Download SCOAP Data Collection Form

2011 (version 012111)
SCOAP Data Collection Form For Adults (effective for discharges starting January 1, 2011)
Note: Complete one form for each procedure.
A new record online should contain patient and procedure information for only one procedure.
§ Core 1: All procedures
‡ Core 2: Not applicable to Appendectomy, Breast
(Exceptions will be noted)
B. Demographics
§B1) First 2 letters of Last Name/First Name: ___ ___ / ___ ___
§B2) Hospital Code: ______
§B3) Date of Birth: _____ / _____ / _____
§B4) Medical record # (optional): ____________
§B5) Admit:
a. Date ____ / ____ / ____
b.Time: ___:____  NA
§B6) Discharge:
a. Date ____ / ____ / ____
b. Time: ___:____  NA
§B7) Gender:
 Male  Female
§B8) Age at Admit _____ (years)
§B9) Race:
 American Indian/ Alaska Native
 Black or African American
 White
 Asian
 Native Hawaiian or Other Pacific Islander
 NA/Unknown
§B10) Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino
§B11) Patient Height: _____ (in)
OR
_____ (cm)
§B12) Patient Weight: _____ (lbs)
OR
_____ (kg)
 NA
§B13) Insurance: (Check all that apply)
13.1 Private:
 No  Yes
13.2 If private, choose one:
 Regence
 Premera
 First Choice
 Group Health
 Aetna
 Cigna
 Uniform Medical
 United Healthcare
 Kaiser
 Other Private
13.3 Medicare:
 No  Yes
13.4 Medicaid:
 No  Yes
13.5 TriCare:
 No  Yes
13.6 Indian Health Svcs:
 No  Yes
13.7 VA benefic.:
 No  Yes
13.8 Uninsured:
 No  Yes
13.9 Self pay:
 No  Yes
13.10 Labor and Industry
 No  Yes
13.11 Other government sponsored programs:
 No  Yes
§B14) Admission is a transfer from another hospital:  No  Yes
§B15) ZIP Code: ____________  NA
493700536
Patient Initials: ___________
Date of Birth: ___________
§B16) Procedure Priority:
 Elective  Non-Elective
§ B17) Discharge disposition:
 Home
 Rehab facility
 SNF
Admit Date: _______________
 Other acute care hospital
 Death: a. If death, specify:
 Death in the O.R.
 Death within 24hrs post-op
 Death after 24 hrs post-op
Indication for operation: Check all that apply within each category
B18) For appendectomy:
 No  Yes
18.1  Appendicitis
18.2  Appendiceal mass
or Cancer
18.3  Other
18.3a (specify):
____________________
B19) For
bariatric/gastric surgery:
 No  Yes
19.1  Morbid obesity
19.2  Revision/reversal
19.3  Other
19.3a (specify):
____________________
19.4  Gastric cancer
19.5  Gastric ulcer
B21) For breast cancer:
B22) For prostate cancer:
B23) For lung cancer:
B24) For liver cancer:
B25) For pancreas cancer:
B26) For kidney cancer:
B27) For esophagus cancer:
B28) For uterine cancer:








No
No
No
No
No
No
No
No
B20) For colon:
 No  Yes
Cancer of colon
Diverticular disease
Colon mass
Radiation colitis
Volvulus
Arteriovenous
malformation
20.7  Ischemic colon
20.8  Polyps
20.9  Rectal prolapse
20.1 
20.2 
20.3 
20.4 
20.5 
20.6 
20.10  GI bleeding
20.11  Perforation
20.12  Cancer of rectum
20.13  Bowel obstruction
20.14  Colostomy
20.15  Ulcerative colitis
20.16  Crohn’s disease
20.17  Stricture
20.18  Gynecological
malignancy
20.19  Iatrogenic
bowel injury
20.20  Other:
20.20a(specify):
___________________
 Yes
 Yes
 Yes (pre-op diagnosis must be non-small cell carcinoma)
 Yes
 Yes
 Yes
 Yes
 Yes
C. Risk Factors
§C1) Cigarette smoker: (within the past year)
 No  Yes
Detailed smoking history: answer for all cases
 Never
 Former (> 1 month)
 Current
If ever a smoker, indicate pack years
_______
 Unknown
 NA
§C2) Most recent laboratory values within 30 days prior to the operation: (unless otherwise specified)
2.1
Albumin:
_____ Gm/dl
 NA (most recent within 6 weeks prior to the operation)
