MOTOPOBJdirectend}{p2col:}*If 2, go to sMATRTAMJBOPOTOMMOTOPOBJset{p_end}{p2col:}*If 2, go to sMATS docs_eprpTAMJBOPOTOMMOTOPOBJps:noami2} {err:dc1day 0} {txt:MATPNEWOBJdocs_eprp}{p2col:}*If 2, go to dMATTNEWOBJMATPNEWOBJMATS414243445152535461626364717273748182838491929394101TAMJBONEWOBJMATPNEWOBJeprp_01_41utpe="Rxng">ܔtMATS1truamivalid 1\Is there evidence in the medical record that the patient had an acute myocardial infarction?1,2Evidence in the medical record = the discharge summary, or other physician documentation (if the discharge summary is not present), must record evidence of myocardial infarction. Rule out MI (r/o) or undetermined diagnoses, such as MI vs. unstable angina are not acceptable. An MI that is a subsequent episode of care is also not acceptable.{p_end}{p2col:}Any order in which AMI is noted in the listing of discharge diagnoses is acceptable. {p_end}{p2col:}If AMI is not noted in the discharge summary but the laboratory reports show elevated serum markers of myocardial damage (i.e., troponin I, troponin T, or CK-MB) (markedly elevated TnT or TnI > 0.1 ng/mL or slightly elevated TnT > 0.01, but < 0.1 ng/mL) and treatment is consistent with AMI (EKG, oxygen, aspirin, beta blockers, NTG, cardiac enzymes, IV unfractionated heparin, analgesics, reperfusion, admission to monitored bed) and AMI is not ruled out, and the diagnosis is not unstable angina, and the AMI admission is not a subsequent episode of care, answer "yes" to the question.{p_end}{p2col:}Note: if the AMI code is 410.x2, answer "2." Cases coded with a fifth digit of 2 are not to be reviewed. {p_end}{p2col:}If the patient is a non-veteran, proceed through the questions. It is care provided by the VHA and not the patient's veteran or non-veteran status that is important.{p_end}{p2col:}If the patient did not have a discharge from inpatient care during the time for which the case was selected, answer "2" because the patient did not have an AMI.begin2amicodevalid 2For the selected episode of care, was the principal diagnosis coded as 410.0 - 410.9, with a fifth digit of 1, as follows:{p_end}{p2col:}410 acute myocardial infarction (sudden, severe death of heart muscle due to decreased coronary blood flow; classification is based on the location of the affected tissue, when known){p_end}{p2col:}o- Includes: cardiac infarction{p_end}{p2col:}o- coronary (artery) embolism, occlusion, rupture, thrombosis{p_end}{p2col:}o- infarction of heart, myocardium, or ventricle{p_end}{p2col:}o- rupture of heart, myocardium, or ventricle{p_end}{p2col:}410.01 of anterolateral wall{p_end}{p2col:}410.11 of other anterior wall{p_end}{p2col:}410.21 of inferolateral wall{p_end}{p2col:}410.31 of inferoposterior wall{p_end}{p2col:}410.41 of other inferior wall{p_end}{p2col:}410.51 of other lateral wall{p_end}{p2col:}410.61 true posterior wall infarction{p_end}{p2col:}410.71 subendocardial infarction {p_end}{p2col:}410.81 of other specified sites{p_end}{p2col:}410.91 unspecified site1,2{p_end}{p2col:}If 1 and truami=2, the record is reported as a JCAHO Category A{p_end}{p2col:}If 1 or 2 and truami=1, go to aprocode{p_end}{p2col:}If 1 or 2 and truami=2, go to uacode[The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."{p_end}{p2col:}Catnum 10 AMI records are selected from cases discharged with a diagnosis code of 410.0 - 410.9, with a fifth digit of 1. A fifth digit of 0 or 2 is not acceptable{p_end}{p2col:}To respond "1," the principal diagnosis code must be one of the listed codes.{p_end}{p2col:}The fifth digit of 0 = episode of care unspecified{p_end}{p2col:}The fifth digit of 1 = initial episode of care for an AMI. Used to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit 1 is assigned regardless of the number of times a patient may be transferred during the initial episode of care.{p_end}{p2col:}The fifth digit of 2 = subsequent episode of care. Used to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation, or treatment for a myocardial infarction that has received initial treatment but is still less than 8 weeks old. Do not review cases coded with a fifth digit of 2 {p_end}{p2col:}JCAHO Category A: the case contains invalid data that prevents assignment to the JCAHO Core Measures population.begin3aprocodevalid 3WWhat was the ICD-9-CM code selected as the principal diagnosis for this medical record. _ _ _. _ _wUse the code assigned by the VAMC. Do not attempt to code the AMI by any code other than that assigned by the facility.begin {err:truami}4othrdx_valid 4JEnter the ICD-9-CM other diagnosis codes selected for this medical record. _ _ _. _ _Enter ALL of the ICD-9-CM other diagnosis codes selected for this medical record. Use the diagnoses listed in the discharge summary for this episode of inpatient care.begin {err:truami}5uacodevalid 5 For the selected episode of care, was either the principal or secondary diagnosis coded as one of the following:{p_end}{p2col:}411.1 Intermediate coronary syndrome{p_end}{p2col:}o- Impending infarction{p_end}{p2col:}o- Preinfarction angina{p_end}{p2col:}o- Preinfarction syndrome{p_end}{p2col:}o- Unstable angina{p_end}{p2col:}411.81 Acute coronary occlusion without myocardial infarction{p_end}{p2col:}o- Acute coronary (artery):{p_end}{p2col:}o- embolism without or not resulting in MI{p_end}{p2col:}o- obstruction without or not resulting in MI{p_end}{p2col:}o- occlusion without or not resulting in MI{p_end}{p2col:}o- thrombosis without or not resulting in MI{p_end}{p2col:}411.89 Other{p_end}{p2col:}o- Coronary insufficiency (acute){p_end}{p2col:}o- Subendocardial ischemia1,2411.1= Intermediate coronary syndrome: impending infarction, preinfarction angina, preinfarction syndrome, unstable angina{p_end}{p2col:}411.1 excludes angina pectoris (413.9) and decubitus (413.0){p_end}{p2col:}411.81 excludes obstruction without infarction due to atherosclerosis (414.00-414.06){p_end}{p2col:}o-excludes occlusion without infarction due to atherosclerosis{p_end}{p2col:}o-(414.00-414.06)begin {txt:truami}6uadocvalid 6aDid the discharge summary or other physician documentation record a diagnosis of unstable angina?b1,2*{p_end}{p2col:}*If 2, the record is excluded.{p_end}{p2col:}If 1, go to Antecedent Care ModuleDiagnosis may also be listed as one of the terms noted in the question "unacode."{p_end}{p2col:}UA is commonly considered to have three presentations: (1) rest angina (2) new onset of severe angina , defined as at least Class III by the CCS classification* (3) increasing angina to at least CCS Class III severity*.{p_end}{p2col:}*CCS Class III Severity: angina with minimal exertion or ordinary activity{p_end}{p2col:}Abstractor may not determine a diagnosis of unstable angina from information in the medical record. The diagnosis must be documented in the record by an MD or DO.{p_end}{p2col:}Exclusion Statement:{p_end}{p2col:}Documentation in the medical record did not confirm that the patient had a diagnosis of Acute Coronary Syndromebegin {txt:truami}7cardrestvalid 7Either at initial presentation to the hospital or during inpatient care, was the first cardiac symptom for this patient a cardiac arrest?J1,2*{p_end}{p2col:}*If 2, go to Antecedent Care Module, else go to survivekThe question refers to the patient who had no previous cardiac symptoms. The initial symptom is a cardiac arrest. The question does not apply to patients presenting with or receiving care for cardiac symptoms. (Examples: patient who arrives in the ED with a cardiac arrest; patient recovering from hip fracture has a cardiac arrest during rehabilitation therapy.)begin {txt:uadoc}8survivevalid 82Did the patient survive the resuscitation attempt?^1,2*{p_end}{p2col:}*If 2, exclude the record.{p_end}{p2col:}If 1, go to Antecedent Care Module]Applicable only to cases in which the patient could not be resuscitated and expired during resuscitation efforts or the effort was abandoned. If no resuscitation was attempted, answer "2."{p_end}{p2col:}Exclusion Statement{p_end}{p2col:}Cardiac arrest occurring in this case precluded abstraction of the data elements required for the Core Measures.begin{txt:uadoc} {err:cardrest}9admtypeacute 1Designate the type of admission for this patient:{p_end}{p2col:}1. Emergency{p_end}{p2col:}2. Urgent{p_end}{p2col:}3. Elective{p_end}{p2col:}5. Trauma{p_end}{p2col:}9. Information not available 1,2,3,5,9uIf the patient was admitted initially to another VAMC, the question is applicable to the type of admission at that VAMC. If the patient was transferred from a community hospital and the type of admission is not known, use "9." {p_end}{p2col:}1. Emergency=the patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.{p_end}{p2col:}2. Urgent=the patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodations.{p_end}{p2col:}3. Elective=the patient's condition permitted adequate time to schedule the availability of a suitable accommodation{p_end}{p2col:}5. Trauma=Visit to the trauma center/hospital as licensed by the state or local government authority to do so, or as verified by the American College of Surgeons and involving a trauma activation.{p_end}{p2col:}9. Information not available=the hospital cannot classify the type of admission. This code is used only on rare occasions.begin10transinacute 2Was the patient received from an emergency department of another hospital?{p_end}{p2col:}1. received from another VAMC{p_end}{p2col:}2. transferred from community hospital ED{p_end}{p2col:}99. not transferred from another ED1,2,9921 or 2 = may be from another VAMC or community hospital, but the patient cannot have been an inpatient. The abstractor must know the patient was transferred from the ED.{p_end}{p2col:}Note: the emergency department of another hospital includes both emergency room AND observation bed/unit stays at that hospital.{p_end}{p2col:}If "1," the questions regarding initial care are applicable to the ED admission and treatment at the first VAMC. {p_end}{p2col:}99 = Patient not received as a transfer from another facility's Emergency Department or unable to determinebegin11admfromacute 3 Designate the admission source for this patient:{p_end}{p2col:}1. Physician referral{p_end}{p2col:}2. Clinical referral{p_end}{p2col:}3. HMO referral{p_end}{p2col:}4. Transfer from a community hospital{p_end}{p2col:}5. Transfer from skilled nursing facility{p_end}{p2col:}6. Transfer from another facility{p_end}{p2col:}7. Emergency room{p_end}{p2col:}8. Court/law enforcement{p_end}{p2col:}9. Information not available{p_end}{p2col:}A Transfer from a critical access hospital{p_end}{p2col:}10. Received from another VAMC'1,2,3,4*,5,6,7,8,9,A,*{p_end}{p2col:}10If transin=1 or 2 (patient was transferred from the ED of another hospital, default to "1" to answer admfrom.{p_end}{p2col:}1. Physician referral=the patient was admitted upon recommendation of the personal physician{p_end}{p2col:}2. Clinic referral=the patient was admitted upon recommendation of the facility's clinic physician{p_end}{p2col:}3. HMO referral=the patient was admitted upon recommendation of a health maintenance organization physician{p_end}{p2col:}4. Transfer from a hospital=the patient was admitted or transferred from an acute care facility where he/she was an inpatient{p_end}{p2col:}(from a private sector facility){p_end}{p2col:}5. Transfer from skilled nursing facility=the patient was admitted as a transfer from a skilled nursing facility where he/she was an inpatient (this or another VAMC NHCU, Intermediate Medicine, community SNF nursing home){p_end}{p2col:}6. Transfer from another facility=the patient was admitted to this healthcare facility as a transfer from a healthcare facility other than an acute care facility or a skilled nursing facility. This includes transfers from nursing homes, long term care facilities, and skilled nursing facility patients that are at a non-skilled level of care (facility other than acute care or NHCU, as for example, Residential Care, DOM, or assisted living) {p_end}{p2col:}7. Emergency room=the patient was admitted to the facility upon recommendation of this facility's ED physician/triage{p_end}{p2col:}8. Court/law enforcement=the patient was admitted upon the direction of a court of law, or upon the request of a law enforcement agency representative{p_end}{p2col:}9. Information not available=the means by which the patient was admitted is not known{p_end}{p2col:}A Transfer from a critical access hospital=the patient was admitted to this facility as a transfer from a critical access hospital where he/she was an inpatient (private sector Medicare-designated){p_end}{p2col:}Answer # "10" has been differentiated from #4 to indicate that the patient was first admitted to another VAMC. This indicates the patient was an inpatient at the first VAMC and was not transferred from the ED. If the patient was transferred from the ED, use default answer #"1."begin12inptacsacute 4CWas the veteran already an inpatient at any VAMC when ACS occurred?<1,2*{p_end}{p2col:}*If 2, go to anyvamc, else go to onsetdoc=Already an inpatient = the veteran had already been formally admitted to this or another VAMC, either for an unrelated problem or for related symptoms such as unstable angina. In either event, to answer "1," the patient must definitely have had an ACS that occurred after the patient had formally become an inpatient.begin {txt:acs_trc}13onsetdocacute 5;Does the record document the date of onset of ACS symptoms?<1,2*{p_end}{p2col:}*If 2, go to symptime, else go to onsetdt ACS symptoms = chest/substernal discomfort, pressure, or pain. May include pain radiating to one or both arms, shoulder, jaw, neck, or back. May be severe epigastric pain, nausea, vomiting, dyspnea, or diaphoresis. Look in nurses notes & progress notes for onset date.begin{err:acs_inpt}14onsetdtacute 6(Enter the date of onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.begin{err:acs_inpt} {err:onsetdoc}15symptimeacute 7;Does the record document the time of onset of ACS symptoms?:1,2*{p_end}{p2col:}*If 2, go to ecgdun, else go to onsetmeData source: nurses notes, progress notes. Look for timed entry of information relating to change in patient condition and complaint of symptoms noted in "onsetdoc."begin{err:acs_inpt}16onsetmeacute 8(Enter the time of onset of ACS symptoms._____{p_end}{p2col:}(UMT)%Enter time in Universal Military Timebegin{err:acs_inpt} {err:symptime}17ecgdunacute 9;Was a 12-lead ECG done following onset of the ACS symptoms?:1,2*{p_end}{p2col:}*If 2, go to hospdt, else go to inptecghRhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead unless documentation indicates otherwise.begin{err:acs_inpt}18inptecgacute 10fIs the date of the ECG done most immediately following onset of ACS symptoms documented in the record?<1,2*{p_end}{p2col:}*If 2, go to docecgtm, else go to inecgdtThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS.begin{err:acs_inpt} {err:ecgdun}19inecgdtacute 11KEnter the date of the ECG done immediately following onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.begin){err:acs_inpt} {err:ecgdun} {err:inptecg}20docecgtmacute 12cDoes the record document the time of the ECG done most immediately following onset of ACS symptoms.;1,2*{p_end}{p2col:}*If 2, go to hospdt, else go to inecgtmeThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS.begin{err:acs_inpt} {err:ecgdun}21inecgtmeacute 13KEnter the time of the ECG done immediately following onset of ACS symptoms.2_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to hospdtIf exact time cannot be known, look for nurses note or progress note indicating ECG was done and patient has likely had an AMI. Use time of this progress note.begin*{err:acs_inpt} {err:ecgdun} {err:docecgtm}22anyvamcacute 14@Did the patient present initially to any VAMC with ACS symptoms?:I,2*{p_end}{p2col:}*If 2, go to hospdt, else go to arrvdoc"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system. The abstractor must be able to secure data from the VAMC to which the patient first presented.begin {err:acs_arr}23arrvdocacute 15ZDoes the record document the date the patient arrived at a VHA hospital with ACS symptoms?;1,2*{p_end}{p2col:}*If 2, go to arrvtime, else go to eddateVDo not use the ambulance record or face sheet for this information. If the patient was admitted for observation, and subsequently admitted to the unit or floor, use the date of admission for observation.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) consider this care as hospital arrival, and enter the date and time treatment for ACS began in the VHA treatment setting as the hospital arrival date and time.begin{err:acs_arr} {err:anyvamc}24eddateacute 163Enter the date the patient arrived at the hospital. mm/dd/yyyyDetermine the earliest date the patient arrived at a VHA hospital, such as the ED or observation unit. Do not use ambulance records to determine arrival date. Enter the exact date.begin){err:acs_arr} {err:anyvamc} {err:arrvdoc}25arrvtimeacute 17ZDoes the record document the time the patient arrived at a VHA hospital with ACS symptoms?91,2*{p_end}{p2col:}*If 2, go to hospdt, else go to edtimeIf the patient was admitted for observation, and subsequently admitted to the unit or floor, use the time the patient arrived at a VHA hospital for observation.begin{err:acs_arr} {err:anyvamc}26edtimeacute 18Enter the time_____{p_end}{p2col:}UMTsDetermine the time the patient arrived at a VHA hospital, such as the ED or observation unit. Enter the exact time.begin*{err:acs_arr} {err:anyvamc} {err:arrvtime}27hospdtacute 19ZIs the date of formal admission to inpatient status at this VAMC documented in the record?:1,2*{p_end}{p2col:}*If 2, go to hosptime, else go to admdtAdmission date = date on which the patient was admitted to inpatient status. Admission to observation and/or arrival date are excluded.begin28admdtacute 20:Enter the date the patient was admitted to inpatient care. mm/dd/yyyyvThe exact date of inpatient admission must be entered. {p_end}{p2col:}Excluded: admission to observation, arrival datebegin {err:hospdt}29hosptimeacute 21ZIs the time of formal admission to inpatient status at this VAMC documented in the record?;1,2*{p_end}{p2col:}*If 2, go to pasthx3, else go to admtimetAdmission time = time the patient was admitted to inpatient status. Excluded: admission to observation, arrival timebegin30admtimeacute 22:Enter the time the patient was admitted to inpatient care._____{p_end}{p2col:}UMTxThe exact time of inpatient admission must be entered in military time. Excluded: admission to observation, arrival datebegin{err:hosptime}31dcdateacute -No documented instructionsbegin32dctimeacute -No documented instructionsbegin33 pasthx3_1acute 23YIndicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}1. Diabetes Mellitus:{break}250.01, 250.03 IDDM,controlled or uncontrolled{break}250.10-250.93, DM with manifestations {break}648.00-648.04, 648.81 DM complicating pregnancy-1,0begin34 pasthx3_2acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}2. Cancer: 140.0-208.91{break}All malignant neoplasms-1,0begin35 pasthx3_3acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}3. Chronic Cerebrovascular Disease: 437.0-437.9, 438.0-438.9{break}Cerebral atherosclerosis, ischemic cerebrovascular disease, hypertensive encephalopathy, cerebral aneurysm, nonruptured, cerebral arteritis, Moyamoya disease, transient global amnesia -1,0begin36 pasthx3_4acute 23 Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}4. Chronic Renal Disease (w, w/o Renal Failure): 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 582.0-583.9, 585-587{break}Hypertensive renal disease, hypertensive heart and renal disease, chronic glomerulonephritis, chronic renal failure, renal sclerosis-1,0begin37 pasthx3_5acute 233Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}5. Chronic Liver Disease: 571.0-572{break}Chronic liver disease and cirrhosis{break}Liver abscess and sequelae of chronic liver disease-1,0begin38 pasthx3_6acute 23IIndicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}6. COPD: 491.21, 493.20, 493.21, 496{break}Obstructive chronic bronchitis, chronic obstructive asthma with status asthmaticus, chronic airway obstruction NEC-1,0begin39 pasthx3_7acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}7. Cardiomyopathy: 425.0-425.9{break}Cardiomyopathies-1,0begin40 pasthx3_8acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}8. Chronic Cardiac Conditions:{break}398.90, 398.91, 398.99, Other rheumatic heart disease{break}402.00-402.91, Hypertensive heart disease,{break}414.8, 414.9, Chronic ischemic heart disease{break}416.0-416.9, Chronic pulmonary heart disease{break}429.1, 429.2, 429.3, Myocardial degeneration, cardiovascular disease, unspecified, cardiomegaly{break}443.81, 443.89, 443.9, Peripheral angiopathy{break}V12.50, unspecified circulatory disease; V15.1, surgery to heart and great vessels-1,0begin41 pasthx3_9acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}9. History of PTCA: V45.82-1,0begin42 pasthx3_10acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}10. History of CABG: V45.81-1,0begin43 pasthx3_11acute 23FIndicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}11. Atherosclerosis and Lipid Disorders: 272.0-272.9; Disorders of lipoid metabolism; 414.0-414.05, Coronary atherosclerosis; 440.0-440.9, atherosclerosis-1,0begin44 pasthx3_12acute 23pIndicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}12. Musculoskeletal Conditions: 714.0-714.33, Rheumatoid arthritis; 715.00-715.98, Osteoarthritis and allied disorders; 720.0, Ankylosing spondylitis;{break}721.90, Spondylosis of unspecified site-1,0begin45 pasthx3_13acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}13. History of MI: 412 Old MI (greater than 8 weeks)-1,0begin46 pasthx3_14acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}14. Patient has none of listed diagnoses-1,0 begin, end47 pasthx3_16acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}16. Documented family history of coronary artery disease-1,0begin48 pasthx3_99acute 23Indicate the active diagnoses, past cardiac procedures, and past history of MI applicable to this patient, as follows:{p_end}{p2col:}Indicate all that apply:{p_end}{p2col:}99. No documentation regarding other diagnoses-1,0begin49pastcvaacute 24EDoes the patient have a history of stroke within the past five years?1,2ICD-9 Code 436. Codes 438.0-438.42 and 438.81-438.9 indicate late effects of cerebrovascular disease. Old stroke without residuals is coded V12.59begin50cathblocacute 25Within the past five years, did the patient have a cardiac catheterization with a finding of > = 50% stenosis in any coronary artery?:1,2*{p_end}{p2col:}*If 2, go to revasc, else go to cathdocStenosis = constriction or narrowing. Buildup of fat, cholesterol, and other substances over time may clog the coronary arteries. The question is applicable to blockage or stenosis of any of the coronary arteries. {p_end}{p2col:}Answer "2" if whether the patient had a cath is unknown, the patient did not have a cath, findings from the cath are unknown or the degree of stenosis in all arteries was < 50%. begin, end51cathdocacute 26Does the record document the date this cardiac cath was performed?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}3. only the year is available=1,2*,3{p_end}{p2col:}*If 2, go to revasc, else go to cathdateIf more than one cardiac cath with a finding of > = 50 % stenosis was performed, the question refers to the date of the most recent cath. If the cath was performed at another VAMC or in the private sector, and the exact date is not available, the year is acceptable at a minimum. begin, end{err:cathbloc}52cathdateacute 27IEnter the date the cath with a finding of > = 50% stenosis was performed. mm/dd/yyyymEnter the exact date where possible. 01 may be used to designate day and month if only the year is available.begin{err:cathbloc} {txt:cathdoc 2}53revasc1acute 28Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}1. PTCA/PCI-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.begin54revasc2acute 28}Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}2. CABG-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.begin55revasc99acute 28Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}99. No documentation of revascularization within the past six months.-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.begin56priorx1acute 29sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}1. aspirin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin57priorx2acute 29xWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}2. beta blocker-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin58priorx3acute 29yWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}3. ACE inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin59priorx4acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}4. lipid-lowering medication-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin60priorx5acute 29sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}5. insulin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin61priorx6acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}6. platelet aggregation inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin62priorx7acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}7. low molecular weight heparin (LMWH)-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin63priorx99acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}99. no documentation patient was on any of these medications-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin64anginumacute 30Enter the number of episodes of angina experienced by the patient within 24 hours prior to presentation to the hospital.{p_end}{p2col:}(Angina is defined as: chest pain or severe epigastric pain, non-traumatic in origin; central/substernal compression or crushing chest pain; pressure, tightness, heaviness, cramping, burning or aching sensation; unexplained indigestion, belching, epigastric pain; radiating pain in neck, jaw, shoulders, back, one or both arms; dyspnea; nausea and/or vomiting; diaphoresis)?______*{p_end}{p2col:}*If 0, go to amisymp, else go to angieaseIIf any of the symptoms of angina were continuous within the 24-hour period (or less) prior to presentation, consider it as one episode. If the pain or other symptom relented for a period of time and then recurred, count each episode of pain (or other symptom) as a separate episode.{p_end}{p2col:}There may be conflicting notes in the ED record, admitting note, H&P, etc, regarding number of episodes of angina. It is suggested that one source, preferably the admitting note, be used as the source of information.{p_end}{p2col:}Enter "0" if the number of episodes of angina is unknown.begin{txt:acs_inpt}65angieaseacute 31^Enter the number of these episodes of angina that were relieved by sublingual NTG and/or rest.______This number is a component of the number of episodes of angina experienced in the last 24 hours and entered in anginum. The question does not reference number of additional episodes.begin{txt:acs_inpt} {txt:anginum 0}66amisymp1acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}1. chest pain or severe epigastric pain, non-traumatic in origin-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin67amisymp2acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}2. central/substernal compression or crushing chest pain-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin68amisymp3acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}3. pressure, tightness, heaviness, cramping, burning or aching sensation-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin69amisymp4acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}4. unexplained indigestion, belching, epigastric pain-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin70amisymp5acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}5. radiating pain in neck, jaw, shoulders, back, one or both arms-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin71amisymp6acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}6. dyspnea-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin72amisymp7acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}7. nausea and/or vomiting-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin73amisymp8acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}8. diaphoresis-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin74 amisymp99acute 32Prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.begin75onsethrsacute 333Enter the number of hours prior to arrival at the VHA hospital that the symptom(s) that brought the patient to the hospital began. {p_end}{p2col:}1. 0 - 1{p_end}{p2col:}2. >1 - 2{p_end}{p2col:}3. >2 - 6{p_end}{p2col:}4. >6 - 12{p_end}{p2col:}5. >12 - 24{p_end}{p2col:}6. >24{p_end}{p2col:}99. not documented1,2,3,4,5,6,99&The patient may have had a number of symptoms occurring over a period of many hours or days. Count the time period from the onset of the symptom that finally became so frightening, severe, or unrelenting that the patient came to the hospital. {p_end}{p2col:}The number of hours prior to hospital arrival that the symptoms began may not be explicitly stated in the record, and may have to be inferred or extrapolated from available documentation. (Examples: "the patient began to experience chest pain shortly before midnight." If hospital arrival time was 4:15 a.m., enter category #3.){p_end}{p2col:}("The patient began taking antacids for severe indigestion yesterday morning, but the epigastric pain continued to worsen until{p_end}{p2col:}presentation at the ED at 3:30 this afternoon." Enter category #6.){p_end}{p2col:}If documentation of the time period is too undefined to determine an approximate number of hours, enter #99.{p_end}{p2col:}If information in the record is conflicting, use only the ED notes or admitting note as the source of information.begin{txt:acs_inpt} {res:(}{txt:amisymp1 0} {res:&} {txt:amisymp2 0} {res:&} {txt:amisymp3 0} {res:&} {txt:amisymp4 0} {res:&} {txt:amisymp5 0}{res:)}76chfsymp1acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}1. 1. heart failure-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin77chfsymp2acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}2. impaired left ventricular function-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin78chfsymp3acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}3. new mitral regurgitation murmur-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin79chfsymp4acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}4. an S3 gallop-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin80chfsymp5acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}5. rales > 3 or 1/3 up-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin81chfsymp6acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}6. documentation of a chest x-ray with evidence of pulmonary edema-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin82chfsymp7acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}7. documentation of cardiogenic shock (severe and persistent hypotension in Trendelenburg)-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin83 chfsymp99acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms documented-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.begin84frstrateacute 35Enter the patient's heart rate recorded closest to the time of presentation to a VHA hospital, or abnormal ECG if ACS occurred as inpatient._____bpmDo not use the ambulance record. Enter the heart rate recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the heart rate recorded at the time the ECG was done.begin {txt:acs_trc}85 arvpress_acute 36vEnter the patient's blood pressure recorded at the time of presentation, or abnormal ECG if ACS occurred as inpatient.---/---Do not use the ambulance record. Enter the blood pressure recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the BP recorded closest to the time of the ECG.begin {txt:acs_trc}86painmeasacute 37At initial presentation, or abnormal ECG if ACS occurred as inpatient, was the patient's level of cardiac pain measured using a 0 - 10 scale?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}3. patient unable to respondC1,2,3*{p_end}{p2col:}*If 2 or 3, go to restang, else go to entrpainPain screening done by a nurse or other discipline is acceptable. Pain screening done by emergency personnel during transport to the hospital is also acceptable. {p_end}{p2col:}Report from an individual other than the patient is not acceptable. {p_end}{p2col:}If the patient has no pain, the abstractor will accept documentation of: pain = 0{p_end}{p2col:}If the patient has no pain, the abstractor will not accept documentation of: "patient denies pain," or "no pain," without use of a scalebegin {txt:acs_trc}87entrpainacute 380Enter the level of pain reported by the patient.______Pain screening may be done by description, color intensity, or faces rating, but a 0 - 10 scale must be used. Answer can only be numeric, zero or greater, and not greater than 10.begin{txt:acs_trc} {err:painmeas 1}88restangacute 39At the time of presentation, or abnormal ECG if the ACS occurred as inpatient, does the record document the patient experienced prolonged ongoing rest pain (pain in chest, arm, or neck{p_end}{p2col:}> 20 minutes)?1,2Documentation of rest pain may be found in the ED notes, admitting notes or H&P. {p_end}{p2col:}Myocardial ischemic pain is usually described as pressing, squeezing, or weightlike. The pain is greatest in the central precordium. The pain frequently radiates in the distribution of the lower cervical nerves and may therefore be felt in the neck, lower jaw, or either shoulder or arm. Myocardial ischemic pain often induces an autonomic response (nausea or vomiting, or sweating.) Myocardial ischemic pain due to coronary arteriosclerosis is usually exertion-related, at least initially. However, the pain of acute MI may occur suddenly when the patient is at rest.{p_end}{p2col:}Rest pain = the patient is sitting or lying in bed and not involved in exertion-related activity.begin {txt:acs_trc}89ekgdone4acute 40OWas a 12-lead EKG performed either prior to or after arrival at a VHA hospital?<1,2*{p_end}{p2col:}*If 2, go to asanone, else go to frstdatePrior to or after arrival at the hospital = examples: in another unit at the VAMC before transfer to acute care, in the ambulance in transport to the hospital, or on arrival at the ED. Review the entire record to determine whether an EKG was done during the episode of care. {p_end}{p2col:}Rhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead unless documentation indicates otherwise. {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.begin {err:acs_arr}90frstdateacute 41[Is the date of the first EKG done after arrival at a VHA hospital documented in the record?<1,2*{p_end}{p2col:}*If 2, go to frstime, else go to arvekgdtThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the date the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.begin{err:acs_arr} {err:ekgdone4}91arvekgdtacute 424Enter the date the first EKG after arrival was done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not applicable.begin+{err:acs_arr} {err:ekgdone4} {err:frstdate}92frstimeacute 43IIs the time of the first EKG done after arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to closdoc, else go to arvekgtmThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the time the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.begin{err:acs_arr} {err:ekgdone4}93arvekgtmacute 444Enter the time the first EKG after arrival was done._____{p_end}{p2col:}UMT-Time must entered in universal military time.begin*{err:acs_arr} {err:ekgdone4} {err:frstime}94closedocacute 45ZIs the date of the EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to timeclos, else go to closdt3The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.) {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable. begin, end{err:acs_arr} {err:ekgdone4}95closdt3acute 46Enter the date. mm/dd/yyyyThis may be the same date as in the question arvekgdt{p_end}{p2col:}Use exact date. The use of 01 to indicate missing day or month is not acceptable.begin+{err:acs_arr} {err:ekgdone4} {err:closedoc}96timeclosacute 47ZIs the time of the EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to closecg, else go to clostme3This may be the same time as in the question arvekgtm.{p_end}{p2col:}The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms.{p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.begin{err:acs_arr} {err:ekgdone4}97clostme3acute 48Enter the time._____{p_end}{p2col:}UMTTime must entered in universal military time{p_end}{p2col:}To convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.begin+{err:acs_arr} {err:ekgdone4} {err:timeclos}98closecgacute 49Is there documented interpretation of the 12-lead ECG performed closest to hospital arrival, or onset of ACS if the veteran was already an inpatient?;1,2*{p_end}{p2col:}*If 2, go to asanone, else go to ecgfindUse the 12-lead ECG performed closest to the time of hospital arrival whether prior to or after arrival at this or another VAMC with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.){p_end}{p2col:}The same concept applies to the ECG done closest to the onset of ACS if the ACS occurred post-admission. Look for interpretation of the 12-lead ECG performed closest to the event. {p_end}{p2col:}Do not use an ECG interpretation done more than one hour prior to hospital arrival or onset of ACS if the veteran was already an inpatient.{p_end}{p2col:}An EKG interpretation is defined as either:{p_end}{p2col:}o- a 12-lead ECG/EKG report in which the name or initials of the MD/NP/ or PA who reviewed the EKG is signed, stamped, or typed on the report.{p_end}{p2col:}o- MD/NP/ or PA notation of ECG/EKG findings. Interpretations may be taken directly from documentation of ECG findings.{p_end}{p2col:}o- If the ECG/EKG interpretation is an electronic "reading," use clinician documentation of the EKG findings unless the clinician "signs off" on the electronic interpretation as described above.{p_end}{p2col:}If the ECG/EKG report is not specifically labeled "12-lead", infer that it was 12-lead if lead marking ( i.e., I, II, III, a VL, a VL, a VF, V1, V2, V3,V4, V5, V6) are noted on the report.{p_end}{p2col:}If the physician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead unless documentation indicates otherwise.{p_end}{p2col:}If unable to determine which 12-lead ECG/EKG was done closest to arrival (e.g., one EKG does not have a time and it cannot be determined whether it is closer to hospital arrival than another EKG which does have a time), or if the time between the pre-arrival is the same (e.g., both were done 15 minutes from arrival time), answer "1" if any of these ECGs/EKGs have ST segment elevation or LBBB documented on the interpretation.begin{txt:acs_trc} {err:ekgdone4}99ecgfindacute 50jWhat were the specific findings from interpretation of the first 12-lead ECG performed closest to hospital arrival or onset of symptoms if the AMI occurred as inpatient?{p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}99. no documentation of any of the aboveD1,2,3,4,5,6,7,8,9,10,11{p_end}{p2col:}99{p_end}{p2col:}Go to asanoneDo Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.begin*{txt:acs_trc} {err:ekgdone4} {err:closecg}100transecgacute 51IDoes the record of this patient transferred from a community hospital document that an ST elevation or LBBB (new or not known to be old) was identified on the initial ECG?{p_end}{p2col:}1. ST elevation or LBBB on initial ECG{p_end}{p2col:}2. no ST elevation or LBBB identified on initial ECG{p_end}{p2col:}99. unable to determine$1,2,99{p_end}{p2col:}Go to transtropDo not attempt to use ECG tracing sent with the patient to answer this question. There must be a documentation of the initial ECG finding, and the interpretation must state ST elevation (or equivalent terminology) or LBBB. {p_end}{p2col:}Information may be taken from medical record documents sent with the patient at the time of transfer, or clinician documentation of discussion with a clinician at the community hospital to which the patient initially presented.begin {err:acs_trc}101asanoneacute 52Does the record document one or more of the following contraindications to aspirin:{p_end}{p2col:}1. Aspirin allergy{p_end}{p2col:}2. Active bleeding on arrival or within 24 hours after arrival{p_end}{p2col:}3. Warfarin/Coumadin as pre-arrival medication{p_end}{p2col:}4. Other reasons documented by MD, NP, or PA{p_end}{p2col:}98. Patient's direct refusal to take aspirin{p_end}{p2col:}documented in the record.