Release Notes:
Data Element
Version 2010B
| Data Element Name: | Surgical Procedure |
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| Collected For: | BM-04b, |
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| Definition: | A surgical procedure was performed using general or neuraxial anesthesia during hospitalization. |
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| Suggested Data Collection Question: | Was a surgical procedure performed using general or neuraxial anesthesia? |
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| Format: | | Length: | 1 |
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| Type: | Numeric |
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| Occurs: | 1 |
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| 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.
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| 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”.
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| Suggested Data Sources: |
Anesthesia record
Preop checklist
Operating room notes
Operative report
Procedure notes
PACU/recovery room record
Intraoperative record |
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- General Anesthesia
- Inhaled gases
- Intravenous
- Endotracheal
- Laryngeal mask airway or anesthesia (LMA)
- Neuraxial Anesthesia
- Spinal block
- Epidural block
- Spinal anesthesia
- Subarachnoid blocks
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- Conscious sedation
- Monitored anesthesia care (MAC)
- Local with sedation
- Local with stand-by
- Peripheral nerve blocks
- Saddle block
- Deep sedation
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Surgical Procedure
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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