Release Notes:
Data Element
Version 2015A
| Data Element Name: | Psychological Trauma History |
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| Collected For: | HBIPS-1, |
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| Definition: | Documentation in the medical record that an admission screening for a psychological trauma history was performed within the first three days of admission.
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| Suggested Data Collection Question: | Is there documentation in the medical record that the patient was screened for a psychological trauma history performed within the first three days of admission? |
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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) Documentation in the medical record includes a screening for a psychological trauma history performed within the first three days of admission.
N (No) Documentation in the medical record does not include a screening for a psychological trauma history 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 a psychological trauma history can not be completed due to the patients inability or unwillingness to answer screening questions within the first thee days of admission OR patient has a previous admission to the psychiatric unit during a single hospitalization.
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| Notes for Abstraction: | A screening for a psychological trauma history must be completed by a qualified psychiatric practitioner e.g., psychiatrist, registered nurse (RN), physicians assistant (PA) or Master of Social Work (MSW) within the first three days of admission. The titles of qualified psychiatric practitioners may 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.
Traumatic life experiences are defined as those that result in responses to life stressors characterized by significant fear, anxiety, panic, terror, dissociation, feelings of complete powerless or strong emotions that have long term effects on behaviors and coping skills¹.
¹American Psychiatric Association. (1994). Diagnostic and statistical manual or mental disorders, Fourth Ed. Washington, DC: APA.
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. |
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| 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
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Examples of psychological trauma may include but are not limited to:
- physical abuse
- sexual abuse
- emotional abuse
- Severe childhood neglect
- victimization, e.g., disasters, criminal activities, crime stigma, identity theft
- combat experiences
- witnessing others being harmed or victimized
- any significant injury or life-threatening disease
- significant psycho/social loss, e.g., bankruptcy, traumatic family loss
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Psychological Trauma History
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
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