STANDARD DATA DICTIONARY #694.5 -- CARDIAC SURGERY RISK ASSESSMENT FILE 6/27/25 PAGE 1
STORED IN ^MCAR(694.5, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.3)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
-----------------------------------------------------------------------------------------------------------------------------------
This file holds data for use on Surgical Risk Assessment form.
DD ACCESS: @
AUDIT ACCESS: @
IDENTIFIED BY: PATIENT (#1)[R], DATE/TIME SURGERY BEGAN (#76)
CROSS
REFERENCED BY: HT (CM)(AC), HT (IN)(AD), WT (LBS)(AE), WT (KG)(AF), PHYSICIAN'S ESTIMATE(AG), DATE OF PHYSICIAN'S ESTIMATE(B),
PATIENT(C)
694.5,.01 DATE OF PHYSICIAN'S ESTIMATE 0;1 DATE (Required)
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date of completion of physician's estimate of operative mortality
DESCRIPTION:
The Date of Completion of Physician's Estimate of Operative Mortality
CROSS-REFERENCE: 694.5^B
1)= S ^MCAR(694.5,"B",$E(X,1,30),DA)=""
2)= K ^MCAR(694.5,"B",$E(X,1,30),DA)
694.5,1 PATIENT 0;2 POINTER TO MEDICAL PATIENT FILE (#690) (Required)
LAST EDITED: AUG 16, 1989
HELP-PROMPT: Enter the patient's name
DESCRIPTION:
This field identifies the patient's name.
CROSS-REFERENCE: 694.5^C
1)= S ^MCAR(694.5,"C",$E(X,1,30),DA)=""
2)= K ^MCAR(694.5,"C",$E(X,1,30),DA)
This cross-reference allow looks-up by Patient.
694.5,2 HOSPITAL OF SURGERY 0;3 POINTER TO INSTITUTION FILE (#4)
HELP-PROMPT: Enter the Hospital where Surgery is to be performed.
DESCRIPTION:
This field identifies the Hospital where Surgery is to be performed.
694.5,3 AGE 0;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<15)!(X?.E1"."1N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 15 and 99, 0 Decimal Digits
DESCRIPTION:
This field identifies the patient's age, between 15 and 99.
694.5,4 HT (IN) 0;5 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>86)!(X<48)!(X?.E1"."1N.N) X
LAST EDITED: AUG 16, 1989
HELP-PROMPT: Enter the Height of the Patient in inches, 48-86
DESCRIPTION:
HEIGHT OF THE PATIENT IN INCHES
CROSS-REFERENCE: 694.5^AD^MUMPS
1)= D RISK^MCARBSA
2)= S:$P(^MCAR(694.5,DA,0),U,6)="" $P(^MCAR(694.5,DA,0),U,9)=""
This cross-reference computes the patient's body surface area from the patient's height and weight
and inserts the computed value into the BODY SURFACE AREA field (#8).
694.5,5 HT (CM) 0;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>218)!(X<122)!(X?.E1"."1N.N) X
LAST EDITED: AUG 16, 1989
HELP-PROMPT: Enter the height of the patient in centimeters,122-218
DESCRIPTION:
Height of the patient in centimeters.
CROSS-REFERENCE: 694.5^AC^MUMPS
1)= D RISK^MCARBSA
2)= S:$P(^MCAR(694.5,DA,0),U,5)="" $P(^MCAR(694.5,DA,0),U,9)=""
This cross-reference computes the patient's body surface area from the patient's height and weight
and inserts the computed value into the BODY SURFACE AREA field (#8).
694.5,6 WT (LBS) 0;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>400)!(X<40)!(X?.E1"."1N.N) X
LAST EDITED: AUG 16, 1989
HELP-PROMPT: Enter the Weight of the Patient in Lbs,40-400
DESCRIPTION:
This field identifies the Patient in pounds.
CROSS-REFERENCE: 694.5^AE^MUMPS
1)= D RISK^MCARBSA
2)= S:$P(^MCAR(694.5,DA,0),U,8)="" $P(^MCAR(694.5,DA,0),U,9)=""
This cross-reference computes the patient's body surface area from the patient's height and weight
and inserts the computed value into the BODY SURFACE AREA field (#8).
694.5,7 WT (KG) 0;8 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>240)!(X<24)!(X?.E1"."1N.N) X
LAST EDITED: AUG 16, 1989
HELP-PROMPT: Type a Number between 24 and 240, 0 Decimal Digits
DESCRIPTION:
This field identifies the weight of the Patient in kilograms.
CROSS-REFERENCE: 694.5^AF^MUMPS
1)= D RISK^MCARBSA
2)= S:$P(^MCAR(694.5,DA,0),U,7)="" $P(^MCAR(694.5,DA,0),U,9)=""
This cross-reference computes the patient's body surface area from the patient's height and weight
and inserts the computed value into the BODY SURFACE AREA field (#8).
