Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023); As of July 1, 2023
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The following aggregate data elements are required to be entered for proportion and ratio measures:·
Denominator
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Number of Unique Patients Within the Numerator (ratio measures only)
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Numerator
Name: | Denominator |
Aggregated For: | Proportion and ratio measures |
Definition: | Summation of denominator cases (proportion) or the denominator component (ratio) for the measure's population during the month. The Denominator is the count of each patient-level record with a measure category assignment of ‘D’ or ‘E’ (i.e., [count of ‘D’ + count of ‘E’] = Denominator). Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers.
NotesNote:·
Denominator = (Psychiatric Inpatient Days - Leave Days), submitted as Hours |
Allowable Values: | 0 through 10,000,000 (whole numbers only) Note: Hospitals entering a zero for this data element will be required to attest that they have no cases in the denominator (i.e., ‘zero denominator’) for the measure for the month. Hospitals with denominator cases are expected to enter the appropriate value for each measure or strata. |
Edits:· |
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Name: | Number of Unique Patients Within the Numerator |
Aggregated For: | Ratio measures only |
Definition: | For the HBIPS-2 and 3, this is the number of unique patients represented in the data element Numerator. If no event occurred during the month (Numerator = 0), enter a zero (0) for this data element. Examples for a single patient with multiple numerator events:·
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Allowable Values: | 0 through 10,000,000 (whole numbers only) |
Edits:· |
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Name: | Numerator |
Aggregated For: | Proportion and ratio measures |
Definition: | Summation of numerator cases (proportion) or the numerator component (ratio) in a measure's population during the month. The Numerator is the count of all patient-level records with a measure category assignment = ‘E.’ Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers.
NotesNote:·
Strata Incorrect Overall Calculation Correct Overall Calculation B 1.3454 Rounded (1.3454) = 1.345 C 2.0044 Rounded (2.0044) = 2.004 D 3.2544 Rounded (3.2544) = 3.254 E 0.0014 Rounded (0.0014) = 0.001 Overall Sum strata (1.3454 + 2.0044+ 3.2544 + 0.0014) = Round overall (6.6056) = 6.606 Sum rounded strata (1.345 + 2.004+ 3.254 + 0.001) = overall 6.604 |
Allowable Values:· |
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Edits:· |
· Stratified
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