Introduction

This section of the manual describes the data elements required to calculate category assignments and measurements for The Joint Commission's National Quality Measures. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. This information is intended to assist in processing patient level data elements for The Joint Commission's National Quality Core Measures.

It is of primary importance that all health care organizations using The Joint Commission's National Quality Core Measures gather and utilize the data elements as defined in this section. This will ensure that the data are standardized and comparable across organizations.

Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital and submitted for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered "general" to each patient's episode of care.

These data elements include:

• Admission Date
• Birthdate
• Health Care Organization Identifier ²
• Hispanic Ethnicity
• Measure Set ^1,2
• Performance Measure Identifier ^1,2
• Race
• Sample ¹
• Sex
• Vendor Tracking ID ^1,2

Data elements that are general for every patient that fall into measures that are reported at time of discharge include:

• Discharge Date
• ICD-9-CM Other Diagnosis Codes
• ICD-9-CM Other Procedure Codes (Optional for all HBIPS measures)
• ICD-9-CM Other Procedure Dates (Optional for all HBIPS measures)
• ICD-9-CM Principal Diagnosis Code
• ICD-9-CM Principal Procedure Code (Optional for all HBIPS measures)
• ICD-9-CM Principal Procedure Date (Optional for all HBIPS measures)
• Payment Source

Data elements that are general for every patient that falls into measures that are reported at the time of the event include:

• Event Date (HBIPS measures only)
• Event Type (HBIPS measures only)
• Psychiatric Care Setting (HBIPS measures only)

Data elements that are general for every patient that falls into specific measures that are reported at the time of discharge include:

• Discharge Disposition

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¹ Transmission Data Element
² These data elements are defined in the Transmission Data Dictionary within the Joint Commission National Quality Core Measures Data Transmission section of this manual

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Episode of Care

An Episode of Care (EOC) is defined as the health care services given during a certain period of time, usually during a hospital stay (e.g., from the day of arrival or admission to the day of discharge). The medical record should be abstracted as it was billed. In the event that there are multiple ED visits within the inpatient medical record, for the same episode of care, it is recommended that the ED visit resulting in the admission to observation or inpatient status be utilized for the purposes of abstraction.

If a patient is transferred from an acute care hospital to another acute care hospital, which is within the same healthcare system and shares the same Joint Commission Health Care Organization Identifier (HCO ID), this should be abstracted as one episode of care.

Data integrity

Editing Zero Values

Verification mechanisms are necessary to assure that zero is the intended data value rather than an initialization value for those data elements which have an allowable value of zero (i.e., 0.0, 0000, 0).

Missing and Invalid Data

Each data element that is applicable per the algorithm for each of the measures within a topic must be “touched” by the abstractor. While this is the expectation, it is recognized that in certain situations information may not be available (e.g., dates, times, codes, etc.). After due diligence in reviewing all allowable data sources within the medical record, if the abstractor determines that a value is not documented, i.e. “missing,” or is unable to determine if a value is documented, the abstractor should select the “UTD - Unable to Determine,” value. The data elements Admission Date, Discharge Date and Birthdate require an actual date for submission of discharge measure information into the Joint Commission’s Data Warehouse, and “UTD” cannot be selected as an allowable value. For Yes/No values the allowable value “No” incorporates the “UTD” into the definition. For data elements containing more than two categorical values and for numerical data elements (i.e., dates, times, etc.), a “UTD” option is included as an allowable value and is classified in the same category as not documented. Files that contain any invalid and/or missing data will be rejected from the Joint Commission’s Data Warehouse. For additional details on the proper handling of missing and/or invalid data, please refer to the Missing and Invalid Data section of this manual.

Interpreting Data Element Definitions and Allowable Values

Every attempt has been made to comprehensively define The Joint Commission's National Quality Core Measure data elements and allowable values in a manner that obviates the need for interpretation. If, after reviewing the General Abstraction Guidelines, the data element definition, including the notes and guidelines for abstraction, an abstractor cannot clearly assign an allowable value, refer to the Resource section of this manual for additional contact information.

