# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | sequence number(+) | 0;1 | NUMERIC | The record number for this extract entry. | ||
1 | year month | 0;2 | FREE TEXT | A six character string representing the year and the month for which this extract was performed. | ||
2 | extract number | 0;3 | POINTER | 727 | AC | The corresponding entry in the DSS EXTRACT LOG file (#727) for this extract. |
3 | facility | 0;4 | FREE TEXT | This is the facility/division where the extract was performed. | ||
4 | patient no. - dfn | 0;5 | POINTER | 2 | An identifying number for the patient at the local site. | |
5 | ssn | 0;6 | FREE TEXT | The patient's social security number. | ||
6 | name | 0;7 | FREE TEXT | The first four characters of the patient's last name. | ||
7 | in out patient indicator | 0;8 | SET OF CODES | I:INPATIENT O:OUTPATIENT | Indicates whether the patient was an inpatient or an outpatient for this extract. | |
8 | day | 0;9 | FREE TEXT | This 8-character string represents the date on which the procedure associated with this Surgery extract record was performed. | ||
9 | case number | 0;10 | FREE TEXT | This character string represents in IEN in the SURGERY file (#130). | ||
10 | surgical specialty | 0;11 | FREE TEXT | The surgical specialty credited for doing this operative procedure. | ||
11 | or room number | 0;12 | FREE TEXT | This character string represents an IEN to the HOSPITAL LOCATION file (#44) for the operating room where the principal operation was performed. | ||
12 | surgeon | 0;13 | FREE TEXT | Person who performed the surgery. | ||
13 | attending surgeon | 0;14 | FREE TEXT | Person who oversaw and/or signed off on this surgery. | ||
14 | anesthesia supervisor | 0;15 | FREE TEXT | Person who oversaw and/or signed off on the anesthesia for this case. | ||
15 | anesthesia technique | 0;16 | SET OF CODES | S:SPINAL E:EPIDURAL O:OTHER G:GENERAL M:MONITORED ANESTHESIA CARE L:LOCAL | The code corresponding to the type of anesthesia technique used during this case. | |
16 | primary/secondary/prosthetics | 0;17 | FREE TEXT | The indicator if this is a primary, secondary or prostheses. | ||
17 | cpt | 0;18 | FREE TEXT | The Current Procedural Terminology (CPT) code for the operative procedure. | ||
19 | patient time | 0;20 | FREE TEXT | The time, in 15 minute increments, the patient was in the OR. | ||
20 | operation time | 0;21 | FREE TEXT | The time, in 15 minute increments, of the principal operative procedure. | ||
21 | anesthesia time | 0;22 | FREE TEXT | The time, in 15 minute increments, of the anesthesia care administered. | ||
22 | prosthesis | 0;23 | POINTER | 131.9 | Describes which locally defined implant, if any, was used. | |
23 | quantity | 0;24 | NUMERIC | This field is obsolete and has been replaced by the NEW QUANTITY field in this file. | ||
25 | movement file # | 0;26 | POINTER | 405 | Current patient movement record associated with this extract record. | |
26 | treating specialty | 0;27 | FREE TEXT | The PTF CODE of the treating specialty associated with this extract record. | ||
27 | cancelled | 0;28 | SET OF CODES | C:C | If set, this field indicates that the surgical procedure was cancelled after being started. | |
28 | time | 0;29 | FREE TEXT | The military time when the patient entered the OR. | ||
29 | or type | 0;30 | FREE TEXT | The OR TYPE of the operating room where this procedure was done. This field is a character string which represents an IEN in the OPERATING ROOM TYPE file (#134). | ||
30 | attending's service | 0;31 | FREE TEXT | The service to which the attending surgeon is assigned. The character string in this field represents an IEN in the NATIONAL SERVICE file (#730). | ||
31 | non-or dss identifier | 0;32 | FREE TEXT | Identifies the non-OR location for this procedure if the non-OR portion of the Surgery Package is used. | ||
