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameacuteRenalFailure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::acuteRenalFailure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 addressPlate
Public SurgeryPreopCompletedList addressPlate

This indicates if the patient's address plate is present on the patient's medical record prior to transport to the operating room.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameADDRESS PLATE
fieldNumber.9812
fileNumber130
formatRule
formatString
generalDescriptionThis indicates if the patient's address plate is present on the patient's medical record prior to transport to the operating room.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameaddressPlate
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::addressPlate
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryPreopCompletedList
Upper1
Upper Value(1)
VisibilityPublic


 admissionTransferDate
Public String admissionTransferDate

NSQIP Definition (2004): If the patient was not initially admitted to the surgical service, the date and time of transfer to surgical service for this surgical episode will be entered from the PIMS package. Enter 'NA' if this date is not applicable, e.g. outpatient not admitted or observed.

Constraints:
Properties:

absMaxLength30
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeFREE TEXT
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameADMISSION/TRANSFER DATE
fieldNumber420
fileNumber130
formatRule
formatString
generalDescriptionNSQIP Definition (2004): If the patient was not initially admitted to the surgical service, the date and time of transfer to surgical service for this surgical episode will be entered from the PIMS package. Enter 'NA' if this date is not applicable, e.g. outpatient not admitted or observed.
helpTextEnter the date of transfer to surgical service for this surgical episode or enter NA if this date is not applicable.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameadmissionTransferDate
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::admissionTransferDate
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 admitPacUTime
Public Datetime admitPacUTime

This is the date/time that the patient was admitted to the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameADMIT PAC(U) TIME
fieldNumber1.17
fileNumber130
formatRule
formatString
generalDescriptionThis is the date/time that the patient was admitted to the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameadmitPacUTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::admitPacUTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 agentOrangeExposure
Public Boolean agentOrangeExposure

This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Agent Orange Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameAGENT ORANGE EXPOSURE
fieldNumber.017
fileNumber130
formatRule
formatString
generalDescriptionThis field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Agent Orange Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.
helpTextIf this case is treating an agent orange exposure problem, enter YES.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameagentOrangeExposure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValues1;0
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::agentOrangeExposure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 airwayIndex
Public AirwayIndexList airwayIndex

This field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being least difficult and 5 being most difficult. The value of this field is based on a computed performance index using the oral-pharyngeal (OP) class and the mandibular space (MS). Performance index = 2.5 x OP - MS length (converted to centimeters) Airway Index ------------ 1 - Performance Index less than 0 2 - Performance index greater than 0 and less than 2 3 - Performance index greater than 2 and less than 3 4 - Performance index greater than 3 and less than 4 5 - Performance index greater than 4

Constraints:
Properties:

absMaxLength40
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameAIRWAY INDEX
fieldNumber901
fileNumber130
formatRule
formatString
generalDescriptionThis field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being least difficult and 5 being most difficult. The value of this field is based on a computed performance index using the oral-pharyngeal (OP) class and the mandibular space (MS). Performance index = 2.5 x OP - MS length (converted to centimeters) Airway Index ------------ 1 - Performance Index less than 0 2 - Performance index greater than 0 and less than 2 3 - Performance index greater than 2 and less than 3 4 - Performance index greater than 3 and less than 4 5 - Performance index greater than 4
helpTextDo NOT enter a value. This field is computed based on the ORAL-PHARYNGEAL SCORE and the MANDIBULAR SPACE.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameairwayIndex
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings1. INDEX LESS THAN OR EQUAL TO 0;2. INDEX > 0 AND LESS THAN OR EQUAL TO 2;3. INDEX > 2 AND LESS THAN OR EQUAL TO 3;4. INDEX > 3 AND LESS THAN OR EQUAL TO 4;5. INDEX GREATER THAN 4
permissableValues1;2;3;4;5
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::airwayIndex
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAirwayIndexList
Upper1
Upper Value(1)
VisibilityPublic


 anesAvailTime
Public Datetime anesAvailTime

This is the date and time that the anesthetist is available to service the patient. Although optional, this information is useful for evaluating operation delays.

Constraints:
Properties:

absMaxLength18
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES AVAIL TIME
fieldNumber.204
fileNumber130
formatRule
formatString
generalDescriptionThis is the date and time that the anesthetist is available to service the patient. Although optional, this information is useful for evaluating operation delays.
helpTextEnter the date/time that the anesthetist is available to service the patient.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesAvailTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesAvailTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 anesCareBillableTime
Public  anesCareBillableTime

This is the total anesthesia care billable time in minutes. It is calculated from all time intervals entered in the multiple anesthesia start and end time fields..

