Introduction

This section of the manual describes the data elements required to calculate category assignments and measurements for the national quality measures. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. This information is intended to assist in processing patient level data elements for national quality measures.

It is of primary importance that all hospitals using national quality measures gather and utilize the data elements as defined in this section. This will ensure that the data are standardized and comparable across hospitals.

Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital and submitted for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered “general” to each patient’s episode of care.

These data elements include:

• Admission Date
• Birthdate
• Discharge Date
• Discharge Status
• Health Care Organization Identifier ^1,4
• Hispanic Ethnicity ²
• Hospital Patient Identifier ²
• ICD-9-CM Other Diagnosis Codes
• ICD-9-CM Other Procedure Codes
• ICD-9-CM Other Procedure Dates
• ICD-9-CM Principal Diagnosis Code
• ICD-9-CM Principal Procedure Code
• ICD-9-CM Principal Procedure Date
• Measure Set ^3,4
• National Provider Identifier ^3,4
• Patient HIC ⁵
• Payment Source - Medicare
• Performance Measure Identifier ^1,3,4
• Point of Origin for Admission or Visit
• Postal Code ²
• Provider ID ^2,4
• Race ²
• Sample ³
• Sex
• Vendor Tracking Identifier ^1,3,4

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¹ The Joint Commission Only
² CMS Only
³ Transmission Data Element
⁴ These data elements are defined in the Transmission Data Dictionary within the National Hospital Quality Measure Data Transmission section of this manual.
⁵ Collected by CMS for patients with a Payment Source - Medicare.

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Data Integrity

Editing Zero Values

Verification mechanisms are necessary to assure that zero is the intended data value rather than an initialization value for those data elements which have an allowable value of zero (i.e., 0.0, 0000, 0).

Missing and Invalid Data

Each data element that is applicable per the algorithm for each of the measures within a topic must be “touched” by the abstractor. While this is the expectation, it is recognized that in certain situations information may not be available (e.g., dates, times, codes, etc.). After due diligence in reviewing all allowable data sources within the medical record, if the abstractor determines that a value is not documented, i.e. “missing,” or is unable to determine if a value is documented, the abstractor should select the “UTD - Unable to Determine,” value. The data elements Admission Date, Discharge Date and Birthdate require an actual date for submission into the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse, and “UTD” cannot be selected as an allowable value. For Yes/No values the allowable value “No” incorporates the “UTD” into the definition. For data elements containing more than two categorical values and for numerical data elements (i.e., dates, times, laboratory values, etc.), a “UTD” option is included as an allowable value and is classified in the same category as not documented. Files that contain any invalid and/or missing data will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. For additional details on the proper handling of missing and/or invalid data, please refer to the Missing and Invalid Data section of this manual.

Interpreting Data Element Definitions and Allowable Values

Every attempt has been made to comprehensively define the national quality measure data elements and allowable values in a manner that obviates the need for interpretation. If, after reviewing the General Abstraction Guidelines, the data element definition, including the notes and guidelines for abstraction, an abstractor cannot clearly assign an allowable value, refer to the Resource section of this manual for additional contact information.

Interpretation of Data Dictionary Terms

Data elements fall into three broad categories in order to support a specific measure set. They include:

• General Data Elements – data elements that must be collected by hospitals for each patient record
  • data elements required for each episode of care (EOC) record submitted
  • data elements used to identify the hospital on each patient record required for each patient-level record submitted
  • patient demographic data required for each episode of care record submitted and used for risk adjustment analysis (where applicable)
• Measure-Specific Data Elements – data elements used by one specific measure or several measures in one specific measure set, such as the heart failure measures
• Algorithm Output Data Elements (The Joint Commission only)– Refer to ORYX Technical guide

