STANDARD DATA DICTIONARY #139.5 -- SURGERY TRANSPLANT ASSESSMENTS FILE 3/24/25 PAGE 1
STORED IN ^SRT( *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 3.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains the organ transplant procedures performed within VHA facilities, as well as outside the VHA.
DD ACCESS: @
RD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
CROSS
REFERENCED BY: DATE OF TRANSPLANT(AC), DATE OF TRANSPLANT(ADT), DATE OF LAST TRANSMISSION(AT), PATIENT(B)
INDEXED BY: WARM ISCHEMIA TIME FOR ORGAN & COLD ISCHEMIA TIME FOR ORGAN (AD), VACO ID & PATIENT (AE), TRANSPLANT TYPE &
ASSESSMENT STATUS & PATIENT (AF), DONOR DATE OF BIRTH (AGE)
139.5,.01 PATIENT 0;1 POINTER TO PATIENT FILE (#2) (Required)
Patient's Name
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the name of the patient.
DESCRIPTION:
This is the name of the patient.
CROSS-REFERENCE: 139.5^B
1)= S ^SRT("B",$E(X,1,30),DA)=""
2)= K ^SRT("B",$E(X,1,30),DA)
RECORD INDEXES: AE (#548), AF (#549)
139.5,1 DATE OF TRANSPLANT 0;2 DATE (Required)
Date of Transplant
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:X<1 X
LAST EDITED: SEP 29, 2008
HELP-PROMPT: Enter Date of Transplant.
DESCRIPTION:
Indicate date organ transplant was completed.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 139.5^ADT^MUMPS
1)= D ADT^SRTPUTL
2)= D KADT^SRTPUTL
The ADT cross reference on the TRANSPLANT DATE field uses the 'inverse' date/time format to sort
and to display cases by inverse chronological order.
CROSS-REFERENCE: 139.5^AC^MUMPS
1)= S ^SRT("AC",X,DA)=$P(^SRT(DA,0),"^")
2)= K ^SRT("AC",X,DA)
The AC cross reference on the DATE OF TRANSPLANT field is used to sort entries by date of
transplant for reports.
139.5,2 SURGERY CASE 0;3 POINTER TO SURGERY FILE (#130)
Surgery Case
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the matching case in the SURGERY file (#130).
DESCRIPTION: This is the case in the SURGERY file associated with this file entry. This field is entered if the
transplant was done in a VA medical center. This field will remain blank if the transplant was done
in a non-VA facility.
WRITE AUTHORITY: ^
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,3 VACO ID .01;11 NUMBER (Required)
VACO ID
INPUT TRANSFORM: K:+X'=X!(X>999999)!(X<1)!(X?.E1"."1N.N) X D:$D(X) CHK^SRTPNEW
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the VACO ID number provided by VA Central Office.
DESCRIPTION: The VACO ID is a unique identifier provided centrally for each patient undergoing a transplant.
This field is required for creating a Transplant Assessment.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AE (#548)
139.5,4 RECIPIENT HEIGHT 0;4 FREE TEXT
Recipient Height
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:+X>300!(+X<0) X D H^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y="NS":"NO STUDY",Y["C":+Y_" CM.",+Y:Y_" INCHES",1:Y)
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter Recipient height.
DESCRIPTION: Indicate the Recipient's height in either inches (in) or centimeters (cm) based upon an actual
measurement (if possible) or based on the Recipient's estimate.
The measurement should be entered in inches (48 to 86) or centimeters (122 to 218). If you are
entering the patient's height in centimeters, enter 'C' after the number of centimeters.
Your answer should be in one of the following two formats.
68 (representing inches)
173C (representing centimeters)
Enter NS for NO STUDY if the patient's height cannot be determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,5 RECIPIENT WEIGHT 0;5 FREE TEXT
Recipient Weight
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:X>700!(X<0) X D W^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y="NS":"NO STUDY",Y["K":+Y_" KG",+Y:Y_" LBS.",1:Y)
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter Recipient weight.
DESCRIPTION: Indicate the Recipient's most recent weight before surgery in either pounds (lbs) or kilograms (kg)
based upon an actual measurement (if possible) or based on the Recipient's estimate.
The weight should be entered in pounds (50 to 700) or kilograms (23 to 318). If you are entering
the patient's weight in kilograms, enter 'K' after the number of kilograms.
Your answer should be in one of the following formats.
178 (weight in pounds)
80K (weight in Kilograms)
Enter NS for NO STUDY if the patient's weight cannot be determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,9 RECIPIENT IVIG 0;9 SET
IVIG Recipient
'1' FOR BEFORE TRANSPLANT;
'2' FOR AFTER TRANSPLANT;
'3' FOR BOTH;
'4' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter status as IVIG Recipient.
DESCRIPTION: Indicate if transplant recipient receives intravenous immunoglobulin (IVIG). IVIG is used to treat
acute humoral rejection after organ transplantation. IVIG is also used to reduce antibody titers
prophylactically to permit ABO incompatible and cross match positive renal transplants.
139.5,10 RECIPIENT ABO BLOOD TYPE 0;10 SET
Recipient ABO Blood Type
'A' FOR A;
'B' FOR B;
'AB' FOR AB;
'O' FOR O;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the ABO blood type of the organ recipient.
DESCRIPTION:
This is the ABO blood type of the organ recipient.
139.5,11 DATE PLACED ON WAITING LIST 0;11 DATE
Date Placed on Waiting List
INPUT TRANSFORM: S %DT="EXP" D ^%DT S X=Y K:X<1 X
LAST EDITED: JUL 16, 2008
HELP-PROMPT: Enter the date that the patient was placed on the waiting list.
DESCRIPTION:
Indicate date entered on UNOS Waiting List for Transplant.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,12 RECIPIENT CMV 0;12 SET
Recipient CMV
'+' FOR POSITIVE;
'-' FOR NEGATIVE;
LAST EDITED: MAY 28, 2008
HELP-PROMPT: Enter the CMV status of transplant recipient.
DESCRIPTION: This is the Recipient CMV status field. The field will capture the cytomegalovirus (CMV) serologic
status of the transplant recipient.
139.5,13 RECIPIENT HLA-A TYPING 0;13 FREE TEXT
Recipient HLA-A Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-A typing of the organ recipient.
DESCRIPTION: This is the HLA-A typing status of the organ recipient. It is Human Leukocyte Antigen (HLA) typing
- described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,14 RECIPIENT HLA-B TYPING 0;14 FREE TEXT
Recipient HLA-B Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-B typing of the organ recipient.
DESCRIPTION: This is the HLA-B typing status of the organ recipient. It is Human Leukocyte Antigen (HLA) typing
- described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,15 RECIPIENT HLA-C TYPING 0;15 FREE TEXT
Recipient HLA-C Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-C typing of the organ recipient.
DESCRIPTION: This is the HLA-C typing status of the organ recipient. It is Human Leukocyte Antigen (HLA) typing
- described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,16 RECIPIENT HLA-BW TYPING 0;16 FREE TEXT
Recipient HLA-BW Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-BW typing of the organ recipient.
DESCRIPTION: This is the HLA-BW typing status of the organ recipient. It is Human Leukocyte Antigen (HLA)
typing - described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format
of # to #,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,17 RECIPIENT HLA-DR TYPING 0;17 FREE TEXT
Recipient HLA-DR Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-DR typing of the organ recipient.
DESCRIPTION: This is the HLA-DR typing status of the organ recipient. It is Human Leukocyte Antigen (HLA)
typing - described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format
of # to #,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,18 RECIPIENT HLA-DQ TYPING 0;18 FREE TEXT
Recipient HLA-DQ Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-DQ typing of the organ recipient.
DESCRIPTION: This is the HLA-DQ typing status of the organ recipient. It is Human Leukocyte Antigen (HLA)
typing - described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format
of # to #,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,19 TRANSPLANT COMMENTS .02;1 FREE TEXT
Transplant Comments
INPUT TRANSFORM: K:$L(X)>130!($L(X)<1) X
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter additional comments as necessary for transplant assessments.
DESCRIPTION: The Transplant comments include additional information not available elsewhere on this form. This
field has a limit of 130 characters.
139.5,20 ACETAMINOPHEN TOXICITY .1;1 SET
Acetaminophen Toxicity
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Acetaminophen Toxicity status of the organ recipient.
DESCRIPTION: Acetaminophen Toxicity is a condition as defined by development of encephalopathy within 8 weeks of
onset of illness and an acetaminophen level exceeding 4000 units/liter or diagnosis as documented
by an attending physician.
139.5,21 ACUTE LIVER FAILURE .1;2 SET
Acute Liver Failure
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Acute Liver Failure status of the organ recipient.
DESCRIPTION: Acute Liver Failure is when a patient develops encephalopathy within 8 weeks of an onset of illness
or as documented by an attending physician.
139.5,22 LUNG CANCER .1;3 SET
Lung Cancer
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the lung cancer status of the organ recipient.
DESCRIPTION: Indicate presence or history of lung cancer with pathology report confirming diagnosis as
documented by attending physician.
139.5,23 ALCOHOLIC CIRRHOSIS .1;4 SET
Alcoholic Cirrhosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter the Alcoholic Cirrhosis status of the organ recipient.
DESCRIPTION: Continued alcohol abuse in many patients will result in the development of alcoholic cirrhosis
which causes permanent scarring of the liver. Answer "YES" if a diagnosis of Alcoholic cirrhosis is
documented by a physician in medical record.
139.5,24 ALPHA 1 ANTI-TRYPSIN DEF .1;5 SET
Alpha 1 Anti-Trypsin Deficiency
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Alpha 1 Anti-Trypsin Deficiency status of the organ recipient.
DESCRIPTION: Alpha 1 Anti-Trypsin Deficiency is the genetic predisposition to produce the protein
(alpha1-antitrypsin) that helps protect the lungs. Indicate if patient has diagnosis of alpha-1
anti-trypsin deficiency documented by an attending physician.
139.5,25 BRONCHIECTASIS .1;6 SET
Bronchiectasis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Bronchiectasis status of the organ recipient.
DESCRIPTION: Bronchiectasis is an abnormal destruction and dilation of the large airways; or a diagnosis of
bronchiectasis documented by an attending physician.
139.5,26 GLOMERULAR SCLEROSIS/NEPHRITIS .1;7 SET
Glomerular Sclerosis/Nephritis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the Glomerular Sclerosis/Nephritis diagnosis status of the organ recipient.
DESCRIPTION:
Glomerular Sclerosis/Nephritis is kidney disease involving primarily the glomeruli.
