Surgery User Manual

Surgery User Manual
SURGERY
USER MANUAL
Version 3.0
July 1993
(Revised March 2012)
Department of Veterans Affairs
Product Development
Revision History
Each time this manual is updated, the Title Page lists the new revised date and this page describes the
changes. If the Revised Pages column lists “All,” replace the existing manual with the reissued manual. If
the Revised Pages column lists individual entries (e.g., 25, 32), either update the existing manual with the
Change Pages Document or print the entire new manual.
Date
Revised Pages
03/12
i-iid, v, vii, 6-11, 81-83, SR*3*176
120, 120a-120b, 140,
144-145, 145a-145b,
146, 151-152, 152a,
178, 207-209, 212c,
212f, 213, 215, 217219, 219a-219b, 220,
222, 224, 226, 228, 230,
232, 234, 236, 239, 241,
243, 245, 247, 276,
327c, 394c, 395-396,
397a, 397c-397d, 411,
432, 449-450, 461, 464,
467-468, 474b, 482,
484, 486, 486a, 523,
525, 527, 549, 553-554
Updated definitions, added new data fields, made
changes to existing fields, data entry screens, reports,
surgery risk assessment transmissions and transplant
components of the VistA Surgery application. For
more details, see the Annual Surgery Updates –
VASQIP 2011, Increment 2, Release Notes.
SR*3*175
Updated definitions and made minor modifications to
the non-cardiac, cardiac and transplant components of
the VistA Surgery application. For more details, see
the Annual Surgery Updates – VASQIP 2011,
Increment 1, Release Notes.
09/11
i-iib, iii-iv, vi, 64, 66,
70, 98-101, 101a-101b,
109-112, 114-118, 122124, 124a-124b, 142152, 152a-152b, 176,
178, 180, 183-184,
184a-184f, 244, 246,
248, 325-326, 326a326b, 327, 327a-327d,
368, 394a-394b, 394c394d, 395-397, 397a397d, 432-433, 441,
449-450, 458-459, 461,
464a, 471-474, 474a474b, 475, 477, 480a,
482, 486-486a,
509,519, 521, 522a,
522c, 527, 534-535,
550, 552-556
April 2004
Patch
Number
Description
Chapter Seven: “CoreFLS/Surgery Interface” has
been removed.
(T. Leggett, PM; B. Thomas, Tech Writer)
(T. Leggett, PM; B. Thomas, Tech Writer)
Surgery V. 3.0 User Manual
i
Date
Revised Pages
Patch
Number
12/10
i-iib, 372, 376, 449-450, SR*3*174
458, 467-468, 468b,
471-474, 474a-474b,
479, 479a, 482, 486,
486a, 522c-522d
11/08
vii-viii, 527-556
SR*3*167
04/08
iii-iv, vi, 160, 165, 168,
171-172, 296-298, 443,
447, 449-450, 459, 471473, 479-479a, 482,
486-486a, 489, 491,
493- 495, 497, 499,
501-502a, 502c, 502d502h, 513-517, 522c522d, 529, 534
SR*3*166
11/07
479-479a, 486a
SR*3*164
Description
Updated the data entry options for the non-cardiac and
cardiac risk management sections; these options have
been changed to match the software. For more details,
see the Annual Surgery Updates – VASQIP 2010
Release Notes.
(T. Leggett, PM; B. Thomas, Tech Writer)
New chapter added for transplant assessments.
Changed Glossary to Chapter 10, and renumbered the
Index.
(M. Montali, PM; G. O‟Connor, Tech Writer)
Updated the data entry options for the non-cardiac and
cardiac risk management sections; these options have
been changed to match the software. For more details,
see the Surgery NSQIP-CICSP Enhancements 2008
Release Notes.
(M. Montali, PM; G. O‟Connor, Tech Writer)
Updated the Resource Data Enter/Edit and the Print a
Surgery Risk Assessment options to reflect the new
cardiac field for CT Surgery Consult Date.
(M. Montali, PM; S. Krakosky, Tech Writer)
09/07
125, 371, 375, 382
SR*3*163
Updated the Service Classification section regarding
environmental indicators, unrelated to this patch.
Updated the Quarterly Report to reflect updates to the
numbers and names of specific specialties in the
NATIONAL SURGICAL SPECIALTY file.
(M. Montali, PM; S. Krakosky, Tech Writer)
06/07
35, 210, 212b
SR*3*159
Updated screens to reflect change of the
environmental indicator “Environmental
Contaminant” to “SWAC” (e.g., SouthWest Asia).
(M. Montali, PM; S. Krakosky, Tech Writer)
06/07
ii
176-180, 180a, 184c-d, SR*3*160
327c-d, 372, 375-376,
446, 449-450, 452-453,
455-456, 458, 461, 468,
470, 472, 479-479a,
482-484, 486a, 489,
491, 493, 495, 497, 499,
501, 502a-d, 504-506,
509-512, 519
Updated the data entry options for the non-cardiac and
cardiac risk management sections; these options have
been changed to match the software. For more details,
see the Surgery NSQIP-CICSP Enhancements 2007
Release Notes.
Updated data entry screens to match software;
changes are unrelated to this patch.
(M. Montali, PM; S. Krakosky, Tech Writer)
Surgery V. 3.0 User Manual
April 2004
Date
Revised Pages
Patch
Number
Description
11/06
10-12, 14, 21-22, 139141, 145-150, 152, 219,
438
SR*3*157
Updated data entry options to display new fields for
collecting sterility information for the Prosthesis
Installed field; updated the Nurse Intraoperative
Report section with these required new fields. For
more details, see the Surgery-Tracking Prosthesis
Items Release Notes.
Updated data entry screens to match software;
changes are unrelated to this patch.
(M. Montali, PM; S. Krakosky, Tech Writer)
08/06
06/06
6-9, 14, 109-112, 122124, 141-149, 151-152,
176, 178-180, 180a-b,
181-184, 184a-d, 185186, 218-219, 326-327,
327a-d, 328-329, 373,
377, 449-450, 452-456,
459, 461-462, 467-468,
468b, 469-470, 470a,
473-474, 474a-474b,
475, 477, 481-486,
486a-b, 489-502, 502ab, 503-504, 509-512
SR*3*153
28-32, 40-50, 64-80,
101-102
SR*3*144
Updated the data entry options for the non-cardiac and
cardiac risk management sections; these options have
been changed to match the software.
Updated data entry options to incorporate
renamed/new Hair Removal documentation fields.
Updated the Nurse Intraoperative Report and
Quarterly Report to include these fields.
For more details, see the Surgery NSQIP/CICSP
Enhancements 2006 Release Notes.
(M. Montali, PM; S. Krakosky, Tech Writer)
Updated options to reflect new required fields
(Attending Surgeon and Principal Preoperative
Diagnosis) for creating a surgery case.
(M. Montali, PM; S. Krakosky, Tech Writer)
06/06
vi, 34-35, 125, 210,
212b, 522a-b
SR*3*152
Updated Service Classification screen example to
display new PROJ 112/SHAD prompt.
This patch will prevent the PRIN PRE-OP ICD
DIAGNOSIS CODE field of the Surgery file from
being sent to the Patient Care Encounter (PCE)
package.
Added the new Alert Coder Regarding Coding Issues
option to the Surgery Risk Assessment Menu option.
(M. Montali, PM; S. Krakosky, Tech Writer)
04/06
445, 464a-b, 465,
480a-b
SR*3*146
Added the new Alert Coder Regarding Coding Issues
option to the Assessing Surgical Risk chapter.
(M. Montali, PM; S. Krakosky, Tech Writer)
April 2004
Surgery V. 3.0 User Manual
iia
Date
Revised Pages
Patch
Number
Description
04/06
6-8, 29, 31-32, 37-38,
40, 43-44, 46-48, 50,
52, 65-67, 71-73, 75-77,
79, 100, 102, 109-112,
117-120, 122-123, 125127, 189-191, 195b,
209-212, 212a-h, 219a,
224-231, 238-242, 273277, 311-313, 315-317,
369, 379- 392, 410,
449-464, 467-468,
468a-b, 469-470, 470a,
471-474, 474a-b, 475479, 479a-b, 480, 483484, 489-502, 507, 519
SR*3*142
Updated the data entry screens to reflect renaming of
the Planned Principal CPT Code field and the
Principal Pre-op ICD Diagnosis Code field. Updated
the Update/Verify Procedure/Diagnosis Coding
option to reflect new functionality. Updated Risk
Assessment options to remove CPT codes from
headers of cases displayed. Updated reports related to
the coding option to reflect final CPT codes.
10/05
9, 109-110, 144, 151,
218
SR*3*147
Updated data entry screens to reflect renaming of the
Preop Shave By field to Preop Hair Clipping By field.
(M. Montali, PM; S. Krakosky, Tech Writer)
08/05
10, 14, 99-100, 114,
119-120, 124, 153-154,
162-164, 164a-b, 190,
192, 209-212f, 238-242
SR*3*119
Updated the Anesthesia Data Entry Menu section (and
other data entry options) to reflect new functionality
for entering multiple start and end times for
anesthesia. Updated examples for Referring Physician
updates (e.g., capability to automatically look up
physician by name). Updated the PCE Filing Status
Report section.
(J. Podolec, PM; B. Manies, Tech Writer)
08/04
iv-vi, 187-189, 195,
195a-195b, 196, 207208, 219a-b, 527-528
SR*3*132
Updated the Table of Contents and Index to reflect
added options. Added the new Non-OR Procedure
Information option and the Tissue Examination Report
option (unrelated to this patch) to the Non-OR
Procedures section.
08/04
31, 43, 46, 66, 71-72,
75-76, 311
SR*3*127
Updated screen captures to display new text for ICD-9
and CPT codes.
iib
For more specific information on changes, see the
Patient Financial Services System (PFSS) – Surgery
Release Notes for this patch.
(M. Montali, PM; S. Krakosky, Tech Writer)
Surgery V. 3.0 User Manual
April 2004
Date
Revised Pages
Patch
Number
Description
08/04
vi, 441, 443, 445-456,
458-459, 461 463, 465,
467-468, 468a-b, 469470, 470a-b, 471, 473474, 474a-b, 474-479,
479a-b, 480-486, 486ab, 519, 531-534
SR*3*125
08/04
6-10, 14, 103, 105-107,
109-112, 114-120, 122124, 141-152, 218-219,
284-287, 324, 370-377
SR*3*129
04/04
All
SR*3*100
Updated the Table of Contents and Index. Clarified
the location of the national centers for NSQIP and
CICSP. Updated the data entry options for the noncardiac and cardiac risk management sections; these
options have been changed to match the software and
new options have been added. For an overview of the
data entry changes, see the Surgery NSQIP/CICSP
Enhancements 2004 Release Notes. Added the
Laboratory Test Result (Enter/Edit) option and the
Outcome Information (Enter/Edit) option to the
Cardiac Risk Assessment Information (Enter/Edit)
menu section. Changed the name of the Cardiac
Procedures Requiring CPB (Enter/Edit) option to
Cardiac Procedures Operative Data (Enter/Edit)
option. Removed the Update Operations as
Unrelated/Related to Death option from the Surgery
Risk Assessment Menu.
Updated examples to include the new levels for the
Attending Code (or Resident Supervision). Also
updated examples to include the new fields for
ensuring Correct Surgery. For specific options
affected by each of these updates, please see the
Resident Supervision/Ensuring Correct Surgery Phase
II Release Notes.
All pages were updated to reflect the most recent
Clinical Ancillary Local Documentation Standards
and the changes resulting from the Surgery Electronic
Signature for Operative Reports project, SR*3*100.
For more information about the specific changes, see
the patch description or the Surgery Electronic
Signature for Operative Reports Release Notes.
April 2004
Surgery V. 3.0 User Manual
iic
(This page included for two-sided copying.)
iid
Surgery V. 3.0 User Manual
April 2004
Table Of Contents
Introduction ............................................................................................................................... 1
Overview .................................................................................................................................................. 1
Documentation Conventions .................................................................................................................... 3
Getting Help and Exiting ................................................................................................................. 3
Using Screen Server ................................................................................................................................. 5
Introduction ...................................................................................................................................... 5
Navigating ........................................................................................................................................ 5
Basics of Screen Server ................................................................................................................... 6
Entering Data ................................................................................................................................... 7
Editing Data ..................................................................................................................................... 8
Turning Pages .................................................................................................................................. 8
Entering or Editing a Range of Data Elements ................................................................................ 9
Working with Multiples ................................................................................................................. 10
Word Processing ............................................................................................................................ 14
Chapter One: Booking Operations ....................................................................................... 15
Introduction ............................................................................................................................................ 15
Key Vocabulary ............................................................................................................................. 15
Exiting an Option or the System .................................................................................................... 16
Option Overview............................................................................................................................ 16
Maintain Surgery Waiting List ............................................................................................................... 17
Print Surgery Waiting List ............................................................................................................. 18
Enter a Patient on the Waiting List ................................................................................................ 21
Edit a Patient on the Waiting List .................................................................................................. 22
Delete a Patient from the Waiting List........................................................................................... 23
Request Operations Menu ...................................................................................................................... 25
Display Availability ....................................................................................................................... 26
Make Operation Requests .............................................................................................................. 28
Delete or Update Operation Requests ............................................................................................ 36
Make a Request from the Waiting List .......................................................................................... 42
Make a Request for Concurrent Cases ........................................................................................... 45
Review Request Information ......................................................................................................... 52
Operation Requests for a Day ........................................................................................................ 53
Requests by Ward .......................................................................................................................... 55
List Operation Requests ......................................................................................................................... 57
Schedule Operations ............................................................................................................................... 59
Display Availability ....................................................................................................................... 60
Schedule Requested Operation ...................................................................................................... 61
Schedule Unrequested Concurrent Cases ...................................................................................... 69
Reschedule or Update a Scheduled Operation ............................................................................... 74
Cancel Scheduled Operation .......................................................................................................... 81
Update Cancellation Reason .......................................................................................................... 83
Schedule Anesthesia Personnel...................................................................................................... 84
Create Service Blockout ................................................................................................................ 85
Delete Service Blockout ................................................................................................................ 87
Schedule of Operations .................................................................................................................. 88
April 2004
Surgery V. 3.0 User Manual
iii
List Scheduled Operations ...................................................................................................................... 91
Chapter Two: Tracking Clinical Procedures ........................................................................ 93
Introduction ............................................................................................................................................ 93
Key Vocabulary ............................................................................................................................. 93
Exiting an Option or the System .................................................................................................... 94
Option Overview............................................................................................................................ 94
Operation Menu ...................................................................................................................................... 95
Using the Operation Menu Options ............................................................................................... 96
Operation Information ................................................................................................................. 103
Surgical Staff ............................................................................................................................... 104
Operation Startup ......................................................................................................................... 108
Operation ..................................................................................................................................... 113
Post Operation.............................................................................................................................. 119
Enter PAC(U) Information .......................................................................................................... 121
Operation (Short Screen) ............................................................................................................. 122
Time Out Verified Utilizing Checklist....................................................................................... 124a
Surgeon‟s Verification of Diagnosis & Procedures ..................................................................... 125
Anesthesia for an Operation Menu .............................................................................................. 128
Operation Report.......................................................................................................................... 129
Anesthesia Report ........................................................................................................................ 131
Nurse Intraoperative Report ......................................................................................................... 140
Tissue Examination Report .......................................................................................................... 153
Enter Referring Physician Information ........................................................................................ 154
Enter Irrigations and Restraints ................................................................................................... 155
Medications (Enter/Edit) .............................................................................................................. 157
Blood Product Verification .......................................................................................................... 158
Anesthesia Menu .................................................................................................................................. 160
Prerequisites ................................................................................................................................. 160
Anesthesia Data Entry Menu ....................................................................................................... 161
Anesthesia Information (Enter/Edit) ............................................................................................ 162
Anesthesia Technique (Enter/Edit) .............................................................................................. 165
Medications (Enter/Edit) .............................................................................................................. 169
Anesthesia Report ........................................................................................................................ 170
Schedule Anesthesia Personnel.................................................................................................... 173
Perioperative Occurrences Menu.......................................................................................................... 175
Key Vocabulary ........................................................................................................................... 175
Intraoperative Occurrences (Enter/Edit) ...................................................................................... 176
Postoperative Occurrences (Enter/Edit) ....................................................................................... 178
Non-Operative Occurrence (Enter/Edit) ...................................................................................... 180
Update Status of Returns Within 30 Days ................................................................................... 181
Morbidity & Mortality Reports .................................................................................................... 183
Non-O.R. Procedures............................................................................................................................ 187
Non-O.R. Procedures (Enter/Edit) ............................................................................................... 188
Edit Non-O.R. Procedure ............................................................................................................. 189
Procedure Report (Non-O.R.) ...................................................................................................... 193
Tissue Examination Report ........................................................................................................ 195a
Non-OR Procedure Information ................................................................................................ 195b
Annual Report of Non-O.R. Procedures ...................................................................................... 196
Report of Non-O.R. Procedures ................................................................................................... 198
iv
Surgery V. 3.0 User Manual
April 2004
Comments Option................................................................................................................................. 205
CPT/ICD Coding Menu ........................................................................................................................ 207
CPT/ICD Update/Verify Menu .................................................................................................... 208
Update/Verify Procedure/Diagnosis Codes ................................................................................. 209
Operation/Procedure Report ........................................................................................................ 213
Nurse Intraoperative Report ......................................................................................................... 217
Non-OR Procedure Information ................................................................................................ 219b
Cumulative Report of CPT Codes ............................................................................................... 220
Report of CPT Coding Accuracy ................................................................................................. 224
List Completed Cases Missing CPT Codes ................................................................................. 230
List of Operations ........................................................................................................................ 232
List of Operations (by Surgical Specialty) ................................................................................... 234
Report of Daily Operating Room Activity ................................................................................... 236
PCE Filing Status Report ............................................................................................................. 238
Report of Non-O.R. Procedures ................................................................................................... 243
Chapter Three: Generating Surgical Reports..................................................................... 249
Introduction .......................................................................................................................................... 249
Exiting an Option or the System .................................................................................................. 249
Option Overview.......................................................................................................................... 249
Surgery Reports .................................................................................................................................... 251
Management Reports ................................................................................................................... 252
List of Operations (by Surgical Priority) ..................................................................................... 267
Surgery Staffing Reports.............................................................................................................. 283
Anesthesia Reports....................................................................................................................... 296
CPT Code Reports ....................................................................................................................... 305
Laboratory Interim Report .................................................................................................................... 319
Chapter Four: Chief of Surgery Reports ............................................................................. 321
Introduction .......................................................................................................................................... 321
Exiting an Option or the System .................................................................................................. 321
Option Overview.......................................................................................................................... 321
Chief of Surgery Menu ......................................................................................................................... 323
View Patient Perioperative Occurrences...................................................................................... 324
Management Reports ................................................................................................................... 325
Unlock a Case for Editing ............................................................................................................ 398
Update Status of Returns Within 30 Days ................................................................................... 399
Update Cancelled Cases ............................................................................................................... 400
Update Operations as Unrelated/Related to Death ...................................................................... 401
Update/Verify Procedure/Diagnosis Codes ................................................................................. 402
Chapter Five: Managing the Software Package .................................................................. 407
Introduction .......................................................................................................................................... 407
Exiting an Option or the System .................................................................................................. 407
Option Overview.......................................................................................................................... 407
Surgery Package Management Menu ................................................................................................... 409
Surgery Site Parameters (Enter/Edit) ........................................................................................... 410
Operating Room Information (Enter/Edit) ................................................................................... 413
Surgery Utilization Menu ............................................................................................................ 414
April 2004
Surgery V. 3.0 User Manual
v
Person Field Restrictions Menu ................................................................................................... 425
Update O.R. Schedule Devices .................................................................................................... 429
Update Staff Surgeon Information ............................................................................................... 430
Flag Drugs for Use as Anesthesia Agents .................................................................................... 431
Update Site Configurable Files .................................................................................................... 432
Surgery Interface Management Menu.......................................................................................... 434
Make Reports Viewable in CPRS ................................................................................................ 440
Chapter Six: Assessing Surgical Risk ................................................................................. 441
Introduction .......................................................................................................................................... 441
Exiting an Option or the System .................................................................................................. 441
Surgery Risk Assessment Menu ........................................................................................................... 443
Non-Cardiac Risk Assessment Information (Enter/Edit) ..................................................................... 445
Creating a New Risk Assessment ................................................................................................ 445
Editing an Incomplete Risk Assessment ...................................................................................... 447
Preoperative Information (Enter/Edit) ......................................................................................... 448
Laboratory Test Results (Enter/Edit) ........................................................................................... 451
Operation Information (Enter/Edit) ............................................................................................. 455
Patient Demographics (Enter/Edit) .............................................................................................. 457
Intraoperative Occurrences (Enter/Edit) ...................................................................................... 459
Postoperative Occurrences (Enter/Edit) ....................................................................................... 461
Update Status of Returns Within 30 Days ................................................................................... 463
Update Assessment Status to „Complete‟ .................................................................................... 464
Alert Coder Regarding Coding Issues ....................................................................................... 464a
Cardiac Risk Assessment Information (Enter/Edit) ............................................................................. 465
Creating a New Risk Assessment ................................................................................................ 465
Clinical Information (Enter/Edit) ................................................................................................. 467
Laboratory Test Results (Enter/Edit) ......................................................................................... 468a
Enter Cardiac Catheterization & Angiographic Data .................................................................. 469
Operative Risk Summary Data (Enter/Edit) ................................................................................ 471
Cardiac Procedures Operative Data (Enter/Edit) ......................................................................... 473
Outcome Information (Enter/Edit) ............................................................................................. 474b
Intraoperative Occurrences (Enter/Edit) ...................................................................................... 475
Postoperative Occurrences (Enter/Edit) ....................................................................................... 477
Resource Data (Enter/Edit) .......................................................................................................... 479
Update Assessment Status to „COMPLETE‟............................................................................... 480
Alert Coder Regarding Coding Issues ....................................................................................... 480a
Print a Surgery Risk Assessment .......................................................................................................... 481
Update Assessment Completed/Transmitted in Error .......................................................................... 487
List of Surgery Risk Assessments ........................................................................................................ 489
Print 30 Day Follow-up Letters ............................................................................................................ 503
Exclusion Criteria (Enter/Edit) ............................................................................................................. 507
Monthly Surgical Case Workload Report ............................................................................................ 509
M&M Verification Report .................................................................................................................... 513
Update 1-Liner Case ............................................................................................................................. 519
Queue Assessment Transmissions ........................................................................................................ 521
Alert Coder Regarding Coding Issues ................................................................................................ 522a
vi
Surgery V. 3.0 User Manual
April 2004
Risk Model Lab Test .......................................................................................................................... 522c
Chapter Seven: Code Set Versioning .................................................................................. 525
Chapter Eight: Assessing Transplants................................................................................ 527
Introduction .......................................................................................................................................... 527
Transplant Assessment Menu ............................................................................................................... 529
Enter/Edit Transplant Assessments ...................................................................................................... 531
Creating a New Transplant Assessment....................................................................................... 531
Edit a Transplant Assessment ...................................................................................................... 536
Print Transplant Assessment ................................................................................................................ 541
Printing a Transplant Assessment ................................................................................................ 541
List of Transplant Assessments ............................................................................................................ 544
Printing a List of Transplant Assessments ................................................................................... 544
Transplant Assessment Parameters (Enter/Edit) .................................................................................. 546
Changing Transplant Assessment Parameters ............................................................................. 546
Chapter Nine: Glossary ........................................................................................................ 549
Index ...................................................................................................................................... 551
April 2004
Surgery V. 3.0 User Manual
vii
(This page included for two-sided copying.)
viii
Surgery V. 3.0 User Manual
April 2004
Introduction
This section provides an overview of the Surgery package, and also provides documentation conventions
used in this Surgery V. 3.0 User Manual. This section also discusses the use of the Screen Server in the
Surgery package.
Overview
The Surgery package is designed to be used by Surgeons, Surgical Residents, Anesthetists, Operating
Room Nurses and other surgical staff. The Surgery package is part of the patient information system that
stores data on the Department of Veterans Affairs (VA) patients who have, or are about to undergo,
surgical procedures. This package integrates booking, clinical, and patient data to provide a variety of
administrative and clinical reports.
The Surgery V. 3.0 User Manual is designed to acquaint the user with the various Surgery options and to
offer specific guidance on the use of the Surgery package. Documentation concerning the Surgery
package, including any subsequent change pages affecting this documentation, can be found at the
Veterans Health Information Systems and Technology Architecture (VistA) Documentation Library
(VDL) on the Internet at http://www.va.gov/vdl/.
April 2004
Surgery V. 3.0 User Manual
1
(This page included for two-sided copying.)
2
Surgery V. 3.0 User Manual
April 2004
Documentation Conventions
This Surgery V. 3.0 User Manual includes documentation conventions, also known as notations, which
are used consistently throughout this manual. Each convention is outlined below.
Convention
Example
Menu option text is italicized.
The Print Surgery Waiting List option
generates the long form surgery Waiting
List for the surgical service(s) selected.
Screen prompts are denoted with quotation marks around
them.
The "Puncture Site:" prompt will display
next.
Responses in bold face indicate user input.
Needle Size: 25G
Text centered between bent parentheses represents a
keyboard key that needs to be pressed for the system to
capture a user response or move the cursor to another
field.
Type Y for Yes or N for No and press
<Enter>.
Press <Tab> to move the cursor to the next
field.
<Enter> indicates that the Enter key (or Return key on
some keyboards) must be pressed.
<Tab> indicates that the Tab key must be pressed.
Indicates especially important or helpful
information.
If the user attempts to reschedule
a case after the schedule close
time for the date of operation,
only the time, and not the date, can be
changed.
Indicates that options are locked with a
particular security key. The user must hold the
particular security key to be able to perform the menu
option.
Without the SROAMIS key the
Anesthesia AMIS option cannot
be accessed.
Getting Help and Exiting
?, ??, ??? One, two or three question marks can be entered at any of the prompts for online help. One
question mark elicits a brief statement of what information is appropriate for the prompt. Two question
marks provide more help, plus the hidden actions, and three question marks will provide more detailed
help, including a list of possible answers, if appropriate.
Typing an up arrow ^ (caret or a circumflex) and pressing <Enter> can be used to exit the current option.
April 2004
Surgery V. 3.0 User Manual
3
(This page included for two-sided copying.)
4
Surgery V. 3.0 User Manual
April 2004
Using Screen Server
This section provides information about using the Screen Server utility with the Surgery software.
Introduction
Screen Server is a screen-based data entry utility. It allows the user to display and select data elements for
entering, editing, and deleting information. The format is designed to display a number of data fields at
one time on a menu. With Screen Server, a number of data elements are displayed at one time on a menu
and the user is able to choose on which element to work.
This section contains a description of the Screen Server format and gives examples of how to respond to
the unique Screen Server prompts. The screen facsimiles used in the examples are taken from the Surgery
software; however, these screens may not display on the terminal monitor exactly as they display in this
manual, because the Surgery package is subject to enhancements and local modifications. In this
document, the different ways to respond to the Screen Server prompt, to perform a task, and to utilize
shortcuts are explained. The shortcuts are listed below:
Enter data
Edit data
Move between pages
Enter/edit a range of data elements
Multiples
Multiple screen shortcuts
Word processing
The user should be familiar with VistA conventions. In the examples, the user‟s response is presented in
bold face text.
Navigating
The user can press the Return key to move through a prompt and go to the next page or item. To return
directly to the Surgery Menu options, the user can enter an up-arrow (^), unless he or she is in a multiple
field. To exit a multiple field, enter two up-arrows (^^).
April 2004
Surgery V. 3.0 User Manual
5
Basics of Screen Server
Each Screen Server arrangement consists of three basic parts: a header, data elements, and an action
prompt. These items are defined in the following table.
Term
Definition
Header
The screen heading contains information specific to the record with which you are
working. This can include the patient name or case number. The information in the
heading is programmed and cannot be easily changed.
Each Screen Server display contains from 1 to 15 data elements (or fields). If
information has been entered for any of the data elements defined, it will display to
the right of the element. Some data elements are multiple fields, meaning they can
contain more than one piece of information. These multiple fields are distinguished
by the word "Multiple" next to the data element. If the multiple field contains
information, the word "Data" will be next to the data element.
The action prompt is at the bottom of each screen. From the prompt "Enter Screen
Server Functions:" you can enter, edit, or delete information from the data elements.
The possible responses to this prompt are explained in more detail on the following
pages. Enter a question mark (?), for help text with possible prompt responses.
Data Elements
Prompt
The following is an example of a Screen Server display with help text.
Example: Screen Server with On-line Help Text
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #16
SURPATIENT,ONE
PAGE 1 OF 3
DATE OF OPERATION:
AUG 01, 2006
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,ONE
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE: REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE:
OTHER PROCEDURES: (MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Header
Data
Elements
Enter Screen Server Function: ?
To change entries, enter your choices (numbers) separated by a ';', or
use a ':' for ranges. i.e. 2;3 or 1:3. Enter 'A' to enter/edit all.
Prompt
If there is more than one page to this screen, entering a '+' or '-'
followed by the number of pages or entering 'P' followed by the page
number will take you to the desired page.
On-line Help
Enter '^' to quit, or '^^' to return to the menu option.
6
Surgery V. 3.0 User Manual
April 2004
Entering Data
To enter or edit data, the user can type the item number corresponding with the data element for which
he/she is entering information and press the <Enter> key. In the following example, we typed the number
10 at the prompt and pressed the <Enter> key. A new prompt appeared allowing us to enter the data. The
software immediately processed this information and produced an updated menu screen and another
action prompt.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #16
SURPATIENT,ONE
PAGE 1 OF 3
DATE OF OPERATION:
AUG 01, 2006
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,ONE
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE: REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE:
OTHER PROCEDURES: (MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Enter Screen Server Function: 13
Time Patient In the O.R.: 13:00
Data
Elements
AUG 1, 2006 AT 13:00
The software processes the information and produces an update.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #16
SURPATIENT,ONE
PAGE 1 OF 3
DATE OF OPERATION:
AUG 01, 2006
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,ONE
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE: REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE:
OTHER PROCEDURES: (MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
AUG 1, 2006 AT 13:00
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Data
Elements
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
7
Editing Data
Changing an existing entry is similar to entering. Once again, the user can type in the number for the data
element he/she wants to change and press <Enter>. In the following example, the number 3 was entered
to change the surgeon name. A new prompt appeared containing the existing value for the data element in
a default format. We entered the new value, “SURSURGEON,TWO.” The software immediately
processed this information and produced an updated screen.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #16
SURPATIENT,ONE
PAGE 1 OF 3
DATE OF OPERATION:
AUG 01, 2006
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,ONE
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE: REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE:
OTHER PROCEDURES: (MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
AUG 1, 2006 AT 13:00
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Data
Elements
Enter Screen Server Function: 3
SURGEON: SURSURGEON,ONE // SURSURGEON,TWO
The software processes the information and produces an update.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #16
SURPATIENT,ONE
PAGE 1 OF 3
DATE OF OPERATION:
AUG 01, 2006
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,TWO
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE: REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE:
OTHER PROCEDURES: (MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
AUG 1, 2006 AT 13:00
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Data
Elements
Enter Screen Server Function:
Turning Pages
No more than 15 data elements will fit on a single Screen Server formatted page, but there can be as
many pages as needed. Because many screens contain more than one page of data elements, the screen
server provides the ability to move between the pages. Pages are numbered in the heading. To go back
one page, enter minus one (-1) at the action prompt. To go forward, enter plus one (+1) or press <Enter>.
The user can move more than one page by combining the minus or plus sign with the number of pages
needed to go backward or forward.
8
Surgery V. 3.0 User Manual
April 2004
Entering or Editing a Range of Data Elements
Colons and semicolons are used as delineators for ranges of item numbers. This allows the user to
respond to two or more data elements on the same page of a screen at one time. Typing a colon and/or
semicolon between the item numbers at the prompt tells the software what elements to display for editing.
Colons are used when the user wants to respond to all numbers within a sequence (for example, 2:5
means items 2, 3, 4, and 5). Semicolons are used to separate the item numbers for non-sequential items
(e.g., 2;5;9;11 means items 2, 5, 9 and 11). To respond to all the data elements on the page, enter “A” for
all.
Example 1: Colon
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #24
SURPATIENT,TWO
ASA CLASS:
PREOP MOOD:
PREOP CONSCIOUS:
PREOP SKIN INTEG:
TRANS TO OR BY:
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
SKIN PREPPED BY (1):
SKIN PREPPED BY (2):
SKIN PREP AGENTS:
SECOND SKIN PREP AGENT:
SURGERY POSITION:
RESTR & POSITION AIDS:
ELECTROGROUND POSITION:
PAGE 2 OF 3
(WORD PROCESSING)
(MULTIPLE)(DATA)
(MULTIPLE)(DATA)
Enter Screen Server Function: 1:6
ASA Class: 2
2-MILD DISTURB.
Preoperative Mood: RELAXED
R
Preoperative Consciousness: ALERT-ORIENTED
Preoperative Skin Integrity: INTACT
I
Transported to O.R. By: STRETCHER
Preop Surgical Site Hair Removal by: SURNURSE,ONE
AO
OS
Example 2: Semicolon
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #24
SURPATIENT,TWO
PAGE 1 OF 3
DATE OF OPERATION:
APR 19, 2006 AT 800
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
OPERATING ROOM:
OR4
SURGERY SPECIALTY:
ORTHOPEDICS
MAJOR/MINOR:
REQ POSTOP CARE:
WARD
CASE SCHEDULE TYPE:
ELECTIVE
REQ ANESTHESIA TECHNIQUE: GENERAL
PATIENT EDUCATION/ASSESSMENT: YES
CANCEL DATE:
CANCEL REASON:
CANCELLATION AVOIDABLE:
DELAY CAUSE:
(MULTIPLE)
Enter Screen Server Function:
Operating Room: OR4// OR2
Major or Minor: MAJOR
April 2004
5;7;
Surgery V. 3.0 User Manual
9
Working with Multiples
The notation MULTIPLE indicates a data element that can have more than one answer. Some multiple
fields have several layers of screens from which to respond. Navigating through the layers may seem
tedious at first, but the user will soon develop speed. Remember, the user can press <Enter> at the
prompt to go back to the main menu screen, or enter an up-arrow (^) to go back to the previous screen.
In the following examples, there are other screens after the initial (also called top-level) screen. With the
multiple screens, a new menu list is built with each entry.
Example: Multiples
** OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #14
PAGE 1 OF 3
TIME PAT IN HOLD AREA: AUG 15, 2001 AT 740
TIME PAT IN OR:
AUG 15, 2001 AT 800
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
TIME OPERATION BEGAN: AUG 15, 2001 AT 900
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
THERMAL UNIT:
(MULTIPLE)
ELECTROCAUTERY UNIT:
ESU COAG RANGE:
ESU CUTTING RANGE:
TIME TOURNIQUET APPLIED: (MULTIPLE)
PROSTHESIS INSTALLED:
(MULTIPLE)(DATA)
REPLACEMENT FLUID TYPE: (MULTIPLE)
IRRIGATION:
(MULTIPLE)
MEDICATIONS:
(MULTIPLE)
Enter Screen Server Function:
** OPERATION **
CASE #14
PROSTHESIS INSTALLED
1
SURPATIENT,THREE
12
SURPATIENT,THREE
PAGE 1
NEW ENTRY
Enter Screen Server Function: 1
Select PROSTHESIS INSTALLED PROSTHESIS ITEM: MANDIBULAR PLATES
PROSTHESIS INSTALLED ITEM: MANDIBULAR PLATES// <Enter>
Notice the three user responses entered above. The first response, 12, told the software that we want to
enter data in the PROSTHESIS INSTALLED field. Then, at the next screen, we entered "1" because we
wanted to make a new prosthesis entry for this case. The third response, MANDIBULAR PLATES, told
the software the kind of prosthesis being installed. The software echoed back the full prosthesis name
"MANDIBULAR PLATES" and we accepted it by pressing <Enter>.
10
Surgery V. 3.0 User Manual
April 2004
Because the PROSTHESIS INSTALLED field can contain multiple answers, a new screen immediately
appeared as follows:
** OPERATION **
CASE #14 SURPATIENT,THREE
PROSTHESIS INSTALLED (MANDIBULAR PLATES)
1
2
3
4
5
6
7
8
9
10
11
PAGE 1
PROSTHESIS ITEM:
MANDIBULAR PLATES
IMPLANT STERILITY CHECKED:
STERILITY EXPIRATION DATE:
RN VERIFIER:
VENDOR:
MODEL:
LOT NUMBER:
SERIAL NUMBER:
STERILE RESP:
SIZE:
QUANTITY:
Enter Screen Server Function: 2:11
Implant Sterility Checked (Y/N): Y YES
Sterility Expiration Date: 01.30.07 (JAN 30, 2007)
RN Verifier: SURNURSE,ONE
OS
Manufacturer/Vendor: SYNTHES
Model: MAXILLOFACIAL
Lot Number: #20-15
Serial Number: 612A874
Who is Accountable for Sterilization: SPD
Size: 10 HOLE
Quantity: 20
The first response, 2:10, corresponds to data elements 2 through 10. We entered data for these elements
one-by-one and the software processed the information and produced this update:
** OPERATION **
CASE #14 SURPATIENT,THREE
PROSTHESIS INSTALLED (MANDIBULAR PLATES)
1
2
3
4
5
6
7
8
9
10
11
PAGE 1 OF 1
PROSTHESIS ITEM:
MANDIBULAR PLATES
IMPLANT STERILITY CHECKED: YES
STERILITY EXPIRATION DATE: JAN 30, 2007
RN VERIFIER:
SURNURSE,ONE
VENDOR:
SYNTHES
MODEL:
MAXILLOFACIAL
LOT NUMBER:
20-15
SERIAL NUMBER:
612A874
STERILE RESP:
SPD
SIZE:
10 HOLE
QUANTITY:
20
Enter Screen Server Function:
<Enter>
Pressing <Enter> will now bring back the top-level screen and allow us to make another entry. As many
as 15 prostheses can be added to this list. If we were to add more prostheses, the N and R shortcuts
discussed on the next two pages would come in handy, but it is a good idea to practice the steps just
covered before attempting the shortcuts.
April 2004
Surgery V. 3.0 User Manual
11
Multiple Screen Shortcuts
The help text for a multiple field mentions the N and R functions. The user can enter a question mark (?)
to view the help text at the prompt, as displayed in the following example.
** OPERATION **
CASE #14 SURPATIENT,THREE
PROSTHESIS INSTALLED
1
2
PROSTHESIS ITEM:
NEW ENTRY
PAGE 1 OF 1
MANDIBULAR PLATES
Enter Screen Server Function: ?
Enter 2N to enter only the top level of this multiple, or the number
of your choice followed by an 'R' to make a duplicate entry.
Press <RET> to continue
N Function
The N function allows the user to enter new entries without going beyond the top level screen, whereas
the R function allows the user to repeat a previous top level response. In the following example we will
build entries by entering the data element number and the letter N:
** OPERATION **
CASE #14 SURPATIENT,THREE
PROSTHESIS INSTALLED
1
2
PAGE 1 OF 1
MANDIBULAR PLATES
NEW ENTRY
Enter Screen Server Function: 2N
Select PROSTHESIS INSTALLED PROSTHESIS ITEM: GLENOID COMPONENT
PROSTHESIS INSTALLED ITEM: GLENOID COMPONENT// <Enter>
Select PROSTHESIS INSTALLED PROSTHESIS ITEM: HUMERAL COMPONENT
PROSTHESIS INSTALLED ITEM: HUMERAL COMPONENT// <Enter>
Select PROSTHESIS INSTALLED PROSTHESIS ITEM: INTRAMEDULLARY PLUG
PROSTHESIS INSTALLED ITEM: INTRAMEDULLARY PLUG// <Enter>
Select PROSTHESIS INSTALLED PROSTHESIS ITEM: <Enter>
The software processes the information and produces an update.
** OPERATION **
CASE #14 SURPATIENT,THREE
PROSTHESIS INSTALLED
1
2
3
4
5
PROSTHESIS
PROSTHESIS
PROSTHESIS
PROSTHESIS
NEW ENTRY
ITEM:
ITEM:
ITEM:
ITEM:
PAGE 1 OF 1
MANDIBULAR PLATES
GLENOID COMPONENT
HUMERAL COMPONENT
INTRAMEDULLARY PLUG
Enter Screen Server Function: <Enter>
R Function
The R function saves the user from typing in the top-level information again. In this example, we have the
same anesthesia technique but different anesthesia agents. By entering the element number we want to
repeat, and the letter R, we avoid having to enter the top-level data again. This feature can also be useful
in cases where the same medication is repeated at different times. After the user enters the item and the
letter R, the software responds with a default prompt. The user can press <Enter> to accept the default.
12
Surgery V. 3.0 User Manual
April 2004
** SHORT SCREEN **
CASE #10
ANESTHESIA TECHNIQUE
SURPATIENT,FOUR
PAGE 1 OF 1
1
ANESTHESIA TECHNIQUE: GENERAL
2
ANESTHESIA TECHNIQUE: LOCAL
3
NEW ENTRY
Enter Screen Server Function: 1R
ANESTHESIA TECHNIQUE: GENERAL// <Enter>
The software processes the information and produces an update.
** SHORT SCREEN **
CASE #10 SURPATIENT,FOUR
ANESTHESIA TECHNIQUE (0)
1
2
3
ANESTHESIA TECHNIQUE:
PRINCIPAL TECH:
ANESTHESIA AGENTS:
GENERAL
(MULTIPLE)
Enter Screen Server Function:
** SHORT SCREEN **
CASE #10
ANESTHESIA TECHNIQUE
0)
ANESTHESIA AGENTS
1
PAGE 1 OF 1
3
SURPATIENT,FOUR
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select ANESTHESIA AGENTS: PROCAINE HYDROCHLORIDE
ANESTHESIA AGENTS: PROCAINE HYDROCHLORIDE // <Enter>
** SHORT SCREEN **
CASE #10 SURPATIENT,FOUR
ANESTHESIA TECHNIQUE (0)
ANESTHESIA AGENTS
1
2
ANESTHESIA AGENTS:
NEW ENTRY
PAGE 1 OF 1
PROCAINE HYDROCHLORIDE
Enter Screen Server Function: <Enter>
The software processes the information and produces an update.
** SHORT SCREEN **
CASE #10 SURPATIENT,FOUR
ANESTHESIA TECHNIQUE (0)
1
2
3
ANESTHESIA TECHNIQUE:
PRINCIPAL TECH:
ANESTHESIA AGENTS:
PAGE 1 OF 1
GENERAL
(MULTIPLE)(DATA)
Enter Screen Server Function:
<Enter>
The updating continues through to the top layer.
** SHORT SCREEN **
CASE #10
ANESTHESIA TECHNIQUE
1
2
3
4
ANESTHESIA TECHNIQUE:
ANESTHESIA TECHNIQUE:
ANESTHESIA TECHNIQUE:
NEW ENTRY
SURPATIENT,FOUR
PAGE 1 OF 1
INTRAVENOUS
LOCAL
INTRAVENOUS
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
13
Word Processing
The phrase “Word Processing” in the menu means that the user can enter as much data as needed to
complete the entry.
Following is an example of how we entered text on a Screen Server word processing field. Notice that we
pressed <Enter> after each line of text as there is no automatic word-wrap:
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #25
SURPATIENT,FOUR
PAGE 3 OF 4
SPONGE, SHARPS, & INST COUNTER:
COUNT VERIFIER:
SURGERY SPECIALTY:
GENERAL
WOUND CLASSIFICATION:
ATTEND SURG:
ATTENDING CODE:
LEVEL D: ATTENDING IN O.R. SUITE, IMMEDIATELY AVAILABLE
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
NURSING CARE COMMENTS: (WORD PROCESSING)
ASA CLASS:
PRINC ANESTHETIST:
ANESTHESIA TECHNIQUE: (MULTIPLE)
ANES CARE TIME BLOCK:
(MULTIPLE)
DELAY CAUSE:
(MULTIPLE)
CANCEL DATE:
Enter Screen Server Function: 9
NURSING CARE COMMENTS:
1>Patient arrived ambulatory from Ambulatory Surgery Unit.
2>Discharged via wheelchair. Lidocaine applied topically.
3> <Enter>
EDIT Option: <Enter>
<Enter>
<Enter>
The software processes the information and produces an update.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #25
SURPATIENT,FOUR
PAGE 3 OF 3
SPONGE, SHARPS, & INST COUNTER:
COUNT VERIFIER:
SURGERY SPECIALTY:
GENERAL
WOUND CLASSIFICATION:
ATTEND SURG:
ATTENDING CODE:
LEVEL D: ATTENDING IN O.R. SUITE, IMMEDIATELY AVAILABLE
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
NURSING CARE COMMENTS: (WORD PROCESSING)(DATA)
ASA CLASS:
PRINC ANESTHETIST:
ANESTHESIA TECHNIQUE: (MULTIPLE)
ANES CARE TIME BLOCK:
(MULTIPLE)
DELAY CAUSE:
(MULTIPLE)
CANCEL DATE:
Enter Screen Server Function:
14
Surgery V. 3.0 User Manual
April 2004
Chapter One: Booking Operations
Introduction
The options described in this chapter facilitate the scheduling of surgical procedures. Automated
scheduling provides better operating room use and greater ease in distributing the operating room
schedule. These options help accomplish the following tasks.
Track patients on a waiting list
Track operation requests
Chart operating room availability
Designate operating rooms for a surgical service
Schedule operations by assigning operating rooms and time slots
Generate operating room schedules on any designated printer in the medical center
Reschedule or cancel any operative procedures
Whether or not the user is booking a case from the Waiting List, Request Operations menu, or Schedule
Operations menu, he/she will be asked to provide preoperative information about the case. Some of the
preoperative information is mandatory and must be entered immediately to proceed with the option, while
other information can be entered later. It is advisable to enter as much information as possible and update
or correct it later. If a prompt cannot be answered, the user can press the <Enter> key to move to the next
item.
Key Vocabulary
The following terms are used in this chapter.
Term
Definition
Concurrent Case
The patient undergoes two operations, by two different specialties, at the
same time in the same operating room.
An institution might have a daily cutoff time for entering requests. After the
cutoff time, the user is prohibited from booking a request for an operation to
take place through midnight of the following day. The user may still book
requests two or more days in advance.
Requests that have been entered but not scheduled. When the patient name is
entered, the software will list the outstanding requests for this patient.
After the data concerning the operation has been entered, the terminal display
device will clear and then present a two-page Screen Server summary. The
Screen Server summary organizes the information entered and gives the user
another opportunity to enter or edit data.
Cutoff Time
Outstanding Requests
Screen Server
April 2004
Surgery V. 3.0 User Manual
15
Exiting an Option or the System
The user can type the up-arrow (^) at any prompt to stop the line of questioning and return to the previous
level in the routine. To completely exit from the system, the user should continue entering up-arrows.
Option Overview
The main options included in this menu are listed below. Each of these options, except the List Operation
Requests option and List Scheduled Operations option, contain submenus. To the left of the option name
is the shortcut synonym that the user can enter to select the option.
Shortcut
W
R
LR
S
LS
16
Option Name
Maintain Surgery Waiting List
Request Operations
List Operation Requests
Schedule Operations
List Scheduled Operations
Surgery V. 3.0 User Manual
April 2004
Maintain Surgery Waiting List
[SROWAIT]
The options within the Maintain Surgery Waiting List menu allow surgeons to develop waiting lists for
selected surgery specialties. The patient can remain on the Waiting List until sufficient information is
available to book the operation for a specific date (see Make a Request from the Waiting List option).
This option is locked with the SROWAIT key.
The Maintain Surgery Waiting List menu contains the following options. To the left is the shortcut
synonym the user can enter to select the option.
Shortcut
W
E
U
D
April 2004
Option Name
Print Surgery Waiting List
Enter a Patient on the Waiting List
Edit a Patient on the Waiting List
Delete a Patient from the Waiting List
Surgery V. 3.0 User Manual
17
Print Surgery Waiting List
[SRSWL2]
Resident surgeons use the Print Surgery Waiting List option to print the waiting list for one or more
surgical specialties. The Waiting List includes the names of patients waiting to have an operation and the
type of operation. Cases entered on the Waiting List are not assigned an operating room or a date of
operation.
The report can be sorted in several different ways. First, the user can sort the report by one or more
surgical specialties. Then, the user can choose to sort the report either alphabetically by patient name, by
the tentative date of the operation, or by the date the case was entered on the waiting list. A brief form can
be requested, as in Example 1, or a long form report, as in Example 2. The long form report includes the
procedure name, comments, referring physician, tentative admission date, patient address, and phone
numbers.
This report has an 80-column format and can be viewed on a software terminal or copied to a printer.
When the screen is full the user will be prompted to press the Return key to continue viewing the list.
Example 1: Print the Surgery Waiting List, Brief Form, Sort By T
Select Maintain Surgery Waiting List Option: W
Print Surgery Waiting List
Surgery Waiting List Reports
Print Report By:
A
T
D
Alphabetical Order by Patient
Tentative Date of Operation
Date Entered on the Waiting List
Enter Selection (A,T, or D): T
Do you want to print the waiting list for all specialties ?
Select Surgical Specialty: 50
AL(OR WHEN NOT DEFINED BELOW)
YES//
N
GENERAL(OR WHEN NOT DEFINED BELOW)
GENER
50
Do you want to print the brief form ?
YES//
<Enter>
Print the Waiting List on which Device: [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------Surgery Waiting List for GENERAL (OR WHEN NOT DEFINED BELOW)
Printed JUN 28, 2001 at 14:10
Date Entered
Patient
Operative Procedure
================================================================================
JAN 19, 2001
SURPATIENT,FIVE
Bunionectomy
Tentative Admission: JAN 23, 2001
Tentative Date of Operation: JAN 23, 2001
-------------------------------------------------------------------------------JAN 21, 2001
SURPATIENT,SIX
REPAIR INGUINAL HERNIA
Tentative Admission: JAN 28, 2001
Tentative Date of Operation: JAN 29, 2001
-------------------------------------------------------------------------------NOV 29, 1999
SURPATIENT,SEVEN
ARTHROSCOPY, RIGHT SHOULDER
Tentative Admission: DEC 29, 1999
Tentative Date of Operation: None Specified
--------------------------------------------------------------------------------
18
Surgery V. 3.0 User Manual
April 2004
Example 2: Print the long form, Sort by D
Select Maintain Surgery Waiting List Option: W
Print Surgery Waiting List
Surgery Waiting List Reports
Print Report By:
A
T
D
Alphabetical Order by Patient
Tentative Date of Operation
Date Entered on the Waiting List
Enter Selection (A,T, or D): D
Do you want to print the waiting list for all specialties ?
Select Surgical Specialty: 50
AL(OR WHEN NOT DEFINED BELOW)
YES//
N
GENERAL(OR WHEN NOT DEFINED BELOW)
GENER
50
Do you want to print the brief form ?
YES//
N
Print the Waiting List on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
19
Surgery Waiting List for GENERAL (OR WHEN NOT DEFINED BELOW)
Printed JAN 20, 2001 at 14:11
================================================================================
Patient:
SURPATIENT,SEVEN (000-84-0987)
Date Entered: DEC 28, 2001 09:08
Procedure:
ARTHROSCOPY, RIGHT SHOULDER
Tentative Admission Date:
JAN 29, 2001
Home Phone: (555) 555-5877
Address:
Work Phone: NOT ENTERED
Referring Physician/Institution:
DR. SURSURGEON
Phone: 555-555-0987
122 1ST AVE.
TUSCALOOSA, ALABAMA 35205
-------------------------------------------------------------------------------Patient:
SURPATIENT,FIVE (000-58-7963)
Date Entered: JAN 19, 2001 15:17
Procedure:
Bunionectomy
Tentative Admission Date:
JAN 23, 2001
Tentative Date of Operation: JAN 23, 2001
Home Phone: NOT ENTERED
Address:
Work Phone: NOT ENTERED
Referring Physician/Institution:
Four Sursurgeon
Phone:
Sylacauga OPC
-------------------------------------------------------------------------------Patient:
SURPATIENT,SIX (000-09-8797)
Date Entered: JAN 21, 2001 13:48
Procedure:
REPAIR INGUINAL HERNIA
Tentative Admission Date:
JAN 28, 2001
Tentative Date of Operation: JAN 29, 2001
Comments:
Bland Diet
Home Phone: 555-555-1233
Address:
117TH SO 40TH ST
BIRMINGHAM, ALABAMA 35217
Work Phone: NOT ENTERED
Referring Physician/Institution:
SURSURGEON
Phone: 555-555-8900
Jefferson OPC
--------------------------------------------------------------------------------
20
Surgery V. 3.0 User Manual
April 2004
Enter a Patient on the Waiting List
[SROW-ENTER]
Resident surgeons use the Enter a Patient on the Waiting List option to enter a patient on the waiting list
for a selected surgical specialty.
First, identify the surgical specialty to which the patient will be assigned. To add a new case to the
waiting list, the user must enter the patient name and the procedure name. Comments, referring physician
name and address, tentative admission date, and tentative operation date can also be added. This
information will appear on the Waiting List Report. Patient names stay on the Waiting List until the data
is used to make a request or until it is deleted.
Example: Enter a Patient on the Waiting List
Select Maintain Surgery Waiting List Option: E
Enter a Patient on the Waiting List
Select Surgical Specialty: 62
PERIPHERAL VASCULAR
...OK? YES// <Enter> (YES)
PERIPHERAL VASCULAR
Select Patient: SURPATIENT,EIGHT
06-04-35
PERIPHERAL VASCULAR 62
000370555
Select Operative Procedure: HAVEST SAPHENOUS VEIN
Select PATIENT: SURPATIENT,EIGHT// <Enter>
General Comments/Special Instructions:
1>Patient is an insulin dependent diabetic.
2><Enter>
EDIT Option: <Enter>
Tentative Admission Date: 08/25/01 (AUG 25, 2001)
Tentative Date of Operation: 08/26/01 (AUG 26, 2001)
Select REFERRING PHYSICIAN: DR. ONE SURSURGEON
Street Address: VAMC HOUSTON
City: HOUSTON
State: TEXAS
Zip Code: 77005
Telephone Number: 555 555-5555
SURPATIENT,EIGHT has been entered on the waiting list for PERIPHERAL VASCULAR
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
21
Edit a Patient on the Waiting List
[SROW-EDIT]
The Edit a Patient on the Waiting List option is used to edit information collected for a patient who is
already on the waiting list. The user enters the patient‟s name first. The user should be certain that the
correct patient has been entered and that the right entry (there can be more than one) has been selected.
Information can then be updated by simply typing in the new data at each prompt. If there is no change
for a response, press the <Enter> key and the cursor will go to the next prompt.
This option allows changes to the procedure name, the referring physician information, comments,
tentative admission date, and/or the tentative operation date. A patient‟s name cannot be edited. A
patient‟s name will stay on the Waiting List until the data is used to make a request or until it is deleted.
Example: Edit Waiting List
Select Maintain Surgery Waiting List Option: U
Edit which Patient ?
SURPATIENT,EIGHT
Edit a Patient on the Waiting List
06-04-35
000370555
Procedures entered on the Waiting List for SURPATIENT,EIGHT
1. PERIPHERAL VASCULAR
HAVEST SAPHENOUS VEIN
Date Entered on List:
AUG 11,2001
Tentative Operation Date: AUG 26,2001
Principal Operative Procedure: HAVEST SAPHENOUS VEIN
Replace HA <Enter> With HAR <Enter> Replace <Enter>
HARVEST SAPHENOUS VEIN
General Comments/Special Instructions:
1>Patient is an insulin dependent diabetic.
EDIT Option: <Enter>
Tentative Admission Date: AUG 25,2001// 8/26 (AUG 26, 2001)
Tentative Date of Operation: AUG 26,2001// 8/27 (AUG 27, 2001)
Select REFERRING PHYSICIAN: DR. ONE SURSURGEON// <Enter>
Referring Physician/Medical Center: DR. ONE SURSURGEON
Replace <Enter>
Street Address: VAMC HOUSON// <Enter>
City: HOUSTON// <Enter>
State: TEXAS// <Enter>
Zip Code: 77005// <Enter>
Telephone Number: 555 555-5555// <Enter>
Press RETURN to continue
22
Surgery V. 3.0 User Manual
April 2004
Delete a Patient from the Waiting List
[SROW-DELETE]
The Delete a Patient from the Waiting List option is used to delete a patient‟s procedure from the Surgery
Waiting List. Enter the patient‟s name and select the procedure from the list of procedures and his or her
entry will be deleted. The software will provide a message that the procedure has been deleted.
Example: Delete Patient From Waiting List
Select Maintain Surgery Waiting List Option: D
Delete which Patient ? SURPATIENT,EIGHT
Delete a Patient from the Waiting List
06-04-35
000370555
Procedures entered on the Waiting List for SURPATIENT,EIGHT
1. PERIPHERAL VASCULAR
HARVEST SAPHENOUS VEIN
Date Entered on List:
AUG 11,2001
Tentative Operation Date: AUG 26,2001
Are you sure that you want to delete this entry ?
YES// <Enter>
SURPATIENT,EIGHT has been removed from the Waiting List.
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
23
(This page included for two-sided copying.)
24
Surgery V. 3.0 User Manual
April 2004
Request Operations Menu
[SROREQ]
The Request Operations menu contains several functions that the surgeons and resident surgeons use to
book an operation. Options within the Request Operations menu are used to book an operation for a
certain day. The surgeon can request, via the software, the operation(s) for a patient on a specific day and
then enter additional information concerning the upcoming operation.
This option is locked with the SROREQ key.
To request an operation, the user must have a patient name, an operative procedure to perform, and a date
to book it. Also required are the Surgeon, Surgical Specialty, and the Indications for Operations. If the
user does not know the anticipated date of surgery, the user can enter the patient on the Waiting List. If
there is enough information to book the operation for a specific time and operating room, the user can use
the Schedule Unrequested Operations option on the Schedule Operation menu to schedule the operation.
The information gathered is collated by the software and used to produce reports. The person in charge of
scheduling (scheduling manager) arranges the operation requests according to the hospital‟s Surgical
Service protocols and schedules the operation by assigning the case an operating room and a time slot.
The options included in the Request Operations menu option are listed below. To the left of the option
name is the shortcut character(s) the user can enter to select the option.
Shortcut
A
R
D
W
CC
V
OR
WR
April 2004
Option Name
Display Availability
Make Operation Requests
Delete or Update Operation Requests
Make a Request from the Waiting List
Make a Request for Concurrent Cases
Review Request Information
Operation Requests for a Day
Requests by Ward
Surgery V. 3.0 User Manual
25
Display Availability
[SRODISP]
The Display Availability option is used to check on the availability of an operating room before booking
an operation. This option allows the user to view the availability of operating rooms on a blockout graph.
This screen is “read-only” with no editing capabilities.
Scheduled operations display on the graph as an equal sign (=) followed by the letter X. The equal sign
before the X indicates the beginning of a scheduled operation. Surgical specialty blockouts are indicated
by an abbreviation for the service (for more information on service blockouts, a function of the
Scheduling menu, see the Create Service Blockouts option).
After entering this option, the user has a choice of viewing the room availability on the blockout graph in
two ways. The user can either view all rooms for a particular date (as in Example 1) or view a particular
operating room for a range of dates (Example 2). Notice, in the first example, that the user can also list
requests, if any have been made.
Condensed Characters
If the display terminal can print condensed characters, a 24-hour graph will display on the screen. If not,
the user will be prompted to select one of three graphs representing different chunks of that day.
Example 1: All O.R.S For One Day
Select Request Operations Option:
A Display Availability
Do you want to view all Operating Rooms on one day ?
Do you want to list requests also ?
YES //
<Enter>
NO// <Enter>
Display Operating Room Availability for which Date ?
T
(DEC 10, 2003)
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2// <Enter>
ROOM
OR1
OR2
OR3
OR4
OR5
OR6
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|=XXX|XXXX|XXXX|gen.|gen.|gen.|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Press RETURN to continue
26
Surgery V. 3.0 User Manual
April 2004
Example 2: One O.R. for a Date Range
Select Request Operations Option:
A Display Availability
Do you want to view all Operating Rooms on one day ?
Begin Display on which Date ?
T
YES //
N
(APR 14, 2003)
Select OPERATING ROOM NAME: OR1
Display of Available Operating Room Time
1. Display Availability (12:00 AM - 12:00 PM)
2. Display Availability (06:00 AM - 08:00 PM)
3. Display Availability (12:00 PM - 12:00 AM)
Select Number: 2// <Enter>
Operating Room: OR1
DATE
04-14-03
04-15-03
04-16-03
04-17-03
04-18-03
04-19-03
04-20-03
04-21-03
04-22-03
04-23-03
04-24-03
04-25-03
04-26-03
04-27-03
04-28-03
(6:00 AM - 8:00 PM)
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|____|____|____|____|eye.|eye.|____|____|____|____|____|____|____|
|____|eye.|eye.|eye.|eye.|eye.|____|____|____|____|____|____|____|____|
|____|gen.|gen.|gen.|gen.|gen.|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|eye.|eye.|eye.|eye.|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|eye.|eye.|____|____|____|____|____|____|____|
|____|eye.|eye.|eye.|eye.|eye.|____|____|____|____|____|____|____|____|
|=XXX|XXXX|XXXX|gen.|gen.|gen.|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|eye.|eye.|eye.|eye.|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|eye.|eye.|____|____|____|____|____|____|____|
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
27
Make Operation Requests
[SROOPREQ]
The Make Operation Requests option allows the resident surgeon or scheduling manager to request an
operation for a patient on a specific day. To request an operation the user must know the patient name, the
operative procedure to be performed, and the date on which to book the procedure.
This option also asks for detailed information concerning the upcoming operation. First, the user will be
prompted to enter required information, including the Date of Operation, Surgeon, Surgical Specialty,
Principal Procedure, and indications for the operation. Facilities can set up additional required fields using
the Surgery Site Parameters (Enter/Edit) option within the Surgery Package Management menu. Then,
the user will be prompted to enter procedure information, such as the estimated case length, blood product
information, and other information about the operation.
The user should enter as much information as possible when making the request. Later, more information
can be added or corrections can be made by using the Delete or Update Operation Requests option.
About Outstanding Requests
When the patient name is entered, the software will list any requests that have been made but not
scheduled. These requests are called outstanding requests. If the user discovers that the request being
entered has already been made, he or she should respond YES to the prompt "Do you want to update the
outstanding request ? ". Answering YES allows the user to view the information and make changes (see
the following example).
If the user is entering a new, separate request for the same patient, he or she should respond NO to this
prompt.
Example: Making an Operation Request
Select Request Operations Option: R
Select Patient:
SURPATIENT,NINE
Make Operation Requests
12-09-51
000345555
NSC VETERAN
The following requests are outstanding for SURPATIENT,NINE:
1.
2.
09-15-99
Release of Hammer Toes
11-20-99
CHOLECYSTECTOMY
Do you want to update the outstanding request ?
YES// <Enter>
Select Operation Request: 1
Prompts that require a response before the user can continue with the option include the following.
"Make a Request for which Date ?"
"Surgeon:"
"Attending Surgeon:"
"Surgical Specialty:"
"Principal Operative Procedure:"
"Principal Preoperative Diagnosis:"
28
Surgery V. 3.0 User Manual
April 2004
Entering Preoperative Information
At this prompt:
The user should do this:
Principal
Preoperative
Diagnosis
Type in the reason this procedure is being performed. The user must enter
information into this field prompt before the option can be completed. The
information entered in this field will automatically populate the Indications
for Operations field, which can be edited through the Screen Server.
Planned Principal
Procedure Code (CPT)
Type in the Current Procedural Terminology (CPT) identifying code for each
procedure. If the code number is not known, the user can enter the type of
operation (i.e., appendectomy) or a body organ and select from a list of
codes.
Estimated Case Length
(HOURS:MINUTES)
Either accept the default answer by pressing the <Enter> key, or enter a
number for the length of time needed for this procedure. If a CPT Code is
entered, the software will display the average length of time for the
procedure based on the Surgical Specialty and CPT Code.
Brief Clinical History
This information will display on the Tissue Examination Report. It should
contain any information relevant to the specimens being sent to the
laboratory. This is a word-processing field.
---------------------------------------------------chart continues----------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
29
At this prompt:
The user should do this:
Select REQ BLOOD
KIND
Enter the type of blood product that will be needed for the operation.
The package coordinator can select a default response to this prompt when
installing the package. If the default product is not what is wanted for a case,
it can be deleted by entering the at-sign (@) at this prompt. The user can then
select the preferred blood product (enter two question marks for a list of
blood products).
If no blood products are needed, do not enter NO or NONE. Instead, press
the <Enter> key to bypass this prompt.
To order more than one product for the same case, use the screen server
summary that concludes the option and select item 9, REQ BLOOD KIND.
This is a multiple field; as many blood products as needed may be entered.
Requested
Preoperative X-Rays
Enter the types of preoperative x-ray films and reports required for delivery
to the operating room before the operation. This field may be left blank if the
user does not intend to order any x-ray products.
Request Clean or
Contaminated
Enter the letter code C for clean or D for contaminated, or type in the first
few letters of either word. This information allows the scheduling manager
to determine how much time is needed between operations for sanitizing a
room.
30
Surgery V. 3.0 User Manual
April 2004
Example: Make Operation Requests
Select Request Operations Option: R
Make Operation Requests
Select Patient: SURPATIENT,TWENTY
03-27-40
000454886
The following request is outstanding for SURPATIENT,TWENTY:
1.
03-09-2002
CARPAL TUNNEL RELEASE
Do you want to update the outstanding request ?
YES// N
Do you want to make a new request for SURPATIENT,TWENTY ? NO// Y
Make a Request for which Date ?
12/1
(DEC 01, 2004)
OPERATION REQUEST: REQUIRED INFORMATION
SURPATIENT,TWENTY (000-45-4886)
DEC 1, 2004
===============================================================================
Surgeon: SURSURGEON,ONE
Attending Surgeon: SURSURGEON,ONE
Surgical Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Principal Operative Procedure: CHOLECYSTECTOMY
Principal Preoperative Diagnosis: CHOLELITHIASIS
50
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue
<Enter>
OPERATION REQUEST: PROCEDURE INFORMATION
SURPATIENT,TWENTY (000-45-4886)
DEC 1, 2004
===============================================================================
Principal Procedure:
CHOLECYSTECTOMY
Planned Principal Procedure Code (CPT): 47480
INCISION OF GALLBLADDER
CHOLECYSTOTOMY OR CHOLECYSTOSTOMY WITH EXPLORATION, DRAINAGE, OR REMOVAL
OF CALCULUS (SEPARATE PROCEDURE)
ACTIVE
Modifier: 66
SURGICAL TEAM
Modifier: <Enter>
Select OTHER PROCEDURE: <Enter>
Estimated Case Length (HOURS:MINUTES): 2:45
Brief Clinical History:
1>SUBSCAPULAR PAIN FOR 3 DAYS. NAUSEA AND VOMITING. ACHOLIC
2>STOOLS. CHOLANGIOGRAM SHOWS COMMON DUCT OBSTRUCTION.
3><Enter>
EDIT Option: <Enter>
April 2004
Surgery V. 3.0 User Manual
Enter a “^” at this
prompt to bypass
entering additional
information related
to this request.
31
OPERATION REQUEST: BLOOD INFORMATION
SURPATIENT,TWENTY (000-45-4886)
DEC 1, 2004
===============================================================================
Request Blood Availability ? YES//
<Enter>
Type and Crossmatch, Screen, or Autologous ? TYPE & CROSSMATCH// <Enter>
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// @
SURE YOU WANT TO DELETE THE ENTIRE REQ BLOOD KIND? Y (YES)
Select REQ BLOOD KIND: FA1 FRESH FROZEN PLASMA, CPDA-1
18201
Units Required: 2
TYPE & CROSSMATCH
OPERATION REQUEST: OTHER INFORMATION
SURPATIENT,TWENTY (000-45-4886)
DEC 1, 2004
===============================================================================
Principal Preoperative Diagnosis: CHOLELITHIASIS// <Enter>
Prin Pre-OP ICD Diagnosis Code: 574.01
574.01
CHOLELITH/AC GB INF-OBST (w C/C
)
...OK? Yes// <Enter> (YES)
Hospital Admission Status: I// <Enter> INPATIENT
Case Schedule Type: U URGENT
First Assistant: SURSURGEON,TWO
Second Assistant: <Enter>
Requested Postoperative Care: WARD
W
Case Schedule Order: 1
Select SURGERY POSITION: SUPINE// <Enter>
Surgery Position: SUPINE// <Enter>
Requested Anesthesia Technique: GENERAL <Enter> GENERAL
Request Frozen Section Tests (Y/N/C): N NO
Requested Preoperative X-Rays: ABDOMIN
Intraoperative X-Rays (Y/N): N
Request Medical Media (Y/N): N
Request Clean or Contaminated: CLEAN
Select REFERRING PHYSICIAN: <Enter>
General Comments: <Enter>
No existing text
Edit? NO// <Enter>
SPD Comments: <Enter>
No existing text
Edit? NO// <Enter>
After entering the request information, the Screen Server redisplays all fields, providing an opportunity to
the user to update the information.
** REQUESTS **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #227
SURPATIENT,TWENTY
PRINCIPAL PROCEDURE: CHOLECYSTECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 47480-66
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 574.01
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: URGENT
SURGERY SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,TWO
SECOND ASST:
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
32
PAGE 1 OF 3
<Enter>
Surgery V. 3.0 User Manual
April 2004
** REQUESTS **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #227
SURPATIENT,TWENTY
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
ABDOMIN
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function: <Enter>
** REQUESTS **
1
SPD COMMENTS:
CASE #227
SURPATIENT,TWENTY
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function: <Enter>
A request has been made for SURPATIENT,TWENTY on 12-01-01.
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
33
Service Classifications
The Surgery software allows the user to associate a patient‟s Service Classification status when entering
or editing a surgical case or Non-OR procedure. Service Classifications can be designated for a surgical
case only if the veteran is first registered with these designations.
The Service Classifications that the user selects for the case also apply to the principal diagnosis.
These classifications default to each Other Postop Diagnosis as they are added to the case.
Updating an Operation Request with Service Classification Information
After the user selects the patient and enters the required data, a screen displays with questions about the
Service Classifications.
If the patient is not enrolled, or his/her status is not populated in enrollment, the software
displays the text “SC/NSC status not found, N will be defaulted into all SC/EI categories.” The
software defaults N into all Service Connected/Environmental Indicator fields related to the case.
If the user changes the SC/EI classifications at the case level, the software prompts the user with the
message “Update all „OTHER POSTOP DIAGNOSIS‟ Eligibility and Service Connected Conditions with
these values?”
34
Surgery V. 3.0 User Manual
April 2004
The following example depicts Service Classification status change when the user updates a case.
The user can also edit diagnosis classification status individually using the Surgeon's Verification of
Diagnosis & Procedures option or the Update/Verify Procedure/Diagnosis Codes option.
Example: Make an Operation Request with Service Classification Information
SURPATIENT,TEN
(000-12-3456)
ALLIED VETERAN
* * * Eligibility Information and Service Connected Conditions * * *
Primary Eligibility: SERVICE CONNECTED 50% to 100%
Combat Vet: NO
A/O Exp.: YES
M/S Trauma: NO
ION Rad.: YES
SWAC: YES
H/N Cancer: NO
PROJ 112/SHAD: YES
SC Percent: 100%
Rated Disabilities: NONE STATED
------------------------------------------------------------------------------Please supply the following required information about this operation:
Treatment
Treatment
Treatment
Treatment
Treatment
related
related
related
related
related
to
to
to
to
to
Service Connected condition (Y/N): N
Agent Orange (Y/N): N NO
Ionizing Radiation Exposure (Y/N): N
SW Asia (Y/N): N NO
PROJ 112/SHAD (Y/N): YES YES
NO
NO
Update all ‘OTHER POSTOP DIAGNOSIS' Eligibility and
Service Connected Conditions with these values? Enter YES or NO. <NO>
Y
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
35
Delete or Update Operation Requests
[SRSUPRQ]
The Delete or Update Operation Requests option is used to delete a request, to update information, or to
change the date of a requested operation. When a user enters this option and selects a patient‟s name and
case, he or she can choose one of the three functions. The three functions are explained below and the
next few pages contain examples of how to use them.
The prompts differ for concurrent cases (operations performed by two different specialties at the same
time on the same patient), as illustrated in Examples 4, 5, and 6. Whenever a user makes a change or
updates information for one of the concurrent cases, the software wants to know if the other case is
affected.
The three functions available in this option are also available in the Request Operations option when the
user selects an outstanding request.
With this function:
The user can:
Delete
Permanently remove an operation request from the software files (Examples 1
and 4). Example 4 shows the deletion of one operation in a set of concurrent
cases.
Change the length of the operation and edit other data fields that were entered
earlier (Example 2). The software can automatically update each case in a set
of two concurrent cases (Example 5).
Alter the operation date of the request (Examples 3 and 6). For a set of
concurrent cases to remain concurrent, the user must change the request date
for both operations (Example 6).
Update Request
Information
Change the Request
Date
36
Surgery V. 3.0 User Manual
April 2004
Example 1: Delete a Request
Select Request Operations Option: D
Select Patient:
SURPATIENT,NINE
Delete or Update Operation Requests
12-09-51
000345555
NSC VETERAN
The following cases are requested for SURPATIENT,NINE:
1. 08-15-01
2. 09-15-01
CHOLECYSTECTOMY
Release of Hammer Toes
Select Operation Request: 2
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 1
Are you sure that you want to delete this request ?
YES// <Enter>
Deleting Operation ...
Press RETURN to continue
Example 2: Update Request Information
Select Request Operations Option: D
Select Patient: SURPATIENT,TWENTY
Delete or Update Operation Requests
03-27-40
000454886
The following case is requested for SURPATIENT,TWENTY:
1. 12-01-01
CHOLECYSTECTOMY
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 2
How long is this procedure ? (HOURS:MINUTES)
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #227
2:45 // 2:30
SURPATIENT,TWENTY
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CHOLECYSTECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 47480-66
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE 574.01
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: URGENT
SURGERY SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,TWO
SECOND ASST:
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
WARD
Enter Screen Server Function: 13
Second Assistant: SURSURGEON,THREE
April 2004
Surgery V. 3.0 User Manual
37
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #227
** UPDATE REQUEST **
<Enter>
CASE #227
SURPATIENT,TWENTY
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
ABDOMIN
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function:
** UPDATE REQUEST **
1
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CHOLECYSTECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 47480-66
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 574.01
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: URGENT
SURGERY SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,TWO
SECOND ASST:
SURSURGEON,THREE
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,TWENTY
<Enter>
CASE #227
SURPATIENT,TWENTY
PAGE 3 OF 3
SPD COMMENTS: (WORD PROCESSING)
Enter Screen Server Function:
<Enter>
Example 3: Change the Request Date
Select Request Operations Option: D Delete or Update Operation Requests
Select Patient:
SURPATIENT,TWENTY
03-27-40
000454886
The following case is requested for SURPATIENT,TWENTY:
1. 12-01-01
CHOLECYSTECTOMY
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 3
Change to which Date ? 11/30
(NOV 30, 2001)
The request for SURPATIENT,TWENTY has been changed to NOV 30, 2001.
Press RETURN to continue
38
Surgery V. 3.0 User Manual
April 2004
Deleting or Updating Requests for Concurrent Cases
Any changes made to one concurrent case can affect the other case. When one of the concurrent cases is
deleted, a prompt will ask if the user wishes to delete the other case also. If the user responds with NO,
the remaining operation will stay in the records as a single case. When the user changes the date of one
operation of a concurrent case, the user must simultaneously change the date for the other operation,
otherwise the operations will no longer be considered concurrent.
When updating a response to a prompt or group of related prompts, the software will ask if the user wants
to store (meaning duplicate) the information in the other case. This saves time by storing the information
into the other case so that it does not have to be entered again. If the user does not want the prompt
response duplicated for the other case, enter N or NO.
Example 4: Delete a Request for Concurrent Cases
Select Request Operations Option: D Delete or Update Operation Requests
Select Patient: SURPATIENT,FOUR
01-16-35
000170555
NSC VETERAN
The following cases are requested for SURPATIENT,FOUR:
1. 03-15-05
2. 08-15-05
3. 08-15-05
APPENDECTOMY
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS
Select Operation Request: 2
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 1
Are you sure that you want to delete this request ?
YES// <Enter>
A concurrent case has been requested for this operation. Do you want to
delete the request for it also ? YES// <Enter>
Responding YES here will delete
both operation requests. NO
leaves the single remaining case,
no longer concurrent.
Deleting Operation ...
Deleting Concurrent Operation ...
Press <Enter> to continue <Enter>
Example 5: Update Request Information for a Concurrent Case
Select Request Operations Option: Delete or Update Operation Requests
Select Patient:
SURPATIENT,TWELVE
02-12-28
000418719
The following cases are requested for SURPATIENT,TWELVE:
1. 03-16-05
2. 03-16-05
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS GRAFT
Select Operation Request: 1
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 2
How long is this procedure ? (HOURS:MINUTES)
April 2004
1:30 // <Enter>
Surgery V. 3.0 User Manual
39
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #178
SURPATIENT,TWELVE
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CAROTID ARTERY ENDARTERECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 35301-59
PRINCIPAL PRE-OP DIAGNOSIS:
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS:
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: PERIPHERAL VASCULAR
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SECOND ASST:
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
SICU
Enter Screen Server Function: 4;5;8
Principal Preoperative Diagnosis: CAROTID ARTERY STENOSIS
Prin Pre-OP ICD Diagnosis Code: 433.1
'C'
CAROTID ARTERY OCCLUSION
COMPLICATION/COMORBIDITY
...OK? YES// <Enter> (YES)
Pre-admission Testing Complete (Y/N): YES
YES
Do you want to store this information in the concurrent case ?
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #178
SURPATIENT,TWELVE
YES//
N
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CAROTID ARTERY ENDARTERECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 35301-59
PRINCIPAL PRE-OP DIAGNOSIS: CAROTID ARTERY STENOSIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 433.10
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING: YES
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: PERIPHERAL VASCULAR
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SECOND ASST:
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
SICU
Enter Screen Server Function: <Enter>
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #178
SURPATIENT,TWELVE
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
SURGERY POSITION:
(MULTIPLE)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
DOPPLER STUDIES
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY:
CROSSMATCH, SCREEN, AUTOLOGOUS:
REQ BLOOD KIND:
(MULTIPLE)
REQ PHOTO:
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function: <Enter>
40
Surgery V. 3.0 User Manual
April 2004
** UPDATE REQUEST **
1
CASE #229
SURPATIENT,TWELVE
PAGE 3 OF 3
SPD COMMENTS: (WORD PROCESSING)
Enter Screen Server Function:
Example 6: Change the Request Date of Concurrent Cases
Select Request Operations Option: D Delete or Update Operation Requests
Select Patient: SURPATIENT,FOUR
01-16-35
000170555
NSC VETERAN
The following cases are requested for SURPATIENT,FOUR:
1.
2.
3.
4.
04-04-05
04-04-05
06-01-05
06-01-05
ARTHROSCOPY, RIGHT KNEE
REMOVE MOLE
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS GRAFT
Select Operation Request: 3
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 3
Change to which Date ? 6/2
(JUN 02, 2005)
There is a concurrent case associated with this operation. Do you want to change the date of it
also ? YES// ?
Enter <Enter> if these cases will remain concurrent, or 'NO' if they will no longer be associated
together.
There is a concurrent case associated with this operation. Do you want to change the date of it
also ? YES// <Enter>
The request for SURPATIENT,FOUR has been changed to JUN 2, 2005.
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
41
Make a Request from the Waiting List
[SRSWREQ]
The Make a Request from the Waiting List option uses data from the Waiting List to make an operation
request. It can save time by moving data from the Waiting List to the request (simultaneously removing it
from the waiting list). As with any request, a date for the surgery is required.
After the user enters the patient name, the software will list any operations on the Waiting List for that
patient. The user then selects the operative procedure wanted. The software will advise if the patient
selected has any outstanding requests.
Each institution might have a daily cutoff time for entering requests. After the cutoff time for a particular
day, the users are prohibited from booking a request for an operation to take place through midnight of
that day.
When a request is made, the user is asked to provide preoperative information about the case. It is best to
enter as much information as available.
Example: Making A Request From the Waiting List
Select Request Operations Option: W
Make a Request from the Waiting List
Make a request from the waiting list for which patient ?
08-16-51
000457212
SURPATIENT,FOURTEEN
Procedures Entered on the Waiting List for SURPATIENT,FOURTEEN:
1. GENERAL(OR WHEN NOT DEFINED BELOW)
REPAIR DIAPHRAGMATIC HERNIA
Date Entered on List:
Is this the correct procedure ?
YES// <Enter>
Make a request for which Date ?
12/1
NOV 17, 2005
(DEC 01, 2005)
OPERATION REQUEST: REQUIRED INFORMATION
SURPATIENT,FOURTEEN (000-45-7212)
DEC 1, 2005
================================================================================
Surgeon: SURSURGEON,TWO
Attending Surgeon: SURSURGEON,TWO
Surgical Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Principal Operative Procedure: REPAIR DIAPHRAGMATIC HERNIA
Principal Preoperative Diagnosis: ACUTE DIAPHRAGMATIC HERNIA
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue <Enter>
Sending a Notification of Appointment Booking for case #229
42
Surgery V. 3.0 User Manual
April 2004
OPERATION REQUEST: PROCEDURE INFORMATION
SURPATIENT,FOURTEEN (000-45-7212)
DEC 1, 2005
================================================================================
Principal Procedure:
REPAIR DIAPHRAGMATIC HERNIA
Planned Principal Procedure Code (CPT): 39540
REPAIR OF DIAPHRAGM HERNIA
REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; ACUTE
Select OTHER PROCEDURE: <Enter>
Estimated Case Length (HOURS:MINUTES): 2:00
BRIEF CLIN HISTORY:
1>Patient was reporting indigestion and a burning
2>sensation in esophagus. Upper GI indicated hernia.
3><Enter>
EDIT Option: <Enter>
OPERATION REQUEST: BLOOD INFORMATION
SURPATIENT,FOURTEEN (000-45-7212)
DEC 1, 2005
================================================================================
Request Blood Availability ? YES// <Enter>
Type and Crossmatch, Screen, or Autologous ? TYPE & CROSSMATCH// <Enter>
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// <Enter>
Required Blood Product: CPDA-1 WHOLE BLOOD// <Enter>
Units Required: 2
TYPE & CROSSMATCH
OPERATION REQUEST: OTHER INFORMATION
SURPATIENT,FOURTEEN (000-45-7212)
DEC 1, 2005
================================================================================
Principal Preoperative Diagnosis: ACUTE DIAPHRAGMATIC HERNIA
Replace <Enter>
Prin Pre-OP ICD Diagnosis Code: 551.3 DIAPHRAGM HERNIA W GANGR (w C/C)
...OK? Yes// <Enter> (YES)
Hospital Admission Status: I// <Enter> INPATIENT
Case Schedule Type: S STANDBY
First Assistant: SURSURGEON,ONE
Second Assistant: <Enter>
Requested Postoperative Care: WARD
W
Case Schedule Order: <Enter>
Select SURGERY POSITION: SUPINE// <Enter>
Surgery Position: SUPINE// <Enter>
Requested Anesthesia Technique: GENERAL GENERAL
Request Frozen Section Tests (Y/N): N NO
Requested Preoperative X-Rays: ABDOMEN
Intraoperative X-Rays (Y/N): N NO
Request Medical Media (Y/N): N NO
Request Clean or Contaminated: C CLEAN
Select REFERRING PHYSICIAN: <Enter>
General Comments: <Enter>
No existing text
Edit? NO// <Enter>
SPD Comments: <Enter>
No existing text
Edit? NO// <Enter>
April 2004
Surgery V. 3.0 User Manual
43
** REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #229
** REQUEST **
CASE #229
<Enter>
SURPATIENT,FOURTEEN
PAGE 2 OF 3
CASE SCHEDULE ORDER:
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
ABDOMEN
INTRAOPERATIVE X-RAYS:
NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN:
(MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY:
(WORD PROCESSING)(DATA)
Enter Screen Server Function:
** REQUEST **
1
PAGE 1 OF 3
PRINCIPAL PROCEDURE: REPAIR DIAPHRAGMATIC HERNIA
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 39540
PRINCIPAL PRE-OP DIAGNOSIS: ACUTE DIAPHRAGMATIC HERNIA
PRIN PRE-OP ICD DIAGNOSIS CODE: 551.3
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
SURGEON:
SURSURGEON,TWO
FIRST ASST:
SURSURGEON,ONE
SECOND ASST:
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,FOURTEEN
CASE #229
<Enter>
SURPATIENT,FOURTEEN
PAGE 3 OF 3
SPD COMMENTS: (WORD PROCESSING)
A request has been made for SURPATIENT,FOURTEEN on 12/01/2005.
Press RETURN to continue:
44
Surgery V. 3.0 User Manual
April 2004
Make a Request for Concurrent Cases
[SRSREQCC]
The Make a Request for Concurrent Cases option is used to book concurrent operations. Concurrent cases
are two operations performed on the same patient by different surgical specialties simultaneously, or
back-to-back in the same room. A request may be made for each case at one time with this option. As
usual, whenever a request is entered, the user is asked to provide preoperative information about the case.
It is best to enter as much information as possible and update it later if necessary.
Mandatory Prompts
After the patient name has been entered, the user will be prompted to enter some required information
about the first case (the mandatory prompts include the date of operation, procedure, surgeon and
attending surgeon, principal preoperative diagnosis, and time needed). If a mandatory prompt is not
answered, the software will not book the operation and will return the user to the Request Operations
menu. After answering the prompts for the first case, the user is prompted to answer the same questions
about the second case. Then, the software will provide a message that the two requests have been entered
and simultaneously prompt the user to select one of the cases for entering detailed information. If the user
does not want to enter detailed preoperative information at this time, pressing the <Enter> key will send
the user to the Request Operations menu. In Example 1, detailed information is entered for the first case
only.
Storing the Request Information
After most prompts, the software will ask if the user wants to store (meaning duplicate) this information
in the concurrent, or other, case. This saves time by storing the information into the other case so that
information does not have to be entered again. If the user does not want the prompt response duplicated
for the other case, he or she should enter N or NO.
Finally, the software will display the Screen Server summary and store any duplicated information into
the other case. At this point, the software will provide another message that the two requests have been
entered and again prompt the user to select either case for entering detailed information. This whole
process may be repeated with the other case by selecting the number for it, or pressing the <Enter> key
to get back to the Request Operations menu.
Updating the Preoperative Information Later
Use the Delete or Update Operation Requests option to change or update any of the information entered
for either or both concurrent cases (Example 2).
April 2004
Surgery V. 3.0 User Manual
45
Example 1: Make a Request for Concurrent Cases
Select Request Operations Option: CC
Make a Request for Concurrent Cases
Request Concurrent Cases for which Patient ?
SURPATIENT,TWELVE
Make a Request for Concurrent Cases on which Date ?
12/1
02-12-28 000418719
(DEC 01, 1999)
FIRST CONCURRENT CASE
OPERATION REQUEST: REQUIRED INFORMATION
SURPATIENT,TWELVE (000-41-8719)
DEC 1, 2005
================================================================================
Surgeon: SURSURGEON,ONE
Attending Surgeon: SURSURGEON,TWO
Surgical Specialty: 62
PERIPHERAL VASCULAR PERIPHERAL VASCULAR
62
Principal Operative Procedure: CAROTID ARTERY ENDARTERECTOMY
Principal Preoperative Diagnosis: CAROTID ARTERY STENOSIS
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue <Enter>
SECOND CONCURRENT CASE
OPERATION REQUEST: REQUIRED INFORMATION
SURPATIENT,TWELVE (000-41-8719)
DEC 1, 2005
===============================================================================
Surgeon: SURSURGEON,TWO
Attending Surgeon: SURSURGEON,ONE
Surgical Specialty: 58
THORACIC SURGERY (INC. CARDIAC SURG.)
SURGERY (INC. CARDIAC SURG.)
58
Principal Operative Procedure: AORTO CORONARY BYPASS GRAFT
Principal Preoperative Diagnosis: CORONARY ARTERY DISEASE
THORACIC
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue <Enter>
The following requests have been entered.
1. Case # 230
DEC 1, 2005
Surgeon: SURSURGEON,ONE
PERIPHERAL VASCULAR
Procedure: CAROTID ARTERY ENDARTERECTOMY
2. Case # 231
DEC 1, 2005
Surgeon: SURSURGEON,TWO
THORACIC SURGERY (INC. CARDIAC SURG.)
Procedure: AORTO CORONARY BYPASS GRAFT
1. Enter Request Information for Case #230
2. Enter Request Information for Case #231
Select Number:
46
(1-2): 2
Surgery V. 3.0 User Manual
April 2004
SECOND CONCURRENT CASE
OPERATION REQUEST: PROCEDURE INFORMATION
SURPATIENT,TWELVE (000-41-8719)
DEC 1, 2005
================================================================================
Principal Procedure:
AORTO CORONARY BYPASS GRAFT
Planned Principal Procedure Code (CPT): 35526 ARTERY BYPASS GRAFT
Modifiers: -66 SURGICAL TEAM
Select OTHER PROCEDURE: <Enter>
Estimated Case Length (HOURS:MINUTES): 3:30
BRIEF CLIN HISTORY:
1>CARDIAC CATH SHOWS 80% OCCLUSION OF THE LAD, 75% OCCLUSION OF
2>RIGHT CORONARY. ALSO, ANTERIOR INFERIOR HYPOKINESIS WITH
3>POOR LEFT VENTRICULAR FUNCTION, 27%.
4><Enter>
EDIT Option: <Enter>
SECOND CONCURRENT CASE
OPERATION REQUEST: BLOOD INFORMATION
SURPATIENT,TWELVE (000-41-8719)
DEC 1, 2005
================================================================================
Request Blood Availability ? N// YES
Type and Crossmatch, Screen, or Autologous ? TYPE & CROSSMATCH// <Enter> TYPE & CROSSMATCH
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// @
SURE YOU WANT TO DELETE THE ENTIRE REQ BLOOD KIND? Y (YES)
Select REQ BLOOD KIND: 04061 CPDA-1 RED BLOOD CELLS, DIVIDED UNIT
04061
Units Required: 4
SECOND CONCURRENT CASE
OPERATION REQUEST: OTHER INFORMATION
SURPATIENT,TWELVE (000-41-8719)
DEC 1, 2005
================================================================================
Prin Pre-OP ICD Diagnosis Code: 996.03 996.03
COMPLICATION/COMORBIDITY
...OK? YES// <Enter> (YES)
Hospital Admission Status: I// <Enter> INPATIENT
'C'
Do you want to store this information in the concurrent case ?
Case Schedule Type: S
MALFUNC CORON BYPASS GRF
YES//
<Enter>
STANDBY
Do you want to store this information in the concurrent case ?
YES// <Enter>
First Assistant: SURSURGEON,SIX
Second Assistant: <Enter>
Requested Postoperative Care: SICU
Do you want to store this information in the concurrent case ?
YES//
<Enter>
YES//
N
Do you want to store this information in the concurrent case ?
YES//
<Enter>
Request Frozen Section Tests (Y/N): N NO
Do you want to store this information in the concurrent case ?
Requested Preoperative X-Rays: DOPPLER STUDIES
YES// <Enter>
Case Schedule Order: 2
Do you want to store this information in the concurrent case ?
Select SURGERY POSITION: SUPINE// <Enter>
Surgery Position: SUPINE// <Enter>
Requested Anesthesia Technique: GENERAL
April 2004
Surgery V. 3.0 User Manual
47
Do you want to store this information in
Intraoperative X-Rays (Y/N): N NO
Do you want to store this information in
Request Medical Media (Y/N): N NO
Do you want to store this information in
Request Clean or Contaminated: C CLEAN
Do you want to store this information in
Select REFERRING PHYSICIAN: <Enter>
General Comments: <Enter>
No existing text
Edit? NO// <Enter>
SPD Comments: <Enter>
No existing text
Edit? NO// <Enter>
the concurrent case ?
YES//
N
the concurrent case ?
YES// <Enter>
the concurrent case ?
YES//
the concurrent case ?
YES// <Enter>
<Enter>
The information to be duplicated in the concurrent case will now be entered....
** REQUESTS **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #231
** REQUESTS **
CASE #231
<Enter>
SURPATIENT,TWELVE
PAGE 2 OF 3
CASE SCHEDULE ORDER: 2
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
DOPPLER STUDIES
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
48
PAGE 1 OF 3
PRINCIPAL PROCEDURE: AORTO CORONARY BYPASS GRAFT
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 35526-66
PRINCIPAL PRE-OP DIAGNOSIS: CORONARY ARTERY DISEASE
PRIN PRE-OP ICD DIAGNOSIS CODE: 996.03
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: THORACIC SURGERY (INC. CARDIAC SURG.)
SURGEON:
SURSURGEON,TWO
FIRST ASST:
SURSURGEON,SIX
SECOND ASST:
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
SICU
Enter Screen Server Function:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,TWELVE
<Enter>
Surgery V. 3.0 User Manual
April 2004
** REQUESTS **
1
CASE #231
SURPATIENT,TWELVE
PAGE 3 OF 3
SPD COMMENTS: (WORD PROCESSING)
Enter Screen Server Function:
<Enter>
The following requests have been entered.
1. Case # 230
DEC 1, 2005
Surgeon: SURSURGEON,ONE
PERIPHERAL VASCULAR
Procedure: CAROTID ARTERY ENDARTERECTOMY
2. Case # 231
DEC 1, 2005
Surgeon: SURSURGEON,TWO
THORACIC SURGERY (INC. CARDIAC SURG.)
Procedure: AORTO CORONARY BYPASS GRAFT
1. Enter Request Information for Case #230
2. Enter Request Information for Case #231
Select Number:
April 2004
(1-2):
Surgery V. 3.0 User Manual
49
Example 2: Update Request Information for a Concurrent Case
Select Request Operations Option: D Delete or Update Operation Requests
Select Patient:
SURPATIENT,TWELVE
02-12-28
000418719
The following cases are requested for SURPATIENT,TWELVE:
1. 03-09-05
2. 12-01-05
3. 12-01-05
REMOVE FACIAL LESIONS
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS GRAFT
Select Operation Request: 2
1. Delete
2. Update Request Information
3. Change the Request Date
Select Number: 2
How long is this procedure ? (HOURS:MINUTES)
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #230
SURPATIENT,TWELVE
** UPDATE REQUEST **
CASE #230
433.1
'C'
CAROTID ARTERY OCCLUSION
SURPATIENT,TWELVE
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CAROTID ARTERY ENDARTERECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 35301-59
PRINCIPAL PRE-OP DIAGNOSIS: CAROTID ARTERY STENOSIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 433.10
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: PERIPHERAL VASCULAR
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SECOND ASST:
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
SICU
Enter Screen Server Function:
50
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CAROTID ARTERY ENDARTERECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 35301-59
PRINCIPAL PRE-OP DIAGNOSIS: CAROTID ARTERY STENOSIS
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: PERIPHERAL VASCULAR
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SECOND ASST:
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
SICU
Enter Screen Server Function: 5
Prin Pre-OP ICD Diagnosis Code: 433.1
COMPLICATION/COMORBIDITY
...OK? YES// <Enter> (YES)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
// 1:30
<Enter>
Surgery V. 3.0 User Manual
April 2004
** UPDATE REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #230
PAGE 2 OF 3
CASE SCHEDULE ORDER:
SURGERY POSITION:
(MULTIPLE)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY:
CROSSMATCH, SCREEN, AUTOLOGOUS:
REQ BLOOD KIND:
(MULTIPLE)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function:
** UPDATE REQUEST **
1
SURPATIENT,TWELVE
<Enter>
CASE #230
SPD COMMENTS:
SURPATIENT,TWELVE
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
51
Review Request Information
[SROREQV]
Surgeons and nurses use the Review Request Information option to edit or review the preoperative
information that was entered when the case was requested. This option can be accessed after the case has
been scheduled.
Example: Review Request Information
Select Request Operations Option: V
Select Patient: SURPATIENT,ONE
Review Request Information
02-23-53
000447629
SURPATIENT,ONE
1. 03-09-99
REVISE MEDIAN NERVE (REQUESTED)
Select Operation:
1
** REVIEW REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #35
PAGE 1 OF 2
PRINCIPAL PROCEDURE: REVISE MEDIAN NERVE
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE: 64721
PRINCIPAL PRE-OP DIAGNOSIS: CARPAL TUNNEL SYNDROME
PRIN PRE-OP ICD DIAGNOSIS CODE: 354.0
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
CASE SCHEDULE TYPE: ELECTIVE
SURGERY SPECIALTY: ORTHOPEDICS
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,THREE
SECOND ASST:
SURSURGEON,TWO
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
WARD
CASE SCHEDULE ORDER: 2ND
Enter Screen Server Function:
** REVIEW REQUEST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
SURPATIENT,ONE
<Enter>
CASE #35
SURPATIENT,ONE
PAGE 2 OF 2
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
REQ PREOP X-RAY:
CARPAL TUNNEL, R WRIST
INTRAOPERATIVE X-RAYS:
REQUEST BLOOD AVAILABILITY: NO
CROSSMATCH, SCREEN, AUTOLOGOUS:
REQ BLOOD KIND:
(MULTIPLE)
REQ PHOTO:
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function:
52
Surgery V. 3.0 User Manual
April 2004
Operation Requests for a Day
[SROP REQ]
The Operation Requests for a Day option allows the scheduling manager to display or print a list of
operation requests. The information from all surgical requests is collected by the software and made
available by date. There are no editing capabilities for this feature. The user has a choice of printing a
cursory short form or a long form encompassing all the request fields.
This report prints in an 80-column format and can be viewed on the screen.
Example 1: Print Operation Requests for a Day, Short Form
Select Request Operations Option: OR
Operation Requests for a Day
Print Requests for which date ? 3/15
(MAR 15, 1999)
Would you like the long or short form ?
SHORT// <Enter>
Do you want the requests for all surgical specialties ?
YES//
N
Print Requests for which Surgical Specialty ? GENERAL
(OR WHEN NOT DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
50
Print the Requests on which Device: HOME// [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------OPERATION REQUESTS FOR GENERAL(OR WHEN NOT DEFINED BELOW)
03/15/99
-----------------------------------------------------------------------------1.
Case Number: 173
Operation Date: 03/15/99
Patient:
SURPATIENT,TWENTY
Ward:
ID#:
000-45-4886
Surgeon: SURSURGEON,ONE
Procedure: CHOLECYSTECTOMY (URGENT ADD TODAY)
Estimated Case Length: 2:30
Requested Anesthesia: GENERAL
2.
Case Number: 180
Operation Date: 03/15/99
Patient:
SURPATIENT,FOURTEEN
Ward: 1 SOUTH
ID#:
000-45-7212
Surgeon: SURSURGEON,TWO
Procedure: REPAIR DIAPHRAGMATIC HERNIA (STANDBY)
Estimated Case Length: 2:00
Requested Anesthesia: GENERAL
Press RETURN to continue
April 2004
<Enter>
Surgery V. 3.0 User Manual
53
Example 2: Long Form
Select Request Operations Option:
OR Operation Requests for a Day
Print Requests for which date ? 3/15
(MAR 15, 1999)
Would you like the long or short form ?
SHORT// L
Do you want the requests for all surgical specialties ?
YES//
N
Print Requests for which Surgical Specialty ? GENERAL
(OR WHEN NOT DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
50
Print the Requests on which Device: HOME// [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------==============================================================================
OPERATION REQUESTS FOR GENERAL(OR WHEN NOT DEFINED BELOW)
ON MAR 15, 1999
-----------------------------------------------------------------------------Patient: SURPATIENT,TWENTY
Age: 51
ID #: 000-45-4886
Ward: NOT ENTERED
Surgeon: SURSURGEON,ONE
Preoperative Diagnosis: CHOLELITHIASIS
Attending: SURSURGEON,ONE
Principal Procedure: CHOLECYSTECTOMY
Other Procedures:
INTRAOPERATIVE CHOLANGIOGRAM
Estimated Case Length: 2:30
Req. Anesthesia Technique: GENERAL
Blood Requested:
CPDA-1 WHOLE BLOOD
UNITS
FRESH FROZEN PLASMA, CPDA-1
Restraints:
SAFETY STRAP
Requested by: SURNURSE,ONE on JAN 7, 1999 13:45
Press <Enter> to continue, or '^' to quit:
2 UNITS
<Enter>
==============================================================================
OPERATION REQUESTS FOR GENERAL(OR WHEN NOT DEFINED BELOW)
ON MAR 15, 1999
-----------------------------------------------------------------------------Patient: SURPATIENT,FOURTEEN
Age: 48
ID #: 000-45-7212
Ward: 1 SOUTH
Surgeon: SURSURGEON,TWO
Attending: SURSURGEON,TWO
Preoperative Diagnosis: ACUTE DIAPHRAGMATIC HERNIA
Principal Procedure: REPAIR DIAPHRAGMATIC HERNIA
Estimated Case Length: 2:00
Req. Anesthesia Technique: GENERAL
Blood Requested:
CPDA-1 WHOLE BLOOD 2 UNITS
Restraints:
SAFETY STRAP
Requested by: SURNURSE,ONE on JAN 13, 1999 14:39
Press RETURN to continue
54
<Enter>
Surgery V. 3.0 User Manual
April 2004
Requests by Ward
[SROWRQ]
Users can utilize the Requests by Ward option to print request information for patients in all wards or a
specific ward. The first prompt asks if the user wants to print the requests for all wards. If not, accept the
NO default and the next prompt will ask "Print schedule for which ward?". If the user enters a question
mark (?), the help screen will list the ward names from which to choose. Patients not assigned to a ward
are listed under the category “Outpatient.”
This report prints in an 80-column format and can be viewed on the screen.