Data Element Dictionary Terms

Term	Definition
Data Element Name:	A short phrase identifying the data element.
Collected For:	Identifies the measure(s) that utilize this data element or specifies that the data element is used for data transmission or verification.
Definition:	A detailed explanation of the data element. A measurement system may include this information in data collection software.
Suggested Data Collection Question:	A suggested wording for a data element question in a data abstraction tool.
Format:	Length = number of characters or digits allowed for the data element Type = type of information the data element contains (i.e., numeric, alphanumeric, date, decimal, or time) Occurs = the number of times the data element occurs in a single episode of care record
Allowable Values:	A list of acceptable responses for this data element
Notes for Abstraction:	Provided to assist abstractor in the selection of appropriate value for a data element
Suggested Data Sources:	Source document from which data can be identified such as administrative or medical record. Some data elements also list excluded data sources that are unacceptable sources for collecting information.
Guidelines for Abstraction:	Designed to assist abstractors in determining how a data element should be answered Note: Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

General Abstraction Guidelines

The General Abstraction Guidelines are a resource designed to assist abstractors in determining how a question should be answered. The abstractor should first refer to the specific notes and guidelines under each data element. These instructions should take precedence over the following General Abstraction Guidelines. All of the allowable values for a given data element are outlined, and notes and guidelines are often included which provide the necessary direction for abstracting a data element. It is important to utilize the information found in the notes and guidelines when entering or selecting the most appropriate answer.

Medical Record Documentation

Documentation which is dated/timed after discharge should not be used unless it was added during the hospital’s normal course of completing a medical record (e.g., discharge summary, diagnosis and procedure coding) per organization policy or within 30 days after discharge, whichever is sooner. (Refer to the Medicare Conditions of Participation for Medical Records, 42CFR428.24(c)(2)(viii).)

Important Note: There are several data elements where abstraction of data from documentation dated/timed after discharge is restricted, and these exceptions are published on the respective data element pages of the data dictionary. Data element specific notes and guidelines always take precedence over the General Abstraction Guidelines.

All documentation in the medical record must be legible and complete. (Refer to the Medicare Conditions of Participation for Medical Records 42CFR428.24(c)(1).) When abstracting a medical record, if a handwritten document is determined to be not legible, other documentation should be reviewed in an attempt to obtain the answer. If no other source document is able to verify the handwritten documentation, only then is the abstractor to answer unable to determine from the medical record documentation, unless otherwise specified.

Data element information should be retrieved from the current medical record, covering the admission and discharge date being abstracted. Information ascertainable from previous testing (e.g., left ventricular ejection fraction) or previous history (e.g., medication contraindications) AND determined to be part of the current medical record may be used in abstraction. For example, if the patient had a previous left ventricular function assessment and this information is available in the current chart being abstracted (e.g., a note made in the progress notes, a previous echo report, or an electronic document), this information should be used. Previous testing or history information used in abstraction should be information that was part of the medical record during hospitalization, when care was being delivered.

The medical record must be abstracted as documented (taken at “face value”). When the value documented is obviously in error (not a valid format/range or outside of the parameters for the data element) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Example:

• Documentation indicates the Antibiotic Administration Time was 3300. No other documentation in the medical record provides a valid time. Since the Antibiotic Administration Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
• Patient expires on 02-12-2008 and documentation indicates the Antibiotic Administration Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”

For those hospitals that have transitioned from a paper-based medical record to an electronic health record (EHR), there should be a policy on what constitutes a current medical record in their EHR environment.

Please note that for auditing/validation purposes, hospitals will need to provide a paper copy of the current medical record in its entirety, including definitions of symbols/abbreviations used and all previous testing or history documents used in abstraction.

Suggested Data Sources

• Suggested Data Sources are listed in alphabetical order, NOT priority order, unless otherwise specified.

Suggested Data Sources are designed to provide guidance to the abstractor as to the locations/sources where the information needed to abstract a data element will likely be found. However, the abstractor is not limited to these sources for abstracting the information and is encouraged to review the entire medical record

• In some instances, a data element may restrict the sources that may be used to gain the information (e.g., LVF Assessment). If so, these sources will be identified and labeled as “Excluded Data Sources.”
• In the course of abstraction, if conflicting information is found in a source other than the suggested data sources, and use of this source is not restricted, consider using this information if it more accurately answers the question, unless otherwise specified.