2.3
Creatinine:
_____ mg/dl
 NA
2.4
HGB:
_____ g/dl
 NA if HGB not available: Hct:
2.5
WBC:
_____ 103
 NA
2.6
HbA1C:
_____ %
 NA (most recent within 3 months prior to the operation)
_____%
(Applicable if Albumin less than 3.0 gm/dl)
‡C3) Was a nutritional intervention performed within 30 days prior to the operation:  No  Yes
If yes, 1. IV based
 No  Yes
2. Oral supplementation  No  Yes
2011 Adult version 01/21/2011
Page 2 of 14
 NA
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
(Evaluate only the first 30 days of the hospitalization)
‡C4) Highest creatinine level during this hospitalization: ______mg/dL
 NA
§C5) Current / recent medications used:
 No  Yes 5.2 Statin
 No  Yes 5.3 Beta Blockers
 No  Yes 5.4 ACE or ARB Inhibitors
 No  Yes 5.5 Therapeutic anticoagulation (within 1 week of surgery)
 No  Yes 5.6 Steroids (within 24 hours of surgery)
§C6) Home O2 use:
 No  Yes
§C7) Home mobility device use:
 No  Yes
D. Comorbidities
If yes, check the best response
Comorbidities:
§D1) Hypertension:
 No  Yes
 No meds
§D2) Diabetes:
 No  Yes
 No meds
 Single non-insulin
 Multiple non-insulin
§D3) Asthma:
 No  Yes
§D4) Sleep Apnea:
 No  Yes
§D5) Coronary Artery Disease: No  Yes
§D6) History of VTE:
 No  Yes
§D7) HIV / AIDS:
 No  Yes
§D8) Current Dialysis
 No  Yes
 CPAP
 Single med
 Multiple meds
 Insulin
 Insulin + Other
 None
 History MI
 PCI, CABG, AICD
 Both
 None
E. Operative/ F. Intra-Operative
§E1) Primary Surgeon: ______________________________________________ (Optional, ID # only – NO names)
§E2) Assistant Type:  No Assistant  MD/DO
 PA
 RNFA
 Other non-MD/DO
 Unknown
Assistant ID :___________________________________ (Optional, ID # only – NO names)
§E3) Anesthesia provider: ___________________________________________ (Optional, ID # only – NO names)
§F1) Time of first Incision:
Time: _____:_____ (24-hr clock)
 NA
§F2) In-room Close Time
Time: _____:_____ (24-hr clock)
 NA
§F3) Date of surgery: _____ / _____ / _____
§F5) Surgical Approach:
2011 Adult version 01/21/2011




F4) In-room close date: _____ / _____ / _____
Laparoscopic/Videoscopic
 Lap/Video converted to open
Lap/Video, hand-assisted
 Open (no lap ports)
Laparoscopic, robotic assistance
Laparoscopic, robotic assistance converted to open
Page 3 of 14
Patient Initials: ___________
Date of Birth: ___________
§F6) ASA Class:
 I
 II
a. Emergent (E):  No  Yes
 III
 IV
Admit Date: _______________
 V
 Already intubated
 NA
§F7) What skin preparation material was used in the OR
 Chlorhexedine
 Chlorhexedine-Alcohol
 Povidone
 Povidone-Alcohol
 Other
§F8) Highest perioperative blood glucose:
_____mg
§F9) Insulin used in perioperative time period:
 No  Yes
§F10) First fasting blood glucose on post op day 1:
_____mg
 NA
 NA
§F11) Highest Blood Glucose within 48 hrs ending at the close of Post-op day 2:
_____mg
 NA
§F12) Lowest Blood Glucose within 48 hrs ending at the close of Post-op day 2:
_____mg
 NA
(If procedure is appendectomy, skip questions 13 and 14)
§F13) Lowest intra-op temperature:
_____oC
OR
_____oF  NA
§F14) First temp on arrival to recovery: _____oC
OR
_____oF  NA (Not applicable if death in the OR)
G. Perioperative Interventions
Perioperative interventions: (Check all that apply)
DVT Prophylaxis: Heparin or low molecular weight heparin or synthetic factor Xa or other drugs used for DVT
prophylaxis excluding ASA:
‡G1) Administered within 24 hours of incision:
If yes,
a. when was prophylaxis given:
 No  Yes  Contraindicated
 Pre-op  Intra-op/Post-op  Both
(Not applicable if death in O.R.)
