scoap data collection form · web viewscoap data collection form for adults (effective for...

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 Asian Black or African American Native Hawaiian or Other Pacific Islander White NA/Unknown

§B10) Ethnicity: Hispanic or Latino Not Hispanic or Latino NA

§B11) Patient Height: _____ (in) OR _____ (cm)

§B12) Patient Weight: _____ (lbs) OR _____ (kg)

§B13) Insurance: (Check all that apply)13.1 Private: No Yes

13.2 If private, choose one: Regence Cigna Premera Uniform Medical First Choice United Healthcare Group Health Kaiser Aetna Other Private

13.3 Medicare: No Yes 13.4 Medicaid: No Yes13.5 TriCare: No Yes 13.6 Indian Health Svcs: No Yes13.7 VA benefic.: No Yes 13.8 Uninsured: No Yes13.9 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

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Patient Initials: ___________ Date of Birth: ___________ Admit Date: _______________

§B16) Procedure Priority: Elective Non-Elective

§ B17) Discharge disposition: Home Other acute care hospital Rehab facility Death: a. If death, specify: SNF 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 categoryB18) For

appendectomy:B19) For

bariatric/gastric surgery:

B20) For colon:

No Yes No Yes No Yes18.1 Appendicitis 19.1 Morbid obesity 20.1 Cancer of colon 20.10 GI bleeding18.2 Appendiceal mass

19.2 Revision/reversal

20.2 Diverticular disease

20.11 Perforation

or Cancer 19.3 Other 20.3 Colon mass 20.12 Cancer of rectum18.3 Other 19.3a (specify): 20.4 Radiation colitis 20.13 Bowel obstruction 18.3a (specify): ____________________ 20.5 Volvulus 20.14 Colostomy____________________ 19.4 Gastric cancer 20.6 Arteriovenous 20.15 Ulcerative colitis

19.5 Gastric ulcer malformation 20.16 Crohn’s disease20.7 Ischemic colon 20.17 Stricture20.8 Polyps 20.18 Gynecological 20.9 Rectal prolapse malignancy

20.19 Iatrogenicbowel injury

20.20 Other: 20.20a(specify):___________________

B21) For breast cancer: No YesB22) For prostate cancer: No YesB23) For lung cancer: No Yes (pre-op diagnosis must be non-small cell carcinoma)B24) For liver cancer: No YesB25) For pancreas cancer: No YesB26) For kidney cancer: No YesB27) For esophagus cancer: No YesB28) For uterine cancer: No 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 Unknown If ever a smoker, indicate pack years _______ 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 NA2.4 HGB: _____ g/dl NA if HGB not available: Hct: _____%

NA2.5 WBC: _____ 103 NA

2011 Cancer Modules 01/21/2011 of 23


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 Yes2. Oral supplementation No Yes

(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 Comorbidities: If yes, check the best response

§D1) Hypertension: No Yes No meds Single med Multiple meds

§D2) Diabetes: No Yes No meds Insulin Single non-insulin Insulin + Other Multiple non-insulin

§D3) Asthma: No Yes

§D4) Sleep Apnea: No Yes CPAP None

§D5) Coronary Artery Disease: No Yes History MI Both PCI, CABG, AICD None

§D6) History of VTE: No Yes

§D7) HIV / AIDS: No Yes

§D8) Current Dialysis No Yes

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: _____ / _____ / _____ F4) In-room close date: _____ / _____ / _____

§F5) Surgical Approach: Laparoscopic/Videoscopic Lap/Video converted to open Lap/Video, hand-assisted Open (no lap ports) Laparoscopic, robotic assistance Laparoscopic, robotic assistance converted to open

§F6) ASA Class: I II III IV V Already intubated NAa. Emergent (E): No Yes

§F7) What skin preparation material was used in the OR Chlorhexedine Chlorhexedine-Alcohol Povidone Povidone-Alcohol Other

§F8) Highest perioperative blood glucose: _____mg NA

§F9) Insulin used in perioperative time period: No Yes

§F10) First fasting blood glucose on post op day 1: _____mg 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: No Yes ContraindicatedIf yes, a. when was prophylaxis given: 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 Yesb. indicate number of days of treatment ordered: ___ days NA

(Not applicable if discharge disposition is death)



‡G3) Ordered on discharge: No Yes ContraindicatedIf 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 (Not applicable if death in O.R.)

Antibiotics: (Not applicable if appy)§G8) On antibiotics for the treatment of infection: No Yes

If yes: a. At this hospital/upon admission No Yesb. At transferring hospital: No Yes (Not applicable if pt not transferred

(B14))

§G9) Were prophylactic antibiotics indicated: No YesIf yes: 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: No Yes Contraindicated

a. was the epidural a PCEA (Patient Controlled Epidural Analgesia) No Yes1. date started: _____/ _____/ _____(mm/dd/yyyy) NA2. placed pre-op No Yes NA3. ordered within 24 hrs post-op: No Yes4. placed post-op No Yes NA5. date discontinued: _____/ _____/ _____(mm/dd/yyyy) NA

‡G11) PCA ordered within 24 hrs post-op: No Yes Contraindicated

a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy) NA

‡G12) Continuous local anesthetic infusion ordered within 24 hrs post-op No Yes Contraindicated

a. if yes, date discontinued: _____/ _____/ _____ (mm/dd/yyyy) NAAdditional Perioperative Medications‡G15) Was Entereg (generic is alvimopan) administered: 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 50-250 ml 251-500 ml

501 - 1000 ml >1000 ml NA



‡G21) Transfusion in O.R. or within 24 hrs post-op: No Yesa. If yes, how many units? 1 unit 2 units 3 units 4 or more units NAb. 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 NAb. 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

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 EventsIndicate 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 YesIf yes, In-hospital Post-discharge

1 Myocardial infarction/ Cardiac arrest No Yes No Yes NA2 Atrial arrhythmia requiring treatment No Yes No Yes NA3 CVA/stroke No Yes No Yes NA4 Unplanned ICU stay/readmit to ICU No Yes No Yes NA5 Fall with injury requiring surgery No Yes No Yes NA6 c-Difficile infection No Yes No Yes NA7 Wound and/or surgical site infection requiring treatment No Yes No Yes NA



8 Pneumonia requiring treatment No Yes No Yes NAa. if yes, on vent prior to diagnosis No Yes No Yes NA

9 UTI requiring treatment No Yes No Yes NA10 Renal insufficiency &/or renal failure No Yes No Yes NA11 Radiologically demonstrated anastomotic leak: No Yes No Yes NA12 Radiologically demonstrated enterocutaneous fistula: No Yes No Yes NA13 Other 1 No Yes No Yes NA

a. specify___________________14 Other 2 No Yes No Yes NA

a. specify___________________

§H3) Non-operative Interventions No YesIf yes, In-hospital Post-discharge

1 Tracheal reintubation: No Yes No Yes NA2 NG tube placed post-op (non-routine): No Yes No Yes NA3 Tracheostomy: No Yes No Yes NA4 Percutaneous drainage: No Yes No Yes NA5 Anticoagulation therapy for presumed/confirmed DVT: No Yes No Yes NA6 Anticoagulation therapy for presumed/confirmed PE: No Yes No Yes NA7 Antibiotic for presumed/confirmed infection: No Yes No Yes NA8 Wound reopened/debridement: No Yes No Yes NA9 Percutaneous arterial embolization for bleeding No Yes No Yes NA10 Endoscopy with intervention for bleeding &/or dilation No Yes No Yes NA11 Other: No Yes No Yes NA

a. specify___________________

§H4) Re-operative Interventions: No YesIf yes, In-hospital Post-discharge

1 Colostomy or ileostomy No Yes No Yes NA2 Abscess drainage No Yes No Yes NA3 Operative drain placement No Yes No Yes NA4 Gastrostomy No Yes No Yes NA5 Gastrostomy revision No Yes No Yes NA6 Anastomotic revision No Yes No Yes NA7 Wound revision No Yes No Yes NA 8 Negative re-exploration No Yes No Yes NA 9 Reoperation for bleeding No Yes No Yes NA10 Implant removal/replacement/revision No Yes No Yes NA



11 Other No Yes No Yes NAa. specify___________________

§H5) Readmission to acute care hospital: No Yesa. if yes, how many: _____ NA

§H6) Post-discharge Death No Yes If yes, a. Date of death_____/_____/_____ NA

§H7) How many days of follow-up were included: less than 30 days 30 days (at least)a. if less than 30 days, how many days included: _________days NA