Example:

The nursing notes state the patient was discharged to a nursing facility, and the social services notes states the patient was discharged to a nursing facility for assisted living. The social services notes, while not listed as a suggested data source, more accurately describes the discharge status and should be used for abstracting the discharge status.

• If, after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select “Unable to Determine (UTD)” as the answer.
• Hospitals often label forms and reports with unique names or titles. Suggested Data Sources are listed by commonly used titles; however, information may be abstracted from any source that is equivalent to those listed.

Example:

If the “nursing admission assessment” is listed as a suggested source, an acceptable alternative might be titled “nurses initial assessment” or “nursing data base.”
Note:
Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

Inclusions/Exclusions

• Inclusions are “acceptable terms” that should be abstracted as positive findings (e.g., “Yes”).
• Inclusion lists are limited to those terms that are believed to be most commonly used in medical record documentation. The list of inclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are “unacceptable terms” that should be abstracted as negative findings (e.g., “No”)
• Exclusion lists are limited to those terms an abstractor may most frequently question whether or not to abstract as a positive finding for a particular element (e.g., “cardiomyopathy” is an unacceptable term for heart failure and should be abstracted as "No"). The list of exclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the inclusion takes precedence over the exclusion and would be abstracted as a positive finding (e.g., answer “Yes”), unless otherwise specified.

Physician/Advanced Practice Nurse/ Physician Assistant Documentation

• Advanced Practice Nurse (APN, APRN) titles may vary between state and clinical specialities. Some common titles that represent the advanced practice nurse role are:
  • Nurse Practitioner (NP)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Clinical Nurse Specialist (CNS)
  • Certified Nurse Midwife (CNM)
• When a physician/advanced practice nurse/ physician assistant (physician/APN/PA) signs a form or report (e.g., ED sheet with triage and nursing information and a physician/APN/PA has signed somewhere on the form), information on that form/report should be considered physician/APN/PA documentation.
• Resident and intern notes should be considered physician documentation. Medical student notes must be co-signed by a physician.

Pharmacist Documentation

Pharmacist titles may vary. Some common titles that represent the pharmacist role are:

• Doctor of Pharmacy (Pharm.D. or D.Ph.)
• Registered Pharmacist (R.Ph.)

Medications

• The approved medication tables contained in the dictionaries may not be inclusive lists of all available therapeutic agents acceptable for a particular data element. Discrepancies must be reported. See Appendix G (resource section) of this manual for contact information.
• Whether or not a medication has been administered to a patient is often clear when using medical record sources such as medication administration records, but documentation can be more ambiguous in other sources, namely, physician orders, ED records, and ambulance records. To make a determination using these sources, use the following criteria:
  • For EHRs only accept documentation that reflects the actual administration of the medication in the context of the chart.
  • If a medication in the physician orders has been initialed and signed off with a time, do NOT presume that the medication was administered. The documentation MUST indicate that the medication was actually given.
  • For an ED or ambulance record, there is no need for documentation indicating that the medication was actually given.

Example:

If the ED or ambulance record reflects “ASA 325mg po 13:00” and no other documentation exists indicating that the medication was actually given (e.g., “given” or “administered”), this is acceptable documentation to abstract.

• When determining whether or not a patient was discharged on a specific medication (e.g., a beta-blocker):
  • If discharge medications are noted using only references such as “continue home meds,” “continue previous medications,” “resume other meds,” “same medications,” or “continue meds,” rather than lists of the names of the discharge medications, the abstractor should select “Yes” if the patient was on the medication in question prior to arrival (or in the case of transfers from acute care hospitals, if the patient was on the medication in question prior to arrival at the first acute care hospital), unless documentation suggests otherwise.
  • If discharge medications are noted using only references such as “continue current medications” or “continue present meds” rather than lists of the names of the discharge medications, the abstractor should select “Yes” if the medication in question was listed as a medication on the day of discharge, unless documentation indicates it was to be discontinued at discharge or suggests otherwise.
  • If discharge medications are noted using general references such as “continue home meds,” “continue previous medications,” “continue current meds,” “continue present meds,” “resume other meds,” or “continue meds,” but a list of the names of the discharge medications also in the record gives conflicting information about what medications the patient was actually discharged on, the abstractor should consider the list most accurate and use only the list in determining whether or not a patient was discharged on a specific medication.

