Data Dictionary ; Revised ; ; , Items in bold italics are recent changes/additions

Transcription

1 Data Dictionary ; Revised ; ; , Items in bold italics are recent changes/additions Demographic information First initial last name Provide only the first initial of the last name. First initial first name Provide only the first initial of the first name. Gender (male/female) Male or female H&P, Op In the case of question about gender where there has been a gender change (either via surgery and/or other treatments), answer with what the chart says the gender is with following exception: If the gender change has been from female to male but the ovaries remain intact, this person should be coded as female. Height Height in inches or cm H&P, anesthesia record Round rather than including a decimal Weight Weight in pounds or kg; if more than one weight listed, the weight H&P, anesthesia record closest in time and prior to the operation. Round rather than including a decimal. NA if this information is not available. Date of birth Date of birth Face sheet (UB-92) Age at admit Age Residence zip code Zip code Face sheet (UB-92) Primary insurance Insurance listed as the first insurance, regardless of whether the procedure in this record is covered or paid for by that insurance. If have private insurance, but their specific insurance company not listed, check other ; do not need to name the company. Face sheet (UB-92) Admit date Date of admission to this hospital for the current stay, regardless of source of admit (e.g., transfer, direct admit, ER) Face sheet, discharge summary

2 Discharge date Date of discharge from this hospital, regardless of disposition (e.g. to home, hospital, SNF). If patient died during this hospital stay, the discharge date is the date of death. Face sheet, discharge summary Patient status 1 Current cigarette smoker Any use of tobacco cigarettes within one year of this admission. H&P, nursing notes 2 Most recent labs within 30 days or on admit: Albumin: mg/dl; creatinine: mg/dl; Hgb: g/dl; WBC: 10(3). NA if not Lab record, H&P albumin, creatinine, hemoglobin, WBCs available. 3 Current/recent medication use (immunosuppression, therapeutic anticoagulation, statins, beta blocker, ACE inhibitor, ARB) Anticoagulants: documentation of use within 1 week of admission; all others, documentation of use upon admission (either at home or ordered on admit).see separate listing for medication names Medication record, H&P 4 Home 02 use Any use of oxygen at home. H&P, nursing assessment, discharge summary, D/C 5 Home mobility device use Use of any mobility device: includes walker, wheelchair, scooter, cane orders H&P, nursing assessment,, discharge summary, D/C orders 6 Comorbidities Hypertension: Yes/No Any mention of hypertension in the medical record on admit H&P, nursing assessment, anesthesia Hypertension meds: none, single, H&P, medication record multiple Diabetes: Yes/No Any mention of diabetes in the medical record on admit H&P Diabetes meds: none, single oral, Medications that patient is using at the time of admit. See separate H&P, medication record multiple oral, insulin, oral + insulin listing for medication names. Asthma: Yes/No H&P, anesthesia record Steroid use Indicate yes if either IV, po, inhaled. H&P, medication record History of VTE: Yes/No Any documentation of venous thrombolembolism, e.g., pulmonary H&P embolus. History of sleep apnea: Yes/No H&P, anesthesia record History of CPAP If Yes to history of sleep apnea, has patient used CPAP (continuous H&P, anesthesia record positive airway pressure) or BiPAP (bi-level positive airway pressure) Coronary artery disease: Yes/No Any diagnosis of coronary artery disease, regardless of severity or H&P treatment. Includes angina. History of MI Documentation of MI, regardless of date or type. H&P PCI, CABG or other coronary Documentation of PCI, CABG, AICD, regardless of date. H&P intervention History of HIV/AIDS: Yes/No Yes, if any documentation of positive HIV/AIDS status H&P

