Performance Measurement Network

Question: History of low vertical incision documented BUT no documentation of classical incision.

MD documented "hx of low vertical incision", however there is no documentation of "classical incision". Per provider, they are two different types of incisions; however, have the same recommendations for delivery.

Is documentation of hx of low vertical incision enough to say yes to prior uterine surgery?

Thank you

Answer:

The documentation provided is not enough to abstract "Yes" to prior uterine surgery.

The only prior uterine surgeries considered for the purposes of the measure are:

  • Prior classical cesarean birth which is defined as a vertical incision into the upper uterine segment
  • Prior myomectomy
  • Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
  • History of a uterine window or thinning or defect of the uterine wall noted during prior uterine surgery or during a past or current ultrasound
  • History of uterine rupture requiring surgical repair
  • History of a cornual ectopic pregnancy
  • History of transabdominal cerclage
  • History of metroplasty and/or prior removal of vestigial horn with entry into the uterine cavity

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: PC-01, Prior Uterine Surgery,
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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