Release Notes:
Data Element
Version 2010B
| Data Element Name: | In-Hospital LDL-Cholesterol Test |
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| Collected For: | AMI-T1a, AMI-T2, , (CMS Optional Test Measure) |
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| Definition: | LDL-cholesterol (LDL-c) test performed during this hospital stay.
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| Suggested Data Collection Question: | Was an LDL-cholesterol (LDL-c) test performed during this hospital stay? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) LDL-c test was performed during this hospital stay.
N (No) LDL-c test was not performed during this hospital stay or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- In the absence of explicit documentation that an LDL-c test was or was not performed during this hospital stay, it should be inferred that a test was done if:
- There is documentation of an LDL-c value from a test performed during this hospital stay, or
- There is physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation which qualitatively describes the results of an LDL-c test performed during this hospital stay (e.g., “lipids elevated”), or
- There is documentation that lipid testing was performed during this hospital stay.
- Do not include an LDL-c value, LDL-c qualitative description, or lipid testing if it cannot be determined that the testing was actually done during this hospital stay.
Examples:
- “Impression: Elevated cholesterol” noted in consultation report done on day of admission
- “Hypercholesterolemia” noted as discharge diagnosis in discharge summary, with no evidence that any lipid testing was done during the hospital stay
- Physician/APN/PA writes “Labs within normal range except for cholesterol,” with no evidence that any lipid testing was done during the hospital stay.
- Do not include lipid testing or qualitative descriptions of lipid test results if it can be determined that LDL-c measurement was not part of the lipid testing.
Examples:
- “Lipid profile done on day 2” per discharge summary, but the laboratory report lists only cholesterol and triglyceride values. Physician/APN/PA notes “Labs: elevated cholesterol,” but the laboratory report lists only a total cholesterol value
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Laboratory report
- Progress notes
- Discharge summary
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
LDL-cholesterol (LDL-c)
- Low den lipoprotein
- Low density lipoprotein (LDL)
Qualitative description of LDL-c test results
- Cholesterol level qualitatively described (e.g., low, normal, elevated, ↑)
- Dyslipidemia (presence or absence)
- Dyslipoproteinemia (presence or absence)
- Hyperbetalipoproteinemia (presence or absence)
- Hypercholesterolemia (presence or absence)
- Hyperlipemia (presence or absence)
- Hyperlipidemia (presence or absence)
- Hyperlipoproteinemia (presence or absence)
- LDL level qualitatively described (e.g., low, normal, elevated, above goal, below Target, ↑)
- LDL-cholesterol (LDL-c) level qualitatively described (e.g., low, normal, elevated, ↑)
- Lipid levels qualitatively described (e.g., low, normal, elevated, ↑)
Lipid testing
- Cholesterol analysis
- Cholesterol check ( ✓ )
- Cholesterol panel
- Cholesterol profile
- Cholesterol testing
- Fasting lipids
- LDL: HDL
- LDL: HDL ratio
- Lipid analysis
- Lipid check (✓)
- Lipid panel
- Lipid profile
- Lipids
- Lipoprotein analysis
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LDL-cholesterol
VLDL (very low density lipoprotein)
Qualitative description of LDL-c test results
Alpha lipoproteinemia (presence or absence)
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In-Hospital LDL-Cholesterol Test
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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