Care Transition Record-Procedures Performed During 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-Procedures Performed During Hospitalization

Collected For:

ACHF-03,

Definition:

Documentation in the care transition record includes procedures performed during hospitalization. Procedures may be diagnostic (e.g., echocardiogram), therapeutic (e.g., thoracentesis), or surgical (e.g., pacemaker insertion).

Suggested Data Collection Question:

Is there documentation in the medical record of a care transition record which includes procedures performed during hospitalization?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation that the care transition record included procedures performed during the hospitalization.

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

Notes for Abstraction:

The procedures performed during hospitalization should be a list of any diagnostic procedure(s), therapeutic procedure(s), or surgery(s) performed during the hospital stay. Procedures described by name, ICD-10-PCS Principal Procedure Code, or ICD-10-PCS Other Procedure Codes are acceptable.
If no procedures were performed during the hospitalization, select YES.
Unchecked checkbox or blank space for documentation of procedures performed during 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-Procedures Performed During Hospitalization

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