139.5,27 GRAFT FAILURE .1;8 SET
Graft Failure
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 28, 2008
HELP-PROMPT: Enter Graft Failure status of the organ recipient.
DESCRIPTION: For kidney transplants, Graft Failure is documented return to maintenance dialysis after a
successful kidney transplant.
For liver transplants, graft failure is failure of transplanted liver caused by the etiologic
factor for which the original transplant was performed or the diagnosis of graft failure from
recurrent disease documented in the medical record.
139.5,28 HBV CIRRHOSIS (HEPATITIS B) .1;9 SET
HBV Cirrhosis (Hepatitis B)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the HBV Cirrhosis (hepatitis B) status of the organ recipient.
DESCRIPTION: Cirrhosis characterized by hepatitis B surface antibody, hepatitis surface antigen, and hepatitis B
core antibody positive and pathology of cirrhosis on liver biopsy.
139.5,29 HCC (HEPATOCELLULAR CA) .1;10 SET
HCC (Hepatocellular CA)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the HCC (Hepatocellular CA) status of the organ recipient.
DESCRIPTION: HCC (Hepatocellular carcinoma) is characterized by the presence of a lesion on two separate liver
imaging studies and at least one of the following: a vascular blush corresponding to the area of
suspicion seen on other imaging studies; an alpha-fetoprotein level of >200 ng/ml; an arteriogram
confirming a tumor; a biopsy confirming HCC; chemoembolization of lesion, radio frequency, cryo, or
chemical ablation of the lesion; or diagnosis of hepatocellular carcinoma documented in medical
record or explant pathology showing hepatocellular carcinoma.
139.5,30 HCV CIRRHOSIS (HEPATITIS C) .1;11 SET
HCV Cirrhosis (Hepatitis C)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the HCV Cirrohosis (hepatitis C) status of the organ recipient.
DESCRIPTION: HCV Cirrohosis (Hepatitis C) is characterized by hepatitis C antibody positive and/or PCR positive
for HCV RNA and pathology of cirrhosis on liver biopsy.
139.5,31 DONOR HEIGHT 1;2 FREE TEXT
Donor Height
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:+X>300!(+X<0) X D H^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y="NS":"NO STUDY",Y["C":+Y_" CM.",+Y:Y_" INCHES",1:Y)
LAST EDITED: JUL 17, 2008
HELP-PROMPT: Enter donor height.
DESCRIPTION: Indicate the Donor's height in either inches (in) or centimeters (cm) based upon an actual
measurement (if possible) or based on estimate.
The measurement should be entered in inches (48 to 86) or centimeters (122 to 218). If you are
entering the donor'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)
Enter NS for NO STUDY if the donor's height cannot be determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,32 INTERSTITIAL LUNG DISEASE .1;13 SET
Interstitial Lung Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Interstitial Lung Disease status of the organ recipient.
DESCRIPTION: Interstitial Lung Disease (ILD) refers to a group of lung diseases which affect the alveolar
epithelium, pulmonary capillary endothelium, basement membrane, perivascular and perilymphatic
tissues; or a diagnosis of interstitial lung disease documented by an attending physician.
139.5,33 MEMBRANOUS NEPHROPATHY .1;14 SET
Membranous Nephropathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Membranous Nephropathy status of the organ recipient.
DESCRIPTION: This is the Membranous Nephropathy status of the organ recipient. Membranous Nephropathy is a
kidney disorder resulting in disruption of kidney function because of inflammation of the
glomerulus and changes in the glomerular basement membrane.
139.5,34 METABOLIC .1;15 SET
Metabolic
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Metabolic status of the organ recipient.
DESCRIPTION: Indicate yes if one of the following diagnoses is recorded in patient's medical record:
hemachromatosis, alpha1 antitrypsin deficiency, Wilson's, Banti's, lupoid.
139.5,35 NASH .1;16 SET
NASH
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Non-alcoholic steatohepatitis status of the organ recipient.
DESCRIPTION: Non-alcoholic steatohepatitis (or non-alcoholic fatty liver disease) - hepatitis or cirrhosis
diagnosed by liver biopsy pathology or a diagnosis of non-alcoholic steatohepatitis (or
non-alcoholic fatty liver disease) documented in the medical record.
139.5,36 DONOR WEIGHT 1;3 FREE TEXT
Donor Weight
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:X>700!(X<0) X D W^SROAMEAS
OUTPUT TRANSFORM: S Y=$S(Y="NS":"NO STUDY",Y["K":+Y_" KILOGRAMS",+Y:Y_" LBS.",1:Y)
LAST EDITED: JUL 17, 2008
HELP-PROMPT: Enter donor weight.
DESCRIPTION: Indicate the Donor's most recent weight before surgery in either pounds (lbs) or kilograms (kg)
based upon an actual measurement (if possible) or based on estimate.
The weight should be entered in pounds (50 to 700) or kilograms (23 to 318). If you are entering
the donor's weight in kilograms, enter 'K' after the number of kilograms.
Your answer should be in one of the following formats.
178 (weight in pounds)
80K (weight in Kilograms)
Enter NS for NO STUDY if the donor's weight cannot be determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,37 POLYCYSTIC DISEASE .1;18 SET
Polycystic Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Polycystic Disease status of the organ recipient.
DESCRIPTION: This is Polycystic Disease status of the organ recipient. Polycystic Disease is a condition in
which multiple cysts on the kidneys cause the kidneys to fail.
139.5,38 PRIMARY BILIARY CHOLANGITIS .1;19 SET
Primary Biliary Cholangitis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Primary Biliary Cholangitis (PBC) status of the organ recipient.
DESCRIPTION: Primary Biliary Cholangitis or Cirrhosis is an autoimmune liver disease where over time an antibody
created within the body attacks and destroys the bile ducts in the liver.
139.5,39 PRIMARY SCLEROSING CHOLANGITIS .1;20 SET
Primary Sclerosing Cholangitis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter the Primary Sclerosing Cholangitis status of the organ recipient.
DESCRIPTION:
Indicate whether a diagnosis of Primary Sclerosing Cholangitis is documented in the medical record.
139.5,40 PULMONARY FIBROSIS .1;21 SET
Pulmonary Fibrosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Pulmonary Fibrosis status of the organ recipient.
DESCRIPTION: Pulmonary Fibrosis involves scarring of the lung. Gradually, the air sacs of the lungs become
replaced by fibrotic tissue. When the scar forms, the tissue becomes thicker causing an
irreversible loss of the tissue's ability to transfer oxygen into the bloodstream. Indicate if
patient has diagnosis of pulmonary fibrosis documented in the medical record.
139.5,41 PULMONARY HYPERTENSION .1;22 SET
Pulmonary Hypertension
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the Pulmonary Hypertension status of the organ recipient.
DESCRIPTION: Indicate if patient has diagnosis of pulmonary hypertension with Mean PA pressure > 35 mmHg
documented in medical record.
139.5,42 RENAL CANCER .1;23 SET
Renal Cancer
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 21, 2008
HELP-PROMPT: Enter the Renal Cancer status of the organ recipient.
DESCRIPTION: This is the Renal Cancer status of the organ recipient. Renal Cancer is malignant neoplasm of the
kidney.
139.5,43 SARCOIDOSIS .1;24 SET
Sarcoidosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Sarcoidosis status of the organ recipient.
DESCRIPTION: Indicate if the patient was diagnosed with clinical manifestations of cardiac sarcoidosis, which is
dependent upon the location and extent of granulomatous inflammation. Cardiac involvement may
precede, follow, or occur concurrently with involvement of the lungs or other organs.
139.5,44 DONOR RACE 44;0 SET Multiple #139.544 (Add New Entry without Asking)
139.544,.01 DONOR RACE 0;1 SET (Multiply asked)
Donor Race
'3' FOR AMERICAN INDIAN OR ALASKA NATIVE;
'A' FOR NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER;
'9' FOR BLACK OR AFRICAN AMERICAN;
'8' FOR ASIAN;
'B' FOR WHITE;
'C' FOR DECLINED TO ANSWER/UNANSWERED;
'D' FOR UNKNOWN BY PATIENT;
LAST EDITED: MAY 06, 2008
HELP-PROMPT: Enter the Donor Race
DESCRIPTION: Indicate the donor-reported race. Select all appropriate responses:
American Indian or Alaskan Native - Patient indicates race as
American Indian or Alaskan Native Native Hawaiian or Pacific Islander - Patient
indicates race as
Native Hawaiian or Pacific Islander Black or African American - Patient indicates race
as Black or
African American Asian - Patient indicates race as Asian White - Patient indicates race
as White Declined to Answer - Patient elects not to indicate race Unknown by Patient - Patient
indicates race as unknown Unanswered - Race unanswered
CROSS-REFERENCE: 139.544^B
1)= S ^SRT(DA(1),44,"B",$E(X,1,30),DA)=""
2)= K ^SRT(DA(1),44,"B",$E(X,1,30),DA)
139.5,45 DONOR GENDER 1;5 SET
Donor Gender
'M' FOR MALE;
'F' FOR FEMALE;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the Donor Gender.
DESCRIPTION:
Indicate donor's gender as "M" if male, "F" if female.
139.5,46 DONOR AGE 1;6 FREE TEXT
Donor Age
INPUT TRANSFORM: S:X="NS"!(X="ns") X="NS" Q:X="NS" K:+X'=X!(X>135)!(X<0) X D Y^SRTPUTL
OUTPUT TRANSFORM: S Y=$S(Y="NS":"NO STUDY",Y:+Y_" YEARS",1:Y)
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the age of the donor.
DESCRIPTION: This is the age of the donor at the time of organ harvest. Field will be automatically calculated
and filled if DONOR DATE OF BIRTH entered. Enter NS for NO STUDY if the donor's age cannot be
determined.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,47 BILIARY STRICTURE .1;26 SET
Biliary Stricture
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Biliary Stricture status of the organ recipient.
DESCRIPTION: Narrowing or occlusion of the bile ducts either extrahepatic (for choledochocholedochostomy or
choledochojejunostomy) or intrahepatic, seen on MRCP, ERCP, or PTC or as documented in the medical
record.
139.5,48 DONOR ABO BLOOD TYPE 1;8 SET
Donor ABO Blood Type
'A' FOR A;
'B' FOR B;
'AB' FOR AB;
'O' FOR O;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the ABO blood type of the organ donor.
DESCRIPTION:
This is the ABO blood type of the organ donor.
139.5,49 DONOR CMV 1;9 SET
Donor CMV
'+' FOR POSITIVE;
'-' FOR NEGATIVE;
LAST EDITED: MAY 06, 2008
HELP-PROMPT: Enter the CMV status of transplant donor.