Diagnostic/Laboratory Tests

Whether or not a diagnostic or laboratory test has been done is usually clear when using medical record sources such as diagnostic test reports, laboratory reports, or progress notes (where a physician might note test findings), but documentation can be more ambiguous in other sources, namely, physician orders and ED records. To make a determination using these sources, use the following criteria:

• If a test in the physician orders has been initialed and signed off with a time, do NOT presume that the test was done. The documentation MUST indicate that the test was actually done (e.g., accompanied by a word such as “done”).
• For an ED record, there is no need for explicit documentation indicating that the test was actually done. For example, if an ED record notes “Lipid profile,” and this is followed by a signature and/or a time, the abstractor should presume the test was performed.

Grids

Instructions for reading values recorded on grids: Measure from the midpoint of the symbol, number and letter. If the value falls between two lines on the grid, abstract the earliest value.

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Alphabetical List of All Data Elements

Data Element Name	Collected For	Associated Measures
ABG Done		PN-1
ACEI Prescribed at Discharge		AMI-3, HF-3
ARB Prescribed at Discharge		AMI-3, HF-3
Active Clinical Staff		HCSS-1, HCSS-2, HCSS-3
Active Labor		PC-01
Admission Date	All Records	BM, HBIPS, PC, TAM
Admission Date-Stroke		STK-01, STK-02, STK-03, STK-04, STK-05, STK-06, STK-07, STK-10
Admission Type
Admission to NICU		PC-05
Admitted for Elective Carotid Endarterectomy	Joint Commission Only	STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Adult Smoking Counseling		AMI-4, HF-4, PN-4
Adult Smoking Counseling-Stroke		STK-9
Adult Smoking History		AMI-4, HF-4, PN-4
Adult Smoking History-Stroke		STK-9
Alcohol Use Status		TAM-05, TAM-06, TAM-07, TAM-08
Alcohol or Drug Dependence		TAM-07, TAM-08
Anesthesia Start Date		BM-06
Another Suspected Source of Infection		PN-6, PN-6a, PN-6b
Antenatal Steroid Administered		PC-03
Antibiotic Administration Date		PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Antibiotic Administration Route		PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Antibiotic Administration Time		PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Antibiotic Allergy		PN-6, PN-6a, PN-6b, SCIP-Inf-2
Antibiotic Name		PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Antibiotic Received		PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Antithrombotic Therapy Administered by End of Hospital Day Two		STK-5
Antithrombotic Therapy Prescribed at Discharge		STK-2
Appropriate Justification for Multiple Antipsychotic Medications		HBIPS-5
Arrival Date		AMI-1, AMI-6, AMI-7a, AMI-8, AMI-8a, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Arrival Date-Stroke		STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Arrival Time		AMI-7, AMI-7a, AMI-8, AMI-8a, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Arrival Time-Stroke		STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Aspirin Prescribed at Discharge		AMI-2
Aspirin Received Within 24 Hours Before or After Hospital Arrival		AMI-1
Assessed for Rehabilitation Services		STK-10
Assessment for Distress		BCC-01
Assessment for Fatigue		BCC-01
Atrial Fibrillation		STK-3
Background Check		HCSS-3
Beta-Blocker Current Medication		SCIP-Card-2
Beta-Blocker During Pregnancy		SCIP-Card-2
Beta-Blocker Perioperative		SCIP-Card-2
