Release Notes:
Data Element
Version 2015A1
| Data Element Name: | Prior Uterine Surgery |
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| Collected For: | PC-01, Joint Commission Only |
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| Definition: | Documentation that the patient had undergone prior uterine surgery. |
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| Suggested Data Collection Question: | Is there documentation that the patient had undergone prior uterine surgery? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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|
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| Allowable Values: |
Y (Yes) The medical record contains documentation that the patient had undergone prior uterine surgery.
N (No) The medical record does not contain documentation that the patient had undergone a prior uterine surgery OR unable to determine from medical record documentation.
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| Notes for Abstraction: | |
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| Suggested Data Sources: |
- History and physical
- Nursing admission assessment
- Progress notes
- Physicians notes
- Prenatal forms
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
The only prior uterine surgeries considered for the purposes of the measure are:
- Prior classical cesarean section which is defined as a vertical incision into the upper uterine segment
- Prior myomectomy
- Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
- History of a uterine window or thinning of the uterine wall noted during prior uterine surgery or during ultrasound
- History of uterine rupture requiring surgical repair
- History of a cornual ectopic pregnancy
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- Prior low transverse cesarean section
- Prior cesarean section without specifying prior classical cesarean section
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Prior Uterine Surgery
Specifications Manual for Joint Commission National Quality Measures (v2015A1)
01/01/2015 - 09/30/2015
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