Microsoft word - scoap data dictionary04.08neonates.children.doc
05.31.06; Revised 06.12.06; 07.24.06; 12.30.06, 07.07,09.07,04.08
Items in bold italics are recent changes/additions
Adults are age 18 years and older; children are greater
than 6 months and less than 18 years of age; neonates or infants are less than 6 months of age.
Provide only the first initial of the last name.
Provide only the first initial of the first name.
This is optional; for internal hospital use only if hospital
downloads own data for internal analysis
In the case of question about gender where there has been a gender change (either via surgery and/or other treatments), answer with what the chart says the gender is with following exception: If the gender change has been from female to male but the ovaries remain intact, this person should be coded as female.
Weight in pounds or kg; if more than one weight listed, the
weight closest in time and prior to the operation. Round rather than including a decimal. NA if this information is not available.
Insurance listed as the first insurance, regardless of whether
the procedure in this record is covered or paid for by that
insurance. If have private insurance, but their specific insurance company not listed, check “other”; do not need to name the company.
Date of admission to this hospital for the current stay,
regardless of source of admit (e.g., transfer, direct admit, ER)
Date of discharge from this hospital, regardless of disposition
(e.g. to home, hospital, SNF). If patient died during this hospital
stay, the discharge date is the date of death. If discharged to Hospice, mark SNF.
Any use of tobacco cigarettes within one year of this
admission. If smoking history is not mentioned anywhere, check “no”.
Most recent labs within 30 days or on admit:
Albumin: g/dl; creatinine: mg/dl; Hgb: g/dl; WBC: 10(3). NA if
Anticoagulants: documentation of use within 1 week of
admission; all others, documentation of use upon admission
anticoagulation, statins, beta blocker, ACE
(either at home or ordered on admit).See separate listing
for medication names for your reference; it may not include very new medications.
H&P, nursing assessment, discharge summary, D/C orders
Use of any mobility device: includes walker, wheelchair,
scooter, cane. The emphasis is on use; check “no” if it is
mentioned that they have this device but do not use any of orders them currently.
Any mention of hypertension in the medical record on admit
Do not include diuretics as medication for treatment of
hypertension unless medical record specifically states the diuretic is being prescribed for hypertension. See separate listing for medication names for your reference; it may not include very new medications.
Any mention of diabetes in the medical record on admit; mark
Medications that patient is using at the time of admit.
Include the new injectable hypoglycemic agent Byetta in
the category of single or multiple, non-insulin meds. Insulin plus other meds means other diabetes meds.
See separate listing for medication names for your reference; it may not include very new medications.
Indicate yes if either IV, po, inhaled. Check all that apply.
Any documentation of venous thrombolembolism, e.g.,
pulmonary embolus or deep vein thrombosis.
If Yes to history of sleep apnea, does patient use CPAP
(continuous positive airway pressure) or BiPAP (bi-level positive airway pressure), or APAP-an auto-titrating CPAP machine.
Any diagnosis of coronary artery disease, regardless of severity
Documentation of MI, regardless of date or type.
Documentation of PCI, CABG, AICD, regardless of date.
Yes/No Yes, if any documentation of positive HIV/AIDS status
Hospital’s ID for primary surgeon; optional if hospital wants to
collect it. Do not submit by surgeon name; only by an ID
Choose diagnosis or indication for the surgery from the drop
down lists; check all that apply. Do not indicate the actual CPT
or ICD9 code. This item is extremely important; is this item is left blank, the case cannot be included in the data analysis.
Use 24-hour clock to indicate the time of the first incision; if
both “anesthesia start time” and “operation start time” are
listed, use “operation start time.” NA if this information not available.
Use 24-hr clock to indicate time of incision closure in OR; if
both “anesthesia end time” and “operation end time” are
listed, use “operation end time.” NA if this information not available.
Indicate the date (mm/dd/yyyy) on which the operation began.
Indicate the date (mm/dd/yyyy) on which the operation ended.
Laparoscopic; lap converted to open; open (no lap ports); lap,
hand assisted. Lap, hand assisted means when an additional incision is made that is ~ the size of a hand so that a hand can be inserted to assist inside the abdomen.
Class I, II, III, or IV NA if Class not available. Already
Any use of insulin in OR; if patient entered OR with insulin
drip, answer Yes. Respond independent of a diagnosis of diabetes.
Record the highest of these three: Fasting BG recorded
anytime prior to the surgery on the day of surgery; BG during surgery; or BG within 60 min. after the surgery. Value in mg Indicate “Not performed” if this testing not done.
In Centigrade NA if not available. Not applicable if death
Heparin, low molecular weight heparin or Administered within 24 hours of incision (include pre or post
op administration within 24 hrs of incision). Include pre and
post-op orders as long as within the 24 hrs of incision.