3 Operative data: for all patients 7 Primary surgeon Hospital s ID for primary surgeon; optional if hospital wants to collect it. Do not submit by surgeon name; only by an ID number 8 Diagnosis or indication for operation Choose diagnosis or indication for the surgery from the drop down lists; check all that apply. Do not indicate the actual CPT or ICD9 code. 9 Time of first incision Use 24-hour clock to indicate the time of the first incision; if both anesthesia start time and operation start time are listed, use operation start time. NA if this information not available. 10 In-room close time Use 24-hr clock to indicate time of incision closure in OR; if both anesthesia end time and operation end time are listed, use operation end time. NA if this information not available. Op record, discharge record Op record, discharge record Anesthesia record Anesthesia record 11 Date of surgery Indicate the date (mm/dd/yyyy) on which the operation began. Anesthesia record 12 In-room close date Indicate the date (mm/dd/yyyy) on which the operation ended. Anesthesia record 13 Method of surgical procedure Laparoscopic; lap converted to open; open (no lap ports); lap, hand Operative record assisted. 14 ASA class Class I, II, III, or IV NA if Class not available. Anesthesia record 15 Was insulin used in the OR: Any use of insulin in OR; if patient entered OR with insulin drip, Anesthesia record answer Yes. Respond independent of a diagnosis of diabetes. 16 Highest perioperative blood glucose the highest of these three: BG recorded within 60 min prior to surgery; during surgery; or within 60 min. after the surgery. Value in mg Indicate Not performed if this testing not done. Anesthesia record 17 Lowest intraoperative temperature In Centigrade NA if not available. Anesthesia record 18 First temp on arrival to recovery room In Centigrade NA if not available. 19 Perioperative interventions: Heparin, low molecular weight heparin or synthetic factor Xa inhibitor administered Was heparin, LMW heparin or synthetic factor Xa inhibitor ordered post-op: Was heparin, LMW heparin or synthetic factor Xa inhibitor ordered on discharge? For all of the above three items: If no, was there a contraindication documented? Administered within 24 hours of incision Regardless of answer to answer immediately above, indicate if there was an order for any of these for in-hospital use after the first 24 hrs Any documentation in the record by any provider that there was a contraindication to patient receiving either heparin, LMW heparin or synthetic factor Xa inhibitor. Surgery record and/or medication administration records Post-op orders Discharge or transfer orders H&P, Operative record, progress notes

4 Intermittent compression in OR: Intermittent compression boots applied in the OR. Beta-blocker: Administered within 12 hr pre-operative Was a beta-blocker ordered post-op: On antibiotics for treatment of infection? Antibiotics within 60 min of incision: Were antibiotics discontinued within 24 hrs after closure: Pain management postop orders: Epidural ordered within 24 hr post-op: Regardless of answer to question immediately above, indicate if beta blocker was ordered as a regularly-administered medication (not prn) post-op. If yes, do not answer the following two questions as patient is being treated for an infection vs being given a prophylactic antibiotic. If the antibiotic is administered > 60 min. of incision, answer No. EXCEPTION: If either vancomycin or a fluoroquinolone is the antibiotic administered, these need to be administered over a two hour time period. If these are administered within two hours prior to the incision, answer Yes. Answer regardless of when antibiotics were started (previous question). E.g., if ABX started 90 minutes before incision and discontinued 12 hrs after closure: answer Yes. This question applies only to colorectal and bariatric procedures. Within 24 hours post-op Includes intrathecal MS placement prior to surgery PCA ordered within 24 hr post-op: NSAID ordered within 24 hr post-op: See separate listing of NSAIDs Other pain management If yes, specify other pain management modality ordered within 24 hrs post-op Nasogastric tube: patient left OR with NGT in place: RBC transfusion: in OR, or within 24 hrs post-op. Mechanical ventilation beyond recovery room: RBC transfusion means packed red blood cells. If no packed RBCs were transfused, enter 0 as leaving it blank will be tallied as a missing answer. If Yes, how many hours total? Total hours of mechanical ventilation until discharge; if patient is on and off ventilator, estimate total hours. NA if pt is a chronic ventilator pt. OP notes, anesthesia record, nursing or medicine progress notes, PACU record Intraoperative record, PACU record, post-op nursing or medicine progress notes

