Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)
- Version 2024: Discharges 01-01-2024 (1Q2024) through 12-31-2024 (4Q2024);
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March 2024
- Version 2025: Discharges 01-01-2025 (1Q2025) through 12-31-2025 (4Q2025);
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January 2025
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Applicable to the following measures: PC-01, PC-02, PC-05, IMM-2, VTE-6, OP-23
Note: VTE-6 was retired as of 12/31/2024 discharges.
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Applicable to the following measures: PC-06, SUB-3, TOB-3
These measures are rate-based proportion measures that are stratified.
The specifications for these measures state that the initial population and sample size are determined for the Overall measure and each stratum are derived from this data pull.
These measures require the entry of multiple Numerator values.
PC-06: The Overall measure is the sum of the Moderate and Severe strata; thus, the Numerator for the Overall Measure will not be entered.
SUB-3 and TOB-3: The Overall measures are not the sum of the measure’s strata; therefore, both the Overall and strata Numerators must be entered.
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Applicable to the following measures: HBIPS-2, HBIPS-3, HBIPS-5
Note: HBIPS-5 was retired as of 12/31/2023 discharges.
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Aggregate Data Element | Data Entry Information |
Overall (a) Initial Population | User enters data
This is to support hospitals which may not have a patient in the initial population every month and psychiatric hospitals which only provide services to children or adults. |
Overall (a) Quarterly Sampling Frequency | Drop-down box
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Overall (a) Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Overall (a) Denominator | User enters data
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Overall (a) Numerator | User enters data |
Overall (a) Number of Unique Patients within the Numerator | HBIPS-2 and 3 only – user enters data. |
Overall (a) Observed Rate | Calculated by DDSP |
Strata B Initial Population | User enters data |
Strata B Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Strata B Denominator | User enters data
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Strata B Numerator | User enters data |
Strata B Number of Unique Patients within the Numerator | HBIPS-2 and 3 only – user enters data. |
Strata B Observed Rate | Calculated by DDSP |
Strata C Initial Population | User enters data |
Strata C Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Strata C Denominator | User enters data
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Strata C Numerator | User enters data |
Strata C Number of Unique Patients within the Numerator | HBIPS-2 and 3 only – user enters data. |
Strata C Observed Rate | Calculated by DDSP |
Strata D Initial Population | User enters data |
Strata D Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Strata D Denominator | User enters data
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Strata D Numerator | User enters data |
Strata D Number of Unique Patients within the Numerator | HBIPS-2 and 3 only – user enters data. |
Strata D Observed Rate | Calculated by DDSP |
Strata E Initial Population | User enters data |
Strata E Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Strata E Denominator | User enters data
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Strata E Number of Unique Patients within the Numerator | HBIPS-2 and 3 only – user enters data. |
Strata E Observed Rate | Calculated by DDSP |
Measure Exclusion(s) | See Section 3 for specific questions and order for each measure. Note: HBIPS-5 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum. |
Total Exclusion Count | Calculated by DDSP |
Total Count of Cases with Category Y or X | Calculated by DDSP |
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Applicable to the following measures: ED-1, ED-2
These measures are continuous variable measures that are stratified and for which the Overall measure is reported.
These measures require the entry of the Initial Population, Quarterly Sampling Frequency, and Hospital Sample Size once.
The specifications for the ED measures state that the initial population and sample size are determined using the Global criteria. The Overall measures and each stratum are derived from this data pull.
These measures require all data elements to be entered for the Overall measure and each of the two strata measures.
Aggregate Data Element | Data Entry Information |
Initial Population | User enters data
This is to support hospitals which may not have a patient in the initial population every month and psychiatric hospitals which only provide services to children or adults. |
Quarterly Sampling Frequency | Drop-down box
|
Hospital Sample Size | User enters data
or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update. |
Overall (a) Population | User enters data
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Overall (a) Minimum Observation | User enters data |
Overall (a) Median Observation | User enters data |
Overall (a) Maximum Observation | User enters data |
Overall (a) Mean Observation | User enters data |
Overall (a) Standard Deviation of the Observation | User enters data |
Strata B Population | User enters data
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Strata B Minimum Observation | User enters data |
Strata B Median Observation | User enters data |
Strata B Maximum Observation | User enters data |
Strata B Mean Observation | User enters data |
Strata B Standard Deviation of the Observation | User enters data |
Strata C Population | User enters data
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Strata C Minimum Observation | User enters data |
Strata C Median Observation | User enters data |
Strata C Maximum Observation | User enters data |
Strata C Mean Observation | User enters data |
Strata C Standard Deviation of the Observation | User enters data |
Measure Exclusion(s) | See Section 3 for specific questions and order for each measure. Note: ED-1 and ED-2 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum. |
Total Exclusion Count | Calculated by DDSP |
Total Count of Cases with Category Y or X | Calculated by DDSP |
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Tool #5 is applicable to the following measures: OP-18
These measures are continuous variable measures that are stratified and for which the Overall measure is not reported.
These measures require the entry of the Initial Population, Quarterly Sampling Frequency, and Hospital Sample Size once.
The specifications for the OP-18 measure states that the initial population and sample size are determined using the OP-ED Throughput criteria and each stratum are derived from this data pull.
The Overall measure is not reported for OP-18.
These measures require all data elements to be entered for each of the measure’s strata. Data is not entered for the Overall measure.
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Tool #6 is applicable to the following measures: SUB-2 and TOB-2
Note: TOB-2/2a was retired as of 12/31/2023 discharges.
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Applicable to the following measures: SDOH-1
Note: SDOH-1 became available as of 2024 discharges.
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Applicable to the following measures: SDOH-2
Note: SDOH-2 became available as of 2024 discharges.
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