Interpretation of Data Dictionary Terms

Data elements fall into three broad categories in order to support a specific measure set. They include:

• General Data Elements – data elements that must be collected by health care organizations for each patient record
  • data elements required for each episode of care (EOC) record submitted
  • data elements used to identify the health care organization on each patient record required for each patient-level record submitted
  • patient demographic data required for each episode of care record submitted and used for risk adjustment analysis (where applicable)
• Measure-Specific Data Elements – data elements used by one specific measure or several measures in one specific measure set, such as in the HBIPS measures
• Algorithm Output Data Elements Refer to ORYX® Technical guide

Data Element Dictionary Terms

Term	Definition
Data Element Name:	A short phrase identifying the data element. For each of identification the data element name is italicized.
Collected For:	Identifies the measure(s) that utilize this data element or specifies that the data element is used for data transmission or verification.
Definition:	A detailed explanation of the data element. A vendor may include this information in data collection software.
Suggested Data Collection Question:	A suggested wording for a data element question in a data abstraction tool.
Format:	Length = number of characters or digits allowed for the data element Type = type of information the data element contains (e.g., numeric, alphanumeric, date, character, or time) Occurs = the number of times the data element occurs in a single episode of care record
Allowable Values:	A list of acceptable responses for this data element
Notes for Abstraction:	Provided to assist abstractor in the selection of appropriate value for a data element
Suggested Data Sources:	Source document from which data can be identified such as administrative or medical record. Some data elements also list excluded data sources that are unacceptable sources for collecting information.
Guidelines for Abstraction:	Designed to assist abstractors in determining how a data element should be answered Note: Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

General Abstraction Guidelines

The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, [Refer to the Medicare Conditions of Participation for Medical Records, 42CFR482.24(c)(2)(viii)], unless otherwise specified in the data element. Documents containing amendments, corrections, or delayed entries must employ the following widely accepted record keeping principles (CMS “Medicare Program Integrity Manual” Chapter 3, Section 3.3.2.4):

• Clearly and permanently identify any amendments, corrections or addenda;
• Clearly indicate the date and author of any amendments, corrections, or addenda; and
• Clearly identify all original content.

Prenatal forms which are available during the hospitalization and become a permanent part of the patient’s medical record (electronic health record/EHR or paper) for the current hospitalization may be used for abstraction. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

Medical Record Documentation

The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, unless otherwise specified in the data element. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

Important Note: There are several data elements where abstraction of data from documentation dated/timed after discharge is restricted, and these exceptions are published on the respective data element pages of the data dictionary. Data element specific notes and guidelines always take precedence over the General Abstraction Guidelines.

All documentation in the medical record must be legible and must be timed, dated and authenticated. However, documentation that is not timed, dated or authenticated may still be used for abstraction if not required by the specific data element. When abstracting a medical record, if a handwritten document is determined to be not legible, other documentation should be reviewed in an attempt to obtain the answer. If no other source document is able to verify the handwritten documentation, only then is the abstractor to answer unable to determine from the medical record documentation, unless otherwise specified in the data element. Authentication may include written signatures, initials, computer key, or other codes.

Data element information should be retrieved from the current medical record, covering the admission and discharge date, or reporting period for event measures being abstracted. Information ascertainable from previous history (e.g., failed trials of monotherapy) AND determined to be part of the current medical record may be used in abstraction. For example, if the patient had previously failed three or more trials of monotherapy and this information is available in the current chart being abstracted (e.g., a note made in the continuing care plan), this information should be used. Previous history information used in abstraction should be information that was part of the medical record during hospitalization, when care was being delivered.

The medical record must be abstracted as documented (taken at “face value”). When the value documented is obviously in error (not a valid format/range or outside of the parameters for the data element) and no other documentation is found that provides this information, the abstractor should select “UTD.” Example:

• Patient expires on 02-12-20XX and documentation indicates the Event Date was 03-12-20XX. Other documentation in the medical record supports the date of death as being accurate. Since the Event Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”

Note: Hospitals should use abbreviations according to their policy. Frequently flow sheets or other documentation contain a ‘key or legend’ that explains what the abbreviation or symbol stands for, especially if unique to that facility.

