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Indiana University

 Guide for Basic HI-IQ Entries

0.  Introduction

 

HI-IQ is our procedure log, complications log and quality assurance database all-in-one.  Maintenance of HI-IQ is a very important aspect of our clinical service, and should not be underestimated.

 

HI-IQ is important to you as a fellow because its data will serve as the procedure record you will use to apply for the CAQ and will take with you to the exam.  You will find the data invaluable in expediting patient work-ups.  Additionally, it will provide a simple, concise way for you to accumulate and review data for presentation at our Morbidity & Mortality conferences.

 

HI-IQ also contains data that are needed by the section for use in requests for staffing increases and new equipment, credentialing and turf battles, fellowship accreditation, clinical research, and for JCAHO and Health Department inspections.

 

HI-IQ data entry must be precise, reproducible, accurate and complete.  Make sure you are not creating duplicate entries by manually searching for the patient’s name.  Verify hospital number and date of birth to ensure you have found the correct patient (as some patients may have the same name).  At University Hospital, old ID numbers (those that contain letters) must be updated.  All fields must be filled out, including “patient status”, “date of birth”, “referring MD” and “ASA class”.  There must always be a sufficiently detailed diagnosis and indication for the procedure(s) performed in the “notes” field, as well as a description of procedure(s) and findings.  Do not abbreviate except with standard, accepted abbreviations, such as PTA.  At University Hospital, please note if a case was performed at Riley Hospital or Methodist Hospital.  At all hospitals, if a procedure was performed out of the department, note where it was performed (in OR, on floor, in cardiac cath lab, etc.).  Patients enrolled in clinical studies should have this noted.  If the procedure is a failure, this must be stated in the Outcomes section. ANY and ALL complications, including their outcome, must be recorded and periodically updated in the Complications section.  Allergies should be entered in that section, especially contrast allergy.

 

Please be extremely careful in your data entry of HI-IQ.  Most errors are due to carelessness and rushing through data entry.  These problems are easily avoidable by reviewing your work before finalizing an entry.

 

The most confusing aspect of HI-IQ data entry is the proper selection of Services.  This Guide was constructed to assist you in this regard.  Examples for correct data entry are given under each major heading.  This list is dynamic and will expand and change as issues arise.


1.  Diagnostic Arteriography

 

Used for diagnostic arterial procedures, including MR angiography and IVUS.

 

Usual thoracic aortogram (eg. trauma, peripheral embolism source):

Arteriography, Diagnostic

Aortic Injections (Non-selective)

Thoracic Aortic Inject

Aortography, Thoracic

 

Usual abdominal aortogram (eg. renal artery stenosis without selective angiogram, mesenteric artery stenosis without selective angiogram)

Arteriography, Diagnostic

Aortic Injections (Non-selective)

Abdominal Aortic Inject

Aortography, Abdomen

 

Usual abdominal aortogram and bilateral lower extremity arteriogram (eg. AAA, PVD, flap planning).  In general, if a subsequent selection of a lower extremity artery is performed for a repeat unilateral arteriogram because the initial study did not come out well, this should NOT be entered in addition to the non-selective.

Arteriography, Diagnostic

Aortic Injections (Non-selective)

Abdominal Aortic Inject

Aortography, Abdomen

Arteriography, Diagnostic

Aortic Injections (Non-selective)

Abdominal Aortic Inject

Pelvis/Lower Ext Angio N.S.

 

Usual selective renal arteriogram (Note: Apply frequency for number of vessels selected; do NOT include non-selective aortic injection):

Arteriography, Diagnostic

Visceral Ang Sel

Renal Ang Sel

 


Usual selective mesenteric arteriogram (Note: Choose all vessels selected; do NOT include non-selective aortic injection):

Arteriography, Diagnostic

Visceral Ang Sel

Celiac Ang Sel

Arteriography, Diagnostic

Visceral Ang Sel

SMA Ang Sel

Arteriography, Diagnostic

Visceral Ang Sel

IMA Ang Sel

 

Usual arch and carotid arteriogram (Note: Apply frequency 2 unless both carotid arteries NOT selected):

Arteriography, Diagnostic

Aortic Injections (Non-selective)

Thoracic Aortic Inject

Cerv-Cerebral Ang N.S.

