Alphabetical Data Element List

Transcription

1 Alphabetical Data Element List Element Name Page # Collected For: Arrival Time 3 All Records Aspirin Received 6 OP-4 Birthdate 8 All Records Discharge Code 9 E/M Code 11 ECG 12 OP-5 ECG Date 13 OP-5 ECG Time 15 OP-5 ED Departure Date 17 OP-3, OP-18 ED Departure Time 19 OP-3, OP-18 Fibrinolytic Administration 21 OP-1, OP-2, OP-3 Fibrinolytic Administration Date 22 OP-1, OP-2 Fibrinolytic Administration Time 23 OP-1, OP-2 First Name 25 All Records Hispanic Ethnicity 26 All Records ICD-10-CM Other Diagnosis Codes 27 OP-4, OP-5. OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-20, OP-21, OP-23 OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-20, OP-21, OP-23 ICD-10-CM Principal Diagnosis Code 28 OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-21, OP-23 Initial ECG Interpretation 29 OP-1, OP-2, OP-3 Last Name 33 All Records Outpatient Encounter Date 34 All Records Patient HIC # 35 Patient Identifier 36 All Records Payment Source 37 All Records Physician 1 38 Optional for All Records Collected by CMS for patients with a Payment Source of Medicare who have a standard HIC number

2 Element Name Page # Collected For: Physician 2 39 Optional for All Records Postal Code 40 All Records Probable Cardiac Chest Pain 41 OP-4, OP-5 Race 43 All Records Reason for Delay in Fibrinolytic Therapy 45 OP-1, OP-2 Reason for No Aspirin on Arrival 47 OP-4 Reason for Not Administering Fibrinolytic Therapy 49 OP-3 Sex 51 All Records Transfer for Acute Coronary Intervention 52 OP-3.

3 Data Element Name: Arrival Time Collected For: All records (used in algorithms for OP-1, OP-2, OP-3, OP-5, OP-18, OP-20, OP-21, OP-23) Definition: The earliest documented time (military time) the patient arrived at the outpatient or emergency department Suggested Data Collection Question: What was the earliest documented time the patient arrived at the outpatient or emergency department? Length: 5 HH:MM (with or without colon) or UTD Type: Time HH = Hour (00 23) MM = Minutes (0 59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of midnight and noon: If the time is in the a.m., conversion is not required. If the time is in the p.m., add 12 to the clock time hour. Examples: Midnight = 0000 Noon = :31 a.m. = :31 p.m. = :59 a.m. = :59 p.m. = 2359 Note: 0000 = midnight. If the time is documented as XX, review supporting documentation to determine if the Outpatient Encounter Date should remain XX or if it should be converted to XX. When converting midnight, or 2400, to 0000, do not forget to change the Outpatient Encounter Date. Example: Midnight or 2400 on XX = 0000 on XX. For times that include seconds, remove the seconds and record the time as is. Example: 1500:35 would be recorded as 1500 If the time of the arrival is unable to be determined from medical record documentation, select UTD. The medical record must be abstracted as documented (taken at face value ). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the arrival time was No other documentation in the list of Only Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for Hour, it is not a valid time, and the abstractor should select UTD..

4 Note: Transmission of a case with an invalid time as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for Arrival Time allows the case to be accepted into the Warehouse. Review the Only Acceptable Sources to determine the earliest time the patient arrived at the ED or observation. The intent is to utilize any documentation which reflects processes that occurred after the arrival at the ED or after arrival to observation. Documentation outside of the Only Acceptable Sources list should not be referenced (e.g., ambulance record, physician office record, H&P). Examples: ED Triage Time ED rhythm strip EMS report indicates patient was receiving EMS care from 0805 through The EMS report is disregarded. Enter 0800 for Arrival Time. ED noted arrival time of Lab report shows blood culture collected at It is not clear that the blood culture was collected in the ED because the lab report does not specify it was collected in the ED (unable to confirm lab report as an Only Acceptable Source). Enter 0945 for Arrival Time. Arrival Time should not be abstracted simply as the earliest time in one of the Only Acceptable Sources, without regard to other substantiating documentation. When looking at the Only Acceptable Sources, if the earliest time documented appears to be an obvious error, this time should not be abstracted. Examples: ED arrival time notes as 2300 on xx. ED MAR shows an antibiotic administration time of 0100 on xx. Surrounding documentation on the ED MAR makes clear that the xx date is an obvious error- Date was not changed to xx. The antibiotic administration date/time would be converted to 0100 on xx. (Please see the note under the Allowable Values section of this data element). Enter 2300 for Arrival Time. ED face sheet lists arrival time of ED Registration Time ED Triage Time ED Consent to treat form has 1:17 time but AM is circled. ED record documentation suggests the 1:17 AM is an obvious error. Enter 1320 for Arrival Time. ED ECG timed as ED Greet Time ED Triage Time There is no documentation in the Only Acceptable Sources which suggests the 1742 is an obvious error. Enter 1742 for Arrival Time. ED RN documents on the nursing triage note, Blood culture collected at ED arrival time is documented as There is no documentation in the Only Acceptable Sources which suggests the 0730 is an obvious error. Enter 0730 for Arrival Time. The source Emergency Department record includes any documentation from the time period that the patient was an ED patient. The source Procedure notes refers to procedures such as cardiac caths, endoscopies, and surgical procedures. Procedure notes do not include ECG and x-ray reports. The Arrival Time may differ from the admission time. Observation Status: If the patient was admitted to observation from an outpatient setting of the hospital, use the time the patient arrived at the ED or on the floor for observation care as the Arrival Time. If the patient was admitted to observation from the ED of the hospital, use the time the patient arrived at the ED as the Arrival Time..

5 Only Acceptable Sources: Emergency Department record, which may include: ED face sheet ED consent/authorization for treatment forms ED/Outpatient registration/sign-in forms ED ECG reports ED telemetry/rhythm strips ED laboratory reports ED x-ray reports Observation record Procedure notes Vital signs graphic record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: Addressographs/stamps.

6 Data Element Name: Aspirin Received Collected For: OP-4 Definition: Aspirin received within 24 hours before emergency department arrival or administered in the emergency department prior to transfer to another facility or inpatient services. Aspirin reduces the tendency of blood to clot by blocking the action of a type of blood cell involved in clotting. Aspirin improves the chances of surviving a heart attack and reduces the risk of recurrence in patients who have experienced a heart attack. Suggested Data Collection Question: Was aspirin received within 24 hours before emergency department arrival or administered prior to transfer? Length: 1 Type: Alphanumeric Y (Yes) Aspirin was received within 24 hours before emergency department arrival or administered in the emergency department prior to transfer. N (No) Aspirin was not received within 24 hours before emergency department arrival or was not administered in the emergency department prior to transfer or was Unable to Determine from medical record documentation. Appendix C, OP Table 1.1, Aspirin and Aspirin-Containing Medications, referred to in the Inclusion Guidelines for Abstraction, is not all-inclusive. If there is documentation the patient received an aspirin/aspirin-containing medication that is not on Appendix C, OP Table 1.1, Aspirin and Aspirin- Containing Medications, you may abstract a Yes for this data element. In the absence of explicit documentation that the patient received aspirin within 24 hours prior to Arrival Time: In cases where the patient was received as a transfer from another hospital (inpatient, outpatient, ED, observation): o Aspirin listed as home medication: Do not make inferences. Additional documentation is needed which clearly suggests the patient took aspirin at home within 24 hours prior to Arrival Time. o Aspirin listed as current medication: If there is documentation that aspirin was a current medication at the transferring facility (e.g., aspirin noted on transfer summary, aspirin noted as current medication in your facility s H&P), then infer aspirin was taken within 24 hours prior to Arrival Time, unless documentation suggests otherwise. If documentation suggests current aspirin refers to home regimen or documentation is not clear whether current means patient was on aspirin at the transferring facility or at home, do not make inferences. Additional documentation is needed which clearly suggests the patient either took aspirin at home or at the transferring facility within 24 hours prior to Arrival Time..

7 In non-transfer cases: Aspirin listed as current or home medication should be inferred as taken within 24 hours prior to Arrival Time, unless documentation suggests otherwise (e.g., documentation that aspirin is on hold prior to arrival for a scheduled procedure). If ASA is listed as a home medication and the last dose is noted as the day prior to arrival but no time, then infer aspirin was taken within 24 hours. When aspirin is noted only as received prior to arrival, without information about the exact time it was received (e.g., baby ASA x4 per the Treatment Prior to Arrival section of the Triage Assessment), infer that the patient took it within 24 hours prior to Arrival Time, unless documentation suggests otherwise. Aspirin documented as PRN current/home medication does not count unless documentation is clear it was taken within 24 hours prior to Arrival Time. If there is documentation in the emergency department record that aspirin was administered in the emergency department prior to transferring the patient to another facility or inpatient services, then select Yes for Aspirin Received. Ambulance record Emergency Department record Inclusion Guidelines for Abstraction: Refer to Appendix C, OP Table 1.1, Aspirin and Aspirin-Containing Medications. Exclusion Guidelines for Abstraction: Aggrenox (aspirin/dipyridamole).

8 Data Element Name: Birthdate Collected For: All records Definition: The month, day, and year the patient was born Note: Patient Age on Outpatient Encounter Date (in years) is calculated by Outpatient Encounter Date minus Birthdate. The algorithm to calculate age must use the month and day portion of encounter date and birthdate to yield the most accurate age. Suggested Data Collection Question: What is the patient s date of birth? Length: 10 MM-DD-YYYY (includes dashes) Type: Date MM = Month (01 12) DD = Day (01 31) YYYY = Year (1880 Current Year) Because this data element is critical in determining the population for all measures, the abstractor should not assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, correct and override the downloaded value. If the abstractor is unable to determine the correct birthdate through chart review, default to the date of birth on the claim information. Outpatient record Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None.

9 Data Element Name: Discharge Code Collected For: OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-20, OP-21, OP-23 Definition: The final place or setting to which the patient was discharged from the outpatient setting Suggested Data Collection Question: What was the patient s discharge code from the outpatient setting? Length: 2 Type: Alphanumeric 1 Home 2 Hospice Home 3 Hospice Health Care Facility 4a Acute Care Facility General Inpatient Care 4b Acute Care Facility Critical Access Hospital 4c Acute Care Facility Cancer Hospital or Children s Hospital 4d Acute Care Facility Department of Defense or Veteran s Administration 5 Other Health Care Facility 6 Expired 7 Left Against Medical Advice/AMA 8 Not Documented or Unable to Determine (UTD) If documentation is contradictory, use the latest documentation. If there is documentation that further clarifies the level of care, that documentation should be used to determine the correct value to abstract. Example: Nursing discharge note documentation reflects that the patient is being discharged to XYZ Hospital. The Social Service notes from the day before discharge further clarify that the patient will be transferred to the rehab unit at XYZ Hospital; select value 5. If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select value 4a. To select value 7, there must be explicit documentation that the patient left against medical advice. Examples: Progress notes state that patient requests to be discharged but that discharge was medically contraindicated at this time. Nursing notes reflect that patient left against medical advice and AMA papers were signed; select value 7. Physician order written to discharge to home. Nursing notes reflect that patient left before discharge instructions could be given; select value 1. Discharge instruction sheet Emergency Department record Nursing discharge notes Physician orders Progress notes Transfer record

10 Excluded Data Sources: UB-04 Inclusion Guidelines for Abstraction: For Value 1: Assisted Living Facilities Court/Law Enforcement includes detention facilities, jails, and prison Home includes board and care, foster or residential care, group or personal care homes, and homeless shelters Home with Home Health Services Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs, and Partial Hospitalization For Value 3: Hospice Care General Inpatient and Respite Hospice Care Residential and Skilled Facilities Hospice Care Other Health Care Facilities (excludes home) For Value 5: Extended or Intermediate Care Facility (ECF/ICF) Long Term Acute Care Hospital (LTACH) Nursing Home or Facility, including Veteran s Administration Nursing Facility Psychiatric Hospital or Psychiatric Unit of a Hospital Rehabilitation Facility, including Inpatient Rehabilitation Facility/Hospital or Rehabilitation Unit of a Hospital Skilled Nursing Facility (SNF), Sub-Acute Care, or Swing Bed Transitional Care Unit (TCU) Exclusion Guidelines for Abstraction: None

11 Data Element Name: E/M Code Collected For: OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-20, OP-21, OP-23 Definition: The code used to report evaluation and management services provided in the hospital outpatient department clinic or emergency department Suggested Data Collection Question: What was the E/M code documented for this outpatient encounter? Length: 5 Type: Alphanumeric Select the E/M Code from Appendix A, OP Table 1.0. Outpatient record Inclusion Guidelines for Abstraction: Refer to Appendix A, OP Table 1.0, EM Codes. Exclusion Guidelines for Abstraction: None

12 Data Element Name: ECG Collected For: OP-5 Definition: Documentation a 12-lead electrocardiogram (ECG) was performed prior to emergency department arrival or in the ED prior to transfer Suggested Data Collection Question: Was an ECG performed within 1 hour before emergency department arrival or in the ED prior to transfer? Length: 1 Type: Alphanumeric Y (Yes) There was an ECG performed within 1 hour before emergency department arrival or in the ED prior to transfer. N (No) There was not an ECG performed within 1 hour before emergency department arrival or in the ED prior to transfer or Unable to Determine from medical record documentation. If there is an ECG performed exactly one hour prior to arrival, select Yes. If there are multiple ECGs performed within one hour prior to emergency department arrival and/or in the ED prior to transfer, select Yes. If a pre-hospital ECG (i.e., ECG performed prior to ED arrival) cannot be confirmed as a 12-lead ECG based on documentation or the ECG strip, then abstract No for ECG. In contrast, if there is documentation of an ECG performed in the ED (i.e., ECG performed after ED arrival) that is not specified as a 12-lead ECG, then abstract Yes for ECG. Ambulance record Emergency Department record Inclusion Guidelines for Abstraction: ECGs performed in the ambulance (within one hour prior to arrival) Exclusion Guidelines for Abstraction: None

13 Data Element Name: ECG Date Collected For: OP-5 Definition: The month, day, and year at which the earliest 12-lead Electrocardiogram (ECG) was performed Suggested Data Collection Question: What is the date the earliest 12-lead Electrocardiogram (ECG) was performed? Length: 10- MM-DD-YYYY (includes dashes) or UTD Type: Date MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx) UTD = Unable to Determine The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid format/range or outside of the parameters of care [after the ECG date]) and no other documentation is found that provides this information, the abstractor should select UTD. Examples: Documentation indicates the ECG date was xx. No other documentation in the list of Only Acceptable Sources provides a valid date. Since the ECG Date is outside of the range listed in the Allowable Values for Day, it is not a valid date, and the abstractor should select UTD. Patient expired on xx, and all documentation within the Only Acceptable Sources indicates the ECG date was xx. Other documentation in the medical record supports the date of death as being accurate. Since the ECG date is after the date of death, it is outside of the parameter of care, and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for ECG Date allows the case to be accepted into the Warehouse. In the event the patient had an ECG performed within 60 minutes prior to arrival at the emergency department, enter the date the patient arrived at this emergency department. If the date of the ECG is unable to be determined from medical record documentation, abstract UTD. Exceptions: If there are multiple ECGs done and the earlier ECG(s) do not have a date but subsequent ECG(s) do, the next available ECG Date may be used. Only collect ECGs performed within 60 minutes prior to arrival or prior to transfer. If there are 2 ECGs performed (one prior to arrival and one after arrival), abstract the ECG performed prior to arrival. Abstract the ECG performed closest to arrival.

14 If the abstractor is unable to determine the ECG was completed within one hour prior to arrival, the next subsequent ECG should be used for ECG Date. Only Acceptable Sources: Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None

15 Data Element Name: ECG Time Collected For: OP-5 Definition: The time (military time) represented in hours and minutes at which the earliest 12-lead Electrocardiogram (ECG) was performed Suggested Data Collection Question: What is the time the earliest 12-lead Electrocardiogram (ECG) was performed? Length: 5 HH-MM (with or without colon) or UTD Type: Time HH = Hour (00 23) MM = Minutes (0 59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of midnight and noon: If the time is in the a.m., conversion is not required. If the time is in the p.m., add 12 to the clock time hour. Examples: Midnight = 0000 Noon = :31 a.m. = :31 p.m. = :59 a.m. = :59 p.m. = 2359 Note: 0000 = midnight. If the time is documented as 0000, xx, review supporting documentation to determine if the ECG Date should remain xx or if should be converted to xx. When converting midnight, or 2400, to 0000, do not forget to change the ECG Date. Example: Midnight or 2400 on xx = 0000 on xx. For times that include seconds, remove the seconds and record the time as is. Example: 1500:35 would be recorded as If the ECG Time is unable to be determined from medical record documentation, select UTD. The medical record must be abstracted as documented (taken at face value ). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the ECG time was No other documentation in the medical record provides a valid time. Since the ECG Time is outside of the range listed in the Allowable Values for Hour, it is not a valid time, and the abstractor should select UTD.

16 Note: Transmission of a case with an invalid time as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for ECG Time allows the case to be accepted into the warehouse. In the event the patient had an ECG performed within 60 minutes prior to arrival at the emergency department, enter the time the patient arrived at this emergency department. Only collect ECGs performed within 60 minutes prior to arrival or prior to transfer. If the abstractor is unable to determine the ECG was completed within one hour prior to arrival, the next subsequent ECG should be used for ECG Time. If there are 2 ECGs performed (one within 60 minutes prior to arrival and one after arrival), abstract the ECG performed prior to arrival. Note: If abstracting the ECG performed prior to arrival, abstract the ED arrival time as the ECG Time. If there were no ECGs performed prior to arrival, abstract the ECG performed closest to the time of arrival. If the time of the ECG is unable to be determined from medical record documentation, abstract UTD. Exceptions: If there are multiple ECGs done and the earlier ECG(s) do not have a time, but subsequent ECG(s) do, the next available ECG Time may be used. Abstract the ECG performed closest to arrival. If the abstractor is unable to determine the ECG was completed within one hour prior to arrival, the next subsequent ECG should be used for ECG Time. If there are multiple times documented for the same ECG, use the printed ECG strip time. If there are multiple ECG times documented and the earlier time can be verified to be invalid, the subsequent time may be used (e.g., ECG strip time indicates the ECG took place three hours prior to the patient arrival and nurses notes indicate a time the patient was at the facility, this time may be used). If the only ECG Time is the strip time and this is known to be invalid/inaccurate, abstract UTD. Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None

17 Data Element Name: ED Departure Date Collected For: OP-3, OP-18 Definition: The month, day, and year at which the patient departed from the emergency department Suggested Data Collection Question: What is the date the patient departed from the emergency department? Length: 10 MM-DD-YYYY (includes dashes) or UTD Type: Date MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx) UTD = Unable to Determine The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid format/range or outside of the parameters of care and no other documentation is found that provides this information), the abstractor should select UTD. Examples: Documentation indicates the ED departure date was xx. No other documentation in the list of Only Acceptable Sources provides a valid date. Since the ED Departure Date is outside of the range listed in the Allowable Values for Day, it is not a valid date, and the abstractor should select UTD. Patient expired on xx, and all documentation within the Only Acceptable Sources indicates the ED Departure Date was xx. Other documentation in the medical record supports the date of death as being accurate. Since the ED Departure Date is after the Discharge Date (death), it is not outside of the parameter of care, and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for ED Departure Date allows the case to be accepted into the warehouse. If the date the patient departed is unable to be determined from medical record documentation, select UTD. If the date of departure is not documented but you are able to determine the date from other documentation, this is acceptable (e.g., you are able to identify from documentation the patient arrived and was transferred on the same day). If there is documentation the patient left against medical advice and it cannot be determined what date the patient left against medical advice, select UTD. For patients who are placed into observation services, use the date of the physician/apn/pa order for observation services as ED Departure Date.