32 | recovery room (pacu) time | 0;33 | FREE TEXT | The time, in 15 minute increments, that the patient spent in the post anesthesia care unit. | ||
33 | placeholder3 | 0;34 | FREE TEXT | Currently Null. | ||
34 | primary care team | 0;35 | FREE TEXT | The primary care team assigned to this patient. | ||
35 | primary care provider | 0;36 | FREE TEXT | The primary care provider assigned to this patient through the Primary Care Management Module (PCMM) application. | ||
36 | admission date | 0;37 | FREE TEXT | This 8-character string represents the date on which the patient's admission occurred. | ||
37 | master patient index | 1;1 | FREE TEXT | A national VA system identifier which uniquely identifies a patient. | ||
38 | dss product department | 1;2 | FREE TEXT | The nationally defined DSS Intermediate Department Number designated to the patient care product being provided. | ||
39 | placeholder | 1;3 | FREE TEXT | Currently NULL. | ||
40 | placeholder | 1;4 | FREE TEXT | Currently NULL. | ||
41 | placeholder | 1;5 | FREE TEXT | Currently NULL. | ||
42 | placeholder | 1;6 | FREE TEXT | Currently NULL. | ||
43 | pc provider person class | 1;7 | FREE TEXT | The VA Code of the Person Class of the Primary Care Provider associated with this record. | ||
44 | associate pc provider | 1;8 | FREE TEXT | The Associate Primary Care Provider assigned to this patient through the Primary Care Management Module (PCMM) application. | ||
45 | assoc. pc prov. person class | 1;9 | FREE TEXT | VA Code of the Person Class of the patient's Associate Primary Care Provider. | ||
46 | placeholder | 1;10 | FREE TEXT | Currently NULL. | ||
47 | cpt code quantity modifiers | 1;11 | FREE TEXT | The 5-character CPT Code of the procedure performed, the Quantity, or how many times the unique code appears in the record, and up to 5 two-character CPT modifiers. | ||
48 | dom,prrtp and saartp indicator | 1;12 | SET OF CODES | P:GEN. PRRTP T:PTSD PRRTP S:DOM. PRRTP H:HOMELESS CWT/TR A:SA CWT/TR D:DOMICILIARY B:PTSD CWT/TR C:GEN. CET/TR | Indicates if the patient is admitted to either a RRTP, PRRTP or SARRTP at the time care is provided. | |
49 | enrollment category | 1;13 | FREE TEXT | Patient's enrollment category. | ||
50 | enrollment status | 1;14 | FREE TEXT | Patient's enrollment status. | ||
51 | placeholder | 1;15 | FREE TEXT | |||
52 | period of service | 1;16 | FREE TEXT | The period of service that best classifies the patient based on eligibility code. | ||
53 | purple heart indicator | 1;17 | BOOLEAN | Y:YES N:NO | Indicates whether or not a patient is a Purple Heart recipient. | |
54 | observation patient indicator | 1;18 | SET OF CODES | NO:NO YES:YES | Indicates if patient is considered to be an observation patient. | |
55 | encounter number | 1;19 | FREE TEXT | The unique number assigned for DSS. | ||
56 | agent orange location | 1;20 | FREE TEXT | Indicates the location where the patient was exposed to Agent Orange. | ||
57 | production division code | 1;21 | FREE TEXT | Identifies the division/facility where the work was performed. | ||
58 | head & neck cancer indicator | 1;22 | BOOLEAN | Y:YES N:NO | Identifies whether patient has head and/or neck cancer. | |
59 | ethnicity | 1;23 | FREE TEXT | The patient's PTF Ethnicity code. | ||
60 | race 1 | 1;24 | FREE TEXT | Self-reported by patient as recorded in VistA patient file. | ||
61 | new quantity | 1;25 | NUMERIC | The quantity of the prosthetic device(s) used for this operative procedure. | ||
62 | dss ip # | 1;26 | NUMERIC | The nationally defined DSS Intermediate Product Number designated to the patient care product. | ||
63 | enrollment priority | 1;27 | FREE TEXT | This field contains the enrollment priority group and the enrollment priority subgroup. | ||
64 | user enrollee | 1;28 | SET OF CODES | U:USER ENROLLED | Indicates whether a Veteran has User Enrollee status for the current or future fiscal year. | |