If heparin is ordered IV, indicate number of units ordered per hour; can be per 24 hrs if that is the order.
Regardless of answer to answer immediately above, indicate if
or synthetic factor Xa inhibitor ordered
there was an order for any of these for in-hospital use after the
first 24 hrs. If the orders change during the post-op period, use the latest orders for your response. You do not need to check to see if the patient actually received the ordered medication. Not applicable if death in the OR
Not applicable if discharge disposition is death.
or synthetic factor Xa inhibitor ordered
Any documentation in the record by any provider that there
was a contraindication to patient receiving either heparin,
Coumadin, LMW heparin or synthetic factor Xa inhibitor. For the “ within 24 hrs of incision” data element, if the patient is having emergent surgery and is on maintenance Coumadin, and the patient is being given medication such as Vit K to reverse the effects of Coumadin, this would be a clear contraindication to having any of the DVT chemoprophylaxis medications in the “within 24 hrs of
Intermittent compression boots applied in the OR.
Administered within 24 hrs pre-operatively
Regardless of answer to question immediately above, indicate if Physician Orders
beta blocker was ordered as a regularly-administered medication (not prn) within 24 hrs post-op. You do not need to check to see if the patient actually received the ordered medication.
On antibiotics for treatment of infection?
If “yes”, do not answer the following two questions as patient
is being treated for an infection vs being given a prophylactic antibiotic.
If the antibiotic is administered > 60 min. of incision, answer
No. EXCEPTION: If either vancomycin or a fluoroquinolone is
the antibiotic administered, these need to be administered over Record/OR Record a two hour time period. If these are administered within two hours prior to the incision, answer Yes.
Answer regardless of when antibiotics were started (previous
question). E.g., if ABX started 90 minutes before incision and discontinued 12 hrs after closure: answer Yes. Not applicable if death in the OR or if antibiotics continued for the treatment of an infection even though patient was originally put on antibiotics as prophylaxis.
This question applies only to colorectal and bariatric
Within 24 hours post-op; not applicable if death in the OR You do not need to check to see if the patient actually received the ordered medication. Contraindications are patient refusal, any coagulopathy, concurrent use of enoxaparin/heparin, and patient anatomy that makes epidural placement not feasible.
You do not need to check to see if the patient actually
received the ordered medication. Contraindications are inability of the patient to understand or manipulate the PCA or opioid intolerance.
You do not need to check to see if the patient actually
received the ordered medication. Contraindications are intolerance of NSAIDS, kidney or liver disease, and platelet dysfunction or a coagulopathy. See separate listing for NSAID medication names for your reference; it may not include very new medications.
Contraindication is opioid intolerance.
If yes, specify other pain management modality ordered within
24 hrs post-op; name class of drug and route
Note: po narcotics are not included in this data element
as are looking at more advanced pain control approaches.
RBC transfusion: in OR, or within 24 hrs
RBC transfusion means packed red blood cells. If no packed
RBCs were transfused, enter “0” as leaving it blank will be
tallied as a missing answer. You can indicate “yes” if the
transfusion was started; do not need to verify that the
If the patient is a chronic ventilator patient, the response
to this is not applicable-the number of ventilator hours
post op for these patients does not represent a
complication. Not applicable if death in the OR
Total hours of mechanical ventilation until discharge; if patient
is on and off ventilator, estimate total hours. Not applicable if pt is a chronic ventilator patient, or if death in the OR.
Home (patient’s or friend’s home), rehab facility, skilled nursing Discharge summary,
facility, other hospital, other location (e.g., hotel, homeless
shelter, homeless), death. Indicate if death in the OR, within 24 hrs after leaving the OR or after 24 hours post op.
If patient had any of the following surgical
This section not applicable if death in the OR.
operations or therapies listed below during
Intent of this question is to capture interventions and therapies
most likely associated with the abdominal procedure recorded
abdominal procedure, select all that apply and
on this form. Check all that apply along with the dates:
indicate the date first performed after surgery.
Abdominal reoperation: colostomy or ileostomy (rescue
stoma); abscess drainage; operative drain placement;
gastrostomy; gastrostomy revision, re-exploration/washout;
anastomotic revision; band replacement; band/port revision;
wound revision or evisceration; negative re-exploration; other
tracheal reintubation; NG replacement; tracheostomy
placement of percutaneous drain (date); anticoag therapy for
presumed/confirmed DVT; anticoagulation therapy for
presumed/confirmed PE; wound re-opened. Wound re-
opended does not include routine wound care-routine
wound care refers to situations where the wound may have been left open in the OR and packing/removing packing and/or probing to keep the wound open may be taking place on a daily basis. This data element refers to situations where the closed wound is reopened secondary to an infection. Anastomotic leak; check if a leak demonstrated by barium enema, upper GI and/or CT scan. Enterocutaneous fistula; check if this demonstrated by barium enema, upper GI and/or CT scan. If an intervention was performed more than once, e.g., tracheal re-intubation twice, indicate the date of the first time it was done.
