• If the date of arrival is unable to be determined from medical record documentation, select “UTD.”
• The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid format/range or outside of the parameters of care [after the _Discharge Date_]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
  Examples:
  • Documentation indicates the Arrival Date was 03- 42 -2008. No other documentation in the list of ONLY ACCEPTABLE SOURCES provides a valid date. Since the Arrival Date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD.”
  • Patient expires on 02-12-2008 and all documentation within the ONLY ACCEPTABLE SOURCES indicates the Arrival Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”
    Note:
    Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Arrival Date allows the case to be accepted into the warehouse.
• Review only the acceptable sources to determine the earliest date the patient arrived at the hospital. This may differ from the admission date.
  Note:
  Medical record documentation from all of the “only acceptable sources” should be carefully examined in determining the most correct date of arrival. Arrival date should NOT be abstracted simply as the earliest date in the acceptable sources, without regard to other (i.e., ancillary services) substantiating documentation. If documentation suggests that the earliest date in the acceptable sources does not reflect the date the patient arrived at the hospital, this date should not be used.
• When reviewing ED records do NOT include any documentation from external sources (e.g., ambulance records, physician/advanced practice nurse/physician assistant [physician/APN/PA] office record, laboratory reports or ECGs) obtained prior to arrival. The intent is to utilize any documentation, which reflects processes that occurred in the ED or hospital.
• If the patient is in an outpatient setting of the hospital (e.g., undergoing dialysis, chemotherapy, cardiac cath) and is subsequently admitted to the hospital, use the date the patient presents to the ED or arrives on the floor for inpatient care as arrival date.
• If the patient is a “Direct Admit” to the cath lab, as a transfer from another ED or acute care hospital, use the date the patient presents to the cath lab as the arrival date.
• For “Direct Admits” to the hospital, use the earliest date the patient arrives at the hospital.
• The source “Any ED documentation” includes ED vital sign record, ED/Outpatient Registration form, triage record and ECG reports, laboratory reports, x-ray reports, etc., if these ancillary services were rendered while the patient was an ED patient.
• The source “Procedure notes” refers to formal documents that describe a procedure that was done (e.g., endoscopy, cardiac cath). ECG and x-ray reports should NOT be considered procedures notes.

ONLY ACCEPTABLE SOURCES

• Vital signs graphic record
• Procedure notes
• Any ED documentation
• Nursing admission assessment/admitting note
• Observation record

• Face sheet