Release Notes:
Data Element
Version 2014A
| Data Element Name: | Labor |
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| Collected For: | PC-01, |
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| Definition: | Documentation by the clinician that the patient was in labor. |
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| Suggested Data Collection Question: | Is there documentation by the clinician that the patient was in labor? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation by the clinician that the patient was in labor.
N (No) There is no documentation by the clinician that the patient was in labor OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- A clinician is defined as a physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).
- Documentation of labor by the clinician should be abstracted at face value. No additional documentation of regular contractions or cervical change is required in order to answer yes to labor.
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| Suggested Data Sources: |
- History and physical
- Nursing notes
- Physician progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
The following are acceptable descriptors for labor:
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The following are not acceptable descriptors for labor:
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Labor
Specifications Manual for Joint Commission National Quality Measures (v2014A)
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
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