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Release Notes:
Data Element
Version 2010A1

Data Element Name: Diagnostic Uncertainty
Collected For: PN-5, PN-5b, PN-5c,
Definition:Specific documentation of a reason(s) that despite being seen by the physician/advanced practice nurse/physician assistant (physician/APN/PA), the patient’s initial clinical picture was questionable, unclear or not suggestive of pneumonia, which caused a delay in the diagnosis of pneumonia at the time of admission.

Suggested Data Collection Question:Is there documentation of a reason(s) that despite being seen by the physician/APN/PA, the patient’s initial clinical picture was questionable, unclear or not suggestive of pneumonia which resulted in a delay in the diagnosis of pneumonia at the time of admission?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation of a reason(s) that despite being seen by the physician/APN/PA, the patient’s initial clinical picture was questionable, unclear or not suggestive of pneumonia which resulted in a delay in the diagnosis of pneumonia at the time of admission.

N   (No)   There is no documentation of a reason(s) that despite being seen by the physician/APN/PA, the patient’s initial clinical picture was questionable, unclear or not suggestive of pneumonia which resulted in a delay in the diagnosis of pneumonia at the time of admission, or unable to determine from medical record documentation.

Notes for Abstraction:
  • Always select “No’ if the diagnosis of pneumonia was not made at the time of admission ( Pneumonia Diagnosis: ED/Direct Admit answered “No” – allowable value “3”).
  • The initial clinical picture is defined for the purposes of this data element as the clinical picture from arrival to admission for ED patients and as the clinical picture on admission for direct admits.
  • The primary intent of this data element is to determine if the physician/APN/PA identified clinical circumstances that would delay the diagnosis of pneumonia.
  • Physician/APN/PA must specifically document both of the following required elements to select “Yes”:
    1) The initial clinical picture was questionable, unclear or not suggestive of pneumonia, etc.
    AND
    2) This resulted in a delay in the diagnosis of pneumonia at the time of admission (There must be documentation of a delay. It cannot be inferred there was a delay.)
  • If the timeframe from arrival in the hospital until the time the patient is seen by the physician/APN/PA, is greater than 6 hours, this is not appropriate documentation to answer “yes” to this data element., i.e. a long wait to be seen/triaged is not appropriate documentation of diagnostic uncertainty.
Suggested Data Sources:

ONLY ACCEPTABLE SOURCES
PHYSICIAN/APN/PA DOCUMENTATION ONLY

  • Emergency department record (ED admits)
  • Physician admitting note (Direct admits)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Documentation must include both of the required elements:
1. Clinical picture was questionable, unclear or not suggestive of pneumonia
  • Clinical picture not clear
  • Diagnostic picture unclear
  • Questionable diagnostic picture
  • Not suggestive of pneumonia
  • No obvious signs of pneumonia
  • No overt evidence of pneumonia
  • Atypical presentation

2. Delay in the diagnosis of pneumonia at the time of admission

  • Answer to Pneumonia Diagnosis: ED/Direct Admit answered “No” – allowable value “3”
  • Radiology reports or consultation
  • Systems reasons for delays in the administration of antibiotics, Examples: antibiotic not available in ED, patient had to sit in the waiting room for 5 hours, chest x-ray delayed

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