Release Notes:
Data Element
Version 2015A
| Data Element Name: | Substance Use |
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| Collected For: | HBIPS-1, |
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| Definition: | Documentation in the medical record that an admission screening for alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use which occurred over the past twelve (12) months performed within the first three days of admission.
N (No) Documentation in the medical record does not include a screening for alcohol and substance use which occurred over the past twelve (12) months 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 alcohol and substance use can not be completed due to the patients inability or unwillingness to answer assessment questions within the first three 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 alcohol and substance use 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. Titles of qualified psychiatric practitioners vary from state to state.
- The intent of this data element is to screen the patient for substance use within the 12 months prior to admission. Documentation of substance use must at a minimum state over the past 12 months. Documentation of a past history of substance use should differentiate the use being either within the past 12 months or prior to the 12 month time frame.
- Documentation of "no history" cannot be used, unless it is associated with a time frame. For example:
- “No history of substance use within the past 12 months.”
Or
- “History of substance use 2 years ago.”
- 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.
- Substance use is defined as the use of psychoactive or mood altering substances, i.e., prescription medications, over the counter medications, inhalants, organic substances, illegal substances and street drugs.
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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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Substance Use
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
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