Arteriography, Diagnostic

Neuro Ang (selective)

Carotid Ang Sel

          CCA Ang Sel

 

Usual pulmonary angiogram (Note: Do NOT enter frequency 2, even when both main pulmonary arteries selected):

Arteriography, Diagnostic

Pulmonary Ang

Pulm Ang Uni/Bilat Sel

 

If IVUS performed in conjunction with or instead of conventional arteriography use:

Arteriography, Diagnostic

Other Angio Dx

Intravascular ultrasound

 

 


Right heart catheterization (usually for pressures and sampling):

Arteriography, Diagnostic

Cardiac Ang

Right Heart Cath

 

All MRA are listed under:

Arteriography, Diagnostic

Other Angio Dx

MRA for renal artery stenosis (including transplants) is MRA Renal

MRA for mesenteric ischemia is MRA Visceral

MRA for AAA is MRA Abdomen

MRA for PVD is MRA Aorta and Runoff (only one entry for whole exam; at the VA you need to click the down arrow to view this choice)


2.  Arterial Intervention

 

Used for interventions in the arterial system.  Be sure to include all diagnostic arteriographic procedures performed in conjunction with the intervention.  Radial arterial line placement is also listed here, although the service is located in Section 1.

 

Usual arterial angioplasty:

Arterial Interventions

PTA Art General

          Choose appropriate vessel

 

Usual arterial stent:

Arterial Interventions

Stent Art General

          Choose appropriate vessel

 

Usual arterial embolization:

Arterial Interventions

Embolization Art General

          Choose appropriate vessel

 

Usual uterine artery embolization for fibroids (Note: Apply frequency 2 to artery selection unless both uterine arteries NOT selected; do NOT apply frequency 2 to embolization procedure):

Arteriography, Diagnostic

Visceral Ang Sel

Hypogastric Ang Sel

Arterial Interventions

Embolization Art General

          Embol Visceral A Gnl

                   Embol Visceral A Other

                             Uterine Fibroid Embo

 

Usual aortic stent-graft for AAA:

Arterial Interventions

Arterial Stent Graft

          Aortic Stent Graft

                   Abdominal Aorta Stent Graft

 


Usual hepatic Lipiodol infusion for HCC identification (Note: Also enter diagnostic angiography services):

Arterial Interventions

Infusion Art (non-lytic)

Inf Visceral A Gnl

                   Inf Celiac A (or Inf SMA if replaced)

 

Usual hepatic chemoembolization (Note: Also enter diagnostic angiography services):

Arterial Interventions

Embolization Art General

          Embol Visceral A Gnl

                   Embol Visceral A Other

                             Hepatic Chembo

 

Usual radial arterial line (usually placed for PET scanner studies):

Arteriography, Diagnostic

Other Angio Dx

Radial artery catheter


3.  Venography

 

Used for venous diagnostic procedures.  If MR venography is performed it is usually listed one level under the conventional venogram.  See Section 4 for TIPS procedures.

 

Usual lower extremity venogram (eg. for DVT):

Venography

Veno Peripheral

Veno, Lower Ext

 

Usual upper extremity venogram, including SVC (eg. for dialysis access planning):

Venography

Veno Peripheral

Veno, Upper Ext

Venography

Veno SVC/IVC

 

 

4.  Venous Intervention

 

Used for interventions in the venous system.  Be sure to also enter any diagnostic service performed in conjunction with the intervention.  Some of these services may be preformed in conjunction with dialysis shunt management services.

 

Usual temporary central venous catheter placement (eg. triple lumen, temporary dialysis):

Venous Intervention Gnl

Venous Access General

Venous Access Direct Placement

          Ven Acc Central Insert

 

Usual PICC line placement:

Venous Intervention Gnl

Venous Access General

Venous Access Direct Placement

          Ven Acc Peripheral Insert (PICC)

 

Usual tunneled catheter placement (dialysis, pheresis, Hickman, TSBCC/“tunneled PICC”):

Venous Intervention Gnl

Venous Access General

Venous Access Tunneled Placement

          Ven Acc Tunnel Ext Port

 

Superior vena cavagram performed to evaluate for central stenosis or occlusion when venous access placement difficult:

Venography

Veno SVC/IVC

 

Usual venous port placement (Note: Give brand and catheter size in Findings):

Venous Intervention Gnl

Venous Access General

Venous Access Tunneled Placement

          Ven Acc w Port (sub q)

 


Usual venous access check (eg. for fibrin sheath, catheter leak):

Venous Intervention Gnl

Venous Access General

Venous Access Line Check

 