Beta-Blocker Prescribed at Discharge		AMI-5
Beta-Blocker Received Within 24 Hours After Hospital Arrival		AMI-6
Birth Weight	Risk Adjustment	PC-04
Birthdate	All Records	BM, HBIPS, PC
Birthdate	All Records	AMI, BCC, CAC, HF, PN, PR, SCIP, STK, TAM
Blood Culture Collected		PN-3a, PN-3b
Brief Intervention		TAM-06
CMS Certification Number	Transmission	HBIPS, PC
Case Identifier	Joint Commission Only	STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Chest X-Ray		PN-1, PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7
Cholesterol Reducing Therapy Prescribed at Discharge		STK-6
Cholesterol Reducing Therapy Prior To Hospitalization		STK-6
Clinical Indication for Plasma		BM-03
Clinical Indication for Platelets		BM-04a, BM-04b
Clinical Indication for Prophylactic Platelets
Clinical Indication for RBCs		BM-02
Clinical Staff		HCSS-1, HCSS-2, HCSS-3
Clinical Trial		PC-01, PC-02, PC-03, PC-04, PC-05
Cognitive Impairment		TAM-01, TAM-02, TAM-03, TAM-05, TAM-06, TAM-07
Comfort Measures Only		AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, AMI-T1a, AMI-T2, HF-1, HF-2, HF-3, HF-4, PN-1, PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7
Comfort Measures Only-Stroke		STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Competency		HCSS-3
Compromised		PN-6, PN-6a, PN-6b
Congenital Anomalies	Risk Adjustment
Consent Addressed Transfusion Benefits
Consent Addressed Transfusion Risks
Continuing Care Plan-Discharge Medications		HBIPS-6, HBIPS-7
Continuing Care Plan-Next Level of Care		HBIPS-6, HBIPS-7
Continuing Care Plan-Principal Discharge Diagnosis		HBIPS-6, HBIPS-7
Continuing Care Plan-Reason for Hospitalization		HBIPS-6, HBIPS-7
Contraindication to Systemic Corticosteroids	Joint Commission Only	CAC-2
Contraindication to Aspirin at Discharge		AMI-2
Contraindication to Aspirin on Arrival		AMI-1
Contraindication to Beta-Blocker - Perioperative		SCIP-Card-2
Contraindication to Beta-Blocker at Discharge		AMI-5
Contraindication to Beta-Blocker on Arrival		AMI-6
Contraindication to Both ACEI and ARB at Discharge		AMI-3, HF-3
Contraindication to Relievers	Joint Commission Only	CAC-1
Contraindication to VTE Prophylaxis		SCIP-VTE-1, SCIP-VTE-2
DVT Prophylaxis Initiated by End of Hospital Day 2		STK-1
Data Source	Transmission	TAM-01, TAM-02, TAM-03, TAM-04, TAM-05, TAM-06, TAM-07, TAM-08
Date
Date IV Thrombolytic Therapy Administered At This Hospital		STK-4
Date Last Known Well		STK-4
Date of Infection		SCIP-Inf-3
Diagnostic Uncertainty		PN-5, PN-5b, PN-5c
Discharge Date	All Records	AMI, CAC, HF, PN, PR, SCIP, STK, TAM
Discharge Date	All Records	BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC
Discharge Instructions Address Activity		HF-1
Discharge Instructions Address Diet		HF-1
Discharge Instructions Address Follow-up		HF-1
Discharge Instructions Address Medications		HF-1
Discharge Instructions Address Symptoms Worsening		HF-1
Discharge Instructions Address Weight Monitoring		HF-1
Discharge Status	All Records	AMI, CAC, HF, PN, PR, SCIP
Discharge Status	All Records	BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-03, TAM-04, TAM-07, TAM-08
Discharge Status-Stroke		STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Do Not Return - Clinical		HCSS-1
Do Not Return - Professional		HCSS-2
Do Not Return Occurrence Identifier		HCSS-1, HCSS-2
Dysphagia Screen		STK-7
Education Addressed Risks, Benefits and Alternatives to Transfusion		BM-01
Education Addresses Activation of Emergency Medical System		STK-8
Education Addresses Follow-up After Discharge		STK-8
