GLOBAL MAP DATA DICTIONARY #130 -- SURGERY FILE 3/24/25 PAGE 1
STORED IN ^SRF( (7 ENTRIES) SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 3)
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Each entry in the SURGERY file contains information regarding a surgery case made up of an operative procedure, or multiple
operative procedures for a patient. The file includes the information necessary for creating the Nurses' Intraoperative Report,
Operation Report, and Anesthesia Report
CROSS
REFERENCED BY: VISIT(AA), DATE OF OPERATION(AC), PRIMARY CANCEL REASON(ACAN), PLANNED PRIN PROCEDURE CODE (ACPT),
TIME PAT IN OR(AD), TIME PROCEDURE BEGAN(ADA), ANES CARE START TIME(AF), ANES CARE MULTIPLE START TIME(AG),
TIME PAT OUT OR(AH), PLANNED POSTOP CARE(AI), TIME OUT VERIFIED(AIN), PREOPERATIVE IMAGING CONFIRMED(AIN),
MARKED SITE CONFIRMED(AIN), ANES CARE MULTIPLE END TIME(AJ), LOCK CASE(AL), PRIN PRE-OP ICD DIAGNOSIS CODE(AM),
TIME PAT OUT OR(AM1), SCHEDULED START TIME(AM2), OP ROOM PROCEDURE PERFORMED(AM3), SCHEDULED END TIME(AMM),
MANDIBULAR SPACE(AMS), HAIR REMOVAL METHOD(AN), TIME PROCEDURE ENDED(AND), PRINC ANESTHETIST(ANES),
OCCURRENCE/NO PROCEDURE(ANON), NON-OR PROCEDURE(ANOR), TIME PAT IN OR(AOE), MALLAMPATI SCALE(AOP),
OP ROOM PROCEDURE PERFORMED(AOR), CASE SCHEDULE TYPE(AP), PRIMARY SURGEON(APCE1), TIME PROCEDURE BEGAN(APCE10),
TIME PROCEDURE ENDED(APCE11), PROVIDER(APCE12), ATTEND PROVIDER(APCE13), SERVICE CONNECTED(APCE16),
AGENT ORANGE EXPOSURE(APCE17), IONIZING RADIATION EXPOSURE(APCE18), SOUTHWEST ASIA CONDITIONS(APCE19),
OP ROOM PROCEDURE PERFORMED(APCE20), ASSOCIATED CLINIC(APCE21), MILITARY SEXUAL TRAUMA(APCE22),
HEAD AND/OR NECK CANCER(APCE23), COMBAT VET(APCE27), PROJ 112/SHAD(APCE28), SURGERY SPECIALTY(APCE3),
ATTENDING SURGEON(APCE4), HOSPITAL ADMISSION STATUS(APCE5), TIME PAT IN OR(APCE6), TIME PAT OUT OR(APCE7),
NON-OR LOCATION(APCE9), TIME PAT OUT OR(AQ), READY TO TRANSMIT?(AQ1), DATE OF OPERATION(AR), PATIENT(ARET),
SURGERY SPECIALTY(ASP), DATE OF OPERATION(ASP1), PRIMARY SURGEON(ASR), TIME PROCEDURE BEGAN(AST),
DATE OF LAST TRANSMISSION(AT), DATE TRANSMITTED(AT1), PRIMARY SURGEON(ATT), PROVIDER(ATTP), VISIT(AV),
PATIENT(B), PRINCIPAL PRE-OP DIAGNOSIS(DADX1), PRINCIPAL DIAGNOSIS(PADX1), PLANNED PRIN DIAGNOSIS CODE(PADX1)
INDEXED BY: PRIMARY SURGEON & PLANNED PRIN PROCEDURE CODE & OP ROOM PROCEDURE PERFORMED & SURGERY SPECIALTY & SCHEDULED START
TIME & SCHEDULED END TIME & PRINCIPAL PROCEDURE & HOSPITAL ADMISSION STATUS & DATE OF OPERATION & CONCURRENT CASE &
ATTENDING SURGEON (AD), PATIENT & DATE OF OPERATION (ADT), CONFIRM PATIENT IDENTITY & PROCEDURE TO BE PERFORMED &
CONFIRM VALID CONSENT & CONFIRM PATIENT POSITION & CORRECT MEDICAL IMPLANTS & ANTIBIOTIC PROPHYLAXIS & APPROPRIATE
DVT PROPHYLAXIS & BLOOD AVAILABILITY & AVAILABILITY OF SPECIAL EQUIP & SITE OF PROCEDURE & MARKED SITE CONFIRMED &
PREOPERATIVE IMAGES CONFIRMED (AE), TIME PAT OUT OR (AES), PRIMARY SURGEON (AES1), PROVIDER (AES2), ATTENDING
SURGEON (AES3), ATTEND PROVIDER (AES4), PRINC ANESTHETIST (AES5), ANESTHESIOLOGIST SUPVR (AES6), DATE OF OPERATION
(AES8), ANES CARE END TIME (AESA), TIME PROCEDURE ENDED & DICTATED SUMMARY EXPECTED (AESP), TIME OUT VERIFIED &
PREOPERATIVE IMAGING CONFIRMED & MARKED SITE CONFIRMED (AG), DATE OF OPERATION (AK), SPONGE FINAL COUNT CORRECT &
SHARPS FINAL COUNT CORRECT & INSTRUMENT FINAL COUNT CORRECT (AO), ASSESSMENT TYPE & ASSESSMENT STATUS & PATIENT
(ARS)
^SRF(D0,0)= (#.01) PATIENT [1P:2] ^ (#.02) OP ROOM PROCEDURE PERFORMED [2P:131.7] ^ (#.03) MAJOR/MINOR [3S] ^ (#.04) SURGERY
==>SPECIALTY [4P:137.45] ^ (#.05) PREOPERATIVE INFECTION [5S] ^ (#38) REQUEST BLOOD AVAILABILITY [6S] ^ (#.07) PREOP
==>SKIN INTEG [7P:135.2] ^ (#.08) PREOP SKIN COLOR [8S] ^ (#.09) DATE OF OPERATION [9D] ^ (#.035) CASE SCHEDULE TYPE
==>[10S] ^ (#.037) CASE SCHEDULE ORDER [11F] ^ (#.011) HOSPITAL ADMISSION STATUS [12S] ^ (#40) CROSSMATCH, SCREEN,
==>AUTOLOGOUS [13S] ^ (#100) ORDER NUMBER [14P:100] ^ (#.015) VISIT [15P:9000010] ^ (#.016) SERVICE CONNECTED [16S] ^
==>(#.017) AGENT ORANGE EXPOSURE [17S] ^ (#.018) IONIZING RADIATION EXPOSURE [18S] ^ (#.019) SOUTHWEST ASIA CONDITIONS
==>[19S] ^ (#.0155) CLASSIFICATION ENTERED (Y/N) [20S] ^ (#.021) ASSOCIATED CLINIC [21P:44] ^ (#.022) MILITARY SEXUAL
==>TRAUMA [22S] ^ (#.023) HEAD AND/OR NECK CANCER [23S] ^ (#.024) COMBAT VET [24S] ^ (#.026) PROJ 112/SHAD [25S] ^
==>(#.013) PLANNED ADMISSION STATUS [26S] ^
^SRF(D0,.1)= (#.11) TRANS TO OR BY [1P:131.01] ^ (#.12) HAIR REMOVAL BY [2P:200] ^ (#101) STAFF/RESIDENT [3S] ^ (#.14) PRIMARY
==>SURGEON [4P:200] ^ (#.15) FIRST ASST [5P:200] ^ (#.16) SECOND ASST [6P:200] ^ (#.175) SKIN PREP AGENTS [7P:135.1] ^
==>(#.18) SKIN PREPPED BY (1) [8P:200] ^ (#.19) PREOP MOOD [9P:135.3] ^ (#.166) ATTENDING/RES SUP CODE [10P:132.9] ^ ^
==>(#4) SKIN PREPPED BY (2) [12P:200] ^ (#.164) ATTENDING SURGEON [13P:200] ^ (#.195) PREOP CONVERSE [14S] ^ (#.196)
==>PREOP CONSCIOUS [15P:135.4] ^ (#.165) *ATTENDING CODE - NOT USED [16S] ^ (#5) SKIN PREPPED BY (3) [17P:200] ^ ^
==>(#.167) PERFUSIONIST [19P:200] ^ (#.168) ASST PERFUSIONIST [20P:200] ^ (#661) PALLIATION [21S] ^
^SRF(D0,.2)= (#.21) ANES CARE START TIME [1D] ^ (#.22) TIME OPERATION BEGAN [2D] ^ (#.23) TIME OPERATION ENDS [3D] ^ (#.24) ANES
==>CARE END TIME [4D] ^ (#.25) BLOOD LOSS (ML) [5N] ^ (#62) GASTRIC OUTPUT [6N] ^ (#.202) NURSE PRESENT TIME [7D] ^
==>(#.204) ANES AVAIL TIME [8D] ^ (#.206) SURG PRESENT TIME [9D] ^ (#.205) TIME PAT IN OR [10D] ^ (#.215) INDUCTION
==>COMPLETE [11D] ^ (#.232) TIME PAT OUT OR [12D] ^ (#.234) OR CLEAN START TIME [13D] ^ (#.236) OR CLEAN END TIME [14D]
