Release Notes:
Data Element
Version 2010B
| Data Element Name: | Neuraxial Anesthesia |
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| Collected For: | , , |
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| Definition: | Documentation that the patient received neuraxial anesthesia for the surgical procedure. Neuraxial anesthesia is medication administered into the epidural space or spinal canal to block sensations of pain. |
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| Suggested Data Collection Question: | Is there documentation that the patient received neuraxial anesthesia for the surgical procedure? |
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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) There is documentation that the patient received neuraxial anesthesia for the surgical procedure.
N (No) There is no documentation that the patient received neuraxial anesthesia for the surgical procedure or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Neuraxial anesthesia may be administered via an epidural (injected into the epidural space) or spinal (usually injected into the cerebrospinal fluid) route
- If an epidural catheter is placed preoperatively for anesthesia or up to 24 hours after Surgery End Time for postoperative pain control, select “Yes”.
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| Suggested Data Sources: |
- Anesthesia record
- Operative report
- Procedure notes
- Medication administration record (MAR)
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Epidural
- Intrathecal anesthesia
- Spinal anesthesia
- Subarachnoid block
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- MAC (monitored anesthesia care)
- Peripheral catheter blocks
- Peripheral nerve blocks
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Neuraxial Anesthesia
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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