{p_end}{p2col:}99. No documented contraindicationS1*,2*,3*,4*,98,99{p_end}{p2col:}*If 1,2,3,4, or 98, go to platagg, else go to asa24#History of allergy, sensitivity, reaction, or intolerance to aspirin also includes medications that contain aspirin. Where there is documentation of an aspirin "allergy" or "sensitivity," regard this as aspirin allergy regardless of what type of reaction might be noted. {p_end}{p2col:}Warfarin/Coumadin as pre-arrival medication = refer to patient's medication regimen just prior to acute care treatment. Include warfarin/Coumadin the patient was on at home, the nursing home, a transferring psychiatric hospital, etc. Do not include warfarin taken in the ambulance en route to the hospital. Include cases where the patient was prescribed warfarin/Coumadin at home, but there is indication it was on temporary hold or the patient was non-compliant.{p_end}{p2col:}"Other reasons" documented by MD, NP, or PA must explicitly link the noted reason with non-prescription of aspirin. If the patient is taking clopidogrel (Plavix) or ticlopidine hydrochloride (Ticlid), clinician documentation must specify the use of this drug is the reason aspirin was not given.begin {txt:acs_trc}102asa24acute 53Did the patient receive aspirin within 24 hours before or after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?;1,2*{p_end}{p2col:}*If 2, go to platagg, else go to aspdate2 = patient did not receive aspirin within the time period or unable to determine from medical record documentation {p_end}{p2col:}If aspirin was taken by the patient or given by emergency personnel on the way to the hospital, answer "1." If ASA was given at another level of care at this VAMC, answer "1."{p_end}{p2col:}Do not assume patient took ASA prior to arrival based solely on aspirin being listed as a pre-arrival or home medication. Documentation must indicate the patient actually took aspirin within the 24-hour time frame.begin{txt:acs_trc} {err:asanone 99}103aspdateacute 54+Enter the date the patient received aspirin mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.begin*{txt:acs_trc} {err:asanone 99} {err:asa24}104asptimeacute 55+Enter the time the patient received aspirin_____{p_end}{p2col:}UMTNIf the patient did not receive aspirin post-admission, or at the time of the ECG if ACS occurred inpatient, and when the patient took aspirin within a 24 hour period prior to arrival cannot be known, (Example: "patient's wife thinks he took aspirin during the night before he came to the hospital"), do not guess. Answer 2 to "asa24."begin*{txt:acs_trc} {err:asanone 99} {err:asa24}105plataggacute 56Did the patient receive a platelet aggregation inhibitor within the first 24 hours after arrival, or abnormal ECG if ACS occurred as inpatient? {p_end}{p2col:}1. clopidogrel (Plavix){p_end}{p2col:}2. ticlopidine (Ticlid){p_end}{p2col:}3. dipyridamole (Persantine){p_end}{p2col:}4. dipyridamole and aspirin (Aggrenox){p_end}{p2col:}98. patient's direct refusal to take platelet aggregation inhibitor documented in record{p_end}{p2col:}99. none of these medicationsp1,2,3,4,98*,99**{p_end}{p2col:}*If 98, go to betanone{p_end}{p2col:}**If 99, go to platcont, else go to platdateClopidogrel and ticlopidine are inhibitors of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in patients with established athererosclerotic cardiovascular disease as evidenced by stroke, TIA, and AMI. Patients who have a true allergy to aspirin and no contraindication to antiplatelet therapy may be given clopidogrel, ticlopidine, or dypyridamole.begin {txt:acs_trc}106platdateacute 57GEnter the date the patient received the platelet aggregation inhibitor. mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.begin!{txt:acs_trc} {txt:platagg 98 99}107platimeacute 58GEnter the time the patient received the platelet aggregation inhibitor.4_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to betanoneEnter the time of administration during the first 24 hours after hospital arrival or transfer to a monitored bed, using military time.begin!{txt:acs_trc} {txt:platagg 98 99}108platcontacute 59yIs there clinician documentation in the record that a platelet aggregation inhibitor is contraindicated for this patient?1,2jPotential adverse effects of platelet aggregation inhibitors: nephrotic syndrome, hyponatremia, blood cell disorders, TTP (thrombotic thrombocytopenic purpura). The abstractor may not make the decision that a platelet aggregation inhibitor is contraindicated because one of these factors is present. There must be clinician documentation of the contraindication.begin{txt:acs_trc} {err:platagg 99}109betanoneacute 60JDoes the record document one or more of the following contraindications/reasons for not prescribing a beta blocker?{p_end}{p2col:}1. Beta blocker allergy{p_end}{p2col:}2. Bradycardia (heart rate less than 60 bpm) on arrival or within 24 hours of arrival while not on a beta blocker {p_end}{p2col:}3. Second or third degree heart block on ECG on arrival or within 24 hours of arrival and does not have a pacemaker{p_end}{p2col:}4. Systolic blood pressure less than 90 mm HG on arrival or within 24 hours of arrival{p_end}{p2col:}5. Other reasons documented by an MD, NP, or PA for not giving a beta blocker within 24 hours after hospital arrival{p_end}{p2col:}7. Heart failure on arrival or within 24 hours after arrival{p_end}{p2col:}8. Shock on arrival or within 24 hours after arrival{p_end}{p2col:}9. Post-heart transplant patient{p_end}{p2col:}10. Severely decompensated heart failure, as evidenced by patient receiving IV dobutamine, milrinone, or nesiritide {p_end}{p2col:}98. patient's direct refusal to take beta blocker documented in record{p_end}{p2col:}99. No documented contraindication1*,2*,3*,4*,5*,7*,8,*{p_end}{p2col:}9*, 10, 98*, 99{p_end}{p2col:}*If 1,2,3,4,5,7,8,9, 10, or 98 go to hepin24, else go to beta24^Option Rules:{p_end}{p2col:}Beta blocker allergy = when there is documentation of a beta blocker "allergy" or "sensitivity," regard this as an allergy regardless of what type of reaction may be noted.{p_end}{p2col:}Bradycardia = must be substantiated by documentation of a heart rate of 60 beats per minute on arrival or within 24 hours of arrival.{p_end}{p2col:}Second or third degree heart block = Do not attempt to use the EKG tracing to answer this question. The EKG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the EKG interpretation does not have to be linked specifically to contraindication to beta-blocker.{p_end}{p2col:}Systolic blood pressure = may be taken from the vital sign records on arrival for the first 24 hours after arrival at the hospital{p_end}{p2col:}Other reasons = MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker{p_end}{p2col:}For example: COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma.{p_end}{p2col:}Heart failure = must be documented by MD, NP, or PA {p_end}{p2col:}Shock = must be documented by an MD, NP, or PAbegin {txt:acs_trc}110beta24acute 61Did the patient receive a beta blocker within 24 hours after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?:1,2*{p_end}{p2col:}*If 2, go to hepin24, else go to bbdateR2 = Beta blocker not given within 24 hours after hospital arrival or ECG if the AMI occurred as inpatient, or unable to determine from medical record documentation{p_end}{p2col:}Refer to drug list for listing of beta blockers.{p_end}{p2col:}Answer "1" if an IV beta blocker (eg. metoprolol) was given in the ED within 24 hours of arrival.begin{txt:acs_trc} {err:betanone 99}111bbdateacute 622Enter the date the patient received a beta blocker mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.begin,{txt:acs_trc} {err:betanone 99} {err:beta24}112bbtimeacute 632Enter the time the patient received a beta blocker_____{p_end}{p2col:}UMTTo convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.begin,{txt:acs_trc} {err:betanone 99} {err:beta24}113specbetaacute 64;Designate the beta blocker the patient received within 24 hours after arrival at the hospital, or ECG if the ACS occurred as inpatient:{p_end}{p2col:}1. metoprolol succinate (Toprol-XL){p_end}{p2col:}2. metoprolol tartrate{p_end}{p2col:}3. bisoprolol (Zebeta or Ziac){p_end}{p2col:}4. carvedilol (Coreg){p_end}{p2col:}5. atenolol (Tenoretic or Tenormin){p_end}{p2col:}6. acebutolol (Sectral) {p_end}{p2col:}7. sotalol (Betapace) {p_end}{p2col:}8. betaxolol (Kerlone) {p_end}{p2col:}9. carteolol (Cartrol) {p_end}{p2col:}10. nadolol (Corgard) {p_end}{p2col:}11. nadolol/bendroflumethiazide (Corzide) {p_end}{p2col:}12. propranolol (Inderal) {p_end}{p2col:}13. propranolol hydrochloride (Inderide) {p_end}{p2col:}14. labetalol (Normodyne or Trandate) {p_end}{p2col:}15. penbutolol sulfate (Levatol) {p_end}{p2col:}16. metoprolol/hydrocholorthiazide (Lopressor HCT ) {p_end}{p2col:}17. penbutolol sulfate (Levatol) {p_end}{p2col:}18. pindolol (Visken) {p_end}{p2col:}19. timolol (Timolide or Blocadren) {p_end}{p2col:}20. timolol/hydrocholorthiazide{p_end}{p2col:}21. brevibloc (EsmololD1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,{p_end}{p2col:}18,19,20,21SBeta blocker generic names are not capitalized. Brand names are capitalized.{p_end}{p2col:}Enter the number corresponding to the generic name documented in the medical record.{p_end}{p2col:}Question is applicable to the beta blocker administered to the patient within 24 hours after arrival at the hospital, or ECG if the ACS symptoms occurred as inpatient.{p_end}{p2col:}Beta blocker the patient may have been taking prior to arrival at the hospital is not applicable to this question.{p_end}{p2col:}Source: medication administered in the ED, admitting note, admission orders, medications givenbegin,{txt:acs_trc} {err:betanone 99} {err:beta24}114hepin24acute 65PDid the patient receive heparin within 24 hours after arrival or ECG if ACS occurred as inpatient?{p_end}{p2col:}1. received nonfractionated heparin{p_end}{p2col:}2. received low molecular weight heparin{p_end}{p2col:}98. patient's direct refusal of heparin documented in record{p_end}{p2col:}99. did not receive heparin within 24 hoursE1,2,98,99*{p_end}{p2col:}*If 98 or 99, go to hgbone, else go to hepdtNonfractionated heparin= heparin sodium (Heparin){p_end}{p2col:}Low molecular weight heparin= enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).{p_end}{p2col:}99 = patient did not receive heparin or did not receive initial dose within 24 hours of arrival, or ECG if the veteran was already an inpatient.begin {txt:acs_trc}115hepdtacute 66+Enter the date the patient received heparin mm/dd/yyyy9Enter the exact date. Month=01 or day=1 is not acceptablebegin!{txt:acs_trc} {txt:hepin24 98 99}116heptmeacute 67+Enter the time the patient received heparin_____{p_end}{p2col:}UMTEnter the time of initial administration during the first 24 hours after hospital arrival or ECG if the veteran was already an inpatient, using military time.begin!{txt:acs_trc} {txt:hepin24 98 99}117hgboneacute 68Enter the value of the first hemoglobin obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient.--. -The hemoglobin concentration is a measure of the total amount of hgb in the peripheral blood. Hgb serves as a vehicle for oxygen and carbon dioxide transportbegin {txt:acs_trc}118hgbunitacute 69CEnter the unit.{p_end}{p2col:}1. 1. g/dl{p_end}{p2col:}2. 2. mmol/L1,2RNormal: Male: 14-18 g/dl or 8.7 -11.2 mmol/L. Female: 12-16 g/dl or 7.4-9.9 mmol/Lbegin {txt:acs_trc}119hgbdtacute 70,Enter the date this hemoglobin was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin {txt:acs_trc}120hgbrefacute 71Is this hemoglobin value within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin {txt:acs_trc}121hctoneacute 72LEnter the value of the first hematocrit obtained following hospital arrival._____[The hematocrit is a measure of the percentage of red blood cells in the total blood volume.begin {txt:acs_trc}122hctunitacute 73ZEnter the unit.{p_end}{p2col:}1. 1. percent{p_end}{p2col:}2. 2. volume fraction (SI units)1,2uNormal: Male: 42%-52% or 0.42-0.52 volume fraction (SI units) Female: 37%-47% or 0.37-0.47 volume fraction (SI units)begin {txt:acs_trc}123dtofhctacute 74,Enter the date this hematocrit was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin {txt:acs_trc}124hctrefacute 75Is this hematocrit value within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin {txt:acs_trc}125platoneacute 76zEnter the first platelet count obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient.______The platelet count is an actual count of the number of platelets (thrombocytes) per cubic milliliter of blood. Normal values for adults/elderly: 150,000-400,000/mm^3begin {txt:acs_trc}126platdoneacute 770Enter the date this platelet count was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin {txt:acs_trc}127platlabacute 78Is this platelet count within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin {txt:acs_trc}128wbconeacute 79|Enter the value of the first WBC obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient._______White blood cell count is a count of the total number of WBCs (leukocytes) in 1 mm^3 of peripheral venous blood. Normal adult values 5000-10000/mm^3begin {txt:acs_trc}129wbcdtacute 80%Enter the date this WBC was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin {txt:acs_trc}130wbclabacute 81Is this white cell count within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin {txt:acs_trc}131hicreatacute 82NEnter the highest serum creatinine value obtained during this episode of care?______The serum creatinine test is used to diagnose impaired renal function. Normal values: Male: 0.6-1.2 mg/dl; Female: 0.5-1.1 mg/dl. Possible critical values: >4mg/dl.begin {txt:acs_trc}132creatdtacute 83Enter the date of this value. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin {txt:acs_trc}133creatrefacute 84Was the highest serum creatinine value within the laboratory normal reference range?{p_end}{p2col:}1. within the normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin {txt:acs_trc}134ckmbdunacute 85&Was a CK-MB obtained for this patient?;1,2*{p_end}{p2col:}*If 2, go to dotrop, else go to ckmbunitCreatine kinase (CK) is found predominantly in heart muscle, skeletal muscle and brain. . (Also called CPK.) CK-MB is more specific for myocardial cells.begin {txt:acs_trc}135ckmbunitacute 86CEnter the unit for CK-MB.{p_end}{p2col:}1. ng/mL{p_end}{p2col:}2. %1,2begin{txt:acs_trc} {err:ckmbdun}136ckmbhiacute 87CEnter the highest CK-MB value recorded during this episode of care.______Normal values CK: Male 12-70 U/ml or 55-170 U/L; Female: 10-55 U/ml or 30-135 U/L. Normal values CK-MB: 0-7 IU/L (less than 4%-6% of total CPK.)begin{txt:acs_trc} {err:ckmbdun}137ckmbdtacute 88$Enter the date of the highest value. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin{txt:acs_trc} {err:ckmbdun}138ckmblabacute 89Was the highest CK-MB value within the laboratory normal reference range?{p_end}{p2col:}1. within laboratory reference range{p_end}{p2col:}3. positive (higher than ULN for reference range)1,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin{txt:acs_trc} {err:ckmbdun}139dotropacute 90/Was a troponin level obtained for this patient?<1,2*{p_end}{p2col:}*If 2, go to cardcare, else go to howtropTroponin is a protein complex consisting of three isotypes, T, I, and C. Troponin has become the marker of choice for diagnosis of myocardial necrosis, and Troponin T and I are powerful tools for risk stratification. Portable devices allow bedside (point of care or POCT) cardiac marker determinations rapidly and accurately. Point of care systems have the advantage of reducing diagnostic delays due to transportation and processing in a central laboratorybegin {txt:acs_trc}140howtropacute 91How was the first troponin level obtained after hospital arrival or ECG if ACS as inpatient?{p_end}{p2col:}1. point of care bedside testing{p_end}{p2col:}2. central laboratory assay1,2Point of care testing= blood sample drawn at the bedside and analyzed immediately for presence of troponin I or troponin T, which identify unstable patients at high risk for occlusion. {p_end}{p2col:}Read ED notes, admitting notes, and progress notes carefully to determine if POCT was used to obtain the first troponin level. Do not reference only the laboratory reports for the initial troponin level.begin{txt:acs_trc} {err:dotrop}141troponeacute 92Enter the result of the first troponin level.{p_end}{p2col:}3. positive (higher than upper limit for reference range){p_end}{p2col:}4. negative (not higher than upper limit for reference range)3,4Point of care bedside testing may only be reported as positive or negative. Values that are reported as an actual numeric value will need to be compared to the reference range to determine if the result exceeds the upper limit of normal (ULN) according to the hospital's laboratory parameters. Consult your liaison for help if you are unsure. If the value is greater than the higher value of the reference range, it is positive.begin{txt:acs_trc} {err:dotrop}142firstdocacute 93Does the record document the draw date of the first troponin level obtained after arrival, or abnormal ECG if ACS occurred as inpatient?=1,2*{p_end}{p2col:}*If 2, go to firstime, else go to entrfrstDraw date = the date the blood sample was drawn. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation that POCT testing was done. If the sample was drawn by the lab, use the date the lab drew the sample.begin{txt:acs_trc} {err:dotrop}143entrfrstacute 942Enter the date the first troponin level was drawn. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.begin){txt:acs_trc} {err:dotrop} {err:firstdoc}144firstimeacute 95Does the record document the draw time of the first troponin level obtained after arrival, or abnormal ECG if ACS occurred as inpatient?<1,2*{p_end}{p2col:}*If 2, go to reprtdoc, else go to whatimeDraw time = the time the blood sample was drawn. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation that POCT testing was done. If the sample was drawn by the lab, use the time the lab drew the sample. If the time the sample was drawn is noted in nurses notes or progress notes, and this time conflicts with lab time, use the earlier time.begin{txt:acs_trc} {err:dotrop}145whatimeacute 962Enter the time the first troponin level was drawn._____{p_end}{p2col:}UMTIf the time the sample was drawn is noted in nurses notes or progress notes, and this time conflicts with lab time, use the earlier time.begin){txt:acs_trc} {err:dotrop} {err:firstime}146reprtdocacute 97QIs the report date of the first troponin level obtained documented in the record?<1,2*{p_end}{p2col:}*If 2, go to reprtime, else go to reprtdtBTroponin level report = the date the troponin results were available to the clinician. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation of the outcome of POCT testing.{p_end}{p2col:}If the sample was drawn by the lab, use the lab report date.begin{txt:acs_trc} {err:dotrop}147reprtdtacute 985Enter the date the first troponin level was reported. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.begin){txt:acs_trc} {err:dotrop} {err:reprtdoc}148reprtimeacute 99HIs the report time of the first troponin level documented in the record?<1,2*{p_end}{p2col:}*If 2, go to labever, else go to reportmeBTroponin level report = the time the troponin results were available to the clinician. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation of the outcome of POCT testing.{p_end}{p2col:}If the sample was drawn by the lab, use the lab report time.begin{txt:acs_trc} {err:dotrop}149reportme acute 1005Enter the time the first troponin level was reported._____{p_end}{p2col:}UMTIf the troponin level was drawn by POCT and the result entered in the progress notes, use the time of the progress note unless the exact time the result was known is documented in the record.begin){txt:acs_trc} {err:dotrop} {err:reprtime}150labever acute 101)Was a subsequent troponin level obtained?;1,2*{p_end}{p2col:}*If 2, go to cardcare, else go to lablvlSubsequent troponin level = additional samples drawn after the first troponin level. Serial troponin levels may be drawn at regular intervals, and may be obtained by POCT or laboratory assay.begin{txt:acs_trc} {err:dotrop}151lablvl acute 1024Enter the result of the highest/peak troponin level._. __vHighest/peak troponin level = of all the troponin samples obtained, enter the highest value reported for this patient.begin({txt:acs_trc} {err:dotrop} {err:labever}152tropdt acute 103!Enter the date of the peak level. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin({txt:acs_trc} {err:dotrop} {err:labever}153trohitm acute 104!Enter the time of the peak level._____{p_end}{p2col:}UMTUEnter the time the blood sample was drawn. Enter the time in universal military time.begin({txt:acs_trc} {err:dotrop} {err:labever}154tropref acute 105Was the highest troponin level within the laboratory reference range?{p_end}{p2col:}3. positive (higher than upper limit for reference range){p_end}{p2col:}4. negative (not higher than upper limit for reference range) 3,4{p_end}{p2col:}Go to cardcareThe reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.begin({txt:acs_trc} {err:dotrop} {err:labever}155 transtrop acute 106Does the record of this patient transferred from a community hospital document that either the initial or peak troponin level was positive?{p_end}{p2col:}2. initial or peak troponin negative{p_end}{p2col:}3. initial and peak troponin positive{p_end}{p2col:}99. unable to determine2,3,99Use documentation sent from the transferring community hospital if this data is available. If there is no information from the transferring hospital, or no documentation of troponin level, answer "3."{p_end}{p2col:}If the patient was transferred soon after presentation to the initial hospital, and the peak troponin level drawn at this VAMC was positive or negative, use this data and answer in accordance with the findings.begin {err:acs_trc}156cardcare acute 107Was Cardiology involved in the care of the patient?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}99. unable to determineP1,2*,99*{p_end}{p2col:}If 2 or 99 go to{p_end}{p2col:}nototx, else go to sawcardEThe cardiologist must be a physician. This question refers to any time during the hospital stay and is not limited to initial presentation or in the ED.{p_end}{p2col:}Answer yes if a cardiologist was attending physician, saw the patient in consultation, or there was consultation by telephone or telemedicine, or a cardiac cath or PTCA was done with 24 hours.{p_end}{p2col:}If the patient was seen by a cardiology resident, the staff practitioner overseeing the resident must be a cardiologist. The staff practitioner must write a personal progress note or an addendum to the resident note. The note must be dated and timed. The staff practitioner's note may reference discussion of the patient with the resident within 24 hours, even though the note is written at a later time. If the staff practitioner does not write a note, the resident must refer in his note to discussion of the case with the staff practitioner. {p_end}{p2col:}A cardiology "Fellow" is considered to have attained a higher level of education than a resident and the rules pertaining to resident supervision do not apply.begin157sawcard acute 108Specify how Cardiology was involved in the care of the patient.{p_end}{p2col:}1. A cardiologist was the attending physician{p_end}{p2col:}2. Cardiology was consulted either in person, by telephone, or telemedicine.1,2$Consultation by cardiology = face to face contact with patient, phone call between the primary provider and the cardiologist in which recommendations are made, or consult via telemedicine.{p_end}{p2col:}If a cardiac catheterization or PTCA was done within 24 hours of admission, this counts as a cardiology consult. Answer #2.{p_end}{p2col:}If the patient was seen by a cardiology resident, the staff practitioner overseeing the resident must be a cardiologist. The staff practitioner must write a personal progress note or an addendum to the resident note. The note must be dated and timed. The staff practitioner's note may reference discussion of the patient with the resident within 24 hours, even though the note is written at a later time. If the staff practitioner does not write a note, the resident must refer in his note to discussion of the case with the staff practitioner. {p_end}{p2col:}A cardiology "Fellow" is considered to have attained a higher level of education than a resident and the rules pertaining to resident supervision do not apply.begin{err:cardcare 1}158cardoc acute 109ZWas the date Cardiology was first involved in the patient's care documented in the record?;1,2*{p_end}{p2col:}*If 2, go to cartmdoc, else go to carddtUInvolvement by cardiology = face to face contact with patient, phone call between the primary provider and the cardiologist in which recommendations are made, or consult via telemedicine.{p_end}{p2col:}If a cardiac catheterization or PTCA was done within 24 hours of admission, use this date as the documented date of cardiology involvement.begin{err:cardcare 1}159carddt acute 110_Enter the date the patient was first seen by Cardiology or a Cardiology consult was first done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.begin{err:cardcare 1} {err:cardoc}160cartmdoc acute 111ZWas the time Cardiology was first involved in the patient's care documented in the record?81,2*{p_end}{p2col:}If 2 go to nototx, else go to cardtmeXThis is the time the consult was done, not the time the request for consult was entered.begin{err:cardcare 1}161cardtme acute 112CEnter the time Cardiology was first involved in the patient's care._____{p_end}{p2col:}UMT3Enter the exact time using universal military time.begin{err:cardcare 1} {err:cartmdoc}162nototx acute 113Within 24 hours after hospital arrival, or time of the event if ACS occurred inpatient, is there explicit documentation of the decision not to treat?>1,2*{p_end}{p2col:}*If 2, go out of module, else go to notxdocDecision not to treat = the record clearly documents that the patient, patient's family, or legal representative wishes comfort measures only, and/or there is agreement that the patient's cardiac condition and co-morbid conditions preclude aggressive treatment.{p_end}{p2col:}Include: "comfort measures only, hospice care, maintain treatment for comfort, terminal care, physician documentation that care is limited at family's request or due to patient's age or chronic illness, palliative care, supportive care only."begin163notxdoc acute 114CWas the date of the decision not to treat documented in the record?;1,2*{p_end}{p2col:}*If 2, go to notxtime, else go to notxdtSources: Admitting note, progress notes, social service notes, MD orders. Date of decision documentation should appear close to the time of arrival or ACS event if the veteran was already an inpatient.begin {err:nototx}164notxdt acute 115Enter the date. mm/dd/yyyyWEnter the exact date. the use of 01 to indicate missing day or month is not acceptable.begin{err:nototx} {err:notxdoc}165notxtime acute 116CWas the time of the decision not to treat documented in the record?>1,2*{p_end}{p2col:}*If 2, go out of module, else go to timentrSources: Admitting note, progress notes, social service notes, MD orders. Time of decision documentation should appear close to the time of arrival or ACS event if the veteran was already an inpatient.begin {err:nototx}166timentr acute 117Enter the time._____{p_end}{p2col:}UMT Enter the time in military time.begin{err:nototx} {err:notxtime}167conththrevasc 1Does the record document any of the following potential contraindications to thrombolytic therapy?{p_end}{p2col:}Absolute contraindications{p_end}{p2col:}1. previous hemorrhagic stroke at any time{p_end}{p2col:}2. other strokes or cerebrovascular events, within one year{p_end}{p2col:}3. known intracranial neoplasm{p_end}{p2col:}4. active internal bleeding (except menses){p_end}{p2col:}5. suspected aortic dissection{p_end}{p2col:}6. acute pericarditis {p_end}{p2col:}7. clinician documentation of late presentation{p_end}{p2col:}8. other contraindication documented by clinician{p_end}{p2col:}Relative contraindications{p_end}{p2col:}9. severe uncontrolled hypertension on presentation{p_end}{p2col:}10. current use of anticoagulants in therapeutic doses{p_end}{p2col:}11. known bleeding problems{p_end}{p2col:}12. recent trauma{p_end}{p2col:}13. recent major surgery, i.e., within three weeks{p_end}{p2col:}14. non-compressible vascular punctures{p_end}{p2col:}15. recent internal bleeding, i.e., within 2 to 4 weeks{p_end}{p2col:}16. prior exposure to streptokinase, if that agent is to be administered, i.e., within 5 days to 2 years{p_end}{p2col:}17. pregnancy{p_end}{p2col:}18. active peptic ulcer{p_end}{p2col:}19. history of chronic, severe hypertension{p_end}{p2col:}20. age > 75 years{p_end}{p2col:}21. Stroke risk score > = 4 risk factors{p_end}{p2col:}22. cardiogenic shock{p_end}{p2col:}99. no documented contraindicationP1,2,3,4,5,6,7,8,9,10,{p_end}{p2col:}11,12,13,14,15, 16,17,18, 19, 20, 21, 22, 994. Active internal bleeding = patient presents to hospital actively bleeding from non-compressible site, such as biopsy site, subclavian artery, ulcer, lacerated viscera or other internal site. Skin lesions or trauma to external surface is not applicable.{p_end}{p2col:}7. Clinician documentation of late presentation = clinician documents too many hours have passed from the beginning of the patient's chest pain to his/her arrival at the hospital.{p_end}{p2col:}8. Other contraindication documented by a clinician= patient or situation-specific reason why patient is not a candidate for thrombolytic therapy{p_end}{p2col:}(Examples: patient's advanced age, multiple system failure, patient or family decided against thrombolytic therapy){p_end}{p2col:}9. Severe uncontrolled hypertension on presentation = systolic BP > 180mm HG or dyastolic BP > 110 mm HG, following therapy in the emergency department, or a clinician's notation diagnosing severe uncontrolled HTN at time of adm.{p_end}{p2col:}10. anticoagulants = warfarin (Coumadin); heparin{p_end}{p2col:}12. recent trauma = within 2 to 4 weeks; includes head trauma or traumatic or prolonged ( > 10 minutes) cardiopulmonary resuscitation (CPR){p_end}{p2col:}21 Stroke Risk Score > = 4 risk factors{p_end}{p2col:}o- age > = 75 years{p_end}{p2col:}o- female{p_end}{p2col:}o- African American descent{p_end}{p2col:}o- prior stroke{p_end}{p2col:}o- admission systolic BP > = 160 mm Hg{p_end}{p2col:}o- use of alteplase{p_end}{p2col:}o- excessive anticoagulation ( INR > = 4; APTT > = 24){p_end}{p2col:}o- below median weight (< = 65 kg for women; <= 80 kg for men){p_end}{p2col:}22. cardiogenic shock = sustained systolic BP < 90 mm Hg and evidence of end-organ hypoperfusion, such as cool extremities and urine output < 30 cc/hr) and CHFbegin{txt:noami1} {txt:acs_trc}168ththgvnrevasc 26Was thrombolytic therapy administered to this patient?91,2*{p_end}{p2col:}*If 2, go to dc24, else go to specththAbbokinase, Activase, Alteplase, Anistreplase, Eminase, Reteplase, Kabikinase, Streptase,Streptokinase, Tissue Plasminogen Activator (TPA), Win-kinase, APSAC = Anisylated plasminogen streptokinase activator complex.begin{txt:noami1} {txt:acs_trc}169specththrevasc 3Indicate which of the following antithrombin agents were administered to the patient:{p_end}{p2col:}1. streptokinase{p_end}{p2col:}2. reteplase{p_end}{p2col:}3. tPA (Alteplase){p_end}{p2col:}4. tenecteplase{p_end}{p2col:}5. other agent administered 1,2,3,4,5[Streptokinase: 1.5 million units (MU) over 60 minutes{p_end}{p2col:}Reteplase (rPA): 10 U over 2 minutes followed by a second 10 U IV bolus 30 minutes later{p_end}{p2col:}Alteplase (tPA): (100 mg maximum), 15 mg IV bolus, then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over the next 60 minutes{p_end}{p2col:}Tenectaplase: IV bolus weight adjustedbegin({txt:noami1} {txt:acs_trc} {err:ththgvn}170thromdtrevasc 4HDoes the record document the date thrombolytic therapy was administered?=1,2*{p_end}{p2col:}*If 2, go to thromtme, else go to ththdateCheck emergency department notes, medication administration record, progress notes, nurses notes for specific date thrombolytic therapy was given. Do not use order sheets for this data element. To answer "1," the date must be identified in the medical record.begin({txt:noami1} {txt:acs_trc} {err:ththgvn}171ththdaterevasc 55Enter the date thrombolytic therapy was administered. mm/dd/yyyyIf there were two different thrombolytic administration episodes, enter the date (and time) the earliest thrombolytic was initiated.{p_end}{p2col:}Enter exact date. Month = 01 or day = 01 is not acceptablebegin6{txt:noami1} {txt:acs_trc} {err:ththgvn} {err:thromdt}172thromtmerevasc 6HDoes the record document the time thrombolytic therapy was administered?81,2*{p_end}{p2col:}If 2, go to dc24, else go to ththtimeIf thrombolytic therapy was initiated in the ambulance and was infusing at the time of arrival, use the hospital arrival time. Do not use order sheets for this data element. To answer "1," the time must be identified in the medical record, except for situation described.begin({txt:noami1} {txt:acs_trc} {err:ththgvn}173ththtimerevasc 7Enter the time_____{p_end}{p2col:}UMT'Time must be in Universal Military Timebegin7{txt:noami1} {txt:acs_trc} {err:ththgvn} {err:thromtme}174dc24revasc 8>Was the patient discharged on the day of arrival at this VAMC?1,24Day of arrival = on the same date as the day of arrival{p_end}{p2col:}Since VAMCs are required to "discharge" rather than "transfer" patients to another acute care facility, this question can mean a "discharge" to another VAMC for cath or PCI, or it can mean the patient was found not to require inpatient care and was sent home. "On the day of arrival" is the focal point of the question. Answer "1" if the patient was "discharged" to another VAMC or community-based hospital on the day of arrival at this VAMC and did not return to this facility within 12 hours.begin{txt:noami1} {txt:acs_trc}175outpcirevasc 9gWas the patient discharged to another acute care hospital for an emergent cardiac cath or probable PCI?;1,2*{p_end}{p2col:}*If 2, go to ptcadne, else go to docneedIf the patient is sent to a hospital associated with this VAMC for a PCI, and returns to this VAMC within 12 hours for further care, answer "2" since this is not considered a discharge.{p_end}{p2col:}Answer "1" if the patient was discharged to another VAMC or community-based acute care hospital, and the record documents a planned cath with consideration of a PTCA/PCI depending on the outcome of the cath.begin{txt:noami1} {txt:acs_trc}176docneed revasc 10Does the record indicate urgent need for catheterization/probable PCI based on ECG interpretation of ST elevation or LBBB (new or not known to be old)?1,2The question presumes that this VAMC does not have the capability to perform a cardiac cath/PCI. Documentation of the need for an emergent cath can state "discharged for a cath or PCI." The abstractor does not need to know whether both will be performed. {p_end}{p2col:}There must be documentation in the record of ECG interpretation as noted, or documentation of a STEMI, and indication that need for intervention is urgent.begin'{txt:noami1} {txt:acs_trc} {err:outpci}177tranplan revasc 11Is there documentation of a plan for discharge, i.e., acceptance by the receiving facility and transportation arrangements made?<1,2*{p_end}{p2col:}*If 2, go to transdoc, else go to planactPlan of transfer must be comprised of the two noted parts: the receiving facility must be contacted and agree to accept the patient, and arrangements for transportation must be made.begin'{txt:noami1} {txt:acs_trc} {err:outpci}178planact revasc 129Does the record document the date the plan was activated?;1,2*{p_end}{p2col:}*If 2, go to plantime, else go to actvdtPPlan activated = the latest date when both components of the plan were completedbegin6{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan}179actvdt revasc 13Enter the date of activation. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable,beginD{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan} {err:planact}180plantime revasc 149Does the record document the time the plan was activated?;1,2*{p_end}{p2col:}*If 2, go to transdoc, else go to actimePPlan activated = the latest time when both components of the plan were completedbegin6{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan}181actime revasc 15Enter the time of activation._____{p_end}{p2col:}UMT0Time must be entered in universal military time.beginE{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan} {err:plantime}182transdoc revasc 16RWas the date of discharge to another acute care hospital documented in the record?<1,2*{p_end}{p2col:}*If 2, go to trnfrtme, else go to trnfrdtgSource: MD orders, progress notes {p_end}{p2col:}Date of transfer = date patient actually left the VAMCbegin'{txt:noami1} {txt:acs_trc} {err:outpci}183trnfrdt revasc 17;Enter the date of discharge to another acute care hospital. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not applicable.begin6{txt:noami1} {txt:acs_trc} {err:outpci} {err:transdoc}184trnfrtme revasc 18RWas the time of discharge to another acute care hospital documented in the record?;1,2*{p_end}{p2col:}*If 2, go to pciback, else go to timeoutfSource: MD orders, progress notes{p_end}{p2col:}Time of transfer = time patient actually left the VAMCbegin'{txt:noami1} {txt:acs_trc} {err:outpci}185timeout revasc 19;Enter the time of discharge to another acute care hospital._____{p_end}{p2col:}UMT0Time must be entered in universal military time.begin6{txt:noami1} {txt:acs_trc} {err:outpci} {err:trnfrtme}186pciback revasc 20QDid the patient return to this VAMC for further inpatient care following the PCI?U1,2{p_end}{p2col:}*If 2, "2" in ptdc will be auto-filled{p_end}{p2col:}Go to cabgdoneReturn may be a period of greater than 12 hours or may be several days later. Return assumes that report of the PTCA/PCI will accompany the patient, or there will be communication between clinicians at each of the respective hospitals.begin'{txt:noami1} {txt:acs_trc} {err:outpci}187ptcadne revasc 21<Was a percutaneous transluminal coronary angioplasty (PTCA/PCI) performed during this episode of care?{p_end}{p2col:}If a PTCA was performed, one of the following codes must be entered in pxcode or othrpxs: 36.01, 36.02, 36.05. If one of these codes is not entered, the "1" answer to this question will not be valid.91*,2{p_end}{p2col:}*If 1, go to firsdt, else go to noptcaPercutaneous transluminal coronary angioplasty is defined as any percutaneous angioplasty procedure (balloon dilation, atherectomy, rotational ablation, etc.) or combination of procedures performed in the infarct-related artery. Cardiac cath alone is not a PTCA.{p_end}{p2col:}If the patient is transferred to a hospital affiliated with this VAMC for a PTCA, returns to this VAMC within 12 hours for further care, and the PTCA report is accessible, answer "1."begin'{txt:noami1} {txt:acs_trc} {txt:outpci}188noptca revasc 22Is there clinician documentation in the record of a reason why PTCA/PCI was not performed?{p_end}{p2col:}98. patient or family refusal{p_end}{p2col:}2. patient co-morbidities preclude procedure{p_end}{p2col:}3. other reason documented{p_end}{p2col:}99. no documented reason&98,2,3,99{p_end}{p2col:}Go to cabgdone_Clinician = MD (or DO), NP, or PA{p_end}{p2col:}Documentation may include patient or family's refusal to consent to PTCA, documentation that patient co-morbidities likely preclude a successful outcome, or other clinical reason why PTCA is not an option for this patient. The reason why PTCA was not performed must be clearly documented by a clinician.begin5{txt:noami1} {txt:acs_trc} {txt:outpci} {txt:ptcadne}189firstdt revasc 23EEnter the date of the first PTCA/PCI performed after hospital arrival mm/dd/yyyy]Exact date must be entered. The use of 01 to indicate missing day or month is not acceptable.begin5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}190baloon3 revasc 24What was the time of the first PTCA/PCI done after hospital arrival? Use the following priority:{p_end}{p2col:}1. Time the wire or balloon reached, passed through, or crossed the lesion{p_end}{p2col:}2. Time of the first balloon inflation (Inflate #1, Balloon ^, #ATM for #minutes, seconds){p_end}{p2col:}3. Time of the first cut or excision of lesion (Cut #1 time, Excimer time, Time rotablade used){p_end}{p2col:}4. Time the balloon, rotablade, or cutter was inserted{p_end}{p2col:}5. Sheath time (Artery time, Cannulation time, Vessel time, Vessel access){p_end}{p2col:}6. Time of lidocaine/procaine injection Infiltration time, Local, Local anesthesia, Xylocaine/procaine injection time{p_end}{p2col:}7. Procedure/case start time (Begin time, Start time)_____{p_end}{p2col:}UMT)"First" PTCA=if more than one PTCA was performed during the episode of care, the first PTCA is the one performed first after arrival at the hospital. {p_end}{p2col:}Use military time. To convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.