18 The inclusion and exclusion lists are not to be considered comprehensive lists of inclusions and exclusions. If there is a discharge date listed on a disposition sheet, this may be abstracted as ED Departure Date. Only Acceptable Sources: Emergency Department record Inclusion Guidelines for Abstraction: ED departure date ED discharge date ED leave date Exclusion Guidelines for Abstraction: Disposition date

19 Data Element Name: ED Departure Time Collected For: OP-3, OP-18 Definition: The time (military time) represented in hours and minutes at which the patient departed from the emergency department Suggested Data Collection Question: What is the time the patient departed from the emergency department? Length: 5 HH-MM (with or without colon) or UTD Type: Time HH = Hour (00 23) MM = Minutes (0 59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of midnight and noon: If the time is in the a.m., conversion is not required. If the time is in the p.m., add 12 to the clock time hour. Examples: Midnight = 0000 Noon = :31 a.m. = :31 p.m. = :59 a.m. = :59 p.m. = 2359 Note: 0000 = midnight. If the time is documented as xx, review supporting documentation to determine if the ED Departure Date should remain xx or if it should be converted to xx. When converting midnight, or 2400, to 0000, do not forget to change the ED Departure Date. Example: Midnight or 2400 on xx = 0000 on xx. The intention is to capture the latest time at which the patient was receiving care in the emergency department, under the care of emergency department services, or awaiting transport to service/care. For times that include seconds, remove the second and record the time as is. Example: 1500:35 would be recorded as The medical record must be abstracted as documented (taken at face value ). When the time documented is obviously in error (not a valid format/range) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the ED departure time was No other documentation in the list of Only Acceptable Sources provides a valid time. Since the ED Departure Time is outside of the range in the Allowable Values for Hour, it is not a valid time, and the abstractor should select UTD.

20 Note: Transmission of a case with an invalid time as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for ED Departure Time allows the case to be accepted into the warehouse. ED Departure Time is the documented time the patient physically left the emergency department. Do not use the time the discharge order was written because it may not represent the actual time of departure. If there is a discharge time listed on the disposition sheet, this may be used for ED Departure Time. When more than one emergency department departure/discharge time is documented, abstract the latest time. Examples: ED nursing notes contain documentation that the patient was transferred to floor at 1800 and transport documentation states that patient left the ED via stretcher at There are multiple times documented for departure. Use the later time of 1815 as ED Departure Time. ED nursing notes contain documentation that the patient departed the ED at ED record contains documentation of medication administration at 0510 and that the patient departed the ED at Physician notes contain documentation of an assessment at As there are multiple departure times documented, enter 0620 for ED Departure Time, as it is the latest time documented. If the time the patient departed is unable to be determined from medical record documentation, select UTD. Example: ED nursing notes documented patient departed from the ED at Nursing notes document medication administration at Physician progress notes document assessment at There is substantial documentation to support that the patient was in the ED after documented departure and no additional documented time of ED departure. Enter UTD for ED Departure Time. If ED Departure Time is documented prior to arrival, abstract as UTD. If patient expired in the ED, use the time of death as the departure time. The inclusion and exclusion lists are not to be considered comprehensive lists of inclusions and exclusions. Observation Status: For patients who are placed into observation services, use the time of the physician/apn/pa order for observation for ED Departure Time. Only Acceptable Sources: Emergency Department record Inclusion Guidelines for Abstraction: Exclusion Guidelines for Abstraction: ED leave time Report called time ED discharge time Disposition time ED departure time Discharge instructions time ED checkout time ED order for observation status

21 Data Element Name: Fibrinolytic Administration Collected For: OP-1, OP-2, OP-3 Definition: Fibrinolytic therapy is the administration of a pharmacological agent intended to cause lysis of a thrombus (destruction or dissolution of a blood clot) Suggested Data Collection Question: Did the patient receive fibrinolytic therapy at this emergency department? Length: 1 Type: Alphanumeric Y (Yes) Fibrinolytic therapy was initiated at this emergency department. N (No) There is no documentation fibrinolytic therapy was initiated at this emergency department, or Unable to Determine from medical record documentation. In the event the patient was brought to the hospital via ambulance and fibrinolytic therapy was infusing at the time of arrival, select Yes. In the event the patient was brought to the emergency department via ambulance and fibrinolytic therapy was infused during transport but was completed at the time of the emergency department arrival, select No. If the first dose of reteplase (Retavase) is given in the ambulance and the second dose is given in the emergency department, select Yes. Emergency Department record Inclusion Guidelines for Abstraction: Refer to Appendix C, OP Table 1.3, Fibrinolytic Agents. Exclusion Guidelines for Abstraction: None

