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

Data Element Name: Discharge Time
Collected For: CSTK-01, CSTK-03, CSTK-06
Definition:The time the patient was discharged from acute care, left against medical advice (AMA), or expired during the hospital stay.
Suggested Data Collection Question:What time was the patient discharged?

Format:
Length:5 — HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Notes for Abstraction:
  • Abstract the earliest documented time of the following:
    • Discharge from acute inpatient care
    • Left against medical advice (AMA)
    • Expired
  • If the time the patient was discharged from acute inpatient care, left AMA, or expired is unable to be determined from medical record documentation, enter “UTD.”
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid format/range) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the patient expired at 3300. No other documentation in the medical record provides a valid time. Since the Time Expired is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
  • If the patient expired and there are multiple times, such as a time the patient was pronounced in physician notes and an administrative time the patient was discharged, use the time the patient was pronounced.
  • If the patient expired and there is not a pronounced time but there is a discharge time, use the discharge time.
  • If the patient was discharged from acute inpatient care, left AMA, transferred out to another facility, or discharged to home, use the time the patient actually left, not the time the order was written.
  • If there are multiple times documented when the patient was discharged from acute inpatient care or left AMA, use the earliest time.

Suggested Data Sources:

  • Nursing notes
  • Progress notes
  • Discharge summary
  • Death certificate
  • Resuscitation records

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

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