{p_end}{p2col:}If conflicting times are documented, use the earliest time.{p_end}{p2col:}Use the designated priority order regardless of whether the culprit lesion is a native coronary vessel or a graft.{p_end}{p2col:}If there is documentation on the procedure sheet of "lesion" accompanied solely by a time (e.g., "8:52 - RCA lesion"), assume this is the time the lesion was crossed (1st priority).{p_end}{p2col:}When applying the priority order and there are conflicting times (e.g., two different balloon inflation times), enter the earliest time.{p_end}{p2col:}This question is also applicable to AMI occurring as inpatient since it is assumed the PTCA/PCI would be the first PTCA/PCI performed after hospital arrival.begin5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}191stentplc revasc 25IWere stents placed during the first PTCA/PCI done after hospital arrival?=1,2*{p_end}{p2col:}*If 2, go to cabgdone, else go to stentnumStents are tiny metal mesh tubes which are placed in the artery after the interventional procedure is performed. The stent acts as a scaffold to provide support inside the artery and helps to prevent restenosis.begin5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}192stentnum revasc 26=Enter the number of stents placed during the first PTCA done.______beginD{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne} {err:stentplc}193cabgdone revasc 27Was a CABG performed during this episode of hospitalization?{p_end}{p2col:}1. performed at this VAMC{p_end}{p2col:}2. performed at another VAMC{p_end}{p2col:}3. performed at a community hospital{p_end}{p2col:}99. no CABG performed during this episode of careL1,2,3,99{p_end}{p2col:}*If 99, go to anypx, as applicable, else go to cabgdtIf the patient is transferred to a hospital affiliated with this VAMC for a CABG, and returns to this VAMC for further care, answer "1."begin {txt:noami1}194cabgdt revasc 28&Enter the date the CABG was performed. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin{txt:noami1} {txt:cabgdone 99}195anypx revasc 29IWas any invasive procedure performed during this episode of care for AMI?=1,2*{p_end}{p2col:}*If 2, go out of module, else go to pxcodeProcedures=invasive procedures requiring some form of anesthesia including local. May be cardiac catheterization, CABG, or other procedure not related to the AMI.begin9{txt:noami1} {txt:outpci} {txt:ptcadne} {err:cabgdone 99}196pxcode revasc 30OWhat was the ICD-9-CM code selected as the principal procedure for this record?--. --wPrincipal procedure= that procedure performed for definitive treatment, rather than for diagnostic or exploratory reasons, or was necessary to treat a complication. The principal procedure is related to the principal diagnosis.{p_end}{p2col:}Percutaneous Transluminal Coronary Angioplasty{p_end}{p2col:}36.01: Single vessel PTCA or coronary atherectomy without mention of thrombolytic agent{p_end}{p2col:}36.02: Single vessel PTCA or coronary atherectomy with mention of thrombolytic agent{p_end}{p2col:}36.05: Multiple vessel PTCA or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent{p_end}{p2col:}If the patient had a PTCA with stent placement (code 36.06) enter the applicable code for the PTCA, not the stent placement. {p_end}{p2col:}If PTCA is not the principal diagnosis, use the principal diagnosis code assigned by the VAMC.begin{txt:noami1} {err:anypx}197othrsdne revasc 31DWere other procedures performed during this episode of care for AMI?<1,2*{p_end}{p2col:}*If 2, go to prinpxdt, else go to othrpxsOther procedures=invasive procedure requiring a form of anesthesia including local. May be PTCA, if not designated as the principal diagnosis, cardiac cath, CABG, or other unrelated procedure.begin{txt:noami1} {err:anypx}198othrpxs_ revasc 32RWhat were the ICD-9-CM code(s) selected as the other procedure(s) for this record?k(1) --. --{p_end}{p2col:}(2) --. -{p_end}{p2col:}(3) --. -{p_end}{p2col:}(4) --. -{p_end}{p2col:}(5) --. --hEnter the ICD-9-CM codes identifying all significant procedures other than the principal procedure. Enter up to five other procedure codes.{p_end}{p2col:}Begin with the first procedure performed after hospital arrival.{p_end}{p2col:}If the patient had a PTCA with stent placement (code 36.06) enter the applicable code for the PTCA, not the stent placement.{p_end}{p2col:}Be alert for the following codes which should be present in the record and entered as either the principal or other procedures, if the procedure was performed: Cardioversion 99.62; CABG 36.10 - 36.19; Pacemaker 37.80, 37.83, 39.64, 37.81, 37.78begin'{txt:noami1} {err:anypx} {err:othrsdne}199prinpxdt revasc 33-What was the date of the principal procedure? mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin{txt:noami1} {err:anypx}200othrdts_ revasc 348What were the dates the other procedures were performed.)mm/dd/yyyy{p_end}{p2col:}Up to five datesEnter the dates corresponding to each of the other procedures performed, beginning with the first procedure performed after hospital arrival. Up to five other dates may be entered.begin'{txt:noami1} {err:anypx} {err:othrsdne}201trans24ccare 1^Was the patient transferred to another acute care hospital on the day of arrival at this VAMC?91*,2{p_end}{p2col:}*If 1, go out of ACS, else go to amadcDay of arrival = on the same date as the day of arrival{p_end}{p2col:}VAMCs are required to "discharge" rather than "transfer" patients to another facility.begin {txt:noami2}202amadcccare 2PDid the patient leave against medical advice on the day of arrival at this VAMC?;1*,2{p_end}{p2col:}*If 1, go out of ACS, else go to arrvexp7Day of arrival = on the same date as the day of arrivalbegin{txt:noami2} {txt:trans24}203arrvexpccare 3:Did the patient expire on the day of arrival at this VAMC?<1*,2{p_end}{p2col:}*If 1, go out of ACS, else go to nogpbloc7Day of arrival = on the same date as the day of arrivalbegin&{txt:noami2} {txt:trans24} {txt:amadc}204 nogpbloc1ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}1. active internal bleeding or history of bleeding within 30 days-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}205 nogpbloc2ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}2. history of intracranial hemorrhage-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}206 nogpbloc3ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}3. intracranial neoplasm-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}207 nogpbloc4ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}4. arteriovenous malformation or aneurysm-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}208 nogpbloc5ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}5. history of thrombocytopenia after previous exposure to GP IIb/IIIa inhibitors-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}209 nogpbloc6ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}6. history of ischemic stroke within 30 days or any history of hemorrhagic stroke-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}210 nogpbloc7ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}7. major surgery or severe trauma within the previous 30 days-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}211 nogpbloc8ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}8. history, symptoms, or findings suggestive of aortic dissection-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}212 nogpbloc9ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}9. severe hypertension (SBP >180 and/or DBP >90), unless corrected prior to administration-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}213 nogpbloc10ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}10. acute pericarditis-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}214 nogpbloc11ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}11. concomitant use of GP IIb/IIIa inhibitor-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}215 nogpbloc98ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}98. patient refused a glycoprotein IIb/IIIa inhibitor-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}216 nogpbloc99ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}99. no documented contraindication-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.begin{txt:noami2} {err:dc1day 0}217gpblocccare 5Did the patient receive a glycoprotein IIb/IIIa inhibitor?{p_end}{p2col:}1. tirofiban (Aggrastat){p_end}{p2col:}2. eptifibatide (Integrilin){p_end}{p2col:}3. abciximab (ReoPro){p_end}{p2col:}99. none of these medicationsC1,2,3,99*{p_end}{p2col:}*If 99, go to reangina, else go to glycodocCurrent data from at least 10 randomized, placebo-controlled, double-blind trials in ACS indicate that intravenous glycoprotein IIb/IIIa inhibitor therapy has a beneficial effect (reduction in death, MI, or revascularization) when used with patients with UA/NSTEMI. However, there is not yet consensus for their routine use in all patients with UA/NSTEMI.{p_end}{p2col:}Glycoprotein IIb/IIIa inhibitors are administered IVbegin.{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0}218glycodocccare 6XIs the date the patient received a glycoprotein IIb/IIIa inhibtor entered in the record?=1,2*{p_end}{p2col:}*If 2, go to gptmedoc, else go to gpblocdt}Glycoprotein IIb/IIIa inhibitors are administered IV. Look in nursing IV medication administration records for date and time.begin>{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99}219gpblocdtccare 7TEnter the date the patient received a glycoprotein{p_end}{p2col:}IIb/IIIa inhibitor. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.beginM{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99} {err:glycodoc}220gptmedocccare 8YIs the time the patient received a glycoprotein IIb/IIIa inhibitor entered in the record?<1,2*{p_end}{p2col:}*If 2 go to reangina, else go to gpbloctmVThe exact time of administration of the glycoprotein IIb/IIIa inhibitor must be known.begin>{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99}221gpbloctmccare 9SEnter the time the patient received a glycoprotein{p_end}{p2col:}IIb/IIIa inhibtor._____{p_end}{p2col:}UMTEnter time in military time.beginM{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99} {err:gptmedoc}222reanginaccare 10NAt any time during the hospitalization, did the patient have recurrent angina?<1,2*{p_end}{p2col:}*If 2, go to advrsent, else go to reangdt{Recurrent angina is defined as: chest pain or severe epigastric pain, non-traumatic in origin; central/substernal compression or crushing chest pain; pressure, tightness, heaviness, cramping, burning or aching sensation; unexplained indigestion, belching, epigastric pain; radiating pain in neck, jaw, shoulders, back, 1 or both arms; dyspnea; nausea and/or vomiting; diaphoresisbegin{txt:noami2} {err:dc1day 0}223reangdt_ccare 11\Enter the date the episode(s) of angina occurred. (A maximum of three dates may be entered.)<mm/dd/yyyy{p_end}{p2col:}mm/dd/yyyy{p_end}{p2col:}mm/dd/yyyy]Exact date must be entered. The use of 01 to indicate missing day or month is not acceptable.begin*{txt:noami2} {err:dc1day 0} {err:reangina}224 advrsent1ccare 12zAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}1. reinfarction/AMI patient mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}225 advrsent2ccare 12rAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}2. cardiogenic shock mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}226 advrsent3ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}3. left ventricular failure requiring use of intra-aortic balloon pump (IABP) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}227 advrsent4ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}4. life-threatening arrhythmia requiring synchronized cardioversion mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}228 advrsent5ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}5. ventricular tachycardia or ventricular fibrillation requiring defibrillation (emergent cardioversion) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}229 advrsent6ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}6. High-risk bradycardia requiring transvenous pacemaker insertion mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}230 advrsent7ccare 12oAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}7. cardiac arrest mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}231 advrsent8ccare 12tAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}8. atrial fibrillation mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}232 advrsent9ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}9. blood transfusion (whole blood or packed red cells only) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin#{txt:noami2} {err:dc1day 0} {res:m}233 advrsent99ccare 12vAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}99. none of these events mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillationbegin{txt:noami2} {err:dc1day 0}234 stroksym1ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}1. disturbances of consciousness-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}235 stroksym2ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}2. loss of limb movement or speech-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}236 stroksym3ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}3. lethargy-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}237 stroksym4ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}4. unresponsiveness-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}238 stroksym5ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}5. slurred speech-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}239 stroksym6ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}6. other-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}240 stroksym99ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}99. no documented neurological symptoms-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.begin{txt:noami2} {err:dc1day 0}241strokeccare 14GAt any time during this episode of care, did the patient have a stroke?<1,2*{p_end}{p2col:}*If 2, go to smokcigs, else go to strokdt[The diagnosis of stroke must be recorded in the medical record by an MD (or DO), NP, or PA.begin{txt:noami2} {err:dc1day 0}242strokdtccare 15#Enter the date the stroke occurred. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin({txt:noami2} {err:dc1day 0} {err:stroke}243scandoneccare 16$Was a CT scan, MRI, or MRA obtained?1,2CT scan=computed tomography{p_end}{p2col:}MRI=magnetic resonance imaging{p_end}{p2col:}MRA = magnetic resonance arteriogram{p_end}{p2col:}Procedures used to detect blood vessel defects in the brainbegin({txt:noami2} {err:dc1day 0} {err:stroke}244wichtypeccare 17Does the record document the type of stroke?{p_end}{p2col:}1. hemorrhagic{p_end}{p2col:}2. thromboembolic (ischemic){p_end}{p2col:}3. thromboembolic with hemorrhagic conversion{p_end}{p2col:}4. other/unknown{p_end}{p2col:}99. type of stroke not documented 1,2,3,4,99DType of stroke must be documented in the record by an MD, NP, or PA.begin({txt:noami2} {err:dc1day 0} {err:stroke}245smokcigsccare 18Does the record document the patient smoked cigarettes any time during the year prior to hospital arrival?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}Z. not documented or not assessedF1,2*, Z* {p_end}{p2col:}*If 2 or Z, go to testress, else go to tobcessThis question refers only to smoking cigarettes and is not pertinent to other forms of tobacco. If conflicting information is documented in the record, use the worst case. (Example: one record entry states patient is a smoker, another entry states patient quit two years ago - consider the patient uses tobacco.) If the record states the patient was a 30-pack/year smoker, and there is no statement that the patient quit smoking, consider the patient a smoker. {p_end}{p2col:}Year prior to hospital arrival = from the date of arrival to the first day of the same month one year previously{p_end}{p2col:}Z=the use of cigarettes during the year prior to hospital arrival was not assessed, or if assessed, was not documented in the record. It is considered the patient was not screened for use of tobacco. {p_end}{p2col:}If the patient was asked about smoking/use of tobacco, and used a form of tobacco other than cigarettes during the past year, answer "2."begin{txt:noami2} {err:dc1day 0}246tobcessccare 19fDid the patient receive smoking/tobacco use cessation advice or counseling during the hospitalization?1,2Adult Smoking Counseling:{p_end}{p2col:}Documentation indicating the patient received one of the following:{p_end}{p2col:}Advice to stop smoking (stop using tobacco) whether or not the patient is a current smoker{p_end}{p2col:}Viewing a tobacco use cessation video{p_end}{p2col:}Given brochure or handouts on tobacco use cessation{p_end}{p2col:}Referred to a smoking cessation class or clinic{p_end}{p2col:}Prescribed a smoking cessation aid such as Nicoderm or Zyban (bupropion.){p_end}{p2col:}If the patient smoked within the year prior to arrival but does not currently smoke, they should still be advised not to smoke. Cessation counseling is still required.{p_end}{p2col:}Respond "1" if patient was given advice, a brochure, pamphlet, or video relative to smoking cessation even if the patient uses another form of tobacco.{p_end}{p2col:}2 = advice/counseling not done, or unable to determine from medical record documentationbegin,{txt:noami2} {err:dc1day 0} {err:smokcigs 1}247testressccare 20Were any of the following non-invasive stress tests for myocardial ischemia performed during this episode of care?{p_end}{p2col:}1. exercise ECG alone{p_end}{p2col:}2. exercise myocardial perfusion thallium imaging {p_end}{p2col:}3. exercise myocardial perfusion Sestamibi imaging{p_end}{p2col:}4. myocardial perfusion imagining by pharmacolgic stress {p_end}{p2col:}5. exercise ventricular function imaging by echocardiography{p_end}{p2col:}6. resting radionuclide angiography (MUGA, Gated Cardiac Scan, Gated Blood Pool Scan){p_end}{p2col:}98. patient's direct refusal of stress-testing documented in record{p_end}{p2col:}99. non-invasive stress testing not performed during episode of cares1,2,3,4,5,6,98*,99**{p_end}{p2col:}*If 98, go to cathdun{p_end}{p2col:}**If 99, go to strespln, else go to stressdt[Patients with an uncomplicated MI may undergo a non-invasive evaluation for ischemia to identify increased cardiovascular risk prior to discharge from the hospital. Applies to both ST-elevation MI and NSTEMI.{p_end}{p2col:}Documentation by the MD, NP or PA in the progress notes that a stress test was done either at the VAMC or elsewhere should be accepted. Documentation of the report in the radiology package is also acceptable.{p_end}{p2col:}1. Exercise ECG alone: ECG is done while the patient performs physical activity on a treadmill or bicycle. {p_end}{p2col:}2. Activity usually performed on a treadmill. Isotope tracer thallium injected one to two minutes before end of exercise or immediately thereafter. Heart is imaged both immediately following exercise and at rest.{p_end}{p2col:}3. Same procedure as thallium imaging, with resting images of heart done prior to treadmill exercise{p_end}{p2col:}4. For patients unable to exercise, cardiac effects of exercise stress are simulated by administration of coronary dilator dipyridamole, adenosine or dobutamine infusion.{p_end}{p2col:}5. Measures the contractile (pumping) function of the heart muscle during exercise{p_end}{p2col:}6. Following injection of radioactive medication, recordings of the heart wall at work are synchronized with the EKG. Evaluates the heart's pumping function and ejection fraction.begin{txt:noami2} {err:dc1day 0}248stressdtccare 21,Enter the date the stress test was performed mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin0{txt:noami2} {err:dc1day 0} {txt:testress 98 99}249stresoutccare 227Enter the result of the stress test {p_end}{p2col:}1. indicative of high risk for further ischemic events{p_end}{p2col:}2. indicative of moderate risk for further ischemic events{p_end}{p2col:}3. indicative of low risk for further ischemic events{p_end}{p2col:}4. equivocal{p_end}{p2col:}99. unable to determine&1,2,3,4,99{p_end}{p2col:}Go to cathdunStress test results must be documented by an MD, NP, or PA.{p_end}{p2col:}Equivocal = unclear, ambiguous, uncertain{p_end}{p2col:}Evidence of ischemia during a stress echocardiogram is an inducible wall motion abnormality during stress.begin0{txt:noami2} {err:dc1day 0} {txt:testress 98 99}250stresplnccare 23BDoes the record document a plan for post-discharge stress testing?1,2There must be documented evidence that a post-discharge non-invasive stress test was planned, although a definitive appointment date is not required.begin-{txt:noami2} {err:dc1day 0} {err:testress 99}251cathdunccare 24vWas a diagnostic cardiac catheterization performed during this episode of care?{p_end}{p2col:}1. cath done at this VAMC (or patient sent out for cath and returned in 12 hours){p_end}{p2col:}2. transferred to another VAMC for cath{p_end}{p2col:}3. transferred to a community hospital for cath{p_end}{p2col:}4. documentation by cardiology that stress test is more reasonable first approach for this patient{p_end}{p2col:}5. documentation by cardiology of known coronary artery lesion(s) not amenable to revascularization{p_end}{p2col:}98. patient's direct refusal of cardiac cath documented in record{p_end}{p2col:}99. cath not done1*,2,3,4,5,98**,99**{p_end}{p2col:}If 1, go to datedone{p_end}{p2col:}**If 4, 5, or 98, go to lvfami{p_end}{p2col:}**If 99, go to plancath, else go to cathbackThis question does not refer to the cardiac cath done in conjunction with a PTCA/PCI. The query is whether a diagnostic cardiac cath was performed, even if the patient had a PCI shortly after admission. They are to be considered two different procedures. {p_end}{p2col:}Cardiac catheterization = an invasive procedure in which a thin plastic tube (catheter) is inserted into an artery or vein in the arm or leg. From there it can be advanced into the chambers of the heart or the coronary arteries. The test can measure blood pressure within the heart, how much oxygen is in the blood, and the pumping ability of the heart muscle. When dye is injected into the coronary arteries, the procedure is called coronary angiography or coronary arteriography. The procedure produces special pictures that can reveal if one or more of the coronary arteries are blocked or if the left ventricle is functioning properly. Cardiac cath without treatment of coronary artery blockages is diagnostic. {p_end}{p2col:}If patient was sent out for a cath and returned in 12 hours, it is considered the same as being done at this VAMC.{p_end}{p2col:}Responses #4 and 5 must be documented in the record by a cardiologist, cardiology fellow, or cardiology resident under appropriate supervision by the attending physician.begin{txt:noami2} {err:dc1day 0}252cathbackccare 25RDid the patient return to this VAMC for further inpatient care following the cath?g1,2*{p_end}{p2col:}*If 2, auto-fill 2 in ptdc and go to end of ACS.{p_end}{p2col:}If 1, go to date doneReturn may be a period of greater than 12 hours or may be several days later. Return assumes that report of the cath will accompany the patient, or there will be communication between clinicians at each of the respective hospitals.begin-{txt:noami2} {err:dc1day 0} {err:cathdun 2 3}253datedoneccare 26DIs the date the cardiac cath was performed documented in the record?<1,2*{p_end}{p2col:}*If 2, go to cathrep, else go to entrdoneVIf more than one cardiac cath was performed, use the date of the first cath performed.begin+{txt:noami2} {err:dc1day 0} {err:cathdun 1}254entrdoneccare 27.Enter the date the cardiac cath was performed. mm/dd/yyyyDEnter the exact date. Do not use 01 to indicate missing day or monthbegin:{txt:noami2} {err:dc1day 0} {err:cathdun 1} {err:datedone}255cathrepccare 28Enter the result of the cardiac catheterization:{p_end}{p2col:}1 Evidence of obstructive CAD{p_end}{p2col:}2. No evidence of obstructive CAD{p_end}{p2col:}99. Unable to determine.1,2,99hEvidence of obstructive CAD: >50% left main stenosis and/or > 70% stenosis of a major epicardial artery.begin+{txt:noami2} {err:dc1day 0} {err:cathdun 1}256plancathccare 29KDoes the record document a plan for cardiac catheterization post-discharge?1,2There must be documented evidence that a post-discharge cardiac catherization was planned, although a definitive appointment date is not required.begin.{txt:noami2} {err:dc1day 0} {err:cathdun 1 99}257lvfamiccare 30Is there documentation in the record that the patient's LVF (left ventricular function) was assessed prior to arrival or during the hospital stay?;1,2*{p_end}{p2col:}*If 2, go to wtdone, else go to efornarrCSee question "efornarr" for tests used to determine LVF.{p_end}{p2col:}LVF may be taken from any knowledge of past EF or LVSD (left ventricular systolic dysfunction) documented in the record. The LVF may also be referred to as "wall motion" or "systolic function."{p_end}{p2col:}BNP blood test is not an assessment for LVF.begin{txt:noami2} {err:dc1day 0}258efornarrccare 31Does the record document the patient has a left ventricular ejection fraction less than 40% or a narrative description of moderate or severe systolic dysfunction?{p_end}{p2col:}1. LVEF < 40%, or narrative description moderate or severe systolic dysfunction{p_end}{p2col:}2. LVEF 40% or >,or narrative description not consistent with moderate or severe systolic dysfunction {p_end}{p2col:}99. unable to determine from medical record documentation1,2,99Tests used to determine left ventricular function = echocardiogram, radionuclide ventriculography (MUGA, RNV, nuclear heart scan, nuclear gated blood pool scan) stress myocardial perfusion scan (thallium scan) or cardiac cath. Ejection fraction is a ballpark figure - not a precise measurement. EF may be taken from any knowledge of past EF or LVSD (left ventricular systolic dysfunction) documented in the record. The lvf may also be referred to as "wall motion" or "systolic function."{p_end}{p2col:}Suggested Data Sources: consultant notes, diagnostic test reports, discharge summary, ED notes, H&P, nurses notes, progress notes {p_end}{p2col:}Note: If systolic function is described as mild to moderate, use response #2.begin({txt:noami2} {err:dc1day 0} {err:lvfami}259lvfdtdocccare 32gIs the date of the test that measured the patient's left ventricular function documented in the record?;1,2*{p_end}{p2col:}*If 2, go to wt done, else go to eftstdtgThis question has changed to ask the date the EF was measured. The year the test was done is acceptable at a minimum. {p_end}{p2col:}Tests used to determine left ventricular function = echocardiogram, radionuclide ventriculography (MUGA, RNV, nuclear heart scan, nuclear gated blood pool scan) stress myocardial perfusion scan (thallium scan) or cardiac cath.begin({txt:noami2} {err:dc1day 0} {err:lvfami}260eftstdtccare 33!Enter the date the test was done. mm/dd/yyyyYear is acceptable at a minimum if the left ventricular function was assessed in the past prior to hospitalization, and this is the only date available. Enter exact day and month if test was recent and dates are available.begin7{txt:noami2} {err:dc1day 0} {err:lvfami} {err:lvfdtdoc}261wtdoneccare 347Is the patient's weight recorded in the medical record?:1,2*{p_end}{p2col:}*If 2, go to nutrisk, else go to wtdateSources: Nursing admission assessment or other information from the inpatient or outpatient record. Assessment form and notes by Dietary Service are a good source of weight and height data.{p_end}{p2col:}If the patient was weighed at admission or during hospitalization, use this weight. Otherwise use most recent notation of weight found in the outpatient record. If more than one weight is recorded during the most recent encounter, and the weights differ, use the lowest weight.begin{txt:noami2} {err:dc1day 0}262wtdateccare 35KEnter the most recent date the patient's weight was recorded in the record. mm/dd/yyyypDay may be entered as 01, if exact date is unknown. At a minimum, the month and year must be entered accurately.begin({txt:noami2} {err:dc1day 0} {err:wtdone}263entrwtccare 361Enter the patient's weight recorded on that date._____Use the weight recorded during hospitalization if patient was weighed. If more than one weight is recorded during the most recent encounter, and the weights differ, use the lowest weight.begin({txt:noami2} {err:dc1day 0} {err:wtdone}264entrunitccare 37DUnit of measure{p_end}{p2col:}1 = pounds{p_end}{p2col:}2 = kilograms1,2BMI is calculated in kilograms. If pounds are entered, the computer will convert pounds to kilograms in making the calculation. The resulting BMI is displayed on the computer screen.begin({txt:noami2} {err:dc1day 0} {err:wtdone}265htdoneccare 383Is patient's height recorded in the medical record?:1,2*{p_end}{p2col:}*If 2, go to nutrisk, else go to entrht>No time period applies to this element. {p_end}{p2col:}If more than one height is recorded, use the most recent.{p_end}{p2col:}EKG readings may be a source of height data, although accuracy of the recorded height may be in question. Use this data if no other height can be found in the inpatient or outpatient records.begin({txt:noami2} {err:dc1day 0} {err:wtdone}266entrhtccare 39Enter the patient's height._____uHeight must be entered wholly in inches or centimeters. If pt. is 5 feet 8 inches, enter 68. 5ft = 60 in. 6ft = 72in.begin5{txt:noami2} {err:dc1day 0} {err:wtdone} {err:htdone}267entrmeasccare 40FUnit of measure{p_end}{p2col:}1 = inches{p_end}{p2col:}2 = centimeters1,2uHeight must be entered wholly in inches or centimeters. If pt. is 5 feet 8 inches, enter 68. 5ft = 60 in. 6ft = 72in.begin5{txt:noami2} {err:dc1day 0} {err:wtdone} {err:htdone}268ptdcdisch 1lEnter the patient's discharge status:{p_end}{p2col:}1. discharged to home care or self care (routine discharge){p_end}{p2col:}2. discharged/transferred to another short term general hospital for inpatient care{p_end}{p2col:}3. discharged/transferred to a skilled nursing facility{p_end}{p2col:}4. discharged/transferred to an intermediate care facility{p_end}{p2col:}5. discharged/transferred to another type of institution for inpatient care {p_end}{p2col:}6. discharged/transferred to home under care of organized home health service organization{p_end}{p2col:}7. left against medical advice or discontinued care{p_end}{p2col:}8. discharged/transferred to home under care of home IV drug therapy provider{p_end}{p2col:}20. expired (or did not recover-Christian Science patient){p_end}{p2col:}41. expired in medical facility, such as hospital, SNF, ICF, or freestanding hospice{p_end}{p2col:}50. hospice - home{p_end}{p2col:}51. hospice - medical facility{p_end}{p2col:}61. discharged/transferred within this institution to hospital-based Medicare approved swing bed{p_end}{p2col:}62. Discharged/transferred to another rehabilitation facility including rehabilitation distinct parts of a hospital{p_end}{p2col:}63. Discharged/transferred to a long-term care hospital{p_end}{p2col:}64. Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare1,2*,3,4,5,6,7*,8,,20*{p_end}{p2col:}41*,50*,51*,61,62,63,{p_end}{p2col:}64{p_end}{p2col:}*If 2, 7, 20, 41, 50, or 51, go to end, else go to finalecgOther non-acute setting = nursing home, Domiciliary, rehabilitation, or other setting where care continues at a lesser level{p_end}{p2col:}To respond "2," it must be known the "other" hospital is an acute-care facility, and the patient's anticipated admission is the same day as discharge from the VAMC.{p_end}{p2col:}To respond "7," a signed AMA document, or progress note by an MD, NP, or PA must appear in the record.{p_end}{p2col:}Response #41 is applicable only for Medicare and CHAMPUS`Hospice care and does not apply to VHA Hospice patients.{p_end}{p2col:}If uncertain of the patient's disposition, ask help from the EPRP Liaison, since accurate discharge status affects the remainder of the AMI questions.begin{txt:noami2} {err:dc1day 0}269finalecgdisch 2*What were the specific findings from interpretation of the last 12-lead ECG performed prior to discharge?{p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}99. no documentation of any of the above(1,2,3,4,5,6,7,8,9,10,11{p_end}{p2col:}99Do Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}270ekgdtdisch 3!Enter the date this ECG was done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}271acetrialdisch 4Does the record document that at discharge, the patient was participating in a clinical trial, testing alternatives to ACEI as first-line heart failure therapy?=1*,2{p_end}{p2col:}*If 1, go to aspdcnot, else go to noacewhy2 = not participating in ACEI clinical trial, or unable to determine from medical record documentation{p_end}{p2col:}Note: this question does not mean the patient was prescribed an ACE inhibitor. Testing alternatives means the use of drugs OTHER THAN ACEI for heart failure therapy.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}272noacewhydisch 5Does the record document any of the following ACEI contraindications?{p_end}{p2col:}1. ACEI allergy{p_end}{p2col:}5. Moderate or severe aortic stenosis{p_end}{p2col:}6. Other reasons documented by an MD, NP, or PA for not prescribing an ACEI at discharge{p_end}{p2col:}98. patient's direct refusal to take ACE inhibitor documented in record{p_end}{p2col:}99. No documented contraindicationS1*,5*,6*,98*,99{p_end}{p2col:}*If 1, 5, 6, or 98, go to aspdcnot, else go to aceidcOption Rules:{p_end}{p2col:}1. ACE allergy = must be specific reference in the record to ACE allergy or sensitivity. Also includes history of angioedema, hives, or rash with ACEI use.{p_end}{p2col:}5. Aortic stenosis = listing of this diagnoses, with the description of moderate or severe, in the record is acceptable. Includes both a current finding or a history of moderate or severe aortic stenosis without mention of repair, replacement, valvuloplasty, or commissurotomy.{p_end}{p2col:}6. Other reasons = must be documentation by MD, NP, or PA which explicitly links the noted reason with non-prescription of an ACE inhibitor. (Examples of other reasons for not prescribing an ACEI are diagnosis of renal artery stenosis, chronic renal dialysis, pregnancy, serum potassium > 5.5 Eq/L that cannot be reduced, or symptomatic hypotension, documented by the MD, NP, or PA as specific reasons for non-use of an ACEI.) {p_end}{p2col:}If the patient is on hydralazine and nitrates or an ARB, and the record documents this drug therapy is a better option than ACEI for the patient, this documentation is to be accepted as "other reason" and will be considered a contraindication.begin5{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial}273aceidcdisch 6WWas an angiotensin converting enzyme inhibitor (ACE inhibitor) prescribed at discharge?<1,2*{p_end}{p2col:}*If 2, go to aspdcnot, else go to onacedc}Enter response #2 if either an ACEI was not prescribed at discharge, or unable to determine from medical record documentationbeginG{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial} {err:noacewhy 99}274onacedcdisch 7Designate the ACE inhibitor prescribed at discharge.{p_end}{p2col:}PBM/MAP{p_end}{p2col:}1. enalapril{p_end}{p2col:}2. captopril{p_end}{p2col:}3. lisinopril{p_end}{p2col:}5. fosinopril{p_end}{p2col:}9. ramipril{p_end}{p2col:}Other than PBM/MAP{p_end}{p2col:}4. benazepril{p_end}{p2col:}6. quinapril{p_end}{p2col:}7. perindopril{p_end}{p2col:}8. moexipril{p_end}{p2col:}10. trandolapril{p_end}{p2col:}11. other1,2,3,4,5,6,7,8,9,10,11"Prescribed for this patient at discharge" = patient may or may not have been on this medication during hospitalization, and it was either continued or prescribed at the time of discharge.{p_end}{p2col:}If the patient is taking an ace inhibitor with the addition of a diuretic or calcium channel blocker, consider only the ace inhibitor. (Example: lisinopril/hydrochlorothiazide, trandolapril/verapamil)beginT{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial} {err:noacewhy 99} {err:aceidc}275aspdcnotdisch 8"Is there documentation in the record the patient has one of the following contraindications or reasons for not prescribing aspirin at discharge:{p_end}{p2col:}1. aspirin allergy{p_end}{p2col:}2. active bleeding on arrival or during hospital stay{p_end}{p2col:}3. Warfarin/Coumadin prescribed at discharge{p_end}{p2col:}4. Other reasons documented by MD, NP, or PA{p_end}{p2col:}for not prescribing aspirin at discharge{p_end}{p2col:}98. patient's direct refusal to take aspirin documented in record{p_end}{p2col:}99.No documented contraindicationW1*,2*,3*,4*,98*,99{p_end}{p2col:}*If 1,2,3,4, or 98, go to platagdc, else go to asarxdc[99 = There is no documentation of contraindications/reasons for not prescribing aspirin at discharge, or unable to determine from medical record documentation{p_end}{p2col:}Allergy to aspirin = vasomotor rhinitis with profuse watery secretions, angioedema, generalized urticaria, bronchoconstriction (shortness of breath and wheezing), or laryngeal edema. History of allergy, sensitivity, reaction, or intolerance to aspirin also includes medications which contain aspirin. Gastrointestinal reactions are not considered true allergy to aspirin.{p_end}{p2col:}"Other reasons" documented by MD, NP, or PA must explicitly link the noted reason with non-prescription of aspirin. If the patient is taking clopidogrel (Plavix) or ticlopidine hydrochloride (Ticlid), clinician documentation must specify the use of this drug is the reason aspirin was not prescribed.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}276asarxdcdisch 90Was the patient prescribed aspirin at discharge?1,2?Enter response #2 if aspirin was not prescribed at discharge, or unable to determine from medical record documentation.{p_end}{p2col:}"Prescribed at discharge" also means recommended or instructed to take aspirin. OTC is equivalent to "prescribed," but the instructions to take aspirin must be documented in the record.begin8{txt:noami2} {err:dc1day 0} {txt:nodc} {err:aspdcnot 99}277platagdcdisch 10Was the patient prescribed a platelet aggregation inhibitor at discharge? {p_end}{p2col:}1. clopidogrel (Plavix){p_end}{p2col:}2. ticlopidine (Ticlid){p_end}{p2col:}3. dipyridamole (Persantine){p_end}{p2col:}4. dipyridamole and aspirin (Aggrenox){p_end}{p2col:}98. patient's direct refusal to take platelet aggregation inhibitor documented in record{p_end}{p2col:}99. none of these medications 1,2,3,4,98,99Clopidogrel and ticlopidine are inhibitors of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in patients with established athererosclerotic cardiovascular disease as evidenced by stroke, TIAs, and AMI. Patients who have a true allergy to aspirin and no contraindication to antiplatelet therapy may be given clopidogrel, ticlopidine, or dypyridamole.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}278hepondcdisch 11Was the patient prescribed low molecular weight heparin at discharge?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}98. patient refused LMWH at discharge1,2,98Low molecular weight heparins are available as subcutaneous injections. Regular monitoring by blood test is not required for LMWH. The does is determined by body weight and correlates well with the desired anticoagulant effect.{p_end}{p2col:}LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).begin&{txt:noami2} {err:dc1day 0} {txt:nodc}279nodcbbdisch 12Does the record document one or more of the following contraindications/reasons for not prescribing a beta blocker at discharge?