• If there is documentation anywhere in the ONLY ACCEPTABLE SOURCES that the patient either currently smokes or is an ex-smoker that quit less than one year prior to hospitalization, select “Yes,” regardless of whether or not there is conflicting documentation. In all other cases, “No” should be selected.
• Classify a form as a nursing admission assessment if the content is typical of nursing admission assessments (e.g., med/surg/social history, current meds, allergies, physical assessment) AND the form is completed/reviewed by a nurse or labeled as a “nursing” form.
• For the History and physical (H&P) source, use only the H&P report for the current admission. The H&P may be a dictated report, a handwritten report on an H&P form, or a separate entry labeled as the H&P in the progress notes. Additional documentation such as a "history" or "physical" existing only as a sub-section within a progress note or consultation note should NOT be used.
• Disregard documentation of smoking history or history of tobacco use if current smoking status or timeframe that patient quit is not defined (e.g., “20 pk/yr smoking history”, “History of tobacco abuse”).
• If there is documentation of current smoking or tobacco use, or smoking or tobacco use within one year prior to arrival, and the type of product is not specified, assume this refers to cigarette smoking and select “Yes.”
• Do not include documentation of smoking history referenced as a “risk factor” (e.g., “risk factor: tobacco,” “risk factor: smoking,” “risk factor: smoker”), where current smoking status is indeterminable.

ONLY ACCEPTABLE SOURCES

• Emergency department record
• History and Physical
• Nursing admission assessment
• Respiratory therapy notes
• Nursing admission notes

Excluded Data Sources:

• Documentation from a transferring facility or a previous admission