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Release Notes:
Data Element
Version 2013B

Data Element Name: Patient Strengths
Collected For: HBIPS-1,
Definition:Documentation in the medical record that an admission screening for a minimum of two patient strengths was performed within the first three days of admission.
Suggested Data Collection Question: Is there documentation in the medical record that the patient was screened for a minimum of two patient strengths within the first three days of admission?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation in the medical record includes a screening for a minimum of two patient strengths performed within the first three days of admission.

N    (No)   Documentation in the medical record does not include a screening for a minimum of two patient strengths OR the screening was not performed within the first three days of admission OR unable to determine from medical record documentation.

X    (Unable to complete admission screening)   Documentation in the medical record that a screening for a minimum of two patient strengths cannot be completed due to the patientís inability or unwillingness to answer screening questions within the first three days of admission OR patient has a previous admission to the psychiatric unit during a single hospitalization.

Notes for Abstraction:A screening for patient strengths must be completed by a qualified psychiatric practitioner, e.g., psychiatrist, psychologist, registered nurse (RN), physicianís assistant (PA) or Master of Social Work (MSW) within the first three days of admission. The titles of qualified psychiatric practitioners may vary from state to state.

If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, select the first admission to the psychiatric unit.

The admission screening timeframe must have occurred within the first three days of admission for psychiatric care. The day after admission is defined as the first day. An admission screen performed in an ambulatory setting, i.e. emergency department, crisis center which results in an admission to an inpatient psychiatric care setting can be used if the screen becomes a permanent part of the medical record.

Suggested Data Sources:

  • Biopsychosocial assessment
  • Emergency department record
  • Functional skills assessment
  • History and physical
  • Individual plan of service
  • Initial assessment form
  • Nursing notes
  • Physician progress notes
  • Psychiatrist assessment/admission form
  • Referral packet
  • School report
  • Social worker assessment

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Examples of adult and older adult patient strengths may include but are not limited to:
  • Assessment of patient optimism that change can occur
  • Motivation and readiness for change
  • Setting and pursuing goals
  • Attempting to realize oneís potential
  • Managing surrounding demands and opportunities
  • Exercising self-direction
  • Vocational interests, i.e., hobbies
  • Interpersonal relationships and supports,i.e., family, friends, peers
  • Cultural/spiritual/religious and community involvement
  • Access to housing/residential stability
  • Steady employment
  • Financial stability
  • Awareness of substance use issues
  • Knowledge of medications

Examples of children and adolescent patient strengths may include but are not limited to:

  • Stable and supportive family
  • Presence of friends
  • School engagement
  • Parent involvement in school
  • Favorable relationships with teachers
  • Assessment of self-esteem, motivation and achievement
  • Refrain from alcohol, drugs, sexual activity
  • Engagement in hobbies, sports, arts and clubs

  • None

Patient Strengths
Specifications Manual for Joint Commission National Quality Measures (v2013B)
Discharges 07-01-13 (3Q13) through 12-31-13 (4Q13)