Example: Print Requests by Ward
Select Request Operations Option:
WR
Requests by Ward
Do you wish to print the requests for all wards ? NO// Y
Print Requests on which Device: [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------Requests for Operations
==============================================================================
Ward: 1 SOUTH
==============================================================================
Patient: SURPATIENT,FOURTEEN (000-45-7212)
Case Number: 180
Date of Operation:
03/15/99
Case Order:
Requested Anesthesia: GENERAL
Operation(s): REPAIR DIAPHRAGMATIC HERNIA
Comments:
-----------------------------------------------------------------------------Press RETURN to continue or '^' to quit. <Enter>
Requests for Operations
==============================================================================
Ward: 2 WEST
==============================================================================
Patient: SURPATIENT,TWELVE (000-41-8719)
Case Number: 178
Date of Operation:
03/15/99
Case Order: 1
Requested Anesthesia: GENERAL
Operation(s): CAROTID ARTERY ENDARTERECTOMY
Comments:
Concurrent Case Number: 179
Procedure: AORTO CORONARY BYPASS GRAFT
Comments:
-----------------------------------------------------------------------------Patient: SURPATIENT,TWELVE (000-41-8719)
Case Number: 179
Date of Operation:
03/15/99
Case Order: 1
Requested Anesthesia: GENERAL
Operation(s): AORTO CORONARY BYPASS GRAFT
Comments:
Concurrent Case Number: 178
Procedure: CAROTID ARTERY ENDARTERECTOMY
Comments:
-----------------------------------------------------------------------------Press RETURN to continue or '^' to quit. <Enter>
April 2004
Surgery V. 3.0 User Manual
55
Requests for Operations
==============================================================================
Ward: OUTPATIENT
==============================================================================
Patient: SURPATIENT,FIFTEEN (000-98-1234)
Case Number: 172
Date of Operation:
03/25/99
Case Order:
Requested Anesthesia:
Operation(s): HEMMORHOIDECTOMY
Comments:
-----------------------------------------------------------------------------Patient: SURPATIENT,TWENTY (000-45-4886)
Case Number: 173
Date of Operation:
03/15/99
Case Order:
Requested Anesthesia: GENERAL
Operation(s): CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
Comments:
-----------------------------------------------------------------------------Patient: SURPATIENT,SIXTEEN (000-11-1111)
Case Number: 175
Date of Operation:
03/14/99
Case Order:
Requested Anesthesia: LOCAL
Operation(s): REMOVE BUNION
Comments:
------------------------------------------------------------------------------
56
Surgery V. 3.0 User Manual
April 2004
List Operation Requests
[SRSRBS]
Users can use the List Operation Requests option to produce a list of requested cases, including cases on
the Waiting List. This report sorts by ward or surgical specialty.
This report prints in an 80-column format and can be viewed on the screen.
Example 1: List Operation Requests, by Specialty
Select Surgery Menu Option:
LR
List Operation Requests
List requests by SPECIALTY or WARD ?
SPECIALTY// <Enter>
Do you want requests for all surgical specialties ? YES// N
List Request for which Specialty ? GENERAL
L(OR WHEN NOT DEFINED BELOW)
50
(OR WHEN NOT DEFINED BELOW)
GENERA
Print to Device: [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------Operative Requests for GENERAL(OR WHEN NOT DEFINED BELOW)
Date
Patient
Ward Location
Case Number
Operative Procedure
========================================================================
APR 4, 1999 SURPATIENT,FOUR
1 SOUTH
180
000-45-7212
REMOVE MOLE
-----------------------------------------------------------------------JUN 1, 1999 SURPATIENT,SEVENTEEN
1 SOUTH
178
000-45-5119
REPAIR DIAPHRAGMATIC HERNIA
-----------------------------------------------------------------------AUG 15, 1999 SURPATIENT,NINE
1 NORTH
145
000-34-5555
CHOLECYSTECTOMY
-----------------------------------------------------------------------Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
57
Example 2: List Operation Requests, by Ward
Select Surgery Menu Option:
LR List Operation Requests
List requests by SPECIALTY or WARD ?
SPECIALTY//
WARD
Do you want requests for all wards ? YES// N
Select Requests for which Ward ? 1 SOUTH
Print the Report on which Device: HOME// [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
Operative Requests for 1 SOUTH
Date
Patient
Surgical Specialty
Case Number
Operative Procedure
========================================================================
APR 4, 1999 SURPATIENT,FOUR
ORTHOPEDICS
179
000-45-7212
ARTHROSCOPY, RIGHT KNEE
-----------------------------------------------------------------------APR 4, 1999 SURPATIENT,THREE
GENERAL
180
000-21-2453
REMOVE MOLE
-----------------------------------------------------------------------JUN 1, 1999 SURPATIENT,SEVENTEEN
GENERAL
178
000-45-5119
REPAIR DIAPHRAGMATIC HERNIA
-----------------------------------------------------------------------JUN 1, 1999 SURPATIENT,TWELVE
PERIPHERAL VASCULAR
181
000-41-8719
CAROTID ARTERY ENDARTERECTOMY
-----------------------------------------------------------------------JUN 1, 1999 SURPATIENT,NINE
THORACIC SURGERY
182
000-34-5555
AORTO CORONARY BYPASS GRAFT
-----------------------------------------------------------------------Press RETURN to continue
58
Surgery V. 3.0 User Manual
April 2004
Schedule Operations
[SROSCHOP]
The options contained within the Schedule Operations menu are designed to be used by surgeons or the
Scheduling Manager to book an operation when the date, time, and operating room are determined. The
scheduling manager may schedule an already requested operation using the Schedule Requested
Operation option. On the other hand, the scheduling manager may book an operation that has not been
previously requested if the date, time and operating room are known. In this case, the Request Operations
option can be skipped and the operation can be scheduled using the Schedule Unrequested Operations
option.
This option is locked with the SROSCH key.
Whether a user is booking a case from the Waiting List, Request Menu, Scheduling Menu, or as a new
surgery, he or she will be asked to provide preoperative information about the case. It is advisable to enter
as much information as possible. Later, the information can be updated.
The information gathered by the Request Operations options is collated by the software and used to
produce reports. The person in charge of scheduling (scheduling manager) arranges the requests
according to the hospital‟s Surgical Service protocols and schedules the operation by assigning the case
an operating room and a time slot. The information gathered by the Schedule Operations menu is collated
by the software and is used to produce reports for the scheduling manager.
Local restrictions can be applied to the scheduling of procedures. For example, a facility can
require CPT codes be entered before a surgical case is scheduled. The Surgery Site Parameters
(Enter/Edit) option is used to select required fields.
The options included in the Schedule Operation menu are listed below. To the left of the option name is
the shortcut synonym that the user can enter to select the option.
Shortcut
A
SR
SU
CON
R
C
UC
AN
B
DB
S
April 2004
Option Name
Display Availability
Schedule Requested Operations
Schedule Unrequested Operations
Schedule Unrequested Concurrent Cases
Reschedule or Update Scheduled Operations
Cancel Scheduled Operation
Update Cancellation Reason
Schedule Anesthesia Personnel
Create Service Blockout
Delete Service Blockout
Schedule of Operations
Surgery V. 3.0 User Manual
59
Display Availability
[SRODISP]
A user can view the availability of operating rooms on a blockout graph before booking an operation with
the Display Availability option. A user might also use this option to check a booking or service blockout.
This feature is the same as the Display Availability option available on the Request Operations menu
option.
Scheduled operations show up on the graph as an equal sign (=) followed by the letter X. The equal sign
before the X indicates the beginning of a scheduled operation. Surgical specialty blockouts are indicated
by an abbreviation for the service. For more information on service blockouts, a function of the
scheduling menu, see the Create Service Blockout option.
If the facility has a display terminal that can print condensed characters, a 24-hour graph will display on
the screen. If not, the user will be prompted to select one of three graphs representing different chunks of
that day.
Example: Display all O.R.s for One Day
Select Schedule Operations Option: A
Display Availability
Do you want to view all Operating Rooms on one day ?
Do you want to list requests also ?
NO//
YES //
<Enter>
<Enter>
Display Operating Room Availability for which Date ?
T
(JUL 01, 1999)
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
ROOM
OR1
OR2
OR3
OR4
OR5
<Enter>
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|uro.|uro.|uro.|uro.|uro.|uro.|uro.|uro.|____|____|____|____|____|
|____|card|card|card|card|card|card|card|card|card|____|____|____|____|
|____|thor|thor|thor|thor|thor|thor|thor|thor|____|____|____|____|____|
|____|gen.|gen.|gen.|gen.|gen.|gen.|gen.|gen.|____|____|____|____|____|
|____|=XXX|XXXX|=XXX|XXXX|____|____|____|____|____|____|____|____|____|
Press RETURN to continue
60
Surgery V. 3.0 User Manual
April 2004
Schedule Requested Operation
[SRSCHD1]
Users utilize the Schedule Requested Operation option to schedule a previously requested operation when
enough information is available to assign an operating room and time slot. The user will also be prompted
to provide anesthesia personnel information. The information entered here is reflected in the Schedule of
Operations report. This option is designed for the scheduling manager to expeditiously schedule any or all
requests on a specific date.
First, the user enters the patient to be scheduled. The software will automatically display all requests for
that patient. The user then picks the request he or she wishes to schedule and assigns the operating room,
beginning and end times, and anesthesia personnel for the case. The user can then choose another patient
to schedule, or press the <Enter> key to leave the option.
The prompts that require a response before the user can continue with this option include the following.
"Schedule a Case for which Operating Room ?"
"Reserve from what time ? (24HR:NEAREST 15 MIN):"
"Reserve to what time ? (24HR:NEAREST 15 MIN):"
Scheduling a Concurrent Case
A concurrent case occurs when a patient undergoes two operations by different surgical specialties
simultaneously, or back-to-back in the same operating room. Example 2 demonstrates scheduling a
requested concurrent case. When a user schedules a concurrent case, he or she must answer the prompt
"There is a concurrent case associated with this operation. Do you want to schedule it for the same time?
(Y/N) ". If the answer is NO, the two cases will no longer be considered concurrent. The user can enter
anesthesia personnel information for each case.
The user should allow enough time for both surgeries when he or she answers the prompts,
"Reserve from what time ? (24HR:NEAREST 15 MIN):" and "Reserve to what time ?
(24HR:NEAREST 15 MIN):".
April 2004
Surgery V. 3.0 User Manual
61
Example 1: Schedule a Requested Operation
Select Schedule Operations Option: SR
Schedule Requested Operations
Select Patient: SURPATIENT,SIX
04-04-30
000098797
The following case is requested for SURPATIENT,SIX:
1. 04-24-99
CHOLECYSTECTOMY
Case Information:
CHOLECYSTECTOMY
By SURSURGEON,TWO
Case # 210
On SURPATIENT,SIX
For 1:00 Hours
Comments:
Is this the correct operation ?
YES// <Enter>
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
ROOM
OR1
OR2
OR3
OR4
OR5
<Enter>
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|____|____|____|____|____|____|gen.|gen.|gen.|____|____|____|____|
|____|card|card|card|card|card|card|card|card|card|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Schedule a Case for which Operating Room ?
OR1
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
7:00
8:00
Principal Anesthetist: SURANESTHETIST,ONE
Anesthesiologist Supervisor: SURANESTHETIST,TWO
Select Patient:
62
Surgery V. 3.0 User Manual
April 2004
Example 2: Schedule Operation for a Concurrent Case
Select Schedule Operations Option: SR
Schedule Requested Operations
Select Patient: SURPATIENT,EIGHTEEN
09-14-54
000223334
The following cases are requested for SURPATIENT,EIGHTEEN:
1. 07-06-99
2. 07-06-99
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS GRAFT
Select Operation Request: 1
Case Information:
CAROTID ARTERY ENDARTERECTOMY
By SURSURGEON,ONE
On SURPATIENT,EIGHTEEN
Case # 262
STANDBY
* Concurrent Case # 263 AORTO CORONARY BYPASS GRAFT
Is this the correct operation ?
YES//
<Enter>
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
ROOM
OR1
OR2
OR3
OR4
OR5
<Enter>
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|card|card|card|card|card|card|card|card|card|____|____|____|____|
|____|orth|orth|orth|orth|orth|orth|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Schedule a Case for which Operating Room ?
OR2
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
7:15
12:30
Principal Anesthetist: SURANESTHETIST,ONE
Anesthesiologist Supervisor: SURANESTHETIST,TWO
There is a concurrent case associated with this operation. Do you want to
schedule it for the same time ? (Y/N) Y
Select Patient:
April 2004
Surgery V. 3.0 User Manual
63
Schedule Unrequested Operations
[SROSRES]
Users can use the Schedule Unrequested Operations option to schedule an operation that has not been
requested. To schedule an operation, the user must determine the date, time, and operating room. The
information entered in this option is reflected in the Schedule of Operations Report.
Whenever a new case is booked, the user is asked to provide preoperative information about the case.
Enter as much information as possible. Later, the information can be updated or corrected.
Prompts that require a response before the user can continue with this option are listed below.
"Schedule Procedure for which Date ?"
"Select Patient:"
"Schedule a case for which operating Room ?"
"Reserve from what time ? (24HR:NEAREST 15 MIN):"
"Reserve to what time ? (24HR:NEAREST 15 MIN):"
“Desired Procedure Date:”
"Surgeon:"
"Attending Surgeon:"
"Surgical Specialty:"
"Principal Operative Procedure:"
"Principal Preoperative Diagnosis:"
64
Surgery V. 3.0 User Manual
April 2004
Entering Preoperative Information
At this prompt:
The user should do this:
Planned Principal Procedure Code (CPT) Enter the Current Procedural Terminology (CPT) identifying
code for each procedure. If the code number is not known, the
user can enter the type of operation (i.e., appendectomy) or a
body organ and select from a list of codes.
Principal Preoperative Diagnosis
Brief Clinical History
Select REQ BLOOD KIND
Type in the reason this procedure is being performed. The user
must enter information into this field prompt before the option
can be completed. The information entered in this field will
automatically populate the Indications for Operations field,
which can be edited through the Screen Server.
Enter any information relevant to the specimens being sent to
the laboratory. This is an open-text word-processing field. This
information will display on the Tissue Examination Report.
Enter the type of blood product needed for the operation.
If no blood products are needed, do not enter NO or NONE;
instead, press the <Enter> key to bypass this prompt.
The package coordinator at each facility can select a default
response to this prompt when installing the package. If the
default product is not what is wanted for a case, it can be
deleted by entering the at-sign (@) at this prompt. Then, the
user can select the preferred blood product. (Enter two question
marks for a list of blood products.)
To order more than one product for the same case, use the
screen server summary that concludes the option. On page two
of the summary, select item 7, REQ BLOOD KIND, to enter as
many blood products as needed.
Requested Preoperative X-Rays
Request Clean or Contaminated
April 2004
Enter the types of preoperative x-ray films and reports required
for delivery to the operating room before the operation. If the
user does not intend to order any x-ray products, this field
should be left blank.
Enter the letter code C for clean or D for contaminated, or type
in the first few letters of either word. This information allows
the scheduling manager to determine how much time is needed
between operations for sanitizing a room.
Surgery V. 3.0 User Manual
65
Example: Schedule an Unrequested Operation
Select Schedule Operations Option: SU
Schedule Unrequested Operations
Schedule a Procedure for which Date ?
7 18 05
Select Patient: SURPATIENT,THREE
(JUL 18, 2005)
12-19-53
000212453
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
ROOM
OR1
OR2
OR3
OR4
OR5
<Enter>
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Schedule a case for which operating Room ?
OR1
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
8:00
13:00
SCHEDULE UNREQUESTED OPERATION: REQUIRED INFORMATION
SURPATIENT,THREE (000-21-2453)
JUL 18, 2005
================================================================================
Desired Procedure Date: 7 18 05 (JUL 18, 2005)
Surgeon: SURSURGEON,ONE
Attending Surgeon: SURSURGEON,TWO
Surgical Specialty: 54
ORTHOPEDICS ORTHOPEDICS
54
Principal Operative Procedure: SHOULDER ARTHROPLASTY-PROSTHESIS
Principal Preoperative Diagnosis: DEGENERATIVE JOINT DISEASE, L SHOULDER
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue
<Enter>
SCHEDULE UNREQUESTED OPERATION: ANESTHESIA PERSONNEL
SURPATIENT,THREE (000-21-2453)
JUL 18, 2005
================================================================================
Principal Anesthetist: SURANESTHETIST,ONE
Anesthesiologist Supervisor: SURANESTHETIST,TWO
SCHEDULE UNREQUESTED OPERATION: PROCEDURE INFORMATION
SURPATIENT,THREE (000-21-2453)
JUL 18, 2005
================================================================================
Principal Procedure:
SHOULDER ARTHROPLASTY-PROSTHESIS
Planned Principal Procedure Code (CPT): 23470 ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIART
Brief Clinical History:
1>CHRONIC DEBILITATING PAIN. X-RAY SHOWS SEVERE
2>DEGENERATIVE OSTEOARTHRITIS.
3><Enter>
EDIT Option: <Enter>
66
Surgery V. 3.0 User Manual
April 2004
SCHEDULE UNREQUESTED OPERATION: BLOOD INFORMATION
SURPATIENT,THREE (000-21-2453)
JUL 18, 2005
================================================================================
Request Blood Availability (Y/N): Y// <Enter> YES
Type and Crossmatch, Screen, or Autologous: TYPE & CROSSMATCH// <Enter> TYPE & CROSSMATCH
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// @
SURE YOU WANT TO DELETE THE ENTIRE REQ BLOOD KIND? Y (YES)
Select REQ BLOOD KIND: FA1 FRESH FROZEN PLASMA, CPDA-1
18201
Units Required: 4
SCHEDULE UNREQUESTED OPERATION: OTHER INFORMATION
SURPATIENT,THREE (000-21-2453)
JUL 18, 2005
================================================================================
Prin Pre-OP ICD Diagnosis Code: 715.11 715.11
...OK? YES// <Enter> (YES)
Hospital Admission Status: I// <Enter> INPATIENT
Case Schedule Type: S STANDBY
First Assistant: TS SURSURGEON,THREE
Second Assistant: SURSURGEON,FOUR
Requested Postoperative Care: W WARD
Case Schedule Order: 1
Requested Anesthesia Technique: G GENERAL
Request Frozen Section Tests (Y/N): N NO
Requested Preoperative X-Rays: LEFT SHOULDER
Intraoperative X-Rays (Y/N/C): Y YES
Request Medical Media (Y/N): N NO
Request Clean or Contaminated: C CLEAN
GENERAL COMMENTS:
1><Enter>
SPD Comments:
1><Enter>
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #264
SURPATIENT,THREE
LOC PRIM OSTEOART-SHLDER
PAGE 1 OF 2
PRINCIPAL PROCEDURE: SHOULDER ARTHROPLASTY-PROSTHESIS
PLANNED PRIN PROCEDURE CODE: 23470
OTHER PROCEDURES:
(MULTIPLE)
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE, L SHOULDER
PRIN PRE-OP ICD DIAGNOSIS CODE: 715.11
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: ORTHOPEDICS
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,THREE
SECOND ASST:
SURSURGEON,FOUR
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
April 2004
<Enter>
Surgery V. 3.0 User Manual
67
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #264
SURPATIENT,THREE
PAGE 2 OF 2
CASE SCHEDULE ORDER: 1
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
LEFT SHOULDER
INTRAOPERATIVE X-RAYS: YES
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
PRINC ANESTHETIST: SURANESTHETIST,ONE
ANESTHESIOLOGIST SUPVR: SURSURGEON,TWO
BRIEF CLIN HISTORY: (WORD PROCESSING)(DATA)
GENERAL COMMENTS:
(WORD PROCESSING)
SPD COMMENTS:
(WORD PROCESSING)
Enter Screen Server Function:
68
Surgery V. 3.0 User Manual
April 2004
Schedule Unrequested Concurrent Cases
[SRSCHDC]
The Schedule Unrequested Concurrent Cases option is used to schedule concurrent cases that have not
been requested. A concurrent case is when a patient undergoes two operations by different surgical
specialties simultaneously, or back to back in the same room. The user can schedule both cases with this
one option. As usual, whenever the user enters a request, he or she is asked to provide preoperative
information about the case. It is best to enter as much information as possible and update it later if
necessary.
Required Prompts
After the patient name is entered, the user will be prompted to enter some required information about the
first case. The mandatory prompts include the date, procedures, surgeon and attending surgeon, principal
preoperative diagnosis, and time needed. If a mandatory prompt is not answered, the software will not
book the operation and will return the cursor to the Schedule Operations menu. After answering the
prompts for the first case, the user will be asked to answer the same prompts for the second case. The
software will then provide a message stating that the two requests have been entered. The user can then
select a case for entering detailed preoperative information. If the user does not want to enter details at
this time, he or she should press the <Enter> key and the cursor will return to the Schedule Operations
menu. In the example, detailed information for the first case has been entered.
Storing the Request Information
After every prompt or group of related prompts, the software will ask if the user wants to store (meaning
duplicate) the answers in the concurrent case. This saves time by storing the information into the other
case so that it does not have to be typed again. The software will then display the screen server summary
and store any duplicated information into the other case. Finally, the software will inform the user that the
two requests have been entered and prompt to select either case for entering detailed information. The
user can select a case or press the <Enter> key to get back to the Schedule Operations menu.
Updating the Preoperative Information Later
Use the Reschedule or Update a Scheduled Operation option to change or update any of the information
entered for either of the concurrent cases.
April 2004
Surgery V. 3.0 User Manual
69
Example: Schedule Unrequested Concurrent Cases
Select Schedule Operations Option: CON
Schedule Unrequested Concurrent Cases
Schedule Concurrent Cases for which Patient ?
000370555
SURPATIENT,EIGHT
Schedule Concurrent Procedures for which Date ?
07 25 2005
06-04-35
(JUL 25, 2005)
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
4
Schedule a case for which operating Room ?
OR2
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
11:15
16:00
(11:15)
(16:00)
FIRST CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: REQUIRED INFORMATION
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 2005
================================================================================
Desired Procedure Date: 07 25 2005 (JUL 25, 2005)
Surgeon: SURSURGEON,ONE
Attending Surgeon: SURSURGEON,ONE
Surgical Specialty: 62
PERIPHERAL VASCULAR
PERIPHERAL VASCULAR
62
Principal Operative Procedure: CAROTID ARTERY ENDARTERECTOMY
Principal Preoperative Diagnosis: CAROTID ARTERY STENOSIS
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue
<Enter>
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: REQUIRED INFORMATION
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 2005
================================================================================
Desired Procedure Date: 07 25 2005 (JUL 25, 2005)
Surgeon: SURSURGEON,TWO
Attending Surgeon: SURSURGEON,ONE
Surgical Specialty: 58
THORACIC SURGERY (INC. CARDIAC SURG.)
SURGERY (INC. CARDIAC SURG.)
58
Principal Operative Procedure: AORTO CORONARY BYPASS GRAFT
Principal Preoperative Diagnosis: UNSTABLE ANGINA
THORACIC
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue
70
<Enter>
Surgery V. 3.0 User Manual
April 2004
The following cases have been entered.
1. Case # 265
JUL 25, 2005
Surgeon: SURSURGEON,ONE
PERIPHERAL VASCULAR
Procedure: CAROTID ARTERY ENDARTERECTOMY
2. Case # 266
JUL 25, 2005
Surgeon: SURSURGEON,TWO
THORACIC SURGERY (INC. CARDIAC SURG.)
Procedure: AORTO CORONARY BYPASS GRAFT
1. Enter Information for Case #265
2. Enter Information for Case #266
Select Number:
(1-2): 1
FIRST CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: ANESTHESIA PERSONNEL
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 2005
================================================================================
Principal Anesthetist: SURANESTHETIST,ONE
Anesthesiologist Supervisor: SURANESTHETIST,TWO
FIRST CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: PROCEDURE INFORMATION
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 2005
================================================================================
Principal Procedure:
CAROTID ARTERY ENDARTERECTOMY
Planned Principal Procedure Code (CPT): RECHANNELING OF ARTERY
THROMBOENDARTERECTOMY, WITH OR WITHOUT PATCH GRAFT; CAROTID, VERTEBRAL,
SUBCLAVIAN, BY NECK INCISION
Modifier: <Enter>
Select OTHER PROCEDURE: <Enter>
Brief Clinical History:
1>Patient with 3 episodes of amaurisis fugax in the last
2>3 months. 6 mo history of increasing angina with little
3>control from nitrates. Carotid arteriogram shows 95%
4>occlusion on right, 80% on left. Angiogram shows 80%
5>occlusion of left main artery.
6><Enter>
EDIT Option: <Enter>
FIRST CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: BLOOD INFORMATION
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 2005
================================================================================
Request Blood Availability (Y/N): N// YES
Type and Crossmatch, Screen, or Autologous: TYPE & CROSSMATCH// TYPE & CROSSMATCH
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// <Enter>
Required Blood Product: CPDA-1 WHOLE BLOOD// <Enter>
Units Required: 2
April 2004
Surgery V. 3.0 User Manual
71
FIRST CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: OTHER INFORMATION
SURPATIENT,EIGHT (000-37-0555)
JUL 25, 1999
================================================================================
Prin Pre-OP ICD Diagnosis Code: 433.11
OCCL&STEN/CAR ART W/CRB INF
COMPLICATION/COMORBIDITY
ACTIVE
Hospital Admission Status: I// <Enter> INPATIENT
Do you want to store this information in the concurrent case ?
Case Schedule Type: S
YES//
N
YES//
<Enter>
YES//
N
YES//
N
YES//
<Enter>
YES//
<Enter>
YES//
N
YES//
N
YES//
Y
YES//
<Enter>
STANDBY
Do you want to store this information in the concurrent case ?
First Assistant: SURSURGEON,FOUR
Second Assistant: TS SURSURGEON,THREE
Requested Postoperative Care: SICU
Do you want to store this information in the concurrent case ?
Case Schedule Order: 2
Do you want to store this information in the concurrent case ?
Requested Anesthesia Technique: G
GENERAL
Do you want to store this information in the concurrent case ?
Request Frozen Section Tests (Y/N): N
NO
Do you want to store this information in the concurrent case ?
Requested Preoperative X-Rays: DOPPLER STUDIES
Do you want to store this information in the concurrent case ?
Intraoperative X-Rays (Y/N/C): N
NO
Do you want to store this information in the concurrent case ?
Request Medical Media (Y/N): N
NO
Do you want to store this information in the concurrent case ?
Request Clean or Contaminated: C
CLEAN
Do you want to store this information in the concurrent case ?
GENERAL COMMENTS:
1><Enter>
SPD Comments:
1><Enter>
The information to be duplicated in the concurrent case will now be entered....
Press RETURN to continue
72
<Enter>
Surgery V. 3.0 User Manual
April 2004
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #265
** SCHEDULING **
<Enter>
CASE #265
SURPATIENT,EIGHT
PAGE 2 OF 3
CASE SCHEDULE ORDER: 2
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
DOPPLER STUDIES
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
PRINC ANESTHETIST: SURANESTHETIST,ONE
ANESTHESIOLOGIST SUPVR: SURANESTHETIST,TWO
BRIEF CLIN HISTORY: (WORD PROCESSING)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
** SCHEDULING **
1
PAGE 1 OF 3
PRINCIPAL PROCEDURE: CAROTID ARTERY ENDARTERECTOMY
PLANNED PRIN PROCEDURE CODE: 35301
OTHER PROCEDURES:
(MULTIPLE)
PRINCIPAL PRE-OP DIAGNOSIS: CAROTID ARTERY STENOSIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 433.1
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: PERIPHERAL VASCULAR
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,FOUR
SECOND ASST:
SURSURGEON,THREE
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
SICU
Enter Screen Server Function:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,EIGHT
<Enter>
CASE #265
SPD COMMENTS:
SURPATIENT,EIGHT
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
73
Reschedule or Update a Scheduled Operation
[SRSCHUP]
The Reschedule or Update a Scheduled Operation option has three uses: 1) to add a concurrent case, 2) to
reschedule an operation for another date, time, and/or operating room, 3) to update the preoperative
information that was entered earlier.
Adding a Concurrent Case (See Example 1)
After the case is selected, the software will ask whether the user wishes to add a concurrent case. If the
response is YES, the software will prompt for information on the second case. To add the case, the user
must enter a surgeon and attending surgeon, a surgical specialty, the principal operative procedure, and a
principal preoperative diagnosis. The software will then inform the user that the case has been added. The
user can then select another case or the same case for entering detailed preoperative information, or the
user can press the <Enter> key to return to the Schedule Operations menu.
Changing the Date, Time, or Operating Room (See Example 2)
If a user does not wish to add a concurrent case, the software will prompt to change the date, time or
operating room. If the user enters YES, the software will erase the old date, time, and operating room and
prompt to re-enter this information. The user will be prompted to select a new date, but if the <Enter>
key is pressed, the software will default to the original date and allow the user to change the room and
time. The software supplies a blockout graph to help with rescheduling.
If the user attempts to reschedule a case after the schedule close time for the date of operation,
only the time, and not the date, can be changed.
Updating the Preoperative Info (See Example 3)
To update the preoperative information that was entered earlier, the user should respond NO to the
prompt asking if the user wishes to change the date, time or operating room. The terminal display screen
will clear and present a two-page Screen Server summary. Any of the data fields may be changed, as in
Example 2.
Example 3 also shows the user how to order more than one blood product for a case.
74
Surgery V. 3.0 User Manual
April 2004
Example 1: How to Add a Concurrent Case to a Scheduled Operation
Select Schedule Operations Option:
R
Select Patient: SURPATIENT,SIX
SURPATIENT,SIX (000-09-8797)
1. 09/16/05
2. 02/02/05
Reschedule or Update a Scheduled Operation
04-04-30
000098797
CARPAL TUNNEL RELEASE (SCHEDULED)
BUNIONECTOMY (SCHEDULED)
Select Number: 1
Do you want to add a concurrent case ?
NO// Y
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: REQUIRED INFORMATION
SURPATIENT,SIX (000-09-8797)
SEP 16, 2005
================================================================================
Surgeon: SURSURGEON,TWO
Attending Surgeon: SURSURGEON,TWO
Surgical Specialty: 54
ORTHOPEDICS ORTHOPEDICS
Principal Operative Procedure: ARTHROSCOPY, R SHOULDER
Principal Preoperative Diagnosis: DEGENERATIVE OSTEOARTHRITIS
54
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press RETURN to continue
<Enter>
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: ANESTHESIA PERSONNEL
SURPATIENT,SIX (000-09-8797)
SEP 16, 2005
================================================================================
Principal Anesthetist: SURANESTHETIST,ONE
Anesthesiologist Supervisor: SURANESTHETIST,TWO
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: PROCEDURE INFORMATION
SURPATIENT,SIX (000-09-8797)
SEP 16, 2005
================================================================================
Principal Procedure:
ARTHROSCOPY, R SHOULDER
Planned Principal Procedure Code (CPT): 23470
RECONSTRUCT SHOULDER JOINT
ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY
ACTIVE
Modifier: <Enter>
Select OTHER PROCEDURE: <Enter>
Brief Clinical History:
1>CHRONIC DEBILITATING PAIN. X-RAY SHOWS SEVERE
2>DEGENERATIVE OSTEOARTHRITIS.
3><Enter>
EDIT Option: <Enter>
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: BLOOD INFORMATION
SURPATIENT,SIX (000-09-8797)
SEP 16, 2005
================================================================================
Request Blood Availability ? YES//
<Enter>
Type and Crossmatch, Screen, or Autologous ? TYPE & CROSSMATCH//
<Enter> TYPE & CROSSMATCH
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// FA1 FRESH FROZEN PLASMA, CPDA-1
18201
Units Required: 2
April 2004
Surgery V. 3.0 User Manual
75
SECOND CONCURRENT CASE
SCHEDULE UNREQUESTED OPERATION: OTHER INFORMATION
SURPATIENT,SIX (000-09-8797)
SEP 16, 2005
================================================================================
Prin Pre-OP ICD Diagnosis Code: 715.90 715.90
OSTEOARTHROS NOS-UNSPEC
ACTIVE
...OK? Yes// <Enter> (Yes)
(Hospital Admission Status: I// <Enter> INPATIENT
Do you want to store this information in the concurrent case ?
Case Schedule Type:
S
YES//
N
YES//
N
YES//
N
YES//
N
YES//
<Enter>
YES//
<Enter>
YES//
N
YES//
<Enter>
STANDBY
Do you want to store this information in the concurrent case ?
First Assistant: TS SURSURGEON,THREE
Second Assistant: <Enter>
Requested Postoperative Care: WARD
Do you want to store this information in the concurrent case ?
Case Schedule Order: 1
Do you want to store this information in the concurrent case ?
Requested Anesthesia Technique: GENERAL
Do you want to store this information in the concurrent case ?
Request Frozen Section Tests (Y/N): N
NO
Do you want to store this information in the concurrent case ?
Requested Preoperative X-Rays:
Intraoperative X-Rays (Y/N): Y
<Enter>
YES
Do you want to store this information in the concurrent case ?
Request Medical Media (Y/N): N
NO
Do you want to store this information in the concurrent case ?
Request Clean or Contaminated: C
CLEAN
Do you want to store this information in the concurrent case ?
YES// <Enter>
GENERAL COMMENTS:
1> <Enter>
SPD Comments:
1><Enter>
The information to be duplicated in the concurrent case will now be entered....
76
Surgery V. 3.0 User Manual
April 2004
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #245
** SCHEDULING **
<Enter>
CASE #245
SURPATIENT,SIX
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
INTRAOPERATIVE X-RAYS: YES
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
PRINC ANESTHETIST: SURANESTHETIST,ONE
ANESTHESIOLOGIST SUPVR: SURANESTHETIST,TWO
BRIEF CLIN HISTORY: (WORD PROCESSING)(DATA)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
** SCHEDULING **
1
PAGE 1 OF 3
PRINCIPAL PROCEDURE: ARTHROSCOPY, R SHOULDER
PLANNED PRIN PROCEDURE CODE: 23470
OTHER PROCEDURES:
(MULTIPLE)
PRINCIPAL PRE-OP DIAGNOSIS: DEGERATIVE OSTEOARTHRITIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 715.90
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: ORTHOPEDICS
SURGEON:
SURSURGEON,TWO
FIRST ASST:
SURSURGEON,THREE
SECOND ASST:
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,SIX
<Enter>
CASE #245
SPD COMMENTS:
Enter Screen Server Function:
SURPATIENT,SIX
PAGE 3 OF 3
(WORD PROCESSING)
<Enter>
The following cases have been entered.
1.
Case # 224
Surgeon: SURSURGEON,ONE
Procedure: CARPAL TUNNEL RELEASE
SEP 16, 2005
NEUROSURGERY
2.
Case # 245
SEP 16, 2005
Surgeon: SURSURGEON,TWO
ORTHOPEDICS
Procedure: ARTHROSCOPY, R SHOULDER
1. Enter Information for Case #224
2. Enter Information for Case #245
Select Number:
April 2004
(1-2):
Surgery V. 3.0 User Manual
77
Example 2:
How to Reschedule an Operation, Change the Date, Time, or Operating Room
Select Schedule Operations Option: R
Reschedule or Update a Scheduled Operation
Select Patient: SURPATIENT,THREE
12-19-53
000212453
SURPATIENT,THREE (000-21-2453)
1. 09/15/05
SHOULDER ARTHROPLASTY-PROTHESIS (SCHEDULED)
Select Number: 1
Do you want to add a concurrent case ?
NO// <Enter>
Do you want to change the date/time or operating room for which this
case is scheduled ? NO// Y
Operating Room Reservations:
Surgeon: SURSURGEON,ONE
Patient: SURPATIENT,THREE
Procedure(s): SHOULDER ARTHROPLASTY-PROTHESIS
Operating Room: OR3
Scheduled Start: SEP 15, 2005 08:00
Scheduled End:
SEP 15, 2005 13:00
Reschedule this Procedure for which Date ?
<Enter>
Since no date has been entered, I must assume that you want to re-schedule
this case for the same date. If you have made a mistake and want to
leave this case scheduled for the same operating room at the same times,
enter RETURN when prompted to select an operating room.
Press RETURN to continue
<Enter>
Display of Available Operating Room Time
1.
2.
3.
4.
Display Availability (12:00 AM - 12:00 PM)
Display Availability (06:00 AM - 08:00 PM)
Display Availability (12:00 PM - 12:00 AM)
Do Not Display Availability
Select Number: 2//
4
Schedule this case for which Operating Room: OR3
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
7:30
13:00
Principal Anesthetist: SURANESTHETIST,ONE// <Enter>
Anesthesiologist Supervisor: SURANESTHETIST,TWO// <Enter>
78
Surgery V. 3.0 User Manual
April 2004
Example 3: How to Update a Scheduled Operation
Select Schedule Operations Option: R
Reschedule or Update a Scheduled Operation
Select Patient: SURPATIENT,THREE
12-19-53
000212453
SURPATIENT,THREE (000-21-2453)
1. 09/15/05
SHOULDER ARTHROPLASTY-PROTHESIS (SCHEDULED)
Select Number: 1
Do you want to add a concurrent case ?
NO// <Enter>
Do you want to change the date/time or operating room for which this
case is scheduled ? NO// <Enter>
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #218
SURPATIENT,THREE
PAGE 1 OF 3
PRINCIPAL PROCEDURE: SHOULDER ARTHOPLASTY-PROSTHESIS
PLANNED PRIN PROCEDURE CODE: 23470
OTHER PROCEDURES:
(MULTIPLE)
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE, L SHOULDER
PRIN PRE-OP ICD DIAGNOSIS CODE: 715.11
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: STANDBY
SURGERY SPECIALTY: ORTHOPEDICS
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,TWO
SECOND ASST:
SURSURGEON,FOUR
ATTEND SURG:
SURSURGEON,ONE
REQ POSTOP CARE:
WARD
Enter Screen Server Function: <Enter>
** SCHEDULING **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #218
SURPATIENT,THREE
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
LEFT SHOULDER
INTRAOPERATIVE X-RAYS: YES
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
PRINC ANESTHETIST: SURANESTHETIST,ONE
ANESTHESIOLOGIST SUPVR: SURANESTHETIST,TWO
BRIEF CLIN HISTORY: (WORD PROCESSING)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
April 2004
8
Surgery V. 3.0 User Manual
79
** SCHEDULING **
CASE #218
REQ BLOOD KIND
1
2
REQ BLOOD KIND:
NEW ENTRY
SURPATIENT,THREE
PAGE 1 OF 1
FRESH FROZEN PLASMA, CPDA-1
Enter Screen Server Function: 2
Select REQ BLOOD KIND: CPDA-1 WHOLE BLOOD
00160
REQ BLOOD KIND: CPDA-1 WHOLE BLOOD// <Enter>
** SCHEDULING **
CASE #218 SURPATIENT,THREE
REQ BLOOD KIND (CPDA-1 WHOLE BLOOD)
1
2
REQ BLOOD KIND:
UNITS REQ:
CPDA-1 WHOLE BLOOD
Enter Screen Server Function:
Units Required: 2
2
** SCHEDULING **
CASE #218 SURPATIENT,THREE
REQ BLOOD KIND (CPDA-1 WHOLE BLOOD)
1
2
REQ BLOOD KIND:
UNITS REQ:
<Enter>
** SCHEDULING **
CASE #218
REQ BLOOD KIND
REQ BLOOD KIND:
REQ BLOOD KIND:
NEW ENTRY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
PAGE 1 OF 1
<Enter>
CASE #218
SURPATIENT,THREE
PAGE 2 OF 3
CASE SCHEDULE ORDER: 1
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
LEFT SHOULDER
INTRAOPERATIVE X-RAYS: YES
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
PRINC ANESTHETIST: SURANESTHETIST,ONE
ANESTHESIOLOGIST SUPVR: SURANESTHETIST,TWO
BRIEF CLIN HISTORY: (WORD PROCESSING)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
** SCHEDULING **
1
SURPATIENT,THREE
FRESH FROZEN PLASMA, CPDA-1
CPDA-1 WHOLE BLOOD
Enter Screen Server Function:
** SCHEDULING **
PAGE 1 OF 1
CPDA-1 WHOLE BLOOD
2
Enter Screen Server Function:
1
2
3
PAGE 1 OF 1
<Enter>
CASE #218
SPD COMMENTS:
SURPATIENT,THREE
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function:
80
Surgery V. 3.0 User Manual
April 2004
Cancel Scheduled Operation
[SRSCAN]
When a scheduled operation is cancelled, the Cancel Scheduled Operation option will remove that case
from the list of scheduled operations. A cancellation will remain in the system as a cancelled case and
will be used in computing the facility‟s cancellation rate.
Enter the patient name and select the operation to be deleted from the choices listed. The "Cancellation
Reason:" prompt is a mandatory prompt. Enter a question mark for a list of cancellation reasons from
which to select. If a mistake is made, or the user finds out later that the cancellation reason was not
correct, the Update Cancellation Reason option allows the cancellation reason to be edited.
If there is a concurrent case associated with the operation being cancelled, the software will ask if the user
wants to cancel it also.
Example 1: Cancel a Single Scheduled Operation
Select Schedule Operations Option: C
Cancel Scheduled Operation
Cancel a Scheduled Procedure for which Patient: SURPATIENT,NINETEEN
000287354 YES
SC VETERAN
01-01-40
SURPATIENT,NINETEEN (000-28-7354)
1. 09/12/11
FRONTAL CRANIOTOMY TO RULE OUT TUMOR (SCHEDULED)
Select Number: 1
Reservation for OR3
Scheduled Start Time: 09-12-11 11:00
Scheduled End Time:
09-12-11 13:00
Patient: SURPATIENT,NINETEEN
Physician: SURSURGEON,ONE
Procedure: FRONTAL CRANIOTOMY TO RULE OUT TUMOR
Is this the correct operation ?
YES// <Enter>
Cancellation Reason: CHANGE IN TREATMENT, PT HEALTH
Cancellation Avoidable: YES// N NO
2
Do you want to create a new request for this cancelled case ??
Make the new request for which Date ?
YES// <Enter>
MAR 12, 2012// <Enter> (MAR 12, 2012)
Creating the new request...
Example 2: Cancel a Scheduled Concurrent Case
Select Schedule Operations Option: C
Cancel Scheduled Operation
Cancel a Scheduled Procedure for which Patient:
000098797
SURPATIENT,SIX
04-04-30
SURPATIENT,SIX (000-09-8797)
1. 09/16/11
2. 09/16/11
ARTHROSCOPY, RIGHT SHOULDER (SCHEDULED)
CARPAL TUNNEL RELEASE (SCHEDULED)
Select Number: 1
April 2004
Surgery V. 3.0 User Manual
81
Reservation for OR2
Scheduled Start Time: 09-16-11 08:00
Scheduled End Time:
09-16-11 13:00
Patient:
SURPATIENT,SIX
Physician: SURSURGEON,TWO
Procedure: ARTHROSCOPY, RIGHT SHOULDER
Is this the correct operation ?
YES//
Cancellation Reason: NO BED AVAILABLE
Cancellation Avoidable: YES// N NO
<Enter>
6
Do you want to create a new request for this cancelled case ??
Make the new request for which Date ?
YES// <Enter>
MAR 29, 2012// <Enter> (MAR 29, 2012)
Creating the new request...
There is a concurrent case associated with this operation.
cancel it also ? YES// <Enter>
Do you want to
Do you want to create a new request for this cancelled case ??
Make the new request for which Date ?
YES// <Enter>
MAR 29, 2012// <Enter> (MAR 29, 2012)
Creating the new request...
82
Surgery V. 3.0 User Manual
April 2004
Update Cancellation Reason
[SRSUPC]
The Update Cancellation Reason option is used to update the cancellation date and reason previously
entered for a selected surgical case.
Example: Update Cancellation Reason
Select Schedule Operations Option:
UC Update Cancellation Reason
Update Cancellation Information for which Patient: SURPATIENT,NINETEEN
000287354
NSC VETERAN
1. 06-01-98
FRONTAL CRANIOTOMY TO RULE OUT TUMOR (CANCELLED)
Select Operation:
1
SURPATIENT,NINETEEN
06-01-98
01-01-40
000-28-7354
Case # 21199
FRONTAL CRANIOTOMY TO RULE OUT TUMOR (CANCELLED)
Cancellation Date: JUN 01,[email protected]:53// <Enter>
Cancellation Reason: LAB TEST// EM EMERGENCY CASE SUPERSEDES
Cancellation Avoidable: NO// <Enter>
Press RETURN to continue
April 2004
EM
<Enter>
Surgery V. 3.0 User Manual
83
Schedule Anesthesia Personnel
[SRSCHDA]
The Schedule Anesthesia Personnel option allows anesthesia staff to assign, or change, anesthesia
personnel for surgery cases. The scheduling manager may have already assigned some personnel to a case
using other menu selections. For the user‟s convenience, the software will default to any previously
entered data.
This option is locked with the SROANES key and will not appear on the menu if the user does
not have this key.
This option is used to enter the names of the principal anesthetist, the supervisor, and anesthesia
techniques for cases scheduled on a specific date. The user should first enter the date, and then select an
operating room. The software will display all cases scheduled in that room. After scheduling personnel
for any or all cases in one operating room, the user can do the same for other operating rooms without
leaving this option.
This option also appears on the Anesthesia menu.
Example: Schedule Anesthesia Personnel
Select Schedule Operations Option: AN
Schedule Anesthesia Personnel
Schedule Anesthesia Personnel for which Date ?
8/16
(AUG 16, 1999)
Schedule Anesthesia Personnel for which Operating Room ?
OR2
Scheduled Operations for OR2
-----------------------------------------------------------------------Case # 5
Patient: SURPATIENT,TWENTY
From: 07:00 To: 09:00
HARVEST SAPHENOUS VEIN
Requested Anesthesia Technique: GENERAL// <Enter>
Principal Anesthetist: SURANESTHETIST,ONE
OS
Anesthesiologist Supervisor: SURANESTHETIST,TWO
Press RETURN to continue, or '^' to quit
112G
TS
<Enter>
Scheduled Operations for OR2
-----------------------------------------------------------------------Case # 14
Patient: SURPATIENT,THREE
From: 13:00 To: 18:00
SHOULDER ARTHROPLASTY
Requested Anesthesia Technique: GENERAL// <Enter>
Principal Anesthetist: SURANESTHETIST,ONE//
<Enter>
Anesthesiologist Supervisor: SURANESTHETIST,TWO
TS
Press RETURN to continue, or '^' to quit
OS
112G
<Enter>
Would you like to continue with another operating room ?
YES//
Schedule Anesthesia Personnel for which Operating Room ?
OR1
<Enter>
There are no cases scheduled for this operating room.
Press RETURN to continue
<Enter>
Would you like to continue with another operating room ?
84
YES// N
Surgery V. 3.0 User Manual
April 2004
Create Service Blockout
[SRSBOUT]
At times, the surgical staff may need to set aside an operating room for a particular service on a recurring
basis. The Create Service Blockout option is used by the scheduling manager to blockout the operating
room(s) on a graph.
The resulting service blockout is automatically charted on a graph that can be viewed from the Display
Availability option. This service blockout does not restrict the operating room to the service, but can assist
the scheduling manager when assigning operating rooms.
The scheduling manager can create the service blockouts by following the example provided on the
following page. The required data fields are listed in the following table.
At this prompt:
The user should do this:
For what service?
Enter a three or four letter abbreviation for the surgical service the room is
being reserved (for example, card for cardiology, gen for general surgery).
Select Operating Room
Select Starting Date
Reserve from what time?
Reserve to what time?
April 2004
Do not use the letter X or an equal sign (=).
Enter the operating room name or code. The operating room must already
exist in the HOSPITAL LOCATION file and the OPERATING ROOM file.
The user should enter a question mark to get a list of operating rooms already
included in these files. The supervisor or package coordinator can add an
operating room to these files.
The user should enter the date for the blockout to begin.
Enter the times for which this room will be blocked-out for a particular
service. A room may be reserved at any time during the 24-hour cycle to the
nearest 15 minutes.
Enter the end time for the service blockout.
Surgery V. 3.0 User Manual
85
Example: Create a Service Blockout
Select Schedule Operations Option: B
Create Service Blockout
For what service ? (3-4 characters, do not use 'X' or '=')
Select Operating Room: OR2
Select Starting Date: T
CARD
(NOV 18, 1999)
Reserve from what time ? (24HR:NEAREST 15 MIN):
Reserve to what time ? (24HR:NEAREST 15 MIN):
7
12
(07:00)
(12:00)
1. Every week, same time
2. Every other week
3. Every month, same day of week & week of month
Select Number:
1
Updating Schedules...
After the service blockout has been created, it will appear on the operating room availability graph
display, as shown below.
ROOM
OR1
OR2
OR3
OR4
OR5
86
6AM
7
8
9
10
11
12
13
14
15
16
17
18
19
20
|____|uro.|uro.|uro.|uro.|uro.|uro.|uro.|uro.|____|____|____|____|____|
|____|card|card|card|card|card|card|card|card|card|____|____|____|____|
|____|thor|thor|thor|thor|thor|thor|thor|thor|____|____|____|____|____|
|____|gen.|gen.|gen.|gen.|gen.|gen.|gen.|gen.|____|____|____|____|____|
|____|=XXX|XXXX|=XXX|XXXX|____|____|____|____|____|____|____|____|____|
Surgery V. 3.0 User Manual
April 2004
Delete Service Blockout
[SRSBDEL]
The following example shows how to remove a service blockout from the blockout graph. A service
blockout can be deleted for just one date or for all the reserved dates.
After starting this option, if the user decides not to delete a service blockout, he or she can enter an uparrow (^) to exit.
Example: Delete Service Blockout
Select Schedule Operations Option: DB
Delete Service Blockout
Select service you wish to delete. (3-4 characters)
CARD
The service 'card' has the following time(s) scheduled:
1. OR1 on Tuesday from 07.00 to 12.00
Which number would you like to delete ? 1
Delete the Blockout starting with which date ?
3/29
(MAR 29, 1999)
Do you want to delete the blockout for this service on this
date only ? NO// <Enter>
Updating Schedules...
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
87
Schedule of Operations
[SROSCH]
The Schedule of Operations option generates the Operating Room Schedule used by the OR nurses,
surgeons, anesthetists and other hospital services. The report lists operations and patients scheduled for a
particular date. It sorts by operating room and includes the procedure(s), blood products requested, and
any preoperative x-rays requested. The schedule also provides anesthesia information and surgeon names.
This report has a 132-column format and is designed to be copied to a printer.
By setting up default printers in the SURGERY SITE PARAMETERS file, this report can be
queued to print in various locations simultaneously. Please see “Chapter 5: Managing the
Software Package” for more information.
Example: Print Schedule of Operations
Select Schedule Operations Option:
S
Schedule of Operations
Print Schedule of Operations for which date ?
9/8
Do you want to print the schedule at all locations ?
(SEP O8, 1999)
NO// <Enter>
This report is designed to use a 132 column format.
DEVICE: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
88
Surgery V. 3.0 User Manual
April 2004
PRINTED: SEP 07, 1999 11:12
MAYBERRY, NC
SURGICAL SERVICE
SCHEDULE OF OPERATIONS
FOR: SEP 08, 1999
PAGE 1
SIGNATURE OF CHIEF: DR. ONE SURSURGEON
____________________
PATIENT
DISPOSITION
PREOPERATIVE DIAGNOSIS
REQ ANESTHESIA
SURGEON
ID#
AGE
START TIME
OPERATION(S)
ANESTHESIOLOGIST
FIRST ASST.
WARD
END TIME
PRIN. ANESTHETIST
ATT SURGEON
====================================================================================================================================
OPERATING ROOM: OR1
SURPATIENT,ONE
000-44-7629
TO BE ADMITTED
Case # 143
46
WARD
07:30
09:30
CARPAL TUNNEL SYNDROME
REVISE MEDIAN NERVE
GENERAL
SURANESTHETIST, T
SURANESTHETIST, O
SURSURGEON, O
SURSURGEON, F
SURSURGEON, O
PREOPERATIVE XRAYS: CARPAL TUNNEL, R WRIST
OPERATING ROOM: OR2
SURPATIENT,FOURTEEN
000-45-7212
48
HICU 212-B
Case # 141
WARD
CHOLELITHIASIS
06:30
CHOLECYSTECTOMY
08:00
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - 2 UNITS
GENERAL
SURANESTHETIST, T
SURANESTHETIST, O
SURSURGEON, O
SURSURGEON, T
SURSURGEON, O
SURPATIENT,TWELVE
000-41-8719
71
TO BE ADMITTED
Case # 142
WARD
ACUTE DIAPHRAGMATIC HERNIA
08:00
REPAIR DIAPHRAGMATIC HERNIA
09:30
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - 2 UNITS
PREOPERATIVE XRAYS: ABDOMEN
GENERAL
SURANESTHETIST, T
SURANESTHETIST, O
SURSURGEON, T
SURSURGEON, O
SURSURGEON, T
SURPATIENT,THIRTY
000-82-9472
48
TO BE ADMITTED
WARD
CAROTID ARTERY STENOSIS
11:15
CAROTID ARTERY ENDARTERECTOMY
16:00
** Concurrent Case #157
AORTO CORONARY BYPASS GRAFT
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - UNITS NOT ENTERED
CPDA-1 WHOLE BLOOD - 2 UNITS
PREOPERATIVE XRAYS: DOPPLER STUDIES
GENERAL
SURANESTHETIST, T
SURANESTHETIST, O
SURSURGEON, O
SURSURGEON, F
SURSURGEON, O
WARD
CORONARY ARTERY DISEASE
11:15
AORTO CORONARY BYPASS GRAFT
16:00
** Concurrent Case #150
CAROTID ARTERY ENDARTERECTOMY
GENERAL
SURANESTHETIST, T
SURANESTHETIST, O
SURSURGEON, T
SURSURGEON, F
SURSURGEON, T
Case # 150
SURPATIENT,THIRTY
000-82-9472
48
TO BE ADMITTED
Case # 157
TOTAL CASES SCHEDULED: 5
April 2004
Surgery V. 3.0 User Manual
89
(This page included for two-sided copying.)
90
Surgery V. 3.0 User Manual
April 2004
List Scheduled Operations
[SRSCD]
The List Scheduled Operations option provides a short form listing of scheduled cases for a given date. It
will sort by surgical specialty, operating room, or ward location.
This report is in 80-column format and can be viewed on the screen.
Example: List Scheduled Operations
Select Surgery Menu Option:
LS
List Scheduled Operations
List of Scheduled Operations:
List Scheduled Operations for which date ?
3/12
(MAR 12, 1999)
Do you want to sort by OPERATING ROOM, SPECIALTY or WARD LOCATION ? SPE
Do you want a list of scheduled operations for a specific specialty ?
Print to Device:
YES//
N
[Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------* Scheduled Operations for GENERAL *
MAR 12, 1999
Start Time
Patient
Operating Room
Ward Location
ID #
===============================================================================
08:00
SURPATIENT,TWENTY
OR2
OUTPATIENT
000-45-4886
CHOLECYSTECTOMY
------------------------------------------------------------------------------Press RETURN to continue
<Enter>
* Scheduled Operations for ORTHOPEDICS *
MAR 12, 1999
Start Time
Patient
Operating Room
Ward Location
ID #
===============================================================================
07:15
SURPATIENT,THREE
OR4
1 WEST
000-21-2453
SHOULDER ARTHROPLASTY-PROTHESIS
------------------------------------------------------------------------------Press RETURN to continue
April 2004
<Enter>
Surgery V. 3.0 User Manual
91
* Scheduled Operations for PERIPHERAL VASCULAR *
MAR 12, 1999
Start Time
Patient
Operating Room
Ward Location
ID #
===============================================================================
11:15
SURPATIENT,EIGHT
OR2
1 NORTH
000-37-0555
CAROTID ARTERY ENDARTERECTOMY
------------------------------------------------------------------------------Press RETURN to continue or '^' to quit.
<Enter>
* Scheduled Operations for THORACIC SURGERY
MAR 12, 1999
*
Start Time
Patient
Operating Room
Ward Location
ID #
===============================================================================
11:15
SURPATIENT,EIGHT
OR2
1 NORTH
000-37-0555
AORTO CORONARY BYPASS GRAFT
------------------------------------------------------------------------------Press RETURN to continue
92
Surgery V. 3.0 User Manual
April 2004
Chapter Two: Tracking Clinical Procedures
Introduction
The options described in this chapter provide online access to medical administration and laboratory
information and provide tracking of operative procedures. They allow the following:
Entry of information specific to an individual surgical case (for example, staff, times, diagnoses,
complications, anesthesia).
Online entry of data inside the operating room during the actual operative procedure.
Generation of patient records and reports.
Key Vocabulary
The following terms are used in this chapter.
Term
Definition
Concurrent Case
The patient undergoes two operations, by two different specialties, at the
same time in the same operating room.
After the data concerning the operation has been entered, the terminal display
device will clear and then present a two-page Screen Server summary. The
Screen Server summary organizes the information entered and gives the user
another opportunity to enter or edit data.
Screen Server
April 2004
Surgery V. 3.0 User Manual
93
Exiting an Option or the System
The user should enter an up-arrow (^) to stop what he or she is currently doing. The user can use the uparrow at almost any prompt to terminate the line of questioning and return to the previous level in the
routine. Continue entering up-arrows to completely exit the system.
Option Overview
The main options included in this chapter are listed in the following table. The Operation Menu option,
Anesthesia Menu option, and the Non-O.R.. Procedures menu contain submenus. To the left of the option
name is the shortcut synonym the user can enter to select the option.
Shortcut
O
A
PO
NON
C
94
Option Name
Operation Menu
Anesthesia Menu
Perioperative Occurrences Menu
Non-O.R. Procedures
Comments
Surgery V. 3.0 User Manual
April 2004
Operation Menu
[SROPER]
The Operation Menu provides operating room personnel with online access to medical administration and
laboratory information and generates post-operative reports, including the Nurse Intraoperative Report
and the Operation Report. The menu options provide the opportunity to delete, edit, or review a patient‟s
operation history or to enter information concerning a new surgery. The Operation Menu allows the user
to select an area on which to concentrate data entry or review, such as post operation or anesthesia
information. It is designed for operating room nurses, surgeons, and anesthetists to use before, during, and
after surgery. The Screen Server utility is used extensively to provide quick access to relevant
information.
This option is locked with the SROPER key.
The Operation Menu contains the following options. To the left is the keyboard shortcut the user can
enter to select the option. A restricted option, such as the Anesthesia Menu, will not display if the user
does not have security clearance for that option.
Shortcut
I
SS
OS
O
PO
PAC
OSS
V
A
OR
AR
NR
TR
R
RP
M
B
April 2004
Option Name
Operation Information
Surgical Staff
Operation Startup
Operation
Post Operation
Enter PAC(U) Information
Operation (Short Screen)
Surgeon's Verification of Diagnosis & Procedures
Anesthesia Menu
Operation Report
Anesthesia Report
Nurse Intraoperative Report
Tissue Examination Report
Enter Referring Physician Information
Enter Irrigations and Restraints
Medications (Enter/Edit)
Blood Product Verification
Surgery V. 3.0 User Manual
95
Using the Operation Menu Options
This section provides information on the following:
accessing the Operation Menu option
entering information
reviewing information
deleting a surgery case
entering a new surgical case
Accessing the Operation Menu
To use one of the Operation Menu options, the user must first identify the patient and case on which he or
she is currently working. When the Operation Menu option is selected, the user will be prompted to enter
a patient name. The software will then list all the cases on record for the patient, including scheduled or
requested cases and any operations that have been started or completed. Each case will have one of the
following designations.
Designation
REQUESTED
SCHEDULED
NOT COMPLETE
COMPLETE
ABORTED
96
Definition
The procedure is booked for a particular day but the time of surgery and the
operating room are not yet confirmed.
The procedure is booked for both an operating room and a day, and the starting
time of the surgery is scheduled.
The start time of the operation is recorded and the patient is still in the operating
room.
The operation is completed and the patient has left the operating room.
The patient entered the operating room, but the operation had to be cancelled.
Surgery V. 3.0 User Manual
April 2004
Following is an example of how the software lists existing cases on record for a patient.
Select Surgery Menu Option: O Operation Menu
Select Patient: SURPATIENT,SIX 04-04-30
000098797
NSC VETERAN
SURPATIENT,SIX 000-09-8797
1. 01-25-92
ARTHROSCOPY, RIGHT SHOULDER (SCHEDULED)
2. 01-05-92
CORONARY BYPASS (REQUESTED)
3. ENTER NEW SURGICAL CASE
Select Operation: <Enter>
The user can select from the case(s) listed or, as in an emergency situation, enter a new surgical case.
When the existing case is selected, the software will ask whether the user wants to:
1) enter information for the case,
2) review the information already entered, or
3) delete the case.
SURPATIENT,SIX 000-09-8797
01-25-92
ARTHROSCOPY, RIGHT SHOULDER (SCHEDULED)
1. Enter Information
2. Review Information
3. Delete Surgery Case
Select Number:
April 2004
1//
Surgery V. 3.0 User Manual
97
Entering Information
First, the user selects the patient name. The Surgery software will then list all the cases on record for the
patient, including scheduled or requested cases and any operations that have been started or completed.
Then, the user selects the appropriate case.
Example: Enter Information
Select Surgery Menu Option: O Operation Menu
Select Patient: SURPATIENT,THREE
12-19-53
SURPATIENT,THREE
000212453
000-21-2453
1. 03-12-92
SHOULDER ARTHROPLASTY-PROSTHESIS (SCHEDULED)
2. 08-15-88
SHOULDER ARTHROPLASTY (NOT COMPLETE)
3. ENTER NEW SURGICAL CASE
Select Operation: 2
SURPATIENT,THREE
08-15-88
000-21-2453
SHOULDER ARTHROPLASTY (NOT COMPLETE)
1. Enter Information
2. Review Information
3. Delete Surgery Case
Select Number:
1//
<Enter>
After the case is displayed, the user will press the <Enter> key or enter the number 1 to enter information
for the case.
SURPATIENT,THREE (000-21-2453)
I
SS
OS
O
PO
PAC
OSS
TO
V
A
OR
AR
NR
TR
R
RP
M
B
Case #14 – MAR 12,1999
Operation Information
Surgical Staff
Operation Startup
Operation
Post Operation
Enter PAC(U) Information
Operation (Short Screen)
Time Out Verified Utilizing Checklist
Surgeon's Verification of Diagnosis & Procedures
Anesthesia for an Operation Menu ...
Operation Report
Anesthesia Report
Nurse Intraoperative Report
Tissue Examination Report
Enter Referring Physician Information
Enter Irrigations and Restraints
Medications (Enter/Edit)
Blood Product Verification
Select Operation Menu Option:
Now the user can select any of the Operation Menu options.
98
Surgery V. 3.0 User Manual
April 2004
Reviewing Information
The user enters the number 2 to access this feature. This feature displays a two-page summary of the case.
The user cannot edit from this feature. Press the <Enter> key at the "Enter Screen Server Function:"
prompt to move to the next page, or enter +1 or -1 to move forward or backward one page.
Example: Review Information
Select Surgery Menu Option: Operation Menu
Select Patient:
SURPATIENT,THREE
12-19-53
SURPATIENT,THREE
000212453
000-21-2453
1. 08-15-99
SHOULDER ARTHROPLASTY (NOT COMPLETE)
2. 03-12-92
SHOULDER ARTHROPLASTY-PROSTHESIS (SCHEDULED)
3. ENTER NEW SURGICAL CASE
Select Operation: 2
SURPATIENT,THREE
08-15-88
000-21-2453
SHOULDER ARTHROPLASTY (NOT COMPLETE)
1. Enter Information
2. Review Information
3. Delete Surgery Case
Select Number:
** REVIEW **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1//
2
CASE #14
SURPATIENT,THREE
TIME PAT IN HOLD AREA: AUG 15, 1999 AT 07:40
TIME PAT IN OR:
AUG 15, 1999 AT 08:00
ANES CARE TIME BLOCK:
(MULTIPLE)
TIME OPERATION BEGAN: AUG 15, 1999 AT 09:00
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
THERMAL UNIT:
(MULTIPLE)
ELECTROCAUTERY UNIT:
ESU COAG RANGE:
ESU CUTTING RANGE:
TIME TOURNIQUET APPLIED: (MULTIPLE)
PROSTHESIS INSTALLED:
(MULTIPLE)
REPLACEMENT FLUID TYPE: (MULTIPLE)
IRRIGATION:
(MULTIPLE)
MEDICATIONS:
(MULTIPLE)
Enter Screen Server Function:
** REVIEW **
1
2
3
4
5
6
7
8
9
10
11
PAGE 1 OF 3
CASE #14
<Enter>
SURPATIENT,THREE
PAGE 2 OF 3
SPONGE COUNT CORRECT (Y/N): YES
SHARPS COUNT CORRECT (Y/N): YES
INSTRUMENT COUNT CORRECT (Y/N):
SPONGE, SHARPS, & INST COUNTER: YES
COUNT VERIFIER:
SEQUENTIAL COMPRESSION DEVICE:
LASER UNIT:
(MULTIPLE)
CELL SAVER:
(MULTIPLE)
NURSING CARE COMMENTS:
(WORD PROCESSING) (DATA)
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE L SHOULDER
PRIN PRE-OP ICD DIAGNOSIS CODE:
April 2004
Surgery V. 3.0 User Manual
99
12
13
14
15
PRINCIPAL PROCEDURE:
SHOULDER ARTHROPLASTY
PLANNED PRIN PROCEDURE CODE :
OTHER PROCEDURES:
(MULTIPLE)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
** REVIEW **
1
CASE #14
<Enter>
SURPATIENT,THREE
BRIEF CLIN HISTORY:
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function:
Deleting a Surgery Case
The user enters the number 3 to access this feature. The Delete Surgery Case feature will permanently
remove all information on the operative procedure from the records; however, only cases that are not
completed can be deleted.
Example: How to Delete A Case
Select Surgery Menu Option: Operation Menu
Select Patient: SURPATIENT,NINE
12-09-51
SURPATIENT,NINE
000345555
NSC VETERAN
000-34-5555
1. 04-26-05
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM (COMPLETED)
2. 12-20-05
REMOVE FACIAL LESIONS (NOT COMPLETE)
3. ENTER NEW SURGICAL CASE
Select Operation: 2
SURPATIENT,NINE
12-20-05
000-34-5555
REMOVE FACIAL LESIONS (NOT COMPLETE)
1. Enter Information
2. Review Information
3. Delete Surgery Case
Select Number:
1//
3
Are you sure that you want to delete this case ?
NO//
Y
Deleting Operation...
100
Surgery V. 3.0 User Manual
April 2004
Entering a New Surgical Case
A new surgical case is a case that has not been previously requested or scheduled. This option is designed
primarily for entering emergency cases. Be aware that a surgical case entered in the records without being
booked through scheduling will not appear on the operating room schedule or as an operative request.
At the "Select Operation:" prompt the user enters the number corresponding to the ENTER NEW
SURGICAL CASE field. He or she will then be prompted to supply preoperative information concerning
the case.
After the user has entered data concerning the operation, the screen will clear and present a two-page
Screen Server summary and provide another opportunity to enter or edit data.
Prompts that require a response include:
"Select the Date of Operation:"
“Desired Procedure Date:”
"Enter the Principal Operative Procedure:"
"Principal Preoperative Diagnosis:"
"Select Surgeon:"
"Attending Surgeon:"
"Select Surgical Specialty:"
Example: Entering a New Surgical Case
Select Surgery Menu Option: O Operation Menu
Select Patient: SURPATIENT,SIX
04-04-30
SURPATIENT,SIX
000098797
000-09-8797
1. ENTER NEW SURGICAL CASE
Select Operation: 1
Select the Date of Operation: T (JAN 14, 2006)
Desired Procedure Date: T (JAN 14, 2006)
Enter the Principal Operative Procedure: APPENDECTOMY
Principal Preoperative Diagnosis: APPENDICITIS
The information entered into the Principal Preoperative Diagnosis field
has been transferred into the Indications for Operation field.
The Indications for Operation field can be updated later if necessary.
Press Return to continue <Enter>
Select Surgeon: SURSURGEON,ONE
Attending Surgeon: SURSURGEON,TWO
Select Surgical Specialty: 50
GENERAL(OR WHEN NOT DEFINED BELOW)
Brief Clinical History:
1>PATIENT WITH 5-DAY HISTORY OF INCREASING ABDOMINAL
2>PAIN, ONSET OF FEVER IN LAST 24 HOURS. REBOUND
3>TENDERNESS IN RIGHT LOWER QUAD. NAUSEA AND
4>VOMITING FOR 3 DAYS.
5><Enter>
EDIT Option: <Enter>
Request Blood Availability (Y/N): N// YES
Type and Crossmatch, Screen, or Autologous: TYPE & CROSSMATCH// <Enter> TYPE & CROSSMATCH
Select REQ BLOOD KIND: CPDA-1 RED BLOOD CELLS// <Enter>
April 2004
Surgery V. 3.0 User Manual
101
Required Blood Product: CPDA-1 RED BLOOD CELLS// <Enter>
Units Required: 2
101a
Surgery V. 3.0 User Manual
April 2004
(This page included for two-sided copying.)
April 2004
Surgery V. 3.0 User Manual
101b
Principal Preoperative Diagnosis: APPENDICITIS// <Enter>
Prin Pre-OP ICD Diagnosis Code: 540.9 540.9
ACUTE APPENDICITIS NOS
PLICATION/COMORBIDITY
ACTIVE
......OK? YES// <Enter> (YES)
COM
Hospital Admission Status: I// <Enter> INPATIENT
Case Schedule Type: EM EMERGENCY
First Assistant: SURSURGEON,ONE
Second Assistant: SURSURGEON,FOUR
Requested Postoperative Care: W WARD
Case Schedule Order: <Enter>
Select SURGERY POSITION: SUPINE// <Enter>
Surgery Position: SUPINE// <Enter>
Requested Anesthesia Technique: G GENERAL
Request Frozen Section Tests (Y/N): N NO
Requested Preoperative X-Rays: <Enter>
Intraoperative X-Rays (Y/N): N NO
Request Medical Media: N NO
Request Clean or Contaminated: C CLEAN
Select REFERRING PHYSICIAN: <Enter>
General Comments:
1> <Enter>
SPD Comments:
No existing text
Edit? NO// <Enter>
** NEW SURGERY **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #185
SURPATIENT,SIX
PRINCIPAL PROCEDURE: APPENDECTOMY
OTHER PROCEDURES:
(MULTIPLE)
PLANNED PRIN PROCEDURE CODE:
PRINCIPAL PRE-OP DIAGNOSIS: APPENDICITIS
PRIN PRE-OP ICD DIAGNOSIS CODE: 540.9
OTHER PREOP DIAGNOSIS: (MULTIPLE)
IN/OUT-PATIENT STATUS: INPATIENT
PRE-ADMISSION TESTING:
CASE SCHEDULE TYPE: EMERGENCY
SURGERY SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
SURGEON:
SURSURGEON,ONE
FIRST ASST:
SURSURGEON,ONE
SECOND ASST:
SURSURGEON,FOUR
ATTEND SURG:
SURSURGEON,TWO
REQ POSTOP CARE:
WARD
Enter Screen Server Function:
<Enter>
** NEW SURGERY **
SURPATIENT,SIX
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
PAGE 1 OF 3
CASE #185
PAGE 2 OF 3
CASE SCHEDULE ORDER:
SURGERY POSITION:
(MULTIPLE)(DATA)
REQ ANESTHESIA TECHNIQUE: GENERAL
REQ FROZ SECT:
NO
REQ PREOP X-RAY:
INTRAOPERATIVE X-RAYS: NO
REQUEST BLOOD AVAILABILITY: YES
CROSSMATCH, SCREEN, AUTOLOGOUS: TYPE & CROSSMATCH
REQ BLOOD KIND:
(MULTIPLE)(DATA)
REQ PHOTO:
NO
REQ CLEAN OR CONTAMINATED: CLEAN
REFERRING PHYSICIAN: (MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
BRIEF CLIN HISTORY: (WORD PROCESSING)(DATA)
Enter Screen Server Function:
** NEW SURGERY **
CASE #185
<Enter>
SURPATIENT,SIX
PAGE 3 OF 3
1
SPD COMMENTS
Enter Screen Server Function:
102
Surgery V. 3.0 User Manual
April 2004
Operation Information
[SROMEN-OPINFO]
Surgeons and other members of the surgical staff use the Operation Information option for a quick
reference on a case. It produces a report that touches on the more important areas of interest recorded for
the case. The report can be viewed on screen but cannot be edited from this option.
An asterisk indicates the principal diagnosis for the case, since some cases have more than one diagnosis.
Notice that the INTRAOP OCCURRENCES field and the POSTOP OCCURRENCES field indicate if
there are occurrences; however, the occurrences will not be defined, as access to this information is
restricted.
Example: Operation Information
Select Operation Menu Option:
I
Operation Information
-------------------------------------------------------------------------------Patient: SURPATIENT,SIX (000-09-8797)
Operation Date: MAR 9, 1999
Surgeon: SURSURGEON,SIXTEEN
Major/Minor:
Attending Surgeon: SURSURGEON,FOUR
Operation Time: 45 Minutes
Attending Code: LEVEL D: ATTENDING IN O.R. SUITE, IMMEDIATELY AVAILABLE
-------------------------------------------------------------------------------Operation(s):
APPENDECTOMY
-------------------------------------------------------------------------------Postop Diagnosis:
Intraop Occurrences: YES
* APPENDICITIS
Postop Occurrences: YES
-------------------------------------------------------------------------------Anesthesia Technique:
Anesthetist: SURANESTHETIST,THREE
INHALATION
ENFLURANE 125ML
-------------------------------------------------------------------------------Wound Classification:
Intraoperative Blood Loss: 100 CC'S
-------------------------------------------------------------------------------Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
103
Surgical Staff
[SROMEN-STAFF]
The Surgical Staff option allows the operating room nurse or scheduling manager to enter or edit the
names of the surgical team prior to the operation. Some data fields may be automatically filled in based
on previous responses. The names entered will be reflected in the Nurse Intraoperative Report and other
staffing reports.
At the "Enter Screen Server Function:" prompt, the user may choose the field(s) to be edited or press the
<Enter> key to continue. Some of the data fields are "multiple" and may contain more than one value.
When a field labeled "multiple" is selected, a new screen is generated so that the user can enter data
related to that multiple. For example, the CIRC SUPPORT, SCRUB SUPPORT, and SCRUBBED
ASSISTANT fields generate new screens that allow the user to add the TIME ON, TIME OFF, REASON
FOR RELIEF, and STATUS. The TIME ON and TIME OFF fields also generate additional screens so
that the user may enter more than one TIME ON/OFF for the same operation as some assistants must
enter and exit more than once.
If entering times on a day other than the day of surgery, enter both the date and the time.
Entering only a time will default the date to the current date.
Field Information
The following are fields that correspond to the Surgical Staff entries.
Field Name
Definition
ATTENDING CODE
This field corresponds to the highest level of supervision
provided by the attending staff surgeon during the procedure.
Enter a question mark (?) to retrieve the list of codes.
If there are more than two assistants scrubbed for this case, they
can be entered here.
This fields includes any observers, such as equipment vendors, in
the operating room.
OTHER SCRUBBED ASSISTANTS
OTHER PERSONS IN O.R.
104
Surgery V. 3.0 User Manual
April 2004
Example: Entering Surgical Staff
Select Operation Menu Option: SS Surgical Staff
** SURGICAL STAFF **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #193
SURPATIENT,THREE
PAGE 1 OF 1
SURGEON:
SURSURGEON,ONE
PGY OF PRIMARY SURGEON:
FIRST ASST:
SURSURGEON,TWELVE
SECOND ASST:
SURSURGEON,TWO
ATTEND SURG:
SURSURGEON,ONE
ATTENDING CODE:
PRINC ANESTHETIST:
SURANESTHETIST,FOUR
ASST ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURSURGEON,TWO
PERFUSIONIST:
ASST PERFUSIONIST:
OR CIRC SUPPORT:
(MULTIPLE)
OR SCRUB SUPPORT:
(MULTIPLE)
OTHER SCRUBBED ASSISTANTS: (MULTIPLE)
OTHER PERSONS IN OR:
(MULTIPLE)
Enter Screen Server Function: 6;13;15
Attending Code: C LEVEL C: ATTENDING IN O.R., NOT SCRUBBED C
The supervising practitioner is physically present in the operative or
procedural room. The supervising practitioner observes and provides
direction. The resident performs the procedure.
** SURGICAL STAFF **
CASE #193
OR SCRUB SUPPORT
1
SURPATIENT,THREE
PAGE 1
NEW ENTRY
Enter Screen Server Function: 1
Select OR SCRUB SUPPORT: SURNURSE,ONE
OR SCRUB SUPPORT: SURNURSE,ONE// <Enter>
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
1
2
3
OR SCRUB SUPPORT:
TIME ON:
STATUS:
PAGE 1
SURNURSE,ONE
(MULTIPLE)
Enter Screen Server Function: 2:3
Educational Status: ?
CHOOSE FROM:
O
ORIENTEE
F
FULLY TRAINED
Educational Status: F FULLY TRAINED
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
TIME ON
1
PAGE 1
NEW ENTRY
Enter Screen Server Function: 1
Select TIME ON: 8:00 (JUN 06, [email protected]:00)
TIME ON: JUN 06, [email protected]:00// <Enter>
April 2004
Surgery V. 3.0 User Manual
105
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
TIME ON (2920606.08)
1
2
3
TIME ON:
TIME OFF:
REASON FOR RELIEF:
PAGE 1
JUN 06, 1999 AT 08:00
Enter Screen Server Function: 2:3
Time Off: 13:00 (JUN 06, [email protected]:00)
Reason for Relief: ?
Enter the code corresponding to the reason for relief.
CHOOSE FROM:
P
PERSONAL
S
SHIFT CHANGE
A
ADMINISTRATIVE
Reason for Relief: S SHIFT CHANGE
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
TIME ON (2920606.08)
1
2
3
TIME ON:
TIME OFF:
REASON FOR RELIEF:
PAGE 1 OF 1
JUN 06, 1999 AT 08:00
JUN 06, 1999 AT 13:00
SHIFT CHANGE
Enter Screen Server Function: <Enter>
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
TIME ON
1
2
TIME ON:
NEW ENTRY
JUN 06, 1999 AT 08:00
Enter Screen Server Function:
<Enter>
** SURGICAL STAFF **
CASE #193 SURPATIENT,THREE
OR SCRUB SUPPORT (SURNURSE,ONE)
1
2
3
OR SCRUB SUPPORT:
TIME ON:
STATUS:
<Enter>
** SURGICAL STAFF **
CASE #193
OR SCRUB SUPPORT
OR SCRUB SUPPORT:
NEW ENTRY
SURPATIENT,THREE
PAGE 1 OF 1
SURNURSE,ONE
Enter Screen Server Function:
<Enter>
** SURGICAL STAFF **
CASE #193
OTHER PERSONS IN OR
1
PAGE 1 OF 1
SURNURSE,ONE
(MULTIPLE)(DATA)
FULLY TRAINED
Enter Screen Server Function:
1
2
PAGE 1 OF 1
SURPATIENT,THREE
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select OTHER PERSONS IN OR: SURTECHNICIAN,ONE
OTHER PERSONS IN OR: SURTECHNICIAN,ONE // <Enter>
106
Surgery V. 3.0 User Manual
April 2004
** SURGICAL STAFF **
CASE #193
OTHER PERSONS IN OR (0)
1
2
OTHER PERSONS IN OR:
TITLE/ORGANIZATION:
SURPATIENT,THREE
PAGE 1 OF 1
ONE SURTECHNICIAN
Enter Screen Server Function: 2
Title and Organization: TECHNICIAN, AMERICAN SURGICAL EQUIP
** SURGICAL STAFF **
CASE #193
OTHER PERSONS IN OR (0)
1
2
OTHER PERSONS IN OR:
TITLE/ORGANIZATION:
<Enter>
** SURGICAL STAFF **
CASE #193
OTHER PERSONS IN OR
OTHER PERSONS IN OR:
NEW ENTRY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,THREE
PAGE 1 OF 1
ONE SURTECHNICIAN
Enter Screen Server Function:
** SURGICAL STAFF **
PAGE 1 OF 1
ONE SURTECHNICIAN
TECHNICIAN, AMERICAN SURGICAL EQUIP
Enter Screen Server Function:
1
2
SURPATIENT,THREE
<Enter>
CASE #193
SURPATIENT,THREE
PAGE 1 OF 1
SURGEON:
SURSURGEON,ONE
PGY OF PRIMARY SURGEON:
FIRST ASST:
SURSURGEON,TWELVE
SECOND ASST:
SURSURGEON,TWO
ATTEND SURG:
SURSURGEON,ONE
ATTENDING CODE:
LEVEL C: ATTENDING IN O.R., NOT SCRUBBED
PRINC ANESTHETIST:
SURANESTHETIST,FOUR
ASST ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHETIST,TWO
PERFUSIONIST:
ASST PERFUSIONIST:
OR CIRC SUPPORT:
(MULTIPLE)
OR SCRUB SUPPORT:
(MULTIPLE)(DATA)
OTHER SCRUBBED ASSISTANTS: (MULTIPLE)
OTHER PERSONS IN OR:
(MULTIPLE)(DATA)
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
107
Operation Startup
[SROMEN-START]
The nurse or other operating room staff uses the Operation Startup option to enter data concerning the
patient‟s preparation for the surgery (for example, diagnosis, delays, skin prep, and position aids). Some
data fields may be automatically filled in based on previous responses.
Some of the data fields are "multiple fields" and can have more than one value. For example, a patient can
have more than one diagnosis or restraint/position aid. When a multiple field is selected, a new screen is
generated so that the user can enter data related to that multiple. At the "Enter Screen Server Function:"
prompt, the user can choose the field(s) to be edited, or press the <Enter> key to go to the next item or
page.
Field Information
The following are fields that correspond to the Operation Startup entries.
Field Name
Definition
MAJOR/MINOR:
RESTR & POSITION AIDS:
Major surgery is any operation performed under general, spinal,
or epidural anesthesia plus all inguinal herniorrhaphies and
carotid endarterectomies, regardless of anesthesia administered.
Minor surgery is any operation not designated as Major.
The user must respond to this prompt if he or she has information
in the CANCEL DATE field. Typing in a question mark (?) at
the "Cancel Reason:" prompt allows the user to select from a list
of cancellation reasons. The "Cancel Reason:" prompt should
only be answered if the case has been aborted. Use the Cancel
Scheduled Case option if the patient has not yet entered the
operating room.
If the actual start time of the surgery is significantly delayed (15
minutes or more, depending on the institution's policy) it is
necessary to select a reason at the "Delay Cause:" prompt. Type
in a question mark (?) at this prompt to select from a list of delay
causes.
A safety strap is automatically included as a restraint.
108
Surgery V. 3.0 User Manual
CANCEL REASON:
DELAY CAUSE:
April 2004
Example: Operation Startup
Select Operation Menu Option: OS
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #159
Operation Startup
SURPATIENT,THREE
PAGE 1 OF 3
DATE OF OPERATION:
DEC 06, 2004 AT 08:00
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE, L SHOULDER
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
OPERATING ROOM:
OR2
SURGERY SPECIALTY:
ORTHOPEDICS
MAJOR/MINOR:
REQ POSTOP CARE:
WARD
CASE SCHEDULE TYPE:
ELECTIVE
REQ ANESTHESIA TECHNIQUE: GENERAL
PATIENT EDUCATION/ASSESSMENT:
CANCEL DATE:
CANCEL REASON:
CANCELLATION AVOIDABLE:
DELAY CAUSE:
(MULTIPLE)
Enter Screen Server Function: 7;11
Major or Minor: J MAJOR
Preoperative Patient Education: Y YES
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #159
SURPATIENT,THREE
PAGE 1 OF 3
DATE OF OPERATION:
DEC 06, 2004 AT 08:00
PRINCIPAL PRE-OP DIAGNOSIS: DEGENERATIVE JOINT DISEASE, L SHOULDER
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
OPERATING ROOM:
OR2
SURGERY SPECIALTY:
ORTHOPEDICS
MAJOR/MINOR:
MAJOR
REQ POSTOP CARE:
WARD
CASE SCHEDULE TYPE:
ELECTIVE
REQ ANESTHESIA TECHNIQUE: GENERAL
PATIENT EDUCATION/ASSESSMENT: YES
CANCEL DATE:
CANCEL REASON:
CANCELLATION AVOIDABLE:
DELAY CAUSE:
(MULTIPLE)
Enter Screen Server Function: <Enter>
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #159
SURPATIENT,THREE
ASA CLASS:
PREOP MOOD:
PREOP CONSCIOUS:
PREOP SKIN INTEG:
TRANS TO OR BY:
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
SKIN PREPPED BY (1):
SKIN PREPPED BY (2):
SKIN PREP AGENTS:
SECOND SKIN PREP AGENT:
SURGERY POSITION:
RESTR & POSITION AIDS:
ELECTROGROUND POSITION:
Enter Screen Server Function:
April 2004
PAGE 2 OF 3
(WORD PROCESSING)
(MULTIPLE)(DATA)
(MULTIPLE)(DATA)
A
Surgery V. 3.0 User Manual
109
ASA Class: 2 2
2-MILD DISTURB.
Preoperative Mood: ?
Enter the code corresponding to the preoperative assessment of the
patient's emotional status upon arrival to the operating room.
Screen prevents selection of inactive entries.
Answer with PATIENT MOOD NAME, or CODE
Choose from:
AGITATED
AG
ANGRY
ANG
ANXIOUS
ANX
APATHETIC
AP
DEPRESSED
D
RELAXED
R
TESTY AND IRRATE, SLEEPY
BUF
Preoperative Mood: ANXIOUS
ANX
Preoperative Consciousness: AO ALERT-ORIENTED
AO
Preoperative Skin Integrity: INTACT
I
Transported to O.R. By: PACU BED
Preop Surgical Site Hair Removal by: SURNURSE,TWO
Surgical Site Hair Removal Method: N NO HAIR REMOVED
Hair Removal Comments:
No existing text
Edit? NO// <Enter>
Skin Prepped By: <Enter>
Skin Prepped By (2): <Enter>
Skin Preparation Agent: HIBICLENS
HI
Second Skin Preparation Agent: <Enter>
Electroground Placement: RAT RIGHT ANT THIGH
** STARTUP **
CASE #159
SURGERY POSITION
1
2
SURGERY POSITION:
NEW ENTRY
SURPATIENT,THREE
PAGE 1
SUPINE
Enter Screen Server Function: 2
Select SURGERY POSITION: SEMISUPINE
SURGERY POSITION: SEMISUPINE// <Enter>
** STARTUP **
CASE #159 SURPATIENT,THREE
SURGERY POSITION (SEMISUPINE)
1
2
SURGERY POSITION:
TIME PLACED:
SEMISUPINE
Enter Screen Server Function:
** STARTUP **
CASE #159
SURGERY POSITION
1
2
3
SURGERY POSITION:
SURGERY POSITION:
NEW ENTRY
<Enter>
SURPATIENT,THREE
PAGE 1 OF 1
SUPINE
SEMISUPINE
Enter Screen Server Function:
<Enter>
** STARTUP **
CASE #159 SURPATIENT,THREE
RESTR & POSITION AIDS
1
2
PAGE 1
PAGE 1 OF 1
RESTR & POSITION AIDS: SAFETY STRAP
NEW ENTRY
Enter Screen Server Function: 2
Select RESTR & POSITION AIDS: FOAM PADS
RESTR & POSITION AIDS: FOAM PADS// <Enter>
110
Surgery V. 3.0 User Manual
April 2004
** STARTUP **
CASE #159 SURPATIENT,THREE
RESTR & POSITION AIDS (FOAM PADS)
1
2
PAGE 1 OF 1
RESTR & POSITION AIDS: FOAM PADS
APPLIED BY:
Enter Screen Server Function:
Applied By: SURNURSE,TWO
** STARTUP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #159
2
SURPATIENT,THREE
ASA CLASS:
PREOP MOOD:
PREOP CONSCIOUS:
PREOP SKIN INTEG:
TRANS TO OR BY:
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
SKIN PREPPED BY (1):
SKIN PREPPED BY (2):
SKIN PREP AGENTS:
SECOND SKIN PREP AGENT:
SURGERY POSITION:
RESTR & POSITION AIDS:
ELECTROGROUND POSITION:
PAGE 2 OF 3
2-MILD DISTURB.
ANXIOUS
ALERT-ORIENTED
INTACT
PACU BED
MONOSKY,ALAN
NO HAIR REMOVED
(WORD PROCESSING)
HIBICLENS
(MULTIPLE)(DATA)
(MULTIPLE)(DATA)
RIGHT ANT THIGH
Enter Screen Server Function: <Enter>
** STARTUP **
1
CASE #159
SURPATIENT,THREE
PAGE 3 OF 3
ELECTROGROUND POSITION (2):
Enter Screen Server Function: 1
Electroground Position (2): LF LEFT FLANK
** STARTUP **
1
CASE #159
SURPATIENT,THREE
PAGE 3 OF 3
ELECTROGROUND POSITION (2):
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
111
(This page included for two-sided copying.)
112
Surgery V. 3.0 User Manual
April 2004
Operation
[SROMEN-OP]
Surgeons and nurses use the Operation option to enter data relating to the operation during or
immediately following the actual procedure. It is very important to record the time of the patient‟s
entrance into the hold area and operating room, the time anesthesia is administered, and the operation start
time.
Many of the data fields are "multiple fields" and can have more than one value. For example, a patient
can have more than one diagnosis or procedure done per operation. When a multiple field is selected, a
new screen is generated so that the user can enter data related to that multiple. The up-arrow (^) can be
used to exit from any multiple field. Enter a question mark (?) for software- assisted instruction.
Field Information
The following are fields that correspond to the Operation entries.
Field Name
Definition
TIME OPERATION BEGAN
The user should check his or her institution‟s policy concerning
an operation‟s start time. In some institutions, this may be the
time of first incision.
If entering times on a day other than the day of surgery, enter both the date and the time.
Entering only a time will default the date to the current date.
April 2004
Surgery V. 3.0 User Manual
113
Example: Operation Option: Entering Information
** OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #173
TIME PAT IN HOLD AREA:
TIME PAT IN OR:
ANES CARE TIME BLOCK:
TIME OPERATION BEGAN:
SPECIMENS:
CULTURES:
THERMAL UNIT:
ELECTROCAUTERY UNIT:
ESU COAG RANGE:
ESU CUTTING RANGE:
TIME TOURNIQUET APPLIED:
PROSTHESIS INSTALLED:
REPLACEMENT FLUID TYPE:
IRRIGATION:
MEDICATIONS:
Enter Screen Server Function:
SURPATIENT,TWENTY
PAGE 1 OF 3
(MULTIPLE)
(WORD PROCESSING)
(WORD PROCESSING)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
1;2;13:14
Time Patient Arrived in Holding Area: 8:50 (MAR 12, [email protected]:50)
Time Patient In the O.R.: 9:00 (MAR 12, [email protected]:00)
** OPERATION **
CASE #173 SURPATIENT,TWENTY
REPLACEMENT FLUID TYPE
1
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select REPLACEMENT FLUID TYPE: RINGERS LACTATED SOLUTION
REPLACEMENT FLUID TYPE: RINGERS LACTATED SOLUTION// <Enter>
** OPERATION **
CASE #173 SURPATIENT,TWENTY
PAGE 1 OF 1
REPLACEMENT FLUID TYPE (RINGERS LACTATED SOLUTION)
1
2
3
4
5
REPLACEMENT FLUID TYPE: RINGERS LACTATED SOLUTION
QTY OF FLUID (ml):
SOURCE ID:
VA IDENT:
REPLACEMENT FLUID COMMENTS: (WORD PROCESSING)
Enter Screen Server Function: 2;3
Quantity of Fluid (ml): 1000
Source Identification Number: TRAVENOL
** OPERATION **
CASE #173 SURPATIENT,TWENTY
PAGE 1 OF 1
REPLACEMENT FLUID TYPE (RINGERS LACTATED SOLUTION)
1
2
3
4
5
REPLACEMENT FLUID TYPE: RINGERS LACTATED SOLUTION
QTY OF FLUID (ml):
1000
SOURCE ID:
TRAVENOL
VA IDENT:
REPLACEMENT FLUID COMMENTS: (WORD PROCESSING)
Enter Screen Server Function:
<Enter>
** OPERATION **
CASE #173 SURPATIENT,TWENTY
REPLACEMENT FLUID TYPE
1
2
REPLACEMENT FLUID TYPE: RINGERS LACTATED SOLUTION
NEW ENTRY
Enter Screen Server Function:
114
PAGE 1 OF 1
<Enter>
Surgery V. 3.0 User Manual
April 2004
** OPERATION **
IRRIGATION
1
CASE #173
SURPATIENT,TWENTY
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select IRRIGATION: NORMAL SALINE
IRRIGATION: NORMAL SALINE// <Enter>
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
1
2
IRRIGATION:
TIME:
NORMAL SALINE
(MULTIPLE)
Enter Screen Server Function:
2
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
TIME
1
PAGE 1 OF 1
PAGE 1
NEW ENTRY
Enter Screen Server Function: 1
Select TIME: 9:40
MAR 12, [email protected]:40
TIME: MAR 12, [email protected]:40// <Enter>
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
TIME (2930601.094)
1
2
3
TIME:
AMOUNT USED:
PROVIDER:
PAGE 1
MAR 12, 1999 AT 09:40
Enter Screen Server Function: 2:3
Amount of Solution Used: 1000
Person Responsible: SURNURSE,THREE
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
TIME (2930601.094)
1
2
3
TIME:
AMOUNT USED:
PROVIDER:
MAR 12, 1999 AT 09:40
1000
SURNURSE,THREE
Enter Screen Server Function:
<Enter>
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
TIME
1
2
TIME:
NEW ENTRY
PAGE 1 OF 1
MAR 12, 1999 AT 09:40
Enter Screen Server Function:
April 2004
PAGE 1 OF 1
<Enter>
Surgery V. 3.0 User Manual
115
** OPERATION **
CASE #173 SURPATIENT,TWENTY
IRRIGATION (NORMAL SALINE)
1
2
IRRIGATION:
TIME:
NORMAL SALINE
(MULTIPLE)(DATA)
Enter Screen Server Function:
** OPERATION **
CASE #173
IRRIGATION
1
2
IRRIGATION:
NEW ENTRY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
<Enter>
SURPATIENT,TWENTY
PAGE 1 OF 1
NORMAL SALINE
Enter Screen Server Function:
** OPERATION **
PAGE 1 OF 1
CASE #173
TIME PAT IN HOLD AREA:
TIME PAT IN OR:
ANES CARE TIME BLOCK:
TIME OPERATION BEGAN:
SPECIMENS:
CULTURES:
THERMAL UNIT:
ELECTROCAUTERY UNIT:
ESU COAG RANGE:
ESU CUTTING RANGE:
TIME TOURNIQUET APPLIED:
PROSTHESIS INSTALLED:
REPLACEMENT FLUID TYPE:
IRRIGATION:
MEDICATIONS:
<Enter>
SURPATIENT,TWENTY
PAGE 1 OF 3
MAR 12, 1999 AT 08:50
MAR 12, 1999 AT 09:00
(MULTIPLE)
(WORD PROCESSING)
(WORD PROCESSING)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
(MULTIPLE)
Enter Screen Server Function: <Enter>
116
Surgery V. 3.0 User Manual
April 2004
** OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #173
SURPATIENT,TWENTY
PAGE 2 OF 3
SPONGE COUNT CORRECT (Y/N):
SHARPS COUNT CORRECT (Y/N):
INSTRUMENT COUNT CORRECT (Y/N):
SPONGE, SHARPS, & INST COUNTER:
COUNT VERIFIER:
SEQUENTIAL COMPRESSION DEVICE:
LASER UNIT:
(MULTIPLE)
CELL SAVER:
(MULTIPLE)
NURSING CARE COMMENTS:
(WORD PROCESSING)
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE:
PRINCIPAL PROCEDURE:
CHOLECYSTECTOMY
PLANNED PRIN PROCEDURE CODE :
OTHER PROCEDURES:
(MULTIPLE)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function: 1:4
Final Sponge Count Correct (Y/N): Y YES
Final Sharps Count Correct (Y/N): Y YES
Final Instrument Count Correct (Y/N): Y YES
Person Responsible for Final Counts: SURNURSE,THREE
** OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #173
SURPATIENT,TWENTY
PAGE 2 OF 3
SPONGE COUNT CORRECT (Y/N): YES
SHARPS COUNT CORRECT (Y/N): YES
INSTRUMENT COUNT CORRECT (Y/N): YES
SPONGE, SHARPS, & INST COUNTER: SURNURSE,THREE
COUNT VERIFIER:
SEQUENTIAL COMPRESSION DEVICE:
LASER UNIT:
(MULTIPLE)
CELL SAVER:
(MULTIPLE)
NURSING CARE COMMENTS:
(WORD PROCESSING)
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE:
PRINCIPAL PROCEDURE:
CHOLECYSTECTOMY
PLANNED PRIN PROCEDURE CODE :
OTHER PROCEDURES:
(MULTIPLE)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function: 9
NURSING CARE COMMENTS:
1>Admitted with prosthesis in place, left eye is artificial eye.
2>Foam pads applied to elbows and knees. Pillow placed
3>under knees.
4><Enter>
EDIT Option: <Enter>
April 2004
Surgery V. 3.0 User Manual
117
** OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #173
SURPATIENT,TWENTY
PAGE 2 OF 3
SPONGE COUNT CORRECT (Y/N): YES
SHARPS COUNT CORRECT (Y/N): YES
INSTRUMENT COUNT CORRECT (Y/N): YES
SPONGE, SHARPS, & INST COUNTER: SURNURSE,THREE
COUNT VERIFIER:
SEQUENTIAL COMPRESSION DEVICE:
LASER UNIT:
(MULTIPLE)
CELL SAVER:
(MULTIPLE)
NURSING CARE COMMENTS:
(WORD PROCESSING)(DATA)
PRINCIPAL PRE-OP DIAGNOSIS: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE:
PRINCIPAL PROCEDURE:
CHOLECYSTECTOMY
PLANNED PRIN PROCEDURE CODE :
OTHER PROCEDURES:
(MULTIPLE)
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)(DATA)
Enter Screen Server Function: <Enter>
** OPERATION **
1
CASE #173
BRIEF CLIN HISTORY:
SURPATIENT,TWENTY
PAGE 3 OF 3
(WORD PROCESSING)
Enter Screen Server Function:
118
Surgery V. 3.0 User Manual
April 2004
Post Operation
[SROMEN-POST]
The Post Operation option concerns the close of the operation, discharge, and post anesthesia recovery. It
is important to enter the operation and anesthesia end times, as well as the time the patient leaves the
operation room, as these fields affect many reports.
Field Information
The following are fields that correspond to the Post Operation option entries.
Field Name
Definition
TIME PAT OUT OR
Entry of this field generates an alert notifying the circulating
nurse that the Nurse Intraoperative Report is ready for signature.
Entry of this multiple generates an alert notifying the anesthetist
that the Anesthesia Report is ready for signature.
ANES CARE TIME BLOCK
Example: Post Operation
Select Operation Menu Option: PO Post Operation
** POST OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #145
SURPATIENT,NINE
PAGE 1 OF 2
DRESSING:
PACKING:
TUBES AND DRAINS:
BLOOD LOSS (ML):
TOTAL URINE OUTPUT (ML):
GASTRIC OUTPUT:
WOUND CLASSIFICATION:
POSTOP MOOD:
POSTOP CONSCIOUS:
POSTOP SKIN INTEG:
TIME OPERATION ENDS:
ANES CARE TIME BLOCK: (MULTIPLE)
TIME PAT OUT OR:
OP DISPOSITION:
DISCHARGED VIA:
Enter Screen Server Function: A
Dressing(s): TELFA
Packing Type: <Enter>
Tubes and Drains: PENROSE
Intraoperative Blood Loss (ml): 200
Total Urine Output (ml): 600
Gastric Output (cc's): 150
Wound Classification: CC CLEAN/CONTAMINATED
Postoperative Mood: RELAXED
R
Postoperative Consciousness: RESTING
R
Postoperative Skin Integrity: INTACT
I
Time the Operation Ends: 12:30 (APR 26, [email protected]:30)
Time Patient Out of the O.R.: 12:50 (APR 26, [email protected]:50)
Postoperative Disposition: PACU (RECOVERY ROOM)
R
Patient Discharged Via: PACU BED
April 2004
Surgery V. 3.0 User Manual
119
** POST OPERATION **
CASE #145
ANES CARE TIME BLOCK
1
SURPATIENT,NINE
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select ANES CARE TIME BLOCK ANES CARE MULTIPLE START TIME: 10:30
APR 26, [email protected]
10:30
ANES CARE TIME BLOCK ANES CARE MULTIPLE START TIME: APR 26, [email protected]:30
// <Enter>
** POST OPERATION **
CASE #145 SURPATIENT,NINE
ANES CARE TIME BLOCK (3050608.153)
1
2
ANES CARE MULTIPLE START TIME: APR 26, [email protected]:30
ANES CARE MULTIPLE END TIME:
Enter Screen Server Function: 2
Anesthesia Care Multiple End Time: 12:40
(APR 26, [email protected]:40)
Does this entry complete all start and end times for this case?
