Specifications Manual for Joint Commission National Quality Measures (v2017B2)

Release Notes:
Data Element
Version 2017B2

Data Element Name: Discharge Time
Collected For: CSTK-01, CSTK-03, CSTK-06,
Definition:Time of documentation of discharge.
Suggested Data Collection Question:What time was the patient discharged?

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

Notes for Abstraction:
  • If the time the patient expired is unable to be determined from medical record documentation, enter “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 patient expired at 3300. No other documentation in the medical record provides a valid time. Since the Time Expired is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
  • If the patient expired and there are multiple times, such as a time the patient was pronounced in physician notes and an administrative time the patient was discharged, use the time the patient was pronounced.
  • If the patient expired and there is not a pronounced time but there is a discharge time, use the discharge time.
  • If the patient was transferred out to another facility or discharged to home, use the time the patient actually left, not the time the order was written.
  • If there are multiple times documented when the patient was discharged, use the earliest time.

Suggested Data Sources:

  • Nursing notes
  • Progress notes
  • Discharge summary
  • Death certificate
  • Resuscitation records

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Discharge Time
Specifications Manual for Joint Commission National Quality Measures (v2017B2)
Discharges 01-01-18 (1Q18) through 06-30-18 (2Q18)
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