V. 81 Sts adult Cardiac Surgery Database Training Manual, Effective 07/01/2014 1/2017



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v. 2.81 STS Adult Cardiac Surgery Database Training Manual, Effective 07/01/2014 1/2017


Introduction



This manual is intended to clarify field definition and intent. This document contains the most up to date instructions for v. 2.81 data abstraction. Do not refer to old manuals or other data definitions. Please review this document prior to submitting clinical questions. FAQs will be added to the document in red to provide additional examples and clarification. Please do not print this document since it will change frequently. Using the web version will ensure that you have the most up to date information. Occasionally there may be changes or important information that will be highlighted here and will be also included in STS Database Newsletters. Use the Ctrl + F function to search for a number or term of interest.

Bookmarks have been added for January 2017 updates.



General Information:

The STS data collection forms should be held for two years.

If you only collect data directly to the software you are not required to create data collection forms to save.
For all questions where the choices include “no” and “unknown”, how should the question be coded when there is no specific documentation?

When a history and physical or a consultation exists in the medical record and the values are not specifically addressed in the documentation, code no. Unknown should be coded only in the circumstance where no clinical documentation exists and the patient cannot give history and supportive documentation.


Will the STS plan to extract data from the EMR?

Some but not all could be collected from the EMR. Some fields are too complex to extract from the EMR in real time. Caution needs to be used with auto data transfer from the EMR.
Is there a list of the procedures that should be included in the Adult Cardiac Surgery Database?

While there is no all inclusive list of procedures to be included, all procedures must include a surgeon that is listed in the participation agreement with the STS.


  1. Administrative




Seq. #: 5


Long Name: Software Vendor Identifier; Short Name: VendorID

Definition: Name (assigned by STS) given to identify software vendor (up to 8 characters). Vendors should use standard name identification across sites. Changes to Vendor Name Identification must be approved by the STS.

Intent/Clarification:


Name must match what is listed as the Active vendor for your Participant ID in the database. Any mismatch will cause your data file submission not to process.


Seq. #: 10


Long Name: Software Version; Short Name: SoftVrsn

Definition: Vendor's software product name and 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 warehouse.

Intent/Clarification:




Seq. #: 15

Long Name: STS Data Version; Short Name: DataVrsn

Definition: Version number of the STS Data Specifications/Dictionary, to which each record conforms. It will identify which fields should have data, and what are the valid data for each field. This must be entered into the record automatically by the software.

Intent/Clarification:


Data version must be appropriate for the procedure date listed in the record. Any mismatch will cause your data file submission not to process. Valid date ranges can be found in the current Software Specifications.

Seq. #: 20


Long Name: On‐Demand Files Version Number; Short Name: OnDemandVrsn

Definition: The version number of the On‐Demand lists in use at the time this data record was created or edited. The value is inserted into the record at the time the record is created or is modified by the user. The version numbers will be specified by the STS.

Intent/Clarification:


Inconsistencies here do not prevent your file from being processed. However, any mismatch will appear in your Data Quality Report (DQR) as a value that could not be interpreted. You should contact your designated Data Submission Coordinator for assistance.


Seq. #: 25


Long Name: Participant ID; Short Name: ParticID

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.

Each participant's data if submitted to harvest must be in one data file. If one participant keeps their data in more than one file (e.g. at two sites), then the participant must combine them back into one file for harvest submission.

If two or more participants share a single purchased software, and enter cases into one database, then the data must be extracted into two different files, one for each participant ID, with each record having the correct participant ID number.

Intent/Clarification:


Each participant's data if submitted to harvest must be in one data file. If one participant keeps their data in more than one file (e.g. at two sites), then the participant must combine them back into one file for harvest submission.

If two or more participants share a single purchased software, and enter cases into one database, then the data must be extracted into two different files, one for each participant ID, with each record having the correct participant ID number.




Seq. #: 30


Long Name: Record ID; 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:


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.


Seq. #: 35


Long Name: Cost Link; Short Name: CostLink

Definition: A participant specified alpha‐numeric code that can be used to link this record's clinical data with the participant's cost information for this patient admission. This information may be used in the future to perform procedure cost analysis (for which the actual cost data would have to be harvested separately). The value in this field must not be the patient's Medical Record Number, Social Security Number or any other patient identifying value.

Intent/Clarification:


This information may be used in the future to perform procedure cost analysis (for which the actual cost data would have to be harvested separately). The value in this field must not be the patient's Medical Record Number, Social Security Number or any other patient identifying value.


Seq. #: 40


Long Name: Patient ID; Short Name: PatID

Definition: An arbitrary value (not a recognizable ID like Social Security Number or Medical Record Number) 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. Once assigned to a patient, this can never be changed or reused. If a patient is admitted to the hospital more than once, each record for that patient will have the same value in this field.

Intent/Clarification:


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 patient, this can never be changed or reused. If a patient is admitted to the hospital more than once, each record for that patient will have the same value in this field.


Seq. #: 45


Long Name: Patient Participating In STS‐Related Clinical Trial; Short Name: ClinTrial

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:


A list of trials will be posted as they are started.

There are currently no STS trials underway in the Adult Cardiac Surgery Database.




Seq. #: 46


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.


Intent/Clarification: Instructions will be provided for each trial.




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