Home » Surgical Incision Time
 Print this page

Release Notes:
Data Element
Version 2010B

Data Element Name: Surgical Incision Time
Collected For: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, , ,
Definition:The time the initial incision was made for the principal procedure.
Suggested Data Collection Question:At what time was the initial incision made for the principal procedure?
Format:
Length:5 - HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format.
With the exception of Midnight and Noon:

  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:
Midnight - 00:00      Noon - 12:00
5:31 am - 05:31     5:31 pm - 17:31
11:59 am - 11:59    11:59 pm - 23:59

Note:
00:00 = midnight. If your electronic system documents time as 00:00 11-24-2007, review supporting documentation to determine if the Surgery Start Date should remain 11-24-2007 or if it should be converted to 11-25-2007. When converting 24:00 to 00:00 do not forget to change the Surgery Start Date.
Example:
Midnight or 24:00 on 11-24-2007 = 00:00 on 11-25-2007

Notes for Abstraction:
  • For times that include “seconds,” remove the seconds and record the time as is.
    Example:
    15:00:35 would be recorded as 15:00
  • If the initial incision time 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 time documented is obviously in error (not a valid time/format) and no other documentation is found that provides this information, the abstractor should select “UTD.”
    Example:
    Documentation indicates the Surgical Incision Time was 3300. No other documentation in the medical record provides a valid time. Since the Surgical Incision Time is outside of the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
    Note:
    Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Surgical Incision Time allows the case to be accepted into the warehouse.
  • If multiple procedures occur during the same surgical episode, and the Principal Procedure is not the first of those, the Surgical Incision Time captured will be the incision that occurs first, and the Surgery End Time will be the end time that occurs last.
    EXCEPTION:
    If a patient has a cystoscopy with stent placement prior to the Principal Procedure and antibiotics were given prior to this procedure, use the Surgery Start/Begin Time (or other synonym) for the cystoscopy.
  • Follow the priority order within the Inclusion List of this data element’s Guidelines for Abstraction:
    1. First, review all sources for any of the first priority synonyms for Surgical Incision Time. If multiple times are found, select the earliest time among the first priority synonyms.
    2. Next, if none of the first priority synonyms are documented, go to the second priority list of synonyms for Surgical Incision Time. If multiple times are found, select the earliest time among the second priority synonyms.
    3. Finally, if none of the first and second priority synonyms are documented, go to the third priority list of synonyms for Surgical Incision Time. If multiple times are found, select the earliest time among the third priority synonyms.
      Note:
      Priority order applies to items in inclusion table, not to source document.
      Also, please note the synonyms in the lists are alphabetized, not prioritized.
Suggested Data Sources:
  • Anesthesia record
  • Operative report
  • Circulation record/OR nurses record
    • Additional Notes:
    Guidelines for Abstraction:
    Inclusion Exclusion
    Follow the priority order below.
    If multiple times are found, use earliest time among the highest priority.

    First priority:

    • Begin time
    • Incision time
    • Operation start time
    • Procedure start time
    • Start of surgery (SOS)
    • Surgery start time
    • Symbol used on grid and indicated in legend to be incision time

    Second priority:

    • Chest time
    • Leg time
    • Skin time
    • Sternotomy time

    Third priority:

    • Anesthesia begin time
    • Anesthesia start time
    • Operating room start time
    • None

    Surgical Incision Time
    Specifications Manual for Joint Commission National Quality Core Measures (2010B)
    Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
    Questions? Ask Question to Joint Commission staff Copyright © 2010 by The Joint Commission.