Suggested Data Sources

• Suggested Data Sources are listed in alphabetical order, NOT priority order, unless otherwise specified in the data element.
• Suggested Data Sources are designed to provide guidance to the abstractor as to the locations/sources where the information needed to abstract a data element will likely be found. However, the abstractor is not limited to these sources for abstracting the information and must review the entire medical record unless otherwise specified in the data element.
• In some instances, a data element may restrict the sources that may be used to gain the information, list a priority in which the sources should be used or may restrict documentation by only physician/advanced practice nurse/physician assistant. If so, these sources will be identified and labeled as “Excluded Data Sources.” "ONLY ACCEPTABLE SOURCES", "Priority Source", or "PHYSICIAN/APN/PA DOCUMENTATION ONLY".
• If, after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select “Unable to Determine (UTD)” as the answer.
• Hospitals often label forms and reports with unique names or titles. Suggested Data Sources are listed by commonly used titles; however, information may be abstracted from any source that is equivalent to those listed.
  • Example:
    If the “nursing admission assessment” is listed as a suggested source, an acceptable alternative might be titled “nurses initial assessment” or “nursing data base.”
    Note:
    Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

Inclusions/Exclusions

• Inclusions are “acceptable terms” that should be abstracted as positive findings (e.g., “Yes”).
• Inclusion lists are limited to those terms that are believed to be most commonly used in medical record documentation. The list of inclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are “unacceptable terms” that should be abstracted as negative findings (e.g., “No”).
• Exclusion lists are limited to those terms an abstractor may most frequently question whether or not to abstract as a positive finding for a particular element (e.g., “cardiomyopathy” is an unacceptable term for heart failure and should be abstracted as "No"). The list of exclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the inclusion takes precedence over the exclusion and would be abstracted as a positive finding (e.g., answer “Yes”), unless otherwise specified in the data element.

Physician/Advanced Practice Nurse/ Physician Assistant Documentation

• Advanced Practice Nurse (APN, APRN) titles may vary among state and clinical specialties. Some common titles that represent the advanced practice nurse role are:
  • Nurse Practitioner (NP)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Clinical Nurse Specialist (CNS)
  • Certified Nurse Midwife (CNM)
• When a physician/advanced practice nurse/ physician assistant (physician/APN/PA) signs a form or report (e.g., ED sheet with triage and nursing information and a physician/APN/PA has signed somewhere on the form), information on that form/report should be considered physician/APN/PA documentation.
• “Rubber” stamped physician/advanced practice nurse/physician assistant (physician/APN/PA) signatures are not acceptable on any document within the medical record. Handwritten, electronic signatures, facsimiles of original written or electronic signatures are acceptable.
• Resident and intern notes should be considered physician documentation. Medical student notes must be co-signed by a physician.
• For the purposes of abstraction, telephone or verbal physician/APN/PA orders (TO/VO) in the medical record are considered physician/APN/PA documentation at the time they were written regardless of whether or not they were authenticated by the physician/APN/PA at the time of abstraction.

Pharmacist Documentation

Pharmacist titles may vary. Some common titles that represent the pharmacist role are:

• Doctor of Pharmacy (Pharm.D. or D.Ph.)
• Registered Pharmacist (R.Ph.)

Medications:

• The approved medication tables contained in the dictionaries may not be inclusive lists of all available therapeutic agents acceptable for a particular data element. Discrepancies must be reported. See Appendix F (resource section) of this manual for contact information.
• Whether or not a medication has been administered to a patient is often clear when using medical record sources such as medication administration records, but documentation can be more ambiguous in other sources, namely, physician orders, ED records, and ambulance records. To make a determination using these sources, use the following criteria:
  • For EHRs only accept documentation that reflects the actual administration of the medication in the context of the chart.
  • If a medication in the physician orders has been initialed and signed off with a time, do NOT presume that the medication was administered. The documentation MUST indicate that the medication was actually given.
  • For an ED or ambulance record, there is no need for documentation indicating that the medication was actually given.
    • Example:
      If the ED or ambulance record reflects “ASA 325mg po 13:00” and no other documentation exists indicating that the medication was actually given (e.g., “given” or “administered”), this is acceptable documentation to abstract.

• When determining whether or not a patient was discharged on a specific medication (e.g., antipsychotic medication):
  • If discharge medications are noted using only references such as “continue home meds,” “continue previous medications,” “resume other meds,” “same medications,” or “continue meds,” rather than lists of the names of the discharge medications, the abstractor should include the medication in the count if the patient was on the medication in question prior to arrival, unless documentation suggests otherwise.
  • If discharge medications are noted using only references such as “continue current medications” or “continue present meds” rather than lists of the names of the discharge medications, the abstractor should include the medication in the count if the medication in question was listed as a medication on the day of discharge, unless documentation indicates it was to be discontinued at discharge or suggests otherwise
  • If discharge medications are noted using general references such as “continue home meds,” “continue previous medications,” “continue current meds,” “continue present meds,” “resume other meds,” or “continue meds,” but a list of the names of the discharge medications also in the record gives conflicting information about what medications the patient was actually discharged on, the abstractor should consider the list most accurate and use only the list in determining whether or not a patient was discharged on a specific medication.
• Hospitals may allow a patient (or his or her caregiver/support person where appropriate) to self-administer both hospital-issued medications and the patient’s own medications brought into the hospital. Hospitals must document the administration of each medication, as reported by the patient (or the patient’s caregiver/support person where appropriate), in the patient’s medical record [42CFR482.23(c)(6)].

Nursing Care Plans, Standing Orders and Protocols

• Per Medicare Conditions of Participation [42CFR482.23(b)(4)] hospitals have the option of having a stand-alone nursing care plan or a single interdisciplinary care plan that addresses nursing and other disciplines.
• Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders if such orders and protocols are dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner responsible for the care of the patient [42CFR482.24(c)(3)].

Diagnostic/Laboratory Tests

Whether or not a diagnostic or laboratory test has been done is usually clear when using medical record sources such as diagnostic test reports, laboratory reports, or progress notes (where a physician might note test findings), but documentation can be more ambiguous in other sources, namely, physician orders and ED records. To make a determination using these sources, use the following criteria:

• If a test in the physician orders has been initialed and signed off with a time, do NOT presume that the test was done. The documentation MUST indicate that the test was actually done (e.g., accompanied by a word such as “done”).
• For an ED record, there is no need for explicit documentation indicating that the test was actually done. For example, if an ED record notes “Lipid profile,” and this is followed by a signature and/or a time, the abstractor should presume the test was performed.

Grids

Instructions for reading values recorded on grids: Measure from the midpoint of the symbol, number and letter. If the value falls between two lines on the grid, abstract the earliest value.

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Alphabetical List of All Data Elements

Data Element Name	Collection Notes	Associated Measures
Admission Date	All Records	ACHF-01, ACHF-02, ACHF-03, ACHF-04, ACHF-05, ACHF-06, AMI-10, AMI-2, CAH-01.1, CAH-02.1, CAH-03, CAH-04, CAH-05, CAH-06, CAH-08.1, CAH-09.1, CAH-10.1, CSTK, HBIPS, HF-3, Osteo, PBM, PC, PN-3a, SCA-03, SUB, TOB
Admission to NICU		PC-05
Antenatal Steroid Therapy Initiated		PC-03
Appropriate Justification for Multiple Antipsychotic Medications		HBIPS-5
Birth Weight	Risk Adjustment	PC-04
Birthdate	All Records	ACHF, ACHFOP, AMI, CAH, CSTK, HBIPS, HF, Osteo, PBM, PC, PN, SCA, SUB, TOB
Bloodstream Infection Present on Admission		PC-04
CMS Certification Number	Hospital Clinical Data File, Optional for All Records	HBIPS, PC
Clinical Trial		ACHF-01, ACHF-02, ACHF-03, ACHF-06, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, CSTK-04, CSTK-06, PC
Continuing Care Plan-Discharge Medications		HBIPS-6, HBIPS-7
Continuing Care Plan-Next Level of Care		HBIPS-6, HBIPS-7
Continuing Care Plan-Principal Discharge Diagnosis		HBIPS-6, HBIPS-7
Continuing Care Plan-Reason for Hospitalization		HBIPS-6, HBIPS-7
Discharge Date	All Records	ACHF-01, ACHF-02, ACHF-03, ACHF-04, ACHF-05, ACHF-06, AMI, CAH-01.1, CAH-02.1, CAH-03, CAH-04, CAH-05, CAH-06, CAH-08.1, CAH-09.1, CAH-10.1, CSTK, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, HF, Osteo, PBM, PC, PICU-03, PN, PSCIP, SCA, SUB, TOB
Discharge Disposition		HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC-04, PC-05
Event Date		HBIPS-2, HBIPS-3
Event Type		HBIPS-2, HBIPS-3
Exclusive Breast Milk Feeding		PC-05
Gestational Age		PC-01, PC-02, PC-03
Health Care Organization Identifier	All Records, Patient Population Data File, Hospital Clinical Data File	HBIPS, PC
Hispanic Ethnicity	All Records	ACHF, AMI, CAC, CAH, CSTK, HBIPS, HF, Osteo, PC, PN, PR, SCA, SCIP, STK
ICD-9-CM Other Diagnosis Codes	All Records	AMI, CAH-01, CAH-02.1, CAH-03, CAH-04, CAH-05, CAH-06, CAH-08, CAH-09.1, CAH-10.1, CSTK-05, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, HF, Osteo, PBM, PC, PICU-03, PN, PSCIP, SUB-03, SUB-04, TOB-02, TOB-03
ICD-9-CM Other Procedure Codes	All Records	ACHF, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, ACHFOP-06, ACHFOP-07, AMI, CAH-01.1, CAH-02.1, CAH-03, CAH-04, CAH-05, CAH-06, CAH-08.1, CAH-09.1, CAH-10.1, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, HBIPS, HF, PBM, PC, PICU, PN, PSCIP, SUB-03, SUB-04
ICD-9-CM Other Procedure Dates	All Records	AMI, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, HBIPS, HF, PBM, PC, PN
ICD-9-CM Principal Diagnosis Code	All Records	ACHF, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, ACHFOP-06, ACHFOP-07, AMI, CAH, CSTK, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, HF, Osteo, PBM, PC, PICU-03, PN, PSCIP, SUB-03, SUB-04, TOB-02, TOB-03
ICD-9-CM Principal Procedure Code	All Records	ACHF, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, ACHFOP-06, ACHFOP-07, AMI, CAH-01.1, CAH-02.1, CAH-03, CAH-04, CAH-05, CAH-06, CAH-08.1, CAH-09.1, CAH-10.1, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, HBIPS, HF, HF-3, IMM, PBM, PC, PICU-03, PN, PSCIP, SUB-03, SUB-04
ICD-9-CM Principal Procedure Date	All Records	ACHF-05a, ACHF-05b, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, ACHFOP-06, ACHFOP-07, AMI, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, HBIPS, HF, PBM, PC, PN
Initial Patient Population Size – Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Initial Patient Population Size – Non-Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Labor		PC-01
Measure Category Assignment	Calculation, Transmission, Hospital Clinical Data File	AMI, HBIPS, HF, PBM, PC, PN
Measure Set	Transmission, Patient Population Data File, Hospital Clinical Data File	HBIPS, PC
Minutes of Physical Restraint		HBIPS-2
Minutes of Seclusion		HBIPS-3
Number of Antipsychotic Medications Prescribed at Discharge		HBIPS-4, HBIPS-5
Parity		PC-02
Patient Referral to Next Level of Care Provider		HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7
Patient Strengths		HBIPS-1
Payment Source	All Records	AMI, CSTK, HBIPS, HF, PC, PN
Predicted Value	Transmission, Risk Adjustment, Hospital Clinical Data File	PC
Prior Uterine Surgery	Joint Commission Only	PC-01
Psychiatric Care Setting	All Records	HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7
Psychiatric Inpatient Days - Medicare Only		HBIPS-2, HBIPS-3
Psychiatric Inpatient Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Psychological Trauma History		HBIPS-1
Race	All Records	ACHF, AMI, CAC, CAH, CSTK, HBIPS, HF, Osteo, PC, PN, PR, SCA, SCIP, STK
Reason for Not Exclusively Feeding Breast Milk		PC-05
Reason for Not Initiating Antenatal Steroid Therapy		PC-03
Sample	Transmission, Aggregate Data File, Hospital Clinical Data File	AMI, HBIPS, HF, PC, PN
Sample Size – Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Sample Size – Non-Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Sampling Frequency	Transmission, Patient Population Data File	HBIPS, PC
Sex	All Records	ACHF, AMI, BCC, BCS, CAH, CSTK, HBIPS, HF, Osteo, PBM, PC, PICU, PN, PSCIP, SCA
Substance Use		HBIPS-1
Total Leave Days - Medicare Only		HBIPS-2, HBIPS-3
Total Leave Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Vendor Tracking Identifier	Transmission, Hospital Clinical Data File	HBIPS, PC
Violence Risk to Others		HBIPS-1
Violence Risk to Self		HBIPS-1