Number of Previous Live Births

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Number of Previous Live Births

Collected For:

PC-02,

Definition:

The number of deliveries resulting in a live birth the patient experienced prior to current hospitalization.

Suggested Data Collection Question:

How many deliveries resulting in a live birth did the patient experience prior to current hospitalization?

Format:

Length:	2 or UTD
Type:	Alphanumeric
Occurs:	1

Allowable Values:

0-50

UTD=Unable to Determine

Notes for Abstraction:

Parity may be used in the absence of documentation of the number of previous live births. If the number for parity documented in the EHR is "one" and includes the delivery for the current hospitalization, abstract zero for previous live births.

The delivery or operating room record should be reviewed first for the number of previous live births. If the number of previous live births 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 the number of previous live births is found. In cases where there is conflicting data, the number of previous live births found in the first document according to the order listed in the Only Acceptable Sources should be used.

If gravidity is documented as one, the number of previous live births should be considered zero.

The previous delivery of live twins or any live multiple gestation is considered one live birth event.

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 Only Acceptable Sources listed below.

If primagravida or nulliparous is documented select zero for the number of previous live births.

GTPAL documentation may be used in the absence of documentation of the number of previous live births. When GTPAL terminology is documented G= Gravida, T= Term, P= Preterm, A= Abortions and L= Living, all previous term and preterm deliveries prior to this hospitalization should be added together to determine the number of previous live births.

If the number of previous live births entered by the clinician in the first document listed 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.

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 note
Discharge summary

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
The following descriptor must precede the number when determining parity: Parity P Examples: parity=2 or g3p2a1	A string of three or more numbers without the alpha designation of "p" preceding the second number can not be used to determine parity. Example: 321 When GTPAL terminology is documented, G= Gravida, T= Term, P= Preterm, A= Abortions, L= Living, P does not equal parity.

Number of Previous Live Births

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