Gestational Age

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Gestational Age

Collected For:

PC-01, PC-02, PC-03,

Definition:

The weeks of gestation completed at the time of delivery.

Gestational age is defined as the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation , irrespective of whether the gestation results in a live birth or a fetal death. This estimate of gestation should be determined by all perinatal factors and assessments such as ultrasound, but not the newborn exam. Ultrasound taken early in pregnancy is preferred (source: American College of Obstetricians and Gynecologists reVITALize Initiative).

Suggested Data Collection Question:

How many weeks of gestation were completed at the time of delivery?

Format:

Length:	3 or UTD
Type:	Alphanumeric
Occurs:	1

Allowable Values:

1-50

UTD=Unable to Determine

Notes for Abstraction:

Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The delivery or operating room record should be reviewed first for gestational age. If gestational age is not recorded in the delivery or operating room record, then continue to review the data sources in the following order: history and physical, prenatal forms,clinician admission progress note and discharge summary until a positive finding for gestational age is found. In cases where there is conflicting data, the gestational age found in the first document according to the order listed above should be used. The phrase "estimated gestational age" is an acceptable descriptor for gestational age.

If the patient has not received prenatal care and no gestational age was documented, select allowable value UTD.

When the admission date is different from the delivery date, use documentation of the gestational age completed closest to the delivery date.

Gestational age should be documented by the clinician as a numeric value between 1-50. Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical Estimated Due Date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date)) / 7 (source: American College of Obstetricians and Gynecologists reVITALize Initiative). The clinician, not the abstractor, should perform the calculation to determine gestational age.

If the gestational age entered by the clinician in the first document listed above is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the first document and the correct number can be supported with documentation in the other acceptable data sources in the medical record, the correct number may be entered.

Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).

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 acceptable data sources listed below.

The EHR takes precedence over a hand written entry if different gestational ages are documented in equivalent data sources, e.g., delivery record and delivery summary.

Suggested Data Sources:

ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:

Delivery record, note or summary
Operating room record, note or summary
History and physical
Prenatal forms
Admission clinician progress notes
Discharge summary

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

Gestational Age

Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)