Prior Uterine Surgery (v2023B)

Specifications Manual for Joint Commission National Quality Measures (v2023B)

Posted: 02/03/2023

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Release Notes:
Data Element
Version 2023B

Name:

Prior Uterine Surgery

Collected For:

PC-01

Definition:

Documentation that the patient had undergone prior uterine surgery.

Question:

Is there documentation that the patient had undergone prior uterine surgery?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) The medical record contains documentation that the patient had undergone prior uterine surgery.

N (No) The medical record does not contain documentation that the patient had undergone a prior uterine surgery OR unable to determine from medical record documentation.

Notes for Abstraction:

In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. Documentation of an inverted T or J incision would be acceptable for allowable value "yes" for prior uterine surgery.

Suggested Data Sources:

History and physical
Nursing admission assessment
Progress notes
Physician's notes
Prenatal forms

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

The only prior uterine surgeries considered for the purposes of the measure are:

Prior classical cesarean birth which is defined as a vertical incision into the upper uterine segment
Prior myomectomy
Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
History of a uterine window or thinning or defect of the uterine wall noted during prior uterine surgery or during a past or current ultrasound
History of uterine rupture requiring surgical repair
History of a cornual ectopic pregnancy
History of transabdominal cerclage
History of metroplasty and/or prior removal of vestigial horn with entry into the uterine cavity
Documentation of prior uterine incision with descriptors including "high" or "vertical" or "mid" or "active segment" or "classical".

Prior low transverse cesarean birth
Prior cesarean birth without specifying prior classical cesarean birth
History of an ectopic pregnancy without specifying cornual ectopic pregnancy
History of a cerclage without specifying transabdominal cerclage

Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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