Attach. 1 Q A.doc

MPSMS DATA DICTIONARY

General Screen Set [SET1]

Instructions:

When variable Help is not sufficient to make an abstraction decision, the General Abstraction Guidelines will be utilized with the following modifications:

Qualifiers

The following Qualifiers should be abstracted as positive findings:

Consistent with

Diagnostic

Evidence of

Indicative of

Most likely

Possible

Presumed

Probable

Suggestive of

The following Qualifiers should be abstracted as negative findings:

Cannot exclude

Cannot rule out

Consider

Could reflect

Could represent

May have

May have had

May indicate

Questionable

Risk of

Ruled out (r'd/o, r/o'd)

Symptoms of

Suspect

Suspicious

"On arrival/Time of admission" Definition:

"On arrival" is the patient's first 24-hours in the hospital upon arrival to the facility.

To determine the 24-hour timeframe, take the Arrival Date and Time and add 24-hours.

Example:

The patient arrives at the hospital on 5/29/02 at 07:30, add 24-hours, which give a timeframe of 07:30 the 29th of May to 07:30 the 30th of May.

The documentation is restricted to arrival documentation. An arrival document is any documentation that is produced within the first 24-hours of the hospitalization.

Guidelines:

Findings will be abstracted from the entire medical record unless a specific variable limits sources.

All dates must be entered in the mm/dd/yyyy format.

To copy the arrival date to any date field that is not in a grid, enter Shift + R.

To copy the admission date to any date field that is not in a grid, enter Shift + A.

To copy the discharge date to any date field that is not in a grid, enter Shift + D.

All times should be entered in military time format.

Unless otherwise stated within the variable Help, Synonym and Inclusion lists are not all-inclusive.

General Culture Abstraction Guidelines:

The Discharge summary will be an EXCLUDED SOURCE for all culture variables.

Gram stain results will not be abstracted as culture results.

Any bacterial growth not identified as a contaminated specimen is a positive culture result.

Contaminated specimens with bacterial growth will be abstracted as a positive culture unless the Lab report states it was contaminated in the Lab and re-collection is recommended. In this case, the Lab will not have actually performed the culture.

If a Lab report states that a contamination is suspected, but shows organism growth, the culture will be abstracted as a positive.

May represent contamination

Minimally contaminated (if other than Lab contamination)

Question of contamination

Beta lactamase is not an organism. It is only a description of an organism (positive vs. negative). It is a test that is sometimes performed on the organisms that grow out in order to guide initial selection of an antibiotic.

Example:

The blood culture report states that the organism grown is beta-lactamase positive staph aureus; abstract staph aureus.

Lab reports vs. other documents when abstracting cultures.

Match preliminary and final reports.

Accession numbers

Collected date and times.

Ordered dates and times noted on lab sheets.

Date Abstraction Guidelines:

1) Only take culture collection date from a lab report if the date shown on that report is clearly marked as "collection date," " date drawn," or "date obtained." Do not take dates from the lab reports if they are unqualified dates, or are marked as anything other than date collected, drawn, or obtained. "Received dates", "log in dates", or "start dates" are not to be abstracted.

2) If there is conflict between the lab sheet collection date and other documentation showing an earlier date, always take the collection date shown on the lab sheet.

3) If the date on the lab sheet is not "collection" date, abstract the earliest date shown in the record indicating the culture was collected. This may include notations on emergency room face sheets that show an order for cultures, with a time written in after the order. Nursing documentation that specimen was collected is acceptable only if it is clear that the sample was actually obtained.

Other abstraction instructions:

1) If there is documentation that a culture is done, and the time frame of the culture collection is documented but there is no report of results available, abstract "Yes" for culture done. Abstract the date if available, if not enter "X". When asked if the culture was positive, select "UTD."

2) When abstracting organisms from culture reports, abstract all organisms on the final report only. If a final report is not available, abstract all organisms from the last preliminary report available.

Example:1:

Collection date 12/01/93

Preliminary report 12/02/93 - few normal flora

Final report 12/03/93 - staphylococcus aureus

Culture positive -- YES

Example:2:

Collection date 08/05/93

Preliminary report 08/07/93 - Enterococcus faecium

Preliminary report 08/11/93 - no bacteria seen

Culture positive --NO

4) Follow these examples for entering aerobic/anaerobic cultures:

Final or last preliminary report states: Staph aureus in aerobic bottle only. No growth in anaerobic bottle. Enter as only one positive culture.

Final or last preliminary report states: Staph aureus in both bottles. Enter as one positive culture.

Two separate final or last preliminary reports are found in labs, one titled anaerobic blood culture, one titled aerobic blood culture each with a separate accession, specimen or sample number; enter each report as a separate culture.

If uncertain, consult a clinical supervisor.

Two lists follow; the first shows the names on the list for data entry. The second should be used for reference for data entry of organisms not on the data entry list. If an organism is found that does not match either list, "Other" should be selected and the organism name typed into the text entry box.

Organism names on entry list:

Other (type in entry)

Acinetobacter

Actinomycosis

Arachnia propionica

Aspergillus, unspecified

Aspergillus flavus

Aspergillus fumigatus

Aspergillus niger

Aspergillus terreus

Bacillus species

Bacteroides

Bifidobacterium

Blastomyces dermatitidis

Bordetella pertussis

Branhamella catarrhalis

Candida krusei

Candida parapsilosis

Candida torulopsis

Candida tropicalis

Candida, albicans

Candida, unspecified

Chlamydia pneumonia (TWAR)

Chlamydia psittaci

Chlamydophila

Citrobacter diversus

Citrobacter freundii

Citrobacter, unspecified

Clostridium difficile

Clostridium perfringens

Clostridium, unspecified

Coagulase Negative Staphylococci

Coccidioides, immitis

Coccidioides, unspecified

Coronavirus

Corynebacterium diphtheriae

Corynebacterium-Other

Coxiella burnetii

Cryptococcus neoformans

Edwardsiella tarda

Edwardsiella, unspecified

Eikanella corrondes

Enterobacter aerogenes

Enterobacter agglomerans

Enterobacter cloacae

Enterobacter, other

Enterobacter, unspecified

Enterococcus

Escherichia coli

Francisella tularensis

Fungus

Fungus-Other

Fusabacterium

Hafnia alvei

Hafnia, unspecified

Hemophilus influenza

Hemophilus parainfluenza

Histoplasma capsulatum

Klebsiella oxytoca

Klebsiella pneumoniae subsp. ozaenae

Klebsiella pneumoniae subsp. pneumoniae

Klebsiella pneumoniae subsp. rhinoscleromatis

Lactobacillus

Legionella micdadei

Legionella pneumophila

Legionella, other

Leptotrichia buccalis

Micrococcus

Moraxella

MRSA (Methicillin resistant staph aureus)

