Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Influenza Vaccination Status

Release Notes:
Data Element
Version 2020B

Name:Influenza Vaccination Status
Collected For: IMM-2
Definition:Documentation of the patient's vaccination status during this influenza season. If found to be a candidate for the influenza vaccine, documentation that the influenza vaccine was given during this hospitalization. The main types of influenza vaccine available are: an attenuated (weakened) live vaccine given as a nasal spray and approved for healthy nonpregnant persons 2-49 years of age, a killed (inactivated) influenza vaccine administered via intramuscular (IM) needle injection for persons 6 months and older, an intradermal vaccine administered to persons 18-64 years old, or a recombinant vaccine administered IM to a person 18 years or older.
Question:What is the patient's influenza vaccination status?

Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    Influenza vaccine was given during this hospitalization.

2   Influenza vaccine was received prior to admission during the current flu season, not during this hospitalization.

3   Documentation of patient's or caregiver’s refusal of influenza vaccine.

4   There was documentation of an allergy/sensitivity to influenza vaccine, anaphylactic latex allergy or anaphylactic allergy to eggs OR is not likely to be effective because of bone marrow transplant within the past 6 months OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination.

5   None of the above/Not documented/Unable to determine from medical record documentation.

6   Only select this allowable value if there is documentation the vaccine has been ordered but has not yet been received by the hospital due to problems with vaccine production or distribution AND allowable values 1-5 are not selected.
Notes for Abstraction:
  • Each year, flu vaccines start to become available usually in September and most influenza vaccine is administered in October — December, but the vaccine is recommended to be administered throughout the influenza season which can last until May in some years. For the purposes of this project, the hospitals are only responsible for discharges October through March.
    • Only influenza vaccines administered during August through March are acceptable.
  • The caregiver is defined as the surrogate decision-maker, or healthcare surrogate and may be a patient’s family member or any other person (e.g., home health, VNA provider, prison official or other law enforcement personnel) who is responsible for the healthcare decision-making and care of the minor patient or the adult patient when that patient is unable to make this decision on his/her own.
  • In order to select “Influenza vaccine was given during this hospitalization,” there must be documentation either on the MAR, nursing notes, standing orders, etc., where the vaccine was dated and signed as administered.
  • In situations where there is documentation that would support more than one of the allowable values, 1-4, select the smallest number.
    Example:
    Nurses' notes have documentation the patient refused. Vaccination order sheet has documentation that the patient was vaccinated during this hospitalization. You will select value “1”, as it is the smallest number.
  • If there is no documentation to support any of the Allowable Values 1-4, and there is physician/APN/PA documentation that they will administer the vaccine after discharge or physician/APN/PA documentation not to administer the vaccine for a reason other than those noted as acceptable in this data element, select Value “5.”
  • If there is conflicting documentation regarding influenza vaccine refusal, select Value “5.”
    Example:
    There is documentation of refusal in the influenza immunization screening for the current admission and the patient did not receive the vaccine, but a subsequent narrative note states the patient wants to receive the vaccine, select Value “5.”
  • If there is conflicting documentation regarding whether the influenza vaccine is current, use documentation reflecting it is current.
    Examples:
    • There is documentation in the medical record stating “influenza vaccination status: current,” but the physician H&P indicates the patient has not received an influenza vaccine this season, select Value “2.”
    • There is documentation in medical record stating “influenza vaccination status: current,” but the influenza vaccination date is from the previous season, select Value “2.”
  • If there is conflicting documentation regarding administration of the vaccine in the hospital, use documentation reflecting the vaccine was given during the admission.
    Examples:
    There is documentation in the medical record indicating the vaccine was given (dated and signed as administered) during the hospital stay, but the discharge summary states order for vaccine was cancelled and patient did not receive vaccine during the hospital stay, select Value “1.”
  • If there is documentation that the patient received the vaccine and only the current year is documented, i.e., no month or day, select value “2”.
    Example:
    There is documentation the patient received the vaccine in 2009 and it is October 2009, select value “2.”
  • If there is documentation the patient received the vaccine the year prior to the current year and the discharge is not January, February or March, select value “5”. Examples:
    • There is documentation the patient received the vaccine in 2008 and it is October 2009, select value “5”.
    • There is documentation the patient received the vaccine in 2008 and it is January 2009, select value “2”.
  • If it is documented in the chart that a patient is “up to date” on their vaccines, you may select Allowable Value “2”. Documentation of “up to date” or “current” in the vaccination record that does not reference the influenza vaccine is not sufficient to select Allowable Value “2.”
  • Documentation of the acronym “UTD,” even with specific reference to the influenza vaccine, is not sufficient to select Allowable Value “2.”
  • Documentation from a pre-admission screening or previous episode of care indicating that the patient received the influenza vaccine with a date from the current season would be acceptable to choose Value “2.”
  • Documentation of influenza vaccine refusal from an admission or encounter that is prior to arrival cannot be used for selecting Value “3.” Information for selecting Value “3” must be assessed and documented within the current admission.
  • Documentation of unavailability due to problems with vaccine production or distribution from an admission or encounter that is prior to arrival cannot be used for selecting Value “6.” Information for selecting Value “6” must be assessed and documented within the current admission.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • Nursing notes
  • Nursing admission assessment
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • Immunization assessment forms
  • Physician progress notes
  • Social service notes
  • Transfer forms
  • Vaccine order sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include those listed below or refer to CDC list of Influenza vaccines at http://www.cdc.gov/flu/protect/vaccine/vaccines.htm.
  • Afluria
  • Flu shot
  • Flu vaccine
  • FluMist
  • FluLaval
  • Fluarix
  • Fluvirin
  • Fluzone
  • Fluzone High Dose
  • Influenza virus vaccine
  • Live attenuated influenza vaccine
  • Quadrivalent influenza vaccine
  • Trivalent influenza vaccine

  • All discharges from April through September
  • Pandemic monovalent vaccine, e.g. H1N1
  • Patients with an organ transplant during the current hospitalization (Appendix A, Table 12.10)

Influenza Vaccination Status
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^