Files > SURGERY

name

SURGERY

number

130

location

^SRF(

description

Each entry in the SURGERY file contains information regarding a surgery case made up of an operative procedure, or multiple operative procedures for a patient. The file includes the information necessary for creating the Nurses' Intraoperative Report, Operation Report, and Anesthesia Report

Fields

#	Name	Location	Type	Details	Index	Description
.01	patient(+)	0;1	POINTER	2	B	This is the name of the patient.
.011	hospital admission status	0;12	SET OF CODES	I:INPATIENT O:OUTPATIENT 1:SAME DAY 2:ADMISSION 3:HOSPITALIZED		Definition Revised (2014): This field indicates the patient's hospital admission status on the date of surgery. Enter "1" or "S" if the operation was same day (the patient was not admitted); "2" or "A" if the patient was admitted on the date of surgery; or "3" or "H" if the patient was already hospitalized on the day prior to the date of surgery.
.015	visit	0;15	POINTER	9000010	AV	This is the visit associated with this case.
.0155	classification entered (y/n)	0;20	BOOLEAN	1:YES 0:NO		This field indicates whether or not classification items have been addressed. This field is used by the software to decide whether to allow the user a choice to update classification information. If the field is NO or null, it will not permit a choice if the site parameter to enter classification information is turned on.
.016	service connected	0;16	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a service connected problem. This information may be passed to the VISIT file (#9000010) for use by PCE.
.017	agent orange exposure	0;17	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Agent Orange Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.
.018	ionizing radiation exposure	0;18	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Ionizing Radiation Exposure. This information may be passed to the VISIT file (#9000010) for use by PCE.
.019	southwest asia conditions	0;19	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem related to service in SW Asia. This information may be passed to the VISIT file (#9000010) for use by PCE.
.02	op room procedure performed	0;2	POINTER	131.7		This is the name of the operating room where the principal operation is performed for this patient. It can be selected by entering the name or abbreviation of the operating room.
.021	associated clinic	0;21	POINTER	44		This is the clinic associated with this surgical case or non-OR procedure. The entry made in this field will be used as the location of the encounter for PCE.
.022	military sexual trauma	0;22	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Military Sexual Trauma. This information may be passed to the VISIT file (#9000010) for use by PCE.
.023	head and/or neck cancer	0;23	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Head and/or Neck Cancer. This information may be passed to the VISIT file (#9000010) for use by PCE.
.024	combat vet	0;24	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to Combat. This information may be passed to the VISIT file (#9000010) for use by PCE.
.026	proj 112/shad	0;25	BOOLEAN	1:YES 0:NO		This field will be used to indicate if this surgery or non-OR procedure is treating a VA patient for a problem that is related to PROJ 112/SHAD. This information may be passed to the VISIT file (#9000010) for use by PCE.
.03	major/minor	0;3	SET OF CODES	J:MAJOR N:MINOR		Definition Revised (2004): Major - Any operation performed under general, spinal, or epidural anesthesia plus all inguinal herniorrhaphies, carotid endarterectomies, parathyroidectomies, thyroidectomies, breast lumpectomies, or endovascular AAA repairs regardless of anesthesia administered. Minor - All operations not designated as Major.
.035	case schedule type	0;10	SET OF CODES	EM:EMERGENCY EL:ELECTIVE A:ADD ON (NON-EMERGENT) S:STANDBY U:URGENT		This is the code describing how this case was scheduled. It is important that this field is entered. The Scheduler may use this field when updating the schedule due to cancellations or insertions. Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related preoperative symptomatology. Answer EMERGENCY if the surgeon and anesthesiologist report the case as emergent
.037	case schedule order	0;11	FREE TEXT			This is the sequence in which the surgeon expects to do the case if he or she has more than one case scheduled for this day. This field is optional, but is very useful to the person scheduling cases if the surgeon has more than one case.
.04	surgery specialty(+)	0;4	POINTER	137.45		Definition Revised (2007): This is the surgical specialty credited for doing this operative procedure. Many reports, including the Annual Report of Surgical Procedures, are sorted by the surgical specialty. This field should be entered prior to completion of this case. (If you enter '?' in the surgical package, it will display the entire local surgical specialty list and a copy of the national list can be found in the Operations Manual.)
.05	req clean or contaminated	0;5	SET OF CODES	C:CLEAN D:CONTAMINATED		This is the description of the wound class for the case. The code entered is used when scheduling the operating room for this procedure.
.07	preop skin integ	0;7	POINTER	135.2		This is the preoperative assessment of the patient's skin integrity upon arrival to the operating room. The information entered will appear on the Nurse Intraoperative Report.
.08	preop skin color	0;8	SET OF CODES	A:ASHEN LBR:LIGHT BROWN DBR:DARK BROWN PI:PINK PA:PALE F:FLUSHED M:MOTTLED C:CYANOTIC I:ICTERIC		This is the code corresponding to the preoperative assessment of the patient's skin color upon arrival to the operating room. If entered, this information will appear on the Nurse Intraoperative Report.
.09	date of operation(+)	0;9	DATE-TIME			This is the date that the case was performed. The date of operation must be entered for all cases.
.11	trans to or by	.1;1	POINTER	131.01		This is the method or device used to deliver the patient to the operating room. This field is optional, but may be useful for documentation of the case.
.111	or circ support	19;0	MULTIPLE	130.28		This is information about the nurses with circulating role responsibilities.
.112	or scrub support	23;0	MULTIPLE	130.36		This is information about the person with scrub role responsibilities.
.12	hair removal by	.1;2	POINTER	200		This is the person responsible for removing the patient's hair in preparation for the operative procedure (if necessary).
.13	restr & position aids	20;0	MULTIPLE	130.31		This is information related to restraints and positioning aids used during this operative procedure.
.14	primary surgeon(+)	.1;4	POINTER	200		This is the name of the person performing the major portion of the principal operative procedure. This field is required as part of the Operation Report. This field may be restricted by locally determined keys so that only people with the appropriate keys can be entered.
.15	first asst	.1;5	POINTER	200		This is the name of the person assisting the surgeon during the operative procedure. The information entered here appears on the Operation Report and Nurse Intraoperative Report.
.16	second asst	.1;6	POINTER	200		This is the name of the second person assisting the surgeon during the operative procedure. If entered, this information appears on the Operation Report and Nurse Intraoperative Report.
.164	attending surgeon	.1;13	POINTER	200		This is the name of the attending staff surgeon responsible for this case. This information appears on the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report.
.165	*attending code - not used	.1;16	SET OF CODES	0:LEVEL 0. ATTENDING DOING THE OPERATION 1:LEVEL 1. ATTENDING IN O.R. ASSISTING THE RESIDENT 2:LEVEL 2. ATTENDING IN O.R., NOT SCRUBBED 3:LEVEL 3. ATTENDING NOT PRESENT IN O.R. SUITE, IMMEDIATELY AVAILABLE		NOTE: This field is replaced by the new ATTENDING CODE field (#.166). This is the code corresponding to the highest level of supervision provided by the attending staff surgeon for this case. This information appears in the Operation Report, Nurse Intraoperative Report, and Attending Surgeon Report. 0 The staff practitioner performs the case but may be assisted by a resident. 1 The supervising practitioner is physically present in the operative or procedural suite and directly involved in the procedure. The resident performs major portions of the procedure. 2 The supervising practitioner is physically present in the operative or procedural suite and immediately available for consultation. The supervising practitioner may observe and provide direction. The resident performs the procedure 3 The supervising practitioner is not physically present in the operative or procedural suite, but is in the facility or on the VA campus. The supervising practitioner is immediately available for resident supervision or consultation as needed. Local policy, as approved by the VISN Academic Affiliations Officer, should define the standard for "availability" of the supervising practitioner. NOTE: The service chief and chief of staff are responsible for periodically reviewing cases done under Level 3 supervision.
.166	attending/res sup code	.1;10	POINTER	132.9		This is the code corresponding to the highest level of resident supervision provided by the attending staff surgeon for this case.
.167	perfusionist	.1;19	POINTER	200		This is the name of the person operating the cardio-pulmonary or organ perfusion apparatus. Although not required, this information may be valuable in documenting the case. If entered, it will appear on the Nurse Intraoperative Report.
.168	asst perfusionist	.1;20	POINTER	200		This is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case.
.175	skin prep agents	.1;7	POINTER	135.1		This is the type of agent used to wash and prepare the operative site. If entered, this information appears on the Nurse Intraoperative Report and is useful in documenting the case.
.18	skin prepped by (1)	.1;8	POINTER	200		This is the name of the person responsible for applying the agent used to wash and prepare the operative site. If entered, this information will appear on the Nurse Intraoperative Report.
.19	preop mood	.1;9	POINTER	135.3		This is the preoperative assessment of the patient's emotional status upon arrival to the operating room. It may be useful in the documentation of the case. If entered, this information will appear on the Nurse Intraoperative Report.
.195	preop converse	.1;14	SET OF CODES	TC:TALKS CONSTANTLY IC:INITIATES CONVERSATION RQ:RESPONDS TO QUESTIONS NA:NOT ANSWER QUESTIONS A:APHASIC D:DYSPHASIC		This is the preoperative assessment of the patient's demonstrated verbal responses upon arrival to the operating room. Although optional, this field may be valuable in documenting this case.
.196	preop conscious	.1;15	POINTER	135.4		This is the preoperative assessment of the patient's level of consciousness upon arrival to the operating room. Although optional, this information may be useful in documenting the case.
.202	nurse present time	.2;7	DATE-TIME			This is the date and time that the nurse was present in the operating room. Times entered without a date will be converted to the date of operation at that time.
.203	time pat in hold area	.2;15	DATE-TIME			This is the date and time that the patient arrived in the holding area. Times entered without a date will be converted to the date of operation at that time.
.204	anes avail time	.2;8	DATE-TIME			This is the date and time that the anesthetist is available to service the patient. Although optional, this information is useful for evaluating operation delays.
.205	time pat in or	.2;10	DATE-TIME			This is the date and time that the patient was transported into the operation room. Times entered without a date will be converted to the date of operation at that time. Definition Revised (2004): Patient in Room (PIR): Time when patient enters the OR/PR.
.206	surg present time	.2;9	DATE-TIME			This is the date and time that the surgeon is available to begin the operative procedure. Although not mandatory, this information is useful for evaluating hospital delays.
.21	anes care start time	.2;1	DATE-TIME			This is the date and time that the anesthesia care began. It is required as part of the anesthesia report. The definition of what constitutes the time anesthesia care begins may vary depending on local anesthesia policy. Non-Cardiac Definition Revised(2004): Anesthesia Start (AS): Time when a member of the anesthesia team begins preparing the patient for an anesthetic.
.213	anes care time block	50;0	MULTIPLE	130.213		This is the date and time for which anesthesia care is provided.
.214	anes care billable time flag	.2;17	BOOLEAN	1:YES 0:NO		This field is a flag that indicates all anesthesia care time has been entered for a case. It is used in calculating the total anesthesia billable time. "Yes" indicates all time has been entered. "No" indicates time entry is not complete.
.215	induction complete	.2;11	DATE-TIME			This is the date and time that the anesthetist declares the patient ready for the start of the operative procedure. Although optional, this information may be useful in management studies.
.218	anes care billable time		COMPUTED			This is the total anesthesia care billable time in minutes. It is calculated from all time intervals entered in the multiple anesthesia start and end time fields..
.22	time operation began	.2;2	DATE-TIME			This is the date and time that the operation began. The definition of this time is usually 'knife fall', but may vary according to local surgery service protocol. Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure).
.23	time operation ends	.2;3	DATE-TIME			Definition Revised (2004): Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, indicate the time the patient was pronounced dead.
.232	time pat out or	.2;12	DATE-TIME			This is the date and time that the patient is taken from the operating room. Times entered without a date will be converted to the date of operation at that time. This information is very significant for operating room management studies. Definition Revised (2011): Indicate the time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element.
.234	or clean start time	.2;13	DATE-TIME			This is the date and time when the 'end of case' or terminal cleaning began. Times entered without a date will be converted to the date of operation at that time.
.236	or clean end time	.2;14	DATE-TIME			This is the date and time when the 'end of case' or terminal cleaning ended. Times entered without a date will be converted to the date of operation at that time.
.24	anes care end time	.2;4	DATE-TIME			This is the date and time that anesthesia care ends. Its definition may vary according to local anesthesia policy. Acceptable time formats include 7:45, 745, T@7:45 and JAN 1@7:45. Times entered without a date will be converted to the date of the operation at that time. Non-Cardiac Definition Revised (2004): Anesthesia Finish (AF): Time at which anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU).
.25	blood loss (ml)	.2;5	NUMERIC			This is the number of milliliters (0-100000) of blood estimated to be lost during the operative procedure (EBL). This information appears on the Nurse Intraoperative report, if entered.
.255	total urine output (ml)	.2;16	NUMERIC			This is the total number of milliliters (0-100000) of urine output during the operative procedure. If entered, this information appears on the Nurse Intraoperative Report.
.27	replacement fluid type	4;0	MULTIPLE	130.04		This is information related to the replacement fluid given intravascularly during the operative procedure.
.28	general comments	5;0	WORD-PROCESSING			These are general comments about the operative procedure. Any information not provided for elsewhere can be entered here.
.29	nursing care comments	7;0	WORD-PROCESSING			These are comments on this case required for documentation on the Nurse Intraoperative Report.
.293	monitors	27;0	MULTIPLE	130.41		This is information related to invasive or non-invasive monitors used during this case.
.31	princ anesthetist	.3;1	POINTER	200		This is the name of the principal anesthesiologist or CRNA (or surgeon, if local anesthesia). This information is extremely important for the Anesthesia Report.
.32	relief anesthetist	.3;2	POINTER	200		This is the name of the anesthetist relieving the principal anesthetist, if applicable. If entered, this information appears on the Anesthesia Report.
.33	asst anesthetist	.3;3	POINTER	200		This is the name of the person assisting the principal anesthetist. If entered, this information appears on the Anesthesia Report.
.34	anesthesiologist supvr	.3;4	POINTER	200		This is the name of anesthesia supervisor. He or she may be the same person entered in the 'PRINC ANESTHETIST' or 'ASST ANESTHETIST' fields. This information is required if the principal anesthetist is in a training status, or CRNA.
.345	anes supervise code	.3;6	POINTER	132.95		This is the code corresponding to the highest level of supervision of the anesthesiology staff supervisor. This information appears on the Anesthesia Report.
.3511	anes personally performed	.2;19	BOOLEAN	0:NO 1:YES		Answer yes only if the anesthesiologist personally performed the entire anesthesia procedure.
.3512	num of concurrent anes cases	.2;20	NUMERIC			Including this case, enter the number of cases that the anesthesiologist supervised where the time of the anesthesia care overlapped with this care. This field is required to support billing for the care and is critical for accurate coding of the primary anesthesia procedure. Enter a zero if the anesthesiologist personally performed the care. Enter 1 if the principal anesthetist was not an anesthesiologist and was medically directed by an anesthesiologist.
.3513	anes concurrent cases	55;0	MULTIPLE	130.3513		This field is for information only and is not required. It will assist in correcting potential errors if a start or end time is edited since other cases could be affected by the edit.
.3514	anes medically directed	.2;22	BOOLEAN	0:NO 1:YES		If the principal anesthetist was other than an anesthesiologist, answer yes if an anesthesiologist supervised the care. Answering no indicates that the anesthetist was unsupervised.
.3515	anes physician available	.2;23	BOOLEAN	0:NO 1:YES		If the anesthetist was a resident, answer yes if the teaching physician was present during all key portions of the procedure and immediately available during the entire procedure.
.36	min intraop temperature (c)	.3;7	NUMERIC			This is the lowest temperature of the patient during the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
.37	anesthesia technique	6;0	MULTIPLE	130.06		This is information about the anesthesia technique used during this case.
.375	medications	22;0	MULTIPLE	130.33		This is information about medication for this case.
.39	irrigation	26;0	MULTIPLE	130.08		This is information related to the irrigation solution.
.42	other procedures	13;0	MULTIPLE	130.16		This is information related to procedures performed in addition to the principal procedure.
.43	planned postop care	.4;3	POINTER	131.6		This is the code corresponding to the location of care after the patient leaves the operating room and/or the post-anesthesia care unit.
.44	or set-up time	.4;4	NUMERIC			This is the number of minutes (0-999) necessary to prepare the operating room for the admission of the patient for the surgical procedure.
.46	op disposition	.4;6	POINTER	131.6		This is the destination of the patient upon transfer from OR staff care.
.47	prosthesis installed	1;0	MULTIPLE	130.01		This is information related to the prosthesis used for this operative procedure.
.48	time tourniquet applied	2;0	MULTIPLE	130.02		This is information related to the application of a tourniquet.
.52	final counts verify correct	.5;1	SET OF CODES	Y:CORRECT N:INCORRECT U:UNKNOWN		This is the code corresponding to the status of the final count at the end of the surgical procedure.
.522	verifier	.5;12	POINTER	200		This is the person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure.
.523	*inst cnt correct	.5;10	SET OF CODES	Y:CORRECT N:INCORRECT U:UNKNOWN		Enter the code corresponding to the status of the final instrument count at the end of the surgical procedure. This field is marked for deletion.
.525	inst cnt verf by	.5;11	POINTER	200		This is the name of the person accountable for verification of the final instrument count.
.54	*surgery position	.5;3	POINTER	132		This field has been asterisked for deletion 18 months from the release of version 3.0 of the DHCP Surgery package. A multiple field titled SURGERY POSITION will be used in it's place.
.55	electroground position	.5;4	POINTER	138		This is the code corresponding to the area of placement of the dispersive electrode pad.
.56	foley catheter size	.5;5	NUMERIC			This is the size of the Foley catheter.
.57	foley catheter inserted by	.5;6	POINTER	200		This is the name of the person accountable for insertion of the Foley catheter. Although this information is optional, it may be useful in documentation of this case.
.61	preop temperature	.6;1	NUMERIC			This is the most recent ward-recorded temperature of the patient prior to transport to the operating room.
.615	preop weight (kg)	.6;10	NUMERIC			This is the most recent ward-recorded weight of the patient prior to transport to the operating room.
.62	preoperative heart rate	.6;2	NUMERIC			This is the most recent ward-recorded heart rate of the patient prior to transport to the operating room.
.63	preop blood pressure	.6;3	FREE TEXT			This is the most recent ward recorded blood pressure of the patient prior to transport to the operating room. Although optional, this information may be useful for documentation of this case.
.64	preop respiratory rate	.6;4	NUMERIC			this is the most recent ward-recorded respiratory rate of the patient prior to transport to the operating room.
.65	final anesthesia temp (c)	.6;5	NUMERIC			This is the temperature, in degrees centigrade, at the time of the end of anesthesia care.
.66	postop pulse	.6;6	NUMERIC			This is the pulse rate of the patient upon admission to the care area immediately after the surgical procedure.
.67	postop bp	.6;7	FREE TEXT			This is the patient's blood pressure upon admission to the care area immediately after the surgical procedure. Although this information is optional, it may be useful in documentation of this case.
.68	postop resp	.6;8	NUMERIC			This is the respiratory rate of the patient upon admission to the care area immediately after the surgical procedure.
.69	time-out document completed by	.6;9	POINTER	200		VASQIP Definition (2014): This is the name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record.
.72	other preop diagnosis	14;0	MULTIPLE	130.17		This is information related to any diagnosis in addition to the principal preoperative diagnosis.
.74	other postop diags	15;0	MULTIPLE	130.18		This is information related to any postoperative diagnosis in addition to the principal postoperative diagnosis.
.75	electrocautery unit	.7;5	FREE TEXT			This is information identifying the electrosurgical unit utilized during the operative procedure. The information may include, but is not limited to, unit number, ground pad lot number and/or expiration date, coag setting, cut setting, blend-BI:Setting and Bipolar BP:Setting. Examples: Electrocautery Unit: #7 HP206 COAG:50 CUT:50 BI:1 Electrocautery Unit: DAISY:18% or DAISY BP:18% Electrocautery Unit: VL#2 EXP 3/20/91 COAG:30 CUT:20 BI:2 #2 BP:20 (VL-VALLEYLAB)
.757	thermal unit	21;0	MULTIPLE	130.32		This is information related to the temperature controlling device.
.76	postop skin integ	.7;6	POINTER	135.2		This is the code corresponding to the assessment of the patient's skin integrity after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
.77	postop skin color	.7;7	SET OF CODES	A:ASHEN LBR:LIGHT BROWN DBR:DEEP BROWN PI:PINK PA:PALE F:FLUSHED C:CYANOTIC I:ICTERIC		This is the code corresponding to the patient's skin color after the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
.79	pacu disposition	.7;9	POINTER	131.6		This is the code corresponding to the destination of the patient immediately after release from the post-anesthesia care unit.
.81	postop mood	.8;1	POINTER	135.3		This is the code corresponding to the assessment of the patient's mood following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
.82	postop convers	.8;2	SET OF CODES	TC:TALKS CONSTANTLY IC:INITIATES CONVERSATION RQ:RESPONDS TO QUESTIONS NA:NOT ANSWER QUESTIONS A:APHASIC D:DYSPHASIC		This is the code corresponding to the assessment of the patient's demonstrated verbal responses at the completion of the surgical procedure.
.821	postop conscious	.8;10	POINTER	135.4		This is the code corresponding to the assessment of the patient's level of consciousness following the operative procedure. If entered, this information will appear on the Nurse Intraoperative Report.
.84	end pulse	.8;4	NUMERIC			This is the patient's pulse rate at the end of the operative procedure.
.85	end bp	.8;5	FREE TEXT			This is the patient's systolic/diastolic blood pressure at the end of the operative procedure. Although optional, this information may be useful in documentation of this case.
.86	end resp	.8;6	NUMERIC			This is the patient's rate of respiration at the end of the operative procedure. This information may be useful in documentation of this case.
.875	packing	.8;11	SET OF CODES	V:VASOLINE I:IODOFORM P:PLAIN B:BETADINE D:DENTALPACKS O:OTHER N:NONE		This is the code corresponding to the type of packing placed during the procedure that will remain in place when the patient is discharged from the operating room.
.971	patient education/assessment	.97;1	SET OF CODES	Y:YES N:NO I:INAPPLICABLE U:UNKNOWN		This indicates whether preoperative patient education and assessment, with documentation of a care plan, were completed during the perioperative care of the patient.
.972	consent sig&wit	.97;2	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether there is a properly signed and witnessed operative consent present in the patient's medical record.
.973	bath & shampoo	.97;3	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates if the patient's preoperatively prescribed bath and shampoo were completed.
.974	rec&xray ready	.97;4	SET OF CODES	Y:YES N:NO I:INCOMPLETE		This indicates whether the patient's x-rays and records are complete.
.975	enema(s) if ord	.97;5	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the administration of preoperative enema(s) were completed, if ordered.
.976	npo as ord/clin mid	.97;6	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether NPO orders were completed prior to the operative procedure as ordered by the surgeon.
.977	*clerk chn days before	.97;7	NUMERIC			This field is not being used and is marked for deletion.
.981	*verfify id tag ssn	.98;1	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the identification bracelet and social security number verification was completed, legal and correct. This field has been marked for deletion.
.9811	care plan in chart	.98;10	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the nursing care plan is present on the patient's medical record prior to transport of the patient into the operating room.
.9812	address plate	.98;11	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates if the patient's address plate is present on the patient's medical record prior to transport to the operating room.
.9813	patient voided	.98;12	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient voided prior to being transported to the operating room.
.9814	preop med&rail up	.98;13	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether preoperative medication was administered and the side rails of the bed were placed in the 'up' position.
.9815	*clerk chn date procedure	.98;14	NUMERIC			This field has been marked for deletion. It should not be used.
.982	prosthesis rem	.98;2	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether prosthetics (dentures, jewelry, hair pieces) have been removed prior to transport to the operating room.
.983	cig, match & val rem	.98;3	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient's tobacco products, matches and valuables have been removed from his or her possession prior to being transported to the operating room.
.984	valuables secured	.98;4	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient's valuables have been secured according to hospital policy.
.985	oral hygiene	.98;5	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient's oral hygiene was completed prior to being transported to the operating room.
.986	freshly shaved	.98;6	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient's facial hair was freshly shaved prior to being transported to the operating room.
.987	clean dressing	.98;7	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates if all appropriate wounds have had clean dressings applied prior to transport to the operating room.
.988	clean hosp cloth	.98;8	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has clean hospital clothing prior to being transported to the operating room.
.989	levin tube/cath	.98;9	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether a Levin tube/catheter is present prior to transport to the operating room.
.991	u/a in 48 hrs	.99;1	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has had a urinalysis within 48 hours prior to being transported to the operating room.
.9911	*clerk chn rec for maj surg	.99;10	NUMERIC			This field has been marked for deletion. It should not be used.
.992	cbc in 48 hrs	.99;2	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has had a CBC within 48 hours prior to being transported to the operating room.
.993	blood type&xmatch	.99;3	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has had blood typing and crossmatching done.
.994	*bleeding & ptt time in 48 hrs	.99;4	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has had bleed and PTT time within 48 hours prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.
.995	*bun in 7 days	.99;5	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This indicates whether the patient has had a BUN within 7 days prior to being transported to the operating room. This field has been marked for deletion in the next version of the Surgery package.
.996	*blood sugar in 7 days	.99;6	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This field determines whether the patient has had a blood sugar test within the last 7 days. This field has been marked for deletion in the next release of the Surgery software.
.997	*serology report	.99;7	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This field has been marked for deletion. It should not be used.
.998	chest xray in 7 days	.99;8	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This field determines whether the patient has had a chest x-ray within the last seven days.
.999	ekg in 24 hrs	.99;9	SET OF CODES	Y:YES N:NO I:INAPPLICABLE		This field determines whether the patient has had an EKG within the last 24 hours.
1.01	req anesthesia technique	1.0;1	SET OF CODES	L:LOCAL S:SPINAL B:BLOCK G:GENERAL C:CHOICE MAC:MONITORED ANESTHESIA CARE E:EPIDURAL		This is the surgeon's choice of anesthesia for the proposed operative procedure. This information will appear on the Schedule of Operations.
1.02	req froz sect	1.0;2	BOOLEAN	Y:YES N:NO		This indicates whether laboratory support is needed to perform frozen section diagnostic tests during the operative procedure.
1.03	req preop x-ray	1.0;3	FREE TEXT			These are the types of preop x-ray films and reports required for delivery to the operating room prior to the surgical procedure.
1.035	intraoperative x-rays	1.0;5	SET OF CODES	Y:YES N:NO C:C-ARM		This indicates if radiology personnel is needed in the operating room for intraoperative radiologic procedures.
1.04	req photo	1.0;4	BOOLEAN	Y:YES N:NO		This indicates whether Medical Media personnel need to be present in the operating room to obtain photographs during the operative procedure.
1.05	req blood kind	11;0	MULTIPLE	130.14		This is information related to the blood product required during this operative procedure.
1.052	req blood avail	1.0;9	BOOLEAN	Y:YES N:NO		This indicates whether the requested blood components are available.
1.09	wound classification	1.0;8	SET OF CODES	C:CLEAN CC:CLEAN/CONTAMINATED D:CONTAMINATED I:DIRTY/INFECTED		Definition Revised (2007): Indicate whether the wound has been classified by the primary surgeon as: >> Class 1 - Clean (C): Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed drainage. Surgical incisional wounds that occur with nonpenetrating (eg blunt) trauma should be included in this category if they meet the criteria. [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.] Examples: - Exploratory laparotomy - Mastectomy or breast reduction - Neck dissection - Nonpenetrating blunt trauma - Thyroidectomy - Total hip replacement - Vascular operations (e.g. AAA, AV fistula, CEA, aortoiliac bypass) - Hernia repair - CABG, AVR - Craniotomy, majority neurosurgery - Pleura biopsy - Sternotomy - Abdominoplasty - Bone anchored hearing aids (BAHA) - Penile prosthesis placement - Dupuytren's release, finger - Liposuction - Carpal tunnel release - Hydrocele repair >> Class 2 - Clean/Contaminated (CC): Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered. (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.) Examples: - Bronchoscopy - Routine appendectomy - Cholecystectomy (e.g., any approach) - Laryngectomy - Small bowel resection - Oropharynx entered - GYN procedures - Vagina entered - Whipple pancreaticoduodenectomy - Pulmonary resection - Transurethral resection of prostate - Head & Neck cancer operations (e.g., oropharynx) - Sigmoid colectomy - Minor break in technique - Gastrointestinal or respiratory tract entered without significant spillage - Genitourinary tract entered in absence of infected urine >> Class 3 - Contaminated (D): Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category. Examples: - Appendectomy for gangrenous appendicitis - Bile spillage during cholecystectomy - Diverticulitis - Laparotomy for penetrating injury with intestinal spillage - Entrance of genitourinary or biliary tracts in presence of infected urine or bile - Necrotic tissue without evidence of purulent drainage (e.g. dry gangrene) >> Class 4 - Dirty/Infected (I): Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the surgical field before the procedure. (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.) Examples: - Excision and drainage of abscess - Myringotomy for otitismedia - Perforated bowel - Peritonitis (abdominal exploration for acute bacterial peritonitis) - Acute bacterial inflammation, without pus - Transection of 'clean' tissue for the purpose of surgical access to a collection of pus - Traumatic wound with foreign bodies, fecal contamination, or delayed treatment, or all of these; or from dirty source
1.098	date/time or request made	1.0;11	DATE-TIME			This is the date and time that the operation request was made. This information is automatically entered at the time of request. If the request date is changed, this field will be updated to reflect the new date/time requested.
1.099	surg sched person	1.0;10	POINTER	200		This is the name of the person requesting or scheduling this operative procedure.
1.11	pac(u) admit score	1.1;1	NUMERIC			This is the objective evaluation numerical score of the patient upon admission to the post anesthesia care unit.
1.12	pac(u) disch score	1.1;2	NUMERIC			This is the objective evaluation numeric score of the patient at discharge from the post anesthesia care unit.
1.13	asa class	1.1;3	POINTER	132.8		VASQIP Definition (2010): Record the American Society of Anesthesiology (ASA) Physical Status Classification of the patient's present physical condition on a scale from 1-6 as it appears on the anesthesia record. Most likely there will be a 2nd assessment of the ASA class prior to anesthesia induction. If this is available, report this most recent assessment. The definitions are: ASA 1 - A normal healthy patient ASA 2 - A patient with mild systemic disease ASA 3 - A patient with severe systemic disease ASA 4 - A patient with severe systemic disease that is a constant threat to life ASA 5 - A moribund patient who is not expected to survive without the operation ASA 6 - A declared brain-dead patient whose organs are being removed for donor purposes ASA 6 cases should be excluded. Classification numbers followed by an 'E' indicate an emergency. Select N for NONE ASSIGNED if no ASA Class is assigned for this patient.
1.14	intraoperative occurrences	10;0	MULTIPLE	130.13		This is information related to any intraoperative occurrences. If there are no occurrences, leave this field blank. 'NONE' is not an acceptable answer.
1.145	returned to surgery	29;0	MULTIPLE	130.43		This is information related to the patient's return to surgery within 30 days of a prior operative procedure.
1.15	surgeon's dictation	12;0	WORD-PROCESSING			This is the Surgeon's dictated operation note.
1.16	postop occurrence	16;0	MULTIPLE	130.22		This is information related to postoperative occurrences.
1.17	admit pac(u) time	1.1;7	DATE-TIME			This is the date/time that the patient was admitted to the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time.
1.18	pac(u) disch time	1.1;8	DATE-TIME			This is the date/time that the patient is discharged from the post anesthesia care unit (recovery room). Times entered without a date will be converted to the date of operation at that time. Non-Cardiac Definition Revised (2004): Discharge from Post-Anesthesia Care Unit (DPACU): Time patient is transported out of PACU.
1.19	postop anes note date	1.1;9	DATE-TIME			This is the date and time that the postoperative note is written in the patient's chart. Times entered without a date will be converted to the date of operation at that time.
1.2	postop anes note	48;0	WORD-PROCESSING			This is the postoperative anesthesia note for this patient.
1.21	operation time		COMPUTED			This is the number of minutes between the operation start and end times.
1.22	anesth induct time		COMPUTED			This is the total number of minutes between the anesthesia care start and induction complete times.
1.23	anes care time		COMPUTED			This is the number of minutes between the anesthesia care start time and anesthesia care end time.
1.24	patient in or time		COMPUTED			This is the number of minutes the patient was in the operating room.
1.25	or clean up time		COMPUTED			This is the number of minutes between the OR clean up start time and OR clean up end time.
1.26	pac(u) time		COMPUTED			This is the number of minutes the patient spent in the PAC(U).
4	skin prepped by (2)	.1;12	POINTER	200		This is the name of a second person performing skin preparation, if applicable. When entered, this information appears on the Nurse Intraoperative Report.
5	skin prepped by (3)	.1;17	POINTER	200		This is the name of the third person performing the preoperative skin preparation. If entered, this information will appear on the Nurse Intraoperative Report.
6	electroground position (2)	.5;13	POINTER	138		This is the code corresponding to the placement of the second dispersive electrode pad.
7	dressing condition	31;1	SET OF CODES	D:DRY S:SEROSANGUINOUS SA:SANGUINOUS N:NO DRESSING		This is the status of the drainage on the dressing. Although optional, this information may be useful in documentation of this case.
8	second skin prep agent	31;2	POINTER	135.1		This is the name of the SECOND antimicrobial agent used to wash and prepare the operative site. Although optional, this information may be useful in documentation of the case.
9	time nurse out of or	31;3	DATE-TIME			This is the date and time that the circulating nurse completed duties for the operative procedure and left the operating room.
10	scheduled start time	31;4	DATE-TIME			This is the date and time that this operative procedure is scheduled to begin.
11	scheduled end time	31;5	DATE-TIME			This is the date and time that this operative procedure is scheduled to end.
12	in or to anes start		COMPUTED			This is the number of minutes between the time anesthesia care began and time that the patient left the operating room.
13	anes start to op start		COMPUTED			This is the number of minutes between the time that anesthesia care started and time that the operation began.
14	in or to op start time		COMPUTED			This is the time between the time the patient enters the operating room to the operation start time.
15	date/time of dictation	31;6	DATE-TIME			This is the date and time that dictation of the operative summary was completed.
17	cancel date	30;1	DATE-TIME			This is the date and time that the operative procedure was canceled.
17.5	cancellation timeframe	30;5	SET OF CODES	1:SURGERY CANCELLED <48 HRS BEFORE SCHEDULED SURGERY 2:SURGERY CANCELLED >48 HRS BEFORE SCHEDULED SURGERY		VASQIP Definition (2014): This indicates when the surgery was cancelled; either less than 48 hours prior to the scheduled surgery time or more than 48 hours prior to the scheduled surgery time.
18	primary cancel reason	31;8	POINTER	135		VASQIP Definition (2014): This is the reason that this surgical case was cancelled. List of valid reasons: 1) Patient Related Issue (e.g., patient did not follow pre-surgery instructions, patient chooses to cancel for any reason) 2) Environmental Issue (OR availability impacted by e.g., air handling, electrical outage, emergency construction, flood, tornado, blizzard, hurricane causing OR hospital closure. If due to staff availability, use #3) 3) Staff Issue (e.g., unavailable surgeon, anesthesia or nursing staff; no documented consent, provider cancels due to change in patient treatment plan) 4) Patient Health Status (Provider cancels due to change in patient health status) 5) More clinically urgent/emergent case superseded this scheduled case 6) Scheduling Issues Not Created By An Emergency Case (previous case overtime, case delayed, double booked, general time constraints, administrative scheduling error) 7) Unavailable Bed 8) Unavailable Equipment [excluding RME] (e.g., vendor, c-arm, implant, malfunctioning equipment) 9) Unavailable Reusable Medical Equipment (RME) (includes defective packaging, damaged instruments or failure of Sterile Processing Services [SPS] to provide reprocessed equipment in a timely manner) 10) Patient scheduled into an earlier date for surgery.
19	cancellation comments	30;4	FREE TEXT			This is the cancellation comments field. If "OTHER" is selected for the CANCEL REASON field (#18), the user will be prompted to enter a comment in this field.
20	diagnostic/therapeutic (y/n)	31;9	BOOLEAN	Y:YES N:NO		This indicates if the anesthesia technique is an anesthesia diagnostic/ therapeutic procedure.
21	wait time start	31;11	DATE-TIME			This is start of the patient's "wait" for Surgery. Typically, this is the date that the patient was notified that Surgery is needed.
22	tubes and drains	3;1	FREE TEXT			This is the type and placement of tubes and drains during the operative process.
23	referring physician	18;0	MULTIPLE	130.03		This is information related to the referring physician.
24	lock case	LOCK;1	SET OF CODES	1:LOCKED 0:UNLOCKED		This indicates whether this case has been completed and locked. Locked cases can only be edited if unlocked by the Chief of Surgery or his or her designee.
25	discharged via	.7;4	POINTER	131.01		This is the code corresponding to the mode of transport used to move the patient from the care area.
26	principal procedure(+)	OP;1	FREE TEXT			This is the name of the principal procedure for this case. All cases must have a principal procedure. The principal procedure must be 3 to 135 characters in length. The procedure name must not contain a semicolon (;), an at-sign (@), an up- arrow (^) or control characters. If the procedure name is longer than 30 characters, it must contain at least one space in every 31 characters of length. If a comma is being used to separate information, a space should follow the comma. Non-Cardiac Definition Revised (2004): The most complex of all the procedures by the primary operating team during this trip to the operating room. Your answer must be at least 3 characters in length. Do not enter an additional procedure if it is covered by a single CPT code. (Note that a single CPT code can cover more than one procedure, e.g., cholecystectomy and common bile duct exploration have a single CPT code). Additional procedures requiring separate CPT codes and/or concurrent procedures will be entered separately below. An exploratory laparotomy should be entered as the principal operative procedure only when no other procedure eligible for assessment has been performed in that particular surgical case.
27	planned prin procedure code	OP;2	POINTER	81		This is the Current Procedural Terminology (CPT) code corresponding with the planned principal procedure. A CPT modifier on the CPT code may be included by appending the modifier to the CPT code separated by a hyphen in the format "XXXXX-YY" where "XXXXX" is the five character CPT code and "YY" is the two character CPT modifier.
27.5	prin assoc diagnosis	PADX;0	MULTIPLE	130.275		This Surgery sub-file is used to store the Procedure/Diagnosis association data.
28	prin. procedure cpt modifier	OPMOD;0	MULTIPLE	130.028
29	*procedure completed	OP;4	BOOLEAN	Y:YES N:NO		This indicates whether the principal operative procedure was completed. This field has been marked for deletion.
30	other scrubbed assistants	28;0	MULTIPLE	130.23		This is information about other persons in the operating room in addition to those already listed as scrubbed.
31	other persons in or	32;0	MULTIPLE	130.24		This is information related to other persons, not scrubbed or otherwise identified, present in the operating room.
32	principal pre-op diagnosis	33;1	FREE TEXT			This is the preoperative diagnosis for which the surgical procedure is being performed.
32.5	prin pre-op icd diagnosis code	34;3	POINTER	80		This is the principal Pre-OP ICD diagnosis code. It should be entered for all cases.
33	principal diagnosis	33;2	FREE TEXT			This is the principal diagnosis for which the non-OR procedure is being performed.
34	principal post-op diag	34;1	FREE TEXT			This is the principal postoperative diagnosis.
35	concurrent case	CON;1	POINTER	130		Definition Revised (2004): An additional operative procedure performed by a different surgical team (i.e., a different specialty/service) under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure (e.g., fixation of a femur fracture in a patient undergoing a laparotomy for trauma). This field should be verified and, if need be, edited postoperatively by the Nurse Reviewer in accordance with the official operating room log.
36	requested	REQ;1	NUMERIC			This indicates whether this case was requested.
37	estimated case length	.4;1	FREE TEXT			This is the amount of time estimated to perform this operative procedure. Your answer should be in the format of "HOURS:MINUTES". For example, if the procedure will last 2 and 1/2 hours, your answer would be 2:30.
38	request blood availability	0;6	BOOLEAN	Y:YES N:NO		This determines whether blood will be requested for this surgical procedure. Enter 'YES' if blood will be requested. Otherwise, enter 'NO'.
39	date of transcription	31;7	DATE-TIME			This is the date and time that transcription of the operative summary was completed.
40	crossmatch, screen, autologous	0;13	SET OF CODES	T:TYPE & CROSSMATCH S:SCREEN A:AUTOLOGOUS		This determines whether the requested blood will be typed and crossmatched, screened, or autologous.
41	dressing	35;1	FREE TEXT			These are the dressing(s) used for this case. Although optional, this information may be useful in documentation of this case.
42	delay cause	17;0	MULTIPLE	130.042		This is information related to the reason why this case did not begin at its scheduled start time.
43	case verification	VER;1	BOOLEAN	Y:YES N:NO		This indicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon.
44	sponge final count correct	25;1	SET OF CODES	Y:YES N:NO, SEE NURSING CARE COMMENTS N/A:NOT APPLICABLE NA:NOT APPLICABLE		This indicates whether the sponge final count was correct. If entered, this information will appear on the Nurse Intraoperative Report.
45	sharps final count correct	25;2	SET OF CODES	Y:YES N:NO, SEE NURSING CARE COMMENTS N/A:NOT APPLICABLE NA:NOT APPLICABLE		This indicates whether the sharps final count was correct. If entered, this information will appear on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital policy.
46	instrument final count correct	25;3	SET OF CODES	Y:YES N:NO, SEE NURSING CARE COMMENTS N/A:NOT APPLICABLE NA:NOT APPLICABLE		This indicates whether the instrument final count was correct for this case. This information appears on the Nurse Intraoperative Report. The type of information entered in this field is determined by local hospital policy.
47	sponge, sharps, & inst counter	25;4	POINTER	200		This is the name of the person doing the final count of sponges, sharps and instruments. If entered, this information appears on the Nurse Intraoperative Report.
48	count verifier	25;5	POINTER	200		This is the name of the person responsible for verifying the final sponge, sharps and instrument counts.
49	specimens	9;0	WORD-PROCESSING			These are the names of specimens sent to the lab for analysis.
50	division	8;1	POINTER	4		This is the name of the institution credited for performing this operative procedure.
51	preop attending concurrence	24;1	BOOLEAN	Y:YES N:NO		This field serves as a flag that the attending has concurred with the preoperative workup.
52	postop attending concurrence	24;2	BOOLEAN	Y:YES N:NO		This field serves as a flag that the attending concurs with the postoperative workup.
53	non-operative occurrences	36;0	MULTIPLE	130.053		These are occurrences that are not related to a surgical procedure. If there are not any non-operative occurrences, leave this field blank. Do not enter 'NO' or 'NONE'.
54	occurrence/no procedure	37;1	BOOLEAN	1:YES 0:NO		This indicates that this case was a occurrence, not related to a surgical procedure.
55	indications for operations	40;0	WORD-PROCESSING			This is a brief statement of the indications for this operative procedure. The information you enter here prints automatically as the first part of the operative summary.
56	pre-admission testing	35;2	BOOLEAN	Y:YES N:NO		This indicates whether pre-admission testing was complete. It will be reflected on the Schedule of Operations for outpatients.
57	esu coag range	.7;1	FREE TEXT			This is the power setting range on the Electrosurgical Unit during coagulation. This information is optional, but may be useful in documenting the case.
58	esu cutting range	.7;2	FREE TEXT			This is the power setting range on the Electrosurgical Unit during cutting. This information is optional, but may be useful in documenting the case.
59	operative findings	38;0	WORD-PROCESSING			This field contains a brief description of the operative findings which appears on the Tissue Examination Report.
60	brief clin history	39;0	WORD-PROCESSING			This field contains a brief clinical history for this patient. It will appear on the Tissue Examination Report.
61	diagnostic results confirm by	.6;11	POINTER	200		This is the name of the person responsible for verifying that the essential diagnostic procedure requirements, as per medical center policy, are available.
