Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Surgery End Date |
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| Collected For: | SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, , , |
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| Definition: | The date the principal procedure ended. |
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| Suggested Data Collection Question: | On what date did the principal procedure end?
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| Format: | | Length: | 10 – MM-DD-YYYY (includes dashes) or UTD |
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| Type: | Date |
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| Occurs: | 1 |
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| Allowable Values: |
MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (2000-9999)
UTD = Unable to Determine
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| Notes for Abstraction: |
- If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Surgery End Date of the initial procedure. Do NOT use the date the patient returns to the OR for closure.
- If the principal procedure end date is unable to be determined from medical record documentation, enter UTD.
- The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid format/range [after Discharge Date_] or outside the parameters of this data element [_Surgery End Date and Surgery End Time cannot be before Surgery Start Date and _Surgery Start Time_]) *and * no other documentation is found that provides this information, the abstractor should select “UTD.”
Examples:
- Documentation indicates the Surgery End Date was 02- 42 -2008. No other documentation in the medical record provides a valid date. Since the Surgery End Date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD.”
- Patient expires on 02-12-2008 and documentation indicates the Surgery End Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Surgery End Date is outside of the parmeter for care (after the Discharge Date [death]), the abstractor should select “UTD.”
Note:
Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Surgery End Date allows the case to be accepted into the warehouse.
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| Suggested Data Sources: |
- Anesthesia record
- Operating room notes
- Operative report
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| Additional Notes: |
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| Guidelines for Abstraction: |
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Surgery End Date
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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