Release Notes:
Data Dictionary Introduction
Version 2010A1
Introduction
This section of the manual describes the data elements required to calculate category assignments and measurements for the 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 national quality measures.
It is of primary importance that all hospitals using 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 hospitals.
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
- Discharge Date
- Discharge Status
- Health Care Organization Identifier 1,4
- Hispanic Ethnicity 2
- Hospital Patient Identifier 2
- ICD-9-CM Other Diagnosis Codes
- ICD-9-CM Other Procedure Codes
- ICD-9-CM Other Procedure Dates
- ICD-9-CM Principal Diagnosis Code
- ICD-9-CM Principal Procedure Code
- ICD-9-CM Principal Procedure Date
- Measure Set 3,4
- National Provider Identifier 3,4
- Patient HIC 5
- Payment Source - Medicare
- Performance Measure Identifier 1,3,4
- Point of Origin for Admission or Visit
- Postal Code 2
- Provider ID 2,4
- Race 2
- Sample 3
- Sex
- Vendor Tracking Identifier 1,3,4
1 The Joint Commission Only
2 CMS Only
3 Transmission Data Element
4 These data elements are defined in the Transmission Data Dictionary within the National Hospital Quality Measure Data Transmission section of this manual.
5 Collected by CMS for patients with a Payment Source - Medicare.
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 submission into the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse, 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, laboratory values, etc.), a “UTD” option is included as an allowable value and is classified in the same category as not documented. Files that contain any invalid and/or missing data will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. 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 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 hospitals for each patient record
- data elements required for each episode of care (EOC) record submitted
- data elements used to identify the hospital 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 the heart failure measures
- Algorithm Output Data Elements (The Joint Commission only)– Refer to ORYX Technical guide
Data Element Dictionary Terms
Term |
Definition |
Data Element Name: |
A short phrase identifying the data element. |
Collected For: |
Identifies the measure(s) that utilize this data element or specifies that the data element is used for data transmission or verification. |
Definition: |
A detailed explanation of the data element. A measurement system may include this information in data collection software. |
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 (i.e., numeric, alphanumeric, date, decimal, 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
Documentation which is dated/timed after discharge should not be used unless it was added during the hospital’s normal course of completing a medical record (e.g., discharge summary, diagnosis and procedure coding) per organization policy or within 30 days after discharge, whichever is sooner. (Refer to the Medicare Conditions of Participation for Medical Records, 42CFR428.24(c)(2)(viii).)
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 complete. (Refer to the Medicare Conditions of Participation for Medical Records 42CFR428.24(c)(1).) 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.
Data element information should be retrieved from the current medical record, covering the admission and discharge date being abstracted. Information ascertainable from previous testing (e.g., left ventricular ejection fraction) or previous history (e.g., medication contraindications) AND determined to be part of the current medical record may be used in abstraction. For example, if the patient had a previous left ventricular function assessment and this information is available in the current chart being abstracted (e.g., a note made in the progress notes, a previous echo report, or an electronic document), this information should be used. Previous testing or 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:
- Documentation indicates the Antibiotic Administration Time was 3300. No other documentation in the medical record provides a valid time. Since the Antibiotic Administration Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
- Patient expires on 02-12-2008 and documentation indicates the Antibiotic Administration Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”
For those hospitals that have transitioned from a paper-based medical record to an electronic health record (EHR), there should be a policy on what constitutes a current medical record in their EHR environment.
Please note that for auditing/validation purposes, hospitals will need to provide a paper copy of the current medical record in its entirety, including definitions of symbols/abbreviations used and all previous testing or history documents used in abstraction.
Suggested Data Sources
- Suggested Data Sources are listed in alphabetical order, NOT priority order, unless otherwise specified.
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 is encouraged to review the entire medical record
- In some instances, a data element may restrict the sources that may be used to gain the information (e.g., LVF Assessment). If so, these sources will be identified and labeled as “Excluded Data Sources.”
- In the course of abstraction, if conflicting information is found in a source other than the suggested data sources, and use of this source is not restricted, consider using this information if it more accurately answers the question, unless otherwise specified.
Example:
The nursing notes state the patient was discharged to a nursing facility, and the social services notes states the patient was discharged to a nursing facility for assisted living. The social services notes, while not listed as a suggested data source, more accurately describes the discharge status and should be used for abstracting the discharge status.
- 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.
Physician/Advanced Practice Nurse/ Physician Assistant Documentation
- Advanced Practice Nurse (APN, APRN) titles may vary between state and clinical specialities. 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.