‡G2) Ordered for in-hospital use after the first 24 hrs post-op:  No  Yes  Contraindicated
If yes,
a. daily treatment ordered:
 No  Yes
b. indicate number of days of treatment ordered: ___ days  NA
(Not applicable if discharge disposition is death)
‡G3) Ordered on discharge:
 No  Yes  Contraindicated
If yes,
a. indicate number of days of treatment prescribed: ___ days  NA
Beta-blocker: (Applicable if current medications include Betablocker (C5.3))
§G5) Administered within 24hrs pre-op
 No  Yes  Contraindicated
§G7) Ordered within 24 hrs post-op:
 No  Yes  Contraindicated
Antibiotics: (Not applicable if appy)
§G8) On antibiotics for the treatment of infection:
If yes:
a. At this hospital/upon admission
b. At transferring hospital:
§G9) Were prophylactic antibiotics indicated:
2011 Adult version 01/21/2011
(Not applicable if death in O.R.)
 No  Yes
 No  Yes
 No  Yes (Not applicable if pt not transferred (B14))
 No  Yes
Page 4 of 14
Patient Initials: ___________
If yes:
Date of Birth: ___________
Admit Date: _______________
a. Administered within 60 min of incision:  No  Yes
b. Discontinued within 24 hrs after closure:  No  Yes (Not applicable if death in O.R.)
Advanced Pain Control Methods: (Not applicable if death in the O.R.)
‡G10) Epidural placed during hospitalization:
a. was the epidural a PCEA (Patient Controlled Epidural Analgesia)
1. date started: _____/ _____/ _____(mm/dd/yyyy)
 NA
2. placed pre-op
 No  Yes  NA
3. ordered within 24 hrs post-op:
 No  Yes
4. placed post-op
 No  Yes  NA
5. date discontinued: _____/ _____/ _____(mm/dd/yyyy)
 NA
 No  Yes
 No  Yes
 Contraindicated
 No  Yes
 Contraindicated
‡G12) Continuous local anesthetic infusion ordered within 24 hrs post-op
 No  Yes
a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy)
 NA
 Contraindicated
‡G11) PCA ordered within 24 hrs post-op:
a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy)
Additional Perioperative Medications
‡G15) Was Entereg (generic is alvimopan) administered:
 NA
 No  Yes
§G16) Was Aloxi (generic is palonosetron hydrochloride) administered:
 No  Yes
(Applicable if patient on statin (C3: Current med))
‡G17) Was a statin ordered post-op for in-hospital use:
 No  Yes (Not applicable if death in the O.R.)
Nasogastric tube: (Not applicable if death in the O.R.)
‡G18) Left O.R. with NG tube in place:
 No  Yes
‡G19) Left O.R. with G tube to drainage in place:
 No  Yes
Red blood cell transfusion:
‡G20) Estimated blood loss during surgery:
 < 50 ml
 501 - 1000 ml
 50-250 ml
 >1000 ml
 251-500 ml
 NA
‡G21) Transfusion in O.R. or within 24 hrs post-op:
 No  Yes
a. If yes, how many units?  1 unit
 2 units
 3 units
 4 or more units
 NA
b. If yes, lowest hemoglobin (Hgb) in the 12 hours prior to the transfusion order: ____ g/dl
 NA
If Hgb not available:
c.
lowest hematocrit (Hct) in the 12 hours prior to the transfusion order: ____ %
 NA
(Report Hgb/Hct only for the transfusion occurring post-op, if multiple transfusion orders report lowest Hgb/Hct prior to any transfusion
in time period)
‡ G22) Transfusion after 24 hrs post-op:
 No  Yes (Evaluate only the first 30 days of the hospitalization)
a. If yes, how many units?  1 unit
 2 units
 3 units
 4 or more units
 NA
b. If yes, lowest Hgb in the 12 hours prior to the transfusion order: ____ g/dl  NA
If Hgb not available:
c.
