Release Notes:
Data Element
Version 2010B
| Data Element Name: | Pre-transfusion Laboratory Testing |
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| Collected For: | BM-03, |
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| Definition: | Documentation of laboratory testing completed prior to the plasma transfusion event. Laboratory testing includes PT/INR and/or coagulation studies could include viscoelastometry (Thromboelastography, Sonoclot) or specific factor assays. |
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| Suggested Data Collection Question: | Was laboratory testing completed prior to the plasma transfusion event? |
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| Format: | | Length: | 1 |
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| Type: | Numeric |
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| Occurs: | 1 - 3 |
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| Allowable Values: |
1 There was documentation of a PT/INR > 2 or aPTT 1.3 x upper limit of reference range (in seconds) or 1.5 x midpoint of reference range (in seconds)and no coagulation studies prior to the plasma transfusion event.
2 There was documentation of a PT/INR ≤ 2 or aPTT 1.3 x upper limit of reference range (in seconds) or 1.5 x midpoint of reference range (in seconds)and no coagulation studies prior to the plasma transfusion event.
3 There was documentation of a PT/INR > 2 or aPTT 1.3 x upper limit of reference range (in seconds) or 1.5 x midpoint of reference range (in seconds)and coagulation studies prior to the plasma transfusion event.
4 There was documentation of a PT/INR ≤ 2 or aPTT 1.3 x upper limit of reference range (in seconds) or 1.5 x midpoint of reference range (in seconds)and coagulation studies prior to the plasma transfusion event.
5 There was no documentation of laboratory testing prior to the plasma transfusion event or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Review the PT/INR or coagulation study closest to the start of the plasma transfusion event ID for allowable values 1 – 4. The result must be completed within 24 hours prior to the start of the plasma transfusion event selected for abstraction.
- Select the laboratory testing results that are associated with the Plasma Event ID selected for abstraction.
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| Suggested Data Sources: |
Anesthesia record
Consultation notes
Emergency department record
History and physical
Laboratory report
Progress notes
Operative report
Blood administration form
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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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Pre-transfusion Laboratory Testing
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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