Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Preoperative Anemia Screening Hemoglobin Result |
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| Collected For: | |
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| Definition: | Preoperative anemia screening hemoglobin (hgb) result. |
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| Suggested Data Collection Question: | What is the patient’s preoperative hemoglobin (hgb) g/dL result from preoperative anemia screening?
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| Format: | | Length: | 1-3 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| 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
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| 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.
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| Suggested Data Sources: |
- Consultation notes
- History and physical
- Progress notes
- Preop checklist
- Pre-arrival laboratory report
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| Additional Notes: |
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| Guidelines for Abstraction: |
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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)
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