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Release Notes:
Data Element
Version 2010A1

Data Element Name: Sex
Collected For: All Records
Definition:The patient's documented sex on arrival at the hospital.
Suggested Data Collection Question:What is the patient’s sex?
Format:
Length:1
Type:Character
Occurs:1
Allowable Values:


M = Male
F = Female
U = Unknown

Notes for Abstraction:
  • Collect the documented patient’s sex at admission or the first documentation after arrival.
  • Consider the sex to be unable to be determined and select “Unknown” if:
    • The patient refuses to provide their sex.
    • Documentation is contradictory.
    • Documentation indicates the patient is a Transexual.
    • Documentation indicates the patient is a Hermaphrodite.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Face sheet
  • Progress notes
  • UB-04 Field Location: 11
  • Nursing admission notes
  • Additional Notes:
    Guidelines for Abstraction:
    Inclusion Exclusion
    • None
    • None

    Sex
    Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
    Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)