Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Posted: 10/30/2019
Home » Care Transition Record-Procedures Performed During Hospitalization

Release Notes:
Data Element
Version 2020A2

Name:Care Transition Record-Procedures Performed During Hospitalization
Collected For: ACHF-03
Definition:Documentation in the care transition record includes procedures performed during hospitalization. Procedures may be diagnostic (e.g., echocardiogram), therapeutic (e.g., thoracentesis), or surgical (e.g., pacemaker insertion).
Question:Is there documentation in the medical record of a care transition record which includes procedures performed during hospitalization?
Allowable Values:

Y (Yes) There is documentation that the care transition record included procedures performed during the hospitalization.

N (No) There is no documentation that the care transition record included procedures performed during the hospitalization, OR unable to determine from medical record documentation.
Notes for Abstraction:

  • The procedures performed during hospitalization should be a list of any diagnostic procedure(s), therapeutic procedure(s), or surgery(s) performed during the hospital stay. Procedures described by name, ICD-10-PCS Principal Procedure Code, or ICD-10-PCS Other Procedure Codes are acceptable.
  • If no procedures were performed during the hospitalization, select YES'.
  • Unchecked checkbox or blank space for documentation of procedures performed during hospitalization, select NO'.
Suggested Data Sources:
  • Aftercare discharge plan
  • Care transition record
  • Continuing care plan
  • Discharge plan
  • Discharge summary
  • Medication reconciliation form
  • Physician orders
  • Progress notes
  • Referral form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Care Transition Record-Procedures Performed During Hospitalization
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Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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