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeCOMPUTED
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES CARE BILLABLE TIME
fieldNumber.218
fileNumber130
formatRule
formatString
generalDescriptionThis is the total anesthesia care billable time in minutes. It is calculated from all time intervals entered in the multiple anesthesia start and end time fields..
helpText-
Is Compositefalse
Is Derivedtrue
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesCareBillableTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareBillableTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 anesCareBillableTimeFlag
Public Boolean anesCareBillableTimeFlag

This field is a flag that indicates all anesthesia care time has been entered for a case. It is used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered. "No" indicates time entry is not complete.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES CARE BILLABLE TIME FLAG
fieldNumber.214
fileNumber130
formatRule
formatString
generalDescriptionThis field is a flag that indicates all anesthesia care time has been entered for a case. It is used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered. "No" indicates time entry is not complete.
helpText"Yes" indicates all anesthesia care time has been entered. "No" indicates time entry is not complete.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesCareBillableTimeFlag
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValues1;0
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareBillableTimeFlag
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 anesCareEndTime
Public Datetime anesCareEndTime

This is the date and time that anesthesia care ends. Its definition may vary according to local anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered without a date will be converted to the date of the operation at that time. NSQIP Definition (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU).

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES CARE END TIME
fieldNumber.24
fileNumber130
formatRule
formatString
generalDescriptionThis is the date and time that anesthesia care ends. Its definition may vary according to local anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered without a date will be converted to the date of the operation at that time. NSQIP Definition (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU).
helpTextEnter the time that the anesthesia staff transfers care to other care providers.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesCareEndTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareEndTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 anesCareStartTime
Public Datetime anesCareStartTime

This is the date and time that the anesthesia care began. It is required as part of the anesthesia report. The definition of what constitutes the time anesthesia care begins may vary depending on local anesthesia policy. NSQIP Definition (2004): Anesthesia Start (AS): Time when a member of the anesthesia team begins preparing the patient for an anesthetic.

Constraints:
Properties:

absMaxLength18
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES CARE START TIME
fieldNumber.21
fileNumber130
formatRule
formatString
generalDescriptionThis is the date and time that the anesthesia care began. It is required as part of the anesthesia report. The definition of what constitutes the time anesthesia care begins may vary depending on local anesthesia policy. NSQIP Definition (2004): Anesthesia Start (AS): Time when a member of the anesthesia team begins preparing the patient for an anesthetic.
helpTextEnter the time a member of the Anesthesia staff begins preparing the patient for surgery in the O.R. suite.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesCareStartTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareStartTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 anesCareTime
Public  anesCareTime

This is the number of minutes between the anesthesia care start time and anesthesia care end time.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeCOMPUTED
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES CARE TIME
fieldNumber1.23
fileNumber130
formatRule
formatString
generalDescriptionThis is the number of minutes between the anesthesia care start time and anesthesia care end time.
helpText-
Is Compositefalse
Is Derivedtrue
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesCareTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 anesCareTimeBlock
Public «File 130.213» AnesCareTimeBlock anesCareTimeBlock
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (anesCareTimeBlock:AnesCareTimeBlock)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity*
NameanesCareTimeBlock
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::anesCareTimeBlock
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 130.213» AnesCareTimeBlock
Upper*
Upper Value(*)
VisibilityPublic


 anesConcurrentCases
Public «File 130» Surgery anesConcurrentCases
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (anesConcurrentCases:Surgery)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameanesConcurrentCases
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::anesConcurrentCases
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 130» Surgery
Upper1
Upper Value(1)
VisibilityPublic


 anesMedicallyDirected
Public Boolean anesMedicallyDirected

If the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist supervised the care. Answering no indicates that the anesthetist was unsupervised.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES MEDICALLY DIRECTED
fieldNumber.3514
fileNumber130
formatRule
formatString
generalDescriptionIf the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist supervised the care. Answering no indicates that the anesthetist was unsupervised.
helpTextChoose from Y YES N NO
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesMedicallyDirected
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsNO;YES
permissableValues0;1
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesMedicallyDirected
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescriptionWas the CRNA medically directed by an anesthesiologist during this care? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = NO.
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 anesPersonallyPerformed
Public Boolean anesPersonallyPerformed

Answer yes only if the anesthesiologist personally performed the entire anesthesia procedure.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES PERSONALLY PERFORMED
fieldNumber.3511
fileNumber130
formatRule
formatString
generalDescriptionAnswer yes only if the anesthesiologist personally performed the entire anesthesia procedure.
helpTextChoose from: Y YES N NO
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesPersonallyPerformed
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsNO;YES
permissableValues0;1
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesPersonallyPerformed
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescriptionDid the anesthesiologist personally perform the anesthesia care? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = No.
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 anesPhysicianAvailable
Public Boolean anesPhysicianAvailable

If the anesthetist was a resident, answer yes if the teaching physician was present during all key portions of the procedure and immediately available during the entire procedure.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES PHYSICIAN AVAILABLE
fieldNumber.3515
fileNumber130
formatRule
formatString
generalDescriptionIf the anesthetist was a resident, answer yes if the teaching physician was present during all key portions of the procedure and immediately available during the entire procedure.
helpTextChoose from Y YES N NO
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesPhysicianAvailable
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsNO;YES
permissableValues0;1
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesPhysicianAvailable
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescriptionWas the teaching physician present during all key portions of the procedure and immediately available during the entire procedure? This field only accepts and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = NO.
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 anesStartToOpStart
Public  anesStartToOpStart

This is the number of minutes between the time that anesthesia care started and time that the operation began.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeCOMPUTED
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANES START TO OP START
fieldNumber13
fileNumber130
formatRule
formatString
generalDescriptionThis is the number of minutes between the time that anesthesia care started and time that the operation began.
helpText-
Is Compositefalse
Is Derivedtrue
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesStartToOpStart
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesStartToOpStart
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 anesSuperviseCode
Public «File 132.95» AnesthesiaSupervisorCodes anesSuperviseCode
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (anesSuperviseCode:AnesthesiaSupervisorCodes)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameanesSuperviseCode
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::anesSuperviseCode
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 132.95» AnesthesiaSupervisorCodes
Upper1
Upper Value(1)
VisibilityPublic


 anesthesiaTechnique
Public «File 130.06» AnethesiaTechnique anesthesiaTechnique
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (anesthesiaTechnique:AnethesiaTechnique)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameanesthesiaTechnique
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::anesthesiaTechnique
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 130.06» AnethesiaTechnique
Upper1
Upper Value(1)
VisibilityPublic


 anesthesiologistSupvr
Public «File 200» NewPerson anesthesiologistSupvr

This is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal anesthetist is in a training status, or CRNA.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANESTHESIOLOGIST SUPVR
fieldNumber.34
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal anesthetist is in a training status, or CRNA.
helpTextEnter the name of the anesthesiology staff supervisor.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesthesiologistSupvr
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::anesthesiologistSupvr
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 anesthetistCategory
Public AnesthetistCategoryList anesthetistCategory

This field holds the category of the principal anesthetist which is used on the Anesthesia AMIS report to enumerate the number of anesthetics administered by each category.

Constraints:
Properties:

absMaxLength17
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANESTHETIST CATEGORY
fieldNumber103
fileNumber130
formatRule
formatString
generalDescriptionThis field holds the category of the principal anesthetist which is used on the Anesthesia AMIS report to enumerate the number of anesthetics administered by each category.
helpTextEnter the code corresponding to the category of the principal anesthetist for this case.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesthetistCategory
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsANESTHESIOLOGIST;NURSE ANESTHETIST;OTHER
permissableValuesA;N;O
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesthetistCategory
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAnesthetistCategoryList
Upper1
Upper Value(1)
VisibilityPublic


 anesthInductTime
Public  anesthInductTime

This is the total number of minutes between the anesthesia care start and induction complete times.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeCOMPUTED
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANESTH INDUCT TIME
fieldNumber1.22
fileNumber130
formatRule
formatString
generalDescriptionThis is the total number of minutes between the anesthesia care start and induction complete times.
helpText-
Is Compositefalse
Is Derivedtrue
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanesthInductTime
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anesthInductTime
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type
Upper1
Upper Value(1)
VisibilityPublic


 angina
Public AnginaList angina

This determines whether the patient has angina. Angina is defined as pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia usually precipitated by exertion or emotion and relieved by rest or nitroglycerine. The Canadian Cardiovascular Society (CCS) classification is now the most commonly used method to record severity of angina. Record according to the most severe angina in the 14 days before surgery: I - Ordinary physical activity, such as walking or climbing stairs does not cause angina. Angina may occur with strenuous or rapid or prolonged exertion at work or recreation. II - There is slight limitation of ordinary activity. Angina may occur with walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, or climbing more than one flight of stairs under normal conditions at a normal pace. III - There is marked limitation of ordinary physical activity. Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace. IV - There is inability to carry on any physical activity without discomfort. Angina may be present at rest.