65 | patient type | 1;29 | SET OF CODES | AC:ACTIVE DUTY AL:ALLIED VETERAN CO:COLLATERAL EM:EMPLOYEE IN:INELIGIBLE MI:MILITARY RETIREE NO:NON-VETERAN (OTHER) NS:NSC VETERAN SC:SC VETERAN TR:TRICARE | Refers to the various types of patient which may be seen at a VA facility. Every patient in the system must have a TYPE specified. | |
66 | cv status eligibility | 1;30 | SET OF CODES | Y:YES E:ELIGIBILITY EXPIRED | Records if veteran served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998. | |
67 | cv eligibility end date | 1;31 | FREE TEXT | Records the Combat Veteran eligibility expiration date of the veteran who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998. | ||
68 | encounter cv | 1;32 | BOOLEAN | Y:YES | Records if veteran served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998. | |
69 | room cleaning time | 1;33 | NUMERIC | ROOM CLEANING TIME is the number of 15 minute intervals required to clean the room. For example, an entry of 3 indicates that it took 45 minutes to clean the room. | ||
70 | holding area time | 1;34 | FREE TEXT | HOLDING AREA TIME field shall contain the time (in 15-minute increments) that the the patient spent in the holding area. | ||
71 | national patient record flag | 1;35 | BOOLEAN | Y:YES | This field records that the patient's record contains 1 or more Category 1 (National) Patient Record Flags. | |
72 | principal anesthetist | 1;36 | FREE TEXT | The principal anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) (or surgeon, if local anesthesia). | ||
73 | surgeon person class | 1;37 | FREE TEXT | The VA Code of the Person Class of the Surgeon associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
74 | attending surgeon pc | 2;1 | FREE TEXT | The VA Code of the Person Class of the Attending Surgeon associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
75 | anesthesia supervisor pc | 2;2 | FREE TEXT | The VA Code of the Person Class of the Anesthesia Supervisor associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
76 | principal anesthetist pc | 2;3 | FREE TEXT | The field will hold the VA Code associated with the active Person Class of the Principal Anesthetist. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
77 | eri | 2;4 | FREE TEXT | This field identifies patients from impacted zip code areas designated by the Federal Emergency Management Agency (FEMA). | ||
78 | agent orange enc indicator | 2;5 | BOOLEAN | Y:YES N:NO | Indicates whether service provided during this patient encounter is related to exposure to Agent Orange. | |
79 | enc head/neck ca | 2;6 | BOOLEAN | Y:YES N:NO | Indicates whether service provided during this patient encounter is related to head and/or neck cancer. | |
80 | oef/oif | 2;7 | FREE TEXT | The Military Operation in which the patient was in combat during the specified time period. This field is a length of nine characters and reflects the OEF or OIF where this patient was in combat. | ||
81 | oef/oif return date | 2;8 | FREE TEXT | The date the patient left the OEF/OIF area, if known. Otherwise, it is the end date of military pay for this OEF/OIF deployment. This date field has a format equal to YYYYMMDD. | ||
82 | clinic pointer | 2;9 | POINTER | 44 | Identifies the clinic associated with surgery specialty for this case. | |
83 | credit stop | 2;10 | FREE TEXT | Identifies the Credit Stop Code of the clinic associated with the surgery specialty for this case. | ||
84 | stop code | 2;11 | FREE TEXT | Identifies the Primary Stop Code of the clinic associated with the surgery specialty for this case. | ||
85 | princ postop diagnosis code | 2;12 | FREE TEXT | The post-op diagnosis for the Principle Procedure. | ||
86 | other postop diagnosis code #1 | 2;13 | FREE TEXT | The first associated diagnosis for the Principle Procedure. | ||
87 | other postop diagnosis code #2 | 2;14 | FREE TEXT | The second associated diagnosis for the Principle Procedure. | ||