** POST OPERATION **
CASE #145 SURPATIENT,NINE
ANES CARE TIME BLOCK (3050608.153)
1
2
PAGE 1 OF 1
(Y/N)//
Y
PAGE 1 OF 1
ANES CARE MULTIPLE START TIME: APR 26, 2005 AT 10:30
ANES CARE MULTIPLE END TIME: APR 26, 2005 AT 12:40
Enter Screen Server Function: <Enter>
** POST OPERATION **
CASE #145
ANES CARE TIME BLOCK
1
2
SURPATIENT,NINE
PAGE 1 OF 1
ANES CARE MULTIPLE START TIME: APR 26, 2005 AT 10:30
NEW ENTRY
Enter Screen Server Function: <Enter>
** POST OPERATION **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #145
DRESSING:
PACKING:
TUBES AND DRAINS:
BLOOD LOSS (ML):
TOTAL URINE OUTPUT (ML):
GASTRIC OUTPUT:
WOUND CLASSIFICATION:
POSTOP MOOD:
POSTOP CONSCIOUS:
POSTOP SKIN INTEG:
TIME OPERATION ENDS:
ANES CARE TIME BLOCK:
TIME PAT OUT OR:
OP DISPOSITION:
DISCHARGED VIA:
SURPATIENT,NINE
PAGE 1 OF 2
TELFA
PENROSE
200
600
150
CLEAN/CONTAMINATED
RELAXED
RESTING
INTACT
APR 26, 2005 AT 12:30
(MULTIPLE) (DATA)
APR 26, 2005 AT 12:50
PACU (RECOVERY ROOM)
PACU BED
Enter Screen Server Function: <Enter>
** POST OPERATION **
1
2
3
4
5
6
7
8
9
10
11
120
CASE #145
SURPATIENT,NINE
PAGE 2 OF 2
PRINCIPAL POST-OP DIAG: CHOLELITHIASIS
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER POSTOP DIAGS:
(MULTIPLE)
PRINCIPAL PROCEDURE:
CHOLECYSTECTOMY
PLANNED PRIN PROCEDURE CODE:
47480
OTHER PROCEDURES:
(MULTIPLE)(DATA)
ATTENDING CODE:
LEVEL C: ATTENDING IN O.R., NOT SCRUBBED
FLASH-CONTAMINATION:
56
FLASH-SPD/OR MGT ISSUE: 0
FLASH-EMERGENCY CASE:
6
FLASH-NO BETTER OPTION: 4
Surgery V. 3.0 User Manual
April 2004
12
13
FLASH-LOANER INSTRUMENT: 9
FLASH-DECONTAMINATION:
12
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
120a
(This page included for two-sided copying.)
120b
Surgery V. 3.0 User Manual
April 2004
Enter PAC(U) Information
[SROMEN-PACU]
Personnel in the Post Anesthesia Care Unit (PACU) use the Enter PAC(U) Information option to enter the
admission and discharge times and scores.
Example: Entering PAC(U) Information
Select Operation Menu Option: PAC
** PACU **
1
2
3
4
CASE #145
ADMIT PAC(U)
PAC(U) ADMIT
PAC(U) DISCH
PAC(U) DISCH
Enter PAC(U) Information
SURPATIENT,NINE
PAGE 1 OF 1
TIME:
SCORE:
TIME:
SCORE:
Enter Screen Server Function: 1:4
PAC(U) Admission Time: 13:00 (APR 26, [email protected]:00)
PAC(U) Admission Score: 10
PAC(U) Discharge Date/Time: 14:00 (APR 26, [email protected]:00)
PAC(U) Discharge Score: 10
** PACU **
1
2
3
4
CASE #145
ADMIT PAC(U)
PAC(U) ADMIT
PAC(U) DISCH
PAC(U) DISCH
TIME:
SCORE:
TIME:
SCORE:
SURPATIENT,NINE
PAGE 1 OF 1
APR 26, 1999 AT 13:00
10
APR 26, 1999 AT 14:00
10
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
121
Operation (Short Screen)
[SROMEN-OUT]
The Operation (Short Screen) option provides a three-page screen of information concerning a surgical
procedure performed on a patient. The Operation (Short Screen) option allows the nurse or surgeon to
easily enter data relating to the operation during, and shortly after, the actual procedure. This time-saving
option can replace the Operation Startup option, the Operation option, and the Post Operation option for
minor surgeries.
When only one anesthesia technique is entered, the software will assume that it is the principal anesthesia
technique for the case. Some data fields may be automatically pre-populated if the case was booked in
advance.
Example: Operation Short Screen
Select Operation Menu Option: OSS
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #186
Operation (Short Screen)
SURPATIENT,TWELVE
PAGE 1 OF 3
DATE OF OPERATION:
MAR 09, 2005
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,FOUR
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE:
REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE: 17000
OTHER PROCEDURES:
(MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
TIME OPERATION BEGAN:
TIME OPERATION ENDS:
Enter Screen Server Function: 13:15
Time Patient In the O.R.: 13:00 (MAR 09, [email protected]:00)
Time the Operation Began: 13:10 (MAR 09, [email protected]:10)
Time the Operation Ends: 13:36 (MAR 09, [email protected]:36)
122
Surgery V. 3.0 User Manual
April 2004
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #186
PAGE 1 OF 3
DATE OF OPERATION:
MAR 09, 2005
IN/OUT-PATIENT STATUS: OUTPATIENT
SURGEON:
SURSURGEON,FOUR
PRINCIPAL PRE-OP DIAGNOSIS: BENIGN LESIONS ON NOSE
PRIN PRE-OP ICD DIAGNOSIS CODE:
OTHER PREOP DIAGNOSIS: (MULTIPLE)
PRINCIPAL PROCEDURE:
REMOVE FACIAL LESIONS
PLANNED PRIN PROCEDURE CODE: 17000
OTHER PROCEDURES:
(MULTIPLE)
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
(WORD PROCESSING)
TIME PAT IN OR:
MAR 09, 2005 AT 13:00
TIME OPERATION BEGAN: MAR 09, 2005 at 13:10
TIME OPERATION ENDS:
MAR 09, 2005 AT 13:36
Enter Screen Server Function:
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,TWELVE
<Enter>
CASE #186
SURPATIENT,TWELVE
PAGE 2 OF 3
TIME PAT OUT OR:
IV STARTED BY:
OR CIRC SUPPORT:
(MULTIPLE)
OR SCRUB SUPPORT:
(MULTIPLE)
OPERATING ROOM:
FIRST ASST:
SPONGE COUNT CORRECT (Y/N):
SHARPS COUNT CORRECT (Y/N):
INSTRUMENT COUNT CORRECT (Y/N):
SPONGE, SHARPS, & INST COUNTER:
COUNT VERIFIER:
SURGERY SPECIALTY:
GENERAL(OR WHEN NOT DEFINED BELOW)
WOUND CLASSIFICATION:
ATTEND SURG:
SURSURGEON,TWO
ATTENDING CODE:
Enter Screen Server Function:
1;5;15
Time Patient Out of the O.R.: 13:40 (MAR 09, [email protected]:40)
Operating Room: OR1
Attending Code: A
LEVEL A: ATTENDING DOING THE OPERATION A
The staff practitioner performs the case, but may be assisted by a
resident.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #186
SURPATIENT,TWELVE
PAGE 2 OF 3
TIME PAT OUT OR:
MAR 12, 2006 AT 13:40
IV STARTED BY:
OR CIRC SUPPORT:
(MULTIPLE)
OR SCRUB SUPPORT:
(MULTIPLE)
OPERATING ROOM:
OR1
FIRST ASST:
SPONGE COUNT CORRECT (Y/N):
SHARPS COUNT CORRECT (Y/N):
INSTRUMENT COUNT CORRECT (Y/N):
SPONGE, SHARPS, & INST COUNTER:
COUNT VERIFIER:
SURGERY SPECIALTY:
GENERAL(OR WHEN NOT DEFINED BELOW)
WOUND CLASSIFICATION:
ATTEND SURG:
SURSURGEON,TWO
ATTENDING CODE:
LEVEL A: ATTENDING DOING THE OPERATION
Enter Screen Server Function:
April 2004
<Enter>
Surgery V. 3.0 User Manual
123
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
CASE #186
SURPATIENT,TWELVE
PAGE 3 OF 3
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
NURSING CARE COMMENTS:
(WORD PROCESSING) (DATA)
ASA CLASS:
PRINC ANESTHETIST:
SURANESTHETIST,FOUR
ANESTHESIA TECHNIQUE:
(MULTIPLE)
ANES CARE TIME BLOCK:
(MULTIPLE)
DELAY CAUSE:
(MULTIPLE)
CANCEL DATE:
CANCEL REASON:
CANCELLATION COMMENTS:
Enter Screen Server Function:
3:4
Nursing Care Comments:
1>PATIENT ARRIVED AMBULATORY FROM AMBULATORY
2>SURGERY UNIT. DISCHARGED VIA WHEELCHAIR, AWAKE,
3>ALERT, ORIENTED.
4><Enter>
EDIT Option: <Enter>
ASA Class: 3 3
3-SEVERE DISTURB.
** SHORT SCREEN **
1
2
3
4
5
6
7
8
9
10
11
CASE #186
PAGE 3 OF 3
SPECIMENS:
(WORD PROCESSING)
CULTURES:
(WORD PROCESSING)
NURSING CARE COMMENTS:
(WORD PROCESSING) (DATA)
ASA CLASS:
3-SEVERE DISTURB.
PRINC ANESTHETIST:
SURANESTHETIST,FOUR
ANESTHESIA TECHNIQUE:
(MULTIPLE)
ANES CARE TIME BLOCK:
(MULTIPLE)
DELAY CAUSE:
(MULTIPLE)
CANCEL DATE:
CANCEL REASON:
CANCELLATION COMMENTS:
Enter Screen Server Function:
124
SURPATIENT,TWELVE
<Enter>
Surgery V. 3.0 User Manual
April 2004
Time Out Verified Utilizing Checklist
[SROMEN-VERF]
This option is used to enter information related to the Time Out Verified Utilizing Checklist.
Example: Time Out Verified Utilizing Checklist
Select Operation Menu Option: Time Out Verified Utilizing Checklist
** TIME OUT CHECKLIST **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #145
SURPATIENT,NINE
PAGE 1 OF 1
CONFIRM PATIENT IDENTITY:
PROCEDURE TO BE PERFORMED:
SITE OF PROCEDURE:
VALID CONSENT FORM:
CONFIRM PATIENT POSITION:
MARKED SITE CONFIRMED:
PREOPERATIVE IMAGES CONFIRMED:
CORRECT MEDICAL IMPLANTS:
AVAILABILITY OF SPECIAL EQUIP:
ANTIBIOTIC PROPHYLAXIS:
APPROPRIATE DVT PROPHYLAXIS:
BLOOD AVAILABILITY:
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY:
Enter Screen Server Function: A
Confirm Correct Patient Identity: Y YES
Confirm Procedure To Be Performed: Y YES
Confirm Site of Procedure, Including Laterality:
Confirm Valid Consent Form: Y YES
Confirm Patient Position: N
NO
Confirm Proc. Site has been Marked Appropriately
ible After Prep: Y YES
Pertinent Medical Images Have Been Confirmed: Y
Correct Medical Implant(s) is Available: Y YES
Availability of Special Equipment: Y YES
Appropriate Antibiotic Prophylaxis: Y YES
Appropriate Deep Vein Thrombosis Prophylaxis: Y
Blood Availability: Y YES
Checklist Comment:
No existing text
Edit? NO// <Enter>
Checklist Confirmed By: SURNURSE,FIVE
Y
YES
and the Site of the Mark is Vis
YES
YES
Checklist Comments should be entered when a "NO" response is entered for any of
the Time Out Verified Utilizing Checklist fields.
Do you want to enter Checklist Comment ? YES//
Checklist Comment:
No existing text
Edit? NO//
** TIME OUT CHECKLIST **
1
2
3
4
5
6
7
8
9
10
11
12
CASE #145
SURPATIENT,NINE
PAGE 1 OF 1
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
YES
PREOPERATIVE IMAGES CONFIRMED: YES
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS: YES
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
April 2004
Surgery V. 3.0 User Manual
124a
13
14
CHECKLIST COMMENT:
CHECKLIST CONFIRMED BY:
(WORD PROCESSING)
SURNURSE,FIVE
Enter Screen Server Function:
124b
Surgery V. 3.0 User Manual
April 2004
Surgeon’s Verification of Diagnosis & Procedures
[SROVER]
Surgeons use this option to verify that the stated procedure(s), diagnosis, and occurrences are correct for a
case. With this option, the surgeon can update the Operation Name, Planned CPT Code, Diagnosis, and
Intraoperative Occurrences before verifying the case. If the case has already been verified, the user will be
asked whether to re-verify it.
If the user responds YES to the prompt "Do you need to update the information above ?" the software
will provide a summary for editing.
If there are no occurrences, the INTRAOP OCCURRENCES field should be left blank. Do not
enter NO or NONE.
The procedure and diagnosis codes are the codes captured with clinical data, and are supplied as defaults
to the Coder when entering the final codes that will be sent to PCE.
Service Classifications
Information relating to a patient‟s status of Service Connected (SC) and Environmental Indicators (EI) are
captured during patient registration. The Surgery software receives this data from enrollment and displays
it when the user creates a case.
In the Surgery software, the patient‟s Service Classification status is determined at the case level when the
case is created. The user can further refine status designations, not only per case, but also per diagnosis.
The system defaults the case-level Service Classification indicators into each Other Postop Diagnosis
field as the user adds the Other Postop Diagnoses. The system allows the user to edit these fields if the
user determines that the defaulted value is incorrect.
April 2004
Surgery V. 3.0 User Manual
125
Example: Surgeon’s Verification of Diagnosis & Procedures
Select Operation Menu Option: V
Surgeon's Verification of Diagnosis & Procedures
SURPATIENT,ONE (000-44-7629)
Operation Date: JUN 5, 2005
-----------------------------------------------------------------------------1. Indications for Operation:
Swelling in the inguinal region.
2. Planned Principal CPT Code: 00830
Assoc. DX: 1. 550.02 BILAT ING HERNIA W GANG
3. Principal Procedure: REMOVE HERNIA
4. Other Procedures:
5. Postoperative Diagnosis:
INGUINAL HERNIA
6. Intraoperative Occurrences: NO OCCURRENCES HAVE BEEN ENTERED
7. Principal Pre-OP Diagnosis: HERNIA
8. Principal Pre-OP Diagnosis Code: 550.02 BILAT ING HERNIA W GANG
-----------------------------------------------------------------------------Do you need to update the information above ?
NO//
Y
Select Information to Edit: 2:3
Planned Principal Procedure Code (CPT): 49521
REREPAIR ING HERNIA, BLOCKE
D
REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED
The Diagnosis to Procedure Associations may no longer be correct.
Delete Diagnosis Associations for this Procedure? N// NO
Modifier: 59
Modifier: <Enter>
DISTINCT PROCEDURAL SERVICE
Principal Procedure: REMOVE HERNIA// REPAIR INGUINAL HERNIA
126
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,ONE (000-44-7629)
Operation Date: JUN 5, 2005
-----------------------------------------------------------------------------1. Indications for Operation:
Swelling in the inguinal region.
2. Planned Principal CPT Code: 49521
REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED
Modifiers: -59
3. Principal Procedure: REPAIR INGUINAL HERNIA
4. Other Procedures:
5. Postoperative Diagnosis:
INGUINAL HERNIA
6. Intraoperative Occurrences: NO OCCURRENCES HAVE BEEN ENTERED
7. Principal Pre-OP Diagnosis: HERNIA
8. Principal Pre-OP Diagnosis Code: 550.02 BILAT ING HERNIA W GANG
-----------------------------------------------------------------------------Do you need to update the information above ? NO// <Enter>
Will you verify that the information on your screen is correct ? YES// <Enter>
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
127
Anesthesia for an Operation Menu
[SROANES]
The Anesthesia for an Operation Menu option is restricted to anesthesia personnel and is
locked with the SROANES key.
This option is designed for convenient entry of data pertaining to the anesthesia agents, personnel and
techniques. When the user selects this option from the Operation Menu option, he or she is given a
submenu of five options.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
that may be entered to select the option.
Shortcut
I
T
M
R
S
Option Name
Anesthesia Information (Enter/Edit)
Anesthesia Technique (Enter/Edit)
Medications (Enter/Edit)
Anesthesia Report
Schedule Anesthesia Personnel
Prerequisites
To use any of these options, other than the Schedule Anesthesia Personnel option, the user must first
select a patient case. For the Schedule Anesthesia Personnel option, a date and then an operating room
must first be selected.
These options can also be accessed from the main Surgery Menu.
Information related to these options is contained in “Chapter Two: Tracking Clinical Procedures,” in the
Anesthesia Menu section.
128
Surgery V. 3.0 User Manual
April 2004
Operation Report
[SROSRPT]
The Operation Report option displays the dictated Operation Report for the patient case selected. This
report contains the surgeon‟s dictation regarding the surgical procedure. The Operation Report is not
electronically signed in the Surgery package. After the dictated Operation Report is uploaded into the
Text Integration Utilities (TIU) package, it is then available for electronic signature through the
Computerized Patient Record System (CPRS) Surgery tab.
When electronically signed, the Operation Report is also viewable through CPRS. The electronically
signed Operation Report replaces VA Form 516. If the Operation Report has not been electronically
signed, then CPRS will only display a stub for that document.
After the dictated Operation Report is transcribed and uploaded into TIU, the TIU software
sends an alert to the surgeon responsible for electronically signing the report.
Until the Operation Report is signed, if the Operation Report option is selected, the following text
displays:
“The Operation Report for this case is not yet available.”
If the Operation Report has been signed, the Operation Report option will display the signed document.
(See the example.)
-----------------------------------------------------printout follows-------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
129
Example: A signed Operation Report
Page: 1
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
OPERATION REPORT
-------------------------------------------------------------------------------NOTE DATED: 07/29/2003 15:15 OPERATION REPORT
VISIT: 07/29/2003 15:15 SURGERY OP REPORT NON-COUNT
SUBJECT: Case #: 73285
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
Visually significant cataract, right eye
Visually significant cataract, right eye
Phacoemulsification with intraocular lens placement, right eye
CLINICAL INDICATIONS: This 64-year-old gentleman complains of decreased
vision in the right eye affecting his activities of daily living. Best
corrected visual acuity is counting fingers at 6 feet, associated with a
2-3+ nuclear sclerotic and 4+ posterior subcapsular cataract in that eye.
ANESTHESIA: Local monitoring with topical Tetracaine and 1% preservative
free Lidocaine.
DESCRIPTION OF THE PROCEDURE: After the risks, benefits and alternatives
of the procedure were explained to the patient, informed consent was
obtained. The patient's right eye was dilated with Phenylephrine,
Mydriacyl and Ocufen. He was brought to the Operating Room and placed on
anesthetic monitors. Topical Tetracaine was given. He was prepped and
draped in the usual sterile fashion for eye surgery. A Lieberman lid
speculum was placed.
A Supersharp was used to create a superior paracentesis port. The anterior
chamber was irrigated with 1% preservative free Lidocaine. The anterior
chamber was filled with Viscoelastic. The diamond groove maker and diamond
keratome were used to create a clear corneal tunneled incision at the
temporal limbus. The cystotome was used to initiate a continuous
capsulorrhexis, which was then completed using Utrata forceps. Balanced
salt solution was used to hydrodissect and hydrodelineate the lens.
Phacoemulsification was used to remove the lens nucleus and epinucleus in a
non-stop horizontal chop fashion. Cortex was removed using irrigation and
aspiration. The capsular bag was filled with Viscoelastic. The wound was
enlarged with a 69 blade. An Alcon model MA60BM posterior chamber
intraocular lens with a power of 24.0 diopters, serial #588502.064, was
folded and inserted with the leading haptic placed into the bag. The
trailing haptic was dialed into the bag with the Lester hook. The wound
was hydrated. The anterior chamber was filled with balanced salt solution.
The wound was tested and found to be self-sealing. Subconjunctival
antibiotics were given, and an eye shield was placed. The patient was
taken in good condition to the Recovery Room. There were no complications.
KJC/PSI
DATE DICTATED: 07/29/03
DATE TRANSCRIBED: 07/29/03
JOB: 629095
Signed by: /es/ FOURTEEN SURSURGEON, M.D.
07/30/2003 10:31
130
Surgery V. 3.0 User Manual
April 2004
Anesthesia Report
[SROARPT]
The Anesthesia Report details anesthesia information for the patient case selected. This option provides
the capability to view/print the report, edit information contained in the report, and electronically sign the
report. This option can also be accessed from the Anesthesia Menu option located on the Operation Menu,
as well as on the main Surgery Menu.
Anesthesia Report (Unsigned)
Upon selecting this option, if the Anesthesia Report is not signed the report will begin displaying. The
Anesthesia Report displays key fields on the first page. Several of these fields are required before the
software will allow the user to electronically sign the report. If any of these fields are left blank, a
warning will appear prompting the user to provide the missing information. The ANES CARE TIME
field, ANESTHESIA TECHNIQUE field, ASA CLASS field, OP DISPOSITION field, and the PRINC
ANESTHETIST field must all be completed before the Anesthesia Report can be electronically signed.
Entering the information into the ANES CARE END TIME field triggers an alert that is sent to
the anesthetist responsible for signing the report. By responding to the alert, the user is taken to
the Anesthesia Report option.
At the bottom of the first screen is the prompt, "Press <return> to continue, 'A' to access Anesthesia
Report functions or '^' to exit:". The Anesthesia Report functions, accessed by entering A at the prompt,
allow the user to edit the report, to view or print the report, or to electronically sign the report.
Example: First page of an Anesthesia Report
MEDICAL RECORD
SURPATIENT,TEN (000-12-3456)
ANESTHESIA REPORT - CASE #267226
PAGE 1
Operating Room: WX OR3
Anesthetist: SURANESTHETIST,SEVEN
Relief Anesth:
Anesthesiologist: SURANESTHESIOLOGIST,ONE
Assist Anesth: SURANESTHETIST,FIVE
Attending Code: LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATE
LY AVAILABLE.
Anes Begin:
FEB 12, 2004
08:00
Anes End: FEB 12, 2004
12:10
ASA Class: * NOT ENTERED *
Operation Disposition: * NOT ENTERED *
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Agent:
ISOFLURANE FOR INHALATION 100ML
Intubated: YES
Trauma: NONE
Press <return> to continue, 'A' to access Anesthesia Report functions
or '^' to exit: A
April 2004
Surgery V. 3.0 User Manual
131
After entering an A at the prompt, the Anesthesia functions are displayed. The following examples
demonstrate how these three functions are accessed and how they operate.
If the user enters a 1, the Anesthesia Report data can be edited.
Example: Edit Report Information
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 1
Edit report information
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
OPERATING ROOM:
WX OR3
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
OP DISPOSITION:
ANESTHESIA TECHNIQUE:
(MULTIPLE) (DATA)
PRINCIPAL PROCEDURE:
MVR
OTHER PROCEDURES:
(MULTIPLE) (DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function: 9
Postoperative Disposition: SICU
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SURPATIENT,TEN PAGE 1 OF 2
S
CASE #267226
SURPATIENT,TEN PAGE 1 OF 2
OPERATING ROOM:
WX OR3
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
OP DISPOSITION:
SICU
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
PRINCIPAL PROCEDURE: MVR
OTHER PROCEDURES:
(MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function: ^
132
Surgery V. 3.0 User Manual
April 2004
If the user enters a 2, the Anesthesia Report can be printed.
Example: Print the Anesthesia Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 2
-----------------------------------------------------printout follows-------------------------------------------------------------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
ANESTHESIA REPORT
-------------------------------------------------------------------------------NOTE DATED: 02/12/2004 08:00 ANESTHESIA REPORT
SUBJECT: Case #: 267226
Operating Room: WX OR3
Anesthetist: SURANESTHETIST,SEVEN
Relief Anesth:
Anesthesiologist: SURANESTHESIOLOGIST,ONE
Assist Anesth: SURANESTHETIST,FIVE
Attending Code: LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATE
LY AVAILABLE.
Anes Begin:
FEB 12, 2004
08:00
Anes End:
FEB 12, 2004
12:10
ASA Class: * NOT ENTERED *
Operation Disposition: SICU
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Agent:
ISOFLURANE FOR INHALATION 100ML
Intubated: YES
Trauma: NONE
Min Intraoperative Temp: 35
Intraoperative Blood Loss: 800 ml
Operation Disposition: SICU
PAC(U) Admit Score:
Urine Output: 750 ml
PAC(U) Discharge Score:
Postop Anesthesia Note Date/Time:
April 2004
Surgery V. 3.0 User Manual
133
To electronically sign the report, the user enters a 3.
Example: Sign the Report Electronically
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 3
In this case, a key field, the ASA CLASS field, has been omitted. The system will prompt the user to
supply the missing information before allowing the report to be electronically signed.
The Anesthesia Report cannot be signed if the ASA CLASS field, or any other key field
information, is missing.
Responding YES to the, "Do you want to enter this information?" prompt allows the user to enter or
correct fields on the Anesthesia Report.
Example: Entering or Correcting a Field on the Anesthesia Report prior to Signature
The following information is required before this report may be signed:
ASA CLASS
Do you want to enter this information? YES// YES
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
SURPATIENT,TEN PAGE 1 OF 2
OPERATING ROOM:
WX OR3
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
OP DISPOSITION:
SICU
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
PRINCIPAL PROCEDURE: MVR
OTHER PROCEDURES:
(MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function: 8
ASA Class: 1 1
1-NO DISTURB.
134
Surgery V. 3.0 User Manual
April 2004
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
SURPATIENT,TEN PAGE 1 OF 2
OPERATING ROOM:
WX OR3
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
1-NO DISTURB.
OP DISPOSITION:
SICU
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
PRINCIPAL PROCEDURE: MVR
OTHER PROCEDURES:
(MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function: ^
After any necessary edits have been made, the report can be electronically signed.
Example: Electronically signing the Anesthesia Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 3
Sign the report electronically
Enter your Current Signature Code: XXX
SURPATIENT,TEN (000-12-3456)
SIGNATURE VERIFIED
Case #267226 - FEB 12, 2004
When typing the electronic
signature code, no
characters will display on
screen.
* * The Anesthesia Report has been electronically signed. * *
Once an Anesthesia Report has been signed, a warning informing the user that the Anesthesia Report has
already been signed will display on screen and an addendum will be required for any future changes.
April 2004
Surgery V. 3.0 User Manual
135
Anesthesia Report (Signed)
After an Anesthesia Report has been signed, any changes to the signed report will require a signed
addendum.
Example: Editing the Signed Report
Select Operation Menu Option: AR
SURPATIENT,TEN (000-12-3456)
Anesthesia Report
Case #267226 - FEB 12, 2004
* * The Anesthesia Report has been electronically signed. * *
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
Select number: 2// 1
Edit report information
If the Anesthesia Report and/or the Nurse Intraoperative Report has already been signed, the
following warning will be displayed. If any data on either signed report is edited, an addendum
to the Anesthesia Report and/or to the Nurse Intraoperative Report will be required.
Example: Warning
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
>>>
WARNING
<<<
Electronically signed reports are associated with this case. Editing
of data that appear on electronically signed reports will require the
creation of addenda to the signed reports.
Enter RETURN to continue or '^' to exit:
<Enter>
The user can proceed to edit the report and sign the required addendum or simply exit.
Example: Editing the Signed Report
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
SURPATIENT,TEN PAGE 1 OF 2
OPERATING ROOM:
WX OR3
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
1-NO DISTURB.
OP DISPOSITION:
SICU
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
PRINCIPAL PROCEDURE: MVR
OTHER PROCEDURES:
(MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function: 1
Operating Room: WX OR3// BO OR1
136
Surgery V. 3.0 User Manual
April 2004
** ANESTHESIA REPORT **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
SURPATIENT,TEN PAGE 1 OF 2
OPERATING ROOM:
BO OR1
PRINC ANESTHETIST: SURANESTHETIST,SEVEN
RELIEF ANESTHETIST:
ANESTHESIOLOGIST SUPVR: SURANESTHESIOLOGIST,ONE
ANES SUPERVISE CODE: 3. STAFF ASSISTING C.R.N.A.
ASST ANESTHETIST:
SURANESTHETIST,FIVE
ANES CARE TIME BLOCK:
(MULTIPLE)(DATA)
ASA CLASS:
1-NO DISTURB.
OP DISPOSITION:
SICU
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
PRINCIPAL PROCEDURE: MVR
OTHER PROCEDURES:
(MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)
MIN INTRAOP TEMPERATURE (C): 35
MONITORS:
(MULTIPLE)
Enter Screen Server Function:
SURPATIENT,TEN (000-12-3456)
^
Case #267226 - FEB 12,2004
An addendum to each of the following electronically signed document(s) is
required:
Nurse Intraoperative Report - Case #267226
Anesthesia Report - Case #267226
If you choose not to create an addendum, the original data will be restored
to the modified fields appearing on the signed reports.
Create addendum? YES// <Enter>
If the user elects to exit these options prior to signing the addendum, all fields on the report
revert back to the values entered when electronically signed.
Addendum for Case #267226 - FEB 12,2004
Patient: SURPATIENT,TEN (000-12-3456)
-------------------------------------------------------------------------------The Operating Room field was changed
from WX OR3
to BO OR1
Enter RETURN to continue or '^' to exit: <Enter>
Do you want to add a comment for this case? NO// YES
Comment: OPERATING ROOM NUMBER WAS CORRECTED.
April 2004
Surgery V. 3.0 User Manual
137
Addendum for Case #267226 - FEB 12,2004
Patient: SURPATIENT,TEN (000-12-3456)
-------------------------------------------------------------------------------The Operating Room field was changed
from WX OR3
to BO OR1
Addendum Comment: OPERATING ROOM NUMBER WAS CORRECTED.
Enter RETURN to continue or '^' to exit: <Enter>
Enter your Current Signature Code: XXX
SIGNATURE VERIFIED
Press RETURN to continue... <Enter>
When typing the electronic
signature code, no
characters will display on
screen.
The Print/View report from beginning function can then be used to view or print the report with the
addendum.
Example: Print/View Report With Addendum
SURPATIENT,TEN (000-12-3456)
Case #267226 - FEB 12, 2004
* * The Anesthesia Report has been electronically signed. * *
Anesthesia Report Functions:
1. Edit report information
2. Print/View report from beginning
Select number: 2// 2
Print/View report from beginning
Do you want WORK copies or CHART copies? WORK// <Enter>
DEVICE: [Select Print Device]
-----------------------------------------------------printout follows-------------------------------------------------------
138
Surgery V. 3.0 User Manual
April 2004
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
ANESTHESIA REPORT
-------------------------------------------------------------------------------NOTE DATED: 02/12/2004 08:00 ANESTHESIA REPORT
SUBJECT: Case #: 267226
Operating Room: WX OR3
Anesthetist: SURANESTHETIST,SEVEN
Anesthesiologist: SURANESTHESIOLOGIST,ONE
Attending Code: 3. STAFF ASSISTING C.R.N.A.
Anes Begin:
FEB 12, 2004
08:00
Relief Anesth:
Assist Anesth: SURANESTHETIST,FIVE
Anes End:
FEB 12, 2004
12:10
ASA Class: 1-NO DISTURB.
Operation Disposition: SICU
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Agent:
ISOFLURANE FOR INHALATION 100ML
Enter RETURN to continue or '^' to exit:
Intubated: YES
Trauma: NONE
Procedure(s) Performed:
Principal: MVR
Min Intraoperative Temp: 35
Intraoperative Blood Loss: 800 ml
Operation Disposition: SICU
PAC(U) Admit Score:
Urine Output: 750 ml
PAC(U) Discharge Score:
Postop Anesthesia Note Date/Time:
Signed by: /es/ SEVEN SURANESTHETIST
03/04/2004 10:59
03/04/2004 11:04
ADDENDUM
The Operating Room field was changed
from WX OR3
to BO OR1
Addendum Comment: OPERATING ROOM NUMBER WAS CORRECTED.
Signed by: /es/ SEVEN SURANESTHETIST
03/04/2004 11:04
April 2004
Surgery V. 3.0 User Manual
139
Nurse Intraoperative Report
[SRONRPT]
The Nurse Intraoperative Report details case information relating to nursing care provided for the patient
during the operative case selected. This option provides the capability to view and print the report, edit
information contained in the report, and electronically sign the report.
With the Surgery Site Parameters option located on the Surgery Package Management Menu, the user
can select one of two different formats for this report. One format includes all field names whether or not
information has been entered. The other format only includes fields that have actual data.
Electronically signed reports may be viewed through CPRS for completed operations.
Nurse Intraoperative Report - Before Electronic Signature
Upon selecting the Nurse Intraoperative Report option, if the Nurse Intraoperative Report is not signed,
the report will begin displaying on the screen. The Nurse Intraoperative Report displays key fields on the
first page. Several of these fields are required before the software will allow the user to electronically sign
the report. If any required fields are left blank, a warning will appear prompting the user to provide the
missing information.
The following fields are required before electronic signature of the Nurse Intraoperative Report:
TIME PAT OUT OR
TIME PAT IN OR
HAIR REMOVAL METHOD
MARKED SITE CONFIRMED
CORRECT PATIENT IDENTITY
PREOPERATIVE IMAGING CONFIRMED
SITE OF PROCEDURE
PROCEDURE TO BE PERFORMED
CONFIRM PATIENT POSITION
VALID CONSENT FORM
ANTIBIOTIC PROPHYLAXIS
CORRECT MEDICAL IMPLANTS
BLOOD AVAILABILITY
APPROPRIATE DVT PROPHYLAXIS
CHECKLIST COMMENT
AVAILABILITY OF SPECIAL EQUIP
If the COUNT VERIFIER field has been entered, the following fields are required:
SPONGE COUNT CORRECT (Y/N)
INSTRUMENT COUNT CORRECT
(Y/N)
SHARPS COUNT CORRECT (Y/N)
SPONGE, SHARPS, & INST COUNTER
If the PROSTHESIS INSTALLED field has an item (or items) entered, the following fields are required
for each item:
IMPLANT STERILITY CHECKED
RN VERIFIER
SERIAL NUMBER
STERILITY EXPIRATION DATE
LOT NUMBER
Entering the TIME PAT OUT OR field triggers an alert that is sent to the nurse responsible for
signing the report. By acting on the alert, the nurse accesses the Nurse Intraoperative Report
option to electronically sign the report.
140
Surgery V. 3.0 User Manual
April 2004
At the bottom of the first screen is the prompt, "Press <return> to continue, 'A' to access Nurse
Intraoperative Report functions, or '^' to exit:". The Nurse Intraoperative Report functions, accessed by
entering A at the prompt, allow the user to edit the report, to view or print the report, or to electronically
sign the report.
Example: First page of the Nurse Intraoperative Report
Select Operation Menu Option: NR
MEDICAL RECORD
Operating Room:
Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
NURSE INTRAOPERATIVE REPORT - CASE #267226
BO OR1
Patient in Hold: JUL 12, 2004
Operation Begin: JUL 12, 2004
Surgeon in OR:
JUL 12, 2004
PAGE 1
Surgical Priority: ELECTIVE
07:30
08:58
07:55
Patient in OR: JUL 12, 2004
Operation End: JUL 12, 2004
Patient Out OR: JUL 12, 2004
08:00
12:10
12:45
Major Operations Performed:
Primary: MVR
Wound Classification: CLEAN
Operation Disposition: SICU
Discharged Via: ICU BED
Surgeon: SURSURGEON,THREE
Attend Surg: SURSURGEON,THREE
Anesthetist: SURANESTHETIST,SEVEN
First Assist: SURSURGEON,FOUR
Second Assist: N/A
Assistant Anesth: N/A
Press <return> to continue, 'A' to access Nurse Intraoperative Report
functions, or '^' to exit: A
April 2004
Surgery V. 3.0 User Manual
141
After the user enters an A at the prompt, the Nurse Intraoperative Report functions are displayed. The
following examples demonstrate how these three functions are accessed and how they operate.
If the user enters a 1, the Nurse Intraoperative Report data can be edited.
Example: Editing the Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 1
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #267226
SURPATIENT,TEN PAGE 1 OF 6
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
PREOPERATIVE IMAGING CONFIRMED:
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS: YES
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY: SURNURSE,FIVE
Enter Screen Server Function: <Enter>
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267226
SURPATIENT,TEN PAGE 2 OF 6
SPONGE COUNT CORRECT (Y/N): YES
SHARPS COUNT CORRECT (Y/N): YES
INSTRUMENT COUNT CORRECT (Y/N): YES
SPONGE, SHARPS, & INST COUNTER: SURNURSE,FIVE
COUNT VERIFIER:
TIME PAT IN HOLD AREA:
JUL 12, 2004 AT 07:30
TIME PAT IN OR:
JUL 12, 2004 AT 08:00
TIME OPERATION BEGAN:
JUL 12, 2004 at 08:58
TIME OPERATION ENDS:
JUL 12, 2004 AT 12:30
SURG PRESENT TIME:
TIME PAT OUT OR:
PRINCIPAL PROCEDURE:
CHOLECYSTECTOMY
OTHER PROCEDURES:
(MULTIPLE)
WOUND CLASSIFICATION:
CLEAN
OP DISPOSITION:
Enter Screen Server Function: 14
Wound Classification: CLEAN// CONTAMINATED
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
142
CASE #267226
CONTAMINATED
SURPATIENT,TEN PAGE 2 OF 6
SPONGE COUNT CORRECT (Y/N): YES
SHARPS COUNT CORRECT (Y/N): YES
INSTRUMENT COUNT CORRECT (Y/N): YES
SPONGE, SHARPS, & INST COUNTER: SURNURSE,FIVE
COUNT VERIFIER:
TIME PAT IN HOLD AREA:
JUL 12, 2004 AT 07:30
TIME PAT IN OR:
JUL 12, 2004 AT 08:00
TIME OPERATION BEGAN:
JUL 12, 2004 at 08:58
TIME OPERATION ENDS:
JUL 12, 2004 AT 12:30
SURG PRESENT TIME:
Surgery V. 3.0 User Manual
April 2004
11
12
13
14
15
TIME PAT OUT OR:
PRINCIPAL PROCEDURE:
OTHER PROCEDURES:
WOUND CLASSIFICATION:
OP DISPOSITION:
Enter Screen Server Function:
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
<Enter>
CASE #267226
SURPATIENT,TEN PAGE 3 OF 6
MAJOR/MINOR:
MAJOR
OPERATING ROOM:
OR1
CASE SCHEDULE TYPE:
ELECTIVE
SURGEON:
SURSURGEON,THREE
ATTEND SURG:
SURSURGEON,THREE
FIRST ASST:
SURSURGEON,FOUR
SECOND ASST:
PRINC ANESTHETIST:
SURANESTHETIST,SEVEN
ASST ANESTHETIST:
OTHER SCRUBBED ASSISTANTS: (MULTIPLE)
OR SCRUB SUPPORT:
(MULTIPLE)(DATA)
OR CIRC SUPPORT:
(MULTIPLE)(DATA)
OTHER PERSONS IN OR:
(MULTIPLE)
PREOP MOOD:
RELAXED
PREOP CONSCIOUS:
RESTING
Enter Screen Server Function:
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CHOLECYSTECTOMY
(MULTIPLE)
CONTAMINATED
<Enter>
CASE #267226
PREOP SKIN INTEG:
PREOP CONVERSE:
HAIR REMOVAL BY:
HAIR REMOVAL METHOD:
HAIR REMOVAL COMMENTS:
SKIN PREPPED BY (1):
SKIN PREPPED BY (2):
SKIN PREP AGENTS:
SECOND SKIN PREP AGENT:
SURGERY POSITION:
RESTR & POSITION AIDS:
ELECTROCAUTERY UNIT:
ESU COAG RANGE:
ESU CUTTING RANGE:
ELECTROGROUND POSITION:
Enter Screen Server Function:
SURPATIENT,TEN PAGE 4 OF 6
INTACT
NOT ANSWER QUESTIONS
SURNURSE,FIVE
OTHER
(WORD PROCESSING)(DATA)
SURNURSE,FIVE
If SHAVING or OTHER is entered as the
Hair Removal Method, then Hair Removal
Comments must be entered before the
report can be electronically signed.
BETADINE
POVIDONE IODINE
(MULTIPLE)(DATA)
(MULTIPLE)(DATA)
^
At the Nurse Intraoperative Report functions, the report can be printed if the user enters a 2.
Example: Printing the Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// <Enter>
-----------------------------------------------------printout follows-------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
143
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
NURSE INTRAOPERATIVE REPORT
-------------------------------------------------------------------------------NOTE DATED: 07/12/2004 08:00 NURSE INTRAOPERATIVE REPORT
SUBJECT: Case #: 267226
Operating Room:
BO OR1
Patient in Hold: JUL 12, 2004
Operation Begin: JUL 12, 2004
Surgeon in OR:
JUL 12, 2004
Surgical Priority: ELECTIVE
07:30
08:58
07:55
Patient in OR: JUL 12, 2004
Operation End: JUL 12, 2004
Patient Out OR: JUL 12, 2004
08:00
12:10
12:45
Major Operations Performed:
Primary: MVR
Wound Classification: CONTAMINATED
Operation Disposition: SICU
Discharged Via: ICU BED
Surgeon: SURSURGEON,THREE
Attend Surg: SURSURGEON,THREE
Anesthetist: SURANESTHETIST,SEVEN
First Assist: SURSURGEON,FOUR
Second Assist: N/A
Assistant Anesth: N/A
Other Scrubbed Assistants: N/A
OR Support Personnel:
Scrubbed
SURNURSE,ONE (FULLY TRAINED)
Circulating
SURNURSE,FIVE (FULLY TRAINED)
SURNURSE,FOUR (FULLY TRAINED)
Other Persons in OR: N/A
Preop Mood:
ANXIOUS
Preop Consc:
ALERT-ORIENTED
Preop Skin Integ: INTACT
Preop Converse: N/A
Confirm Correct Patient Identity: YES
Confirm Procedure to be Performed: YES
Confirm Site of the Procedure, including laterality: YES
Confirm Valid Consent Form: YES
Confirm Patient Position: YES
Confirm Proc. Site has been Marked Appropriately and that the Site of the
Mark is Visible After Prep and Draping: YES
Pertinent Medical Images have been Confirmed: YES
Correct Medical Implant(s) is available: YES
Availability of Special Equipment: YES
Appropriate Antibiotic Prophylaxis: YES
Appropriate Deep Vein Thrombosis Prophylaxis: YES
Blood Availability: YES
Checklist Comment: NO COMMENTS ENTERED
Checklist Confirmed By: SURNURSE,FIVE
Skin Prep By: SURNURSE,FOUR
Skin Prep By (2): SURNURSE,FIVE
Skin Prep Agent: BETADINE SCRUB
2nd Skin Prep Agent: POVIDONE IODINE
Preop Surgical Site Hair Removal by: SURNURSE,FIVE
Surgical Site Hair Removal Method: OTHER
Hair Removal Comments: SHAVING AND DEPILATORY COMBINATION USED.
Surgery Position(s):
SUPINE
Restraints and Position Aids:
SAFETY STRAP
ARMBOARD
FOAM PADS
KODEL PAD
STIRRUPS
Flash Sterilization Episodes:
Contamination:
144
Placed: N/A
Applied
Applied
Applied
Applied
Applied
By:
By:
By:
By:
By:
N/A
N/A
N/A
N/A
N/A
0
Surgery V. 3.0 User Manual
April 2004
SPD Processing/OR Management Issues: 0
Emergency Case:
0
No Better Option:
0
Loaner or Short Notice Instrument:
0
Decontamination of Instruments Not for Use In Patient: 0
Electrocautery Unit:
ESU Coagulation Range:
ESU Cutting Range:
Electroground Position(s):
8845,5512
50-35
35-35
RIGHT BUTTOCK
LEFT BUTTOCK
Material Sent to Laboratory for Analysis:
Specimens:
1. MITRAL VALVE
Cultures: N/A
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Tubes and Drains:
#16FOLEY, #18NGTUBE, #36 &2 #32RA CHEST TUBES
Tourniquet: N/A
Thermal Unit: N/A
Prosthesis Installed:
Item: MITRAL VALVE
Implant Sterility Checked (Y/N): YES
Sterility Expiration Date: DEC 15, 2004
RN Verifier: SURNURSE,ONE
Vendor: BAXTER EDWARDS
Model: 6900
Lot Number: T87-12321
Serial Number: 945673WRU
Sterile Resp: SPD
Size: LG
Quantity: 2
Medications: N/A
Irrigation Solution(s):
HEPARINIZED SALINE
NORMAL SALINE
COLD SALINE
Blood Replacement Fluids: N/A
Sponge Count:
Sharps Count:
Instrument Count:
Counter:
Counts Verified By:
YES
NOT APPLICABLE
SURNURSE,FOUR
SURNURSE,FIVE
Dressing: DSD, PAPER TAPE, MEPORE
Packing: NONE
Blood Loss: 800 ml
Postoperative
Postoperative
Postoperative
Postoperative
Mood:
Consciousness:
Skin Integrity:
Skin Color:
Urine Output: 750 ml
RELAXED
ANESTHETIZED
SUTURED INCISION
N/A
Laser Unit(s): N/A
Sequential Compression Device: NO
April 2004
Surgery V. 3.0 User Manual
145
Cell Saver(s): N/A
Devices: N/A
Nursing Care Comments:
PATIENT STATES HE IS ALLERGIC TO PCN. ALL WRVAMC INTRAOPERATIVE NURSING
STANDARDS WERE MONITORED THROUGHOUT THE PROCEDURE. VANCYMYCIN PASTE WAS
APPLIED TO STERNUM.
145a
Surgery V. 3.0 User Manual
April 2004
(This page included for two-sided copying.)
April 2004
Surgery V. 3.0 User Manual
145b
To electronically sign the report, the user enters a 3 at the Nurse Intraoperative Report functions prompt.
Example: Signing the Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 3
The Nurse Intraoperative Report may only be signed by a circulating nurse on the case. At the
time of electronic signature, the software checks for data in key fields. The nurse will not be able
to sign the report if the following fields are not entered:
TIME PATIENT IN OR
MARKED SITE CONFIRMED
PREOPERATIVE IMAGING CONFIRMED
PROCEDURE TO BE PERFORMED
VALID CONSENT FORM
CORRECT MEDICAL IMPLANTS
APPROPRIATE DVT PROPHYLAXIS
AVAILABILITY OF SPECIAL EQUIP
TIME PATIENT OUT OF OR
CORRECT PATIENT IDENTITY
HAIR REMOVAL METHOD
SITE OF THE PROCEDURE
PATIENT POSITION
ANTIBIOTIC PROPHYLAXIS
BLOOD AVAILABILITY
CHECKLIST COMMENT
If the COUNT VERIFIER field is entered, the other counts related fields must be populated.
These count fields include the following:
SPONGE COUNT CORRECT
INSTRUMENT COUNT CORRECT (Y/N)
SHARPS COUNT CORRECT (Y/N)
SPONGE, SHARPS, & INST COUNTER
If the PROSTHESIS INSTALLED field has an item (or items) entered, the following fields are
required for each item:
IMPLANT STERILITY CHECKED (Y/N)
RN VERIFIER
SERIAL NUMBER
STERILITY EXPIRATION DATE
LOT NUMBER
If any of the key fields are missing, the software will require them to be entered prior to signature. In the
following example, the final sponge count must be entered before the nurse is allowed to electronically
sign the report.
Example: Missing Field Warning
The following information is required before this report may be signed:
ANTIBIOTIC PROPHYLAXIS
CHECKLIST COMMENT
Do you want to enter this information? YES// YES
146
Surgery V. 3.0 User Manual
April 2004
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #267226
SURPATIENT,TEN PAGE 1 OF 6
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
YES
PREOPERATIVE IMAGES CONFIRMED: YES
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS:
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY: SURNURSE,FIVE
Enter Screen Server Function: 10
Appropriate Antibiotic Prophylaxis: Y
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #267226
YES
SURPATIENT,TEN PAGE 1 OF 6
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
YES
PREOPERATIVE IMAGES CONFIRMED: YES
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS: YES
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY: SURNURSE,FIVE
Enter Screen Server Function: ^
If any of the Time Out Verified Utilizing Checklist fields is answered with “NO”, then the user
is prompted to enter information in the CHECKLIST COMMENT field. Entry in the
CHECKLIST COMMENT field is required in such cases where “NO” has been entered before
the user can electronically sign the Nurse Intraoperative Report.
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report electronically
Select number: 2// 3
Sign the report electronically
Enter your Current Signature Code: XXXXXX
SIGNATURE VERIFIED
Press RETURN to continue... <Enter>
April 2004
Surgery V. 3.0 User Manual
When typing the electronic
signature code, no
characters will display on
screen.
147
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
* * The Nurse Intraoperative Report has been electronically signed. * *
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
Select number: 2// ^
Nurse Intraoperative Report - After Electronic Signature
After the report has been signed, any changes to the report will require a signed addendum.
Example: Editing the Signed Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
* * The Nurse Intraoperative Report has been electronically signed. * *
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
Select number: 2// 1
Edit report information
If the Anesthesia Report and/or the Nurse Intraoperative Report is already signed, the following
warning will be displayed. If any data on either signed report is edited, an addendum to the
Anesthesia Report and/or to the Nurse Intraoperative Report will be required.
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12,2004
>>>
WARNING
<<<
Electronically signed reports are associated with this case. Editing
of data that appear on electronically signed reports will require the
creation of addenda to the signed reports.
Enter RETURN to continue or '^' to exit: <Enter>
148
Surgery V. 3.0 User Manual
April 2004
First, the user makes the edits to the desired field.
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #267226
SURPATIENT,TEN PAGE 1 OF 6
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
YES
PREOPERATIVE IMAGES CONFIRMED: YES
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS:
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY: SURNURSE,FOUR
Enter Screen Server Function: 14
Checklist Confirmed By: SURNURSE,FOUR // SURNURSE,FIVE
** NURSE INTRAOP **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CASE #267226
SURPATIENT,TEN PAGE 1 OF 6
CONFIRM PATIENT IDENTITY: YES
PROCEDURE TO BE PERFORMED: YES
SITE OF PROCEDURE:
YES
VALID CONSENT FORM:
YES
CONFIRM PATIENT POSITION: YES
MARKED SITE CONFIRMED:
YES
PREOPERATIVE IMAGES CONFIRMED: YES
CORRECT MEDICAL IMPLANTS: YES
AVAILABILITY OF SPECIAL EQUIP: YES
ANTIBIOTIC PROPHYLAXIS: YES
APPROPRIATE DVT PROPHYLAXIS: YES
BLOOD AVAILABILITY:
YES
CHECKLIST COMMENT:
(WORD PROCESSING)
CHECKLIST CONFIRMED BY: SURNURSE,FIVE
Enter Screen Server Function: ^
An addendum is required before the edit can be made to the signed report.
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
An addendum to each of the following electronically signed document(s) is
required:
Nurse Intraoperative Report - Case #267226
If you choose not to create an addendum, the original data will be restored
to the modified fields appearing on the signed reports.
Create addendum? YES//
<Enter>
Addendum for Case #267226 - JUL 12,2004
Patient: SURPATIENT,TEN (000-12-3456)
-------------------------------------------------------------------------------The Checklist Confirmed By field was changed
from SURNURSE,FOUR
to SURNURSE,FIVE
Enter RETURN to continue or '^' to exit: <Enter>
Before the addendum is signed, comments may be added.
April 2004
Surgery V. 3.0 User Manual
149
Example: Signing the Addendum
Comment: OPERATION END TIME WAS CORRECTED.
Addendum for Case #267226 - JUL 12,2004
Patient: SURPATIENT,TEN (000-12-3456)
-------------------------------------------------------------------------------The Checklist Confirmed By field was changed
from SURNURSE,FOUR
to SURNURSE,FIVE
Addendum Comment: OPERATION END TIME WAS CORRECTED.
Enter RETURN to continue or '^' to exit:
Enter your Current Signature Code: XXXXXX
SIGNATURE VERIFIED..
Press RETURN to continue... <Enter>
When typing the electronic
signature code, no
characters will display on
screen.
Example: Printing the Nurse Intraoperative Report
SURPATIENT,TEN (000-12-3456)
Case #267226 - JUL 12, 2004
* * The Nurse Intraoperative Report has been electronically signed. * *
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
Select number: 2// 2
Print/View report from beginning
Do you want WORK copies or CHART copies? WORK// <Enter>
DEVICE: HOME//
[Select Print Device]
----------------------------------------------------------printout follows-----------------------------------------------
150
Surgery V. 3.0 User Manual
April 2004
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
NURSE INTRAOPERATIVE REPORT
-------------------------------------------------------------------------------NOTE DATED: 07/12/2004 08:00 NURSE INTRAOPERATIVE REPORT
SUBJECT: Case #: 267226
Operating Room:
BO OR1
Patient in Hold: JUL 12, 2004
Operation Begin: JUL 12, 2004
Surgeon in OR:
JUL 12, 2004
Surgical Priority: ELECTIVE
07:30
08:58
07:55
Patient in OR: JUL 12, 2004
Operation End: JUL 12, 2004
Patient Out OR: JUL 12, 2004
08:00
12:30
12:45
Major Operations Performed:
Primary: MVR
Wound Classification: CONTAMINATED
Operation Disposition: SICU
Discharged Via: ICU BED
Surgeon: SURSURGEON,THREE
Attend Surg: SURSURGEON,THREE
Anesthetist: SURANESTHETIST,SEVEN
First Assist: SURSURGEON,FOUR
Second Assist: N/A
Assistant Anesth: N/A
Other Scrubbed Assistants: N/A
OR Support Personnel:
Scrubbed
SURNURSE,ONE (FULLY TRAINED)
Circulating
SURNURSE,FIVE (FULLY TRAINED)
SURNURSE,FOUR (FULLY TRAINED)
Other Persons in OR: N/A
Preop Mood:
ANXIOUS
Preop Consc:
ALERT-ORIENTED
Preop Skin Integ: INTACT
Preop Converse: N/A
Confirm Correct Patient Identity: YES
Confirm Procedure to be Performed: YES
Confirm Site of the Procedure, including laterality: YES
Confirm Valid Consent Form: YES
Confirm Patient Position: YES
Confirm Proc. Site has been Marked Appropriately and that the Site of the
Mark is Visible After Prep and Draping: YES
Pertinent Medical Images have been Confirmed: YES
Correct Medical Implant(s) Is Available: YES
Availability of Special Equipment: YES
Appropriate Antibiotic Prophylaxis: YES
Appropriate Deep Vein Thrombosis Prophylaxis: YES
Blood Availability: YES
Checklist Comment: NO COMMENTS ENTERED
Checklist Confirmed By: SURNURSE,FOUR
Skin Prep By: SURNURSE,FOUR
Skin Prep By (2): SURNURSE,FIVE
Skin Prep Agent: BETADINE SCRUB
2nd Skin Prep Agent: POVIDONE IODINE
Preop Surgical Site Hair Removal by: SURNURSE,FIVE
Surgical Site Hair Removal Method: OTHER
Hair Removal Comments: SHAVING AND DEPILATORY COMBINATION USED.
Surgery Position(s):
SUPINE
Restraints and Position Aids:
SAFETY STRAP
ARMBOARD
FOAM PADS
KODEL PAD
STIRRUPS
Placed: N/A
Applied
Applied
Applied
Applied
Applied
By:
By:
By:
By:
By:
N/A
N/A
N/A
N/A
N/A
Flash Sterilization Episodes:
April 2004
Surgery V. 3.0 User Manual
151
Contamination:
0
SPD Processing/OR Management Issues: 0
Emergency Case:
0
No Better Option:
0
Loaner or Short Notice Instrument:
0
Decontamination of Instruments Not for Use In Patient: 0
Electrocautery Unit:
ESU Coagulation Range:
ESU Cutting Range:
Electroground Position(s):
8845,5512
50-35
35-35
RIGHT BUTTOCK
LEFT BUTTOCK
Material Sent to Laboratory for Analysis:
Specimens:
1. MITRAL VALVE
Cultures: N/A
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Tubes and Drains:
#16FOLEY, #18NGTUBE, #36 &2 #32RA CHEST TUBES
Tourniquet: N/A
Thermal Unit: N/A
Prosthesis Installed:
Item: MITRAL VALVE
Implant Sterility Checked (Y/N): YES
Sterility Expiration Date: DEC 15, 2004
RN Verifier: SURNURSE,ONE
Vendor: BAXTER EDWARDS
Model: 6900
Lot Number: T87-12321
Serial Number: 945673WRU
Sterile Resp: SPD
Size: LG
Quantity: 2
Medications: N/A
Irrigation Solution(s):
HEPARINIZED SALINE
NORMAL SALINE
COLD SALINE
Blood Replacement Fluids: N/A
Sponge Count:
Sharps Count:
Instrument Count:
Counter:
Counts Verified By:
YES
YES
NOT APPLICABLE
SURNURSE,FOUR
SURNURSE,FIVE
Dressing: DSD, PAPER TAPE, MEPORE
Packing: NONE
Blood Loss: 800 ml
Postoperative
Postoperative
Postoperative
Postoperative
Mood:
Consciousness:
Skin Integrity:
Skin Color:
Urine Output: 750 ml
RELAXED
ANESTHETIZED
SUTURED INCISION
N/A
Laser Unit(s): N/A
Sequential Compression Device: NO
Cell Saver(s): N/A
Devices: N/A
Nursing Care Comments:
152
Surgery V. 3.0 User Manual
April 2004
PATIENT STATES HE IS ALLERGIC TO PCN. ALL WRVAMC INTRAOPERATIVE NURSING
STANDARDS WERE MONITORED THROUGHOUT THE PROCEDURE. VANCYMYCIN PASTE WAS
APPLIED TO STERNUM.
07/17/2004 16:42
Signed by: /es/ FIVE SURNURSE
07/13/2004 10:41
ADDENDUM
The Checklist Confirmed By field was changed
from SURNURSE,FOUR to SURNURSE,FIVE
Addendum Comment: OPERATION END TIME WAS CORRECTED.
Signed by: /es/ FIVE SURNURSE
07/17/2004 16:42
April 2004
Surgery V. 3.0 User Manual
152a
(This page included for two-sided copying.)
152b
Surgery V. 3.0 User Manual
April 2004
Tissue Examination Report
[SROTRPT]
The Tissue Examination Report option is used to generate the Tissue Examination Report that contains
information about cultures and specimens sent to the laboratory.
This report prints in an 80-column format and can be viewed on the screen.
Example: Tissue Examination Report
Select Operation Menu Option: T Tissue Examination Report
DEVICE: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------------------------------------------------------------------------------------MEDICAL RECORD
|
TISSUE EXAMINATION
-------------------------------------------------------------------------------Specimen Submitted By:
Obtained: MAR 09, 1999
OR1, SURGERY CASE # 187
-------------------------------------------------------------------------------Specimen(s):
-------------------------------------------------------------------------------Brief Clinical History:
Subscapular pain for 3 days. Nausea and vomiting.
Increased serum amylase.
-------------------------------------------------------------------------------Operative Procedure(s):
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
-------------------------------------------------------------------------------Preoperative Diagnosis:
CHOLECYSTITIS
-------------------------------------------------------------------------------Operative Findings:
THE GALLBLADDER HAD A FEW ADHESIONS EASILY REMOVED
AND WAS FOUND TO BE FIRMLY DISTENDED WITH STONES.
-------------------------------------------------------------------------------Postoperative Diagnosis:
Signature and Title
CHOLECYSTITIS
SURSURGEON,TWO
-------------------------------------------------------------------------------Attending Surgeon: SURSURGEON,ONE
-------------------------------------------------------------------------------PATHOLOGY REPORT
-------------------------------------------------------------------------------Name of Laboratory
Accession Number(s)
-------------------------------------------------------------------------------Gross Description, Histologic Examination and Diagnosis
(Continue on reverse side)
-------------------------------------------------------------------------------PATHOLOGIST'S SIGNATURE
DATE:
-------------------------------------------------------------------------------SURPATIENT,NINE
AGE: 48
SEX: MALE
ID # 000-34-5555
ETHNICITY: NOT HISPANIC
REGISTER NO.
RACE: WHITE, ASIAN
WARD:
ROOM-BED:
-------------------------------------------------------------------------------VAMC: MAYBERRY, NC
REPLACEMENT FORM 515
April 2004
Surgery V. 3.0 User Manual
153
Enter Referring Physician Information
[SROMEN-REFER]
The Enter Referring Physician Information option allows the surgical staff to enter the name, address, and
phone number of the individual or institution that referred the patient. The scheduling manager usually
enters referring physician information when the operation is booked. This information shows up on many
reports.
First, users identify the surgical specialty to which the patient will be assigned. To add a new case to the
waiting list, the user must enter the patient‟s name and the procedure name. The user can also add
comments, referring physician name and address, tentative admission date, and tentative operation date.
This information will appear on the Waiting List Report. Patient names stay on the waiting list until the
data is used to make a request or until the data is deleted.
After entering a Referring Physician name or partial name, the system prompts, "Is this a VA Physician
from this facility? (Y/N): <Y>". If the user answers Y, a list of VA physician names displays that
matches the data entered. The user selects from those listed. The physician‟s address and telephone
number are also copied into the corresponding fields if the data is available. If no selection is made, the
system accepts the information entered as free text.
If the referring physician is not from that VA facility, then the system uses the information already
entered as the Referring Physician name, or the user can enter the appropriate name.
Example: Enter Referring Physician Information
Select Operation Menu Option: R
Enter Referring Physician Information
Select REFERRING PHYSICIAN: SURPHYSICIAN,ONE
Is this a VA physician from this facility? (Y/N): Y
Lookup: NAME
2 SURPHYSICIAN,O
OJ
112
SURGICAL STUDENT
3 SURPHYSICIAN,S
4 SURPHYSICIAN,S A
5 SURPHYSICIAN,S T
6 SURPHYSICIAN,T
Press <RETURN> to see more, ‘^’ to exit this list, ‘^^’ to exit all lists, OR
CHOOSE 1-5:
154
Surgery V. 3.0 User Manual
April 2004
Enter Irrigations and Restraints
[SROMEN-REST]
The Enter Irrigations and Restraints option is designed to allow the nurse to quickly document the
irrigation solutions or the restraint and positioning devices used in a case. The list of solutions or devices
can be different at each facility.
At the "Select Number:" prompt, the user should choose the number corresponding to the solution or
device. For more than one choice, numbers are separated with a comma. If an item has been selected
before, a default prompt will appear. The user can enter an at-sign (@) to delete the selection, as in
Example 3.
Example 1: Entering Irrigations
Select Operation Menu Option: RP
Enter Irrigations or Restraints
Enter/Edit Irrigations or Restraints and Positioning Aids:
1. Irrigations
2. Restraints and Positioning Aids
Select Number: 1
IRRIGATION SOLUTIONS
================================================================
1.
3.
5.
7.
9.
11.
13.
15.
AEROSP/PXYN
BETADINE SOLUTION
HEPARINIZED SALINE
KANTREX SOLUTION
NEOMYCIN
NORMAL SALINE
SORBITAL
VEIN GRAFT SOLUTION
2.
4.
6.
8.
10.
12.
14.
16.
BACITRACIN SOLUTION
HEPARIN
ICED SALINE
KEFLEX SOLUTION
NEOMYCIN SOLUTION
POVODINE
STERILE WATER
THROMBIN
Select the number(s) corresponding to your choice: 2,15
Entering BACITRACIN SOLUTION ...
Entering VEIN GRAFT SOLUTION ...
Press <Enter> to continue
<Enter>
Example 2: Restraints and Positioning Aids
Select Operation Menu Option: RP
Enter Irrigations or Restraints
Enter/Edit Irrigations or Restraints and Positioning Aids:
1. Irrigations
2. Restraints and Positioning Aids
Select Number: 2
April 2004
Surgery V. 3.0 User Manual
155
Restraints and Positioning Aids
========================================================================
1.
ARMSHEET
2.
SAFETY STRAP
3.
ARMBOARD
4.
VAC PAC
5.
FOAM PADS
6.
PILLOW
7.
AXILLARY ROLL
8.
ADHESIVE TAPE
9.
SURGERY ARMBOARD
10.
KIDNEY REST
11.
SANDBAG
12.
OVERHEAD ARMREST
13.
ROLLED SHEET
14.
LEG HOLDER
15.
FOOT EXTENSION
16.
STIRRUPS
17.
FRACTURE TABLE
18.
OTHER
Select the number(s) corresponding to your choice: 3,6,9
Entering ARMBOARD ...
Entering PILLOW ...
Entering SURGERY ARMBOARD ...
Press <Enter> to continue
<Enter>
Example 3: Deleting Restraints and Positioning Aids
Select Operation Menu Option: RP
Enter Irrigations or Restraints
Enter/Edit Irrigations or Restraints and Positioning Aids:
1. Irrigations
2. Restraints and Positioning Aids
Select Number: 2
Restraints and Positioning Aids
========================================================================
1.
ARMSHEET
2.
SAFETY STRAP
3.
ARMBOARD
4.
VAC PAC
5.
FOAM PADS
6.
PILLOW
7.
AXILLARY ROLL
8.
ADHESIVE TAPE
9.
SURGERY ARMBOARD
10.
KIDNEY REST
11.
SANDBAG
12.
OVERHEAD ARMREST
13.
ROLLED SHEET
14.
LEG HOLDER
15.
FOOT EXTENSION
16.
STIRRUPS
17.
FRACTURE TABLE
18.
OTHER
Select the number(s) corresponding to your choice: 3
Entering ARMBOARD ...
RESTR & POSITION AIDS: ARMBOARD// @
SURE YOU WANT TO DELETE THE ENTIRE RESTR & POSITION AIDS? Y
(YES)
Press <Enter> to continue
156
Surgery V. 3.0 User Manual
April 2004
Medications (Enter/Edit)
[SROANES MED]
The Medications (Enter/Edit) option allows the user to enter all the medications administered on a case. It
is designed to aid in quickly entering many different medications for a case.
In one entry, the user can enter the medication, dosage, route, and time given with the use of slashes
between these categories. After one medication has been entered, the software will return the cursor to the
beginning prompt so that the user can enter another medication for the case. When the user is finished
entering medications for the case, he or she should press the <Enter> key to return to the menu.
About the prompts
"ENTER MEDICATION/DOSE(MG)/ROUTE/TIME:" Respond to this prompt with the medication,
dosage, route, and time given separated by slashes. If the software needs more specific information about
the medication, the user will be prompted. In the example below, the software reads "Valium" and then
asks the user to select from the Valiums on file. A question mark can be entered in place of one of the
categories in order to get help or more information. In the example, a question mark was entered in place
of the route. Then, in response to the question mark, the software offered a list of acceptable routes.
Example: Entering Medication
Select Operation Menu Option: Medications (Enter/Edit)
ENTER MEDICATION/DOSE(MG)/ROUTE/TIME: DIAZEPAM/5MG/?/8:00
1
2
3
4
5
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
10MG S.R. CAP
10MG S.T.
15 MG S.R. CAP
2MG S.T.
5MG S.T.
N/F
***NOT MANUFACTURED***
NOTE RESTRICTIONS (ON OPTS ONLY)
N/F
NOTE RESTRICTIONS
N/F
NOTE RESTRICTIONS (ON OPTS ONLY)
Press <RETURN> to see more, '^' to exit this list, OR
CHOOSE 1-5: 5
Route entered is not one of the available choices.
Please enter medication route again.
Choose from:
IV
INTRAVENOUS
T
TOPICAL
IR
IRRIGATION
IM
INTRAMUSCULAR
R
RECTAL
S
SUBLINGUAL
SC
SUBCUTANEOUS
IN
INFILTRATE
O
OTHER
P
PREPUMP
OR
ORAL
Enter ROUTE: IV
INTRAVENOUS
MEDICATION ENTERED ....
ENTER MEDICATION/DOSE(MG)/ROUTE/TIME:
April 2004
Surgery V. 3.0 User Manual
157
Blood Product Verification
[SR BLOOD PRODUCT VERIFICATION]
The Blood Product Verification option is used for transfusion error risk management. This option is used
in conjunction with a bar code reader to confirm that the blood product is assigned to the patient. The
functionality provided by this option is meant as an additional check for proper patient identification and
should never be relied upon as the primary check.
This option prompts the user to scan the blood product unit ID, after which the software checks the Blood
Bank files for an association with the patient identified. If there are multiple entries with the unit ID
scanned, these entries will be listed along with the Blood Component, Patient Associated, and Expiration
Date. The user will then be prompted to select the one that matches the blood product about to be
administered. If the selected product is not associated with the patient identified, a warning message will
be displayed.
There are certain valid scenarios that are internal to the Blood Bank that may result in a blood component
not being readable using the scanner and therefore may give an unexpected response. There will be some
rare instances in which this option may not produce an expected result. After verifying proper patient
identification, the option may be attempted again; however, it is recommended that the unit ID be typed in
manually rather than be scanned in these cases.
Blood product manufacturers are required to label all units of blood in a consistent manner. The barcode
that is to be scanned at the "Enter Blood Product Identifier:" prompt will always be the barcode in the
upper-left portion of the blood product label. Since this label can be in close proximity to the ABO/Rh
label, care should be taken not to read both labels during a scan. One way to accomplish this would be to
use a finger or some other convenient object to cover the label that the user does not wish to have read
during the scanning process. The light emitted from the scanner itself will cause no harm to skin, latex, or
any other object with which it comes in contact.
Example: Option displayed with no discrepancies
Select Operation Menu Option: BLOOD PRODUCT VERIFICATION
To use BAR CODE READER
Pass reader wand over a GROUP-TYPE ( ABO/Rh) label
=>
Enter Blood Product Identifier: KW10945
1) Unit ID: KW10945
CPDA-1 RED BLOOD CELLS
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: NOV 27,1997
2) Unit ID: KW10945
FRESH FROZEN PLASMA, ACD-A
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: MAY 19,1998
3) Unit ID: KW10945
PLATELETS, POOLED, IRRADIATED
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: MAR 24,1998
Select the blood product matching the unit label: (1-3): 2
No Discrepancies Found
158
Surgery V. 3.0 User Manual
April 2004
Example: Option displayed with discrepancies
Select Operation Menu Option: BLOOD PRODUCT VERIFICATION
To use BAR CODE READER
Pass reader wand over a GROUP-TYPE ( ABO/Rh) label
=>
Enter Blood Product Identifier: KW10945
1) Unit ID: KW10945
CPDA-1 RED BLOOD CELLS
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: NOV 27,1997
2) Unit ID: KW10945
FRESH FROZEN PLASMA, ACD-A
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: MAY 19,1998
3) Unit ID: KW10945
PLATELETS, POOLED, IRRADIATED
Patient: SURPATIENT,FOURTEEN 000-45-7212
Expiration Date: MAR 24,1998
Select the blood product matching the unit label: (1-3): 3
**WARNING**
Blood Product Expiration Date is later than today's date.
April 2004
Surgery V. 3.0 User Manual
159
Anesthesia Menu
[SROANES1]
The Anesthesia Menu is restricted to Anesthesia personnel and is locked with the SROANES
key. It is designed for the convenient entry of data pertaining to the anesthesia agents and
techniques used in a surgery.
The main options included in this menu are listed below. The Anesthesia Data Entry Menu contains suboptions. To the left of the option name is the shortcut synonym the user can enter to select the option.
Shortcut
E
R
S
Option Name
Anesthesia Data Entry Menu
Anesthesia Report
Schedule Anesthesia Personnel
Prerequisites
To use the Anesthesia Data Entry Menu or the Anesthesia Report option, the user must first select a
patient case. The user must select an operating room to use the Schedule Anesthesia Personnel option.
160
Surgery V. 3.0 User Manual
April 2004
Anesthesia Data Entry Menu
[SROANES-D]
The Anesthesia Data Entry Menu allows the user to enter anesthesia data pertinent to a selected case. The
information entered in these sub-options is reflected on the Anesthesia Report.
To use any option within the Anesthesia Data Entry Menu, the user must first enter a patient name and
choose a patient case, as shown below.
Example: How to Select a Case for the Data Entry Menu
Select Surgery Menu Option:
E
R
A
S
A
Anesthesia Menu
Anesthesia Data Entry Menu
Anesthesia Report
Anesthesia AMIS
Schedule Anesthesia Personnel
Select Anesthesia Menu Option: E
Select Patient: SURPATIENT,NINE
SURPATIENT,NINE
Anesthesia Data Entry Menu
12-09-51
000345555
NSC VETERAN
000-34-5555
1. 04-26-99
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM (COMPLETED)
2. 11-20-98
Release of Hammer Toes (REQUESTED)
3. ENTER NEW SURGICAL CASE
Select Operation: 1
SURPATIENT,NINE (000-34-5555)
I
T
M
Case #145 – APR 26,1999
Anesthesia Information (Enter/Edit)
Anesthesia Technique (Enter/Edit)
Medications (Enter/Edit)
Select Anesthesia Data Entry Menu Option:
April 2004
Surgery V. 3.0 User Manual
161
Anesthesia Information (Enter/Edit)
[SROMEN-ANES]
Anesthesia staff uses this option to enter anesthesia related information for a given case. The first group
of prompts affects the Anesthesia AMIS Report. Some of the data fields may be automatically filled in
from previous responses.
At the "Enter Screen Server Function:" prompt, the user can choose the field(s) to be edited, or press the
<Enter> key to continue. Some of the data fields are "multiple" and may contain more than one value.
When a multiple field is selected, a new screen is generated so that the user can enter data related to that
multiple. For instance, the MONITORS field generates a new screen for adding the device, time installed,
and time removed. The TIME INSTALLED field and TIME REMOVED field generate additional screens
so that the user may enter more than one time installed/removed for the same operation.
About the prompts
The prompts are described as follows:
"Is this the Principal Technique (Y/N): " — Asks if the user has entered a technique that is the
primary anesthesia technique for the case. The user should always establish the principal
technique as this information affects many reports.
"Would you like to enter additional anesthesia related information ? " — If the user wants to enter
more detailed information concerning the case, he or she must answer YES to this prompt. Two
Screen Server-formatted pages are then provided for entering more anesthesia information for the
case.
"Does this entry complete all start and end times for this case? "— The user should answer YES
only if the block of time just completed is the final block of time for the case that he or she is
documenting.
An Anesthesia Care Questionnaire will be added to allow a more complete capture of clinical data, which
will support coding and billing efforts. The results of the questionnaire are crucial for a coder to use in
order to select the proper modifier. Modifiers are required for reimbursement for all anesthesia services.
This information can be accessed through the Anesthesia menu, specifically through the Anesthesia Data
Entry Menu. The user selects a patient and surgical case and completes the anesthesia information.
After completion, the user is prompted with the question, "Would you like to enter additional anesthesia
related information? " The questions associated with the Anesthesia Care Questionnaire (shown as
numbers 8-12 on the last screen display in this section) are located on page two of the anesthesia
information sheet.
162
Surgery V. 3.0 User Manual
April 2004
Example: Entering Anesthesia Information
Select Anesthesia Data Entry Menu Option: I
Anesthesia Information (Enter/Edit)
The following information is required for the Anesthesia AMIS.
Principal Anesthetist: SURANESTHETIST,THREE// <Enter>
Select ANESTHESIA TECHNIQUE: G (G
GENERAL)
Is this the Principal Technique (Y/N): YES// <Enter>
Was the Patient Intubated ? (Y/N): Y YES
Trauma Resulting from Intubation Process: NONE// <Enter>
Select ANESTHESIA AGENTS: ENFLURANE
N/F
Dose (mg): 125
Diagnostic/Therapeutic (Y/N): NO// <Enter>
ASA Class: 2
2-MILD DISTURB.
Mallampati Scale:
Mandibular Space (length in mm):
Would you like to enter additional anesthesia related information ? NO//Y
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #145
SURPATIENT,NINE PAGE 1 OF 2
ANESTHESIOLOGIST SUPVR:
ANES SUPERVISE CODE:
PRINC ANESTHETIST:
SURANESTHETIST,THREE
RELIEF ANESTHETIST:
ASST ANESTHETIST:
ANES CARE TIME BLOCK: (MULTIPLE)
INDUCTION COMPLETE:
ASA CLASS:
2-MILD DISTURB.
BLOOD LOSS (ML):
200
MIN INTRAOP TEMPERATURE (C):
FINAL ANESTHESIA TEMP (C):
TOTAL URINE OUTPUT (ML): 1
OP DISPOSITION:
PACU (RECOVERY ROOM)
POSTOP ANES NOTE:
ORAL-PHARYNGEAL SCORE: CLASS 2
Enter Screen Server Function: 6
** ANESTHESIA INFO **
CASE #145
ANES CARE TIME BLOCK
1
SURPATIENT,NINE
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select ANES CARE TIME BLOCK ANES CARE MULTIPLE START TIME: 4/[email protected]:20
ANES CARE TIME BLOCK ANES CARE MULTIPLE START TIME: APR 26, [email protected]:20
//
** ANESTHESIA INFO **
CASE #145 SURPATIENT,NINE
ANES CARE TIME BLOCK (3030426.092)
1
2
PAGE 1 OF 1
ANES CARE MULTIPLE START TIME: APR 26, 1999 AT 09:20
ANES CARE MULTIPLE END TIME:
Enter Screen Server Function: 2
Anesthesia Care Multiple End Time: 4/[email protected]:45
(APR 26, [email protected]:45)
Does this entry complete all start and end times for this case?
** ANESTHESIA INFO **
CASE #145 SURPATIENT,NINE
ANES CARE TIME BLOCK (3030426.092)
1
2
(Y/N)//
Y
PAGE 1 OF 1
ANES CARE MULTIPLE START TIME: APR 26, 1999 AT 09:20
ANES CARE MULTIPLE END TIME: APR 26, 1999 AT 12:45
Enter Screen Server Function:
April 2004
<Enter>
Surgery V. 3.0 User Manual
163
** ANESTHESIA INFO **
CASE #145
ANES CARE TIME BLOCK
1
2
SURPATIENT,NINE
PAGE 1 OF 1
ANES CARE MULTIPLE START TIME: APR 26, 2003 AT 09:20
NEW ENTRY
Enter Screen Server Function:
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
<Enter>
CASE #145
SURPATIENT,NINE PAGE 1 OF 2
ANESTHESIOLOGIST SUPVR:
ANES SUPERVISE CODE:
PRINC ANESTHETIST:
SURANESTHETIST, THREE
RELIEF ANESTHETIST:
ASST ANESTHETIST:
ANES CARE TIME BLOCK: (MULTIPLE) (DATA)
INDUCTION COMPLETE:
ASA CLASS:
2-MILD DISTURB.
BLOOD LOSS (ML):
200
MIN INTRAOP TEMPERATURE (C):
FINAL ANESTHESIA TEMP (C):
TOTAL URINE OUTPUT (ML): 1
OP DISPOSITION:
PACU (RECOVERY ROOM)
POSTOP ANES NOTE:
ORAL-PHARYNGEAL SCORE: CLASS 2
Enter Screen Server Function: 9:12
Intraoperative Blood Loss (ml): 200// 500
Lowest Intraoperative Temperature (C): 28
Final Anesthesia Temperature (C): 37
Total Urine Output (ml): 1// 1800
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #145
SURPATIENT,NINE
PAGE 1 OF 2
ANESTHESIOLOGIST SUPVR:
ANES SUPERVISE CODE:
PRINC ANESTHETIST:
SURANESTHETIST, THREE
RELIEF ANESTHETIST:
ASST ANESTHETIST:
ANES CARE TIME BLOCK: (MULTIPLE)(DATA)
INDUCTION COMPLETE:
ASA CLASS:
2-MILD DISTURB.
BLOOD LOSS (ML):
500
MIN INTRAOP TEMPERATURE (C): 28
FINAL ANESTHESIA TEMP (C): 37
TOTAL URINE OUTPUT (ML): 1800
OP DISPOSITION:
PACU (RECOVERY ROOM)
POSTOP ANES NOTE:
ORAL-PHARYNGEAL SCORE: CLASS 2
Enter Screen Server Function: <Enter>
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
CASE #145
PAGE 2 OF 2
MANDIBULAR SPACE:
80
REPLACEMENT FLUID TYPE: (MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)(DATA)
MONITORS:
(MULTIPLE)
GENERAL COMMENTS:
(WORD PROCESSING)
THERMAL UNIT:
(MULTIPLE)(DATA)
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
ANES PERSONALLY PERFORMED:
NUM OF CONCURRENT ANES CASES:
ANES CONCURRENT CASES: (MULTIPLE)
ANES MEDICALLY DIRECTED:
ANES PHYSICIAN AVAILABLE:
Enter Screen Server Function:
164
SURPATIENT,NINE
4
Surgery V. 3.0 User Manual
April 2004
** ANESTHESIA INFO **
MONITORS
1
CASE #145
PAGE 1
NEW ENTRY
Enter Screen Server Function:
Select MONITORS: ECG
MONITORS: ECG// <Enter>
1
2
3
4
SURPATIENT,NINE
** ANESTHESIA INFO **
MONITORS (ECG)
MONITORS:
TIME INSTALLED:
TIME REMOVED:
APPLIED BY:
1
CASE #145
SURPATIENT,NINE
PAGE 1
ECG
Enter Screen Server Function: 2:4
Time Applied: 4/[email protected]:20 (APR 26, [email protected]:20)
Time Removed: 4/[email protected]:45 (APR 26, [email protected]:45)
Person Applying the Monitor: SURNURSE,ONE
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
CASE #145
SURPATIENT,NINE
PAGE 2 OF 2
MANDIBULAR SPACE:
80
REPLACEMENT FLUID TYPE: (MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)(DATA)
MONITORS:
(MULTIPLE)(DATA)
GENERAL COMMENTS:
(WORD PROCESSING)
THERMAL UNIT:
(MULTIPLE)(DATA)
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
ANES PERSONALLY PERFORMED:
NUM OF CONCURRENT ANES CASES:
ANES CONCURRENT CASES: (MULTIPLE)
ANES MEDICALLY DIRECTED:
ANES PHYSICIAN AVAILABLE:
Enter Screen Server Function: 8:12
Anesthesiologist Personally Performed: NO NO
Number Of Concurrent Anesthesiology Cases: <Enter>
Anesthesiologist Medically Directed: Y YES
Teaching Physician Present: Y YES
** ANESTHESIA INFO **
CASE #145
SURPATIENT,NINE
PAGE 1
ANES CONCURRENT CASES
1
NEW ENTRY
Enter Screen Server Function: <Enter>
** ANESTHESIA INFO **
1
2
3
4
5
6
7
8
9
10
11
12
CASE #145
SURPATIENT,NINE
PAGE 2 OF 2
MANDIBULAR SPACE:
80
REPLACEMENT FLUID TYPE: (MULTIPLE)(DATA)
MEDICATIONS:
(MULTIPLE)(DATA)
MONITORS:
(MULTIPLE)(DATA)
GENERAL COMMENTS:
(WORD PROCESSING)
THERMAL UNIT:
(MULTIPLE)(DATA)
ANESTHESIA TECHNIQUE: (MULTIPLE)(DATA)
ANES PERSONALLY PERFORMED: NO
NUM OF CONCURRENT ANES CASES:
ANES CONCURRENT CASES: (MULTIPLE)
ANES MEDICALLY DIRECTED: NO
ANES PHYSICIAN AVAILABLE: YES
Enter Screen Server Function: <Enter>
April 2004
Surgery V. 3.0 User Manual
164a
(This page included for two-sided copying.)
164b
Surgery V. 3.0 User Manual
April 2004
Anesthesia Technique (Enter/Edit)
[SROMEN-ANES TECH]
The Anesthesia Technique (Enter/Edit) option is used to enter information concerning the anesthesia
technique. More than one anesthesia technique can be entered for a case. When the user is finished
entering the first technique, he or she should select this option again to start entering another anesthesia
technique.
The Surgery software recognizes the following anesthesia techniques, each with different sets of prompts.
G
M
S
E
O
L
R
GENERAL
MONITORED ANESTHESIA CARE
SPINAL
EPIDURAL
OTHER
LOCAL
REGIONAL
Another choice for an anesthesia technique is NO ANESTHESIA. This selection does not include any
additional prompts.
About the prompts
"Diagnostic/ Therapeutic (Y/N):" The user should answer Y or YES if the anesthesia procedure is itself a
surgical procedure. The user will then have an opportunity to define the surgical (operative) procedure.
"Is this the Principal Technique (Y/N):" This prompt asks the user whether or not the technique being
entered is the primary anesthesia technique for the case. For the technique being entered to appear on the
Anesthesia AMIS Report, answer this prompt with a Y or YES.
"Select ANESTHESIA AGENTS:" The user can enter more than one anesthesia agent for a case by using
the up-arrow (^) to jump to the "Select ANESTHESIA AGENTS:" prompt.
April 2004
Surgery V. 3.0 User Manual
165
Example 1: General Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: G (GENERAL)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): Y YES
Trauma Resulting from Intubation Process: NONE//
<Enter> NONE
Select ANESTHESIA AGENTS: ?
More than one anesthesia agent may be entered for each technique.
The ANESTHESIA AGENT field uses entries from the institution's local DRUG file. Prior to
using the Surgery package, drugs that will be used as anesthesia agents must be flagged (using
the Chief of Surgery Menu) by the user's package coordinator. If the user experiences problems
entering an agent, it is likely that the drug being chosen has not been flagged.
Select ANESTHESIA AGENTS: ENFLURANE
Dose (mg): <Enter>
Approach Technique: D DIRECT VISION LARYNGOSCOPY
Endotracheal Tube Route: O ORAL
Type of Laryngoscope: M MACINTOSH
Laryngoscope Size: 3
Was a Stylet Used ? (Y/N): Y YES
Was Topical Lidocaine Used ? (Y/N): Y YES
Was Intravenous Lidocaine Administered ? (Y/N): N NO
Type of Endotracheal Tube: P PVC LOW PRESSURE
Endotracheal Tube Size: 3
Location where the Endotracheal Tube was Removed: O OR
Who Removed the Endotracheal Tube ?: SURANESTHETIST,SIX
Was Reintubation Required within 8 Hours ? (Y/N): N NO
Was a Heat and Moisture Exchanger Used ? (Y/N): N NO
Was a Bacterial Filter Used ? (Y/N): N NO
Oral-Pharyngeal (OP) Score: 1 CLASS 1
Mandibular Space (length in mm): 65
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0// No (No Editing)
GENERAL COMMENTS:
1> <Enter>
Example 2: Monitored Anesthesia Care Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: M (MONITORED ANESTHESIA CARE)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: VALIUM
Dose (mg): 5
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//NO
(No Editing)
GENERAL COMMENTS:
1> <Enter>
166
Surgery V. 3.0 User Manual
April 2004
Example 3: Spinal Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: S (SPINAL)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: PONTOCAINE
Dose (mg): 5
Was the Catheter placed for Continuous Administration ? (Y/N): NO
// <Enter>
NO
Baricity: 1// <Enter> HYPERBARIC
Puncture Site: 2 L3-4
Needle Size: 25G 25G
Neurodermatone Anesthesia Sensory Level: T6 T6
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//
(No Editing)
GENERAL COMMENTS:
1><Enter>
Example 4: Epidural Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: E (EPIDURAL)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: LIDOCAINE
Dose (mg): 5
Was the Catheter placed for Continuous Administration ? (Y/N): YES
// <Enter> YES
Puncture Site: 2 L3-4
Dural Puncture ? (Y/N): NO// Y YES
Who Removed the Catheter ?:
213 SURANESTHETIST,SIX
Date/Time that the Catheter was Removed: 5/[email protected]:30 (MAY 04, [email protected]:30)
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//
(No Editing)
GENERAL COMMENTS:
1>LOSS OF RESISTANCE TECHNIQUE
2><Enter>
EDIT Option: <Enter>
Example 5: Other Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: O (OTHER)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: LIDOCAINE
Dose (mg): 5
Select BLOCK SITE: ABDOMINAL WALL
Y4300
ARE YOU ADDING 'ABDOMINAL WALL' AS A NEW BLOCK SITE (THE 1ST FOR THIS ANESTHESIA TECHNIQUE)? Y
(YES)
Length of Needle (cm): 3
Gauge Size of the Needle: 22
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//
(No Editing)
GENERAL COMMENTS:
1> <Enter>
April 2004
Surgery V. 3.0 User Manual
167
Example 6: Local Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO// <Enter>
Select ANESTHESIA TECHNIQUE: L (LOCAL)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: LIDOCAINE
Dose (mg): 5
Select BLOCK SITE: OROPHARYNX
60200
ARE YOU ADDING 'OROPHARYNX' AS A NEW BLOCK SITE (THE 1ST FOR THIS ANESTHESIA TECHNIQUE)? Y
(YES)
Length of Needle (cm): <Enter>
Gauge Size of the Needle: <Enter>
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//
(No Editing)
GENERAL COMMENTS:
1>
Example 7: Regional Technique
Select Anesthesia Data Entry Menu Option: T Anesthesia Technique (Enter/Edit)
Diagnostic/Therapeutic (Y/N): NO//
Select ANESTHESIA TECHNIQUE: LOCAL// R (R
REGIONAL)
Is this the Principal Technique (Y/N): YES// <Enter> YES
Was the Patient Intubated ? (Y/N): N NO
Select ANESTHESIA AGENTS: LIDOCAINE
Dose (mg): 5
Select BLOCK SITE: OROPHARYNX
60200
ARE YOU ADDING 'OROPHARYNX' AS A NEW BLOCK SITE (THE 1ST FOR THIS ANESTHESIA TECHNIQUE)? Y
(YES)
Length of Needle (cm): <Enter>
Gauge Size of the Needle: <Enter>
Oral-Pharyngeal (OP) Score: CLASS 1// <Enter>
Mandibular Space (length in mm): 65// <Enter>
Airway Index: 1. INDEX LESS THAN OR EQUAL TO 0//
(No Editing)
GENERAL COMMENTS:
1>
168
Surgery V. 3.0 User Manual
April 2004
Medications (Enter/Edit)
[SROANES MED]
Anesthesia staff members use the Medications (Enter/Edit) option to enter medications administered on a
case. This is the last sub-option of the Anesthesia Data Entry Menu.
This option is designed to help the user quickly enter many different medications for a case. In one entry,
the user can enter the medication, dosage, route, and time given with the use of slashes between these
categories. (This is a different type of prompt response from what has been used elsewhere). After the
user has finished entering one medication, the software will return the cursor to the beginning prompt so
that he or she can enter another medication for the case. When the user finishes entering medications for
the case, he or she should press the <Enter> key to return to the Anesthesia Data Entry Menu.
About the prompts
"ENTER MEDICATION/DOSE(MG)/ROUTE/TIME:" Respond to this prompt with the medication,
dosage, route, and time given separated by slashes. If the software needs more specific information about
the medication, the user will be prompted. In the example, the software reads "Valium" and then asks the
user to select from the Valiums on file. A question mark can be entered in place of one of the categories
in order to get help or more information. In the following example, a question mark was entered in place
of the route. Then, in response to the question mark, the software offered a list of acceptable routes.
Example: Entering a Medication
Select Anesthesia Data Entry Menu Option: M
Medications (Enter/Edit)
ENTER MEDICATION/DOSE(MG)/ROUTE/TIME: VALIUM/5MG/?/7:50
1
VALIUM 5MG
N/F
2
VALIUM DIAZEPAM 10MG S.T.
ENT/ANESTHESIA/PSYCHIATRY/PARAPLEGICS
3
VALIUM DIAZEPAM 2MG S.T.
ENT/ANESTHESIA/PSYCHIATRY/PARAPLEGICS
TYPE '^' TO STOP, OR
CHOOSE 1-3: 1
(JAN 13, 1999 07:50)
N/F
N/F
RESTRICTED TO
RESTRICTED TO
Route entered is not one of the available choices.
Please enter medication route again.
Choose from:
IV
INTRAVENOUS
T
TOPICAL
IR
IRRIGATION
IM
INTRAMUSCULAR
R
RECTAL
S
SUBLINGUAL
SC
SUBCUTANEOUS
IN
INFILTRATE
O
OTHER
P
PREPUMP
OR
ORAL
ENTER ROUTE: IV
MEDICATION ENTERED ....
ENTER MEDICATION/DOSE(MG)/ROUTE/TIME:
April 2004
Surgery V. 3.0 User Manual
169
Anesthesia Report
[SROARPT]
Anesthesia staff uses the Anesthesia Report option to print all the anesthesia information entered for a
case. When a hard copy of this report is made, space is provided for the Anesthetist's signature. This
option is located on the Anesthesia Menu option. It can also be accessed from the Operation Menu option.
For more information, see the Anesthesia Report section in the Operation Menu section of this manual.
170
Surgery V. 3.0 User Manual
April 2004
Page 171 has been deleted. The Anesthesia AMIS option has been removed.
April 2004
Surgery V. 3.0 User Manual
171
Page 172 has been deleted. The Anesthesia AMIS option has been removed.
172
Surgery V. 3.0 User Manual
April 2004
Schedule Anesthesia Personnel
[SRSCHDA]
Anesthesia staff uses the Schedule Anesthesia Personnel option to assign or change anesthesia personnel
for surgery cases. The Scheduling Manager can also assign personnel to the selected case using other
menu options.
This Schedule Anesthesia Personnel option is locked with the SROANES key and will not
appear on the menu if the user does not have this key.
With this option, the user can enter an anesthesia technique and the names of the principal anesthetist and
supervisor. When an operating room is selected, the software will present all cases scheduled for that
room. After scheduling personnel for cases in one operating room, the user can do the same for other
operating rooms without leaving this option. For convenience, the software will default to the anesthetist
and anesthesiologist supervisor previously scheduled for that room.
Example: Scheduling Anesthesia Personnel
Select Anesthesia Menu Option: S Schedule Anesthesia Personnel
Schedule Anesthesia Personnel for which Date ? 4/26 (APR 26,1999)
Schedule Anesthesia Personnel for which Operating Room ?
OR2
Scheduled Operations for OR2
----------------------------------------------------------------------------Case # 145
Patient: SURPATIENT,NINE
From: 09:00 To: 12:00
CHOLECYSTECTOMY
Requested Anesthesia Technique: GENERAL// <Enter>
Principal Anesthetist: SURANESTHETIST,THREE
TS
Anesthesiologist Supervisor: SURANESTHESIOLOGIST,TWO// <Enter>
Press <Enter> to continue, or '^' to quit
<Enter>
Scheduled Operations for OR2
----------------------------------------------------------------------------Case # 148
Patient: SURPATIENT,THREE
From: 13:00 To: 18:00
SHOULDER ARTHROPLASTY
Requested Anesthesia Technique: GENERAL// <Enter>
Principal Anesthetist: SURANESTHETIST,THREE// <Enter>
Anesthesiologist Supervisor: SURSURGEON,TWO// <Enter>
Press <Enter> to continue, or '^' to quit
TS
DA
<Enter>
Would you like to continue with another operating room ?
YES//
Schedule Anesthesia Personnel for which Operating Room ?
OR3
April 2004
Surgery V. 3.0 User Manual
<Enter>
173
Scheduled Operations for OR3
----------------------------------------------------------------------------Case # 136
Patient: SURPATIENT,FORTY
From: 07:00 To: 10:30
CHOLECYSECTOMY
Requested Anesthesia Technique: GENERAL// <Enter>
Principal Anesthetist: SURSURGEON,ONE
OS
Anesthesiologist Supervisor: SURANESTHESIOLOGIST,TWO //
Press <Enter> to continue, or '^' to quit
<Enter>
<Enter>
Would you like to continue with another operating room ?
YES// Y
Schedule Anesthesia Personnel for which Operating Room ?
OR1
There are no cases scheduled for this operating room.
Press RETURN to continue
<Enter>
Would you like to continue with another operating room ?
174
YES// N
Surgery V. 3.0 User Manual
April 2004
Perioperative Occurrences Menu
[SRO COMPLICATIONS MENU]
Surgeons use options within the Perioperative Occurrences Menu option to enter or edit occurrences that
occur before, during, and/or after a surgical procedure. It is also possible to enter occurrences for a patient
who did not have a surgical procedure performed. The user can enter more than one occurrence per
patient.
This option is locked with the SROCOMP key.
Occurrences will be included on the Chief of Surgery‟s Morbidity & Mortality Reports.
Please review specific institution policy to determine what is considered an occurrence for any
category.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
the user can enter to select the option.
Shortcut
I
P
N
U
M
Option Name
Intraoperative Occurrences (Enter/Edit)
Postoperative Occurrences (Enter/Edit)
Non-Operative Occurrences (Enter/Edit)
Update Status of Returns Within 30 Days
Morbidity & Mortality Reports
Key Vocabulary
The following terms are used in this section.
Term
Definition
Intraoperative Occurrence
Postoperative Occurrence
Non-Operative Occurrence
Occurrence that occurs during the procedure.
Occurrence that occurs after the procedure.
Occurrence that develops before a surgical procedure is performed.
April 2004
Surgery V. 3.0 User Manual
175
Intraoperative Occurrences (Enter/Edit)
[SRO INTRAOP COMP]
The Intraoperative Occurrences (Enter/Edit) option is used to add information about an occurrence that
occurs during the procedure. The user can also use this option to change the information. Occurrence
information will be reflected in the Chief of Surgery‟s Morbidity & Mortality Report.
First, the user should select an operation. The software will then list any occurrences already entered for
that operation. The user may edit a previously entered occurrence or can type the word NEW and press
the <Enter> key to enter a new occurrence.
At the prompt "Enter a New Intraoperative Occurrence:" the user can enter two question marks (??) to get
a list of categories. Be sure to enter a category for all occurrences to satisfy Surgery Central Office
reporting needs.
Example: Entering Intraoperative Occurrences
Select Perioperative Occurrences Menu Option: I
Select Patient: SURPATIENT,FIFTY
SURPATIENT,FIFTY
Intraoperative Occurrences (Enter/Edit)
10-28-45
000459999
000-45-9999
1. 06-30-06
CHOLECYSTECTOMY (COMPLETED)
2. 03-10-07
HEMORRHOIDECTOMY (COMPLETED)
Select Operation: 1
SURPATIENT,FIFTY (000-45-9999)
Case #213
JUN 30,2006
CHOLECYSTECTOMY
-----------------------------------------------------------------------------There are no Intraoperative Occurrences entered for this case.
Enter a New Intraoperative Occurrence: CARDIAC ARREST REQUIRING CPR
Definition Revised (2011): 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.
Patients with AICDs that fire but the patient does not lose
consciousness should be excluded.
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
Press RETURN to continue: <Enter>
176
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,FIFTY (000-45-9999)
Case #213
JUN 30,2006
CHOLECYSTECTOMY
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
-----------------------------------------------------------------------------Select Occurrence Information: 4:5
SURPATIENT,FIFTY (000-45-9999)
-----------------------------------------------------------------------------Type of Treatment Instituted: CPR
Outcome to Date: ?
CHOOSE FROM:
U
UNRESOLVED
I
IMPROVED
D
DEATH
W
WORSE
Outcome to Date: I IMPROVED
SURPATIENT,FIFTY (000-45-9999)
Case #213
JUN 30,2006
CHOLECYSTECTOMY
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
CPR
IMPROVED
-----------------------------------------------------------------------------Select Occurrence Information:
April 2004
Surgery V. 3.0 User Manual
177
Postoperative Occurrences (Enter/Edit)
[SRO POSTOP COMP]
The Postoperative Occurrences (Enter/Edit) option is used to add information about an occurrence that
occurs after the procedure. The user can also utilize this option to change the information. Occurrence
information will be reflected in the Chief of Surgery's Morbidity & Mortality Report.
First, the user selects an operation. The software will then list any occurrences already entered for that
operation. The user can choose to edit a previously entered occurrence or type the word NEW and press
the <Enter> key to enter a new occurrence.
At the prompt "Enter a New Postoperative Complication:" the user can enter two question marks (??) to
get a list of categories. Be sure to enter a category for all occurrences in order to satisfy Surgery Central
Office reporting needs.
Example: Entering a Postoperative Occurrence
Select Perioperative Occurrences Menu Option: P
Select Patient: SURPATIENT,SEVENTEEN
SURPATIENT,SEVENTEEN R.
Postoperative Occurrence (Enter/Edit)
09-13-28
000455119
000-45-5119
1. 04-18-07
CRANIOTOMY (COMPLETED)
2. 03-18-07
REPAIR INCARCERATED INGUINAL HERNIA (COMPLETED)
Select Operation: 2
SURPATIENT,SEVENTEEN (000-45-5119)
Case #202
MAR 18,2007
REPAIR INCARCERATED INGUINAL HERNIA
-----------------------------------------------------------------------------There are no Postoperative Occurrences entered for this case.
Enter a New Postoperative Occurrence: ACUTE RENAL FAILURE
VASQIP Definition (2011):
Indicate if the patient developed new renal failure requiring renal
replacement therapy or experienced an exacerbation of preoperative
renal failure requiring initiation of renal replacement therapy (not on
renal replacement therapy preoperatively) within 30 days
postoperatively. Renal replacement therapy is defined as venous to
venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis
[CVAHD], peritoneal dialysis, hemofiltration, hemodiafiltration or
ultrafiltration.
TIP: If the patient refuses dialysis report as an occurrence because
he/she did require dialysis.
Press RETURN to continue: <Enter>
178
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,SEVENTEEN (000-45-5119)
Case #202
MAR 18,2007
REPAIR INCARCERATED INGUINAL HERNIA
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
ACUTE RENAL FAILURE
ACUTE RENAL FAILURE
-----------------------------------------------------------------------------Select Occurrence Information: 4:6
SURPATIENT,SEVENTEEN (000-45-5119)
Case #202
MAR 18,2007
REPAIR INCARCERATED INGUINAL HERNIA
-----------------------------------------------------------------------------Treatment Instituted: ANTIBIOTICS
Outcome to Date: I IMPROVED
Date/Time the Occurrence was Noted: 3/20
(MAR 20, 2007)
SURPATIENT,SEVENTEEN R. (000-45-5119)
Case #202
MAR 18,2007 REPAIR INCARCERATED INGUINAL HERNIA
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
ACUTE RENAL FAILURE
ACUTE RENAL FAILURE
DIALYSIS
IMPROVED
03/20/07
-----------------------------------------------------------------------------Select Occurrence Information:
April 2004
Surgery V. 3.0 User Manual
179
Non-Operative Occurrence (Enter/Edit)
[SROCOMP]
The Non-Operative Occurrence (Enter/Edit) option is used to enter or edit occurrences that are not related
to surgical procedures. A non-operative occurrence is an occurrence that develops before a surgical
procedure is performed.
At the "Occurrence Category:" prompt, the user can enter two question marks (??) to get a list of
categories. Be sure to enter a category for each occurrence in order to satisfy Surgery Central Office
reporting needs.
Example: Entering a Non-Operative Occurrence
Select Perioperative Occurrences Menu Option: N
Non-Operative Occurrences (Enter/Edit)
NOTE: You are about to enter an occurrence for a patient that has not had an
operation during this admission. If this patient has a surgical procedure
during the current admission, use the option to enter or edit intraoperative
and postoperative occurrences.
Select PATIENT NAME: SURPATIENT,SEVENTEEN
09-13-28
000455119
SURPATIENT,SEVENTEEN
1.
