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Release Notes:
Data Element
Version 2014A1

Data Element Name: Prior Uterine Surgery
Collected For: PC-01, Joint Commission Only
Definition:Documentation that the patient had undergone prior uterine surgery.
Suggested Data Collection Question:Is there documentation that the patient had undergone prior uterine surgery?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) The medical record contains documentation that the patient had undergone prior uterine surgery.

N (No) The medical record does not contain documentation that the patient had undergone a prior uterine surgery OR unable to determine from medical record documentation.

Notes for Abstraction:
Suggested Data Sources:

  • History and physical
  • Nursing admission assessment
  • Progress notes
  • Physician’s notes
  • Prenatal forms
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
The only prior uterine surgeries considered for the purposes of the measure are:
  • Prior classical cesarean section which is defined as a vertical incision into the upper uterine segment
  • Prior myomectomy
  • Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
  • History of a uterine window or thinning of the uterine wall noted during prior uterine surgery or during ultrasound
  • History of uterine rupture requiring surgical repair

  • Prior low transverse cesarean section
  • Prior cesarean section without specifying prior classical cesarean section

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