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mnemonic |
QUESTION TEXT |
RESPONSE |
DEFINITIONS/DECISION RULES |
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1 |
nonvet
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1*,2
*If 1, except the record. |
Exception Statement:
The patient was a non-veteran user of a VHA
inpatient facility.
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2 |
inptcare |
Did the patient have an inpatient episode
of care at this VAMC, as indicated by the discharge date shown on the pull
list? |
1,2* *If 2, except the record |
The “date indicated on the pull list” is the
apparent date of discharge. The
question addresses whether the patient had an actual inpatient episode of
care and not whether the discharge date is correct
Exception Statement:
Although the case was selected by apparent discharge date, the patient did not have an inpatient episode of care at that time. |
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3 |
amicode |
For
the selected episode of care, was the principal diagnosis coded as 410.0 -
410.9, with a fifth digit of 1, as follows: 410 acute myocardial
infarction (sudden, severe death of heart
muscle due to decreased coronary blood flow;
classification is based on the location of the affected tissue, when known) 410.41 of other inferior wall |
1,2 |
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Acute MI records are selected from cases discharged with a diagnosis code of 410.0 – 410.9, with a fifth digit of 1. A fifth digit of 0 or 2 is not acceptable To respond “1,” the principal diagnosis code must be one of the listed codes. The fifth digit of 0 = episode of care unspecified The fifth digit of 1 = initial episode of care for an AMI. Used to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit 1 is assigned regardless of the number of times a patient may be transferred during the initial episode of care. The fifth digit of 2 = subsequent
episode of care. Used to designate an
episode of care following the initial episode when the patient is admitted
for further observation, evaluation, or treatment for a myocardial infarction
that has received initial treatment but is still less than 8 weeks old. Cases coded with fifth digit of 2 are
not to be reviewed. |
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# |
mnemonic |
QUESTION TEXT |
RESPONSE |
DEFINITIONS/DECISION RULES |
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4 |
aprocode |
What
was the AMI ICD-9-CM code selected as the principal diagnosis for this
medical record. |
_ _ _. _ _ |
Use the code assigned by the VAMC. Do not attempt to code the AMI by any code other than that assigned by the facility. |
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5 |
trueami |
1*,2** *If 1 and amicode=1, go to othhrdx *If 1 and
amicode=2, except the record with Exception Statement #1 (JCAHO Category A) **If 2 and amicode=1, except the record with Exception Statement #2 (JCAHO Category
A) **If 2 and amicode=2, except the record with Exception Statement #2 (JCAHO Category
B) |
To respond ‘yes,” the discharge summary, or other physician documentation (if the discharge summary is not present), must record a definitive diagnosis of myocardial infarction. Rule out MI (r/o) or undetermined diagnoses, such as MI vs unstable angina are not acceptable. An MI that is a subsequent episode of care is also not acceptable. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Exception Statement #1 The record was miscoded and
cannot be included in the JCAHO Core Measures sample. Exception Statement #2 Physician documentation in the record does not support a definitive, principal diagnosis of Acute MI. |
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6 |
othrdx |
Enter
the ICD-9-CM other diagnosis codes selected for this medical record. |
---. -- |
Enter ALL of the ICD-9-CM other
diagnosis codes selected for this medical record. Use the diagnoses listed in the discharge summary for this
episode of inpatient care. |
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7 |
hospdt |
Is
the date of formal admission to inpatient status documented in the record? |
1,2* *If 2, go to hosptime, else go to admdt |
Admission date = date on which
the patient was admitted to inpatient status. Admission to observation and/or arrival date are excluded. |
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8 |
admdt |
Enter
the date the patient was admitted to inpatient care. |
mm/dd/yyyy |
The exact date of inpatient admission must be entered. The use of 01 to designate an unknown day or month is not acceptable. Excluded: admission to observation, arrival date |
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# |
mnemonic |
QUESTION TEXT |
RESPONSE |
DEFINITIONS/DECISION RULES |
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9 |
hosptime |
Is the time of formal admission to
inpatient status documented in the record? |
1,2* *If 2, go to admtype, else go
to admtime |
Admission time = time the patient was admitted to
inpatient status. Excluded:
admission to observation, arrival date |
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10 |
admtime |
Enter the time the patient was
admitted to inpatient care. |
_____ military time |
The exact time of inpatient admission must be entered in military time. Excluded: admission to observation, arrival date |
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11 |
admtype |
Designate
the type of admission for this patient: 1.
Emergency 2.
Urgent 3.
Elective 5.
Trauma 9.
Information not available |
1,2,3,5,9 |
1. Emergency=the patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room. 2. Urgent=the patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodations. 3. Elective=the patient’s condition permitted adequate time to schedule the availability of a suitable accommodation 5. Trauma=Visit to the trauma center/hospital as licensed by the state or local government authority to do so, or as verified by the American College of Surgeons and involving a trauma activation. 9.
Information not available=the hospital cannot classify
the type of admission. This code is
used only on rare occasions. |
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12 |
transedd |
Was
the patient received as a transfer from an emergency department of another
hospital? 1.
yes 2.
no 3.
unable to determine |
1,2,3 |
1 = may be from another VAMC or community hospital, but the patient cannot have been an inpatient. The abstractor must know the patient was transferred from the ED. Note: the emergency department of another hospital includes both emergency room AND observation bed/unit stays at that hospital. 2 = Patient not received as a transfer from another facility’s Emergency Department 3 = unable to determine from medical record documentation. Counted as a “no” response. Suggested Data Sources: Emergency department record, face sheet, nursing admission assessment, progress notes, transfer forms |
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# |
mnemonic |
QUESTION TEXT |
RESPONSE |
DEFINITIONS/DECISION RULES |
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