GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL January 2018 Table of Contents 1. Demographics ................................................................................................................................................................. 2 2. Follow Up ........................................................................................................................................................................ 9 3. Admission ..................................................................................................................................................................... 10 4. Pre-Operative Evaluation ............................................................................................................................................. 14 5. Diagnosis (Category of Disease) ................................................................................................................................... 49 6. Procedure ..................................................................................................................................................................... 72 7. Post-Operative Events ................................................................................................................................................ 114 8. Discharge .................................................................................................................................................................... 141 9. Quality Measures ....................................................................................................................................................... 145 10. Nodal Stations ........................................................................................................................................................ 148 1/2018 1 GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL January 2018 The training manual is intended to clarify data definitions, provide examples and answer FAQs. It will be updated with new FAQs. 1. Demographics Seq. #: 10 Long Name: Operations Table Record Identifier Short Name: RecordID Definition: An arbitrary, unique value generated by the software that permanently identifies each record in the participant's database (note that unlike the PatID value, this does not identify the individual patient). The value of the identifier is a combination of a code assigned to the software developer by the STS, and a value generated by the software to create a unique value. Once assigned to a record, this value can never be changed or reused. The data warehouse will use this value to communicate issues about individual records with the participant. It may also be used by the data warehouse to link this record to other clinical data. Intent/Clarification: A record should be initiated for inpatient and outpatient thoracic procedures on every visit to the operating room (includes the Endoscopy Suite or Outpatient Surgical Center) whether planned or unplanned. Seq. #: 20 Long Name: Procedures Table Record Identifier Short Name: RecordID Definition: This field is the foreign key that links this record with the associated records in the "Operations" table. Seq. #: 30 Long Name: Software Vendor's Identification Short Name: VendorID Definition: Software vendor's identification assigned by the STS. Seq. #: 40 Long Name: Vendor's Software Version Number Short Name: SoftVrsn Definition: Vendor's software product version number identifying the software which created this record. Vendor controls the value in this field. Version passing certification/harvest testing will be noted at the data warehouse. Seq. #: 50 Long Name: Version Of STS Data Specification Short Name: DataVrsn Definition: Version number of the STS Data Specifications/Dictionary, to which the record conforms. The value will identify which fields should have data, and what are the valid data values for those fields. It must be the version implemented in the software at the time the record was created. The value must be entered into the record automatically by the software. Seq. #: 60 Long Name: Participant ID Short Name: ParticID 1/2018 2 GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL January 2018 Definition: Participant ID is a unique number assigned to each database participant by the STS. A database participant is defined as one entity that signs a Participation Agreement with the STS, submits one data file to the harvest, and gets back one report on their data. The participant ID must be entered into each record. Intent/Clarification: Each participant's data, if submitted to harvest, must be in one data file. If one participant keeps data in more than one file (e.g. at two sites), the participant must combine them back into one file for harvest submission. If two or more participants share single purchased software and enter cases into one database, the data must be extracted into two different files, one for each participant ID, with each record having the correct participant ID number. Seq. #: 70 Long Name: Operations Table Patient Identifier Short Name: PatID Definition: The foreign key that links this record with the associated records in the "Demographics" table. Intent/Clarification: Once assigned to a patient, this number can never be changed or reused. Seq. #: 80 Long Name: Demographics Table Patient Identifier Short Name: PatID Definition: An arbitrary value that uniquely and permanently identifies each patient. The value of the identifier is a combination of a code assigned to the software developer by the STS, and a value generated by the software to create a unique value. The value in this field cannot be a value that would identify the patient outside of the database (such as Medical Record Number or Social Security Number). Once a value has been assigned to a patient, it can never be changed or reused. This field is the primary key that links this record with the associated records in the "Operations" table. Seq. #: 90 Long Name: Demographics Table Data Version Short Name: DemogDataVrsn Definition: Version number of the STS Data Specifications/Dictionary, to which the Demographics record conforms. The value will identify which fields should have data, and what are the valid data for those fields. It must be the version implemented in the software at the time the record was created. The value must be entered into the record automatically by the software. Note that the data version of the demographics record does not necessarily need to match the data version of all of the associated operation records for that patient. This is because new data versions might be implemented in the software and used for the creation of operation records after a demographics record has been created for a patient. Seq. #: 100 Long Name: Medical Record # Short Name: MedRecN Definition: Indicate the patient's medical record number at the hospital where surgery occurred. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: 1/2018 3 GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL January 2018 This field is not required for record inclusion Seq. #: 110 Long Name: Patient's First Name Short Name: PatFName Definition: Indicate the patient's medical record number at the hospital where surgery occurred. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: This field is not required for record inclusion Seq. #: 121 Long Name: Patient's Middle Name Short Name: PatMName Definition: Indicate the patient's middle name as documented in the medical record. Leave "blank" if no middle name. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: Leave “blank” if no middle initial. This field is not required for record inclusion Seq. #: 130 Long Name: Patient's Last Name Short Name: PatLName Definition: Indicate the patient's medical record number at the hospital where surgery occurred. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: This field is not required for record inclusion Seq. #: 140 Long Name: Social Security Number Short Name: SSN Definition: Indicate the patient’s Social Security Number (SSN). Although this is the Social Security Number in the USA, other countries may have a different National Patient Identifier Number. For example in Canada, this would be the Social Insurance Number. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: This field is not required for record inclusion Seq. #: 151 Long Name: Patient Participating In STS-Related Clinical Trial Short Name: ClinTrial 1/2018 4 GENERAL THORACIC SURGERY DATABASE v.2.3 TRAINING MANUAL January 2018 Definition: Indicate which, if any, STS-related clinical trial in which the patient is participating. The STS will assign a code to each clinical trial as they begin collecting data. Intent/Clarification: This applies only to STS trials. The instructions will be posted here when trials are available. There are currently no trials underway. Seq. #: 152 Long Name: Patient Participating In STS-Related Clinical Trial - Patient ID Short Name: ClinTrialPatID Definition: Indicate the patient identifier used to identify the patient in the clinical trial. Seq. #: 160 Long Name: Date Of Birth Short Name: DOB Definition: Indicate the patient's date of birth using 4-digit format for year. This field should be collected in compliance with state/local privacy laws. Intent/Clarification: