Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Laparoscope |
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| Collected For: | SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, , , |
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| Definition: | A surgical procedure performed entirely with a laparoscope or other fiber optic scope. |
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| Suggested Data Collection Question: | Was the procedure performed entirely by laparoscope or other fiber optic scope? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
1 (Yes) There is documentation the surgical procedure was performed entirely by laparoscope or other fiber optic scope.
2 (No) There is documentation the surgical procedure was not performed entirely by laparoscope or other fiber optic scope.
3 (UTD) Unable to determine from medical record documentation that the surgical procedure was performed entirely by laparoscope or other fiber optic scope.
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| Notes for Abstraction: |
- Examples:
- Patient had a laparoscopic cholecystectomy with no incision other than those to insert the laparoscopic equipment, select 1, “Yes.”
- Patient had a laparoscopically-assisted vaginal hysterectomy; select 2, “No.”
- Patient had a “hand-assisted” or “laparoscopically assisted” colon resection, where the laparoscopic insertion sites were extended (incision was extended or an additional incision was made); select 2, “No.”
- The procedure was coded as performed entirely laparoscopically, but the operative report indicates that the surgeon converted to an open procedure; select 2, “No.”
- ICD-9-CM codes may not be a reliable source to determine if the procedure was performed entirely by laparoscope or other fiber optic scope. Therefore, it is recommended that abstractors refer to the following Suggested Data Sources.
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| Suggested Data Sources: |
- Consultation notes
- History and physical
- Physician orders
- Operative report
- Anesthesia evaluation
- Operating room record
- Physician progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Endoscope
- Fiber optic scope
- Thoracoscope
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- Hand-assisted laparoscopic procedures
- Laparoscopically-assisted procedures
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Laparoscope
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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