Constraints:
Properties:

absMaxLength9
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANGINA
fieldNumber267
fileNumber130
formatRule
formatString
generalDescriptionThis determines whether the patient has angina. Angina is defined as pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia usually precipitated by exertion or emotion and relieved by rest or nitroglycerine. The Canadian Cardiovascular Society (CCS) classification is now the most commonly used method to record severity of angina. Record according to the most severe angina in the 14 days before surgery: I - Ordinary physical activity, such as walking or climbing stairs does not cause angina. Angina may occur with strenuous or rapid or prolonged exertion at work or recreation. II - There is slight limitation of ordinary activity. Angina may occur with walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, or climbing more than one flight of stairs under normal conditions at a normal pace. III - There is marked limitation of ordinary physical activity. Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace. IV - There is inability to carry on any physical activity without discomfort. Angina may be present at rest.
helpTextEnter the CCS classification associated with the severity of angina in the 14 days preceding surgery.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Nameangina
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsCLASS I;CLASS II;CLASS III;CLASS IV
permissableValuesI;II;III;IV
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::angina
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAnginaList
Upper1
Upper Value(1)
VisibilityPublic


 anginaOneMonthPrior
Public SurgeryHistoryList anginaOneMonthPrior

NSQIP Definition (2004): Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. Documentation in the chart by the physician should state 'angina' or 'anginal equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had angina at any time within 30 days prior to surgery.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameANGINA ONE MONTH PRIOR
fieldNumber395
fileNumber130
formatRule
formatString
generalDescriptionNSQIP Definition (2004): Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. Documentation in the chart by the physician should state 'angina' or 'anginal equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had angina at any time within 30 days prior to surgery.
helpTextEnter 'YES' if the patient has had angina within one month prior to surgery.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameanginaOneMonthPrior
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::anginaOneMonthPrior
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 aorticStenosis
Public AorticStenosisList aorticStenosis

CICSP Definition (2007): Indicate the severity of any aortic stenosis documented. This question should be answered using either the left ventricular angiogram (hemodynamic cath data) or the cardiac ultrasound examination. Numbers may be converted to describe the severity of the aortic stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Both transvalvular gradient and estimated valve orifice area are used to assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is obtained by converting the velocity of blood flow across the valve measured by the Doppler principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the descriptive categories. Indicate the one most appropriate response: None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow velocity is stated to be normal (< 1.0 M/sec). Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice area is 1.7 - 2.5 cm2 Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the valve orifice area is 1.0 -1.6 cm2 Severe - The mean pressure gradient is > 50 mm Hg and/or the valve orifice area is < 1.0 cm2 NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameAORTIC STENOSIS
fieldNumber477
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2007): Indicate the severity of any aortic stenosis documented. This question should be answered using either the left ventricular angiogram (hemodynamic cath data) or the cardiac ultrasound examination. Numbers may be converted to describe the severity of the aortic stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Both transvalvular gradient and estimated valve orifice area are used to assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is obtained by converting the velocity of blood flow across the valve measured by the Doppler principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the descriptive categories. Indicate the one most appropriate response: None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow velocity is stated to be normal (< 1.0 M/sec). Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice area is 1.7 - 2.5 cm2 Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the valve orifice area is 1.0 -1.6 cm2 Severe - The mean pressure gradient is > 50 mm Hg and/or the valve orifice area is < 1.0 cm2 NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
helpTextEnter severity of aortic stenosis using LV angiogram or cardiac ultrasound.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameaorticStenosis
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsNONE/TRIVIAL;MILD;MODERATE;SEVERE;NO STUDY
permissableValues0;1;2;3;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::aorticStenosis
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAorticStenosisList
Upper1
Upper Value(1)
VisibilityPublic


 aorticSystolicPressure
Public String aorticSystolicPressure

CICSP Definition (2004): Indicate the patient's aortic systolic pressure measured prior to left ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic pressure was not measured, entering "NS" for "No Study/Unknown" is also allowed.

Constraints:
Properties:

absMaxLength30
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeFREE TEXT
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameAORTIC SYSTOLIC PRESSURE
fieldNumber358
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2004): Indicate the patient's aortic systolic pressure measured prior to left ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic pressure was not measured, entering "NS" for "No Study/Unknown" is also allowed.
helpTextEnter the aortic systolic pressure (15-300) measured prior to left ventricular angiography most closely preceding surgery.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameaorticSystolicPressure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::aorticSystolicPressure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 aorticValveProcedure
Public ValveProcedureList aorticValveProcedure

VASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other

Constraints:
Properties:

absMaxLength36
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameAORTIC VALVE PROCEDURE
fieldNumber367
fileNumber130
formatRule
formatString
generalDescriptionVASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other
helpTextEnter the appropriate aortic valve procedure performed on this patient.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameaorticValveProcedure
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NONE;MECHANICAL;STENTED BIOPROSTHETIC;STENTLESS BIOPROSTHETIC;HOMOGRAFT;PRIMARY REPAIR;PRIMARY REPAIR & ANNULOPLASTY DEVICE;ANNULOPLASTY DEVICE ALONE;AUTOGRAFT (ROSS);OTHER
permissableValuesY;N;M;S;B;H;PR;PA;AN;AU;O
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::aorticValveProcedure
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeValveProcedureList
Upper1
Upper Value(1)
VisibilityPublic


 asaClass
Public «File 132.8» AsaClass asaClass
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (asaClass:AsaClass)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameasaClass
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::asaClass
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 132.8» AsaClass
Upper1
Upper Value(1)
VisibilityPublic


 ascites
Public SurgeryHistoryList ascites

VASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within 30 days prior to the operation. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASCITES
fieldNumber212
fileNumber130
formatRule
formatString
generalDescriptionVASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within 30 days prior to the operation. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).
helpTextEnter 'YES' if the patient has the presence of fluid accumulation in the peritoneal cavity.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
Nameascites
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::ascites
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 asdRepair
Public Boolean asdRepair

This determines if there was a procedure performed to repair an atrial septal defect.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASD REPAIR
fieldNumber376
fileNumber130
formatRule
formatString
generalDescriptionThis determines if there was a procedure performed to repair an atrial septal defect.
helpTextEnter 'YES' if there was a repair of an atrial septal defect.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameasdRepair
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::asdRepair
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 assessmentCompletedBy
Public «File 200» NewPerson assessmentCompletedBy

This is the name of the person who completed this surgery risk assessment.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASSESSMENT COMPLETED BY
fieldNumber272.1
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the person who completed this surgery risk assessment.
helpTextEnter the name of the person who completed the assessment.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameassessmentCompletedBy
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::assessmentCompletedBy
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 assessmentStatus
Public AssessmentStatusList assessmentStatus

This is the current status of the surgery risk assessment. When creating a new assessment, the status will automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this field will be updated to 'COMPLETED'. After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.

Constraints:
Properties:

absMaxLength13
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASSESSMENT STATUS
fieldNumber235
fileNumber130
formatRule
formatString
generalDescriptionThis is the current status of the surgery risk assessment. When creating a new assessment, the status will automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this field will be updated to 'COMPLETED'. After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.
helpTextEnter the current status of this surgery risk assessment.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameassessmentStatus
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsINCOMPLETE;COMPLETE;TRANSMITTED;NO ASSESSMENT
permissableValuesI;C;T;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::assessmentStatus
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAssessmentStatusList
Upper1
Upper Value(1)
VisibilityPublic


 assessmentType
Public AssessmentTypeList assessmentType

This determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.

Constraints:
Properties:

absMaxLength11
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASSESSMENT TYPE
fieldNumber284
fileNumber130
formatRule
formatString
generalDescriptionThis determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameassessmentType
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsCARDIAC;NON-CARDIAC
permissableValuesC;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::assessmentType
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeAssessmentTypeList
Upper1
Upper Value(1)
VisibilityPublic


 associatedClinic
Public «File 44» HospitalLocation associatedClinic
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (associatedClinic:HospitalLocation)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameassociatedClinic
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::associatedClinic
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 44» HospitalLocation
Upper1
Upper Value(1)
VisibilityPublic


 asstAnesthetist
Public «File 200» NewPerson asstAnesthetist

This is the name of the person assisting the principal anesthetist. If entered, this information appears on the Anesthesia Report.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASST ANESTHETIST
fieldNumber.33
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the person assisting the principal anesthetist. If entered, this information appears on the Anesthesia Report.
helpTextEnter the name of the assistant to the principal anesthetist.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameasstAnesthetist
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::asstAnesthetist
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 asstPerfusionist
Public «File 200» NewPerson asstPerfusionist

This is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameASST PERFUSIONIST
fieldNumber.168
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case.
helpTextEnter the name of the person assisting the perfusionist.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameasstPerfusionist
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::asstPerfusionist
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 attendingCode
Public «File 132.9» AttendingCodes attendingCode
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (attendingCode:AttendingCodes)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NameattendingCode
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::attendingCode
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 132.9» AttendingCodes
Upper1
Upper Value(1)
VisibilityPublic


 attendProvider
Public «File 200» NewPerson attendProvider

This is the name of the attending staff provider responsible for this case. This information appears on several reports.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameATTEND PROVIDER
fieldNumber124
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the attending staff provider responsible for this case. This information appears on several reports.
helpTextEnter the name of the attending staff provider. This is required when the provider is in training status.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameattendProvider
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::attendProvider
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 attendSurg
Public «File 200» NewPerson attendSurg