694.5,8 BODY SURFACE AREA 0;9 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."3N.N) X
LAST EDITED: AUG 16, 1989
HELP-PROMPT: In Square Meters--This is computed automatically from Weight and Height
DESCRIPTION:
Body surface area in square meters, computed from weight and height.
UNEDITABLE
694.5,20 DIABETES 1;1 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'Yes' indicates Glucose Intolerance Requiring Treatment With Oral Hypoglycemic Agents or Insulin
Within 30 Days Preceding Heart Surgery
DESCRIPTION: A 'Yes' indicates Glucose Intolerance Requiring Treatment with Oral Hypoglycemic Agents or Insulin
within 30 days Preceding Heart Surgery
694.5,21 COPD 1;2 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'Yes' indicates Chronic Obstructive Pulmonary Disease Resulting in Functional Disability, and/or
Hospitalization, and/or Requiring Bronchodilator Therapy, and/or FEV1>75% of Predicted
DESCRIPTION: A 'Yes' indicates Chronic Obstructive Pulmonary Disease Resulting in Functional Disability, and/or
Hospitalization, and/or Requiring Bronchodilator Therapy, and/or FEV1>75% of Predicted.
694.5,22 CIGARETTE SMOKING (PACK YEARS) 1;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>500)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: In Pack-Years, average number of packs per day times years smoked. (Do not include Pipe,Cigar
Smoking, or Chewing Tobacco)
DESCRIPTION: In Pack-Years, average number of packs per day times year smoked. (Do not include Pipe, Cigar
Smoking, or Chewing Tobacco).
694.5,23 CURRENT SMOKER 1;4 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates the Patient is a Current Smoker
DESCRIPTION:
'Yes' indicates the patient is a current smoker.
694.5,24 ACTIVE ENDOCARDITIS 1;5 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' if 2 or More Positive Blood Cultures,or New Vegetations, or Acute Valve Dysfunction of
Infectious Cause, or On Antibiotic RX for Endocarditis within 2 weeks preceeding Surgery
DESCRIPTION: 'Yes' if 2 or More positive blood cultures, or new vegetations, or acute valve dysfunction of
infectious cause, or on antibiotic RX for endocarditis within 2 weeks preceding surgery.
694.5,25 I.V. NTG PREOPERATIVELY 1;6 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates I.V. Nitroglycerine Administered within 48 Hours Preceding Surgery
DESCRIPTION:
'Yes' indicates I.V. Nitroglycerine administered within 48 hours preceding surgery.
694.5,26 ANGIOPLASTY 1;7 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates Percutaneous Transluminal Coronary Angioplasty Performed or Attempted Within the 24
Hours Preceding Surgery.
DESCRIPTION: 'Yes' indicates Percutaneous Transluminal Coronary Angioplasty performed or attempted within the 24
hours preceding surgery.
694.5,27 PRIOR HEART SURGERY 1;8 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates any form or Prior Heart Surgery Performed through a Thoracotomy During Separate,
Preceding Hospitalization
DESCRIPTION: 'Yes' indicates any form of Prior Heart Surgery performed through a Thoracotomy during separate,
preceding hospitalization.
694.5,28 HISTORY OF CHF 1;9 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates Symptoms of Pulmonary Congestion or Low Cardiac Output Requiring Therapy with
Digitalis, and/or Diuretic, and/or an ACE Inhibitor
DESCRIPTION: 'Yes' indicates symptoms of Pulmonary Congestion or Low Cardiac Output Requiring Therapy with
Digitalis, and/or Diuretic, and/or an ACE Inhibitor
694.5,29 CURRENT DIGITALIS USE 1;10 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates Use of any Digitalis Preparation (Digoxin, Lanoxin,Digitoxin,etc.) within 2 weeks
preceding surgery
DESCRIPTION: 'Yes' indicates use of any Digitalis preparation (Digoxin, Lanoxin, Digitoxin, etc.) within 2 weeks
preceding surgery.
694.5,30 CURRENT DIURETIC USE 1;11 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates Use of any Diuretic agent with 2 weeks preceding surgery
DESCRIPTION:
'Yes' indicates use of any Diuretic agent within 2 weeks preceding surgery.
694.5,31 PERIPHERAL VASCULAR DISEASE 1;12 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates Obstruction of Arteries to Legs Resulting in Symptoms, and/or Surgery, and/or
Angiographically Demonstrated Stenosis => 50%
DESCRIPTION: 'Yes' indicates obstruction of Arteries to Legs resulting in Symptoms, and/or Surgery, and/or
Angiographically demonstrated Stenosis=>50%.
