• 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 time of arrival 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 Arrival Time was 3300. No other documentation in the list of ONLY ACCEPTABLE SOURCES provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
  Note:
  Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Arrival Time allows the case to be accepted into the warehouse.
• Review only the acceptable sources to determine the earliest time the patient arrived at the hospital. This may differ from the admission time.
  Note:
  Medical record documentation from all of the “only acceptable sources” should be carefully examined in determining the most correct time of arrival. Arrival time should NOT be abstracted simply as the earliest time in the acceptable sources, without regard to other (i.e., ancillary services) substantiating documentation. If documentation suggests that the earliest time in the acceptable sources does not reflect the time the patient arrived at the hospital, this time should not be used.
• 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 which reflects processes that occurred in the ED or hospital.
• If the patient is in an outpatient setting of the hospital (e.g., undergoing dialysis, chemotherapy, cardiac cath) and is subsequently admitted to the hospital, use the time the patient presents to the ED or arrives on the floor as the arrival time.
• If the patient is a “Direct Admit” to the cath lab, as a transfer from another ED or acute care hospital, use the time the patient presents to the cath lab as the arrival time.
• For “Direct Admits” to the hospital, use the earliest time the patient arrives at the hospital.
• The source “Any ED documentation” includes ED vital sign record, ED/Outpatient Registration form, triage record and ECG reports, laboratory reports, x-ray reports, etc., if these ancillary services were rendered while the patient was an ED patient.
• The source “Procedure notes” refers to formal documents that describe a procedure that was done (e.g., endoscopy, cardiac cath). ECG and x-ray reports should NOT be considered procedure notes.

ONLY ACCEPTABLE SOURCES

• Vital signs graphic record
• Procedure notes
• Any ED documentation
• Nursing admission assessment/admitting note
• Observation record

• Face sheet