Release Notes:
Data Element
Version 2018A
| Data Element Name: |
Initial Encounter |
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| Collected For: |
PAL |
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| Definition: | A patient who has received a consultation with any member of the palliative care service team. |
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| Suggested Data Collection Question: | Did the patient receive a palliative care service initial encounter at the organization? |
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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) There is documentation in the medical record that the patient received an initial encounter consultation with a member of the palliative care team.
N (No) There is no documentation in medical record that the patient received an initial encounter consultation with a member of the palliative care team or unable to determine from the medical record documentation.
|
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| Notes for Abstraction: |
- “Consultation” indicates that the patient received a face to face encounter visit with 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).
- A formal order for a consultation does not need to be present in the medical record.
- Do not include attempted visits, use the first face to face visit.
|
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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: |
|
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
|
None
|
None |
|
Initial Encounter
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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