Release Notes:
Data Element
Version 2018B1
| Name: | Non-aneurysmal |
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| Collected For: |
CSTK-03 |
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| Definition: | Patients with documentation of non-aneurysmal SAH or SAH related to head trauma any time during the hospital stay.
Non-aneurysmal SAH refers to hemorrhage in the subarachnoid space that is not attributed to the ruptured of a cerebral aneurysm.
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| Question: | Is there documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma? |
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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 any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma.
N (No) There is no documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma, OR unable to determine from the medical record documentation.
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| Notes for Abstraction: |
- The timeframe for documentation of this data element is any time during the hospital stay from hospital arrival to discharge.
- Only accept terms identified in the list of inclusions. No other terminology will be accepted.
- Terms must be documented by a physician/APN/PA only.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
- Head trauma
- Non-aneurysmal
- Not aneurysmal
- Trauma
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- Trauma other than head
- Trauma or traumatic injuries involving body parts other than the head
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