Release Notes:
Data Element
Version 2018B1
| Name: | Discharge Code |
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| Collected For: |
ACHFOP, ASR-OP-2, STK-OP-1 |
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| Definition: | The final place or setting to which the patient was discharged from the outpatient setting. |
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| Question: | What was the patient's discharge code from the outpatient setting? |
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| Format: |
| Length: | 2 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
1 Home
2 Hospice - Home
3 Hospice — Health Care Facility
4a Acute Care Facility- General Inpatient Care
4b Acute Care Facility- Critical Access Hospital
4c Acute Care Facility- Cancer Hospital or Children's Hospital
4d Acute Care Facility — Department of Defense or Veteran's Administration
5 Other Health Care Facility
6 Expired
7 Left Against Medical Advice/AMA
8 Not Documented or Unable to Determine (UTD)
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| Notes for Abstraction: |
- If documentation is contradictory, use the latest documentation. If there is documentation that further clarifies the level of care that documentation should be used to determine the correct value to abstract.
Example:
- Nursing discharge note documentation reflects that the patient is being discharged to “XYZ” Hospital. The Social Service notes from the day before discharge further clarify that the patient will be transferred to the rehab unit of “XYZ” Hospital, select value “5”.
- If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select value “4a”.
- When determining whether to select value 7 (“Left Against Medical Advise"):
- A signed AMA form is not required for this data element, but in the absence of a signed form, the medical record must contain physician or nurse documentation that the patient left against medical advice or AMA.
- For this data element, a signed AMA form is not required.
- Do not consider AMA documentation and other disposition documentation as “contradictory.” If any source states the patient left against medical advice, select value 7, regardless of whether the AMA documentation was written last (e.g., AMA form signed and discharge instruction sheet states “Discharged home with belongings”—Select value 7).
- Physician order written to discharge to home. Nursing notes reflect that the patient left before discharge instructions could be given; select value 1.
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| Suggested Data Sources: |
- Discharge instruction sheet
- Emergency Department Record
- Nursing discharge notes
- Physician orders
- Progress notes
- Transfer record
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| Additional Notes: |
Excluded Data Sources: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
For Value 1:
- Assisted Living Facilities
- Court/Law Enforcement — includes detention facilities, jails, and prison
- Home — includes board and care, foster or residential care, group or personal care homes, and homeless shelters
- Home with Home Health Services
- Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs and Partial Hospitalization
For Value 3:
- Hospice Care - General Inpatient and Respite
- Hospice Care - Residential and Skilled Facilities
- Hospice Care - Other Health Care Facilities (excludes home)
For Value 5:
- Extended or Intermediate Care Facility (ECF/ICF)
- Long Term Acute Care Hospital (LTACH)
- Nursing Home or Facility including Veteran's Administration Nursing Facility
- Psychiatric Hospital or Psychiatric Unit of a Hospital
- Rehabilitation Facility including Inpatient Rehabilitation Facility/Hospital or Rehabilitation Unit of a Hospital
- Skilled Nursing Facility (SNF), Sub-Acute Care or Swing Bed
- Transitional Care Unit (TCU)
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None |
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