694.5,32 CEREBRAL VASCULAR DISEASE 1;13 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates History of TIA, nonembolic stroke, or angiographic evidence of cerebral arterial
obstruction => 50%, or Ulcerated plaque
DESCRIPTION: 'Yes' indicates history of TIA, nonembolic stroke, or angiographic evidence of cerebral arterial
obstruction => 50%, or Ulcerated plaque.
694.5,33 PRIOR MYOCARDIAL INFARCTION 1;14 SET
'1' FOR OCCURED WITHIN 24 HRS OF SURGERY;
'2' FOR OCCURED BETWEEN 24 HRS AND 7 DAYS OF SURGERY;
'3' FOR OCCURED BETWEEN 7 DAYS AND NOT MORE THAN 30 DAYS OF SURGERY;
'4' FOR OCCURED GREATER THAN 30 DAYS OF SURGERY;
HELP-PROMPT: Enter 1-4 if two of the following occured: 1)Typical Pain,2) Enzyme Rise and Fall, and 3) New
Q-waves on the electrocardiogram
DESCRIPTION: Enter 1-4 if two of the following occurred: 1)Typical Pain, 2)Enzyme Rise and Fall, and 3) New
Q-waves on the electrocardiogram.
694.5,33.5 PRIOR MI 4;13 SET
'1' FOR None;
'2' FOR < or equal to 7 days of surg.;
'3' FOR > 7 days of surg.;
LAST EDITED: MAY 16, 1990
HELP-PROMPT: Enter a code from 1-3, or ?? for further HELP.
DESCRIPTION: Enter 1 did not occur:
2 occured within a week before surgery:
3 occured more than a week before surgery
if two of the following occurred: a) Typical Pain, b) Enzyme Rise and Fall, and c) New Q-waves on
the electrocardiogram.
694.5,34 PREOPERATIVE IABP 1;15 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates intraaortic balloon pump (IABP) in use at sometime during the 48 hours preceding
surgery
DESCRIPTION: 'Yes' indicates intra-aortic balloon pump (IABP) in use at some time during the 48 hours preceding
surgery.
694.5,35 UNSTABLE ANGINA 1;16 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 15, 1990
HELP-PROMPT: 'YES' Indicates angina occuring at rest or prolonged angina unresponsive to nitroglycerine
DESCRIPTION:
'Yes' indicates angina occurring at rest or prolonged angina unresponsive to nitroglycerine.
694.5,36 NYHA FUNCTIONAL CLASS 1;17 SET
'1' FOR NO SYMPTOMS AT ANY LEVEL OF ACTIVITY;
'2' FOR SYMPTOMS ON MORE THAN ORDINARY ACTIVITY;
'3' FOR SYMPTOMS ON ACTIVITIES OF DAILY LIVING;
'4' FOR SYMPTOMS AT REST;
LAST EDITED: MAY 16, 1990
HELP-PROMPT: Enter the one response that most closely reflects the patient's limitation from heart disease in 2
weeks preceding surgery
DESCRIPTION: The following functional classes are defined :
I - heart disease with no symptoms limiting activity
II - slight limitation of physical activity by fatigue, dyspnea,
or angina
III - marked limitation of physical activity by fatigue, dyspnea,
or angina, but no symptoms at rest
IV - symptoms at rest and/or inability to carry out any physical
activity without symptoms of dyspnea, fatigue, or angina
694.5,37 HYPERTENSION 1;18 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates any history of hypertension requiring therapy, and/or 2 or more blood pressures >
140/95
DESCRIPTION: 'Yes' indicates any history of hypertension requiring therapy, and/or 2 or more blood pressures >
140/95.
694.5,38 PULMONARY RALES 1;19 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates rales heard at lung base(s) not clearing with cough and not due to pneumonic
process within 2 weeks of surgery
DESCRIPTION: 'Yes' indicates rales heard at lung base(s) not clearing with cough and not due to pneumonic
process within 2 weeks of surgery.
694.5,39 RESTING ST-SEGMENT DEPRESSION 1;20 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates horizontal or downsloping ST-segment depression on the resting electrocardiogram =>
0.5 mm within 2 weeks of surgery
DESCRIPTION: 'Yes' indicates horizontal or downsloping ST-segment depression on the resting electrocardiogram =>
0.5 mm within 2 weeks of surgery.
694.5,40 CARDIOMEGALY BY CHEST X-RAY 1;21 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates overall cardiac enlargement, and/or cardiothoracic ration => 0.5 on chest x-ray
within the 30 days preceding surgery
DESCRIPTION: 'Yes' indicates overall cardiac enlargement, and/or cardiothoracic ration => 0.5 on chest x-ray
within the 30 days preceding surgery.
