Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record-Reason for Hospitalization |
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| Collected For: |
ACHF-03 |
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| Definition: | Documentation in the care transition record includes the reason for hospitalization. The reason for hospitalization should be a short synopsis describing the events the patient experienced prior to this hospitalization. The reason for hospitalization may be listed as the triggering or precipitating event prior to the patient's admission to the hospital. |
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| Question: | Is there documentation in the medical record of a care transition record which includes the reason for hospitalization? |
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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: |
Y (Yes) There is documentation that the care transition record included the reason for hospitalization.
N (No) There is no documentation that the care transition record included the reason for hospitalization, OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If the patient's primary diagnosis and/or other or secondary diagnoses are listed on the care transition record, select YES'.
- Documentation of the patient's “chief complaint” on the care transition, select YES'.
- Unchecked checkbox or blank space for documentation of reason for hospitalization, select NO'.
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| Suggested Data Sources: |
- Aftercare discharge plan
- Care transition record
- Continuing care plan
- Discharge plan
- Discharge summary
- Medication reconciliation form
- Physician orders
- Progress notes
- Referral form
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| Additional Notes: |
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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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