lowest hematocrit (Hct) in the 12 hours prior to the transfusion order: ____ %
 NA
(If multiple transfusion orders, report lowest post-op Hgb/Hct prior to any transfusion in time period)
‡G23) Last Hgb prior to discharge: _____g/dl  NA (Applicable for recipients of any transfusion: G21 or G22)
If Hgb not available:
Last Hct prior to discharge: _____%
 NA
Post-op respiratory support
‡G24) Mechanical ventilation:
 No  Yes  Not applicable-chronic ventilator
b. total vent hours:
 less than 12hrs 12 to less than 24 hrs  24 to less than 48 hrs  48 to less than 96 hrs  96+ hrs
2011 Adult version 01/21/2011
Page 5 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
Renal/urologic function
‡G25) Urinary catheter removed before discharge:
 No  Yes  Not applicable -- no urinary catheter or pt
has permanent indwelling urinary catheter
a. If yes, Postop day urinary catheter removed:
_____  NA
H. Post-operative Events
Indicate if the patient experienced any of the listed events during the first 30 post-op days.
Select all that apply and note if the event occurred during the index hospitalization or after discharge from the index hospitalization. Include
only events that were unplanned and occurred after the index procedure. Evaluate 30 post-op days only. (Not applicable if death in the O.R.)
§H1) Post-discharge follow-up attempted:  No  Yes
§H2) Post-operative occurences
 No  Yes
If yes,
In-hospital
Post-discharge
1 Myocardial infarction/ Cardiac arrest
 No  Yes
 No  Yes NA
2 Atrial arrhythmia requiring treatment
 No  Yes
 No  Yes NA
3 CVA/stroke
 No  Yes
 No  Yes NA
4 Unplanned ICU stay/readmit to ICU
 No  Yes
 No  Yes NA
5 Fall with injury requiring surgery
 No  Yes
 No  Yes NA
6 c-Difficile infection
7 Wound and/or surgical site infection requiring
treatment
 No  Yes
 No  Yes NA
 No  Yes
 No  Yes NA
8 Pneumonia requiring treatment
 No  Yes
 No  Yes NA
 No  Yes
 No  Yes NA
9 UTI requiring treatment
 No  Yes
 No  Yes NA
10 Renal insufficiency &/or renal failure
 No  Yes
 No  Yes NA
11 Radiologically demonstrated anastomotic leak:
12 Radiologically demonstrated enterocutaneous
fistula:
 No  Yes
 No  Yes NA
 No  Yes
 No  Yes NA
13 Other 1
 No  Yes
 No  Yes NA
 No  Yes
 No  Yes NA
a. if yes, on vent prior to diagnosis
a. specify___________________
14 Other 2
a. specify___________________

§H3) Non-operative Interventions
 No  Yes
If yes,
In-hospital
Post-discharge
1 Tracheal reintubation:
 No  Yes
 No  Yes NA
2 NG tube placed post-op (non-routine):
 No  Yes
 No  Yes NA
3 Tracheostomy:
 No  Yes
 No  Yes NA
4 Percutaneous drainage:
 No  Yes
 No  Yes NA
5 Anticoagulation therapy for presumed/confirmed DVT:
 No  Yes
 No  Yes NA
6 Anticoagulation therapy for presumed/confirmed PE:
 No  Yes
 No  Yes NA
7 Antibiotic for presumed/confirmed infection:
 No  Yes
 No  Yes NA
8 Wound reopened/debridement:
 No  Yes
 No  Yes NA
9 Percutaneous arterial embolization for bleeding
 No  Yes
 No  Yes NA
2011 Adult version 01/21/2011
Page 6 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
10 Endoscopy with intervention for bleeding &/or dilation
 No  Yes
 No  Yes NA
11 Other:
 No  Yes
 No  Yes NA
a. specify___________________
§H4) Re-operative Interventions:
 No  Yes
If yes,
In-hospital
Post-discharge
1 Colostomy or ileostomy
 No  Yes
 No  Yes NA
2 Abscess drainage
 No  Yes
 No  Yes NA
3 Operative drain placement
 No  Yes
 No  Yes NA
4 Gastrostomy
 No  Yes
 No  Yes NA
5 Gastrostomy revision
 No  Yes
 No  Yes NA
6 Anastomotic revision
 No  Yes
 No  Yes NA
7 Wound revision
 No  Yes
 No  Yes NA
8 Negative re-exploration
 No  Yes
 No  Yes NA
9 Reoperation for bleeding
 No  Yes
 No  Yes NA
10 Implant removal/replacement/revision
 No  Yes
 No  Yes NA
11 Other
 No  Yes
 No  Yes NA
a. specify___________________
§H5) Readmission to acute care hospital:
a. if yes, how many:
§H6) Post-discharge Death
 No  Yes
_____  NA
 No  Yes
If yes,
§H7) How many days of follow-up were included:
a. if less than 30 days, how many days included:
a. Date of death _____/_____/_____
 less than 30 days
 30 days (at least)
_________days  NA
§H8) Method(s) used to obtain the post-discharge follow-up information: (check all that apply)
1. Phone
 No  Yes
2. Letter/survey
 No  Yes
3. Medical record
 No  Yes
4. Email
 No  Yes
2011 Adult version 01/21/2011
Page 7 of 14
 NA
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
I. Bariatric Procedures
Complete this section for the appropriate operation.
