Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Minutes of Seclusion

Release Notes:
Data Element
Version 2020B2

Name:Minutes of Seclusion
Collected For: HBIPS-3
Definition:The total minutes recorded in the medical record that a patient was held in Event Type 2 (seclusion) during the associated Event Date.
Question:What was the total number of minutes recorded in the medical record that the patient was held in Event Type 2 (seclusion) during the Event Date?
Format:
Length:4 or UTD
Type:Alphanumeric
Occurs:1
Allowable Values:


1-1440
UTD= Unable to Determine
Notes for Abstraction: Event Type 2 (seclusion(s)) should be reported in whole minutes. Events less than or equal to 60 seconds should be reported as 1 minute (i.e., event duration of 2 minutes 5 seconds is reported as 3 minutes).

For each patient enter the Minutes of Seclusion that corresponds with the Event Date and Event Type.

If a patient is in Event Type 2 (seclusion) and then changed to Event Type 1 (physical restraint(s)), the time for Event Type 2 (seclusion) STOPS. The initiation of Event Type 1 (physical restraint(s)) stops the time for Event Type 2 (seclusion).

If a patient is in Event Type 1 (physical restraint(s)) and Event Type 2 (seclusion) at the same time, the time should be counted as Minutes of Physical Restraint. Time in physical restraints supersedes time in seclusion.

Select unable to determine when either the start or stop time OR the total number of minutes of Event Type 2 (seclusion) event is missing from the medical record and the total Minutes of Seclusion can not be calculated for the associated Event Date.

See guidelines for abstraction for definition of an Event Type 2 (seclusion).

When an Event Type 2 (seclusion) starts at school or during an off-campus outing; this event should be reported.

Suggested Data Sources:
  • Licensed independent practitioner orders
  • Nursing flow sheet
  • Nursing notes
  • Observation sheets
  • Physician orders
  • Progress notes
  • Psychiatrist notes
  • Seclusion monitoring form
  • Therapist notes

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. This includes but is not limited to ¹:
  • Manually or electronically locked doors
  • One-way doors
  • The presence of staff proximal to the room preventing exit or the threat of consequences if the patient leaves the room

¹ 42 CFR Part 482, Medicare and Medicaid Programs; Hospital Conditions of Participation: Patient's Rights

  • Time-out
  • Quarantine due to infectious disease

Minutes of Seclusion
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Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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