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Cardiac Surgery Report, Adult
(age 18 and over)
NEW YORK STATE DEPARTMENT OF HEALTH
New York State Cardiac Advisory Committee
Facility Name
PFI Number
Sequence Number
I. Patient Information
Patient Name
(last) (first)
Medical Record Number
Social Security Number Date of Birth
Sex
Ethnicity
Race Residence Code (see instructions)
m
1
Male
1
Hispanic
1
White
4
Asian
2
Female
2
Non-Hispanic
2
Black
5
Pacific Islander
3
Native American
8
Other
Primary payer
d
y
State or Country (if 99 code is used)
Medicaid
Hospital Admission Date
m
d
y
Transfer PFI
II. Procedural Information
Hospital that Performed Diagnostic Cath
Physicians
Hospital Name Anesth. (Start)
m
d
y
Prior Surgery this Admission 1
Anesth. (End)
Yes
2
No
CABG Information
Date
Minimally Invasive
Total Conduits
m
d
y
2
Converted to Standard Incision
Arterial Conduits
Cardiac Procedures this OR Visit
3
4
Converted from Off Pump to On Pump
Distal Anastomoses
5
Entire Procedure Off Pump
IMA Grafting
Congenital Diagnosis
1
License #
Primary Surgeon
PFI
Date of Surgery
1
Name
2
IIa. Peri-operative Information
Induction of Anesthesia
:
Hematocrit
Skin Closure Time
:
1st in OR
%
Pre-op Beta-Blocker
Pre-Induction BP
/
Lowest on CPB
%
Extubation in 24 hrs
Post-Op Temp
.
Last on CPB
%
Post-Op Beta-Blocker
Post-Op
%
°C
Temp Route
Process
Post–Op Glucose
Control Protocol
Used?
III. Pre-Op Surgical Risk Factors (answer all that apply)
Surgical Priority
1
Elective
2
Urgent
3
Emergency
Height
Stress Testing
cm
kg
IMA Grafting
0 – Never
1 – This OR Visit
2 – Prior to this OR
Temp Route
4 – Tympanic
1 – Pulm Artery
2 – Rectal/Bladder 8 – Other
3 – Nasopharyngeal 9 – Unknown
DOH-2254a (7/09) page 1 of 2 Donee
Don
Type
Weight
Ejection Fraction
CCS Functional Class
%
Creatinine
.
m g/dl
Measure
Result
Process
1 – Yes
2 – Contra
3 – Neither
Stress Testing
Done
1 – Yes
2 – No
9 – Unknown
Type
1 – Standard Exercise
2 – Echo
3 – w/SPECT MPI
4 – w/CMR
9 – Not Done/Unknown
Results
1 - Neg.
2 - Pos., Low
3 - Pos., Intermed
4 - Pos., High
5 - Pos., Risk Unavail.
6 - Indeterminate
7 - Unavailable
9 - Not Done/Unknown
July-Dec 2009 Discharges
III. Pre-Op Surgical Risk Factors, continued (answer all that apply)
Vessels Diseased (check all that apply)
LMT
1
50 - 69%
3
90 - 100%
2
70 - 89%
4
5
Proximal LAD
50 - 69%
70 - 100%
Mid/Dist LAD or Major Diag
6
50 - 69%
7
70 - 100%
Valve Disease
Aortic
Stenosis:
Incompetence:
0
1A
2
Valve Codes
0 – None
1 – Mild
2 – Moderate
3 – Severe
LCX or Large Marg
10
50 - 69%
11
70 - 100%
Other Patient Characteristics
(check all that apply)
50-69% stenosis with sig FFR/IVUS
Chronic total occlusion is only stenosis
Prior CABG - 3VD & multiple graft failure
LIMA used - no longer functional
LIMA used - patent to native coronary
None of the pre-op risk factors listed below were present
Previous Open Heart Operations
1
Anti-anginal Med Therapy
(check all that apply)
Beta Blockers
Ca Channel Blockers
Long Acting Nitrates
Ranolazine
Other
Mitral Tricuspid
RCA or PDA
50 - 69%
70 - 100%
8
9
Previous MI (most recent)
Previous CABG-Patent Grafts
9
4
<6 hours
Previous CABG-No Patent Grafts
5
6-23 hours Any Other Previous Cardiac
Surgery
6
10
Cerebr
Cer
ebrovascular
ebr
ovascular Disease
Hemodynamic Instability
at time of procedure
Periph
eripher
eral
er
al Vascular
Vascular Disease
days
(use 21 for 21 or more)
12
Unstable
13
Shock
Sh
ock
18
Congestive Heart Failure, Current
25
Hepati
epaticc Failure
Failure
39
Any Previous Organ Transplant
19
Congestive Heart Failure, Past
27
Renal
Ren
al Failure
Failure, Dialysis
Dialysis
40
Heart Transplant Candidate
63
BNP, 3x Normal
30
Emer
Em
erggen
er
ency
cy Tr
Tran
ansfer
sfer to OR after Dx Cath
62
Active Endocarditis
20
Malignant Ventricular Arrhythmia
31
Emer
Em
erggen
er
ency
cy Tr
Tran
ansfer
sfer to OR after PCI
21
Chronic Obstructive Pulmonary Disease
32
Previ
Pr
evious
evi
ous PCI, This Ad
Admissi
mission
on
23
Extensive Aortic Atherosclerosis
33
PCI Befor
Befor
oree This Ad
Admissi
mission
on
24
Diabetes Requiring Medication
38
Stentt Thrombosis
Sten
Thrombosis
IV. Major Events Following Operation (answer all that apply)
0
None
5
Bleeding Requiring Reoperation
1
Stroke (new neurological deficit) Intra-Op to 24 hrs
8
Sepsis or Endocarditis
9
G-I Bleeding, Perforation or Infarction
1A
Stroke (new neurological deficit) over 24 hrs
2
Q-wave MI
10
Renal Failure
4
Deep Sternal Wound Infection (bone-related)
13
Respiratory Failure
14
Unplanned Cardiac Reoperation or interventional procedure
V. Discharge Information
Discharged Alive to:
30 Day Status:
Died in:
11
Hom
omee
2
Operatin
Oper
atingg Room
atin
6
In Tr
Tran
ansit
sit to Other
Other Facility
1
Live
12
Hospi
ospice
ce
3
Recovery Room
8
Elsewher
Elsewh
eree in Hospital
er
Hospital (specify)
2
Dead
13
Acute Care
Care Facility
4
Critical
Criti
cal Care
Care Unit
Unit
9
Unkn
nknown
own
14
Skilled NH
5
Medical/Surgical Floor
15
Inpatient Physical Medicine & Rehab
19
Other (specify)
Hospital Discharge Date
m
d
y
VI. Person Completing Report
Name DOH-2254a (7/09) page 2 of 2 Referring Physician
July-Dec 2009 Discharges