Introduction

This section of the manual describes the data elements required to calculate category assignments and measurements for The Joint Commission's National Quality Measures. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. This information is intended to assist in processing patient level data elements for The Joint Commission's National Quality Measures.

It is of primary importance that all health care organizations using The Joint Commission's National Quality Measures gather and utilize the data elements as defined in this section. This will ensure that the data are standardized and comparable across organizations.

Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital and submitted for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered "general" to each patient's episode of care.

These data elements include:

• Admission Date
• Birthdate
• Health Care Organization Identifier
• Hispanic Ethnicity
• Measure Set
• Race
• Sex

Data elements that are general for every patient that fall into measures that are reported at time of discharge include:

• Discharge Date
• ICD-10-CM Other Diagnosis Codes
• ICD-10-PCS Other Procedure Codes (Optional for all HBIPS measures)
• ICD-10-PCS Other Procedure Dates (Optional for all HBIPS measures)
• ICD-10-CM Principal Diagnosis Code
• ICD-10-PCS Principal Procedure Code (Optional for all HBIPS measures)
• ICD-10-PCS Principal Procedure Date (Optional for all HBIPS measures)
• Payment Source

Data elements that are general for every patient that falls into measures that are reported at the time of the event include:

• Event Date (HBIPS measures only)
• Event Type (HBIPS measures only)
• Psychiatric Care Setting (HBIPS measures only)

Data elements that are general for every patient that falls into specific measures that are reported at the time of discharge include:

• Discharge Disposition

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Episode of Care

An Episode of Care (EOC) is defined as the health care services given during a certain period of time, usually during a hospital stay (e.g., from the day of arrival or admission to the day of discharge). The medical record should be abstracted as it was billed. In the event that there are multiple ED visits within the inpatient medical record, for the same episode of care, it is recommended that the ED visit resulting in the admission to observation or inpatient status be utilized for the purposes of abstraction.

If a patient is transferred from an acute care hospital to another acute care hospital, which is within the same healthcare system and shares the same Joint Commission Health Care Organization Identifier (HCO ID), this should be abstracted as one episode of care.

Data integrity

Editing Zero Values

Verification mechanisms are necessary to assure that zero is the intended data value rather than an initialization value for those data elements which have an allowable value of zero (i.e., 0.0, 0000, 0).

Missing and Invalid Data

Each data element that is applicable per the algorithm for each of the measures within a topic must be touched by the abstractor. While this is the expectation, it is recognized that in certain situations information may not be available (e.g., dates, times, codes, etc.). After due diligence in reviewing all allowable data sources within the medical record, if the abstractor determines that a value is not documented, i.e. missing, or is unable to determine if a value is documented, the abstractor should select the UTD - Unable to Determine, value. The data elements Admission Date, Discharge Date and Birthdate require an actual date for discharge measure, and UTD cannot be selected as an allowable value. For Yes/No values the allowable value No incorporates the UTD into the definition. For data elements containing more than two categorical values and for numerical data elements (i.e., dates, times, etc.), a UTD option is included as an allowable value and is classified in the same category as not documented. For additional details on the proper handling of missing and/or invalid data, please refer to the Missing and Invalid Data section of this manual.

Interpreting Data Element Definitions and Allowable Values

Every attempt has been made to comprehensively define The Joint Commission's National Quality Measure data elements and allowable values in a manner that obviates the need for interpretation. If, after reviewing the General Abstraction Guidelines, the data element definition, including the notes and guidelines for abstraction, an abstractor cannot clearly assign an allowable value, refer to the Resource section of this manual for additional contact information.

