Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Violence Risk to Others
Collected For: HBIPS-1
Definition:Documentation in the medical record that an admission screening for violence risk to others over the past six months was performed within the first three days of admission. Violence Risk to Others includes: threats of violence and/or actual commission of violence toward others. Documentation should include violence risk within the 6 months prior to admission AND any lifetime risk of violence to others beyond the 6 months prior to admission.
Suggested Data Collection Question:Is there documentation in the medical record that the patient was screened for violence risk to others over the past six months was performed within the first three days of admission?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation in the medical record includes a screening for violence risk to others over the past six months performed within the first three days of admission.

N    (No)   Documentation in the medical record does not include a screening for violence risk to others over the past six months OR the screening was not performed within the first three days of admission OR unable to determine from medical record documentation.

X    (Unable to complete admission screening)   Documentation in the medical record that a screening for violence risk to others over the past six months can not be completed due to the patient's inability or unwillingness to answer assessment questions within the first three days of admission OR patient has a previous admission the psychiatric unit during a single hospitalization.

Notes for Abstraction:
  • A screening for violence risk to others must be completed by a qualified psychiatric practitioner e.g., psychiatrist, registered nurse (RN), physician's assistant (PA) or Master of Social Work (MSW) within the first three days of admission. Titles of qualified psychiatric practitioners vary from state to state.
  • The intent of this data element is to screen the patient for being a violence risk to others within the 6 months prior to admission. Documentation of violence risk must at a minimum state over the past 6 months. Documentation of a past history of violence risk should differentiate the risk being either within the past 6 months or prior to the 6 month time frame.
  • Documentation of "no history" cannot be used, unless it is associated with a time frame. For example:
    • “No history of violence risk to others within the past 6 months.”
    • Or
    • “History of violence risk to others over a year ago.”

  • If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, select the first admission to the psychiatric unit.
  • The admission screening timeframe must have occurred within the first three days of admission for psychiatric care. The day after admission is defined as the first day. An admission screen performed in an ambulatory setting, i.e. emergency department, crisis center which results in an admission to an inpatient psychiatric care setting can be used if the screen becomes a permanent part of the medical record.
  • Some examples of violence risk to others include but are not limited to the following: thoughts of harm to others, intentional infliction of harm on someone else by the patient, homicidal thoughts by the patient and thoughts of harming someone else by the patient.

  • If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient.
Suggested Data Sources:

  • Biopsychosocial assessment
  • Emergency department record
  • Functional skills assessment
  • History and physical
  • Individual plan of service
  • Initial assessment form
  • Nursing notes
  • Physician progress notes
  • Psychiatrist assessment/admission form
  • Referral packet
  • School report
  • Social worker assessment
Additional Notes:

Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Violence Risk to Others
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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