| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | anesthesia technique | 0;1 | SET OF CODES | G:GENERAL M:MONITORED ANESTHESIA CARE S:SPINAL E:EPIDURAL R:REGIONAL O:OTHER L:LOCAL N:NO ANESTHESIA | This is the anesthesia technique used during this case corresponding to the American Board of Anesthesiologists universal list of anesthesia techniques (except for REGIONAL, LOCAL and NO ANESTHESIA). If entered, this information will appear on various anesthesia reports. Select regional for peripheral nerve blocks or other techniques other than spinal or epidural. | |
| .05 | principal tech | 0;3 | BOOLEAN | Y:YES N:NO | This indicates whether this technique is the principal technique for this procedure. If this is the only technique used, 'YES' must be entered at this prompt. General anesthesia should take precedence over all other forms of anesthesia. | |
| 2 | patient status | 0;4 | SET OF CODES | I:INDUCED A:AWAKE S:SEDATED | This indicates the status of the patient while anesthetized. | |
| 3 | approach | 0;5 | SET OF CODES | D:DIRECT VISION LARYNGOSCOPY R:RAPID SEQUENCE B:BLIND BL:BLIND LARYNGOSCOPY F:FIBEROPTIC LARYNGOSCOPY | This is the code corresponding to the approach technique used for endotracheal intubation. This information is not required, but may be useful for documentation. | |
| 4 | route | 0;6 | SET OF CODES | O:ORAL N:NASAL T:TRACHEOSTOMY | This is the code corresponding to the route of the endotracheal tube to the trachea. This information is not required, but may be useful for documentation. | |
| 5 | laryngoscope type | 0;7 | SET OF CODES | M:MACINTOSH MI:MILLER G:GUEDEL W:WIS-FOREGGER FS:FIBEROPTIC STYLET FB:FIBEROPTIC BRONCHOSCOPE FL:FIBEROPTIC LARYNGOSCOPE O:OTHER | This is the code corresponding to the type of scope or laryngoscope blade used to facilitate endotracheal intubation. Although not required, it may be useful for documentation. | |
| 6 | laryngoscope size | 0;8 | NUMERIC | This is the size of the laryngoscope used to facilitate endotracheal intubation. This information is not required, but may be useful for documentation. | ||
| 7 | stylet used (y/n) | 0;9 | BOOLEAN | Y:YES N:NO | This indicates whether a stylet was used to shape the endotracheal tube during intubation. This information is optional, but may be useful in documentation of this case. | |
| 8 | lidocaine topical | 0;10 | BOOLEAN | Y:YES N:NO | This indicates whether topical lidocaine is utilized to facilitate endotracheal intubation. This information is not required, but may be useful for documentation. | |
| 9 | lidocaine iv | 0;11 | BOOLEAN | Y:YES N:NO | This indicates whether intravenous lidocaine is administered prior to the endotracheal intubation. This information is not required, but may be useful for documentation. | |
| 10 | tube type | 0;12 | SET OF CODES | P:PVC LOW PRESSURE S:SILASTIC LOW PRESSURE R:REINFORCED B:BIVONA CUFF 2R:2 LUMEN, RT. ENDOBRONCHIAL 2L:2 LUMEN, LT. ENDOBRONCHIAL T:TRACHEOSTOMY CUFFED L:LASER PROTECTED O:OTHER | This is the code corresponding to the type of endotracheal tube used during the major portion of the procedure. This information is not required, but may be useful for documentation. | |
| 11 | tube size | 0;13 | NUMERIC | This is the size of the endotracheal tube. This information is not required, but may be useful for documentation. | ||
| 12 | trauma | 0;14 | SET OF CODES | 1:NONE 2:LIP LACERATION OR HEMATOMA 3:TOOTH CHIPPED, LOOSENED OR LOST 4:TONGUE HEMATOMA OR LACERATION 5:PHARYNGEAL LACERATION 6:OTHER LARYNGEAL INJURY 7:FAILURE TO INTUBATE AS INTENDED | Definition Revised (2004): The code corresponding to trauma resulting from the endotracheal intubation process. This should be documented on the anesthesia record. Choose from: 1. None 2. Lip laceration or hematoma 3. Tooth chipped, loosened or lost 4. Tongue hematoma or laceration 5. Pharyngeal laceration 6, Other laryngeal injury 7. Failure to intubate as intended This information is entered by Anesthesia personnel and is not the responsibility of the Nurse Reviewer. | |
| 13 | bite block (y/n) | 0;15 | BOOLEAN | Y:YES N:NO | This indicates if a bite block is used to protect the endotracheal tube. This information is not required, but may be useful for documentation. | |
| 14 | tube lubrication | 0;16 | BOOLEAN | Y:YES N:NO | This indicates whether lubrication was used with the endotracheal tube. Although not required, this information may be useful for documentation. | |
| 15 | taped at length | 0;17 | NUMERIC | This is the length of the endotracheal tube at the external reference point. This information is not required, but may be useful for documentation of this case. | ||
| 16 | breath sounds ok bilat | 0;18 | BOOLEAN | Y:YES N:NO | This indicates whether breath sounds are audible and equal bilaterally. This information is not required, but may be useful for documentation. | |
| 17 | heat, moisture exchanger | 0;19 | BOOLEAN | Y:YES N:NO | This indicates whether a passive heat and moisture exchanger is used in the breathing circuit. This information is not required, but may be useful for documentation and review. | |