==>^ (#.203) TIME PAT IN HOLD AREA [15D] ^ (#.255) TOTAL URINE OUTPUT (ML) [16N] ^ (#.214) ANES CARE BILLABLE TIME FLAG
==>[17S] ^ ^ (#.3511) ANES PERSONALLY PERFORMED [19S] ^ (#.3512) NUM OF CONCURRENT ANES CASES [20N] ^ ^ (#.3514) ANES
==>MEDICALLY DIRECTED [22S] ^ (#.3515) ANES PHYSICIAN AVAILABLE [23S] ^
^SRF(D0,.3)= (#.31) PRINC ANESTHETIST [1P:200] ^ (#.32) RELIEF ANESTHETIST [2P:200] ^ (#.33) ASST ANESTHETIST [3P:200] ^ (#.34)
==>ANESTHESIOLOGIST SUPVR [4P:200] ^ (#63) IV STARTED BY [5P:200] ^ (#.345) ANES SUPERVISE CODE [6P:132.95] ^ (#.36)
==>MIN INTRAOP TEMPERATURE (C) [7N] ^ (#103) ANESTHETIST CATEGORY [8S] ^ (#901) AIRWAY INDEX [9S] ^ ^ (#901.1)
==>MALLAMPATI SCALE [11S] ^ (#901.2) MANDIBULAR SPACE [12N] ^
^SRF(D0,.4)= (#37) ESTIMATED CASE LENGTH [1F] ^ (#905) READY TO TRANSMIT? [2S] ^ (#.43) PLANNED POSTOP CARE [3P:131.6] ^ (#.44)
==>OR SET-UP TIME [4N] ^ ^ (#.46) OP DISPOSITION [6P:131.6] ^ (#903) DEATH UNRELATED/RELATED [7S] ^
^SRF(D0,.5)= (#.52) FINAL COUNTS VERIFY CORRECT [1S] ^ ^ (#.54) *SURGERY POSITION [3P:132] ^ (#.55) ELECTROGROUND POSITION
==>[4P:138] ^ (#.56) FOLEY CATHETER SIZE [5N] ^ (#.57) FOLEY CATHETER INSERTED BY [6P:200] ^ ^ ^ ^ (#.523) *INST CNT
==>CORRECT [10S] ^ (#.525) INST CNT VERF BY [11P:200] ^ (#.522) VERIFIER [12P:200] ^ (#6) ELECTROGROUND POSITION (2)
==>[13P:138] ^
^SRF(D0,.6)= (#.61) PREOP TEMPERATURE [1N] ^ (#.62) PREOPERATIVE HEART RATE [2N] ^ (#.63) PREOP BLOOD PRESSURE [3F] ^ (#.64)
==>PREOP RESPIRATORY RATE [4N] ^ (#.65) FINAL ANESTHESIA TEMP (C) [5N] ^ (#.66) POSTOP PULSE [6N] ^ (#.67) POSTOP BP
==>[7F] ^ (#.68) POSTOP RESP [8N] ^ (#.69) TIME-OUT DOCUMENT COMPLETED BY [9P:200] ^ (#.615) PREOP WEIGHT (Kg) [10N] ^
==>(#61) DIAGNOSTIC RESULTS CONFIRM BY [11P:200] ^ (#74) TIME-OUT COMPLETED [12D] ^
^SRF(D0,.7)= (#57) ESU COAG RANGE [1F] ^ (#58) ESU CUTTING RANGE [2F] ^ (#127) SEQUENTIAL COMPRESSION DEVICE [3S] ^ (#25)
==>DISCHARGED VIA [4P:131.01] ^ (#.75) ELECTROCAUTERY UNIT [5F] ^ (#.76) POSTOP SKIN INTEG [6P:135.2] ^ (#.77) POSTOP
==>SKIN COLOR [7S] ^ (#128) LASER TYPE [8F] ^ (#.79) PACU DISPOSITION [9P:131.6] ^
^SRF(D0,.8)= (#.81) POSTOP MOOD [1P:135.3] ^ (#.82) POSTOP CONVERS [2S] ^ ^ (#.84) END PULSE [4N] ^ (#.85) END BP [5F] ^ (#.86)
==>END RESP [6N] ^ ^ ^ ^ (#.821) POSTOP CONSCIOUS [10P:135.4] ^ (#.875) PACKING [11S] ^
^SRF(D0,.9)= (#612) ORIGINAL DESIRED DATE [1D] ^ (#613) D/T OF DESIRED PROCEDURE DATE [2D] ^ (#614) ORIGINAL SCHEDULED DATE [3D]
==>^ (#615) D/T OF SCHEDULED DATE ENTRY [4D] ^ (#616) DESIRED PROCEDURE DATE [5D] ^ (#617) SCHEDULED DATE [6D] ^
^SRF(D0,.97)= (#.971) PATIENT EDUCATION/ASSESSMENT [1S] ^ (#.972) CONSENT SIG&WIT [2S] ^ (#.973) BATH & SHAMPOO [3S] ^ (#.974)
==>REC&XRAY READY [4S] ^ (#.975) ENEMA(S) IF ORD [5S] ^ (#.976) NPO AS ORD/CLIN MID [6S] ^ (#.977) *CLERK CHN DAYS
==>BEFORE [7N] ^
^SRF(D0,.98)= (#.981) *VERFIFY ID TAG SSN [1S] ^ (#.982) PROSTHESIS REM [2S] ^ (#.983) CIG, MATCH & VAL REM [3S] ^ (#.984)
==>VALUABLES SECURED [4S] ^ (#.985) ORAL HYGIENE [5S] ^ (#.986) FRESHLY SHAVED [6S] ^ (#.987) CLEAN DRESSING [7S] ^
==>(#.988) CLEAN HOSP CLOTH [8S] ^ (#.989) LEVIN TUBE/CATH [9S] ^ (#.9811) CARE PLAN IN CHART [10S] ^ (#.9812) ADDRESS
==>PLATE [11S] ^ (#.9813) PATIENT VOIDED [12S] ^ (#.9814) PREOP MED&RAIL UP [13S] ^ (#.9815) *CLERK CHN DATE PROCEDURE
==>[14N] ^
^SRF(D0,.99)= (#.991) U/A IN 48 HRS [1S] ^ (#.992) CBC IN 48 HRS [2S] ^ (#.993) BLOOD TYPE&XMATCH [3S] ^ (#.994) *BLEEDING & PTT
==>TIME IN 48 HRS [4S] ^ (#.995) *BUN IN 7 DAYS [5S] ^ (#.996) *BLOOD SUGAR IN 7 DAYS [6S] ^ (#.997) *SEROLOGY REPORT
==>[7S] ^ (#.998) CHEST XRAY IN 7 DAYS [8S] ^ (#.999) EKG IN 24 HRS [9S] ^ (#.9911) *CLERK CHN REC FOR MAJ SURG [10N]
==>^
^SRF(D0,1,0)=^130.01PA^^ (#.47) PROSTHESIS INSTALLED
^SRF(D0,1,D1,0)= (#.01) PROSTHESIS ITEM [1P:131.9] ^ (#1) VENDOR [2F] ^ (#2) MODEL [3F] ^ (#3) *STERILE CODE [4F] ^ (#2.5)
==>LOT/SERIAL NO [5F] ^ (#4) *STERILE NUMBER [6F] ^ (#5) STERILE RESP [7S] ^
^SRF(D0,1,D1,1)= (#6) SIZE [1F] ^ (#7) QUANTITY [2N] ^ (#11) LOT NUMBER [3F] ^ (#12) SERIAL NUMBER [4F] ^ (#13) PROVIDER READ
==>BACK PERFORMED [5S] ^
^SRF(D0,1,D1,2)= (#8) IMPLANT STERILITY CHECKED [1S] ^ (#9) STERILITY EXPIRATION DATE [2D] ^ (#10) RN VERIFIER [3P:200] ^
^SRF(D0,1.1)= (#1.11) PAC(U) ADMIT SCORE [1N] ^ (#1.12) PAC(U) DISCH SCORE [2N] ^ (#1.13) ASA CLASS [3P:132.8] ^ (#136) SPINAL
==>LEVEL [4F] ^ ^ ^ (#1.17) ADMIT PAC(U) TIME [7D] ^ (#1.18) PAC(U) DISCH TIME [8D] ^ (#1.19) POSTOP ANES NOTE DATE
==>[9D] ^
^SRF(D0,2,0)=^130.02DA^^ (#.48) TIME TOURNIQUET APPLIED
^SRF(D0,2,D1,0)= (#.01) TIME TOURNIQUET APPLIED [1D] ^ (#1) SITE APPLIED [2S] ^ (#2) TOURNIQUET APPL. BY [3P:200] ^ (#3) TIME
==>TOURNIQUET REL. [4D] ^ (#4) PRESSURE [5F] ^
^SRF(D0,3)= (#22) TUBES AND DRAINS [1F] ^
^SRF(D0,4,0)=^130.04PA^^ (#.27) REPLACEMENT FLUID TYPE
^SRF(D0,4,D1,0)= (#.01) REPLACEMENT FLUID TYPE [1P:133.7] ^ (#1) QTY OF FLUID (ml) [2N] ^ ^ (#3) SOURCE ID [4F] ^ (#4) VA IDENT
==>[5F] ^
^SRF(D0,4,D1,1,0)=^130.12^^ (#5) REPLACEMENT FLUID COMMENTS
^SRF(D0,4,D1,1,D2,0)= (#.01) REPLACEMENT FLUID COMMENT [1W] ^
^SRF(D0,5,0)=^130.05^^ (#.28) GENERAL COMMENTS
^SRF(D0,5,D1,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,6,0)=^130.06SA^^ (#.37) ANESTHESIA TECHNIQUE
^SRF(D0,6,D1,0)= (#.01) ANESTHESIA TECHNIQUE [1S] ^ ^ (#.05) PRINCIPAL TECH [3S] ^ (#2) PATIENT STATUS [4S] ^ (#3) APPROACH [5S]
==>^ (#4) ROUTE [6S] ^ (#5) LARYNGOSCOPE TYPE [7S] ^ (#6) LARYNGOSCOPE SIZE [8N] ^ (#7) STYLET USED (Y/N) [9S] ^
==>(#8) LIDOCAINE TOPICAL [10S] ^ (#9) LIDOCAINE IV [11S] ^ (#10) TUBE TYPE [12S] ^ (#11) TUBE SIZE [13N] ^ (#12)
==>TRAUMA [14S] ^ (#13) BITE BLOCK (Y/N) [15S] ^ (#14) TUBE LUBRICATION [16S] ^ (#15) TAPED AT LENGTH [17N] ^ (#16)
