STANDARD DATA DICTIONARY #130 -- SURGERY FILE 3/24/25 PAGE 1
STORED IN ^SRF( (7 ENTRIES) SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 3)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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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
IDENTIFIED BY: DATE OF OPERATION (#.09)[R], PRINCIPAL PROCEDURE (#26)[R]
POINTED TO BY: SURGERY field (#14) of the OE/RR PATIENT EVENT File (#100.2)
CONCURRENT CASE field (#35) of the SURGERY File (#130)
PREVIOUSLY SCHEDULED CASE field (#78) of the SURGERY File (#130)
RESCHEDULED CASE field (#79) of the SURGERY File (#130)
ANES CONCURRENT CASES field (#.01) of the ANES CONCURRENT CASES sub-field (#130.3513) of the SURGERY File (#130)
RETURNED TO SURGERY field (#.01) of the RETURNED TO SURGERY sub-field (#130.43) of the SURGERY File (#130)
REQUIRED FIELDS FOR SCHEDULING field (#.01) of the REQUIRED FIELDS FOR SCHEDULING sub-field (#133.028) of the
SURGERY SITE PARAMETERS File (#133)
SURGERY CASE field (#.01) of the SURGERY PROCEDURE/DIAGNOSIS CODES File (#136)
SURGERY CASE field (#2) of the SURGERY TRANSPLANT ASSESSMENTS File (#139.5)
SURGICAL CASE # field (#14.01) of the PFSS ACCOUNT File (#375)
SCHEDULED OPERATION field (#130) of the INTERNAL DISTRIBUTION ORDER/ADJ. File (#445.3)
REQUESTING PACKAGE REFERENCE field (#1405) of the TIU DOCUMENT File (#8925)
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)
LAST MODIFIED: AUG 22,2024@15:23:04
130,.01 PATIENT 0;1 POINTER TO PATIENT FILE (#2) (Required)
Patient's Name
LAST EDITED: AUG 23, 2016
DESCRIPTION: This is the name of the patient.
DELETE TEST: 1,0)= I 1 D EN^DDIOL("Deletion from this file is not allowed !!",,"!!,?2")
CROSS-REFERENCE: 130^B
1)= S ^SRF("B",$E(X,1,30),DA)=""
2)= K ^SRF("B",$E(X,1,30),DA)
CROSS-REFERENCE: 130^ARET^MUMPS
1)= Q
2)= D ^SROKRET
The ARET cross reference on the PATIENT field removes returns to surgery that are defined for other
cases when a case is deleted. In addition, the ARET cross reference includes logic to remove AL
and AUD nodes (on case deletion) that may exist because of the reverse set and kill logic on the AL
and AUD cross references.
RECORD INDEXES: ADT (#1417), ARS (#1418)
130,.011 HOSPITAL ADMISSION STATUS 0;12 SET
Hospital Admission Status
'I' FOR INPATIENT;
'O' FOR OUTPATIENT;
'1' FOR SAME DAY;
'2' FOR ADMISSION;
'3' FOR HOSPITALIZED;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter the code corresponding to the hospital admission status on the calendar day of surgery.
DESCRIPTION: Definition Revised (2015): This field indicates the patient's acute hospital admission status on
the calendar day of surgery. Enter "1" or "S" if the operation was same day (the patient was not
admitted); "2" or "A" if the patient was admitted on the calendar day of surgery; or "3" or "H" if
the patient was already hospitalized on the calendar day prior to surgery. Observation is
considered outpatient care, not related to an inpatient admission, therefore entered as "1" or "S".
SCREEN: S DIC("S")="I Y"
EXPLANATION: Screen prevents selection of retired codes.
CROSS-REFERENCE: 130^APCE5^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
RECORD INDEXES: AD (#196)
130,.013 PLANNED ADMISSION STATUS 0;26 SET
Planned Admission Status
'1' FOR SAME DAY;
'2' FOR ADMITTED;
'3' FOR HOSPITALIZED;
LAST EDITED: MAY 22, 2015
HELP-PROMPT: Enter the code corresponding to the planned admission status for this surgical case.
DESCRIPTION: This field indicates the patient's planned hospital admission status for the calendar day of
surgery.
Enter "1" or "S" if the operation is planned as SAME day (the patient will not be admitted). Enter"
2" or "A" if the patient will be ADMITTED on the calendar day of surgery. Enter "3" or "H" if the
patient will already be HOSPITALIZED on the calendar day prior to the date of surgery.
130,.015 VISIT 0;15 POINTER TO VISIT FILE (#9000010)
Visit
LAST EDITED: SEP 17, 1996
HELP-PROMPT: Enter the visit associated with this occasion of service.
DESCRIPTION:
This is the visit associated with this case.
CROSS-REFERENCE: 130^AV
1)= S ^SRF("AV",$E(X,1,30),DA)=""
2)= K ^SRF("AV",$E(X,1,30),DA)
This is a regular cross reference to be used for sorting.
CROSS-REFERENCE: 130^AA^MUMPS
1)= D ADD^AUPNVSIT
2)= D SUB^AUPNVSIT
This MUMPS cross reference maintains the dependency count for this visit in the VISIT file.
130,.0155 CLASSIFICATION ENTERED (Y/N) 0;20 SET
Classification Entered (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 01, 1996
HELP-PROMPT: Enter YES if classification information has been entered (as appropriate).
DESCRIPTION: This field indicates whether or not classification items have been addressed. This field is used
by the software to decide whether to allow the user a choice to update classification information.
If the field is NO or null, it will not permit a choice if the site parameter to enter
classification information is turned on.
130,.016 SERVICE CONNECTED 0;16 SET
Treatment related to Service Connected condition (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating a service connected problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a service connected problem. This information may be passed to the VISIT file (#9000010) for
use by PCE.
CROSS-REFERENCE: 130^APCE16^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.017 AGENT ORANGE EXPOSURE 0;17 SET
Treatment related to Agent Orange Exposure (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating an agent orange exposure problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Agent Orange Exposure. This information may be passed to the
VISIT file (#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE17^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.018 IONIZING RADIATION EXPOSURE 0;18 SET
Treatment related to Ionizing Radiation Exposure (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating an Ionizing Radiation Exposure problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Ionizing Radiation Exposure. This information may be passed to
the VISIT file (#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE18^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.019 SOUTHWEST ASIA CONDITIONS 0;19 SET
Treatment related to service in SW Asia (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: JUL 26, 2006
HELP-PROMPT: If this case is treating a SW Asia problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem related to service in SW Asia. This information may be passed to the VISIT file
(#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE19^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.02 OP ROOM PROCEDURE PERFORMED 0;2 POINTER TO OPERATING ROOM FILE (#131.7)
Operating Room Procedure Performed
INPUT TRANSFORM: S DIC("S")="I $$ORDIV^SROUTL0(+Y,$G(SRSITE(""DIV""))),('$P(^SRS(+Y,0),U,6))" D ^DIC K DIC S DIC=DIE
,X=+Y K:Y<0 X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the name of the operating room where the principal operation is performed.
DESCRIPTION: This is the name of the operating room where the principal operation is performed for this patient.
It can be selected by entering the name or abbreviation of the operating room.
SCREEN: S DIC("S")="I $$ORDIV^SROUTL0(+Y,$G(SRSITE(""DIV""))),('$P(^SRS(+Y,0),U,6))"
EXPLANATION: Screen limits selection to active operating rooms for the division.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AOR^MUMPS
1)= I $P(^SRF(DA,0),"^",9)'="" S ^SRF("AOR",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)=""
2)= K ^SRF("AOR",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)
The AOR cross reference on the OPERATING ROOM field is used in various reports when sorting by
operating room.
CROSS-REFERENCE: 130^AM3^MUMPS
1)= D AM3^SROXR2
2)= D KILLAM3^SROXR2
The AM3 cross reference on the OPERATING ROOM field updates the AMM cross reference when the
OPERATING ROOM is edited if the case has been scheduled.
CROSS-REFERENCE: 130^APCE20^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
RECORD INDEXES: AD (#196)
130,.021 ASSOCIATED CLINIC 0;21 POINTER TO HOSPITAL LOCATION FILE (#44)
Associated Clinic
INPUT TRANSFORM: S DIC("S")="I $$HL^SROUTL0(Y,$G(SRSITE(""DIV""))),$$CLINIC^SROUTL(Y,$S($D(DA):DA,1:""""))" D ^DIC K
DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the clinic associated with this case.
DESCRIPTION: This is the clinic associated with this surgical case or non-OR procedure. The entry made in this
field will be used as the location of the encounter for PCE.
SCREEN: S DIC("S")="I $$HL^SROUTL0(Y,$G(SRSITE(""DIV""))),$$CLINIC^SROUTL(Y,$S($D(DA):DA,1:""""))"
EXPLANATION: Select active, count clinic at the user's division.
CROSS-REFERENCE: 130^APCE21^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.022 MILITARY SEXUAL TRAUMA 0;22 SET
Treatment related to Military Sexual Trauma (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating a problem related to Military Sexual Trauma, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Military Sexual Trauma. This information may be passed to the
VISIT file (#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE22^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.023 HEAD AND/OR NECK CANCER 0;23 SET
Treatment related to Head and/or Neck Cancer (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating a problem related to Head and/or Neck Cancer, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Head and/or Neck Cancer. This information may be passed to the
VISIT file (#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE23^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.024 COMBAT VET 0;24 SET
Treatment related to Combat (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 31, 2005
HELP-PROMPT: If this case is treating a problem related to Combat, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Combat. This information may be passed to the VISIT file
(#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE27^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.026 PROJ 112/SHAD 0;25 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: NOV 17, 2005
HELP-PROMPT: If this case is treating a problem related to PROJ 112/SHAD, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to PROJ 112/SHAD. This information may be passed to the VISIT file
(#9000010) for use by PCE.
CROSS-REFERENCE: 130^APCE28^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,.03 MAJOR/MINOR 0;3 SET
Major or Minor
'J' FOR MAJOR;
'N' FOR MINOR;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.03 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the code corresponding to the case type.
DESCRIPTION: Definition Revised (2004): Major - Any operation performed under general, spinal, or epidural
anesthesia plus all inguinal herniorrhaphies, carotid
endarterectomies, parathyroidectomies, thyroidectomies, breast
lumpectomies, or endovascular AAA repairs regardless of
anesthesia administered.
Minor - All operations not designated as Major.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.035 CASE SCHEDULE TYPE 0;10 SET
Case Schedule Type
'EM' FOR EMERGENCY;
'EL' FOR ELECTIVE;
'A' FOR ADD ON (NON-EMERGENT);
'S' FOR STANDBY;
'U' FOR URGENT;
INPUT TRANSFORM: I $D(DA) D EM^SROAUTLC I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.035 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter code describing how the case is scheduled.
DESCRIPTION: This is the code describing how this case was scheduled. It is important that this field is
entered. The Scheduler may use this field when updating the schedule due to cancellations or
insertions.
Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as
possible and no later than 12 hours after the patient has been admitted to the hospital or after
the onset of related preoperative symptomatology. Answer EMERGENCY if the surgeon and
anesthesiologist report the case as emergent
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AP^MUMPS
1)= D NOW^SROAUTLC
2)= D KNOW^SROAUTLC
This cross reference stuffs the current date/time into the Date/Time of Cardiac Surgical Priority
field (414.1).
130,.037 CASE SCHEDULE ORDER 0;11 FREE TEXT
Case Schedule Order
INPUT TRANSFORM: K:$L(X)>35!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.037 D ^SROCON Q
LAST EDITED: JAN 31, 1991
HELP-PROMPT: Enter the sequence when more than one patient is scheduled by a surgeon or service on the same
date, i.e. 1ST, 2ND or 3RD.
DESCRIPTION: This is the sequence in which the surgeon expects to do the case if he or she has more than one
case scheduled for this day. This field is optional, but is very useful to the person scheduling
cases if the surgeon has more than one case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.04 SURGERY SPECIALTY 0;4 POINTER TO LOCAL SURGICAL SPECIALTY FILE (#137.45) (Required)
Surgical Specialty
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 08, 2021
HELP-PROMPT: Enter the assigned surgical specialty, or section, of the surgeon.
DESCRIPTION: Definition Revised (2007): This is the surgical specialty credited for doing this operative
procedure. Many reports, including the Annual Report of Surgical Procedures, are sorted by the
surgical specialty. This field should be entered prior to completion of this case. (If you enter
'?' in the surgical package, it will display the entire local surgical specialty list and a copy of
the national list can be found in the Operations Manual.)
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130^ASP^MUMPS
1)= I $P(^SRF(DA,0),"^",9)'="" S ^SRF("ASP",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)=DA
2)= K ^SRF("ASP",X,$E($P(^SRF(DA,0),"^",9),1,7),DA)
The ASP cross reference on the SURGERY SPECIALTY field is used by various reports to sort by the
surgical specialty and within surgical specialty by date of operation.
CROSS-REFERENCE: 130^APCE3^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: ^^TRIGGER^130^2006
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X I $$GET1^DIQ(137.45,X_",",12)]"",$$GET1^DIQ(130,DA_",",2
006)="" I X S X=DIV S Y(1)=$S($D(^SRF(D0,"OP")):^("OP"),1:"") S X=$P(Y(1),U,3),X=X S DIU=X K Y S X=
DIV S X="N" X ^DD(130,.04,1,3,1.4)
1.4)= S DIH=$G(^SRF(DIV(0),"OP")),DIV=X S $P(^("OP"),U,3)=DIV,DIH=130,DIG=2006 D ^DICR
2)= Q
CREATE CONDITION)= I $$GET1^DIQ(137.45,X_",",12)]"",$$GET1^DIQ(130,DA_",",2006)=""
CREATE VALUE)= "N"
DELETE VALUE)= NO EFFECT
FIELD)= #2006
This cross reference checks the chosen specialty to determine if the field ROBOTICS DEFAULT (#12)
in the LOCAL SURGICAL SPECIALTY file (#137.45) is entered as N. If flagged to default to NO, the
ROBOTICS ASSISTANCE (Y/N) field (#2006) will be automatically set to NO. There is no value stored
if the field ROBOTICS DEFAULT field is not entered. If deleted or changed, the entry is not
affected.
RECORD INDEXES: AD (#196)
130,.05 PREOPERATIVE INFECTION 0;5 SET
Preoperative Infection
'C' FOR CLEAN;
'D' FOR CONTAMINATED;
'S' FOR SPECIAL CONSIDERATIONS;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter the code corresponding to the wound classification, for scheduling purposes.
DESCRIPTION: Enter the letter code C for clean, D for contaminated, or S for infections that require special
considerations (type in the first few letters of any word). This information allows the scheduling
manager to determine how much time is needed between operations for sanitizing a room. "Special
considerations" is for infections that have local or national requirements for special room
cleaning (e.g., CJD, VRE, MRSA).
130,.07 PREOP SKIN INTEG 0;7 POINTER TO SKIN INTEGRITY FILE (#135.2)
Preoperative Skin Integrity
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.07 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the preoperative assessment of the patient's skin integrity upon
arrival to the operating room.
DESCRIPTION: This is the preoperative assessment of the patient's skin integrity upon arrival to the operating
room. The information entered will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.08 PREOP SKIN COLOR 0;8 SET
Preoperative Skin Color
'A' FOR ASHEN;
'LBR' FOR LIGHT BROWN;
'DBR' FOR DARK BROWN;
'PI' FOR PINK;
'PA' FOR PALE;
'F' FOR FLUSHED;
'M' FOR MOTTLED;
'C' FOR CYANOTIC;
'I' FOR ICTERIC;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.08 D ^SROCON Q
LAST EDITED: AUG 22, 1990
HELP-PROMPT: Enter the code corresponding to the preoperative assessment of the patient's skin color upon
arrival to the operating room.
DESCRIPTION: This is the code corresponding to the preoperative assessment of the patient's skin color upon
arrival to the operating room. If entered, this information will appear on the Nurse
Intraoperative Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.09 DATE OF OPERATION 0;9 DATE (Required)
Date of Operation
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X I $D(X) D SCH^SRODATE
LAST EDITED: MAR 10, 2017
HELP-PROMPT: Enter the date that the principal operation was performed. The patient may have more than
principal operation (and operative record) on the same day.
DESCRIPTION:
This is the date that the case was performed. The date of operation must be entered for all cases.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the TIME PAT IN OR field of the SURGERY File
TRIGGERED by the DATE OF PROCEDURE field of the SURGERY File
CROSS-REFERENCE: 130^AC^MUMPS
1)= S ^SRF("AC",X,DA)=$P(^SRF(DA,0),"^")
2)= K ^SRF("AC",X,DA)
The AC cross reference on the DATE OF OPERATION field is used to sort entries by date of operation
for reports.
CROSS-REFERENCE: 130^ASP1^MUMPS
1)= D SP^SROXR1
2)= D KSP^SROXR1
The ASP1 cross reference on the DATE OF OPERATION field updates the ASP and the AOR cross
references when the date of operation is changed.
CROSS-REFERENCE: 130^AR^MUMPS
1)= D AR^SROXR1
2)= D KAR^SROXR1
The AR cross reference on the DATE OF OPERATION field is used to sort and display requested cases.
This cross reference is created when a case is requested or when the request date is changed. Upon
scheduling the request, the AR cross reference for the case is deleted.
FIELD INDEX: AES8 (#386) MUMPS IR ACTION
Short Descr: Update TIU when Date of Operation is changed.
Description: This cross-reference is responsible for updating the REFERENCE DATE field (#1301) in the TIU
DOCUMENT file (#8925) for all Reports when the DATE OF OPERATION field (#9) in the SURGERY file
(#130) is edited.
Set Logic: D AES8^SROESX0 Q
Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
Kill Logic: Q
X(1): DATE OF OPERATION (130,.09) (forwards)
FIELD INDEX: AK (#412) MUMPS IR ACTION
Short Descr: PFSS field monitor flag.
Description: This cross-reference will be checked before sending a notification to the PFSS after editing the
Date Of Operation field.
Set Logic: I ($P(X1(1),".")'=$P(X2(1),"."))&(X2(1)'="") S ^TMP("SRPFSS",$J)="" Q
Set Cond: Q
Kill Logic: I ($P(X1(1),".")'=$P(X2(1),"."))&(X1(1)'="") S ^TMP("SRPFSS",$J)="" Q
Kill Cond: Q
X(1): DATE OF OPERATION (130,.09) (forwards)
RECORD INDEXES: AD (#196), ADT (#1417)
130,.11 TRANS TO OR BY .1;1 POINTER TO SURGERY TRANSPORTATION DEVICES FILE (#131.01)
Transported to O.R. By
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.11 D ^SROCON Q
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the transporting device, or method, used to deliver the patient to the operating room.
DESCRIPTION: This is the method or device used to deliver the patient to the operating room. This field is
optional, but may be useful for documentation of the case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.111 OR CIRC SUPPORT 19;0 POINTER Multiple #130.28 (Add New Entry without Asking)
O.R. Circulating Nurse
DESCRIPTION: This is information about the nurses with circulating role responsibilities.
INDEXED BY: OR CIRC SUPPORT (AES7)
130.28,.01 OR CIRC SUPPORT 0;1 POINTER TO NEW PERSON FILE (#200)
O.R. Circulating Nurse
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130.28,.01"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0
X
LAST EDITED: FEB 07, 2002
DESCRIPTION: This is the person with the circulating role responsibilities. This information will appear on
the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130.28,.01"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
FIELD INDEX: AES7 (#389) MUMPS ACTION
Short Descr: Update TIU when the circulating support is changed.
Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the
EXPECTED SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Nurse Intraoperative
Report when the circulating support is edited.
Set Logic: D SET4^SROESX0
Set Cond: S X=X1(1)'=X2(1)
Kill Logic: D SET4^SROESX0
Kill Cond: S X=X2(1)=""
X(1): OR CIRC SUPPORT (130.28,.01) (forwards)
130.28,2 TIME ON 1;0 DATE Multiple #130.29 (Add New Entry without Asking)
Time Responsibilities Began
DESCRIPTION: This is the date and time that this person's circulating role responsibilities began. (Both date
and time should be entered).
130.29,.01 TIME ON 0;1 DATE
Time On
INPUT TRANSFORM:S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:
X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 08, 1993
HELP-PROMPT: Enter the DATE/TIME that the circulating nurse entered the OR.
DESCRIPTION: Enter the date/time that this person's circulating role responsibilities began. Note: Both the
date and time must be entered for this field.
PRE-LOOKUP: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="RTX" D ^%DT S X=Y K:Y<1 X
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.29,1 TIME OFF 0;2 DATE
Time Off
INPUT TRANSFORM:S SRSUB=19,SRP=1 D OFF2^SROVAR S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
OUTPUT TRANSFORM:X ^DD("DD")
LAST EDITED: JUN 01, 1993
HELP-PROMPT: Enter the date/time that the circulating role responsibilities ended.
DESCRIPTION: This is the date and time that the circulating role responsibilities ended. Times entered without
a date will be converted to the date of the operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.29,2 REASON FOR RELIEF 0;3 SET
Reason for Relief
'P' FOR PERSONAL;
'S' FOR SHIFT CHANGE;
'A' FOR ADMINISTRATIVE;
LAST EDITED: AUG 19, 1985
HELP-PROMPT: Enter the code corresponding to the reason for relief.
DESCRIPTION: This is the reason why the circulating support person was relieved, or left the operating room
during this case. Although optional, this information may be important in documenting the case.
130.29,3 COMMENT 1;0 WORD-PROCESSING #130.3
Comments
DESCRIPTION: This includes any comments or information pertaining to this person or his or her role as
circulating support for the case.
LAST EDITED: AUG 19, 1985
DESCRIPTION: This includes any comments or information pertaining to this person or his or her role as
circulating support for the case.
130.28,3 STATUS 0;3 SET
Educational Status
'O' FOR ORIENTEE;
'F' FOR FULLY TRAINED;
LAST EDITED: AUG 28, 1990
DESCRIPTION: Enter the code corresponding to the educational preparation of the registered nurse assuming
circulating role responsibilities.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.112 OR SCRUB SUPPORT 23;0 POINTER Multiple #130.36 (Add New Entry without Asking)
O.R. Scrub Nurse
DESCRIPTION: This is information about the person with scrub role responsibilities.
130.36,.01 OR SCRUB SUPPORT 0;1 POINTER TO NEW PERSON FILE (#200)
O.R. Scrub Nurse
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130.36,.01"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0
X
LAST EDITED: SEP 07, 1993
HELP-PROMPT: Enter the name of the person assuming the scrub role responsibilities.
DESCRIPTION: This is the name of the person assuming scrub role responsibilities. Although optional, this
information will appear on the Nurse Intraoperative Report if entered.
SCREEN: S DIC("S")="S RESTRICT=""130.36,.01"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.36,1 TIME ON 1;0 DATE Multiple #130.37 (Add New Entry without Asking)
Time On
DESCRIPTION: This is the date/time that this person's responsibilities for scrub support began. Both date and
time must be entered.
130.37,.01 TIME ON 0;1 DATE
Time On
INPUT TRANSFORM:S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:
X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
OUTPUT TRANSFORM:X ^DD("DD")
LAST EDITED: DEC 08, 1993
HELP-PROMPT: ENTER THE DATE/TIME ON FOR THIS OR SCRUB NURSE
DESCRIPTION: This is the date/time that this person's scrub role responsibilities began. Both the date and time
must be entered.
PRE-LOOKUP: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="RTX" D ^%DT S X=Y K:Y<1 X
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.37,1 TIME OFF 0;2 DATE
Time Off
INPUT TRANSFORM:S SRSUB=23,SRP=1 D OFF2^SROVAR S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 01, 1993
DESCRIPTION: This is the date and time that this person's scrub role responsibilities ended. Times entered
without a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.37,2 REASON FOR RELIEF 0;3 SET
Reason for Relief
'P' FOR PERSONAL;
'S' FOR SHIFT CHANGE;
'A' FOR ADMINISTRATIVE;
LAST EDITED: AUG 21, 1985
HELP-PROMPT: Enter the code corresponding to the reason for relief.
DESCRIPTION: This is the reason why this person was relieved of his or her scrub role responsibilities prior to
the end of this case. Although optional, this information may be useful in documentation of the
case.
130.37,3 COMMENT 1;0 WORD-PROCESSING #130.38
DESCRIPTION: This information is used in documenting this person's scrub support responsibilities.
Comments
LAST EDITED: AUG 21, 1985
DESCRIPTION: This is information used in documenting the scrub support responsibilities of this person.
130.36,3 STATUS 0;3 SET
Educational Status
'O' FOR ORIENTEE;
'F' FOR FULLY TRAINED;
LAST EDITED: AUG 21, 1985
DESCRIPTION: This is the code corresponding to the educational preparation of the person assuming scrub role
responsibilities.
130,.12 HAIR REMOVAL BY .1;2 POINTER TO NEW PERSON FILE (#200)
Preop Surgical Site Hair Removal by
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.12"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: APR 03, 2006
HELP-PROMPT: If the patient had hair removed for the procedure, enter the name of the person responsible for
removing the patient's hair. This field may be restricted based on locally defined keys.
DESCRIPTION: This is the person responsible for removing the patient's hair in preparation for the operative
procedure (if necessary).
SCREEN: S DIC("S")="S RESTRICT=""130,.12"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: This field may be restricted based on locally defined keys.
130,.13 RESTR & POSITION AIDS 20;0 POINTER Multiple #130.31 (Add New Entry without Asking)
Restraint and Positioning Aids
DESCRIPTION: This is information related to restraints and positioning aids used during this operative
procedure.
130.31,.01 RESTR & POSITION AIDS 0;1 POINTER TO RESTRAINTS AND POSITIONAL AIDS FILE (#132.05)
Restraints and Positioning Aids
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the list of restraints and positioning devices used during the operative procedure.
DESCRIPTION: This is the restraint or positioning aid needed for securing the patient for the operative
procedure. This information appears on the Nurse Intraoperative Report if entered.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive file entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
130.31,1 APPLIED BY 0;2 POINTER TO NEW PERSON FILE (#200)
Applied By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130.31,1"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT: Enter the name of the person who applied the aid.
DESCRIPTION: This is the person responsible for applying the restraint or positioning aid. Although optional,
this information may be useful in documenting this case. If entered, it will appear on the Nurse
Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130.31,1"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130.31,2 RESTRAINT COMMENTS 0;3 FREE TEXT
Restraint/Positioning Aid Comments
INPUT TRANSFORM: K:$L(X)>45!($L(X)<1) X
LAST EDITED: APR 07, 1992
HELP-PROMPT: Your answer must be 1-45 characters in length.
DESCRIPTION: This contains brief comments related to where or why a restraint or positioning aid was applied.
Your answer can be up to 45 characters in length.
130,.14 PRIMARY SURGEON .1;4 POINTER TO NEW PERSON FILE (#200) (Required) (audited)
Primary Surgeon
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.14"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the name of the privileged person who performs the major portion of the principal operation.
DESCRIPTION: This is the name of the person performing the major portion of the principal operative procedure.
This field is required as part of the Operation Report.
This field may be restricted by locally determined keys so that only people with the appropriate
keys can be entered.
SCREEN: S DIC("S")="S RESTRICT=""130,.14"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries into this field may be restricted based on locally selected keys.
AUDIT: YES, ALWAYS
CROSS-REFERENCE: 130^ASR^MUMPS
1)= D STAFF^SROXR1
2)= D KSTAFF^SROXR1
The ASR cross reference on the SURGEON field is used to update the STAFF/RESIDENT field when a
surgeon is entered.
CROSS-REFERENCE: 130^APCE1^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: 130^ATT^MUMPS
1)= D ATT^SROXR1
2)= D KATT^SROXR1
This cross reference updates the ATTEND SURG field with the SURGEON if the SURGERY RESIDENTS (Y/N)
site parameter is NO.
FIELD INDEX: AES1 (#380) MUMPS ACTION
Short Descr: Update TIU when surgeon is changed.
Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED
SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Operation Report when the surgeon is
edited.
Set Logic: D SET^SROESX0
Set Cond: S X=X1(1)'=X2(1)
Kill Logic: Q
Kill Cond: S X=0
X(1): PRIMARY SURGEON (130,.14) (forwards)
RECORD INDEXES: AD (#196)
130,.15 FIRST ASST .1;5 POINTER TO NEW PERSON FILE (#200)
First Assistant
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.15"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person assisting the surgeon during the major portion of the principal
operation.
DESCRIPTION: This is the name of the person assisting the surgeon during the operative procedure. The
information entered here appears on the Operation Report and Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.15"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally defined keys.
130,.16 SECOND ASST .1;6 POINTER TO NEW PERSON FILE (#200)
Second Assistant
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.16"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person assisting the surgeon.
DESCRIPTION: This is the name of the second person assisting the surgeon during the operative procedure. If
entered, this information appears on the Operation Report and Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.16"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.164 ATTENDING SURGEON .1;13 POINTER TO NEW PERSON FILE (#200)
Attending Surgeon
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.164"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the name of the attending staff surgeon. This is required when the surgeon is in training
status.
DESCRIPTION: This is the name of the attending staff surgeon responsible for this case. This information
appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.164"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
DELETE TEST: 1,0)= I 1 D EN^DDIOL("The ATTEND SURGEON can't be deleted.",,"!!,?2")
CROSS-REFERENCE: 130^APCE4^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
FIELD INDEX: AES3 (#382) MUMPS ACTION
Short Descr: Update TIU when attending surgeon is changed.
Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the
ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Operation Report when
the attending surgeon is edited.
Set Logic: D SET1^SROESX0
Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
Kill Logic: D SET1^SROESX0
Kill Cond: S X=X2(1)=""
X(1): ATTENDING SURGEON (130,.164) (forwards)
RECORD INDEXES: AD (#196)
130,.165 *ATTENDING CODE - NOT USED .1;16 SET
*Attending Code - No Longer Used
'0' FOR LEVEL 0. ATTENDING DOING THE OPERATION;
'1' FOR LEVEL 1. ATTENDING IN O.R. ASSISTING THE RESIDENT;
'2' FOR LEVEL 2. ATTENDING IN O.R., NOT SCRUBBED;
'3' FOR LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATELY AVAILABLE;
LAST EDITED: JUN 18, 2004
HELP-PROMPT: Enter the code corresponding to the highest level of supervision provided by the attending staff
surgeon.
DESCRIPTION: NOTE: This field is replaced by the new ATTENDING CODE field (#.166).
This is the code corresponding to the highest level of supervision provided by the attending staff
surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative
Report, and Attending Surgeon Report.
0 The staff practitioner performs the case but may be assisted by
a resident.
1 The supervising practitioner is physically present in the
operative or procedural suite and directly involved in the
procedure. The resident performs major portions of the procedure.
2 The supervising practitioner is physically present in the
operative or procedural suite and immediately available for
consultation. The supervising practitioner may observe and
provide direction. The resident performs the procedure
3 The supervising practitioner is not physically present in the
operative or procedural suite, but is in the facility or on the
VA campus. The supervising practitioner is immediately available
for resident supervision or consultation as needed. Local policy,
as approved by the VISN Academic Affiliations Officer, should
define the standard for "availability" of the supervising
practitioner. NOTE: The service chief and chief of staff
are responsible for periodically reviewing cases done under
Level 3 supervision.
WRITE AUTHORITY: ^
UNEDITABLE
130,.166 ATTENDING/RES SUP CODE .1;10 POINTER TO ATTENDING CODES FILE (#132.9)
Attending/Res Sup Code
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the code corresponding to the highest level of supervision provided by the attending staff
surgeon.
DESCRIPTION: This is the code corresponding to the highest level of resident supervision provided by the
attending staff surgeon for this case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
130,.167 PERFUSIONIST .1;19 POINTER TO NEW PERSON FILE (#200)
Perfusionist
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.167"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person operating the cardio-pulmonary or organ perfusion apparatus.
DESCRIPTION: This is the name of the person operating the cardio-pulmonary or organ perfusion apparatus.
Although not required, this information may be valuable in documenting the case. If entered, it
will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.167"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.168 ASST PERFUSIONIST .1;20 POINTER TO NEW PERSON FILE (#200)
Assistant Perfusionist
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.168"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person assisting the perfusionist.
DESCRIPTION: This is the name of the person assisting the perfusionist. If applicable, this information may be
valuable in documentation of this case.
SCREEN: S DIC("S")="S RESTRICT=""130,.168"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.175 SKIN PREP AGENTS .1;7 POINTER TO SKIN PREP AGENTS FILE (#135.1)
Skin Preparation Agent
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.175 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the name of the skin prep agent used to wash and prepare the
operative site.
DESCRIPTION: This is the type of agent used to wash and prepare the operative site. If entered, this
information appears on the Nurse Intraoperative Report and is useful in documenting the case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.18 SKIN PREPPED BY (1) .1;8 POINTER TO NEW PERSON FILE (#200)
Skin Prepped By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.18"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person performing the preop skin preparation.
DESCRIPTION: This is the name of the person responsible for applying the agent used to wash and prepare the
operative site. If entered, this information will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.18"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.19 PREOP MOOD .1;9 POINTER TO PATIENT MOOD FILE (#135.3)
Preoperative Mood
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.19 D ^SROCON Q
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the code corresponding to the preoperative assessment of the patient's emotional status upon
arrival to the operating room.
DESCRIPTION: This is the preoperative assessment of the patient's emotional status upon arrival to the operating
room. It may be useful in the documentation of the case. If entered, this information will appear
on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.195 PREOP CONVERSE .1;14 SET
Preoperative Conversation
'TC' FOR TALKS CONSTANTLY;
'IC' FOR INITIATES CONVERSATION;
'RQ' FOR RESPONDS TO QUESTIONS;
'NA' FOR NOT ANSWER QUESTIONS;
'A' FOR APHASIC;
'D' FOR DYSPHASIC;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.195 D ^SROCON Q
LAST EDITED: AUG 22, 1990
HELP-PROMPT: Enter the code corresponding to the preoperative assessment of the patient's demonstrated verbal
responses upon arrival to the operating room.
DESCRIPTION: This is the preoperative assessment of the patient's demonstrated verbal responses upon arrival to
the operating room. Although optional, this field may be valuable in documenting this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.196 PREOP CONSCIOUS .1;15 POINTER TO PATIENT CONSCIOUSNESS FILE (#135.4)
Preoperative Consciousness
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.196 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the preoperative assessment of the patient's level of consciousness
upon arrival to the operating room.
DESCRIPTION: This is the preoperative assessment of the patient's level of consciousness upon arrival to the
operating room. Although optional, this information may be useful in documenting the case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.202 NURSE PRESENT TIME .2;7 DATE
Time Nurse was Present
INPUT TRANSFORM: S Z=$E($P(^SRF(D0,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"
),"^") S SRFLD=.202 D ^SROCON Q
LAST EDITED: AUG 22, 1990
HELP-PROMPT: Enter the date/time that the nurse was present in the operating room.
DESCRIPTION: This is the date and time that the nurse was present in the operating room. Times entered without
a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.203 TIME PAT IN HOLD AREA .2;15 DATE
Time Patient Arrived in Holding Area
INPUT TRANSFORM: S Z=$E($P(^SRF(DA,0),U,9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X) S %DT="ETX" D ^%DT S X=Y
K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.203 D ^SROCON Q
LAST EDITED: DEC 09, 1993
HELP-PROMPT: Enter the date/time that the patient arrived in the holding area.
DESCRIPTION: This is the date and time that the patient arrived in the holding area. Times entered without a
date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.204 ANES AVAIL TIME .2;8 DATE
Anesthesia Available Time
INPUT TRANSFORM: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA),0),U,9),1,7) D TIME^SROVAR S %DT="TX" D ^%DT S X=Y K:Y<1!(X'[
".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.204 D ^SROCON Q
LAST EDITED: MAY 20, 1993
HELP-PROMPT: Enter the date/time that the anesthetist is available to service the patient.
DESCRIPTION: This is the date and time that the anesthetist is available to service the patient. Although
optional, this information is useful for evaluating operation delays.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.205 TIME PAT IN OR .2;10 DATE
Time Patient In the O.R.
INPUT TRANSFORM: S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"
),"^") N SRFLD S SRFLD=.205 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the date/time that the patient was transported into the operating room.
DESCRIPTION: This is the date and time that the patient was transported into the operation room. Times entered
without a date will be converted to the date of operation at that time.
Definition Revised (2004): Patient in Room (PIR): Time when patient enters the OR/PR.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^130^.09
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X
K Y S X=DIV S X=DIV S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09
D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X
K Y X ^DD(130,.205,1,1,2.1) X ^DD(130,.205,1,1,2.4)
2.1)= S X=DIV S X=X,Y(1)=X S X=1,Y(2)=X S X=7,X=$E(Y(1),Y(2),X)
2.4)= S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
CREATE VALUE)= TIME PAT IN OR
DELETE VALUE)= $E(OLD TIME PAT IN OR,1,7)
FIELD)= DATE OF OPERATION
This trigger on the TIME PAT IN OR field updates the DATE OF OPERATION field with the date/time the
patient went into the operating room.
CROSS-REFERENCE: 130^APCE6^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: 130^AD^MUMPS
1)= D VALIDAT^SROCVER
2)= Q
This MUMPS cross-reference on the TIME PAT IN OR field is used to invoke the CPT and ICD-9 codes
revalidation checks in routine ^SROCVER.
CROSS-REFERENCE: 130^AOE^MUMPS
1)= I $L($T(OR1^ORMEVNT1)) D OR1^ORMEVNT1(DA,X)
2)= I $L($T(OR2^ORMEVNT1)) D OR2^ORMEVNT1(DA)
This MUMPS cross reference allows the CPRS to automatic discontinue or release orders when the
patient enters the OR.
130,.206 SURG PRESENT TIME .2;9 DATE
Surgeon Present Time
INPUT TRANSFORM: S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
LAST EDITED: SEP 24, 1987
HELP-PROMPT: Enter the time that the authorized surgeon is available to begin the operation.
DESCRIPTION: This is the date and time that the surgeon is available to begin the operative procedure. Although
not mandatory, this information is useful for evaluating hospital delays.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.21 ANES CARE START TIME .2;1 DATE
Anesthesia Care Start Time
INPUT TRANSFORM: S Z=$E($P(^SRF(D0,0),U,9),1,7) D TIME^SROVAR S %DT="ETX" D ^%DT S X=Y K:Y<1!(X'[".") X I $D(X),$D(^
SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=.21 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the time a member of the Anesthesia staff begins preparing the patient for surgery in the
O.R. suite.
DESCRIPTION: This is the date and time that the anesthesia care began. It is required as part of the anesthesia
report. The definition of what constitutes the time anesthesia care begins may vary depending on
local anesthesia policy.
Non-Cardiac Definition Revised(2004): Anesthesia Start (AS): Time when a member of the anesthesia
team begins preparing the patient for an anesthetic.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AF^MUMPS
1)= Q:'$D(SRTN)!('$D(SRSITE("IV")))!('$D(DT)) I SRSITE("IV") D IV^SROXR1
2)= Q
The AF MUMPS cross reference on this field is responsible for canceling current IV orders for a
patient undergoing a surgical or non-OR procedure if the site parameter is set to allow
cancellation of IV orders.
This cross reference compares the time entered in the ANES CARE START TIME field with the current
time. If the difference is more than 24 hours, order cancellation is not allowed. If the difference
is more than 1 hour, but not more than 24 hours, the user is warned that a considerable amount of
time has passed since the start of the operation or procedure. Finally, if order cancellation is
allowed, the user is prompted to cancel current IV orders or not. If the user chooses to cancel IV
orders, the Surgery software calls DCOR^PSIVACT.
130,.213 ANES CARE TIME BLOCK 50;0 DATE Multiple #130.213 (Add New Entry without Asking)
DESCRIPTION:
This is the date and time for which anesthesia care is provided.
130.213,.01 ANES CARE MULTIPLE START TIME 0;1 DATE
Anesthesia Care Multiple Start Time
INPUT TRANSFORM:I $D(X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X D STIME^SROANEST I $D(X),$D(^SRF(DA(1),"CON")),$P
(^("CON"),"^") S SRFLD=.01,SRFLAG=1 D ^SROCON Q
LAST EDITED: APR 12, 2004
HELP-PROMPT: Enter the time a member of the Anesthesia staff begins preparing the patient for surgery in the
O.R. suite or if the care is interrupted, the time the care resumes.
DESCRIPTION: This is the date and time that this block of anesthesia care began or if the care is interrupted,
the time the care resumed. It is required as part of the anesthesia report. The definition of what
constitutes the time anesthesia care begins may vary depending on local anesthesia policy.
Anesthesia care starts when the anesthesia practitioner begins to prepare the patient for
anesthesia services in the operating room or an equivalent area.
PRE-LOOKUP: S SRFLAG=1 D SINPUT^SROANEST
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:130.213^B
1)= S ^SRF(DA(1),50,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),50,"B",$E(X,1,30),DA)
CROSS-REFERENCE:130^AG^MUMPS
1)= D CSET^SROANEST
2)= D DEL^SROANEST
The set cross reference is used to update the value of ANES CARE START TIME, field .21.
The delete cross reference is used to delete the value in ANES CARE START TIME, FIELD .21, when the
first ANES CARE MULTIPLE START TIME value is deleted.
130.213,1 ANES CARE MULTIPLE END TIME 0;2 DATE
Anesthesia Care Multiple End Time
INPUT TRANSFORM:D SINPUT^SROANEST I $D(X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X D FINALT^SROANEST I $D(X),$D(^S
RF(DA(1),"CON")),$P(^("CON"),"^") S SRFLD=1,SRFLAG=1 D ^SROCON Q
LAST EDITED: APR 12, 2004
HELP-PROMPT: Enter the time that the anesthesia staff transfers care to other care providers or the time that
care has been interrupted.
DESCRIPTION: This is the date and time that anesthesia care ends or is interrupted. Its definition may vary
according to local anesthesia policy. It ends when the anesthesia practitioner is no longer
furnishing anesthesia services to the patient, that is, when the patient may be placed safely under
postoperative care.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:130^AJ^MUMPS
1)= D CSET^SROANEST
2)= D DEL^SROANEST
The set cross reference is used to update the value of ANES CARE END TIME, field .24.
The delete cross reference is used to delete the value in ANES CARE END TIME, field .24, when the
last ANES CARE MULTIPLE END TIME value is deleted.
130,.214 ANES CARE BILLABLE TIME FLAG .2;17 SET
Anesthesia Care Billable Time Flag
'1' FOR YES;
'0' FOR NO;
LAST EDITED: SEP 05, 2003
HELP-PROMPT: "Yes" indicates all anesthesia care time has been entered. "No" indicates time entry is not
complete.
DESCRIPTION: This field is a flag that indicates all anesthesia care time has been entered for a case. It is
used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered.
"No" indicates time entry is not complete.
130,.215 INDUCTION COMPLETE .2;11 DATE
Induction Complete Time
INPUT TRANSFORM: S SRN=.2,SRP=1,SR130="ANES CARE START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON"))
,$P(^("CON"),"^") S SRFLD=.215 D ^SROCON Q
LAST EDITED: JAN 09, 1998
HELP-PROMPT: Enter the time that the anesthetist declares the patient ready for the start of the surgical
procedure.
DESCRIPTION: This is the date and time that the anesthetist declares the patient ready for the start of the
operative procedure. Although optional, this information may be useful in management studies.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.218 ANES CARE BILLABLE TIME ; COMPUTED
Anesthesia Care Billable Time
MUMPS CODE: S X=$$BILLTIME^SROANEST
ALGORITHM: S X=$$BILLTIME^SROANEST
LAST EDITED: MAR 11, 2004
DESCRIPTION: This is the total anesthesia care billable time in minutes. It is calculated from all time
intervals entered in the multiple anesthesia start and end time fields..
130,.22 TIME OPERATION BEGAN .2;2 DATE
Time the Operation Began
INPUT TRANSFORM: S Z=$E($P(^SRF(DA,0),U,9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
LAST EDITED: JAN 03, 2011
HELP-PROMPT: Enter the time of the start of the surgical procedure. Exclude the skin prep time.
DESCRIPTION: This is the date and time that the operation began. The definition of this time is usually 'knife
fall', but may vary according to local surgery service protocol.
Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is
begun (e.g., incision for a surgical procedure).
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.23 TIME OPERATION ENDS .2;3 DATE
Time the Operation Ends
INPUT TRANSFORM: N SRN,SRP,SR130 S SRN=.2,SRP=2,SR130="TIME OPERATION BEGAN" D TERM^SROVAR K:Y<1 X
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the time wherein all surgical procedures related to this operation are complete.
DESCRIPTION: Definition Revised (2004): Procedure/Surgery Finish (PF): Time when all instrument and sponge
counts are completed and verified as correct; all postoperative radiological studies to be done in
the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have
completed all procedure-related activities on the patient. Should the patient expire in the
operating room, indicate the time the patient was pronounced dead.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.232 TIME PAT OUT OR .2;12 DATE
Time Patient Out of the O.R.
INPUT TRANSFORM: N SRN,SRP,SR130,SRFLD S SRN=.2,SRP=10,SR130="TIME PAT IN OR" D TERM^SROVAR K:Y<1 X I $D(X) D ATT^SR
OUTL1 I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.232 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the time that the patient is taken from the operating room, i.e. 7:45, 0745, 745, T@7:45, JAN
1@745 ...
DESCRIPTION: This is the date and time that the patient is taken from the operating room. Times entered without
a date will be converted to the date of operation at that time. This information is very
significant for operating room management studies.
Definition Revised (2011): Indicate the time the patient was transported out of the operating room.
If the patient dies prior to leaving the OR, then indicate the time of death for this data element.
DELETE TEST: 1,0)= I $$DEL^SROESX(DA,"1,2") D EN^DDIOL("The TIME PAT OUT OR can't be deleted. This case has one
or more operative",,"!!,?2") D EN^DDIOL("reports associated with it.",,"!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AH^MUMPS
1)= I $D(^SRF(DA,14)),'$D(^(15)) S %X="^SRF(DA,14,",%Y="^SRF(DA,15," D %XY^%RCR S ^(0)="^130.18A"_U
_$P(^SRF(DA,15,0),U,3,4) K %X,%Y
2)= Q
The AH cross reference on the TIME PAT OUT OR field moves the OTHER PREOP DIAGNOSIS information
into the OTHER POSTOP DIAGS subfile when the TIME PAT OUT OR is entered.
CROSS-REFERENCE: 130^AM1^MUMPS
1)= D AM1^SROXR2
2)= Q
The AM1 cross reference on the TIME PAT OUT OR field is responsible for removing the AMM cross
reference for the case and for updating the scheduling display graph. In addition, if the case is
a requested case, the AR cross reference is removed if it still exists.
CROSS-REFERENCE: 130^APCE7^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: 130^AQ^MUMPS
1)= D AQ^SROXR4
2)= D KAQ^SROXR4
This MUMPS cross reference is used by the transmission process to the national database.
FIELD INDEX: AES (#379) MUMPS ACTION
Short Descr: Create/delete stub entries in TIU for nurse/operation reports.
Description: This cross reference is responsible for creating stub entries in TIU for the nurse intraoperative
report and the operation report when the TIME PAT OUT OR field (#.232) is entered. It is also
responsible for deleting the stub entries in TIU for these same reports, if unsigned, when the TIME
PAT OUT OR field (#.232) is deleted. No action occurs if the value in the TIME PATOUT OR field
(#.232) is modified.
Set Logic: D AES^SROESX
Set Cond: S X=X1(1)=""
Kill Logic: D KAES^SROESX
Kill Cond: S X=X2(1)=""
X(1): TIME PAT OUT OR (130,.232) (forwards)
130,.234 OR CLEAN START TIME .2;13 DATE
Time O.R. Cleaning Began
INPUT TRANSFORM: S SRN=.2,SRP=12,SR130="TIME PAT OUT OR" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(
^("CON"),"^") S SRFLD=.234 D ^SROCON Q
LAST EDITED: JAN 09, 1998
HELP-PROMPT: Enter the date/time when the 'end of case' cleaning, or terminal cleaning began.
DESCRIPTION: This is the date and time when the 'end of case' or terminal cleaning began. Times entered without
a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.236 OR CLEAN END TIME .2;14 DATE
Time O.R. Cleaning Ended
INPUT TRANSFORM: S SRN=.2,SRP=13,SR130="OR CLEAN START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON"))
,$P(^("CON"),"^") S SRFLD=.236 D ^SROCON Q
LAST EDITED: JAN 09, 1998
HELP-PROMPT: Enter the date/time when the 'end of case' or terminal cleaning ended.
DESCRIPTION: This is the date and time when the 'end of case' or terminal cleaning ended. Times entered without
a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.24 ANES CARE END TIME .2;4 DATE
Anesthesia Care End Time
INPUT TRANSFORM: N SRN,SRP,SR130,SRFLD S SRN=.2,SRP=1,SR130="ANES CARE START TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D
(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.24 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the time that the anesthesia staff transfers care to other care providers.
DESCRIPTION: This is the date and time that anesthesia care ends. Its definition may vary according to local
anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered
without a date will be converted to the date of the operation at that time.
Non-Cardiac Definition Revised (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns
over care of the patient to a post anesthesia care team (either PACU or ICU).
DELETE TEST: 1,0)= I $$DEL^SROESX(DA,"4") D EN^DDIOL("The ANES CARE END TIME field cannot be deleted. This case
has an",,"!!,?2") D EN^DDIOL("Anesthesia Report associated with it.",,"!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
FIELD INDEX: AESA (#387) MUMPS ACTION
Short Descr: Create/delete stub entries in TIU for anesthesia report.
Description: This cross reference is responsible for creating a stub entry in TIU for the anesthesia report when
the ANES CARE END TIME field (#.24) is entered. It is also responsible for deleting the stub entry
in TIU for this report, if unsigned, when the ANES CARE END TIME field (#.24) is deleted. No
action occurs if the value in the ANES CARE END TIME field (#.24) is modified.
Set Logic: D AESA^SROESXA
Set Cond: S X=X1(1)=""
Kill Logic: D KAESA^SROESXA
Kill Cond: S X=X2(1)=""
X(1): ANES CARE END TIME (130,.24) (forwards)
130,.25 BLOOD LOSS (ML) .2;5 NUMBER
Intraoperative Blood Loss (ml)
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.25 D
^SROCON Q
LAST EDITED: MAY 14, 1992
HELP-PROMPT: Enter the number of milliliters (0-100000) of blood estimated to be lost during the procedure
(EBL).
DESCRIPTION: This is the number of milliliters (0-100000) of blood estimated to be lost during the operative
procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.255 TOTAL URINE OUTPUT (ML) .2;16 NUMBER
Total Urine Output (ml)
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.255
D ^SROCON Q
LAST EDITED: AUG 22, 1990
HELP-PROMPT: Enter the number of milliliters (0-100000) of urine output during the operative procedure. (If
measured)
DESCRIPTION: This is the total number of milliliters (0-100000) of urine output during the operative procedure.
If entered, this information appears on the Nurse Intraoperative Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.27 REPLACEMENT FLUID TYPE 4;0 POINTER Multiple #130.04 (Add New Entry without Asking)
Replacement Fluid Type
DESCRIPTION: This is information related to the replacement fluid given intravascularly during the operative
procedure.
130.04,.01 REPLACEMENT FLUID TYPE 0;1 POINTER TO SURGERY REPLACEMENT FLUIDS FILE (#133.7)
Replacement Fluid Type
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the type of fluid given intravascularly during the operative period.
DESCRIPTION: This is the type of replacement fluid given intravascularly during the operative procedure.
Each unique blood product should be entered separately. This field is considered optional, but
is a significant element of the Nurse's Intraoperative Report. The definition of this field may
vary according to local policy.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
130.04,1 QTY OF FLUID (ml) 0;2 NUMBER
Quantity of Fluid (ml)
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter a whole number between 0 and 100000.
DESCRIPTION: This is the number of milliliters of replacement fluid given to the patient intravascularly
during the operative procedure.
130.04,3 SOURCE ID 0;4 FREE TEXT
Source Identification Number
INPUT TRANSFORM: K:$L(X)>30!($L(X)<2) X
LAST EDITED: APR 21, 1984
HELP-PROMPT: Enter the number or unique identification provided by the supplier, 2 to 30 characters.
DESCRIPTION: This is the unique identification number or code provided by the supplier of this replacement
fluid. Although optional, this information may be useful in documentation of this case.
130.04,4 VA IDENT 0;5 FREE TEXT
VA Identification
INPUT TRANSFORM: K:$L(X)>30!($L(X)<2) X
LAST EDITED: APR 21, 1984
HELP-PROMPT: Answer must be 2 to 30 characters in length.
DESCRIPTION: This is the unique identification characters assigned by the local blood bank for type specific
blood components.
130.04,5 REPLACEMENT FLUID COMMENTS 1;0 WORD-PROCESSING #130.12
Replacement Fluid Comments
DESCRIPTION: These are comments related to this specific fluid type. This information will be used in
documentation of the case.
Replacement Fluid Comments
LAST EDITED: MAY 19, 1984
HELP-PROMPT:
DESCRIPTION: These are comments related to this specific fluid type. This information is used in
documenting the case.
130,.28 GENERAL COMMENTS 5;0 WORD-PROCESSING #130.05
General Comments
DESCRIPTION: These are general comments about the operative procedure. Any information not provided for
elsewhere can be entered here.
General Comments
LAST EDITED: MAY 19, 1984
DESCRIPTION: These are general comments about the operative procedure(s). Any information not provided for
elsewhere may be entered here.
130,.29 NURSING CARE COMMENTS 7;0 WORD-PROCESSING #130.07
Nursing Care Comments
DESCRIPTION:
These are comments on this case required for documentation on the Nurse Intraoperative Report.
Nursing Care Comments
LAST EDITED: JUN 22, 1984
DESCRIPTION: These are comments that affect or address nursing care delivery for the operative procedure(s)
that are not addressed elsewhere. This information reflects activities that may affect patient
outcomes.
130,.293 MONITORS 27;0 POINTER Multiple #130.41 (Add New Entry without Asking)
Physiologic Monitors
DESCRIPTION: This is information related to invasive or non-invasive monitors used during this case.
130.41,.01 MONITORS 0;1 POINTER TO MONITORS FILE (#133.4)
Monitor
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the type of physiologic monitor used.
DESCRIPTION: This is the physiologic monitor used during this case. More than one monitor may be entered.
The information entered appears as part of the anesthesia record.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.41,1 TIME INSTALLED 0;2 DATE
Time Applied
INPUT TRANSFORM: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:D0),0),U,9),1,7) D TIME^SROVAR K:Y<1 X
LAST EDITED: DEC 13, 1993
HELP-PROMPT: Enter the time that the monitor was applied to the patient.
DESCRIPTION: This is the time that the monitor was applied to the patient. Times entered without a date will
be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.41,2 TIME REMOVED 0;3 DATE
Time Removed
INPUT TRANSFORM: S SRSUB=27,SRP=2 D OFF1^SROVAR S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 01, 1993
HELP-PROMPT: Enter the time that the monitor was removed from the patient.
DESCRIPTION: This is the date and time that the monitor was removed from the patient. Times entered without a
date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.41,3 APPLIED BY 0;4 POINTER TO NEW PERSON FILE (#200)
Person Applying the Monitor
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130.41,3"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT: Enter the name of the person who applied the monitor.
DESCRIPTION: This is the name of the person responsible for applying the monitor to the patient. Although
optional, this information may be useful in documentation for this case.
SCREEN: S DIC("S")="S RESTRICT=""130.41,3"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.31 PRINC ANESTHETIST .3;1 POINTER TO NEW PERSON FILE (#200)
Principal Anesthetist
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.31"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 07, 2002
HELP-PROMPT: This may be the anesthesiologist or CRNA (or surgeon, if local)
DESCRIPTION: This is the name of the principal anesthesiologist or CRNA (or surgeon, if local anesthesia). This
information is extremely important for the Anesthesia Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.31"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
CROSS-REFERENCE: 130^ANES^MUMPS
1)= D ANES^SROXR1
2)= D KANES^SROXR1
The ANES cross reference on the PRINC ANESTHETIST field updates the ANESTHETIST CATEGORY field when
a principal anesthetist is entered.
FIELD INDEX: AES5 (#384) MUMPS ACTION
Short Descr: Update TIU when principal anesthetist is changed.
Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED
SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Anesthesia Report when the principal
anesthetist is edited.
Set Logic: D SET2^SROESX0
Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
Kill Logic: D SET2^SROESX0
Kill Cond: S X=X2(1)=""
X(1): PRINC ANESTHETIST (130,.31) (forwards)
130,.32 RELIEF ANESTHETIST .3;2 POINTER TO NEW PERSON FILE (#200)
Relief Anesthetist
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.32"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the relief anesthetist (if applicable)
DESCRIPTION: This is the name of the anesthetist relieving the principal anesthetist, if applicable. If
entered, this information appears on the Anesthesia Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.32"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.33 ASST ANESTHETIST .3;3 POINTER TO NEW PERSON FILE (#200)
Assistant Anesthetist
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.33"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the assistant to the principal anesthetist.
DESCRIPTION: This is the name of the person assisting the principal anesthetist. If entered, this information
appears on the Anesthesia Report.
SCREEN: S DIC("S")="S RESTRICT=""130,.33"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.34 ANESTHESIOLOGIST SUPVR .3;4 POINTER TO NEW PERSON FILE (#200)
Anesthesiologist Supervisor
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.34"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 07, 2002
HELP-PROMPT: Enter the name of the anesthesiology staff supervisor.
DESCRIPTION: This is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC
ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal
anesthetist is in a training status, or CRNA.
SCREEN: S DIC("S")="S RESTRICT=""130,.34"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
FIELD INDEX: AES6 (#385) MUMPS ACTION
Short Descr: UPdate TIU when anesthesiologist supervisor is changed.
Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the
ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Anesthesia Report when
the anesthesiologist supervisor is edited.
Set Logic: D SET3^SROESX0
Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
Kill Logic: D SET3^SROESX0
Kill Cond: S X=X2(1)=""
X(1): ANESTHESIOLOGIST SUPVR (130,.34) (forwards)
130,.345 ANES SUPERVISE CODE .3;6 POINTER TO ANESTHESIA SUPERVISOR CODES FILE (#132.95)
Anesthesiologist's Supervisor Code
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.345 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the code corresponding to the highest level of supervision of the anesthesiology staff
supervisor.
DESCRIPTION: This is the code corresponding to the highest level of supervision of the anesthesiology staff
supervisor. This information appears on the Anesthesia Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.3511 ANES PERSONALLY PERFORMED .2;19 SET
Anesthesiologist Personally Performed
'0' FOR NO;
'1' FOR YES;
LAST EDITED: SEP 08, 2003
HELP-PROMPT: Choose from: Y YES N NO
DESCRIPTION:
Answer yes only if the anesthesiologist personally performed the entire anesthesia procedure.
TECHNICAL DESCR: Did the anesthesiologist personally perform the anesthesia care? This field only accepts and
displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = No.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.3512 NUM OF CONCURRENT ANES CASES .2;20 NUMBER
Number Of Concurrent Anesthesiology Cases
INPUT TRANSFORM: K:X<1!(X>9) X
LAST EDITED: SEP 04, 2003
HELP-PROMPT: Enter the total number of concurrent anesthesia procedures to this anesthesia care including this
care.
DESCRIPTION: Including this case, enter the number of cases that the anesthesiologist supervised where the time
of the anesthesia care overlapped with this care. This field is required to support billing for the
care and is critical for accurate coding of the primary anesthesia procedure. Enter a zero if the
anesthesiologist personally performed the care. Enter 1 if the principal anesthetist was not an
anesthesiologist and was medically directed by an anesthesiologist.
TECHNICAL DESCR: Total number of concurrent cases the anesthesiologist supervised during this care? This field can
contain only one digit.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.3513 ANES CONCURRENT CASES 55;0 POINTER Multiple #130.3513 (Add New Entry without Asking)
DESCRIPTION: This field is for information only and is not required. It will assist in correcting potential
errors if a start or end time is edited since other cases could be affected by the edit.
TECHNICAL DESCR:
This field lists the concurrent anesthesia cases to this case by the SURGERY case number.
130.3513,.01 ANES CONCURRENT CASES 0;1 POINTER TO SURGERY FILE (#130)
LAST EDITED: NOV 23, 2004
HELP-PROMPT: Enter the Surgery Package case numbers of the surgical cases that were concurrent to this one.
DESCRIPTION: This field is for information only and is not required. It will assist in correcting potential
errors if a start or end time is edited since other cases could be affected by the edit.
TECHNICAL DESCR:
This field lists the concurrent anesthesia cases to this case by the SURGERY case number.
CROSS-REFERENCE: 130.3513^B
1)= S ^SRF(DA(1),55,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),55,"B",$E(X,1,30),DA)
130,.3514 ANES MEDICALLY DIRECTED .2;22 SET
Anesthesiologist Medically Directed
'0' FOR NO;
'1' FOR YES;
LAST EDITED: SEP 08, 2003
HELP-PROMPT: Choose from Y YES N NO
DESCRIPTION: If the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist
supervised the care. Answering no indicates that the anesthetist was unsupervised.
TECHNICAL DESCR: Was the CRNA medically directed by an anesthesiologist during this care? This field only accepts
and displays a "Y" for yes or "N" for no. The set of codes stores/translates 1 = YES and 0 = NO.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.3515 ANES PHYSICIAN AVAILABLE .2;23 SET
Teaching Physician Present
'0' FOR NO;
'1' FOR YES;
LAST EDITED: SEP 08, 2003
HELP-PROMPT: Choose from Y YES N NO
DESCRIPTION: If the anesthetist was a resident, answer yes if the teaching physician was present during all key
portions of the procedure and immediately available during the entire procedure.
TECHNICAL DESCR: Was the teaching physician present during all key portions of the procedure and immediately
available during the entire procedure? This field only accepts and displays a "Y" for yes or "N"
for no. The set of codes stores/translates 1 = YES and 0 = NO.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.36 MIN INTRAOP TEMPERATURE (C) .3;7 NUMBER
Lowest Intraoperative Temperature (C)
INPUT TRANSFORM: K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X I $D(X),$D(DA),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.3
6 D ^SROCON Q
LAST EDITED: JAN 03, 1995
HELP-PROMPT: Type a Number between 0 and 50, 1 Decimal Digit
DESCRIPTION: This is the lowest temperature of the patient during the operative procedure. If entered, this
information will appear on the Nurse Intraoperative Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.37 ANESTHESIA TECHNIQUE 6;0 SET Multiple #130.06 (Add New Entry without Asking)
Anesthesia Technique
LAST EDITED: MAR 15, 2007
DESCRIPTION: This is information about the anesthesia technique used during this case.
130.06,.01 ANESTHESIA TECHNIQUE 0;1 SET
Anesthesia Technique
'G' FOR GENERAL;
'M' FOR MONITORED ANESTHESIA CARE;
'S' FOR SPINAL;
'E' FOR EPIDURAL;
'R' FOR REGIONAL;
'O' FOR OTHER;
'L' FOR LOCAL;
'N' FOR NO ANESTHESIA;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter an anesthesia technique from the available list of techniques.
DESCRIPTION: This is the anesthesia technique used during this case corresponding to the American Board of
Anesthesiologists universal list of anesthesia techniques (except for REGIONAL, LOCAL and NO
ANESTHESIA). If entered, this information will appear on various anesthesia reports. Select
regional for peripheral nerve blocks or other techniques other than spinal or epidural.
SCREEN: S DIC("S")="I Y'=""O"""
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
130.06,.05 PRINCIPAL TECH 0;3 SET
Is this the Principal Technique (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: D CHECK^SROPRIN
LAST EDITED: MAR 16, 2004
DESCRIPTION: This indicates whether this technique is the principal technique for this procedure. If this is
the only technique used, 'YES' must be entered at this prompt. General anesthesia should take
precedence over all other forms of anesthesia.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.06,2 PATIENT STATUS 0;4 SET
Patient Status
'I' FOR INDUCED;
'A' FOR AWAKE;
'S' FOR SEDATED;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates the status of the patient while anesthetized.
130.06,3 APPROACH 0;5 SET
Approach Technique
'D' FOR DIRECT VISION LARYNGOSCOPY;
'R' FOR RAPID SEQUENCE;
'B' FOR BLIND;
'BL' FOR BLIND LARYNGOSCOPY;
'F' FOR FIBEROPTIC LARYNGOSCOPY;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the approach technique used for endotracheal intubation. This
information is not required, but may be useful for documentation.
130.06,4 ROUTE 0;6 SET
Endotracheal Tube Route
'O' FOR ORAL;
'N' FOR NASAL;
'T' FOR TRACHEOSTOMY;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the route of the endotracheal tube to the trachea. This
information is not required, but may be useful for documentation.
130.06,5 LARYNGOSCOPE TYPE 0;7 SET
Type of Laryngoscope
'M' FOR MACINTOSH;
'MI' FOR MILLER;
'G' FOR GUEDEL;
'W' FOR WIS-FOREGGER;
'FS' FOR FIBEROPTIC STYLET;
'FB' FOR FIBEROPTIC BRONCHOSCOPE;
'FL' FOR FIBEROPTIC LARYNGOSCOPE;
'O' FOR OTHER;
LAST EDITED: AUG 12, 1987
DESCRIPTION: This is the code corresponding to the type of scope or laryngoscope blade used to facilitate
endotracheal intubation. Although not required, it may be useful for documentation.
130.06,6 LARYNGOSCOPE SIZE 0;8 NUMBER
Laryngoscope Size
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT: ENTER A WHOLE NUMBER BETWEEN 1 AND 100.
DESCRIPTION: This is the size of the laryngoscope used to facilitate endotracheal intubation. This
information is not required, but may be useful for documentation.
130.06,7 STYLET USED (Y/N) 0;9 SET
Was a Stylet Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether a stylet was used to shape the endotracheal tube during intubation. This
information is optional, but may be useful in documentation of this case.
130.06,8 LIDOCAINE TOPICAL 0;10 SET
Was Topical Lidocaine Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether topical lidocaine is utilized to facilitate endotracheal intubation. This
information is not required, but may be useful for documentation.
130.06,9 LIDOCAINE IV 0;11 SET
Was Intravenous Lidocaine Administered ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether intravenous lidocaine is administered prior to the endotracheal
intubation. This information is not required, but may be useful for documentation.
