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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Pneumonia Diagnosis: ED/Direct Admit

Release Notes:
Data Element
Version 2015A

Data Element Name: Pneumonia Diagnosis: ED/Direct Admit
Collected For: CAH-04, PN-3a,
Definition:Documentation of the diagnosis of pneumonia either as the Emergency Department diagnosis/impression, or as an admission diagnosis/impression for the direct admit patient within 24 hours after arrival to the hospital.
Suggested Data Collection Question:Was there documentation of the diagnosis of pneumonia either as an Emergency Department diagnosis/impression, or as an admission diagnosis/impression for the direct admit patient?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    There is physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation that pneumonia was a diagnosis/impression in the ED or as an admission diagnosis/impression upon direct admit.

2   There is no physician/APN/PA documentation that pneumonia was a diagnosis/impression in the ED, or as an admission diagnosis/impression upon direct admit.

3   Unable to determine from medical record documentation.

Notes for Abstraction:
  • Only consider diagnoses that have been documented by a Physician/APN/PA within 24 hours of patient’s arrival at the hospital. Do not accept any diagnosis that is documented greater than 24 hours after patient’s arrival to the hospital.
  • Only accept documentation of a pneumonia diagnosis that is clearly described as a diagnosis, impression or plan to treat. Do not take anything that is labeled as a differential diagnosis.
  • If your hospital labels the differential diagnosis using a different name (e.g. first impression), it must be clear that this is only a differential diagnosis.
  • Pneumonia need not be the primary or only diagnosis. However, if the diagnosis of pneumonia is documented as a differential diagnosis (DDx), select value “"2."”
    Examples:
    • Under a heading of Diagnosis/Impression, the physician documents COPD vs. pneumonia – select value "“1.”"
    • In the ED narrative the physician documents: DDx – pancreatitis vs. acute alcoholic hepatitis vs. PUD vs. abdominal perforation vs. UTI/pyelo vs. PNA – select value “"2."”
  • Diagnosis of pneumonia cannot be taken from the chest x-ray, discharge summary, coding or billing documents.
  • Inclusions used with adjectives or phrases such as “"need to evaluate for,"” "“possible,”" “"questionable," “ "“rule out”" or "“suspected"” should be answered with a value "“1."” Negative adjectives or phrases such as “"doubt"” or "“no"” would be a value "“2."”
  • If there is any documentation of a diagnosis of "“aspiration pneumonia"” on an ONLY ACCEPTABLE SOURCE, select value "“2."”
    Example:
    ED diagnosis "“Pneumonia vs. aspiration pneumonia."”
  • If there is documentation of a diagnosis of pneumonia and a diagnosis of "“aspiration pneumonia”" on the same or different Only Acceptable Sources, select value “"2."”
    Example:
    Admit H&P: Clinical Diagnosis/Impression: Pneumonia; Admitting Physician Orders: Diagnosis: Aspiration Pneumonia
  • If the admit orders refer to a Pneumonia Pathway or equivalent, or the Pneumonia Pathway contains orders to admit, select value "“1.”" Do not select value "“1"” if the Pneumonia Pathway is being used for a different diagnosis.
    Example:
    Pneumonia/Bronchitis Pathway with COPD written as the diagnosis. Since pneumonia was not written in or selected as an admitting diagnosis, select value "“2."”

