
File Surgery(130) Data List
| PATIENT |
HOSPITAL ADMISSION STATUS |
PLANNED ADMISSION STATUS |
VISIT |
CLASSIFICATION ENTERED (Y/N) |
SERVICE CONNECTED |
AGENT ORANGE EXPOSURE |
IONIZING RADIATION EXPOSURE |
SOUTHWEST ASIA CONDITIONS |
OP ROOM PROCEDURE PERFORMED |
ASSOCIATED CLINIC |
MILITARY SEXUAL TRAUMA |
HEAD AND/OR NECK CANCER |
COMBAT VET |
PROJ 112/SHAD |
MAJOR/MINOR |
CASE SCHEDULE TYPE |
CASE SCHEDULE ORDER |
SURGERY SPECIALTY |
PREOPERATIVE INFECTION |
PREOP SKIN INTEG |
PREOP SKIN COLOR |
DATE OF OPERATION |
TRANS TO OR BY |
OR CIRC SUPPORT |
OR SCRUB SUPPORT |
HAIR REMOVAL BY |
RESTR & POSITION AIDS |
PRIMARY SURGEON |
FIRST ASST |
SECOND ASST |
ATTENDING SURGEON |
*ATTENDING CODE - NOT USED |
ATTENDING/RES SUP CODE |
PERFUSIONIST |
ASST PERFUSIONIST |
SKIN PREP AGENTS |
SKIN PREPPED BY (1) |
PREOP MOOD |
PREOP CONVERSE |
PREOP CONSCIOUS |
NURSE PRESENT TIME |
TIME PAT IN HOLD AREA |
ANES AVAIL TIME |
TIME PAT IN OR |
SURG PRESENT TIME |
ANES CARE START TIME |
ANES CARE TIME BLOCK |
ANES CARE BILLABLE TIME FLAG |
INDUCTION COMPLETE |
ANES CARE BILLABLE TIME |
TIME OPERATION BEGAN |
TIME OPERATION ENDS |
TIME PAT OUT OR |
OR CLEAN START TIME |
OR CLEAN END TIME |
ANES CARE END TIME |
BLOOD LOSS (ML) |
TOTAL URINE OUTPUT (ML) |
REPLACEMENT FLUID TYPE |
GENERAL COMMENTS |
NURSING CARE COMMENTS |
MONITORS |
PRINC ANESTHETIST |
RELIEF ANESTHETIST |
ASST ANESTHETIST |
ANESTHESIOLOGIST SUPVR |
ANES SUPERVISE CODE |
ANES PERSONALLY PERFORMED |
NUM OF CONCURRENT ANES CASES |
ANES CONCURRENT CASES |
ANES MEDICALLY DIRECTED |
ANES PHYSICIAN AVAILABLE |
MIN INTRAOP TEMPERATURE (C) |
ANESTHESIA TECHNIQUE |
MEDICATIONS |
IRRIGATION |
OTHER PROCEDURES |
PLANNED POSTOP CARE |
OR SET-UP TIME |
OP DISPOSITION |
PROSTHESIS INSTALLED |
TIME TOURNIQUET APPLIED |
FINAL COUNTS VERIFY CORRECT |
VERIFIER |
*INST CNT CORRECT |
INST CNT VERF BY |
*SURGERY POSITION |
ELECTROGROUND POSITION |
FOLEY CATHETER SIZE |
FOLEY CATHETER INSERTED BY |
PREOP TEMPERATURE |
PREOP WEIGHT (Kg) |
PREOPERATIVE HEART RATE |
PREOP BLOOD PRESSURE |
PREOP RESPIRATORY RATE |
FINAL ANESTHESIA TEMP (C) |
POSTOP PULSE |
POSTOP BP |
POSTOP RESP |
TIME-OUT DOCUMENT COMPLETED BY |