130.06,10 TUBE TYPE 0;12 SET
Type of Endotracheal Tube
'P' FOR PVC LOW PRESSURE;
'S' FOR SILASTIC LOW PRESSURE;
'R' FOR REINFORCED;
'B' FOR BIVONA CUFF;
'2R' FOR 2 LUMEN, RT. ENDOBRONCHIAL;
'2L' FOR 2 LUMEN, LT. ENDOBRONCHIAL;
'T' FOR TRACHEOSTOMY CUFFED;
'L' FOR LASER PROTECTED;
'O' FOR OTHER;
LAST EDITED: AUG 12, 1987
DESCRIPTION: This is the code corresponding to the type of endotracheal tube used during the major portion of
the procedure. This information is not required, but may be useful for documentation.
130.06,11 TUBE SIZE 0;13 NUMBER
Endotracheal Tube Size
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<1)!(X?.E1"."2N.N) X
LAST EDITED: JAN 03, 1995
HELP-PROMPT: Type a Number between 1 and 100, 1 Decimal Digit
DESCRIPTION: This is the size of the endotracheal tube. This information is not required, but may be useful
for documentation.
130.06,12 TRAUMA 0;14 SET
Trauma Resulting from Intubation Process
'1' FOR NONE;
'2' FOR LIP LACERATION OR HEMATOMA;
'3' FOR TOOTH CHIPPED, LOOSENED OR LOST;
'4' FOR TONGUE HEMATOMA OR LACERATION;
'5' FOR PHARYNGEAL LACERATION;
'6' FOR OTHER LARYNGEAL INJURY;
'7' FOR FAILURE TO INTUBATE AS INTENDED;
LAST EDITED: NOV 30, 2010
DESCRIPTION: Definition Revised (2004): The code corresponding to trauma resulting from the endotracheal
intubation process. This should be documented on the anesthesia record. Choose from:
1. None
2. Lip laceration or hematoma
3. Tooth chipped, loosened or lost
4. Tongue hematoma or laceration
5. Pharyngeal laceration
6, Other laryngeal injury
7. Failure to intubate as intended
This information is entered by Anesthesia personnel and is not the responsibility of the Nurse
Reviewer.
130.06,13 BITE BLOCK (Y/N) 0;15 SET
Was a Bite Block Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates if a bite block is used to protect the endotracheal tube. This information is not
required, but may be useful for documentation.
130.06,14 TUBE LUBRICATION 0;16 SET
Was Tube Lubrication Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
DESCRIPTION: This indicates whether lubrication was used with the endotracheal tube. Although not required,
this information may be useful for documentation.
130.06,15 TAPED AT LENGTH 0;17 NUMBER
Taped at what Length
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT: ENTER A WHOLE NUMBER BETWEEN 1 AND 100
DESCRIPTION: This is the length of the endotracheal tube at the external reference point. This information is
not required, but may be useful for documentation of this case.
130.06,16 BREATH SOUNDS OK BILAT 0;18 SET
Are Breath Sounds Audible and Equal Bilaterally ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether breath sounds are audible and equal bilaterally. This information is not
required, but may be useful for documentation.
130.06,17 HEAT, MOISTURE EXCHANGER 0;19 SET
Was a Heat and Moisture Exchanger Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether a passive heat and moisture exchanger is used in the breathing circuit.
This information is not required, but may be useful for documentation and review.
130.06,18 BACT. FILTER IN CIRCUIT 0;20 SET
Was a Bacterial Filter Used ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
DESCRIPTION: This indicates whether a bacterial filter is used in the breathing circuit. This information is
not required, but may be useful for documentation.
130.06,19 END VENT. T.V. 0;21 NUMBER
Anesthesia Ventilator Tidal Volume
INPUT TRANSFORM: K:+X'=X!(X>20000)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT: Enter a whole number between 1 and 20000.
DESCRIPTION: This is the anesthesia ventilator tidal volume setting at the end of the case.
130.06,20 END VENT. RATE 0;22 NUMBER
Anesthesia Ventilator Rate
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT: Enter a whole number between 1 and 1000.
DESCRIPTION: This is the anesthesia ventilator rate setting at the end of the operative procedure.
130.06,21 EXTUBATED IN 0;23 SET
Location where the Endotracheal Tube was Removed
'O' FOR OR;
'P' FOR PACU;
'S' FOR SICU;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the location wherein the endotracheal tube is removed. This
information is not required, but may be useful for documentation, review or concurrent
monitoring.
130.06,22 REINTUBATED W/I 8 HRS. 0;24 SET
Was Reintubation Required within 8 Hours ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether the patient required reintubation within 8 hours for ventilatory
insufficiency or airway obstruction. Do not include intubation for a following surgical
procedure.
130.06,23 PREOXYGENATION 0;25 SET
Preoxygenation ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
DESCRIPTION: This is used to document the process of preoxygenation prior to induction of anesthesia.
130.06,24 ANESTHESIA AGENTS 1;0 POINTER Multiple #130.47 (Add New Entry without Asking)
Anesthesia Agents
DESCRIPTION: This is information related to the anesthesia agents used for this technique.
130.47,.01 ANESTHESIA AGENTS 0;1 POINTER TO DRUG FILE (#50)
Anesthesia Agent
INPUT TRANSFORM: S DIC("S")="I $$SCR^SROMED("""",""S"")",D="B^C" D MIX^DIC1 K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JAN 30, 2008
DESCRIPTION: More than one anesthesia agent may be entered for each technique.
The ANESTHESIA AGENT field uses entries from your local DRUG file. Prior to using the Surgery
package, drugs that will be used as anesthesia agents must be flagged (using the Chief's Menu)
by your package coordinator. If you are having problems entering an agent, it is likely that
the drug you are choosing has not been flagged.
SCREEN: S DIC("S")="I $$SCR^SROMED("""",""S"")"
EXPLANATION: ENTRY MUST BE FLAGGED FOR USE AS AN ANESTHESIA AGENT
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.47,1 DOSE (mg) 0;2 FREE TEXT
Dose (mg)
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X D ZERO^SROUTL1
LAST EDITED: JAN 13, 2011
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
This is the end total dose (in mgs) for nonvolatile agents.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.06,25 CONTINUOUS 2;1 SET
Was the Catheter placed for Continuous Administration ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether a catheter is placed for continuous or intermittent administration of a
drug for spinal or epidural anesthesia.
130.06,26 BARICITY 2;2 SET
Baricity
'1' FOR HYPERBARIC;
'2' FOR HYPOBARIC;
'3' FOR ISOBARIC;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the baricity of the anesthesia drug fluid vehicle in
relationship to the spinal fluid.
130.06,27 PUNCTURE SITE 2;3 SET
Puncture Site
'1' FOR L2-3;
'2' FOR L3-4;
'3' FOR L4-5;
'4' FOR L5-S1;
'5' FOR OTHER;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the spinal or epidural needle puncture site. This
information is not required, but may be useful for documentation and review.
130.06,28 SPINAL APPROACH 2;4 SET
Spinal Approach
'M' FOR MIDLINE;
'L' FOR LATERAL;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This is the code corresponding to the approach of the placement of the spinal or epidural
needle. This information is not required, but may be useful for documentation and review.
130.06,29 NEEDLE SIZE 2;5 SET
Needle Size
'1' FOR 20G;
'2' FOR 22G;
'3' FOR 25G;
'4' FOR 16 G TOUHY;
'5' FOR 26G;
LAST EDITED: JUN 18, 1987
DESCRIPTION: This is the code corresponding to the needle size used for the spinal or epidural technique.
This information is not required, but may be useful for documentation and review.
130.06,30 EPIDURAL METHOD 3;1 SET
What Epidural Method was Used ?
'H' FOR HANGING DROP;
'L' FOR LOSS OF RESISTANCE;
'B' FOR BOTH;
LAST EDITED: MAR 13, 1995
DESCRIPTION: This is the code corresponding to the method used to determine the placement of the epidural
needle. This information is not required, but may be useful for documentation and review.
130.06,31 MULTIPLE ATTEMPTS 3;2 SET
Were Multiple Attempts Required ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether more than one skin puncture was required to achieve proper placement of
the needle.
130.06,32 TEST DOSE 4;0 POINTER Multiple #130.48 (Add New Entry without Asking)
Epidural Test Dose
DESCRIPTION: This is information related to the test dose of the anesthesia agent.
130.48,.01 TEST DOSE 0;1 POINTER TO DRUG FILE (#50)
Epidural Test Dose
INPUT TRANSFORM: S DIC("S")="I $$SCR^SROMED("""",""S"")",D="B^C" D MIX^DIC1 K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JAN 30, 2008
DESCRIPTION:
This is the name of the drug used for the epidural test dose.
SCREEN: S DIC("S")="I $$SCR^SROMED("""",""S"")"
EXPLANATION: ENTRY MUST BE FLAGGED AS AN ANESTHESIA AGENT
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130.48^B
1)= S ^SRF(DA(2),6,DA(1),4,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),6,DA(1),4,"B",$E(X,1,30),DA)
130.48,1 DOSE (mg) 0;2 FREE TEXT
Dose (mg)
INPUT TRANSFORM: K:$L(X)>15!($L(X)<1) X D ZERO^SROUTL1
LAST EDITED: JAN 13, 2011
HELP-PROMPT: Answer must be 1-15 characters in length.
DESCRIPTION:
This is the number of milligrams used of the test drug.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.06,33 TEST DOSE VOL (ml) 3;3 NUMBER
Test Dose Volume (ml)
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT: Enter a whole number between 1 and 10.
DESCRIPTION:
This is the volume (mls.) of the test dose fluid vehicle.
130.06,34 DURAL PUNCTURE 3;4 SET
Dural Puncture ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 26, 1987
DESCRIPTION: This indicates whether dural puncture is recognized during the epidural needle or catheter
placement. This information is not required.
130.06,35 CATHETER REMOVED BY 3;5 POINTER TO NEW PERSON FILE (#200)
Who Removed the Catheter ?
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.06,35"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0
X
LAST EDITED: FEB 04, 1992
HELP-PROMPT:Enter the name of the person who removed the catheter.
DESCRIPTION:This is the name of the person removing the continuous catheter from the puncture site. This
information is not required, but may be useful for documentation and review.
SCREEN: S DIC("S")="S RESTRICT=""130.06,35"" D KEY^SROXPR I $D(SROK)"
EXPLANATION:Entries in this field may be restricted based on locally selected keys.
130.06,36 ADMINISTRATION METHOD 3;6 SET
Method of Administration
'B' FOR BOLUS;
'I' FOR INTERMITTENT;
'D' FOR DRIP INFUSION;
LAST EDITED: JAN 26, 1987
DESCRIPTION:This is the code corresponding to the method of administration of the anesthetic agent. This
information is not required.
130.06,37 PURPOSE 3;7 SET
Reason for using a Regional Technique
'1' FOR FOR SURGICAL PROCEDURE;
'2' FOR FOR PAIN RELIEF POST-OP;
'3' FOR FOR CHRONIC PAIN CONTROL;
LAST EDITED: JAN 26, 1987
DESCRIPTION:This is the code corresponding to the reason for using a regional technique. This information is
not required, but may be useful for documentation and review.
130.06,38 BLOCK SITE 5;0 POINTER Multiple #130.49
Regional Block Site
DESCRIPTION:This is information about the block site.
130.49,.01 BLOCK SITE 0;1 POINTER TO TOPOGRAPHY FIELD FILE (#61)
Regional Block Site
LAST EDITED: JAN 26, 1987
DESCRIPTION:This is the name or SNOMED code of the site of the anesthetic regional block. This information
is not required, but may be useful for documentation and review.
CROSS-REFERENCE:130.49^B
1)= S ^SRF(DA(2),6,DA(1),5,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),6,DA(1),5,"B",$E(X,1,30),DA)
130.49,1 NEEDLE LENGTH, CM. 0;2 NUMBER
Length of Needle (cm)
INPUT TRANSFORM:K:+X'=X!(X>50)!(X<1)!(X?.E1"."4N.N) X
LAST EDITED: JAN 19, 1988
HELP-PROMPT:Type a Number between 1 and 50, 3 Decimal Digits
DESCRIPTION:This is the length of the needle (in cms.) used for the administration of the agent for regional
block.
130.49,2 NEEDLE GAUGE 0;3 NUMBER
Gauge Size of the Needle
INPUT TRANSFORM:K:+X'=X!(X>50)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JAN 26, 1987
HELP-PROMPT:Enter a whole number between 1 and 50.
DESCRIPTION:This is the gauge size of the needle used for administration of the agent for regional block.
130.06,39 EXTUBATED BY 6;1 POINTER TO NEW PERSON FILE (#200)
Who Removed the Endotracheal Tube ?
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.06,39"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y
<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT:Enter the person responsible for extubation.
DESCRIPTION:This is the name of the person responsible for removing the endotracheal tube. Although
optional, this information may be useful for documentation.
SCREEN: S DIC("S")="S RESTRICT=""130.06,39"" D KEY^SROXPR I $D(SROK)"
EXPLANATION:Entries in this field may be restricted based on locally selected keys.
130.06,40 ANESTHESIA COMMENTS 7;0 WORD-PROCESSING #130.5
Anesthesia Comments
DESCRIPTION:These are comments related to anesthesia care for this case.
Anesthesia Comments
LAST EDITED: FEB 02, 1987
DESCRIPTION:This is information about the anesthesia care for this case.
130.06,41 MONITORED ANES CARE ?(Y/N) 8;1 SET
Monitored Anesthesia Care ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 18, 1987
DESCRIPTION:This indicates whether the anesthesia personnel monitored this patient without anesthesia.
This information is not required, but may be useful for documentation and review.
130.06,42 INTUBATED ? (Y/N) 8;2 SET
Was the Patient Intubated ? (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 18, 1987
DESCRIPTION:This indicates whether an endotracheal tube is placed.
130.06,43 LEVEL 8;3 SET
Neurodermatone Anesthesia Sensory Level
'T4' FOR T4;
'T6' FOR T6;
'T8' FOR T8;
'T10' FOR T10;
'T12' FOR T12;
'ONE-SIDED' FOR ONE-SIDED;
LAST EDITED: JUN 18, 1987
DESCRIPTION:This is the code corresponding to the neurodermatome anesthesia sensory level.
130.06,44 DATE/TIME CATHETER REMOVED 8;4 DATE
Date/Time that the Catheter was Removed
INPUT TRANSFORM:S Z=$E($P(^SRF(D0,0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X),%DT="ETX" D ^%
DT S X=Y K:Y<1 X K Z
LAST EDITED: DEC 09, 1993
DESCRIPTION:
This is the date/time that the continuous regional block catheter was removed. Times entered
without a date will be converted to the date of the operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.375 MEDICATIONS 22;0 POINTER Multiple #130.33 (Add New Entry without Asking)
Medications
DESCRIPTION:
This is information about medication for this case.
130.33,.01 MEDICATIONS 0;1 POINTER TO DRUG FILE (#50)
Medications
INPUT TRANSFORM: S DIC("S")="I $$SCR^SROMED(1,"""")",D="B^C" D MIX^DIC1 K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JAN 30, 2008
HELP-PROMPT: Answer must be 4-20 characters in length
DESCRIPTION: This is the name of the medication (generic or proprietary). More than one medication may be
entered for each case.
SCREEN: S DIC("S")="I $$SCR^SROMED(1,"""")"
EXPLANATION: Inactive Drugs are not selectable.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.33,1 TIME ADM 1;0 DATE Multiple #130.34 (Add New Entry without Asking)
Date/Time the Medication was Administered
DESCRIPTION: This is information related to the administration of the medication.
130.34,.01 TIME ADM 0;1 DATE
Date/Time Administered
INPUT TRANSFORM:S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:
X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 08, 1993
HELP-PROMPT: Enter the unique date/time that an individual medication is given.
DESCRIPTION: This is the date and time that this medication was administered.
PRE-LOOKUP: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="RTX" D ^%DT S X=Y K:Y<1 X
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.34,1 DOSE 0;2 FREE TEXT
Dose
INPUT TRANSFORM:N SRX K:$L(X)>15!($L(X)<1) X I $D(X) S SRX=$P(X,+X,2),X=+X D ZERO^SROUTL1 S X=X_SRX
LAST EDITED: APR 21, 2011
HELP-PROMPT: Enter the dose given at this time, including units. Your answer must be 1 to 15 characters in
length.
DESCRIPTION: This is the dose of the medication, including units (mg, ml, etc.), given at this time. Although
optional, this information may be useful in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.34,2 ORDERED BY 0;3 POINTER TO NEW PERSON FILE (#200)
Medication Ordered By
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.34,2"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT: Enter the name of the person who ordered the medication.
DESCRIPTION: This is the name of the person ordering this dose of medication. This information is optional, but
may be useful in documentation.
SCREEN: S DIC("S")="S RESTRICT=""130.34,2"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130.34,3 ADMIN BY 0;4 POINTER TO NEW PERSON FILE (#200)
Medication Administered By
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.34,3"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT: Enter the name of the person who administered the medication.
DESCRIPTION: This is the name of the person administering this dose of the medication. This information is
optional, but may be useful for documentation of the case.
SCREEN: S DIC("S")="S RESTRICT=""130.34,3"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130.34,4 ROUTE 0;5 SET
Route of Administration
'IV' FOR INTRAVENOUS;
'T' FOR TOPICAL;
'IR' FOR IRRIGATION;
'IM' FOR INTRAMUSCULAR;
'R' FOR RECTAL;
'S' FOR SUBLINGUAL;
'SC' FOR SUBCUTANEOUS;
'IN' FOR INFILTRATE;
'O' FOR OTHER;
'P' FOR PREPUMP;
'OR' FOR ORAL;
LAST EDITED: APR 16, 1998
HELP-PROMPT:
DESCRIPTION: This is the code corresponding to the route of administration of the medication.
130.34,5 MEDICATION COMMENTS 0;6 FREE TEXT
Medication Comments
INPUT TRANSFORM:K:$L(X)>60!($L(X)<2) X
LAST EDITED: MAY 24, 1993
HELP-PROMPT: Your answer must be 2-60 characters in length.
DESCRIPTION: These are comments pertaining to the administration of the medication at this time.
130,.39 IRRIGATION 26;0 POINTER Multiple #130.08 (Add New Entry without Asking)
Solution used for Irrigation
DESCRIPTION: This is information related to the irrigation solution.
130.08,.01 IRRIGATION 0;1 POINTER TO IRRIGATION FILE (#133.6)
Irrigation Solution
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the solution(s) used for irrigation during the operative procedure.
DESCRIPTION: This is the type of solution used for irrigation during the operative procedure. If entered,
this information appears on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
130.08,1 TIME 1;0 DATE Multiple #130.39 (Add New Entry without Asking)
Date/Time the Irrigation Solution was Utilized
DESCRIPTION: This is information related to the time that the irrigation solution was utilized.
130.39,.01 TIME 0;1 DATE
Time Utilized
INPUT TRANSFORM:S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:
X) K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
OUTPUT TRANSFORM:X ^DD("DD")
LAST EDITED: DEC 08, 1993
HELP-PROMPT: Enter the date/time that the irrigation solution was utilized.
DESCRIPTION: This is the date and time that the irrigation solution was utilized. This information is optional,
but may be useful for documentation of this case.
PRE-LOOKUP: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(2)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="RTX" D ^%DT S X=Y K:Y<1 X
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.39,1 AMOUNT USED 0;2 NUMBER
Amount of Solution Used
INPUT TRANSFORM:K:+X'=X!(X>999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 23, 1985
HELP-PROMPT: Enter a whole number between 0 and 999999.
DESCRIPTION: This is the total amount of irrigation solution used in the operative site.
130.39,2 PROVIDER 0;3 POINTER TO NEW PERSON FILE (#200)
Person Responsible
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.39,2"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 05, 1992
HELP-PROMPT: Enter the name of the provider.
DESCRIPTION: This is the name of the person responsible for the irrigation solution. Although this information
is optional, it may be useful for documentation of this case.
SCREEN: S DIC("S")="S RESTRICT=""130.39,2"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.42 OTHER PROCEDURES 13;0 Multiple #130.16 (Add New Entry without Asking)
Other Operative Procedures (Same Specialty)
LAST EDITED: DEC 06, 1991
DESCRIPTION: This is information related to procedures performed in addition to the principal procedure.
INDEXED BY: OTHER PROCEDURE & PLANNED OTHER PROC CPT CODE (AC)
130.16,.01 OTHER PROCEDURE 0;1 FREE TEXT (Multiply asked)
Other Procedure (Same Specialty)
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X D:$D(X) PROC^SROPROC,OCPTASO^SROADX2(0) K:$G(X)="" X
LAST EDITED: NOV 01, 2004
HELP-PROMPT: Your answer must be 1 to 50 characters in length.
DESCRIPTION: VASQIP Definition (2010): An additional operative procedure performed by the same surgical team
(i.e., the same specialty/service) under the same anesthetic which has a CPT code different from
that of the Principal Operative Procedure (e.g., a splenectomy performed in the course of a
cholecystectomy). This field should be verified. If need be, report discrepancies to the
official CPT coder for surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AC (#625)
130.16,1.5 PROCEDURE CODE COMMENTS 1;0 WORD-PROCESSING #130.26
Operation Code Comments
LAST EDITED: DEC 06, 1991
DESCRIPTION: These are comments related to this procedure.
Procedure Code Comments
LAST EDITED: DEC 06, 1991
DESCRIPTION: These are comments related to this procedure.
130.16,2 COMPLETED 0;3 SET
Procedure Complete (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 26, 1988
DESCRIPTION: This indicates whether this procedure was completed.
130.16,3 PLANNED OTHER PROC CPT CODE 2;1 POINTER TO CPT FILE (#81)
Planned Other Procedure CPT Code
INPUT TRANSFORM:D OCPTASO^SROADX2(1) K:X="" X D IN^SROCPT S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA(1))
:DA(1),1:""""),+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM:D OTHDISP^SROCPT
LAST EDITED: JUN 06, 2005
HELP-PROMPT: Enter the planned CPT code for this procedure.
DESCRIPTION: This is the Current Procedural Terminology (CPT) code corresponding to this planned operative
procedure. A CPT modifier on the CPT code may be included by appending the modifier to the CPT code
separated by a hyphen in the format "XXXXX-YY" where "XXXXX" is the five character CPT code and
"YY" is the two character CPT modifier.
SCREEN: S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA(1)):DA(1),1:""""),+Y)"
EXPLANATION: Screen out Inactive Codes
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:130.16^ACPT1^MUMPS
1)= D SOTH^SROMOD
2)= D KOTH^SROMOD
This MUMPS cross reference provides for updating CPT modifiers for other procedure CPT codes. CPT
modifiers for the OTHER PROCEDURE CPT CODE field (#3) of the OTHER PROCEDURES multiple field (#.42)
in SURGERY file (#130) are stored in the OTHER PROCEDURE CPT MODIFIER field (#.01) of the OTHER
PROCEDURE CPT MODIFIER multiple field (#4) of the OTHER PROCEDURES multiple field (#.42).
After selecting a CPT code, this cross reference prompts the user for a CPT modifier. If a CPT
modifier was entered concatenated with a hyphen to the CPT code, this CPT modifier is displayed as
a default modifier. Upon entering a CPT modifier, the user is prompted for another CPT modifier
until the user makes a null entry. CPT modifier input is controlled by the input transform on the
OTHER PROCEDURE CPT MODIFIER field (#.01 of sub-file #130.164). At the CPT modifier prompt, the
user may enter a question mark (?) to see a list of CPT modifiers already entered and a list of
acceptable CPT modifiers to choose from. If the user selects a modifier already entered, the user
may change or delete the modifier. If a user enters a new CPT code, replacing a previously entered
CPT code, KILL logic on the ACPT1 cross reference deletes any previously entered CPT modifiers for
the old CPT code before the SET logic prompts the user to enter CPT modifiers for the new CPT code.
RECORD INDEXES: AC (#625)
130.16,4 OTHER PROCEDURE CPT MODIFIER MOD;0 POINTER Multiple #130.164
INDEXED BY: OTHER PROCEDURE CPT MODIFIER (AC)
130.164,.01 OTHER PROCEDURE CPT MODIFIER 0;1 POINTER TO CPT MODIFIER FILE (#81.3) (Multiply asked)
Other Procedure CPT Modifier
INPUT TRANSFORM:S DIC("S")="I $$OTH^SROMOD" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM:D DISPLAY^SROMOD
LAST EDITED: NOV 22, 2002
HELP-PROMPT: Enter a CPT modifier for this procedure.
DESCRIPTION: This is a procedural coding modifier used to indicate that the other procedure performed has been
altered by some specific circumstance but not changed in its definition or code.
SCREEN: S DIC("S")="I $$OTH^SROMOD"
EXPLANATION: Screen prevents selection of modifier inappropriate for CPT code.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
FIELD INDEX: AC (#199) MUMPS IR ACTION
Short Descr: CoreFLS fields monitor flag.
Description: This cross-reference will be checked before sending a notification to the CoreFLS software after
editing any of these fields.
Set Logic: S ^TMP("CSLSUR1",$J)="" Q
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Logic: S ^TMP("CSLSUR1",$J)="" Q
Kill Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Whole Kill: Q
X(1): OTHER PROCEDURE CPT MODIFIER (130.164,.01) (forwards)
130.16,5 OTHER ASSOC DIAGNOSIS OADX;0 Multiple #130.165 (Add New Entry without Asking)
LAST EDITED: FEB 27, 2004
DESCRIPTION: The OTHER ASSOC DIAGNOSIS is used to associate diagnoses to OTHER PROCEDURES. This information
is needed to generate a clean claim.
130.165,.01 OTHER ASSOC DIAGNOSIS 0;1 NUMBER
Other Associated Diagnosis
INPUT TRANSFORM:K:+X'=X!(X>99999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 06, 2005
HELP-PROMPT: The associated Diagnosis can only be added via the Surgery Menu options.
DESCRIPTION: The OTHER ASSOC DIAGNOSIS is used to associate diagnoses to OTHER PROCEDURES. This information
is needed to generate a clean claim.
CROSS-REFERENCE:130.165^B
1)= S ^SRF(DA(2),13,DA(1),"OADX","B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),13,DA(1),"OADX","B",$E(X,1,30),DA)
130,.43 PLANNED POSTOP CARE .4;3 POINTER TO SURGERY DISPOSITION FILE (#131.6)
Planned Postop Care
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3),($P(^(0),U,2)'=""OBS""),($P(^(0),U,2)'=""M"")" D ^DIC K DIC S DIC=$G(DI
E),X=+Y K:Y<0 X
LAST EDITED: FEB 13, 2014
HELP-PROMPT: Enter the planned postop care disposition for this patient.
DESCRIPTION: This is the code corresponding to the location of care after the patient leaves the operating room
and/or the post-anesthesia care unit.
SCREEN: S DIC("S")="I '$P(^(0),U,3),($P(^(0),U,2)'=""OBS""),($P(^(0),U,2)'=""M"")"
EXPLANATION: Screen prevents selection of inactive file entries.
CROSS-REFERENCE: 130^AI^MUMPS
1)= I $S('$D(^SRF(DA,.7)):1,$P(^(.7),U,9)="":1,1:0) S $P(^SRF(DA,.7),U,9)=X
2)= Q
The AI cross reference on the REQ POSTOP CARE field stuffs the requested post-operative care entry
into the PACU DISPOSITION field.
130,.44 OR SET-UP TIME .4;4 NUMBER
O.R. Set-Up Time
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.44 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a number between 0 and 999.
DESCRIPTION: This is the number of minutes (0-999) necessary to prepare the operating room for the admission of
the patient for the surgical procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.46 OP DISPOSITION .4;6 POINTER TO SURGERY DISPOSITION FILE (#131.6)
Postoperative Disposition
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: AUG 21, 2014
HELP-PROMPT: Enter the destination of the patient from the OR and PACU.
DESCRIPTION:
This is the destination of the patient upon transfer from OR staff care.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive file entries.
130,.47 PROSTHESIS INSTALLED 1;0 POINTER Multiple #130.01 (Add New Entry without Asking)
Prosthetic Devices
DESCRIPTION: This is information related to the prosthesis used for this operative procedure.
130.01,.01 PROSTHESIS ITEM 0;1 POINTER TO PROSTHESIS FILE (#131.9)
Name of Implanted Prosthetic Device
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,6)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the name of the implanted prosthetic device.
DESCRIPTION: This is the name of the implanted prosthetic device required for this operative procedure. If
entered, this information appears on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,6)"
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
CROSS-REFERENCE: 130.01^AC^MUMPS
1)= D PRO^SROXR4
2)= Q
The AC cross reference on the PROSTHESIS ITEM field of the PROSTHESIS INSTALLED multiple stuffs
the default information stored in the PROSTHESIS file (131.9).
130.01,1 VENDOR 0;2 FREE TEXT
Manufacturer/Vendor
INPUT TRANSFORM: K:$L(X)>64!($L(X)<2) X
HELP-PROMPT: Your answer must be 2 to 64 characters in length.
DESCRIPTION: This is the name of the manufacturer of the implanted prosthetic device.
130.01,2 MODEL 0;3 FREE TEXT
Model
INPUT TRANSFORM: K:$L(X)>64!($L(X)<2) X
HELP-PROMPT: Your answer must be 2 to 64 characters in length.
DESCRIPTION: This is the model of the implanted prosthetic device.
130.01,2.5 LOT/SERIAL NO 0;5 FREE TEXT
Lot/Serial Number
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: AUG 25, 1984
HELP-PROMPT: Your answer must be 1 to 30 characters in length.
DESCRIPTION: This is the lot/serial number of the implanted prosthetic device.
130.01,3 *STERILE CODE 0;4 FREE TEXT
Sterilization Number
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: AUG 25, 1984
HELP-PROMPT: Your answer must be 1 to 30 characters in length.
DESCRIPTION:
This is the sterilization number of the implanted device. This field is marked for deletion.
130.01,4 *STERILE NUMBER 0;6 FREE TEXT
Sterilization Number
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: FEB 02, 1993
HELP-PROMPT: Your answer must be 1 to 30 characters in length.
DESCRIPTION: This is the sterilization number of the implanted prosthetic device. This field is marked for
deletion.
130.01,5 STERILE RESP 0;7 SET
Who is Accountable for Sterilization
'M' FOR MANUFACTURER;
'SPD' FOR SPD;
'SUR' FOR SURGERY;
LAST EDITED: SEP 15, 1984
HELP-PROMPT: Enter the code corresponding to sterilization accountability.
DESCRIPTION: This is the code corresponding to the sterilization accountability. Although this information is
optional, it may be useful in documentation of this case.
130.01,6 SIZE 1;1 FREE TEXT
Size
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: JAN 15, 1987
HELP-PROMPT: Your answer must be 1 to 30 characters in length.
DESCRIPTION: This is the size of the implanted prosthetic device.
130.01,7 QUANTITY 1;2 NUMBER
Quantity
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: NOV 14, 1989
HELP-PROMPT: Type a Number between 1 and 99999, 0 Decimal Digits
DESCRIPTION: This is the quantity of this prosthetic device used for this operative procedure.
130.01,8 IMPLANT STERILITY CHECKED 2;1 SET
Implant Sterility Checked (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 29, 2006
HELP-PROMPT: Enter YES or NO, documenting whether implant sterility was checked.
DESCRIPTION: This field documents whether or not the implant sterility was checked. Your answer should be YES
or NO. This field is required for all prosthesis items entered for a surgery case.
130.01,9 STERILITY EXPIRATION DATE 2;2 DATE
Sterility Expiration Date
INPUT TRANSFORM: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:D0),0),U,9),1,7) D EN3^SROVAR K:Y<1 X
LAST EDITED: AUG 21, 2006
HELP-PROMPT: Enter the sterility expiration date.
DESCRIPTION: This field documents the sterility expiration date. This field is required for all prosthesis
items entered for a surgery case. Expiration Date can not be prior to Date of Operation.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.01,10 RN VERIFIER 2;3 POINTER TO NEW PERSON FILE (#200)
RN Verifier
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.01,10"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0
X
LAST EDITED: AUG 18, 2006
HELP-PROMPT: Enter the name of the person that verified the sterility information.
DESCRIPTION: This is the name of the person that verified the sterility information. This field may be
restricted by locally determined keys so that only people with the appropriate keys can be entered.
SCREEN: S DIC("S")="S RESTRICT=""130.01,10"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on already selected keys.
130.01,11 LOT NUMBER 1;3 FREE TEXT
Lot Number
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 01, 2011
HELP-PROMPT: Answer must be 1 to 30 characters in length. Enter "NA" if this prosthesis does not have a Lot
Number.
DESCRIPTION: Indicate the lot number of the prosthesis that was implanted during surgery. This is a required
field. Enter "NA" if this prosthesis does not have a Lot Number.
130.01,12 SERIAL NUMBER 1;4 FREE TEXT
Serial Number
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: NOV 04, 2011
HELP-PROMPT: Answer must be 1-30 characters in length. Enter "NA" if this prosthesis does not have a Serial
Number.
DESCRIPTION: Indicate the serial number of the prosthesis that was implanted during surgery. This is a required
field. Enter "NA" if this prosthesis does not have a Serial Number.
130.01,13 PROVIDER READ BACK PERFORMED 1;5 SET
Provider Read Back Performed
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter YES or NO, documenting whether read back performed by provider.
DESCRIPTION: VASQIP Definition (2014): An additional step is performed immediately prior to the implantation of
the medical device. The privileged provider performing the procedure must confirm the correct
implant with a team member, including a "read-back" of all relevant information. For Ophthalmologic
intraocular lens implant procedures, the immediate intra-operative pre-implant "read-back" must
include intraocular lens implant style, power and expiration date.
130,.48 TIME TOURNIQUET APPLIED 2;0 DATE Multiple #130.02 (Add New Entry without Asking)
Date/Time Tourniquet Applied
LAST EDITED: JAN 11, 1993
DESCRIPTION: This is information related to the application of a tourniquet.
130.02,.01 TIME TOURNIQUET APPLIED 0;1 DATE
Date/Time Tourniquet Applied
INPUT TRANSFORM:S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(1)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 08, 1993
HELP-PROMPT: Enter the date/time that the tourniquet was applied.
DESCRIPTION: This is the date and time that the tourniquet was applied. If entered, this information will
appear on the Nurse Intraoperative Report.
PRE-LOOKUP: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:DA(1)),0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X)
K %DT,Z S %DT="RTX" D ^%DT S X=Y K:Y<1 X
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.02,1 SITE APPLIED 0;2 SET
Site Applied
'RL' FOR RIGHT UPPER LEG;
'RA' FOR RIGHT UPPER ARM;
'LG' FOR LEFT UPPER LEG;
'LA' FOR LEFT UPPER ARM;
'AR' FOR RIGHT ANKLE;
'AL' FOR LEFT ANKLE;
'RW' FOR RIGHT LOWER ARM;
'LW' FOR LEFT LOWER ARM;
'O' FOR OTHER;
LAST EDITED: JUN 21, 2002
HELP-PROMPT: Enter the code corresponding to the site wherein the tourniquet is applied.
DESCRIPTION: This is the code corresponding to the location on the body where the tourniquet is applied.
130.02,2 TOURNIQUET APPL. BY 0;3 POINTER TO NEW PERSON FILE (#200)
Person Applying the Tourniquet
INPUT TRANSFORM:S DIC("S")="S RESTRICT=""130.02,2"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person who applied the tourniquet cuff.
DESCRIPTION: This is the person responsible for the application of the tourniquet cuff at this time. Although
optional, this information may be useful in documentation of this case.
SCREEN: S DIC("S")="S RESTRICT=""130.02,2"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130.02,3 TIME TOURNIQUET REL. 0;4 DATE
Date/Time Tourniquet Released
INPUT TRANSFORM:S SRSUB=2,SRP=1 D OFF1^SROVAR S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 01, 1993
HELP-PROMPT: Enter the date/time that the pressure on the tourniquet cuff is released
DESCRIPTION: This is the date and time that the tourniquet was released. Times entered without a date will be
converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.02,4 PRESSURE 0;5 FREE TEXT
Pressure Applied (in TORR)
INPUT TRANSFORM:K:$L(X)>12!($L(X)<1) X
LAST EDITED: AUG 25, 1984
HELP-PROMPT: Enter the pressure (in TORR) applied to the cuff. Your answer must be 1 to 12 characters in
length.
DESCRIPTION: This is the amount of pressure (in TORR) applied to the cuff. This information is optional, but
may be useful in documentation of the case.
130,.52 FINAL COUNTS VERIFY CORRECT .5;1 SET
Status of Final Counts
'Y' FOR CORRECT;
'N' FOR INCORRECT;
'U' FOR UNKNOWN;
LAST EDITED: AUG 23, 1990
DESCRIPTION: This is the code corresponding to the status of the final count at the end of the surgical
procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.522 VERIFIER .5;12 POINTER TO NEW PERSON FILE (#200)
Final Counts Verified By
LAST EDITED: DEC 05, 1991
HELP-PROMPT: Enter the name of the verifier.
DESCRIPTION: This is the person responsible for verifying that the final sponge, sharps, and instrument counts
are correct at the end of this operative procedure.
130,.523 *INST CNT CORRECT .5;10 SET
Status of the Final Instrument Count
'Y' FOR CORRECT;
'N' FOR INCORRECT;
'U' FOR UNKNOWN;
LAST EDITED: DEC 29, 1987
DESCRIPTION: Enter the code corresponding to the status of the final instrument count at the end of the surgical
procedure.
This field is marked for deletion.
130,.525 INST CNT VERF BY .5;11 POINTER TO NEW PERSON FILE (#200)
Instrument Count Verified By
LAST EDITED: DEC 05, 1991
HELP-PROMPT: Enter the name of the person accountable for the verification of the final instrument count.
DESCRIPTION: This is the name of the person accountable for verification of the final instrument count.
130,.54 *SURGERY POSITION .5;3 POINTER TO SURGERY POSITION FILE (#132)
LAST EDITED: OCT 23, 1991
HELP-PROMPT: Enter the position of the patient during the surgery procedure.
DESCRIPTION: This field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP
Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.
130,.55 ELECTROGROUND POSITION .5;4 POINTER TO ELECTROGROUND POSITIONS FILE (#138)
Electroground Placement
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.55 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the area of placement of the dispersive electrode pad.
DESCRIPTION: This is the code corresponding to the area of placement of the dispersive electrode pad.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.56 FOLEY CATHETER SIZE .5;5 NUMBER
Foley Catheter Size
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.56 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 100.
DESCRIPTION: This is the size of the Foley catheter.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.57 FOLEY CATHETER INSERTED BY .5;6 POINTER TO NEW PERSON FILE (#200)
Foley Catheter Inserted By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.57"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person accountable for the insertion of the Foley catheter.
DESCRIPTION: This is the name of the person accountable for insertion of the Foley catheter. Although this
information is optional, it may be useful in documentation of this case.
SCREEN: S DIC("S")="S RESTRICT=""130,.57"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.61 PREOP TEMPERATURE .6;1 NUMBER
Preoperative Temperature
INPUT TRANSFORM: K:+X'=X!(X>200)!(X<0)!(X?.E1"."2N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.61 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a number between 0 and 200.
DESCRIPTION: This is the most recent ward-recorded temperature of the patient prior to transport to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.615 PREOP WEIGHT (Kg) .6;10 NUMBER
Preoperative Weight (Kg)
INPUT TRANSFORM: K:+X'=X!(X>500)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.615 D ^
SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 500.
DESCRIPTION: This is the most recent ward-recorded weight of the patient prior to transport to the operating
room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.62 PREOPERATIVE HEART RATE .6;2 NUMBER
Preoperative Heart Rate
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.62 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 300.
DESCRIPTION: This is the most recent ward-recorded heart rate of the patient prior to transport to the operating
room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.63 PREOP BLOOD PRESSURE .6;3 FREE TEXT
Preoperative Blood Pressure
INPUT TRANSFORM: K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.63 D
^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the most recent ward recorded blood pressure of the patient prior to transport to the
operating room.
DESCRIPTION: This is the most recent ward recorded blood pressure of the patient prior to transport to the
operating room. Although optional, this information may be useful for documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.64 PREOP RESPIRATORY RATE .6;4 NUMBER
Preoperative Respiratory Rate
INPUT TRANSFORM: K:+X'=X!(X>200)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.64 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 200.
DESCRIPTION: this is the most recent ward-recorded respiratory rate of the patient prior to transport to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.65 FINAL ANESTHESIA TEMP (C) .6;5 NUMBER
Final Anesthesia Temperature (C)
INPUT TRANSFORM: K:+X'=X!(X>45)!(X<4)!(X?.E1"."2N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.65 D ^SR
OCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 4 and 45.
DESCRIPTION: This is the temperature, in degrees centigrade, at the time of the end of anesthesia care.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.66 POSTOP PULSE .6;6 NUMBER
Postoperative Pulse Rate
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.66 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 300.
DESCRIPTION: This is the pulse rate of the patient upon admission to the care area immediately after the
surgical procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.67 POSTOP BP .6;7 FREE TEXT
Postoperative Blood Pressure
INPUT TRANSFORM: K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.67 D
^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the patient's blood pressure upon admission to the care area immediately after the surgical
procedure.
DESCRIPTION: This is the patient's blood pressure upon admission to the care area immediately after the surgical
procedure. Although this information is optional, it may be useful in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.68 POSTOP RESP .6;8 NUMBER
Postoperative Respiratory Rate
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.68 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 300.
DESCRIPTION: This is the respiratory rate of the patient upon admission to the care area immediately after the
surgical procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.69 TIME-OUT DOCUMENT COMPLETED BY .6;9 POINTER TO NEW PERSON FILE (#200)
Time-out Document Completed By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,.69"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: AUG 20, 2014
HELP-PROMPT: Enter the person confirming that there is valid consent.
DESCRIPTION: VASQIP Definition (2014): This is the name of the person verifying the patient's identification
band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent
on the patient's record.
SCREEN: S DIC("S")="S RESTRICT=""130,.69"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,.72 OTHER PREOP DIAGNOSIS 14;0 Multiple #130.17 (Add New Entry without Asking)
Other Preoperative Diagnosis
DESCRIPTION: This is information related to any diagnosis in addition to the principal preoperative diagnosis.
130.17,.01 OTHER PREOP DIAGNOSIS 0;1 FREE TEXT (Multiply asked)
Additional Preoperative Diagnosis
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL
LAST EDITED: MAY 04, 2000
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: This is the name of an additional preoperative diagnosis, not provided in the principal
preoperative diagnosis.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.17,1 *PAIRED ORGAN 0;2 SET
'L' FOR LEFT;
'R' FOR RIGHT;
'B' FOR BILATERAL;
'N' FOR NOT APPLICABLE;
'U' FOR UNKNOWN;
LAST EDITED: SEP 17, 1985
DESCRIPTION: This is the code corresponding to the side of the body related to this preoperative diagnosis, if
applicable.
130.17,2 DIAGNOSIS COMMENTS 1;0 WORD-PROCESSING #130.2
Diagnosis Comments
DESCRIPTION: These are comments related to the additional preoperative diagnosis.
Diagnosis Comments
LAST EDITED: AUG 27, 1984
DESCRIPTION: These are comments related to the additional preoperative diagnosis.
130.17,3 ICD DIAGNOSIS CODE 0;3 POINTER TO ICD DIAGNOSIS FILE (#80)
ICD Diagnosis Code
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA(1))
OUTPUT TRANSFORM: I $G(Y) S Y=$$OUT^SROICD(Y)
LAST EDITED: FEB 17, 2012
HELP-PROMPT: Enter the ICD Diagnosis code which corresponds with this diagnosis.
DESCRIPTION: This is the ICD Diagnosis Code which corresponds with this diagnosis. Entering this field is
optional, but may be valuable in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.74 OTHER POSTOP DIAGS 15;0 Multiple #130.18 (Add New Entry without Asking)
Other Postoperative Diagnosis
LAST EDITED: OCT 26, 1992
DESCRIPTION: This is information related to any postoperative diagnosis in addition to the principal
postoperative diagnosis.
130.18,.01 OTHER POSTOP DIAGS 0;1 FREE TEXT (Multiply asked)
Other Postoperative Diagnosis
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PDXCHK^SROADX2(0) K:$G(X)="" X
LAST EDITED: JUL 26, 2006
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: This is the name of a postoperative diagnosis other than the principal postoperative diagnosis.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^130.18^4
1)= X ^DD(130.18,.01,1,1,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,1
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,16) X ^DD(130.18,.01,1,1,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,4,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,1)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,1)=DIV,DIH=130.18,DIG=4 D ^DICR
2)= Q
CREATE CONDITION)= SERVICE CONNECTED=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,16)
DELETE VALUE)= NO EFFECT
FIELD)= SERVICE CONNECTED
CROSS-REFERENCE:^^TRIGGER^130.18^10
1)= X ^DD(130.18,.01,1,2,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,7
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,24) X ^DD(130.18,.01,1,2,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,10,0
)),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,7)_":",2),$C(59))="
"
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,7)=DIV,DIH=130.18,DIG=10 D ^DICR
2)= Q
CREATE CONDITION)= COMBAT VET=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,24)
DELETE VALUE)= NO EFFECT
FIELD)= COMBAT VET
CROSS-REFERENCE:^^TRIGGER^130.18^5
1)= X ^DD(130.18,.01,1,3,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,2
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,17) X ^DD(130.18,.01,1,3,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,5,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,2)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,2)=DIV,DIH=130.18,DIG=5 D ^DICR
2)= Q
CREATE CONDITION)= AGENT ORANGE=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,17)
DELETE VALUE)= NO EFFECT
FIELD)= AGENT
CROSS-REFERENCE:^^TRIGGER^130.18^6
1)= X ^DD(130.18,.01,1,4,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,3
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,18) X ^DD(130.18,.01,1,4,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,6,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,3)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,3)=DIV,DIH=130.18,DIG=6 D ^DICR
2)= Q
CREATE CONDITION)= IONIZING RADIATION EXPOSURE=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,18)
DELETE VALUE)= NO EFFECT
FIELD)= IONIZI
CROSS-REFERENCE:^^TRIGGER^130.18^9
1)= X ^DD(130.18,.01,1,5,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,6
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,19) X ^DD(130.18,.01,1,5,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,9,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,6)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,6)=DIV,DIH=130.18,DIG=9 D ^DICR
2)= Q
CREATE CONDITION)= SOUTHWEST ASIA CONDITIONS=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,19)
DELETE VALUE)= NO EFFECT
FIELD)= SOUTHWEST
CROSS-REFERENCE:^^TRIGGER^130.18^7
1)= X ^DD(130.18,.01,1,6,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,4
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,22) X ^DD(130.18,.01,1,6,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,7,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,4)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,4)=DIV,DIH=130.18,DIG=7 D ^DICR
2)= Q
CREATE CONDITION)= MILITARY SEXUAL TRAUMA=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,22)
DELETE VALUE)= NO EFFECT
FIELD)= MILITARY
CROSS-REFERENCE:^^TRIGGER^130.18^8
1)= X ^DD(130.18,.01,1,7,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,5
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,23) X ^DD(130.18,.01,1,7,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,8,0)
),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,5)_":",2),$C(59))=""
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,5)=DIV,DIH=130.18,DIG=8 D ^DICR
2)= Q
CREATE CONDITION)= HEAD AND/OR NECK CANCER=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,23)
DELETE VALUE)= NO EFFECT
FIELD)= HEAD
CROSS-REFERENCE:^^TRIGGER^130.18^11
1)= X ^DD(130.18,.01,1,8,1.3) I X S X=DIV S Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P(Y(1),U,8
),X=X S DIU=X K Y S X=DIV S X=$P(^SRF(DA(1),0),U,25) X ^DD(130.18,.01,1,8,1.4)
1.3)= K DIV S DIV=X,D0=DA(1),DIV(0)=D0,D1=DA,DIV(1)=D1 S Y(0)=X S Y(2)=$C(59)_$P($G(^DD(130.18,11,0
)),U,3),Y(1)=$S($D(^SRF(D0,15,D1,2)):^(2),1:"") S X=$P($P(Y(2),$C(59)_$P(Y(1),U,8)_":",2),$C(59))="
"
1.4)= S DIH=$G(^SRF(DIV(0),15,DIV(1),2)),DIV=X S $P(^(2),U,8)=DIV,DIH=130.18,DIG=11 D ^DICR
2)= Q
CREATE CONDITION)= PROJ 112=""
CREATE VALUE)= S X=$P(^SRF(DA(1),0),U,25)
DELETE VALUE)= NO EFFECT
FIELD)= PRO
CROSS-REFERENCE:130.18^DADX1^MUMPS
1)= Q
2)= D DELASOC^SROADX2
This MUMPS cross reference removes associations to procedures upon edits or deletes of the
diagnosis.
130.18,1 *PAIRED ORGANS 0;2 SET
'R' FOR RIGHT;
'L' FOR LEFT;
'B' FOR BILATERAL;
'N' FOR NOT APPLICABLE;
'U' FOR UNKNOWN;
LAST EDITED: SEP 17, 1985
DESCRIPTION: This is the code corresponding to the side of the body related to this preoperative diagnosis, if
applicable. This field is marked for deletion.
130.18,2 DIAGNOSIS COMMENTS 1;0 WORD-PROCESSING #130.19
Diagnosis Comments
DESCRIPTION: These are comments related to the additional postoperative diagnosis.
Diagnosis Comments
LAST EDITED: AUG 27, 1984
DESCRIPTION: These are comments related to the additional postoperative diagnosis.
130.18,3 PLANNED ICD DIAGNOSIS CODE 0;3 POINTER TO ICD DIAGNOSIS FILE (#80)
Planned Other ICD Diagnosis Code
INPUT TRANSFORM:D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA(1)):DA(1),$G(SRTN):SRTN,1:""))
OUTPUT TRANSFORM:I $G(Y) S Y=$$OUT^SROICD(Y)
LAST EDITED: JUL 02, 2012
HELP-PROMPT: Enter the planned ICD Diagnosis Code that corresponds to this diagnosis.
DESCRIPTION:
This is the planned ICD-CM code corresponding with this postoperative diagnosis.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE:130.18^PADX^MUMPS
1)= Q
2)= D DELASOC^SROADX2
This MUMPS cross reference removes associations to procedures upon edits or deletes of the
diagnosis.
130.18,4 SERVICE CONNECTED 2;1 SET (Required)
Treatment related to Service Connected condition (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: AUG 12, 2003
HELP-PROMPT: If this case is treating a service connected problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA
patient for a service connected problem. This information may be passed to the VISIT file
(#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,5 AGENT ORANGE EXPOSURE 2;2 SET (Required)
Treatment related to Agent Orange Exposure (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 12, 2003
HELP-PROMPT: If this case is treating an agent orange exposure problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Agent Orange Exposure. This information may be passed to the
VISIT file (#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,6 IONIZING RADIATION EXPOSURE 2;3 SET (Required)
Treatment related to Ionizing Radiation Exposure (Y/N)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: AUG 12, 2003
HELP-PROMPT: If this case is treating an Ionizing Radiation Exposure problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Ionizing Radiation Exposure. This information may be passed to
the VISIT file (#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,7 MILITARY SEXUAL TRAUMA 2;4 SET (Required)
Treatment related to Military Sexual Trauma (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: AUG 12, 2003
HELP-PROMPT: If this case is treating a problem related to Military Sexual Trauma, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Military Sexual Trauma. This information may be passed to the
VISIT file (#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,8 HEAD AND/OR NECK CANCER 2;5 SET (Required)
Treatment related to Head and/or Neck Cancer (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: AUG 12, 2003
HELP-PROMPT: If this case is treating a problem related to Head and/or Neck Cancer, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Head and/or Neck Cancer. This information may be passed to the
VISIT file (#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,9 SOUTHWEST ASIA CONDITIONS 2;6 SET (Required)
Treatment related to service in SW Asia (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: JUL 26, 2006
HELP-PROMPT: If this case is treating a SW Asia problem, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to service in SW Asia. This information may be passed to the VISIT
file (#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,10 COMBAT VET 2;7 SET (Required)
Treatment related to Combat (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: FEB 10, 2004
HELP-PROMPT: If this case is treating a problem related to Combat, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to Combat. This information may be passed to the VISIT file
(#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130.18,11 PROJ 112/SHAD 2;8 SET (Required)
Treatment related to PROJ 112/SHAD (Y/N)
'0' FOR NO;
'1' FOR YES;
LAST EDITED: NOV 17, 2005
HELP-PROMPT: If this case is treating a problem related to PROJ 112/SHAD, enter YES.
DESCRIPTION: This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient
for a problem that is related to PROJ 112/SHAD. This information may be passed to the VISIT file
(#9000010) for use by PCE.
NOTES: TRIGGERED by the OTHER POSTOP DIAGS field of the OTHER POSTOP DIAGS sub-field of the SURGERY File
130,.75 ELECTROCAUTERY UNIT .7;5 FREE TEXT
Electrocautery Unit
INPUT TRANSFORM: K:$L(X)>50!($L(X)<2) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.75 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Your answer must be 2-50 characters in length.
DESCRIPTION: This is information identifying the electrosurgical unit utilized during the operative procedure.
The information may include, but is not limited to, unit number, ground pad lot number and/or
expiration date, coag setting, cut setting, blend-BI:Setting and Bipolar BP:Setting. Examples:
Electrocautery Unit: #7 HP206 COAG:50 CUT:50 BI:1
Electrocautery Unit: DAISY:18% or DAISY BP:18%
Electrocautery Unit: VL#2 EXP 3/20/91 COAG:30 CUT:20 BI:2 #2 BP:20
(VL-VALLEYLAB)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.757 THERMAL UNIT 21;0 Multiple #130.32 (Add New Entry without Asking)
Thermal Unit
DESCRIPTION: This is information related to the temperature controlling device.
130.32,.01 THERMAL UNIT 0;1 FREE TEXT
Thermal Unit
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: SEP 22, 1987
HELP-PROMPT: Your answer must be 3 to 30 characters, including identifying number and device type.
DESCRIPTION: This is information identifying the specific temperature controlling device.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
130.32,1 TIME ON 0;2 DATE
Date/Time Turned On
INPUT TRANSFORM: S Z=$E($P(^SRF($S($D(SRTN):SRTN,1:D0),0),"^",9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
LAST EDITED: JAN 05, 1988
HELP-PROMPT: Enter the date/time that the temperature controlling device was activated.
DESCRIPTION: This is the date and time that the thermal unit was activated. Times entered without a date will
be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.32,2 TEMPERATURE 0;3 NUMBER
Temperature Setting
INPUT TRANSFORM: K:+X'=X!(X>110)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 01, 1993
HELP-PROMPT: Enter a whole number between 0 and 110.
DESCRIPTION: This is the temperature setting of the temperature controlling device.
130.32,3 TIME OFF 0;4 DATE
Date/Time Turned Off
INPUT TRANSFORM: S SRSUB=21,SRP=2 D OFF1^SROVAR S %DT="ERTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 01, 1993
HELP-PROMPT: Enter the date/time that the temperature controlling device was deactivated.
DESCRIPTION: This is the date and time that the thermal unit was turned off. Times entered without a date
will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.76 POSTOP SKIN INTEG .7;6 POINTER TO SKIN INTEGRITY FILE (#135.2)
Postoperative Skin Integrity
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.76 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the assessment of the patient's skin integrity after the surgical
procedure.
DESCRIPTION: This is the code corresponding to the assessment of the patient's skin integrity after the
operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.77 POSTOP SKIN COLOR .7;7 SET
Postoperative Skin Color
'A' FOR ASHEN;
'LBR' FOR LIGHT BROWN;
'DBR' FOR DEEP BROWN;
'PI' FOR PINK;
'PA' FOR PALE;
'F' FOR FLUSHED;
'C' FOR CYANOTIC;
'I' FOR ICTERIC;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.77 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the code corresponding to the patient's skin color.
DESCRIPTION: This is the code corresponding to the patient's skin color after the operative procedure. If
entered, this information will appear on the Nurse Intraoperative Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.79 PACU DISPOSITION .7;9 POINTER TO SURGERY DISPOSITION FILE (#131.6)
PAC(U) Disposition
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(DA),$D(X),$P($G(^SRF(DA,"CON"
)),"^") S SRFLD=.79 D ^SROCON
LAST EDITED: SEP 22, 1994
HELP-PROMPT: Enter the destination of the patient immediately after release from the post-anesthesia care unit.
DESCRIPTION: This is the code corresponding to the destination of the patient immediately after release from the
post-anesthesia care unit.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive file entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.81 POSTOP MOOD .8;1 POINTER TO PATIENT MOOD FILE (#135.3)
Postoperative Mood
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.81 D ^SROCON Q
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the code corresponding to the assessment of the patient's mood following the surgical
procedure.
DESCRIPTION: This is the code corresponding to the assessment of the patient's mood following the operative
procedure. If entered, this information will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.82 POSTOP CONVERS .8;2 SET
Postoperative Conversation
'TC' FOR TALKS CONSTANTLY;
'IC' FOR INITIATES CONVERSATION;
'RQ' FOR RESPONDS TO QUESTIONS;
'NA' FOR NOT ANSWER QUESTIONS;
'A' FOR APHASIC;
'D' FOR DYSPHASIC;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.82 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This is the code corresponding to the assessment of the patient's demonstrated verbal responses at
the completion of the surgical procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.821 POSTOP CONSCIOUS .8;10 POINTER TO PATIENT CONSCIOUSNESS FILE (#135.4)
Postoperative Consciousness
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=.821 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the assessment of the patient's level of consciousness after the
surgical procedure.
DESCRIPTION: This is the code corresponding to the assessment of the patient's level of consciousness following
the operative procedure. If entered, this information will appear on the Nurse Intraoperative
Report.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.84 END PULSE .8;4 NUMBER
End Pulse Rate
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.84 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 300.
DESCRIPTION: This is the patient's pulse rate at the end of the operative procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.85 END BP .8;5 FREE TEXT
End Blood Pressure
INPUT TRANSFORM: K:$L(X)>10!($L(X)<2)!'(X?1N.N1"/"1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.85 D
^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter blood pressure systolic/diastolic.
DESCRIPTION: This is the patient's systolic/diastolic blood pressure at the end of the operative procedure.
Although optional, this information may be useful in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.86 END RESP .8;6 NUMBER
End Respiratory Rate
INPUT TRANSFORM: K:+X'=X!(X>200)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.86 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a whole number between 0 and 200.
DESCRIPTION: This is the patient's rate of respiration at the end of the operative procedure. This information
may be useful in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.875 PACKING .8;11 SET
Packing Type
'V' FOR VASOLINE;
'I' FOR IODOFORM;
'P' FOR PLAIN;
'B' FOR BETADINE;
'D' FOR DENTALPACKS;
'O' FOR OTHER;
'N' FOR NONE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.875 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This is the code corresponding to the type of packing placed during the procedure that will remain
in place when the patient is discharged from the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.971 PATIENT EDUCATION/ASSESSMENT .97;1 SET
Patient Education/Assessment
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
'U' FOR UNKNOWN;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.971 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether preoperative patient education and assessment, with documentation of a care
plan, were completed during the perioperative care of the patient.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.972 CONSENT SIG&WIT .97;2 SET
Consent Signed & Witnessed
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.972 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether there is a properly signed and witnessed operative consent present in the
patient's medical record.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.973 BATH & SHAMPOO .97;3 SET
Bath & Shampoo (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.973 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates if the patient's preoperatively prescribed bath and shampoo were completed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.974 REC&XRAY READY .97;4 SET
X-Rays and Records Complete
'Y' FOR YES;
'N' FOR NO;
'I' FOR INCOMPLETE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.974 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient's x-rays and records are complete.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.975 ENEMA(S) IF ORD .97;5 SET
Administration of Enema(s) Completed
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.975 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the administration of preoperative enema(s) were completed, if ordered.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.976 NPO AS ORD/CLIN MID .97;6 SET
Completion of NPO Orders
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.976 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether NPO orders were completed prior to the operative procedure as ordered by the
surgeon.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.977 *CLERK CHN DAYS BEFORE .97;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 20, 1984
HELP-PROMPT: Enter a whole number between 0 and 100000.
DESCRIPTION:
This field is not being used and is marked for deletion.
130,.981 *VERFIFY ID TAG SSN .98;1 SET
Completed Verification of ID Bracelet and SSN
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
LAST EDITED: APR 18, 1984
DESCRIPTION: This indicates whether the identification bracelet and social security number verification was
completed, legal and correct.
This field has been marked for deletion.
130,.9811 CARE PLAN IN CHART .98;10 SET
Care Plan in Chart (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9811 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the nursing care plan is present on the patient's medical record prior to
transport of the patient into the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.9812 ADDRESS PLATE .98;11 SET
Address Plate (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9812 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates if the patient's address plate is present on the patient's medical record prior to
transport to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.9813 PATIENT VOIDED .98;12 SET
Did the Patient Void
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9813 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient voided prior to being transported to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.9814 PREOP MED&RAIL UP .98;13 SET
Preoperative Meds Administered & Rail 'Up'
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.9814 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether preoperative medication was administered and the side rails of the bed were
placed in the 'up' position.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.9815 *CLERK CHN DATE PROCEDURE .98;14 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 20, 1984
HELP-PROMPT: Enter a whole number between 0 and 100000.
DESCRIPTION: This field has been marked for deletion. It should not be used.
130,.982 PROSTHESIS REM .98;2 SET
Prosthetics Removed (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.982 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether prosthetics (dentures, jewelry, hair pieces) have been removed prior to
transport to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.983 CIG, MATCH & VAL REM .98;3 SET
Tobacco Products and Valuables Removed (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.983 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient's tobacco products, matches and valuables have been removed from
his or her possession prior to being transported to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.984 VALUABLES SECURED .98;4 SET
Valuables Secured (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.984 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient's valuables have been secured according to hospital policy.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.985 ORAL HYGIENE .98;5 SET
Oral Hygiene Completed (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.985 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient's oral hygiene was completed prior to being transported to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.986 FRESHLY SHAVED .98;6 SET
Freshly Shaved (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.986 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient's facial hair was freshly shaved prior to being transported to
the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.987 CLEAN DRESSING .98;7 SET
Clean Dressings (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.987 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates if all appropriate wounds have had clean dressings applied prior to transport to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.988 CLEAN HOSP CLOTH .98;8 SET
Clean Hospital Clothing (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.988 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient has clean hospital clothing prior to being transported to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.989 LEVIN TUBE/CATH .98;9 SET
Levin Tube/Catheter (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.989 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether a Levin tube/catheter is present prior to transport to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.991 U/A IN 48 HRS .99;1 SET
Urinalysis Within 48 Hours (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.991 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient has had a urinalysis within 48 hours prior to being transported
to the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.9911 *CLERK CHN REC FOR MAJ SURG .99;10 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100000)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 20, 1984
HELP-PROMPT: Enter a whole number between 0 and 100000.
DESCRIPTION: This field has been marked for deletion. It should not be used.
130,.992 CBC IN 48 HRS .99;2 SET
CBC Within 48 Hours (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.992 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient has had a CBC within 48 hours prior to being transported to the
operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.993 BLOOD TYPE&XMATCH .99;3 SET
Blood Type & Crossmatch (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.993 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether the patient has had blood typing and crossmatching done.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.994 *BLEEDING & PTT TIME IN 48 HRS .99;4 SET
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
LAST EDITED: APR 18, 1984
DESCRIPTION: This indicates whether the patient has had bleed and PTT time within 48 hours prior to being
transported to the operating room.
This field has been marked for deletion in the next version of the Surgery package.
130,.995 *BUN IN 7 DAYS .99;5 SET
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
LAST EDITED: APR 18, 1984
DESCRIPTION: This indicates whether the patient has had a BUN within 7 days prior to being transported to the
operating room.
This field has been marked for deletion in the next version of the Surgery package.
130,.996 *BLOOD SUGAR IN 7 DAYS .99;6 SET
Blood Sugar Test in 7 Days (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.996 D ^SROCON Q
LAST EDITED: OCT 26, 1992
DESCRIPTION: This field determines whether the patient has had a blood sugar test within the last 7 days. This
field has been marked for deletion in the next release of the Surgery software.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.997 *SEROLOGY REPORT .99;7 SET
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
LAST EDITED: APR 18, 1984
DESCRIPTION: This field has been marked for deletion. It should not be used.
130,.998 CHEST XRAY IN 7 DAYS .99;8 SET
Chest X-Ray Within 7 Days (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.998 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This field determines whether the patient has had a chest x-ray within the last seven days.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,.999 EKG IN 24 HRS .99;9 SET
EKG Within 24 Hours (Y/N)
'Y' FOR YES;
'N' FOR NO;
'I' FOR INAPPLICABLE;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=.999 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This field determines whether the patient has had an EKG within the last 24 hours.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.01 REQ ANESTHESIA TECHNIQUE 1.0;1 SET
Requested Anesthesia Technique
'L' FOR LOCAL;
'S' FOR SPINAL;
'B' FOR BLOCK;
'G' FOR GENERAL;
'C' FOR CHOICE;
'MAC' FOR MONITORED ANESTHESIA CARE;
'E' FOR EPIDURAL;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.01 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the surgeon's choice for proposed surgery.
DESCRIPTION: This is the surgeon's choice of anesthesia for the proposed operative procedure. This information
will appear on the Schedule of Operations.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.02 REQ FROZ SECT 1.0;2 SET
Request Frozen Section Tests (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.02 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates whether laboratory support is needed to perform frozen section diagnostic tests
during the operative procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.03 REQ PREOP X-RAY 1.0;3 FREE TEXT
Requested Preoperative X-Rays
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.03 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Your answer must be 1 to 50 characters in length.
DESCRIPTION: These are the types of preop x-ray films and reports required for delivery to the operating room
prior to the surgical procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.035 INTRAOPERATIVE X-RAYS 1.0;5 SET
Intraoperative X-Rays (Y/N/C)
'Y' FOR YES;
'N' FOR NO;
'C' FOR C-ARM;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.035 D ^SROCON Q
LAST EDITED: APR 19, 1993
DESCRIPTION: This indicates if radiology personnel is needed in the operating room for intraoperative radiologic
procedures.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.04 REQ PHOTO 1.0;4 SET
Request Medical Media (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.04 D ^SROCON Q
LAST EDITED: NOV 16, 1992
DESCRIPTION: This indicates whether Medical Media personnel need to be present in the operating room to obtain
photographs during the operative procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.05 REQ BLOOD KIND 11;0 Multiple #130.14 (Add New Entry without Asking)
Required Blood Products
DESCRIPTION: This is information related to the blood product required during this operative procedure.