{p_end}{p2col:}1. Beta blocker allergy{p_end}{p2col:}2. Bradycardia (heart rate less than 60 bpm) on day of discharge or day prior to discharge while not on a beta blocker{p_end}{p2col:}3. Second or third degree heart block on ECG on arrival or during hospitalization and does not have a pacemaker{p_end}{p2col:}4. Systolic blood pressure less than 90 mm HG on day of discharge or day prior to discharge while not on a beta blocker{p_end}{p2col:}5. Other reasons documented by an MD, NP, or PA for not prescribing a beta blocker at discharge{p_end}{p2col:}9. Post-heart transplant patient{p_end}{p2col:}10. Severely decompensated heart failure, as evidenced by patient receiving IV dobutamine, milrinone, or nesiritide during acute care{p_end}{p2col:}98. patient's direct refusal to take beta blocker documented in record{p_end}{p2col:}99.No documented contraindicationr1*,2*,3*,4*,5*,9*,10*{p_end}{p2col:}98*,99{p_end}{p2col:}*If 1,2,3,4,5,9, 10, or 98, go to end, else go to blkatdc:Contraindication = a factor or condition that renders the administration of a drug or agent or the performance of a procedure or other practice inadvisable, improper, and/or undesirable.{p_end}{p2col:}Option Rules:{p_end}{p2col:}Beta blocker allergy = must be specific reference in the record to allergy or intolerance to beta-blockers{p_end}{p2col:}Bradycardia = may be taken from the vital sign records for the day of discharge and the day prior to discharge {p_end}{p2col:}Second or third degree heart block = Do not attempt to use the EKG tracing to answer this question. The EKG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the EKG interpretation does not have to be linked specifically to contraindication to beta-blocker.{p_end}{p2col:}Systolic blood pressure = may be taken from the vital sign records for the day of discharge and the day prior to discharge{p_end}{p2col:}Other reasons = MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker{p_end}{p2col:}COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma.begin&{txt:noami2} {err:dc1day 0} {txt:nodc}280blkatdcdisch 137Was the patient prescribed a beta-blocker at discharge?81,2*{p_end}{p2col:}*If 2, go to end, else go to wichbbdc~Enter response #2 if a beta-blocker was not prescribed at discharge, or unable to determine from medical record documentation.begin6{txt:noami2} {err:dc1day 0} {txt:nodc} {err:nodcbb 99}281wichbbdcdisch 14Designate the beta blocker prescribed for the patient at discharge.{p_end}{p2col:}1. metoprolol succinate (Toprol-XL){p_end}{p2col:}2. metoprolol tartrate{p_end}{p2col:}3. bisoprolol (Zebeta or Ziac){p_end}{p2col:}4. carvedilol (Coreg){p_end}{p2col:}5. atenolol (Tenoretic or Tenormin){p_end}{p2col:}6. acebutolol (Sectral) {p_end}{p2col:}7. sotalol (Betapace) {p_end}{p2col:}8. betaxolol (Kerlone) {p_end}{p2col:}9. carteolol (Cartrol) {p_end}{p2col:}10. nadolol (Corgard) {p_end}{p2col:}11. nadolol/bendroflumethiazide (Corzide) {p_end}{p2col:}12. propranolol (Inderal) {p_end}{p2col:}13. propranolol hydrochloride (Inderide) {p_end}{p2col:}14. labetalol (Normodyne or Trandate) {p_end}{p2col:}15. penbutolol sulfate (Levatol) {p_end}{p2col:}16. metoprolol/hydrocholorthiazide (Lopressor HCT ) {p_end}{p2col:}17. penbutolol sulfate (Levatol) {p_end}{p2col:}18. pindolol (Visken) {p_end}{p2col:}19. timolol (Timolide or Blocadren) {p_end}{p2col:}20. timolol/hydrocholorthiazideA1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,{p_end}{p2col:}18,19,20Beta blocker generic names are not capitalized. Brand names are capitalized.{p_end}{p2col:}Enter the number corresponding to the generic name documented in the medical record.{p_end}{p2col:}"Prescribed for this patient at discharge" = patient may or may not have been on this medication during hospitalization, and it was either continued or prescribed at the time of discharge.{p_end}{p2col:}Source: discharge instructions, discharge orders, discharge summarybeginD{txt:noami2} {err:dc1day 0} {txt:nodc} {err:nodcbb 99} {err:blkatdc}TAMJBONEWOBJeprp_02_42able-row> = 0.1 ng/mL or slightly elevated TnT > 0.03, but < 0.1 ng/mL) and treatment is consistent with AMI (EKG, oxygen, aspirin, beta blockers, NTG, cardiac enzymes, IV unfractionated heparin, analgesics, reperfusion, admission to monitored bed) and AMI is not ruled out, and the diagnosis is not unstable angina, and the AMI admission is not a subsequent episode of care, answer "yes" to the question.{p_end}{p2col:}Note: if the AMI code is 410.x2, answer "2." Cases coded with a fifth digit of 2 are not to be reviewed. {p_end}{p2col:}If the patient is a non-veteran, proceed through the questions. It is care provided by the VHA and not the patient's veteran or non-veteran status that is important.{p_end}{p2col:}If the patient did not have a discharge from inpatient care during the time for which the case was selected, answer "2" because the patient did not have an AMI.reword2amicodevalid 2For the selected episode of care, was the principal diagnosis coded as 410.0 - 410.9, with a fifth digit of 1, as follows:{p_end}{p2col:}410 acute myocardial infarction (sudden, severe death of heart muscle due to decreased coronary blood flow; classification is based on the location of the affected tissue, when known){p_end}{p2col:}o- Includes: cardiac infarction{p_end}{p2col:}o- coronary (artery) embolism, occlusion, rupture, thrombosis{p_end}{p2col:}o- infarction of heart, myocardium, or ventricle{p_end}{p2col:}o- rupture of heart, myocardium, or ventricle{p_end}{p2col:}410.01 of anterolateral wall{p_end}{p2col:}410.11 of other anterior wall{p_end}{p2col:}410.21 of inferolateral wall{p_end}{p2col:}410.31 of inferoposterior wall{p_end}{p2col:}410.41 of other inferior wall{p_end}{p2col:}410.51 of other lateral wall{p_end}{p2col:}410.61 true posterior wall infarction{p_end}{p2col:}410.71 subendocardial infarction {p_end}{p2col:}410.81 of other specified sites{p_end}{p2col:}410.91 unspecified site1,2{p_end}{p2col:}If 1 and truami=2, the record is reported as a JCAHO Category A{p_end}{p2col:}If 1 or 2 and truami=1, go to aprocode{p_end}{p2col:}If 1 or 2 and truami=2, go to uacodeThe principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."{p_end}{p2col:}The question refers to the principal diagnosis at the facility in which the case is being reviewed. (Example: patient is admitted to first VAMC for surgery, has an AMI after surgery, and is transferred to VAMC #2 for AMI care. AMI is not the principal diagnosis at the first VAMC, but is the principal diagnosis at VAMC #2.){p_end}{p2col:}Catnum 10 AMI records are selected from cases discharged with a diagnosis code of 410.0 - 410.9, with a fifth digit of 1. A fifth digit of 0 or 2 is not acceptable{p_end}{p2col:}To respond "1," the principal diagnosis code must be one of the listed codes.{p_end}{p2col:}The fifth digit of 0 = episode of care unspecified{p_end}{p2col:}The fifth digit of 1 = initial episode of care for an AMI. Used to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit 1 is assigned regardless of the number of times a patient may be transferred during the initial episode of care.{p_end}{p2col:}The fifth digit of 2 = subsequent episode of care. Used to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation, or treatment for a myocardial infarction that has received initial treatment but is still less than 8 weeks old. Do not review cases coded with a fifth digit of 2 {p_end}{p2col:}JCAHO Category A: the case contains invalid data that prevents assignment to the JCAHO Core Measures population.revised definition3aprocodevalid 3WWhat was the ICD-9-CM code selected as the principal diagnosis for this medical record. _ _ _. _ _wUse the code assigned by the VAMC. Do not attempt to code the AMI by any code other than that assigned by the facility. {err:truami}4othrdx_valid 4JEnter the ICD-9-CM other diagnosis codes selected for this medical record. _ _ _. _ _Enter ALL of the ICD-9-CM other diagnosis codes selected for this medical record. Use the diagnoses listed in the discharge summary for this episode of inpatient care. {err:truami}5uacodevalid 5 For the selected episode of care, was either the principal or secondary diagnosis coded as one of the following:{p_end}{p2col:}411.1 Intermediate coronary syndrome{p_end}{p2col:}o- Impending infarction{p_end}{p2col:}o- Preinfarction angina{p_end}{p2col:}o- Preinfarction syndrome{p_end}{p2col:}o- Unstable angina{p_end}{p2col:}411.81 Acute coronary occlusion without myocardial infarction{p_end}{p2col:}o- Acute coronary (artery):{p_end}{p2col:}o- embolism without or not resulting in MI{p_end}{p2col:}o- obstruction without or not resulting in MI{p_end}{p2col:}o- occlusion without or not resulting in MI{p_end}{p2col:}o- thrombosis without or not resulting in MI{p_end}{p2col:}411.89 Other{p_end}{p2col:}o- Coronary insufficiency (acute){p_end}{p2col:}o- Subendocardial ischemia1,2411.1= Intermediate coronary syndrome: impending infarction, preinfarction angina, preinfarction syndrome, unstable angina{p_end}{p2col:}411.1 excludes angina pectoris (413.9) and decubitus (413.0){p_end}{p2col:}411.81 excludes obstruction without infarction due to atherosclerosis (414.00-414.06){p_end}{p2col:}o-excludes occlusion without infarction due to atherosclerosis{p_end}{p2col:}o-(414.00-414.06) {txt:truami}6uadocvalid 6aDid the discharge summary or other physician documentation record a diagnosis of unstable angina?b1,2*{p_end}{p2col:}*If 2, the record is excluded.{p_end}{p2col:}If 1, go to Antecedent Care ModuleDiagnosis may also be listed as one of the terms noted in the question "unacode."{p_end}{p2col:}UA is commonly considered to have three presentations: (1) rest angina (2) new onset of severe angina , defined as at least Class III by the CCS classification* (3) increasing angina to at least CCS Class III severity*.{p_end}{p2col:}*CCS Class III Severity: angina with minimal exertion or ordinary activity{p_end}{p2col:}Abstractor may not determine a diagnosis of unstable angina from information in the medical record. The diagnosis must be documented in the record by an MD or DO.{p_end}{p2col:}Exclusion Statement:{p_end}{p2col:}Documentation in the medical record did not confirm that the patient had a diagnosis of Acute Coronary Syndrome {txt:truami}7cardrestvalid 7Either at initial presentation to the hospital or during inpatient care, was the first cardiac symptom for this patient a cardiac arrest?J1,2*{p_end}{p2col:}*If 2, go to Antecedent Care Module, else go to survivekThe question refers to the patient who had no previous cardiac symptoms. The initial symptom is a cardiac arrest. The question does not apply to patients presenting with or receiving care for cardiac symptoms. (Examples: patient who arrives in the ED with a cardiac arrest; patient recovering from hip fracture has a cardiac arrest during rehabilitation therapy.) {err:truami}8survivevalid 82Did the patient survive the resuscitation attempt?^1,2*{p_end}{p2col:}*If 2, exclude the record.{p_end}{p2col:}If 1, go to Antecedent Care Module]Applicable only to cases in which the patient could not be resuscitated and expired during resuscitation efforts or the effort was abandoned. If no resuscitation was attempted, answer "2."{p_end}{p2col:}Exclusion Statement{p_end}{p2col:}Cardiac arrest occurring in this case precluded abstraction of the data elements required for the Core Measures.{err:truami} {err:cardrest}9admtypeacute 1Designate the type of admission for this patient:{p_end}{p2col:}1. Emergency{p_end}{p2col:}2. Urgent{p_end}{p2col:}3. Elective{p_end}{p2col:}5. Trauma{p_end}{p2col:}9. Information not available 1,2,3,5,9uIf the patient was admitted initially to another VAMC, the question is applicable to the type of admission at that VAMC. If the patient was transferred from a community hospital and the type of admission is not known, use "9." {p_end}{p2col:}1. Emergency=the patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.{p_end}{p2col:}2. Urgent=the patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodations.{p_end}{p2col:}3. Elective=the patient's condition permitted adequate time to schedule the availability of a suitable accommodation{p_end}{p2col:}5. Trauma=Visit to the trauma center/hospital as licensed by the state or local government authority to do so, or as verified by the American College of Surgeons and involving a trauma activation.{p_end}{p2col:}9. Information not available=the hospital cannot classify the type of admission. This code is used only on rare occasions.10transinacute 2Was the patient received from an emergency department of another hospital?{p_end}{p2col:}1. received from another VAMC{p_end}{p2col:}2. transferred from community hospital ED{p_end}{p2col:}99. not transferred from another ED1,2,9921 or 2 = may be from another VAMC or community hospital, but the patient cannot have been an inpatient. The abstractor must know the patient was transferred from the ED.{p_end}{p2col:}Note: the emergency department of another hospital includes both emergency room AND observation bed/unit stays at that hospital.{p_end}{p2col:}If "1," the questions regarding initial care are applicable to the ED admission and treatment at the first VAMC. {p_end}{p2col:}99 = Patient not received as a transfer from another facility's Emergency Department or unable to determine11admfromacute 3 Designate the admission source for this patient:{p_end}{p2col:}1. Physician referral{p_end}{p2col:}2. Clinical referral{p_end}{p2col:}3. HMO referral{p_end}{p2col:}4. Transfer from a community hospital{p_end}{p2col:}5. Transfer from skilled nursing facility{p_end}{p2col:}6. Transfer from another facility{p_end}{p2col:}7. Emergency room{p_end}{p2col:}8. Court/law enforcement{p_end}{p2col:}9. Information not available{p_end}{p2col:}A Transfer from a critical access hospital{p_end}{p2col:}10. Received from another VAMC'1,2,3,4*,5,6,7,8,9,A,*{p_end}{p2col:}10If transin=1 or 2 (patient was transferred from the ED of another hospital, default to "1" to answer admfrom.{p_end}{p2col:}1. Physician referral=the patient was admitted upon recommendation of the personal physician{p_end}{p2col:}2. Clinic referral=the patient was admitted upon recommendation of the facility's clinic physician{p_end}{p2col:}3. HMO referral=the patient was admitted upon recommendation of a health maintenance organization physician{p_end}{p2col:}4. Transfer from a hospital=the patient was admitted or transferred from an acute care facility where he/she was an inpatient{p_end}{p2col:}(from a private sector facility){p_end}{p2col:}5. Transfer from skilled nursing facility=the patient was admitted as a transfer from a skilled nursing facility where he/she was an inpatient (this or another VAMC NHCU, Intermediate Medicine, community SNF nursing home){p_end}{p2col:}6. Transfer from another facility=the patient was admitted to this healthcare facility as a transfer from a healthcare facility other than an acute care facility or a skilled nursing facility. This includes transfers from nursing homes, long term care facilities, and skilled nursing facility patients that are at a non-skilled level of care (facility other than acute care or NHCU, as for example, Residential Care, DOM, or assisted living) {p_end}{p2col:}7. Emergency room=the patient was admitted to the facility upon recommendation of this facility's ED physician/triage{p_end}{p2col:}8. Court/law enforcement=the patient was admitted upon the direction of a court of law, or upon the request of a law enforcement agency representative{p_end}{p2col:}9. Information not available=the means by which the patient was admitted is not known{p_end}{p2col:}A Transfer from a critical access hospital=the patient was admitted to this facility as a transfer from a critical access hospital where he/she was an inpatient (private sector Medicare-designated){p_end}{p2col:}Answer # "10" has been differentiated from #4 to indicate that the patient was first admitted to another VAMC. This indicates the patient was an inpatient at the first VAMC and was not transferred from the ED. If the patient was transferred from the ED, use default answer #"1."12inptacsacute 4CWas the veteran already an inpatient at any VAMC when ACS occurred?<1,2*{p_end}{p2col:}*If 2, go to anyvamc, else go to onsetdoc=Already an inpatient = the veteran had already been formally admitted to this or another VAMC, either for an unrelated problem or for related symptoms such as unstable angina. In either event, to answer "1," the patient must definitely have had an ACS that occurred after the patient had formally become an inpatient. {txt:acs_trc}13onsetdocacute 5;Does the record document the date of onset of ACS symptoms?<1,2*{p_end}{p2col:}*If 2, go to symptime, else go to onsetdt ACS symptoms = chest/substernal discomfort, pressure, or pain. May include pain radiating to one or both arms, shoulder, jaw, neck, or back. May be severe epigastric pain, nausea, vomiting, dyspnea, or diaphoresis. Look in nurses notes & progress notes for onset date.{err:acs_inpt}14onsetdtacute 6(Enter the date of onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.{err:acs_inpt} {err:onsetdoc}15symptimeacute 7;Does the record document the time of onset of ACS symptoms?:1,2*{p_end}{p2col:}*If 2, go to ecgdun, else go to onsetmeData source: nurses notes, progress notes. Look for timed entry of information relating to change in patient condition and complaint of symptoms noted in "onsetdoc."{err:acs_inpt}16onsetmeacute 8(Enter the time of onset of ACS symptoms._____{p_end}{p2col:}(UMT)%Enter time in Universal Military Time{err:acs_inpt} {err:symptime}17ecgdunacute 9;Was a 12-lead ECG done following onset of the ACS symptoms?:1,2*{p_end}{p2col:}*If 2, go to hospdt, else go to inptecghRhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead unless documentation indicates otherwise.{err:acs_inpt}18inptecgacute 10oIs the date of the abnormal ECG done most immediately following onset of ACS symptoms documented in the record?<1,2*{p_end}{p2col:}*If 2, go to docecgtm, else go to inecgdtThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS.reword{err:acs_inpt} {err:ecgdun}19inecgdtacute 11TEnter the date of the abnormal ECG done immediately following onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.reword){err:acs_inpt} {err:ecgdun} {err:inptecg}20docecgtmacute 12lDoes the record document the time of the abnormal ECG done most immediately following onset of ACS symptoms.;1,2*{p_end}{p2col:}*If 2, go to hospdt, else go to inecgtmeThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS.reword{err:acs_inpt} {err:ecgdun}21inecgtmeacute 13TEnter the time of the abnormal ECG done immediately following onset of ACS symptoms.2_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to hospdtIf exact time cannot be known, look for nurses note or progress note indicating ECG was done and patient has likely had an AMI. Use time of this progress note.reword*{err:acs_inpt} {err:ecgdun} {err:docecgtm}22anyvamcacute 14@Did the patient present initially to any VAMC with ACS symptoms?:I,2*{p_end}{p2col:}*If 2, go to hospdt, else go to arrvdoc"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system. The abstractor must be able to secure data from the VAMC to which the patient first presented.end {err:acs_arr}23arrvdocacute 15ZDoes the record document the date the patient arrived at a VHA hospital with ACS symptoms?;1,2*{p_end}{p2col:}*If 2, go to arrvtime, else go to eddateVDo not use the ambulance record or face sheet for this information. If the patient was admitted for observation, and subsequently admitted to the unit or floor, use the date of admission for observation.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) consider this care as hospital arrival, and enter the date and time treatment for ACS began in the VHA treatment setting as the hospital arrival date and time.{err:acs_arr} {err:anyvamc}24eddateacute 163Enter the date the patient arrived at the hospital. mm/dd/yyyyDetermine the earliest date the patient arrived at a VHA hospital, such as the ED or observation unit. Do not use ambulance records to determine arrival date. Enter the exact date.){err:acs_arr} {err:anyvamc} {err:arrvdoc}25arrvtimeacute 17ZDoes the record document the time the patient arrived at a VHA hospital with ACS symptoms?91,2*{p_end}{p2col:}*If 2, go to hospdt, else go to edtimeIf the patient was admitted for observation, and subsequently admitted to the unit or floor, use the time the patient arrived at a VHA hospital for observation.end{err:acs_arr} {err:anyvamc}26edtimeacute 18Enter the time_____{p_end}{p2col:}UMTsDetermine the time the patient arrived at a VHA hospital, such as the ED or observation unit. Enter the exact time.*{err:acs_arr} {err:anyvamc} {err:arrvtime}27hospdtacute 19ZIs the date of formal admission to inpatient status at this VAMC documented in the record?:1,2*{p_end}{p2col:}*If 2, go to hosptime, else go to admdtAdmission date = date on which the patient was admitted to inpatient status. Admission to observation and/or arrival date are excluded.end28admdtacute 20:Enter the date the patient was admitted to inpatient care. mm/dd/yyyyvThe exact date of inpatient admission must be entered. {p_end}{p2col:}Excluded: admission to observation, arrival date {err:hospdt}29hosptimeacute 21ZIs the time of formal admission to inpatient status at this VAMC documented in the record?;1,2*{p_end}{p2col:}*If 2, go to pasthx3, else go to admtimetAdmission time = time the patient was admitted to inpatient status. Excluded: admission to observation, arrival timeend30admtimeacute 22:Enter the time the patient was admitted to inpatient care._____{p_end}{p2col:}UMTxThe exact time of inpatient admission must be entered in military time. Excluded: admission to observation, arrival date{err:hosptime}31dcdateacute -No documented instructions32dctimeacute -No documented instructions33 pasthx3_1acute 23=Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}1. Diabetes Mellitus:{break}250.01, 250.03 IDDM,controlled or uncontrolled{break}250.10-250.93, DM with manifestations {break}648.00-648.04, 648.81 DM complicating pregnancy-1,0reword34 pasthx3_2acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}2. Cancer: 140.0-208.91{break}All malignant neoplasms-1,0reword35 pasthx3_3acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}3. Chronic Cerebrovascular Disease: 437.0-437.9, 438.0-438.9{break}Cerebral atherosclerosis, ischemic cerebrovascular disease, hypertensive encephalopathy, cerebral aneurysm, nonruptured, cerebral arteritis, Moyamoya disease, transient global amnesia -1,0reword36 pasthx3_4acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}4. Chronic Renal Disease (w, w/o Renal Failure): 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 582.0-583.9, 585-587{break}Hypertensive renal disease, hypertensive heart and renal disease, chronic glomerulonephritis, chronic renal failure, renal sclerosis-1,0reword37 pasthx3_5acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}5. Chronic Liver Disease: 571.0-572{break}Chronic liver disease and cirrhosis{break}Liver abscess and sequelae of chronic liver disease-1,0reword38 pasthx3_6acute 23-Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}6. COPD: 491.21, 493.20, 493.21, 496{break}Obstructive chronic bronchitis, chronic obstructive asthma with status asthmaticus, chronic airway obstruction NEC-1,0reword39 pasthx3_7acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}7. Cardiomyopathy: 425.0-425.9{break}Cardiomyopathies-1,0reword40 pasthx3_8acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}8. Chronic Cardiac Conditions:{break}398.90, 398.91, 398.99, Other rheumatic heart disease{break}402.00-402.91, Hypertensive heart disease,{break}414.8, 414.9, Chronic ischemic heart disease{break}416.0-416.9, Chronic pulmonary heart disease{break}429.1, 429.2, 429.3, Myocardial degeneration, cardiovascular disease, unspecified, cardiomegaly{break}443.81, 443.89, 443.9, Peripheral angiopathy{break}V12.50, unspecified circulatory disease; V15.1, surgery to heart and great vessels{break}428.xx, Congestive heart failure -1,0revised question41 pasthx3_9acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}9. History of PTCA: V45.82-1,0reword42 pasthx3_10acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}10. History of CABG: V45.81-1,0reword43 pasthx3_11acute 23*Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}11. Atherosclerosis and Lipid Disorders: 272.0-272.9; Disorders of lipoid metabolism; 414.0-414.05, Coronary atherosclerosis; 440.0-440.9, atherosclerosis-1,0reword44 pasthx3_12acute 23TIndicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}12. Musculoskeletal Conditions: 714.0-714.33, Rheumatoid arthritis; 715.00-715.98, Osteoarthritis and allied disorders; 720.0, Ankylosing spondylitis;{break}721.90, Spondylosis of unspecified site-1,0reword45 pasthx3_13acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}13. History of MI: 412 Old MI (greater than 8 weeks)-1,0reword46 pasthx3_16acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}16. Documented family history of coronary artery disease-1,0reword47 pasthx3_17acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}17. History of alcohol abuse-1,0begin48 pasthx3_99acute 23Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}99. None of listed diagnoses-1,0revised question49pastcvaacute 24EDoes the patient have a history of stroke within the past five years?1,2ICD-9 Code 436. Codes 438.0-438.42 and 438.81-438.9 indicate late effects of cerebrovascular disease. Old stroke without residuals is coded V12.5950cathfiveacute 25KWithin the past five years, did the patient have a cardiac catheterization?:1,2*{p_end}{p2col:}*If 2, go to revasc, else go to blocathnAnswer "2" if the patient did not have a cardiac catheterization or whether the patient had a cath is unknown.begin51blocathacute 26mAt any cath done within the five-year period, was there a finding of > = 50% stenosis in any coronary artery?;1,2*{p_end}{p2col:}*If 2, go to revasc, else go to cathdateStenosis = constriction or narrowing. Buildup of fat, cholesterol, and other substances over time may clog the coronary arteries. The question is applicable to blockage or stenosis of any of the coronary arteries.begin{err:cathfive}52cathdateacute 27IEnter the date the cath with a finding of > = 50% stenosis was performed. mm/dd/yyyymEnter the exact date where possible. 01 may be used to designate day and month if only the year is available.{err:cathfive} {err:blocath}53revasc1acute 28Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}1. PTCA/PCI-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.54revasc2acute 28}Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}2. CABG-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.55revasc99acute 28Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}99. No documentation of revascularization within the past six months.-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.56priorx1acute 29sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}1. aspirin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).57priorx2acute 29xWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}2. beta blocker-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).58priorx3acute 29yWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}3. ACE inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).59priorx4acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}4. lipid-lowering medication-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).60priorx5acute 29sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}5. insulin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).61priorx6acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}6. platelet aggregation inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).62priorx7acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}7. low molecular weight heparin (LMWH)-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).63priorx99acute 29Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}99. no documentation patient was on any of these medications-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).64anginumacute 30Enter the number of episodes of angina experienced by the patient within 24 hours prior to presentation to the hospital.{p_end}{p2col:}(Angina is defined as: chest pain or severe epigastric pain, non-traumatic in origin; central/substernal compression or crushing chest pain; pressure, tightness, heaviness, cramping, burning or aching sensation; unexplained indigestion, belching, epigastric pain; radiating pain in neck, jaw, shoulders, back, one or both arms; dyspnea; nausea and/or vomiting; diaphoresis)?______*{p_end}{p2col:}*If 0, go to amisymp, else go to angieaseIIf any of the symptoms of angina were continuous within the 24-hour period (or less) prior to presentation, consider it as one episode. If the pain or other symptom relented for a period of time and then recurred, count each episode of pain (or other symptom) as a separate episode.{p_end}{p2col:}There may be conflicting notes in the ED record, admitting note, H&P, etc, regarding number of episodes of angina. It is suggested that one source, preferably the admitting note, be used as the source of information.{p_end}{p2col:}Enter "0" if the number of episodes of angina is unknown.{txt:acs_inpt}65angieaseacute 31^Enter the number of these episodes of angina that were relieved by sublingual NTG and/or rest.______This number is a component of the number of episodes of angina experienced in the last 24 hours and entered in anginum. The question does not reference number of additional episodes.{txt:acs_inpt} {txt:anginum 0}66amisymp1acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}1. chest pain or severe epigastric pain, non-traumatic in origin-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo67amisymp2acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}2. central/substernal compression or crushing chest pain-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo68amisymp3acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}3. pressure, tightness, heaviness, cramping, burning or aching sensation-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo69amisymp4acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}4. unexplained indigestion, belching, epigastric pain-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo70amisymp5acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}5. radiating pain in neck, jaw, shoulders, back, one or both arms-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo71amisymp6acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}6. dyspnea-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo72amisymp7acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}7. nausea and/or vomiting-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo73amisymp8acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}8. diaphoresis-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo74 amisymp99acute 32Within 24 hours prior to or on arrival at this or another VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms-1,0Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.typo75onsethrsacute 333Enter the number of hours prior to arrival at the VHA hospital that the symptom(s) that brought the patient to the hospital began. {p_end}{p2col:}1. 0 - 1{p_end}{p2col:}2. >1 - 2{p_end}{p2col:}3. >2 - 6{p_end}{p2col:}4. >6 - 12{p_end}{p2col:}5. >12 - 24{p_end}{p2col:}6. >24{p_end}{p2col:}99. not documented1,2,3,4,5,6,99&The patient may have had a number of symptoms occurring over a period of many hours or days. Count the time period from the onset of the symptom that finally became so frightening, severe, or unrelenting that the patient came to the hospital. {p_end}{p2col:}The number of hours prior to hospital arrival that the symptoms began may not be explicitly stated in the record, and may have to be inferred or extrapolated from available documentation. (Examples: "the patient began to experience chest pain shortly before midnight." If hospital arrival time was 4:15 a.m., enter category #3.){p_end}{p2col:}("The patient began taking antacids for severe indigestion yesterday morning, but the epigastric pain continued to worsen until{p_end}{p2col:}presentation at the ED at 3:30 this afternoon." Enter category #6.){p_end}{p2col:}If documentation of the time period is too undefined to determine an approximate number of hours, enter #99.{p_end}{p2col:}If information in the record is conflicting, use only the ED notes or admitting note as the source of information.{txt:acs_inpt} {res:(}{txt:amisymp1 0} {res:&} {txt:amisymp2 0} {res:&} {txt:amisymp3 0} {res:&} {txt:amisymp4 0} {res:&} {txt:amisymp5 0}{res:)}76chfsymp1acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}1. 1. heart failure-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.77chfsymp2acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}2. impaired left ventricular function-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.78chfsymp3acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}3. new mitral regurgitation murmur-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.79chfsymp4acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}4. an S3 gallop-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.80chfsymp5acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}5. rales > 3 or 1/3 up-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.81chfsymp6acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}6. documentation of a chest x-ray with evidence of pulmonary edema-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.82chfsymp7acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}7. documentation of cardiogenic shock (severe and persistent hypotension in Trendelenburg)-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.83 chfsymp99acute 34At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms documented-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.84frstrateacute 35Enter the patient's heart rate recorded closest to the time of presentation to a VHA hospital, or abnormal ECG if ACS occurred as inpatient._____bpmDo not use the ambulance record. Enter the heart rate recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the heart rate recorded at the time the ECG was done. {txt:acs_trc}85 arvpress_acute 36vEnter the patient's blood pressure recorded at the time of presentation, or abnormal ECG if ACS occurred as inpatient.---/---Do not use the ambulance record. Enter the blood pressure recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the BP recorded closest to the time of the ECG. {txt:acs_trc}86painmeasacute 37At initial presentation, or abnormal ECG if ACS occurred as inpatient, was the patient's level of cardiac pain measured using a 0 - 10 scale?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}3. patient unable to respondC1,2,3*{p_end}{p2col:}*If 2 or 3, go to restang, else go to entrpainPain screening done by a nurse or other discipline is acceptable. Pain screening done by emergency personnel during transport to the hospital is also acceptable. {p_end}{p2col:}Report from an individual other than the patient is not acceptable. {p_end}{p2col:}If the patient has no pain, the abstractor will accept documentation of: pain = 0{p_end}{p2col:}If the patient has no pain, the abstractor will not accept documentation of: "patient denies pain," or "no pain," without use of a scale {txt:acs_trc}87entrpainacute 380Enter the level of pain reported by the patient.______Pain screening may be done by description, color intensity, or faces rating, but a 0 - 10 scale must be used. Answer can only be numeric, zero or greater, and not greater than 10.{txt:acs_trc} {err:painmeas 1}88restangacute 39At the time of presentation, or abnormal ECG if the ACS occurred as inpatient, does the record document the patient experienced prolonged ongoing rest pain (pain in chest, arm, or neck{p_end}{p2col:}> 20 minutes)?1,2Documentation of rest pain may be found in the ED notes, admitting notes or H&P. {p_end}{p2col:}Myocardial ischemic pain is usually described as pressing, squeezing, or weightlike. The pain is greatest in the central precordium. The pain frequently radiates in the distribution of the lower cervical nerves and may therefore be felt in the neck, lower jaw, or either shoulder or arm. Myocardial ischemic pain often induces an autonomic response (nausea or vomiting, or sweating.) Myocardial ischemic pain due to coronary arteriosclerosis is usually exertion-related, at least initially. However, the pain of acute MI may occur suddenly when the patient is at rest.{p_end}{p2col:}Rest pain = the patient is sitting or lying in bed and not involved in exertion-related activity. {txt:acs_trc}89ekgdone4acute 409Was a 12-lead EKG performed either prior to or after arrival at a VHA hospital?{p_end}{p2col:}A diagnosis of AMI or Unstable Angina with no ECG done during the episode of care is problematic data. If the question is answered "no," request the help of the EPRP Liaison in locating an ECG that may have been missed.<1,2*{p_end}{p2col:}*If 2, go to asanone, else go to frstdatePrior to or after arrival at the hospital = examples: in another unit at the VAMC before transfer to acute care, in the ambulance in transport to the hospital, or on arrival at the ED. Review the entire record to determine whether an EKG was done during the episode of care. {p_end}{p2col:}Rhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead if lead markings are noted in the report. {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.reword {err:acs_arr}90frstdateacute 41cIs the date of the first 12-lead EKG done after arrival at a VHA hospital documented in the record?<1,2*{p_end}{p2col:}*If 2, go to frstime, else go to arvekgdtThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the date the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.reword{err:acs_arr} {err:ekgdone4}91arvekgdtacute 42<Enter the date the first 12-lead EKG after arrival was done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not applicable.revised question+{err:acs_arr} {err:ekgdone4} {err:frstdate}92frstimeacute 43QIs the time of the first 12-lead EKG done after arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to closdoc, else go to arvekgtmThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the time the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.reword{err:acs_arr} {err:ekgdone4}93arvekgtmacute 44<Enter the time the first 12-lead EKG after arrival was done._____{p_end}{p2col:}UMT-Time must entered in universal military time.revised question*{err:acs_arr} {err:ekgdone4} {err:frstime}94closdocacute 45bIs the date of the 12-lead EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to timeclos, else go to closdt3The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.) {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.begin{err:acs_arr} {err:ekgdone4}95closdt3acute 46Enter the date. mm/dd/yyyyThis may be the same date as in the question arvekgdt{p_end}{p2col:}Use exact date. The use of 01 to indicate missing day or month is not acceptable.*{err:acs_arr} {err:ekgdone4} {err:closdoc}96timeclosacute 47bIs the time of the 12-lead EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to closecg, else go to clostme3This may be the same time as in the question arvekgtm.{p_end}{p2col:}The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms.{p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.reword{err:acs_arr} {err:ekgdone4}97clostme3acute 48Enter the time._____{p_end}{p2col:}UMTTime must entered in universal military time{p_end}{p2col:}To convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.+{err:acs_arr} {err:ekgdone4} {err:timeclos}98closecgacute 49Is there documented interpretation of the 12-lead ECG performed closest to hospital arrival, or onset of ACS if the veteran was already an inpatient?{p_end}{p2col:}A diagnosis of AMI or Unstable Angina with no interpretation of the initial ECG documented in the record is problematic data. Review the Definitions/Decision Rules and ask the EPRP Liaison for assistance if unable to identify the ECG closest to hospital arrival.{p_end}{p2col:}If the ECG done closest to hospital arrival is non-diagnostic or even normal, but a later reading by a cardiologist or a later ECG indicates a STEMI or NSTEMI, return to question inptacs and answer "1." Enter the date and time of the diagnostic ECG. You may have to change amicode in the Validation Module to a "2," but this will be your judgment.;1,2*{p_end}{p2col:}*If 2, go to asanone, else go to ecgfindUse the 12-lead ECG performed closest to the time of hospital arrival whether prior to or after arrival at this or another VAMC with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.){p_end}{p2col:}The same concept applies to the ECG done closest to the onset of ACS if the ACS occurred post-admission. Look for interpretation of the 12-lead ECG performed closest to the event. {p_end}{p2col:}Do not use an ECG interpretation done more than one hour prior to hospital arrival or onset of ACS if the veteran was already an inpatient.