§H8) Method(s) used to obtain the post-discharge follow-up information: (check all that apply)

1. Phone No Yes2. Letter/survey No Yes3. Medical record No Yes4. Email No Yes



L. Serious Reportable EventsData collected for SCOAP: No Yes

L1) Were there any serious reportable events?- No YesIf yes, (Check all that apply)

1 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 Yes2011 Cancer Modules 01/21/2011 of 23


17 Was there a patient death or serious disability associated with the use of restraints or bedrails?

No Yes



M. Breast ProceduresComplete this section for the appropriate operation.

M1) Presentation type (pre-op information): check all that apply

1. Atypical or high-risk lesion (e.g. ADH, ALH, LCIS)

No Yes

2. Ductal carcinoma in situ No Yes if yes, Multicentric? No Yes

3. Invasive carcinoma No Yes If yes, Clinical Stage (pre-op) Stage 0

Stage I Stage IIA Stage IIB

Stage IIIA Stage IIIB Stage IIIC Stage IV NA

Multicentric? No Yes M2) Procedure of record: check all that apply

if yes,1. Mastectomy No Yes Left Right

Bilateral2. Modified Radical Mastectomy No Yes Left Right

BilateralAdditional procedures at the time of Mastectomy

3. Prophylactic Mastectomy No Yes Left Right 4. Axillary Lymph Node Dissection No Yes Left Right

Bilateral5. Reconstruction - Autologous No Yes Left Right

Bilateral6. Reconstruction-Tissue Expander and Implant Insertion No Yes Left Right

BilateralM3) Sentinel lymph node biopsy: No Yes

if yes, a. Site: Left Right Bilateralb. Blue dye used (Methylene or isosulfan blue): No Yes NAc. Radiocolloid used: No Yes NA

M4) Method of diagnosis: Needle Biopsy (palpation or image-guided) No Yes

Open surgical (excisional/incisional) biopsy No Yes

M5) Pathological stage (post-op): (choose one for each Stage Category)

1. T Stage TX T0 Tis T1 T2 T3 T4 NA2. N Stage NX N0 N0(i+) N1 N2 N3 NA3. M Stage MX M0 M1 NA

M6) Breast cancer type: 1. ER positive No Yes NA2. PR positive No Yes NA3. Her2Neu positive No Yes NA

M7) Histological grade: 1 2 3M8) Number of lymph nodes removed _______ NAM9) Number of lymph nodes positive for cancer _______ NA2011 Cancer Modules 01/21/2011 of 23


M10) Breast conserving surgery counseling provided for T1 & T2: No Yes NA



N. Prostate ProceduresComplete this section for the appropriate operation.

N1) Diagnosis method-check all that apply1. PSA No Yes 2. Digital Rectal Exam No Yes 3. Preoperative Imaging- CT with contrast within 90 days No Yes4. Preoperative Imaging -Bone scan within 90 days No Yes

N2) Tissue diagnosis method-check all that apply1. Needle Biopsy prior to surgery No Yes 2. TURP prior to surgery No Yes

N3) Procedure type: Radical retropubic prostatectomy Radical perineal prostatectomy

N4) Prior prostate cancer treatment (pre-operative) No Yes if yes, check all that apply

1. External Radiation No Yes 2. Bracytherapy No Yes 3. Androgen Deprivation No Yes 4. Cryotherapy No Yes 5. Other No Yes

N5) Urinary continence prior to surgery No Yes NA N6) Potent prior to surgery No Yes NAN7) Prostate Specific Antigen (PSA) most recent within 90 days ____ ng/ml NA

N8) Gleason scores1. Pre-operative score: 5 6 3+4=7 4+3=7 7 NOS 8 9

10 NA2. Post-operative score: 5 6 3+4=7 4+3=7 7 NOS 8 9

10 NA

N9) Rectal injury during prostatectomy No Yesif yes, was a colostomy performed (during procedure) No Yes

N10) Nerves spared: None Unilateral Bilateral NAN11) Number of lymph nodes removed and studied ___________ NA

