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Release Notes:
Data Element
Version 2010B

Data Element Name: Pre-transfusion Laboratory Testing
Collected For: BM-03,
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.
Suggested Data Collection Question:Was laboratory testing completed prior to the plasma transfusion event?
Format:
Length:1
Type:Numeric
Occurs:1 - 3
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.

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.
Suggested Data Sources:
  • Anesthesia record
  • Consultation notes
  • Emergency department record
  • History and physical
  • Laboratory report
  • Progress notes
  • Operative report
  • Blood administration form
  • Additional Notes:
    Guidelines for Abstraction:
    Inclusion Exclusion
    None None

    Pre-transfusion Laboratory Testing
    Specifications Manual for Joint Commission National Quality Core Measures (2010B)
    Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)