Age |
BMI |
Sex |
Race/ Ethnicity |
White |
Other |
Functional Status |
Prior to surgery |
Independent |
Partially or Totally Dependent |
Prior to current illness |
Independent |
Partially or Totally Dependent |
ASA |
1= No Disturbance |
2= Mild Disturbance |
3= Severe Disturbance |
4= Life Threatening |
5= Moribund |
Pulmonary |
Dyspnea |
COPD |
Current pneumonia |
Cardiac |
History of CHF (within 30 days) |
MI (within 6 months) |
Cardiac Surgery (previous) |
Angina (within 30 days) |
Hypertension |
Central Nervous System |
Impaired sensorium |
CVA (with neurological deficit) |
TIA |
CNS Tumor |
Hepatobiliary |
Ascites |
Renal |
Acute Renal Failure |
On Dialysis |
Nutritional/Immune Other |
Steroid use for chronic condition |
Weight loss >10% |
Disseminated cancer |
Bleeding disorder |
Transfusion >4 U PRBCs |
Chemotherapy |
Radiotherapy |
Sepsis |
Surgical Descriptors
|
Prior Operation |
Type of resection* |
Ileocolectomy |
Segmental colectomy |
Transfer from Healthcare facility |
Admitted directly from home |
Acute Care Hospital |
Chronic Care Facility |
Other |
CPT Code |
44140 |
44160 |
44204 |
44205 |
Open vs. closed |
Anastomosis vs. partial removal |
Bowel Preparation* |
Oral Antibiotics with Bowel Preparation* |
Outcome
|
Clostridium difficile infection (CDI)* |