Anesthesia Record Terminology
Description: Patient’s last name
Description: Patient’s first name
Description: Patient’s middle name
Date of Birth
Description: Patient’s date of birth
Values: M, F, U (M = Male, F = Female, U = Unknown)
Description: Patient’s gender
Medical Record Number
Description: Patient’s ID number associated with their entire medical record, and not specific to any single hospital visit/admission.
Description: Patient’s ID number associated with a single hospital visit/admission. An Encounter Number may also be referred to as a Visit Number or Account Number. Importantly, the Encounter Number is barcoded on the patient’s wrist band and is used to identify the patient’s current admission.
Place of Service Code
Values: IP, AMB (IP = Inpatient, AMB = Ambulatory)
Description: This specifies the type of entity where service(s) were rendered. Commonly coded as a value of “21”, “22” or “24”. QCDRs require this information to be submitted with their quality data.
ASA Status with Emergency
Values: 1, 1E, 2, 2E, 3, 3E, 4, 4E, 5, 5E, 6.
Description: Identifies severity of the patient’s clinical condition.
Values: GENERAL, MAC, SPINAL, REGIONAL, EPIDURAL, LABOR_EPIDURAL, TOPICAL
Description: This is the primary type of anesthetic used for the procedure. Even if multiple techniques were used, only one should be selected for this field. Typically when Regional is used in cobmination with General, a “General” anesthetic will be selected.
Description: The 10-digit number assigned to the surgeon of record.
Anesthesia Provider(s) NPI
Description: The 10-digit number assigned to the anesthesia provider.
Anesthesia Provider(s) Type
Values: Physician, CRNA
Description: The type of provider corresponding to the NPI provided above.
Date of Service
Description: The data on which anesthesia service began and equivalent to the Anesthesia Start Date.
Description: Name of the anesthetizing location. For example, “OR 1” or “Cath Lab 1”.
Description: Date and Time the patient was told the case would start.
Description: Date and Time the patient arrives to the operating room.
Description: Date and Time the patient has been induced, vascular access obtained, and any regional or neuraxial procedures have been completed. It’s the time the anesthesia team typically allows the surgical team to begin their positioning and prepping of the patient for start of procedure.
Description: Date and Time incision is made or the procedure begins.
Description: Date and Time surgery is complete.
Description: Date and Time the patient arrives to the either PACU or ICU. If the patient does not “transfer” physcially to another location following anesthesia, this is the time a handoff to another team occurs, in which the new team is responsible for monitoring the patient followin anesthesia.
Description: Date and Time the continuous anesthetic care as ended.
Values: PACU, ICU
Description: The patient’s area of treatment following their anesthetic. This is used to code certain CMS measures which distinguish if patients are transferred to the PACU or ICU. We also visualize this information in our Population Health charts to help you better understand the acuity of your patients and the effects that may have on average efficiency times.
PACU Pain Score
Values: 0-10, Unknown
Description: The patient’s pain score in the PACU within 15 minutes of arrival. If patient is sedated or otherwise unable to report a score, a value of “unknown” may be reported.
Hypothermia (Temp <35.5 C)
Description: A temperature of <35.5 degrees centigrade in the immediate postoperative period within 15 minutes of arrival in PACU.
Handoff Protocol Used
Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible care team or team member.
The key handoff elements that must be included in the transfer of care protocol or checklist include:
- Identification of patient, key family member(s) or patient surrogate
- Identification of responsible practitioner (primary service)
- Discussion of pertinent medical history
- Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)
- Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure
- Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration.
- Opportunity for questions and acknowledgement of understanding of report from the receiving team.
Surgical Safety Checklist Used
Description: Percentage of patients, regardless of age, who undergo a surgical procedure under anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of anesthesia.
The WHO Surgical Safety Checklist includes the following items before Induction of Anesthesia:
- Has the patient confirmed his/her identity, site, procedure and consent?
- Is the site marked?
- Is the anesthesia machine and medication check complete?
- Is the pulse oximeter on the Patient And Functioning?
- Does the Patient have a:
- Known Allergy?
- Difficult Airway/Aspiration Risk?
- Risk of >500 ml Blood Loss (7ml/kg in children)?
Dysrhythmia requiring intervention
Description: Arrhythmia that requires intervention with anti-arrhythmics other than anesthetics. Does not include beta blockade for cases for HR < 100.
