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Release Notes:
Data Element
Version 2014A1

Data Element Name: Labor
Collected For: PC-01,
Definition:Documentation by the clinician that the patient was in labor.
Suggested Data Collection Question:Is there documentation by the clinician that the patient was in labor?
Format:
Length:1
Type:Alphanumeric
Occurs:1
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.

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.
Suggested Data Sources:

  • History and physical
  • Nursing notes
  • Physician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
The following are acceptable descriptors for labor:

  • Active
  • Early
  • Spontaneous
The following are not acceptable descriptors for labor:

  • Latent
  • Prodromal

Labor
Specifications Manual for Joint Commission National Quality Measures (v2014A1)
Discharges 01-01-14 (1Q14) through 12-31-14 (4Q14)