{p_end}{p2col:}An EKG interpretation is defined as either:{p_end}{p2col:}o- a 12-lead ECG/EKG report in which the name or initials of the MD/NP/ or PA who reviewed the EKG is signed, stamped, or typed on the report.{p_end}{p2col:}o- MD/NP/ or PA notation of ECG/EKG findings. Interpretations may be taken directly from documentation of ECG findings.{p_end}{p2col:}o- If the ECG/EKG interpretation is an electronic "reading," use clinician documentation of the EKG findings unless the clinician "signs off" on the electronic interpretation as described above.{p_end}{p2col:}If the ECG/EKG report is not specifically labeled "12-lead", infer that it was 12-lead if lead marking ( i.e., I, II, III, a VL, a VL, a VF, V1, V2, V3,V4, V5, V6) are noted on the report.{p_end}{p2col:}If the physician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead if lead markings are noted in the report.{p_end}{p2col:}If unable to determine which 12-lead ECG/EKG was done closest to arrival (e.g., one EKG does not have a time and it cannot be determined whether it is closer to hospital arrival than another EKG which does have a time), or if the time between the pre-arrival is the same (e.g., both were done 15 minutes from arrival time), answer "1" if any of these ECGs/EKGs have ST segment elevation or LBBB documented on the interpretation.revised question{txt:acs_trc} {err:ekgdone4}99ecgfindacute 50jWhat were the specific findings from interpretation of the first 12-lead ECG performed closest to hospital arrival or onset of symptoms if the AMI occurred as inpatient?{p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}99. no documentation of any of the aboveD1,2,3,4,5,6,7,8,9,10,11{p_end}{p2col:}99{p_end}{p2col:}Go to asanoneDo Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.end*{txt:acs_trc} {err:ekgdone4} {err:closecg}100transecgacute 51IDoes the record of this patient transferred from a community hospital document that an ST elevation or LBBB (new or not known to be old) was identified on the initial ECG?{p_end}{p2col:}1. ST elevation or LBBB on initial ECG{p_end}{p2col:}2. no ST elevation or LBBB identified on initial ECG{p_end}{p2col:}99. unable to determine$1,2,99{p_end}{p2col:}Go to transtropDo not attempt to use ECG tracing sent with the patient to answer this question. There must be a documentation of the initial ECG finding, and the interpretation must state ST elevation (or equivalent terminology) or LBBB. {p_end}{p2col:}Information may be taken from medical record documents sent with the patient at the time of transfer, or clinician documentation of discussion with a clinician at the community hospital to which the patient initially presented.end {err:acs_trc}101asanoneacute 52Does the record document one or more of the following contraindications to aspirin:{p_end}{p2col:}1. Aspirin allergy{p_end}{p2col:}2. Active bleeding on arrival or within 24 hours after arrival{p_end}{p2col:}3. Warfarin/Coumadin as pre-arrival medication{p_end}{p2col:}4. Other reasons documented by MD, NP, or PA{p_end}{p2col:}98. Patient's direct refusal to take aspirin{p_end}{p2col:}documented in the record.{p_end}{p2col:}99. No documented contraindicationS1*,2*,3*,4*,98,99{p_end}{p2col:}*If 1,2,3,4, or 98, go to platagg, else go to asa24#History of allergy, sensitivity, reaction, or intolerance to aspirin also includes medications that contain aspirin. Where there is documentation of an aspirin "allergy" or "sensitivity," regard this as aspirin allergy regardless of what type of reaction might be noted. {p_end}{p2col:}Warfarin/Coumadin as pre-arrival medication = refer to patient's medication regimen just prior to acute care treatment. Include warfarin/Coumadin the patient was on at home, the nursing home, a transferring psychiatric hospital, etc. Do not include warfarin taken in the ambulance en route to the hospital. Include cases where the patient was prescribed warfarin/Coumadin at home, but there is indication it was on temporary hold or the patient was non-compliant.{p_end}{p2col:}"Other reasons" documented by MD, NP, or PA must explicitly link the noted reason with non-prescription of aspirin. If the patient is taking clopidogrel (Plavix) or ticlopidine hydrochloride (Ticlid), clinician documentation must specify the use of this drug is the reason aspirin was not given. {txt:acs_trc}102asa24acute 53Did the patient receive aspirin within 24 hours before or after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?;1,2*{p_end}{p2col:}*If 2, go to platagg, else go to aspdate2 = patient did not receive aspirin within the time period or unable to determine from medical record documentation {p_end}{p2col:}If aspirin was taken by the patient or given by emergency personnel on the way to the hospital, answer "1." If ASA was given at another level of care at this VAMC, answer "1."{p_end}{p2col:}Do not assume patient took ASA prior to arrival based solely on aspirin being listed as a pre-arrival or home medication. Documentation must indicate the patient actually took aspirin within the 24-hour time frame.{txt:acs_trc} {err:asanone 99}103aspdateacute 54+Enter the date the patient received aspirin mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.*{txt:acs_trc} {err:asanone 99} {err:asa24}104asptimeacute 55+Enter the time the patient received aspirin_____{p_end}{p2col:}UMTNIf the patient did not receive aspirin post-admission, or at the time of the ECG if ACS occurred inpatient, and when the patient took aspirin within a 24 hour period prior to arrival cannot be known, (Example: "patient's wife thinks he took aspirin during the night before he came to the hospital"), do not guess. Answer 2 to "asa24."*{txt:acs_trc} {err:asanone 99} {err:asa24}105plataggacute 56Did the patient receive a platelet aggregation inhibitor within the first 24 hours after arrival, or abnormal ECG if ACS occurred as inpatient? {p_end}{p2col:}1. clopidogrel (Plavix){p_end}{p2col:}2. ticlopidine (Ticlid){p_end}{p2col:}3. dipyridamole (Persantine){p_end}{p2col:}4. dipyridamole and aspirin (Aggrenox){p_end}{p2col:}98. patient's direct refusal to take platelet aggregation inhibitor documented in record{p_end}{p2col:}99. none of these medicationsp1,2,3,4,98*,99**{p_end}{p2col:}*If 98, go to betanone{p_end}{p2col:}**If 99, go to platcont, else go to platdateClopidogrel and ticlopidine are inhibitors of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in patients with established athererosclerotic cardiovascular disease as evidenced by stroke, TIA, and AMI. Patients who have a true allergy to aspirin and no contraindication to antiplatelet therapy may be given clopidogrel, ticlopidine, or dypyridamole. {txt:acs_trc}106platdateacute 57GEnter the date the patient received the platelet aggregation inhibitor. mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.!{txt:acs_trc} {txt:platagg 98 99}107platimeacute 58GEnter the time the patient received the platelet aggregation inhibitor.4_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to betanoneEnter the time of administration during the first 24 hours after hospital arrival or transfer to a monitored bed, using military time.!{txt:acs_trc} {txt:platagg 98 99}108platcontacute 59yIs there clinician documentation in the record that a platelet aggregation inhibitor is contraindicated for this patient?1,2jPotential adverse effects of platelet aggregation inhibitors: nephrotic syndrome, hyponatremia, blood cell disorders, TTP (thrombotic thrombocytopenic purpura). The abstractor may not make the decision that a platelet aggregation inhibitor is contraindicated because one of these factors is present. There must be clinician documentation of the contraindication.{txt:acs_trc} {err:platagg 99}109betanoneacute 60JDoes the record document one or more of the following contraindications/reasons for not prescribing a beta blocker?{p_end}{p2col:}1. Beta blocker allergy{p_end}{p2col:}2. Bradycardia (heart rate less than 60 bpm) on arrival or within 24 hours of arrival while not on a beta blocker {p_end}{p2col:}3. Second or third degree heart block on ECG on arrival or within 24 hours of arrival and does not have a pacemaker{p_end}{p2col:}4. Systolic blood pressure less than 90 mm HG on arrival or within 24 hours of arrival{p_end}{p2col:}5. Other reasons documented by an MD, NP, or PA for not giving a beta blocker within 24 hours after hospital arrival{p_end}{p2col:}7. Heart failure on arrival or within 24 hours after arrival{p_end}{p2col:}8. Shock on arrival or within 24 hours after arrival{p_end}{p2col:}9. Post-heart transplant patient{p_end}{p2col:}10. Severely decompensated heart failure, as evidenced by patient receiving IV dobutamine, milrinone, or nesiritide {p_end}{p2col:}98. patient's direct refusal to take beta blocker documented in record{p_end}{p2col:}99. No documented contraindication1*,2*,3*,4*,5*,7*,8,*{p_end}{p2col:}9*, 10, 98*, 99{p_end}{p2col:}*If 1,2,3,4,5,7,8,9, 10, or 98 go to hepin24, else go to beta24^Option Rules:{p_end}{p2col:}Beta blocker allergy = when there is documentation of a beta blocker "allergy" or "sensitivity," regard this as an allergy regardless of what type of reaction may be noted.{p_end}{p2col:}Bradycardia = must be substantiated by documentation of a heart rate of 60 beats per minute on arrival or within 24 hours of arrival.{p_end}{p2col:}Second or third degree heart block = Do not attempt to use the EKG tracing to answer this question. The EKG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the EKG interpretation does not have to be linked specifically to contraindication to beta-blocker.{p_end}{p2col:}Systolic blood pressure = may be taken from the vital sign records on arrival for the first 24 hours after arrival at the hospital{p_end}{p2col:}Other reasons = MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker{p_end}{p2col:}For example: COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma.{p_end}{p2col:}Heart failure = must be documented by MD, NP, or PA {p_end}{p2col:}Shock = must be documented by an MD, NP, or PA {txt:acs_trc}110beta24acute 61Did the patient receive a beta blocker within 24 hours after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?:1,2*{p_end}{p2col:}*If 2, go to hepin24, else go to bbdateR2 = Beta blocker not given within 24 hours after hospital arrival or ECG if the AMI occurred as inpatient, or unable to determine from medical record documentation{p_end}{p2col:}Refer to drug list for listing of beta blockers.{p_end}{p2col:}Answer "1" if an IV beta blocker (eg. metoprolol) was given in the ED within 24 hours of arrival.{txt:acs_trc} {err:betanone 99}111bbdateacute 622Enter the date the patient received a beta blocker mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.,{txt:acs_trc} {err:betanone 99} {err:beta24}112bbtimeacute 632Enter the time the patient received a beta blocker_____{p_end}{p2col:}UMTTo convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.,{txt:acs_trc} {err:betanone 99} {err:beta24}113specbetaacute 64;Designate the beta blocker the patient received within 24 hours after arrival at the hospital, or ECG if the ACS occurred as inpatient:{p_end}{p2col:}1. metoprolol succinate (Toprol-XL){p_end}{p2col:}2. metoprolol tartrate{p_end}{p2col:}3. bisoprolol (Zebeta or Ziac){p_end}{p2col:}4. carvedilol (Coreg){p_end}{p2col:}5. atenolol (Tenoretic or Tenormin){p_end}{p2col:}6. acebutolol (Sectral) {p_end}{p2col:}7. sotalol (Betapace) {p_end}{p2col:}8. betaxolol (Kerlone) {p_end}{p2col:}9. carteolol (Cartrol) {p_end}{p2col:}10. nadolol (Corgard) {p_end}{p2col:}11. nadolol/bendroflumethiazide (Corzide) {p_end}{p2col:}12. propranolol (Inderal) {p_end}{p2col:}13. propranolol hydrochloride (Inderide) {p_end}{p2col:}14. labetalol (Normodyne or Trandate) {p_end}{p2col:}15. penbutolol sulfate (Levatol) {p_end}{p2col:}16. metoprolol/hydrocholorthiazide (Lopressor HCT ) {p_end}{p2col:}17. penbutolol sulfate (Levatol) {p_end}{p2col:}18. pindolol (Visken) {p_end}{p2col:}19. timolol (Timolide or Blocadren) {p_end}{p2col:}20. timolol/hydrocholorthiazide{p_end}{p2col:}21. brevibloc (EsmololD1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,{p_end}{p2col:}18,19,20,21SBeta blocker generic names are not capitalized. Brand names are capitalized.{p_end}{p2col:}Enter the number corresponding to the generic name documented in the medical record.{p_end}{p2col:}Question is applicable to the beta blocker administered to the patient within 24 hours after arrival at the hospital, or ECG if the ACS symptoms occurred as inpatient.{p_end}{p2col:}Beta blocker the patient may have been taking prior to arrival at the hospital is not applicable to this question.{p_end}{p2col:}Source: medication administered in the ED, admitting note, admission orders, medications given,{txt:acs_trc} {err:betanone 99} {err:beta24}114hepin24acute 65PDid the patient receive heparin within 24 hours after arrival or ECG if ACS occurred as inpatient?{p_end}{p2col:}1. received nonfractionated heparin{p_end}{p2col:}2. received low molecular weight heparin{p_end}{p2col:}98. patient's direct refusal of heparin documented in record{p_end}{p2col:}99. did not receive heparin within 24 hoursE1,2,98,99*{p_end}{p2col:}*If 98 or 99, go to hgbone, else go to hepdtNonfractionated heparin= heparin sodium (Heparin){p_end}{p2col:}Low molecular weight heparin= enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).{p_end}{p2col:}99 = patient did not receive heparin or did not receive initial dose within 24 hours of arrival, or ECG if the veteran was already an inpatient. {txt:acs_trc}115hepdtacute 66+Enter the date the patient received heparin mm/dd/yyyy9Enter the exact date. Month=01 or day=1 is not acceptable!{txt:acs_trc} {txt:hepin24 98 99}116heptmeacute 67+Enter the time the patient received heparin_____{p_end}{p2col:}UMTEnter the time of initial administration during the first 24 hours after hospital arrival or ECG if the veteran was already an inpatient, using military time.!{txt:acs_trc} {txt:hepin24 98 99}117hgboneacute 68Enter the value of the first hemoglobin obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient.--. -The hemoglobin concentration is a measure of the total amount of hgb in the peripheral blood. Hgb serves as a vehicle for oxygen and carbon dioxide transport {txt:acs_trc}118hgbunitacute 69CEnter the unit.{p_end}{p2col:}1. 1. g/dl{p_end}{p2col:}2. 2. mmol/L1,2RNormal: Male: 14-18 g/dl or 8.7 -11.2 mmol/L. Female: 12-16 g/dl or 7.4-9.9 mmol/L {txt:acs_trc}119hgbdtacute 70,Enter the date this hemoglobin was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {txt:acs_trc}120hgbrefacute 71Is this hemoglobin value within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured. {txt:acs_trc}121hctoneacute 72LEnter the value of the first hematocrit obtained following hospital arrival._____[The hematocrit is a measure of the percentage of red blood cells in the total blood volume. {txt:acs_trc}122hctunitacute 73ZEnter the unit.{p_end}{p2col:}1. 1. percent{p_end}{p2col:}2. 2. volume fraction (SI units)1,2uNormal: Male: 42%-52% or 0.42-0.52 volume fraction (SI units) Female: 37%-47% or 0.37-0.47 volume fraction (SI units) {txt:acs_trc}123dtofhctacute 74,Enter the date this hematocrit was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {txt:acs_trc}124hctrefacute 75Is this hematocrit value within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured. {txt:acs_trc}125platoneacute 76zEnter the first platelet count obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient.______The platelet count is an actual count of the number of platelets (thrombocytes) per cubic milliliter of blood. Normal values for adults/elderly: 150,000-400,000/mm^3 {txt:acs_trc}126platdoneacute 770Enter the date this platelet count was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {txt:acs_trc}127platlabacute 78Is this platelet count within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured. {txt:acs_trc}128wbconeacute 79|Enter the value of the first WBC obtained following arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient._______White blood cell count is a count of the total number of WBCs (leukocytes) in 1 mm^3 of peripheral venous blood. Normal adult values 5000-10000/mm^3 {txt:acs_trc}129wbcdtacute 80%Enter the date this WBC was obtained. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {txt:acs_trc}130wbclabacute 81Is this white cell count within the laboratory normal reference range?{p_end}{p2col:}1. within normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured. {txt:acs_trc}131hicreatacute 82NEnter the highest serum creatinine value obtained during this episode of care?______The serum creatinine test is used to diagnose impaired renal function. Normal values: Male: 0.6-1.2 mg/dl; Female: 0.5-1.1 mg/dl. Possible critical values: >4mg/dl. {txt:acs_trc}132creatdtacute 83Enter the date of this value. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {txt:acs_trc}133creatrefacute 84Was the highest serum creatinine value within the laboratory normal reference range?{p_end}{p2col:}1. within the normal reference range{p_end}{p2col:}2. lower than the normal reference range{p_end}{p2col:}3. higher than the normal reference range1,2,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured. {txt:acs_trc}134ckmbdunacute 85&Was a CK-MB obtained for this patient?;1,2*{p_end}{p2col:}*If 2, go to dotrop, else go to ckmbunitCreatine kinase (CK) is found predominantly in heart muscle, skeletal muscle and brain. . (Also called CPK.) CK-MB is more specific for myocardial cells. {txt:acs_trc}135ckmbunitacute 86CEnter the unit for CK-MB.{p_end}{p2col:}1. ng/mL{p_end}{p2col:}2. %1,2{txt:acs_trc} {err:ckmbdun}136ckmbhiacute 87CEnter the highest CK-MB value recorded during this episode of care.______Normal values CK: Male 12-70 U/ml or 55-170 U/L; Female: 10-55 U/ml or 30-135 U/L. Normal values CK-MB: 0-7 IU/L (less than 4%-6% of total CPK.){txt:acs_trc} {err:ckmbdun}137ckmbdtacute 88$Enter the date of the highest value. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.{txt:acs_trc} {err:ckmbdun}138ckmblabacute 89Was the highest CK-MB value within the laboratory normal reference range?{p_end}{p2col:}1. within laboratory reference range{p_end}{p2col:}3. positive (higher than ULN for reference range)1,3The reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.{txt:acs_trc} {err:ckmbdun}139dotropacute 90/Was a troponin level obtained for this patient?<1,2*{p_end}{p2col:}*If 2, go to cardcare, else go to howtropTroponin is a protein complex consisting of three isotypes, T, I, and C. Troponin has become the marker of choice for diagnosis of myocardial necrosis, and Troponin T and I are powerful tools for risk stratification. Portable devices allow bedside (point of care or POCT) cardiac marker determinations rapidly and accurately. Point of care systems have the advantage of reducing diagnostic delays due to transportation and processing in a central laboratory {txt:acs_trc}140howtropacute 91How was the first troponin level obtained after hospital arrival or ECG if ACS as inpatient?{p_end}{p2col:}1. point of care bedside testing{p_end}{p2col:}2. central laboratory assay1,2Point of care testing= blood sample drawn at the bedside and analyzed immediately for presence of troponin I or troponin T, which identify unstable patients at high risk for occlusion. {p_end}{p2col:}Read ED notes, admitting notes, and progress notes carefully to determine if POCT was used to obtain the first troponin level. Do not reference only the laboratory reports for the initial troponin level.{txt:acs_trc} {err:dotrop}141troponeacute 92Enter the result of the first troponin level.{p_end}{p2col:}3. positive (higher than upper limit for reference range){p_end}{p2col:}4. negative (not higher than upper limit for reference range)3,4Point of care bedside testing may only be reported as positive or negative. Values that are reported as an actual numeric value will need to be compared to the reference range to determine if the result exceeds the upper limit of normal (ULN) according to the hospital's laboratory parameters. Consult your liaison for help if you are unsure. If the value is greater than the higher value of the reference range, it is positive.{txt:acs_trc} {err:dotrop}142firstdocacute 93Does the record document the draw date of the first troponin level obtained after arrival, or abnormal ECG if ACS occurred as inpatient?=1,2*{p_end}{p2col:}*If 2, go to firstime, else go to entrfrstvDraw date = the date the blood sample was drawn. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation that POCT testing was done. If the sample was drawn by the lab, use the date the lab drew the sample.{p_end}{p2col:}If the draw date and time are not recorded, but the report date and time are within 60 minutes of arrival, enter the arrival date and time as the draw date and time. Physician order date and time may also be used if draw date and time are not recorded but the troponin level has been reported within 60 minutes of the physician's order.revised definition{txt:acs_trc} {err:dotrop}143entrfrstacute 942Enter the date the first troponin level was drawn. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.){txt:acs_trc} {err:dotrop} {err:firstdoc}144firstimeacute 95Does the record document the draw time of the first troponin level obtained after arrival, or abnormal ECG if ACS occurred as inpatient?<1,2*{p_end}{p2col:}*If 2, go to reprtdoc, else go to whatimeDraw time = the time the blood sample was drawn. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation that POCT testing was done. If the sample was drawn by the lab, use the time the lab drew the sample. If the time the sample was drawn is noted in nurses notes or progress notes, and this time conflicts with lab time, use the earlier time.{txt:acs_trc} {err:dotrop}145whatimeacute 962Enter the time the first troponin level was drawn._____{p_end}{p2col:}UMTIf the time the sample was drawn is noted in nurses notes or progress notes, and this time conflicts with lab time, use the earlier time.){txt:acs_trc} {err:dotrop} {err:firstime}146reprtdocacute 97QIs the report date of the first troponin level obtained documented in the record?<1,2*{p_end}{p2col:}*If 2, go to reprtime, else go to reprtdtBTroponin level report = the date the troponin results were available to the clinician. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation of the outcome of POCT testing.{p_end}{p2col:}If the sample was drawn by the lab, use the lab report date.{txt:acs_trc} {err:dotrop}147reprtdtacute 985Enter the date the first troponin level was reported. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.){txt:acs_trc} {err:dotrop} {err:reprtdoc}148reprtimeacute 99HIs the report time of the first troponin level documented in the record?<1,2*{p_end}{p2col:}*If 2, go to labever, else go to reportmeBTroponin level report = the time the troponin results were available to the clinician. If the sample was drawn at the point of care, and the results immediately available, look in the progress note for documentation of the outcome of POCT testing.{p_end}{p2col:}If the sample was drawn by the lab, use the lab report time.{txt:acs_trc} {err:dotrop}149reportme acute 1005Enter the time the first troponin level was reported._____{p_end}{p2col:}UMTIf the troponin level was drawn by POCT and the result entered in the progress notes, use the time of the progress note unless the exact time the result was known is documented in the record.){txt:acs_trc} {err:dotrop} {err:reprtime}150labever acute 101)Was a subsequent troponin level obtained?;1,2*{p_end}{p2col:}*If 2, go to cardcare, else go to lablvlSubsequent troponin level = additional samples drawn after the first troponin level. Serial troponin levels may be drawn at regular intervals, and may be obtained by POCT or laboratory assay.{txt:acs_trc} {err:dotrop}151lablvl acute 1024Enter the result of the highest/peak troponin level._. __vHighest/peak troponin level = of all the troponin samples obtained, enter the highest value reported for this patient.({txt:acs_trc} {err:dotrop} {err:labever}152tropdt acute 103!Enter the date of the peak level. mm/dd/yyyyEnter the date the blood sample was drawn. Enter the exact date. The use of 01 to indicate unknown month or day is not acceptable.({txt:acs_trc} {err:dotrop} {err:labever}153trohitm acute 104!Enter the time of the peak level._____{p_end}{p2col:}UMTUEnter the time the blood sample was drawn. Enter the time in universal military time.({txt:acs_trc} {err:dotrop} {err:labever}154tropref acute 105Was the highest troponin level within the laboratory reference range?{p_end}{p2col:}3. positive (higher than upper limit for reference range){p_end}{p2col:}4. negative (not higher than upper limit for reference range) 3,4{p_end}{p2col:}Go to cardcareThe reference range may vary for each VAMC laboratory, so the question must be answered in accordance with the reference range for the facility in which the abstractor is working. Be certain the reference range is expressed in the same units in which the value was measured.({txt:acs_trc} {err:dotrop} {err:labever}155 transtrop acute 106Does the record of this patient transferred from a community hospital document that either the initial or peak troponin level was positive?{p_end}{p2col:}2. initial or peak troponin negative{p_end}{p2col:}3. initial and peak troponin positive{p_end}{p2col:}99. unable to determine2,3,99Use documentation sent from the transferring community hospital if this data is available. If there is no information from the transferring hospital, or no documentation of troponin level, answer "3."{p_end}{p2col:}If the patient was transferred soon after presentation to the initial hospital, and the peak troponin level drawn at this VAMC was positive or negative, use this data and answer in accordance with the findings. {err:acs_trc}156cardcare acute 107Was Cardiology involved in the care of the patient?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}99. unable to determineP1,2*,99*{p_end}{p2col:}If 2 or 99 go to{p_end}{p2col:}nototx, else go to sawcardEThe cardiologist must be a physician. This question refers to any time during the hospital stay and is not limited to initial presentation or in the ED.{p_end}{p2col:}Answer yes if a cardiologist was attending physician, saw the patient in consultation, or there was consultation by telephone or telemedicine, or a cardiac cath or PTCA was done with 24 hours.{p_end}{p2col:}If the patient was seen by a cardiology resident, the staff practitioner overseeing the resident must be a cardiologist. The staff practitioner must write a personal progress note or an addendum to the resident note. The note must be dated and timed. The staff practitioner's note may reference discussion of the patient with the resident within 24 hours, even though the note is written at a later time. If the staff practitioner does not write a note, the resident must refer in his note to discussion of the case with the staff practitioner. {p_end}{p2col:}A cardiology "Fellow" is considered to have attained a higher level of education than a resident and the rules pertaining to resident supervision do not apply.157sawcard acute 108Specify how Cardiology was involved in the care of the patient.{p_end}{p2col:}1. A cardiologist was the attending physician{p_end}{p2col:}2. Cardiology was consulted either in person, by telephone, or telemedicine.1,2$Consultation by cardiology = face to face contact with patient, phone call between the primary provider and the cardiologist in which recommendations are made, or consult via telemedicine.{p_end}{p2col:}If a cardiac catheterization or PTCA was done within 24 hours of admission, this counts as a cardiology consult. Answer #2.{p_end}{p2col:}If the patient was seen by a cardiology resident, the staff practitioner overseeing the resident must be a cardiologist. The staff practitioner must write a personal progress note or an addendum to the resident note. The note must be dated and timed. The staff practitioner's note may reference discussion of the patient with the resident within 24 hours, even though the note is written at a later time. If the staff practitioner does not write a note, the resident must refer in his note to discussion of the case with the staff practitioner. {p_end}{p2col:}A cardiology "Fellow" is considered to have attained a higher level of education than a resident and the rules pertaining to resident supervision do not apply.{err:cardcare 1}158cardoc acute 109ZWas the date Cardiology was first involved in the patient's care documented in the record?;1,2*{p_end}{p2col:}*If 2, go to cartmdoc, else go to carddtUInvolvement by cardiology = face to face contact with patient, phone call between the primary provider and the cardiologist in which recommendations are made, or consult via telemedicine.{p_end}{p2col:}If a cardiac catheterization or PTCA was done within 24 hours of admission, use this date as the documented date of cardiology involvement.{err:cardcare 1}159carddt acute 110_Enter the date the patient was first seen by Cardiology or a Cardiology consult was first done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.{err:cardcare 1} {err:cardoc}160cartmdoc acute 111ZWas the time Cardiology was first involved in the patient's care documented in the record?81,2*{p_end}{p2col:}If 2 go to nototx, else go to cardtmeXThis is the time the consult was done, not the time the request for consult was entered.{err:cardcare 1}161cardtme acute 112CEnter the time Cardiology was first involved in the patient's care._____{p_end}{p2col:}UMT3Enter the exact time using universal military time.{err:cardcare 1} {err:cartmdoc}162nototx acute 113Within 24 hours after hospital arrival, or time of the event if ACS occurred inpatient, is there explicit documentation of the decision not to treat?>1,2*{p_end}{p2col:}*If 2, go out of module, else go to notxdocDecision not to treat = the record clearly documents that the patient, patient's family, or legal representative wishes comfort measures only, and/or there is agreement that the patient's cardiac condition and co-morbid conditions preclude further treatment.{p_end}{p2col:}Include: "comfort measures only, hospice care, maintain treatment for comfort, terminal care, physician documentation that care is limited at family's request or due to patient's age or chronic illness, palliative care, supportive care only."reword163notxdoc acute 114CWas the date of the decision not to treat documented in the record?;1,2*{p_end}{p2col:}*If 2, go to notxtime, else go to notxdtSources: Admitting note, progress notes, social service notes, MD orders. Date of decision documentation should appear close to the time of arrival or ACS event if the veteran was already an inpatient. {err:nototx}164notxdt acute 115Enter the date. mm/dd/yyyyWEnter the exact date. the use of 01 to indicate missing day or month is not acceptable.{err:nototx} {err:notxdoc}165notxtime acute 116CWas the time of the decision not to treat documented in the record?>1,2*{p_end}{p2col:}*If 2, go out of module, else go to timentrSources: Admitting note, progress notes, social service notes, MD orders. Time of decision documentation should appear close to the time of arrival or ACS event if the veteran was already an inpatient. {err:nototx}166timentr acute 117Enter the time._____{p_end}{p2col:}UMT Enter the time in military time.{err:nototx} {err:notxtime}167conththrevasc 1Does the record document any of the following potential contraindications to thrombolytic therapy?{p_end}{p2col:}Absolute contraindications{p_end}{p2col:}1. previous hemorrhagic stroke at any time{p_end}{p2col:}2. other strokes or cerebrovascular events, within one year{p_end}{p2col:}3. known intracranial neoplasm{p_end}{p2col:}4. active internal bleeding (except menses){p_end}{p2col:}5. suspected aortic dissection{p_end}{p2col:}6. acute pericarditis {p_end}{p2col:}7. clinician documentation of late presentation{p_end}{p2col:}8. other contraindication documented by clinician{p_end}{p2col:}Relative contraindications{p_end}{p2col:}9. severe uncontrolled hypertension on presentation{p_end}{p2col:}10. current use of anticoagulants in therapeutic doses{p_end}{p2col:}11. known bleeding problems{p_end}{p2col:}12. recent trauma{p_end}{p2col:}13. recent major surgery, i.e., within three weeks{p_end}{p2col:}14. non-compressible vascular punctures{p_end}{p2col:}15. recent internal bleeding, i.e., within 2 to 4 weeks{p_end}{p2col:}16. prior exposure to streptokinase, if that agent is to be administered, i.e., within 5 days to 2 years{p_end}{p2col:}17. pregnancy{p_end}{p2col:}18. active peptic ulcer{p_end}{p2col:}19. history of chronic, severe hypertension{p_end}{p2col:}20. age > 75 years{p_end}{p2col:}21. Stroke risk score > = 4 risk factors{p_end}{p2col:}22. cardiogenic shock{p_end}{p2col:}99. no documented contraindicationP1,2,3,4,5,6,7,8,9,10,{p_end}{p2col:}11,12,13,14,15, 16,17,18, 19, 20, 21, 22, 994. Active internal bleeding = patient presents to hospital actively bleeding from non-compressible site, such as biopsy site, subclavian artery, ulcer, lacerated viscera or other internal site. Skin lesions or trauma to external surface is not applicable.{p_end}{p2col:}7. Clinician documentation of late presentation = clinician documents too many hours have passed from the beginning of the patient's chest pain to his/her arrival at the hospital.{p_end}{p2col:}8. Other contraindication documented by a clinician= patient or situation-specific reason why patient is not a candidate for thrombolytic therapy{p_end}{p2col:}(Examples: patient's advanced age, multiple system failure, patient or family decided against thrombolytic therapy){p_end}{p2col:}9. Severe uncontrolled hypertension on presentation = systolic BP > 180mm HG or dyastolic BP > 110 mm HG, following therapy in the emergency department, or a clinician's notation diagnosing severe uncontrolled HTN at time of adm.{p_end}{p2col:}10. anticoagulants = warfarin (Coumadin); heparin{p_end}{p2col:}12. recent trauma = within 2 to 4 weeks; includes head trauma or traumatic or prolonged ( > 10 minutes) cardiopulmonary resuscitation (CPR){p_end}{p2col:}21 Stroke Risk Score > = 4 risk factors{p_end}{p2col:}o- age > = 75 years{p_end}{p2col:}o- female{p_end}{p2col:}o- African American descent{p_end}{p2col:}o- prior stroke{p_end}{p2col:}o- admission systolic BP > = 160 mm Hg{p_end}{p2col:}o- use of alteplase{p_end}{p2col:}o- excessive anticoagulation ( INR > = 4; APTT > = 24){p_end}{p2col:}o- below median weight (< = 65 kg for women; <= 80 kg for men){p_end}{p2col:}22. cardiogenic shock = sustained systolic BP < 90 mm Hg and evidence of end-organ hypoperfusion, such as cool extremities and urine output < 30 cc/hr) and CHF{txt:noami1} {txt:acs_trc}168ththgvnrevasc 26Was thrombolytic therapy administered to this patient?91,2*{p_end}{p2col:}*If 2, go to dc24, else go to specththAbbokinase, Activase, Alteplase, Anistreplase, Eminase, Reteplase, Kabikinase, Streptase,Streptokinase, Tissue Plasminogen Activator (TPA), Win-kinase, APSAC = Anisylated plasminogen streptokinase activator complex.{txt:noami1} {txt:acs_trc}169specththrevasc 3Indicate which of the following antithrombin agents were administered to the patient:{p_end}{p2col:}1. streptokinase{p_end}{p2col:}2. reteplase{p_end}{p2col:}3. tPA (Alteplase){p_end}{p2col:}4. tenecteplase{p_end}{p2col:}5. other agent administered 1,2,3,4,5[Streptokinase: 1.5 million units (MU) over 60 minutes{p_end}{p2col:}Reteplase (rPA): 10 U over 2 minutes followed by a second 10 U IV bolus 30 minutes later{p_end}{p2col:}Alteplase (tPA): (100 mg maximum), 15 mg IV bolus, then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over the next 60 minutes{p_end}{p2col:}Tenectaplase: IV bolus weight adjusted({txt:noami1} {txt:acs_trc} {err:ththgvn}170thromdtrevasc 4HDoes the record document the date thrombolytic therapy was administered?=1,2*{p_end}{p2col:}*If 2, go to thromtme, else go to ththdateCheck emergency department notes, medication administration record, progress notes, nurses notes for specific date thrombolytic therapy was given. Do not use order sheets for this data element. To answer "1," the date must be identified in the medical record.({txt:noami1} {txt:acs_trc} {err:ththgvn}171ththdaterevasc 55Enter the date thrombolytic therapy was administered. mm/dd/yyyyIf there were two different thrombolytic administration episodes, enter the date (and time) the earliest thrombolytic was initiated.{p_end}{p2col:}Enter exact date. Month = 01 or day = 01 is not acceptable6{txt:noami1} {txt:acs_trc} {err:ththgvn} {err:thromdt}172thromtmerevasc 6HDoes the record document the time thrombolytic therapy was administered?81,2*{p_end}{p2col:}If 2, go to dc24, else go to ththtimeIf thrombolytic therapy was initiated in the ambulance and was infusing at the time of arrival, use the hospital arrival time. Do not use order sheets for this data element. To answer "1," the time must be identified in the medical record, except for situation described.({txt:noami1} {txt:acs_trc} {err:ththgvn}173ththtimerevasc 7Enter the time_____{p_end}{p2col:}UMT'Time must be in Universal Military Time7{txt:noami1} {txt:acs_trc} {err:ththgvn} {err:thromtme}174dc24revasc 8>Was the patient discharged on the day of arrival at this VAMC?1,24Day of arrival = on the same date as the day of arrival{p_end}{p2col:}Since VAMCs are required to "discharge" rather than "transfer" patients to another acute care facility, this question can mean a "discharge" to another VAMC for cath or PCI, or it can mean the patient was found not to require inpatient care and was sent home. "On the day of arrival" is the focal point of the question. Answer "1" if the patient was "discharged" to another VAMC or community-based hospital on the day of arrival at this VAMC and did not return to this facility within 12 hours.{txt:noami1} {txt:acs_trc}175outpcirevasc 9gWas the patient discharged to another acute care hospital for an emergent cardiac cath or probable PCI?;1,2*{p_end}{p2col:}*If 2, go to ptcadne, else go to docneedIf the patient is sent to a hospital associated with this VAMC for a PCI, and returns to this VAMC within 12 hours for further care, answer "2" since this is not considered a discharge.{p_end}{p2col:}Answer "1" if the patient was discharged to another VAMC or community-based acute care hospital, and the record documents a planned cath with consideration of a PTCA/PCI depending on the outcome of the cath.{txt:noami1} {txt:acs_trc}176docneed revasc 10Does the record indicate urgent need for catheterization/probable PCI based on ECG interpretation of ST elevation or LBBB (new or not known to be old)?1,2The question presumes that this VAMC does not have the capability to perform a cardiac cath/PCI. Documentation of the need for an emergent cath can state "discharged for a cath or PCI." The abstractor does not need to know whether both will be performed. {p_end}{p2col:}There must be documentation in the record of ECG interpretation as noted, or documentation of a STEMI, and indication that need for intervention is urgent.'{txt:noami1} {txt:acs_trc} {err:outpci}177tranplan revasc 11Is there documentation of a plan for discharge, i.e., acceptance by the receiving facility and transportation arrangements made?<1,2*{p_end}{p2col:}*If 2, go to transdoc, else go to planactPlan of transfer must be comprised of the two noted parts: the receiving facility must be contacted and agree to accept the patient, and arrangements for transportation must be made.'{txt:noami1} {txt:acs_trc} {err:outpci}178planact revasc 129Does the record document the date the plan was activated?;1,2*{p_end}{p2col:}*If 2, go to plantime, else go to actvdtPPlan activated = the latest date when both components of the plan were completed6{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan}179actvdt revasc 13Enter the date of activation. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable,D{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan} {err:planact}180plantime revasc 149Does the record document the time the plan was activated?;1,2*{p_end}{p2col:}*If 2, go to transdoc, else go to actimePPlan activated = the latest time when both components of the plan were completed6{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan}181actime revasc 15Enter the time of activation._____{p_end}{p2col:}UMT0Time must be entered in universal military time.E{txt:noami1} {txt:acs_trc} {err:outpci} {err:tranplan} {err:plantime}182transdoc revasc 16RWas the date of discharge to another acute care hospital documented in the record?<1,2*{p_end}{p2col:}*If 2, go to trnfrtme, else go to trnfrdtgSource: MD orders, progress notes {p_end}{p2col:}Date of transfer = date patient actually left the VAMC'{txt:noami1} {txt:acs_trc} {err:outpci}183trnfrdt revasc 17;Enter the date of discharge to another acute care hospital. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not applicable.6{txt:noami1} {txt:acs_trc} {err:outpci} {err:transdoc}184trnfrtme revasc 18RWas the time of discharge to another acute care hospital documented in the record?;1,2*{p_end}{p2col:}*If 2, go to pciback, else go to timeoutfSource: MD orders, progress notes{p_end}{p2col:}Time of transfer = time patient actually left the VAMC'{txt:noami1} {txt:acs_trc} {err:outpci}185timeout revasc 19;Enter the time of discharge to another acute care hospital._____{p_end}{p2col:}UMT0Time must be entered in universal military time.6{txt:noami1} {txt:acs_trc} {err:outpci} {err:trnfrtme}186pciback revasc 20QDid the patient return to this VAMC for further inpatient care following the PCI? 1,2{p_end}{p2col:}Go to cabgdoneReturn may be a period of greater than 12 hours or may be several days later. Return assumes that report of the PTCA/PCI will accompany the patient, or there will be communication between clinicians at each of the respective hospitals.'{txt:noami1} {txt:acs_trc} {err:outpci}187ptcadne revasc 21<Was a percutaneous transluminal coronary angioplasty (PTCA/PCI) performed during this episode of care?{p_end}{p2col:}If a PTCA was performed, one of the following codes must be entered in pxcode or othrpxs: 36.01, 36.02, 36.05. If one of these codes is not entered, the "1" answer to this question will not be valid.91*,2{p_end}{p2col:}*If 1, go to firsdt, else go to noptcaPercutaneous transluminal coronary angioplasty is defined as any percutaneous angioplasty procedure (balloon dilation, atherectomy, rotational ablation, etc.) or combination of procedures performed in the infarct-related artery. Cardiac cath alone is not a PTCA.{p_end}{p2col:}If the patient is transferred to a hospital affiliated with this VAMC for a PTCA, returns to this VAMC within 12 hours for further care, and the PTCA report is accessible, answer "1."'{txt:noami1} {txt:acs_trc} {txt:outpci}188noptca revasc 22Is there clinician documentation in the record of a reason why PTCA/PCI was not performed?{p_end}{p2col:}98. patient or family refusal{p_end}{p2col:}2. patient co-morbidities preclude procedure{p_end}{p2col:}3. other reason documented{p_end}{p2col:}99. no documented reason&98,2,3,99{p_end}{p2col:}Go to cabgdone_Clinician = MD (or DO), NP, or PA{p_end}{p2col:}Documentation may include patient or family's refusal to consent to PTCA, documentation that patient co-morbidities likely preclude a successful outcome, or other clinical reason why PTCA is not an option for this patient. The reason why PTCA was not performed must be clearly documented by a clinician.5{txt:noami1} {txt:acs_trc} {txt:outpci} {txt:ptcadne}189firstdt revasc 23EEnter the date of the first PTCA/PCI performed after hospital arrival mm/dd/yyyy]Exact date must be entered. The use of 01 to indicate missing day or month is not acceptable.5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}190baloon3 revasc 24What was the time of the first PTCA/PCI done after hospital arrival? Use the following priority:{p_end}{p2col:}1. Time the wire or balloon reached, passed through, or crossed the lesion{p_end}{p2col:}2. Time of the first balloon inflation (Inflate #1, Balloon ^, #ATM for #minutes, seconds){p_end}{p2col:}3. Time of the first cut or excision of lesion (Cut #1 time, Excimer time, Time rotablade used){p_end}{p2col:}4. Time the balloon, rotablade, or cutter was inserted{p_end}{p2col:}5. Sheath time (Artery time, Cannulation time, Vessel time, Vessel access){p_end}{p2col:}6. Time of lidocaine/procaine injection Infiltration time, Local, Local anesthesia, Xylocaine/procaine injection time{p_end}{p2col:}7. Procedure/case start time (Begin time, Start time)_____{p_end}{p2col:}UMT)"First" PTCA=if more than one PTCA was performed during the episode of care, the first PTCA is the one performed first after arrival at the hospital. {p_end}{p2col:}Use military time. To convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.{p_end}{p2col:}If conflicting times are documented, use the earliest time.{p_end}{p2col:}Use the designated priority order regardless of whether the culprit lesion is a native coronary vessel or a graft.{p_end}{p2col:}If there is documentation on the procedure sheet of "lesion" accompanied solely by a time (e.g., "8:52 - RCA lesion"), assume this is the time the lesion was crossed (1st priority).{p_end}{p2col:}When applying the priority order and there are conflicting times (e.g., two different balloon inflation times), enter the earliest time.{p_end}{p2col:}This question is also applicable to AMI occurring as inpatient since it is assumed the PTCA/PCI would be the first PTCA/PCI performed after hospital arrival.5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}191stentplc revasc 25IWere stents placed during the first PTCA/PCI done after hospital arrival?=1,2*{p_end}{p2col:}*If 2, go to cabgdone, else go to stentnumStents are tiny metal mesh tubes which are placed in the artery after the interventional procedure is performed. The stent acts as a scaffold to provide support inside the artery and helps to prevent restenosis.5{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne}192stentnum revasc 26=Enter the number of stents placed during the first PTCA done.______D{txt:noami1} {txt:acs_trc} {txt:outpci} {err:ptcadne} {err:stentplc}193cabgdone revasc 27Was a CABG performed during this episode of hospitalization?{p_end}{p2col:}1. performed at this VAMC{p_end}{p2col:}2. performed at another VAMC{p_end}{p2col:}3. performed at a community hospital{p_end}{p2col:}99. no CABG performed during this episode of careL1,2,3,99{p_end}{p2col:}*If 99, go to anypx, as applicable, else go to cabgdtIf the patient is transferred to a hospital affiliated with this VAMC for a CABG, and returns to this VAMC for further care, answer "1." {txt:noami1}194cabgdt revasc 28&Enter the date the CABG was performed. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.{txt:noami1} {txt:cabgdone 99}195anypx revasc 29IWas any invasive procedure performed during this episode of care for AMI?=1,2*{p_end}{p2col:}*If 2, go out of module, else go to pxcodeProcedures=invasive procedures requiring some form of anesthesia including local. May be cardiac catheterization, CABG, or other procedure not related to the AMI.9{txt:noami1} {txt:outpci} {txt:ptcadne} {err:cabgdone 99}196pxcode revasc 30OWhat was the ICD-9-CM code selected as the principal procedure for this record?--. --wPrincipal procedure= that procedure performed for definitive treatment, rather than for diagnostic or exploratory reasons, or was necessary to treat a complication. The principal procedure is related to the principal diagnosis.{p_end}{p2col:}Percutaneous Transluminal Coronary Angioplasty{p_end}{p2col:}36.01: Single vessel PTCA or coronary atherectomy without mention of thrombolytic agent{p_end}{p2col:}36.02: Single vessel PTCA or coronary atherectomy with mention of thrombolytic agent{p_end}{p2col:}36.05: Multiple vessel PTCA or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent{p_end}{p2col:}If the patient had a PTCA with stent placement (code 36.06) enter the applicable code for the PTCA, not the stent placement. {p_end}{p2col:}If PTCA is not the principal diagnosis, use the principal diagnosis code assigned by the VAMC.{txt:noami1} {err:anypx}197othrsdne revasc 31DWere other procedures performed during this episode of care for AMI?<1,2*{p_end}{p2col:}*If 2, go to prinpxdt, else go to othrpxsOther procedures=invasive procedure requiring a form of anesthesia including local. May be PTCA, if not designated as the principal diagnosis, cardiac cath, CABG, or other unrelated procedure.{txt:noami1} {err:anypx}198othrpxs_ revasc 32RWhat were the ICD-9-CM code(s) selected as the other procedure(s) for this record?k(1) --. --{p_end}{p2col:}(2) --. -{p_end}{p2col:}(3) --. -{p_end}{p2col:}(4) --. -{p_end}{p2col:}(5) --. --hEnter the ICD-9-CM codes identifying all significant procedures other than the principal procedure. Enter up to five other procedure codes.{p_end}{p2col:}Begin with the first procedure performed after hospital arrival.{p_end}{p2col:}If the patient had a PTCA with stent placement (code 36.06) enter the applicable code for the PTCA, not the stent placement.{p_end}{p2col:}Be alert for the following codes which should be present in the record and entered as either the principal or other procedures, if the procedure was performed: Cardioversion 99.62; CABG 36.10 - 36.19; Pacemaker 37.80, 37.83, 39.64, 37.81, 37.78'{txt:noami1} {err:anypx} {err:othrsdne}199prinpxdt revasc 33-What was the date of the principal procedure? mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.{txt:noami1} {err:anypx}200othrdts_ revasc 348What were the dates the other procedures were performed.)mm/dd/yyyy{p_end}{p2col:}Up to five datesEnter the dates corresponding to each of the other procedures performed, beginning with the first procedure performed after hospital arrival. Up to five other dates may be entered.'{txt:noami1} {err:anypx} {err:othrsdne}201trans24ccare 1^Was the patient transferred to another acute care hospital on the day of arrival at this VAMC?91*,2{p_end}{p2col:}*If 1, go out of ACS, else go to amadcDay of arrival = on the same date as the day of arrival{p_end}{p2col:}VAMCs are required to "discharge" rather than "transfer" patients to another facility. {txt:noami2}202amadcccare 2PDid the patient leave against medical advice on the day of arrival at this VAMC?;1*,2{p_end}{p2col:}*If 1, go out of ACS, else go to arrvexp7Day of arrival = on the same date as the day of arrival{txt:noami2} {txt:trans24}203arrvexpccare 3:Did the patient expire on the day of arrival at this VAMC?<1*,2{p_end}{p2col:}*If 1, go out of ACS, else go to nogpbloc7Day of arrival = on the same date as the day of arrival&{txt:noami2} {txt:trans24} {txt:amadc}204 nogpbloc1ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}1. active internal bleeding or history of bleeding within 30 days-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}205 nogpbloc2ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}2. history of intracranial hemorrhage-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}206 nogpbloc3ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}3. intracranial neoplasm-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}207 nogpbloc4ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}4. arteriovenous malformation or aneurysm-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}208 nogpbloc5ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}5. history of thrombocytopenia after previous exposure to GP IIb/IIIa inhibitors-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}209 nogpbloc6ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}6. history of ischemic stroke within 30 days or any history of hemorrhagic stroke-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}210 nogpbloc7ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}7. major surgery or severe trauma within the previous 30 days-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}211 nogpbloc8ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}8. history, symptoms, or findings suggestive of aortic dissection-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}212 nogpbloc9ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}9. severe hypertension (SBP >180 and/or DBP >90), unless corrected prior to administration-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}213 nogpbloc10ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}10. acute pericarditis-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}214 nogpbloc11ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}11. concomitant use of GP IIb/IIIa inhibitor-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}215 nogpbloc98ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}98. patient refused a glycoprotein IIb/IIIa inhibitor-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}216 nogpbloc99ccare 4Does the record document any of the following contraindications to GP IIb/IIIa inhibitors?{p_end}{p2col:}99. no documented contraindication-1,0The most common adverse drug reactions associated with GP IIb/IIIa inhibitors are both major and minor bleeding and acute profound thrombocytopenia. Acute profound thrombocytopenia is defined as platelet count dropping to less than 50,000/mm within 24 hours of infusion.{p_end}{p2col:}If the patient has a documented diagnosis of acute pericarditis, intracranial neoplasm, arteriovenous malformation or aneurysm, ischemic stroke within the past 30 days or history of any hemorrhagic stroke, the abstractor may accept these as contraindications to use of a GP IIb/IIIa inhibitor without other documentation.{p_end}{p2col:}All other contraindications require notation by a clinician of their occurrence.{txt:noami2} {err:dc1day 0}217gpblocccare 5Did the patient receive a glycoprotein IIb/IIIa inhibitor?{p_end}{p2col:}1. tirofiban (Aggrastat){p_end}{p2col:}2. eptifibatide (Integrilin){p_end}{p2col:}3. abciximab (ReoPro){p_end}{p2col:}99. none of these medicationsC1,2,3,99*{p_end}{p2col:}*If 99, go to reangina, else go to glycodocCurrent data from at least 10 randomized, placebo-controlled, double-blind trials in ACS indicate that intravenous glycoprotein IIb/IIIa inhibitor therapy has a beneficial effect (reduction in death, MI, or revascularization) when used with patients with UA/NSTEMI. However, there is not yet consensus for their routine use in all patients with UA/NSTEMI.{p_end}{p2col:}Glycoprotein IIb/IIIa inhibitors are administered IV.{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0}218glycodocccare 6XIs the date the patient received a glycoprotein IIb/IIIa inhibtor entered in the record?=1,2*{p_end}{p2col:}*If 2, go to gptmedoc, else go to gpblocdt}Glycoprotein IIb/IIIa inhibitors are administered IV. Look in nursing IV medication administration records for date and time.>{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99}219gpblocdtccare 7TEnter the date the patient received a glycoprotein{p_end}{p2col:}IIb/IIIa inhibitor. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.M{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99} {err:glycodoc}220gptmedocccare 8YIs the time the patient received a glycoprotein IIb/IIIa inhibitor entered in the record?<1,2*{p_end}{p2col:}*If 2 go to reangina, else go to gpbloctmVThe exact time of administration of the glycoprotein IIb/IIIa inhibitor must be known.>{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99}221gpbloctmccare 9SEnter the time the patient received a glycoprotein{p_end}{p2col:}IIb/IIIa inhibtor._____{p_end}{p2col:}UMTEnter time in military time.M{txt:noami2} {err:dc1day 0} {txt:nogpbloc99 0} {txt:gpbloc 99} {err:gptmedoc}222reanginaccare 10NAt any time during the hospitalization, did the patient have recurrent angina?<1,2*{p_end}{p2col:}*If 2, go to advrsent, else go to reangdt{Recurrent angina is defined as: chest pain or severe epigastric pain, non-traumatic in origin; central/substernal compression or crushing chest pain; pressure, tightness, heaviness, cramping, burning or aching sensation; unexplained indigestion, belching, epigastric pain; radiating pain in neck, jaw, shoulders, back, 1 or both arms; dyspnea; nausea and/or vomiting; diaphoresis{txt:noami2} {err:dc1day 0}223reangdt_ccare 11\Enter the date the episode(s) of angina occurred. (A maximum of three dates may be entered.)<mm/dd/yyyy{p_end}{p2col:}mm/dd/yyyy{p_end}{p2col:}mm/dd/yyyy]Exact date must be entered. The use of 01 to indicate missing day or month is not acceptable.*{txt:noami2} {err:dc1day 0} {err:reangina}224 advrsent1ccare 12zAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}1. reinfarction/AMI patient mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}225 advrsent2ccare 12rAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}2. cardiogenic shock mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}226 advrsent3ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}3. left ventricular failure requiring use of intra-aortic balloon pump (IABP) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}227 advrsent4ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}4. life-threatening arrhythmia requiring synchronized cardioversion mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}228 advrsent5ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}5. ventricular tachycardia or ventricular fibrillation requiring defibrillation (emergent cardioversion) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}229 advrsent6ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}6. High-risk bradycardia requiring transvenous pacemaker insertion mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}230 advrsent7ccare 12oAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}7. cardiac arrest mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}231 advrsent8ccare 12tAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}8. atrial fibrillation mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}232 advrsent9ccare 12At any time during this episode of care, did any of the following events occur?{p_end}{p2col:}9. blood transfusion (whole blood or packed red cells only) mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation#{txt:noami2} {err:dc1day 0} {res:m}233 advrsent99ccare 12vAt any time during this episode of care, did any of the following events occur?{p_end}{p2col:}99. none of these events mm/dd/yyyyReinfarction/AMI patient: occurrence of further vessel occlusion and cardiac muscle damage in patient admitted and treated for AMI{p_end}{p2col:}Cardiogenic shock is characterized by a low blood pressure (generally less than 90 mm/Hg) with signs of hypoperfusion such as cool clammy skin, oliguria, or altered sensorium.{p_end}{p2col:}The abstractor may not make this determination. The diagnosis of cardiogenic shock must be documented by a clinician.{p_end}{p2col:}Intra-aortic balloon pump is placed within the patient's descending aorta. The balloon inflates and deflates with each cardiac cycle. the purpose of the IABP is to allow the heart muscle to rest and improve perfusion to the coronary arteries.{p_end}{p2col:}Cardioversion=the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. {p_end}{p2col:}Synchronized cardioversion=the delivery of a synchronised external electrical impulse via the chest wall in order to revert an arrythmia to sinus rhythm. The current is delivered at a pre-determined point in the cardiac cycle. Patient is prepared and anaesthetized.{p_end}{p2col:}Emergent=unsynchronized/defibrillation indicated by ventricular tachycardia or ventricular fibrillation{txt:noami2} {err:dc1day 0}234 stroksym1ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}1. disturbances of consciousness-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}235 stroksym2ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}2. loss of limb movement or speech-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}236 stroksym3ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}3. lethargy-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}237 stroksym4ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}4. unresponsiveness-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}238 stroksym5ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}5. slurred speech-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}239 stroksym6ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}6. other-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}240 stroksym99ccare 13At any time during this episode of care, did the patient have any of the following neurological symptoms?{p_end}{p2col:}99. no documented neurological symptoms-1,0ZNeurological symptoms must be documented by an MD, NP, or PA. Do not take information from nurses notes unless there is corroborating information documented in progress notes or elsewhere by an MD, NP, or PA.{p_end}{p2col:}If the patient had none of the listed symptoms and no symptoms that could be construed as neurological, enter response #99.{txt:noami2} {err:dc1day 0}241strokeccare 14GAt any time during this episode of care, did the patient have a stroke?<1,2*{p_end}{p2col:}*If 2, go to smokcigs, else go to strokdt[The diagnosis of stroke must be recorded in the medical record by an MD (or DO), NP, or PA.{txt:noami2} {err:dc1day 0}242strokdtccare 15#Enter the date the stroke occurred. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.({txt:noami2} {err:dc1day 0} {err:stroke}243scandoneccare 16$Was a CT scan, MRI, or MRA obtained?1,2CT scan=computed tomography{p_end}{p2col:}MRI=magnetic resonance imaging{p_end}{p2col:}MRA = magnetic resonance arteriogram{p_end}{p2col:}Procedures used to detect blood vessel defects in the brain({txt:noami2} {err:dc1day 0} {err:stroke}244wichtypeccare 17Does the record document the type of stroke?{p_end}{p2col:}1. hemorrhagic{p_end}{p2col:}2. thromboembolic (ischemic){p_end}{p2col:}3. thromboembolic with hemorrhagic conversion{p_end}{p2col:}4. other/unknown{p_end}{p2col:}99. type of stroke not documented 1,2,3,4,99DType of stroke must be documented in the record by an MD, NP, or PA.({txt:noami2} {err:dc1day 0} {err:stroke}245smokcigsccare 18Does the record document the patient smoked cigarettes any time during the year prior to hospital arrival?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}Z. not documented or not assessedF1,2*, Z* {p_end}{p2col:}*If 2 or Z, go to testress, else go to tobcessThis question refers only to smoking cigarettes and is not pertinent to other forms of tobacco. If conflicting information is documented in the record, use the worst case. (Example: one record entry states patient is a smoker, another entry states patient quit two years ago - consider the patient uses tobacco.) If the record states the patient was a 30-pack/year smoker, and there is no statement that the patient quit smoking, consider the patient a smoker. {p_end}{p2col:}Year prior to hospital arrival = from the date of arrival to the first day of the same month one year previously{p_end}{p2col:}Z=the use of cigarettes during the year prior to hospital arrival was not assessed, or if assessed, was not documented in the record. It is considered the patient was not screened for use of tobacco. {p_end}{p2col:}If the patient was asked about smoking/use of tobacco, and used a form of tobacco other than cigarettes during the past year, answer "2."{txt:noami2} {err:dc1day 0}246tobcessccare 19fDid the patient receive smoking/tobacco use cessation advice or counseling during the hospitalization?1,2Adult Smoking Counseling:{p_end}{p2col:}Documentation indicating the patient received one of the following:{p_end}{p2col:}Advice to stop smoking (stop using tobacco) whether or not the patient is a current smoker{p_end}{p2col:}Viewing a tobacco use cessation video{p_end}{p2col:}Given brochure or handouts on tobacco use cessation{p_end}{p2col:}Referred to a smoking cessation class or clinic{p_end}{p2col:}Prescribed a smoking cessation aid such as Nicoderm or Zyban (bupropion.){p_end}{p2col:}If the patient smoked within the year prior to arrival but does not currently smoke, they should still be advised not to smoke. Cessation counseling is still required.{p_end}{p2col:}Respond "1" if patient was given advice, a brochure, pamphlet, or video relative to smoking cessation even if the patient uses another form of tobacco.{p_end}{p2col:}2 = advice/counseling not done, or unable to determine from medical record documentation,{txt:noami2} {err:dc1day 0} {err:smokcigs 1}247testressccare 20Were any of the following non-invasive stress tests for myocardial ischemia performed during this episode of care?{p_end}{p2col:}1. exercise ECG alone{p_end}{p2col:}2. exercise myocardial perfusion thallium imaging {p_end}{p2col:}3. exercise myocardial perfusion Sestamibi imaging{p_end}{p2col:}4. myocardial perfusion imagining by pharmacolgic stress {p_end}{p2col:}5. exercise ventricular function imaging by echocardiography{p_end}{p2col:}6. resting radionuclide angiography (MUGA, Gated Cardiac Scan, Gated Blood Pool Scan){p_end}{p2col:}98. patient's direct refusal of stress-testing documented in record{p_end}{p2col:}99. non-invasive stress testing not performed during episode of cares1,2,3,4,5,6,98*,99**{p_end}{p2col:}*If 98, go to cathdun{p_end}{p2col:}**If 99, go to strespln, else go to stressdt[Patients with an uncomplicated MI may undergo a non-invasive evaluation for ischemia to identify increased cardiovascular risk prior to discharge from the hospital. Applies to both ST-elevation MI and NSTEMI.{p_end}{p2col:}Documentation by the MD, NP or PA in the progress notes that a stress test was done either at the VAMC or elsewhere should be accepted. Documentation of the report in the radiology package is also acceptable.{p_end}{p2col:}1. Exercise ECG alone: ECG is done while the patient performs physical activity on a treadmill or bicycle. {p_end}{p2col:}2. Activity usually performed on a treadmill. Isotope tracer thallium injected one to two minutes before end of exercise or immediately thereafter. Heart is imaged both immediately following exercise and at rest.{p_end}{p2col:}3. Same procedure as thallium imaging, with resting images of heart done prior to treadmill exercise{p_end}{p2col:}4. For patients unable to exercise, cardiac effects of exercise stress are simulated by administration of coronary dilator dipyridamole, adenosine or dobutamine infusion.{p_end}{p2col:}5. Measures the contractile (pumping) function of the heart muscle during exercise{p_end}{p2col:}6. Following injection of radioactive medication, recordings of the heart wall at work are synchronized with the EKG. Evaluates the heart's pumping function and ejection fraction.{txt:noami2} {err:dc1day 0}248stressdtccare 21,Enter the date the stress test was performed mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.0{txt:noami2} {err:dc1day 0} {txt:testress 98 99}249stresoutccare 227Enter the result of the stress test {p_end}{p2col:}1. indicative of high risk for further ischemic events{p_end}{p2col:}2. indicative of moderate risk for further ischemic events{p_end}{p2col:}3. indicative of low risk for further ischemic events{p_end}{p2col:}4. equivocal{p_end}{p2col:}99. unable to determine&1,2,3,4,99{p_end}{p2col:}Go to cathdunStress test results must be documented by an MD, NP, or PA.{p_end}{p2col:}Equivocal = unclear, ambiguous, uncertain{p_end}{p2col:}Evidence of ischemia during a stress echocardiogram is an inducible wall motion abnormality during stress.0{txt:noami2} {err:dc1day 0} {txt:testress 98 99}250stresplnccare 23BDoes the record document a plan for post-discharge stress testing?1,2There must be documented evidence that a post-discharge non-invasive stress test was planned, although a definitive appointment date is not required.-{txt:noami2} {err:dc1day 0} {err:testress 99}251cathdunccare 24vWas a diagnostic cardiac catheterization performed during this episode of care?{p_end}{p2col:}1. cath done at this VAMC (or patient sent out for cath and returned in 12 hours){p_end}{p2col:}2. transferred to another VAMC for cath{p_end}{p2col:}3. transferred to a community hospital for cath{p_end}{p2col:}4. documentation by cardiology that stress test is more reasonable first approach for this patient{p_end}{p2col:}5. documentation by cardiology of known coronary artery lesion(s) not amenable to revascularization{p_end}{p2col:}98. patient's direct refusal of cardiac cath documented in record{p_end}{p2col:}99. cath not done1*,2,3,4,5,98**,99**{p_end}{p2col:}If 1, go to datedone{p_end}{p2col:}**If 4, 5, or 98, go to lvfami{p_end}{p2col:}**If 99, go to plancath, else go to cathbackThis question does not refer to the cardiac cath done in conjunction with a PTCA/PCI. The query is whether a diagnostic cardiac cath was performed, even if the patient had a PCI shortly after admission. They are to be considered two different procedures. {p_end}{p2col:}Cardiac catheterization = an invasive procedure in which a thin plastic tube (catheter) is inserted into an artery or vein in the arm or leg. From there it can be advanced into the chambers of the heart or the coronary arteries. The test can measure blood pressure within the heart, how much oxygen is in the blood, and the pumping ability of the heart muscle. When dye is injected into the coronary arteries, the procedure is called coronary angiography or coronary arteriography. The procedure produces special pictures that can reveal if one or more of the coronary arteries are blocked or if the left ventricle is functioning properly. Cardiac cath without treatment of coronary artery blockages is diagnostic. {p_end}{p2col:}If patient was sent out for a cath and returned in 12 hours, it is considered the same as being done at this VAMC.{p_end}{p2col:}Responses #4 and 5 must be documented in the record by a cardiologist, cardiology fellow, or cardiology resident under appropriate supervision by the attending physician.{txt:noami2} {err:dc1day 0}252cathbackccare 25RDid the patient return to this VAMC for further inpatient care following the cath?1,2{p_end}{p2col:}Go to lvfamiReturn may be a period of greater than 12 hours or may be several days later. Return assumes that report of the cath will accompany the patient, or there will be communication between clinicians at each of the respective hospitals.-{txt:noami2} {err:dc1day 0} {err:cathdun 2 3}253datedoneccare 26DIs the date the cardiac cath was performed documented in the record?<1,2*{p_end}{p2col:}*If 2, go to cathrep, else go to entrdoneVIf more than one cardiac cath was performed, use the date of the first cath performed.end+{txt:noami2} {err:dc1day 0} {err:cathdun 1}254entrdoneccare 27.Enter the date the cardiac cath was performed. mm/dd/yyyyDEnter the exact date. Do not use 01 to indicate missing day or month:{txt:noami2} {err:dc1day 0} {err:cathdun 1} {err:datedone}255cathrepccare 28Enter the result of the cardiac catheterization:{p_end}{p2col:}1 Evidence of obstructive CAD{p_end}{p2col:}2. No evidence of obstructive CAD{p_end}{p2col:}99. Unable to determine.1,2,99hEvidence of obstructive CAD: >50% left main stenosis and/or > 70% stenosis of a major epicardial artery.+{txt:noami2} {err:dc1day 0} {err:cathdun 1}256plancathccare 29KDoes the record document a plan for cardiac catheterization post-discharge?1,2There must be documented evidence that a post-discharge cardiac catherization was planned, although a definitive appointment date is not required..{txt:noami2} {err:dc1day 0} {err:cathdun 1 99}257lvfamiccare 30Is there documentation in the record that the patient's LVF (left ventricular function) was assessed prior to arrival or during the hospital stay?;1,2*{p_end}{p2col:}*If 2, go to wtdone, else go to efornarrCSee question "efornarr" for tests used to determine LVF.{p_end}{p2col:}LVF may be taken from any knowledge of past EF or LVSD (left ventricular systolic dysfunction) documented in the record. The LVF may also be referred to as "wall motion" or "systolic function."{p_end}{p2col:}BNP blood test is not an assessment for LVF.end{txt:noami2} {err:dc1day 0}258efornarrccare 31Does the record document the patient has a left ventricular ejection fraction less than 40% or a narrative description of moderate or severe systolic dysfunction?{p_end}{p2col:}1. LVEF < 40%, or narrative description moderate or severe systolic dysfunction{p_end}{p2col:}2. LVEF 40% or >,or narrative description not consistent with moderate or severe systolic dysfunction {p_end}{p2col:}99. unable to determine from medical record documentation1,2,99Tests used to determine left ventricular function = echocardiogram, radionuclide ventriculography (MUGA, RNV, nuclear heart scan, nuclear gated blood pool scan) stress myocardial perfusion scan (thallium scan) or cardiac cath. Ejection fraction is a ballpark figure - not a precise measurement. EF may be taken from any knowledge of past EF or LVSD (left ventricular systolic dysfunction) documented in the record. The lvf may also be referred to as "wall motion" or "systolic function."{p_end}{p2col:}Suggested Data Sources: consultant notes, diagnostic test reports, discharge summary, ED notes, H&P, nurses notes, progress notes {p_end}{p2col:}Note: If systolic function is described as mild to moderate, use response #2.({txt:noami2} {err:dc1day 0} {err:lvfami}259lvfdtdocccare 32gIs the date of the test that measured the patient's left ventricular function documented in the record?;1,2*{p_end}{p2col:}*If 2, go to wt done, else go to eftstdtgThis question has changed to ask the date the EF was measured. The year the test was done is acceptable at a minimum. {p_end}{p2col:}Tests used to determine left ventricular function = echocardiogram, radionuclide ventriculography (MUGA, RNV, nuclear heart scan, nuclear gated blood pool scan) stress myocardial perfusion scan (thallium scan) or cardiac cath.({txt:noami2} {err:dc1day 0} {err:lvfami}260eftstdtccare 33!Enter the date the test was done. mm/dd/yyyyYear is acceptable at a minimum if the left ventricular function was assessed in the past prior to hospitalization, and this is the only date available. Enter exact day and month if test was recent and dates are available.7{txt:noami2} {err:dc1day 0} {err:lvfami} {err:lvfdtdoc}261wtdoneccare 347Is the patient's weight recorded in the medical record?:1,2*{p_end}{p2col:}*If 2, go to nutrisk, else go to wtdateSources: Nursing admission assessment or other information from the inpatient or outpatient record. Assessment form and notes by Dietary Service are a good source of weight and height data.{p_end}{p2col:}If the patient was weighed at admission or during hospitalization, use this weight. Otherwise use most recent notation of weight found in the outpatient record. If more than one weight is recorded during the most recent encounter, and the weights differ, use the lowest weight.{txt:noami2} {err:dc1day 0}262wtdateccare 35KEnter the most recent date the patient's weight was recorded in the record. mm/dd/yyyypDay may be entered as 01, if exact date is unknown. At a minimum, the month and year must be entered accurately.({txt:noami2} {err:dc1day 0} {err:wtdone}263entrwtccare 361Enter the patient's weight recorded on that date._____Use the weight recorded during hospitalization if patient was weighed. If more than one weight is recorded during the most recent encounter, and the weights differ, use the lowest weight.({txt:noami2} {err:dc1day 0} {err:wtdone}264entrunitccare 37DUnit of measure{p_end}{p2col:}1 = pounds{p_end}{p2col:}2 = kilograms1,2BMI is calculated in kilograms. If pounds are entered, the computer will convert pounds to kilograms in making the calculation. The resulting BMI is displayed on the computer screen.({txt:noami2} {err:dc1day 0} {err:wtdone}265htdoneccare 383Is patient's height recorded in the medical record?:1,2*{p_end}{p2col:}*If 2, go to nutrisk, else go to entrht>No time period applies to this element. {p_end}{p2col:}If more than one height is recorded, use the most recent.{p_end}{p2col:}EKG readings may be a source of height data, although accuracy of the recorded height may be in question. Use this data if no other height can be found in the inpatient or outpatient records.({txt:noami2} {err:dc1day 0} {err:wtdone}266entrhtccare 39Enter the patient's height._____uHeight must be entered wholly in inches or centimeters. If pt. is 5 feet 8 inches, enter 68. 5ft = 60 in. 6ft = 72in.5{txt:noami2} {err:dc1day 0} {err:wtdone} {err:htdone}267entrmeasccare 40FUnit of measure{p_end}{p2col:}1 = inches{p_end}{p2col:}2 = centimeters1,2uHeight must be entered wholly in inches or centimeters. If pt. is 5 feet 8 inches, enter 68. 5ft = 60 in. 6ft = 72in.5{txt:noami2} {err:dc1day 0} {err:wtdone} {err:htdone}268ptdcdisch 1lEnter the patient's discharge status:{p_end}{p2col:}1. discharged to home care or self care (routine discharge){p_end}{p2col:}2. discharged/transferred to another short term general hospital for inpatient care{p_end}{p2col:}3. discharged/transferred to a skilled nursing facility{p_end}{p2col:}4. discharged/transferred to an intermediate care facility{p_end}{p2col:}5. discharged/transferred to another type of institution for inpatient care {p_end}{p2col:}6. discharged/transferred to home under care of organized home health service organization{p_end}{p2col:}7. left against medical advice or discontinued care{p_end}{p2col:}8. discharged/transferred to home under care of home IV drug therapy provider{p_end}{p2col:}20. expired (or did not recover-Christian Science patient){p_end}{p2col:}41. expired in medical facility, such as hospital, SNF, ICF, or freestanding hospice{p_end}{p2col:}50. hospice - home{p_end}{p2col:}51. hospice - medical facility{p_end}{p2col:}61. discharged/transferred within this institution to hospital-based Medicare approved swing bed{p_end}{p2col:}62. Discharged/transferred to another rehabilitation facility including rehabilitation distinct parts of a hospital{p_end}{p2col:}63. Discharged/transferred to a long-term care hospital{p_end}{p2col:}64. Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare1,2*,3,4,5,6,7*,8,,20*{p_end}{p2col:}41*,50*,51*,61,62,63,{p_end}{p2col:}64{p_end}{p2col:}*If 2, 7, 20, 41, 50, or 51, go to end, else go to finalecgOther non-acute setting = nursing home, Domiciliary, rehabilitation, or other setting where care continues at a lesser level{p_end}{p2col:}To respond "2," it must be known the "other" hospital is an acute-care facility, and the patient's anticipated admission is the same day as discharge from the VAMC.{p_end}{p2col:}To respond "7," a signed AMA document, or progress note by an MD, NP, or PA must appear in the record.{p_end}{p2col:}Response #41 is applicable only for Medicare and CHAMPUS`Hospice care and does not apply to VHA Hospice patients.{p_end}{p2col:}If uncertain of the patient's disposition, ask help from the EPRP Liaison, since accurate discharge status affects the remainder of the AMI questions.end{txt:noami2} {err:dc1day 0}269finalecgdisch 2yWhat were the specific findings from interpretation of the last 12-lead ECG performed prior to discharge?{p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}97. no ECG done during entire episode of care {p_end}{p2col:}99. none of above-listed ECG findings documented in recordU1,2,3,4,5,6,7,8,9,10,11,97*,99{p_end}{p2col:}*If 97, go to acetrial, else go to ekgdtDo Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.coding: categories&{txt:noami2} {err:dc1day 0} {txt:nodc}270ekgdtdisch 3!Enter the date this ECG was done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable.8{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:finalecg 97}271acetrialdisch 4Does the record document that at discharge, the patient was participating in a clinical trial, testing alternatives to ACEI as first-line heart failure therapy?=1*,2{p_end}{p2col:}*If 1, go to aspdcnot, else go to noacewhy2 = not participating in ACEI clinical trial, or unable to determine from medical record documentation{p_end}{p2col:}Note: this question does not mean the patient was prescribed an ACE inhibitor. Testing alternatives means the use of drugs OTHER THAN ACEI for heart failure therapy.&{txt:noami2} {err:dc1day 0} {txt:nodc}272noacewhydisch 5Does the record document any of the following ACEI contraindications?{p_end}{p2col:}1. ACEI allergy{p_end}{p2col:}5. Moderate or severe aortic stenosis{p_end}{p2col:}6. Other reasons documented by an MD, NP, or PA for not prescribing an ACEI at discharge{p_end}{p2col:}98. patient's direct refusal to take ACE inhibitor documented in record{p_end}{p2col:}99. No documented contraindicationS1*,5*,6*,98*,99{p_end}{p2col:}*If 1, 5, 6, or 98, go to aspdcnot, else go to aceidcOption Rules:{p_end}{p2col:}1. ACE allergy = must be specific reference in the record to ACE allergy or sensitivity. Also includes history of angioedema, hives, or rash with ACEI use.