Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Healthcare Associated PN |
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| Collected For: | PN-6, PN-6a, PN-6b, |
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| Definition: | Documentation that the patient had risk for healthcare associated pneumonia prior to admission for this hospital episode as determined by the presence of at least one of the following:
1) Acute care hospitalization within the last 90 days (calendar days)
2) Residence in a nursing home or extended care facility for any amount of time within the last 90 days
3) Chronic dialysis within the last 30 days prior to this hospitalization
4) Wound care, tracheostomy care or ventilator care provided by a health care professional within the last 30 days
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| Suggested Data Collection Question: | Is there documentation the patient had risk for healthcare associated pneumonia? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes)The patient has documented risk for healthcare associated pneumonia.
N (No) The patient has no documented risk for healthcare associated pneumonia or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- For the purpose of the Pneumonia Project, chronic dialysis is defined as ESRD (End Stage Renal Disease) with peritoneal dialysis or hemodialysis.
- For the purpose of this data element, an extended care facility is a non-apartment based institutional setting where 24-hour nursing care is provided. This INCLUDES – Nursing Homes, Skilled Nursing Facilities, ECF, ICF, Hospice Facilities, SNF Rehab Units, Sub-acute Care, Transitional Care, Respite Care, Inpatient Rehab Unit or Facility and VA Nursing Facilities. This EXCLUDES – Assisted Living, Board and Care, Group Homes, Personal Care Homes, Residential Care, Chemical Dependency Treatment, Drug Rehab, Psych Unit or Facility or Hospice at home.
- Do not make an assumption as to the patient’s previous length of stay based on the procedure they received. Only use dates or phrases such as “in the hospital a couple of days last month,” etc.
- If the hospital abstractor determines that a patient had resided at an extended care facility/nursing home within the 90 days prior to hospital arrival, that determination will not be challenged during validation unless there is contradictory information in the medical record.
- If there is physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation that the patient has “healthcare associated pneumonia”, “HCAP” or “nosocomial pneumonia”, select “Yes.”
- If “wound care” is documented in the medical record but with no timeframe to ascertain that the wound care was provided within the last 30 days, (i.e., “history of”, “about a month ago”, etc.) select “No.”
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
- Admission face sheet
- Nursing admission notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- CAVH
- Continuous arterio-venous hemofiltration
- Continuous veno-venous hemofiltration
- CVVH
- Hemodialysis
- Peritoneal dialysis
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Healthcare Associated PN
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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