| 18 | bact. filter in circuit | 0;20 | BOOLEAN | Y:YES N:NO | This indicates whether a bacterial filter is used in the breathing circuit. This information is not required, but may be useful for documentation. | |
| 19 | end vent. t.v. | 0;21 | NUMERIC | This is the anesthesia ventilator tidal volume setting at the end of the case. | ||
| 20 | end vent. rate | 0;22 | NUMERIC | This is the anesthesia ventilator rate setting at the end of the operative procedure. | ||
| 21 | extubated in | 0;23 | SET OF CODES | O:OR P:PACU S:SICU | This is the code corresponding to the location wherein the endotracheal tube is removed. This information is not required, but may be useful for documentation, review or concurrent monitoring. | |
| 22 | reintubated w/i 8 hrs. | 0;24 | BOOLEAN | Y:YES N:NO | This indicates whether the patient required reintubation within 8 hours for ventilatory insufficiency or airway obstruction. Do not include intubation for a following surgical procedure. | |
| 23 | preoxygenation | 0;25 | BOOLEAN | Y:YES N:NO | This is used to document the process of preoxygenation prior to induction of anesthesia. | |
| 24 | anesthesia agents | 1;0 | MULTIPLE | 130.47 | This is information related to the anesthesia agents used for this technique. | |
| 25 | continuous | 2;1 | BOOLEAN | Y:YES N:NO | This indicates whether a catheter is placed for continuous or intermittent administration of a drug for spinal or epidural anesthesia. | |
| 26 | baricity | 2;2 | SET OF CODES | 1:HYPERBARIC 2:HYPOBARIC 3:ISOBARIC | This is the code corresponding to the baricity of the anesthesia drug fluid vehicle in relationship to the spinal fluid. | |
| 27 | puncture site | 2;3 | SET OF CODES | 1:L2-3 2:L3-4 3:L4-5 4:L5-S1 5:OTHER | This is the code corresponding to the spinal or epidural needle puncture site. This information is not required, but may be useful for documentation and review. | |
| 28 | spinal approach | 2;4 | SET OF CODES | M:MIDLINE L:LATERAL | This is the code corresponding to the approach of the placement of the spinal or epidural needle. This information is not required, but may be useful for documentation and review. | |
| 29 | needle size | 2;5 | SET OF CODES | 1:20G 2:22G 3:25G 4:16 G TOUHY 5:26G | This is the code corresponding to the needle size used for the spinal or epidural technique. This information is not required, but may be useful for documentation and review. | |
| 30 | epidural method | 3;1 | SET OF CODES | H:HANGING DROP L:LOSS OF RESISTANCE B:BOTH | This is the code corresponding to the method used to determine the placement of the epidural needle. This information is not required, but may be useful for documentation and review. | |
| 31 | multiple attempts | 3;2 | BOOLEAN | Y:YES N:NO | This indicates whether more than one skin puncture was required to achieve proper placement of the needle. | |
| 32 | test dose | 4;0 | MULTIPLE | 130.48 | This is information related to the test dose of the anesthesia agent. | |
| 33 | test dose vol (ml) | 3;3 | NUMERIC | This is the volume (mls.) of the test dose fluid vehicle. | ||
| 34 | dural puncture | 3;4 | BOOLEAN | Y:YES N:NO | This indicates whether dural puncture is recognized during the epidural needle or catheter placement. This information is not required. | |
| 35 | catheter removed by | 3;5 | POINTER | 200 | This is the name of the person removing the continuous catheter from the puncture site. This information is not required, but may be useful for documentation and review. | |
| 36 | administration method | 3;6 | SET OF CODES | B:BOLUS I:INTERMITTENT D:DRIP INFUSION | This is the code corresponding to the method of administration of the anesthetic agent. This information is not required. | |
| 37 | purpose | 3;7 | SET OF CODES | 1:FOR SURGICAL PROCEDURE 2:FOR PAIN RELIEF POST-OP 3:FOR CHRONIC PAIN CONTROL | This is the code corresponding to the reason for using a regional technique. This information is not required, but may be useful for documentation and review. | |
| 38 | block site | 5;0 | MULTIPLE | 130.49 | This is information about the block site. | |
| 39 | extubated by | 6;1 | POINTER | 200 | This is the name of the person responsible for removing the endotracheal tube. Although optional, this information may be useful for documentation. | |
| 40 | anesthesia comments | 7;0 | WORD-PROCESSING | These are comments related to anesthesia care for this case. | ||
| 41 | monitored anes care ?(y/n) | 8;1 | BOOLEAN | Y:YES N:NO | This indicates whether the anesthesia personnel monitored this patient without anesthesia. This information is not required, but may be useful for documentation and review. | |
| 42 | intubated ? (y/n) | 8;2 | BOOLEAN | Y:YES N:NO | This indicates whether an endotracheal tube is placed. | |
| 43 | level | 8;3 | SET OF CODES | T4:T4 T6:T6 T8:T8 T10:T10 T12:T12 ONE-SIDED:ONE-SIDED | This is the code corresponding to the neurodermatome anesthesia sensory level. | |
| 44 | date/time catheter removed | 8;4 | DATE-TIME | This is the date/time that the continuous regional block catheter was removed. Times entered without a date will be converted to the date of the operation at that time. |
Error: Invalid Global File Type: 130.06