694.5,41 PLEURAL EFFUSION 1;22 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' Indicates pleural effusion on any chest x-ray in the month preceding surgery
DESCRIPTION:
'Yes' indicates pleural effusion on any chest x-ray in the month preceding surgery.
694.5,42 SERUM CREATININE (MG/DL) 1;23 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>20)!(X<0)!(X?.E1"."2N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 20, 1 Decimal Digit
DESCRIPTION:
This field identifies a number between 0 and 20, 1 decimal digit.
694.5,43 ROOM AIR PaO2 1;24 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>105)!(X<20)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the partial pressure of oxygen (in mm Hg) of oxygen in arterial blood while breathing room
air for => 15 minutes (20-105)
DESCRIPTION: This field identifies the partial pressure of oxygen (in mm Hg) of oxygen in arterial blood while
breathing room air for => 15 minutes (20-105).
694.5,44 FEV1 1;25 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<10)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the forced expired volume in 1 second (FEV1) expressed as % of predicted normal value
measured within the 6 months preceding surgery (10-100)
DESCRIPTION: This field identifies the forced expired volume in 1 second (FEV1) expressed as % of predicted
normal value measured within the 6 months preceding surgery (10-100).
694.5,45 LV SYSTOLIC PRESSURE (mm Hg) 2;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>240)!(X<40)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the Left Ventricular Systolic pressure measured at the catherization most closely preceding
surgery. Use the 1 most closely reflecting basal conditions (40-240)
DESCRIPTION: This field identifies the Left Ventricular Systolic pressure measured at the catheterization most
closely preceding surgery. Use the 1 most closely reflecting basal conditions (40-240).
694.5,46 AORTIC SYSTOLIC PRESSURE 2;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>300)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 300, 0 Decimal Digits
DESCRIPTION:
This field identifies a number between 0 and 300, 0 decimal digits.
694.5,47 PA SYSTOLIC PRESSURE (MM HG) 2;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>150)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 150, 0 Decimal Digits
DESCRIPTION:
This field identifies a number between 0 and 150, 0 decimal digits.
694.5,48 MEAN PA WEDGE PRESSURE (MM HG) 2;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 99, 0 Decimal Digits
DESCRIPTION:
This field identifies a number between 0 and 99, 0 decimal digits.
694.5,49 MEAN RA PRESSURE (mm Hg) 2;5 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>40)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Average right atrial pressure measured at the catherization most closely preceding surgery. Use the
1 most closely reflecting basal conditions (0-40)
DESCRIPTION: This field identifies the average right atrial pressure measured at the catheterization most
closely preceding surgery. Use the 1 most closely reflecting basal conditions (0-40).
694.5,50 LV END-DIASTOLIC PRESSURE 2;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 99, 0 Decimal Digits
DESCRIPTION:
This field identifies a number between 0 and 99, 0 decimal digits.
694.5,60 LV EJECTION FRACTION 3;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>.99)!(X<.02)!(X?.E1"."3N.N) X
HELP-PROMPT: Left Ventricular ejection fraction measured by catherization,jradionuclide angiogram (MUGA), or
echo within 6 months preceding surgery (.02-.99)
DESCRIPTION: This field identifies the left ventricular ejection fraction measures by catheterization,
radionuclide angiogram (MUGA), or echo within 6 months preceding surgery (.02 - .99).
694.5,61 PROXIMAL ANTERIOR SEGMENT 3;2 SET
'1' FOR NORMAL MOTION;
'2' FOR MILD HYPOKINESIS;
'3' FOR SEVERE HYPOKINESIS;
'4' FOR AKINESIS;
'5' FOR DYSKINESIS;
'6' FOR FRANK ANEURYSM;
HELP-PROMPT: Score right anterior oblique contrast angiogram or apical 2 chamber 2D echo view: 1-6
DESCRIPTION: This field identifies the score of the right anterior oblique contrast angiogram or apical 2
chamber 2D echo view: 1-6.
694.5,62 MIDANTERIOR SEGMENT 3;3 SET
'1' FOR NORMAL MOTION;
'2' FOR MILD HYPOKINESIS;
'3' FOR SEVERE HYPOKINESIS;
'4' FOR AKINESIS;
'5' FOR DYSKINESIS;
'6' FOR FRANK ANEURYSM;
HELP-PROMPT: Score right anterior oblique contrast angiogram or apical 2 chamber 2D echo view: 1-6
DESCRIPTION: This field identifies the score of the right anterior oblique contrast angiogram or apical 2
chamber 2D echo view: 1-6.
694.5,63 APEX 3;4 SET
'1' FOR NORMAL MOTION;
'2' FOR MILD HYPOKINESIS;
'3' FOR SEVERE HYPOKINESIS;
'4' FOR AKINESIS;
'5' FOR DYSKINESIS;
'6' FOR FRANK ANEURYSM;
HELP-PROMPT: Score right anterior oblique contrast angiogram or apical 2 chamber 2D echo view: 1-6
DESCRIPTION: This field identifies the score of the right anterior oblique contrast angiogram or apical 2
chamber 2D echo view: 1-6.
