Patient Initials: ______Date of Birth: ______Admit Date: ______
2011 (version 012111)
SCOAP Data Collection Form For Adults (effective for discharges starting January 1, 2011)
Note: Complete one form for each procedure.
A new record online should contain patient and procedure information for only one procedure.
§ Core 1: All procedures
‡ Core 2: Not applicable to Appendectomy, Breast
(Exceptions will be noted)
B. Demographics§B1) First 2 letters of Last Name/First Name: ______/ ______§B2) Hospital Code: ______
§B3) Date of Birth: _____ / _____ / _____
§B4) Medical record # (optional): ______
§B5) Admit: a. Date ____ / ____ / ____ b.Time: ___:____ £ NA
§B6) Discharge: a. Date ____ / ____ / ____ b. Time: ___:____ £ NA
§B7) Gender: Male Female §B8) Age at Admit _____ (years)
§B9) Race: American Indian/ Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Islander
White NA/Unknown
§B10) Ethnicity: Hispanic or Latino Not Hispanic or Latino NA
§B11) Patient Height: _____ (in) OR _____ (cm)
§B12) Patient Weight: _____ (lbs) OR _____ (kg)
§B13) Insurance: (Check all that apply)
13.1 Private: No Yes
13.2 If private, choose one:
Regence Cigna
Premera Uniform Medical
First Choice United Healthcare
Group Health Kaiser
Aetna Other Private
13.3 Medicare: No Yes 13.4 Medicaid: No Yes
13.5 TriCare: No Yes 13.6 Indian Health Svcs: No Yes
13.7 VA benefic.: No Yes 13.8 Uninsured: No Yes
13.9 Self pay: No Yes 13.10 Labor and Industry No Yes
13.11 Other government sponsored programs: No Yes
§B14) Admission is a transfer from another hospital: No Yes
§B15) ZIP Code: ______£ NA
§B16) Procedure Priority: Elective Non-Elective
§ B17) Discharge disposition: Home Other acute care hospital
Rehab facility Death: a. If death, specify:
SNF Death in the O.R.
Death within 24hrs post-op
Death after 24 hrs post-op
Indication for operation: Check all that apply within each category
B18) For appendectomy: / B19) For bariatric/gastric surgery: / B20) For colon:No Yes / No Yes / No Yes
18.1 Appendicitis / 19.1 Morbid obesity / 20.1 Cancer of colon / 20.10 GI bleeding
18.2 Appendiceal mass / 19.2 Revision/reversal / 20.2 Diverticular disease / 20.11 Perforation
or Cancer / 19.3 Other / 20.3 Colon mass / 20.12 Cancer of rectum
18.3 Other / 19.3a (specify): / 20.4 Radiation colitis / 20.13 Bowel obstruction
18.3a (specify): / ______/ 20.5 Volvulus / 20.14 Colostomy
______/ 19.4 Gastric cancer / 20.6 Arteriovenous / 20.15 Ulcerative colitis
19.5 Gastric ulcer / malformation / 20.16 Crohn’s disease
20.7 Ischemic colon / 20.17 Stricture
20.8 Polyps / 20.18 Gynecological
20.9 Rectal prolapse / malignancy
20.19 Iatrogenic
bowel injury
20.20 Other:
20.20a(specify):
______
B21) For breast cancer: No Yes
B22) For prostate cancer: No Yes
B23) For lung cancer: No Yes (pre-op diagnosis must be non-small cell carcinoma)
B24) For liver cancer: No Yes
B25) For pancreas cancer: No Yes
B26) For kidney cancer: No Yes
B27) For esophagus cancer: No Yes
B28) For uterine cancer: No Yes
C. Risk Factors§C1) Cigarette smoker: (within the past year) No Yes
Detailed smoking history: answer for all cases
¡ Never ¡ Former (> 1 month) ¡ Current ¡ Unknown
If ever a smoker, indicate pack years ______£ NA
§C2) Most recent laboratory values within 30 days prior to the operation: (unless otherwise specified)
