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Release Notes:
Data Element
Version 2010A1

Data Element Name: Preoperative Anemia Screening Hemoglobin Result
Collected For:
Definition:Preoperative anemia screening hemoglobin (hgb) result.
Suggested Data Collection Question:What is the patient’s preoperative hemoglobin (hgb) g/dL result from preoperative anemia screening?

Allowable Values:

Enter the patient’s hemoglobin result, in g/dL for the preoperative anemia screening test performed within 14 – 45 days prior to the Anesthesia Start Date.

UTD = Unable to Determine

Notes for Abstraction:
  • Select the preoperative hemoglobin (hgb) result associated with the elective surgery selected for abstraction.
  • For abstraction, select either the pre-transfusion hematocrit result or the hemoglobin result; both are not required.
  • Document a 7g/dL hemoglobin result as 7.
  • If an hgb value on the pre-operative laboratory report conflicts with that from another source of documentation for the same specimen, enter the value from the laboratory report.
  • If a result from the test performed is not documented or if unable to determine from medical record documentation (e.g., anemia testing was done 3 weeks before the anesthesia start date but no values are available), select “UTD.”
  • The medical record must be abstracted as documented (taken at “face value”). When the value documented is obviously in error (not a valid number or greater than 999) and no other documentation is found that provides this information, the abstractor should select “UTD.”
  • Example: Documentation indicates the Preoperative Anemia Screening Hemoglobin Result 11000 g/dL. No other documention in the medical provides a valid value. Since the Preoperative Anemia Screening Hemoglobin Result outside of the range listed in the Format Length (greater than 9999), it is not a valid value and the abstractor should select “UTD.”
  • Note: Transmission of a case with an invalid value will be rejected from the database. Use of “UTD” for Preoperative Anemia Screening Result allows the case to be accepted into the database.
Suggested Data Sources:
  • Consultation notes
  • History and physical
  • Progress notes
  • Preop checklist
  • Pre-arrival laboratory report
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

Preoperative Anemia Screening Hemoglobin Result
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)