AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM - PEDIATRIC Data Collection Worksheet
|
|
- Gregory Crawford
- 5 years ago
- Views:
Transcription
1 AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM - PEDIATRIC Data Collection Worksheet *IDN LMRN Cycle Number Case Number DEMOGRAPHICS PATIENT First Name: MI: Last Name: Street Address: City / Town: State / Province: Zip: Country: *DOB: / / (mm/dd/yyyy) Gestational Age: wks. Gender: Male Female Race: White American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander Unknown / Not Reported Hispanic Ethnicity: Yes No Preferred Language: English Spanish PARENT/GUARDIAN 1 First Name: MI: Last Name: Relationship: Mother Father Grandmother Grandfather Sister Brother Aunt Uncle Foster Parent Guardian Other Status: Parent/ Legal Guardian Primary Caregiver Current Caregiver 30 day follow-up contact Check box if address is same as the patient s address Street Address: City / Town: State / Province: Zip: Country: Contact Number(s): Home: Work: Cell: Preferred Language: English Spanish PARENT/GUARDIAN 2 First Name: MI: Last Name: Relationship: Mother Father Grandmother Grandfather Sister Brother Aunt Uncle Foster Parent Guardian Other Status: Parent/ Legal Guardian Primary Caregiver Current Caregiver 30 day follow-up contact Check box if address is same as the patient s address Street Address: City / Town: State / Province: Zip: Country: Contact Number(s): Home: Work: Cell: Preferred Language: English Spanish Version date: July 1, ACS NSQIP-P
2 SURGICAL PROFILE Status: Inpatient Outpatient Elective Surgery: Yes No Unknown Hospital Admission Date: / / Transfer / Origin Status: Admitted from home/clinic/dr. s office Transferred from outside hospital (NICU, PICU, Inpatient general, Adult ICU) Chronic Care / Rehab / Intermed Care / Spinal Cord Other Admitted through ER, including outside ER with direct hospital admission Admitting Service on Admission: (select one) 1. Pediatric Cardiac Surgery 8. Plastics 15. General Surgery 2. Pediatric Neurosurgery 9. Neonatal Critical Care Service 16. Gynecology 3. Pediatric Orthopedic Surgery 10. Pediatric Critical Care Service 17. Neurosurgery 4. Pediatric Otolaryngology (ENT) 11. Pediatric Medical Service 18. Orthopedics 5. Pediatric Surgery 12. Adult Critical Care Service 19. Otolaryngology (ENT) 6. Pediatric Urology 13. Adult Medical Service 20. Transplant Surgery 7. Pediatric Plastics 14. Cardiovascular-Thoracic 21. Urology Payor Status: (select all that apply) Commercial Medicare Workman s Comp/Auto Other Blue Cross/Blue Shield Medicaid Self Pay HMO/PPO Champus Unknown *Date of Operation: / / Principal Operative Procedure: CPT Code: Principal Anesthesia Technique: (select one) General Epidural Regional None Unknown Spinal Caudal Local Other *Surgical Specialty (select one) 1. Pediatric Cardiovascular-Thoracic 6. Pediatric Urology 11. Gynecology 2. Pediatric Neurosurgery 7. Pediatric Plastics 12. Neurosurgery 3. Pediatric Orthopedic Surgery 8. Plastics 13. Orthopedics 4. Pediatric Otolaryngology 9. Cardiovascular-Thoracic 14. Otolaryngology (ENT) 5. Pediatric Surgery 10. General Surgery 15. Urology Attending Surgeon s Name: _ LCN: Attending Surgeon s IDN: Encounter Number: _ PREOPERATIVE INFORMATION GENERAL Height CM Inches Unknown Weight KG Pounds Unknown Diabetes Requiring Therapy NO Non-insulin Insulin DNR Status YES NO Premature Birth (# weeks gestation) NO Less than Unknown PULMONARY Ventilator Dependence YES NO Version date: July 1, ACS NSQIP-P
3 Current Pneumonia YES NO History Asthma YES NO History of Cystic Fibrosis YES NO Bronchopulmonary Dysplasia / Chronic Lung Disease YES NO Oxygen Support YES NO Tracheostomy YES NO Structural Pulmonary / Airway Abnormality YES NO GASTROINTESTINAL Biliary / Liver/ Pancreatic Disease YES NO Esophageal / Gastric / Intestinal Disease YES NO CARDIAC Previous Cardiac Surgery / Cardiac Intervention YES NO Cardiac Risk Factors RENAL None Minor Major Severe Acute Renal Failure YES NO Currently Requiring Or On Dialysis YES NO CENTRAL NERVOUS SYSTEM Coma YES NO CVA/Stroke or Traumatic / Acquired Brain Injury w/ Resulting Neurological Deficit YES NO Tumor Involving CNS YES NO Developmental Delay / Impaired Cognitive Status YES NO Seizure Disorder YES NO Cerebral Palsy YES NO Structural CNS Abnormality YES NO Neuromuscular Disorder YES NO Intraventricular Hemorrhage (IVH) Grade No IVH Grade 1 Grade 2 IVH reported but no grade assigned Grade 3 Grade 4 IMMUNOLOGY Immune Diseases / Immunosuppressant Use YES NO Steroid Use (w/in 30 days) YES NO Bone Marrow Transplant YES NO Solid Organ Transplant YES NO NUTRITIONAL / IMMUNE/ ONCOLOGY / OTHER Childhood Malignancy YES NO Open wound with or without infection YES NO Weight loss > 10% / Failure to Thrive YES NO Nutritional Support YES NO Bleeding Disorder YES NO Hematologic Disorder YES NO Chemotherapy for Malignancy (w/in 30 days) YES NO Radiotherapy for Malignancy (w/in 90 days) YES NO SIRS / Sepsis / Septic Shock (w/in 48 hrs) SIRS SEPSIS Septic Shock Version date: July 1, ACS NSQIP-P