Complete only for the appropriate operation. Complete one form for each procedure; do not list multiple procedures on the same form.
Documentation of any previous operation in the abdomen,
regardless of date or facility. Include if it took place during this hospitalization, but prior to this operation. Foregut includes abdominal esophagus, stomach, small intestine, small bowel resection.
The procedure being recorded on this form. Bypass [proximal
or distal], biliopancreatic bypass, biliopancreatic bypass with
duodenal switch, adjustable band [and size]. Proximal gastric bypass is a Roux limb less than or equal to 150 cm. Indicate the band size for the lap band procedure. ”AP standard” is a brand name that is an 11cm size and “AP Large” is a 12.2 cm size. In the unusual event that a band surgery is converted to a bypass, the operation type is a bypass surgery and “yes” should be checked on the “prior foregut surgery” question above.
Scope, methylene blue, air injected via tube or syringe,
palpation/inspection, other (specify briefly). Check all that apply
Abstract charts only for non-elective appendectomies; not for incidental appendectomies or for trauma
Was another abdominal or pelvic procedure
Answer Yes if another procedure such as a colectomy or
ovarian cystectomy was performed at the same time as the appendectomy If yes, indicate whether the concurrently performed procedure was gynecologic in nature or was a colon or gall bladder procedure
Was any imaging done within 24 hours prior to this
appendectomy? If yes, indicate if CT or ultrasound. If other type of imaging done (e.g., abdominal xray), leave blank. “Plain films” do not count as pre-op imaging for the dx of appendicitis.
Imaging results: consistent with appendicitis,
If either CT or ultrasound, indicate if scan results were
consistent with, not consistent with appendicitis, or
Prior ER visit within one week prior to the
Answer yes if patient seen in any ER or urgent care (includes a
physician office visit if the patient was seen urgently) setting within one week of and prior to this operation. Answer No if patient only seen in this hospital’s ER, and admitted immediately from that ER visit. The intent of the question is to identify patients who were seen for suspected appendicitis in an urgent or emergent situation within a week prior to this procedure. If there was an ER/urgent care visit in this time frame that is clearly non-abdominal (e.g., fracture), answer No.
Pathology results: appendeceal pathology
Pathology results confirm appendeceal pathology: confirmed or
consistent with appendicitis, inflammation, appendeceal tumor. Statements in the path report such as “mild early” or “very early” appendicitis indicate appendeceal pathology.
Patient experienced perforated appendix.
Documentation of any previous operation in the colon or
pelvis, regardless of date or facility; includes hysterectomy and
small bowel resection. Include if it took place during this hospitalization, but prior to this operation.
If colostomy performed, was there a prior
If yes, name of hospital at which performed
Indicate if known (free text). Otherwise leave blank.
Elective, non-elective. An elective procedure is one that is
performed on a patient whose symptoms and/or disease has
been stable in the days or weeks prior to the procedure. Typically elective cases are scheduled at least several days before the procedure. Non-elective procedures (which include urgent and emergent status) are required to minimize or address further clinical deterioration.
Check the type of operation that was performed.
“Low anterior resection” references removal of sigmoid colon and/or top of rectum with re-attachment of the colon and lower rectum. Lf hemicolectomy includes +/- removal of transverse colon; this also includes “sigmoid colon resection”. Rt hemicolectomy includes resection of the terminal ileum and partial cecetomy as well as an ileocecal resection and cecum to transverse colon bypass. Abdominoperineal resection references removal of the rectum from a combined approach with both an abdominal and perineal incision. “Total abdominal colectomy” means all of
the right transverse and left colon removed along with the sigmoid. In the rare event that the surgery is a “perineal proctectomy with colanal handsewn anastomosis transanally” this should be categorized as an Abdominal Perineal Resection.
Ostomy: colostomy, ileostomy, protective
A protective stoma is when an ileostomy or colostomy is
done at the same time as the anastomosis to “protect” it from leaking-most commonly done when a low rectal anastomosis is done.
Colocolon (colon to colon(, Ileocolon (ileum to colon)
Ileoanal (ileum to anal), coloanal (colon to anal) If you cannot determine what type of anastomosis was done, mark “cannot be determined”. Colon to rectum should be marked as a colocolon.
If ileoanal or coloanal, was pouch created?
Scope, methylene blue, air injected via tube or syringe,
palpation/inspection, other (free text) Check all that apply
In the event that the pre-op dx of CA was based on a prior
colonoscopy and the surgery is a follow up procedure to
remove additional suspicious tissue, and no additional
cancer was found, this finding does not revoke the pre-op
dx. In this event, the answer to this data element is “yes” unless there is a statement in the medical record to the contrary.
