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Release Notes:
Data Element
Version 2010A1

Data Element Name: Pneumococcal Vaccination Status
Collected For: PN-2,
Definition:Documentation of the patient's pneumococcal vaccination status. If found to be a candidate for the vaccine, documentation that the pneumococcal 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 pneumococcal vaccine status?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    Pneumococcal vaccine was given during this hospitalization: The patient received pneumococcal vaccine during the current hospitalization, even if it was also given anytime in the past.

2   Pneumococcal vaccine was received in the past, not during this hospitalization: The patient received pneumococcal vaccine anytime in the past.

3   Documentation of patient's refusal of pneumococcal vaccine: There is documentation of the patient refusing pneumococcal vaccine.

4   Allergy/sensitivity to pneumococcal vaccine: There is documentation of an allergy/sensitivity to pneumococcal vaccine OR is medically contraindicated because of a bone marrow transplant within the past 12 months OR currently receiving a scheduled course of chemotherapy or radiation therapy, or received chemotherapy or radiation during this hospitalization.

5   None of the above/Not documented/UTD: None of the allowable values above are appropriate, there was no documentation of pneumococcal vaccination status or unable to determine from medical record documentation.

Notes for Abstraction:In order to select “Pneumococcal 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.”
  • Autologous stem cell transplant and ASCT are other names for a bone marrow transplant
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Nursing admission assessment
  • Progress notes
  • Physician orders
  • Discharge summary
  • Immunization assessment forms
  • Medication sheets
  • Social service notes
  • Transfer forms
  • Vaccine order sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Pneumococcal vaccine
  • Pneumonia shot
  • Pneumonia vaccine
  • Pneumovax
  • Pneumovax 23
  • Pnu-imune 23
  • Polyvalent pneumonia vaccine

Patients with specific documented allergy/sensitivity (should be accompanied by the exact complication) to vaccine, including hypersensitivity to any component in the vaccine, including thimerosal. Also, sizeable local reaction at injection site (> 10.2 cm), or the occurrence of any type of an immediate or delayed hypersensitivity reaction or the occurrence of neurological signs and symptoms following administration. (May not be based solely on physician/APN/PA’s preference.)

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