Release Notes:
Data Element
Version 2018A
| Data Element Name: |
Dyspnea Severity |
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| Collected For: |
PAL-03 |
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| Definition: | Evaluation of the patient for the presence or absence of dyspnea (shortness of breath) and its severity at the time of the palliative care initial encounter. |
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| Suggested Data Collection Question: | What was the severity of dyspnea when the patient was first screened for dyspnea during the palliative care initial encounter? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
0 None
1 Mild
2 Moderate
3 Severe
4 Dyspnea severity not able to be rated
5 There is no documentation that the patient was screened for dyspnea, or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Select “0” if documented in the medical record the patient’s dyspnea severity score was none. This would include a score of 0 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient reports no discomfort and is breathing shallowly but without signs of distress; no concerns about breathing from patient or family.”
- Select “1” if documented in the medical record the patient’s dyspnea severity score was mild. This would include a score of 1–3 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient unable to speak; observed during 20-minute evaluation; respiratory rate 28 with intermittent use of abdominal breathing; some wheezing on exam but good air movement.”
- Select “2” if documented in the medical record the patient’s dyspnea severity score was moderate. This would include a score of 4–6 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient reports he is currently not experiencing any shortness of breath. Patient reports that he does become short of breath when walking from the bed to the bathroom. Patient reports that when he is short of breath, shortness of breath is mild to moderate, depending on activity level.”
- Select “3” if documented in the medical record the patient’s dyspnea severity score was severe. This would include a score of 7–10 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient reports great difficulty with breathing when walking to the bathroom; breathing is eased after resting and better if using oxygen when active.”
- Select “4” if documented in the medical record the patient had dyspnea, but the patient’s dyspnea severity was not able to be evaluated by any manner. This would include documentation that staff was unable to rate severity by observation or patient was unable or declined to use a rating scale. Example: “patient intubated.”
- Select “5” if there is no documentation that the patient was screened for dyspnea, or unable to determine from medical record documentation. Example: “patient very drowsy; appears to be comfortable during visit.”
- If documentation indicates the patient had shortness of breath, but severity was not evaluated in any manner, select “5”.
- A screening for dyspnea must include evaluating the patient for presence or absence of dyspnea (shortness of breath), and if dyspnea is present, rating of its severity. Structured clinical evaluation for dyspnea is not well defined, therefore documentation found in the medical record for screening of dyspnea may vary and may not include use of a standardized tool for rating severity.
- Examples of scales that may be used include, but are not limited to:
- Modified Borg Scale (MBS) – Rating of Perceived Dyspnea (RPD)
- Edmonton Symptom Assessment System (ESAS)
- Memorial Symptom Assessment Scale
- Visual Analogue Scale (VAS)
- The Numeric Rating Scale (NRS)
- Medical Research Council Dyspnea Scale
- Baseline Dyspnea Index (BDI)
- Respiratory Distress Observation Scale (RDOS)
- It is possible that at the time of the palliative care initial encounter there will have been multiple screenings for dyspnea that were documented in the clinical record. For purposes of this measure use the dyspnea screening based on the first dyspnea screening that appears during the palliative care initial encounter.
- If a range is provided, such as mild to moderate, select the highest level of severity recorded.
- The clinical record could include patient’s self-report of distress or “trouble breathing” from shortness of breath or dyspnea; documentation of shortness of breath or dyspnea at rest, upon exertion, etc.; patient/family report of shortness of breath; observed clinical signs of distress from shortness of breath; and/or documentation that the symptom is distressing or limits patient function or quality of life.
- Evidence of a “positive” screen for shortness of breath should consider whether shortness of breath was an active problem for the patient at the time of the screening clinical encounter. In determining whether shortness of breath was an active problem for the patient, providers may need to consider historical report of patient’s shortness of breath, documentation of patient’s self-report of distress, and observed clinical signs of shortness of breath at the time of the encounter in which the screening was conducted. On the basis of reports of recent symptoms and current treatment, the assessing clinician may determine that dyspnea is an active problem, even if shortness of breath does not occur during the initial encounter.
- The initial screening documentation may be completed by any member of the palliative care core interdisciplinary team. The core interdisciplinary team is comprised of the following: Physician(s); Registered nurse(s) or advanced practice nurse(s); Chaplain(s) or, spiritual care professional(s); Social worker(s).
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| Suggested Data Sources: |
- Palliative care consultation notes
- Palliative care team progress notes
- Palliative care initial encounter notes
- Palliative care admission assessment
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| Additional Notes: |
Notes adapted from: Guidance Manual for Completion of the Hospice Item Set (HIS), Centers for Medicare and Medicaid Services, Hospice Quality Reporting Program, V 1.02 Effective June 28, 2015
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
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None
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None |
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Dyspnea Severity
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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