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Release Notes:
Data Element
Version 2010B

Data Element Name: Alcohol or Drug Dependence
Collected For: TAM-07, TAM-08,
Definition:Documentation in the medical record that the patient is alcohol or drug dependent. This documentation can be in the form of a DSM-IV code for alcohol or drug dependence, an ICD-9-CM code, or narrative documentation in which the physician or other qualified health professional explicitly documents alcohol or drug dependence.
Suggested Data Collection Question:Is there documentation in the medical record that the patient has an alcohol or drug dependence?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation in the medical record that the patient has an alcohol or drug dependence.

N (No) There is no documentation in the medical record that the patient has an alcohol or drug dependence, or unable to determine from medical record documentation.

Notes for Abstraction:
  • The abstractor should not try to determine if alcohol or drug abuse exists from documentation of symptoms. The health care provider must document explicity that the patient has an alcohol or drug dependence.
  • For example, if documentation in the record indicates the patient has drink-seeking or drug seeking behavior or alcohol or drug tolerance, but does not specifically use the terminology "alcohol (or drug) dependent" or "suspect alcohol dependence", select No.
  • If the specific terms utilized in the inclusion notes below are used, select Yes.
  • If a DSM-IV code for alcohol or drug dependence is documented, select Yes.
Suggested Data Sources:
  • Consultation notes
  • History and physical
  • Progress notes
  • Coding Records
  • Physician Progress Notes
    • Additional Notes:
    Guidelines for Abstraction:
    Inclusion Exclusion
    • Alcohol dependent/dependence
    • Drug dependent/dependence
    • Appears to have
    • Consider
    • Consistent with (C/W)
    • Diagnostic of
    • Evidence of
    • Indicative of
    • Likely
    • Most likely
    • Probable
    • Representative of
    • See Appendix A code Table 12.1 for ICD-9-CM codes for Alcohol Dependence, and Table 12.2 for ICD-9-CM codes for Drug Dependence
    • Refer to Appendix D Table 2.6 for Qualifiers and Modifiers

    Alcohol or Drug Dependence
    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.