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Question: Follow-up to UserQuestion102705

This is follow up to a prior question: "Earliest Aneurysm Repair or Surgical Interv Procedure Time";.

This was the earliest documented procedure, but I wanted to clarify that I could abstract the date and time listed at the top of the handwritten operative note of 3/29/15, 1045 as the date and time of the procedure in the absence of a specific "procedure start time" or other inclusion terms. This is the only date/time reference I have but it does not specify "procedure start," etc.

Answer:

Inclusion guidelines for abstraction state to use the earliest time associated with an inclusion term on the procedure record first. If no inclusion term on the procedure record, then look for an inclusion term in other suggested sources (e.g. operative note. If no inclusion terms in other sources, look for alternative terms.

EVD is often the first procedure performed for hemorrhagic patients, so the EVD time should be used. Since EVD may be a bedside procedure and nost likely not documented on a "procedure record", we will have to modify the abstraction guidelines for ICD-9-CM Principal Procedure Time to clarify this point. It is OK to use EVD time for procedure time if that is the earliest documented time. Hope this clarifies for you. )

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK, Earliest Aneurysm Repair or Surgical Intervention Procedure Time
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