88 | other postop diagnosis code #3 | 2;15 | FREE TEXT | The third associated diagnosis for the Principle Procedure. | ||
89 | other postop diagnosis code #4 | 2;16 | FREE TEXT | The fourth associated diagnosis for the Principle Procedure. | ||
90 | other postop diagnosis code #5 | 2;17 | FREE TEXT | The fifth associated diagnosis for the Principle Procedure. | ||
91 | anesthesia supervisor npi | 2;18 | FREE TEXT | A standard unique life-long identifier of the person who oversaw and/or signed off on the anesthesia for the surgical procedure. This field has a length of fifteen characters. | ||
92 | associate pc provider npi | 2;19 | FREE TEXT | A standard unique life-long identifier of the associate primary care provider. This field has a length of fifteen characters. | ||
93 | attending surgeon npi | 2;20 | FREE TEXT | A standard unique life-long identifier of the person who oversaw and/or signed off on the surgical procedure. This field has a length of fifteen characters. | ||
94 | primary care provider npi | 2;21 | FREE TEXT | A standard unique life-long identifier of the primary care provider. This field has a length of fifteen characters. | ||
95 | principle anesthetist npi | 2;22 | FREE TEXT | A standard unique life-long identifier of the principal anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) who provided anesthesia for the surgical procedure. This field has a length of fifteen characters. | ||
96 | surgeon npi | 2;23 | FREE TEXT | A standard unique life-long identifier of the person who performed the surgical procedure. This field has a length of fifteen characters. | ||
97 | encounter swac | 2;24 | BOOLEAN | Y:YES N:NO | This field indicates if treatment provided during this patient encounter is related to exposure to Southwest Asia conditions while serving in the Southwest Asia Theater of Operations. | |
98 | radiation encounter indicator | 2;25 | BOOLEAN | Y:YES N:NO | Indicates whether service provided during this patient encounter is related to exposure to ionizing radiation. | |
99 | mst encounter indicator | 2;26 | BOOLEAN | Y:YES N:NO | Indicates if treatment provided during this patient encounter is related to Military Sexual Trauma. Values: Y=YES, N=NO | |
100 | encounter sc | 2;27 | BOOLEAN | Y:YES N:NO | Indicates if treatment provided during this patient encounter is Service Connected. | |
101 | agent orange status | 2;28 | SET OF CODES | Y:YES N:NO U:UNKNOWN | Indicates if patient was exposed to Agent Orange. | |
102 | sw asia conditions | 2;29 | SET OF CODES | Y:YES N:NO U:UNKNOWN | Indicate if patient claims exposure to Southwest Asia Conditions. | |
103 | radiation status | 2;30 | BOOLEAN | Y:YES N:NO | Indicates if patient claims exposure to ionizing radiation. Values: Y=YES, N=NO | |
104 | mst status | 2;31 | SET OF CODES | Y:Screened, reports MST N:Screened, does not report MST D:Screened, declines to answer U:Unknown | Indicates if patient claims Military Sexual Trauma Values: Y=SCREENED, REPORTS MST N=SCREENED, DOES NOT REPORT MST D=SCREENED, DECLINES TO ANSWER U=UNKNOWN | |
105 | shad status | 2;32 | SET OF CODES | Y:YES N:NO U:UNKNOWN | Data is Y if this patient was exposed to Shipboard Hazard and Defense. N if not, or U if unknown. | |
106 | encounter shad | 2;33 | BOOLEAN | Y:YES N:NO | Indicates if treatment provided during this patient encounter is related to exposure PROJ 112/SHAD condition. Values: Y=YES, N=NO | |
107 | first asst | 3;1 | FREE TEXT | This is the name of the person assisting the surgeon during the operative procedure. | ||
108 | first asst pc | 3;2 | FREE TEXT | The VA Code of the Person Class of the First Asst associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
109 | first asst npi | 3;3 | FREE TEXT | A standard unique life-long identifier of the First Assistant. This field has a length of 15 characters. | ||
