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

Name:PACU Discharge Time
Collected For: THKR-IP-2, THKR-OP-2
Definition:The time the patient was discharged from the PACU following the total hip or total knee replacement.
Question:What time was the patient discharged from the PACU following the total hip or total knee replacement?
Format:
Length:5-HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
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

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31

Note: When converting Midnight or 24:00 to 00:00 do not forget to change the PACU Discharge Date. Example: Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • The intent is to capture the time the patient physically left the PACU. If a patient is discharged from a PACU level of care, however, remains in the PACU, do not abstract this time. EXCEPTION: In the outpatient setting, if a patient is discharged to home from the PACU setting, use the time anesthesia cleared the patient to the next level of care as the PACU discharge time.
  • If multiple PACU discharge times are documented, select the latest time.
  • If the PACU Discharge Time is unable to be determined from medical record documentation, select “UTD.”
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time format) or is outside of the parameters of care (after Discharge Date or Outpatient Departure Date) and no other documentation is found that provides this information, the abstractor should select “UTD.”
    Example:
    • Documentation indicates the PACU Discharge Time was 24:11. No other documentation in the medical record provides a valid time. Since the PACU Discharge Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
Suggested Data Sources:
  • Anesthesia record
  • Nursing notes
  • Nursing flow sheet
  • Post Anesthesia Care Unit (PACU) Record
  • Recovery Room Record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

PACU Discharge 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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