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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)
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- Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); March 2024
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Introduction
This section of the manual describes the aggregate data elements hospitals must calculate prior to entering their chart-abstracted measure data into the Direct Data Submission Platform (DDSP). It includes the definition and allowable values for each aggregate data element. In addition, data edits and statistical equations are provided as appropriate.
Data Edits and Statistical Equations
For each aggregate data element, data edits and statistical equations are provided below as appropriate. The statistical equations have been provided to assist in your proper calculation of these data element. The edits will be executed on the DDSP and will result in an error message. In addition, the DDSP will ensure data is entered correctly from the perspective of allowable values and whole numbers.
Stratified Measures
Stratified measures are classified into several groups (strata) to assist in the analysis and interpretation of the measure. The overall or un-stratified measure evaluates all the strata together. The stratified measure or each stratum consists of a subset of the overall measure.
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PC-06 contains three strata (Overall, Severe, and Moderate).
The Denominator value for all three strata is the same, so it is only entered once.
The Severe Rate and Moderate Rate strata have different Numerator values, so a value for each of these strata must be entered.
HBIPS-5 contains five strata (Overall, Children, Adolescent, Adult, and Older Adult).
The Denominator and Numerator values for each of the five strata are different, so a separate value for both Denominator and Numerator must be entered for each stratum.
ED-1 contains three strata (Overall, Reporting, and Psychiatric/Mental Health Patients).
The Maximum Observation, Mean Observation, Median Observation, Minimum Observation, Population, and Standard Deviation of the Observation must be entered for each stratum.
Attestation Of Zero Cases
Hospitals will be capable of attesting to having zero cases in two different manners.
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Denominator: If a zero is entered into the Denominator field for a month, the user will be promoted to check theZero Denominator Attestation box to attest that the zero Denominator count is valid.
Aggregate Data Elements Overview
The aggregate data elements that require entry on the DDSP are divided below into (1) those required for all measures, (2) those required for proportion or ratio measures, and (3) those required for continuous variable measures.
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Continue to the next section: Data Element Dictionary Terms
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