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 Ethnicity: Yes No Unknown MI: Address: City: State: Zip Code: Country (if not US): Home #: ( ) - Work #: ( ) - Cell #: ( ) - Preferred Language: English Spanish 1
Form 2: Case Form - Surgical Profile Case Number: SURGICAL PROFILE *CPT Code: *Principal Operative Procedure: If the Principle Operative Procedure is a Revision or Unlisted Procedure Code, select appropriate procedure: Revision Mini-loop gastric bypass Other Endoscopic primary or revisional procedure for weight loss If CPT is a Band, select band brand: RealizeTM Band (Ethicon) Lap-BandTM (Allergan/Inamed) Unknown N/A *Hospital Admission Date: / / *Operation Date: / / (Required field) Name of Attending/ Surgeon (and Surgeon ID Number): LCN (not required): Encounter Number (not required): 2
Form 2: Case Form - Preop Case Number: PREOP *Height unknown cm in BMI (auto-calculated in workstation) *Weight unknown kg lbs General Cardiac *Diabetes Mellitus Non-insulin History of Myocardial No Insulin Infarction Yes *Current Smoker w/in 1 year *Functional Health Status No Yes No *Previous PCI /PTCA Yes No Independent Partially Dependent Totally Dependent Unknown *Previous Cardiac Surgery Yes No Pulmonary *Hypertension requiring medication Yes *History of Severe COPD Yes No # of anti-hypertensive meds Oxygen Dependent Yes No Hyperlipidemia requiring medication Yes History of Pulmonary Embolism Obstructive Sleep Apnea req. CPAP / BiPAP Gastrointestinal GERD req. medications (w/in 30 days prior to surgery) Yes No Vascular Yes Yes No No No No Vein Thrombosis Req. Therapy Yes No Venous Stasis Yes No Renal *Currently requiring or on dialysis Yes No Renal Insufficiency Yes No Musculoskeletal Is the patient s ambulation limited most or all of the time? Nutritional / Immune / Oncology / Other Yes No *Steroid/Immunosuppressant Use for Chronic Condition Yes No Therapeutic anticoagulation Yes No Previous obesity surgery/foregut surgery Yes No 3
Form 2: Case Form Preop Labs/Operation Case Number: PREOP LABS All Pre-op Labs Unknown *Preop Albumin: / / *Preop Hematocrit: / / NOTES: (If desired, e.g., list antihypertensive meds for future reference): OPERATION First Assistant level of training: None PA/NP/RNFA Resident (PGY 1-5+) MIS Fellow Attending Weight Loss Surgeon Attending Other *Emergency Case? Yes No *ASA Class: 1 2 3 4 5 None Assigned Surgical Approach: N.O.T.E.S. (Natural Orifice Transluminal Endoscopic Surgery) Single Incision Robotic-assisted Conventional laparoscopic (thoracoscopic) Laparoscopic assisted (thoracoscopic assisted) Hand-assisted Open Notes: 4
Form 2: Case Form Operation (cont.) Case Number: OPERATION (cont.) Was it converted to another approach: Yes No If yes, then what was the final operative approach: Single Incision Robotic-assisted Conventional laparoscopic (thoracoscopic) Laparoscopic assisted (thoracoscopic assisted) Hand-assisted Open Notes: Was the case aborted? Yes No If yes, please explain: Was a drain placed at the time of the initial operation? Yes No Was a swallow study performed the day of or the day after the procedure? Yes, routine Yes, selective No *Procedure / Surgery Start Time: Date / / *Procedure / Surgery Finish Time: Date / / Time : Time : Was the anastomosis/staple line checked with a provocative test to assess for leak? Yes No N/A (only if no anastomosis/staple line) If CPT is a Gastric Sleeve: Bougie (or sizing device) size French cm Not Documented Distance from the pylorus # (in cm) Not documented Staple line reinforcement: Yes No Oversew: Yes No 5
Form 2: Case Form Other Procedures Case Number: OTHER PROCEDURES *Other Procedures CPT *Concurrent Procedures CPT 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 6
Form 2: Case Form Occurrences Case Number: INTRAOP OCCURRENCE Was there an intraoperative occurrence? Yes No If yes, select from the following: Cardiac Arrest requiring CPR Myocardial Infarction Unplanned Intubation Death During Operation Other (list ICD 9 Code) Comments: POSTOP OCCURRENCE Was there a postoperative occurrence? Yes No If yes, select from the following: Note: The postoperative occurrence(s) reflect 30 days postoperatively from date of surgery. Date Treatment** Wound Occurrences Superficial Incisional SSI / / Deep Incisional SSI / / Organ/Space SSI / / Wound Disruption / / Respiratory Occurrences Pneumonia / / Unplanned Intubation / / Pulmonary Embolism / / On Ventilator > 48 hours / / Urinary Tract Occurrences Progressive Renal Insufficiency / / Acute Renal Failure / / Urinary Tract Infection / / **Although not required for this program, you may wish to document treatment of the occurrence for internal quality monitoring. 7
