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

Data Element Name: Care Transition Record-Procedures Performed During Hospitalization
Collected For: ACHF-03
Definition:Documentation in the care transition record includes procedures performed during hospitalization. Procedures may be diagnostic (e.g., echocardiogram), therapeutic (e.g., thoracentesis), or surgical (e.g., pacemaker insertion).
Suggested Data Collection Question:Is there documentation in the medical record of a care transition record which includes procedures performed during hospitalization?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation that the care transition record included procedures performed during the hospitalization.

N (No) There is no documentation that the care transition record included procedures performed during the hospitalization, OR unable to determine from medical record documentation.
Notes for Abstraction:

  • The procedures performed during hospitalization should be a list of any diagnostic procedure(s), therapeutic procedure(s), or surgery(s) performed during the hospital stay. Procedures described by name, ICD-10-PCS Principal Procedure Code, or ICD-10-PCS Other Procedure Codes are acceptable.
  • If no procedures were performed during the hospitalization, select ‘YES'.
  • Unchecked checkbox or blank space for documentation of procedures performed during hospitalization, select ‘NO'.
Suggested Data Sources:

  • Aftercare discharge plan
  • Care transition record
  • Continuing care plan
  • Discharge plan
  • Discharge summary
  • Medication reconciliation form
  • Physician orders
  • Progress notes
  • Referral form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Care Transition Record-Procedures Performed During Hospitalization
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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