Cardiovascular Surgery 30 Day Patient Follow Up
[pic] Patient Name: _____________________________________
Procedure: ____________________________________Surgeon: ____________________________
Date of Surgery: ____________________ Date Return Visit: _________________________________
--------------------------------------------------------------------------------------------------------------------------------------------
ALIVE, NO ISSUES @ 30 Days
Readmission to any hospital within 30 Days from Date of Discharge: Yes No
Readmission Reason: ___Anticoagulation Complication – Pharmacological
___ Anticoagulation Complication – Valvular __ Transplant Rejection
___Arrhythmias/Heart Block __ Other – Related Readmission
___Congestive Heart Failure __ Other – Nonrelated Readmission
___Coronary Artery/Graft Dysfunction __ Vascular Complication, Acute
___DVT __ VAD Complication
Readmit Date (if known) ___Endocarditis ___Valve Dysfunction ___Infection – Deep Sternum/Mediastinitis ___Unknown
___Infection – Conduit Harvest Site ___Other Planned Readmission
___ Myocardial Infarction and /or Recurrent Angina
___PE
___Pericardial Effusion and/or Tamponade
___Permanent CVA
___ Pleural Effusion and/or Tamponade
___Pleural effusion requiring intervention
___Pneumonia
___Renal Failure
___Respiratory Complication, Other
___ Stroke
___TIA
Readmit Reason – Primary Procedure: ___ OR for Bleeding
___Pacemaker Insertion/AICD
___PCI
___Pericardiotomy/Pericardiocentesis
___OR for Coronary Arteries
___OR for Valve
___Dialysis
___OR for Vascular
___OR for Sternal Debridement or Muscle Flap
___No Procedure Performed
___Other Procedure
___Thoracentesis/Chest tube Insertion
___Wound Vac
___Unknown
-----------------------------------------------------------------------------------------------------------------------------------------
30 Day Follow up Status: ___ Case Completed, Date: _____________
___ Still In Hospital, Date: ______________
___ Re Check Date: ___________________
Medical Record Number: ________________ ___ Re Check Date: ___________________
___Changed in STS Cardiac Surgery Database
Mortality: Yes No
Discharge Status: Dead Alive
Status at 30 days after surgery: Dead Alive
Operative Death: Yes No (if yes, please complete the following)
Date of Mortality: ______________________ Location of Death: ___OR during initial surgery
___Hospital
___Home
___Other Care Facility
___OR during Reoperation
Primary Cause of Death: ___Cardiac ___Vavlular
___Renal ___Other (Explain) _______________________________________________________
___Vasc ___Unknown
___Infection
___Pulm
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Michigan STS Database
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