Mucor (any species)

Mycobacterium, other

Mycoplasma pneumoniae

Neisseria gonorrhoeae

Neisseria lactamica

Neisseria meningitidis

Neisseria, unspecified

Nocardioides

Norcardia

Paracoccidioides brasiliensis

Peptostreptococcus

Propionibacterium acnes

Proteus

Proteus mirabilis

Proteus penneri

Proteus valgaris

Proteus-Other

Providencia alcalifaciens

Pseudoallescheriasis

Pseudomonas

Pseudomonas aeruginosa

Pseudomonas, other

Respiratory syncytial virus

Rothia dentocariosa

Salmonella species

Selenomonas sputigena

Serratia liquefaciens

Serratia marcescens

Serratia, unspecified

Staphylococcus aureus (pyogenes)

Staphylococcus epidermidis

Staphylococcus-NOS

Staphylococcus-Other

Streptococcus canis

Streptococcus group A (pyogenes)

Streptococcus group B (agalactiae)

Streptococcus group C

Streptococcus group D (bovis; suis)

Streptococcus pneumoniae

Streptococcus-NOS

Streptococcus-Other

Treponema denticola

Veillonella

Vibrio sputorum

Viridans streptococci

VRE (Vancomycin resistant enterococcus)

Yersinia enterocolitica

Yersinia pestis

Yersinia pseudotuberculosis

Yersinia, unspecified

Zygomycosis Absidia species

Zygomycosis Mucor species

Zygomycosis Rhizapus species

Zygomycosis, unspecified

Additional instructions for entry:

Acinetobacter baumanii = Acinetobacter

Acinetobacter coalcoaeticus = Acinetobacter

Acinetobacter haemolyticus = Acinetobacter

Acinetobacter lwoffii = Acinetobacter

Alcaligenes xylosoxidans = Other

Alpha hemolytic streptococcus = Streptococcus, NOS

Alpha strep = Streptococcus, NOS

Alpha strep not group A = Streptococcus, Other

Alpha streptococcus Haemophilus = two entries, 1) Streptococcus, NOS and 2) Hemophilus influenza

Aspergillus, not fumigatus = Aspergillus, unspecified

B-hemolytic group A strep = Streptococcus group A

Bacteriodes fragilis = Bacteroides

Beta hemolytic strep group A = Streptococcus group A

Beta hemolytic streptococcus group B = Streptococcus group B (agalactiae)

Beta hemolytic streptococci group G = Streptococcus, other

Beta strep = Streptococcus, NOS

Beta strep group F = Streptococcus, Other

Branhamella = Branhamella catarrhalis

Calcoaceticus = Acinetobacter

Candida glabrata = Candida, Unspecified

C. diffcile toxin = Clostridium, unspecified

Citrobacter koserii = Citrobacter, unspecified

Coag negative staph = Coagulase negative Staphylococci

Coag positive staph = Staphylococcus aureus (pyogenes)

Coliform = Enterobacter, Unspecified

Comamonas acidovorans = Pseudomonas, Other

Corynebacterium xerosis = Corynebacterium, Other

Corynebacterium species = Corynebacterium, Other

Diphtheroids = Corynebacterium, Other

Enterobacter group use Enterobacter, Unspecified

Enterobacter, taylorae = Enterobacter, unspecified

Enterococcus durans = Enterococcus

Enterococcus faecalis = Enterococcus

Enterococcus faecium = Enterococcus

Enterococcus group D = Enterococcus

Flavobacterium indologenes = Other

Gamma strep, NOS = Streptococcus, Other

Gamma streptococcus = Streptococcus, Other

H. influenza III = Hemophilus influenza

H. Influenza type A, NOS = Hemophilus influenza

H. Influenza type A, viral = Influenza A virus

Hemophilus (no other identification given) = -Hemophilus influenza

Haemophilus/Haemophilus species = Hemophilus influenza

Haemophilus influenza B = Hemophilus influenza

Haemophilus influenza Biotype III = Hemophilus influenza

Hemophilus parahemolyticus = Hemophilus parainfluenza

Kleb-enterobacter = Enterobacter, Unspecified

Klebsiella = Klebsiella pneumonia subsp. pneumoniae

Klebsiella pneumonia = Klebsiella pneumoniae subsp. pneumoniae

Lactose fermenter = Other

Maltophilia (Maltophila) = Pseudomonas, Other

Mannitol negative staph = Staphylococcus epidermidis

Micro aerophilic streptococcus = Streptococcus, other

Micrococci use Micrococcus

Mold = Fungus, other

Moraxella branhamella catarrhalis = Moraxella

Moraxella catarrhalis = Moraxella

Moraxella osloensis = Moraxella

Morganella morgani = Proteus, Other

Mycobacterium = Mycobacterium, Other

Mycobacterium avium = Mycobacterium, Other

Mycobacterium gordonae = Mycobacterium, other

Neisseria = Neisseria, unspecified

Neisseria saprophytic = Neisseria, unspecified

Non A, non B, beta hemolytic strep = Streptococcus, Other

Non-hemolytic Strep = Streptococcus, Other

Oospora = Fungus, Other

Pasturella = Other

Pneumococcus = Streptococcus pneumoniae

Proteus species = Proteus, Other

Pseudomonas = Pseudomonas, Other

Pseudomonas fluorescens = Pseudomonas, other

Pseudamonas paucimobilis = Pseudomonas, Other

Saccharomyces Cerevisiae = Fungus, Other

Salmonella = Salmonella species

Sept or non-septated hyphae = Fungus, other

Staph = Staphylococcus, NOS

Staphylococcus auricularis = Staphylococcus, Other

Staphylococcus capitis = Staphylococcus, Other

Staphylococcus coagulase negative = Coagulase negative Staphylococci

Staphylococcus, coagulase positive = Staph aureus

Staphylococcus haemolyticus = Staphylococcus, Other

Staphylococcus hominis = Staphylococcus, Other

Staphylococcus warneri = Staphylococcus, Other

Streptococcus constellatus = Viridans streptococci

Streptococci B Beta hemolytic group H = Streptococcus, Other

Streptococcus group A / B-hemolytic = Streptococcus group A

Streptococci group G = Streptococcus, Other

Streptococcus sang = Viridans streptococci

Streptococcus viridans = Viridans Streptococci

Torulopsis = Candida torulopsis

Torulopsis glabrata = Candida torulopsis

Trichosporon penicillatum = Fungus, Other

Tuberculosis = Mycobacterium tuberculosis

Vibrio parahemolyticus = Other

Xanthomonas maltophila = Pseudomonas, Other

Yeast = Fungus, Other

Yeast, not cryptococcus = Fungus, Other

Zygomycetes = Zygomycosis, unspecified

Antibiotics:

Abelcet

A-Cillin

Adoxa alatrofloxacin mesylate

Albamycin

AmBisome amikacin amikacin sulfate

Amikacin Sulfate-Sodium Chloride

Amikin

Amikin Pediatric aminosalicylic acid amoxicillin amoxicillin (as trihydrate) amoxicillin-clavulanate

Amoxicot

Amoxil

Amoxil Pediatric Drops

Amphotec amphotericin B amphotericin B cholesteryl sulfate amphotericin B lipid complex amphotericin B liposomal amphotericin liposomal ampicillin ampicillin (anhydrous) ampicillin sodium ampicillin-probenecid ampicillin-sulbactam

Ancef

Ancobon

Anidulafungin

Apo-metronidazole

Aralen Hydrochloride

Aralen Phosphate

Arestin atovaquone

Augmentin

Augmentin ES-600

Avelox

Avelox I.V.

Azactam

Azasite azithromycin

Azo Gantanol

Azo Gantrisin

Azo-Sulfisoxazole

Azo-Truxazole aztreonam

Azulfidine

Azulfidine EN-tabs bacampicillin bacampicillin hydrochloride

Baci-IM

Baci-Rx bacitracin

Bactocill

Bactramycin

Bactrim

Bactrim DS

Bactrim I.V.

Bactrim Pediatric balsalazide

Beepen-VK

Biaxin

Biaxin XL

Biaxin XL-Pak

Bicillin C-R

Bicillin L-A

Biocef

Biomox

Bio-Statin

Cancidas carbenicillin carbenicillin indanyl sodium caspofungin caspofungin acetate

Cayston

Ceclor

Ceclor CD

Ceclor Pulvules

Cedax cefaclor

Cefaclor CD cefadroxil

Cefadroxil Monohydate

Cefadyl cefamandole cefamandole nafate cefazolin cefazolin sodium cefdinir cefditoren cefditoren pivoxil cefepime cefepime hydrochloride cefixime

Cefizox cefmetazole cefmetazole sodium

Cefobid cefonicid cefonicid sodium cefoperazone cefoperazone sodium

Cefotan cefotaxime cefotaxime sodium cefotetan cefotetan disodium cefoxitin cefoxitin sodium cefpodoxime cefpodoxime proxetil cefprozil ceftazidime ceftazidime sodium ceftibuten

Ceftin ceftizoxime ceftizoxime sodium ceftriaxone ceftriaxone sodium cefuroxime cefuroxime axetil cefuroxime sodium

Cefzil cephalexin cephalexin hydrochloride cephalexin monohydrate cephalothin cephalothin sodium cephapirin cephapirin sodium cephradine

Ceptaz chloramphenicol chloramphenicol sodium succinate

Chloromycetin

Chloromycetin Sodium Succinate chloroquine chloroquine hydrochloride chloroquine phosphate cilastatin sodium

Cinobac cinoxacin

Cipro

Cipro I.V.

ciprofloxacin ciprofloxacin hydrochloride

Claforan clarithromycin clavulanate potassium

Cleocin HCl

Cleocin Pediatric

Cleocin Phosphate clindamycin clindamycin hydrochloride clindamycin palmitate hydrochloride clindamycin phosphate clotrimazole cloxacillin cloxacillin sodium

Cloxapen colistimethate colistimethate sodium

Coly Mycin M

Cotrim

Cotrim DS

Cotrim Pediatric

Cubicin

Cystex dalfopristin dalfopristin-quinupristin

Daptomycin

Declomycin demeclocycline demeclocycline hydrochloride dicloxacillin dicloxacillin sodium

Diflucan

Dipentum dirithromycin

Doribax

Doripenem

Doryx

Doxy Lemmon

Doxy-Caps doxycycline doxycycline calcium doxycycline hyclate doxycycline monohydrate

Doxy-D

Duricef

Dycill

Dynabac

Dynacin

Dynapen

E.E.S. Granules

E.E.S.-200

E.E.S.-400

E.E.S.-400 Filmtab

E-Mycin enoxacin

Eraxis ertapenem ertapenem sodium

Eryc

EryPed

Eryped 200

Eryped 400

Ery-Tab

Erythrocin Lactobionate

Erythrocin Stearate Filmtab erythromycin

Erythromycin Base

Erythromycin ES erythromycin estolate erythromycin ethylsuccinate erythromycin gluceptate erythromycin lactobionate erythromycin stearate

Erythromycin, Suspension erythromycin-sulfisoxazole

Eryzole ethionamide

Factive

Famazole

Flagyl

Flagyl 375

Flagyl ER

Flagyl I.V.

Flagyl I.V. RTU

Floxin

Floxin I.V.

fluconazole flucytosine

Fortaz fosfomycin fosfomycin tromethamine

Fulvicin P/G

Fulvicin U/F

Fungizone

Fungizone For Tissue Culture

Furadantin furazolidone

Furoxone

Gantanol

Gantrisin

Gantrisin Pediatric

Garamycin gatifloxacin gemifloxacin gemifloxacin mesylate gentamicin gentamicin sulfate

Geocillin

G-Mycin grepafloxacin grepafloxacin hydrochloride

Grifulvin V

Grisactin 250

Grisactin 500

Grisactin Ultra griseofulvin griseofulvin, microcrystalline griseofulvin, ultramicrocrystalline

Gris-PEG

Hiprex

Humatin hydroxychloroquine

Hydroxychloroquine Sulfate hyoscyamine-methenamine

Ilosone

Ilotycin Gluceptate imipenem imipenem-cilastatin

Invanz

Isoject Permapen isoniazid itraconazole

Jenamicin kanamycin kanamycin sulfate

Kantrex

Keflex

Keflin

Keftab

Kefurox

Kefzol

Ketek

Ketek Pad ketoconazole

Lagyl

Lamisil

Ledercillin VK

Levaquin levofloxacin

Lincocin lincomycin lincomycin hydrochloride

Lincorex linezolid

L-Mycin lomefloxacin lomefloxacin hydrochloride

Lorabid

Lorabid Pulvules loracarbef

Lyphocin

Macrobid

Macrodantin

Mandelamine

Mandol

Marcillin

Maxaquin

Maxipime

Mefoxin

Mepron meropenem

Merrem methenamine methenamine hippurate methenamine mandelate methenamine-sodium acid phosphate methenamine-sodium biphosphate methicillin methicillin sodium

Metizol

Metro I.V.

