Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Clinical Indication for Plasma |
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| Collected For: | BM-03, |
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| Definition: | Documentation by the physician/advance practice nurse/physician assistant (physician/APN/PA) of the clinical indication for the plasma transfusion event. |
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| Suggested Data Collection Question: | What was the clinical indication documented by the physician/APN/PA for the plasma transfusion event? |
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| Format: | | Length: | 1 |
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| Type: | Numeric |
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| Occurs: | 1 - 3 |
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| Allowable Values: |
1 Bleeding
2 No bleeding, but scheduled for invasive procedure
3 No bleeding - emergent reversal of Coumadin
4 Other
5 No documentation of clinical indication for the plasma transfusion. |
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| Notes for Abstraction: |
- The clinical indication for the transfusion must be documented within 24 hours after the start of the transfusion event.
- Select the first three plasma transfusion events closest to hospital arrival for abstraction.
- Select “1’ if there is documentation of ‘hemorrhage’ or a massive transfusion protocol was used.
- Select "3" only if the patient had to have an "emergency" procedure.
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA DOCUMENTATION OF THE CLINICAL INDICATION FOR ADMINISTERING BLOOD:
- Anesthesia record
- Consultation notes
- Emergency department record
- History and physical
- Physician orders
- Progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
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None |
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Clinical Indication for Plasma
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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