130.14,.01 REQ BLOOD KIND 0;1 FREE TEXT (Multiply asked)
Required Blood Product
INPUT TRANSFORM: D ITRAN^VBECA5A
LAST EDITED: JUL 29, 2002
HELP-PROMPT: Answer must be 3-45 characters in length
DESCRIPTION: This is the blood product required during this operative procedure. More than one type of blood
product may be ordered for a procedure.
EXECUTABLE HELP: D LIST66^VBECA5A
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.14,1 UNITS REQ 0;2 NUMBER
Units Required
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 22, 1984
HELP-PROMPT: Enter a whole number between 0 and 100.
DESCRIPTION: This is the number of units of this blood product type estimated to be required for this
procedure.
130.14,2 SCREEN, CROSSMATCH, AUTOLOGOUS 0;3 SET
Screen, Crossmatch, or Autologous
'C' FOR CROSSMATCH;
'S' FOR SCREEN;
'A' FOR AUTOLOGOUS;
LAST EDITED: SEP 11, 1990
DESCRIPTION: This indicates whether the blood product is screened, crossmatched, or autologous.
130.14,3 REASON NOT USE STD 1;0 WORD-PROCESSING #130.27
Reason the Standard Amount wasn't Used
DESCRIPTION: This indicates why the standard unit of this blood product was not used.
Reason not to use the Standard Amount
LAST EDITED: APR 29, 1985
DESCRIPTION: This field contains the reason why the number of units of this blood component ordered differs
from the maximum blood order system requirement.
130,1.052 REQ BLOOD AVAIL 1.0;9 SET
Requested Blood Components Available (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.052 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter 'Y' if the blood components are available as requested.
DESCRIPTION: This indicates whether the requested blood components are available.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.09 WOUND CLASSIFICATION 1.0;8 SET
Wound Classification
'C' FOR CLEAN;
'CC' FOR CLEAN/CONTAMINATED;
'D' FOR CONTAMINATED;
'I' FOR DIRTY/INFECTED;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=1.09 D ^SROCON Q
LAST EDITED: MAR 08, 2023
HELP-PROMPT: Enter the code corresponding to the classification of the wound in relationship to the
contamination and increasing risk of infection at the time of completion of the surgical procedure.
DESCRIPTION: Definition Revised (2018): Indicate whether the wound has been classified by the primary surgeon
as:
>> Class 1 - Clean (C): An uninfected surgical wound in which no inflammation or infection is
encountered and the respiratory, alimentary, genital, or urinary tracts are not entered. Clean
wounds are primarily closed and, if necessary, drained with closed drainage. Surgical Wound
incisions that are made after nonpenetrating (e.g. blunt) trauma should be included in this
category if they meet the criteria.
>> Class 2 - Clean/Contaminated (CC): A surgical wound in which the respiratory, alimentary,
genital, or urinary tracts are entered under controlled conditions and without unusual
contamination. Specifically included in this category are surgical procedures involving the
biliary tract, appendix, vagina, and oropharynx, provided no evidence of infection is encountered
and no major break in technique occurs.
>> Class 3 - Contaminated (D): [1] an open, fresh, accidental wound. [2] a surgical procedure in
which a major break in sterile technique occurs (e.g. emergency open cardiac massage) or [3] when
gross spillage from the gastrointestinal tract and [4] incisions in which acute, nonpurulent
inflammation is encountered.
>> Class 4 - Dirty/Infected (I): Dirty/Infected (I): [1] an old traumatic wound with retained or
devitalized tissue, [2] a wound that involves existing clinical infection or [3] perforated
viscera. This definition suggests that the organisms causing postoperative infection were present
in the wound before the surgical procedure.
SCREEN: S DIC("S")="N SRZ S SRZ=1 S:(Y=""C""&($$WOND^SROUTL1(Y))) SRZ=0 I SRZ"
EXPLANATION: Screen "CLEAN" if planned CPT matches one of the CPTs that cannot be classified as clean.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.098 DATE/TIME OR REQUEST MADE 1.0;11 DATE
Date/Time OR Request Made
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: SEP 05, 1990
DESCRIPTION: This is the date and time that the operation request was made. This information is automatically
entered at the time of request. If the request date is changed, this field will be updated to
reflect the new date/time requested.
UNEDITABLE
130,1.099 SURG SCHED PERSON 1.0;10 POINTER TO NEW PERSON FILE (#200)
Person Requesting/Scheduling this Case
LAST EDITED: DEC 05, 1991
DESCRIPTION: This is the name of the person requesting or scheduling this operative procedure.
130,1.11 PAC(U) ADMIT SCORE 1.1;1 NUMBER
PAC(U) Admission Score
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.11 D ^
SROCON Q
LAST EDITED: MAR 22, 1996
HELP-PROMPT: Enter a number between 0 and 100, 2 decimal digits.
DESCRIPTION: This is the objective evaluation numerical score of the patient upon admission to the post
anesthesia care unit.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.12 PAC(U) DISCH SCORE 1.1;2 NUMBER
PAC(U) Discharge Score
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.12 D ^
SROCON Q
LAST EDITED: MAR 22, 1996
HELP-PROMPT: Enter a number between 0 and 100, 2 decimal digits. Use the objective discharge criteria score.
DESCRIPTION: This is the objective evaluation numeric score of the patient at discharge from the post anesthesia
care unit.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.13 ASA CLASS 1.1;3 POINTER TO ASA CLASS FILE (#132.8)
ASA Class
INPUT TRANSFORM: I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") N SRFLD S SRFLD=1.13 D ^SROCON Q
OUTPUT TRANSFORM: S Y=$S(Y["E":$P(^SRO(132.8,$E(Y)+6,0),"^",2),Y:$P(^SRO(132.8,Y,0),"^",2),Y="N":$P(^SRO(132.8,13,0),
"^",2),1:Y)
LAST EDITED: JUN 28, 2010
HELP-PROMPT: Select ASA code: Number followed by 'E' if Emergency.
DESCRIPTION: VASQIP Definition (2010): Record the American Society of Anesthesiology (ASA) Physical Status
Classification of the patient's present physical condition on a scale from 1-6 as it appears on the
anesthesia record. Most likely there will be a 2nd assessment of the ASA class prior to anesthesia
induction. If this is available, report this most recent assessment. The definitions are:
ASA 1 - A normal healthy patient
ASA 2 - A patient with mild systemic disease
ASA 3 - A patient with severe systemic disease
ASA 4 - A patient with severe systemic disease that is a constant
threat to life
ASA 5 - A moribund patient who is not expected to survive without
the operation
ASA 6 - A declared brain-dead patient whose organs are being
removed for donor purposes
ASA 6 cases should be excluded.
Classification numbers followed by an 'E' indicate an emergency.
Select N for NONE ASSIGNED if no ASA Class is assigned for this patient.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.14 INTRAOPERATIVE OCCURRENCES 10;0 Multiple #130.13 (Add New Entry without Asking)
Intraoperative Occurrences
LAST EDITED: MAR 30, 1992
DESCRIPTION: This is information related to any intraoperative occurrences. If there are no occurrences, leave
this field blank. 'NONE' is not an acceptable answer.
130.13,.01 INTRAOPERATIVE OCCURRENCES 0;1 FREE TEXT (Multiply asked)
Intraoperative Occurrences
INPUT TRANSFORM: K:$L(X)>40!($L(X)<3)!($E(X,1,5)["NONE")!($E(X,1,5)["None")!($E(X,1,5)["none") X
LAST EDITED: MAR 30, 1992
HELP-PROMPT: If there is a occurrence, your answer should be 3 to 40 characters in length.
DESCRIPTION: This is the name of the intraoperative occurrence. If no occurrences exist, this field should be
left blank. Do not enter 'NONE'. It will not be accepted.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.13,.05 OUTCOME TO DATE 0;6 SET
Outcome to Date
'U' FOR UNRESOLVED;
'I' FOR IMPROVED;
'D' FOR DEATH;
'W' FOR WORSE;
LAST EDITED: JAN 25, 1991
DESCRIPTION: This is the code corresponding to the outcome of this intraoperative occurrence.
130.13,1 OCCURRENCE COMMENTS 1;0 WORD-PROCESSING #130.21
Occurrence Comments
DESCRIPTION: These are comments related to this intraoperative occurrence.
Occurrence Comments
LAST EDITED: SEP 15, 1984
DESCRIPTION: These are comments concerning this intraoperative occurrence.
130.13,2 TREATMENT INSTITUTED 2;1 FREE TEXT
Type of Treatment Instituted
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: MAR 25, 1987
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: This is descriptive information related to the type of treatment instituted as a result of this
occurrence.
130.13,3 OCCURRENCE CATEGORY 0;2 POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5) (Required)
Occurrence Category
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2),$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: NOV 13, 1995
HELP-PROMPT: Enter the name of the category most closely related to this occurrence.
DESCRIPTION: This is the name of the category in which this occurrence will be grouped. The category should
be entered for all occurrences and will be used for Surgery Central Office Reporting Needs.
SCREEN: S DIC("S")="I '$P(^(0),U,2),$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive occurrence categories.
130.13,4 ICD DIAGNOSIS CODE 0;3 POINTER TO ICD DIAGNOSIS FILE (#80)
ICD Diagnosis Code
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA(1)):DA(1),$G(SRTN):SRTN,1:""))
LAST EDITED: APR 17, 2013
HELP-PROMPT: Enter the ICD Diagnosis code corresponding to this intraoperative occurrence.
DESCRIPTION: If the occurrence entered does not fit in any of the predefined categories, it must have an ICD
Diagnosis code entered.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.13,5 INTRAOP DEVICE TYPE 0;7 SET
Intraop Device Type
'1' FOR IABP;
'2' FOR VAD;
'3' FOR TAH;
'4' FOR ECMO;
'5' FOR MULTIPLE DEVICES;
LAST EDITED: MAY 13, 2015
HELP-PROMPT: Enter Intraop device Type.
DESCRIPTION: VASQIP Definition (2015): Indicate the patient left the operating room suite with a new IABP,
VAD, TAH, ECMO, or MULTIPLE DEVICES for circulatory support that were placed during this
operation.
1. IABP 2. VAD 3. TAH 4. ECMO 5. MULTIPLE DEVICES
130,1.145 RETURNED TO SURGERY 29;0 POINTER Multiple #130.43 (Add New Entry without Asking)
Case Numbers for Return to Surgery
DESCRIPTION: This is information related to the patient's return to surgery within 30 days of a prior operative
procedure.
130.43,.01 RETURNED TO SURGERY 0;1 POINTER TO SURGERY FILE (#130)
Case Number for Return to Surgery within 30 days
INPUT TRANSFORM: S DIC("S")="I $P(^(0),""^"")=$P(^SRF(DA,0),""^"")" D ^DIC K DIC S DIC=DIE,X=+Y,DINUM=X K:Y<0 X
LAST EDITED: JAN 22, 1991
DESCRIPTION: This indicates the case number if the patient has been returned to surgery within 30 days.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130.43^B
1)= S ^SRF(DA(1),29,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),29,"B",$E(X,1,30),DA)
130.43,1 REASON 0;2 SET
Reason for Return
'R' FOR RETREATMENT;
'C' FOR COMPLICATION;
'N' FOR NEW PROBLEM;
LAST EDITED: AUG 23, 1986
HELP-PROMPT: Enter the code corresponding to the reason that this patient was returned to surgery.
DESCRIPTION: This is the reason that the patient was returned to surgery.
130.43,2 RET TO SURGERY COMMENTS 1;0 WORD-PROCESSING #130.44
Comments Related to the Return Case
DESCRIPTION: These are comments about the return to surgery which may be helpful in documentation of this
case.
Comments
LAST EDITED: AUG 23, 1986
DESCRIPTION: These are comments about the return to surgery that may be useful in documentation of this
case.
130.43,3 RELATED/UNRELATED 0;3 SET
Return Related or Unrelated to this Case
'U' FOR UNRELATED TO THIS CASE;
'R' FOR RELATED TO THIS CASE;
LAST EDITED: MAR 31, 1992
HELP-PROMPT: Enter 'R' if this return within 30 days is related to this case.
DESCRIPTION: This determines whether the return within 30 days is related to any of the operations performed
in this case. If so, enter 'R' for 'RELATED'. Otherwise, enter 'U' for 'UNRELATED'.
130,1.15 SURGEON'S DICTATION 12;0 WORD-PROCESSING #130.15
Surgeon's Operation Notes
DESCRIPTION: This is the Surgeon's dictated operation note.
Surgeon's Operation Notes
LAST EDITED: AUG 25, 1984
DESCRIPTION: This is the Surgeon's dictated Operation Note.
130,1.16 POSTOP OCCURRENCE 16;0 Multiple #130.22 (Add New Entry without Asking)
Postoperative Occurrence
DESCRIPTION: This is information related to postoperative occurrences.
130.22,.01 POSTOP OCCURRENCE 0;1 FREE TEXT (Multiply asked)
Postoperative Occurrence
INPUT TRANSFORM: K:$L(X)>40!($L(X)<3)!($E(X,1,5)["NONE")!($E(X,1,5)["None")!($E(X,1,5)["none") X
LAST EDITED: NOV 08, 1988
HELP-PROMPT: If a postoperative occurrence exists, your answer should be 3 to 40 characters.
DESCRIPTION: This is the name of a occurrence encountered postoperatively. If there are no occurrences, this
field should be left blank. 'NONE' will not be accepted.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.22,.05 OUTCOME TO DATE 0;6 SET
Outcome to Date
'U' FOR UNRESOLVED;
'I' FOR IMPROVED;
'D' FOR DEATH;
'W' FOR WORSE;
LAST EDITED: JAN 25, 1991
DESCRIPTION: This is the code corresponding to the outcome of this postoperative occurrence.
130.22,2 DATE COMP NOTED 0;7 DATE
Date/Time the Occurrence was Noted
INPUT TRANSFORM: S %DT="EXPT" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 13, 2007
HELP-PROMPT: Enter the date/time that this occurrence was noted.
DESCRIPTION: This is the date that this postoperative occurrence was noted in the patient's record.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.22,3 TREATMENT INSTITUTED 2;1 FREE TEXT
Treatment Instituted
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: APR 15, 1987
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: This is descriptive information about the treatment instituted as a result of this occurrence.
130.22,4 OCCURRENCE COMMENTS 1;0 WORD-PROCESSING #130.224
Occurrence Comments
DESCRIPTION: These are comments about this postoperative occurrence.
Occurrence Comments
LAST EDITED: DEC 05, 1988
DESCRIPTION: These are comments about this postoperative occurrence.
130.22,5 OCCURRENCE CATEGORY 0;2 POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5) (Required)
Occurrence Category
INPUT TRANSFORM: S DIC("S")=$$CO^SROCMPS D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: AUG 22, 2000
HELP-PROMPT: Enter the name of the category most closely related to this occurrence.
DESCRIPTION: This is the name of the category in which this occurrence may be grouped. It should be entered
for all occurrences and will be used by Surgery Central Office for reporting needs.
SCREEN: S DIC("S")=$$CO^SROCMPS
EXPLANATION: Screen prevents selection of inactive occurrence category and selection of cardiac only category on
non-cardiac case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.22,6 ICD DIAGNOSIS CODE 0;3 POINTER TO ICD DIAGNOSIS FILE (#80)
ICD Diagnosis Code
INPUT TRANSFORM:D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA(1)):DA(1),$G(SRTN):SRTN,1:""))
OUTPUT TRANSFORM:I $G(Y) S Y=$$OUT^SROICD(Y)
LAST EDITED: JUL 14, 2012
HELP-PROMPT: Enter the ICD Diagnosis code corresponding to this postoperative occurrence.
DESCRIPTION: If the occurrence entered does not fit in any of the predefined categories, an ICD Diagnosis Code
must be entered.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.22,7 SEPSIS CATEGORY 0;4 SET
Sepsis Category
'1' FOR SIRS;
'2' FOR SEPSIS;
'3' FOR SEPTIC SHOCK;
LAST EDITED: JAN 09, 2014
HELP-PROMPT: Select the appropriate category of sepsis for this occurrence.
DESCRIPTION: Definition Revised (2014): 2. Sepsis is the systemic response to infection.
Answer YES if both of the following criteria are met:
Clinical documentation of infection (such as wound with purulent
drainage, ruptured bowel with free air, etc.); a positive culture
from any site thought to be causative; or specialized laboratory
evidence of causative infection (such as viral DNA in blood).
AND
the presence of two or more of the following systemic responses:
Temperature > 38 degrees C or < 36 degrees C
HR > 90 beats/minute
RR > 20 breaths /minute or PaCO2 < 32 mmHg
WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature
neutrophils ("bands")
3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it
is associated with organ and/or circulatory dysfunction.
Terminology such as Severe Sepsis/Septic Shock/Refractory Septic
Shock/Refractory Septic Shock and Multiple Organ Dysfunction
Syndrome (MODS) all fall into this category.
Answer YES if the definition of SEPSIS is present AND there is
documented organ and/or circulatory dysfunction defined by one or more
of the following:
- Areas of acutely mottled skin not related to peripheral vascular
disease
- Capillary refilling requires three seconds or longer not
related to peripheral vascular disease
- Urine output <0.5 mL/kg for at least one hour, or renal
replacement therapy
- Lactate >2 mmol/L
- Abrupt change in mental status
- Abnormal EEG findings
- Platelet count < 100,000 platelets/mL
- Disseminated intravascular coagulation (DIC)
- Acute lung injury or acute respiratory distress syndrome (ARDS)
- New cardiac dysfunction as defined by ECHO or direct measurement
of the cardiac index
- An arterial systolic blood pressure (SBP) of =90 mm Hg or a mean
arterial pressure (MAP) =70 mm Hg for at least 1 hour despite
adequate fluid resuscitation, adequate intravascular volume status,
or the need for vasopressors to maintain SBP >=90 mm Hg or
MAP >=70 mm Hg.
For the patient that had sepsis preoperatively, continuation of
the preoperatively identified signs postoperatively would not be
reported as a new postoperative sepsis. Worsening of the preope-
ratively identified signs would be reported as a new postoperative
sepsis.
SCREEN: S DIC("S")="I Y'=1"
EXPLANATION: Screen prevents selection of inactive code.
130.22,8 CPB STATUS 0;5 SET
Cardiopulmonary Bypass Status
'0' FOR None;
'1' FOR On-bypass;
'2' FOR Off-bypass;
LAST EDITED: APR 23, 2014
HELP-PROMPT: Enter NONE, ON BYPASS, or OFF BYPASS.
DESCRIPTION: Definition Revised (2014): Indicate the CPB status if the patient underwent a repeat operation on
the heart after the patient had left the operating room from the initial operation and within
current hospitalization or within 30 days of the initial operation. Indicate the one appropriate
response:
None - no repeat cardiac surgical procedure post-operatively within 30
days of initial operation. On-bypass - patient underwent a repeat cardiac surgical
procedure
utilizing CPB. Off-bypass - patient underwent a repeat cardiac surgical procedure not
utilizing CPB.
130.22,9 STROKE/CVA DURATION 0;8 SET
Stroke/CVA Duration
'1' FOR NO SYMPTOMS;
'2' FOR <24 HOURS;
'3' FOR 24-72 HOURS;
'4' FOR >72 HOURS;
LAST EDITED: JUL 11, 2011
HELP-PROMPT: Enter code (1, 2, 3 or 4) that best describes the Stroke/CVA duration.
DESCRIPTION: VASQIP Definitions (2011): Indicate if the patient developed a new neurologic deficit with onset
immediately post-operatively or occurring within the 30 days after surgery. Neurologic deficits
are defined as an embolic, thrombotic, or hemorrhagic vascular accident or stroke with motor,
sensory, or cognitive dysfunction (e.g., hemiplegia,hemiparesis, aphasia, sensory deficit, impaired
memory). Indicate the duration as follows:
1) no symptoms
2) symptomatic duration less than 24 hours
3) symptomatic duration of 24-72 hours
4) symptomatic duration >72 hours
130.22,10 INDWELLING URETHRAL CATHETER 0;9 SET
Indwelling Urethral Catheter
'1' FOR IN PLACE;
'2' FOR RECENT REMOVAL;
'3' FOR SHORT DURATION;
'4' FOR DISTANT REMOVAL;
'5' FOR NO CATHETER;
LAST EDITED: MAR 09, 2015
HELP-PROMPT: Enter whether or not the patient has an indwelling urinary catheter in place and if so, indicate
the specific timeline.
DESCRIPTION: VASQIP Definition (2015): At the time of specimen collection for suspected urinary tract infection
during the post-operative 30 day period, answer the following about indwellilng urethral catheter:
I- IN PLACE >2 calendar days on the day of UTI
Signs/Symptoms and UTI Culture sample
R- RECENTLY REMOVED, had been in place >2 calendar
days but removed the day of or the day before
UTI Signs/Symptoms and UTI Culture sample
S- SHORT DURATION, present at the time of UTI
Signs/Symptoms and UTI Culture sample but had
not been present <2 calendar days
D- DISTANT REMOVAL, placed in the perioperative
period and present >2 calendar days, but
removed>2 calendar days prior to UTI
Signs/Symptoms and UTI Culture sample
N- NO CATHETER, did not have an indwelling uretheral
catheter >2 calendar days
130.22,11 UTI SIGN/SYMPTOMS URG/FREQ/DYS 0;10 SET
UTI Signs/Symptoms (Urgency/Freq/Dysuria)
'Y' FOR HAS URGENCY, FREQUENCY, OR DYSURIA WITH NO OTHER RECOGNIZED CAUSE;
'N' FOR DOES NOT HAVE URGENCY, FREQUENCY OR DYSURIA;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter YES or NO to indicate presence of UTI urgency or frequency or dysuria.
DESCRIPTION: VASQIP Definition (2014): This indicates the patient complains of urinary urgency or urinary
frequency or dysuria.
130.22,12 UTI SIGNS/SYMPTOMS FEVER 0;11 SET
UTI Signs/Symptoms Fever
'Y' FOR FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SYMPTOMS;
'N' FOR NO FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SIGNS OR SYMPTOMS;
LAST EDITED: JUN 10, 2014
HELP-PROMPT: Enter yes or no to indicate presence of fever at the time of culture or onset of signs/symptoms.
DESCRIPTION: VASQIP Definition (2014): This indicates the patient has a fever >38C at the time of culture or
onset of signs or symptoms.
130.22,13 UTI SIGNS/SYMPTOMS TENDERNESS 0;12 SET
UTI Signs/Symptoms Tenderness
'Y' FOR SUPRAPUBIC, COSTOVERTEBRAL ANGLE PAIN;
'N' FOR NO SUPRAPUBIC TENDERNESS, COSTOVERTEBRAL ANGLE PAIN;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter YES or NO to indicate presence of suprapubic tenderness or costovertebral angle pain or
tenderness.
DESCRIPTION: VASQIP Definition (2014): This indicates the patient has suprapubic tenderness or costovertebral
angle pain or tenderness.
130.22,14 UTI CULTURE 0;13 SET
UTI Culture
'1' FOR POS CULTURE >10E5, 1-2 SPECIES;
'2' FOR POS CULTURE 10E3-10E5, 1-2 SPECIES DIPSTICK(+), PYURIA, OR GRAM (+);
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter UTI Culture indicator.
DESCRIPTION: VASQIP Definition (2014): This indicates that 1. The patient has a positive urine culture, that is,
>10^5 colony-
forming units (CFU)/ml with no more than 2 species of microor-
ganisms OR 2. The patient has a positive urine culture of >10^3 and <10^5 colony
forming units (CFU)/mL with no more than 2 species of microorganisms
AND one of the following three items:
a. Positive dipstick for leukocyte esterase and/ or nitrate;
b. Pyuria (urine specimen with >10 white blood cell [WBC]/mm3 of
unspun urine or > 3 WBC high-power field of spun urine);
c. Microorganisms seen on Gram's stain of unspun urine
130.22,15 POSTOP DEVICE TYPE 0;14 SET
Postop Device Type
'1' FOR IABP;
'2' FOR VAD;
'3' FOR TAH;
'4' FOR ECMO;
'5' FOR MULTIPLE DEVICES;
LAST EDITED: MAR 25, 2015
HELP-PROMPT: Enter Postop device Type.
DESCRIPTION: VASQIP Definition (2015): Indicate the patient required post-op placement of a new IABP, VAD, TAH,
ECMO, or MULTIPLE DEVICES for circulatory support within 30 days post-operatively.
1. IABP 2. VAD 3. TAH 4. ECMO 5. MULTIPLE DEVICES
130,1.17 ADMIT PAC(U) TIME 1.1;7 DATE
PAC(U) Admission Time
INPUT TRANSFORM: S SRN=.2,SRP=12,SR130="TIME PAT OUT OR" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$P(
^("CON"),"^") S SRFLD=1.17 D ^SROCON Q
LAST EDITED: JAN 09, 1998
DESCRIPTION: This is the date/time that the patient was admitted to the post anesthesia care unit (recovery
room). Times entered without a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.18 PAC(U) DISCH TIME 1.1;8 DATE
PAC(U) Discharge Date/Time
INPUT TRANSFORM: N SRN,SRP,SR130,SRFLD S SRN=1.1,SRP=7,SR130="ADMIT PAC(U) TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X
),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=1.18 D ^SROCON Q
LAST EDITED: MAR 24, 2011
DESCRIPTION: This is the date/time that the patient is discharged from the post anesthesia care unit (recovery
room). Times entered without a date will be converted to the date of operation at that time.
Non-Cardiac Definition Revised (2004): Discharge from Post-Anesthesia Care Unit (DPACU): Time
patient is transported out of PACU.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.19 POSTOP ANES NOTE DATE 1.1;9 DATE
Date/Time Postoperative Note Entered
INPUT TRANSFORM: S SRN=.2,SRP=3,SR130="TIME OPERATION ENDS" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),
$P(^("CON"),"^") S SRFLD=1.19 D ^SROCON Q
LAST EDITED: OCT 23, 2000
DESCRIPTION: This is the date and time that the postoperative note is written in the patient's chart. Times
entered without a date will be converted to the date of operation at that time.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,1.2 POSTOP ANES NOTE 48;0 WORD-PROCESSING #130.1
Postoperative Anesthesia Note
DESCRIPTION:
This is the postoperative anesthesia note for this patient.
Postop Anesthesia Note
LAST EDITED: OCT 23, 2000
HELP-PROMPT: Enter the postop anesthesia note for this patient.
DESCRIPTION:
This is the postop anesthesia note for this patient.
130,1.21 OPERATION TIME ; COMPUTED
Operation Time
MUMPS CODE: X ^DD(130,1.21,9.2) S X1=Y(130,1.21,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.21,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.21,1),U,3),Y(130,1.21,2)=X S X=
$P(Y(130,1.21,1),U,2)
ALGORITHM: MINUTES(TIME OPERATION ENDS,TIME OPERATION BEGAN)
LAST EDITED: SEP 26, 1991
DESCRIPTION: This is the number of minutes between the operation start and end times.
130,1.22 ANESTH INDUCT TIME ; COMPUTED
Anesthesia Induction Time
MUMPS CODE: X ^DD(130,1.22,9.2) S X1=Y(130,1.22,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.22,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.22,1),U,11),Y(130,1.22,2)=X S X
=$P(Y(130,1.22,1),U,1)
ALGORITHM: MINUTES(INDUCTION COMPLETE,ANES CARE START TIME)
DESCRIPTION: This is the total number of minutes between the anesthesia care start and induction complete times.
130,1.23 ANES CARE TIME ; COMPUTED
Anesthesia Care Time
MUMPS CODE: X ^DD(130,1.23,9.2) S X1=Y(130,1.23,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.23,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.23,1),U,4),Y(130,1.23,2)=X S X=
$P(Y(130,1.23,1),U,1)
ALGORITHM: MINUTES(ANES CARE END TIME,ANES CARE START TIME)
LAST EDITED: NOV 20, 1984
DESCRIPTION: This is the number of minutes between the anesthesia care start time and anesthesia care end time.
130,1.24 PATIENT IN OR TIME ; COMPUTED
Patient in Operating Room Time
MUMPS CODE: X ^DD(130,1.24,9.2) S X1=Y(130,1.24,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.24,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.24,1),U,12),Y(130,1.24,2)=X S X
=$P(Y(130,1.24,1),U,10)
ALGORITHM: MINUTES(TIME PAT OUT OR,TIME PAT IN OR)
DESCRIPTION: This is the number of minutes the patient was in the operating room.
130,1.25 OR CLEAN UP TIME ; COMPUTED
O.R. Clean Up Time
MUMPS CODE: X ^DD(130,1.25,9.2) S X1=Y(130,1.25,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.25,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,1.25,1),U,14),Y(130,1.25,2)=X S X
=$P(Y(130,1.25,1),U,13)
ALGORITHM: MINUTES(OR CLEAN END TIME,OR CLEAN START TIME)
DESCRIPTION: This is the number of minutes between the OR clean up start time and OR clean up end time.
130,1.26 PAC(U) TIME ; COMPUTED
PAC(U) Time
MUMPS CODE: X ^DD(130,1.26,9.2) S X1=Y(130,1.26,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,1
2)-$E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,1.26,1)=$S($D(^SRF(D0,1.1)):^(1.1),1:"") S X=$P(Y(130,1.26,1),U,8),Y(130,1.26,2)=X S
X=$P(Y(130,1.26,1),U,7)
ALGORITHM: MINUTES(PAC(U) DISCH TIME,ADMIT PAC(U) TIME)
DESCRIPTION: This is the number of minutes the patient spent in the PAC(U).
130,4 SKIN PREPPED BY (2) .1;12 POINTER TO NEW PERSON FILE (#200)
Skin Prepped By (2)
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,4"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the second person performing the preop skin preparation, if appropriate.
DESCRIPTION: This is the name of a second person performing skin preparation, if applicable. When entered, this
information appears on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,4"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,5 SKIN PREPPED BY (3) .1;17 POINTER TO NEW PERSON FILE (#200)
Skin Prepped By (3)
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,5"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person performing the preop skin preparation.
DESCRIPTION: This is the name of the third person performing the preoperative skin preparation. If entered,
this information will appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,5"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locallly selected keys.
130,6 ELECTROGROUND POSITION (2) .5;13 POINTER TO ELECTROGROUND POSITIONS FILE (#138)
Electroground Position (2)
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=6 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the code corresponding to the placement of the second dispersive electrode pad.
DESCRIPTION: This is the code corresponding to the placement of the second dispersive electrode pad.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,7 DRESSING CONDITION 31;1 SET
Dressing Condition
'D' FOR DRY;
'S' FOR SEROSANGUINOUS;
'SA' FOR SANGUINOUS;
'N' FOR NO DRESSING;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=7 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter the status of the drainage on the dressing.
DESCRIPTION: This is the status of the drainage on the dressing. Although optional, this information may be
useful in documentation of this case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,8 SECOND SKIN PREP AGENT 31;2 POINTER TO SKIN PREP AGENTS FILE (#135.1)
Second Skin Preparation Agent
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=8 D ^SROCON Q
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the name of the 2ND antimicrobial agent used to wash and prepare the operative site.
DESCRIPTION: This is the name of the SECOND antimicrobial agent used to wash and prepare the operative site.
Although optional, this information may be useful in documentation of the case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,9 TIME NURSE OUT OF OR 31;3 DATE
Time Nurse Out of O.R.
INPUT TRANSFORM: S SRN=.2,SRP=7,SR130="NURSE PRESENT TIME" D TERM^SROVAR K:Y<1 X I $D(DA),$D(X),$D(^SRF(DA,"CON")),$
P(^("CON"),"^") S SRFLD=9 D ^SROCON Q
LAST EDITED: JAN 09, 1998
DESCRIPTION: This is the date and time that the circulating nurse completed duties for the operative procedure
and left the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,10 SCHEDULED START TIME 31;4 DATE
Scheduled to Start at what Time
INPUT TRANSFORM: S %DT="ETR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 28, 2011
HELP-PROMPT: Enter the Scheduled Start Time.
DESCRIPTION: This is the date and time that this operative procedure is scheduled to begin.
CROSS-REFERENCE: 130^AM2^MUMPS
1)= D AM2^SROXR2
2)= D KILLAM2^SROXR2
The AM2 cross reference on the SCHEDULED START TIME field resets the AMM cross reference for the
case when the scheduled start time is edited.
CROSS-REFERENCE: ^^TRIGGER^130^614
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,3)="
" I X S X=DIV S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,3),X=X S DIU=X K Y S X=DIV S X=DI
V,X=$P(X,".",1) X ^DD(130,10,1,2,1.4)
1.4)= S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,3)=DIV,DIH=130,DIG=614 D ^DICR
2)= Q
CREATE CONDITION)= #614=""
CREATE VALUE)= DATE(SCHEDULED START TIME)
DELETE VALUE)= NO EFFECT
FIELD)= #614
If the SCHEDULED START TIME field (#10) is set for the first time, then the ORIGINAL SCHEDULED DATE
field (#614) will be set.
CROSS-REFERENCE: ^^TRIGGER^130^617
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,6),X=X S DIU=
X K Y S X=DIV S X=DIV,X=$P(X,".",1) S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,6)=DIV,DIH=130,DIG
=617 D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,6),X=X S DIU=
X K Y S X="" S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,6)=DIV,DIH=130,DIG=617 D ^DICR
CREATE VALUE)= DATE(SCHEDULED START TIME)
DELETE VALUE)= @
FIELD)= #617
This trigger is responsible for updating the SCHEDULED DATE field (#617) whenever the SCHEDULED
START TIME field (#10) is updated.
RECORD INDEXES: AD (#196)
130,11 SCHEDULED END TIME 31;5 DATE
Scheduled to End at what Time
INPUT TRANSFORM: S %DT="ETR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 22, 2002
DESCRIPTION: This is the date and time that this operative procedure is scheduled to end.
CROSS-REFERENCE: 130^AMM^MUMPS
1)= D AMM^SROXR2
2)= D KILLAMM^SROXR2
The AMM cross reference on the SCHEDULED END TIME field sets the AMM cross reference for the case
if the operating room and the scheduled start time are defined.
RECORD INDEXES: AD (#196)
130,12 IN OR TO ANES START ; COMPUTED
MUMPS CODE: X ^DD(130,12,9.2) S X1=Y(130,12,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$
E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,12,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,12,1),U,1),Y(130,12,2)=X S X=$P(Y(1
30,12,1),U,10)
ALGORITHM: MINUTES(ANES CARE START TIME,TIME PAT IN OR)
DESCRIPTION: This is the number of minutes between the time anesthesia care began and time that the patient left
the operating room.
130,13 ANES START TO OP START ; COMPUTED
Time Between Anesthesia Start and Operation Start Times
MUMPS CODE: X ^DD(130,13,9.2) S X1=Y(130,13,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$
E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,13,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,13,1),U,2),Y(130,13,2)=X S X=$P(Y(1
30,13,1),U,1)
ALGORITHM: MINUTES(TIME OPERATION BEGAN,ANES CARE START TIME)
DESCRIPTION: This is the number of minutes between the time that anesthesia care started and time that the
operation began.
130,14 IN OR TO OP START TIME ; COMPUTED
Time Between Time in OR and Operation Start Time
MUMPS CODE: X ^DD(130,14,9.2) S X1=Y(130,14,2) S Y=$E(X1_"000",9,10)-$E(X_"000",9,10)*60+$E(X1_"00000",11,12)-$
E(X_"00000",11,12),X2=X,X=$P(X,".",1)'=$P(X1,".",1) D ^%DTC:X S X=X*1440+Y
9.2 = S Y(130,14,1)=$S($D(^SRF(D0,.2)):^(.2),1:"") S X=$P(Y(130,14,1),U,2),Y(130,14,2)=X S X=$P(Y(1
30,14,1),U,10)
ALGORITHM: MINUTES(TIME OPERATION BEGAN,TIME PAT IN OR)
DESCRIPTION: This is the time between the time the patient enters the operating room to the operation start
time.
130,15 DATE/TIME OF DICTATION 31;6 DATE
Date/Time of Dictation
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 13, 1993
DESCRIPTION: This is the date and time that dictation of the operative summary was completed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,17 CANCEL DATE 30;1 DATE
Cancellation Date/Time
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 20, 1992
HELP-PROMPT: Enter the date and time on which this case was cancelled.
DESCRIPTION: This is the date and time that the operative procedure was canceled.
130,17.5 CANCELLATION TIMEFRAME 30;5 SET
Cancellation Timeframe
'1' FOR SURGERY CANCELLED <48 HRS BEFORE SCHEDULED SURGERY;
'2' FOR SURGERY CANCELLED >48 HRS BEFORE SCHEDULED SURGERY;
LAST EDITED: MAR 03, 2014
HELP-PROMPT: Select the response that appropriately fits the cancellation timeframe.
DESCRIPTION: VASQIP Definition (2014): This indicates when the surgery was cancelled; either less than 48 hours
prior to the scheduled surgery time or more than 48 hours prior to the scheduled surgery time.
130,18 PRIMARY CANCEL REASON 31;8 POINTER TO SURGERY CANCELLATION REASON FILE (#135)
Primary Cancellation Reason
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,4)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the reason why this scheduled case was cancelled.
DESCRIPTION: VASQIP Definition (2014): This is the reason that this surgical case was cancelled. List of valid
reasons:
1) Patient Related Issue (e.g., patient did not follow pre-surgery
instructions, patient chooses to cancel for any reason) 2) Environmental Issue (OR
availability impacted by e.g., air
handling, electrical outage, emergency construction, flood, tornado,
blizzard, hurricane causing OR hospital closure. If due to staff
availability, use #3) 3) Staff Issue (e.g., unavailable surgeon, anesthesia or nursing
staff; no documented consent, provider cancels due to change in
patient treatment plan) 4) Patient Health Status (Provider cancels due to change in patient
health status) 5) More clinically urgent/emergent case superseded this scheduled
case 6) Scheduling Issues Not Created By An Emergency Case (previous case
overtime, case delayed, double booked, general time constraints,
administrative scheduling error) 7) Unavailable Bed 8) Unavailable Equipment [excluding RME]
(e.g.,
vendor, c-arm, implant, malfunctioning equipment) 9) Unavailable Reusable Medical Equipment
(RME) (includes defective
packaging, damaged instruments or failure of Sterile Processing
Services [SPS] to provide reprocessed equipment in a timely manner) 10) Patient scheduled into
an earlier date for surgery.
SCREEN: S DIC("S")="I '$P(^(0),U,4)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^ACAN^MUMPS
1)= D CAN^SROXR4
2)= D KCAN^SROXR4
The ACAN cross reference on the CANCEL REASON field functions to stuff for the CANCEL REASON the
default CANCELLATION AVOIDABLE (Y or N) as defined in the SURGERY CANCELLATION REASON file. It
also stuffs the CANCELLED BY field with the user if not already defined.
130,18.5 CASE ABORTED 30;6 SET
Case Aborted
'1' FOR NO;
'2' FOR YES-PRE ANESTHESIA;
'3' FOR YES-POST ANESTHESIA;
LAST EDITED: JUN 08, 2015
HELP-PROMPT: Enter Case Aborted flag.
DESCRIPTION: Any medication or intervention, other than a peripheral IV, performed by anesthesia is considered
post-anesthesia. This includes any anesthesia or intervention performed by anesthesia staff in the
preoperative holding area.
130,19 CANCELLATION COMMENTS 30;4 FREE TEXT
Cancellation Comments
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: APR 20, 2011
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: This is the cancellation comments field. If "OTHER" is selected for the CANCEL REASON field (#18),
the user will be prompted to enter a comment in this field.
130,20 DIAGNOSTIC/THERAPEUTIC (Y/N) 31;9 SET
Diagnostic/Therapeutic (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=20 D ^SROCON Q
LAST EDITED: AUG 23, 1990
DESCRIPTION: This indicates if the anesthesia technique is an anesthesia diagnostic/ therapeutic procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,21 WAIT TIME START 31;11 DATE
Start of Patient's Wait Time
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 28, 2007
HELP-PROMPT: This is the start of the patient's "wait" for Surgery.
DESCRIPTION: This is start of the patient's "wait" for Surgery. Typically, this is the date that the patient was
notified that Surgery is needed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,22 TUBES AND DRAINS 3;1 FREE TEXT
Tubes and Drains
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=22 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Answer must be 1 to 80 characters in length.
DESCRIPTION: This is the type and placement of tubes and drains during the operative process.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,23 REFERRING PHYSICIAN 18;0 Multiple #130.03 (Add New Entry without Asking)
Referring Physician/Medical Center
DESCRIPTION: This is information related to the referring physician.
130.03,.01 REFERRING PHYSICIAN 0;1 FREE TEXT
Referring Physician/Medical Center
INPUT TRANSFORM: D REFPHY^SROWL K:$L(X)>50!($L(X)<1) X
LAST EDITED: NOV 17, 2003
HELP-PROMPT: Enter the name of the referring physician. Your answer must be 1 to 50 characters long.
DESCRIPTION: This is the name of the referring physician, or medical center. Although optional, this
information may be useful in documentation of this case.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130.03^B
1)= S ^SRF(DA(1),18,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),18,"B",$E(X,1,30),DA)
130.03,1 STREET ADDRESS 0;2 FREE TEXT
Street Address
INPUT TRANSFORM: K:$L(X)>75!($L(X)<1) X
LAST EDITED: AUG 12, 1987
HELP-PROMPT: Your answer must be 1 to 75 characters in length.
DESCRIPTION:
This is the street address of the referring physician.
130.03,2 CITY 0;3 FREE TEXT
City
INPUT TRANSFORM: K:$L(X)>45!($L(X)<1) X
LAST EDITED: AUG 12, 1987
HELP-PROMPT: Your answer must be 1 to 45 characters in length.
DESCRIPTION:
This is the city of the referring physician.
130.03,3 STATE 0;4 POINTER TO STATE FILE (#5)
State
LAST EDITED: AUG 12, 1987
HELP-PROMPT: Enter the state of the referring physician.
DESCRIPTION: This is the state of the referring physician.
130.03,4 ZIP CODE 0;5 FREE TEXT
Zip Code
INPUT TRANSFORM: K:$L(X)>10!($L(X)<5)!'(X?.N) X
LAST EDITED: MAY 11, 1993
HELP-PROMPT: Your answer must be 5-10 characters in length.
DESCRIPTION: This is the zip code of the referring physician.
130.03,5 PHONE NUMBER 0;6 FREE TEXT
Phone Number
INPUT TRANSFORM: K:$L(X)>14!($L(X)<1) X
LAST EDITED: AUG 12, 1987
HELP-PROMPT: Your answer must be 1 to 14 characters in length.
DESCRIPTION: This is the referring physician's telephone number.
130.03,6 REF PHY 200 LINK 0;7 POINTER TO NEW PERSON FILE (#200)
Pointer To NEW PERSON File (#200)
LAST EDITED: SEP 04, 2003
HELP-PROMPT: The VA record number of the Referring Physician.
DESCRIPTION: Field (not accessed by the user) is a pointer to the NEW PERSON file. It is populated when a
Referring Physician is selected from the NEW PERSON file with the record number from NEW PERSON
file.
TECHNICAL DESCR: Pointer Field (not accessed by the user) to the NEW PERSON file. It will be populated when and if
the Referring Physician is selected from the NEW PERSON file (#200).
130,24 LOCK CASE LOCK;1 SET
Case Locked
'1' FOR LOCKED;
'0' FOR UNLOCKED;
LAST EDITED: MAR 12, 1992
HELP-PROMPT: This field will be equal to 1 if the case has been completed and locked, or 0 if it is still open.
DESCRIPTION: This indicates whether this case has been completed and locked. Locked cases can only be edited if
unlocked by the Chief of Surgery or his or her designee.
CROSS-REFERENCE: 130^AL^MUMPS
1)= K ^SRF("AL",DA)
2)= S ^SRF("AL",DA)=""
The AL cross reference on the LOCK CASE field uses reverse set and kill logic to flag cases that
have been locked, then unlocked. The cross reference for the case is set when the field is deleted
and is killed when the field is set.
130,25 DISCHARGED VIA .7;4 POINTER TO SURGERY TRANSPORTATION DEVICES FILE (#131.01)
Patient Discharged Via
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X I $D(X),$D(^SRF(DA,"CON")),$P(^("C
ON"),"^") S SRFLD=25 D ^SROCON Q
LAST EDITED: JUN 02, 1992
HELP-PROMPT: Enter the mode of transport used to take patient from the care area.
DESCRIPTION: This is the code corresponding to the mode of transport used to move the patient from the care
area.
SCREEN: S DIC("S")="I '$P(^(0),U,3)"
EXPLANATION: Screen prevents selection of inactive entries.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,26 PRINCIPAL PROCEDURE OP;1 FREE TEXT (Required)
Principal Procedure
INPUT TRANSFORM: K:$L(X)>135!($L(X)<3) X D:$D(X) PROC^SROPROC,PCPTASO^SROADX2(0) K:$G(X)="" X
LAST EDITED: JAN 03, 2011
HELP-PROMPT: Your answer must be 3-135 characters in length and must not contain an up-arrow (^).
DESCRIPTION: This is the name of the principal procedure for this case. All cases must have a principal
procedure.
The principal procedure must be 3 to 135 characters in length. The procedure name must not contain
a semicolon (;), an at-sign (@), an up- arrow (^) or control characters. If the procedure name is
longer than 30 characters, it must contain at least one space in every 31 characters of length. If
a comma is being used to separate information, a space should follow the comma.
Non-Cardiac Definition Revised (2004): The most complex of all the procedures by the primary
operating team during this trip to the operating room. Your answer must be at least 3 characters in
length. Do not enter an additional procedure if it is covered by a single CPT code. (Note that a
single CPT code can cover more than one procedure, e.g., cholecystectomy and common bile duct
exploration have a single CPT code). Additional procedures requiring separate CPT codes and/or
concurrent procedures will be entered separately below. An exploratory laparotomy should be entered
as the principal operative procedure only when no other procedure eligible for assessment has been
performed in that particular surgical case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AD (#196)
130,27 PLANNED PRIN PROCEDURE CODE OP;2 POINTER TO CPT FILE (#81)
Planned Principal Procedure Code (CPT)
INPUT TRANSFORM: D IN^SROCPT S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA):DA,1:""""),+Y)" D ^DIC K DIC S DIC
=DIE,X=+Y K:Y<0 X K:'$$CHK^SROCPT($G(X)) X D PCPTASO^SROADX2(1) K:$G(X)="" X
OUTPUT TRANSFORM: D DISPLAY^SROCPT
LAST EDITED: JUN 22, 2015
HELP-PROMPT: Enter the planned CPT code for the principal procedure.
DESCRIPTION: This is the Current Procedural Terminology (CPT) code corresponding with the planned principal
procedure. A CPT modifier on the CPT code may be included by appending the modifier to the CPT code
separated by a hyphen in the format "XXXXX-YY" where "XXXXX" is the five character CPT code and
"YY" is the two character CPT modifier.
SCREEN: S DIC("S")="I $$ACTIV^SROCPT($S($D(SRTN):SRTN,$D(DA):DA,1:""""),+Y)"
EXPLANATION: Screen out Inactive Codes
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^ACPT^MUMPS
1)= D SPRIN^SROMOD
2)= D KPRIN^SROMOD
This MUMPS cross reference provides for updating CPT modifiers for the principal procedure code.
CPT modifiers for the PRINCIPAL PROCEDURE CODE field (#27) are stored in the PRIN. PROCEDURE CPT
MODIFIER field (#.01) of the PRIN. PROCEDURE CPT MODIFIER multiple field (#28) in SURGERY file
(#130).
After selecting a CPT code, this cross reference prompts the user for a CPT modifier. If a CPT
modifier was entered concatenated with a hyphen to the CPT code, this CPT modifier is displayed as
a default modifier. Upon entering a CPT modifier, the user is prompted for another CPT modifier
until the user makes a null entry. CPT modifier input is controlled by the input transform on the
PRIN. PROCEDURE CPT MODIFIER field (#28). At the CPT modifier prompt, the user may to enter a
question mark (?) to see a list of CPT modifiers already entered and a list of acceptable CPT
modifiers to choose from. If the user selects a modifier already entered, the user may change or
delete the modifier. If a user enters a new CPT code, replacing a previously entered CPT code,
KILL logic on the ACPT cross reference deletes any previously entered CPT modifiers for the old CPT
code before the SET logic prompts the user to enter CPT modifiers for the new CPT code.
RECORD INDEXES: AD (#196)
130,27.5 PRIN ASSOC DIAGNOSIS PADX;0 Multiple #130.275 (Add New Entry without Asking)
LAST EDITED: FEB 27, 2004
DESCRIPTION:
This Surgery sub-file is used to store the Procedure/Diagnosis association data.
130.275,.01 PRIN ASSOC DIAGNOSIS 0;1 NUMBER
Pointer To ICD DIAGNOSIS File (#80)
INPUT TRANSFORM: K:+X'=X!(X>99999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 06, 2005
HELP-PROMPT: This field can only be changed via the Surgery Menu. All entries outside of the Surgery menu
will not be filed.
DESCRIPTION: This field holds the IEN of the associated diagnosis. It is used to store the
Procedure/Diagnosis association data needed to create a clean claim. This field can only be
changed via the Surgery menu.
CROSS-REFERENCE: 130.275^B
1)= S ^SRF(DA(1),"PADX","B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),"PADX","B",$E(X,1,30),DA)
130,28 PRIN. PROCEDURE CPT MODIFIER OPMOD;0 POINTER Multiple #130.028
LAST EDITED: FEB 23, 1999
INDEXED BY: PRIN. PROCEDURE CPT MODIFIER (AC)
130.028,.01 PRIN. PROCEDURE CPT MODIFIER 0;1 POINTER TO CPT MODIFIER FILE (#81.3) (Multiply asked)
Principal Procedure CPT Modifier
INPUT TRANSFORM: S DIC("S")="I $$SCR27^SROMOD" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: D DISPLAY^SROMOD
LAST EDITED: NOV 22, 2002
HELP-PROMPT: Enter a CPT Modifier for this procedure.
DESCRIPTION: This is a procedural coding modifier used to indicate that the principal procedure performed has
been altered by some specific circumstance but not changed in its definition or code.
SCREEN: S DIC("S")="I $$SCR27^SROMOD"
EXPLANATION: Screen prevents selection of modifier inappropriate for CPT code.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
FIELD INDEX: AC (#197) MUMPS IR ACTION
Short Descr: CoreFLS fields monitor flag.
Description: This cross-reference will be checked before sending a notification to the CoreFLS software after
editing any of these fields.
Set Logic: S ^TMP("CSLSUR1",$J)="" Q
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Logic: S ^TMP("CSLSUR1",$J)="" Q
Kill Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Whole Kill: Q
X(1): PRIN. PROCEDURE CPT MODIFIER (130.028,.01) (forwards)
130,29 *PROCEDURE COMPLETED OP;4 SET
Principal Operative Procedure Complete (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 17, 1987
DESCRIPTION: This indicates whether the principal operative procedure was completed.
This field has been marked for deletion.
130,30 OTHER SCRUBBED ASSISTANTS 28;0 POINTER Multiple #130.23 (Add New Entry without Asking)
Other Scrubbed Assistants
DESCRIPTION: This is information about other persons in the operating room in addition to those already listed
as scrubbed.
130.23,.01 OTHER SCRUBBED ASSISTANTS 0;1 POINTER TO NEW PERSON FILE (#200)
Other Scrubbed Assistants
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130.23,.01"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0
X
LAST EDITED: MAY 26, 1993
HELP-PROMPT: Enter the names of persons other than those already listed as scrubbed.
DESCRIPTION: These are names of persons in the operating room other than those that are already listed as
scrubbed.
SCREEN: S DIC("S")="S RESTRICT=""130.23,.01"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130.23^B
1)= S ^SRF(DA(1),28,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),28,"B",$E(X,1,30),DA)
130.23,1 COMMENTS 1;0 WORD-PROCESSING #130.35
Comments
DESCRIPTION: These are comments related to this person that may be useful in documentation of this case.
Comments
LAST EDITED: OCT 07, 1987
DESCRIPTION: These are comments related to this person that may be useful in documentation of this case.
130,31 OTHER PERSONS IN OR 32;0 Multiple #130.24 (Add New Entry without Asking)
Other Persons in O.R.
DESCRIPTION: This is information related to other persons, not scrubbed or otherwise identified, present in the
operating room.
130.24,.01 OTHER PERSONS IN OR 0;1 FREE TEXT
Other Persons in O.R.
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: SEP 22, 1987
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: These are the names of other persons not scrubbed, or otherwise identified, present in the
operating room.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
CROSS-REFERENCE: 130.24^B
1)= S ^SRF(DA(1),32,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),32,"B",$E(X,1,30),DA)
130.24,1 TITLE/ORGANIZATION 0;2 FREE TEXT
Title and Organization
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: SEP 22, 1987
HELP-PROMPT: Your answer must be 1 to 60 characters in length.
DESCRIPTION: This is the title and/or organization of this person. Since your answer may be up to 60
characters, you may prefer to enter a reason for this person being in the operating room.
130,32 PRINCIPAL PRE-OP DIAGNOSIS 33;1 FREE TEXT
Principal Preoperative Diagnosis
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0)
LAST EDITED: OCT 06, 2003
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION:
This is the preoperative diagnosis for which the surgical procedure is being performed.
DELETE TEST: 1,0)= I 1 D EN^DDIOL("The PRINCIPAL PRE-OP DIAGNOSIS can't be deleted.",,"!!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^130^34
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,34)):^(34),1:"") S X=$P(Y(1),U,1),X=X S DIU=
X K Y S X=DIV S X=DIV X ^DD(130,32,1,1,1.4)
1.4)= S DIH=$S($D(^SRF(DIV(0),34)):^(34),1:""),DIV=X S %=$P(DIH,U,2,999),DIU=$P(DIH,U,1),^(34)=DIV_
$S(%]"":U_%,1:""),DIH=130,DIG=34 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,34)):^(34),1:"") S X=$P(Y(1),U,1),X=X S DIU=
X K Y X ^DD(130,32,1,1,2.1) X ^DD(130,32,1,1,2.4)
2.1)= S X=DIV S Y(1)=$S($D(^SRF(D0,33)):^(33),1:"") S X=$P(Y(1),U,1)
2.4)= S DIH=$S($D(^SRF(DIV(0),34)):^(34),1:""),DIV=X S %=$P(DIH,U,2,999),DIU=$P(DIH,U,1),^(34)=DIV_
$S(%]"":U_%,1:""),DIH=130,DIG=34 D ^DICR:$O(^DD(DIH,DIG,1,0))>0
CREATE VALUE)= PRINCIPAL PRE
DELETE VALUE)= PRINCIPAL PRE
FIELD)= PRINCIPAL PO
This trigger on the PRINCIPAL PRE-OP DIAGNOSIS field stuffs the PRINCIPAL POST-OP DIAGNOSIS field
with what is entered as the PRINCIPAL PRE-OP DIAGNOSIS.
CROSS-REFERENCE: 130^DADX1^MUMPS
1)= Q
2)= D DELASOC^SROADX2
This cross reference removes associations from diagnosis being deleted.
130,32.5 PRIN PRE-OP ICD DIAGNOSIS CODE 34;3 POINTER TO ICD DIAGNOSIS FILE (#80)
Prin Pre-op ICD Diagnosis Code
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
LAST EDITED: MAR 11, 2014
HELP-PROMPT: Enter the ICD Diagnosis code for the principal Pre-OP diagnosis.
DESCRIPTION:
This is the principal Pre-OP ICD diagnosis code. It should be entered for all cases.
SCREEN: S DIC("S")="I $P(^(0),""^"",9)'=1"
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AM^MUMPS
1)= S $P(^SRF(DA,34),"^",2)=X
2)= Q
This cross reference stuffs the current value of the PRIN PRE-OP ICD DIAGNOSIS CODE field (#32.5)
into the PRIN DIAGNOSIS CODE field (#66).
130,33 PRINCIPAL DIAGNOSIS 33;2 FREE TEXT
Principal Diagnosis
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0) K:$G(X)="" X
LAST EDITED: OCT 06, 2003
HELP-PROMPT: Answer must be 1-40 characters in length.
DESCRIPTION:
This is the principal diagnosis for which the non-OR procedure is being performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^PADX1^MUMPS
1)= Q
2)= D PRINASOD^SROADX2
THIS CROSS REFERENCE REMOVES ASSOCIATIONS TO PROCEDURES UPON EDITS OR DELETES OF THE DIAGNOSIS.
130,34 PRINCIPAL POST-OP DIAG 34;1 FREE TEXT
Principal Postoperative Diagnosis
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X D:$D(X) DIAG^SROUTL,PRINASO^SROADX2(0) K:$G(X)="" X
LAST EDITED: OCT 06, 2003
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION:
This is the principal postoperative diagnosis.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the PRINCIPAL PRE-OP DIAGNOSIS field of the SURGERY File
130,35 CONCURRENT CASE CON;1 POINTER TO SURGERY FILE (#130)
Concurrent Surgical Case
LAST EDITED: MAR 24, 2011
DESCRIPTION: Definition Revised (2004): An additional operative procedure performed by a different surgical team
(i.e., a different specialty/service) under the same anesthetic which has a CPT code different from
that of the Principal Operative Procedure (e.g., fixation of a femur fracture in a patient
undergoing a laparotomy for trauma). This field should be verified and, if need be, edited
postoperatively by the Nurse Reviewer in accordance with the official operating room log.
RECORD INDEXES: AD (#196)
130,36 REQUESTED REQ;1 NUMBER
Was this Case Requested (Y/N)
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: DEC 15, 1987
HELP-PROMPT: Enter '1' if this case has been requested.
DESCRIPTION: This indicates whether this case was requested.
130,37 ESTIMATED CASE LENGTH .4;1 FREE TEXT
Estimated Case Length (HOURS:MINUTES)
INPUT TRANSFORM: K:$L(X)>7!($L(X)<1)!'(X?.N1":"2N)!($P(X,":",2)>59) X
LAST EDITED: OCT 02, 1992
HELP-PROMPT: Enter the estimated amount of time to perform this procedure.
DESCRIPTION: This is the amount of time estimated to perform this operative procedure. Your answer should be in
the format of "HOURS:MINUTES". For example, if the procedure will last 2 and 1/2 hours, your
answer would be 2:30.
TECHNICAL DESCR: This field may be stuffed with an answer by using the routine ^SRSAVG. The routine ^SRSAVG
calculates the average length of time based on information from previous cases using the surgical
specialty and CPT Code.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,38 REQUEST BLOOD AVAILABILITY 0;6 SET
Request Blood for this Surgical Case (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: DEC 30, 1991
HELP-PROMPT: Enter 'YES' if you want to request blood for this procedure.
DESCRIPTION: This determines whether blood will be requested for this surgical procedure. Enter 'YES' if blood
will be requested. Otherwise, enter 'NO'.
TECHNICAL DESCR: This field determines whether blood will be requested. If answered 'YES', you will then be
prompted for the fields CROSSMATCH, SCREEN, OR AUTOLOGOUS, and REQUESTED BLOOD KIND.
130,39 DATE OF TRANSCRIPTION 31;7 DATE
Date of Transcription
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 14, 1988
DESCRIPTION: This is the date and time that transcription of the operative summary was completed.
130,40 CROSSMATCH, SCREEN, AUTOLOGOUS 0;13 SET
Type & Crossmatch, Screen, or Autologous
'T' FOR TYPE & CROSSMATCH;
'S' FOR SCREEN;
'A' FOR AUTOLOGOUS;
LAST EDITED: DEC 30, 1991
HELP-PROMPT: Enter whether the blood requested is type and crossmatched, screened, or autologous.
DESCRIPTION: This determines whether the requested blood will be typed and crossmatched, screened, or
autologous.
TECHNICAL DESCR: This will determine whether the requested blood is screened, type and crossmatched, or autologous.
If Typed and crossmsatched, you will then be prompted for the requested blood kind and units.
130,41 DRESSING 35;1 FREE TEXT
Dressing(s)
INPUT TRANSFORM: K:$L(X)>100!($L(X)<1) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the dressing(s) used for this case. Answer must be 1-100 characters in length.
DESCRIPTION: These are the dressing(s) used for this case. Although optional, this information may be useful in
documentation of this case.
130,42 DELAY CAUSE 17;0 POINTER Multiple #130.042 (Add New Entry without Asking)
Reason for the Delay
DESCRIPTION: This is information related to the reason why this case did not begin at its scheduled start time.
130.042,.01 DELAY CAUSE 0;1 POINTER TO SURGICAL DELAY FILE (#132.4)
Delay Reason
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter reason the operative procedure did not begin at the scheduled time.
DESCRIPTION: This is the reason why the operative procedure did not begin at the scheduled start time.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive entries.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
CROSS-REFERENCE: 130.042^B
1)= S ^SRF(DA(1),17,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),17,"B",$E(X,1,30),DA)
130.042,1 DELAY TIME 0;2 NUMBER
Delay Time
INPUT TRANSFORM: K:+X'=X!(X>600)!(X<1)!(X?.E1"."1N.N) X
OUTPUT TRANSFORM: S Y=Y_" MINUTES"
LAST EDITED: AUG 19, 1988
HELP-PROMPT: Enter the number of minutes (1-600) that this case was delayed.
DESCRIPTION: This is the number of minutes (1-600) that this case was delayed due to this cause. Although
optional, this information will appear on the Report of Delayed Operations.
130.042,2 DELAY COMMENTS 1;0 WORD-PROCESSING #130.422
TECHNICAL DESCR: This is a word processing type field containing comments related to the delay cause.
Delay Comments
LAST EDITED: JAN 29, 1992
HELP-PROMPT: Enter comments related to this delay.
DESCRIPTION: This contains comments related to the delay cause.
TECHNICAL DESCR: This is a word-processing type field containing comments related to the delay cause.
130,43 CASE VERIFICATION VER;1 SET
Case Verification (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 14, 1988
DESCRIPTION: This indicates whether the principal operative procedure, CPT code, perioperative occurrences and
diagnosis were verified by the surgeon.
130,44 SPONGE FINAL COUNT CORRECT 25;1 SET
Sponge Final Count Correct
'Y' FOR YES;
'N' FOR NO, SEE NURSING CARE COMMENTS;
'N/A' FOR NOT APPLICABLE;
'NA' FOR NOT APPLICABLE;
LAST EDITED: SEP 11, 2014
HELP-PROMPT: Enter 'Y' if the final sponge count is correct.
DESCRIPTION: This indicates whether the sponge final count was correct. If entered, this information will
appear on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="I Y'=""N/A"""
EXPLANATION: Screen prevents selection of inactive code.
RECORD INDEXES: AO (#402)
130,45 SHARPS FINAL COUNT CORRECT 25;2 SET
Sharps Final Count Correct
'Y' FOR YES;
'N' FOR NO, SEE NURSING CARE COMMENTS;
'N/A' FOR NOT APPLICABLE;
'NA' FOR NOT APPLICABLE;
LAST EDITED: SEP 11, 2014
HELP-PROMPT: Enter 'Y' if the final sharps count is correct.
DESCRIPTION: This indicates whether the sharps final count was correct. If entered, this information will
appear on the Nurse Intraoperative Report. The type of information entered in this field is
determined by local hospital policy.
SCREEN: S DIC("S")="I Y'=""N/A"""
EXPLANATION: Screen prevents selection of inactive code.
RECORD INDEXES: AO (#402)
130,46 INSTRUMENT FINAL COUNT CORRECT 25;3 SET
Instrument Final Count Correct
'Y' FOR YES;
'N' FOR NO, SEE NURSING CARE COMMENTS;
'N/A' FOR NOT APPLICABLE;
'NA' FOR NOT APPLICABLE;
LAST EDITED: SEP 11, 2014
HELP-PROMPT: Enter 'Y' if the instrument final count is correct.
DESCRIPTION: This indicates whether the instrument final count was correct for this case. This information
appears on the Nurse Intraoperative Report. The type of information entered in this field is
determined by local hospital policy.
SCREEN: S DIC("S")="I Y'=""N/A"""
EXPLANATION: Screen prevents selection of inactive code.
RECORD INDEXES: AO (#402)
130,47 SPONGE, SHARPS, & INST COUNTER 25;4 POINTER TO NEW PERSON FILE (#200)
Person Responsible for Final Counts
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,47"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person doing the final counts.
DESCRIPTION: This is the name of the person doing the final count of sponges, sharps and instruments. If
entered, this information appears on the Nurse Intraoperative Report.
SCREEN: S DIC("S")="S RESTRICT=""130,47"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,48 COUNT VERIFIER 25;5 POINTER TO NEW PERSON FILE (#200)
Count Verifier
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,48"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the name of the person verifying the final counts.
DESCRIPTION: This is the name of the person responsible for verifying the final sponge, sharps and instrument
counts.
SCREEN: S DIC("S")="S RESTRICT=""130,48"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,49 SPECIMENS 9;0 WORD-PROCESSING #130.049
Specimens
DESCRIPTION: These are the names of specimens sent to the lab for analysis.
Specimens
LAST EDITED: AUG 15, 1988
DESCRIPTION: These are the names of specimens sent to the laboratory for analysis.
130,50 DIVISION 8;1 POINTER TO INSTITUTION FILE (#4)
Medical Center Division
LAST EDITED: AUG 23, 1990
DESCRIPTION: This is the name of the institution credited for performing this operative procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,51 PREOP ATTENDING CONCURRENCE 24;1 SET
Preoperative Attending Concurrence (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 23, 1990
DESCRIPTION:
This field serves as a flag that the attending has concurred with the preoperative workup.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,52 POSTOP ATTENDING CONCURRENCE 24;2 SET
Postoperative Attending Concurrence
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 23, 1990
DESCRIPTION:
This field serves as a flag that the attending concurs with the postoperative workup.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,53 NON-OPERATIVE OCCURRENCES 36;0 Multiple #130.053 (Add New Entry without Asking)
Non-Operative Occurrences
LAST EDITED: FEB 26, 1995
DESCRIPTION: These are occurrences that are not related to a surgical procedure. If there are not any
non-operative occurrences, leave this field blank. Do not enter 'NO' or 'NONE'.
130.053,.01 NON-OPERATIVE OCCURRENCES 0;1 FREE TEXT
Non-Operative Occurrences
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: JUL 20, 1990
HELP-PROMPT: Your answer must be 1-40 characters in length.
