Release Notes:
Data Element
Version 2010B
| Data Element Name: | Consent Addressed Transfusion Benefits |
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| Collected For: | |
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| Definition: | Documentation by the physician/advance practice nurse/physician assistant (physician/APN/PA) that information addressing the benefits of transfusion was discussed with the patient/caregiver prior to transfusion. |
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| Suggested Data Collection Question: | Was there documentation that the benefits of transfusion was discussed with patient/caregiver prior to transfusion? |
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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) Information addressing the benefits of transfusion was discussed with the patient/caregiver prior to transfusion.
N (No) Information addressing the benefits of transfusion was not discussed with the patient/caregiver prior to transfusion or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Documentation that addresses the benefits of transfusion must include the specific benefits of the blood product (s) that was administered to select “Yes”.
- Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may have been covered in the discussion with the patient/caregiver.
- If the patient refused information about transfusion benefits, select “Yes.”
- The caregiver is defined as the patient’s family or any other person (e.g., guardian) who will be responsible for care of the patient.
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA DOCUMENTATION:
- Admission forms
- Consent form
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
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None |
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Consent Addressed Transfusion Benefits
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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