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Release Notes:
Data Element
Version 2010A1

Data Element Name: Consent Addressed Transfusion Risks
Collected For:
Definition:Documentation by the physician/advance practice nurse/physician assistant (physician/APN/PA) that information addressing the risks of transfusion was provided to the patient/caregiver prior to transfusion.
Suggested Data Collection Question:Was there documentation that risks associated with transfusion was discussed with the patient/caregiver prior to transfusion?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) Information addressing the risks of transfusion was discussed with the patient/caregiver prior to transfusion.

N (No) Information addressing the risks of transfusion was not discussed with the patient/caregiver prior to transfusion or unable to determine from medical record documentation.

Notes for Abstraction:
  • Documentation that addresses the risks of transfusion must include the specific risks of the blood product (s) that was administered to select “Yes”.
  • Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may have been covered in the discussion with the patient/caregiver.
  • If the patient refused information about transfusion risks, select “Yes.”
  • The caregiver is defined as the patient’s family or any other person (e.g., guardian) who will be responsible for care of the patient.
Suggested Data Sources:

ONLY PHYSICIAN/APN/PA DOCUMENTATION:

  • Admission forms
  • Consent form
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
All components
  • Infectious diseases
  • Allergic reactions
Red Blood Cells/Platelets
  • Septic/toxic reactions
  • Febrile reactions
  • GVHD (graft versus host disease)
Plasma
  • Circulatory overload
List is not all inclusive

None

Consent Addressed Transfusion Risks
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)