Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | FixFracture | 3445 | Non-Cranial - Open/Closed Reduct,Int/Ex Fix of Fracture | 1989-10-01 - Variable Added |
NON-CRANIAL SURGERY - ARCHIVE
See subdomain notes
Definition
Lists all non-cranial surgeries during acute hospitalization.
FRACTURES - ARCHIVE
Definition
Open or closed reduction, internal or external fixation of fracture(s). This includes only those reductions and fixations which require a surgical procedure.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Internal fixations include pinning, screws, rodding, fusions, bone grafting, etc. External fixations include halo, external fixation device for pelvic fracture, etc.
ORIF of oral/facial bones is coded under variable NSRGORAL – Non-Cranial Surgery - Oral or Maxillo- Mandibulo-facial.
Variables
Codes and Values
ID 3445
For Form: [Form 1]
For Variables: [FixFracture]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
GASTROSTOMY - ARCHIVE
Definition
Percutaneous placement or surgical opening of stomach with insertion of drainage tube
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Gastrostomy may initially be for draining until bowel function returns then can be used for feeding, code as yes if used for either.
*Do not confuse with nasogastric or oralgastric tubes (which are not coded).
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Gastrostomy | 3464 | Non-Cranial - Gastrostomy | 1989-10-01 - Variable Added |
Codes and Values
ID 3464
For Form: [Form 1]
For Variables: [Gastrostomy]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
JEJUNOSTOMY - ARCHIVE
Definition
Surgical opening of jejunum with insertion of drainage tube.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Jejunostomy may initially be for draining until bowel function returns then can be used for feeding, code as yes if used for either.
*Do not confuse with nasogastric or oralgastric tube (which are not coded)
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Jejunostomy | 3480 | Non-Cranial - Jejunostomy | 1989-10-01 - Variable Added |
Codes and Values
ID 3480
For Form: [Form 1]
For Variables: [Jejunostomy]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
LAPAROTOMY - ARCHIVE
Definition
This variable documents any surgical incision (including mini-laparotomy and laparoscopy) and exploration of the abdomen to determine abdominal site of bleeding.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Peritoneal lavage is to be coded under NSRGLAV (Peritoneal Lavage)
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Laparotomy | 3481 | Non-Cranial - Laparotomy/Minilap | 1989-10-01 - Variable Added |
Codes and Values
ID 3481
For Form: [Form 1]
For Variables: [Laparotomy]
Code | Description |
|---|---|
1 | No |
2 | Yes: Positive as the Source of Bleeding |
3 | Yes: Negative as the Source of Bleeding |
9 | Unknown |
History
No history found for the Domain.
ORAL FACIAL - ARCHIVE
Definition
Any surgical procedure performed on the oral cavity or the maxillo- or mandibulo- facial areas.
Form
[X] Form 1 [ ] Form 2
Source
- Abstraction (acute record)
Details
List others on coding sheet.
Do not code enucleation of eye.
Code ORIF of oral/facial bones under this variable.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | OralFacial | 3493 | Non-Cranial - Oral/Maxi-/Mandi- Facial | 1989-10-01 - Variable Added |
Codes and Values
ID 3493
For Form: [Form 1]
For Variables: [OralFacial]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
PERITONEAL LAVAGE - ARCHIVE
Definition
Diagnostic lavage via either puncture or incision to determine abdominal site of bleeding.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Medical Record documentation for this variable may read “DPL negative” or “DPL positive”.
Laparotomy, mini-laparotomy and laparoscopy is to be coded under Var. 170o.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | PeritonealLavage | 3499 | Non-Cranial - Peritoneal Lavage | 1989-10-01 - Variable Added |
Codes and Values
ID 3499
For Form: [Form 1]
For Variables: [PeritonealLavage]
Code | Description |
|---|---|
1 | No |
2 | Yes, Positive As The Source of Bleeding |
3 | Yes, Negative As The Source of Bleeding |
9 | Unknown |
History
No history found for the Domain.
THORACOSTOMY - ARCHIVE
Definition
Chest tube(s) inserted through chest wall into lung.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Chest tube(s) inserted through chest wall into lung.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | TubeThoracostomy | 3572 | Non-Cranial - Tube Thoracostomy | 1989-10-01 - Variable Added |
Codes and Values
ID 3572
For Form: [Form 1]
For Variables: [TubeThoracostomy]
Code | Description |
|---|---|
1 | Not done |
2 | Either Right or Left: Unilateral |
4 | Bilateral |
9 | Unknown |
History
No history found for the Domain.
THORACOTOMY - ARCHIVE
Definition
Surgical incision in the chest wall *except for reasons of placing a chest gtube. Patient may have thoracotomy and also tube thoracostomy (chest tube).
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Thoracotomy | 3558 | Non-Cranial - Thoracotomy | 1989-10-01 - Variable Added |
Codes and Values
ID 3558
For Form: [Form 1]
For Variables: [Thoracotomy]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
TRACHEOSTOMY - ARCHIVE
Definition
Surgical incision of the trachea for insertion of a tube to relieve upper airway obstruction and facilitate ventilation.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
Code as yes regardless of where tracheostomy performed (e.g., by EMS or at a community hospital prior to admission to model system.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Tracheostomy | 3563 | Non-Cranial - Tracheostomy | 1989-10-01 - Variable Added |
Codes and Values
ID 3563
For Form: [Form 1]
For Variables: [Tracheostomy]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.