European Surgical Outcomes Study (EuSOS)
Operating Room case record form
Age
ASA  I
years
 II
 III
Gender  M
 IV
 F
Current smoker  Y
 V
Black ethnicity  Y
 N
 N
Chronic co-morbid disease (tick all that apply):
 Coronary artery disease
 Congestive heart failure
 Diabetes mellitus with insulin therapy
 Cirrhosis
 Metastatic cancer
 Diabetes mellitus (no insulin)
 Stroke or Transient ischaemic attack
 COPD / Asthma
Most recent blood results (no more than 28 days before surgery):
Haemoglobin
.
g/dl or g/L#
Leucocytes
.
x109/L
Sodium
mmol/L
Urea/BUN
.
Creatinine
mmol/L or mg/dl#
.
µmol/L or mg/dl#
Anaesthesia induction time (24h) & date:
h
h
:
m
m
# indicate units used
d
d
0
4
2
0
1
1
Anaesthetic technique (tick all that apply)
 General
 Spinal
 Epidural
 Sedation
 Local
 Other regional
Surgical procedure category (select single most appropriate):
 Orthopaedic
 Breast
 Gynaecological
 Vascular
 Upper gastro-intestinal
 Lower gastro-intestinal
 Hepato-biliary
 Plastics / Cutaneous
 Urological
 Kidney
 Head and neck
 Other
Surgical checklist used (e.g. WHO checklist)?
 Y
 N
EuSOS unique patient ID
EuSOS Operating Room case record form v1.4

Patient name: ___________________________________
Page 1 of 2
DOB
d
d
m
m
y
y
y
y
Most senior anaesthetist present in operating room
 Attending
 Middle Grade
 Junior (<3 years in anaesthesia)
Most senior surgeon present in operating room
 Attending
 Middle Grade
 Junior (<3 years in surgery)
Intra-abdominal surgery
 Y
 N
Intra-thoracic surgery
 Y
 N
Laparoscopic surgery
 Y
 N
Laparoscopic assisted surgery
 Y
 N
Central venous catheter inserted?
 Y
 N
Cardiac output monitoring during surgery?
 Doppler ultrasound
 Arterial wave form analysis
 Pulmonary artery catheter
 Other
 None
Urgency of surgery:
 Elective  Urgent
 Emergency
Severity of surgery:
 Minor
 Intermediate
 Major
Blood loss during surgery:
ml
End of surgery time (24 hr clock) & date:
h
h
:
m
m
d
d
0
4
2
0
1
1
Post-operative Follow Up
Duration of post-anaesthetic recovery stay
h
h
m
:
m
Invasive ventilation within 24 hrs of surgery
 Y
 N
Non-invasive ventilation within 24 hrs of surgery
 Y
 N
Inotrope / vasopressor infusion within 24 hrs of surgery
 Y
 N
Survival to hospital discharge?
 Y
 N
Date of hospital discharge (or death):
d
d
m
m
2
0
1
 Y
Critical care admission any time during hospital stay?
 N
EuSOS unique patient ID
EuSOS Operating Room case record form v1.4

Patient name: ___________________________________
Page 2 of 2
DOB
d
d
m
m
y
y
y
y