1. Patient Identifiers (Local Only – for PHI scrubbing/BRI)

• • • Full name* 
    • DOB* 
    • SSN* 
    • MRN* 
    • Gender (sex at birth, legal sex, gender identity) 

*Stored locally only. Not transmitted to MPOG. 

2. Basic Case Information

• • • Admission type 
    • Surgical service 
    • Age at procedure 
    • Facility & procedure room type 
    • Primary procedure text 
    • Primary diagnosis text 

3. Preoperative Data

Required 

• • • ASA status 
    • Anesthetic plan 
    • Height (within 30 days before procedure) 
    • Weight (within 30 days before procedure) 
    • Basic comorbidities from H&P (cardiac, pulmonary, endocrine, renal, etc.)† 
    • Home medications (name, dose, frequency) 
    • Core physiologic variables (SBP, DBP, HR, Temp, Temp route) 

† H&P timeframe is determined by the site’s extract.  

• • • Review of Systems, preop notes, events, nursing notes 
    • Substance use history 
    • Emergency status 
    • Admission status (inpatient/outpatient) 
    • PMH, PSH, anesthesia history 
    • Race/ethnicity 
    • Smoking/Tobacco Use status 
    • Last Menstrual Period 

4. Intraoperative Data

Case Times 

• • • Anesthesia start/end 
    • In room/out room 
    • Procedure start/end 
    • Incision time 
    • PACU phases I/II/III in/out 

Monitoring & Physiologic Data (machine + manual) 

• • • SBP/DBP (invasive, non-invasive, continuous) 
    • HR (EKG & SpO2) 
    • Respiration Rate 
    • SpO2 
    • Temperature & route 
    • Train of Four 
    • Pain scores 
    • Ventilator data (mode, TV, RR, PEEP, pressures, I:E, gases) 

Medications & Fluids 

• • • All intraop meds (start/end times for infusions) 
    • IV fluids 
    • Vasopressors, inotropes, antihypertensives 
    • Antibiotics, insulin, steroids, antiemetics, pain meds 

Intake/Output 

• • • IV intake 
    • Blood products (PRBC, plasma, platelets, cell saver, whole blood) 
    • EBL, urine, emesis 

Notes & Events 

• • • Airway, line, block placement notes 
    • Procedure/anesthesia notes 
    • Intraop events 
    • Provider handoffs 

Staff Tracking 

• • • Sign-in/out for attendings 
    • All anesthesia, surgical, nursing, perfusion, trainee roles 

5. Postoperative Data

• • • PACU notes & events 
    • PACU phase times (In/Out, Phase I, II, III times, Transfer to Floor Time) 
    • Postop physiologic data  
    • Postop handoff & destination 
    • In-hospital mortality 

6. Outcomes

• • • In-hospital mortality 
    • Postoperative Nausea and Vomiting (PONV) 
    • Reintubation 
    • Difficult intubation 
    • Hypothermia 
    • Dysrhythmia 
    • Dental injury 
    • Laryngospasm 
    • Failed/inadequate block or neuraxial 
    • Cardiac arrest 

7. Procedures & Clinical Events to Capture

Airway 

• • • ETT/LMA placement, size, removal 
    • Intubation/extubation 

Blocks / Neuraxial 

• • • Spinal, epidural, labor epidural, CSE, regional 
    • Needle size, location, technique, paresthesia 

OB 

• • • Contraction frequency/duration 
    • FHR, Apgar 
    • Delivery of newborn/placenta 
    • Uterine incision 

Lines / Cardiac / Bypass 

• • • Arterial line placement, size, location 
    • Cardiopulmonary bypass timing & components 
    • Circulatory arrest, cooling, clamp times, cardioplegia 

8. Charge Capture & Billing

• • • Hospital discharge billing codes 
    • Professional anesthesia billing codes 
    • Primary payer 
    • All discharge diagnoses from stay 

9. Labs

• • • All labs ±365 days from DOS 
    • Extendable if patient has additional cases 

10. Supplemental (Optional Extracts)

• • • Microbiology
    • Patient attributes