5 20 Discharge disposition Home (patient s or friend s home), rehab facility, skilled nursing facility, other hospital, other location (e.g., hotel, homeless shelter, homeless), death. Discharge summary, discharge orders 21 If patient had any of the following surgical operations or therapies listed below during this hospitalization and following the abdominal procedure, select all that apply and indicate the date first performed after surgery. If had none of these, check None. Intent of this question is to capture interventions and therapies most likely associated with the abdominal procedure recorded on this form. Check all that apply along with the dates: Abdominal reoperation: colostomy or ileostomy (rescue stoma); abscess drainage; operative drain placement; gastrostomy; gastrostomy revision, re-exploration/washout; anastomotic revision; band replacement; band/port revision; wound revision or evisceration; negative re-exploration; other [specify] tracheal reintubation; NG replacement; tracheostomy placement of percutaneous drain (date); anticoag therapy for presumed/confirmed DVT; anticoagulation therapy for presumed/confirmed PE; wound reopened. Anastomotic leak; check if a leak demonstrated by barium enema, upper GI and/or CT scan. Enterocutaneous fistula; check if this demonstrated by barium enema, upper GI and/or CT scan. If an intervention was performed more than once, e.g., tracheal reintubation twice, indicate the date of the first time it was done. Progress notes or discharge diagnoses list Operation-specific information: Complete only for the appropriate operation. Complete one form for each procedure; do not list multiple procedures on the same form. Bariatric 22 Prior foregut surgery Documentation of any previous operation in the abdomen, regardless of date or facility. Include if it took place during this hospitalization, but prior to this operation. Foregut includes abdominal esophagus, stomach, small intestine. 23 Procedure of record: type of procedure The procedure being recorded on this form. Bypass [proximal or distal], biliopancreatic bypass, biliopancreatic bypass with duodenal switch, adjustable band [and size]. Proximal gastric bypass is a Roux limb less than or equal to 150 cm. In the unusual event that a band surgery is converted to a bypass, the operation type is a bypass surgery and yes should be checked on the prior foregut surgery question above. H&P, discharge summary. Op record, discharge summary 24 Was stomach divided Yes/No/NA NA for lap band surgeries Op record 25 Was anastamosis tested Yes/No/NA NA for lap band surgeries Op record If yes, how tested: Scope, methylene blue, air injected via tube or syringe, palpation/inspection, other (specify briefly). Check all that apply Op record

6 Appendectomy Abstract charts only for non-elective appendectomies; not for incidental appendectomies or for trauma 26 Was another abdominal or pelvic procedure performed concurrently 27 Preop imaging within 24 hours: CT scan, ultrasound Imaging results: consistent with appendicitis, not consistent with appendicitis, indeterminate 28 Prior ER visit within one week prior to the operation: Answer Yes if another procedure such as a colectomy or ovarian cystectomy was performed at the same time as the appendectomy If yes, indicate whether the concurrently performed procedure was gynecologic in nature or was a colon or gall bladder procedure Was any imaging done within 24 hours prior to this appendectomy? If yes, indicate if CT or ultrasound. If other type of imaging done (e.g., abdominal xray), leave blank. Plain films do not count as pre-op imaging for the dx of appendicitis. If either CT or ultrasound, indicate if scan results were consistent with, not consistent with appendicitis, or indeterminate. Answer yes if patient seen in any ER or urgent care (includes a physician office visit if the patient was seen urgently) setting within one week of and prior to this operation. Answer No if patient only seen in this hospital s ER, and admitted immediately from that ER visit. The intent of the question is to identify patients who were seen for suspected appendicitis in an urgent or emergent situation within a week prior to this procedure. If there was an ER/urgent care visit in this time frame that is clearly non-abdominal (e.g., fracture), answer No. Pathology results confirm appendeceal pathology: confirmed or consistent with appendicitis, inflammation, appendeceal tumor. Op record Imaging studies Pathology report ER record, H&P 29 Pathology results: appendeceal pathology Pathology report 30 Perforated appendix: Patient experienced perforated appendix. Pathology report Colon Operation 31 Prior colon or pelvic surgery Documentation of any previous operation in the colon or pelvis, regardless of date or facility; includes hysterectomy. Include if it took place during this hospitalization, but prior to this operation. 32 Procedure priority Elective, non-elective. An elective procedure is one that is performed on a patient whose symptoms and/or disease has been stable in the days or weeks prior to the procedure. Typically elective cases are scheduled at least several days before the procedure. Non-elective procedures (which include urgent and emergent status) are required to minimize or address further clinical deterioration. 33 Operation type Check the type of operation that was performed. Low anterior resection references removal of sigmoid colon and/or top of rectum with re-attachment of the colon and lower rectum. H&P, Admit note, progress notes H&P, admit note, progress note Op

