1
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Contents
* Indicates significant edits/additions with the current version of the dictionary
B1) Initials .......................................................................................................................... 6
B2) Hospital Identification Code ........................................................................................ 7
B3) Date of birth ................................................................................................................. 8
B4) Medical/Hospital record number (optional) ................................................................ 9
*B5) Admit date & time ................................................................................................... 10
*B6) Discharge date & time ............................................................................................. 11
B7) Gender ........................................................................................................................ 12
*B9) Race.......................................................................................................................... 13
*B10) Ethnicity ................................................................................................................. 15
B8) Age at admit ............................................................................................................... 16
Units of Measure for Height & Weight ............................................................................ 17
B11) Height ....................................................................................................................... 18
B12) Weight ...................................................................................................................... 19
*B13) Insurance ................................................................................................................ 20
B14) Transfer from another hospital................................................................................. 22
B15) Residence zip code ................................................................................................... 23
C1) Current cigarette smoker ............................................................................................ 24
C2) Recent laboratory values ............................................................................................ 25
C3) Current/recent medications ........................................................................................ 26
C4) Home oxygen use ....................................................................................................... 27
C5) Home mobility device use ......................................................................................... 28
D1) Hypertension ............................................................................................................. 29
D2) Diabetes ..................................................................................................................... 30
D3) Asthma ....................................................................................................................... 31
D4) History of Sleep Apnea .............................................................................................. 32
D5) Coronary Artery Disease ........................................................................................... 33
D6) History of Venous Thrombolembolism ..................................................................... 34
D7) History of HIV or AIDS ............................................................................................ 35
E1) Primary Surgeon......................................................................................................... 36
E1a) Surgeon Specialty ..................................................................................................... 37
*E2) Other Physician Identification.................................................................................. 38
*E3) Anesthesia provider .................................................................................................. 39
E4) Appendectomy ........................................................................................................... 40
E4.1) Indication: Appendicitis .......................................................................................... 41
E4.2) Indication: Appendeceal mass / cancer ................................................................... 42
E4.3) Indication: Appendectomy - Other.......................................................................... 43
E5) Bariatric ...................................................................................................................... 44
E5.1) Indication: Morbid Obesity ..................................................................................... 45
E5.2) Indication: Bariatric Surgery – Other ...................................................................... 46
E6) Colon .......................................................................................................................... 47
Version 3.1
2
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.1) Indication: Cancer of the Colon .............................................................................. 48
*E6.2) Indication: Diverticular disease............................................................................. 49
E6.3) Indication: Trauma .................................................................................................. 51
E6.4) Indication: Radiation Colitis ................................................................................... 52
E6.5) Indication: Volvulus ................................................................................................ 53
E6.6) Indication: Arteriovenous Malformation ................................................................ 54
E6.7) Indication: Ischemic Colon ..................................................................................... 55
E6.8) Indication: Polyps.................................................................................................... 56
E6.9) Indication: Rectal Prolapse ..................................................................................... 57
E6.10) Indication: Gastrointestinal (GI) Bleeding ............................................................ 58
E6.11) Indication: Perforation .......................................................................................... 59
E6.12) Indication: Cancer of the Rectum ......................................................................... 60
E6.13) Indication: Bowel Obstruction .............................................................................. 61
E6.14) Indication: Colostomy ........................................................................................... 62
E6.15) Indication: Ulcerative Colitis ................................................................................ 63
E6.16) Indication: Crohn’s Disease .................................................................................. 64
E6.17) Indication: Stricture ............................................................................................... 65
*E6.18) Indication: Gynecological Malignancy ............................................................... 66
*E6.19) Indication: Iatrogenic Colectomy ........................................................................ 67
E6.20) Indication: Colon Surgery – Other ........................................................................ 68
F1) Time of First Incision ................................................................................................. 69
F2) In-room Close Time ................................................................................................... 70
F3) Date of Surgery .......................................................................................................... 71
F4) In-room Close Date .................................................................................................... 72
F5) Surgical Approach ...................................................................................................... 73
F6) ASA Class .................................................................................................................. 74
*F7) Highest Perioperative Blood Glucose ...................................................................... 75
F8) Insulin Used Perioperatively ...................................................................................... 76
*F9) Highest blood glucose on post op day 1 ................................................................... 77
*F10) Highest blood glucose on post op day 2 ................................................................. 78
F11) Lowest post-op blood glucose .................................................................................. 79
F12) Lowest Intra-operative Temperature ........................................................................ 80
F13) Death in the Operating Room ................................................................................... 81
F14) First Temperature on Arrival to Recovery Room .................................................... 82
*G1) DVT Prophylaxis- Within 24 hour of incision ........................................................ 83
*G2) DVT Prophylaxis – Ordered Post - op ..................................................................... 85
*G3) DVT Prophylaxis – Order on Discharge ................................................................. 87
G4) Intermittent pneumatic compression in the OR ......................................................... 89
G5) Beta Blocker administered within 24 hours pre-op ................................................... 90
*G6) Beta Blocker administered intraoperatively ............................................................ 91
G7) Beta Blocker ordered within 24 hrs post-op .............................................................. 92
G8) Antibiotics: On antibiotics for the treatment of infection .......................................... 93
G9) Antibiotics: Were prophylactic antibiotics indicated ................................................ 94
G9a) Antibiotics: Administered within 60 minutes .......................................................... 95
G9b) Antibiotics: Discontinued within 24 hours .............................................................. 96
G10) Pain management: Epidural ..................................................................................... 97
Version 3.1
3
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G10a) Pain management: PCEA ....................................................................................... 98
G11) Pain management: PCA ........................................................................................... 99
G12) Pain management: NSAID .................................................................................... 100
G13) Pain management: Narcotic drip ........................................................................... 101
G14) Pain management: Other........................................................................................ 102
G14a) Pain management: Other, specify modality ......................................................... 103
G15) Entereg administered ............................................................................................. 104
*G16) Aloxi administered............................................................................................... 105
*G17) Statin post-op ....................................................................................................... 106
G18) Nasogastric tube..................................................................................................... 107
G19) Gastrostomy tube drainage .................................................................................... 108
*G20) Estimated Blood Loss .......................................................................................... 109
G21) Red blood cell transfusion ..................................................................................... 110
G21a) Red blood cell transfusion units........................................................................... 111
*G21b) Lowest hemoglobin ........................................................................................... 112
*G22) Red blood cell transfusion after 24 hrs post-op ................................................... 113
*G22a) Red blood cell transfusion units ......................................................................... 114
*G22b) Lowest hemoglobin ........................................................................................... 115
*G23) Last hemoglobin prior to discharge ..................................................................... 116
G24) Mechanical ventilation........................................................................................... 117
G24a) Mechanical ventilation hours ............................................................................... 118
*G25) Highest Creatinine ............................................................................................... 119
*G26) Postoperative events ............................................................................................ 120
*G27) Discharge Disposition.......................................................................................... 121
G27a) Discharge: Death Specification............................................................................ 122
H1) Reintervention: Any................................................................................................. 123
H2) Reintervention: Abdominal re-operation ................................................................. 125
H2.1) Reintervention: Colostomy or ileostomy .............................................................. 126
H2.2) Reintervention: Abscess drainage......................................................................... 127
H2.3) Reintervention: Operative Drain Placement ......................................................... 128
H2.4) Reintervention: Gastrostomy ................................................................................ 129
H2.5) Reintervention: Gastrostomy revision .................................................................. 130
H2.6) Reintervention: Anastomotic revision .................................................................. 131
H2.7) Reintervention: Band Replacement ...................................................................... 132
H2.8) Reintervention: Band/port revision....................................................................... 133
H2.9) Reintervention: Wound revision or evisceration .................................................. 134
H2.10) Reintervention: Negative re-exploration ............................................................ 135
*H2.11) Reintervention: Reoperation for bleeding ........................................................ 136
H2.12) Reintervention: Other Reoperation ..................................................................... 137
H3) Reintervention: Tracheal reintubation ..................................................................... 138
H4) Reintervention: NG tube replacement ..................................................................... 139
H5) Reintervention: Tracheostomy................................................................................. 140
H6) Reintervention: Percutaneous drain ......................................................................... 141
H7) Reintervention: Anticoagulation therapy for DVT .................................................. 142
H8) Reintervention: Anticoagulation therapy for PE ..................................................... 143
*H9) Reintervention: Antibiotic for infection ................................................................ 144
Version 3.1
4
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H10) Reintervention: Wound reopened .......................................................................... 145
H11) Reintervention: Radiologically demonstrated leak ................................................ 146
H12) Reintervention: Radiologically demonstrated fistula ............................................ 147
H13) Reintervention: Other ............................................................................................ 148
I1) Bariatric: Prior foregut surgery ................................................................................. 149
*I2) Bariatric: Procedure of record ................................................................................. 150
I3) Bariatric: Stomach divided ........................................................................................ 152
*I4) Post-op urinary catheter .......................................................................................... 153
*I5) Bariatric: Distal anastomosis technique .................................................................. 154
*I6) Bariatric: Proximal anastomosis technique ............................................................. 155
I7) Bariatric: Anastomosis tested .................................................................................... 156
I7.x) Bariatric: Anastomosis test type ............................................................................. 157
*J1) Appendectomy: Pregnant ........................................................................................ 158
*J2) Appendectomy: ER/Urgent Visit ............................................................................ 159
*J3) Appendectomy: Admit through ER ........................................................................ 160
J4) Appendectomy: Concurrent procedure performed ................................................... 161
*J5) Appendectomy: Preoperative imaging .................................................................... 162
J6) Appendectomy: Appendeceal pathology .................................................................. 163
J7) Appendectomy: Perforated appendix ........................................................................ 164
K1) Colon/rectal: Prior surgery ...................................................................................... 165
K2) Colon/rectal: Procedure order/importance ............................................................... 166
K3) Colon/rectal: Resection within 30 days ................................................................... 167
*K4) Colon/rectal: Procedure priority & procedure staging........................................... 168
*K5) Colon/rectal: Operation type.................................................................................. 169
K6) Colon/rectal: Ostomy type ....................................................................................... 171
*K7) Colon/rectal: Anastomosis ..................................................................................... 172
*K8) Colon/rectal: Anastomosis technique .................................................................... 174
K9) Colon/rectal: Anastomosis tested ............................................................................ 175
*K10) Colon/rectal: Post-op urinary catheter ................................................................. 176
*K11) Colon/rectal: Bowel Prep ..................................................................................... 177
*K12) Colon/rectal: Diet advanced ................................................................................ 178
*K13) Colon/rectal: Post-op cancer diagnosis ................................................................ 179
K14) Colon/rectal: Lymph nodes removed..................................................................... 180
K15) Colon/rectal: Lymph nodes positive for cancer. .................................................... 181
K16) Colon/rectal: Metastatic disease ............................................................................ 182
K17) Colon/rectal: Cancer Margins ................................................................................ 183
*K18) Colon/rectal: T Stage ........................................................................................... 184
*K19) Colon/rectal: Procedure done for palliation ......................................................... 185
*K20) Colon/rectal: Preoperative neoadjuvant treatment.............................................. 186
*K21) Colon/rectal: Distance of the tumor from the anal verge .................................... 187
*K22) Colon/rectal: Tumor fixed to underlying structures ........................................... 188
*K23) Colon/rectal:Total mesorectal excision (TME) ................................................... 189
*K24) Colon/rectal: Stage determination methodology ................................................. 191
*K25) Colon/rectal: Diverticular disease........................................................................ 192
*K26) Colon/rectal: Prior episodes of diverticular disease ............................................ 193
*L) Post-discharge: 30-day follow up............................................................................ 194
Version 3.1
5
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L1) Post-discharge: Wound occurrences ..................................................................... 195
*L2) Post-discharge: Respiratory occurrences .............................................................. 197
*L3) Post-discharge: Urinary tract occurrences ............................................................. 199
*L4) Post-discharge: CNS occurences............................................................................ 201
*L5) Post-discharge: Cardiac occurrences...................................................................... 202
*L6) Post-discharge: Other occurences ......................................................................... 204
*L7.x) Post-discharge: Readmitted to acute care ........................................................... 206
*L8) Post-discharge: Death............................................................................................. 207
Appendix A: Medications ............................................................................................... 208
Appendix B: Colon/rectal procedure diagram ................................................................ 213
* Indicates significant edits/additions with the current version of the dictionary
Version 3.1
6
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B1) Initials
Location: Adult Form, B. Demographics
Definition: First 2 initials of last name/ First 2 initials of first name.
Example: John Smith: Last Name: SM First Name: JO
(Historic information: Was only first initial of both names)
SORCE alias:
xxx
xxx
ARMUS Variable Name(s):
Field Format: Text
Value Codes:
Allowable Values: two characters: A thru Z for each name; 4 characters total
Data Storage Type: Character
Suggested Data Source: Admission/demographic sheet
Abstraction Notes: This is a required field; unable to analyze the data without this
information.
Exclusions: None
Version 3.1
7
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B2) Hospital Identification Code
Location: Adult Form, B. Demographics
Definition: Numer code assigned to each hospital by SCOAP
SORCE alias:
siteid
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: New site id numbers are assigned by FHCQ when a hospital
begins participation in SCOAP
Abstraction Notes: This is a required field; unable to retrieve or analyze the data by
hospital without this information. This field should be populated automatically online.
Verify that it is correct at the time of data entry.
Exclusions: None
Version 3.1
8
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B3) Date of birth
Location: Adult Form, B. Demographics
Definition: Date patient was born
SORCE alias:
dobdt
ARMUS Variable Name(s):
Field Format: Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet
Abstraction Notes: This is a required field; must know the date of birth in order to
verify that this is an adult and for potential risk adjustment.
Exclusions: None
Version 3.1
9
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B4) Medical/Hospital record number (optional)
Location: Adult Form, B. Demographics
Definition: The specific hospital record number
SORCE alias:
hosprec
ARMUS Variable Name(s):
Field Format: Text
Value Codes:
Allowable Values: Characters & Numbers: Dependent on hospital
Data Storage Type: Character
Suggested Data Source: Admission/demographic sheet
Abstraction Notes: This is an optional field; is for hospital’s internal use only. You will
want to know your hospital’s decision regarding whether or not to include this
information as generation of surgeon specific reports is dependent on entering this
information.
Exclusions: As this is totally an optional field, no entries for this data element are
required.
Version 3.1
10
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*B5) Admit date & time
Location: Adult Form, B. Demographics
Definition: Date & time patient was admitted to the hospital
SORCE alias:
admitdt
admittm
ARMUS Variable Name(s):
Field Format: Date, Time
Value Codes:
Allowable Values: mm/dd/yyyy, 00:00 – 23:59
Data Storage Type: Date/time
Suggested Data Source: Admission/demographic sheet
Abstraction Notes: This is a required field; must know the admit date in order to
calculate LOS. If the patient was admitted as an observation patient vs as in inpatient but
then went on to have surgery as an inpatient, use the date that the patient was admitted as
an observation patient.
Exclusions: None
Version 3.1
11
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*B6) Discharge date & time
Location: Adult Form, B. Demographics
Definition: Date & time patient was discharged
SORCE alias:
dischdt
dischtm
ARMUS Variable Name(s):
Field Format: Date, time
Value Codes:
Allowable Values: mm/dd/yyyy, 00:00 – 23:59
Data Storage Type: Date/Time
Suggested Data Source: Admission/demographic sheet or discharge summary
Abstraction Notes: This is a required field; must know the discharge date in order to
calculate LOS.
Exclusions: None
Version 3.1
12
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B7) Gender
Location: Adult Form, B. Demographics
Definition: Gender of the patient; male or female
SORCE alias:
sex
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1 = male
2 = female
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or discharge summary
Abstraction Notes: In case of question about gender where there has been a gender
change (either via surgery and/or other treatments), answer with what the chart says the
gender is with the following exception: If the gender change has been from female to
male, but the ovaries remain, this patient should be coded as female.
Exclusions: None. This is a required field as data analysis sometimes differentiates
males from females.
Version 3.1
13
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*B9) Race
Location: Adult Form, B. Demographics
Definition: Race: Select from the following choices of race. If documentation indicates
the patient has more than one race (e.g. Black-White or Indian-White), select the first
listed race.
Hispanic/Latino Ethnicity is a separate variable (listed below) where you can report the
patient’s ethnicity.
• American Indian or Alaska Native: A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.
• Asian: A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
• Black or African American: A person having origins in any of the black racial groups
of Africa. Terms such as "Haitian" can be used in addition to "Black or African
American.
• Native Hawaiian or Other Pacific Islander: A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
• White: A person having origins in any of the original peoples of Europe, the
MiddleEast, or North Africa.
• Unknown: if documentation does not state patient’s race, report as Unknown.
Note: Hispanic Ethnicity is required in addition to this data element.
Revision: April 1, 2009 4-2 ACS NSQIP
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1 = American Indian/ Alaskan Native
2 = Asian
3 = Black/ African American
4 = Native Hawaiian/ Other Pacific Islander
5 = White
6 = NA/Unknown
Version 3.1
14
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or discharge summary; H&P or
Nursing History/ Admission note.
Abstraction Notes: Although the terms Hispanic and Latino are actually descriptions of
the patient’s ethnicity, it is not uncommon to find them referenced as race. If the patient’s
race is documented only as Hispanic/Latino, select ‘White’. If the patient’s race is
documented as mixed Hispanic/Latino with another race, use whatever race is listed (e.g.
Black-Hispanic – select Black).
Exclusions: None.
Version 3.1
15
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*B10) Ethnicity
Location: Adult Form, B. Demographics,
Definition: Hispanic Ethnicity: Document if the patient is of Hispanic ethnicity or
Latino. Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or origin, regardless of race. The term,
"Spanish origin," can be used in addition to "Hispanic or Latino."
Although the terms Hispanic and Latino are actually descriptions of the patient’s
ethnicity, it is not uncommon to find them referenced as race. If the patient’s race is
documented only as
Hispanic/Latino, select ‘White’ for race & indicate Hispanic or Latino for ethnicity. If the
patient’s race is documented as mixed Hispanic/Latino with another race, be sure to
indicate whatever race is listed (e.g. Black-Hispanic – selectBlack) as well as Hispanic or
Latino for ethnicity.
Indicate NA if unable to determine etnicity from medical record documentation.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes:
1 = Hispanic or Latino
2 = Not Hispanic nor Latino
3 = Not Available/Unknown
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or discharge summary; H&P or
Nursing History/ Admission note.
Abstraction Notes: If the patient’s race is documented only as Hispanic/Latino, select
“White” race & “Hispanic/Latino” ethnicity. If the patient’s race is documented as mixed
Hispanic/Latino with another race, indicate “Hispanic/Latino” ethnicity and record race
as whatever race is listed (e.g. Black-Hispanic - select Black).
Exclusions: None.
Version 3.1
16
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B8) Age at admit
Location: Adult Form, B. Demographics
Definition: Age of patient on admit date in years
SORCE alias: computedage;
Historic variables: age, ageunit
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: numbers (18 – 100)
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or discharge summary
Abstraction Notes: The age will be automatically calculated when you have entered the
birth date of the patient as well as the admit date. This data element is listed, not because
you have to calculate the age, but because you will see this on the hard copy of the tool.