Usual over-the-wire venous access change (PICC, temporary, or tunneled) (Note: Do NOT use “Venous Access Stripping” if stripping was performed in conjunction with catheter change):

Venous Intervention Gnl

Venous Access General

Venous Access Line Change

 

Usual infusion of thrombolytic for venous access with fibrin sheath/thrombus:

Venous Intervention Gnl

Venous Access General

Venous Access Thrombolysis

 

Usual tunneled catheter or port removal (Note: Do not use if catheter changed over a wire, but do use if an old catheter was removed and a new catheter placed via a new access).  Always record catheter data (type, size, and access site), whether cuff was removed, whether tip was sent for culture, and whether cutdown was required (Note: Non-tunneled catheter and PICC removals are not recorded in HI-IQ as a separate entry.  They may be added as an addendum in the Notes section in the placement entry.):

Venous Intervention Gnl

Venous Access General

Venous Access Explant

 

Usual IVC filter placement (Note: Always note type of filter used and access used):

Venography

Veno SVC/IVC

Venous Intervention Gnl

Filter Placement

Filter IVC

 

Usual venous (including pulmonary artery) foreign body retrieval:

Venous Intervention Gnl

FB Manip Venous

FB Retrieval Venous

 


Usual adrenal vein sampling (Note: Apply frequency 2 to venogram unless both adrenal veins NOT selected.  Do NOT apply frequency 2 to sampling procedure.):

Venography

          Veno Central/Visceral Sel

                   Adrenal Veno

Venous Intervention Gnl

Venous Sampling Select

Venous Sample Non-neuro

          Venous Sample Adrenal V

 

Usual de novo TIPS creation:

Venous Intervention Gnl

TIPS

TIPS Primary

 

Usual TIPS revision with new stent placement (Note: Do NOT enter TIPS venogram):

Venous Intervention Gnl

TIPS

TIPS Secondary/Redo

          TIPS Redo Stent

 

TIPS venogram without any intervention:

Venography

Veno Portal

TIPS venogram


5.  Dialysis Shunt Management

 

Used for diagnostic and interventional procedures on dialysis fistulas and grafts.  Dialysis catheter placement, removal and revision do NOT go in this section.  Some of the more complex procedures will require use of services from Section 4.

 

Usual diagnostic angiogram on a fistula or graft:

Dialysis Shunt Management

          Dialysis Shunt Angio

 

If graft/outflow vein angioplasty is also performed:

Dialysis Shunt Management

          Dialysis Shunt PTA

 

If central vein angioplasty is also performed:

Venous Intervention Gnl

Venous PTA Gnl

          Venous PTA Central

 

If embolization is also performed, such as for a non-maturing native fistula with competing veins:

Venous Intervention Gnl

Venous Embolization

 

Usual graft declot with angioplasty make 3 entries:

Dialysis Shunt Management

          Dialysis Shunt Angio

Dialysis Shunt Management

          Dialysis Shunt PTA

Dialysis Shunt Management

Dialysis Shunt Revascularization

                        Dialysis Shunt Thrombectomy


6.  Biliary Intervention

 

Used for hepatobiliary procedures and tube preventive maintenance.  Biliary biopsy is part of Section 9.

 

Usual de novo biliary drainage (internal/external):

Biliary Intervention Gnl

PTCholangiography

Biliary Intervention Gnl

Perc Biliary Drainage

          Perc Bil Drn Int/Ext

 

Usual preventive maintenance tube check (cholangiogram) and change/upsize (Note: Change frequency if more than 1 tube):

Biliary Intervention Gnl

Bile, Tube Maint Gnl

Bile, Tube Check

Biliary Intervention Gnl

Bile, Tube Maint Gnl

Bile, Tube Exchg

 

If a cholangioplasty is performed also add:

Biliary Intervention Gnl

Bile Stricture Dil

 

If a choledochoscopy to remove stones is performed also add:

Biliary Intervention Gnl

Bile, Stone Removal

          Transhepatic Stone Rem

                   Choledochoscopy

 

Usual percutaneous cholecystostomy:

Biliary Intervention Gnl

Cholecystostomy

 


7.  GI Intervention

 

Used for GI access procedures.

