Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record-Procedures Performed During Hospitalization |
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| Collected For: |
ACHF-03 |
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| Definition: | Documentation in the care transition record includes procedures performed during hospitalization. Procedures may be diagnostic (e.g., echocardiogram), therapeutic (e.g., thoracentesis), or surgical (e.g., pacemaker insertion). |
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| Question: | Is there documentation in the medical record of a care transition record which includes procedures performed during 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 procedures performed during the hospitalization.
N (No) There is no documentation that the care transition record included procedures performed during the hospitalization, OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- The procedures performed during hospitalization should be a list of any diagnostic procedure(s), therapeutic procedure(s), or surgery(s) performed during the hospital stay. Procedures described by name, ICD-10-PCS Principal Procedure Code, or ICD-10-PCS Other Procedure Codes are acceptable.
- If no procedures were performed during the hospitalization, select YES'.
- Unchecked checkbox or blank space for documentation of procedures performed during 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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