==>BREATH SOUNDS OK BILAT [18S] ^ (#17) HEAT, MOISTURE EXCHANGER [19S] ^ (#18) BACT. FILTER IN CIRCUIT [20S] ^
==>(#19) END VENT. T.V. [21N] ^ (#20) END VENT. RATE [22N] ^ (#21) EXTUBATED IN [23S] ^ (#22) REINTUBATED W/I 8
==>HRS. [24S] ^ (#23) PREOXYGENATION [25S] ^
^SRF(D0,6,D1,1,0)=^130.47PA^^ (#24) ANESTHESIA AGENTS
^SRF(D0,6,D1,1,D2,0)= (#.01) ANESTHESIA AGENTS [1P:50] ^ (#1) DOSE (mg) [2F] ^
^SRF(D0,6,D1,2)= (#25) CONTINUOUS [1S] ^ (#26) BARICITY [2S] ^ (#27) PUNCTURE SITE [3S] ^ (#28) SPINAL APPROACH [4S] ^ (#29)
==>NEEDLE SIZE [5S] ^
^SRF(D0,6,D1,3)= (#30) EPIDURAL METHOD [1S] ^ (#31) MULTIPLE ATTEMPTS [2S] ^ (#33) TEST DOSE VOL (ml) [3N] ^ (#34) DURAL PUNCTURE
==>[4S] ^ (#35) CATHETER REMOVED BY [5P:200] ^ (#36) ADMINISTRATION METHOD [6S] ^ (#37) PURPOSE [7S] ^
^SRF(D0,6,D1,4,0)=^130.48PA^^ (#32) TEST DOSE
^SRF(D0,6,D1,4,D2,0)= (#.01) TEST DOSE [1P:50] ^ (#1) DOSE (mg) [2F] ^
^SRF(D0,6,D1,5,0)=^130.49P^^ (#38) BLOCK SITE
^SRF(D0,6,D1,5,D2,0)= (#.01) BLOCK SITE [1P:61] ^ (#1) NEEDLE LENGTH, CM. [2N] ^ (#2) NEEDLE GAUGE [3N] ^
^SRF(D0,6,D1,6)= (#39) EXTUBATED BY [1P:200] ^
^SRF(D0,6,D1,7,0)=^130.5^^ (#40) ANESTHESIA COMMENTS
^SRF(D0,6,D1,7,D2,0)= (#.01) ANESTHESIA COMMENTS [1W] ^
^SRF(D0,6,D1,8)= (#41) MONITORED ANES CARE ?(Y/N) [1S] ^ (#42) INTUBATED ? (Y/N) [2S] ^ (#43) LEVEL [3S] ^ (#44) DATE/TIME
==>CATHETER REMOVED [4D] ^
^SRF(D0,7,0)=^130.07^^ (#.29) NURSING CARE COMMENTS
^SRF(D0,7,D1,0)= (#.01) NURSING CARE COMMENTS [1W] ^
^SRF(D0,8)= (#50) DIVISION [1P:4] ^
^SRF(D0,9,0)=^130.049^^ (#49) SPECIMENS
^SRF(D0,9,D1,0)= (#.01) SPECIMENS [1W] ^
^SRF(D0,10,0)=^130.13A^^ (#1.14) INTRAOPERATIVE OCCURRENCES
^SRF(D0,10,D1,0)= (#.01) INTRAOPERATIVE OCCURRENCES [1F] ^ (#3) OCCURRENCE CATEGORY [2P:136.5] ^ (#4) ICD DIAGNOSIS CODE [3P:80]
==>^ ^ ^ (#.05) OUTCOME TO DATE [6S] ^ (#5) INTRAOP DEVICE TYPE [7S] ^
^SRF(D0,10,D1,1,0)=^130.21^^ (#1) OCCURRENCE COMMENTS
^SRF(D0,10,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,10,D1,2)= (#2) TREATMENT INSTITUTED [1F] ^
^SRF(D0,11,0)=^130.14A^^ (#1.05) REQ BLOOD KIND
^SRF(D0,11,D1,0)= (#.01) REQ BLOOD KIND [1F] ^ (#1) UNITS REQ [2N] ^ (#2) SCREEN, CROSSMATCH, AUTOLOGOUS [3S] ^
^SRF(D0,11,D1,1,0)=^130.27^^ (#3) REASON NOT USE STD
^SRF(D0,11,D1,1,D2,0)= (#.01) REASON NOT USE STD [1W] ^
^SRF(D0,12,0)=^130.15^^ (#1.15) SURGEON'S DICTATION
^SRF(D0,12,D1,0)= (#.01) SURGEON'S DICTATION [1W] ^
^SRF(D0,13,0)=^130.16A^^ (#.42) OTHER PROCEDURES
^SRF(D0,13,D1,0)= (#.01) OTHER PROCEDURE [1F] ^ ^ (#2) COMPLETED [3S] ^
^SRF(D0,13,D1,1,0)=^130.26^^ (#1.5) PROCEDURE CODE COMMENTS
^SRF(D0,13,D1,1,D2,0)= (#.01) PROCEDURE CODE COMMENTS [1W] ^
^SRF(D0,13,D1,2)= (#3) PLANNED OTHER PROC CPT CODE [1P:81] ^
^SRF(D0,13,D1,MOD,0)=^130.164P^^ (#4) OTHER PROCEDURE CPT MODIFIER
^SRF(D0,13,D1,MOD,D2,0)= (#.01) OTHER PROCEDURE CPT MODIFIER [1P:81.3] ^
^SRF(D0,13,D1,OADX,0)=^130.165A^^ (#5) OTHER ASSOC DIAGNOSIS
^SRF(D0,13,D1,OADX,D2,0)= (#.01) OTHER ASSOC DIAGNOSIS [1N] ^
^SRF(D0,14,0)=^130.17A^^ (#.72) OTHER PREOP DIAGNOSIS
^SRF(D0,14,D1,0)= (#.01) OTHER PREOP DIAGNOSIS [1F] ^ (#1) *PAIRED ORGAN [2S] ^ (#3) ICD DIAGNOSIS CODE [3P:80] ^
^SRF(D0,14,D1,1,0)=^130.2^^ (#2) DIAGNOSIS COMMENTS
^SRF(D0,14,D1,1,D2,0)= (#.01) DIAGNOSIS COMMENTS [1W] ^
^SRF(D0,15,0)=^130.18A^^ (#.74) OTHER POSTOP DIAGS
^SRF(D0,15,D1,0)= (#.01) OTHER POSTOP DIAGS [1F] ^ (#1) *PAIRED ORGANS [2S] ^ (#3) PLANNED ICD DIAGNOSIS CODE [3P:80] ^
^SRF(D0,15,D1,1,0)=^130.19^^ (#2) DIAGNOSIS COMMENTS
^SRF(D0,15,D1,1,D2,0)= (#.01) DIAGNOSIS COMMENTS [1W] ^
^SRF(D0,15,D1,2)= (#4) SERVICE CONNECTED [1S] ^ (#5) AGENT ORANGE EXPOSURE [2S] ^ (#6) IONIZING RADIATION EXPOSURE [3S] ^ (#7)
==>MILITARY SEXUAL TRAUMA [4S] ^ (#8) HEAD AND/OR NECK CANCER [5S] ^ (#9) SOUTHWEST ASIA CONDITIONS [6S] ^ (#10)
==>COMBAT VET [7S] ^ (#11) PROJ 112/SHAD [8S] ^
^SRF(D0,16,0)=^130.22A^^ (#1.16) POSTOP OCCURRENCE
^SRF(D0,16,D1,0)= (#.01) POSTOP OCCURRENCE [1F] ^ (#5) OCCURRENCE CATEGORY [2P:136.5] ^ (#6) ICD DIAGNOSIS CODE [3P:80] ^ (#7)
==>SEPSIS CATEGORY [4S] ^ (#8) CPB STATUS [5S] ^ (#.05) OUTCOME TO DATE [6S] ^ (#2) DATE COMP NOTED [7D] ^ (#9)
==>STROKE/CVA DURATION [8S] ^ (#10) INDWELLING URETHRAL CATHETER [9S] ^ (#11) UTI SIGN/SYMPTOMS URG/FREQ/DYS [10S]
==>^ (#12) UTI SIGNS/SYMPTOMS FEVER [11S] ^ (#13) UTI SIGNS/SYMPTOMS TENDERNESS [12S] ^ (#14) UTI CULTURE [13S] ^
==>(#15) POSTOP DEVICE TYPE [14S] ^
^SRF(D0,16,D1,1,0)=^130.224^^ (#4) OCCURRENCE COMMENTS
^SRF(D0,16,D1,1,D2,0)= (#.01) OCCURRENCE COMMENTS [1W] ^
^SRF(D0,16,D1,2)= (#3) TREATMENT INSTITUTED [1F] ^
^SRF(D0,17,0)=^130.042PA^^ (#42) DELAY CAUSE
^SRF(D0,17,D1,0)= (#.01) DELAY CAUSE [1P:132.4] ^ (#1) DELAY TIME [2N] ^
^SRF(D0,17,D1,1,0)=^130.422^^ (#2) DELAY COMMENTS
^SRF(D0,17,D1,1,D2,0)= (#.01) DELAY COMMENTS [1W] ^
^SRF(D0,18,0)=^130.03A^^ (#23) REFERRING PHYSICIAN
^SRF(D0,18,D1,0)= (#.01) REFERRING PHYSICIAN [1F] ^ (#1) STREET ADDRESS [2F] ^ (#2) CITY [3F] ^ (#3) STATE [4P:5] ^ (#4) ZIP CODE
==>[5F] ^ (#5) PHONE NUMBER [6F] ^ (#6) REF PHY 200 LINK [7P:200] ^
^SRF(D0,19,0)=^130.28PA^^ (#.111) OR CIRC SUPPORT
^SRF(D0,19,D1,0)= (#.01) OR CIRC SUPPORT [1P:200] ^ ^ (#3) STATUS [3S] ^
^SRF(D0,19,D1,1,0)=^130.29DA^^ (#2) TIME ON
^SRF(D0,19,D1,1,D2,0)= (#.01) TIME ON [1D] ^ (#1) TIME OFF [2D] ^ (#2) REASON FOR RELIEF [3S] ^
^SRF(D0,19,D1,1,D2,1,0)=^130.3^^ (#3) COMMENT
^SRF(D0,19,D1,1,D2,1,D3,0)= (#.01) COMMENT [1W] ^
^SRF(D0,20,0)=^130.31PA^^ (#.13) RESTR & POSITION AIDS
^SRF(D0,20,D1,0)= (#.01) RESTR & POSITION AIDS [1P:132.05] ^ (#1) APPLIED BY [2P:200] ^ (#2) RESTRAINT COMMENTS [3F] ^
^SRF(D0,21,0)=^130.32A^^ (#.757) THERMAL UNIT
^SRF(D0,21,D1,0)= (#.01) THERMAL UNIT [1F] ^ (#1) TIME ON [2D] ^ (#2) TEMPERATURE [3N] ^ (#3) TIME OFF [4D] ^
^SRF(D0,22,0)=^130.33PA^^ (#.375) MEDICATIONS