DESCRIPTION:
Indicate whether the donor tested positive or negative to Cytomegalovirus.
139.5,50 LAS SCORE AT LISTING 0;19 NUMBER
LAS Score at Listing
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter the LAS Score at Listing.
DESCRIPTION: Lung allocation score (LAS) is a calculated value which is used by the United Network for Organ
Sharing (UNOS) based upon a number of factors including age, geographic distance, lab test results,
and disease diagnosis for prospective lung transplants recipients. Indicate patient Lung Allocation
Score at Listing with UNOS. Enter a number between 0 and 100.
139.5,51 LAS SCORE AT TRANSPLANT 0;20 NUMBER
LAS Score at Transplant
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter the LAS Score at Transplant.
DESCRIPTION: Lung allocation score (LAS) is a calculated value which is used by the United Network for Organ
Sharing (UNOS) based upon a number of factors including age, geographic distance, lab test results,
and disease diagnosis for prospective lung transplants recipients. Indicate patient Lung Allocation
Score at Transplant with UNOS. Enter a number between 0 and 100.
139.5,52 MELD SCORE AT LISTING 0;21 NUMBER
MELD Score at Listing
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<6)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter the MELD Score at Listing.
DESCRIPTION: Biologic Model of End Stage Liver Disease score plus the extra points as defined by UNOS (for
example, for HCC or an appeal has been made for higher MELD score due to other clinical entities)
at time of listing and as documented in the UNOS data base. Enter a number between 6 and 40.
139.5,53 BIOLOGIC MELD SCORE AT LISTING 0;22 NUMBER
Biologic MELD score at listing
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<6)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter the Biologic MELD Score at Listing.
DESCRIPTION: Actual Model of End Stage Liver Disease score using the laboratory values of bilirubin, creatinine,
and INR at the time of listing and as documented in the UNOS data base. Enter a number between 6
and 40.
139.5,54 MELD SCORE AT TRANSPLANT 0;23 NUMBER
MELD score at transplant
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<6)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter the MELD Score at Transplant.
DESCRIPTION: Biologic Model of End Stage Liver Disease score plus the extra points as defined by UNOS (for
example, for HCC, or an appeal has been made for higher MELD score due to other clinical entities)
at time of transplant and as documented in the UNOS data base. Enter a number between 6 and 40.
139.5,55 BIOLOGIC MELD SCORE AT TRANSP .01;10 NUMBER
Biologic MELD score at transplant
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<6)!(X?.E1"."1N.N) X
LAST EDITED: MAY 14, 2008
HELP-PROMPT: Enter the Biologic MELD Score at Transplant.
DESCRIPTION: Actual Model of End Stage Liver Disease score using the laboratory values of bilirubin, creatinine,
and INR at the time of transplant and as documented in the UNOS data base. Enter a number between 6
and 40.
139.5,56 BILE LEAK .11;20 SET
Bile Leak
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Bile Leak status of the organ recipient.
DESCRIPTION: Evidence of extravasation of bile from the biliary tree by a cholangiogram. The contrast imaging
studies to obtain a cholangiogram include: ERCP, PTC, MRCP, or tube cholangiogram. A HIDA scan can
also reveal a bile leak. In addition, bile leak can be identified as documented in the medical
record.
139.5,57 UNOS STATUS AT TIME OF TRANSP .01;9 SET
UNOS Status at time of Transplant
'A' FOR 1A;
'B' FOR 1B;
'2' FOR 2;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the UNOS Status at the time of Transplant.
DESCRIPTION: Indicate the UNOS (United Network for Organ Sharing database) status at the time the transplant
procedure was performed.
139.5,58 UNOS STATUS AT TIME OF LISTING 0;8 SET
UNOS Status at time of Listing
'A' FOR 1A;
'B' FOR 1B;
'2' FOR 2;
'7' FOR 7 - ON HOLD;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the UNOS Status at the time of listing.
DESCRIPTION: Indicate the UNOS (United Network for Organ Sharing database) status at the time the heart
transplant procedure was listed.
139.5,59 DIABETIC RETINOPATHY .5;1 SET
Diabetic Retinopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter YES if organ recipient is diagnosed with diabetic retinopathy.
DESCRIPTION: Diabetic Retinopathy is damage to the blood vessels in the retina as a consequence of diabetes
mellitus. Enter YES if organ recipient is diagnosed with this condition. Otherwise, enter NO.
139.5,60 DIABETIC NEUROPATHY .5;2 SET
Diabetic Neuropathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Diabetic Neuropathy status of the organ recipient.
DESCRIPTION: Enter the Diabetic Neuropathy status of the organ recipient. Diabetic Neuropathy is damage to the
nervous system as a consequence of diabetes mellitus which can include peripheral neuropathy
(sensory nervous system) or autonomic neuropathy (autonomic nervous system) or as defined by the
attending physician.
139.5,61 CARDIAC DISEASE .5;3 SET
Cardiac Disease (CAD, AF, EF<50%)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the presence of Cardiac Disease (CAD, AF, EF<50%) in organ recipient.
DESCRIPTION: Any documented cardiac abnormality (i.e. EKG abnormality, fixed or reversible defects, cardiac
disease on heart catheterization, hypertension, and hyperlipidemia).
139.5,62 INOTROPE DEPENDENT PRE-TRANSP .5;4 SET
Inotrope Dependent Pre-Transplant
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Indicate whether the patient required an inotropic agent.
DESCRIPTION: Indicate if the patient required an inotropic agent (dobutamine, milrinone, levophed, etc.) to
maintain adequate cardiac output while awaiting a donor heart.
139.5,63 DIVISION 8;1 POINTER TO INSTITUTION FILE (#4)
Medical Center Division
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the name of the division associated with this transplant.
DESCRIPTION:
This is the name of the institution credited for performing this transplant.
139.5,64 DONOR HLA-A TYPING 1;10 FREE TEXT
Donor HLA-A Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-A typing of the organ donor.
DESCRIPTION: This is the HLA-A typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,65 DONOR HLA-B TYPING 1;11 FREE TEXT
Donor HLA-B Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-B typing of the organ donor.
DESCRIPTION: This is the HLA-B typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,66 DONOR HLA-C TYPING 1;12 FREE TEXT
Donor HLA-C Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-C typing of the organ donor.
DESCRIPTION: This is the HLA-C typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,67 DONOR HLA-BW TYPING 1;13 FREE TEXT
Donor HLA-BW Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-BW typing of the organ donor.
DESCRIPTION: This is the HLA-BW typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,68 CROSSMATCH D/R 3;7 SET
Crossmatch D/R
'+' FOR POSITIVE;
'-' FOR NEGATIVE;
LAST EDITED: MAY 06, 2008
HELP-PROMPT: Enter status of Crossmatch between donor and recipient.
DESCRIPTION: Crossmatch is pretransfusion testing or compatibility testing. It is a series of procedures used to
give an indication of blood group compatibility between the donor and the recipient and to detect
irregular antibodies in the recipient's serum.
139.5,69 DECEASED DONOR 3;1 SET
Deceased Donor
'1' FOR DCD (Donor after Cardiac Death);
'2' FOR ECD (Extended Criteria Donor);
'3' FOR SCD (Standard Criteria Donor);
'4' FOR ECD-DCD;
'NS' FOR NO STUDY;
LAST EDITED: SEP 11, 2008
HELP-PROMPT: Enter the type of the deceased donor.
DESCRIPTION: Transplanted organ was harvested from a deceased donor. Acceptable answers include DCD (Donor after
Cardiac Death), ECD (Extended Criteria Donor), SCD (Standard Criteria Donor), ECD-DCD, and No
Study.
139.5,70 DONOR DATE OF BIRTH 1;1 DATE
Donor Date of Birth
INPUT TRANSFORM: S %DT="EP" D ^%DT S X=Y K:1701231>X!(DT
35 mmHg for right heart catheterization measurement.
139.5,72 DONOR HLA-DQ TYPING 1;14 FREE TEXT
Donor HLA-DQ Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-DQ typing of the organ donor.
DESCRIPTION: This is the HLA-DQ typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,73 DONOR HLA-DR TYPING 1;15 FREE TEXT
Donor HLA-DR Typing
INPUT TRANSFORM: K:$L(X)>19!($L(X)<1) X I $D(X) D HLA^SRTPUTL
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter the HLA-DR typing of the organ donor.
DESCRIPTION: This is the HLA-DR typing status of the organ Donor. It is Human Leukocyte Antigen (HLA) typing -
described as A, B, C, BW, DQ, & DR locus. Acceptable answers are numerical in the format of # to
#,#,#,#. The numbers between commas can be from 0 to 9999.
NS (No Study) is also an acceptable response for heart transplants assessments.
139.5,74 PULMONARY HYPER/ELEVATED PAP .5;5 SET
Pulmonary Hypertension / Elevated PAP Not Reversible
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the status of Pulmonary Hypertension / Elevated PAP not reversible.
DESCRIPTION: Indicate if the patient has Pulmonary Hypertension or an Elevated PAP not reversible by sodium
nitroprusside (Nipride).
139.5,75 LIVER DISEASE .5;6 SET
Liver Disease (Hep C+, Hep B+, cirrhosis)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the presence of Liver Disease (Hep C+, Hep B+, cirrhosis) in organ recipient.
DESCRIPTION: Indicate the presence of liver disease such as positive HCV, Hep BsAg, or documented cirrhosis in
organ transplant recipient.
139.5,76 COPD .5;7 SET
COPD
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter status of COPD.
DESCRIPTION: Indicate if the patient has chronic obstructive pulmonary disease (COPD) resulting in functional
disability, and/or hospitalization, and/or requiring chronic bronchodilator therapy, and/or an FEV1
of less than 75% of predicted.
139.5,77 DONOR SUBSTANCE ABUSE 1;4 SET
Donor Substance Abuse
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 19, 2008
HELP-PROMPT: Enter the Donor Substance Abuse status of the organ donor.
DESCRIPTION: This is any documented history of illicit or recreational drug abuse of the donor. The route may
be intravenous, subcutaneous, intranasal, oral, or inhaled. The drugs may include opioids,
methamphetamines, cocaine, hallucinogens, marijuana, alcohol or other substances.
139.5,78 PORTO PULMONARY HYPERTENSION .5;9 SET
Porto Pulmonary Hypertension
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Porto Pulmonary Hypertension status of the organ recipient.
DESCRIPTION: The pulmonary arterial vasculopathy associated with elevated pulmonary artery pressure (mean >
35mmHg) and as a consequence of severe hepatic dysfunction or as documented in the medical record.