- Resident and intern notes should be considered physician documentation. Medical student notes must be co-signed by a physician.
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.
- Whether or not a medication has been administered to a patient is often clear when using medical record sources such as medication administration records, but documentation can be more ambiguous in other sources, namely, physician orders, ED records, and ambulance records. To make a determination using these sources, use the following criteria:
- 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 ED or ambulance record, there is no need for documentation indicating that the medication was actually given.
Example:
If the ED or ambulance record reflects “ASA 325mg po 13:00” and no other documentation exists 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., a beta-blocker):
- 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 select “Yes” if the patient was on the medication in question prior to arrival (or in the case of transfers from acute care hospitals, if the patient was on the medication in question prior to arrival at the first acute care hospital), 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 select “Yes” 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.
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.
Alphabetical List of All Data Elements
Data Element Name |
Collected For |
Associated Measures |
Admission Type |
|
|
Clinical Indication for Prophylactic Platelets |
|
|
Congenital Anomalies |
Risk Adjustment |
|
Consent Addressed Transfusion Benefits |
|
|
Consent Addressed Transfusion Risks |
|
|
Date |
|
|
Emergency Order Date |
|
|
Emergency Order Time |
|
|
Emergency Transfusion |
|
|
Emergency Transfusion Date |
|
|
Emergency Transfusion Time |
|
|
ICD Population Size |
Transmission, Aggregate Data File |
|
Multiple Births |
Risk Adjustment |
|
Number of Cases with UTD Allowable Values |
Transmission, Aggregate Data File |
|
Number of Rejected Cases |
Transmission, Aggregate Data File |
|
Performance Measure Identifier |
Transmission, Aggregate Data File |
|
Performance Measurement System Identifier |
Transmission, Aggregate Data File |
|
Point of Origin for Admission or Visit |
All Records |
|
Pre-transfusion Hemoglobin |
|
|
Pre-transfusion Hemoglobin |
|
|
Pre-transfusion Platelet Count |
|
|
Preoperative Anemia Screening Hematocrit Result |
|
|
Preoperative Anemia Screening Hemoglobin Result |
|
|
Provider ID |
Transmission |
|
Transfusion Type |
|
|
Unique Blinded Health Care Organization Identifier |
|
|
Discharge Status |
All Records |
AMI, CAC, HF, PN, PR, SCIP |
First Name |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP |
Hospital Patient Identifier |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP |
Last Name |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP |
Measure Category Assignment |
Joint Commission Only, Calculation, Transmission, Hospital Clinical Data File |
AMI, CAC, HF, PN, PR, SCIP |
Patient HIC# |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP |
Physician 1 |
All Records, Optional for All Records |
AMI, CAC, HF, PN, PR, SCIP |
Point of Origin for Admission or Visit |
All Records |
AMI, CAC, HF, PN, PR, SCIP |
Postal Code |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP |
Provider ID |
CMS Only, Transmission, CMS Transmission |
AMI, CAC, HF, PN, PR, SCIP |
Hispanic Ethnicity |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP, STK |
Race |
All Records, CMS Only |
AMI, CAC, HF, PN, PR, SCIP, STK |
Birthdate |
All Records |
AMI, CAC, HF, PN, PR, SCIP, STK, TAM |
Discharge Date |
All Records |
AMI, CAC, HF, PN, PR, SCIP, STK, TAM |
Physician 2 |
All Records, Optional for All Records |
AMI, CAC, HF, PN, SCIP |