DESCRIPTION: This is a occurrence that is not related to a surgical procedure. If there are not any
non-operative occurrences, this field should be left blank. Do not enter 'NO' or 'NONE'.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
CROSS-REFERENCE: 130.053^B
1)= S ^SRF(DA(1),36,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),36,"B",$E(X,1,30),DA)
130.053,1 OUTCOME TO DATE 0;2 SET
Outcome to Date
'U' FOR UNRESOLVED;
'I' FOR IMPROVED;
'D' FOR DEATH;
'W' FOR WORSE;
LAST EDITED: JAN 25, 1991
HELP-PROMPT: Enter the outcome of this occurrence to date.
DESCRIPTION: This is the outcome to date of this non-operative occurrence.
130.053,2 DATE OCCURRENCE NOTED 0;3 DATE
Date Occurrence was Noted
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUL 20, 1990
HELP-PROMPT: Enter the date that this occurrence was noted.
DESCRIPTION: This is the date that this occurrence was noted. The time of day can be entered, but is not
required.
130.053,3 TREATMENT INSTITUTED 0;4 FREE TEXT
Treatment Instituted
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: JUL 20, 1990
HELP-PROMPT: Your answer must be 1-40 characters in length.
DESCRIPTION: This is the type of treatment instituted as a result of this non-operative occurrence.
130.053,4 OCCURRENCE COMMENTS 1;0 WORD-PROCESSING #130.534
Occurrence Comments
DESCRIPTION: This is information that may be helpful in documentation of the non-operative occurrence.
Occurrence Comments
LAST EDITED: JUL 20, 1990
HELP-PROMPT: Enter comments regarding this occurrence.
DESCRIPTION: This is information that might be helpful in documentation of the non-operative occurrence.
130.053,5 OCCURRENCE CATEGORY 0;5 POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5) (Required)
Occurrence Category
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 17, 1994
HELP-PROMPT: Enter the category most closely related to this occurrence.
DESCRIPTION: This is the name of the category for which this occurrence will be grouped for Surgery Central
Office reporting needs.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive occurrence categories.
130,54 OCCURRENCE/NO PROCEDURE 37;1 SET
Occurrence/No Procedure
'1' FOR YES;
'0' FOR NO;
LAST EDITED: NOV 18, 1988
DESCRIPTION: This indicates that this case was a occurrence, not related to a surgical procedure.
CROSS-REFERENCE: 130^ANON^MUMPS
1)= S ^SRF("ANON",$P(^SRF(DA,0),"^"),DA)=""
2)= K ^SRF("ANON",$P(^SRF(DA,0),"^"),DA)
The ANON cross reference on the OCCURRENCE/NO PROCEDURE field is used to flag cases that have
non-operative occurrences entered.
130,55 INDICATIONS FOR OPERATIONS 40;0 WORD-PROCESSING #130.055
Indications for Operations
DESCRIPTION: This is a brief statement of the indications for this operative procedure. The information you
enter here prints automatically as the first part of the operative summary.
Indications for Operations
LAST EDITED: JUL 20, 1990
HELP-PROMPT: Enter the indications for this operative procedure.
DESCRIPTION: This is a brief statement of the indications for this operative procedure. The information you
enter here prints automatically as the first part of the operative summary.
130,56 PRE-ADMISSION TESTING 35;2 SET
Pre-admission Testing Complete (Y/N)
'Y' FOR YES;
'N' FOR NO;
INPUT TRANSFORM: I $D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=56 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Answer 'YES' if pre-admission testing was complete.
DESCRIPTION: This indicates whether pre-admission testing was complete. It will be reflected on the Schedule of
Operations for outpatients.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,57 ESU COAG RANGE .7;1 FREE TEXT
ESU Coagulation Range
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=57 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the power setting range on the Electrosurgical Unit during coagulation. This information
is optional, but may be useful in documenting the case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,58 ESU CUTTING RANGE .7;2 FREE TEXT
ESU Cutting Range
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=58 D ^SROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION: This is the power setting range on the Electrosurgical Unit during cutting. This information is
optional, but may be useful in documenting the case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,59 OPERATIVE FINDINGS 38;0 WORD-PROCESSING #130.059
Operative Findings
DESCRIPTION: This field contains a brief description of the operative findings which appears on the Tissue
Examination Report.
Operative Findings
LAST EDITED: JUL 16, 1990
HELP-PROMPT: Enter a brief description of the operative findings.
DESCRIPTION: This field contains a brief description of the operative findings which appears on the Tissue
Examination Report.
130,60 BRIEF CLIN HISTORY 39;0 WORD-PROCESSING #130.09
Brief Clinical History
DESCRIPTION: This field contains a brief clinical history for this patient. It will appear on the Tissue
Examination Report.
Brief Clinical History
LAST EDITED: JUL 16, 1990
HELP-PROMPT: Enter a Brief Clinical History.
DESCRIPTION: This field will contain a brief clinical history which will appear on the Tissue Examination
Report. It should contain any information relevant to the specimens being sent to the
laboratory.
130,61 DIAGNOSTIC RESULTS CONFIRM BY .6;11 POINTER TO NEW PERSON FILE (#200)
Diagnostic Results Confirmed By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,61"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: NOV 06, 1992
HELP-PROMPT: Enter the name of the person verifying diagnostic procedure requirements.
DESCRIPTION: This is the name of the person responsible for verifying that the essential diagnostic procedure
requirements, as per medical center policy, are available.
SCREEN: S DIC("S")="S RESTRICT=""130,61"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,62 GASTRIC OUTPUT .2;6 NUMBER
Gastric Output (cc's)
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X I $D(X),$D(^SRF(DA,"CON")),$P(^("CON"),"^") S SRFLD=62 D ^S
ROCON Q
LAST EDITED: AUG 23, 1990
HELP-PROMPT: Enter a Number between 0 and 9999, 0 Decimal Digits.
DESCRIPTION: This is the gastric output during the operative procedure. It is recorded in cc's, and appears on
the Nurse Intraoperative Report.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,63 IV STARTED BY .3;5 POINTER TO NEW PERSON FILE (#200)
IV Started By
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,63"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: FEB 04, 1992
HELP-PROMPT: Enter the Person who Started the IV.
DESCRIPTION: This is the name of the person that started the IV for this operative procedure.
SCREEN: S DIC("S")="S RESTRICT=""130,63"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
130,64 CULTURES 41;0 WORD-PROCESSING #130.064
Cultures
DESCRIPTION: These are the names of cultures sent to the laboratory for examination.
Cultures
LAST EDITED: SEP 11, 1990
HELP-PROMPT: Enter the names of cultures sent to the lab.
DESCRIPTION: These are the names of cultures sent to the Laboratory for examination.
130,65 SURGERY POSITION 42;0 POINTER Multiple #130.065 (Add New Entry without Asking)
Surgery Position
DESCRIPTION: This is the position in which the patient is placed for this operative procedure. This information
will appear on the Nurse Intraoperative Report.
130.065,.01 SURGERY POSITION 0;1 POINTER TO SURGERY POSITION FILE (#132)
Surgery Position
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,4)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 03, 1992
HELP-PROMPT: Enter the position in which the patient is placed for this procedure.
DESCRIPTION: This is the position in which the patient is placed for this operative procedure. More than one
position may be entered for each case.
SCREEN: S DIC("S")="I '$P(^(0),U,4)"
EXPLANATION: Screen prevents selection of inactive entries.
130.065,1 TIME PLACED 0;2 DATE
Date/Time Placed
INPUT TRANSFORM: S Z=$E($P(^SRF(DA(1),0),"^",9),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
LAST EDITED: OCT 23, 1991
HELP-PROMPT: Enter the time that the patient was placed in this position.
DESCRIPTION: This is the date/time that the patient was placed in this position. Times without a date can be
entered.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,66 PLANNED PRIN DIAGNOSIS CODE 34;2 POINTER TO ICD DIAGNOSIS FILE (#80)
Planned Principal Diagnosis Code
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA):DA,$G(SRTN):SRTN,1:""))
OUTPUT TRANSFORM: I $G(Y) S Y=$$OUT^SROICD(Y)
LAST EDITED: JUL 28, 2014
HELP-PROMPT: Enter the planned ICD Diagnosis code for the principal diagnosis.
DESCRIPTION:
This is the planned principal postoperative ICD diagnosis code assigned by the clinician.
DELETE TEST: 1,0)= I 1 D EN^DDIOL("The PRIN DIAGNOSIS CODE can't be deleted.",,"!!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^PADX1^MUMPS
1)= Q
2)= D PRINASOD^SROADX2
This MUMPS cross reference removes associations to procedures upon edits or deletes of the
diagnosis.
130,67 CANCELLATION AVOIDABLE 30;2 SET
Cancellation Avoidable
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: OCT 09, 1991
HELP-PROMPT: Enter 'YES' if this cancellation was avoidable, or 'NO' if it was unavoidable.
DESCRIPTION: This field contains a set of codes used to flag a cancellation as being avoidable or unavoidable.
It is used when determining the percentage of avoidable cancellations.
130,68 SCHEDULED PROCEDURE SP;1 FREE TEXT
Scheduled Procedure
INPUT TRANSFORM: K:$L(X)>135!($L(X)<1) X
LAST EDITED: DEC 13, 1990
HELP-PROMPT: Your answer must be 1-135 characters in length.
DESCRIPTION: This field contains the scheduled (or original) principal procedure for this case. It will be
compared to the actual procedure completed.
130,69 CODING VERIFIER VER;2 POINTER TO NEW PERSON FILE (#200)
Coding Verifier
LAST EDITED: OCT 24, 2011
HELP-PROMPT: Enter the name of the person entering the CPT and ICD codes for this case.
DESCRIPTION: This is the person who last updated procedure and/or diagnosis descriptions and/or codes for this
case using the Update/Verify Procedure/Diagnosis Codes [SRCODING EDIT] option. This field is
updated automatically by the option when information is changed.
130,70 CANCELLED BY 30;3 POINTER TO NEW PERSON FILE (#200)
Operation Cancelled By
LAST EDITED: DEC 05, 1991
HELP-PROMPT: Enter the name of the person who cancelled this operative procedure.
DESCRIPTION: This is the name of the person who cancelled this surgical case. This information is automatically
entered when a case is cancelled.
130,71 TIME OUT VERIFIED VER;3 SET
Time Out Verification Completed (Y/N)
'Y' FOR YES;
'N' FOR NO (see TIME OUT VERIFIED COMMENTS);
LAST EDITED: JUL 23, 2004
HELP-PROMPT: Enter YES if the "Time Out" verification process was completed prior to the start of the procedure.
DESCRIPTION: This field refers to the completion of a "Time Out" verification process prior to the start of the
procedure. A designated member of the OR team states the name of the patient, the procedure to be
performed, the location of the site (including laterality if applicable), and the specifications of
the implant to be used (if applicable). At a minimum, this process must include the surgeon the
circulating nurse, and the anesthesia provider. This practice is further defined by local hospital
policy.
If entered "NO", a justification should be documented in the Time Out Verified Comments.
CROSS-REFERENCE: 130^AIN^MUMPS
1)= D IN^SRENSCS
2)= Q
This MUMPS cross reference maintains the associated comment field if this field is answered with
"NO".
FIELD INDEX: AG (#376) MUMPS IR ACTION
Short Descr: Timestamp fields update
Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
X(1): TIME OUT VERIFIED (130,71) (forwards)
X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
X(3): MARKED SITE CONFIRMED (130,73) (forwards)
130,72 PREOPERATIVE IMAGING CONFIRMED VER;4 SET
Preoperative Imaging Confirmed
'Y' FOR YES;
'I' FOR IMAGING NOT REQUIRED FOR THIS PROCEDURE;
'N' FOR NO - IMAGING REQUIRED BUT NOT VIEWED (see IMAGING CONFIRMED COMMENTS);
LAST EDITED: JUL 22, 2004
HELP-PROMPT: Enter YES if the imaging data was confirmed, "I" if there was no imaging required, or "NO" if the
image was not viewed.
DESCRIPTION: This field refers to the completion of the verification process for the presence of relevant
imaging data to confirm the operative site for the correct patient are available, properly labeled
and properly presented, and verified by two members of the operating team prior to the start of the
procedure.
This practice is further defined by local hospital policy.
If entered "NO", a justification should be documented in the Imaging Confirmed Comments.
CROSS-REFERENCE: 130^AIN^MUMPS
1)= D IN^SRENSCS
2)= Q
This MUMPS cross reference maintains the associated comment field if this field is answered with
"NO".
FIELD INDEX: AG (#376) MUMPS IR ACTION
Short Descr: Timestamp fields update
Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
X(1): TIME OUT VERIFIED (130,71) (forwards)
X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
X(3): MARKED SITE CONFIRMED (130,73) (forwards)
130,73 MARKED SITE CONFIRMED VER;5 SET
Mark on Surgical Site Confirmed
'Y' FOR YES;
'M' FOR MARKING NOT REQUIRED FOR THIS PROCEDURE;
'N' FOR NO - MARKING REQUIRED BUT NOT DONE (see MARKED SITE COMMENTS);
LAST EDITED: JUL 22, 2004
HELP-PROMPT: Enter YES if the "Marked Site" confirmation process was completed prior to the start of the
procedure.
DESCRIPTION: The site can and must be marked in almost all cases. Mucous membranes and other sites not on the
skin cannot be marked using standard methods and do not need to be. See applicable VHA Handbooks
and Directives for further information and guidance.
If entered "NO", a justification should be documented in the Marked Site Comments.
CROSS-REFERENCE: 130^AIN^MUMPS
1)= D IN^SRENSCS
2)= Q
This MUMPS cross reference maintains the associated comment field if this field is answered with
"NO".
FIELD INDEX: AG (#376) MUMPS IR ACTION
Short Descr: Timestamp fields update
Description: Automatically capture the timestamp fields when the corresponding field is entered or changed.
Set Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Set Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
Kill Logic: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Cond: N I S I=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) D NOW^%DTC S $P(^SRF(DA,"VERD"),"^",I+2)=%
X(1): TIME OUT VERIFIED (130,71) (forwards)
X(2): PREOPERATIVE IMAGING CONFIRMED (130,72) (forwards)
X(3): MARKED SITE CONFIRMED (130,73) (forwards)
130,74 TIME-OUT COMPLETED .6;12 DATE
Time-Out Completed
INPUT TRANSFORM: D TIME^SROUTL K:Y<1!(X'[".") X
LAST EDITED: SEP 25, 2014
HELP-PROMPT: Enter the time the Time-Out was completed.
DESCRIPTION: VASQIP Definition (2014): This indicates the actual time when the entire Time-Out process was
completed by the OR team. It will be documented using Military Time format.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,75 TOV TIMESTAMP VERD;3 DATE
Time Out Verified Timestamp
INPUT TRANSFORM: S %DT="EST" D ^%DT S X=Y K:X<1 X
LAST EDITED: FEB 04, 2004
HELP-PROMPT: (No range limit on date)
DESCRIPTION:
This field is updated whenever the TIME OUT VERIFIED field (#71) is entered or changed.
WRITE AUTHORITY: ^
UNEDITABLE
130,76 IMAG TIMESTAMP VERD;4 DATE
Imaging Confirmed Timestamp
INPUT TRANSFORM: S %DT="EST" D ^%DT S X=Y K:X<1 X
LAST EDITED: FEB 04, 2004
HELP-PROMPT: (No range limit on date)
DESCRIPTION: This field is updated whenever the PREOPERATIVE IMAGING CONFIRMED field (#72) is entered or
changed.
WRITE AUTHORITY: ^
UNEDITABLE
130,77 SITE MARK TIMESTAMP VERD;5 DATE
Site Mark Verified Timestamp
INPUT TRANSFORM: S %DT="EST" D ^%DT S X=Y K:X<1 X
LAST EDITED: FEB 04, 2004
HELP-PROMPT: (No range limit on date)
DESCRIPTION:
This field is updated whenever the MARKED SITE CONFIRMED field (#73) is entered or changed.
WRITE AUTHORITY: ^
UNEDITABLE
130,78 PREVIOUSLY SCHEDULED CASE SP;2 POINTER TO SURGERY FILE (#130)
Previously Scheduled Case That Was Cancelled
LAST EDITED: AUG 10, 2011
HELP-PROMPT: Enter the previously scheduled, now cancelled, case.
DESCRIPTION:
This field identifies the previously scheduled case that was cancelled and replaced by this case.
130,79 RESCHEDULED CASE SP;3 POINTER TO SURGERY FILE (#130)
Replacement Case for This Cancelled Case
LAST EDITED: AUG 12, 2011
HELP-PROMPT: Enter the replacement case to be scheduled later.
DESCRIPTION: This field identifies the new surgery case that will be scheduled later to replace this cancelled
case.
130,80 SPD COMMENTS 80;0 WORD-PROCESSING #130.8
DESCRIPTION: This word-processing field contains any information for SPD that cannot be entered elsewhere.
These comments will be sent to SPD via the Surgery/CoreFLS interface.
SPD Comments
LAST EDITED: SEP 05, 2002
DESCRIPTION: This word-processing field contains any information for SPD that cannot be entered elsewhere.
These comments will be sent to SPD via the Surgery/CoreFLS interface.
130,81 DYNAMED NOTIFIED 31;10 SET
DynaMed Notification Sent
'1' FOR YES;
'0' FOR NO;
LAST EDITED: NOV 27, 2002
HELP-PROMPT: Enter YES if notification has been sent to DynaMed.
DESCRIPTION: YES indicates at least one notification has been sent to DynaMed by way of the CoreFLS interface. A
null value or zero indicates no notification has been sent. The first notification sent to DynaMed
will be a NEW APPOINTMENT notification. Subsequent notifications will be for edit, cancel or delete
notifications, as appropriate.
130,82 TIME OUT VERIFIED COMMENTS 82;0 WORD-PROCESSING #130.082
LAST EDITED: APR 29, 2004
DESCRIPTION: This word-processing field contains comments related to the TIME OUT VERIFIED field. The
information entered in this field clarifies entry that is entered as "NO".
Time Out Verification Comments
LAST EDITED: MAY 21, 2004
DESCRIPTION: This word-processing field contains comments related to the TIME OUT VERIFIED field. The
information entered in this field clarifies entry that is entered as "NO".
130,83 IMAGING CONFIRMED COMMENTS 83;0 WORD-PROCESSING #130.083
DESCRIPTION: This word-processing field contains comments related to the PREOPERATIVE IMAGING CONFIRMED field.
The information entered in this field clarifies entry that is entered as "NO".
Imaging Confirmed Comments
LAST EDITED: MAY 21, 2004
DESCRIPTION: This word-processing field contains comments related to the PREOPERATIVE IMAGING CONFIRMED field.
The information entered in this field clarifies entry that is entered as "NO".
130,84 MARKED SITE COMMENTS 84;0 WORD-PROCESSING #130.084
LAST EDITED: APR 28, 2004
DESCRIPTION: This word-processing field contains comments related to the MARKED SITE CONFIRMED field. The
information entered in this field clarifies entry that is entered as "NO".
Mark on Surgical Site Comments
LAST EDITED: MAY 21, 2004
DESCRIPTION: This word-processing field contains comments related to the MARKED SITE CONFIRMED field. The
information entered in this field clarifies entry that is entered as "NO".
130,85 CHECKLIST COMMENT 51;0 WORD-PROCESSING #130.085
LAST EDITED: FEB 16, 2011
DESCRIPTION: This field is a comment that is required if any of the listed below fields for the Time Out
Verified Utilizing Checklist had a response of "No".
- CONFIRM PATIENT IDENTITY (#600)
- PROCEDURE TO BE PERFORMED (#601)
- VALID CONSENT FORM (#603)
- CONFIRM PATIENT POSITION (#604)
- CORRECT MEDICAL IMPLANTS (#607)
- ANTIBIOTIC PROPHYLAXIS (#608)
- APPROPRIATE DVT PROPHYLAXIS (#609)
- BLOOD AVAILABILITY (#610)
- AVAILABILITY OF SPECIAL EQUIP (#611)
- SITE OF PROCEDURE (#602)
- MARKED SITE CONFIRMED (#605)
- REOPERATIVE IMAGES CONFIRMED (#606)
Checklist Comment
LAST EDITED: FEB 16, 2011
DESCRIPTION: This word-processing field contains comments related to the listed below fields if any is entered
as "NO".
- CORRECT PATIENT IDENTITY
- PROCEDURE TO BE PERFORMED
- SITE OF THE PROCEDURE
- VALID CONSENT FORM
- PATIENT POSITION
- MARKED SITE CONFIRMED
- PREOPERATIVE IMAGING CONFIRMED
- CORRECT MED IMPLANTS
- AVAILABILITY OF SPECIAL EQUIP
- APPRO ANTIBIOTIC PROPHYLAXIS
- APPROPRIATE DVT PROPHYLAXIS
- BLOOD AVAILABILITY
130,100 ORDER NUMBER 0;14 POINTER TO ORDER FILE (#100)
LAST EDITED: FEB 28, 1992
HELP-PROMPT: Enter the Order number for ues within the OE/RR module.
DESCRIPTION: This is the pointer to the ORDER file (100). It will be created when a case is requested.
TECHNICAL DESCR: This is the pointer to the ORDER file (100). It is contained in the 14th piece of the zero node.
130,101 STAFF/RESIDENT .1;3 SET
Resident or Staff Surgeon
'R' FOR RESIDENT;
'S' FOR STAFF;
LAST EDITED: APR 15, 1992
HELP-PROMPT: Enter 'R' if the surgeon for this case was a resident, or 'S' if the surgeon was staff.
DESCRIPTION: This determines whether the surgeon was a resident or staff. It will be used for categorizing
procedures in the Annual Report of Surgical Procedures.
TECHNICAL DESCR: This field is automatically entered based on the SR STAFF SURGEON security key.
130,102 REASON FOR NO ASSESSMENT RA;7 SET
Reason for not Creating an Assessment
'0' FOR NON-SURGEON CASE;
'1' FOR ANESTHESIA TYPE;
'2' FOR EXCEEDS MAX ASSMNTS;
'3' FOR EXCEEDS MAX TURPS;
'4' FOR INCLSN CRTA NOT MET;
'5' FOR PREVIOUS CASE;
'6' FOR 10% RULE;
'7' FOR PRIOR INDEX PROC;
'8' FOR CONCURRENT CASE;
'9' FOR EXCEEDS MAX HERNIAS;
'A' FOR ABORTED;
LAST EDITED: AUG 24, 2015
HELP-PROMPT: Enter the reason why no assessment was done on this surgical case.
DESCRIPTION: VASQIP Definition (2015): This is the reason why no assessment was entered for this particular
surgical case. It should be entered if any VASQIP CPT-eligible procedure was excluded from the risk
assessment module.
0 - Non-surgeon performed the procedure
2 - Number of surgical cases entered into the Surgical Package
exceeded 36 over an 8 day time frame
3 - Number of TURPs or TURBTs exceeded 5 cases over an 8 day time
frame
4 - Surgical case does not meet inclusion criteria (VASQIP excluded
case, CPT code, ASA 6)
6 - 10% Rule: Surgical Quality Nurse can exclude up to 10%
non-mandatory cases in a 12 month calendar year
8 - Case was a concurrent case, secondary to an assessed primary case
9 - Number of hernias exceeded 5 cases over an 8 day time frame
A - Aborted: case was cancelled after the patient entered the operating
room prior to incision
SCREEN: S DIC("S")="I ""157""'[Y"
EXPLANATION: Screen prevents selection of inactive codes.
130,103 ANESTHETIST CATEGORY .3;8 SET
Anesthetist Category
'A' FOR ANESTHESIOLOGIST;
'N' FOR NURSE ANESTHETIST;
'O' FOR OTHER;
LAST EDITED: NOV 05, 1992
HELP-PROMPT: Enter the code corresponding to the category of the principal anesthetist for this case.
DESCRIPTION: This field holds the category of the principal anesthetist which is used on the Anesthesia AMIS
report to enumerate the number of anesthetics administered by each category.
130,118 NON-OR PROCEDURE NON;1 SET
Non-OR Procedure
'Y' FOR YES;
LAST EDITED: JAN 22, 1992
HELP-PROMPT: Enter 'YES' is this case is a non-OR procedure.
DESCRIPTION:
This field is a flag signifying this case is a non-OR surgical procedure.
CROSS-REFERENCE: 130^ANOR^MUMPS
1)= S ^SRF("ANOR",$P(^SRF(DA,0),"^"),DA)=""
2)= K ^SRF("ANOR",$P(^SRF(DA,0),"^"),DA)
The ANOR cross reference on the NON-OR PROCEDURE field is used to flag cases as non-O.R.
procedures.
130,119 NON-OR LOCATION NON;2 POINTER TO HOSPITAL LOCATION FILE (#44)
Non-OR Location
INPUT TRANSFORM: S DIC("S")="I $$NONORDIV^SROUTL0(DA,+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the non-OR location (file 44) where this procedure was performed.
DESCRIPTION:
This is the location (file 44) where this non-OR procedure was performed.
SCREEN: S DIC("S")="I $$NONORDIV^SROUTL0(DA,+Y)"
EXPLANATION: This screen checks inactivation and reactivation dates as well as the institution field for multi-d
ivision hospitals.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^APCE9^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
130,120 DATE OF PROCEDURE NON;3 DATE (Required)
Date of Procedure
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: SEP 19, 1997
HELP-PROMPT: Enter the date that the non-OR procedure was performed.
DESCRIPTION: This is the date that the non-OR procedure was performed. The date of procedure must be entered
for all non-OR cases.
CROSS-REFERENCE: ^^TRIGGER^130^.09
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X
K Y S X=DIV S X=DIV S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09
D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,0)):^(0),1:"") S X=$P(Y(1),U,9),X=X S DIU=X
K Y S X="" S DIH=$S($D(^SRF(DIV(0),0)):^(0),1:""),DIV=X S $P(^(0),U,9)=DIV,DIH=130,DIG=.09 D ^DICR
CREATE VALUE)= DATE OF PROCEDURE
DELETE VALUE)= @
FIELD)= DATE OF OPERATION
This trigger on the DATE OF PROCEDURE field is used to update the DATE OF OPERATION field when the
date of procedure is entered or edited. The DATE OF PROCEDURE field is used with non-O.R.
procedures, and the DATE OF OPERATION field is updated to assist in sorting cases for reports.
130,121 TIME PROCEDURE BEGAN NON;4 DATE
Time Procedure Began
INPUT TRANSFORM: S Z=$E($P(^SRF(DA,"NON"),U,3),1,7) D TIME^SROVAR K:Y<1!(X'[".") X
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the time of the start of the non-OR procedure.
DESCRIPTION:
This is the date and time that the non-OR procedure began.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AST^MUMPS
1)= D AST^SRONXR
2)= D KILLAST^SRONXR
The AST cross reference on the TIME PROCEDURE BEGAN field updates the ANES CARE START TIME if the
non-O.R. procedure is an Anesthesiology procedure, that is, if the case is assigned to the
Anesthesiology Medical Specialty.
CROSS-REFERENCE: 130^APCE10^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: 130^ADA^MUMPS
1)= D VALIDAT^SROCVER
2)= Q
This MUMPS cross-reference on the TIME PROCEDURE BEGAN field is used to invoke the CPT and ICD-9
codes revalidation checks in routine ^SROCVER.
130,122 TIME PROCEDURE ENDED NON;5 DATE
Time Procedure Ended
INPUT TRANSFORM: S SRN="NON",SRP=4,SR130="TIME PROCEDURE BEGAN" D TERM^SROVAR K:Y<1 X I $D(X) D ATTP^SROUTL1
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the time that the non-OR procedure was completed.
DESCRIPTION:
This is the date and time that all the procedures for this non-OR case are complete.
DELETE TEST: 1,0)= I $$DEL^SROESX(DA,"3") D EN^DDIOL("The TIME PROCEDURE ENDED field can't be deleted. This case
has a Procedure Report associated with it.",,"!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AND^MUMPS
1)= D AND^SRONXR
2)= D KILLAND^SRONXR
The AND cross reference on the TIME PROCEDURE ENDED field updates the ANES CARE END TIME if the
non-O.R. procedure is assigned to the Anesthesiology Medical Specialty.
CROSS-REFERENCE: 130^APCE11^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
RECORD INDEXES: AESP (#388)
130,123 PROVIDER NON;6 POINTER TO NEW PERSON FILE (#200) (Required)
Provider
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,123"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the name of the privileged person who performs the major portion of the principle procedure.
DESCRIPTION: This is the person who performs the major portion of the principal non-OR procedure. This field is
required for several reports.
SCREEN: S DIC("S")="S RESTRICT=""130,123"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: Entries in this field may be restricted based on locally selected keys.
CROSS-REFERENCE: 130^APCE12^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
CROSS-REFERENCE: 130^ATTP^MUMPS
1)= D ATTP^SROXR1
2)= D KATTP^SROXR1
This cross reference updates the ATTEND PROVIDER field with the PROVIDER if the SURGERY RESIDENTS
(Y/N) site parameter is NO.
FIELD INDEX: AES2 (#381) MUMPS ACTION
Short Descr: Update TIU when provider is changed.
Description: This cross reference is responsible for updating the AUTHOR/DICTATOR field (#1202) and the EXPECTED
SIGNER field (#1204) in the TIU DOCUMENT file (#8925) for the Procedure Report (Non-OR) when the
provider is edited.
Set Logic: D SET^SROESX0
Set Cond: S X=X1(1)'=X2(1)
Kill Logic: Q
Kill Cond: S X=0
X(1): PROVIDER (130,123) (forwards)
130,124 ATTEND PROVIDER NON;7 POINTER TO NEW PERSON FILE (#200)
Attending Provider
INPUT TRANSFORM: S DIC("S")="S RESTRICT=""130,124"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAY 31, 2005
HELP-PROMPT: Enter the name of the attending staff provider. This is required when the provider is in training
status.
DESCRIPTION: This is the name of the attending staff provider responsible for this case. This information
appears on several reports.
SCREEN: S DIC("S")="S RESTRICT=""130,124"" D KEY^SROXPR I $D(SROK)"
EXPLANATION: This field contains a screen which may be used to restrict entries based on locally defined keys.
DELETE TEST: 1,0)= I $P($G(^SRF(DA,"NON")),"^",5) D EN^DDIOL("The Attending Provider cannot be deleted on a comp
leted non-OR procedure! ",,"!!,?2")
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^APCE13^MUMPS
1)= D APCE^SROPCEX
2)= Q
This MUMPS cross reference updates PCE.
FIELD INDEX: AES4 (#383) MUMPS ACTION
Short Descr: Update TIU when attending provider is changed.
Description: This cross reference is responsible for updating the EXPECTED COSIGNER field (#1208) and the
ATTENDING PHYSICIAN field (#1209) in the TIU DOCUMENT file (#8925) for the Procedure Report
(Non-OR) when the attending provider is edited.
Set Logic: D SET1^SROESX0
Set Cond: S X=((X1(1)'=X2(1))&(X2(1)'=""))
Kill Logic: D SET1^SROESX0
Kill Cond: S X=X2(1)=""
X(1): ATTEND PROVIDER (130,124) (forwards)
130,125 MEDICAL SPECIALTY NON;8 POINTER TO MEDICAL SPECIALTY FILE (#723) (Required)
Medical Specialty
LAST EDITED: MAR 03, 1993
HELP-PROMPT: Enter the assigned medical specialty of the provider.
DESCRIPTION: This is the medical specialty credited for doing this non-OR procedure.
Many reports are sorted by the medical specialty. This field should be
entered prior to completion of this non-OR procedure.
130,126 PROCEDURE OCCURRENCE 43;0 Multiple #130.0126
DESCRIPTION: This is a occurrence that is related to a non-O.R. procedure. If there are not any non-O.R.
procedure occurrences, this field should be left blank. Do not enter 'NO' or 'NONE'.
130.0126,.01 PROCEDURE OCCURRENCE 0;1 FREE TEXT (Multiply asked)
Non-O.R. Procedure Occurrence
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: AUG 24, 1992
HELP-PROMPT: Your answer must be 1-40 characters in length.
DESCRIPTION: This is a occurrence that is related to a non-O.R. procedure. If there are not any non-O.R.
procedure occurrences, this field should be left blank. Do not enter 'NO' or 'NONE'.
CROSS-REFERENCE: 130.0126^B
1)= S ^SRF(DA(1),43,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),43,"B",$E(X,1,30),DA)
130.0126,1 OUTCOME TO DATE 0;2 SET
Outcome to Date
'U' FOR UNRESOLVED;
'I' FOR IMPROVED;
'D' FOR DEATH;
'W' FOR WORSE;
LAST EDITED: AUG 24, 1992
HELP-PROMPT: Enter the outcome of this occurrence to date.
DESCRIPTION: This is the outcome to date of this non-O.R. procedure occurrence.
130.0126,2 DATE OCCURRENCE NOTED 0;3 DATE
Date Occurrence was Noted
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: AUG 24, 1992
HELP-PROMPT: Enter the date that this occurrence was noted.
DESCRIPTION: This is the date that this occurrence was noted. The time of day can be entered, but is not
required.
130.0126,3 TREATMENT INSTITUTED 0;4 FREE TEXT
Treatment Instituted
INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: AUG 24, 1992
HELP-PROMPT: Your answer must be 1-40 characters in length.
DESCRIPTION: This is the type of treatment instituted as a result of this non-O.R. procedure occurrence.
130.0126,4 OCCURRENCE COMMENTS 1;0 WORD-PROCESSING #130.1264
DESCRIPTION: This is information that may be helpful in documentation of the non-O.R. procedure occurrence.
Occurrence Comments
LAST EDITED: JUN 19, 1996
HELP-PROMPT: Enter comments regarding this occurrence.
DESCRIPTION: This is information that may be helpful in documentation of the non-O.R. procedure occurrence.
130.0126,5 OCCURRENCE CATEGORY 0;5 POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5) (Required)
Occurrence Category
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,2)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 17, 1994
HELP-PROMPT: Enter the category most closely related to this occurrence.
DESCRIPTION: This is the name of the category for which this occurrence will be grouped for Surgery Central
Office reporting needs.
SCREEN: S DIC("S")="I '$P(^(0),U,2)"
EXPLANATION: Screen prevents selection of inactive occurrence categories.
130,127 SEQUENTIAL COMPRESSION DEVICE .7;3 SET
Sequential Compression Device (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 22, 1992
HELP-PROMPT: Enter 'YES' if a sequential compression device was used.
DESCRIPTION: This determines whether a sequential compression device was used.
130,128 LASER TYPE .7;8 FREE TEXT
Type of Laser
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: SEP 25, 1992
HELP-PROMPT: Your answer must be 1-30 characters in length.
DESCRIPTION: This determines whether a laser was used during this procedure. If applicable, enter the type of
laser used during this surgical procedure.
130,129 LASER UNIT 44;0 Multiple #130.0129 (Add New Entry without Asking)
DESCRIPTION:
These are the laser units, if any, used during this procedure.
130.0129,.01 LASER UNIT/ID 0;1 FREE TEXT (Multiply asked)
Laser Unit/ID
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: AUG 30, 2000
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
This is the name or ID of the laser unit used during this procedure,
CROSS-REFERENCE: 130.0129^B
1)= S ^SRF(DA(1),44,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),44,"B",$E(X,1,30),DA)
130.0129,1 LASER DURATION 0;2 NUMBER
Laser Duration
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X
LAST EDITED: JAN 11, 2001
HELP-PROMPT: Enter the time in minutes that the laser was used.
DESCRIPTION:
This is the duration in minutes that the laser unit was applied.
130.0129,2 WATTAGE 0;3 NUMBER
Wattage
INPUT TRANSFORM: K:+X'=X!(X>10000)!(X<0)!(X?.E1"."3N.N) X
LAST EDITED: JAN 11, 2001
HELP-PROMPT: Enter the watts (joules/second) used by the laser.
DESCRIPTION:
This is the number of watts (joules/sec) used by the laser during the procedure.
130.0129,3 LASER OPERATOR 0;4 POINTER TO NEW PERSON FILE (#200)
Laser Operator
LAST EDITED: JAN 11, 2001
HELP-PROMPT: Enter the name of the authorized laser operator.
DESCRIPTION: This is the authorized laser operator who operated this laser unit during this procedure. If the
person cannot be entered in this field, enter the name in the LASER COMMENTS field (#5) for this
laser unit.
130.0129,4 PLUME EVACUATOR 0;5 SET
Plume Evacuator
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 11, 2001
HELP-PROMPT: Enter YES if smoke plume reduction measures were implemented.
DESCRIPTION:
This field determines if a plume evacuator was used with this laser unit.
130.0129,5 LASER COMMENTS 1;0 WORD-PROCESSING #130.1295
Laser Comments
DESCRIPTION: This word-processing field contains comments about the use of this laser unit during this
procedure.
Laser Comments
LAST EDITED: JAN 11, 2001
HELP-PROMPT: Enter any comments related to the use of this laser unit.
DESCRIPTION: This word-processing field contains comments about the use of this laser unit during this
procedure.
130,130 CELL SAVER 45;0 Multiple #130.013 (Add New Entry without Asking)
DESCRIPTION:
These are the cell savers, if any, used during this procedure.
130.013,.01 CELL SAVER ID 0;1 FREE TEXT (Multiply asked)
Cell Saver ID
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: SEP 01, 2000
HELP-PROMPT: Enter machine identification name and/or number.
DESCRIPTION:
This field identifies the cell saver that was used during this procedure.
CROSS-REFERENCE: 130.013^B
1)= S ^SRF(DA(1),45,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),45,"B",$E(X,1,30),DA)
130.013,1 CELL SAVER OPERATOR 0;2 POINTER TO NEW PERSON FILE (#200)
Cell Saver Operator
LAST EDITED: JUL 05, 2002
HELP-PROMPT: Enter the name of the authorized cell saver operator.
DESCRIPTION: This is the authorized cell saver operator during this procedure. If the person cannot be
entered in this field, enter the name in the CELL SAVER COMMENTS field (#5) for this cell saver.
130.013,2 AMT SALVAGED (ML) 0;3 NUMBER
Amount Salvaged (ml)
INPUT TRANSFORM: K:+X'=X!(X>999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 10, 2000
HELP-PROMPT: Enter the total amount in milliliters of fluid collected.
DESCRIPTION:
This is the amount of fluid in milliliters collected during the procedure.
130.013,3 AMT REINFUSED (ML) 0;4 NUMBER
Amount Reinfused (ml)
INPUT TRANSFORM: K:+X'=X!(X>999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 10, 2000
HELP-PROMPT: Enter the total amount in milliliters of fluid reinfused.
DESCRIPTION: This is the amount of fluid in milliliters that was reinfused into the patient during this
procedure.
130.013,4 DISPOSABLES USED 1;0 Multiple #130.0134 (Add New Entry without Asking)
DESCRIPTION:
These are the disposable items used with this cell saver during this procedure.
130.0134,.01 DISPOSABLES NAME 0;1 FREE TEXT (Multiply asked)
Disposables Name
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: SEP 01, 2000
HELP-PROMPT: Enter the name of the disposable product used with this cell saver.
DESCRIPTION:
This is the name of the disposable product used with this cell saver during this procedure.
CROSS-REFERENCE: 130.0134^B
1)= S ^SRF(DA(2),45,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),45,DA(1),1,"B",$E(X,1,30),DA)
130.0134,1 LOT NUMBER 0;2 FREE TEXT
Lot Number
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: SEP 01, 2000
HELP-PROMPT: Enter the product lot number for this disposable product.
DESCRIPTION:
This is the lot number for this disposable used with the cell saver.
130.0134,2 QUANTITY 0;3 NUMBER
Quantity
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 10, 2000
HELP-PROMPT: Enter the number of products with the same name and lot number used.
DESCRIPTION: This is the quantity of disposable products with the same name and lot number used with this
cell saver during this procedure.
130.013,5 CELL SAVER COMMENTS 2;0 WORD-PROCESSING #130.0135
Cell Saver Comments
DESCRIPTION: These comments contain additional information related to the use of this cell saver during this
procedure.
Cell Saver Comments
LAST EDITED: SEP 14, 2001
HELP-PROMPT: Enter additional information about the use of this cell saver.
DESCRIPTION: These comments contain additional information related to the use of this cell saver used
during this procedure.
130,131 DEVICE(S) 46;1 FREE TEXT
Device(s)
INPUT TRANSFORM: K:$L(X)>70!($L(X)<1) X
LAST EDITED: SEP 05, 2000
HELP-PROMPT: Answer must be 1-70 characters in length.
DESCRIPTION:
This field documents devices used in this procedure that are not documented elsewhere.
130,135 LASER PERFORMED 56;0 Multiple #130.11 (Add New Entry without Asking)
DESCRIPTION:
This is information related to the laser performed, if any, used during this procedure.
130.11,.01 LASER NAME 0;1 FREE TEXT
Laser Name
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: JUN 25, 2015
HELP-PROMPT: Answer must be 3-30 characters in length.
DESCRIPTION: Indicate type of Laser used in the procedure, if more than one laser enter data for each laser
used.
CROSS-REFERENCE: 130.11^B
1)= S ^SRF(DA(1),56,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),56,"B",$E(X,1,30),DA)
130.11,1 LASER TYPE 0;2 SET
Laser Type
'1' FOR HOLMIUM-YAG;
'2' FOR NEODYMIUM-(NG-YAG);
'3' FOR CO2;
'4' FOR KTP;
'5' FOR EYE DIODE GREEN (532 NM);
'6' FOR EYE DIODE (810 NM);
'7' FOR OTHER;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the type of laser from the available list.
DESCRIPTION: Indicate type of Laser used in the procedure; if more than one laser enter data for each laser
used.
1- HOLMIUM-YAG 2- NEODYMIUM-(NG-YAG) 3- CO2 4- KTP 5- EYE DIODE GREEN (532 NM) 6- EYE DIODE (810
NM) 7- OTHER
130.11,2 LASER START TIME 0;3 DATE
Laser Start Time
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the laser start date and time.
DESCRIPTION: This is the date and time of first use of the laser for this case using the format
xx/xx/xx@xx:xx.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.11,3 LASER END TIME 0;4 DATE
Laser End Date
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the laser end date and time.
DESCRIPTION:
This is the date and time of last use of the laser for this case using the format xx/xx/xx@xx:xx.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130.11,4 LASER TEST FIRE 0;5 SET
Laser Test Fire
'1' FOR YES;
'2' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if laser was test fired prior to use for this case.
DESCRIPTION:
This field is used to determine if laser was test fired prior to use for this case.
130.11,5 LASER DELIVERY SYSTEM 0;6 SET
Laser Delivery System
'1' FOR ENDOSCOPE;
'2' FOR HAND PIECE;
'3' FOR HEAD PIECE;
'4' FOR LAPAROSCOPE;
'5' FOR LASER FIBER;
'6' FOR MICROSCOPE;
'7' FOR OTHER;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter type(s) of delivery system used for laser for this case.
DESCRIPTION: This field is used to enter the type(s) of delivery system used for laser for this case.
1- ENDOSCOPE 2- HAND PIECE 3- HEAD PIECE 4- LAPAROSCOPE 5- LASER FIBER 6- MICROSCOPE 7- OTHER
130.11,6 PULSE MODE 0;7 SET
Pulse Mode
'1' FOR CONTINUOUS;
'2' FOR REPEAT PULSE;
'3' FOR SINGLE PULSE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the laser pulse mode(s) used for this case.
DESCRIPTION: This field is used to enter the type(s) of laser pulse mode(s) used for this case.
1- CONTINUOUS 2- REPEAT PULSE 3- SINGLE PULSE
130.11,7 POWER/AVERAGE POWER 0;8 NUMBER
Power/Average Power
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the laser power setting or average laser power setting used during the case as a number
between 0 and 1000, 1 decimal digit.
DESCRIPTION: This is the laser power or average power used for this case. This a number between 0 and 1000,1
decimal digit (xxxx.x).
130.11,8 INTERVAL/REPETITION RATE 0;9 NUMBER
Interval/Repetition Rate
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the laser Interval between pulses or the repetition rate for this case as a number between
0 and 1000, 1 decimal digit.
DESCRIPTION: This is the laser Interval between pulses or the repetition rate for this case. This a number
between 0 and 1000, 1 decimal digit (xxxx.x).
130.11,9 TOTAL JOULES DELIVERED 0;10 NUMBER
Total Joules Delivered
INPUT TRANSFORM: K:+X'=X!(X>99999.9)!(X<0)!(X?.E1"."2N.N) X
LAST EDITED: MAR 17, 2022
HELP-PROMPT: Type a number between 0 and 99999.9, 1 decimal digit.
DESCRIPTION: This is the laser total Joules delivered for this case. This a number between 0 and 99999.9, 1
decimal digit (xxxxx.x).
130.11,10 WATTS DELIVERED 0;11 NUMBER
Watts Delivered
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the watts (joules/second) used by the laser as a number between 0 and 1000, 1 decimal
digit.
DESCRIPTION: This is the total watts delivered for this case. This a number between 0 and 1000, 1 decimal
digit (xxxx.x).
130.11,11 WAVE FORM 0;12 FREE TEXT
Wave Form
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the wave form used for this case, 1-50 characters in length.
DESCRIPTION:
This is the laser wave form use for this case.
130.11,12 PULSE WIDTH 0;13 NUMBER
Pulse Width
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Type a number between 0 and 1000, 1 decimal digit.
DESCRIPTION: This is the laser pulse width used for this case. This a number between 0 and 1000, 1 decimal
digit (xxxx.x).
130.11,13 ENERGY JOULES 0;14 NUMBER
Energy Joules
INPUT TRANSFORM: K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the energy joules used for this case, as a number between 0 and 1000, 1 decimal digit.
DESCRIPTION: This is the laser energy joules used for this case. This a number between 0 and 1000, 1 decimal
digit (xxxx.x).
130.11,14 LASER DURATION 0;15 NUMBER
Laser Duration (seconds)
INPUT TRANSFORM: K:+X'=X!(X>10000)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: MAR 16, 2021
HELP-PROMPT: Enter the time in seconds that the laser was used.
DESCRIPTION: This is the duration of laser use in seconds for this case. This is a number between 0 and
10,000.
130.11,15 PATIENT PRECAUTIONS 1;0 SET Multiple #130.1115
LAST EDITED: JUN 26, 2015
DESCRIPTION:
This is the laser patient safety precaution(s) used for this case.
130.1115,.01 PATIENT PRECAUTIONS 0;1 SET
Patient Precautions
'1' FOR EYE PADS;
'2' FOR TAPE;
'3' FOR SAFETY GLASSES/GOGGLES;
'4' FOR LASER ET TUBE;
'5' FOR MOIST DRAPES;
'6' FOR WATER AVAILABLE;
'7' FOR RECTAL PACK;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Choose the laser patient safety precaution(s) used for this case.
DESCRIPTION: This is the laser patient safety precaution(s) used for this case. Enter all that were used:
1- EYE PADS 2- TAPE 3- SAFETY GLASSES/GOGGLES 4- LASER ET TUBE 5- MOIST DRAPES 6- WATER
AVAILABLE 7- RECTAL PACK
CROSS-REFERENCE: 130.1115^B
1)= S ^SRF(DA(2),56,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),56,DA(1),1,"B",$E(X,1,30),DA)
130.11,16 LASER ON STANDBY 0;17 SET
Laser On Standby When Not In Use
'1' FOR YES;
'2' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if laser was placed in standby mode when not in active use for this case.
DESCRIPTION: This field is used to determine if the laser was placed in standby mode when inactive during
the case. Answer YES if laser was placed in standby mode
130.11,17 LASER OFF AND KEY SECURED 0;18 SET
Laser Off and Key Secured At End Of Use
'1' FOR YES;
'2' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if laser was turned off and the key secured after use for this case.
DESCRIPTION: This field is used to determine if the laser was turned off and the key secured after use for
this case. Answer Yes if laser was turned off and the key secured after use for this case.
130.11,18 PERSONNEL PRECAUTIONS 2;0 SET Multiple #130.1118
LAST EDITED: JUN 26, 2015
DESCRIPTION:
This is information related to the laser personnel safety precaution(s) used for this case.
130.1118,.01 PERSONNEL PRECAUTIONS 0;1 SET
Personnel Precautions
'1' FOR EYE SAFETY FILTER (MICROSCOPE);
'2' FOR HIGH FILTRATION MASKS;
'3' FOR SAFETY GLASSES INSPECTED;
'4' FOR SAFETY GLASSES USED;
'5' FOR SIGNAGE ON DOORS WITH APPROPRIATE WAVE LENGTH;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Choose the laser personnel safety precaution(s) used for this case.
DESCRIPTION:
This is the laser personnel safety precautions used for this case.
CROSS-REFERENCE: 130.1118^B
1)= S ^SRF(DA(2),56,DA(1),2,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(2),56,DA(1),2,"B",$E(X,1,30),DA)
130.11,19 LASER COMMENTS 3;0 WORD-PROCESSING #130.1119
DESCRIPTION: This word-processing field contains comments about the use of this laser unit during this
procedure.
Laser Comments
LAST EDITED: MAY 30, 2015
HELP-PROMPT: Enter any comments related to the use of this laser performed.
130,136 SPINAL LEVEL 1.1;4 FREE TEXT
Spinal Level
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the spinal level of the planned procedure. Answer must be 1-50 characters in length.
DESCRIPTION:
This is the spinal level(s) of the planned procedure as free text, for example L1 or L1-L2.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,200 OPERATIONS THIS ADMISSION 200;51 NUMBER
Operations this Admission
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS" X=NYUK K NYUK
LAST EDITED: SEP 12, 1991
HELP-PROMPT: Enter the total number of operations prior to the index procedure for this hospital admission.
DESCRIPTION: This is the total number of surgical procedures, prior to the index or principal operation, which
required the patient to be taken to the operating room for any type of surgical intervention during
this hospital admission. Include all procedures whether or not they are part of the
inclusion/exclusion criteria.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,201 REDO PROCEDURE 200;53 SET
Redo Procedure (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: FEB 03, 1995
HELP-PROMPT: If this was a return to surgery to re-do a procedure, enter 'YES'.
DESCRIPTION: This determines whether the principal operative procedure was a reoperation in the same anatomic
location for the same purpose as the first operation regardless of the length of time from the
original surgical date.
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen limits selection to Phase III choices.
130,202 *CURRENT SMOKER 200;3 SET
*Current Smoker
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 12, 2011
HELP-PROMPT: Enter the code (YES or NO) describing the patient's status as a smoker prior to surgery.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Non-Cardiac Definition Revised (2006): If the patient has smoked cigarettes in the year prior to
admission for surgery enter YES. Do not include patients who smoke cigars or pipes or use chewing
tobacco.
130,202.1 PACK/YEARS 208;9 FREE TEXT
Pack/Year Cigarette History
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>200)!(X<0)!(X?.E1"."2N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Type a Number between 0 and 200, 1 Decimal Digit.
DESCRIPTION: Definition Revised (2004): If the patient has ever been a smoker, enter the total number of
pack/years of smoking for this patient. Pack-years are defined as the number of packs of cigarettes
smoked per day times the number of years the patient has smoked. If the patient has never been a
smoker, enter "0". If pack-years are >200, just enter 200. If smoking history cannot be determined,
enter "NS". The possible range for number of pack-years is 0 to 200. If the chart documents
differing values for pack year cigarette history, or ranges for either packs/day or number of years
patient has smoked, select the highest value documented, unless you are confident in a particular
documenter's assessment (e.g., preoperative anesthesia evaluation often includes a more accurate
assessment of this value because of the impact it may have on the patient's response to
anesthesia).
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,203 HISTORY OF COPD 200;11 SET
History of Severe COPD (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 12, 2015
HELP-PROMPT: Enter 'YES' if the patient has a defined condition of COPD.
DESCRIPTION: VASQIP Definition (2015): Chronic obstructive pulmonary disease (such as emphysema and/or chronic
bronchitis) resulting in any one or more of the following in the 30 days preoperative:
-Functional disability from COPD (e.g., dyspnea, inability to
perform ADLs)
-Hospitalization in the past for treatment of COPD
-Requires chronic bronchodilator therapy with oral or inhaled agents
-An FEV1 prior to bronchodilator treatment, of <75% of predicted on
pulmonary function testing
Do not include patients whose only pulmonary disease is acute asthma, an acute and chronic
inflammatory disease of the airways resulting in bronchospasm. Do not include patients with diffuse
interstitial fibrosis or sarcoidosis.
Choose from: Y YES N NO
130,204 VENTILATOR DEPENDENT 200;10 SET
Ventilator Dependent in 48 Hours Preceding Surgery
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient was dependent on a ventilator at any time within the 48 hours prior to
surgery.
DESCRIPTION: Definition Revised (2004): A preoperative patient requiring ventilator-assisted respirations at any
time during the 48 hours preceding surgery. This does not include the treatment of sleep apnea with
CPAP.
130,205 PRIOR MI 206;14 SET
Prior MI
'0' FOR NO;
'1' FOR YES, < OR EQUAL 7 DAYS PREOP;
'2' FOR YES, >7 DAYS AND <6 MONTHS PREOP;
'3' FOR UNKNOWN;
'4' FOR YES, >6 MONTHS PREOP;
'5' FOR UNKNOWN;
LAST EDITED: MAY 13, 2015
HELP-PROMPT: Enter the category that most accurately reflects the patient's most recent Myocardial Infarction.
DESCRIPTION: Definition Revised (2015): Indicate the patient's most recent history of myocardial infarction
within 6 months prior to surgery as diagnosed in his or her medical records. Select the one
appropriate response:
0. No 1. Yes, < or equal to 7 days prior to surgery 2. Yes, > 7 days and < 6 months prior to
surgery 4. Yes, > 6 months prior to surgery 5. Unknown
SCREEN: S DIC("S")="I Y'=3"
EXPLANATION: Screen prevents selection of retired codes.
130,206 VASCULAR (Y/N) 200;40 SET
Vascular (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if the patient has any vascular problems or disease.
DESCRIPTION: This determines whether the patient has any vascular problems.
130,207 *CONGESTIVE HEART FAILURE 206;19 SET
*Congestive Heart Failure
'N' FOR NONE;
'I' FOR CARDIAC DISEASE, NO SYMPTOMS;
'II' FOR SLIGHT LIMITATION;
'III' FOR MARKED LIMITATION;
'IV' FOR SYMPTOMS AT REST;
'U' FOR UNKNOWN;
LAST EDITED: JUN 22, 2015
HELP-PROMPT: Enter the NYHA Class associated with the severity of Congestive Heart Failure in the 30 days
preceding surgery.
DESCRIPTION: Definition Revised (2014): The New York Heart Association (NYHA) functional classification is used
as a subjective assessment of the severity of congestive heart failure. Indicate whether the
patient has congestive heart failure if the patient chart or patient self-report indicates a
history of congestive heart failure or any mention of symptomatic manifestations in the NYHA
Classification within the 30 days before surgery. Indicate the one most appropriate response:
None - no congestive heart failure. Class I - cardiac disease, no symptoms of abnormal fatigue,
dyspnea,
or angina. Class II - slight limitation of physical activity by fatigue, dyspnea,
or angina. The patient gets unusual fatigue, dyspnea, and/or
angina only upon performing more strenuous activities, such as
climbing two or more flights of stairs without stopping. Class III - marked limitation of
physical activity by fatigue, dyspnea,
or angina. The patient gets unusual fatigue, dyspnea, and/or
angina upon performing ordinary activities, such as walking
several blocks or climbing a flight of stairs. Class IV - symptoms at rest and/or inability
to carry out any
physical activity without symptoms of fatigue, dyspnea or angina.
The patient has symptoms of unusual fatigue, dyspnea, and/or
angina at rest or when performing minimal activity, such as
walking across the room. Unknown - Unknown
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,208 *HYPERTENSION REQUIRING MEDS 200;36 SET
*Hypertension Requiring Medication (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 16, 2014
HELP-PROMPT: Enter 'YES' if the patient has a history of hypertension requiring medications.
DESCRIPTION: Definition Revised (2004): The patient has a persistent elevation of systolic blood pressure >140
mm Hg or a diastolic blood pressure >90 mm Hg or requires an antihypertensive treatment (e.g.,
diuretics, beta blockers, ACE inhibitors, calcium channel blockers) at the time the patient is
being considered as a candidate for surgery which should be no longer than 30 days prior to
surgery. Hypertension must be documented in the patient's chart.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,209 CARDIOMEGALY 206;6 SET
Cardiomegaly on Chest X-Ray (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 20, 2004
HELP-PROMPT: Enter 'YES' if there is cardiac enlargement on chest x-ray.
DESCRIPTION: Definition Revised (2004): Indicate if the patient has generalized cardiac enlargement of any or
all of the cardiac chambers by standard or portable chest x-ray within 30 days preceding surgery.
130,210 CENTRAL NERVOUS SYSTEM (Y/N) 200;18 SET
Central Nervous System (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if this patient has a history of illnesses related to the central nervous system.
DESCRIPTION: This determines whether the patient has a history of illness related to the central nervous system
(CNS).
130,211 CURRENTLY ON DIALYSIS 200;39 SET
Currently Requiring or On Dialysis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 17, 2006
HELP-PROMPT: Enter YES if the patient is currently on dialysis.
DESCRIPTION: Definition Revised (2006): Acute or chronic renal failure requiring periodic peritoneal dialysis,
hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration within 2 weeks prior to
surgery.
130,212 ASCITES 200;15 SET
Ascites Within 30 Days Prior to Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient has the presence of fluid accumulation in the peritoneal cavity.
DESCRIPTION: VASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the
peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within
30 days prior to the operation. Documentation should state a history of or active liver disease
(e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider
telangiectasia).
130,213 ESOPHAGEAL VARICES 200;16 SET
Esophageal Varices (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 06, 2015
HELP-PROMPT: Enter 'YES' if this patient has esophageal varices.
DESCRIPTION: Definition Revised (2015): Esophageal varices are engorged collateral veins in the esophagus that
bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in
portal pressure results in esophageal varices that are most frequently demonstrated by direct
visualization at esophagoscopy. Esophageal varices must be present preoperatively and must be
documented on a recent EGD, MRI or CT scan performed within 6 months prior to the surgical
procedure.
Choose from: Y- YES N- NO NS- NO STUDY
130,214 PGY OF PRIMARY SURGEON 200;52 NUMBER
PGY of Primary Surgeon ('0' for Staff Surgeon)
INPUT TRANSFORM: K:+X'=X!(X>12)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAR 12, 2004
HELP-PROMPT: Enter the post graduate year of the surgeon, or '0' for a staff surgeon.
DESCRIPTION: Definition Revised (2004): Enter the number of surgical residency postgraduate years of the primary
surgeon (1-12). Enter 0 if the primary surgeon is a staff/attending surgeon and not a surgical
resident or fellow. PGYs greater than 12 should be reported as '12'.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,215 WEIGHT LOSS > 10% 200;48 SET
Weight Loss >10% in the 6 Months Prior to Surgery
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the body weight loss is more than 10% in the 6 months prior to surgery.
DESCRIPTION: Definition Revised (2007): A >10% decrease in body weight in the six month interval immediately
preceding surgery as manifested by serial weights in the chart, as reported by the patient, or as
evidenced by change in clothing size or severe cachexia. Exclude patients who have intentionally
lost weight as part of a weight reduction program.
130,216 BLEEDING DISORDERS 200;49 SET
Bleeding (Coagulation) Disorder
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter YES if the patient has a history of a bleeding disorder.
DESCRIPTION: VASQIP Definition (2014): Bleeding (coagulation) disorder is a condition that places the patient at
risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K
deficiency, hemophilia, von Willebrand disease). Answer YES if the patient has a documented
bleeding (coagulation) disorder that is either chronic or acute.
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,217 TRANSFUSION > 4 RBC UNITS 200;50 SET
Transfusion >4 RBC Units Within 72 Hrs Prior to Surgery
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient required a transfusion of more than 4 units in 72 hours prior to surgery.
DESCRIPTION: Definition Revised (2004): Preoperative loss of blood necessitating a minimum of 5 units of whole
blood/packed red cells transfused during the 72 hours prior to surgery including any blood
transfused in the emergency room.
130,218 OPEN WOUND 200;46 SET
Open Wound With or Without Infection (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has an open wound with or without infection.
DESCRIPTION: Definition Revised (2007): Evidence of an open wound that communicates to the air by direct
exposure, with or without cellulitis or purulent exudate. This does not include osteomyelitis or
localized abscesses. The wound must communicate to the air by direct exposure. Report mandible
fractures under this preoperative variable.
130,218.1 PREOPERATIVE SEPSIS 206;8 SET
Preoperative Sepsis in the 48 Hours Prior to Surgery
'Y' FOR YES;
'N' FOR NONE;
'1' FOR SIRS;
'2' FOR SEPSIS;
'3' FOR SEPTIC SHOCK;
'NS' FOR NO STUDY;
LAST EDITED: JAN 09, 2014
HELP-PROMPT: Enter the patient's septic status in the 48 hours prior to surgery.
DESCRIPTION: Definition Revised (2014): 2. Sepsis is the systematic response to infection.
Answer YES if both of the following criteria are met:
a) Clinical documentation of infection (such as wound with
purulent drainage, ruptured bowel with free air, etc.); or a
positive culture from any site thought to be causative; or
specialized laboratory evidence of causative infection (such
as viral DNA in blood).
AND
b) The presence of two or more of the following systemic responses:
- Temperature > 38 degrees C or < 36 degrees C
- HR > 90 beats/minute
- RR > 20 breaths /minute or PaCO2 < 32 mmHg
- WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature
neutrophils ("bands")
3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it
is associated with organ and/or circulatory dysfunction.
Terminology such as Severe Sepsis/Septic Shock/Refractory Septic
Shock and Multiple Organ Dysfunction Syndrome (MODS) all fall
into this category.
Answer YES if the definition of SEPSIS is present AND there is
documented organ and/or circulatory dysfunction defined by one or
more of the following:
- Areas of acutely mottled skin not related to peripheral vascular
disease
- Capillary refilling requires three seconds or longer not
related to peripheral vascular disease
- Urine output <0.5 mL/kg for at least one hour, or renal
replacement therapy
- Lactate >2 mmol/L
- Abrupt change in mental status
- Abnormal EEG findings
- Platelet count < 100,000 platelets/mL
- Disseminated intravascular coagulation (DIC)
- Acute lung injury or acute respiratory distress syndrome (ARDS)
- New cardiac dysfunction as defined by ECHO or direct measurement
of the cardiac index
- An arterial systolic blood pressure (SBP) of <=90 mm Hg or a mean
arterial pressure (MAP) <=70 mm Hg for at least 1 hour despite
adequate fluid resuscitation, adequate intravascular volume
status, or the need for vasopressors to maintain SBP >= 90 mm
Hg or MAP >=70 mm Hg.
SCREEN: S DIC("S")="I ""N23""[Y"
EXPLANATION: Screen prevents selection of retired codes.
130,219 PREOPERATIVE HEMOGLOBIN 201;20 FREE TEXT
Preoperative Hemoglobin (g/dl)
INPUT TRANSFORM: K:$L(X)>7!($L(X)<1) X I $D(X) S SRCICSP=1 D NUM^SROAL21
LAST EDITED: APR 15, 2011
HELP-PROMPT: Your answer must be 1-7 characters in length.
DESCRIPTION: Definition Revised (2004): Indicate the patient's hemoglobin result (g/dl) preoperatively evaluated
closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No
Study/Unknown" is not allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,220 *PREVIOUS PCI 200;32 SET
*Previous PCI (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 15, 2014
HELP-PROMPT: Enter 'Y' if this patient has undergone a percutaneous coronary intervention (PCI).
DESCRIPTION: Definition Revised (2007): The patient has undergone or has had an attempt at percutaneous coronary
intervention at any time. This includes either balloon dilatation or stent placement. This does not
include valvuloplasty procedures.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,221 PREOPERATIVE CPK 201;6 NUMBER
Preoperative CPK (U/L)
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>6000)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the result of the preoperative CPK test. Your answer should be between 0 and 6000.
DESCRIPTION: This is the result of the preoperative creatinine phosphokinase (CPK) test.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,222 PREOPERATIVE MB BAND 201;7 NUMBER
Preoperative MB Band
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the result of the preoperative MB band.
DESCRIPTION: This is the value of the preoperative methyline blue (MB) band. Your answer must be between 0 and
50.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,223 PREOPERATIVE SERUM CREATININE 201;4 FREE TEXT
Preoperative Serum Creatinine (mg/dl)
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) N SRCICSP S SRCICSP=1 D NUM^SROAL21
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: Definition Revised (2011): This is the serum creatinine result (mg/dl) most closely preceding
surgery - not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters
in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS"
for "No Study" is allowed for non-cardiac case assessments.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,224 PREOPERATIVE BUN 201;5 FREE TEXT
Preoperative BUN (mg/dl)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 09, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative Blood Urea Nitrogen (BUN) test. Data input must be 1 to 5
numeric characters in length which may include a prefix of a less than or greater than sign "<" or
">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,225 PREOPERATIVE SERUM ALBUMIN 201;8 FREE TEXT
Preoperative Serum Albumin (g/dl)
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JAN 19, 2011
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: Definition Revised (2011): This is the serum albumin result (g/dl) most closely preceding surgery -
not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters in length
which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No
Study" is allowed for non-cardiac case assessments.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,226 PREOPERATIVE SGPT 201;10 NUMBER
Preoperative SGPT (mU/ml)
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>1000)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the result of the preoperative SGPT test. Your answer should be between 0 and 1000.
