Release Notes:
Data Element
Version 2018B1
| Name: | Sex |
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| Collected For: |
All Records |
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| Definition: | The patient's documented sex on arrival at the hospital. |
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| Question: | What is the patient's sex on arrival? |
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| Format: |
| Length: | 1 |
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| Type: | Character |
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| Occurs: | 1 |
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| Allowable Values: |
M = Male
F = Female
U = Unknown
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| Notes for Abstraction: |
- Collect the documented patient's sex at admission or the first documentation after arrival.
- Consider the sex to be unable to be determined and select “Unknown” if:
- The patient refuses to provide their sex.
- Documentation is contradictory.
- Documentation indicates the patient is a Transexual.
- Documentation indicates the patient is a Hermaphrodite.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Face sheet
- Progress notes
- Nursing admission notes
- UB-04
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| Additional Notes: |
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| Guidelines for Abstraction: |
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