Aspirin Received Within 24 Hours Before or After Hospital Arrival |
|
AMI-1 |
Contraindication to Aspirin on Arrival |
|
AMI-1 |
Comfort Measures Only |
|
AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, AMI-T1a, AMI-T2, HF-1, HF-2, HF-3, HF-4, PN-1, PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7 |
Transfer From Another ED |
|
AMI-1, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b |
Arrival Date |
|
AMI-1, AMI-6, AMI-7a, AMI-8, AMI-8a, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b |
Aspirin Prescribed at Discharge |
|
AMI-2 |
Contraindication to Aspirin at Discharge |
|
AMI-2 |
ACEI Prescribed at Discharge |
|
AMI-3, HF-3 |
ARB Prescribed at Discharge |
|
AMI-3, HF-3 |
Contraindication to Both ACEI and ARB at Discharge |
|
AMI-3, HF-3 |
LVSD |
|
AMI-3, HF-3 |
Adult Smoking Counseling |
|
AMI-4, HF-4, PN-4 |
Adult Smoking History |
|
AMI-4, HF-4, PN-4 |
Beta-Blocker Prescribed at Discharge |
|
AMI-5 |
Contraindication to Beta-Blocker at Discharge |
|
AMI-5 |
Beta-Blocker Received Within 24 Hours After Hospital Arrival |
|
AMI-6 |
Contraindication to Beta-Blocker on Arrival |
|
AMI-6 |
Fibrinolytic Administration Date |
|
AMI-7, AMI-7a |
Fibrinolytic Administration Time |
|
AMI-7, AMI-7a |
Reason for Delay in Fibrinolytic Therapy |
|
AMI-7, AMI-7a |
Fibrinolytic Administration |
|
AMI-7, AMI-7a, AMI-8, AMI-8a |
Initial ECG Interpretation |
|
AMI-7, AMI-7a, AMI-8, AMI-8a |
Arrival Time |
|
AMI-7, AMI-7a, AMI-8, AMI-8a, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b |
First PCI Date |
|
AMI-8, AMI-8a |
First PCI Time |
|
AMI-8, AMI-8a |
Non-Primary PCI |
|
AMI-8, AMI-8a |
Reason for Delay in PCI |
|
AMI-8, AMI-8a |
Plan for LDL-Cholesterol Test |
|
AMI-T1a |
Pre-Arrival Lipid-Lowering Agent |
|
AMI-T1a |
Reason for No LDL-Cholesterol Testing |
|
AMI-T1a |
In-Hospital LDL-Cholesterol Test |
|
AMI-T1a, AMI-T2 |
Pre-Arrival LDL-Cholesterol Qualitative Description |
|
AMI-T1a, AMI-T2 |
Pre-Arrival LDL-Cholesterol Test |
|
AMI-T1a, AMI-T2 |
Pre-Arrival LDL-Cholesterol Value |
|
AMI-T1a, AMI-T2 |
First In-Hospital LDL-Cholesterol Qualitative Description |
|
AMI-T2 |
First In-Hospital LDL-Cholesterol Value |
|
AMI-T2 |
Lipid-Lowering Agent Prescribed at Discharge |
|
AMI-T2 |
Reason for No Lipid-Lowering Therapy |
|
AMI-T2 |
Birthdate |
All Records |
BM, HBIPS, PC |
ICD-9-CM Other Procedure Codes |
All Records |
BM, HBIPS, PC |
ICD-9-CM Other Procedure Dates |
All Records |
BM, HBIPS, PC |
ICD-9-CM Principal Procedure Code |
All Records |
BM, HBIPS, PC |
ICD-9-CM Principal Procedure Date |
All Records |
BM, HBIPS, PC |
Sex |
All Records |
BM, HBIPS, PC |
Admission Date |
All Records |
BM, HBIPS, PC, TAM |
Discharge Date |
All Records |
BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC |
ICD-9-CM Other Diagnosis Codes |
All Records |
BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-02, TAM-03, TAM-07 |
ICD-9-CM Principal Diagnosis Code |
All Records |
BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-02, TAM-03, TAM-07 |
Discharge Status |
All Records |
BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-03, TAM-04, TAM-07, TAM-08 |
Unique Blinded Case Identifier |
All Records |
BM, TAM |
Education Addressed Risks, Benefits and Alternatives to Transfusion |
|
BM-01 |
Transfusion Consent |
|
BM-01 |
Clinical Indication for RBCs |
|
BM-02 |
Pre-transfusion Hematocrit |
|
BM-02 |
Pre-transfusion Hemoglobin |
|
BM-02 |
RBC Event Total Doses |
|
BM-02 |
RBC Event ID |
|
BM-02, BM-05 |
Clinical Indication for Plasma |
|
BM-03 |
Plasma Event Total Doses |
|
BM-03 |
Pre-transfusion Laboratory Testing |
|
BM-03 |
Plasma Event ID |
|
BM-03, BM-05 |
Pre-transfusion Platelet Testing |
|
BM-04a |
Clinical Indication for Platelets |
|
BM-04a, BM-04b |
Platelet Event Total Doses |
|
BM-04a, BM-04b |
Pre-transfusion Platelet Count |
