NOTE: Refer also to data element Postoperative Infections for further clarification. Date of Infection should reflect the first time there is documentation that the patient has an infection following the principal procedure.

• If the date of the infection is unable to be determined from medical record documentation, enter 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 parameter of care [after Discharge Date] or the parameter for this data element [before the Surgery Start Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
  Examples:
  • Documentation indicates the Date of Infection was 02- 42 -2008. No other documentation in the medical record provides a valid date. Since the Date of Infection 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 documentation indicates the Date of Infection was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Date of Infection 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 Date of Infection allows the case to be accepted into the warehouse.

• Consultation notes
• Progress notes
• Discharge summary