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Specifications Manual for Joint Commission National Quality Measures (v2015B2)
Home » Labor

Release Notes:
Data Element
Version 2015B2

Data Element Name: Labor
Collected For: PC-01,
Definition:Documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth.
Suggested Data Collection Question:Is there documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth?
Format:
Length:1
Type:Alphanumeric
Occurs:1
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.

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.
Suggested Data Sources:

  • History and physical
  • Nursing notes
  • Medication administration record (MAR)
  • Physician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
The following are acceptable descriptors for labor:

  • Active
  • Early
  • Spontaneous
The following are not acceptable descriptors for labor:

  • Latent
  • Prodromal

Labor
Specifications Manual for Joint Commission National Quality Measures (v2015B2)
Discharges 10-01-15 (4Q15) through 06-30-16 (2Q16)
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