110 | second asst | 3;4 | FREE TEXT | This is the name of the second person assisting the surgeon during the operative procedure. | ||
111 | second asst pc | 3;5 | FREE TEXT | The VA Code of the Person Class of the Second Asst associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
112 | second asst npi | 3;6 | FREE TEXT | A standard unique life-long identifier of the Second Assistant. This field has a length of 15 characters. | ||
113 | perfusionist | 3;7 | FREE TEXT | This is the name of the person operating the cardio-pulmonary or organ perfusion apparatus. | ||
114 | perfusionist pc | 3;8 | FREE TEXT | The VA Code of the Person Class of the Perfusionist associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
115 | perfusionist npi | 3;9 | FREE TEXT | A standard unique life-long identifier of the Perfusionist. This field has a length of 15 characters. | ||
116 | asst perfusionist | 3;10 | FREE TEXT | This is the name of the person assisting the perfusionist. If applicable, this information may be valuable in documentation of this case. | ||
117 | asst perfusionist pc | 3;11 | FREE TEXT | The VA Code of the Person Class of the Asst Perfusionist associated with this record. The VA Code is always of the form "V"_six numeric digits; exactly 7. | ||
118 | asst perfusionist npi | 3;12 | FREE TEXT | A standard unique life-long identifier of the Asst Perfusionist. This field has a length of 15 characters. | ||
119 | anesthesia severity assessment | 3;13 | FREE TEXT | NSQIP Definition (2004): 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. | ||
120 | patcat | 3;14 | SET OF CODES | AD:Active Duty ADD:Active Duty Dependent FNRS:Former Non-Remarried Spouse RET:Retired RETD:Retiree Dependent RES:Reservist REC:Recruit TDRL:Temporary Disability TFL:TRICARE for Life | This is the Patient's category which will be used for FHCC (Federal Health Care Center) Reconciliation. DSS must capture and report DoD patients so that the FHCC reconciliation process can function as designed. "Reconciliation" is the process used within the new FHCC to determine which patients DoD pays for and which VA pays for. | |
121 | date of birth | 3;15 | FREE TEXT | Patient's date of birth. | ||
122 | vietnam | 3;16 | SET OF CODES | Y:YES N:NO U:UNKNOWN | Indicates if patient is a Vietnam era veteran. | |
123 | camp lejeune status | 3;17 | BOOLEAN | Y:YES N:NO | Indicates if patient was exposed to contaminated water while stationed at Camp Lejeune, NC between January 1, 1957 and December 31, 1987. | |
124 | encounter camp lejeune | 3;18 | BOOLEAN | Y:YES N:NO | Indicates if episode of care is related to exposure to contaminated water while stationed at Camp Lejeune, NC between January 1, 1957 and December 31, 1987. | |
125 | concurrent case | 3;19 | SET OF CODES | C:CONCURRENT CASE | 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 Principle Operative Procedure (e.g., fixation of a femur fracture in a patient undergoing a laparotomy for trauma). | |
126 | principle postop icd-10 code | 3;20 | FREE TEXT | The post-op diagnosis for the Principle Procedure. | ||
127 | other postop icd-10 code #1 | 3;21 | FREE TEXT | The first associated diagnosis for the Principle Procedure. | ||
128 | other postop icd-10 code #2 | 3;22 | FREE TEXT | The second associated diagnosis for the Principle Procedure. | ||
129 | other postop icd-10 code #3 | 3;23 | FREE TEXT | The third associated diagnosis for the Principle Procedure. | ||
130 | other postop icd-10 code #4 | 3;24 | FREE TEXT | The fourth associated diagnosis for the Principle Procedure. | ||
131 | other postop icd-10 code #5 | 3;25 | FREE TEXT | The fifth associated diagnosis for the Principle Procedure. | ||
132 | combat veteran indicator | 3;26 | BOOLEAN | Y:YES N:NO | Identifies if the patient served in a combat zone. | |
133 | combat veteran location | 3;27 | FREE TEXT | Identifies the war in which the combat service was incurred. |
Not Referenced