694.5,64 MIDINFERIOR SEGMENT 3;5 SET
'1' FOR NORMAL MOTION;
'2' FOR MILD HYPOKINESIS;
'3' FOR SEVERE HYPOKINESIS;
'4' FOR AKINESIS;
'5' FOR DYSKINESIS;
'6' FOR FRANK ANEURYSM;
HELP-PROMPT: Score right anterior oblique contrast angiogram or apical 2 chamber 2D echo view: 1-6
DESCRIPTION: This field identifies the score of the right anterior oblique contrast angiogram or apical 2
chamber 2D echo view: 1-6.
694.5,65 PROXIMAL INFERIOR SEGMENT 3;6 SET
'1' FOR NORMAL MOTION;
'2' FOR MILD HYPOKINESIS;
'3' FOR SEVERE HYPOKINESIS;
'4' FOR AKINESIS;
'5' FOR DYSKINESIS;
'6' FOR FRANK ANEURYSM;
HELP-PROMPT: Score right anterior oblique contrast angiogram or apical 2 chamber 2D echo view: 1-6
DESCRIPTION: This field identifies the score of the right anterior oblique contrast angiogram or apical 2
chamber 2D echo view: 1-6.
694.5,66 LEFT MAIN CORONARY STENOSIS 4;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Give % reduction in luminal diameter of most severe stenosis (0-100)
DESCRIPTION:
This gives % reduction in luminal diameter of most severe stenosis (0-100)
694.5,66.5 NUMBER OF MAJOR CORONARIES 4;14 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>3)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAY 23, 1994
HELP-PROMPT: Type a Number between 0 and 3, 0 Decimal Digits
DESCRIPTION:
This gives number of major coronary arteries (LAD), right with PDA.
694.5,67 LEFT ANT. DESC. STENOSIS 4;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Give % reduction in luminal diameter of most severe stenosis (0-100)
DESCRIPTION:
This gives % reduction in luminal diameter of most severe stenosis (0-100)
694.5,68 LEFT ANT. DESC. DISTAL DISEASE 4;3 SET
'0' FOR NO SIGNIFICANT DISTAL DISEASE (< 20% DIAMETER REDUCTION);
'2' FOR MODERATE DISTAL DISEASE (20-50 % DIAMETER REDUCTION);
'3' FOR SEVERE DISTAL DISEASE (GREATER THAN OR EQUAL TO 50% DIAMETER REDUCTION);
LAST EDITED: AUG 17, 1989
HELP-PROMPT: Score Distal Vessel Disease as 0,2, or 3
DESCRIPTION:
Score Distal Vessel Disease as 0, 2, or 3.
694.5,69 RIGHT CORONARY STENOSIS 4;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Give % reduction in luminal diameter of most severe stenosis (0-100). Include posterior descending
regardless of origin.
DESCRIPTION: Gives % reduction in luminal diameter of most severe stenosis (0-100). Include posterior
descending regardless or origin.
694.5,70 R. COR. DISTAL VES. DISEASE 4;5 SET
'0' FOR NO SIGNIFICANT DISTAL DISEASE (< 20% DIAMETER REDUCTION);
'2' FOR MODERATE DISTAL DISEASE (20-50 % DIAMETER REDUCTION);
'3' FOR SEVERE DISTAL DISEASE (GREATER THAN OR EQUAL TO 50% DIAMETER REDUCTION);
LAST EDITED: AUG 17, 1989
HELP-PROMPT: Score Distal Vessel Disease as 0,2, or 3
DESCRIPTION:
This field identifies the Distal Vessel Disease as 0, 2, or 3.
694.5,71 CIRCUMFLEX CORONARY STENOSIS 4;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Give % reduction in luminal diameter of most severe stenosis; include all significant marginals
(0-100)
DESCRIPTION: Gives % reduction in luminal diameter of most severe stenosis; include all significant marginals
(0-100).
694.5,72 CIRC. COR. DISTAL VES. DISEASE 4;7 SET
'0' FOR NO SIGNIFICANT DISTAL DISEASE (< 20% DIAMETER REDUCTION);
'2' FOR MODERATE DISTAL DISEASE (20-50 % DIAMETER REDUCTION);
'3' FOR SEVERE DISTAL DISEASE (GREATER THAN OR EQUAL TO 50% DIAMETER REDUCTION);
LAST EDITED: AUG 17, 1989
HELP-PROMPT: Score Distal Vessel Disease as 0,2, or 3
DESCRIPTION:
Scores Distal Vessel Disease as 0, 2, or 3.
