Cardiac Surgery Outcomes Form
Please complete this form to assess and record key outcomes following cardiac surgery.
Patient Medical Record Number
*
Surgery Case Identifier
*
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Cardiac Procedure
*
Please Select
CABG (Coronary Artery Bypass Grafting)
Valve Replacement/Repair
Aortic Surgery
Congenital Heart Surgery
Other
Primary Postoperative Outcome
*
Alive without complications
Alive with complications
Deceased
Major Postoperative Complications (select all that apply)
*
None
Infection
Bleeding
Arrhythmia
Stroke
Renal Failure
Respiratory Failure
Other
30-Day Readmission
*
No
Yes
Current Follow-Up Status
*
Please Select
In follow-up
Lost to follow-up
Completed follow-up
Overall Outcome Assessment
*
Excellent
Good
Fair
Poor
Submit Outcome
Should be Empty: