ALERT! Warning: your browser isn't supported. Please install a modern one, like Firefox, Opera, Safari, Chrome or the latest Internet Explorer. Thank you!
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Home » Discharge Time

Release Notes:
Data Element
Version 2016B1

Data Element Name: Discharge Time
Collected For: CSTK-01, CSTK-03, CSTK-06,
Definition:The documented time (military time) the patient was discharged from acute care, left against medical advice, or expired during this stay.
Suggested Data Collection Question:What is the time the patient was discharged from acute care, left against medical advice (AMA), or expired?

Format:
Length:5 – HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Discharge Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Discharge Date. Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “seconds”, remove the seconds and record the military time. Example: 15:00:35 would be recorded as 15:00.
  • For patients who expire during the hospital stay, the time that the patient was pronounced / time of death should be used for the discharge time.
  • If the patient was transferred, use the time the patient was actually transferred to another facility, not the time the order was written.
  • If there are multiple times documented, use the latest time. The administrative time of discharge is acceptable if there is no documentation of a later time of discharge present in the medical record.
  • If the time of discharge is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid format/range) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the Discharge Time was 3300. No other documentation in the list of ONLY ACCEPTABLE SOURCES provides a valid time. Since the Discharge Time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Discharge Time allows the case to be accepted into the warehouse.

Suggested Data Sources:

  • Face sheet
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Administrative form
  • Death certificate
  • Resuscitation records
  • Transfer note
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Discharge Time
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
Questions? Ask Question to Joint Commission staff Copyright © 2016 by The Joint Commission.
^