Interpretation of Data Dictionary Terms

Data elements fall into three broad categories in order to support a specific measure set. They include:

• General Data Elements – data elements that must be collected by health care organizations for each patient record
  • data elements required for each episode of care (EOC) record submitted
  • data elements used to identify the health care organization on each patient record required for each patient-level record submitted
  • patient demographic data required for each episode of care record submitted and used for risk adjustment analysis (where applicable)
• Measure-Specific Data Elements – data elements used by one specific measure or several measures in one specific measure set, such as in the HBIPS measures
• Algorithm Output Data Elements used to determine measure result

Data Element Dictionary Terms

Term	Definition
Data Element Name:	A short phrase identifying the data element. For each of identification the data element name is italicized.
Collected For:	Identifies the measure(s) that utilize this data element or specifies that the data element is used for data processing or verification.
Definition:	A detailed explanation of the data element. Data collection software may include this information.
Suggested Data Collection Question:	A suggested wording for a data element question in a data abstraction tool.
Format:	Length = number of characters or digits allowed for the data element Type = type of information the data element contains (e.g., numeric, alphanumeric, date, character, or time) Occurs = the number of times the data element occurs in a single episode of care record
Allowable Values:	A list of acceptable responses for this data element
Notes for Abstraction:	Provided to assist abstractor in the selection of appropriate value for a data element
Suggested Data Sources:	Source document from which data can be identified such as administrative or medical record. Some data elements also list excluded data sources that are unacceptable sources for collecting information.
Guidelines for Abstraction:	Designed to assist abstractors in determining how a data element should be answered Note: Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

General Abstraction Guidelines

The General Abstraction Guidelines are a resource designed to assist abstractors in determining how a question should be answered. The abstractor should first refer to the specific notes and guidelines under each data element. These instructions should take precedence over the following General Abstraction Guidelines. All of the allowable values for a given data element are outlined, and notes and guidelines are often included which provide the necessary direction for abstracting a data element. It is important to utilize the information found in the notes and guidelines when entering or selecting the most appropriate answer.

Medical Record Documentation

The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, [Refer to the Medicare Conditions of Participation for Medical Records, 42CFR482.24©(2)(viii)], unless otherwise specified in the data element. Documents containing amendments, corrections, or delayed entries must employ the following widely accepted record keeping principles (CMS Medicare Program Integrity Manual Chapter 3, Section 3.3.2.4):

• Clearly and permanently identify any amendments, corrections or addenda;
• Clearly indicate the date and author of any amendments, corrections, or addenda; and
• Clearly identify all original content.

It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

Prenatal forms which are available during the hospitalization and become a permanent part of the patient's medical record (electronic health record/EHR or paper) for the current hospitalization may be used for abstraction.

Important Note: There are several data elements where abstraction of data from documentation dated/timed after discharge is restricted, and these exceptions are published on the respective data element pages of the data dictionary. Data element specific notes and guidelines always take precedence over the General Abstraction Guidelines.

All documentation in the medical record must be legible and must be timed, dated and authenticated. However, documentation that is not timed, dated or authenticated may still be used for abstraction if not required by the specific data element. When abstracting a medical record, if a handwritten document is determined to be not legible, other documentation should be reviewed in an attempt to obtain the answer. If no other source document is able to verify the handwritten documentation, only then is the abstractor to answer unable to determine from the medical record documentation, unless otherwise specified in the data element. Authentication may include written signatures, initials, computer key, or other codes.

Data element information should be retrieved from the current medical record, covering the admission and discharge date, or reporting period for event measures being abstracted. Information ascertainable from previous history (e.g., failed trials of monotherapy) AND determined to be part of the current medical record may be used in abstraction. For example, if the patient had previously failed three or more trials of monotherapy and this information is available in the current chart being abstracted (e.g., a note made in the continuing care plan), this information should be used. Previous history information used in abstraction should be information that was part of the medical record during hospitalization, when care was being delivered.

The medical record must be abstracted as documented (taken at face value). When the value documented is obviously in error (not a valid format/range or outside of the parameters for the data element) and no other documentation is found that provides this information, the abstractor should select UTD. Example:

• Patient expires on 02-12-20XX and documentation indicates the Event Date was 03-12-20XX. Other documentation in the medical record supports the date of death as being accurate. Since the Event Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select UTD.

Note: Hospitals should use abbreviations according to their policy. Frequently flow sheets or other documentation contain a 'key or legend' that explains what the abbreviation or symbol stands for, especially if unique to that facility.