^SRF(D0,22,D1,0)= (#.01) MEDICATIONS [1P:50] ^
^SRF(D0,22,D1,1,0)=^130.34DA^^ (#1) TIME ADM
^SRF(D0,22,D1,1,D2,0)= (#.01) TIME ADM [1D] ^ (#1) DOSE [2F] ^ (#2) ORDERED BY [3P:200] ^ (#3) ADMIN BY [4P:200] ^ (#4) ROUTE
==>[5S] ^ (#5) MEDICATION COMMENTS [6F] ^
^SRF(D0,23,0)=^130.36PA^^ (#.112) OR SCRUB SUPPORT
^SRF(D0,23,D1,0)= (#.01) OR SCRUB SUPPORT [1P:200] ^ ^ (#3) STATUS [3S] ^
^SRF(D0,23,D1,1,0)=^130.37DA^^ (#1) TIME ON
^SRF(D0,23,D1,1,D2,0)= (#.01) TIME ON [1D] ^ (#1) TIME OFF [2D] ^ (#2) REASON FOR RELIEF [3S] ^
^SRF(D0,23,D1,1,D2,1,0)=^130.38^^ (#3) COMMENT
^SRF(D0,23,D1,1,D2,1,D3,0)= (#.01) COMMENT [1W] ^
^SRF(D0,24)= (#51) PREOP ATTENDING CONCURRENCE [1S] ^ (#52) POSTOP ATTENDING CONCURRENCE [2S] ^
^SRF(D0,25)= (#44) SPONGE FINAL COUNT CORRECT [1S] ^ (#45) SHARPS FINAL COUNT CORRECT [2S] ^ (#46) INSTRUMENT FINAL COUNT CORRECT
==>[3S] ^ (#47) SPONGE, SHARPS, & INST COUNTER [4P:200] ^ (#48) COUNT VERIFIER [5P:200] ^ (#630) POSSIBLE ITEM
==>RETENTION [6S] ^ (#633) WOUND SWEEP [7S] ^ (#636) INTRA-OPERATIVE X-RAY [8S] ^ (#639) REPORT GIVEN TO [9P:200] ^
^SRF(D0,26,0)=^130.08PA^^ (#.39) IRRIGATION
^SRF(D0,26,D1,0)= (#.01) IRRIGATION [1P:133.6] ^
^SRF(D0,26,D1,1,0)=^130.39DA^^ (#1) TIME
^SRF(D0,26,D1,1,D2,0)= (#.01) TIME [1D] ^ (#1) AMOUNT USED [2N] ^ (#2) PROVIDER [3P:200] ^
^SRF(D0,27,0)=^130.41PA^^ (#.293) MONITORS
^SRF(D0,27,D1,0)= (#.01) MONITORS [1P:133.4] ^ (#1) TIME INSTALLED [2D] ^ (#2) TIME REMOVED [3D] ^ (#3) APPLIED BY [4P:200] ^
^SRF(D0,28,0)=^130.23PA^^ (#30) OTHER SCRUBBED ASSISTANTS
^SRF(D0,28,D1,0)= (#.01) OTHER SCRUBBED ASSISTANTS [1P:200] ^
^SRF(D0,28,D1,1,0)=^130.35^^ (#1) COMMENTS
^SRF(D0,28,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,29,0)=^130.43PA^^ (#1.145) RETURNED TO SURGERY
^SRF(D0,29,D1,0)= (#.01) RETURNED TO SURGERY [1P:130] ^ (#1) REASON [2S] ^ (#3) RELATED/UNRELATED [3S] ^
^SRF(D0,29,D1,1,0)=^130.44^^ (#2) RET TO SURGERY COMMENTS
^SRF(D0,29,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,30)= (#17) CANCEL DATE [1D] ^ (#67) CANCELLATION AVOIDABLE [2S] ^ (#70) CANCELLED BY [3P:200] ^ (#19) CANCELLATION
==>COMMENTS [4F] ^ (#17.5) CANCELLATION TIMEFRAME [5S] ^ (#18.5) CASE ABORTED [6S] ^
^SRF(D0,31)= (#7) DRESSING CONDITION [1S] ^ (#8) SECOND SKIN PREP AGENT [2P:135.1] ^ (#9) TIME NURSE OUT OF OR [3D] ^ (#10)
==>SCHEDULED START TIME [4D] ^ (#11) SCHEDULED END TIME [5D] ^ (#15) DATE/TIME OF DICTATION [6D] ^ (#39) DATE OF
==>TRANSCRIPTION [7D] ^ (#18) PRIMARY CANCEL REASON [8P:135] ^ (#20) DIAGNOSTIC/THERAPEUTIC (Y/N) [9S] ^ (#81) DYNAMED
==>NOTIFIED [10S] ^ (#21) WAIT TIME START [11D] ^
^SRF(D0,32,0)=^130.24A^^ (#31) OTHER PERSONS IN OR
^SRF(D0,32,D1,0)= (#.01) OTHER PERSONS IN OR [1F] ^ (#1) TITLE/ORGANIZATION [2F] ^
^SRF(D0,33)= (#32) PRINCIPAL PRE-OP DIAGNOSIS [1F] ^ (#33) PRINCIPAL DIAGNOSIS [2F] ^
^SRF(D0,34)= (#34) PRINCIPAL POST-OP DIAG [1F] ^ (#66) PLANNED PRIN DIAGNOSIS CODE [2P:80] ^ (#32.5) PRIN PRE-OP ICD DIAGNOSIS
==>CODE [3P:80] ^
^SRF(D0,35)= (#41) DRESSING [1F] ^ (#56) PRE-ADMISSION TESTING [2S] ^
^SRF(D0,36,0)=^130.053A^^ (#53) NON-OPERATIVE OCCURRENCES
^SRF(D0,36,D1,0)= (#.01) NON-OPERATIVE OCCURRENCES [1F] ^ (#1) OUTCOME TO DATE [2S] ^ (#2) DATE OCCURRENCE NOTED [3D] ^ (#3)
==>TREATMENT INSTITUTED [4F] ^ (#5) OCCURRENCE CATEGORY [5P:136.5] ^
^SRF(D0,36,D1,1,0)=^130.534^^ (#4) OCCURRENCE COMMENTS
^SRF(D0,36,D1,1,D2,0)= (#.01) OCCURRENCE COMMENTS [1W] ^
^SRF(D0,37)= (#54) OCCURRENCE/NO PROCEDURE [1S] ^
^SRF(D0,38,0)=^130.059^^ (#59) OPERATIVE FINDINGS
^SRF(D0,38,D1,0)= (#.01) OPERATIVE FINDINGS [1W] ^
^SRF(D0,39,0)=^130.09^^ (#60) BRIEF CLIN HISTORY
^SRF(D0,39,D1,0)= (#.01) BRIEF CLIN HISTORY [1W] ^
^SRF(D0,40,0)=^130.055^^ (#55) INDICATIONS FOR OPERATIONS
^SRF(D0,40,D1,0)= (#.01) INDICATIONS FOR OPERATIONS [1W] ^
^SRF(D0,41,0)=^130.064^^ (#64) CULTURES
^SRF(D0,41,D1,0)= (#.01) CULTURES [1W] ^
^SRF(D0,42,0)=^130.065PA^^ (#65) SURGERY POSITION
^SRF(D0,42,D1,0)= (#.01) SURGERY POSITION [1P:132] ^ (#1) TIME PLACED [2D] ^
^SRF(D0,43,0)=^130.0126^^ (#126) PROCEDURE OCCURRENCE
^SRF(D0,43,D1,0)= (#.01) PROCEDURE OCCURRENCE [1F] ^ (#1) OUTCOME TO DATE [2S] ^ (#2) DATE OCCURRENCE NOTED [3D] ^ (#3) TREATMENT
==>INSTITUTED [4F] ^ (#5) OCCURRENCE CATEGORY [5P:136.5] ^
^SRF(D0,43,D1,1,0)=^130.1264^^ (#4) OCCURRENCE COMMENTS
^SRF(D0,43,D1,1,D2,0)= (#.01) OCCURRENCE COMMENTS [1W] ^
^SRF(D0,44,0)=^130.0129A^^ (#129) LASER UNIT
^SRF(D0,44,D1,0)= (#.01) LASER UNIT/ID [1F] ^ (#1) LASER DURATION [2N] ^ (#2) WATTAGE [3N] ^ (#3) LASER OPERATOR [4P:200] ^ (#4)
==>PLUME EVACUATOR [5S] ^
^SRF(D0,44,D1,1,0)=^130.1295^^ (#5) LASER COMMENTS
^SRF(D0,44,D1,1,D2,0)= (#.01) LASER COMMENTS [1W] ^
^SRF(D0,45,0)=^130.013A^^ (#130) CELL SAVER
^SRF(D0,45,D1,0)= (#.01) CELL SAVER ID [1F] ^ (#1) CELL SAVER OPERATOR [2P:200] ^ (#2) AMT SALVAGED (ML) [3N] ^ (#3) AMT
==>REINFUSED (ML) [4N] ^
^SRF(D0,45,D1,1,0)=^130.0134A^^ (#4) DISPOSABLES USED
^SRF(D0,45,D1,1,D2,0)= (#.01) DISPOSABLES NAME [1F] ^ (#1) LOT NUMBER [2F] ^ (#2) QUANTITY [3N] ^
^SRF(D0,45,D1,2,0)=^130.0135^^ (#5) CELL SAVER COMMENTS
^SRF(D0,45,D1,2,D2,0)= (#.01) CELL SAVER COMMENTS [1W] ^
^SRF(D0,46)= (#131) DEVICE(S) [1F] ^
^SRF(D0,47,0)=^130.0904^^ (#904) REVIEW OF DEATH COMMENTS
^SRF(D0,47,D1,0)= (#.01) REVIEW OF DEATH COMMENTS [1W] ^
^SRF(D0,48,0)=^130.1^^ (#1.2) POSTOP ANES NOTE
^SRF(D0,48,D1,0)= (#.01) POSTOP ANES NOTE [1W] ^
^SRF(D0,49,0)=^130.0508^^ (#508) HAIR REMOVAL COMMENTS
^SRF(D0,49,D1,0)= (#.01) HAIR REMOVAL COMMENTS [1W] ^
^SRF(D0,50,0)=^130.213DA^^ (#.213) ANES CARE TIME BLOCK
^SRF(D0,50,D1,0)= (#.01) ANES CARE MULTIPLE START TIME [1D] ^ (#1) ANES CARE MULTIPLE END TIME [2D] ^
^SRF(D0,51,0)=^130.085^^ (#85) CHECKLIST COMMENT
^SRF(D0,51,D1,0)= (#.01) CHECKLIST COMMENT [1W] ^
