Appendix__A.pdf

Appendix A: List of Variables of Interest for Analysis

Data Item

Required Data

Element Type of Visit Patient First Given Name Y ED, IP, OP Patient Second Given Name (midde name) Y ED, IP, OP Patient Surname (last name) Y ED, IP, OP Patient Generational Suffix (eg Jr, Sr) Y ED, IP, OP Patient Address Y ED, IP, OP Patient City Y ED, IP, OP Patient State Y ED, IP, OP Patient Zip Y ED, IP, OP Patient SSN Y ED, IP, OP Patient Medicare number Y ED, IP, OP Patient's medical record number Y ED, IP, OP Patient Date of Birth Y ED, IP, OP Patient Sex Y ED, IP, OP Patient Race Y ED, IP, OP Patient Ethnicity Y ED, IP, OP Encounter number (unique identifier for a hospital encounter) Y ED, IP, OP

Date/Time of admission/visit/arrival Y ED, IP, OP

Date/Time of departure/discharge Y ED, IP, OP Expected source(s) of payment Y ED, IP, OP Discharge disposition (Return appointment, Referred, Routine discharge (if surgery), Admitted to ED/hospital, died at the hospital etc.) Y ED, IP, OP

Reason for Visit Y ED, IP, OP Diagnoses, including primary in

ICD-10-CM Y ED, IP, OP

Active problems Y ED, IP, OP Lab Tests Y ED, IP, OP

Provided or Ordered Diagnostic testing and results (e.g., lab, imaging, EKG, audiometry, biopsy) Y ED, IP, OP Procedures, Theraputic and/or Diagnostic (IP=ICD-10-PCS; ED and OPD=CPT and HPCS Y ED, IP, OP Provided or Ordered Diagnostic and/or Therapeutic procedures, including surgery and non medication treatments (e.g. physical therapy, speech therapy, home health care), including start and end datetime and results Y ED, IP, OP Medications on admission, during hospital stay and at discharge, please include the following data elements:

1) Medication Name

2) Medication Code (RxNorm)

3) Medication Start DateTime

4) Medication End DateTime Y ED, IP, OP

Planned medication activity - Medications on discharge, please include the following data elements:

1) Medication Name

2) Medication Code (RxNorm)

3) Medication Start DateTime

4) Medication End DateTime Y ED, IP, OP Immunizations - previous and administered Y ED, IP, OP

Vital signs on arrival and last taken -most recent height, most recent weight, and blood pressure Y ED, IP, OP

Data Item

Required Data

Element Type of Visit

Admission diagnosis Y IP Date/Time of provider contact Y ED Vital signs on arrival and last taken -pulse, respiratory rate, pulse oximetry

Y ED

If admitted to hospital, Hospital discharge date

Y ED

If admitted to hospital, Hospital discharge disposition

Y ED

Seen by PCP Y OP

Referral visit Y OP Smoking Status

Y OP

Clinician notes (e.g., physicians', nurses', P.A.s', N.P.s' and C.N.M.s' notes)

Y ED, OP

Temperature on arrival and last taken

Y ED, OP

Data Item Required

Data Element

Type of Visit

Patient Marital Status N ED, IP, OP

NPI of physicians N ED, IP, OP

Types of care providers seen (including attending, resident, intern, N.P., P. A., consulting, specialist(s), Nurse, mental health providers, social workers)

N ED, IP, OP

Priority of admission N IP

ICU, NICU, or CCU number of days of care

N IP

Present on Admission (POA) flags for diagnoses

N IP

Patient Residence Type N ED

Date/Time of admission order N ED

Date/Time bed requested for hospital admission order or transfer

N ED

Was patient triaged? N ED Triage System N ED

Triage Level N ED Mode of arrival N ED Point of Origin N ED Was this patient seen in this ED and discharged in the prior 72 hours?

N ED

If admitted to observation unit, Dates and times (ED discharge, observation unit discharge)

N ED

If admitted to hospital, Specialty of admitting physician (e.g. hospitalist)

N ED

If admitted to hospital, Type of unit admitted to

N ED

If admitted to hospital, Hospital discharge diagnosis

N ED

Pain level N ED Type of clinic/location where visit occurred (family practice, cardiology, etc.)

N OP

Has patient been seen in clinic/location before

N OP

If yes, how many visits in previous 12 months (excluding this visit)

N OP

Anesthesia Provider Type N OP

Is this visit for a new problem, chronic problem (routine or flare-up), preventive care, pre-/post-surgery, surgery/procedure

N OP

Did someone attempt to follow-up with this patient within 24-hours after this surgery

N OP

If follow-up attempt was made, what was learned?

N OP

Type(s) of Anesthesia administered N OP

Gestation week (if applicable) N OP

Patient Asthmatic N OP Asthma Severity N OP

Asthma Control N OP

Initial or follow-up visit? N ED, OP

If injury, cause and intentionality N ED, OP

Required Data Element:

Y=Yes N=No, optional but would like to have

Type of Visit:

IP=Inpatient ED=Emergency Department OPD=Outpatient Department