Suggested Data Sources

• Suggested Data Sources are listed in alphabetical order, NOT priority order, unless otherwise specified in the data element.
• Suggested Data Sources are designed to provide guidance to the abstractor as to the locations/sources where the information needed to abstract a data element will likely be found. However, the abstractor is not limited to these sources for abstracting the information and must review the entire medical record unless otherwise specified in the data element.
• In some instances, a data element may restrict the sources that may be used to gain the information, list a priority in which the sources should be used or may restrict documentation by only physician/advanced practice nurse/physician assistant. If so, these sources will be identified and labeled as Excluded Data Sources. "ONLY ACCEPTABLE SOURCES", "Priority Source", or "PHYSICIAN/APN/PA DOCUMENTATION ONLY".
• If, after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select Unable to Determine (UTD) as the answer.
• Hospitals often label forms and reports with unique names or titles. Suggested Data Sources are listed by commonly used titles; however, information may be abstracted from any source that is equivalent to those listed.
  • Example:
    If the nursing admission assessment is listed as a suggested source, an acceptable alternative might be titled nurses initial assessment or nursing data base.
    Note:
    Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

Inclusions/Exclusions

• Inclusions are acceptable terms that should be abstracted as positive findings (e.g., Yes).
• Inclusion lists are limited to those terms that are believed to be most commonly used in medical record documentation. The list of inclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are unacceptable terms that should be abstracted as negative findings (e.g., No).
• Exclusion lists are limited to those terms an abstractor may most frequently question whether or not to abstract as a positive finding for a particular element (e.g., cardiomyopathy is an unacceptable term for heart failure and should be abstracted as "No"). The list of exclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the inclusion takes precedence over the exclusion and would be abstracted as a positive finding (e.g., answer Yes), unless otherwise specified in the data element.

Physician/Advanced Practice Nurse/ Physician Assistant Documentation

• Advanced Practice Nurse (APN, APRN) titles may vary among state and clinical specialties. Some common titles that represent the advanced practice nurse role are:
  • Nurse Practitioner (NP)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Clinical Nurse Specialist (CNS)
  • Certified Nurse Midwife (CNM)
• When a physician/advanced practice nurse/ physician assistant (physician/APN/PA) signs a form or report (e.g., ED sheet with triage and nursing information and a physician/APN/PA has signed somewhere on the form), information on that form/report should be considered physician/APN/PA documentation.
• Rubber stamped physician/advanced practice nurse/physician assistant (physician/APN/PA) signatures are not acceptable on any document within the medical record. Handwritten, electronic signatures, facsimiles of original written or electronic signatures are acceptable.
• Resident and intern notes should be considered physician documentation. Medical student notes must be co-signed by a physician.
• For the purposes of abstraction, telephone or verbal physician/APN/PA orders (TO/VO) in the medical record are considered physician/APN/PA documentation at the time they were written regardless of whether or not they were authenticated by the physician/APN/PA at the time of abstraction.

Pharmacist Documentation

Pharmacist titles may vary. Some common titles that represent the pharmacist role are:

• Doctor of Pharmacy (Pharm.D. or D.Ph.)
• Registered Pharmacist (R.Ph.)

Medications:

• The approved medication tables contained in the dictionaries may not be inclusive lists of all available therapeutic agents acceptable for a particular data element. Discrepancies must be reported. See Appendix G (resource section) of this manual for contact information.
• For EHRs only accept documentation that reflects the actual administration of the medication in the context of the chart.
• If a medication in the physician orders has been initialed and signed off with a time, do NOT presume that the medication was administered. The documentation MUST indicate that the medication was actually given.
• For an EMT or ambulance record, there is no need for documentation indicating that the medication was actually given.
  Example:
  If the EMT or ambulance record reflects “Epinephrine 0.05 mcg/kg/min IV 13:00” without indicating that the medication was actually given (e.g., “given” or “administered”), this is acceptable documentation to abstract.
• When determining whether or not a patient was discharged on a specific medication (e.g., antipsychotic medication):
  • If discharge medications are noted using only references such as continue home meds, continue previous medications, resume other meds, same medications, or continue meds, rather than lists of the names of the discharge medications, the abstractor should include the medication in the count if the patient was on the medication in question prior to arrival, unless documentation suggests otherwise.
  • If discharge medications are noted using only references such as continue current medications or continue present meds rather than lists of the names of the discharge medications, the abstractor should include the medication in the count if the medication in question was listed as a medication on the day of discharge, unless documentation indicates it was to be discontinued at discharge or suggests otherwise
  • If discharge medications are noted using general references such as continue home meds, continue previous medications, continue current meds, continue present meds, resume other meds, or continue meds, but a list of the names of the discharge medications also in the record gives conflicting information about what medications the patient was actually discharged on, the abstractor should consider the list most accurate and use only the list in determining whether or not a patient was discharged on a specific medication.
• Hospitals may allow a patient (or his or her caregiver/support person where appropriate) to self-administer both hospital-issued medications and the patient's own medications brought into the hospital. Hospitals must document the administration of each medication, as reported by the patient (or the patient's caregiver/support person where appropriate), in the patient's medical record [42CFR482.23©(6)].

Nursing Care Plans, Standing Orders and Protocols

• Per Medicare Conditions of Participation [42CFR482.23(b)(4)] hospitals have the option of having a stand-alone nursing care plan or a single interdisciplinary care plan that addresses nursing and other disciplines.
• Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders if such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner responsible for the care of the patient [42CFR482.24©(3)].

Diagnostic/Laboratory Tests

Whether or not a diagnostic or laboratory test has been done is usually clear when using medical record sources such as diagnostic test reports, laboratory reports, or progress notes (where a physician might note test findings), but documentation can be more ambiguous in other sources, namely, physician orders and ED records. To make a determination using these sources, use the following criteria:

• If a test in the physician orders has been initialed and signed off with a time, do NOT presume that the test was done. The documentation MUST indicate that the test was actually done (e.g., accompanied by a word such as done).
• For an ED record, there is no need for explicit documentation indicating that the test was actually done. For example, if an ED record notes Lipid profile, and this is followed by a signature and/or a time, the abstractor should presume the test was performed.

Grids

Instructions for reading values recorded on grids: Measure from the midpoint of the symbol, number and letter. If the value falls between two lines on the grid, abstract the earliest value.

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Alphabetical List of All Data Elements

