Sub-Field: 130.22

Parent File	Name	Number	Package
SURGERY(#130)	POSTOP OCCURRENCE	130.22	Surgery

Field #	Name	Loc	Type	Details
.01	POSTOP OCCURRENCE	0;1	FREE TEXT	INPUT TRANSFORM: `K:$L(X)>40!($L(X)<3)!($E(X,1,5)["NONE")!($E(X,1,5)["None")!($E(X,1,5)["none") X` LAST EDITED: `NOV 08, 1988` HELP-PROMPT: `If a postoperative occurrence exists, your answer should be 3 to 40 characters.` DESCRIPTION: `This is the name of a occurrence encountered postoperatively. If there are no occurrences, this field should be left blank. 'NONE' will not be accepted.` DELETE TEST: `.01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0` NOTES: `XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER`
.05	OUTCOME TO DATE	0;6	SET	'U' FOR UNRESOLVED; 'I' FOR IMPROVED; 'D' FOR DEATH; 'W' FOR WORSE; LAST EDITED: `JAN 25, 1991` DESCRIPTION: `This is the code corresponding to the outcome of this postoperative occurrence.`
2	DATE COMP NOTED	0;7	DATE	INPUT TRANSFORM: `S %DT="EXPT" D ^%DT S X=Y K:Y<1 X` LAST EDITED: `MAR 13, 2007` HELP-PROMPT: `Enter the date/time that this occurrence was noted.` DESCRIPTION: `This is the date that this postoperative occurrence was noted in the patient's record.` NOTES: `XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER`
3	TREATMENT INSTITUTED	2;1	FREE TEXT	INPUT TRANSFORM: `K:$L(X)>40!($L(X)<1) X` LAST EDITED: `APR 15, 1987` HELP-PROMPT: `Your answer must be 1 to 40 characters in length.` DESCRIPTION: `This is descriptive information about the treatment instituted as a result of this occurrence.`
4	OCCURRENCE COMMENTS	1;0	WORD-PROCESSING #130.224	DESCRIPTION: `These are comments about this postoperative occurrence.`
5	OCCURRENCE CATEGORY	0;2	POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5)	**********************REQUIRED FIELD********************** PERIOPERATIVE OCCURRENCE CATEGORY(#136.5) INPUT TRANSFORM: `S DIC("S")=$$CO^SROCMPS D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X` LAST EDITED: `AUG 22, 2000` HELP-PROMPT: `Enter the name of the category most closely related to this occurrence.` DESCRIPTION: `This is the name of the category in which this occurrence may be grouped. It should be entered for all occurrences and will be used by Surgery Central Office for reporting needs.` SCREEN: `S DIC("S")=$$CO^SROCMPS` EXPLANATION: `Screen prevents selection of inactive occurrence category and selection of cardiac only category on non-cardiac case.` NOTES: `XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER`
6	ICD DIAGNOSIS CODE	0;3	POINTER TO ICD DIAGNOSIS FILE (#80)	ICD DIAGNOSIS(#80) INPUT TRANSFORM: `S DIC("S")="I $$ACTIV^SROICD($S($D(SRTN):SRTN,$D(DA(1)):DA(1),1:""""),+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X` LAST EDITED: `APR 11, 2003` HELP-PROMPT: `Enter the ICD Diagnosis code corresponding to this postoperative occurrence.` DESCRIPTION: `If the occurrence entered does not fit in any of the predefined categories, an ICD Diagnosis Code must be entered.` SCREEN: `S DIC("S")="I $$ACTIV^SROICD($S($D(SRTN):SRTN,$D(DA(1)):DA(1),1:""""),+Y)"` EXPLANATION: `Screen prevents selection of inactive diagnosis.` NOTES: `XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER`
7	SEPSIS CATEGORY	0;4	SET	'1' FOR SIRS; '2' FOR SEPSIS; '3' FOR SEPTIC SHOCK; LAST EDITED: `JAN 24, 2006` HELP-PROMPT: `Select the appropriate category of sepsis for this occurrence.` DESCRIPTION: `NSQIP Definition (2007): The body's response to insult can be documented as one of two levels with the successive level building on the previous level. You should only document the highest level identified using the` criteria below. 1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following: - Temp >38 degrees C or <36 degrees C - HR >90 bpm - RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa) - WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms - Anion gap acidosis: this is defined by either: [Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is greater than 16, then an anion gap acidosis is present. or Na - [Cl + HCO3 (or serum CO2)]. If this number is greater than 12, then an anion gap acidosis is present. and one of the following: - positive blood culture - clinical documentation of purulence at any site thought to be causative 2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents. SCREEN: `S DIC("S")="I Y'=1"` EXPLANATION: `Screen prevents selection of inactive code.`
8	CPB STATUS	0;5	SET	'0' FOR None; '1' FOR On-bypass; '2' FOR Off-bypass; LAST EDITED: `MAR 01, 2006` HELP-PROMPT: `Enter NONE, ON BYPASS, or OFF BYPASS.` DESCRIPTION: `CICSP Definition (2006): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or` within 30 days of the initial operation. Use the same criteria to define a cardiac surgery as listed on page 1 of the CICSP Instructions/Definitions. (Do NOT submit a separate second form for this second cardiac procedure if it occurs within 30 days post-operatively.) Indicate the one appropriate response: None - no repeat cardiac surgical procedure post-operatively during index hospitalization or within 30 days of initial operation. On-bypass - patient underwent a repeat cardiac surgical procedure utilizing CPB. Off-bypass - patient underwent a repeat cardiac surgical procedure not utilizing CPB.