I1) Prior foregut surgery:
 No  Yes
I2) Procedure of record:
(check all that apply)
1. Gastric bypass (proximal)
 No  Yes
2. Gastric bypass (distal)
 No  Yes
3. Other gastric bypass:
 No  Yes
a. If other, specify Roux length: _____cm  NA
4. Sleeve gastrectomy
 No  Yes
5. Sleeve gastrectomy with small bowel resection
 No  Yes
6. Biliopancreatic bypass
 No  Yes
7. Biliopancreatic bypass with duodenal switch
 No  Yes
8. Reversal of prior jejunoileal bypass
 No  Yes
9. Takedown of vertical band gastroplasty
 No  Yes
10. Revision of gastric bypass
 No  Yes
I3) Does the bariatric procedure include the removal of a previously placed band
I5) Anastomosis (either distal or proximal) stapled:
a. If stapled, sealing device (e.g. Seam Guard) used:
I7) Anastomosis/ staple line tested:
 No  Yes
 No  Yes  Unknown
 No  Yes
 No  Yes
Note: Cannot infer that if a scope was used for some purpose during the surgery, that it was used for testing anastomosis; Op
note must specifically state that was used for anastomosis testing.
If yes, indicate how tested:
7.1 Scope
 No  Yes
7.2 Methylene blue
 No  Yes
7.3 Air/saline injected
 No  Yes
7.4 Palpation/inspection
 No  Yes
7.5 Other
 No  Yes
2011 Adult version 01/21/2011
a. Specify:____________________________
Page 8 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
J. Non-elective Appendectomy
Complete this section for the appropriate operation.
J1) Was the patient pregnant?
 No  Yes (Applicable if female)
a. If yes, number of weeks pregnant:
_____  NA
J2) ER/urgent care visit within one week and more than 12 hrs prior to operation:
If yes:
2.1 Where:
 this facility  other facility
a. If other, facility name: ___________________________
 No  Yes
J3) Was patient admitted to this hospital through this hospital’s ER:  No  Yes
if yes, indicate date and time of arrival at ER:
a. Date _____/_____/_____ NA
b. Time ____:_____ NA
J4) Concurrent abdominal or pelvic procedure performed:
(e.g. colectomy, ovarian cystectomy)
a. If yes, type:
 Gynecologic
J5) Pre-op imaging within 24 hrs:
 Colon
For CT scan:,
5.1.0 Was more than one CT scan performed
Characteristics of the most recent CT scan:
5.1.1 Date and time of CT scan :
a. IV
b. Oral
c. Rectal
a. CT scan
b. Ultrasound
c. MRI
 No  Yes
 No  Yes
 No  Yes
 No  Yes
Date: _____/_____/_____ NA
5.1.2 Use of contrast  No  Yes  NA
Route: (choose all that apply)
Time: ____:_____ NA
If yes,
 No  Yes
 No  Yes
 No  Yes
5.1.3 Dose Length Product (DLP): ___________
 NA
 Consistent with appendicitis  Not consistent with appendicitis
 Indeterminate
5.1.5 Imaging performed at:
 this facility  other facility
For Ultrasound:
5.2.1 Date and time of Ultrasound:
5.2.2 Imaging results:
 Other, b. specify______________
 No  Yes
If yes, specify type: (choose all that apply)
5.1.4 Imaging results:
 Gall bladder
 No  Yes
Date: _____/_____/_____ NA
Time: ____:_____ NA
 Consistent with appendicitis  Not consistent with appendicitis
 Indeterminate
5.2.3 Imaging performed at:
 this facility  other facility
For MRI:
5.3.1 Date and time of MRI:
5.3.2 Imaging results:
Date: _____/_____/_____ NA
 Consistent with appendicitis  Not consistent with appendicitis
 Indeterminate
5.3.3 Imaging performed at:
 this facility  other facility
J6) Pathology results: appendiceal pathology
 No  Yes
J7) Perforated appendix:
 No  Yes
2011 Adult version 01/21/2011
Time: ____:_____ NA
Page 9 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
K. Colon Procedures
Complete this section for the appropriate operation.