Metronid metronidazole metronidazole benzoate metronidazole hydrochloride

Metryl

Mezlin mezlocillin mezlocillin sodium

Micafungin miconazole

Minocin minocycline minocycline hydrochloride

Monistat I.V.

Monocid

Monodox

Monurol moxifloxacin moxifloxacin hydrochloride

Moxilin

Mycamine

Mycelex Troche

Mycifradin

Mycostatin

Mycostatin Pastilles nafcillin nafcillin sodium nalidixic acid

Nallpen

Nebcin

Nebcin Pediatric

Nebupent

Neggram

Neo-Fradin

Neo Metric neomycin neomycin base (as neomycin sulfate) neomycin sulfate

Neo-Rx

Neo-Tab netilmicin netilmicin sulfate

Netromycin

Neutrexin

Nilstat

Nitro Macro nitrofurantoin nitrofurantoin monohydrate nitrofurantoin, macrocrystals

Nizoral norfloxacin

Noroxin novobiocin novobiocin sodium

Noxafil

Nydrazid

Nystatin

Nystex ofloxacin

Omnicef

Omnicef Omni-Pac

Omnipen

Omnipen-N

Oracea oxacillin oxacillin sodium oxytetracycline oxytetracycline hydrochloride oxytetracycline/phenazopyridine/sulfamethizol

Panmycin paromomycin paromomycin sulfate

Paromycin

Paser D/R

PC Pen VK

PCE Dispertab

Pediazole

Penetrex penicillin penicillin G benzathine penicillin G potassium penicillin G procaine penicillin G sodium penicillin V potassium

Pentam 300 pentamidine pentamidine isethionate

Pen-V

Pen-Vee K

Periostat

Pfizerpen phenazopyridine phenazopyridine hydrochloride phenazopyridine-sulfamethoxazole phenazopyridine-sulfisoxazole piperacillin piperacillin sodium piperacillin-tazobactam

Pipracil

Plaquenil Sulfate

Polycillin-PRB polymyxin B sulfate posaconazole primaquine primaquine phosphate

Primaxin IM

Primaxin IV

Primsol

Principen

Proloprim

Proquin XR

Protostat pyrazinamide quinacrine

Quinacrine HCL Dihydrate quinacrine hydrochloride dihydrate

Quineprox quinupristin

Raxar

Robimycin

Robitet 500

Rocephin

Rocephin IM Convenience Kit

Satric

Septra

Septra DS

Septra I.V.

Septra Infusion

SK-Metronidazole

SMX-TMP Plain

Solodyn sparfloxacin spectinomycin spectinomycin hydrochloride

Spectracef

Spectrobid

Sporanox

Staphcillin streptomycin streptomycin sulfate sulbactam sodium sulfadiazine

Sulfadiazine Sodium sulfamethizole sulfamethoxazole sulfamethoxazole-trimethoprim

Sulfamethoxazole-Trimethoprim DS sulfasalazine

Sulfatrim

Sulfatrim Pediatric

Sulfatrim Suspension sulfisoxazole sulfisoxazole acetyl

Sumycin

Suprax

Suspen

Synercid

Tao

Tazicef

Tazidime tazobactam sodium

Tegopen

Telavancin

Telithromycin

Tequin

Tequin Teqpaq terbinafine terbinafine hydrochloride

Terramycin

Terramycin IM

Tetra 500

Tetracap

Tetracon tetracycline tetracycline hydrochloride

Thiosulfil Forte

Ticar ticarcillin ticarcillin disodium ticarcillin-clavulanate

Tigecycline

Timentin

Tindamox

Tinidazole

Tobi tobramycin tobramycin sulfate

Totacillin

Totacillin-N

Trecator-SC trimethoprim trimetrexate trimetrexate glucuronate

Trimox

Trimpex

Trobicin troleandomycin

Tygacil

Ultracef

Unasyn

Unipen

Urex

Urisedamine

Urobiotic-250

Urolene Blue

Uro-Phosphate

Uroplus

Uroplus DS

Vanco

Vancocin

Vancocin HCl

Vancocin HCl Pulvules

Vancoled vancomycin

Vancomycin HCl vancomycin hydrochloride

Vantin

V-Cillin K

Vectrin

Veetids

Velosef

Vfend

Vibativ

Vibramycin

Vibramycin Calcium

Vibramycin Hyclate

Vibramycin Monohydrate

Vibra-Tabs

Voriconazale

Wycillin

Wymox

Zagam

Zagam Respipac

Zartan

Zefazone

Zefazone I.V.

Zinacef

Zithromax

Zithromax IV

Zithromax Z-Pak

Zosyn

Zmax

Zyvox

Demographics Screen [DEMO]

Social Security Number (NCH) [SSN]

Social Security Number [PSMSSN]

Question:

What was the patient's Social Security Number?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Emergency room notes, History and physical (H&P), Progress notes, Nursing admission assessment.

Instructions:

Enter the patient's Social Security Number.

Guidelines:

Use documentation from the Face sheet first. If there is no documentation or conflicting documentation on the Face sheet, look at the additional sources. If there is no documentation or conflicting documentation on the additional sources, enter Shift ? (X).

If the only documentation within the entire medical record contains all 9's or all 0's, enter Shift ? (X).

If a number is documented as a SSN and contains too many or too few numbers, look further for other documentation. If no other documentation is available, enter Shift ? (X).

Do not abstract "123456789". Enter Shift ? (X) if this is the only documentation.

Do not abstract a number as the SSN unless specifically labeled as such.

Synonyms/Inclusions:

SS

SS#

SSN

SSAN

SS No.

Social Security Administration Number

Medicare ID/HIC number (NCH) [HICNUM]

Medicare ID/HIC number [PSMHIC]

Question:

What was the patient's Medicare ID/Health Insurance Claim (HIC) number?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Emergency room notes, History and physical (H&P), Progress notes, Nursing admission assessment.

Instructions:

Enter the patient's Medicare ID/Health Insurance Claim (HIC) number.

Guidelines:

Use documentation from the Face sheet first. If there is no documentation or conflicting documentation on the Face sheet, look at the additional sources. If there is no documentation or conflicting documentation on the additional sources, enter Shift ? (X).

Do not abstract "123456789A". Enter Shift ? (X) if this is the only documentation.