^SRF(D0,52)= (#619) IMMED USE-CONTAMINATION [1N] ^ (#620) IMMED USE-SPS/OR MGT ISSUE [2N] ^ (#621) IMMED USE-EMERGENCY CASE [3N]
==>^ (#622) IMMED USE-NO BETTER OPTION [4N] ^ (#623) IMMED USE-LOANER INSTRUMENT [5N] ^ (#624) IMMED
==>USE-DECONTAMINATION [6N] ^
^SRF(D0,53,0)=^130.0635^^ (#635) WOUND SWEEP COMMENTS
^SRF(D0,53,D1,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,54,0)=^130.0637^^ (#637) INTRA-OPERATIVE X-RAY COMMENTS
^SRF(D0,54,D1,0)= (#.01) COMMENTS [1W] ^
^SRF(D0,55,0)=^130.3513PA^^ (#.3513) ANES CONCURRENT CASES
^SRF(D0,55,D1,0)= (#.01) ANES CONCURRENT CASES [1P:130] ^
^SRF(D0,56,0)=^130.11A^^ (#135) LASER PERFORMED
^SRF(D0,56,D1,0)= (#.01) LASER NAME [1F] ^ (#1) LASER TYPE [2S] ^ (#2) LASER START TIME [3D] ^ (#3) LASER END TIME [4D] ^ (#4)
==>LASER TEST FIRE [5S] ^ (#5) LASER DELIVERY SYSTEM [6S] ^ (#6) PULSE MODE [7S] ^ (#7) POWER/AVERAGE POWER [8N] ^
==>(#8) INTERVAL/REPETITION RATE [9N] ^ (#9) TOTAL JOULES DELIVERED [10N] ^ (#10) WATTS DELIVERED [11N] ^ (#11)
==>WAVE FORM [12F] ^ (#12) PULSE WIDTH [13N] ^ (#13) ENERGY JOULES [14N] ^ (#14) LASER DURATION [15N] ^ ^ (#16)
==>LASER ON STANDBY [17S] ^ (#17) LASER OFF AND KEY SECURED [18S] ^
^SRF(D0,56,D1,1,0)=^130.1115S^^ (#15) PATIENT PRECAUTIONS
^SRF(D0,56,D1,1,D2,0)= (#.01) PATIENT PRECAUTIONS [1S] ^
^SRF(D0,56,D1,2,0)=^130.1118S^^ (#18) PERSONNEL PRECAUTIONS
^SRF(D0,56,D1,2,D2,0)= (#.01) PERSONNEL PRECAUTIONS [1S] ^
^SRF(D0,56,D1,3,0)=^130.1119^^ (#19) LASER COMMENTS
^SRF(D0,56,D1,3,D2,0)= (#.01) LASER COMMENTS [1W] ^
^SRF(D0,57,0)=^130.0664^^ (#664) DONOR VESSEL UNOS ID
^SRF(D0,57,D1,0)= (#.01) DONOR VESSEL UNOS ID [1F] ^
^SRF(D0,58,0)=^130.25P^^ (#680) SPECIAL EQUIPMENT
^SRF(D0,58,D1,0)= (#.01) SPECIAL EQUIPMENT [1P:131.3] ^
^SRF(D0,59,0)=^130.0681P^^ (#681) PLANNED IMPLANTS
^SRF(D0,59,D1,0)= (#.01) PLANNED IMPLANTS [1P:131.5] ^
^SRF(D0,60,0)=^130.0682P^^ (#682) SPECIAL SUPPLIES
^SRF(D0,60,D1,0)= (#.01) SPECIAL SUPPLIES [1P:131.04] ^
^SRF(D0,61,0)=^130.0683P^^ (#683) SPECIAL INSTRUMENTS
^SRF(D0,61,D1,0)= (#.01) SPECIAL INSTRUMENTS [1P:131.02] ^
^SRF(D0,62,0)=^130.0684P^^ (#684) PHARMACY ITEMS
^SRF(D0,62,D1,0)= (#.01) PHARMACY ITEMS [1P:131.06] ^
^SRF(D0,63,0)=^130.0647S^^ (#647) ORGANS TO BE TRANSPLANTED
^SRF(D0,63,D1,0)= (#.01) ORGANS TO BE TRANSPLANTED [1S] ^
^SRF(D0,80,0)=^130.8^^ (#80) SPD COMMENTS
^SRF(D0,80,D1,0)= (#.01) SPD COMMENTS [1W] ^
^SRF(D0,82,0)=^130.082^^ (#82) TIME OUT VERIFIED COMMENTS
^SRF(D0,82,D1,0)= (#.01) TIME OUT VERIFIED COMMENTS [1W] ^
^SRF(D0,83,0)=^130.083^^ (#83) IMAGING CONFIRMED COMMENTS
^SRF(D0,83,D1,0)= (#.01) IMAGING CONFIRMED COMMENTS [1W] ^
^SRF(D0,84,0)=^130.084^^ (#84) MARKED SITE COMMENTS
^SRF(D0,84,D1,0)= (#.01) MARKED SITE COMMENTS [1W] ^
^SRF(D0,200)= (#402) GENERAL (Y/N) [1S] ^ (#346) *DIABETES [2S] ^ (#202) *CURRENT SMOKER [3S] ^ (#246) ETOH > 2 DRINKS/DAY [4S] ^
==>(#324) DRUG ADDICTION [5S] ^ (#325) DYSPNEA [6S] ^ (#238) DNR STATUS [7S] ^ (#240) *FUNCTIONAL HEALTH STATUS [8S] ^
==>(#241) PULMONARY (Y/N) [9S] ^ (#204) VENTILATOR DEPENDENT [10S] ^ (#203) HISTORY OF COPD [11S] ^ (#326) CURRENT
==>PNEUMONIA [12S] ^ (#244) HEPATOBILIARY (Y/N) [13S] ^ (#268) HEPATOMEGALY [14S] ^ (#212) ASCITES [15S] ^ (#213)
==>ESOPHAGEAL VARICES [16S] ^ (#327) ACTIVE HEPATITIS [17S] ^ (#210) CENTRAL NERVOUS SYSTEM (Y/N) [18S] ^ (#332)
==>IMPAIRED SENSORIUM [19S] ^ (#397) SEVERE HEAD TRAUMA (Y/N) [20S] ^ (#333) COMA [21S] ^ (#398) QUADRIPLEGIA (Y/N)
==>[22S] ^ (#399) PARAPLEGIA (Y/N) [23S] ^ (#400) HEMIPLEGIA/HEMIPARESIS (Y/N) [24S] ^ (#334) *HISTORY OF TIA'S [25S]
==>^ (#335) *CVA/STROKE WITH NEURO DEFICIT [26S] ^ (#336) *CVA/STROKE - NO NEURO DEFICIT [27S] ^ (#337) NEURO
==>DEGENERATIVE DISEASE [28S] ^ (#401) TUMOR INVOLVING CNS (Y/N) [29S] ^ (#242) CARDIAC (Y/N) [30S] ^ (#394) *HISTORY
==>OF MI [31S] ^ (#220) *PREVIOUS PCI [32S] ^ (#266) *PREVIOUS CARDIAC SURGERY [33S] ^ (#395) *ANGINA ONE MONTH PRIOR
==>[34S] ^ (#396) *CHF WITHIN ONE MONTH [35S] ^ (#208) *HYPERTENSION REQUIRING MEDS [36S] ^ (#243) RENAL (Y/N) [37S] ^
==>(#328) RENAL FAILURE [38S] ^ (#211) CURRENTLY ON DIALYSIS [39S] ^ (#206) VASCULAR (Y/N) [40S] ^ (#329)
==>*REVASCULARIZATION/AMPUTATION [41S] ^ (#330) REST PAIN/GANGRENE (Y/N) [42S] ^ (#331) ABSENT PERIPHERAL PULSES [43S]
==>^ (#245) NUTRITIONAL/IMMUNE/OTHER [44S] ^ (#338) DISSEMINATED CANCER (Y/N) [45S] ^ (#218) OPEN WOUND [46S] ^ (#339)
==>STEROID USE FOR CHRONIC COND. [47S] ^ (#215) WEIGHT LOSS > 10% [48S] ^ (#216) BLEEDING DISORDERS [49S] ^ (#217)
==>TRANSFUSION > 4 RBC UNITS [50S] ^ (#200) OPERATIONS THIS ADMISSION [51N] ^ (#214) PGY OF PRIMARY SURGEON [52N] ^
==>(#201) REDO PROCEDURE [53S] ^ (#340) INTRAOP RBC UNITS TRANSFUSED [54F] ^ (#618) POSITIVE DRUG SCREENING [55S] ^
==>(#640) PCI [56S] ^ (#641) HYPERTENSION [57S] ^ (#642) BLEEDING RISK DUE TO MED [58S] ^ (#643) ANGINA TIMEFRAME
==>[59S] ^
^SRF(D0,200.1)= (#486) GASTROINTESTINAL (Y/N) [1S] ^ (#492) PREOP FUNCT. HEALTH STATUS [2S] ^ (#269) PREGNANCY [3S] ^ (#443)
==>INTRAOP DISSEMINATED CANCER [4S] ^ (#510) *CURRENT SMOKER (CARDIAC) [5S] ^ (#446) INTRAOPERATIVE ASCITES [6S] ^
==>(#236.1) HEIGHT MEASUREMENT DATE [7D] ^ (#237.1) PREOPERATIVE SLEEP APNEA [8S] ^ (#517) TOBACCO USE [9S] ^ (#518)
==>TOBACCO USE TIMEFRAME [10S] ^ (#519) DIABETES MELLITUS CHRONIC [11S] ^ (#520) DIABETES MELLITUS PREOP MGMT [12S]
==>^ (#521) CVD REPAIR/OBSTRUCTION [13S] ^ (#522) HISTORY OF CVD [14S] ^ (#667) SLEEP APNEA-COMPLIANCE [15S] ^
^SRF(D0,201)= (#270) PREOPERATIVE SERUM SODIUM [1F] ^ (#271) PREOPERATIVE POTASSIUM [2N] ^ (#273) PREOPERATIVE GLUCOSE [3N] ^
==>(#223) PREOPERATIVE SERUM CREATININE [4F] ^ (#224) PREOPERATIVE BUN [5F] ^ (#221) PREOPERATIVE CPK [6N] ^ (#222)