This is the name of the attending staff surgeon responsible for this case. This information appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameATTEND SURG
fieldNumber.164
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the attending staff surgeon responsible for this case. This information appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.
helpTextEnter the name of the attending staff surgeon. This is required when the surgeon is in training status.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NameattendSurg
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::attendSurg
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 bathAndShampoo
Public SurgeryPreopCompletedList bathAndShampoo

This indicates if the patient's preoperatively prescribed bath and shampoo were completed.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBATH & SHAMPOO
fieldNumber.973
fileNumber130
formatRule
formatString
generalDescriptionThis indicates if the patient's preoperatively prescribed bath and shampoo were completed.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebathAndShampoo
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bathAndShampoo
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryPreopCompletedList
Upper1
Upper Value(1)
VisibilityPublic


 batistaProcedureUsedYN
Public Boolean batistaProcedureUsedYN

Was the Batista procedure used, Yes or No?

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBATISTA PROCEDURE USED (Y/N)
fieldNumber439
fileNumber130
formatRule
formatString
generalDescriptionWas the Batista procedure used, Yes or No?
helpTextEnter whether the Batista Procedure was used or not.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebatistaProcedureUsedYN
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::batistaProcedureUsedYN
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 bleedingDisorders
Public SurgeryHistoryList bleedingDisorders

VASQIP Definition (2010): Any condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K deficiency, hemophilias, thrombocytopenia, chronic anticoagulation therapy that has not been discontinued prior to surgery). Do not include the patient on chronic aspirin therapy. Lab values should not be used to determine this variable except in the case of platelet counts for determining thrombocytopenia. Use whatever the low range number is for your facility to make this determination. Anything less than your local low range should be considered thrombocytopenia. Please refer to the VASQIP Definitions for a table of medications that impact the patient's risk for bleeding. Please utilize the associated time frames for discontinuation of medication not lab values to determine your answer to this variable. The time frames are up to and including the day or hour listed. If there is no documentation of discontinuation of medication, answer 'yes' for bleeding disorder.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBLEEDING DISORDERS
fieldNumber216
fileNumber130
formatRule
formatString
generalDescriptionVASQIP Definition (2010): Any condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K deficiency, hemophilias, thrombocytopenia, chronic anticoagulation therapy that has not been discontinued prior to surgery). Do not include the patient on chronic aspirin therapy. Lab values should not be used to determine this variable except in the case of platelet counts for determining thrombocytopenia. Use whatever the low range number is for your facility to make this determination. Anything less than your local low range should be considered thrombocytopenia. Please refer to the VASQIP Definitions for a table of medications that impact the patient's risk for bleeding. Please utilize the associated time frames for discontinuation of medication not lab values to determine your answer to this variable. The time frames are up to and including the day or hour listed. If there is no documentation of discontinuation of medication, answer 'yes' for bleeding disorder.
helpTextEnter YES if the patient has a history of a bleeding disorder.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebleedingDisorders
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bleedingDisorders
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 bloodLossMl
Public Integer bloodLossMl

This is the number of milliliters (0-100000) of blood estimated to be lost during the operative procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.

Constraints:
Properties:

absMaxLength6
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeNUMERIC
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBLOOD LOSS (ML)
fieldNumber.25
fileNumber130
formatRule
formatString
generalDescriptionThis is the number of milliliters (0-100000) of blood estimated to be lost during the operative procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.
helpTextEnter the number of milliliters (0-100000) of blood estimated to be lost during the procedure (EBL).
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebloodLossMl
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bloodLossMl
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeInteger
Upper1
Upper Value(1)
VisibilityPublic


 bloodTypeAndXmatch
Public SurgeryPreopCompletedList bloodTypeAndXmatch

This indicates whether the patient has had blood typing and crossmatching done.

Constraints:
Properties:

absMaxLength12
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBLOOD TYPE&XMATCH
fieldNumber.993
fileNumber130
formatRule
formatString
generalDescriptionThis indicates whether the patient has had blood typing and crossmatching done.
helpText-
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebloodTypeAndXmatch
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;INAPPLICABLE
permissableValuesY;N;I
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bloodTypeAndXmatch
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryPreopCompletedList
Upper1
Upper Value(1)
VisibilityPublic


 bnp
Public String bnp

VASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.