Form 2: Case Form Occurrences (cont.) Case Number: POSTOP OCCURRENCE (cont.) Date Treatment** CNS Occurrences Stroke/CVA / / Coma > 24 hours / / Peripheral Nerve Injury / / Cardiac Occurrences Cardiac Arrest req. CPR / / Myocardial Infarction / / Other Occurrences Transfusion Intraop/Postop (72h of surgery start time) / / Amount of blood transfused within 72 hours of surgery start (Units) Vein Thrombosis Requiring Therapy / / Sepsis / / Septic Shock / / Other (list ICD 9 code) / / Unplanned Admission to the ICU within 30 days: Yes No **Although not required for this program, you may wish to document treatment of the occurrence for internal quality monitoring. 8
Form 2: Case Form Discharge Case Number: DISCHARGE *Acute Hospital Discharge Date: / / *Hospital Discharge Destination: Skilled care not home Separate Acute Care Unskilled facility not home Rehab Facility which was home Expired Home Unknown *Still in Hospital > 30 days Postoperative Death w/in 30 Days of Procedure: Yes No Date of Death: / / Unknown Comments: 9
Form 3: 30-Day Follow-up Case Number: VISIT PERIOD Were you able to follow the patient for the full 30 days? Yes No What is the assessment date? : / / Is the patient alive? Yes No Was an exam performed by a bariatric physician or PA/NP? Yes No Was the patient seen by any clinician? Yes No GENERAL Height: cm in Weight: kg lb Date weight taken: / / BMI: Weight: kg lb Date weight taken: / / BMI: Was anticoagulation initiated for presumed/confirmed vein thrombosis/pe? Yes No Was an incisional hernia noted on exam? Yes No Was an operative drain still present at 30 days? Yes No READMISSIONS/REOPERATIONS Was the patient readmitted to the hospital since the last follow-up? Yes No (If yes, complete Form 5) Did the patient have any post-bariatric surgical operations or Yes No interventions performed since the last follow-up? (If yes, complete Form 5) MORTALITY INFORMATION Date of Death: / / Suspected Cause of Death: (select code number from list below) Code Suspected Reason Code Suspected Reason 1 Anastomotic/Staple Line Leak 13 Incisional Hernia 2 GI Perforation 14 Bleeding 3 Other Abdominal Sepsis 15 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 16 Pulmonary Embolism 5 Intestinal Obstruction 17 Pneumonia 6 Gastric Distention 18 Other Respiratory Failure 7 Fluid, electrolyte, or nutritional depletion 19 Infection/Fever 8 Anastomotic Ulcer 20 Band Slippage/Prolapse 9 Gastro-Gastric Fistula 21 Band Erosion 10 Gallstone Disease 22 LAGB Port, Tubing or Band problem 11 Wound Infection/Evisceration 23 Bile Reflux Gastritis 12 Internal Hernia 24 Other 10
Form 3: 30-Day Follow-up Attempts to Contact Patient Case Number: ATTEMPTS BY THE BARIATRIC CENTER TO CONTACT PATIENT Was a follow-up appointment made but patient did not show for appointment? Yes No Was a phone call placed to the patient? Once Twice Never Was a letter sent to the patient? Once Twice Never Was the patient s care transferred to another bariatric specialist? Yes No If yes, please list name. Name: Is patient refusing long-term follow-up? Yes No Is the patient lost to follow-up? Yes No PATIENT CONTACT MANAGEMENT Not a required field Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: 11
Form 4: Long Term Follow-up Case Number: Time period for this visit: 6 months Annual enter year #: What is the assessment date? : / / Is the patient alive? Yes No Was an exam performed by a bariatric physician or PA/NP? Yes No Was the patient seen by any clinician? Yes No GENERAL Height: cm in Weight: kg lb BMI: Date weight taken: / / Weight: kg lb BMI: Date weight taken: / / Weight: kg lb BMI: Date weight taken: / / Was anticoagulation initiated for presumed/confirmed DVT/PE? Yes No Was an incisional hernia noted on exam? Yes No COMORBIDITY Sleep Apnea GERD req. meds. Hyperlipidemia req. meds. Yes No Not Documented Yes No Not Documented Yes No Not Documented Hypertension req. meds. Yes No Not Documented If yes, # of antihypertensive meds: Diabetes Yes No Not Documented If yes, select: Non-insulin Insulin 12
Form 4: Long Term Follow-up (cont.) Case Number: Time period for this visit: 6 months Annual enter year #: READMISSIONS/REOPERATIONS Was the patient readmitted to the hospital since the last follow-up? Yes No (If yes, complete Form 5) Did the patient have any post-bariatric surgical operations or Yes No interventions performed since the last follow-up? (If yes, complete Form 5) MORTALITY INFORMATION Date of Death: / / Suspected Cause of Death: (select code number from list below) Code Suspected Reason Code Suspected Reason 1 Anastomotic/Staple Line Leak 13 Incisional Hernia 2 GI Perforation 14 Bleeding 3 Other Abdominal Sepsis 15 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 16 Pulmonary Embolism 5 Intestinal Obstruction 17 Pneumonia 6 Gastric Distention 18 Other Respiratory Failure 7 Fluid, electrolyte, or nutritional depletion 19 Infection/Fever 8 Anastomotic Ulcer 20 Band Slippage/Prolapse 9 Gastro-Gastric Fistula 21 Band Erosion 10 Gallstone Disease 22 LAGB Port, Tubing or Band problem 11 Wound Infection/Evisceration 23 Bile Reflux Gastritis 12 Internal Hernia 24 Other 13
