1. Full name*
2. Date of birth*
3. Social security number*
4. Medical record number*
5. Gender

*These identifiers are needed for PHI scrubbing and the Blinded Recorded Index. They are NOT sent to the central repository.

Basic Case Information

1. Admission type
2. Age at time of operation
3. Facility and operating room type
4. Primary procedure text
5. Primary diagnosis text

Preoperative Documentation†

1. ASA status
2. Height
3. Weight
4. Labs taken up to 365 days before anesthesia
5. Basic comorbidities (cardiac, pulmonary, endrocrine, renal, hepatic, immunologic) entered into preoperative H&P‡
6. Home medications

†This list is the minimum requirement, but it is strongly encouraged that institutions contribute more data elements.
‡This is required for all Blue Cross Blue Shield participating sites

Intraoperative Documentation

1. Case times
2. Fluid inputs and outputs
3. Medication administrations
4. Observational and procedure notes
   1. Examples include tourniquet up, bypass start, intubation notes
5. Point of care labs
6. Staff tracking
7. Sign-in/outs for anesthesia attendings
8. Vital signs, machine captured minute-by-minute

Postoperative Documentation

1. Labs taken up to 365 days after anesthesia
2. In hospital all cause mortality

Outcomes

1. In-hospital mortality

Charge Capture & Administration

1. Hospital discharge billing codes
2. Professional fee anesthesia billing codes
3. Primary payer