139.5,79 BLEEDING ESOPH/GASTRIC VARICES .5;10 SET
History of Bleeding Esophageal and/or Gastric Varices
'B' FOR BLEEDING;
'NB' FOR NOT BLEEDING;
'N' FOR NO;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the History of Bleeding Esophageal and/or Gastric Varices status of the organ recipient.
DESCRIPTION: The presence of upper gastrointestinal bleeding from esophageal or gastric varices any time in the
patient's medical history.
139.5,80 PRE-TRANSPLANT MALIGNANCY .5;11 SET
Pre-Transplant Malignancy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Pre-transplant Malignancy status of the organ recipient.
DESCRIPTION: This is Pre-transplant Malignancy status of the organ recipient. Pre-transplant Malignancy is any
history of solid organ, blood cell, or lymph node malignancy prior to kidney transplantation.
139.5,81 PRE-TRANSPLANT SKIN MALIGNANCY .5;12 SET
History of Preop Transplant Skin Malignancy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter the status of the history of pre-transplant skin malignancy of the organ recipient.
DESCRIPTION: Indicate if the patient has any neoplasm or tumor of the skin that is biopsy-proven to be malignant
prior to organ transplant.
139.5,82 OTHER PRE-TRANS MALIGNANCY .5;13 SET
History of Other Pre-Transplant Malignancy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the history of other pre-transplant malignancy status (other than skin) of the organ
recipient.
DESCRIPTION: Indicate if patient has history of solid organ, blood cell, or lymph node malignancy (other than
skin) prior to organ transplantation.
139.5,83 RECIPIENT SUBSTANCE ABUSE .5;14 SET
Recipient Substance Abuse
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 29, 2008
HELP-PROMPT: Enter the Recipient Substance Abuse status of the organ recipient.
DESCRIPTION: Indicate if there is any documented history of illicit or recreational drug abuse by the organ
recipient. The route may be intravenous, subcutaneous, intranasal, oral, or inhaled. The drugs
may include opioids, methamphetamines, cocaine, hallucinogens, marijuana, alcohol or other
substances.
139.5,84 ACTIVE INFECTION FOR PSC .5;15 SET
Active Infection for PSC
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the status of active infection in liver.
DESCRIPTION: The presence of infection related to the diseased biliary tract in the native liver at the time of
liver transplantation. The infection would be manifest as cholangitis, bacteremia, or biliary
sepsis.
139.5,85 WARM ISCHEMIA TIME FOR ORGAN 3;4 NUMBER
Warm Ischemia Time For Organ
INPUT TRANSFORM: K:+X'=X!(X>3000)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: AUG 27, 2008
HELP-PROMPT: Enter the warm ischemia time for organ in minutes (0-3000).
DESCRIPTION: Enter warm ischemia time for organ in minutes as written on transplant data sheet or operative
note. This is defined by the time that the donor organ is off ice until the time of reperfusion.
RECORD INDEXES: AD (#547)
139.5,86 ACUTE/CHRONIC ENCEPHALOPATHY .5;17 SET
Acute or Chronic Encephalopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Acute or Chronic Encephalopathy status of the organ recipient.
DESCRIPTION: History of new onset of hepatic encephalopathy, recurrent hepatic encephalopathy, or a state of
ongoing, continued hepatic encephalopathy as documented in the medical record.
139.5,87 COLD ISCHEMIA TIME FOR ORGAN 3;5 NUMBER
Cold Ischemia Time for Organ
INPUT TRANSFORM: K:+X'=X!(X>6000)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: AUG 27, 2008
HELP-PROMPT: Enter the cold ischemia time for organ in minutes (0-6000).
DESCRIPTION: Enter cold ischemia time for organ in minutes as written on transplant data sheet or operative
note. This is defined by the time that the donor organ is cross-clamped to the time that the donor
organ is removed from the ice.
RECORD INDEXES: AD (#547)
139.5,88 HISTORY OF ASCITES .5;19 SET
History of Ascites
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter 'YES' if the organ recipient has a history of fluid accumulation in the peritoneal cavity.
DESCRIPTION: The presence of ascites fluid (presence of fluid accumulation in the peritoneal cavity noted on
physical exam, abdominal ultrasound, or abdominal CT/MRI) at any time in the patient's medical
history.
139.5,89 TOTAL ISCHEMIA TIME FOR ORGAN 3;6 NUMBER
Total Ischemia Time for Organ
INPUT TRANSFORM: K:+X'=X!(X>9999)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: AUG 27, 2008
HELP-PROMPT: Enter the total ischemia time for organ in minutes (0-9999).
DESCRIPTION: Enter the total ischemia time for organ in minutes which is the sum of warm ischemia time and cold
ischemia time.
TECHNICAL DESCR: If both the Warm and Cold Ischemia fields contain values, the "AD" cross reference populates this
field with the sum of their values.
139.5,90 NON-COMPLIANCE (MED AND DIET) .5;21 SET
Non-Compliance (Med and Diet)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Indicate if organ recipient is non-compliant regarding medication and/or diet.
DESCRIPTION: Enter the non-compliance (medication and diet) status of the organ recipient. This refers to
documented history of nonadherence/noncompliance to medical regimens such as diet, exercise,
monitoring blood sugars, attending scheduled appointments and laboratory draws when requested.
139.5,91 ON METHADONE .5;22 SET
On Methadone
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Methadone status of the organ recipient.
DESCRIPTION: Patient who has had previous substance abuse with opioids and is currently prescribed methadone by
a physician or methadone clinic. This patient would be yes for drug abuse variable as well.
139.5,92 POST-TX PROPHYLAXIS - TB .5;23 SET
Post Transplant Prophylaxis for TB/Antimycobacterial Treatment
'Y' FOR YES;
'N' FOR NO;
'NA' FOR NOT APPLICABLE;
LAST EDITED: DEC 06, 2010
HELP-PROMPT: Enter the Post Transplant Prophylaxis for TB/Antimycobacterial Treatment status of the patient.
DESCRIPTION: Definition Revised (2010): Indicate whether patient is receiving post-transplant prophylaxis
Tuberculosis/Antimycobacterial drugs continuously post operatively for at least 30 days. Indicate
Yes if patient receiving therapy. Indicate No if patient is indicated to receive therapy but
doesn't. Indicate Not Applicable if patient is not indicated to receive therapy.
139.5,94 REJECTION .11;19 SET
Rejection
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter status of organ rejection in patient.
DESCRIPTION: A diagnosis of acute rejection as made by pathologic evaluation of allograft biopsy or a diagnosis
of acute rejection as documented in the medical record.
139.5,95 IGA NEPHROPATHY .1;17 SET
IgA Nephropathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the IgA Nephropathy status of organ recipient.
DESCRIPTION: IgA Nephropathy is a kidney disorder caused by deposits of the protein immunoglobulin A (IgA)
inside the glomeruli within the kidney. The chronic kidney disease may progress over a period of 10
to 20 years. If this disorder leads to end-stage renal disease, the patient must go on dialysis or
receive a kidney transplant.
139.5,96 CALCINEURIN INHIBITOR TOXICITY .11;4 SET
Calcineurin Inhibitor Toxicity
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the Calcineurin Inhibitor Toxicity status of transplant recipient
DESCRIPTION: Cyclosporin and tacrolimus are calcineurin inhibitors and are widely used as immunosuppressive
therapy. Among the toxicities of the calcineurin inhibitor class are nephrotoxicity manifest as
acute renal failure, hyperkalemia with or without acidosis and progressive chronic renal failure
and neurotoxicity manifest primarily as tremors and headache.
139.5,97 LITHIUM TOXICITY .11;9 SET
Lithium Toxicity
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the status of Lithium Toxicity for organ recipient.
DESCRIPTION: Mild to moderate acute toxic reactions may occur at lithium drug concentrations from 1.5 - 2
mmol/L, and moderate to severe reactions at concentrations above 2 mmol/L. In patients with normal
renal clearance the acute toxic manifestations appear to occur in a fairly predictable sequence
related to lithium concentrations. Thirst and polyuria may be followed by increased drowsiness,
ataxia, tinnitus and blurred vision, indicating early intoxication. As intoxication progresses the
following manifestations may be encountered: confusion, increasing disorientation, muscle
twitchings, hyperreflexia, nystagmus, seizures, diarrhea, vomiting, and eventually coma and death.
Long term lithium use can also cause nephrogenic diabetes insipidus and a chronic tubulointersitial
nephritis with progressive chronic kidney disease leading to ESRD.
139.5,98 OBSTRUCTIVE UROPATHY FROM BPH .11;10 SET
Obstructive Uropathy from BPH
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter status of Obstructive Uropathy from BPH.
DESCRIPTION: Obstructive uropathy from BPH is a non-cancerous enlargement of the prostate gland causing
obstruction to the free flow of urine due to narrowing of the urethra. As obstruction progresses,
the bladder decompensates, increasingly larger amounts of residual urine are left behind. Infection
is frequently associated with the residual urine. This can be transmitted to the upper urinary
tracts, with ensuing hydroureter, hydronephrosis and progressive renal damage and if untreated to
ESRD.
139.5,99 AUTOIMMUNE HEPATITIS .11;11 SET
Autoimmune Hepatitis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 04, 2008
HELP-PROMPT: Enter the Autoimmune Hepatitis status of the organ recipient.
DESCRIPTION: Hepatitis or cirrhosis due to immune cell attack of the liver causing inflammation and or cell
death; or diagnosis of autoimmune hepatitis documented in medical record.
139.5,100 CRYPTOGENIC CIRRHOSIS .11;12 SET
Cryptogenic Cirrhosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Cryptogenic Cirrhosis status of the organ recipient.
DESCRIPTION: Cryptogenic Cirrhosis is cirrhosis of the liver by biopsy with no specific etiology for the
cirrhosis.
139.5,101 CHRONIC REJECTION .11;13 SET
Chronic Rejection
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Chronic Rejection status of the organ recipient.
DESCRIPTION: The diagnosis of chronic rejection as made by pathologic evaluation or a diagnosis of chronic
rejection documented in the medical record.
139.5,102 HEPATIC ARTERY THROMBOSIS .11;14 SET
Hepatic Artery Thrombosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Hepatic Artery Thrombosis status of the organ recipient.
DESCRIPTION: Thrombosis of the liver allograft hepatic artery documented by ultrasound duplex, angiogram, or
another vascular imaging study; or a diagnosis of hepatic artery thrombosis documented in the
medical record.
