Substance Use (v2019A)

Specifications Manual for Joint Commission National Quality Measures (v2019A)

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Release Notes:
Data Element
Version 2019A

Name:

Substance Use

Collected For:

HBIPS-1

Definition:

Documentation in the medical record that an admission screening for substance use and alcohol use which occurred over the past twelve (12) months was performed within the first three days of admission. The screening must include: the type, amount, frequency of use and any problems due to past use.

Question:

Is there documentation in the medical record that the patient was screened for substance use and alcohol use which occurred over the past twelve (12) months within the first three days of admission?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) Documentation in the medical record includes a screening for substance use and alcohol use which occurred over the past twelve (12) months performed within the first three days of admission.

N (No) Documentation in the medical record does not include a screening for substance use and alcohol use which occurred over the past twelve (12) months OR the screening was not performed within the first three days of admission OR unable to determine from medical record documentation.

X (Unable to complete admission screening) Documentation in the medical record that a screening for substance use and alcohol use cannot be completed due to the patient's inability or unwillingness to answer assessment questions within the first three days of admission OR patient has a previous admission to the psychiatric unit during a single hospitalization.

Notes for Abstraction:

For the purpose of this data element, substance refers to alcohol, drugs and any other substances used for purposes other than intended.

A screening for substance use and alcohol use must be completed by a qualified psychiatric practitioner e.g., psychiatrist, registered nurse (RN), physician's assistant (PA) or Master of Social Work (MSW) within the first three days of admission. Titles of qualified psychiatric practitioners vary from state to state.

The intent of this data element is to screen the patient for substance use within the 12 months prior to admission. Documentation of substance use must at a minimum state over the past 12 months. Documentation of a past history of substance use should differentiate the use being either within the past 12 months or prior to the 12 month time frame.

Documentation of "no history" cannot be used, unless it is associated with a time frame. For example:

“No history of substance use within the past 12 months.”
“History of substance use 2 years ago.”

The admission screening timeframe must have occurred within the first three days of admission for psychiatric care. The day after admission is defined as the first day. An admission screen performed in an ambulatory setting, i.e. emergency department, crisis center which results in an admission to an inpatient psychiatric care setting can be used if the screen becomes a permanent part of the medical record.

Substance use is defined as the use of psychoactive or mood altering substances, i.e., prescription medications, over the counter medications, inhalants, organic substances, illegal substances and street drugs.

If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient.

If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, select the first admission to the psychiatric unit.

Suggested Data Sources:

Biopsychosocial assessment
Emergency department record
Functional skills assessment
History and physical
Individual plan of service
Initial assessment form
Nursing notes
Physician progress notes
Psychiatrist assessment/admission form
Referral packet
School report
Social worker assessment

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Some examples of problems due to past substance and/or alcohol use include, but are not limited to:

Job loss
Feeling that life is out of control and fear of what might happen
Loss of family support
Arrested for drug possession
Sustained bodily harm for failure to pay for drugs
Girlfriend/boyfriend/spouse ended relationship
Loss of driver’s license
Uncontrolled anger
Attempted suicide
Estranged from family members

None

Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

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