{p_end}{p2col:}5. Aortic stenosis = listing of this diagnoses, with the description of moderate or severe, in the record is acceptable. Includes both a current finding or a history of moderate or severe aortic stenosis without mention of repair, replacement, valvuloplasty, or commissurotomy.{p_end}{p2col:}6. Other reasons = must be documentation by MD, NP, or PA which explicitly links the noted reason with non-prescription of an ACE inhibitor. (Examples of other reasons for not prescribing an ACEI are diagnosis of renal artery stenosis, chronic renal dialysis, pregnancy, serum potassium > 5.5 Eq/L that cannot be reduced, or symptomatic hypotension, documented by the MD, NP, or PA as specific reasons for non-use of an ACEI.) {p_end}{p2col:}If the patient is on hydralazine and nitrates, and the record documents this drug therapy is a better option than ACEI for the patient, this documentation is to be accepted as "other reason" and will be considered a contraindication.reword5{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial}273aceidcdisch 6WWas an angiotensin converting enzyme inhibitor (ACE inhibitor) prescribed at discharge?;1,2*{p_end}{p2col:}*If 2, go to arbatdc, else go to onacedc}Enter response #2 if either an ACEI was not prescribed at discharge, or unable to determine from medical record documentationG{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial} {err:noacewhy 99}274onacedcdisch 7Designate the ACE inhibitor prescribed at discharge.{p_end}{p2col:}PBM/MAP{p_end}{p2col:}1. enalapril{p_end}{p2col:}2. captopril{p_end}{p2col:}3. lisinopril{p_end}{p2col:}5. fosinopril{p_end}{p2col:}9. ramipril{p_end}{p2col:}Other than PBM/MAP{p_end}{p2col:}4. benazepril{p_end}{p2col:}6. quinapril{p_end}{p2col:}7. perindopril{p_end}{p2col:}8. moexipril{p_end}{p2col:}10. trandolapril{p_end}{p2col:}11. other41,2,3,4,5,6,7,8,9,10,11{p_end}{p2col:}Go to aspdcnot"Prescribed for this patient at discharge" = patient may or may not have been on this medication during hospitalization, and it was either continued or prescribed at the time of discharge.{p_end}{p2col:}If the patient is taking an ace inhibitor with the addition of a diuretic or calcium channel blocker, consider only the ace inhibitor. (Example: lisinopril/hydrochlorothiazide, trandolapril/verapamil)T{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial} {err:noacewhy 99} {err:aceidc}275arbatdcdisch 8XWas an was an angiotensin II receptor antagonist (ARB or AIIRA) prescribed at discharge?1,2"Prescribed for this patient at discharge" = ARB or AIIRA was either continued or prescribed at the time of discharge.{p_end}{p2col:}Generic name: losartan potassium Brand name: Cozaar; others include valsartan, irbesartan, candesartan, telmisartan, eprosartan, and olmesartanbeginT{txt:noami2} {err:dc1day 0} {txt:nodc} {txt:acetrial} {err:noacewhy 99} {txt:aceidc}276aspdcnotdisch 9"Is there documentation in the record the patient has one of the following contraindications or reasons for not prescribing aspirin at discharge:{p_end}{p2col:}1. aspirin allergy{p_end}{p2col:}2. active bleeding on arrival or during hospital stay{p_end}{p2col:}3. Warfarin/Coumadin prescribed at discharge{p_end}{p2col:}4. Other reasons documented by MD, NP, or PA{p_end}{p2col:}for not prescribing aspirin at discharge{p_end}{p2col:}98. patient's direct refusal to take aspirin documented in record{p_end}{p2col:}99.No documented contraindicationW1*,2*,3*,4*,98*,99{p_end}{p2col:}*If 1,2,3,4, or 98, go to platagdc, else go to asarxdc[99 = There is no documentation of contraindications/reasons for not prescribing aspirin at discharge, or unable to determine from medical record documentation{p_end}{p2col:}Allergy to aspirin = vasomotor rhinitis with profuse watery secretions, angioedema, generalized urticaria, bronchoconstriction (shortness of breath and wheezing), or laryngeal edema. History of allergy, sensitivity, reaction, or intolerance to aspirin also includes medications which contain aspirin. Gastrointestinal reactions are not considered true allergy to aspirin.{p_end}{p2col:}"Other reasons" documented by MD, NP, or PA must explicitly link the noted reason with non-prescription of aspirin. If the patient is taking clopidogrel (Plavix) or ticlopidine hydrochloride (Ticlid), clinician documentation must specify the use of this drug is the reason aspirin was not prescribed.&{txt:noami2} {err:dc1day 0} {txt:nodc}277asarxdcdisch 100Was the patient prescribed aspirin at discharge?1,2?Enter response #2 if aspirin was not prescribed at discharge, or unable to determine from medical record documentation.{p_end}{p2col:}"Prescribed at discharge" also means recommended or instructed to take aspirin. OTC is equivalent to "prescribed," but the instructions to take aspirin must be documented in the record.8{txt:noami2} {err:dc1day 0} {txt:nodc} {err:aspdcnot 99}278platagdcdisch 11Was the patient prescribed a platelet aggregation inhibitor at discharge? {p_end}{p2col:}1. clopidogrel (Plavix){p_end}{p2col:}2. ticlopidine (Ticlid){p_end}{p2col:}3. dipyridamole (Persantine){p_end}{p2col:}4. dipyridamole and aspirin (Aggrenox){p_end}{p2col:}98. patient's direct refusal to take platelet aggregation inhibitor documented in record{p_end}{p2col:}99. none of these medications 1,2,3,4,98,99Clopidogrel and ticlopidine are inhibitors of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in patients with established athererosclerotic cardiovascular disease as evidenced by stroke, TIAs, and AMI. Patients who have a true allergy to aspirin and no contraindication to antiplatelet therapy may be given clopidogrel, ticlopidine, or dypyridamole.&{txt:noami2} {err:dc1day 0} {txt:nodc}279hepondcdisch 12Was the patient prescribed low molecular weight heparin at discharge?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}98. patient refused LMWH at discharge1,2,98Low molecular weight heparins are available as subcutaneous injections. Regular monitoring by blood test is not required for LMWH. The does is determined by body weight and correlates well with the desired anticoagulant effect.{p_end}{p2col:}LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).&{txt:noami2} {err:dc1day 0} {txt:nodc}280nodcbbdisch 13Does the record document one or more of the following contraindications/reasons for not prescribing a beta blocker at discharge?{p_end}{p2col:}1. Beta blocker allergy{p_end}{p2col:}2. Bradycardia (heart rate less than 60 bpm) on day of discharge or day prior to discharge while not on a beta blocker{p_end}{p2col:}3. Second or third degree heart block on ECG on arrival or during hospitalization and does not have a pacemaker{p_end}{p2col:}4. Systolic blood pressure less than 90 mm HG on day of discharge or day prior to discharge while not on a beta blocker{p_end}{p2col:}5. Other reasons documented by an MD, NP, or PA for not prescribing a beta blocker at discharge{p_end}{p2col:}9. Post-heart transplant patient{p_end}{p2col:}10. Severely decompensated heart failure, as evidenced by patient receiving IV dobutamine, milrinone, or nesiritide during acute care{p_end}{p2col:}98. patient's direct refusal to take beta blocker documented in record{p_end}{p2col:}99.No documented contraindication1*,2*,3*,4*,5*,9*,10*{p_end}{p2col:}98*,99{p_end}{p2col:}*If 1,2,3,4,5,9, 10, or 98, go to cardfolo (as applicable), else go to blkatdc:Contraindication = a factor or condition that renders the administration of a drug or agent or the performance of a procedure or other practice inadvisable, improper, and/or undesirable.{p_end}{p2col:}Option Rules:{p_end}{p2col:}Beta blocker allergy = must be specific reference in the record to allergy or intolerance to beta-blockers{p_end}{p2col:}Bradycardia = may be taken from the vital sign records for the day of discharge and the day prior to discharge {p_end}{p2col:}Second or third degree heart block = Do not attempt to use the EKG tracing to answer this question. The EKG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the EKG interpretation does not have to be linked specifically to contraindication to beta-blocker.{p_end}{p2col:}Systolic blood pressure = may be taken from the vital sign records for the day of discharge and the day prior to discharge{p_end}{p2col:}Other reasons = MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker{p_end}{p2col:}COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma.&{txt:noami2} {err:dc1day 0} {txt:nodc}281blkatdcdisch 147Was the patient prescribed a beta-blocker at discharge?M1,2*{p_end}{p2col:}*If 2, go to cardfolo (as applicable), else go to wichbbdc~Enter response #2 if a beta-blocker was not prescribed at discharge, or unable to determine from medical record documentation.6{txt:noami2} {err:dc1day 0} {txt:nodc} {err:nodcbb 99}282wichbbdcdisch 15Designate the beta blocker prescribed for the patient at discharge.{p_end}{p2col:}1. metoprolol succinate (Toprol-XL){p_end}{p2col:}2. metoprolol tartrate{p_end}{p2col:}3. bisoprolol (Zebeta or Ziac){p_end}{p2col:}4. carvedilol (Coreg){p_end}{p2col:}5. atenolol (Tenoretic or Tenormin){p_end}{p2col:}6. acebutolol (Sectral) {p_end}{p2col:}7. sotalol (Betapace) {p_end}{p2col:}8. betaxolol (Kerlone) {p_end}{p2col:}9. carteolol (Cartrol) {p_end}{p2col:}10. nadolol (Corgard) {p_end}{p2col:}11. nadolol/bendroflumethiazide (Corzide) {p_end}{p2col:}12. propranolol (Inderal) {p_end}{p2col:}13. propranolol hydrochloride (Inderide) {p_end}{p2col:}14. labetalol (Normodyne or Trandate) {p_end}{p2col:}15. penbutolol sulfate (Levatol) {p_end}{p2col:}16. metoprolol/hydrocholorthiazide (Lopressor HCT ) {p_end}{p2col:}17. penbutolol sulfate (Levatol) {p_end}{p2col:}18. pindolol (Visken) {p_end}{p2col:}19. timolol (Timolide or Blocadren) {p_end}{p2col:}20. timolol/hydrocholorthiazideA1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,{p_end}{p2col:}18,19,20Beta blocker generic names are not capitalized. Brand names are capitalized.{p_end}{p2col:}Enter the number corresponding to the generic name documented in the medical record.{p_end}{p2col:}"Prescribed for this patient at discharge" = patient may or may not have been on this medication during hospitalization, and it was either continued or prescribed at the time of discharge.{p_end}{p2col:}Source: discharge instructions, discharge orders, discharge summaryD{txt:noami2} {err:dc1day 0} {txt:nodc} {err:nodcbb 99} {err:blkatdc}TAMJBONEWOBJeprp_03_43''"'MATS&1cardrestvalid 1Either at initial presentation to the hospital or during inpatient care, was the first cardiac symptom for this patient a cardiac arrest?:1,2*{p_end}{p2col:}*If 2, go to truami, else go to surviveoThe question refers to the patient who had no previous cardiac symptoms. The initial symptom is a cardiac arrest. (Examples: patient who arrives in the ED with a cardiac arrest; patient recovering from hip fracture has a cardiac arrest during rehabilitation therapy.) The question does not apply to patients presenting with or receiving any care for cardiac symptoms.reword2survivevalid 22Did the patient survive the resuscitation attempt?N1,2*{p_end}{p2col:}*If 2, exclude the record.{p_end}{p2col:}If 1, go to truamiaApplicable only to cases in which the patient could not be resuscitated and expired during resuscitation efforts or the effort was abandoned. If no resuscitation was attempted, answer "2."{p_end}{p2col:}Exclusion Statement{p_end}{p2col:}Cardiac arrest occurring in this case precluded abstraction of the data elements required for the AMI Core Measures.reword{err:cardrest}3truamivalid 3\Is there evidence in the medical record that the patient had an acute myocardial infarction?1,2Evidence in the medical record = the discharge summary, or other physician documentation (if the discharge summary is not present), must record evidence of myocardial infarction. Rule out MI (r/o) or undetermined diagnoses, such as MI vs. unstable angina are not acceptable. An MI that is a subsequent episode of care is also not acceptable.{p_end}{p2col:}Any order in which AMI is noted in the listing of discharge diagnoses is acceptable. {p_end}{p2col:}If AMI is not noted in the discharge summary but the laboratory reports show elevated serum markers of myocardial damage (i.e., troponin I, troponin T, or CK-MB) (e.g., troponin T > = 0.1 ng/mL or slightly elevated TnT > 0.03, but < 0.1 ng/mL) and treatment is consistent with AMI (EKG, oxygen, aspirin, beta blockers, NTG, cardiac enzymes, IV unfractionated heparin, analgesics, reperfusion, admission to monitored bed) and AMI is not ruled out, and the diagnosis is not unstable angina, and the AMI admission is not a subsequent episode of care, answer "yes" to the question.{p_end}{p2col:}Note: if the AMI code is 410.x2, answer "2." Cases coded with a fifth digit of 2 are not to be reviewed. {p_end}{p2col:}If the patient is a non-veteran, proceed through the questions. It is care provided by the VHA and not the patient's veteran or non-veteran status that is important.{p_end}{p2col:}If the patient did not have a discharge from inpatient care during the time for which the case was selected, answer "2" because the patient did not have an AMI.4amicodevalid 4For the selected episode of care, was the principal diagnosis coded as 410.0 - 410.9, with a fifth digit of 1, as follows:{p_end}{p2col:}410 acute myocardial infarction (sudden, severe death of heart muscle due to decreased coronary blood flow; classification is based on the location of the affected tissue, when known){p_end}{p2col:}o- Includes: cardiac infarction{p_end}{p2col:}o- coronary (artery) embolism, occlusion, rupture, thrombosis{p_end}{p2col:}o- infarction of heart, myocardium, or ventricle{p_end}{p2col:}o- rupture of heart, myocardium, or ventricle{p_end}{p2col:}410.01 of anterolateral wall{p_end}{p2col:}410.11 of other anterior wall{p_end}{p2col:}410.21 of inferolateral wall{p_end}{p2col:}410.31 of inferoposterior wall{p_end}{p2col:}410.41 of other inferior wall{p_end}{p2col:}410.51 of other lateral wall{p_end}{p2col:}410.61 true posterior wall infarction{p_end}{p2col:}410.71 subendocardial infarction {p_end}{p2col:}410.81 of other specified sites{p_end}{p2col:}410.91 unspecified site1,2{p_end}{p2col:}If 1 or 2 and truami=1, go to aprocode{p_end}{p2col:}If 1 or 2 and truami=2, go to uacode{p_end}{p2col:}If 1 and truami=2, the record is reported as a JCAHO Category B.The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."{p_end}{p2col:}The question refers to the principal diagnosis at the facility in which the case is being reviewed. (Example: patient is admitted to first VAMC for surgery, has an AMI after surgery, and is transferred to VAMC #2 for AMI care. AMI is not the principal diagnosis at the first VAMC, but is the principal diagnosis at VAMC #2.){p_end}{p2col:}Catnum 10 AMI records are selected from cases discharged with a diagnosis code of 410.0 - 410.9, with a fifth digit of 1. A fifth digit of 0 or 2 is not acceptable{p_end}{p2col:}To respond "1," the principal diagnosis code must be one of the listed codes.{p_end}{p2col:}The fifth digit of 0 = episode of care unspecified{p_end}{p2col:}The fifth digit of 1 = initial episode of care for an AMI. Used to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit 1 is assigned regardless of the number of times a patient may be transferred during the initial episode of care.{p_end}{p2col:}The fifth digit of 2 = subsequent episode of care. Used to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation, or treatment for a myocardial infarction that has received initial treatment but is still less than 8 weeks old. Do not review cases coded with a fifth digit of 2revised definition, end5uacodevalid 5For the selected episode of care, was the principal diagnosis coded as one of the following:{p_end}{p2col:}411.1 Intermediate coronary syndrome{p_end}{p2col:}o- Impending infarction{p_end}{p2col:}o- Preinfarction angina{p_end}{p2col:}o- Preinfarction syndrome{p_end}{p2col:}o- Unstable angina{p_end}{p2col:}411.81 Acute coronary occlusion without myocardial infarction{p_end}{p2col:}o- Acute coronary (artery):{p_end}{p2col:}o- embolism without or not resulting in MI{p_end}{p2col:}o- obstruction without or not resulting in MI{p_end}{p2col:}o- occlusion without or not resulting in MI{p_end}{p2col:}o- thrombosis without or not resulting in MI{p_end}{p2col:}411.89 Other{p_end}{p2col:}o- Coronary insufficiency (acute){p_end}{p2col:}o- Subendocardial ischemia1,2411.1= Intermediate coronary syndrome: impending infarction, preinfarction angina, preinfarction syndrome, unstable angina{p_end}{p2col:}411.1 excludes angina pectoris (413.9) and decubitus (413.0){p_end}{p2col:}411.81 excludes obstruction without infarction due to atherosclerosis (414.00-414.06){p_end}{p2col:}o-excludes occlusion without infarction due to atherosclerosis{p_end}{p2col:}o-(414.00-414.06)revised question {txt:truami}6uadocvalid 6aDid the discharge summary or other physician documentation record a diagnosis of unstable angina?T1,2*{p_end}{p2col:}*If 2, the record is excluded.{p_end}{p2col:}If 1, go to aprocodeQThe diagnosis may not be listed as "unstable angina," but may be recorded as one of the terms noted in the question "unacode." If the diagnosis is listed as one of these terms, answer "1."{p_end}{p2col:}UA is commonly considered to have three presentations: (1) rest angina (2) new onset of severe angina , defined as at least Class III by the CCS classification* (3) increasing angina to at least CCS Class III severity*.{p_end}{p2col:}*CCS Class III Severity: angina with minimal exertion or ordinary activity{p_end}{p2col:}Abstractor may not determine a diagnosis of unstable angina from information in the medical record. The diagnosis must be documented in the record by an MD or DO.{p_end}{p2col:}Exclusion Statement:{p_end}{p2col:}Documentation in the medical record did not confirm that the patient had a diagnosis of Acute Coronary Syndromerevised definition {txt:truami}7aprocodevalid 7WWhat was the ICD-9-CM code selected as the principal diagnosis for this medical record. _ _ _. _ _Use the code assigned by the VAMC. Do not attempt to code the AMI by any code other than that assigned by the facility. Same 410.xx code entered in aprocode cannot be entered in othrdx.revised definition8othrdx_valid 8JEnter the ICD-9-CM other diagnosis codes selected for this medical record. _ _ _. _ _Enter ALL of the ICD-9-CM other diagnosis codes selected for this medical record. Use the diagnoses listed in the discharge summary for this episode of inpatient care.9anypxvalid 9IWas any invasive procedure performed during this episode of care for AMI?:1,2*{p_end}{p2col:}*If 2, go to admtype, else go to pxcodeProcedures=invasive procedures requiring some form of anesthesia including local. May be cardiac catheterization, CABG, or another procedure not related to the AMI.typo10pxcodevalid 10What was the ICD-9-CM code selected as the principal procedure for this record?{p_end}{p2col:}Principal procedure= that procedure performed for definitive treatment, rather than for diagnostic or exploratory reasons, or was necessary to treat a complication. The principal procedure is related to the principal diagnosis.{p_end}{p2col:}Determine whether the patient had a PCI before attempting to enter any procedure code.--. --Percutaneous Coronary Intervention{p_end}{p2col:}36.01: Single vessel percutaneous coronary intervention (PCI) or coronary atherectomy without mention of thrombolytic agent{p_end}{p2col:}36.02: Single vessel percutaneous coronary intervention (PCI) or coronary atherectomy with mention of thrombolytic agent{p_end}{p2col:}36.05: Multiple vessel percutaneous coronary intervention (PCI) or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent{p_end}{p2col:}If the patient had a PCI with stent placement (code 36.06) enter the applicable code for the PCI, not the stent placement. {p_end}{p2col:}If PCI is not the principal diagnosis, use the principal diagnosis code assigned by the VAMC.revised definition {err:anypx}11prinpxdtvalid 11-What was the date of the principal procedure? mm/dd/yyyyWEnter the exact date. The use of 01 to indicate unknown month or day is not acceptable. {err:anypx}12othrsdnevalid 12DWere other procedures performed during this episode of care for AMI?;1,2*{p_end}{p2col:}*If 2, go to admtype, else go to othrpxsOther procedures=invasive procedure requiring a form of anesthesia including local. May be PCI, if not designated as the principal diagnosis, cardiac cath, CABG, or other unrelated procedure.reword {err:anypx}13othrpxs_valid 13What were the ICD-9-CM code(s) selected as the other procedure(s) for this record?{p_end}{p2col:}Enter the ICD-9-CM codes identifying all significant procedures other than the principal procedure. Enter up to five other procedure codes.k(1) --. --{p_end}{p2col:}(2) --. -{p_end}{p2col:}(3) --. -{p_end}{p2col:}(4) --. -{p_end}{p2col:}(5) --. --Begin with the first procedure performed after hospital arrival.{p_end}{p2col:}If the patient had a PCI with stent placement (code 36.06) enter the applicable code for the PCI, not the stent placement.{p_end}{p2col:}Be alert for the following codes which should be present in the record and entered as either the principal or other procedures, if the procedure was performed: Cardioversion 99.62; CABG 36.10 - 36.19; Pacemaker 37.80, 37.83, 39.64, 37.81, 37.78reword{err:anypx} {err:othrsdne}14othrdts_valid 148What were the dates the other procedures were performed.)mm/dd/yyyy{p_end}{p2col:}Up to five datesEnter the dates corresponding to each of the other procedures performed, beginning with the first procedure performed after hospital arrival. Up to five other dates may be entered.{err:anypx} {err:othrsdne}15admtypevalid 15Designate the type of admission for this patient:{p_end}{p2col:}1. Emergency{p_end}{p2col:}2. Urgent{p_end}{p2col:}3. Elective{p_end}{p2col:}5. Trauma{p_end}{p2col:}9. Information not available 1,2,3,5,9uIf the patient was admitted initially to another VAMC, the question is applicable to the type of admission at that VAMC. If the patient was transferred from a community hospital and the type of admission is not known, use "9." {p_end}{p2col:}1. Emergency=the patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.{p_end}{p2col:}2. Urgent=the patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodations.{p_end}{p2col:}3. Elective=the patient's condition permitted adequate time to schedule the availability of a suitable accommodation{p_end}{p2col:}5. Trauma=Visit to the trauma center/hospital as licensed by the state or local government authority to do so, or as verified by the American College of Surgeons and involving a trauma activation.{p_end}{p2col:}9. Information not available=the hospital cannot classify the type of admission. This code is used only on rare occasions.16transinvalid 16Was the patient received from an emergency department of another hospital?{p_end}{p2col:}1. received from another VAMC{p_end}{p2col:}2. transferred from community hospital ED{p_end}{p2col:}99. not transferred from another EDP1,2,99{p_end}{p2col:}If transin = 1 or 2, computer will default to 1 for admfrom21 or 2 = may be from another VAMC or community hospital, but the patient cannot have been an inpatient. The abstractor must know the patient was transferred from the ED.{p_end}{p2col:}Note: the emergency department of another hospital includes both emergency room AND observation bed/unit stays at that hospital.{p_end}{p2col:}If "1," the questions regarding initial care are applicable to the ED admission and treatment at the first VAMC. {p_end}{p2col:}99 = Patient not received as a transfer from another facility's Emergency Department or unable to determine17admfromvalid 17 Designate the admission source for this patient:{p_end}{p2col:}1. Physician referral{p_end}{p2col:}2. Clinical referral{p_end}{p2col:}3. HMO referral{p_end}{p2col:}4. Transfer from a community hospital{p_end}{p2col:}5. Transfer from skilled nursing facility{p_end}{p2col:}6. Transfer from another facility{p_end}{p2col:}7. Emergency room{p_end}{p2col:}8. Court/law enforcement{p_end}{p2col:}9. Information not available{p_end}{p2col:}A Transfer from a critical access hospital{p_end}{p2col:}10. Received from another VAMC'1,2,3,4*,5,6,7,8,9,A,*{p_end}{p2col:}10tIf transin=1 or 2 (patient was transferred from the ED of another hospital, default to "1" to answer admfrom.{p_end}{p2col:}1. Physician referral=the patient was admitted upon recommendation of the personal physician{p_end}{p2col:}2. Clinic referral=the patient was admitted upon recommendation of the facility's clinic physician{p_end}{p2col:}3. HMO referral=the patient was admitted upon recommendation of a health maintenance organization physician{p_end}{p2col:}4. Transfer from a hospital=the patient was admitted or transferred from an acute care facility where he/she was an inpatient{p_end}{p2col:}(from a private sector facility){p_end}{p2col:}5. Transfer from skilled nursing facility=the patient was admitted as a transfer from a skilled nursing facility where he/she was an inpatient (this or another VAMC NHCU, Intermediate Medicine, community SNF nursing home){p_end}{p2col:}6. Transfer from another facility=the patient was admitted to this healthcare facility as a transfer from a healthcare facility other than an acute care facility or a skilled nursing facility. This includes transfers from nursing homes, long term care facilities, and skilled nursing facility patients that are at a non-skilled level of care (facility other than acute care or NHCU, as for example, Residential Care, DOM, or assisted living) {p_end}{p2col:}7. Emergency room=the patient was admitted to the facility upon recommendation of this facility's ED physician/triage{p_end}{p2col:}8. Court/law enforcement=the patient was admitted upon the direction of a court of law, or upon the request of a law enforcement agency representative{p_end}{p2col:}9. Information not available=the means by which the patient was admitted is not known{p_end}{p2col:}A Transfer from a critical access hospital=the patient was admitted to this facility as a transfer from a critical access hospital where he/she was an inpatient (private sector Medicare-designated){p_end}{p2col:}Answer # "10" has been differentiated from #4 to indicate that the patient was first admitted to another VAMC. This indicates the patient was an inpatient at the first VAMC and was not transferred from the ED.revised definition18admdtvalid 18QEnter the date the patient was formally admitted to inpatient status at the VAMC. mm/dd/yyyyAdmission date = date on which the patient was admitted to inpatient status. Admission to observation and/or arrival date are excluded. {p_end}{p2col:}Sources: Emergency Department record, Face sheet, H&P, Nursing admission assessment, Physician ordersrevised question19admtimevalid 19QEnter the time the patient was formally admitted to inpatient status at the VAMC._____{p_end}{p2col:}UMTThe exact time of inpatient admission must be entered in military time. {p_end}{p2col:}If the time is in the a.m., conversion is not required.{p_end}{p2col:}If the time is in the p.m., add 12 to the clock time hour.{p_end}{p2col:}Excluded: admission to observation, arrival daterevised question20acsptdcvalid 20AEnter the patient's discharge status:{p_end}{p2col:}1. discharged to home care or self care (routine discharge){p_end}{p2col:}2. discharged/transferred to another short term general hospital for inpatient care{p_end}{p2col:}3. discharged/transferred to a skilled nursing facility with Medicare certification{p_end}{p2col:}4. discharged/transferred to an intermediate care facility{p_end}{p2col:}5. discharged/transferred to another type of institution for inpatient care{p_end}{p2col:}6. discharged/transferred to home under care of organized home health service organization{p_end}{p2col:}7. left against medical advice or discontinued care{p_end}{p2col:}8. discharged/transferred to home under care of home IV drug therapy provider{p_end}{p2col:}20. expired {p_end}{p2col:}41. Hospice patients who expired in medical facility, such as hospital, SNF, ICF, or freestanding hospice{p_end}{p2col:}43. Discharged/transferred to another federal hospital{p_end}{p2col:}50. Hospice - home{p_end}{p2col:}51. Hospice - medical facility{p_end}{p2col:}61. discharged/transferred within this institution to hospital-based Medicare approved swing bed{p_end}{p2col:}62. Discharged/transferred to inpatient rehabilitation facility (IRF) including rehabilitation distinct parts of a hospital{p_end}{p2col:}63. Discharged/transferred to a Medicare certified long-term care hospital{p_end}{p2col:}64. Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare{p_end}{p2col:}65. Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital>1,2,3,4,5,6,7*,8,20*{p_end}{p2col:}41*,43*,50,51,61,62,6364,65mTo respond "2," it must be known the "other" hospital is a non-VHA acute-care facility.{p_end}{p2col:}To respond "7," a signed AMA document, or progress note by an MD, NP, or PA must appear in the record.{p_end}{p2col:}Response #41 is applicable only for Medicare and CHAMPUS`Hospice care and does not apply to VHA Hospice patients.{p_end}{p2col:}Use 43 if the patient was discharged/transferred from this VAMC to another VAMC or other federal hospital.{p_end}{p2col:}If uncertain of the patient's disposition, ask help from the EPRP Liaison, since the correct discharge status affects the remainder of the ACS questions.begin21eddateacute 15Enter the date the patient arrived at a VHA hospital. mm/dd/yyyyDetermine the earliest date the patient arrived at a VHA hospital, such as in the ED or observation unit. If the patient first presented to a VAMC other than the facility under review, use the date and time of arrival at the first VAMC.{p_end}{p2col:}Do not use ambulance records to determine arrival date. If the patient was admitted for observation, and subsequently admitted to the unit or floor, use the date of admission for observation. {p_end}{p2col:}Enter the exact date. The questions regarding date and time of arrival are also applicable to cases in which the ACS occurred after the veteran was already an inpatient.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) consider this care as hospital arrival, and enter the date and time treatment for ACS began in the VHA treatment setting as the hospital arrival date and time.revised definition22edtimeacute 25Enter the time the patient arrived at a VHA hospital.____{p_end}{p2col:}UMTEnter the earliest documented time of arrival. This will likely differ from the admission time. If the patient first presented to a VAMC other than the facility under review, use the date and time of arrival at the first VAMC.{p_end}{p2col:}Determine the time the patient arrived at a VHA hospital, such as the ED or observation unit. Enter the exact time. {p_end}{p2col:}If the patient was admitted for observation, and subsequently admitted to the unit or floor, use the time the patient arrived at a VHA hospital for observation.{p_end}{p2col:}Enter the time in Universal Military Time:{p_end}{p2col:}If the time is in the a.m., conversion is not required.{p_end}{p2col:}If the time is in the p.m., add 12 to the clock time hour.revised definition23dcdateacute -No documented instructions24dctimeacute -No documented instructions25 pasthx3_1acute 3=Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}1. Diabetes Mellitus:{break}250.01, 250.03 IDDM,controlled or uncontrolled{break}250.10-250.93, DM with manifestations {break}648.00-648.04, 648.81 DM complicating pregnancy-1,026 pasthx3_2acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}2. Cancer: 140.0-208.91{break}All malignant neoplasms-1,027 pasthx3_3acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}3. Chronic Cerebrovascular Disease: 437.0-437.9, 438.0-438.9{break}Cerebral atherosclerosis, ischemic cerebrovascular disease, hypertensive encephalopathy, cerebral aneurysm, nonruptured, cerebral arteritis, Moyamoya disease, transient global amnesia -1,028 pasthx3_4acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}4. Chronic Renal Disease (w, w/o Renal Failure): 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 582.0-583.9, 585-587{break}Hypertensive renal disease, hypertensive heart and renal disease, chronic glomerulonephritis, chronic renal failure, renal sclerosis-1,029 pasthx3_5acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}5. Chronic Liver Disease: 571.0-572{break}Chronic liver disease and cirrhosis{break}Liver abscess and sequelae of chronic liver disease-1,030 pasthx3_6acute 3-Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}6. COPD: 491.21, 493.20, 493.21, 496{break}Obstructive chronic bronchitis, chronic obstructive asthma with status asthmaticus, chronic airway obstruction NEC-1,031 pasthx3_7acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}7. Cardiomyopathy: 425.0-425.9{break}Cardiomyopathies-1,032 pasthx3_8acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}8. Chronic Cardiac Conditions:{break}398.90, 398.91, 398.99, Other rheumatic heart disease{break}402.00-402.91, Hypertensive heart disease,{break}414.8, 414.9, Chronic ischemic heart disease{break}416.0-416.9, Chronic pulmonary heart disease{break}429.1, 429.2, 429.3, Myocardial degeneration, cardiovascular disease, unspecified, cardiomegaly{break}443.81, 443.89, 443.9, Peripheral angiopathy{break}V12.50, unspecified circulatory disease; V15.1, surgery to heart and great vessels{break}428.xx, Congestive heart failure -1,033 pasthx3_9acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}9. History of PTCA: V45.82-1,034 pasthx3_10acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}10. History of CABG: V45.81-1,035 pasthx3_11acute 3*Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}11. Atherosclerosis and Lipid Disorders: 272.0-272.9; Disorders of lipoid metabolism; 414.0-414.05, Coronary atherosclerosis; 440.0-440.9, atherosclerosis-1,036 pasthx3_12acute 3TIndicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}12. Musculoskeletal Conditions: 714.0-714.33, Rheumatoid arthritis; 715.00-715.98, Osteoarthritis and allied disorders; 720.0, Ankylosing spondylitis;{break}721.90, Spondylosis of unspecified site-1,037 pasthx3_13acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}13. History of MI: 412 Old MI (greater than 8 weeks)-1,038 pasthx3_16acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}16. Documented family history of coronary artery disease-1,039 pasthx3_17acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}17. History of alcohol abuse-1,040 pasthx3_99acute 3Indicate all applicable active diagnoses, past medical history, past cardiac procedures, and past history of MI for this patient:{p_end}{p2col:}99. None of listed diagnoses-1,041pastcvaacute 4EDoes the patient have a history of stroke within the past five years?1,2ICD-9 Code 436. Codes 438.0-438.42 and 438.81-438.9 indicate late effects of cerebrovascular disease. Old stroke without residuals is coded V12.5942cathfiveacute 5KWithin the past five years, did the patient have a cardiac catheterization?:1,2*{p_end}{p2col:}*If 2, go to revasc, else go to blocathnAnswer "2" if the patient did not have a cardiac catheterization or whether the patient had a cath is unknown.43blocathacute 6mAt any cath done within the five-year period, was there a finding of > = 50% stenosis in any coronary artery?;1,2*{p_end}{p2col:}*If 2, go to revasc, else go to cathdateStenosis = constriction or narrowing. Buildup of fat, cholesterol, and other substances over time may clog the coronary arteries. The question is applicable to blockage or stenosis of any of the coronary arteries.{err:cathfive}44cathdateacute 7IEnter the date the cath with a finding of > = 50% stenosis was performed. mm/dd/yyyymEnter the exact date where possible. 01 may be used to designate day and month if only the year is available.{err:cathfive} {err:blocath}45revasc1acute 8|Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}1. PCI-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.reword46revasc2acute 8}Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}2. CABG-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.47revasc99acute 8Does the record document that the patient had a revascularization procedure within the last six months?{p_end}{p2col:}99. No documentation of revascularization within the past six months.-1,0Look for documentation in the H&P or admitting note that a PTCA/PCI or CABG was performed within the past 6 months. Procedure may have been done at this or another VAMC, or at a private sector facility.48priorx1acute 9sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}1. aspirin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).49priorx2acute 9xWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}2. beta blocker-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).50priorx3acute 9yWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}3. ACE inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).51priorx4acute 9Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}4. lipid-lowering medication-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).52priorx5acute 9sWas the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}5. insulin-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).53priorx6acute 9Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}6. platelet aggregation inhibitor-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).54priorx7acute 9Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}7. low molecular weight heparin (LMWH)-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).55priorx99acute 9Was the patient on any of the following medications prior to presentation to the hospital?{p_end}{p2col:}99. no documentation patient was on any of these medications-1,0The question refers to medications being taken routinely by the patient, at his/her place of residence, prior to presenting to the hospital with ACS symptoms. Medications given once the patient has arrived at the hospital are excluded from the question.{p_end}{p2col:}1. Aspirin = 81 to 325 mg qd; see JCAHO Medication Table for listing of aspirin and aspirin-containing medications {p_end}{p2col:}2. Beta blocker = see JCAHO listing of beta blocker medications{p_end}{p2col:}3. ACEI = see JCAHO listing of ACE inhibitor medications.{p_end}{p2col:}4. Lipid lowering medication = Statins: fluvastatin sodium (Lescol); atorvastatin calcium (Lipitor); lovastatin (Mevacor); pravastatin sodium (Pravachol); simvastatin (Zocor) {p_end}{p2col:}Niacin: niacin extended release tablets (Niaspan); {p_end}{p2col:}Bile Acid Binding Resins: colestipol hydrochloride (Colestid); colesevelam hydrochloride (Welchol); cholestyramine (Questran); {p_end}{p2col:}Fibrates: clofibrate (Atromid-S); gemfibrozil (Lopid); fenofibrate (Tricor); {p_end}{p2col:}Cholesterol absorption inhibitors: ezetimibe (Zetia) {p_end}{p2col:}5. Insulin Synonyms/Inclusions: 70/30, 50/50, continuous subcutaneous, infusion of insulin (CS11), HUMALOG, HUMULIN, ILETIN I or II, insulin pen, insulin pump, LENTE, LISPRO, MDI, NOVOLIN, NOVOLIN penfill, NOVO NORDISK, NPH, Regular, SEMILENTE, ULTRALENTE, VELOSULIN{p_end}{p2col:}6. Platelet aggregation inhibitors = clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), dipyridamole and aspirin (Aggrenox{p_end}{p2col:}7. LMWH: enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).56inptacsacute 10CWas the veteran already an inpatient at any VAMC when ACS occurred?1,2*{p_end}{p2col:}*If 2, go to anginum, else go to onsetdoc{p_end}{p2col:}If 2 and transin=2, or admfrom=4 or A, go to comunecgGAlready an inpatient = the veteran had already been formally admitted to this or another VAMC, either for an unrelated problem or for related symptoms such as unstable angina. In either event, to answer "1," the patient must definitely have had an ACS that occurred after the patient had been formally admitted as an inpatient.reword57onsetdocacute 11;Does the record document the date of onset of ACS symptoms?<1,2*{p_end}{p2col:}*If 2, go to symptime, else go to onsetdt ACS symptoms = chest/substernal discomfort, pressure, or pain. May include pain radiating to one or both arms, shoulder, jaw, neck, or back. May be severe epigastric pain, nausea, vomiting, dyspnea, or diaphoresis. Look in nurses notes & progress notes for onset date.{err:acs_inpt}58onsetdtacute 12(Enter the date of onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.