Patients seen in the Emergency Department
  • For purposes of this data element, an ED admit is any patient who receives treatment, care or evaluation in the ED.
  • For patients admitted to observation from the ED, who later result in inpatient status, a diagnosis/impression of pneumonia must be documented while the patient was in the ED.
  • For the purposes of this data element, the “"ED form"” is an area or section within the ED record for the physician/APN/PA to list diagnoses or impressions.
  • A pneumonia diagnosis written within narrative documentation can be used, but it must be clearly documented as a diagnosis/impression or a plan to treat for pneumonia.
    Example:
    • Physician documents “Start patient on Levaquin to cover pneumonia,” select value "“1.”"
    • Physician documents patient has possible pneumonia or UTI, select value "“2.”"
  • Only select UTD (value "“3"”) if there is a place in the ED chart to document an ED diagnosis/impression and this area is left blank. However, if there are multiple areas to document an ED diagnosis/impression and any are completed, select value "“1"” or "“2"” as applicable.
  • ED face sheets can only be used if signed by a physician/APN/PA.
  • If the same emergency room physician/APN/PA who completed the ED forms did not include pneumonia as a diagnosis or impression but completes an admit note or order with an admission diagnosis of pneumonia or a Pneumonia Pathway or equivalent that was initiated upon admission, select value "“1."”
  • If the ED physician does not document a diagnosis/impression of pneumonia and a hospitalist, attending physician or consultant admits the patient for pneumonia, select value “"2.”"
  • Those cases where the patient is seen in the emergency department but the medical record does not contain an ED form, which is different than just leaving the form blank (e.g., the physician treating the patient in the ED documented everything on an admit note) are limited to the following ONLY ACCEPTABLE SOURCES: Admitting notes, Admitting physician orders and Admit H&P.

Direct Admits
  • For the purposes of this data element, a direct admit is any patient who does not receive treatment, care or evaluation in the ED.
  • For patients who are a direct admit to observation, who later result in inpatient status, a diagnosis/impression of pneumonia must be documented upon admission to observation.
  • Pneumonia need not be the primary or only diagnosis/impression but included in the ONLY ACCEPTABLE SOURCES for a Direct Admit as a diagnosis/impression.
  • When the patient is a direct admit and is not seen in the ED, the diagnosis of pneumonia should be found on the following ONLY ACCEPTABLE SOURCES to select value 1: Admitting notes, Admitting physician orders, Admit History & Physical (H&P).
  • An Admit History & Physical (H&P) is an H&P labeled as such or contains documentation regarding admission. A History & Physical can be used ONLY if the physician/APN/PA documents on one of the ONLY ACCEPTABLE SOURCES to “"see H&P,"” or the H&P is an Admit H&P written or dictated within 24 hours of arrival.
  • An admission note is any note labeled as such or contains documentation regarding admission.
  • The initial progress note is not one of the ONLY ACCEPTABLE SOURCES for a Direct Admit and not considered an admission note unless it contains documentation regarding admission.
  • An undated and/or untimed document is not an acceptable source.
  • Only select UTD (value "“3"”) if there is no documentation of ANY diagnosis in any of the ONLY ACCEPTABLE SOURCES. If there is ANY diagnosis mentioned select value "“1" or "“2"” as applicable.
Suggested Data Sources:

ONLY ACCEPTABLE SOURCES
PHYSICIAN/APN/PA DOCUMENTATION ONLY
  • Direct Admit
    • Admit History & Physical (H&P)
    • Admitting notes
    • Admitting physician orders
    • Physician admission note
  • Emergency Department Record
    • ED admitting notes
    • ED face sheet – only if signed by the physician/APN/PA
    • ED form
    • ED history and physical
    • ED physician orders

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
This list is ALL Inclusive
  • Admission Pneumonia Diagnosis Codes (except for aspiration pneumonia)
  • Admission Pneumonia Pathway (or equivalent)
  • BOOP (bronchiolitis obliterans organizing pneumonia)
  • CAP (community acquired pneumonia)
  • COP (cryptogenic organizing pneumonia)
  • HAP or HCAP (healthcare acquired pneumonia)
  • Infiltrate
  • Lower respiratory infection
  • Lower respiratory tract infection
  • Lower lobe infection
  • Lower lung infection
  • NAP (nosocomial pneumonia)
  • PCP (pneumocystis carinii pneumonia)
  • Persistent pneumonia
  • PN
  • PNA
  • PNE
  • Pneu
  • Pneumonia
  • Pneumonic process
  • Pneumonitis
  • Resolving pneumonia
  • VAP (ventilator acquired pneumonia)

  • Aspiration pneumonia
  • Chronic infiltrate
  • Chronic pneumonia
  • History of any of the Inclusion terms with no current context
  • Pneumonia caused by chemical agents or aerosolized medications
  • Post-obstructive pneumonia
  • Recent pneumonia
  • Recurrent pneumonia
  • S/P (status post) pneumonia

Pneumonia Diagnosis: ED/Direct Admit
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
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