ENTER A NEW NON-OPERATIVE OCCURRENCE
Select Number:
1
Select the Date of Occurrence: 063007 (JUN 30, 2007)
Name of the Surgeon Treating the Complication: SURSURGEON,ONE
Name of the Attending Surgeon: SURSURGEON,TWO
Surgical Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Select NON-OPERATIVE OCCURRENCES: SYSTEMIC SEPSIS
Occurrence Category: SYSTEMIC SEPSIS
Definition Revised (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
180
Surgery V. 3.0 User Manual
April 2004
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.
Treatment Instituted: ANTIBIOTICS
Outcome to Date: U UNRESOLVED
Occurrence Comments:
1>Cancel scheduled surgery for this week. Reschedule later.
2><Enter>
EDIT Option: <Enter>
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
180a
(This page included for two-sided copying.)
180b
Surgery V. 3.0 User Manual
April 2004
Update Status of Returns Within 30 Days
[SRO UPDATE RETURNS]
The Update Status of Returns Within 30 Days option will define a case as related or unrelated to another
case. When a new surgical case is entered into the software, the user is asked whether it is related to any
previous cases within the past 30 days. This option is designed to update that information.
The user should first enter the patient name and select a case. The software will list any cases that
occurred within 30 days prior to the selected case and will indicate if the listed cases have been flagged as
related or unrelated. At this point the user may update the status of the cases listed.
Example: Updating Status of Returns Within 30 days
Select Perioperative Occurrences Menu Option:
0 Days
Select Patient: SURPATIENT,SIXTY
N-VETERAN (OTHER)
SURPATIENT,SIXTY
Update Status of Returns Within 3
03-03-59
000567821
NO
NO
000-56-7821
1. 07-06-99
REPAIR INGUINAL HERNIA (COMPLETED)
2. 06-25-99
CHOLECYSTECTOMY, APPENDECTOMY (COMPLETED)
3. 06-23-99
CHOLEDOCHOTOMY (COMPLETED)
4. 04-10-98
CRANIOTOMY (COMPLETED)
Select Operation: 3
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,1999
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. 07/06/99
REPAIR INGUINAL HERNIA - UNRELATED
2. 06/25/99
CHOLECYSTECTOMY - UNRELATED
------------------------------------------------------------------------------Select Number: 2
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,1999
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------2. 06/25/99
CHOLECYSTECTOMY - UNRELATED
------------------------------------------------------------------------------This return to surgery is currently defined as UNRELATED to the case selected.
Do you want to change this status ? NO// Y
April 2004
Surgery V. 3.0 User Manual
181
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,1999
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. 07/06/99
REPAIR INGUINAL HERNIA - UNRELATED
2. 06/25/99
CHOLECYSTECTOMY (- RELATED
------------------------------------------------------------------------------Select Number:
182
Surgery V. 3.0 User Manual
April 2004
Morbidity & Mortality Reports
[SROMM]
The Morbidity & Mortality Reports option generates two reports: the Perioperative Occurrences Report
and the Mortality Report. The Perioperative Occurrences Report includes all cases that have occurrences,
both intraoperatively and postoperatively, and can be sorted by specialty, attending surgeon, or
occurrence category. The Mortality Report includes all cases performed within the selected date range
that had a death within 30 days after surgery, and sort by specialty within a date range. Each surgical
specialty will begin on a separate page.
After the user enters the date range, the software will ask whether to generate both reports. If the user
answers NO, the software will ask the user to select from the Perioperative Occurrences Report or the
Mortality Report.
These reports have a 132-column format and are designed to be copied to a printer.
Example 1: Printing the Perioperative Occurrences Report – Sorted by Specialty
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
April 2004
(1-3): 1// <Enter>
Surgery V. 3.0 User Manual
183
Do you want to print this report for all Surgical Specialties ?
YES// N
Print the report for which Specialty ? GENERAL (OR WHEN NOT DEFINED BELOW)
Select an Additional Specialty <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
184
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUL 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
PATIENT
ATTENDING SURGEON
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
PRINCIPAL OPERATION
TREATMENT
OPERATION DATE
====================================================================================================================================
GENERAL(OR WHEN NOT DEFINED BELOW)
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,TWELVE
000-41-8719
JUL 07, [email protected]:15
SURSURGEON,THREE
REPAIR DIAPHRAGMATIC HERNIA
MYOCARDIAL INFARCTION
ASPIRIN THERAPY
URINARY TRACT INFECTION *
IV ANTBIOTICS
SURPATIENT,FOURTEEN
000-45-7212
JUL 31, [email protected]:00
SURSURGEON,FIVE
CHOLECYSTECTOMY, APPENDECTOMY
I
(07/09/06)
SUPERFICIAL WOUND INFECTION *
ANTIBIOTICS
(08/02/06)
I
I
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
184a
Example 2: Printing the Perioperative Occurrences Report – Sorted by Attending Surgeon
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
(1-3): 1// 2
Do you want to print this report for all Attending Surgeons ? YES//N
Print the report for which Attending Surgeon ? SURGEON,ONE
Select an Additional Attending Surgeon:
<Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
184b
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUL 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
PATIENT
SURGICAL SPECIALTY
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
PRINCIPAL OPERATION
TREATMENT
OPERATION DATE
====================================================================================================================================
ATTENDING: SURGEON,ONE
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,TWELVE
000-41-8719
JUL 07, [email protected]:15
GENERAL(OR WHEN NOT DEFINED BELOW)
REPAIR DIAPHRAGMATIC HERNIA
MYOCARDIAL INFARCTION
ASPIRIN THERAPY
URINARY TRACT INFECTION *
IV ANTBIOTICS
I
(07/09/06)
I
SURPATIENT,THREE
000-21-2453
JUL 22, [email protected]:00
CARDIAC SURGERY
CABG
REPEAT VENTILATOR SUPPORT W/IN 30 DAYS *
I
SURPATIENT,FOURTEEN
000-45-7212
JUL 31, [email protected]:00
GENERAL(OR WHEN NOT DEFINED BELOW)
CHOLECYSTECTOMY, APPENDECTOMY
SUPERFICIAL WOUND INFECTION *
ANTIBIOTICS
I
(08/02/06)
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
184c
Example 3: Printing the Perioperative Occurrences Report – Sorted by Occurrence Category
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
(1-3): 1// 3
Do you want to print this report for all occurrence categories? YES// NO
Print the report for which Occurrence Category ? ACUTE RENAL FAILURE
Definition Revised (2011): Indicate if the patient developed new
renal failure requiring renal replacement therapy or experienced an
exacerbation of preoperative renal failure requiring initiation of
renal replacement therapy (not on renal replacement therapy
preoperatively) within 30 days postoperatively.
TIP: If the patient refuses dialysis report as an occurrence because
he/she did require dialysis.
Select an Additional Occurrence Category:
<Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
184d
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUN 1,2007 TO: JUN 30,2007
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2007
PATIENT
ATTENDING SURGEON
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
SURGICAL SPECIALTY
TREATMENT
OPERATION DATE
PRINCIPAL OPERATION
====================================================================================================================================
CATEGORY: ACUTE RENAL FAILURE
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,SEVENTEEN
000-45-5119
JUN 18, [email protected]:15
SURGEON,TWO
GENERAL
REPAIR INCARCERATED INGUINAL HERNIA
ACUTE RENAL FAILURE
DIALYSIS
I
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
184e
(This page included for two-sided copying.)
184f
Surgery V. 3.0 User Manual
April 2004
Example 4: Printing the Mortality Report
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 2
Start with Date: 1/1/06 (JAN 01, 2006)
End with Date: 7/31/06 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
185
MAYBERRY, NC
SURGICAL SERVICE
MORTALITY REPORT
FROM: JAN 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
OPERATION DATE
PATIENT
PRINCIPAL OPERATIVE PROCEDURE
DATE OF DEATH
ID#
AUTOPSY (Y/N)
====================================================================================================================================
OTORHINOLARYNGOLOGY (ENT)
-----------------------------------------------------------------------------------------------------------------------------------JAN 22, 2006
SURPATIENT,SIXTEEN
000-11-1111
LARYNGOSCOPY, BRONCHOSCOPY, ESOPHAGOGASTROSCOPY
FEB 09, 2006
NO
JAN 27, 2006
SURPATIENT,TWO
000-45-1982
BRONCHOSCOPY
FEB 26, 2006
NOT AVAILABLE
JAN 29, 2006
SURPATIENT,SIXTEEN
000-11-1111
BILATERAL NECK DISECTION, LARYNGECTOMY
FEB 09, 2006
NO
FEB 08, 2006
SURPATIENT,SIXTEEN
000-11-1111
LIGATION LT INTERNAL JUGLAR , EXPLORATORY LAPARATOMY
FEB 09, 2006
NO
FEB 19, 2006
SURPATIENT,TEN
000-12-3456
TRACH
FEB 21, 2006
NO
JUL 20, 2006
SURPATIENT,FORTY
000-77-7777
LARYNGOSCOPY W/ BX, ESOPHAGOSCOPY
NOV 01, 2006
NOT AVAILABLE
186
Surgery V. 3.0 User Manual
April 2004
Non-O.R. Procedures
[SRONOP]
The Non-O.R. Procedures option, located in the main Surgery Menu and locked with the
SROPER key, is designed for documenting and reviewing Non-O.R. Procedures.
A Non-O.R. Procedure is any procedure not performed in an operating room, but which still involves
surgical or anesthesia providers. Any procedures involving anesthesia providers will display on the
Anesthesia AMIS Report.
The main options included in this menu are listed below. The first option, Non-O.R.. Procedures (Enter
Edit), contains options to enter or update cases. To the left of the option name is the shortcut synonym the
user can enter to select the option.
Shortcut
E
A
R
April 2004
Option Name
Non-O.R.. Procedures (Enter/Edit)
Annual Report of Non-O.R.. Procedures
Report of Non-O.R.. Procedures
Surgery V. 3.0 User Manual
187
Non-O.R. Procedures (Enter/Edit)
[SRONOP-ENTER]
The Non-O.R. Procedures (Enter/Edit) option allows the user to enter, edit, or delete information related
to a Non-O.R. Procedure. The editing feature branches to another submenu that allows the user to enter or
edit anesthesia information for a procedure. To use one of the Non-O.R. Procedures (Enter/Edit) options,
the user must first identify the patient on which he or she is working.
Accessing the Non-O.R. Procedures Menu
When the Non-O.R. Procedures (Enter/Edit) option is selected, the user will be prompted to enter a
patient name. The Surgery software will then list all non-O.R. procedures on record for the patient.
SURPATIENT,FIFTEEN
1. APR 22, 2002
000-98-1234
BRONCHOSCOPY
2. NEW PROCEDURE
Select Procedure: 1
The user can select from the procedure(s) listed or enter a new procedure. When selecting an existing
procedure, the software will ask whether the user wants to 1) edit information for the case, or 2) delete the
procedure, as follows.
SURPATIENT,FIFTEEN
APR 22, 2002
000-98-1234
BRONCHOSCOPY
Do you want to edit or delete this procedure ?
1. Edit
2. Delete
Select Number:
1// 1
If the user enters 2 to delete, the software will permanently remove the procedure from the records. On
the other hand, if the user accepts the default answer, 1, to edit the existing procedure, the software will
display the Non-O.R. Procedures (Enter/Edit) menu option. The user will see the following options.
SURPATIENT,FIFTEEN (000-98-1234)
E
AI
AM
AT
PR
TR
I
Case #267260 - APR 22,2002
Edit Non-O.R. Procedure
Anesthesia Information (Enter/Edit)
Medications (Enter/Edit)
Anesthesia Technique (Enter/Edit)
Procedure Report (Non-O.R.)
Tissue Examination Report
Non-OR Procedure Information
Select Non-O.R. Procedures (Enter/Edit) Option:
Three of these sub-options, the Anesthesia Information (Enter/Edit) option, the Medications (Enter/Edit)
option, and the Anesthesia Technique (Enter/Edit) option, are the same as the sub-options of the same
name on the Anesthesia Menu option.
188
Surgery V. 3.0 User Manual
April 2004
Edit Non-O.R. Procedure
[SRONOP-EDIT]
The Edit Non-O.R. Procedure option on the Non-O.R. Procedures menu allows the user to enter or edit
data on the selected procedure.
The DICTATED SUMMARY EXPECTED field is used to determine whether a dictated summary will be
required for this Non-O.R. Procedure case. If NO is entered into the DICTATED SUMMARY
EXPECTED field, no alerts will be generated and no report information will be displayed. If YES is
entered into the DICTATED SUMMARY EXPECTED field, an alert will be sent to the appropriate
provider when the dictated summary is uploaded, informing him or her that the Procedure Summary is
ready for signature.
The DICTATED SUMMARY EXPECTED field is used to determine whether a dictated
summary will be required for a Non-O.R. Procedure case.
Example: Setting the DICTATED SUMMARY EXPECTED field to YES
SURPATIENT,FIFTEEN (000-98-1234)
E
AI
AM
AT
PR
TR
I
Case #267260 - APR 22,2002
Edit Non-O.R. Procedure
Anesthesia Information (Enter/Edit)
Medications (Enter/Edit)
Anesthesia Technique (Enter/Edit)
Procedure Report (Non-O.R.)
Tissue Examination Report
Non-OR Procedure Information
Select Non-O.R. Procedures (Enter/Edit) Option: E
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267260
Edit Non-O.R. Procedure
SURPATIENT,FIFTEEN PAGE 1 OF 3
DATE OF PROCEDURE: APR 22, 2002
PRINCIPAL PROCEDURE: BRONCHOSCOPY
PLANNED PRIN PROCEDURE CODE:
MEDICAL SPECIALTY: GENERAL SURGERY
DICTATED SUMMARY EXPECTED:
IN/OUT-PATIENT STATUS:
TIME PROCEDURE BEGAN:
TIME PROCEDURE ENDED:
PROVIDER:
SURSURGEON,FIFTEEN
NON-OR LOCATION:
ASSOCIATED CLINIC:
PRINCIPAL DIAGNOSIS:
PLANNED PRIN DIAGNOSIS CODE:
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function: 5
Dictated Summary Expected: YES YES
April 2004
Surgery V. 3.0 User Manual
189
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267260
SURPATIENT,FIFTEEN PAGE 1 OF 3
DATE OF PROCEDURE: APRIL 22, 2002
PRINCIPAL PROCEDURE: BRONCHOSCOPY
PLANNED PRIN PROCEDURE CODE:
MEDICAL SPECIALTY: GENERAL SURGERY
DICTATED SUMMARY EXPECTED: YES
IN/OUT-PATIENT STATUS:
TIME PROCEDURE BEGAN:
TIME PROCEDURE ENDED:
PROVIDER:
SURSURGEON, FIFTEEN
NON-OR LOCATION:
ASSOCIATED CLINIC:
PRINCIPAL DIAGNOSIS:
PLANNED PRIN DIAGNOSIS CODE:
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function: <Enter>
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267260
SURPATIENT,FIFTEEN PAGE 2 OF 3
OPERATIVE FINDINGS: (WORD PROCESSING)
ATTEND PROVIDER:
ATTENDING CODE:
PRINC ANESTHETIST:
ANESTHESIOLOGIST SUPVR:
ANES CARE TIME BLOCK:
(MULTIPLE)
ANESTHESIA TECHNIQUE:
(MULTIPLE)
ANES SUPERVISE CODE:
DIAGNOSTIC/THERAPEUTIC (Y/N):
ASA CLASS:
OTHER PROCEDURES:
(MULTIPLE)
OTHER POSTOP DIAGS:
(MULTIPLE)
PROCEDURE OCCURRENCE:
(MULTIPLE)
SPECIMENS:
(WORD PROCESSING)
GENERAL COMMENTS:
(WORD PROCESSING)
Enter Screen Server Function: <Enter>
** NON-O.R. PROCEDURE **
1
2
CASE #267260
SURPATIENT,FIFTEEN PAGE 3 OF 3
CANCEL DATE:
CANCEL REASON:
Enter Screen Server Function:
190
Surgery V. 3.0 User Manual
April 2004
If the user wishes to edit information in the Procedure Report (Non-O.R.), the Edit Non-O.R.. Procedure
option on the Non-O.R.. Procedures menu can be used.
Example: Using the Edit Non-O.R. Procedure option
SURPATIENT,FIFTEEN (000-98-1234)
E
AI
AM
AT
PR
TR
Case #267260 - APR 22,2002
Edit Non-O.R. Procedure
Anesthesia Information (Enter/Edit)
Medications (Enter/Edit)
Anesthesia Technique (Enter/Edit)
Procedure Report (Non-O.R.)
Tissue Examination Report
Select Non-O.R. Procedures (Enter/Edit) Option: E
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267260
SURPATIENT,FIFTEEN PAGE 1 OF 3
DATE OF PROCEDURE: APR 22, 2002
PRINCIPAL PROCEDURE: BRONCHOSCOPY
PLANNED PRIN PROCEDURE CODE:
MEDICAL SPECIALTY: GENERAL SURGERY
DICTATED SUMMARY EXPECTED: YES
IN/OUT-PATIENT STATUS:
TIME PROCEDURE BEGAN: APR 22, 2002 AT 08:50
TIME PROCEDURE ENDED: APR 22, 2002 AT 09:27
PROVIDER:
SURSURGEON,FIFTEEN
NON-OR LOCATION:
ASSOCIATED CLINIC:
PRINCIPAL DIAGNOSIS:
PLANNED PRIN DIAGNOSIS CODE:
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function: 8
Time Procedure Ended: APR 22,[email protected]:27// 917
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Edit Non-O.R. Procedure
CASE #267260
(APR 22, [email protected]:17)
SURPATIENT,FIFTEEN PAGE 1 OF 3
DATE OF PROCEDURE: APR 22, 2002
PRINCIPAL PROCEDURE: BRONCHOSCOPY
PLANNED PRIN PROCEDURE CODE:
MEDICAL SPECIALTY: GENERAL SURGERY
DICTATED SUMMARY EXPECTED: YES
IN/OUT-PATIENT STATUS:
TIME PROCEDURE BEGAN: APR 22, 2002 AT 08:50
TIME PROCEDURE ENDED: APR 22, 2002 AT 09:17
PROVIDER:
SURSURGEON,FIFTEEN
NON-OR LOCATION:
ASSOCIATED CLINIC:
PRINCIPAL DIAGNOSIS:
PLANNED PRIN DIAGNOSIS CODE:
INDICATIONS FOR OPERATIONS: (WORD PROCESSING)
BRIEF CLIN HISTORY: (WORD PROCESSING)
Enter Screen Server Function:
April 2004
<Enter>
Surgery V. 3.0 User Manual
191
** NON-O.R. PROCEDURE **
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CASE #267260
OPERATIVE FINDINGS: (WORD PROCESSING)
ATTEND PROVIDER:
ATTENDING CODE:
PRINC ANESTHETIST:
ANESTHESIOLOGIST SUPVR:
ANES CARE TIME BLOCK:
(MULTIPLE)
ANESTHESIA TECHNIQUE:
(MULTIPLE)
ANES SUPERVISE CODE:
DIAGNOSTIC/THERAPEUTIC (Y/N):
ASA CLASS:
OTHER PROCEDURES:
(MULTIPLE)
OTHER POSTOP DIAGS:
(MULTIPLE)
PROCEDURE OCCURRENCE:
(MULTIPLE)
SPECIMENS:
(WORD PROCESSING)
GENERAL COMMENTS:
(WORD PROCESSING)
Enter Screen Server Function:
** NON-O.R. PROCEDURE **
1
2
SURPATIENT,FIFTEEN PAGE 2 OF 3
<Enter>
CASE #267260
SURPATIENT,FIFTEEN PAGE 3 OF 3
CANCEL DATE:
CANCEL REASON:
Enter Screen Server Function: ^
192
Surgery V. 3.0 User Manual
April 2004
Procedure Report (Non-O.R.)
[SR NON-OR REPORT]
The Procedure Report (Non-O.R..) option details operation information for the patient case selected. This
report includes the Procedure Summary section. The Procedure Summary is dictated by the provider after
completing the Non-O.R. procedure and then is electronically signed.
Prior to Signature
The Edit Non-O.R. Procedure option on the Non-O.R. Procedures menu is used to enter the non-O.R.
procedure data. The DICTATED SUMMARY EXPECTED field is used to determine whether a dictated
summary will be required for this non-O.R. procedure. This field is a required entry when creating a new
non-O.R. procedure and may be edited using the Edit Non-O.R. Procedure option. Entering YES in this
field allows a Procedure Summary to be uploaded and signed in TIU, making a Procedure Report (NonO.R.) available for this procedure.
The DICTATED SUMMARY EXPECTED field is used to determine whether a dictated
summary will be required for a Non-O.R. Procedure case.
After the Procedure Summary has been electronically signed, the Procedure Report (Non-O.R..) is
viewable through CPRS. If the Procedure Summary has not been electronically signed, the following
displays:
“* * A Non-O.R. Procedure Summary is not available. * *”
After the Procedure Summary is transcribed and uploaded into TIU, the TIU software sends an
alert to the provider responsible for electronically signing the report. The provider can then sign
using CPRS options or the List Manager.
April 2004
Surgery V. 3.0 User Manual
193
After Electronic Signature
After electronic signature, the report is available for viewing.
Example 1: Printing a Procedure (Non-O.R.) Report when the Procedure Summary has been signed
SURPATIENT,ONE (000-44-7629)
Case #267236 - FEB 13, 2002
Select Non-O.R. Procedures (Enter/Edit) Option: PR
Procedure Report (Non-O.R.)
Do you want WORK copies or CHART copies? WORK// <Enter>
DEVICE: HOME//
[Select Print Device]
-----------------------------------------------------report follows---------------------------------------------------------
194
Surgery V. 3.0 User Manual
April 2004
-------------------------------------------------------------------------------SURPATIENT,ONE 000-44-7629
PROCEDURE REPORT
-------------------------------------------------------------------------------NOTE DATED: 02/13/2002 00:00 PROCEDURE REPORT
SUBJECT: Case #: 267236
PREOPERATIVE DIAGNOSIS:
RESPIRATORY FAILURE, PROLONGED TRACHEAL INTUBATION
AND FAILURE TO WEAN
POSTOPERATIVE DIAGNOSIS:
PROCEDURE PERFORMED:
PROVIDER:
SAME
OPEN TRACHEOSTOMY
DR. SURSURGEON
ASSISTANT PROVIDER:
ANESTHESIA:
GENERAL ENDOTRACHEAL ANESTHESIA
ESTIMATED BLOOD LOSS:
COMPLICATIONS:
MINIMAL
NONE
INDICATIONS FOR PROCEDURE: The patient is a sixty-four-year-old gentleman
with a rather extensive past surgical history, mostly significant for status
post esophagogastrectomy and presented to the hospital approximately three
weeks ago with abdominal pain. Diagnostic evaluation consisted of an abdominal
CT scan, liver function tests and right upper quadrant ultrasound, all of
which were consistent with a diagnosis of acalculus cholecystitis. Because of
these findings, the patient was brought to the operating room approximately
three weeks ago where an open cholecystectomy was performed. The patient subsequent to that has
had a very rocky postoperative course, most significantly focusing around persistently spiking
fevers with sources significant for an E-coli sinusitis as well as a Staphylococcus E-coli
pneumonia with no evidence of bacteremia. As a result of all of this sepsis and persistent
spiking fevers, the patient has had a pneumonia, the patient has had a rather difficult time
weaning from the ventilator and because of the
almost three week period since his last operation with persistent endotracheal
tube in place, the patient was brought to the operating room for an open
tracheostomy procedure.
DESCRIPTION OF PROCEDURE: After appropriate consent was obtained from the
patient’s next of kin and the risks and benefits were explained to her, the
patient was then brought to the operating room where general endotracheal
anesthesia was induced. The area was prepped and draped in the usual fashion
with a towel roll under the patient’s scapula and the neck extended.
A longitudinal incision of approximately 2 cm was made just below the cricoid
cartilage. The strap muscles were taken down using Bovee electrocautery. The
isthmus of the thyroid was clamped and tied off using 2-0 silk x two.
Hemostasis was assured. The thyroid cartilage was carefully dissected
directly onto it. The window in the third ring of the trachea was opened
after placement of retraction sutures of 0 silk, The hatch was cut open using
a hatch box shape. This opening was then dilated using the tracheal dilator.
The endotracheal tube was pulled back. A #7 Tracheostomy tube was placed with
ease. Breath sounds were assured. The patient was oxygenating well and the
stay sutures were placed. The patient tolerated the procedure well. The skin
was closed with 0 silk and trachea tip was applied. The patient tolerated the
procedure well. The endotracheal tube was finally removed. He was brought to
the Surgical Intensive Care Unit in stable, but critical condition.
Three Sursurgeon, M.D.
TS/jer:jw J#:
514 DD:
02-13-02 DT:
02-13-02
Signed by: /es/ THREE SURSURGEON
02/13/2002 16:40
Enter RETURN to continue or '^' to exit: ^
April 2004
Surgery V. 3.0 User Manual
195
Tissue Examination Report
[SROTRPT]
The Tissue Examination Report option is used to generate the Tissue Examination Report that contains
information about cultures and specimens sent to the laboratory for a non-OR procedure.
This report prints in an 80-column format and can be viewed on the screen.
Example: Tissue Examination Report
Select Non-O.R. Procedures (Enter/Edit) Option: TR
DEVICE: [Select Print Device]
Tissue Examination Report
-------------------------------------printout follows---------------------------------------------------------------------------------------------------------------MEDICAL RECORD
|
TISSUE EXAMINATION
-------------------------------------------------------------------------------Specimen Submitted By:
Obtained: AUG 13, 2004
OR1, SURGERY CASE # 267260
-------------------------------------------------------------------------------Specimen(s): BIOPSY OF STOMACH LINING
-------------------------------------------------------------------------------Brief Clinical History:
The patient has had a pneumonia, and had a rather difficult time weaning
from the ventilator and because of the almost three week period since
his last operation with persistent endotracheal tube in place, the
patient was brought to the operating room for an open tracheostomy procedure.
-------------------------------------------------------------------------------Operative Procedure(s):
OPEN TRACHEOSTOMY
-------------------------------------------------------------------------------Preoperative Diagnosis:
RESPIRATORY FAILURE, PROLONGED TRACHEAL INTUBATION
AND FAILURE TO WEAN
-------------------------------------------------------------------------------Operative Findings:
-------------------------------------------------------------------------------Postoperative Diagnosis:
Signature and Title
FOREIGN BODY IN TRACHEA
SURSURGEON,TWO
-------------------------------------------------------------------------------Attending Surgeon: SURSURGEON,ONE
-------------------------------------------------------------------------------PATHOLOGY REPORT
-------------------------------------------------------------------------------Name of Laboratory
Accession Number(s)
-------------------------------------------------------------------------------Gross Description, Histologic Examination and Diagnosis
(Continue on reverse side)
-------------------------------------------------------------------------------PATHOLOGIST'S SIGNATURE
DATE:
-------------------------------------------------------------------------------SURPATIENT,FIFTEEN (000-98-1234) Age: 64
SEX: MALE
ID # 000-98-1234
ETHNICITY: NOT HISPANIC
REGISTER NO.
RACE: WHITE, ASIAN
WARD:
ROOM-BED:
-------------------------------------------------------------------------------VAMC: MAYBERRY, NC
REPLACEMENT FORM 515
Press RETURN to continue
195a
Surgery V. 3.0 User Manual
August 2004
Non-OR Procedure Information
[SR NON-OR INFO]
The Non-OR Procedure Information option displays information on the selected non-OR procedure, with
the exception of the provider's dictated summary.
This report prints in an 80-column format and can be viewed on the screen.
Example: Non-OR Procedure Information Report
SURPATIENT,FIFTEEN (000-98-1234)
Case #267260 - APR 22,2002
Select Non-O.R. Procedures (Enter/Edit) Option: I
Non-O.R. Procedure Information
DEVICE: HOME// [Select Print Device]
-------------------------------------printout follows--------------------------------SURPATIENT,FIFTEEN (000-98-1234) Age: 64
PAGE 1
NON-O.R. PROCEDURE - CASE #267260
Printed: AUG 13, [email protected]:40
------------------------------------------------------------------------------Med. Specialty: PULMONARY, NON-TB
Location: NON OR
Principal Diagnosis:
FAILURE TO WEAN
Provider: SURSURGEON,TWO
Patient Status: INPATIENT
Attending: SURSURGEON,FIFTEEN
Attending Code: LEVEL F: NON-OR PROCEDURE DONE IN THE OR, ATTENDING IDENTIFIED
Attend Anesth: N/A
Anesthesia Supervisor Code: N/A
Anesthetist: N/A
Anesthesia Technique(s): N/A
Proc Begin:
AUG 13, 2004
09:00
Proc End:
AUG 13, 2004
10:00
Procedure(s) Performed:
Principal: OPEN TRACHEOSTOMY
Indications for Procedure:
FOREIGN BODY IN TRACHEA.
Brief Clinical History:
The patient is a sixty-four-year-old gentleman with a rather extensive past
surgical history, mostly significant for status post esophagogastrectomy and
presented to the hospital approximately three weeks ago with abdominal pain.
Diagnostic evaluation consisted of an abdominal CT scan, liver function
tests and right upper quadrant ultrasound, all of which were consistent
with a diagnosis of acalculus cholecystitis. Because of these findings,
the patient was brought to the operating room approximately three weeks ago
where an open cholecystectomy was performed.
Specimens: BIOPSY OF STOMACH LINING.
Dictated Summary Expected: YES
Enter RETURN to continue or '^' to exit:
August 2004
Surgery V. 3.0 User Manual
195b
Annual Report of Non-O.R. Procedures
[SRONOP-ANNUAL]
The Annual Report of Non-O.R.. Procedures option generates the Annual Report of Non-O.R.
Procedures. It displays the total number of non-O.R. procedures within the selected date range based on
CPT code.
This report prints in an 80-column format and can be viewed on the screen.
Example: Annual Report of Non-O.R. Procedures
Select Non-O.R. Procedures Option:
A
Annual Report of Non-O.R. Procedures
Annual Report of Non-O.R. Procedures
Starting with Date: 3/2 (MAR 02, 1999)
Ending with Date: 3/30 (MAR 30, 1999)
Print the report on which Device: [Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
196
Surgery V. 3.0 User Manual
April 2004
ANNUAL REPORT OF NON-O.R. PROCEDURES
FROM: MAR 2,1999 TO: MAR 30,1999
CPT - PROCEDURE
SPECIALTY
TOTAL
================================================================================
CARDIOLOGY
92960
HEART ELECTROCONVERSION
2
Press RETURN to continue, or '^' to quit:
<Enter>
ANNUAL REPORT OF NON-O.R. PROCEDURES
FROM: MAR 2,1999 TO: MAR 30,1999
CPT - PROCEDURE
SPECIALTY
TOTAL
==============================================================================
GENERAL SURGERY
11404
REMOVAL OF SKIN LESION
1
Press RETURN to continue, or '^' to quit:
<Enter>
ANNUAL REPORT OF NON-O.R. PROCEDURES
FROM: MAR 2,1999 TO: MAR 30,1999
CPT - PROCEDURE
SPECIALTY
TOTAL
==============================================================================
GENERAL(ACUTE MEDICINE)
11423
64510
REMOVAL OF SKIN LESION
INJECTION FOR NERVE BLOCK
1
1
Press RETURN to continue, or '^' to quit:
<Enter>
ANNUAL REPORT OF NON-O.R. PROCEDURES
FROM: MAR 2,1999 TO: MAR 30,1999
CPT - PROCEDURE
SPECIALTY
TOTAL
==============================================================================
PSYCHIATRY
90870
ELECTROCONVULSIVE THERAPY
3
Press RETURN to continue, or '^' to quit:
<Enter>
ANNUAL REPORT OF NON-O.R. PROCEDURES
SUMMARY OF ALL SPECIALTIES
FROM: MAR 2,1999 TO: MAR 30,1999
==============================================================================
CARDIOLOGY
TOTAL NON-O.R. PROCEDURES: 2
GENERAL SURGERY
TOTAL NON-O.R. PROCEDURES: 1
GENERAL(ACUTE MEDICINE)
TOTAL NON-O.R. PROCEDURES: 2
PSYCHIATRY
TOTAL NON-O.R. PROCEDURES: 3
TOTAL NON-O.R. PROCEDURES FOR THIS MEDICAL CENTER: 8
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
197
Report of Non-O.R. Procedures
[SRONOR]
This report chronologically lists non-O.R. procedures, and can be sorted by specialty, provider, or
location.
This report prints in a 132-column format and must be copied to a printer.
Example 1: Report of Non-O.R. Procedures by Specialty
Select Non-O.R. Procedures Option:
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
1// <Enter>
Do you want to print the report for all Specialties ?
Print the Report for which Specialty ?
YES// N
Cardiology
This report is designed to use a 132 column format.
Print on Device:
[Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
198
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
PATIENT (ID#)
PROVIDER
START TIME
CASE #
LOCATION (IN/OUT-PAT STATUS)
PROCEDURE(S)
FINISH TIME
====================================================================================================================================
*** SPECIALTY: CARDIOLOGY ***
03/02/92
501
SURPATIENT,TWELVE (000-41-8719)
AMBULATORY SURGERY (OUTPATIENT)
SURSURGEON,TWO
CARDIOVERSION
03/02/92 13:05
03/02/92 14:10
03/13/92
500
SURPATIENT,SIXTY (000-56-7821)
ICU (INPATIENT)
SURSURGEON,TWO
CARDIOVERSION
03/13/92 14:00
03/13/92 14:25
April 2004
Surgery V. 3.0 User Manual
199
Example 2: Report of Non-O.R. Procedures by Provider
Select Non-O.R. Procedures Option:
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
2// <Enter>
Do you want to print the report for all Providers ?
Print the Report for which Provider ?
YES// N
SURSURGEON,SIXTEEN
SS
This report is designed to use a 132 column format.
Print on Device:
[Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
200
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
PATIENT (ID#)
SPECIALTY
START TIME
CASE #
LOCATION (IN/OUT-PAT STATUS)
PROCEDURE(S)
FINISH TIME
====================================================================================================================================
*** PROVIDER SURSURGEON,SIXTEEN ***
03/12/92
195
SURPATIENT,TWO (000-45-1982)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
ELECTROCONVULSIVE THERAPY
03/12/92 08:00
03/12/92 09:00
03/23/92
240
SURPATIENT,NINE (000-34-5555)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
ELECTROCONVULSIVE THERAPY
03/23/92 08:10
03/23/92 08:40
03/25/92
266
SURPATIENT,FOURTEEN (000-45-7212)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
ELECTROCONVULSIVE THERAPY
03/12/92 09:30
03/12/92 10:15
April 2004
Surgery V. 3.0 User Manual
201
Example 3: Report of Non-O.R. Procedures by Location
Select Non-O.R. Procedures Option:
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
2// <Enter>
Do you want to print the report for all Locations ?
Print the Report for which location ?
YES// N
AMBULATORY SURGERY
This report is designed to use a 132 column format.
Print the report on which Device:
[Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
202
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
PATIENT (ID#)
PROVIDER
START TIME
CASE #
SPECIALTY (IN/OUT-PAT STATUS)
PROCEDURE(S)
FINISH TIME
====================================================================================================================================
*** LOCATION: AMBULATORY SURGERY ***
03/02/92
201
SURPATIENT,TWELVE (000-41-8719)
CARDIOLOGY (OUTPATIENT)
SURSURGEON,TWO
CARDIOVERSION
03/02/92 13:05
03/02/92 14:10
03/06/92
198
SURPATIENT,TWENTY (000-45-4886)
GENERAL(ACUTE MEDICINE) (OUTPATIENT)
SURSURGEON,FOUR
EXCISION OF SKIN LESION
03/07/92 16:30
03/07/92 17:08
03/09/92
193
SURPATIENT,FIFTY (000-45-9999)
GENERAL(ACUTE MEDICINE) (OUTPATIENT)
SURANESTHETIST,ONE
STELLATE NERVE BLOCK
03/09/92 09:45
03/09/92 10:21
03/13/92
200
SURPATIENT,SIXTY (000-56-7821)
CARDIOLOGY (INPATIENT)
SURSURGEON,TWO
CARDIOVERSION
03/13/92 14:00
03/13/92 14:25
03/17/92
191
SURPATIENT,EIGHTEEN (000-22-3334)
GENERAL SURGERY (OUTPATIENT)
SURSURGEON,FOUR
EXCISION OF SKIN LESION
03/17/92 13:30
03/17/92 14:42
April 2004
Surgery V. 3.0 User Manual
203
(This page included for two-sided copying.)
204
Surgery V. 3.0 User Manual
April 2004
Comments Option
[SROMEN-COM]
Surgeons use the Comments option to respond to the GENERAL COMMENTS field for a surgical case or
non-O.R. procedure. This option is designed to give surgeons an opportunity to directly add general
comments after a case has been booked. The GENERAL COMMENTS field may already contain
information added by the person booking the operation.
After selecting the patient case, the surgeon can add the general comments using the VA FileMan wordprocessing device, demonstrated below. The surgeon must press the <Enter> key at the end of each line
with this type of word processing. The surgeon would press the <Enter> key again when he or she is
through with the comments.
Example: Enter General Comments
Select Surgery Menu Option:
C
Select Patient: SURPATIENT,THREE
1. 11/20/99
2. 11/20/99
Comments
08-15-42
000212453
CAROTID ARTERY ENDARTERECTOMY (COMPLETED)
AORTO CORONARY BYPASS GRAFT (CANCELLED)
Select Number: 1
General Comments:
1>Patient at high risk due to severe hypertension. Pre-operative
2>evaluation recommended treatment by other than surgical means.
3>This treatment, however, was unsuccessful necessitating
4>surgery. Patient should be monitored closely & anesthesia time
5>kept to a minimum.
6> <Enter>
EDIT Option: <Enter>
Select Surgery Menu Option:
April 2004
Surgery V. 3.0 User Manual
205
(This page included for two-sided copying.)
206
Surgery V. 3.0 User Manual
April 2004
CPT/ICD Coding Menu
[SRCODING MENU]
The Surgery CPT/ICD Coding Menu option was developed to help assure access to the most accurate
source documentation and to provide a means for efficient coding entry and validation. It provides coders
with special, limited access to the VistA Surgery package.
From the menu, coders have ready access to the Operation Report, which is dictated by the surgeon
postoperatively and contains the most comprehensive and accurate description of the procedure(s)
actually performed. Coders can also view the Nurse Intraoperative Report, which is often an important
supplementary source of data.
Using the same menu, coders can add and edit procedures, CPT codes, diagnoses, and International
Classification of Diseases (ICD) codes, without having to rely on a paper-based system. Options are
available to assist surgery staff and others who perform coding validation, as are several commonly used
reports.
The Surgery CPT/ICD Coding Menu contains the following options. To the left is the shortcut synonym
the user can enter to select the option:
Shortcut
EDIT CPT/ICD
C
A
M
L
LS
U
D
PS
R
April 2004
Option Name
Update/Verify Menu ...
Cumulative Report of CPT Codes
Report of CPT Coding Accuracy
List Completed Cases Missing CPT Codes
List of Operations
List of Operations (by Surgical Specialty)
List of Undictated Operations
Report of Daily Operating Room Activity
PCE Filing Status Report
Report of Non-O.R. Procedures
Surgery V. 3.0 User Manual
207
CPT/ICD Update/Verify Menu
[SRCODING UPDATE/VERIFY MENU]
The CPT/ICD Update/Verify Menu is locked with the SR CODER security key.
This option provides coding personnel with access to review and edit procedure and diagnosis
information. It also provides access to the Operation Report and Nurse Intraoperative Report for
operations and to the Procedure Report (Non-O.R.) for non-O.R. procedures.
The CPT/ICD Update/Verify Menu contains the following options. To the left is the shortcut synonym the
user can enter to select the option.
Shortcut
UV
OR
NR
PI
Option Name
Update/Verify Procedure/Diagnosis Codes
Operation/Procedure Report
Nurse Intraoperative Report
Non-OR Procedure Information
To access the CPT/ICD Update/Verify Menu, the user must first identify the patient and case. When the
user selects EDIT for the CPT/ICD Update/Verify Menu from the CPT/ICD Coding Menu, the user will
be prompted to enter a patient name. The software will then list all the cases on record for the patient,
including any operations that are completed or are in progress and any non-O.R. procedures.
Select CPT/ICD Coding Menu Option: EDIT
CPT/ICD Update/Verify Menu
Select Patient: SURPATIENT,TWELVE
C VETERAN
SURPATIENT,TWELVE
02-12-28
000418719
YES
S
000-41-8719
1. 08-07-99
REPAIR DIAPHRAGMATIC HERNIA (COMPLETED)
2. 02-24-99
CYSTOSCOPY (NON-OR PROCEDURE)
3. 02-18-03
TRACHEOSTOMY (COMPLETED)
4. 09-04-97
CHOLECYSTECTOMY (COMPLETED)
5. 09-28-95
INGUINAL HERNIA (COMPLETED)
6. 08-31-95
HIP REPLACEMENT (COMPLETED)
Select Case: 3
SURPATIENT,TWELVE (000-41-8719)
UV
OR
NR
PI
Case #124 - FEB 18,2003
Update/Verify Procedure/Diagnosis Codes
Operation/Procedure Report
Nurse Intraoperative Report
Non-OR Procedure Information
Select CPT/ICD Update/Verify Menu Option:
From this point, the user can select any of the CPT/ICD Update/Verify Menu options.
208
Surgery V. 3.0 User Manual
April 2004
Update/Verify Procedure/Diagnosis Codes
[SRCODING EDIT]
The Update/Verify Procedure/Diagnosis Codes option allows the user to enter the final codes and
associated information required for PCE upon completion of a Surgery case.
The procedure and diagnoses codes entered/edited through this option will be the coded
information that is sent to the Patient Care Encounter (PCE) package. After the case is coded, the
user will select to send the information to PCE.
When the user first edits a case through this option, the values will be pre-populated, using the values for
planned codes entered by the nurse or surgeon. If there is no Planned Principal Procedure Code or no
Principal Pre-op Diagnosis Code, then the Surgery software will prompt for the final CPT and ICD codes.
Because a case can have more than one procedure and/or diagnosis, the user can associate one or more
diagnosis with each procedure. The Surgery software displays the diagnoses in the order in which the user
entered them in the case. The user can then associate and reorder the relevant diagnoses to each
procedure.
The user can also edit the service classifications for the Postoperative Diagnoses.
The following examples depict using the Update/Verify Procedure/Diagnosis Codes option to edit a
Bronchoscopy, with no planned CPT or ICD codes entered by a clinician.
Example: Entering Required Information
Select CPT/ICD Update/Verify Menu Option: UV
Codes
Update/Verify Procedure/Diagnosis
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: NOT ENTERED
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: NOT ENTERED
Assoc. DX:
NO Assoc. DX ENTERED
4. Other CPT Code:
NOT ENTERED
--------------------------------------------------------------The following information is required before continuing.
Principal Postop Diagnosis Code (ICD):934.0
...OK? Yes//
(Yes) <Enter>
April 2004
934.0
FOREIGN BODY IN TRACHEA
Surgery V. 3.0 User Manual
209
Because the patient has a service-connected status, the Surgery software displays a service-connected
prompt:
SURPATIENT,TWELVE (000-41-8719)
SC VETERAN
* * * Eligibility Information and Service Connected Conditions * * *
Primary Eligibility: SERVICE CONNECTED 50% TO 100%
Combat Vet: NO
A/O Exp.: YES
M/S Trauma: NO
ION Rad.: YES
SWAC: NO
H/N Cancer: NO
PROJ 112/SHAD: NO
SC Percent: 50%
Rated Disabilities: NONE STATED
-------------------------------------------------------Please supply the following required information about this operation:
Treatment related to Service Connected condition (Y/N): YES
Treatment related to Agent Orange Exposure (Y/N): YES
Treatment related to Ionizing Radiation Exposure (Y/N): YES
Note that when a Postop Diagnosis Code is entered, it is automatically associated to a Principal CPT
code, even if a CPT code is not entered.
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: NOT ENTERED
Assoc. DX: 934.0 -FOREIGN BODY IN TRACHEA
4. Other CPT Code:
NOT ENTERED
--------------------------------------------------------------The following information is required before continuing.
Principal Procedure Code (CPT): 31622 DX BRONCHOSCOPE/WASH
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE;
DIAGNOSTIC, WITH OR WITHOUT CELL WASHING (SEPARATE PROCEDURE)
Modifier: <Enter>
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31622 DX BRONCHOSCOPE/WASH
Assoc. DX: 934.0 FOREIGN BODY IN TRACHEA
4. Other CPT Code:
NOT ENTERED
--------------------------------------------------------------Enter number of item to edit (1-4):
Because all required information is now entered, the user can select to automatically send the information
to PCE, or wait until other information is entered.
Is the coding of this case complete and ready to send to PCE? NO// <Enter>
210
Surgery V. 3.0 User Manual
April 2004
Example: Editing the Principal CPT Code
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31622 DX BRONCHOSCOPE/WASH
Assoc. DX: 934.0 FOREIGN BODY IN TRACHEA
4. Other CPT Code:
NOT ENTERED
--------------------------------------------------------------Enter number of item to edit (1-4): 3
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Principal Procedure:
CPT Code: 31622 DX BRONCHOSCOPE/WASH
Modifiers: NOT ENTERED
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
Select one of the following:
1
2
Update Principal Procedure CPT Code
Update Associated Diagnoses
Enter selection (1 or 2): 1// 1
Update Principal Procedure CPT Code
Principal Procedure Code (CPT): 31622// 31623
DX BRONCHOSCOPE/BRUSH
BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH BRUSHING OR PROTECTED BRUSHINGS
Modifier:
The Diagnosis to Procedure Associations may no longer be correct.
Delete all Principal Associated Diagnoses? N// <Enter> NO
Editing or deleting any diagnosis or procedures may cause any associated diagnoses to be
incorrect; the software prompts the user to check any diagnosis to procedure associations. The
user can select to delete all associated diagnoses, or keep all associations.
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------CPT Code: 31623 DX BRONCHOSCOPE/BRUSH
Modifiers: NOT ENTERED
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
Only the following ICD Diagnosis Codes can be associated:
1. 934.0-FOREIGN BODY IN TRACHEA
Select the number(s) of the Diagnosis Code to associate to
the procedure selected: 1// <Enter>
April 2004
Surgery V. 3.0 User Manual
211
Example: Entering a New Other Procedure CPT Code
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31623 DX BRONCHOSCOPE/BRUSH
Assoc. DX: 934.0 FOREIGN BODY IN TRACHEA
4. Other CPT Code:
NOT ENTERED
--------------------------------------------------------------Enter number of item to edit (1-4): 4
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Other Procedures:
1. Enter NEW Other Procedure
Enter selection:
(1-1): 1
Enter new OTHER PROCEDURE CPT code: 43200
ESOPHAGUS ENDOSCOPY
ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION
OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)
Modifier: <Enter>
All procedures must be associated with a diagnosis; the Surgery software allows the user to associate any
or all available diagnoses to a single procedure. If more than one diagnosis if available, then the user
enters the associations sequentially for the association.
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 43200 ESOPHAGUS ENDOSCOPY
Modifiers: NOT ENTERED
Assoc. DX: NOT ENTERED
-------------------------------------------------------------------------------Only the following ICD Diagnosis Codes can be associated:
1. 934.0-FOREIGN BODY IN TRACHEA
Select the number(s) of the Diagnosis Code to associate to
the procedure selected: 1// <Enter>
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 43200 ESOPHAGUS ENDOSCOPY
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
2. Enter NEW Other Procedure Code
Enter selection:
212
(1-2): <Enter>
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31623 DX BRONCHOSCOPE/BRUSH
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
4. Other CPT Code: 43200 ESOPHAGUS ENDOSCOPY
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
-------------------------------------------------------------------------------Enter number of item to edit (1-4):
Example: Editing Service Connected/Environmental Indicators (SC/EIs)
To edit service connected or environmental indicators, the user selects either the Principal Postop
Diagnosis Code or the Other Postop Diagnosis Code.
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31623 DX BRONCHOSCOPE/BRUSH
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
4. Other CPT Code: 43200 ESOPHAGUS ENDOSCOPY
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
-------------------------------------------------------------------------------Enter number of item to edit (1-4): 1
The following shows an example of the Principal Postop Diagnosis Code being edited.
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Principal Postop Diagnosis:
ICD9 Code: 934.0 FOREIGN BODY IN TRACHEA
SC:Y
AO:Y
IR:Y
Select one of the following:
1
2
Update Principal Postop Diagnosis Code
Update Service Connected/Environmental Indicators only
Enter selection (1 or 2): 1// 2
rs only
April 2004
Update Service Connected/Environmental Indicato
Surgery V. 3.0 User Manual
212a
The information displayed for this patient show Service Connected status of less than 50%, and the Agent
Orange Exposure and Ionizing Radiation indicators associated with the diagnosis. The software gives the
user the option to update all diagnoses with the same service-connected indicators simultaneously.
SURPATIENT,TWELVE
(000-41-8719)
SC VETERAN
* * * Eligibility Information and Service Connected Conditions * * *
Primary Eligibility: SC LESS THAN 50%
Combat Vet: NO
A/O Exp.: YES
M/S Trauma: NO
ION Rad.: YES
SWAC: NO
H/N Cancer: NO
PROJ 112/SHAD: NO
SC Percent: %
Rated Disabilities: NONE STATED
------------------------------------------------------------------------------Please supply the following required information about this operation:
Treatment related to Service Connected condition (Y/N): YES// <Enter>
Treatment related to Agent Orange Exposure (Y/N): NO
Treatment related to Ionizing Radiation Exposure (Y/N): YES
Update all 'OTHER POSTOP DIAGNOSIS' Eligibility and Service Connected
Conditions with these values (Y/N)? NO// <Enter>
SURPATIENT,TWELVE (000-41-8719)
Case #10062
JUN 08, 2005
BRONCHOSCOPY
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 31623 DX BRONCHOSCOPE/BRUSH
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
4. Other CPT Code: 43200 ESOPHAGUS ENDOSCOPY
Assoc. DX: 934.0-FOREIGN BODY IN TRACHE
-------------------------------------------------------------------------------Enter number of item to edit (1-4):
212b
Surgery V. 3.0 User Manual
April 2004
The following examples depict using the Update/Verify Procedure/Diagnosis Codes option to edit a
cardiac procedure (CABG), with clinician-entered Planned CPT and ICD codes.
Example: Editing Final Codes and Sending the Case to PCE
Select CPT/ICD Coding Menu Option: EDIT
Select Patient:
SC VETERAN
CPT/ICD Update/Verify Menu
SURPATIENT,SEVENTEEN
SURPATIENT,SEVENTEEN
3-29-20
000455119
YES
000-45-5119
1. 07-15-05
CABG (COMPLETED)
2. 06-09-05
NASAL ENDOSCOPY (COMPLETED)
Select Case: 1
Division: ALBANY
SURPATIENT,SEVENTEEN (000-45-5119)
UV
OR
NR
PI
(500)
Case #314 - JUL 15,2005
Update/Verify Procedure/Diagnosis Codes
Operation/Procedure Report
Nurse Intraoperative Report
Non-OR Procedure Information
Select CPT/ICD Update/Verify Menu Option: UV
Codes
Update/Verify Procedure/Diagnosis
Because the nurse or surgeon entered a Planned Principal CPT Code and a Preoperative Diagnosis Code,
the corresponding fields pre-fill with those clinician-entered values when the user accesses the case
through the Update/Verify Procedure/Diagnosis Codes option.
The user can either accept the codes that have been pre-operatively entered, or the user can edit the codes
as necessary. In this example, the codes will be adjusted to accurately reflect the procedures by adding
Other Postop Diagnosis Codes and Other CPT Codes.
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 402.01 HYP HEART DIS MALIGN WITH FAIL
2. Other Postop Diagnosis Code:
NOT ENTERED
3. Principal CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
4. Other CPT Code:
NOT ENTERED
-------------------------------------------------------------------------------Enter number of item to edit (1-4): 2
April 2004
Surgery V. 3.0 User Manual
212c
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Postop Diagnosis:
1. Enter NEW Other Postop Diagnosis Code
Enter selection:
(1-1): 1
Enter new OTHER POSTOP DIAGNOSIS Code: 599.0
(w C/C)
...OK? Yes// <Enter> (Yes)
599.0
URIN TRACT INFECTION NOS
Please review and update procedure associations for this diagnosis.
Press Enter/Return key to continue <Enter>
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Postop Diagnosis:
1. ICD9 Code: 599.0 URIN TRACT INFECTION NOS
SC:N
2. Enter NEW Other Postop Diagnosis Code
Enter selection:
(1-2): <Enter>
Now the Other CPT Code will be entered.
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 402.01 HYP HEART DIS MALIGN WITH FAIL
2. Other Postop Diagnosis Code:
599.0 URIN TRACT INFECTION NOS
3. Principal CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
4. Other CPT Code:
NOT ENTERED
-------------------------------------------------------------------------------Enter number of item to edit (1-4): 4
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. Enter NEW Other Procedure Code
Enter selection:
(1-1): 1
Enter new OTHER PROCEDURE CPT code: 33510
CABG, VEIN, SINGLE
CORONARY ARTERY BYPASS, VEIN ONLY; SINGLE CORONARY VENOUS GRAFT
Modifier: <Enter>
212d
Surgery V. 3.0 User Manual
April 2004
When additional diagnoses and procedure codes are entered, the user should review the procedure to
diagnosis associations to ensure that the associations are correct. In this example, additional associations
will be assigned.
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33510 CABG, VEIN, SINGLE
Modifiers: NOT ENTERED
Assoc. DX: NOT ENTERED
-------------------------------------------------------------------------------Only the following ICD Diagnosis Codes can be associated:
1. 402.01-HYP HEART DIS MALIGN WITH FAIL
2. 599.0-URIN TRACT INFECTION NOS
Select the number(s) of the Diagnosis Code to associate to
the procedure selected: 1// 1,2
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
2. Enter NEW Other Procedure Code
Enter selection:
599.0-URIN TRACT INFECTION N
(1-2): <Enter>
The Surgery case displays the updated values.
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 402.01 HYP HEART DIS MALIGN WITH FAIL
2. Other Postop Diagnosis Code:
599.0 URIN TRACT INFECTION NOS
3. Principal CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
4. Other CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
599.0-URIN TRACT INFECTION N
-------------------------------------------------------------------------------Enter number of item to edit (1-4): <Enter>
Because the coding for the case is completed, the user can select to stop editing the case and send the case
to PCE.
Is the coding of this case complete and ready to send to PCE? NO// YES
Coding completed and sent to PCE.
Press Enter/Return key to continue
April 2004
Surgery V. 3.0 User Manual
212e
Prior to sending the case to PCE, the Surgery software checks to see if a specific code, 065.0
CRIMEAN HEMORRHAGIC FEV, is entered as a diagnosis code. If it is entered, the software
prompts the user to make sure that the code is correct for the specified case. This check is added
to prevent the inadvertent assignment of code 065.0 when "CHF" is entered for the Principal or
Other ICD Diagnosis codes.
After the case has been sent to PCE, any changes made to the case through the Update/Verify
Procedure/Diagnosis Codes option will be automatically sent to PCE.
Example: Editing a Case After Sending to PCE
Select CPT/ICD Update/Verify Menu Option: UV
Codes
Update/Verify Procedure/Diagnosis
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Coding for this case has been completed and sent to PCE.
Are you sure you want to edit this case? NO// YES
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 402.01 HYP HEART DIS MALIGN WITH FAIL
2. Other Postop Diagnosis Code:
599.0 URIN TRACT INFECTION NOS
3. Principal CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
4. Other CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
599.0-URIN TRACT INFECTION N
-------------------------------------------------------------------------------Enter number of item to edit (1-4): 4
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
2. Enter NEW Other Procedure Code
Enter selection:
212f
599.0-URIN TRACT INFECTION N
(1-2): 1
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33510 CABG, VEIN, SINGLE
Modifiers: NOT ENTERED
Assoc. DX: 402.01-HYP HEART DIS MALIGN
599.0-URIN TRACT INFECTION N
Select one of the following:
1
2
Update Other Procedure CPT Code
Update Associated Diagnoses
Enter selection (1 or 2): 1//
<Enter> Update Other Procedure CPT Code
Other Procedure CPT Code: 33510// 33517
CABG, ARTERY-VEIN, SINGLE
CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S);
SINGLE VEIN GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL
GRAFT)
Modifier: <Enter>
The Diagnosis to Procedure Associations may no longer be correct.
Delete all Other Associated Diagnoses? N// Y YES
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33517 CABG, ARTERY-VEIN, SINGLE
Modifiers: NOT ENTERED
Assoc. DX: NOT ENTERED
-------------------------------------------------------------------------------Only the following ICD Diagnosis Codes can be associated:
1. 402.01-HYP HEART DIS MALIGN WITH FAIL
2. 599.0-URIN TRACT INFECTION NOS
Select the number(s) of the Diagnosis Code to associate to
the procedure selected: 1// 1,2
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Other Procedures:
1. CPT Code: 33517 CABG, ARTERY-VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
2. Enter NEW Other Procedure Code
Enter selection:
April 2004
599.0-URIN TRACT INFECTION N
(1-2): <Enter>
Surgery V. 3.0 User Manual
212g
SURPATIENT,SEVENTEEN (000-45-5119)
Case #314
JUL 15, 2005
CABG
-------------------------------------------------------------------------------Surgery Procedure PCE/Billing Information:
1. Principal Postop Diagnosis Code: 402.01 HYP HEART DIS MALIGN WITH FAIL
2. Other Postop Diagnosis Code:
599.0 URIN TRACT INFECTION NOS
3. Principal CPT Code: 33510 CABG, VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
4. Other CPT Code: 33517 CABG, ARTERY-VEIN, SINGLE
Assoc. DX: 402.01-HYP HEART DIS MALIGN
599.0-URIN TRACT INFECTION N
-------------------------------------------------------------------------------Enter number of item to edit (1-4): <Enter>
Coding completed and sent to PCE.
Press Enter/Return key to continue
212h
Surgery V. 3.0 User Manual
April 2004
Operation/Procedure Report
[SRCODING OP REPORT]
The Operation/Procedure Report option is used by the coders to print the Operation Report for an
operation or the Procedure Report (Non-O.R.) for a non-O.R. procedure.
Any user may print this report, which prints in an 80-column format and can be viewed on the screen or
copied to a printer.
Example 1: Operation Report
Select CPT/ICD Update/Verify Menu Option: OR
DEVICE: [Select Print Device]
Operation/Procedure Report
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
213
________________________________________________________________________________
Page: 1
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
OPERATION REPORT
-------------------------------------------------------------------------------NOTE DATED: 07/29/2003 15:15 OPERATION REPORT
VISIT: 07/29/2003 15:15 SURGERY OP REPORT NON-COUNT
SUBJECT: Case #: 73285
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
Visually significant cataract, right eye
Visually significant cataract, right eye
Phacoemulsification with intraocular lens placement, right eye
CLINICAL INDICATIONS: This 64-year-old gentleman complains of decreased
vision in the right eye affecting his activities of daily living. Best
corrected visual acuity is counting fingers at 6 feet, associated with a
2-3+ nuclear sclerotic and 4+ posterior subcapsular cataract in that eye.
ANESTHESIA: Local monitoring with topical Tetracaine and 1% preservative
free Lidocaine.
DESCRIPTION OF THE PROCEDURE: After the risks, benefits and alternatives
of the procedure were explained to the patient, informed consent was
obtained. The patient's right eye was dilated with Phenylephrine,
Mydriacyl and Ocufen. He was brought to the Operating Room and placed on
anesthetic monitors. Topical Tetracaine was given. He was prepped and
draped in the usual sterile fashion for eye surgery. A Lieberman lid
speculum was placed.
A Supersharp was used to create a superior paracentesis port. The anterior
chamber was irrigated with 1% preservative free Lidocaine. The anterior
chamber was filled with Viscoelastic. The diamond groove maker and diamond
keratome were used to create a clear corneal tunneled incision at the
temporal limbus. The cystotome was used to initiate a continuous
capsulorrhexis, which was then completed using Utrata forceps. Balanced
salt solution was used to hydrodissect and hydrodelineate the lens.
Phacoemulsification was used to remove the lens nucleus and epinucleus in a
non-stop horizontal chop fashion. Cortex was removed using irrigation and
aspiration. The capsular bag was filled with Viscoelastic. The wound was
enlarged with a 69 blade. An Alcon model MA60BM posterior chamber
intraocular lens with a power of 24.0 diopters, serial #588502.064, was
folded and inserted with the leading haptic placed into the bag. The
trailing haptic was dialed into the bag with the Lester hook. The wound
was hydrated. The anterior chamber was filled with balanced salt solution.
The wound was tested and found to be self-sealing. Subconjunctival
antibiotics were given, and an eye shield was placed. The patient was
taken in good condition to the Recovery Room. There were no complications.
KJC/PSI
DATE DICTATED: 07/29/03
DATE TRANSCRIBED: 07/29/03
JOB: 629095
Signed by: /es/ FOURTEEN SURSURGEON, M.D.
07/30/2003 10:31
214
Surgery V. 3.0 User Manual
April 2004
Example 2: Procedure Report (Non-OR)
Select CPT/ICD Update/Verify Menu Option: OR
DEVICE: [Select Print Device]
Operation/Procedure Report
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
215
-------------------------------------------------------------------------------SURPATIENT,ONE 000-44-7629
PROCEDURE REPORT
-------------------------------------------------------------------------------NOTE DATED: 02/13/2002 00:00 PROCEDURE REPORT
SUBJECT: Case #: 267236
PREOPERATIVE DIAGNOSIS:
RESPIRATORY FAILURE, PROLONGED TRACHEAL INTUBATION
AND FAILURE TO WEAN
POSTOPERATIVE DIAGNOSIS:
PROCEDURE PERFORMED:
SURGEON:
SAME
OPEN TRACHEOSTOMY
DR. SURSURGEON
ASSISTANT SURGEON:
ANESTHESIA:
GENERAL ENDOTRACHEAL ANESTHESIA
ESTIMATED BLOOD LOSS:
COMPLICATIONS:
MINIMAL
NONE
INDICATIONS FOR PROCEDURE: The patient is a forty-nine-year-old gentleman
with a rather extensive past surgical history, mostly significant for status
post esophagogastrectomy and presented to the hospital approximately three
weeks ago with abdominal pain. Diagnostic evaluation consisted of an abdominal
CT scan, liver function tests and right upper quadrant ultrasound, all of
which were consistent with a diagnosis of acalculus cholecystitis. Because of
these findings, the patient was brought to the operating room approximately
three weeks ago where an open cholecystectomy was performed. The patient subsequent to that has
had a very rocky postoperative course, most significantly focusing around persistently spiking
fevers with sources significant for an E-coli sinusitis as well as a Staphylococcus E-coli
pneumonia with no evidence of bacteremia. As a result of all of this sepsis and persistent
spiking fevers, the patient has had a pneumonia, the patient has had a rather difficult time
weaning from the ventilator and because of the
almost three week period since his last operation with persistent endotracheal
tube in place, the patient was brought to the operating room for an open
tracheostomy procedure.
DESCRIPTION OF PROCEDURE: After appropriate consent was obtained from the
patient’s next of kin and the risks and benefits were explained to her, the
patient was then brought to the operating room where general endotracheal
anesthesia was induced. The area was prepped and draped in the usual fashion
with a towel roll under the patient’s scapula and the neck extended.
A longitudinal incision of approximately 2 cm was made just below the cricoid
cartilage. The strap muscles were taken down using Bovee electrocautery. The
isthmus of the thyroid was clamped and tied off using 2-0 silk x two.
Hemostasis was assured. The thyroid cartilage was carefully dissected
directly onto it. The window in the third ring of the trachea was opened
after placement of retraction sutures of 0 silk, The hatch was cut open using
a hatch box shape. This opening was then dilated using the tracheal dilator.
The endotracheal tube was pulled back. A #7 Tracheostomy tube was placed with
ease. Breath sounds were assured. The patient was oxygenating well and the
stay sutures were placed. The patient tolerated the procedure well. The skin
was closed with 0 silk and trachea tip was applied. The patient tolerated the
procedure well. The endotracheal tube was finally removed. He was brought to
the Surgical Intensive Care Unit in stable, but critical condition.
Three Sursurgeon, M.D.
TS/jer:jw J#:
514 DD:
02-13-02 DT:
02-13-02
Signed by: /es/ THREE SURSURGEON
02/13/2002 16:40
Enter RETURN to continue or '^' to exit: ^
216
Surgery V. 3.0 User Manual
April 2004
Nurse Intraoperative Report
[SRCODING NURSE REPORT]
The Nurse Intraoperative Report option is used by the coders to print the Nurse Intraoperative Report for
an operation. This report is not available for non-O.R. procedures.
This report prints in an 80-column format and can be viewed on the screen or copied to a printer.
Example: Nurse Intraoperative Report
Select CPT/ICD Update/Verify Menu Option: NR
DEVICE: [Select Print Device]
Nurse Intraoperative Report
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
217
-------------------------------------------------------------------------------SURPATIENT,TEN 000-12-3456
NURSE INTRAOPERATIVE REPORT
-------------------------------------------------------------------------------NOTE DATED: 02/12/2004 08:00 NURSE INTRAOPERATIVE REPORT
SUBJECT: Case #: 267226
Operating Room:
BO OR1
Patient in Hold: JUL 12, 2004
Operation Begin: JUL 12, 2004
Surgeon in OR:
JUL 12, 2004
Surgical Priority: ELECTIVE
07:30
08:58
07:55
Patient in OR: JUL 12, 2004
Operation End: JUL 12, 2004
Patient Out OR: JUL 12, 2004
08:00
12:10
12:15
Major Operations Performed:
Primary: MVR
Other:
ATRIAL SEPTAL DEFECT REPAIR
Other:
TEE
Wound Classification: CONTAMINATED
Operation Disposition: SICU
Discharged Via: ICU BED
Surgeon: SURSURGEON,THREE
Attend Surg: SURSURGEON,THREE
Anesthetist: SURANESTHETIST,SEVEN
First Assist: SURSURGEON,FOUR
Second Assist: N/A
Assistant Anesth: N/A
Other Scrubbed Assistants: N/A
OR Support Personnel:
Scrubbed
SURNURSE,ONE (FULLY TRAINED)
Circulating
SURNURSE,FIVE (FULLY TRAINED)
SURNURSE,FOUR (FULLY TRAINED)
Other Persons in OR: N/A
Preop Mood:
ANXIOUS
Preop Skin Integ: INTACT
Preop Consc:
ALERT-ORIENTED
Preop Converse: N/A
Valid Consent/ID Band Confirmed By: SURSURGEON,FOUR
Mark on Surgical Site Confirmed: YES
Marked Site Comments: NO COMMENTS ENTERED
Preoperative Imaging Confirmed: YES
Imaging Confirmed Comments: NO COMMENTS ENTERED
Time Out Verification Completed: YES
Time Out Verified Comments: NO COMMENTS ENTERED
Skin Prep By: SURNURSE,FOUR
Skin Prep By (2): SURNURSE,FIVE
Skin Prep Agent: BETADINE SCRUB
2nd Skin Prep Agent: POVIDONE IODINE
Preop Surgical Site Hair Removal by: SURNURSE,FIVE
Surgical Site Hair Removal Method: OTHER
Hair Removal Comments: SHAVING AND DEPILATORY COMBINATION USED.
Surgery Position(s):
SUPINE
Restraints and Position Aids:
SAFETY STRAP
ARMBOARD
FOAM PADS
KODEL PAD
STIRRUPS
Placed: N/A
Applied
Applied
Applied
Applied
Applied
By:
By:
By:
By:
By:
N/A
N/A
N/A
N/A
N/A
Flash Sterilization Episodes:
Contamination:
0
SPD Processing/OR Management Issues: 0
Emergency Case:
0
218
Surgery V. 3.0 User Manual
April 2004
No Better Option:
0
Loaner or Short Notice Instrument:
0
Decontamination of Instruments Not for Use In Patient: 0
Electrocautery Unit:
ESU Coagulation Range:
8845,5512
50-35
ESU Cutting Range:
35-35
Electroground Position(s): RIGHT BUTTOCK
LEFT BUTTOCK
Material Sent to Laboratory for Analysis:
Specimens:
1. MITRAL VALVE
Cultures: N/A
Anesthesia Technique(s):
GENERAL (PRINCIPAL)
Tubes and Drains:
#16FOLEY, #18NGTUBE, #36 &2 #32RA CHEST TUBES
Tourniquet: N/A
Thermal Unit: N/A
Prosthesis Installed:
Item: MITRAL VALVE
Implant Sterility Checked (Y/N): YES
Sterility Expiration Date: DEC 15, 2004
RN Verifier: SURNURSE,ONE
Vendor: BAXTER EDWARDS
Model: 6900
Lot Number: T87-12321
Serial Number: 945673WRU
Sterile Resp: MANUFACTURER
Size: LG
Quantity: 2
Medications: N/A
Irrigation Solution(s):
HEPARINIZED SALINE
NORMAL SALINE
COLD SALINE
Blood Replacement Fluids: N/A
Sponge Count:
Sharps Count:
Instrument Count:
Counter:
Counts Verified By:
YES
YES
NOT APPLICABLE
SURNURSE,FOUR
SURNURSE,FIVE
Dressing: DSD, PAPER TAPE, MEPORE
Packing: NONE
Blood Loss: 800 ml
Postoperative
Postoperative
Postoperative
Postoperative
Mood:
Consciousness:
Skin Integrity:
Skin Color:
Urine Output: 750 ml
RELAXED
ANESTHETIZED
SUTURED INCISION
N/A
Laser Unit(s): N/A
Sequential Compression Device: NO
Cell Saver(s): N/A
April 2004
Surgery V. 3.0 User Manual
219
Devices: N/A
Signed by: /es/ FIVE SURNURSE
03/04/2004 10:41
219a
Surgery V. 3.0 User Manual
April 2004
Non-OR Procedure Information
[SR NON-OR INFO]
The Non-OR Procedure Information option displays information on the selected non-OR procedure, with
the exception of the provider's dictated summary.
This report prints in an 80-column format and can be viewed on the screen.
Example: Non-OR Procedure Information
SURPATIENT,FIFTEEN (000-98-1234)
UV
OR
NR
PI
Case #267260 - APR 22,2002
Update/Verify Procedure/Diagnosis Codes
Operation/Procedure Report
Nurse Intraoperative Report
Non-OR Procedure Information
Select CPT/ICD Update/Verify Menu Option: I
Non-O.R. Procedure Information
DEVICE: HOME// [Select Print Device]
-------------------------------------printout follows--------------------------------SURPATIENT,FIFTEEN (000-98-1234) Age: 60
PAGE 1
NON-O.R. PROCEDURE - CASE #267260
Printed: AUG 04, [email protected]:40
------------------------------------------------------------------------------Med. Specialty: GENERAL
Location: NON OR
Principal Diagnosis: LARYNGEAL/TRACHEAL BURN
Provider: SURSURGEON,FIFTEEN
Attending:
Attending Code:
Patient Status: NOT ENTERED
Attend Anesth: N/A
Anesthesia Supervisor Code: N/A
Anesthetist: N/A
Anesthesia Technique(s): N/A
Proc Begin:
JAN 14, 2004
08:00
Proc End:
JAN 14, 2004
09:00
Procedure(s) Performed:
Principal: BRONCHOSCOPY
Dictated Summary Expected: YES
Enter RETURN to continue or '^' to exit:
April 2004
Surgery V. 3.0 User Manual
219b
Cumulative Report of CPT Codes
[SROACCT]
The Cumulative Report of CPT Codes option counts and reports the number of times a procedure was
performed (based on CPT codes) during a specified date range. There is also a column showing how
many times it was in the Other Operative Procedure category.
After the user enters the date range, the software will ask if the user wants the Cumulative Report of CPT
Codes to include only operating room surgical procedures, non-O.R. procedures, or both.
These reports have a 132-column format and are designed to be copied to a printer.
Example 1: Print the Cumulative Report of CPT Codes for only OR Surgical Procedures
Select CPT/ICD Coding Menu Option: C
Cumulative Report of CPT Codes
Cumulative Report of CPT Codes
Start with Date: 3/28 (MAR 28, 1999)
End with Date: 4/3 (APR 03, 1999)
Include which cases on the Cumulative Report of CPT Codes ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures.
Select Number:
1// <Enter>
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
220
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
CUMULATIVE REPORT OF CPT CODES
FROM: MAR 28,1999 TO: APR 3,1999
REVIEWED BY
DATE REVIEWED:
O.R. SURGICAL PROCEDURES
CPT CODE - SHORT DESCRIPTION
TOTAL PROCEDURES
TOTAL PRINCIPAL PROCEDURES
TOTAL OTHER PROCEDURES
====================================================================================================================================
10060 DRAINAGE OF SKIN ABSCESS
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11440 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11441 REMOVAL OF SKIN LESION
4
4
0
-----------------------------------------------------------------------------------------------------------------------------------11641 REMOVAL OF SKIN LESION
4
2
2
-----------------------------------------------------------------------------------------------------------------------------------24075 REMOVE ARM/ELBOW LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------26989 HAND/FINGER SURGERY
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------30520 REPAIR OF NASAL SEPTUM
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------31231 NASAL ENDOSCOPY, DX
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------45315 PROCTOSIGMOIDOSCOPY
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------45330 SIGMOIDOSCOPY, DIAGNOSTIC
7
7
0
-----------------------------------------------------------------------------------------------------------------------------------45333 SIGMOIDOSCOPY & POLYPECTOMY
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------45378 DIAGNOSTIC COLONOSCOPY
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------45385 COLONOSCOPY, LESION REMOVAL
3
3
0
-----------------------------------------------------------------------------------------------------------------------------------47600 REMOVAL OF GALLBLADDER
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------49000 EXPLORATION OF ABDOMEN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------49505 REPAIR INGUINAL HERNIA
2
1
1
-----------------------------------------------------------------------------------------------------------------------------------66984 REMOVE CATARACT, INSERT LENS
4
3
1
-----------------------------------------------------------------------------------------------------------------------------------68801 DILATE TEAR DUCT OPENING
1
1
0
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
221
Example 2: Print the Cumulative Report of CPT Codes for only Non-OR Procedures
Select CPT/ICD Coding Menu Option: C
Cumulative Report of CPT Codes
Cumulative Report of CPT Codes
Start with Date: 7 1 99
End with Date: 12 31 99
(JUL 01, 1999)
(DEC 31, 1999)
Include which cases on the Cumulative Report of CPT Codes ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures.
Select Number:
1// 2
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
222
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
CUMULATIVE REPORT OF CPT CODES
FROM: JUL 1,1999 TO: DEC 31,1999
REVIEWED BY
DATE REVIEWED:
NON-O.R. PROCEDURES
CPT CODE - SHORT DESCRIPTION
TOTAL PROCEDURES
TOTAL PRINCIPAL PROCEDURES
TOTAL OTHER PROCEDURES
====================================================================================================================================
10060 DRAINAGE OF SKIN ABSCESS
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------10061 DRAINAGE OF SKIN ABSCESS
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11040 DEBRIDE SKIN PARTIAL
8
8
0
-----------------------------------------------------------------------------------------------------------------------------------11042 DEBRIDE SKIN/TISSUE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11100 BIOPSY OF SKIN LESION
11
11
0
-----------------------------------------------------------------------------------------------------------------------------------11402 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11420 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11620 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11640 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11730 REMOVAL OF NAIL PLATE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11750 REMOVAL OF NAIL BED
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------12001 REPAIR SUPERFICIAL WOUND(S)
3
3
0
-----------------------------------------------------------------------------------------------------------------------------------12011 REPAIR SUPERFICIAL WOUND(S)
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------14060 SKIN TISSUE REARRANGEMENT
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------15782 ABRASION TREATMENT OF SKIN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------17340 CRYOTHERAPY OF SKIN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------20550 INJ TENDON/LIGAMENT/CYST
23
23
0
-----------------------------------------------------------------------------------------------------------------------------------29799 CASTING/STRAPPING PROCEDURE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------46083 INCISE EXTERNAL HEMORRHOID
2
2
0
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
223
Report of CPT Coding Accuracy
The Report of CPT Coding Accuracy lists cases sorted by the CPT code used in the PRINCIPAL
PROCEDURES field and OTHER OPERATIVE PROCEDURES field entered by the coder. This option
is designed to help check the accuracy of the coding procedures.
About the prompts
"Do you want to print the Report of CPT Coding Accuracy for all CPT Codes ?" The user should reply
NO to this prompt to produce the report for only one CPT code. The user will then be prompted to enter
the CPT code or category.
"Do you want to sort the Report of CPT Coding Accuracy by Surgical Specialty ?" The user should press
the <Enter> key if he or she wants to sort the report by specialty. Enter NO to sort the report by date
only.
"Do you want to print the Report to Check Coding Accuracy for all Surgical Specialties ?" The user can
enter the code or name of the surgical service he or she wants the report to be based on. Or, the user can
press the <Enter> key to print the report for all surgical specialties.
Example 1: Print the Report of CPT Coding Accuracy for OR Surgical Procedures, sorted by Surgical
Specialty
Select CPT/ICD Coding Menu Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 10 8 04 (OCT 08, 2004)
End with Date: 10 8 04 (OCT 08, 2004
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// <Enter>
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// <Enter>
Do you want to sort the Report of CPT Coding Accuracy by
Surgical Specialty ? YES// <Enter>
Do you want to print the Report to Check Coding Accuracy for all
Surgical Specialties ? YES// NO
Print the Coding Accuracy Report for which Surgical Specialty ? 50
L(OR WHEN NOT DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
GENERA
50
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
224
Surgery V. 3.0
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FOR GENERAL(OR WHEN NOT DEFINED BELOW)
FROM: OCT 8,2004 TO: OCT 8,2004
PAGE
1
REVIEWED BY:
DATE REVIEWED:
O.R. SURGICAL PROCEDURES
PROCEDURE DATE
PATIENT
PROCEDURES
SURGEON/PROVIDER
CASE #
ID#
ATTEND SURG/PROV
====================================================================================================================================
47600 REMOVAL OF GALLBLADDER
PRINCIPAL PROCEDURES
DESCRIPTION: CHOLECYSTECTOMY;
-----------------------------------------------------------------------------------------------------------------------------------10/08/04 07:00
SURPATIENT,EIGHTEEN
CHOLECYSTECTOMY
SURSURGEON,TWO
63072
000-22-3334
SURSURGEON,FOUR
CPT Codes: 47600-22
====================================================================================================================================
47605 REMOVAL OF GALLBLADDER
OTHER PROCEDURES
DESCRIPTION: CHOLECYSTECTOMY;
WITH CHOLANGIOGRAPHY
-----------------------------------------------------------------------------------------------------------------------------------10/08/04 10:00
SURPATIENT,TWELVE
INGUINAL HERNIA , OTHER OPERATIONS:
SURSURGEON,FOUR
63077
000-41-8719
CHOLECYSTECTOMY
SURSURGEON,FOUR
CPT Codes: 49521, 47605-22
====================================================================================================================================
49505 REPAIR INGUINAL HERNIA
PRINCIPAL PROCEDURES
DESCRIPTION: REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER;
REDUCIBLE
-----------------------------------------------------------------------------------------------------------------------------------10/08/04 06:00
SURPATIENT,FOUR
INGUINAL HERNIA
SURSURGEON,FOUR
63071
000-45-7212
SURSURGEON,SIXTEEN
CPT Codes: 49505
====================================================================================================================================
April 2004
Surgery V. 3.0 User Manual
225
Example 2: Print the Report of CPT Coding Accuracy for OR Surgical Procedures, sorted by Date
Select CPT/ICD Coding Menu Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 10 1 04 (OCT 01, 2004)
End with Date: 10 7 04 (OCT 07, 2004)
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// <Enter>
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// <Enter>
Do you want to sort the Report of CPT Coding Accuracy by
Surgical Specialty ? YES// N
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
226
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FROM: OCT 1,2004 TO: OCT 7,2004
PAGE
1
REVIEWED BY:
DATE REVIEWED:
O.R. SURGICAL PROCEDURES
PROCEDURE DATE
CASE #
PATIENT
PROCEDURES
SURGEON/PROVIDER
ID#
ATTEND SURG/PROV
SPECIALTY
====================================================================================================================================
31365 REMOVAL OF LARYNX
PRINCIPAL PROCEDURES
DESCRIPTION: LARYNGECTOMY;
TOTAL, WITH RADICAL NECK DISSECTION
-----------------------------------------------------------------------------------------------------------------------------------10/03/04 07:00
SURPATIENT,NINETEEN
PULMONARY LOBECTOMY
SURSURGEON,SEVENTEEN
63059
000-28-7354
SURSURGEON,FOUR
THORACIC SURGERY (INC. CARDIAC SURG.)
CPT Codes: 31365
====================================================================================================================================
32440 REMOVAL OF LUNG
PRINCIPAL PROCEDURES
DESCRIPTION: REMOVAL OF LUNG, TOTAL PNEUMONECTOMY;
-----------------------------------------------------------------------------------------------------------------------------------10/03/04 10:00
SURPATIENT,TWENTY
PULMONARY LOBECTOMY
SURSURGEON,FOUR
63060
000-45-4886
SURSURGEON,FOUR
THORACIC SURGERY (INC. CARDIAC SURG.)
CPT Codes: 32440
10/04/04 06:00
63069
SURPATIENT,TEN
000-12-3456
THORACIC SURGERY (INC. CARDIAC SURG.)
PULMONARY LOBECTOMY
SURSURGEON,TWO
SURSURGEON,TWO
CPT Codes: 32440
====================================================================================================================================
April 2004
Surgery V. 3.0 User Manual
227
Example 3: Print the Report of CPT Coding Accuracy for Non-OR Procedures, sorted by CPT Code and
Medical Specialty
Select CPT/ICD Coding Menu Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 1 1 05 (JAN 01, 2005)
End with Date: 8 31 05 (AUG 31, 2005)
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// 2
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// N
Print the Coding Accuracy Report for which CPT Code ? 92960
HEART ELECTROCONVERSION
CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF
ARRHYTHMIA, EXTERNAL
Do you want to sort the Report of CPT Coding Accuracy by
Medical Specialty ? YES// <Enter>
Do you want to print the Report to Check Coding Accuracy for all
Medical Specialties ? YES// N
Print the Coding Accuracy Report for which Medical Specialty ?
MEDICINE
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
228
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FOR MEDICINE
FROM: JAN 1,2005 TO: AUG 31,2005
PAGE
1
REVIEWED BY:
DATE REVIEWED:
NON-O.R. PROCEDURES
PROCEDURE DATE
PATIENT
PROCEDURES
SURGEON/PROVIDER
CASE #
ID#
ATTEND SURG/PROV
====================================================================================================================================
92960 HEART ELECTROCONVERSION
PRINCIPAL PROCEDURES
DESCRIPTION: CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF
ARRHYTHMIA, EXTERNAL
-----------------------------------------------------------------------------------------------------------------------------------01/24/05
SURPATIENT,SEVENTEEN
CARDIOVERSION
SURSURGEON,TWO
15499
000-45-5119
SURSURGEON,TWO
CPT Codes: 92690
02/09/05
15701
SURPATIENT,NINE
000-34-5555
CARDIOVERSION
SURSURGEON,ONE
SURSURGEON,TWO
CPT Codes: 92960
03/29/05
15912
SURPATIENT,FIFTEEN
000-98-1234
CARDIOVERSION
SURSURGEON,THREE
CPT Codes: 92960
08/04/05
16669
SURPATIENT,SIX
000-09-8797
CARDIOVERSION
SURSURGEON,TWO
SURSURGEON,FOUR
CPT Codes: 92960
08/25/05
16828
SURPATIENT,TWO
000-45-1982
CARDIOVERSION
SURSURGEON,TWO
SURSURGEON,TWO
CPT Codes: 92960
April 2004
Surgery V. 3.0 User Manual
229
List Completed Cases Missing CPT Codes
[SRSCPT
The List Completed Cases Missing CPT Codes option generates a report of completed cases that are
missing the Principal CPT code for a specified date range. Only procedures that have CPT codes will be
counted on the Annual Report of Surgical Procedures.
After the user enters the date range, the software will ask whether the user wants the Cumulative Report
of CPT Codes to include: 1) only operating room surgical procedures, 2) non-O.R. procedures, or 3) both.
This report is in an 80-column format and can be viewed on the screen.
Example: List Completed Cases Missing CPT Codes
Select CPT/ICD Coding Menu Option: M
List Completed Cases Missing CPT Codes
Print list of Completed Cases Missing CPT Codes for
1. OR Surgical Procedures.
2. Non-OR Procedures.
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// 1
Do you want the list for all Surgical Specialties ?
YES//
<Enter>
Start with Date: 2/1 (FEB 01, 2005)
End with Date: 4/30 (APR 30, 2005)
Print the List of Cases Missing CPT codes to which Printer ?
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
230
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
Completed Cases Missing CPT Codes
O.R. Surgical Procedures
From: FEB 1,2005 To: APR 30,2005
Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Operation Date
Patient (ID#)
Surgeon/Provider
Case #
================================================================================
FEB 01, 2005
SURPATIENT,TWO (000-45-1982)
SURSURGEON,TWO
53708
* EXC LEFT PREAURICULAR LESION
-------------------------------------------------------------------------------FEB 08, 2005
SURPATIENT,FIVE (000-58-7963)
SURSURGEON,ONE
53747
* EXCISION LESIONS SCALP
* N/A (CPT: MISSING)
-------------------------------------------------------------------------------MAR 12, 2005
SURPATIENT,SEVEN (000-84-0987)
SURSURGEON,TWO
53973
* COLONOSCOPY
-------------------------------------------------------------------------------MAR 23, 2005
SURPATIENT,FORTYONE (000-43-2109)
SURSURGEON,ONE
54030
* COLONOSCOPY/ATTEMPTED
-------------------------------------------------------------------------------APR 27, 2005
SURPATIENT,THIRTY (000-82-9472)
SURSURGEON,SEVENTEEN
54325
* EXCISION RT FOREARM LESIONS
* EXC LESION, RT EAR
* EXC LESION, RT FOREHEAD
* EXC LESION RT SCALP
* RXC LESION, NOSE
* EXC LESION, LEFT EAR
* EXC LESION, LEFT FOREARM
* EXC LESION, TOP OF HEAD
* EXC LESION, LEFT NECK
--------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
231
List of Operations
[SROPLIST]
The List of Operations report contains general information for completed cases within a specified date
range. It sorts the cases by date and includes the procedure(s), surgical service, length of actual operation,
surgeons, and anesthesia technique. This report also includes aborted cases.
This report has a 132-column format and is designed to be copied to a printer.
Example: List of Operations
Select CPT/ICD Coding Menu Option: L
List of Operations
List of Operations
Start with Date: 10/8 (OCT 08, 1999)
End with Date: 10/8 (OCT 08, 1999)
This report is designed to use a 132 column format.
Print to device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
232
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS
FROM: OCT 8,1999 TO: OCT 8,1999
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: OCT 20,1999
DATE
CASE #
PATIENT
SERVICE
SURGEON
ANESTHESIA TECH
ID#
OPERATION(S)
1ST ASSISTANT
PRIORITY
2ND ASSISTANT
====================================================================================================================================
10/08/99
63071
SURPATIENT,FOUR
000-45-7212
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/08/99
63072
SURPATIENT,EIGHTEEN
000-22-3334
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
CHOLECYSTECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 50 MIN.
10/08/99
63073
SURPATIENT,FIFTYONE
000-23-3221
URGENT, ADD TODAY
OPHTHALMOLOGY
INTRAOCCULAR LENS, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,FOUR
SPINAL
OP TIME: 50 MIN.
10/08/99
63074
SURPATIENT,FIVE
000-58-7963
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
HIP REPLACEMENT
SURSURGEON,FOUR
SURSURGEON,FOUR
SURSURGEON,FIVE
NOT ENTERED
OP TIME: 50 MIN.
10/08/99
63075
SURPATIENT,SIX
000-09-8797
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
PULMONARY LOBECTOMY
SURSURGEON,TWO
SURSURGEON,THREE
SURSURGEON,TWO
NOT ENTERED
OP TIME: 45 MIN.
10/08/99
63077
SURPATIENT,TWELVE
000-41-8719
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
INGUINAL HERNIA, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,THREE
GENERAL
OP TIME: 63 MIN.
10/08/99
63076
SURPATIENT,FOURTEEN
000-45-7212
ELECTIVE
UROLOGY
TURP
SURSURGEON,TWO
SURSURGEON,FOUR
SURSURGEON,TWO
GENERAL
OP TIME: 45 MIN.
TOTAL CASES: 7
April 2004
Surgery V. 3.0 User Manual
233
List of Operations (by Surgical Specialty)
[SROPLIST1]
The List of Operations (by Surgical Specialty) report contains general information for completed cases
within a selected date range. It sorts the cases by surgical specialty and case number.
This report includes information on case type, length of actual operation, surgeon names, and anesthesia
technique. The user can request a list for all specialties or a selected specialty.
This report has a 132-column format and is designed to be copied to a printer.
Example: List of Operations by Surgical Specialty
Select CPT/ICD Coding Menu Option: LS
List of Operations (by Surgical Specialty)
List of Operations sorted by Surgical Specialty
Start with Date: 10/4 (OCT 04, 1999)
End with Date: 10/8 (OCT 08, 1999)
Do you want to print the report for all Specialties ?
Print the report for which Surgical Specialty ?
YES//
N
GENERAL (OR WHEN NOT DEFINED BELOW)
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
234
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS BY SERVICE
FROM: OCT 4,1999 TO: OCT 8,1999
PAGE 1
DATE REVIEWED:
REVIEWED BY:
DATE PRINTED: SEP 20,1999
DATE
CASE #
PATIENT
OPERATION(S)
SURGEON
ANESTHESIA
ID#
FIRST ASSISTANT
TECHNIQUE
PRIORITY
SECOND ASSISTANT
====================================================================================================================================
*GENERAL(OR WHEN NOT DEFINED BELOW)*
10/04/99
63066
SURPATIENT,THREE
000-21-2453
STANDBY
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,TWO
SURSURGEON,ONE
GENERAL
OP TIME: 40 MIN.
10/04/99
63067
SURPATIENT,EIGHT
000-37-0555
ELECTIVE
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/04/99
63068
SURPATIENT,ONE
000-44-7629
ELECTIVE
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 45 MIN.
10/07/99
63070
SURPATIENT,SIXTY
000-56-7821
ELECTIVE
INGUINAL HERNIA
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 45 MIN.
10/08/99
63071
SURPATIENT,FOUR
000-17-0555
ELECTIVE
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/08/99
63072
SURPATIENT,EIGHTEEN
000-22-3334
ELECTIVE
CHOLECYSTECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 50 MIN.
10/08/99
63077
SURPATIENT,TWELVE
000-41-8719
ELECTIVE
INGUINAL HERNIA, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,THREE
GENERAL
OP TIME: 63 MIN.
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 7
April 2004
Surgery V. 3.0 User Manual
235
Report of Daily Operating Room Activity
[SROPACT]
The Report of Daily Operating Room Activity option generates a report listing cases started between 6:00
AM on the date selected and 5:59 AM of the following day for all operating rooms.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print the Report of Daily Operating Room Activity
Select CPT/ICD Coding Menu Option: D
Report of Daily Operating Room Activity
Print the Report of Daily Activity for which Date ?
3/9
This report will include all cases started between MAR
and MAR 10, 1999 at 5:59 AM.
(MAR 09, 1999)
9, 1999 at 6:00 AM
It is designed to use a 132 column format.
Print the Report to which Device ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
236
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
DAILY REPORT OF OPERATING ROOM ACTIVITY
FOR: MAR 09, 1999
PATIENT
TIME IN OR
POSTOPERATIVE DIAGNOSIS
ANESTHESIOLOGIST
SURGEON
ID #
AGE
TIME OUT OR
PROCEDURE(S)
PRIN. ANESTHETIST
FIRST ASST.
WARD
CASE NUMBER
ATT SURGEON
====================================================================================================================================
OPERATING ROOM: OR1
SURPATIENT,TWELVE
000-41-8719
61
1 NORTH 161-1
03/09 08:00
03/09 09:10
194
INGUINAL HERNIA
INGUINAL HERNIA
SURANESTHESIOLOGIST,O
SURANESTHETIST,F
SURSURGEON,E
SURSURGEON,O
SURSURGEON,T
03/09 09:15
03/09 12:40
187
CHOLECYSTITIS
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
SURANESTHESIOLOGIST,T
SURANESTHETIST,O
SURSURGEON,T
SURSURGEON,F
SURSURGEON,T
03/09 19:56
03/09 21:05
188
APPENDICITIS
APPENDECTOMY, COLONOSCOPY, CHOLECYSTECTOMY, CRAIN
SURANESTHESIOLOGIST,T
SURANESTHETIST,F
SURSURGEON,S
SURSURGEON,F
SURSURGEON,F
OPERATING ROOM: OR3
SURPATIENT,NINE
000-34-5555
48
OUTPATIENT
OPERATING ROOM: OR5
SURPATIENT,SIX
000-09-8797
1 WEST 101-1
April 2004
50
Surgery V. 3.0 User Manual
237
PCE Filing Status Report
[SRO PCE STATUS]
The PCE Filing Status Report option provides a report of the Patient Care Encounter (PCE) filing status
of completed cases performed during the selected date range in accordance with the site parameter
controlling PCE updates. If this site parameter is turned off, the report will show no cases. The report may
be printed for O.R. surgical cases, non-O.R. procedures or both. The report may also be printed for all
specialties or for a single specialty only.
This report is intended to be used as a tool in the review of Surgery case information that is passed to
PCE. The report uses 2 status categories:
(1) FILED - This status indicates that case information has already been filed with PCE.
(2) NOT FILED - This status indicates that the case information has not been filed with PCE. The case
may or may not be missing information needed to file with PCE.
Two forms of the report are available: the short and the long forms. The short form uses an 80-column
format and does not include surgeon/provider, attending, principal post-op diagnosis, and CPT and ICD-9
code information. The totals printed at the end will show only the total cases for each status.
The long form uses a 132-column format and prints case information including the surgeon/provider, the
attending, the specialty, the principal post-op diagnosis, and the principal procedure. If the PCE filing
status is FILED, the CPT codes and ICD diagnosis codes will be printed. If the filing status is NOT
FILED, information fields needed for PCE filing that do not contain data will be printed. At the end of the
report, the number of cases in each PCE filing status will be printed, plus the number of CPT and ICD
codes for cases with a status of FILED.
The PCE Filing Status report will display missing clinical indicator data information, per encounter. This
indicates to the user what information is missing. The report displays CPT codes that do not have an
associated diagnostic code, and textual diagnoses that do not have a corresponding ICD diagnosis code.
238
Surgery V. 3.0 User Manual
April 2004
Example 1: PCE Filing Status Report (Short Form)
Select CPT/ICD Coding Menu Option: PS
PCE Filing Status Report
Report of PCE Filing Status
This report displays the filing status of completed cases performed during the
selected date range.
Print PCE filing status of completed cases for
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 6 8 (JUN 08, 2005)
End with Date: 6 10 (JUN 10, 2005)
Print the long form or the short form ? SHORT// <Enter>
Print the PCE Filing Status Report to which Printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
239
ALBANY
PCE FILING STATUS REPORT
For Completed O.R. Surgical Procedures
From: JUN 8,2005 To: JUN 10,2005
Report Printed: JUL 19,[email protected]:40
PAGE 1
DATE OF OPERATION
CASE #
PATIENT NAME
PATIENT ID (AGE)
FILING STATUS
SPECIALTY
SCHED STATUS
PRINCIPAL PROCEDURE
================================================================================
JUN 8,[email protected]:00
SURPATIENT,TWELVE
045-14-6822 (80)
NOT FILED
277
GENERAL(OR WHEN NOT
<NONE>
TURP
Missing Information:
1. CLASSIFICATION INFORMATION
2. PRINCIPAL PROCEDURE CODE
3. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
-------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,NINETYONE 604-06-1451P (53)
FILED
292
GENERAL(OR WHEN NOT
<NONE>
APPENDECTOMY
-------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,FORTYONE
104-04-0550P (55)
FILED
295
GENERAL(OR WHEN NOT
<NONE>
REMOVE THYROID CYST
-------------------------------------------------------------------------------FILED:
NOT FILED:
2
1
----TOTAL CASES:
3
240
Surgery V. 3.0 User Manual
April 2004
Example 2: PCE Filing Status Report (Long Form)
Select CPT/ICD Coding Menu Option: PS
PCE Filing Status Report
Report of PCE Filing Status
This report displays the filing status of completed cases performed during the
selected date range.
Print PCE filing status of completed cases for
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 6 8
(JUN 08, 2005)
End with Date: 6 10 (JUN 10, 2005)
Print the long form or the short form ? SHORT// LONG
Print the PCE Filing Status Report to which Printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
241
ALBANY
PCE FILING STATUS REPORT
For Completed O.R. Surgical Procedures
From: JUN 8,2005 To: JUN 10,2005
Report Printed: JUL 19,[email protected]:19
PAGE 1
DATE OF OPERATION
CASE #
PATIENT NAME
SURGEON
SPECIALTY
PCE FILING STATUS
PATIENT ID (AGE)
ATTENDING
PRINCIPAL POST-OP DIAGNOSIS
SCHED STATUS
PRINCIPAL PROCEDURE
====================================================================================================================================
JUN 8,[email protected]:00
SURPATIENT,TWELVE
SURSURGEON,ONE
GENERAL(OR WHEN NOT DEFINED BELOW)
NOT FILED
277
000-41-8719 (80)
SURSURGEON,ONE
TURPY
<NONE>
TURP
Missing Information:
1. CLASSIFICATION INFORMATION
2. PRINCIPAL PROCEDURE CODE
3. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
-----------------------------------------------------------------------------------------------------------------------------------JUN 9,[email protected]:00
SURPATIENT,FIFTEEN
SURSURGEON,THREE
GENERAL(OR WHEN NOT DEFINED BELOW)
NOT FILED
280
000-98-1234 (60)
SURSURGEON,ONE
HERNIA, INGUINAL
<NONE>
HERNIA REPAIR
Missing Information:
1. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
2. OTHER PROCEDURE CPT MISSING ASSOCIATED DIAGNOSIS ICD CODE
-----------------------------------------------------------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,NINETYONE
SURSURGEON,ONE
GENERAL(OR WHEN NOT DEFINED BELOW)
FILED
292
000-06-1451
(53)
SURSURGEON,ONE
NOT ENTERED
<NONE>
APPENDECTOMY
CPT Code: 44950
APPENDECTOMY
ICD Diagnosis Code: 540.1 ABSCESS OF APPENDIX
ICD Diagnosis Code: 560.31 GALLSTONE ILEUS
-----------------------------------------------------------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,FORTYONE
SURSURGEON,THREE
GENERAL(OR WHEN NOT DEFINED BELOW)
FILED
295
000-04-0550
(55)
SURSURGEON,THREE
THYROID CYST
<NONE>
REMOVE THYROID CYST
CPT Code: 60200 REMOVE THYROID LESION
ICD Diagnosis Code: 246.2 CYST OF THYROID
-----------------------------------------------------------------------------------------------------------------------------------CPT
ICD
CASES CODES
CODES
FILED:
2
2
2
NOT FILED:
2
----- --------TOTAL:
3
2
2
242
Surgery V. 3.0 User Manual
April 2004
Report of Non-O.R. Procedures
[SRONOR]
The Report of Non-O.R. Procedures option chronologically lists non-O.R. procedures sorted by surgical
specialty or surgeon. This report can be sorted by specialty, provider, or location.
This report prints in a 132-column format and must be copied to a printer.
Example 1: Report of Non-O.R. Procedures by Specialty
Select CPT/ICD Coding Menu Option: R
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
1// <Enter>
Do you want to print the report for all Specialties ?
Print the Report for which Specialty ?
YES// N
CARDIOLOGY
This report is designed to use a 132 column format.
Print on Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
243
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
CASE #
PATIENT (ID#)
LOCATION (IN/OUT-PAT STATUS)
PROVIDER
START TIME
PRINCIPAL ANESTHETIST
FINISH TIME
ANESTHESIOLOGIST SUPERVISOR
PROCEDURE(S)
====================================================================================================================================
*** SPECIALTY: CARDIOLOGY ***
03/02/99
501
SURPATIENT,TWELVE (000-41-8719)
AMBULATORY SURGERY (OUTPATIENT)
SURSURGEON,TWO
SURANESTHETIST,TWO
SURANESTHETIST,ONE
CARDIOVERSION
03/02/99 13:05
03/02/99 14:10
03/13/99
500
SURPATIENT,SIXTY (000-56-7821)
ICU (INPATIENT)
SURSURGEON,TWO
SURANESTHETIST,FOUR
SURANESTHETIST,ONE
CARDIOVERSION
03/13/99 14:00
03/13/99 14:25
244
Surgery V. 3.0 User Manual
April 2004
Example 2: Report of Non-O.R. Procedures by Provider
Select CPT/ICD Coding Menu Option: R
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
1// 2
Do you want to print the report for all Providers ?
Print the Report for which Provider ?
YES// N
SURSURGEON,SIXTEEN
This report is designed to use a 132 column format.
Print on Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
245
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
CASE #
PATIENT (ID#)
LOCATION (IN/OUT-PAT STATUS)
SPECIALTY
START TIME
PRINCIPAL ANESTHETIST
FINISH TIME
ANESTHESIOLOGIST SUPERVISOR
PROCEDURE(S)
====================================================================================================================================
*** PROVIDER SURSURGEON,SIXTEEN ***
03/12/99
195
SURPATIENT,TWO (000-45-1982)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
SURANESTHETIST,TWO
SURANESTHETIST,ONE
ELECTROCONVULSIVE THERAPY
03/12/99 08:00
03/12/99 09:00
03/23/99
240
SURPATIENT,NINE (000-34-5555)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
SURANESTHETIST,SIX
SURANESTHETIST,ONE
ELECTROCONVULSIVE THERAPY
03/23/99 08:10
03/23/99 08:40
03/25/99
266
SURPATIENT,FOURTEEN (000-45-7212)
PAC(U) - ANESTHESIA (INPATIENT)
PSYCHIATRY
SURANESTHETIST,TWO
SURANESTHETIST,ONE
ELECTROCONVULSIVE THERAPY
03/12/99 09:30
03/12/99 10:15
246
Surgery V. 3.0 User Manual
April 2004
Example 3: Report of Non-O.R. Procedures by Location
Select CPT/ICD Coding Menu Option: R
Report of Non-O.R. Procedures
Report of Non-OR Procedures
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/31 (MAR 31, 1999)
How do you want the report sorted ?
