Download Form

Cardiac Surgery Report, Adult
(age 18 and over)
NEW YORK STATE DEPARTMENT OF HEALTH
State Cardiac Advisory Committee
Facility Name
PFI Number
Sequence Number
I. Patient Information
Patient Name (last)
(first)
Medical Record Number
(m.i.)
Social Security Number
Age in Years
Date of Birth
m
Sex
1 Male
Ethnicity
1 Hispanic
Race
1 White
2
2
2
8
Female
Non-Hispanic
Residence (see instructions)
Code
State or Country
d
y
Hospital Admission
Date
Black
Other
m
d
y
d
y
II. Procedural Information
Hospital That Performed Diagnostic Cath
Hospital Name
PFI
Primary Physician Performing Operation
Name
License Number
Date of Primary Surgery
m
Primary Cardiac Procedure
SCAC Code (see instructions)
Other Cardiac Procedure
SCAC Code (see instructions)
LIMA to LAD
Minimally Invasive
VATS
0
No
0
No
0
No
1
2
With no other arterial grafts
With other arterial grafts
1
Yes
1
Yes
Converted to
Standard Incision
Cardioplegia
IV Heparin within 48 hours Pre-op
0
None
0
Not Used
1
2
Cold
Warm
1
2
Antegrade
Retrograde
1
2
Discontinued < 3 hours Pre-op
Discontinued 3-48 hours Pre-op
3
Both
3
Both
1
Intermittent
1
Crystalloid
2
Continuous
2
Blood
3
Both
Global Myocardial Ischemic Time
minutes
Cardiopulmonary Bypass Time
minutes
Converted from off pump to on pump
III. Major Events Following Operation (check all that apply)
0
None
5
Bleeding Requiring Reoperation
1
Stroke (new neurological deficit) Intra-Op to 24 hrs
8
Sepsis or Endocarditis
1A
2
4
Stroke (new neurological deficit) over 24 hrs
Transmural MI (new Q waves)
9
10
G-I Bleeding, Perforation or Infarction
Renal Failure, dialysis
Deep Sternal Wound Infection (bone-related)
13
Respiratory Failure
IV. Discharge Information
Discharged to:
11
Home
Died in:
2
30 Day Status:
Operating Room
6
In Transit to Other Facility
1
Live
Elsewhere in Hospital (specify)
2
9
Dead
Unknown
12
13
Hospice
Acute Care Fac (Rehab)
3
4
Recovery Room
Critical Care Unit
8
14
19
Skilled NH
Other (specify)
5
Medical/Surgical Floor
Hospital Discharge Date
m
DOH-2254a (2/99) page 1 of 2
d
y
V. Pre-Op Surgical Risk Factors (answer all that apply)
Surgical Priority
1
2
Elective
Urgent
3
Emergency
Ejection Fraction
Height
cm
Measure
%
Weight
kg
1
2
Calculated
Estimated
9
Unknown
Angina:
CCS Functional Class
(all CABG patients)
see instructions
Stress Test Results
1
LV Angiogram
1
Positive
2
3
Echocardiogram
Radionuclide Studies
2
3
Negative
Not Done
4
8
TEE including Intra-Op
Other
9
Unknown
9
Unknown
1
Class I
2
3
Class II
Class III
4
Class IV
Vessels Diseased (check all that apply)
LMT
Prox LAD or Major Diag
Mid/Dist LAD or Major Diag RCA or PDA
LCX or Larger Marg
1
50 - 69%
4
50 - 69%
6
50 - 69%
8
50 - 69%
10
50 - 69%
2
3
70 - 89%
90 - 100%
5
70 - 100%
7
70 - 100%
9
70 - 100%
11
70 - 100%
Valvular Stenosis and Incompetence(valve patients only)
Stenosis:
Incompetence:
None
Mild
Aortic
Mitral
0
0
1
1
2
2
3
3
Tricuspid
Aortic
0
0
1
1
2
2
3
3
Mitral
0
1
2
3
Tricuspid
0
1
2
3
Pulmonary Artery Pressure (valve patients only)
Systolic
Cardiac Index (valve patients only)
liters/min/m2
0
Moderate
mm Hg
Severe
Mean Wedge
mm Hg
None of the pre-op risk factors listed below were present
Previous Open Heart Operations
Peripheral Vascular Disease
Previous MI (most recent)
1
One
4
<6 hours
2
3
Two
Three or more
5
6
6-23 hours
days
(use 21 for 21 or more)
7
Stroke
Hemodynamic Instability
at time of procedure
9
10
Carotid/Cerebrovascular
Aortoiliac
12
13
Unstable
Shock
11
Femoral/Popliteal
37
CPR
8
Check here if Transmural MI
14
More than one Previous MI
28
Immune System Deficiency
15
Hypertension History
29
IABP Pre-op
16
17
IV NTG within 24 hours before operation
ECG Evidence of Left Ventricular Hypertrophy
30
31
Emergency Transfer to OR after Dx Cath
Emergency Transfer to OR after PTCA
18
19
Congestive Heart Failure, this admission
Congestive Heart Failure, before this admission
32
33
Previous PTCA, this admission
PTCA before this admission
20
Malignant Ventricular Arrhythmia
34
Thrombolytic Therapy within 7 days
21
22
Chronic Obstructive Pulmonary Disease
Myocardial Rupture
35
36
Smoking history, in past 2 weeks
Smoking history, in past year
23
24
Extensively Calcified Ascending Aorta
Diabetes requiring medication
38
Stent Thrombosis
25
Hepatic Failure
Report the following risk factors for Valve surgery only
26
27
Renal Failure, creatinine > 2.5 mg/dl
Renal Failure, dialysis
61
62
Cardiomegaly (>50% C-T ratio)
Active Endocarditis
VI. Person Completing Report
Name
Referring Physician
Date
m
d
y
DOH-2254a (2/99) page 2 of 2