abortedTimeframeCategorizes when the surgical case was aborted as either: Pre-anesthesia; Post-anesthesia; not-aborted. Any medication or intervention, other than a peripheral IV, performed by anesthesia is considered post-anesthesia. This includes any anesthesia or intervention performed by anesthesia staff in the preoperative holding area. [FileMan 130,18.5].
admissionStatusIndicates the patient's acute hospital admission status on the calendar day of surgery. Possible values include: The operation was same day (the patient was not admitted); The patient was admitted on the calendar day of surgery; or The patient was already hospitalized on the calendar day prior to surgery. [FileMan 130,.011]
anesthesiaThe loss of sensation and usually of consciousness without loss of vital functions artificially produced by the administration of one or more agents that block the passage of pain impulses along nerve pathways to the brain Source: Merriam-Webster's Medical Dictionary, 2002 Merriam-Webster, Inc.
assistantPerfusionistThe person assisting the perfusionist. [FileMan 130,.168]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.
associatedClinicIdentifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]
attendingSurgeonThe attending staff surgeon responsible for this case. The need for this information is made necessary when the surgeon performing the procedure is in a training status. [FileMan 130,.164]Identifies the attending staff provider responsible for this case. This is required when the provider is in training status. [FileMan 130,124]
bloodLossThe amount of blood (in milliliters) estimated to be lost during the operative procedure (EBL). [Fileman 130,.25]
bodyFluidPointer to replacement fluid given intravascularly during the operative procedure. [Fileman 130,.27].
briefClinicalHistoryA brief clinical history for this patient. It will appear on the Tissue Examination Report. [FileMan 130,60]
cardiacSurgeryEvaluationPointer to information collected to measure quality as defined by NSQIP/CICSP.
catheterInsertedByThe person accountable for insertion of the Foley catheter. [FileMan 130,.57]
cellSaverPointer to any cell savers used during this procedure. [Fileman 130.130].
circSupportIdentifies the nurse with operating room circulating role responsibilities during the time of the surgery. [FileMan 130,.111]. A circulating nurse is a registered nurse who works in the operating room environment. The circulating nurse does not scrub in and performs job duties that cannot be done by staff that is scrubbed in and must remain sterile.
didPatientVoidIndicates whether the patient voided prior to being transported to the operating room. Possible values include: Yes; No; Inapplicable. [FileMan 130,.9813]
dischargedViaCategorizes the mode of transport used to move the patient from the care area. [FileMan 130,25].
doNotResuscitateStatusIf the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the only condition under which a DNR order is official in the 30 days prior to this surgery], enter Yes. If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the patient, enter Yes. Answer No if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order. Possible Values include: Yes; No; No study. [FileMan 130, 238]
dressingConditionCategorizes the status of the drainage on the dressing. Possible values include: Dry; Serosanguinous; Sanguinous; No dressing. [FileMan 130,7]
dressingsUsedThe dressing(s) used for this case (free text). [FileMan 130,41]
electrodePositionCategorizes the area of placement (body site) of the dispersive electrode pad. [FileMan 130,.55]Categorizes the placement (body site) of the second dispersive electrode pad. [FileMan 130,6]
electrosurgicalUnitPointer to the electrosurgical unit utilized during the operative procedure. [FileMan 130,.75]
endAssessmentPointer to an assessment of the patient's vital signs upon completion of the operative procedure.
finalCountsPerformer"This is the name of the person doing the final count of sponges, sharps and instruments." [FileMan 130,47]
finalCountsVerifiedCategorizes the status of the final count of sponges, sharps, and instruments, etc. at the end of the surgical procedure. Possible values include: Correct; Incorrect; Unknown. [FileMan 130,.52]
finalCountsVerifierThe person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure. [FileMan 130,.522]Identifies the person responsible for verifying the final sponge, sharps and instrument counts. [FileMan 130,48]
firstAssistantThe person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.15]
foleyCatheterSize gastricOutputThe gastric output, in cubic centimeters, during the operative procedure. [FileMan 130,62]
hairRemovalSupportIdentifies the person responsible for removing the patient's hair in preparation for the operative procedure (if necessary). [FileMan 130,.12]
idConsentVerifiedByThe name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record. [FileMan 130,.69]
imagePointers to images that are related to this case. [FileMan 130,2005]
inductionCompleteTimeThe date and time that the anesthetist declares the patient ready for the start of the operative procedure. [FileMan 130,.215]
intraOpOccurrencePointer to information related to any intraoperative occurrences. [FileMan 130,1.14]
irrigationPointer to information related to the irrigation solution used. [Fileman 130,.39].
