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

Data Element Name: Prior Uterine Surgery
Collected For: PC-01
Definition:Documentation that the patient had undergone prior uterine surgery.
Suggested Data Collection Question:Is there documentation that the patient had undergone prior uterine surgery?
Format:
Length:1
Type:Alphanumeric
Occurs:1
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.
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.
Suggested Data Sources:

  • History and physical
  • Nursing admission assessment
  • Progress notes
  • Physician's notes
  • Prenatal forms
Additional Notes:
Guidelines for Abstraction:
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
  • 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

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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