==>PREOPERATIVE MB BAND [7N] ^ (#225) PREOPERATIVE SERUM ALBUMIN [8F] ^ (#228) PREOPERATIVE TOTAL BILIRUBIN [9F] ^
==>(#226) PREOPERATIVE SGPT [10N] ^ (#227) PREOPERATIVE SGOT [11F] ^ (#229) PREOPERATIVE ALK PHOSPHATASE [12F] ^
==>(#230) PREOPERATIVE WBC [13F] ^ (#234) PREOPERATIVE HEMATOCRIT [14F] ^ (#231) PREOPERATIVE PLATELET COUNT [15F] ^
==>(#233) PREOPERATIVE PTT [16F] ^ (#232) PREOPERATIVE PT [17F] ^ (#316) PREOPERATIVE PTT CONTROL [18N] ^ (#315)
==>PREOPERATIVE PT CONTROL [19N] ^ (#219) PREOPERATIVE HEMOGLOBIN [20F] ^ (#457) HDL (CARDIAC) [21F] ^ (#458) SERUM
==>TRIGLYCERIDE (CARDIAC) [22F] ^ (#459) SERUM POTASSIUM (CARDIAC) [23F] ^ (#460) SERUM BILIRUBIN (CARDIAC) [24F] ^
==>(#461) LDL (CARDIAC) [25F] ^ (#462) TOTAL CHOLESTEROL (CARDIAC) [26F] ^ (#487) PREOPERATIVE INR [27F] ^ (#504)
==>HEMOGLOBIN A1C [28F] ^ (#507) BNP [29F] ^
^SRF(D0,202)= (#304) PREOP SERUM SODIUM, DATE [1D] ^ (#303) PREOP POTASSIUM, DATE [2D] ^ (#302) PREOPERATIVE GLUCOSE, DATE [3D] ^
==>(#290) PREOP SERUM CREATININE, DATE [4D] ^ (#291) PREOPERATIVE BUN, DATE [5D] ^ (#288) PREOPERATIVE CPK, DATE [6D]
==>^ (#289) PREOPERATIVE MB BAND, DATE [7D] ^ (#292) PREOP SERUM ALBUMIN, DATE [8D] ^ (#295) PREOP TOTAL BILIRUBIN,
==>DATE [9D] ^ (#293) SGPT, DATE PERFORMED [10D] ^ (#294) SGOT, DATE PERFORMED [11D] ^ (#296) PREOP ALK PHOSPHATASE,
==>DATE [12D] ^ (#297) PREOPERATIVE WBC, DATE [13D] ^ (#301) PREOP HEMATOCRIT, DATE [14D] ^ (#298) PREOP PLATELET
==>COUNT, DATE [15D] ^ (#300) PREOPERATIVE PTT, DATE [16D] ^ (#299) PREOPERATIVE PT, DATE [17D] ^ ^ ^ (#239)
==>PREOPERATIVE HEMOGLOBIN, DATE [20D] ^ (#457.1) HDL, DATE [21F] ^ (#458.1) SERUM TRIGLYCERIDE, DATE (CAR) [22F] ^
==>(#459.1) SERUM POTASSIUM, DATE(CARDIAC) [23F] ^ (#460.1) SERUM BILIRUBIN, DATE (CARD) [24F] ^ (#461.1) LDL, DATE
==>(CARDIAC) [25F] ^ (#462.1) TOTAL CHOLESTEROL, DATE [26F] ^ (#487.1) PREOPERATIVE INR, DATE [27D] ^
^SRF(D0,202.1)= (#504.1) HEMOGLOBIN A1C, DATE [1F] ^ (#507.1) BNP DATE [2F] ^
^SRF(D0,203)= (#274) HIGHEST SERUM SODIUM [1F] ^ (#405) LOW SERUM SODIUM [2F] ^ (#275) HIGHEST POTASSIUM [3F] ^ (#406) LOW
==>POTASSIUM [4F] ^ (#276) HIGHEST GLUCOSE [5N] ^ (#277) HIGHEST SERUM CREATININE [6F] ^ (#278) HIGHEST CPK [7F] ^
==>(#279) HIGHEST CPK-MB [8F] ^ (#280) HIGHEST TOTAL BILIRUBIN [9F] ^ (#281) HIGHEST WBC [10F] ^ (#282) LOWEST SERUM
==>ALBUMIN [11N] ^ (#283) LOWEST HEMATOCRIT [12F] ^ (#455) HIGHEST SERUM TROPONIN I [13F] ^ (#456) HIGHEST SERUM
==>TROPONIN T [14F] ^ (#444) PREOPERATIVE ANION GAP [15F] ^ (#445) HIGHEST ANION GAP [16F] ^
^SRF(D0,204)= (#305) HIGH SERUM SODIUM, DATE [1D] ^ (#407) LOW SODIUM, DATE [2D] ^ (#306) HIGH POTASSIUM, DATE [3D] ^ (#408) LOW
==>POTASSIUM, DATE [4D] ^ (#307) HIGH GLUCOSE, DATE [5D] ^ (#308) HIGH SERUM CREATININE, DATE [6D] ^ (#309) HIGH CPK,
==>DATE [7D] ^ (#310) HIGH CPK-MB, DATE [8D] ^ (#311) HIGH TOTAL BILIRUBIN, DATE [9D] ^ (#312) HIGHEST WBC, DATE [10D]
==>^ (#313) LOW SERUM ALBUMIN, DATE [11D] ^ (#314) LOW HEMATOCRIT, DATE [12D] ^ (#455.1) HIGH SERUM TROPONIN I, DATE
==>[13D] ^ (#456.1) HIGH SERUM TROPONIN T, DATE [14D] ^ (#444.1) PREOP ANION GAP, DATE [15D] ^ (#445.1) HIGH ANION
==>GAP, DATE [16D] ^ (#338.3) CHEMO FOR MALIG LAST 90 DAYS [17S] ^
^SRF(D0,205)= (#247) LENGTH OF POST-OP STAY [1F] ^ (#341) 30 DAY POSTOP STATUS [2S] ^ (#342) DATE OF DEATH [3F] ^ (#262) RETURN
==>TO OR WITHIN 30 DAYS [4S] ^ (#403) WOUND OCCURRENCES [5S] ^ (#248) SUPERFICIAL INCISIONAL SSI [6S] ^ (#249) DEEP
==>INCISIONAL SSI [7S] ^ (#404) WOUND DISRUPTION [8S] ^ (#318) RESPIRATORY OCCURRENCES [9S] ^ (#251) PNEUMONIA [10S] ^
==>(#412) UNPLANNED INTUBATION (Y/N) [11S] ^ (#252) PULMONARY EMBOLISM [12S] ^ (#285) ON VENTILATOR >48 HOURS [13S] ^
==>(#253) OTHER RESPIRATORY OCCURRENCE [14P:80] ^ (#319) URINARY TRACT OCCURRENCES [15S] ^ (#409) RENAL INSUFFICIENCY
==>[16S] ^ (#254) ACUTE RENAL FAILURE [17S] ^ (#255) URINARY TRACT INFECTION [18S] ^ (#286) OTHER URINARY TRACT
==>OCCURRENCE [19P:80] ^ (#320) CNS OCCURRENCES [20S] ^ (#256) STROKE/CVA [21S] ^ (#410) COMA > 24 HOURS POSTOP [22S]
==>^ (#287) PERIPHERAL NERVE INJURY [23S] ^ (#343) OTHER CNS OCCURRENCE [24P:80] ^ (#321) CARDIAC OCCURRENCES [25S] ^
==>(#411) CARDIAC ARREST REQ CPR [26S] ^ (#258) MYOCARDIAL INFARCTION [27S] ^ (#259) PULMONARY EDEMA [28S] ^ (#344)
==>OTHER CARDIAC OCCURRENCE [29P:80] ^ (#322) OTHER OCCURRENCES [30S] ^ (#345) ILEUS/BOWEL OBSTRUCTION [31S] ^ (#257)
==>POSTOP BLEEDING/TRANSFUSIONS [32S] ^ (#261) GRAFT/PROSTHESIS/FLAP FAILURE [33S] ^ (#263) DVT/THROMBOPHLEBITIS [34S]
==>^ (#250) SYSTEMIC SEPSIS [35S] ^ (#392) OTHER OCCURRENCES (ICD) [36P:80] ^ (#488) ORGAN/SPACE SSI [37S] ^ (#489)
==>OTHER WOUND OCCURRENCE [38P:80] ^ (#447) CLOSTRIDIUM DIFFICILE COLITIS [39S] ^ (#448) POSTOP ATRIAL FIBRILLATION
==>[40S] ^ (#342.1) 30 DAY DEATH [41S] ^ (#644) SYMPTOMATIC UTI [42S] ^ (#645) *MECHANICAL VENT W/N 30 DAYS [43S] ^
==>(#422) OUT-OF-OR UNPLANNED INTUBATION [44S] ^
^SRF(D0,206)= (#236) HEIGHT [1F] ^ (#237) WEIGHT [2F] ^ (#338.1) *CHEMOTHERAPY IN LAST 30 DAYS [3S] ^ (#338.2) RADIOTHERAPY IN
==>LAST 90 DAYS [4S] ^ (#347) FEV1 [5F] ^ (#209) CARDIOMEGALY [6S] ^ (#348) *PULMONARY RALES [7S] ^ (#218.1)
==>PREOPERATIVE SEPSIS [8S] ^ (#415) MITRAL REGURGITATION [9S] ^ (#349) ACTIVE ENDOCARDITIS [10S] ^ (#350) *RESTING ST
==>DEPRESSION [11S] ^ ^ (#351) *PCI [13S] ^ (#205) PRIOR MI [14S] ^ (#352) NUM OF PRIOR HEART SURGERIES [15S] ^
==>(#265) PERIPHERAL ARTERIAL DISEASE [16S] ^ (#264) *CEREBRAL VASCULAR DISEASE [17S] ^ (#267) ANGINA SEVERITY [18S] ^
==>(#207) *CONGESTIVE HEART FAILURE [19S] ^ (#353) CURRENT DIURETIC USE [20S] ^ (#354) *CURRENT DIGOXIN USE [21S] ^
==>(#355) IV NTG WITHIN 48 HOURS [22S] ^ (#356) PREOPERATIVE USE OF IABP [23S] ^ (#357) LVEDP [24F] ^ (#358) AORTIC