4 Inotropic Support (at time of surgery) YES NO Previous CPR w/in 7 days (prior to surgery) YES NO Prior Operation w/in 30 Days YES NO Congenital Malformation(s): I) Neonate < 1500 g at time of surgery YES NO II) Neonate 1500 g or Infants/Children/Teenagers YES NO Blood Transfusions (w/in 48 hrs of surgery) YES NO NEONATAL PATIENT INFORMATION Term Neonate Premature Neonate Gestational Age: weeks Location of Birth: Inborn Outborn Small for Gestational Age: Yes No Mode of Delivery: Vaginal delivery Scheduled C-Section Birth Weight: kg or lbs oz Unknown Unscheduled C-Section Unknown/Not Documented Birth Length: cm or inches Unknown Head circumference at birth: cm or inches Unknown APGAR score 1 minute (0-10): Unknown APGAR score 5 minutes (0-10): Unknown LABORATORY DATA E INFORMATION PREOPERATIVE LAB DATA Value Unknown Date No preoperative labs drawn No labs drawn Serum Sodium (Na) / / Blood Urea Nitrogen (BUN) / / Creatinine (Cr) / / Albumin (ALB) / / Total Bilirubin (TB) / / Serum Glutamic-Oxaloacetic Transaminase (SGOT)/(AST) / / Alkaline Phosphatase (Alk Phos) / / White Blood Count (WBC) / / Hematocrit (Hct) / / Platelets (Plt) / / Prothrombin Time (PT) / / Internat l Normalized Ratio (INR) / / Partial Thromboplastin Time (PTT) / / OPERATIVE INFORMATION Case Status: Elective Urgent Emergent Wound Classification: Clean Clean/ Contaminated Contaminated Dirty/Infected ASA Class (circle one): None Assigned (for local anes. only) Version date: July 1, ACS NSQIP-P
5 OPERATIVE TIMES: Patient in Room: : Procedure / Surgery Start: : Patient Out Of Room: : Anesthesia Start: : Procedure/Surgery Finish: : Anesthesia Finish: : ADDITIONAL OPERATIVE PROCEDURES 1. Other Procedure CPT 1. Concurrent Procedure CPT OCCURRENCES INTRAOPERATIVE OCCURRENCES: YES NO Cardiac Arrest requiring CPR (If yes, select from the following) Death During Operation Unplanned Extubation Other ICD-9 Code: _ POSTOPERATIVE OCCURRENCES: YES NO (Although not required for this program, you may wish to document treatment and outcome to date of the occurrence for internal quality monitoring) Date Comments Wound Occurrences Superficial Incisional SSI / / Incisional SSI / / Organ/Space SSI / / Wound Disruption / / Respiratory Occurrences Pneumonia / / Unplanned Intubation / / Pulmonary Embolism / / Urinary Tract Occurrences Progressive Renal Insufficiency / / Acute Renal Failure / / Urinary Tract Infection (UTI) / / CNS Occurrences Coma > 24 hours / / CVA/Stroke or Intracranial Hemorrhage / / Seizure / / Nerve Injury / / IVH Grade / / Grade 1 Grade 2 Grade 3 Grade 4 Unknown /Specific grade not documented Cardiac Occurrences Cardiac Arrest Req. CPR / / Other Postoperative Occurrences Bleeding Requiring Transfusion (72 hr. surgery start time) / / # of mls / units transfused: Graft/Prosthesis/Flap Failure / / Venous Thrombosis requiring Therapy / / Sepsis / Septic Shock / / Central Line-Assoc. Bloodstream Infect. / / Other: ICD-9 Code: / / HOSPITAL DISCHARGE INFORMATION Oxygen at Discharge (or at 30 days if still in hospital): YES NO Nutritional Requirement at Discharge (or at 30 days if still in-hospital): YES NO Version date: July 1, ACS NSQIP-P
6 Total number of days of mechanical ventilation: If > than 30 days, check box Discharge Destination: Skilled Care Facility, not Home Unskilled Facility, not Home Facility which was not Home Rehab Home Separate Acute care (transferred to another acute care facility) Expired Unknown Post-op ICD.9 Code Diagnosis: Still in hospital >30 days: YES NO (NOTE: If this box is checked, completion of hospital discharge date is optional) Hospital Discharge Date: / / (mm/dd/yyyy) Postoperative Death: Postop Death w/in 30 days: YES NO Postop Death > 30 days: (if remained in acute care) YES NO Date of death: / / Unknown Date of death: / / Unknown Readmission Readmission for any reason within 30 days of the principal procedure? YES NO If YES, date: / / Information Source (select one) Medical Record Patient / Family Report Other If yes, enter the primary ICD-9 code associated with the readmission: ICD-9 code Unplanned Reoperation Did