K1) Prior colon or pelvic surgery:
 No  Yes
K3) Prior colon resection within 30 days?
 No  Yes
3a If yes, indicate at which hospital performed________________________________________________
K5) Operation type: (Select all that apply)
5.1 Right/Transverse hemicolectomy
 No  Yes
5.2 Left hemicolectomy
 No  Yes
5.3 Low anterior resection (LAR)
 No  Yes
5.4 Abdominal Perineal Resection (APR)
 No  Yes
5.5 Total abdominal colectomy
 No  Yes
5.6 Stoma takedown
 No  Yes
5.7 Perineal proctectomy
 No  Yes
5.8 Abdominal proctectomy
 No  Yes
5.9 Additional (Staged) procedure –
planned return to the OR during current admission:  No  Yes
K6) Ostomy:
 No ostomy
 Colostomy
 Ileostomy
K7) Anastomosis:
 No  Yes
If yes,
7a. specify type:  Colocolon (colon to colon)
 Ileocolon (ileum to colon)
 Ileoanal (ileum to anal)
 Protective stoma
 Coloanal (colon to anal)
 Cannot be determined
7b. Was pouch created:  No  Yes
K8) Anastomosis stapled:
 No  Yes  Unknown
a. If stapled, sealing device (e.g. Seam Guard) used:  No  Yes
K9) Anastomosis tested:
 No  Yes (Applicable only if anastomosis)
Note: Cannot infer that if a scope was used for some purpose during the surgery, that it was used for testing anastomosis;
Op note must specifically state that was used for anastomosis testing.
If yes, specify:
9.1 Scope
 No  Yes
9.2 Methylene blue
 No  Yes
9.3 Air/saline injected
 No  Yes
9.4 Palpation/inspection
 No  Yes
9.5 Other
 No  Yes (Specify:____________________________)
K11) Bowel prep used:
If yes, (select all that apply)
 No  Yes
a. Mechanical
 No  Yes  NA
b. Oral Antibiotics
 No  Yes  NA
K12) Diet advanced beyond clear liquids/ice chips:
a. Post op day diet successfully advanced: _____
2011 Adult version 01/21/2011
 No  Yes
 NA
Page 10 of 14
Patient Initials: ___________
Date of Birth: ___________
K13) Post-op cancer diagnosis:
 No  Yes
Admit Date: _______________
Complete questions 14-24 only if the pre or postoperative diagnosis for colorectal surgery is cancer. If the preoperative diagnosis is for
something other than cancer, but cancer is found during the surgery, complete this set of data elements.
K14) Was preoperative neoadjuvant treatment given?  No  Yes (moved to apply to colon & rectal cancer)
If yes, type of therapy:
a. chemotherapy therapy:  No  Yes
b. radiation therapy:
 No  Yes
if radiation therapy,
c. time interval between the end of preoperative radiation and surgery?______(number of weeks)
K15) Number of lymph nodes removed and studied:
___________
 NA
K16) Number of lymph nodes positive for cancer:
___________
 NA
K17) Metastatic disease beyond lymph nodes:  No  Yes
K18) Margins free of cancer:
If yes, specify:
 No  Yes
a. cm to distal margin:
 <1 cm
b. cm to proximal margin:  <1 cm
K19) T stage (based on pathology):
(e.g. liver, diaphragm, peritoneum)
 1-2 cm
 1-2 cm
 Tis
 T1
 T2
 pTO
 pTx
 pyTO
 >2 cm
 >2 cm
 T3
 NA
 NA
 T4
 NA
Questions 20– 24 for rectal cancer only
K20) Procedure done for palliation:  No  Yes
K21) Was the distance of the tumor from the anal verge defined?  No  Yes
If yes,
21.1 distance determined by: (Check all that apply)
a. rigid scope
 No  Yes
b. flexible scope
 No  Yes
c. digital exam
 No  Yes
d. NA/Unknown
 No  Yes
21.2. Distance from the anal verge? _____(cm)
 NA
21.3. Was the distance determined after neoadjuvant therapy?  No  Yes  NA
K22) Was the tumor fixed to underlying structures?