1. By Specialty
2. By Provider
3. By Location
Select Number:
1// 3
Do you want to print the report for all Locations ?
Print the Report for which Location ?
YES// N
AMBULATORY SURGERY
This report is designed to use a 132 column format.
Print on Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
247
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF NON-O.R. PROCEDURES
FROM: MAR 1,1999 TO: MAR 31,1999
REVIEWED BY:
DATE REVIEWED:
DATE
CASE #
PATIENT (ID#)
SPECIALTY (IN/OUT-PAT STATUS)
PROVIDER
START TIME
PRINCIPAL ANESTHETIST
FINISH TIME
ANESTHESIOLOGIST SUPERVISOR
PROCEDURE(S)
====================================================================================================================================
*** LOCATION: AMBULATORY SURGERY ***
03/02/99
201
SURPATIENT,TWELVE (000-41-8719)
CARDIOLOGY (OUTPATIENT)
SURSURGEON,TWO
SURANESTHETIST,FOUR
SURANESTHETIST,ONE
CARDIOVERSION
03/02/99 13:05
03/02/99 14:10
03/06/99
198
SURPATIENT,TWENTY (000-45-4886)
GENERAL(ACUTE MEDICINE) (OUTPATIENT)
SURSURGEON,FOUR
SURANESTHETIST,FIVE
SURANESTHETIST,ONE
EXCISION OF SKIN LESION
03/07/99 16:30
03/07/99 17:08
03/09/99
193
SURPATIENT,FIFTY (000-45-9999)
GENERAL (ACUTE MEDICINE) (OUTPATIENT)
SURANESTHETIST,ONE
SURANESTHETIST,FIVE
SURANESTHETIST,SEVEN
STELLATE NERVE BLOCK
03/09/99 09:45
03/09/99 10:21
03/13/99
200
SURPATIENT,SIXTY (000-56-7821)
CARDIOLOGY (INPATIENT)
SURSURGEON,TWO
SURANESTHETIST,TWO
SURANESTHETIST,ONE
CARDIOVERSION
03/13/99 14:00
03/13/99 14:25
03/17/99
194
SURPATIENT,EIGHTEEN (000-22-3334)
GENERAL SURGERY (OUTPATIENT)
SURSURGEON,FOUR
SURANESTHETIST,SIX
SURANESTHETIST,SEVEN
EXCISION OF SKIN LESION
03/17/99 13:30
03/17/99 14:42
248
Surgery V. 3.0 User Manual
April 2004
Chapter Three: Generating Surgical Reports
Introduction
The Surgery package integrates clinical and patient data to provide a variety of reports for Surgery
Service management. This chapter describes reports that are generated for Surgical Service staff. Among
the reports generated are the Annual Report of Surgical Procedures, Anesthesia AMIS, Attending
Surgeons Report, and Nurse Staffing Report.
Exiting an Option or the System
The user can enter an up-arrow (^) to stop what he or she is doing. The up-arrow can be used at almost
any prompt to stop the line of questioning and return to the previous level in the option. The user should
continue entering up-arrows to completely exit the system.
Option Overview
The main options included in this chapter are listed below. The Surgery Reports menu contains
submenus. To the left of the option name is the shortcut synonym the user can enter to select the option.
A restricted option (such as the Surgery Reports menu) will not display if the user does not have security
clearance for that option.
Shortcut
SR
L
April 2004
Option Name
Surgery Reports
Laboratory Interim Report
Surgery V. 3.0 User Manual
249
(This page included for two-sided copying.)
250
Surgery V. 3.0 User Manual
April 2004
Surgery Reports
[SRORPTS]
The Chief of Surgery and staff members use the Surgery Reports menu to select various reports for the
Surgical Service. Among the reports generated are the Annual Report of Surgical Procedures, Anesthesia
AMIS, Attending Surgeons Report, and Nurse Staffing Report.
This menu is locked with the SROREP key.
All of the menu items below contain sub-options. To the left of the menu name is the shortcut synonym
the user can enter to select the option.
Shortcut
Option Name
M
Management Reports
S
Surgery Staffing Reports
A
Anesthesia Reports
CPT
CPT Code Reports
April 2004
Surgery V. 3.0 User Manual
251
Management Reports
[SR MANAGE REPORTS]
The Management Reports menu provides access to several Management Reports options. These options
generate reports on completed cases, meaning cases that have an entry for the TIME PAT OUT OR field.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
the user can enter to select the option.
Shortcut
S
A
L
LD
LS
LP
P
U
D
PS
NOX
252
Option Name
Schedule of Operations
Annual Report of Surgical Procedures
List of Operations
List of Operations (by Postoperative Disposition)
List of Operations (by Surgical Specialty)
List of Operations (by Surgical Priority)
Report of Surgical Priorities
List of Undictated Operations
Report of Daily Operating Room Activity
PCE Filing Status Report
Outpatient Encounters Not Transmitted to NPCD
Surgery V. 3.0 User Manual
April 2004
Schedule of Operations
[SROSCH]
The Schedule of Operations option generates the Operating Room Schedule used by the operating room
nurses, surgeons, anesthetists, and other hospital services. The report lists operations and patients
scheduled for a particular date. It sorts by operating room and includes the procedure(s), blood products
requested, and any preoperative x-rays requested. The schedule also provides anesthesia information and
surgeon names.
This report can be printed on multiple printers simultaneously. Use the options included within the
Surgery Package Management Menu option to enter the name of all printers on which the schedule will
print.
This report has a 132-column format and is designed to be copied to a printer with wide paper.
Example: Print Schedule of Operations
Select Management Reports Option:
S
Schedule of Operations
Print Schedule of Operations for which date ?
9/8
(SEP 08, 1999)
This report is designed to use a 132 column format.
Print the Report on which device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
253
PRINTED: SEP 07, 1999 11:12
MAYBERRY, NC
SURGICAL SERVICE
SCHEDULE OF OPERATIONS
FOR: SEP 08, 1999
PAGE 1
SIGNATURE OF CHIEF: DR. MOE HOWARD
____________________
PATIENT
DISPOSITION
PREOPERATIVE DIAGNOSIS
REQ ANESTHESIA
SURGEON
ID#
AGE
START TIME
OPERATION(S)
ANESTHESIOLOGIST
FIRST ASST.
WARD
END TIME
PRIN. ANESTHETIST
ATT SURGEON
====================================================================================================================================
OPERATING ROOM: OR1
SURPATIENT,ONE
000-44-7629
TO BE ADMITTED
Case # 143
46
WARD
07:30
09:30
CARPAL TUNNEL SYNDROME
REVISE MEDIAN NERVE
GENERAL
SURANESTHESIOLOGIST,O
SURANESTHETIST, T
SURSURGEON, O
SURSURGEON, F
SURSURGEON, O
PREOPERATIVE XRAYS: CARPAL TUNNEL, R WRIST
OPERATING ROOM: OR2
SURPATIENT,FOURTEEN
000-45-7212
48
HICU 212-B
Case # 141
WARD
CHOLELITHIASIS
06:30
CHOLECYSTECTOMY
08:00
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - 2 UNITS
PREOPERATIVE XRAYS: ABDOMIN
GENERAL
SURANESTHESIOLOGIST,F
SURANESTHETIST, O
SURSURGEON, O
SURSURGEON, T
SURSURGEON, O
SURPATIENT,TWELVE
000-41-8719
60
TO BE ADMITTED
Case # 142
WARD
ACUTE DIAPHRAGMATIC HERNIA
08:00
REPAIR DIAPHRAGMATIC HERNIA
09:30
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - 2 UNITS
PREOPERATIVE XRAYS: ABDOMEN
GENERAL
SURANESTHESIOLOGIST,T
SURANESTHETIST, O
SURSURGEON, T
SURSURGEON, O
SURSURGEON, T
SURPATIENT,THIRTY
000-82-9472
48
TO BE ADMITTED
WARD
CAROTID ARTERY STENOSIS
11:15
CAROTID ARTERY ENDARTERECTOMY
16:00
** Concurrent Case #157
AORTO CORONARY BYPASS GRAFT
REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
CPDA-1 RED BLOOD CELLS - UNITS NOT ENTERED
CPDA-1 WHOLE BLOOD - 2 UNITS
PREOPERATIVE XRAYS: DOPPLER STUDIES
GENERAL
SURANESTHESIOLOGIST,T
SURANESTHETIST, F
SURSURGEON, O
SURSURGEON, F
SURSURGEON, O
WARD
CORONARY ARTERY DISEASE
11:15
AORTO CORONARY BYPASS GRAFT
16:00
** Concurrent Case #150
CAROTID ARTERY ENDARTERECTOMY
GENERAL
SURANESTHESIOLOGIST,O
SURANESTHETIST, O
SURSURGEON, T
SURSURGEON, F
SURSURGEON, T
Case # 150
SURPATIENT,THIRTY
000-82-9472
48
TO BE ADMITTED
Case # 157
TOTAL CASES SCHEDULED: 5
254
Surgery V. 3.0 User Manual
April 2004
Annual Report of Surgical Procedures
[SROARSP]
The Annual Report of Surgical Procedures option is used to generate the Annual Report of Surgical
Procedures required by VA Central Office. This report counts the number of times a procedure was
performed, based on the CPT code entry, within a surgical specialty.
The report includes only cases that have not been cancelled and that have an entry for the TIME PAT
OUT OR field. Procedures without CPT codes are not included in this report.
This report can be generated for any date range, not only annually.
The report has a 132-column format and is designed to be copied to a printer.
Example: Annual Report of Surgical Procedures
Select Management Reports Option:
A
Annual Report of Surgical Procedures
Annual Report of Surgical Procedures
Start with Date: 9/1 (SEP 01, 2001)
End with Date: 9/30 (SEP 30, 2001)
Do you want to print the Annual Report of Surgical Procedures for all Surgical Specialties?
YES// <Enter>
This report is designed to use a 132 column format, and must be run on a printer.
Select Printer:
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
255
MAYBERRY, NC
SURGICAL SERVICE
ANNUAL REPORT OF SURGICAL PROCEDURES
FROM: SEP 1,2001 TO: SEP 30,2001
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: OCT 20,2001
MAJOR
MINOR
CPT CODE - OPERATION
TOTAL
STAFF RESIDENT
TOTAL
STAFF RESIDENT
TOTAL
-----------------------------------------------------------------------------------------------------------------------------------NEUROSURGERY
-----------------------------------------------------------------------------------------------------------------------------------61304 OPEN SKULL FOR EXPLORATION
1
1
0
1
0
0
0
61680 INTRACRANIAL VESSEL SURGERY
1
0
0
0
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------TOTALS FOR NEUROSURGERY:
2
1
0
1
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------ORTHOPEDICS
-----------------------------------------------------------------------------------------------------------------------------------27130 TOTAL HIP REPLACEMENT
2
0
0
0
1
1
2
27236 REPAIR OF THIGH FRACTURE
1
0
0
0
0
1
1
-----------------------------------------------------------------------------------------------------------------------------------TOTALS FOR ORTHOPEDICS:
3
0
0
0
1
2
3
-----------------------------------------------------------------------------------------------------------------------------------OTORHINOLARYNGOLOGY (ENT)
-----------------------------------------------------------------------------------------------------------------------------------31365 REMOVAL OF LARYNX
2
0
0
0
2
0
2
-----------------------------------------------------------------------------------------------------------------------------------TOTALS FOR OTORHINOLARYNGOLOGY (ENT):
2
0
0
0
2
0
2
-----------------------------------------------------------------------------------------------------------------------------------THORACIC SURGERY (INC. CARDIAC SURG.)
-----------------------------------------------------------------------------------------------------------------------------------32480 PARTIAL REMOVAL OF LUNG
2
0
0
0
1
1
2
32500 PARTIAL REMOVAL OF LUNG
1
0
0
0
1
0
1
33510 CABG, VEIN, SINGLE
1
0
0
0
0
1
1
-----------------------------------------------------------------------------------------------------------------------------------TOTALS FOR THORACIC SURGERY (INC. CARDIAC SURG.): 4
0
0
0
2
2
4
-----------------------------------------------------------------------------------------------------------------------------------====================================================================================================================================
TOTAL OPERATIONS:
11
1
0
1
6
4
10
====================================================================================================================================
256
Surgery V. 3.0 User Manual
April 2004
List of Operations
[SROPLIST]
The List of Operations option contains general information for completed cases within a specified date
range. It sorts the cases by date and includes the procedure(s), surgical service, length of actual operation,
surgeons, and anesthesia technique. This report also includes aborted cases.
This report has a 132-column format and is designed to be copied to a printer.
Example: List of Operations
Select Management Reports Option:
L
List of Operations
List of Operations
Start with Date: 10/8 (OCT 08, 2001)
End with Date: 10/8 (OCT 08, 2001)
This report is designed to use a 132 column format.
Print to device:
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
257
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS
FROM: OCT 8,2001 TO: OCT 8,2001
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: SEP 20,2001
DATE
CASE #
PATIENT
SERVICE
SURGEON
ANESTHESIA TECH
ID#
OPERATION(S)
1ST ASSISTANT
PRIORITY
2ND ASSISTANT
====================================================================================================================================
10/08/01
63071
SURPATIENT,FOUR
000-17-0555
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/08/01
63072
SURPATIENT,EIGHTEEN
000-22-3334
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
CHOLECYSTECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 50 MIN.
10/08/01
63073
SURPATIENT,FIFTYONE
000-23-3221
URGENT, ADD TODAY
OPHTHALMOLOGY
INTRAOCCULAR LENS, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,FOUR
SPINAL
OP TIME: 50 MIN.
10/08/01
63074
SURPATIENT,FIVE
000-58-7963
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
HIP REPLACEMENT
SURSURGEON,FOUR
SURSURGEON,FOUR
SURSURGEON,FIVE
NOT ENTERED
OP TIME: 50 MIN.
10/08/01
63075
SURPATIENT,SIX
000-09-8797
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
PULMONARY LOBECTOMY
SURSURGEON,TWO
SURSURGEON,THREE
SURSURGEON,TWO
NOT ENTERED
OP TIME: 45 MIN.
10/08/01
63077
SURPATIENT,TWELVE
000-41-8719
ELECTIVE
GENERAL(OR WHEN NOT DEFINED BELOW)
INGUINAL HERNIA, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,THREE
GENERAL
OP TIME: 63 MIN.
10/08/01
63076
SURPATIENT,FOURTEEN
000-45-7212
ELECTIVE
UROLOGY
TURP
SURSURGEON,TWO
SURSURGEON,FOUR
SURSURGEON,TWO
GENERAL
OP TIME: 45 MIN.
TOTAL CASES: 7
258
Surgery V. 3.0 User Manual
April 2004
List of Operations (by Postoperative Disposition)
The List of Operations (by Postoperative Disposition) option contains general information for completed
cases within a selected date range. It sorts the cases by postoperative disposition and by case number.
Reports may also be sorted by specialty.
This report includes information on case type, length of actual operation, surgeon names, and anesthesia
technique.
This report has a 132-column format and is designed to be copied to a printer.
Example 1: List of Operations by Postoperative Disposition (All Dispositions)
Select Management Reports Option: LD
List of Operations (by Postoperative Disposition)
List of Operations by Postoperative Disposition:
Start with Date: 10/8 (OCT 08, 2001)
End with Date: 10/8 (OCT 08, 2001)
Print the List of Operations for which of the following ?
1. All Dispositions
2. A Specific Disposition
3. No Disposition Entered
Enter selection: 1// 1
All Dispositions
Do you want the report sorted by surgical specialty ?
Print for all surgical specialties ?
Y// <Enter>
Y// N
Print the report for which Specialty ?
GENERAL(OR WHEN NOT DEFINED BELOW)
Select An Additional Specialty: <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
259
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS BY POSTOP DISPOSITION
FROM: OCT 8,2001 TO: OCT 8,2001
POSTOP DISPOSITION: WARD
DATE
CASE #
PATIENT
ID#
DATE PRINTED: OCT 20,2001
REVIEWED BY:
DATE REVIEWED:
PAGE
1
SURGEON
ANESTHESIA TECH
1ST ASST
IN/OUT-PAT STATUS
2ND ASST
OP TIME
----------------------------------------------------------------------------------------------------------------------------------->> GENERAL(OR WHEN NOT DEFINED BELOW) <<
10/08/01
63072
SURPATIENT,EIGHTEEN
000-22-3334
10/08/01
63077
SURPATIENT,TWELVE
000-41-8719
10/08/01
63071
SURPATIENT,FOUR
000-17-0555
OPERATION(S)
CHOLECYSTECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OUTPATIENT
50 MIN.
INGUINAL HERNIA, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,THREE
GENERAL
OUTPATIENT
63 MIN.
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OUTPATIENT
50 MIN.
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 3
260
Surgery V. 3.0 User Manual
April 2004
Example 2: List of Operations by Postoperative Disposition (A Specific Disposition)
Select Management Reports Option: LD
List of Operations (by Postoperative Disposition)
List of Operations by Postoperative Disposition:
Start with Date: 10/4 (OCT 04, 2001)
End with Date: 10/8 (OCT 08, 2001)
Print the List of Operations for which of the following ?
1. All Dispositions
2. A Specific Disposition
3. No Disposition Entered
Enter selection: 1// 2
A Specific Disposition
Print the report for which Disposition ?
OUTPATIENT
Do you want the report sorted by surgical specialty ?
O
Y// N
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
261
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS BY POSTOP DISPOSITION
FROM: OCT 4,2001 TO: OCT 8,2001
POSTOP DISPOSITION: OUTPATIENT
DATE
CASE #
DATE PRINTED: OCT 20,2001
REVIEWED BY:
DATE REVIEWED:
PATIENT
ID#
OPERATION(S)
10/04/01
63066
SURPATIENT,THREE
000-21-2453
(GENERAL)
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,TWO
SURSURGEON,ONE
GENERAL
OUTPATIENT
40 MIN.
10/04/01
63067
SURPATIENT,EIGHT
000-37-0555
(GENERAL)
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OUTPATIENT
50 MIN.
10/04/01
63068
SURPATIENT,NINE
000-17-0555
(GENERAL)
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OUTPATIENT
45 MIN.
10/07/01
63070
SURPATIENT,SIXTY
000-56-7821
(GENERAL)
INGUINAL HERNIA
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OUTPATIENT
45 MIN.
10/08/01
63071
SURPATIENT,FOUR
000-17-0555
(GENERAL)
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OUTPATIENT
50 MIN.
PAGE
1
SURGEON
ANESTHESIA TECH
1ST ASST
IN/OUT-PAT STATUS
2ND ASST
OP TIME
------------------------------------------------------------------------------------------------------------------------------------
TOTAL OUTPATIENT: 5
262
Surgery V. 3.0 User Manual
April 2004
Example 3: List of Operations by Postoperative Disposition (No Disposition Entered)
Select Management Reports Option: LD
List of Operations (by Postoperative Disposition)
List of Operations by Postoperative Disposition:
Start with Date: 10/4 (OCT 04, 2001)
End with Date: 10/8 (OCT 08, 2001)
Print the List of Operations for which of the following ?
1. All Dispositions
2. A Specific Disposition
3. No Disposition Entered
Enter selection: 1// 3
No Disposition Entered
Do you want the report sorted by surgical specialty ?
Y// N
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
263
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS BY POSTOP DISPOSITION
FROM: OCT 4,2001 TO: OCT 8,2001
POSTOP DISPOSITION: DISPOSITION NOT ENTERED
DATE
CASE #
PATIENT
ID#
OPERATION(S)
10/04/01
63069
SURPATIENT,TEN
000-12-3456
(THORACIC SURGERY )
PULMONARY LOBECTOMY
10/08/01
63073
SURPATIENT,FIFTYONE
000-23-3221
(OPHTHALMOLOGY)
10/08/01
63076
SURPATIENT,FOURTEEN
000-45-7212
(UROLOGY)
DATE PRINTED: SEP 20,2001
REVIEWED BY:
DATE REVIEWED:
PAGE
1
SURGEON
ANESTHESIA TECH
1ST ASST
IN/OUT-PAT STATUS
2ND ASST
OP TIME
------------------------------------------------------------------------------------------------------------------------------------
INTRAOCCULAR LENS, CHOLECYSTECTOMY
TURP
SURSURGEON,TWO
SURSURGEON,FIVE
SURSURGEON,ONE
GENERAL
OUTPATIENT
60 MIN.
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,FOUR
SPINAL
OUTPATIENT
50 MIN.
SURSURGEON,TWO
SURSURGEON,FOUR
SURSURGEON,TWO
GENERAL
OUTPATIENT
45 MIN.
TOTAL DISPOSITION NOT ENTERED: 3
264
Surgery V. 3.0 User Manual
April 2004
List of Operations (by Surgical Specialty)
The List of Operations (by Surgical Specialty) option contains general information for completed cases
within a selected date range. It sorts the cases by surgical specialty and case number.
This report includes information on case type, length of actual operation, surgeon names, and anesthesia
technique. The user can request a list for all specialties or a selected specialty.
This report has a 132-column format and is designed to be copied to a printer.
Example: List of Operations by Surgical Specialty
Select Management Reports Option: LS
List of Operations (by Surgical Specialty)
List of Operations sorted by Surgical Specialty
Start with Date: 10/4 (OCT 04, 2001)
End with Date: 10/8 (OCT 08, 2001)
Do you want to print the report for all Specialties ?
Print the report for which Surgical Specialty ?
YES//
N
GENERAL (OR WHEN NOT DEFINED BELOW)
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
265
MAYBERRY, NC
SURGICAL SERVICE
LIST OF OPERATIONS BY SERVICE
FROM: OCT 4,2001 TO: OCT 8,2001
PAGE 1
DATE REVIEWED:
REVIEWED BY:
DATE PRINTED: SEP 20,2001
DATE
CASE #
PATIENT
OPERATION(S)
SURGEON
ANESTHESIA
ID#
FIRST ASSISTANT
TECHNIQUE
PRIORITY
SECOND ASSISTANT
====================================================================================================================================
*GENERAL(OR WHEN NOT DEFINED BELOW)*
10/04/01
63066
SURPATIENT,THREE
000-21-2453
STANDBY
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,TWO
SURSURGEON,ONE
GENERAL
OP TIME: 40 MIN.
10/04/01
63067
SURPATIENT,EIGHT
000-37-0555
ELECTIVE
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/04/01
63068
SURPATIENT,TEN
000-12-3456
ELECTIVE
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 45 MIN.
10/07/01
63070
SURPATIENT,SIXTY
000-56-7821
ELECTIVE
INGUINAL HERNIA
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 45 MIN.
10/08/01
63071
SURPATIENT,FOUR
000-17-0555
ELECTIVE
INGUINAL HERNIA
SURSURGEON,FOUR
SURSURGEON,ONE
SURSURGEON,TWO
GENERAL
OP TIME: 50 MIN.
10/08/01
63072
SURPATIENT,EIGHTEEN
000-22-3334
ELECTIVE
CHOLECYSTECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 50 MIN.
10/08/01
63077
SURPATIENT,FIVE
000-58-7963
ELECTIVE
INGUINAL HERNIA, CHOLECYSTECTOMY
SURSURGEON,FOUR
SURSURGEON,THREE
SURSURGEON,TWO
GENERAL
OP TIME: 63 MIN.
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 7
266
Surgery V. 3.0 User Manual
April 2004
List of Operations (by Surgical Priority)
The List of Operations (by Surgical Priority) option generates a report containing general information for
completed cases within a selected date range. It sorts the cases by surgical priority and surgical specialty.
This report includes information on case type, length of actual operation, surgeon names, and anesthesia
technique. The user can request a list for all priorities or a selected priority. One or more surgical
specialties can also be specified.
This report has a 132-column format and is designed to be copied to a printer.
Example: List of Operations by Surgical Priority
Select Management Reports Option:
LP
List of Operations (by Surgical Priority)
List of Operations by Surgical Priority:
Start with Date: 8/1 (AUG 01, 2001)
End with Date: 9/30 (SEP 30, 2001)
Print List of Operations for all priorities ? Y// N
Print report for which Priority ?
1.
2.
3.
4.
5.
6.
EMERGENCY
ELECTIVE
ADD ON TODAY (NONEMERGENT)
STANDBY
URGENT ADD TODAY
PRIORITY NOT ENTERED
Select Number:
1// 4
Do you want the report sorted by surgical specialty ? Y// <Enter>
Print for all surgical specialties ? Y// <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device:
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
267
ISC-BIRMINGHAM, AL
SURGICAL SERVICE
LIST OF OPERATIONS BY SURGICAL PRIORITY
FROM: AUG 1,2001 TO: SEP 30,2001
SURGICAL PRIORITY: STANDBY
DATE
CASE #
PAGE:
1
DATE PRINTED: OCT 20,2001
REVIEWED BY:
DATE REVIEWED:
PATIENT
ID#
OPERATION(S)
SURGEON
ANESTHESIA TECH
1ST ASST
2ND ASST
----------------------------------------------------------------------------------------------------------------------------------->> THORACIC SURGERY (INC. CARDIAC SURG.) <<
08/21/01
62901
SURPATIENT,THREE
000-21-2453
PULMONARY LOBECTOMY
SURSURGEON,FOUR
SURSURGEON,TWO
SURSURGEON,ONE
GENERAL
OP TIME: 170 MIN.
09/02/01
63002
SURPATIENT,NINE
000-34-5555
PULMONARY LOBECTOMY
SURSURGEON,TWO
SURSURGEON,TWO
GENERAL
OP TIME: 95 MIN.
09/29/01
63042
SURPATIENT,FOURTEEN
000-45-7212
PULMONARY LOBECTOMY
SURSURGEON,TWO
SURSURGEON,FOUR
GENERAL
OP TIME: 90 MIN.
TOTAL THORACIC SURGERY (INC. CARDIAC SURG.): 3
268
Surgery V. 3.0 User Manual
April 2004
Report of Surgical Priorities
The Report of Surgical Priorities option provides the total number of completed surgical cases for each
surgical priority, such as elective, emergency, and urgent within a date range. The user can sort the report
by all surgical specialties, one surgical specialty (Example 1), or by all operations within a date range
(Example 2).
This report has an 80-column format and can be viewed on your terminal display screen.
Example 1: Print Report of Surgical Priorities for a specialty
Select Management Reports Option: P
Report of Surgical Priorities
Report of Surgical Priorities
Start with Date: 3/1 (MAR 01, 2001)
End with Date: T (MAR 26, 2001)
Do you want to review this information sorted by Surgical Specialty ?
Do you want to print this report for all Surgical Specialties ?
Print the report for which Surgical Specialty ? 50
GENERAL(OR WHEN NOT DEFINED BELOW)
50
Print the Report on which Device:
YES// <Enter>
YES// N
GENERAL(OR WHEN NOT DEFINED BELOW)
[Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------MAYBERRY, NC
SURGICAL SERVICE
TOTAL OPERATIONS BY SURGICAL PRIORITY
FROM: MAR 1,2001 TO: MAR 26,2001
_____________________________________________________________________________
GENERAL(OR WHEN NOT DEFINED BELOW)
1.
2.
3.
4.
5.
ELECTIVE
URGENT
EMERGENCY
ADD ON (NON-EMERGENT)
STANDBY
TOTAL SURGICAL CASES:
April 2004
1
1
2
0
1
5
Surgery V. 3.0 User Manual
269
Example 2: Print Report of Surgical Priorities for all Operations
Select Management Reports Option: P
Report of Surgical Priorities
Report of Surgical Priorities
Start with Date: 3/1 (MAR 01, 2001)
End with Date: T (MAR 26, 2001)
Do you want to review this information sorted by Surgical Specialty ?
Print the Report on which Device:
YES// N
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
MAYBERRY, NC
SURGICAL SERVICE
TOTAL OPERATIONS BY SURGICAL PRIORITY
FROM: MAR 1,2001 TO: MAR 26,2001
_____________________________________________________________________________
1.
2.
3.
4.
5.
6.
ELECTIVE
URGENT
EMERGENCY
ADD ON (NON-EMERGENT)
STANDBY
PRIORITY NOT ENTERED
TOTAL SURGICAL CASES:
270
3
2
2
0
4
4
15
Surgery V. 3.0 User Manual
April 2004
Report of Daily Operating Room Activity
The Report of Daily Operating Room Activity option generates a report listing cases started between 6:00
AM on the date selected and 5:59 AM of the following day for all operating rooms.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print the Report of Daily Operating Room Activity
Select Management Reports Option: D
Report of Daily Operating Room Activity
Print the Report of Daily Activity for which Date ?
3/9
This report will include all cases started between MAR
and MAR 10, 2001 at 5:59 AM.
(MAR 09, 2001)
9, 2001 at 6:00 AM
It is designed to use a 132 column format.
Print the Report to which Device ?
[Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
271
MAYBERRY, NC
SURGICAL SERVICE
DAILY REPORT OF OPERATING ROOM ACTIVITY
FOR: MAR 09, 2001
PATIENT
TIME IN OR
POSTOPERATIVE DIAGNOSIS
ANESTHESIOLOGIST
SURGEON
ID #
AGE
TIME OUT OR
PROCEDURE(S)
PRIN. ANESTHETIST
FIRST ASST.
WARD
CASE NUMBER
ATT SURGEON
====================================================================================================================================
OPERATING ROOM: OR1
SURPATIENT,TWELVE
000-41-8719
62
1 NORTH 161-1
03/09 08:00
03/09 09:10
194
INGUINAL HERNIA
INGUINAL HERNIA
SURANESTHESIOLOGIST,O
SURANESTHETIST,F
SURSURGEON,E
SURSURGEON,O
SURSURGEON,T
03/09 09:15
03/09 12:40
187
CHOLECYSTITIS
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
SURANESTHESIOLOGIST,T
SURANESTHETIST,O
SURSURGEON,T
SURSURGEON,F
SURSURGEON,T
03/09 19:56
03/09 21:05
188
APPENDICITIS
APPENDECTOMY, COLONOSCOPY, CHOLECYSTECTOMY, CRAIN
SURANESTHESIOLOGIST,T
SURANESTHETIST,F
SURSURGEON,S
SURSURGEON,F
SURSURGEON,F
OPERATING ROOM: OR3
SURPATIENT,NINE
000-34-5555
48
OUTPATIENT
OPERATING ROOM: OR5
SURPATIENT,SIX
000-09-8797
1 WEST 101-1
272
50
Surgery V. 3.0 User Manual
April 2004
PCE Filing Status Report
The PCE Filing Status Report option provides a report of the Patient Care Encounter (PCE) filing status
of completed cases performed during the selected date range in accordance with the site parameter
controlling PCE updates. If this site parameter is turned off, the report will show no cases. The report may
be printed for O.R. surgical cases, non-O.R. procedures or both. The report may also be printed for all
specialties or for a single specialty only.
This report is intended to be used as a tool in the review of Surgery case information that is passed to
PCE. The report uses 2 status categories:
(1) FILED - This status indicates that case information has already been filed with PCE.
(2) NOT FILED - This status indicates that the case information has not been filed with PCE. The case
may or may not be missing information needed to file with PCE.
Two forms of the report are available: the short and the long forms. The short form uses an 80-column
format and does not include surgeon/provider, attending, principal post-op diagnosis, and CPT and ICD-9
code information. The totals printed at the end will show only the total cases for each status.
The long form uses a 132-column format and prints case information including the surgeon/provider, the
attending, the specialty, the principal post-op diagnosis, and the principal procedure. If the PCE filing
status is FILED, the CPT codes and ICD diagnosis codes will be printed. If the filing status is NOT
FILED, information fields needed for PCE filing that do not contain data will be printed. At the end of the
report, the number of cases in each PCE filing status will be printed, plus the number of CPT and ICD
codes for cases with a status of FILED.
The PCE Filing Status report will display missing clinical indicator data information, per encounter. This
indicates to the user what information is missing. The report displays CPT codes that do not have an
associated diagnostic code, and textual diagnoses that do not have a corresponding ICD diagnosis code.
April 2004
Surgery V. 3.0 User Manual
273
Example 1: PCE Filing Status Report (Short Form)
Select Management Reports Option: PS
PCE Filing Status Report
Report of PCE Filing Status
This report displays the filing status of completed cases performed during the
selected date range.
Print PCE filing status of completed cases for
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 6 8 (JUN 08, 2005)
End with Date: 6 10 (JUN 10, 2005)
Print the long form or the short form ? SHORT// <Enter>
Print the PCE Filing Status Report to which Printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
274
Surgery V. 3.0 User Manual
April 2004
ALBANY
PCE FILING STATUS REPORT
For Completed O.R. Surgical Procedures
From: JUN 8,2005 To: JUN 10,2005
Report Printed: JUL 19,[email protected]:40
PAGE 1
DATE OF OPERATION
CASE #
PATIENT NAME
PATIENT ID (AGE)
FILING STATUS
SPECIALTY
SCHED STATUS
PRINCIPAL PROCEDURE
================================================================================
JUN 8,[email protected]:00
SURPATIENT,TWELVE
000-14-6822 (80)
NOT FILED
277
GENERAL(OR WHEN NOT
<NONE>
TURP
Missing Information:
1. CLASSIFICATION INFORMATION
2. PRINCIPAL PROCEDURE CODE
3. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
-------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,NINETYONE 000-06-1451 (53)
FILED
292
GENERAL(OR WHEN NOT
<NONE>
APPENDECTOMY
-------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,FORTYONE
000-04-0550 (55)
FILED
295
GENERAL(OR WHEN NOT
<NONE>
REMOVE THYROID CYST
-------------------------------------------------------------------------------FILED:
NOT FILED:
2
1
----TOTAL CASES:
3
April 2004
Surgery V. 3.0 User Manual
275
Example 2: PCE Filing Status Report (Long Form)
Select CPT/ICD Coding Menu Option: PS
PCE Filing Status Report
Report of PCE Filing Status
This report displays the filing status of completed cases performed during the
selected date range.
Print PCE filing status of completed cases for
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 6 8
(JUN 08, 2005)
End with Date: 6 10 (JUN 10, 2005)
Print the long form or the short form ? SHORT// LONG
Print the PCE Filing Status Report to which Printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
276
Surgery V. 3.0 User Manual
April 2004
ALBANY
PCE FILING STATUS REPORT
For Completed O.R. Surgical Procedures
From: JUN 8,2005 To: JUN 10,2005
Report Printed: JUL 19,[email protected]:19
PAGE 1
DATE OF OPERATION
CASE #
PATIENT NAME
SURGEON
SPECIALTY
PCE FILING STATUS
PATIENT ID (AGE)
ATTENDING
PRINCIPAL POST-OP DIAGNOSIS
SCHED STATUS
PRINCIPAL PROCEDURE
====================================================================================================================================
JUN 8,[email protected]:00
SURPATIENT,TWELVE
SURSURGEON,ONE
GENERAL(OR WHEN NOT DEFINED BELOW)
NOT FILED
277
000-41-8719 (80)
SURSURGEON,ONE
TURPY
<NONE>
TURP
Missing Information:
1. CLASSIFICATION INFORMATION
2. PRINCIPAL PROCEDURE CODE
3. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
-----------------------------------------------------------------------------------------------------------------------------------JUN 9,[email protected]:00
SURPATIENT,FIFTEEN
SURSURGEON,THREE
GENERAL(OR WHEN NOT DEFINED BELOW)
NOT FILED
280
000-98-1234 (60)
SURSURGEON,ONE
HERNIA, INGUINAL
<NONE>
HERNIA REPAIR
Missing Information:
1. PRIN PROCEDURE CODE MISSING ASSOCIATED DIAGNOSIS CODE
2. OTHER PROCEDURE CPT MISSING ASSOCIATED DIAGNOSIS ICD CODE
-----------------------------------------------------------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,NINETYONE
SURSURGEON,ONE
GENERAL(OR WHEN NOT DEFINED BELOW)
FILED
292
000-06-1451
(53)
SURSURGEON,ONE
NOT ENTERED
<NONE>
APPENDECTOMY
CPT Code: 44950
APPENDECTOMY
ICD Diagnosis Code: 540.1 ABSCESS OF APPENDIX
ICD Diagnosis Code: 560.31 GALLSTONE ILEUS
-----------------------------------------------------------------------------------------------------------------------------------JUN 10,[email protected]:00
SURPATIENT,FORTYONE
SURSURGEON,THREE
GENERAL(OR WHEN NOT DEFINED BELOW)
FILED
295
000-04-0550
(55)
SURSURGEON,THREE
THYROID CYST
<NONE>
REMOVE THYROID CYST
CPT Code: 60200 REMOVE THYROID LESION
ICD Diagnosis Code: 246.2 CYST OF THYROID
-----------------------------------------------------------------------------------------------------------------------------------CPT
ICD
CASES CODES
CODES
FILED:
2
2
2
NOT FILED:
2
----- --------TOTAL:
3
2
2
April 2004
Surgery V. 3.0 User Manual
277
Outpatient Encounters Not Transmitted to NPCD
Outpatient surgical and non-O.R. procedures that are filed as encounters in the PCE package without an
active count clinic identified for each encounter are not transmitted to the National Patient Care Database
(NPCD) as workload. The Outpatient Encounters Not Transmitted to NPCD option may be used as a tool
for identifying these encounters that represent uncounted workload so that corrective actions may be
taken in the Surgery package to insure these procedures are associated with an active count clinic. After
corrections are made, these encounters may be re-filed with PCE to be transmitted to NPCD.
This option provides functionality:
To count and/or list surgical cases and non-O.R. procedures that have entries in PCE but have no
matching entries in the OUTPATIENT ENCOUNTER file or have matching entries that are noncount encounters or encounters requiring action.
To re-file with PCE the cases identified as having no matching entries in the OUTPATIENT
ENCOUNTER file or having matching entries that are non-count encounters or encounters
requiring action.
Both the report and the re-filing process may be run for O.R. surgical cases, non-O.R. procedures or both.
The report and the re-filing process may be run for a specific specialty or for all specialties and may be
run for a selected date range.
Example 1: Print List of Cases
Select Management Reports Option: NOX
NPCD
Outpatient Encounters Not Transmitted to
Outpatient Surgery Encounters Not Transmitted to NPCD
Surgical cases filed with PCE that have no Scheduling appointment status
or that have an appointment status of ACTION REQUIRED or NON-COUNT indicate
surgical encounters that have not transmitted to the National Patient
Care Database. This option is intended as a tool to identify these
encounters and, after taking appropriate corrective measures, to
reinitiate the encounter transmission process.
1. Print list of cases.
2. Print total number of cases only.
3. Re-file cases in PCE.
Select Number: 1// <Enter>
Print the list for the following.
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 5/1 (MAY 01, 2001)
End with Date: 5/15 (MAY 15, 2001)
Print report on which printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
278
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
Outpatient Surgery Encounters Not Transmitted to NPCD
For Completed O.R. Surgical Procedures
From: MAY 1,2001 To: MAY 15,2001
Report Printed: MAY 20,[email protected]:44
Page 1
DATE OF OPERATION
CASE #
SPECIALTY
SCHED STATUS
PATIENT NAME
PRINCIPAL PROCEDURE
PATIENT ID (AGE)
====================================================================================================================================
MAY 1,[email protected]:00
63028
GENERAL(OR WHEN NOT
<NONE>
SURPATIENT,FOURTEEN
CHOLECYSTECTOMY
000-45-7212 (50)
-----------------------------------------------------------------------------------------------------------------------------------MAY 3,[email protected]:45
63092
GENERAL(OR WHEN NOT
<NONE>
SURPATIENT,SIXTY
CHOLEDOCHOTOMY
000-56-7821 (42)
-----------------------------------------------------------------------------------------------------------------------------------MAY 7,[email protected]:15
63142
GENERAL(OR WHEN NOT
<NONE>
SURPATIENT,TWELVE
REPAIR DIAPHRAGMATIC HERNIA
000-41-8719 (73)
-----------------------------------------------------------------------------------------------------------------------------------MAY 12,[email protected]:00
63191
GENERAL(OR WHEN NOT
<NONE>
SURPATIENT,NINE
INGUINAL HERNIA
000-34-5555 (64)
-----------------------------------------------------------------------------------------------------------------------------------MAY 14,[email protected]:00
63208
GENERAL(OR WHEN NOT
ACTION REQUIRED
SURPATIENT,TWELVE
CHOLECYSTECTOMY
000-41-8719 (73)
-----------------------------------------------------------------------------------------------------------------------------------MAY 15,[email protected]:01
63180
GENERAL(OR WHEN NOT
<NONE>
SURPATIENT,SIXTY
CHOLECYSTECTOMY
000-56-7821 (42)
-----------------------------------------------------------------------------------------------------------------------------------SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
Total with NO status:
Total with NON-COUNT:
Total with ACTION REQUIRED:
5
0
1
----Total cases identified:
6
April 2004
Surgery V. 3.0 User Manual
279
Example 2: Print Total Number of Cases Only
Select Management Reports Option: NOX
NPCD
Outpatient Encounters Not Transmitted to
Outpatient Surgery Encounters Not Transmitted to NPCD
Surgical cases filed with PCE that have no Scheduling appointment status
or that have an appointment status of ACTION REQUIRED or NON-COUNT indicate
surgical encounters that have not transmitted to the National Patient
Care Database. This option is intended as a tool to identify these
encounters and, after taking appropriate corrective measures, to
reinitiate the encounter transmission process.
1. Print list of cases.
2. Print total number of cases only.
3. Re-file cases in PCE.
Select Number: 1// 2
Print the list for the following.
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// <Enter>
Do you want the report for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 5/1 (MAY 01, 2001)
End with Date: 5/15 (MAY 15, 2001)
Print report on which printer ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
280
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
Outpatient Surgery Encounters Not Transmitted to NPCD
Page 1
For Completed O.R. Surgical Procedures
From: MAY 1,2001 To: MAY 15,2001
Report Printed: MAY 20,[email protected]:25
================================================================================
SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
Total with NO status:
Total with NON-COUNT:
Total with ACTION REQUIRED:
5
0
1
----Total cases identified:
6
April 2004
Surgery V. 3.0 User Manual
281
Example 3: Re-File Cases in PCE
Select Management Reports Option: NOX
NPCD
Outpatient Encounters Not Transmitted to
Outpatient Surgery Encounters Not Transmitted to NPCD
Surgical cases filed with PCE that have no Scheduling appointment status
or that have an appointment status of ACTION REQUIRED or NON-COUNT indicate
surgical encounters that have not transmitted to the National Patient
Care Database. This option is intended as a tool to identify these
encounters and, after taking appropriate corrective measures, to
reinitiate the encounter transmission process.
1. Print list of cases.
2. Print total number of cases only.
3. Re-file cases in PCE.
Select Number: 1// 3
Re-file the following.
1. O.R. Surgical Procedures
2. Non-O.R. Procedures
3. Both O.R. Surgical Procedures and Non-O.R. Procedures (All Specialties)
Select Number (1, 2 or 3): 1// 1
Do you want re-filing for all Surgical Specialties ? YES// NO
Select Surgical Specialty: 50
OR WHEN NOT DEFINED BELOW)
GENERAL(OR WHEN NOT DEFINED BELOW)
GENERAL(
50
Start with Date: 5/1 (MAY 01, 2001)
End with Date: 5/15 (MAY 15, 2001)
Requested Start Time: NOW// (MAY 20, [email protected]:37:32)
(Task #652379)
Press RETURN to continue
282
<Enter>
Surgery V. 3.0 User Manual
April 2004
Surgery Staffing Reports
[SR STAFFING REPORTS]
The Surgery Staffing Reports menu provides access to several staffing related report options.
The options included in this submenu are listed below. To the left of the option name is the shortcut
synonym the user can enter to select the option.
Shortcut
Option Name
A
Attending Surgeon Reports
S
Surgeon Staffing Report
N
Surgical Nurse Staffing Report
NS
Scrub Nurse Staffing Report
NC
Circulating Nurse Staffing Report
April 2004
Surgery V. 3.0 User Manual
283
Attending Surgeon Reports
[SROATT]
The Attending Surgeon Reports option generates the Attending Surgeon Report, which provides staffing
information for completed cases (Example 1). The Attending Surgeon Cumulative Report is a table with
cumulative totals for each attending code (Example 2). You can print these reports separately or you can
print both reports at one time.
The Attending Surgeon Report can be sorted by surgical specialty. They can also be generated for an
individual surgeon, or for all attending surgeons.
The Attending Surgeon Report has a 132-column format and is designed to be copied to a printer. The
Attending Surgeon Cumulative Report has an 80-column format and can be viewed on the screen.
Example 1: Print the Attending Surgeon Report
Select Surgery Staffing Reports Option: A
Attending Surgeon Reports
Attending Surgeon Report
Starting with which Date ? 6/9 (JUN 09, 2004)
Ending with which Date ? 6/18 (JUN 18, 2004)
Do you want to print the report for all Attending Surgeons ?
YES// <Enter>
Attending Surgeon Reports
1. Attending Surgeon Report
2. Attending Surgeon Cumulative Report
3. Attending Surgeon Report and Attending Surgeon Cumulative Report
Select the number corresponding with the desired report(s):
1
Start report for each attending surgeon on a new page ? NO// <Enter>
Do you want the report for all Surgical Specialties ?
Print the Report for which Surgical Specialty ? 50
FINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
YES//
N
GENERAL(OR WHEN NOT DE
50
The Attending Surgeon Report was designed to use a 132 column format.
Print the report on which Device ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
284
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
ATTENDING SURGEON REPORT
FROM: JUN 9,2004 TO: JUN 18,2004
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: JUN 20,2004
DATE
CASE #
PATIENT
PRINCIPAL DIAGNOSIS
SURGEON
ID#
PRINCIPAL OPERATIVE PROCEDURE
1ST ASST
ATTENDING CODE
2ND ASST
====================================================================================================================================
GENERAL(OR WHEN NOT DEFINED BELOW)
==================================
ATTENDING SURGEON: SURSURGEON,TWO
----------------------------06/17/04
203
SURPATIENT,FOURTEEN
000-45-7212
LEVEL B: ATTENDING IN O.R., SCRUBBED
CHOLELITHIASIS
CHOLECYSTECTOMY
SURSURGEON,ONE
SURSURGEON,FOUR
06/18/04
202
SURPATIENT,SEVENTEEN
000-45-5119
LEVEL B: ATTENDING IN O.R., SCRUBBED
INCARCERATED INGUINAL HERNIA
REPAIR INCARCERATED INGUINAL HERNIA
SURSURGEON,ONE
SURSURGEON,FOUR
03/09/04
494
SURPATIENT,TWELVE
000-41-8719
ATTENDING CODE NOT ENTERED
INCARCERATED INGUINAL HERNIA
INGUINAL HERNIA
SURSURGEON,THREE
SURSURGEON,FOUR
ATTENDING SURGEON: SURSURGEON,ONE
----------------------------06/10/04
189
SURPATIENT,FIFTYONE
RUPTURED TUBOOVARIAN ABSCESS
000-23-3221
DRAINAGE OF OVARIAN CYST
LEVEL E: EMERGENCY CARE, ATTENDING CONTACTED ASAP
SURSURGEON,FOUR
06/09/04
187
SURPATIENT,NINE
CHOLECYSTITIS
000-34-5555
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
LEVEL C: ATTENDING IN O.R., NOT SCRUBBED
SURSURGEON,TWO
SURSURGEON,FOUR
SURSURGEON,THREE
ATTENDING SURGEON: SURSURGEON,FOUR
----------------------------06/09/04
188
April 2004
SURPATIENT,SIX
APPENDICITIS
000-09-8797
APPENDECTOMY, COLONOSCOPY, CHOLECYSTECTOMY
LEVEL D: ATTENDING IN O.R. SUITE, IMMEDIATELY AVAILABLE
Surgery V. 3.0 User Manual
SURSURGEON,SIX
SURSURGEON,FOUR
285
Example 2: Print the Attending Surgeon Cumulative Report
Select Surgery Staffing Reports Option: A
Attending Surgeon Reports
Attending Surgeon Report
Starting with which Date ? 6/9 (JUN 09, 2004)
Ending with which Date ? 6/18 (JUN 18, 2004)
Do you want to print the report for all Attending Surgeons ?
YES// <Enter>
Attending Surgeon Reports
1. Attending Surgeon Report
2. Attending Surgeon Cumulative Report
3. Attending Surgeon Report and Attending Surgeon Cumulative Report
Select the number corresponding with the desired report(s):
Do you want the report for all Surgical Specialties ?
Print the Report for which Surgical Specialty ? 50
FINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
YES//
2
N
GENERAL(OR WHEN NOT DE
50
The Attending Surgeon Cumulative Report was designed to use a 80 column format.
Print the report on which Device ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
286
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
ATTENDING SURGEON CUMULATIVE REPORT
FROM: JUN 9,2004 TO: JUN 18,2004
==============================================================================
GENERAL(OR WHEN NOT DEFINED BELOW)
ATTENDING CODE
TOTAL CASES
-----------------------LEVEL B: ATTENDING IN O.R., SCRUBBED
2
LEVEL C: ATTENDING IN O.R., NOT SCRUBBED
1
LEVEL D: ATTENDING IN O.R. SUITE, IMMEDIATELY AVAILABLE
1
LEVEL E: EMERGENCY CARE, ATTENDING CONTACTED ASAP
1
* ATTENDING CODE NOT ENTERED
1
TOTAL CASES FROM 06/09/04 TO 06/18/04
April 2004
Surgery V. 3.0 User Manual
6
287
Surgeon Staffing Report
[SROSUR]
The Surgeon Staffing Report option lists completed cases sorted by the surgeon and his or her role (i.e.,
attending, first assistant) for each case. The report provides the procedure, diagnosis and operation
date/time.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print Surgeon Staffing Report
Select Surgery Staffing Reports Option: S
Surgeon Staffing Report
Surgeon Staffing Report
Start with Date: 3/2 (MAR 02, 2001)
End with Date: 3/31 (MAR 31, 2001)
Do you want to print this report for an individual surgeon ?
Select Surgeon: SURSURGEON,ONE
YES//
<Enter>
This report is designed to use a 132 column format.
Print the report on which Device ? [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
288
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
SURGEON STAFFING REPORT
FROM: MAR 2,2001 TO: MAR 31,2001
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: APR 20,2001
DATE/TIME
PATIENT
OPERATION(S)
DIAGNOSIS
CASE #
ID #
====================================================================================================================================
** SURSURGEON,ONE **
ROLE: ATTENDING SURGEON
MAR 09, [email protected]:15
187
SURPATIENT,NINE
000-34-5555
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
CHOLECYSTITIS
MAR 10, [email protected]:00
189
SURPATIENT,FIFTYONE
000-23-3221
DRAINAGE OF OVARIAN CYST
APPENDICITIS
MAR 10, [email protected]:00
200
SURPATIENT,FIFTY
000-45-9999
HEMORRHOIDECTOMY
EXTERNAL HEMORRHOIDS
MAR 10, [email protected]:00
199
SURPATIENT,TWO
000-45-1982
CHOLECYSTECTOMY WITH CHOLANGIOGRAM
CHOLELITHIASIS WITH BILIARY COLIC
MAR 17, [email protected]:55
203
SURPATIENT,FOURTEEN
000-45-7212
CHOLECYSTECTOMY
CHOLELITHIASIS
MAR 18, [email protected]:30
202
SURPATIENT,SEVENTEEN REPAIR INCARCERATED INGUINAL HERNIA
000-45-5119
ROLE: SURGEON
April 2004
Surgery V. 3.0 User Manual
INCARCERATED INGUINAL HERNIA
289
Surgical Nurse Staffing Report
[SRONSR]
This option generates the Surgical Nurse Staffing Report that lists completed cases within a specified date
range. It provides the names of the scrub nurse, the circulating nurse, and the operation times.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print Surgical Nurse Staffing Report
Select Surgery Staffing Reports Option: N
Surgical Nurse Staffing Report
Surgical Nurse Staffing Report
Do you want the report for all nurses ?
YES// <Enter>
Start with Date: 3/9 (MAR 09, 2001)
End with Date: 3/10 (MAR 10, 2001)
This report is designed to use a 132 column format.
Print the report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
290
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
SURGICAL NURSE STAFFING REPORT
FROM: MAR 9,2001 TO: MAR 10,2001
DATE
CASE #
OPERATION(S)
SCRUB NURSE
CIRC. NURSE
TIME IN
TIME OUT
ELAPSED (MINS)
====================================================================================================================================
03/09/01 SURPATIENT,TWELVE
194
000-41-8719
INGUINAL HERNIA
SURNURSE,TWO
SURNURSE,FIVE
08:00
09:10
70
03/09/01 SURPATIENT,NINE
187
000-34-5555
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
SURNURSE,THREE
SURNURSE,ONE
09:15
12:40
205
03/09/01 SURPATIENT,SIX
188
000-09-8797
APPENDECTOMY, COLONOSCOPY, CHOLECYSTECTOMY
SURNURSE,THREE
SURNURSE,SIX
19:56
21:05
69
03/10/01 SURPATIENT,FIFTYONE
189
000-23-3221
DRAINAGE OF OVARIAN CYST
SURNURSE,THREE
SURNURSE,SEVEN
07:00
08:54
114
03/10/01 SURPATIENT,TWO
199
000-45-1982
CHOLECYSTECTOMY WITH CHOLANGIOGRAM
SURNURSE,TWO
SURNURSE,FIVE
08:00
10:08
128
03/10/01 SURPATIENT,FIFTY
200
000-45-9999
HEMORRHOIDECTOMY
SURNURSE,THREE
SURNURSE,ONE
14:00
14:55
55
April 2004
PATIENT
ID#
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: MAR 20,2001
Surgery V. 3.0 User Manual
291
Scrub Nurse Staffing Report
[SROSNR]
The Scrub Nurse Staffing Report option lists each operating room scrub nurse and the completed cases
they are assigned to within a specified date range. It also provides the circulating nurses, other scrub
nurses, and operation times.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print Scrub Nurse Staffing Report
Select Surgery Staffing Reports Option: NS
Scrub Nurse Staffing Report
Scrub Nurse Staffing Report
Do you want the report for all nurses ?
YES// <Enter>
Start with Date: 3/8 (MAR 08, 2001)
End with Date: 3/20 (MAR 20, 2001)
This report is designed to use a 132 column format.
Print the report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
292
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
SCRUB NURSE STAFFING REPORT
FROM: MAR 8,2001 TO: MAR 20,2001
DATE
CASE #
PATIENT
ID#
OPERATION(S)
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: MAR 22,2001
SCRUB NURSE
CIRC. NURSE
TIME IN
TIME OUT
ELAPSED (MINS)
====================================================================================================================================
SURNURSE,THREE
SURNURSE,SEVEN
SURNURSE,ONE
07:30
09:03
93
SURNURSE,ONE
09:15
12:40
205
** SURNURSE,SEVEN **
03/18/01 SURPATIENT,SEVENTEEN
202
000-45-5119
REPAIR INCARCERATED INGUINAL HERNIA
** SURNURSE,THREE **
03/09/01 SURPATIENT,NINE
187
000-34-5555
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
SURNURSE,THREE
03/09/01 SURPATIENT,SIX
188
000-09-8797
APPENDECTOMY, COLONOSCOPY, CHOLECYSTECTOMY,
SURNURSE,THREE
03/10/01 SURPATIENT,FIFTYONE
189
000-23-3221
DRAINAGE OF OVARIAN CYST
SURNURSE,THREE
SURNURSE,SEVEN
07:00
08:54
114
03/10/01 SURPATIENT,FIFTY
200
000-45-9999
HEMORRHOIDECTOMY
SURNURSE,THREE
SURNURSE,ONE
14:00
14:55
55
03/17/01 SURPATIENT,FOURTEEN
203
000-45-7212
CHOLECYSTECTOMY
SURNURSE,THREE
SURNURSE,ONE
12:55
14:30
95
03/18/01 SURPATIENT,SEVENTEEN
202
000-45-5119
REPAIR INCARCERATED INGUINAL HERNIA
SURNURSE,THREE
SURNURSE,SEVEN
SURNURSE,ONE
07:30
09:03
93
April 2004
Surgery V. 3.0 User Manual
19:56
21:05
69
293
Circulating Nurse Staffing Report
[SROCNR]
The Circulating Nurse Staffing Report option provides nurse staffing information, sorted by the
circulating nurse's name. It lists the circulating nurses and the completed cases they are assigned to within
a specified date range. The report includes the scrub nurse, other circulating nurses, and operation times.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print Circulating Nurse Staffing Report
Select Surgery Staffing Reports Option: NC
Circulating Nurse Staffing Report
Circulating Nurse Staffing Report
Do you want the report for all nurses ?
YES// <Enter>
Start with Date: 3/2 (MAR 02, 2001)
End with Date: 3/31 (MAR 31, 2001)
This report is designed to use a 132 column format.
Print the report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
294
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
CIRCULATING NURSE STAFFING REPORT
FROM: MAR 2,2001 TO: MAR 31,2001
DATE
CASE #
PATIENT
ID#
OPERATION(S)
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: APR 21,2001
SCRUB NURSE
CIRC. NURSE
TIME IN
TIME OUT
ELAPSED (MINS)
====================================================================================================================================
SURNURSE,THREE
SURNURSE,SEVEN
07:00
08:54
114
** SURNURSE,SEVEN **
03/10/01 SURPATIENT,FIFTYONE
189
000-23-3221
DRAINAGE OF OVARIAN CYST
** SURNURSE,ONE **
03/09/01 SURPATIENT,NINE
187
000-34-5555
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM
SURNURSE,THREE
SURNURSE,ONE
09:15
12:40
205
03/10/01 SURPATIENT,FIFTY
200
000-45-9999
HEMORRHOIDECTOMY
SURNURSE,THREE
SURNURSE,ONE
14:00
14:55
55
03/17/01 SURPATIENT,FOURTEEN
203
000-45-7212
CHOLECYSTECTOMY
SURNURSE,THREE
SURNURSE,ONE
12:55
14:30
95
03/18/01 SURPATIENT,SEVENTEEN
202
000-45-5119
REPAIR INCARCERATED INGUINAL HERNIA
SURNURSE,THREE
SURNURSE,SEVEN
SURNURSE,ONE
07:30
09:03
93
SURNURSE,THREE
SURNURSE,TWO
09:00
09:20
** SURNURSE,TWO **
03/03/01 SURPATIENT,SIXTY
205
000-56-7821
April 2004
REMOVE CATARACTS, RETRO BULBAR BLOCK
Surgery V. 3.0 User Manual
295
Anesthesia Reports
[SR ANESTH REPORTS]
The Anesthesia Reports menu provides options for printing various anesthesia reports.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
the user can enter to select the option:
Shortcut
Option Name
P
List of Anesthetic Procedures
D
Anesthesia Provider Report
296
Surgery V. 3.0 User Manual
April 2004
Page 297 has been deleted. The Anesthesia AMIS option has been removed.
April 2004
Surgery V. 3.0 User Manual
297
Page 298 has been deleted. The Anesthesia AMIS option has been removed.
298
Surgery V. 3.0 User Manual
April 2004
List of Anesthetic Procedures
[SROANP]
The List of Anesthetic Procedures option generates a report listing each completed case within the date
range selected. It sorts by date order and provides the anesthesia personnel. This report also provides the
anesthesia start, end, and elapsed times for each case.
After the user enters the date range, the software will ask whether the user wants the List of Anesthetic
Procedures to include 1) only operating room surgical procedures, 2) non-O.R. procedures, or 3) both.
These reports have a 132-column format and are designed to be copied to a printer.
Example 1: Print the List of Anesthetic Procedures for only O.R. Surgical Procedures
Select Anesthesia Reports Option: P
List of Anesthetic Procedures
List of Anesthetic Procedures
Start with Date: 8/8 (AUG 08, 2001)
End with Date: 8/25 (AUG 25, 2001)
Print List of Anesthetic Procedures for
1. O.R. Surgical Procedures.
2. Non-O.R. Procedures.
3. Both O.R. Surgical Procedures and Non-O.R. Procedures.
Select Number:
1// <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
299
O.R. SURGICAL PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
LIST OF ANESTHETIC PROCEDURES
FROM: AUG 8,2001 TO: AUG 25,2001
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: SEP 21,2001
DATE
CASE #
PATIENT
PRINCIPAL DIAGNOSIS
PRIN ANESTHETIST
START TIME
ID#
PROCEDURE(S)
ANESTH TECHNIQUE
END TIME
ASA CLASS
ANESTH AGENT
ELAPSED
====================================================================================================================================
08/08/01 08:00 SURPATIENT,NINE
ABDOMINAL WOUND DEHISCENSE
SURANESTHETIST,ONE 08:00
63085
000-34-5555
CLOSURE ABDOMINAL DEHISCENSE
GENERAL
10:30
MILD DISTURB.
DESFLURANE 240ML BTL 90
08/12/01 08:30
63090
SURPATIENT,SIX
000-09-8797
SEVERE DISTURB.
CA OF LARYNX
LARYNGECTOMY
SURANESTHETIST,FOUR 08:35
GENERAL
10:35
SUFENTANIL CITRATE 5 120
08/16/01 08:00
63094
SURPATIENT,FOURTEEN
000-45-7212
NO DISTURB.
LESION RT EAR LOBE
EXC LESION LESIO RT EAR LOBE
SURANESTHETIST,ONE 08:05
LOCAL
08:30
LIDOCAINE 2% (20MG/M 25
08/21/01 06:00
63100
SURPATIENT,FORTYONE
000-43-2109
MILD DISTURB.
DIAGNOSTIC COLONOSCOPY
COLONOSCOPY
SURANESTHETIST,TWO
GENERAL
PROPOFOL 20ML INJ
08/21/01 07:00
63104
SURPATIENT,THREE
000-21-2453
SEVERE DISTURB.
PARATHYROID ADENOMA
PARATHYROID EXPLORATION AND EXCISION ADENOMA
SURANESTHETIST,FOUR 07:00
GENERAL
09:00
SUFENTANIL CITRATE 5 120
08/22/01 10:10
63106
SURPATIENT,FIFTYTWO
000-99-8888
MILD DISTURB.
HX OF POLYP
COLONOSCOPY, POLYPECTOMY
SURANESTHETIST,ONE
GENERAL
PROPOFOL 20ML INJ
08/22/01 09:56
63110
SURPATIENT,SIXTY
000-56-7821
MILD DISTURB.
CHOLECYSTITIS
LAP CHOLE
SURANESTHETIST,TWO 10:00
GENERAL
11:55
DESFLURANE 240ML BTL 115
08/24/01 14:55
63115
SURPATIENT,FOURTEEN
000-45-7212
MILD DISTURB.
INGUINAL HERNIA
INGUINAL HERNIA REPAIR
SURANESTHETIST,FOUR 14:55
GENERAL
16:05
PROPOFOL 20ML INJ
70
300
Surgery V. 3.0 User Manual
06:00
07:05
65
10:15
11:15
60
April 2004
Example 2: Print the List of Anesthetic Procedures for only Non-OR Procedures
Select Anesthesia Reports Option: P
List of Anesthetic Procedures
List of Anesthetic Procedures
Start with Date: 1/1 (JAN 01, 2001)
End with Date: 1/7 (JAN 07, 2001)
Print List of Anesthetic Procedures for
1. O.R. Surgical Procedures.
2. Non-O.R. Procedures.
3. Both O.R. Surgical Procedures and Non-O.R. Procedures.
Select Number:
1// 2
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
301
NON-O.R. PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
LIST OF ANESTHETIC PROCEDURES
FROM: JAN 1,2001 TO: JAN 7,2001
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: JAN 15,2001
DATE
CASE #
PATIENT
PRINCIPAL DIAGNOSIS
PRIN ANESTHETIST
START TIME
ID#
PROCEDURE(S)
ANESTH TECHNIQUE
END TIME
ASA CLASS
ANESTH AGENT
ELAPSED
====================================================================================================================================
01/02/01
SURPATIENT,SIXTEEN
TB
SURANESTHETIST,ONE
09:43
51051
000-11-1111
BRONCHOSCOPY
GENERAL
10:25
MILD DISTURB.
PHENOBARBITAL SODIUM 42
01/02/01
51053
SURPATIENT,SIXTEEN
000-11-1111
MILD DISTURB.
ILEITIS
COLONSCOPY
SURANESTHETIST,TWO
OTHER
FENTANYL 250MCG/5ML
10:00
11:10
70
01/02/01
51057
SURPATIENT,SEVEN
000-84-0987
NO DISTURB.
ESOPHAGEAL VARICES
ESOPHAGOSCOPY
SURANESTHETIST,FOUR
GENERAL
PROPOFOL 20ML INJ
13:10
13:45
35
01/04/01
51169
SURPATIENT,SIXTY
000-56-7821
MILD DISTURB.
HISTOPLASMOSIS
BRONCHOSCOPY
SURANESTHETIST,THREE 08:20
OTHER
09:15
FENTANYL 250MCG/5ML 55
01/04/01
88
SURPATIENT,FORTY
000-77-7777
NO DISTURB.
CARDIAC ARRYTHMIA
CARDIOVERSION
SURANESTHETIST,TWO
18:50
GENERAL
19:25
PHENOBARBITAL 30MG/7 35
01/07/01
51181
SURPATIENT,TEN
000-12-3456
MILD DISTURB.
HISTOPLASMOSIS
BRONCHOSCOPY
SURANESTHETIST,THREE 10:05
OTHER
11:05
FENTANYL 250MCG/5ML 60
01/07/01
51185
SURPATIENT,EIGHT
000-37-0555
MILD DISTURB.
CHRONIC DEPRESSION
ELECTROCONVULSIVE THERAPY
SURANESTHETIST,TWO
13:10
OTHER
13:35
MIDAZOLAM 1MG/1ML 2M 25
302
Surgery V. 3.0 User Manual
April 2004
Anesthesia Provider Report
[SROADOC]
The Anesthesia Provider Report option provides information concerning the anesthesia staff and
techniques for completed cases within a selected date range. This report can be generated for all
anesthesia providers or the user can specify one. It sorts the cases by the principal anesthetist and includes
information on anesthesia personnel, technique, agent, level of supervision, and elapsed anesthesia time.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print the Anesthesia Provider Report
Select Anesthesia Reports Option: D
Anesthesia Provider Report
Anesthesia Provider Report
Start with Date: 3/2 (MAR 02, 2001)
End with Date: 3/15 (MAR 15, 2001)
Do you want to print the report for all Anesthesia Providers ? YES// N
Print the report for which Anesthesia Provider ?
SURANESTHETIST,ONE
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
303
MAYBERRY, NC
SURGICAL SERVICE
ANESTHESIA PROVIDER REPORT
FROM: MAR 23,2001 TO: MAR 24,2001
DATE
CASE #
PATIENT
ID#
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: MAR 29,2001
PROCEDURE(S)
SUPERVISOR
ASA CLASS
LEVEL OF SUPERVISION
RELIEF ANESTH
PRINCIPAL TECHNIQUE ELAPSED ANES TIME
ASST ANESTH
ANESTHESIA AGENT
====================================================================================================================================
***** SURANESTHETIST,ONE *****
03/23/01
54014
SURPATIENT, O
000-44-7629
ESS, SEPTO,WITH LEFT TURBINECTOMY SCAR REVISION
SURANESTHETIST,T MILD DISTURB.
SURANESTHETIST,F GENERAL
DESFLURANE 240ML BTL
1
105 MINS.
03/23/01
54020
SURPATIENT, F
000-45-7212
COLONOSCOPY/ATTEMPTED
SURANESTHETIST,T MILD DISTURB.
GENERAL
SURANESTHETIST,S DESFLURANE 240ML BTL
1
55 MINS.
03/23/01
54050
SURPATIENT, N
000-34-5555
CYSTO, RETROGRADE, STENT
SURANESTHETIST,T MILD DISTURB.
GENERAL
SURANESTHETIST,F DESFLURANE 240ML BTL
1
45 MINS.
03/24/01
54023
SURPATIENT, F
000-58-7963
COLONOSCOPY/POLYPECTOMY
SURANESTHETIST,T SEVERE DISTURB.
GENERAL
SURANESTHETIST,S PROPOFOL 20ML INJ
1
50 MINS.
03/24/01
54025
SURPATIENT, E
000-37-0555
COLONOSCOPY
SURANESTHETIST,T MILD DISTURB.
GENERAL
SURANESTHETIST,F DESFLURANE 240ML BTL
1
65 MINS.
03/24/01
54024
NON-OR
SURPATIENT, S
000-56-7821
CARDIOVERSION
SURANESTHETIST,T SEVERE DISTURB.
GENERAL
SURANESTHETIST,S MIDAZOLAM 1MG/1ML 2M
1
35 MINS.
03/24/01
54058
SURPATIENT, S
000-45-5119
HEMORRHOIDECTOMY
SURANESTHETIST,T SEVERE DISTURB.
SPINAL
SURANESTHETIST,F BUPIVACAINE 0.25%
1
45 MINS.
03/24/01
54079
SURPATIENT, F
000-99-8888
EXPL LAP, LYSIS OF ADHESIONS
SURANESTHETIST,T SEVERE DIST.-EMERG
SURANESTHETIST,F GENERAL
SURANESTHETIST,S DESFLURANE 240ML BTL
1
120 MINS.
304
Surgery V. 3.0 User Manual
April 2004
CPT Code Reports
[SR CPT REPORTS]
The CPT Code Reports menu contains reports based on CPT codes.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
the user can enter to select the option.
Shortcut
Option Name
C
Cumulative Report of CPT Codes
A
Report of CPT Coding Accuracy
M
List Completed Cases Missing CPT Codes
April 2004
Surgery V. 3.0 User Manual
305
Cumulative Report of CPT Codes
[SROACCT]
The Cumulative Report of CPT Codes option counts and reports the number of times a procedure was
performed (based on CPT codes) during a specified date range. There is also a column showing how
many times the procedure was in the Principal Procedure category, and how many times it was in the
Other Operative Procedure category.
After the date range is entered, the software will ask if the user wants the Cumulative Report of CPT
Codes to include 1) only operating room surgical procedures, 2) non-O.R. procedures, or 3) both.
These reports have a 132-column format and are designed to be copied to a printer.
Example 1: Print the Cumulative Report of CPT Codes for only OR Surgical Procedures
Select CPT Code Reports Option: C
Cumulative Report of CPT Codes
Cumulative Report of CPT Codes
Start with Date: 3/28 (MAR 28, 2001)
End with Date: 4/3 (APR 03, 2001)
Include which cases on the Cumulative Report of CPT Codes ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures.
Select Number:
1// <Enter>
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
306
Surgery V. 3.0 User Manual
April 2004
O.R. SURGICAL PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
CUMULATIVE REPORT OF CPT CODES
FROM: MAR 28,2001 TO: APR 3,2001
REVIEWED BY
DATE REVIEWED:
CPT CODE - SHORT DESCRIPTION
TOTAL PROCEDURES
TOTAL PRINCIPAL PROCEDURES
TOTAL OTHER PROCEDURES
====================================================================================================================================
10060 DRAINAGE OF SKIN ABSCESS
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11440 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11441 REMOVAL OF SKIN LESION
4
4
0
-----------------------------------------------------------------------------------------------------------------------------------11641 REMOVAL OF SKIN LESION
4
2
2
-----------------------------------------------------------------------------------------------------------------------------------24075 REMOVE ARM/ELBOW LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------26989 HAND/FINGER SURGERY
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------30520 REPAIR OF NASAL SEPTUM
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------31231 NASAL ENDOSCOPY, DX
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------45315 PROCTOSIGMOIDOSCOPY
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------45330 SIGMOIDOSCOPY, DIAGNOSTIC
7
7
0
-----------------------------------------------------------------------------------------------------------------------------------45333 SIGMOIDOSCOPY & POLYPECTOMY
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------45378 DIAGNOSTIC COLONOSCOPY
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------45385 COLONOSCOPY, LESION REMOVAL
3
3
0
-----------------------------------------------------------------------------------------------------------------------------------47600 REMOVAL OF GALLBLADDER
1
0
1
-----------------------------------------------------------------------------------------------------------------------------------49000 EXPLORATION OF ABDOMEN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------49505 REPAIR INGUINAL HERNIA
2
1
1
-----------------------------------------------------------------------------------------------------------------------------------66984 REMOVE CATARACT, INSERT LENS
4
3
1
-----------------------------------------------------------------------------------------------------------------------------------68801 DILATE TEAR DUCT OPENING
1
1
0
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
307
Example 2: Print the Cumulative Report of CPT Codes for only Non-O.R. Procedures
Select CPT Code Reports Option: C
Cumulative Report of CPT Codes
Cumulative Report of CPT Codes
Start with Date: 7 1 01
End with Date: 12 31 01
(JUL 01, 2001)
(DEC 31, 2001)
Include which cases on the Cumulative Report of CPT Codes ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures.
Select Number:
1// 2
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
308
Surgery V. 3.0 User Manual
April 2004
NON-O.R. PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
CUMULATIVE REPORT OF CPT CODES
FROM: JUL 1,2001 TO: DEC 31,2001
REVIEWED BY
DATE REVIEWED:
CPT CODE - SHORT DESCRIPTION
TOTAL PROCEDURES
TOTAL PRINCIPAL PROCEDURES
TOTAL OTHER PROCEDURES
====================================================================================================================================
10060 DRAINAGE OF SKIN ABSCESS
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------10061 DRAINAGE OF SKIN ABSCESS
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11040 DEBRIDE SKIN PARTIAL
8
8
0
-----------------------------------------------------------------------------------------------------------------------------------11042 DEBRIDE SKIN/TISSUE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11100 BIOPSY OF SKIN LESION
11
11
0
-----------------------------------------------------------------------------------------------------------------------------------11402 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11420 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11620 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11640 REMOVAL OF SKIN LESION
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11730 REMOVAL OF NAIL PLATE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------11750 REMOVAL OF NAIL BED
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------12001 REPAIR SUPERFICIAL WOUND(S)
3
3
0
-----------------------------------------------------------------------------------------------------------------------------------12011 REPAIR SUPERFICIAL WOUND(S)
2
2
0
-----------------------------------------------------------------------------------------------------------------------------------14060 SKIN TISSUE REARRANGEMENT
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------15782 ABRASION TREATMENT OF SKIN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------17340 CRYOTHERAPY OF SKIN
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------20550 INJ TENDON/LIGAMENT/CYST
23
23
0
-----------------------------------------------------------------------------------------------------------------------------------29799 CASTING/STRAPPING PROCEDURE
1
1
0
-----------------------------------------------------------------------------------------------------------------------------------46083 INCISE EXTERNAL HEMORRHOID
2
2
0
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
309
Report of CPT Coding Accuracy
[SR CPT ACCURACY]
The Report of CPT Coding Accuracy option lists cases sorted by the CPT code used in the PRINCIPAL
PROCEDURES field and OTHER OPERATIVE PROCEDURES field. This option is designed to help
check the accuracy of the coding procedures.
About the prompts
"Do you want to print the Report of CPT Coding Accuracy for all CPT Codes ?" The user should reply
NO to this prompt to produce the report for only one CPT code. The software will then prompt the user to
enter the CPT code or category.
"Do you want to sort the Report of CPT Coding Accuracy by Surgical Specialty ?" The user should press
the <Enter> key if he or she wants to sort the report by specialty. The user would enter NO to sort the
report by date only.
"Do you want to print the Report to Check Coding Accuracy for all Surgical Specialties ?" The user can
enter the code or name of the surgical service he or she wants the report to be based on or can press the
<Enter> key to print the report for all surgical specialties.
Example 1: Print the Report of CPT Coding Accuracy for OR Surgical Procedures, sorted by Surgical
Specialty
Select CPT Code Reports Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 10 8 01 (OCT 08, 2001)
End with Date: 10 8 01 (OCT 08, 2001)
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// <Enter>
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// <Enter>
Do you want to sort the Report of CPT Coding Accuracy by
Surgical Specialty ? YES// <Enter>
Do you want to print the Report to Check Coding Accuracy for all
Surgical Specialties ? YES// NO
Print the Coding Accuracy Report for which Surgical Specialty ? 50
L(OR WHEN NOT DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
GENERA
50
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
310
Surgery V. 3.0 User Manual
April 2004
O.R. SURGICAL PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FOR GENERAL(OR WHEN NOT DEFINED BELOW)
FROM: OCT 8,2001 TO: OCT 8,2001
REVIEWED BY:
DATE REVIEWED:
PAGE
1
PROCEDURE DATE
PATIENT
PROCEDURES
SURGEON/PROVIDER
CASE #
ID#
ATTEND SURG/PROV
====================================================================================================================================
47600 REMOVAL OF GALLBLADDER
PRINCIPAL PROCEDURES
DESCRIPTION: CHOLECYSTECTOMY;
-----------------------------------------------------------------------------------------------------------------------------------10/08/01 07:00
SURPATIENT,EIGHTEEN
CHOLECYSTECTOMY
SURSURGEON,TWO
63072
000-22-3334
CPT Codes:47600-22
SURSURGEON,FOUR
====================================================================================================================================
47605 REMOVAL OF GALLBLADDER
OTHER PROCEDURES
DESCRIPTION: CHOLECYSTECTOMY;
WITH CHOLANGIOGRAPHY
-----------------------------------------------------------------------------------------------------------------------------------10/08/01 10:00
SURPATIENT,TWELVE
INGUINAL HERNIA, OTHER OPERATIONS:
SURSURGEON,FOUR
63077
000-41-8719
CHOLECYSTECTOMY (
SURSURGEON,FOUR
CPT Codes: 49521, 47605-22
====================================================================================================================================
49505 REPAIR INGUINAL HERNIA
PRINCIPAL PROCEDURES
DESCRIPTION: REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER;
REDUCIBLE
-----------------------------------------------------------------------------------------------------------------------------------10/08/01 06:00
SURPATIENT,FOUR
INGUINAL HERNIA
SURSURGEON,FOUR
63071
000-45-7212
CPT Codes: 49505
SURSURGEON,SIXTEEN
====================================================================================================================================
April 2004
Surgery V. 3.0 User Manual
311
Example 2: Print the Report of CPT Coding Accuracy for OR Surgical Procedures, sorted by Date
Select CPT Code Reports Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 10 1 01 (OCT 01, 2001)
End with Date: 10 7 01 (OCT 07, 2001)
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// <Enter>
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// <Enter>
Do you want to sort the Report of CPT Coding Accuracy by
Surgical Specialty ? YES// N
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
312
Surgery V. 3.0 User Manual
April 2004
O.R. SURGICAL PROCEDURES
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FROM: OCT 1,2001 TO: OCT 7,2001
REVIEWED BY:
DATE REVIEWED:
PAGE
1
PROCEDURE DATE
CASE #
PATIENT
PROCEDURES
SURGEON/PROVIDER
ID#
ATTEND SURG/PROV
SPECIALTY
====================================================================================================================================
31365 REMOVAL OF LARYNX
PRINCIPAL PROCEDURES
DESCRIPTION: LARYNGECTOMY;
TOTAL, WITH RADICAL NECK DISSECTION
-----------------------------------------------------------------------------------------------------------------------------------10/03/01 07:00
SURPATIENT,NINETEEN
PULMONARY LOBECTOMY
SURSURGEON,SEVENTEEN
63059
000-28-7354
CPT Codes: 31365
SURSURGEON,FOUR
THORACIC SURGERY (INC. CARDIAC SURG.)
====================================================================================================================================
32440 REMOVAL OF LUNG
PRINCIPAL PROCEDURES
DESCRIPTION: REMOVAL OF LUNG, TOTAL PNEUMONECTOMY;
-----------------------------------------------------------------------------------------------------------------------------------10/03/01 10:00
SURPATIENT,TWENTY
PULMONARY LOBECTOMY
SURSURGEON,FOUR
63060
000-45-4886
CPT Codes: 32440
SURSURGEON,FOUR
THORACIC SURGERY (INC. CARDIAC SURG.)
10/04/01 06:00
63069
SURPATIENT,TEN
000-12-3456
THORACIC SURGERY (INC. CARDIAC SURG.)
PULMONARY LOBECTOMY
CPT Codes: 32440
SURSURGEON,TWO
SURSURGEON,TWO
====================================================================================================================================
32480 PARTIAL REMOVAL OF LUNG
PRINCIPAL PROCEDURES
DESCRIPTION: REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;
SINGLE LOBE (LOBECTOMY)
-----------------------------------------------------------------------------------------------------------------------------------10/03/01 06:00
SURPATIENT,TWELVE
PULMONARY LOBECTOMY
SURSURGEON,TWO
63049
000-41-8719
CPT Codes: 32480
SURSURGEON,ONE
THORACIC SURGERY (INC. CARDIAC SURG.)
10/03/01 07:00
63050
April 2004
SURPATIENT,SEVENTEEN
000-45-5119
THORACIC SURGERY (INC. CARDIAC SURG.)
PULMONARY LOBECTOMY
CPT Codes: 32480
Surgery V. 3.0 User Manual
SURSURGEON,TWO
SURSURGEON,TWO
313
Example 3: Print the Report of CPT Coding Accuracy for Non-O.R. Procedures, sorted by CPT Code and
Medical Specialty
Select CPT Code Reports Option: A
Report of CPT Coding Accuracy
Report to Check CPT Coding Accuracy
Start with Date: 1 1 01 (JAN 01, 2001)
End with Date: 8 31 01 (AUG 31, 2001)
Print the Report of CPT Coding Accuracy for which cases ?
1. OR Surgical Procedures
2. Non-OR Procedures
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// 2
Do you want to print the Report of CPT Coding Accuracy for all
CPT Codes ? YES// N
Print the Coding Accuracy Report for which CPT Code ? 92960
HEART ELECTROCONVERSION
CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF
ARRHYTHMIA, EXTERNAL
Do you want to sort the Report of CPT Coding Accuracy by
Medical Specialty ? YES// <Enter>
Do you want to print the Report to Check Coding Accuracy for all
Medical Specialties ? YES// N
Print the Coding Accuracy Report for which Medical Specialty ?
MEDICINE
This report is designed to use a 132 column format.
Select Device: [Select Print Device]
--------------------------------------------printout follows-----------------------------------
314
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF CPT CODING ACCURACY
FOR MEDICINE
FROM: JAN 1,2001 TO: AUG 31,2001
NON-O.R. PROCEDURES
REVIEWED BY:
DATE REVIEWED:
PAGE
1
PROCEDURE DATE
PATIENT
PROCEDURES
SURGEON/PROVIDER
CASE #
ID#
ATTEND SURG/PROV
====================================================================================================================================
92960 HEART ELECTROCONVERSION
PRINCIPAL PROCEDURES
DESCRIPTION: CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF
ARRHYTHMIA, EXTERNAL
-----------------------------------------------------------------------------------------------------------------------------------01/24/95
SURPATIENT,SEVENTEEN
CARDIOVERSION
SURSURGEON,TWO
15499
000-45-5119
CPT Codes (92960)
SURSURGEON,TWO
02/09/95
15701
SURPATIENT,NINE
000-34-5555
CARDIOVERSION
CPT Codes (92960)
SURSURGEON,ONE
SURSURGEON,TWO
03/29/95
15912
SURPATIENT,FIFTEEN
000-98-1234
CARDIOVERSION
CPT Codes (92960)
SURSURGEON,THREE
08/04/95
16669
SURPATIENT,SIX
000-09-8797
CARDIOVERSION (
CPT Codes (92960)
SURSURGEON,TWO
SURSURGEON,FOUR
08/25/95
16828
SURPATIENT,TWO
000-45-1982
CARDIOVERSION
CPT Codes (92960)
SURSURGEON,TWO
SURSURGEON,TWO
April 2004
Surgery V. 3.0 User Manual
315
List Completed Cases Missing CPT Codes
[SRSCPT]
The List Completed Cases Missing CPT Codes option generates a report of completed cases that are
missing the Principal CPT code for a specified date range. Only procedures that have CPT codes will be
counted on the Annual Report of Surgical Procedures.
After the date range has been entered, the software will ask if the user wants the Cumulative Report of
CPT Codes to include: 1) only operating room surgical procedures, 2) non-O.R. procedures, or 3) both.
This report is in an 80-column format and can be viewed on the screen.
Example: List Completed Cases Missing CPT Codes
Select CPT Code Reports Option: M
List Completed Cases Missing CPT Codes
Print list of Completed Cases Missing CPT Codes for
1. OR Surgical Procedures.
2. Non-OR Procedures.
3. Both OR Surgical Procedures and Non-OR Procedures (All Specialties).
Select Number:
1// 1
Do you want the list for all Surgical Specialties ?
YES//
<Enter>
Start with Date: 2/1 (FEB 01, 2005)
End with Date: 4/30 (APR 30, 2005)
Print the List of Cases Missing CPT codes to which Printer ?
[Select Print Device]
--------------------------------------------------printout follows------------------------------------------------
316
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
Completed Cases Missing CPT Codes
O.R. Surgical Procedures
From: FEB 1,2005 To: APR 30,2005
Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Operation Date
Patient (ID#)
Surgeon/Provider
Case #
================================================================================
FEB 01, 2005
SURPATIENT,TWO (000-45-1982)
SURSURGEON,TWO
53708
* EXC LEFT PREAURICULAR LESION
-------------------------------------------------------------------------------FEB 08, 2005
SURPATIENT,FIVE (000-58-7963)
SURSURGEON,ONE
53747
* EXCISION LESIONS SCALP
-------------------------------------------------------------------------------MAR 12, 2005
SURPATIENT,SEVEN (000-84-0987)
SURSURGEON,TWO
53973
* COLONOSCOPY
-------------------------------------------------------------------------------MAR 23, 2005
SURPATIENT,FORTYONE (000-43-2109)
SURSURGEON,ONE
54030
* COLONOSCOPY/ATTEMPTED
-------------------------------------------------------------------------------APR 27, 2005
SURPATIENT,THIRTY (000-82-9472)
SURSURGEON,SEVENTEEN
54325
* EXCISION RT FOREARM LESIONS
* EXC LESION, RT EAR
* EXC LESION, RT FOREHEAD
* EXC LESION RT SCALP
* RXC LESION, NOSE
* EXC LESION, LEFT EAR
* EXC LESION, LEFT FOREARM
* EXC LESION, TOP OF HEAD
* EXC LESION, LEFT NECK
--------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
317
(This page included for two-sided copying.)
318
Surgery V. 3.0 User Manual
April 2004
Laboratory Interim Report
[SRO-LRRP]
The Laboratory Interim Report option accesses the Laboratory Package to show what lab tests the patient
has had. This option will print or display interim reports for a selected patient, within a given time period.
The printout will go in inverse date order. This report will output all tests for the time period specified.
This option only prints verified results and does not output the microbiology reports.
Example: Print Laboratory Interim Report
Select Surgery Menu Option: L
Laboratory Interim Report
Select Patient Name: SURPATIENT,SIXTY
03-03-59
NON-VETERAN (OTHER)
Date to START with: TODAY//5 15 01 (MAY 15, 2001)
Date to END with: T-7//5 1 01 (MAY 01, 2001)
DEVICE: [Select Print Device]
000567821
NO
---------------------------------------------------------printout follows---------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
319
SURPATIENT,SIXTY
SSN: 000-56-7821
SEX: F
AGE: 42
09/21/2001 1:21 pm
LOC: LRC
Provider: SURSURGEON,FOUR
Specimen: SERUM
Accession [UID]: CH 0513 1 [3471330001]
05/13/1997 07:00
Test name
Result
units
Ref. range
GLUCOSE
87
mg/dL
60 - 123
UREA NITROGEN
22
mg/dL
11 24
CREATININE
1.8
mg/dl
1 - 2.1
POTASSIUM
4.4
meq/L
3.5 - 4.8
SODIUM
143
meq/L
135 - 145
CHLORIDE
103
meq/L
95 - 105
CO2
27.0
meq/L
20 32
CALCIUM
8.7
mg/dL
8.5 11
==============================================================================
KEY: "L"=Abnormal low, "H"=Abnormal high, "*"=Critical value
SURPATIENT,SIXTY
320
000-56-7821
09/21/2001 1:21 pm
PRESS '^' TO STOP
Surgery V. 3.0 User Manual
April 2004
Chapter Four: Chief of Surgery Reports
Introduction
This chapter describes options and reports for the exclusive use of the Surgical Service Chief, or his or
her designee. The Chief has access to lists of cancellations, the Morbidity and Mortality Report, and
Patient Occurrences.
Exiting an Option or the System
The user should enter an up-arrow (^) to stop what he or she is doing. The up-arrow can be used at almost
any prompt to terminate the line of questioning and return to the previous level in the routine. Continuing
to enter up-arrows will cause the user to completely exit the system.
Option Overview
The main options included in this chapter are listed below. To the left of the option name is the shortcut
synonym that the user can enter to select the option. The Chief of Surgery Menu option will not display if
the user does not have proper security clearance.
Shortcut
CH
April 2004
Option Name
Chief of Surgery Menu
Surgery V. 3.0 User Manual
321
(This page included for two-sided copying.)
322
Surgery V. 3.0 User Manual
April 2004
Chief of Surgery Menu
[SROCHIEF]
The Chief of Surgery Menu is a restricted option (locked with the SROCHIEF key), allowing access to
various management reports and functions. It is designed for the Chief of Surgery and his or her
designees. The options available from this menu are shown in the following table.
Shortcut
V
M
U
RET
CAN
D
CODE
April 2004
Option or Menu Name
View Patient Perioperative Occurrences
Management Reports
Unlock a Case for Editing
Update Status of Returns Within 30 Days
Update Cancelled Case ...
Update Operations as Unrelated/Related to Death
Update/Verify Procedure/Diagnosis Codes
Surgery V. 3.0 User Manual
323
View Patient Perioperative Occurrences
[SROMEN-M&M]
The View Patient Perioperative Occurrences option is designed to provide a quick view of any
occurrences for a particular case. This report can be viewed on a screen.
Example: View Patient Perioperative Occurrences
Select Chief of Surgery Menu Option: V
View Patient Perioperative Occurrences
Select Patient: SURPATIENT,NINE
09-01-50
SURPATIENT,NINE
000345555
000-34-5555
1. 09-15-04
BYPASS (REQUESTED)
2. 09-15-04
CAROTID ARTERY ENDARTERECTOMY (SCHEDULED)
3. 03-09-04
CHOLECYSTECTOMY, INTRAOPERATIVE CHOLANGIOGRAM (COMPLETED)
Select Operation: 3
SURPATIENT,NINE (000-34-5555)
OCCURRENCES
-------------------------------------------------------------------------------Date of Operation:
JUN 09, 2004 09:15
Principal Operation: CHOLECYSTECTOMY (47480)
Surgeon:
SURSURGEON,TWO
Attending Surgeon: SURSURGEON,ONE
Attending Code:
LEVEL B: ATTENDING IN O.R., SCRUBBED
Principal Postop Diagnosis:
CHOLECYSTITIS (574.01)
Intraoperative Occurrences:
PUNCTURED MESENTERIC ARTERY
Outcome: IMPROVED
Postoperative Occurrences:
EDEMA (03/10/92)
Outcome: IMPROVED
Press RETURN to continue
324
<Enter>
Surgery V. 3.0 User Manual
April 2004
Management Reports
[SRO-CHIEF REPORTS]
The Management Reports menu is designed to give the Chief of Surgery various management reports.
The reports contained on this menu are listed below. To the left of the option/report name is the shortcut
synonym that the user can enter to select the option.
Shortcut
MM
MV
CD
D
V
RET
A
NS
ICU
OR
WC
BA
KEY
OC
DS
April 2004
Option Name
Morbidity & Mortality Reports
M&M Verification Report
Comparison of Preop and Postop Diagnosis
Delay and Cancellation Reports ...
List of Unverified Surgery Cases
Report of Returns to Surgery
Report of Daily Operating Room Activity
Report of Cases Without Specimens
Report of Unscheduled Admissions to ICU
Operating Room Utilization Report
Wound Classification Report
Print Blood Product Verification Audit Log
Key Missing Surgical Package Data
Admitted w/in 14 days of Out Surgery If Postop
Occ
Death Within 30 Days of Surgery
Surgery V. 3.0 User Manual
325
Morbidity & Mortality Reports
[SROMM]
The Morbidity & Mortality Reports option generates two reports: the Perioperative Occurrences Report
and the Mortality Report. The Perioperative Occurrences Report includes all cases that have occurrences,
both intraoperatively and postoperatively, and can be sorted by specialty, attending surgeon, or
occurrence category. The Mortality Report includes all cases performed within the selected date range
that had a death within 30 days after surgery, and sort by specialty within a date range. Each surgical
specialty will begin on a separate page.
After the user enters the date range, the software will ask whether to generate both reports. If the user
answers NO, the software will ask the user to select from the Perioperative Occurrences Report or the
Mortality Report.
These reports have a 132-column format and are designed to be copied to a printer.
Example 1: Printing the Perioperative Occurrences Report – Sorted by Specialty
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
326
(1-3): 1// <Enter>
Surgery V. 3.0 User Manual
April 2004
Do you want to print this report for all Surgical Specialties ?
YES// N
Print the report for which Specialty ? GENERAL (OR WHEN NOT DEFINED BELOW)
Select an Additional Specialty <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
326a
(This page included for two-sided copying.)
326b
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUL 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
PATIENT
ATTENDING SURGEON
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
PRINCIPAL OPERATION
TREATMENT
OPERATION DATE
====================================================================================================================================
GENERAL(OR WHEN NOT DEFINED BELOW)
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,TWELVE
000-41-8719
JUL 07, [email protected]:15
SURSURGEON,THREE
REPAIR DIAPHRAGMATIC HERNIA
MYOCARDIAL INFARCTION
ASPIRIN THERAPY
URINARY TRACT INFECTION *
IV ANTBIOTICS
SURPATIENT,FOURTEEN
000-45-7212
JUL 31, [email protected]:00
SURSURGEON,FIVE
CHOLECYSTECTOMY, APPENDECTOMY
I
(07/09/06)
SUPERFICIAL WOUND INFECTION *
ANTIBIOTICS
(08/02/06)
I
I
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
327
Example 2: Printing the Perioperative Occurrences Report – Sorted by Attending Surgeon
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
(1-3): 1// 2
Do you want to print this report for all Attending Surgeons ? YES//N
Print the report for which Attending Surgeon ? SURGEON,ONE
Select an Additional Attending Surgeon:
<Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
327a
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUL 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
PATIENT
SURGICAL SPECIALTY
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
PRINCIPAL OPERATION
TREATMENT
OPERATION DATE
====================================================================================================================================
ATTENDING: SURGEON,ONE
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,TWELVE
000-41-8719
JUL 07, [email protected]:15
GENERAL(OR WHEN NOT DEFINED BELOW)
REPAIR DIAPHRAGMATIC HERNIA
MYOCARDIAL INFARCTION
ASPIRIN THERAPY
URINARY TRACT INFECTION *
IV ANTBIOTICS
I
(07/09/06)
I
SURPATIENT,THREE
000-21-2453
JUL 22, [email protected]:00
CARDIAC SURGERY
CABG
REPEAT VENTILATOR SUPPORT W/IN 30 DAYS *
I
SURPATIENT,FOURTEEN
000-45-7212
JUL 31, [email protected]:00
GENERAL(OR WHEN NOT DEFINED BELOW)
CHOLECYSTECTOMY, APPENDECTOMY
SUPERFICIAL WOUND INFECTION *
ANTIBIOTICS
I
(08/02/06)
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
327b
Example 3: Printing the Perioperative Occurrences Report – Sorted by Occurrence Category
Select Perioperative Occurrences Menu Option: M
Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 1
Print Report for:
1. Intraoperative Occurrences
2. Postoperative Occurrences
3. Intraoperative and Postoperative Occurrences
Select Number:
(1-3): 3
Start with Date: 7/1 (JUL 01, 2006)
End with Date: 7/31 (JUL 31, 2006)
Do you want to print all divisions? YES// <Enter>
Print report by
1. Surgical Specialty
2. Attending Surgeon
3. Occurrence Category
Select 1, 2 or 3:
(1-3): 1// 3
Do you want to print this report for all occurrence categories? YES// NO
Print the report for which Occurrence Category ? ACUTE RENAL FAILURE
VASQIP Definition (2011):
Indicate if the patient developed new renal failure requiring renal
replacement therapy or experienced an exacerbation of preoperative
renal failure requiring initiation of renal replacement therapy (not on
renal replacement therapy preoperatively) within 30 days
postoperatively. Renal replacement therapy is defined as venous to
venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis
[CVAHD], peritoneal dialysis, hemofiltration, hemodiafiltration or
ultrafiltration.
TIP: If the patient refuses dialysis report as an occurrence because
he/she did require dialysis.
Select an Additional Occurrence Category:
<Enter>
This report is designed to use a 132 column format.
Print the Report on which Device: [Select Print Device]
----------------------------------------------------------report follows--------------------------------------------------
327c
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
PERIOPERATIVE OCCURRENCES-INTRAOP/POSTOP
FROM: JUN 1,2007 TO: JUN 30,2007
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2007
PATIENT
ATTENDING SURGEON
OCCURRENCE(S) - (DATE)
OUTCOME
ID#
SURGICAL SPECIALTY
TREATMENT
OPERATION DATE
PRINCIPAL OPERATION
====================================================================================================================================
CATEGORY: ACUTE RENAL FAILURE
-----------------------------------------------------------------------------------------------------------------------------------SURPATIENT,SEVENTEEN
000-45-5119
JUN 18, [email protected]:15
SURGEON,TWO
GENERAL
REPAIR INCARCERATED INGUINAL HERNIA
ACUTE RENAL FAILURE
DIALYSIS
I
-----------------------------------------------------------------------------------------------------------------------------------OUTCOMES: U - UNRESOLVED, I - IMPROVED, W - WORSE, D - DEATH
'*' Represents Postoperative Occurrences
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
327d
Example 4: Print the Mortality Report
Select Management Reports Option:
MM Morbidity & Mortality Reports
The Morbidity and Mortality Reports include the Perioperative Occurrences
Report and the Mortality Report. Each report will provide information
from cases completed within the date range selected.
Do you want to generate both reports ?
YES//
N
1. Perioperative Occurrences Report
2. Mortality Report
Select Number:
(1-2): 2
Start with Date: 1/1/02
(JAN 01, 2002)
End with Date: 12/31/02
(DEC 31, 2002)
This report is designed to use a 132 column format.
Print report on which Device: [Select Print Device]
----------------------------------------------------------printout follows-------------------------------------------------
328
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
MORTALITY REPORT
FROM: JAN 1,2006 TO: JUL 31,2006
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 22,2006
OPERATION DATE
PATIENT
PRINCIPAL OPERATIVE PROCEDURE
DATE OF DEATH
ID#
AUTOPSY (Y/N)
====================================================================================================================================
OTORHINOLARYNGOLOGY (ENT)
-----------------------------------------------------------------------------------------------------------------------------------JAN 22, 2006
SURPATIENT,SIXTEEN
000-11-1111
LARYNGOSCOPY, BRONCHOSCOPY, ESOPHAGOGASTROSCOPY
FEB 09, 2006
NO
JAN 27, 2006
SURPATIENT,TWO
000-45-1982
BRONCHOSCOPY
FEB 26, 2006
NOT AVAILABLE
JAN 29, 2006
SURPATIENT,SIXTEEN
000-11-1111
BILATERAL NECK DISECTION, LARYNGECTOMY
FEB 09, 2006
NO
FEB 08, 2006
SURPATIENT,SIXTEEN
000-11-1111
LIGATION LT INTERNAL JUGLAR , EXPLORATORY LAPARATOMY
FEB 09, 2006
NO
FEB 19, 2006
SURPATIENT,TEN
000-12-3456
TRACH
FEB 21, 2006
NO
JUL 20, 2006
SURPATIENT,FORTY
000-77-7777
LARYNGOSCOPY W/ BX, ESOPHAGOSCOPY
NOV 01, 2006
NOT AVAILABLE
April 2004
Surgery V. 3.0 User Manual
329
M&M Verification Report
[SRO M&M VERIFICATION REPORT]
The M&M Verification Report option produces the M&M Verification Report that may be useful for (1)
reviewing occurrences and their assignments to operations and (2) reviewing deaths unrelated/related
assignments to operations
Two varieties of this report are available. The first variety provides a report of all patients who had
operations within the selected date range and experienced intraoperative occurrences, postoperative
occurrences, or death within 90 days of surgery. The second variety provides a similar report for all riskassessed operations that are in a completed state but have not yet been transmitted to the national
database.
Variety #1: Report information is printed patient-by-patient, listing all operations for the patient that
occurred during the selected date range, as well as any operations that may have occurred within 30 days
prior to any postoperative occurrences or within 90 days prior to death. Therefore, this report may include
some operations that were performed prior to the selected date range, and, if printed by specialty, may
include operations performed by other specialties. For every operation that is listed, the intraoperative and
postoperative occurrences are also listed. The report also includes information about whether the
operation was unrelated or related to death as well as the risk assessment type and status (if assessed). The
report may be printed for a selected list of surgical specialties.
Variety #2: Report information is printed patient-by-patient in a format similar to Variety #1. This report
lists all risk-assessed operations that are in a completed state but have not yet been transmitted to the
national database and that have intraoperative occurrences, postoperative occurrences, or death within 90
days of surgery. The report includes any operations that may have occurred within 30 days prior to any
postoperative occurrences or within 90 days prior to death. Therefore, this report may include some other
operations that may or may not be risk assessed, and, if risk assessed, may have any risk assessment status
(incomplete, complete, or transmitted). Every patient listed on this report will have at least one operation
with a risk assessment status of “complete.”
Example 1: Generate an M&M Verification Report (Full Report)
Select Management Reports Option: MV
M&M Verification Report
M&M Verification Report
The M&M Verification Report is a tool to assist in the review of occurrences
and their assignments to operations and in the review of death unrelated or
related assignments to operations. Two varieties of this report are available.
The first variety provides a report of all patients who had operations within
the selected date range who experienced intraoperative occurrences,
postoperative occurrences, or death within 90 days of surgery. The second
variety provides a similar report for all risk assessed operations that are in
a completed state but have not yet transmitted to the national database.
Print which variety of the report ?
1. Print full report for selected date range.
2. Print pre-transmission report for completed risk assessments.
Enter selection (1 or 2): 1// <Enter>
Start with Date: 12 31 01 (DEC 31, 2001)
End with Date: 1 31 02 (JAN 31, 2002)
330
Surgery V. 3.0 User Manual
April 2004
Do you want to print this report for all Surgical Specialties ? YES//
<Enter>
This report is designed to use a 132 column format.