139.5,103 LIVING DONOR 3;2 SET
Living Donor
'R' FOR RELATED;
'U' FOR UNRELATED;
'NS' FOR NO STUDY;
LAST EDITED: MAY 15, 2008
HELP-PROMPT: Enter the type of the living donor.
DESCRIPTION:
Transplanted organ was harvested from a living donor.
139.5,104 DONOR WITH MALIGNANCY 3;3 SET
Donor with Malignancy
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 19, 2008
HELP-PROMPT: Enter the status of the Donor with Malignancy.
DESCRIPTION: Indicate if the donor has or has a history of a cancer, neoplasm, or tumor that grows in an
uncontrolled manner, invading nearby tissue and metastasizing (spreading) to other sites through
the bloodstream. Entering 'NS' for 'No Study/Unknown' is also allowed.
139.5,105 PRIMARY NON-FUNCTION .11;16 SET
Primary Non-Function
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter the Primary Non-Function of Liver status for the organ recipient.
DESCRIPTION: Primary Non-Function is defined as failure in the function of the liver allograft within 7 days of
liver transplantation as defined by 1) or 2):
1) AST > 4999 and one or both of the following: an INR >2.4, acidosis,
defined as having an arterial pH < 7.31 or venous pH of 7.25 and/or
lactate > 3.9 mMol/L;
2) anhepatic candidate; or diagnosis of primary non-function
documented in the medical record.
139.5,106 SECOND SCLEROSING CHOLANGITIS .11;17 SET
Secondary Sclerosing Cholangitis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Secondary Sclerosing Cholangitis (SSC) status of the organ recipient.
DESCRIPTION:
A diagnosis of secondary sclerosing cholangitis in medical record.
139.5,107 TOXIC EXPOSURE .11;18 SET
Toxic Exposure
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Toxic Exposure status of the organ recipient.
DESCRIPTION: Hepatitis and or necrosis of the liver due to a known hepatotoxic agent or diagnosis of toxic
exposure causing liver failure as documented in medical record.
139.5,108 HIV POSITIVE .5;8 SET
HIV + (positive)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter YES if organ recipient is HIV positive.
DESCRIPTION: Enter YES if organ recipient is HIV positive on laboratory test or HIV positive as documented in
the medical record. Otherwise, enter NO.
139.5,109 POST-TX PROPHYLAXIS - CMV .5;20 SET
Post Transplant Prophylaxis for CMV/Antiviral Treatment
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Post Transplant Prophylaxis for CMV/Antiviral Treatment status of the patient.
DESCRIPTION: This is the Post Transplant Prophylaxis for CMV/Antiviral Treatment status of a patient who is
receiving ganciclovir, valganciclovir, or acyclovir continuously post operatively for at least 30
days.
139.5,110 POST-TX PROPHYLAXIS - PCP .55;1 SET
Post Transplant Prophylaxis for PCP/Antibacterial Treatment
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Post Transplant Prophylaxis for PCP/Antibacterial Treatment status of the patient.
DESCRIPTION: This is the Post Transplant Prophylaxis for PCP/Antibacterial Treatment status of a patient
receiving septra/bactrim, pentamidine, or dapsone continuously post operatively for at least 30
days.
139.5,111 PORTAL VEIN THROMBOSIS .11;21 SET
Portal Vein Thrombosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Portal Vein Thrombosis status of the organ recipient.
DESCRIPTION: Thrombosis of the liver allograft portal vein documented by ultrasound duplex, angiogram, or CT
angiogram or MRI; or a diagnosis of portal vein thrombosis as documented in the medical record.
139.5,112 OTHER CARDIOMYOPATHY .11;15 FREE TEXT
Other Cardiomyopathy
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter description of other cardiomyopathy. Your answer must be 1-60 characters.
DESCRIPTION: If the patient was diagnosed with any other form of cardiomyopathy that is not listed elsewhere on
this form, specify details into the comment field.
139.5,113 LUNG DISEASE .55;3 SET
Lung Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUN 04, 2008
HELP-PROMPT: Record the presence or absence of lung disease (COPD, Pulmonary HTN, Interstitial Disease) in organ
recipient.
DESCRIPTION: Indicate the presence of lung disease such as documented COPD, pulmonary hypertension, or
interstitial disease in organ transplant recipient.
139.5,114 RENAL IMPAIRMENT .55;4 SET
Renal Impairment (Serum Creatinine >1.5)
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Renal Impairment (Serum Creatinine >1.5) status.
DESCRIPTION:
Renal dysfunction is evidenced by a serum creatinine results over 1.5 mg/dl.
139.5,115 INFECTION REQ ANTIBIOTICS .5;16 SET
Active Infection Requiring Antibiotics
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the pre-transplant status of infection requiring antibiotics of the organ recipient.
DESCRIPTION: Indicate the presence of infection in recipient of the target organ or system requiring antibiotic
treatment.
139.5,116 BLEEDING/TRANSFUSIONS 10;1 SET
Bleeding/Transfusions
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter status of Bleeding/Transfusions for organ recipient.
DESCRIPTION: 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. Report as
an occurrence for five or more units of packed red blood cell 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.
139.5,117 PNEUMONIA 10;2 SET
Pneumonia
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter status of Pneumonia for organ recipient.
DESCRIPTION: 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
139.5,118 ON VENTILATOR >48 HOURS 10;3 SET
On Ventilator > 48 Hours
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 19, 2011
HELP-PROMPT: Enter if patient remained on ventilator greater than 48 hours after transplant.
DESCRIPTION: Definition Revised (2011): Total duration of ventilator-assisted respirations during postoperative
hospitalization was >48 hours. This can occur at any time during the 30-day period postoperatively.
This time assessment is CUMULATIVE, not necessarily consecutive. Ventilator-assisted respirations
can be via endotracheal tube, nasotracheal tube, or tracheostomy tube.
139.5,119 CARDIAC ARREST REQ CPR 10;4 SET
Cardiac Arrest Requiring CPR
'N' FOR NO;
'I' FOR INTRAOPERATIVELY;
'P' FOR POSTOPERATIVELY;
LAST EDITED: APR 19, 2011
HELP-PROMPT: Enter if patient suffered 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.
139.5,120 PSYCHOSIS .11;22 SET
Psychosis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Psychosis status of the organ recipient.
DESCRIPTION: Documentation in the medical record of a mental state involving a loss of contact with reality that
may include hallucinations, delusional beliefs, or personality changes or the diagnosis of
psychosis in the medical record.
139.5,121 STROKE/CVA 10;6 SET
Stroke/CVA
'Y' FOR YES;
'N' FOR NO;
'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 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). 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
SCREEN: S DIC("S")="I ""YN""'[Y"
EXPLANATION: Screen prevents selection of YES and NO.
139.5,122 COMA > 24 HOURS POSTOP 10;7 SET
Coma Greater than 24 Hours Postop (Y/N)
'Y' FOR YES;
'N' FOR NO;
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.)
139.5,123 SUPERFICIAL INCISIONAL SSI 10;8 SET
Superficial Incisional SSI
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Indicate if the patient has been diagnosed with a Superficial Incisional Surgical Site Infection
(SSI).
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).
139.5,124 DEEP INCISIONAL SSI 10;9 SET
Deep Incisional SSI
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Indicate if the patient has been diagnosed with a Deep Incisional Surgical Site Infection (SSI)
DESCRIPTION: Definition Revised (2004): Deep Incision SSI is an infection that occurs within 30 days after the
operation and the infection appears to be related to the operation and infection involved deep soft
tissues (e.g., fascial and muscle layers) of the incision and at least one of the following:
- Purulent drainage from the deep incision but not from the
organ/space component of the surgical site.
- A deep incision spontaneously dehisces or is deliberately opened by
a surgeon when the patient has at least one of the following signs
or symptoms: fever (>38 C), localized pain, or tenderness, unless
site is culture-negative.
- An abscess or other evidence of infection involving the deep
incision is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
- Diagnosis of a deep incision SSI by a surgeon or attending
physician.
Note:
- Report infection that involves both superficial and deep incision
sites as deep incisional SSI.
- Report an organ/space SSI that drains through the incision as a deep
incisional SSI.
139.5,125 SYSTEMIC SEPSIS 10;10 SET
Systemic Sepsis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Indicate if the patient has been diagnosed with a 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 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.
139.5,126 RETURN TO SURGERY W/I 30 DAYS 10;11 SET
Return to Surgery within 30 days
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter YES/NO whether Returned to Surgery within 30 Days.
DESCRIPTION: This field documents returns to the operating room including all surgical procedures that required
the patient to be taken to the surgical operating room for intervention of any kind.
139.5,127 SEIZURES .11;23 SET
Seizures
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Seizures status of the organ recipient.
DESCRIPTION: Documentation of a sudden change in behavior due to an excessive electrical activity in the brain
or the diagnosis of seizure in the medical record.
139.5,128 EMPHYSEMA .1;12 SET
Emphysema
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter status of emphysema in organ recipient.
DESCRIPTION: Emphysema is a chronic obstructive pulmonary disease that is caused by loss of elasticity of the
lung tissue from destruction of structures supporting the alveoli and/or destruction of capillaries
feeding the alveoli which often results in shortness of breath. Indicate if the patient has a
diagnosis of emphysema documented by an attending physician.
139.5,129 OTHER DIAGNOSIS .1;25 FREE TEXT
Other Diagnosis
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter description of other Diagnosis.
DESCRIPTION: If the patient was diagnosed with any other condition that is not listed elsewhere on this form,
specify details into the comment field. Free text field will have a limit of 50 characters.
139.5,130 NEW MECHANICAL CIRCULATORY 10;5 SET
New Mechanical Circulatory Support
'N' FOR NO;
'I' FOR INTRAOPERATIVELY;
'P' FOR POSTOPERATIVELY;
LAST EDITED: MAR 24, 2011
HELP-PROMPT: Indicate if patient required New Mechanical Circulatory Support after transplant.
DESCRIPTION: Definition Revised (2004): Indicate if the patient left the operating room suite with or required
post-op placement of a new IABP, ECMO, or VAD for circulatory support within 30 days
perioperatively. A "yes" response is appropriate even if the pump is only used for a short time
perioperatively. A "yes" response, however, is only correct if the patient did not enter the
operating room with this same mechanical circulatory support, and the device insertion occurred
AFTER the induction of anesthesia.
If patient had/required new mechanical circulatory support, indicate whether the placement occurred
intraoperatively or postoperatively. Indicate the one appropriate response:
- intraoperatively: occurring while patient was in the operating
room. - postoperatively: occurring after patient left the operating room.
