Release Notes:
Data Element
Version 2016B1
| 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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|
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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, e.g., admit for management of labor, orders for labor, etc. 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, e.g.:
- contractions every 4 to 5 minutes
- regular contractions and dilation
- effacement 50% with contractions every 3 minutes
- steady contractions
- 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
- Physician orders
- Medication administration record (MAR)
- Labor flow sheet
- 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:
- Active
- Early
- Latent
- Spontaneous
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The following is not an acceptable descriptor for labor: |
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Labor
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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