If a number is labeled as the HIC#, but contains too many digits and cannot be entered, enter Shift ? (X).

Synonyms/Inclusions:

HMO or Private Insurance if labeled as a Medicare number.

MC#

Medicare Subscriber Number

Payment source [PS7PYMNT]

Question:

Is Medicare the payer?

Sources:

Facesheet

Instructions:

Options:

a.

Mark "Yes" if Medicare is the payer.

b.

Mark "No" if Medicare is not the payer.

c.

Mark "UTD" if there is insufficient information or if documentation is illegible.

Date of birth (NCH) [BENE_DOB]

Date of birth [PSMDOB]

Question:

What was the patient's date of birth?

Sources:

Preferred Sources:

Face sheet.

Additional Sources:

Admission record, ER record, Registration form.

Instructions:

Guidelines:

Use documentation from the Face sheet first. If there is no documentation or conflicting documentation on the Face sheet, look at the additional sources. If there is no documentation or conflicting documentation on the additional sources, enter Shift ? (X).

If there is no date of birth documented in the record, enter Shift ? (X).

A four-digit year must be entered for this variable (i.e. 07/30/1925).

Race (NCH) [RACE_CD]

Race [PSMRACE]

Question:

What was the patient's race?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Emergency room record, History and physical (H&P), Nursing admission assessment, Physician assessment, EKG.

Instructions:

Enter the patient's race as defined below. For the purposes of this variable, the patient's race is synonymous with origin/nationality.

Guidelines:

Use documentation from the Face sheet first. If there is no documentation or conflicting documentation on the Face sheet, look at the additional sources. If there is no documentation or conflicting documentation on the additional sources, select "UTD".

Do not use a number system to abstract the race unless a number key is provided.

If the only documentation found in the medical record states 'Hispanic', select "UTD"

Do not use a patient's language to determine race. Look for further documentation.

If "C" is the first documentation of race that you see, look further for clarification. Although "C" often means Caucasian, this is not always true. If no further documentation is available, select "UTD".

Options:

a.

Mark "Caucasian/White" if the patient's race was Caucasian/White or having origins in Europe, the Middle East or North Africa.

Synonyms/Inclusions:

Ca

CAU

Caucasian

Iranian

Middle Easterner

W

WH

Whi

White b.

Mark "African American/Black/Negro" if the patient's race was African American/Black/Negro.

Synonyms/Inclusions:

AA

African-American

B

Black

Haitian

Negro c.

Mark "American Indian/Alaska Native" if the patient's race was American Indian/Alaska Native.

Synonyms/Inclusions:

Alaska Native

American Indian

Any recognized tribal entity in North and South America (including Central America) (i.e., Aztec, Cherokee, Apache)

Native American d.

Mark "Asian" if the patient's race was Asian/Far East/Indian.

Synonyms/Inclusions:

Asian

Asian-American

Cambodian

Chinese

Far East

Filipino

Japanese

Korean

Malaysian

Oriental

Pakistani

South East Asian

Thailand

Vietnamese e.

Mark "Native Hawaiian/Pacific Islander" if the patient's race was Native Hawaiian/Pacific Islander.

Synonyms/Inclusions:

Guam

Hawaiian

Other Pacific Islands

Samoan f.

Mark "Other" if the race does not fit into one of the categories.

Synonyms/Inclusions:

Mixed Race g.

Mark "UTD" if there is insufficient information or if documentation is illegible.

Synonyms/Inclusions:

A

O

Hispanic

Spanish

Ethnic [ETHNIC]

Hispanic [PSMETHN]

Question:

Is the patient Hispanic?

Sources:

Preferred Sources:

Admission face sheet, Discharge summary, Emergency room record, History and physical (H&P), Nursing admission assessment, Discharge summary.

Instructions:

Determine if the patient's ethnicity is Hispanic.

Options:

a.

Mark "Yes" if:

the record documents that the patient is Hispanic.

the patient is Hispanic of mixed ethnicity.

Synonyms/Inclusions:

Any mixed ethnicity which includes Hispanic

Black-Hispanic

Central American

Chicano

Cuban

H

Hispanic

Latin American

Latino/Latina

Mexican

Mexican-American

Puerto Rican

South American

Spanish

White-Hispanic b.

Mark "No" if:

the patient's ethnicity is something other than Hispanic.

the patient's ethnicity is not addressed.

the patient is not identified as Hispanic.

Last name (NCH) [BENESRNM]

Last name [PS7LSTNM]

Question:

What is the patient last name?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Emergency room notes, History and physical (H&P), Progress notes, Nursing admission assessment.

Instructions:

Enter the patient's last name.

First name (NCH) [BENEGVNM]

First name [PS71STNM]

Question:

What is the patient's first name?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Emergency room notes, History and physical (H&P), Progress notes, Nursing admission assessment.

Instructions:

Enter the patient's first name.

ZIP code (NCH) [BENE_ZIP]

Zip Code [PS7ZIP]

Question:

What is the patient's zip code?

Sources:

Facesheet.

Instructions:

Enter the patient's zip code.

Arrival date [PSMARRDT]

Question:

What was the date the patient arrived at the hospital?

Sources:

Preferred Sources:

Emergency room notes, History and physical (H&P), Progress notes, Nursing admission assessment.

Instructions:

NOTE:

This may differ from the admission date.

Guidelines:

Do not use the face sheet or ambulance record for this information. The intent of this variable is to capture the earliest time the patient was in the hospital.

If the patient is admitted for 23-hour observation and later admitted to the unit or floor, abstract the date the patient arrived at the hospital for the 23-hour observation.

Do not take dates from address-o-graphs/stamps.

Arrival dates can be taken from signed consent forms and half-and-half ER forms (half Registration/half Clinical information or Consent form).

If the patient is admitted to the hospital to a non-acute care unit (i.e. psychiatric or rehab), and is then transferred to acute care, the arrival date would be the date the patient is transferred to the acute care phase.

Patient expire [PS2EXPIR]

Question:

Did the patient expire?

Sources:

Preferred Sources:

Discharge summary, Physician progress notes.

Instructions:

Options:

a.

Mark "Yes" if the patient expired.

b.

Mark "No" if the patient did not expire.

Admission date (NCH) [ADMSN_DT]

Adm. date [PSMADMDT]

Question:

What was the date the patient was admitted to the hospital?

Sources:

Preferred Sources:

Emergency Room Notes, Face Sheet, Discharge Summary, History & Physical (H&P), Progress Notes, Nursing Admission Assessment.

Instructions:

Guidelines:

If either the admission date or the discharge date do not agree with the UB-92 information, give the chart to your supervisor or troubleshooter for further investigation.