Data Element Name	Collection Notes	Associated Measures
ACEI Prescribed for LVSD in the Outpatient Setting		ACHFOP-02
ARB Prescribed for LVSD in the Outpatient Setting		ACHFOP-02
Activity Recommendation — Duration of Activity		ACHFOP-05
Activity Recommendation — Intensity of Activity		ACHFOP-05
Activity Recommendation — Type of Activity		ACHFOP-05
Admission Date	All Records	ACHF, ASR-IP, CCCIP, CSTK, ED, HBIPS, IMM, PAL, PC, STK, SUB, THKR-IP, TOB, VTE
Admission to NICU		PC-05
Admitting Diagnosis		CSTK-04
Advance Directive Executed		ACHF-05, ACHFOP-07
Alcohol Use Status		SUB-2, SUB-3
Aldosterone Receptor Antagonist Prescribed for LVSD at Discharge		CCCIP-02
Aldosterone Receptor Antagonist Prescribed in the Outpatient Setting		ACHFOP-03
Ambulation		THKR-IP-2, THKR-OP-2
Ambulation Date		THKR-IP-2, THKR-OP-2
Ambulation Time		THKR-IP-2, THKR-OP-2
Anticoagulation Therapy Prescribed at Discharge		STK-3
Antithrombotic Therapy Administered by End of Hospital Day 2		ASR-IP-2, STK-5
Antithrombotic Therapy Prescribed at Discharge		ASR-IP-3, STK-2
Appropriate Justification for Multiple Antipsychotic Medications		HBIPS-5
Arrival Date		ASR-IP-1, ASR-IP-2, CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-07, CSTK-09, CSTK-11, ED-1, STK-4, STK-5
Arrival Time		ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-07, CSTK-09, CSTK-11, ED-1, STK-4, STK-OP-1
Assessed for Rehabilitation Services		STK-10
Atrial Fibrillation/Flutter		STK-3
Birth Weight		PC-06
Birthdate	All Records	ACHF, ACHFOP, ASR-IP, ASR-OP, CCCIP, CCCOP, CSTK, ED, HBIPS, IMM, PAL, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting		ACHFOP-01
Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge		ACHF-01
Brief Intervention		SUB-2
CMS Certification Number	Optional for All Records	HBIPS
CPT® Code	All Records	CCCOP-01, CCCOP-03
CPT® Code Procedure Date		CCCOP-01, CCCOP-03, THKR-OP-2, THKR-OP-4
CPT® Codes with Modifier		THKR-OP
Cardiac Rehabilitation Attendance		CCCIP-05, CCCOP-03
Care Transition Record Transmitted		ACHF-03
Care Transition Record-Discharge Medications		ACHF-03
Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed		ACHF-03
Care Transition Record-Procedures Performed During Hospitalization		ACHF-03
Care Transition Record-Reason for Hospitalization		ACHF-03
Care Transition Record-Treatment(s)/Service(s) Provided		ACHF-03
Clinical Trial		ACHF-01, ACHF-02, ACHF-03, ACHF-06, ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05, CCCIP-01, CCCIP-02, CCCIP-03, CCCIP-04, CCCOP-01, CCCOP-02, CSTK-04, CSTK-06, STK, VTE-6
Comfort Measures Only		ACHF, ASR-IP-2, ASR-IP-3, ASR-OP-2, CCCIP-01, CCCIP-02, CCCIP-03, CCCIP-04, CCCOP-01, CCCOP-02, CSTK-01, CSTK-03, CSTK-04, CSTK-06, STK-1, STK-10, STK-2, STK-3, STK-5, STK-6, STK-8, STK-OP-1, SUB-2, SUB-3, TOB-2, TOB-3, VTE-6
Communication of Outpatient Referral to Patient		CCCIP-03, CCCIP-04, CCCOP-01, CCCOP-02
Date Last Known Well		ASR-IP-1, ASR-OP-1, STK-4
Decision to Admit Date		ED-2
Decision to Admit Time		ED-2
Delayed Endovascular Rescue Procedure		CSTK-09, CSTK-11
Discharge Code		ACHFOP, ASR-OP-2, CCCOP-01, CCCOP-02, CCCOP-03, STK-OP-1, THKR-OP-2, THKR-OP-3
Discharge Date	All Records	ACHF, ASR-IP-1, ASR-IP-2, ASR-IP-3, CCCIP, CSTK, ED, HBIPS-1, HBIPS-5, IMM, PAL, PC, STK, SUB, THKR-IP, TOB, VTE
Discharge Disposition		ACHF, ASR-IP-3, CCCIP, CSTK-02, CSTK-10, HBIPS-5, IMM-2, PAL-05, PC-05, PC-06, STK-10, STK-2, STK-3, STK-6, STK-8, SUB-3, THKR-IP-2, THKR-IP-3, TOB-3