a. If yes, was it fixed after neoadjuvant therapy?
K23) Total mesorectal excision (TME) done
a. Distance to radial margin:
b. TME capsule intact:
 No  Yes
 No  Yes  NA
 No  Yes
 <1 cm
 1-2 cm
 No  Yes  NA
 >2 cm
 NA
K24) Was EUS, TRUS or MRI used to define the stage:
 No  Yes
if yes, specify:
a. Endoscopic ultrasound (EUS)
 No  Yes
b. Transrectal ultrasound (TRUS)
 No  Yes
c. MRI
 No  Yes
2011 Adult version 01/21/2011
Page 11 of 14
 NA
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
Questions 25 – 26 for diverticular disease only
K25) Characterize the diverticular disease:
indicate type, check all that apply:
a. acute diverticulitis:
b. current gastrointestinal bleeding:
c. colovesical fistula:
d. stricture:
e. other colon fistulas:
K26) Prior episodes of diverticular disease
If yes,
 No
 No
 No
 No
 No
 Yes
 Yes
 Yes
 Yes
 Yes
 No  Yes  NA
a. How many prior episodes of treated acute diverticulitis?
1
2
 3 – 10
b. Was patient treated as an inpatient for any of the episodes?
2011 Adult version 01/21/2011
 >10
 NA
 No  Yes  NA
Page 12 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
L. Serious Reportable Events
Data collected for SCOAP:  No  Yes
L1) Were there any serious reportable events?-  No  Yes
1
If yes, (Check all that apply)
Was surgery performed on the wrong body part?
 No  Yes
2
Was surgery performed on the wrong patient?
 No  Yes
3
Was the wrong surgical procedure performed on the patient?
 No  Yes
4
Was there an unintended retention of a foreign object in the patient after surgery?
 No  Yes
5
Was there intraoperative or immediately postoperative death in an ASA Class I patient?
 No  Yes
6
Was there a patient death or serious disability associated with the use of contaminated drugs,
devices, or biologics?
 No  Yes
7
Was there a patient death or serious disability associated with the use or function of a device in
patient care in which the device is used or functions other than as intended?
 No  Yes
8
Was there a patient death or serious disability associated with intravascular air embolism?
 No  Yes
9
Was there a patient death or serious disability associated with a medication error during this
admission (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong
rate, wrong preparation, or wrong route of administration)?
 No  Yes
10
Was there a patient death or serious disability associated with a hemolytic reaction due to the
administration of ABO/HLA-incompatible blood or blood products?
 No  Yes
11
Was there a patient death or serious disability associated with hypoglycemia during this admission?
 No  Yes
12
Were there Stage 3 or 4 pressure ulcers acquired during this admission?
 No  Yes
13
Did patient death or serious disability associated with an electric shock?
 No  Yes
14
Was there any incident in which a line designated for oxygen or other gas to be delivered to the
patient contained the wrong gas or was contaminated by toxic substances?
 No  Yes
15
Was there patient death or serious disability associated with a burn incurred from any source?
 No  Yes
16
Was there a patient death or serious disability associated with a fall?
 No  Yes
17
Was there a patient death or serious disability associated with the use of restraints or bedrails?
 No  Yes
2011 Adult version 01/21/2011
Page 13 of 14
Patient Initials: ___________
Date of Birth: ___________
Admit Date: _______________
X. Hospital Comments
Optional Hospital-specific Comment fields: (data will not be exported to SCOAP)
These fields are intended for notes about the case, data of interest to hospitals not collected by SCOAP
Comment 1:____________________________________________________________
Comment 2: ___________________________________________________________
Comment 3: ___________________________________________________________
2011 Adult version 01/21/2011
Page 14 of 14