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

Data Element Name: Admission to NICU
Collected For: PC-05
Definition:Documentation that the newborn was admitted to the Neonatal Intensive Care Unit (NICU) at this hospital any time during the hospitalization.
Suggested Data Collection Question:Was the newborn admitted to the NICU at this hospital at any time during the hospitalization?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation that the newborn was admitted to the NICU at this hospital at any time during the hospitalization.

N (No) There is no documentation that the newborn was admitted to the NICU at this hospital at any time during the hospitalization or unable to determine from medical record documentation.
Notes for Abstraction:A NICU is defined as a hospital unit providing critical care services which is organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness (source: American Academy of Pediatrics). Names of NICUs may vary from hospital to hospital. Level designations and capabilities also vary from region to region and cannot be used alone to determine if the nursery is a NICU.

If the newborn is admitted to the NICU for observation or transitional care, select allowable value “no”. Transitional care is defined as a stay of 4 hours or less in the NICU. There is no time limit for admission to observation.

If an order to admit to the NICU is not found in the medical record, there must be supporting documentation present in the medical record indicating that the newborn received critical care services in the NICU in order to answer “yes”. Examples of supporting documentation include, but are not limited to the NICU admission assessment and NICU flow sheet.

If your hospital does not have a NICU, you must always select Value "no" regardless of any reason a newborn is admitted to a nursery.
Suggested Data Sources:

  • Nursing notes
  • Discharge summary
  • Physician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

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