isMajorCategorizes the surgery case as major or minor. A Major case is any operation performed under general, spinal, or epidural anesthesia plus all inguinal herniorrhaphies, carotid endarterectomies, parathyroidectomies, thyroidectomies, breast lumpectomies, or endovascular abdominal aortic aneurysm (AAA) repairs regardless of anesthesia administered. All other operations are designated as Minor. [FileMan 130,.015]
isNonORSurgicalProcedureIndicates whether this case is a non-operating-room surgical procedure. [FileMan 130,118]
ivStartedByIdentifies the person that started the IV for this operative procedure. [FileMan 130,63]
labRequestLaboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).
labResultsResults of laboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).
laserPointer to any laser units used during this procedure. [FileMan 130,129]
minimumTemperatureThe lowest temperature of the patient (in degrees Centigrade) during the operative procedure. [FileMan 130,.36]
nonOperativeOccurrencePointer to occurrences that are not related to a surgical procedure. [FileMan 130,53]
nonOrLocationIndicates the non-operating-room location where the surgical procedure was performed. [FileMan 130,119]
nonOrOccurrencePointer to an occurrence that is related to a non-O.R. procedure [FileMan 130,126]
opDispositionThe destination of the patient upon transfer from OR staff care. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.46]
operatingRoomIdentifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]
operationEndTimeThe date and time that the operation ended. Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, this is the time that the patient was pronounced dead. [FileMan 130,.23]The date and time that all the procedures for this non-OR case are complete. [FileMan 130,122]
operationStartTimeThe date and time that the operation began. The definition of this time is usually 'knife fall', but may vary depending on the type of surgery being performed. Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure). [FileMan 130,.22]The date that the non-OR procedure was performed. [FileMan 130,120]The time of the start of the non-OR procedure. [FileMan 130,121]
operativeFindingsA brief description of the operative findings which appears on the Tissue Examination Report. [FileMan 130,59]
otherDeviceDevices used in this procedure that are not documented elsewhere. [Fileman 130.131].
otherPersonsInOrIdentifies other persons, not scrubbed or otherwise identified, present in the operating room. [FileMan 130,31]
otherPostOpDiagnosisAny postoperative diagnosis in addition to the principal postoperative diagnosis. [FileMan 130,.74]
otherPreOpDiagnosisAny diagnosis in addition to the principal preoperative diagnosis. [FileMan 130,.72]
otherProcedurePointer to procedures performed in addition to the principal surgical procedure. [FileMan 130,.42]
otherScrubbedPersonnelIdentifies other persons in the operating room in addition to those already listed as scrubbed. [FileMan 130,30]
pacuAdmitScoreThe objective evaluation numerical score of the patient upon admission to the post anesthesia care unit. [FileMan 130,1.11]
pacuAdmitTimeThe date/time that the patient was admitted to the post anesthesia care unit (recovery room). [FileMan 130,1.17]
pacuDischargeScoreThe objective evaluation numeric score of the patient at discharge from the post anesthesia care unit. [FileMan 130,1.12]
pacuDischargeTimeThe date/time that the patient is discharged from the post anesthesia care unit (recovery room).[FileMan 130,1.18]
pacuDispositionThe destination of the patient immediately after release from the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.79]
perfusionistThe person operating the cardio-pulmonary or organ perfusion apparatus. [FileMan 130,.167]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.
physiologicMonitoringPointer to information related to invasive or non-invasive monitors used during this case. [FileMan 130,.293]
plannedAdmissionStatusThis field indicates the patient's planned hospital admission status for the calendar day of surgery. Possible values include: The operation is planned as same day (the patient will not be admitted); The patient will be admitted on the calendar day of surgery; or The patient will already be hospitalized on the calendar day prior to the date of surgery. [FileMan 130,.013]
plannedDispositionThe location of care after the patient leaves the operating room and/or the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.43]
postOpAssessmentPointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. immediately after the surgical procedure.
postOpOccurrencePointer to information related to postoperative occurrences. [FileMan 130,1.16]
preOpAssessmentPointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. upon arrival to the operating room.