OTHER PREOP DIAGNOSIS |
OTHER POSTOP DIAGS |
ELECTROCAUTERY UNIT |
THERMAL UNIT |
POSTOP SKIN INTEG |
POSTOP SKIN COLOR |
PACU DISPOSITION |
POSTOP MOOD |
POSTOP CONVERS |
POSTOP CONSCIOUS |
END PULSE |
END BP |
END RESP |
PACKING |
PATIENT EDUCATION/ASSESSMENT |
CONSENT SIG&WIT |
BATH & SHAMPOO |
REC&XRAY READY |
ENEMA(S) IF ORD |
NPO AS ORD/CLIN MID |
*CLERK CHN DAYS BEFORE |
*VERFIFY ID TAG SSN |
CARE PLAN IN CHART |
ADDRESS PLATE |
PATIENT VOIDED |
PREOP MED&RAIL UP |
*CLERK CHN DATE PROCEDURE |
PROSTHESIS REM |
CIG, MATCH & VAL REM |
VALUABLES SECURED |
ORAL HYGIENE |
FRESHLY SHAVED |
CLEAN DRESSING |
CLEAN HOSP CLOTH |
LEVIN TUBE/CATH |
U/A IN 48 HRS |
*CLERK CHN REC FOR MAJ SURG |
CBC IN 48 HRS |
BLOOD TYPE&XMATCH |
*BLEEDING & PTT TIME IN 48 HRS |
*BUN IN 7 DAYS |
*BLOOD SUGAR IN 7 DAYS |
*SEROLOGY REPORT |
CHEST XRAY IN 7 DAYS |
EKG IN 24 HRS |
REQ ANESTHESIA TECHNIQUE |
REQ FROZ SECT |
REQ PREOP X-RAY |
INTRAOPERATIVE X-RAYS |
REQ PHOTO |
REQ BLOOD KIND |
REQ BLOOD AVAIL |
WOUND CLASSIFICATION |
DATE/TIME OR REQUEST MADE |
SURG SCHED PERSON |
PAC(U) ADMIT SCORE |
PAC(U) DISCH SCORE |
ASA CLASS |
INTRAOPERATIVE OCCURRENCES |
RETURNED TO SURGERY |
SURGEON'S DICTATION |
POSTOP OCCURRENCE |
ADMIT PAC(U) TIME |
PAC(U) DISCH TIME |
POSTOP ANES NOTE DATE |
POSTOP ANES NOTE |
OPERATION TIME |
ANESTH INDUCT TIME |
ANES CARE TIME |
PATIENT IN OR TIME |
OR CLEAN UP TIME |
PAC(U) TIME |
SCHEDULED START TIME |
ORDER NUMBER |
TIU OPERATIVE SUMMARY |
TIU NURSE INTRAOP REPORT |
TIU PROCEDURE REPORT (NON-OR) |
TIU ANESTHESIA REPORT |
DICTATED SUMMARY EXPECTED |
CPT ON NURSE REPORT |
ICD ON NURSE REPORT |
STAFF/RESIDENT |
REASON FOR NO ASSESSMENT |
ANESTHETIST CATEGORY |
SCHEDULED END TIME |
NON-OR PROCEDURE |
NON-OR LOCATION |
IN OR TO ANES START |
DATE OF PROCEDURE |
TIME PROCEDURE BEGAN |
TIME PROCEDURE ENDED |
PROVIDER |
ATTEND PROVIDER |
MEDICAL SPECIALTY |
PROCEDURE OCCURRENCE |
SEQUENTIAL COMPRESSION DEVICE |
LASER TYPE |
LASER UNIT |
ANES START TO OP START |
CELL SAVER |
DEVICE(S) |
LASER PERFORMED |
SPINAL LEVEL |
IN OR TO OP START TIME |
DATE/TIME OF DICTATION |
CANCEL DATE |
CANCELLATION TIMEFRAME |
PRIMARY CANCEL REASON |