A "no" response is appropriate if the circulatory support device was placed as a prophylaxis before
the induction of anesthesia; however, if it was placed for any reason after the induction of
anesthesia, then a "yes" response is appropriate. A "no" response is also appropriate if the
primary operation is to insert a ventricular assist device.
139.5,131 PREOP FUNCTIONAL HEALTH STATUS .5;18 SET
Preop Functional Health Status
'I' FOR INDEPENDENT;
'P' FOR PARTIALLY DEPENDENT;
'T' FOR TOTALLY DEPENDENT;
'U' FOR UNKNOWN;
LAST EDITED: JUL 17, 2008
HELP-PROMPT: Enter the level of self care that summarizes the patient's status prior to surgery.
DESCRIPTION: Definition Revised (2008): This is a question that focuses on the patient's abilities to perform
activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are
defined as 'the activities usually performed in the course of a normal day in a person's life'.
ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level
of self-care for activities of daily living demonstrated by this patient at the time the patient is
being considered as a candidate for surgery (which should be no longer than 30 days prior to
surgery). If the patient's status changes prior to surgery, that change should be reflected in your
assessment. For this time point, report the level of functional health status as defined by the
following criteria.
(1) Independent: The patient does not require assistance from another
person for any activities of daily living. This includes a person
who is able to function independently with prosthetics, equipment,
or devices.
(2) Partially dependent: The patient requires some assistance from
another person for activities of daily living. This includes a
person who utilizes prosthetics, equipment, or devices but still
requires some assistance from another person for ADLs.
(3) Totally dependent: The patient requires total assistance for all
activities of daily living.
(4) Unknown: If unable to ascertain the functional status for the time
point of 'prior to the current illness' only, report as unknown.
All patients with psychiatric illnesses should be evaluated for their ability to function with or
without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with
schizophrenia is able to care for him/herself without the assistance of nursing care, he/she is
considered independent.
139.5,132 PERIPHERAL VASCULAR DISEASE .5;25 SET
Peripheral Vascular Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter status of Peripheral Vascular Disease.
DESCRIPTION: Indicate if the patient has peripheral vascular disease, defined as disease of the arteries to legs
below bifurcation of aorta manifested by exertional claudication, and/or ischemic rest pain, and/or
prior revascularization procedure(s) on vessels to legs, and/or absent or diminished pulses in
legs, and/or angiographic evidence of noniatrogenic peripheral arterial obstruction greater than or
equal to 50% of luminal diameter.
139.5,133 GRAFT FAILURE DATE 10;13 FREE TEXT
Graft Failure 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: JUN 19, 2008
HELP-PROMPT: Enter the date of Graft Failure.
DESCRIPTION: This is the date of Graft Failure and return to maintenance dialysis after successful kidney
transplant. System will also accept an entry for NS (No Study)
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,134 PANCREAS 11;1 SET
Pancreas
'S' FOR SPK;
'P' FOR PAK;
'N' FOR NO STUDY;
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter type of pancreas transplant.
DESCRIPTION: Occasionally, the kidney is transplanted together with the pancreas. SPK is a simultaneous pancreas
transplant and kidney transplant. Both organs would be from the same donor. PAK is a pancreas
transplant after a kidney transplant.
139.5,135 GLUCOSE AT TIME OF LISTING 11;2 FREE TEXT
Glucose at Time of Listing
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter value of Glucose at Time of Listing.
DESCRIPTION: Glucose is blood sugar. Blood glucose helps measure pancreas function. This is the blood glucose
level of organ recipient at the time of listing as a transplant candidate. Enter NS to represent
"No Study" if this information is not available.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,136 C-PEPTIDE AT TIME OF LISTING 11;3 FREE TEXT
C-peptide at Time of Listing
INPUT TRANSFORM: N SRX S SRX=X K:X'?.N.1".".2N!(X>9)!(X<0)!(X?.E1"."2.N) X S:"nsNS"[SRX X="NS" I $D(X) S:X?1".".N X=
"0"_X
LAST EDITED: MAY 24, 2011
HELP-PROMPT: Enter value of C-peptide at Time of Listing. (#.#)
DESCRIPTION: Definition Revised (2010): C-peptide is a peptide which is made when proinsulin is split into
insulin and c-peptide. Proinsulin is released from the pancreas into the blood in response to a
rise in serum glucose. Acceptable answers are numerical in the format of #.#. Enter NS to
represent "No Study" if this information is not available.
139.5,137 PANCREATIC DUCT ANASTOMOSIS 11;4 SET
Pancreatic Duct Anastomosis
'B' FOR BLADDER;
'E' FOR ENTERIC;
'NS' FOR NO STUDY;
LAST EDITED: JUN 04, 2008
HELP-PROMPT: Enter type of Pancreatic Duct Anastomosis.
DESCRIPTION: The pancreatic duct anastomosis refers to the anastomosis of the duodenal pouch, which is connected
to the pancreas, for drainage of the digestive enzymes. The anastomosis will be to the bladder, or
to the intestine (enteric).
139.5,138 GLUCOSE POST TRANSPLANT 11;5 FREE TEXT
Glucose Post Transplant
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter value of Glucose Post Transplant.
DESCRIPTION: Glucose is blood sugar. Blood glucose helps measure pancreas function. Enter the blood glucose
level of the organ recipient after transplant.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,139 AMYLASE POST TRANSPLANT 11;6 FREE TEXT
Amylase Post Transplant
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter value of Amylase Post Transplant.
DESCRIPTION: Amylase is an enzyme produced by the pancreas to help digest carbohydrates. It is measured by a
blood level. Enter the blood amylase level of the organ recipient after transplant. Enter NS to
represent "No Study" if this information is not available.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,140 LIPASE POST TRANSPLANT 11;7 FREE TEXT
Lipase Post Transplant
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter value of Lipase Post Transplant.
DESCRIPTION: Lipase is a fat digesting enzyme. It is primarily made in the pancreas. Enter the blood lipase
level of the organ recipient after transplant. Enter NS to represent "No Study" if this
information is not available.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,141 INSULIN REQ POST TRANSPLANT 11;8 SET
Insulin Required Post transplant
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: MAY 20, 2008
HELP-PROMPT: Enter status of Insulin Required Post Transplant.
DESCRIPTION: Insulin is a hormone made by the islet cells in the pancreas. It controls sugar in the blood by
moving it into the cells where it can be used for energy. Indicate if insulin treatment was
necessary after the transplant.
139.5,142 ORAL HYPOGLYCEMICS/POST TRANS 11;9 SET
Oral Hypoglycemics Required Post Transplant
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: JUN 04, 2008
HELP-PROMPT: Enter status of Oral Hypoglycemics Required Post Transplant.
DESCRIPTION: Oral hypoglycemics are oral medications taken to lower blood glucose levels. Indicate if oral
hypoglycemics were administered to lower blood glucose levels after the transplant.
139.5,143 PRA AT LISTING .01;3 NUMBER
PRA at Listing
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: APR 30, 2008
HELP-PROMPT: Enter a number between 0-99 representing the PRA at Listing of organ recipient with UNOS.
DESCRIPTION: Indicate the Panel Reactive Antibody of organ recipient at time of listing with UNOS. PRA
represents the percent of the U.S. population that the anti-human antibody in the organ recipient's
blood reacts with.
139.5,144 PRA AT TRANSPLANT .01;4 NUMBER
PRA at Transplant
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter a number between 0-99 representing the PRA at time of transplant.
DESCRIPTION: Indicate the Panel Reactive Antibody of organ recipient at time of transplant. PRA represents the
percent of the U.S. population that the anti-human antibody in the organ recipient's blood reacts
with.
139.5,145 HYPERTENSION REQUIRING MEDS .55;5 SET
Hypertension Requiring Meds
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter status of Hypertension Requiring Meds.
DESCRIPTION: Hypertension is characterized by high blood pressure repeatedly exceeding 140 over 90mm Hg - a
systolic pressure above 140 with a diastolic pressure above 90.
For heart transplant assessments, indicate if the patient has a documented history of hypertension
with or without current treatment of antihypertensive medication(s).
139.5,146 TRANSFUSION >4 RBC UNITS .55;6 SET
Transfusion >4 RBC Units
'Y' FOR YES;
'N' FOR NO;
'NS' FOR NO STUDY;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter YES if the patient required a transfusion of more than 4 units in 72 hours prior to surgery.
DESCRIPTION: 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.
139.5,147 *DIABETES MELLITUS .55;7 SET
*Diabetes Mellitus
'N' FOR NO;
'D' FOR DIET;
'O' FOR ORAL;
'I' FOR INSULIN;
LAST EDITED: JUL 12, 2011
HELP-PROMPT: Enter status of Diabetes Mellitus.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
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.
SCREEN: S DIC("S")="I $$F147^SRTPUTL($G(SRTPP,DA))"
EXPLANATION: Screen out DIET for Lung, Liver, and Kidney
139.5,148 REOPERATION FOR BLEEDING 10;12 SET
Reoperation for Bleeding
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter if patient required Reoperation for Bleeding.
DESCRIPTION: Definition Revised (2004): Indicate if there was any re-exploration of the thorax for suspected
bleeding within 30 days of surgery.
139.5,149 AMIODARONE USE .55;8 SET
Amiodarone Use
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter status of Amiodarone Use.
DESCRIPTION: Amiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias, both ventricular
and supraventricular arrhythmias. Indicate if the patient has a history of current or past use of
Amiodarone.
139.5,150 HEPARIN SENSITIVITY .55;9 SET
Heparin Sensitivity
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the status of Heparin Sensitivity.
DESCRIPTION:
Indicate if the patient has heparin sensitivity.
139.5,151 HYPERLIPIDEMIA HISTORY .55;10 SET
Hyperlipidemia History
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the status of Hyperlipidemia History.
DESCRIPTION: Indicate if the patient has a history of elevated cholesterol, as defined as a fasting LDL level >
160 mg/dL, a fasting triglyceride level > 200 mg/dL, or current/past use of drugs (statins, niacin,
fibrates) to treat elevated cholesterol levels.
139.5,152 VENTRICULAR TACHYCARDIA .55;11 SET
Ventricular Tachycardia
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the status of Ventricular Tachycardia.
DESCRIPTION: Indicate if the patient had rapid beating of the heart-paroxysmal tachycardia originating in an
ectopic focus in the ventricle.
139.5,153 PRIOR BLOOD TRANSFUSION .55;12 SET
Prior Blood Transfusion
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the status of Prior Blood Transfusion.
DESCRIPTION:
Indicate if the patient has ever received a transfusion of blood and/or blood products.
