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Release Notes:
Data Element
Version 2010B1

Data Element Name: Gestational Age
Collected For: PC-01, PC-02, PC-03,
Definition:The weeks of gestation completed at the time of delivery.

Gestational age is defined as the number of weeks that have elapsed between the first day of the last normal menstrual period (not presumed time of conception) and the date of delivery, irrespective of whether the gestation results in a live birth or a fetal death.

Suggested Data Collection Question:How many weeks of gestation were completed at the time of delivery?
Format:
Length:2 or UTD
Type:Alphanumeric
Occurs:1
Allowable Values:

1-50

UTD=Unable to Determine

Notes for Abstraction:Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The history and physical should be reviewed first for gestational age. If gestational age is not recorded in the history and physical, then continue to review the data sources in the following order: prenatal forms, delivery or operating room record and clinician admission progress note until a positive finding for gestational age is found. In cases where there is conflicting data, the gestational age found in the first document according to the order listed above should be used. The phrase "estimated gestational age" is an acceptable descriptor for gestational age.

The clinician admission progress note may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).

If the patient has not received prenatal care, and the gestational age is unknown, select allowable value UTD.

Suggested Data Sources:

ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:

  • History and physical
  • Prenatal forms
  • Delivery room record
  • Operating room record
  • Admission clinician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Gestational Age
Specifications Manual for Joint Commission National Quality Measures (v2010B1)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)