Reason for Not Ambulating the Day of Surgery (v2019A)

Specifications Manual for Joint Commission National Quality Measures (v2019A)

Print this page

Home » Reason for Not Ambulating the Day of Surgery

Release Notes:
Data Element
Version 2019A

Name:

Reason for Not Ambulating the Day of Surgery

Collected For:

THKR-IP-2, THKR-OP-2

Definition:

Reasons for not ambulating the patient on the day of surgery.

Question:

Is there documentation of a reason for not ambulating the patient on the day of surgery?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation of a reason for not ambulating the patient on the day of surgery.

N (No) There is no documentation of a reason for not ambulating the patient on the day of surgery or unable to determine from medical record documentation.

Notes for Abstraction:

To select “Yes” for this data element, documentation of a reason for not ambulating the patient on the day of surgery must be dated on or prior to the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery.
Reasons for not ambulating the patient must be documented by a physician/APN/PA/nurse/physical therapist/occupational therapist.
If reasons are not mentioned in the context of ambulation, do not make inferences.
Examples:
- PA documents hypotensive episode of 90/60 postoperatively on the PACU Discharge Date. No linkage to reason for not ambulating. Select “No”.
- MD writes an order on the PACU Discharge Date, “do not ambulate patient today due to nausea and vomiting”. Select “Yes”.
- Physical therapist documents that the patient was wheelchair bound prior to surgery and therefore did not ambulate the day of surgery. Select “Yes”.
If the data element “Postoperative ICU Admit or Transfer” was abstracted as “Yes”, select “Yes”.
In the absence of a medical reason documented by the physician/APN/PA/nurse/physical therapist/occupational therapist, patient/family/caregiver refusal is not an acceptable stand alone reason for not ambulating on the day of surgery.

Suggested Data Sources:

Consultation notes
Nursing notes
Progress notes
Physician orders
Physician's notes
Procedure notes
PACU/recovery room record
Therapy notes (e.g., physical therapy, occupational therapy, kinesiotherapy)

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	Patient/Family/Caregiver Refusal

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

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.