Education Addresses Medication Prescribed		STK-8
Education Addresses Risk Factors for Stroke		STK-8
Education Addresses Warning Signs and Symptoms of Stroke		STK-8
Elective Surgery		BM-06, BM-07
Emergency Order Date
Emergency Order Time
Emergency Transfusion
Emergency Transfusion Date
Emergency Transfusion Time
Event Date	All Records	HBIPS-2, HBIPS-3
Event Type	All Records	HBIPS-2, HBIPS-3
Exclusive Breast Milk Feeding		PC-05
Fibrinolytic Administration		AMI-7, AMI-7a, AMI-8, AMI-8a
Fibrinolytic Administration Date		AMI-7, AMI-7a
Fibrinolytic Administration Time		AMI-7, AMI-7a
First In-Hospital LDL-Cholesterol Qualitative Description		AMI-T2
First In-Hospital LDL-Cholesterol Value		AMI-T2
First Name	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP
First PCI Date		AMI-8, AMI-8a
First PCI Time		AMI-8, AMI-8a
Follow-up Contact		TAM-04, TAM-08
Follow-up Contact Date (test data element)		TAM-04, TAM-08
Gestational Age		PC-01, PC-02, PC-03
Glucose POD 1		SCIP-Inf-4
Glucose POD 2		SCIP-Inf-4
Health Care Organization Identifier	Transmission, Aggregate Data File, Patient Population Data File	HBIPS, PC
Health Status		HCSS-3
Healthcare Associated PN		PN-6, PN-6a, PN-6b
Hispanic Ethnicity	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP, STK
Home Management Plan of Care Document Addresses Arrangements for Follow-up Care	Joint Commission Only	CAC-3
Home Management Plan of Care Document Addresses Environmental Control and Control of Other Triggers	Joint Commission Only	CAC-3
Home Management Plan of Care Document Addresses Methods and Timing of Rescue Actions	Joint Commission Only	CAC-3
Home Management Plan of Care Document Addresses Use of Controllers	Joint Commission Only	CAC-3
Home Management Plan of Care Document Addresses Use of Relievers	Joint Commission Only	CAC-3
Home Management Plan of Care Document Given to Patient/Caregiver	Joint Commission Only	CAC-3
Home Management Plan of Care Document Present	Joint Commission Only	CAC-3
Hospital Patient Identifier	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP
Hours Worked		HCSS-1, HCSS-2
ICD Population Size	Transmission, Aggregate Data File
ICD-9-CM Other Diagnosis Codes	All Records	BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-02, TAM-03, TAM-07
ICD-9-CM Other Procedure Codes	All Records	BM, HBIPS, PC
ICD-9-CM Other Procedure Dates	All Records	BM, HBIPS, PC
ICD-9-CM Principal Diagnosis Code	All Records	BM, HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7, PC, TAM-02, TAM-03, TAM-07
ICD-9-CM Principal Procedure Code	All Records	BM, HBIPS, PC
ICD-9-CM Principal Procedure Date	All Records	BM, HBIPS, PC
ICU Transfer or Admission Within First 24 Hours		PN-3a, PN-6, PN-6a, PN-6b
IV Thrombolytic Therapy Administered		STK-4
Identified Pathogen		PN-6, PN-6a, PN-6b
In-Hospital LDL-Cholesterol Test		AMI-T1a, AMI-T2
Infection Prior to Anesthesia		SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7
Influenza Vaccination Status		PN-7
Initial Blood Culture Collection Date		PN-3a, PN-3b
Initial Blood Culture Collection Time		PN-3a, PN-3b
Initial ECG Interpretation		AMI-7, AMI-7a, AMI-8, AMI-8a
Initial Patient Population Size – Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Initial Patient Population Size – Non-Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Job Appropriate Credentials		HCSS-3
Joint Revision		SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
LDL ≥ 100 mg/dL		STK-6
LVF Assessment		HF-2
LVSD		AMI-3, HF-3
Laparoscope		SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, SCIP-VTE-1, SCIP-VTE-2