the patient have an unplanned return to the operating room for a surgical procedure w/in the 30-day postoperative period? If yes, surgery date: / / CPT code: ICD-9 Code: Source (select one) Medical Record Patient/Family Report Other Note: If CPT code is not documented, describe the surgery in the procedure description box. Was the return to the OR for a post operative occurrence that was likely related to the principal procedure or to any additional surgery ("other" or "concurrent" procedures) performed under the same anesthetic as the principal procedure? YES NO Unknown Did the patient have a SECOND unplanned return to the operating room for a surgical procedure, within the 30-day postoperative period? YES NO If yes, surgery date: / / CPT code: ICD-9 Code: Source (select one) Medical Record Patient/Family Report Other Note: If CPT code is not documented, describe the surgery in the procedure description box. Was the SECOND return to the OR for a post operative occurrence that was likely related to the principal procedure or to any additional surgery ("other" or "concurrent" procedures) performed under the same anesthetic as the principal procedure?? YES NO Unknown Were there more than two unplanned reoperations for a postoperative occurrence likely related to the principal surgery within 30 days? YES NO If yes, enter information in comments box. Version date: July 1, ACS NSQIP-P
7 FOLLOW-UP Follow Up Within 30 Days Were you able to follow the case for the full 30 days? YES NO Note: Answer yes for death within 30 days of surgical procedure) If you were unable to obtain the 30-day follow up information: A) How many days (0-29) were you able to follow this case? B) Which methods were used to obtain the 30-day follow-up information? Select all that apply. Note: A minimum of three attempts should be made to contact the patient Method # of attempts Method # of attempts Phone Documentation Letter Other Patient Contact Management Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Version date: July 1, ACS NSQIP-P
Form 1: Demographics
Form 1: Demographics Case Number: *LMRN: *DOB: / / *Gender: Male Female *Race: White Native Hawaiian/Other Pacific Islander Black or African American Asian American Indian or Alaska Native Unknown *Hispanic
More informationDemographics. MBSAQIP Case Number: *ACS NSQIP Case Number: *LMRN: *DOB: / / *Gender: Male Female
Demographics MBSAQIP Case Number: *IDN: *ACS NSQIP Case Number: Name: *LMRN: *DOB: / / *Gender: Male Female *Race: White Black or African American American Indian or Alaska Native Native Hawaiian/Other
More informationDemographics IDN: DOB: / / Gender: Male Female. Race: White Black or African American American Indian or Alaska Native
MBSAQIP Case Number: Name: Demographics IDN: LMRN: DOB: / / Gender: Male Female Race: White Black or African American American Indian or Alaska Native Native Hawaiian/Other Pacific Islander Asian Unknown
More informationHow to Address an Inappropriately high Mortality Rate? Joe Sharma, MD Associate Professor of Surgery NSQIP Surgical Champion
How to Address an Inappropriately high Mortality Rate? Joe Sharma, MD Associate Professor of Surgery NSQIP Surgical Champion Disclosure Slide No COI and no disclosures. Hospital Mortality rate : is it
More information4. Which survey program does your facility use to get your program designated by the state?
TRAUMA SURVEY Please complete one survey for each TCD designation you have in your facility. There would be a maximum of three surveys completed if your facility was designated as a trauma, stroke and
More informationA Comparative Analysisof Male versus Female Breast Cancer in the ACS NSQIP Database
A Comparative Analysisof Male versus Female Breast Cancer in the ACS NSQIP Database Lindsay Petersen, MD Rush University Medical Center Chicago, IL I would like to recognize my coauthors: Andrea Madrigrano,
More informationUnderstanding Readmissions in Pediatric Surgery
Understanding Readmissions in Pediatric Surgery Afif Kulaylat MD MSc, Anthony Tsai MD, Dorothy Rocourt MD, Kathryn Martin MD, Brett Engbrecht MD MPH, Mary Santos MD MEd, Robert Cilley MD, Christopher Hollenbeak
More information2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process
Quality ID #358: Patient-Centered Surgical Risk Assessment and Communication National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes 2018 OPTIONS FOR INDIVIDUAL MEASURES:
More informationACUTE KIDNEY INJURY (AKI) ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) ADVANCED DIRECTIVE LIMITING CARE...91 AGE...9 AGE UNITS...
