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Release Notes:
Data Element
Version 2010A1

Data Element Name: LVF Assessment
Collected For: HF-2,
Definition:Documentation that left ventricular systolic function (LVSF) was assessed either prior to arrival, during hospitalization, or is planned for after discharge or reason documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) for not assessing LVSF prior to arrival, during hospitalization, or planned for after discharge. LVSF assessment is a measure of left ventricular contractility, and may be described either quantitatively (e.g., “left ventricular ejection fraction = 30%”) or qualitatively (e.g., “moderate left ventricular systolic dysfunction”).
Suggested Data Collection Question:Is there documentation of at least one of the following:
  • Left ventricular systolic function (LVSF) assessment at anytime prior to arrival or during this hospitalization
  • A plan for LVSF assessment after discharge
  • A reason documented by a physician/APN/PA for not assessing LVSF
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation in the medical record that the LVSF was assessed prior to arrival, during the hospital stay, or is planned for after discharge.

N   (No)   No documentation that LVSF was assessed either prior to arrival or during this hospital stay nor a plan to assess LVSF after discharge, AND there is no reason documented by a physician/APN/PA for not assessing LVSF, or unable to determine from medical record documentation.

R   (R)   Reason documented by physician/APN/PA for not assessing LVSF prior to arrival, during hospital stay, or planned after discharge.

Notes for Abstraction:
  • There is no time limitation on pre-arrival LVSF assessments: LVSF assessments done anytime prior to hospital arrival are acceptable.
  • In the absence of explicit documentation that an LVSF assessment was done, it should be inferred that an assessment was done if:
    • An echocardiogram, appropriate nuclear medicine test, or a cardiac catheterization with a left ventriculogram was done during this hospital stay (Note: In the absence of noted LVSF findings, give credit for test unless there’s a notation re inability to assess LVSF - e.g., "Rapid A-fib. Unable to assess LV function." - select "Reason"), or
    • There is documentation one of the above diagnostic tests was performed anytime prior to arrival (e.g., “Echo done last March”), or
    • There is documentation of LVSF, either as an ejection fraction or a narrative qualitative description (e.g., “Pt. admitted with severe LV dysfunction”).
  • In determining whether there is a reason documented by physician/APN/PA for not assessing LVSF, reasons must be explicitly documented (e.g., “ESRD, life expectancy < 1 month, will not measure EF,” echo done but no LVSF findings noted AND physician notes “Technically difficult study. LVSF could not be measured.”) or clearly implied (e.g., “Patient refusing echo,”“Limited life expectancy, will not do any further evaluation,” “EF measurement not indicated”). If reasons are not mentioned in the context of LVSF assessments, do not make inferences (e.g., Do not assume that the physician/APN/PA is not assessing LVSF because the patient is already on ACEI therapy or is of advanced age). If the physician/APN/PA documents that he is deferring LVSF assessment to another physician/APN/PA, this should NOT count as a reason for not assessing LVSF during hospital stay (nor a reason for not planning an assessment after discharge) unless the reason/problem underlying the deferral is also noted (e.g., Select "No" if “Consulting cardiologist to evaluate pt. for echo” or "Pt. to follow up with physician/APN/PA re measuring EF as outpatient").
  • In determining whether there is a plan to assess LVSF after discharge, the plan must be documented as definitive (e.g., “Will measure EF after discharge”). Documentation which indicates only that an LVSF assessment after discharge will be considered (e.g., “May do echo in 1 month”) is not sufficient.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Physician orders
  • Discharge summary
  • Diagnostic test reports
  • Operative notes
  • Procedure notes
  • Discharge instruction sheet
  • Discharge planning notes

Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay)

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Refer to Appendix H, Table 1.2 LVSF Assessment Inclusion Table.
Left ventricular systolic function (LVSF)
  • Cardiomyopathy not described as endstage
  • Contractility/hypocontractility
  • Left ventricular compliance
  • Left ventricular dilatation
  • Left ventricular dilation
  • Left ventricular systolic function, or any of the other terms in the LVSF Assessment Inclusion Table, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
  • Left ventricular hypertrophy (LVH)

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