If the calculated age does not appear correct there maybe a problem with either the
admission date or birth date, as entered in the database.
Exclusions: None. This is a required field as data analysis sometimes differentiates
depending on the age of the patient and to be sure that the patient is an adult for data
analysis.
Version 3.1
17
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Units of Measure for Height & Weight
Location: Adult Form, B. Demographics
Definition: Indicate English if height and weight will be recorded as inches and pounds,
respectively. Indicate Metric if height and weight will be recorded as cm and kilograms,
respectively. The units for height and weight must be consistent; both must be English or
both must be Metric.
SORCE alias:
measunit
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=English
2=Metric
3=Na
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Abstraction Notes: This field is required in order to enter the values for height and
weight in the subsequent fields.
Exclusions: None
Version 3.1
18
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B11) Height
Location: Adult Form, B. Demographics
Definition: Height of patient in inches or cm
SORCE alias:
inch
cm
Historic variables: ft heightn
ARMUS Variable Name(s):
Field Format: Numbers
Value Codes:
Allowable Values: (inch) 40 - 90 or (cm) 100 - 210
Data Storage Type: Numeric
Suggested Data Source: Nursing assessment; H&P
Abstraction Notes: Round rather than including a decimal. This information is
especially important for the surgeries for which it is important to know the BMI, as the
BMI is calculated from the height and weight.
Exclusions: None
Version 3.1
19
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B12) Weight
Location: Adult Form, B. Demographics
Definition: Weight of patient in pounds or kilograms
SORCE alias:
lbs
kgs
Historic variable: weightn
(weight NA)
ARMUS Variable Name(s):
Field Format: Numbers
Value Codes:
Allowable Values: (lbs) 0 – 600 or (kgs) 0 – 232.00
Data Storage Type: Numeric
Suggested Data Source: Nursing assessment; H&P
Abstraction Notes: Round rather than including a decimal. This is especially important
for the surgeries for which it is important to know the BMI, as the BMI is calculated from
the height and weight.
Exclusions: None
Version 3.1
20
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*B13) Insurance
Location: Adult Form, B. Demographics
Definition: What type of insurance does the patient have, if any
SORCE alias:
Insurance Variables (check all that apply)
ins_priv
ins_mcare
ins_mcaid
ins_tri
ins_ihs
ins_va
ins_self
ins_unins
ins_landi
privatetype
(private insurance specification)
Historic variable: insurnce
ARMUS Variable Name(s):
Field Format: Yes/No
Multiple choice
Value Codes:
type of private insurance:
1=Regence
2=Premera
3=First Choice
4=Group Health
5=Aetna
6=Cigna
7=Uniform Medical
8=United Healthcare
9=Kaiser
10=Other Private
Allowable Values: Any option that is listed; may check both private and uninsured
and/or self pay if the patient has private insurance but that policy does not cover this
procedure.
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic/face sheet
Version 3.1
21
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Abstraction Notes: Check all that appy, regardless of whether or not the procedure in
the record is covered or paid for by that insurance or health plan. If have private
insurance, check “private” and then indicate which private company the patient has. If
have private insurance, but the specific insurance company isn’t identified, check “other”.
If the patient is uninsured and/or are self pay, check these appropriately. This information
is important so that data analysis by health plan can be done.
Exclusions: This section is optional if the hospital objects to providing this data.
Version 3.1
22
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B14) Transfer from another hospital
Location: Adult Form, B. Demographics
Definition: Was this admission a transfer from another hospital
SORCE alias:
transfer
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or H&P
Abstraction Notes: The intent of this data element is assist in data analysis as when the
patient has been transferred from another hospital, this often means that the patient is
more complex and/or has already had complications from a procedure.
Exclusions: None.
Version 3.1
23
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
B15) Residence zip code
Location: Adult Form, B. Demographics
Definition: Zip code of patient’s primary residence
SORCE alias:
zipcode
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes:
Allowable Values: US or Canadian zip codes; either 5 digit or 9 digit
Data Storage Type: Numeric
Suggested Data Source: Admission/demographic sheet or discharge summary
Abstraction Notes: US or Canadian zip codes may be entered. This information is
potentially important for data analysis by zip code.
Exclusions: None
Version 3.1
24
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
C1) Current cigarette smoker
Location: Adult Form, C. Risk Factors
Definition: Any use of tobacco or marijuana cigarettes within one year of this
admission.
SORCE alias:
cursmkr
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Nursing admission record or H&P
Abstraction Notes: If smoking history is not mentioned anywhere, check “no”.
The intent of this question is to have information for risk adjustment.
Exclusions: None
Version 3.1
25
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
C2) Recent laboratory values
Location: Adult Form, C. Risk Factors
Definition: Most recent labs within 30 days prior to the surgery; creatinine, hemoglobin,
WBCs; may be up to 6weeks prior to the surgery for albumin and pre-albumin. If
collected, report lab value. In the event there is more than one value for any of these, e.g.
a WBC was done both 25 days prior and upon admission, record the most recent.
SORCE alias:
Lab Value
albumin
creat
hgb
wbc
prealbum
Value NA
albna
creatna
hgbna
wbcna
prealbna
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes:
Allowable Values:
Albumin: 1- 6 g/dl;
Creatinine: 0.1 – 15.0 mg/dl;
Hgb: 10 - 20 g/dl;
WBC: 0.5 – 30.0 10(3).
Pre-albumin: mg/dL;
Data Storage Type: Numeric
Suggested Data Source: Nursing admission record, laboratory reports or H&P. If the
H&P differs from the nursing admission record or the laboratory reports, take the nursing
admission record or laboratory reports.
Abstraction Notes: The intent of this question is to have information for risk
adjustment. Pre-albumin can be used rather than albumin
Exclusions: None
Version 3.1
26
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
C3) Current/recent medications
Location: Adult Form, C. Risk Factors
Definition: Current/recent medications use: immunosuppressants, statins, beta blockers,
ACEI or ARB, therapeutic anticoagulation within 1 week of surgery.
SORCE alias:
immuno
statin
betablkr
aceiarb
anticoag
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Nursing admission record, medication record, or H&P. If the
nursing admission record/medication record differs with the H&P, take the information in
the nursing admission record/medication record.
Abstraction Notes: The intent of this question is to have information for risk
adjustment. Anticogulants: documentation of use within 1 week of admission; all othersdocumentation or report of patient of use upon admission, either at home or ordered upon
admit. Chemotherapy for cancer treatment is not considered to be an immunosuppressant
medication.
Exclusions: None
Version 3.1
27
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
C4) Home oxygen use
Location: Adult Form, C. Risk Factors
Definition: Any use of oxygen use at home
SORCE alias:
oxygenuse
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Nursing admission record, medication record, or H&P
Abstraction Notes: The intent of this question is to have information for risk
adjustment. The emphasis is on current use; not just that they have it available or have
used it in the past. Use of CPAP or BiPap does not count as using oxygen at home.
Exclusions: None
Version 3.1
28
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
C5) Home mobility device use
Location: Adult Form, C. Risk Factors
Definition: Use of any mobility device: includes walker, wheelchair, scooter, cane.
SORCE alias:
mobility
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Nursing assessment, medication record, or H&P
Abstraction Notes: The intent of this question is to have information for risk
adjustment. The emphasis is on use; check “no” if it is mentioned that the device is at
home but not used currently.
Exclusions: None
Version 3.1
29
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D1) Hypertension
Location: Adult Form, D. Comorbidities
Definition: Any mention of hypertension in the medical record on admit, if yes, select
the best response to the number of individual medications used to treat the hypertension:
no meds; single med; multiple meds. Please see Appendix A for a list of medications
commonly used to treat hypertension.
SORCE alias:
hyprtnsn
hyprmeds
ARMUS Variable Name(s):
Field Format: Yes/No
Multiple Choice
Value Codes: 1=Yes;2=No
1=No meds
2=Single med
3=Multiple meds
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes: The question applies to all cases.
Exclusions: Do not assume that a patient is hypertensive if the only indication of such is
that the patient is on one of the drugs that is commonly used to treat hypertension as these
medications are also used for other conditions.
Pulmonary hypertension is excluded; is not hypertension.
Version 3.1
30
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D2) Diabetes
Location: Adult Form, D. Comorbidities
Definition: Any mention of diabetes in the medical record on admit, if yes, select the
best response to the individual medications used in treatment: no meds; single noninsulin, multiple non-insulin; insulin; insulin plus other meds.. Please see Appendix A for
a list of commonly used medications.
SORCE alias:
diabetes
diameds
ARMUS Variable Name(s):
Field Format: Yes/No
Multiple Choice
Value Codes: 1=Yes;2=No
1=No meds
2=Single non-insulin
3=Multiple non-insulin
4=Insulin
5=Insulin plus other meds
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes:
If the record indicate “borderline diabetic” select yes.
Include the new injectable hypoglycemic agent Byetta in the category of single or
multiple, non-insulin meds.
Do not mark the patient as being diabetic unless this is clearly a diagnosis. Patients may
be on metformin for a metabolic syndrome, but this does not mean they are diabetic.
Exclusions: None
Version 3.1
31
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D3) Asthma
Location: Adult Form, D. Comorbidities
Definition: Any mention of asthma in the medical record on admit, if yes, select the best
response to the individual medications used in treatment: steroid use; inhalant; none. This
element is designed so abstractors may select both steroid and inhalant or none. Please
see Appendix A for a list of suggested medications.
SORCE alias:
asthma
steroid
inhalant
no_asthmed
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1= Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes: Route of steroid may be IV, PO, or inhaled.
Exclusions: None
Version 3.1
32
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D4) History of Sleep Apnea
Location: Adult Form, D. Comorbidities
Definition: Any mention of sleep apnea in the medical record on admit.Iif yes, does the
patient use a CPAP (continuous positive airway pressure), BiPAP (bi-level positive
airway pressure), APAP (auto-titrating CPAP) machine, or any other assisted breathing
apparatus for the treatment of sleep apnea.
SORCE alias:
slpapnea
cpap_adult1
Historic variable: cpap_adult0
ARMUS Variable Name(s):
Field Format: Yes/No
Multiple Choice
Value Codes: 1=Yes;2=No
1=CPAP
2=None
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes:
Exclusions: None
Version 3.1
33
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D5) Coronary Artery Disease
Location: Adult Form, D. Comorbidities
Definition: Any diagnosis of coronary artery disease or angina. If yes, is there
documentation of Myocardial Infarction (MI), Percutaneous Coronary Intervention (PCI),
Coronary Artery Bypass Graft (CABG), or Automatic Implantable Cardioverter
Defibrillators (AICD).
SORCE alias
cad
hxmi
cadsurg
cad_none
Historical variable: cadtype
ARMUS Variable Name(s):
Field Format:
Yes/No
Multiple Choice
Value Codes: 1=Yes;2=No
1=History of MI
2=PCI, CABG, AICD
3=Both
4=None
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes: Check all that apply.
Exclusions: None
Version 3.1
34
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D6) History of Venous Thrombolembolism
Location: Adult Form, D. Comorbidities
Definition:
Any documentation that the patient has a history of venous
thrombolembolism including pulmonary embolus or deep vein thrombosis.
SORCE alias:
vtehx
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes
Abstraction Notes:.
Exclusions: None
Version 3.1
35
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
D7) History of HIV or AIDS
Location: Adult Form, D. Comorbidities
Definition:
Any documentation in the medical record that the patient is HIV
positive or has AIDS.
SORCE alias:
hivaids
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia
record
Abstraction Notes:
Exclusions: None
Version 3.1
36
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E1) Primary Surgeon
Location: Adult Form, E. Operative
Definition: This is an optional field that individual hospitals may use, if they choose, to
identify the primary surgeon for each case. Do not submit names; only ID numbers as
this information is to be used for specific surgeon data reports with the name of the
surgeon known only to the hospital
SORCE alias:
surgeon
ARMUS Variable Name(s):
Field Format: Text
Value Codes: Determined by individual hospitals
Allowable Values: Codes only; no names
Data Storage Type: Character
Suggested Data Source: Internal physician ID#
Abstraction Notes: Consistency within site is essential for proper use of this field: If
letters are used in the code be sure that there is no distinction between upper and lower
case. For example, M1234 and m1234 will be interpreted as the same id number.
Exclusions: This is an optional field, but if your hospital wants this information, there are
no exclusions.
Version 3.1
37
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E1a) Surgeon Specialty
Location: Adult Form, E. Operative
Definition: Indicate the primary surgeon’s specialty; General/colorectal or OB/GYN
surgeon
SORCE alias:
surgeontype
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes:
1=General/colorectal surgeon
2=OB/GYN surgeon
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Internal hospital information; Medical Records
Abstraction Notes: If the surgeon specialty is not known, check with your QI Dept or
with Medical Records. This field is required whether or not the individual surgeon is
identified.
Exclusions: None
Version 3.1
38
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*E2) Other Physician Identification
Location: Adult Form, E. Operative
Definition: This is an optional field that individual hospitals may use, if they choose, to
identify an additional physician for each case. Do not submit names; only ID.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Text
Value Codes: Determined by individual hospitals
Allowable Values: Codes only; no names. Letters and numbers allowed
Data Storage Type: Character
Suggested Data Source: Internal physician ID#
Abstraction Notes: Consistency within site is essential for proper use of this field: If
letters are used in the code be sure that there is no distinction between upper and lower
case. For example, M1234 and m1234 will be interpreted as the same id number. Some
sites may want to use this field to identify additional physicians.
Exclusions: This is an optional field, but if your hospital wants this information, there are
no exclusions.
Version 3.1
39
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*E3) Anesthesia provider
Location: Adult Form, E. Operative
Definition: This is an optional field that individual hospitals may use, if they choose, to
identify an anesthesia provider for each case. Do not submit names; only ID.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Text
Value Codes: Determined by individual hospitals
Allowable Values: Codes only; no names
Data Storage Type: Character
Suggested Data Source: Internal physician/anesthesia provider ID#
Abstraction Notes: Consistency within site is essential for proper use of this field: If
letters are used in the code be sure that there is no distinction between upper and lower
case. For example, M1234 and m1234 will be interpreted as the same id number.
Exclusions: This is an optional field, but if your hospital wants this information, there are
no exclusions.
Version 3.1
40
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E4) Appendectomy
Location: Adult Form, E. Operative
Definition: Indicate that the SCOAP eligible procedure is a non-elective appendectomy.
A non-elective appendectomy is one done in the context of an acute condition; not done
as an elective procedure along with another operation.
Note Enter information for only one procedure type: Appendectomy, Bariatric or Colon.
An affirmative response (Yes) to either question 27, 28, or 29 will insure the appropriate
questions are available for data entry. The other two procedure questions should be
given a negative response (No).
SORCE alias:
appendectomy
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that procedure is checked. Other data collected,
recorded and reported is dependant on the procedure group reported.
Exclusions
Version 3.1
41
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E4.1) Indication: Appendicitis
Location: Adult Form, E. Operative
Definition: Non-elective procedure only done in the context of an acute condition;
procedure is not described as an elective, planned, interval, or incidental case.
SORCE alias:
ind_appy
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: Appendectomies that are not the primary procedure (often referred to as
incidental), or are categorized as planned, interval, or are done on an elective basis. For
example, a patient who was taken to the OR for a total abdominal hysterectomy and
during the procedure also had her appendix removed is considered to have had an
incidental appendectomy and is therefore NOT considered to be a SCOAP case.
Please note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or
CPT codes, all appendectomies performed at your hospital will likely appear on the list.
Each abstractor is to use their judgment as to whether the case is appropriate to submit to
SCOAP based on the guidance in this definition.
Version 3.1
42
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E4.2) Indication: Appendeceal mass / cancer
Location: Adult Form, E. Operative
Definition: Appendectomy done with the diagnosis of appendeceal mass or cancer; not
for acute appendicitis
SORCE alias:
ind_mass
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions:
Note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or CPT
codes, all appendectomies performed at your hospital will likely appear on the list. Each
abstractor is to use their judgment as to whether the case is appropriate to submit to
SCOAP based on the guidance in this definition.
Version 3.1
43
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E4.3) Indication: Appendectomy - Other
Location: Adult Form, E. Operative
Definition: Non-elective procedure only done in the context of an acute condition;
procedure was not described as an elective, planned, interval, or incidental case.
SORCE alias:
ind_appoth
ind_apptxt
(other specified)
ARMUS Variable Name(s):
Field Format: Yes/No
Text
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source: H&P, OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting. This option should be extremely rare.
Exclusions: Appendectomies that are not the primary procedure (often referred to as
incidental), or are categorized as planned, interval, or are done on an elective basis. For
example, a patient who was taken to the OR for a total abdominal hysterectomy and
during the procedure also had her appendix removed is considered to have had an
incidental appendectomy and is therefore NOT considered to be a SCOAP case.
Please note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or
CPT codes, all appendectomies performed at your hospital will likely appear on the list.
Each abstractor is to use their judgment as to whether the case is appropriate to submit to
SCOAP based on the guidance in this definition.
Version 3.1
44
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E5) Bariatric
Location: Adult Form, E. Operative
Definition: Indicate that the SCOAP eligible procedure is a bariatric procedure
Note Enter information for only one procedure type: Appendectomy, Bariatric or Colon.
An affirmative response (Yes) to either question 27, 28, or 29 will insure the appropriate
questions are available for data entry. The other two procedure questions should be
given a negative response (No).
SORCE alias:
bariatric
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that procedure is checked. Other data collected,
recorded and reported is dependant on the procedure group reported.
Exclusions
Version 3.1
45
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E5.1) Indication: Morbid Obesity
Location: Adult Form, E. Operative
Definition: Procedure done in the context of treatment for morbid obesity. Procedure of
record may be referred to as: gastric bypass, roux-en-y bypass, lap band, biliopancreatic
bypass, or duodenal switch bypass.
SORCE alias:
ind_obese
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
46
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E5.2) Indication: Bariatric Surgery – Other
Location: Adult Form, E. Operative
Definition: Bariatric procedures which are performed for reasons other than the
treatment of morbid obesity
SORCE alias:
ind_obesoth
ind_obestxt
(other specified)
ARMUS Variable Name(s):
Field Format: Yes/No
Text
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
47
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6) Colon
Location: Adult Form, E. Operative
Definition: Indicate that the SCOAP eligible procedure is a colon/rectal operation
Note Enter information for only one procedure type: Appendectomy, Bariatric or Colon.
An affirmative response (Yes) to either question 27, 28, or 29 will insure the appropriate
questions are available for data entry. The other two procedure questions should be
given a negative response (No).
SORCE alias:
colonrectal
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that procedure is checked. Other data collected,
recorded and reported is dependant on the procedure group reported.
Exclusions
Version 3.1
48
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.1) Indication: Cancer of the Colon
Location: Adult Form, E. Operative
Definition: Procedure done for treatment for cancers of the colon or large intestine,
which is the lower part of the digestive system. Most colon cancers begin as small,
benign clumps of cells called adenomatous polyps. Over time these polyps become colon
cancers.
