Performance Measurement Network

Question: Birth Weight suggested Sources

Is the Patient Plan of Care, which is completed by nursing, an acceptable source to abstract Birth Weight?

Thank you

Answer:

The plan of care would be an allowable source only if the birth weight was not recorded anywhere else in the record. The suggested (and preferrable sources) are In Order of Priority:

  • NICU admission assessment or notes
  • Delivery record
  • Operating room record
  • History and physical
  • Nursing notes
  • Nursery record
  • Physician progress notes

Additionally from the Notes for Abstraction:

  • The NICU admission assessment or notes should be reviewed first for the birth weight. In the absence of admission to the NICU, the delivery record or operating room record should be reviewed next for the birth weight. In cases where there is conflicting data, use the document recording the birth weight closest to the time of delivery.
  • It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the suggested data sources listed below.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: PC-06, Birth Weight,
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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