2.1 Albumin: _____ Gm/dl £ NA (most recent within 6 weeks prior to the operation)
2.3 Creatinine: _____ mg/dl £ NA
2.4 HGB: _____ g/dl £ NA if HGB not available: Hct: _____% £ NA
2.5 WBC: _____ 103 £ NA
2.6 HbA1C: _____ % £ NA (most recent within 3 months prior to the operation)
(Applicable if Albumin less than 3.0 gm/dl)
‡C3) Was a nutritional intervention performed within 30 days prior to the operation: No Yes
If yes, 1. IV based No Yes
2. Oral supplementation No Yes
(Evaluate only the first 30 days of the hospitalization)
‡C4) Highest creatinine level during this hospitalization: ______mg/dL £ NA
§C5) Current / recent medications used:
No Yes 5.2 Statin
No Yes 5.3 Beta Blockers
No Yes 5.4 ACE or ARB Inhibitors
No Yes 5.5 Therapeutic anticoagulation (within 1 week of surgery)
No Yes 5.6 Steroids (within 24 hours of surgery)
§C6) Home O2 use: No Yes
§C7) Home mobility device use: No Yes
D. ComorbiditiesComorbidities: If yes, check the best response
§D1) Hypertension: No Yes No meds Single med Multiple meds
§D2) Diabetes: No Yes No meds Insulin
Single non-insulin Insulin + Other
Multiple non-insulin
§D3) Asthma: No Yes
§D4) Sleep Apnea: No Yes CPAP None
§D5) Coronary Artery Disease: No Yes History MI Both
PCI, CABG, AICD None
§D6) History of VTE: No Yes
§D7) HIV / AIDS: No Yes
§D8) Current Dialysis No Yes
E. Operative/ F. Intra-Operative§E1) Primary Surgeon: ______(Optional, ID # only – NO names)
§E2) Assistant Type: No Assistant MD/DO PA RNFA Other non-MD/DO Unknown
Assistant ID :______(Optional, ID # only – NO names)
§E3) Anesthesia provider: ______(Optional, ID # only – NO names)
§F1) Time of first Incision: Time: _____:_____ (24-hr clock) £ NA
§F2) In-room Close Time Time: _____:_____ (24-hr clock) £ NA
§F3) Date of surgery: _____ / _____ / _____ F4) In-room close date: _____ / _____ / _____
§F5) Surgical Approach: Laparoscopic/Videoscopic Lap/Video converted to open
Lap/Video, hand-assisted Open (no lap ports)
Laparoscopic, robotic assistance
Laparoscopic, robotic assistance converted to open
§F6) ASA Class: I II III IV V Already intubated NA
a. Emergent (E): No Yes
§F7) What skin preparation material was used in the OR
Chlorhexedine
Chlorhexedine-Alcohol
Povidone
Povidone-Alcohol
Other
§F8) Highest perioperative blood glucose: _____mg £ NA
§F9) Insulin used in perioperative time period: No Yes
§F10) First fasting blood glucose on post op day 1: _____mg £ NA
§F11) Highest Blood Glucose within 48 hrs ending at the close of Post-op day 2: _____mg £ NA
§F12) Lowest Blood Glucose within 48 hrs ending at the close of Post-op day 2: _____mg £ NA
(If procedure is appendectomy, skip questions 13 and 14)
§F13) Lowest intra-op temperature: _____oC OR _____oF £ NA
§F14) First temp on arrival to recovery: _____oC OR _____oF £ NA (Not applicable if death in the OR)
G. Perioperative InterventionsPerioperative interventions: (Check all that apply)
DVT Prophylaxis: Heparin or low molecular weight heparin or synthetic factor Xa or other drugs used for DVT prophylaxis excluding ASA:
‡G1) Administered within 24 hours of incision: No Yes Contraindicated
If yes, a. when was prophylaxis given: Pre-op Intra-op/Post-op Both
(Not applicable if death in O.R.)