Enter the date the patient was admitted to the hospital as an inpatient. If the patient arrives through the ER and is held in observation for a day or two, use the actual date of admission to the hospital for the admission date, not the arrival date to the ER. This guideline applies to both observation stays and ER stays which extend past midnight.

Discharge date (NCH) [CLM_THRU]

D/C date [PSMDCDT]

Question:

What was the date the patient was discharged from the hospital, left against medical advice, or expired?

Sources:

Preferred Sources:

Discharge summary, Transfer note, Nursing discharge note, Progress notes, Test reports, Graphic sheet.

Instructions:

Guidelines:

If either the admission date or the discharge date found in the chart do not agree with the UB-92 information, give the chart to your supervisor or troubleshooter for further investigation.

If the patient is discharged and readmitted on the same day, you will abstract all dates of service as one hospital stay..

Example: Cover sheet has the dates of service as 9/21/09-9/23/09. The patient was discharged on 9/23/09 and readmitted the same day. He was then discharged again on 9/25/09. You will abstract the discharge date of 9/25/09.

Gender (NCH) [BENE_SEX]

Gender [PSMSEX]

Question:

What was the patient's gender?

Sources:

Priority Sources:

Face sheet.

Additional Sources:

Registration form, Admission record, ER record, Nursing assessment.

Instructions:

Guidelines:

Do not use a number system for abstracting gender unless a key is included in the record (i.e. 1=Male, 2=Female, etc).

Use documentation from the Face sheet first. If there is no documentation or conflicting documentation on the Face sheet, look at the additional sources. If there is no documentation or conflicting documentation on the additional sources, select "UTD".

Options:

a.

Mark "Male" if the patient was male.

b.

Mark "Female" if the patient was female.

c.

Mark "UTD" if there is insufficient information or if documentation is illegible.

Hospital number (NCH) [PROV_NUM]

Provider number [PS7PRVNM]

Question:

What is the provider number for this record?

Sources:

Coversheet

Instructions:

Enter the provider number for this record.

Hospital Patient Identifier [PS7HPI]

Question:

What was the number used by the hospital to identify this patient's stay?

Sources:

Coversheet

Instructions:

The number used by the hospital to identify this patient's stay.

Arrival date label [PS7LABEL]

State ID [PS7STATE]

Question:

What is the state ID?

Sources:

Facesheet, Coversheet.

Instructions:

Enter the two character state abbreviation.

Hx/CF 1 Screen [COND]

History or Current Conditions [PSMLAB1]

Cancer [PSMCANCR]

Question:

Is there documentation of a history or current finding of cancer?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary.

Sources Excluded:

Test reports (this includes Cardiac caths and Echocardiograms), Lab reports.

Instructions:

Indicate whether or not there is documentation of a history or current finding of cancer.

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of cancer.

Synonyms/Inclusions:

Acute leukemia

Acute myelogenous leukemia (AML)

Astroblastoma

Astrocytoma

Brain CA

Brain cancer

Brain malignancy

Breast cancer

Burkitt's lymphoma

Ca

Cancers ending in "oma"

Carcinoma with metastasis

Cerebellar carcinoma

Craniopharyngioma

Disseminated cancer

Dukes C or D

Ependymoma

Ganglioneuroma

Glioblastoma

Glioblastoma multiforme

Glioma

Hemangioblastoma

Hodgkin's disease

Inoperable tumor/cancer (inoperable in that it cannot be surgically removed)

Leukemia

Lymphoblastic leukemia (ALL)

Lymphoma

Lymphocytic leukemia (CLL)

Lymphosarcoma

Malignancy

Malignant glioma

Malignant meningioma

Malignant neoplasm

Medulloblastoma

Melanoma

Melanoma with metastasis

Meningioma

Metastasis

Metastatic carcinoma

Metastatic intraparenchymal tumor

Metastatic leptomeningeal carcinomatosis

Metastatic neoplasm

Mets Ca

Myelocytic leukemia (CML)

Multiple myeloma

Non-Hodgkin's lymphoma (NHL)

Oligodendroglioma

Sarcoma with metastasis

Seminoma

Squamous cell carcinoma (any site except skin)

Tumor with metastasis

Waldenstrom's macroglobulinemia

Exclusions:

Tubular adenoma b.

Mark "No" if there is no documentation of a history or current finding of cancer.

Cerebrovascular Disease (CVD) [PSMCVD]

Question:

Is there documentation of a history or current finding of cerebrovascular disease (CVD)?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary.

Sources Excluded:

Test reports (this includes Cardiac caths and Echocardiograms), Lab reports.

Instructions:

Indicate whether or not there is documentation of a history or current finding of cerebrovascular disease (CVD).

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of cerebrovascular disease.

b.

Mark "No" if there is no documentation of a history or current finding of cerebrovascular disease.

Synonyms/Inclusions:

Amaurosis fugax

Anterior circulation event

Brain infarct

Carotid arterial disease

Carotid arterial occlusion

Carotid endarterectomy (CEA)

Carotid stenosis, marked, significant, >80%

Cerebellar stroke

Cerebral artery occlusion

Cerebral artery thrombosis

Cerebral bleed

Cerebral bleeding/hemorrhage

Cerebral embolism

Cerebral infarct

Cerebral hemorrhage

Cerebral occlusion

Cerebral thromboembolism

Cerebral thrombosis

Cerebrovascular accident (CVA)

Cerebrovascular disease

Cerebrovascular incident (CVI)

CNS intracranial blood vessel distribution stroke/bleed

Brainstem stroke/bleed

Cerebellar stroke/bleed

Frontal stroke/bleed

Medullary stroke/bleed

Occipital stroke/bleed

Parietal stroke/bleed

Pontine stroke/bleed

Posterior fossa stroke/bleed

Temporal stroke/bleed

CVA

CVA, age undetermined

Epidural hematoma (EDH)

Epidural hemorrhage

Hemorrhagic cerebrovascular accident (CVA)

Hemorrhagic infarct of the brain

Hemorrhagic stroke

Intracerebral bleed/hemorrhage (ICH)

Intracranial bleed/hemorrhage (ICH)

Infarct of the brain

Intracerebral bleed or hemorrhage

Intracranial bleed or hemorrhage

Intraparenchymal hemorrhage

Ischemic event (right/left)

Ischemic changes

Ischemic stroke/infarct

Lacunar infarct

Meningeal hemorrhage

Parietal lobe infarct

Parietal lobe stroke

Reversible ischemic neurologic deficit (RIND)

Right or left carotid circulation/distribution stroke

Right or left hemispheric stroke/infarct

Stroke

Subarachnoid hemorrhage

Subdural hematoma

Subdural hemorrhage

Thromboembolic cerebral event

Transient ischemic attack (TIA)

Vertebrobasilar stroke

Exclusions:

Multi-infarct dementia

CHF/Pulmonary Edema [PSMCHFPE]

Question:

Is there documentation of a history or current finding of CHF/Pulmonary Edema?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary, Anesthesia record.