|
BM-04a, BM-04b |
Platelet Event ID |
|
BM-04a, BM-04b, BM-05 |
Surgical Procedure |
|
BM-04b |
Patient ID Verification |
|
BM-05 |
Transfusion Order |
|
BM-05 |
Transfusion Start Date |
|
BM-05 |
Transfusion Start Time |
|
BM-05 |
Vital Sign Monitoring |
|
BM-05 |
Anesthesia Start Date |
|
BM-06 |
Preoperative Anemia Screening |
|
BM-06 |
Preoperative Anemia Screening Date |
|
BM-06 |
Elective Surgery |
|
BM-06, BM-07 |
Preoperative Blood Type Testing |
|
BM-07 |
Contraindication to Relievers |
Joint Commission Only |
CAC-1 |
Relievers Administered |
Joint Commission Only |
CAC-1 |
Contraindication to Systemic Corticosteroids |
Joint Commission Only |
CAC-2 |
Systemic Corticosteroids Administered |
Joint Commission Only |
CAC-2 |
Home Management Plan of Care Document Addresses Arrangements for Follow-up Care |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Addresses Environmental Control and Control of Other Triggers |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Addresses Methods and Timing of Rescue Actions |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Addresses Use of Controllers |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Addresses Use of Relievers |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Given to Patient/Caregiver |
Joint Commission Only |
CAC-3 |
Home Management Plan of Care Document Present |
Joint Commission Only |
CAC-3 |
CMS Certification Number |
Transmission |
HBIPS, PC |
Health Care Organization Identifier |
Transmission, Aggregate Data File, Patient Population Data File |
HBIPS, PC |
Initial Patient Population Size – Medicare Only |
Transmission, Patient Population Data File |
HBIPS, PC |
Initial Patient Population Size – Non-Medicare Only |
Transmission, Patient Population Data File |
HBIPS, PC |
Measure Category Assignment |
Calculation, Transmission, Hospital Clinical Data File |
HBIPS, PC |
Measure Set |
Transmission, Patient Population Data File, Hospital Clinical Data File |
HBIPS, PC |
Measurement Value |
Calculation, Transmission, Hospital Clinical Data File |
HBIPS, PC |
National Provider Identifier |
Transmission |
HBIPS, PC |
Payment Source |
All Records |
HBIPS, PC |
Sample |
Transmission, Aggregate Data File, Hospital Clinical Data File |
HBIPS, PC |
Sample Size – Medicare Only |
Transmission, Patient Population Data File |
HBIPS, PC |
Sample Size – Non-Medicare Only |
Transmission, Patient Population Data File |
HBIPS, PC |
Sampling Frequency |
Transmission, Patient Population Data File |
HBIPS, PC |
Vendor Tracking Identifier |
Transmission, Hospital Clinical Data File |
HBIPS, PC |
Patient Strengths |
|
HBIPS-1 |
Psychological Trauma History |
|
HBIPS-1 |
Substance Use |
|
HBIPS-1 |
Violence Risk to Others |
|
HBIPS-1 |
Violence Risk to Self |
|
HBIPS-1 |
Psychiatric Care Setting |
All Records |
HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7 |
Minutes of Physical Restraint |
|
HBIPS-2 |
Event Date |
All Records |
HBIPS-2, HBIPS-3 |
Event Type |
All Records |
HBIPS-2, HBIPS-3 |
Psychiatric Inpatient Days - Medicare Only |
|
HBIPS-2, HBIPS-3 |
Psychiatric Inpatient Days-Non-Medicare Only |
|
HBIPS-2, HBIPS-3 |
Total Leave Days - Medicare Only |
|
HBIPS-2, HBIPS-3 |
Total Leave Days-Non-Medicare Only |
|
HBIPS-2, HBIPS-3 |
Minutes of Seclusion |
|
HBIPS-3 |
Number of Antipsychotic Medications Prescribed at Discharge |
|
HBIPS-4, HBIPS-5 |
Patient Referral to Next Level of Care Provider |
|
HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7 |
Appropriate Justification for Multiple Antipsychotic Medications |
|
HBIPS-5 |
Continuing Care Plan-Discharge Medications |
|
HBIPS-6, HBIPS-7 |
Continuing Care Plan-Next Level of Care |
|
HBIPS-6, HBIPS-7 |
Continuing Care Plan-Principal Discharge Diagnosis |
|
HBIPS-6, HBIPS-7 |
