Release Notes:
Data Element
Version 2010B
| Data Element Name: | Other Surgeries |
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| Collected For: | SCIP-Inf-1, SCIP-Inf-3, |
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| Definition: | Other procedures requiring general or spinal/epidural anesthesia that occurred within three days (four days for CABG or Other Cardiac Surgery) prior to or after the principal procedure during this hospital stay. |
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| Suggested Data Collection Question: | Were there any other procedures requiring general or spinal/epidural anesthesia that occurred within three days (four days for CABG or Other Cardiac Surgery) prior to or after the principal procedure during this hospital stay? |
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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: |
Y (Yes) There is documentation of another procedure requiring general or spinal/epidural anesthesia that occurred within three days (four days for CABG or Other Cardiac Surgery) prior to or after the principal procedure during this hospital stay.
N (No) There is no documentation of any other procedure requiring general or spinal/epidural anesthesia that occurred within three days (four days for CABG or Other Cardiac Surgery) prior to or after the principal procedure during this hospital stay or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- This data element is used to exclude cases that have another major surgical procedure (requiring an incision and general or spinal/epidural anesthesia) performed within three days (four days for CABG and Other Cardiac Surgery) prior to or after the principal procedure during this hospital stay.
- For the purposes of this data element, if pocketed cardiac devices (pacemakers, defibrillators, pulse generators, etc) are implanted during this hospital stay and within three days (four days for CABG and Other Cardiac Surgery) prior to or after the principal procedure, select “Yes.” The prophylactic antibiotics given for the implanted cardiac device could interfere with the prophylaxis for the principal procedure.
- The following are two scenarios that must be clarified:
- If multiple procedures are performed during the same surgical episode, select “No.”
- If other procedures are performed during separate surgical episodes requiring general or spinal/epidural anesthesia and occur within three days (four days for CABG or Other Cardiac Surgery) of the principal procedure during this hospital stay, select “Yes.”
- For other surgical procedures requiring general or spinal/epidural anesthesia performed prior to the principal procedure during this hospital stay, the three days (four days for CABG or Other Cardiac Surgery) window begins at the Surgery End Time of the earlier procedure and ends at the Surgical Incision Time of the principal procedure.
- For other surgical procedures requiring general or spinal/epidural anesthesia that occur after the principal procedure during this hospital stay, the three days (four days for CABG or Other Cardiac Surgery) window begins at the Surgery End Time of the principal procedure and ends at the Surgical Incision Time of the subsequent procedure.
- If multiple procedures occur during the same surgical episode, the Surgical Incision Time captured will be the incision that occurs first and the Surgery End Time will be the end time that occurs last.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing notes
- Discharge summary
- Admitting physician orders
- Admitting progress notes
- Physician admission notes
- Physician progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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Other Surgeries
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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