SORCE alias:
ind_cancer
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
During colectomy surgery for colon cancer, the cancer and nearby
tissue is removed and the remaining sections of colon are rejoined
(anastomosis).
During a colostomy, the surgeon removes the cancer and
surrounding tissue then creates an opening (stoma) in the abdomen
through which waste can leave the body. Colostomy can be
permanent or temporary depending on the specific situation.
Version 3.1
49
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*E6.2) Indication: Diverticular disease
Location: Adult Form, E. Operative
Definition: Diverticula are small, bulging pouches in the digestive tract, most commonly
occurring in the large intestine but can also be found in the esophagus, stomach, and
small intestine. Diverticulitis occurs when one or more of these pouches become
inflamed or infected, causing severe abdominal pain, fever, nausea, and a marked change
in bowel habits. This occurs in 10-25% of persons with diverticulosis. Tears in the colon
leading to bleeding or perforations may occur; intestinal obstruction may occur
(constipation or diarrhea does not rule out this possibility); and peritonitis, abscess
formation, sepsis and fistula formation are also possible occurences. Serious cases of
diverticulitis require surgical removal of the diseased portion of the colon.
SORCE alias:
ind_div (historic variable: diverticulitis)
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
50
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Version 3.1
51
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.3) Indication: Trauma
Location: Adult Form, E. Operative
Definition: Procedures performed to correct trauma to the colon. Most commonly
caused by traffic accidents or sporting injuries. When trauma is the indication for
operation, determine whether the trauma was caused by blunt force or a penetrating
injury.
SORCE alias:
ind_trauma
ind_traumatype
(type specified)
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
52
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.4) Indication: Radiation Colitis
Location: Adult Form, E. Operative
Definition: Radiation colitis is a condition that occurs as a side effect of cancer radiation
therapy to the abdomen or pelvis and occurs when a large number of cells in the colon die
as a result of the radiation therapy. If radiation colitis is acute symptoms will most often
develop within 8 weeks of starting treatment; if the condition is chronic, symptoms may
not occur for months or years after beginning treatment. In very rare cases of severe
radiation colitis, surgery will be performed to bypass the large intestine (colon resection)
or remove it entirely (colectomy).
SORCE alias:
ind_rad
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
53
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.5) Indication: Volvulus
Location: Adult Form, E. Operative
Definition: Volvulus is a type of intestinal obstruction that involves twisting of the
colon. The condition is sometimes referred to as a mechanical obstruction meaning that
the intestine is physically either partial or completely blocked. Volvulus most commonly
occurs in the small intestine but does occur in the colon about 15% of the time.
SORCE alias:
ind_volv
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
54
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.6) Indication: Arteriovenous Malformation
Location: Adult Form, E. Operative
Definition: Arteriovenous malformations (AVM), are dilated blood vessels which are
usually located close to the inside surface of the bowel. AVMs have a tendency to bleed
small amounts of blood over time which often results in anemia or low red cell count.
Some AVMs can be cauterized but others are more extensive and require surgical
intervention.
SORCE alias:
ind_art
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OP record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
55
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.7) Indication: Ischemic Colon
Location: Adult Form, E. Operative
Definition: Ischemic colitis is when part of the colon becomes inflamed and injured
usually due to blood clots in the arteries leading to the colon. The cause is usually
impaired blood flow to the colon which can lead to permanent colon damage. Chronic
ischemic colitis is usually associated with the build-up of fatty deposits (atherosclerosis),
but it can also be related to diabetes, a hernia, colon cancer or radiation to the abdomen.
Less often, it can be caused by medications such as NSAIDs, hormone replacement
therapy, antipsychotic drugs, or blood pressure pills. The term necrotic colon may be
used instead of ischemic colon.
SORCE alias:
ind_isch
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
56
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.8) Indication: Polyps
Location: Adult Form, E. Operative
Definition: Polyps are small clumps of cells that form on the colon lining. The vast
majority ore harmless, but some may become cancerous over time. They can cause rectal
bleeding, a change in bowel habits and abdominal pain, but most do not cause symptoms
so regular screening is recommended for early detection and removal. Most can be
removed during a colonoscopy, but polyps that are too large or cannot be reached to be
removed during the colonoscopy must be removed surgically.
SORCE alias:
ind_polyp
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
57
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.9) Indication: Rectal Prolapse
Location: Adult Form, E. Operative
Definition: Rectal prolapse (rectum slips or falls out of place) occurs when the muscles
and ligaments that hold the rectum firmly in place weaken due to age, long-term
constipation and/or the stress of childbirth. Rarely, large hemorrhoids may cause rectal
prolapse. Rectal prolapse can be partial, meaning that only the inner lining of the rectum
protrudes from the anus. In the later stages, large portions of the rectum protrude from the
anus. Corrective surgery may be done through an abdominal or perineal approach.
SORCE alias:
ind_prolap
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
58
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.10) Indication: Gastrointestinal (GI) Bleeding
Location: Adult Form, E. Operative
Definition: GI bleeding comes from many causes and is broken into 2 classifications,
upper and lower. Upper GI bleeding originates from the first part of the GI tract: the
esophagus, stomach, or duodenum. Most common causes are peptic ulcers, gastritis, or
esophageal varicies.
Lower GI bleeding originates in the portions of the GI tract farther down the digestive
system: segment of the small intestine, large intestine, rectum, and anus. Diverticulitis,
polyps, hemorrhoids, anal fissures are most commonly the cause of the bleeding.
SORCE alias:
ind_gi
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
59
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.11) Indication: Perforation
Location: Adult Form, E. Operative,
Definition: Perforation of the GI tract is defined as the complete penetration of the wall
of the stomach, small intestine or large bowel which results in the leak of intestinal
contents into the abdominal cavity. Perforation is always treated as an emergent situation
and usually an exploratory laparotomy will be performed to close the defect and a
peritoneal wash will be performed. The patient will be treated aggressively with
antibiotics, IV fluids, and bowel rest.
SORCE alias:
ind_perf
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
60
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.12) Indication: Cancer of the Rectum
Location: Adult Form, E. Operative
Definition: Rectal cancer is cancer of the last 8 to 10 inches of the colon. Most rectal
cancers begin as small, non-cancerous clusters of cells called adenomatous polyps.
SORCE alias:
ind_canrec
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
61
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.13) Indication: Bowel Obstruction
Location: Adult Form, E. Operative
Definition: Intestinal obstruction is a blockage of the small intestine or colon. The most
common causes of obstruction are: adhesions, hernias or tumors. If left untreated,
intestinal obstruction can cause the blocked parts of the intestine to die which can lead to
perforation, severe infection, and shock. Obstructions are usually treated on an emergent
basis.
SORCE alias:
ind_bowel
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
62
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.14) Indication: Colostomy
Location: Adult Form, E. Operative,
Definition: A colostomy is a surgically created opening in the wall of the abdomen
created from a remaining portion of the bowel for the elimination of body waste into a
special bag. Sometimes a colostomy is temporary, allowing the colon or rectum time to
heal after an extensive surgery but in some cases the colostomy may be permanent.
SORCE alias:
ind_colostomy
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
63
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.15) Indication: Ulcerative Colitis
Location: Adult Form, E. Operative
Definition: Ulcerative colitis is an inflammatory bowel disease that causes chronic
inflammation of the digestive tract; the innermost lining of the colon and rectum are
usually the most effected. Surgery usually means removing the entire colon and rectum
which is called a proctocolectomy. Next the surgeon will create an ileoanal anastomosis
by constructing a pouch from the end of the small intestine attached directly to the
anus—which spares the patient from dealing with a colostomy bag.
SORCE alias:
ind_ulc
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
64
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.16) Indication: Crohn’s Disease
Location: Adult Form, E. Operative
Definition: Crohn’s disease is a type of inflammatory bowel disease in which the lining
of the digestive tract becomes inflamed. The inflammation often spreads deep into the
layers of affected tissue which is both painful and debilitating to the patient. Surgery is
only a temporary measure but can often provide the patient with years of remission. The
surgeon will remove the damaged portion of the colon and reconnect the healthy sections.
Sometimes the surgeon will also close fistulas or drain abscesses.
SORCE alias:
ind_crohns
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
65
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.17) Indication: Stricture
Location: Adult Form, E. Operative
Definition: Stricture is a form of bowel obstruction defined as a narrowing of the width
of the passageway of the involved segments of the bowel. This narrowing is often caused
by chronic inflammation which causes scarring of the tissue so strictures are commonly
found in patients with Crohn’s disease. An intestinal obstruction that is caused by
stricture can lead to perforation so surgery is often indicated. The surgeon will resect the
entire narrowed segment of the bowel.
SORCE alias:
ind_strict
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
66
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*E6.18) Indication: Gynecological Malignancy
Location: Adult Form, E. Operative
Definition:
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
67
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*E6.19) Indication: Iatrogenic Colectomy
Location: Adult Form, E. Operative
Definition: Colon surgery that was done secondary to trauma/perforation, bleeding or
ischemia secondary to a medical or surgical intervention
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
68
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
E6.20) Indication: Colon Surgery – Other
Location: Adult Form, E. Operative
Definition: Any colon surgery performed for a reason other than those listed. One
example would be a case that was primarily an ovarian cancer (TAH) and it was
discovered that the tumor invaded the colon.
SORCE alias:
ind_coloth
ind_coltxt
(other specified)
ARMUS Variable Name(s):
Field Format: Yes/No
Text
Value Codes: 1=Yes;2=No
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source: OR record, OR log, anesthesia record, discharge record
Abstraction Notes: Extremely important that an operative procedure is checked. Cases
are included or excluded from appropriate reports based on this element and this element
is also used in many calculations for reporting.
Exclusions: None
Version 3.1
69
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F1) Time of First Incision
Location: Adult Form, F. Intra Operative
Definition: Use 24-hour clock to indicate the time of the first incision.
SORCE alias: ):
incistime
incisna
(time not available)
ARMUS Variable Name(s):
Field Format: Yes/No
Time (14:00 equals 2:00 p.m.)
Value Codes:
Allowable Values: 00:00 – 23:59
Data Storage Type: Numeric; Date/Time
Suggested Data Source: Anesthesia record, OR log
Abstraction Notes: If both the anesthesia start time and the operation start time are
listed, use the operation start time. Select NA if this information is not available.
Exclusions: None
Version 3.1
70
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F2) In-room Close Time
Location: Adult Form, F. Intra Operative
Definition: Use 24-hour clock to indicate the time of incision closure in the OR.
SORCE alias:
closetime
closena
(time not available)
ARMUS Variable Name(s):
Field Format: Yes/No
Time (14:00 equals 2:00 p.m.)
Value Codes:
Allowable Values: 00:00 – 23:59
Data Storage Type: Numeric; Date/Time
Suggested Data Source: Anesthesia record, OR log
Abstraction Notes: If both the anesthesia end time and the operation end time are listed,
use the operation end time which is defined as the end of the closure time. Select NA if
this information is not available.
Exclusions: None
Version 3.1
71
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F3) Date of Surgery
Location: Adult Form, F. Intra Operative
Definition: Indicate the date on which the operation began
SORCE alias:
surgdt
ARMUS Variable Name(s):
Field Format: Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Date/Time
Suggested Data Source: Anesthesia record, OR log
Abstraction Notes: This information is important as is used in data analysis for several
metrics.
Exclusions: None
Version 3.1
72
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F4) In-room Close Date
Location: Adult Form, F. Intra Operative
Definition: Indicate the date on which the operation ended
SORCE alias:
closdt
ARMUS Variable Name(s):
Field Format: Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Date/Time
Suggested Data Source: Anesthesia record, OR log
Abstraction Notes: This information is important as is used in data analysis for several
metrics.
Exclusions: None
Version 3.1
73
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F5) Surgical Approach
Location: Adult Form, F. Intra Operative
Definition: What was the method of the surgical procedure?
 Laparoscopic means that the procedure was done entirely through the vision of the
laparoscope usually utilizing several small incisions and trocars
 Laparoscopic converted to open means that after the surgeon began the operation an
unexpected complication arose that made it necessary to open the abdomen
 Laparoscopic, hand-assisted means that an additional incision was made that is the so
that the surgeon’s hand could be inserted into the abdomen to assist the operation
 Open means that there was one incision and no lap ports were used
 Laparoscopic surgeries may have robotic assistance.
SORCE alias:
surgproc
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Laparoscopic
2=Lap converted to open
3=Lap, hand-assisted
4=Open
5=Laparoscopic, robotic assistance
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative record; OR log
Abstraction Notes: Unless the surgeon indicates that the laparoscopic surgery was hand
assisted, indicate that the approach was laparoscopic. The use of instruments through an
additional incision does not mean the approach was “laparoscopic, hand assisted”.
Insertion of a hand is usually done to further explore or to assist with removal of larger
than expected tissue. If the surgeon states in the operative report that the surgical
approach was laparoscopic, but it is obvious from the report that the trocars were
removed, abdoment deflated and the incision enlarged to allow hand assistance, this
would be hand assisted.
Exclusions: None
Version 3.1
74
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F6) ASA Class
Location: Adult Form, F. Intra Operative
Definition: The American Association of Anesthesiologists (ASA) score subjectively
categorizes patients into five subgroups by preoperative physical fitness. It was devised
in 1941 by the ASA as a statistical tool for retrospective analysis of hospital records.
ASA classification makes no adjustment for age, sex, weight, pregnancy, nature of the
planned surgery, skill of the anesthesiologist or surgeon, or the degree of pre-theatre
preparation or facilities for postoperative care.
Table 1. ASA Scores.
Class
Physical status
Example
I
A completely healthy patient
II
A patient with mild systemic disease
A fit patient with an inguinal hernia
Essential hypertension, mild diabetes
without end organ damage
III
A patient with severe systemic disease that is not incapacitating
A patient with incapacitating disease that
is a constant threat to life
A moribund patient who is not expected to live 24 hours with or without
surgery
IV
V
Angina, moderate to severe COPD
Advanced COPD, cardiac failure
Ruptured aortic aneurysm, massive
pulmonary embolism
E
Emergency case
*Societies of Anesthesiologists
SORCE alias:
asaclass
ARMUS Variable Name(s):
Field Format: Mulitple Choice
Value Codes: 1 = I
2 = II
3 = III
4 = IV
7=V
5 = Already Intubated
6 = NA
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Anesthesia record
Abstraction Notes: There will not be an ASA score if the patient was already intubated;
if intubated, check “already intubated”.
Exclusions: None
Version 3.1
75
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*F7) Highest Perioperative Blood Glucose
Location: Adult Form, F. Intra Operative
Definition: Record the highest fasting blood glucose test results within 24 hours of
incision: blood glucose recorded prior to incision, any blood glucose result during time
frame that the patient was in the OR, blood glucose result with 60-minutes of operative
close time. If no test performed indicate “No”
SORCE alias:
peribg
bg_not
(blood glucose not performed)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 10 – 900 mg/dl
Data Storage Type: Numeric
Suggested Data Source: Anesthesia record; OR log; H&P, RN intake assessment; OR
holding records; ED records
Abstraction Notes: The question applies to ALL procedures: (appendectomy, colorectal
and bariatric procedures).
Exclusions:
Version 3.1
76
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F8) Insulin Used Perioperatively
Location: Adult Form, F. Intra Operative
Definition: Was insulin administered during the perioperative period-anytime prior to
incision on the day of surgery, during the time that the patient was in the OR, or within
60 minutes of the closing of the incision
SORCE alias:
insulin
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes;
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Anesthesia record, OR log, nursing admit or preop notes,
PACU record
Abstraction Notes: The question applies to all procedures and patients.
Exclusions:
Version 3.1
77
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*F9) Highest blood glucose on post op day 1
Location: Adult Form, F. Intra Operative
Definition: Highest recorded blood glucose during post op day 1
Check NA if not done. Post op day 1 is defined as the 24 hour time period that begins at
midnight of the day following the day the surgery was finished. The day of surgery is day
0. Surgery finish time is defined as anesthesia end time.
SORCE alias:
postbg1
postbg1_na
(blood glucose not performed)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 10 – 900 mg/dl
Data Storage Type: Numeric
Suggested Data Source: PACU record (if in PACU during any of post op day 1);
nursing record/notes
Abstraction Notes: The question applies all procedures and all patients
Exclusions: Dearh in the OR
Version 3.1
78
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*F10) Highest blood glucose on post op day 2
Location: Adult Form, F. Intra Operative
Definition: Highest recorded blood glucose during post op day 2
Check NA if not done. Post op day 2 is defined as the 24 time period that begins at
midnight of the second day following the day the surgery was finished. The day of
surgery is day 0.
SORCE alias:
postbg2
postbg2_na
(blood glucose not performed)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 10 – 900 mg/dl
Data Storage Type: Numeric
Suggested Data Source: Nursing record/notes
Abstraction Notes: The question applies to all procedures and all patients.
Exclusions: Death in the OR
Version 3.1
79
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F11) Lowest post-op blood glucose
Location: Adult Form, F. Intra Operative
Definition: Lowest recorded blood glucose during the 48 hrs ending at the close of Post
Op Day 2. Post op day 2 is defined as the 24 time period that begins at midnight of the
second day following the day the surgery was finished. The day of surgery is day 0.
SORCE alias:
lowpostbg
lowpostbg_na
(blood glucose not performed)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 10 – 900 mg/dl
Data Storage Type: Numeric
Suggested Data Source: Nursing record/notes
Abstraction Notes: The question applies to all procedures and all patients.
Exclusions: Death in the OR
Version 3.1
80
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F12) Lowest Intra-operative Temperature
Location: Adult Form, F. Intra Operative
Definition: The lowest temperature recorded during the operation, after the incision and
before closure
SORCE alias:
lowtemp
lowtpna
(temp not available)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 32.0 – 41.0
(degrees centigrade)
Data Storage Type: Numeric
Suggested Data Source: Anesthesia record
Abstraction Notes: The question applies only to colorectal and bariatric procedures. The
intent is to know if the patient was cold during the operation.
Exclusions: Appendectomy cases
Version 3.1
81
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F13) Death in the Operating Room
Location: Adult Form, F. Intra Operative
Definition: Did the patient expire while in the operating room?
SORCE alias:
or_death
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Anesthesia record; OR log; OP record, Discharge summary
Abstraction Notes: The question applies to all procedures.
Exclusions: None
Version 3.1
82
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
F14) First Temperature on Arrival to Recovery Room
Location: Adult Form, F. Intra Operative
Definition: What was the first recorded temperature upon arrival to the recovery room or
ICU? This is defined as within the 30 minute immediately prior to or the 15 minutes
immediately after anesthesia end time. If there is no recorded temperature within 15
miutes after anesthesia end time, then check for the last temperature recorded within the
30minute time period just prior to anesthesia endtime
SORCE alias:
frsttemp
firstna
(temp not available)
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes; 2=No
Allowable Values: 34.0 – 41.0
(degrees centigrade)
Data Storage Type: Numeric
Suggested Data Source: PACU record; ICU record
Abstraction Notes: The question applies only to colorectal and bariatric procedures.
