Specifications Manual for Joint Commission National Quality Measures (v2019A1)
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Release Notes:
Data Element
Version 2019A1

Name:ED Departure Time
Collected For: ASR-OP-2, STK-OP-1
Definition:The time (military time) represented in hours and minutes at which the patient departed from the emergency department.
Question:What is the time the patient departed from the emergency department?
Length:5 — HH:MM (with or without colon) or UTD
Allowable Values:

HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format.
With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required.
  • If the time is in the p.m., add 12 to the clock time hour.

Midnight - 00:00      Noon - 12:00
5:31 am - 05:31      5:31 pm - 17:31
11:59 am - 11:59     11:59 pm - 23:59

00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the ED Departure Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.
When converting Midnight or 24:00 to 00:00, do not forget to change the ED Departure Date.
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “seconds”, remove the seconds and record the military time. Example: 15:00:35 would be recorded as 15:00.
  • The intention is to capture the latest time at which the patient was receiving care in the emergency department, under the care of emergency department services, or awaiting transport to services/care.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid format/range) and no other documentation is found that provides this information, the abstractor should select “UTD”."
    Documentation indicates the ED Departure Time was 3300. No other documentation in the list of ONLY ACCEPTABLE SOURCES provides a valid time. Since the ED Departure Time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”."
    Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission's Data Warehouse. Use of “UTD” for ED Departure Time allows the case to be accepted into the warehouse.
  • ED Departure Time is the documented time the patient physically left the emergency department.
    • ED nursing notes documented the “ED Departure Time” as 1030, however, vital signs are documented at 1040. There is no documentation to support that the patient was in the ED at 1040. Enter 1030 for ED Departure Time.
    • ED nursing notes document patient departed from the ED at 0730. ED nursing notes document medication administration at 0735. Enter 0730 for ED Departure Time.
  • If the time the patient departed is unable to be determined from medical record documentation, select, “UTD.”
    • ED nursing notes document patient departed from the ED at 1225. Nursing notes document medication administration at 1245. Physician progress notes document assessment at 1310. There is substantial documentation to support that the patient was in the ED after documented departure and no additional documented time of ED departure. Enter UTD for ED Departure Time .
  • When more than one emergency department departure/discharge time is documented abstract the latest time.
    • ED nursing notes contain documentation that the patient was transferred to floor at 1800 and transport documentation states that patient left the ED via stretcher at 1815. There are multiple times documented for departure. Use the later time of 1815 as ED Departure Time.
    • ED nursing notes contain documentation that the patient departed the ED at 0500. ED record contains documentation of medication administration at 0510 and that the patient departed the ED at 0620. Physician notes contain documentation of an assessment at 0540. As there are multiple departure times documented, enter 0620 for ED Departure Time as it is the latest time documented.
  • If patient expired in the ED, use the time of death as the departure time.
  • Do not use the time the discharge order was written because it may not represent the actual time of departure.
  • If ED Departure Time is documented prior to arrival abstract UTD.
  • For patients who are placed into observation services, use the time of the physician/APN/PA order for observation for ED Departure Time .
  • The intent of this guidance is to abstract the time that the patient is no longer under the care of the ED. When a patient is placed into observation, their clinical workflow may vary from patients who are not placed into observation prior to departure from the ED, so the observation order may be used instead of the actual ED Departure Time .
  • If there is a discharge time listed on a disposition sheet, this may be used for ED Departure Time .
  • The inclusion and exclusion lists are not to be considered comprehensive lists of inclusions and exclusions.
Suggested Data Sources: ONLY ACCEPTABLE SOURCES:
  • Emergency Department record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • ED leave time
  • ED discharge time
  • ED departure time
  • ED checkout time
  • ED order for observation status
  • Release time
  • Out time
  • Gone time
  • Transport documented time
  • The event log, registration sheet, transfer record, etc. (if a discharge time is noted and the document is part of the permanent medical record)
  • Transfer time
  • Report called time
  • Disposition time
  • Discharge instructions time
  • Coding summary
  • Physicians discharge summary
  • ED record released from holding time
  • Chart closed time
  • Off the tracking board time

ED Departure Time
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Specifications Manual for Joint Commission National Quality Measures (v2019A1)
Discharges 10-01-19 through 12-31-19 (4Q19)


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