22 Data Element Name: Fibrinolytic Administration Date Collected For: OP-1, OP-2 Definition: The month, day, and year primary fibrinolytic therapy was administered at this facility. Fibrinolytic therapy is the administration of a pharmacological agent intended to cause lysis of a thrombus (destruction or dissolution of a blood clot). Suggested Data Collection Question: What was the date primary fibrinolytic therapy was initiated during this hospital stay? Length: 10 MM-DD-YYYY (includes dashes) or UTD Type: Date MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx) UTD = Unable to Determine If the date primary fibrinolytic therapy was initiated is unable to be determined from medical record documentation, enter UTD. The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the Fibrinolytic Administration Date was xx. No other documentation in the medical record provides a valid date. Since the Fibrinolytic Administration Date is outside of the range listed in the Allowable Values for Day, it is not a valid date, and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for Fibrinolytic Administration Date allows the case to be accepted into the warehouse. If there are two or more different fibrinolytic administration dates (either different fibrinolytic episodes or corresponding with the same episode), enter the earliest date. In the event the patient was brought to the hospital via ambulance and fibrinolytic therapy was infusing at the time of hospital arrival, enter the date the patient arrived at this hospital. Ambulance record Discharge summary Emergency Department record ICU/Nursing flow sheets IV flow sheets Medication administration record Nursing notes Transfer sheet Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: Fibrinolytics given during or after a PCI

23 Data Element Name: Fibrinolytic Administration Time Collected For: OP-1, OP-2 Definition: The time (military time) that primary fibrinolytic therapy started. Fibrinolytic therapy is the administration of a pharmacological agent intended to cause lysis of a thrombus (destruction or dissolution of a blood clot). Suggested Data Collection Question: What was the time primary fibrinolytic therapy was initiated during this hospital stay? Length: 5 HH-MM (with or without colon) or UTD Type: Time HH = Hour (00 23) MM = Minutes (0 59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of midnight and noon: If the time is in the a.m., conversion is not required. If the time is in the p.m., add 12 to the clock time hour. Examples: Midnight = 0000 Noon = :31 a.m. = :31 p.m. = :59 a.m. = :59 p.m. = 2359 Note: 0000 = midnight. If the time is documented as xx, review documentation to determine if the Fibrinolytic Administration Date should remain xx or if it should be converted to xx. When converting midnight, or 2400, to 0000, do not forget to change the Fibrinolytic Administration Date. Example: Midnight or 2400 on xx = 0000 on xx. For times that include seconds, remove the seconds and record the time as is. Example: 1500:35 would be recorded as If the time primary fibrinolytic therapy was initiated is unable to be determined from medical record documentation, enter UTD. The medical record must be abstracted as documented (taken at face value ). When the time documented is obviously in error (not a valid time/format) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the Fibrinolytic Administration Time was No other documentation in the medical record provides a valid time. Since the Fibrinolytic Administration Time is outside of the range listed in the Allowable Values for Hour, it is not a valid time, and the abstractor should select UTD.

24 Note: Transmission of a case with an invalid time as described above will be rejected from the CMS Clinical Data Warehouse. Use of UTD for Fibrinolytic Administration Time allows the case to be accepted into the warehouse. If there are two or more different fibrinolytic administration times (either different fibrinolytic episodes or corresponding with the same episode), enter the earliest time. In the event the patient was brought to the hospital via ambulance and fibrinolytic therapy was infusing at the time of hospital arrival, enter the time the patient arrived at this hospital. Ambulance record Emergency department record ICU/nursing flow sheets IV flow sheets Medication administration record Nursing notes Transfer sheet Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: Fibrinolytics given during or after a PCI

25 Data Element Name: First Name Collected For: All records Definition: The patient s first name Suggested Data Collection Question: What is the patient s first name? Length: 30 Type: Character Enter the patient s first name. None Outpatient record Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None 2-140

26 Data Element Name: Hispanic Ethnicity Collected For: All records Definition: Documentation that the patient is of hispanic ethnicity or Latino Suggested Data Collection Question: Is the patient of hispanic ethnicity or Latino? Length: 1 Type: Character Y (Yes) Patient is of hispanic ethnicity or Latino. N (No) Patient is not of hispanic ethnicity or Latino or unable to determine from medical record documentation. The data element Race is required in addition to this data element. Outpatient record Emergency Department record Inclusion Guidelines for Abstraction: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term Spanish origin can be used in addition to Hispanic or Latino. Examples: Black-Hispanic Chicano H Hispanic Latin American Latino/Latina Mexican-American Spanish White-Hispanic Exclusion Guidelines for Abstraction: None 2-141

27 Data Element Name: ICD-10-CM Other Diagnosis Codes Collected For: OP-4, OP-5 Definition: The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM) codes associated with the diagnosis for this record Suggested Data Collection Question: What were the ICD-10-CM other diagnosis codes selected for this medical record? Length: 8 (without decimal point or dot) Type: Alphanumeric Occurs: 24 Any valid diagnosis code as per the CMS ICD-10-CM master code table (Code Descriptions in Tabular Order): None Outpatient record Emergency Department record UB-04 Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None 2-142

28 Data Element Name: ICD-10-CM Principal Diagnosis Code Collected For: OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-21, OP-23 Definition: The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM) code associated with the diagnosis established after study to be chiefly responsible for the outpatient encounter Suggested Data Collection Question: What was the ICD-10-CM code selected as the principal diagnosis for this record? Length: 8 (without decimal point or dot) Type: Alphanumeric Any valid diagnosis code as per the CMS ICD-10-CM master code table (Code Descriptions in Tabular Order): None Outpatient record Emergency Department record UB-04 Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None 2-143