ACUTE KIDNEY INJURY (AKI)...122 ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)...124 ADVANCED DIRECTIVE LIMITING CARE...91 AGE...9 AGE UNITS...10 AIRBAG DEPLOYMENT...30 AIS PREDOT CODE...118 AIS SEVERITY...119
More informationECLS Registry Form Extracorporeal Life Support Organization (ELSO)
ECLS Registry Form Extracorporeal Life Support Organization (ELSO) Center ID: Center name: Run No (for this patient) Unique ID: Birth Date/Time Sex: (M, F) Race: (Asian, Black, Hispanic, White, Other)
More informationInfluenza-Associated Pediatric Mortality Case Report Form Form Approved OMB No
Influenza-Associated Pediatric Mortality Case Report Form Form Approved OMB No. 0920-0004 STATE USE ONLY DO NOT SEND INFORMATION IN THIS SECTION TO CDC Last Name: First Name: County: Address: City: State,
More informationQ1 Contact Information
Q1 Contact Information Answered: 7 Skipped: 0 ANSWER CHOICES Hospital Name of Person Completing Survey Email RESPONSES 100.00% 7 100.00% 7 100.00% 7 # HOSPITAL DATE 1 Saint Luke's Hospital of Kansas City
More informationAugust SCR Educational Call
ugust SCR Educational Call SCR Certification Exam CS NSQIP SCR Certification Exam Policy is posted to the CS NSQIP Main page 2014 Exam- Round 1 starts September 8 Round 1- will be open for 3 weeks Rounds
More informationInfluenza-Associated Pediatric Deaths Case Report Form
STATE USE ONLY DO NOT SEND INFORMATION IN THIS SECTION TO CDC Form approved OMB No. 0920-0007 Last Name: First Name: County: Address: City: State, Zip: Patient Demographics 1. State: 2. County: 3. State
More informationProprietary Acute Care Indicators
Proprietary Acute Care Indicators Indicator 1a: Device-Associated Infections in the Intensive Care Unit Central Line-Associated Bloodstream Infections in the APICU, CCU, MICU, M/S ICU, & SICU Ventilator-Associated
More informationPredicting Short Term Morbidity following Revision Hip and Knee Arthroplasty
Predicting Short Term Morbidity following Revision Hip and Knee Arthroplasty A Review of ACS-NSQIP 2006-2012 Arjun Sebastian, M.D., Stephanie Polites, M.D., Kristine Thomsen, B.S., Elizabeth Habermann,
More informationSURGERY OR ANESTHESIA
Patient Safety Event Report Hospital SURGERY OR ANESTHESIA Use this form to report an event involving a surgical or other invasive procedure (e.g., colonoscopy), or the administration of anesthesia. Do
More informationPerioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program Pediatrics
CLINICAL ARTICLE J Neurosurg Pediatr 19:361 371, 2017 Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program Pediatrics Benjamin J.
More informationBrandon A. Sherrod, BS, James M. Johnston, MD, and Brandon G. Rocque, MD, MS
clinical article J Neurosurg Pediatr 18:350 362, 2016 Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College
More informationKAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
More informationPEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Division of Otolaryngology Main Phone: 847 504-3300 Main Fax: 847 504-3305 Mihir Bhayani, MD Judy L. Chen, MD Mark E. Gerber, MD, FACS, FAAP Joseph Raviv, MD Ilana Seligman, MD, FACS, FAAP Michael J. Shinners,
More informationSURGERY OR ANESTHESIA
Common Formats Aggregate Report Hospital SURGERY OR ANESTHESIA DEFINITION OF EVENT EVENTS INCLUSIONS Event type Incidents 823 174 257 225 167 Harm 735 154 228 205 148 No harm 88 20 29 20 19 Can t tell
More informationEnhanced Recovery After Colorectal Surgery at Royal Inland Hospital Kamloops, BC. Our Data Experience
Enhanced Recovery After Colorectal Surgery at Royal Inland Hospital Kamloops, BC Our Data Experience No Disclosures 1/26/2015 2 Purpose To tell our story of how we collect and share our ERACS data 1/26/2015
More informationAdmission/Discharge Form for Infants Born in Please DO NOT mail or fax this form to the CPQCC Data Center. This form is for internal use ONLY.
Selection Criteria Admission/Discharge Form for Infants Born in 2016 To be eligible, you MUST answer YES to at least one of the possible criteria (A-C) A. 401 1500 grams o Yes B. GA range 22 0/7 31 6/7
More informationEGD Data Collection Form
Sociodemographic Information Type Zip Code Gender Height (in inches) Race Ethnicity Inpatient Outpatient Male Female Birth Date Weight (in pounds) American Indian (Native American) or Alaska Native Asian
More informationAmerican College of Surgeons National Surgical Quality Improvement Program
American College of Surgeons National Surgical Quality Improvement Program Program Overview ACS NSQIP is a data-driven, risk-adjusted, outcomes-based program to measure and improve the quality of surgical
More informationThe following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS.
