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Sub-Field: 130.22

Package: Surgery

SURGERY(#130)-->130.22

Sub-Field: 130.22


Information

Parent File Name Number Package
SURGERY(#130) POSTOP OCCURRENCE 130.22 Surgery

Details

Field # Name Loc Type Details
.01 POSTOP OCCURRENCE 0;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<3)!($E(X,1,5)["NONE")!($E(X,1,5)["None")!($E(X,1,5)["none") X
  • LAST EDITED:  NOV 08, 1988
  • HELP-PROMPT:  If a postoperative occurrence exists, your answer should be 3 to 40 characters.
  • DESCRIPTION:  This is the name of a occurrence encountered postoperatively. If there are no occurrences, this field should be left blank. 'NONE' will not be accepted.
  • DELETE TEST:  .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
.05 OUTCOME TO DATE 0;6 SET
  • 'U' FOR UNRESOLVED;
  • 'I' FOR IMPROVED;
  • 'D' FOR DEATH;
  • 'W' FOR WORSE;

  • LAST EDITED:  JAN 25, 1991
  • DESCRIPTION:  This is the code corresponding to the outcome of this postoperative occurrence.
2 DATE COMP NOTED 0;7 DATE

  • INPUT TRANSFORM:  S %DT="EXPT" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  MAR 13, 2007
  • HELP-PROMPT:  Enter the date/time that this occurrence was noted.
  • DESCRIPTION:  This is the date that this postoperative occurrence was noted in the patient's record.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
3 TREATMENT INSTITUTED 2;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>40!($L(X)<1) X
  • LAST EDITED:  APR 15, 1987
  • HELP-PROMPT:  Your answer must be 1 to 40 characters in length.
  • DESCRIPTION:  This is descriptive information about the treatment instituted as a result of this occurrence.
4 OCCURRENCE COMMENTS 1;0 WORD-PROCESSING #130.224

  • DESCRIPTION:  These are comments about this postoperative occurrence.
5 OCCURRENCE CATEGORY 0;2 POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5)
************************REQUIRED FIELD************************
PERIOPERATIVE OCCURRENCE CATEGORY(#136.5)

  • INPUT TRANSFORM:  S DIC("S")=$$CO^SROCMPS D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  AUG 22, 2000
  • HELP-PROMPT:  Enter the name of the category most closely related to this occurrence.
  • DESCRIPTION:  This is the name of the category in which this occurrence may be grouped. It should be entered for all occurrences and will be used by Surgery Central Office for reporting needs.
  • SCREEN:  S DIC("S")=$$CO^SROCMPS
  • EXPLANATION:  Screen prevents selection of inactive occurrence category and selection of cardiac only category on non-cardiac case.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
6 ICD DIAGNOSIS CODE 0;3 POINTER TO ICD DIAGNOSIS FILE (#80) ICD DIAGNOSIS(#80)

  • INPUT TRANSFORM:  D GETAPI^SROICDGT("SURG","DIAG",$S($G(DA(1)):DA(1),$G(SRTN):SRTN,1:""))
  • OUTPUT TRANSFORM:  I $G(Y) S Y=$$OUT^SROICD(Y)
  • LAST EDITED:  JUL 14, 2012
  • HELP-PROMPT:  Enter the ICD Diagnosis code corresponding to this postoperative occurrence.
  • DESCRIPTION:  If the occurrence entered does not fit in any of the predefined categories, an ICD Diagnosis Code must be entered.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
7 SEPSIS CATEGORY 0;4 SET
  • '1' FOR SIRS;
  • '2' FOR SEPSIS;
  • '3' FOR SEPTIC SHOCK;

