Release Notes:
Data Element
Version 2015A
| 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. There is no requirement for acceptable descriptors to be present in order to answer "yes" to labor.
- Documentation of regular contractions or cervical change without mention of labor cannot be used 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:
|
The following are not acceptable descriptors for labor:
|
|
Labor
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
^
Warning: your browser isn't supported. Please install a modern one, like Firefox, Opera, Safari, Chrome or the latest Internet Explorer.
Thank you!