• For times that include “seconds,” remove the seconds and record the time as is.
  Example:
  15:00:35 would be recorded as 15:00
• If the principal procedure end time 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 time documented is obviously in error (not a valid time/format or outside of the parameters of care for this data element [ Surgery End Date/Surgery End Time cannot be before Surgery Start Date/Surgical Incision Time ]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
  Examples:
  • Documentation indicates the Surgery End Time was 3300. No other documentation in the medical record provides a valid time. Since the Surgery End Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
  • Documentation indicates the Surgery End Date was 3-11-2008, Surgery End Time was 1100, Surgery Start Date was 3-11-2008 and Surgical Incision Time was 2100. Documentation in the medical record support the Surgery Start Date and the Surgical Incision Time as being accurate. No other documentation in the medical record provides an accurate Surgery End Time. Since Surgery End Date/Surgery End Time are before the Surgery Start Date/Surgical Incision Time, it is outside of the paramenter of care for this data element and the abstractor should select “UTD.”
    Note:
    Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Surgery End Time allows the case to be accepted into the warehouse.
• If multiple procedures occur during the same surgical episode, the Surgical Incision Time captured will be the incision that occurs first and the Surgery End Time will be the end time that occurs last.
• If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Surgery End Time of the initial procedure. Do NOT use the date/time the patient returns to the OR for closure.

Follow the priority order within the Inclusion List of this data element’s Guidelines for Abstraction:

1. First, review all sources for any of the first priority synonyms for Surgery End Time. If multiple times are found, select the earliest time among the first priority synonyms.
2. Next, if none of the first priority synonyms are documented, go to the second priority list of synonyms for Surgery End Time. If multiple times are found, select the earliest time among the second priority list of synonyms.
3. Finally, if none of the first and second priority synonyms are documented, go to the third priority list of synonyms for Surgery End Time. If multiple times are found, select the earliest time among the third priority list of synonyms.
   Note:
   Priority order applies to items in inclusion table, not to source document. Also, please note the synonyms in the lists are alphabetized, not prioritized.

• Anesthesia record
• Circulation record
• Operative report