Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)
Home » ED Departure Time

Release Notes:
Data Element
Version 2020A

Name:ED Departure Time
Collected For: ASR-OP-2, ED-1, ED-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?
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
11:59 am - 11:59     11:59 pm - 23:59

Note:
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.
Example:
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."
    Example:
    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 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. (e.g., nurse’s notes state “18:00 transfer to floor-room 300” and other documentation includes a time that the patient left the ED via stretcher, abstract the later time or nurses notes state “18:00 transport to unit” and other documentation includes a time that the patient actually left the ED to be transferred, abstract the later time).
  • If the time the patient departed is unable to be determined from medical record documentation, select, “UTD.”
  • When more than one acceptable emergency department departure/discharge time is documented, abstract the latest time.
    Example:
    Two departure times are found in the nurse’s notes: 12:03 via wheelchair and 12:20 via wheelchair. Select the later time of 12:20.
  • Do not use documentation of vital signs or medications if they are later than the ED departure time.
  • Do not use the time the discharge order was written because it may not represent the actual time of departure.
  • Data fields representing ED Departure Time in electronic documentation for this specific episode of care are acceptable to use as long as the fields are easily understood to mean departure. Information found in an electronically interfaced event log or Admit/Decision/Transfer (ADT) is acceptable provided this information is part of the submitted medical record covering the arrival to discharge time being abstracted.
    Examples
    • Patient departed
    • Patient transferred off the floor (OTF)
    • Check out time
    • Transported to ED
  • If there is a departure time listed within a disposition heading from the ED, this may be used for ED Departure Time.
  • For patients who are placed into observation outside the services of the emergency department, abstract the time of departure from the emergency department.
    • If the patient is placed into observation services and remains in the ED or in a unit of the ED abstract the time they depart the ED or ED unit for the floor/surgery etc. Do not abstract the time they are placed into observation services.
      STK-OP-1 AND ASR-OP-2 MEASURES ONLY
      EXCEPTION: For patients who are placed into observation services in a bed outside the ED, e.g., inpatient bed, select the time that the patient is transferred to another hospital and actually leaves your hospital (Discharge Time) and not the time of departure from the emergency department.
  • For patients who are placed into observation under the services of the emergency department, abstract the time of departure from the observation services.
    • If a patient is seen in the ED and admitted to an observation unit of the ED, then discharged from the observation unit, abstract the time they depart the observation unit.
    • If the patient is placed into observation services and remains in the ED or in a unit of the ED abstract the time they depart the ED or ED unit for the floor/surgery, transfer to another hospital, admission to an inpatient bed, etc. Do not abstract the time they are placed into observation services or the time that the observation order was written.
  • If the documented ED Departure Time is prior to arrival, enter “UTD.”
  • If the patient expired in the ED, use the time of death as the 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 Check Out Time
  • ED Departure Time
  • ED Discharge Time
  • ED Leave Time
  • ED Transport Time
  • Patient Admission Time
  • Report called time

ED Departure Time
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Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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