694.5,73 GENERAL MEDICAL CONDITION 4;8 SET
'0' FOR GOOD;
'1' FOR FAIR;
'2' FOR POOR;
LAST EDITED: MAY 23, 1994
HELP-PROMPT: Grade according to general nutrition, concomitant non-cardiac diseases, mental status, debility
,etc. (0-2)
DESCRIPTION: Grades according to general nutrition, concomitant non-cardiac diseases, mental status, debility,
etc. (0-2).
694.5,74 PRIORITY OF SURGERY 4;9 SET
'1' FOR ELECTIVE;
'2' FOR URGENT;
'3' FOR EMERGENT;
LAST EDITED: AUG 17, 1989
HELP-PROMPT: Elective indicates No Alteration in Surgical Schedule,Urgent indicates Surgery must be performed
within 24-72 hrs,Emergent indicates surgery must be performed within 24 hours of diagnosis.
DESCRIPTION: This elective indicates No Alteration in Surgical Schedule, Urgent indicates Surgery must be
performed within 24-72 hours, Emergent indicates surgery must be performed with 24 hours of
diagnosis.
694.5,75 ESTIMATE OF MORTALITY 4;10 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."2N.N) X
LAST EDITED: JUN 21, 1990
HELP-PROMPT: Type a Number between 0 and 100, 1 Decimal Digit
DESCRIPTION:
This field identifies a number between 0 and 100.
694.5,75.5 INTENDED OPERATIVE PROCEDURE 4;11 SET
'1' FOR Coronary Artery Bypass Graft(s) and/or LV Aneurysectomy;
'2' FOR Aortic Valve Replacement-with or without CABG;
'3' FOR Mitral Valve Replacement-with or without CABG;
'4' FOR Great Vessel Repair;
'5' FOR Any Other Procedure;
LAST EDITED: AUG 25, 1989
HELP-PROMPT: Enter a code from 1-5.
DESCRIPTION:
This allows the user to choose the intended operative procedure.
694.5,76 DATE/TIME SURGERY BEGAN 10;1 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date/time surgery began. If this time and date precedes time and date that physician's
estimate of mortality was entered, no estimated risk will be calculated
DESCRIPTION: This field identifies the date/time the surgery began. If this time and date precedes time and
date that physician's estimate or mortality was entered, no estimated risk will be calculated.
694.5,77 BYPASS GRAFTS WITH VEIN 10;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the number of distal anastomoses constructed with vein grafts (0-9)
DESCRIPTION:
This field identifies the number of distal anastomoses constructed with vein grafts (0-9).
694.5,78 BYPASS GRAFTS WITH ARTERY 10;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>4)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the number of distal anastomoses constructed with an internal mammary artery (0-4).
DESCRIPTION: This field identifies the number of distal anastomoses constructed with an internal mammary artery
(0-4).
694.5,79 GREAT VESSEL REPAIR W BYPASS 10;4 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates primary procedure was repair of aorta or other great vessels requiring left heart
bypass with or without aortic valve replacement or CABG.
DESCRIPTION: 'Yes' indicates primary procedure was repair of aorta or other great vessels requiring left heart
bypass with or without aortic valve replacement or CABG.
694.5,80 CARDIAC TRANSPLANT 10;5 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates orthotopic or heterotopic transplant. Heart-Lung transplant should be listed under
'Other'
DESCRIPTION: 'Yes' indicates orthotopic or heterotopic transplant. Heart-lung transplant should be listed under
'Other'.
694.5,81 MITRAL VALVE REPLACEMENT 10;6 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates mitral valve replacement was performed with or without additional procedure(s)
DESCRIPTION:
'Yes' indicates mitral valve replacement was performed with or without additional procedure(s).
694.5,82 AORTIC VALVE REPLACEMENT 10;7 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates aortic valve replacement was performed with or without additional procedure(s)
DESCRIPTION:
'Yes' indicates aortic valve replacement was performed with or without additional procedure(s).
694.5,83 TRICUSPID VALVE REPLACEMENT 10;8 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates tricuspid valve replacement was performed with or without additional procedure(s)
DESCRIPTION: 'Yes' indicates tricuspid valve replacement was performed with cardiopulmonary bypass with or
without additional procedure(s).
694.5,84 VALVE REPAIR 10;9 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates repair of any cardiac valve was performed with cardiopulmonary bypass with or
without additional procedure(s)
DESCRIPTION: 'Yes' indicates repair of any cardiac valve was performed with cardiopulmonary bypass with or
without additional procedure(s).
694.5,85 LV ANEURYSECTOMY OR PLICATION 10;10 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates resection or plication of left ventricular aneurysm with or without additional
procedure(s)
DESCRIPTION: 'Yes' indicates resection or plication of left ventricular aneurysm with or without additional
procedure(s).
