Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Clinical Indication for RBCs |
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| Collected For: | BM-02, |
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| Definition: | Documentation by the physician/advance practice nurse/physician assistant (physician/APN/PA) of the clinical indication for the red blood cell (RBCs) transfusion event. |
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| Suggested Data Collection Question: | What was the clinical indication documented by the physician/APN/PA for the RBC 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: |
Select the indication for the RBC transfusion event:
1 Bleeding
2 No bleeding, but evidence of inadequate oxygen delivery
3 Other
4 No documentation of clinical indication for the RBC 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 RBC transfusion events after hospital arrival for abstraction.
- Select “1’ if there is documentation of ‘hemorrhage’ or a massive transfusion protocol was used.
- Select “2” if there is documentation that the patient is exhibiting signs and symptoms consistent with a low blood count that cannot be resolved unless blood is administered. For example: there is documentation such as: shortness of breath at rest (with no other cause such as underlying pulmonary dysfunction), syncope or fainting (once hypovolemia is ruled out), tachycardia or hypotension (that volume replacement failed to correct), unresponsive or signs of organ ischemia (somulence, or ST segment changes).
- Select "3" if there is an indication for RBCs but unable to determine if blood was administered due to an oxygen deficit.
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA DOCUMENTATION OF THE CLINICAL INDICATION FOR ADMINISTERING RBCs:
- Anesthesia record
- Consultation notes
- Emergency department record
- Operative notes
- 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 RBCs
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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