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Release Notes:
Data Element
Version 2010A1

Data Element Name: Postoperative Infections
Collected For: SCIP-Inf-3,
Definition:Any infection documented in the postoperative period, following the principal procedure. Postoperative period is defined as within two days (three days for CABG or Other Cardiac Surgery) after Surgery End Date with day of surgery being day zero.
Suggested Data Collection Question:Were any infections documented postoperatively?

Allowable Values:

Y    (Yes)   There is physician/advanced practice nurse/physician assistant (physician/APN/PA documentation that the patient had an infection postoperatively following the principal procedure.

N   (No)   There is no physician/APN/PA documentation that the patient had an infection postoperatively following the principal procedure or unable to determine from medical record documentation.

Notes for Abstraction:
  • If there is documentation of an infection or possible/suspected infection, select “Yes.”
  • Documentation of symptoms (example: fever, elevated white blood cells, etc.) should not be considered infections unless documented as an infection or possible/suspected infection. Example: Do not assume infection if a wound/surgical site is described as reddened, swollen and hot, as other conditions can also cause these symptoms.
  • The physician/APN/PA documentation of postoperative infection must be written after surgical incision.
  • If documentation of an infection occurs more than two days postoperatively (three days for CABG or Other Cardiac Surgery) with the day of surgery being day zero, select “No.”
  • Only accept documentation of a postoperative infection in discharge summaries that are dated (dictated or written) within 2 days (3 days for CABG or Other Cardiac Surgery) postoperatively with the day of surgery being day zero. If the discharge summary is dated (dictated or written) outside of that timeframe, it should not be considered documentation of a postoperative infection.
Suggested Data Sources:
  • Anesthesia record
  • Consultation notes
  • Progress notes
  • Discharge summary
Excluded Data Sources:
Any documentation of infection from pathology reports.

Do NOT use Table 5.09 as a reference for Postoperative Infections. This data element has an inclusion table to use as a guideline that provides the types of infection that are acceptable. Please reference this inclusion table when answering this data element.

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Abscess
  • Bloodstream infection
  • Bone infection
  • Cellulitis
  • Gangrene
  • Fecal Contamination
  • H. pylori
  • Necrotic/ischemic/infarcted bowel
  • Osteomyelitis
  • Other documented infection
  • Pneumonia or other lung infection
  • Sepsis
  • Surgical site or wound infection
  • Urinary tract infection (UTI)

  • Colonized MRSA
  • History (Hx) of MRSA
  • Viral infections

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