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Release Notes:
Data Element
Version 2010A1

Data Element Name: Neuraxial Anesthesia
Collected For: , ,
Definition:Documentation that the patient received neuraxial anesthesia for the surgical procedure. Neuraxial anesthesia is medication administered into the epidural space or spinal canal to block sensations of pain.
Suggested Data Collection Question:Is there documentation that the patient received neuraxial anesthesia for the surgical procedure?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation that the patient received neuraxial anesthesia for the surgical procedure.

N   (No)   There is no documentation that the patient received neuraxial anesthesia for the surgical procedure or unable to determine from medical record documentation.

Notes for Abstraction:
  • Neuraxial anesthesia may be administered via an epidural (injected into the epidural space) or spinal (usually injected into the cerebrospinal fluid) route
  • If an epidural catheter is placed preoperatively for anesthesia or up to 24 hours after Surgery End Time for postoperative pain control, select “Yes”.
Suggested Data Sources:
  • Anesthesia record
  • Operative report
  • Procedure notes
  • Medication administration record (MAR)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Epidural
  • Intrathecal anesthesia
  • Spinal anesthesia
  • Subarachnoid block

  • MAC (monitored anesthesia care)
  • Peripheral catheter blocks
  • Peripheral nerve blocks

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