Release Notes:
Data Element
Version 2018A
| Data Element Name: |
Initial Encounter Date |
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| Collected For: |
PAL |
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| Definition: | The date that the patient was first seen in consultation by any member of the palliative care service. |
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| Suggested Data Collection Question: | What was the date the patient was first seen in consultation by any member of the palliative care service? |
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| Format: |
| Length: | 10 – MM-DD-YYYY (includes dashes) or UTD |
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| Type: | Date |
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| Occurs: | 1 |
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|
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| Allowable Values: |
MM = Month (01-12)
DD = Day (01-31)
YYYY =Year (20xx)
UTD =Unable to Determine |
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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.
- If multiple palliative care consultations took place, use the first face to face meeting date with any palliative care team member.
- Do not include attempted visits, use the first face to face visit.
- If the month and/or day contain only a single digit, enter a “0” in the first box of the month and/or day. For example, November 1, 20xx, would be entered as 11-01-20xx.
- The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
Example:
Documentation indicates the palliative care initial encounter date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the palliative care initial encounter date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD.”
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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 |
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Initial Encounter Date
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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