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
331
MAYBERRY, NC
M&M Verification Report
From: DEC 31,2001 To: JAN 31,2002
Report Generated: FEB 21,2002
Page 1
Reviewed By:
Date Reviewed:
Death
Assessment
Op Date
Specialty
Procedure(s)
Related Occurrence(s) - (Date)
Type/Status
====================================================================================================================================
>>> SURPATIENT,THIRTY (000-82-9472) - DIED 02/27/02
01/06/02
GENERAL
TOTAL LARYNGECTOMY
NO
NON-CARD/T
12/29/01
THORACIC
CABG, VEIN, SIX+
NO
CARDIAC/I
11/20/01
PERIPHERAL
LT CAROTID ENDOARTERECTOMY
N/A
OTHER OCCURRENCE (11/20/01)
ICD: 998.4 FB LEFT DURING PROCEDURE
URINARY TRACT INFECTION * (12/08/01)
ICD: 599.0 URIN TRACT INFECTION NOS
OTHER RESPIRATORY OCCURRENCE * (11/25/01)
ICD: 478.25 EDEMA PHARYNX/NASOPHARYX
OTHER OCCURRENCE * (NO DATE)
ICD: 530.1 ESOPHAGITIS
NON-CARD/T
11/02/01
PERIPHERAL
EVACUATION OF HEMATOMA LT.THIGH
YES
DVT/THROMBOPHLEBITIS * (11/06/01)
ICD: 453.8 VENOUS THROMBOSIS NEC
BLEEDING/TRANSFUSIONS * (11/04/01)
BLEEDING/TRANSFUSIONS * (11/06/01)
BLEEDING/TRANSFUSIONS * (11/06/01)
NON-CARD/I
------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------Occurrences(s): '*' Denotes Postop Occurrence
Assessment Status - I:Incomplete, C:Complete, T:Transmitted
------------------------------------------------------------------------------------------------------------------------------------
332
Surgery V. 3.0 User Manual
April 2004
Example 2: Generate an M&M Verification Report (Pre-Transmission Report)
Select Management Reports Option: MV
M&M Verification Report
M&M Verification Report
The M&M Verification Report is a tool to assist in the review of occurrences
and their assignments to operations and in the review of death unrelated or
related assignments to operations. Two varieties of this report are available.
The first variety provides a report of all patients who had operations within
the selected date range who experienced intraoperative occurrences,
postoperative occurrences, or death within 90 days of surgery. The second
variety provides a similar report for all risk assessed operations that are in
a completed state but have not yet transmitted to the national database.
Print which variety of the report ?
1. Print full report for selected date range.
2. Print pre-transmission report for completed risk assessments.
Enter selection (1 or 2): 1// 2
Do you want to print this report for all Surgical Specialties ? YES//
<Enter>
This report is designed to use a 132 column format.
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
333
MAYBERRY, NC
M&M Verification Report
Pre-Transmission Report for Completed Assessments
Report Generated: DEC 31,2002
Page 1
Reviewed By:
Date Reviewed:
Death
Assessment
Op Date
Specialty
Procedure(s)
Related Occurrence(s) - (Date)
Type/Status
====================================================================================================================================
>>> SURPATIENT,FOUR (000-17-0555) - DIED 12/30/[email protected]:16
12/24/02
UROLOGY
CYSTOSCOPY
YES
EXCLUDED/C
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,FIFTYTWO (000-99-8888) - DIED 03/02/[email protected]:20
01/31/02
GENERAL
LEFT BKA STUMP DEBRIDEMENT & REVISION
?
URINARY TRACT INFECTION * (02/09/02)
ICD: 599.0 URIN TRACT INFECTION NOS
PNEUMONIA * (02/15/02)
ICD: 485. BRONCOPNEUMONIA ORG NOS
EXCLUDED/C
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,ONE (000-44-7629) - DIED 08/13/[email protected]:00
08/05/02
PERIPHERAL
LEFT LEG ABOVE KNEE AMPUTATION, RIGHT
LEG ABOVE KNEE AMPUTATION
NO
EXCLUDED/C
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,SIXTEEN (000-11-1111) - DIED 10/01/02
08/21/02
PERIPHERAL
OMEGAPORT PLACEMENT
?
EXCLUDED/C
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,FIVE (000-58-7963) - DIED 04/08/02
03/14/02
GENERAL
HICKMAN CATH PLACMENT
NO
EXCLUDED/C
------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------Occurrences(s): '*' Denotes Postop Occurrence
Assessment Status - I:Incomplete, C:Complete, T:Transmitted
------------------------------------------------------------------------------------------------------------------------------------
334
Surgery V. 3.0 User Manual
April 2004
Comparison of Preop and Postop Diagnosis
[SROPPC]
The Comparison of Preop and Postop Diagnosis option generates a list of completed cases in which the
principal preoperative and principal postoperative diagnoses are different.
Example: Print Comparison of Preop and Postop Diagnosis Report
Select Management Reports Option: CD
Comparison of Preop and Postop Diagnosis
Comparison of Preop and Postop Diagnosis
Start with Date: 3/1 (MAR 01, 2002)
End with Date: 3/31 (MAR 31, 2002)
This report is designed to use a 132 column format.
Print the Report on which device: [Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
335
MAYBERRY, NC
SURGICAL SERVICE
COMPARISON OF PREOP AND POSTOP DIAGNOSIS
FROM: MAR 1,2002 TO: MAR 31,2002
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: APR 22,2002
DATE
CASE #
PATIENT
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
WOUND CLASS
ID #
SURGICAL SPECIALTY
-----------------------------------------------------------------------------------------------------------------------------------03/03/02 SURPATIENT,ONE
APPENDICITIS
ACUTE APPENDICITIS
D
63064
000-44-7629
GENERAL
03/04/02
63066
SURPATIENT,THREE
000-21-2453
GENERAL
BILATERAL INGUINAL HERNIA
BILATERAL INGUINAL HERNIA, WITH GANGRENE
C
03/04/02
63068
SURPATIENT,TEN
000-12-3456
GENERAL
BILATERAL INGUINAL HERNIA
BILAT INGUINAL HERNIA
C
03/08/02
63072
SURPATIENT,EIGHTEEN
000-22-3334
GENERAL
CHOLECYSTITIS
CHOLECYSTITIS WITH OBSTRUCTION
C
-----------------------------------------------------------------------------------------------------------------------------------WOUND CLASSIFICATION CODES:
C: CLEAN, CC: CLEAN/CONTAMINATED, D: CONTAMINATED, I: INFECTED
336
Surgery V. 3.0 User Manual
April 2004
Delay and Cancellation Reports
[SRO DEL MENU]
The Delay and Cancellation Reports menu provides access to various reports used to track delays and
cancellations. The reports on this menu are listed below. To the left of the option/report name is the
shortcut synonym the user can enter to select the option.
Shortcut
D
R
T
C
A
April 2004
Option Name
Report of Delayed Operations
Report of Delay Reasons
Report of Delay Time
Report of Cancellations
Report of Cancellation Rates
Surgery V. 3.0 User Manual
337
Report of Delayed Operations
[SRODELA]
The Report of Delayed Operations option will list all cases that have been delayed within a specified date
range. The report sorts by surgical service and includes both the delay cause and delay time.
This report is in a 132-column format and should be copied to a printer with wide paper.
Example: Report of Delayed Operations
Select Delay and Cancellation Reports Option: D
Report of Delayed Operations
Report of Delayed Operations
Start with which Date ? 7/1 (JUL 01, 1999)
End with which Date ? 7/31 (JUL 31, 1999)
Do you want to print the Report of Delayed Operations for all Surgical
Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print the Report on which device ? [Select Print Device]
----------------------------------------------------------report follows----------------------------------------------------
338
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF DELAYED OPERATIONS
NEUROSURGERY
FROM: JUL 1,1999 TO: JUL 31,1999
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 13,1999
DATE
PATIENT
ATTENDING SURGEON
DELAY COMMENTS
DELAY TIME
ID #
OPERATION(S)
====================================================================================================================================
OPERATING SURGEON NOT PRESENT
----------------------------07/13/99
30 MINS.
SURPATIENT,SEVENTEEN
000-45-5119
SURSURGEON,THREE
L3-4 LUMBAR LAMINECTOMY WITH PARTIAL
FACETECTOMY AND LEFT
NEUROFORAMINOTOMY, ADDITIONAL L4-5
STAFF SURGEON NOT PRESENT
-------------------------
07/28/99
45 MINS.
April 2004
SURPATIENT,SIXTY
000-56-7821
SURSURGEON,TWO
RT. MEDIAN NERVE DECOMPRESSION AT
WRIST
Surgery V. 3.0 User Manual
WEDNESDAY UNIVERSITY MEETING
339
Report of Delay Reasons
[SROREAS]
The Report of Delay Reasons option lists reasons for delays, and the number of occurrences for delayed
operations, within a specified date range.
This report is in an 80-column format and can be viewed on your screen.
Example: Report of Delay Reasons
Select Delay and Cancellation Reports Option: R
Report of Delay Reasons
Report of Delayed Operations
Start with which Date ? 3/1 (MAR 01, 1999)
End with which Date ? 3/31 (MAR 31, 1999)
Do you want to print the Report of Delay Reasons for all Surgical
Specialties ? YES// <Enter>
Do you want to display the totals for each Surgical Specialty ?
YES// ?
Enter RETURN to display the totals for delay reasons for each specialty. If
you want to display the totals for all delay reasons for the entire medical
center, enter 'NO'.
Do you want to display the totals for each Surgical Specialty ?
YES// <Enter>
Print the Report on which device: [Select Print Device]
----------------------------------------------------------printout follows--------------------------------------------------
340
Surgery V. 3.0 User Manual
April 2004
REPORT OF DELAY REASONS
FROM 03/01/99 TO 03/31/99
GENERAL(OR WHEN NOT DEFINED BELOW)
---------------------------------ANESTHETIST NOT PRESENT
SPECIAL EQUIPMENT NOT READY
OTHER
1
1
1
TOTAL DELAYS FOR GENERAL(OR WHEN NOT DEFINED BELOW)
3
OTORHINOLARYNGOLOGY (ENT)
------------------------OPERATING SURGEON NOT PRESENT
1
TOTAL DELAYS FOR OTORHINOLARYNGOLOGY (ENT)
Press RETURN to continue, or '^' to quit:
1
<Enter>
REPORT OF DELAY REASONS
FROM 03/01/99 TO 03/31/99
================================================================================
OPERATING SURGEON NOT PRESENT
ANESTHETIST NOT PRESENT
SPECIAL EQUIPMENT NOT READY
OTHER
1
1
1
1
TOTAL DELAY REASONS
4
Press RETURN to continue
April 2004
<Enter>
Surgery V. 3.0 User Manual
341
Report of Delay Time
[SRO DELAY TIME]
The Report of Delay Time option provides the total amount of delay time for each delay reason for a
specified date range. The report sorts by surgical specialty.
This report is in an 80-column format and can be viewed on a screen.
Example: Report of Delay Time
Select Delay and Cancellation Reports Option: T
Report of Delay Time
Report of Delay Time
Start with which Date ?
End with which Date ?
3/1
3/31
(MAR 01, 1999)
(MAR 31, 1999)
Do you want to print the Report of Delay Time for all delay reasons ?
YES// ?
Enter RETURN to print this report for all delay reasons, or 'NO' to select
a specific delay reason.
Do you want to print the Report of Delay Time for all delay reasons ?
YES// <Enter>
Do you want to print the Report of Delayed Operations for all Surgical
Specialties ? YES// <Enter>
Print the Report on which device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
342
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
Report of Delay Times
From 03/01/99 To 03/31/99
PAGE 1
# OF
MINUTES
SURGICAL SPECIALTY
DELAYS
DELAYED
================================================================================
>> Delay Reason: OPERATING SURGEON NOT PRESENT <<
OTORHINOLARYNGOLOGY (ENT)
1
15
------------------------------------------------------------------------------->> Delay Reason: ANESTHETIST NOT PRESENT <<
GENERAL(OR WHEN NOT DEFINED BE
1
30
------------------------------------------------------------------------------->> Delay Reason: SPECIAL EQUIPMENT NOT READY <<
GENERAL(OR WHEN NOT DEFINED BE
1
10
Press RETURN to continue, or '^' to quit. <Enter>
MAYBERRY, NC
Report of Delay Times
From 03/01/99 To 03/31/99
PAGE 2
# OF
MINUTES
SURGICAL SPECIALTY
DELAYS
DELAYED
================================================================================
>> Delay Reason: OTHER <<
GENERAL(OR WHEN NOT DEFINED BE
1
15
Press RETURN to continue, or '^' to quit. <Enter>
April 2004
Surgery V. 3.0 User Manual
343
MAYBERRY, NC
Report of Delay Times
From 03/01/99 To 03/31/99
PAGE 3
# OF
MINUTES
DELAY REASON
DELAYS
DELAYED
================================================================================
OPERATING SURGEON NOT PRESENT
1
15
ANESTHETIST NOT PRESENT
1
30
SPECIAL EQUIPMENT NOT READY
1
10
OTHER
1
15
TOTAL
Press RETURN to continue
344
4
70
<Enter>
Surgery V. 3.0 User Manual
April 2004
Report of Cancellations
[SROCAN]
The Report of Cancellations option is designed to provide information for cases that have been scheduled
and cancelled.
This report is in a 132-column format and must be copied to a printer.
Example: Print Report of Cancellations
Select Delay and Cancellation Reports Option: C
Report of Cancellations
Report of Cancellations
NOTE: This report contains all cancelled cases, including those that were
cancelled after the patient had entered the operating room. Aborted
cases are identified by an '*' next to the procedure name.
Start with Date: 3/1 (MAR 01, 1999)
End with Date: 3/3 (MAR 03, 1999)
Do you want to print the report for all Surgical Specialties ?
YES//
<Enter>
This report is designed to use a 132 column format.
Print the Report on which device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
345
MAYBERRY, NC
REPORT OF CANCELLATIONS
FROM 03/01/99 TO 03/03/99
PRINTED: MAR 23, 1999
DATE
CASE #
PATIENT
ID#
OPERATION(S)
PAGE: 1
REVIEWED BY:
DATE REVIEWED:
CANCEL DATE
REASON
====================================================================================================================================
>> SURGICAL SPECIALTY: OPHTHALMOLOGY <<
MAR 01, 1999
31725
SURPATIENT,FIVE
000-58-7963
* PHACEOMULSIFICATION, LENS IMPLANT OS
MAR 01, 1999
MEDICAL
11:00
------------------------------------------------------------------------------------------------------------------------------------
>> SURGICAL SPECIALTY: ORTHOPEDICS <<
MAR 01, 1999
32066
SURPATIENT,FIVE
000-58-7963
LT. TOTAL KNEE ARTHROPLASTY
MAR 01, 1999
MEDICAL
08:01
MAR 03, 1999
32143
SURPATIENT,THREE
000-21-2453
HARDWARE REMOVAL RT. ANKLE
MAR 03, 1999 12:49
ADMINISTRATIVE CANCELLATION
------------------------------------------------------------------------------------------------------------------------------------
>> SURGICAL SPECIALTY: PLASTIC SURGERY (INCLUDES HEAD AND NECK) <<
MAR 01, 1999
32089
SURPATIENT,TEN
000-12-3456
DEBRIDMENT OF BACK, NECK WOUNDS, GOLDWEIGHT TO
RT. EYE, RT. LATERAL CANTHOPLASTY
MAR 01, 1999
SURGEON
07:36
MAR 03, 1999
32141
SURPATIENT,TEN
000-12-3456
PRIMARY CLOSURE LT. CHEEK, SKIN GRAFT VS SKIN
FLAP
APR 02, 1999 08:21
PATIENT NOT NPO
------------------------------------------------------------------------------------------------------------------------------------
>> SURGICAL SPECIALTY: THORACIC SURGERY (INC. CARDIAC SURG.) <<
MAR 01, 1999
32013
SURPATIENT,FORTY
000-77-7777
LT. THORACOTOMY, LOBECTOMY, PNEUMONECTOMY
MAR 01, 1999
MEDICAL
07:35
------------------------------------------------------------------------------------------------------------------------------------
>> SURGICAL SPECIALTY: UROLOGY <<
MAR 03, 1999
32119
SURPATIENT,NINETEEN
000-28-7354
TRANSURETHRAL RESECTION OF BLADDER TUMOR
MAR 19, 1999 08:00
PATIENT/GUARDIAN REFUSES
------------------------------------------------------------------------------------------------------------------------------------
>> SURGICAL SPECIALTY: PODIATRY <<
MAR 02, 1999
31865
SURPATIENT,SEVENTEEN
000-45-5119
1ST METATARSL REMODELING RT. FOOT, REMOVAL OF
SOFT TISSUE NODULE RT. FOOT
MAR 29, 1999
MEDICAL
08:52
------------------------------------------------------------------------------------------------------------------------------------
346
Surgery V. 3.0 User Manual
April 2004
Report of Cancellation Rates
[SROCRAT]
The Report of Cancellation Rates option generates a report on the calculations of cancellation rates. This
report can be printed for one or a few surgical specialties (Example 1), or for all surgical specialties
(Example 2). Emergency cases are not included in this report.
This report is in an 80-column format and can be viewed on your screen.
How the Cancellation Rates Are Calculated
Cancellation Rate for Scheduled Cases =
(Total Cancels / Total Scheduled) x 100
Avoidable Cancellation Rate for Scheduled Cases =
(Total Avoidable Cancels / Total Scheduled) x 100
Avoidable Cancellation rate for all Cancelled Cases =
(Total Avoidable Cancels / Total Cancels) x 100
Example 1: View for Individual Surgical Specialties
Select Delay and Cancellation Reports Option: A
Report of Cancellation Rates
Report of Cancellation Rates
Start with which Date ? 3/2 (MAR 02, 1999)
End with which Date ? 3/20 (MAR 20, 1999)
Do you want to print the report for all Surgical Specialties ?
YES//
N
Print the report for which Specialty ? 50
GENERAL(OR WHEN NOT DEFINED BELOW)
Select An Additional Specialty: ORTHOPEDICS 54
ORTHOPEDICS
Select An Additional Specialty: PLASTIC SURGERY (INCLUDES HEAD AND NECK) PROCTOLOGY 56
PLASTIC SURGERY (INCLUDES HEAD AND NECK)
Select An Additional Specialty: <Enter>
Print the Report on which device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
347
** GENERAL(OR WHEN NOT DEFINED BELOW) **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
18
CASES: 17 %
SCHEDULED CASES: 0 %
CANCELLED CASES: 0 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-----------------------------------------------------------------------------PREV. CASE LENGTH
3
0
--------TOTAL CANCELLATIONS
3
0
Press RETURN to continue, or '^' to quit:
<Enter>
** ORTHOPEDICS **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
23
CASES: 26 %
SCHEDULED CASES: 9 %
CANCELLED CASES: 33 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-----------------------------------------------------------------------------ADMINISTRATIVE CANCELLATION
1
1
MEDICAL
4
1
SCHEDULING ERROR
1
0
--------TOTAL CANCELLATIONS
6
2
Press RETURN to continue, or '^' to quit:
<Enter>
** PLASTIC SURGERY (INCLUDES HEAD AND NECK) **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
10
CASES: 30 %
SCHEDULED CASES: 20 %
CANCELLED CASES: 67 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-----------------------------------------------------------------------------PATIENT NOT NPO
1
1
PREV. CASE LENGTH
1
0
SURGEON
1
1
--------TOTAL CANCELLATIONS
3
2
Press RETURN to continue, or '^' to quit:
348
<Enter>
Surgery V. 3.0 User Manual
April 2004
Example 2: View for All Specialties
Select Delay and Cancellation Reports Option: A
Report of Cancellation Rates
Report of Cancellation Rates
Start with which Date ? 3/2 (MAR 02, 1999)
End with which Date ? 3/20 (MAR 20, 1999)
Do you want to print the report for all Surgical Specialties ?
YES//
<Enter>
Do you want to display the cancellation reasons for each Surgical
Specialty ? YES// <Enter>
Print the Report on which device: [Select Print Device]
---------------------------------------------------------printout follows-------------------------------------------------** GENERAL(OR WHEN NOT DEFINED BELOW) **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
18
CASES: 17 %
SCHEDULED CASES: 0 %
CANCELLED CASES: 0 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------PREV. CASE LENGTH
3
0
--------TOTAL CANCELLATIONS
3
0
Press RETURN to continue, or '^' to quit:
<Enter>
** NEUROSURGERY **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
8
CASES: 25 %
SCHEDULED CASES: 13 %
CANCELLED CASES: 50 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------OPERATING ROOM
1
0
PATIENT NO-SHOW
1
1
--------TOTAL CANCELLATIONS
2
1
Press RETURN to continue, or '^' to quit: <Enter>
** ORTHOPEDICS **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
23
CASES: 26 %
SCHEDULED CASES: 9 %
CANCELLED CASES: 33 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------ADMINISTRATIVE CANCELLATION
1
1
MEDICAL
4
1
SCHEDULING ERROR
1
0
--------TOTAL CANCELLATIONS
6
2
Press RETURN to continue, or '^' to quit:
April 2004
<Enter>
Surgery V. 3.0 User Manual
349
** OTORHINOLARYNGOLOGY (ENT) **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
18
CASES: 6 %
SCHEDULED CASES: 6 %
CANCELLED CASES: 100 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------SCHEDULING ERROR
1
1
--------TOTAL CANCELLATIONS
1
1
Press RETURN to continue, or '^' to quit:
<Enter>
** PERIPHERAL VASCULAR **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
16
CASES: 25 %
SCHEDULED CASES: 6 %
CANCELLED CASES: 25 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------MEDICAL
2
0
PREV. CASE LENGTH
1
0
SCHEDULING ERROR
1
1
--------TOTAL CANCELLATIONS
4
1
Press RETURN to continue, or '^' to quit:
<Enter>
** PLASTIC SURGERY (INCLUDES HEAD AND NECK) **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
10
CASES: 30 %
SCHEDULED CASES: 20 %
CANCELLED CASES: 67 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------PATIENT NOT NPO
1
1
PREV. CASE LENGTH
1
0
SURGEON
1
1
--------TOTAL CANCELLATIONS
3
2
Press RETURN to continue, or '^' to quit:
<Enter>
** PODIATRY **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
14
CASES: 7 %
SCHEDULED CASES: 0 %
CANCELLED CASES: 0 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------MEDICAL
1
0
--------TOTAL CANCELLATIONS
1
0
Press RETURN to continue, or '^' to quit:
350
<Enter>
Surgery V. 3.0 User Manual
April 2004
** UROLOGY **
TOTAL SCHEDULED SURGICAL CASES:
CANCELLATION RATE FOR SCHEDULED
AVOIDABLE CANCELLATION RATE FOR
AVOIDABLE CANCELLATION RATE FOR
11
CASES: 18 %
SCHEDULED CASES: 0 %
CANCELLED CASES: 0 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------MEDICAL
1
0
PATIENT/GUARDIAN REFUSES
1
0
--------TOTAL CANCELLATIONS
2
0
Press RETURN to continue, or '^' to quit:
<Enter>
TOTAL SURGICAL CASES SCHEDULED FOR MAYBERRY, NC: 118
CANCELLATION RATE FOR SCHEDULED CASES: 19 %
AVOIDABLE CANCELLATION RATE FOR SCHEDULED CASES: 6 %
AVOIDABLE CANCELLATION RATE FOR CANCELLED CASES: 32 %
CANCELLATION REASON
TOTAL CANCELS
TOTAL AVOIDABLE
-------------------------------------------------------------------------------ADMINISTRATIVE CANCELLATION
1
1
MEDICAL
8
1
OPERATING ROOM
1
0
PATIENT NO-SHOW
1
1
PATIENT NOT NPO
1
1
PATIENT/GUARDIAN REFUSES
1
0
PREV. CASE LENGTH
5
0
SCHEDULING ERROR
3
2
SURGEON
1
1
--------TOTAL CANCELLATIONS
22
7
Press RETURN to continue, or '^' to quit:
<Enter>
PERCENT AVOIDABLE CANCELLATIONS
----------------------------------SURGICAL SPECIALTY
SCHEDULED CASES
CANCELLED CASES
================================================================================
GENERAL(OR WHEN NOT DEFINED BELOW)
NEUROSURGERY
ORTHOPEDICS
OTORHINOLARYNGOLOGY (ENT)
PERIPHERAL VASCULAR
PLASTIC SURGERY (INCLUDES HEAD AND NECK)
PODIATRY
UROLOGY
Press RETURN to continue
April 2004
0
13
9
6
6
20
0
0
%
%
%
%
%
%
%
%
0
50
33
100
25
67
0
0
%
%
%
%
%
%
%
%
<Enter>
Surgery V. 3.0 User Manual
351
List of Unverified Surgery Cases
[SROUNV]
The List of Unverified Surgery Cases option will generate a list of all completed surgery cases that have
not had the procedure, diagnosis, and complications verified. The user can verify a case using the
Surgeon‟s Verification of Diagnosis & Procedures option in the Operation Menu. This list can be
compiled for one or all surgical specialties.
This report is in an 80-column format and can be viewed on your screen.
Example: List of Unverified Surgery Cases
Select Management Reports Option: V
List of Unverified Surgery Cases
Do you want the list for all Surgical Specialties ?
YES//
N
Select Surgical Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Start with Date: 3/9
End with Date: 3/20
50
(MAR 09, 1999)
(MAR 20, 1999)
Print the List of Unverified Cases to which Printer ? [Select Print Device]
---------------------------------------------------------printout follows-------------------------------------------------List of Unverified Cases for GENERAL(OR WHEN NOT DEFINED BELOW)
Operation Date
Patient (Case #)
Surgeon
Patient ID #
Attending Surgeon
================================================================================
MAR 9, 1999
SURPATIENT,SIX (15188)
SURSURGEON,SIXTEEN
000-09-8797
SURSURGEON,FOUR
APPENDECTOMY * CPT CODE MISSING *
-------------------------------------------------------------------------------MAR 10, 1999
SURPATIENT,FIFTYONE (15189)
SURSURGEON,FOUR
000-23-3221
SURSURGEON,ONE
DRAINAGE OF OVARIAN CYST * CPT CODE MISSING *
-------------------------------------------------------------------------------MAR 10, 1999
SURPATIENT,TWO (15199)
SURSURGEON,ONE
000-45-1982
NOT ENTERED
CHOLECYSTECTOMY WITH CHOLANGIOGRAM * CPT CODE MISSING *
-------------------------------------------------------------------------------MAR 17, 1999
SURPATIENT,FOURTEEN (15203)
SURSURGEON,ONE
000-45-7212
SURSURGEON,TWO
CHOLECYSTECTOMY * CPT CODE MISSING *
-------------------------------------------------------------------------------MAR 18, 1999
SURPATIENT,SEVENTEEN (15202)
SURSURGEON,ONE
000-45-5119
SURSURGEON,TWO
REPAIR INCARCERATED INGUINAL HERNIA * CPT CODE MISSING *
-------------------------------------------------------------------------------Press RETURN to continue, or '^' to quit:. <Enter>
352
Surgery V. 3.0 User Manual
April 2004
Report of Returns to Surgery
[SRORET]
The Report of Returns to Surgery option lists cases that have had related surgical procedures performed
within 30 days of the date of the operation. The user must enter the date range by which the software will
sort.
This report has a 132-column format and must be copied to a printer with wide paper.
Example: Print the Report of Returns to Surgery
Select Management Reports Option: RET
Report of Returns to Surgery
Report of Returns to Surgery
Start with Date: 7/1 (JUL 01, 1999)
End with Date: 7/14 (JUL 14, 1999)
This report will list cases completed during the date range entered that
have had return cases associated with them. It is designed to use a 132
column format.
Print the Report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
353
MAYBERRY, NC
SURGICAL SERVICE
REPORT OF RETURNS TO SURGERY
FROM: JUL 1,1999 TO: JUL 14,1999
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: AUG 27,1999
OPERATION DATE
PATIENT (ID#)
PRINCIPAL OPERATIVE PROCEDURE
====================================================================================================================================
JUL 03, 1999
SURPATIENT,SEVENTEEN (000-45-5119)
RETURNS TO SURGERY:
JUL 07, 1999
JUL 06, 1999
354
RIGHT FOOT
IRRIGATION AND DEBRIDEMENT OF LT. FOOT
IRRIGATION AND DEBRIDEMENT OF LT. FOOT
EXPLORATORY LAPAROTOMY
TRACHEOSTOMY
SURPATIENT,ONE (000-44-7629)
RETURNS TO SURGERY:
JUL 13, 1999
EXCISION OF GRANULATION TISSUE RT. FOOT
STSG FROM RT. THIGH TO
SURPATIENT,FORTYONE (000-43-2109)
RETURNS TO SURGERY:
AUG 05, 1999
JUL 10, 1999
CREATION OF A-V FISTULA W/VASCULAR GRAFT, RT ARM
SURPATIENT,FORTY (000-77-7777)
RETURNS TO SURGERY:
JUL 14, 1999
JUL 07, 1999
ATTEMPTED REVISION OF LEFT ARM A-V FISTULA WITH GRAFT
SURPATIENT,TWO (000-45-1982)
RETURNS TO SURGERY:
AUG 03, 1999
JUL 06, 1999
EXPLORATORY LAPAROTOMY
SURPATIENT,FIVE (000-21-2453)
RETURNS TO SURGERY:
JUL 15, 1999
JUL 06, 1999
REPAIR GASTRIC PERFORATION
RIGHT LOWER QUADRANT EXPLORATION
SIGMOID COLECTOMY
Surgery V. 3.0 User Manual
April 2004
Report of Daily Operating Room Activity
[SROPACT]
The Report of Daily Operating Room Activity option provides a list of completed cases started between
6:00 AM on the date selected and 5:59 AM of the following day for all operating rooms.
Example: Print the Report of Daily Operating Room Activity
Select Management Reports Option: A Report of Daily Operating Room Activity
Print the Report of Daily Activity for which Date ?
7/1
(JUL 01, 1999)
This report will include all cases started between MAR 12, 1992 at 6:00 AM
and MAR 13, 1992 at 5:59 AM.
It is designed to use a 132 column format.
Print the Report to which Device ?
[Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
355
MAYBERRY, NC
SURGICAL SERVICE
DAILY REPORT OF OPERATING ROOM ACTIVITY
FOR: JUL 01, 1999
PATIENT
TIME IN OR
POSTOPERATIVE DIAGNOSIS
ANESTHESIOLOGIST
SURGEON
ID #
AGE
TIME OUT OR
PROCEDURE(S)
PRIN. ANESTHETIST
FIRST ASST.
WARD
CASE NUMBER
ATT SURGEON
====================================================================================================================================
OPERATING ROOM: CYSTO1
SURPATIENT,SIX
000-09-8797
OUTPATIENT
07/01 14:00
07/01 16:05
33536
GROSS HEMATURIA
CYSTOURETHROSCOPY WITH BLADDER BIOPSY,
TRANSURETHRAL RESECTION OF BLADDER TUMOR
SURSANESTHESIOLOGIST,O SURSURGEON,F
SURANESTHETIST,F
SURSURGEON,O
SURPATIENT,NINETEEN
000-28-7354
59
OUTPATIENT
07/01 08:00
07/01 16:30
33512
LEFT COLD FOOT
LEFT FEMORO-TIB TO TIB PERONEAL TRUNK
SAPHENOUS,IN-SITU, TIBIAL-PERONEAL EMBOLECTOMY,
EXCLUSION OF POPLITEAL ANEURYSM, COMPLETION
ANGIOGRAPHY, COMPLETION DUPLEX
SURSANESTHESIOLOGIST,O SURSURGEON,T
SURANESTHETIST,F
SURSURGEON,F
SURSURGEON,O
SURPATIENT,SEVENTEEN
000-45-5119
73
OUTPATIENT
07/01 09:10
07/01 13:00
33521
RT. CAROTID STENOSIS
RT. CAROTID ENDARTERECTOMY
SURSANESTHESIOLOGIST,T SURSURGEON,F
07/01 06:00
07/01 07:35
33519
APPENDICITIS
APPENDECTOMY
07/01 07:45
07/01 12:00
33409
RT. EAR,RT. EYELID BASAL CELL CA
EXCISION OF RT. UPPER EYELID BASAL CELL CA,
EXCISION OF RT. EAR BASAL CELL CA
07/01 07:50
07/01 10:27
33399
SINUSITIS ,RHNOPHYMA,NASAL OBSTRUCTION
SEPTOPLASTY, TURBINECTOMY, INTERNAL INTRA NASAL
SYNOIDECTOMY, LASER RESURFACE OF NOSE, NASAL
POLYECTOMY RT., NASAL POLYPECTOMY LT.
69
OPERATING ROOM: OR1
SURSURGEON,S
OPERATING ROOM: OR2
SURPATIENT,TEN
000-12-3456
OUTPATIENT
60
SURSANESTHESIOLOGIST,O SURSURGEON,F
SURSANESTHESIOLOGIST,O
SURSURGEON,S
OPERATING ROOM: OR4
SURPATIENT,FIVE
000-58-7963
75
OUTPATIENT
SURSANESTHESIOLOGIST,O SURSURGEON,S
SURSANESTHESIOLOGIST,O
SURSURGEON,F
OPERATING ROOM: OR5
SURPATIENT,SIXTEEN
000-11-1111
96
OUTPATIENT
356
Surgery V. 3.0 User Manual
SURSANESTHESIOLOGIST,O SURSURGEON,F
SURSANESTHESIOLOGIST,O
SURSURGEON,S
April 2004
Report of Cases Without Specimens
[SROSPEC]
The Report of Cases Without Specimens option lists all completed cases in which there were no
specimens taken from the operative site. The report can be printed for an individual surgical specialty, if it
is needed.
This report is in a 132-column format and must be copied to a printer with wide paper.
Example: Print the Report of Cases without Specimens
Select Management Reports Option: NS
Report of Cases Without Specimens
Report of Cases Without Specimens
Starting with which Date ? 7/12 (JUL 12, 1999)
Ending with which Date ? 7/14 (JUL 14, 1999)
Do you want the report sorted by Surgical Specialty ?
NO// <Enter>
This report is designed to use a 132 column format.
Print the Report on which Device ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
357
MAYBERRY, NC
SURGICAL SERVICE
CASES WITHOUT SPECIMENS
FROM: JUL 12,1999 TO: JUL 14,1999
PAGE 1
REVIEWED BY:
DATE REVIEWED:
DATE PRINTED: JUL 27,1999
DATE
CASE #
PATIENT
PATIENT ID
SURGICAL SPECIALTY
SURGEON
POSTOPERATIVE DIAGNOSIS
ATTENDING SURGEON
OPERATIVE PROCEDURE
====================================================================================================================================
07/12/99
SURPATIENT,TEN
PERIPHERAL VASCULAR
SURSURGEON,THREE
33613
000-12-3456
RENAL FAILURE
SURSURGEON,ONE
PLACEMENT OF LEFT FEMORAL DIALYSIS
TESSIO-CATHETER
07/12/99
33616
SURPATIENT,FOUR
000-17-0555
OTORHINOLARYNGOLOGY (ENT)
NASAL OBSTRUCTION
LEFT LATERAL RHINOTOMY WITH RECONSTRUCTION OF
NASAL VESTIBULE
SURSURGEON,TWO
SURSURGEON,ONE
07/12/99
33659
SURPATIENT,SIXTEEN
000-11-1111
UROLOGY
SIGMOID CA
CYSTOURETOROSCOPY, RETROGRADE PYELOGRAPHY,
BILATERAL URETERAL STENT PLACEMENT
SURSURGEON,FOUR
SURSURGEON,FOUR
07/12/99
33653
SURPATIENT,SEVENTEEN
000-45-5119
GENERAL(OR WHEN NOT DEFINED BELOW)
PROLONGED ANTIBOTIC THERAPHY
PLACEMENT OF HICKMAN CATHETER
SURSURGEON,TWO
SURSURGEON,SEVEN
07/13/99
33554
SURPATIENT,FIFTY
000-45-9999
OPHTHALMOLOGY
CATARACT OS
PHACEOMULSIFICATION, LENS IMPLANT OS
SURSURGEON,ONE
SURSURGEON,ONE
07/14/99
33598
SURPATIENT,TEN
000-12-3456
PLASTIC SURGERY (INCLUDES HEAD AND NECK)
MOH'S DEFECT LT. UPPER LIP
FLAP CLOSURE OF MOHS DEFECT LEFT UPPER LIP
SURSURGEON,ONE
SURSURGEON,FOUR
07/14/99
33645
SURPATIENT,EIGHTEEN
000-22-3334
PLASTIC SURGERY (INCLUDES HEAD AND NECK)
INFECTED DIABETIC FOOT
DEBRIDEMENT RIGHT FOOT, SKIN GRAFT RT THIGH TO RT
FOOT
SURSURGEON,SIX
SURSURGEON,TWO
TOTAL CASES WITHOUT SPECIMENS: 7
358
Surgery V. 3.0 User Manual
April 2004
Report of Unscheduled Admissions to ICU
[SROICU]
The Report of Unscheduled Admissions to ICU option lists all unscheduled admissions to the Intensive
Care Unit (ICU) based on the requested (expected) postoperative care and actual postoperative
disposition.
This report is in a 132-column format and must be copied to a printer with wide paper.
Example: Print Report of Unscheduled Admissions to ICU
Select Management Reports Option: ICU
Report of Unscheduled Admissions to ICU
Report of Unscheduled Admissions to the ICU
Starting with which Date ? 7/1 (JUL 01, 1999)
Ending with which Date ? 7/31 (JUL 32, 1999)
Do you want the report for a specific Surgical Specialty ?
NO//
<Enter>
This report is designed to use a 132 column format.
Print the Report on which Device ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
359
MAYBERRY, NC
SURGICAL SERVICE
UNSCHEDULED ADMISSIONS TO ICU
FROM 07/01/99 TO 07/31/99
REVIEWED BY:
DATE REVIEWED:
DATE
PATIENT
SURGICAL SPECIALTY
SURGEON
PATIENT ID
POSTOPERATIVE DIAGNOSIS
ATTENDING SURGEON
REQ DISPOSITION/POSTOP DISPOSITION
OPERATIVE PROCEDURE(S)
====================================================================================================================================
07/01/99
SURPATIENT,EIGHTEEN
GENERAL(OR WHEN NOT DEFINED BELOW)
SURSURGEON,ONE
000-22-3334
APPENDICITIS
SURSURGEON,THREE
PACU (RECOVERY ROOM)/SICU
APPENDECTOMY
07/06/99
SURPATIENT,TEN
000-12-3456
WARD/SICU
GENERAL(OR WHEN NOT DEFINED BELOW)
INABILITY TO TAKE ORAL OR USE NG TUBE
PLACEMENT OF G-TUBE
SURSURGEON,ONE
SURSURGEON,FOUR
07/08/99
SURPATIENT,TWELVE
000-41-8719
WARD/MICU
GENERAL(OR WHEN NOT DEFINED BELOW)
GANGRENE LT. FOOT
LT. BELOW KNEE AMPUTATION
SURSURGEON,ONE
SURSURGEON,THREE
07/23/99
SURPATIENT,TEN
000-12-3456
WARD/SICU
PERIPHERAL VASCULAR
IV ACCESS
PLACEMENT OF HICKMAN CATHATER, INTRODUCTION OF
DOBHOFF TUBE
SURSURGEON,ONE
SURSURGEON,FOUR
07/27/99
SURPATIENT,FORTY
000-77-7777
WARD/MICU
GENERAL(OR WHEN NOT DEFINED BELOW)
RT BUTTOCK ABCESS
I AND D OF RIGHT BUTTOCK ABSCESS
SURSURGEON,ONE
SURSURGEON,TWO
07/29/99
SURPATIENT,FOUR
000-17-0555
WARD/MICU
GENERAL(OR WHEN NOT DEFINED BELOW)
INCARCERATED EPIGASTRIC HERNIA
REPAIR OF INCARCERATED EPIGASTRIC HERNIA
SURSURGEON,ONE
SURSURGEON,TWO
360
Surgery V. 3.0 User Manual
April 2004
Operating Room Utilization Report
[SR OR UTL1]
The Operating Room Utilization Report option prints utilization information for a selected date range for
all operating rooms or for a single operating room. The report displays the percent utilization, the number
of cases, the total operation time and the time worked outside normal hours for each operating room
individually and all operating rooms collectively.
How the Percent Utilization is Derived
The percent utilization is derived by dividing the total operation time for all operations (including total
time patients were in OR, plus the cleanup time allowed for each case) by the total functioning time, as
defined in the SURGERY UTILIZATION file. The quotient is then multiplied by 100.
This report must be copied to a printer with wide paper
Example: Print the Operating Room Utilization Report
Select Management Reports Option: OR
Operating Room Utilization Report
Operating Room Utilization Report
Print utilization information starting with which date ?
Print utilization information through which date ?
3/9
3/8
(MAR 08, 1999)
(MAR 09, 1999)
Do you want to print the Operating Room Utilization Report for all
operating rooms ? YES// <Enter>
Print the Operating Room Utilization Report on which Device ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
361
MAYBERRY, NC
PAGE 1
SURGICAL SERVICE
OPERATING ROOM UTILIZATION REPORT
FOR ALL OPERATING ROOMS FROM: MAR 8,1999 TO: MAR 9,1999
DATE PRINTED: MAR 17,1999
====================================================================================================================================
OPERATING ROOM
PERCENT UTILIZATION
TOTAL OPERATION TIME
TIME WORKED OUTSIDE NORMAL HRS
(INCLUDING OR MAINTENANCE)
====================================================================================================================================
OR1
70%
NUMBER OF CASES
3
17 hrs and 35 mins
6 hrs and 20 mins
-----------------------------------------------------------------------------------------------------------------------------------OR2
39%
1
7 hrs and 25 mins
1 hr and 10 mins
-----------------------------------------------------------------------------------------------------------------------------------OR3
133%
8
23 hrs and 42 mins
2 hrs and 30 mins
-----------------------------------------------------------------------------------------------------------------------------------OR4
29%
3
4 hrs and 41 mins
-
-----------------------------------------------------------------------------------------------------------------------------------OR5
84%
7
18 hrs and 50 mins
5 hrs and 25 mins
-----------------------------------------------------------------------------------------------------------------------------------OR6
0
0
-
-
-----------------------------------------------------------------------------------------------------------------------------------OR7
0
0
-
-
-----------------------------------------------------------------------------------------------------------------------------------TOTAL UTILIZATION FOR
ALL ROOMS
63%
22
72 hrs and 13 mins
15 hrs and 25 mins
====================================================================================================================================
362
Surgery V. 3.0 User Manual
April 2004
Wound Classification Report
[SROWC]
The Wound Classification Report option generates a report showing the total number of surgical cases in
each of the various wound classifications for a specified date range. The report is sorted by surgical
service.
After selecting a date range, the user has the choice of printing one of three reports.
Wound Classification Report: The user enters the number 1 to print this summary of wound
classifications entered for surgical cases performed during the date range.
List of Operations by Wound Classification: The user enters the number 2 to print this list of
operations sorted by wound classification and by surgical specialty performed during the date
range.
Clean Wound Infection Summary: The user enters the number 3 to print this summary of clean
wound infections.
These reports are in an 80-column format and can be viewed on the screen.
Example 1: Wound Classification Report (Summary)
Select Management Reports Option: WC
Wound Classification Report
Wound Classification Report
Start with Date: 7/1 (JUL 01, 1999)
End with Date: 7/15 (JUL 15, 1999)
Print which of the following ?
1. Wound Classification Report (Summary)
2. List of Operations by Wound Classification
3. Clean Wound Infection Summary
Select Number:
1// <Enter>
Do you want to print the report for all Surgical Specialties ?
YES//
Print the report for which Specialty ? GENERAL(OR WHEN NOT DEFINED BE
50
Select An Additional Specialty: ORTHOPEDICS
54
Select An Additional Specialty: <Enter>
N
LOW)
Print on Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
363
WOUND CLASSIFICATION REPORT
FROM: JUL 1,1999 TO: JUL 15,1999
-----------------------------------------------------------------------------SURGICAL SERVICE
CLEAN
CLEAN
CONTAMINATED
CONTAMINATED
INFECTED
NO CLASS
ENTERED
GENERAL
ORTHOPEDICS
9
9
10
0
4
0
3
0
0
0
SUB TOTAL:
18
10
4
3
0
TOTAL:
35
CLEAN WOUND INFECTION RATE:
Press RETURN to continue
364
0.0%
<Enter>
Surgery V. 3.0 User Manual
April 2004
Example 2: List of Operations by Wound Classification
Select Management Reports Option: WC
Wound Classification Report
Wound Classification Report
Start with Date: 7/8 (JUL 08, 1999)
End with Date: 7/8 (JUL 08, 1999)
Print which of the following ?
1. Wound Classification Report (Summary)
2. List of Operations by Wound Classification
3. Clean Wound Infection Summary
Select Number:
1// 2
Do you want to print the report for all Wound Classifications ? YES//
N
Print report for which Wound Classification ?
1.
2.
3.
4.
5.
CLEAN
CLEAN/CONTAMINATED
CONTAMINATED
INFECTED
NO CLASS ENTERED
Select Number:
1
Do you want to print the report for all Surgical Specialties ?
YES//
N
Print the report for which Specialty ? GENERAL(OR WHEN NOT DEFINED BELOW)
Select An Additional Specialty: PERIPHERAL VASCULAR 62
Select An Additional Specialty: <Enter>
Print on Device:
50
[Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
365
List of Surgical Cases by Wound Classification
FROM: JUL 8,1999 TO: JUL 8,1999
Wound Classification: CLEAN
DATE PRINTED: JUL 27,1999
Page:
1
Operation Date
Patient
Surgeon/Provider
Case #
ID #
==============================================================================
>> GENERAL(OR WHEN NOT DEFINED BELOW) <<
JUL 08, 1999
33280
SURPATIENT,TEN
SURSURGEON,ONE
000-12-3456
* RT. INGUINAL HERNIA REPAIR
-----------------------------------------------------------------------------JUL 08, 1999
SURPATIENT,FOUR
SURSURGEON,FOUR
33629
000-17-0555
* INCARCERATED UMBILICAL HERNIA REPAIR
-----------------------------------------------------------------------------Press RETURN to continue, or '^' to quit: <Enter>
List of Surgical Cases by Wound Classification
FROM: JUL 8,1999 TO: JUL 8,1999
Wound Classification: CLEAN
DATE PRINTED: JUL 27,1999
Page:
2
Operation Date
Patient
Surgeon/Provider
Case #
ID #
==============================================================================
>> PERIPHERAL VASCULAR <<
JUL 08, 1999
33478
SURPATIENT,FORTY
SURSURGEON,ONE
000-77-7777
* LEFT CAROTID ENDARTERECTOMY
* REOPERATION LEFT CAROTID
-----------------------------------------------------------------------------JUL 08, 1999
SURPATIENT,TWO
SURSURGEON,TWO
33575
000-45-1982
* LT. A-V FISTULA WITH LOOP VEIN GRAFT
-----------------------------------------------------------------------------Press RETURN to continue
366
<Enter>
Surgery V. 3.0 User Manual
April 2004
Example 3: Clean Wound Infection Summary
Select Management Reports Option: WC
Wound Classification Report
Wound Classification Report
Start with Date: 6/1 (JUN 01, 1999)
End with Date: 6/30 (JUN 30, 1999)
Print which of the following ?
1. Wound Classification Report (Summary)
2. List of Operations by Wound Classification
3. Clean Wound Infection Summary
Select Number:
1// 3
Do you want to print the report for all Surgical Specialties ?
YES// <Enter>
Print on Device: [Select Print Device]
----------------------------------------------------------printout follows---------------------------------------------MAYBERRY, NC
SURGICAL SERVICE
CLEAN WOUND INFECTION SUMMARY
FROM: JUN 1,1999 TO: JUN 30,1999
DATE PRINTED: JUL 18,1999
REVIEWED BY:
DATE REVIEWED:
SURGICAL SERVICE
CLEAN WOUNDS
INFECTIONS
INFECTION RATE
==============================================================================
GENERAL
21
1
4.8%
GYNECOLOGY
0
0
0.0%
NEUROSURGERY
11
0
0.0%
OPHTHALMOLOGY
30
0
0.0%
ORTHOPEDICS
20
1
5.0%
OTORHINOLARYNGOLOGY
6
0
0.0%
PLASTIC SURGERY
7
0
0.0%
PROCTOLOGY
0
0
0.0%
THORACIC SURGERY
2
0
0.0%
UROLOGY
2
0
0.0%
ORAL SURGERY
0
0
0.0%
PODIATRY
14
0
0.0%
PERIPHERAL VASCULAR
28
0
0.0%
CARDIAC SURGERY
0
0
0.0%
TRANSPLANTATION
0
0
0.0%
ANESTHESIOLOGY
0
0
0.0%
RHEUMATOLOGY
1
0
0.0%
PULMONARY
0
0
0.0%
GASTROENTEROLOGY
0
0
0.0%
NO SPECIALTY ENTERED
0
0
0.0%
TOTAL
April 2004
142
2
Surgery V. 3.0 User Manual
1.4%
367
Pages 368-392 have been deleted. The Quarterly Report Menus have been removed.
368
Surgery V. 3.0 User Manual
April 2004
Print Blood Product Verification Audit Log
[SR BLOOD PRODUCT VERIFY AUDIT]
The Blood Product Verification Audit Log option is used to print the KERNEL audit log for the Blood
Product Verification option.
Prior to printing entries from the KERNEL audit log for the Blood Product Verification option (located
on the Operation Menu), the audit function must be turned on either through the System Manager Menu
option or by invoking the Establish System Audit Parameters option in KERNEL, as shown in the
following example.
Example: Establish System Audit Parameters
Select Systems Manager Menu Option: SYStem Security
Select System Security Option: AUDIt Features
Select Audit Features Option: MAintain System Audit Options
Select Maintain System Audit Options Option: EStablish System Audit Parameters
Kernel Site Parameter edit
DOMAIN: [Enter your domain here.]
OPTION AUDIT: SPECIFIC OPTIONS AUDITED
INITIATE AUDIT: [Enter date here.]
FAILED ACCESS ATTEMPTS:
TERMINATE AUDIT: [Enter date here.]
Option to audit
SR BLOOD PRODUCT VERIFICATION
Namespace to audit
User to audit
Device to audit
______________________________________________________________________________
COMMAND:
April 2004
Press <PF1>H for help
Surgery V. 3.0 User Manual
Insert
393
Example: Print Blood Product Verification Audit Log
Select Management Reports Option: BA
Print Blood Product Verification Audit Log
Enter a date range to print the Blood Verification Audit Log.
* Previous selection: DATE/TIME from Feb 21,1999
START WITH DATE/TIME: FIRST// <Enter>
DEVICE: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
MENU OPTION AUDIT LOG
APR 2,1999
3:04 PM
PAGE 1
-----------------------------------------------------------------------------*** OPTION: SR BLOOD PRODUCT VERIFICATION
USER: SURSURGEON,TWO
DATE/TIME (ENTRY): MAR 5,1999 09:24
(EXIT): MAR 5,1999 09:24
CPU: VAA
DEVICE: _LTA8720:
JOB: 541070010
*** OPTION: SR BLOOD PRODUCT VERIFICATION
USER: SURSURGEON,SIX
DATE/TIME (ENTRY): MAR 5,1999 09:24
(EXIT): MAR 5,1999 09:24
CPU: VAA
DEVICE: _LTA8720:
JOB: 541070010
*** OPTION: SR BLOOD PRODUCT VERIFICATION
USER: SURSURGEON,ONE
DATE/TIME (ENTRY): MAR 6,1999 13:06
(EXIT): MAR 6,1999 13:07
CPU: VAA
DEVICE: _LTA1411:
JOB: 541072157
*** OPTION: SR BLOOD PRODUCT VERIFICATION
USER: SURSURGEON,ONE
DATE/TIME (ENTRY): MAR 6,1999 13:10
(EXIT): MAR 6,1999 13:11
CPU: VAA
DEVICE: _LTA1411:
JOB: 541072157
*** OPTION: SR BLOOD PRODUCT VERIFICATION
USER: SURSURGEON,ONE
DATE/TIME (ENTRY): MAR 6,1999 13:20
(EXIT): MAR 6,1999 13:20
CPU: VAA
DEVICE: _LTA1411:
JOB: 541072157
394
Surgery V. 3.0 User Manual
April 2004
Key Missing Surgical Package Data
[SROQ MISSING DATA]
The Key Missing Surgical Package Data option generates a list of surgical cases performed within the
selected date range that are missing key information. This report includes surgical cases with an entry in
the TIME PAT IN OR field and does not include aborted cases.
This report has a 132-column format and is designed to be copied to a printer.
Example: Key Missing Surgical Package Data
Select Management Reports Option: KEY
Key Missing Surgical Package Data
Report of Key Missing Surgical Package Data
For surgical cases with an entry in the TIME PAT IN OR field and that are not
aborted, this option generates a report of cases missing any of the following
pieces of information:
In/Out-Patient Status
Major/Minor
Case Schedule Type
Attending Code
Time Pat Out OR
Wound Classification
ASA Class
CPT Code (Principal)
Start with Date: Start with Date: 4 1
End with Date: 4 30 (APR 30, 2005)
(APR 01, 2005)
Do you want the report for all Surgical Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print the report to which Printer ?
[Select Print Device]
----------------------------------------------------------printout follows----------------------------------------
April 2004
Surgery V. 3.0 User Manual
394a
MAYBERRY, NC
Report of Key Missing Surgical Package Data
From: APR 1,2005 To: APR 30,2005
Report Printed: MAY 11,[email protected]:09
PAGE 1
DATE OF OPERATION
PATIENT NAME
SURGICAL SPECIALTY
MISSING ITEMS
CASE #
PATIENT ID (AGE)
PRINCIPAL PROCEDURE
====================================================================================================================================
APR 6,[email protected]:40
SURPATIENT,ONE
OPHTHALMOLOGY
D
32474
000-44-7629 (46)
PHACHOEMULSIFICATION, LENS IMPLANT OD
APR 12,[email protected]:00
32508
SURPATIENT,FORTYONE
000-43-2109 (78)
OPHTHALMOLOGY
PHACOEMULSIFICATION, LENS IMPLANT OS
D
APR 12,[email protected]:50
32534
SURPATIENT,ONE
000-44-7629 (46)
PLASTIC SURGERY (INCLUDES HEAD AND NECK)
EXCISION OF RT. WRIST MASS
D
APR 12,[email protected]:00
32544
SURPATIENT,THIRTY
000-82-9472 (48)
OPHTHALMOLOGY
PHACOEMULSIFICATION OD
D
APR 13,[email protected]:20
32513
SURPATIENT,FIFTYTWO
000-99-8888 (79)
OPHTHALMOLOGY
PHACOEMULSIFICATION, LENS IMPLANT OD
D
APR 15,[email protected]:05
32351
SURPATIENT,FIFTY
000-45-9999 (44)
GENERAL(OR WHEN NOT DEFINED BELOW)
EXCISIONAL BIOPSY MASS RT. BREAST
D
APR 19,[email protected]:00
32580
SURPATIENT,SEVENTEEN
000-45-5119 (71)
OPHTHALMOLOGY
PHACOEMULSIFICATION LENS IMPLANT OD
D
APR 27,[email protected]:15
32684
SURPATIENT,SIXTY
000-56-7821 (40)
OPHTHALMOLOGY
TRABECULECTOMY OD
F
TOTAL CASES MISSING DATA: 8
-----------------------------------------------------------------------------------------------------------------------------------MISSING ITEMS CODES: A-IN/OUT-PATIENT STATUS,
B-MAJOR/MINOR,
C-CASE SCHEDULE TYPE,
D-ATTENDING CODE,
E-TIME PAT OUT OR,
F-WOUND CLASSIFICATION,
G-ASA CLASS,
H-CPT CODE (PRINCIPAL)
394b
Surgery V. 3.0 User Manual
April 2004
Admitted w/in 14 days of Out Surgery If Postop Occ
[SROQADM]
The Admitted w/in 14 days of Out Surgery If Postop Occ option displays a list of patients with completed outpatient
surgical cases that resulted in at least one postoperative occurrence and a hospital admission within 14 days of the
surgery.
This report has a 132-column format and is designed to be copied to a printer with wide paper.
Example: Report of Admitted w/in 14 days of Out Surgery If Postop Occ
Select Management Reports Option: OC Admitted w/in 14 days of Out Surgery If Po
stop Occ
Outpatient Cases with Postop Occurrences
and Admissions Within 14 Days
This report displays the completed outpatient surgical cases which resulted in
at least one postoperative occurrence and a hospital admission within 14 days.
Start with Date: 9 1 04 (SEP 01, 2004)
End with Date: 12 31 04 (DEC 31, 2004)
Do you want the report for all Surgical Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print the report to which Printer ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
394c
MAYBERRY, NC
OUTPATIENT CASES WITH POSTOP OCCURRENCES AND ADMISSIONS WITHIN 14 DAYS
From: SEP 1,2004 To: DEC 31,2004
Report Printed: FEB 12,[email protected]:44
PAGE 1
DATE OF OPERATION
PATIENT NAME
SURGICAL SPECIALTY
ANESTHESIA TECHNIQUE
DATE OF ADMISSION
CASE #
PATIENT ID (AGE)
PROCEDURE(S) PERFORMED
*OCCURRENCE - (DATE)
====================================================================================================================================
SEP 24,[email protected]:30
SURPATIENT,FORTY
THORACIC SURGERY (INC. CARDIAC
GENERAL
OCT 3,[email protected]:11
30395
000-77-7777 (72)
MEDIASTINOSCOPY WITH NODE BIOPSY
*OTHER OCCURRENCE - (10/03/04)
SEP 25,[email protected]:30
SURPATIENT,EIGHTEEN
30544
000-22-3334 (71)
*OTHER OCCURRENCE - (09/28/04)
GENERAL(OR WHEN NOT DEFINED BE
LEFT INGUINAL HERNIORRAPHY
HYDROCELECTOMY
GENERAL
SEP 28, [email protected]:06
NOV 18,[email protected]:45
SURPATIENT,FIFTEEN
31034
000-98-1234 (55)
*SUPERFICIAL WOUND INFECTION - (11/28/04)
PLASTIC SURGERY (INCLUDES HEAD
GENERAL
GANGLION CYST LT. WRIST
INCLUSION OF CYST INDEX FINGER LT.
EXCISION OF LIPOMA OF LT. FOOT
APPLICATION SHORT ARM SPLINT
NOV 28, [email protected]:51
DEC 9,[email protected]:35
SURPATIENT,EIGHT
31242
000-37-0555 (64)
*SUPERFICIAL WOUND INFECTION - (12/29/04)
ORTHOPEDICS
GENERAL
ORIF RT ULNA
REPAIR RT. DISTALRADIOULNAR FX (
DEC 9, [email protected]:55
DEC 31,[email protected]:30
SURPATIENT,FIFTYONE
31277
000-23-3221 (31)
*OTHER CNS OCCURRENCE - (01/05/03)
OTORHINOLARYNGOLOGY (ENT)
GENERAL
DEC 31, [email protected]:02
NASAL SINUS SURGERY WITH BIL SPENOETHMOID POLYPECTOMY (CPT Code: 31205)
BILATERAL ANTROSTOMY
BILATERAL TURBINECTOMY
TOTAL CASES: 5
394d
Surgery V. 3.0 User Manual
April 2004
Deaths Within 30 Days of Surgery
[SROQD]
The Deaths Within 30 Days of Surgery option lists patients who had surgery within the selected date
range, died within 30 days of surgery. Two separate reports are available through this option.
1. Total Cases Summary: This report may be printed in one of three ways.
A. All Cases
The report will list all patients who had surgery within the selected date range and who died within 30
days of surgery, along with all of the patients' operations that were performed during the selected date
range.
B. Outpatient Cases Only
The report will list only the surgical cases that are associated with deaths that are counted as
outpatient (ambulatory) deaths.
C. Inpatient Cases Only
The report will list only the surgical cases that are associated with deaths that are counted as inpatient
deaths.
2. Specialty Procedures: This report will list the surgical cases that are associated with deaths that are
counted for the national surgical specialty linked to the local surgical specialty. Cases are listed by
national surgical specialty.
These reports have a 132-column format and are designed to be copied to a printer.
April 2004
Surgery V. 3.0 User Manual
395
Example 1: Deaths Within 30 Days of Surgery - Total Cases Summary
Select Management Reports Option: DS
Deaths Within 30 Days of Surgery
Deaths Within 30 Days of Surgery
This report lists patients who had surgery within the selected date range
and who died within 30 days of surgery.
Start with Date: 4/1 (APR 01, 2005)
End with Date: 4/30 (APR 30, 2005)
Print which report?
1. Total Cases Summary
2. National Specialty Procedures
Select number: 1// 1
Total Cases Summary
Print Deaths within 30 Days of Surgery for
A - All cases
O - Outpatient cases only
I - Inpatient cases only
Select Letter (I, O or A): A// All Cases
This report is designed to use a 132 column format.
Print the report to which Printer ?
[Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
396
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
DEATHS WITHIN 30 DAYS OF SURGERY
FOR SURGERY PERFORMED FROM: APR 1,2005 TO: APR 30,2005
Report Printed: MAY 18,[email protected]:09
PAGE 1
DEATH
OP DATE
CASE #
IN/OUT
SURGICAL SPECIALTY
PROCEDURE(S)
RELATED
====================================================================================================================================
>>> SURPATIENT,FORTY (000-77-7777) - DIED 05/12/05 AGE: 70
04/13/05
32571
INPAT
GENERAL(OR WHEN NOT DEFINED BELOW)
EXPLORATORY LAPAROTOMY
RIGHT HEMICOLECTOMY
ILEOSTOMY
MUCOUS FISTULA OF COLON
UNRELATED
04/24/05
32693
INPAT
GENERAL(OR WHEN NOT DEFINED BELOW)
CLOSURE OF ABDOMINAL WALL FASCIA
UNRELATED
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,TEN (000-12-3456) - DIED 05/12/05 AGE: 68
04/26/05
32702
INPAT
THORACIC SURGERY (INC. CARDIAC SURG
RIGHT THORACOTOMY WITH LUNG BIOPSY
DIAPHRAGM BIOPSY
UNRELATED
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,SIXTY (000-56-7821) - DIED 04/30/05 AGE: 40
04/21/05
32567
INPAT
THORACIC SURGERY (INC. CARDIAC SURG
ESOPHAGECTOMY
ESOPHAGOSCOPY
BRONCHOSCOPY
FEEDING TUBE JEJUNOSTOMY
RELATED
-----------------------------------------------------------------------------------------------------------------------------------TOTAL DEATHS: 3
April 2004
Surgery V. 3.0 User Manual
397
Example 2: Deaths Within 30 Days of Surgery - Specialty Procedures
Select Management Reports Option: DS Deaths Within 30 Days of Surgery
Deaths Within 30 Days of Surgery
This report lists patients who had surgery within the selected date range
and who died within 30 days of surgery.
Start with Date: 4/1 (APR 01, 2005)
End with Date: 4/30 (APR 30, 2005)
Print which report?
1. Total Cases Summary
2. National Specialty Procedures
Select number: 1// 2
Specialty Procedures
Do you want the report for all National Surgical Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print the report to which Printer ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
397a
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
DEATHS WITHIN 30 DAYS OF SURGERY LISTED FOR SPECIALTY PROCEDURES
FOR SURGERY PERFORMED FROM: APR 1,2005 TO: APR 30,2005
Report Printed: MAY 18,[email protected]:38
PAGE 1
OP DATE
PATIENT NAME
DATE OF DEATH
LOCAL SPECIALTY
IN/OUT
DEATH RELATED
CASE #
PATIENT ID# (AGE)
PROCEDURE(S)
====================================================================================================================================
>>> GENERAL SURGERY <<<
04/24/05
32693
SURPATIENT,FORTY
000-77-7777 (70)
05/12/05
GENERAL(OR WHEN NOT DEFINED BELOW)
CLOSURE OF ABDOMINAL WALL FASCIA
INPAT
UNRELATED
TOTAL DEATHS FOR GENERAL SURGERY: 1
----------------------------------------------------------------------------------------------------------------------------------->>> THORACIC SURGERY <<<
04/26/05
32702
SURPATIENT,TEN
000-12-3456 (68)
05/12/05
THORACIC SURGERY (INC. CARDIAC SURG.)
RIGHT THORACOTOMY WITH LUNG BIOPSY
DIAPHRAGM BIOPSY
INPAT
UNRELATED
04/21/05
32567
SURPATIENT,SIXTY
000-56-7821 (40)
04/30/05
THORACIC SURGERY (INC. CARDIAC SURG.)
ESOPHAGECTOMY
ESOPHAGOSCOPY
BRONCHOSCOPY
FEEDING TUBE JEJUNOSTOMY
INPAT
RELATED
TOTAL DEATHS FOR THORACIC SURGERY: 2
-----------------------------------------------------------------------------------------------------------------------------------TOTAL FOR ALL SPECIALTIES: 3
April 2004
Surgery V. 3.0 User Manual
397b
Pages 397c and 397d have been deleted.
397c
Surgery V. 3.0 User Manual
April 2004
(This page included for two-sided copying.)
April 2004
Surgery V. 3.0 User Manual
397d
Unlock a Case for Editing
[SRO-UNLOCK]
The Chief of Surgery, or a designee, uses the Unlock a Case for Editing option to unlock a case so that it
can be edited. A case that has been completed will automatically lock within a specified time after the
date of operation. When a case is locked, the data cannot be edited.
With this option, the selected case will be unlocked so that the user can use another option (such as in the
Operation Menu option or Anesthesia Menu option) to make changes. The case will automatically re-lock
in the evening. The package coordinator has the ability to set the automatic lock times.
Although the case may be unlocked to allow editing, any field that is included in an electronically signed
report, for example in the Nurse Intraoperative Report, will require the creation of an addendum to the
report before the edit can be completed.
Example: Unlock a Case for Editing
Select Chief of Surgery Menu Option:
Select PATIENT NAME:
1. 05-15-91
2. 05-15-91
Select Number:
Unlock a Case for Editing
SURPATIENT,THREE
08-15-91
000212453
CAROTID ARTERY ENDARTERECTOMY
AORTO CORONARY BYPASS GRAFT
1
Press <Enter> to continue. <Enter>
Case #115 is now unlocked
Select Chief of Surgery Menu Option:
398
Surgery V. 3.0 User Manual
April 2004
Update Status of Returns Within 30 Days
[SRO UPDATE RETURNS]
The Update Status of Returns Within 30 Days option is used to update the status of Returns to Surgery
within 30 days of a surgical case.
Example: Update Status of Returns
Select Chief of Surgery Menu Option: RET
Select Patient: SURPATIENT,FIFTY
SURPATIENT,FIFTY
Update Status of Returns Within 30 Days
10-28-45
000459999
000-45-9999
1. 07-13-92
SPLENECTOMY (NOT COMPLETE)
2. 06-30-92
CHOLECYSTECTOMY (COMPLETED)
3. 03-10-92
HEMORRHOIDECTOMY (COMPLETED)
Select Operation: 2
SURPATIENT,FIFTY (000-45-9999)
Case #213
RETURNS TO SURGERY
JUN 30,1992
CHOLECYSTECTOMY (CPT MISSING)
-----------------------------------------------------------------------------1. 07/13/92
SPLENECTOMY (CPT MISSING) - RELATED
This return to surgery is currently defined as RELATED to the case selected.
Do you want to change this status ? NO// Y
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
399
Update Cancelled Cases
[SRO UPDATE CANCELLED CASE]
This option is locked with the SROCHIEF key and will not appear on the menu if the user
does not have this key.
Normally, a cancelled case cannot be accessed for editing. However, the restricted Update Cancelled
Cases option allows the Chief of Surgery to edit a cancelled case.
When the user enters this option, the software will allow access to the Operations Menu option.
Example: Update a Cancelled Case
Select Chief of Surgery Menu Option: CAN
Update Cancelled Case
Update Cancelled Case
Select Patient: SURPATIENT,FOURTEEN
SURPATIENT,FOURTEEN
08-16-51
000457212
000-45-7212
1. 09-16-99
CHOLECYSTECTOMY (CANCELLED)
2. 09-15-99
CHOLECYSTECTOMY (CANCELLED)
Select Operation: 2
SURPATIENT,FOURTEEN (000-45-7212)
I
SS
OS
O
PO
PAC
OSS
V
A
OR
AR
NR
TR
R
RP
Case #15644 - SEP 15,1992
Operation Information
Surgical Staff
Operation Startup
Operation
Post Operation
Enter PAC(U) Information
Operation (Short Screen)
Surgeon's Verification of Diagnosis & Procedures
Anesthesia for an Operation Menu ...
Operation Report
Anesthesia Report
Nurse Intraoperative Report
Tissue Examination Report
Enter Referring Physician Information
Enter Irrigations and Restraints
Select Update Cancelled Case Option:
400
Surgery V. 3.0 User Manual
April 2004
Update Operations as Unrelated/Related to Death
[SRO DEATH RELATED]
The Update Operations as Unrelated/Related to Death option is used to update the status of operations
performed within 90 days prior to death. The status is either UNRELATED or RELATED TO DEATH.
With this option the user can add comments to further document the review of death.
Example: Updating an Operation as Related to Death
Select Surgery Risk Assessment Menu Option: D
Update Operations as Unrelated/Related to Death
Update Operations as Unrelated or Related to Death
Select Patient: SURPATIENT,THIRTY
01-12-32
000829472
NO
NON-VETERAN (OTHER)
Update Operations as Unrelated or Related to Death
SURPATIENT,THIRTY
000-82-9472
* DIED 02/27/00 *
Operations in 90 Days Prior to Death:
1. 01/29/00
CABG, VEIN, SIX+ (33516) - UNRELATED
>>> Died 29 days postop. <<<
2. 01/06/00
TOTAL LARYNGECTOMY (CPT MISSING) - UNRELATED
>>> Died 52 days postop. <<<
3. 12/02/99
EVACUATION OF HEMATOMA LT.THIGH (27301) - UNRELATED
>>> Died 87 days postop. <<<
Select Number of Operation to be Updated:
(1-3): 1
Update Operations as Unrelated or Related to Death
SURPATIENT,THIRTY
1. 01/29/00
000-82-9472
* DIED 02/27/00 *
CABG, VEIN, SIX+ (33516) - UNRELATED
>>> Died 29 days postop. <<<
Was the Death Unrelated or Related to the Surgery?: UNRELATED
// R RELATED
Review of Death Comments:
No existing text
Edit? NO// <Enter>
Update Operations as Unrelated or Related to Death
SURPATIENT,THIRTY
000-82-9472
* DIED 02/27/00 *
Operations in 90 Days Prior to Death:
1. 01/29/00
CABG, VEIN, SIX+ (33516) - RELATED
>>> Died 29 days postop. <<<
2. 01/06/00
TOTAL LARYNGECTOMY (CPT MISSING) - UNRELATED
>>> Died 52 days postop. <<<
3. 12/02/99
EVACUATION OF HEMATOMA LT.THIGH (27301) - UNRELATED
>>> Died 87 days postop. <<<
Select Number of Operation to be Updated:
(1-3): <Enter>
Update Operations as Unrelated or Related to Death
Select Patient:
April 2004
Surgery V. 3.0 User Manual
401
Update/Verify Procedure/Diagnosis Codes
[SRCODING EDIT]
The Update/Verify Procedure/Diagnosis Codes option is used to edit and/or verify the CPT and ICD-9
codes for an operation or non-O.R. procedure.
Select Chief of Surgery Menu Option: CODE
Select Patient: D8719
YES
SC VETERAN
Update/Verify Procedure/Diagnosis Codes
SURPATIENT,TWELVE
02-12-28
000418719
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------1. Principal Procedure: TRACHEOSTOMY
2. Principal CPT Code: NOT ENTERED
3. Other Procedures: ** INFORMATION ENTERED **
4. Postoperative Diagnosis: FOREIGN BODY IN TRACHEA
5. Principal Diagnosis Code: NOT ENTERED
6. Other Postop Diagnosis: ** INFORMATION ENTERED **
-----------------------------------------------------------------------------Select Information to Edit: ?
Enter the number corresponding to the information you want to update. You may
enter 'ALL' to update all the information displayed on this screen, or a
range of numbers separated by a ':' to update more than one item.
Select Information to Edit: 2
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Principal Procedure Code (CPT): 31600
INCISION OF WINDPIPE
TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
Modifier: 59
DISTINCT PROCEDURAL SERVICE
Modifier: <Enter>
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------1. Principal Procedure: TRACHEOSTOMY
2. Principal CPT Code: 31600 INCISION OF WINDPIPE
TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
Modifiers: -59
3. Other Procedures: ** INFORMATION ENTERED **
4. Postoperative Diagnosis: FOREIGN BODY IN TRACHEA
5. Principal Diagnosis Code: NOT ENTERED
6. Other Postop Diagnosis: ** INFORMATION ENTERED **
-----------------------------------------------------------------------------Select Information to Edit: 3
402
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Procedures:
1. BRONCHOSCOPY
CPT Code: NOT ENTERED
2. Enter NEW Other Procedure
Enter selection:
(1-2): 1
BRONCHOSCOPY
CPT Code: NOT ENTERED
OTHER PROCEDURE: BRONCHOSCOPY// <Enter>
OTHER PROCEDURE CPT CODE: 31622
DX BRONCHOSCOPE/WASH
BRONCHOSCOPY; DIAGNOSTIC, (FLEXIBLE OR RIGID), WITH OR WITHOUT CELL
WASHING
Modifier: <Enter>
Press RETURN to continue
<Enter>
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Procedures:
1. BRONCHOSCOPY
CPT Code: 31622 DX BRONCHOSCOPE/WASH
2. Enter NEW Other Procedure
Enter selection:
(1-2): 2
Enter new OTHER PROCEDURE: ESOPHAGOSCOPY
OTHER PROCEDURE CPT CODE: 43200
ESOPHAGUS ENDOSCOPY
ESOPHAGOSCOPY, RIGID OR FLEXIBLE;
DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR
WASHING (SEPARATE PROCEDURE)
Modifier: <Enter>
Press RETURN to continue
<Enter>
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Procedures:
1. BRONCHOSCOPY
CPT Code: 31622 DX BRONCHOSCOPE/WASH
2. ESOPHAGOSCOPY
CPT Code: 43200 ESOPHAGUS ENDOSCOPY
3. Enter NEW Other Procedure
Enter selection:
April 2004
(1-3): <Enter>
Surgery V. 3.0 User Manual
403
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------1. Principal Procedure: TRACHEOSTOMY
2. Principal CPT Code: 31600 INCISION OF WINDPIPE
TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
Modifiers: -59
3. Other Procedures: ** INFORMATION ENTERED **
4. Postoperative Diagnosis: FOREIGN BODY IN TRACHEA
5. Principal Diagnosis Code: NOT ENTERED
6. Other Postop Diagnosis: ** INFORMATION ENTERED **
-----------------------------------------------------------------------------Select Information to Edit: 5
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Prin Pre-OP ICD Diagnosis Code: 934.0
...OK? Yes// <Enter>
934.0
FOREIGN BODY IN TRACHEA
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------1. Principal Procedure: TRACHEOSTOMY
2. Principal CPT Code: 31600 INCISION OF WINDPIPE
TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
Modifiers: -59
3. Other Procedures: ** INFORMATION ENTERED **
4. Postoperative Diagnosis: FOREIGN BODY IN TRACHEA
5. Principal Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
6. Other Postop Diagnosis: ** INFORMATION ENTERED **
-----------------------------------------------------------------------------Select Information to Edit: 6
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Postop Diagnosis:
1. Enter NEW Other Postop Diagnosis
Enter selection:
(1-1): 1
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Postop Diagnosis:
1. Enter NEW Other Postop Diagnosis
Enter selection:
(1-1): 1
Enter new OTHER POSTOP DIAGNOSIS: LARYNGEAL/TRACHEAL BURN
ICD DIAGNOSIS CODE: 947.1 947.1
BURN LARYNX/TRACHEA/LUNG
...OK? Yes// <Enter>
404
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------Other Postop Diagnosis:
1. LARYNGEAL/TRACHEAL BURN
ICD9 Code: 947.1 BURN LARYNX/TRACHEA/LUNG
2. Enter NEW Other Postop Diagnosis
Enter selection:
(1-2): <Enter>
SURPATIENT,TWELVE (000-41-8719)
Operation Date: FEB 18, [email protected]:45
Case #124
-----------------------------------------------------------------------------1. Principal Procedure: TRACHEOSTOMY
2. Principal CPT Code: 31600 INCISION OF WINDPIPE
TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
Modifiers: -59
3. Other Procedures: ** INFORMATION ENTERED **
4. Postoperative Diagnosis: FOREIGN BODY IN TRACHEA
5. Principal Diagnosis Code: 934.0 FOREIGN BODY IN TRACHEA
6. Other Postop Diagnosis: ** INFORMATION ENTERED **
-----------------------------------------------------------------------------Select Information to Edit:
April 2004
Surgery V. 3.0 User Manual
405
(This page included for two-sided copying.)
406
Surgery V. 3.0 User Manual
April 2004
Chapter Five: Managing the Software Package
Introduction
This chapter describes options designed for the exclusive use of the Surgery package coordinator. The
package coordinator can configure certain Surgery package fields to conform to a facility‟s needs.
Exiting an Option or the System
The user should enter an up-arrow (^) to stop what he or she is doing. The up-arrow can be used at almost
any prompt to terminate the line of questioning and return to the previous level in the routine. The user
would continue entering up-arrows to completely exit the system.
Option Overview
The main option included in this menu is listed below. To the left of the option name is the shortcut
synonym that the user can enter to select the option. This is a restricted option and only users with the
SRCOORD security key have access.
Shortcut
M
April 2004
Option Name
Surgery Package Management Menu
Surgery V. 3.0 User Manual
407
(This page included for two-sided copying.)
408
Surgery V. 3.0 User Manual
April 2004
Surgery Package Management Menu
[SRO PACKAGE MANAGEMENT]
The Surgery Package Management Menu provides access to options that are used to manage the Surgery
software. Each option is discussed in the rest of this chapter.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
that the user can enter to select the option.
Shortcut
S
OR
SU
KEY
SD
U
D
F
SI
V
April 2004
Option Name
Surgery Site Parameters (Enter/Edit)
Operating Room Information (Enter/Edit)
Surgery Utilization Menu ...
Person Field Restrictions Menu ...
Update O.R. Schedule Devices
Update Staff Surgeon Information
Flag Drugs for Use as Anesthesia Agents
Update Site Configurable Files
Surgery Interface Management Menu ...
Make Reports Viewable in CPRS
Surgery V. 3.0 User Manual
409
Surgery Site Parameters (Enter/Edit)
[SROPARAM]
Surgical Service managers use this option to create or update local site parameters for the Surgery
package.
A question mark or two can be entered to access the help text at any prompt.
Example: Enter Surgery Site Parameters
Select Surgery Package Management Menu Option: S
Edit Parameters for which Surgery Site:
MAYBERRY, NC
1
2
3
4
5
6
7
8
9
10
11
12
Surgery Site Parameters (Enter/Edit)
MAYBERRY, NC
(999)
PAGE 1 OF 2
MAIL CODE FOR ANESTHESIA: 112G
CANCEL IVS:
CANCEL
DEFAULT BLOOD COMPONENT: CPDA-1 RED BLOOD CELLS
CHIEF'S NAME:
DR. THREE SURSURGEON
LOCK AFTER HOW MANY DAYS:
REQUEST DEADLINE:
15:00
SCHEDULE CLOSE TIME: 14:00
NURSE INTRAOP REPORT: PRINT TITLES WITH INFO ONLY
CARDIAC ASSESSMENT IN USE (Y/N): YES
ASK FOR RISK PREOP INFO: NO
PCE UPDATE ACTIVATION DATE: OCT 01, 1999
SURGICAL RESIDENTS (Y/N): NO
Enter Screen Server Function: 5
Lock Completed Cases after How Many Days ?: 14
MAYBERRY, NC
1
2
3
4
5
6
7
8
9
10
11
12
(999)
MAIL CODE FOR ANESTHESIA: 112G
CANCEL IVS:
CANCEL
DEFAULT BLOOD COMPONENT: CPDA-1 RED BLOOD CELLS
CHIEF'S NAME:
DR. THREE SURSURGEON
LOCK AFTER HOW MANY DAYS: 14
REQUEST DEADLINE:
15:00
SCHEDULE CLOSE TIME: 14:00
NURSE INTRAOP REPORT: PRINT TITLES WITH INFO ONLY
CARDIAC ASSESSMENT IN USE (Y/N): YES
ASK FOR RISK PREOP INFO: NO
PCE UPDATE ACTIVATION DATE: OCT 01, 1999
SURGICAL RESIDENTS (Y/N): NO
Enter Screen Server Function:
410
PAGE 1 OF 2
<Enter>
Surgery V. 3.0 User Manual
April 2004
MAYBERRY, NC
1
2
3
4
5
6
7
8
9
10
11
12
13
(999)
PAGE 2 OF 2
REQUIRED FIELDS FOR SCHEDULING: (MULTIPLE)(DATA)
REQUEST CUTOFF FOR SUNDAY: SATURDAY
REQUEST CUTOFF FOR MONDAY: FRIDAY
REQUEST CUTOFF FOR TUESDAY: MONDAY
REQUEST CUTOFF FOR WEDNESDAY: TUESDAY
REQUEST CUTOFF FOR THURSDAY: WEDNESDAY
REQUEST CUTOFF FOR FRIDAY: THURSDAY
REQUEST CUTOFF FOR SATURDAY: FRIDAY
HOLIDAY SCHEDULING ALLOWED: (MULTIPLE)(DATA)
INACTIVE?:
AUTOMATED CASE CART ORDERING: YES
ANESTHESIA REPORT IN USE: YES
DEFAULT CLINIC FOR DOCUMENTS:
Enter Screen Server Function:
1
MAYBERRY, NC (999)
REQUIRED FIELDS FOR SCHEDULING
1
PAGE 1 OF 1
NEW ENTRY
Enter Screen Server Function: 1
Select REQUIRED FIELDS FOR SCHEDULING: 27 PRINCIPAL PROCEDURE CODE
ARE YOU ADDING 'PRINCIPAL PROCEDURE CODE' AS
A NEW REQUIRED FIELDS FOR SCHEDULING (THE 1ST FOR THIS SURGERY SITE PARAMETERS)? Y
REQUIRED FIELDS FOR SCHEDULING: PRINCIPAL PROCEDURE CODE
// <Enter>
MAYBERRY, NC (999)
REQUIRED FIELDS FOR SCHEDULING
1
2
(YES)
PAGE 1 OF 1
(PRINCIPAL PROCEDURE CODE)
REQUIRED FIELDS FOR SCHEDULING: PRINCIPAL PROCEDURE CODE
COMMENTS:
(WORD PROCESSING)
Enter Screen Server Function: 2
Comments:
1>This field is required for SPD.
2><Enter>
EDIT Option: <Enter>
MAYBERRY, NC (999)
REQUIRED FIELDS FOR SCHEDULING
1
2
REQUIRED FIELDS FOR SCHEDULING: PRINCIPAL PROCEDURE CODE
COMMENTS:
(WORD PROCESSING)(DATA)
Enter Screen Server Function:
<Enter>
MAYBERRY, NC (999)
REQUIRED FIELDS FOR SCHEDULING
1
2
PAGE 1 OF 1
(PRINCIPAL PROCEDURE CODE)
PAGE 1 OF 1
REQUIRED FIELDS FOR SCHEDULING: PRINCIPAL PROCEDURE CODE
NEW ENTRY
Enter Screen Server Function:
April 2004
<Enter>
Surgery V. 3.0 User Manual
411
MAYBERRY, NC
1
2
3
4
5
6
7
8
9
10
11
12
13
(999)
PAGE 2 OF 2
REQUIRED FIELDS FOR SCHEDULING: (MULTIPLE)(DATA)
REQUEST CUTOFF FOR SUNDAY: SATURDAY
REQUEST CUTOFF FOR MONDAY: FRIDAY
REQUEST CUTOFF FOR TUESDAY: MONDAY
REQUEST CUTOFF FOR WEDNESDAY: TUESDAY
REQUEST CUTOFF FOR THURSDAY: WEDNESDAY
REQUEST CUTOFF FOR FRIDAY: THURSDAY
REQUEST CUTOFF FOR SATURDAY: FRIDAY
HOLIDAY SCHEDULING ALLOWED: (MULTIPLE)(DATA)
INACTIVE?:
AUTOMATED CASE CART ORDERING: YES
ANESTHESIA REPORT IN USE: YES
DEFAULT CLINIC FOR DOCUMENTS:
Enter Screen Server Function:
412
Surgery V. 3.0 User Manual
April 2004
Operating Room Information (Enter/Edit)
[SRO-ROOM]
The Operating Room Information (Enter/Edit) option is used to enter or edit information pertinent to a
selected operating room, including start and end times, and cleaning time.
At the TYPE field, the user can enter two question marks (??) to get a list of operating room types from
which to select. If an operating room is not in service, the user can enter "YES" at the INACTIVE field to
make the operating room inactive and prevent its use by other people using the Surgery software.
Example: Entering Operating Room Information
Select Surgery Package Management Menu Option: OR
Operating Room Information (Enter/Edit)
Enter/Edit Information for which Operating Room ?
OR1
OR1
1
2
3
4
5
6
7
** Update O.R. **
LOCATION:
PERSON RESP.:
TELEPHONE:
TYPE:
CLEANING TIME:
REMARKS:
INACTIVE?:
PAGE 1 OF 1
1 WEST
SURSURGEON,ONE
534-1231
GENERAL PURPOSE OPERATING ROOM
15
Enter Screen Server Function: 2
Person Responsible for this Operating Room: SURSURGEON,ONE// SURSURGEON,THIRTY
OR1
1
2
3
4
5
6
7
** Update O.R. **
LOCATION:
PERSON RESP.:
TELEPHONE:
TYPE:
CLEANING TIME:
REMARKS:
INACTIVE?:
PAGE 1 OF 1
1 WEST
SURSURGEON,THIRTY
555-555-1234
GENERAL PURPOSE OPERATING ROOM
15
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
413
Surgery Utilization Menu
[SR OR UTIL]
The Surgery Utilization Menu contains options designed to help determine operating room use. With this
menu, Surgery Service managers can schedule the normal operating hours for an operating room, as well
as the actual hours an operating room was in use. Operating rooms can also be inactivated. A report can
be generated to see what percentage of available hours an operating room was in use and to see if an O.R.
was used outside normal hours.
Shortcut
E
N
R
H
P
414
Option Name
Operating Room Utilization (Enter/Edit)
Normal Daily Hours (Enter/Edit)
Operating Room Utilization Report
Report of Normal Operating Room Hours
Purge Utilization Information
Surgery V. 3.0 User Manual
April 2004
Operating Room Utilization (Enter/Edit)
[SR UTIL EDIT ROOM]
The Operating Room Utilization (Enter/Edit) option is used to update the actual start and end times for
operating rooms on a selected date, one operating room at a time. This information is used when
generating the operating room utilization reports.
The user first enters the date, then the name of the operating room. The software will default to the start
and end times and allow the times to be edited. There is also a prompt for inactivating a room. If the user
does not want to edit an entry, pressing the <Enter> key will display the next prompt.
When the user is finished entering or editing times for an operating room, he or she will be prompted for
the name of the next operating room. If the user does not wish to edit times for any more operating rooms
on this date, he or she should press the <Enter> key. The software will then prompt for a new date and
the cycle begins again. When the user is finished editing times, he or she can press the <Enter> key or
enter an up-arrow (^) to exit this option.
Example: Enter and Edit Operating Room Times
Select Surgery Utilization Menu Option: E
Operating Room Utilization (Enter/Edit)
Update Start and End Times for Operating Rooms
Update Times for which Date ?
T
(NOV 03, 2003)
Operating Room Utilization on NOV 3, 2003
-----------------------------------------------------------------------------Update Start and End Times for which Operating Room ?
OR1
Time this Operating Room Begins Functioning: 07:00
// <Enter>
Time this Operating Room Stops Functioning: 17:00
// 13:50 (NOV 03, [email protected]:50)
Has this Room been Inactivated on this Date ? (Y/N): N
NO
Operating Room Utilization on NOV 3, 2003
-----------------------------------------------------------------------------Update Start and End Times for which Operating Room ?
OR2
Time this Operating Room Begins Functioning: 07:00
// <Enter>
Time this Operating Room Stops Functioning: 17:00
// 13:30 (NOV 03, [email protected]:30)
Has this Room been Inactivated on this Date ? (Y/N): N
April 2004
NO
Surgery V. 3.0 User Manual
415
Operating Room Utilization on NOV 3, 2003
-----------------------------------------------------------------------------Update Start and End Times for which Operating Room ?
OR3
Time this Operating Room Begins Functioning: 07:00
// <Enter>
Time this Operating Room Stops Functioning: 17:00
// <Enter>
Has this Room been Inactivated on this Date ? (Y/N): Y
YES
Operating Room Utilization on NOV 3, 2003
-----------------------------------------------------------------------------Update Start and End Times for which Operating Room ?
<Enter>
Update Start and End Times for Operating Rooms and Surgical Specialties
Update Times for which Date ?
416
Surgery V. 3.0 User Manual
April 2004
Normal Daily Hours (Enter/Edit)
[SR NORMAL HOURS]
The Normal Daily Hours (Enter/Edit) option is used to schedule the normal start and end times of an
operating room for each day of the week, one operating room at a time. The information is used to help
determine operating room use on a weekly basis.
First, the user enters the name of the operating room. Beginning with Sunday, the software will provide
an editing schedule for each day of the week and prompt for normal start and end times for each day.
There is also a prompt for inactivating a room. When the schedules for the week have been completed, the
user will be prompted for the name of the next operating room for which to enter times. When the use
finishes editing times, he or she can press the <Enter> key or enter an up-arrow (^) to exit this option.
At the "Select information to edit:" prompt, the user can 1) enter the letter A to update all the information
on the schedule, 2) enter a number to update information in the corresponding field, 3) enter a range of
numbers separated by a colon (:), or 4) press the <Enter> key to move to the next day's schedule. To edit
the schedule for a particular day, the user enters an up-arrow followed by a day of the week. For example,
to edit Friday's schedule, ^Friday would be entered. This is demonstrated in the following example.
The start and end times must be in military time. Also, use a leading zero when the hour is a
single digit (e.g., 7 AM is 07:00).
Example: Enter Normal Start and End Times for an Operating Room
Select Surgery Utilization Menu Option: N
Normal Daily Hours (Enter/Edit)
==============================================================================
Normal Daily Schedules for Operating Rooms
==============================================================================
Enter the name of the operating room: OR1
Editing the SUNDAY Schedule for the OR1 Operating Room
==============================================================================
1. Normal Start Time:
2. Normal End Time:
3. Inactive (Y/N):
07:00
15:30
==============================================================================
Select information to edit: <Enter>
April 2004
Surgery V. 3.0 User Manual
417
Editing the MONDAY Schedule for the OR1 Operating Room
==============================================================================
1. Normal Start Time:
2. Normal End Time:
3. Inactive (Y/N):
==============================================================================
Select information to edit: 1:2
Normal Starting Time: 07:00
Normal Ending Time: 15:30
Editing the MONDAY Schedule for the OR1 Operating Room
==============================================================================
1. Normal Start Time:
2. Normal End Time:
3. Inactive (Y/N):
07:00
15:30
==============================================================================
Select information to edit: ^FRIDAY
Editing the FRIDAY Schedule for the OR1 Operating Room
==============================================================================
1. Normal Start Time:
2. Normal End Time:
3. Inactive (Y/N):
==============================================================================
Select information to edit: 1:2
Normal Starting Time: 07:00
Normal Ending Time: 15:30
Editing the FRIDAY Schedule for the OR1 Operating Room
==============================================================================
1. Normal Start Time:
2. Normal End Time:
3. Inactive (Y/N):
07:00
15:30
==============================================================================
Select information to edit: ^
==============================================================================
Normal Daily Schedules for Operating Rooms
==============================================================================
Enter the name of the operating room: ^
418
Surgery V. 3.0 User Manual
April 2004
Operating Room Utilization Report
[SR OR UTL1]
The Operating Room Utilization Report option prints utilization information, within a selected date range,
for all operating rooms or for a single operating room. The report displays the percent utilization, the
number of cases, the total operation time and the time worked outside normal hours for each operating
room individually and all operating rooms collectively.
How the Percent Utilization is Derived
The percent utilization is derived by dividing the total operation time for all operations (including total
time patients were in O.R., plus the cleanup time allowed for each case) by the total functioning time as
defined in the SURGERY UTILIZATION file. The quotient is then multiplied by 100.
This report has a 132-column format and is designed to be copied to a printer.
Example: Print the Operating Room Utilization Report
Select Management Reports Option: OR
Operating Room Utilization Report
Operating Room Utilization Report
Print utilization information starting with which date ?
Print utilization information through which date ?
3/9
3/8
(MAR 08, 2003)
(MAR 09, 2003)
Do you want to print the Operating Room Utilization Report for all
operating rooms ? YES// <Enter>
Print the Operating Room Utilization Report on which Device ? [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
419
MAYBERRY, NC
PAGE 1
SURGICAL SERVICE
OPERATING ROOM UTILIZATION REPORT
FOR ALL OPERATING ROOMS FROM: MAR 8,2003 TO: MAR 9, 2003
DATE PRINTED: MAR 17,2003
====================================================================================================================================
OPERATING ROOM
PERCENT UTILIZATION
TOTAL OPERATION TIME
TIME WORKED OUTSIDE NORMAL HRS
(INCLUDING OR MAINTENANCE)
====================================================================================================================================
OR1
70%
NUMBER OF CASES
3
17 hrs and 35 mins
6 hrs and 20 mins
-----------------------------------------------------------------------------------------------------------------------------------OR2
39%
1
7 hrs and 25 mins
1 hr and 10 mins
-----------------------------------------------------------------------------------------------------------------------------------OR3
133%
8
23 hrs and 42 mins
2 hrs and 30 mins
-----------------------------------------------------------------------------------------------------------------------------------OR4
29%
3
4 hrs and 41 mins
-
-----------------------------------------------------------------------------------------------------------------------------------OR5
84%
7
18 hrs and 50 mins
5 hrs and 25 mins
-----------------------------------------------------------------------------------------------------------------------------------OR6
0
0
-
-
-----------------------------------------------------------------------------------------------------------------------------------OR7
0
0
-
-
-----------------------------------------------------------------------------------------------------------------------------------TOTAL UTILIZATION FOR
ALL ROOMS
63%
22
72 hrs and 13 mins
15 hrs and 25 mins
====================================================================================================================================
420
Surgery V. 3.0 User Manual
April 2004
Report of Normal Operating Room Hours
[SR OR HOURS]
The Report of Normal Operating Room Hours option provides the start time and the end time of the
normal working hours for all operating rooms or for the selected operating room for each date within the
specified date range. The total time of the normal working day is displayed for each operating room for
each date.
Example: Print Operating Room Normal Working Hours Report
Select Surgery Utilization Menu Option: H
Report of Normal Operating Room Hours
Operating Room Normal Working Hours Report
Print normal working hours starting with which date ?
3/1
Print normal working hours through which date ?
(MAR 12, 1999)
3/12
(MAR 01, 1999)
Do you want to print the Operating Room Normal Working Hours Report for all
operating rooms ? YES// <Enter>
Print the report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
421
OPERATING ROOM NORMAL WORKING HOURS
FROM 03/01/99 TO 03/12/99
OPERATING ROOM
START TIME
END TIME
TOTAL TIME
-----------------------------------------------------------------------------** MAR 1, 1999 **
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
15:30
15:30
** INACTIVE **
** INACTIVE **
17:00
** MAR
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
OR1
OR2
422
07:00
07:00
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
6, 1999 **
15:30
15:30
15:30
13:30
17:00
** MAR
8
8
8
6
5, 1999 **
15:30
15:30
15:30
13:30
17:00
** MAR
10 hrs
4, 1999 **
15:30
15:30
15:30
13:30
17:00
** MAR
8 hrs and 30 mins
8 hrs and 30 mins
8 hrs and 30 mins
3, 1999 **
15:30
15:30
15:30
13:30
17:00
** MAR
10 hrs
2, 1999 **
15:30
15:30
15:30
** INACTIVE **
17:00
** MAR
8 hrs and 30 mins
8 hrs and 30 mins
7, 1999 **
15:30
15:30
8 hrs and 30 mins
8 hrs and 30 mins
Surgery V. 3.0 User Manual
April 2004
OPERATING ROOM NORMAL WORKING HOURS
FROM 03/01/99 TO 03/12/99
OPERATING ROOM
START TIME
END TIME
TOTAL TIME
-----------------------------------------------------------------------------** MAR 7, 1999 **
OR3
OR4
OR5
07:00
** INACTIVE **
** INACTIVE **
17:00
** MAR
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
8, 1999 **
15:30
15:30
** INACTIVE **
** INACTIVE **
17:00
** MAR
10 hrs
8 hrs and 30 mins
8 hrs and 30 mins
10 hrs
9, 1999 **
15:30
15:30
15:30
** INACTIVE **
17:00
8 hrs and 30 mins
8 hrs and 30 mins
8 hrs and 30 mins
10 hrs
** MAR 10, 1999 **
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
15:30
15:30
15:30
13:30
17:00
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
8
8
8
6
hrs and 30
hrs and 30
hrs and 30
hrs and 30
10 hrs
mins
mins
mins
mins
** MAR 11, 1999 **
OR1
OR2
OR3
OR4
OR5
07:00
07:00
07:00
07:00
07:00
15:30
15:30
15:30
13:30
17:00
** MAR 12, 1999 **
OR1
OR2
OR3
OR4
OR5
April 2004
07:00
07:00
07:00
07:00
07:00
15:30
15:30
15:30
13:30
17:00
Surgery V. 3.0 User Manual
423
Purge Utilization Information
[SR PURGE UTILIZATION]
The Purge Utilization Information option is used to purge utilization information for a selected date
range. After selecting a starting date, the user can purge all utilization information for dates prior to, and
including, that specified starting date.
Example: Purge Utilization Information
Select Surgery Utilization Menu Option: P
Purge Utilization Information
Purge Utilization Information
Starting with Date: 2/1
(FEB 28, 1999)
This option will purge all utilization information for the dates prior to (and
including) FEB 28, 1999.
Are you sure that you want to purge for this date range ?
NO// Y
The option to purge utilization data has been queued.
Press RETURN to continue
424
Surgery V. 3.0 User Manual
April 2004
Person Field Restrictions Menu
[SROKEY MENU]
The Person Field Restrictions Menu contains options used by the package coordinator to maintain
restrictions applied to person-type fields (meaning a field that points to the NEW PERSON field) in files.
The options included in this menu are listed below. To the left of the option name is the shortcut synonym
the user can enter to select the option. None of these options will display if the user does not have proper
security clearance.
Shortcut
E
R
April 2004
Option Name
Enter Restrictions for 'Person' Fields
Remove Restrictions on 'Person' Fields
Surgery V. 3.0 User Manual
425
Enter Restrictions for 'Person' Fields
[SROKEY ENTER]
The Enter Restrictions for 'Person' Fields option allows IRM personnel to assign a key to a specific
person-type field (meaning any field that points to the NEW PERSON field) in a file or sub-file.
A key limits the acceptable responses to a field. The Surgery software can be tailored to limit acceptable
responses in the field to only those people assigned one of the keys used to restrict the field. For example,
a prompt asking for the name of the attending surgeon can be modified to accept only the names of
surgeons. Additionally, a field can have more than one key assigned to it; thus, the ATTENDING
SURGEON field can be modified to accept the names of surgeons and other surgical staff.
Example 1 below shows how to enter the surgeon key for the SURGEON field in the SURGERY file.
Example 2 shows how to enter the surgeon, nurse, and anesthetist keys for a sub-field in the SURGERY
file.
Keys can be removed using the Remove Restrictions on 'Person' Fields option.
The user can enter one or two question marks to access the on-line help if assistance is needed while
interacting with the software. A question mark can also be entered at the "Select Additional Key:" prompt
for a list of keys from which to select.
Example 1: Enter Restrictions
Select Person Field Restrictions Menu Option: E
Enter Restrictions for 'Person' Fields
Add 'PERSON' Field Restrictions:
Select File: SURGERY
1
SURGERY
2
SURGERY CANCELLATION REASON
3
SURGERY DISPOSITION
4
SURGERY EXTRACT
5
SURGERY INTERFACE PARAMETER
Press <RETURN> to see more, '^' to exit this list, OR
CHOOSE 1-5: 1 SURGERY
Select FIELD: SURGEON
1
SURGEON
2
SURGEON'S DICTATION
(word-processing)
CHOOSE 1-2: 1 SURGEON
There are no keys restricting entries in this field.
Do you want to add a key ?
YES// <Enter>
Select Additional Key: SR SURGEON
Select Additional Key: <Enter>
Entering Keys...
426
Surgery V. 3.0 User Manual
April 2004
Example 2: Enter Restrictions
Select Person Field Restrictions Menu Option: E
Enter Restrictions for 'Person' Fields
Add 'PERSON' Field Restrictions:
Select File: SURGERY
1
SURGERY
2
SURGERY CANCELLATION REASON
3
SURGERY DISPOSITION
4
SURGERY EXTRACT
5
SURGERY INTERFACE PARAMETER
Press <RETURN> to see more, '^' to exit this list, OR
CHOOSE 1-5: 1 SURGERY
Select FIELD: RESTR & POSITION AIDS
(multiple)
Select RESTR & POSITION AIDS SUB-FIELD: APPLIED BY
There are no keys restricting entries in this field.
Do you want to add a key ?
Select
Select
Select
Select
Additional
Additional
Additional
Additional
Key:
Key:
Key:
Key:
YES// <Enter>
SR NURSE
SR SURGEON
SR ANESTHETIST
<Enter>
Entering Keys...
April 2004
Surgery V. 3.0 User Manual
427
Remove Restrictions on 'Person' Fields
[SROKEY REMOVE]
The Remove Restrictions on 'Person' Fields option allows IRM personnel to remove a key to a specific
person-type field in a specific file. A key limits the acceptable responses to a field; removing a key
removes a restriction on the acceptable responses.
