Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Adult Smoking History-Stroke |
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| Collected For: | , |
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| Definition: | Documentation that the adult patient has smoked cigarettes anytime during the year prior to hospital arrival. Adult is defined as 18 years of age or older. |
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| Suggested Data Collection Question: | Did the adult patient smoke cigarettes anytime during the year prior to hospital arrival? |
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| Format: | | Length: | |
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| Type: | Alphanumeric |
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| Occurs: | |
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| Allowable Values: |
Y (Yes, there is documentation that the adult patient smoked cigarettes anytime during the year prior to hospital arrival.)
N (No, there is documentation that the adult patient did not smoke cigarettes anytime during the year prior to hospital arrival OR smoking history was not addressed OR unable to determine from medical record documentation.
NOTE: If the ICD-9-M Other Diagnosis Code 305.1 exists, then default the allowable value to Y (Yes).
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| Notes for Abstraction: | In some cases smoking history documentation in one medical record source may further clarify the patient's smoking history documented in another medical record source. Examples:
- Progress note states “history of smoking” and the nursing admission assessment notes “quit 2 years ago” – select “No.”
- Discharge summary states smoker without specifying the type of tobacco and the ED record specifies the type of tobacco as cigar – select “No.”
In cases where conflicting information about the patient's smoking history is documented and there is no specific documentation that the patient has not smoked during the year prior to hospital arrival, select “Yes.” Examples:
- “Current smoker” per H&P, but ED note states “Non-smoker” – select “Yes”
- “Cigarette Smoking: Yes, 1-2 cigarettes a day” on nursing admission note, but “Smoking – Quit” on H&P – select “Yes.”
- “Recent smoker” in H&P, but progress note states “Smokes – No” – select “Yes.”
In cases where at least one source has specific documentation that the patient has not smoked anytime during the year prior to hospital arrival, select “No.” Examples:
- “Current smoker” per H&P, but consultation note states patient “quit 2 years ago” – select “No.”
- “ + tobacco use” per ED note, “Smoker – Yes” per nursing admission note, but H&P states, “Quit smoking in 2002” – select “No.”
- Progress note states “Still smokes occasionally” but nursing admission assessment has “No” circled next to “Tobacco use within past year” – select “No.”
If there is documentation of current smoking or tobacco use, or a history of smoking or tobacco use, and the type of product is not specified, assume this refers to cigarette smoking.
Do not include documentation of smoking history referenced as a “risk factor” (e.g., “risk factor: tobacco,” “risk factor: smoking,” “risk factor: smoker”), where current smoking status is indeterminable.
If there is a history of smoking and documentation that the patient quit “several months ago,” infer the patient smoked within one year prior to arrival, and select “Yes.”
If there is a history of smoking and documentation indicates the patient quit, but the timeframe in which the patient quit is not clear, select “No.”
Examples:
- Nursing admission assessment documents patient as “ex-smoker” or “former smoker,” or simply notes pt. “quit smoking” - select “No.”
- “History of tobacco abuse” per H&P, and consultation note states “nonsmoker” - select “No” (not a case of conflicting information).
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Respiratory therapy notes
- Nursing admission assessment
- Progress notes
- Discharge summary
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Cigarette smoking within one year prior to hospital arrival
- + smoker, type of product not identified
- + tobacco use, type of product not identified
- History of cigarette use without mention of a time frame, if no indication that patient quit
- History of smoking (type of product not identified), without mention of a time frame, if no indication that patient quit
- History of smoking and documentation that the patient quit “several months ago”
- History of smoking within one year prior to arrival, type of product not identified
- History of tobacco use (type of product not identified), without mention of a time frame, if no indication that patient quit
- History of tobacco use within one year prior to arrival, type of product not identified
- Recent smoker
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Cigarette smoking within one year prior to hospital arrival
- Chewing tobacco use only
- Cigar smoking only
- Cigarette smoking within one year prior to arrival or any of the other inclusion terms described using one of the following qualifiers: cannot exclude, cannot rule out, may have, may have had, may indicate, possible, suggestive of, suspect or suspicious
- Illegal drug use only (e.g., marijuana)
- Oral tobacco use only
- Pipe smoking only
- Remote smoker (smoked in the past, but greater than one year ago)
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Adult Smoking History-Stroke
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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