Continuing Care Plan-Reason for Hospitalization |
|
HBIPS-6, HBIPS-7 |
Do Not Return - Clinical |
|
HCSS-1 |
Do Not Return Occurrence Identifier |
|
HCSS-1, HCSS-2 |
Hours Worked |
|
HCSS-1, HCSS-2 |
Active Clinical Staff |
|
HCSS-1, HCSS-2, HCSS-3 |
Clinical Staff |
|
HCSS-1, HCSS-2, HCSS-3 |
Do Not Return - Professional |
|
HCSS-2 |
Background Check |
|
HCSS-3 |
Competency |
|
HCSS-3 |
Health Status |
|
HCSS-3 |
Job Appropriate Credentials |
|
HCSS-3 |
Personnel File Record Identifier |
|
HCSS-3 |
Discharge Instructions Address Activity |
|
HF-1 |
Discharge Instructions Address Diet |
|
HF-1 |
Discharge Instructions Address Follow-up |
|
HF-1 |
Discharge Instructions Address Medications |
|
HF-1 |
Discharge Instructions Address Symptoms Worsening |
|
HF-1 |
Discharge Instructions Address Weight Monitoring |
|
HF-1 |
LVF Assessment |
|
HF-2 |
Predicted Value |
Transmission, Risk Adjustment, Hospital Clinical Data File |
PC |
Active Labor |
|
PC-01 |
Spontaneous Rupture of Membranes |
|
PC-01 |
Gestational Age |
|
PC-01, PC-02, PC-03 |
Clinical Trial |
|
PC-01, PC-02, PC-03, PC-04, PC-05 |
Parity |
|
PC-02 |
Antenatal Steroid Administered |
|
PC-03 |
Reason for Not Administering Antenatal Steroid |
|
PC-03 |
Birth Weight |
Risk Adjustment |
PC-04 |
Newborn Admission Source |
|
PC-04, PC-05 |
Admission to NICU |
|
PC-05 |
Exclusive Breast Milk Feeding |
|
PC-05 |
Reason for Not Exclusively Feeding Breast Milk |
|
PC-05 |
ABG Done |
|
PN-1 |
Pulse Oximetry Done |
|
PN-1 |
Chest X-Ray |
|
PN-1, PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7 |
Pneumonia Diagnosis: ED/Direct Admit |
|
PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b |
Pneumococcal Vaccination Status |
|
PN-2 |
Blood Culture Collected |
|
PN-3a, PN-3b |
Initial Blood Culture Collection Date |
|
PN-3a, PN-3b |
Initial Blood Culture Collection Time |
|
PN-3a, PN-3b |
ICU Transfer or Admission Within First 24 Hours |
|
PN-3a, PN-6, PN-6a, PN-6b |
Antibiotic Administration Date |
|
PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Antibiotic Administration Time |
|
PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Antibiotic Name |
|
PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Antibiotic Received |
|
PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Diagnostic Uncertainty |
|
PN-5, PN-5b, PN-5c |
Another Suspected Source of Infection |
|
PN-6, PN-6a, PN-6b |
Compromised |
|
PN-6, PN-6a, PN-6b |
Healthcare Associated PN |
|
PN-6, PN-6a, PN-6b |
Identified Pathogen |
|
PN-6, PN-6a, PN-6b |
Pseudomonas Risk |
|
PN-6, PN-6a, PN-6b |
Antibiotic Administration Route |
|
PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Antibiotic Allergy |
|
PN-6, PN-6a, PN-6b, SCIP-Inf-2 |
Risk Factors for Drug-Resistant Pneumococcus |
|
PN-6, PN-6b |
Influenza Vaccination Status |
|
PN-7 |
Beta-Blocker Current Medication |
|
SCIP-Card-2 |
Beta-Blocker During Pregnancy |
|
SCIP-Card-2 |
Beta-Blocker Perioperative |
|
SCIP-Card-2 |
Contraindication to Beta-Blocker - Perioperative |
|
SCIP-Card-2 |
Laparoscope |
|
SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, SCIP-VTE-1, SCIP-VTE-2 |
Surgery Start Date |
|
SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, SCIP-VTE-1, SCIP-VTE-2 |
Perioperative Death |
|
SCIP-Card-2, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7 |
Joint Revision |
|
SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Oral Antibiotics |
|
SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 |
Infection Prior to Anesthesia |
|
SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7 |
Surgical Incision Time |
|
SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-VTE-1, SCIP-VTE-2 |
Other Surgeries |
|
SCIP-Inf-1, SCIP-Inf-3 |
Vancomycin |
|
SCIP-Inf-2 |
Surgery End Date |
|
SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-VTE-1, SCIP-VTE-2 |