29 Data Element Name: Initial ECG Interpretation Collected For: OP-1, OP-2, OP-3 Definition: ST-segment elevation based on the documentation of the electrocardiogram (ECG) performed closest to emergency department arrival. The normal ECG is composed of a P wave (atrial depolarization), Q, R, and S waves (QRS complex, ventricular depolarization), and a T wave (ventricular repolarization). The ST-segment, the segment between the QRS complex and the T wave, may be elevated when myocardial injury (AMI) occurs. Suggested Data Collection Question: Is there documentation of ST-segment elevation on the electrocardiogram (ECG) performed closest to emergency department arrival? Length: 1 Type: Alphanumeric Y (Yes) ST-segment elevation on the interpretation of the 12-lead ECG performed closest to emergency department arrival. N (No) No ST-elevation on the interpretation of the 12-lead ECG performed closest to emergency department arrival, no interpretation or report available for the ECG performed closest to emergency department arrival, or unable to determine from medical record documentation. Methodology: 1. Identify the ECG performed closest to arrival, either before or after emergency department arrival, but not more than 1 hour prior to arrival. If unable to determine which ECG was performed closest to arrival select No. Exception: If the pre-arrival ECG and the first ECG performed after arrival at the hospital are exactly the same amount of time away from hospital arrival (e.g., both ECGs are 10 minutes away from Arrival Time), use the first ECG performed after hospital arrival. 2. Start with review of the signed tracing. Determine if the terms or phrases are Inclusions or Exclusions. Evaluate findings line by line. Do not cross reference between lines except for those Exclusions with with mention of phrasing (e.g., LVH and ST-elevation noted on separate lines on the same ECG meets the Exclusion ST-elevation with any mention of early repolarization, left ventricular hypertrophy (LVH), normal variant, pericarditis, or Printzmetal/Printzmetals variant in one interpretation ). If you have an Exclusion, select No, regardless of other documentation, and there is no need to review further. 3. If there is no signed tracing, or in the absence of an Exclusion on the signed tracing, proceed to other interpretations that clearly refer to the ECG done closest to arrival. Only those terms specifically identified or referred to by the physician/apn/pa as ECG findings and where documentation is clear it is from the ECG performed closest to arrival should be considered in abstraction (e.g., STEMI listed only as a physician diagnosis or impression would not be used). Do not cross reference findings between interpretations unless otherwise specified. If you encounter an Exclusion in any of the other interpretations, select No, regardless of other documentation, and there is no need to review further

30 4. At the end of your review, if you have no Exclusions, and either the signed ECG tracing or interpretations of this ECG tracing include at least one Inclusion, select Yes. Otherwise, select No. ECG interpretation is defined as: 12-lead tracing with name/initials of the physician/advanced practice nurse/physician assistant (physician/apn/pa) who reviewed the ECG signed or typed on the report, or Physician/APN/PA documentation of ECG findings in another source (e.g., ED record). Do not measure ST-segments from the tracing itself. Consider a tracing 12-lead if it has the appropriate markings (the presence of at least 12-leads: I, II, III, AVR, AVL, AVF, V1 V6). If ECG documentation outside of a tracing is not specified as 12-lead, assume it is 12-lead unless documentation indicates otherwise. Disregard any description of an MI or ST-segment that is not on either the Inclusion list or the Exclusion list. If documentation is contradictory within the same interpretation or between different interpretations, select No. Examples: ST-elevation and No ST-elevation Acute anterior MI and no acute MI o Documentation such as STEMI and no ST-elevation should not be considered contradictory for the purposes of this data element. Notations which describe ST-elevation as old, chronic, or previously seen, or which state ST-elevation and no new changes, unchanged, no acute changes, or no significant changes when compared to a prior ECG should be disregarded. Other documentation of ST-elevation within the same interpretation or a different interpretation may still count as an Inclusion or Exclusion. Exception: When the ST-elevation on the ECG done closest to arrival is described as previously seen on an ECG done by EMS or physician office prior to arrival, this ST-elevation may count as an Inclusion. Documentation must be explicit within the ECG interpretation itself (e.g., Initial ECG shows ST-elevation 1mm V1-V2. Improved from ECG done in the field ). Abstractors should not make inferences based on documentation outside of the interpretation (context, sequence of events, etc.). Notations which describe ST-elevation as a range where it cannot be determined if elevation is less than 1 mm/.10mv (e.g., mm ST-elevation, ST greater than 0.06 mv V2-V6 ) should be disregarded. Other documentation of ST-elevation within the same interpretation or a different interpretation may still count as an Inclusion or Exclusion. If any of the inclusion terms are described using the qualifier possible or potential, disregard that finding (neither Inclusion nor Exclusion). Do not consider subendocardial an MI location (e.g., acute subendocardial MI should be disregarded). Physician/APN/PA Documentation Only ECG reports Emergency Department record 2-145