CASE ABORTED |
CANCELLATION COMMENTS |
DIAGNOSTIC/THERAPEUTIC (Y/N) |
OPERATIONS THIS ADMISSION |
IMAGE |
ROBOTIC ASSISTANCE (Y/N) |
REDO PROCEDURE |
*CURRENT SMOKER |
PACK/YEARS |
HISTORY OF COPD |
VENTILATOR DEPENDENT |
PRIOR MI |
VASCULAR (Y/N) |
*CONGESTIVE HEART FAILURE |
*HYPERTENSION REQUIRING MEDS |
CARDIOMEGALY |
WAIT TIME START |
CENTRAL NERVOUS SYSTEM (Y/N) |
CURRENTLY ON DIALYSIS |
ASCITES |
ESOPHAGEAL VARICES |
PGY OF PRIMARY SURGEON |
WEIGHT LOSS > 10% |
BLEEDING DISORDERS |
TRANSFUSION > 4 RBC UNITS |
OPEN WOUND |
PREOPERATIVE SEPSIS |
PREOPERATIVE HEMOGLOBIN |
TUBES AND DRAINS |
*PREVIOUS PCI |
PREOPERATIVE CPK |
PREOPERATIVE MB BAND |
PREOPERATIVE SERUM CREATININE |
PREOPERATIVE BUN |
PREOPERATIVE SERUM ALBUMIN |
PREOPERATIVE SGPT |
PREOPERATIVE SGOT |
PREOPERATIVE TOTAL BILIRUBIN |
PREOPERATIVE ALK PHOSPHATASE |
REFERRING PHYSICIAN |
PREOPERATIVE WBC |
PREOPERATIVE PLATELET COUNT |
PREOPERATIVE PT |
PREOPERATIVE PTT |
PREOPERATIVE HEMATOCRIT |
ASSESSMENT STATUS |
HEIGHT |
HEIGHT MEASUREMENT DATE |
WEIGHT |
PREOPERATIVE SLEEP APNEA |
DNR STATUS |
PREOPERATIVE HEMOGLOBIN, DATE |
LOCK CASE |
*FUNCTIONAL HEALTH STATUS |
PULMONARY (Y/N) |
CARDIAC (Y/N) |
RENAL (Y/N) |
HEPATOBILIARY (Y/N) |
NUTRITIONAL/IMMUNE/OTHER |
ETOH > 2 DRINKS/DAY |
LENGTH OF POST-OP STAY |
SUPERFICIAL INCISIONAL SSI |
DEEP INCISIONAL SSI |
DISCHARGED VIA |
SYSTEMIC SEPSIS |
PNEUMONIA |
PULMONARY EMBOLISM |
OTHER RESPIRATORY OCCURRENCE |
ACUTE RENAL FAILURE |
URINARY TRACT INFECTION |
STROKE/CVA |
POSTOP BLEEDING/TRANSFUSIONS |
MYOCARDIAL INFARCTION |
PULMONARY EDEMA |
PRINCIPAL PROCEDURE |
DATE TRANSMITTED |
DATE OF LAST TRANSMISSION |
GRAFT/PROSTHESIS/FLAP FAILURE |
RETURN TO OR WITHIN 30 DAYS |
DVT/THROMBOPHLEBITIS |
*CEREBRAL VASCULAR DISEASE |
PERIPHERAL ARTERIAL DISEASE |
*PREVIOUS CARDIAC SURGERY |
ANGINA SEVERITY |
HEPATOMEGALY |
PREGNANCY |
PLANNED PRIN PROCEDURE CODE |
PRIN ASSOC DIAGNOSIS |
PREOPERATIVE SERUM SODIUM |
PREOPERATIVE POTASSIUM |
DATE ASSESSMENT COMPLETED |
ASSESSMENT COMPLETED BY |
PREOPERATIVE GLUCOSE |
HIGHEST SERUM SODIUM |
HIGHEST POTASSIUM |
HIGHEST GLUCOSE |
HIGHEST SERUM CREATININE |
HIGHEST CPK |
HIGHEST CPK-MB |