139.5,154 CREATININE ON TRANSPLANT DAY .55;13 NUMBER
Creatinine on Day of Transplant
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<.1)!(X?.E1"."2.N) X
LAST EDITED: JUN 30, 2008
HELP-PROMPT: Enter Creatinine results.
DESCRIPTION: Indicate the patient's Serum Creatinine result (mg/dl) preoperatively evaluated closest to
transplant surgery but not greater than 72 hours before surgery.
139.5,155 DILATED CARDIOMYOPATHY .1;27 SET
Dilated Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the status of Dilated Cardiomyopathy in organ recipient.
DESCRIPTION: Indicate whether the patient was diagnosed with dilated cardiomyopathy (DCM) as characterized by
dilation and impaired contraction of one or both ventricles - generally with an ejection fraction <
40%
139.5,156 CORONARY ARTERY DISEASE .11;1 SET
Coronary Artery Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the status of Coronary Artery Disease.
DESCRIPTION: Indicate if patient was diagnosed with coronary plaque formation or endothelial inflammation of the
lining of the coronary arteries.
139.5,157 ISCHEMIC CARDIOMYOPATHY .11;2 SET
Ischemic Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter the Ischemic Cardiomyopathy status of the organ recipient.
DESCRIPTION: Indicate if the patient was diagnosed with ischemic cardiomyopathy, primarily due to fixed or
non-fixed ischemic damage of the myocardium.
139.5,158 ALCOHOLIC CARDIOMYOPATHY .11;3 SET
Alcoholic Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the Alcoholic Cardiomyopathy status of the organ recipient.
DESCRIPTION:
Indicate if the patient was diagnosed with myocardial disease due to chronic alcoholism.
139.5,159 VALVULAR CARDIOMYOPATHY .11;5 SET
Valvular Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 07, 2008
HELP-PROMPT: Enter the Valvular Cardiomyopathy status of the organ recipient.
DESCRIPTION: Indicate if the patient was diagnosed with valvular cardiomyopathy thought to be secondary to
valvular disease, usually of the aortic or mitral valve.
139.5,160 IDIOPATHIC CARDIOMYOPATHY .11;6 SET
Idiopathic Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Idiopathic Cardiomyopathy status of the organ recipient.
DESCRIPTION:
Indicate if the patient was diagnosed with idiopathic cardiomyopathy.
139.5,161 VIRAL CARDIOMYOPATHY .11;7 SET
Viral Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Viral Cardiomyopathy status of the organ recipient.
DESCRIPTION: Indicate if the patient was diagnosed with viral cardiomyopathy. Viral infection is the most
common cause of myocarditis and has been implicated in the development of DCM. Viruses known to
involve the myocardium include Coxsackievirus, Influenza virus, Adenovirus, Echovirus,
Cytomegalovirus, and Human Immunodeficiency Virus.
139.5,162 PERIPARTUM CARDIOMYOPATHY .11;8 SET
Peripartum Cardiomyopathy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the Peripartum Cardiomyopathy status of the organ recipient.
DESCRIPTION: Indicate if the patient was diagnosed with cardiac failure in the period before, during, or after
pregnancy and delivery.
139.5,163 PVR BEFORE VASODILATION .01;5 NUMBER
PVR Before Vasodilation
INPUT TRANSFORM: D PVR^SRTPUTL
LAST EDITED: MAY 19, 2008
HELP-PROMPT: Enter PVR Before Vasodilation in Woods Unit.
DESCRIPTION: Indicate the patient's Pulmonary Vascular Resistance measured in Woods Units before vasodilation in
numerical format of #.# . Entering "NS" for "No Study/Unknown" is also allowed, if not applicable
and PVR (wood units) after Vasodilation is obtained.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,164 PVR AFTER VASODILATION .01;6 NUMBER
PVR After Vasodilation
INPUT TRANSFORM: D PVR^SRTPUTL
LAST EDITED: JUN 04, 2008
HELP-PROMPT: Enter PVR After Vasodilation in Woods Unit.
DESCRIPTION: Indicate the patient's Pulmonary Vascular Resistance measured in Woods Units after vasodilation.
Entering "NS" for "No Study/Unknown" is also allowed, if not applicable and PVR (wood units) before
Vasodilation is obtained.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,165 LVEF% .01;7 NUMBER
LVEF %
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
OUTPUT TRANSFORM: S Y=$S(+Y:Y_" %",1:Y)
LAST EDITED: MAY 14, 2008
HELP-PROMPT: Enter LVEF (Left Ventricular Ejection Fraction) percentage.
DESCRIPTION: Indicate the most recent pre-transplant Left Ventricular Ejection Fraction as measured by MUGA scan
or Echocardiogram.
139.5,166 PRA% .01;8 NUMBER
PRA %
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
OUTPUT TRANSFORM: S Y=$S(+Y:Y_" %",1:Y)
LAST EDITED: MAY 14, 2008
HELP-PROMPT: Enter PRA (Panel Reactive Antibody) percentage.
DESCRIPTION: Indicate the most recent T-cell and B-cell pre-transplant Percent Reactive Antibodies as measured
by flow cyometry.
139.5,167 PA SYSTOLIC PRESSURE 0;6 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: JUN 18, 2008
HELP-PROMPT: Enter PA Systolic Pressure from -30 to 150 mm HG.
DESCRIPTION: 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
139.5,168 PAW MEAN PRESSURE 0;7 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: JUN 18, 2008
HELP-PROMPT: Enter PAW Mean Pressure from -15 to 80 mm HG.
DESCRIPTION: 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
139.5,169 FEV1 .55;14 FREE TEXT
FEV1
INPUT TRANSFORM: N SRX S SRX=X K:+X'=X!(X>9.9)!(X<1)!(X?.E1"."2.N) X S:SRX="NS"!(SRX="ns") X="NS"
LAST EDITED: JUN 19, 2008
HELP-PROMPT: Enter value of FEV1 in Liters.
DESCRIPTION: Indicate the amount of forced expiratory volume in one second from the most recent pulmonary
function test prior to surgery. Enter 'NS' for No Study if there has been no FEV1 measured in the
year preceding surgery.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,170 DATE OF DEATH 10;19 FREE TEXT
Date/Time of Death
INPUT TRANSFORM: N SRX S SRX=X,%DT="EPT" D ^%DT S X=Y K:Y<1!(DT3 MONTHS PRIOR TO SURGERY (REMOTE SMOKER);
LAST EDITED: SEP 01, 2011
HELP-PROMPT: Enter Current Smoker status.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
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 w/i 2 weeks prior to surgery
3 = Smoking w/i 2 weeks to 3 months prior to surgery
4 = Remote Smoker (more than 3 months prior to surgery)
139.5,172 PRIOR MI .55;16 SET
Prior MI
'0' FOR NONE;
'1' FOR LESS THAN OR EQUAL 7 DAYS OF SURG;
'2' FOR GREATER THAN 7 DAYS PRIOR TO SURG;
LAST EDITED: AUG 11, 2008
HELP-PROMPT: Enter the category that most accurately reflects the patient's most recent Myocardial Infarction.
DESCRIPTION: Indicate whether the patient has a history of a non-Q-wave or Q-wave myocardial infarction as
diagnosed in his or her medical records. Myocardial infarction may be indicated by the presence of
one of the following: 1) typical rise and fall in biochemical markers, 2) cardiac pain, 3) typical
ECG changes (new Q-waves, ST segment elevation or depression). In the absence of the above
supporting data, a clear statement or diagnosis of prior myocardial infarction in the chart will
suffice; however, the patient's statement, "I've had a heart attack" is insufficient evidence.
Indicate the one appropriate response:
None - The patient has never had a previous Myocardial Infarction.
<=7 days of surg - The patient had a previous Myocardial Infarction
within 7 days prior to surgery.
>7 days prior to surg - The patient had a Myocardial Infarction more
than 7 days prior to surgery."
The field for PRIOR MI shall be added to the data entry option for Non-VA heart transplant
assessments.
139.5,173 NUM OF PRIOR HEART SURGERIES .55;17 SET
Number of Prior Heart Surgeries
'0' FOR None;
'1' FOR 1;
'2' FOR 2;
'3' FOR 3;
'>' FOR >3;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Enter Number of Prior Heart Surgeries.
DESCRIPTION: 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.
139.5,174 *CEREBRAL VASCULAR DISEASE .55;18 SET
*Cerebral Vascular Disease
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 20, 2011
HELP-PROMPT: Enter status of Cerebral Vascular Disease.
DESCRIPTION: This field has been flagged as obsolete for VASQIP. It should no longer be used.
Indicate if the patient has cerebral vascular disease, defined as 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. (NOTE: Stroke should be broadly interpreted to include intracerebral or subarachnoid
bleeding.)
139.5,175 CONGESTIVE HEART FAILURE .55;19 SET
Congestive Heart Failure (CHF)
'1' FOR Class I;
'2' FOR Class II;
'3' FOR Class III;
'4' FOR Class IV;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter class of Congestive Heart Failure (NYHA Functional Class).
DESCRIPTION: Indicate whether the patient has congestive heart failure if the patient chart or patient
self-report indicates a history of congestive heart failure within the 30 days before surgery.
Congestive heart failure is defined as the inability of the heart to pump a sufficient quantity of
blood to meet the metabolic needs of the body or can do so only at increased ventricular filling
pressure. Common manifestations are identified:
From the history: 1) Abnormal limitation in exercise tolerance due to dyspnea, fatigue
or angina.
2) Orthopnea (dyspnea on lying supine).
3) Paroxysmal nocturnal dyspnea (PND) - awakening from sleep with
dyspnea which is relieved by assuming an upright posture).
From the physical examination: 4) Increased jugular venous pressure.
5) Pulmonary rales on physical examination.
From the chest x-ray: 6) Cardiomegaly, and
7) Pulmonary vascular engorgement.
The New York Heart Association functional classification is commonly used as a subjective
assessment of the severity of congestive heart failure. If none of the above manifestations have
been present or congestive heart failure is not mentioned as an active problem in the 30 days
before surgery, indicate Class I. Any mention of above manifestations requires the indication of a
stage other than Class I. Indicate the one most appropriate response:
Class I - cardiac disease, 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.
139.5,176 IV NTG WITHIN 48 HOURS .55;20 SET
IV NTG within 48 Hours
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Did patient receive intravenous (IV) nitroglycerin (NTG) within 48 hours preceding surgery?
DESCRIPTION: Indicate if the patient was administered nitroglycerin intravenously within 48 hours prior to
surgery.
139.5,177 CURRENT DIGOXIN USE .55;21 SET
Current Digoxin Use
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter status of Current Digoxin Use.