DESCRIPTION: This is the result of the preoperative serum glutamic pyruvic transaminase (SGPT) test.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,227 PREOPERATIVE SGOT 201;11 FREE TEXT
Preoperative SGOT (mU/ml)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative serum glutamic oxaloacetic (SGOT) test. Data input must be 1
to 5 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,228 PREOPERATIVE TOTAL BILIRUBIN 201;9 FREE TEXT
Preoperative Total Bilirubin (mg/dl)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative total bilirubin test. Data input must be 1 to 5 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,229 PREOPERATIVE ALK PHOSPHATASE 201;12 FREE TEXT
Preoperative Alkaline Phosphatase (mU/ml)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative alkaline phosphatase test. Data input must be 1 to 5
numeric characters in length which may include a prefix of a less than or greater than sign "<" or
">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,230 PREOPERATIVE WBC 201;13 FREE TEXT
Preoperative WBC (X 1000/mm3)
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the result of the preoperative white blood count (WBC). Data input must be 1 to 4 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,231 PREOPERATIVE PLATELET COUNT 201;15 FREE TEXT
Preoperative Platelet Count (X 1000/mm3)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative platelet count. Data input must be 1 to 5 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,232 PREOPERATIVE PT 201;17 FREE TEXT
Preoperative PT (seconds)
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the result of the preoperative prothombin time (PT). Data input must be 1 to 4 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,233 PREOPERATIVE PTT 201;16 FREE TEXT
Preoperative PTT (seconds)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative partial thromboplastin time (PTT). Data input must be 1 to 5
numeric characters in length which may include a prefix of a less than or greater than sign "<" or
">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,234 PREOPERATIVE HEMATOCRIT 201;14 FREE TEXT
Preoperative Hematocrit
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the result of the preoperative hematocrit test. Data input must be 1 to 4 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,235 ASSESSMENT STATUS RA;1 SET
Assessment Status
'I' FOR INCOMPLETE;
'C' FOR COMPLETE;
'T' FOR TRANSMITTED;
'N' FOR NO ASSESSMENT;
LAST EDITED: MAR 10, 2017
HELP-PROMPT: Enter the current status of this surgery risk assessment.
DESCRIPTION: This is the current status of the surgery risk assessment. When creating a new assessment, the
status will automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this
field will be updated to 'COMPLETED'. After the assessment is transmitted, this field will be
automatically updated to 'TRANSMITTED'.
RECORD INDEXES: ARS (#1418)
130,236 HEIGHT 206;1 FREE TEXT
Patient's Height
INPUT TRANSFORM: K:+X>300!(+X<0) X D H^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y["C":+Y_" CENTIMETERS",+Y:Y_" INCHES",1:Y)
LAST EDITED: JUN 29, 2010
HELP-PROMPT: Enter the patient's height.
DESCRIPTION: VASQIP Definition (2010): Height: Report the patient's most recent height before surgery documented
in the medical record in either inches (25 to 86 in) or centimeters (63 to 218 cm). If you are
entering the patient's height in centimeters, enter 'C' after the number of centimeters.
Your answer should be in one of the following two formats.
68 (representing inches)
173C (representing centimeters)
The software pulls the most recent height measurement, regardless of when it was taken. The date of
the measurement returned by the capture process is displayed on the data input screen.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^130^236.1
1)= Q
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,7),X=X
S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,7)=DIV,DIH=130,DIG=236.1 D ^D
ICR
CREATE VALUE)= NO EFFECT
DELETE VALUE)= @
FIELD)= HEIGHT MEASUREMENT DATE
130,236.1 HEIGHT MEASUREMENT DATE 200.1;7 DATE
Date of Height Measurement
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 27, 2007
HELP-PROMPT: Enter the date of the height measurement.
DESCRIPTION:
This is the date of the patient's height measurement. This date is taken from the VITALS software.
NOTES: TRIGGERED by the HEIGHT field of the SURGERY File
130,237 WEIGHT 206;2 FREE TEXT
Patient's Weight
INPUT TRANSFORM: K:+X>999!(+X<0) X D W^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y["K":+Y_" KILOGRAMS",+Y:Y_" LBS.",1:Y)
LAST EDITED: JUL 09, 2010
HELP-PROMPT: Enter the patient's weight most closely preceding surgery.
DESCRIPTION: VASQIP Definition (2010): Weight: Report the patient's most recent weight before surgery documented
in the medical record in either pounds (50 to 999 lbs) or kilograms (23 to 453 kg). If you are
entering the patient's weight in kilograms, enter 'K' after the number of kilograms. The software
pulls the latest value up to 30 days prior to surgery. If no value is found in the Vitals software,
the nurse reviewer must enter the value manually.
Your answer should be in one of the following formats.
178 (weight in pounds)
80K (weight in Kilograms)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,237.1 PREOPERATIVE SLEEP APNEA 200.1;8 SET
Preoperative Sleep Apnea
'1' FOR NONE - LEVEL 1;
'2' FOR SUSPICION OF SLEEP APNEA - LEVEL 2;
'3' FOR SLEEP APNEA CONFIRMED - LEVEL 3;
OUTPUT TRANSFORM: S Y=$S(Y=1:"LEVEL 1",Y=2:"LEVEL 2",Y=3:"LEVEL 3",1:"")
LAST EDITED: JAN 17, 2014
HELP-PROMPT: Identify whether the Patient has sleep apnea preoperatively.
DESCRIPTION: VASQIP Definition (2014): Sleep Apnea is a disorder of respiration whereby the individual has
hypoxic and/or apneic periods during sleep due to prolapse or flaccidity of oropharyngeal
structures, which improves with positive airway pressure (i.e., CPAP or BIPAP). Select one of the
following categories that best indicates the patient's level of sleep apnea.
Level 1 = None: No diagnosis or suspicion of Sleep Apnea Level 2 = Suspicion of Sleep Apnea: No
sleep study has been done,
however the patient has TWO or MORE of the following risk
factors for Sleep Apnea:
a) Obesity (BMI > 35)
b) Thick neck (men > 17 inches, women > 16 inches)
c) Snoring, loud or frequent
d) Observed apneas (partner/roommate reported observing
obstruction episodes during sleep)
e) Frequent arousals from sleep or choking during sleep
f) Daytime somnolence
g) Patient reports diagnosis of sleep apnea even if sleep
study results are not in the medical record Level 3 = Sleep Apnea: Sleep apnea
confirmed by Sleep Study OR
patient currently uses CPAP/BIPAP at home.
Answer Options:
- None
- Suspicion of Sleep Apnea
- Sleep Apnea Confirmed
130,238 DNR STATUS 200;7 SET
DNR Status (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient has requested not to be resuscitated.
DESCRIPTION: Definition Revised (2004): If the patient has had a Do-Not-Resuscitate (DNR) order written in the
physician's order sheet of the patient's chart and it has been signed or co-signed by an attending
physician [this is the only condition under which a DNR order is official in the VA in the 30 days
prior to this surgery], enter "YES". If the DNR order as defined above was rescinded immediately
prior to surgery in order to operate on the patient, enter "YES". Answer "NO" if DNR discussions
are documented in the progress note, but no official DNR order has been written in the physician
order sheet or if the attending physician has not signed the official order.
130,239 PREOPERATIVE HEMOGLOBIN, DATE 202;20 DATE
Date Preoperative Hemoglobin was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date preop Hemoglobin was performed.
DESCRIPTION:
This is the date that the preoperative hemoglobin test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,240 *FUNCTIONAL HEALTH STATUS 200;8 SET
*Functional status
'1' FOR INDEPENDENT;
'2' FOR PARTIALLY DEPENDENT;
'3' FOR TOTALLY DEPENDENT;
'4' FOR UNKNOWN;
LAST EDITED: JUN 24, 2015
HELP-PROMPT: Enter the level of self care that summarizes the patient's status prior to surgery.
DESCRIPTION: VASQIP Definition (2011): This is a question that focuses on the patient's abilities to perform
activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are
defined as 'the activities usually performed in the course of a normal day in a person's life'.
ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level
of self-care for activities of daily living demonstrated by this patient at the time the patient is
being considered as a candidate for surgery (which should be no longer than 30 days prior to
surgery). If the patient's status changes prior to surgery, that change should be reflected in your
assessment. For this time point, report the level of functional health status as defined by the
following criteria.
(1) Independent: The patient does not require assistance from another person for any activities of
daily living. This includes a person who is able to function independently with prosthetics,
equipment, or devices.
(2) Partially dependent: The patient requires some assistance from another person for activities
of daily living. This includes a person who utilizes prosthetics, equipment, or devices but still
requires some assistance from another person for ADLs.
(3) Totally dependent: The patient requires total assistance for all activities of daily living.
(4) Unknown: If unable to ascertain the functional status.
All patients with psychiatric illnesses should be evaluated for their ability to function with or
without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with
schizophrenia is able to care for him/herself without the assistance of nursing care, he/she is
considered independent.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,241 PULMONARY (Y/N) 200;9 SET
Pulmonary (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if this patient has a history of pulmonary illnesses.
DESCRIPTION:
This determines whether the patient has a history of pulmonary illnesses.
130,242 CARDIAC (Y/N) 200;30 SET
Cardiac (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if this patient has a history of cardiac illnesses.
DESCRIPTION: This determines whether the patient has a history of cardiac illnesses.
130,243 RENAL (Y/N) 200;37 SET
Renal (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if this patient has a history of renal illnesses.
DESCRIPTION: This determines whether the patient has a history of renal illnesses.
130,244 HEPATOBILIARY (Y/N) 200;13 SET
Hepatobiliary (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 22, 1991
HELP-PROMPT: Enter 'YES' if this patient has a history of hepatobiliary illnesses.
DESCRIPTION: This determines whether the patient has a history of hepatobiliary illnesses.
130,245 NUTRITIONAL/IMMUNE/OTHER 200;44 SET
Nutritional/Immune/Other (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has a history of general/nutritional/immune illness.
DESCRIPTION: This determines whether the patient has a history of illness related to nutrition, immune
deficiencies or other general deficiencies.
130,246 ETOH > 2 DRINKS/DAY 200;4 SET
ETOH >2 Drinks Per Day in the Two Weeks Prior to Admission
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient admits to having greater than two drinks per day within the two weeks
prior to admission.
DESCRIPTION: Definition Revised (2004): The patient admits to drinking >2 ounces of hard liquor or more than two
12 oz. cans of beer or more than two 6 oz. glasses of wine per day in the two weeks prior to
admission. If the patient is a "binge drinker" divide out the numbers of drinks during the binge by
seven days, and then apply the definition.
130,247 LENGTH OF POST-OP STAY 205;1 FREE TEXT
Length of Postoperative Hospital Stay
INPUT TRANSFORM: S:X="NA"!(X="na") X="NA" Q:X="NA" K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 28, 2004
HELP-PROMPT: Enter the total number of days this patient remained in the hospital after his or her operation.
Enter NA if LENGTH OF POST-OP STAY is not applicable.
DESCRIPTION: Definition Revised (2004): The software will automatically calculate the total number of days that
the patient stayed in the acute care services of the medical center. The number of days should
include the day after surgery and the date of discharge or transfer to intermediate or chronic care
facilities.
Enter NA if LENGTH OF POST-OP STAY is not applicable.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,248 SUPERFICIAL INCISIONAL SSI 205;6 SET
Superficial Incisional Surgical Site Infection (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if this patient had a superficial incisional surgical site infection.
DESCRIPTION: Definition Revised (2004): Superficial incisional SSI is an infection that occurs within 30 days
after the operation and infection involves only skin or subcutaneous tissue of the incision and at
least one of the following:
- Purulent drainage, with or without laboratory confirmation, from the
superficial incision.
- Organisms isolated from an aseptically obtained culture of fluid or
tissue from the superficial incision.
- At least one of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, or heat and superficial
incision is deliberately opened by the surgeon, unless incision is
culture-negative.
- Diagnosis of superficial incisional SSI by the surgeon or attending
physician.
Do not report the following conditions as SSI:
- Stitch abscess (minimal inflammation and discharge confined to the
points of suture penetration).
- Infected burn wound.
- Incisional SSI that extends into the fascial and muscle layers (see
deep incisional SSI).
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,249 DEEP INCISIONAL SSI 205;7 SET
Deep Incisional Surgical Site Infection (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 13, 2015
HELP-PROMPT: Enter YES if this patient had a deep incisional surgical site infection.
DESCRIPTION: Definition Revised (2015): Deep Incisional SSI is an infection that occurs within 30 days after the
operation and the infection appears to be related to the operation and infection involved deep soft
tissues (e.g., fascial and muscle layers) of the incision and at least one of the following:
- Purulent drainage from the deep incision but not from the
organ/space component of the surgical site.
- A deep incision spontaneously dehisces or is deliberately opened by
a surgeon when the patient has at least one of the following signs
or symptoms: fever (>38 C), localized pain, or tenderness, unless
site is culture-negative.
- An abscess or other evidence of infection involving the deep
incision is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
- Diagnosis of a deep incision SSI by a surgeon or attending
physician.
NOTE: Please consult with the operating surgeon for assignment of organ/space vs. deep wound
infection occurrences.
130,250 SYSTEMIC SEPSIS 205;35 SET
Systemic Sepsis
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has been diagnosed as having postoperative systemic sepsis.
DESCRIPTION: Definition Revised (2007): Sepsis is a vast clinical entity that takes a variety of forms. The
spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. Please
report the most significant level using the criteria below:
1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has
clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of
severe clinical insults. This syndrome is clinically recognized by the presence of two or more of
the following:
- Temp >38 degrees C or <36 degrees C
- HR >90 bpm
- RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa)
- WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band)
forms
- Anion gap acidosis: this is defined by either:
[Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is
greater than 16, then an anion gap acidosis is present.
or
Na - [Cl + HCO3 (or serum CO2)]. If this number is greater
than 12, then an anion gap acidosis is present.
and one of the following:
- positive blood culture
- clinical documentation of purulence or positive culture from any
site thought to be causative
2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or
circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of
SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction
include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of
circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents.
* For the patient that had sepsis preoperatively, worsening of any of the above signs
postoperatively would be reported as a postoperative sepsis.
Examples:
A patient comes into the emergency room with signs of sepsis - WBC 31, Temperature 104. CT shows an
abdominal abscess. He is given antibiotics and is then taken emergently to the OR to drain the
abscess. He receives antibiotics intraoperatively. Postoperatively his WBC and Temperature are
trending down.
POD#1 WBC 24, Temp 102
POD#2 WBC 14, Temp 100
POD#3 WBC 10, Temp 99 This patient does not have postoperative sepsis as his WBC and Temperature
are improving each postoperative day.
Patient comes into the ER with s/s of sepsis - WBC 31, Temp 104. CT shows an abdominal abscess. He
is given antibiotics and is taken emergently to the OR to drain the abscess. He receives
antibiotics intraoperatively. Postoperatively his WBC and Temp are as follows:
POD#1 WBC 28, Temp 103
POD#2 WBC 24, Temp 102.6
POD#3 WBC 22, Temp 102
POD#4 WBC 21, Temp 101.6
POD#5 WBC 30, Temp 104 This patient does have postoperative sepsis because on postoperative day
#5, his WBC and Temperature increase. The patient is having worsening of the defined signs of
sepsis.
130,251 PNEUMONIA 205;10 SET
Pneumonia (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 18, 2004
HELP-PROMPT: Enter YES if the patient has a postoperative occurrence of pneumonia.
DESCRIPTION: Definition Revised (2007): Inflammation of the lungs caused primarily by bacteria, viruses, and/or
chemical irritants, usually manifested by chills, fever, pain in the chest, cough, purulent, bloody
sputum. Enter YES if the patient has pneumonia meeting the definition of pneumonia below AND
pneumonia not present preoperatively.
Pneumonia must meet one of the following TWO criteria:
Criterion 1.
Rales or dullness to percussion on physical examination of chest AND
any of the following:
a. New onset of purulent sputum or change in character of sputum
b. Organism isolate from blood culture
c. Isolation of pathogen from specimen obtained by transtracheal
aspirate, bronchial brushing, or biopsy
OR
Criterion 2.
Chest radiographic examination shows new or progressive infiltrate,
consolidation, cavitation, or pleural effusion AND any of the
following:
a. New onset of purulent sputum or change in character of sputum
b. Organism isolated from blood culture
c. Isolation of pathogen from specimen obtained by transtracheal
aspirate, bronchial brushing, or biopsy
d. Isolation of virus or detection of viral antigen in respiratory
secretions
e. Diagnostic single antibody titer (IgM) or fourfold increase in
paired serum samples (IgG) for pathogen
f. Histopathologic evidence of pneumonia
*If pneumonia was present preoperatively and resolved postoperatively and a new pneumonia is
identified within 30 days after surgery, the following criteria must be met in order to report as a
postoperative pneumonia occurrence:
- Patient must have completed the antibiotic course for the
previous pneumonia.
- Patient must have evidence of a clear chest x-ray after the
previous pneumonia and prior to the new pneumonia.
- There must be evidence of a new isolate of micro-organism on
culture.
130,252 PULMONARY EMBOLISM 205;12 SET
Pulmonary Embolism (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has had a postoperative pulmonary embolism.
DESCRIPTION: Definition Revised (2007): Lodging of a blood clot in a pulmonary artery with subsequent
obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep
leg veins or the pelvic venous system. Enter "YES" if the patient has a V-Q scan interpreted as
high probability of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram
or positive Spiral CT exam. Treatment usually consists of:
- Initiation of anticoagulation therapy
- Placement of mechanical interruption (e.g. Greenfield Filter), for
patients in whom anticoagulation is contraindicated or already
instituted.
130,253 OTHER RESPIRATORY OCCURRENCE 205;14 POINTER TO ICD DIAGNOSIS FILE (#80)
Other Respiratory Occurrence (ICD Diagnosis)
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",$G(DA))
OUTPUT TRANSFORM: I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
LAST EDITED: MAR 18, 2013
HELP-PROMPT: Enter the ICD Diagnosis code related to the postoperative respiratory occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other respiratory occurrences that you feel to be significant
and that are not covered by the predefined respiratory occurrence categories. Enter the ICD-CM code
for this entry.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,254 ACUTE RENAL FAILURE 205;17 SET
Acute Renal Failure Requiring Dialysis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 08, 2011
HELP-PROMPT: Enter YES if the patient has acute renal failure.
DESCRIPTION: 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.
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,255 URINARY TRACT INFECTION 205;18 SET
Urinary Tract Infection (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has a postoperative urinary tract infection.
DESCRIPTION: Definition Revised (2004): Postoperative symptomatic urinary tract infection must meet one of the
following TWO criteria:
1. One of the following: fever (>38 degrees C), urgency, frequency,
dysuria, or suprapubic tenderness AND a urine culture of >100,000
colonies/ml urine with no more than two species of organisms
OR
2. Two of the following: fever (>38 degrees C), urgency, frequency,
dysuria, or suprapubic tenderness AND any of the following:
- Dipstick test positive for leukocyte esterase and/or nitrate
- Pyuria (>10 WBCs/cc or >3 WBC/hpf of unspun urine)
- Organisms seen on Gram stain of unspun urine
- Two urine cultures with repeated isolation of the same uropathogen
with >100 colonies/ml urine in non-voided specimen
- Urine culture with <100,000 colonies/ml urine of single
uropathogen in patient being treated with appropriate
antimicrobial therapy
- Physician's diagnosis
- Physician institutes appropriate antimicrobial therapy
130,256 STROKE/CVA 205;21 SET
Stroke/CVA
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 22, 2011
HELP-PROMPT: Enter status of Stroke/CVA.
DESCRIPTION: VASQIP Definitions (2011): Indicate if the patient developed a new neurologic deficit with onset
immediately post-operatively or occurring within the 30 days after surgery. Neurologic deficits
are defined as an embolic, thrombotic, or hemorrhagic vascular accident or stroke with motor,
sensory, or cognitive dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit,
impaired memory).
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,257 POSTOP BLEEDING/TRANSFUSIONS 205;32 SET
Bleeding Requiring >4 Units RBCs or WB Transfused in 72 hrs Postop (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient had bleeding requiring >4 units PRBC's or whole blood within 72 hours
postoperatively.
DESCRIPTION: Definition Revised (2004): Any transfusion (including autologous) of packed red blood cells or
whole blood given from the time the patient leaves the operating room up to and including 72 hours
postoperatively. Enter YES for five or more units of packed red blood cell units in the
postoperative period including hanging blood from the OR that is finished outside of the OR. If
the patient receives shed blood, autologous blood, cell saver blood or pleurovac postoperatively,
this is counted if greater than four units. The blood may be given for any reason.
130,258 MYOCARDIAL INFARCTION 205;27 SET
Myocardial Infarction (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 09, 2014
HELP-PROMPT: Enter YES if the patient has had a myocardial infarction.
DESCRIPTION: VASQIP Definition (2014): Indicate the presence of a peri-operative MI that occurs either
intraoperatively or postoperatively within 30 days: The term acute MI should be used when there
is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia.
Under these conditions any ONE of the following criteria meets the diagnosis for MI:
1. Detection of a rise and/or fall of cardiac biomarker values
[preferably cardiac troponin (cTn)] with at least one value above
the 99th percentile Upper Reference Limit (URL) AND at least one
of the following:
a. Symptoms suggestive of myocardial ischemia
b. New or presumed new significant ST-segment-T wave (ST-T) changes
c. New left bundle branch block (LBBB).
d. Development of pathological Q waves in the ECG
e. Imaging evidence of new loss of viable myocardium
f. New regional wall motion abnormality
g. Identification of an intracoronary thrombus by angiography or
autopsy 2. Cardiac death with symptoms suggestive of myocardial ischemia and
presumed new ischemic ECG changes or new LBBB, but death occurred
before cardiac biomarkers were obtained, or before cardiac
biomarker values would be increased.
3. Percutaneous coronary intervention (PCI) related MI is arbitrarily
defined by elevation of cTn values (>5x 99th percentile URL) in
patients with normal baseline values (<99th percentile URL) or a
rise of cTn values >20% if the baseline values are elevated and
are stable or falling,
AND at least one of the following:
a. Symptoms suggestive of myocardial ischemia
b. Presumed new ischemic ECG changes
c. Angiographic findings consistent with a procedural complication
d. Imaging evidence of new loss of viable myocardium
e. New regional wall motion abnormality
4. Stent thrombosis associated with MI when detected by coronary
angiography or autopsy in the setting of myocardial ischemia and
with a rise and/or fall of cardiac biomarker values with at least
one value above the 99th percentile URL.
5. Coronary artery bypass grafting (CABG) related MI is arbitrarily
defined by elevation of cardiac biomarker values (>10x 99th
percentile URL) in patients with normal baseline cTn values
(<99th percentile URL),
AND at least one of the following
a. Development of pathological Q waves in the ECG
b. New LBBB
c. Angiographic documented new graft or new native coronary
artery occlusion
d. Imaging evidence of new loss of viable myocardium
e. New regional wall motion abnormality
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,259 PULMONARY EDEMA 205;28 SET
Pulmonary Edema Requiring IV Diuretic Therapy (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has postoperative pulmonary edema requiring IV diuretic therapy.
DESCRIPTION: This determines whether the patient has developed postoperative distress requiring treatment and
diagnosis of CHF or pulmonary edema or Adult Respiratory Distress Syndrome.
130,260 DATE TRANSMITTED RA;4 DATE
Date Transmitted
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 05, 2007
HELP-PROMPT: Enter the Date that this Assessment was transmitted.
DESCRIPTION: This is the date (or date/time) that this surgery risk assessment was transmitted.
CROSS-REFERENCE: 130^AT1^MUMPS
1)= D AT1^SROXR4
2)= D KAT1^SROXR4
This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases
by the DATE TRANSMITTED field.
130,260.1 DATE OF LAST TRANSMISSION RA;8 DATE
Last Transmission Date
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: NOV 05, 2007
DESCRIPTION: This is the date of the retransmission if this risk assessment has been retransmitted to the
national database. An assessment can be updated and retransmitted within 14 days of the original
transmission date. If there was no retransmission of this assessment, this is the date of the
original transmission.
CROSS-REFERENCE: 130^AT^MUMPS
1)= D AT^SROXR4
2)= D KAT^SROXR4
This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases
by the DATE OF LAST TRANSMISSION field.
130,261 GRAFT/PROSTHESIS/FLAP FAILURE 205;33 SET
Graft/Prosthesis/Flap Failure (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter YES if the patient has had a postoperative graft, flap, or prosthesis failure.
DESCRIPTION: Definition Revised (2015): An extracardiac graft (including myocutaneous flaps or skin grafts) or
prosthesis (including stents, mesh) is considered to have failed when it requires additional
intervention via return to the operating room or interventional radiology. Failures include those
caused by an infectious process or a mechanical issue.
130,262 RETURN TO OR WITHIN 30 DAYS 205;4 SET
Return to OR within 30 Days of Index Procedure (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient had a return to the operating room within 30 days of this surgery.
DESCRIPTION: Definition Revised (2004): Returns to the operating room include all surgical procedures that
required the patient to be taken to the surgical operating room for intervention of any kind will
automatically be entered by the software.
130,263 DVT/THROMBOPHLEBITIS 205;34 SET
Deep Vein Thrombosis (DVT)/Thrombophlebitis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 07, 2014
HELP-PROMPT: Enter YES if the patient has postoperative DVT/Thrombophlebitis.
DESCRIPTION: VASQIP Definition (2014): The identification of a new blood clot or thrombus within the deep venous
system of an extremity, which may be coupled with inflammation. This does not include
intra-parenchymal clots of solid organs or free intra-peritoneal clots. This diagnosis is confirmed
by a duplex, venogram, CT scan or other imaging modality. The patient must be treated with or have
documented recommendation for: therapeutic anti-coagulation therapy OR placement of a vena cava
filter OR clipping of the vena cava.
130,264 *CEREBRAL VASCULAR DISEASE 206;17 SET
*Cerebral Vascular Disease (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 18, 2011
HELP-PROMPT: Enter 'YES' if this patient has disease of the arteries to the head.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
This determines whether the patient has disease of the arteries to the head manifested by previous
stroke (cerebral vascular accident), and/or transient ischemic attack (TIA), and/or prior surgical
repair (e.g. carotid endarterectomy), and/or greater than or equal to 50% obstruction of luminal
diameter documented by contrast angiography or duplex ultrasound examination.
130,265 PERIPHERAL ARTERIAL DISEASE 206;16 SET
Peripheral Arterial Disease
'Y' FOR YES;
'N' FOR NO;
'1' FOR NO;
'2' FOR YES-W/O ANGI,REVASC,or AMPUT;
'3' FOR YES-W HX ANGI,REVASC,or AMPUT;
'4' FOR UNKNOWN;
LAST EDITED: MAY 12, 2015
HELP-PROMPT: Select appropriate response from 1 to 3.
DESCRIPTION: VASQIP Definition (2015): Indicate if the patient has peripheral arterial disease (previously
"peripheral vascular disease"), defined as disease of the arteries of the extremities. Peripheral
arterial disease, most commonly identified in the legs but on occasion in the arms, is manifested
by at least one of the following: exertional claudication, ischemic rest pain, ischemic ulcers or
gangrene, prior revascularization procedure(s) on vessels or amputation of one or more extremity
for arterial occlusive disease, absent or diminished pulses in legs, or invasive (i.e.
angiographic) or non-invasive (i.e. ultrasound) evidence of non-iatrogenic peripheral arterial
obstruction greater than or equal to 50% of luminal diameter.
Indicate the one appropriate response:
1. No
2. Yes, without angioplasty, revascularization, or amputation
procedure
3. Yes, with any history of angioplasty, or revascularization, or
amputation procedure, regardless of laterality
SCREEN: S DIC("S")="I ""123""[Y"
EXPLANATION: Screen prevents selection of inactive entries.
130,266 *PREVIOUS CARDIAC SURGERY 200;33 SET
*Previous Cardiac Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 08, 2014
HELP-PROMPT: Enter 'YES' if this patient has had a previous cardiac surgery.
DESCRIPTION: Definition Revised (2006): Any major cardiac surgical procedure (performed either as an 'off-pump'
repair or utilizing cardiopulmonary bypass). This includes coronary artery bypass graft surgery,
valve replacement or repair, repair of atrial or ventricular septal defects, great thoracic vessel
repair, cardiac transplant, left ventricular aneurysmectomy, insertion of left ventricular assist
devices, etc. Do not include pacemaker insertions or automatic implantable
cardioverter-defibrillator (AICD) insertions.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,267 ANGINA SEVERITY 206;18 SET
Angina Severity
'N' FOR NONE;
'I' FOR CLASS I;
'II' FOR CLASS II;
'III' FOR CLASS III;
'IV' FOR CLASS IV;
'U' FOR UNKNOWN;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the CCS classification associated with the severity of angina in the 14 days preceding
surgery.
DESCRIPTION: VASQIP Definition (2014): Indicate whether the patient has angina, defined as pain or discomfort
between the diaphragm and mandible resulting from myocardial ischemia, usually precipitated by
exertion or emotion and relieved by rest or nitroglycerin. The Canadian Cardiovascular Society
(CCS) classification is used to record severity of angina. Indicate the one appropriate response,
according to the most severe angina in the 30 days prior to surgery:
None - No angina Class I - Ordinary physical activity, such as walking or climbing
stairs does not cause angina. Angina may occur with
strenuous or rapid or prolonged exertion at work or
recreation. Class II - There is slight limitation of ordinary activity.
Angina may occur with walking or climbing stairs rapidly,
walking uphill, walking or stair climbing after meals or
in the cold, in the wind, or under emotional stress, or
walking more than two blocks on the level, or climbing more
than one flight of stairs under normal conditions at a
normal pace. Class III - There is marked limitation of ordinary physical activity.
Angina may occur after walking one or two blocks on the
level or climbing one flight of stairs under normal
conditions at a normal pace. Class IV - There is inability to carry on any physical
activity
without discomfort. Angina may be present at rest. Unknown - Unknown
130,268 HEPATOMEGALY 200;14 SET
Presence of Hepatomegaly (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 19, 1991
HELP-PROMPT: Enter 'YES' if the physician has noted the presence of hepatomegaly in his History and Physical.
DESCRIPTION: This determines whether the patient has the presence of hepatomegaly. Hepatomegaly is defined as
enlargement of the liver indicated usually by palpation of the lower border of the liver below the
right costal margin or a liver span greater than 10 cm. Hepatomegaly may be noted in acute
hepatitis, fatty infiltration, passive congestion, and early biliary obstruction. It is usually
noted by the physician under the abdominal portion of the H&P.
130,269 PREGNANCY 200.1;3 SET
Pregnancy Status
'NO' FOR NO;
'NA' FOR NOT APPLICABLE;
'Y' FOR YES;
LAST EDITED: FEB 14, 2007
HELP-PROMPT: Enter the preoperative pregnancy status of this patient.
DESCRIPTION: Definition Revised (2007): Pregnancy is the process by which a woman carries a developing fetus in
her uterus, beginning at conception and ending in birth, miscarriage or abortion. Answer Yes if
there is documentation in the patient's medical record that the patient is currently pregnant.
130,270 PREOPERATIVE SERUM SODIUM 201;1 FREE TEXT
Preoperative Serum Sodium
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative serum sodium test. Data input must be 1 to 5 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,271 PREOPERATIVE POTASSIUM 201;2 NUMBER
Preoperative Potassium
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>8)!(X<1.5)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 28, 1991
HELP-PROMPT: Enter the result of the preoperative potassium test. Your answer must be between 1.5 and 8.0.
DESCRIPTION: This is the result of the preoperative potassium test.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,272 DATE ASSESSMENT COMPLETED RA;5 DATE
Date Assessment Completed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: FEB 21, 1992
DESCRIPTION: This is the date that the Assessment was completed. This field will be updated if the assessment
was transmitted in error.
130,272.1 ASSESSMENT COMPLETED BY RA;9 POINTER TO NEW PERSON FILE (#200)
Assessment Completed By
LAST EDITED: MAY 05, 2010
HELP-PROMPT: Enter the name of the person who completed the assessment.
DESCRIPTION:
This is the name of the person who completed this surgery risk assessment.
130,273 PREOPERATIVE GLUCOSE 201;3 NUMBER
Preoperative Glucose
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>1200)!(X<20)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the result of the preoperative glucose test. Your answer should be between 20 and 1200.
DESCRIPTION: This is the result of the preoperative glucose test.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,274 HIGHEST SERUM SODIUM 203;1 FREE TEXT
Highest Postoperative Serum Sodium
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the highest result of a postoperative serum sodium test for the selected patient. Data
input must be 1 to 5 numeric characters in length which may include a prefix of a less than or
greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,275 HIGHEST POTASSIUM 203;3 FREE TEXT
Highest Postoperative Potassium
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the highest result of a potassium test for the selected patient. Data input must be 1 to 3
numeric characters in length which may include a prefix of a less than or greater than sign "<" or
">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,276 HIGHEST GLUCOSE 203;5 NUMBER
Highest Postoperative Glucose
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>1200)!(X<20)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the highest postoperative glucose result. Your answer should be between 20 and 1200.
DESCRIPTION: This is the highest result of a postoperative glucose test for the patient selected.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,277 HIGHEST SERUM CREATININE 203;6 FREE TEXT
Highest Postoperative Serum Creatinine
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the highest postoperative serum creatinine result for the selected patient. Data input must
be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than
sign "<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,278 HIGHEST CPK 203;7 FREE TEXT
Highest Postoperative CPK
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: This is the highest result of a postoperative CPK test for the patient selected. Data input must be
1 to 6 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,279 HIGHEST CPK-MB 203;8 FREE TEXT
Highest Postoperative CPK-MB
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the highest result of a postoperative CP-MB Band for this patient. Data input must be 1 to
4 numeric characters in length which may include a prefix of a less than or greater than sign "<"
or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,280 HIGHEST TOTAL BILIRUBIN 203;9 FREE TEXT
Highest Postoperative Total Bilirubin
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the highest postoperative total bilirubin result recorded for this patient. Data input must
be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than
sign "<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,281 HIGHEST WBC 203;10 FREE TEXT
Highest Postoperative WBC
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the highest postoperative WBC for the patient selected. Data input must be 1 to 4 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,282 LOWEST SERUM ALBUMIN 203;11 NUMBER
Lowest Postoperative Serum Albumin
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>50)!(X<0)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the highest postoperative serum albumin test result. Your answer must be between 0 and 50.
DESCRIPTION: This is the lowest postoperative serum albumin result for the patient selected.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,283 LOWEST HEMATOCRIT 203;12 FREE TEXT
Lowest Postoperative Hematocrit
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the lowest postoperative hematocrit result recorded for this patient. Data input must be 1
to 4 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,284 ASSESSMENT TYPE RA;2 SET
Risk Assessment Type (Cardiac or Non-Cardiac)
'C' FOR CARDIAC;
'N' FOR NON-CARDIAC;
LAST EDITED: MAR 28, 1991
DESCRIPTION: This determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.
RECORD INDEXES: ARS (#1418)
130,285 ON VENTILATOR >48 HOURS 205;13 SET
On Ventilator > or = 48 Hours (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 01, 2015
HELP-PROMPT: Enter YES if the total duration of ventilator-assisted respiration during the 30 days postoperative
was > or = 48 hours.
DESCRIPTION: Definition Revised (2015): Total duration of ventilator-assisted respirations during postoperative
hospitalization after leaving the OR was >48 hours. This can occur at any time during the 30-day
period postoperatively. This time assessment is CUMULATIVE, not necessarily consecutive.
Ventilator-assisted respirations can be via endotracheal tube, nasotracheal tube, or tracheostomy
tube. This definition also applies if the patient was on the ventilator preoperatively and remained
on the ventilator postoperatively >48 hours.
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,286 OTHER URINARY TRACT OCCURRENCE 205;19 POINTER TO ICD DIAGNOSIS FILE (#80)
Other Urinary Tract Occurrences (ICD Diagnosis)
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
OUTPUT TRANSFORM: I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
LAST EDITED: FEB 17, 2012
HELP-PROMPT: Enter the ICD Diagnosis code for the postoperative urinary tract occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other urinary occurrences which you feel to be significant and
that are not covered by the predefined urinary tract occurrence categories. Enter the ICD-CM code
for this entry.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,287 PERIPHERAL NERVE INJURY 205;23 SET
Peripheral Nerve Injury (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has major peripheral neurological injuries.
DESCRIPTION: Definition Revised (2007): Peripheral nerve damage may result from damage to the nerve fibers, cell
body, or myelin sheath during surgery. Peripheral nerve injuries which result in motor deficits
only to the cervical plexus, brachial plexus, ulnar plexus, lumbar-sacral plexus (sciatic nerve),
peroneal nerve, and/or the femoral nerve should be included.
130,288 PREOPERATIVE CPK, DATE 202;6 DATE
Date Preoperative CPK was Performed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the preoperative CPK test was performed.
DESCRIPTION: This is the date that the preoperative CPK was performed.
130,289 PREOPERATIVE MB BAND, DATE 202;7 DATE
Date Preoperative MB Band was Performed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the preoperative MB Band was performed.
DESCRIPTION: This is the date that the preoperative MB Band was performed.
130,290 PREOP SERUM CREATININE, DATE 202;4 DATE
Date Preoperative Serum Creatinine was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Serum Creatinine was performed.
DESCRIPTION: This is the date that the preoperative Serum Creatinine test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,291 PREOPERATIVE BUN, DATE 202;5 DATE
Date Preoperative BUN was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative BUN was performed.
DESCRIPTION: This is the date that the preoperative BUN was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,292 PREOP SERUM ALBUMIN, DATE 202;8 DATE
Date Preoperative Serum Albumin was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Serum Albumin was performed.
DESCRIPTION: This is the date that the preoperative Serum Albumin test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,293 SGPT, DATE PERFORMED 202;10 DATE
Date Preoperative SGPT was Performed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the preoperative SGPT was performed.
DESCRIPTION: This is the date that the preoperative SGPT was performed.
130,294 SGOT, DATE PERFORMED 202;11 DATE
Date Preoperative SGOT was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative SGOT was performed.
DESCRIPTION: This is the date that the preoperative SGOT was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,295 PREOP TOTAL BILIRUBIN, DATE 202;9 DATE
Date Preoperative Total Bilrubin was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Total Bilirubin was performed.
DESCRIPTION: This is the date that the preoperative total bilirubin was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,296 PREOP ALK PHOSPHATASE, DATE 202;12 DATE
Date Preoperative Alkaline Phosphatase was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Alkaline Phosphatase was performed.
DESCRIPTION: This is the date that the preoperative alkaline phosphatase test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,297 PREOPERATIVE WBC, DATE 202;13 DATE
Date Preoperative WBC was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative WBC was performed.
DESCRIPTION: This is the date that the preoperative WBC test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,298 PREOP PLATELET COUNT, DATE 202;15 DATE
Date Preoperative Platelet Count was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Platelet Count was performed.
DESCRIPTION: This is the date that the preoperative platelet count was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,299 PREOPERATIVE PT, DATE 202;17 DATE
Date Preoperative PT was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative PT was performed.
DESCRIPTION: This is the date that the preoperative PT test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,300 PREOPERATIVE PTT, DATE 202;16 DATE
Date Preoperative PTT was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative PTT was performed.
DESCRIPTION: This is the date that the preoperative PTT test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,301 PREOP HEMATOCRIT, DATE 202;14 DATE
Date Preoperative Hematocrit was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Hematocrit test was performed.
DESCRIPTION: This is the date that the preoperative hematocrit was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,302 PREOPERATIVE GLUCOSE, DATE 202;3 DATE
Date Preoperative Glucose was Performed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the preoperative Glucose test was performed.
DESCRIPTION: This is the date that the preoperative glucose test was performed.
130,303 PREOP POTASSIUM, DATE 202;2 DATE
Date Preoperative Potassium was Performed
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the preoperative Potassium test was performed.
DESCRIPTION: This is the date that the preoperative potassium test was performed.
130,304 PREOP SERUM SODIUM, DATE 202;1 DATE
Date Preoperative Serum Sodium was Performed
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative Serum Sodium test was performed.
DESCRIPTION: This is the date that the preoperative serum sodium test was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,305 HIGH SERUM SODIUM, DATE 204;1 DATE
Date Highest Serum Sodium was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest Serum Sodium result was recorded.
DESCRIPTION: This is the date that the highest Serum Sodium result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,306 HIGH POTASSIUM, DATE 204;3 DATE
Date Highest Potassium was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest Potassium result was recorded.
DESCRIPTION: This is the date that the highest Potassium result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,307 HIGH GLUCOSE, DATE 204;5 DATE
Date Highest Glucose was Recorded
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the highest Glucose result was recorded.
DESCRIPTION: This is the date that the highest Glucose result was recorded.
130,308 HIGH SERUM CREATININE, DATE 204;6 DATE
Date Highest Serum Creatinine was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest Serum Creatinine result was recorded.
DESCRIPTION: This is the date that the highest Serum Creatinine result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,309 HIGH CPK, DATE 204;7 DATE
Date Highest CPK was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest CPK result was recorded.
DESCRIPTION: This is the date that the highest CPK result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,310 HIGH CPK-MB, DATE 204;8 DATE
Date Highest CPK-MB Band was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest CPK-MB Band result was recorded.
DESCRIPTION: This is the date that the highest CPK-MB Band result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,311 HIGH TOTAL BILIRUBIN, DATE 204;9 DATE
Date Highest Total Bilirubin was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest Total Bilirubin result was recorded.
DESCRIPTION: This is the date that the highest Total Bilirubin was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,312 HIGHEST WBC, DATE 204;10 DATE
Date Highest WBC was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest WBC result was recorded.
DESCRIPTION: This is the date that the highest WBC was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,313 LOW SERUM ALBUMIN, DATE 204;11 DATE
Date Lowest Serum Albumin was Recorded
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date that the lowest Serum Albumin result was recorded.
DESCRIPTION: This is the date that the lowest Serum Albumin result was recorded.
130,314 LOW HEMATOCRIT, DATE 204;12 DATE
Date Lowest Hematocrit was Recorded
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the lowest Hematocrit result was recorded.
DESCRIPTION: This is the date that the lowest Hematocrit result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,315 PREOPERATIVE PT CONTROL 201;19 NUMBER
Preoperative PT Control
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>15)!(X<9)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the preoperative PT Control result. Your answer must be between 9 and 15.
DESCRIPTION: This is the result of the preoperative PT control. Your answer must be between 9 and 15.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,316 PREOPERATIVE PTT CONTROL 201;18 NUMBER
Preoperative PTT Control
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>40)!(X<15)!(X?.E1"."2N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: JUL 15, 1991
HELP-PROMPT: Enter the preoperative PTT Control result. Your answer must be between 15 and 40.
DESCRIPTION: This is the preoperative PTT control result. Your answer must be between 15 and 40.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,318 RESPIRATORY OCCURRENCES 205;9 SET
Postoperative Respiratory Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if this patient has had postoperative respiratory occurrences.
DESCRIPTION: This determines whether the patient had postoperative respiratory occurrences. A respiratory
occurrence is defined as an impairment to the lungs to perform their ventilatory function. This
may be due to impairment of gas exchange in the lung or obstruction of the free flow of air to the
lung.
130,319 URINARY TRACT OCCURRENCES 205;15 SET
Postoperative Urinary Tract Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient has had postoperative urinary tract occurrences.
DESCRIPTION: This determines whether the patient has had postoperative urinary tract occurrences. Urinary tract
occurrences are defined as difficulties related to the organs and ducts participating in the
secretion and elimination of urine.
130,320 CNS OCCURRENCES 205;20 SET
CNS Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient has had any postoperative CNS occurrences.
DESCRIPTION: This determines whether the patient has had any postoperative central nervous system (CNS)
occurrences. These occurrences are defined as difficulties related to the brain and spinal cord,
with their nerves and end-organs that control voluntary acts.
130,321 CARDIAC OCCURRENCES 205;25 SET
Cardiac Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient has had any postoperative cardiac occurrences.
DESCRIPTION: This determines whether the patient has had any postoperative cardiac occurrences. Cardiac
occurrences are defined as difficulties encountered involving the cardiac system.
130,322 OTHER OCCURRENCES 205;30 SET
Other Postoperative Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient has had other occurrences not included in the other occurrence
categories.
DESCRIPTION: This determines whether the patient has had postoperative occurrences, such as Graft/Prosthesis
Failure or Unplanned Return to OR, not included in any of the other categories.
130,323 CREATE RISK ASSESSMENT RA;6 SET
Do you want to create a Risk Assessment for this Surgical Case
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 24, 1991
HELP-PROMPT: Enter 'YES' if you are going to create a risk assessment for this surgical case.
DESCRIPTION: This determines whether a risk assessment will be created for this surgical case. If answered
'NO', the information will automatically be completed so that the information will be transmitted
without any additional intervention.
130,324 DRUG ADDICTION 200;5 SET
Drug Addiction (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if this patient admits to recreational or narcotic substance abuse.
DESCRIPTION: This determines whether this patient has a history of recreational or narcotic substance abuse.
There is no time limit on this data element.
130,325 DYSPNEA 200;6 SET
Dyspnea
'1' FOR NO;
'2' FOR MODERATE EXERTION;
'3' FOR AT REST;
'NS' FOR NO STUDY;
LAST EDITED: FEB 20, 2005
HELP-PROMPT: Enter the category that most appropriately applies to this patient.
DESCRIPTION: Definition Revised (2007): The patient describes difficult, painful, or labored breathing. Dyspnea
may be symptomatic of numerous disorders that interfere with adequate ventilation or perfusion of
the blood with oxygen. The dyspneic patient is subjectively aware of difficulty with breathing.
Select one of the following categories that best indicates the patient's subjective experience
coupled with your objective assessment:
(1) No dyspnea
(2) Dyspnea upon moderate exertion (e.g., is unable to climb one
flight of stairs without shortness of breath)
(3) Dyspnea at rest (e.g., cannot complete a sentence without needing
to take a breath)
The time frame is at the time the patient is being considered as a candidate for surgery (which
should be no longer than 30 days prior to surgery). If the patient's dyspnea status worsens prior
to surgery, report the most severe.
130,326 CURRENT PNEUMONIA 200;12 SET
Current Pneumonia (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has Pneumonia.
DESCRIPTION: Definition Revised (2007): Report patients with evidence of pneumonia at the time the patient is
brought to the OR. Patients with pneumonia must meet ONE of the following two criteria:
Criterion 1.
Rales or dullness to percussion on physical examination of chest AND
any of the following:
a. New onset of purulent sputum or change in character of sputum
b. Organism isolate from blood culture
c. Isolation of pathogen from specimen obtained by transtracheal
aspirate, bronchial brushing, or biopsy
OR
Criterion 2.
Chest radiographic examination shows new or progressive infiltrate,
consolidation, cavitation, or pleural effusion AND any of the
following:
a. New onset of purulent sputum or change in character of sputum
b. Organism isolated from blood culture
c. Isolation of pathogen from specimen obtained by transtracheal
aspirate, bronchial brushing, or biopsy
d. Isolation of virus or detection of viral antigen in respiratory
secretions
e. Diagnostic single antibody titer (IgM) or fourfold increase in
paired serum samples (IgG) for pathogen
f. Histopathologic evidence of pneumonia
130,327 ACTIVE HEPATITIS 200;17 SET
Active Hepatitis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if this patient has active hepatitis.
DESCRIPTION: This determines whether the patient has active hepatitis. Active Hepatitis is defined as an active
inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral
hepatitis documented by positive serologies (A,B, or C) and recent excessive alcohol intake, or
drug induced hepatitis.
130,328 RENAL FAILURE 200;38 SET
Acute Renal Failure (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 01, 2004
HELP-PROMPT: Enter YES if the patient has acute renal failure.
DESCRIPTION: Definition Revised (2004): The clinical condition associated with rapid, steadily increasing
azotemia (increase in BUN), and a rising creatinine of above 3 mg/dl. Acute renal failure should
be noted within 24 hours prior to surgery.
130,329 *REVASCULARIZATION/AMPUTATION 200;41 SET
*History of Revascularization/Amputation for PVD (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 24, 2014
HELP-PROMPT: Enter 'YES' if the patient has a history of revascularization/amputation for PVD.
DESCRIPTION: Definition Revised (2004): Any type of angioplasty or revascularization procedure for
atherosclerotic peripheral vascular disease (PVD) (e.g., aorto-femoral, femoral-femoral,
femoral-popliteal) or a patient who has had any type of amputation procedure for PVD (e.g., toe
amputations, transmetatarsal amputations, below the knee or above the knee amputations). Patients
who have had amputation for trauma or a resection of abdominal aortic aneurysms should not be
included.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,330 REST PAIN/GANGRENE (Y/N) 200;42 SET
Rest Pain/Gangrene (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient suffers from rest pain/gangrene.
DESCRIPTION: Definition Revised (2007): Rest pain is a more severe form of ischemic pain due to occlusive
disease, which occurs at rest and is manifested as a severe, unrelenting pain aggravated by
elevation and often preventing sleep. Gangrene is a marked skin discoloration and disruption
indicative of death and decay of tissues in the extremities due to severe and prolonged ischemia.
Include patients with ischemic ulceration and/or tissue loss related to peripheral vascular
disease. Do not include Fournier's gangrene. Report only if within the 30 days preoperatively.
130,331 ABSENT PERIPHERAL PULSES 200;43 SET
Absent Peripheral Pulses (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has been diagnosed as having absent peripheral pulses.
DESCRIPTION: This determines whether the patient has been diagnosed on the physical examination to have absent
femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as
present or absent in the remaining limb.
130,332 IMPAIRED SENSORIUM 200;19 SET
Impaired Sensorium (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 15, 2015
HELP-PROMPT: Enter YES if this patient has impaired sensorium.
DESCRIPTION: Definition Revised (2015): Patient is acutely confused and/or delirious and responds to verbal
and/or mild tactile stimulation. Patients should be noted to have developed an impaired sensorium
if they have mental status changes, and/or delirium in the context of the current illness. Patients
with chronic or long-standing mental status changes secondary to chronic mental illness (e.g.,
schizophrenia) or chronic dementing illnesses (e.g., multi-infarct dementia, senile dementia of the
Alzheimer's type) should not be included. Answer "Yes" if the criteria for this definition applies
at any time within 48 hours preop. If the patient develops impaired sensorium, then progresses to a
coma, and remains in a coma entering surgery, report just coma.
Choose from: Y YES N NO NS NO STUDY
130,333 COMA 200;21 SET
Coma (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUN 29, 2004
HELP-PROMPT: Enter YES if the patient is in a coma.
DESCRIPTION: Definition Revised (2004): Patient is unconscious, postures to painful stimuli, or is unresponsive
to all stimuli entering surgery. This does not include drug-induced coma.
130,334 *HISTORY OF TIA'S 200;25 SET
*History of TIA's (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 18, 2011
HELP-PROMPT: Enter YES if the patient has a history of TIA's.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2004): Transient ischemic attacks (TIAs) are focal neurologic deficits (e.g.
numbness of an arm or amaurosis fugax) of sudden onset and brief duration (usually <30 minutes),
which usually reflect dysfunction in a cerebral vascular distribution. These attacks may be
recurrent and, at times, may precede a stroke.
130,335 *CVA/STROKE WITH NEURO DEFICIT 200;26 SET
*CVA/Stroke With Neurologic Deficit (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 18, 2011
HELP-PROMPT: Enter YES if the patient has a history CVA/stroke with residual neurologic deficit.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or
hemorrhagic) with persistent residual motor, sensory, or cognitive dysfunction. (e.g., hemiplegia,
hemiparesis, aphasia, sensory deficit, impaired memory). If the neurological deficit is
hemiplegia/hemiparesis, also enter YES to Hemiplegia/Hemiparesis in addition to CVA/Stroke.
130,336 *CVA/STROKE - NO NEURO DEFICIT 200;27 SET
*CVA/Stroke With No Neurologic Deficit (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUL 18, 2011
HELP-PROMPT: Enter YES if the patient has a history of CVA/Stroke with no neurologic deficit.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or
hemorrhagic) with neurologic deficit(s) lasting at least 30 minutes, but no current residual
neurologic dysfunction or deficit.
130,337 NEURO DEGENERATIVE DISEASE 200;28 SET
Neuromuscular Degenerative Disease (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has a neuromuscular degenerative disease.
DESCRIPTION: This determines whether the patient has neuromuscular degenerative disease. It is defined as any
of a number of congenital, hereditary, or acquired diseases resulting in chronic neurological
deficits. Common examples of these diseases include muscular dystrophy, amyotrophic lateral
sclerosis (ALS or 'Lou Gerhig's Disease'), multiple sclerosis, and poliomyelitis.
130,338 DISSEMINATED CANCER (Y/N) 200;45 SET
Disseminated Cancer (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has disseminated cancer.
DESCRIPTION: VASQIP Definition (2010): Disseminated cancer: Patients who have cancer known to be present prior
to the start of surgery that:
(1) Has spread to one site or more sites in addition to the primary
site
AND
(2) In whom the presence of multiple metastases indicates the cancer
is widespread, fulminant, or near terminal. Other terms describing
disseminated cancer include "diffuse," "widely metastatic,"
"widespread," or "carcinomatosis", or AJCC "Stage IV" cancer.
Common sites of metastases include major organs (e.g., brain,
lung, liver, meninges, abdomen, peritoneum, pleura, and bone).
You may use the National Cancer Institute as a reference in
determining whether a patient has AJCC Stage IV cancer, when the
TNM information is the only information documented. Refer to the
following website for assistance with translating TNM values with
AJCC staging:
http://www.cancer.gov/cancertopics/pdq/adulttreatment
Examples:
- A patient with a primary breast cancer with positive nodes in the
axilla does NOT qualify for this definition. The tumor has spread to
a site other than the primary site, but does not have widespread
metastases. A patient with primary breast cancer with positive nodes
in the axilla AND liver metastases does qualify, because the tumor
has spread to the axilla and other major organs.
- A patient with colon cancer and no positive nodes or distant
metastases does NOT qualify. A patient with colon cancer and several
local lymph nodes positive for tumor, but no other evidence of
metastatic disease does NOT qualify. A patient with colon cancer
with liver metastases and/or peritoneal seeding with tumor does
qualify.
- A patient with adenocarcinoma of the prostate confined to the
capsule does NOT qualify. A patient with prostate cancer that
extends through the capsule of the prostate only does NOT qualify.
A patient with prostate cancer with bony metastases DOES qualify.
Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma
under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia
(CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.
130,338.1 *CHEMOTHERAPY IN LAST 30 DAYS 206;3 SET
*Chemotherapy Within 30 Days Prior to Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 22, 2015
HELP-PROMPT: Enter YES if patient has undergone chemotherapy in the 30 days prior to surgery.
DESCRIPTION: Definition Revised (2007): Enter "YES" if the patient had any chemotherapy treatment for cancer in
the 30 days prior to surgery. Chemotherapy may include, but is not restricted to, oral and
parenteral treatment with chemotherapeutic agents for malignancies such as colon, breast, lung,
head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic
malignancies such as lymphoma, leukemia, and multiple myeloma. Do not count if treatment consists
solely of hormonal therapy. (See Operations Manual for list of chemotherapeutic agents.)
Chemotherapy treatment must be for malignancy.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,338.2 RADIOTHERAPY IN LAST 90 DAYS 206;4 SET
Radiotherapy Within 90 Days Prior to Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if patient had radiotherapy in the 90 days prior to surgery.
DESCRIPTION: Definition Revised (2004): Enter "YES" if the patient had any radiotherapy treatment for cancer in
the 90 days prior to surgery. If the patient had radiation seeds implanted, count if implantation
is within 90 days prior to the operation.
130,338.3 CHEMO FOR MALIG LAST 90 DAYS 204;17 SET
Chemotherapy for Malignancy Less Than 90 Days Preop
'1' FOR NO CHEMO;
'2' FOR W/IN 30 DAYS;
'3' FOR 31-90 DAYS;
LAST EDITED: MAY 12, 2015
HELP-PROMPT: Enter timeframe of chemotherapy in the 90 days prior to surgery.
DESCRIPTION: Definition Revised (2015): Enter the timeframe of chemotherapy treatment for cancer in the 90 days
prior to surgery. Chemotherapy may include, but is not restricted to, oral and parenteral treatment
with chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and
gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma,
leukemia, and multiple myeloma. Do not include if treatment consists solely of hormonal therapy.
Chemotherapy treatment must be for malignancy.
130,339 STEROID USE FOR CHRONIC COND. 200;47 SET
Oral or Parenteral Steroid Use for Chronic Condition
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 02, 2015
HELP-PROMPT: Enter YES if the patient requires oral or parenteral steroid use for a chronic condition.
DESCRIPTION: Definition Revised (2015): Patient has required the regular administration of oral or parenteral
corticosteroid medications (e.g., Prednisone, Decadron) in the 30 days prior to admission for a
chronic medical condition (e.g., COPD, asthma, rheumatologic disease, rheumatoid arthritis,
inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or
corticosteroids administered by inhalation or rectally. Do not include patients who only receive
short course steroids (duration 10 days or less) in the 30 days prior to surgery. (See list of
corticosteroids in Operations Manual.)
Choose from: Y- YES N- NO NS- NO STUDY
130,340 INTRAOP RBC UNITS TRANSFUSED 200;54 FREE TEXT
Number of RBC Units Given Intraoperatively
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JAN 07, 2014
HELP-PROMPT: Enter the number of red blood cells transfused. Your answer should be from 0 to 99.
DESCRIPTION: Definition Revised (2014): Indicate the number of packed or whole red blood cells given during the
operative procedure as it appears on the anesthesia record. The amount of blood reinfused from the
cell saver should also be noted here. The algorithm for cell saver volume to RBC unit determination
is:
0 units - 0-124 cc's
1 unit - 125 - 375 cc's
2 units - 376 - 625 cc's
3 units - 626 - 875 cc's
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,341 30 DAY POSTOP STATUS 205;2 SET
30 Day Postoperative Status
'1' FOR DISCHARGED ALIVE;
'2' FOR DIED IN HOSPITAL;
'3' FOR REMAINS IN VAMC FACILITY;
'4' FOR TRANSFERRED TO ANOTHER VAMC;
'5' FOR READMITTED;
'NS' FOR NO STUDY;
LAST EDITED: JUL 14, 1991
HELP-PROMPT: Enter the status of the patient 30 days postoperatively.
DESCRIPTION: This is the patient's status 30 days postoperatively. Please select one of the following
categories.
1. Discharged alive to home, nursing home, rehabilitation, or
psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your
VAMC facility in the ICU, on a medical-surgical
floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of
another VAMC
facility from your VAMC without going home 5. Patient was discharged home, but was readmitted
to any
hospital within 30 days postoperatively due to a postoperative
complication as confirmed by the Chief Surgical Resident,
Principle Investigator, or Chief of Surgery. If the patient
was readmitted due to a postoperative complication, please
enter the information in the outcome section of the assessment.
130,342 DATE OF DEATH 205;3 FREE TEXT
Date/Time of Death
INPUT TRANSFORM: N SRX S SRX=X,%DT="EPT" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: MAY 25, 2011
HELP-PROMPT: Enter the date/time that the patient died.
DESCRIPTION:
If the patient has died, this is the date/time of death.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^130^342.1
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,205)):^(205),1:"") S X=$P(Y(1),U,41),X=X S D
IU=X K Y X ^DD(130,342,1,1,1.1) S DIH=$G(^SRF(DIV(0),205)),DIV=X S $P(^(205),U,41)=DIV,DIH=130,DIG=
342.1 D ^DICR
1.1)= S X=DIV S X=$S(X="NA"!($P($G(^SRF(D0,.2)),U,3)=""):"N",$$FMDIFF^XLFDT(X,$P(^SRF(D0,.2),U,3))>
30:"N",1:"Y")
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,205)):^(205),1:"") S X=$P(Y(1),U,41),X=X S D
IU=X K Y S X="" S DIH=$G(^SRF(DIV(0),205)),DIV=X S $P(^(205),U,41)=DIV,DIH=130,DIG=342.1 D ^DICR
CREATE VALUE)= S X=$S(X="NA"!($P($G(^SRF(D0,.2)),U,3)=""):"N",$$FMDIFF^XLFDT(X,$P(^SRF(D0,.2),U,3))
>30:"N",1:"Y")
DELETE VALUE)= @
FIELD)= #342.1
If the number of days between TIME OPERATION ENDS (#.23) and DATE OF DEATH (#342) is less than or
equal 30, set 30 DAY DEATH (#342.1) to YES, otherwise, set the 30 DAY DEATH (#342.1) to NO if DATE
OF DEATH (#342) is greater than 30 or "NA" is entered.
130,342.1 30 DAY DEATH 205;41 SET
30-Day Death
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 12, 2011
HELP-PROMPT: This field indicates whether operative death has occurred within 30 days of surgery.
DESCRIPTION: This field indicates whether operative death has occurred within 30 days of surgery. This field
auto populates based on an entry into the DATE OF DEATH field (#342). If Date of Death occurs
within 30 days or less of the Date of Operation, then this field is automatically updated to "Yes"
when the Date of Death is saved. If the Date of Death is greater than 30 days from the Date of
Operation or "NA" is entered then this field is automatically updated to "No" when the Date of
Death is saved.
NOTES: TRIGGERED by the DATE OF DEATH field of the SURGERY File
130,343 OTHER CNS OCCURRENCE 205;24 POINTER TO ICD DIAGNOSIS FILE (#80)
Other CNS Occurrence
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
OUTPUT TRANSFORM: I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
LAST EDITED: FEB 17, 2012
HELP-PROMPT: Enter the ICD Diagnosis code for any other CNS occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other neurologic related occurrences, which you feel to be
significant and that are not covered by the predefined CNS occurrence categories. Enter the ICD-CM
code for this entry.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,344 OTHER CARDIAC OCCURRENCE 205;29 POINTER TO ICD DIAGNOSIS FILE (#80)
Other Cardiac Occurrence
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
OUTPUT TRANSFORM: I $G(Y) S Y=$$ICDC^SROICD(Y),Y=$P(Y,"^")_" "_$P(Y,"^",3)
LAST EDITED: JAN 10, 2013
HELP-PROMPT: Enter the ICD Diagnosis code corresponding to the cardiac occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other cardiac related surgical occurrences which you feel to
be significant and that are not covered by the predefined occurrence categories. Enter the ICD-CM
code for this entry.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,345 ILEUS/BOWEL OBSTRUCTION 205;31 SET
Prolonged Ileus/Bowel Obstruction (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has a postoperative intestinal obstruction.
DESCRIPTION: This determines whether the patient has prolonged ileus or bowel obstruction. Ileus is obstruction
of the intestines from a variety of causes including mechanical obstruction, peritonitis,
adhesions, or post surgically as a result of functional dysmotility by the bowel. Bowel
obstruction is any hindrance to the passage of the intestinal contents. Prolonged ileus or
obstruction is defined as persisting longer than 5 days postoperatively.
130,346 *DIABETES 200;2 SET
*Diabetes Mellitus Requiring Therapy With Oral Agents or Insulin
'N' FOR NO;
'O' FOR ORAL;
'I' FOR INSULIN;
LAST EDITED: JUL 12, 2011
HELP-PROMPT: Enter the patient's diabetes status.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2004): Diabetes mellitus is a metabolic disorder of the pancreas whereby the
individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to
prevent a hyperglycemic/metabolic acidosis. Report the treatment regimen of the patient's chronic,
long-term management. Do not include a patient if diabetes is controlled by diet alone.
No: No diagnosis of diabetes or diabetes controlled by diet alone
Oral: A diagnosis of diabetes requiring therapy with an oral
hypoglycemic agent (see list of oral hypoglycemic agents in
Operations Manual)
Insulin: A diagnosis of diabetes requiring daily insulin therapy (see
list of insulin therapy agents in Operations Manual)
130,347 FEV1 206;5 FREE TEXT
FEV1
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>9.9)!(X<0)!(X?.E1"."2N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: MAR 11, 2015
HELP-PROMPT: Enter the FEV1 on the most recent PFT's (0 to 9.9).
DESCRIPTION: Definition revised (2015): This is the forced expiratory volume (in liters) in one second from the
most recent pulmonary function test prior to surgery. Identify only a FEV1 value that is
pre-bronochodilator treatment. Enter 'NS' if there has been no pulmonary function tests in the
preceding year.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,348 *PULMONARY RALES 206;7 SET
*Pulmonary Rales (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 05, 2015
HELP-PROMPT: Enter 'YES' if the patient has pulmonary rales within the two weeks preceding surgery.
DESCRIPTION: Definition Revised (2004): Indicate if the chart documents rales not clearing with cough (and not
due to pneumonic process) heard within two weeks before surgery. Do not include rales that clear
with coughing, as these are usually due to atelectasis and carry a much more benign connotation.
Please note, crackles are another common approach to noting that rales are present.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,349 ACTIVE ENDOCARDITIS 206;10 SET
Active Endocarditis (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 20, 2004
HELP-PROMPT: Enter 'YES' if the patient is being treated, or has been treated within two weeks prior to surgery,
for active endocarditis.
DESCRIPTION: Definition Revised (2004): Indicate if the patient is being treated with antibiotics for active
infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery.
Endocarditis is defined as two or more blood cultures positive for the same organism, usually with
evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of
positive blood cultures, there should be clear evidence of valve infection and/or destruction by
ultrasound or direct observation at surgery with subsequent histologic confirmation.
130,350 *RESTING ST DEPRESSION 206;11 SET
*Resting ST Depression (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 05, 2015
HELP-PROMPT: Enter 'YES' if the patient has defined Resting ST Depression.
DESCRIPTION: This determines whether the patient has a ST-segment depression greater than or equal to 1 mm in
any lead on standard resting electrocardiogram (ECG), and/or ECG diagnosis of subendocardial
ischemia, left ventricular strain, or left ventricular hypertrophy with repolarization abnormality.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,351 *PCI 206;13 SET
'1' FOR NONE RECENT;
'2' FOR 12-72 HOURS PRIOR TO SURGERY;
'0' FOR NONE;
'3' FOR <12 hrs;
'12' FOR 12 - 72 hrs;
'72' FOR >72 hrs - 7 days;
'7' FOR >7 days;
LAST EDITED: JAN 15, 2014
HELP-PROMPT: Enter the category that most accurately reflects the patient's Percutaneous Coronary Intervention.
DESCRIPTION: Definition Revised (2004): Indicate whether/when the patient had a percutaneous coronary
intervention (PCI) prior to surgery. Previously, this data field was listed as a percutaneous
transluminal coronary angiography (PTCA) [e.g., balloon angioplasty, directional coronary
atherectomy (DCA), transluminal extraction catheter (TEC), stent, rotoblader, etc.] Indicate the
one appropriate response, even if the procedure was not fully successful.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
SCREEN: S DIC("S")="I ""1,2""'[Y"
EXPLANATION: Screen prevents selection of
130,352 NUM OF PRIOR HEART SURGERIES 206;15 SET
Number of Prior Heart Surgeries
'Y' FOR YES;
'0' FOR NONE;
'1' FOR 1;
'2' FOR 2;
'3' FOR 3;
'>' FOR >3;
LAST EDITED: MAR 11, 2004
HELP-PROMPT: Enter number of prior heart surgeries during a separate preceding hospitalization.