62	gastric output	.2;6	NUMERIC			This is the gastric output during the operative procedure. It is recorded in cc's, and appears on the Nurse Intraoperative Report.
63	iv started by	.3;5	POINTER	200		This is the name of the person that started the IV for this operative procedure.
64	cultures	41;0	WORD-PROCESSING			These are the names of cultures sent to the laboratory for examination.
65	surgery position	42;0	MULTIPLE	130.065		This is the position in which the patient is placed for this operative procedure. This information will appear on the Nurse Intraoperative Report.
66	planned prin diagnosis code	34;2	POINTER	80		This is the planned principal postoperative ICD diagnosis code assigned by the clinician.
67	cancellation avoidable	30;2	BOOLEAN	Y:YES N:NO		This field contains a set of codes used to flag a cancellation as being avoidable or unavoidable. It is used when determining the percentage of avoidable cancellations.
68	scheduled procedure	SP;1	FREE TEXT			This field contains the scheduled (or original) principal procedure for this case. It will be compared to the actual procedure completed.
69	coding verifier	VER;2	POINTER	200		This is the person who last updated procedure and/or diagnosis descriptions and/or codes for this case using the Update/Verify Procedure/Diagnosis Codes [SRCODING EDIT] option. This field is updated automatically by the option when information is changed.
70	cancelled by	30;3	POINTER	200		This is the name of the person who cancelled this surgical case. This information is automatically entered when a case is cancelled.
71	time out verified	VER;3	SET OF CODES	Y:YES N:NO (see TIME OUT VERIFIED COMMENTS)		This field refers to the completion of a "Time Out" verification process prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider. This practice is further defined by local hospital policy. If entered "NO", a justification should be documented in the Time Out Verified Comments.
72	preoperative imaging confirmed	VER;4	SET OF CODES	Y:YES I:IMAGING NOT REQUIRED FOR THIS PROCEDURE N:NO - IMAGING REQUIRED BUT NOT VIEWED (see IMAGING CONFIRMED COMMENTS)		This field refers to the completion of the verification process for the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. This practice is further defined by local hospital policy. If entered "NO", a justification should be documented in the Imaging Confirmed Comments.
73	marked site confirmed	VER;5	SET OF CODES	Y:YES M:MARKING NOT REQUIRED FOR THIS PROCEDURE N:NO - MARKING REQUIRED BUT NOT DONE (see MARKED SITE COMMENTS)		The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. See applicable VHA Handbooks and Directives for further information and guidance. If entered "NO", a justification should be documented in the Marked Site Comments.
74	time-out completed	.6;12	DATE-TIME			VASQIP Definition (2014): This indicates the actual time when the entire Time-Out process was completed by the OR team. It will be documented using Military Time format.
75	tov timestamp	VERD;3	DATE-TIME			This field is updated whenever the TIME OUT VERIFIED field (#71) is entered or changed.
76	imag timestamp	VERD;4	DATE-TIME			This field is updated whenever the PREOPERATIVE IMAGING CONFIRMED field (#72) is entered or changed.
77	site mark timestamp	VERD;5	DATE-TIME			This field is updated whenever the MARKED SITE CONFIRMED field (#73) is entered or changed.
78	previously scheduled case	SP;2	POINTER	130		This field identifies the previously scheduled case that was cancelled and replaced by this case.
79	rescheduled case	SP;3	POINTER	130		This field identifies the new surgery case that will be scheduled later to replace this cancelled case.
80	spd comments	80;0	WORD-PROCESSING			This word-processing field contains any information for SPD that cannot be entered elsewhere. These comments will be sent to SPD via the Surgery/CoreFLS interface.
81	dynamed notified	31;10	BOOLEAN	1:YES 0:NO		YES indicates at least one notification has been sent to DynaMed by way of the CoreFLS interface. A null value or zero indicates no notification has been sent. The first notification sent to DynaMed will be a NEW APPOINTMENT notification. Subsequent notifications will be for edit, cancel or delete notifications, as appropriate.
82	time out verified comments	82;0	WORD-PROCESSING			This word-processing field contains comments related to the TIME OUT VERIFIED field. The information entered in this field clarifies entry that is entered as "NO".
83	imaging confirmed comments	83;0	WORD-PROCESSING			This word-processing field contains comments related to the PREOPERATIVE IMAGING CONFIRMED field. The information entered in this field clarifies entry that is entered as "NO".
84	marked site comments	84;0	WORD-PROCESSING			This word-processing field contains comments related to the MARKED SITE CONFIRMED field. The information entered in this field clarifies entry that is entered as "NO".
85	checklist comment	51;0	WORD-PROCESSING			This field is a comment that is required if any of the listed below fields for the Time Out Verified Utilizing Checklist had a response of "No". - CONFIRM PATIENT IDENTITY (#600) - PROCEDURE TO BE PERFORMED (#601) - VALID CONSENT FORM (#603) - CONFIRM PATIENT POSITION (#604) - CORRECT MEDICAL IMPLANTS (#607) - ANTIBIOTIC PROPHYLAXIS (#608) - APPROPRIATE DVT PROPHYLAXIS (#609) - BLOOD AVAILABILITY (#610) - AVAILABILITY OF SPECIAL EQUIP (#611) - SITE OF PROCEDURE (#602) - MARKED SITE CONFIRMED (#605) - REOPERATIVE IMAGES CONFIRMED (#606)
100	order number	0;14	POINTER	100		This is the pointer to the ORDER file (100). It will be created when a case is requested.
101	staff/resident	.1;3	SET OF CODES	R:RESIDENT S:STAFF		This determines whether the surgeon was a resident or staff. It will be used for categorizing procedures in the Annual Report of Surgical Procedures.
102	reason for no assessment	RA;7	SET OF CODES	0:NON-SURGEON CASE 1:ANESTHESIA TYPE 2:EXCEEDS MAX ASSMNTS 3:EXCEEDS MAX TURPS 4:STUDY CRITERIA 5:PREVIOUS CASE 6:10% RULE 7:PRIOR INDEX PROC 8:CONCURRENT CASE 9:EXCEEDS MAX HERNIAS		VASQIP Definition (2014): This is the reason why no assessment was entered for this particular surgical case. It should be entered if any major procedure was excluded from the risk assessment module. 0 - Non-surgeon performed the procedure 2 - Number of surgical cases entered into the Surgical Risk Study exceeded 36 over an 8 day time frame 3 - Number of TURPs or TURBTs exceeded 5 cases over an 8 day time frame 4 - Study exclusion criteria prohibits patient entry 6 - Surgical Quality Nurse exclusion of up to 10% of assessments within the fiscal year 8 - Case was a concurrent case, secondary to an assessed primary case 9 - Number of hernias exceeded 5 cases over an 8 day time frame
103	anesthetist category	.3;8	SET OF CODES	A:ANESTHESIOLOGIST N:NURSE ANESTHETIST O:OTHER		This field holds the category of the principal anesthetist which is used on the Anesthesia AMIS report to enumerate the number of anesthetics administered by each category.
118	non-or procedure	NON;1	BOOLEAN	Y:YES		This field is a flag signifying this case is a non-OR surgical procedure.
119	non-or location	NON;2	POINTER	44		This is the location (file 44) where this non-OR procedure was performed.
120	date of procedure(+)	NON;3	DATE-TIME			This is the date that the non-OR procedure was performed. The date of procedure must be entered for all non-OR cases.
121	time procedure began	NON;4	DATE-TIME			This is the date and time that the non-OR procedure began.
122	time procedure ended	NON;5	DATE-TIME			This is the date and time that all the procedures for this non-OR case are complete.
123	provider(+)	NON;6	POINTER	200		This is the person who performs the major portion of the principal non-OR procedure. This field is required for several reports.
124	attend provider	NON;7	POINTER	200		This is the name of the attending staff provider responsible for this case. This information appears on several reports.
125	medical specialty(+)	NON;8	POINTER	723		This is the medical specialty credited for doing this non-OR procedure. Many reports are sorted by the medical specialty. This field should be entered prior to completion of this non-OR procedure.
126	procedure occurrence	43;0	MULTIPLE	130.0126		This is a occurrence that is related to a non-O.R. procedure. If there are not any non-O.R. procedure occurrences, this field should be left blank. Do not enter 'NO' or 'NONE'.
127	sequential compression device	.7;3	BOOLEAN	Y:YES N:NO		This determines whether a sequential compression device was used.
128	laser type	.7;8	FREE TEXT			This determines whether a laser was used during this procedure. If applicable, enter the type of laser used during this surgical procedure.
129	laser unit	44;0	MULTIPLE	130.0129		These are the laser units, if any, used during this procedure.
130	cell saver	45;0	MULTIPLE	130.013		These are the cell savers, if any, used during this procedure.
131	device(s)	46;1	FREE TEXT			This field documents devices used in this procedure that are not documented elsewhere.
200	operations this admission	200;51	NUMERIC			This is the total number of surgical procedures, prior to the index or principal operation, which required the patient to be taken to the operating room for any type of surgical intervention during this hospital admission. Include all procedures whether or not they are part of the inclusion/exclusion criteria.
201	redo procedure	200;53	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the principal operative procedure was a reoperation in the same anatomic location for the same purpose as the first operation regardless of the length of time from the original surgical date.
202	*current smoker	200;3	SET OF CODES	Y:YES N:NO NS:NO STUDY		This field has been flagged as obsolete for VASQIP. It should no longer be used. Non-Cardiac Definition Revised (2006): If the patient has smoked cigarettes in the year prior to admission for surgery enter YES. Do not include patients who smoke cigars or pipes or use chewing tobacco.
202.1	pack/years	208;9	FREE TEXT			Definition Revised (2004): If the patient has ever been a smoker, enter the total number of pack/years of smoking for this patient. Pack-years are defined as the number of packs of cigarettes smoked per day times the number of years the patient has smoked. If the patient has never been a smoker, enter "0". If pack-years are >200, just enter 200. If smoking history cannot be determined, enter "NS". The possible range for number of pack-years is 0 to 200. If the chart documents differing values for pack year cigarette history, or ranges for either packs/day or number of years patient has smoked, select the highest value documented, unless you are confident in a particular documenter's assessment (e.g., preoperative anesthesia evaluation often includes a more accurate assessment of this value because of the impact it may have on the patient's response to anesthesia).
203	history of copd	200;11	BOOLEAN	Y:YES N:NO		VASQIP Definition (2011): Chronic obstructive pulmonary disease (such as emphysema and/or chronic bronchitis) resulting in any one or more of the following: - Functional disability from COPD (e.g., dyspnea, inability to perform ADLs) - Hospitalization in the past for treatment of COPD - Requires chronic bronchodilator therapy with oral or inhaled agents (see list of bronchodilators below) - An FEV1 of <75% of predicted on pulmonary function testing Do not include patients whose only pulmonary disease is acute asthma, an acute and chronic inflammatory disease of the airways resulting in bronchospasm. Do not include patients with diffuse interstitial fibrosis or sarcoidosis. (This list may not be all-inclusive. Please check your hospital formulary)
204	ventilator dependent	200;10	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): A preoperative patient requiring ventilator-assisted respirations at any time during the 48 hours preceding surgery. This does not include the treatment of sleep apnea with CPAP.
205	prior mi	206;14	SET OF CODES	0:NO 1:YES, < OR EQUAL TO 7 DAYS PRIO TO SURG 2:YES, BETWEEN 7 DAYS AND 6 MONTHS PRIOR TO SURG 3:UNKNOWN		Definition Revised (2014): Indicate if the patient has a history of myocardial infarction within 6 months prior to surgery as diagnosed in his or her medical records. Select the one appropriate response: 0. No 1. Yes, less than or equal to 7 days prior to surgery 2. Yes, between 7 days and 6 months prior to surgery 3. Unknown
206	vascular (y/n)	200;40	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has any vascular problems.
207	congestive heart failure	206;19	SET OF CODES	N:NONE I:CARDIAC DISEASE, NO SYMPTOMS II:SLIGHT LIMITATION III:MARKED LIMITATION IV:SYMPTOMS AT REST U:UNKNOWN		Definition Revised (2014): 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. The New York Heart Association functional classification is used as a subjective assessment of the severity of congestive heart failure. Indicate the one most appropriate response: None - no congestive heart failure. Class I - cardiac disease, no symptoms of abnormal fatigue, dyspnea, or angina. Class II - slight limitation of physical activity by fatigue, dyspnea, or angina. The patient gets unusual fatigue, dyspnea, and/or angina only upon performing more strenuous activities, such as climbing two or more flights of stairs without stopping. Class III - marked limitation of physical activity by fatigue, dyspnea, or angina. The patient gets unusual fatigue, dyspnea, and/or angina upon performing ordinary activities, such as walking several blocks or climbing a flight of stairs. Class IV - symptoms at rest and/or inability to carry out any physical activity without symptoms of fatigue, dyspnea or angina. The patient has symptoms of unusual fatigue, dyspnea, and/or angina at rest or when performing minimal activity, such as walking across the room. Unknown - Unknown
208	*hypertension requiring meds	200;36	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): The patient has a persistent elevation of systolic blood pressure >140 mm Hg or a diastolic blood pressure >90 mm Hg or requires an antihypertensive treatment (e.g., diuretics, beta blockers, ACE inhibitors, calcium channel blockers) at the time the patient is being considered as a candidate for surgery which should be no longer than 30 days prior to surgery. Hypertension must be documented in the patient's chart.
209	cardiomegaly	206;6	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the patient has generalized cardiac enlargement of any or all of the cardiac chambers by standard or portable chest x-ray within 30 days preceding surgery.
210	central nervous system (y/n)	200;18	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of illness related to the central nervous system (CNS).
211	currently on dialysis	200;39	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2006): Acute or chronic renal failure requiring periodic peritoneal dialysis, hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration within 2 weeks prior to surgery.
212	ascites	200;15	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2010): Ascites within 30 days prior to surgery: The presence of fluid in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI within 30 days prior to the operation. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).
213	esophageal varices	200;16	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Esophageal varices are engorged collateral veins in the esophagus that bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal pressure results in esophageal varices that are most frequently demonstrated by direct visualization at esophagoscopy. Esophageal varices must be present preoperatively and must be documented on a recent EGD or CT scan performed within 6 months prior to the surgical procedure.
214	pgy of primary surgeon	200;52	NUMERIC			Definition Revised (2004): Enter the number of surgical residency postgraduate years of the primary surgeon (1-12). Enter 0 if the primary surgeon is a staff/attending surgeon and not a surgical resident or fellow. PGYs greater than 12 should be reported as '12'.
215	weight loss > 10%	200;48	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): A >10% decrease in body weight in the six month interval immediately preceding surgery as manifested by serial weights in the chart, as reported by the patient, or as evidenced by change in clothing size or severe cachexia. Exclude patients who have intentionally lost weight as part of a weight reduction program.
216	bleeding disorders	200;49	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2014): Bleeding (coagulation) disorder is a condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (e.g., vitamin K deficiency, hemophilia, von Willebrand disease). Answer YES if the patient has a documented bleeding (coagulation) disorder that is either chronic or acute.
217	transfusion > 4 rbc units	200;50	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Preoperative loss of blood necessitating a minimum of 5 units of whole blood/packed red cells transfused during the 72 hours prior to surgery including any blood transfused in the emergency room.
218	open wound	200;46	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Evidence of an open wound that communicates to the air by direct exposure, with or without cellulitis or purulent exudate. This does not include osteomyelitis or localized abscesses. The wound must communicate to the air by direct exposure. Report mandible fractures under this preoperative variable.
218.1	preoperative sepsis	206;8	SET OF CODES	Y:YES N:NONE 1:SIRS 2:SEPSIS 3:SEPTIC SHOCK NS:NO STUDY		Definition Revised (2014): 2. Sepsis is the systematic response to infection. Answer YES if both of the following criteria are met: a) Clinical documentation of infection (such as wound with purulent drainage, ruptured bowel with free air, etc.); or a positive culture from any site thought to be causative; or specialized laboratory evidence of causative infection (such as viral DNA in blood). AND b) The presence of two or more of the following systemic responses: - Temperature > 38 degrees C or < 36 degrees C - HR > 90 beats/minute - RR > 20 breaths /minute or PaCO2 < 32 mmHg - WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature neutrophils ("bands") 3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Terminology such as Severe Sepsis/Septic Shock/Refractory Septic Shock and Multiple Organ Dysfunction Syndrome (MODS) all fall into this category. Answer YES if the definition of SEPSIS is present AND there is documented organ and/or circulatory dysfunction defined by one or more of the following: - Areas of acutely mottled skin not related to peripheral vascular disease - Capillary refilling requires three seconds or longer not related to peripheral vascular disease - Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy - Lactate >2 mmol/L - Abrupt change in mental status - Abnormal EEG findings - Platelet count < 100,000 platelets/mL - Disseminated intravascular coagulation (DIC) - Acute lung injury or acute respiratory distress syndrome (ARDS) - New cardiac dysfunction as defined by ECHO or direct measurement of the cardiac index - An arterial systolic blood pressure (SBP) of <=90 mm Hg or a mean arterial pressure (MAP) <=70 mm Hg for at least 1 hour despite adequate fluid resuscitation, adequate intravascular volume status, or the need for vasopressors to maintain SBP >= 90 mm Hg or MAP >=70 mm Hg.
219	preoperative hemoglobin	201;20	FREE TEXT			Definition Revised (2004): Indicate the patient's hemoglobin result (g/dl) preoperatively evaluated closest to surgery but not greater than 30 days before surgery. Entering "NS" for "No Study/Unknown" is not allowed.
220	*previous pci	200;32	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): The patient has undergone or has had an attempt at percutaneous coronary intervention at any time. This includes either balloon dilatation or stent placement. This does not include valvuloplasty procedures.
221	preoperative cpk	201;6	NUMERIC			This is the result of the preoperative creatinine phosphokinase (CPK) test.
222	preoperative mb band	201;7	NUMERIC			This is the value of the preoperative methyline blue (MB) band. Your answer must be between 0 and 50.
223	preoperative serum creatinine	201;4	FREE TEXT			Definition Revised (2011): This is the serum creatinine result (mg/dl) most closely preceding surgery - not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for non-cardiac case assessments.
224	preoperative bun	201;5	FREE TEXT			This is the result of the preoperative Blood Urea Nitrogen (BUN) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
225	preoperative serum albumin	201;8	FREE TEXT			Definition Revised (2011): This is the serum albumin result (g/dl) most closely preceding surgery - not to exceed 30 days for Cardiac surgery. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is allowed for non-cardiac case assessments.
226	preoperative sgpt	201;10	NUMERIC			This is the result of the preoperative serum glutamic pyruvic transaminase (SGPT) test.
227	preoperative sgot	201;11	FREE TEXT			This is the result of the preoperative serum glutamic oxaloacetic (SGOT) test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
228	preoperative total bilirubin	201;9	FREE TEXT			This is the result of the preoperative total bilirubin test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
229	preoperative alk phosphatase	201;12	FREE TEXT			This is the result of the preoperative alkaline phosphatase test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
230	preoperative wbc	201;13	FREE TEXT			This is the result of the preoperative white blood count (WBC). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
231	preoperative platelet count	201;15	FREE TEXT			This is the result of the preoperative platelet count. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
232	preoperative pt	201;17	FREE TEXT			This is the result of the preoperative prothombin time (PT). Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
233	preoperative ptt	201;16	FREE TEXT			This is the result of the preoperative partial thromboplastin time (PTT). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
234	preoperative hematocrit	201;14	FREE TEXT			This is the result of the preoperative hematocrit test. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
235	assessment status	RA;1	SET OF CODES	I:INCOMPLETE C:COMPLETE T:TRANSMITTED N:NO ASSESSMENT		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'.
236	height	206;1	FREE TEXT			VASQIP Definition (2010): Height: Report the patient's most recent height before surgery documented in the medical record in either inches (25 to 86 in) or centimeters (63 to 218 cm). If you are entering the patient's height in centimeters, enter 'C' after the number of centimeters. Your answer should be in one of the following two formats. 68 (representing inches) 173C (representing centimeters) The software pulls the most recent height measurement, regardless of when it was taken. The date of the measurement returned by the capture process is displayed on the data input screen.
236.1	height measurement date	200.1;7	DATE-TIME			This is the date of the patient's height measurement. This date is taken from the VITALS software.
237	weight	206;2	FREE TEXT			VASQIP Definition (2010): Weight: Report the patient's most recent weight before surgery documented in the medical record in either pounds (50 to 999 lbs) or kilograms (23 to 453 kg). If you are entering the patient's weight in kilograms, enter 'K' after the number of kilograms. The software pulls the latest value up to 30 days prior to surgery. If no value is found in the Vitals software, the nurse reviewer must enter the value manually. Your answer should be in one of the following formats. 178 (weight in pounds) 80K (weight in Kilograms)
237.1	preoperative sleep apnea	200.1;8	SET OF CODES	1:NONE - LEVEL 1 2:SUSPICION OF SLEEP APNEA - LEVEL 2 3:SLEEP APNEA CONFIRMED - LEVEL 3		VASQIP Definition (2014): Sleep Apnea is a disorder of respiration whereby the individual has hypoxic and/or apneic periods during sleep due to prolapse or flaccidity of oropharyngeal structures, which improves with positive airway pressure (i.e., CPAP or BIPAP). Select one of the following categories that best indicates the patient's level of sleep apnea. Level 1 = None: No diagnosis or suspicion of Sleep Apnea Level 2 = Suspicion of Sleep Apnea: No sleep study has been done, however the patient has TWO or MORE of the following risk factors for Sleep Apnea: a) Obesity (BMI > 35) b) Thick neck (men > 17 inches, women > 16 inches) c) Snoring, loud or frequent d) Observed apneas (partner/roommate reported observing obstruction episodes during sleep) e) Frequent arousals from sleep or choking during sleep f) Daytime somnolence g) Patient reports diagnosis of sleep apnea even if sleep study results are not in the medical record Level 3 = Sleep Apnea: Sleep apnea confirmed by Sleep Study OR patient currently uses CPAP/BIPAP at home. Answer Options: - None - Suspicion of Sleep Apnea - Sleep Apnea Confirmed
238	dnr status	200;7	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the only condition under which a DNR order is official in the VA in the 30 days prior to this surgery], enter "YES". If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the patient, enter "YES". Answer "NO" if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order.
