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Release Notes:
Data Element
Version 2013B

Data Element Name: Substance Use
Collected For: HBIPS-1,
Definition:Documentation in the medical record that an admission screening for alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use which occurred over the past twelve (12) months performed within the first three days of admission.

N    (No)   Documentation in the medical record does not include a screening for alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use can not be completed due to the patientís inability or unwillingness to answer assessment 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 alcohol and substance use must be completed by a qualified psychiatric practitioner e.g., psychiatrist, registered nurse (RN), physicianís assistant (PA) or Master of Social Work (MSW) within the first three days of admission. Titles of qualified psychiatric practitioners 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.

Substance use is defined as the use of psychoactive or mood altering substances, i.e., prescription medications, over the counter medications, inhalants, organic substances, illegal substances and street drugs.

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
  • None
  • None

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