Data elements that meet criteria using this datatype should document the completion of the physical exam indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The time the physical examination activity begins. stopTime – The time the physical examination activity ends. NOTE - timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
Subject.Statement
DataType
The time the data element was entered into the clinical software. Note, some datatypes include both Relevant Time and Author dateTime attributes. The purpose is to accommodate Author dateTime if the actual start and stop times are not available when evaluating for feasibility, and also to allow specification of a time for Negation Rationale.
Relevant Period addresses the time between the start of an action to the end of an action. Each datatype using relevant period defines specific definitions for the start and stop time for the action listed.
The thought process or justification for the datatype. In some measures, specific treatments are acceptable inclusion criteria only if a justified reason is present. Each of these measures uses a value set (often, but not exclusively, using SNOMED- CT®) to express acceptable justification reasons. Other measures specify reasons as justification for exclusions. Examples include patient, system, or medical-related reasons for declining to perform specific actions. Each of these measures also uses a value set to express acceptable justification reasons for declining to perform expected actions.
The final consequences or data collected from the datatype. Results can be used in five ways, to express: That a result is present in the electronic record but any entry is acceptable. A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units – examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). Beginning with QDM 5.3 measures use CQL logic to express the mathematical operators to constrain desired results to those above or below a certain threshold. A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct referenced code. A result as a dateTime (Assessment, Performed and components).
The anatomical site or structure where the diagnosis/problem manifests itself (a). The anatomical site or structure where that is the focus of the action represented by the datatype (b).
Indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the “negation rationale” attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies Vs lack of documentation about allergies). The syntax in the human readable HQMF is address in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, “Procedure, Performed not done.” QDM 5.0 DRAFT uses the syntax, “Procedure, not Performed.” Note: Some datatypes include both Relevant Time and Author dateTime attributes. The purpose is to accommodate Author dateTime if the actual start and stop times are not available when evaluating for feasibility, and also to allow specification of a time for Negation Rationale.
Elements included or documented as part of evaluations or test panels. Examples include: specific questions included in assesments, tests included in a laboratory test panel, observations included in a cardiac exam during a physical examination. Each assessment, diagnostic study, laboratory test, physical exam or procedure may have one or more components.