Cardiac arrest (unplanned)
Description: Any alteration in cardiac activity requiring CPR and/or unplanned defibrillation within the first 24 hours after the completion of an anesthetic.
Description: Unexpected death within 24 hours after completion of anesthesia, in-hospital death.
Stroke, CVA, or coma
Description: Unspecified cause of supratentorial neurologic dysfunction requiring evaluation or intervention. Includes TIA, hemorrhage, anoxic or metabolic coma. Symptoms occurring within 24 hours of OR end and persisting > 24 hours.
Description: Any scenario felt to be indicative of myocardial ischemia that requires intervention after physician evaluation.
Description: New myocardial infarction from induction of anesthesia until 24 hours after OR end, diagnosed by troponin, CK MB or any other criteria of American College of Cardiology.
Vascular access injury
Description: An event arising from an attempt at securing vascular access (arterial, central venous, or peripheral venous) requiring intervention.
Description: Uncontrolled hypertension defined as > 180 systolic or > 110 diastolic.
Description: Observation of gastric contents in oropharynx in unprotected airway or in LMA or ETT, suspected or confirmed.
Pneumothorax (related to anesthesia)
Description: A new onset of a pneumothorax in the perioperative period following anesthetically performed perithoracic vascular procedures.
Failed regional anesthetic
Description: Regional anesthesia intended as primary anesthetic that requires GA.
Systemic local anesthetic toxicity
Description: Any CNS or Cardiac effects following instillation of LA for regional block thought to be related to systemic LA levels.
Peripheral nerve injury following regional
Description: The new onset of peripheral nerve injury identified within 24 hours of an anesthetic in the absence of a known surgical cause.
Description: Patient requires either manual assistance for ventilation or reintubation following paralytic secondary to inadequate reversal.
Reintubation (trial extubation)
Description: Any patient who requires tracheal re-intubation in the PACU after receiving anesthesia who had a formal trial of extubation.
Reintubation (no trial extubation)
Description: Any patient who requires tracheal re-intubation in the PACU after receiving anesthesia who did NOT have a formal trial of extubation.
Medication administration error
Description: Wrong drug or dose given requiring treatment or resulting in harm to the patient.
Adverse transfusion reaction
Description: Clinical diagnosis of definite or suspected transfusion reaction during or following transfusion of blood products confirmed by blood bank results to be possibly incompatible with patient blood. New onset of fever, chills, rash, flank pain or back pain, bloody urine, fainting or dizziness, kidney failure, delayed anemia, lung dysfunction or shock.
Description: Immediate sensitivity response after exposure to specific antigen; results in life-threatening respiratory distress; usually followed by vascular collapse, shock, urticaria, angioedema and pruritus.
Wrong site surgery
Description: Regional block or surgery performed on incorrect site or side.
Description: Incorrect patient arrives to OR or procedure room.
Description: Difficult airway equipment is brought to the room after induction and used when difficult airway is encountered unexpectedly.
Unplanned hospital admission
Description: Patient admitted to the hospital from the PACU that was originally scheduled to go home.
Unplanned ICU admission
Description: A patient admitted to the ICU within 24 hours of anesthesia care when the need for ICU care is determined after the induction of anesthesia.
Wrong surgical procedure
Description: Incorrect surgical procedure performed.
Description: Unintended change in the patient’s perioperative dental status.
Description: Any loss of visual field or acuity following anesthesia not related periocular treatments (eye drops, ointments, or eye surgery) lasting more than 24 hours.
Description: Suspected MH following induction of general anesthesia requiring treatment with Dantrolene.
Awareness under GA
Description: Awareness under anesthesia occurs when a patient remembers events during surgery/procedure while under general anesthetic. Does not include recall of events during periods of intended intra-operative “wake-up” or sedation.
Description: Mechanism for providers to add any comments/complications they may feel is necessary to report, but not available in any of the options available.
Description: Any malfunction requiring intervention not part of routine device/machine checkout.
Fire in OR
Description: Fire in OR, not contacting patient.
Airway fire in OR
Description: Any fire in patient airway.
Description: Any ocular surface injury requiring evaluation, follow up, or treatment.
Fall in OR
Description: Patient fall while under anesthesia care while in OR or procedure room.
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