  • LAST EDITED:  JAN 09, 2014
  • HELP-PROMPT:  Select the appropriate category of sepsis for this occurrence.
  • DESCRIPTION:  Definition Revised (2014): 2. Sepsis is the systemic response to infection.
    Answer YES if both of the following criteria are met:
    Clinical documentation of infection (such as wound with purulent
    drainage, ruptured bowel with free air, etc.); a positive culture
    from any site thought to be causative; or specialized laboratory
    evidence of causative infection (such as viral DNA in blood).
    AND
    the presence of two or more of the following systemic responses:
    Temperature > 38 degrees C or < 36 degrees C
    HR > 90 beats/minute
    RR > 20 breaths /minute or PaCO2 < 32 mmHg
    WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature
    neutrophils ("bands")
    3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it
    is associated with organ and/or circulatory dysfunction.
    Terminology such as Severe Sepsis/Septic Shock/Refractory Septic
    Shock/Refractory Septic Shock and Multiple Organ Dysfunction
    Syndrome (MODS) all fall into this category.
    Answer YES if the definition of SEPSIS is present AND there is
    documented organ and/or circulatory dysfunction defined by one or more
    of the following:
    - Areas of acutely mottled skin not related to peripheral vascular
    disease
    - Capillary refilling requires three seconds or longer not
    related to peripheral vascular disease
    - Urine output <0.5 mL/kg for at least one hour, or renal
    replacement therapy
    - Lactate >2 mmol/L
    - Abrupt change in mental status
    - Abnormal EEG findings
    - Platelet count < 100,000 platelets/mL
    - Disseminated intravascular coagulation (DIC)
    - Acute lung injury or acute respiratory distress syndrome (ARDS)
    - New cardiac dysfunction as defined by ECHO or direct measurement
    of the cardiac index
    - An arterial systolic blood pressure (SBP) of =90 mm Hg or a mean
    arterial pressure (MAP) =70 mm Hg for at least 1 hour despite
    adequate fluid resuscitation, adequate intravascular volume status,
    or the need for vasopressors to maintain SBP >=90 mm Hg or
    MAP >=70 mm Hg.
    For the patient that had sepsis preoperatively, continuation of
    the preoperatively identified signs postoperatively would not be
    reported as a new postoperative sepsis. Worsening of the preope-
    ratively identified signs would be reported as a new postoperative
    sepsis.
  • SCREEN:  S DIC("S")="I Y'=1"
  • EXPLANATION:  Screen prevents selection of inactive code.
8 CPB STATUS 0;5 SET
  • '0' FOR None;
  • '1' FOR On-bypass;
  • '2' FOR Off-bypass;

  • LAST EDITED:  APR 23, 2014
  • HELP-PROMPT:  Enter NONE, ON BYPASS, or OFF BYPASS.
  • DESCRIPTION:  Definition Revised (2014): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or
    within 30 days of the initial operation. Indicate the one appropriate response:
    None - no repeat cardiac surgical procedure post-operatively within 30
    days of initial operation. On-bypass - patient underwent a repeat cardiac surgical procedure
    utilizing CPB. Off-bypass - patient underwent a repeat cardiac surgical procedure not
    utilizing CPB.
9 STROKE/CVA DURATION 0;8 SET
  • '1' FOR NO SYMPTOMS;
  • '2' FOR <24 HOURS;
  • '3' FOR 24-72 HOURS;
  • '4' FOR >72 HOURS;

  • LAST EDITED:  JUL 11, 2011
  • HELP-PROMPT:  Enter code (1, 2, 3 or 4) that best describes the Stroke/CVA duration.
  • DESCRIPTION:  VASQIP Definitions (2011): Indicate if the patient developed a new neurologic deficit with onset immediately post-operatively or occurring within the 30 days after surgery. Neurologic deficits are defined as an embolic,
    thrombotic, or hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (e.g., hemiplegia,hemiparesis, aphasia, sensory deficit, impaired memory). Indicate the duration as follows:
    1) no symptoms
    2) symptomatic duration less than 24 hours
    3) symptomatic duration of 24-72 hours
    4) symptomatic duration >72 hours
10 INDWELLING URETHRAL CATHETER 0;9 SET
  • '1' FOR IN PLACE;
  • '2' FOR RECENT REMOVAL;
  • '3' FOR SHORT DURATION;
  • '4' FOR DISTANT REMOVAL;
  • '5' FOR NO CATHETER;

