Surgical COAP
Data Dictionary
05.31.06; Revised 06.12.06; 07.24.06
Items in bold italics are recent changes/additions
Number / Data element / Definition / Source in Medical RecordDemographic information
First initial last name
/ Provide only the first initial of the last name.First initial first name
/ Provide only the first initial of the first name.Gender (male/female) / Male or female / H&P, Op Record
Height / Height in inches or cm
Round rather than including a decimal / H&P, anesthesia record
Weight / 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. / H&P, anesthesia record
Date of birth / Date of birth / Face sheet (UB-92)
Age at admit / Age
Residence zip code / Zip code / Face sheet (UB-92)
Primary insurance / Insurance listed as the first insurance, regardless of whether the procedure in this record is covered or paid for by that insurance. / Face sheet (UB-92)
Admit date / Date of admission to this hospital for the current stay, regardless of source of admit (e.g., transfer, direct admit, ER) / Face sheet, discharge summary
Discharge date / 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. / Face sheet, discharge summary
Patient status
1 / Current cigarette smoker / Any use of tobacco cigarettes within one year of this admission. / H&P, nursing notes2 / Most recent labs within 30 days or on admit: albumin, creatinine, hemoglobin, WBCs / Albumin: mg/dl; creatinine: mg/dl; Hgb: g/dl; WBC: 10(3). NA if not available. / Lab record, H&P
3 / Current/recent medication use (immunosuppression, therapeutic anticoagulation, statins, beta blocker, ACE inhibitor, ARB) / Anticoagulants: documentation of use within 1 week of admission; all others, documentation of use upon admission (either at home or ordered on admit).See separate listing for medication names / Medication record, H&P
4
/Home 02 use
/ Any use of oxygen at home. / H&P, nursing assessment, discharge summary, D/C orders5
/Home mobility device use
/ Use of any mobility device: includes walker, wheelchair, scooter, cane / H&P, nursing assessment, , discharge summary, D/C orders6
/Comorbidities
Hypertension: Yes/No / Any mention of hypertension in the medical record on admit / H&P, nursing assessment, anesthesia- Hypertension meds: none, single, multiple
Diabetes: Yes/No / Any mention of diabetes in the medical record on admit / H&P
- Diabetes meds: none, single oral, multiple oral, insulin, oral + insulin
Asthma: Yes/No / H&P, anesthesia record
- Steroid use
History of VTE: Yes/No / Any documentation of venous thrombolembolism, e.g., pulmonary embolus. / H&P
History of sleep apnea: Yes/No / H&P, anesthesia record
- History of CPAP
Coronary artery disease: Yes/No / Any diagnosis of coronary artery disease, regardless of severity or treatment. Includes angina. / H&P
- History of MI
- PCI, CABG or other coronary intervention
History of HIV/AIDS: / Yes/No Yes, if any documentation of positive HIV/AIDS status / H&P
Operative data: for all patients
7 / Primary surgeon / Hospital’s ID for primary surgeon; optional if hospital wants to collect it. / Op record, discharge record8 / Diagnosis or indication for operation / 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. / Op record, discharge record
9 / Time of first incision / 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. / Anesthesia record
10 / In-room close time / 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. / Anesthesia record
11 / Date of surgery / Indicate the date (mm/dd/yyyy) on which the operation began. / Anesthesia record
12 / In-room close date / Indicate the date (mm/dd/yyyy) on which the operation ended. / Anesthesia record
13 / Method of surgical procedure / Laparoscopic; lap converted to open; open (no lap ports); lap, hand assisted. / Operative record
14 / ASA class / Class I, II, III, or IV NA if Class not available. / Anesthesia record
15 / Was insulin used in the OR: No/Yes / Any use of insulin in OR; if patient entered OR with insulin drip, answer Yes. Respond independent of a diagnosis of diabetes. / Anesthesia record
16 / Highest perioperative blood glucose / Record the highest of these three: BG recorded within 60 min prior to surgery; during surgery; or within 60 min. after the surgery. Value in mg
Indicate “Not performed” if this testing not done. / Anesthesia record
17 / Lowest intraoperative temperature / In Centigrade NA if not available. / Anesthesia record
18 / First temp on arrival to recovery room / In Centigrade NA if not available.
19 / Perioperative interventions:
- Heparin or low molecular weight heparin: No/Yes
- Was heparin or LMW heparin ordered post-op: No/Yes
- Intermittent compression in OR: No/Yes
- Beta-blocker: No/Yes
- Was a beta-blocker ordered post-op: No/Yes
- Antibiotics within 60 min of incision: No/Yes
- Were antibiotics discontinued within 24 hrs after closure: No/Yes
- Pain management postop orders:
- Epidural ordered within 24 hr post-op: No/Yes
Includes intrathecal MS placement prior to surgery
- PCA ordered within 24 hr post-op: No/Yes
- NSAID ordered within 24 hr post-op: No/Yes
- Nasogastric tube: patient left OR with NGT in place: No/Yes
- RBC transfusion: in OR, or within 24 hrs post-op.