Discharge Time		CSTK-01, CSTK-03, CSTK-06
Discussion of Advance Directives/Advance Care Planning		ACHF-04, ACHFOP-06
Dyspnea Severity		PAL-03
E/M Code		ACHFOP, ASR-OP-1, ASR-OP-2, CCCOP-01, CCCOP-02, CCCOP-03, STK-OP-1
ED Departure Date		ASR-OP-2, ED-1, ED-2, STK-OP-1
ED Departure Time		ASR-OP-2, ED-1, ED-2, STK-OP-1
ED Patient		ASR-IP-1, ED-1, ED-2, STK-4
Education Addresses Activation of Emergency Medical System		STK-8
Education Addresses Follow-up After Discharge		STK-8
Education Addresses Medication Prescribed at Discharge		STK-8
Education Addresses Risk Factors for Stroke		STK-8
Education Addresses Warning Signs and Symptoms of Stroke		STK-8
Elective Carotid Intervention		CSTK-01, CSTK-02, CSTK-05, CSTK-07, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12, STK
Event Date		HBIPS-2, HBIPS-3
Event Type		HBIPS-2, HBIPS-3
Exclusive Breast Milk Feeding		PC-05
Failed Attempt at Thrombectomy		CSTK-08, CSTK-11, CSTK-12
First Pass Date		CSTK-07
First Pass Time		CSTK-07
First Pass of a Mechanical Reperfusion Device		CSTK-07
Gestational Age		PC-01, PC-02
Goals of Care		PAL-04
Health Care Organization Identifier	All Records
High-intensity Statin at Discharge		CCCIP-01
Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation		CSTK-05
Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation		CSTK-05
Hispanic Ethnicity	All Records	ACHF, ASR-IP, ASR-OP, CCCIP, CCCOP, CSTK, ED, HBIPS, IMM, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
History of Stillbirth		PC-01
IA Alteplase or MER Initiation Date		CSTK-05
IA Alteplase or MER Initiation Time		CSTK-05
IA Route of Alteplase Administration		CSTK-05, CSTK-07
IA Thrombolytic Initiation		CSTK-07
IA Thrombolytic Initiation Date		CSTK-07
IA Thrombolytic Initiation Time		CSTK-07
ICD-10-CM Other Diagnosis Codes	All Records	CCCIP, CCCOP, CSTK-05, ED, HBIPS-1, HBIPS-5, IMM, PC, STK, SUB, THKR-IP, THKR-OP, TOB, VTE
ICD-10-CM Principal Diagnosis Code	All Records	ACHF, ACHFOP, ASR-IP, ASR-OP, CCCIP, CCCOP, CSTK, ED, HBIPS-1, HBIPS-5, IMM, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
ICD-10-PCS Other Procedure Codes	All Records	ACHF, ACHFOP, CCCIP-03, CCCIP-05, CCCOP-01, CCCOP-03, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, ED, HBIPS, IMM, PC, STK, SUB, THKR-IP, TOB, VTE
ICD-10-PCS Other Procedure Dates	All Records	CCCIP-03, CCCIP-05, CCCOP-01, CCCOP-03, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, ED, HBIPS, IMM, PC, STK, SUB, TOB, VTE
ICD-10-PCS Other Procedure Times		CSTK-01, CSTK-03
ICD-10-PCS Principal Procedure Code	All Records	ACHF, ACHFOP, CCCIP-03, CCCIP-05, CCCOP-01, CCCOP-03, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, ED, HBIPS, IMM, PC, STK, SUB, THKR-IP, TOB, VTE
ICD-10-PCS Principal Procedure Date	All Records	ACHF-05, ACHFOP, CCCIP-03, CCCIP-05, CCCOP-01, CCCOP-03, CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, ED, HBIPS, IMM, PC, STK, SUB, THKR-IP-2, THKR-IP-4, TOB, VTE
ICD-10-PCS Principal Procedure Time		CSTK-01, CSTK-03
INR Value > 1.4		CSTK-04
IV Alteplase Initiation		ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-05, CSTK-10, STK-4, STK-OP-1
IV Alteplase Initiation Date		ASR-IP-1, ASR-OP-1, CSTK-05, STK-4
IV Alteplase Initiation Time		ASR-IP-1, ASR-OP-1, CSTK-05, STK-4
IV Alteplase Prior to IA or Mechanical Reperfusion Therapy		CSTK-05, CSTK-08, CSTK-10
IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival		ASR-IP-2, STK-5
Influenza Vaccination Status		IMM-2
Initial Blood Glucose Value at Hospital Arrival		CSTK-05, CSTK-08, CSTK-10
Initial Blood Pressure at Hospital Arrival		CSTK-05, CSTK-08, CSTK-10
Initial Encounter		PAL
Initial Encounter Date		PAL
Initial Hunt and Hess Scale Date		CSTK-03
Initial Hunt and Hess Scale Performed		CSTK-03
Initial Hunt and Hess Scale Time		CSTK-03
Initial ICH Score Date		CSTK-03
Initial ICH Score Performed		CSTK-03
Initial ICH Score Time		CSTK-03
Initial NIHSS Less Than 6		CSTK-09, CSTK-11
Initial NIHSS Score Date		CSTK-01
Initial NIHSS Score Performed		CSTK-01
Initial NIHSS Score Time		CSTK-01
Initial NIHSS Score at Hospital Arrival		CSTK-05, CSTK-08, CSTK-10
Initial Platelet Count at Hospital Arrival		CSTK-05, CSTK-08, CSTK-10
LVSD		ACHF-01, ACHFOP-01, ACHFOP-02, ACHFOP-03, CCCIP-02, CCCIP-04, CCCOP-02
Labor		PC-01
Last Known Well		ASR-IP-1, ASR-OP-1, STK-4
MER Eligibility		STK-OP-1
Measure Category Assignment	All Records, Calculation	ASR-IP, ASR-OP, CSTK, ED, HBIPS, IMM, PC, STK, STK-OP, SUB, TOB, VTE
Measurement Value	Calculation	CSTK, ED, HBIPS, PC
Minutes of Physical Restraint		HBIPS-2
Minutes of Seclusion		HBIPS-3
Modified Rankin Score (mRS)		CSTK-02, CSTK-10
Modified Rankin Score (mRS) Date		CSTK-02, CSTK-10
NIHSS Score Documented Closest to IA Alteplase or MER Initiation		CSTK-05
NIHSS Score Documented Closest to IV Alteplase Initiation		CSTK-05
New York Heart Association (NYHA) Classification		ACHFOP-03, ACHFOP-04
Nimodipine Administration		CSTK-06
Nimodipine Administration Date		CSTK-06
Nimodipine Administration Time		CSTK-06
Non-aneurysmal		CSTK-03
Number of Antipsychotic Medications Prescribed at Discharge		HBIPS-5
Outpatient Departure Date		THKR-OP-2
Outpatient Encounter Date		ACHFOP, ASR-OP-1, ASR-OP-2, CCCOP-01, CCCOP-02, CCCOP-03, STK-OP-1, THKR-OP
PACU Discharge Date		THKR-IP-2, THKR-OP-2
PACU Discharge Time		THKR-IP-2, THKR-OP-2
Pain Character		PAL-02
Pain Duration		PAL-02
Pain Effect		PAL-02
Pain Factors		PAL-02
Pain Frequency		PAL-02
Pain Location		PAL-02
Pain Severity		PAL-01, PAL-02
Patient Status at Discharge		HBIPS-5
Patient Strengths		HBIPS-1
Payment Source	All Records	ASR-IP, ASR-OP, CSTK, ED, HBIPS, IMM, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
Positive Brain Image		CSTK-05
Positive Brain Image Date		CSTK-05
Positive Brain Image Time		CSTK-05
Post-Discharge Appointment Scheduled Within 7 Days		ACHF-02
Post-Discharge Evaluation Conducted Within 72 Hours		ACHF-06
Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade		CSTK-08, CSTK-11, CSTK-12
Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date		CSTK-11, CSTK-12
Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time		CSTK-11, CSTK-12
Postoperative ICU Admit or Transfer		THKR-IP-2, THKR-OP-2
Pre-Stroke Modified Rankin Score (mRS)		CSTK-10
Preoperative Assessments Completed		THKR-IP-4, THKR-OP-4
Preoperative Assessments Completion Date		THKR-IP-4, THKR-OP-4
Prescription for Alcohol or Drug Disorder Medication		SUB-3
Prescription for Tobacco Cessation Medication		TOB-3
Previous Live Births		PC-02
Prior Uterine Surgery		PC-01
Procoagulant Reversal Agent Initiation		CSTK-04
Psychiatric Care Setting	All Records	HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5
Psychiatric Inpatient Days - Medicare Only		HBIPS-2, HBIPS-3