Sources Excluded:

Test reports (this includes Cardiac caths and Echocardiograms), Lab reports.

Instructions:

Indicate whether or not there is documentation of a history or current finding of CHF/Pulmonary Edema.

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Do not include findings from a chest x-ray (CXR), but do include restatements of a report by a physician.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of CHF/Pulmonary Edema.

b.

Mark "No" if there is no documentation of a history or current finding of CHF/Pulmonary Edema.

Synonyms/Inclusions:

Biventricular failure

Cardiac decompensation

Cardiac failure

Cardiomyopathy (all types)

Congestive heart failure (CHF)

Diastolic ventricular dysfunction

Edema of the lung

Heart failure (HF)

Heart failure (right or left)

Left or right ventricular failure

Pulmonary edema (excluding non-cardiac pulmonary edema or ARDS)

Pump failure

Systolic ventricular dysfunction

Ventricular failure - right or left

Wet lungs

Exclusions:

Diffuse infiltrate

Diffuse interstitial pulmonary edema

Edema of the legs (pedal edema)

Enlarged vessels

Fullness of pulmonary vasculature

Interstitial congestion

Interstitial edema

Jugular venous distention (JVD)

Perihilar vascular congestion

Pulmonary vascular engorgement

Rales

Vascular congestion

Venous congestion

Volume or fluid overload

X-ray report findings

COPD [PSMCOPD]

Question:

Is there documentation of a history or current finding of COPD?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary, Anesthesia record.

Sources Excluded:

Test reports (this includes Cardiac caths and Echocardiograms), Lab reports.

Instructions:

Indicate whether or not there is documentation of a history or current finding COPD.

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is a history or current finding of COPD.

b.

Mark "No" if there is no documentation of a history or current finding of COPD.

Synonyms/Inclusions:

Asthmatic bronchitis

Chronic airflow limitation (CAL)

Chronic bronchitis

Chronic obstructive airway disease (COAD)

Chronic obstructive lung disease (COLD)

Chronic obstructive pulmonary disease (COPD)

Cor Pulmonale

Emphysema

Coronary artery disease [PS3CAD]

Question:

Is there documentation of a history or current finding of coronary artery disease (CAD)?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician's orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary, Signed ECG reports with evidence of CAD.

Instructions:

Indicate whether or not there is documentation of a history or current finding of coronary artery disease (CAD).

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of coronary artery disease.

b.

Mark "No" if there is no documentation of a history or current finding of coronary artery disease.

Synonyms/Inclusions:

Acute coronary syndrome (ACS)

Angina

Atherosclerosis

Atherosclerotic heart disease (ASHD)

Atheroma

Cardiac bypass surgery

Coronary angioplasty with or without stent placement

Coronary artery angioplasty

Coronary artery bypass surgery (CABG)

Coronary artery disease (CAD)

Coronary artery surgery

Coronary atherectomy

Coronary balloon angioplasty

Coronary heart disease

Coronary ischemia

Coronary revascularization

Coronary thrombosis

Heart attack

Myocardial infarction (MI)

Myocardial revascularization

NSTEMI (non-ST elevation MI)

Percutaneous transluminal angioplasty of the coronary artery

Percutaneous transluminal coronary angioplasty (PTCA)

Percutaneous transluminal coronary excimer

Percutaneous transluminal coronary laser

Percutaneous transluminal coronary rotorblade

STEMI (ST elevation MI)

Unstable angina

Diabetes [PSMDM]

Question:

Is there documentation of a history or current finding of diabetes (DM)?

Sources:

Consults, ER Physician's note, History and Physical (H&P), Physician orders, Progress notes, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary.

Sources Excluded:

Test reports (this includes Cardiac caths and Echocardiograms), Lab reports.

Instructions:

Indicate whether or not there is documentation of a history or current finding of diabetes.

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of diabetes.

b.

Mark "No" if there is no documentation of a history or current finding of diabetes.

Synonyms/Inclusions:

Adult onset diabetes mellitus (AODM)

Borderline diabetes

Brittle diabetes

Diabetes

Diabetes mellitus (DM)

Diabetes mellitus (DM) - treated with diet, insulin or oral agents

Diabetic ketoacidosis (DKA)

Diet-controlled diabetes

DM Type 1 or Type II

Insulin dependent diabetes mellitus (IDDM)

Juvenile diabetes

Juvenile onset diabetes mellitus (JODM)

Ketosis prone diabetes

Maturity onset diabetes of the young (MODY)

Non-insulin dependent diabetes mellitus (NIDDM)

Steroid induced diabetes

Type I diabetes mellitus

Type II diabetes mellitus

Exclusions:

Diabetes insipidus

Gestational diabetes

Hypertension [HYPERT]

Question:

Is there documentation of a history or current finding of hypertension?

Sources:

Anesthesia notes, ER notes, Physician notes, Consult notes, History and physical (H&P), Physician orders, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary.

Instructions:

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of hypertension.

Synonyms/Inclusions:

(up arrow) BP

Accelerated blood pressure

Benign hypertension

Borderline hypertension

Essential hypertension

High Blood Pressure (HBP)

Hypertension (HTN)

Hypertensive heart disease

Labile hypertension

Malignant hypertension

Renal hypertension

Renovascular hypertension

Systemic hypertension

Systolic hypertension

Uncontrolled hypertension

Exclusions:

Intraocular hypertension

Portal hypertension

Pulmonary hypertension b.

Mark "No" if there is no documentation of a history or current finding of hypertension.

Peripheral vascular disease [PVD]

Question:

Is there documentation of a history or current finding of peripheral vascular disease?

Sources:

Anesthesia notes, ER notes, Physician notes, Consult notes, History and physical (H&P), Physician orders, Pathology reports, Death certificates, Autopsy reports (if the diagnosis is listed under the final list of diagnoses), Discharge summary.

Instructions:

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or current finding of peripheral vascular disease.