PRIN. PROCEDURE CPT MODIFIER |
HIGHEST TOTAL BILIRUBIN |
HIGHEST WBC |
LOWEST SERUM ALBUMIN |
LOWEST HEMATOCRIT |
ASSESSMENT TYPE |
ON VENTILATOR >48 HOURS |
OTHER URINARY TRACT OCCURRENCE |
PERIPHERAL NERVE INJURY |
PREOPERATIVE CPK, DATE |
PREOPERATIVE MB BAND, DATE |
*PROCEDURE COMPLETED |
PREOP SERUM CREATININE, DATE |
PREOPERATIVE BUN, DATE |
PREOP SERUM ALBUMIN, DATE |
SGPT, DATE PERFORMED |
SGOT, DATE PERFORMED |
PREOP TOTAL BILIRUBIN, DATE |
PREOP ALK PHOSPHATASE, DATE |
PREOPERATIVE WBC, DATE |
PREOP PLATELET COUNT, DATE |
PREOPERATIVE PT, DATE |
OTHER SCRUBBED ASSISTANTS |
PREOPERATIVE PTT, DATE |
PREOP HEMATOCRIT, DATE |
PREOPERATIVE GLUCOSE, DATE |
PREOP POTASSIUM, DATE |
PREOP SERUM SODIUM, DATE |
HIGH SERUM SODIUM, DATE |
HIGH POTASSIUM, DATE |
HIGH GLUCOSE, DATE |
HIGH SERUM CREATININE, DATE |
HIGH CPK, DATE |
OTHER PERSONS IN OR |
HIGH CPK-MB, DATE |
HIGH TOTAL BILIRUBIN, DATE |
HIGHEST WBC, DATE |
LOW SERUM ALBUMIN, DATE |
LOW HEMATOCRIT, DATE |
PREOPERATIVE PT CONTROL |
PREOPERATIVE PTT CONTROL |
RESPIRATORY OCCURRENCES |
URINARY TRACT OCCURRENCES |
PRINCIPAL PRE-OP DIAGNOSIS |
PRIN PRE-OP ICD DIAGNOSIS CODE |
CNS OCCURRENCES |
CARDIAC OCCURRENCES |
OTHER OCCURRENCES |
CREATE RISK ASSESSMENT |
DRUG ADDICTION |
DYSPNEA |
CURRENT PNEUMONIA |
ACTIVE HEPATITIS |
RENAL FAILURE |
*REVASCULARIZATION/AMPUTATION |
PRINCIPAL DIAGNOSIS |
REST PAIN/GANGRENE (Y/N) |
ABSENT PERIPHERAL PULSES |
IMPAIRED SENSORIUM |
COMA |
*HISTORY OF TIA'S |
*CVA/STROKE WITH NEURO DEFICIT |
*CVA/STROKE - NO NEURO DEFICIT |
NEURO DEGENERATIVE DISEASE |
DISSEMINATED CANCER (Y/N) |
*CHEMOTHERAPY IN LAST 30 DAYS |
RADIOTHERAPY IN LAST 90 DAYS |
CHEMO FOR MALIG LAST 90 DAYS |
STEROID USE FOR CHRONIC COND. |
PRINCIPAL POST-OP DIAG |
INTRAOP RBC UNITS TRANSFUSED |
30 DAY POSTOP STATUS |
DATE OF DEATH |
30 DAY DEATH |
OTHER CNS OCCURRENCE |
OTHER CARDIAC OCCURRENCE |
ILEUS/BOWEL OBSTRUCTION |
*DIABETES |
FEV1 |
*PULMONARY RALES |
ACTIVE ENDOCARDITIS |
CONCURRENT CASE |
*RESTING ST DEPRESSION |
*PCI |
NUM OF PRIOR HEART SURGERIES |
CURRENT DIURETIC USE |
*CURRENT DIGOXIN USE |
IV NTG WITHIN 48 HOURS |
PREOPERATIVE USE OF IABP |
LVEDP |
AORTIC SYSTOLIC PRESSURE |
