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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.` `Occurrence Comments` LAST EDITED: `DEC 05, 1988` 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	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	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	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	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	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	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	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	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	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`