Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. or HOOS Pain, Function Daily Living Subscales]

• Select "UTD" if unable to determine the date the preoperative general health and joint specific functional status assessments were completed.
• If the general health and joint specific functional status assessments were completed on 2 different dates, select the earliest completion date.
• Information regarding the preoperative general health and joint specific functional status assessments determined to be part of the current medical record may be used in abstraction.
• Information can be retrieved from the actual assessment tools or a copy of the assessment tools in the current medical record or references to the tools present in the current medical record.
  Examples:
  
  • Scanned copies of the VR-12 and the HOOS Jr. assessments are present in the current medical record and dated 2/1/2016. Abstract 2/1/2016.
  • The preadmitting nurse documents “VR-12 and HOOS Jr. assessments completed on 2/1/2016”. Abstract 2/1/2016.
• When the date documented is obviously invalid, e.g., a date after the Discharge Date/Outpatient Departure Date or in an invalid format (12-39-20xx), and if no other documentation is found that provides the correct information, the abstractor should select “UTD.”
  Example:
  
  • Patient discharged on 02-12-20xx and documentation indicates the Preoperative Assessments Completion Date was 03-12-20xx. Other documentation in the medical record supports the date of discharge as being accurate. Since the Preoperative Assessments Completion Date is outside of the parmeter for care (after the Discharge Date), the abstractor should select “UTD.”
• If the Preoperative Assessments Completion Date is incorrect (in error) but it is a valid date and the correct date can be found and supported with other documentation in the medical record, use the correct date for Preoperative Assessments Completion Date. If supporting documentation of the correct date cannot be found, the medical record must be abstracted as documented (at “face value.”)
  Example:
  
  • If the patient’s date of surgery is 2/1/2016 and the scanned preoperative general health and joint specific functional status assessments are dated 1/15/2016, however, the preprocedure nursing documentation indicates that the assessments were completed on 1/15/2015, abstract 1/15/2016.

• Nursing notes
• Nursing admission assessment
• Progress notes
• Care management notes
• Functional/Health Status Assessment
• General health and joint specific functional status assessments
• Physicians’ office notes (in current medical record)
• Preadmitting notes
• Social work notes
• Therapy notes (e.g., physical therapy, occupational therapy, kinesiotherapy)