Release Notes:
Data Element
Version 2010B
| Data Element Name: | Vital Sign Monitoring |
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| Collected For: | BM-05, |
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| Definition: | Documentation of blood pressure (BP) and temperature monitored at specific intervals for the transfusion. The intervals include:
BP
- Pre-transfusion, within 15 minutes of the initiation of the transfusion and within one hour of transfusion completion
Temperature
- Pre-transfusion, during the transfusion and within four hours of transfusion completion
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| Suggested Data Collection Question: | Was there documentation of BP and temperature monitored for all of the specified intervals for the transfusion? |
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| Format: | | Length: | 2 |
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| Type: | Numeric |
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| Occurs: | 1 -27 |
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| Allowable Values: |
1 There was documentation for all of the BP AND temperature monitoring intervals for the transfusion.
2 There was no documentation for all of the blood pressure and temperature monitoring intervals for the transfusion or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Blood pressure must be recorded at the following times: pre-transfusion, within 15 minutes of the initiation of the transfusion and within one hour of transfusion completion. Temperature must be recorded at all of the following times: pre-transfusion, during the transfusion and within four hours of transfusion completion. To select "1", all recordings must be documented.
- The pre-transfusion BP and temperature must be within one hour of the Transfusion Start Time.
- For platelets that may be transfused within 15 minutes, select "1" if the pre-transfusion and the within one hour of transfusion completion BP is documented.
- Vitals documented at the completion of the transfusion are considered “within one hour of transfusion completion".
- The "unit" or "dose" information for the Vital Sign Monitoring data element must be associated with the blood product event ID that was selected for abstraction.
- Up to three units (bags) of RBCs or doses of platelets or plasma can be abstracted per event.
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| Suggested Data Sources: |
- Anesthesia record
- Consultation notes
- Emergency department record
- Nursing notes
- Progress notes
- Operative 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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Vital Sign Monitoring
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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