Care Transition Record-Reason for Hospitalization

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Care Transition Record-Reason for Hospitalization

Collected For:

ACHF-03,

Definition:

Documentation in the care transition record includes the reason for hospitalization. The reason for hospitalization should be a short synopsis describing the events the patient experienced prior to this hospitalization. The reason for hospitalization may be listed as the triggering or precipitating event prior to the patients admission to the hospital.

Suggested Data Collection Question:

Is there documentation in the medical record of a care transition record which includes the reason for hospitalization?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation that the care transition record included the reason for hospitalization.

N (No) There is no documentation that the care transition record included the reason for hospitalization, OR unable to determine from medical record documentation.

Notes for Abstraction:

If the patients primary diagnosis and/or other or secondary diagnoses are listed on the care transition record, select YES.
Documentation of the patients chief complaint on the care transition, select YES.
Unchecked checkbox or blank space for documentation of reason for hospitalization, select NO.

Suggested Data Sources:

Aftercare discharge plan
Care transition record
Continuing care plan
Discharge plan
Discharge summary
Medication reconciliation form
Physician orders
Progress notes
Referral form

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

Care Transition Record-Reason for Hospitalization

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