Constraints:
Properties:

absMaxLength5
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeFREE TEXT
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBNP
fieldNumber507
fileNumber130
formatRule
formatString
generalDescriptionVASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.
helpTextAnswer must be 1-5 characters in length.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength5
minLength1
modReason
Multiplicity0..1
Namebnp
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bnp
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 bnpDate
Public String bnpDate

VASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter "NS" for No Study if the BNP test was not performed.

Constraints:
Properties:

absMaxLength30
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeFREE TEXT
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBNP DATE
fieldNumber507.1
fileNumber130
formatRule
formatString
generalDescriptionVASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter "NS" for No Study if the BNP test was not performed.
helpTextThis is the date that the BNP was performed.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebnpDate
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bnpDate
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 bridgeToTransplantDevice
Public Boolean bridgeToTransplantDevice

CICSP Definition (2006): Indicate if patient received a mechanical support device (excluding IABP) as a bridge to cardiac transplant during the same admission as the transplant procedure; or patient received the device as destination therapy (does not intend to have a cardiac transplant), either with or without placing the patient on cardiopulmonary bypass.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameBRIDGE TO TRANSPLANT/DEVICE
fieldNumber481
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2006): Indicate if patient received a mechanical support device (excluding IABP) as a bridge to cardiac transplant during the same admission as the transplant procedure; or patient received the device as destination therapy (does not intend to have a cardiac transplant), either with or without placing the patient on cardiopulmonary bypass.
helpTextEnter 'YES' if patient received a mechanical support device as a bridge to cardiac transplant.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamebridgeToTransplantDevice
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::bridgeToTransplantDevice
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 briefClinHistory
Public «File 130.09» BriefClinHistory briefClinHistory
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (briefClinHistory:BriefClinHistory)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity*
NamebriefClinHistory
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::briefClinHistory
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 130.09» BriefClinHistory
Upper*
Upper Value(*)
VisibilityPublic


 cancelDate
Public Datetime cancelDate

This is the date and time that the operative procedure was canceled.

Constraints:
Properties:

absMaxLength18
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCANCEL DATE
fieldNumber17
fileNumber130
formatRule
formatString
generalDescriptionThis is the date and time that the operative procedure was canceled.
helpTextEnter the date and time on which this case was cancelled.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecancelDate
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cancelDate
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 cancellationAvoidable
Public Boolean cancellationAvoidable

This field contains a set of codes used to flag a cancellation as being avoidable or unavoidable. It is used when determining the percentage of avoidable cancellations.

Constraints:
Properties:

absMaxLength3
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCANCELLATION AVOIDABLE
fieldNumber67
fileNumber130
formatRule
formatString
generalDescriptionThis field contains a set of codes used to flag a cancellation as being avoidable or unavoidable. It is used when determining the percentage of avoidable cancellations.
helpTextEnter 'YES' if this cancellation was avoidable, or 'NO' if it was unavoidable.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecancellationAvoidable
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO
permissableValuesY;N
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cancellationAvoidable
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 cancelledBy
Public «File 200» NewPerson cancelledBy

This is the name of the person who cancelled this surgical case. This information is automatically entered when a case is cancelled.

Constraints:
Properties:

absMaxLength35
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypePOINTER
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCANCELLED BY
fieldNumber70
fileNumber130
formatRule
formatString
generalDescriptionThis is the name of the person who cancelled this surgical case. This information is automatically entered when a case is cancelled.
helpTextEnter the name of the person who cancelled this operative procedure.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecancelledBy
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileNameNEW PERSON
pointerFileNumber200
Qualified NameHybrid::Surgery::Classes::Surgery::cancelledBy
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
Type«File 200» NewPerson
Upper1
Upper Value(1)
VisibilityPublic


 cancelReason
Public «File 135» SurgeryCancellationReason cancelReason
Constraints:
Properties:

AggregationNone
Alias
Association«VistaAssociationDictionary» (cancelReason:SurgeryCancellationReason)
Association End
businessRule[]
Class«File 130» Surgery
Datatype
dateAdded
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
formatRule
formatString
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isNullableFalse
Keywords
Lower0
Lower Value(0)
modReason
Multiplicity0..1
NamecancelReason
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
Qualified NameHybrid::Surgery::Classes::Surgery::cancelReason
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary
synonym
Template Parameter
Type«File 135» SurgeryCancellationReason
Upper1
Upper Value(1)
VisibilityPublic