primarySurgeonThe person performing the major portion of the principal operative procedure. [FileMan 130,.14]
principalPostOpDiagnosisThe principal diagnosis for which the non-OR procedure is being performed (free text). [FileMan 130,33]The principal postoperative diagnosis (coded). [FileMan 130,34]
principalPreOpDiagnosisThe preoperative diagnosis for which the surgical procedure is being performed (free text). [FileMan 130,32]The principal Pre-OP ICD diagnosis code (coded). [FileMan 130,32.5]
prosthesisInstalledPointer to information related to the prosthesis used for this operative procedure. [FileMan 130,.47]
restraintOrPositionalAidAppliedPointer to information related to restraints and positioning aids used during this operative procedure.. [FileMan 130,.13]
scheduleTypeCategorizes how this surgery case was scheduled. This information is useful for prioritizing changes to the schedule. Possible values include: Emergency; Elective; Add-on (non-emergent); Stand-by, Urgent. Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related preoperative symptomatology. [FileMan 130,.035]
scrubSupportIdentifies the nurse with scrub role responsibilities during the time of the surgery. [FileMan 130,.112]. A Scrub nurse, also called a perioperative nurse, is a registered nurse who works directly with the surgeon within the sterile field by passing instruments, sponges, and other items needed during the surgical procedure.
secondAssistantThe second person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.16]
skinPrepAgentThe type of agent used to wash and prepare the operative site. [FileMan 130,.175]. Note that this might point to a MedicinalProduct in the future.
skinPreppedByThe person responsible for applying the agent used to wash and prepare the operative site. [FileMan 130,.18]The second person performing skin preparation, if applicable. [FileMan 130,4]The third person performing the preoperative skin preparation. [FileMan 130,5]
specimenPointer to any specimen(s) collected and sent to the lab for analysis. [FileMan 130,49] (Note that in VistA, this is a string field, in FHIM is is a pointer to the Specimen class).
surgeonSupervisoryLevelCategorizes the highest level of resident supervision provided by the attending staff surgeon for this case. [FileMan 130,.166]. Possible values include: Attending performed the operation; Attending in the operating room assisting the resident; Attending in the operating room but not scrubbed; Attending not present in the operating room suite but immediately available, etc.
surgeryPositionPointer to the position in which the patient is placed for this operative procedure. [FileMan 130,64]
surgerySpecialtyThe surgical specialty assigned to the surgeon performing this operative procedure. Used for aggregating and reporting cases by specialty or department. [FileMan 130,.04]
thermalUnitUtilizationPointer to information related to the temperature controlling device. [FileMan 130,.757]
timePatientLeftORThe date and time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element. [FileMan 130,.232]
timeTimeOutCompletedThe actual time when the entire Time-Out process was completed by the OR team. [FileMan 130,74]
totalUrineOutputThe amount of urine (in milliliters) output during the operative procedure. [Fileman 130,.255]
tourniquetAppliedPointer to information related to the application of a tourniquet. [FileMan 130,.48]
transportMethodThe method or device used to deliver the patient to the operating room. [FileMan 130,.11]
tubesAndDrainsA textual description of the type and placement of tubes and drains during the operative process. [FileMan 130,22]
verificationCommentsProvides additional explaination in those cases where the Time-Out Verified property is set to No. [FileMan 130,82]Provides additional explaination in those cases where the Imaging Verified property is set to No. [FileMan 130,83]Provides additional explaination in those cases where the Marked Site Verified property is set to No. [FileMan 130,84]
wasCaseVerifiedIndicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon. [FileMan 130,43]
wasMarkedSiteVerifiedIndicates whether a "Marked Site" confirmation process was completed prior to the start of the procedure. The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,73]
wasPreOpImagingConfirmedIndicates whether a verification process was completed in which the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,72]
wasSeqCompressDeviceUsedIndicates a whether sequential compression device was used. [FileMan 130,127]
wasTimeOutVerifiedIndicates whether a "Time Out" verification process was conducted prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,71]
woundClassificationIndicates whether the wound has been classified by the primary surgeon as:Class 1 - Clean: Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed drainage. Surgical incisional wounds that occur with nonpenetrating (e.g., blunt) trauma should be included in this category if they meet the criteria. [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.]Class 2 - Clean/Contaminated: Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered. (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.)Class 3 - Contaminated: Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.Class 4 - Dirty/Infected: Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the surgical field before the procedure. (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.)[FileMan 130,1.09]
FHIM::Common::ActionPerformed