Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Reason for Not Ambulating the Day of Surgery

Release Notes:
Data Element
Version 2020B2

Name:Reason for Not Ambulating the Day of Surgery
Collected For: THKR-IP-2, THKR-OP-2
Definition:Reasons for not ambulating the patient on the day of surgery.
Question:Is there documentation of a reason for not ambulating the patient on the day of surgery?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)   There is documentation of a reason for not ambulating the patient on the day of surgery.

N (No)   There is no documentation of a reason for not ambulating the patient on the day of surgery or unable to determine from medical record documentation.
Notes for Abstraction:
  • To select “Yes” for this data element, documentation of a reason for not ambulating the patient on the day of surgery must be dated on or prior to the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery.
  • Reasons for not ambulating the patient must be documented by a physician/APN/PA/nurse/physical therapist/occupational therapist.
  • If reasons are not mentioned in the context of ambulation, do not make inferences.
    Examples:
    • PA documents hypotensive episode of 90/60 postoperatively on the PACU Discharge Date. No linkage to reason for not ambulating. Select “No”.
    • MD writes an order on the PACU Discharge Date, “do not ambulate patient today due to nausea and vomiting”. Select “Yes”.
    • Physical therapist documents that the patient was wheelchair bound prior to surgery and therefore did not ambulate the day of surgery. Select “Yes”.
  • If the data element “Postoperative ICU Admit or Transfer” was abstracted as “Yes”, select “Yes”.
  • In the absence of a medical reason documented by the physician/APN/PA/nurse/physical therapist/occupational therapist, patient/family/caregiver refusal is not an acceptable stand alone reason for not ambulating on the day of surgery.
Suggested Data Sources:
  • Consultation notes
  • Nursing notes
  • Progress notes
  • Physician orders
  • Physician's notes
  • Procedure notes
  • PACU/recovery room record
  • Therapy notes (e.g., physical therapy, occupational therapy, kinesiotherapy)

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None Patient/Family/Caregiver Refusal

Reason for Not Ambulating the Day of Surgery
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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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