7 Lf hemicolectomy includes +/- removal of transverse colon; this also includes sigmoid colon resection. Rt hemicolectomy includes resection of the terminal ileum and partial cecetomy as well as an ileocecal resection and cecum to transverse colon bypass. Abdominoperineal resection references removal of the rectum from a combined approach with both an abdominal and perineal incision. Total abdominal colectomy means all of the right transverse and left colon removed along with the sigmoid. Colostomy takedown may be charted as a colostomy takedown with colorectal anastomosis. 34 Ostomy: colostomy, ileostomy, protective Op record stoma or no ostomy 35 If colostomy performed, was there a prior colon Yes/No H&P resection within 30 days? If yes, name of hospital at which performed Indicate if known (free text). Otherwise leave blank. H&P, Discharge Summary 36 Anastamosis: Yes/No Op record If yes, and pouch created: If pouch was created, indicate type: ileoanal or coloanal Op record 37 Was anastamosis tested: Yes/No Op record If yes, how tested: Scope, methylene blue, air injected via tube or syringe, Op record palpation/inspection, other (free text) Check all that apply 38 Pathology findings Preop diagnosis confirmed: yes, no Op record, path report 39 Number of lymph nodes removed If none, indicate zero (0). Path report. 40 Margins free of CA If yes, indicate Cm to both distal and proximal margins Path report 41 T stage Check the appropriate stage Path report

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9 Medications Note: lists are not all-inclusive, and trade names may change. Drug Class Names Comments Anticoagulants Heparin Coumadin Warfarin Low molecular weight heparin Fragmin (dalteparin) Lovenox (enoxaparin) Aristra (fondaparinux) Innohep (tinzaparin) Antidiabetic agents Insulin Acarbose Glimepiride Glipizide Glyburide Metformin hydrochloride Miglitol Pioglitazone hydrochloride Rosiglitazone maleate Tolazamide Tolbutamide (with or without sodium) Immunosuppressives Prednisone Cortisone Methotrexate Do not include inhaled medications, e.g., for asthma. Beta Blockers Acebutolol Atenolol Betapace (sotalol) Betaxolol Bisoprolol Blocadren (timolol) Brevibloc (esmolol) Cartrol (carteolol) Carteolol Carvedilol Coreg (carvedilol) Esmolol Inderal (propranolol) Innopran ( ) Kerlone (betaxolol) Labetalol Levatol (penbutolol) Lopressor (metoprolol) Metoprolol Nadolol Normodyne (labetlol) Penbutolol Pindolol Proranolol Sectral (acebutolol) Sotalol Tenormin(atenolol) Timolol Toprol (metoprolol) Alone or in combination. * indicates combination drug.

10 Drug Class Names Comments Trandate (labetalol) Visken (pindolol) Zebeta (bisoprolol) *atenolol/chlorthalidone *bisoprolol/hctz *Corzide (bendroflumethiazide/nadolol) *HCTZ/propranolol *Inderide ( ) *Lopressor HCT ( ) *Tenoretic (atenolol/chlorthalidone) *Timolide (HCTZ/timolol) *Ziac (bisoprolol/hctz) Statins Atorvastatin calcium (Lipitor) Fluvastatin sodium (Lescol) Lovastatin (Mevacor) Pravastatin sodium (Pravachol) Rosuvastatin calcium (Crestor) Simvastatin (Zocor) ACE Inhibitors Benazepril hydrochloride Captopril Analapril Maleate Fosinopril Sodium Lisinopril Moexipril hydrochloride Perindopril erbumine Quianpril hydrochloride Ramipril trandolapril ARBs Candesartan Cilexitil Eprosartan Mesylate Irbesartan Losartan Potassium Olmesartan Medoxomil Telmisartan Valsartan NSAIDs Celecoxib Diclofenac (potassium or sodium) Diflunisal Etodolac Fenoprofen calcium Flurbiprofen (with/without sodium) Ibuprofen Indomethacin (with/without sodium trihydrate) Ketoprofen Ketorolac tromethamine Eclofenamate sodium Mefanemic acid Meloxicam Nabumetone Naproxen (with/without sodium) Oxaprozin Piroxicam Rofecoxib Sulindac Tolmetin sodium Valdecoxib