694.5,86 OTHER PROCEDURE(S) 11;0 POINTER Multiple #694.586 (Add New Entry without Asking)
DESCRIPTION:
This allows the user to enter information about other procedures.
694.586,.01 OTHER PROCEDURE(S) 0;1 POINTER TO DIAG/THERAP INTERVENT FILE (#699.6) (Multiply asked)
INPUT TRANSFORM: S DIC("S")="I $D(^MCAR(699.6,""D"",""S"",+Y))" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: AUG 30, 1989
HELP-PROMPT: Enter an appropriate intervention code.
DESCRIPTION:
This allows the user to enter information about other procedures.
SCREEN: S DIC("S")="I $D(^MCAR(699.6,""D"",""S"",+Y))"
EXPLANATION: CHOOSES ALLOWABLE PROCEDURES FOR REPORT
CROSS-REFERENCE: 694.586^B
1)= S ^MCAR(694.5,DA(1),11,"B",$E(X,1,30),DA)=""
2)= K ^MCAR(694.5,DA(1),11,"B",$E(X,1,30),DA)
694.5,87 TOTAL CROSS CLAMP TIME 13;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>600)!(X<0)!(X?.E1"."1N.N) X
HELP-PROMPT: Enter the total duration of aortic cross clamp time in minutes (0-600)
DESCRIPTION:
This enters the total duration of aortic cross clamp time in minutes (0-600)
694.5,88 TOTAL CIRCULATORY ARREST 13;2 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: Answer 'YES' or 'NO'
DESCRIPTION:
Should answer with 'Yes' or 'No'.
694.5,89 INTEROPERATIVE USE OF BALLOON 13;3 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates use of intraaortic balloon regardless of whether placed pre- or intra-operatively
DESCRIPTION:
'Yes' indicates use of intra-aortic balloon regardless of whether placed pre- or intra-operatively.
694.5,90 OPERATIVE DEATH 13;4 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates death from any cause within 30 days of surgery in or out of the hospital, or after
30 days if a direct result of a surgical complication
DESCRIPTION: 'Yes' indicates death from any cause within 30 days of surgery in or out of the hospital, or after
30 days if a direct result of a surgical complication.
694.5,91 DATE OF OPERATIVE DEATH 13;5 DATE
INPUT TRANSFORM: S %DT="ETX" D ^%DT S X=Y K:Y<1 X
HELP-PROMPT: Enter the date of operative death
DESCRIPTION:
This field identifies the date of operative death.
694.5,92 POSTOPERATIVE IABP 13;6 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates an Intraaortic balloon pump was used at any time during the postoperative
hospitilization, regardless of whether it had been placed earlier
DESCRIPTION: 'Yes' indicates an Intra-aortic balloon pump was used at any time during the post operative
hospitalization, regardless of whether it had been placed earlier.
694.5,93 PERIOPERATIVE MYOCAR. INFARC. 13;7 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates appearance of new or significantly widened Q-waves on postoperative
electrocardiogram
DESCRIPTION: 'Yes' indicates appearance of new or significantly widened Q-waves on postoperative
electrocardiogram.
694.5,94 ENDOCARDITIS 13;8 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' incidates new onset of endocarditis diagnosed within the 30 days following surgery
DESCRIPTION:
'Yes' indicates new onset of endocarditis diagnosed within the 30 days following surgery.
694.5,95 RENAL FAILURE 13;9 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates development of exacerbation of renal failure requiring initiation of dialysis
during the postoperative hospitalization.
DESCRIPTION: 'Yes' indicates development of exacerbation of renal failure requiring initiation of dialysis
during the postoperative hospitalization.
694.5,96 LOW CARDIAC OUTPUT 13;10 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: AUG 25, 1989
HELP-PROMPT: 'YES' indicates cardiac index < 2.0 L/min/M2 for => 6 hours postoperatively or evidence of poor
peripheral perfusion (e.g. IABPor sustained use of positive inotropic agents)
DESCRIPTION: 'Yes' indicates cardiac index < 2.0 L/min/M2 for => 6 hours postoperative or evidence of poor
peripheral perfusion (e.g. IABP or sustained use of positive inotropic agents).
694.5,97 MEDIASTINITIS 13;11 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates any infection below sternum during postoperative hospitalization or appearing
within the 30 days following surgery
DESCRIPTION: 'Yes' indicates any infection below sternum during postoperative hospitalization or appearing
within the 30 days following surgery.
694.5,98 REOPERATION FOR BLEEDING 13;12 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' if any reexploration of thorax for excessive bleeding during postoperative hospitalization
DESCRIPTION:
'Yes' if any re-exploration of thorax for excessive bleeding during postoperative hospitalization.