239	preoperative hemoglobin, date	202;20	DATE-TIME			This is the date that the preoperative hemoglobin test was performed.
240	functional health status	200;8	SET OF CODES	1:INDEPENDENT 2:PARTIALLY DEPENDENT 3:TOTALLY DEPENDENT 4:UNKNOWN		VASQIP Definition (2011): This is a question that focuses on the patient's abilities to perform activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are defined as 'the activities usually performed in the course of a normal day in a person's life'. ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level of self-care for activities of daily living demonstrated by this patient at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's status changes prior to surgery, that change should be reflected in your assessment. For this time point, report the level of functional health status as defined by the following criteria. (1) Independent: The patient does not require assistance from another person for any activities of daily living. This includes a person who is able to function independently with prosthetics, equipment, or devices. (2) Partially dependent: The patient requires some assistance from another person for activities of daily living. This includes a person who utilizes prosthetics, equipment, or devices but still requires some assistance from another person for ADLs. (3) Totally dependent: The patient requires total assistance for all activities of daily living. (4) Unknown: If unable to ascertain the functional status. All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with schizophrenia is able to care for him/herself without the assistance of nursing care, he/she is considered independent.
241	pulmonary (y/n)	200;9	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of pulmonary illnesses.
242	cardiac (y/n)	200;30	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of cardiac illnesses.
243	renal (y/n)	200;37	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of renal illnesses.
244	hepatobiliary (y/n)	200;13	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of hepatobiliary illnesses.
245	nutritional/immune/other	200;44	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of illness related to nutrition, immune deficiencies or other general deficiencies.
246	etoh > 2 drinks/day	200;4	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): The patient admits to drinking >2 ounces of hard liquor or more than two 12 oz. cans of beer or more than two 6 oz. glasses of wine per day in the two weeks prior to admission. If the patient is a "binge drinker" divide out the numbers of drinks during the binge by seven days, and then apply the definition.
247	length of post-op stay	205;1	FREE TEXT			Definition Revised (2004): The software will automatically calculate the total number of days that the patient stayed in the acute care services of the medical center. The number of days should include the day after surgery and the date of discharge or transfer to intermediate or chronic care facilities. Enter NA if LENGTH OF POST-OP STAY is not applicable.
248	superficial incisional ssi	205;6	SET OF CODES	Y:YES N:NO NS:NO STUDY		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).
249	deep incisional ssi	205;7	SET OF CODES	Y:YES N:NO NS:NO STUDY		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.
250	systemic sepsis	205;35	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. Please report the most significant level using the criteria below: 1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following: - Temp >38 degrees C or <36 degrees C - HR >90 bpm - RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa) - WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms - Anion gap acidosis: this is defined by either: [Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is greater than 16, then an anion gap acidosis is present. or Na - [Cl + HCO3 (or serum CO2)]. If this number is greater than 12, then an anion gap acidosis is present. and one of the following: - positive blood culture - clinical documentation of purulence or positive culture from any site thought to be causative 2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents. * For the patient that had sepsis preoperatively, worsening of any of the above signs postoperatively would be reported as a postoperative sepsis. Examples: A patient comes into the emergency room with signs of sepsis - WBC 31, Temperature 104. CT shows an abdominal abscess. He is given antibiotics and is then taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively. Postoperatively his WBC and Temperature are trending down. POD#1 WBC 24, Temp 102 POD#2 WBC 14, Temp 100 POD#3 WBC 10, Temp 99 This patient does not have postoperative sepsis as his WBC and Temperature are improving each postoperative day. Patient comes into the ER with s/s of sepsis - WBC 31, Temp 104. CT shows an abdominal abscess. He is given antibiotics and is taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively. Postoperatively his WBC and Temp are as follows: POD#1 WBC 28, Temp 103 POD#2 WBC 24, Temp 102.6 POD#3 WBC 22, Temp 102 POD#4 WBC 21, Temp 101.6 POD#5 WBC 30, Temp 104 This patient does have postoperative sepsis because on postoperative day #5, his WBC and Temperature increase. The patient is having worsening of the defined signs of sepsis.
251	pneumonia	205;10	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Inflammation of the lungs caused primarily by bacteria, viruses, and/or chemical irritants, usually manifested by chills, fever, pain in the chest, cough, purulent, bloody sputum. Enter YES if the patient has pneumonia meeting the definition of pneumonia below AND pneumonia not present preoperatively. Pneumonia must meet one of the following TWO criteria: Criterion 1. Rales or dullness to percussion on physical examination of chest AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolate from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy OR Criterion 2. Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolated from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy d. Isolation of virus or detection of viral antigen in respiratory secretions e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen f. Histopathologic evidence of pneumonia *If pneumonia was present preoperatively and resolved postoperatively and a new pneumonia is identified within 30 days after surgery, the following criteria must be met in order to report as a postoperative pneumonia occurrence: - Patient must have completed the antibiotic course for the previous pneumonia. - Patient must have evidence of a clear chest x-ray after the previous pneumonia and prior to the new pneumonia. - There must be evidence of a new isolate of micro-organism on culture.
252	pulmonary embolism	205;12	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous system. Enter "YES" if the patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram or positive Spiral CT exam. Treatment usually consists of: - Initiation of anticoagulation therapy - Placement of mechanical interruption (e.g. Greenfield Filter), for patients in whom anticoagulation is contraindicated or already instituted.
253	other respiratory occurrence	205;14	POINTER	80		Definition Revised (2004): Enter any other respiratory occurrences that you feel to be significant and that are not covered by the predefined respiratory occurrence categories. Enter the ICD-CM code for this entry.
254	acute renal failure	205;17	SET OF CODES	Y:YES N:NO NS:NO STUDY		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.
255	urinary tract infection	205;18	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Postoperative symptomatic urinary tract infection must meet one of the following TWO criteria: 1. One of the following: fever (>38 degrees C), urgency, frequency, dysuria, or suprapubic tenderness AND a urine culture of >100,000 colonies/ml urine with no more than two species of organisms OR 2. Two of the following: fever (>38 degrees C), urgency, frequency, dysuria, or suprapubic tenderness AND any of the following: - Dipstick test positive for leukocyte esterase and/or nitrate - Pyuria (>10 WBCs/cc or >3 WBC/hpf of unspun urine) - Organisms seen on Gram stain of unspun urine - Two urine cultures with repeated isolation of the same uropathogen with >100 colonies/ml urine in non-voided specimen - Urine culture with <100,000 colonies/ml urine of single uropathogen in patient being treated with appropriate antimicrobial therapy - Physician's diagnosis - Physician institutes appropriate antimicrobial therapy
256	stroke/cva	205;21	SET OF CODES	Y:YES N:NO NS:NO STUDY		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).
257	postop bleeding/transfusions	205;32	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Any transfusion (including autologous) of packed red blood cells or whole blood given from the time the patient leaves the operating room up to and including 72 hours postoperatively. Enter YES for five or more units of packed red blood cell units in the postoperative period including hanging blood from the OR that is finished outside of the OR. If the patient receives shed blood, autologous blood, cell saver blood or pleurovac postoperatively, this is counted if greater than four units. The blood may be given for any reason.
258	myocardial infarction	205;27	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2014): Indicate the presence of a peri-operative MI that occurs either intraoperatively or postoperatively within 30 days: The term acute MI should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Under these conditions any ONE of the following criteria meets the diagnosis for MI: 1. Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile Upper Reference Limit (URL) AND at least one of the following: a. Symptoms suggestive of myocardial ischemia b. New or presumed new significant ST-segment-T wave (ST-T) changes c. New left bundle branch block (LBBB). d. Development of pathological Q waves in the ECG e. Imaging evidence of new loss of viable myocardium f. New regional wall motion abnormality g. Identification of an intracoronary thrombus by angiography or autopsy 2. Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB, but death occurred before cardiac biomarkers were obtained, or before cardiac biomarker values would be increased. 3. Percutaneous coronary intervention (PCI) related MI is arbitrarily defined by elevation of cTn values (>5x 99th percentile URL) in patients with normal baseline values (<99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling, AND at least one of the following: a. Symptoms suggestive of myocardial ischemia b. Presumed new ischemic ECG changes c. Angiographic findings consistent with a procedural complication d. Imaging evidence of new loss of viable myocardium e. New regional wall motion abnormality 4. Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least one value above the 99th percentile URL. 5. Coronary artery bypass grafting (CABG) related MI is arbitrarily defined by elevation of cardiac biomarker values (>10x 99th percentile URL) in patients with normal baseline cTn values (<99th percentile URL), AND at least one of the following a. Development of pathological Q waves in the ECG b. New LBBB c. Angiographic documented new graft or new native coronary artery occlusion d. Imaging evidence of new loss of viable myocardium e. New regional wall motion abnormality
259	pulmonary edema	205;28	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has developed postoperative distress requiring treatment and diagnosis of CHF or pulmonary edema or Adult Respiratory Distress Syndrome.
260	date transmitted	RA;4	DATE-TIME			This is the date (or date/time) that this surgery risk assessment was transmitted.
260.1	date of last transmission	RA;8	DATE-TIME			This is the date of the retransmission if this risk assessment has been retransmitted to the national database. An assessment can be updated and retransmitted within 14 days of the original transmission date. If there was no retransmission of this assessment, this is the date of the original transmission.
261	graft/prosthesis/flap failure	205;33	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Mechanical failure of an extracardiac graft/or prosthesis including myocutaneous flaps and skin grafts requiring return to the operating room, interventional radiology, or a balloon angioplasty.
262	return to or within 30 days	205;4	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Returns to the operating room include all surgical procedures that required the patient to be taken to the surgical operating room for intervention of any kind will automatically be entered by the software.
263	dvt/thrombophlebitis	205;34	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2014): The identification of a new blood clot or thrombus within the deep venous system of an extremity, which may be coupled with inflammation. This does not include intra-parenchymal clots of solid organs or free intra-peritoneal clots. This diagnosis is confirmed by a duplex, venogram, CT scan or other imaging modality. The patient must be treated with or have documented recommendation for: therapeutic anti-coagulation therapy OR placement of a vena cava filter OR clipping of the vena cava.
264	*cerebral vascular disease	206;17	BOOLEAN	Y:YES N:NO		This field has been flagged as obsolete for VASQIP. It should no longer be used. This determines whether the patient has disease of the arteries to the head manifested by previous stroke (cerebral vascular accident), and/or transient ischemic attack (TIA), and/or prior surgical repair (e.g. carotid endarterectomy), and/or greater than or equal to 50% obstruction of luminal diameter documented by contrast angiography or duplex ultrasound examination.
265	peripheral arterial disease	206;16	SET OF CODES	Y:YES N:NO 1:NO 2:YES-W/O ANGI,REVASC,or AMPUT 3:YES-W HX ANGI,REVASC,or AMPUT 4:UNKNOWN		VASQIP Definition (2014): Indicate if the patient has peripheral arterial disease (previously "peripheral vascular disease"), defined as disease of the arteries to legs below bifurcation of aorta manifested by at least one of the following: exertional claudication, ischemic rest pain, prior revascularization procedure(s) on vessels to legs, absent or diminished pulses in legs, or angiographic evidence of non-iatrogenic peripheral arterial obstruction greater than or equal to 50% of luminal diameter. Indicate the one appropriate response: 1. No 2. YES, WITHOUT ANGIOPLASTY, REVASCULARIZATION, OR AMPUTATION PROCEDURE 3. YES, WITH ANY HISTORY OF ANGIOPLASTY, OR REVASCULARIZATION, OR AMPUTATION PROCEDURE, REGARDLESS OF LATERALITY 4. UNKNOWN
266	*previous cardiac surgery	200;33	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2006): Any major cardiac surgical procedure (performed either as an 'off-pump' repair or utilizing cardiopulmonary bypass). This includes coronary artery bypass graft surgery, valve replacement or repair, repair of atrial or ventricular septal defects, great thoracic vessel repair, cardiac transplant, left ventricular aneurysmectomy, insertion of left ventricular assist devices, etc. Do not include pacemaker insertions or automatic implantable cardioverter-defibrillator (AICD) insertions.
267	angina severity	206;18	SET OF CODES	N:NONE I:CLASS I II:CLASS II III:CLASS III IV:CLASS IV U:UNKNOWN		VASQIP Definition (2014): Indicate whether the patient has angina, defined as pain or discomfort between the diaphragm and mandible resulting from myocardial ischemia, usually precipitated by exertion or emotion and relieved by rest or nitroglycerin. The Canadian Cardiovascular Society (CCS) classification is used to record severity of angina. Indicate the one appropriate response, according to the most severe angina in the 30 days prior to surgery: None - No angina Class I - Ordinary physical activity, such as walking or climbing stairs does not cause angina. Angina may occur with strenuous or rapid or prolonged exertion at work or recreation. Class II - There is slight limitation of ordinary activity. Angina may occur with walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, or climbing more than one flight of stairs under normal conditions at a normal pace. Class III - There is marked limitation of ordinary physical activity. Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace. Class IV - There is inability to carry on any physical activity without discomfort. Angina may be present at rest. Unknown - Unknown
268	hepatomegaly	200;14	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has the presence of hepatomegaly. Hepatomegaly is defined as enlargement of the liver indicated usually by palpation of the lower border of the liver below the right costal margin or a liver span greater than 10 cm. Hepatomegaly may be noted in acute hepatitis, fatty infiltration, passive congestion, and early biliary obstruction. It is usually noted by the physician under the abdominal portion of the H&P.
269	pregnancy	200.1;3	SET OF CODES	NO:NO NA:NOT APPLICABLE Y:YES		Definition Revised (2007): Pregnancy is the process by which a woman carries a developing fetus in her uterus, beginning at conception and ending in birth, miscarriage or abortion. Answer Yes if there is documentation in the patient's medical record that the patient is currently pregnant.
270	preoperative serum sodium	201;1	FREE TEXT			This is the result of the preoperative serum sodium test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
271	preoperative potassium	201;2	NUMERIC			This is the result of the preoperative potassium test.
272	date assessment completed	RA;5	DATE-TIME			This is the date that the Assessment was completed. This field will be updated if the assessment was transmitted in error.
272.1	assessment completed by	RA;9	POINTER	200		This is the name of the person who completed this surgery risk assessment.
273	preoperative glucose	201;3	NUMERIC			This is the result of the preoperative glucose test.
274	highest serum sodium	203;1	FREE TEXT			This is the highest result of a postoperative serum sodium test for the selected patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
275	highest potassium	203;3	FREE TEXT			This is the highest result of a potassium test for the selected patient. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
276	highest glucose	203;5	NUMERIC			This is the highest result of a postoperative glucose test for the patient selected.
277	highest serum creatinine	203;6	FREE TEXT			This is the highest postoperative serum creatinine result for the selected patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
278	highest cpk	203;7	FREE TEXT			This is the highest result of a postoperative CPK test for the patient selected. Data input must be 1 to 6 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
279	highest cpk-mb	203;8	FREE TEXT			This is the highest result of a postoperative CP-MB Band for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
280	highest total bilirubin	203;9	FREE TEXT			This is the highest postoperative total bilirubin result recorded for this patient. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
281	highest wbc	203;10	FREE TEXT			This is the highest postoperative WBC for the patient selected. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
282	lowest serum albumin	203;11	NUMERIC			This is the lowest postoperative serum albumin result for the patient selected.
283	lowest hematocrit	203;12	FREE TEXT			This is the lowest postoperative hematocrit result recorded for this patient. Data input must be 1 to 4 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
284	assessment type	RA;2	SET OF CODES	C:CARDIAC N:NON-CARDIAC		This determines whether this surgical risk assessment is a cardiac or non-cardiac procedure.
285	on ventilator >48 hours	205;13	SET OF CODES	Y:YES N:NO NS:NO STUDY		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.
286	other urinary tract occurrence	205;19	POINTER	80		Definition Revised (2004): Enter any other urinary occurrences which you feel to be significant and that are not covered by the predefined urinary tract occurrence categories. Enter the ICD-CM code for this entry.
287	peripheral nerve injury	205;23	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Peripheral nerve damage may result from damage to the nerve fibers, cell body, or myelin sheath during surgery. Peripheral nerve injuries which result in motor deficits only to the cervical plexus, brachial plexus, ulnar plexus, lumbar-sacral plexus (sciatic nerve), peroneal nerve, and/or the femoral nerve should be included.
288	preoperative cpk, date	202;6	DATE-TIME			This is the date that the preoperative CPK was performed.
289	preoperative mb band, date	202;7	DATE-TIME			This is the date that the preoperative MB Band was performed.
290	preop serum creatinine, date	202;4	DATE-TIME			This is the date that the preoperative Serum Creatinine test was performed.
291	preoperative bun, date	202;5	DATE-TIME			This is the date that the preoperative BUN was performed.
292	preop serum albumin, date	202;8	DATE-TIME			This is the date that the preoperative Serum Albumin test was performed.
293	sgpt, date performed	202;10	DATE-TIME			This is the date that the preoperative SGPT was performed.
294	sgot, date performed	202;11	DATE-TIME			This is the date that the preoperative SGOT was performed.
295	preop total bilirubin, date	202;9	DATE-TIME			This is the date that the preoperative total bilirubin was performed.
296	preop alk phosphatase, date	202;12	DATE-TIME			This is the date that the preoperative alkaline phosphatase test was performed.
297	preoperative wbc, date	202;13	DATE-TIME			This is the date that the preoperative WBC test was performed.
298	preop platelet count, date	202;15	DATE-TIME			This is the date that the preoperative platelet count was performed.
299	preoperative pt, date	202;17	DATE-TIME			This is the date that the preoperative PT test was performed.
300	preoperative ptt, date	202;16	DATE-TIME			This is the date that the preoperative PTT test was performed.
301	preop hematocrit, date	202;14	DATE-TIME			This is the date that the preoperative hematocrit was performed.
302	preoperative glucose, date	202;3	DATE-TIME			This is the date that the preoperative glucose test was performed.
303	preop potassium, date	202;2	DATE-TIME			This is the date that the preoperative potassium test was performed.
304	preop serum sodium, date	202;1	DATE-TIME			This is the date that the preoperative serum sodium test was performed.
305	high serum sodium, date	204;1	DATE-TIME			This is the date that the highest Serum Sodium result was recorded.
306	high potassium, date	204;3	DATE-TIME			This is the date that the highest Potassium result was recorded.
307	high glucose, date	204;5	DATE-TIME			This is the date that the highest Glucose result was recorded.
308	high serum creatinine, date	204;6	DATE-TIME			This is the date that the highest Serum Creatinine result was recorded.
309	high cpk, date	204;7	DATE-TIME			This is the date that the highest CPK result was recorded.
310	high cpk-mb, date	204;8	DATE-TIME			This is the date that the highest CPK-MB Band result was recorded.
311	high total bilirubin, date	204;9	DATE-TIME			This is the date that the highest Total Bilirubin was recorded.
312	highest wbc, date	204;10	DATE-TIME			This is the date that the highest WBC was recorded.
313	low serum albumin, date	204;11	DATE-TIME			This is the date that the lowest Serum Albumin result was recorded.
314	low hematocrit, date	204;12	DATE-TIME			This is the date that the lowest Hematocrit result was recorded.
315	preoperative pt control	201;19	NUMERIC			This is the result of the preoperative PT control. Your answer must be between 9 and 15.
316	preoperative ptt control	201;18	NUMERIC			This is the preoperative PTT control result. Your answer must be between 15 and 40.
318	respiratory occurrences	205;9	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient had postoperative respiratory occurrences. A respiratory occurrence is defined as an impairment to the lungs to perform their ventilatory function. This may be due to impairment of gas exchange in the lung or obstruction of the free flow of air to the lung.
319	urinary tract occurrences	205;15	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has had postoperative urinary tract occurrences. Urinary tract occurrences are defined as difficulties related to the organs and ducts participating in the secretion and elimination of urine.
320	cns occurrences	205;20	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has had any postoperative central nervous system (CNS) occurrences. These occurrences are defined as difficulties related to the brain and spinal cord, with their nerves and end-organs that control voluntary acts.
321	cardiac occurrences	205;25	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has had any postoperative cardiac occurrences. Cardiac occurrences are defined as difficulties encountered involving the cardiac system.
322	other occurrences	205;30	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has had postoperative occurrences, such as Graft/Prosthesis Failure or Unplanned Return to OR, not included in any of the other categories.
323	create risk assessment	RA;6	BOOLEAN	Y:YES N:NO		This determines whether a risk assessment will be created for this surgical case. If answered 'NO', the information will automatically be completed so that the information will be transmitted without any additional intervention.
324	drug addiction	200;5	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether this patient has a history of recreational or narcotic substance abuse. There is no time limit on this data element.
325	dyspnea	200;6	SET OF CODES	1:NO 2:MODERATE EXERTION 3:AT REST NS:NO STUDY		Definition Revised (2007): The patient describes difficult, painful, or labored breathing. Dyspnea may be symptomatic of numerous disorders that interfere with adequate ventilation or perfusion of the blood with oxygen. The dyspneic patient is subjectively aware of difficulty with breathing. Select one of the following categories that best indicates the patient's subjective experience coupled with your objective assessment: (1) No dyspnea (2) Dyspnea upon moderate exertion (e.g., is unable to climb one flight of stairs without shortness of breath) (3) Dyspnea at rest (e.g., cannot complete a sentence without needing to take a breath) The time frame is at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's dyspnea status worsens prior to surgery, report the most severe.
326	current pneumonia	200;12	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Report patients with evidence of pneumonia at the time the patient is brought to the OR. Patients with pneumonia must meet ONE of the following two criteria: Criterion 1. Rales or dullness to percussion on physical examination of chest AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolate from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy OR Criterion 2. Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolated from blood culture c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy d. Isolation of virus or detection of viral antigen in respiratory secretions e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen f. Histopathologic evidence of pneumonia
327	active hepatitis	200;17	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has active hepatitis. Active Hepatitis is defined as an active inflammation of the liver evidenced by elevated liver enzymes. The most common causes are viral hepatitis documented by positive serologies (A,B, or C) and recent excessive alcohol intake, or drug induced hepatitis.