Exclusions: Appendectomy cases or if death in the OR
Version 3.1
83
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G1) DVT Prophylaxis- Within 24 hour of incision
Location: Adult Form, G. Perioperative Interventions
Definition: Heparin or low molecular weight heparin or synthetic factor Xa administered
within 24 hrs of incision. This time period is defined as 24 hours prior to the surgical
incision through discharge from post-anesthesia care/recovery area. If yes, indicate
medication, dosage and frequency of the order. If no, was contraindication documented?
SORCE alias:
Historic variable: hep12hr
ARMUS Variable Name(s):
Within 24 hrs of incision
Heparin
dose
frequency
hours
Enoxaparin
dose
frequency
hours
Dalteparin
dose
frequency
hours
Tinzaparin
dose
frequency
hours
Fondaparinux
dose
frequency
hours
Field Format
Multiple Choice
Yes/No
Number
Multiple Choice
Number
Yes/No
Number
Multiple Choice
Number
Yes/No
Number
Multiple Choice
Number
Yes/No
Number
Multiple Choice
Number
Yes/No
Number
Multiple Choice
Number
Allowable Values*
1=Yes, 2=No, 3=Contraindicated
5000 – 10000 units
1 - 24
20 – 120 mg
1 - 24
2500 – 10000 IU
1 - 24
10000 – 30000 units
1 - 24
2.5 – 10.0 mg
1 - 24
Data Storage Type: Numeric
Suggested Data Source: Medication Administration Record, Perioperative Nursing
Record, Anesthesia Record
Abstraction Notes: If IV order for Heparin indicate number of units ordered per hour;
can be per 24 hours if that is the order. Patients on Coumadin for the treatment of atrial
fibrillation meet this metric. While the surgeon may not have used the word
Version 3.1
84
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
“contraindication”, examples of contraindications are an order for Vitamin K and/or a
blood transfusion.
Special note: The reason for the detailed data elements for this and the other DVT
prophylaxis items are that after a 3 year period that ends December 2010, a grant will
fund analysis of this data to determine if there is any relationship between DVT
prophylaxis measures and re-admits for DVTs or pulmonary embolism.
Exclusions: Not applicable if death in the OR or for appendectomy case
Version 3.1
85
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G2) DVT Prophylaxis – Ordered Post - op
Location: Adult Form, G. Perioperative Interventions
Definition: Heparin, LMW heparin, Coumadin synthetic factor Xa ordered post-op for
in-hospital use after the first 24 hrs; if yes, indicate medication, dosage and frequency of
the order. If no, was contraindication documented?
SORCE alias:
Historic variable: heppost
ARMUS Variable Name(s):
Ordered Post-op
Heparin
dose
frequency
hours
days
Enoxaparin
dose
frequency
hours
days
Dalteparin
dose
frequency
hours
days
Tinzaparin
dose
frequency
hours
days
Fondaparinux
dose
frequency
hours
days
Coumadin
dose
frequency
hours
Field Format
Multiple Choice
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Allowable Values*
1=Yes, 2=No, 3=Contraindicated
5000 - 10000 units
1 - 24
0 - 90
20 -120 mg
1 - 24
0 - 90
2500 - 10000 IU
1 - 24
0 - 90
10000 -30000 units
1 - 24
0 - 90
2.5 – 10.0 mg
1 - 24
0 - 90
1.0 – 10.0 mg
1 - 24
Version 3.1
86
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
days
Number
0 - 90
Data Storage Type: Numeric
Suggested Data Source: Post-Op Physician Orders
Abstraction Notes: Indicate if there was an order for in-house use of prophylaxis after
the first 24 hours post-op. If medication order changed during the hospital stay post-op,
indicate all the medications that were ordered. If order for same medication changes
during this time period, select order closest to discharge. You do not need to verify if
prophylaxis was actually administered. Patients on the Coumadin for the treatment of
atrial fibrillation may meet this metric. While the surgeon may not have used the word
“contraindication”, examples of contraindications are an order for Vitamin K and/or a
blood transfusion.
Exclusions: Not applicable if death in the OR or for appendectomy case
Version 3.1
87
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G3) DVT Prophylaxis – Order on Discharge
Location: Adult Form, G. Perioperative Interventions
Definition: Heparin, LMW heparin, Coumadin synthetic factor Xa ordered on discharge;
if yes, indicate medication, dosage and frequency of the order. If no, was
contraindication documented?
Ordered on discharge
Heparin
dose
frequency
hours
days
Enoxaparin
dose
frequency
hours
days
Dalteparin
dose
frequency
hours
days
Tinzaparin
dose
frequency
hours
days
Fondaparinux
dose
frequency
hours
days
Coumadin
dose
frequency
hours
days
Field Format
Multiple Choice
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Yes/No
Number
Multiple Choice
Number
Number
Allowable Values*
1=Yes, 2=No, 3=Contraindicated
5000 - 10000 units
1 - 24
0 - 90
20 -120 mg
1 - 24
0 - 90
2500 - 10000 IU
1 - 24
0 - 90
10000 -30000 units
1 - 24
0 - 90
2.5 – 10.0 mg
1 - 24
0 - 90
1.0 – 10.0 mg
1 - 24
0 - 90
Data Storage Type: Numeric
Version 3.1
88
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Suggested Data Source: Discharge summary or discharge/transfer orders, Discharge
Instruction Sheet
Abstraction Notes: If the discharge order includes only the medication dosage and
frequency, but not the number of days, check “number of days not specified”. Patients on
Coumadin for the treatment of atrial fibrillation may meet the criterion for this metric.
While the surgeon may not have used the word “contraindication”, examples of
contraindications are an order for Vitamin K and/or a blood transfusion.
Exclusions: Not applicable if discharge disposition is death or if appendectomy case
Version 3.1
89
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G4) Intermittent pneumatic compression in the OR
Location: Adult Form, G. Perioperative Interventions
Definition: Was the patient on intermittent pneumatic compression in the OR? Yes or no
SORCE alias:
pneucomp
pneucomp_na
(not available)
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 =Yes
2= No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR record, anesthesia record; Physician orders
Abstraction Notes: This refers to whether or not the patient had intermittent
compression boots applied and used in the OR. This is a care process to help prevent
DVTs.
Exclusions: Appendectomy cases
Version 3.1
90
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G5) Beta Blocker administered within 24 hours pre-op
Location: Adult Form, G. Perioperative Interventions
Definition: Beta Blocker given within the 24 hour period prior to being in the OR
yes or no, or contraindicated.
SORCE alias:
betapre
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, Preop notes; Physician
orders
Abstraction Notes: There must be some documentation that the beta blocker was
actually taken, but the documentation does not need to include the exact time; this cannot
be inferred from the fact that the patient has been on beta blockers routinely.
Contraindications include low blood pressure, slow heart rate or if the patient is on
vasopressors to raise their blood pressure; also if there is any documentation regarding a
contraindication for any other reason. The intent of this and the next BB data element is
to determine if those who were on BB medications prior to having surgery are not
abruptly withdrawn.
Exclusions: Appendectomy cases
Version 3.1
91
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G6) Beta Blocker administered intraoperatively
Location: Adult Form, G. Perioperative Interventions
Definition: Beta Blocker given within the intraopertive time period-the time when the
patient is in the OR through discharge from the post anesthesia care/recovery area. If the
patient is admitted to another location other than the post anesthesia area, e.g. ICU, the
recovery period ends a maximum of 6 hours after arrival to the recovery area.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, Preop notes; Physician
orders
Abstraction Notes: There must be some documentation that the beta blocker was
actually given, but the documentation does not need to include the exact time; this cannot
be inferred from the fact that the patient has been on beta blockers routinely.
Contraindications include low blood pressure, slow heart rate or if the patient is on
vasopressors to raise their blood pressure; also if there is any documentation regarding a
contraindication for any other reason. The intent of this and the next BB data element is
to determine if those who were on BB medications prior to having surgery are not
abruptly withdrawn.
Exclusions: Appendectomy cases
Version 3.1
92
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G7) Beta Blocker ordered within 24 hrs post-op
Location: Adult Form, G. Perioperative Interventions
Definition: Beta Blocker ordered within 24 hours post-op; beta blockers given anytime
prior to incision and prior to discharge from the post anesthesia/recovery area are not
included as being given post-op. Indicate yes or no, or contraindicated
SORCE alias:
betapost
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values:
Data Storage Type: Numeric
Abstraction Notes: Check if a beta blocker is ordered post-op as a regularly
administered medication. The emphasis is on if the beta blocker was ordered; you do not
need to check to see if it was administered.
Contraindications include low blood pressure, slow heart rate or if the patient is on
vasopressors to raise their blood pressure; also if there is any documentation regarding a
contraindication for any other reason.
Exclusions: Appendectomy cases or if death in the OR
Version 3.1
93
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G8) Antibiotics: On antibiotics for the treatment of infection
Location: Adult Form, G. Perioperative Interventions
Definition: On antibiotics for the treatment of an infection? Yes or no. If yes, at this
hospital/upon admission or at a transferring hospital?
SORCE alias:
antiprev
antihosp1
antihosp2
(this hospital)
(transferring hospital)
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2= No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, Physician orders
Abstraction Notes: Check yes if the patient was being treated with antibiotics for a preexisting infection. The patient may have been placed on antibiotics for the treatment of
an infection prior to admission so come into the hospital having already been placed on
antibiotics at home or upon admission. If the patient is on a chronic low dose antibiotic
for a chronic condition such as acne, this is not a prophylactic antibiotic for the surgery in
question. In this situation, check “no” for pt being treated for an infection as they are not
being treated for an active infection. In the rare event that an antibiotic as being taken for
some other unusual reason that had nothing to do with the surgery in question and has not
been taken within approximately 8 hours of the surgery, the patient still qualifies for a
prophylactic antibiotic, and should it should be given.
Exclusions: Appendectomy cases
Version 3.1
94
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G9) Antibiotics: Were prophylactic antibiotics indicated
Location: Adult Form, G. Perioperative Interventions
Definition: Were prophylactic antibiotics indicated? Yes or no
SORCE alias:
antiproph
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2= No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, Physician orders
Abstraction Notes:
The answer should be “yes” unless the patient is already being
treated for a pre-existing infection as prophylactic antibiotics are indicated for all
bariatric and colorectal cases.
Exclusions: Appendectomy cases or if death in the OR
Version 3.1
95
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G9a) Antibiotics: Administered within 60 minutes
Location: Adult Form, G. Perioperative Interventions
Definition: Was the antibiotic delivered within 60 min? Yes or no
SORCE alias:
antiadmn
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2= No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, Physician orders
Abstraction Notes: Within 60 minutes means within 60 minutes of the incision being
made; the dose does not necessarily have to be completely infused prior to the incision
being made. Patients who receive vancomycin or a fluoroquinolone for prophylactic
antibiotics should have the antibiotics initiated within two hours prior to the surgical
incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone,
it is acceptable to start these antibiotics within two hours prior to incision time.
Exclusions: Appendectomy cases or if death in the OR
Version 3.1
96
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G9b) Antibiotics: Discontinued within 24 hours
Location: Adult Form, G. Perioperative Interventions
Definition:
Was the antibiotic discontinued within 24 after incision closure? Yes or no
Incision closure time is defined as anesthesia end time
SORCE alias:
antidisc1
Historic Variable: antidisc0
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2=No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Physician orders, PACU notes, nursing record, MAR
Abstraction Notes:
In order to answer yes to the prophylactic antibiotic being discontinued within 24 hours,
the prophylactic antibiotic must have been discontinued within 24 hours of the incision
being closed. This time is defined as anesthesia end time. If an infection is found during
the surgery time, and antibiotics are then ordered for treatment of the infection, and the
prophylactic antibiotic was discontinued within the 24 hr time period, the answer to this
data element can still be “yes”.
This is important as the goal of prophylaxis is to provide benefit to the patient with as
little risk as possible. Intraoperative dosing may be needed for long operations as it is
important to maintain therapeutic serum and tissue levels throughout the operation.
Exclusions: Appendectomy cases or if death in the OR
Version 3.1
97
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G10) Pain management: Epidural
Location: Adult Form, G. Perioperative Interventions
Definition: Epidural ordered for pain control within 24 hours of procedure completion.
No, Yes, If no, contraindicated, no or yes
SORCE alias:
pain_epi
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures.
Includes intrathecal MS placement prior to surgery. You do not need to check to see if
the patient actually received the ordered medication.
Contraindications are patient refusal, any coagulopathy, concurrent use of
enoxaparin/heparin, and patient anatomy that makes epidural placement not feasible.
Exclusions: Appendectomy or death in the OR
Version 3.1
98
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G10a) Pain management: PCEA
Location: Adult Form, G. Perioperative Interventions
Definition: Patient controlled epidural analgesic (PCEA) ordered for pain control within
24 hours of procedure completion. No, Yes
SORCE alias:
pain_pcea
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2=No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures.
Includes intrathecal MS placement prior to surgery. You do not need to check to see if
the patient actually received the ordered medication.
Contraindications are patient refusal, any coagulopathy, concurrent use of
enoxaparin/heparin, patient anatomy that makes epidural placement not feasible, and
inability of patient to understand and/or manipulate the PCEA.
Exclusions: Appendectomy or death in the OR
Version 3.1
99
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G11) Pain management: PCA
Location: Adult Form, G. Perioperative Interventions
Definition: Patient Controlled Analgesia (PCA) with the use of IV narcotics ordered for
pain control within 24 hours of procedure completion. No, Yes, If no, contraindicated,
no or yes
SORCE alias:
pain_pca
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures. You
do not need to check to see that the patient actually received the medication.
Contraindications are inability of the patient to understand or manipulate the PCA or
opioid intolerance.
Exclusions: Appendectomy or death in the OR
Version 3.1
100
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G12) Pain management: NSAID
Location: Adult Form, G. Perioperative Interventions
Definition: NSAID ordered for pain control within 24 hours of procedure completion.
No, Yes, If no, contraindicated, no or yes
SORCE alias:
pain_nsaid
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures. You
do not need to check to see that the patient actually received the ordered medication.
Contraindications are intolerance of NSAIDS, kidney or liver disease, and platelet
dysfunction or a coagulopathy. See separate listing for NSAID medication names for
your reference; it may not include very new medications.
Exclusions: Appendectomy or death in the OR
Version 3.1
101
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G13) Pain management: Narcotic drip
Location: Adult Form, G. Perioperative Interventions
Definition: Narcotic drip ordered for pain control within 24 hours of procedure
completion. No, Yes, If no, contraindicated, no or yes
A narcotic drip is defined as a peripheral IV infusion that is continuous.
SORCE alias:
pain_narc
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Contraindicated
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures. The
pain management data elements are meant to see if advanced pain control measures are
being used for good pain control. Intermittent or prn IV or IM narcotics are not included.
Contraindication is opioid intolerance.
Exclusions: Appendectomy or death in the OR
Version 3.1
102
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G14) Pain management: Other
Location: Adult Form, G. Perioperative Interventions
Definition: Other pain control measures ordered for pain control within 24 hours of
procedure completion.
SORCE alias:
pain_oth
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2=No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures. Is
yes, specify other pain management modality ordered within 24 hrs post-op; name class
of drug and route. PO narcotics and prn IV narcotics are not included in this data element
as the intent of this set of data elements is to look at more advanced pain control
approaches. An example of something that would be categorized as “other” is
subarachnoid anesthesia within the first 24 hours post op. Spinal anesthesia would be an
example of a type of pain management that would go in this category.
Exclusions: Appendectomy or death in the OR
Version 3.1
103
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G14a) Pain management: Other, specify modality
Location: Adult Form, G. Perioperative Interventions
Definition: Specify the type of pain control method other than epidural, PCA, NSAID or
narcotic drip that was ordered for pain control within 24 hours of procedure completion.
SORCE alias:
pain_txt
ARMUS Variable Name(s):
Field Format: Text
Value Codes:
Allowable Values: Not applicable
Data Storage Type: Character
Suggested Data Source: Operative note, Discharge Note, Anesthesia Record
Abstraction Notes: The question applies only to colorectal and bariatric procedures.
Exclusions: Appendectomy or death in the OR
Version 3.1
104
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G15) Entereg administered
Location: Adult Form, G. Perioperative Interventions
Definition: Was Entereg (generic is alvimopan) administered after this surgery? No or
Yes; Applicable only to non-lap band bariatric and colorectal surgeries
SORCE Alias:
entereg
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
OR record, PACU notes, MAR
Abstraction Notes:
This is a new drug that blocks the negative effect of
narcotics on the gut-for prevention of ileus. Randomized, controlled trials have shown to
decrease the LOS after gastrointestinal surgery by >20 hrs. Entereg generally is given
within 4 hours preop, and then bid orally for up to 15 doses. This data is being captured
to ascertain if LOS is shorter for the SCOAP patients that receive Entereg.
Exclusions:
Appendectomy and lap band bariatric surgeries; death in the OR.
Version 3.1
105
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G16) Aloxi administered
Location: Adult Form, G. Perioperative Interventions
Definition: Was Aloxi administered at any time during the hospitalization? No or Yes;
Applicable to ALL surgeries
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
OR record, PACU notes, MAR
Abstraction Notes:
Exclusions:
Version 3.1
106
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G17) Statin post-op
Location: Adult Form, G. Perioperative Interventions
Definition: Answer whether or not a statin was ordered post-op for in-hospital use.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note, Anesthesia record, Nursing or Medicine
progress notes, PACU record
Abstraction Notes:
Exclusions: Not applicable if death in the OR
Version 3.1
107
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G18) Nasogastric tube
Location: Adult Form, G. Perioperative Interventions
Definition: Answer whether or not patient left the operating room with a nasogastric
tube in place.
SORCE alias:
nasotube
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note, Anesthesia record, Nursing or Medicine
progress notes, PACU record
Abstraction Notes:
Exclusions: Not applicable if death in the OR
Version 3.1
108
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G19) Gastrostomy tube drainage
Location: Adult Form, G. Perioperative Interventions
Definition: Answer whether or not patient left the operating room with a gastrostomy
tube set to drain in place.
SORCE alias:
gastube
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note, Anesthesia record, Nursing or Medicine
progress notes, PACU record
Abstraction Notes:
Exclusions: Not applicable if death in the OR
Version 3.1
109
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G20) Estimated Blood Loss
Location: Adult Form, G. Perioperative Interventions
Definition: Estimated blood loss during surgery? Choose the category that best describes
the amount of blood loss: less than 50cc, 50 – 250cc or more than 250cc.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple choice
Value Codes: 1 = <50cc
2 = 50-250cc
3 = >250cc
4 = NA
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note.
Abstraction Notes:
Exclusions: Appendectomy
Version 3.1
110
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G21) Red blood cell transfusion
Location: Adult Form, G. Perioperative Interventions
Definition: Answer whether or not patient received a red blood cell transfusion (RBC)
or packed red blood cells (PRBC) in the OR or within 24 hours of procedure completion.
