Medical Record Committee provides assistance with auditing the medical record for quality of documentation

* Abdominal hysterectomy Excision of uterus through an abdominal incision with or without concurrent excision of ovary and/or Fallopian tube. * Bile duct, liver, or pancreatic surgery Operative procedures on the bile duct, gall bladder, liver or pancreas, excluding cholecystectomy without exploration of the bile duct and biopsy of lesions. * Breast surgery Breast reconstruction, mammoplasty, excision of lesion, tissue or breast including radical, modified, or quadrant resection, lumpectomy, incisional biopsy. * Cardiac surgery (non-CABG) Open chest procedures on valves or septum of heart; excludes coronary artery bypass graft, surgery on vessels, heart transplantation, or pacemaker implantation. * Cholecystectomy (non-laparoscopic) Partial or total excision of the gall bladder, excluding laparoscopic approach and procedures involving exploration of the bile duct. * Coronary artery bypass graft Open chest procedure to perform direct revascularization of heart, for example, using suitable vein from leg for grafting, internal mammary artery, among others. * Cranial surgery Incision through the skull to excise, repair, or explore the brain, excludes taps or punctures. * Gastric surgery Incision, excision or anastomosis of stomach, including partial or total gastrectomy, vagotomy, pyloromyotomy, pyloroplasty and gastroenterostomy. * Hip replacement Replacement of the hip joint, including resurfacing of any part of the joint, revision of a previous replacement and conversion from a previous hemiarthroplasty or bone fixation. Excludes replacement of head of femur alone * Knee replacement Replacement of all or part of knee joint (with or without patella resurfacing), including revision of a previous replacement. Patella resurfacing and patella replacement are not included in the surveillance. * Large bowel surgery Incision, excision or anastomosis of the large bowel, including procedures which involve anastomosis of small to large bowel. * Limb amputation Total or partial amputation or disarticulation of the upper or lower limbs, including digits * Reduction of long bone fracture Includes open or closed reduction of fracture of long bones requiring intramedullary or extramedullary fixation where an incision is made to establish fixation. Excludes: external fixation, hip replacement following fracture, fracture of the neck of femur or open reduction of small bones

ESWL is a noninvasive procedure that breaks down stones in parts of the urinary system, in the pancreas and in the bile ducts. It uses shock waves that are aimed at stones, with the help of X-rays or ultrasound. Stones in the kidneys and ureter often pass on their own after EWSL. Stones in other locations, such as the pancreatic duct, may need to be extracted with an endoscope (a hollow tube with a light and instruments) that can trap and remove stones.

• This committee reviews the credentials of medical staff according to the medical staff bylaws to ensure that the appointees meet the criteria according to the standards and to recommend accordingly