Form 4: Long Term Follow-up Attempts to Contact Patient Case Number: Time period for this visit: 6 months Annual enter year #: ATTEMPTS BY THE BARIATRIC CENTER TO CONTACT PATIENT Was a follow-up appointment made but patient did not show for appointment? Yes No Was a phone call placed to the patient? Once Twice Never Was a letter sent to the patient? Once Twice Never Was the patient s care transferred to another bariatric specialist? Yes No If yes, please list name. Name: Is patient refusing long-term follow-up? Yes No Is the patient lost to follow-up? Yes No PATIENT CONTACT MANAGEMENT Not a required field Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax E-mail Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: 14
Form 5: Readmissions and Reoperations Case Number: Time period for this visit: 30-day 6 months Annual enter year #: HOSPITAL READMISSIONS Readmission #1: Date of Admission: / / Date of Discharge: / / Information Source: Medical Record Other Was this readmission likely related to a bariatric procedure? Yes No Suspected reason for admission (enter code from table below): Comments: Readmission #2: Date of Admission: / / Date of Discharge: / / Information Source: Medical Record Other Was this readmission likely related to a bariatric procedure? Yes No Suspected reason for admission (enter code from table below): Comments: Readmission #3: Date of Admission: / / Date of Discharge: / / Information Source: Medical Record Other Was this readmission likely related to a bariatric procedure? Yes No Suspected reason for admission (enter code from table below): Comments: Suspected Reason Code Suspected Reason 1 Anastomotic/Staple Line Leak 13 Incisional Hernia 2 GI Perforation 14 Bleeding 3 Other Abdominal Sepsis 15 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 16 Pulmonary Embolism 5 Intestinal Obstruction 17 Pneumonia 6 Gastric Distention 18 Other Respiratory Failure 7 Fluid, electrolyte, or nutritional depletion 19 Infection/Fever 8 Anastomotic Ulcer 20 Band Slippage/Prolapse 9 Gastro-Gastric Fistula 21 Band Erosion 10 Gallstone Disease 22 LAGB Port, Tubing or Band problem 11 Wound Infection/Evisceration 23 Bile Reflux Gastritis 12 Internal Hernia 24 Other 15
Form 5: Readmissions and Reoperations (cont.) Case Number: Time period for this visit: 30-day 6 months Annual enter year #: SURGICAL PROCEDURES PERFORMED AFTER THE INDEX BARIATRIC PROCEDURE Reoperation #1: Reoperation/Intervention (see table below) Suspected reason for reoperation (enter code from table below): Date Performed: / / Information Source: Medical Record Other Was this reoperation likely related to a bariatric procedure? Yes No Comments: Reoperation #2: Reoperation/Intervention (see table below) Suspected reason for reoperation (enter code from table below): Date Performed: / / Information Source: Medical Record Other Was this reoperation likely related to a bariatric procedure? Yes No Comments: Reoperation #3: Reoperation/Intervention (see table below) Suspected reason for reoperation (enter code from table below): Date Performed: / / Information Source: Medical Record Other Was this reoperation likely related to a bariatric procedure? Yes No Comments: 16
Form 5: Readmissions and Reoperations (cont.) Case Number: Time period for this visit: 30-day 6 months Annual enter year #: Selections for Reoperations/Interventions Abdominal Reoperation Operative Drain Placement Gastrostomy Anastomotic Revision Band Removal Band, Tubing or Port Revision Band Placement Internal Hernia Repair Incisional Hernia Repair Cholecystectomy Bowel Resection Re-exploration Other Reoperations/Interventions Tracheostomy Endoscopy Gastro-gastric fistula closure ERCP Placement of Percutaneous Drain Other (please specify) Suspected Reasons for Intervention Code Suspected Reason Code Suspected Reason 1 Anastomotic/Staple Line Leak 13 Incisional Hernia 2 GI Perforation 14 Bleeding 3 Other Abdominal Sepsis 15 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 16 Pulmonary Embolism 5 Intestinal Obstruction 17 Pneumonia 6 Gastric Distention 18 Other Respiratory Failure 7 Fluid, electrolyte or nutritional depletion 19 Infection/Fever 8 Anastomotic Ulcer 20 Band Slippage/Prolapse 9 Gastro-Gastric Fistula 21 Band Erosion 10 Gallstone Disease 22 LAGB Port, Tubing or Band problem 11 Wound Infection/Evisceration 23 Bile Reflux Gastritis 12 Internal Hernia 24 Other 17