Last Name	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP
Lipid-Lowering Agent Prescribed at Discharge		AMI-T2
Measure Category Assignment	Calculation, Transmission, Hospital Clinical Data File	HBIPS, PC
Measure Category Assignment	Joint Commission Only, Calculation, Transmission, Hospital Clinical Data File	AMI, CAC, HF, PN, PR, SCIP
Measure Set	Transmission, Patient Population Data File, Hospital Clinical Data File	HBIPS, PC
Measurement Value	Calculation, Transmission, Hospital Clinical Data File	HBIPS, PC
Minutes of Physical Restraint		HBIPS-2
Minutes of Seclusion		HBIPS-3
Multiple Births	Risk Adjustment
NPO (Nothing by Mouth) For Entire Hospital Stay		STK-7
National Provider Identifier	Transmission	HBIPS, PC
Neuraxial Anesthesia		SCIP-VTE-1, SCIP-VTE-2
Newborn Admission Source		PC-04, PC-05
Non-Primary PCI		AMI-8, AMI-8a
Number of Antipsychotic Medications Prescribed at Discharge		HBIPS-4, HBIPS-5
Number of Cases with UTD Allowable Values	Transmission, Aggregate Data File
Number of Rejected Cases	Transmission, Aggregate Data File
Oral Antibiotics		SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3
Other Surgeries		SCIP-Inf-1, SCIP-Inf-3
Parity		PC-02
Patient Ambulatory at End of Hospital Day Two		STK-1
Patient Discharged on Anticoagulation Therapy		STK-3
Patient HIC#	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP
Patient ID Verification		BM-05
Patient Referral to Next Level of Care Provider		HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7
Patient Strengths		HBIPS-1
Payment Source	All Records	HBIPS, PC
Performance Measure Identifier	Transmission, Aggregate Data File
Performance Measurement System Identifier	Transmission, Aggregate Data File
Perioperative Death		SCIP-Card-2, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7
Personnel File Record Identifier		HCSS-3
Physician 1	All Records, Optional for All Records	AMI, CAC, HF, PN, PR, SCIP
Physician 2	All Records, Optional for All Records	AMI, CAC, HF, PN, SCIP
Plan for LDL-Cholesterol Test		AMI-T1a
Plasma Event ID		BM-03, BM-05
Plasma Event Total Doses		BM-03
Platelet Event ID		BM-04a, BM-04b, BM-05
Platelet Event Total Doses		BM-04a, BM-04b
Pneumococcal Vaccination Status		PN-2
Pneumonia Diagnosis: ED/Direct Admit		PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Point of Origin for Admission or Visit	All Records	AMI, CAC, HF, PN, PR, SCIP
Point of Origin for Admission or Visit	All Records
Point of Origin for Admission or Visit-Stroke	CMS Only	STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Postal Code	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP
Postoperative Infections		SCIP-Inf-3
Pre-Arrival LDL-Cholesterol Qualitative Description		AMI-T1a, AMI-T2
Pre-Arrival LDL-Cholesterol Test		AMI-T1a, AMI-T2
Pre-Arrival LDL-Cholesterol Value		AMI-T1a, AMI-T2
Pre-Arrival Lipid-Lowering Agent		AMI-T1a
Pre-transfusion Hematocrit		BM-02
Pre-transfusion Hemoglobin		BM-02
Pre-transfusion Hemoglobin
Pre-transfusion Hemoglobin
Pre-transfusion Laboratory Testing		BM-03
Pre-transfusion Platelet Count
Pre-transfusion Platelet Count		BM-04a, BM-04b
Pre-transfusion Platelet Testing		BM-04a
Preadmission Warfarin		SCIP-VTE-1, SCIP-VTE-2
Predicted Value	Transmission, Risk Adjustment, Hospital Clinical Data File	PC
Preoperative Anemia Screening		BM-06
Preoperative Anemia Screening Date		BM-06
Preoperative Anemia Screening Hematocrit Result
Preoperative Anemia Screening Hemoglobin Result
Preoperative Blood Type Testing		BM-07
Preoperative Hair Removal		SCIP-Inf-6