‡G2) Ordered for in-hospital use after the first 24 hrs post-op: No Yes Contraindicated
If yes, a. daily treatment ordered: No Yes
b. indicate number of days of treatment ordered: ___ days £ NA
(Not applicable if discharge disposition is death)
‡G3) Ordered on discharge: No Yes Contraindicated
If yes, a. indicate number of days of treatment prescribed: ___ days £ NA
Beta-blocker: (Applicable if current medications include Betablocker (C5.3))
§G5) Administered within 24hrs pre-op No Yes Contraindicated
§G7) Ordered within 24 hrs post-op: No Yes Contraindicated (Not applicable if death in O.R.)
Antibiotics: (Not applicable if appy)
§G8) On antibiotics for the treatment of infection: No Yes
If yes: a. At this hospital/upon admission No Yes
b. At transferring hospital: No Yes (Not applicable if pt not transferred (B14))
§G9) Were prophylactic antibiotics indicated: No Yes
If yes: a. Administered within 60 min of incision: No Yes
b. Discontinued within 24 hrs after closure: No Yes (Not applicable if death in O.R.)
Advanced Pain Control Methods: (Not applicable if death in the O.R.)
‡G10) Epidural placed during hospitalization: No Yes Contraindicated
a. was the epidural a PCEA (Patient Controlled Epidural Analgesia) No Yes
1. date started: _____/ _____/ _____(mm/dd/yyyy) £ NA
2. placed pre-op No Yes NA
3. ordered within 24 hrs post-op: No Yes
4. placed post-op No Yes NA
5. date discontinued: _____/ _____/ _____(mm/dd/yyyy) £ NA
‡G11) PCA ordered within 24 hrs post-op: No Yes Contraindicated
a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy) £ NA
‡G12) Continuous local anesthetic infusion ordered within 24 hrs post-op No Yes Contraindicated
a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy) £ NA
Additional Perioperative Medications
‡G15) Was Entereg (generic is alvimopan) administered: No Yes
§G16) Was Aloxi (generic is palonosetron hydrochloride) administered: No Yes
(Applicable if patient on statin (C3: Current med))
‡G17) Was a statin ordered post-op for in-hospital use: No Yes (Not applicable if death in the O.R.)
Nasogastric tube: (Not applicable if death in the O.R.)
‡G18) Left O.R. with NG tube in place: No Yes
‡G19) Left O.R. with G tube to drainage in place: No Yes
Red blood cell transfusion:
‡G20) Estimated blood loss during surgery: < 50 ml 50-250 ml 251-500 ml
501 - 1000 ml >1000 ml NA
‡G21) Transfusion in O.R. or within 24 hrs post-op: No Yes
a. If yes, how many units? 1 unit 2 units 3 units 4 or more units NA
b. If yes, lowest hemoglobin (Hgb) in the 12 hours prior to the transfusion order: ____ g/dl £ NA
If Hgb not available:
c. lowest hematocrit (Hct) in the 12 hours prior to the transfusion order: ____ % £ NA
(Report Hgb/Hct only for the transfusion occurring post-op, if multiple transfusion orders report lowest Hgb/Hct prior to any transfusion in time period)
‡ G22) Transfusion after 24 hrs post-op: No Yes (Evaluate only the first 30 days of the hospitalization)
a. If yes, how many units? 1 unit 2 units 3 units 4 or more units NA
b. If yes, lowest Hgb in the 12 hours prior to the transfusion order: ____ g/dl £ NA
If Hgb not available:
c. lowest hematocrit (Hct) in the 12 hours prior to the transfusion order: ____ % £ NA
(If multiple transfusion orders, report lowest post-op Hgb/Hct prior to any transfusion in time period)
‡G23) Last Hgb prior to discharge: _____g/dl £ NA (Applicable for recipients of any transfusion: G21 or G22)
If Hgb not available:
Last Hct prior to discharge: _____% £ NA
Post-op respiratory support
‡G24) Mechanical ventilation: No Yes Not applicable-chronic ventilator
b. total vent hours:
less than 12hrs 12 to less than 24 hrs 24 to less than 48 hrs 48 to less than 96 hrs 96+ hrs
Renal/urologic function
‡G25) Urinary catheter removed before discharge:
No Yes Not applicable -- no urinary catheter or pt
has permanent indwelling urinary catheter
a. If yes, Postop day urinary catheter removed: _____ £ NA
H. Post-operative EventsIndicate if the patient experienced any of the listed events during the first 30 post-op days.
Select all that apply and note if the event occurred during the index hospitalization or after discharge from the index hospitalization. Include only events that were unplanned and occurred after the index procedure. Evaluate 30 post-op days only. (Not applicable if death in the O.R.)