N12) Number of lymph nodes positive for cancer ___________ NA

N13) Clinical staging (pre-op): choose only one, be as specfic as possibleT

Stage

TX T0 T1 T2 T3 T4 NA

T1a

T1b

T1c

T2a

T2b

T2c

T3a

T3b

T3c

T4a

T4b

N14) Pathological stage (post-op): (choose one for each Stage Category, be as specfic as possible)

1. T Stage TX T0 T1 T2 T3 T4 NA

T1a T1b T1c

T2a

T2b

T2c

T3a

T3b

T3c

T4a

T4b2. N

Stage N0 N1 N2 N3 NA



3. M Stage MX

M0

M1a

M1b

M1c NA



O. Lung ProceduresComplete this section for the appropriate operation.O1) Prior operation for lung cancer: No Yes O2) Medical treatment for lung cancer:

1. Pre-op Chemotherapy No Yes 2. Pre-op Thoracic Radiation No Yes

O3) Pre-op CT: No Yes a. within 60 days of admission No Yes

O4) Pre-op Chest PET: No Yes a. within 60 days of admission No Yes

O5) Pre-op PFT’s1. FEV 1 No Yes a. if yes, %Predicted: ______ NA 2. DLCO No Yes a. if yes, %Predicted: ______ NA

O6) Zubrod Score: (Most severe score within 2 weeks of surgery. Eg., a patient enters the hospital with a Zubrod score of 1, but after 1 week in the hospital, Zubrod changes to 3, then score should be 3)

0 : Normal Activity, no symptoms 3 : Symptoms, in bed >50% but <100% 1 : Symptoms, fully ambulatory 4 : Bedridden 2 : Symptoms, in bed <=50% NA

O7) Operation type: check all that apply if yes,1. Wedge Resection No Yes Left Right

Bilateral2. Segmentectomy No Yes Left Right

Bilateral3. Sleeve lobectomy No Yes Left Right

Bilateral4. Bilobectomy No Yes Left Right

Bilateral5. Lobectomy No Yes Left Right

Bilateral6. Pneumonectomy No Yes Left Right

O8) Smoking cessation counseling offered: No Yes (Applicable if current smoker)O9) Chest tube removed before discharge: No Yes

if removed, a. date: ___/___/___ NA O10) Clinical Staging (pre-op):

T Stage

TX

T0

Tis

T1a

T1b

T2a

T2b

T3

T4

NA

O11) Pathological Stage (post-op): (choose one for each Stage Category)1. T Stage

TX T0

Tis

T1a

T1b

T2a

T2b

T3

T4

NA

2. N Stage N0

N1

N2

N3

NA

3. M Stage MX M0 M1a M1b M1c NA



P. Liver Procedures

P1) Indication for operation: (check all that apply)1. HCC No Yes 2. Adenoma No Yes 3. Metastatic lesion No Yes 4. Hemangioma No Yes 5. Cyst No Yes 6. Other No Yes

If metastatic lesion, origin: Colon OtherIf metastatic lesion, detection: Synchronous Metachronous

If metachronous, time lapse from initial diagnosis: _______ months NAP2) Presumed etiology of cirrhosis/lesion:

1. HCV No Yes 2. HBV No Yes 3. Alcohol No Yes 4. PSC No Yes 5. NASH No Yes6. Other No Yes

P3) Child’s Class: A B C NA

P4) Prior intervention: No Yes If yes, what procedure has been done: (check all that apply) 1. Resection No Yes 2. Transplant No Yes3. Radiofrequency ablation No Yes 4. TACE No Yes 5. Other ablation No Yes6. ERCP stent/PTC drain No Yes7. Radiation therapy No Yes8. Chemotherapy No Yes9. Liver biopsy No Yes10. Other No Yes

P5) Operation type: 1. Hepatectomy No Yes2. Radiofrequency ablation No Yes3. Microwave coagulation therapy No Yes4. Other Ablation No YesIf hepatectomy, indicate type & segments:

Type:a. Left hepatectomy No Yes b. Right hepatectomy No Yes c. Extended hepatectomy No Yes d. Wedge No Yese. Segmentectomy No Yes Segment(s): I No Yes V No Yes II No Yes VI No Yes III No Yes VII No YesIV No Yes VIII No Yes