- Mechanical ventilation beyond recovery room: No/Yes
- If Yes, how many hours total?
20
/Discharge disposition
/ Home (patient’s or friend’s home), rehab facility, skilled nursing facility, other hospital, other location (e.g., hotel, homeless shelter, homeless), death. /Discharge summary, discharge orders
21
/If patient had any of the following surgical operations or therapies listed below during this hospitalization and following the abdominal procedure, select all that apply and indicate the date first performed after surgery.
/ Intent of this question is to capture interventions and therapies most likely associated with the abdominal procedure recorded on this form. Check all that apply: Abdominal reoperation and date(s) (colostomy or ileostomy [rescue stoma]); abscess drainage; operative drain placement; gastrostomy; anastomotic revision; band replacement; band/port revision; wound revision or evisceration; negative re-exploration; other [specify]; tracheal reintubation (date); tracheostomy (date); placement of percutaneous drain (date); anticoag therapy for presumed/confirmed DVT; anticoagulation therapy for presumed/confirmed PE; wound reopened.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. / Progress notes or discharge diagnoses list
Operation-specific information: / Complete only for the appropriate operation. Complete one form for each procedure; do not list multiple procedures on the same form.
Bariatric
22
/Prior foregut surgery
/ 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. / H&P, discharge summary.23 / Procedure of record: type of procedure / 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. / Op record, discharge summary
24 / Was stomach divided / Yes/No/NA NA for lap band surgeries / Op record
25 / Was anastamosis tested / “Visual inspection” does not count as testing the anastomosis.
Yes/No/NA NA for lap band surgeries / Op record
If yes, how tested: / Scope, methylene blue, air injected via tube or syringe, other (specify briefly). / Op record
Appendectomy
Abstract charts only for non-elective appendectomies
26 / Was another abdominal or pelvic procedure performed concurrently No/Yes / 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 / Op record
27 / Preop imaging within 24 hours: CT scan, ultrasound / 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. / Imaging studies
Imaging results: consistent with appendicitis, not consistent with appendicitis, indeterminate / If either CT or ultrasound, indicate if scan results were consistent with, not consistent with appendicitis, or indeterminate. / Pathology report
28 / Prior ER visit within one week prior to the operation: No/Yes / 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. / ER record, H&P
29
/Pathology results: appendeceal pathology No/Yes
/ Pathology results confirm appendeceal pathology: confirmed or consistent with appendicitis, inflammation, appendeceal tumor. /Path report
30
/Perforated appendix: No/Yes
/ Patient experienced perforated appendix. /Path report
Colon Operation31 / Prior colon or pelvic surgery / Documentation of any previous operation in the colon or pelvis, regardless of date or facility. Include if it took place during this hospitalization, but prior to this operation.
32 / Procedure priority / 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.
33 / Operation type / 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. “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. / Op Record
34 / Ostomy: colostomy, ileostomy, protective stoma or no ostomy / Op record
35 / If colostomy performed, was there a prior colon resection within 30 days? / Yes/No / H&P
If yes, name of hospital at which performed / Indicate if known (free text). Otherwise leave blank. / H&P, Discharge Summary
36 / Anastamosis: / Yes/No / Op record
If yes, and pouch created: / If pouch was created, indicate type: ileoanal or coloanal / Op record
37 / Was anastamosis tested: / Yes/No / Op record
If yes, how tested: / Scope, methylene blue, air injected via tube or syringe, other (free text) / Op record
38
/Pathology findings
/ Preop diagnosis confirmed: yes, no / Op record, path report39
/Number of lymph nodes removed
/ If none, indicate zero (0). / Path report.Medications
Note: lists are not all-inclusive, and trade names may change.
Drug Class / Names / CommentsAnticoagulants / Heparin
Coumadin
Warfarin
Low molecular weight heparin
Antidiabetic agents / Insulin
Acarbose
Glimepiride
Glipizide
Glyburide
Metformin hydrochloride
Miglitol
Pioglitazone hydrochloride
Rosiglitazone maleate
Tolazamide
Tolbutamide (with or without sodium)
Immunosuppressives / Prednisone
Cortisone
Methotrexate / Do not include inhaled medications, e.g., for asthma.
Beta Blockers / Acebutolol
Atenolol
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) / Alone or in combination. * indicates combination drug.
Statins / Atorvastatin calcium (Lipitor)
Fluvastatin sodium (Lescol)
Lovastatin (Mevacor)
Pravastatin sodium (Pravachol)
Rosuvastatin calcium (Crestor)
Simvastatin (Zocor)
ACE Inhibitors / Benazepril hydrochloride
Captopril
Analapril Maleate
Fosinopril Sodium
Lisinopril
Moexipril hydrochloride
Perindopril erbumine
Quianpril hydrochloride
Ramipril
trandolapril
ARBs / Candesartan Cilexitil
Eprosartan Mesylate
Irbesartan
Losartan Potassium
Olmesartan Medoxomil
Telmisartan
Valsartan
NSAIDs / Celecoxib
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