DESCRIPTION: Indicate if the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin, etc.) within
the two weeks prior to surgery.
139.5,178 CURRENT DIURETIC USE .55;22 SET
Current Diuretic Use
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter status of Current Diuretic Use.
DESCRIPTION:
Indicate if the patient has used any diuretic preparation within the two weeks prior to surgery.
139.5,179 PREOP CIRCULATORY DEVICE .55;23 SET
Preoperative Circulatory Device
'N' FOR NONE;
'I' FOR IABP;
'V' FOR VAD;
'A' FOR ARTIFICIAL HEART;
'O' FOR OTHER;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Enter status of Preoperative Use of New Mechanical Circulatory Device within 2 Weeks of Surgery.
DESCRIPTION: Indicate whether there was any use of any device to assist ventricular function at the time the
patient presents for surgery. 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 - Another type of Mechanical Circulatory Device was placed.
139.5,181 ASSESSMENT STATUS RA;1 SET
Assessment Status
'I' FOR INCOMPLETE;
'C' FOR COMPLETE;
'T' FOR TRANSMITTED;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter the current status of this transplant 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: AF (#549)
139.5,182 TRANSPLANT TYPE RA;2 SET
Transplant Type
'K' FOR KIDNEY;
'LI' FOR LIVER;
'LU' FOR LUNG;
'H' FOR HEART;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: The Transplant Type is the name of the organ transplanted.
DESCRIPTION: The Transplant Type is the name of the organ transplanted. This field only allows selection of
KIDNEY, LIVER, LUNG, or HEART.
RECORD INDEXES: AF (#549)
139.5,183 RE-TRANSMISSION RA;3 SET
Re-Transmission
'0' FOR NOT RE-TRANSMITTED;
'1' FOR RE-TRANSMITTED;
LAST EDITED: JUL 09, 2008
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.
139.5,184 DATE TRANSMITTED RA;4 DATE
Date Transmitted
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:Y<1 X
LAST EDITED: FEB 25, 2008
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.
139.5,185 VA/NON VA INDICATOR RA;5 SET (Required)
VA or Non-VA Indicator
'V' FOR VA;
'N' FOR NON-VA;
LAST EDITED: JUL 08, 2008
HELP-PROMPT: Indicate whether the transplant was performed in a VA or Non-VA facility.
DESCRIPTION:
This field indicates whether the transplant was performed in VA facility or Non-VA facility.
139.5,187 DATE STARTED DIALYSIS .01;1 FREE TEXT
Date Started Dialysis
INPUT TRANSFORM: N SRX S SRX=X,%DT="EP" 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: AUG 27, 2008
HELP-PROMPT: Enter the date patient began dialysis.
DESCRIPTION: Indicate date that patient began renal replacement therapy due to renal failure. System will also
accept an entry for NS (No Study).
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
139.5,188 DATE OF LAST TRANSMISSION RA;8 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:X<1 X
LAST EDITED: MAY 22, 2008
HELP-PROMPT: (No range limit on date)
DESCRIPTION: This is the date of the retransmission if this assessment has been retransmitted to the national
database. If there was no retransmission of this assessment, this is the date of the original
transmission.
CROSS-REFERENCE: 139.5^AT^MUMPS
1)= D AT^SRTPUTL
2)= D KAT^SRTPUTL
This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases
by the DATE OF LAST TRANSMISSION field.
139.5,189 TRACHEOSTOMY 10;14 SET
Tracheostomy
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JUL 09, 2008
HELP-PROMPT: Enter status of Tracheostomy for organ recipient.
DESCRIPTION: 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 postoperatively.
139.5,190 MEDIASTINITIS 10;15 SET
Mediastinitis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter status of Mediastinitis for organ recipient.
DESCRIPTION: 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.
139.5,191 RENAL FAILURE REQ. DIALYSIS 10;16 SET
Renal Failure Requiring Dialysis
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 31, 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.
139.5,192 PERIOPERATIVE MI 10;17 SET
Perioperative MI
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 31, 2011
HELP-PROMPT: Enter YES if the patient has had a myocardial infarction.
DESCRIPTION: VASQIP Definition (2011): Indicate the presence of a peri-operative MI that occurs either
intraoperatively or postoperatively within 30 days:
Non-Cardiac Surgery: A new transmural acute myocardial infarction as manifested by new Q-waves on
ECG. (Non-Q-wave infarctions should be entered under "Other Occurrence").
Cardiac Surgery: A new transmural acute myocardial infarction as manifested by at least one of the
following criteria: 1. Development of new Q-waves in two or more contiguous ECG leads; 2.
Evolutionary ST-segment elevations; 3. New or presumably new LBBB pattern on the ECG.
139.5,193 OPERATIVE DEATH 10;18 SET
Operative Death
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: APR 08, 2008
HELP-PROMPT: Indicate if patient died within 30 days of transplant surgery.
DESCRIPTION: 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).
139.5,197 PLASMAPHERESIS .01;2 SET
Plasmapheresis
'1' FOR BEFORE TRANSPLANT;
'2' FOR AFTER TRANSPLANT ;
'3' FOR BOTH;
'4' FOR NO;
LAST EDITED: APR 09, 2008
HELP-PROMPT: Enter the status of Plasmapheresis treatment for organ recipient.
DESCRIPTION: Plasmapheresis is the procedure of removing, treating, and returning of plasma from blood
circulation. It is an extracorporeal therapy.
139.5,198 TOBACCO USE .55;24 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^139.5^199
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRT(D0,.55)):^(.55),1:"") S X=$P(Y(1),U,25),X=X S D
IU=X K Y S X=DIV S X=$S(X<3:"NA",1:"") S DIH=$G(^SRT(DIV(0),.55)),DIV=X S $P(^(.55),U,25)=DIV,DIH=1
39.5,DIG=199 D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^SRT(D0,.55)):^(.55),1:"") S X=$P(Y(1),U,25),X=X S D
IU=X K Y S X="" S DIH=$G(^SRT(DIV(0),.55)),DIV=X S $P(^(.55),U,25)=DIV,DIH=139.5,DIG=199 D ^DICR
CREATE VALUE)= S X=$S(X<3:"NA",1:"")
DELETE VALUE)= @
FIELD)= TOBACCO USE TIMEFRAME
Trigger to set the TOBACCO USE TIMEFRAME field (#199) to "NA" for NOT APPLICABLE if the TOBACCO USE
field (#198) is set to a value less than 3.
139.5,199 TOBACCO USE TIMEFRAME .55;25 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 CHK199^SRTPUTL
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 TRANSPLANT ASSESSMENTS File
139.5,200 DIABETES MELLITUS CHRONIC .55;26 SET
Diabetes Mellitus: Chronic, Long-term Management
'1' FOR NO;
'2' FOR DIET;
'3' FOR ORAL;
'4' FOR INSULIN;
LAST EDITED: SEP 23, 2011
HELP-PROMPT: Enter appropriate code for chronic, long-term Diabetes Mellitus management.
DESCRIPTION: VASQIP Definitions (2011): 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 - a diagnosis of diabetes requiring therapy with an oral
hypoglycemic agent
Insulin - a diagnosis of diabetes requiring daily insulin therapy
139.5,201 DIABETES MELLITUS PREOP MGMT .55;27 SET
Diabetes Mellitus: Management Prior to Surgery
'1' FOR NO;
'2' FOR DIET;
'3' FOR ORAL;
'4' FOR INSULIN;
LAST EDITED: SEP 23, 2011
HELP-PROMPT: Enter appropriate code for management of Diabetes Mellitus in the two weeks prior to surgery.
DESCRIPTION: VASQIP Definitions (2011): Indicate the treatment regimen for patients with a diagnosis 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 in the
two weeks preceding surgery
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
139.5,202 CVD REPAIR/OBSTRUCTION .55;28 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)
139.5,203 HISTORY OF CVD .55;29 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)
FILES POINTED TO FIELDS
INSTITUTION (#4) DIVISION (#63)
PATIENT (#2) PATIENT (#.01)
SURGERY (#130) SURGERY CASE (#2)
File #139.5
Record Indexes:
AD (#547) RECORD MUMPS IR ACTION
Short Descr: Auto-populate the TOTAL ISCHEMIA TIME FOR ORGAN field (#89).
Description: This cross-reference is to auto-populate TOTAL ISCHEMIA TIME FOR ORGAN field (#89) based on what was entered
for Warm and Cold Ischemia fields. The Total Ischemia is the sum of warm ischemia time and cold ischemia time.
Set Logic: S $P(^SRT($S($D(SRTPP):SRTPP,1:DA),3),"^",6)=X2(1)+X2(2)
Set Cond: S X=(X2(1)'="")&(X2(2)'="")
Kill Logic: Q
Kill Cond: S X=0
Whole Kill: Q
X(1): WARM ISCHEMIA TIME FOR ORGAN (139.5,85) (forwards)
X(2): COLD ISCHEMIA TIME FOR ORGAN (139.5,87) (forwards)
AE (#548) RECORD REGULAR IR SORTING ONLY
Short Descr: This is a sort only index of the VACO ID & PATIENT fields.
Set Logic: S ^SRT("AE",X(1),X(2),DA)=""
Kill Logic: K ^SRT("AE",X(1),X(2),DA)
Whole Kill: K ^SRT("AE")
X(1): VACO ID (139.5,3) (Subscr 1) (forwards)
X(2): PATIENT (139.5,.01) (Subscr 2) (forwards)
AF (#549) RECORD REGULAR IR SORTING ONLY
Short Descr: This is a sort index of the TRANSPLANT TYPE, ASSESSMENT STATUS & DFN
Description: This cross reference lists transplant assessments according to their type, their assessment status, the
patient's DFN and the internal entry number (IEN) in the SURGERY TRANSPLANT ASSESSMENTS file (#139.5). This
cross reference is used by the transmission routine SRTPMIT to identify which transplant assessments are
COMPLETE and thus ready for transmission. The cross reference list of assessments is updated when the
ASSESSMENT STATUS field (#181) is changed.
Set Logic: S ^SRT("AF",X(1),X(2),X(3),DA)=""
Set Cond: S X=(X(1)'="")
Kill Logic: K ^SRT("AF",X(1),X(2),X(3),DA)
Kill Cond: S X=(X(1)'="")
Whole Kill: K ^SRT("AF")
X(1): TRANSPLANT TYPE (139.5,182) (Subscr 1) (forwards)
X(2): ASSESSMENT STATUS (139.5,181) (Subscr 2) (forwards)
X(3): PATIENT (139.5,.01) (Subscr 3) (forwards)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):