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Release Notes:
Data Element
Version 2012A

Data Element Name: Active Labor
Collected For: PC-01,
Definition:Documentation that the patient was in active labor or presented with regular uterine contractions with cervical change before medical induction and/or cesarean section.
Suggested Data Collection Question:Is there documentation that the patient was in active labor or presented with regular uterine contractions with cervical change before medical induction and/or cesarean section?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation that the patient was in active labor or presented with regular uterine contractions with cervical change before medical induction and/or cesarean section.

N (No) There is no documentation that the patient was in active labor or presented with regular uterine contractions with cervical change before medical induction and/or cesarean section OR unable to determine from medical record documentation.

Notes for Abstraction:If the patient presents without a previous cesarean section scar with regular uterine contractions with demonstrated cervical change, e.g., cervical dilation increased from 1cm to 2cm before eventual augmentation and/or cesarean section, select allowable value "Yes".

If the patient presents with a previous cesarean section scar with regular uterine contractions with demonstrated cervical change, e.g., cervical dilation increases from 1cm to 2cm or a cervix dilated 2cm or more before repeat cesarean section, select allowable value "Yes".

Suggested Data Sources:

  • History and physical
  • Nursing notes
  • Physician progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Active Labor
Specifications Manual for Joint Commission National Quality Measures (v2012A)
Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12)