Psychiatric Inpatient Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Psychological Trauma History		HBIPS-1
Race	All Records	ACHF, ASR-IP, ASR-OP, CCCIP, CCCOP, CSTK, ED, HBIPS, IMM, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
Reason for Extending the Initiation of IV Alteplase		ASR-IP-1, ASR-OP-1, STK-4
Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient Setting		ACHFOP-02
Reason for No Activity Recommendations in the Outpatient Setting		ACHFOP-05
Reason for No Administration of VTE Prophylaxis		VTE-6
Reason for No Aldosterone Receptor Antagonist Prescribed at Discharge		CCCIP-02
Reason for No Aldosterone Receptor Antagonist Prescribed in the Outpatient Setting		ACHFOP-03
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting		ACHFOP-01
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge		ACHF-01
Reason for No Cardiac Rehabilitation Enrollment		CCCIP-05, CCCOP-03
Reason for No Post-Discharge Appointment Within 7 Days		ACHF-02
Reason for No Referral to Outpatient Cardiac Rehabilitation Program		CCCIP-03, CCCIP-04, CCCOP-01, CCCOP-02, CCCOP-03
Reason for No Regional Anesthesia		THKR-IP-1, THKR-OP-1
Reason for No Tobacco Cessation Medication During the Hospital Stay		TOB-2
Reason for No Tobacco Cessation Medication at Discharge		TOB-3
Reason for No VTE Prophylaxis – Hospital Admission		STK-1
Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2		ASR-IP-2, STK-5
Reason for Not Administering Nimodipine Treatment		CSTK-06
Reason for Not Administering a Procoagulant Reversal Agent		CSTK-04
Reason for Not Ambulating the Day of Surgery		THKR-IP-2, THKR-OP-2
Reason for Not Discharging Patient to Home		THKR-IP-3, THKR-OP-3
Reason for Not Initiating IV Alteplase		ASR-IP-1, ASR-OP-1, STK-4
Reason for Not Prescribing Anticoagulation Therapy at Discharge		STK-3
Reason for Not Prescribing Antithrombotic Therapy at Discharge		ASR-IP-3, STK-2
Reason for Not Prescribing Statin Medication at Discharge		STK-6
Reason for Not Prescribing a High-Intensity Statin		CCCIP-01
Reason for Oral Factor Xa Inhibitor		STK-1
Referral for Addictions Treatment		SUB-3
Referral for Outpatient Tobacco Cessation Counseling		TOB-3
Referral to Outpatient Cardiac Rehabilitation		CCCIP-03, CCCIP-04, CCCIP-05, CCCOP-01, CCCOP-02, CCCOP-03
Regional Anesthesia		THKR-IP-1, THKR-OP-1
Resident of Other Health Care Facility		THKR-IP-3, THKR-OP-3
Sex	All Records	ACHF, ASR-IP, ASR-OP, CCCIP, CCCOP, CSTK, ED, HBIPS, IMM, PAL, PC, STK, STK-OP, SUB, THKR-IP, THKR-OP, TOB, VTE
Site of Primary Vessel Occlusion		CSTK-08, CSTK-11, CSTK-12
Skin Puncture		CSTK-09, CSTK-12
Skin Puncture Date		CSTK-09, CSTK-12
Skin Puncture Time		CSTK-09, CSTK-12
Statin Medication Prescribed at Discharge		STK-6
Substance Use		HBIPS-1
Suspected Large Vessel Occlusion (LVO)		STK-OP-1
Term Newborn		PC-05, PC-06
Time Last Known Well		ASR-IP-1, ASR-OP-1, STK-4
Tobacco Use Status		TOB-2, TOB-3
Tobacco Use Treatment FDA-Approved Cessation Medication		TOB-2
Tobacco Use Treatment Practical Counseling		TOB-2
Total Leave Days - Medicare Only		HBIPS-2, HBIPS-3
Total Leave Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Treatment Preferences		PAL-04
Treatment Preferences Document		PAL-05
VTE Confirmed		VTE-6
VTE Diagnostic Test		VTE-6
VTE Present at Admission		VTE-6
VTE Prophylaxis		STK-1
VTE Prophylaxis Date		STK-1
VTE Prophylaxis Status		VTE-6
Violence Risk to Others		HBIPS-1
Violence Risk to Self		HBIPS-1