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

Data Element Name: Gestational Age
Collected For: PC-01, PC-02, PC-03
Definition:The weeks of gestation completed at the time of delivery.

Gestational age is defined as the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation , irrespective of whether the gestation results in a live birth or a fetal death. This estimate of gestation should be determined by all perinatal factors and assessments such as ultrasound, but not the newborn exam. Ultrasound taken early in pregnancy is preferred (source: American College of Obstetricians and Gynecologists reVITALize Initiative).
Suggested Data Collection Question:How many weeks of gestation were completed at the time of delivery?
Format:
Length:3 or UTD
Type:Alphanumeric
Occurs:1
Allowable Values:

1-50

UTD=Unable to Determine
Notes for Abstraction:Gestational age should be rounded off to the nearest completed week, not the following week.
For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

Gestational age should be documented by the clinician as a numeric value between 1-50. Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical Estimated Due Date (EDD) based on the following formula:
Gestational Age = (280 - (EDD - Reference Date)) / 7 (source: American College of Obstetricians and Gynecologists reVITALize Initiative).

The clinician, not the abstractor, should perform the calculation to determine gestational age.

The delivery or operating room record should be reviewed first for gestational age; documentation of a valid number should be abstracted.

If the gestational age in the delivery or operating room record is missing, obviously incorrect (in error, e.g. 3.6), or there is conflicting data, then continue to review the following data sources, starting with the document completed closest to the delivery until a positive finding for gestational age is found:
  • History and physical
  • Clinician admission progress note
  • Prenatal forms
  • Discharge summary

Gestational age documented closest to the time of delivery (not including the newborn exam) should be abstracted.

The phrase "estimated gestational age" is an acceptable descriptor for gestational age.

If no gestational age was documented (e.g. the patient has not received prenatal care), select allowable value UTD.

Documentation in the acceptable data sources may be written by the following clinicians:
  • Physician
  • Certified nurse midwife (CNM)
  • Advanced practice nurse/physician assistant (APN/PA)
  • Registered nurse (RN)

It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below.

The EHR takes precedence over a hand written entry if different gestational ages are documented in equivalent data sources, e.g., delivery record and delivery summary.
Suggested Data Sources:

ONLY ACCEPTABLE SOURCES:
  • Delivery or Operating room record, note or summary
  • History and physical
  • Admission clinician progress notes
  • Prenatal forms
  • Discharge summary

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Gestational Age
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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