Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Transfusion Order |
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| Collected For: | BM-05, |
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| Definition: | An order to transfuse was written by the physician/advance practice nurse/physician assistant (physician/APN/PA) prior to the initiation of the transfusion. |
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| Suggested Data Collection Question: | Was there documentation of an order to transfuse prior to the transfusion? |
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| Format: | | Length: | 1 |
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| Type: | Numeric |
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| Occurs: | 1 - 9 |
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| Allowable Values: |
1 There was documentation of an order to transfused prior to transfusion.
2 There was no documentation of an order to transfuse prior to transfusion or unable to determine from medical record documentation. |
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| Notes for Abstraction: |
- A verbal or telephone order that was written prior to the transfusion is acceptable.
- The Transfusion Order must be associated with the blood product event ID that was selected for abstraction. For example, if a patient received RBCs, the abstractor will select the first order for RBCs "Transfuse one unit of RBCs" as RBC Event ID #1.
- Select “N” if there is only an order to T & C or T & S.
- Note: Transfusion Order is written per event and may apply to more than one unit (bag) or dose. For example: An order written to "Transfuse two doses of platelets" would apply to both units that were administered.
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA DOCUMENTATION OF THE ORDER TO TRANSFUSE:
- 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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Transfusion Order
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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