==>SYSTOLIC PRESSURE [25F] ^ (#359) PA SYSTOLIC PRESSURE [26F] ^ (#360) PAW MEAN PRESSURE [27F] ^ (#361) LEFT MAIN
==>STENOSIS [28F] ^ (#362) CORONARIES WITH STENOSIS [29N] ^ (#363) LV CONTRACTION SCORE [30S] ^ (#364) ESTIMATE OF
==>MORTALITY [31N] ^ (#364.1) ESTIMATE OF MORTALITY, DATE [32F] ^ (#362.1) LAD STENOSIS [33F] ^ (#362.2) RIGHT
==>CORONARY STENOSIS [34F] ^ (#362.3) CIRCUMFLEX STENOSIS [35F] ^ (#450) TOTAL ISCHEMIC TIME [36N] ^ (#451) TOTAL CPB
==>TIME [37N] ^ (#463) *HYPERTENSION [38S] ^ (#466) TRACHEOSTOMY [39S] ^ (#467) NEW MECHANICAL CIRCULATORY [40S] ^
==>(#472) *CARDIAC SURG PERFORMED NON-VA [41S] ^ (#485) PRIOR HEART SURGERY [42F] ^
^SRF(D0,206.1)= (#430) CARDIAC RISK PREOP COMMENTS [1F] ^
^SRF(D0,206.2)= (#431) CARDIAC RESOURCE DATA COMMENTS [1F] ^
^SRF(D0,207)= (#365) *NUMBER WITH VEIN [1N] ^ (#366) *NUMBER WITH IMA [2N] ^ (#367) *AORTIC VALVE PROCEDURE [3S] ^ (#368) *MITRAL
==>VALVE PROCEDURE [4S] ^ (#369) *TRICUSPID VALVE PROCEDURE [5S] ^ (#370) VALVE REPAIR [6S] ^ (#371) *LV
==>ANEURYSMECTOMY [7S] ^ (#372) *GREAT VESSEL REPAIR (Y/N) [8S] ^ (#373) *CARDIAC TRANSPLANT [9S] ^ (#374)
==>ELECTROPHYSIOLOGIC PROCEDURE [10S] ^ (#375) MISC. CARDIAC PROCEDURES [11S] ^ (#376) *ASD REPAIR [12S] ^ (#380) *VSD
==>REPAIR [13S] ^ (#377) *MYXOMA RESECTION [14S] ^ (#381) *FOREIGN BODY REMOVAL [15S] ^ (#378) *MYECTOMY [16S] ^
==>(#382) *PERICARDIECTOMY [17S] ^ (#379) *OTHER TUMOR RESECTION [18S] ^ (#383) OTHER PROCEDURES (Y/N) [19S] ^ (#416)
==>*NUMBER WITH OTHER CONDUIT [20N] ^ (#440) CARDIAC CATHETERIZATION DATE [21D] ^ (#441) MINIMALLY INVASIVE PROC (Y/N)
==>[22S] ^ (#439) BATISTA PROCEDURE USED (Y/N) [23S] ^ (#464) *NUMBER WITH RADIAL ARTERY [24N] ^ (#465) *NUMBER WITH
==>OTHER ARTERY [25N] ^ (#468) INCISION TYPE [26S] ^ (#469) CONVERT FROM OFF PUMP TO CPB [27S] ^ (#493) *PULMONARY
==>VALVE PROCEDURE [28S] ^ (#423) CONGESTIVE HEART FAILURE PREOP [29S] ^
^SRF(D0,207.1)= (#383.1) OTHER CARDIAC PROCEDURES [1F] ^ (#505) *ENDOVASCULAR REPAIR [2S] ^
^SRF(D0,208)= (#384) OPERATIVE DEATH [1S] ^ (#385) *PERIOPERATIVE MI [2S] ^ (#386) ENDOCARDITIS [3S] ^ (#387) LOW CARDIAC OUTPUT
==>> 6 HOURS [4S] ^ (#388) MEDIASTINITIS [5S] ^ (#389) REOPERATION FOR BLEEDING [6S] ^ (#391) REPEAT CARDIAC SURG
==>PROCEDURE [7S] ^ (#390) *STROKE [8S] ^ (#202.1) PACK/YEARS [9F] ^ (#417) RACE [10S] ^ (#413) TRANSFER STATUS [11S]
==>^ (#414) CARDIAC SURGICAL PRIORITY [12S] ^ (#414.1) SURGICAL PRIORITY, DATE [13D] ^ (#418) HOSPITAL ADMISSION DATE
==>[14F] ^ (#419) HOSPITAL DISCHARGE DATE [15F] ^ (#420) ADMISSION/TRANSFER DATE [16F] ^ (#421) DISCHARGE/TRANSFER
==>DATE [17F] ^ (#442) EMPLOYMENT STATUS PREOPERATIVE [18S] ^ (#509) PREOP ATRIAL FIBRILLATION [19S] ^ ^ ^ (#470)
==>D/T PATIENT EXTUBATED [22F] ^ (#471) D/T PATIENT DISCH FROM ICU [23F] ^
^SRF(D0,208.1)= (#452) OBSERVATION ADMISSION DATE [1F] ^ (#453) OBSERVATION DISCHARGE DATE [2F] ^ (#454) OBSERVATION TREATING
==>SPECIALTY [3P:42.4] ^
^SRF(D0,209)= (#473) HOMELESS [1S] ^ (#474) PREOP CIRCULATORY DEVICE [2S] ^ (#475) *DIABETES (CARDIAC) [3S] ^ (#476) PROCEDURE
==>TYPE [4S] ^ (#477) AORTIC STENOSIS [5S] ^ (#478) RE-DO LAD STENOSIS [6F] ^ (#479) RE-DO RT CORONARY STENOSIS [7F] ^
==>(#480) RE-DO CIRCUMFLEX STENOSIS [8F] ^ (#481) BRIDGE TO TRANSPLANT/DEVICE [9S] ^ (#482) *MAZE PROCEDURE [10S] ^
==>(#483) *TMR [11S] ^ (#490) *REPEAT VENTILATOR W/IN 30 DAY [12S] ^ (#502) *OTHER CARDIAC PROCEDURES (Y/N) [13S] ^
==>(#512) *MAZE PROCEDURE [14S] ^ (#513) SURGERY CONSULT DATE [15F] ^ (#515) PRIMARY CAUSE FOR DELAY [16S] ^ (#516)
==>SURGERY CONSULT REQUESTED [17F] ^
^SRF(D0,209.1)= (#484) *OTHER CARDIAC PROCEDURES-LIST [1F] ^
^SRF(D0,209.2)= (#491) OTHER NON-CT PROCEDURES [1F] ^
^SRF(D0,210)= (#662) IMPAIRED COGNITIVE FUNCTION [1S] ^ (#666) LIVER DISEASE/CIRRHOSIS [2S] ^ (#668) IMMUNOCOMPROMISED STATE
==>PREOP [3S] ^ (#669) PULMONARY HTN [4S] ^ (#670) RESIDENCE 30 DAYS PREOP [5S] ^ (#671) AMBULATION DEVICE PREOP [6S]
==>^ (#672) NUTRITIONAL SUPPLEMENT PREOP [7S] ^ (#673) HISTORY OF CANCER DIAGNOSIS [8S] ^ (#674) HX RAD RX PLANNED
==>SURG FIELD [9S] ^ (#675) PRIOR INFEC/INFLAM SURG FIELD [10S] ^ (#676) HX DEEP VEIN THROMBOSIS [11S] ^ (#677) PRIOR
==>SURG SAME OP FIELD [12S] ^ ^ (#685) DC/REL DESTINATION [14S] ^
^SRF(D0,211)= (#686) AORTIC REGURGITATION [1S] ^ (#687) INJURY TO ADJACENT ORGAN [2S] ^ (#688) STOMA COMPLICATIONS [3S] ^ (#689)
==>NON-UNION [4S] ^ (#690) IMPLANT INFECTIONS [5S] ^ (#691) CHYLE/LYMPH LEAK [6S] ^ (#692) ANASTOMOTIC LEAK [7S] ^
==>(#693) FISTULA [8S] ^ (#694) NECROTIZING SOFT TISS INFECT [9S] ^ (#695) OTHER BLOOD PRODUCT UNITS [10S] ^ (#696)
==>PRESSORS USED INTRAOP [11S] ^ (#697) MITRAL STENOSIS [12S] ^ (#698) PCI INTERVENTION [13S] ^ (#699) ATRIAL
==>ARRHYTHMIAS [14S] ^ (#700) HEAD OR NECK CANCER [15S] ^ (#701) MACULAR DEGENERATION [16S] ^ (#702) GLAUCOMA [17S] ^
==>^ (#704) HX RETINAL DETACHMENT [19S] ^ (#705) AXIAL LEN/ANTERIOR CHAM DEP [20S] ^ (#706) CORNEAL GUTTAE/FUCHS ENDO
==>[21S] ^ (#707) DIABETIC RETINOPATHY [22S] ^ (#708) COMPLEX CATARACT [23S] ^ (#709) STATIN 30 DAYS PREOP [24S] ^
==>(#710) IPSILAT CORTICAL EVENT PREOP [25S] ^ (#711) PREOP MODIFIED RANKIN SCORE [26N] ^ (#712) CAROTID SUR ANATOMIC
==>HIGH RISK [27S] ^ (#713) BYPASS CRITICAL LIMB ISCHEMIA [28S] ^ ^ (#715) ENDOLEAK AT COMPLETION [30S] ^ (#716) HIGH
==>HEART RATE 6HRS PREOP [31N] ^ (#717) HIGH HEART RATE INTRAOP [32N] ^ (#718) LOW ARTERIAL PRESS 6HRS PREOP [33N] ^
==>(#719) HIGH LACTIC ACID 6HRS PREOP [34N] ^ (#722) LOWEST PH INTRAOP [35N] ^ (#723) LOW ARTERIAL PRESS INTRAOP [36N]
==>^ (#724) OLIGURIA <60CC/2HRS 6HRS PREOP [37S] ^ (#725) OLIGURIA URINE OUTPUT INTRAOP [38S] ^ (#727) LOWEST
