Release Notes:
Data Element
Version 2016B1
Data Element Name: | Sex |
Collected For: | All Records |
Definition: | The patient's documented sex on arrival at the hospital. |
Suggested Data Collection Question: | What is the patients sex on arrival? |
Format: | Length: | 1 | Type: | Character | Occurs: | 1 |
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Allowable Values: |
M = Male
F = Female
U = Unknown
|
Notes for Abstraction: |
- Collect the documented patients sex at admission or the first documentation after arrival.
- Consider the sex to be unable to be determined and select Unknown if:
- The patient refuses to provide their sex.
- Documentation is contradictory.
- Documentation indicates the patient is a Transexual.
- Documentation indicates the patient is a Hermaphrodite.
|
Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Face sheet
- Progress notes
- Nursing admission notes
- UB-04
|
Additional Notes: |
|
Guidelines for Abstraction: |
|
Sex
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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