SORCE alias:
trnsfusn
rbc_na
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note, PACU record, post-op nursing or medicine
progress notes.
Abstraction Notes: You can indicate “yes” if the transfusion was started; do not need to
verify that the transfusion was completed.
Exclusions: Appendectomy or if death in the OR
Version 3.1
111
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G21a) Red blood cell transfusion units
Location: Adult Form, G. Perioperative Interventions
Definition: If red blood cells were transfused, how many units were transfused within 24
hours of procedure completion.
SORCE alias:
trnsunit
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: whole numbers (1-30)
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Nursing summary
Abstraction Notes: Only include those units that began transfusion in the OR or within
24 hours post-op. You do not need to check to see that the units were completely
transfused.
Exclusions: Appendectomy or if death in the OR
Version 3.1
112
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G21b) Lowest hemoglobin
Location: Adult Form, G. Perioperative Interventions
Definition: If transfusion, indicate the lowest recorded hemoglobin in the 12 hours prior
the the transfusion order.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: 4.5 – 20.0
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Nursing summary, Lab values
document
Abstraction Notes:
Exclusions: Appendectomy
Version 3.1
113
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G22) Red blood cell transfusion after 24 hrs post-op
Location: Adult Form, G. Perioperative Interventions
Definition: Answer whether or not patient received a red blood cell transfusion (RBC)
or packed red blood cells (PRBC) after 24 hours post-op; if yes, how many units?
Note: Evaluate only the first 30 post-op days of a hospitalization that is longer than 30
days.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note, PACU record, post-op nursing or medicine
progress notes.
Abstraction Notes: You can indicate “yes” if the transfusion was started; do not need to
verify that the transfusion was completed.
Exclusions: Appendectomy or if death in the OR
Version 3.1
114
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G22a) Red blood cell transfusion units
Location: Adult Form, G. Perioperative Interventions
Definition: If red blood cells were transfused, how many units were transfused after 24
hours post-op.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: whole numbers (1-30)
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Nursing summary
Abstraction Notes: Only include those units that began transfusing after 24 hours postop. You do not need to check to see that the units were completely transfused.
Exclusions: Appendectomy or if death in the OR
Version 3.1
115
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G22b) Lowest hemoglobin
Location: Adult Form, G. Perioperative Interventions
Definition: If transfusion, indicate the lowest recorded hemoglobin in the 12 hours prior
the transfusion order.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: 4.5 – 20.0
Data Storage Type: Numeric
Suggested Data Source: Operative note, Discharge Note, Nursing summary, Lab values
document
Abstraction Notes:
Exclusions: Appendectomy
Version 3.1
116
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G23) Last hemoglobin prior to discharge
Location: Adult Form, G. Perioperative Interventions
Definition: The last hemoglobin that was reported prior to actual discharge.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: 4.5 – 20.0
Data Storage Type: Numeric
Suggested Data Source: Lab values documents, Discharge Note, Nursing summary
Abstraction Notes:
Exclusions: Appendectomy
Version 3.1
117
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G24) Mechanical ventilation
Location: Adult Form, G. Perioperative Interventions
Definition: Answer if there was mechanical ventilation performed at any time beyond the
recovery room.
SORCE alias:
vent
mechna
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Nursing notes of care beyond the recovery room; respiratory
therapy record
Abstraction Notes: If the patient is chronic ventilator patient, the response to this is not
applicable-the number of ventilator hours post op for these patients does not represent a
complication. You should round up the number to the nearest whole number, e.g. rather
than enter 24.6 hrs, enter 25 hrs. Also, do not spend an inordinate amount of time to
determine this number as many times the patient may be off and on the ventilator several
times; documentation regarding exactly when these times occurred may not be clear.
Exclusions: Death in the OR or chronic ventilator patient
Version 3.1
118
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G24a) Mechanical ventilation hours
Location: Adult Form, G. Perioperative Interventions
Definition: Total number of hours patient received mechanical beyond the recovery
room.
SORCE alias:
venthrs
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: 3 digits (1 – 3000)
Data Storage Type: Numeric
Suggested Data Source: Nursing notes for care given beyond recovery room; respiratory
therapy record
Abstraction Notes: If patient is off and on ventilator, estimate total hours that the
patient was mechanically ventilated.
Exclusions: Death in the OR, or chronic ventilator patient
Version 3.1
119
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G25) Highest Creatinine
Location: Adult Form, G. Perioperative Interventions
Definition:. Highest creatinine level during this hospitalization; from admission to
discharge.
Note: Evaluate only the first 30 post-op days of a hospitalization that is longer than 30
days.
SORCE alias:
ARMUS Variable Name(s):
Field Format:
Number
Value Codes:
Allowable Values: 0.1 – 15.0 mg/dl
Data Storage Type: Numeric
Suggested Data Source: Laboratory tests
Abstraction Notes:
Exclusions: Appendectomy cases
Version 3.1
120
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G26) Postoperative events
Location: Adult Form, G. Perioperative Interventions
Definition: Did any of these events occur during the postoperative time period:
myocardial infarction (heart attack), cardiovascular accident (CVA or stroke), an
unplanned ICU stay, a fall with injury requiring surgical intervention or a c-Difficile
infection. If yes, indicate all that apply.
Check c-Difficile infection only if there is laboratory confirmation of infection.
Note: Record only events that occurred during the first 30 post-op days of the current
hospitalization. Post discharge events are recorded elsewhere.
SORCE alias:
pop_events
pop_mi
pop_cva
pop_icu
pop_fall
pop_cdiff
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1= Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: PACU record, nursing notes, progress notes, discharge
summary
Abstraction Notes: The intent of this question is to determine complications that may
have affected a number of the outcomes metrics. An unplanned ICU stay refers to any
ICU stay that was not planned prior to the surgery, e.g. for some surgeries, the normal
progression after surgery is to move from the PACU to ICU for at least a short stay.
Exclusions: Death in the OR
Version 3.1
121
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*G27) Discharge Disposition
Location: Adult Form, G. Perioperative Interventions
Definition: Location patient was discharged to from the hospital. If patient expired in
hospital, location would be recorded as “death”.
SORCE alias:
disption
ARMUS Variable Name(s):
Field Format: Multiple choice
Value Codes: 1=Home
2=Rehab facility
3=SNF (skilled nursing facility)
4=Other location Option removed
5=Other acute care hospital
6=Death
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Discharge Summary, Nursing notes
Abstraction Notes: Indicate SNF if discharged to Hospice unit or care program. For a
discharge with home health care or to any place where the patient lives permanently,
including a family or group home, choose “home” as the discharge disposition.
Exclusions: None
Version 3.1
122
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
G27a) Discharge: Death Specification
Location: Adult Form, G. Perioperative Interventions
Definition: If patient expired prior to discharge from hospital, define when event
occurred.
SORCE alias:
disption_sp
ARMUS Variable Name(s):
Field Format: Multiple choice
Value Codes: 1=Death in the O.R.
2=Death within 24 hrs post-op
3=Death after 24 hrs post-op
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Discharge Summary
Abstraction Notes:
Exclusions: None
Version 3.1
123
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H1) Reintervention: Any
Location: Adult Form, H. Reintervention
Definition: If the patient had any of the surgical operations or therapies listed below
during this hospitalization and following the abdominal procedure within 30 days,
select “Yes” If the patient did not have any, select “No”
(Not applicable if death in the O.R.)
Abdominal re-operation: Any or any of the listed Abdominal procedures below:
Colostomy or ileostomy
Abscess drainage
Operative drain placement
Gastrostomy
Gastrostomy revision
Re-exploration/washout (option removed)
Anastomotic revision
Band replacement
Band/port revision
Wound revision
Negative re-exploration
Reoperation for bleeding
Other (specify:_________________)
Tracheal reintubation
NG tube replacement (non-routine)
Tracheostomy
Placement of percutaneous drain
Anticoagulation therapy for presumed/confirmed DVT
Anticoagulation therapy for presumed/confirmed PE
Antibiotic for presumed/confirmed infection
Wound reopened
Radiologically demonstrated anastomotic leak
Radiologically demonstrated enterocutaneous fistula
Other (specify :_____________________________________________________)
SORCE alias:
intvn_none
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR Record, Procedural transcription, Special Procedures, CT,
Endoscopy Area, Discharge Summary
Abstraction Notes: This is a required field. If any of the re-operative events occur
within the OR during the index surgery, e.g. re-intubated due to laryngospasam or an NG
tube was placed during the index operation, this is not a re-intervention.
Version 3.1
124
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Exclusions: Death in OR
Version 3.1
125
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2) Reintervention: Abdominal re-operation
Location: Adult Form, H. Reintervention
Definition: If the patient had any of the surgical operations listed below during this
hospitalization and following the abdominal procedure and within 30 days, select
“Abdominal re-operation” (Not applicable if death in the O.R.)
Colostomy or ileostomy
Abscess drainage
Operative drain placement
Gastrostomy
Gastrostomy revision
Re-exploration/washout (option removed)
Anastomotic revision
Band replacement
Band/port revision
Wound revision
Negative re-exploration
Reoperation for bleeding
Other (specify:_________________)
SORCE alias:
intvn_abreop
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: OR Record, Procedural transcription, Special Procedures, CT,
Endoscopy Area, Discharge Summary
Abstraction Notes: This is not a required field unless a reintervention occurred.
Exclusions: Death in OR
Version 3.1
126
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.1) Reintervention: Colostomy or ileostomy
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operations “Colostomy or ileostomy” during
this hospitalization and following the abdominal procedure and within 30 days, select
“Colostomy or ileostomy” and enter the date of the reintervention. (Not applicable if
death in the O.R.)
SORCE alias:
intvn_ostomy
dt_ostomy
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Special Procedures, CT,
Endoscopy Area, Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
127
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.2) Reintervention: Abscess drainage
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Abscess drainage” during this
hospitalization and following the abdominal procedure and within 30 days, select
“Abscess drainage” and enter the date of the reintervention. (Not applicable if death in
the O.R.)
SORCE alias:
intvn_abss
dt_abss
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
128
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.3) Reintervention: Operative Drain Placement
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Operative Drain Placement”
during this hospitalization and following the abdominal procedure and within 30 days,
select “Operative Drain Placement” and enter the date of the reintervention. (Not
applicable if death in the O.R.)
SORCE alias:
intvn_opdrain
dt_opdrain
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
129
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.4) Reintervention: Gastrostomy
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Gastrostomy” during this
hospitalization and following the abdominal procedure and within 30 days, select
“Gastrostomy” and enter the date of the reintervention. Includes if the gastrostomy was
for placement of a feeding tube of any kind. (Not applicable if death in the O.R.)
SORCE alias:
intvn_gastro
dt_gastro
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
130
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.5) Reintervention: Gastrostomy revision
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Gastrostomy revision” during
this hospitalization and following the abdominal procedure and within 30 days, select
“Gastrostomy revision” and enter the date of the reintervention. (Not applicable if death
in the O.R.)
SORCE alias:
intvn_gasrev
dt_gasrev
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
131
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.6) Reintervention: Anastomotic revision
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Anastomotic revision” during
this hospitalization and following the abdominal procedure and within 30 days, select
“Anastomotic revision” and enter the date of the reintervention. (Not applicable if death
in the O.R.)
SORCE alias:
intvn_anast
dt_anast
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
132
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.7) Reintervention: Band Replacement
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Band Replacement” during this
hospitalization and following the abdominal procedure and within 30 days, select “Band
Replacement” and enter the date of the reintervention. (Not applicable if death in the
O.R.)
SORCE alias:
intvn_band
dt_band
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
133
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.8) Reintervention: Band/port revision
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Band/port revision” during this
hospitalization and following the abdominal procedure and within 30 days, select
“Band/port revision” and enter the date of the reintervention. (Not applicable if death in
the O.R.)
SORCE alias:
intvn_bprev
dt_bprev
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
134
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.9) Reintervention: Wound revision or evisceration
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Wound revision or evisceration”
during this hospitalization and following the abdominal procedure and within 30 days,
select “Wound revision or evisceration” and enter the date of the reintervention. (Not
applicable if death in the O.R.)
SORCE alias:
intvn_evis
dt_evis
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
135
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.10) Reintervention: Negative re-exploration
Location: Adult Form, H. Reintervention
Definition: If the patient had the surgical operation(s) “Negative re-exploration” during
this hospitalization and following the abdominal procedure and within 30 days, select
“Negative re-exploration” and enter the date of the reintervention. (Not applicable if
death in the O.R.)
SORCE alias:
intvn_reexp
dt_reexp
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field. Negative re-exploration means that the
surgeon took the patient back to surgery to determine is there was a problem in the
surgical area because the patient has symptoms that suggest this, and did not find
anything that was problematic; therefore, is a negative finding.
Exclusions: Death in OR
Version 3.1
136
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*H2.11) Reintervention: Reoperation for bleeding
Location: Adult Form, H. Reintervention
Definition: If the patient had surgical operation(s) for bleeding (including the post-op
diagnosis of hematoma evacuation, bleeding, hemorrhage or hemostasis) select
“reoperation for bleeding” and enter the date of the reintervention. The reoperation
should have occurred during this hospitalization and following the index abdominal
procedure and within 30 days, (Not applicable if death in the O.R.)
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
137
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H2.12) Reintervention: Other Reoperation
Location: Adult Form, H. Reintervention
Definition: If the patient had another surgical operation(s) that is not listed and within
30 days postoperatively, please select “Other”, describe the procedure on the “specify”
notation and list the date of the “Other” reintervention. (Not applicable if death in the
O.R.)
SORCE alias:
intvn_reopoth
dt_reopoth
txt_reopoth
ARMUS Variable Name(s):
Field Format: Yes/No; Date; Text
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time;Character
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
138
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H3) Reintervention: Tracheal reintubation
Location: Adult Form, H. Reintervention
Definition: If the patient has to be reintubated during this hospitalization and following
the abdominal procedure and within 30 days because of respiratory or other issues, select
“Tracheal reintubation” and enter the date of the reintervention. (Not applicable if death
in the O.R.)
SORCE alias:
intvn_intube
dt_intube
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary, Respiratory therapy record, Anesthesia Record, PACU record
Abstraction Notes: This is not a required field. If this occurs more than once, enter the
date of the first re-intubation only.
Exclusions: Death in OR, other procedures requiring general or spinal anesthesia after
the principle procedure.
Version 3.1
139
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H4) Reintervention: NG tube replacement
Location: Adult Form, H. Reintervention
Definition: (Non-routine) NG tube replacement during this hospitalization and following
the abdominal procedure and within 30 days because of loss of initial NG tube function
or other issues, select “NG tube replacement” and enter the date of the reintervention.
(Not applicable if death in the O.R.)
SORCE alias:
intvn_ngrepl
dt_ngrepl
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary, Respiratory therapy record, Anesthesia Record, PACU record,
Nurses Note
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
140
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H5) Reintervention: Tracheostomy
Location: Adult Form, H. Reintervention
Definition: Tracheostomy performed during this hospitalization and within 30 days of
the operation, perioperatively or postoperatively because of loss of airway, chronic
ventilator support or other issues, select “Tracheostomy” and enter the date of the
reintervention. (Not applicable if death in the O.R.)
SORCE alias:
intvn_trach
dt_trach
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary, Respiratory therapy record, Anesthesia Record, PACU record,
Nurses Note, ICU (flow sheet) record
Abstraction Notes: This is not a required field.
Exclusions: Death in OR, patient has Tracheostomy prior to admission.
Version 3.1
141
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H6) Reintervention: Percutaneous drain
Location: Adult Form, H. Reintervention
Definition: Use or placement of percutaneous drain during this hospitalization and
within 30 days postoperatively due to abscess, fluid collection or other issues, select
“Placement of percutaneous drain” and enter the date of the reintervention. (Not
applicable if death in the O.R.)
SORCE alias:
intvn_percdrain
dt_percdrain
ARMUS Variable Name(s):
Field Format: Yes/No; Date
Value Codes:
Allowable Values: mm/dd/yyyy
Data Storage Type: Numeric; Date/Time
Suggested Data Source: OR Record, Procedural transcription, Progress Notes,
Discharge Summary, Anesthesia Record, Nurses Note, ICU (flow sheet) record, Special
Procedures record
Abstraction Notes: This is not a required field.
Exclusions: Death in OR, Appendectomy.
Version 3.1
142
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H7) Reintervention: Anticoagulation therapy for DVT
Location: Adult Form, H. Reintervention
Definition: Use of Anticoagulation therapy for presumed/confirmed DVT (Deep Vein
Thrombosis) during this hospitalization and within 30 days, select “Anticoagulation
therapy for presumed/confirmed DVT” (Not applicable if death in the O.R.)
SORCE alias:
intvn_dvt
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
143
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H8) Reintervention: Anticoagulation therapy for PE
Location: Adult Form, H. Reintervention
Definition: Use of Anticoagulation therapy for presumed/confirmed PE (Pulmonary
Embolism) during this hospitalization and within 30 days, select “Anticoagulation
therapy for presumed/confirmed PE”
(Not applicable if death in the O.R.)
SORCE alias:
intvn_pe
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record, Radiology Report
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
144
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*H9) Reintervention: Antibiotic for infection
Location: Adult Form, H. Reintervention
Definition: Use of antibiotic for presumed/confirmed infection during this
hospitalization and within 30 days.(Not applicable if death in the O.R.) Indicate type of
infection: wound/skin, pnuemonia, UTI, other. Check all that apply (Does not include cDifficile)
SORCE alias:
intvn_infect
inf_skin
inf_pneumo
inf_uti
inf_other
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record, Radiology Report, Medication Administration Report
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
145
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H10) Reintervention: Wound reopened
Location: Adult Form, H. Reintervention
Definition: Wound reopened during this hospitalization and within 30 days, select
“Wound reopened” (Not applicable if death in the O.R.)
SORCE alias:
intvn_wound
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record
Abstraction Notes: This is not a required field. Wound re-opened does not include
routine wound care-routine wound care refers to situations where the wound may have
been left open in the OR and packing/removing packing and/or probing to keep the
wound open may be taking place on a daily basis. The intent of this data element is to
note when the closed wound is reopened secondary to a presumed infection.
Exclusions: Death in OR
Version 3.1
146
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H11) Reintervention: Radiologically demonstrated leak
Location: Adult Form, H. Reintervention
Definition: Radiologically demonstrated anastomotic leak during this hospitalization
and within 30 days from the operation, select “Radiologically demonstrated anastomotic
leak”
(Not applicable if death in the O.R.)
SORCE alias:
intvn_leak
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record, Radiology Report
Abstraction Notes: This is not a required field. Check if a leak demonstrated by barium
enema, upper GI and/or CT scan.
Exclusions: Death in OR
Version 3.1
147
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H12) Reintervention: Radiologically demonstrated fistula
Location: Adult Form, H. Reintervention
Definition: Radiologically demonstrated enterocutaneous fistula during this
hospitalization and within 30 days from the operation, select “Radiologically
demonstrated enterocutaneous fistula.” (Not applicable if death in the O.R.)