Page 1 The following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS. Appendix TABLE E-1 Care-Module Trigger Events That May Indicate an Adverse
More informationMAKING THE NSQIP PARTICIPANT USE DATA FILE (PUF) WORK FOR YOU
MAKING THE NSQIP PARTICIPANT USE DATA FILE (PUF) WORK FOR YOU Hani Tamim, PhD Clinical Research Institute Department of Internal Medicine American University of Beirut Medical Center Beirut - Lebanon Participant
More informationOutcomes of Patients with Preoperative Weight Loss following Colorectal Surgery
Outcomes of Patients with Preoperative Weight Loss following Colorectal Surgery Zhobin Moghadamyeghaneh MD 1, Michael J. Stamos MD 1 1 Department of Surgery, University of California, Irvine Nothing to
More informationWelcome to the Rubin Institute for Advanced Orthopedics!
Welcome to the Rubin Institute for Advanced Orthopedics! Dear New Patient, Welcome to the Rubin Institute for Advanced Orthopedics! Our goal is to provide you with caring, compassionate and professional
More informationADMISSION/DISCHARGE FORM FOR INFANTS BORN IN 2019 DO NOT mail or fax this form to the CPQCC Data Center. This form is for internal use ONLY.
1 Any eligible inborn infant who dies in the delivery room or at any other location in your hospital within 12 hours after birth and prior to admission to the NICU is defined as a "Delivery Room Death."
More informationThe Harvard community has made this article openly available. Please share how this access benefits you. Your story matters.
Higher Rates of Packed Red Blood Cell and Fresh Frozen Plasma Transfusion are Associated with Increased Death and Complication in Non-Massively Transfused Patients: An Explanation for the Increased Burden
More informationSubject ID: I N D # # U A * Consent Date: Day Month Year
IND Study # Eligibility Checklist Pg 1 of 15 Instructions: Check the appropriate box for each Inclusion and Exclusion Criterion below. Each criterion must be marked and all protocol criteria have to be
More informationComparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery
Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Abdullah Wafa, M.D. General Surgery Resident, PGY2 St. Joseph Mercy Health System Ann Arbor
More informationNew Jersey Cardiac Catheterization Data Registry, Version 2.0 (Please report data only for patients 16 years or older.)
A. ADMINISTRATIVE New Jersey Cardiac Catheterization Data Registry, Version 2.0 (Please report data only for patients 16 years or older.) 1. Facility Code: 2. Facility Name: 3. Procedure Type (Choose only
More informationSupplementary Online Content
Supplementary Online Content Abt NB, Flores JM, Baltodano PA, et al. Neoadjuvant chemotherapy and short-term in patients undergoing mastectomy with and without breast reconstruction. JAMA Surg. Published
More informationMichael Minarich, MD General Surgery Resident, PGY4 Cooper University Hospital
BMI as Major Preoperative Risk Factor for Intraabdominal Infection After Distal Pancreatectomy: an Analysis of National Surgical Quality Improvement Program Database Michael Minarich, MD General Surgery
More informationPEDIATRIC NSQIP INTERNAL QUALITY ASSESSMENT THINGS YOU CAN DO AT HOME SALT LAKE, 2012
PEDIATRIC NSQIP INTERNAL QUALITY ASSESSMENT THINGS YOU CAN DO AT HOME SALT LAKE, 2012 INTERNAL QUALITY AUDIT IT ALL BEGINS WITH ACCURATE AND CONSISTENT DATA INTERNAL QUALITY AUDIT WHAT DO YOU KNOW ABOUT
More informationNorth Carolina Inpatient Hospital Discharge Data - Data Dictionary FY 2016 Alphabetic List of Variables and Attributes Standard Research File
North Carolina Inpatient Hospital Discharge Data - Data Dictionary FY 2016 Alphabetic List of Variables and Attributes Standard Research File For a standard research file request one of three variables
More informationPLACE LABEL HERE. Radiation Therapy Oncology Group Phase II Nasopharyngeal Cancer Follow-Up Form
F1 AMENDED DATA Radiation Therapy Oncology Group Phase II Nasopharyngeal Cancer Follow-Up Form YES No INSTRUCTIONS: Submit this form at the appropriate follow-up interval and at death Dates are recorded
More informationGWTG-CAD: Mission: Lifeline Focus July 2017 PMT FORM SELECTION. Pre-Hospital/Arrival
GWTG-CAD: Mission: Lifeline Focus July 2017 PMT FORM SELECTION Page 1 Legend: BOLD = Required ^ = MLL Data Element Admin (Tab) ^Patient ID: Physician/Provider NPI: DOB: / / ^Arrival Date/Time: Race: Hispanic
More informationMBSAQIP Complex Clinical Scenarios & Variable Review
MBSAQIP Complex Clinical Scenarios & Variable Review Disclosure The following planners, speakers, moderators, and/or panelists of the CME/CEU activity have no relevant financial relationships with commercial
More informationIs laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass?
Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry Sandhya B. Kumar MD, Barbara C. Hamilton MD, Soren Jonzzon,
More informationIdentifying Meaningful Outcomes: The Case of Otolaryngology Emily F. Boss, MD MPH FACS
Identifying Meaningful Outcomes: The Case of Otolaryngology Emily F. Boss, MD MPH FACS Pediatric Otolaryngology Head and Neck Surgery Armstrong Institute for Patient Safety and Quality Center for Health
More informationASTS TRANSQIP Beta Phase Informational Webinar
ASTS TRANSQIP Beta Phase Informational Webinar December 2, 2016 Ryutaro Hirose, MD Stuart Greenstein, MD TransQIP A collaborative effort between ASTS and the American College of Surgeons A National Transplant
More informationUNIVERSITY OF WASHINGTON
UNIVERSITY OF WASHINGTON THE FETAL ALCOHOL SYNDROME DIAGNOSTIC AND PREVENTION NETWORK (FAS DPN) Center for Human Development and Disability Dear Sir or Madam, Thank you very much for your request for an
More informationACS-NSQIP 2015 Julietta Chang MD, Ali Aminian MD, Stacy A Brethauer MD, Philip R Schauer MD Bariatric and Metabolic Institute
ACS-NSQIP 2015 Julietta Chang MD, Ali Aminian MD, Stacy A Brethauer MD, Philip R Schauer MD Bariatric and Metabolic Institute Disclosures Authors: No disclosures ACS-NSQIP Disclaimer: The American College
More informationAMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM. SAR Models. Vanessa Thompson, PhD
AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM SAR Models Vanessa Thompson, PhD ACS NSQIP National Conference General Session: Stats I July 26, 2015 No disclosures Overview
More informationEACTS Adult Cardiac Database
EACTS Adult Cardiac Database Quality Improvement Programme List of changes to Version 2.0, 13 th Dec 2018, compared to version 1.0, 1 st May 2014. INTRODUCTORY NOTES This document s purpose is to list
More informationEpisodes of Care Risk Adjustment
Episodes of Care Risk Adjustment Episode Types Wave 1 Asthma Acute Exacerbation Perinatal Total Joint Replacement Wave 2 Acute Percutaneous Coronary Intervention COPD Acute Exacerbation Non-acute Percutaneous
More informationChapter 4 ACS NSQIP PEDIATRIC VARIABLES & DEFINITIONS
4.1 PATIENT & CASE IDENTIFIERS Chapter 4 ACS NSQIP PEDIATRIC VARIABLES & DEFINITIONS *IDN: The identification number (IDN) is a unique number, which permanently identifies the patient in the ACS NSQIP
More informationCriteria for Peer Review
1. ORYN Data (Core Measures) 2. QIO Reports 3. Data Advantage Reports 4. Surgery Review Indicators: Morbidity/Mortality Code Blue Review Autopsy Criteria Met If YES chart contains documentation of discussion
More information311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
More informationInvasive Bacterial Disease
Invasive Bacterial Disease Neisseria meningitidis, Haemophilus influenzae, and Group B Streptococcus (Streptococcus agalactiae) Case Report Form Electronic Disease Surveillance System Division of Surveillance
More informationRecommendations for Hospital Quality Measures in 2011:
Pediatric Measures: Recommendations for Hospital Quality Measures in 2011: Based on the input of a group of healthcare stakeholders, the following new hospital measures are recommended: 1) Home Management
More informationCenter for Reproductive Medicine Advanced Reproductive Technologies
Center for Reproductive Medicine Advanced Reproductive Technologies www.ivfminnesota.com Recessive Disease Screening Recessive conditions are conditions that result from two recessive genes being passed
More informationNEW PATIENT HEALTH HISTORY
Meeks and Zilberfarb Orthopedics 1101 Beacon Street. Brookline, MA 02246 40 Allied Drive, Dedham, MA 02026 Tel: 617-232-2663 Fax: 617-232-6342 Tel:781-326-1561 Fax:781-326-1562 Jeffrey L. Zilberfarb, MD
More informationDr Yuen Wai-Cheung HA Convention 2011
Dr Yuen Wai-Cheung HA Convention 2011 Outlines Why HA benchmarks hospitals? How to do a successful benchmarking? Using SOMIP as an example How to read and understand SOMIP report? Benchmarking Benchmarking
More informationInfratentorial neurosurgery is an independent risk factor for respiratory failure and death following intracranial tumor resection
--- Supplemental Digital Content--- Infratentorial neurosurgery is an independent risk factor for respiratory failure and death following intracranial tumor resection Alana M. Flexman Bradley Merriman
More informationDiscussion of Complex Clinical Scenarios and Variable Review ACS NSQIP Clinical Support Team
Discussion of Complex Clinical Scenarios and Variable Review CS NSQIP Clinical Support Team SCR Open Q& Calls The CS NSQIP Clinical Team is trialing Open format Q& calls for NSQIP SCRs Participation in
More informationThe Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization within the National Surgical Quality Improvement Database
The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization within the National Surgical Quality Improvement Database Joseph B. Oliver, MD MPH, Amy L. Davidow, PhD, Kimberly
More informationLong Term Follow-up. 6 Month 1 Year Annual enter year #: What is the assessment date: / / Unknown. Is the patient alive? Yes No
Long Term Follow-up 6 Month 1 Year Annual enter year #: What is the assessment date: / / Unknown Is the patient alive? Yes No Was an exam performed by a bariatric physician or PA/NP? Yes No Was the patient
More informationAmerican College of Surgeons National Surgical Quality Improvement Program Pediatric: A Phase 1 Report
ORIGINAL SCIENTIFIC ARTICLES American College of Surgeons National Surgical Quality Improvement Program Pediatric: A Phase 1 Report Mehul V Raval, MD, MS, Peter W Dillon, MD, FACS, Jennifer L Bruny, MD,
More informationNEW DEFINITION FORMAT AND DIFFICULT VARIABLE DEFINITIONS
NEW DEFINITION FORMAT AND DIFFICULT VARIABLE DEFINITIONS Bruce L. Hall, MD, PhD, MBA, FACS Clinical Support Physician Lead Paula Farrell, RN, BSN ACS NSQIP Clinical Support Specialist Case Studies &
More informationCenter for Reproductive Medicine Advanced Reproductive Technologies
Center for Reproductive Medicine Advanced Reproductive Technologies www.ivfminnesota.com New Patient Questionnaire Name DOB Age Marital Status: Single Married Partnered Separated Divorced Remarried Occupation
More informationPAAQS Reference Guide
Q. 1 Patient's Date of Birth (DOB) *Required Enter patient's date of birth PAAQS Reference Guide Q. 2 Starting Anesthesiologist *Required Record the anesthesiologist that started the case Q. 3 Reporting
More informationCell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
More informationPERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2006
PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2006 PATIENT IDENTIFICATION [Before completing please read instructions at the bottom of this page and on pages 5 and 6] MAKE CORRECTIONS
More informationAdult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
More informationPATIENT REGISTRATION FORMS
Today s Date: Preferred Office: Trevose Newtown Warrington Northeast Horsham PATIENT INFORMATION Patient s Last Name: First Name: Middle: Nickname: Date of Birth: Age: Gender: Student: Part Time Full Time
More informationPRE SURGICAL TESTING DEPARTMENT ADVOCATE LUTHERAN GENERAL HOSPITAL STANDARD FOR CHART REVIEW
Purpose: To provide a standard action plan for chart review of pre-admission testing done for scheduled surgical patients. PST will follow these guidelines for review, taking into consideration the patient
More informationInterQual Level of Care 2018 Index
InterQual Level of Care 2018 Index Long-Term Acute Care (LTAC) Criteria The Index is an alphabetical listing of conditions and/or diagnoses designed to guide the user to the criteria subset where a specific
More informationCODING KNOWLEDGE AND SKILLS ASSESSMENT Inpatient Coding Test
CODING KNOWLEDGE AND SKILLS ASSESSMENT Inpatient Coding Test Section I: Please read the following questions carefully and select the best multiple choice or true/false answer. 1) A coding professional
More informationEAST MULTICENTER STUDY DATA COLLECTION TOOL
EAST MULTICENTER STUDY DATA COLLECTION TOOL Multicenter Study: Effect of Regional Anesthesia on Delirium in Geriatric Trauma Patients with Multiple Rib Fractures Enrolling Center: Enrolling Co-investigators:
More informationPEDIATRIC INTENSIVE CARE UNIT SKILLS CHECKLIST
PEDIATRIC INTENSIVE CARE UNIT SKILLS CHECKLIST Name: RN Date: Directions: Please complete this checklist as accurately as possible. Answer each and every one. A=Performs proficiently and independently
More informationAppendix G Explanation/Clarification Summary
Appendix G Explanation/Clarification Summary Summary of Changes for Recommendations Alignment of measures with VBP by fiscal year Measures and service dates were adjusted to be consistent with the FY2016
More informationSUB TOPIC 3 : CLINICAL INDICATORS (CLINICAL QUALITY ASSURANCE CQA)
SUB TOPIC 3 : CLINICAL INDICATORS (CLINICAL QUALITY ASSURANCE CQA) DEPARTMENT INDICATORS STANDARD ANESTHESIOLOGY Incidence of re-intubation in recovery 0.3% Intraoperative and in recovery CPR Unplanned
More informationChildren s of Alabama. Birmingham, Alabama
Preoperative Evaluation of Pediatric Patients Heather Rankin, CRNA, MSN Children s of Alabama Birmingham, Alabama Objectives Define NPO guidelines Review history assessment Review system assessment Review
More informationChickenpox Death. West Virginia Electronic Disease Surveillance System
Chickenpox Death Electronic Disease Surveillance System Division of Surveillance and Disease Control Infectious Disease Epidemiology Program Phone: 304-558-5358 or 800-423-1271 in Fax: 304-558-8736 Investigation
More informationACS NSQIP Pediatric SCR: Complex Clinical Scenarios and Variable Review
ACS NSQIP Pediatric SCR: Complex Clinical Scenarios and Variable Review Disclosures The following planners, speakers, moderators, and/or panelists of the CME/CEU activity have no relevant financial relationships
More informationNew Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
