Release Notes:
Data Element
Version 2010A2
| Data Element Name: | Active Labor |
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| Collected For: | PC-01, |
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| Definition: | Documentation that the patient was in active labor with regular uterine contractions with cervical change before medical induction and/or cesarean section. |
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| Suggested Data Collection Question: | Is there documentation that the patient was in active labor with regular uterine contractions with cervical change before medical induction and/or cesarean section? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation that the patient was in active labor with regular uterine contractions with cervical change before medical induction and/or cesarean section.
N (No) There is no documentation that the patient was in active labor with regular uterine contractions with cervical change before medical induction and/or cesarean section OR unable to determine from medical record documentation.
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| Notes for Abstraction: | If the patient presents without a previous cesarean section scar with regular uterine contractions with demonstrated cervical change, e.g., cervical dilation increased from 1cm to 2cm before eventual augmentation and/or cesarean section, select allowable value "Yes".
If the patient presents with a previous cesarean section scar with regular uterine contractions with demonstrated cervical change, e.g., cervical dilation increases from 1cm to 2cm or a cervix dilated 2cm or more before repeat cesarean section, select allowable value "Yes". |
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| Suggested Data Sources: |
- History and physical
- Nursing notes
- Physician progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
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None |
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Active Labor
Specifications Manual for Joint Commission National Quality Core Measures (2010A2)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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