Release Notes:
Data Element
Version 2010B
| Data Element Name: | Surgery Start Date |
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| Collected For: | SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, , , |
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| Definition: | The date the principal procedure started. |
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| Suggested Data Collection Question: | On what date did the principal procedure start? |
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| Format: | | Length: | 10 – MM-DD-YYYY (includes dashes) or UTD |
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| Type: | Date |
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| Occurs: | 1 |
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| Allowable Values: |
MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (2000-9999)
UTD = Unable to Determine
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| Notes for Abstraction: |
- If the principal procedure start date 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 parameters of care [after Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
Examples:
- Documentation indicates the Surgery Start Date was 02- 42 -2008. No other documentation in the medical record provides a valid date. Since the Surgery Start 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 documentation indicates the Surgery Start Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Surgery Start Date is outside of the parameter of care (after the Discharge Date [death]), 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 Surgery Start Date allows the case to be accepted into the warehouse.
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| Suggested Data Sources: |
- Anesthesia record
- Preop checklist
- Operating room notes
- Operative report
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| Additional Notes: |
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| Guidelines for Abstraction: |
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Surgery Start Date
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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