If none, indicate zero (0) While more lymph nodes may have
been removed than were examined or studies, only state
the number of lymph nodes that were removed and examined. While it may not always be appropriate/feasible for lymph nodes to be removed for a rectal cancer surgery, put (0) if none removed. Data analysis will not include these cases in the denominator for the current data reports.
If yes, indicate Cm to both distal and proximal margins; NA if
Check the appropriate stage; NA if info not available
Defines data elements that are specific to
Indicate the number of days/months/years, e.g. 26 d, 13 w, 12 y
If the infant was born at your facility and the surgery is done during this index hospitalization, put one day as the age at admit.
See separate listing for medication names for your
reference; it may not include very new medications.
Check yes if stated as such by the surgeon/MD.
UGI with SBFT-Upper GI with Small Bowel Folow Thru US-Ultrasound Define pH probe
Note: lists are not all-inclusive, and trade names may change.
Coumadin Warfarin Low molecular weight heparin Fragmin (dalteparin) Lovenox (enoxaparin) Aristra (fondaparinux) Innohep (tinzaparin)
Lyrica (pregablin) Neurontin (gabapentin) Depakote/Depekene Keppra (levetiracetam) Tegretol (carbamzapine) Topomax (topiramte) Trileptal (oxcarbazine) Zonegran (zonisamide) Lamictal (lamotrigene) Klonopin (clonazepam) Valium (diazepam) Tranxene (chlorazepate)
Acarbose Glimepiride Glipizide Glyburide Metformin hydrochloride Miglitol Pioglitazone hydrochloride Rosiglitazone maleate Tolazamide Tolbutamide (with or without sodium)
Do not include inhaled medications, e.g., for asthma.
Cortisone Methotrexate Cyclosporine Azasan (azathioprine) CellCept (mycophenoiate mofetil) Myfortic (mycophenolic acide) Neoral (cyclosporine) Prograf (tacrolimus) Rapamune (sirolimus) Sandimmune (cyclosporine)
Alone or in combination. * indicates combination
Betapace (sotalol) Betaxolol Bisoprolol Blocadren (timolol) Brevibloc (esmolol)
Cartrol (carteolol) Carteolol Carvedilol Coreg (carvedilol) Esmolol Inderal (propranolol) Innopran (“) Kerlone (betaxolol) Labetalol Levatol (penbutolol) Lopressor (metoprolol) Metoprolol Nadolol Normodyne (labetlol) Penbutolol Pindolol Proranolol Sectral (acebutolol) Sotalol Tenormin(atenolol) Timolol Toprol (metoprolol) Trandate (labetalol) Visken (pindolol) Zebeta (bisoprolol) *atenolol/chlorthalidone *bisoprolol/HCTZ *Corzide (bendroflumethiazide/nadolol) *HCTZ/propranolol *Inderide (“) *Lopressor HCT (“) *Tenoretic (atenolol/chlorthalidone) *Timolide (HCTZ/timolol) *Ziac (bisoprolol/HCTZ)
Maxzide (triamterene/hydrochorthiazide) Edecrin (ethacrynic acid) Lasix (furosemide) Dyrenium (triamterene) Diuril Midamor (amiloride HCL)
Avinza Combunox Demerol DepoDur Darvocet Dilaudid (hydromorphone) Duragesic Lortab MS Contin (morphine sulfate) Numorphan Morphine Sulfate OxyContin (oxycodone) Perocet Percodan Tylenol with Codeine Vicodin (hydrocodone)
Fluvastatin sodium (Lescol) Lovastatin (Mevacor) Pravastatin sodium (Pravachol) Rosuvastatin calcium (Crestor) Simvastatin (Zocor)
Captopril Analapril Maleate Fosinopril Sodium Lisinopril Moexipril hydrochloride Perindopril erbumine Quianpril hydrochloride Ramipril trandolapril
Eprosartan Mesylate Irbesartan Losartan Potassium Olmesartan Medoxomil Telmisartan Valsartan
Diclofenac (potassium or sodium) Diflunisal Etodolac Fenoprofen calcium Flurbiprofen (with/without sodium) Ibuprofen Indomethacin (with/without sodium trihydrate) Ketoprofen Ketorolac tromethamine Eclofenamate sodium Mefanemic acid Meloxicam Nabumetone Naproxen (with/without sodium) Oxaprozin Piroxicam Rofecoxib Sulindac Tolmetin sodium Valdecoxib
Preparing the Transparency Template HOW TO CREATE A STRUCTURAL 1. Photocopy the templates from Appendixes 5a and 5b onto an 8'' x 11'' SUMMARY FOR THE RORSCHACH transparency. Do not enlarge or reduce the size of the form. (It’s ofteneasiest to take the book to a full-service photocopy store where you canpurchase a single transparency and have them photocopy it for you.)2. Place the p
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