DESCRIPTION: Definition Revised (2006): Indicate the number of previous heart surgeries the patient has had upon
current admission, by referencing the patient history. The prior heart surgery/ies would have
occurred during a separate hospitalization (more than 30 days prior to current surgery). Both on
and off-pump cardiac surgical procedures should be considered. Count all surgical procedures
performed during separate hospital admissions (not the number of grafts, and not additional
procedures performed during the same admission due to a postoperative occurrence). Indicate the
one appropriate response: 0, 1, 2, 3, >3.
SCREEN: S DIC("S")="I ""Y""'[Y"
EXPLANATION: Screen prevents selection of Y code
130,353 CURRENT DIURETIC USE 206;20 SET
Current Diuretic Use (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 27, 1991
HELP-PROMPT: Enter 'YES' if the patient used any diuretic preparation within two weeks of surgery.
DESCRIPTION: This determines whether the patient has used any diuretic preparation within the two weeks prior to
surgery.
130,354 *CURRENT DIGOXIN USE 206;21 SET
*Current Digoxin Use (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 05, 2015
HELP-PROMPT: Enter 'YES' if the patient used any digitalis preparation within two weeks of surgery.
DESCRIPTION: This determines whether the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin,
ect.) within the two weeks prior to surgery.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,355 IV NTG WITHIN 48 HOURS 206;22 SET
IV NTG within 48 Hours Preceding Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 23, 1991
HELP-PROMPT: Enter 'YES' if the patient was given nitroglycerin intravenously within 48 hours prior to surgery.
DESCRIPTION: This determines whether the patient was administered nitroglycerin intravenously within 48 hours
prior to surgery.
130,356 PREOPERATIVE USE OF IABP 206;23 SET
Preoperative use of IABP (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 27, 1991
HELP-PROMPT: Enter 'YES' if an intra-aortic ballon pump (IABP) was used within two weeks prior to surgery.
DESCRIPTION: This determines whether there was any use of an intra-aortic balloon pump (IABP) within the two
weeks prior to surgery.
130,357 LVEDP 206;24 FREE TEXT
Left Ventricular End-Diastolic Pressure
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>60)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the LVEDP measured following the 'a' wave (if present) at catheterization. Your answer must
be between 0 and 60.
DESCRIPTION: Definition Revised (2004): Indicate the patient's left ventricular end-diastolic pressure measured
following the a-wave (if present) at the cardiac catheterization most recent prior to surgery. If
LVEDP was not measured, entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,358 AORTIC SYSTOLIC PRESSURE 206;25 FREE TEXT
Aortic Systolic Pressure
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>300)!(X<15)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the aortic systolic pressure (15-300) measured prior to left ventricular angiography most
closely preceding surgery.
DESCRIPTION: Definition Revised (2004): Indicate the patient's aortic systolic pressure measured prior to left
ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic
pressure was not measured, entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,359 PA SYSTOLIC PRESSURE 206;26 FREE TEXT
PA Systolic Pressure
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>150)!(X<-30)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the patient's PA systolic pressure (-30 to 150).
DESCRIPTION: Definition Revised (2004): For patients having a right heart catheterization, indicate the
patient's pulmonary artery (PA) systolic pressure at the catheterization most recent prior to
surgery. PA pressures obtained in the operating room prior to surgery are acceptable if they are
obtained prior to anesthesia induction. If no right heart catheterization performed, entering "NS"
for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,360 PAW MEAN PRESSURE 206;27 FREE TEXT
PAW Mean Pressure
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>80)!(X<-15)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the mean pulmonary artery wedge (PAW) pressure (-15 to 80).
DESCRIPTION: Definition Revised (2004): For patients having a right heart catheterization, indicate the
patient's mean pulmonary artery wedge (PAW) [also called pulmonary capillary] pressure or left
atrial pressure measured at the catheterization most recent prior to surgery. PAW pressures
obtained in the operating room prior to surgery are acceptable if they are obtained prior to
anesthesia induction. If no right heart or transseptal catheterization performed, entering "NS" for
"No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,361 LEFT MAIN STENOSIS 206;28 FREE TEXT
Left Main Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the percent (0-100) diameter reduction of the left main coronary artery.
DESCRIPTION: Definition Revised (2004): Indicate the most severe percent diameter reduction of the left main
coronary artery, including its most distal portion. If there is no obstruction of the left main
coronary artery, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,362 CORONARIES WITH STENOSIS 206;29 NUMBER
Major Coronaries with Stenosis(es) Greater or Equal to 50%
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>3)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS" X="NS" K NYUK
LAST EDITED: AUG 05, 1991
HELP-PROMPT: Enter the category related to the number of major coronaries with stenosis(es). Your answer should
be from 0 to 3.
DESCRIPTION: This is the category corresponding to the number of major coronaries with stenosis greater than or
equal to 50%. The categories are as follows.
0 - no stenosis in any coronary artery greater than or equal to
50% (exclude diagonals)
1 - one or more stenoses greater than or equal to 50% in the
left anterior descending (does not include diagonals)
or, circumflex (circumflex includes the marginal branches
and ramus intermedius),
or the right (right includes the posterior descending even
if a branch of the circumflex)
2 - Stenoses greater than or equal to 50% in the
left main coronary artery,
or the left anterior descending (does not include diagonals) and
the right (right includes the posterior descending even if a
branch of the circumflex),
or the left anterior descending (does not include diagonals) and
circumflex (circumflex includes the marginals and ramus intermedius),
or the circumflex (circumflex includes the marginals and ramus
intermedius) and the right (right includes the posterior descending
even if a branch of the circumflex)
3 - Stenoses greater than or equal to 50% in the
left anterior descending (does not include diagonals) and the
circumflex (circumflex includes the marginals and ramus intermedius)
and right (right includes the posterior descending even if a branch
of the circumflex)
or left main and right (right includes the posterior descending
even if a branch of the circumflex)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,362.1 LAD STENOSIS 206;33 FREE TEXT
Left Anterior Descending (LAD) Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the percent (0-100) stenosis.
DESCRIPTION: Definition Revised (2004): Indicate the most severe percent stenosis in the left anterior
descending coronary artery. Synonyms for this artery include: LAD, AD, and anterior descending (but
does not include the diagonals). If there is no obstruction of the LAD, indicate zero. Entering
"NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,362.2 RIGHT CORONARY STENOSIS 206;34 FREE TEXT
Right Coronary Artery Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the percent (0-100) stenosis.
DESCRIPTION: Definition Revised (2004): Indicate the most severe percent stenosis in the right coronary artery.
Include the proximal third of the posterior descending coronary artery. The right coronary artery
initially runs in the groove between the right ventricle and right atrium; it usually gives off
branches to both the right and left ventricles and the right atrium. The branches to the right
atrium (sinus node artery) and right ventricle (conus branch and acute marginal branches) are
commonly ignored when describing coronary artery disease. However, the right coronary artery is the
most common source for the posterior descending coronary artery and often gives-off branches to the
posterior-lateral free wall of the left ventricle. These are often known as left ventricular
extension branches and are considered branches of the circumflex for the coding of severity of
coronary disease. If there is no obstruction of these coronary arteries, indicate zero. Entering
"NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,362.3 CIRCUMFLEX STENOSIS 206;35 FREE TEXT
Circumflex Coronary Artery Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Enter the percent (0-100) stenosis.
DESCRIPTION: Definition Revised (2004): Indicate the most severe percent stenosis in the circumflex coronary
artery, including marginal branches and ramus intermedius considered to be of adequate size for
bypass grafting. Both the anatomy and nomenclature for describing the circumflex coronary artery
can be confusing -- in part, because of the marked variability from patient to patient. The true
circumflex lies in the groove separating the left atrium from the left ventricle (A-V groove) for a
variable distance following its origination from the left main coronary artery. Typically, it
gives-off one or more branches that leave the A-V groove to supply the posterior-lateral free wall
of the left ventricle. These are known as marginal branches. A few patients have a branch to the
posterior-lateral free wall of the left ventricle arising exactly at the bifurcation of the left
main coronary artery into the left anterior descending coronary artery and the circumflex coronary
artery. Strictly speaking, this vessel is neither a diagonal branch of the left anterior descending
coronary artery nor a marginal branch of the circumflex coronary artery. This is often called the
"ramus intermedius" or "trifurcation branch". If there is no obstruction of these coronary
arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,363 LV CONTRACTION SCORE 206;30 SET
LV Contraction Grade
'I' FOR > OR EQUAL 0.55 NORMAL;
'II' FOR 0.45-0.54 MILD DYSFUNC.;
'III' FOR 0.35-0.44 MOD. DYSFUNC.;
'IIIa' FOR 0.40-0.44 MOD. DYSFUNC. A;
'IIIb' FOR 0.35-0.39 MOD. DYSFUNC. B;
'IV' FOR 0.25-0.34 SEVERE DYSFUNC.;
'V' FOR <0.25 VERY SEVERE DYSFUNC.;
'NS' FOR NO STUDY;
LAST EDITED: JUL 28, 2004
HELP-PROMPT: Enter the grade that best describes left ventricular function.
DESCRIPTION: Definition Revised (2004): Indicate the left ventricular contraction grade, where the function is
assessed from the preoperative contrast ventriculogram, radionuclide angiogram, or 2-D
echocardiogram. If ejection fraction is available, indicate the corresponding grade; otherwise,
indicate the grade that qualitatively reflects left ventricular function. Ejection fraction is
defined as the proportion of blood that is ejected during each ventricular contraction compared
with the total ventricular filling volume. Indicate the one most appropriate response: I - Ejection
fraction >= 0.55 or narrative reports indicating normal left ventricular function.
II - Ejection fraction range from 0.45 to 0.54 or narrative report indicating mild left ventricular
dysfunction.
IIIa - Ejection fraction range from 0.40 to 0.44 or narrative report indicating moderate left
ventricular dysfunction. If "moderate" is the only rating available, select this category.
IIIb - Ejection fraction range from 0.35 to 0.39 or narrative report indicating moderately severe
left ventricular dysfunction.
IV - Ejection fraction range from 0.25 to 0.34 or narrative report indicating severe left
ventricular dysfunction.
V - Ejection fraction < 0.25 or narrative report indicating very severe left ventricular
dysfunction.
NS - If unable to make an assessment of the patient's left ventricular contraction grade or no
study was performed, entering "NS" for "No Study/Unknown" is also allowed.
SCREEN: S DIC("S")="I Y'=""III"""
EXPLANATION: Screen prevents selection of code III.
130,364 ESTIMATE OF MORTALITY 206;31 NUMBER
Physician's Preoperative Estimate of Operative Mortality
INPUT TRANSFORM: S NYUK=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
LAST EDITED: JAN 25, 2007
HELP-PROMPT: Enter the physician's preoperative estimate of operative mortality.
DESCRIPTION: Definition Revised (2006): This is the physician's (cardiologist or cardiac surgeon) subjective
estimate of operative mortality based on the assessment of the total clinical picture. (To avoid
bias introduced by knowledge of outcome, this must be completed preoperatively. Do not calculate
from the computer program provided to you.)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,364.1 ESTIMATE OF MORTALITY, DATE 206;32 FREE TEXT
Date/Time of Estimate of Operative Mortality
INPUT TRANSFORM: N SRX S SRX=X,%DT="ETXRP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS" D:$D(X) NC^SROAUTL
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: NOV 06, 2007
HELP-PROMPT: Enter the date and time that the estimate of operative mortality was documented.
DESCRIPTION:
This is the date and time that the estimate of mortality information was collected.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,365 *NUMBER WITH VEIN 207;1 NUMBER
*CABG Distal Anastomoses with Vein
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 05, 1991
HELP-PROMPT: Enter the number of CABG distal anastomoses to native coronary arteries with vein.
DESCRIPTION: This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
with vein regardless of whether other procedures were performed. Do not leave this information
blank. If no coronary artery bypass grafts were performed, enter '0'.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,366 *NUMBER WITH IMA 207;2 NUMBER
*CABG Distal Anastomoses with IMA
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 05, 1991
HELP-PROMPT: Enter the number of CABG distal anastomoses to native coronary arteries with IMA.
DESCRIPTION: This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
with internal mammary arteries (IMA) regardless of whether other procedures were performed. Do not
leave this field blank. If no coronary artery bypass grafts were performed, enter '0'.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,367 *AORTIC VALVE PROCEDURE 207;3 SET
*Aortic Valve Procedure
'Y' FOR YES;
'N' FOR NONE;
'M' FOR MECHANICAL;
'S' FOR STENTED BIOPROSTHETIC;
'B' FOR STENTLESS BIOPROSTHETIC;
'H' FOR HOMOGRAFT;
'PR' FOR PRIMARY REPAIR;
'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
'AN' FOR ANNULOPLASTY DEVICE ALONE;
'AU' FOR AUTOGRAFT (ROSS);
'O' FOR OTHER;
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter the appropriate aortic valve procedure performed on this patient.
DESCRIPTION: VASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the
native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct
regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional
procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair
was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate
the one most appropriate procedure:
* None
* Mechanical Valve
* Stented Bioprosthetic Valve
* Stentless Bioprosthetic Valve
* Homograft
* Primary Valve Repair
* Primary Valve Repair and Annuloplasty Device
* Annuloplasty Device alone
* Autograft Procedure (Ross Procedure)
* Other
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
SCREEN: S DIC("S")="I ""Y""'[Y"
EXPLANATION: Screen prevents selection of inactive code.
130,368 *MITRAL VALVE PROCEDURE 207;4 SET
*Mitral Valve Procedure
'Y' FOR YES;
'N' FOR NONE;
'M' FOR MECHANICAL;
'S' FOR STENTED BIOPROSTHETIC;
'B' FOR STENTLESS BIOPROSTHETIC;
'H' FOR HOMOGRAFT;
'PR' FOR PRIMARY REPAIR;
'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
'AN' FOR ANNULOPLASTY DEVICE ALONE;
'AU' FOR AUTOGRAFT (ROSS);
'O' FOR OTHER;
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter the appropriate mitral valve procedure performed on this patient.
DESCRIPTION: VASQIP Definition (2010): Indicate if the patient had a mitral valve replacement (either the native
or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct
regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional
procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair
was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate
the one most appropriate procedure:
* None
* Mechanical Valve
* Stented Bioprosthetic Valve
* Stentless Bioprosthetic Valve
* Homograft
* Primary Valve Repair
* Primary Valve Repair and Annuloplasty Device
* Annuloplasty Device alone
* Autograft Procedure (Ross Procedure)
* Other
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
SCREEN: S DIC("S")="I ""Y""'[Y"
EXPLANATION: Screen prevents selection of inactive code.
130,369 *TRICUSPID VALVE PROCEDURE 207;5 SET
*Tricuspid Valve Procedure
'Y' FOR YES;
'N' FOR NONE;
'M' FOR MECHANICAL;
'S' FOR STENTED BIOPROSTHETIC;
'B' FOR STENTLESS BIOPROSTHETIC;
'H' FOR HOMOGRAFT;
'PR' FOR PRIMARY REPAIR;
'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
'AN' FOR ANNULOPLASTY DEVICE ALONE;
'AU' FOR AUTOGRAFT (ROSS);
'O' FOR OTHER;
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter the appropriate tricuspid valve procedure performed on this patient.
DESCRIPTION: VASQIP Definition (2010): Indicate if the patient had a tricuspid valve replacement (either the
native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct
regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional
procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair
was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate
the one most appropriate procedure:
* None
* Mechanical Valve
* Stented Bioprosthetic Valve
* Stentless Bioprosthetic Valve
* Homograft
* Primary Valve Repair
* Primary Valve Repair and Annuloplasty Device
* Annuloplasty Device alone
* Autograft Procedure (Ross Procedure)
* Other
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
SCREEN: S DIC("S")="I ""Y""'[Y"
EXPLANATION: Screen prevents selection of inactive code.
130,370 VALVE REPAIR 207;6 SET
Valve Repair
'Y' FOR YES;
'1' FOR AORTIC;
'2' FOR MITRAL;
'3' FOR TRICUSPID;
'4' FOR OTHER/COMBINATION;
'5' FOR NONE;
LAST EDITED: MAR 01, 2006
HELP-PROMPT: Indicate whether/where patient had a reparative procedure to a native valve.
DESCRIPTION: Definition Revised (2006): Indicate if the patient has had any reparative procedure to a native
valve, either with or without placing the patient on cardiopulmonary bypass. Valve repair is
defined as a procedure performed on the native valve to relieve stenosis and/or correct
regurgitation (annuloplasty, commissurotomy, etc.); the native valve remains in place. Indicate the
one appropriate response.
SCREEN: S DIC("S")="I ""Y""'[Y"
EXPLANATION: Screen prevents selection of Y entries.
130,371 *LV ANEURYSMECTOMY 207;7 SET
*LV Aneurysmectomy (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient had a resection or plication of left ventricular aneurysm with or
without additional procedures.
DESCRIPTION: This determines whether the patient had a resection or plication of a left ventricular aneurysm
with or without additional procedures.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,372 *GREAT VESSEL REPAIR (Y/N) 207;8 SET
*Great Vessel Repair (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAR 14, 2006
HELP-PROMPT: Enter 'YES' if the patient had a primary procedure to repair the aorta or other great vessels.
DESCRIPTION: Definition Revised (2006): Indicate if patient had a thoracic great vessel open repair of the aorta
(ascending, transverse, and/or descending) or other great vessels, with or without cardiopulmonary
bypass, with or without aortic valve replacement, CABG, or other procedure but excluding an
endovascular repair of the descending thoracic aorta.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,373 *CARDIAC TRANSPLANT 207;9 SET
*Cardiac Transplant (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 09, 2006
HELP-PROMPT: Enter 'YES' if the patient had a cardiac transplant.
DESCRIPTION: Definition Revised (2006): Indicate if an orthotopic or heterotopic transplant was performed at
this procedure either with or without placing the patient on cardiopulmonary bypass. (YES/NO)
Heart-lung transplant should be listed under "Other cardiac procedures."
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,374 ELECTROPHYSIOLOGIC PROCEDURE 207;10 SET
Electrophysiologic Procedure (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if an electrophysiologic procedure was performed.
DESCRIPTION: This determines whether any procedure was performed with cardiopulmonary bypass to correct an
electrophysiologic disturbance, such as resection of bypass tract(s) for WPW or endocardial
resection for ventricular tachycardia. (This does not include implantation of automatic internal
cardiac defibrillator AICD)
130,375 MISC. CARDIAC PROCEDURES 207;11 SET
Miscellaneous Cardiac Procedures
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 05, 1991
HELP-PROMPT: Enter 'YES' if any of the miscellaneous cardiac procedures were performed.
DESCRIPTION: This determines whether there were any miscellaneous cardiac procedures performed.
130,376 *ASD REPAIR 207;12 SET
*ASD Repair (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if there was a repair of an atrial septal defect.
DESCRIPTION: This determines if there was a procedure performed to repair an atrial septal defect.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,377 *MYXOMA RESECTION 207;14 SET
*Myxoma Resection (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if there was a resection of an atrial myxoma.
DESCRIPTION: This determines whether a resection of an atrial myxoma was performed.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,378 *MYECTOMY 207;16 SET
*Myectomy (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 24, 2011
HELP-PROMPT: Enter 'YES' if the patient had a myectomy.
DESCRIPTION: Definition Revised (2011): Indicate if patient had resection of a portion of the interventricular
septum, with or without placing the patient on cardiopulmonary bypass. (YES/NO)
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,379 *OTHER TUMOR RESECTION 207;18 SET
*Other Tumor Resection (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 29, 2004
HELP-PROMPT: Enter 'YES' if the patient had a resection of any tumor other than atrial myxoma from the heart
requiring CPB.
DESCRIPTION: Definition Revised (2004): Indicate if patient had resection of any tumor other than atrial myxoma
from the heart either with or without placing the patient on cardiopulmonary bypass.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,380 *VSD REPAIR 207;13 SET
*VSD Repair (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient had a procedure to repair a ventricular septal defect (VSD).
DESCRIPTION: This determines whether the patient had a procedure performed to repair a ventricular septal
defect.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,381 *FOREIGN BODY REMOVAL 207;15 SET
*Foreign Body Removal (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient had a procedure to remove any foreign body from the heart.
DESCRIPTION: This determines whether a procedure was performed to remove any foreign body (e.g. bullet or
catheter fragment) from the heart with the aid of cardiopulmonary bypass.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,382 *PERICARDIECTOMY 207;17 SET
*Pericardiectomy (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient had a pericardiectomy on CPB.
DESCRIPTION: This determines whether the patient had a resection of the parietal pericardium with the aid of
cardiopulmonary bypass. (NOTE: most pericardiectomies are performed without cardiopulmonary
bypass)
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,383 OTHER PROCEDURES (Y/N) 207;19 SET
Other Procedures (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 27, 1992
HELP-PROMPT: Enter 'YES' if the patient had any other surgical procedure on the heart and/or great vessels
requiring CPB.
DESCRIPTION: This determines whether the patient had any other surgical procedure on the heart and/or great
vessels (including AICD placement) requiring cardiopulmonary bypass.
130,383.1 OTHER CARDIAC PROCEDURES 207.1;1 FREE TEXT
Other Procedure(s) Requiring Cardiopulmonary Bypass (List)
INPUT TRANSFORM: S NYUK=X K:$L(X)>235!($L(X)<3) X S:NYUK="NS" X=NYUK K NYUK
LAST EDITED: MAR 11, 2004
HELP-PROMPT: Answer must be 3-235 characters in length.
DESCRIPTION: Definition Revised (2004): This is the free text description of other procedures requiring
cardiopulmonary bypass that were performed on this patient at the same time as the primary cardiac
procedure.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,384 OPERATIVE DEATH 208;1 SET
Operative Death (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAR 28, 2006
HELP-PROMPT: Enter 'YES' if the patient died. Enter "??" for the complete definition of OPERATIVE DEATH.
DESCRIPTION: Definition Revised (2006): Indicate if the patient died within the 30 days after surgery in or out
of the hospital regardless of cause; or within the index hospitalization regardless of cause; or
patient died greater than 30 days as a direct result of a perioperative occurrence of the surgery
(e.g., mediastinitis). ("Discharge" can be noted when the patient leaves the Acute Care arena.)
130,385 *PERIOPERATIVE MI 208;2 SET
*Perioperative Myocardial Infarction (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 28, 2011
HELP-PROMPT: Enter 'YES' if the patient had a perioperative myocardial infarction.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2011): Indicate the presence of a peri-operative MI as documented by the
following criteria:
0-24 Hours Post-Op
The CK-MB (or CK if MB not available) must be greater than or
equal to 5-times the upper limit of normal, with or without new
Q waves present in two or more contiguous ECG leads. No symptoms
required.
>24 Hours Post-Op
Indicate the presence of a peri-operative MI (> 24 hours post-op)
as documented by at least one of the following criteria:
1. Evolutionary ST- segment elevations
2. Development of new Q-waves in two or more contiguous ECG leads
3. New or presumably new LBBB pattern on the ECG
4. The CK-MB (or CK if MB not available) must be greater than or
equal to 3 times the upper limit of normal.
Because normal limits of certain blood tests may vary, please check with your lab for normal limits
for CK-MB and total CK. Defining Reference Control Values (Upper Limit of Normal): Reference values
must be determined in each laboratory by studies using specific assays with appropriate quality
control, as reported in peer-reviewed journals.
Acceptable imprecision (coefficient of variation) at the 99th percentile for each assay should be
defined as < or = to 10%. Each individual laboratory should confirm the range of reference values
in their specific setting. This element should not be coded as an adverse event for evolving MI's
unless their enzymes peak, fall, and then have a second peak.
130,386 ENDOCARDITIS 208;3 SET
Endocarditis (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 15, 2011
HELP-PROMPT: Enter 'YES' if the patient has any postoperative intracardiac infection.
DESCRIPTION: Definition Revised (2004): Indicate if the chart documents that active endocarditis was present
within 30 days postoperatively. Endocarditis is defined as any postoperative intracardiac infection
(usually on a valve) documented by two or more positive blood cultures with the same organism,
and/or development of vegetations and valve destruction seen by echo or repeat surgery, and/or
histologic evidence of infection at repeat surgery or autopsy. Patients with preoperative
endocarditis who have the above evidence of persistent infection should be included.
130,387 LOW CARDIAC OUTPUT > 6 HOURS 208;4 SET
Low Cardiac Output > 6 Hours (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 'YES' if the patient has low cardiac output for greater than or equal to 6 hours.
DESCRIPTION: This determines whether the patient has had a postoperative cardiac index of less than 2.0 L/min/M2
and/or peripheral manifestations (e.g. oliguria) of low cardiac output present for 6 or more hours
following surgery requiring inotropic and/or intra-aortic balloon pump support.
130,388 MEDIASTINITIS 208;5 SET
Mediastinitis (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 09, 2004
HELP-PROMPT: Enter 'YES' if the patient has a bacterial infection below the sternum.
DESCRIPTION: Definition Revised (2004): Indicate if the patient developed a bacterial infection involving the
sternum or deep to the sternum requiring drainage and anti-microbial therapy diagnosed within 30
days after surgery.
130,389 REOPERATION FOR BLEEDING 208;6 SET
Reoperation for Bleeding (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAR 06, 2015
HELP-PROMPT: Enter 'YES' if the patient had a re-exploration of the thorax for suspected bleeding.
DESCRIPTION: Definition Revised (2015): Indicate if there was any re-exploration of the thorax for suspected
bleeding after the patient left the operating room and within 30 days of surgery.
130,390 *STROKE 208;8 SET
*Stroke (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 11, 2011
HELP-PROMPT: Enter 'YES' if the patient has any new objective neurologic defect lasting > or = 30 minutes.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Cardiac Definition Revised (2004): Indicate if there was any new objective neurologic deficit
lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after
surgery.
130,391 REPEAT CARDIAC SURG PROCEDURE 208;7 SET
Repeat Cardiac Surgical Procedure (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 12, 2015
HELP-PROMPT: Enter YES if a repeat operation on the heart occurred.
DESCRIPTION: Definition Revised (2014): Indicate the CPB status if the patient underwent a repeat operation on
the heart after the patient had left the operating room from the initial operation and within
current hospitalization or within 30 days of the initial operation.
130,392 OTHER OCCURRENCES (ICD) 205;36 POINTER TO ICD DIAGNOSIS FILE (#80)
Other Occurrences (ICD)
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: FEB 17, 2012
HELP-PROMPT: Enter the ICD Diagnosis Code for any other occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other surgical occurrences which you feel to be significant
and that are not covered by the predefined occurrence categories. Enter the ICD-CM code for this
entry.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,393 RE-TRANSMISSION RA;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: AUG 20, 1991
HELP-PROMPT: Enter 1 if this assessment will be re-transmitted.
DESCRIPTION: This determines whether the assessment will be re-transmitted. It will automatically be set to '1'
when a transmitted assessment is updated to an INCOMPLETE status to edit and re-transmit.
130,394 *HISTORY OF MI 200;31 SET
*History of MI Within Past 6 Months (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: FEB 07, 2014
HELP-PROMPT: Enter 'YES' if the patient has a history of MI in the 6 months prior to surgery.
DESCRIPTION: Definition Revised (2004): The history of a non-Q wave or a Q wave infarct in the six months prior
to surgery as diagnosed in the patient's medical record.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,395 *ANGINA ONE MONTH PRIOR 200;34 SET
*Angina within 30 Days Preceding Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 22, 2014
HELP-PROMPT: Enter 'YES' if the patient has had angina within one month prior to surgery.
DESCRIPTION: Definition Revised (2004): Pain or discomfort between the diaphragm and the mandible resulting from
myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest
discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to
the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or
interscapular region. Documentation in the chart by the physician should state 'angina' or 'anginal
equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had
angina at any time within 30 days prior to surgery.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,396 *CHF WITHIN ONE MONTH 200;35 SET
*CHF Within 30 Days Prior to Surgery (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 16, 2014
HELP-PROMPT: Enter 'YES' if the patient has had CHF within one month prior to surgery.
DESCRIPTION: Definition Revised (2004): Congestive Heart Failure is the inability of the heart to pump a
sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased
ventricular filling pressure. Only newly diagnosed CHF within the previous 30 days or a diagnosis
of chronic CHF with new signs or symptoms in the 30 days prior to surgery fulfills this definition.
Common manifestations are:
- Abnormal limitation in exercise tolerance due to dyspnea or fatigue
- Orthopnea (dyspnea on lying supine)
- Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea)
- Increased jugular venous pressure
- Pulmonary rales on physical examination
- Cardiomegaly
- Pulmonary vascular engorgement
Should be noted in the medical record as CHF, congestive heart failure, or pulmonary edema.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,397 SEVERE HEAD TRAUMA (Y/N) 200;20 SET
Severe Head Trauma (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: SEP 10, 1991
HELP-PROMPT: Enter 'YES' if the patient has sustained severe head trauma.
DESCRIPTION: This determines whether the patient has sustained open or closed trauma to the head from external
force, violence, or accident with resulting impairment in neurological function as manifested by
motor, sensory, or cognitive impairments.
130,398 QUADRIPLEGIA (Y/N) 200;22 SET
Quadriplegia/Tetraplegia/Quadriparesis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 24, 2007
HELP-PROMPT: Enter 'YES' if the patient has total or partial paralysis or paresis of all four extremities.
DESCRIPTION: Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in
total or partial paralysis or paresis (weakness) of all four extremities.
130,399 PARAPLEGIA (Y/N) 200;23 SET
Paraplegia/Paraparesis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter 'YES' if the patient has total or partial paralysis or paresis of the lower extremities.
DESCRIPTION: Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in
total or partial paralysis or paresis (weakness) of the lower extremities.
130,400 HEMIPLEGIA/HEMIPARESIS (Y/N) 200;24 SET
Hemiplegia/Hemiparesis (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has total or partial paralysis or paresis on one side of the body.
DESCRIPTION: Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in
total or partial paralysis or paresis (weakness) of one side of the body. Enter YES if the patient
has hemiplegia/hemiparesis (that has not recovered or been rehabilitated) upon arrival to the OR.
Enter YES if there is hemiplegia or hemiparesis associated with a CVA/Stroke also.
130,401 TUMOR INVOLVING CNS (Y/N) 200;29 SET
Tumor Involving CNS (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has a tumor involving the central nervous system.
DESCRIPTION: Definition Revised (2007): Space-occupying tumor of the brain and spinal cord, which may be benign
(e.g., meningiomas, ependymoma, oligodendroglioma) or primary (e.g., astrocytoma, glioma,
glioblastoma multiform) or secondary malignancies (e.g., metastatic lung, breast, malignant
melanoma). Other tumors that may involve the CNS include lymphomas and sarcomas. Answer "YES" even
if the tumor was not treated. A patient with metastatic cancer with boney mets to spine is a CNS
tumor. Answer "NO" if tumor was removed.
130,402 GENERAL (Y/N) 200;1 SET
General Medical Problems (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 12, 1991
HELP-PROMPT: Enter 'YES' if the patient has any general medical problems.
DESCRIPTION: This determines whether the patient has any general medical problems, such as diabetes, dyspnea, or
alcohol related illnesses.
130,403 WOUND OCCURRENCES 205;5 SET
Postoperative Wound Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: FEB 26, 1995
HELP-PROMPT: Enter 'YES' if the patient has any postoperative wound occurrences.
DESCRIPTION:
This determines whether the patient had any postoperative wound occurrences.
130,404 WOUND DISRUPTION 205;8 SET
Wound Disruption (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JAN 07, 2014
HELP-PROMPT: Enter Yes if the patient has postoperative wound disruption.
DESCRIPTION: Definition Revised (2014): Separation of the skin and musculofascial layers of a surgical wound
(any surgical site whether primary or secondary, e.g. vein harvest incision), which may be partial
or complete.
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,405 LOW SERUM SODIUM 203;2 FREE TEXT
Lowest Serum Sodium
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the lowest postoperative serum sodium result recorded within 30 days postoperatively. Data
input must be 1 to 5 numeric characters in length which may include a prefix of a less than or
greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,406 LOW POTASSIUM 203;4 FREE TEXT
Lowest Postoperative Potassium
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: APR 10, 1997
HELP-PROMPT: Answer must be 1-3 characters in length.
DESCRIPTION: This is the lowest recorded postoperative potassium result. Data input must be 1 to 3 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,407 LOW SODIUM, DATE 204;2 DATE
Date of Lowest Serum Sodium
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the lowest postoperative serum sodium was recorded.
DESCRIPTION: This is the date that the lowest serum sodium test result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,408 LOW POTASSIUM, DATE 204;4 DATE
Date of Lowest Postoperative Potassium
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the lowest postoperative potassium was recorded.
DESCRIPTION: This is the date that the lowest potassium test result was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,409 RENAL INSUFFICIENCY 205;16 SET
Progressive Renal Insufficiency (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient has progressive renal insufficiency.
DESCRIPTION: Definition Revised (2004): The reduced capacity of the kidney to perform its function as evidenced
by a rise in creatinine of >2 mg/dl from preoperative value, but with no requirement for dialysis.
130,410 COMA > 24 HOURS POSTOP 205;22 SET
Coma Greater than 24 Hours Postop (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 19, 2011
HELP-PROMPT: Enter YES if the patient has significantly impaired level of consciousness > or = 24 hours
postoperatively.
DESCRIPTION: Definition Revised (2011): Indicate if either postoperatively or within 30 days of surgery there
was a significantly decreased level of consciousness (exclude transient disorientation or
psychosis) for greater than or equal to 24 hours as evidenced by lack of response to deep, painful
stimuli. Do not include drug-induced coma (e.g. Propofol drips, etc.)
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,411 CARDIAC ARREST REQ CPR 205;26 SET
Cardiac Arrest Requiring CPR (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 28, 2011
HELP-PROMPT: Enter YES if the patient has had postoperative cardiac arrest requiring CPR.
DESCRIPTION: Definition Revised (2011): Indicate if there was any cardiac arrest requiring external or open
cardiopulmonary resuscitation (CPR) occurring in the operating room, ICU, ward, or out-of-hospital
after the chest had been completely closed and within 30 days of surgery. Patients with AICDs that
fire but the patient does not lose consciousness should be excluded.
If patient had cardiac arrest requiring CPR, indicate whether the arrest occurred intraoperatively
or postoperatively. Indicate the one appropriate response: - intraoperatively: occurring while
patient was in the operating room - postoperatively: occurring after patient left the operating
room.
TECHNICAL DESCR: The user indicates whether cardiac arrest requiring CPR occurred intraoperatively or
postoperatively by the menu option selected to record the occurrence. Intraoperative occurrences
are recorded in the INTRAOPERATIVE OCCURRENCES multiple field (#1.14) in the SURGERY file (#130).
Postoperative occurrences are recorded in the POSTOP OCCURRENCE multiple field (#1.16) multiple
field (#1.14) in the SURGERY file (#130).
SCREEN: S DIC("S")="I Y'=""NS"""
EXPLANATION: Screen prevents selection of retired code.
130,412 UNPLANNED INTUBATION (Y/N) 205;11 SET
Unplanned Intubation for Respiratory/Cardiac Failure (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter YES if the patient had an unplanned intubation due to respiratory or cardiac failure.
DESCRIPTION: Definition Revised (2004): Patient required placement of an endotracheal tube and mechanical or
assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe
respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated
for their surgery, unplanned intubation occurs after they have been extubated after surgery. In
patients who were not intubated during surgery, intubation at any time after their surgery is
considered unplanned.
130,413 TRANSFER STATUS 208;11 SET
Transfer Status
'1' FOR NOT TRANSFERRED;
'2' FOR NON-VAMC ACUTE CARE HOSPITAL;
'3' FOR VAMC ACUTE CARE HOSPITAL;
'4' FOR NON-VA NURSING/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY;
'5' FOR VA NURSING HOME/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY;
'6' FOR OTHER;
LAST EDITED: JUL 01, 2004
HELP-PROMPT: Enter the transfer status of this patient upon admission.
DESCRIPTION: Definition Revised (2004): Was the patient transferred directly from another healthcare facility
and admitted to this hospital? Please select from the following choices. If the patient was
admitted from home, select #1. If the patient was transferred from another facility, please select
from choices #2-6.
(1) Not transferred from a health care facility; admitted directly
from home
(2) Non-VAMC Acute Care Hospital
(3) VAMC Acute Care Hospital
(4) Non-VA Nursing Home/Chronic Care Facility/Spinal Cord Injury
Unit/Intermediate Care Unit
(5) VA Nursing Home/Chronic Care Facility/Spinal Cord Injury
Unit/Intermediate Care Unit
(6) Other (for example, Domiciliary)
* If a patient arrives from another hospital's emergency department, report as #1. If you cannot
determine what kind of facility, enter "OTHER".
130,414 CARDIAC SURGICAL PRIORITY 208;12 SET
Cardiac Surgical Priority
'1' FOR ELECTIVE;
'2' FOR URGENT;
'3' FOR EMERGENT (ONGOING ISCHEMIA);
'4' FOR EMERGENT (HEMODYNAMIC COMPROMISE);
'5' FOR EMERGENT (ARREST WITH CPR);
LAST EDITED: JAN 22, 2007
HELP-PROMPT: Enter the surgical priority that most accurately reflects the acuity of patient's cardiovascular
condition at the time of transport to the operating room.
DESCRIPTION: If this is a cardiac procedure, this is the surgical priority reflecting the patient's
cardiovascular condition at the time of transport to the operating room:
1. Elective - Patient placed on elective schedule with surgery usually
performed > 72 hours following catheterization.
2. Urgent - Clinical condition mandates prompt surgery usually within
12 to 72 hours of catheterization (patients clinically stable on a
circulatory support system should be included in this category).
3. Emergent (ongoing ischemia) - Clinical condition mandates immediate
surgery usually on day of catheterization because of ischemia
despite medical therapy, such as intravenous nitroglycerine.
Ischemia should be manifested as chest pain and/or ST-segment
depression.
4. Emergent (hemodynamic compromise) - Persistent hypotension (arterial
systolic pressure < 80 mm Hg) and/or low cardiac output (cardiac
index < 2.0 L/min/MxM) despite iontropic and/or mechanical
circulatory support mandates immediate surgery within hours of the
cardiac catheterization.
5. Emergent (arrest with CPR) - Patient is taken to the operating room
in full cardiac arrest with the circulation supported by
cardiopulmonary resuscitation (excludes patients being adequately
perfused by a cardiopulmonary support system).
130,414.1 SURGICAL PRIORITY, DATE 208;13 DATE
Date/Time of Cardiac Surgical Priority
INPUT TRANSFORM: S %DT="ETXRP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 08, 2008
HELP-PROMPT: Enter the date and time that the cardiac surgical priority was documented.
DESCRIPTION:
This is the date and time that the cardiac surgical priority information was collected.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,415 MITRAL REGURGITATION 206;9 SET
Mitral Regurgitation
'0' FOR NONE;
'1' FOR MILD;
'2' FOR MODERATE;
'3' FOR SEVERE;
'NS' FOR NO STUDY;
LAST EDITED: JUL 21, 2004
HELP-PROMPT: Enter the code describing presence/severity of mitral regurgitation.
DESCRIPTION: Definition Revised (2004): Indicate the severity of any mitral regurgitation documented for the
patient. This question should be answered using either the left ventricular angiogram or the
cardiac ultrasound examination. Adjectives used to describe the severity of the mitral
regurgitation on the cardiac cath report should be converted to a four-point scale: 1+ = mild, 2 or
3+ = moderate, and 4+ = severe.
Diagnosis by angiogram:
=======================
The following definitions should be used to assess the presence/severity of mitral regurgitation
based on the interpretation of the contrast left ventricular angiogram:
None/Trivial - There is no visible systolic regurgitation across the mitral valve. Trace or trivial
notations of mitral regurgitation should be listed as none.
Mild - Definite contrast can be seen in the left atrium following left ventricular injection, but
the left atrium never fills to the same opacity as the left ventricle.
Moderate - The left atrium fills to the same opacity as the left ventricle over two or more
systoles.
Severe - The left atrium fills to the same opacity as the left ventricle over a single systole.
NS - If unable to make an assessment of the patient's left ventricular contraction grade or no
study was performed, entering "NS" for "No Study/Unknown" is also allowed.
Diagnosis by cardiac ultrasound:
================================
The following definitions are commonly used to assess the presence/severity of mitral regurgitation
based on the interpretation of the cardiac ultrasound examination:
None/Trivial - No regurgitant jet is seen on the Doppler study. Trace or trivial notations of
mitral regurgitation should be listed as none.
Mild - The area of the regurgitant jet is 0 - 4 cm2.
Moderate - The area of the regurgitant jet is >4 - 8 cm2.
Severe - The area of the regurgitant jet is greater than 8 cm2 or greater than one third of the
total left atrial area.
NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
130,416 *NUMBER WITH OTHER CONDUIT 207;20 NUMBER
*CABG Distal Anastomoses with Other Conduit
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUL 21, 2004
HELP-PROMPT: Type a Number between 0 and 9, 0 Decimal Digits
DESCRIPTION: Definition Revised (2004): This is the number of coronary artery bypass graft (CABG) anastomoses to
native coronary arteries with other conduit(s) regardless of whether other procedures were
performed. Do not leave this information blank. If no coronary artery bypass grafts with other
conduits were performed, enter '0'.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,417 RACE 208;10 SET
Patient's Race
'1' FOR HISPANIC, WHITE;
'2' FOR HISPANIC, BLACK;
'3' FOR AMERICAN INDIAN OR ALASKA NATIVE;
'4' FOR BLACK, NOT OF HISPANIC ORIGIN;
'5' FOR ASIAN OR PACIFIC ISLANDER;
'6' FOR WHITE, NOT OF HISPANIC ORIGIN;
'7' FOR UNKNOWN;
LAST EDITED: MAR 06, 1996
DESCRIPTION:
This is the race of the patient. This is a standard set of codes and should not be edited.
130,418 HOSPITAL ADMISSION DATE 208;14 FREE TEXT
Hospital Admission Date/Time
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2011
HELP-PROMPT: Enter the date and time of the hospital admission associated with this surgical case.
DESCRIPTION: Definition Revised (2011): The date and time of the hospital admission to this VAMC associated with
this surgical case as found in the PIMS package. If the patient was admitted directly to surgery
and then admitted to the hospital, use the date of surgery as the date of admission. Entering NA
for "NOT APPLICABLE" is allowed for non-cardiac surgery patients.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,419 HOSPITAL DISCHARGE DATE 208;15 FREE TEXT
Hospital Discharge Date/Time
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: APR 20, 2011
HELP-PROMPT: Enter the date and time of the hospital discharge associated with this surgical case.
DESCRIPTION: Definition Revised (2011): Indicate the date of the hospital discharge associated with this
surgical case. Patients transferred to a referring facility should be indicated as discharged from
current admission. Patients transferred to the psychiatric unit or any chronic care facility
located at the VA facility (e.g., a nursing home) should be indicated as discharged from current
admission at the date and time of the transfer to this different facility. (Do not indicate the
date of data input, unless the patient was actually discharged on this same date.)
Patients who remain as inpatients for reasons other than for post- open heart procedures should
continue to be followed until discharged (including the rehabilitation service) even if the
cardiothoracic team discharges the patient from their service or would discharge the patient home.
If the patient remains in the hospital and/or has subsequent surgeries, indicate such in the
CARDIAC RESOURCE DATA COMMENTS field (#431.)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,420 ADMISSION/TRANSFER DATE 208;16 FREE TEXT
Admitted/Transferred to Surgical Service Date/Time
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 08, 2008
HELP-PROMPT: Enter the date of transfer to surgical service for this surgical episode or enter NA if this date
is not applicable.
DESCRIPTION: Definition Revised (2004): If the patient was not initially admitted to the surgical service, the
date and time of transfer to surgical service for this surgical episode will be entered from the
PIMS package. Enter 'NA' if this date is not applicable, e.g. outpatient not admitted or observed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,421 DISCHARGE/TRANSFER DATE 208;17 FREE TEXT
Date Discharged/Transferred to Chronic Care
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 08, 2008
HELP-PROMPT: Enter date and time of the patient's discharge or transfer from the surgical or medical service to
a chronic care setting, or enter NA if this date is not applicable.
DESCRIPTION: Definition Revised (2004): The date and time of the patient's discharge or transfer from the
surgical or medical service to a chronic care setting. i.e., spinal cord injury unit, psychiatric
facility or psychiatric unit, nursing home care unit or facility, or intermediate medicine. Acute
care beds must be established locally with the assistance of your station IRM service.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,422 OUT-OF-OR UNPLANNED INTUBATION 205;44 SET
Out-Of-OR Unplanned Intubation Within 30 Days
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 29, 2015
HELP-PROMPT: Enter Yes if the patient had Out-Of-OR unplanned intubation within 30 days.
DESCRIPTION: VASQIP Definition (2015): Patient required unplanned placement of an endotracheal tube or other
similar breathing tube out of the operating room for ventilator support within 30 days following
surgery regardless of cause. This definition includes:
1) patients re-intubated out of the operating room following planned
extubation and
2) patients who self-extubate out of the operating room and were not
immediately re-intubated.
130,423 CONGESTIVE HEART FAILURE PREOP 207;29 SET
Preop Congestive Heart Failure
'0' FOR N CARD DX, CHF, OR SX;
'1' FOR Y CARD DX/CHF, N SX;
'2' FOR Y CARD DX/CHF, Y MILD SX;
'3' FOR Y CARD DX/CHF, Y MARKED SX;
'4' FOR Y CARD DX/CHF, Y SX AT REST;
'5' FOR N CARD DX/CHF, SX UNKNOWN;
'6' FOR Y CARD DX/CHF, SX UNKNOWN;
LAST EDITED: AUG 25, 2015
HELP-PROMPT: Indicate whether the patient has Congestive Heart Failure in the 30 days prior to surgery.
DESCRIPTION: VASQIP Definition (2015): Indicate whether the patient has congestive heart failure if the patient
chart or patient self-report indicates a history of congestive heart failure with one of the
following that describes symptoms in the 30 days before surgery. Indicate the one most appropriate
response:
0 - Documented history of no cardiac disease or congestive heart
failure, and no symptoms of abnormal fatigue, dyspnea, or angina. 1 - Documented history of
cardiac disease or congestive heart failure;
no symptoms of abnormal fatigue, dyspnea, or angina. 2 - Documented history of cardiac disease
or congestive heart failure;
slight limitation of physical activity by fatigue, dyspnea, or
angina.
The patient gets unusual fatigue, dyspnea, and/or angina only upon
performing more strenuous activities, such as climbing two or more
flights of stairs without stopping. 3 - Documented history of cardiac disease or congestive
heart failure;
marked limitation of physical activity by fatigue, dyspnea, or
angina. The patient gets unusual fatigue, dyspnea, and/or angina
upon performing ordinary activities, such as walking several blocks
or climbing a flight of stairs. 4 - Documented history of cardiac disease or congestive heart
failure;
symptoms at rest and/or inability to carry out any physical
activity without symptoms of fatigue, dyspnea or angina. The
patient has symptoms of unusual fatigue, dyspnea, and/or angina
at rest or when performing minimal activity, such as walking across
the room. 5 - No documented history of cardiac disease or congestive heart
failure, and symptomatology is unknown (e.g., documentation not
found or could not be determined with available information) 6 - Documented history of cardiac
disease or congestive heart failure,
and symptomatology is unknown (e.g., documentation not found or
could not be determined with available information)
130,430 CARDIAC RISK PREOP COMMENTS 206.1;1 FREE TEXT
Preoperative Risk Summary Data
INPUT TRANSFORM: K:$L(X)>130!($L(X)<1) X
LAST EDITED: FEB 09, 2006
HELP-PROMPT: Answer must be 1-130 characters in length.
DESCRIPTION: Definition Revised (2006): Indicate in the comment field any preoperative patient risk factors (not
previously entered above) that may contribute to this patient's risk of operative mortality. (The
maximum length of this field is 130 characters.)
130,431 CARDIAC RESOURCE DATA COMMENTS 206.2;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>130!($L(X)<1) X
LAST EDITED: JAN 21, 2014
HELP-PROMPT: Answer must be 1-130 characters in length.
DESCRIPTION: Definition Revised (2014): Indicate additional comments related to this case prior to transmission
to Denver by the SQN/Data Manager (limit 130 characters).
130,439 BATISTA PROCEDURE USED (Y/N) 207;23 SET
Batista Procedure Used (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 04, 1997
HELP-PROMPT: Enter whether the Batista Procedure was used or not.
DESCRIPTION:
Was the Batista procedure used, Yes or No?
130,440 CARDIAC CATHETERIZATION DATE 207;21 DATE
Cardiac Catheterization Date
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" S %DT="ETPX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: SEP 07, 2000
HELP-PROMPT: Enter the date of the cardiac catheterization closest to and prior to the date of operation or
enter NS if unknown or not applicable.
DESCRIPTION: Record the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS
if unknown or not applicable.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,441 MINIMALLY INVASIVE PROC (Y/N) 207;22 SET
Minimally Invasive Procedure Technique Used (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 17, 1997
DESCRIPTION:
Was a minimally invasive procedure technique used, Yes or No?
130,442 EMPLOYMENT STATUS PREOPERATIVE 208;18 SET
Employment Status Preoperatively
'1' FOR EMPLOYED FULL TIME;
'2' FOR EMPLOYED PART TIME;
'3' FOR NOT EMPLOYED;
'4' FOR SELF EMPLOYED;
'5' FOR RETIRED;
'6' FOR ACTIVE MILITARY DUTY;
'9' FOR UNKNOWN;
LAST EDITED: OCT 28, 1997
HELP-PROMPT: Enter the patient's employment status preoperatively.
DESCRIPTION: Employment status preoperatively is to be defined in the broad sense of regularly performed work
activity with remuneration.
130,443 INTRAOP DISSEMINATED CANCER 200.1;4 SET
Intraoperative Disseminated Cancer (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: FEB 13, 2007
HELP-PROMPT: Enter YES if cancer was found during the operative procedure.
DESCRIPTION: VASQIP Definition (2010): Intraoperative Disseminated Cancer: Patients who have cancer that was
found during the operative procedure that:
(1) Has spread to one site or more sites in addition to the primary
site
AND
(2) In whom the presence of multiple metastases indicates the cancer
is widespread, fulminant, or near terminal. Other terms describing
disseminated cancer include "diffuse," "widely metastatic,"
"widespread," or "carcinomatosis" or AJCC "Stage IV" cancer.
Common sites of metastases include major organs (e.g., brain,
lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You
may use the National Cancer Institute as a reference in
determining whether a patient has AJCC Stage IV cancer, when the
TNM information is the only information documented. Refer to the
following website for assistance with translating TNM values with
AJCC staging:
http://www.cancer.gov/cancertopics/pdq/adulttreatment
Examples:
- A patient with a primary breast cancer with positive nodes in the
axilla does NOT qualify for this definition. The tumor has spread
to a site other than the primary site, but does not have widespread
metastases. A patient with primary breast cancer with positive
nodes in the axilla AND liver metastases does qualify, because the
tumor has spread to the axilla and other major organs.
- A patient with colon cancer and no positive nodes or distant
metastases does NOT qualify. A patient with colon cancer and
several local lymph nodes positive for tumor, but no other evidence
of metastatic disease does NOT qualify. A patient with colon cancer
with liver metastases and/or peritoneal seeding with tumor does
qualify.
- A patient with adenocarcinoma of the prostate confined to the
capsule does NOT qualify. A patient with prostate cancer that
extends through the capsule of the prostate only does NOT qualify. A
patient with prostate cancer with bony metastases DOES qualify.
* Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma
under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia
(CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.
SCREEN: S DIC("S")="I ""NS""'=Y"
EXPLANATION: Screen prevents selection of inactive code.
130,444 PREOPERATIVE ANION GAP 203;15 FREE TEXT
Preoperative Anion Gap
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JAN 27, 2006
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative Anion Gap calculation. Data input must be 1 to 5 numeric
characters in length which may include a prefix of a less than or greater than sign "<" or ">".
Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,444.1 PREOP ANION GAP, DATE 204;15 DATE
Date Preoperative Anion Gap was Recorded
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date the preoperative Anion Gap was recorded.
DESCRIPTION:
This is the date the preoperative Anion Gap was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,445 HIGHEST ANION GAP 203;16 FREE TEXT
Highest Postoperative Anion Gap
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JAN 27, 2006
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the highest postoperative anion gap recorded. Data input must be 1 to 5
numeric characters in length which may include a prefix of a less than or greater than sign "<" or
">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,445.1 HIGH ANION GAP, DATE 204;16 DATE
Date Highest Anion Gap was Recorded
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest postop Anion Gap was recorded.
DESCRIPTION:
This is the date that the highest postoperative Anion Gap was recorded.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,446 INTRAOPERATIVE ASCITES 200.1;6 SET
Intraoperative Ascites
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 22, 2007
HELP-PROMPT: Enter Yes or No. NS is not allowed.
DESCRIPTION: VASQIP Definition (2010): Intraoperative Ascites: The presence of fluid accumulation in the
peritoneal cavity noted during the operative procedure. Documentation should state a history of or
active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver
failure, or spider telangiectasia).
130,447 CLOSTRIDIUM DIFFICILE COLITIS 205;39 SET
Clostridium Difficile Colitis (C. difficile)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: NOV 02, 2007
HELP-PROMPT: Enter YES if this patient had postoperative C. difficile colitis.
DESCRIPTION: Definition Revised (2008): C. difficile-associated disease occurs when the normal intestinal flora
is altered, allowing C. difficile to flourish in the intestinal tract and produce a toxin that
causes a watery diarrhea. C. difficile diarrhea is confirmed by the presence of a toxin in a stool
specimen. Answer yes only if you have a positive culture for C. difficile and/or a toxin assay and
diagnosis of C. difficile documented in the chart.
130,448 POSTOP ATRIAL FIBRILLATION 205;40 SET
Postoperative Atrial Fibrillation
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter YES if the patient had a new onset postoperatively of atrial fibrillation/flutter (AF).
DESCRIPTION: VASQIP Definition (2010) Indicate whether the patient had a new onset of atrial
fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been
present preoperatively.
130,450 TOTAL ISCHEMIC TIME 206;36 NUMBER
Total Ischemic Time (minutes)
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 02, 1997
HELP-PROMPT: Type a Number between 0 and 9999, 0 Decimal Digits
DESCRIPTION: Record in minutes the duration of time the ascending aorta is totally cross-clamped. Do not
include the duration of partial aorta cross-clamp used for sewing the proximal anastomoses.
130,451 TOTAL CPB TIME 206;37 NUMBER
Total CPB (Cardiopulmonary ByPass) Time (minutes)
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: OCT 08, 1997
HELP-PROMPT: Type a Number between 0 and 9999, 0 Decimal Digits
DESCRIPTION: Record in minutes the total cardiopulmonary bypass time. This includes the total duration of full
and partial cardiopulmonary bypass from all episodes of cardiopulmonary bypass. This information
can generally be found on the perfusionist record and/or the anesthesia record.
130,452 OBSERVATION ADMISSION DATE 208.1;1 FREE TEXT
Observation Admission Date/Time
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: MAR 12, 2015
HELP-PROMPT: Enter the date and time the patient was admitted for observation or enter NA if this information is
not applicable.
DESCRIPTION: Definition Revised (2015): An observation patient is one who presents with a medical condition with
a significant degree of instability or disability, and who needs to be monitored, evaluated and
assessed for either admission to inpatient status or assignment to care in another setting. An
observation patient can occupy a special bed set aside for this purpose or may occupy a bed in any
unit of a hospital, i.e., urgent care, medical unit. These types of patients should be evaluated
against standard inpatient criteria. These beds are not designed to be a holding area for Emergency
Rooms. The length-of-stay in observation beds will not exceed 47 hours and 59 minutes. Following
surgery, if the patient was admitted for observation, this is the date and time of admission for
observation. If this information is not applicable, enter NA.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,453 OBSERVATION DISCHARGE DATE 208.1;2 FREE TEXT
Observation Discharge Date/Time
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 08, 2008
HELP-PROMPT: Enter the date and time the patient was discharged from observation or enter NA if this information
is not applicable.
DESCRIPTION: Definition Revised (2004): If the patient was admitted for observation following surgery, this is
the date and time of discharge from observation. If this information in not applicable, enter NA.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,454 OBSERVATION TREATING SPECIALTY 208.1;3 POINTER TO SPECIALTY FILE (#42.4)
Observation Treating Specialty
INPUT TRANSFORM: S:X="NA"!(X="na") X="NA" Q:X="NA" S DIC("S")="I $P(^DIC(42.4,Y,0),U)[""OBSERVATION""" D ^DIC K DIC
S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAR 16, 2004
HELP-PROMPT: Enter the observation treating specialty associated with the admission for observation or enter NA
if this information is not applicable.
DESCRIPTION: Definition Revised (2004): If the patient was admitted for observation following surgery, this is
the observation treating specialty to which the patient was admitted. If this information is not
applicable, enter NA.
SCREEN: S DIC("S")="I $P(^DIC(42.4,Y,0),U)[""OBSERVATION"""
EXPLANATION: Screen allows selection of OBSERVATION specialties only.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,455 HIGHEST SERUM TROPONIN I 203;13 FREE TEXT
Highest Postoperative Serum Troponin I
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: FEB 09, 1999
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the highest postoperative serum cardiac troponin I test. Data input must be
1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,455.1 HIGH SERUM TROPONIN I, DATE 204;13 DATE
Date Highest Postop Troponin I was Performed
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest postop troponin I was performed.
DESCRIPTION:
This is the date that the highest postop serum troponin I was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,456 HIGHEST SERUM TROPONIN T 203;14 FREE TEXT
Highest Postoperative Serum Troponin T
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: FEB 09, 1999
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the highest postoperative serum cardiac troponin T test. Data input must be
1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,456.1 HIGH SERUM TROPONIN T, DATE 204;14 DATE
Date Highest Postop Troponin T was Performed
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the highest postop troponin T was performed.
DESCRIPTION:
This is the date that the highest postop serum troponin T was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,457 HDL (CARDIAC) 201;21 FREE TEXT
HDL (mg/dl)
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: FEB 22, 2006
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2006): Indicate the HDL result (mg/dl) preoperatively evaluated closest to
surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,457.1 HDL, DATE 202;21 FREE TEXT
HDL, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: This is the date that the HDL was performed and must not be more than 1000 days before surgery.
DESCRIPTION: Definition Revised (2006): Indicate the date that the preoperative HDL value was assessed. Enter
"NS" for No Study if the HDL test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,458 SERUM TRIGLYCERIDE (CARDIAC) 201;22 FREE TEXT
Serum Triglyceride (mg/dl)
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:$L(X)>6!($L(X)<1) X
LAST EDITED: FEB 22, 2006
HELP-PROMPT: Answer must be 1-6 characters in length
DESCRIPTION: Definition Revised (2006): Indicate the Serum Triglyceride result (mg/dl) preoperatively
evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,458.1 SERUM TRIGLYCERIDE, DATE (CAR) 202;22 FREE TEXT
Serum Triglyceride, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: This is the date that the Serum Triglyceride was performed and must not be more than 1000 days
before surgery.
DESCRIPTION: Definition Revised (2006): Indicate the date that the preoperative Serum Triglyceride value was
assessed. Enter "NS" for No Study if the Serum Triglyceride test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,459 SERUM POTASSIUM (CARDIAC) 201;23 FREE TEXT
Serum Potassium (mg/L)
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JUN 30, 2004
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2004): Indicate the serum potassium result (mg/L) preoperatively evaluated
closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is
allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,459.1 SERUM POTASSIUM, DATE(CARDIAC) 202;23 FREE TEXT
Serum Potassium, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the Serum Potassium was performed.
DESCRIPTION: Definition Revised (2004): Indicate the date that the preoperative Serum Potassium value was
assessed. Enter "NS" for No Study if the Serum Potassium test was not performed or was performed
more than 90 days before surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,460 SERUM BILIRUBIN (CARDIAC) 201;24 FREE TEXT
Serum Bilirubin (mg/dl)
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JUN 30, 2004
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2004): Indicate the serum bilirubin result (mg/dl) preoperatively evaluated
closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is
allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,460.1 SERUM BILIRUBIN, DATE (CARD) 202;24 FREE TEXT
Serum Bilirubin, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the Serum Bilirubin was performed.
DESCRIPTION: Definition Revised (2004): Indicate the date that the preoperative Serum Bilirubin value was
assessed. Enter "NS" for No Study if the Serum Bilirubin test was not performed or was performed
more than 90 days before surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,461 LDL (CARDIAC) 201;25 FREE TEXT
LDL (mg/dl)
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: MAR 08, 2006
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2006): Indicate the LDL result (mg/dl) preoperatively evaluated closest to
surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,461.1 LDL, DATE (CARDIAC) 202;25 FREE TEXT
LDL, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: This is the date that the LDL was performed and must not be more than 1000 days before surgery.
DESCRIPTION: Definition Revised (2006): Indicate the date that the preoperative LDL value was assessed. Enter
"NS" for No Study if the LDL test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,462 TOTAL CHOLESTEROL (CARDIAC) 201;26 FREE TEXT
Total Cholesterol (mg/dl)
INPUT TRANSFORM: K:$L(X)>6!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: FEB 22, 2006
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2006): Indicate the Total Cholesterol result (mg/dl) preoperatively evaluated
closest to surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,462.1 TOTAL CHOLESTEROL, DATE 202;26 FREE TEXT
Total Cholesterol, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JAN 19, 2007
HELP-PROMPT: This is the date that the Total Cholesterol was performed and must not be more than 1000 days
before surgery.
DESCRIPTION: Definition Revised (2006): Indicate the date that the preoperative Total Cholesterol value was
assessed. Enter "NS" for No Study if the Cholesterol test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,463 *HYPERTENSION 206;38 SET
*History of Hypertension (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 16, 2014
HELP-PROMPT: Enter YES if there is any indication that the patient has hypertension.
DESCRIPTION: Definition Revised (2004): Indicate if the patient has a documented history of hypertension with or
without current treatment of antihypertensive medication(s). If a diuretic agent is prescribed to
treat hypertension, indicate Yes for both the hypertension and the diuretic questions. (YES/NO).
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,464 *NUMBER WITH RADIAL ARTERY 207;24 NUMBER
*Number with Radial Artery
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: JUL 05, 2000
HELP-PROMPT: Enter the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
performed with radial artery(ies).
DESCRIPTION: This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
with radial artery(ies) regardless of whether other procedures were performed. Do not leave blank,
enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with
radial artery. Note that any CABG distal anastomoses performed without placing the patient on
cardiopulmonary bypass are to be recorded.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,465 *NUMBER WITH OTHER ARTERY 207;25 NUMBER
*Number with Other Artery
INPUT TRANSFORM: K:+X'=X!(X>10)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: AUG 24, 2000
HELP-PROMPT: Enter the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
performed with other artery(ies).
DESCRIPTION: This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries
with other artery(ies) regardless of whether other procedures were performed. Do not leave blank,
enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with other
artery(ies). Note that any CABG distal anastomoses performed without placing the patient on
cardiopulmonary bypass are to be recorded.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,466 TRACHEOSTOMY 206;39 SET
Tracheostomy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 09, 2004
HELP-PROMPT: Enter YES if a postoperative tracheostomy was performed on this patient.
DESCRIPTION: Definition Revised (2004): Indicate if a procedure to cut into the trachea and insert a tube to
overcome tracheal obstruction or to facilitate extended mechanical ventilation was performed within
30 days of surgery.
130,467 NEW MECHANICAL CIRCULATORY 206;40 SET
New Mechanical Circulatory Support
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 07, 2014
HELP-PROMPT: Enter NO if new mechanical circulatory support was not necessary perioperatively.
DESCRIPTION: Definition Revised (2014): Indicate if the patient left the operating room suite with or required
post-op placement of a new IABP, ECMO, or VAD for circulatory support within 30 days
post-operatively.
130,468 INCISION TYPE 207;26 SET
Incision Type
'FS' FOR FULL STERNOTOMY;
'FT' FOR FULL THORACOTOMY;
'LP' FOR LIMITED PARASTERNAL APPROACH;
'LS' FOR LIMITED STERNOTOMY;
'LT' FOR LIMITED THORACOTOMY;
'OL' FOR OTHER LIMITED SURG APPROACH;
'NS' FOR NO STUDY/UNKNOWN;
LAST EDITED: SEP 19, 2000
HELP-PROMPT: Select the appropriate description of the incision used for cardiac access.
DESCRIPTION: This describes the incision used for cardiac access, according to the operative report. (Do not
include incisions for port access.) Enter NS if incision type is unknown.
- Limited Sternotomy: The incision cuts through a small portion (less
than half of the length) of the sternum (the narrow, flat bone in
the median line of the thorax in the front of the chest).
- Full Sternotomy: The incision cuts through the entire length of the
sternum (the narrow, flat bone in the median line of the thorax in
the front of the chest).
- Limited Thoracotomy: A small surgical incision through a portion of
the chest wall, but not along the sternum. For example, an
anterolateral thoracotomy approach may be used in LIMA to LAD
grafting.
- Full Thoracotomy: A larger surgical incision running across the
chest wall, but not along the sternum. This may be a left
submammary incision, which requires the resection of the fourth
costal cartilage and /or deflation of the left lung.
- Limited Parasternal Approach: The incision cuts beside a small
portion (less than 0.5 of the length) of the sternum, on a line
midway between the sternal margin and an imaginary line passing
through the nipple.
- Other Limited Surgical Approach: An incision or incision set used to
visualize the operating field that is not listed above.
130,469 CONVERT FROM OFF PUMP TO CPB 207;27 SET
Convert from Off Pump to CPB
'1' FOR NO (began off-pump/ stayed off-pump);
'2' FOR YES-PLANNED;
'3' FOR YES-UNPLANNED;
'4' FOR YES-UNKNOWN IF PLANNED;
'5' FOR NA (began on-pump/ stayed on-pump);
'NS' FOR NO STUDY/UNKNOWN;
LAST EDITED: DEC 23, 2013
HELP-PROMPT: Was this procedure begun as an off-pump procedure, but changed so that CPB was used for any reason,
or any length of time?