328	renal failure	200;38	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): The clinical condition associated with rapid, steadily increasing azotemia (increase in BUN), and a rising creatinine of above 3 mg/dl. Acute renal failure should be noted within 24 hours prior to surgery.
329	*revascularization/amputation	200;41	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Any type of angioplasty or revascularization procedure for atherosclerotic peripheral vascular disease (PVD) (e.g., aorto-femoral, femoral-femoral, femoral-popliteal) or a patient who has had any type of amputation procedure for PVD (e.g., toe amputations, transmetatarsal amputations, below the knee or above the knee amputations). Patients who have had amputation for trauma or a resection of abdominal aortic aneurysms should not be included.
330	rest pain/gangrene (y/n)	200;42	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Rest pain is a more severe form of ischemic pain due to occlusive disease, which occurs at rest and is manifested as a severe, unrelenting pain aggravated by elevation and often preventing sleep. Gangrene is a marked skin discoloration and disruption indicative of death and decay of tissues in the extremities due to severe and prolonged ischemia. Include patients with ischemic ulceration and/or tissue loss related to peripheral vascular disease. Do not include Fournier's gangrene. Report only if within the 30 days preoperatively.
331	absent peripheral pulses	200;43	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has been diagnosed on the physical examination to have absent femoral, popliteal, or pedal pulses. If he or she has had a previous amputation, record pulses as present or absent in the remaining limb.
332	impaired sensorium	200;19	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient is acutely confused and/or delirious and responds to verbal and/or mild tactile stimulation. Patients should be noted to have developed an impaired sensorium if they have mental status changes, and/or delirium in the context of the current illness. Patients with chronic or long-standing mental status changes secondary to chronic mental illness (e.g., schizophrenia) or chronic dementing illnesses (e.g., multi-infarct dementia, senile dementia of the Alzheimer's type) should not be included. This assessment of the patient's mental status should be within 48 hours prior to the surgical procedure. If the patient develops impaired sensorium, then progresses to a coma, and remains in a coma entering surgery, report just coma. Example: A patient is admitted to the orthopedics service after a fall with a fractured hip. The patient is also noted to be dehydrated and febrile. He is disoriented to place and time and seems confused. His family reports that he has been oriented and alert prior to the fall. This patient has an impaired sensorium on the basis of his confusion and disorientation. Example: A patient is admitted to the general surgical service with biliary sepsis and high spiking fevers. While febrile, the patient is noted by the clinician to be disoriented and confused. This patient has an impaired sensorium. Example: A long-term resident of a VA nursing home with chronic schizophrenia is admitted for an elective hernia repair. He is noted to have long-standing mental status changes and is chronically disoriented to place, time, and person. Although this patient has disorientation, his mental status changes are long-standing, chronic, and unchanged and would not qualify for "impaired sensorium." Note: These examples would apply only if noted within 48 hours prior to surgery
333	coma	200;21	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient is unconscious, postures to painful stimuli, or is unresponsive to all stimuli entering surgery. This does not include drug-induced coma.
334	*history of tia's	200;25	SET OF CODES	Y:YES N:NO NS:NO STUDY		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2004): Transient ischemic attacks (TIAs) are focal neurologic deficits (e.g. numbness of an arm or amaurosis fugax) of sudden onset and brief duration (usually <30 minutes), which usually reflect dysfunction in a cerebral vascular distribution. These attacks may be recurrent and, at times, may precede a stroke.
335	*cva/stroke with neuro deficit	200;26	SET OF CODES	Y:YES N:NO NS:NO STUDY		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with persistent residual motor, sensory, or cognitive dysfunction. (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory). If the neurological deficit is hemiplegia/hemiparesis, also enter YES to Hemiplegia/Hemiparesis in addition to CVA/Stroke.
336	*cva/stroke - no neuro deficit	200;27	SET OF CODES	Y:YES N:NO NS:NO STUDY		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2004): History of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with neurologic deficit(s) lasting at least 30 minutes, but no current residual neurologic dysfunction or deficit.
337	neuro degenerative disease	200;28	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has neuromuscular degenerative disease. It is defined as any of a number of congenital, hereditary, or acquired diseases resulting in chronic neurological deficits. Common examples of these diseases include muscular dystrophy, amyotrophic lateral sclerosis (ALS or 'Lou Gerhig's Disease'), multiple sclerosis, and poliomyelitis.
338	disseminated cancer (y/n)	200;45	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2010): Disseminated cancer: Patients who have cancer known to be present prior to the start of surgery that: (1) Has spread to one site or more sites in addition to the primary site AND (2) In whom the presence of multiple metastases indicates the cancer is widespread, fulminant, or near terminal. Other terms describing disseminated cancer include "diffuse," "widely metastatic," "widespread," or "carcinomatosis", or AJCC "Stage IV" cancer. Common sites of metastases include major organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You may use the National Cancer Institute as a reference in determining whether a patient has AJCC Stage IV cancer, when the TNM information is the only information documented. Refer to the following website for assistance with translating TNM values with AJCC staging: http://www.cancer.gov/cancertopics/pdq/adulttreatment Examples: - A patient with a primary breast cancer with positive nodes in the axilla does NOT qualify for this definition. The tumor has spread to a site other than the primary site, but does not have widespread metastases. A patient with primary breast cancer with positive nodes in the axilla AND liver metastases does qualify, because the tumor has spread to the axilla and other major organs. - A patient with colon cancer and no positive nodes or distant metastases does NOT qualify. A patient with colon cancer and several local lymph nodes positive for tumor, but no other evidence of metastatic disease does NOT qualify. A patient with colon cancer with liver metastases and/or peritoneal seeding with tumor does qualify. - A patient with adenocarcinoma of the prostate confined to the capsule does NOT qualify. A patient with prostate cancer that extends through the capsule of the prostate only does NOT qualify. A patient with prostate cancer with bony metastases DOES qualify. Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.
338.1	chemotherapy in last 30 days	206;3	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Enter "YES" if the patient had any chemotherapy treatment for cancer in the 30 days prior to surgery. Chemotherapy may include, but is not restricted to, oral and parenteral treatment with chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma. Do not count if treatment consists solely of hormonal therapy. (See Operations Manual for list of chemotherapeutic agents.) Chemotherapy treatment must be for malignancy.
338.2	radiotherapy in last 90 days	206;4	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Enter "YES" if the patient had any radiotherapy treatment for cancer in the 90 days prior to surgery. If the patient had radiation seeds implanted, count if implantation is within 90 days prior to the operation.
339	steroid use for chronic cond.	200;47	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient has required the regular administration of oral or parenteral corticosteroid medications (e.g., Prednisone, Decadron) in the 30 days prior to admission for a chronic medical condition (e.g., COPD, asthma, rheumatologic disease, rheumatoid arthritis, inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally. Do not include patients who only receive short course steroids (duration 10 days or less) in the 30 days prior to surgery. (See list of corticosteroids in Operations Manual.)
340	intraop rbc units transfused	200;54	FREE TEXT			Definition Revised (2014): Indicate the number of packed or whole red blood cells given during the operative procedure as it appears on the anesthesia record. The amount of blood reinfused from the cell saver should also be noted here. The algorithm for cell saver volume to RBC unit determination is: 0 units - 0-124 cc's 1 unit - 125 - 375 cc's 2 units - 376 - 625 cc's 3 units - 626 - 875 cc's
341	30 day postop status	205;2	SET OF CODES	1:DISCHARGED ALIVE 2:DIED IN HOSPITAL 3:REMAINS IN VAMC FACILITY 4:TRANSFERRED TO ANOTHER VAMC 5:READMITTED NS:NO STUDY		This is the patient's status 30 days postoperatively. Please select one of the following categories. 1. Discharged alive to home, nursing home, rehabilitation, or psychiatric facility 2. Died in Hospital perioperatively or postoperatively 3. Still in your VAMC facility in the ICU, on a medical-surgical floor, or undergoing rehabilitation therapy. 4. Transferred to the ICU or acute care floor of another VAMC facility from your VAMC without going home 5. Patient was discharged home, but was readmitted to any hospital within 30 days postoperatively due to a postoperative complication as confirmed by the Chief Surgical Resident, Principle Investigator, or Chief of Surgery. If the patient was readmitted due to a postoperative complication, please enter the information in the outcome section of the assessment.
342	date of death	205;3	FREE TEXT			If the patient has died, this is the date/time of death.
342.1	30 day death	205;41	BOOLEAN	Y:YES N:NO		This field indicates whether operative death has occurred within 30 days of surgery. This field auto populates based on an entry into the DATE OF DEATH field (#342). If Date of Death occurs within 30 days or less of the Date of Operation, then this field is automatically updated to "Yes" when the Date of Death is saved. If the Date of Death is greater than 30 days from the Date of Operation or "NA" is entered then this field is automatically updated to "No" when the Date of Death is saved.
343	other cns occurrence	205;24	POINTER	80		Definition Revised (2004): Enter any other neurologic related occurrences, which you feel to be significant and that are not covered by the predefined CNS occurrence categories. Enter the ICD-CM code for this entry.
344	other cardiac occurrence	205;29	POINTER	80		Definition Revised (2004): Enter any other cardiac related surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-CM code for this entry.
345	ileus/bowel obstruction	205;31	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has prolonged ileus or bowel obstruction. Ileus is obstruction of the intestines from a variety of causes including mechanical obstruction, peritonitis, adhesions, or post surgically as a result of functional dysmotility by the bowel. Bowel obstruction is any hindrance to the passage of the intestinal contents. Prolonged ileus or obstruction is defined as persisting longer than 5 days postoperatively.
346	*diabetes	200;2	SET OF CODES	N:NO O:ORAL I:INSULIN		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2004): Diabetes mellitus is a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. Report the treatment regimen of the patient's chronic, long-term management. Do not include a patient if diabetes is controlled by diet alone. No: No diagnosis of diabetes or diabetes controlled by diet alone Oral: A diagnosis of diabetes requiring therapy with an oral hypoglycemic agent (see list of oral hypoglycemic agents in Operations Manual) Insulin: A diagnosis of diabetes requiring daily insulin therapy (see list of insulin therapy agents in Operations Manual)
347	fev1	206;5	FREE TEXT			This is the forced expiratory volume in one second from the most recent pulmonary function test prior to surgery. Enter 'NS' if there has been no pulmonary function tests in the preceding year.
348	pulmonary rales	206;7	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the chart documents rales not clearing with cough (and not due to pneumonic process) heard within two weeks before surgery. Do not include rales that clear with coughing, as these are usually due to atelectasis and carry a much more benign connotation. Please note, crackles are another common approach to noting that rales are present.
349	active endocarditis	206;10	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the patient is being treated with antibiotics for active infection on or near a cardiac valve at the time of surgery or within 2 weeks prior to surgery. Endocarditis is defined as two or more blood cultures positive for the same organism, usually with evidence of a valvular vegetation or valve dysfunction by cardiac ultrasound. In the absence of positive blood cultures, there should be clear evidence of valve infection and/or destruction by ultrasound or direct observation at surgery with subsequent histologic confirmation.
350	resting st depression	206;11	BOOLEAN	Y:YES N:NO		This determines whether the patient has a ST-segment depression greater than or equal to 1 mm in any lead on standard resting electrocardiogram (ECG), and/or ECG diagnosis of subendocardial ischemia, left ventricular strain, or left ventricular hypertrophy with repolarization abnormality.
351	*pci	206;13	SET OF CODES	1:NONE RECENT 2:12-72 HOURS PRIOR TO SURGERY 0:NONE 3:<12 hrs 12:12 - 72 hrs 72:>72 hrs - 7 days 7:>7 days		Definition Revised (2004): Indicate whether/when the patient had a percutaneous coronary intervention (PCI) prior to surgery. Previously, this data field was listed as a percutaneous transluminal coronary angiography (PTCA) [e.g., balloon angioplasty, directional coronary atherectomy (DCA), transluminal extraction catheter (TEC), stent, rotoblader, etc.] Indicate the one appropriate response, even if the procedure was not fully successful.
352	num of prior heart surgeries	206;15	SET OF CODES	Y:YES 0:NONE 1:1 2:2 3:3 >:>3		Definition Revised (2006): Indicate the number of previous heart surgeries the patient has had upon current admission, by referencing the patient history. The prior heart surgery/ies would have occurred during a separate hospitalization (more than 30 days prior to current surgery). Both on and off-pump cardiac surgical procedures should be considered. Count all surgical procedures performed during separate hospital admissions (not the number of grafts, and not additional procedures performed during the same admission due to a postoperative occurrence). Indicate the one appropriate response: 0, 1, 2, 3, >3.
353	current diuretic use	206;20	BOOLEAN	Y:YES N:NO		This determines whether the patient has used any diuretic preparation within the two weeks prior to surgery.
354	current digoxin use	206;21	BOOLEAN	Y:YES N:NO		This determines whether the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin, ect.) within the two weeks prior to surgery.
355	iv ntg within 48 hours	206;22	BOOLEAN	Y:YES N:NO		This determines whether the patient was administered nitroglycerin intravenously within 48 hours prior to surgery.
356	preoperative use of iabp	206;23	BOOLEAN	Y:YES N:NO		This determines whether there was any use of an intra-aortic balloon pump (IABP) within the two weeks prior to surgery.
357	lvedp	206;24	FREE TEXT			Definition Revised (2004): Indicate the patient's left ventricular end-diastolic pressure measured following the a-wave (if present) at the cardiac catheterization most recent prior to surgery. If LVEDP was not measured, entering "NS" for "No Study/Unknown" is also allowed.
358	aortic systolic pressure	206;25	FREE TEXT			Definition Revised (2004): Indicate the patient's aortic systolic pressure measured prior to left ventricular angiography at the catheterization most recent prior to surgery. If aortic systolic pressure was not measured, entering "NS" for "No Study/Unknown" is also allowed.
359	pa systolic pressure	206;26	FREE TEXT			Definition Revised (2004): For patients having a right heart catheterization, indicate the patient's pulmonary artery (PA) systolic pressure at the catheterization most recent prior to surgery. PA pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.
360	paw mean pressure	206;27	FREE TEXT			Definition Revised (2004): For patients having a right heart catheterization, indicate the patient's mean pulmonary artery wedge (PAW) [also called pulmonary capillary] pressure or left atrial pressure measured at the catheterization most recent prior to surgery. PAW pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart or transseptal catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.
361	left main stenosis	206;28	FREE TEXT			Definition Revised (2004): Indicate the most severe percent diameter reduction of the left main coronary artery, including its most distal portion. If there is no obstruction of the left main coronary artery, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
362	coronaries with stenosis	206;29	NUMERIC			This is the category corresponding to the number of major coronaries with stenosis greater than or equal to 50%. The categories are as follows. 0 - no stenosis in any coronary artery greater than or equal to 50% (exclude diagonals) 1 - one or more stenoses greater than or equal to 50% in the left anterior descending (does not include diagonals) or, circumflex (circumflex includes the marginal branches and ramus intermedius), or the right (right includes the posterior descending even if a branch of the circumflex) 2 - Stenoses greater than or equal to 50% in the left main coronary artery, or the left anterior descending (does not include diagonals) and the right (right includes the posterior descending even if a branch of the circumflex), or the left anterior descending (does not include diagonals) and circumflex (circumflex includes the marginals and ramus intermedius), or the circumflex (circumflex includes the marginals and ramus intermedius) and the right (right includes the posterior descending even if a branch of the circumflex) 3 - Stenoses greater than or equal to 50% in the left anterior descending (does not include diagonals) and the circumflex (circumflex includes the marginals and ramus intermedius) and right (right includes the posterior descending even if a branch of the circumflex) or left main and right (right includes the posterior descending even if a branch of the circumflex)
362.1	lad stenosis	206;33	FREE TEXT			Definition Revised (2004): Indicate the most severe percent stenosis in the left anterior descending coronary artery. Synonyms for this artery include: LAD, AD, and anterior descending (but does not include the diagonals). If there is no obstruction of the LAD, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
362.2	right coronary stenosis	206;34	FREE TEXT			Definition Revised (2004): Indicate the most severe percent stenosis in the right coronary artery. Include the proximal third of the posterior descending coronary artery. The right coronary artery initially runs in the groove between the right ventricle and right atrium; it usually gives off branches to both the right and left ventricles and the right atrium. The branches to the right atrium (sinus node artery) and right ventricle (conus branch and acute marginal branches) are commonly ignored when describing coronary artery disease. However, the right coronary artery is the most common source for the posterior descending coronary artery and often gives-off branches to the posterior-lateral free wall of the left ventricle. These are often known as left ventricular extension branches and are considered branches of the circumflex for the coding of severity of coronary disease. If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
362.3	circumflex stenosis	206;35	FREE TEXT			Definition Revised (2004): Indicate the most severe percent stenosis in the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for bypass grafting. Both the anatomy and nomenclature for describing the circumflex coronary artery can be confusing -- in part, because of the marked variability from patient to patient. The true circumflex lies in the groove separating the left atrium from the left ventricle (A-V groove) for a variable distance following its origination from the left main coronary artery. Typically, it gives-off one or more branches that leave the A-V groove to supply the posterior-lateral free wall of the left ventricle. These are known as marginal branches. A few patients have a branch to the posterior-lateral free wall of the left ventricle arising exactly at the bifurcation of the left main coronary artery into the left anterior descending coronary artery and the circumflex coronary artery. Strictly speaking, this vessel is neither a diagonal branch of the left anterior descending coronary artery nor a marginal branch of the circumflex coronary artery. This is often called the "ramus intermedius" or "trifurcation branch". If there is no obstruction of these coronary arteries, indicate zero. Entering "NS" for "No Study/Unknown" is also allowed.
363	lv contraction score	206;30	SET OF CODES	I:> OR EQUAL 0.55 NORMAL II:0.45-0.54 MILD DYSFUNC. III:0.35-0.44 MOD. DYSFUNC. IIIa:0.40-0.44 MOD. DYSFUNC. A IIIb:0.35-0.39 MOD. DYSFUNC. B IV:0.25-0.34 SEVERE DYSFUNC. V:<0.25 VERY SEVERE DYSFUNC. NS:NO STUDY		Definition Revised (2004): Indicate the left ventricular contraction grade, where the function is assessed from the preoperative contrast ventriculogram, radionuclide angiogram, or 2-D echocardiogram. If ejection fraction is available, indicate the corresponding grade; otherwise, indicate the grade that qualitatively reflects left ventricular function. Ejection fraction is defined as the proportion of blood that is ejected during each ventricular contraction compared with the total ventricular filling volume. Indicate the one most appropriate response: I - Ejection fraction >= 0.55 or narrative reports indicating normal left ventricular function. II - Ejection fraction range from 0.45 to 0.54 or narrative report indicating mild left ventricular dysfunction. IIIa - Ejection fraction range from 0.40 to 0.44 or narrative report indicating moderate left ventricular dysfunction. If "moderate" is the only rating available, select this category. IIIb - Ejection fraction range from 0.35 to 0.39 or narrative report indicating moderately severe left ventricular dysfunction. IV - Ejection fraction range from 0.25 to 0.34 or narrative report indicating severe left ventricular dysfunction. V - Ejection fraction < 0.25 or narrative report indicating very severe left ventricular dysfunction. NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
364	estimate of mortality	206;31	NUMERIC			Definition Revised (2006): This is the physician's (cardiologist or cardiac surgeon) subjective estimate of operative mortality based on the assessment of the total clinical picture. (To avoid bias introduced by knowledge of outcome, this must be completed preoperatively. Do not calculate from the computer program provided to you.)
364.1	estimate of mortality, date	206;32	FREE TEXT			This is the date and time that the estimate of mortality information was collected.
365	*number with vein	207;1	NUMERIC			This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with vein regardless of whether other procedures were performed. Do not leave this information blank. If no coronary artery bypass grafts were performed, enter '0'.
366	*number with ima	207;2	NUMERIC			This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with internal mammary arteries (IMA) regardless of whether other procedures were performed. Do not leave this field blank. If no coronary artery bypass grafts were performed, enter '0'.
367	*aortic valve procedure	207;3	SET OF CODES	Y:YES N:NONE M:MECHANICAL S:STENTED BIOPROSTHETIC B:STENTLESS BIOPROSTHETIC H:HOMOGRAFT PR:PRIMARY REPAIR PA:PRIMARY REPAIR & ANNULOPLASTY DEVICE AN:ANNULOPLASTY DEVICE ALONE AU:AUTOGRAFT (ROSS) O:OTHER		VASQIP Definition (2010): Indicate if the patient had an aortic valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other
368	*mitral valve procedure	207;4	SET OF CODES	Y:YES N:NONE M:MECHANICAL S:STENTED BIOPROSTHETIC B:STENTLESS BIOPROSTHETIC H:HOMOGRAFT PR:PRIMARY REPAIR PA:PRIMARY REPAIR & ANNULOPLASTY DEVICE AN:ANNULOPLASTY DEVICE ALONE AU:AUTOGRAFT (ROSS) O:OTHER		VASQIP Definition (2010): Indicate if the patient had a mitral valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other
369	*tricuspid valve procedure	207;5	SET OF CODES	Y:YES N:NONE M:MECHANICAL S:STENTED BIOPROSTHETIC B:STENTLESS BIOPROSTHETIC H:HOMOGRAFT PR:PRIMARY REPAIR PA:PRIMARY REPAIR & ANNULOPLASTY DEVICE AN:ANNULOPLASTY DEVICE ALONE AU:AUTOGRAFT (ROSS) O:OTHER		VASQIP Definition (2010): Indicate if the patient had a tricuspid valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other
370	valve repair	207;6	SET OF CODES	Y:YES 1:AORTIC 2:MITRAL 3:TRICUSPID 4:OTHER/COMBINATION 5:NONE		Definition Revised (2006): Indicate if the patient has had any reparative procedure to a native valve, either with or without placing the patient on cardiopulmonary bypass. Valve repair is defined as a procedure performed on the native valve to relieve stenosis and/or correct regurgitation (annuloplasty, commissurotomy, etc.); the native valve remains in place. Indicate the one appropriate response.