PA SYSTOLIC PRESSURE |
REQUESTED |
PAW MEAN PRESSURE |
LEFT MAIN STENOSIS |
CORONARIES WITH STENOSIS |
LAD STENOSIS |
RIGHT CORONARY STENOSIS |
CIRCUMFLEX STENOSIS |
LV CONTRACTION SCORE |
ESTIMATE OF MORTALITY |
ESTIMATE OF MORTALITY, DATE |
*NUMBER WITH VEIN |
*NUMBER WITH IMA |
*AORTIC VALVE PROCEDURE |
*MITRAL VALVE PROCEDURE |
*TRICUSPID VALVE PROCEDURE |
ESTIMATED CASE LENGTH |
VALVE REPAIR |
*LV ANEURYSMECTOMY |
*GREAT VESSEL REPAIR (Y/N) |
*CARDIAC TRANSPLANT |
ELECTROPHYSIOLOGIC PROCEDURE |
MISC. CARDIAC PROCEDURES |
*ASD REPAIR |
*MYXOMA RESECTION |
*MYECTOMY |
*OTHER TUMOR RESECTION |
REQUEST BLOOD AVAILABILITY |
*VSD REPAIR |
*FOREIGN BODY REMOVAL |
*PERICARDIECTOMY |
OTHER PROCEDURES (Y/N) |
OTHER CARDIAC PROCEDURES |
OPERATIVE DEATH |
*PERIOPERATIVE MI |
ENDOCARDITIS |
LOW CARDIAC OUTPUT > 6 HOURS |
MEDIASTINITIS |
REOPERATION FOR BLEEDING |
DATE OF TRANSCRIPTION |
*STROKE |
REPEAT CARDIAC SURG PROCEDURE |
OTHER OCCURRENCES (ICD) |
RE-TRANSMISSION |
*HISTORY OF MI |
*ANGINA ONE MONTH PRIOR |
*CHF WITHIN ONE MONTH |
SEVERE HEAD TRAUMA (Y/N) |
QUADRIPLEGIA (Y/N) |
PARAPLEGIA (Y/N) |
SKIN PREPPED BY (2) |
CROSSMATCH, SCREEN, AUTOLOGOUS |
HEMIPLEGIA/HEMIPARESIS (Y/N) |
TUMOR INVOLVING CNS (Y/N) |
GENERAL (Y/N) |
WOUND OCCURRENCES |
WOUND DISRUPTION |
LOW SERUM SODIUM |
LOW POTASSIUM |
LOW SODIUM, DATE |
LOW POTASSIUM, DATE |
RENAL INSUFFICIENCY |
DRESSING |
COMA > 24 HOURS POSTOP |
CARDIAC ARREST REQ CPR |
UNPLANNED INTUBATION (Y/N) |
TRANSFER STATUS |
CARDIAC SURGICAL PRIORITY |
SURGICAL PRIORITY, DATE |
MITRAL REGURGITATION |
*NUMBER WITH OTHER CONDUIT |
RACE |
HOSPITAL ADMISSION DATE |
HOSPITAL DISCHARGE DATE |
DELAY CAUSE |
ADMISSION/TRANSFER DATE |
DISCHARGE/TRANSFER DATE |
OUT-OF-OR UNPLANNED INTUBATION |
CONGESTIVE HEART FAILURE PREOP |
CASE VERIFICATION |
CARDIAC RISK PREOP COMMENTS |
CARDIAC RESOURCE DATA COMMENTS |
BATISTA PROCEDURE USED (Y/N) |
SPONGE FINAL COUNT CORRECT |
CARDIAC CATHETERIZATION DATE |
MINIMALLY INVASIVE PROC (Y/N) |
EMPLOYMENT STATUS PREOPERATIVE |
INTRAOP DISSEMINATED CANCER |
PREOPERATIVE ANION GAP |
PREOP ANION GAP, DATE |
HIGHEST ANION GAP |
HIGH ANION GAP, DATE |
INTRAOPERATIVE ASCITES |
