Transcription

M ACS2021 Data Dictionary

Revision 01/12/2021Table of ContentsTab 1 – Identifiers. 101)Center . 102)Medical Record Number (MRN) . 103)Visit Number (CSN) . 104)MACS Case Number . 115)SCOAP Case Number . 11Tab 2 – Demographics . 126)First Name . 127)Last Name. 128)Date of Birth (mm/dd/yyyy) . 129)Sex . 1310)Race. 1311)Ethnicity. 1412)Address (1234 Main Street) . 1513)City . 1514)State .1515)ZIP Code. 1616)Phone (XXX-XXX-XXXX) . 1617)Email . 1618)Insurance . 16Tab 3 - Arrival. 1719)ED Arrival Date . 1720)ED Arrival Time (Military Time 00:00) . 1821)Admit Date . 1822)Admit Time (Military Time 00:00) . 1923)Point of Entry . 1924)Surgery Consult Date (mm/dd/yyyy) . 2025)Consult Surgeon . 2126)ACS Service . 2127)Type of Service . 222

Revision 01/12/2021Tab 4 – Risk Factors . 2228)Height (cm) . 2229)Weight (kg) . 2330)Ascites . 2331)CHF w/in 30 Days . 2432)COPD (Severe) . 2433)COVID-19 . 2534)Current Cancer/Malignancy . 2535)Diabetes Mellitus . 2636)Dialysis w/in 2 Weeks. 2637)Disseminated Cancer . 2738)Hypertension . 2739)Functional Health Status. 2840)Personal History of DVT/PE . 2841)Preoperative Sepsis . 2942)Sleep Apnea . 3043)Solid Organ Transplant . 3144)Steroid/Immunosuppressive Medication . 3145)Tobacco w/in 1 year – Cigarette. 3346)Ventilator Dependent w/in 48 Hours . 33Tab 5 – Readmission . 3447)MACS Readmit . 3448)Index Disease . 3449)Prior Appendectomy . 3550)Prior Cholecystectomy . 35Tab 6 – Disease . 3651)PRIMARY ICD-10 Code . 3652)SECONDARY ICD-10 Code. 3753)Organ System . 37Tab 7 - Appendix . 3854)Diagnosis CT Scan . 383

Revision 01/12/202155)CT Results . 3956)CT Findings . 3957)Diagnosis Ultrasound. 4058)Ultrasound Results . 4059)Diagnosis MRI . 4160)MRI Results . 4161)Pathology Result . 4262)Appendicitis Type . 4263)Medical Management . 4364)IV Antibiotic #1 Class . 4365)Duration of IV Antibiotic #1 (calendar days) . 4466)IV Antibiotic #2 Class . 4467)Duration of IV Antibiotic #2 (calendar days) . 4568)IV Antibiotic #3 Class . 4569)Duration of IV Antibiotic #3 (calendar days) . 4670)Duration of Home Antibiotic (calendar days) . 4671)Home Oral Antibiotic #1 Class . 4772)Home Oral Antibiotic #2 Class . 4773)Home IV Antibiotic Class. 4874)Appendectomy Within 12 Months . 49Tab 8 - Gall Bladder . 5075)Diagnosis Ultrasound. 5076)Diagnosis CT Scan . 5077)Diagnosis HIDA . 5078)Diagnosis EUS. 5179)Diagnosis ERCP . 5180)Diagnosis MRI/MRCP. 5281)Intra-Op Cholangiogram . 5282)Secondary Ultrasound . 5383)Secondary CT Scan. 5384)Secondary HIDA . 534

Revision 01/12/202185)Secondary EUS . 5486)Secondary ERCP . 5487)Secondary MRI/MRCP . 5588)Non-Operative Management . 55Tab 9 - Small Bowel Obstruction . 5589)Prior Small Bowel Obstruction . 5590)Number Prior Admits for Small Bowel Obstruction . 5691)Prior Abdominal Procedures . 5792)Prior Open Laparotomy . 5793)Prior Laparoscopy. 5894)Prior Mesh . 5895)Prior Radiation . 5896)Metastatic Malignancy . 5997)CT Scan . 5998)CT Scan Date (mm/dd/yyyy) . 6099)CT Scan Time (Military Time 00:00) . 60100)Enteral Contrast . 60101)CT Findings . 61102)Other CT Findings . 61103)Obstruction Related to Adhesions. 62104)Gastrografin Challenge . 62105)Gastrografin Challenge Date (mm/dd/yyyy) . 63106)Gastrografin Challenge Time (Military Time 00:00) . 63107)Gastrografin Result . 63Tab 10 – Exploratory Laparotomy .64108)Abdominal X-Ray. 64109)Abdominal X-Ray Date (mm/dd/yyyy) . 64110)Abdominal X-Ray Time (Military Time 00:00) . 65111)CT Scan . 65112)CT Scan Date (mm/dd/yyyy) . 65113)CT Scan Time (Military Time 00:00) . 665

Revision 01/12/2021114)CT Findings . 66115)Other CT Findings . 67116)NEWS 2 Score – Respiratory Rate (bpm) . 67117)NEWS 2 Score – Hypercapnic Respiratory Failure. 68118)NEWS 2 Score – SpO2 . 68119)NEWS 2 Score – SpO2 in Respiratory Failure . 69120)NEWS 2 Score – Supplemental O2 or Room Air . 69121)NEWS 2 Score – Temperature . 70122)NEWS 2 Score – Systolic Blood Pressure (mmHg) . 70123)NEWS 2 Score – Pulse (bpm) . 71124)NEWS 2 Score – Consciousness . 71125)SIRS Criteria – WBC 12,000/mm, 4,000/mm, or 10% bands . 72126)Blood Gas Type . 72127)Blood Gas Values. 73128)Sepsis Antibiotic Date (mm/dd/yyyy) . 73129)Sepsis Antibiotic Time (Military Time 00:00) . 74130)Goal Directed Fluid Therapy. 74131)Total Ventilator Calendar Days . 75132)ICU Admission Date (mm/dd/yyyy) . 75133)ICU Admission Time (Military Time 00:00) . 75134)ICU Discharge Date (mm/dd/yyyy) . 76135)ICU Discharge Time (Military Time 00:00) . 76Tab 11 – Interventional Radiology.76136)Interventional Radiology . 76137)IR Procedure . 77138)IR Procedure Date (mm/dd/yyyy) . 77139)IR Procedure Time (Military Time 00:00) . 78Tab 12 – Operation . 78140)Operation .