31 Inclusion Guidelines for Abstraction: ST-segment elevation Myocardial infarction (MI), with any mention of location or combinations of locations (e.g., anterior, apical, basal, inferior, lateral, posterior, or combination), if described as acute/evolving (e.g., posterior AMI ) Q wave MI, if described as acute/evolving ST ST consistent with injury or acute/evolving MI ST abnormality consistent with injury or acute/evolving MI ST changes consistent with injury or acute/evolving MI ST-elevation (STE) ST-elevation myocardial infarction (STEMI) ST-segment noted as greater than or equal to.10mv ST-segment noted as greater than or equal to 1 mm STEMI or equivalent Transmural MI, if described as acute/evolving Exclusion Guidelines for Abstraction: ST-segment elevation Documentation of the absence of STEMI (In reference to the ECG performed closest to arrival) e.g., No STEMI, not consistent with STEMI, not diagnostic of STEMI. Non Q wave MI (NQWMI) Non ST-elevation MI (NSTEMI) ST-elevation (ST ) clearly described as confined to one lead All ST-elevation (ST, STE) in one interpretation described in one or more of the following ways: Minimal Non-diagnostic Non-specific ST-elevation or ST-segment noted as less than.10 mv in elevation ST-elevation or ST-segment noted as less than 1mm in elevation ST-elevation (or ST-segment noted as greater than or equal to.10mv/1mm) described using one of the negative modifiers or qualifiers listed under the Exclusion Guidelines for Abstraction ST-elevation (ST ) with any mention of the following in one interpretation: Early repolarization Left ventricular hypertrophy (LVH) Normal variant Pericarditis Printzmetal/Printzmetal s variant ST, ST abnormality, or ST changes consistent with injury or acute/evolving MI or any of the myocardial infarction (MI) inclusion terms described using one of the negative modifiers or qualifiers listed under the Exclusion Guidelines for Abstraction ST-segment elevation, or any of the other ST-segment elevation inclusion terms, with any mention of pacemaker/pacing (unless atrial only or nonfunctioning pacemaker) in one interpretation 2-146

32 Qualifiers and Modifiers The following qualifiers and modifiers should be abstracted as negative findings, unless otherwise specified. Consider this list all-inclusive: Qualifiers And/or (+/-; e.g., ST abnormalities consistent with ischemia and/or injury ), except when comparing only Inclusions (e.g., ST segment elevation and/or STEMI ) Cannot exclude Cannot rule out Could/may/might be Could/may/might have Could/may/might have been Could/may/might have had Could/may/might indicate Or, except when comparing only Inclusions Questionable (?) Risk of Ruled out (r d/o, r/o d) Suggestive of Suspect Suspicious Vs., except when comparing only Inclusions Modifiers: Borderline Insignificant/not significant/no significance Minor Scant Slight Sub-clinical Subtle Trace Trivial 2-147

33 Data Element Name: Last Name Collected For: All records Definition: The patient s last name Suggested Data Collection Question: What is the patient s last name? Length: 60 Type: Character Enter the patient s last name. None Outpatient record Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None 2-148

34 Data Element Name: Outpatient Encounter Date Collected For: All records Definition: The documented month, day, and year the patient arrived in the hospital outpatient setting Suggested Data Collection Question: What was date the patient arrived in the hospital outpatient setting? Length: 10 MM-DD-YYYY (includes dashes) Type: Date MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx) The intent of this data element is to determine the date the patient arrived in the hospital outpatient setting. UTD is not an allowable value. Consider the outpatient encounter date as the earliest documented date the patient arrived in the applicable hospital outpatient setting. Outpatient record Emergency Department record Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: Preoperative tests or screening 2-156

35 Data Element Name: Patient HIC # Collected For: Collected by CMS for patients with a Payment Source of Medicare who have a standard HIC number Definition: The patient s Medicare health insurance claim number Suggested Data Collection Question: What is the patient s Medicare/HIC number? Length: 7-12 Type: Character General Rules No embedded dashes or spaces or special characters Must have both alpha and numeric characters Alpha characters must be upper case Length cannot be more than 12 or less than 7 characters For alphanumeric values, do not allow all numeric values to be 9s. For example, do not allow 1 alpha , etc. If First Character Is Numeric: Suffix rules: If the first character is numeric (0 9), then the first 9 characters must be numeric. Examples: HIC # length: 10 Rule: 9 numeric + 1 alpha HIC # length: 11 Rule: 9 numeric + 1 alpha + 1 numeric or 9 numeric + 2 alpha If First Character Is Alpha: Prefix rules: If the first character is alpha, there must be 1 3 characters followed by 6 or 9 numbers. HIC # length: 7 Rule: 1 alpha + 6 numeric HIC # length: 8 Rule: 2 alpha + 6 numeric HIC # length: 9 Rule: 3 alpha + 6 numeric HIC # length: 10 Rule: 1 alpha + 9 numeric HIC # length: 11 Rule: 2 alpha + 9 numeric HIC # length: 12 Rule: 3 alpha + 9 numeric Patient HIC # is required for data transmission of all cases that have a standard HIC #. Refer to the Hospital Outpatient Quality Measure Data Transmission section for further guidance. Emergency Department record Face sheet UB-04 Inclusion Guidelines for Abstraction: None Exclusion Guidelines for Abstraction: None