DESCRIPTION: Definition Revised (2004): Indicate whether patient was converted from off cardiopulmonary bypass
assistance to on cardiopulmonary bypass during the cardiac surgical procedure. Indicate the one
appropriate response:
No - There was no conversion that occurred for the off-pump case
performed (i.e., the off-pump case remained off-pump throughout
the operation). NA - The procedure was NOT an off-pump case (i.e., procedure began
on-pump and remained on- pump throughout the case). [The default
will be set to N/A.] Yes, planned - The procedure was begun as an off-pump procedure but
changed to on-pump for any length of time; the change was planned
due to decision made prior to operation to perform some vessels
off-pump and some on-pump in order to minimize total CPB time. Yes, unplanned - The procedure
was begun as an off-pump procedure but
changed to on-pump for any length of time; the change was
unplanned and determined in the operating room due to inability
to safely perform revascularization. NS/Unknown - If documentation is not sufficient to
answer, entering
"NS" for "No Study/Unknown" is also allowed.
SCREEN: S DIC("S")="I Y'=4&'(Y=1&($P($G(^SRF(DA,206)),""^"",37)))"
EXPLANATION: Screen prevents selection of 4-YES-UNKNOWN IF PLANNED entry and prevents selection of 1-NO (began o
ff-pump/ stayed off-pump) if CPB Time >0.
130,470 D/T PATIENT EXTUBATED 208;22 FREE TEXT
Date and Time Patient Extubated
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="RI"!(SRX="ri") X="RI"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: DEC 07, 2010
HELP-PROMPT: Enter the exact date and time that the endotracheal tube is pulled for the first time after the
surgery.
DESCRIPTION: Definition Revised (2008): Indicate the date that the endotracheal tube is pulled for the first
time after surgery. If a tracheostomy is performed to replace an oral intubation tube, intubation
is considered continuous so the patient has not been extubated as long as the patient continues to
require ventilator support. If the patient dies while intubated, indicate the date of death for
this data element. Indicate "extubated prior to leaving the OR" in the Resource Comment if patient
is extubated prior to leaving the OR.
RI - The patient remains intubated and on ventilator at 30 days after surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,471 D/T PATIENT DISCH FROM ICU 208;23 FREE TEXT
Date and Time Patient Discharged from ICU
INPUT TRANSFORM: N SRX S SRX=X,%DT="ERTXP" D ^%DT S X=Y K:Y<1 X S:SRX="RI"!(SRX="ri") X="RI"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: JUN 10, 2010
HELP-PROMPT: Enter the first date and time of the discharge from the intensive care unit (ICU).
DESCRIPTION: VASQIP Definition (2010): This is the first date and time of the discharge from the intensive care
unit (ICU). ICU is usually a surgical unit (SICU), although it may also include a post-anesthesia
recovery unit off the operating room. It may also be a general ICU in which medical patients are
also managed (MICU, CCU). This will always be the unit into which the patient goes immediately
after surgery and is stabilized, ventilated and ultimately extubated. Do not include lower acuity
units where the patient goes subsequently (i.e. stepdown, transitional care, telemetry, etc.). Do
not include subsequent readmissions to the ICU.
RI - The patient remains in ICU at 30 days after surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,472 *CARDIAC SURG PERFORMED NON-VA 206;41 SET
*Cardiac surgery contracted and performed at a non-VA facility
'Y' FOR YES;
'N' FOR NO;
'NS' FOR UNKNOWN;
LAST EDITED: JAN 14, 2014
HELP-PROMPT: Enter Yes if the surgery was performed at a non-VA facility through a contract arrangement.
DESCRIPTION: Definition Revised (2004): Indicate whether the patient's cardiac surgery was performed in a non-VA
facility through a contracted arrangement, even if part of the post-surgical care is provided at
the VA. A "contract" facility is one established to be an affiliate with the VA medical center,
and it is most typically a University Hospital. In rare cases a "contract" facility may be a
community hospital when there is no University affiliate for the VAMC. By contrast, a "fee-basis"
patient surgery should not be indicated as a "contract" facility. Typically, a "fee-basis"
establishment is an agreement by the VA Chief of Staff to out-source a patient to a community
hospital. That hospital then bills the Chief of Staff for care rendered on the patient. VASQIP
does not wish to capture the patient data on the "fee-basis" patients. If the patient is not
entered into VISTA, send a paper form to Denver for hand-entry, unless your facility contracts-out
a majority of its cases. Enter "NS" if funding for the procedure is not known. The default is to
NO if a response is not entered.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,473 HOMELESS 209;1 SET
Homeless (Yes/No)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY/UNKNOWN;
LAST EDITED: APR 01, 2004
HELP-PROMPT: Enter 'YES' if the patient does not have a fixed dwelling.
DESCRIPTION: Definition Revised (2004): If the patient indicates he/she does not have a fixed dwelling, indicate
the person's status as homeless.
130,474 PREOP CIRCULATORY DEVICE 209;2 SET
Preop use of circulatory Device
'N' FOR NONE;
'I' FOR IABP;
'V' FOR VAD (includes BIVAD);
'A' FOR ARTIFICIAL HEART;
'O' FOR OTHER;
LAST EDITED: JUN 29, 2010
HELP-PROMPT: Enter the Preoperative use of new mechanical circulatory device within 2 wks of surgery.
DESCRIPTION: VASQIP Definition (2010): Indicate whether there was any use of any device to assist ventricular
function at the time the patient presents for surgery (or placed in the OR before anesthesia
induction). Indicate the one appropriate response:
None - No New Mechanical Circulatory Device was placed.
IABP - An intra-aortic balloon pump was placed to assist ventricular
function.
VAD - A ventricular assist device (e.g., LVAD, BIVAD) was placed to
assist ventricular function.
Artificial Heart - An artificial heart was placed to assist ventricular
function.
Other - An other type of Mechanical Circulatory Device was placed.
130,475 *DIABETES (CARDIAC) 209;3 SET
*Diabetes
'N' FOR NO;
'D' FOR DIET;
'O' FOR ORAL;
'I' FOR INSULIN;
LAST EDITED: JUL 12, 2011
HELP-PROMPT: Enter the patient's diabetes status.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Definition Revised (2006): Indicate if the patient has diabetes treated with diet, oral, and/or
insulin therapy. Diabetes is defined as a metabolic disorder of the pancreas whereby the individual
requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a
hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate
Insulin therapy. Indicate the one most appropriate response. No - no diagnosis of diabetes. Diet -
a diagnosis of diabetes that is controlled by diet alone in the two weeks preceding surgery (the
only prescribed treatment has been diabetic relief). Oral - a diagnosis of diabetes requiring
therapy with an oral hypoglycemic agent in the two weeks preceding surgery. Insulin - a diagnosis
of diabetes requiring daily insulin therapy in the two weeks preceding surgery.
130,476 PROCEDURE TYPE 209;4 SET
Procedure Type
'C' FOR CATH;
'I' FOR IVUS;
'B' FOR BOTH/COMBINATION;
'NS' FOR NO STUDY/UNKNOWN;
LAST EDITED: JUL 21, 2004
HELP-PROMPT: Enter procedure type, which was used for the cardiac catheterization and/or angiographic data.
DESCRIPTION: Definition Revised (2004): Indicate which test was used for the cardiac catheterization and/or
angiographic data. Indicate the one most appropriate response:
Cath - A diagnostic procedure in which a catheter is introduced into a
large vein, usually of an arm or leg, and threaded through the
circulatory system to the heart to determine blood pressure and the
rate of flow in the vessels and chambers of the heart and the
identification of abnormal anatomy. IVUS - Intravascular Ultrasound may be used either alone or
in
combination with results from the cardiac catheterization. If used
alone, indicate IVUS as the only test from which procedure results
are calculated. Both - If both IVUS and Cath are available and both tests were
analyzed for the results, indicate Both/Combination. NS - If no cath study is available,
entering NS for "No Study/Unknown"
is also allowed.
130,477 AORTIC STENOSIS 209;5 SET
Aortic Stenosis
'0' FOR NONE/TRIVIAL;
'1' FOR MILD;
'2' FOR MODERATE;
'3' FOR SEVERE;
'NS' FOR NO STUDY;
LAST EDITED: APR 16, 2007
HELP-PROMPT: Enter severity of aortic stenosis using LV angiogram or cardiac ultrasound.
DESCRIPTION: Definition Revised (2007): Indicate the severity of any aortic stenosis documented. This question
should be answered using either the left ventricular angiogram (hemodynamic cath data) or the
cardiac ultrasound examination. Numbers may be converted to describe the severity of the aortic
stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ =
moderate, and 4+ = severe. Both transvalvular gradient and estimated valve orifice area are used to
assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is
obtained by converting the velocity of blood flow across the valve measured by the Doppler
principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on
flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an
adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the
following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the
descriptive categories. Indicate the one most appropriate response:
None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice
area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow
velocity is stated to be normal (< 1.0 M/sec).
Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice
area is 1.7 - 2.5 cm2
Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the
valve orifice area is 1.0 -1.6 cm2
Severe - The mean pressure gradient is > 50 mm Hg and/or the valve
orifice area is < 1.0 cm2
NS - If no study was performed, entering "NS" for "No Study/Unknown"
is also allowed.
130,478 RE-DO LAD STENOSIS 209;6 FREE TEXT
Re-Do Lad Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Type a number between 0 and 100, 0 Decimal Digits
DESCRIPTION: Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to
the left anterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,479 RE-DO RT CORONARY STENOSIS 209;7 FREE TEXT
Re-Do Right Coronary Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Type a number between 0 and 100, 0 Decimal Digits
DESCRIPTION: Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to
the right coronary artery or posterior descending coronary artery. Entering "NS" for "No
Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,480 RE-DO CIRCUMFLEX STENOSIS 209;8 FREE TEXT
Re-Do Circumflex Stenosis
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: SEP 23, 2005
HELP-PROMPT: Type a number between 0 and 100, 0 Decimal Digits
DESCRIPTION: Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to
the circumflex coronary artery, including marginal branches and ramus intermedius considered to be
of adequate size for bypass grafting. Entering "NS" for "No Study/Unknown" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,481 BRIDGE TO TRANSPLANT/DEVICE 209;9 SET
Device for bridge to cardiac transplant / Destination therapy
'Y' FOR YES;
'N' FOR NONE;
'B' FOR BRIDGE TO TRANSPLANT;
'D' FOR DESTINATION THERAPY;
LAST EDITED: JUN 24, 2015
HELP-PROMPT: Enter the intended use of the mechanical support device implanted during this surgical procedure.
DESCRIPTION: Definition Revised (2015): Indicate the intended use of the mechanical support device implanted
during this surgical procedure (excluding IABP) as either a bridge to cardiac transplantation or
patient received the device as destination therapy (does not intend to have a cardiac transplant),
either with or without placing the patient on cardiopulmonary bypass.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182 and was re-activated with patch SR*3*184.
SCREEN: S DIC("S")="I Y'=""Y"""
EXPLANATION: Screen prevents selection of retired codes.
130,482 *MAZE PROCEDURE 209;10 SET
*Maze Procedure
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 05, 2006
HELP-PROMPT: Enter Yes if Maze procedure was done.
DESCRIPTION: Definition Revised (2004): Indicate if patient had a Maze procedure either with or without placing
the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to
interrupt atrial conduction pathways often associated with atrial fibrillation or atrial flutter.
It may be performed alone or in combination with other cardiac procedures. (YES/NO).
130,483 *TMR 209;11 SET
*Transmyocardial Laser Revascularization
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAR 11, 2004
HELP-PROMPT: Enter 'YES' to indicate if patient received a transmyocardial laser procedure (TMR).
DESCRIPTION: Definition Revised (2004): Indicate if patient received a transmyocardial laser procedure (TMR) to
make "channels" or small holes directly into the heart muscle, either with or without placing the
patient on cardiopulmonary bypass. The TMR may be done in combination with a CABG procedure or as
a stand-alone procedure.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,484 *OTHER CARDIAC PROCEDURES-LIST 209.1;1 FREE TEXT
*Other cardiac procedures (specify)
INPUT TRANSFORM: S NYUK=X K:$L(X)>60!($L(X)<3) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
LAST EDITED: APR 04, 2006
HELP-PROMPT: Answer must be 3-60 characters in length.
DESCRIPTION: Definition Revised (2006): Specify if any cardiac surgical procedure (not listed above) was
performed alone or in conjunction with the index procedure, either with or without placing the
patient on cardiopulmonary bypass.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,485 PRIOR HEART SURGERY 206;42 FREE TEXT
Prior Heart Surgery
INPUT TRANSFORM: K:X["""" X I $D(X) K:$L(X)>10!($L(X)<1) X
LAST EDITED: FEB 06, 2014
HELP-PROMPT: Answer must be 1-10 characters in length
DESCRIPTION: Definition Revised (2014): Indicate all applicable types of heart surgery performed, either on or
off-pump. Indicate all appropriate responses:
None - Patient has not had a previous cardiac surgery procedure
CABG-only - Patient has had a previous coronary artery bypass
graft (CABG-only) procedure
Valve-only - Patient has had a previous valve-only procedure
CABG/Valve - Patient has had a previous combination CABG/valve
procedure
Other - Patient has had a previous cardiac procedure(s) other
than CABG and Valve surgery, such as repair of atrial or
ventricular septal defects, great thoracic vessel repair,
cardiac transplant, left ventricular aneurysmectomy, insertion
of ventricular assist devices, total artificial hearts, Maze
procedures, etc." (Do not include pacemaker
insertions or automatic implantable cardioverter-defibrillator
(AICD) insertions; do not include pericardectomy if done off
pump).
CABG/Other - Patient has had a previous cardiac surgery that
included a CABG with a concurrent "Other" cardiac procedure.
Unknown - Unknown
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,486 GASTROINTESTINAL (Y/N) 200.1;1 SET
Gastrointestinal (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: DEC 11, 2003
HELP-PROMPT: Enter 'YES' if this patient has a history of gastrointestinal problems.
DESCRIPTION: This determines whether the patient has a history of gastrointestinal problems such as esophageal
varices.
130,487 PREOPERATIVE INR 201;27 FREE TEXT
Preoperative INR
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: JAN 18, 2004
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: This is the result of the preoperative INR (International Normalized Ratio). Data input must be 1
to 5 numeric characters in length which may include a prefix of a less than or greater than sign
"<" or ">". Entering "NS" for "No Study" is also allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,487.1 PREOPERATIVE INR, DATE 202;27 DATE
Date Preoperative INR was Performed
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 19, 2007
HELP-PROMPT: Enter the date that the preoperative INR was performed.
DESCRIPTION:
This is the date that the preoperative INR was performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,488 ORGAN/SPACE SSI 205;37 SET
Organ/Space SSI Occurrences (Y/N)
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Enter YES if this patient had postoperative organ/space SSI occurrences within 30 days.
DESCRIPTION: Definition Revised (2015): Organ/Space SSI is an infection that occurs within 30 days after the
operation and the infection appears to be related to the operation and the infection involves any
part of the anatomy (e.g., organs or spaces) , other than the incision, which was opened or
manipulated during an operation and at least one of the following:
- Purulent drainage from a drain that is placed through a stab wound
into the organ/space.
- Organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space.
- An abscess or other evidence of infection involving the organ/space
that is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
- Diagnosis of an organ/space SSI by a surgeon or attending physician.
NOTE: Please consult with the operating surgeon for assignment of organ/space vs. deep wound
infection occurrences.
130,489 OTHER WOUND OCCURRENCE 205;38 POINTER TO ICD DIAGNOSIS FILE (#80)
Other Wound Occurrence
INPUT TRANSFORM: D GETAPI^SROICDGT("SURG","DIAG",DA)
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: FEB 17, 2012
HELP-PROMPT: Enter the ICD Diagnosis code for any other wound occurrence.
DESCRIPTION: Definition Revised (2004): Enter any other wound occurrences that you feel to be significant and
that are not covered by the predefined wound occurrence categories. Enter the ICD-CM code for this
entry. (Example: Seromas, ICD-CM code: 998.13)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,490 *REPEAT VENTILATOR W/IN 30 DAY 209;12 SET
*Repeat Ventilator Support within 30 days
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 27, 2014
HELP-PROMPT: Enter Yes if the patient was placed on ventilator support.
DESCRIPTION: Definition Revised (2008): Indicate if the patient was placed on ventilator support postoperatively
within 30 days and this repeat ventilator support is related to the index operation (For example,
the patient is on the ventilator intra-op and immediately post-op. Then patient is weaned and the
ventilator is discontinued. Later, the patient gets into trouble and mechanical ventilation has to
be reinstated.) However, if the patient returns to the OR within 30 days and gets extubated
immediately after, it is not considered repeat ventilator support.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,491 OTHER NON-CT PROCEDURES 209.2;1 FREE TEXT
Other non-CT procedures - independently requiring CPB
INPUT TRANSFORM: S NYUK=X K:$L(X)>245!($L(X)<3) X S:NYUK="NS"!(NYUK="ns") X="NS" K NYUK
LAST EDITED: JUN 29, 2004
HELP-PROMPT: Answer must be 3-245 characters in length.
DESCRIPTION: Definition Revised (2004): If any other procedure - other than cardiothoracic - performed requiring
placing the patient on cardiopulmonary bypass, specify details into the comment field. If no other
non-CT procedure requiring CPB was performed, indicate "NS" for "No Study/Unknown" in the text
field.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,492 PREOP FUNCT. HEALTH STATUS 200.1;2 SET
Functional Health Status Prior to Surgery
'1' FOR INDEPENDENT;
'2' FOR PARTIALLY DEPENDENT;
'3' FOR TOTALLY DEPENDENT;
'4' FOR UNKNOWN;
LAST EDITED: MAY 22, 2015
HELP-PROMPT: Enter the level of self care that summarizes the patient's status prior to surgery.
DESCRIPTION: Definition Revised (2015): This is a question that focuses on the patient's abilities to perform
activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are
defined as 'the activities usually performed in the course of a normal day in a person's life'.
ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level
of self-care for activities of daily living demonstrated by this patient at the time the patient is
being considered as a candidate for surgery (which should be no longer than 30 days prior to
surgery). If the patient's status changes prior to surgery, that change should be reflected in your
assessment. For this time point, report the level of functional health status as defined by the
following criteria.
(1) Independent: The patient does not require assistance from another
person for any activities of daily living. This includes a person
who is able to function independently with prosthetics, equipment,
or devices.
(2) Partially dependent: The patient requires some assistance from
another person for activities of daily living. This includes a
person who utilizes prosthetics, equipment, or devices but still
requires some assistance from another person for ADLs.
(3) Totally dependent: The patient requires assistance for all
activities of daily living.
SCREEN: S DIC("S")="I Y'=4"
EXPLANATION: Screen prevents selection of retired code.
130,493 *PULMONARY VALVE PROCEDURE 207;28 SET
*Pulmonary Valve Procedure
'N' FOR NONE;
'M' FOR MECHANICAL;
'S' FOR STENTED BIOPROSTHETIC;
'B' FOR STENTLESS BIOPROSTHETIC;
'H' FOR HOMOGRAFT;
'PR' FOR PRIMARY REPAIR;
'PA' FOR PRIMARY REPAIR & ANNULOPLASTY DEVICE;
'AN' FOR ANNULOPLASTY DEVICE ALONE;
'AU' FOR AUTOGRAFT (ROSS);
'O' FOR OTHER;
LAST EDITED: JUN 14, 2010
HELP-PROMPT: Enter the appropriate pulmonary valve procedure performed on this patient.
DESCRIPTION: VASQIP Definition (2010): Indicate if the patient had a pulmonary valve replacement (either the
native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct
regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional
procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair
was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate
the one most appropriate procedure:
* None
* Mechanical Valve
* Stented Bioprosthetic Valve
* Stentless Bioprosthetic Valve
* Homograft
* Primary Valve Repair
* Primary Valve Repair and Annuloplasty Device
* Annuloplasty Device alone
* Autograft Procedure (Ross Procedure)
* Other
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,500 PFSS ACCOUNT REFERENCE PFSS;1 POINTER TO PFSS ACCOUNT FILE (#375)
PFSS Account Reference
LAST EDITED: JUN 08, 2005
HELP-PROMPT: Enter the PFSS Account Reference associated with this case.
DESCRIPTION: This is the PFSS Account Reference number by which Surgery will reference an external account
number for purposes of attaching charges for 1st or 3rd party billing.
DELETE AUTHORITY: ^
WRITE AUTHORITY: ^
130,502 *OTHER CARDIAC PROCEDURES (Y/N) 209;13 SET
*Other Cardiac Procedures (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAR 20, 2006
HELP-PROMPT: Enter 'YES' if there are other cardiac procedures.
DESCRIPTION: Definition Revised (2006): Indicate if any cardiac surgical procedure (not listed above) was
performed alone or in conjunction with the index procedure, either with or without placing the
patient on cardiopulmonary bypass (YES/NO).
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,504 HEMOGLOBIN A1C 201;28 FREE TEXT
Hemoglobin A1c
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:$L(X)>6!($L(X)<1) X
LAST EDITED: NOV 30, 2010
HELP-PROMPT: Answer must be 1-6 characters in length.
DESCRIPTION: Definition Revised (2006)/(2007): Indicate the Hemoglobin A1c result (%) preoperatively evaluated
closest to surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,504.1 HEMOGLOBIN A1C, DATE 202.1;1 FREE TEXT
Hemoglobin A1c, Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: NOV 30, 2010
HELP-PROMPT: This is the date that the Hemoglobin A1c was performed and must not be more than 1000 days before
surgery.
DESCRIPTION: Definition Revised (2006)/(2007): Indicate the date that the preoperative Hemoglobin A1c value was
assessed. Enter "NS" for No Study if the Hemoglobin A1c test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,505 *ENDOVASCULAR REPAIR 207.1;2 SET
*Endovascular Repair of Aorta
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 22, 2014
HELP-PROMPT: Enter Yes if an endovascular repair of the aorta was done with a cardiothoracic surgeon attending.
DESCRIPTION: VASQIP Definition (2010): Indicate if the patient had an endovascular repair of the descending
thoracic aorta, ascending aorta, and/or aortic arch (e.g., aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic disruption) with or without involving coverage
of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic
extension(s), if required, to level of celiac artery origin, with or without cardiopulmonary
bypass. To include in VASQIP, an attending cardiothoracic surgeon must have been present and
involved in the procedure. It is typically done under general anesthesia and may be performed in
the operating room or interventional radiology operating area.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,506 HAIR REMOVAL METHOD VER;6 SET
Surgical Site Hair Removal Method
'C' FOR CLIPPER;
'D' FOR DEPILATORY;
'N' FOR NO HAIR REMOVED;
'P' FOR PATIENT REMOVED OWN HAIR;
'S' FOR SHAVING;
'U' FOR NOT DOCUMENTED;
'O' FOR OTHER;
LAST EDITED: MAR 23, 2006
HELP-PROMPT: Enter the method used to remove hair prior to Surgery.
DESCRIPTION: This is the method used to remove hair prior to surgery. Shaving is not a preferred method for
hair removal. If SHAVING is selected, a comment must be entered in the HAIR REMOVAL COMMENTS field
explaining why SHAVING was used. If OTHER is selected, comments must be entered explaining the
method used.
CROSS-REFERENCE: 130^AN^MUMPS
1)= D HR^SRENSCS
2)= Q
This MUMPS cross reference maintains the Hair Removal Comments field if this field is answered with
"S".
130,507 BNP 201;29 FREE TEXT
B-type Natriuretic Peptide (BNP)
INPUT TRANSFORM: K:$L(X)>5!($L(X)<1) X I $D(X) D NUM^SROAL21
LAST EDITED: AUG 03, 2010
HELP-PROMPT: Answer must be 1-5 characters in length.
DESCRIPTION: VASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to
surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,507.1 BNP DATE 202.1;2 FREE TEXT
B-type Natriuretic Peptide (BNP) Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NS"!(SRX="ns") X="NS"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: APR 30, 2010
HELP-PROMPT: This is the date that the BNP was performed.
DESCRIPTION: VASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter
"NS" for No Study if the BNP test was not performed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,508 HAIR REMOVAL COMMENTS 49;0 WORD-PROCESSING #130.0508
DESCRIPTION: If SHAVING is selected as the hair removal method, a comment must be entered explaining why SHAVING
was used. If OTHER is selected as the hair removal method, comments must be entered explaining the
method used.
Hair Removal Comments
LAST EDITED: MAR 20, 2006
DESCRIPTION: If SHAVING is selected as the hair removal method, a comment must be entered explaining why
SHAVING was used. If OTHER is selected as the hair removal method, comments must be entered
explaining the method used.
130,509 PREOP ATRIAL FIBRILLATION 208;19 SET
Preoperative Atrial Fibrillation
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 02, 2010
HELP-PROMPT: Indicate whether atrial fibrillation or flutter is present within two weeks of the procedure.
(Yes/No)
DESCRIPTION: VASQIP Definition (2010): This field indicates whether atrial fibrillation or flutter is present
within two weeks of the procedure. Enter YES or NO. Note: NS is not allowed.
130,510 *CURRENT SMOKER (CARDIAC) 200.1;5 SET
*Current Smoker
'1' FOR NEVER A SMOKER;
'2' FOR WITHIN 2 WEEKS OF SURGERY;
'3' FOR 2 WEEKS TO 3 MONTHS PRIOR TO SURGERY;
'4' FOR >3 MONTHS PRIOR TO SURGERY (REMOTE SMOKER);
LAST EDITED: SEP 01, 2011
HELP-PROMPT: Enter the code describing the patient's status as a smoker prior to surgery.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Cardiac Definition Revised (2006): Indicate the patient's smoking status from information from the
patient, or the chart, that best describes the patient's use of tobacco in any form (pipe, cigar,
cigarette, tobacco chew). If more than one representation is found, please record according to the
most conservative (most recent) quit date:
1 = never a smoker 2 = smoking within two weeks prior to surgery 3 = smoking within 2 weeks to 3
months prior to surgery 4 = remote smoker (more than 3 months prior to surgery)
130,512 *MAZE PROCEDURE 209;14 SET
*Maze Procedure
'N' FOR NO MAZE PERFORMED;
'F' FOR FULL MAZE;
'M' FOR MINI MAZE;
LAST EDITED: JUN 28, 2006
HELP-PROMPT: Enter NO MAZE PERFORMED, FULL MAZE or MINI MAZE.
DESCRIPTION: Definition Revised (2006): Indicate if patient had a Maze procedure either with or without placing
the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to
interrupt abnormal atrial conduction pathways that cause atrial fibrillation or atrial flutter. It
may be performed alone or in combination with other cardiac procedures. (A Maze does not include an
amputation/resection of the atrial appendage as an isolated procedure; an intraoperative
electrophysiologic mapping procedure; nor any surgical or ablation procedure conducted on the
ventricle for control of ventricular arrhythmias.) Indicate the one most appropriate response:
No - No Maze performed
Full Maze - The procedure is most often performed on-bypass through a median sternotomy. A
combination of incisions and thermal (cryo) or radiofrequency ablations of the atrial wall pathways
are done, typically including amputation/resection of the one or both atrial appendices. The
procedure thus creates a "maze" of electrical propogation roots involving the entire atrial
myocardium with only one side of entrance (the sinus node) and one side of exit (the AV node).
Mini-Maze - A more limited and simpler procedure than the traditional full maze, the Mini-Maze is
based on the finding that in most patients, ectopic foci located in the pulmonary veins are
responsible for the initiation of atrial fib. Radiofrequency or a cryo-ablation probe is used
either inside or outside of the pulmonary vein ostia to destroy the foci. It can be performed with
or without resection of the atrial appendage and includes no incision or minimal incisions to the
left atrium, rather than the extensive atrial surgical procedure conducted for the full Maze. The
Mini can be performed on or off bypass through a median sternotomy or performed thorascopically to
the outside of the pulmonary veins.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*182.
130,513 SURGERY CONSULT DATE 209;15 FREE TEXT
Surgery Consult Date
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA" D:$D(X) NC^SROAUTL
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: MAR 03, 2008
HELP-PROMPT: Indicate the date patient first consulted by Surgery Service for the operation.
DESCRIPTION: Indicate the date that the patient was first consulted by Surgery for the operation as typically
documented by a note by a member of Surgery Specialty that will perform the procedure (e.g.,
attending surgeon, fellow, nurse). For non-cardiac assessments, enter NA if this date is not
applicable or cannot be determined.
For Cardiothoracic (CT) Surgery, this date is usually on or just after the diagnostic
catheterization date.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,515 PRIMARY CAUSE FOR DELAY 209;16 SET
Primary Cause for Delay for Cardiac Surgery
'RL' FOR RESOURCE LIMITATION;
'PH' FOR PATIENT HEALTH;
'PP' FOR PATIENT PREFERENCE;
'O' FOR OTHER;
'NS' FOR NO STUDY/UNKNOWN;
'N' FOR NONE;
LAST EDITED: DEC 17, 2007
HELP-PROMPT: Enter the primary cause for delay if greater than 30 days.
DESCRIPTION: Definition Revised (2008): This field contains the primary cause for delay. If a Cardiac patient's
surgery is greater than 30 days from initial VA Cardiothoracic Surgery Consultation (as calculated
between the CT CONSULT DATE to DATE OF SURGERY), user shall enter cause as defined in the field. If
date is less than or equal to 30 days, system shall automatically default entry to None.
- Resource Limitation: Due to staffing or other facility limitation,
e.g., OR scheduling, physician availability, ICU bed capacity
- Patient Health: Due to patient health issue, e.g., vascular consult,
additional tests
- Patient Preference: Due to a non-health related patient preference,
e.g., vacation
- Other
- NS/Unknown: Unable to Locate Reason for Delay. Entering "NS" for "No
Study/Unknown" is also allowed.
- None
SCREEN: S DIC("S")="I Y'=""N"""
EXPLANATION: Screen prevents selection of NONE.
130,516 SURGERY CONSULT REQUESTED 209;17 FREE TEXT
Date Surgery Consult Requested
INPUT TRANSFORM: N SRX S SRX=X,%DT="EXP" D ^%DT S X=Y K:Y<1 X S:SRX="NA"!(SRX="na") X="NA"
OUTPUT TRANSFORM: S Y(0)=Y D DATE^SROAUTL
LAST EDITED: FEB 28, 2008
HELP-PROMPT: This is the date the Surgery Service is requested to consult with the patient.
DESCRIPTION: This is the date that the patient's physician requests that Surgery Service consult with the
patient. It is not the date that the consult took place.
Enter NA if this date is not applicable or cannot be determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,517 TOBACCO USE 200.1;9 SET
Tobacco Use
'1' FOR NEVER USED TOBACCO;
'2' FOR NO USE IN LAST 12 MOS;
'3' FOR CIGARETTES ONLY;
'4' FOR OTHER (NO CIGARETTES);
'5' FOR CIGARETTES PLUS OTHER;
LAST EDITED: SEP 23, 2011
HELP-PROMPT: Indicate the patient's type of tobacco product used in the 12 months prior to surgery.
DESCRIPTION: VASQIP Definitions (2011): Indicate the patient's type of tobacco product used in the 12 months
prior to surgery. Select one:
1 = Never used tobacco
2 = No tobacco use in the last 12 months
3 = Cigarettes only
4 = Pipe, cigar, snuff, or chewing tobacco only (no cigarettes)
5 = Cigarettes plus one or more of pipe, cigar, snuff, or chewing
tobacco
CROSS-REFERENCE: ^^TRIGGER^130^518
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,10),X=X
S DIU=X K Y S X=DIV S X=$S(X<3:"NA",1:"") S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,10)=D
IV,DIH=130,DIG=518 D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,200.1)):^(200.1),1:"") S X=$P(Y(1),U,10),X=X
S DIU=X K Y S X="" S DIH=$G(^SRF(DIV(0),200.1)),DIV=X S $P(^(200.1),U,10)=DIV,DIH=130,DIG=518 D ^D
ICR
CREATE VALUE)= S X=$S(X<3:"NA",1:"")
DELETE VALUE)= @
FIELD)= #518
Trigger to set the TOBACCO USE TIMEFRAME field (#518) to "NA" for NOT APPLICABLE if the TOBACCO USE
field (#517) is set to a value less than 3.
130,518 TOBACCO USE TIMEFRAME 200.1;10 SET
Tobacco Use Timeframe
'1' FOR WITHIN 2 WEEKS;
'2' FOR 2 WKS TO 3 MOS;
'3' FOR 3 TO 12 MONTHS;
'NA' FOR NOT APPLICABLE;
INPUT TRANSFORM: D CHK518^SROAPRE1
LAST EDITED: AUG 16, 2011
HELP-PROMPT: Indicate the timeframe of tobacco use prior to surgery.
DESCRIPTION: VASQIP Definitions (2011): If the patient used tobacco products in the 12 months prior to surgery,
indicate the timeframe:
1 = within the 2 weeks prior to surgery
2 = between 2 weeks and 3 months prior to surgery
3 = between 3 months and 12 months prior to surgery
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the TOBACCO USE field of the SURGERY File
130,519 DIABETES MELLITUS CHRONIC 200.1;11 SET
Diabetes Mellitus: Chronic, Long-Term Management
'1' FOR NO;
'2' FOR DIET;
'3' FOR ORAL +/- NON-INSULIN INJ;
'4' FOR INSULIN;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter appropriate code for chronic, long-term Diabetes Mellitus management.
DESCRIPTION: VASQIP Definitions (2015): Indicate the chronic, long-term treatment regimen for patients with a
diagnosis of Diabetes Mellitus. Diabetes Mellitus is defined as a metabolic disorder of the
pancreas whereby the individual requires diet modification, daily dosages of exogenous parenteral
insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the
patient is on both Oral and Insulin therapy, indicate Insulin therapy.
No - no diagnosis of diabetes
Diet - a diagnosis of diabetes that is controlled by diet alone
Oral +/- Non-Insulin Inj - a diagnosis of diabetes requiring
therapy with an oral and/or non-insulin injectable
hypoglycemic agent
Insulin - a diagnosis of diabetes requiring daily insulin therapy
Choose from: 1. NO 2. DIET 3. ORAL +/- NON-INSULIN INJ 4. INSULIN
130,520 DIABETES MELLITUS PREOP MGMT 200.1;12 SET
Diabetes Mellitus: Management Prior to Surgery
'1' FOR NO;
'2' FOR DIET;
'3' FOR ORAL +/- NON-INSULIN INJ;
'4' FOR INSULIN;
LAST EDITED: APR 30, 2015
HELP-PROMPT: Enter appropriate code for management of Diabetes Mellitus in the two weeks prior to surgery.
DESCRIPTION: VASQIP Definitions (2015): Enter appropriate code for management of Diabetes Mellitus in the two
weeks prior to surgery. Diabetes Mellitus is defined as a metabolic disorder of the pancreas
whereby the individual requires diet modification, daily dosages of exogenous parenteral insulin or
an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both
Oral and Insulin therapy, indicate Insulin therapy.
No - no diagnosis of diabetes
Diet - a diagnosis of diabetes that is controlled by diet alone
Oral +/- Non-Insulin Inj - a diagnosis of diabetes requiring therapy
with an oral and/or non-insulin injectable hypoglycemic agent
Insulin - a diagnosis of diabetes requiring daily insulin therapy
Choose from: 1. NO 2. DIET 3. ORAL +/- NON-INSULIN INJ 4. INSULIN
130,521 CVD REPAIR/OBSTRUCTION 200.1;13 SET
Prior Surgical Repair/Carotid Artery Obstruction
'0' FOR NO CVD;
'1' FOR YES - NO SURGICAL REPAIR;
'2' FOR YES - PRIOR SURGICAL REPAIR;
LAST EDITED: SEP 23, 2011
HELP-PROMPT: Enter value of 0-2 to indicate CVD.
DESCRIPTION: VASQIP Definitions (2011): Select one of the following if patient has indication of Cerebrovascular
Disease (CVD):
0 = No CVD indication
1 = Yes, CVD indication by documented obstruction of carotid artery
luminal diameter greater than or equal to 50% obstruction of the
carotid artery documented by contrast angiography or duplex
ultrasound examination which did not result in surgical repair.
2 = Yes, CVD indication resulting in prior carotid artery surgical
repair (e.g., carotid endarterectomy or stenting).
130,522 HISTORY OF CVD 200.1;14 SET
History of CVD Events
'0' FOR NO CVD;
'1' FOR HISTORY OF TIA'S;
'2' FOR CVA/STROKE - NO NEURO DEFICIT;
'3' FOR CVA/STROKE W/ NEURO DEFICIT;
LAST EDITED: SEP 23, 2011
HELP-PROMPT: Enter value of 0-3 to indicate if the patient has history of CVD events.
DESCRIPTION: VASQIP Definitions (2011): Indicate if the patient has a history of cerebrovascular accident by
selecting one of the following indications: (If multiple events, select the one with greatest
severity.):
0 = No CVD
1= History of Transient Ischemic Attacks: Transient ischemic attacks
(TIAs) are focal neurologic deficits (e.g. numbness of an arm or
amaurosis fugax) of sudden onset and brief duration (usually <30
minutes), which usually reflect dysfunction in a cerebral vascular
distribution.
These attacks may be recurrent and, at times, may precede a stroke
2= CVA/Stroke with no neurological deficit: History of
a cerebrovascular accident (embolic, thrombotic, or hemorrhagic)
with neurologic deficit(s) lasting at least 30 minutes, but no
current residual neurologic dysfunction or deficit
3= CVA/Stroke with neurological deficit: History of a cerebrovascular
accident (embolic, thrombotic, or hemorrhagic) with persistent
residual motor, sensory, or cognitive dysfunction. (e.g.,
hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory)
130,600 CONFIRM PATIENT IDENTITY VER;7 SET
Confirm Correct Patient Identity
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 22, 2011
HELP-PROMPT: Enter YES if the patient identity was confirmed.
DESCRIPTION: This field verifies the patient identity has been confirmed. Your answer should be "Yes" or "No".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,601 PROCEDURE TO BE PERFORMED VER;8 SET
Confirm Procedure To Be Performed
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 22, 2011
HELP-PROMPT: Enter YES if the procedure to be confirmed was checked.
DESCRIPTION: This field verifies the procedure to be performed has been confirmed. Your answer should be "Yes"
or "No".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,602 SITE OF PROCEDURE VER;9 SET
Confirm Site of Procedure, Including Laterality
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 22, 2011
HELP-PROMPT: Enter YES if the confirm site of procedure including laterality was checked.
DESCRIPTION: This field verifies the site of procedure, including laterality, has been confirmed. Your answer
should be "Yes" or "No".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,603 CONFIRM VALID CONSENT VER;10 SET
Confirm Valid Consent
'Y' FOR YES;
'N' FOR NO;
'1' FOR YES, i-MED;
'2' FOR YES, PAPER;
'3' FOR YES, TELEPHONE;
'4' FOR NO, EMERGENCY;
'5' FOR NO, NOT EMERGENCY;
LAST EDITED: MAY 23, 2014
HELP-PROMPT: Select the appropriate response from options 1 to 5.
DESCRIPTION: VASQIP Definition (2014): This field verifies that a valid consent form has been confirmed. Your
answer should be one of the following:
1-YES, i-MED
2-YES, PAPER
3-YES, TELEPHONE
4-NO, EMERGENCY
5-NO, NOT EMERGENCY
If you answer 4 or 5, you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
SCREEN: S DIC("S")="I Y"
EXPLANATION: Screen prevents selection of inactive entries.
RECORD INDEXES: AE (#198)
130,604 CONFIRM PATIENT POSITION VER;11 SET
Confirm Patient Position
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 22, 2011
HELP-PROMPT: Enter YES if patient position was confirmed.
DESCRIPTION: This field verifies that the patient position has been confirmed. Your answer should be "Yes" or
"No".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,605 MARKED SITE CONFIRMED VER;12 SET
Confirm Proc. Site has been Marked Appropriately and the Site of the Mark is Visible After Prep
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 19, 2014
HELP-PROMPT: Answer YES if the site was physically marked or if arm band was verified instead of marking.
DESCRIPTION: The site must be marked in all cases. If the patient refuses marking, or if the site is
inappropriate to marking, such as mucous membranes and other sites not on the skin that cannot be
marked using standard methods, then wristbands must be used for marked site. See applicable VHA
Handbooks and Directives for further information and guidance.
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,606 PREOPERATIVE IMAGES CONFIRMED VER;13 SET
Confirm Pertinent Medical Images Available in the OR
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: FEB 03, 2014
HELP-PROMPT: Enter "YES" if the imaging data was confirmed, "NA" if there was no imaging required, or "NO" if
the image was not viewed.
DESCRIPTION: This field refers to the completion of the verification process for the presence of relevant
imaging data to confirm the operative site for the correct patient are available, properly labeled
and properly presented, and verified by two members of the operating team prior to the start of the
procedure. This practice is further defined by local hospital policy.
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,607 CORRECT MEDICAL IMPLANTS VER;14 SET
Confirm Correct Medical Implant(s) is available
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: FEB 03, 2014
HELP-PROMPT: Enter YES if the correct medical implant(s) confirmed.
DESCRIPTION: This field verifies that the availability of correct medical implant(s) has been confirmed. Your
answer should be "Yes", "No" or "NA".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,608 ANTIBIOTIC PROPHYLAXIS VER;15 SET
Confirm Appropriate Antibiotic Prophylaxis
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
'NI' FOR NOT INDICATED;
LAST EDITED: MAY 23, 2014
HELP-PROMPT: Enter YES if the appropriate antibiotic prophylaxis confirmed.
DESCRIPTION: VASQIP Definition (2014): This field verifies that the appropriate antibiotic prophylaxis has been
confirmed. Your answer should be "Yes", "No" or "NI".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
SCREEN: S DIC("S")="I Y'=""NA"""
EXPLANATION: Screen prevents selection of inactive entries.
RECORD INDEXES: AE (#198)
130,609 APPROPRIATE DVT PROPHYLAXIS VER;16 SET
Confirm Appropriate Deep Vein Thrombosis Prophylaxis
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
'NI' FOR NOT INDICATED;
LAST EDITED: MAY 19, 2014
HELP-PROMPT: Enter YES if the appropriate deep vein thrombosis prophylaxis was confirmed.
DESCRIPTION: VASQIP Definition (2014): This field verifies that the appropriate deep vein thrombosis prophylaxis
has been confirmed. Your answer should be "Yes", "No" or "NI".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
SCREEN: S DIC("S")="I Y'=""NA"""
EXPLANATION: Screen prevents selection of retired codes.
RECORD INDEXES: AE (#198)
130,610 BLOOD AVAILABILITY VER;17 SET
Confirm Blood Available (Operating Room or in-house Blood Bank)
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
'NI' FOR NOT INDICATED;
LAST EDITED: JUL 13, 2015
HELP-PROMPT: Enter YES if Blood is required and is available. Enter NO if Blood is required and not available.
Enter NI if Blood not indicated.
DESCRIPTION: VASQIP Definition (2015): This field verifies that the blood availability has been confirmed. Your
answer should be "Yes", "No" or "NI". Enter YES if the Blood was required and availability was
confirmed. Enter NO if the Blood was required and was not available. Enter NI if Blood was NOT
INDICATED (not required) for this procedure. If there was a "type and screen" only, indicate NI.
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT field (#85). A
'NO' response confirms that blood was REQUIRED for the procedure but NOT AVAILABLE. Indicate the
reason why the blood was not available in the comment section. A 'NI' response means that blood
was NOT INDICATED for this procedure and should not be noted in the comment section. Choose "NI"
in the selection category.
SCREEN: S DIC("S")="I Y'=""NA"""
EXPLANATION: Screen prevents selection of inactive entries.
RECORD INDEXES: AE (#198)
130,611 AVAILABILITY OF SPECIAL EQUIP VER;18 SET
Confirm Availability of Special Equipment
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: FEB 03, 2014
HELP-PROMPT: Enter YES if the availability of special equipment was confirmed.
DESCRIPTION: This field verifies that the availability of special equipment has been confirmed. Your answer
should be "Yes", "No" or "NA".
If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
RECORD INDEXES: AE (#198)
130,612 ORIGINAL DESIRED DATE .9;1 DATE
Original Desired Procedure Date
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 25, 2011
HELP-PROMPT: Enter the Original Desired Procedure Date.
DESCRIPTION: This field is the original desired date for surgery to occur, as agreed upon by the provider and
patient. That agreed upon date is when the patient desires the surgery to occur and when the
provider feels it is appropriate to schedule the surgery. If the DESIRED PROCEDURE DATE field
(#616) is updated, the value of this field will not change.
WRITE AUTHORITY: ^
130,613 D/T OF DESIRED PROCEDURE DATE .9;2 DATE
Date/Time of Desired Procedure Date Entry
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 25, 2011
HELP-PROMPT: Enter the Date/Time of Desired Procedure Date Entry.
DESCRIPTION: This field is the Date/Time stamp for when the provider saves the ORIGINAL DESIRED DATE field
(#612) for surgical case in the system.
WRITE AUTHORITY: ^
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,614 ORIGINAL SCHEDULED DATE .9;3 DATE
Original Scheduled Date
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAY 11, 2011
HELP-PROMPT: Enter the Original Scheduled Date.
DESCRIPTION:
This field is the original scheduled date for surgery to occur, as entered by the OR scheduler.
WRITE AUTHORITY: ^
NOTES: TRIGGERED by the SCHEDULED START TIME field of the SURGERY File
CROSS-REFERENCE: ^^TRIGGER^130^615
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRF(D0,.9)):^(.9),1:"") S X=$P(Y(1),U,4),X=X S DIU=
X K Y X ^DD(130,614,1,1,1.1) S DIH=$G(^SRF(DIV(0),.9)),DIV=X S $P(^(.9),U,4)=DIV,DIH=130,DIG=615 D
^DICR
1.1)= S X=DIV N %I,%H,% D NOW^%DTC S X=% S X=X,Y(1)=$G(X) S X=1,Y(2)=$G(X) S X=12,X=$E(Y(1),Y(2),X)
2)= Q
CREATE VALUE)= $E(NOW,1,12)
DELETE VALUE)= NO EFFECT
FIELD)= #615
The D/T OF SCHEDULED DATE ENTRY field (#615) is set when the ORIGINAL SCHEDULED DATE field (#614)
is set.
130,615 D/T OF SCHEDULED DATE ENTRY .9;4 DATE
Date/Time of Scheduled Date Entry
INPUT TRANSFORM: S %DT="ET" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 21, 2011
HELP-PROMPT: Enter the Date/Time of Scheduled Date.
DESCRIPTION: This field is the Date/Time stamp for when the OR Scheduler saves the ORIGINAL SCHEDULED DATE field
(#614) for the surgical case in the system.
WRITE AUTHORITY: ^
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the ORIGINAL SCHEDULED DATE field of the SURGERY File
130,616 DESIRED PROCEDURE DATE .9;5 DATE
Desired Procedure Date
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 20, 2011
HELP-PROMPT: Enter the Desired Procedure Date.
DESCRIPTION: This field is the desired date for surgery to occur, as agreed upon by the provider and patient.
That agreed upon date is when the patient desires the surgery to occur and when the provider feels
it is appropriate to schedule the surgery.
130,617 SCHEDULED DATE .9;6 DATE
Scheduled Date
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 20, 2011
HELP-PROMPT: Enter the Scheduled Date.
DESCRIPTION: This field is updated with the new date whenever the OR Scheduler modifies the SCHEDULED START TIME
field (#10) for the surgical case.
NOTES: TRIGGERED by the SCHEDULED START TIME field of the SURGERY File
130,618 POSITIVE DRUG SCREENING 200;55 SET
Positive Drug Screening
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NA;
'1' FOR NOT DONE;
'2' FOR NEGATIVE RESULT;
'3' FOR POS NOT Rx;
'4' FOR POS Rx;
LAST EDITED: JUN 29, 2015
HELP-PROMPT: Select the response that appropriately fits the positive drug screening.
DESCRIPTION: VASQIP Definition (2015): Indicate if any drug (excluding alcohol) screening (e.g., blood or
urine) was performed within 2 weeks prior to surgery. If the patient is being prescribed a
medication, such as methadone, respond with answer options as indicated below. If the drug screen
was positive for both a prescribed and non-prescribed drug, select the answer for a substance that
was not prescribed.
1. Not Done - drug screening was not performed
2. Drug screening was performed and the result was negative
3. Drug screening was performed and the result was positive for
substance not prescribed
4. Drug screening was performed and the result was positive for a
prescribed substance
SCREEN: S DIC("S")="I Y"
EXPLANATION: Screen prevents selection of inactive entries.
130,619 IMMED USE-CONTAMINATION 52;1 NUMBER
Immed Use Steril-Contamination
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of a
specialty item (one of a kind) in the OR.
130,620 IMMED USE-SPS/OR MGT ISSUE 52;2 NUMBER
Immed Use Steril-SPS Processing/OR Management Issues
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to SPS processing and OR
management issues (unsterile from SPS, hole in package, available in SPS but not sterilized, not
processed in time, missing in set, or broken in set).
130,621 IMMED USE-EMERGENCY CASE 52;3 NUMBER
Immed Use Steril-Emergency Case
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to an Emergency Case, such
as instruments used on previous case.
130,622 IMMED USE-NO BETTER OPTION 52;4 NUMBER
Immed Use Steril-No Better Option
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to items for which there may
be no better option (batteries, radioactive implants (seeds)).
130,623 IMMED USE-LOANER INSTRUMENT 52;5 NUMBER
Immed Use Steril-Loaner or Short Notice Instrument
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to loaner or short notice
instrument excluding implants (instrument(s) not available with sufficient time to reprocess
completely).
130,624 IMMED USE-DECONTAMINATION 52;6 NUMBER
Immed Use Steril-Decontamination of Instruments Not for Use In Patient
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter number of cycles. Default value is zero. Acceptable values from 0 to 99.
DESCRIPTION: Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of
instruments already in use in OR for any reason not included in tracking.
130,630 POSSIBLE ITEM RETENTION 25;6 SET
Possible Item Retention
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 18, 2022
HELP-PROMPT: **THIS FIELD IS NO LONGER USED** Answer YES if the surgical field has the potential for leaving
behind a sponge, sharp, or instrument.
DESCRIPTION: VASQIP Definition (2015): This field is intended to capture whether the surgical field has the
potential for leaving a retained surgical item, including sponge, sharp, or instrument behind. A
retained surgical item includes instruments, sharps, sponges or any materials used by the surgical
team performing the operative procedure. Sharps include surgical needles, aspirating needles,
blunt needles, scalpel blades or any items with a sharp or pointed edge posing a risk for skin
puncture by the surgical team. Sponges include cotton gauze sponges, laparotomy pads, surgical
towels or any absorbent materials not intended to remain in the patient's body after the surgical
procedure is completed.
Note: This field does not identify that a retained surgical item actually was found or occurred.
UNEDITABLE
130,633 WOUND SWEEP 25;7 SET
Wound Sweep
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter YES to indicate that a wound sweep (e.g., manual exploration) was done. This question must be
answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
DESCRIPTION: VASQIP Definition (2015): This indicates that a both a visual and manual methodical wound
exploration is performed prior to closing the surgical wound to ensure that all surgical items are
accounted for and extracted. This question must be answered if any of the final sponge, sharps or
instrument counts are recorded as incorrect. Note: The microscopic check for a cataract case is the
same as the "wound sweep".
130,635 WOUND SWEEP COMMENTS 53;0 WORD-PROCESSING #130.0635
DESCRIPTION: VASQIP Definition (2014): These are comments related to the reason(s) a wound sweep was or was not
performed that may be useful in the documentation of this case and/or subsequent comments related
to the wound sweep findings.
Wound Sweep Comments
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter any comments related to wound sweep.
DESCRIPTION: VASQIP Definition (2014): These are comments related to the reason(s) a wound sweep was or was
not performed that may be useful in the documentation of this case and/or subsequent comments
related to the wound sweep findings.
130,636 INTRA-OPERATIVE X-RAY 25;8 SET
Intra-Operative X-Ray
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 21, 2014
HELP-PROMPT: Enter YES to indicate that an intraoperative x-ray was done. This question must be answered if any
of the final sponge, sharps or instrument counts are recorded as incorrect.
DESCRIPTION: VASQIP Definition (2014): This indicates that a radiograph of the entire surgical field to rule out
a retained surgical item was performed and interpreted by a physician at the completion of the
surgical procedure, prior to the patient's transfer from the Operating Room. This question must be
answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
130,637 INTRA-OPERATIVE X-RAY COMMENTS 54;0 WORD-PROCESSING #130.0637
LAST EDITED: DEC 27, 2013
DESCRIPTION: VASQIP Definition (2014): These are comments related to the reason(s) an intraoperative x-ray was
or was not performed that may be useful in the documentation of this case and/or subsequent
comments related to the radiograph findings.
Intraoperative X-Ray Comments
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter any comments related to intraoperative x-ray.
DESCRIPTION: VASQIP Definition (2014): These are comments related to the reason(s) an intraoperative x-ray was
or was not performed that may be useful in the documentation of this case and/or subsequent
comments related to the radiograph findings.
130,638 LATERALITY OF PROCEDURE OP;5 SET
Laterality Of Procedure
'1' FOR NA;
'2' FOR LEFT;
'3' FOR RIGHT;
'4' FOR BILATERAL;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter left or right or bilateral when laterality is applicable to the procedure.
DESCRIPTION: This indicates that the side of the procedure is identified as either left, right or bilateral,
when applicable to the procedure.
130,639 REPORT GIVEN TO 25;9 POINTER TO NEW PERSON FILE (#200)
Report Given To
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the name of the staff member who received the postoperative report from the OR staff member.
DESCRIPTION: This indicates the name of the staff member who received the postoperative report from the OR staff
member.
130,640 PCI 200;56 SET
'1' FOR NONE;
'2' FOR <12 HRS OF SURG;
'3' FOR >12 HRS - 7 DAYS;
'4' FOR >7 DAYS;
'5' FOR UNKNOWN;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter the category that most accurately reflects the patient's Percutaneous Coronary Intervention.
DESCRIPTION: VASQIP Definition (2014): Indicate the time period of the patient's most recent percutaneous
coronary artery intervention (PCI) prior to surgery. This does not include percutaneous valve
interventions including valvuloplasty and valve replacement. Indicate the one appropriate response,
even if the procedure was not fully successful: 1. None - The patient never had a previous PCI. 2.
<12 hr of surg - The patient had a PCI less than 12 hours prior to
surgery. 3. >12 hr - 7 days - The patient had a PCI between 12 hours and 7
days prior to surgery. 4. >7 days - The patient had a PCI more than 7 days prior to surgery.
5. Unknown
130,641 HYPERTENSION 200;57 SET
Hypertension
'1' FOR NO;
'2' FOR YES WITHOUT MED;
'3' FOR YES WITH MED;
'4' FOR UNKNOWN;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Enter YES if there is any indication that the patient has hypertension.
DESCRIPTION: VASQIP Definition (2014): Indicate if the patient has a documented history of hypertension within
the 30 days prior to surgery. Select the one appropriate response: 1. No history of hypertension
2. Yes without medication therapy 3. Yes with medication therapy (antihypertensive therapy:
diuretics,
beta blockers, ACE inhibitors, calcium channel blockers, etc.) 4. Unknown
130,642 BLEEDING RISK DUE TO MED 200;58 SET
Increased Bleeding Risk Due To Medication
'1' FOR NO BLEEDING RISK MED;
'2' FOR CHRONIC ASPIRIN NOT D'C;
'3' FOR BLEEDING RISK MED D'C;
'4' FOR BLEEDING RISK MED NOT D'C;
'N' FOR NO BLEEDING RISK FROM MED;
'Y' FOR BLEEDING RISK MED NOT D'C;
LAST EDITED: JUL 16, 2015
HELP-PROMPT: Enter indicator of bleeding risk due to medication.
DESCRIPTION: VASQIP Definition (2015): Bleeding risk due to medication is present if: 1) a patient is on chronic
anticoagulation (e.g. a thrombin inhibitor or an antiplatelet agent other than aspirin) and/or an
acute anticoagulant or thrombolytic agent; AND 2) the agent was not discontinued before surgery in
sufficient time for reversal of anticoagulant effect.
Select the one appropriate response: N - The patient is not on medications that increase bleeding
risk OR
was on meds that increased bleeding risk that were all discontinued
in sufficient time for reversal prior to surgery Y - The patient was on pre-operative
medication(s) that increase
bleeding risk AND one or more were NOT discontinued in sufficient
time for reversal prior to surgery
SCREEN: S DIC("S")="I 'Y"
EXPLANATION: Screen prevents selection of inactive entries.
130,643 ANGINA TIMEFRAME 200;59 SET
Angina Timeframe
'1' FOR NO ANGINA;
'2' FOR W/N 14 DAY OF SURGERY;
'3' FOR W/N 15-30 DAYS OF SURGERY;
'4' FOR UNKNOWN;
LAST EDITED: FEB 14, 2014
HELP-PROMPT: Indicate time period when the angina was most recently present.
DESCRIPTION: VASQIP Definition (2014): Indicate time period when the angina was most recently present: 1. No
Angina 2. Within 14 days prior to surgery 3. Within 15-30 days prior to surgery 4. Unknown
130,644 SYMPTOMATIC UTI 205;42 SET
Symptomatic UTI
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 17, 2015
HELP-PROMPT: Enter YES if the patient has any postoperative Symptomatic UTI-Culture occurrences.
DESCRIPTION: Definition Revised (2015): SYMPTOMATIC UTI - CULTURE plus SIGN/SYMPTOM within 1 calendar day of
each other: a. UTI Signs/Symptoms: Urg/Freq/Dys
Yes = Patient has urgency, frequency, or dysuria with no other
recognized cause
No = Patient does not complain of urgency, frequency or dysuria OR
has a catheter in place
b. UTI Signs/Symptoms: Fever
Yes = Patient has a fever > 38C at the time of culture or onset
of symptoms
No = Patient does not have a fever > 38C at the time of culture
or onset of signs or symptoms
c. UTI Signs/Symptoms: Tenderness
Yes = Patient has suprapubic tenderness, costovertebral angle
pain or tenderness with no other recognized cause
No = Patient does not have suprapubic tenderness, costovertebral
angle pain or tenderness
d. UTI Culture: (must choose 1 or 2)
1. Patient has a positive urine culture that is > 10^5 colony-
forming units (CFU)/ml with no more than 2 species of
microorganisms
2. A positive urine culture of >=10^3 and <10^5 colony-forming
units (CFU)/ml with no more than 2 species of microorganisms
plus one of the following three items: a) positive dipstick for
leukocyte esterase and/or nitrate; b) Pyuria (urine specimen
with > 10 white blood cell [WBC]/mm3 of unspun urine or > 3
WBC high-power field of spun urine) or c) microorganisms seen
of Gram's stain of unspun urine
INDWELLING URETHRAL CATHETER At the time of specimen collection for suspected urinary tract
infection during the post-operative 30 day period, answer the following about indwelling urethral
catheter:
I) IN PLACE > 2 calendar days on the day of UTI Signs/Symptoms and UTI Culture sample.
R) RECENTLY REMOVED, had been in place > 2 calendar days but removed the day of or the day before
UTI Signs/Symptoms and UTI Culture sample.
S) SHORT DURATION, present at the time of UTI Signs/Symptoms and UTI Culture sample but had not
been present > 2 calendar days.
D) DISTANT REMOVAL, placed in the perioperative period and present >2 calendar days, but removed >2
calendar days prior to UTI Signs/Symptoms and UTI Culture sample.
N) NO CATHETER, did not have an indwelling urethral catheter > 2 calendar days
130,645 *MECHANICAL VENT W/N 30 DAYS 205;43 SET
*Mechanical Ventilation within 30 Days
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 01, 2015
HELP-PROMPT: Enter Yes if the patient was placed on ventilator support.
DESCRIPTION: Definition Revised (2014): Indicate if ventilator support required within 30 days after initial
post-operative extubation: If the patient was placed on ventilator support postoperatively for any
reason within 30 days AND occurred during the same admission in-hospital. (For example, the patient
is on the ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is
discontinued. Later, the patient gets into trouble and mechanical ventilation has to be
reinstated.) In patients who were not intubated during surgery, intubation at any time after their
surgery is considered an occurrence.
TECHNICAL DESCR:
This field became obsolete in patch SR*3*184.
130,647 ORGANS TO BE TRANSPLANTED 63;0 SET Multiple #130.0647
LAST EDITED: JUN 26, 2015
DESCRIPTION:
This is information related to the organ(s) that will be transplanted.
130.0647,.01 ORGANS TO BE TRANSPLANTED 0;1 SET
Organs to be Transplanted
'1' FOR HEART;
'2' FOR LUNG;
'3' FOR KIDNEY;
'4' FOR LIVER;
'5' FOR PANCREAS;
'6' FOR INTESTINE;
'7' FOR OTHER;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the organ(s) that will be transplanted.
CROSS-REFERENCE: 130.0647^B
1)= S ^SRF(DA(1),63,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),63,"B",$E(X,1,30),DA)
130,648 UNOS NUMBER VER1;2 FREE TEXT
UNOS Identification Number of Donor
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the UNOS number of the donor. Must be 1-10 characters in length.
DESCRIPTION:
This is the UNOS identification number of the donor.
130,649 DONOR SEROLOGY HCV VER1;3 SET
Donor Serology Hepatitis C virus (HCV)
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the Hepatitis C virus (HCV) status for the transplant donor.
DESCRIPTION: This is the Hepatitis C virus (HCV) status for the transplant donor. Enter 'Yes' if positive, 'N'
if negative, 'NA' if unknown or not tested.
130,650 DONOR SEROLOGY HBV VER1;4 SET
Donor Serology Hepatitis B Virus (HBV)
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the Hepatitis B virus (HBV) status for the transplant donor.
DESCRIPTION: This is the Hepatitis B virus (HBV) status for the transplant donor. Enter 'Yes' if positive, 'N'
if negative, 'NA' if unknown or not tested.
130,651 DONOR SEROLOGY CMV VER1;5 SET
Donor Serology Cytomegalovirus (CMV)
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the Cytomegalovirus (CMV) status for the transplant donor.
DESCRIPTION: This is the Cytomegalovirus (CMV) status for the transplant donor. Enter 'Yes' if positive, 'N' if
negative, 'NA' if unknown or not tested.
130,652 DONOR SEROLOGY HIV VER1;6 SET
Donor Serology HIV
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Enter the HIV status for the transplant donor.
DESCRIPTION: This is the HIV status for the transplant donor. Enter 'Yes' if positive, 'N' if negative, 'NA' if
unknown or not tested.
130,653 DONOR ABO TYPE VER1;7 SET
Donor ABO Type
'1' FOR A RH(+);
'2' FOR A RH(-);
'3' FOR B RH(+);
'4' FOR B RH(-);
'5' FOR AB RH(+);
'6' FOR AB RH(-);
'7' FOR O RH(+);
'8' FOR O RH(-);
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the ABO Type of the transplant donor.
DESCRIPTION:
This is the ABO Type of the transplant donor.
130,654 RECIPIENT ABO TYPE VER1;8 SET
Recipient ABO Type
'1' FOR A RH(+);
'2' FOR A RH(-);
'3' FOR B RH(+);
'4' FOR B RH(-);
'5' FOR AB RH(+);
'6' FOR AB RH(-);
'7' FOR O RH(+);
'8' FOR O RH(-);
LAST EDITED: JUN 25, 2015
HELP-PROMPT: Enter the ABO Type of the transplant recipient.
DESCRIPTION:
This is the ABO Type of the transplant recipient.
130,655 BLOOD BANK ABO VERIFICATION VER1;9 SET
Blood Bank Verification of ABO Type
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the blood bank verified the ABO type of the transplant recipient.
DESCRIPTION:
This field documents whether the blood bank verified the ABO type of the transplant recipient.
130,656 OR ABO VERIFICATION (Y/N) VER1;10 SET
OR Verification of ABO Type (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the OR has verified ABO type of transplant recipient.
DESCRIPTION:
This field documents whether the OR has verified the ABO type of transplant recipient.
130,657 SURGEON VERIFYING UNET VER1;11 POINTER TO NEW PERSON FILE (#200)
Surgeon Performing UNET Verification
LAST EDITED: MAY 27, 2015
HELP-PROMPT: Enter the name of the Surgeon verifying UNET.
DESCRIPTION:
Document the transplant surgeon who completed required UNET verification.
130,658 ORGAN VER PRE-ANESTHESIA VER1;12 SET
Organ Verification Prior to Anesthesia
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the organ was verified prior to anesthesia.
DESCRIPTION:
This field documents whether the organ was verified prior to anesthesia.
130,659 SURGEON VER DONOR ORG PRE-ANES VER1;13 POINTER TO NEW PERSON FILE (#200)
Surgeon Verifying Organ Prior to Donor Anesthesia
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter the Name of the Surgeon that verified the organ prior to donor anesthesia.
DESCRIPTION: For a live donor case, enter the name of the surgeon who documented the organ to be removed and
transplanted, including laterality when applicable.
130,660 ORGAN VER PRE-TRANSPLANT VER1;14 SET
Organ Verification Prior to Transplant
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the organ was verified prior to transplant.
DESCRIPTION:
This field documents whether the organ was verified prior to transplant.
130,661 PALLIATION .1;21 SET
Palliation
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if the planned surgical procedure was for palliation, either therapeutic or diagnostic.
DESCRIPTION: This field indicates whether the procedure was intended for palliation, either therapeutic or
diagnostic.
130,662 IMPAIRED COGNITIVE FUNCTION 210;1 SET
Impaired Cognitive Function in the 90 Days Preop
'0' FOR NONE-NO IMPAIRMENT;
'1' FOR YES-DOCUMENTED HISTORY;
'2' FOR YES-DOCUMENTED AND DECLINING;
'3' FOR NO DOCUMENTATION;
LAST EDITED: MAY 13, 2015
HELP-PROMPT: Enter selection options for impaired cognitive function
DESCRIPTION: Indicate if there is any documented history of memory loss, functional deficits or declining
cognitive skills in the 90 days prior to surgery.
130,663 DONOR VESSEL USAGE VER1;15 SET
Donor Vessel Usage
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if donor vessels were used.
DESCRIPTION:
This field documents if donor vessels were used.
130,664 DONOR VESSEL UNOS ID 57;0 Multiple #130.0664
DESCRIPTION:
This field documents the UNOS identification number of the vessel(s) donor(s).
130.0664,.01 DONOR VESSEL UNOS ID 0;1 FREE TEXT
Donor Vessel UNOS ID
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the UNOS identification number of the vessel(s) donor.
