Release Notes:
Data Element
Version 2010B
| Data Element Name: | Pre-Arrival LDL-Cholesterol Value |
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| Collected For: | AMI-T1a, AMI-T2, , (CMS Optional Test Measures) |
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| Definition: | LDL-c cholesterol (LDL-c) value from test done in the past year.
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| Suggested Data Collection Question: | What is the patient’s LDL-cholesterol (LDL-c), in mg/dL or mg/100 ml, from the LDL-c test performed within one year prior to hospital arrival? |
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| Format: | | Length: | 3 or UTD |
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| Type: | Numeric |
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| Occurs: | 1 |
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| Allowable Values: |
- Enter the patient’s LDL-c value, in mg/dL or mg/100 ml, from the LDL-c test performed within one year prior to hospital arrival.
- UTD = Unable to Determine
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| Notes for Abstraction: |
- When more than one LDL-c value from the past year is documented, enter the LDL-c from the test performed closest to the time of hospital arrival. If unable to determine which value was drawn closest to hospital arrival time, enter the highest value.
- Direct and calculated (indirect) LDL-c values are acceptable. If both direct and calculated LDL-c values are documented for the same specimen date/time, enter the direct LDL-c value.
- If the indirect LDL-c is reported as not calculated because high triglycerides render the LDL-c calculation inaccurate, consider the calculated LDL-c value equal to 0 (zero).
- If an LDL-c value on the pre-arrival laboratory report conflicts with that from another source of documentation for the same specimen, enter the value from the laboratory report.
- If a pre-arrival laboratory report documents discrepant LDL-c values for the same specimen, enter the highest value.
- If sources other than a laboratory report document discrepant LDL-c values for the same specimen, enter the highest value.
- Disregard LDL-c values reported in units of mmol/L or any other unit of measurement other than mg/dL or mg/100 ml. If the unit of measurement is not documented, assume the unit of measurement is mg/dL.
- If an LDL-c value from the LDL-c test performed within one year prior to hospital arrival is not documented or if unable to determine from medical record documentation (e.g., LDL-c testing was done within the past year but no values are available), enter UTD.
- The medical record must be abstracted as documented (taken at “face value”). When the value documented is obviously in error (not a valid number or greater than 999) and no other documentation is found that provides this information, the abstractor should select “UTD.”
Example:
Documentation indicates the Pre-Arrival LDL-Cholesterol Value was 1000 mg/dL. No other documention in the medical provides a valid value. Since the Pre-Arrival LDL-Cholesterol Value is outside of the range listed in the Format Length (greater than 999), it is not a valid value and the abstractor should select “UTD.”
Note:
Transmission of a case with an invalid value will be rejected from the QIO Clinical Warehouse. Use of “UTD” for Pre-Arrival LDL-Cholesterol Value allows the case to be accepted into the warehouse.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
- Pre-arrival laboratory reports
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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)
- Value described as “bad cholesterol”
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LDL-cholesterol (LDL-c)
LDL (very low density lipoprotein)
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Pre-Arrival LDL-Cholesterol Value
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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