P6) Intra-op Ultrasound used: Yes No



P7) Pre-op imaging: No Yes 1. CT No Yes2. Ultrasound No Yes3. MRI No Yes 4. PET or PET/CT No Yes

P8) Imaging results: 1. Number of lesions: _______ NA2. Size of largest lesion: ________cm NA3. Location of lesion(s):

I No Yes V No Yes II No Yes VI No Yes III No Yes VII No YesIV No Yes VIII No Yes

4. Extra-hepatic extent of disease: No Yes5. Vascular invasion: No Yes

If yes, which vessel:a. IVC No Yesb. Portal vein No Yesc. Hepatic artery No Yesd. Hepatic vein No Yes

P9) Vascular resection/anastomosis: No Yes If yes, specify:

a. IVC No Yesb. Portal vein No Yesc. Hepatic artery No Yes

P10) Pringle time: ________minutes NAP11) Central line placed/used for CVP monitoring: No Yes

PathologyP12) Post-op cancer diagnosis: No Yes



Q. Pancreas ProceduresQ1) Indication:

1. Adenocarcinoma No Yes2. Cystic lesion No Yes3. Neuroendocrine tumor No Yes4. Necrotizing pancreatitis No Yes5. Chronic pancreatitis No Yes6. Other No Yes

Q2) Prior intervention: No Yes1. EUS No Yes If yes:

a. lymph node FNA No Yes NA2. ERCP No Yes If yes:

a. sphincterotomy No Yes NAb. stenting No Yes NA

If stenting, what type: Plastic Metal NAQ3) Operation type: choose one

Whipple Total pancreatectomy Distal pancreatectomy Peustow or other drainage procedure Enucleation Necrosectomy

OtherAll operation types:1. J-tube placed: No Yes2. Intra-op Ultrasound used: No Yes 3. Method of parenchymal division: Cautery Scalpel StapledIf Whipple:4. Method of pancreaticojejunostomy: duct-to mucosa dunking/invagination

a. Pancreaticojejunostomy stented: No Yes5. Method of choledochojejunostomy: Continous Interrupted6. Gastrojejunostomy fashioned: antecolic retrocolic7. Pylorus preserved: No Yes

If Distal pancreatectomy:8. Method of stump closure: oversew staple ductal ligation fibrin glue9. Spleen: splenectomy splenic preservation

Q4) Pre-op imaging: No Yes 1. CT No Yes2. Ultrasound No Yes3. MRI No Yes4. PET or PET/CT No Yes

Q5) Imaging Results:1. Location of lesion: Head Body Tail2. Size of lesion: ________cm NA3. Vascular invasion: No Yes If yes, specify:

a. Superior mesenteric vein (SMV) No Yesb. Superior mesenteric artery (SMA) No Yesc. Portal vein No Yes

Q6) Vascular resection/anastomosis: No Yes If yes, specify:1. Superior mesenteric vein (SMV) No Yes2. Superior mesenteric artery (SMA) No Yes3. Portal vein No Yes



Q7) Drains left: No Yesa. at the anastomosis or anastamoses: No Yesb. at the pancreatic stump: No Yes (Applicable to distal pancreatectomy)

PathologyQ8) Post-op cancer diagnosis: No YesQ9) Staging

1. pT stage: Tis T1 T2 T3 T4 NA2. pN stage: N0 N1 NA3. pM stage: M0 M1 NA



R. Kidney ProceduresR1) Indications

1. Tumor/mass (unspecified/unknown type) No Yes2. Diagnosed Cancer No Yes3. Complex Renal Cyst No Yes

R2) Procedure site: Left Right BilateralR3) Procedure type:

1. Partial Nephrectomy No Yes2. Total Nephrectomy No Yes3. Cryotherapy No Yes4. Radiofrequency ablation No Yes

R4) History of kidney stones No YesR5) Prior kidney cancer treatment No Yes

1. Partial Nephrectomy No Yes a. if yes, Left Right 2. Total Nephrectomy No Yes a. if yes, Left Right

R6) Biopsy prior to surgery No Yes R7) Pre-operative imaging No Yes

1. Kidney CT No Yes2. Chest X-ray No Yes3. Chest CT No Yes4. Chest Bone scan No Yes5. Kidney MRI No Yes6. Kidney Ultrasound No Yes