§H1) Post-discharge follow-up attempted: No Yes§H2) Post-operative occurences / No Yes
If yes, / In-hospital / Post-discharge
1 Myocardial infarction/ Cardiac arrest / No Yes / No Yes NA
2 Atrial arrhythmia requiring treatment / No Yes / No Yes NA
3 CVA/stroke / No Yes / No Yes NA
4 Unplanned ICU stay/readmit to ICU / No Yes / No Yes NA
5 Fall with injury requiring surgery / No Yes / No Yes NA
6 c-Difficile infection / No Yes / No Yes NA
7 Wound and/or surgical site infection requiring treatment / No Yes / No Yes NA
8 Pneumonia requiring treatment / No Yes / No Yes NA
a. if yes, on vent prior to diagnosis / No Yes / No Yes NA
9 UTI requiring treatment / No Yes / No Yes NA
10 Renal insufficiency &/or renal failure / No Yes / No Yes NA
11 Radiologically demonstrated anastomotic leak: / No Yes / No Yes NA
12 Radiologically demonstrated enterocutaneous fistula: / No Yes / No Yes NA
13 Other 1 / No Yes / No Yes NA
a. specify______
14 Other 2 / No Yes / No Yes NA
a. specify______
§H3) Non-operative Interventions / No Yes
If yes, / In-hospital / Post-discharge
1 Tracheal reintubation: / No Yes / No Yes NA
2 NG tube placed post-op (non-routine): / No Yes / No Yes NA
3 Tracheostomy: / No Yes / No Yes NA
4 Percutaneous drainage: / No Yes / No Yes NA
5 Anticoagulation therapy for presumed/confirmed DVT: / No Yes / No Yes NA
6 Anticoagulation therapy for presumed/confirmed PE: / No Yes / No Yes NA
7 Antibiotic for presumed/confirmed infection: / No Yes / No Yes NA
8 Wound reopened/debridement: / No Yes / No Yes NA
9 Percutaneous arterial embolization for bleeding / No Yes / No Yes NA
10 Endoscopy with intervention for bleeding &/or dilation / No Yes / No Yes NA
11 Other: / No Yes / No Yes NA
a. specify______
§H4) Re-operative Interventions: / No Yes
If yes, / In-hospital / Post-discharge
1 Colostomy or ileostomy / No Yes / No Yes NA
2 Abscess drainage / No Yes / No Yes NA
3 Operative drain placement / No Yes / No Yes NA
4 Gastrostomy / No Yes / No Yes NA
5 Gastrostomy revision / No Yes / No Yes NA
6 Anastomotic revision / No Yes / No Yes NA
7 Wound revision / No Yes / No Yes NA
8 Negative re-exploration / No Yes / No Yes NA
9 Reoperation for bleeding / No Yes / No Yes NA
10 Implant removal/replacement/revision / No Yes / No Yes NA
11 Other / No Yes / No Yes NA
a. specify______
§H5) Readmission to acute care hospital: No Yes
a. if yes, how many: _____ £ NA
§H6) Post-discharge Death No Yes If yes, a. Date of death _____/_____/_____ £ NA
§H7) How many days of follow-up were included: less than 30 days 30 days (at least)
a. if less than 30 days, how many days included: ______days £ NA
§H8) Method(s) used to obtain the post-discharge follow-up information: (check all that apply)
1. Phone No Yes
2. Letter/survey No Yes
3. Medical record No Yes