Part 3:
Discharge
Discharge
Surgeon sig. to approve doc:
_____________________________
Congenital STS Registry
* Discharge date: _____
_____
_____
Form completed by: ____________________
Use military time
Mortality Date:
____ ______ _____
Operative Mortality:
Yes
No
Mortality assigned to this
operation: Yes No
Operation a re operation during
this admission:
Yes Planned reoperation
No
Endotracheal Intubation Performed: yes
no
Intubation date/time:___________
___________
Extubation date/time: __________
___________
Extubated in OR : yes
no
Reintubated after initial postop Extubation: yes
no
Final Extubation date/time:___________ ___________
Yes Unplanned reoperation
 Reoperation after this Operation during this
Admission:
Alive
Dead
Discharge Status:
Complications:
Circle all that apply
Yes
No
Discharge
Location:
or
None
20 Reparation during this admission (unplanned reparation)
30 Postoperative cardiac arrest
40 Postoperative mechanical circulatory support (IABP, VAD, ECMO, or CPS)
50 Postoperative complete AV block requiring temporary pacemaker
60 Postoperative complete AV block requiring permanent pacemaker
70 Postoperative arrhythmia
80 Postoperative low cardiac output
90 Postoperative acidosis
Home
Acute Care Center
Chronic Care Center
30 day status:
Alive
Dead
Unknown
Readmit within 30 days:
Yes
No
if yes Readmission date:_ _/ _
_/ _ _
if yes Primary Readmission
Reason (circle one):
100 Sternum left open
26= Thrombotic Complication
27= Embolic Complication
28= Hemorrhagic Complication
Pulmonary vein obstruction
29= Stenoic Complication
Postoperative pulmonary hypertension crises (PA pressure > systemic pressure)
2=Arrhythmias/Heart Block
Postoperative respiratory insufficiency requiring mechanical ventilator support >7days
3=Congestive Heart Failure
Postoperative respiratory insufficiency requiring reiteration
30=Cardiac Transplant Rejection
Postoperative tracheotomy
31=Myocardial Iscemia
14=Renal Failure
Pneumonia
6=Pericardial effusion and/or
Pneumothorax
Tamponade
Pleural effusion requiring drainage
32=Pleural Effusion
Chylothorax
33=Neurologic Complication
Acute renal failure requiring temporary dialysis
7=Respiratory Complication/Airway
Acute renal failure requiring permanent dialysis
Complication
Bleeding requiring reparation
34=Septic/Infectious Complication
35=Cardiovascular Device
Wound dehiscence
Complications
Wound Infection
36=Residual/Recurrent
Mediastinitis
Cardiovascular Defects
Postop endocarditis
37=Failure to Thrive
Postop septicemia
25=VAD Complications
Phrenic nerve injury/paralyzed diaphragm
38=Other Cardiovascular
Complication
Recurrent laryngeal nerve injury/paralyzed Vocal cord
998=Other-Readmission related to
Postoperative neurological deficit persisting at discharge
surgical procedure for this admission
Postoperative new onset seizures
999=Other-Readmission NOT related
Other postoperative complication
to surgical procedure for this
admission
110 Pericardial effusion requiring drainage
120 Systemic vein obstruction
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
310
320
330
777
Satou revised 10.30.07