Specifications Manual for Joint Commission National Quality Measures (v2018A1)
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Release Notes:
Data Element
Version 2018A1

Data Element Name: Arrival Time
Collected For: ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-07, CSTK-09, CSTK-11, STK-4
Definition:The earliest documented time (military time) the patient arrived at the hospital.
Suggested Data Collection Question:What was the earliest documented time the patient arrived at the hospital?
Format:
Length:5 - HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:

Enter the earliest documented time of arrival
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

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Arrival Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting 24:00 to 00:00 do not forget to change the Arrival Date.
Example: Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “seconds,” remove the seconds and record the time as is.
    Example:
    15:00:35 would be recorded as 15:00.
  • If the time of arrival is unable to be determined from medical record documentation, select “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 Arrival Time was 3300. No other documentation in the list of Only Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
    Note: Transmission of a case with an invalid time as described above will be rejected from the CMS Clinical Warehouse and the Joint Commission''s Data Warehouse. Use of “UTD” for Arrival Time allows the case to be accepted into the warehouse.
  • Review the Only Acceptable Sources to determine the earliest time the patient arrived at the ED, nursing floor, or observation, or as a direct admit to the cath lab. The intent is to utilize any documentation which reflects processes that occurred after arrival at the ED or after arrival to the nursing floor/observation/cath lab for a direct admit.
  • Documentation outside of the Only Acceptable Sources list should NOT be referenced (e.g., ambulance record, physician office record, H&P).
    Examples:
    • ED Triage Time 0800. ED rhythm strip 0830. EMS report indicates patient was receiving EMS care from 0805 through 0825. The EMS report is disregarded. Enter 0800 for Arrival Time.
    • ED noted arrival time of 0945. Lab report shows blood culture collected at 0830. It is not clear that the blood culture was collected in the ED because the lab report does not specify it was collected in the ED (unable to confirm lab report as an Only Acceptable Source). Enter 0945 for Arrival Time.
    • ED Triage Time 1525. EMS report indicates patient was receiving care 1435 through 1455. ED report documents time of head CT 1505. The EMS report is disregarded. Enter 1505 for Arrival Time.
  • Arrival time should NOT be abstracted simply as the earliest time in one of the Only Acceptable Sources, without regard to other substantiating documentation. When looking at the Only Acceptable Sources, if the earliest time documented appears to be an obvious error, this time should not be abstracted.
    Examples:
    • ED arrival time noted as 2300 on 10-28-20xx. ED MAR shows an antibiotic administration time of 0100 on 10-28-20xx. Surrounding documentation on the ED MAR makes clear that the 10-28-20xx date is an obvious error - Date was not changed to 10-29-20xx. The antibiotic administration date/time would be converted to 0100 on 10-29-20xx. Enter 2300 for Arrival Time.
    • ED face sheet lists arrival time of 13:20. ED Registration Time 13:25. ED Triage Time 13:30. ED consent to treat form has 1:17 time but “AM” is circled. ED record documentation suggests the 1:17 AM is an obvious error. Enter 13:20 for Arrival Time.
    • ED ECG timed as 1742. ED Greet Time 2125. ED Triage Time 2130. There is no documentation in the Only Acceptable Sources which suggests the 1742 is an obvious error. Enter 1742 for Arrival Time.
    • ED RN documents on the nursing triage note, “Blood culture collected at 0730.” ED arrival time is documented as 1030. There is no documentation in the Only Acceptable Sources which suggests the 0730 is an obvious error. Enter 0730 for Arrival Time.
  • The source “Emergency Department record”" includes any documentation from the time period that the patient was an ED patient (e.g., ED face sheet, ED consent/Authorization for treatment forms, ED/Outpatient Registration/sign-in forms, ED vital sign record, ED triage record, ED physician orders, ED ECG reports, ED telemetry/rhythm strips, ED laboratory reports, ED x-ray reports, ED head CT scan, CTA, MRI, MRA reports).
  • The source “Procedure notes” refers to procedures such as cardiac caths, endoscopies, and surgical procedures. Procedure notes do not include ECG and x-ray reports.
  • The arrival time may differ from the admission time.
  • If the patient is in either an outpatient setting of the hospital other than observation status (e.g., dialysis, chemotherapy, cardiac cath) or a SNF unit of the hospital, and is subsequently admitted to acute inpatient, use the time the patient arrived at the ED or on the floor for acute inpatient care as the arrival time.
  • Observation status:
    • If the patient was admitted to observation from an outpatient setting of the hospital, use the time the patient arrived at the ED or on the floor for observation care as the arrival time.
    • If the patient was admitted to observation from the ED of the hospital, use the time the patient arrived at the ED as the arrival time.
  • Direct Admits:
    • If the patient is a “Direct Admit” to the cath lab, use the earliest time the patient arrived at the cath lab (or cath lab staging/holding area) as the arrival time.
    • For “Direct Admits” to acute inpatient or observation, use the earliest time the patient arrived at the nursing floor or in observation (as documented in the Only Acceptable Sources) as the arrival time.
  • If the patient was transferred from your hospital''s satellite/free-standing ED or from another hospital within your hospital''s system (as an inpatient or ED patient), and there is one medical record for the care provided at both facilities, use the arrival time at the first facility.
    CSTK, STK, AND ASR MEASURES ONLY
    EXCEPTION: Use the arrival time at the comprehensive stroke center/primary stroke center.
Suggested Data Sources:

ONLY ACCEPTABLE SOURCES
  • Emergency department record
  • Nursing admission assessment/admitting note
  • Observation record
  • Procedure notes
  • Vital signs graphic record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None Addressographs/Stamps

Arrival Time
Specifications Manual for Joint Commission National Quality Measures (v2018A1)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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