SORCE alias:
intvn_fistula
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record, Radiology Report
Abstraction Notes: This is not a required field. Check if this demonstrated by barium
enema, upper GI and/or CT scan.
Exclusions: Death in OR
Version 3.1
148
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
H13) Reintervention: Other
Location: Adult Form, H. Reintervention
Definition: Reintervention during this hospitalization which is significant to this
admission and is not listed in the list below, select “Other”. Specify with a short
description in the text field provided. (Not applicable if death in the O.R.)
Colostomy or ileostomy
Abscess drainage
Operative drain placement
Gastrostomy
Gastrostomy revision
Re-exploration/washout (option removed)
Anastomotic revision
Band replacement
Band/port revision
Wound revision
Negative re-exploration
Reoperation for bleeding
Other (specify:_________________)
Tracheal Reintubation
NG tube replacement (non-routine)
Tracheostomy
Placement of Percutaneous drain
Anticoagulation therapy for presumed/confirmed DVT
Anticoagulation therapy for presumed/confirmed PE
Antibiotic for presumed infection
Wound reopened
Radiologically demonstrated anastomotic leak
Radiologically demonstrated enterocutaneous fistula
SORCE alias:
intvn_other
txt_other
ARMUS Variable Name(s):
Field Format: Yes/No; Text
Value Codes:
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source: Progress Notes, Discharge Summary, Nurses Note, ICU (flow
sheet) record, Radiology Report, Ultrasound Report
Abstraction Notes: This is not a required field.
Exclusions: Death in OR
Version 3.1
149
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
I1) Bariatric: Prior foregut surgery
Location: Adult Form, I. Bariatric
Definition: Documentation of any previous operation in the abdomen, regardless of date
or facility. Include if it took place during this hospitalization, but prior to this operation.
Foregut is the anterior part of the alimentary canal, from the mouth to the duodenum at
the entrance of the bile duct. At this point it is contiguous with the midgut. Structures of
the foregut are the esophagus, stomach, duodenum, live, gallbladder and the superior
portion of the pancreas. Foregut surgeries include surgeries such as small bowel surgery;
cholecystectomies, surgery for biliary obstructions or surgery for gastric cancer.
SORCE alias:
priorsx
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2=No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: H&P, MD or nursing admission notes, discharge summary
Abstraction Notes: Usually found in surgical history in the H&P
Exclusions: None
Version 3.1
150
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*I2) Bariatric: Procedure of record
Location: Adult Form, I. Bariatric
Definition: What type of procedure did the patient have performed. Bypass (proximal or
distal), biliopancreatic bypass, liliopancreatic bypass with duodenal switch, adjustable
band (and size).
Proximal gastric bypass is a Roux limb less then or equal to 150cm.
Distal gastric bypass is a Roux limb greater than 150cm PLUS a “common channel” of
less than 200 cm.
Other gastric bypass: If a Roux limb is greater than 150 cm, but there is no mention of the
common channel being less than 200 cm, indicate “other gatric bypass” and specify the
Roux length.
Indicate the band size for the lap band procedure. “AP standard” is a brand name that is
an 11cm size and “AP Large” is a 12.2cm size.
In the unusual event that a band surgery is converted to a bypass, the operation type is a
bypass surgery and “yes” should be checked on the “prior foregut surgery” question
above.
SORCE alias:
barproc
roux
smbowel
bandsize
sizespec
ARMUS Variable Name(s):
Field Format: Multiple Choice, Yes/No
Value Codes:
Procedure Type
1=Gastric bypass (proximal)
2=Gastric bypass (distal)
3=Biliopancreatic bypass
4=Biliopancreatic bypass with duodenal switch
5=Adjustable Lap Band
6=Sleeve gastrectomy
7=Other gastric bypass
Band Size
1=9.5cm
2=10cm
3=11cm
4=AP Standard
5=AP Large
6=Other
7=NA (not available)
Small Bowel
Resection
1 = Yes
2 = No
Allowable Values: Not applicable
Version 3.1
151
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Data Storage Type: Numeric
Suggested Data Source: Operative report, discharge summary
Abstraction Notes:
Exclusions: None
Version 3.1
152
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
I3) Bariatric: Stomach divided
Location: Adult Form, I. Bariatric
Definition: Was the stomach divided during the procedure
SORCE alias:
divided
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Not applicable for lap band operations
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative record
Abstraction Notes:
Exclusions: None
Version 3.1
153
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*I4) Post-op urinary catheter
Location: Adult Form, I. Bariatric
Definition: Indicate if the urinary catheter was removed prior to discharge. If yes,
indicate on which post-op day. The day of surgery is day zero. Not applicable if no
urinary catheter in place post-op or if patient has a permanent indwelling urinary catheter.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
3=Not applicable
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Nursing or surgeon notes, discharge summary
Abstraction Notes:
Exclusions: None
Version 3.1
154
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*I5) Bariatric: Distal anastomosis technique
Location: Adult Form, I. Bariatric
Definition: Indicate if the anastomosis technique is described. Specify whether the
anastomosis was stapled and/or handsewn.
If stapled, indicate whether circular or linear. If linear, indicate the number of fires of
the stapler and if a sealing device was used. If a sealing device was used, indicate how
many devices.
Note: This information is optional at this time
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes:
1=Yes
2=No
staple type
1=circular
2=linear
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative record
Abstraction Notes: .
Exclusions: lap band operations and sleeve gastrectomy without small bowel resection
Version 3.1
155
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*I6) Bariatric: Proximal anastomosis technique
Location: Adult Form, I. Bariatric
Definition: Indicate if the anastomosis technique is described. Specify whether the
anastomosis was stapled and/or handsewn.
If stapled, indicate whether circular or linear. If linear, indicate the number of fires of
the stapler and if a sealing device was used. If a sealing device was used, indicate how
many devices.
Note: This information is optional at this time
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes:
1=Yes
2=No
staple type
1=circular
2=linear
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative record
Abstraction Notes: .
Exclusions: lap band operations
Version 3.1
156
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
I7) Bariatric: Anastomosis tested
Location: Adult Form, I. Bariatric
Definition: Was the anastamosis tested
SORCE alias:
b_anastest
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 1=Yes
2=No
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative record
Abstraction Notes: Do not infer that if a scope was used during the procedure that it
was used for anastomosis testing; the Op Note must specifically state that the scope was
used for anastomosis testing.
Exclusions: Lap band operations
Version 3.1
157
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
I7.x) Bariatric: Anastomosis test type
Location: Adult Form, I. Bariatric
Definition: How was the anastomosis tested
SORCE alias:
b_scope
b_methblue
b_airinjct
b_palp
b_other
b_testtxt
Historic Variable: b_testtype
(other specified)
ARMUS Variable Name(s):
Field Format: Yes/No; Text
Value Codes:
Allowable Values: Not applicable
Data Storage Type: Numeric; Character
Suggested Data Source: Op record
Abstraction Notes: Do not infer any type of testing; the type of testing must be
specifically stated in the Op Note.
Exclusions:
Version 3.1
158
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*J1) Appendectomy: Pregnant
Location: Adult Form, J. Non-elective Appendectomy
Definition: If the patient is female, was she pregnant? No/yes If yes, indicate number
of weeks pregnant.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: ER record, H&P, operative note; discharge summary
Abstraction Notes:
Exclusions: None
Version 3.1
159
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*J2) Appendectomy: ER/Urgent Visit
Location: Adult Form, J. Non-elective Appendectomy
Definition: Any urgent care visit within one week and greater than 12 hours prior to this
operation; includes a clinic or ER visit; may also include an admission to a hospital for
s/s of appendicitis but the surgery was not done until another admission within the same
week. If yes, indicate at this facility or at another facility. If another facility, name the
facility.
SORCE alias:
ervisit
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple choice; Text
Value Codes: 1 = Yes
2 = No
1 = this facility
2 = other facility
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source: ER record, H&P, operative note; discharge summary
Abstraction Notes: Answer “yes” if patient seen in an urgent care visit of any kind
within one week and greater than 12 hours prior to the surgery. Answer “no” if patient
only seen in this hospital’s ER and admitted immediately from that ER visit. The intent
of this question is to identify patients who were seen for suspected appendicitis in an
urgent or emergent situation within a week prior to this procedure but surgery was not
done at that time. If there was an ER/urgent care visit in this time frame that is clearly
non-abdominal, e.g. fracture, answer “no”.
Exclusions: None
Version 3.1
160
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*J3) Appendectomy: Admit through ER
Location: Adult Form, J. Non-elective Appendectomy
Definition: Indicate if the patient was admitted for surgery through the ER at this
hospital. If yes, record date and time of arrival at the ER.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Date/Time
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric; Date/Time
Suggested Data Source: ER record, H&P, operative note; discharge summary
Abstraction Notes:
Exclusions: None
Version 3.1
161
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
J4) Appendectomy: Concurrent procedure performed
Location: Adult Form, J. Non-elective Appendectomy
Definition: Another abdominal or pelvic procedure performed concurrently with the
appendectomy. If yes, specify type.
SORCE alias:
appyplus
plustype
ARMUS Variable Name(s):
Field Format: Yes/No ; Multiple Choice
Value Codes:
1 = Yes
2 = No
1=Gynecologic
2=Colon
3=Gall bladder
4=Other
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note; discharge summary
Abstraction Notes: Answer “yes” if another procedure such as a colectomy or ovarian
cystectomy ws performed at the same time as the appendectomy. If yes, indicate whether
the concurrently performed procedure was gynecologic in nature or was colon, gall
bladder or other surgery.
Exclusions: None
Version 3.1
162
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*J5) Appendectomy: Preoperative imaging
Location: Adult Form, J. Non-elective Appendectomy
Definition: Imaging performed within 24 hrs preop. If yes, specify type of imaging (CT
scan and/or ultrasound and/or MRI), For each type of imaging, indicate date & time of
imaging and the imaging results (consistent or not consistent with appendicitis, or results
were indeterminate). Also indicate if the imaging study was performed at the admitting
hospital or another facility
If CT scan, specify the use of contrast and the route
SORCE alias:
Imaging
preopimg
Type
imgtype_ct
imgtype_us
imgtype_mri
Results
imgrslt_ct
imgrslt_us
imgrslt_mri
Date
ct_dt
us_dt
mri_dt
Time
ct_time
us_time
mri_time
Contrast
contrast
route
ARMUS Variable Name(s):
Field Format: Yes/No; Date/Time; Multiple Choice
Value Codes:
Imaging
1 = Yes
2 = No
Results
0=Consistent
1=Not consistent
2=Indeterminate
Location
1 = this facility
2 = other facility
Contrast route
0=IV
1=Oral
2=Rectal
Allowable Values:
Data Storage Type: Numeric; Date/time
Suggested Data Source: H&P, operative note, radiology report, discharge summary
Abstraction Notes: If yes, indicate CT scan and/or ultrasound. No other imaging study,
such as abdominal x-rays are applicable as they are not diagnostic for appendicitis.
If contrast is used for CT scan, indicate all routes. If the surgeon and radiologist
statements, differ, answer according to the radiologist report. Check “yes” if the report
states “probable appendicitis”. Check “indeterminate” if report states “possible
appendicitis”.
Exclusions: None
Version 3.1
163
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
J6) Appendectomy: Appendeceal pathology
Location: Adult Form, J. Non-elective Appendectomy
Definition: Appendeceal pathology confirmation consistent with acute appendicitis,
early appendicitis, mild appendicitis, inflammation or appendeceal tumor; inflammatory
fluid in the abdomen
SORCE alias:
pathrslt
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note; discharge summary; pathology report
Abstraction Notes: Statements in the pathology report such as “mild early” or “very
early” appendicitis also indicate appendeceal pathology. Fibrous obliteration of the tip of
the appendix does not indicate appendeceal pathology. If either the imaging or operative
report differs with the pathology report, the answer should be based on the pathology
report. In rare instances, the post op dx may be infracted epiploic appendage of the
vermiform appendix. This is a rare event that masquerades as acute appendicitis; the
epiploic appendage is located directly on the serosal surface of the appendix itself. The
pathology report would indicate this dx vs appendeceal pathology.
Exclusions: None
Version 3.1
164
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
J7) Appendectomy: Perforated appendix
Location: Adult Form, J. Non-elective Appendectomy
Definition: Pathology reports confirms perforated appendix. Pathology reports state
perforated appendix, ruptured appendix, peritonitis due to perforated appendix or
periappendicitis; pus in the abdomen
SORCE alias:
perfappx
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Operative note; pathology report, discharge summary
Abstraction Notes: If the operative report and the pathology report differ, answer
according to the pathology report with the following exception: In some cases, the
surgeon will state clearly that the appendix was ruptured, but the pathology report may
not be clear as in some cases of rupture, the appendix may be so badly damaged that
pathology only receives fragments and the pathologist will not be able to say the
appendix was ruptured.
Exclusions: None
Version 3.1
165
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K1) Colon/rectal: Prior surgery
Location: Adult Form, K. Colon Operation
Definition: Documentation of any previous colon or pelvic surgery, regardless of date or
facility. This includes hysterectomy, cholecystectomy, appendectomy and small bowel
resection. Include if it took place during this hospitalization but prior to this operation.
SORCE Alias:
priorsrg
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
H&P, Admit note (Nsg or MD), Progress notes.
Abstraction Notes:
This is to determine the complexity of the case. For
instance, a change in the anatomy or multiple adhesions. Does not include a prior
colonoscopy.
Exclusions:
none
Version 3.1
166
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K2) Colon/rectal: Procedure order/importance
Location: Adult Form, K. Colon Operation
Definition: Is the current colon procedure the primary or secondary operation? If
secondary, indicate category of the primary surgery. Gynecological, gall bladder,
vascular or other.
SORCE Alias:
procorder
primtype
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes:
Colon op Order
0=Primary
1=Secondary
Primary op Type
0=Gyne
1=Gall bladder
2=Vascular
3=Other
Allowable Values:
Data Storage Type:Numeric
Suggested Data Source: H&P, Admit note (Nsg or MD), Operative record, Progress
notes.
Abstraction Notes: This is to assist in the determination of the complexity of the case.
Exclusions: None
Version 3.1
167
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K3) Colon/rectal: Resection within 30 days
Location: Adult Form, K. Colon Operation
Definition: Was there a prior colon resection done anywhere within 30 days prior to this
surgery? Indicate, if known, the name of the previous hospital via the Washingon state
hospitals in the pull-down menu. If the hospital is not listed, select “other”.
SORCE alias:
resectn
hospital
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric; Character
Suggested Data Source:
H&P, Admit note (Nsg or MD), Progress Notes
Abstraction Notes:
This is to determine if there had been a leak or is a
complication of the previous surgery. Naming the facility will indicate if there has been a
transfer due to complications.
Exclusions: None
Version 3.1
168
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K4) Colon/rectal: Procedure priority & procedure staging
Location: Adult Form, K. Colon Operation
Definition: Elective or Non-elective. An elective procedure is one that is performed on a
patient whose symptoms and /or disease has been stable in the days or weeks prior to the
procedure. Typically elective cases are scheduled at least several days in advance. Nonelective procedures (including urgent or emergent) are required to minimize or address
further clinical deterioration.
If non-elective, indicate if the procedure is part of a planned staged process.
SORCE alias:
procpri
procstaged
ARMUS Variable Name(s):
Field Format: Multiple choice; Yes/No
Value Codes: 0=Elective
1=Non-Elective
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: H&P, Anesthesia note, Admit note, Progress note.
Abstraction Notes: This assists in the determination of the risk of complications. If
surgeon comes into another type of case to fix a colon perforation that occurred during
the surgery, this is considered an emergent case.
Exclusions:
None
Version 3.1
169
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K5) Colon/rectal: Operation type
Location: Adult Form, K. Colon Operation
Definition: Describe the type of operation performed. Check all that apply:
Right hemicolectomy – This term can be associated with resection of the terminal ileum,
including the cecum, to approximately the mid transverse colon. Other terms used in
association with it are: Assending colon, cecectomy, hepatic flexure. Transverse colons
are also included in this category.
Left hemicolectomy- includes the removal of the left side of the transverse colon all the
way to the sigmoid colon.This also includes a “sigmoid colon resection”. Other terms
used: splenic flexure, desending colon.
Low Anterior Resection: references the removal of the sigmoid colon usually with the
top of the rectum with reattachment of the colon to the higher to mid rectum. The lower
rectum and anal sphincter usually are not involved.
Abdominal Perineal Resection (APR): references the removal of the rectum from a
combined approach with both an abdominal and perineal incision. This surgery always
has a colostomy. Other terms used: Perineal proctectomy with an ileostomy or
colostomy. Also known as an APER, abdominal perineal excision of the rectum.
Frequently you will find two surgeons – one for the”clean” portion and one for the
“dirty” or rectum removal perianally. The anus is sewn shut.
Total Abdominal Colectomy –is associated with the removal of the left, right, and
sigmoid. The rectal stump remains in place. An ileostomy or ileoanal anastomosis can be
done. Anastomsis are frequently done with the creation of pouches. Included under this
heading is a Panproctocolectomy and an Ileoanal Pullthrough. If a R hemi and an LAR
are done in the same surgery, this is also a TAC.
Stoma Takedown -is referring to the rejoining of a temporary or protective stoma and
may include a partial colon resection. This includes a colostomy or illeostomy takedown.
Perineal proctectomy – perineal incision with the partial removal of the rectum/sigmoid
with a perineal anastomosis for a prolapse or mass removal from the rectum.
Abdominal protectomy - Surgical resection of the rectum-performed through an
abdominal incision ONLY. Does not remove anus or most distal rectum. The end of the
colon remaining may be reattached to the anus as an anastomosis. This anastomosis is
often but not always associated with a protective stoma (often an ileostomy) because it is
a higher risk reconnection. Often, no reconnection is made and a permanent colostomy is
created.
Additional procedure to establish intestinal continuity - Any other operation that does
not fit in the above types of operations in which previously divided colon segments are
reattached in a follow up surgery(e.g. a staged procedure). This most commonly occurs in
trauma cases, in cases where the index operation was terminated prematurely due to
Version 3.1
170
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
patient condition, or if there was a question of bowel ischemia. These are often referred
to as staged procedures as they are done in planned stages.
Also see Appendix B-colon diagram
SORCE Alias:
colproc
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 0=Right Hemicolectomy
1=Left Hemicolectomy
2=Low Anterior Resection
3=Abdominal Perineal Resection
4=Total Abdominal Colectomy
5=Colostomy Takedown
6=Perineal Proctectomy
7=Abdominal Proctectomy
8=Additional procedure to establish intestinal continuity
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Op record and discharge summary
Abstraction Notes: If there is a case of 2 different types of colon surgery in one
operation use the original intention. For instance, pt going for Stoma Takedown but due
to previous scarring has to do an LAR. The surgery would be the Takedown. Another
word for ischemic bowel is necrotic bowel.