CLOSTRIDIUM DIFFICILE COLITIS |
POSTOP ATRIAL FIBRILLATION |
SHARPS FINAL COUNT CORRECT |
TOTAL ISCHEMIC TIME |
TOTAL CPB TIME |
OBSERVATION ADMISSION DATE |
OBSERVATION DISCHARGE DATE |
OBSERVATION TREATING SPECIALTY |
HIGHEST SERUM TROPONIN I |
HIGH SERUM TROPONIN I, DATE |
HIGHEST SERUM TROPONIN T |
HIGH SERUM TROPONIN T, DATE |
HDL (CARDIAC) |
HDL, DATE |
SERUM TRIGLYCERIDE (CARDIAC) |
SERUM TRIGLYCERIDE, DATE (CAR) |
SERUM POTASSIUM (CARDIAC) |
SERUM POTASSIUM, DATE(CARDIAC) |
INSTRUMENT FINAL COUNT CORRECT |
SERUM BILIRUBIN (CARDIAC) |
SERUM BILIRUBIN, DATE (CARD) |
LDL (CARDIAC) |
LDL, DATE (CARDIAC) |
TOTAL CHOLESTEROL (CARDIAC) |
TOTAL CHOLESTEROL, DATE |
*HYPERTENSION |
*NUMBER WITH RADIAL ARTERY |
*NUMBER WITH OTHER ARTERY |
TRACHEOSTOMY |
NEW MECHANICAL CIRCULATORY |
INCISION TYPE |
CONVERT FROM OFF PUMP TO CPB |
SPONGE, SHARPS, & INST COUNTER |
D/T PATIENT EXTUBATED |
D/T PATIENT DISCH FROM ICU |
*CARDIAC SURG PERFORMED NON-VA |
HOMELESS |
PREOP CIRCULATORY DEVICE |
*DIABETES (CARDIAC) |
PROCEDURE TYPE |
AORTIC STENOSIS |
RE-DO LAD STENOSIS |
RE-DO RT CORONARY STENOSIS |
COUNT VERIFIER |
RE-DO CIRCUMFLEX STENOSIS |
BRIDGE TO TRANSPLANT/DEVICE |
*MAZE PROCEDURE |
*TMR |
*OTHER CARDIAC PROCEDURES-LIST |
PRIOR HEART SURGERY |
GASTROINTESTINAL (Y/N) |
PREOPERATIVE INR |
PREOPERATIVE INR, DATE |
ORGAN/SPACE SSI |
OTHER WOUND OCCURRENCE |
SPECIMENS |
*REPEAT VENTILATOR W/IN 30 DAY |
OTHER NON-CT PROCEDURES |
PREOP FUNCT. HEALTH STATUS |
*PULMONARY VALVE PROCEDURE |
SKIN PREPPED BY (3) |
DIVISION |
PFSS ACCOUNT REFERENCE |
*OTHER CARDIAC PROCEDURES (Y/N) |
HEMOGLOBIN A1C |
HEMOGLOBIN A1C, DATE |
*ENDOVASCULAR REPAIR |
HAIR REMOVAL METHOD |
BNP |
BNP DATE |
HAIR REMOVAL COMMENTS |
PREOP ATRIAL FIBRILLATION |
PREOP ATTENDING CONCURRENCE |
*CURRENT SMOKER (CARDIAC) |
SURGERY CONSULT DATE |
PRIMARY CAUSE FOR DELAY |
SURGERY CONSULT REQUESTED |
TOBACCO USE |
TOBACCO USE TIMEFRAME |
DIABETES MELLITUS CHRONIC |
POSTOP ATTENDING CONCURRENCE |
DIABETES MELLITUS PREOP MGMT |
CVD REPAIR/OBSTRUCTION |
HISTORY OF CVD |
NON-OPERATIVE OCCURRENCES |
OCCURRENCE/NO PROCEDURE |
INDICATIONS FOR OPERATIONS |
PRE-ADMISSION TESTING |