Surgery End Time |
|
SCIP-Inf-2, SCIP-Inf-3, SCIP-VTE-1, SCIP-VTE-2 |
Date of Infection |
|
SCIP-Inf-3 |
Postoperative Infections |
|
SCIP-Inf-3 |
Glucose POD 1 |
|
SCIP-Inf-4 |
Glucose POD 2 |
|
SCIP-Inf-4 |
Preoperative Hair Removal |
|
SCIP-Inf-6 |
Temperature Value |
|
SCIP-Inf-7 |
Contraindication to VTE Prophylaxis |
|
SCIP-VTE-1, SCIP-VTE-2 |
Neuraxial Anesthesia |
|
SCIP-VTE-1, SCIP-VTE-2 |
Preadmission Warfarin |
|
SCIP-VTE-1, SCIP-VTE-2 |
VTE Prophylaxis |
|
SCIP-VTE-1, SCIP-VTE-2 |
VTE Timely |
|
SCIP-VTE-2 |
Admission Date-Stroke |
|
STK-01, STK-02, STK-03, STK-04, STK-05, STK-06, STK-07, STK-10 |
DVT Prophylaxis Initiated by End of Hospital Day 2 |
|
STK-1 |
Patient Ambulatory at End of Hospital Day Two |
|
STK-1 |
Admitted for Elective Carotid Endarterectomy |
Joint Commission Only |
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Arrival Date-Stroke |
|
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Arrival Time-Stroke |
|
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Case Identifier |
Joint Commission Only |
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Comfort Measures Only-Stroke |
|
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Discharge Status-Stroke |
|
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Point of Origin for Admission or Visit-Stroke |
CMS Only |
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Report Period |
Joint Commission Only |
STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9 |
Assessed for Rehabilitation Services |
|
STK-10 |
Antithrombotic Therapy Prescribed at Discharge |
|
STK-2 |
Atrial Fibrillation |
|
STK-3 |
Patient Discharged on Anticoagulation Therapy |
|
STK-3 |
Date IV Thrombolytic Therapy Administered At This Hospital |
|
STK-4 |
Date Last Known Well |
|
STK-4 |
IV Thrombolytic Therapy Administered |
|
STK-4 |
Time IV Thrombolytic Therapy Administered at This Hospital |
|
STK-4 |
Time Last Known Well |
|
STK-4 |
Antithrombotic Therapy Administered by End of Hospital Day Two |
|
STK-5 |
Cholesterol Reducing Therapy Prescribed at Discharge |
|
STK-6 |
Cholesterol Reducing Therapy Prior To Hospitalization |
|
STK-6 |
LDL ≥ 100 mg/dL |
|
STK-6 |
Dysphagia Screen |
|
STK-7 |
NPO (Nothing by Mouth) For Entire Hospital Stay |
|
STK-7 |
Education Addresses Activation of Emergency Medical System |
|
STK-8 |
Education Addresses Follow-up After Discharge |
|
STK-8 |
Education Addresses Medication Prescribed |
|
STK-8 |
Education Addresses Risk Factors for Stroke |
|
STK-8 |
Education Addresses Warning Signs and Symptoms of Stroke |
|
STK-8 |
Adult Smoking Counseling-Stroke |
|
STK-9 |
Adult Smoking History-Stroke |
|
STK-9 |
Tobacco Use Status |
|
TAM-01, TAM-02, TAM-03, TAM-04 |
Cognitive Impairment |
|
TAM-01, TAM-02, TAM-03, TAM-05, TAM-06, TAM-07 |
Tobacco Use Treatment FDA-Approved Cessation Medication |
|
TAM-02 |
Tobacco Use Treatment Practical Counseling |
|
TAM-02 |
Reason for No Tobacco Cessation Medication |
|
TAM-02, TAM-03 |
Tobacco Use Treatment |
|
TAM-02, TAM-04 |
Prescription for Tobacco Cessation Medication |
|
TAM-03 |
Referral for Outpatient Tobacco Cessation Counseling |
|
TAM-03 |
Tobacco Use Status Post-Discharge (test data element) |
|
TAM-04 |
Follow-up Contact |
|
TAM-04, TAM-08 |
Follow-up Contact Date (test data element) |
|
TAM-04, TAM-08 |
Alcohol Use Status |
|
TAM-05, TAM-06, TAM-07, TAM-08 |
Brief Intervention |
|
TAM-06 |
Prescription for Alcohol or Drug Dependence Medication |
|
TAM-07 |
Referral for Addictions Treatment |
|
TAM-07 |
Alcohol or Drug Dependence |
|
TAM-07, TAM-08 |
Substance Use Status Post-Discharge |
|
TAM-08 |
Related Topics
|
Data Dictionary Introduction
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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