In the example below, the key that permits the name of an anesthetist is removed from the RESTRAINTS
& POSITION AIDS field, leaving the nurse and surgeon keys intact. All of the keys can be removed at
one time by entering ALL at the "Select Number or „ALL‟:" prompt.
Example: Remove Restrictions
Select Person Field Restrictions Menu Option: R
Remove Restrictions on 'Person' Fields
Remove 'PERSON' field restrictions:
Select File: SURGERY
1
SURGERY
2
SURGERY CANCELLATION REASON
3
SURGERY DISPOSITION
4
SURGERY EXTRACT
5
SURGERY INTERFACE PARAMETER
Press <RETURN> to see more, '^' to exit this list, OR
CHOOSE 1-5: 1 SURGERY
Select FIELD: RESTR & POSITION AIDS
(multiple)
Select RESTR & POSITION AIDS SUB-FIELD: APPLIED BY
Current Restrictions for this Field:
1. SR NURSE
2. SR SURGEON
3. SR ANESTHETIST
Do you want to remove one of these keys ?
YES// <Enter>
Select Number or "ALL": 3
Select Person Field Restrictions Option:
428
Surgery V. 3.0 User Manual
April 2004
Update O.R. Schedule Devices
[SR UPDATE SCHEDULE DEVICE]
The Update O.R. Schedule Devices option is used to update the list of devices that will print the Schedule
of Operations when printing to all pre-defined printers.
Example: Add a New Schedule Device
Select Surgery Package Management Menu Option: SD
Update O.R. Schedule Devices
Update O.R. Schedule Devices
---------------------------Select OR SCHEDULE DEVICES: SPD PTR
ARE YOU ADDING 'SPD PTR ' AS A NEW OR SCHEDULE DEVICES (THE 1ST FOR THIS SURGERY
SITE PARAMETERS)? Y (YES)
Select OR SCHEDULE DEVICES:
April 2004
Surgery V. 3.0 User Manual
429
Update Staff Surgeon Information
[SROSTAFF]
The Update Staff Surgeon Information option allows the designation of a user as a staff surgeon by
assigning a security key called SR STAFF SURGEON. The Annual Report of Surgical Procedures will
count cases performed by holders of this security key as having been performed by “staff.” All other cases
will be counted as performed by “resident.”
Example 1: Designate a Staff Surgeon
Select Surgery Package Management Menu Option: U
Update Staff Surgeon Information
Update Information for which Surgeon: SURSURGEON,ONE
Do you want to designate this person as a 'Staff Surgeon' ? YES// <Enter>
SURSURGEON,ONE is now designated as a staff surgeon.
Press RETURN to continue
Example 2: Remove Staff Surgeon Designation
Select Surgery Package Management Menu Option: U
Update Staff Surgeon Information
Update Information for which Surgeon: SURSURGEON,ONE
This person is already designated as a staff surgeon. Do you want to remove
that designation ? NO// Y
Removing key designating SURSURGEON,ONE as a staff surgeon...
Press RETURN to continue
430
Surgery V. 3.0 User Manual
April 2004
Flag Drugs for Use as Anesthesia Agents
[SROCODE]
Surgery Service managers use the Flag Drugs for Use as Anesthesia Agents option to mark drugs for use
as anesthesia agents. If the drug is not flagged, the user will not be able to select it as an entry for the
ANESTHESIA AGENT data field.
To flag a drug, it must already be listed in the Pharmacy DRUG file. To add a drug to this file, the user
should contact the facility‟s Pharmacy Package Coordinator.
Example: Flag Drugs Used as Anesthesia Agents
Select Surgery Package Management Menu Option:
Enter the name of the drug you wish to flag:
D
Flag Drugs for use as Anesthesia Agents
HALOTHANE
Do you want to flag this drug for SURGERY (Y/N)? YES
Enter the name of the drug you wish to flag:
April 2004
Surgery V. 3.0 User Manual
431
Update Site Configurable Files
[SR UPDATE FILES]
The Update Site Configurable Files option is designed for the package coordinator to add, edit, or
inactivate file entries for the site-configurable files.
The software provides a numbered list of site-configurable files. The user should enter the number
corresponding to the file that he or she wishes to update. The software will default to any previously
entered information on the entry and provide a chance to edit it. The last prompt asks whether the user
wants to inactivate the entry; answering Yes or 1 will inactivate the entry.
Example 1: Add a New Entry to a Site-Configurable File
Select Surgery Package Management Menu Option:
F
Update Site Configurable Files
==============================================================================
Update Site Configurable Surgery Files
==============================================================================
1. Surgery Transportation Devices
2. Prosthesis
3. Surgery Positions
4. Restraints and Positional Aids
5. Surgical Delay
6. Monitors
7. Irrigations
8. Surgery Replacement Fluids
9. Skin Prep Agents
10. Skin Integrity
11. Patient Mood
12. Patient Consciousness
13. Local Surgical Specialty
14. Electroground Positions
15. Surgery Dispositions
==============================================================================
Update Information for which File ?
2
Update Information in the Prosthesis file.
==============================================================================
Select PROSTHESIS NAME: HUMERAL
ARE YOU ADDING 'HUMERAL' AS A NEW PROSTHESIS (THE 112TH)?
NAME: HUMERAL // HUMERAL COMPONENT
VENDOR: AMERICAN
MODEL: NEER II
STERILE RESP: MANUFACTURER
SIZE: STEM 150 MM, HEAD 22 MM
QUANTITY: <Enter>
LOT NUMBER: F19705-1087
SERIAL NUMBER: <Enter>
INACTIVE?: <Enter>
Y (YES)
Select PROSTHESIS NAME:
432
Surgery V. 3.0 User Manual
April 2004
Example 2: Re-Activate an Entry
Select Surgery Package Management Menu Option:
F
Update Site Configurable Files
==============================================================================
Update Site Configurable Surgery Files
==============================================================================
1. Surgery Transportation Devices
2. Prosthesis
3. Surgery Positions
4. Restraints and Positional Aids
5. Surgical Delay
6. Monitors
7. Irrigations
8. Surgery Replacement Fluids
9. Skin Prep Agents
10. Skin Integrity
11. Patient Mood
12. Patient Consciousness
13. Local Surgical Specialty
14. Electroground Positions
15. Surgery Dispositions
==============================================================================
Update Information for which File ?
6
Update Information in the Monitors file.
==============================================================================
Select MONITORS NAME: ECG
NAME: ECG// <Enter>
INACTIVE?: YES// @
SURE YOU WANT TO DELETE? Y
** INACTIVE **
(YES)
Select MONITORS NAME:
April 2004
Surgery V. 3.0 User Manual
433
Surgery Interface Management Menu
[SRHL INTERFACE]
The Surgery Interface Management Menu contains options that allow the user to set up certain interface
parameters that control the processing of Health Level 7 (HL7) messages. The interface adheres to the
HL7 protocol and forms the basis for the exchange of health care information between the VistA Surgery
package and any ancillary system.
Currently, there are four options on the Surgery Interface Management Menu.
Shortcut
I
F
T
P
434
Option Name
Flag Interface Fields
File Download
Table Download
Update Interface Parameter Field
Surgery V. 3.0 User Manual
April 2004
Flag Interface Fields
[SRHL INTERFACE FLDS]
The Flag Interface Fields option allows the package coordinator to set the INTERFACE field in the
SURGERY INTERFACE file. The categories listed on the first screen correspond to entries in
SURGERY INTERFACE file. These categories are listed in the Surgery HL7 Interface Specifications
document as being the OBR (Observation Request) text identifiers. Each identifier corresponds to several
fields in the VistA Surgery package. This allows the user to control the flow of data between the VistA
Surgery package and the ancillary system on a field-by-field basis.
The option lists each identifier and its current setting. To receive the data coming from the ancillary
system for a category, the flag the flag should be set to R for receive. To ignore the data, the flag should
be set to N for not receive. To see a second underlying layer of OBX (Observation/Result) text identifiers
(the SURGERY file fields) and their settings, the OBR (Observation Request) text identifier should be set
to R for receive. The option will allow the user to toggle the settings for a range of items or for individual
items.
Example: Flagging Operation Information to be Received
Select Surgery Interface Management Menu Option: I
Flag Interface Fields
Surgery Interface Setup Menu
To change the setting in one of the following categories, enter the
corresponding number.
(R - Receive)
(S - Send)
(S/R - Send and Receive)
(I - Ignore)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
OPERATION (S/R)
TOURNIQUET (I)
MONITOR (I)
MEDICATION (R)
ANESTHESIA (R)
PROCEDURE (I)
PROCEDURE OCCURRENCE (I)
INTRAOPERATIVE OCCURRENCE (I)
POSTOPERATIVE OCCURRENCE (I)
NONOPERATIVE OCCURRENCE (I)
Enter a number: ?
The categories above refer to VistA Surgery data fields. Below are examples:
OPERATION -> File 130 fields.
TOURNIQUET -> TIME TOURNIQUET APPLIED (#.48) and File 130.02 fields.
MONITOR -> MONITORS (#.293) and File 130.41 fields.
MEDICATION -> MEDICATIONS (#.375) and File 130.33 fields.
ANESTHESIA -> ANESTHESIA TECHNIQUE (#.37) and File 130.06 fields.
Enter the corresponding number of the category you wish to edit. To edit
underlying fields, set the category to R for receive or S to send.
Enter a number: 1
Do you wish to change the current setting of OPERATION: IGNORE// RECEIVE
OPERATION DATA
Toggle the current setting to (R)eceive, (S)end, or (I)gnore.
April 2004
Surgery V. 3.0 User Manual
435
1. TIME OPERATION BEGAN (S)
2. TIME OPERATION ENDS (S)
3. NURSE PRESENT TIME (I)
4. TIME PATIENT IN HOLDING AREA (I)
5. ANESTHESIA AVAILABLE TIME (I)
6. TIME PATIENT IN OR (S)
7. SURGEON PRESENT TIME (I)
8. ANESTHESIA CARE START TIME (I)
9. ANESTHESIA CARE END TIME (I)
10. TIME PATIENT OUT OR (I)
11. PRIN. ANES. (I)
12. RELIEF ANESTHETIST (I)
13. ASSISTANT ANESTHETIST (I)
14. ANES. SUPER. (I)
15. BLOOD LOSS (I)
16. TOTAL URINE OUTPUT (I)
Enter a number: ?
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
OR SETUP TIME (I)
ANESTHESIA TEMP (I)
HR (I)
RR (I)
BP (I)
ASA CLASS (I)
CASE SCHEDULE TYPE (I)
ATTENDING CODE (I)
REPLACEMENT FLUID (R)
INDUCTION COMPLETE (I)
ANES. SUPERVISE CODE (I)
SURGEON PGY (I)
OR LOCATION (I)
PAC(U) ADMIT TIME (I)
PAC(U) DISCHARGE TIME (I)
The items above refer to VistA Surgery package fields. Below are examples:
HR -> End Pulse (#.84)
BP -> End BP
(#.85)
RR -> End Resp (#.86)
To toggle the current setting of an item, enter its corresponding number.
436
Surgery V. 3.0 User Manual
April 2004
File Download
[SRHL DOWNLOAD INTERFACE FILES]
The File Download option is used to download Surgery interface files to the Automated Anesthesia
Information System (AAIS). The process is currently being done by a screen capture to a file. In the
future, this will be changed to a background task that can be queued to send HL7 master file updates.
Example: Downloading Interface Files
Select Surgery Interface Management Menu Option: F File Download
Surgery Interface File Download Option
1.
2.
3.
4.
5.
6.
7.
8.
CPT4
ICD9
MEDICATION
MONITOR
PERSONNEL
REPLACEMENT FLUID
ANES SUPERVISE CODE
LOCATION
Enter file to Capture: (1-8): 4
Update the MONITOR file? YES// <Enter>
Queuing message
April 2004
Surgery V. 3.0 User Manual
437
Table Download
[SRHL DOWNLOAD SET OF CODES]
The Table Download option downloads the SURGERY file set of codes to the AAIS. This process is
currently being done by a screen capture to a file. In the future, this will be changed to a background task
that can be queued to send HL7 master file updates.
Example: Downloading Surgery Set of Codes
Select Surgery Interface Management Menu Option: T Table Download
Surgery Interface Table Setup Menu
This option allows the users to populate table files on the Automated
Anesthesia Information System.
1.
2.
3.
4.
5.
6.
7.
8.
9.
CASE SCHEDULE TYPE
ATTENDING CODE
SITE TOURNIQUET APPLIED
MEDICATION ROUTE
PRINCIPAL ANES TECHNIQUE (Y/N)
PATIENT STATUS
ANESTHESIA ROUTE
ANESTHESIA APPROACH
LARYNGOSCOPE TYPE
10.
11.
12.
13.
14.
15.
16.
17.
18.
TUBE TYPE
EXTUBATED IN
BARICITY
EPIDURAL METHOD
ADMINISTRATION METHOD
PROCEDURE OCCURRENCE OUTCOME
INTRAOP OCCURRENCE OUTCOME
POSTOP OCCURRENCE OUTCOME
NONOP OCCURRENCE OUTCOME
Enter a list or range of numbers (1-18): 2
Update the ATTENDING CODE table? YES// <Enter>
MAD Sending HL7 Master File addition message.....
438
Surgery V. 3.0 User Manual
April 2004
Update Interface Parameter Field
[SRHL DOWNLOAD SET OF CODES]
The Update Interface Parameter Field option may be used to edit the parameter that determines which
Surgery HL7 interface will be used, the interface compatible with HL7 V. 1.6 or the older one compatible
with HL7 V. 1.5.
If applications communicating with the Surgery HL7 interface must use the interface designed for use
with HL7 V. 1.5, YES should be entered. Otherwise, NO should be entered or this field should be left
blank.
Example: Updating Interface Parameter Field
Select Surgery Interface Management Menu Option: P
Update Interface Parameter Field
This option may be used to edit the parameter that determines which Surgery
HL7 interface will be used, the interface compatible with HL7 v1.6 or the
older one compatible with HL7 v1.5.
If applications communicating with the Surgery HL7 interface must use the
interface designed for HL7 v1.5, enter YES. Otherwise, enter NO or
or leave this field blank.
Use Surgery Interface Compatible with VistA HL7 v1.5 (Y/N): NO
April 2004
Surgery V. 3.0 User Manual
439
Make Reports Viewable in CPRS
[SR VIEW HISTORICAL REPORTS]
This option allows Operation Reports, Nurse Intraoperative Reports, Anesthesia Reports, and Procedure
Reports (Non-O.R.) for historical cases to be moved into TIU as “electronically unsigned” to make them
viewable on the CPRS Surgery tab. This option lets the user move reports by division, if necessary.
Select Surgery Package Management Menu Option: V
Make Reports Viewable in CPRS
Make Reports Viewable in CPRS
This option allows Operation Reports, Nurse Intraoperative Reports,
Anesthesia Reports and Procedure Reports (Non-O.R.) for historical
cases to be moved into TIU as "electronically unsigned" to make
them viewable within the CPRS Surgery tab. Historical cases are
cases performed before the Surgery Electronic Signature for
Operative Reports feature was implemented.
These "electronically unsigned" reports will contain a disclaimer
stating: "This information is provided from historical files and
cannot be verified that the author has authenticated/approved this
information. The authenticated source document in the patient's
medical record should be reviewed to ensure that all information
concerning this event has been reviewed or noted."
CAUTION!! This is a system intensive process that creates new
documents in TIU. Please ensure adequate disk space availability
before running this process.
Enter starting date for reports to be moved:
T-180
(MAR 19, 2003)
Move reports for all divisions? YES// NO
1. ALBANY
2. PHILADELPHIA, PA
3. SAN JUAN, PR
Select Number:
(1-3): 1
Do you want to move the Operation Reports (Y/N)? NO// YES
Do you want to move the Nurse Intraoperative Reports (Y/N)? NO// YES
Do you want to move the Anesthesia Reports (if used) (Y/N)? NO// YES
Do you want to move the Procedure Reports (Non-O.R.) (Y/N)? NO// YES
The following reports for cases performed MAR 19, 2003 to the present
for ALBANY will be moved.
Operation Report
Nurse Intraoperative Report
Anesthesia Report
Procedure Report (Non-O.R.)
Is this correct (Y/N)? NO// YES
Requested Start Time: NOW//
<Enter>
(SEP 15, [email protected]:13:21)
Queued as task #158943
Press RETURN to continue.
440
Surgery V. 3.0 User Manual
April 2004
Chapter Six: Assessing Surgical Risk
Introduction
Unadjusted surgical mortality and morbidity rates can vary dramatically from hospital to hospital in the
VA hospital system, as well as in the private sector. This can be the result of differences in patient mix, as
well as differences in quality of care. Studies are being conducted to develop surgical risk assessment
models for many of the major surgical procedures done in the VA system. It is hoped that these models
will correct differences in patient mix between the hospitals so that remaining differences in adjusted
mortality and morbidity might be an indicator of differences in quality of care. The objective of this
module is to facilitate data entry and transmission to the national centers in Denver, Colorado, where the
data is analyzed. The Veterans Affairs Surgery Quality Improvement Program (VASQIP) Executive
Committee oversees the overall direction of the Surgery Risk Assessment program.
This Risk Assessment part of the Surgery software provides medical centers a mechanism to track
information related to surgical risk and operative mortality. It gives surgeons an on-line method of
evaluating and tracking patient probability of operative mortality. For example, a patient with a history of
chronic illness may be more “at risk” than a patient with no prior illness.
Exiting an Option or the System
To get out of an option, the user should enter an up-arrow (^). The up-arrow can be entered at almost any
prompt to terminate the line of questioning and return to the previous level in the routine. To completely
exit the system, the user continues entering up-arrows.
April 2004
Surgery V. 3.0 User Manual
441
(This page included for two-sided copying.)
442
Surgery V. 3.0 User Manual
April 2004
Surgery Risk Assessment Menu
[SROA RISK ASSESSMENT]
The Surgery Risk Assessment Menu option provides the designated Surgical Clinical Nurse Reviewer with
on-line access to medical information. The menu options provide the opportunity to edit, list, print, and
update an existing assessment for a patient or to enter information concerning a new risk assessment.
This option is locked with the SR RISK ASSESSMENT key.
This chapter follows the main menu of the Risk Assessment module and contains descriptions of the
options and sub-options needed to maintain a Risk Assessment, transmit data, and create reports. The
options are organized to follow a logical workflow sequence. Each option description is divided into two
main parts: an overview and a detailed example.
The top-level options included in this menu are listed in the following table. To the left is the shortcut
synonym that the user can enter to select the option.
Shortcut
N
C
P
U
L
F
R
M
V
O
T
CODE
ERM
April 2004
Option Name
Non-Cardiac Assessment Information (Enter/Edit) ...
Cardiac Risk Assessment Information (Enter/Edit) ...
Print a Surgery Risk Assessment
Update Assessment Completed/Transmitted in Error
List of Surgery Risk Assessments
Print 30 Day Follow-up Letters
Exclusion Criteria (Enter/Edit)
Monthly Surgical Case Workload Report
M&M Verification Report
Update 1-Liner Case
Queue Assessment Transmissions
Alert Coder Regarding Coding Issues
Risk Model Lab Test (Enter/Edit)
Surgery V. 3.0 User Manual
443
(This page included for two-sided copying.)
444
Surgery V. 3.0 User Manual
April 2004
Non-Cardiac Risk Assessment Information (Enter/Edit)
[SROA ENTER/EDIT]
The nurse reviewer uses the Non-Cardiac Risk Assessment Information (Enter/Edit) option to enter a new
risk assessment for a non-cardiac patient. This option is also used to make changes to an assessment that
has already been entered. Cardiac cases are evaluated differently from non-cardiac cases and are entered
into the software from different options. See the section, “Cardiac Risk Assessment Information
(Enter/Edit)” for more information about risk assessments for cardiac cases.
The following options are available from this option, and let the user add in-depth data for a case. To the
left is the shortcut synonym that the user can enter to select the option.
Shortcut
PRE
LAB
O
D
IO
PO
RET
U
CODE
Option Name
Preoperative Information (Enter/Edit)
Laboratory Test Results (Enter/Edit)
Operation Information (Enter/Edit)
Patient Demographics (Enter/Edit)
Intraoperative Occurrences (Enter/Edit)
Postoperative Occurrences (Enter/Edit)
Update Status of Returns Within 30 Days
Update Assessment Status to 'COMPLETE'
Alert Coder Regarding Coding Issues
The following example demonstrates how to create a new risk assessment for non-cardiac patients and
how to get to the sub-option menu below.
Creating a New Risk Assessment
1. The user is prompted to select either a patient name or a case. Selecting by case lets the user enter a
specific surgery case number. Selecting by patient will display any previously entered assessments for
a patient. An asterisk (*) indicates cardiac cases. The user can then choose to create a new assessment
or edit one of the previously entered assessments.
2. After choosing an operation on which to report, the user should respond YES to the prompt, "Are you
sure that you want to create a Risk Assessment for this surgical case ? " The user must answer YES
(or press the <Enter> key to accept the YES default) to get to any of the sub-options. If the answer is
NO, the case created in step 1 will not be considered an assessment, although it can appear on some
lists, and the software will return the user to the "Select Patient:" prompt.
3. Preoperative, operative, postoperative, and lab information is entered and edited using the suboption(s).
If assistance is needed while interacting with the software, the user should enter one or two question
marks (??) to access the on-line help.
April 2004
Surgery V. 3.0 User Manual
445
Example: Creating a New Risk Assessment (Non-Cardiac)
Select Surgery Risk Assessment Menu Option: N
Non-Cardiac Assessment Information (Enter/Edit)
Select Patient: ?
To lookup by patient, enter patient name or patient ID. To lookup by
surgical case/assessment number, enter the number preceded by "#",
e.g., for case 12345 enter "#12345" (no spaces).
Select Patient:
SURPATIENT,THREE
SURPATIENT,THREE
01-01-45
000212453
000-21-2453
1. 02-01-95
INTRAOCCULAR LENS (INCOMPLETE)
2. 02-01-95
HIP REPLACEMENT (INCOMPLETE)
3. 09-18-91
FEMORAL POPLITEAL BYPASS GRAFT (INCOMPLETE)
4.
----
NSC VETERAN
CREATE NEW ASSESSMENT
Select Surgical Case: 4
SURPATIENT,THREE
1. 10-03-91
000-21-2453
ABDOMINAL AORTIC ANEURYSM RESECTION (NOT COMPLETE)
Select Operation: 1
When selecting a case to be assessed, if coding is completed for the case, and only excluded CPT
codes are assigned, the software warns the Nurse Reviewer with the message:
“Based on the CPT Codes assigned for this case, this case should be excluded.”
This is only a warning. The Nurse Reviewer may still create the assessment.
When selecting a case to be assessed, if no CPT codes have been assigned to the case, the
software warns the Nurse Reviewer with the message:
“No CPT Codes have been assigned for this case.”
This is only a warning. The Nurse Reviewer may still create the assessment.
Are you sure that you want to create a Risk Assessment for this surgical
case ? YES// <Enter>
To enter information for the risk assessment, use the sub-options from this menu option. These options
are described in the following sections. For example, to enter operation information, select the Operation
Information Enter/Edit option.
446
Surgery V. 3.0 User Manual
April 2004
Editing an Incomplete Risk Assessment
To edit an incomplete risk assessment, the user can either select the assessment by patient or by surgery
case number.
Example: Using the Select by Case Number Function to Edit an Incomplete Assessment
Select Surgery Risk Assessment Menu Option: N
Non-Cardiac Assessment Information (Enter/Edit)
Select Patient: #210
SURPATIENT,TEN
03-22-02
000-12-3456
HIP REPLACEMENT (INCOMPLETE)
1. Enter Risk Assessment Information
2. Delete Risk Assessment Entry
3. Update Assessment Status to 'COMPLETE'
Select Number:
1// <Enter>
Division: ALBANY
SURPATIENT,TEN
PRE
LAB
O
D
IO
PO
RET
U
CODE
(500)
000-12-3456
Case #210 - MAR 22,2002
Preoperative Information (Enter/Edit)
Laboratory Test Results (Enter/Edit)
Operation Information (Enter/Edit)
Patient Demographics (Enter/Edit)
Intraoperative Occurrences (Enter/Edit)
Postoperative Occurrences (Enter/Edit)
Update Status of Returns Within 30 Days
Update Assessment Status to 'COMPLETE'
Alert Coder Regarding Coding Issues
Select Non-Cardiac Assessment Information (Enter/Edit) Option:
These options are described in the following sections.
April 2004
Surgery V. 3.0 User Manual
447
Preoperative Information (Enter/Edit)
[SROA PREOP DATA]
The Preoperative Information (Enter/Edit) option is used to enter or edit preoperative assessment
information. The software will present two pages. At the bottom of each page is a prompt to select one or
more preoperative items to edit. If the user does not want to edit any items on the page, pressing the
<Enter> key will advance to the next page or, if the user is already on page two, will exit the option.
About the "Select Preoperative Information to Edit:" Prompt
At this prompt the user enters the item number he or she wishes to edit. Entering A for ALL allows the
user to respond to every item on the page, or a range of numbers separated by a colon (:) can be entered to
respond to a range of items. Number-letter combinations can also be used, such as 2C, to update a field
within a group, such as CURRENT PNEUMONIA.
Each prompt at the category level allows for an entry of YES or NO. If NO is entered, each item under
that category will automatically be answered NO. On the other hand, responding YES at the category
level allows the user to respond individually to each item under the main category.
For instance, if number 2 is chosen, and the "PULMONARY:" prompt is answered YES, the user will be
asked if the patient is ventilator dependent, has a history of COPD, and has pneumonia. If the
"PULMONARY:" prompt is answered NO, the software will place a NO response in all the fields of the
Pulmonary group. The majority of the prompts in this option are designed to accept the letters Y, N, or
NS for YES, NO, and NO STUDY.
After the information has been entered or edited, the terminal display screen will clear and present a
summary. The summary organizes the information entered and provides another chance to enter or edit
data.
This functionality allows the nurse reviewer to duplicate preoperative information from an earlier
operation within 60 days of the date of operation on the same patient.
Example 1: Enter/Edit Preoperative Information
Select Non-Cardiac Assessment Information (Enter/Edit) Option: PRE
(Enter/Edit)
Preoperative Information
This patient had a previous non-cardiac operation on APR 28,[email protected]:00
Case #63592
CHOLEDOCHOTOMY
Do you want to duplicate the preoperative information from the earlier assessment in this
assessment? YES// NO
448
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,SIXTY (000-56-7821)
Case #63592
PAGE: 1 OF 2
JUN 23,1998
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. GENERAL:
3. HEPATOBILIARY:
A. Height:
A. Ascites:
B. Weight:
C. Diabetes - Long Term:
4. GASTROINTESTINAL:
D. Diabetes - 2 Wks Preop:
A. Esophageal Varices:
E. Tobacco Use:
F. Tobacco Use Timeframe: NOT APPLICABLE
G. ETOH > 2 Drinks/Day:
5. CARDIAC:
H. Positive Drug Screening:
A. CHF Within 1 Month:
I. Dyspnea:
B. MI Within 6 Months:
J. Preop Sleep Apnea:
C. Previous PCI:
K. DNR Status:
D. Previous Cardiac Surgery:
L. Preop Funct Status:
E. Angina Within 1 Month:
F. Hypertension Requiring Meds:
2. PULMONARY:
A. Ventilator Dependent:
6. VASCULAR:
B. History of Severe COPD:
A. Revascularization/Amputation:
C. Current Pneumonia:
B. Rest Pain/Gangrene:
-------------------------------------------------------------------------------Select Preoperative Information to Edit: 1:3
SURPATIENT,SIXTY (000-56-7821)
Case #63592
JUN 23,1998
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------GENERAL: YES
Patient's Height 65 INCHES//: 62
Patient's Weight 140 POUNDS//: 175
Diabetes Mellitus: Chronic, Long-Term Management: I INSULIN
Diabetes Mellitus: Management Prior to Surgery: I INSULIN
Tobacco Use: 2 NO USE IN LAST 12 MOS
Tobacco Use Timeframe: NOT APPLICABLE// <enter>
ETOH >2 Drinks Per Day in the Two Weeks Prior to Admission: N NO
Positive Drug Screening: N NO
Dyspnea: N
1
NO
2
NO STUDY
Choose 1-2: 1 NO
Preoperative Sleep Apnea: NONE NONE - LEVEL 1
DNR Status (Y/N): N NO
Functional Health Status at Evaluation for Surgery: 1 INDEPENDENT
PULMONARY: NO
HEPATOBILIARY: NO
April 2004
Surgery V. 3.0 User Manual
449
SURPATIENT,SIXTY (000-56-7821)
Case #63592
PAGE: 1 OF 2
JUN 23,1998
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. GENERAL:
NO
3. HEPATOBILIARY:
NO
A. Height:
62 INCHES
A. Ascites:
NO
B. Weight:
175 LBS.
C. Diabetes - Long Term:
INSULIN 4. GASTROINTESTINAL:
D. Diabetes - 2 Wks Preop:
INSULIN
A. Esophageal Varices:
E. Tobacco Use: NO USE IN LAST 12 MOS
F. Tobacco Use Timeframe: NOT APPLICABLE
G. ETOH > 2 Drinks/Day:
5. CARDIAC:
H. Positive Drug Screening:
NO
A. CHF Within 1 Month:
I. Dyspnea:
NO
B. MI Within 6 Months:
J. Preop Sleep Apnea:
LEVEL 1
C. Previous PCI:
K. DNR Status:
NO
D. Previous Cardiac Surgery:
L. Preop Funct Status:
INDEPENDENT
E. Angina Within 1 Month:
F. Hypertension Requiring Meds:
2. PULMONARY:
NO
A. Ventilator Dependent:
NO
6. VASCULAR:
B. History of Severe COPD:
NO
A. Revascularization/Amputation:
C. Current Pneumonia:
NO
B. Rest Pain/Gangrene:
-------------------------------------------------------------------------------Select Preoperative Information to Edit: <Enter>
SURPATIENT,SIXTY (000-56-7821)
Case #63592
PAGE: 2 OF 2
JUN 23,1998
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. RENAL:
A. Acute Renal Failure:
B. Currently on Dialysis:
3. NUTRITIONAL/IMMUNE/OTHER:
A. Disseminated Cancer:
B. Open Wound:
C. Steroid Use for Chronic Cond.:
D. Weight Loss > 10%:
E. Bleeding Disorders:
F. Transfusion > 4 RBC Units:
G. Chemotherapy W/I 30 Days:
H. Radiotherapy W/I 90 Days:
I. Preoperative Sepsis:
J. Pregnancy:
NOT APPLICABLE
2. CENTRAL NERVOUS SYSTEM:
A. Impaired Sensorium:
B. Coma:
C. Hemiplegia:
D. CVD Repair/Obstruct:
E. History of CVD:
F. Tumor Involving CNS:
-------------------------------------------------------------------------------Select Preoperative Information to Edit: 3E
SURPATIENT,SIXTY (000-56-7821)
Case #63592
JUN 23,1998
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------History of Bleeding Disorders (Y/N): Y
YES
SURPATIENT,SIXTY (000-56-7821)
Case #63592
PAGE: 2 OF 2
JUN 23,1998
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. RENAL:
A. Acute Renal Failure:
B. Currently on Dialysis:
3. NUTRITIONAL/IMMUNE/OTHER:
A. Disseminated Cancer:
B. Open Wound:
C. Steroid Use for Chronic Cond.:
2. CENTRAL NERVOUS SYSTEM:
D. Weight Loss > 10%:
A. Impaired Sensorium:
E. Bleeding Disorders:
YES
B. Coma:
F. Transfusion > 4 RBC Units:
C. Hemiplegia:
G. Chemotherapy W/I 30 Days:
D. CVD Repair/Obstruct:
H. Radiotherapy W/I 90 Days:
E. History of CVD:
I. Preoperative Sepsis:
F. Tumor Involving CNS:
J. Pregnancy:
NOT APPLICABLE
-------------------------------------------------------------------------------Select Preoperative Information to Edit:
450
Surgery V. 3.0 User Manual
April 2004
Laboratory Test Results (Enter/Edit)
[SROA LAB]
Use the Laboratory Test Results (Enter/Edit) option to enter or edit preoperative and postoperative lab
information for an individual risk assessment. The option is divided into the three features listed below.
The first two features allow the user to merge (also called “capture” or “load”) lab information into the
risk assessment from the VistA software. The third feature provides a two-page summary of the lab
profile and allows direct editing of the information.
1. Capture Preoperative Laboratory Information
2. Capture Postoperative Laboratory Information
3. Enter, Edit, or Review Laboratory Test Results
To “capture” preoperative lab data, the user must provide both the date and time the operation began.
Likewise, to capture postoperative lab data, the user must provide both the date and time the operation
was completed. If this information has already been entered, the system will not prompt for it again.
If assistance is needed while interacting with the software, entering one or two question marks (??) will
access the on-line help.
Example 1: Capture Preoperative Laboratory Information
Select Non-Cardiac Assessment Information (Enter/Edit) Option: LAB
(Enter/Edit)
Laboratory Test Results
SURPATIENT,FORTY (000-77-7777)
Case #68112
SEP 19, 2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------Enter/Edit Laboratory Test Results
1. Capture Preoperative Laboratory Information
2. Capture Postoperative Laboratory Information
3. Enter, Edit, or Review Laboratory Test Results
Select Number: 1
This selection loads the most recent lab data for tests performed within 90 days before the
operation.
Do you want to automatically load preoperative lab data ?
YES// <Enter>
The ‘Time Operation Began’ must be entered before continuing.
Do you want to enter ‘Time Operation Began’ at this time ?
Time the Operation Began:
8:00
YES//
<Enter>
(SEP 25, [email protected]:00)
..Searching lab record for latest preoperative test data….
..Moving preoperative lab test data to Surgery Risk Assessment file….
Press <RET> to continue
April 2004
<Enter>
Surgery V. 3.0 User Manual
451
Example 2: Capture Postoperative Laboratory Information
Select Non-Cardiac Assessment Information (Enter/Edit) Option: LAB
(Enter/Edit)
Laboratory Test Results
1. Capture Preoperative Laboratory Information
2. Capture Postoperative Laboratory Information
3. Enter, Edit, or Review Laboratory Test Results
Select Number: 2
This selection loads highest or lowest lab data for tests performed within 30 days after the
operation.
Do you want to automatically load postoperative lab data ?
YES// <Enter>
‘Time the Operation Ends’ must be entered before continuing.
Do you want to enter the time that the operation was completed at
this time ? YES//
<Enter>
Time the Operation Ends: 12:00
(SEP 25, [email protected]:00)
..Searching lab record for postoperative lab test data….
..Moving postoperative lab data to Surgery Risk Assessment file….
Press <RET> to continue
Example 3: Enter, Edit, or Review Laboratory Test Results
Select Non-Cardiac Assessment Information (Enter/Edit) Option: LAB
(Enter/Edit)
Laboratory Test Results
Enter/Edit Laboratory Test Results
1. Capture Preoperative Laboratory Information
2. Capture Postoperative Laboratory Information
3. Enter, Edit, or Review Laboratory Test Results
Select Number: 3
SURPATIENT,FORTY (000-77-7777)
Case #68112
PAGE: 1 OF 2
LATEST PREOP LAB RESULTS IN 90 DAYS PRIOR TO SURGERY UNLESS OTHERWISE SPECIFIED
SEP 19,2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------1. Anion Gap (in 48 hrs.):
12
(SEP 18,2003)
2. Serum Sodium:
139
(SEP 18,2003)
3. BUN:
13
(SEP 18,2003)
4. Serum Creatinine:
1
(SEP 18,2003)
5. Serum Albumin:
4
(SEP 18,2003)
6. Total Bilirubin:
.8
(SEP 18,2003)
7. SGOT:
29
(SEP 18,2003)
8. Alkaline Phosphatase:
120
(SEP 18,2003)
9. WBC:
12.8 (SEP 18,2003)
10. Hematocrit:
45.7 (SEP 18,2003)
11. Platelet Count:
NS
12. PTT:
NS
13. PT:
NS
14. INR:
NS
15. Hemoglobin A1c (1000 days):
NS
-----------------------------------------------------------------------------Select Preoperative Laboratory Information to Edit: 11:13
452
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,FORTY (000-77-7777)
Case #68112
SEP 19,2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------Preoperative Platelet Count (X 1000/mm3): 289
Date Preoperative Platelet Count was Performed: 9/18/03 (SEP 18, 2003)
Preoperative PTT (seconds): 33.7
Date Preoperative PTT was Performed: 9/18/03 (SEP 18, 2003)
Preoperative PT (seconds): 11.8
Date Preoperative PT was Performed: 9/18/03 (SEP 18, 2003)
SURPATIENT,FORTY (000-77-7777)
Case #68112
PAGE: 1 OF 2
LATEST PREOP LAB RESULTS IN 90 DAYS PRIOR TO SURGERY UNLESS OTHERWISE SPECIFIED
SEP 19,2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------1. Anion Gap (in 48 hrs.):
12
(SEP 18,2003)
2. Serum Sodium:
139
(SEP 18,2003)
3. BUN:
13
(SEP 18,2003)
4. Serum Creatinine:
1
(SEP 18,2003)
5. Serum Albumin:
4
(SEP 18,2003)
6. Total Bilirubin:
.8
(SEP 18,2003)
7. SGOT:
29
(SEP 18,2003)
8. Alkaline Phosphatase:
120
(SEP 18,2003)
9. WBC:
12.8 (SEP 18,2003)
10. Hematocrit:
45.7 (SEP 18,2003)
11. Platelet Count:
289
(SEP 18,2003)
12. PTT:
33.7 (SEP 18,2003)
13. PT:
11.8 (SEP 18,2003)
14. INR:
NS
15. Hemoglobin A1c (1000 days):
NS
-----------------------------------------------------------------------------Select Preoperative Laboratory Information to Edit:
<Enter>
SURPATIENT,FORTY (000-77-7777)
Case #68112
PAGE: 2 OF 2
POSTOP LAB RESULTS WITHIN 30 DAYS AFTER SURGERY
SEP 19,2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------1. Highest Anion Gap:
12
(SEP 20,2003)
2. Highest Serum Sodium:
139
(SEP 20,2003)
3. Lowest Serum Sodium:
135
(SEP 20,2003)
4. Highest Potassium:
4.4
(SEP 20,2003)
5. Lowest Potassium:
3.4
(SEP 20,2003)
6. Highest Serum Creatinine:
1.2
(SEP 20,2003)
7. Highest CPK:
NS
8. Highest CPK-MB Band:
NS
9. Highest Total Bilirubin:
NS
10. Highest WBC:
11.8
(SEP 20,2003)
11. Lowest Hematocrit:
40.3
(SEP 20,2003)
12. Highest Troponin I:
10.18
(SEP 24,2003)
13. Highest Troponin T:
12.13
(SEP 24,2003)
-----------------------------------------------------------------------------Select Postoperative Laboratory Information to Edit: 2
April 2004
Surgery V. 3.0 User Manual
453
SURPATIENT,FORTY (000-77-7777)
Case #68112
SEP 19,1998
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------Highest Postoperative Serum Sodium: 139// 144
Date Highest Serum Sodium was Recorded: 9/21/03
(SEP 21, 2003)
SURPATIENT,FORTY (000-77-7777)
Case #68112
PAGE: 2 OF 2
POSTOP LAB RESULTS WITHIN 30 DAYS AFTER SURGERY
SEP 19,2003
CHOLEDOCHOTOMY
-----------------------------------------------------------------------------1. Highest Anion Gap:
12
(SEP 20,2003)
2. Highest Serum Sodium:
144
(SEP 21,2003)
3. Lowest Serum Sodium:
135
(SEP 20,2003)
4. Highest Potassium:
4.4
(SEP 20,2003)
5. Lowest Potassium:
3.4
(SEP 20,2003)
6. Highest Serum Creatinine:
1.2
(SEP 20,2003)
7. Highest CPK:
NS
8. Highest CPK-MB Band:
NS
9. Highest Total Bilirubin:
NS
10. Highest WBC:
11.8
(SEP 20,2003)
11. Lowest Hematocrit:
40.3
(SEP 20,2003)
12. Highest Troponin I:
10.18
(SEP 24,2003)
13. Highest Troponin T:
12.13
(SEP 24,2003)
-----------------------------------------------------------------------------Select Postoperative Laboratory Information to Edit:
454
Surgery V. 3.0 User Manual
April 2004
Operation Information (Enter/Edit)
[SROA OPERATION DATA]
The Operation Information (Enter/Edit) option is used to enter or edit information related to the
operation. At the bottom of each page is a prompt to select one or more operative items to edit. If the user
does not want to edit any items on the page, pressing the <Enter> key will exit the option. If they are not
already there, it is important that the operation‟s beginning and ending times be entered so that the user
can later enter postoperative information.
About the "Select Operative Information to Edit:" Prompt
The user should first enter the item number to edit at the "Select Operative Information to Edit:" prompt.
To respond to every item on the page, the user should enter A for ALL or enter a range of numbers
separated by a colon (:) to respond to a range of items.
After the information has been entered or edited, the display will clear and present a summary. The
summary organizes the information entered and provides another chance to enter or edit data. If
information has been entered for the OTHER PROCEDURES field or the CONCURRENT
PROCEDURES field, the summary will display ***INFORMATION ENTERED*** to the right of the
items.
If assistance is needed while interacting with the software, the user should enter one or two question
marks (??) to receive on-line help.
Example: Enter/Edit Operation Information
Select Non-Cardiac Assessment Information (Enter/Edit) Option: O
Information (Enter/Edit)
Operation
SURPATIENT,EIGHT (000-37-0555)
Case #264
PAGE: 1 OF 2
Surgeon: SURSURGEON,ONE
>> Coding Complete <<
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------This information
Postop Diagnosis Code (ICD9): NOT ENTERED
cannot be edited.
1. Surgical Specialty:
ORTHOPEDICS
2. Principal Operation:
ARTHROSCOPY, LEFT KNEE
3. CPT Codes (view only):
29873-LT
4. Other Procedures:
5. Concurrent Procedure:
6. PGY of Primary Surgeon:
7. Surgical Priority:
ELECTIVE
8. Wound Classification:
CLEAN
9. ASA Classification:
1-NO DISTURB.
10. Princ. Anesthesia Technique: GENERAL
11. RBC Units Transfused:
12. Intraop Disseminated Cancer: NO
13. Intraoperative Ascites
NO
-------------------------------------------------------------------------------Select Operative Information to Edit: 8:9
SURPATIENT,EIGHT (000-37-0555)
Case #264
Surgeon: SURSURGEON,ONE
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------Wound Classification: CLEAN// CL
1
CLEAN
2
CLEAN/CONTAMINATED
Choose 1-2: 2 CLEAN/CONTAMINATED
April 2004
Surgery V. 3.0 User Manual
455
ASA Class: 1-NO DISTURB.// 2
2
2-MILD DISTURB.
SURPATIENT,EIGHT (000-37-0555)
Case #264
PAGE: 1 OF 2
Surgeon: SURSURGEON,ONE
>> Coding Complete <<
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------Postop Diagnosis Code (ICD9): NOT ENTERED
1. Surgical Specialty:
ORTHOPEDICS
2. Principal Operation:
ARTHROSCOPY, LEFT KNEE
3. CPT Codes (view only):
29873-LT
4. Other Procedures:
5. Concurrent Procedure:
6. PGY of Primary Surgeon:
7. Surgical Priority:
ELECTIVE
8. Wound Classification:
CLEAN/CONTAMINATED
9. ASA Classification:
2-MILD DISTURB.
10. Princ. Anesthesia Technique: GENERAL
11. RBC Units Transfused:
12. Intraop Disseminated Cancer: NO
13. Intraoperative Ascites
NO
-------------------------------------------------------------------------------Select Operative Information to Edit: <Enter>
SURPATIENT,EIGHT (000-37-0555)
Case #264
PAGE: 2 OF 2
Surgeon: SURSURGEON,ONE
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Patient in Room (PIR):
Procedure/Surgery Start Time (PST):
Procedure/Surgery Finish (PF):
Patient Out of Room (POR):
Anesthesia Start (AS):
Anesthesia Finish (AF):
Discharge from PACU (DPACU):
JUN
JUN
JUN
JUN
JUN
JUN
07,
07,
07,
07,
07,
07,
2005
2005
2005
2005
2005
2005
07:00
07:10
08:15
08:40
06:30
09:00
-------------------------------------------------------------------------------Select Operative Information to Edit:
456
Surgery V. 3.0 User Manual
April 2004
Patient Demographics (Enter/Edit)
[SROA DEMOGRAPHICS]
The surgical clinical nurse reviewer uses the Patient Demographics (Enter/Edit) option to capture patient
demographic information from the Patient Information Management System (PIMS) record. The nurse
reviewer can also enter, edit, and review this information. The demographic fields captured from PIMS
are Race, Ethnicity, Hospital Admission Date, Hospital Discharge Date, Admission/Transfer Date,
Discharge/Transfer Date, Observation Admission Date, Observation Discharge Date, and Observation
Treating Specialty. With this option, the nurse reviewer can also edit the length of postoperative hospital
stay, in/out-patient status, and transfer status.
The Race and Ethnicity information is displayed, but cannot be updated within this or any other
Surgery package option.
Example: Entering Patient Demographics
Select Non-Cardiac Assessment Information (Enter/Edit) Option: D
aphics (Enter/Edit)
Patient Demogr
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------Enter/Edit Patient Demographic Information
1. Capture Information from PIMS Records
2. Enter, Edit, or Review Information
Select Number:
(1-2): 1
Are you sure you want to retrieve information from PIMS records ? YES// <Enter>
...EXCUSE ME, JUST A MOMENT PLEASE...
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------Enter/Edit Patient Demographic Information
1. Capture Information from PIMS Records
2. Enter, Edit, or Review Information
Select Number:
April 2004
(1-2): 2
Surgery V. 3.0 User Manual
457
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Transfer Status:
Observation Admission Date/Time:
Observation Discharge Date/Time:
Observation Treating Specialty:
Hospital Admission Date/Time:
Hospital Discharge Date/Time:
Admit/Transfer to Surgical Svc.:
Discharge/Transfer to Chronic Care:
Length of Postop Hospital Stay:
In/Out-Patient Status:
Patient's Ethnicity:
Patient's Race:
Date of Death:
30-Day Death:
NOT TRANSFERRED
NA
NA
NA
JUN 06, [email protected]:15
JUN 21, [email protected]:32
JUN 06, [email protected]:30
JUN 21, [email protected]:32
15 Days
INPATIENT
NOT HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKA NATIVE, ASIAN
NA
NO
-------------------------------------------------------------------------------Select number of item to edit:
458
Surgery V. 3.0 User Manual
April 2004
Intraoperative Occurrences (Enter/Edit)
[SRO INTRAOP COMP]
The nurse reviewer uses the Intraoperative Occurrences (Enter/Edit) option to enter or change
information related to intraoperative occurrences (called complications in earlier versions). Every
occurrence entered must have a corresponding occurrence category. For a list of occurrence categories,
enter a question mark (?) at the "Enter a New Intraoperative Occurrence:" prompt.
After an occurrence category has been entered or edited, the screen will clear and present a summary. The
summary organizes the information entered and provides another chance to enter or edit data.
Example: Enter an Intraoperative Occurrence
Select Non-Cardiac Assessment Information (Enter/Edit) Option: IO
(Enter/Edit)
Intraoperative Occurrences
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------There are no Intraoperative Occurrences entered for this case.
Enter a New Intraoperative Occurrence: CARDIAC ARREST REQUIRING CPR
Definition Revised (2011): 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.
Patients with AICDs that fire but the patient does not lose
consciousness should be excluded.
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.
Press RETURN to continue: <Enter>
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
-------------------------------------------------------------------------------Select Occurrence Information: 4:5
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-------------------------------------------------------------------------------Type of Treatment Instituted: CPR
Outcome to Date: I IMPROVED
April 2004
Surgery V. 3.0 User Manual
459
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
CPR
IMPROVED
-----------------------------------------------------------------------------Select Occurrence Information: <Enter>
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------Enter/Edit Intraoperative Occurrences
1.
CARDIAC ARREST REQUIRING CPR
Category: CARDIAC ARREST REQUIRING CPR
Select a number (1), or type 'NEW' to enter another occurrence:
460
Surgery V. 3.0 User Manual
April 2004
Postoperative Occurrences (Enter/Edit)
[SRO POSTOP COMP]
The nurse reviewer uses the Postoperative Occurrences (Enter/Edit) option to enter or change
information related to postoperative occurrences (called complications in earlier versions). Every
occurrence entered must have a corresponding occurrence category. For a list of occurrence categories,
the user should enter a question mark (?) at the "Enter a New Postoperative Occurrence:" prompt.
After an occurrence category has been entered or edited, the screen will clear and present a summary. The
summary organizes the information entered and provides another chance to enter or edit data.
Example: Enter a Postoperative Occurrence
Select Non-Cardiac Assessment Information (Enter/Edit) Option: PO
(Enter/Edit)
Postoperative Occurrences
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------There are no Postoperative Occurrences entered for this case.
Enter a New Postoperative Occurrence: ACUTE RENAL FAILURE
VASQIP Definition (2011):
Indicate if the patient developed new renal failure requiring renal
replacement therapy or experienced an exacerbation of preoperative
renal failure requiring initiation of renal replacement therapy (not on
renal replacement therapy preoperatively) within 30 days
postoperatively. Renal replacement therapy is defined as venous to
venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis
[CVAHD], peritoneal dialysis, hemofiltration, hemodiafiltration or
ultrafiltration.
TIP: If the patient refuses dialysis report as an occurrence because
he/she did require dialysis.
Press RETURN to continue: <Enter>
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
ACUTE RENAL FAILURE
ACUTE RENAL FAILURE
-----------------------------------------------------------------------------Select Occurrence Information: 4
April 2004
Surgery V. 3.0 User Manual
461
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------Treatment Instituted: DIALYSIS
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
ACUTE RENAL FAILURE
ACUTE RENAL FAILURE
DIALYSIS
-----------------------------------------------------------------------------Select Occurrence Information: <Enter>
SURPATIENT,EIGHT (000-37-0555)
Case #264
JUN 7,2005
ARTHROSCOPY, LEFT KNEE
-----------------------------------------------------------------------------Enter/Edit Postoperative Occurrences
1.
ACUTE RENAL FAILURE
Category: ACUTE RENAL FAILURE
Select a number (1), or type 'NEW' to enter another occurrence:
462
Surgery V. 3.0 User Manual
April 2004
Update Status of Returns Within 30 Days
[SRO UPDATE RETURNS]
The Update Status of Returns Within 30 Days option is used to update the status of Returns to Surgery
within 30 days of a surgical case.
Example: Update Status of Returns
Select Non-Cardiac Assessment Information (Enter/Edit) Option: RET
s of Returns Within 30 Days
SURPATIENT,SIXTY
Update Statu
000-56-7821
1. 07-06-05
REPAIR INGUINAL HERNIA (COMPLETED)
2. 06-25-05
CHOLECYSTECTOMY, APPENDECTOMY (COMPLETED)
3. 06-23-05
CHOLEDOCHOTOMY (COMPLETED)
4. 04-10-04
CRANIOTOMY (COMPLETED)
Select Operation: 3
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,2005
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. 07/06/05
REPAIR INGUINAL HERNIA - UNRELATED
2. 06/25/05
CHOLECYSTECTOMY - UNRELATED
------------------------------------------------------------------------------Select Number: 2
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,2005
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------2. 06/25/05
CHOLECYSTECTOMY - UNRELATED
------------------------------------------------------------------------------This return to surgery is currently defined as UNRELATED to the case selected.
Do you want to change this status ? NO// Y
SURPATIENT,SIXTY (000-56-7821)
Case #62192
RETURNS TO SURGERY
JUN 23,2005
CHOLEDOCHOTOMY
-------------------------------------------------------------------------------1. 07/06/05
REPAIR INGUINAL HERNIA - UNRELATED
2. 06/25/05
CHOLECYSTECTOMY - RELATED
------------------------------------------------------------------------------Select Number:
April 2004
Surgery V. 3.0 User Manual
463
Update Assessment Status to ‘Complete’
[SROA COMPLETE ASSESSMENT]
Use the Update Assessment Status to „Complete‟ option to upgrade the status of an assessment to
Complete. A complete assessment has enough information for it to be transmitted to the centers where
data are analyzed. Only complete assessments are transmitted. After updating the status, the patient‟s
entire Surgery Risk Assessment Report can be printed. This report can be copied to a screen or to a
printer.
Example : Update Assessment Status to COMPLETE
Select Non-Cardiac Assessment Information (Enter/Edit) Option: U
ent Status to 'COMPLETE'
Update Assessm
This assessment is missing the following items:
1. Rest Pain/Gangrene (Y/N)
Do you want to enter the missing items at this time? NO// YES
FOREIGN BODY REMOVAL (Y/N): N NO
Are you sure you want to complete this assessment ? NO// YES
Updating the current status to 'COMPLETE'...
Do you want to print the completed assessment ?
464
YES//
NO
Surgery V. 3.0 User Manual
April 2004
Alert Coder Regarding Coding Issues
[SROA CODE ISSUE]
This option allows the nurse reviewer to send an alert to the coder when there may be an issue with the
CPT codes or the Postoperative Diagnosis codes for a Surgery case. When this option is selected, the
nurse reviewer can enter a free-text message that will be sent to the coder on record, as well as to a predefined mail group identified in the Surgery Site Parameter titled CODE ISSUE MAIL GROUP. The
message will not be sent if there is no coder, or if the mail group is not defined.
Example : Alert Coder Regarding Coding Issues
Select Non-Cardiac Assessment Information (Enter/Edit) Option: CODE
Regarding Coding Issues
Select Patient: SURPATIENT,TWO
SC VETERAN
SURPATIENT,THREE
4-3-23
000451982
Alert Coder
YES
000-45-1982
1. 05-10-05
CHOLECYSTECOMY (COMPLETED)
2. 01-27-06
BRONCHOSCOPY (COMPLETED)
Select Operation: 1
SURPATIENT,TWO (000-45-1982)
Case #10102
MAY 10,2005
CHOLECYSTECTOMY
-------------------------------------------------------------------The following "final" codes have been entered for the case.
Principal CPT Code: 47563 LAPARO CHOLECYSTECTOMY/GRAPH
Other CPT Codes:
NOT ENTERED
Postop Diagnosis Code (ICD9): 540.9
ACUTE APPENDICITIS NOS
If you believe that the information coded is not correct and would like to
alert the coders of the potential issue, enter a brief description of your
concern below.
Do you want to alert the coders (Y/N)? YES// <Enter>
==[ WRAP ]==[ INSERT ]=====< Coding Discrepancy Comments >===[ <PF1>H=Help ]====
I have reviewed this case for VASQIP. The final Principal CPT Code entered
is 47563. I would like to talk to you regarding the code. I think the code
should be 47562. Please call me at X2545.
<=======T=======T=======T=======T=======T=======T=======T=======T=======T>======
1. Transmit Message
2. Edit Text
Select Number:
1//
<Enter>
Transmitting message...
April 2004
Surgery V. 3.0 User Manual
464a
(This page included for two-sided copying.)
464b
Surgery V. 3.0 User Manual
April 2004
Cardiac Risk Assessment Information (Enter/Edit)
[SROA CARDIAC ENTER/EDIT]
The Surgical Clinical Nurse Reviewer uses the options within the Cardiac Risk Assessment Information
(Enter/Edit) menu to create a new risk assessment for a cardiac patient. Cardiac cases are evaluated
differently from non-cardiac cases, and the prompts are different. This option is also used to make
changes to an assessment that has already been entered.
The example below demonstrates how to create a new risk assessment for cardiac patients and get to the
sub-option menu as follows.
Shortcut
CLIN
LAB
CATH
OP
CARD
OUT
IO
PO
R
U
CODE
Option Name
Clinical Information (Enter/Edit)
Laboratory Test Results (Enter/Edit)
Enter Cardiac Catheterization & Angiographic Data
Operative Risk Summary Data (Enter/Edit)
Cardiac Procedures Operative Data (Enter/Edit)
Outcome Information (Enter/Edit)
Intraoperative Occurrences (Enter/Edit)
Postoperative Occurrences (Enter/Edit)
Resource Data
Update Assessment Status to „COMPLETE‟
Alert Coder Regarding Coding Issues
These sub-options are used for entering more in-depth data for a case, and are described in this chapter.
Creating a New Risk Assessment
1. Enter either the patient‟s name/patient ID (for example, SURPATIENT,NINETEEN) or the surgical
case assessment number preceded by # (for example, #47063). If the patient has any previous
assessments, they will be displayed. An asterisk (*) indicates a cardiac case. The user can now choose
to create a new assessment or edit one of the previously entered assessments.
2. After choosing an operation on which to report, the user should respond YES to the prompt "Are you
sure that you want to create a Risk Assessment for this surgical case ?" The user must answer YES
(or press the <Enter> key to accept the YES default) to get to any of the sub-options. If the answer
given is NO, the case created in step 1 will not be considered an assessment, although it can appear
on some lists, and the software will return the user to the "Select Patient:" prompt.
3. The screen will clear and present the sub-options menu. The user can select a sub-option now to enter
more in-depth information for the case, or press the <Enter> key to return to the main menu.
April 2004
Surgery V. 3.0 User Manual
465
Example: Creating A New Risk Assessment (Cardiac)
Select Surgery Risk Assessment Menu Option: C Cardiac Risk Assessment Information (Enter/Edit)
Select Patient: SURPATIENT,FORTY
SURPATIENT,FORTY
1.
----
03-03-45
000777777
NSC VETERAN
000-77-7777
CREATE NEW ASSESSMENT
Select Surgical Case: 1
SURPATIENT,FORTY
000-77-7777
1. 01-18-95
CORONARY ARTERY BYPASS (COMPLETED)
2. 06-18-93
INGUINAL HERNIA (COMPLETED)
Select Operation: 1
Are you sure that you want to create a Risk Assessment for this surgical
case ? YES// <Enter>
466
Surgery V. 3.0 User Manual
April 2004
Clinical Information (Enter/Edit)
[SROA CLINICAL INFORMATION]
The Clinical Information (Enter/Edit) option is used to enter the clinical information required for a
cardiac risk assessment. The software will present one page; at the bottom of the page is a prompt to
select one or more items to edit. If the user does not want to edit any items on the page, pressing the
<Enter> key will advance the user to another option.
About the "Select Clinical Information to Edit:" Prompt
At the "Select Clinical Information to Edit:" prompt, the user should enter the item number to edit. The
user can then enter an A for ALL to respond to every item on the page, or enter a range of numbers
separated by a colon (:) to respond to a range of items.
After the information has been entered or edited, the terminal display screen will clear and present a
summary. The summary organizes the information entered and provides another chance to enter or edit
data. If assistance is needed while interacting with the software, the user can enter one or two question
marks (??) to receive on-line help.
Example: Enter Clinical Information
Select Cardiac Risk Assessment Information (Enter/Edit) Option: CLIN
Information (Enter/Edit)
Clinical
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1. Height:
63 in
16. Prior MI:
2. Weight:
170 lb
17. Num Prior Heart Surgeries:
3. Diabetes - Long Term:
18. Prior Heart Surgeries:
4. Diabetes - 2 Wks Preop:
19. Peripheral Vascular Disease:
5. COPD:
20. CVD Repair/Obstruct:
6. FEV1:
21. History of CVD:
7. Cardiomegaly (X-ray):
22. Angina (use CCS Class):
8. Pulmonary Rales:
23. CHF (use NYHA Class):
9. Tobacco Use:
24. Current Diuretic Use:
10. Tobacco Use Timeframe: NOT APPLICABLE 25. Current Digoxin Use:
11. Positive Drug Screening:
26. IV NTG within 48 Hours:
12. Active Endocarditis:
27. Preop Circulatory Device:
13. Resting ST Depression:
28. Hypertension (Y/N):
14. Functional Status:
29. Preop Atrial Fibrillation:
15. PCI:
-------------------------------------------------------------------------------Select Clinical Information to Edit: A
April 2004
Surgery V. 3.0 User Manual
467
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Patient's Height: 63 INCHES// 76
Patient's Weight: 170 LBS// 210
Diabetes Mellitus: Chronic, Long-Term Management: I INSULIN
Diabetes Mellitus: Management Prior to Surgery: I INSULIN
History of Severe COPD (Y/N): Y YES
FEV1 : NS
Cardiomegaly on Chest X-Ray (Y/N): Y YES
Pulmonary Rales (Y/N): Y YES
Tobacco Use: 3 CIGARETTES ONLY
Tobacco Use Timeframe: 1 WITHIN 2 WEEKS
Positive Drug Screening: N NO
Active Endocarditis (Y/N): N NO
Resting ST Depression (Y/N): N NO
Functional Status: I INDEPENDENT
PCI: 0 NONE
Prior Myocardial Infarction: 1 LESS THAN OR EQUAL TO 7 DAYS PRIOR TO SURGERY
Number of Prior Heart Surgeries: 1 1
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Prior heart surgeries:
0. None
1. CABG-only
2. Valve-only
3. CABG/Valve
4. Other
5. CABG/Other
Enter your choice(s) separated by commas
(0-5): // 2
2 - Valve-only
Peripheral Vascular Disease (Y/N): Y YES
Prior Surgical Repair/Carotid Artery Obstruction: 0 NO CVD
History of CVD Events: 0 NO CVD
Angina (use CCS Functional Class): IV CLASS IV
Congestive Heart Failure (use NYHA Functional Class): II SLIGHT LIMITATION
Current Diuretic Use (Y/N): Y YES
Current Digoxin Use (Y/N): N NO
IV NTG within 48 Hours Preceding Surgery (Y/N): Y YES
Preop use of circulatory Device: N NONE
History of Hypertension (Y/N): Y YES
Preoperative Atrial Fibrillation: N NO
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------1. Height:
76 in
16. Prior MI:
< OR = 7 DAYS
2. Weight:
210 lb
17. Num Prior Heart Surgeries:
1
3. Diabetes - Long Term:
INSULIN
18. Prior Heart Surgeries: VALVE-ONLY
4. Diabetes - 2 Wks Preop:
INSULIN
19. Peripheral Vascular Disease: YES
5. COPD:
YES
20. CVD Repair/Obstruct:
NO CVD
6. FEV1:
NS
21. History of CVD:
NO CVD
7. Cardiomegaly (X-ray):
YES
22. Angina (use CCS Class):
IV
8. Pulmonary Rales:
YES
23. CHF (use NYHA Class):
II
9. Tobacco Use:
CIGARETTES ONLY 24. Current Diuretic Use:
YES
10. Tobacco Use Timeframe: WITHIN 2 WEEKS 25. Current Digoxin Use:
NO
11. Positive Drug Screening: NO
26. IV NTG within 48 Hours:
YES
12. Active Endocarditis:
NO
27. Preop Circulatory Device:
NONE
13. Resting ST Depression:
NO
28. Hypertension (Y/N):
YES
14. Functional Status:
INDEPENDENT 29. Preop Atrial Fibrillation:
NO
15. PCI:
NONE
-------------------------------------------------------------------------------Select Clinical Information to Edit:
468
Surgery V. 3.0 User Manual
April 2004
Laboratory Test Results (Enter/Edit)
[SROA LAB-CARDIAC]
The Laboratory Test Results (Edit/Edit) option is used to enter or edit preoperative laboratory test results
for an individual cardiac risk assessment. The option is divided into the two features listed below. The
first feature allows the user to merge (also called “capture” or “load”) lab information into the risk
assessment from the VistA software. The second feature provides a two-page summary of the lab profile
and allows direct editing of the information.
1. Capture Laboratory Information
2. Enter, Edit, or Review Laboratory Test Results
To “capture” preoperative lab data, the user must provide both the date and time the operation began. If
this information has already been entered, the system will not prompt for it again.
If assistance is needed while interacting with the software, entering one or two question marks (??) allows
the user to access the on-line help.
About the "Select Laboratory Information to Edit:" Prompt
At this prompt the user enters the item number to edit. Entering A for ALL allows the user to respond to
every item on the page, or a range of numbers separated by a colon (:) can be entered to respond to a
range of items.
After the information has been entered or edited, the terminal display screen will clear and present a
summary. The summary organizes the information entered and provides another chance to enter or edit
data.
Example: Enter Laboratory Test Results
Select Cardiac Risk Assessment Information (Enter/Edit) Option: LAB
Test Results (Enter/Edit)
Laboratory
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------Enter/Edit Laboratory Test Results
1. Capture Laboratory Information
2. Enter, Edit, or Review Laboratory Test Results
Select Number: 1
This selection loads the most recent cardiac lab data for tests performed
preoperatively.
Do you want to automatically load cardiac lab data ?
YES// <Enter>
..Searching lab record for latest test data....
Press <RET> to continue
August 2004
<Enter>
Surgery V. 3.0 User Manual
468a
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------Enter/Edit Laboratory Test Results
1. Capture Laboratory Information
2. Enter, Edit, or Review Laboratory Test Results
Select Number: 2
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
PREOPERATIVE LABORATORY RESULTS
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
HDL:
LDL:
Total Cholesterol:
Serum Triglyceride:
Serum Potassium:
Serum Bilirubin:
Serum Creatinine:
Serum Albumin:
Hemoglobin:
Hemoglobin A1c:
BNP:
NS
168
321
>70
NS
NS
NS
NS
NS
NS
NS
(JAN 2004)
(JAN 2004)
(JAN 2004)
-------------------------------------------------------------------------------Select Laboratory Information to Edit: 1
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
PREOPERATIVE LABORATORY RESULTS
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------HDL (mg/dl): NS// 177
HDL, Date: JAN, 2005 (JAN 2005)
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
PREOPERATIVE LABORATORY RESULTS
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
HDL:
LDL:
Total Cholesterol:
Serum Triglyceride:
Serum Potassium:
Serum Bilirubin:
Serum Creatinine:
Serum Albumin:
Hemoglobin:
Hemoglobin A1c:
BNP:
177
168
321
>70
NS
NS
NS
NS
NS
NS
NS
(JAN
(JAN
(JAN
(JAN
2005)
2004)
2004)
2004)
-------------------------------------------------------------------------------Select Laboratory Information to Edit:
468b
Surgery V. 3.0 User Manual
August 2004
Enter Cardiac Catheterization & Angiographic Data
[SROA CATHETERIZATION]
The Enter Cardiac Catheterization & Angiographic Data option is used to enter or edit cardiac
catheterization and angiographic information for a cardiac risk assessment. The software will present one
page. At the bottom of the page is a prompt to select one or more items to edit. If the user does not want
to edit any items on the page, pressing the <Enter> key will advance the user to another option.
About the "Select Cardiac Catheterization and Angiographic Information to Edit:" Prompt
At this prompt the user enters the item number to edit. Entering A for ALL allows the user to respond to
every item on the page, or a range of numbers separated by a colon (:) can be entered to respond to a
range of items.
After the information has been entered or edited, the screen will clear and present a summary. The
summary organizes the information entered and provides another chance to enter or edit data.
Example: Enter Cardiac Catheterization & Angiographic Data
Select Cardiac Risk Assessment Information (Enter/Edit) Option: CATH
Catheterization & Angiographic Data
Enter Cardiac
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 OF 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1. Procedure:
2. LVEDP:
3. Aortic Systolic Pressure:
For patients having right heart cath
4. PA Systolic Pressure:
5. PAW Mean Pressure:
6. LV Contraction Grade (from contrast
or radionuclide angiogram or 2D echo):
7. Mitral Regurgitation:
8. Aortic Stenosis:
-------------------------------------------------------------------------------Select Cardiac Catheterization and Angiographic Information to Edit: A
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 OF 2
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Procedure Type: NS NO STUDY/UNKNOWN
Do you want to automatically enter 'NS' for NO STUDY for all other fields within
this option ? YES// <Enter>
April 2004
Surgery V. 3.0 User Manual
469
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 OF 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1. Procedure:
2. LVEDP:
3. Aortic Systolic Pressure:
NS
NS
NS
For patients having right heart cath
4. PA Systolic Pressure:
NS
5. PAW Mean Pressure:
NS
6. LV Contraction Grade (from contrast
or radionuclide angiogram or 2D echo): NO LV STUDY
7. Mitral Regurgitation:
8. Aortic Stenosis:
NS
NS
-------------------------------------------------------------------------------Select Cardiac Catheterization and Angiographic Information to Edit: A
Procedure Type: NO STUDY/UNKNOWN// CATH CATH
You have changed the answer from "NS".
Do you want to clear 'NS' from all other fields within this option ? NO// N
NO
Left Ventricular End-Diastolic Pressure: NS// 56
Aortic Systolic Pressure: NS// 120
PA Systolic Pressure: NS//30
PAW Mean Pressure: NS//15
LV Contraction Grade: NS//?
Enter the grade that best describes left ventricular function.
Screen prevents selection of code III.
Choose from:
I
> EQUAL 0.55 NORMAL
II
0.45-0.54 MILD DYSFUNC.
IIIa
0.40-0.44 MOD. DYSFUNC. A
IIIb
0.35-0.39 MOD. DYSFUNC. B
IV
0.25-0.34 SEVERE DYSFUNC.
V
<0.25 VERY SEVERE DYSFUNC.
NS
NO STUDY
LV Contraction Grade: NO STUDY//IIIa 0.40-0.44 MOD. DYSFUNC. A
Mitral Regurgitation: NO STUDY//?
Enter the code describing presence/severity of mitral regurgitation.
Choose from:
0
NONE
1
MILD
2
MODERATE
3
SEVERE
NS
NO STUDY
Mitral Regurgitation: NO STUDY//2 MODERATE
Aortic Stenosis: NO STUDY//1 MILD
470
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 OF 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------1. Procedure:
Cath
2. LVEDP:
56 mm Hg
3. Aortic Systolic Pressure: 120 mm Hg
For patients having right heart cath
4. PA Systolic Pressure:
30 mm Hg
5. PAW Mean Pressure:
15 mm Hg
6. LV Contraction Grade (from contrast
or radionuclide angiogram or 2D echo): IIIa 0.40-0.44 MODERATE DYSFUNCTION A
7. Mitral Regurgitation:
8. Aortic Stenosis:
MODERATE
MILD
-------------------------------------------------------------------------------Select Cardiac Catheterization and Angiographic Information to Edit: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 2 of 2
JUN 18,2005
CORONARY ARTERY BYPASS
------------------------------------------------------------------------------------ Native Coronaries ----1. Left main stenosis:
2. LAD Stenosis:
3. Right coronary stenosis:
4. Circumflex Stenosis:
If
5.
6.
7.
NS
NS
NS
NS
a Re-do, indicate stenosis in graft to:
LAD:
NS
Right coronary:
NS
Circumflex:
NS
-------------------------------------------------------------------------------Select Cardiac
Right Coronary
Enter the
Right Coronary
Catheterization and Angiographic Information to Edit: 3
Artery Stenosis: NS// ?
percent (0-100) stenosis.
Artery Stenosis: NS// 30
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 2 of 2
JUN 18,2005
CORONARY ARTERY BYPASS
------------------------------------------------------------------------------------ Native Coronaries ----1. Left main stenosis:
2. LAD Stenosis:
3. Right coronary stenosis:
4. Circumflex Stenosis:
If
5.
6.
7.
NS
NS
30
NS
a Re-do, indicate stenosis in graft to:
LAD:
NS
Right coronary:
NS
Circumflex:
NS
-------------------------------------------------------------------------------Select Cardiac Catheterization and Angiographic Information to Edit:
August 2004
Surgery V. 3.0 User Manual
470a
(This page included for two-sided copying.)
470b
Surgery V. 3.0 User Manual
August 2004
Operative Risk Summary Data (Enter/Edit)
[SROA CARDIAC OPERATIVE RISK]
The Operative Risk Summary Data (Enter/Edit) option is used to enter or edit operative risk summary
data for the cardiac surgery risk assessments. This option records the physician‟s subjective estimate of
operative mortality. To avoid bias, this should be completed preoperatively. The software will present one
page. At the bottom of the page is a prompt to select one or more items to edit. If the user does not want
to edit any of the items, the <Enter> key can be pressed to proceed to another option.
About the "Select Operative Risk Summary Information to Edit:" prompt
At this prompt the user enters the item number to edit. Entering A for ALL allows the user to respond to
every item on the page, or a range of numbers separated by a colon (:) can be entered to respond to a
range of items.
Example: Operative Risk Summary Data
Select Cardiac Risk Assessment Information (Enter/Edit) Option: OP
(Enter/Edit)
Operative Risk Summary Data
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
>> Coding Complete <<
-----------------------------------------------------------------------------1. Physician's Preoperative Estimate of Operative Mortality: 78%
A. Date/Time Collected: JUN 17,[email protected]:15
2. ASA Classification:
1-NO DISTURB.
3. Surgical Priority:
4. Preoperative Risk Factors: NONE
5. CPT Codes (view only):
6. Wound Classification:
33510
CLEAN
This information
cannot be edited.
-----------------------------------------------------------------------------Select Operative Risk Summary Information to Edit: 1:3
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Physician's Preoperative Estimate of Operative Mortality: 78
// 32
Date/Time of Estimate of Operative Mortality: JUN 17, [email protected]:15
// <Enter>
ASA Class: 1-NO DISTURB.// 3 3
3-SEVERE DISTURB.
Cardiac Surgical Priority: ?
Enter the surgical priority that most accurately reflects the acuity of
patient's cardiovascular condition at the time of transport to the
operating room.
Choose from:
1
ELECTIVE
2
URGENT
3
EMERGENT (ONGOING ISCHEMIA)
4
EMERGENT (HEMODYNAMIC COMPROMISE)
5
EMERGENT (ARREST WITH CPR)
Cardiac Surgical Priority: 3 EMERGENT (ONGOING ISCHEMIA)
Date/Time of Cardiac Surgical Priority: JUN 18,[email protected]:29 (JUN 18, [email protected]:29)
April 2004
Surgery V. 3.0 User Manual
471
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1
JUN 18,2005
CORONARY ARTERY BYPASS
>> Coding Complete <<
-----------------------------------------------------------------------------1. Physician's Preoperative Estimate of Operative Mortality: 32%
A. Date/Time Collected:
JUN 18,2005 18:15
2. ASA Classification:
3-SEVERE DISTURB.
3. Surgical Priority:
EMERGENT (ONGOING ISCHEMIA)
A. Date/Time Collected:
JUN 18,2005 13:29
4. Preoperative Risk Factors: NONE
5. CPT Codes (view only):
6. Wound Classification:
33510
CLEAN
*** NOTE: D/Time of Surgical Priority should be < the D/Time Patient in OR.***
-----------------------------------------------------------------------------Select Operative Risk Summary Information to Edit:
The Surgery software performs data checks on the following fields:
The Date/Time Collected field for Physician's Preoperative Estimate of Operative Mortality
should be earlier than the Time Pat In OR field. This field is no longer auto-populated.
The Date/Time Collected field for Surgical Priority should be earlier than the Time Pat In OR
field. This field is no longer auto-populated.
If the date entered does not conform to the specifications, then the Surgery software displays a
warning at the bottom of the screen.
472
Surgery V. 3.0 User Manual
April 2004
Cardiac Procedures Operative Data (Enter/Edit)
[SROA CARDIAC PROCEDURES]
The Cardiac Procedures Operative Data (Enter/Edit) option is used to enter or edit information related to
cardiac procedures requiring cardiopulmonary bypass (CPB). The software will present two pages. At the
bottom of the page is a prompt to select one or more items to edit. If the user does not want to edit any
items on the page, pressing the <Enter> key will advance the user to another option.
About the "Select Operative Information to Edit:" prompt
At this prompt, the user enters the item number to edit. Entering A for ALL allows the user to respond to
every item on the page, or a range of numbers separated by a colon (:) can be entered to respond to a
range of items. You can also use number-letter combinations, such as 11B, to update a field within a
group, such as VSD Repair.
Each prompt at the category level allows for an entry of YES or NO. If NO is entered, each item under
that category will automatically be answered NO. On the other hand, responding YES at the category
level allows the user to respond individually to each item under the main category.
Entry of N shall allow the user to Set All to No for the Cardiac Procedures fields. A verification prompt
will follow to ensure that user understands the entry.
Fields that do not have YES/NO responses will be updated as follows.
Items #1-#5 are numeric and their values will be set to 0.
Valve Procedures will be set to NONE
#13 Maze Procedure will be set to NO MAZE PERFORMED
After the information has been entered or edited, the terminal display screen will clear and present a
summary. The summary organizes the information entered and provides another chance to enter or edit
data.
Example: Enter Cardiac Procedures Operative Data
Select Cardiac Risk Assessment Information (Enter/Edit) Option: CARD
ocedures Operative Data (Enter/Edit)
Cardiac Pr
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 OF 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------Cardiac surgical procedures with or without cardiopulmonary bypass
CABG distal anastomoses:
13. Maze procedure:
1. Number with vein:
14. ASD repair:
2. Number with IMA:
15. VSD repair:
3. Number with Radial Artery:
16. Myectomy:
4. Number with Other Artery:
17. Myxoma resection:
5. Number with Other Conduit:
18. Other tumor resection:
19. Cardiac transplant:
6. LV Aneurysmectomy:
20. Great Vessel Repair:
7. Bridge to transplant/Device:
21. Endovascular Repair:
8. TMR:
22. Other cardiac procedures:
9. Aortic Valve Procedure:
10. Mitral Valve Procedure:
11. Tricuspid Valve Procedure:
12. Pulmonary Valve Procedure:
-------------------------------------------------------------------------------Select Cardiac Procedures Operative Information to Edit: A
April 2004
Surgery V. 3.0 User Manual
473
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------CABG Distal Anastomoses with Vein: 1
CABG Distal Anastomoses with IMA: 1
Number with Radial Artery: 0
Number with Other Artery: 1
CABG Distal Anastomoses with Other Conduit: 1
LV Aneurysmectomy (Y/N): N NO
Device for bridge to cardiac transplant / Destination therapy: ??
Definition Revised (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.
Choose from:
N
NONE
B
BRIDGE TO
TRANSPLANT
D
DESTINATION THERAPY
Device for bridge to cardiac transplant / Destination therapy: N NONE
Transmyocardial Laser Revascularization: N NO
Aortic Valve Procedure: ??
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
Choose from:
N
NONE
M
MECHANICAL
S
STENTED BIOPROSTHETIC
B
STENTLESS BIOPROSTHETIC
H
HOMOGRAFT
PR
PRIMARY REPAIR
PA
PRIMARY REPAIR & ANNULOPLASTY DEVICE
AN
ANNULOPLASTY DEVICE ALONE
AU
AUTOGRAFT (ROSS)
O
OTHER
Aortic Valve Procedure: PR PRIMARY REPAIR
Mitral Valve Procedure: N NONE
Tricuspid Valve Procedure: N NONE
Pulmonary Valve Procedure: N NONE
Maze Procedure: N NO MAZE PERFORMED
ASD Repair (Y/N): N NO
VSD Repair (Y/N): N NO
Myectomy (Y/N): N NO
Myxoma Resection (Y/N): N NO
Other Tumor Resection (Y/N): N NO
Cardiac Transplant (Y/N): N NO
Great Vessel Repair (Y/N): N NO
Endovascular Repair of Aorta: N NO
474
Surgery V. 3.0 User Manual
April 2004
Other Cardiac Procedures (Y/N): N
NO
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 1 of 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------Cardiac surgical procedures with or without cardiopulmonary bypass
CABG distal anastomoses:
13. Maze procedure: NO MAZE PERFORMED
1. Number with vein:
1
14. ASD repair:
NO
2. Number with IMA:
1
15. VSD repair:
NO
3. Number with Radial Artery:
0
16. Myectomy:
NO
4. Number with Other Artery:
1
17. Myxoma resection:
NO
5. Number with Other Conduit:
1
18. Other tumor resection:
NO
19. Cardiac transplant:
NO
6. LV Aneurysmectomy:
NO
20. Great Vessel Repair:
NO
7. Bridge to transplant/Device: NONE
21. Endovascular Repair:
NO
8. TMR:
NO
22. Other cardiac procedures: NO
9. Aortic Valve Procedure:
PRIMARY REPAIR
10. Mitral Valve Procedure:
NONE
11. Tricuspid Valve Procedure:
NONE
12. Pulmonary Valve Procedure:
NONE
-------------------------------------------------------------------------------Select Operative Information to Edit: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
PAGE: 2 of 2
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------------------Indicate other cardiac procedures only if done with cardiopulmonary bypass
-------------------------------------------------------------------------------1. Foreign Body Removal:
2. Pericardiectomy:
Other Operative Data details:
-----------------------------3. Total CPB Time:
4. Total Ischemic Time:
5. Incision Type:
6. Convert Off Pump to CPB: N/A (began on-pump/ stayed on-pump)
-------------------------------------------------------------------------------Select Operative Information to Edit:
April 2004
Surgery V. 3.0 User Manual
474a
Outcome Information (Enter/Edit)
[SROA CARDIAC-OUTCOMES]
This option is used to enter or edit outcome information for cardiac procedures.
Example: Enter Outcome Information
Select Cardiac Risk Assessment Information (Enter/Edit) Option: OUT
ormation (Enter/Edit)
Outcome Inf
SURPATIENT,TWENTY (000-45-4886)
Case #238
PAGE: 1
OUTCOMES INFORMATION
FEB 10,2004
CABG
-------------------------------------------------------------------------------0. Operative Death:
NO
Perioperative (30 day) Occurrences:
----------------------------------1. Perioperative MI:
NO
2. Endocarditis:
NO
3. Superficial Incisional SSI:
NO
4. Mediastinitis:
YES
5. Cardiac arrest requiring CPR:
YES
6. Reoperation for bleeding:
NO
7. On ventilator >= 48 hr:
NO
8. Repeat cardiac surg procedure: NO
9.
10.
11.
12.
13.
14.
15.
16.
Tracheostomy:
Repeat ventilator w/in 30 days:
Stroke/CVA:
Coma >= 24 hr:
New Mech Circ Support:
Postop Atrial Fibrillation:
Wound Disruption:
Renal failure require dialysis:
YES
YES
NO
NO
YES
NO
YES
NO
-------------------------------------------------------------------------------Select Outcomes Information to Edit: 8
Repeat Cardiac Surgical Procedure (Y/N): NO// Y
Cardiopulmonary Bypass Status: ?
YES
Enter NONE, ON BYPASS, or OFF BYPASS.
0
None
1
On-bypass
2
Off-bypass
Cardiopulmonary Bypass Status: 1
On-bypass
SURPATIENT,TWENTY (000-45-4886)
Case #238
PAGE: 1
OUTCOMES INFORMATION
FEB 10,2004
CABG
-------------------------------------------------------------------------------0. Operative Death:
NO
Perioperative (30 day) Occurrences:
----------------------------------1. Perioperative MI:
NO
2. Endocarditis:
NO
3. Superficial Incisional SSI:
NO
4. Mediastinitis:
YES
5. Cardiac arrest requiring CPR:
YES
6. Reoperation for bleeding:
NO
7. On ventilator >= 48 hr:
NO
8. Repeat cardiac surg procedure: YES
9.
10.
11.
12.
13.
14.
15.
16.
Tracheostomy:
Repeat ventilator w/in 30 days:
Stroke/CVA:
Coma >= 24 hr:
New Mech Circ Support:
Postop Atrial Fibrillation:
Wound Disruption:
Renal failure require dialysis:
YES
YES
NO
NO
YES
NO
YES
NO
-------------------------------------------------------------------------------Select Outcomes Information to Edit:
474b
Surgery V. 3.0 User Manual
April 2004
Intraoperative Occurrences (Enter/Edit)
[SRO INTRAOP COMP]
The nurse reviewer uses the Intraoperative Occurrences (Enter/Edit) option to enter or change
information related to intraoperative occurrences. Every occurrence entered must have a corresponding
occurrence category. For a list of occurrence categories, the user can enter a question mark (?) at the
"Enter a New Intraoperative Occurrence:" prompt.
After an occurrence category has been entered or edited, the screen will clear and present a summary. The
summary organizes the information entered and provides another opportunity to enter or edit data.
Example: Enter an Intraoperative Occurrence
Select Cardiac Risk Assessment Information (Enter/Edit) Option: IO
(Enter/Edit)
Intraoperative Occurrences
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------There are no Intraoperative Occurrences entered for this case.
Enter a New Intraoperative Occurrence: CARDIAC ARREST REQUIRING CPR
Definition Revised (2011): 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.
Patients with AICDs that fire but the patient does not lose
consciousness should be excluded.
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
Press RETURN to continue: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
CARDIAC ARREST REQUIRING CPR
Occurrence Category: CARDIAC ARREST REQUIRING CPR
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
-----------------------------------------------------------------------------Select Occurrence Information: 2:5
April 2004
Surgery V. 3.0 User Manual
475
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Occurrence Category: CARDIAC ARREST REQUIRING CPR
// <Enter>
ICD Diagnosis Code: 102.8 102.8
LATENT YAWS
...OK? YES// <Enter>
(YES)
Type of Treatment Instituted: CPR
Outcome to Date: I IMPROVED
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
102.8
CPR
IMPROVED
-----------------------------------------------------------------------------Select Occurrence Information: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Enter/Edit Intraoperative Occurrences
1.
CARDIAC ARREST REQUIRING CPR
Category: CARDIAC ARREST REQUIRING CPR
Select a number (1), or type 'NEW' to enter another occurrence:
476
Surgery V. 3.0 User Manual
April 2004
Postoperative Occurrences (Enter/Edit)
[SRO POSTOP COMP]
The nurse reviewer uses the Postoperative Occurrences (Enter/Edit) option to enter or change
information related to postoperative occurrences. Every occurrence entered must have a corresponding
occurrence category. For a list of occurrence categories, the user can enter a question mark (?) at the
"Enter a New Postoperative Occurrence:" prompt.
After an occurrence category has been entered or edited, the screen will clear and present a summary. The
summary organizes the information entered and provides another opportunity to enter or edit data.
Example: Enter a Postoperative Occurrence
Select Cardiac Risk Assessment Information (Enter/Edit) Option: PO
(Enter/Edit)
Postoperative Occurrences
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------There are no Postoperative Occurrences entered for this case.
Enter a New Postoperative Occurrence: CARDIAC ARREST REQUIRING CPR
Definition Revised (2011): 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.
Patients with AICDs that fire but the patient does not lose
consciousness should be excluded.
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
Press RETURN to continue: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
-----------------------------------------------------------------------------Select Occurrence Information: 4:6
April 2004
Surgery V. 3.0 User Manual
477
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Treatment Instituted: CPR
Outcome to Date: I IMPROVED
Date/Time the Occurrence was Noted: 6/19/05
(JUN 19, 2005)
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
Occurrence:
Occurrence Category:
ICD Diagnosis Code:
Treatment Instituted:
Outcome to Date:
Date Noted:
Occurrence Comments:
CARDIAC ARREST REQUIRING CPR
CARDIAC ARREST REQUIRING CPR
CPR
IMPROVED
06/19/05
-----------------------------------------------------------------------------Select Occurrence Information: <Enter>
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-----------------------------------------------------------------------------Enter/Edit Intraoperative Occurrences
1.
CARDIAC ARREST REQUIRING CPR
Category: CARDIAC ARREST REQUIRING CPR
Select a number (1), or type 'NEW' to enter another occurrence:
478
Surgery V. 3.0 User Manual
April 2004
Resource Data (Enter/Edit)
[SROA CARDIAC RESOURCE]
The nurse reviewer uses the Resource Data (Enter/Edit) option to enter, edit, or review risk assessment
and cardiac patient demographic information such as hospital admission, discharge dates, and other
information related to the surgical episode.
Example: Resource Data (Enter/Edit)
Select Cardiac Risk Assessment Information (Enter/Edit) Option: R
Resource Data
SURPATIENT,TEN (000-12-3456)
Case #49413
OCT 18,2007
CABG X3 USING LSVG TO OMB,LV EXT. OF RCA,LIMA TO LAD
-------------------------------------------------------------------------------Enter/Edit Patient Resource Data
1. Capture Information from PIMS Records
2. Enter, Edit, or Review Information
Select Number:
(1-2): 1
Are you sure you want to retrieve information from PIMS records ? YES// <Enter>
...HMMM, I'M WORKING AS FAST AS I CAN...
SURPATIENT,TEN (000-12-3456)
Case #49413
OCT 18,2007
CABG X3 USING LSVG TO OMB,LV EXT. OF RCA,LIMA TO LAD
-------------------------------------------------------------------------------Enter/Edit Patient Resource Data
1. Capture Information from PIMS Records
2. Enter, Edit, or Review Information
Select Number:
(1-2): 2
SURPATIENT,TEN (000-12-3456)
Case #49413
OCT 18,2007
CABG X3 USING LSVG TO OMB,LV EXT. OF RCA,LIMA TO LAD
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Hospital Admission Date:
Hospital Discharge Date:
Cardiac Catheterization Date:
Time Patient In OR:
Date/Time Operation Began:
Date/Time Operation Ended:
Time Patient Out OR:
Date/Time Patient Extubated:
Date/Time Discharged from ICU:
Homeless:
Surg Performed at Non-VA Facility:
Resource Data Comments:
Employment Status Preoperatively:
FEB 11, [email protected]:39
FEB 16, [email protected]:44
FEB
FEB
FEB
FEB
12,
12,
12,
12,
[email protected]:30
[email protected]:40
[email protected]:30
[email protected]:40
FEB 16, [email protected]:44
NO
NO
EMPLOYED PART TIME
Select Resource Information to Edit:
April 2004
Surgery V. 3.0 User Manual
479
Employment Status Preoperatively: EMPLOYED FULL TIME// ?
Enter the patient's employment status preoperatively.
Choose from:
1
EMPLOYED FULL TIME
2
EMPLOYED PART TIME
3
NOT EMPLOYED
4
SELF EMPLOYED
5
RETIRED
6
ACTIVE MILITARY DUTY
9
UNKNOWN
Employment Status Preoperatively: 3 NOT EMPLOYED
SURPATIENT,TEN (000-12-3456)
Case #49413
OCT 18,2007
CABG X3 USING LSVG TO OMB,LV EXT. OF RCA,LIMA TO LAD
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Hospital Admission Date:
Hospital Discharge Date:
Cardiac Catheterization Date:
Time Patient In OR:
Date/Time Operation Began:
Date/Time Operation Ended:
Time Patient Out OR:
Date/Time Patient Extubated:
Date/Time Discharged from ICU:
Homeless:
Surg Performed at Non-VA Facility:
Resource Data Comments:
Employment Status Preoperatively:
FEB 11, [email protected]:39
FEB 16, [email protected]:44
FEB
FEB
FEB
FEB
12,
12,
12,
12,
[email protected]:30
[email protected]:40
[email protected]:30
[email protected]:40
FEB 16, [email protected]:44
NO
NO
NOT EMPLOYED
-------------------------------------------------------------------------------Select Resource Information to Edit:
The Surgery software performs data checks on the following fields:
The Date/Time Patient Extubated field should be later than the Time Patient Out OR field, and
earlier than the Date/Time Discharged from ICU field.
The Date/Time Discharged from ICU field should be later than the Date/Time Patient Extubated
field, and equal to or earlier than the Hospital Discharge Date field.
If the date entered does not conform to the specifications, then the Surgery software displays a
warning at the bottom of the screen.
479a
Surgery V. 3.0 User Manual
April 2004
(This page included for two-sided copying.)
April 2004
Surgery V. 3.0 User Manual
479b
Update Assessment Status to ‘COMPLETE’
[SROA COMPLETE ASSESSMENT]
The Update Assessment Status to „COMPLETE‟ option is used to upgrade the status of an assessment to
“Complete.” A complete assessment has enough information for it to be transmitted to the centers where
data are analyzed. Only complete assessments are transmitted. This option also notifies the user if
procedure (CPT) and diagnosis (ICD-9) coding has not been completed.
After updating the status, the user can print the patient‟s entire Surgery Risk Assessment Report. This
report can be copied to a screen or to a printer.
Example: Update Assessment Status to COMPLETE
Select Cardiac Risk Assessment Information (Enter/Edit) Option: U
ment Status to 'COMPLETE'
Update Assess
This assessment is missing the following items:
1. Foreign Body Removal (Y/N)
Do you want to enter the missing items at this time? NO// YES
FOREIGN BODY REMOVAL (Y/N): N NO
Are you sure you want to complete this assessment ? NO// YES
Updating the current status to 'COMPLETE'...
Do you want to print the completed assessment ?
480
YES//
NO
Surgery V. 3.0 User Manual
April 2004
Alert Coder Regarding Coding Issues
[SROA CODE ISSUE]
This option allows the nurse reviewer to send an alert to the coder when there may be an issue with the
CPT codes or the Postoperative Diagnosis codes for a Surgery case. When this option is selected, the
nurse reviewer can enter a free-text message that will be sent to the coder on record, as well as to a predefined mail group identified in the Surgery Site Parameter titled CODE ISSUE MAIL GROUP. The
message will not be sent if there is no coder, or if the mail group is not defined.
Example : Alert Coder Regarding Coding Issues
Select Cardiac Risk Assessment Information (Enter/Edit) Option: CODE
Regarding Coding Issues
Select Patient: SURPATIENT,NINETEEN
SC VETERAN
SURPATIENT,NINETEEN
000287354
Alert Coder
YES
000-28-7354
1. 05-10-05
CHOLECYSTECOMY (COMPLETED)
2. 06-18-05
* CORONARY ARTERY BYPASS (COMPLETED)
Select Operation: 2
SURPATIENT,NINETEEN (000-28-7354)
Case #60183
JUN 18,2005
CORONARY ARTERY BYPASS
-------------------------------------------------------------------The following "final" codes have been entered for the case.
Principal CPT Code: 33510
Other CPT Codes:
NOT ENTERED
Postop Diagnosis Code (ICD9): 402.10
HYP HEART DIS BENING W/0 FAIL
If you believe that the information coded is not correct and would like to
alert the coders of the potential issue, enter a brief description of your
concern below.
Do you want to alert the coders (Y/N)? YES// <Enter>
==[ WRAP ]==[ INSERT ]=====< Coding Discrepancy Comments >===[ <PF1>H=Help ]====
I have reviewed this case for VASQIP. The final Principal CPT Code entered
is 33510. I would like to talk to you regarding the code. I think the code
should be 33502. Please call me at X2545.
<=======T=======T=======T=======T=======T=======T=======T=======T=======T>======
1. Transmit Message
2. Edit Text
Select Number:
April 2004
1//
<Enter>
Surgery V. 3.0 User Manual
480a
(This page included for two-sided copying.)
480b
Surgery V. 3.0 User Manual
April 2004
Print a Surgery Risk Assessment
[SROA PRINT ASSESSMENT]
The Print a Surgery Risk Assessment option prints an entire Surgery Risk Assessment Report for an
individual patient. This report can be displayed temporarily on a screen. As the report fills the screen, the
user will be prompted to press the <Enter> key to go to the next page. A permanent record can be made
by copying the report to a printer. When using a printer, the report is formatted slightly differently from
the way it displays on the terminal.
Example 1: Print Surgery Risk Assessment for a Non-Cardiac Case
Select Surgery Risk Assessment Menu Option: P
Print a Surgery Risk Assessment
Do you want to batch print assessments for a specific date range ? NO//
Select Patient: SURPATIENT,FORTY
ERAN
SURPATIENT,FORTY
05-07-23
000777777
NO
<Enter>
NSC VET
000-77-7777
1. 02-10-04
* CABG (INCOMPLETE)
2. 01-09-06
APPENDECTOMY (COMPLETED)
Select Surgical Case: 2
Print the Completed Assessment on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
481
VA NON-CARDIAC RISK ASSESSMENT
Assessment: 236
PAGE 1
FOR SURPATIENT,FORTY 000-77-7777 (COMPLETED)
================================================================================
Medical Center: ALBANY
Age:
81
Sex:
MALE
Operation Date:
JAN 09, 2006
Ethnicity: NOT HISPANIC OR LATINO
Race:
AMERICAN INDIAN OR ALASKA
NATIVE, NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER, WHITE
Transfer Status: NOT TRANSFERRED
Observation Admission Date:
NA
Observation Discharge Date:
NA
Observation Treating Specialty:
NA
Hospital Admission Date:
JAN 7,2006
11:15
Hospital Discharge Date:
JAN 12,2006 10:30
Admitted/Transferred to Surgical Service:
JAN 7,2006
11:15
In/Out-Patient Status:
INPATIENT
Assessment Completed by:
SURNURSE,SEVEN
---------------------------------------------------------------------------------PREOPERATIVE INFORMATION
GENERAL:
NO
Height:
70 INCHES
Weight:
180 LBS.
Diabetes - Long Term:
NO
Diabetes - 2 Wks Preop:
NO
Tobacco Use:
NEVER USED TOBACCO
Tobacco Use Timeframe: NOT APPLICABLE
ETOH > 2 Drinks/Day:
NO
Positive Drug Screening:
NO
Dyspnea:
NO
Preop Sleep Apnea:
LEVEL 1
DNR Status:
NO
Preop Funct Status:
INDEPENDENT
PULMONARY:
Ventilator Dependent:
History of Severe COPD:
Current Pneumonia:
NO
NO
NO
NO
RENAL:
Acute Renal Failure:
Currently on Dialysis:
YES
NO
NO
CENTRAL NERVOUS SYSTEM:
YES
Impaired Sensorium:
NO
Coma:
NO
Hemiplegia:
NO
History of TIAs:
NO
CVD Repair/Obstruct:
YES/NO SURG
History of CVD:
HIST OF TIA'S
Tumor Involving CNS:
NO
HEPATOBILIARY:
Ascites:
NO
NO
GASTROINTESTINAL:
Esophageal Varices:
NO
NO
CARDIAC:
CHF Within 1 Month:
MI Within 6 Months:
Previous PCI:
Previous Cardiac Surgery:
Angina Within 1 Month:
Hypertension Requiring Meds:
NO
NO
NO
NO
NO
NO
NO
VASCULAR:
Revascularization/Amputation:
Rest Pain/Gangrene:
NO
NO
NO
NUTRITIONAL/IMMUNE/OTHER:
YES
Disseminated Cancer:
NO
Open Wound:
NO
Steroid Use for Chronic Cond.: NO
Weight Loss > 10%:
NO
Bleeding Disorders:
NO
Transfusion > 4 RBC Units:
NO
Chemotherapy W/I 30 Days:
NO
Radiotherapy W/I 90 Days:
NO
Radiotherapy W/I 90 Days:
NO
Preoperative Sepsis:
NONE
Pregnancy:
NOT APPLICABLE
OPERATION DATE/TIMES INFORMATION
Patient in Room (PIR):
Procedure/Surgery Start Time (PST):
Procedure/Surgery Finish (PF):
Patient Out of Room (POR):
Anesthesia Start (AS):
Anesthesia Finish (AF):
Discharge from PACU (DPACU):
482
JAN
JAN
JAN
JAN
JAN
JAN
JAN
9,2006
9,2006
9,2006
9,2006
9,2006
9,2006
9,2006
07:25
07:25
08:00
08:10
07:15
08:08
09:15
Surgery V. 3.0 User Manual
April 2004
VA NON-CARDIAC RISK ASSESSMENT
Assessment: 236
PAGE 2
FOR SURPATIENT,FORTY 000-77-7777 (COMPLETED)
================================================================================
OPERATIVE INFORMATION
Surgical Specialty: GENERAL(OR WHEN NOT DEFINED BELOW)
Principal Operation: APPENDECTOMY
Procedure CPT Codes: 44950
Concurrent Procedure:
CPT Code:
PGY of Primary Surgeon:
Emergency Case (Y/N):
Wound Classification:
ASA Classification:
Principal Anesthesia Technique:
RBC Units Transfused:
Intraop Disseminated Cancer:
Intraoperative Ascites:
0
NO
CONTAMINATED
3-SEVERE DISTURB.