694.5,99 REPEAT CARDIOPULMONARY BYPASS 13;13 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates any surgical procedure requiring cardio pulmonary bypass during post-operative
hospitalization or within 30 days of initial operation.
DESCRIPTION: 'Yes' indicates any surgical procedure requiring cardiopulmonary bypass during post-operative
hospitalization or within 30 days of initial operation.
694.5,100 ON VENTILATOR (48 HRS OR MORE) 13;14 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates total duration of ventilator-assisted respiration during postoperative
hospitalization was => 48 hours.
DESCRIPTION: 'Yes' indicates total duration of ventilator-assisted respiration during postoperative
hospitalization was => 48 hours.
694.5,101 COMA (24 HRS OR MORE) 13;15 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates significantly impaired level of consciousness (exclude transient disorientation or
psychosis) for => 48 hours during postoperative hospilitization
DESCRIPTION: 'Yes' indicates significantly impaired level of consciousness (exclude transient disorientation or
psychosis) for => 48 hours during postoperative hospitalization.
694.5,102 STROKE 13;16 SET
'Y' FOR YES;
'N' FOR NO;
HELP-PROMPT: 'YES' indicates objective neurologic deficit lasting => 30 minutes with onset intra- or
post-operatively
DESCRIPTION: 'Yes' indicates objective neurologic deficit lasting => 30 minutes with onset intra- or
post-operatively.
694.5,103 PTCA 4;12 SET
'1' FOR none recent;
'2' FOR 12 - 72 hr;
'3' FOR <12 hr;
LAST EDITED: MAY 15, 1990
HELP-PROMPT: Percutaneous transluminal coronary artery angioplasty.
DESCRIPTION:
This field identifies percutaneous transluminal coronary artery angioplasty.
694.5,104 LV CONTRACTION SCORE 4;15 SET
'1' FOR I > 0.54 Normal;
'2' FOR II 0.45-0.54 Mild dysfunction;
'3' FOR III 0.35-0.44 Moderate dysfunction;
'4' FOR IV 0.25-0.34 Severe dysfunction;
'5' FOR V <0.25 Very severe dysfunction;
'0' FOR ? unknown No LV study;
LAST EDITED: MAY 16, 1990
HELP-PROMPT: Enter a code from 0-5 indicating the patient's LV Contraction range.
DESCRIPTION:
This field identifies the LV Contraction score.
694.5,105 ELECTROPHYSIOLOGIC PROCEDURE 4;16 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: MAY 16, 1990
HELP-PROMPT: Enter (Y)es or (N)o.
DESCRIPTION:
This field identifies the electrophysiologic procedure.
694.5,106 PHYSICIAN ESTIMATE DATE 4;17 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 07, 1990
HELP-PROMPT: Enter a date (and time, if desired).
DESCRIPTION:
This field identifies the physician's estimate date.
694.5,107 PHYSICIAN'S ESTIMATE 4;18 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."3N.N) X
LAST EDITED: JUN 08, 1990
HELP-PROMPT: Type a Number between 0 and 100, 2 Decimal Digits
DESCRIPTION: This field identifies a number between 0 and 100, 2 decimal digits and is the estimate survival
rate of the patient.
CROSS-REFERENCE: 694.5^AG^MUMPS
1)= S $P(^MCAR(694.5,DA,4),U,17)=DT
2)= S $P(^MCAR(694.5,DA,4),U,18)=""
This cross-reference updates the fields PHYSICIAN'S ESTIMATE (#107) and PHYSICIAN'S ESTIMATE DATE
(#106).
FILES POINTED TO FIELDS
DIAG/THERAP INTERVENT (#699.6) OTHER PROCEDURE(S):OTHER PROCEDURE(S) (#.01)
INSTITUTION (#4) HOSPITAL OF SURGERY (#2)
MEDICAL PATIENT (#690) PATIENT (#1)
INPUT TEMPLATE(S):
MCARSRAPOST JUN 11, 1990@15:49 USER #0
MCARSRAPRE JUN 08, 1990@12:18 USER #0
PRINT TEMPLATE(S):
MCARSR MAY 13, 1996@10:12 USER #0 ^MCAROS0 @
MCARSR1 MAY 13, 1996@10:13 USER #0 ^MCAROS1 CARDIAC SURGERY RISK ASSESSMENT LIST
MCARSR2 MAY 13, 1996@10:14 USER #0 ^MCAROS2 CARDIAC SURGERY RISK ASSESSMENT LIST
MCARSR3 MAY 13, 1996@10:15 USER #0 ^MCAROS3 CARDIAC SURGERY RISK ASSESSMENT LIST
MCARSR4 MAY 13, 1996@10:15 USER #0 ^MCAROS4 @
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):