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Release Notes:
Data Element
Version 2010B

Data Element Name: Surgical Procedure
Collected For: BM-04b,
Definition:A surgical procedure was performed using general or neuraxial anesthesia during hospitalization.
Suggested Data Collection Question:Was a surgical procedure performed using general or neuraxial anesthesia?
Format:
Length:1
Type:Numeric
Occurs:1
Allowable Values:

1    There is documentation that a surgical procedure was performed using general or neuraxial anesthesia.

2    There is no documentation that a surgical procedure was performed using general or neuraxial anesthesia or unable to determine from medical record documentation.

Notes for Abstraction:
  • If unable to determine if the patient had a surgical procedure and/or whether general or neuraxial anesthesia was used from medical record documentation, select 2.
Suggested Data Sources:
  • Anesthesia record
  • Preop checklist
  • Operating room notes
  • Operative report
  • Procedure notes
  • PACU/recovery room record
  • Intraoperative record
  • Additional Notes:
    Guidelines for Abstraction:
    Inclusion Exclusion
    • General Anesthesia
      • Inhaled gases
      • Intravenous
      • Endotracheal
      • Laryngeal mask airway or anesthesia (LMA)
    • Neuraxial Anesthesia
      • Spinal block
      • Epidural block
      • Spinal anesthesia
      • Subarachnoid blocks

    • Conscious sedation
    • Monitored anesthesia care (MAC)
    • Local with sedation
    • Local with stand-by
    • Peripheral nerve blocks
    • Saddle block
    • Deep sedation

    Surgical Procedure
    Specifications Manual for Joint Commission National Quality Core Measures (2010B)
    Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)