Release Notes:
Data Element
Version 2010A2
| Data Element Name: | Sex |
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| Collected For: | All Records |
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| Definition: | The patient's documented sex on arrival at the hospital. |
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| Suggested Data Collection Question: | What is the patient’s sex? |
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| Format: | | Length: | 1 |
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| Type: | Character |
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| Occurs: | 1 |
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| Allowable Values: |
M = Male
F = Female
U = Unknown
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| Notes for Abstraction: |
- Collect the documented patient’s sex at admission or the first documentation after arrival.
- Consider the sex to be unable to be determined and select “Unknown” if:
- The patient refuses to provide their sex.
- Documentation is contradictory.
- Documentation indicates the patient is a Transexual.
- Documentation indicates the patient is a Hermaphrodite.
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| Suggested Data Sources: |
Consultation notes
Emergency department record
History and physical
Face sheet
Progress notes
UB-04 Field Location: 11
Nursing admission notes |
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| Additional Notes: |
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| Guidelines for Abstraction: |
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Sex
Specifications Manual for Joint Commission National Quality Core Measures (2010A2)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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