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Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Home » Positive Brain Image Time

Release Notes:
Data Element
Version 2016B1

Data Element Name: Positive Brain Image Time
Collected For: CSTK-05,
Definition:The time (military time) for which a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was documented. Early hemorrhagic transformation occurs in about one in ten patients with acute ischemic stroke, but only parenchymal hematoma predicts poor outcomes, according to the research.
Suggested Data Collection Question:What was the time of the positive brain image?
Length:5 - HH-MM (with or without colon) or UTD
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


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

00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Positive Bain Image 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 Positive Brain Image Date.
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • Use the time at which symptomatic intracranial hemorrhage was first documented following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different symptomatic intracranial hemorrhage times (either different brain images or corresponding with the same brain image), enter the earliest time.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • If the time of symptomatic intracranial hemorrhage 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 time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Documentation indicates primary brain image time was 3300. No other documentation in the medical record provides a valid time. Since primary brain image time is outside of the range listed 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 Joint Commission’s Data Warehouse. Use of “UTD” for Primary Brain Image Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

  • Diagnostic test reports
  • Brain imaging reports
  • Radiology reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

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