Surgery User Manual

Surgery User Manual
SURGERY
USER MANUAL
Version 3.0
July 1993
(Revised May 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
May 2012
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
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
SR*3*176
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
SR*3*176
May 2012
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)
May 2012
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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
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May 2012
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.
May 2012
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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
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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
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Surgery V. 3.0 User Manual
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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
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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 (^^).
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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.
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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:
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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.
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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
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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>.
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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.
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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.
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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
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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...
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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
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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 ?
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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
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** 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
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13
FLASH-LOANER INSTRUMENT: 9
FLASH-DECONTAMINATION:
12
Enter Screen Server Function:
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-------------------------------------------------------------------------------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
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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.
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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-------------------------------------------------------
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-------------------------------------------------------------------------------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
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:
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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
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
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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.
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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
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-------------------------------------------------------------------------------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:
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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:
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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
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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:
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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>
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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
May 2012
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
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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.
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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>
May 2012
934.0
FOREIGN BODY IN TRACHEA
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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>
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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
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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>
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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
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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
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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--------------------------------------------------
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________________________________________________________________________________
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
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Example 2: Procedure Report (Non-OR)
Select CPT/ICD Update/Verify Menu Option: OR
DEVICE: [Select Print Device]
Operation/Procedure Report
----------------------------------------------------------printout follows--------------------------------------------------
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-------------------------------------------------------------------------------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: ^
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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--------------------------------------------------
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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
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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
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Devices: N/A
Signed by: /es/ FIVE SURNURSE
03/04/2004 10:41
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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:
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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--------------------------------------------------
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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
------------------------------------------------------------------------------------------------------------------------------------
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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--------------------------------------------------
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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
------------------------------------------------------------------------------------------------------------------------------------
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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--------------------------------------------------
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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
====================================================================================================================================
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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--------------------------------------------------
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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
====================================================================================================================================
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
--------------------------------------------------------------------------------
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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
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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--------------------------------------------------
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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
------------------------------------------------------------------------------------------------------------------------------------
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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--------------------------------------------------
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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--------------------------------------------------
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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.
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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--------------------------------------------------
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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
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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--------------------------------------------------
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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
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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:
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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:
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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:
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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
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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
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May 2012
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
May 2012
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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
SR*3*176
May 2012
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
May 2012
Surgery V. 3.0 User Manual
SR*3*176
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
SR*3*176
May 2012
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
May 2012
Surgery V. 3.0 User Manual
SR*3*176
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
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SR*3*176
May 2012
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
SR*3*176
May 2012
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
SR*3*176
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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)
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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)
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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
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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
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07/28/06 15:31)
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Number with Radial Artery:
Number with Other Artery:
Number with Other Conduit:
LV Aneurysmectomy:
Bridge to transplant/Device:
TMR:
0
1
1
NO
NONE
NO
Myectomy:
Myxoma resection:
Other tumor resection:
Cardiac transplant:
Great Vessel Repair:
Endovascular Repair:
Other Cardiac procedure(s):
Aortic Valve Procedure:
PRIMARY REPAIR
Mitral Valve Procedure:
NONE
Tricuspid Valve Procedure:
NONE
Pulmonary Valve Procedure:
NONE
* Other Cardiac procedures (Specify):
NO
NO
NO
NO
NO
NO
NO
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
May 2012
000-34-5555 assessment #238 ***
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Page 523 has been deleted. Chapter Seven: CoreFLS/Surgery Interface has been removed..
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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.
May 2012
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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
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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.
May 2012
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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
May 2012
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.
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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
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
May 2012
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
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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
SR*3*176
May 2012
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