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3ENDOMETRIAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS
DATA COLLECTION FORM CONTINUED
VII. POSTOPERATIVE COMPLICATIONS WITHIN 30 DAYS
Patient Medical Record Number
Date of Birth
Zip Code
Date of Occurrence
Unplanned ICU transfer or admission:
Yes
No
Postoperative Complication:
Yes
No
Grade 2 Complication:
Wound Infection
UTI
Pneumonia
Other Condition Requiring
Requiring Antibiotics
Antibiotics
Yes
No
PE
(select all applicable)
Blood Transfusion
Total Parenteral Nutrition
DVT
Lymphatic
Bowel Perforation
Other
Wound Disruption
or Obstruction
Return to OR
Bleeding
Fistula
Abdominal Abscess
Cuff Dehiscence
Grade 3 Complication:
Yes
No
PEG
Laparoscopy
Upper Endoscopy
Endoscopic Procedures
(select all applicable)
Colonoscopy
Other
Interventional Radiology
Ureteral Stent Placement
Colonic Stent
Other:
Cardiac
CNS
Hematologic
Organ Failure
GI/Hepatic
Renal
Respiratory
Date of Death
Grade 4 Complication: Postoperative Complication-Related Death:
Yes
No
1192SGO-0825
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