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Specifications Manual for Joint Commission National Quality Measures (v2015B1)
Home » Birth Weight

Release Notes:
Data Element
Version 2015B1

Data Element Name: Birth Weight
Collected For: PC-04, Risk Adjustment
Definition:The weight (in grams) of a newborn at the time of delivery.

Note:

453.5 grams = 1 pound

28.35 grams = 1 ounce

It is recommended that each ORYX Vendor provide the ability to enter birth weight in either grams or pounds. However, all birth weights must be converted to grams prior to indicator calculation.
Suggested Data Collection Question:What was the weight of the newborn at delivery?
Format:
Length:4 or UTD
Type:Alphanumeric
Occurs:1
Allowable Values:

150 through 8165 grams
UTD = Unable to Determine

Note: When converting from pounds and ounces to grams, do not round to the nearest pound before converting the weight to grams. Round to the nearest whole number after the conversion to grams.
Notes for Abstraction:
  • Newborns with birth weights less than 150 grams need to be verified that the baby was live born and for data quality purposes. Birth weights greater than 8165 grams need to be verified for data quality. Abstractors should review all of the suggested data sources to verify the accuracy of the data.
  • If the birth weight is unable to be determined from medical record documentation, enter "UTD".
  • The medical record must be abstracted as documented (taken at “face value”). When the value documented is not a valid number/value per the definition of this data element and no other documentation is found that provides this information, the abstractor should select “UTD.”
    Example:
    Documentation indicates the Birth Weight was 0 grams. No other documentation in the medical record provides a valid value. Since the Birth Weight is not a valid value, the abstractor should select “UTD.”
    *Note:*
    Transmission of a case with an invalid value as described above will be rejected from the Joint Commission’s Data Warehouse. Use of “UTD” for Birth Weight allows the case to be accepted into the warehouse.
  • The NICU admission assessment or notes should be reviewed first for the birth weight. In the absence of admission to the NICU, the delivery record or operating room record should be reviewed next for the birth weight. In cases where there is conflicting data, use the document recording the birth weight closest to the time of delivery.
  • It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the suggested data sources listed below.
  • For newborns received into the hospital as a transfer, the admission birth weight may be used if the original birth weight is not available.
  • If the birth weight is recorded in pounds and ounces and also in grams, abstract the value for grams.
Suggested Data Sources:

In Order of Priority:

  • NICU admission assessment or notes
  • Delivery record
  • Operating room record
  • History and physical
  • Nursing notes
  • Nursery record
  • Physician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Birth Weight
Specifications Manual for Joint Commission National Quality Measures (v2015B1)
Discharges from 10/01/2015 to 06/30/2016
Questions? Ask Question to Joint Commission staff Copyright © 2015 by The Joint Commission.
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