371	*lv aneurysmectomy	207;7	BOOLEAN	Y:YES N:NO		This determines whether the patient had a resection or plication of a left ventricular aneurysm with or without additional procedures.
372	*great vessel repair (y/n)	207;8	BOOLEAN	Y:YES N:NO		Definition Revised (2006): Indicate if patient had a thoracic great vessel open repair of the aorta (ascending, transverse, and/or descending) or other great vessels, with or without cardiopulmonary bypass, with or without aortic valve replacement, CABG, or other procedure but excluding an endovascular repair of the descending thoracic aorta.
373	*cardiac transplant	207;9	BOOLEAN	Y:YES N:NO		Definition Revised (2006): Indicate if an orthotopic or heterotopic transplant was performed at this procedure either with or without placing the patient on cardiopulmonary bypass. (YES/NO) Heart-lung transplant should be listed under "Other cardiac procedures."
374	electrophysiologic procedure	207;10	BOOLEAN	Y:YES N:NO		This determines whether any procedure was performed with cardiopulmonary bypass to correct an electrophysiologic disturbance, such as resection of bypass tract(s) for WPW or endocardial resection for ventricular tachycardia. (This does not include implantation of automatic internal cardiac defibrillator AICD)
375	misc. cardiac procedures	207;11	BOOLEAN	Y:YES N:NO		This determines whether there were any miscellaneous cardiac procedures performed.
376	*asd repair	207;12	BOOLEAN	Y:YES N:NO		This determines if there was a procedure performed to repair an atrial septal defect.
377	*myxoma resection	207;14	BOOLEAN	Y:YES N:NO		This determines whether a resection of an atrial myxoma was performed.
378	*myectomy	207;16	BOOLEAN	Y:YES N:NO		Definition Revised (2011): Indicate if patient had resection of a portion of the interventricular septum, with or without placing the patient on cardiopulmonary bypass. (YES/NO)
379	*other tumor resection	207;18	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if patient had resection of any tumor other than atrial myxoma from the heart either with or without placing the patient on cardiopulmonary bypass.
380	*vsd repair	207;13	BOOLEAN	Y:YES N:NO		This determines whether the patient had a procedure performed to repair a ventricular septal defect.
381	*foreign body removal	207;15	BOOLEAN	Y:YES N:NO		This determines whether a procedure was performed to remove any foreign body (e.g. bullet or catheter fragment) from the heart with the aid of cardiopulmonary bypass.
382	*pericardiectomy	207;17	BOOLEAN	Y:YES N:NO		This determines whether the patient had a resection of the parietal pericardium with the aid of cardiopulmonary bypass. (NOTE: most pericardiectomies are performed without cardiopulmonary bypass)
383	other procedures (y/n)	207;19	BOOLEAN	Y:YES N:NO		This determines whether the patient had any other surgical procedure on the heart and/or great vessels (including AICD placement) requiring cardiopulmonary bypass.
383.1	other cardiac procedures	207.1;1	FREE TEXT			Definition Revised (2004): This is the free text description of other procedures requiring cardiopulmonary bypass that were performed on this patient at the same time as the primary cardiac procedure.
384	operative death	208;1	BOOLEAN	Y:YES N:NO		Definition Revised (2006): Indicate if the patient died within the 30 days after surgery in or out of the hospital regardless of cause; or within the index hospitalization regardless of cause; or patient died greater than 30 days as a direct result of a perioperative occurrence of the surgery (e.g., mediastinitis). ("Discharge" can be noted when the patient leaves the Acute Care arena.)
385	*perioperative mi	208;2	BOOLEAN	Y:YES N:NO		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2011): Indicate the presence of a peri-operative MI as documented by the following criteria: 0-24 Hours Post-Op The CK-MB (or CK if MB not available) must be greater than or equal to 5-times the upper limit of normal, with or without new Q waves present in two or more contiguous ECG leads. No symptoms required. >24 Hours Post-Op Indicate the presence of a peri-operative MI (> 24 hours post-op) as documented by at least one of the following criteria: 1. Evolutionary ST- segment elevations 2. Development of new Q-waves in two or more contiguous ECG leads 3. New or presumably new LBBB pattern on the ECG 4. The CK-MB (or CK if MB not available) must be greater than or equal to 3 times the upper limit of normal. Because normal limits of certain blood tests may vary, please check with your lab for normal limits for CK-MB and total CK. Defining Reference Control Values (Upper Limit of Normal): Reference values must be determined in each laboratory by studies using specific assays with appropriate quality control, as reported in peer-reviewed journals. Acceptable imprecision (coefficient of variation) at the 99th percentile for each assay should be defined as < or = to 10%. Each individual laboratory should confirm the range of reference values in their specific setting. This element should not be coded as an adverse event for evolving MI's unless their enzymes peak, fall, and then have a second peak.
386	endocarditis	208;3	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the chart documents that active endocarditis was present within 30 days postoperatively. Endocarditis is defined as any postoperative intracardiac infection (usually on a valve) documented by two or more positive blood cultures with the same organism, and/or development of vegetations and valve destruction seen by echo or repeat surgery, and/or histologic evidence of infection at repeat surgery or autopsy. Patients with preoperative endocarditis who have the above evidence of persistent infection should be included.
387	low cardiac output > 6 hours	208;4	BOOLEAN	Y:YES N:NO		This determines whether the patient has had a postoperative cardiac index of less than 2.0 L/min/M2 and/or peripheral manifestations (e.g. oliguria) of low cardiac output present for 6 or more hours following surgery requiring inotropic and/or intra-aortic balloon pump support.
388	mediastinitis	208;5	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the patient developed a bacterial infection involving the sternum or deep to the sternum requiring drainage and anti-microbial therapy diagnosed within 30 days after surgery.
389	reoperation for bleeding	208;6	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if there was any re-exploration of the thorax for suspected bleeding within 30 days of surgery.
390	*stroke	208;8	BOOLEAN	Y:YES N:NO		This field has been flagged as obsolete for VASQIP. It should no longer be used. Cardiac Definition Revised (2004): Indicate if there was any new objective neurologic deficit lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after surgery.
391	repeat cardiac surg procedure	208;7	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or within 30 days of the initial operation.
392	other occurrences (icd)	205;36	POINTER	80		Definition Revised (2004): Enter any other surgical occurrences which you feel to be significant and that are not covered by the predefined occurrence categories. Enter the ICD-CM code for this entry.
393	re-transmission	RA;3	NUMERIC			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.
394	*history of mi	200;31	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): The history of a non-Q wave or a Q wave infarct in the six months prior to surgery as diagnosed in the patient's medical record.
395	*angina one month prior	200;34	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs, and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. Documentation in the chart by the physician should state 'angina' or 'anginal equivalent'. For patients on anti-anginal medications, enter 'yes' only if the patient has had angina at any time within 30 days prior to surgery.
396	*chf within one month	200;35	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Congestive Heart Failure is the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure. Only newly diagnosed CHF within the previous 30 days or a diagnosis of chronic CHF with new signs or symptoms in the 30 days prior to surgery fulfills this definition. Common manifestations are: - Abnormal limitation in exercise tolerance due to dyspnea or fatigue - Orthopnea (dyspnea on lying supine) - Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea) - Increased jugular venous pressure - Pulmonary rales on physical examination - Cardiomegaly - Pulmonary vascular engorgement Should be noted in the medical record as CHF, congestive heart failure, or pulmonary edema.
397	severe head trauma (y/n)	200;20	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has sustained open or closed trauma to the head from external force, violence, or accident with resulting impairment in neurological function as manifested by motor, sensory, or cognitive impairments.
398	quadriplegia (y/n)	200;22	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of all four extremities.
399	paraplegia (y/n)	200;23	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of the lower extremities.
400	hemiplegia/hemiparesis (y/n)	200;24	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of one side of the body. Enter YES if the patient has hemiplegia/hemiparesis (that has not recovered or been rehabilitated) upon arrival to the OR. Enter YES if there is hemiplegia or hemiparesis associated with a CVA/Stroke also.
401	tumor involving cns (y/n)	200;29	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2007): Space-occupying tumor of the brain and spinal cord, which may be benign (e.g., meningiomas, ependymoma, oligodendroglioma) or primary (e.g., astrocytoma, glioma, glioblastoma multiform) or secondary malignancies (e.g., metastatic lung, breast, malignant melanoma). Other tumors that may involve the CNS include lymphomas and sarcomas. Answer "YES" even if the tumor was not treated. A patient with metastatic cancer with boney mets to spine is a CNS tumor. Answer "NO" if tumor was removed.
402	general (y/n)	200;1	BOOLEAN	Y:YES N:NO		This determines whether the patient has any general medical problems, such as diabetes, dyspnea, or alcohol related illnesses.
403	wound occurrences	205;5	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient had any postoperative wound occurrences.
404	wound disruption	205;8	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2014): Separation of the skin and musculofascial layers of a surgical wound (any surgical site whether primary or secondary, e.g. vein harvest incision), which may be partial or complete.
405	low serum sodium	203;2	FREE TEXT			This is the lowest postoperative serum sodium result recorded within 30 days postoperatively. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
406	low potassium	203;4	FREE TEXT			This is the lowest recorded postoperative potassium result. Data input must be 1 to 3 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
407	low sodium, date	204;2	DATE-TIME			This is the date that the lowest serum sodium test result was recorded.
408	low potassium, date	204;4	DATE-TIME			This is the date that the lowest potassium test result was recorded.
409	renal insufficiency	205;16	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): The reduced capacity of the kidney to perform its function as evidenced by a rise in creatinine of >2 mg/dl from preoperative value, but with no requirement for dialysis.
410	coma > 24 hours postop	205;22	SET OF CODES	Y:YES N:NO NS:NO STUDY		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.)
411	cardiac arrest req cpr	205;26	SET OF CODES	Y:YES N:NO NS:NO STUDY		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.
412	unplanned intubation (y/n)	205;11	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Patient required placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated for their surgery, unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated during surgery, intubation at any time after their surgery is considered unplanned.
413	transfer status	208;11	SET OF CODES	1:NOT TRANSFERRED 2:NON-VAMC ACUTE CARE HOSPITAL 3:VAMC ACUTE CARE HOSPITAL 4:NON-VA NURSING/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY 5:VA NURSING HOME/CHRONIC CARE/SCI/INTERMEDIATE CARE FACILITY 6:OTHER		Definition Revised (2004): Was the patient transferred directly from another healthcare facility and admitted to this hospital? Please select from the following choices. If the patient was admitted from home, select #1. If the patient was transferred from another facility, please select from choices #2-6. (1) Not transferred from a health care facility; admitted directly from home (2) Non-VAMC Acute Care Hospital (3) VAMC Acute Care Hospital (4) Non-VA Nursing Home/Chronic Care Facility/Spinal Cord Injury Unit/Intermediate Care Unit (5) VA Nursing Home/Chronic Care Facility/Spinal Cord Injury Unit/Intermediate Care Unit (6) Other (for example, Domiciliary) * If a patient arrives from another hospital's emergency department, report as #1. If you cannot determine what kind of facility, enter "OTHER".
414	cardiac surgical priority	208;12	SET OF CODES	1:ELECTIVE 2:URGENT 3:EMERGENT (ONGOING ISCHEMIA) 4:EMERGENT (HEMODYNAMIC COMPROMISE) 5:EMERGENT (ARREST WITH CPR)		If this is a cardiac procedure, this is the surgical priority reflecting the patient's cardiovascular condition at the time of transport to the operating room: 1. Elective - Patient placed on elective schedule with surgery usually performed > 72 hours following catheterization. 2. Urgent - Clinical condition mandates prompt surgery usually within 12 to 72 hours of catheterization (patients clinically stable on a circulatory support system should be included in this category). 3. Emergent (ongoing ischemia) - Clinical condition mandates immediate surgery usually on day of catheterization because of ischemia despite medical therapy, such as intravenous nitroglycerine. Ischemia should be manifested as chest pain and/or ST-segment depression. 4. Emergent (hemodynamic compromise) - Persistent hypotension (arterial systolic pressure < 80 mm Hg) and/or low cardiac output (cardiac index < 2.0 L/min/MxM) despite iontropic and/or mechanical circulatory support mandates immediate surgery within hours of the cardiac catheterization. 5. Emergent (arrest with CPR) - Patient is taken to the operating room in full cardiac arrest with the circulation supported by cardiopulmonary resuscitation (excludes patients being adequately perfused by a cardiopulmonary support system).
414.1	surgical priority, date	208;13	DATE-TIME			This is the date and time that the cardiac surgical priority information was collected.
415	mitral regurgitation	206;9	SET OF CODES	0:NONE 1:MILD 2:MODERATE 3:SEVERE NS:NO STUDY		Definition Revised (2004): Indicate the severity of any mitral regurgitation documented for the patient. This question should be answered using either the left ventricular angiogram or the cardiac ultrasound examination. Adjectives used to describe the severity of the mitral regurgitation on the cardiac cath report should be converted to a four-point scale: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Diagnosis by angiogram: ======================= The following definitions should be used to assess the presence/severity of mitral regurgitation based on the interpretation of the contrast left ventricular angiogram: None/Trivial - There is no visible systolic regurgitation across the mitral valve. Trace or trivial notations of mitral regurgitation should be listed as none. Mild - Definite contrast can be seen in the left atrium following left ventricular injection, but the left atrium never fills to the same opacity as the left ventricle. Moderate - The left atrium fills to the same opacity as the left ventricle over two or more systoles. Severe - The left atrium fills to the same opacity as the left ventricle over a single systole. NS - If unable to make an assessment of the patient's left ventricular contraction grade or no study was performed, entering "NS" for "No Study/Unknown" is also allowed. Diagnosis by cardiac ultrasound: ================================ The following definitions are commonly used to assess the presence/severity of mitral regurgitation based on the interpretation of the cardiac ultrasound examination: None/Trivial - No regurgitant jet is seen on the Doppler study. Trace or trivial notations of mitral regurgitation should be listed as none. Mild - The area of the regurgitant jet is 0 - 4 cm2. Moderate - The area of the regurgitant jet is >4 - 8 cm2. Severe - The area of the regurgitant jet is greater than 8 cm2 or greater than one third of the total left atrial area. NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
416	*number with other conduit	207;20	NUMERIC			Definition Revised (2004): This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other conduit(s) regardless of whether other procedures were performed. Do not leave this information blank. If no coronary artery bypass grafts with other conduits were performed, enter '0'.
417	race	208;10	SET OF CODES	1:HISPANIC, WHITE 2:HISPANIC, BLACK 3:AMERICAN INDIAN OR ALASKA NATIVE 4:BLACK, NOT OF HISPANIC ORIGIN 5:ASIAN OR PACIFIC ISLANDER 6:WHITE, NOT OF HISPANIC ORIGIN 7:UNKNOWN		This is the race of the patient. This is a standard set of codes and should not be edited.
418	hospital admission date	208;14	FREE TEXT			Definition Revised (2011): The date and time of the hospital admission to this VAMC associated with this surgical case as found in the PIMS package. If the patient was admitted directly to surgery and then admitted to the hospital, use the date of surgery as the date of admission. Entering NA for "NOT APPLICABLE" is allowed for non-cardiac surgery patients.
419	hospital discharge date	208;15	FREE TEXT			Definition Revised (2011): Indicate the date of the hospital discharge associated with this surgical case. Patients transferred to a referring facility should be indicated as discharged from current admission. Patients transferred to the psychiatric unit or any chronic care facility located at the VA facility (e.g., a nursing home) should be indicated as discharged from current admission at the date and time of the transfer to this different facility. (Do not indicate the date of data input, unless the patient was actually discharged on this same date.) Patients who remain as inpatients for reasons other than for post- open heart procedures should continue to be followed until discharged (including the rehabilitation service) even if the cardiothoracic team discharges the patient from their service or would discharge the patient home. If the patient remains in the hospital and/or has subsequent surgeries, indicate such in the CARDIAC RESOURCE DATA COMMENTS field (#431.)
420	admission/transfer date	208;16	FREE TEXT			Definition Revised (2004): If the patient was not initially admitted to the surgical service, the date and time of transfer to surgical service for this surgical episode will be entered from the PIMS package. Enter 'NA' if this date is not applicable, e.g. outpatient not admitted or observed.
421	discharge/transfer date	208;17	FREE TEXT			Definition Revised (2004): The date and time of the patient's discharge or transfer from the surgical or medical service to a chronic care setting. i.e., spinal cord injury unit, psychiatric facility or psychiatric unit, nursing home care unit or facility, or intermediate medicine. Acute care beds must be established locally with the assistance of your station IRM service.
430	cardiac risk preop comments	206.1;1	FREE TEXT			Definition Revised (2006): Indicate in the comment field any preoperative patient risk factors (not previously entered above) that may contribute to this patient's risk of operative mortality. (The maximum length of this field is 130 characters.)
431	cardiac resource data comments	206.2;1	FREE TEXT			Definition Revised (2014): Indicate additional comments related to this case prior to transmission to Denver by the SQN/Data Manager (limit 130 characters).
439	batista procedure used (y/n)	207;23	BOOLEAN	Y:YES N:NO		Was the Batista procedure used, Yes or No?
440	cardiac catheterization date	207;21	DATE-TIME			Record the appropriate date of the most recent cardiac catheterization prior to surgery. Enter NS if unknown or not applicable.
441	minimally invasive proc (y/n)	207;22	BOOLEAN	Y:YES N:NO		Was a minimally invasive procedure technique used, Yes or No?
442	employment status preoperative	208;18	SET OF CODES	1:EMPLOYED FULL TIME 2:EMPLOYED PART TIME 3:NOT EMPLOYED 4:SELF EMPLOYED 5:RETIRED 6:ACTIVE MILITARY DUTY 9:UNKNOWN		Employment status preoperatively is to be defined in the broad sense of regularly performed work activity with remuneration.
443	intraop disseminated cancer	200.1;4	SET OF CODES	Y:YES N:NO NS:NO STUDY		VASQIP Definition (2010): Intraoperative Disseminated Cancer: Patients who have cancer that was found during the operative procedure that: (1) Has spread to one site or more sites in addition to the primary site AND (2) In whom the presence of multiple metastases indicates the cancer is widespread, fulminant, or near terminal. Other terms describing disseminated cancer include "diffuse," "widely metastatic," "widespread," or "carcinomatosis" or AJCC "Stage IV" cancer. Common sites of metastases include major organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, and bone). You may use the National Cancer Institute as a reference in determining whether a patient has AJCC Stage IV cancer, when the TNM information is the only information documented. Refer to the following website for assistance with translating TNM values with AJCC staging: http://www.cancer.gov/cancertopics/pdq/adulttreatment Examples: - A patient with a primary breast cancer with positive nodes in the axilla does NOT qualify for this definition. The tumor has spread to a site other than the primary site, but does not have widespread metastases. A patient with primary breast cancer with positive nodes in the axilla AND liver metastases does qualify, because the tumor has spread to the axilla and other major organs. - A patient with colon cancer and no positive nodes or distant metastases does NOT qualify. A patient with colon cancer and several local lymph nodes positive for tumor, but no other evidence of metastatic disease does NOT qualify. A patient with colon cancer with liver metastases and/or peritoneal seeding with tumor does qualify. - A patient with adenocarcinoma of the prostate confined to the capsule does NOT qualify. A patient with prostate cancer that extends through the capsule of the prostate only does NOT qualify. A patient with prostate cancer with bony metastases DOES qualify. * Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML) and Stage IV Lymphoma under this variable. Do not report Chronic Lymphocytic Leukemia (CLL), Chronic Myelogenous Leukemia (CML), Multiple Myeloma or Lymphomas that are Stage I-III as disseminated cancer.
444	preoperative anion gap	203;15	FREE TEXT			This is the result of the preoperative Anion Gap calculation. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
444.1	preop anion gap, date	204;15	DATE-TIME			This is the date the preoperative Anion Gap was recorded.
445	highest anion gap	203;16	FREE TEXT			This is the result of the highest postoperative anion gap recorded. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
445.1	high anion gap, date	204;16	DATE-TIME			This is the date that the highest postoperative Anion Gap was recorded.
446	intraoperative ascites	200.1;6	BOOLEAN	Y:YES N:NO		VASQIP Definition (2010): Intraoperative Ascites: The presence of fluid accumulation in the peritoneal cavity noted during the operative procedure. Documentation should state a history of or active liver disease (e.g. jaundice, encephalopathy, hepatomegaly, portal hypertension, liver failure, or spider telangiectasia).
447	clostridium difficile colitis	205;39	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2008): C. difficile-associated disease occurs when the normal intestinal flora is altered, allowing C. difficile to flourish in the intestinal tract and produce a toxin that causes a watery diarrhea. C. difficile diarrhea is confirmed by the presence of a toxin in a stool specimen. Answer yes only if you have a positive culture for C. difficile and/or a toxin assay and diagnosis of C. difficile documented in the chart.
448	postop atrial fibrillation	205;40	BOOLEAN	Y:YES N:NO		VASQIP Definition (2010) Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been present preoperatively.
450	total ischemic time	206;36	NUMERIC			Record in minutes the duration of time the ascending aorta is totally cross-clamped. Do not include the duration of partial aorta cross-clamp used for sewing the proximal anastomoses.
451	total cpb time	206;37	NUMERIC			Record in minutes the total cardiopulmonary bypass time. This includes the total duration of full and partial cardiopulmonary bypass from all episodes of cardiopulmonary bypass. This information can generally be found on the perfusionist record and/or the anesthesia record.
452	observation admission date	208.1;1	FREE TEXT			Definition Revised (2004): An observation patient is one who presents with a medical condition with a significant degree of instability or disability, and who needs to be monitored, evaluated and assessed for either admission to inpatient status or assignment to care in another setting. An observation patient can occupy a special bed set aside for this purpose or may occupy a bed in any unit of a hospital, i.e., urgent care, medical unit. These types of patients should be evaluated against standard inpatient criteria. These beds are not designed to be a holding area for Emergency Rooms. The length-of-stay in observation beds will not exceed 23 hours. Following surgery, if the patient was admitted for observation, this is the date and time of admission for observation. If this information is not applicable, enter NA.
