Release Notes:
Data Element
Version 2015B1
| Data Element Name: | Labor |
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| Collected For: | PC-01, |
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| Definition: | Documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth. |
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| Suggested Data Collection Question: | Is there documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth? |
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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) There is documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth.
N (No) There is no documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth OR unable to determine from medical record documentation.
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| 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 with or without cervical change; i.e., dilation, effacement without mention of labor may be used to answer "yes" to labor.
- Induction of labor is defined as the use of medications or other methods to bring on (induce) labor. Methods of induction of labor include, but are not limited to:
- Administration of Oxytocin (Pitocin)
- Artificial rupture of membranes (AROM) or amniotomy
- Insertion of a catheter with an inflatable balloon to dilate the cervix
- Ripening of the cervix with prostaglandins, i.e. Cervidil, Prepidil, Cytotec, etc.
- Stripping of the membranes when the clinician sweeps a gloved finger over the thin membranes that connect the amniotic sac to the wall of the uterus.
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| Suggested Data Sources: |
- History and physical
- Nursing notes
- Medication administration record (MAR)
- Physician progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
The following are acceptable descriptors for labor:
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The following are not acceptable descriptors for labor:
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Labor
Specifications Manual for Joint Commission National Quality Measures (v2015B1)
Discharges from 10/01/2015 to 06/30/2016
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