More information34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone
34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone 215-590-3630 www.chop.edu/gastroenterology Please complete this form prior to your child s visit. Please fax to (215) 590-7224 or e-mail it
More informationWhat ASMBS Members Need to Know About: New Medicare Payment Policy Governing Bariatric Surgery and Hospital Acquired Conditions (HACs)
What ASMBS Members Need to Know About: New Medicare Payment Policy Governing Bariatric Surgery and Hospital Acquired Conditions (HACs) Robin Blackstone, MD, FACS, FASMBS Beginning October 1, 2008, Medicare
More informationIN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2006
IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2006 PATIENT IDENTIFICATION [Before completing please read instructions at the bottom of this page and on pages 5 and 6] MAKE
More informationTEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
More informationTENNCARE Bundled Payment Initiative: Description of Bundle Risk Adjustment for Wave 8 Episodes
TENNCARE Bundled Payment Initiative: Description of Bundle Risk Adjustment for Wave 8 Episodes Acute Seizure, Syncope, Acute Gastroenteritis, Pediatric Pneumonia, Bronchiolitis, Colposcopy, Hysterectomy,
More informationConsultant Services to Kansas Family Physicians
Consultant Services to Kansas Family Physicians The purpose of this study is to track the use of consultants. An e-mail survey was sent to 114 Kansas family physicians The survey was launched on 11/25/2009
More informationJanuary 2015 Updates. Dec.4, 2014 SCR Education Call
January 2015 Updates Dec.4, 2014 SCR Education Call Trauma codes Trauma cases specifically: Any injury with a principal ICD-9 or ICD-10 diagnostic code will be excluded from sampling within the range of:
More informationMeasure #164 (NQF 0129): Coronary Artery Bypass Graft (CABG): Prolonged Intubation National Quality Strategy Domain: Effective Clinical Care
Measure #164 (NQF 0129): Coronary Artery Bypass Graft (CABG): Prolonged Intubation National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY DESCRIPTION:
More informationCODING KNOWLEDGE AND SKILLS ASSESSMENT Section I: Please read the following questions carefully and select the best answer.
CODING KNOWLEDGE AND SKILLS ASSESSMENT Section I: Please read the following questions carefully and select the best answer. 1.) A coding professional may assume a cause and effect relationship between
More informationRole of IONM in reducing the incidence and severity in pediatric patients with AIS
Role of IONM in reducing the incidence and severity in pediatric patients with AIS Mohamed Nassef M.D PGY 2 ANESTHESIA McMaster University DEC 9, 2015 Objectives: Literature Review on neurological complications
More informationEmergency Department Suite
Emergency Department Suite This suite of Pediatric Learning Solutions (PLS) online courseware and curriculums provides 24/7 access to the foundational knowledge and just-in-time job aids clinicians working
More informationShallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname:
More informationSECTION 1: INCLUSION, EXCLUSION & RANDOMISATION INFORMATION
SECTION 1: INCLUSION, EXCLUSION & RANDOMISATION INFORMATION DEMOGRAPHIC INFORMATION Given name Family name Date of birth Consent date Gender Female Male Date of surgery INCLUSION & EXCLUSION CRITERIA YES
More informationAppendix 1: Supplementary tables [posted as supplied by author]
Appendix 1: Supplementary tables [posted as supplied by author] Table A. International Classification of Diseases, Ninth Revision, Clinical Modification Codes Used to Define Heart Failure, Acute Myocardial
More information6/30/2015. Lunch and Learn. Objectives. Who owns Quality and Patient Safety? We all do It s a Balance of Responsibility
Lunch and Learn Patient Safety Indicators June 11, 2014 Objectives List at least 3 entities that drive patient quality and safety initiatives Define AHRQ Patient Safety Indicators Describe the 10 diagnoses
More informationSCNIR 1107 NE 45 th St, Suite #345 Seattle, WA REGISTRATION FORM. Reviewer s Signature: PHYSICIAN CONTACT INFORMATION
Physician Name: Institution Name: Institution Address: FOR OFFICE USE ONLY Registration: Approved Date: Not approved Reviewer s Signature: PHYSICIAN CONTACT INFORMATION Specialty: City: State/Province:
More informationUser Guide for the 2016 ACS NSQIP Pediatric Participant Use Data File (PUF)
User Guide for the 2016 ACS NSQIP Pediatric Participant Use Data File (PUF) American College of Surgeons National Surgical Quality Improvement Program - Pediatric Released: October 2017 ACS NSQIP PEDIATRIC
More informationSUSTAIN BASELINE DATA COLLECTION FORM. Revised 2/4/2014 (both pediatric and adult data elements) 1. Gestational age at birth ( weeks gestation)
SUSTAIN BASELINE DATA COLLECTION FORM Patient Demographics Revised 2/4/2014 (both pediatric and adult data elements) Did the patient begin Home PN over 90 days ago? Yes No Date began Home PN Patient Number
More information