Synonym/Inclusion:

Arteriosclerosis obliterans

Atherosclerosis

Chronic arterial insufficiency

Claudication (any qualifier)

Hardening of the arteries

Ischemic muscle pain

Peripheral artery disease (PAD)

Peripheral arterial obstructive/occlusive disease (PAOD)

Peripheral vascular disease (any qualifier)

PVD

Peripheral Vascular Insufficiency b.

Mark "No" if there is no documentation of a history or current finding of peripheral vascular disease.

Renal disease [PS3RENAL]

Question:

Is there documentation of a history or finding on admission of renal disease?

Sources:

Only Acceptable Sources:

Consults, ER Physician's note, History and Physical (H&P).

Instructions:

Indicate whether or not there is documentation of a history or finding on admission of renal disease.

Guidelines:

Use PHYSICIAN DOCUMENTATION ONLY. This includes physician extenders such as nurse practitioners and physician assistants.

Options:

a.

Mark "Yes" if there is documentation of a history or finding on admission of renal disease.

Synonyms/Inclusions:

Acute renal failure

Azotemia/Pre-Renal Azotemia

Chronic dialysis

Chronic renal disease (CRD)

Chronic renal failure (CRF)

Chronic renal insufficiency (CRI)

Diabetic renal disease

Dialysis dependent

End stage renal disease (ESRD)

End stage renal failure

Glomerulopathy

Glomerulonephritis

Kimmelstiel-Wilson disease

Nephroscleroisis

Nephrotic syndrome

Nephropathy, any qualifier

Polycystic disease

Renal failure not specified as acute or chronic

Renal insufficiency

Renal stenosis

Uremia

Unspecified kidney disease without other descriptors

Exclusions:

Dialysis unless documented as "chronic dialysis" or "dialysis dependent" b.

Mark "No" if there is no documentation of a history or finding on admission of renal disease.

Hx/CF 2 Screen [COND2]

Label 2 [PS2LAB1]

Antibiotics prior to arrival [PS3ABXB]

Question:

Was the patient receiving antibiotics prior to arrival?

Sources:

Progress notes, History and Physical (H&P), Consult notes, Discharge summary, Nursing notes/Admission assessment, ER records.

Instructions:

Guidelines:

Any documentation that the patient was receiving antibiotics prior to arrival is acceptable.

The only date/time limitations are "prior to arrival".

Options:

a.

Mark "Yes" if there is documentation that the patient was receiving antibiotics prior to arrival.

b.

Mark "No" if there is no documentation that the patient was receiving antibiotics prior to arrival.

Oral corticosteroids PTA [PS2PRMED]

Question:

Was there documentation that the patient was taking oral corticosteroids prior to arrival?

Sources:

Consults, ER documentation, History and Physical (H&P), Nursing admission assessment, Nursing notes, Physician orders, Progress orders, Discharge summary.

Instructions:

Guidelines:

If medication is only documented as PTA med, home med or current med, assume it was taken within 7 days PTA (unless specifically documented as discontinued and/or stopped before the 7 day PTA time frame).

If the route of administration is not documented, assume it was oral.

Include only medications the patient was taking within the seven days prior to arrival to the hospital. To determine the seven-day timeframe, take the Arrival date and subtract seven days.

Example:

The patient arrives at the hospital on 5/29/02 - subtract 7 days, 29 - 7 = 22. May 22 to May 29 is the timeframe.

Do not include meds given in the ambulance on the way to the first hospital's ER.

If the patient was taking a medication within 7 days prior to arrival, abstract as a positive for this variable. If the documentation states, "The patient d/c'd her (medication name), do not abstract as a positive for the applicable medication category for this variable. The documentation must show that the patient was taking the medication within the 7-day time frame.

Inhalers are not considered oral corticosteroids.

The medication lists are not all inclusive. Refer to an appropriate resource to establish if a medication is an inclusion for any of these options.

If the documentation states the patient discontinued his medication 3 days ago, abstract it as a positive for this variable.

Include both brand and generic names for the medications that are listed.

Options:

a.

Mark "Yes" if the patient was taking oral corticosteroids prior to arrival.

b.

Mark "No" if the patient was not taking oral corticosteroids prior to arrival.

Corticosteroids Synonyms/Inclusions:

Alti-Prednisone

Apo-Prednisone

Aristocort

Betamethasone

Betnelan

Budesonide

Celestone

Cordex Forte

Cortalone

Cortef

Cortisone

Cortone

Decadron

Deenar

Delta-Cortef

Deltasone

Deronil

Dexameth

Dexamethasone

Dexasone

Dexone

Dexone LA

Entocort

Entocort EC

Flo Pred

Gammacorten

Hexadrol

Hycort

Hydrocortisone

Hydrocortone

Kenacort

Liquid-Pred

Medrol

Methylprednisolone

Novo-Prednisone

Ora Pred ODT

Orasone

Pedia-Pred

Prednisolone

Prednisone

Prelone

Pre-Pred

Sterane

Sterapred

Triamcinolone

Winpred

Current findings [PS2LAB2]

Cigarette smoker [PSMSMOKE]

Question:

Was there a history of smoking within one year prior to arrival, or was the patient a current smoker at the time of arrival?

Sources:

Preferred Sources:

History and physical (H&P), Emergency room notes, Nursing admission notes, Progress notes, Discharge summary.

Instructions:

Guidelines:

Abstract inhaled tobacco products only.

If conflicting information is documented, abstract the worst case. If conflicting information is documented but one piece of information further clarifies the other, abstract the more specific documentation.

Examples:

If one document states that the patient is a current smoker, and another states that the patient quit two years ago, abstract Yes. The documentation is conflicting, abstract the worst case.

If one document states lengthy history of smoking, and another states non-smoker, abstract "No".

If one document states history of smoking, and another states quit two years ago, abstract "No". History is further defined as two years.

If tobacco is listed as a risk factor on the H&P, but another document states quit 25 years ago, abstract "No". Tobacco use is further defined by 25 years ago. Take the more specific documentation.

The patient was a 30 pack/yr smoker, but there is no notation that she stopped smoking, mark "Yes."

If unable to determine, abstract "No."

Options:

a.

Mark "Yes" if:

there was a history of cigarette use within the year prior to the arrival date.

the patient is a current smoker.

there was documentation that the patient was a smoker but cannot determine if the timeframe is within one year.

b.

Mark "No" if:

there was not a history of smoking within one year prior to arrival.

the patient is not a current smoker.

Inclusions:

+ smoker

+ tobacco use

Cigar smoking

Current smoking

Former smoker

History of cigarette use within one year prior to arrival

History of smoking within one year prior to arrival where the type of product is not identified

History of smoking/tobacco/cigarette use without mention of a time frame

History of tobacco use within one year…