Surgical procedures and follow-up (Surgical procedures and follow-up)

Version: from 01/01/2020 - 31/12/2020
Status: inactive
How to create a CSV file for this data collection?

Start date: 01/01/2020
End date creation: 09/05/2023
End date submission: 09/05/2023
End date comments: 09/05/2023

Full view CSV column names Validation rules Reference lists Computed expressions Additional information CSV extract

1 Patient

patient identificator

Patient identificator

Help

Please encode a social security identification number (SSIN). Please note that the patient ID is always pseudonymised before being transferred to Healthdata.

Technical specs

CSV column name:

patient_id

Required:

true

Validation

The validity of the national register number is checked with the mod97 check.

Fields

Section help

Please encode a social security identification number (SSIN). Please note that the patient ID is always pseudonymised before being transferred to Healthdata.

text

Internal patient ID

Help

This field can be used to enter an internal ID or reference number. It is available for internal use only and is not transferred to Healthdata. If there is an integration between HD4DP and your organisation's patient administration system, additional patient identification information such as date of birth, sex and SSIN can be automatically enriched based on this internal patient ID. Please do not encode the social security identification number (SSIN) in this field. The SSIN must be encoded in the field 'National registry ID of the patient'.

Technical specs

CSV column name:

patient_id|internal_patient_id

Required:

false

boolean

Generated

Help

The patient_id|generated column can be set to 'TRUE' for an automatically generated patient_id.This column should only be added in case the patient_id is empty. If the column is set to 'TRUE', a patient_id is automatically generated based on the name, first name, date of birth and sex of the patient.

Technical specs

CSV column name:

patient_id|generated

Required:

false

Options

Label	Value
Yes	TRUE
No	FALSE

text

Last name

Help

The name of the patient is never transferred to Healthdata and is available for your information only.

Technical specs

CSV column name:

patient_id|name

Required:

noSSIN(Needed only if no national register number is entered)

text

First name

Help

The first name of the patient is never transferred and is available for your information only.

Technical specs

CSV column name:

patient_id|first_name

Required:

noSSIN(Needed only if no national register number is entered)

date

Date of birth

Technical specs

Format:

DD/MM/YYYY

CSV column name:

patient_id|date_of_birth

Required:

noSSIN(Needed only if no national register number is entered)

Validation

The date of birth cannot be in the future (error)
Date of birth cannot be after date of death (error)

choice

Sex

Technical specs

CSV column name:

patient_id|sex

Required:

noSSIN(Needed only if no national register number is entered)

Options

Label	Value
Female	F
Male	M
Unknown	U

text

Place of residence

Technical specs

CSV column name:

patient_id|place_of_residence

Reference list:

POSTAL_CODE

Required:

false

boolean

Deceased?

Technical specs

CSV column name:

patient_id|deceased

Required:

false

Options

Label	Value
Yes	TRUE
No	FALSE

date

Date of death

Technical specs

Format:

DD/MM/YYYY

CSV column name:

patient_id|date_of_death

Only when:

Required:

false

Validation

The date of death cannot be in the future (error)
Date of birth cannot be after date of death (error)

2 Procedures

date

Date of surgical intervention

Technical specs

Format:

DD/MM/YYYY

CSV column name:

DT_SURG_INTVENT

Required:

true

Validation

The date of surgical intervention cannot be in the future (error)

text

NHSN operation category

Help

NHSN operation category, must refer to a NHSN code declared for this surveillance period in the participation screen.

Technical specs

CSV column name:

CD_NHSN_OP_CAT

Length:

Reference list:

SSI_NHSN

Required:

true

number

Surgical intervention number

Help

surgical intervention no (1-3, use 1 as default), in case of multiple interventions of same Operation category with different incisions on this patient on the same date

Technical specs

CSV column name:

NR_SURG_INTVENT

Length:

Required:

true

list

Procedure(s) (ICD-9-CM)

This is a container for multiple answers. See the reference documentation for more details. Below you can find the information about the fields of the container

Help

If available, provide an ICD-9-CM OR a ICD-10-PCS code; provide up to 3 codes for one NHSN operation category

List items

Section help

If available, provide an ICD-9-CM OR a ICD-10-PCS code; provide up to 3 codes for one NHSN operation category

text

Code

Technical specs

CSV column name:

OPICD9_1|CD_ICD_9_CM_PROC

Length:

Reference list:

SSI_ICD9CM

Required:

false

list

Procedure(s) (ICD-10-PCS)

This is a container for multiple answers. See the reference documentation for more details. Below you can find the information about the fields of the container

Help

If available, provide an ICD-9-CM OR a ICD-10-PCS code; provide up to 3 codes for one NHSN operation category

List items

Section help

If available, provide an ICD-9-CM OR a ICD-10-PCS code; provide up to 3 codes for one NHSN operation category

text

Code

Technical specs

CSV column name:

OPICD10_1|CD_ICD_10_CM_PROC

Length:

Reference list:

SSI_ICD10PCS

Required:

false

choice

Multiple intervention type

Technical specs

CSV column name:

CD_MULT_INTVENT_TPE

Required:

false

Options

Label	Value
Single intervention (1)	1
Multiple: same incision, same NHSN category (2)	2
Multiple: same incision, other NHSN category (3)	3
Multiple: other incision (4)	4
Unknown (9)	9

choice

Antibiotic prophylaxis

Technical specs

CSV column name:

CD_ABP

Required:

false

Options

Label	Value
No antibiotics (1)	1
Routine antibiotic prophylaxis (2)	2
Therapeutic antibiotics or exceptional antibiotic prophylaxis (3)	3
Unknown (9)	9

fieldset

Risk index variables

Help

Risk index variables are optional. IMPORTANT: encoding will be only valid if possible for the entire set of variables!

Fields

Section help

Risk index variables are optional. IMPORTANT: encoding will be only valid if possible for the entire set of variables!

text

Time of first incision

Help

Alternatively, specify duration of operation.

Technical specs

CSV column name:

risk_index_variables|TX_START_TIME_INTVENT

Length:

Required:

false

text

Time of wound closure

Help

Alternatively, specify duration of operation.

Technical specs

CSV column name:

risk_index_variables|TX_END_TIME_INTVENT

Length:

Required:

false

number

Duration of the surgical intervention (min)

Help

Alternatively, specify time of incision and time of wound closure.

Technical specs

CSV column name:

risk_index_variables|MS_SURG_INTVENT_DURA

Only when:

Required:

false

choice

Wound class

Technical specs

CSV column name:

risk_index_variables|CD_WOUND_CLASS

Required:

false

Options

Label	Value
Clean (1)	1
Clean - contaminated (2)	2
Contaminated (3)	3
Dirty - infected (4)	4
Unknown (9)	9

choice

ASA score

Technical specs

CSV column name:

risk_index_variables|CD_ASA_SCORE

Required:

false

Options

Label	Value
Healthy (1)	1
Mild systemic disease (2)	2
Severe systemic disease (3)	3
Incapacitating disease (4)	4
Moribund (5)	5
Unknown (9)	9

choice

Elective surgery?

Technical specs

CSV column name:

risk_index_variables|CD_ELECTIVE_SURG

Required:

false

Options

Label	Value
Yes (1)	1
No (0)	0
Unknown (9)	9

choice

Laparoscopy / endoscopy?

Technical specs

CSV column name:

risk_index_variables|CD_LAPA_ENDO

Required:

false

Options

Label	Value
Yes (1)	1
No (0)	0
Unknown (9)	9

3 Follow-up

date

Discharge date

Help

Date of discharge from hospital

Technical specs

Format:

DD/MM/YYYY

CSV column name:

DT_DISCH

Required:

false

Validation

The discharge date cannot be in the future (error)

choice

Status at discharge from hospital

Technical specs

CSV column name:

CD_DISCH_STA

Required:

false

Options

Label	Value
Alive (1)	1
Deceased (4)	4
Unknown (9)	9

date

Last date with info about this patient

Help

Last post-discharge surveillance (PDS) date when info about this patient was obtained. Only encode under optional 'registration of PDS data'. This info will be used to calculate completeness of PDS follow-up. IMPORTANT: even when organizing PDS, it is NOT mandatory to encode this info .

Technical specs

Format:

DD/MM/YYYY

CSV column name:

DT_LAST_INFO_ON_PAT

Required:

false

Validation

The last date with info about this patient cannot be in the future (error)

choice

Provider of info at this date

Help

Provider of the info on the last follow-up date for this patient. Only encode under optional 'registration of post-discharge surveillance (PDS) follow-up'. This info will be used to calculate completeness of PDS follow-up. IMPORTANT: even when organizing PDS, it is NOT mandatory to encode this info.

Technical specs

CSV column name:

CD_PROV_INFO_ON_PAT

Required:

false

Options

Label	Value
General practitioner (1)	1
Infection control practitioner (2)	2
Laboratory (3)	3
Readmissions (4)	4
Surgeon (5)	5
Other (6)	6
Unknown (9)	9

date

Last date when patient was actually seen

Help

Last post-discharge surveillance (PDS) date when this patient was actually seen. Only encode under optional 'registration of PDS data'. This info will be used to calculate completeness of PDS follow-up. IMPORTANT: even when organizing PDS, it is NOT mandatory to encode this info.

Technical specs

Format:

DD/MM/YYYY

CSV column name:

DT_PAT_LAST_SEEN

Required:

false

Validation

The last date when patient was actually seen cannot be in the future (error)

choice

Type of contact at this date

Help

Provider of the info when patient was last seen. Only encode under optional 'registration of post-discharge surveillance (PDS) follow-up'. This info will be used to calculate completeness of PDS follow-up. IMPORTANT: even when organizing PDS, it is NOT mandatory to encode this info.

Technical specs

CSV column name:

CD_TPE_LAST_CONT

Required:

false

Options

Label	Value
General practitioner (1)	1
Outpatient department (2)	2
Hospital readmission (3)	3
Surgeon private consultation (4)	4
Other (5)	5
Unknown (9)	9