453	observation discharge date	208.1;2	FREE TEXT			Definition Revised (2004): If the patient was admitted for observation following surgery, this is the date and time of discharge from observation. If this information in not applicable, enter NA.
454	observation treating specialty	208.1;3	POINTER	42.4		Definition Revised (2004): If the patient was admitted for observation following surgery, this is the observation treating specialty to which the patient was admitted. If this information is not applicable, enter NA.
455	highest serum troponin i	203;13	FREE TEXT			This is the result of the highest postoperative serum cardiac troponin I test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
455.1	high serum troponin i, date	204;13	DATE-TIME			This is the date that the highest postop serum troponin I was performed.
456	highest serum troponin t	203;14	FREE TEXT			This is the result of the highest postoperative serum cardiac troponin T test. Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
456.1	high serum troponin t, date	204;14	DATE-TIME			This is the date that the highest postop serum troponin T was performed.
457	hdl (cardiac)	201;21	FREE TEXT			Definition Revised (2006): Indicate the HDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
457.1	hdl, date	202;21	FREE TEXT			Definition Revised (2006): Indicate the date that the preoperative HDL value was assessed. Enter "NS" for No Study if the HDL test was not performed.
458	serum triglyceride (cardiac)	201;22	FREE TEXT			Definition Revised (2006): Indicate the Serum Triglyceride result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
458.1	serum triglyceride, date (car)	202;22	FREE TEXT			Definition Revised (2006): Indicate the date that the preoperative Serum Triglyceride value was assessed. Enter "NS" for No Study if the Serum Triglyceride test was not performed.
459	serum potassium (cardiac)	201;23	FREE TEXT			Definition Revised (2004): Indicate the serum potassium result (mg/L) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.
459.1	serum potassium, date(cardiac)	202;23	FREE TEXT			Definition Revised (2004): Indicate the date that the preoperative Serum Potassium value was assessed. Enter "NS" for No Study if the Serum Potassium test was not performed or was performed more than 90 days before surgery.
460	serum bilirubin (cardiac)	201;24	FREE TEXT			Definition Revised (2004): Indicate the serum bilirubin result (mg/dl) preoperatively evaluated closest to surgery but not greater than 90 days before surgery. Entering "NS" for "No Study" is allowed.
460.1	serum bilirubin, date (card)	202;24	FREE TEXT			Definition Revised (2004): Indicate the date that the preoperative Serum Bilirubin value was assessed. Enter "NS" for No Study if the Serum Bilirubin test was not performed or was performed more than 90 days before surgery.
461	ldl (cardiac)	201;25	FREE TEXT			Definition Revised (2006): Indicate the LDL result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
461.1	ldl, date (cardiac)	202;25	FREE TEXT			Definition Revised (2006): Indicate the date that the preoperative LDL value was assessed. Enter "NS" for No Study if the LDL test was not performed.
462	total cholesterol (cardiac)	201;26	FREE TEXT			Definition Revised (2006): Indicate the Total Cholesterol result (mg/dl) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
462.1	total cholesterol, date	202;26	FREE TEXT			Definition Revised (2006): Indicate the date that the preoperative Total Cholesterol value was assessed. Enter "NS" for No Study if the Cholesterol test was not performed.
463	*hypertension	206;38	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if the patient has a documented history of hypertension with or without current treatment of antihypertensive medication(s). If a diuretic agent is prescribed to treat hypertension, indicate Yes for both the hypertension and the diuretic questions. (YES/NO).
464	*number with radial artery	207;24	NUMERIC			This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with radial artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with radial artery. Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.
465	*number with other artery	207;25	NUMERIC			This is the number of coronary artery bypass graft (CABG) anastomoses to native coronary arteries with other artery(ies) regardless of whether other procedures were performed. Do not leave blank, enter "zero" in the appropriate place if no coronary artery bypass grafts were performed with other artery(ies). Note that any CABG distal anastomoses performed without placing the patient on cardiopulmonary bypass are to be recorded.
466	tracheostomy	206;39	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if a procedure to cut into the trachea and insert a tube to overcome tracheal obstruction or to facilitate extended mechanical ventilation was performed within 30 days of surgery.
467	new mechanical circulatory	206;40	BOOLEAN	Y:YES N:NO		Definition Revised (2014): Indicate if the patient left the operating room suite with or required post-op placement of a new IABP, ECMO, or VAD for circulatory support within 30 days post-operatively.
468	incision type	207;26	SET OF CODES	FS:FULL STERNOTOMY FT:FULL THORACOTOMY LP:LIMITED PARASTERNAL APPROACH LS:LIMITED STERNOTOMY LT:LIMITED THORACOTOMY OL:OTHER LIMITED SURG APPROACH NS:NO STUDY/UNKNOWN		This describes the incision used for cardiac access, according to the operative report. (Do not include incisions for port access.) Enter NS if incision type is unknown. - Limited Sternotomy: The incision cuts through a small portion (less than half of the length) of the sternum (the narrow, flat bone in the median line of the thorax in the front of the chest). - Full Sternotomy: The incision cuts through the entire length of the sternum (the narrow, flat bone in the median line of the thorax in the front of the chest). - Limited Thoracotomy: A small surgical incision through a portion of the chest wall, but not along the sternum. For example, an anterolateral thoracotomy approach may be used in LIMA to LAD grafting. - Full Thoracotomy: A larger surgical incision running across the chest wall, but not along the sternum. This may be a left submammary incision, which requires the resection of the fourth costal cartilage and /or deflation of the left lung. - Limited Parasternal Approach: The incision cuts beside a small portion (less than 0.5 of the length) of the sternum, on a line midway between the sternal margin and an imaginary line passing through the nipple. - Other Limited Surgical Approach: An incision or incision set used to visualize the operating field that is not listed above.
469	convert from off pump to cpb	207;27	SET OF CODES	1:NO (began off-pump/ stayed off-pump) 2:YES-PLANNED 3:YES-UNPLANNED 4:YES-UNKNOWN IF PLANNED 5:NA (began on-pump/ stayed on-pump) NS:NO STUDY/UNKNOWN		Definition Revised (2004): Indicate whether patient was converted from off cardiopulmonary bypass assistance to on cardiopulmonary bypass during the cardiac surgical procedure. Indicate the one appropriate response: No - There was no conversion that occurred for the off-pump case performed (i.e., the off-pump case remained off-pump throughout the operation). NA - The procedure was NOT an off-pump case (i.e., procedure began on-pump and remained on- pump throughout the case). [The default will be set to N/A.] Yes, planned - The procedure was begun as an off-pump procedure but changed to on-pump for any length of time; the change was planned due to decision made prior to operation to perform some vessels off-pump and some on-pump in order to minimize total CPB time. Yes, unplanned - The procedure was begun as an off-pump procedure but changed to on-pump for any length of time; the change was unplanned and determined in the operating room due to inability to safely perform revascularization. NS/Unknown - If documentation is not sufficient to answer, entering "NS" for "No Study/Unknown" is also allowed.
470	d/t patient extubated	208;22	FREE TEXT			Definition Revised (2008): Indicate the date that the endotracheal tube is pulled for the first time after surgery. If a tracheostomy is performed to replace an oral intubation tube, intubation is considered continuous so the patient has not been extubated as long as the patient continues to require ventilator support. If the patient dies while intubated, indicate the date of death for this data element. Indicate "extubated prior to leaving the OR" in the Resource Comment if patient is extubated prior to leaving the OR. RI - The patient remains intubated and on ventilator at 30 days after surgery.
471	d/t patient disch from icu	208;23	FREE TEXT			VASQIP Definition (2010): This is the first date and time of the discharge from the intensive care unit (ICU). ICU is usually a surgical unit (SICU), although it may also include a post-anesthesia recovery unit off the operating room. It may also be a general ICU in which medical patients are also managed (MICU, CCU). This will always be the unit into which the patient goes immediately after surgery and is stabilized, ventilated and ultimately extubated. Do not include lower acuity units where the patient goes subsequently (i.e. stepdown, transitional care, telemetry, etc.). Do not include subsequent readmissions to the ICU. RI - The patient remains in ICU at 30 days after surgery.
472	*cardiac surg performed non-va	206;41	SET OF CODES	Y:YES N:NO NS:UNKNOWN		Definition Revised (2004): Indicate whether the patient's cardiac surgery was performed in a non-VA facility through a contracted arrangement, even if part of the post-surgical care is provided at the VA. A "contract" facility is one established to be an affiliate with the VA medical center, and it is most typically a University Hospital. In rare cases a "contract" facility may be a community hospital when there is no University affiliate for the VAMC. By contrast, a "fee-basis" patient surgery should not be indicated as a "contract" facility. Typically, a "fee-basis" establishment is an agreement by the VA Chief of Staff to out-source a patient to a community hospital. That hospital then bills the Chief of Staff for care rendered on the patient. VASQIP does not wish to capture the patient data on the "fee-basis" patients. If the patient is not entered into VISTA, send a paper form to Denver for hand-entry, unless your facility contracts-out a majority of its cases. Enter "NS" if funding for the procedure is not known. The default is to NO if a response is not entered.
473	homeless	209;1	SET OF CODES	Y:YES N:NO NS:NO STUDY/UNKNOWN		Definition Revised (2004): If the patient indicates he/she does not have a fixed dwelling, indicate the person's status as homeless.
474	preop circulatory device	209;2	SET OF CODES	N:NONE I:IABP V:VAD (includes BIVAD) A:ARTIFICIAL HEART O:OTHER		VASQIP Definition (2010): Indicate whether there was any use of any device to assist ventricular function at the time the patient presents for surgery (or placed in the OR before anesthesia induction). Indicate the one appropriate response: None - No New Mechanical Circulatory Device was placed. IABP - An intra-aortic balloon pump was placed to assist ventricular function. VAD - A ventricular assist device (e.g., LVAD, BIVAD) was placed to assist ventricular function. Artificial Heart - An artificial heart was placed to assist ventricular function. Other - An other type of Mechanical Circulatory Device was placed.
475	*diabetes (cardiac)	209;3	SET OF CODES	N:NO D:DIET O:ORAL I:INSULIN		This field has been flagged as obsolete for VASQIP. It should no longer be used. Definition Revised (2006): Indicate if the patient has diabetes treated with diet, oral, and/or insulin therapy. Diabetes is defined as a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin therapy. Indicate the one most appropriate response. No - no diagnosis of diabetes. Diet - a diagnosis of diabetes that is controlled by diet alone in the two weeks preceding surgery (the only prescribed treatment has been diabetic relief). Oral - a diagnosis of diabetes requiring therapy with an oral hypoglycemic agent in the two weeks preceding surgery. Insulin - a diagnosis of diabetes requiring daily insulin therapy in the two weeks preceding surgery.
476	procedure type	209;4	SET OF CODES	C:CATH I:IVUS B:BOTH/COMBINATION NS:NO STUDY/UNKNOWN		Definition Revised (2004): Indicate which test was used for the cardiac catheterization and/or angiographic data. Indicate the one most appropriate response: Cath - A diagnostic procedure in which a catheter is introduced into a large vein, usually of an arm or leg, and threaded through the circulatory system to the heart to determine blood pressure and the rate of flow in the vessels and chambers of the heart and the identification of abnormal anatomy. IVUS - Intravascular Ultrasound may be used either alone or in combination with results from the cardiac catheterization. If used alone, indicate IVUS as the only test from which procedure results are calculated. Both - If both IVUS and Cath are available and both tests were analyzed for the results, indicate Both/Combination. NS - If no cath study is available, entering NS for "No Study/Unknown" is also allowed.
477	aortic stenosis	209;5	SET OF CODES	0:NONE/TRIVIAL 1:MILD 2:MODERATE 3:SEVERE NS:NO STUDY		Definition Revised (2007): Indicate the severity of any aortic stenosis documented. This question should be answered using either the left ventricular angiogram (hemodynamic cath data) or the cardiac ultrasound examination. Numbers may be converted to describe the severity of the aortic stenosis on the cardiac cath report to the adjectives describing the severity: 1+ = mild, 2 or 3+ = moderate, and 4+ = severe. Both transvalvular gradient and estimated valve orifice area are used to assess the severity of obstruction (stenosis) of a valve. The transvalvular pressure gradient is obtained by converting the velocity of blood flow across the valve measured by the Doppler principle to pressure drop using the Bernoulli equation. The pressure drop, which is dependent on flow, can be converted to estimated valve orifice area if flow is known. If the echo report uses an adjective to describe the severity of stenosis, indicate the corresponding adjective. Use the following to convert mean (not peak) transvalvular gradients, orifice areas, or both, to the descriptive categories. Indicate the one most appropriate response: None/Trivial - The mean pressure gradient is < 5 mm Hg, and/or orifice area is > 2.5 cm2, and/or the aortic valve leaflets or aortic flow velocity is stated to be normal (< 1.0 M/sec). Mild - The mean pressure gradient is 5 - 20 mm Hg and/or the orifice area is 1.7 - 2.5 cm2 Moderate - The mean pressure gradient is >20 - 50 mm Hg and/or the valve orifice area is 1.0 -1.6 cm2 Severe - The mean pressure gradient is > 50 mm Hg and/or the valve orifice area is < 1.0 cm2 NS - If no study was performed, entering "NS" for "No Study/Unknown" is also allowed.
478	re-do lad stenosis	209;6	FREE TEXT			Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the left anterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.
479	re-do rt coronary stenosis	209;7	FREE TEXT			Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the right coronary artery or posterior descending coronary artery. Entering "NS" for "No Study/Unknown" is also allowed.
480	re-do circumflex stenosis	209;8	FREE TEXT			Definition Revised (2004): If a re-do, indicate the most severe percent stenosis in the graft to the circumflex coronary artery, including marginal branches and ramus intermedius considered to be of adequate size for bypass grafting. Entering "NS" for "No Study/Unknown" is also allowed.
481	*bridge to transplant/device	209;9	SET OF CODES	Y:YES N:NONE B:BRIDGE TO TRANSPLANT D:DESTINATION THERAPY		Definition Revised (2006): Indicate if patient received a mechanical support device (excluding IABP) as a bridge to cardiac transplant during the same admission as the transplant procedure; or patient received the device as destination therapy (does not intend to have a cardiac transplant), either with or without placing the patient on cardiopulmonary bypass.
482	*maze procedure	209;10	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt atrial conduction pathways often associated with atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (YES/NO).
483	*tmr	209;11	BOOLEAN	Y:YES N:NO		Definition Revised (2004): Indicate if patient received a transmyocardial laser procedure (TMR) to make "channels" or small holes directly into the heart muscle, either with or without placing the patient on cardiopulmonary bypass. The TMR may be done in combination with a CABG procedure or as a stand-alone procedure.
484	*other cardiac procedures-list	209.1;1	FREE TEXT			Definition Revised (2006): Specify if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass.
485	prior heart surgery	206;42	FREE TEXT			Definition Revised (2014): Indicate all applicable types of heart surgery performed, either on or off-pump. Indicate all appropriate responses: None - Patient has not had a previous cardiac surgery procedure CABG-only - Patient has had a previous coronary artery bypass graft (CABG-only) procedure Valve-only - Patient has had a previous valve-only procedure CABG/Valve - Patient has had a previous combination CABG/valve procedure Other - Patient has had a previous cardiac procedure(s) other than CABG and Valve surgery, such as repair of atrial or ventricular septal defects, great thoracic vessel repair, cardiac transplant, left ventricular aneurysmectomy, insertion of ventricular assist devices, total artificial hearts, Maze procedures, etc." (Do not include pacemaker insertions or automatic implantable cardioverter-defibrillator (AICD) insertions; do not include pericardectomy if done off pump). CABG/Other - Patient has had a previous cardiac surgery that included a CABG with a concurrent "Other" cardiac procedure. Unknown - Unknown
486	gastrointestinal (y/n)	200.1;1	SET OF CODES	Y:YES N:NO NS:NO STUDY		This determines whether the patient has a history of gastrointestinal problems such as esophageal varices.
487	preoperative inr	201;27	FREE TEXT			This is the result of the preoperative INR (International Normalized Ratio). Data input must be 1 to 5 numeric characters in length which may include a prefix of a less than or greater than sign "<" or ">". Entering "NS" for "No Study" is also allowed.
487.1	preoperative inr, date	202;27	DATE-TIME			This is the date that the preoperative INR was performed.
488	organ/space ssi	205;37	SET OF CODES	Y:YES N:NO NS:NO STUDY		Definition Revised (2004): Organ/Space SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation and at least one of the following: - Purulent drainage from a drain that is placed through a stab wound into the organ/space. - Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. - An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination. - Diagnosis of an organ/space SSI by a surgeon or attending physician. Site-Specific Classifications of Organ/Space Surgical Site Infection -------------------------------------------------------------------- Arterial or venous infection Meningitis or ventriculitis Breast abscess or mastitis Myocarditis or pericarditis Disc space Oral cavity (mouth, tongue, or Ear, mastoid gums) Endocarditis Osteomyelitis Endometritis Other infections of the lower Eye, other than conjunctivitis respiratory tract (e.g. abscess Gastrointestinal tract or empyema) Intra-abdominal, not specified Other male or female reproductive elsewhere tract Intracranial, brain abscess or Sinusitis dura Spinal abscess without meningitis Joint or bursa Upper respiratory tract Mediastinitis Vaginal cuff
489	other wound occurrence	205;38	POINTER	80		Definition Revised (2004): Enter any other wound occurrences that you feel to be significant and that are not covered by the predefined wound occurrence categories. Enter the ICD-CM code for this entry. (Example: Seromas, ICD-CM code: 998.13)
490	*repeat ventilator w/in 30 day	209;12	BOOLEAN	Y:YES N:NO		Definition Revised (2008): Indicate if the patient was placed on ventilator support postoperatively within 30 days and this repeat ventilator support is related to the index operation (For example, the patient is on the ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is discontinued. Later, the patient gets into trouble and mechanical ventilation has to be reinstated.) However, if the patient returns to the OR within 30 days and gets extubated immediately after, it is not considered repeat ventilator support.
491	other non-ct procedures	209.2;1	FREE TEXT			Definition Revised (2004): If any other procedure - other than cardiothoracic - performed requiring placing the patient on cardiopulmonary bypass, specify details into the comment field. If no other non-CT procedure requiring CPB was performed, indicate "NS" for "No Study/Unknown" in the text field.
492	preop funct. health status	200.1;2	SET OF CODES	1:INDEPENDENT 2:PARTIALLY DEPENDENT 3:TOTALLY DEPENDENT 4:UNKNOWN		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.
493	*pulmonary valve procedure	207;28	SET OF CODES	N:NONE M:MECHANICAL S:STENTED BIOPROSTHETIC B:STENTLESS BIOPROSTHETIC H:HOMOGRAFT PR:PRIMARY REPAIR PA:PRIMARY REPAIR & ANNULOPLASTY DEVICE AN:ANNULOPLASTY DEVICE ALONE AU:AUTOGRAFT (ROSS) O:OTHER		VASQIP Definition (2010): Indicate if the patient had a pulmonary valve replacement (either the native or a prosthetic valve) or a repair (on the native valve to relieve stenosis and/or correct regurgitation -annuloplasty, commissurotomy, etc.); performed with or without additional procedure(s); either with or without placing the patient on cardiopulmonary bypass. (If a repair was attempted, but a replacement occurred, indicate the details of the replacement valve.) Indicate the one most appropriate procedure: * None * Mechanical Valve * Stented Bioprosthetic Valve * Stentless Bioprosthetic Valve * Homograft * Primary Valve Repair * Primary Valve Repair and Annuloplasty Device * Annuloplasty Device alone * Autograft Procedure (Ross Procedure) * Other
500	pfss account reference	PFSS;1	POINTER	375		This is the PFSS Account Reference number by which Surgery will reference an external account number for purposes of attaching charges for 1st or 3rd party billing.
502	*other cardiac procedures (y/n)	209;13	BOOLEAN	Y:YES N:NO		Definition Revised (2006): Indicate if any cardiac surgical procedure (not listed above) was performed alone or in conjunction with the index procedure, either with or without placing the patient on cardiopulmonary bypass (YES/NO).
504	hemoglobin a1c	201;28	FREE TEXT			Definition Revised (2006)/(2007): Indicate the Hemoglobin A1c result (%) preoperatively evaluated closest to surgery. Entering "NS" for "No Study" is allowed.
504.1	hemoglobin a1c, date	202.1;1	FREE TEXT			Definition Revised (2006)/(2007): Indicate the date that the preoperative Hemoglobin A1c value was assessed. Enter "NS" for No Study if the Hemoglobin A1c test was not performed.
505	*endovascular repair	207.1;2	BOOLEAN	Y:YES N:NO		VASQIP Definition (2010): Indicate if the patient had an endovascular repair of the descending thoracic aorta, ascending aorta, and/or aortic arch (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with or without involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, with or without cardiopulmonary bypass. To include in VASQIP, an attending cardiothoracic surgeon must have been present and involved in the procedure. It is typically done under general anesthesia and may be performed in the operating room or interventional radiology operating area.
506	hair removal method	VER;6	SET OF CODES	C:CLIPPER D:DEPILATORY N:NO HAIR REMOVED P:PATIENT REMOVED OWN HAIR S:SHAVING U:NOT DOCUMENTED O:OTHER		This is the method used to remove hair prior to surgery. Shaving is not a preferred method for hair removal. If SHAVING is selected, a comment must be entered in the HAIR REMOVAL COMMENTS field explaining why SHAVING was used. If OTHER is selected, comments must be entered explaining the method used.
507	bnp	201;29	FREE TEXT			VASQIP Definition (2010): Indicate the BNP result (pg/mL) preoperatively evaluated closest to surgery but not greater than 180 days before surgery. Entering "NS" for "No Study" is allowed.
507.1	bnp date	202.1;2	FREE TEXT			VASQIP Definition (2010): Indicate the date that the preoperative BNP value was assessed. Enter "NS" for No Study if the BNP test was not performed.
508	hair removal comments	49;0	WORD-PROCESSING			If SHAVING is selected as the hair removal method, a comment must be entered explaining why SHAVING was used. If OTHER is selected as the hair removal method, comments must be entered explaining the method used.
509	preop atrial fibrillation	208;19	BOOLEAN	Y:YES N:NO		VASQIP Definition (2010): This field indicates whether atrial fibrillation or flutter is present within two weeks of the procedure. Enter YES or NO. Note: NS is not allowed.
510	*current smoker (cardiac)	200.1;5	SET OF CODES	1:NEVER A SMOKER 2:WITHIN 2 WEEKS OF SURGERY 3:2 WEEKS TO 3 MONTHS PRIOR TO SURGERY 4:>3 MONTHS PRIOR TO SURGERY (REMOTE SMOKER)		This field has been flagged as obsolete for VASQIP. It should no longer be used. Cardiac Definition Revised (2006): Indicate the patient's smoking status from information from the patient, or the chart, that best describes the patient's use of tobacco in any form (pipe, cigar, cigarette, tobacco chew). If more than one representation is found, please record according to the most conservative (most recent) quit date: 1 = never a smoker 2 = smoking within two weeks prior to surgery 3 = smoking within 2 weeks to 3 months prior to surgery 4 = remote smoker (more than 3 months prior to surgery)
512	*maze procedure	209;14	SET OF CODES	N:NO MAZE PERFORMED F:FULL MAZE M:MINI MAZE		Definition Revised (2006): Indicate if patient had a Maze procedure either with or without placing the patient on cardiopulmonary bypass. A Maze procedure is a surgical intervention used to interrupt abnormal atrial conduction pathways that cause atrial fibrillation or atrial flutter. It may be performed alone or in combination with other cardiac procedures. (A Maze does not include an amputation/resection of the atrial appendage as an isolated procedure; an intraoperative electrophysiologic mapping procedure; nor any surgical or ablation procedure conducted on the ventricle for control of ventricular arrhythmias.) Indicate the one most appropriate response: No - No Maze performed Full Maze - The procedure is most often performed on-bypass through a median sternotomy. A combination of incisions and thermal (cryo) or radiofrequency ablations of the atrial wall pathways are done, typically including amputation/resection of the one or both atrial appendices. The procedure thus creates a "maze" of electrical propogation roots involving the entire atrial myocardium with only one side of entrance (the sinus node) and one side of exit (the AV node). Mini-Maze - A more limited and simpler procedure than the traditional full maze, the Mini-Maze is based on the finding that in most patients, ectopic foci located in the pulmonary veins are responsible for the initiation of atrial fib. Radiofrequency or a cryo-ablation probe is used either inside or outside of the pulmonary vein ostia to destroy the foci. It can be performed with or without resection of the atrial appendage and includes no incision or minimal incisions to the left atrium, rather than the extensive atrial surgical procedure conducted for the full Maze. The Mini can be performed on or off bypass through a median sternotomy or performed thorascopically to the outside of the pulmonary veins.
513	surgery consult date	209;15	FREE TEXT			Indicate the date that the patient was first consulted by Surgery for the operation as typically documented by a note by a member of Surgery Specialty that will perform the procedure (e.g., attending surgeon, fellow, nurse). For non-cardiac assessments, enter NA if this date is not applicable or cannot be determined. For Cardiothoracic (CT) Surgery, this date is usually on or just after the diagnostic catheterization date.
515	primary cause for delay	209;16	SET OF CODES	RL:RESOURCE LIMITATION PH:PATIENT HEALTH PP:PATIENT PREFERENCE O:OTHER NS:NO STUDY/UNKNOWN N:NONE		Definition Revised (2008): This field contains the primary cause for delay. If a Cardiac patient's surgery is greater than 30 days from initial VA Cardiothoracic Surgery Consultation (as calculated between the CT CONSULT DATE to DATE OF SURGERY), user shall enter cause as defined in the field. If date is less than or equal to 30 days, system shall automatically default entry to None. - Resource Limitation: Due to staffing or other facility limitation, e.g., OR scheduling, physician availability, ICU bed capacity - Patient Health: Due to patient health issue, e.g., vascular consult, additional tests - Patient Preference: Due to a non-health related patient preference, e.g., vacation - Other - NS/Unknown: Unable to Locate Reason for Delay. Entering "NS" for "No Study/Unknown" is also allowed. - None
516	surgery consult requested	209;17	FREE TEXT			This is the date that the patient's physician requests that Surgery Service consult with the patient. It is not the date that the consult took place. Enter NA if this date is not applicable or cannot be determined.
517	tobacco use	200.1;9	SET OF CODES	1:NEVER USED TOBACCO 2:NO USE IN LAST 12 MOS 3:CIGARETTES ONLY 4:OTHER (NO CIGARETTES) 5:CIGARETTES PLUS OTHER		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
518	tobacco use timeframe	200.1;10	SET OF CODES	1:WITHIN 2 WEEKS 2:2 WKS TO 3 MOS 3:3 TO 12 MONTHS NA:NOT APPLICABLE		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
519	diabetes mellitus chronic	200.1;11	SET OF CODES	1:NO 2:DIET 3:ORAL 4:INSULIN		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
520	diabetes mellitus preop mgmt	200.1;12	SET OF CODES	1:NO 2:DIET 3:ORAL 4:INSULIN		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
521	cvd repair/obstruction	200.1;13	SET OF CODES	0:NO CVD 1:YES - NO SURGICAL REPAIR 2:YES - PRIOR SURGICAL REPAIR		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).
522	history of cvd	200.1;14	SET OF CODES	0:NO CVD 1:HISTORY OF TIA'S 2:CVA/STROKE - NO NEURO DEFICIT 3:CVA/STROKE W/ NEURO DEFICIT		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)
600	confirm patient identity	VER;7	BOOLEAN	Y:YES N:NO		This field verifies the patient identity has been confirmed. Your answer should be "Yes" or "No". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
601	procedure to be performed	VER;8	BOOLEAN	Y:YES N:NO		This field verifies the procedure to be performed has been confirmed. Your answer should be "Yes" or "No". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
602	site of procedure	VER;9	BOOLEAN	Y:YES N:NO		This field verifies the site of procedure, including laterality, has been confirmed. Your answer should be "Yes" or "No". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
603	confirm valid consent	VER;10	SET OF CODES	Y:YES N:NO 1:YES, i-MED 2:YES, PAPER 3:YES, TELEPHONE 4:NO, EMERGENCY 5:NO, NOT EMERGENCY		VASQIP Definition (2014): This field verifies that a valid consent form has been confirmed. Your answer should be one of the following: 1-YES, i-MED 2-YES, PAPER 3-YES, TELEPHONE 4-NO, EMERGENCY 5-NO, NOT EMERGENCY If you answer 4 or 5, you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
604	confirm patient position	VER;11	BOOLEAN	Y:YES N:NO		This field verifies that the patient position has been confirmed. Your answer should be "Yes" or "No". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
605	marked site confirmed	VER;12	BOOLEAN	Y:YES N:NO		The site must be marked in all cases. If the patient refuses marking, or if the site is inappropriate to marking, such as mucous membranes and other sites not on the skin that cannot be marked using standard methods, then wristbands must be used for marked site. See applicable VHA Handbooks and Directives for further information and guidance. If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
606	preoperative images confirmed	VER;13	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE		This field refers to the completion of the verification process for the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. This practice is further defined by local hospital policy. If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
607	correct medical implants	VER;14	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE		This field verifies that the availability of correct medical implant(s) has been confirmed. Your answer should be "Yes", "No" or "NA". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
608	antibiotic prophylaxis	VER;15	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE NI:NOT INDICATED		VASQIP Definition (2014): This field verifies that the appropriate antibiotic prophylaxis has been confirmed. Your answer should be "Yes", "No" or "NI". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
609	appropriate dvt prophylaxis	VER;16	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE NI:NOT INDICATED		VASQIP Definition (2014): This field verifies that the appropriate deep vein thrombosis prophylaxis has been confirmed. Your answer should be "Yes", "No" or "NI". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
610	blood availability	VER;17	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE		VASQIP Definition (2014): This field verifies that the blood availability has been confirmed. Your answer should be "Yes", "No" or "NA". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
611	availability of special equip	VER;18	SET OF CODES	Y:YES N:NO NA:NOT APPLICABLE		This field verifies that the availability of special equipment has been confirmed. Your answer should be "Yes", "No" or "NA". If you answer "NO", you'll be asked to justify your answer in the CHECKLIST COMMENT (#85) field.
612	original desired date	.9;1	DATE-TIME			This field is the original desired date for surgery to occur, as agreed upon by the provider and patient. That agreed upon date is when the patient desires the surgery to occur and when the provider feels it is appropriate to schedule the surgery. If the DESIRED PROCEDURE DATE field (#616) is updated, the value of this field will not change.
613	d/t of desired procedure date	.9;2	DATE-TIME			This field is the Date/Time stamp for when the provider saves the ORIGINAL DESIRED DATE field (#612) for surgical case in the system.
614	original scheduled date	.9;3	DATE-TIME			This field is the original scheduled date for surgery to occur, as entered by the OR scheduler.
615	d/t of scheduled date entry	.9;4	DATE-TIME			This field is the Date/Time stamp for when the OR Scheduler saves the ORIGINAL SCHEDULED DATE field (#614) for the surgical case in the system.
616	desired procedure date	.9;5	DATE-TIME			This field is the desired date for surgery to occur, as agreed upon by the provider and patient. That agreed upon date is when the patient desires the surgery to occur and when the provider feels it is appropriate to schedule the surgery.
617	scheduled date	.9;6	DATE-TIME			This field is updated with the new date whenever the OR Scheduler modifies the SCHEDULED START TIME field (#10) for the surgical case.
618	positive drug screening	200;55	SET OF CODES	Y:YES N:NO NA:NA 1:NOT DONE 2:NEGATIVE RESULT 3:POS NOT Rx 4:POS Rx		VASQIP Definition (2014): Indicate if any drug screening (e.g., blood or urine) was performed within 2 weeks prior to surgery. If patient is being prescribed a medication, such as methadone, respond with yes or no as indicated below. 1. Not Done - drug screening was not performed 2. Drug screening was performed and the result was negative 3. Drug screening was performed and the result was positive for substance not prescribed 4. Drug screening was performed and the result was positive for a prescribed substance
619	immed use-contamination	52;1	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of a specialty item (one of a kind) in the OR.
620	immed use-sps/or mgt issue	52;2	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to SPS processing and OR management issues (unsterile from SPS, hole in package, available in SPS but not sterilized, not processed in time, missing in set, or broken in set).
621	immed use-emergency case	52;3	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to an Emergency Case, such as instruments used on previous case.
622	immed use-no better option	52;4	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to items for which there may be no better option (batteries, radioactive implants (seeds)).
623	immed use-loaner instrument	52;5	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to loaner or short notice instrument excluding implants (instrument(s) not available with sufficient time to reprocess completely).
624	immed use-decontamination	52;6	NUMERIC			Indicate the number of cycles of Immediate Use Steam Sterilization due to contamination of instruments already in use in OR for any reason not included in tracking.
630	possible item retention	25;6	BOOLEAN	Y:YES N:NO		VASQIP Definition (2014): A retained surgical item includes instruments, sharps, sponges or any materials used by the surgical team performing the operative procedure. Sharps include surgical needles, aspirating needles, blunt needles, scalpel blades or any items with a sharp or pointed edge posing a risk for skin puncture by the surgical team. Sponges include cotton gauze sponges, laparotomy pads, surgical towels or any absorbent materials not intended to remain in the patient's body after the surgical procedure is completed.
633	wound sweep	25;7	BOOLEAN	Y:YES N:NO		VASQIP Definition (2014): This indicates that a both a visual and manual methodical wound exploration is performed prior to closing the surgical wound to ensure that all surgical items are accounted for and extracted. This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
635	wound sweep comments	53;0	WORD-PROCESSING			VASQIP Definition (2014): These are comments related to the reason(s) a wound sweep was or was not performed that may be useful in the documentation of this case and/or subsequent comments related to the wound sweep findings.
636	intra-operative x-ray	25;8	BOOLEAN	Y:YES N:NO		VASQIP Definition (2014): This indicates that a radiograph of the entire surgical field to rule out a retained surgical item was performed and interpreted by a physician at the completion of the surgical procedure, prior to the patient's transfer from the Operating Room. This question must be answered if any of the final sponge, sharps or instrument counts are recorded as incorrect.
637	intra-operative x-ray comments	54;0	WORD-PROCESSING			VASQIP Definition (2014): These are comments related to the reason(s) an intraoperative x-ray was or was not performed that may be useful in the documentation of this case and/or subsequent comments related to the radiograph findings.
638	laterality of procedure	OP;5	SET OF CODES	1:NA 2:LEFT 3:RIGHT 4:BILATERAL		This indicates that the side of the procedure is identified as either left, right or bilateral, when applicable to the procedure.
639	report given to	25;9	POINTER	200		This indicates the name of the staff member who received the postoperative report from the OR staff member.
640	pci	200;56	SET OF CODES	1:NONE 2:<12 HRS OF SURG 3:>12 HRS - 7 DAYS 4:>7 DAYS 5:UNKNOWN		VASQIP Definition (2014): Indicate the time period of the patient's most recent percutaneous coronary artery intervention (PCI) prior to surgery. This does not include percutaneous valve interventions including valvuloplasty and valve replacement. Indicate the one appropriate response, even if the procedure was not fully successful: 1. None - The patient never had a previous PCI. 2. <12 hr of surg - The patient had a PCI less than 12 hours prior to surgery. 3. >12 hr - 7 days - The patient had a PCI between 12 hours and 7 days prior to surgery. 4. >7 days - The patient had a PCI more than 7 days prior to surgery. 5. Unknown
641	hypertension	200;57	SET OF CODES	1:NO 2:YES WITHOUT MED 3:YES WITH MED 4:UNKNOWN		VASQIP Definition (2014): Indicate if the patient has a documented history of hypertension within the 30 days prior to surgery. Select the one appropriate response: 1. No history of hypertension 2. Yes without medication therapy 3. Yes with medication therapy (antihypertensive therapy: diuretics, beta blockers, ACE inhibitors, calcium channel blockers, etc.) 4. Unknown
642	bleeding risk due to med	200;58	SET OF CODES	1:NO BLEEDING RISK MED 2:CHRONIC ASPIRIN NOT D'C 3:BLEEDING RISK MED D'C 4:BLEEDING RISK MED NOT D'C		VASQIP Definition (2014): Bleeding risk due to medication is present if a patient is on chronic anticoagulation, an antiplatelet agent, thrombin inhibitor or thrombolytic agent that was not discontinued prior to midnight the day of surgery . Select the one appropriate response: 1. The patient does not take medications that increase bleeding risk 2. The patient was only on chronic aspirin therapy which was not discontinued prior to midnight the day of surgery (>=81 mg/day) 3. The patient was on pre-operative medication(s) that increase bleeding risk, but discontinued prior to midnight the day of surgery 4. The patient was on pre-operative medication(s) that increase bleeding risk, and one or more were NOT discontinued prior to midnight the day of surgery
643	angina timeframe	200;59	SET OF CODES	1:NO ANGINA 2:W/N 14 DAY OF SURGERY 3:W/N 15-30 DAYS OF SURGERY 4:UNKNOWN		VASQIP Definition (2014): Indicate time period when the angina was most recently present: 1. No Angina 2. Within 14 days prior to surgery 3. Within 15-30 days prior to surgery 4. Unknown
644	symptomatic uti	205;42	BOOLEAN	Y:YES N:NO		Definition Revised (2014): SYMPTOMATIC UTI - CULTURE plus SIGN/SYMPTOM within 1 calendar day of each other: a. UTI Signs/Symptoms: Urg/Freq/Dys Yes = Patient has urgency, frequency, or dysuria with no other recognized cause No = Patient does not complain of urgency, frequency or dysuria OR has a catheter in place b. UTI Signs/Symptoms: Fever Yes = Patient has a fever > 38C at the time of culture or onset of symptoms No = Patient does not have a fewer > 38C at the time of culture or onset of signs or symptoms c. UTI Signs/Symptoms: Tenderness Yes = Patient has suprapubic tenderness, costovertebral angle pain or tenderness with no other recognized cause No = Patient does not have suprapubic tenderness, costovertebral angle pain or tenderness d. UTI Culture: (must choose 1 or 2) 1. Patient has a positive urine culture that is > 10^5 colony- forming units (CFU)/ml with no more than 2 species of microorganisms 2. A positive urine culture of >=10^3 and <10^5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms plus one of the following three items: a) positive dipstick for leukocyte esterase and/or nitrate; b) Pyuria (urine specimen with > 10 white blood cell [WBC]/mm3 of unspun urine or > 3 WBC high-power field of spun urine) or c) microorganisms seen of Gram's stain of unspun urine INDWELLING URETHRAL CATHETER > 2 CALENDAR DAYS At the time of the procedure or during the post-operative 30 day period, did the patient have an indwelling urethral catheter in for > 2 calendar days (with day 1 being the day of catheter insertion) 1) Yes, in place on the day of UTI Signs/Symptoms and UTI Culture obtained 2) Yes, removed the day of or the day before UTI Signs/Symptoms and UTI Culture obtained 3) No, urethral catheter in place < or = to 2 calendar days but had an indwelling urethral catheter in place at time of UTI Signs/ Symptoms and UTI Culture obtained 4) No, urethral catheter in place < or = 2 calendar days and indwelling urethral catheter was not in place at the time of UTI Signs/Symptoms and UTI Culture obtained 5) No, did not have an indwelling urethral catheter at the time of the procedure or during the post-operative 30 day period
645	mechanical vent w/n 30 days	205;43	BOOLEAN	Y:YES N:NO		Definition Revised (2014): Indicate if ventilator support required within 30 days after initial post-operative extubation: If the patient was placed on ventilator support postoperatively for any reason within 30 days AND occurred during the same admission in-hospital. (For example, the patient is on the ventilator intra-op and immediately post-op. Then patient is weaned and the ventilator is discontinued. Later, the patient gets into trouble and mechanical ventilation has to be reinstated.) In patients who were not intubated during surgery, intubation at any time after their surgery is considered an occurrence.
901	airway index	.3;9	SET OF CODES	1:1. INDEX LESS THAN OR EQUAL TO 0 2:2. INDEX > 0 AND LESS THAN OR EQUAL TO 2 3:3. INDEX > 2 AND LESS THAN OR EQUAL TO 3 4:4. INDEX > 3 AND LESS THAN OR EQUAL TO 4 5:5. INDEX GREATER THAN 4		This field describes the degree of difficulty of airway management on a scale of 1 to 5, 1 being least difficult and 5 being most difficult. The value of this field is based on a computed performance index using the oral-pharyngeal (OP) class and the mandibular space (MS). Performance index = 2.5 x OP - MS length (converted to centimeters) Airway Index ------------ 1 - Performance Index less than 0 2 - Performance index greater than 0 and less than 2 3 - Performance index greater than 2 and less than 3 4 - Performance index greater than 3 and less than 4 5 - Performance index greater than 4
901.1	mallampati scale	.3;11	SET OF CODES	1:CLASS 1 2:CLASS 2 3:CLASS 3 4:CLASS 4		Definition Revised (2004): The Mallampati classification relates tongue size to pharyngeal size. This test is performed with the patient in sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum. The subsequent classification is assigned based upon the pharyngeal structures that are visible: Class I - visualization of the soft palate, fauces, uvula, and anterior and posterior pillars. Class II - visualization of the soft palate, fauces, and uvula. Class III - visualization of the soft palate and the base of the uvula. Class IV - soft palate is not visible at all. The classification assigned by the clinician may vary if the patient is in the supine position (instead of sitting). If the patient phonates, this falsely improves the view. If the patient arches his or her tongue, the uvula is falsely obscured. A class I view suggests ease of intubation and correlates with a laryngoscopic view grade I 99 to 100% of the time. Class IV view suggests a poor laryngoscopic view, grade III or IV 100% of the time. Refer to the Operations Manual for a visual depiction of the Mallampati Classification.
901.2	mandibular space	.3;12	NUMERIC			In the sitting position with head extended, enter the distance between the inside of the mentum and the top of the thyroid cartilage in millimeters. The mandibular space (MS) and the oral-pharyngeal (OP) score are used in figuring a performance index which is translated to the patient's airway index. (Performance Index = 2.5 x OP - MS length in cm)
903	death unrelated/related	.4;7	SET OF CODES	U:UNRELATED R:RELATED		This indicates if death was unrelated to this surgery.
904	review of death comments	47;0	WORD-PROCESSING			This word processing field contains comments about the review of death.
905	ready to transmit?	.4;2	SET OF CODES	R:READY T:TRANSMITTED		This field is set to R (ready) by a MUMPS cross reference the TIME PAT OUT OR field. When this case is transmitted to the national database at the end of the quarter, this field will be updated to T (transmitted). This field serves as a flag that indicates the transmission status of this case.
1000	tiu operative summary	TIU;1	POINTER	8925		This is the operative summary for this case stored in TIU.
1001	tiu nurse intraop report	TIU;2	POINTER	8925		This is the Nurse Intraoperative Report for this case stored in TIU.
1002	tiu procedure report (non-or)	TIU;3	POINTER	8925		This is the Procedure Report (Non-OR) for this non-OR procedure.
1003	tiu anesthesia report	TIU;4	POINTER	8925		This is the Anesthesia Report for this case.
1004	dictated summary expected	TIU;5	BOOLEAN	1:YES 0:NO		This field indicates if the provider will dictate a summary of this procedure to be electronically signed. Enter YES if a dictated summary is expected. Enter NO or leave blank if no summary is expected.
1005	cpt on nurse report	TIU;6	BOOLEAN	1:YES 0:NO		This field reflects the content of the CPT ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time an automatic addendum is made to the report to determine whether the CPT codes should appear on the report.
1006	icd on nurse report	TIU;7	BOOLEAN	1:YES 0:NO		This field reflects the content of the ICD ON NURSE INTRAOP site parameter in SURGERY SITE PARAMETERS file (#133). This field will be set at the time the Nurse Intraoperative Report is signed and will be checked any time an automatic addendum is made to the report to determine whether the ICD codes should appear on the report.
2005	image	2005;0	MULTIPLE	130.02005		This sub-file contains pointers to images in the Imaging file (#2005) that are related to this case.