 cardiacArrestReqCpr
Public SurgeryHistoryList cardiacArrestReqCpr

CICSP Definition (2004): Indicate if there was any cardiac arrest requiring external or open cardiopulmonary resuscitation (CPR) occurring in the operating room, ICU, ward, or out-of-hospital after the chest had been completely closed and within 30 days of surgery. (YES/NO) If patient had cardiac arrest requiring CPR, indicate whether the arrest occurred intraoperatively or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while patient was in the operating room - postoperatively: occurring after patient left the operating room NSQIP Definition (2006): The absence of cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support. Patients with AICDs that fire but the patient does not lose consciousness should be excluded.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCARDIAC ARREST REQ CPR
fieldNumber411
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2004): Indicate if there was any cardiac arrest requiring external or open cardiopulmonary resuscitation (CPR) occurring in the operating room, ICU, ward, or out-of-hospital after the chest had been completely closed and within 30 days of surgery. (YES/NO) If patient had cardiac arrest requiring CPR, indicate whether the arrest occurred intraoperatively or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while patient was in the operating room - postoperatively: occurring after patient left the operating room NSQIP Definition (2006): The absence of cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support. Patients with AICDs that fire but the patient does not lose consciousness should be excluded.
helpTextEnter YES if the patient has had postoperative cardiac arrest requiring CPR.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecardiacArrestReqCpr
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cardiacArrestReqCpr
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 cardiacCatheterizationDate
Public Datetime cardiacCatheterizationDate

Record the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS if unknown or not applicable.

Constraints:
Properties:

absMaxLength18
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeDATE/TIME
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCARDIAC CATHETERIZATION DATE
fieldNumber440
fileNumber130
formatRule
formatString
generalDescriptionRecord the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS if unknown or not applicable.
helpTextEnter the date of the cardiac catheterization closest to and prior to the date of operation or enter NS if unknown or not applicable.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecardiacCatheterizationDate
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cardiacCatheterizationDate
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeDatetime
Upper1
Upper Value(1)
VisibilityPublic


 cardiacOccurrences
Public SurgeryHistoryList cardiacOccurrences

This determines whether the patient has had any postoperative cardiac occurrences. Cardiac occurrences are defined as difficulties encountered involving the cardiac system.

Constraints:
Properties:

absMaxLength8
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeSET
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCARDIAC OCCURRENCES
fieldNumber321
fileNumber130
formatRule
formatString
generalDescriptionThis determines whether the patient has had any postoperative cardiac occurrences. Cardiac occurrences are defined as difficulties encountered involving the cardiac system.
helpTextEnter 'YES' if the patient has had any postoperative cardiac occurrences.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength-
minLength-
modReason
Multiplicity0..1
NamecardiacOccurrences
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeaningsYES;NO;NO STUDY
permissableValuesY;N;NS
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cardiacOccurrences
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeSurgeryHistoryList
Upper1
Upper Value(1)
VisibilityPublic


 cardiacResourceDataComments
Public String cardiacResourceDataComments

CICSP Definition (2006): Indicate additional comments related to this case prior to transmission to Denver by the SCNR/Data Manager (limit 130 characters).

Constraints:
Properties:

absMaxLength130
AggregationNone
Alias
Association
Association End
businessRule[]
Class«File 130» Surgery
dataTypeFREE TEXT
Datatype
dateAdded12/10/12
dateModified
Default
Default Value
enumeratedBaseDomain
externalMapLocation
externalMapType
fieldNameCARDIAC RESOURCE DATA COMMENTS
fieldNumber431
fileNumber130
formatRule
formatString
generalDescriptionCICSP Definition (2006): Indicate additional comments related to this case prior to transmission to Denver by the SCNR/Data Manager (limit 130 characters).
helpTextAnswer must be 1-130 characters in length.
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
isMultipleFalse
isNullableFalse
isRequiredFalse
Keywords
Lower0
Lower Value(0)
maxLength130
minLength1
modReason
Multiplicity0..1
NamecardiacResourceDataComments
Name Expression
Namespace«File 130» Surgery
note
Opposite
originalClass
originalName
Owner«File 130» Surgery
Owning Association
Owning Template Parameter
permissableValueMeanings-
permissableValues-
pointerFileName-
pointerFileNumber-
Qualified NameHybrid::Surgery::Classes::Surgery::cardiacResourceDataComments
referenceDocumentHyperlink[]
referenceDocumentPage[]
referenceDocumentTitle[]
referenceInfo
requestedBy
StereotypeAttributeDictionary, VistaAttributeDictionary
subFileNumber-
synonym
technicalDescription-
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 cardiacRiskPreopComments
Public String cardiacRiskPreopComments

CICSP Definition (2006): Indicate in the comment field any preoperative patient risk factors (not previously entered above) that may contribute to this patient's risk of operative mortality. (The maximum length of this field is 130 characters.)

Constraints:
Properties:

<
absMaxLength130
AggregationNone
Alias
Association