R8) Lymph nodes removed and studied: No YesR9) Margins free of cancer: No YesR10) Tumor characteristics

1. Fuhrman Grade 1 2 3 4 NA2. Upper Pole No Yes3. Mid Pole No Yes4. Lower Pole No Yes5. Tumor Exact Size _______cm NA (Largest cross-sectional diameter)

R11) Histopathology1. Clear cell No Yes2. Papillary No Yes3. Collecting duct No Yes4. Chromophobe No Yes5. Oncocytoma No Yes6. Other malignant No Yes7. Other benign No Yes

R12) Ureteral stent placement No Yesif yes, intra-op placement No Yes

post-op placement No Yes



S. Esophagus Procedures

S1) Prior esophageal operation No YesS2) Prior cardiothoracic surgery No YesS3) Operation type: Partial Esophagectomy with Thoracic incision

Partial Esophagectomy without Thoracic incision Total Esophagectomy with Thoracic incision Total Esophagectomy without Thoracic incision

S4) Pre-op chemotherapy No Yes a. if yes, when: <=6 mos from surgery >6 mos NA

S5) Pre-op thoracic radiation No Yesa. if yes, when: <=6 mos from surgery >6 mos NA

S6) Chest and abdomen CT No Yesa. within 60 days of admission No Yes

S7) PET scan No Yes a. within 60 days of admission No Yes

S8) Endoscopy with biopsy prior to surgery No Yes

S9) Pre-op PFT’s1. FEV 1 No Yes a. if yes, %Predicted: ______ NA 2. DLCO No Yes a. if yes, %Predicted: ______ NA

S10) Zubrod Score: (Most severe score within 2 weeks of surgery. Eg., a patient enters the hospital with a Zubrod score of 1, but after 1 week in the hospital, Zubrod changes to 3, then score should be 3)

0 : Normal Activity, no symptoms 3 : Symptoms, in bed >50% but <100% 1 : Symptoms, fully ambulatory 4 : Bedridden 2 : Symptoms, in bed <=50% NA

S11) Smoking cessation counseling offered: No Yes (Applicable if current smoker)S12) Chest tube removed before discharge: No Yes

if removed, date: ___/___/___ NA S13) Swallow study done postoperatively to check for leak No Yes



T. HysterectomyT1) Indications:

1. Endometrial cancer No Yes 3. Other gyn cancer No Yes2. Complex Atypical Hyperplasia No Yes 4. Other benign diagnosis

No YesT2) Operation type: (mark all that apply)

1. Total hysterectomy No Yes a. with BSO or USO No Yes b. with prolapse procedure No Yes c. with incontinence procedure No Yes d. cervix NOT removed No Yes 2. Radical hysterectomy No Yes

T3) Surgical Approach: Vaginal only No YesT4) Intraoperative Events: No Yes

1. Injury to bowel No Yes 4. Vascular injury No Yes 2. Injury to bladder No Yes 5. Cystoscopy No Yes 3. Injury to ureter No Yes

T5) Prior pelvic surgery and/or procedures: No Yes1. Endometrial ablation: No Yes2. Surgery for incontinence No Yes 3. Vaginal delivery No Yes 4. C-section No Yes 5. Other pelvic surgery for gynecological condition No Yes

T6) Levonorgestrel-releasing intrauterine system (e.g Mirena IUD) use in past six months No Yes

T7) Pre-op biopsy and/or D&C in the last 90 days No YesIf yes, Biopsy results: choose one

Grade 1 Endometrial Cancer Complex Atypical Hyperplasia Grade 2 Endometrial Cancer Biopsy Benign Grade 3 Endometrial Cancer Unknown

T8) Pelvic lymph nodes removed _______ NAT9) Paraaortic lymph nodes removed _______ NAT10) Weight of uterus

1. Preoperative estimate: Normal >normal to 12 weeks >=12 weeks NA 2. Postoperative: _______grams NA

T11) Postoperative pathology1. Pathological Stage: Choose one

Stage IA Stage IIA Stage IIIA Stage IVA

Stage IB Stage IIB Stage IIIB Stage IVB

Stage IC Stage IIIC

Stage IIIC1 Staging incomplete

Stage IIIC2 NA

2. Pathological Grade: Grade 1 Grade 2 Grade 3 NA



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: ___________________________________________________________


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