==>BICARBONATE INTRAOP [39N] ^ (#728) UNITS TRANSFUSED 6HRS PREOP [40N] ^ (#729) VASOPRESSOR USAGE AT OR ENTRY [41S] ^
==>(#730) CARDIAC ARREST 24HRS PREOP [42S] ^ (#731) DIC 6HRS PREOP [43S] ^ (#732) HYPOXEMIA W/IN 6HRS PREOP [44S] ^
==>(#733) ENDOLEAK AT FOLLOW-UP [45S] ^ (#734) CARDIAC ARREST INTRAOP [46S] ^ (#735) FLOPPY IRIS INTRAOP [47S] ^
==>(#736) PREOP VISUAL ACUITY [48S] ^ (#737) POSTOP VISUAL ACUITY [49S] ^ (#738) ENDOPHTHALMITIS TYPE [50S] ^ (#739)
==>CYSTOID MACULAR EDEMA [51S] ^ (#740) DISLOCATION OF OPERATIVE JOINT [52S] ^ (#741) PERIPROSTHETIC FRACTURES [53S] ^
==>(#742) D/T PAT ARRIVES HOSP DAY SURG [54D] ^ (#743) D/T PAT LEAVES HOSP DAY SURG [55D] ^ (#744) KIDNEY DONOR
==>PROFILE INDEX [56N] ^ (#745) EXPECTED POST TRANSPLANT INDEX [57N] ^
^SRF(D0,2005,0)=^130.02005P^^ (#2005) IMAGE
^SRF(D0,2005,D1,0)= (#.01) IMAGE [1P:2005] ^
^SRF(D0,1.0)= (#1.01) REQ ANESTHESIA TECHNIQUE [1S] ^ (#1.02) REQ FROZ SECT [2S] ^ (#1.03) REQ PREOP X-RAY [3F] ^ (#1.04) REQ
==>PHOTO [4S] ^ (#1.035) INTRAOPERATIVE X-RAYS [5S] ^ ^ ^ (#1.09) WOUND CLASSIFICATION [8S] ^ (#1.052) REQ BLOOD
==>AVAIL [9S] ^ (#1.099) SURG SCHED PERSON [10P:200] ^ (#1.098) DATE/TIME OR REQUEST MADE [11D] ^
^SRF(D0,CON)= (#35) CONCURRENT CASE [1P:130] ^
^SRF(D0,LOCK)= (#24) LOCK CASE [1S] ^
^SRF(D0,NON)= (#118) NON-OR PROCEDURE [1S] ^ (#119) NON-OR LOCATION [2P:44] ^ (#120) DATE OF PROCEDURE [3D] ^ (#121) TIME
==>PROCEDURE BEGAN [4D] ^ (#122) TIME PROCEDURE ENDED [5D] ^ (#123) PROVIDER [6P:200] ^ (#124) ATTEND PROVIDER
==>[7P:200] ^ (#125) MEDICAL SPECIALTY [8P:723] ^
^SRF(D0,OP)= (#26) PRINCIPAL PROCEDURE [1F] ^ (#27) PLANNED PRIN PROCEDURE CODE [2P:81] ^ (#2006) ROBOTIC ASSISTANCE (Y/N) [3S]
==>^ (#29) *PROCEDURE COMPLETED [4S] ^ (#638) LATERALITY OF PROCEDURE [5S] ^
^SRF(D0,OPMOD,0)=^130.028P^^ (#28) PRIN. PROCEDURE CPT MODIFIER
^SRF(D0,OPMOD,D1,0)= (#.01) PRIN. PROCEDURE CPT MODIFIER [1P:81.3] ^
^SRF(D0,PADX,0)=^130.275A^^ (#27.5) PRIN ASSOC DIAGNOSIS
^SRF(D0,PADX,D1,0)= (#.01) PRIN ASSOC DIAGNOSIS [1N] ^
^SRF(D0,PFSS)= (#500) PFSS ACCOUNT REFERENCE [1P:375] ^
^SRF(D0,RA)= (#235) ASSESSMENT STATUS [1S] ^ (#284) ASSESSMENT TYPE [2S] ^ (#393) RE-TRANSMISSION [3N] ^ (#260) DATE TRANSMITTED
==>[4D] ^ (#272) DATE ASSESSMENT COMPLETED [5D] ^ (#323) CREATE RISK ASSESSMENT [6S] ^ (#102) REASON FOR NO ASSESSMENT
==>[7S] ^ (#260.1) DATE OF LAST TRANSMISSION [8D] ^ (#272.1) ASSESSMENT COMPLETED BY [9P:200] ^
^SRF(D0,REQ)= (#36) REQUESTED [1N] ^
^SRF(D0,SP)= (#68) SCHEDULED PROCEDURE [1F] ^ (#78) PREVIOUSLY SCHEDULED CASE [2P:130] ^ (#79) RESCHEDULED CASE [3P:130] ^
^SRF(D0,TIU)= (#1000) TIU OPERATIVE SUMMARY [1P:8925] ^ (#1001) TIU NURSE INTRAOP REPORT [2P:8925] ^ (#1002) TIU PROCEDURE REPORT
==>(NON-OR) [3P:8925] ^ (#1003) TIU ANESTHESIA REPORT [4P:8925] ^ (#1004) DICTATED SUMMARY EXPECTED [5S] ^ (#1005) CPT
==>ON NURSE REPORT [6S] ^ (#1006) ICD ON NURSE REPORT [7S] ^
^SRF(D0,VER)= (#43) CASE VERIFICATION [1S] ^ (#69) CODING VERIFIER [2P:200] ^ (#71) TIME OUT VERIFIED [3S] ^ (#72) PREOPERATIVE
==>IMAGING CONFIRMED [4S] ^ (#73) MARKED SITE CONFIRMED [5S] ^ (#506) HAIR REMOVAL METHOD [6S] ^ (#600) CONFIRM
==>PATIENT IDENTITY [7S] ^ (#601) PROCEDURE TO BE PERFORMED [8S] ^ (#602) SITE OF PROCEDURE [9S] ^ (#603) CONFIRM
==>VALID CONSENT [10S] ^ (#604) CONFIRM PATIENT POSITION [11S] ^ (#605) MARKED SITE CONFIRMED [12S] ^ (#606)
==>PREOPERATIVE IMAGES CONFIRMED [13S] ^ (#607) CORRECT MEDICAL IMPLANTS [14S] ^ (#608) ANTIBIOTIC PROPHYLAXIS [15S] ^
==>(#609) APPROPRIATE DVT PROPHYLAXIS [16S] ^ (#610) BLOOD AVAILABILITY [17S] ^ (#611) AVAILABILITY OF SPECIAL EQUIP
==>[18S] ^
^SRF(D0,VER1)= ^ (#648) UNOS NUMBER [2F] ^ (#649) DONOR SEROLOGY HCV [3S] ^ (#650) DONOR SEROLOGY HBV [4S] ^ (#651) DONOR
==>SEROLOGY CMV [5S] ^ (#652) DONOR SEROLOGY HIV [6S] ^ (#653) DONOR ABO TYPE [7S] ^ (#654) RECIPIENT ABO TYPE [8S] ^
==>(#655) BLOOD BANK ABO VERIFICATION [9S] ^ (#656) OR ABO VERIFICATION (Y/N) [10S] ^ (#657) SURGEON VERIFYING UNET
==>[11P:200] ^ (#658) ORGAN VER PRE-ANESTHESIA [12S] ^ (#659) SURGEON VER DONOR ORG PRE-ANES [13P:200] ^ (#660) ORGAN
==>VER PRE-TRANSPLANT [14S] ^ (#663) DONOR VESSEL USAGE [15S] ^ (#665) DONOR VESSEL DISPOSITION [16S] ^ ^ (#746)
==>BLOOD BANK ABO VER COMMENTS [18F] ^ (#747) D/T BLOOD BANK ABO VERIF [19D] ^ (#748) OR ABO VER COMMENTS [20F] ^
==>(#749) D/T OR ABO VERIF [21D] ^ (#750) UNET VERIF BY SURGEON (Y/N) [22S] ^ (#751) SURGEON VER ORGAN PRE-ANES
==>[23P:200] ^ (#752) DONOR ORG VER PRE-ANES [24S] ^ (#753) SURGEON VER ORG PRE-TRANSPLANT [25P:200] ^
^SRF(D0,VERD)= ^ ^ (#75) TOV TIMESTAMP [3D] ^ (#76) IMAG TIMESTAMP [4D] ^ (#77) SITE MARK TIMESTAMP [5D] ^ (#720) HIGH LACTIC
==>ACID INTRAOP [6N] ^ (#721) LOWEST PH 6HRS PREOP [7N] ^ (#726) LOWEST BICARBONATE 6HRS PREOP [8N] ^
INPUT TEMPLATE(S):
^DIE(1246)= SREQUEST
^DIE(1761)= SREQUEST-ICD10
^DIE(1241)= SRISK-MISC
^DIE(1243)= SRISK-NOCARD
^DIE(1242)= SRISK-NOCOMP
^DIE(1239)= SRNON-OR
^DIE(1245)= SRO-NOCOMP
^DIE(1234)= SROANES-AMIS
^DIE(1667)= SROARPT
^DIE(1236)= SROCOMP
^DIE(1222)= SROMEN-ANES
^DIE(1226)= SROMEN-ANES TECH
^DIE(1231)= SROMEN-COMP
^DIE(1225)= SROMEN-OPER
^DIE(1223)= SROMEN-OUT
^DIE(1233)= SROMEN-PACU
^DIE(1224)= SROMEN-POST
^DIE(1227)= SROMEN-REFER
^DIE(1220)= SROMEN-STAFF
^DIE(1237)= SROMEN-START
^DIE(1751)= SROMEN-VERF
^DIE(1767)= SROMEN-VERF1
^DIE(1768)= SROMEN-VERF2
^DIE(1666)= SRONRPT
^DIE(1771)= SRONRPT1
^DIE(1772)= SRONRPT2
^DIE(1244)= SROTHER
^DIE(1232)= SROVER
^DIE(1247)= SRSCHED-UNREQUESTED
^DIE(1760)= SRSCHED-UNREQUESTED-ICD10
^DIE(1235)= SRSREQV
^DIE(1221)= SRSRES-ENTRY
^DIE(1769)= SRSRES-ENTRY1
^DIE(1229)= SRSRES-SCHED
^DIE(1770)= SRSRES-SCHED1
^DIE(1228)= SRSRES1
^DIE(1230)= SRSRES2
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):