Colectomies are categorized primarily by the resected part of the intestinal tract. Even if
only a very small section of the colon is removed, such as if a perforation occurred during
a colonoscopy and the repair involves removal of a very small section of the colon along
with suturing, this is still a colectomy and is categorized by the segment of the colon that
was removed.
Hartmann’s procedure is a poorly defined tem that refers to what is done with the distal
segment of the intestinal tract that is left behind and not attached; a stoma is always
involved, The surgeon may reference doing a Hartmann’s procedure along with a Left or
Right hemicolectomy or with a Low Anterior Resection or abdominal proctectomy.
Exclusions:
None
Version 3.1
171
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K6) Colon/rectal: Ostomy type
Location: Adult Form, K. Colon Operation
Definition: Colostomy – the colon is brought out through the abdominal wall to the
skin for evacuation of bowel contents.
Ileostomy – a portion of the small intestine is brought out through the skin
for evacation of bowel contents. It can be brought out as a “loop” (both ends are brought
out) or an “end ileostomy”(one end only)
Protective Stoma – is a temporary ostomy or one that is used so that a
section of the bowel may heal. This can be a colostomy or an ileostomy and is done at the
same time as the anastomosis to “protect” it from leaking. It is often used with the
creation of ileoanal or “J” pouches.
No Ostomy - None
SORCE Alias:
ostmytype
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes: 0=No ostomy
1=Colostomy
2=Ileostomy
3=Protective stoma
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Op record and discharge summary
Abstraction Notes:
Exclusions:
None
Version 3.1
172
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K7) Colon/rectal: Anastomosis
Location: Adult Form, K. Colon Operation
Definition: Was anastomosis done? If yes, specify what type of anastomosis:
Colocolon – colon to colon ( includes colon to rectum)
Ileocolon – ileum to colon
Ileoanal – ileum to anal
Coloanal – colon to anus
If the anastomosis was ileoanal or coloanal, indicate if a pouch was created.
Indicate if a pouch was created (applicable to all anastomosis types).
SORCE Alias:
anastmss
anastype
analpouch
anypouch
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes
1=Yes
2= No
0=Colocolon
1=Ileocolon
2=Ileoanal
3=Coloanal
4=Unable to be determined
No Pouch (Historic value)
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Operative record
Abstration Notes:
A pouch is an internal reservoir. Usually a protective stoma
is created after the colon and the rectum have been removed. The anus and the
surrounding muscle are left in place. In the case of an ileoanal or J pouch,a portion of the
ileum is shaped and attached to a rectal stump or the anus to work like the rectum, storing
waste until a bowel movement. This is frequently done in a 2 or 3 stage procedure to
insure healing of the pouch. After a period of time, a piece of colon or ileum is joined to
the new pouch and bowel contents will then be excreted “normally”. It is frequently done
for patients with Ulcerative Colitis or Familial Adenomatous Polyposis.
Version 3.1
173
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
If a jejunocolon anastomosis is described, choose ileocolon as the type as this is
essentially the same thing; however, ~ 4-5 feet of small bowel would have to be resected
for this type of anastomosis to occur.
Exclusions:
None
Version 3.1
174
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K8) Colon/rectal: Anastomosis technique
Location: Adult Form, K. Colon Operation
Definition: Indicate if the technique is described. If yes, specify whether the
anastomosis was stapled and/or handsewn. If stapled, indicate if the staple device was
circular or linear. If stapled, indicate if a sealing device was used. If a sealing device
used, indicate how many.
Note: This information is optional at this time
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes:
1=Yes
2=No
staple type
1=circular
2=linear
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Operative record
Abstraction Notes:
Exclusions: None
Version 3.1
175
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K9) Colon/rectal: Anastomosis tested
Location: Adult Form, K. Colon Operation
Definition: Was the anastomosis tested? If yes, indicate the type of test: Check all that
apply:
Scope – sigmoidoscope/protocscope or flexible endoscope inserted into the
rectum during surgery to insure the anastomosis is intact and patent.
Methylene Blue – the instillation of dye to assess for leaks.
Air injection – via a tube or syringe into the intestine which is then immersed in
saline to check for air bubbles.
Palpation/inspection.
Other – free text any other type of inspection
SORCE alias:
c_anastest
c_scope
c_methblue
c_airinjct
c_palp
c_other
c_testtxt
(other specified)
Historic Variable: c_testtype
ARMUS Variable Name(s):
Field Format: Yes/No; Text
Value Codes: 1=Yes 2=No
Allowable Values: Not applicable
Data Storage Type: Numeric; Character
Suggested Data Source:
Op note
Abstraction Notes:
This question is only applicable to an anastomosis of the
lower resections due to the inability to test the others. This would include L Hemi, LAR,
TAC. Do not infer that if a scope was used during the procedure that it was used for
anastomosis testing; the Op Note must specifically state that the scope was used for
anastomosis testing.
Exclusions:
Right hemicolectomies
Version 3.1
176
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K10) Colon/rectal: Post-op urinary catheter
Location: Adult Form, K. Colon Operation
Definition: Indicate if the urinary catheter was removed prior to discharge. If yes,
indicate on which post-op day. The day of surgery is day zero. Not applicable if no
urinary catheter in place post-op or if the patient has a permanent indwelling urinary
catheter.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Multiple Choice; Number
Value Codes: 1=Yes
2=No
3=Not applicable
Allowable Values: Not applicable
Data Storage Type: Numeric
Suggested Data Source: Nursing or surgeon notes, discharge summary
Abstraction Notes:
Exclusions: None
Version 3.1
177
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K11) Colon/rectal: Bowel Prep
Location: Adult Form, K. Colon Operation
Definition: Indicate if bowel prep was used prior to surgery. If yes, indicate the type of
preparation: mechanical and/or antibiotics.
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes 2=No
Allowable Values: Not applicable
Data Storage Type: Numeric; Character
Suggested Data Source:
Admit note, nursing note, Op note
Abstraction Notes:
Exclusions:
Version 3.1
178
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K12) Colon/rectal: Diet advanced
Location: Adult Form, K. Colon Operation
Definition: Indicate if the patient’s diet was advanced beyond clear liquids/ice chips. If
yes, specify the post-op day the diet was successfully advanced (without regression). The
day of surgery is day zero
SORCE alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Number
Value Codes: 1=Yes 2=No
Allowable Values: Not applicable
Data Storage Type: Numeric; Character
Suggested Data Source:
Nursing notes, Op note, Post-op medical & surgical notes.
Abstraction Notes:
Exclusions:
Version 3.1
179
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K13) Colon/rectal: Post-op cancer diagnosis
Location: Adult Form, K. Colon Operation
Definition: Did the patient have postoperative the diagnosis of cancer?
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1=Yes
2= No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Path report
Abstraction Notes: If the preoperative diagnosis is for something other than for cancer,
but cancer is found during the surgery, answer “yes” and complete the following
questions that have to do with a finding of cancer.
Exclusions:
Version 3.1
180
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K14) Colon/rectal: Lymph nodes removed
Location: Adult Form, K. Colon Operation
Definition: If none, indicate a zero, 0. While more lymph nodes may have been removed
than were examined or studied, only state the number of lymph nodes that were removed
and examined.
SORCE Alias:
lmphrmvd
lmph_na
(not available)
ARMUS Variable Name(s):
Field Format: Number
Value Codes:
Allowable Values: Whole numbers (0 – 30)
Data Storage Type: Numeric
Suggested Data Source:
Path report
Abstraction Notes:
The suggested amount is greater than 12 nodes for staging
of the cancer to help determine the course of treatment. The count can stop when a
positive lymph node is identified, If there are no positive nodes, then the count should go
to at least 12 nodes to avoid false negative results.
Exclusions:
Cases without cancer as the postoperative diagnosis.
Version 3.1
181
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K15) Colon/rectal: Lymph nodes positive for cancer.
Location: Adult Form, K. Colon Operation
Definition: If none, indicate zero 0.
SORCE Alias:
lmphcanc
ARMUS Variable Name(s):
Field Format: Number
Value Code:
Allowable Values: Whole numbers (0 – 30)
Data Storage Type: Numeric
Suggested Data Source:
Path report
Abstraction Notes: If no nodes were found as positive for cancer, be sure to indicate 0
rather than leaving this item blank.
Exclusions:
Cases without cancer as the postoperative diagnosis.
Version 3.1
182
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K16) Colon/rectal: Metastatic disease
Location: Adult Form, K. Colon Operation
Definition: Has the cancer spread beyond the colorectal area (e.g. liver, diaphragm,
peritoneum).
SORCE Alias:
metascanc
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
H&P if a staging CT or PET Scan has been done
Op report – visualization by the Surgeon
Path report
Abstraction Notes:
The surgeon may have done a staging CT or PET Scan
prior to the surgery if he is suspicious of metastasis; this may be noted in the H&P. The
Op note may include that the surgeon visually scaned the area e.g. liver, peritoneum and
noted spread. The Path report may contain biopsies of other organs.
Exclusions:
Cases without cancer as the postoperative diagnosis.
Version 3.1
183
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
K17) Colon/rectal: Cancer Margins
Location: Adult Form, K. Colon Operation
Definition: Are the margins free of cancer? If yes, how far away is normal tissue from
the cancerous tumor or lesion? Indicated the distance to the distal margin and the
proximal margin
SORCE Alias:
mrg_cafree
mrg_distal
mrg_prox
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes: 1= Yes 2= No
0 = < 1 cm
1 = 1 – 2 cm
2 = > 2 cm
3 = Not available
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Path report
Abstraction Notes:
This element applies to both rectal and colon cancers with
the exception of radial margins, which is applicable only to rectal cancer specimens. The
intent is to help guide further treatment recommendations. Pathologists may state the
proximal margin as the small bowel margin for a R colectomy or total colectomy. They
may also state the distal as colonic and the proximal as ileal.
Exclusions:
Cases without cancer as the postoperative diagnosis.
Version 3.1
184
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K18) Colon/rectal: T Stage
Location: Adult Form, K. Colon Operation
Definition: Staging unique to colon cancer: Tis through Ptx:. Check the appropriate stage
or NA. Stage reported should be based on pathology report.
Tis: The cancer is in the earliest stage. It involves only the mucosa. It has not grown
beyond the muscularis mucosa (inner muscle layer).
T1: The cancer has grown through the muscularis mucosa and extends into the
submucosa.
T2: The cancer has grown through the submucosa and extends into the muscularis
propria (outer muscle layer).
T3: The cancer has grown through the muscularis propria and into the subserosa but
not to any neighboring organs or tissues.
T4: The cancer has grown through the wall of the colon or rectum and into nearby
tissues or organs.
pTX: Presumptive primary site is not available for assessment
pTO: Presumptive primary site is available for evaluation there is no evidence of primary
tumor
pyTO: Presumptive primary site is available for evaluation and no evidence of residual
cancer after prior treatment.
SORCE Alias:
tstage
ARMUS Variable Name(s):
Field Format: Multiple Choice
Value Codes:
0=T1
1=T2
2=T3
3=T4
4=Tis
5=NA
6=pTO
7=pTx
8=pyTO
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Path report
Abstraction Notes:
Exclusions:
None
Version 3.1
185
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K19) Colon/rectal: Procedure done for palliation
Location: Adult Form, K. Colon Operation
Definition:
Was the surgery done for palliation rather than for curative reasons?
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes: 1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
H&P; Operative report
Abstraction Notes:
the operative report.
This should be clearly stated in either or both the H&P and
Exclusions:
Cases without rectal cancer as the postoperative diagnosis.
Version 3.1
186
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K20) Colon/rectal: Preoperative neoadjuvant treatment
Location: Adult Form, K. Colon Operation
Definition: Was radiation or chemotherapy done prior to the surgery
If yes, indicate if the therapy was chemotherapy or radiation was used. If radiation was
used, indicate what the time interval was between the end of the preoperative radiation
and the current surgery in number of weeks (round off to a whole number).
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Yes/No
Value Codes:
1=Yes
2=No
Allowable Values: 000 (weeks)
Data Storage Type: Numeric
Suggested Data Source:
H&P or the operative report
Abstraction Notes:
the operative report.
This should be clearly stated in either or both the H&P and
Exclusions:
Cases without rectal cancer as the postoperative diagnosis.
Version 3.1
187
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K21) Colon/rectal: Distance of the tumor from the anal verge
Location: Adult Form, K. Colon Operation
Definition: Was the distance of the tumor from the anal verge defined? If yes, indicate if
the distance was determined by the use of a rigid scope, a flexible scope and/or by digital
exam. Indicate the distance in cm. Indicate if the distance was determined after
neoadjunvant therapy of any kind?
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Yes/No; Multiple Choice; Number
Value Codes:
1=Yes
2=No
3=Not available
Allowable Values:
00.0 (cm)
Data Storage Type: Numeric
Suggested Data Source:
H&P and/or the operative report
Abstraction Notes:
the operative report.
This should be clearly stated in either or both the H&P or
Exclusions:
Cases without rectal cancer as the postoperative diagnosis.
Version 3.1
188
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K22) Colon/rectal: Tumor fixed to underlying structures
Location: Adult Form, K. Colon Operation
Definition:Was the cancer/tumor fixed to underlying tissues or structures?
If yes, did the surgeon indicate that the tumor became fixed after chemotherapy or
radiation?
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes:
1=Yes
2=No
3=Not available
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Path report or the operative report
Abstraction Notes:
and pathology report.
This should be clearly stated in either or both the operative
Exclusions:
Cases without rectal cancer as the postoperative diagnosis.
Version 3.1
189
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K23) Colon/rectal:Total mesorectal excision (TME)
Location: Adult Form, K. Colon Operation
Definition: Was a total mesorectal excision done? Indicate the distance to the radial
margin. Indicate if the TME capsule was intact.
TME is the precise dissection of the rectum and all pararectal lymph nodes within an
oncologic package; the mesorectal envelope. It has become universally accepted as the
preferred technique for surgical excision of rectal cancer as it results in lower rates of
local recurrence, is associated with increased sparing of the anal sphincter and, as it is
nerve sparing, is less likely than an abdominoperineal resection to lead to bladder and
sexual dysfunction.
SORCE Alias:
messexn
mrg_rad
capsule
ARMUS Variable Name(s):
Field Format: Yes/No; Multiple Choice
Value Codes:
Messorectal excision
1=Yes
2=No
Distance to radial
margin
0 = < 1 cm
1 = 1 – 2 cm
2 = > 2 cm
3 = Not available
TME capsule
1=Yes
2=No
3=Not available
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Path report or the operative report
Abstraction Notes:
and pathology report.
This should be clearly stated in either or both the operative
Version 3.1
190
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Exclusions:
Cases without cancer as the postoperative diagnosis.
Version 3.1
191
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K24) Colon/rectal: Stage determination methodology
Location: Adult Form, K. Colon Operation
Definition: Was the stage determined by the use of endoscopic ultrasound (EUS),
transrectal ultrasound (TRUS) or by MRI? If yes, indicate which method(s) were used.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1=Yes
2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
H&P or the operative report
Abstraction Notes:
the operative report.
This should be clearly stated in either or both the H&P and
Exclusions:
Cases without rectal cancer as the postoperative diagnosis.
Version 3.1
192
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K25) Colon/rectal: Diverticular disease
Location: Adult Form, K. Colon Operation
Definition: Diverticular disease (Diverticulosisis) is the condition of having diverticula
in the colon, which are outpocketings of the colonic mucosa and submucosa through
weaknesses of muscle layers in the colon wall. Infection of a diverticulum can result in
diverticulitis. This occurs in 10-25% of persons with diverticulosis. Tears in the colon
leading to bleeding or perforations may occur; intestinal obstruction may occur
(constipation or diarrhea does not rule this possibility out); and peritonitis, abscess
formation, sepsis, and fistula formation are also possible occurrences.
Indicate which of the listed conditions characterize the patient’s diverticular disease:
acute diverticulitis, current gastrointestinal bleeding, colovesical fistula and/or stricture.
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Yes/No
Value Codes
1=Yes
2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Operative record, H&P, Discharge summary
Abstration Notes:
Exclusions:
If patient did not have colectomy due to diverticular disease.
Version 3.1
193
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*K26) Colon/rectal: Prior episodes of diverticular disease
Location: Adult Form, K. Colon Operation
Definition: Indicate if there were any prior episodes of diverticular disease. If yes,
indicate how many prior treated episodes of diverticular disease the patient had. Indcate
if patient was treated as an inpatient for any prior episodes.
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Multiple choice; Number
Value Codes
1 = Yes
2 = No
3 = Not available (NA)
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Operative record, H&P, Discharge summary
Abstration Notes:
Exclusions:
If patient did not have colectomy due to diverticular disease.
Version 3.1
194
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L) Post-discharge: 30-day follow up
Location: Adult Form, L. Post-discharge
Definition: Indicate if the 30-day post-discharge information has been collected.
Complete the items in this section only if there is access to events that occur within the
first 30 days AFTER discharge from the index hospitalization. If the information is
unavailable, select “no”
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Yes/No
Value Codes
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source:
Abstration Notes:
Exclusions: Patients that died during the index hospitalization
Version 3.1
195
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L1) Post-discharge: Wound occurrences
Location: Adult Form, L. Post-discharge
Definition: Indicate if pt developed a superficial surgical site infection, a deep incisional
surgical site infection, an organ/space surgical infection or other wound infection. If
other, specify type.
Superficial Incisional SSI: Superficial incisional SSI is an infection that occurs within 30
days after the operation and infection involves only skin or subcutaneous tissue of the
incision and at least one of the following:
 Purulent drainage, with or without laboratory confirmation, from the superficial
incision.
 Organisms isolated from an aseptically obtained culture of fluid or tissue from
thesuperficial incision.
 At least one of the following signs or symptoms of infection: pain or tenderness,
localized swelling, redness, or heat AND superficial incision is deliberately
opened by the surgeon, unless incision is culture-negative.
 Diagnosis of superficial incisional SSI by the surgeon or attending physician.
The following conditions are not an SSI:
o Stitch abscess (minimal inflammation and discharge confined to the points of
o suture penetration).
o Infected burn wound.
o Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).
Deep Incisional SSI: Deep Incision SSI is an infection that occurs within 30 days after the
operation and the infection appears to be related to the operation and infection involved
deep soft tissues (for example, fascial and muscle layers) of the incision and at least one of
the following:
 Purulent drainage from the deep incision but not from the organ/space
component of the surgical site.
 A deep incision spontaneously dehisces or is deliberately opened by a surgeon
when the patient has at least one of the following signs or symptoms: fever (> 38
C), localized pain, or tenderness, unless site is culture-negative.
 An abscess or other evidence of infection involving the deep incision is found on
direct examination, during reoperation, or by histopathologic or radiologic
examination.
 Diagnosis of a deep incision SSI by a surgeon or attending physician.
Note:
o Report infection that involves both superficial and deep incision sites as deep incisional
SSI.
o Report an organ/space SSI that drains through the incision as a deep incisional SSI.
Version 3.1
196
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Organ/Space SSI: Organ/Space SSI is an infection that occurs within 30 days after the
operation and the infection appears to be related to the operation and the infection involves
any part of the anatomy (for example, organs or spaces), other than the incision, which was
opened or manipulated during an operation and at least one of the following:
 Purulent drainage from a drain that is placed through a stab wound into the
organ/space.
 Organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space.
 An abscess or other evidence of infection involving the organ/space that is
found on direct examination, during reoperation, or by histopathologic or
radiologic examination.
 Diagnosis of an organ/space SSI by a surgeon or attending physician.
SORCE Alias:
ARMUS Variable Name(s):
Field Format:
Yes/No
Value Codes:
1=Yes
2=No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes, Discharge summary , laboratory reports
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
197
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L2) Post-discharge: Respiratory occurrences
Location: Adult Form, L. Post-discharge
Definitions: Indicate if any respiratory complications occurred.
If yes, indicate if the complication was pneumonia, an unplanned intubation, a pulmonary
embolism, if on a ventilator longer than 48 hrs, or other. If other, specify.
Pneumonia: Enter “Yes” if the patient has pneumonia meeting the definition below
AND pneumonia was not present preoperatively. Patients with pneumonia must meet
criteria from both Radiology and Signs/Symptoms/Laboratory sections listed as follows:
Radiology:
One definitive chest radiological exam (x-ray or CT)* with at least one of the
following:
• New or progressive and persistent infiltrate
• Consolidation or opacity
• Cavitation
*Note: In patients with underlying pulmonary or cardiac disease (e.g. respiratory distress
syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive
pulmonary disease), two or more serial chest radiological exams (xray or CT) are
required.
Signs/Symptoms/Laboratory:
FOR ANY PATIENT, at least one of the following:
 Fever (>380C or >100.40F) with no other recognized cause
 Leukopenia (<4000 WBC/mm3) or leukocytosis(≥12,000 WBC/mm3)
 For adults ≥ 70 years old, altered mental status with no other recognized cause
And
At least one of the following:
 5% Bronchoalveolar lavage (BAL) -obtained cells contain intracellular
bacteria on direct microscopic exam (e.g., Gram stain)
 Positive growth in blood culture not related to another source of infection
 Positive growth in culture of pleural fluid
 Positive quantitative culture from minimally contaminated lower respiratory
tract (LRT) specimen (e.g. BAL or protected specimen brushing)
Or
At least two of the following:
 New onset of purulent sputum, or change in character of sputum, or increased
respiratory secretions, or increased suctioning requirements
 New onset or worsening cough, or dyspnea, or tachypnea
 Rales or bronchial breath sounds
 Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 ≤ 240),
increased oxygen requirements, or increased ventilator demand)
Version 3.1
198
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Unplanned Intubation for Respiratory/Cardiac Failure: Patient required placement of
an endotracheal tube and mechanical or assisted ventilation because of the onset of
respiratory or cardiac failure manifested by severe respiratory distress, hypoxia,
hypercarbia, or respiratory acidosis. In patients who were intubated for their surgery,
unplanned intubation occurs after they have been extubated after surgery. In patients who
were not intubated during surgery, intubation at any time after their surgery is considered
unplanned.
Pulmonary Embolism: Lodging of a blood clot in a pulmonary artery with subsequent
obstruction of blood supply to the lung parenchyma. The blood clots usually originate
from the deep leg veins or the pelvic venous system. Enter "YES" if the patient has a V-Q
scan interpreted as high probability of pulmonary embolism or a positive CT spiral exam,
pulmonary arteriogram or CT angiogram. Treatment usually consists of:
 Initiation of anticoagulation therapy
 Placement of mechanical interruption (for example Greenfield Filter), for patients
in whom anticoagulation is contraindicated or already instituted.
On Ventilator > 48 hours: Total duration of ventilator-assisted respirations during
postoperative hospitalization was greater than 48 hours. This can occur at any time during
the 30-day period postoperatively. This time assessment is CUMULATIVE, not
necessarily consecutive. Ventilator-assisted respirations can be via endotracheal tube,
nasotracheal tube,or tracheostomy tube.
Other Respiratory Occurrence: Enter any other respiratory occurrences that you feel to
be significant and are not covered by the above outcome criteria.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes; discharge summary, laboratory reports;
radiology reports.
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
199
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L3) Post-discharge: Urinary tract occurrences
Location: Adult Form, L. Post-discharge
Definitions: Indicate if a urinary tract complication occurred. If yes, indicate if was
progressive renal failure, acute renal failure, a urinary tract infection or other. If other,
specify.
Progressive Renal Insufficiency: The reduced capacity of the kidney to perform
itsfunction as evidenced by a rise in creatinine of >2 mg/dl from preoperative value, but
with no requirement for dialysis.
Acute Renal Failure Requiring Dialysis: In a patient who did not require dialysis
preoperatively, worsening of renal dysfunction postoperatively requiring hemodialysis,
peritoneal dialysis, hemofiltration, hemodiafiltration, or ultrafiltration. TIP: If the patient
refuses dialysis you would still answer ‘Yes’ to this variable because he/she did require
dialysis.
Urinary Tract Infection: Postoperative symptomatic urinary tract infection must meet one
of the following TWO criteria:
One of the following:
� fever (>38 degrees C)
� urgency
� frequency
� dysuria
� suprapubic tenderness
AND a urine culture of > 100,000 colonies/ml urine with no more than two species of
organisms
OR
Two of the following:
� fever (>38 degrees C)
� urgency
� frequency
� dysuria
� suprapubic tenderness
AND any of the following:
 Dipstick test positive for leukocyte esterase and/or nitrate
 Pyuria (>10 WBCs/mm3 or > 3 WBC/hpf of unspun urine)
 Organisms seen on Gram stain of unspun urine
 Two urine cultures with repeated isolation of the same uropathogen with >100
colonies/ml urine in non-voided specimen
 Urine culture with < 100,000 colonies/ml urine of single uropathogen in patient
being treated with appropriate antimicrobial therapy
 Physician's diagnosis
Version 3.1
200
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010

Physician institutes appropriate antimicrobial therapy
Other Urinary Occurrence: Enter any other urinary occurrences which you feel to be
significant and that are not covered by the above outcome criteria.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes; discharge summary, laboratory reports;
radiology reports.
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
201
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L4) Post-discharge: CNS occurences
Location: Adult Form, L. Post-discharge
Definitions: Indicate if a central nervous system (CNS) complication occurred. If yes,
indicate if the complication was a CVA/stroke, comatose time for more than 24 hrs,
peripheral nerve injury, or other. If other, specify.
Stroke/Cerebral Vascular Accident (CVA): Patient develops an embolic, thrombotic, or
hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (for
example, hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory) that persists
for 24 or more hours.
Coma >24 Hours: Patient is unconscious, or postures to painful stimuli, or is unresponsive
to all stimuli (exclude transient disorientation or psychosis) for greater than 24 hours. Do not
include drug-induced coma (for example Propofol drips).
Peripheral Nerve Injury: Peripheral nerve damage may result from damage to the nerve
fibers, cell body, or myelin sheath during surgery. Peripheral nerve injuries which result in
motor deficits to the cervical plexus, brachial plexus, ulnar plexus, lumbar-sacral plexus
(sciatic nerve), peroneal nerve, and/or the femoral nerve should be included.
Other CNS Occurrence: Enter any other neurologic related occurrences that you feel to
be significant and that are not covered by the above outcome criteria.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes; discharge summary, radiology reports.
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
202
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L5) Post-discharge: Cardiac occurrences
Location: Adult Form, L. Post-discharge
Definition: Did the patient have a cardiac complication occur? If yes, indicate if was a
cardiac arrest requiring CPR, a myocardial infarction (heart attack), or other. If other,
specify.
Cardiac Arrest Requiring CPR: The absence of cardiac rhythm or presence of
chaoticcardiac rhythm that results in loss of consciousness requiring the initiation of any
component of basic and/or advanced cardiac life support. Patients with automatic
implantable cardioverter defibrillator (AICD) that fire but the patient has no loss of
consciousness should be excluded.
Myocardial Infarction: An acute myocardial infarction occurring within 30 days following
surgery as manifested by one of the following:
♦ Documentation of ECG changes indicative of acute MI(one or more of the following):
o ST elevation > 1 mm in two or more contiguous leads
o New left bundle branch
o New q-wave in two of more contiguous leads
♦ New elevation in troponin greater than 3 times upper level of the reference range in the
setting of suspected myocardial ischemia
♦ Physician diagnosis of myocardial infarction
Other Cardiac Occurrence: Enter any other cardiac related surgical occurrences that you
feel to be significant and that are not covered by the above outcome criteria.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes; discharge summary, radiology reports.
Abstraction Notes:
Version 3.1
203
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Exclusions:
Patients that died during the index hospitalization
Version 3.1
204
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L6) Post-discharge: Other occurences
Location: Adult Form, L. Post-discharge
Definition: Did the patient have any of the following complications: bleeding that
required greater than 4 units of red blood cells (RBC) in the first 72 hrs of admission, a
graft/prosthesis/flap failure, a deep vein thrombosis (DVT) requiring treatment, systemic
sepsis, systemic septic shock, or other.
Bleeding Requiring >4 Units PRBC's or Whole Blood Transfusions within the First
72 Hours After Surgery: Any transfusion (including autologous) of packed red blood
cells or whole blood given from the time the patient leaves the operating room up to and
including 72 hours postoperatively. Enter "YES" for five or more units of packed red
blood cell units in the postoperative period including hanging blood from the OR that is
finished outside of the OR. If the patient receives shed blood, autologous blood, cell
saver blood or pleurovac postoperatively, this is counted if greater than four units. The
blood may be given for any reason.
Deep Vein Thrombosis (DVT)/Requiring Therapy: The identification of a new blood
clot or thrombus within the venous system, which may be coupled with inflammation.
This diagnosis is confirmed by a duplex, venogram or CT scan. The patient must be
treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of
the vena cava.
Sepsis: Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of
disorders spans from relatively mild physiologic abnormalities to septic shock. Please
report the most significant level using the criteria below:
Systemic Sepsis: Sepsis is the systemic response to infection. Report this variable if the
patient has two of the following clinical signs and symptoms of SIRS:
� Temp >38o C (100.4 o F) or < 36 o C (96.8 o F)
� HR >90 bpm
� RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa)
� WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms
� Anion gap acidosis: this is defined by either:
� [Na + K] – [Cl + HCO3 (or serum CO2)]. If this number is greater than 16,
then an anion gap acidosis is present.
� Na – [Cl + HCO3 (or serum CO2)]. If this number is greater than 12, then an
anion gap acidosis is present.
and one of the following:
� positive blood culture
� clinical documentation of purulence or positive culture from any site thought to
be causative
Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ
and/or circulatory dysfunction. Report this variable if the patient has sepsis AND
documented organ and/or circulatory dysfunction. Examples of organ dysfunction
Version 3.1
205
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of
circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor
agents. Severe Sepsis/Septic Shock is assigned when it appears to be related to Sepsis and
not a Cardiogenic or Hypovolemic etiology.
*Note: For the patient that had sepsis preoperatively, worsening of any of the above signs
postoperatively would be reported as a postoperative sepsis.
Other Occurrence: Enter any other surgical occurrences which you feel to be significant
and that are not covered by the above outcome criteria.
SORCE Alias:
ARMUS Variable Name(s):
Field Format: Yes/No
Value Codes:
1 = Yes
2 = No
Allowable Values:
Data Storage Type: Numeric
Suggested Data Source: Progress notes; discharge summary, radiology reports.
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
206
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L7.x) Post-discharge: Readmitted to acute care
Location: Adult Form, L. Post-discharge
Definitions: Was patient readmitted to an acute care facility? If so, indicate the date of
admission and the primary diagnosis: ICD-9 diagnosis code. Indicate if the patient
returned to the operating room for a procedure. If yes, indicate the procedure using ICD9 procedure codes and/or CPT codes.
Note: There are ICD-9 codes for diagnoses (volume 1) and procedures (volume 3). Be
sure to use the correct set of codes.
SORCE Alias
ARMUS Variable Name(s):
Field Format: Yes/No; Date/Time; Text
Value Codes:
1=Yes
2=No
Allowable Values:
000.00
00.00
xxxxx
(ICD9 diagnosis codes: text due to leading zeros, and letters)
(ICD9 procedure codes:text due to leading zeros)
(5 characters: CPT codes are text; may contain numbers & letters)
Data Storage Type: Numeric; Character
Suggested Data Source: Demographic sheet of the acute care readmit chart; operative
record; discharge summary
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
207
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
*L8) Post-discharge: Death
Location: Adult Form, L. Post-discharge
Definitions: Did the patient die within 30 days of discharge from the index
hospitalization? If yes, enter the date of death
SORCE Alias
ARMUS Variable Name(s):
Field Format:
Yes/No; Date/Time
Value Codes:
1=Yes
2=No
Allowable Values:
Data Storage Type: Numeric; Date/time
Suggested Data Source: Readmit chart if the patient was readmitted; clinic notes of the
follow up physician if patient not readmitted
Abstraction Notes:
Exclusions:
Patients that died during the index hospitalization
Version 3.1
208
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Appendix A: Medications
Note: lists are not all-inclusive, and trade names may change.
Drug Class
ACE Inhibitors
ARBs
Anticoagulants
Anticonvulsants
Names
Benazepril hydrochloride
Captopril
Analapril Maleate
Fosinopril Sodium
Lisinopril
Moexipril hydrochloride
Perindopril erbumine
Quianpril hydrochloride
Ramipril
trandolapril
Candesartan Cilexitil
Eprosartan Mesylate
Irbesartan
Losartan Potassium
Olmesartan Medoxomil
Telmisartan
Valsartan
Comments
These may be used for the
treatment of hypertension.
If the patient is on one of
these medications, and the
medical record does not
specify another reason for
being on this medication,
assume that it is being used
to treat hypertension.
These may be used for the
treatment of hypertension.
If the patient is on one of
these medications, and the
medical record does not
specify another reason for
being on this medication,
assume that it is being used
to treat hypertension.
Heparin
Coumadin
Warfarin
Low molecular weight heparin
Fragmin (dalteparin)
Lovenox (enoxaparin)
Aristra (fondaparinux)
Innohep (tinzaparin)
Gabitrel (tiagebine)
Lyrica (pregablin)
Neurontin (gabapentin)
Depakote/Depekene
Keppra (levetiracetam)
Tegretol (carbamzapine)
Topomax (topiramte)
Trileptal (oxcarbazine)
Zonegran (zonisamide)
Lamictal (lamotrigene)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (chlorazepate)
Version 3.1
209
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Drug Class
Antidiabetic agents
Antiplatelet agents
Beta Blockers
Names
Insulin
Acarbose
Byetta
Glimepiride
Glipizide
Glyburide
Metformin hydrochloride
Miglitol
Pioglitazone hydrochloride
Rosiglitazone maleate
Tolazamide
Tolbutamide (with or without
sodium)
Aggrenox (combo of ASA and
extended release dipyridamole)
Aspirin (ASA)
Plavis (Clopidogral)
Pletal (cilostrazol)
Persantine (Dipyridamole)
Ticlid (ticolidine)
Comments
Acebutolol
Atenolol
Betapace (sotalol)
Betaxolol
Bisoprolol
Blocadren (timolol)
Brevibloc (esmolol)
Cartrol (carteolol)
Carteolol
Carvedilol
Coreg (carvedilol)
Esmolol
Inderal (propranolol)
Innopran (“)
Kerlone (betaxolol)
Labetalol
Levatol (penbutolol)
Lopressor (metoprolol)
Metoprolol
Nadolol
Normodyne (labetlol)
Penbutolol
Pindolol
Alone or in combination. *
indicates combination drug.
These may be used for the
treatment of hypertension.
If the patient is on one of
these medications, and the
medical record does not
specify another reason for
being on this medication,
assume that it is being used
to treat hypertension.
Version 3.1
210
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Drug Class
Names
Proranolol
Sectral (acebutolol)
Sotalol
Tenormin(atenolol)
Timolol
Toprol (metoprolol)
Trandate (labetalol)
Visken (pindolol)
Zebeta (bisoprolol)
*atenolol/chlorthalidone
*bisoprolol/HCTZ
*Corzide
(bendroflumethiazide/nadolol)
*HCTZ/propranolol
*Inderide (“)
*Lopressor HCT (“)
*Tenoretic
(atenolol/chlorthalidone)
*Timolide (HCTZ/timolol)
*Ziac (bisoprolol/HCTZ)
Diuretics
Dyazide
(hydrochlorthiazide/triamterene)
Maxzide
(triamterene/hydrochorthiazide)
Edecrin (ethacrynic acid)
Lasix (furosemide)
Dyrenium (triamterene)
Diuril
Midamor (amiloride HCL)
Immunosuppressives/ Prednisone
steroids
Cortisone
Methotrexate
Cyclosporine
Azasan (azathioprine)
CellCept (mycophenoiate mofetil)
Myfortic (mycophenolic acide)
Neoral (cyclosporine)
Prograf (tacrolimus)
Rapamune (sirolimus)
Sandimmune (cyclosporine)
Narcotics
Comments
These may be used for the
treatment of hypertension.
If the patient is on one of
these medications, and the
medical record does not
specify another reason for
being on this medication,
assume that it is being used
to treat hypertension.
Do not include inhaled
medications, e.g., for
asthma.
Actiq
Avinza
Combunox
Version 3.1
211
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Drug Class
NSAIDs
Statins
Names
Demerol
DepoDur
Darvocet
Dilaudid (hydromorphone)
Duragesic
Duramorph
Fentanyl
Lortab
MS Contin (morphine sulfate)
Nubain
Numorphan
Morphine Sulfate
OxyContin (oxycodone)
Perocet
Percodan
Tylenol with Codeine
Vicodin (hydrocodone)
Zydone
Celecoxib
Diclofenac (potassium or sodium)
Diflunisal
Etodolac
Fenoprofen calcium
Flurbiprofen (with/without
sodium)
Ibuprofen
Indomethacin (with/without
sodium trihydrate)
Ketoprofen
Ketorolac tromethamine
Eclofenamate sodium
Mefanemic acid
Meloxicam
Nabumetone
Naproxen (with/without sodium)
Oxaprozin
Piroxicam
Rofecoxib
Sulindac
Tolmetin sodium
Valdecoxib
Atorvastatin calcium (Lipitor)
Fluvastatin sodium (Lescol)
Lovastatin (Mevacor)
Comments
Version 3.1
212
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Drug Class
Vasodilators
Vasopressors
Names
Pravastatin sodium (Pravachol)
Rosuvastatin calcium (Crestor)
Simvastatin (Zocor)
Cardene (nicardipine)
Esmolol (beta blocker but used to
lower BP at times)
Labetalol (beta blocker but used
to lower BP at times)
Nipride (nitroprusside)
Tridil (nitroglycerin)
Dopamine
Levophed (norepinephrine)
Neosynephrine (phenylephrine)
Vasopressin
Comments
Version 3.1
213
SCOAP Data Dictionary
Specifications for Discharges beginning 1/1/2010
Appendix B: Colon/rectal procedure diagram
Version 3.1