{err:acs_inpt} {err:onsetdoc}59symptimeacute 13;Does the record document the time of onset of ACS symptoms?:1,2*{p_end}{p2col:}*If 2, go to ecgdun, else go to onsetmeData source: nurses notes, progress notes. Look for timed entry of information relating to change in patient condition and complaint of symptoms noted in "onsetdoc."{err:acs_inpt}60onsetmeacute 14(Enter the time of onset of ACS symptoms._____{p_end}{p2col:}(UMT)%Enter time in Universal Military Time{err:acs_inpt} {err:symptime}61ecgdunacute 157Was a 12-lead ECG done following onset of ACS symptoms?;1,2*{p_end}{p2col:}*If 2, go to amisymp, else go to inptecghRhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead unless documentation indicates otherwise.typo{err:acs_inpt}62inptecgacute 16oIs the date of the abnormal ECG done most immediately following onset of ACS symptoms documented in the record?<1,2*{p_end}{p2col:}*If 2, go to docecgtm, else go to inecgdtThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS. If the first ECG done following ACS symptoms was normal but a later ECG was abnormal or diagnostic for ACS, use the date and time of the abnormal ECG.revised definition{err:acs_inpt} {err:ecgdun}63inecgdtacute 17YEnter the date of the abnormal ECG done most immediately following onset of ACS symptoms. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.reword){err:acs_inpt} {err:ecgdun} {err:inptecg}64docecgtmacute 18lDoes the record document the time of the abnormal ECG done most immediately following onset of ACS symptoms.<1,2*{p_end}{p2col:}*If 2, go to amisymp, else go to inecgtmeThis question is applicable only to veterans who were already an inpatient when the ACS occurred. The question does not refer to a routine ECG on admission, but to the ECG done when the patient complained of chest pain or other symptoms indicative of ACS.{err:acs_inpt} {err:ecgdun}65inecgtmeacute 19YEnter the time of the abnormal ECG done most immediately following onset of ACS symptoms.3_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to amisympIf exact time cannot be known, look for nurses note or progress note indicating ECG was done and patient has likely had an AMI. Use time of this progress note.reword*{err:acs_inpt} {err:ecgdun} {err:docecgtm}66anginumacute 20Enter the number of episodes of angina experienced by the patient within 24 hours prior to presentation to the hospital.{p_end}{p2col:}(Angina is defined as: chest pain or severe epigastric pain, non-traumatic in origin; central/substernal compression or crushing chest pain; pressure, tightness, heaviness, cramping, burning or aching sensation; unexplained indigestion, belching, epigastric pain; radiating pain in neck, jaw, shoulders, back, one or both arms; dyspnea; nausea and/or vomiting; diaphoresis)?______*{p_end}{p2col:}*If 0, go to amisymp, else go to angieaseIIf any of the symptoms of angina were continuous within the 24-hour period (or less) prior to presentation, consider it as one episode. If the pain or other symptom relented for a period of time and then recurred, count each episode of pain (or other symptom) as a separate episode.{p_end}{p2col:}There may be conflicting notes in the ED record, admitting note, H&P, etc, regarding number of episodes of angina. It is suggested that one source, preferably the admitting note, be used as the source of information.{p_end}{p2col:}Enter "0" if the number of episodes of angina is unknown. {err:acs_arr}67angieaseacute 21^Enter the number of these episodes of angina that were relieved by sublingual NTG and/or rest.______This number is a component of the number of episodes of angina experienced in the last 24 hours and entered in anginum. The question does not reference number of additional episodes.{err:acs_arr} {txt:anginum 0}68amisymp1acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}1. chest pain or severe epigastric pain, non-traumatic in origin-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}69amisymp2acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}2. central/substernal compression or crushing chest pain-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}70amisymp3acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}3. pressure, tightness, heaviness, cramping, burning or aching sensation-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}71amisymp4acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}4. unexplained indigestion, belching, epigastric pain-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}72amisymp5acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}5. radiating pain in neck, jaw, shoulders, back, one or both arms-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}73amisymp6acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}6. dyspnea-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}74amisymp7acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}7. nausea and/or vomiting-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}75amisymp8acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}8. diaphoresis-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}76 amisymp99acute 22Within 24 hours prior to, or on arrival at any VAMC, or abnormal ECG if ACS occurred as inpatient, did the veteran have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms-1,0c"Any VAMC" includes this or another VAMC. The question refers to any acute care hospital within the VHA system. If the patient presented first to a VAMC other than the VAMC in which the case is being reviewed, questions regarding care will be pertinent to both hospitals, since care is expected to be seamless within the VHA system.{p_end}{p2col:}Prior to or on arrival = patient was experiencing one of more of these symptoms at home or elsewhere, during transport to the hospital, or at the time of initial presentation to the hospital. Even if the sysmptom(s) had subsided by the time the patient presented to the hospital, indicate the symptom(s) that occurred prior to presentation.{p_end}{p2col:}The question is also applicable to those patients who were already an inpatient when ACS occurred. The ECG referenced is the ECG done in response to the patient's complaints of ACS symptoms, i.e., chest pain or pressure, pain radiating to neck, jaw, or arm, dyspnea, etc. Routine ECG done on admission or prior to non-cardiac surgery is not applicable. Enter the symptoms which were responsible for hospital personnel performing the ECG.{p_end}{p2col:}If anginum > 0, and abstractor enters 99 in response to amisymp, computer edit will warn that answers are contradictory. Abstractor will be instructed to re-check medical record documentation to ensure entry of accurate data.revised definition{txt:acs_both}77onsethrsacute 231Enter the number of hours prior to arrival at a VHA hospital that the symptom(s) that brought the patient to the hospital began. {p_end}{p2col:}1. 0 - 1{p_end}{p2col:}2. >1 - 2{p_end}{p2col:}3. >2 - 6{p_end}{p2col:}4. >6 - 12{p_end}{p2col:}5. >12 - 24{p_end}{p2col:}6. >24{p_end}{p2col:}99. not documented1,2,3,4,5,6,99The patient may have had a number of symptoms occurring over a period of many hours or days. Count the time period from the onset of the symptom(s) that finally became so frightening, severe, or unrelenting that the patient came to the hospital. {p_end}{p2col:}The number of hours prior to hospital arrival that the symptoms began may not be explicitly stated in the record, and may have to be inferred or extrapolated from available documentation. (Examples: "the patient began to experience chest pain shortly before midnight." If hospital arrival time was 4:15 a.m., enter category #3.){p_end}{p2col:}("The patient began taking antacids for severe indigestion yesterday morning, but the epigastric pain continued to worsen until{p_end}{p2col:}presentation at the ED at 3:30 this afternoon." Enter category #6.){p_end}{p2col:}If information in the record is conflicting, use only the ED notes or admitting note as the source of information. Use #99 only if there was no information regarding onset of symptoms.reword{err:acs_arr} {res:(}{txt:amisymp1 0} {res:&} {txt:amisymp2 0} {res:&} {txt:amisymp3 0} {res:&} {txt:amisymp4 0} {res:&} {txt:amisymp5 0}{res:)}78chfsymp1acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}1. 1. heart failure-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}79chfsymp2acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}2. impaired left ventricular function-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}80chfsymp3acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}3. new mitral regurgitation murmur-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}81chfsymp4acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}4. an S3 gallop-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}82chfsymp5acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}5. rales > 3 or 1/3 up-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}83chfsymp6acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}6. documentation of a chest x-ray with evidence of pulmonary edema-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}84chfsymp7acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}7. documentation of cardiogenic shock (severe and persistent hypotension in Trendelenburg)-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}85 chfsymp99acute 24At the time of presentation to the hospital, or abnormal ECG if ACS occurred as inpatient, did the patient have any of the following symptoms?{p_end}{p2col:}99. none of these symptoms documented-1,0MR murmur, S3 gallop, rales, or cardiogenic shock must be documented in the record by an MD, NP, or PA. The abstractor may not make this judgment based on other documentation in the record.{p_end}{p2col:}MR murmur: Heard on auscultation of the heart, it is a murmur due to leakage or backward flow of blood current through the mitral valve.{p_end}{p2col:}Rales are abnormal sounds heard on auscultation of the chest. Documentation in the record must specify rales > 3, or 1/3 up.{p_end}{p2col:}Chest x-ray evidence of pulmonary edema may be taken from the chest x-ray report, but the abstractor must be certain the x-ray was done at the time of presentation to the hospital, or transfer to a monitored bed if the AMI occurred post-admission.{txt:acs_both}86frstrateacute 25Enter the patient's heart rate recorded closest to the time of presentation to a VHA hospital, or abnormal ECG if ACS occurred as inpatient._____bpmDo not use the ambulance record. Enter the heart rate recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the heart rate recorded at the time the ECG was done.{txt:acs_both}87 arvpress_acute 26vEnter the patient's blood pressure recorded at the time of presentation, or abnormal ECG if ACS occurred as inpatient.---/---Do not use the ambulance record. Enter the blood pressure recorded at the earliest time following patient arrival at the hospital. Use data recorded in the ED or observation unit. If the veteran was already an inpatient, use the BP recorded closest to the time of the ECG.{txt:acs_both}88painmeasacute 27At initial presentation, or abnormal ECG if ACS occurred as inpatient, was the patient's level of cardiac pain measured using a 0 - 10 scale?{p_end}{p2col:}1. yes{p_end}{p2col:}2. no{p_end}{p2col:}3. patient unable to respondC1,2,3*{p_end}{p2col:}*If 2 or 3, go to restang, else go to entrpainPain screening done by a nurse or other discipline is acceptable. Pain screening done by emergency personnel during transport to the hospital is also acceptable. {p_end}{p2col:}Report from an individual other than the patient is not acceptable. {p_end}{p2col:}If the patient has no pain, the abstractor will accept documentation of: pain = 0{p_end}{p2col:}If the patient has no pain, the abstractor will not accept documentation of: "patient denies pain," or "no pain," without use of a scale{txt:acs_both}89entrpainacute 280Enter the level of pain reported by the patient.______Pain screening may be done by description, color intensity, or faces rating, but a 0 - 10 scale must be used. Answer can only be numeric, zero or greater, and not greater than 10.{txt:acs_both} {err:painmeas 1}90restangacute 29At the time of presentation, or abnormal ECG if the ACS occurred as inpatient, does the record document the patient experienced prolonged ongoing rest pain (pain in chest, arm, or neck{p_end}{p2col:}> 20 minutes)?1,2Documentation of rest pain may be found in the ED notes, admitting notes or H&P. {p_end}{p2col:}Myocardial ischemic pain is usually described as pressing, squeezing, or weightlike. The pain is greatest in the central precordium. The pain frequently radiates in the distribution of the lower cervical nerves and may therefore be felt in the neck, lower jaw, or either shoulder or arm. Myocardial ischemic pain often induces an autonomic response (nausea or vomiting, or sweating.) Myocardial ischemic pain due to coronary arteriosclerosis is usually exertion-related, at least initially. However, the pain of acute MI may occur suddenly when the patient is at rest.{p_end}{p2col:}Rest pain = the patient is sitting or lying in bed and not involved in exertion-related activity.{txt:acs_both}91ekgdone4acute 30AWas a 12-lead ECG performed either prior to or after arrival at a VHA hospital?{p_end}{p2col:}A diagnosis of AMI or Unstable Angina with no ECG done during the episode of care is problematic data. If unable to find an ECG or notation of an ECG done prior to or during this episode of care, ask the Liaison for assistance.|1,2*{p_end}{p2col:}*If 2, go to asanone, else go to frstdate{p_end}{p2col:}If inptacs =1, go to closecg, else go to frstdate+Prior to or after arrival at the hospital = examples: in another unit at the VAMC before transfer to acute care, in the ambulance in transport to the hospital, or on arrival at the ED. Review the entire record to determine whether an EKG was done during the episode of care. {p_end}{p2col:}Rhythm strip is not acceptable. EKG must be that performed using the 12 standard leads: the 3 bipolar limb leads, the 3 augmented unipolar limb leads, and the 6 standard precordial leads.{p_end}{p2col:}If the clinician references ECG findings but does not specify the ECG was 12-lead, infer that it was 12-lead if lead markings are noted in the report. {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival, or 1 hour prior to onset of ACS symptoms if the veteran was already an inpatient, is not applicable.reword{txt:acs_both}92frstdateacute 31cIs the date of the first 12-lead ECG done after arrival at a VHA hospital documented in the record?<1,2*{p_end}{p2col:}*If 2, go to frstime, else go to arvekgdtThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the date the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.typo{err:acs_arr} {err:ekgdone4}93arvekgdtacute 32<Enter the date the first 12-lead ECG after arrival was done. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not applicable.{p_end}{p2col:}If the ECG is date and time-stamped, use this date and time. If a notation of the date and time of the initial ECG has been entered in the record by an MD, nurse, or other personnel, and this date/time is earlier, use the notation date/time.revised definition+{err:acs_arr} {err:ekgdone4} {err:frstdate}94frstimeacute 33QIs the time of the first 12-lead ECG done after arrival documented in the record?=1,2*{p_end}{p2col:}*If 2, go to alsoclos, else go to arvekgtmThis is the first EKG done after the patient entered a VHA hospital. If the patient presented initially to another VAMC, the question refers to the time the first EKG at that hospital was done.{p_end}{p2col:}Note: if ACS symptoms occurred in any VHA treatment setting (outpatient clinic, NHCU, Residential Treatment, etc.), and the patient was treated in that setting prior to transfer to the ED (ASA, ECG, troponin drawn, etc.) use the date of the EKG done in that setting.typo{err:acs_arr} {err:ekgdone4}95arvekgtmacute 34<Enter the time the first 12-lead ECG after arrival was done._____{p_end}{p2col:}UMT-Time must entered in universal military time.{p_end}{p2col:}If the ECG is date and time-stamped, use this date and time. If a notation of the date and time of the initial ECG has been entered in the record by an MD, nurse, or other personnel, and this date/time is earlier, use the notation date/time.revised definition*{err:acs_arr} {err:ekgdone4} {err:frstime}96alsoclosacute 35dWas the first 12-lead ECG done after hospital arrival also the ECG done closest to hospital arrival?;1*,2{p_end}{p2col:}*If 1, go to closecg, else go to closdocThe first ECG done after hospital arrival should also be the one done closest to hospital arrival unless an ECG was done in the ambulance within minutes prior to arrival. Look at EMT record to determine whether a 12-lead ECG was done on the way to the hospital.begin{err:acs_arr} {err:ekgdone4}97closdocacute 36bIs the date of the 12-lead EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to timeclos, else go to closdt3The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.) {p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.+{err:acs_arr} {err:ekgdone4} {txt:alsoclos}98closdt3acute 37Enter the date. mm/dd/yyyyThis may be the same date as in the question arvekgdt{p_end}{p2col:}Use exact date. The use of 01 to indicate missing day or month is not acceptable.9{err:acs_arr} {err:ekgdone4} {txt:alsoclos} {err:closdoc}99timeclosacute 38bIs the time of the 12-lead EKG performed closest to VHA hospital arrival documented in the record?<1,2*{p_end}{p2col:}*If 2, go to closecg, else go to clostme3This may be the same time as in the question arvekgtm.{p_end}{p2col:}The ECG performed closest to hospital arrival should be the first or initial ECG done closest to the event. "Closest to the event" may be immediately prior to the event or immediately following patient presentation at a VHA hospital with ACS symptoms.{p_end}{p2col:}EKG done more than 1 hour prior to hospital arrival is not applicable.+{err:acs_arr} {err:ekgdone4} {txt:alsoclos}100clostme3acute 39Enter the time._____{p_end}{p2col:}UMTTime must entered in universal military time{p_end}{p2col:}To convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.:{err:acs_arr} {err:ekgdone4} {txt:alsoclos} {err:timeclos}101closecgacute 40 Is there documented interpretation of the 12-lead ECG performed closest to hospital arrival, or onset of ACS if the veteran was already an inpatient?{p_end}{p2col:}A diagnosis of AMI or Unstable Angina with no interpretation of the initial ECG documented in the record is problematic data. Review the Definitions/Decision Rules, and ask the EPRP Liaison for assistance if unable to identify the ECG closest to hospital arrival, or the ECG done most immediately following onset of ACS symptoms if the veteran was an inpatient.<1,2*{p_end}{p2col:}*If 2, go to nextecg, else go to ecgintrpUse the 12-lead ECG performed closest to the time of hospital arrival whether prior to or after arrival at this or another VAMC with ACS symptoms. (Example: 12-lead EKG done in ambulance 10 minutes prior to hospital arrival and a second one done in the ED 30 minutes after arrival. Use the EKG done in the ambulance.){p_end}{p2col:}The same concept applies to the ECG done closest to the onset of ACS if the ACS occurred post-admission. Look for interpretation of the 12-lead ECG performed closest to the event. {p_end}{p2col:}Do not use an ECG interpretation done more than one hour prior to hospital arrival or onset of ACS if the veteran was already an inpatient.{p_end}{p2col:}An EKG interpretation is defined as either:{p_end}{p2col:}o- a 12-lead ECG/EKG report in which the name or initials of the MD/NP/ or PA who reviewed the EKG is signed, stamped, or typed on the report.{p_end}{p2col:}o- MD/NP/ or PA notation of ECG/EKG findings. Interpretations may be taken directly from documentation of ECG findings.{p_end}{p2col:}o- If the ECG/EKG interpretation is an electronic "reading," do not use clinician documentation of the EKG findings unless the clinician "signs off" on the electronic interpretation as described above. {p_end}{p2col:}If the ECG/EKG report is not specifically labeled "12-lead", infer that it was 12-lead if lead marking ( i.e., I, II, III, a VL, a VL, a VF, V1, V2, V3,V4, V5, V6) are noted on the report.{p_end}{p2col:}If the physician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead if lead markings are noted in the report.{p_end}{p2col:}If unable to determine which 12-lead ECG/EKG was done closest to arrival (e.g., one EKG does not have a time and it cannot be determined whether it is closer to hospital arrival than another EKG which does have a time), or if the time between the pre-arrival is the same (e.g., both were done 15 minutes from arrival time), answer "1" if any of these ECGs have ST segment elevation or LBBB documented on the interpretation.revised question{txt:acs_both} {err:ekgdone4}102nextecgacute 41<Was there a subsequent ECG with a documented interpretation?<1.2*{p_end}{p2col:}*If 2, go to asanone, else go to nxtdocdtUse the ECG done second closest to hospital arrival if there is a documented interpretation of this ECG. If there is no interpretation of the second closest ECG, look further in the record until a documented ECG interpretation is found.{p_end}{p2col:}An EKG interpretation is defined as either:{p_end}{p2col:}o- a 12-lead ECG/EKG report in which the name or initials of the MD/NP/ or PA who reviewed the EKG is signed, stamped, or typed on the report.{p_end}{p2col:}o- MD/NP/ or PA notation of ECG/EKG findings. Interpretations may be taken directly from documentation of ECG findings.{p_end}{p2col:}o- If the ECG/EKG interpretation is an electronic "reading," do not use clinician documentation of the EKG findings unless the clinician "signs off" on the electronic interpretation as described above. {p_end}{p2col:}If the ECG/EKG report is not specifically labeled "12-lead", infer that it was 12-lead if lead marking ( i.e., I, II, III, a VL, a VL, a VF, V1, V2, V3,V4, V5, V6) are noted on the report.{p_end}{p2col:}If the physician references ECG/EKG findings but does not specify the ECG/EKG was 12-lead, infer that it was 12-lead if lead markings are noted in the report.begin+{txt:acs_both} {err:ekgdone4} {txt:closecg}103nxtdocdtacute 42<Is the date of the interpreted ECG documented in the record?=1,2*{p_end}{p2col:}*If 2, go to nexdoctm, else go to nextdateIf the ECG is date and time-stamped, use this date and time. If a notation of the date and time of the interpreted ECG has been entered in the record by an MD, nurse, or other personnel, and this date/time is earlier, use the notation date/time.begin9{txt:acs_both} {err:ekgdone4} {txt:closecg} {err:nextecg}104nextdateacute 43;Enter the date of the ECG with a documented interpretation. mm/dd/yyyyWEnter the exact date. The use of 01 to indicate missing day or month is not acceptable.beginH{txt:acs_both} {err:ekgdone4} {txt:closecg} {err:nextecg} {err:nxtdocdt}105nexdoctmacute 44<Is the time of the interpreted ECG documented in the record?<1,2*{p_end}{p2col:}*If 2, go to ecgintrp, else go to nextimeIf the ECG is date and time-stamped, use this date and time. If a notation of the date and time of the interpreted ECG has been entered in the record by an MD, nurse, or other personnel, and this date/time is earlier, use the notation date/time.begin9{txt:acs_both} {err:ekgdone4} {txt:closecg} {err:nextecg}106nextimeacute 45;Enter the time of the ECG with a documented interpretation.______{p_end}{p2col:}UMTTime must be entered in Universal Military Time.{p_end}{p2col:}If the time is in the a.m., conversion is not required.{p_end}{p2col:}If the time is in the p.m., add 12 to the clock time hour.beginH{txt:acs_both} {err:ekgdone4} {txt:closecg} {err:nextecg} {err:nexdoctm}107ecgintrpacute 46What were the specific findings from interpretation of the ECG performed closest to hospital arrival, a subsequent ECG, or the ECG following onset of symptoms if the AMI occurred as inpatient?{p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression, old and/or unchanged{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient or dynamic ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}12. ST segment depression, new or not known to be old{p_end}{p2col:}99. no documentation of any of the above1,2,3,4,5,6,7,8,9,10,11, {p_end}{p2col:}12, 99{p_end}{p2col:}Go to asanone{p_end}{p2col:}If 1 or 2 is entered, and truami=2, the computer will warn the abstractor the data is contradictory.Do Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.begin+{txt:acs_both} {err:ekgdone4} {err:nextecg}108comunecgacute 47Does the record of this patient transferred from a community hospital document that any of the following were identified on the initial ECG? {p_end}{p2col:}1. ST segment elevation{p_end}{p2col:}o-Acute myocardial infarction (AMI) or myocardial infarction (MI) with any mention of location or combination of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination){p_end}{p2col:}o-Q wave AMI{p_end}{p2col:}o-Q-wave MI, if described as acute{p_end}{p2col:}o-ST ({p_end}{p2col:}o-ST changes consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation consistent with injury, infarct, ischemia, or MI{p_end}{p2col:}o-ST elevation myocardial infarction (STEMI){p_end}{p2col:}o-ST segment noted as > = .10mV{p_end}{p2col:}o-Transmural AMI{p_end}{p2col:}o-Transmural MI, if described as acute {p_end}{p2col:}2. Left bundle branch block (LBBB) (new or not known to be old){p_end}{p2col:}o-intermittent LBBB{p_end}{p2col:}o-intraventricular conduction delay of LBBB type{p_end}{p2col:}o-variable LBBB{p_end}{p2col:}3. LBBB old {p_end}{p2col:}4. ST segment depression, old and/or unchanged{p_end}{p2col:}5. T wave inversion{p_end}{p2col:}6. Non-specific ST segment and T wave changes {p_end}{p2col:}7. Normal ECG{p_end}{p2col:}8. Q waves{p_end}{p2col:}9. Right bundle branch block{p_end}{p2col:}10. Transient or dynamic ST segment changes in association with rest angina{p_end}{p2col:}11. Sustained ventricular tachycardia runs and/or sustained ventricular tachycardia with hypotension{p_end}{p2col:}12. ST segment depression, new or not known to be old{p_end}{p2col:}99. no documentation of any of the aboveK1,2,3,4,5,6,7,8,9,10,11,{p_end}{p2col:}12, 99{p_end}{p2col:}Go to transtropDo Not include the following as ST elevation:{p_end}{p2col:}o- Non Q wave MI (NQWMI){p_end}{p2col:}o- Non ST elevation MI (NSTEMI){p_end}{p2col:}o- ST elevation due to early repolarization{p_end}{p2col:}o- ST elevation due to left ventricular hypertrophy (LVH){p_end}{p2col:}o- ST elevation due to normal variant{p_end}{p2col:}o- ST elevation with mention of pericarditis{p_end}{p2col:}o- ST elevation with mention of Printzmetal/Printzmetal's variant{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described as old or previously seen{p_end}{p2col:}o- ST segment elevation, or any of the other ST segment elevation inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do Not include the following as Left Bundle Branch Block {p_end}{p2col:}o- incomplete left bundle branch block (LBBB){p_end}{p2col:}o- intraventricular conduction delay (IVCD){p_end}{p2col:}o- left bundle branch block (LBBB), or any other left bundle branch block inclusion terms, described using one of the following qualifiers: cannot exclude, cannot rule out, diagnostic of, may have, may have mad, may indicate, possible, suggestive of, suspect, or suspicious{p_end}{p2col:}Do not use the EKG tracing to answer this question. The ST segment elevation or left bundle branch block must be identified from the ECG interpretation or by clinician documentation.begin{txt:acs_arr} {txt:acs_inpt}109asanoneacute 48Does the record document one or more of the following contraindications to aspirin:{p_end}{p2col:}1. Aspirin allergy{p_end}{p2col:}2. Active bleeding on arrival or within 24 hours after arrival{p_end}{p2col:}3. Warfarin/Coumadin as pre-arrival medication{p_end}{p2col:}4. Other reasons documented by MD, NP, or PA{p_end}{p2col:}98. Patient's direct refusal to take aspirin{p_end}{p2col:}documented in the record.{p_end}{p2col:}99. No documented contraindicationS1*,2*,3*,4*,98,99{p_end}{p2col:}*If 1,2,3,4, or 98, go to platagg, else go to asa241. History of allergy, sensitivity, reaction, or intolerance to aspirin also includes medications that contain aspirin. Where there is documentation of an aspirin "allergy" or "sensitivity," regard this as aspirin allergy regardless of what type of reaction might be noted. {p_end}{p2col:}2. When unable to determine for certain whether bleeding occurred on arrival or within 24 hours after arrival, do not select this option.{p_end}{p2col:}3. Warfarin/Coumadin as pre-arrival medication = refer to patient's medication regimen just prior to acute care treatment. Include warfarin/Coumadin the patient was on at home, the nursing home, a transferring psychiatric hospital, etc. Do not include warfarin taken in the ambulance en route to the hospital. Include cases where the patient was prescribed warfarin/Coumadin at home, but there is indication it was on temporary hold or the patient was non-compliant.{p_end}{p2col:}4. "Other reasons" documented by MD, NP, or PA must explicitly link the noted reason with non-prescription of aspirin. If the patient is taking clopidogrel (Plavix) or ticlopidine hydrochloride (Ticlid), clinician documentation must specify the use of this drug is the reason aspirin was not given.{p_end}{p2col:}5. For documentation of OB+ stools, look in lab reports and nursing notes. When determining whether there is post-procedure bleeding noted as abnormal, do NOT consider sandbags applied to the groin area post-PCI or cardiac cath.revised definition{txt:acs_both}110asa24acute 49Did the patient receive aspirin within 24 hours before or after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?;1,2*{p_end}{p2col:}*If 2, go to platagg, else go to aspdate2 = patient did not receive aspirin within the time period or unable to determine from medical record documentation {p_end}{p2col:}If aspirin was taken by the patient or given by emergency personnel on the way to the hospital, answer "1." If ASA was given at another level of care at this VAMC, answer "1."{p_end}{p2col:}Do not assume patient took ASA prior to arrival based solely on aspirin being listed as a pre-arrival or home medication. Documentation must indicate the patient actually took aspirin within the 24-hour time frame.{txt:acs_both} {err:asanone 99}111aspdateacute 50+Enter the date the patient received aspirin mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.+{txt:acs_both} {err:asanone 99} {err:asa24}112asptimeacute 51+Enter the time the patient received aspirin_____{p_end}{p2col:}UMTNIf the patient did not receive aspirin post-admission, or at the time of the ECG if ACS occurred inpatient, and when the patient took aspirin within a 24 hour period prior to arrival cannot be known, (Example: "patient's wife thinks he took aspirin during the night before he came to the hospital"), do not guess. Answer 2 to "asa24."+{txt:acs_both} {err:asanone 99} {err:asa24}113plataggacute 52Did the patient receive a platelet aggregation inhibitor within the first 24 hours after arrival, or abnormal ECG if ACS occurred as inpatient? {p_end}{p2col:}1. clopidogrel (Plavix){p_end}{p2col:}2. ticlopidine (Ticlid){p_end}{p2col:}3. dipyridamole (Persantine){p_end}{p2col:}4. dipyridamole and aspirin (Aggrenox){p_end}{p2col:}98. patient's direct refusal to take platelet aggregation inhibitor documented in record{p_end}{p2col:}99. none of these medicationsp1,2,3,4,98*,99**{p_end}{p2col:}*If 98, go to betanone{p_end}{p2col:}**If 99, go to platcont, else go to platdateClopidogrel and ticlopidine are inhibitors of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in patients with established athererosclerotic cardiovascular disease as evidenced by stroke, TIA, and AMI. Patients who have a true allergy to aspirin and no contraindication to antiplatelet therapy may be given clopidogrel, ticlopidine, or dypyridamole.{txt:acs_both}114platdateacute 53GEnter the date the patient received the platelet aggregation inhibitor. mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable."{txt:acs_both} {txt:platagg 98 99}115platimeacute 54GEnter the time the patient received the platelet aggregation inhibitor.4_____{p_end}{p2col:}UMT{p_end}{p2col:}Go to betanoneEnter the time of administration during the first 24 hours after hospital arrival or transfer to a monitored bed, using military time."{txt:acs_both} {txt:platagg 98 99}116platcontacute 55yIs there clinician documentation in the record that a platelet aggregation inhibitor is contraindicated for this patient?1,2jPotential adverse effects of platelet aggregation inhibitors: nephrotic syndrome, hyponatremia, blood cell disorders, TTP (thrombotic thrombocytopenic purpura). The abstractor may not make the decision that a platelet aggregation inhibitor is contraindicated because one of these factors is present. There must be clinician documentation of the contraindication.{txt:acs_both} {err:platagg 99}117betanoneacute 56JDoes the record document one or more of the following contraindications/reasons for not prescribing a beta blocker?{p_end}{p2col:}1. Beta blocker allergy{p_end}{p2col:}2. Bradycardia (heart rate less than 60 bpm) on arrival or within 24 hours of arrival while not on a beta blocker {p_end}{p2col:}3. Second or third degree heart block on ECG on arrival or within 24 hours of arrival and does not have a pacemaker{p_end}{p2col:}4. Systolic blood pressure less than 90 mm HG on arrival or within 24 hours of arrival{p_end}{p2col:}5. Other reasons documented by an MD, NP, or PA for not giving a beta blocker within 24 hours after hospital arrival{p_end}{p2col:}7. Heart failure on arrival or within 24 hours after arrival{p_end}{p2col:}8. Shock on arrival or within 24 hours after arrival{p_end}{p2col:}9. Post-heart transplant patient{p_end}{p2col:}10. Severely decompensated heart failure, as evidenced by patient receiving IV dobutamine, milrinone, or nesiritide {p_end}{p2col:}98. patient's direct refusal to take beta blocker documented in record{p_end}{p2col:}99. No documented contraindication1*,2*,3*,4*,5*,7*,8,*{p_end}{p2col:}9*, 10*, 98*, 99{p_end}{p2col:}*If 1,2,3,4,5,7,8,9, 10, or 98 go to hepin24, else go to beta24^Option Rules:{p_end}{p2col:}Beta blocker allergy = when there is documentation of a beta blocker "allergy" or "sensitivity," regard this as an allergy regardless of what type of reaction may be noted.{p_end}{p2col:}Bradycardia = must be substantiated by documentation of a heart rate of 60 beats per minute on arrival or within 24 hours of arrival.{p_end}{p2col:}Second or third degree heart block = Do not attempt to use the EKG tracing to answer this question. The EKG interpretation of second or third degree heart block must be documented in the record by a clinician or by electronic interpretation. Documentation of the EKG interpretation does not have to be linked specifically to contraindication to beta-blocker.{p_end}{p2col:}Systolic blood pressure = may be taken from the vital sign records on arrival for the first 24 hours after arrival at the hospital{p_end}{p2col:}Other reasons = MD, NP, or PA documentation must explicitly link the noted reason with non-prescription of a beta-blocker{p_end}{p2col:}For example: COPD listed as a diagnosis is not a specific contraindication to beta-blocker therapy. There must be clinician documentation that beta-blockers have not been prescribed for this patient due to his/her COPD or asthma.{p_end}{p2col:}Heart failure = must be documented by MD, NP, or PA {p_end}{p2col:}Shock = must be documented by an MD, NP, or PA{txt:acs_both}118beta24acute 57Did the patient receive a beta blocker within 24 hours after arrival at a VHA hospital, or abnormal ECG if ACS occurred as inpatient?:1,2*{p_end}{p2col:}*If 2, go to hepin24, else go to bbdateR2 = Beta blocker not given within 24 hours after hospital arrival or ECG if the AMI occurred as inpatient, or unable to determine from medical record documentation{p_end}{p2col:}Refer to drug list for listing of beta blockers.{p_end}{p2col:}Answer "1" if an IV beta blocker (eg. metoprolol) was given in the ED within 24 hours of arrival. {txt:acs_both} {err:betanone 99}119bbdateacute 582Enter the date the patient received a beta blocker mm/dd/yyyy?Enter the exact date. Month = 01 or day = 01 is not acceptable.-{txt:acs_both} {err:betanone 99} {err:beta24}120bbtimeacute 592Enter the time the patient received a beta blocker_____{p_end}{p2col:}UMTTo convert from am/pm time to military, add 12 to 1:00 pm and after. To convert from military to am/pm, subtract 12 after 1:00 p.m., i.e., 1842 hrs = 6:42 p.m.-{txt:acs_both} {err:betanone 99} {err:beta24}121specbetaacute 60;Designate the beta blocker the patient received within 24 hours after arrival at the hospital, or ECG if the ACS occurred as inpatient:{p_end}{p2col:}1. metoprolol succinate (Toprol-XL){p_end}{p2col:}2. metoprolol tartrate{p_end}{p2col:}3. bisoprolol (Zebeta or Ziac){p_end}{p2col:}4. carvedilol (Coreg){p_end}{p2col:}5. atenolol (Tenoretic or Tenormin){p_end}{p2col:}6. acebutolol (Sectral) {p_end}{p2col:}7. sotalol (Betapace) {p_end}{p2col:}8. betaxolol (Kerlone) {p_end}{p2col:}9. carteolol (Cartrol) {p_end}{p2col:}10. nadolol (Corgard) {p_end}{p2col:}11. nadolol/bendroflumethiazide (Corzide) {p_end}{p2col:}12. propranolol (Inderal) {p_end}{p2col:}13. propranolol hydrochloride (Inderide) {p_end}{p2col:}14. labetalol (Normodyne or Trandate) {p_end}{p2col:}15. penbutolol sulfate (Levatol) {p_end}{p2col:}16. metoprolol/hydrocholorthiazide (Lopressor HCT ) {p_end}{p2col:}17. penbutolol sulfate (Levatol) {p_end}{p2col:}18. pindolol (Visken) {p_end}{p2col:}19. timolol (Timolide or Blocadren) {p_end}{p2col:}20. timolol/hydrocholorthiazide{p_end}{p2col:}21. brevibloc (EsmololD1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,{p_end}{p2col:}18,19,20,21SBeta blocker generic names are not capitalized. Brand names are capitalized.{p_end}{p2col:}Enter the number corresponding to the generic name documented in the medical record.{p_end}{p2col:}Question is applicable to the beta blocker administered to the patient within 24 hours after arrival at the hospital, or ECG if the ACS symptoms occurred as inpatient.{p_end}{p2col:}Beta blocker the patient may have been taking prior to arrival at the hospital is not applicable to this question.{p_end}{p2col:}Source: medication administered in the ED, admitting note, admission orders, medications given-{txt:acs_both} {err:betanone 99} {err:beta24}122hepin24acute 61PDid the patient receive heparin within 24 hours after arrival or ECG if ACS occurred as inpatient?{p_end}{p2col:}1. received nonfractionated heparin{p_end}{p2col:}2. received low molecular weight heparin{p_end}{p2col:}98. patient's direct refusal of heparin documented in record{p_end}{p2col:}99. did not receive heparin within 24 hoursE1,2,98,99*{p_end}{p2col:}*If 98 or 99, go to dotrop, else go to hepdtNonfractionated heparin= heparin sodium (Heparin){p_end}{p2col:}Low molecular weight heparin= enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), nadroparin (Fraxiparine), reviparin (Clivarin), and certoparin (Sandoparin).{p_end}{p2col:}99 = patient did not receive heparin or did not receive initial dose within 24 hours of arrival, or ECG if the veteran was already an inpatient.{txt:acs_both}123hepdtacute 62+Enter the date the patient received heparin mm/dd/yyyy9Enter the exact date. Month=01 or day=1 is not acceptable"{txt:acs_both} {txt:hepin24 98 99}124heptmeacute 63+Enter the time the patient received heparin_____{p_end}{p2col:}UMTEnter the time of initial administration during the first 24 hours after hospital arrival or ECG if the veteran was already an inpatient, using military time."{txt:acs_both} {txt:hepin24 98 99}125dotropacute 64/Was a troponin level obtained for this patient?;1,2*{p_end}{p2col:}*If 2, go to hgbdone, else go to howtropTroponin is a protein complex consisting of three isotypes, T, I, and C. Troponin has become the marker of choice for diagnosis of myocardial necrosis, and Troponin T and I are powerful tools for risk stratification. Portable devices allow bedside (point of care or POCT) cardiac marker determinations rapidly and accurately. Point of care systems have the advantage of reducing diagnostic delays due to transportation and processing in a central laboratory{txt:acs_both}126howtropacute 65How was the first troponin level obtained after hospital arrival or ECG if ACS as inpatient?{p_end}{p2col:}1. point of care bedside testing{p_end}{p2col:}2. central laboratory assay1,2Poin