 

Usual percutaneous gastrostomy:

GI Intervention Gnl

Percutaneous UGI Access

Gastrostomy

 

Usual placement of jejunostomy through existing gastrostomy (may be done in combination with percutaneous gastrostomy procedure):

GI Intervention Gnl

GI Interven Other

G to J conversion

 

Placement of single transgastric jejunostomy tube:

GI Intervention Gnl

Percutaneous UGI Access

Gastrojejunostomy

 

Usual preventive maintenance GI tube change (Note: Do NOT enter GI Tube Check unless necessary, as below):

GI Intervention Gnl

GI Tube Maintenance Gnl

          GI Tube Exchange

 

Usual GI tube check (Note: Use only if there is a definite problem with the tube that requires a tube check for evaluation, not part of preventive maintenance):

GI Intervention Gnl

GI Tube Maintenance Gnl

          GI Tube Check


8.  GU Intervention

 

Used for GU access and drainage procedures.

 

Usual antegrade pyelogram, usually performed in conjunction with nephrostomy tube placement:

GU Intervention Gnl

Antegrade Pyelogram

 

Usual external nephrostomy tube placement:

GU Intervention Gnl

Nephrostomy

          Nephrost External

 

Usual conversion of external nephrostomy to antegrade J-J ureteral stent with placement of external catheter to retain access (which will be removed the next day):

GU Intervention Gnl

Ureteral Stent (double J)

          Ureter Double J Antegrade

 

Usual percutaneous cystostomy (even if CT guided):

GU Intervention Gnl

Cystostomy

 

Usual percutaneous access and tract dilatation for nephrolithotomy in OR:

GU Intervention Gnl

Nephrostomy

          Nephrost External

GU Intervention Gnl

Renal Stone Manipulation

          Neph Tract Dilitation (Stone Dz)

 

Usual preventive maintenance tube check and change:

GU Intervention Gnl

GU Tube Maintenance Gnl

          GU Tube Check

GU Intervention Gnl

GU Tube Maintenance Gnl

          GU Exchange


9. Biopsy/Dx Fluid Aspiration

 

Use when we only remove a sample of tissue or fluid.  For all biopsies give information in Findings including: where biopsy taken (“L lobe liver”, “R kidney upper pole”), size of sample (“18 gauge core”), number of samples, number of passes.

 

Usual percutaneous liver biopsy for diffuse disease:

Biopsy/Dx Fluid Aspiration Gnl

          Bx/Asp Abd/Retroperit

                   Bx/Asp Hepatobiliary

                             Bx Liver Medical Dz

 

Usual percutaneous renal biopsy for diffuse disease (transplant or native):

Biopsy/Dx Fluid Aspiration Gnl

          Bx/Asp Abd/Retroperit

                   Bx/Asp Genitourinary

                             Bx Renal Medical dz

 

Usual transjugular liver biopsy:

Biopsy/Dx Fluid Aspiration Gnl

          Bx/Asp Trans-venous

                   Bx/Asp Trans-venous, Liver

 

If hepatic vein wedge pressures also done add:

Venography

          Veno Central/Visceral Sel

                   Hepatic Veno

                             Hepatic vein wedge pressures

 

Usual bile duct biopsy (even when performed via biliary drain access):

Biopsy/Dx Fluid Aspiration Gnl

          Bx/Asp Abd/Retroperit

                   Bx/Asp Hepatobiliary

                             Bx Bile Ducts

 


10.  Drainage

 

Use any time a catheter is placed, even if removed immediately after drainage.

 

Usual abdominal abscess drain:

Drainage, General

          Drain Abscess/Infection

                   Drain Intraperitoneal Infect

 

Usual retroperitoneal abscess drain:

Drainage, General

          Drain Abscess/Infection

                   Drain Retroperitoneal Infect

 

Usual therapeutic paracentesis:

Drainage, General

          Drain NonInfected Collect

                   Drain Intraperitoneal NonInf

 

Usual therapeutic thoracentesis:

Drainage, General

          Drain NonInfected Collect

                   Drain Thorax NonInf

                             Drn Pleura NonInf

                                      Drn Pleural Eff NonInf

 

Usual abscess drain tube change/upsize/reposition, including preventive maintenance:

Drainage, General

          Tube Maint

                   Tube Exch

 

Usual abscessogram (when tube not changed, not for preventive maintenance):

Drainage, General

          Tube Maint

                   Tube Check

 


Usual peritoneal dialysis catheter manipulation:

Drainage, General

          Drainage, Other

                   Peritoneal dialysis catheter manipulation

 

 

11.  Miscellaneous Intervention

 

Category nearly never used.  We may use in the near future for Direct Tumor Injection.  Also includes Lymphangiography, Myelography, Arthrography and a few others.