Prescription for Alcohol or Drug Dependence Medication		TAM-07
Prescription for Tobacco Cessation Medication		TAM-03
Provider ID	Transmission
Provider ID	CMS Only, Transmission, CMS Transmission	AMI, CAC, HF, PN, PR, SCIP
Pseudomonas Risk		PN-6, PN-6a, PN-6b
Psychiatric Care Setting	All Records	HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7
Psychiatric Inpatient Days - Medicare Only		HBIPS-2, HBIPS-3
Psychiatric Inpatient Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Psychological Trauma History		HBIPS-1
Pulse Oximetry Done		PN-1
RBC Event ID		BM-02, BM-05
RBC Event Total Doses		BM-02
Race	All Records, CMS Only	AMI, CAC, HF, PN, PR, SCIP, STK
Reason for Delay in Fibrinolytic Therapy		AMI-7, AMI-7a
Reason for Delay in PCI		AMI-8, AMI-8a
Reason for No LDL-Cholesterol Testing		AMI-T1a
Reason for No Lipid-Lowering Therapy		AMI-T2
Reason for No Tobacco Cessation Medication During the Hospital Stay		TAM-02
Reason for No Tobacco Cessation Medication at Discharge		TAM-03
Reason for Not Administering Antenatal Steroid		PC-03
Reason for Not Exclusively Feeding Breast Milk		PC-05
Referral for Addictions Treatment		TAM-07
Referral for Outpatient Tobacco Cessation Counseling		TAM-03
Relievers Administered	Joint Commission Only	CAC-1
Report Period	Joint Commission Only	STK-1, STK-10, STK-2, STK-3, STK-4, STK-5, STK-6, STK-7, STK-8, STK-9
Risk Factors for Drug-Resistant Pneumococcus		PN-6, PN-6b
Sample	Transmission, Aggregate Data File, Hospital Clinical Data File	HBIPS, PC
Sample Size – Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Sample Size – Non-Medicare Only	Transmission, Patient Population Data File	HBIPS, PC
Sampling Frequency	Transmission, Patient Population Data File	HBIPS, PC
Sex	All Records	BCC, BM, HBIPS, PC
Spontaneous Rupture of Membranes		PC-01
Substance Use		HBIPS-1
Substance Use Status Post-Discharge		TAM-08
Surgery End Date		SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-VTE-1, SCIP-VTE-2
Surgery End Time		SCIP-Inf-2, SCIP-Inf-3, SCIP-VTE-1, SCIP-VTE-2
Surgery Start Date		SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, SCIP-VTE-1, SCIP-VTE-2
Surgical Incision Time		SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-VTE-1, SCIP-VTE-2
Surgical Procedure		BM-04b
Systemic Corticosteroids Administered	Joint Commission Only	CAC-2
Temperature Value		SCIP-Inf-7
Time IV Thrombolytic Therapy Administered at This Hospital		STK-4
Time Last Known Well		STK-4
Tobacco Use Status		TAM-01, TAM-02, TAM-03, TAM-04
Tobacco Use Status Post-Discharge (test data element)		TAM-04
Tobacco Use Treatment
Tobacco Use Treatment FDA-Approved Cessation Medication		TAM-02
Tobacco Use Treatment Practical Counseling		TAM-02
Total Leave Days - Medicare Only		HBIPS-2, HBIPS-3
Total Leave Days-Non-Medicare Only		HBIPS-2, HBIPS-3
Transfer From Another ED		AMI-1, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Transfusion Consent		BM-01
Transfusion Order		BM-05
Transfusion Start Date		BM-05
Transfusion Start Time		BM-05
Transfusion Type
Unique Blinded Case Identifier	All Records	BCC, BM, TAM
Unique Blinded Health Care Organization Identifier
VTE Prophylaxis		SCIP-VTE-1, SCIP-VTE-2
VTE Timely		SCIP-VTE-2
Vancomycin		SCIP-Inf-2
Vendor Tracking Identifier	Transmission, Hospital Clinical Data File	HBIPS, PC
Violence Risk to Others		HBIPS-1
Violence Risk to Self		HBIPS-1
Vital Sign Monitoring		BM-05

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Related Topics

Related Topics
a. Table of Contents
j1. Transmission Alphabetical Data Dictionary