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Release Notes:
Data Element
Version 2010A1

Data Element Name: Influenza Vaccination Status
Collected For: PN-7,
Definition:Documentation of the patient's vaccination status during this flu season. If found to be a candidate for the vaccine, documentation that the influenza vaccine was given during this hospitalization. A vaccine is a suspension of an attenuated (weakened) or killed microorganism, such as bacteria or virus, administered for the prevention, amelioration, or treatment of infectious diseases.
Suggested Data Collection Question:What is the patient’s influenza vaccination status?

Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    Influenza vaccine was given during this hospitalization.

2   Influenza vaccine was received prior to admission during the current flu season*, not during this hospitalization.

3   Documentation of patient's refusal of influenza vaccine.

4   There was documentation of an allergy/sensitivity to influenza vaccine OR is medically contraindicated because of bone marrow transplant within the past 12 months OR prior history of Guillian-Barré syndrome.

5   None of the above/Not documented/Unable to determine from medical record documentation.

6   Only select this allowable value if there is documentation the vaccine has been ordered but has not yet been received by the hospital due to problems with vaccine production or distribution AND allowable values 1-5 are not selected.

Notes for Abstraction:
  • *The current flu season begins when this season’s flu vaccine is made available to the public (i.e., if the vaccine is available in September, the flu season is September - March However, for the purposes of this project, the hospitals are only responsible for discharges October - March.)
  • In order to select “Influenza vaccine was given during this hospitalization,” there must be documentation either on the MAR, nursing notes, standing orders, etc., where the vaccine was dated and signed as administered.
  • In situations where there is documentation that would support more than one of the allowable values, 1-4, select the smallest number.
    Example:
    Nurses notes have documentation the patient refused. Vaccination order sheet has documentation that the patient was vaccinated during this hospitalization. You will select value 1, as it is the smallest number.
  • If there is no documentation to support any of the allowable values 1-4, and there is physician documentation that they will administer the vaccine after discharge, select “5.”
  • If there is documentation that the patient received the vaccine and only the current year is documented, i.e., no month or day, select – “2.”
    Example:
    There is documentation the patient received the vaccine in 2007 and it is October 2007, select – “2.”
  • If there is documentation the patient received the vaccine the year prior to the current year and the discharge is not January, February or March, select – “5.”
    Examples:
    • There is documentation the patient received the vaccine in 2006 and it is October 2007, select – “5.”
    • There is documentation the patient received the vaccine in 2007 and it is January 2008, select “2.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • Nursing notes
  • Nursing admission assessment
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • Immunization assessment forms
  • Physician progress notes
  • Social service notes
  • Transfer forms
  • Vaccine order sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
All patients discharged during October, November, December, January, February, or March
  • Flu immune
  • Flu shield
  • Flu shot
  • Flu vaccine
  • Fluax
  • Fluogen
  • Fluvirin
  • Fluzone
  • Influenza virus vaccine
  • Trivalent influenza vaccine

  • All discharges from April – September
  • Patients allergic to eggs or other specific allergy/sensitivity to the vaccine. The allergy/sensitivity should be accompanied by the exact complication. Must be a specific allergy/sensitivity not just physician/advanced practice nurse/physician assistant (physician/APN/PA) preference

Influenza Vaccination Status
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
Questions? Ask Question to Joint Commission staff Copyright © 2010 by The Joint Commission.