ESU COAG RANGE |
ESU CUTTING RANGE |
OPERATIVE FINDINGS |
ELECTROGROUND POSITION (2) |
BRIEF CLIN HISTORY |
CONFIRM PATIENT IDENTITY |
PROCEDURE TO BE PERFORMED |
SITE OF PROCEDURE |
CONFIRM VALID CONSENT |
CONFIRM PATIENT POSITION |
MARKED SITE CONFIRMED |
PREOPERATIVE IMAGES CONFIRMED |
CORRECT MEDICAL IMPLANTS |
ANTIBIOTIC PROPHYLAXIS |
APPROPRIATE DVT PROPHYLAXIS |
DIAGNOSTIC RESULTS CONFIRM BY |
BLOOD AVAILABILITY |
AVAILABILITY OF SPECIAL EQUIP |
ORIGINAL DESIRED DATE |
D/T OF DESIRED PROCEDURE DATE |
ORIGINAL SCHEDULED DATE |
D/T OF SCHEDULED DATE ENTRY |
DESIRED PROCEDURE DATE |
SCHEDULED DATE |
POSITIVE DRUG SCREENING |
IMMED USE-CONTAMINATION |
GASTRIC OUTPUT |
IMMED USE-SPS/OR MGT ISSUE |
IMMED USE-EMERGENCY CASE |
IMMED USE-NO BETTER OPTION |
IMMED USE-LOANER INSTRUMENT |
IMMED USE-DECONTAMINATION |
IV STARTED BY |
POSSIBLE ITEM RETENTION |
WOUND SWEEP |
WOUND SWEEP COMMENTS |
INTRA-OPERATIVE X-RAY |
INTRA-OPERATIVE X-RAY COMMENTS |
LATERALITY OF PROCEDURE |
REPORT GIVEN TO |
CULTURES |
PCI |
HYPERTENSION |
BLEEDING RISK DUE TO MED |
ANGINA TIMEFRAME |
SYMPTOMATIC UTI |
*MECHANICAL VENT W/N 30 DAYS |
ORGANS TO BE TRANSPLANTED |
UNOS NUMBER |
DONOR SEROLOGY HCV |
SURGERY POSITION |
DONOR SEROLOGY HBV |
DONOR SEROLOGY CMV |
DONOR SEROLOGY HIV |
DONOR ABO TYPE |
RECIPIENT ABO TYPE |
BLOOD BANK ABO VERIFICATION |
OR ABO VERIFICATION (Y/N) |
SURGEON VERIFYING UNET |
ORGAN VER PRE-ANESTHESIA |
SURGEON VER DONOR ORG PRE-ANES |
PLANNED PRIN DIAGNOSIS CODE |
ORGAN VER PRE-TRANSPLANT |
PALLIATION |
IMPAIRED COGNITIVE FUNCTION |
DONOR VESSEL USAGE |
DONOR VESSEL UNOS ID |
DONOR VESSEL DISPOSITION |
LIVER DISEASE/CIRRHOSIS |
SLEEP APNEA-COMPLIANCE |
IMMUNOCOMPROMISED STATE PREOP |
PULMONARY HTN |
CANCELLATION AVOIDABLE |
RESIDENCE 30 DAYS PREOP |
AMBULATION DEVICE PREOP |
NUTRITIONAL SUPPLEMENT PREOP |
HISTORY OF CANCER DIAGNOSIS |
HX RAD RX PLANNED SURG FIELD |
PRIOR INFEC/INFLAM SURG FIELD |
HX DEEP VEIN THROMBOSIS |
PRIOR SURG SAME OP FIELD |
SCHEDULED PROCEDURE |
SPECIAL EQUIPMENT |
PLANNED IMPLANTS |
SPECIAL SUPPLIES |
SPECIAL INSTRUMENTS |
PHARMACY ITEMS |
DC/REL DESTINATION |
AORTIC REGURGITATION |
INJURY TO ADJACENT ORGAN |