  • LAST EDITED:  MAR 09, 2015
  • HELP-PROMPT:  Enter whether or not the patient has an indwelling urinary catheter in place and if so, indicate the specific timeline.
  • DESCRIPTION:  VASQIP Definition (2015): At the time of specimen collection for suspected urinary tract infection during the post-operative 30 day period, answer the following about indwellilng urethral catheter:
    I- IN PLACE >2 calendar days on the day of UTI
    Signs/Symptoms and UTI Culture sample
    R- RECENTLY REMOVED, had been in place >2 calendar
    days but removed the day of or the day before
    UTI Signs/Symptoms and UTI Culture sample
    S- SHORT DURATION, present at the time of UTI
    Signs/Symptoms and UTI Culture sample but had
    not been present <2 calendar days
    D- DISTANT REMOVAL, placed in the perioperative
    period and present >2 calendar days, but
    removed>2 calendar days prior to UTI
    Signs/Symptoms and UTI Culture sample
    N- NO CATHETER, did not have an indwelling uretheral
    catheter >2 calendar days
11 UTI SIGN/SYMPTOMS URG/FREQ/DYS 0;10 SET
  • 'Y' FOR HAS URGENCY, FREQUENCY, OR DYSURIA WITH NO OTHER RECOGNIZED CAUSE;
  • 'N' FOR DOES NOT HAVE URGENCY, FREQUENCY OR DYSURIA;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter YES or NO to indicate presence of UTI urgency or frequency or dysuria.
  • DESCRIPTION:  
    VASQIP Definition (2014): This indicates the patient complains of urinary urgency or urinary frequency or dysuria.
12 UTI SIGNS/SYMPTOMS FEVER 0;11 SET
  • 'Y' FOR FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SYMPTOMS;
  • 'N' FOR NO FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SIGNS OR SYMPTOMS;

  • LAST EDITED:  JUN 10, 2014
  • HELP-PROMPT:  Enter yes or no to indicate presence of fever at the time of culture or onset of signs/symptoms.
  • DESCRIPTION:  
    VASQIP Definition (2014): This indicates the patient has a fever >38C at the time of culture or onset of signs or symptoms.
13 UTI SIGNS/SYMPTOMS TENDERNESS 0;12 SET
  • 'Y' FOR SUPRAPUBIC, COSTOVERTEBRAL ANGLE PAIN;
  • 'N' FOR NO SUPRAPUBIC TENDERNESS, COSTOVERTEBRAL ANGLE PAIN;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter YES or NO to indicate presence of suprapubic tenderness or costovertebral angle pain or tenderness.
  • DESCRIPTION:  
    VASQIP Definition (2014): This indicates the patient has suprapubic tenderness or costovertebral angle pain or tenderness.
14 UTI CULTURE 0;13 SET
  • '1' FOR POS CULTURE >10E5, 1-2 SPECIES;
  • '2' FOR POS CULTURE 10E3-10E5, 1-2 SPECIES DIPSTICK(+), PYURIA, OR GRAM (+);

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter UTI Culture indicator.
  • DESCRIPTION:  VASQIP Definition (2014): This indicates that 1. The patient has a positive urine culture, that is, >10^5 colony-
    forming units (CFU)/ml with no more than 2 species of microor-
    ganisms OR 2. The patient has a positive urine culture of >10^3 and <10^5 colony
    forming units (CFU)/mL with no more than 2 species of microorganisms
    AND one of the following three items:
    a. Positive dipstick for leukocyte esterase and/ or nitrate;
    b. Pyuria (urine specimen with >10 white blood cell [WBC]/mm3 of
    unspun urine or > 3 WBC high-power field of spun urine);
    c. Microorganisms seen on Gram's stain of unspun urine
15 POSTOP DEVICE TYPE 0;14 SET
  • '1' FOR IABP;
  • '2' FOR VAD;
  • '3' FOR TAH;
  • '4' FOR ECMO;
  • '5' FOR MULTIPLE DEVICES;

  • LAST EDITED:  MAR 25, 2015
  • HELP-PROMPT:  Enter Postop device Type.
  • DESCRIPTION:  VASQIP Definition (2015): Indicate the patient required post-op placement of a new IABP, VAD, TAH, ECMO, or MULTIPLE DEVICES for circulatory support within 30 days post-operatively.
    1. IABP 2. VAD 3. TAH 4. ECMO 5. MULTIPLE DEVICES
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