Decision to Admit Time (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:

Decision to Admit Time

Collected For:

ED-2

Definition:

The documented time (military time) the decision to admit to observation or inpatient status occurred. Decision to admit to observation or inpatient status time is the time the physician/APN/PA makes the decision to admit the patient from the emergency department to the hospital for continued care in the facility.

Question:

What was the earliest documented time of the decision to admit?

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
11:59 am - 11:59     11:59 pm - 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Arrival Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting 24:00 to 00:00 do not forget to change the Arrival Date.
Example: Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx

Notes for Abstraction:

For times that include “seconds,” remove the seconds and record the time as is.
Example:
15:00:35 would be recorded as 15:00.
If the decision to admit to observation or inpatient status is unable to be determined from medical record documentation, select “UTD.”
The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid format/range) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Example:
Documentation indicates the Decision to Admit Time was 3300. No other documentation in the list of Only Acceptable Sources provides a valid time. Since the Decision to Admit Time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”

When reviewing ED records do NOT include any documentation from external sources (e.g., ambulance records, physician/advanced practice nurse/physician assistant [physician/APN/PA] office record, laboratory reports or ECGs) obtained prior to arrival. The intent is to utilize any documentation that reflects processes that occurred in the ED or hospital.
For purposes of this data element, the source “Emergency Department record” includes any documentation from the time of ED arrival to the time the patient physically departed from the ED.
Example:
ED departure is at 11:00 on 03-12-20xx. The attending physicians admit orders written in the inpatient record at 10:00 on 03-12-20xx are considered part of the ED record.
Disregard physician/APN/PA narrative documentation of a consult or orders for consult, transfer to another physician’s service, or discussion with another physician since this does not reflect a decision was made.
Examples that reflect a decision to admit was not made:
- ED physician note states “Discussed case with hospitalist.” This is only documentation that a discussion occurred, there is no documentation regarding a decision to admit.
- ED physician note states “Discussed patient with Dr. Jones who recommends admission.” This reflects a discussion occurred and a recommendation was made to admit, but does not indicate a decision was made to admit.
- ED physician note states “Contacted Dr. Smith for admission consult.” This reflects a consult has been requested for admission, but does not indicate a decision to admit has been made.
- ED physician note states “Possible admission pending cardiology consult.” This reflects a consult was ordered and admission is possible, but does not indicate a decision to admit has been made.
  Examples that reflect a decision to admit was made:
- ED physician note states “Discussed case with hospitalist on call, plan to admit.” The note references a discussion with another physician with “plan to admit” documented, indicating a decision to admit has been made.
- ED physician note states “Discussed case with Dr. Brown who will admit patient to ICU.” The note references a discussion with another physician with “who will admit patient” documented, indicating a decision to admit has been made.
If there is more than one time of documentation for the decision to admit, use the following order to determine which date to abstract.
1.Specified time the decision to admit was documented.
2.Specified time the decision to admit was documented in a non-narrative location (e.g., flowsheet, checklist, screening).
3.Note opened time for the decision to admit documented in a non-narrative location without a specified time (e.g., flowsheet, checklist, screening).
4.Note opened time for narrative documentation identifying the decision to admit was made without a specified time.
Decision to Admit Time includes physician/APN/PA documentation of a decision to send the patient to cath lab or surgery.
Example:
The ED physician documents that he/she is sending the patient to the OR for surgery. The decision to admit to observation or inpatient status time will abstract as the time this was documented.
Use the time from the earliest documentation of decision to admit for either observation or inpatient.
Example:
The physician ordered “Admit Observation Service.” Four hours later the physician wrote an order to admit the patient to inpatient status. These orders were written while the patient was still receiving care in the ED. Use the earlier order for Observation Services to abstract decision as time.
Data fields representing ‘decision to admit’ in electronic documentation for this specific episode of care are acceptable to use as long as they are the earliest physician/APN/PA documentation and clearly defined to capture the date an observation status or inpatient admit decision was documented. Information found in an electronically interfaced event log or Admit/Decision/Transfer (ADT) is acceptable provided this information is part of the submitted medical record covering the arrival to discharge date being abstracted.
Examples:
- Decision to Admit
- Dispo
- Disposition set to admit
For purposes of this data element " Decision to Admit Time " is the time on which the physician/APN/PA makes the decision to admit the patient from the emergency department to the hospital. This will not necessarily coincide with the time the patient is officially admitted to inpatient status.
If the decision to admit the patient to observation or inpatient status is made, but the actual request for a bed is delayed until an inpatient bed is available, record the date the physician/APN/PA communicated the decision to admit.
If the decision to admit to observation or inpatient status date is dated prior to the date of patient arrival or after the date of departure, select “UTD.”

Example:
The APN saw the patient in the clinic and sent him/her to the ED for admission. Select UTD.

For documentation of a decision to admit accompanied by an indicator, the examples below should be used. Documentation containing a positive indicator should be used for a decision to admit, documentation containing a negative indicator should not be used for a decision to admit.
- Positive Indicators
  - Plan to admit
  - Doctors accepts admission
  - Plan to hospitalize
  - Admit to doctor
  - Need to admit
- Negative Indicators
  - Request admission
  - May need admission
  - Doctor will accept patient
  - Recommend admission
  - Would like to admit

Suggested Data Sources:

Only Acceptable Sources
Emergency Department Record

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Admit Order Time Disposition Time	Bed assignment Time Direct admit patients seen in the ED Report Called Time

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

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