STOMA COMPLICATIONS |
NON-UNION |
CODING VERIFIER |
IMPLANT INFECTIONS |
CHYLE/LYMPH LEAK |
ANASTOMOTIC LEAK |
FISTULA |
NECROTIZING SOFT TISS INFECT |
OTHER BLOOD PRODUCT UNITS |
PRESSORS USED INTRAOP |
MITRAL STENOSIS |
PCI INTERVENTION |
ATRIAL ARRHYTHMIAS |
DRESSING CONDITION |
CANCELLED BY |
HEAD OR NECK CANCER |
MACULAR DEGENERATION |
GLAUCOMA |
HX RETINAL DETACHMENT |
AXIAL LEN/ANTERIOR CHAM DEP |
CORNEAL GUTTAE/FUCHS ENDO |
DIABETIC RETINOPATHY |
COMPLEX CATARACT |
STATIN 30 DAYS PREOP |
TIME OUT VERIFIED |
IPSILAT CORTICAL EVENT PREOP |
PREOP MODIFIED RANKIN SCORE |
CAROTID SUR ANATOMIC HIGH RISK |
BYPASS CRITICAL LIMB ISCHEMIA |
ENDOLEAK AT COMPLETION |
HIGH HEART RATE 6HRS PREOP |
HIGH HEART RATE INTRAOP |
LOW ARTERIAL PRESS 6HRS PREOP |
HIGH LACTIC ACID 6HRS PREOP |
PREOPERATIVE IMAGING CONFIRMED |
HIGH LACTIC ACID INTRAOP |
LOWEST PH 6HRS PREOP |
LOWEST PH INTRAOP |
LOW ARTERIAL PRESS INTRAOP |
OLIGURIA <60CC/2HRS 6HRS PREOP |
OLIGURIA URINE OUTPUT INTRAOP |
LOWEST BICARBONATE 6HRS PREOP |
LOWEST BICARBONATE INTRAOP |
UNITS TRANSFUSED 6HRS PREOP |
VASOPRESSOR USAGE AT OR ENTRY |
CARDIAC ARREST 24HRS PREOP |
DIC 6HRS PREOP |
HYPOXEMIA W/IN 6HRS PREOP |
ENDOLEAK AT FOLLOW-UP |
CARDIAC ARREST INTRAOP |
FLOPPY IRIS INTRAOP |
PREOP VISUAL ACUITY |
POSTOP VISUAL ACUITY |
ENDOPHTHALMITIS TYPE |
CYSTOID MACULAR EDEMA |
TIME-OUT COMPLETED |
DISLOCATION OF OPERATIVE JOINT |
PERIPROSTHETIC FRACTURES |
D/T PAT ARRIVES HOSP DAY SURG |
D/T PAT LEAVES HOSP DAY SURG |
KIDNEY DONOR PROFILE INDEX |
EXPECTED POST TRANSPLANT INDEX |
BLOOD BANK ABO VER COMMENTS |
D/T BLOOD BANK ABO VERIF |
OR ABO VER COMMENTS |
D/T OR ABO VERIF |
TOV TIMESTAMP |
UNET VERIF BY SURGEON (Y/N) |
SURGEON VER ORGAN PRE-ANES |
DONOR ORG VER PRE-ANES |
SURGEON VER ORG PRE-TRANSPLANT |
IMAG TIMESTAMP |
SITE MARK TIMESTAMP |
PREVIOUSLY SCHEDULED CASE |
RESCHEDULED CASE |
SECOND SKIN PREP AGENT |
SPD COMMENTS |
DYNAMED NOTIFIED |
TIME OUT VERIFIED COMMENTS |
IMAGING CONFIRMED COMMENTS |
MARKED SITE COMMENTS |
CHECKLIST COMMENT |
TIME NURSE OUT OF OR |
AIRWAY INDEX |
MALLAMPATI SCALE |
MANDIBULAR SPACE |
DEATH UNRELATED/RELATED |
REVIEW OF DEATH COMMENTS |
READY TO TRANSMIT? |