GENERAL
0
NO
NO
PREOPERATIVE LABORATORY TEST RESULTS
Anion Gap:
Serum Sodium:
Serum Creatinine:
BUN:
Serum Albumin:
Total Bilirubin:
SGOT:
Alkaline Phosphatase:
White Blood Count:
Hematocrit:
Platelet Count:
PTT:
PT:
INR:
Hemoglobin A1c:
12
144.6
.9
18
3.5
.9
46
34
15.9
43.4
356
25.9
12.1
1.54
NS
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
(JAN
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
7,2006)
POSTOPERATIVE LABORATORY RESULTS
* Highest Value
** Lowest Value
* Anion Gap: 11
* Serum Sodium: 148
** Serum Sodium: 144.2
* Potassium: 4.5
** Potassium: 4.5
* Serum Creatinine: 1.4
* CPK: 88
* CPK-MB Band: <1
* Total Bilirubin: 1.3
* White Blood Count: 12.2
** Hematocrit: 42.9
* Troponin I: 1.42
* Troponin T: NS
April 2004
(JAN 7,2006)
(JAN 12,2006)
(FEB 2,2006)
(JAN 12,2006)
(JAN 12,2006)
(FEB 2,2006)
(JAN 12,2006)
(JAN 12,2006)
(JAN 12,2006)
(JAN 12,2006)
(JAN 12,2006)
(JAN 12,2006)
Surgery V. 3.0 User Manual
483
VA NON-CARDIAC RISK ASSESSMENT
Assessment: 236
PAGE 3
FOR SURPATIENT,FORTY 000-77-7777 (COMPLETED)
================================================================================
OUTCOME INFORMATION
Postoperative Diagnosis Code (ICD9): 540.1 ABSCESS OF APPENDIX
Length of Postoperative Hospital Stay: 3 DAYS
Date of Death:
Return to OR Within 30 Days: NO
PERIOPERATIVE OCCURRENCE INFORMATION
WOUND OCCURRENCES:
Superficial Incisional SSI:
Deep Incisional SSI:
Wound Disruption:
* 427.31 ATRIAL FIBRILLATI
YES
NO
NO
01/10/06
01/10/06
CNS OCCURRENCES:
Stroke/CVA:
Coma > 24 Hours:
Peripheral Nerve Injury:
YES
NO
NO
01/10/06
URINARY TRACT OCCURRENCES:
Renal Insufficiency:
Acute Renal Failure:
Urinary Tract Infection:
YES
NO
NO
01/11/06
CARDIAC OCCURRENCES:
Arrest Requiring CPR:
Myocardial Infarction:
YES
NO
01/09/06
RESPIRATORY OCCURRENCES:
Pneumonia:
Unplanned Intubation:
Pulmonary Embolism:
On Ventilator > 48 Hours:
* 477.0 RHINITIS DUE TO P
YES
NO
NO
NO
NO
01/12/06
OTHER OCCURRENCES:
YES
Bleeding/Transfusions:
NO
Graft/Prosthesis/Flap Failure:
NO
DVT/Thrombophlebitis:
NO
Systemic Sepsis: SEPTIC SHOCK 01/11/06
Organ/Space SSI:
01/11/06
C. difficile Colitis:
NO
* indicates Other (ICD)
484
Surgery V. 3.0 User Manual
April 2004
Example 2: Print Surgery Risk Assessment for a Cardiac Case
Select Surgery Risk Assessment Menu Option: P
Print a Surgery Risk Assessment
Do you want to batch print assessments for a specific date range ? NO//
Select Patient: R9922
VETERAN
SURPATIENT,NINE
SURPATIENT,NINE
12-19-51
000345555
<Enter>
NO
SC
000-34-5555
1. 07-01-06
* CABG X3 (1A,2V), ARTERIAL GRAFTING (TRANSMITTED)
2. 03-27-05
INGUINAL HERNIA (TRANSMITTED)
3. 07-03-04
PULMONARY LOBECTOMY (TRANSMITTED)
Select Surgical Case: Select Surgical Case: 1
Print the Completed Assessment on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
485
VA SURGICAL QUALITY IMPROVEMENT PROGRAM – CARDIAC SPECIALTY
================================================================================
I. IDENTIFYING DATA
Patient: SURPATIENT,NINE 000-34-5555
Case #: 238
Fac./Div. #: 500
Surgery Date: 07/01/06
Address: Anyplace Way
Phone: NS/Unknown
Zip Code: 33445-1234
Date of Birth: 12/19/51
================================================================================
II. CLINICAL DATA
Gender:
MALE
Age:
56
Height:
72 in
Prior MI:
NONE
Weight:
177 lb
Number of prior heart surgeries:
NONE
Diabetes - Long Term:
NO
Prior heart surgeries:
None
Diabetes - 2 Wks Preop:
NO
Peripheral Vascular Disease:
NO
COPD:
NO
CVD Repair/Obstruct:
YES/PRIOR SURG
FEV1:
NS
History of CVD:
CVA W/O NEURO DEF
Cardiomegaly (X-ray):
NO
Angina (use CCS Class):
II
Pulmonary Rales:
NO
CHF (use NYHA Class):
II
Tobacco Use:
NEVER USED TOBACCO
Current Diuretic Use:
NO
Tobacco Use Timeframe: NOT APPLICABLE
Current Digoxin Use:
NO
Positive Drug Screening: NO
IV NTG 48 Hours Preceding Surgery: NO
Active Endocarditis:
NO
Preop Circulatory Device:
NONE
Resting ST Depression:
NO
Hypertension:
YES
Functional Status:
INDEPENDENT
Preoperative Atrial Fibrillation: NO
PCI:
None
III. DETAILED LABORATORY INFO - PREOPERATIVE VALUES
Creatinine:
mg/dl (NS)
T. Cholesterol:
Hemoglobin:
mg/dl (NS)
HDL:
Albumin:
g/dl (NS)
LDL:
Triglyceride:
mg/dl (NS)
Hemoglobin A1c:
Potassium:
mg/L (NS)
BNP:
T. Bilirubin:
mg/dl (NS)
mg/dl
mg/dl
mg/dl
%
mg/dl
(NS)
(NS)
(NS)
(NS)
(NS)
IV. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA
Cardiac Catheterization Date: 06/28/06
Procedure:
NS
Native Coronaries:
LVEDP:
NS
Left Main Stenosis:
NS
Aortic Systolic Pressure: NS
LAD Stenosis:
NS
Right Coronary Stenosis:
NS
For patients having right heart cath:
Circumflex Stenosis:
NS
PA Systolic Pressure:
NS
PAW Mean Pressure:
NS
If a Re-do, indicate stenosis
in graft to:
LAD:
NS
Right coronary (include PDA): NS
Circumflex:
NS
-----------------------------------------------------------------------------LV Contraction Grade (from contrast or radionuclide angiogram or 2D Echo):
Grade
Ejection Fraction Range
Definition
NO LV STUDY
-----------------------------------------------------------------------------Mitral Regurgitation:
NS
Aortic stenosis:
NS
V. OPERATIVE RISK SUMMARY DATA
Physician's Preoperative
Estimate of Operative Mortality: NS
ASA Classification:
3-SEVERE DISTURB.
Surgical Priority:
ELECTIVE
Principal CPT Code:
33517
Other Procedures CPT Codes:
33510
Preoperative Risk Factors:
Wound Classification:
CLEAN
486
07/28/06 15:30)
07/28/06 15:31)
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,NINE 00-34-5555
================================================================================
VI. OPERATIVE DATA
Cardiac surgical procedures with or without cardiopulmonary bypass
CABG distal anastomoses:
Maze procedure:
NO MAZE PERFORMED
Number with Vein:
1
ASD repair:
NO
Number with IMA:
1
VSD repair:
NO
Number with Radial Artery:
0
Myectomy:
NO
Number with Other Artery:
1
Myxoma resection:
NO
Number with Other Conduit:
1
Other tumor resection:
NO
LV Aneurysmectomy:
NO
Cardiac transplant:
NO
Bridge to transplant/Device:
NONE
Great Vessel Repair:
NO
TMR:
NO
Endovascular Repair:
NO
Other Cardiac procedure(s):
NO
Aortic Valve Procedure:
PRIMARY REPAIR
Mitral Valve Procedure:
NONE
Tricuspid Valve Procedure:
NONE
Pulmonary Valve Procedure:
NONE
* Other Cardiac procedures (Specify):
Indicate other cardiac procedures only if done with cardiopulmonary bypass
Foreign body removal:
YES
Pericardiectomy:
YES
Other Operative Data details
Total CPB Time:
85 min
Total Ischemic Time: 60 min
Incision Type:
FULL STERNOTOMY
Conversion Off Pump to CPB: N/A (began on-pump/ stayed on-pump)
VII. OUTCOMES
Operative Death:
NO
Date of Death:
Perioperative (30 day) Occurrences:
Perioperative MI:
NO
Endocarditis:
NO
Superficial Incisional SSI:
NO
Mediastinitis:
NO
Cardiac Arrest Requiring CPR:
NO
Reoperation for Bleeding:
NO
On ventilator > or = 48 hr:
NO
Repeat cardiac Surg procedure:
NO
Tracheostomy:
NO
Ventilator supp within 30 days:
NO
Stroke/CVA:
NO SYMPTOMS
Coma > or = 24 Hours:
NO
New Mech Circulatory Support:
NO
Postop Atrial Fibrillation:
NO
Wound Disruption:
NO
Renal Failure Requiring Dialysis: NO
VIII. RESOURCE DATA
Hospital Admission Date: 06/30/06 06:05
Hospital Discharge Date: 07/10/06 08:50
Time Patient In OR:
07/10/06 10:00
Operation Began: 07/01/06 10:10
Operation Ended:
07/10/06 12:30
Time Patient Out OR: 07/01/06 12:20
Date and Time Patient Extubated:
07/10/06 13:13
Postop Intubation Hrs: +1.9
Date and Time Patient Discharged from ICU:
07/10/06 08:00
Patient is Homeless:
NS
Cardiac Surg Performed at Non-VA Facility:
UNKNOWN
Resource Data Comments:
================================================================================
IX. SOCIOECONOMIC, ETHNICITY, AND RACE
Employment Status Preoperatively:
SELF EMPLOYED
Ethnicity:
NOT HISPANIC OR LATINO
Race Category(ies):
AMERICAN INDIAN OR ALASKA NATIVE,
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER, WHITE
X. DETAILED DISCHARGE INFORMATION
Discharge ICD Codes: 414.01 V70.7
433.10
285.1
412.
307.9
427.31
Type of Disposition: TRANSFER
Place of Disposition: HOME-BASED PRIMARY CARE (HBPC)
Primary care or referral VAMC identification code: 526
Follow-up VAMC identification code: 526
*** End of report for SURPATIENT,NINE
April 2004
000-34-5555 assessment #238 ***
Surgery V. 3.0 User Manual
486a
(This page included for two-sided copying.)
486b
Surgery V. 3.0 User Manual
April 2004
Update Assessment Completed/Transmitted in Error
[SROA TRANSMITTED IN ERROR]
The Update Assessment Completed/Transmitted in Error option is used to change the status of a
completed or transmitted assessment that contains errors or has been entered in error. The status will
change from Completed or Transmitted to Incomplete so that the user can edit the assessment.
Transmitted assessments will be re-transmitted if they are re-completed within 14 days of the original
transmission date.
Example: Update Assessment Completed/Transmitted in Error
Select Surgery Risk Assessment Menu Option: U
Select Patient: SURPATIENT,NINETEEN
Update Assessment Completed/Transmitted in Error
03-03-30
000287354
SC VETERAN
SURPATIENT,NINETEEN 000-28-7354
1. 02-08-95
CORONARY ARTERY BYPASS (INCOMPLETE)
2. 01-25-95
PULMONARY LOBECTOMY (TRANSMITTED)
Select Surgical Case: 2
Are you sure that you want to change the status of this assessment
from 'TRANSMITTED' to 'INCOMPLETE' ? YES// <Enter>
The Assessment Status has been changed to 'INCOMPLETE'.
Press <Enter> to continue
April 2004
Surgery V. 3.0 User Manual
487
(This page included for two-sided copying.)
488
Surgery V. 3.0 User Manual
April 2004
List of Surgery Risk Assessments
[SROA ASSESSMENT LIST]
The List of Surgery Risk Assessments option is used to print lists of assessments within a date range. Lists
of assessments in different phases of completion (for example, incomplete, completed, or transmitted) or
a list of all surgical cases entered in the Surgery Risk Assessment software can be printed. The user can
also request that the list be sorted by surgical service. The software will prompt for a beginning date and
an ending date. The examples in this section illustrate printing assessments in the following formats.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of Incomplete Assessments
List of Completed Assessments
List of Transmitted Assessments
List of Non-Assessed Major Surgical Cases
List of All Major Surgical Cases
List of All Surgical Cases
List of Completed/Transmitted Assessments Missing Information
List of 1-Liner Cases Missing Information
List of Eligible Cases
List of Cases With No CPT Codes
Summary List of Assessed Cases
Example 1: List of Incomplete Assessments
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 1
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
489
INCOMPLETE RISK ASSESSMENTS
MAYBERRY, NC
SURGERY SERVICE
FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
ASSESSMENT #
PATIENT
OPERATIVE PROCEDURE(S)
ANESTHESIA TECHNIQUE
OPERATION DATE
SURGEON
====================================================================================================================================
** SURGICAL SPECIALTY: CARDIAC SURGERY **
28519
JAN 05, 2006
SURPATIENT,NINE 000-34-5555
SURSURGEON,ONE
* CABG X3 (2V,1A)
GENERAL
CPT Codes: 33736
-----------------------------------------------------------------------------------------------------------------------------------** SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW) **
63063
JUN 09, 2006
SURPATIENT,ONE
000-44-7629
SURSURGEON,TWO
INGUINAL HERNIA
SPINAL
CPT Codes: 49521
-----------------------------------------------------------------------------------------------------------------------------------** SURGICAL SPECIALTY: NEUROSURGERY **
63154
JUN 24, 2006
SURPATIENT,EIGHT 000-37-0555
SURSURGEON,FOUR
CRANIOTOMY
NOT ENTERED
CPT Codes: NOT ENTERED
------------------------------------------------------------------------------------------------------------------------------------
490
Surgery V. 3.0 User Manual
April 2004
Example 2: List of Completed Assessments
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 2
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
491
COMPLETED RISK ASSESSMENTS
MAYBERRY, NC
SURGERY SERVICE
FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
ASSESSMENT #
PATIENT
DATE COMPLETED
ANESTHESIA TECHNIQUE
OPERATION DATE
OPERATIVE PROCEDURE
====================================================================================================================================
** SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW) **
92
FEB 23, 2006
SURPATIENT,SIXTY 000-56-7821
CHOLEDOCHOTOMY
CPT Code: 47420
FEB 28, 2006
GENERAL
63045
MAR 01, 2006
SURPATIENT,FORTYONE 000-43-2109
INGUINAL HERNIA
CPT Code: 49521
MAR 29, 2006
GENERAL
-----------------------------------------------------------------------------------------------------------------------------------** SURGICAL SPECIALTY: OPHTHALMOLOGY **
1898
APR 28, 2006
SURPATIENT,FORTYONE 000-43-2109
INTRAOCCULAR LENS
MAY 28, 2006
GENERAL
CPT Codes: NOT ENTERED
------------------------------------------------------------------------------------------------------------------------------------
492
Surgery V. 3.0 User Manual
April 2004
Example 3: List of Transmitted Assessments
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 3
Print by Date of Operation or by Date of Transmission ?
1. Date of Operation
2. Date of Transmission
Select Number:
(1-2): 1// <Enter>
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print which Transmitted Cases ?
1. Assessed Cases Only
2. Excluded Cases Only
3. Both Assessed and Excluded
Select Number:
(1-3): 1// <Enter>
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// N
Print the Report for which Surgical Specialty: GENERAL SURGERY
SURGERY
1
50 GENERAL SURGERY
50
2
50 GASTROENTEROLOGY
50
GASTR
3
50 TWO GENERAL
50
TG
CHOOSE 1-3: <Enter> SURGERY GENERAL SURGERY
50
50
GENERAL
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
493
TRANSMITTED RISK ASSESSMENTS
MAYBERRY, NC
SURGERY SERVICE
OPERATION DATES FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
ASSESSMENT #
PATIENT
TRANSMISSION DATE
ANESTHESIA TECHNIQUE
OPERATION DATE
PRINCIPAL OPERATIVE PROCEDURE
====================================================================================================================================
** SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW) **
63076
JAN 08, 2006
SURPATIENT,FOURTEEN 000-45-7212
INGUINAL HERNIA
CPT Codes: 49521
FEB 12, 2006
GENERAL
63077
FEB 08, 2006
SURPATIENT,FIVE 000-58-7963
INGUINAL HERNIA, OTHER PROC1
CPT Codes: NOT ENTERED
FEB 30, 2006
GENERAL
63103
MAR 27, 2006
SURPATIENT,NINE 000-34-5555
INGUINAL HERNIA
CPT Codes: 49521
APR 09, 2006
GENERAL
63171
MAY 17, 2006
SURPATIENT,FIFTYTWO 000-99-8888
JUN 05, 2006
GENERAL
CHOLECYSTECTOMY
CPT Codes: 47600
------------------------------------------------------------------------------------------------------------------------------------
494
Surgery V. 3.0 User Manual
April 2004
Example 4: List of Non-Assessed Major Surgical Cases
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 4
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// N
Print the Report for which Surgical Specialty: GENERAL(OR WHEN NOT
DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
50
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
495
NON-ASSESSED MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
MAYBERRY, NC
SURGERY SERVICE
FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
CASE #
PATIENT
ANESTHESIA TECHNIQUE
OPERATION DATE
OPERATIVE PROCEDURE(S)
SURGEON
====================================================================================================================================
SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
63071
FEB 08, 2006
SURPATIENT,FOUR 000-17-0555
INGUINAL HERNIA
CPT Codes: 49505
GENERAL
SURSURGEON,TWO
63136
MAR 07, 2006
SURPATIENT,EIGHT
CHOLECYSTECTOMY
CPT Codes: 47605
GENERAL
SURSURGEON,TWO
000-34-5555
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 2
------------------------------------------------------------------------------------------------------------------------------------
496
Surgery V. 3.0 User Manual
April 2004
Example 5: List of All Major Surgical Cases
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 5
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// N
Print the Report for which Surgical Specialty: GENERAL(OR WHEN NOT
DEFINED BELOW) GENERAL(OR WHEN NOT DEFINED BELOW)
50
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
497
ALL MAJOR SURGICAL CASES BY SURGICAL SPECIALTY
MAYBERRY, NC
SURGERY SERVICE
FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
CASE #
PATIENT
ASSESSMENT STATUS
ANESTHESIA TECHNIQUE
OPERATION DATE
OPERATIVE PROCEDURE(S)
EXCLUSION CRITERIA
SURGEON
====================================================================================================================================
SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
63110
JAN 23, 2006
SURPATIENT,SIXTY
CHOLEDOCHOTOMY
CPT Codes: 47420
63131
APR 21, 2006
63136
JUN 07, 2006
000-56-7821
COMPLETED
SCNR WAS ON A/L
GENERAL
SURSURGEON,TWO
SURPATIENT,FIFTYTWO 000-99-8888
PERINEAL WOUND EXPLORATION
CPT Codes: NOT ENTERED
NO ASSESSMENT
GENERAL
SURSURGEON,NINE
SURPATIENT,EIGHT
CHOLECYSTECTOMY
CPT Codes: 47600
NO ASSESSMENT
GENERAL
SURSURGEON,ONE
000-34-5555
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 3
------------------------------------------------------------------------------------------------------------------------------------
498
Surgery V. 3.0 User Manual
April 2004
Example 6: List of All Surgical Cases
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 6
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// N
Print the Report for which Surgical Specialty: 50
GENERAL(OR WHEN NOT DEFINED BELOW)
50
GENERAL(OR WHEN NOT DEFINED BELOW)
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
This report is designed to print to your screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
499
ALL SURGICAL CASES BY SURGICAL SPECIALTY
MAYBERRY, NC
SURGERY SERVICE
FROM: JAN 1,2006 TO: JUN 30,2006
PAGE 1
DATE REVIEWED:
REVIEWED BY:
CASE #
PATIENT
ASSESSMENT STATUS
ANESTHESIA TECHNIQUE
OPERATION DATE
PRINCIPAL OPERATIVE PROCEDURE
EXCLUSION CRITERIA
SURGEON
====================================================================================================================================
SURGICAL SPECIALTY: GENERAL(OR WHEN NOT DEFINED BELOW)
63110
JAN 23, 2006
SURPATIENT,SIXTY
CHOLEDOCHOTOMY
CPT Code: 47420
63079
APR 02, 2006
000-56-7821
COMPLETED
SCNR WAS ON A/L
GENERAL
SURSURGEON,TWO
SURPATIENT,FIFTYTWO 000-99-8888
INGUINAL HERNIA
CPT Codes: NOT ENTERED
INCOMPLETE
GENERAL
SURSURGEON,ONE
63131
APR 21, 2006
SURPATIENT,FIFTYTWO 000-99-8888
PERINEAL WOUND EXPLORATION
CPT Codes: NOT ENTERED
NO ASSESSMENT
GENERAL
SURSURGEON,NINE
63180
JUN 23, 2006
SURPATIENT,SIXTY
CHOLECYSTECTOMY
CPT Codes: 47600
NO ASSESSMENT
NOT ENTERED
SURSURGEON,ONE
000-56-7821
TOTAL GENERAL(OR WHEN NOT DEFINED BELOW): 4
------------------------------------------------------------------------------------------------------------------------------------
500
Surgery V. 3.0 User Manual
April 2004
Example 7: List of Completed/Transmitted Assessments Missing Information
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 7
Start with Date: 1 1 06 (JAN 01, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number: (1-2): 1
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
501
COMPLETED/TRANSMITTED ASSESSMENTS MISSING INFORMATION
MAYBERRY, NC
FROM: JAN 1,2006 TO: JUN 30,2006
DATE PRINTED: JUL 13,2006
PAGE 1
** GENERAL(OR WHEN NOT DEFINED BELOW)
ASSESSMENT #
PATIENT
TYPE
STATUS
OPERATION DATE
OPERATION(S)
================================================================================
63172
SURPATIENT,FIFTYTWO 000-99-8888
NON-CARDIAC
TRANSMITTED
MAY 17, 2006
REPAIR ARTERIAL BLEEDING
CPT Code: 33120
Missing information:
1. The final coding for Procedure and Diagnosis is not complete.
2. Anesthesia Technique
-----------------------------------------------------------------------------63185
SURPATIENT,SIXTEEN 000-11-1111
NON-CARDIAC
TRANSMITTED
APR 17, 2006
INGUINAL HERNIA, CHOLECYSTECTOMY
Missing information:
1. The final coding for Procedure and Diagnosis is not complete.
2. Concurrent Case
3. History of COPD (Y/N)
4. Ventilator Dependent Greater than 48 Hrs (Y/N)
5. Weight Loss > 10% of Usual Body Weight (Y/N)
6. Transfusion Greater than 4 RBC Units this Admission (Y/N)
-----------------------------------------------------------------------------63080
SURPATIENT,THIRTY 000-82-9472
EXCLUDED
COMPLETE
JAN 03, 2006
TURP
Missing information:
1. The final coding for Procedure and Diagnosis is not complete.
TOTAL FOR GENERAL(OR WHEN NOT DEFINED BELOW): 3
TOTAL FOR ALL SPECIALTIES: 3
502
Surgery V. 3.0 User Manual
April 2004
Example 8: List of 1-Liner Cases Missing Information
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 8
Start with Date: 2 27 06 (FEB 27, 2006)
End with Date: 6 30 06 (JUN 30, 2006)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
502a
1-LINER CASES MISSING INFORMATION
MABERRY, NC
FROM: FEB 27,2006 TO: JUN 30,2006
DATE PRINTED: JUN 30,2006
PAGE 1
** UROLOGY
CASE #
PATIENT
TYPE
STATUS
OP DATE
OPERATION(S)
================================================================================
317
APR 10, 2006
SURPATIENT,FOURTEEN 000-45-7212
CARDIAC
COMPLETE
Vasectomy
CPT Codes: NOT ENTERED
Missing information:
1. The final coding for Procedure and Diagnosis is not complete.
2. Attending Code
3. Wound Classification
4. ASA Class
-------------------------------------------------------------------------------TOTAL FOR UROLOGY: 1
502b
Surgery V. 3.0 User Manual
April 2004
Example 9: List of Eligible Cases
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 9
Start with Date: 6 1 06 (JUN 01, 2006)
End with Date: 6 30 07 (JUN 30, 2007)
Print which Eligible Cases ?
1.
2.
3.
4.
Assessed Cases Only
Excluded Cases Only
Non-Assessed Cases only
All Cases
Select Number:
(1-4): 1// <Enter>
Print by Surgical Specialty ? YES// <Enter>
Print report for ALL specialties ? YES// NO
NO
Print the Report for which Surgical Specialty: GENERAL SURGERY
50
GENERAL SURGERY
Do you want to print all divisions? YES// NO
1. MAYBERRY, NC
2. PHILADELPHIA, PA
Select Number:
(1-2): 1
Print the List of Assessments to which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
502c
CASES ELIGIBLE FOR ASSESSMENT
MAYBERRY, NC
FROM: JUN 1,2006 TO: JUN 30,2007
DATE PRINTED: JUN 30,2007
PAGE 1
'*' Denotes Eligible CPT Code
>>> CARDIAC SURGERY
CASE #
PATIENT
TYPE
STATUS
OP DATE
OPERATION(S)
================================================================================
10095
SURPATIENT,SEVENTY 000-00-0125
CARDIAC
COMPLETE
JUN 04, 2006
CABG, REGRAFT
>>> Final CPT Coding is not complete.
CPT Codes: *33510, *33511
-------------------------------------------------------------------------------10084
SURPATIENT,NINE 000-34-5555
CARDIAC
COMPLETE
JUL 08, 2006
CABG
CPT Codes: *33502, 11402
-------------------------------------------------------------------------------10380
SURPATIENT,THREE 000-21-2453
NOT LOGGED
COMPLETE
FEB 06, 2007
CORONARY ARTERY BYPASS
CPT Codes: NOT ENTERED
-------------------------------------------------------------------------------10383
SURPATIENT,ONE 000-44-7629
NON-CARDIAC
COMPLETE
FEB 08, 2007
STENT
CPT Codes: NOT ENTERED
-------------------------------------------------------------------------------TOTAL FOR CARDIAC SURGERY: 4
>>> GENERAL SURGERY
CASE #
PATIENT
TYPE
STATUS
OP DATE
OPERATION(S)
================================================================================
10061
SURPATIENT,FIFTEEN 666-98-1288
NON-CARDIAC
COMPLETE
FEB 11, 2007
APPENDECTOMY, SPLENECTOMY
>>> Final CPT Coding is not complete.
CPT Codes: *44955, *38100
-------------------------------------------------------------------------------10079
SURPATIENT,SEVENTY 000-00-0125
EXCLUDED
COMPLETE
MAR 31, 2007
HERNIA
>>> Final CPT Coding is not complete.
CPT Codes: *49521, *49521
-------------------------------------------------------------------------------TOTAL FOR GENERAL SURGERY: 2
502d
Surgery V.3.0 User Manual
April 2004
Example 10: List of Cases With No CPT Codes
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 10
Start with Date: 1 1 07 (JAN 01, 2007)
End with Date: T (JAN 23, 2008)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// <Enter>
Print the List of Assessments to which Device: HOME// [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
502e
CASES WITHOUT CPT CODES
ALBANY - ALL DIVISIONS
FROM: JAN 1,2007 TO: JAN 23,2008
DATE PRINTED: JAN 23,2008
PAGE 1
>>> CARDIAC SURGERY
CASE #
PATIENT
TYPE
STATUS
OP DATE
OPERATION(S)
================================================================================
10429
SURPATIENT,TEN 666-12-3456
CARDIAC
COMPLETE
FEB 12, 2007
CABG
-------------------------------------------------------------------------------10420
SURPATIENT,F. 666-00-0804
CARDIAC
TRANSMITTED
FEB 12, 2007
CABG
-------------------------------------------------------------------------------10423
SURPATIENT,TWO 666-45-1982
CARDIAC
INCOMPLETE
MAR 12, 2007
cabg
-------------------------------------------------------------------------------10430
SURPATIENT,EIGHT 666-37-0555
CARDIAC
INCOMPLETE
MAR 18, 2007
CABG X3
-------------------------------------------------------------------------------10374
SURPATIENT,NINE 666-34-5555
NOT LOGGED
NO ASSESSMENT
MAY 10, 2007
CABG X 3
-------------------------------------------------------------------------------TOTAL FOR CARDIAC SURGERY: 5
TOTAL FOR ALL SPECIALTIES: 5
502f
Surgery V.3.0 User Manual
April 2004
Example 11: Summary List of Assessed Cases
Select Surgery Risk Assessment Menu Option: L List of Surgery Risk Assessments
List of Surgery Risk Assessments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List of
List of
List of
List of
List of
List of
List of
List of
List of
List of
Summary
Incomplete Assessments
Completed Assessments
Transmitted Assessments
Non-Assessed Major Surgical Cases
All Major Surgical Cases
All Surgical Cases
Completed/Transmitted Assessments Missing Information
1-Liner Cases Missing Information
Eligible Cases
Cases With No CPT Codes
List of Assessed Cases
Select the Number of the Report Desired:
(1-11): 11
Start with Date: 01 01 08 (JAN 01, 2008)
End with Date: 01 30 08 (JAN 30, 2008)
Print by Surgical Specialty ?
YES// <Enter>
Print report for ALL specialties ?
YES// <Enter>
Do you want to print all divisions? YES// NO
1. ALBANY
2. PHILADELPHIA, PA
Select Number: (1-2): 1
Print the List of Assessments to which Device: HOME// [Select Print Device]
April 2004
Surgery V. 3.0 User Manual
502g
SUMMARY LIST OF ASSESSED CASES
ALBANY
FROM: JAN 1,2001 TO: JAN 23,2008
DATE PRINTED: JAN 23,2008
PAGE 1
SURGICAL SPECIALTY
INCOMPLETE | COMPLETE | TRANSMITTED | EXCLUDED
================================================================================
CARDIAC SURGERY
8
1
1
0
GENERAL SURGERY
17
1
1
6
NEUROSURGERY
1
0
1
0
OPHTHALMOLOGY
2
0
0
0
ORTHOPEDICS
2
0
0
0
OTORHINOLARYNGOLOGY (ENT)
1
0
0
0
PLASTIC SURGERY (INCLUDES HEAD
2
0
0
0
TWO GENERAL
1
0
0
0
UROLOGY
0
0
0
1
TOTAL FOR ALL SPECIALTIES:
502h
34
2
Surgery V.3.0 User Manual
3
7
April 2004
Print 30 Day Follow-up Letters
[SROA REPRINT LETTERS]
The Surgical Clinical Nurse Reviewer uses the Print 30 Day Follow-up Letters option to automatically
print a letter, or a batch of letters, addressed to a specific patient or patients.
About the "Do you want to print the letter for a specific assessment?" Prompt
The user responds YES to this prompt in order to print a follow-up letter for a single assessment. The
software will ask the user to select the patient and case for which the letter will be printed. See Example 1
below.
The user responds NO to this prompt if he or she wants to print a batch of follow-up letters for surgical
cases within a data range. The software will ask for the beginning and ending dates of the date range for
which the letters will be printed. See Example 2 on the following pages.
If the patient has died, the software notifies the user of the death, and will not print the letter.
Also, if a patient has not been discharged, the follow up letter will not print.
Example 1: Print a Single Follow-up Letter
Select Surgery Risk Assessment Menu Option: F
Print 30 Day Follow-up Letters
Do you want to edit the text of the letter? NO// <Enter>
Do you want to print the letter for a specific assessment ?
Select Patient:
SURPATIENT,NINETEEN
03-03-30
YES// <Enter>
000287354
SC VETERAN
SURPATIENT,NINETEEN 000-28-7354
1. 06-18-06
CORONARY ARTERY BYPASS (INCOMPLETE)
2. 01-25-06
PULMONARY LOBECTOMY (TRANSMITTED)
Select Surgical Case: 1
Print 30 Day Letters on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
503
NINETEEN SURPATIENT
JUL 18, 2006
Operation Date: 06/18/06
Specialty: GENERAL SURGERY
Dear Mr. Surpatient,
One month ago, you had an operation at the VA Medical Center. We are
interested in how you feel. Have you had any health problems since your
operation ? We would like to hear from you. Please take a few minutes
to answer these questions and return this letter in the self-addressed
stamped envelope.
Have you been to a hospital or seen a doctor for any reason since your
operation ?
___ Yes ___ No
If you answered NO, you do not need to answer any more questions. Please
return this sheet in the self-addressed stamped envelope.
If you have answered YES, please answer the following questions.
1) Have you been seen in an outpatient clinic or doctor's office ?
___ Yes ___ No
Why did you go to the clinic or doctor's office ? ________________
Where ? (name and location) _____________________
Date ? ________
Who was your doctor ? ____________________________________________
2) Were you admitted to a hospital ?
___ Yes
___ No
Why did you go to the hospital ? _________________________________
Where ? (name and location) _____________________
Date ? ________
Who was your doctor ? ____________________________________________
Please return this letter whether or not you have had any medical problems.
Your health and opinion are important to us. Thank you.
Sincerely,
Surgical Clinical Nurse Reviewer
504
Surgery V. 3.0 User Manual
April 2004
Example 2: Print Letters Within a Date Range
Select Surgery Risk Assessment Menu Option:
P Print 30 Day Follow-up Letters
Do you want to print the letter for a specific assessment ?
YES//
N
This option will allow you to reprint the 30 day follow up letters for the date that they were
originally printed. When printed automatically, the letters print 25 days after the date of
operation.
Print letters for BEGINNING date: TODAY// 6/1/07 (JUN 01, 2007)
Print letters for ENDING date: TODAY// <Enter> (JUN 02, 2007)
Print 30 Day Letters on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
505
FORTYONE SURPATIENT
87 NORTH STREET
PHILADELPHIA, PA 91776
JUN 02, 2007
Operation Date: 05/08/07
Specialty: GENERAL SURGERY
Dear Mr. Surpatient,
One month ago, you had an operation at the VA Medical Center. We are
interested in how you feel. Have you had any health problems since your
operation ? We would like to hear from you. Please take a few minutes
to answer these questions and return this letter in the self-addressed
stamped envelope.
Have you been to a hospital or seen a doctor for any reason since your
operation ?
___ Yes ___ No
If you answered NO, you do not need to answer any more questions. Please
return this sheet in the self-addressed stamped envelope.
If you have answered YES, please answer the following questions.
1) Have you been seen in an outpatient clinic or doctor's office ?
___ Yes ___ No
Why did you go to the clinic or doctor's office ? ________________
Where ? (name and location) _____________________
Date ? ________
Who was your doctor ? ____________________________________________
2) Were you admitted to a hospital ?
___ Yes
___ No
Why did you go to the hospital ? _________________________________
Where ? (name and location) _____________________
Date ? ________
Who was your doctor ? ____________________________________________
Please return this letter whether or not you have had any medical problems. Your health and
opinion are important to us. Thank You.
Sincerely,
Surgical Clinical Nurse Reviewer
506
Surgery V. 3.0 User Manual
April 2004
Exclusion Criteria (Enter/Edit)
[SR NO ASSESSMENT REASON]
The Exclusion Criteria (Enter/Edit) option is used to flag major cases that will not have a surgery risk
assessment due to certain exclusion criteria. At the prompt "Reason an Assessment was not Created:"
enter a question mark (?) to see a list of reasons.
Example: Enter Reason for No Assessment
Select Surgery Risk Assessment Menu Option: R Exclusion Criteria (Enter/Edit)
Select Patient: R9922
VETERAN
SURPATIENT,NINE
SURPATIENT,NINE
03-03-34
000345555
NO
SC
000-34-5555
1. 11-01-04
TURP (COMPLETED)
2. 08-01-03
CABG X3 (1A,2V), ARTERIAL GRAFTING (COMPLETED)
3. 07-03-01
PULMONARY LOBECTOMY, TURP (COMPLETED)
Select Operation: 1
Reason an Assessment was not Created: 6
SCNR WAS ON ANNUAL LEAVE
SURPATIENT,NINE (000-34-5555)
Case #63159
Transmission Status: QUEUED TO TRANSMIT
NOV 1,2004
TURP (CPT Code: 52601-59)
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
Exclusion Criteria:
SCNR WAS ON A/L
Surgical Priority:
ELECTIVE
Surgical Specialty:
UROLOGY
Principal Anesthesia Technique: GENERAL
Major or Minor:
MAJOR
-------------------------------------------------------------------------------Select Excluded Case Information to Edit:
April 2004
Surgery V. 3.0 User Manual
507
(This page included for two-sided copying.)
508
Surgery V. 3.0 User Manual
April 2004
Monthly Surgical Case Workload Report
[SROA MONTHLY WORKLOAD REPORT]
The Monthly Surgical Case Workload Report option generates the Monthly Surgical Case Workload
Report that may be printed and/or transmitted to the VASQIP national database. The report can be printed
for a specific month, or for a range of months.
Example: Monthly Surgical Case Workload Report – Single Month
Select Surgery Risk Assessment Menu Option: M
Monthly Surgical Case Workload Report
Report of Monthly Case Workload Totals
Print which report?
1. Report for Single Month
2. Report for Range of Months
Select Number (1 or 2): 1//
<Enter>
This option provides a report of the monthly risk assessment surgical case
workload totals which include the following categories:
1. All cases performed
2. Eligible cases
3. Eligible cases meeting exclusion criteria
4. Assessed cases
5. Not logged eligible cases
6. Cardiac cases
7. Non-cardiac cases
8. Assessed cases per day (based on 20 days/month)
The second part of this report provides the total number of incomplete
assessments remaining for the month selected and the prior 12 months.
Compile workload totals for which month and year? MAY 2007//
Do you want to print all divisions? YES//
<Enter>
<Enter>
This report may be printed and/or transmitted to the national database.
Do you want this report to be transmitted to the central database? NO// <Enter>
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
509
MAYBERRY, NC
REPORT OF MONTHLY SURGICAL CASE WORKLOAD
FOR MAY 2007
-------------------------------------------------TOTAL CASES PERFORMED
=
249
TOTAL ELIGIBLE CASES
=
227
CASES MEETING EXCLUSION CRITERIA =
114
NON-SURGEON CASE
=
55
EXCEEDS MAX. ASSESSMENTS
=
0
EXCEEDS MAXIMUM TURPS
=
0
STUDY CRITERIA
=
59
SCNR WAS ON A/L
=
0
CONCURRENT CASE
=
0
EXCEEDS MAXIMUM HERNIAS
=
0
ASSESSED CASES
=
135
NOT LOGGED ELIGIBLE CASES
=
0
CARDIAC CASES
=
16
NON-CARDIAC CASES
=
119
ASSESSED CASES PER DAY
=
6.75
--------------------------------------------------
NUMBER OF INCOMPLETE ASSESSMENTS REMAINING FOR PAST YEAR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
510
2006
2006
2006
2006
2006
2006
2006
2006
2007
2007
2007
2007
2007
CARDIAC
------0
0
0
0
0
0
0
0
0
0
0
0
15
------15
NON-CARDIAC
----------0
0
0
0
0
0
0
0
0
0
0
0
82
----------82
TOTAL
----0
0
0
0
0
0
0
0
0
0
0
0
97
----97
Surgery V. 3.0 User Manual
April 2004
Example: Monthly Surgical Case Workload Report – Range of Months
Select Surgery Risk Assessment Menu Option: M
Monthly Surgical Case Workload Report
Report of Monthly Case Workload Totals
Print which report?
1. Report for Single Month
2. Report for Range of Months
Select Number (1 or 2): 1//
2
Start with which month and year? OCT 2006//
End with which month and year? MAY 2007//
Do you want to print all divisions? YES//
(OCT 2006)
(MAY 2007)
<Enter>
<Enter>
<Enter>
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
511
ALBANY - ALL DIVISIONS
REPORT OF SURGICAL CASE WORKLOAD
FOR OCT 2005 THROUGH MAY 2006
-------------------------------------------------TOTAL CASES PERFORMED
=
30
TOTAL ELIGIBLE CASES
=
5
CASES MEETING EXCLUSION CRITERIA =
1
NON-SURGEON CASE
=
0
ANESTHESIA TYPE
=
0
EXCEEDS MAX. ASSESSMENTS
=
0
EXCEEDS MAXIMUM TURPS
=
0
STUDY CRITERIA
=
0
SCNR WAS ON A/L
=
1
CONCURRENT CASE
=
0
EXCEEDS MAXIMUM HERNIAS
=
0
ASSESSED CASES
=
20
NOT LOGGED ELIGIBLE CASES
=
0
CARDIAC CASES
=
4
NON-CARDIAC CASES
=
16
--------------------------------------------------
512
Surgery V. 3.0 User Manual
April 2004
M&M Verification Report
[SRO M&M VERIFICATION REPORT]
The M&M Verification Report option produces the M&M Verification Report, which may be useful for:
reviewing occurrences and their assignment to operations
reviewing death unrelated/related assignments to operations
The full report includes all patients who had operations within the selected date range who experienced
intraoperative occurrences, postoperative occurrences or death within 90 days of surgery. The pretransmission report is similar but includes operations with completed risk assessments that have not yet
transmitted to the national database.
Full Report:
Information is printed by patient, listing all operations for the patient that occurred during the selected
date range, plus any operations that may have occurred within 30 days prior to any postoperative
occurrences or within 90 days prior to death. Therefore, this report may include some operations that were
performed prior to the selected date range and, if printed by specialty, may include operations performed
by other specialties. For every operation listed, the intraoperative and postoperative occurrences are listed.
The report indicates if the operation was flagged as unrelated or related to death and the risk assessment
type and status. The report may be printed for a selected list of surgical specialties.
Pre-Transmission Report:
Information is printed in a format similar to the full report. This report lists all completed risk assessed
operations that have not yet transmitted to the national database and that have intraoperative occurrences,
postoperative occurrences, or death within 90 days of surgery. The report includes any operations that
may have occurred within 30 days prior to any postoperative occurrences or within 90 days prior to death.
Therefore, this report may include some operations that may or may not be risk assessed, and, if risk
assessed, may have a status other than 'complete'. However, every patient listed on this report will have at
least one operation with a risk assessment status of 'complete'.
Example 1: Generate an M&M Verification Report (Full Report)
Select Surgery Risk Assessment Menu Option: V
M&M Verification Report
M&M Verification Report
The M&M Verification Report is a tool to assist in the review of occurrences
and their assignment to operations and in the review of death unrelated or
related assignments to operations.
The full report includes all patients who had operations within the selected
date range who experienced intraoperative occurrences, postoperative
occurrences or death within 90 days of surgery. The pre-transmission report
is similar but includes only operations with completed risk assessments that
have not yet transmitted to the national database.
April 2004
Surgery V. 3.0 User Manual
513
Print which report ?
1. Full report for selected date range.
2. Pre-transmission report for completed risk assessments.
Enter selection (1 or 2): 1// <Enter>
Start with Date: 03 01 07 (MAR 01, 2007)
End with Date: 03 30 07 (MAR 30, 2007)
Do you want to print all divisions? YES// <Enter>
Do you want to print this report for all Surgical Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
514
Surgery V. 3.0 User Manual
April 2004
ALBANY - ALL DIVISIONS
M&M Verification Report
From: MAR 1,2007 To: MAR 30,2007
Report Generated: APR 23,2007
Page 1
REVIEWED BY:
DATE REVIEWED:
OP DATE
CASE #
SURGICAL SPECIALTY
ASSESSMENT TYPE
STATUS
DEATH RELATED
PRINCIPAL PROCEDURE
====================================================================================================================================
>>> SURPATIENT,FIVE (666-58-7963)
03/01/07
10401
GENERAL SURGERY
APPENDECTOMY
CPT Codes: 44970
Occurrences: ACUTE RENAL FAILURE
NON-CARDIAC
** POSTOP **
TRANSMITTED
N/A
(03/02/07)
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,ONE (666-44-7629)
03/07/07
10421
GENERAL SURGERY
NON-CARDIAC
TRANSMITTED
N/A
APPENDECTOMY, CHOLECYSTECTOMY
CPT Codes: 44950, 47610
Occurrences: URINARY TRACT INFECTION ** POSTOP ** (03/09/07)
ACUTE RENAL FAILURE ** POSTOP ** (03/10/07)
OTHER RESPIRATORY OCCURRENCE ** POSTOP ** (03/10/07)
ICD: 478.25 EDEMA PHARYNX/NASOPHARYX
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,TWO (666-45-1982)
03/07/07
10422
NEUROSURGERY
LAMINECTOMY
CPT Codes: 22630
Occurrences: OTHER OCCURRENCE (03/07/07)
ICD: 415.19 OTH PULM EMB & INFARC
NON-CARDIAC
TRANSMITTED
N/A
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,ELEVEN (666-00-0748) - DIED 03/10/[email protected]:50
03/10/07
10100
GENERAL SURGERY
NON-CARDIAC
INCOMPLETE
NO
REMOVAL OF GALLBLADDER
CPT Codes: 47600
Occurrences: PULMONARY EMBOLISM ** POSTOP ** (03/10/07)
>>> Comments:
Patient complained of chest pain and shortness of breath. Heparin was administered immediately by IV.
Date of Death: 03/10/[email protected]:50
Review of Death Comments: Patient expired from large pulmonary embolus before anticoagulant treatment could take effect.
Patient's obesity and prolonged immobilization were likely contributing factors.
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
515
Example 2: Generate an M&M Verification Report (Pre-Transmission Report)
Select Surgery Risk Assessment Menu Option: V
M&M Verification Report
M&M Verification Report
The M&M Verification Report is a tool to assist in the review of occurrences
and their assignment to operations and in the review of death unrelated or
related assignments to operations.
The full report includes all patients who had operations within the selected
date range who experienced intraoperative occurrences, postoperative
occurrences or death within 90 days of surgery. The pre-transmission report
is similar but includes only operations with completed risk assessments that
have not yet transmitted to the national database.
Print which variety of the report ?
1. Print full report for selected date range.
2. Print pre-transmission report for completed risk assessments.
Enter selection (1 or 2): 1// 2
Do you want to print all divisions? YES// <Enter>
Do you want to print this report for all Surgical Specialties ? YES// <Enter>
This report is designed to use a 132 column format.
Print report on which Device: [Select Print Device]
---------------------------------------------------------printout follows--------------------------------------------------
516
Surgery V. 3.0 User Manual
April 2004
ALBANY - ALL DIVISIONS
M&M Verification Report
PRE-TRANSMISSION REPORT FOR COMPLETED ASSESSMENTS
Report Generated: OCT 23,2007
Page 1
REVIEWED BY:
DATE REVIEWED:
OP DATE
CASE #
SURGICAL SPECIALTY
ASSESSMENT TYPE
STATUS
DEATH RELATED
PRINCIPAL PROCEDURE
====================================================================================================================================
>>> SURPATIENT,TWELVE (666-00-0762)
09/21/07
45466
PLASTIC SURGERY
RHINOPLASTY
CPT Codes: 30410
Occurrences: DEEP INCISIONAL SSI
NON-CARDIAC
** POSTOP **
COMPLETE
N/A
(09/23/07)
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,FIFTEEN (666-00-0194)
09/16/07
45475
EAR, NOSE, THROAT (ENT)
LARYNGECTOMY (TOTAL)
CPT Codes: 31360
Occurrences: BLEEDING/TRANSFUSIONS ** POSTOP ** (09/17/07)
>>> Comments:
Esophageal varices were the source of bleeding.
NON-CARDIAC
COMPLETE
N/A
----------------------------------------------------------------------------------------------------------------------------------->>> SURPATIENT,FORTY (666-00-4174)
09/19/07
45499
GENERAL SURGERY
INGUINAL HERNIA
CPT Codes: 49505
Occurrences: URINARY TRACT INFECTION
NON-CARDIAC
** POSTOP **
COMPLETE
N/A
(09/21/07)
------------------------------------------------------------------------------------------------------------------------------------
April 2004
Surgery V. 3.0 User Manual
517
(This page included for two-sided copying.)
518
Surgery V. 3.0 User Manual
April 2004
Update 1-Liner Case
[SROA ONE-LINER UPDATE]
The Update 1-Liner option may be used to enter missing data for the 1-liner cases (major cases marked
for exclusion from assessment, minor cases, and cardiac-assessed cases that transmit to the VASQIP
database as a single line or two of data). Cases edited with this option will be queued for transmission to
the VASQIP database at Chicago.
Example: Update 1-Liner Case
Select Surgery Risk Assessment Menu Option: O
Update 1-Liner Case
Select Patient: SURPATIENT,TWELVE
SC VETERAN
SURPATIENT,TWELVE
02-12-28
000418719
YES
000-41-8719
1. 08-07-04
REPAIR DIAPHRAGMATIC HERNIA (COMPLETED)
2. 02-18-99
TRACHEOSTOMY, BRONCHOSCOPY, ESOPHAGOSCOPY (COMPLETED)
3. 09-04-97
CHOLECYSTECTOMY (COMPLETED)
Select Case: 1
SURPATIENT,TWELVE
(000-41-8719)
Case #142
Transmission Status: QUEUED TO TRANSMIT
>> Coding Complete <<
AUG 7,2004
REPAIR DIAPHRAGMATIC HERNIA (CPT Code: 39540)
-------------------------------------------------------------------------------1. In/Out-Patient Status:
OUTPATIENT
2. Surgical Specialty:
GENERAL(OR WHEN NOT DEFINED BELOW)
3. Surgical Priority:
STANDBY
4. Attending Code:
LEVEL A. ATTENDING DOING THE OPERATION
5. ASA Class:
2-MILD DISTURB.
6. Wound Classification:
7. Anesthesia Technique:
GENERAL
8. CPT Codes (view only):
39540
9. Other Procedures:
***NONE ENTERED***
-------------------------------------------------------------------------------Select number of item to edit: 6
Wound Classification: C
CLEAN
SURPATIENT,TWELVE
(000-41-8719)
Case #142
Transmission Status: QUEUED TO TRANSMIT
>> Coding Complete <<
AUG 7,2004
REPAIR DIAPHRAGMATIC HERNIA (CPT Code: 39540)
-------------------------------------------------------------------------------1. In/Out-Patient Status:
OUTPATIENT
2. Surgical Specialty:
GENERAL(OR WHEN NOT DEFINED BELOW)
3. Surgical Priority:
STANDBY
4. Attending Code:
LEVEL A. ATTENDING DOING THE OPERATION
5. ASA Class:
2-MILD DISTURB.
6. Wound Classification:
CLEAN
7. Anesthesia Technique:
GENERAL
8. CPT Codes (view only):
39540
9. Other Procedures:
***NONE ENTERED***
-------------------------------------------------------------------------------Select number of item to edit:
April 2004
Surgery V. 3.0 User Manual
519
(This page included for two-sided copying.)
520
Surgery V. 3.0 User Manual
April 2004
Queue Assessment Transmissions
[SROA TRANSMIT ASSESSMENTS]
The Queue Assessment Transmissions option may be used to manually queue the VASQIP transmission
process to run at a selected time. The VASQIP transmission process is a part of the nightly maintenance
and cleanup process.
Example: Queue Assessment Transmissions
Select Surgery Risk Assessment Menu Option: T
Queue Assessment Transmissions
Transmit Surgery Risk Assessments
Requested Start Time: NOW// <Enter>
Queued as task #2651700
Press RETURN to continue
April 2004
Surgery V. 3.0 User Manual
521
(This page included for two-sided copying.)
522
Surgery V. 3.0 User Manual
April 2004
Alert Coder Regarding Coding Issues
[SROA CODE ISSUE]
This option allows the nurse reviewer to send an alert to the coder when there may be an issue with the
CPT codes or the Postoperative Diagnosis codes for a Surgery case. When this option is selected, the
nurse reviewer can enter a free-text message that will be sent to the coder on record, as well as to a predefined mail group identified in the Surgery Site Parameter titled CODE ISSUE MAIL GROUP. The
message will not be sent if there is no coder, or if the mail group is not defined.
Example : Alert Coder Regarding Coding Issues
Select Surgery Risk Assessment Menu Option: CODE
Issues
Alert Coder Regarding Coding
Select Patient: SURPATIENT,TWELVE
SC VETERAN
SURPATIENT,TWELVE
02-12-28
000418719
YES
000-41-8719
1. 08-07-04
REPAIR DIAPHRAGMATIC HERNIA (COMPLETED)
2. 02-18-99
TRACHEOSTOMY, BRONCHOSCOPY, ESOPHAGOSCOPY (COMPLETED)
3. 09-04-97
CHOLECYSTECTOMY (COMPLETED)
Select Operation: 1
SURPATIENT,TWELVE (000-41-8719)
Case #142
AUG 7,2004
REPAIR DIAPHRAGMATIC HERNIA
-------------------------------------------------------------------The following "final" codes have been entered for the case.
Principal CPT Code: 39540 REPAIR DIAPHRAGMATIC HERNIA
Other CPT Codes:
NOT ENTERED
Postop Diagnosis Code (ICD9): 551.3 DIAPHRAGM HERNIA W GANGR (w C/C)
If you believe that the information coded is not correct and would like to
alert the coders of the potential issue, enter a brief description of your
concern below.
Do you want to alert the coders (Y/N)? YES// <Enter>
==[ WRAP ]==[ INSERT ]=====< Coding Discrepancy Comments >===[ <PF1>H=Help ]====
I have reviewed this case for VASQIP. The final Principal CPT Code entered
is 39540. I would like to talk to you regarding the code. I think the code
should be 39541. Please call me at X2545.
<=======T=======T=======T=======T=======T=======T=======T=======T=======T>======
1. Transmit Message
2. Edit Text
Select Number:
1//
<Enter>
Transmitting message...
April 2004
Surgery V. 3.0 User Manual
522a
(This page included for two-sided copying.)
522b
Surgery V. 3.0 User Manual
April 2004
Risk Model Lab Test
[SROA LAB TEST EDIT]
In order to assist the nurse reviewer, in the Surgery Risk Assessment Menu is the Risk Model Lab Test
(Enter/Edit) option, which allows the nurse to map VASQIP data in the RISK MODEL LAB TEST file
(#139.2). The option synonym is ERM.
Risk Model Lab Test (Enter/Edit)
Select Surgery Risk Assessment Menu Option:
Risk Model Lab Test (Enter/Edit)
Risk Model Lab Test (Enter/Edit)
Select item to edit from list below:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
ALBUMIN
ALKALINE PHOSPHATASE
ANION GAP
B-TYPE NATRIURETIC PEPTIDE
BUN
CHOLESTEROL
CPK
CPK-MB
CREATININE
HDL
HEMATOCRIT
HEMOGLOBIN
HEMOGLOBIN A1C
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
INR
LDL
PLATELET COUNT
POTASSIUM
PT
PTT
SGOT
SODIUM
TOTAL BILIRUBIN
TRIGLYCERIDE
TROPONIN I
TROPONIN T
WHITE BLOOD COUNT
Enter number (1-25): 6
Risk Model Lab Test (Enter/Edit)
Test Name: CHOLESTEROL
Laboratory Data Name(s): NONE ENTERED
Specimen: SERUM
Do you want to edit this test ? NO// YES
Select LABORATORY DATA NAME: CHOLESTEROL
1
CHOLESTEROL
2
CHOLESTEROL CRYSTALS
CHOOSE 1-2: 1 CHOLESTEROL
Select LABORATORY DATA NAME: <Enter>
Specimen: SERUM// <Enter>
April 2004
Surgery V. 3.0 User Manual
522c
Risk Model Lab Test (Enter/Edit)
Select item to edit from list below:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
ALBUMIN
ALKALINE PHOSPHATASE
ANION GAP
B-TYPE NATRIURETIC PEPTIDE
BUN
CHOLESTEROL
CPK
CPK-MB
CREATININE
HDL
HEMATOCRIT
HEMOGLOBIN
HEMOGLOBIN A1C
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
INR
LDL
PLATELET COUNT
POTASSIUM
PT
PTT
SGOT
SODIUM
TOTAL BILIRUBIN
TRIGLYCERIDE
TROPONIN I
TROPONIN T
WHITE BLOOD COUNT
Enter number (1-26):
522d
Surgery V. 3.0 User Manual
April 2004
Page 523 has been deleted. Chapter Seven: CoreFLS/Surgery Interface has been removed.
April 2004
Surgery V. 3.0 User Manual
523
(This page included for two-sided copying.)
524
Surgery V. 3.0 User Manual
April 2004
Chapter Seven: Code Set Versioning
The Code Set Versioning enhancement to the Surgery package ensures that only CPT codes, CPT
modifiers, and ICD-9 codes that are active for the operation or procedure date will be available for
selection by the user, regardless of when the CPT entry or edit is made. Also, when a future operation or
procedure date is entered, only active codes will be available.
It is possible that a new code set will be loaded between the time that an operation or procedure is
scheduled and the time the operation or procedure occurs. Re-validation of the codes and modifiers occurs
when the date and time that a patient enters the operating room is entered in the Surgery package. If the
code (CPT or ICD-9) or CPT modifier is invalid — inactive for the date of operation or procedure — the
inactive codes or modifiers will be deleted. Then, these two actions transpire:
1. A warning message displays on the screen, corresponding to the specific code or modifier that is
inactive.
2. A MailMan message is sent to the surgeon (or provider), attending surgeon of record, and to the
user who edited the record. The MailMan message contains the patient‟s name, date of operation,
case number, free-text operation or procedure name, CPT or ICD-9 codes, CPT modifiers deleted
(if any), and the reason for deletion.
The first sample warning message shows an inactive CPT code, its modifiers, and ICD-9 codes, and the
second warning message is for a Non-O.R. procedure.
Example: Warning Message to Surgeon
The following codes are no longer active and will be deleted for case # 12426.
OTHER PROCEDURE CPT CODE:
99900
CPT MODIFIER:
08 – SAMPLE MODIFIER
PRINCIPAL DIAGNOSIS CODE:
600.0
New active codes must be re-entered. A MailMan message will be sent to the surgeon and attending
surgeon of record and to the user who edited the record with case details for follow-up.
Example: Warning Message to Provider
The following codes are no longer active and will be deleted for case #:242
PRINCIPAL CPT CODE:
CPT MODIFIER:
00869
23 UNUSUAL ANESTHESIA
New active codes must be re-entered. A MailMan message will be sent to
the provider and attending provider of record and to the user who edited
the record with case details for follow-up.
The following sample MailMan message is sent to the surgeon, attending surgeon of record, and to the
user who edited the record. The sample shows ICD-9 codes, CPT codes, and CPT modifiers that are
inactive.
April 2004
Surgery V. 3.0 User Manual
525
Example: MailMan Message to Surgeon
Subj: ICD-9 OR CPT CODE DELETION [#43805] 01/15/[email protected]:00
1 line
From: SURGERY PACKAGE In 'IN' basket.
Page 1
------------------------------------------------------------------Patient: SURPATIENT,TWELVE
CASE #: 12426
OPERATION DATE: 1/15/03
HERNIA REPAIR
The following codes are no longer active and were deleted for this case when the TIME PAT IN OR
field was entered.
PRINCIPAL CPT CODE:
CPT MODIFIER:
99900
08
PRINCIPAL DIAGNOSIS CODE:
600.0
New active codes must be re-entered.
Enter message action (in IN basket): Ignore//
For Non-O.R. procedures, the MailMan message is sent to the provider and attending provider.
Example: MailMan Message to Provider
Subj: ICD-9 OR CPT CODE DELETION [#88073] 06/26/[email protected]:32 12 lines
From: SURGERY PACKAGE In 'IN' basket.
Page 1 *New*
------------------------------------------------------------------------------Patient: SURPATIENT,ONE
CASE #: 242
OPERATION DATE: JUN 26, 2003
STELLATE NERVE BLOCK
The following codes are no longer active and were deleted for this
case when the Time Procedure Began was entered.
PRINCIPAL CPT CODE:
CPT MODIFIER:
00869
23 UNUSUAL ANESTHESIA
New active codes must be re-entered.
Enter message action (in IN basket): Ignore//
The following options allow for re-validation of the ICD-9 and CPT codes and modifiers when the TIME
PAT IN OR field or TIME PROCEDURE BEGAN field is entered.
Operation
Operation (Short Screen)
Edit Non-O.R. Procedure
Operation Information (Enter/Edit)
Resource Data
526
Surgery V. 3.0 User Manual
April 2004
Chapter Eight: Assessing Transplants
Introduction
The Transplant Assessment module allows qualified personnel to create and manage transplant
assessments. Menu options provide the ability to enter transplant assessment information for a patient and
transmit the assessment to the Veterans Affairs Surgery Quality Improvement Program (VASQIP)
national databases. Options are also provided to print and list transplant assessments.
April 2004
Surgery V. 3.0 User Manual
527
(This page included for two-sided copying.)
528
Surgery V. 3.0 User Manual
April 2004
Transplant Assessment Menu
[SR TRANSPLANT ASSESSMENT]
The Transplant Assessment Menu contains options that allow transplant coordinators to create and
manage transplant assessments for the following transplant types.
Kidney
Liver
Lung
Heart
The menu options provide the opportunity to enter information concerning a new transplant assessment
and to edit, list, print, and update an existing patient assessment.
This menu is locked with the SR TRANSPLANT security key.
This chapter follows the main menu of the Transplant Assessment module and contains descriptions of
the options and sub-options needed to maintain a transplant assessment, transmit data, and create reports.
The options are organized to follow a logical workflow sequence. Each option description is divided into
two main parts: an overview and a detailed example.
The top-level options included in this menu are listed in the following table. To the left is the shortcut
synonym that the user can enter to select the option.
Shortcut
E
P
L
S
April 2004
Option Name
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Surgery V. 3.0 User Manual
529
(This page included for two-sided copying.)
530
Surgery V. 3.0 User Manual
April 2004
Enter/Edit Transplant Assessments
[SR TRANSPLANT ENTER/EDIT]
Transplant coordinators use the Enter/Edit Transplant Assessments option to enter a new transplant
assessment. This option is also used to make changes to an assessment that has already been entered. This
option also allows the assessment to be completed and transmitted.
Creating a New Transplant Assessment
Perform the following steps to create a transplant assessment.
1. The user is prompted to select a patient name which will display any previously entered assessments
for the patient selected. The user can then choose to create a new assessment.
2. After choosing to create a new assessment, the user will select one of the following transplant types.
Kidney
Liver
Lung
Heart
Note: The ability to select a transplant type is based on how your transplant assessment parameters
are set. Your facility may not perform every type of transplant.
3. After choosing a transplant type, the user responds to the prompt, “Is this a VA or a Non-VA
Transplant (V or N):” with one of the following responses.
V for VA
N for non-VA
Note: If the user identifies the transplant as non-VA, the user will be asked to enter the transplant
date.
Note: If the user identifies the transplant as VA, the user will be asked to associate the assessment
with an existing Surgery case.
4. The user then supplies a VACO ID number and presses <Enter>. A series of data entry forms appear
and must be filled in to complete the transplant assessment.
If assistance is needed while interacting with the software, the user should enter one or two question
marks (??) to access the on-line help.
April 2004
Surgery V. 3.0 User Manual
531
Example: Creating a New Transplant Assessment
In our example for creating a new transplant assessment, a VA Kidney Transplant will be created. The
process for creating a lung, liver, and heart transplant assessments is similar. Because the option works
the same for creating these other organ transplant assessments, a specific example for these other organs
will not be displayed.
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: E Enter/Edit Transplant Assessments
Select Patient:
SURPATIENT,NINETYSIX
SURPATIENT,NINETYSIX
1.
----
05-05-64
666000288
NSC VETERAN
666-00-0288
CREATE NEW TRANSPLANT ASSESSMENT
Select Assessment: 1
1.
2.
3.
4.
Kidney
Liver
Lung
Heart
Select Type of Transplant:
(1-4):1
Is this a VA or a Non-VA Transplant (V or N): V
SURPATIENT,NINETYSIX
666-00-0288
1. 09-03-98
APPENDECTOMY (COMPLETED)
2. 06-17-08
KIDNEY TRANSPLANT (COMPLETED)
Select Operation: 2
Sure you want to create a Transplant Assessment for this surgical case? YES// Y
VACO ID: 12121
532
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 1 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RECIPIENT INFORMATION
-------------------------------------------------------------------------------1. VACO ID:
12121
2. Date Placed on Waiting:
3. Date Started Dialysis:
4. Recipient ABO Blood Type:
5. Recipient CMV:
Diagnosis Information
======================
6. Calcineurin Inhibitor Toxicity:
7. Glomerular Sclerosis/Nephritis:
8. Graft Failure:
9. IgA Nephropathy:
10. Lithium Toxicity:
11. Membranous Nephropathy:
13.
14.
15.
16.
Obstructive Uropathy from BPH:
Polycistic Disease:
Renal Cancer:
Rejection:
12. Transplant Comments:
------------------------------------------------------------------------------Select Transplant Information to Edit: 2:5
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
JUN 17,2008
KIDNEY TRANSPLANT
--------------------------------------------------------------------------------
Date Placed on Waiting List: 05/04/2008 (MAY 04, 2008)
Date Started Dialysis: 1 21 08 (JAN 21, 2008)
Recipient ABO Blood Type: O O
Recipient CMV: + POSITIVE
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 1 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RECIPIENT INFORMATION
-------------------------------------------------------------------------------1. VACO ID:
12121
2. Date Placed on Waiting:
MAY 04, 2008
3. Date Started Dialysis:
JAN 21, 2008
4. Recipient ABO Blood Type: O
5. Recipient CMV:
POSITIVE
Diagnosis Information
======================
6. Calcineurin Inhibitor Toxicity:
13. Obstructive Uropathy from BPH:
7. Glomerular Sclerosis/Nephritis:
14. Polycistic Disease:
8. Graft Failure:
15. Renal Cancer:
9. lgA Nephropathy:
16. Rejection:
10. Lithium Toxicity:
11. Membranous Nephropathy:
12. Transplant Comments:
------------------------------------------------------------------------------Select Transplant Information to Edit: <Enter>
April 2004
Surgery V. 3.0 User Manual
533
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 2 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
KIDNEY TRANSPLANT INFORMATION
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
Warm Ischemia time:
Cold Ischemia time:
Total Ischemia time:
Crossmatch D/R:
PRA at Listing:
PRA at Transplant:
IVIG Recipient:
Plasmapheresis:
HLA Typing (#,#,#,#)
====================
9. Recipient HLA-A:
10. Recipient HLA-B:
11. Recipient HLA-C:
12. Recipient HLA-DR:
13. Recipient HLA-BW:
14. Recipient HLA-DQ:
------------------------------------------------------------------------------Select Transplant Information to Edit: <Enter>
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 3 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RISK ASSESSMENT
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Diabetic Retinopathy:
Diabetic Neuropathy:
Cardiac Disease:
Liver Disease:
HIV + (positive):
Lung Disease:
Pre-Transplant Malignancy:
Active Infection Immediately Pre-TX req. Antibiotics:
Non-Compliance (Med and Diet):
Recipient Substance Abuse:
Post-TX Prophylaxis for CMV/Antiviral Treatment:
Post-TX Prophylaxis for PCP/Antibiotic Treatment:
Post-TX Prophylaxis for TB/Antimycobacterial Treatment:
Graft Failure Date:
------------------------------------------------------------------------------Select Transplant Information to Edit: <Enter>
534
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 4 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
DONOR INFORMATION
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Donor Race:
Donor Gender:
Donor Height:
Donor Weight:
Donor DOB:
Donor Age:
Donor ABO Blood Type:
Donor CMV:
Donor Substance Abuse:
Deceased Donor:
Living Donor:
Donor with Malignancy:
HLA Typing (#,#,#,#)
====================
13. Donor HLA-A:
14. Donor HLA-B:
15. Donor HLA-C:
16. Donor HLA-DR:
17. Donor HLA-BW:
18. Donor HLA-DQ:
------------------------------------------------------------------------------Select Transplant Information to Edit: <Enter>
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 5 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
PANCREAS INFORMATION
-------------------------------------------------------------------------------1.
2.
3.
4.
5.
6.
7.
8.
9.
Pancreas (SPK/PAK):
Glucose at Time of Listing:
C-peptide at Time of Listing:
Pancreatic Duct Anastomosis:
Glucose Post Transplant:
Amylase Post Transplant:
Lipase Post Transplant:
Insulin Req Post transplant:
Oral Hypoglycemics Req Post-TX:
NO
NO
NO
NO
NO
NO
NO
NO
NO
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
------------------------------------------------------------------------------Select Transplant Information to Edit: <Enter>
Are you ready to complete and transmit this transplant assessment? NO// <Enter>
April 2004
Surgery V. 3.0 User Manual
535
Edit a Transplant Assessment
When selecting an existing transplant assessment, the user has the following options.
Enter Transplant Assessment Information
Delete Transplant Assessment Entry
Update Transplant Assessment Status to 'COMPLETE'
Change VA/Non-VA Transplant Indicator
Enter Transplant Assessment Information
Example: Editing a Transplant Assessment
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: E Enter/Edit Transplant Assessments
Select Patient:
SURPATIENT,NINETYSIX
SURPATIENT,NINETYSIX
05-05-64
NSC VETERAN
666-00-0288
1. 06-17-08
KIDNEY TRANSPLANT (INCOMPLETE)
2.
CREATE NEW TRANSPLANT ASSESSMENT
----
666000288
Select Assessment: 1
SURPATIENT,NINETYSIX
06-17-06
1.
2.
3.
4.
KIDNEY TRANSPLANT (INCOMPLETE)
Enter Transplant Assessment Information
Delete Transplant Assessment Entry
Update Transplant Assessment Status to 'COMPLETE'
Change VA/Non-VA Transplant Indicator
Select Number: 1// <Enter>
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 1 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RECIPIENT INFORMATION
-------------------------------------------------------------------------------1. VACO ID:
12121
2. Date Placed on Waiting:
MAY 04, 2008
3. Date Started Dialysis:
JAN 21, 2008
4. Recipient ABO Blood Type: O
5. Recipient CMV:
POSITIVE
Diagnosis Information
======================
6. Calcineurin Inhibitor Toxicity:
13. Obstructive Uropathy from BPH:
7. Glomerular Sclerosis/Nephritis:
14. Polycistic Disease:
8. Graft Failure:
15. Renal Cancer:
9. lgA Nephropathy:
16. Rejection:
10. Lithium Toxicity:
11. Membranous Nephropathy:
12. Transplant Comments:
------------------------------------------------------------------------------Select Transplant Information to Edit: 6
536
Surgery V. 3.0 User Manual
April 2004
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
JUN 17,2008
KIDNEY TRANSPLANT
CASE: 482
--------------------------------------------------------------------------------
Calcineurin Inhibitor Toxicity: Y
YES
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 1 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RECIPIENT INFORMATION
-------------------------------------------------------------------------------1. VACO ID:
12121
2. Date Placed on Waiting:
MAY 04, 2008
3. Date Started Dialysis:
JAN 21, 2008
4. Recipient ABO Blood Type: O
5. Recipient CMV:
POSITIVE
Diagnosis Information
======================
6. Calcineurin Inhibitor Toxicity: YES 13. Obstructive Uropathy from BPH:
7. Glomerular Sclerosis/Nephritis:
14. Polycistic Disease:
8. Graft Failure:
15. Renal Cancer:
9. lgA Nephropathy:
16. Rejection:
10. Lithium Toxicity:
11. Membranous Nephropathy:
12. Transplant Comments:
------------------------------------------------------------------------------Select Transplant Information to Edit: 7:10
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
JUN 17,2008
KIDNEY TRANSPLANT
--------------------------------------------------------------------------------
Glomerular Sclerosis/Nephritis: Y
Graft Failure: N NO
IgA Nephropathy: N NO
Lithium Toxicity: Y YES
YES
SURPATIENT,NINETYSIX (0288)
VACO ID: 12121
CASE: 482
PAGE: 1 OF 5
JUN 17,2008
KIDNEY TRANSPLANT
RECIPIENT INFORMATION
-------------------------------------------------------------------------------1. VACO ID:
12121
2. Date Placed on Waiting:
MAY 04, 2008
3. Date Started Dialysis:
JAN 21, 2008
4. Recipient ABO Blood Type: O
5. Recipient CMV:
POSITIVE
Diagnosis Information
======================
6. Calcineurin Inhibitor Toxicity: YES 13. Obstructive Uropathy from BPH:
7. Glomerular Sclerosis/Nephritis: YES 14. Polycistic Disease:
8. Graft Failure:
NO
15. Renal Cancer:
9. lgA Nephropathy:
NO
16. Rejection:
10. Lithium Toxicity:
YES
11. Membranous Nephropathy:
12. Transplant Comments:
------------------------------------------------------------------------------Select Transplant Information to Edit: ^
April 2004
Surgery V. 3.0 User Manual
537
Deleting a Transplant Assessment
Example: Deleting a Transplant Assessment
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: E Enter/Edit Transplant Assessments
Select Patient:
SURPATIENT,NINETYONE
SURPATIENT,NINETYONE
05-05-64
NSC VETERAN
666-00-0288
1. 07-25-08
HEART TRANSPLANT (INCOMPLETE)
2.
CREATE NEW TRANSPLANT ASSESSMENT
----
666000288
Select Assessment: 1
SURPATIENT,NINETYONE
07-25-08
1.
2.
3.
4.
666-00-0288
HEART TRANSPLANT (INCOMPLETE)
Enter Transplant Assessment Information
Delete Transplant Assessment Entry
Update Transplant Assessment Status to 'COMPLETE'
Change VA/Non-VA Transplant Indicator
Select Number: 1// 2
Are you sure that you want to delete this assessment ? NO// Y
Deleting Transplant Assessment...
Press <RET> to continue <Enter>
538
Surgery V. 3.0 User Manual
April 2004
Update a Transplant Assessment to Complete
Upon leaving the last data entry page, the following prompt appears.
Are you ready to complete and transmit this transplant assessment NO//
If the user presses <Enter>, the assessment remains incomplete and not transmitted. If the user enters
YES, the assessment is completed and transmitted immediately.
Alternatively, the user can complete and transmit the assessment using the following screen below.
Example: Update a Transplant Assessment to Complete
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: E Enter/Edit Transplant Assessments
Select Patient:
SURPATIENT,NINETYTHREE
SURPATIENT,NINETYTHREE
08-08-08
1.
2.
3.
4.
05-05-64
666000288
NSC VETERAN
666-00-0288
LUNG TRANSPLANT (INCOMPLETE)
Enter Transplant Assessment Information
Delete Transplant Assessment Entry
Update Transplant Assessment Status to 'COMPLETE'
Change VA/Non-VA Transplant Indicator
Select Number: 1// 3
Are you ready to complete and transmit this transplant assessment NO// YES
April 2004
Surgery V. 3.0 User Manual
539
Change VA/Non-VA Transplant Indicator
Example: Changing the Transplant Indicator
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: E Enter/Edit Transplant Assessments
Select Patient:
SURPATIENT,ONE
08-08-08
1.
2.
3.
4.
SURPATIENT,ONE
05-05-64
666000288
NSC VETERAN
666-00-0288
LUNG TRANSPLANT (INCOMPLETE)
Enter Transplant Assessment Information
Delete Transplant Assessment Entry
Update Transplant Assessment Status to 'COMPLETE'
Change VA/Non-VA Transplant Indicator
Select Number: 1// 4
This assessment has a current status of 'Incomplete'
The Transplant Assessment Indicator is a Non-VA type
Are you sure that you want to change the indicator to VA? NO// Y
SURPATIENT,ONE
1. 08-08-08
666-00-0288
LUNG TRANSPLANT (COMPLETE)
Select Operation: 1
Sure you want to assign this Surgical case to the Transplant Assessment? YES//<Enter>
Changing Assessment type...
Press <RET> to continue <Enter>
540
Surgery V. 3.0 User Manual
April 2004
Print Transplant Assessment
[SRTP PRINT ASSESSMENT]
The Print Transplant Assessment option is used to print a single Surgery transplant assessment.
The following example demonstrates how to print a transplant assessment.
Printing a Transplant Assessment
1. The user is prompted to select a patient name which will display any previously entered assessments
for that patient. The user can then choose an assessment.
2. After choosing the assessment, the user will select a printing device.
3. The assessment displays.
If assistance is needed while interacting with the software, the user should enter one or two question
marks (??) to access the on-line help.
April 2004
Surgery V. 3.0 User Manual
541
Example: Printing a Transplant Assessment
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: P
Select Patient:
SURPATIENT,NINETYFIVE
SURPATIENT,NINETYFIVE
1. 07-28-08
Print Transplant Assessment
05-05-34
234516666
NSC VETERAN
234-51-6666
KIDNEY TRANSPLANT (INCOMPLETE)
Select Assessment: 1
Print the Transplant Assessment on which Device: HOME// ENTER PRINTER NAME
---------------------------------------------------------printout follows-------------------------------------------------KIDNEY TRANSPLANT ASSESSMENT
VA SURGERY CASE #482
PAGE 1
FOR SURPATIENT,NINETYSIX 666-00-0288 (INCOMPLETE)
Medical Center: ALBANY
================================================================================
RECIPIENT INFORMATION
Age:
Gender:
VACO ID:
74
Transplant Date:
JULY 28, 2008
Ethnicity: UNANSWERED
Race:
UNANSWERED
12121
Date Placed on Waiting:
Date Started Dialysis:
Calcineurin Inhibitor Toxicity:
Glomerular Sclerosis/Nephritis:
Graft Failure:
IgA Nephropathy:
Lithium Toxicity:
YES
NO
NO
YES
Recipient CMV:
Recipient ABO Blood Type:
Membranous Nephropathy:
Obstructive Uropathy from BPH:
Polycistic Disease:
Renal Cancer:
Rejection:
Transplant Comments:
KIDNEY TRANSPLANT INFORMATION
Ischemia Time for Organ (minutes)
- Warm Ischemia:
- Cold Ischemia:
- Total Ischemia:
Crossmatch D/R:
PRA at Listing:
PRA at Transplant:
IVIG Recipient:
Plasmapheresis:
542
Recipient
Recipient
Recipient
Recipient
Recipient
Recipient
HLA-A:
HLA-B:
HLA-C:
HLA-DR:
HLA-BW:
HLA-DQ:
Surgery V. 3.0 User Manual
April 2004
RISK ASSESSMENT
Diabetic Retinopathy:
Diabetic Neuropathy:
Cardiac Disease:
Liver Disease:
HIV + (positive):
Lung Disease:
Pre-Transplant Malignancy:
Active Infection Immediately
Pre-Trans Req. Antibiotics:
Non-Compliance (Med and Diet):
Recipient Substance Abuse:
Post Transplant Prophylaxis for
- CMV/Antiviral Treatment:
- PCP/Antibiotic Treatment:
- TB/Antimycobacterial Treatment:
Graft Failure Date:
DONOR INFORMATION
Donor Race:
Donor Gender:
Donor Height:
Donor Weight:
Donor DOB:
Donor Age:
ABO Blood Type:
Donor CMV:
Substance Abuse:
Deceased Donor:
Living Donor:
With Malignancy:
Donor
Donor
Donor
Donor
Donor
Donor
HLA-A:
HLA-B:
HLA-C:
HLA-DR:
HLA-BW:
HLA-DQ:
KIDNEY TRANSPLANT ASSESSMENT
VA SURGERY CASE #482
PAGE 2
FOR SURPATIENT,NINETYSIX 666-00-0288 (INCOMPLETE)
Medical Center: ALBANY
================================================================================
PANCREAS INFORMATION
Pancreas (SPK/PAK):
Glucose at Time of Listing:
C-peptide at Time of Listing:
Pancreatic Duct Anastomosis:
Glucose Post Transplant:
Amylase Post Transplant:
Lipase Post Transplant:
Insulin Req Post Transplant:
Oral Hypoglycemics Req. Post TX:
April 2004
NO
NO
NO
NO
NO
NO
NO
NO
NO
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
STUDY
Surgery V. 3.0 User Manual
543
List of Transplant Assessments
[SRTP ASSESSMENT LIST]
The List of Transplant Assessments option is used to print a list of Surgery transplant assessments.
The following example demonstrates how to print a list of transplant assessments.
Printing a List of Transplant Assessments
1. The user is prompted to enter a start date and end date.
2. After choosing a date range, the user will select one of the following transplant assessment list
types.
Incomplete Only
Transmitted/Complete
All
3. After choosing a transplant assessment list type, the user will select one of the following
transplant types.
Kidney
Liver
Lung
Heart
All
4. If the facility is multi-divisional, after choosing a transplant type, the user responds to the prompt,
“Do you want to print all divisions? YES//.” The user should respond YES to print all divisions,
or NO and then select a single division.
5. At the “Print the List of Transplant Assessments to which Device:” prompt, select a printer or
print to the screen.
6. The list of transplant assessments prints.
If assistance is needed while interacting with the software, the user should enter one or two question
marks (??) to access the on-line help.
544
Surgery V. 3.0 User Manual
April 2004
Example: List of Transplant Assessments
Division: ALBANY
E
P
L
S
(500)
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: L
List of Transplant Assessments
Start with Date: 070708 (JUL 07, 2008)
End with Date: 083008 (AUG 30, 2008)
Print which Assessment Status ?
1. Incomplete Only
2. Complete/Transmitted
3. ALL
Select Number:
(1-3): 3// 3
Select Type of Transplant ?
1.
2.
3.
4.
5.
Kidney
Liver
Lung
Heart
ALL
Select Number:
(1-5): 5// 5
Do you want to print all divisions? YES// <ENTER>
This report is designed to print to your terminal screen or a printer. When
using a printer, a 132 column format is used.
Print the List of Transplant Assessments to which Device: HOME// <ENTER>
LIST OF TRANSPLANT ASSESSMENTS
FROM: JUL 7,2008 TO: AUG 30,2008
VACO ID
PATIENT
TRANSPLANT DATE STATUS
SURGERY CASE # ORGAN TYPE
===============================================================================
22222
SURPATIENT,EIGHTY (666-00-0038)
JUL 09, 2008
INCOMPLETE
N/A
HEART
------------------------------------------------------------------------------179992
SURPATIENT,EIGHTY (666-00-0038)
JUL 21, 2008
INCOMPLETE
N/A
LIVER
------------------------------------------------------------------------------107992
SURPATIENT,EIGHTY (666-00-0038)
JUL 21, 2008
INCOMPLETE
N/A
LUNG
------------------------------------------------------------------------------62345
SURPATIENT,N. (666-00-0279)
JUL 25, 2008
INCOMPLETE
N/A
HEART
------------------------------------------------------------------------------Press <RET> to continue, or '^' to quit
April 2004
Surgery V. 3.0 User Manual
545
Transplant Assessment Parameters (Enter/Edit)
[SR TRANSPLANT PARAMETERS]
The transplant coordinator uses the Transplant Assessment Parameters (Enter/Edit) option to change the
list of organ transplants assessed at their VA facility. The values entered for these parameters will limit
the choices displayed when entering a transplant assessment.
The following example demonstrates how to change transplant assessment parameters.
Changing Transplant Assessment Parameters
1. The user should enter a surgery site at the prompt, “Edit Parameters for which Surgery Site”.
2. After entering a surgery site, the user should verify the chosen surgery site (which displays) and
should choose YES at the prompt, “...OK? Yes//”.
3. The user can change any of the following parameter options.
Kidney transplants assessed:
Liver transplants assessed:
Lung transplants assessed:
Heart transplants assessed:
546
Surgery V. 3.0 User Manual
April 2004
Example: Changing Transplant Assessment Parameters
In this example, the facility does Kidney and Liver Transplant Assessments.
Division: ALBANY
E
P
L
S
Enter/Edit Transplant Assessments
Print Transplant Assessment
List of Transplant Assessments
Transplant Assessment Parameters (Enter/Edit)
Select Transplant Assessment Menu Option: S
Edit Parameters for which Surgery Site:
...OK? Yes//<Enter>
ALBANY
1
2
3
4
(500)
Transplant Assessment Parameters (Enter/Edit)
ALBANY
NY
VAMC
(500)
500
PAGE 1 OF 1
KIDNEY TRANSPLANTS ASSESSED:
LIVER TRANSPLANTS ASSESSED:
LUNG TRANSPLANTS ASSESSED:
HEART TRANSPLANTS ASSESSED:
Enter Screen Server Function: 1:4
KIDNEY TRANSPLANTS ASSESSED: YES
LIVER TRANSPLANTS ASSESSED: YES
LUNG TRANSPLANTS ASSESSED: NO
HEART TRANSPLANTS ASSESSED: NO
ALBANY
1
2
3
4
(500)
PAGE 1 OF 1
KIDNEY TRANSPLANTS ASSESSED: YES
LIVER TRANSPLANTS ASSESSED: YES
LUNG TRANSPLANTS ASSESSED: NO
HEART TRANSPLANTS ASSESSED: NO
Enter Screen Server Function:
April 2004
Surgery V. 3.0 User Manual
547
(This page included for two-sided copying.)
548
Surgery V. 3.0 User Manual
April 2004
Chapter Nine: Glossary
The following table contains terms that are used throughout the Surgery V.3.0 User Manual, and will aid
the user in understanding the use of the Surgery package.
Term
Definition
Aborted
Case status indicating the case was cancelled after the patient entered the
operating room. Cases with ABORTED status must contain entries in TIME
PAT OUT OR field (#.205) and/or TIME PAT IN OR field (#.232), plus
CANCEL DATE field (#17) and/or CANCEL REASON field (#18).
This is the American Society of Anesthesiologists classification relating to the
patient‟s physiologic status. Numbers followed by an 'E' indicate an
emergency.
Code that corresponds to the highest level of supervision provided by the
attending staff surgeon during the procedure.
Graph showing the availability of operating rooms.
Case status indicating that an entry has been made in the CANCEL DATE
field and/or the CANCEL REASON field without the patient entering the
operating room.
VA Center for Cooperative Studies in Health Services located at Hines,
Illinois.
Continuous Improvement in Cardiac Surgery Program.
Case status indicating that an entry has been made in the TIME PAT OUT OR
field.
A patient undergoing two operations by different surgical specialties at the
same time, or back to back, in the same operating room.
Also called Operation Code. CPT stands for Current Procedural Terminology.
Cathode ray tube display. A display device that uses a cathode ray tube.
Perioperative occurrence during the procedure.
ASA Class
Attending Code
Blockout Graph
Cancelled Case
CCSHS
CICSP
Completed Case
Concurrent Case
CPT Code
CRT
Intraoperative
Occurrence
Major
Minor
New Surgical Case
Non-Operative
Occurrence
Not Complete
NSQIP
Operation Code
April 2004
Any operation performed under general, spinal, or epidural anesthesia plus all
inguinal herniorrhaphies and carotid endarterectomies regardless of anesthesia
administered.
All operations not designated as Major.
A surgical case that has not been previously requested or scheduled such as an
emergency case. A surgical case entered in the records without being booked
through scheduling will not appear on the Schedule of Operations or as an
operative request.
Occurrence that develops before a surgical procedure is performed.
Case status indicating one of the following two situations with no entry in the
TIME PAT OUT OR field (#.232).
1) Case has entry in TIME PAT IN OR field (#.205).
2) Case has not been requested or scheduled.
National Surgical Quality Improvement Program.
Identifying code for reporting medical services and procedures performed by
physicians. See CPT Code.
Surgery V. 3.0 User Manual
549
PACU
Postoperative
Occurrence
Procedure Occurrence
Requested
Risk Assessment
Scheduled
Screen Server
Screen Server
Function
Service Blockouts
Transplant
Assessments
VASQIP
550
Post Anesthesia Care Unit.
Perioperative occurrence following the procedure.
Occurrence related to a non-O.R. procedure.
Operation has been slotted for a particular day but the time and operating room
are not yet firm.
Part of the Surgery software that provides medical centers a mechanism to
track information related to surgical risk and operative mortality. Completed
assessments are transmitted to the VASQIP national database for statistical
analysis.
Operation has both an operating room and a scheduled starting time, but the
operation has not yet begun.
A format for displaying data on a cathode ray tube display. Screen Server is
designed specifically for the Surgery Package.
The Screen Server prompt for data entry.
The reservation of an operating room for a particular service on a recurring
basis. The reservation is charted on a blockout graph.
Part of the Surgery software that provides medical centers a mechanism to
track information related to transplant risk and operative mortality. Completed
assessments are transmitted to the VASQIP national database for statistical
analysis.
Veterans Affairs Surgery Quality Improvement Program.
Surgery V. 3.0 User Manual
April 2004
Index
A
coding
checking accuracy of procedures, 311
entry, 207
validation, 207
AAIS, 437, 438
anesthesia
comments
agents, 130, 162
entering data, 163
printing information, 170
staff, 164
techniques, 162
adding, 205
completed cases, 355, 357
PCE filing status of, 238, 273
report of, 232, 234, 257, 265, 267
reports on, 252
staffing information for, 285
surgical priority, 269
anesthesia agents
flagging a drug, 431
anesthesia personnel, 61, 130
complications, 94, 460
concurrent case, 94
assigning, 173
scheduling, 84
anesthesia technique
adding, 74
defined, 15
scheduling, 61
scheduling unrequested operations, 69
entering information, 165, 173
assessment
changing existing, 465
changing status of, 487
creating new, 465
upgrading status of, 465
condensed characters, 26
count clinic
active, 278
Automated Anesthesia Information System
(AAIS), 437, 438
B
bar code reader, 160
blockout an operating room, 86
blockout graph, 60
Blood Bank, 160
blood product
label, 160
verification, 160
book an operation, 25
book concurrent operation, 45
C
cancellation rates
calculations, 347
CPT codes, 59, 207, 220, 224, 255, 525
CPT modifiers, 525
cultures, 155, 197
cutoff time, 15, 42
D
death totals, 378
deaths
reviewing, 330
within 30 days of surgery, 183, 327
within 90 days of surgery, 330
delays
reasons for, 340
devices, 157
updating list of, 429
diagnosis, 115, 208, 238, 273
dosage, 159, 169
downloading Surgery set of codes, 438
case
cancelled, 345
cardiac, 465
delayed, 338
designation, 97
editing cancelled, 400
list of requested, 57
scheduled, 97, 345
updating the cancellation date, 83
updating the cancellation reason, 83
verifying, 352
Chief of Surgery, 178, 251, 398
Code Set Versioning, 525
April 2004
E
electronically signing a report
Anesthesia Report, 133, 136
Nurse Intraoperative Report, 148
Enter/Edit Transplant Assessments, 531
F
flag a drug, 431
Surgery V. 3.0 User Manual
551
entering, 176
intraoperative, 330, 460, 475
adding information about an, 176
M&M Verification Report, 330
number of for delayed operations, 340
postoperative, 330, 462
reviewing, 330
viewing, 325
G
Glossary, 549
H
HL7, 434, 435, 439
master file updates, 437, 438
Operating Room
hospital admission, 385
determining use of, 414
entering information, 413
percent utilization, 361
rescheduling, 74
reserving on a recurring basis, 86
utilization reports, 415
viewing availability of, 26
viewing availability of, 60
I
ICD9 codes, 207, 525
interim reports, 320
intraoperative occurrence
entering, 460, 475
Operating Room Schedule, 89, 253
operation
irrigation solutions, 157
K
KERNEL audit log, 393
Key Missing Surgical Package Data, 394a
L
laboratory information, 96
entering, 452
Laboratory Package, 320
list of requested cases, 57
List of Transplant Assessments, 544
M
operation information
entering or editing, 456
medical administration, 96
medications, 159, 169
mortality and morbidity rates, 183, 326
multiple fields, 110
operation request
deleting, 36
printing a list, 53
Options
N
new surgical case, 102
non-count encounters, 278
non-O.R. procedure, 187
deleting data, 188
editing data, 188
entering data, 188
NSQIP transmission process, 521
nurse staffing information, 295
nursing care, 142
O
occurrence, 180
adding information about a postoperative, 178
editing, 176
552
book concurrent, 45
booking, 25, 59
canceling scheduled, 81
close of, 121
delayed, 110, 338, 340
discharge, 121
outstanding requests, 28
patient preparation, 110
post anesthesia recovery, 121
requesting, 25
rescheduling, 74
scheduled, 26
scheduled by surgical specialty, 92
scheduling requested, 59
scheduling unrequested, 64
starting time, 115
Admissions Within 14 Days of Outpatient Surgery, 394c
Anesthesia Data Entry Menu, 163
Anesthesia for an Operation Menu, 130
Anesthesia Information (Enter/Edit), 164
Anesthesia Menu, 162
Anesthesia Provider Report, 304
Anesthesia Report, 133, 170
Anesthesia Reports, 297
Anesthesia Technique (Enter/Edit), 165
Annual Report of Non-O.R. Procedures, 196
Annual Report of Surgical Procedures, 255
Attending Surgeon Reports, 285
Blood Product Verification, 160
Cancel Scheduled Operation, 81
Cardiac Procedures Requiring CPB (Enter/Edit), 473
Chief of Surgery, 324
Chief of Surgery Menu, 322
Circulating Nurse Staffing Report, 295
Clinical Information (Enter/Edit), 467
Comments Option, 205
Surgery V. 3.0 User Manual
April 2004
Comparison of Preop and Postop Diagnosis, 335
CPT Code Reports, 306
CPT/ICD Coding Menu, 207
CPT/ICD Update/Verify Menu, 208
Create Service Blockout, 86
Cumulative Report of CPT Codes, 220, 307
Deaths Within 30 Days of Surgery, 395
Delay and Cancellation Reports, 337
Delete a Patient from the Waiting List, 23
Delete or Update Operation Requests, 36
Delete Service Blockout, 88
Display Availability, 26, 60
Edit a Patient on the Waiting List, 22
Edit Non-O.R. Procedure, 190
Ensuring Correct Surgery Compliance Report, 395
Enter a Patient on the Waiting List, 21
Enter Cardiac Catheterization & Angiographic Data,
469
Enter Irrigations and Restraints, 157
Enter PAC(U) Information, 123
Enter Referring Physician Information, 156
Enter Restrictions for 'Person' Fields, 426
Exclusion Criteria (Enter/Edit), 507
File Download, 437
Flag Drugs for Use as Anesthesia Agents, 431
Flag Interface Fields, 435
Intraoperative Occurrences (Enter/Edit), 176, 460, 475
Laboratory Interim Report, 320
Laboratory Test Results (Enter/Edit), 452, 469
List Completed Cases Missing CPT Codes, 230, 317
List of Anesthetic Procedures, 300
List of Invasive Diagnostic Procedures, 387
List of Operations, 232, 257
List of Operations (by Postoperative Disposition), 259
List of Operations (by Surgical Priority), 267
List of Operations (by Surgical Specialty), 234, 265
List of Surgery Risk Assessments, 489
List of Unverified Surgery Cases, 352
List Operation Requests, 57
List Scheduled Operations, 92
M&M Verification Report, 330, 513
Maintain Surgery Waiting List menu, 17
Make a Request for Concurrent Cases, 45
Make a Request from the Waiting List, 42
Make Operation Requests, 28
Make Reports Viewable in CPRS, 440
Management Reports, 252, 326
Medications (Enter/Edit), 159, 169
Monthly Surgical Case Workload Report, 509
Morbidity & Mortality Reports, 183, 327
Non-Cardiac Risk Assessment Information (Enter/Edit),
445
Non-O.R. Procedures, 187
Non-O.R. Procedures (Enter/Edit), 188
Non-Operative Occurrence (Enter/Edit), 180
Normal Daily Hours (Enter/Edit), 417
Nurse Intraoperative Report, 142, 217
Operating Room Information (Enter/Edit), 413
Operating Room Utilization (Enter/Edit), 415
Operating Room Utilization Report, 361, 419
Operation, 115
Operation (Short Screen), 124
April 2004
Operation Information, 105
Operation Information (Enter/Edit), 456
Operation Menu, 96
Operation Report, 131
Operation Requests for a Day, 53
Operation Startup, 110
Operation/Procedure Report, 213
Operative Risk Summary Data (Enter/Edit), 471
Outpatient Encounters Not Transmitted to NPCD, 278
Patient Demographics (Enter/Edit), 458
PCE Filing Status Report, 238, 273
Perioperative Occurrences Menu, 175
Person Field Restrictions Menu, 425
Post Operation, 121
Postoperative Occurrences (Enter/Edit), 178, 462, 477
Print 30 Day Follow-up Letters, 503
Print a Surgery Risk Assessment, 481
Print Blood Product Verification Audit Log, 393
Print Surgery Waiting List, 18
Procedure Report (Non-O.R.), 194
Purge Utilization Information, 424
Queue Assessment Transmissions, 521
Remove Restrictions on 'Person' Fields, 428
Report of Cancellation Rates, 347
Report of Cancellations, 345
Report of Cases Without Specimens, 357
Report of CPT Coding Accuracy, 224, 311
Report of Daily Operating Room Activity, 236, 271, 355
Report of Delay Reasons, 340
Report of Delay Time, 342
Report of Delayed Operations, 338
Report of Non-O.R. Procedures, 198, 243
Report of Normal Operating Room Hours, 421
Report of Returns to Surgery, 353
Report of Surgical Priorities, 269
Report of Unscheduled Admissions to ICU, 359
Request Operations menu, 25
Requests by Ward, 55
Reschedule or Update a Scheduled Operation, 74
Resource Data (Enter/Edit), 479
Review Request Information, 52
Risk Assessment, 465
Schedule Anesthesia Personnel, 84, 173
Schedule of Operations, 89, 253
Schedule Operations, 59
Schedule Requested Operation, 61
Schedule Unrequested Concurrent Cases, 69
Schedule Unrequested Operations, 64
Scrub Nurse Staffing Report, 293
Surgeon Staffing Report, 289
Surgeon‟s Verification of Diagnosis & Procedures, 127
Surgery Interface Management Menu, 434
Surgery Package Management Menu, 409
Surgery Reports, 251
Surgery Site Parameters (Enter/Edit), 410
Surgery Staffing Reports, 284
Surgery Utilization Menu, 414
Surgical Nurse Staffing Report, 291
Surgical Staff, 106
Table Download, 438
Tissue Examination Report, 155
Unlock a Case for Editing, 398
Surgery V. 3.0 User Manual
553
Update 1-Liner Case, 519
Update Assessment Completed/Transmitted in Error,
487
Update Assessment Status to „Complete‟, 465, 477, a
Update Assessment Status to „COMPLETE‟, 478
Update Cancellation Reason, 83
Update Cancelled Cases, 400
Update Interface Parameter Field, 439
Update O.R. Schedule Devices, 429
Update Operations as Unrelated/Related to Death, 401
Update Site Configurable Files, 432
Update Staff Surgeon Information, 430
Update Status of Returns Within 30 Days, 181, 399, 464
Update/Verify Procedure/Diagnosis Codes, 209, 402
View Patient Perioperative Occurrences, 325
Wound Classification Report, 363
Options:, 197, 199, 220
outstanding requests
defined, 15
P
PACU, 123
PCE filing status, 238, 273
percent utilization, 361, 419
person-type field
assigning a key, 426
removing a key, 426, 428
Pharmacy Package Coordinator, 431
positioning devices, 157
Post Anesthesia Care Unit (PACU), 123
postoperative occurrence,
entering, 462, 468, 477
preoperative assessment
entering information, 449
preoperative information, 15
editing, 52
entering, 29, 65
reviewing, 52
updating, 74
Preoperative Information (Enter/Edit), 449
principal diagnosis, 105
Printing a Transplant Assessment, 541
procedure
deleting, 23
dictating a summary, 190
editing data for non-O.R., 190
entering data for non-O.R., 190
filed as encounters, 278
summary for non-O.R., 194
purging utilization information, 424
Q
quick reference on a case, 105
554
R
Referring physician information, 156
reporting
tracking cancellations, 337
tracking delays, 337
reports
Anesthesia Provider Report, 304
Anesthesia Report, 133
Annual Report of Non-O.R. Procedures, 196
Annual Report of Surgical Procedures, 255
Attending Surgeon Cumulative Report, 285, 287
Attending Surgeon Report, 285
Cases Without Specimens, 357
Circulating Nurse Staffing Report, 295
Clean Wound Infection Summary, 367
Comparison of Preop and Postop Diagnosis, 335
Completed Cases Missing CPT Codes, 230, 317
Cumulative Report of CPT Codes, 220, 222, 307, 309
Daily Operating Room Activity, 236
Daily Operating Room Activity, 271
Daily Operating Room Activity, 326
Daily Operating Room Activity, 355
Daily Operating Room Activity, 355
Ensuring Correct Surgery Compliance Report, 395, 396
Laboratory Interim Report, 320
List of Anesthetic Procedures, 300, 302
List of Operations, 232, 257
List of Operations (by Surgical Specialty), 234
List of Operations by Postoperative Disposition, 259,
261, 263
List of Operations by Surgical Priority, 267
List of Operations by Surgical Specialty, 265
List of Operations by Wound Classification, 365
List of Unverified Cases, 352
M&M Verification Report, 330, 333, 513, 516
Monthly Surgical Case Workload Report, 509, 511
Mortality Report, 183, 327, 328
Nurse Intraoperative Report, 143
Operating Room Normal Working Hours Report, 421
Operating Room Utilization Report, 419
Operation Report, 132, 213
Operation Requests, 57
Operation Requests for a Day, 53
Outpatient Surgery Encounters Not Transmitted to
NPCD, 278, 281
PCE Filing Status Report, 239, 241, 274, 276
Perioperative Occurrences Report, 183, 327
Procedure Report (Non-O.R.), 196, 216
Procedure Report (Non-OR), 215
Re-Filing Cases in PCE, 283
Report of Cancellation Rates, 347, 349
Report of Cancellations, 345
Report of CPT Coding Accuracy, 224, 311, 313, 315
Report of CPT Coding Accuracy for OR Surgical
Procedures, 226, 228
Report of Daily Operating Room Activity, 271
Report of Delay Time, 342
Report of Delayed Operations, 338
Report of Non-O.R. Procedures, 198, 200, 202, 243,
245, 247
Surgery V. 3.0 User Manual
April 2004
Report of Returns to Surgery, 353
Report of Surgical Priorities, 269, 270
Requests by Ward, 55
Schedule of Operations, 89
Scheduled Operations, 92
Scrub Nurse Staffing Report, 293
Surgeon Staffing Report, 289
Surgery Risk Assessment, 481, 485
Surgery Waiting List, 18
Surgical Nurse Staffing Report, 291
Tissue Examination Report, 155, 197
Unscheduled Admissions to ICU, 359
Wound Classification Report, 363
unlocking, 398
Surgery package coordinator, 407
Surgery Site parameters
entering, 410
Surgical Service Chief, 322
Surgical Service managers, 410
surgical specialty, 21, 57, 74, 234
Surgical staff, 106
T
time given, 159, 169
Time Out Verified Utilizing Checklist, 124a
transfusion
request an operation, 25
restraint, 110, 157
risk assessment, 330
changing, 445
creating, 445, 544
creating cardiac, 465
entering non-cardiac patient, 445
entering the clinical information for cardiac case, 467
Risk Assessment, 481, 550
Risk Assessment module, 443
Risk Model Lab Test, 522
route, 159, 169
error risk management, 160
transplant assessment
change VA/Non-VA indicator, 540
changing, 531
creating, 531
deleting, 538
editing, 536
entering, 531
printing, 541
update to complete, 539
Transplant Assessment, 550
Transplant Assessment module, 529
transplant assessment parameters
S
schedule an unrequested operation, 64
scheduled, 79, 84, 99, 550
scheduling a concurrent case, 61
Screen Server, 94
change, 546
Transplant Assessment Parameters, 546
data elements, 6
Defined, 5
editing data, 8
entering a range of elements, 9
entering data, 7
header, 6
multiple screen shortcut, 12
multiples, 10
Navigation, 5
prompt, 6
turning pages, 8
word processing, 14
service blockout, 60
creating, 86
removing, 88
short form listing of scheduled cases, 92
site-configurable files, 432
specimens, 155, 197
staff surgeon
designating a user as, 430
surgeon key, 426
Surgery
major,defined, 110
minor,defined, 110
Surgery case
cancelled, 400
April 2004
Surgery V. 3.0 User Manual
555
U
utilization information, 361, 419
purging, 424
V
VA Central Office, 255
VASQIP, 509, 519, 521, 522c, 527, 550
W
Waiting List
adding a new case, 21
deleting a procedure, 23
editing a patient on the, 22
entering a patient, 21
printing, 18
waiting lists, 17
workload
report, 509
uncounted, 278
wound classification, 363
556
Surgery V. 3.0 User Manual
April 2004
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF

advertisement