Field #

Name

Loc

Type

Details

.01

POSTOP OCCURRENCE

0;1

FREE TEXT

INPUT TRANSFORM: K:$L(X)>40!($L(X)<3)!($E(X,1,5)["NONE")!($E(X,1,5)["None")!($E(X,1,5)["none") X
LAST EDITED: NOV 08, 1988
HELP-PROMPT: If a postoperative occurrence exists, your answer should be 3 to 40 characters.
DESCRIPTION: This is the name of a occurrence encountered postoperatively. If there are no occurrences, this field should be left blank. 'NONE' will not be accepted.
DELETE TEST: .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER

.05

OUTCOME TO DATE

0;6

SET

'U' FOR UNRESOLVED;
'I' FOR IMPROVED;
'D' FOR DEATH;
'W' FOR WORSE;

LAST EDITED: JAN 25, 1991
DESCRIPTION: This is the code corresponding to the outcome of this postoperative occurrence.

2

DATE COMP NOTED

0;7

DATE

INPUT TRANSFORM: S %DT="EXPT" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAR 13, 2007
HELP-PROMPT: Enter the date/time that this occurrence was noted.
DESCRIPTION: This is the date that this postoperative occurrence was noted in the patient's record.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER

3

TREATMENT INSTITUTED

2;1

FREE TEXT

INPUT TRANSFORM: K:$L(X)>40!($L(X)<1) X
LAST EDITED: APR 15, 1987
HELP-PROMPT: Your answer must be 1 to 40 characters in length.
DESCRIPTION: This is descriptive information about the treatment instituted as a result of this occurrence.

4

OCCURRENCE COMMENTS

1;0

WORD-PROCESSING #130.224

DESCRIPTION: These are comments about this postoperative occurrence.

5

OCCURRENCE CATEGORY

0;2

POINTER TO PERIOPERATIVE OCCURRENCE CATEGORY FILE (#136.5)

************************REQUIRED FIELD************************

PERIOPERATIVE OCCURRENCE CATEGORY(#136.5)

INPUT TRANSFORM: S DIC("S")=$$CO^SROCMPS D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: AUG 22, 2000
HELP-PROMPT: Enter the name of the category most closely related to this occurrence.
DESCRIPTION: This is the name of the category in which this occurrence may be grouped. It should be entered for all occurrences and will be used by Surgery Central Office for reporting needs.
SCREEN: S DIC("S")=$$CO^SROCMPS
EXPLANATION: Screen prevents selection of inactive occurrence category and selection of cardiac only category on non-cardiac case.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER

6

ICD DIAGNOSIS CODE

0;3

POINTER TO ICD DIAGNOSIS FILE (#80)

ICD DIAGNOSIS(#80)

INPUT TRANSFORM: S DIC("S")="I $$ACTIV^SROICD($S($D(SRTN):SRTN,$D(DA(1)):DA(1),1:""""),+Y)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: APR 11, 2003
HELP-PROMPT: Enter the ICD Diagnosis code corresponding to this postoperative occurrence.
DESCRIPTION: If the occurrence entered does not fit in any of the predefined categories, an ICD Diagnosis Code must be entered.
SCREEN: S DIC("S")="I $$ACTIV^SROICD($S($D(SRTN):SRTN,$D(DA(1)):DA(1),1:""""),+Y)"
EXPLANATION: Screen prevents selection of inactive diagnosis.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER

7

SEPSIS CATEGORY

0;4

SET

'1' FOR SIRS;
'2' FOR SEPSIS;
'3' FOR SEPTIC SHOCK;

LAST EDITED: JAN 24, 2006
HELP-PROMPT: Select the appropriate category of sepsis for this occurrence.

DESCRIPTION: NSQIP Definition (2007): The body's response to insult can be documented as one of two levels with the successive level building on the previous level. You should only document the highest level identified using the

criteria below.

1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults.

This syndrome is clinically recognized by the presence of two or more of the following:

- Temp >38 degrees C or <36 degrees C

- HR >90 bpm

- RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa)

- WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band)

forms

- Anion gap acidosis: this is defined by either:

[Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is

greater than 16, then an anion gap acidosis is present.

or

Na - [Cl + HCO3 (or serum CO2)]. If this number is greater

than 12, then an anion gap acidosis is present.

and one of the following:

- positive blood culture

- clinical documentation of purulence at any site thought to be

causative

2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND

documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension,

requirement of inotropic or vasopressor agents.

SCREEN: S DIC("S")="I Y'=1"
EXPLANATION: Screen prevents selection of inactive code.

8

CPB STATUS

0;5

SET

'0' FOR None;
'1' FOR On-bypass;
'2' FOR Off-bypass;

LAST EDITED: MAR 01, 2006
HELP-PROMPT: Enter NONE, ON BYPASS, or OFF BYPASS.

DESCRIPTION: CICSP Definition (2006): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or

within 30 days of the initial operation. Use the same criteria to define a cardiac surgery as listed on page 1 of the CICSP Instructions/Definitions. (Do NOT submit a separate second form for this second cardiac

procedure if it occurs within 30 days post-operatively.) Indicate the one appropriate response:

None - no repeat cardiac surgical procedure post-operatively during

index hospitalization or within 30 days of initial operation.  On-bypass - patient underwent a repeat cardiac surgical procedure

utilizing CPB.  Off-bypass - patient underwent a repeat cardiac surgical procedure

not utilizing CPB.

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Package: Surgery

SURGERY(#130)-->130.22

Sub-Field: 130.22

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