DESCRIPTION: This field documents the UNOS identification number of the vessel(s) donor(s). If there is more
than one donor enter the UNOS number for each donor.
CROSS-REFERENCE: 130.0664^B
1)= S ^SRF(DA(1),57,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),57,"B",$E(X,1,30),DA)
130,665 DONOR VESSEL DISPOSITION VER1;16 SET
Donor Vessel Disposition if not used
'N' FOR NO DONOR VESSELS RECEIVED;
'D' FOR DISCARDED;
'R' FOR RETURNED TO OPO;
'S' FOR STORED;
'NA' FOR NOT APPLICABLE;
LAST EDITED: MAY 18, 2022
HELP-PROMPT: Enter disposition of donor vessels.
DESCRIPTION:
Document disposition of donor vessels.
130,666 LIVER DISEASE/CIRRHOSIS 210;2 SET
Liver Disease/Cirrhosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is a diagnosis of cirrhosis.
DESCRIPTION: This field documents whether there are biopsy, imaging, and/or clinical criteria to support
diagnosis of cirrhosis.
130,667 SLEEP APNEA-COMPLIANCE 200.1;15 SET
Sleep Apnea-Compliance
'1' FOR NIGHTLY;
'2' FOR > OR EQUAL 4 TIMES A WEEK;
'3' FOR < 4 TIMES A WEEK;
'4' FOR NOT DOCUMENTED;
INPUT TRANSFORM: D CHK667^SROAPRE
LAST EDITED: JUN 23, 2015
HELP-PROMPT: Enter the level of the patient's reported compliance with sleep apnea treatment.
DESCRIPTION:
If yes to Level 3 Sleep Apnea, indicate level of patient's reported compliance with treatment.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,668 IMMUNOCOMPROMISED STATE PREOP 210;3 SET
Immunocompromised State Preop
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'Y' if the patient has received a medication known to suppress immune system function within
30 days prior to operation.
DESCRIPTION: This field documents if the patient has received any medication in a dosage known to suppress
immune system function within 30 days prior to operation.
130,669 PULMONARY HTN 210;4 SET
Pulmonary HTN
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if the patient has pulmonary hypertension.
DESCRIPTION: This field documents if the patient has pulmonary hypertension documented on invasive or
non-invasive cardiac testing.
130,670 RESIDENCE 30 DAYS PREOP 210;5 SET
Current Residence (w/in 30 days prior to surgery)
'1' FOR HOME;
'2' FOR ACUTE CARE FACILITY;
'3' FOR LONG TERM CARE;
'4' FOR HOMELESS;
'5' FOR UNKNOWN;
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Enter the patient's current residence within 30 days prior to surgery.
DESCRIPTION: Describe the current residence of the patient in the 30 days prior to surgery. If multiple answer
options apply, select the highest level applicable within the 30 days preoperative.
1. Home (patient has their own residence or a similar dwelling e.g.
residence of a family member) 2. Acute Care Facility (patient was transferred to the VA that
performed
the surgery from an acute care facility, VA or non-VA) 3. Long Term Care (patient came from an
extended care facility or
nursing home, VA or non-VA) 4. Homeless (patient does not have a fixed dwelling (homeless)
and/or
came from a supervised public or private shelter or transitional
housing facility) 5. Unknown
Note: Answer 4 if the patient lacks a fixed dwelling, including an individual whose primary
residence during the night is a supervised public or private facility (e.g., shelters) that
provides temporary living accommodations, an individual who is a resident in transitional housing
facility, or an individual who lives in another individual's/family's home and would otherwise be
homeless.
130,671 AMBULATION DEVICE PREOP 210;6 SET
Ambulation Device
'1' FOR AMBULATES W/OUT ASSISTIVE DEVICE;
'2' FOR AMBULATES WITH CANE OR WALKER;
'3' FOR USES MANUAL WHEELCHAIR INDEPENDENTLY;
'4' FOR DOES NOT AMBULATE OR USE MANUAL WHEELCHAIR INDEPENDENTLY;
LAST EDITED: JUN 23, 2015
HELP-PROMPT: Enter the degree of mechanical assistance, if any, needed for ambulation in the 30 days prior to
surgery.
DESCRIPTION: Describe the degree of mechanical assistance, if any, needed for ambulation in the 30 days prior to
surgery.
1. Ambulates without assistive device 2. Ambulates with cane or walker 3. Uses manual wheelchair
independently 4. Does not ambulate or use manual wheelchair independently.
Note: If the patient ambulates with assistance from another individual, select either 1 or 2 as
appropriate. If they use a motorized wheelchair only, select 4.
130,672 NUTRITIONAL SUPPLEMENT PREOP 210;7 SET
Preop Nutritional Supplementation
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if the patient received a prescribed nutrition supplement with protein for at least five
days prior to surgery.
DESCRIPTION: This field documents if the patient received a prescribed nutrition supplement with protein for at
least five days prior to surgery.
130,673 HISTORY OF CANCER DIAGNOSIS 210;8 SET
History of Cancer Diagnosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if the patient has a history of any cancer regardless of stage or treatment.
DESCRIPTION: This field documents if the patient has a history of any cancer regardless of stage or treatment.
For skin cancers include all melanomas and squamous cell cancers with nodal involvement. Exclude
basal cell cancer.
130,674 HX RAD RX PLANNED SURG FIELD 210;9 SET
History of Radiation Therapy to Planned Surgical Field
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 14, 2015
HELP-PROMPT: Enter Yes if the patient received therapeutic radiation to the region of the planned surgical
field.
DESCRIPTION: This field documents if the patient received therapeutic radiation to the region of the planned
surgical field.
130,675 PRIOR INFEC/INFLAM SURG FIELD 210;10 SET
Prior infection or inflammation in planned surgical field
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if the patient has had an infection or an acute inflammatory process within the 90 days
prior to the operation that locally involves the planned surgical field.
DESCRIPTION: This field documents if the patient has had an infection or an acute inflammatory process within
the 90 days prior to the operation that locally involves the planned surgical field.
130,676 HX DEEP VEIN THROMBOSIS 210;11 SET
History of Deep Vein Thrombosis or Pulmonary Embolism (DVT/PE)
'1' FOR NEITHER DVT NOR PE;
'2' FOR DVT WITHOUT PE;
'3' FOR PE WITHOUT DVT;
'4' FOR BOTH DVT AND PE;
LAST EDITED: MAY 13, 2015
HELP-PROMPT: Enter the patient's history of DVT/PE.
DESCRIPTION: Indicate diagnosis of deep venous thrombosis and/or pulmonary embolism confirmed by imaging. Do
not include DVT or PE that was clinically suspected but not confirmed by imaging.
130,677 PRIOR SURG SAME OP FIELD 210;12 SET
Number of Prior Surgery in same Operative field
'0' FOR NO PREVIOUS SURGERIES;
'1' FOR 1 PREVIOUS SURGERY;
'2' FOR 2 PREVIOUS SURGERIES;
'3' FOR 3 PREVIOUS SURGERIES;
'4' FOR 4 PREVIOUS SURGERIES;
'5' FOR 5 PREVIOUS SURGERIES;
'6' FOR >5 PREVIOUS SURGERIES;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the number of procedures that the patient has had performed in the same operative field.
DESCRIPTION: This field documents the number of procedures that the patient has had performed in the body cavity
or surgical field that is to undergo the current procedure.
130,680 SPECIAL EQUIPMENT 58;0 POINTER Multiple #130.25
DESCRIPTION:
This is information related to the Special Equipment's to be used for this operative procedure.
130.25,.01 SPECIAL EQUIPMENT 0;1 POINTER TO SPECIAL EQUIPMENT FILE (#131.3)
Special Equipment
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.3))" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter all Special Equipment item(s) requested for the planned surgical procedure.
DESCRIPTION: This is information related to the planned Special equipment to be used for this operative
procedure. Enter all special equipment needed.
SCREEN: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.3))"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130.25^B
1)= S ^SRF(DA(1),58,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),58,"B",$E(X,1,30),DA)
130,681 PLANNED IMPLANTS 59;0 POINTER Multiple #130.0681
LAST EDITED: JUN 26, 2015
DESCRIPTION: This is information related to the planned implants device(s) to be used for this operative
procedure.
130.0681,.01 PLANNED IMPLANTS 0;1 POINTER TO PLANNED IMPLANT FILE (#131.5)
Planned Implants
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.5))" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the name of the planned implant device.
DESCRIPTION: This is information related to the planned implants to be used for this operative procedure.
Enter all planned implants.
SCREEN: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.5))"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130.0681^B
1)= S ^SRF(DA(1),59,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),59,"B",$E(X,1,30),DA)
130,682 SPECIAL SUPPLIES 60;0 POINTER Multiple #130.0682
DESCRIPTION:
This is information related to the Special Supplies to be used for this operative procedure.
130.0682,.01 SPECIAL SUPPLIES 0;1 POINTER TO SPECIAL SUPPLIES FILE (#131.04)
Special Supplies
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.04))" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter all supplies requested for the planned surgical procedure.
DESCRIPTION: This is information related to the special supplies to be used for this operative procedure.
Enter all surgical supplies needed for the surgical procedure.
SCREEN: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.04))"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130.0682^B
1)= S ^SRF(DA(1),60,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),60,"B",$E(X,1,30),DA)
130,683 SPECIAL INSTRUMENTS 61;0 POINTER Multiple #130.0683
DESCRIPTION:
This is information related to the Special Instruments to be used for this operative procedure.
130.0683,.01 SPECIAL INSTRUMENTS 0;1 POINTER TO SPECIAL INSTRUMENTS FILE (#131.02)
Special Instruments
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.02))" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Enter special instrument(s) requested for the planned surgical procedure.
DESCRIPTION: This is information related to the special instruments to be used for this operative procedure.
Enter all special instruments needed for the surgical procedure.
SCREEN: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.02))"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130.0683^B
1)= S ^SRF(DA(1),61,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),61,"B",$E(X,1,30),DA)
130,684 PHARMACY ITEMS 62;0 POINTER Multiple #130.0684
DESCRIPTION:
This is information related to the Pharmacy Items to be used for this operative procedure.
130.0684,.01 PHARMACY ITEMS 0;1 POINTER TO PHARMACY ITEMS FILE (#131.06)
Pharmacy Items
INPUT TRANSFORM: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.06))" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the pharmacy item(s) requested for the planned surgical procedure. Answer must be 4-20
characters in length.
DESCRIPTION: This is the name of the medication(s) (generic or proprietary) requested for this surgical
procedure. More than one medication may be entered for each case.
SCREEN: S DIC("S")="I '$P(^(0),U,3)&($$SCR^SRTOVRF(131.06))"
EXPLANATION: Screen prevents selection of inactive entries.
CROSS-REFERENCE: 130.0684^B
1)= S ^SRF(DA(1),62,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),62,"B",$E(X,1,30),DA)
130,685 DC/REL DESTINATION 210;14 SET
DC/REL Destination
'1' FOR HOME;
'2' FOR ACUTE CARE FACIL VA/NON-VA;
'3' FOR EXTENDED CARE FACIL (NON-REHAB);
'4' FOR REHABILITATION CENTER;
'5' FOR SHELTER/TRANSITIONAL HOUSING;
'6' FOR PATIENT DEATH;
'7' FOR OTHER;
LAST EDITED: SEP 02, 2015
HELP-PROMPT: Enter the patient's destination after hospital discharge or ambsurg release.
DESCRIPTION: Indicate the patient's initial destination upon discharge from a VA hospital acute care admission
or release from an ambulatory surgery or observation location following an assessed surgery.
1. Home (patient returned to their own residence or to a similar
setting e.g. residence of a family member), 2. Acute Care Facility (patient was transferred
after the inpatient
surgery to another acute care facility, VA or non-VA, or was
admitted to acute care after an ambulatory surgery) 3. Extended Care Facility,
Non-Rehabilitation (patient returned to or
entered an extended care facility for a purpose other than
rehabilitation, VA or non-VA) 4. Rehabilitation Center (patient entered a rehabilitation
facility for
the purpose of postoperative recovery, e.g. physical or occupational
therapy) 5. Shelter/Transitional Housing (patient does not have a fixed dwelling
(homeless) and enters a supervised public or private shelter or
transitional housing facility) 6. Patient Death (patient died during the postoperative admission
or at
the ambulatory surgery center). 7. Other.
130,686 AORTIC REGURGITATION 211;1 SET
Aortic Regurgitation
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient has aortic regurgitation documented on invasive or non-invasive cardiac
testing.
DESCRIPTION: This field documents if the patient has aortic regurgitation documented on invasive or non-invasive
cardiac testing.
130,687 INJURY TO ADJACENT ORGAN 211;2 SET
Injury To Adjacent Organ
'0' FOR NO;
'1' FOR YES, WITH INTERVENTION;
'2' FOR YES, WITH NO INTERVENTION REQ;
LAST EDITED: JUN 29, 2015
HELP-PROMPT: Enter the level of intervention required in the event of unintended injury.
DESCRIPTION: This field documents the level of intervention required in the event of an unintended injury to an
adjacent organ/structure during the surgical procedure. Choose from the following answer options:
0. No unintended injury to an adjacent organ/structure during the
surgical procedure. 1. Unintended injury to an adjacent organ/structure that resulted
in an intervention to manage the injury. 2. Unintended injury to an adjacent organ/structure
that did not
require intervention to manage the injury.
130,688 STOMA COMPLICATIONS 211;3 SET
Stoma Complications
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if any condition of a stoma requires surgical intervention within 30 days
postoperative.
DESCRIPTION: This field document any condition of a stoma which requires surgical intervention/revision within
30 days from date of stoma creation.
130,689 NON-UNION 211;4 SET
Non-Union
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if surgeon confirms a diagnosis of non-union.
DESCRIPTION: This field documents if either there is not complete healing of the involved bony structure by 6
months after surgery or if the surgeon confirms a diagnosis of non-union.
130,690 IMPLANT INFECTIONS 211;5 SET
Implant Infections
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if infection of, in, or surrounding a non-human-derived foreign body occurs.
DESCRIPTION: This field documents if infection of, in, or surrounding a non-human-derived foreign body occurs
within 365 days following permanent implantation by an invasive procedure in the operating room.
130,691 CHYLE/LYMPH LEAK 211;6 SET
Chyle/Lymph Leak (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Enter 'YES' if there is clinical/imaging diagnosis of leakage from or collection of chyle/lymph.
DESCRIPTION: This field documents if there is clinical or imaging diagnosis of leakage from or collection of
chyle/lymph in the surgical field region.
130,692 ANASTOMOTIC LEAK 211;7 SET
Anastomotic Leak (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if an anastomosis in the GI, urinary, or respiratory tract does not heal within 30
days.
DESCRIPTION: This field documents if an anastomosis in the GI, urinary, or respiratory tract does not heal as
evidenced by infection adjacent to or in the same body cavity OR by development of a fistula within
30 days of the surgical procedure.
130,693 FISTULA 211;8 SET
Fistula
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if an abnormal connection occurs between a hollow or tubular organ and the body
surface.
DESCRIPTION: This field documents if an abnormal connection occurs between a hollow or tubular organ and the
body surface, or between two hollow or tubular organs within 90 days of the index surgical
procedure.
130,694 NECROTIZING SOFT TISS INFECT 211;9 SET
Necrotizing Soft Tissue Infection (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter 'YES' if the surgical procedure is performed to treat necrotizing soft tissue infection.
DESCRIPTION: This field documents if the surgical procedure is performed to treat necrotizing soft tissue
infection with or without skin, muscle, or fascial necrosis.
130,695 OTHER BLOOD PRODUCT UNITS 211;10 SET
Other Blood Product Units
'0' FOR NONE;
'1' FOR PLATELETS;
'2' FOR FRESH FROZEN PLASMA;
'3' FOR PLASMA AND PLATELETS;
'4' FOR ANY OTHER COMBINATION;
'5' FOR ANY OTHER BLOOD PRODUCT;
LAST EDITED: MAY 19, 2015
HELP-PROMPT: Enter '1, 2, 3, 4, or 5' to indicate the specific blood product(s) that were administered or '0' if
none was administered.
DESCRIPTION: Blood products commonly administered in the operating room include platelets and fresh frozen
plasma. Answer 1, 2, 3, 4, or 5 to indicate the specific blood product or combination of blood
products that were administered in the operating room. Answer 0 if no product was administered.
Do not include packed red blood cells (PRBCs) or cell saver blood when answering this question, as
these are documented separately.
130,696 PRESSORS USED INTRAOP 211;11 SET
Pressors Used In the OR
'0' FOR NO;
'1' FOR YES-BOLUS;
'2' FOR YES-CONTINUOUS INFUSION;
LAST EDITED: MAY 19, 2015
HELP-PROMPT: Select the Pressors used with the intent to raise blood pressure in the operating room.
DESCRIPTION: Pressors are medications used with the intent to raise blood pressure. For this variable, a
pressor must be administered for the intent of increasing blood pressure while the patient is in
the operating room. Enter 0 if no medications were administered or if the intent of medicine
administration is for reasons other than increasing blood pressure. Enter 1 if one or more pressor
medications were administered via bolus. Enter 2 if one or more pressor medications were
administered via continuous infusion.
130,697 MITRAL STENOSIS 211;12 SET
Mitral Stenosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient has mitral stenosis documented.
DESCRIPTION: This field documents if patient has mitral stenosis documented on invasive or non-invasive cardiac
testing.
130,698 PCI INTERVENTION 211;13 SET
PCI Intervention (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient has had prior percutaneous coronary artery intervention.
DESCRIPTION: This field documents if the patient has had prior treatment of coronary artery stenosis or
occlusion by catheter-based techniques, such as percutaneous transluminal coronary angioplasty,
atherectomy, laser angioplasty, or implantation of coronary stents.
130,699 ATRIAL ARRHYTHMIAS 211;14 SET
Atrial Arrhythmias (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Enter Yes for documented history of atrial arrhythmias.
DESCRIPTION: This field documents a history of atrial arrhythmias, including atrial fibrillation, atrial
flutter, paroxysmal supraventricular tachycardia, or Wolff-Parkinson-White (WPW) syndrome.
130,700 HEAD OR NECK CANCER 211;15 SET
History Of Head Or Neck Cancer (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes for documented history of specific head or neck cancers.
DESCRIPTION: This field documents a history of cancers of the mouth, nose, sinuses, salivary glands, throat OR
skin cancers of the head/neck with lymph nodes metastases in the neck. Do not include any skin
cancer without lymph node involvement.
130,701 MACULAR DEGENERATION 211;16 SET
Macular Degeneration (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if there is medical record documentation of the diagnosis for the operative eye.
DESCRIPTION: This field documents if there is medical record documentation of the diagnosis for the operative
eye.
130,702 GLAUCOMA 211;17 SET
Glaucoma (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if there is medical record documentation of a glaucoma diagnosis for the operative eye.
DESCRIPTION: This field documents if there is medical record documentation of a glaucoma diagnosis for the
operative eye.
130,704 HX RETINAL DETACHMENT 211;19 SET
History Of Retinal Detachment (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if there is medical record documentation of a history of retinal detachment for the
operative eye.
DESCRIPTION: This field documents if there is medical record documentation of a history of retinal detachment
for the operative eye.
130,705 AXIAL LEN/ANTERIOR CHAM DEP 211;20 SET
Extreme Axial Length Or Anterior Chamber Depth (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if either axial length is > 30 mm or anterior chamber depth is > 6 mm.
DESCRIPTION:
This field documents if either axial length is > 30 mm or anterior chamber depth is > 6 mm.
130,706 CORNEAL GUTTAE/FUCHS ENDO 211;21 SET
Corneal Guttae/Fuchs Endo Dystrophy (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is medical record documentation of the diagnosis of corneal guttae/Fuchs
endothelial in the operative eye.
DESCRIPTION: This field documents the diagnosis of corneal guttae/Fuchs endothelial dystrophy in the operative
eye.
130,707 DIABETIC RETINOPATHY 211;22 SET
Diabetic Retinopathy (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is medical record documentation of the diagnosis diabetic retinopathy for the
operative eye.
DESCRIPTION: This field documents if there is medical record documentation of the diagnosis of diabetic
retinopathy for the operative eye.
130,708 COMPLEX CATARACT 211;23 SET
Complex Cataract
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is medical record documentation of the diagnosis of complex cataract in the
operative eye.
DESCRIPTION: This field documents if there is medical record documentation of the diagnosis of complex cataract
in the operative eye.
130,709 STATIN 30 DAYS PREOP 211;24 SET
Statin 30 Days Preop
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient was prescribed and compliant with usage of a statin for 30 days or
greater preoperatively.
DESCRIPTION: This field documents if the patient was prescribed and compliant with usage of a statin for 30 days
or greater preoperatively.
130,710 IPSILAT CORTICAL EVENT PREOP 211;25 SET
Ipsilateral Cortical Event w/in 6 months prior to surgery
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient was documented to have a history of an ipsilateral cortical event within
180 days prior to surgery.
DESCRIPTION: This field documents if the patient was documented to have a history of a cerebrovascular accident,
reversible ischemic neurological deficit or a transient ischemic attack within the 180 days prior
to surgery.
130,711 PREOP MODIFIED RANKIN SCORE 211;26 NUMBER
Preop Modified Rankin Score
INPUT TRANSFORM: K:+X'=X!(X>5)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the calculated modified Rankin score. Leave blank if not able to calculate.
DESCRIPTION:
This field documents the calculated modified Rankin score. Leave blank if not able to calculate.
130,712 CAROTID SUR ANATOMIC HIGH RISK 211;27 SET
Carotid Surgery Anatomic High Risk
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if carotid surgery was previously performed as described in the description.
DESCRIPTION: This field documents if carotid surgery is being performed in a patient with a previously radiated
neck, there has been a prior ipsilateral radical neck dissection or carotid surgery, the carotid
bifurcation is at C-2 or higher, or if there is a bull-like or inextensible neck.
130,713 BYPASS CRITICAL LIMB ISCHEMIA 211;28 SET
Bypass For Critical Limb Ischemia
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter Yes if ankle-brachial blood pressure index is less than or equal to 0.4 or if there is
ischemic tissue/ulceration due to vascular disease.
DESCRIPTION: For lower extremity inflow or leg bypass procedures, enter Yes if ankle-brachial blood pressure
index is less than or equal to 0.4 or if there is ischemic tissue/ulceration due to vascular
disease.
130,715 ENDOLEAK AT COMPLETION 211;30 SET
Endoleak At Completion
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient has an endoleak at the time of exit from the operating room.
DESCRIPTION:
This field documents if the patient has an endoleak at the time of exit from the operating room.
130,716 HIGH HEART RATE 6HRS PREOP 211;31 NUMBER
Highest Heart Rate W/IN 6 Hours of OR Start
INPUT TRANSFORM: K:+X'=X!(X>250)!(X<30)!(X?.E1"."1.N) X
LAST EDITED: JUN 04, 2015
HELP-PROMPT: Enter a number from 30-250 with no decimal places.
DESCRIPTION: Enter the highest heart rate in beats per minute recorded in the medical record during the 6 hours
preceding entry into the operating room.
130,717 HIGH HEART RATE INTRAOP 211;32 NUMBER
Highest Heart Rate in the OR
INPUT TRANSFORM: K:+X'=X!(X>250)!(X<30)!(X?.E1"."1.N) X
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter a number from 30-250 with no decimal places.
DESCRIPTION: Enter the highest heart rate in beats per minute recorded in anesthesia records from time of entry
to time of exit from the operating room.
130,718 LOW ARTERIAL PRESS 6HRS PREOP 211;33 NUMBER
Lowest Mean Arterial Pressure W/N 6 Hrs of OR Start
INPUT TRANSFORM: K:+X'=X!(X>200)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Enter a number from 0 to 200 with no decimal places.
DESCRIPTION: Enter the lowest mean arterial blood pressure recorded in medical records for the 6 hours preceding
entry into the operating room.
130,719 HIGH LACTIC ACID 6HRS PREOP 211;34 NUMBER
Highest Lactic Acid Within 6 Hrs of OR Start
INPUT TRANSFORM: K:+X'=X!(X>30)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Type a number between 0 and 30, 1 decimal digit.
DESCRIPTION: Enter the highest lactic acid (units = mmol/liter) measured from during the 6 hours prior to entry
into the operating room. Do not enter a value if arterial pH was not measured in the 6 hours
preceding entry into the operating room.
130,720 HIGH LACTIC ACID INTRAOP VERD;6 NUMBER
Highest Lactic Acid in the OR
INPUT TRANSFORM: K:+X'=X!(X>30)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Enter a number from 0 to 30 with 1 decimal place.
DESCRIPTION: Enter the highest lactic acid (units = mmol/liter) measured from entry into the operating room to
exit from the operating room. Do not enter a value if lactic acid was not measured in the
operating room.
130,721 LOWEST PH 6HRS PREOP VERD;7 NUMBER
Lowest PH Within 6 Hours Prior to OR Start
INPUT TRANSFORM: K:+X'=X!(X>7.6)!(X<6.8)!(X?.E1"."3.N) X
LAST EDITED: JUL 09, 2015
HELP-PROMPT: Enter a number from 6.80 to 7.60 with 3 significant digits use the format X.YZ where must X be 6 or
7 and YZ may be 00-99.
DESCRIPTION: Enter the lowest arterial pH obtained during the 6 hours prior to entry into the operating room.
Do not enter a value if arterial pH was not measured in the 6 hours preceding entry into the
operating room.
130,722 LOWEST PH INTRAOP 211;35 NUMBER
Lowest PH in the OR
INPUT TRANSFORM: K:+X'=X!(X>7.6)!(X<6.8)!(X?.E1"."3.N) X
LAST EDITED: MAY 19, 2015
HELP-PROMPT: Enter a number from 6.80 to 7.60 with 3 significant Digits use the format X.YZ where must X be 6 or
7 and YZ may be 00-99.
DESCRIPTION: Enter the lowest arterial pH obtained between from entry to and exit from the operation room. Do
not enter a value if pH was not measured in the operation room.
130,723 LOW ARTERIAL PRESS INTRAOP 211;36 NUMBER
Lowest Mean Arterial Pressure in the OR
INPUT TRANSFORM: K:+X'=X!(X>200)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: MAY 19, 2015
HELP-PROMPT: Type a number between 0 and 200, 0 decimal digits.
DESCRIPTION: Enter the lowest mean arterial blood pressure recorded in anesthesia records between entry to and
exit from the operating room.
130,724 OLIGURIA <60CC/2HRS 6HRS PREOP 211;37 SET
Oliguria <60 CC/2 Hrs Within 6 Hrs Prior to OR Start
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if urine output was less than 60 cc over any two hour period for the 6 hours prior to
entry into the operating room.
DESCRIPTION: This field documents if urine output was less than 60 cc over any two hour period for the 6 hours
prior to entry into the operating room.
130,725 OLIGURIA URINE OUTPUT INTRAOP 211;38 SET
Oliguria, Average Urine Output <30 CC/Hr in the OR
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if total urine output from room entry to exit was less than 30 cc/hr.
DESCRIPTION:
This field documents if total urine output from room entry to exit was less than 30 cc/hr.
130,726 LOWEST BICARBONATE 6HRS PREOP VERD;8 NUMBER
Lowest Bicarbonate Within 6 Hrs Prior to OR Start
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter a number from 0-40 with 1 decimal place.
DESCRIPTION: Enter the lowest bicarbonate measurement (mmol/L) from an electrolyte panel or arterial blood gas
obtained during the 6 hours prior to entry into the operating room. Do not enter a value if
bicarbonate was not measured in the 6 hours preceding entry into the operating room.
130,727 LOWEST BICARBONATE INTRAOP 211;39 NUMBER
Lowest Biocarbonate in the OR
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<0)!(X?.E1"."2.N) X
LAST EDITED: MAY 18, 2015
HELP-PROMPT: Enter a number from 0 to 40 with on decimal place.
DESCRIPTION: Enter the lowest bicarbonate measurement (mmol/L) from an electrolyte panel or arterial blood gas
obtained between entry and exit from the operating room. Do not enter a value if bicarbonate was
not measured in the operating room.
130,728 UNITS TRANSFUSED 6HRS PREOP 211;40 NUMBER
Number of Units Transfused W/IN 6 Hrs Prior to OR Start
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: MAY 22, 2015
HELP-PROMPT: Enter a number from 0 to 100.
DESCRIPTION: Enter the number of units of packed RBC or whole blood transfused within 6 hours preceding entry
into the operating room. Enter 0 if there were no blood transfusions.
130,729 VASOPRESSOR USAGE AT OR ENTRY 211;41 SET
Vasopressor Usage At Time of OR Entry
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter Yes if one or more medications are being continuously infused with intent to increase blood
pressure at the time of entry to the operating room.
DESCRIPTION: This field documents if one or more medications are being continuously infused with intent to
increase blood pressure at the time of entry to the operating room. Enter No if such medications
are being administered intermittently or if the intent of medical infusion is for reasons other
than increasing blood pressure.
130,730 CARDIAC ARREST 24HRS PREOP 211;42 SET
Cardiac Arrest Within 24 Hrs of OR Start
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Answer Yes if cardiac arrest occurs within the 24 hours prior to entry into the operating room.
DESCRIPTION: Cardiac arrest is the sudden cessation of cardiac function due to absence of cardiac rhythm or
presence of a disordered rhythm that results in loss of effective circulation requiring the
initiation of any component of basic and/or advanced cardiac life support. Exclude firing of AICD
unless the patient becomes unconscious. Answer Yes if cardiac arrest occurs within the 24 hours
prior to entry into the operating room.
130,731 DIC 6HRS PREOP 211;43 SET
Overt DIC Within 6 Hours Prior to OR Start
'1' FOR SCORE <5;
'2' FOR SCORE > OR EQUAL 5;
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Indicate the ISTH score for Disseminated Intravascular Coagulation (DIC) in the 6 hrs preop.
DESCRIPTION: This field documents the International Society on Thrombosis and Haemostasis (ISTH) score for
Disseminated Intravascular Coagulation (DIC) in the 6 hrs prior to OR start time.
130,732 HYPOXEMIA W/IN 6HRS PREOP 211;44 SET
Hypoxemia Within 6 Hours of OR Start
'1' FOR NOT MEASURED;
'2' FOR PAO2/FIO2 < 200 ;
'3' FOR PAO2/FIO2 200-249;
'4' FOR PAO2/FIO2 250-299;
'5' FOR PAO2/FIO2 > 300;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Indicate the PaO2:FiO2 ratio.
DESCRIPTION:
This field documents the PaO2:FiO2 ratio.
130,733 ENDOLEAK AT FOLLOW-UP 211;45 SET
Endoleak At Follow-Up
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if the patient has an endoleak at the time of surgical follow-up.
DESCRIPTION: This field documents if the patient has an endoleak at the time of surgical postoperative
follow-up.
130,734 CARDIAC ARREST INTRAOP 211;46 SET
Cardiac Arrest in the OR
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 26, 2015
HELP-PROMPT: Answer Yes if cardiac arrest occurs at any time between entry and exit from the operating room.
DESCRIPTION: Cardiac arrest is the sudden cessation of cardiac function due to absence of cardiac rhythm or
presence of a disordered rhythm that results in loss of effective circulation requiring the
initiation of any component of basic and/or advanced cardiac life support. Exclude firing of AICD
unless the patient becomes unconscious. Answer Yes if cardiac arrest occurs at any time between
entry to and exit from the operating room.
130,735 FLOPPY IRIS INTRAOP 211;47 SET
Floppy Iris in the OR
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is medical record documentation of the diagnosis of intraoperative floppy iris
for the operative eye.
DESCRIPTION: This field documents if there is medical record documentation of the diagnosis of intraoperative
floppy iris for the operative eye.
130,736 PREOP VISUAL ACUITY 211;48 SET
Preop Visual Acuity
'1' FOR 20/20 OR BETTER;
'2' FOR > 20/20 - 20/50;
'3' FOR > 20/50 - 20/100;
'4' FOR > 20/100 - 20/200;
'5' FOR > 20/200;
'6' FOR HAND MOTION;
'7' FOR LIGHT PERCEPTION;
'8' FOR NO LIGHT PERCEPTION;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Report best corrected visual acuity for the operative eye within 60 days prior to surgical
procedure.
DESCRIPTION: This field documents the best corrected visual acuity for the operative eye within 60 days prior to
surgical procedure.
130,737 POSTOP VISUAL ACUITY 211;49 SET
Postop Visual Acuity
'1' FOR 20/20 OR BETTER;
'2' FOR > 20/20 - 20/50;
'3' FOR > 20/50 - 20/100;
'4' FOR > 20/100 - 20/200;
'5' FOR > 20/200;
'6' FOR HAND MOTION;
'7' FOR LIGHT PERCEPTION;
'8' FOR NO LIGHT PERCEPTION;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Report best corrected visual acuity for the operative eye within 60 days after the surgical
procedure.
DESCRIPTION: This field documents the best corrected visual acuity for the operative eye within 60 days after
the surgical procedure.
130,738 ENDOPHTHALMITIS TYPE 211;50 SET
Endophthalmitis Type
'0' FOR NO ENDOPHTHALMITIS;
'1' FOR BACTERIAL;
'2' FOR TASS;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Select 0, 1, or 2 to indicate the Endophthalmitis Type.
DESCRIPTION: This field documents the appropriate response to indicate the Endophthalmitis Type.
0- No endophthalmitis 1- Bacterial 2- TASS
130,739 CYSTOID MACULAR EDEMA 211;51 SET
Cystoid Macular Edema
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes if there is medical record documentation of the diagnosis of cystoid macular edema for
the operative eye.
DESCRIPTION: This field documents if there is medical record documentation of the diagnosis of cystoid macular
edema for the operative eye.
130,740 DISLOCATION OF OPERATIVE JOINT 211;52 SET
Dislocation of Operative Joint
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes for dislocation of a prosthetic joint within 90 days of its implantation regardless of
treatment performed.
DESCRIPTION: This field documents dislocation of a prosthetic joint within 90 days of its implantation
regardless of treatment performed.
130,741 PERIPROSTHETIC FRACTURES 211;53 SET
Periprosthetic Fractures
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Answer Yes for fracture adjacent to or involving a prosthetic within 90 days of its implantation.
DESCRIPTION: This field documents fracture adjacent to or involving a prosthetic within 90 days of its
implantation.
130,742 D/T PAT ARRIVES HOSP DAY SURG 211;54 DATE
Date/Time Patient Arrives for Day Surgery
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 10, 2015
HELP-PROMPT: Enter Date/Time patient arrives for day surgery.
DESCRIPTION:
Date/Time patient arrives for day surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,743 D/T PAT LEAVES HOSP DAY SURG 211;55 DATE
Date/Time Patient Leaves Hospital After Day Surgery
INPUT TRANSFORM: S %DT="ER" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Enter Date/Time patient leaves hospital after day surgery.
DESCRIPTION:
Date/Time patient leaves hospital after day surgery.
130,744 KIDNEY DONOR PROFILE INDEX 211;56 NUMBER
Kidney Donor Profile Index (KDPI)
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: APR 21, 2015
HELP-PROMPT: Enter the percent (0-100) of the kidney donor profile index.
DESCRIPTION:
Kidney Donor Profile Index (KDPI).
130,745 EXPECTED POST TRANSPLANT INDEX 211;57 NUMBER
Expected Post Transplant Index (EPTI)
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: APR 21, 2015
HELP-PROMPT: Enter the percent (0-100) expected post transplant index.
DESCRIPTION:
Expected Post Transplant Index (EPTI).
130,746 BLOOD BANK ABO VER COMMENTS VER1;18 FREE TEXT
Blood Bank ABO Verification Comments
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter comments for blood bank verification of ABO type of the transplant recipient.
DESCRIPTION: This field is for comments regarding blood bank verification of ABO type of the transplant
recipient.
130,747 D/T BLOOD BANK ABO VERIF VER1;19 DATE
Date/Time of Blood Bank ABO Verification
INPUT TRANSFORM: S %DT="ER" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 30, 2015
HELP-PROMPT: Enter the date and time when the blood bank verified the ABO type of the transplant recipient.
DESCRIPTION:
Enter the date and time when the blood bank verified the ABO type of the transplant recipient.
130,748 OR ABO VER COMMENTS VER1;20 FREE TEXT
OR ABO Verification Comments
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter comments for verification of ABO type of the transplant recipient in the operating room.
DESCRIPTION: This field is for comments on for verification of ABO type of the transplant recipient in the
operating room.
130,749 D/T OR ABO VERIF VER1;21 DATE
Date and Time OR ABO Verification
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the date and time when the ABO type of the transplant recipient was verified in the operating
room.
DESCRIPTION: This field documents the date and time when the ABO type of the transplant recipient was verified
in the operating room.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
130,750 UNET VERIF BY SURGEON (Y/N) VER1;22 SET
UNET Verification by Surgeon (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the transplant surgeon completed required UNET verification.
DESCRIPTION:
This field documents whether the transplant surgeon completed required UNET verification.
130,751 SURGEON VER ORGAN PRE-ANES VER1;23 POINTER TO NEW PERSON FILE (#200)
Surgeon Verifying Organ Prior to Anesthesia
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the Name of the surgeon who verified the organ prior to anesthesia.
DESCRIPTION: This field documents the Name of the surgeon who documented that the labeling of the organ to be
transplanted matches associated documentation for the anticipated donor and recipient.
130,752 DONOR ORG VER PRE-ANES VER1;24 SET
Donor Organ Verification Prior to Anesthesia
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter whether the organ to be removed and transplanted, including laterality when applicable, was
documented prior to donor anesthesia.
DESCRIPTION: This field documents whether the organ to be removed and transplanted, including laterality when
applicable, was documented prior to donor anesthesia. For cases not involving live donors, select
'NA' for not applicable.
130,753 SURGEON VER ORG PRE-TRANSPLANT VER1;25 POINTER TO NEW PERSON FILE (#200)
Surgeon Verifying the Organ Prior to Transplant
LAST EDITED: JUN 26, 2015
HELP-PROMPT: Enter the Name of the Surgeon that verified the organ prior to transplant.
DESCRIPTION: This field documents the name of the surgeon who documented the organ to be transplanted. For
cases where the organ is not transplanted, enter NA.
130,901 AIRWAY INDEX .3;9 SET
Airway Index
'1' FOR 1. INDEX LESS THAN OR EQUAL TO 0;
'2' FOR 2. INDEX > 0 AND LESS THAN OR EQUAL TO 2;
'3' FOR 3. INDEX > 2 AND LESS THAN OR EQUAL TO 3;
'4' FOR 4. INDEX > 3 AND LESS THAN OR EQUAL TO 4;
'5' FOR 5. INDEX GREATER THAN 4;
LAST EDITED: MAY 10, 1995
HELP-PROMPT: Do NOT enter a value. This field is computed based on the ORAL-PHARYNGEAL SCORE and the MANDIBULAR
SPACE.
DESCRIPTION: This field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being
least difficult and 5 being most difficult. The value of this field is based on a computed
performance index using the oral-pharyngeal (OP) class and the mandibular space (MS).
Performance index = 2.5 x OP - MS length (converted to centimeters)
Airway Index
------------
1 - Performance Index less than 0
2 - Performance index greater than 0 and less than 2
3 - Performance index greater than 2 and less than 3
4 - Performance index greater than 3 and less than 4
5 - Performance index greater than 4
SCREEN: S DIC("S")="I $P(^SRF(DA,.3),U,11)&$P(^SRF(DA,.3),U,12)"
EXPLANATION: Screen checks for OP Score and Mandibular Space.
UNEDITABLE
130,901.1 MALLAMPATI SCALE .3;11 SET
Mallampati Scale
'1' FOR CLASS 1;
'2' FOR CLASS 2;
'3' FOR CLASS 3;
'4' FOR CLASS 4;
INPUT TRANSFORM: I $P($G(^SRF(DA,"CON")),"^") N SRFLD S SRFLD=901.1 D ^SROCON Q
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Enter the Mallampati Scale class.
DESCRIPTION: Definition Revised (2004): The Mallampati classification relates tongue size to pharyngeal size.
This test is performed with the patient in sitting position, the head held in a neutral position,
the mouth wide open, and the tongue protruding to the maximum. The subsequent classification is
assigned based upon the pharyngeal structures that are visible:
Class I - visualization of the soft palate, fauces, uvula, and
anterior and posterior pillars. Class II - visualization of the soft palate, fauces,
and uvula. Class III - visualization of the soft palate and the base of the uvula. Class IV -
soft palate is not visible at all.
The classification assigned by the clinician may vary if the patient is in the supine position
(instead of sitting). If the patient phonates, this falsely improves the view. If the patient
arches his or her tongue, the uvula is falsely obscured. A class I view suggests ease of intubation
and correlates with a laryngoscopic view grade I 99 to 100% of the time. Class IV view suggests a
poor laryngoscopic view, grade III or IV 100% of the time. Refer to the Operations Manual for a
visual depiction of the Mallampati Classification.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AOP^MUMPS
1)= D OP^SROAUTL
2)= D K901^SROAUTL
This MUMPS cross reference is used to update the AIRWAY INDEX field (#901) when the MALLAMPATI
SCALE field is edited.
130,901.2 MANDIBULAR SPACE .3;12 NUMBER
Mandibular Space (length in mm)
INPUT TRANSFORM: K:+X'=X!(X>150)!(X<20)!(X?.E1"."1N.N) X I $D(X),$P($G(^SRF(DA,"CON")),"^") S SRFLD=901.2 D ^SROCON
Q
LAST EDITED: FEB 29, 1996
HELP-PROMPT: Enter the mandibular space in millimeters. Type a number between 20 and 150.
DESCRIPTION: In the sitting position with head extended, enter the distance between the inside of the mentum and
the top of the thyroid cartilage in millimeters. The mandibular space (MS) and the oral-pharyngeal
(OP) score are used in figuring a performance index which is translated to the patient's airway
index.
(Performance Index = 2.5 x OP - MS length in cm)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 130^AMS^MUMPS
1)= D MS^SROAUTL
2)= D K901^SROAUTL
This MUMPS cross reference is used to update the AIRWAY INDEX field (#901) when the MANDIBULAR
SPACE field is edited.
130,903 DEATH UNRELATED/RELATED .4;7 SET
Was the Death Unrelated or Related to the Surgery?
'U' FOR UNRELATED;
'R' FOR RELATED;
LAST EDITED: NOV 06, 1995
HELP-PROMPT: Enter "U" if the death was not related to the Surgical procedure.
DESCRIPTION:
This indicates if death was unrelated to this surgery.
130,904 REVIEW OF DEATH COMMENTS 47;0 WORD-PROCESSING #130.0904
Review of Death Comments
LAST EDITED: DEC 15, 1995
DESCRIPTION:
This word processing field contains comments about the review of death.
Review of Death Comments
LAST EDITED: DEC 15, 1995
HELP-PROMPT: Enter comments related to the review of this patient's death.
DESCRIPTION: This word-processing field contains comments relating to the review of this patient's death
following surgery.
130,905 READY TO TRANSMIT? .4;2 SET
Ready to Transmit ?
'R' FOR READY;
'T' FOR TRANSMITTED;
LAST EDITED: JAN 23, 1997
HELP-PROMPT: Enter R if ready to transmit or T if already transmitted.
DESCRIPTION: This field is set to R (ready) by a MUMPS cross reference the TIME PAT OUT OR field. When this
case is transmitted to the national database at the end of the quarter, this field will be updated
to T (transmitted). This field serves as a flag that indicates the transmission status of this
case.
CROSS-REFERENCE: 130^AQ1^MUMPS
1)= D AQ1^SROXR4
2)= D KAQ1^SROXR4
This MUMPS cross reference updates the AQ cross reference list of cases that are are ready to be
transmitted to the national database.
130,1000 TIU OPERATIVE SUMMARY TIU;1 POINTER TO TIU DOCUMENT FILE (#8925)
TIU Operative Summary
LAST EDITED: AUG 28, 2000
HELP-PROMPT: Enter the TIU document that holds the operative summary for this case.
DESCRIPTION:
This is the operative summary for this case stored in TIU.
130,1001 TIU NURSE INTRAOP REPORT TIU;2 POINTER TO TIU DOCUMENT FILE (#8925)
TIU Nurse Intraoperative Report
LAST EDITED: MAY 24, 2002
HELP-PROMPT: Enter the TIU document that holds the Nurse Intraoperative Report for this case.
DESCRIPTION:
This is the Nurse Intraoperative Report for this case stored in TIU.
130,1002 TIU PROCEDURE REPORT (NON-OR) TIU;3 POINTER TO TIU DOCUMENT FILE (#8925)
TIU Procedure Report (Non-OR)
LAST EDITED: OCT 19, 2000
HELP-PROMPT: Enter the TIU document that holds the procedure summary for this non-OR procedure.
DESCRIPTION:
This is the Procedure Report (Non-OR) for this non-OR procedure.
130,1003 TIU ANESTHESIA REPORT TIU;4 POINTER TO TIU DOCUMENT FILE (#8925)
TIU Anesthesia Report
LAST EDITED: OCT 19, 2000
HELP-PROMPT: Enter the TIU document that holds the Anesthesia Report for this case.
DESCRIPTION:
This is the Anesthesia Report for this case.
130,1004 DICTATED SUMMARY EXPECTED TIU;5 SET
Dictated Summary Expected
'1' FOR YES;
'0' FOR NO;
LAST EDITED: FEB 25, 2004
HELP-PROMPT: Enter YES if a summary of this procedure will be dictated.
DESCRIPTION: This field indicates if the provider will dictate a summary of this procedure to be electronically
signed. Enter YES if a dictated summary is expected. Enter NO or leave blank if no summary is
expected.
SCREEN: S DIC("S")="I '$$DEL^SROESX(DA,""3"")"
EXPLANATION: Screen prevents change if a Procedure Report is associated with the case.
DELETE TEST: 1,0)= I $$DEL^SROESX(DA,"3") D EN^DDIOL("The DICTATED SUMMARY EXPECTED field cannot be deleted. Thi
s case has a",,"!!,?2") D EN^DDIOL("Procedure Report associated with it.",,"!,?2")
RECORD INDEXES: AESP (#388)
130,1005 CPT ON NURSE REPORT TIU;6 SET
CPT on Nurse Intraoperative Report
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 25, 2000
HELP-PROMPT: Enter YES if the CPT ON NURSE INTRAOP site parameter is set to YES, INCLUDE CPT at the time the
nurse intraoperative report is signed.
DESCRIPTION: This field reflects the content of the CPT ON NURSE INTRAOP site parameter in SURGERY SITE
PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is
signed and will be checked any time an automatic addendum is made to the report to determine
whether the CPT codes should appear on the report.
130,1006 ICD ON NURSE REPORT TIU;7 SET
'1' FOR YES;
'0' FOR NO;
LAST EDITED: OCT 26, 2011
HELP-PROMPT: Enter YES if the ICD ON NURSE INTRAOP site parameter is set to YES, INCLUDE ICD at the time the
nurse intraoperative report is signed.
DESCRIPTION: This field reflects the content of the ICD ON NURSE INTRAOP site parameter in SURGERY SITE
PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is
signed and will be checked any time an automatic addendum is made to the report to determine
whether the ICD codes should appear on the report.
130,2005 IMAGE 2005;0 POINTER Multiple #130.02005
DESCRIPTION: This sub-file contains pointers to images in the Imaging file (#2005) that are related to this
case.
130.02005,.01 IMAGE 0;1 POINTER TO IMAGE FILE (#2005) (Multiply asked)
Image
LAST EDITED: APR 17, 1997
HELP-PROMPT: This is the image stored in the IMAGE file (#2005).
DESCRIPTION:
This field identifies an image in the IMAGE file (#2005) that is related to this case.
CROSS-REFERENCE: 130.02005^B
1)= S ^SRF(DA(1),2005,"B",$E(X,1,30),DA)=""
2)= K ^SRF(DA(1),2005,"B",$E(X,1,30),DA)
130,2006 ROBOTIC ASSISTANCE (Y/N) OP;3 SET
Robotic Assistance (Y/N)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 29, 2021
HELP-PROMPT: Enter YES if robotic assistance was used for any part of the procedure.
DESCRIPTION: This field indicates whether robotic assistance was used for any portion of the procedure. It must
be entered prior to signing the Nurse Intraoperative Report. Enter YES if robotic assistance was
used during the procedure. Otherwise, enter NO.
NOTES: TRIGGERED by the SURGERY SPECIALTY field of the SURGERY File
FILES POINTED TO FIELDS
ANESTHESIA SUPERVISOR CODES
(#132.95) ANES SUPERVISE CODE (#.345)
ASA CLASS (#132.8) ASA CLASS (#1.13)
ATTENDING CODES (#132.9) ATTENDING/RES SUP CODE (#.166)
CPT (#81) PLANNED PRIN PROCEDURE CODE (#27)
OTHER PROCEDURES:PLANNED OTHER PROC CPT CODE (#3)
CPT MODIFIER (#81.3) PRIN. PROCEDURE CPT MODIFIER:PRIN. PROCEDURE CPT MODIFIER (#.01)
OTHER PROCEDURE CPT MODIFIER:OTHER PROCEDURE CPT MODIFIER (#.01)
DRUG (#50) MEDICATIONS:MEDICATIONS (#.01)
ANESTHESIA AGENTS:ANESTHESIA AGENTS (#.01)
TEST DOSE:TEST DOSE (#.01)
ELECTROGROUND POSITIONS (#138) ELECTROGROUND POSITION (#.55)
ELECTROGROUND POSITION (2) (#6)
HOSPITAL LOCATION (#44) ASSOCIATED CLINIC (#.021)
NON-OR LOCATION (#119)
ICD DIAGNOSIS (#80) PRIN PRE-OP ICD DIAGNOSIS CODE (#32.5)
PLANNED PRIN DIAGNOSIS CODE (#66)
OTHER RESPIRATORY OCCURRENCE (#253)
OTHER URINARY TRACT OCCURRENCE (#286)
OTHER CNS OCCURRENCE (#343)
OTHER CARDIAC OCCURRENCE (#344)
OTHER OCCURRENCES (ICD) (#392)
OTHER WOUND OCCURRENCE (#489)
INTRAOPERATIVE OCCURRENCES:ICD DIAGNOSIS CODE (#4)
OTHER PREOP DIAGNOSIS:ICD DIAGNOSIS CODE (#3)
OTHER POSTOP DIAGS:PLANNED ICD DIAGNOSIS CODE (#3)
POSTOP OCCURRENCE:ICD DIAGNOSIS CODE (#6)
IMAGE (#2005) IMAGE:IMAGE (#.01)
INSTITUTION (#4) DIVISION (#50)
IRRIGATION (#133.6) IRRIGATION:IRRIGATION (#.01)
LOCAL SURGICAL SPECIALTY
(#137.45) SURGERY SPECIALTY (#.04)
MEDICAL SPECIALTY (#723) MEDICAL SPECIALTY (#125)
MONITORS (#133.4) MONITORS:MONITORS (#.01)
NEW PERSON (#200) HAIR REMOVAL BY (#.12)
PRIMARY SURGEON (#.14)
FIRST ASST (#.15)
SECOND ASST (#.16)
ATTENDING SURGEON (#.164)
PERFUSIONIST (#.167)
ASST PERFUSIONIST (#.168)
SKIN PREPPED BY (1) (#.18)
PRINC ANESTHETIST (#.31)
RELIEF ANESTHETIST (#.32)
ASST ANESTHETIST (#.33)
ANESTHESIOLOGIST SUPVR (#.34)
VERIFIER (#.522)
INST CNT VERF BY (#.525)
FOLEY CATHETER INSERTED BY (#.57)
TIME-OUT DOCUMENT COMPLETED BY (#.69)
SURG SCHED PERSON (#1.099)
SKIN PREPPED BY (2) (#4)
SKIN PREPPED BY (3) (#5)
SPONGE, SHARPS, & INST COUNTER (#47)
COUNT VERIFIER (#48)
DIAGNOSTIC RESULTS CONFIRM BY (#61)
IV STARTED BY (#63)
CODING VERIFIER (#69)
CANCELLED BY (#70)
PROVIDER (#123)
ATTEND PROVIDER (#124)
ASSESSMENT COMPLETED BY (#272.1)
REPORT GIVEN TO (#639)
SURGEON VERIFYING UNET (#657)
SURGEON VER DONOR ORG PRE-ANES (#659)
SURGEON VER ORGAN PRE-ANES (#751)
SURGEON VER ORG PRE-TRANSPLANT (#753)
PROSTHESIS INSTALLED:RN VERIFIER (#10)
LASER UNIT:LASER OPERATOR (#3)
CELL SAVER:CELL SAVER OPERATOR (#1)
TIME TOURNIQUET APPLIED:TOURNIQUET APPL. BY (#2)
REFERRING PHYSICIAN:REF PHY 200 LINK (#6)
ANESTHESIA TECHNIQUE:CATHETER REMOVED BY (#35)
EXTUBATED BY (#39)
OTHER SCRUBBED ASSISTANTS:OTHER SCRUBBED ASSISTANTS (#.01)
OR CIRC SUPPORT:OR CIRC SUPPORT (#.01)
RESTR & POSITION AIDS:APPLIED BY (#1)
TIME ADM:ORDERED BY (#2)
ADMIN BY (#3)
OR SCRUB SUPPORT:OR SCRUB SUPPORT (#.01)
TIME:PROVIDER (#2)
MONITORS:APPLIED BY (#3)
OPERATING ROOM (#131.7) OP ROOM PROCEDURE PERFORMED (#.02)
ORDER (#100) ORDER NUMBER (#100)
PATIENT (#2) PATIENT (#.01)
PATIENT CONSCIOUSNESS (#135.4) PREOP CONSCIOUS (#.196)
POSTOP CONSCIOUS (#.821)
PATIENT MOOD (#135.3) PREOP MOOD (#.19)
POSTOP MOOD (#.81)
PERIOPERATIVE OCCURRENCE CATEG
(#136.5) PROCEDURE OCCURRENCE:OCCURRENCE CATEGORY (#5)
NON-OPERATIVE OCCURRENCES:OCCURRENCE CATEGORY (#5)
INTRAOPERATIVE OCCURRENCES:OCCURRENCE CATEGORY (#3)
POSTOP OCCURRENCE:OCCURRENCE CATEGORY (#5)
PFSS ACCOUNT (#375) PFSS ACCOUNT REFERENCE (#500)
PHARMACY ITEMS (#131.06) PHARMACY ITEMS:PHARMACY ITEMS (#.01)
PLANNED IMPLANT (#131.5) PLANNED IMPLANTS:PLANNED IMPLANTS (#.01)
PROSTHESIS (#131.9) PROSTHESIS INSTALLED:PROSTHESIS ITEM (#.01)
RESTRAINTS AND POSITIONAL AIDS
(#132.05) RESTR & POSITION AIDS:RESTR & POSITION AIDS (#.01)
SKIN INTEGRITY (#135.2) PREOP SKIN INTEG (#.07)
POSTOP SKIN INTEG (#.76)
SKIN PREP AGENTS (#135.1) SKIN PREP AGENTS (#.175)
SECOND SKIN PREP AGENT (#8)
SPECIAL EQUIPMENT (#131.3) SPECIAL EQUIPMENT:SPECIAL EQUIPMENT (#.01)
SPECIAL INSTRUMENTS (#131.02) SPECIAL INSTRUMENTS:SPECIAL INSTRUMENTS (#.01)
SPECIAL SUPPLIES (#131.04) SPECIAL SUPPLIES:SPECIAL SUPPLIES (#.01)
SPECIALTY (#42.4) OBSERVATION TREATING SPECIALTY (#454)
STATE (#5) REFERRING PHYSICIAN:STATE (#3)
SURGERY (#130) CONCURRENT CASE (#35)
PREVIOUSLY SCHEDULED CASE (#78)
RESCHEDULED CASE (#79)
ANES CONCURRENT CASES:ANES CONCURRENT CASES (#.01)
RETURNED TO SURGERY:RETURNED TO SURGERY (#.01)
SURGERY CANCELLATION REASON
(#135) PRIMARY CANCEL REASON (#18)
SURGERY DISPOSITION (#131.6) PLANNED POSTOP CARE (#.43)
OP DISPOSITION (#.46)
PACU DISPOSITION (#.79)
SURGERY POSITION (#132) *SURGERY POSITION (#.54)
SURGERY POSITION:SURGERY POSITION (#.01)
SURGERY REPLACEMENT FLUIDS
(#133.7) REPLACEMENT FLUID TYPE:REPLACEMENT FLUID TYPE (#.01)
SURGERY TRANSPORTATION DEVICES
(#131.01) TRANS TO OR BY (#.11)
DISCHARGED VIA (#25)
SURGICAL DELAY (#132.4) DELAY CAUSE:DELAY CAUSE (#.01)
TIU DOCUMENT (#8925) TIU OPERATIVE SUMMARY (#1000)
TIU NURSE INTRAOP REPORT (#1001)
TIU PROCEDURE REPORT (NON-OR) (#1002)
TIU ANESTHESIA REPORT (#1003)
TOPOGRAPHY FIELD (#61) BLOCK SITE:BLOCK SITE (#.01)
VISIT (#9000010) VISIT (#.015)
File #130
Record Indexes:
AD (#196) RECORD MUMPS IR ACTION
Short Descr: CoreFLS fields monitor flag.
Description: This cross-reference will be checked before sending a notification to the CoreFLS software after editing any of
these fields.
Set Logic: S ^TMP("CSLSUR1",$J)="" Q
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Logic: S ^TMP("CSLSUR1",$J)="" Q
Kill Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Whole Kill: Q
X(1): PRIMARY SURGEON (130,.14) (forwards)
X(2): PLANNED PRIN PROCEDURE CODE (130,27) (forwards)
X(3): OP ROOM PROCEDURE PERFORMED (130,.02) (forwards)
X(4): SURGERY SPECIALTY (130,.04) (forwards)
X(5): SCHEDULED START TIME (130,10) (forwards)
X(6): SCHEDULED END TIME (130,11) (forwards)
X(7): PRINCIPAL PROCEDURE (130,26) (forwards)
X(8): HOSPITAL ADMISSION STATUS (130,.011) (forwards)
X(9): DATE OF OPERATION (130,.09) (forwards)
X(10): CONCURRENT CASE (130,35) (forwards)
X(11): ATTENDING SURGEON (130,.164) (forwards)
ADT (#1417) RECORD MUMPS IR SORTING ONLY
Short Descr: Inverse date of operation index
Description: The "ADT" index on the DATE OF OPERATION (#.09) field uses the inverse date/time format to sort and to display
cases by inverse chronological order.
Set Logic: S ^SRF("ADT",$E(X(1),1,30),$E(X(2),1,14),DA)=9999999.999999-X(2)
Kill Logic: K ^SRF("ADT",$E(X(1),1,30),$E(X(2),1,14),DA)
Whole Kill: K ^SRF("ADT")
X(1): PATIENT (130,.01) (Subscr 1) (Len 30) (forwards)
X(2): DATE OF OPERATION (130,.09) (Subscr 2) (Len 14) (forwards)
Transform (Storage): S X=9999999.999999-X
AE (#198) RECORD MUMPS IR ACTION
Short Descr: Checklist comment update
Description: This MUMPS cross reference maintains the CHECKLIST COMMENT field (#85) if any of these fields are answered with
"NO".
Set Logic: D ^SRTOVRF Q
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I (X1(I)'=X2(I)&(X2(I)="N"))!(X1(3)'=X2(3)&(X2(3)>3)) S X=1 Q
Kill Logic: Q
X(1): CONFIRM PATIENT IDENTITY (130,600) (forwards)
X(2): PROCEDURE TO BE PERFORMED (130,601) (forwards)
X(3): CONFIRM VALID CONSENT (130,603) (forwards)
X(4): CONFIRM PATIENT POSITION (130,604) (forwards)
X(5): CORRECT MEDICAL IMPLANTS (130,607) (forwards)
X(6): ANTIBIOTIC PROPHYLAXIS (130,608) (forwards)
X(7): APPROPRIATE DVT PROPHYLAXIS (130,609) (forwards)
X(8): BLOOD AVAILABILITY (130,610) (forwards)
X(9): AVAILABILITY OF SPECIAL EQUIP (130,611) (forwards)
X(10): SITE OF PROCEDURE (130,602) (forwards)
X(11): MARKED SITE CONFIRMED (130,605) (forwards)
X(12): PREOPERATIVE IMAGES CONFIRMED (130,606) (forwards)
AESP (#388) RECORD MUMPS ACTION
Short Descr: Create/delete stub entries in TIU for procedure reports (non-OR).
Description: This cross reference is responsible for creating a stub entry in TIU for the non-OR procedure report when the
TIME PROCEDURE ENDED field (#122) is entered and the DICTATED SUMMARY EXPECTED field (#1004) is set to YES. It
is also responsible for deleting the stub entry in TIU for this report, if unsigned, when the TIME PROCEDURE
ENDED field (#122) is deleted or if the DICTATED SUMMARY EXPECTED field (#1004) is deleted or changed to NO.
No action occurs if the value in the TIME PROCEDURE ENDED field (#122) is modified.
Set Logic: D AESP^SROESXP
Set Cond: S X=$$SCOND^SROESXP(.X1,.X2)
Kill Logic: D KAESP^SROESXP
Kill Cond: S X=$$KCOND^SROESXP(.X1,.X2)
X(1): TIME PROCEDURE ENDED (130,122) (forwards)
X(2): DICTATED SUMMARY EXPECTED (130,1004) (forwards)
AO (#402) RECORD MUMPS IR ACTION
Short Descr: Wound Sweep and Intra-Operative monitor flag
Description: This MUMPS cross reference maintains the WOUND SWEEP and INTRA- OPERATIVE X-RAY fields and comments fields
related to them if any of these fields and fields (#44, #45, #46) are answered with "NO".
Set Logic: S ^TMP("SR182",$J)=""
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I),X2(I)="N" S X=1 Q
Kill Logic: K ^TMP("SR182",$J)
Kill Cond: Q
X(1): SPONGE FINAL COUNT CORRECT (130,44) (forwards)
X(2): SHARPS FINAL COUNT CORRECT (130,45) (forwards)
X(3): INSTRUMENT FINAL COUNT CORRECT (130,46) (forwards)
ARS (#1418) RECORD REGULAR IR SORTING ONLY
Short Descr: This is the current status of the surgery risk assessment.
Description: This is the current status of the surgery risk assessment. When creating a new assessment, the status will
automatically be entered as 'INCOMPLETE'. Upon completion of the assessment, this field will be updated to
'COMPLETED'. After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.
Set Logic: S ^SRF("ARS",$E(X(1),1,2),$E(X(2),1,2),$E(X(3),1,30),DA)=""
Kill Logic: K ^SRF("ARS",$E(X(1),1,2),$E(X(2),1,2),$E(X(3),1,30),DA)
Whole Kill: K ^SRF("ARS")
X(1): ASSESSMENT TYPE (130,284) (Subscr 1) (Len 2) (forwards)
X(2): ASSESSMENT STATUS (130,235) (Subscr 2) (Len 2) (forwards)
X(3): PATIENT (130,.01) (Subscr 3) (Len 30) (forwards)
Subfile #130.16
Record Indexes:
AC (#625) RECORD MUMPS IR ACTION
Short Descr: CoreFLS fields monitor flag.
Description: This cross-reference will be checked before sending a notification to the CoreFLS software after editing any of
these fields.
Set Logic: S ^TMP("CSLSUR1",$J)="" Q
Set Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Kill Logic: S ^TMP("CSLSUR1",$J)="" Q
Kill Cond: N I S (X,I)=0 F S I=$O(X1(I)) Q:'I I X1(I)'=X2(I) S X=1 Q
Whole Kill: Q
X(1): OTHER PROCEDURE (130.16,.01) (forwards)
X(2): PLANNED OTHER PROC CPT CODE (130.16,3) (forwards)
INPUT TEMPLATE(S):
SREQUEST APR 01, 2015@13:19 USER #0
SREQUEST-ICD10 APR 01, 2015@13:31 USER #0
SRISK-MISC FEB 07, 1995@13:43 USER #0
SRISK-NOCARD MAR 02, 1992@14:07 USER #0
SRISK-NOCOMP DEC 15, 1992@10:40 USER #0
SRNON-OR SEP 15, 2004@11:10 USER #0
SRO-NOCOMP MAR 19, 2020@16:47 USER #0
SROANES-AMIS MAY 10, 1995@09:04 USER #0
SROARPT JUN 03, 2005@13:08 USER #0
SROCOMP DEC 04, 1990@15:45 USER #0
SROMEN-ANES OCT 03, 2003@16:08 USER #0
SROMEN-ANES TECH NOV 30, 1998@08:30 USER #0
SROMEN-COMP DEC 04, 1990@15:46 USER #0
SROMEN-OPER NOV 17, 2022@16:18 USER #0
SROMEN-OUT SEP 14, 2022@15:01 USER #0
SROMEN-PACU JUL 12, 1990@10:36 USER #0
SROMEN-POST FEB 10, 2014@10:00 USER #0
SROMEN-REFER JUL 12, 1990@10:51 USER #0
SROMEN-STAFF MAY 10, 2004@13:26 USER #0
SROMEN-START APR 01, 2015@12:37 USER #0
SROMEN-VERF DEC 26, 2013@13:26 USER #0
SROMEN-VERF1 JUN 26, 2015@10:27 USER #0
SROMEN-VERF2 MAY 21, 2015@10:42 USER #0
SRONRPT SEP 25, 2023@09:28 USER #0
SRONRPT1 NOV 14, 2023@12:52 USER #0
SRONRPT2 SEP 25, 2023@09:30 USER #0
SROTHER MAR 24, 1992@12:09 USER #0
SROVER MAY 15, 1992@12:20 USER #0
SRSCHED-UNREQUESTED AUG 18, 2014@15:55 USER #0
SRSCHED-UNREQUESTED-ICD10 JUN 01, 2018@14:35 USER #0
SRSREQV MAR 02, 2015@16:00 USER #0
SRSRES-ENTRY MAY 07, 2015@15:15 USER #0
SRSRES-ENTRY1 MAY 30, 2015@13:46 USER #0
SRSRES-SCHED MAY 07, 2015@14:43 USER #0
SRSRES-SCHED1 MAY 30, 2015@13:43 USER #0
SRSRES1 AUG 18, 2014@15:11 USER #0
SRSRES2 NOV 09, 2011@12:42 USER #0
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):