Release Notes:
Data Element
Version 2018A
| Data Element Name: |
Prior Uterine Surgery |
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| Collected For: |
PC-01 |
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| Definition: | Documentation that the patient had undergone prior uterine surgery. |
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| Suggested Data Collection Question: | Is there documentation that the patient had undergone prior uterine surgery? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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|
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| Allowable Values: |
Y (Yes) The medical record contains documentation that the patient had undergone prior uterine surgery.
N (No) The medical record does not contain documentation that the patient had undergone a prior uterine surgery OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. An inverted T or J incision would be acceptable only if there is also documentation that the incision extended into the upper uterine segment. |
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| Suggested Data Sources: |
- History and physical
- Nursing admission assessment
- Progress notes
- Physician's notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
The only prior uterine surgeries considered for the purposes of the measure are:
- Prior classical cesarean birth which is defined as a vertical incision into the upper uterine segment
- Prior myomectomy
- Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
- History of a uterine window or thinning or defect of the uterine wall noted during prior uterine surgery or during a past or current ultrasound
- History of uterine rupture requiring surgical repair
- History of a cornual ectopic pregnancy
- History of transabdominal cerclage
- History of metroplasty and/or prior removal of vestigial horn with entry into the uterine cavity
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- Prior low transverse cesarean birth
- Prior cesarean birth without specifying prior classical cesarean birth
- History of an ectopic pregnancy without specifying cornual ectopic pregnancy
- History of a cerclage without specifying transabdominal cerclage
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Prior Uterine Surgery
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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