ecqm.dataelement

Encounter Inpatient Performed

Description:

Clinical Focus: This set of values identify the most common inpatient encounter types.

Data Element Scope: The intent of this data element is to identify patients who have had an inpatient encounter. Using the Quality Data Model, this particular element will map to the 'encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing inpatient encounter should be included.

Exclusion Criteria: None.

Subject constrained to the Encounter Inpatient

QDM Datatype: EncounterPerformed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

Used By:

• CMS108v7,
• CMS111v7,
• CMS113v7,
• CMS117v7,
• CMS122v7,
• CMS123v7,
• CMS124v7,
• CMS125v7,
• CMS127v7,
• CMS128v7,
• CMS130v7,
• CMS131v7,
• CMS134v7,
• CMS136v8,
• CMS137v7,
• CMS139v7,
• CMS146v7,
• CMS153v7,
• CMS154v7,
• CMS155v7,
• CMS156v7,
• CMS164v7,
• CMS165v7,
• CMS190v7,
• CMS26v6,
• CMS31v7,
• CMS32v8,
• CMS52v7,
• CMS53v7,
• CMS55v7,
• CMS56v7,
• CMS65v8,
• CMS66v7,
• CMS74v8,
• CMS75v7,
• CMS90v8,
• CMS9v7

Included in Unions:

• DeliveryEncounterwithJustifyingConditionsUnion,
• DenominatorExceptions0Union,
• InitialPopulationUnion,
• MeasurePopulationExclusionsUnion,
• Numerator3Union,
• Numerator5Union,
• NumeratorUnion,
• SingleLiveBirthEncounterUnion

QDM Attributes

Subject.Statement

Defined in Activity

DataType

Constrained in EncounterInpatientPerformed

EncounterInpatient

RelevantPeriod

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.

DischargeDisposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.

FacilityLocations

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include, but are not limited to, intensive care units (ICUs), non- ICUs, burn critical-care unit, neonatal ICU, and respiratory-care unit. Each Encounter, Performed may have 1 or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as: Encounter, Performed: Inpatient Admission, ICU (location period), Non-ICU Admission (location period), Rehab (location period)

Diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses syntax is preferred. Referencing the same diagnosis using Encounter, Performed (diagnoses attribute) and Diagnosis (datatype) should only occur if the measure must define a specified length of a prevalence period, e.g., The measure must assure that the diagnoseis have been present for at least some defined time period before the encounter, and were addressed during the Encounter

PrincipalDiagnosis

The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.