Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Ambulation Time

Release Notes:
Data Element
Version 2020B

Name:Ambulation Time
Collected For: THKR-IP-2, THKR-OP-2
Definition:The time the patient first ambulated following the surgical procedure.
Question:At what time did the patient first ambulate following the surgical procedure?
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
Notes for Abstraction:
  • Select “UTD” if unable to determine the ambulation time.
  • Review the record to determine the earliest time the patient ambulated following the surgical procedure. There is no minimum distance requirement.
  • Ambulation with assistive devices (e.g., walker, cane) and/or physical assist (e.g., therapist, nurse) is acceptable.
  • Ambulation in the PACU is acceptable.
  • Documentation that the patient actually ambulated must be present. Do not assume the patient ambulated based solely on documentation that physical/occupational therapy saw the patient.
  • See the list of terms listed in the Inclusion/Exclusion Guidelines to determine if documentation supports ambulation.
  • Ambulation can be documented by any member of the healthcare team including but not limited to physician, advanced practice nurse, physician assistant, nurse, nurse assistant, clinical technician, physical therapist, occupational therapist, kinesiotherapist.
  • 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.”
Suggested Data Sources:
  • Nursing notes
  • Progress notes
  • Flowsheets
  • Rehabilitation records
  • Therapy notes (e.g., physical therapy, occupational therapy, kinesiotherapy)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Ambulate
  • Step
  • Walk

  • Bedside commode usage
  • Dangle
  • Out of bed order
  • Sit in bed
  • Sit out of bed
  • Sit to Stand
  • Stand
  • Transfer from bed to chair
  • Up to chair

Ambulation Time
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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