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Data Dictionary Introduction
Version 2010A1

Data Dictionary

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 MeasuresSorted ascending
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

Related Topics
a. Table of Contents
j1. Transmission Alphabetical Data Dictionary

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