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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This portion of the Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH) provides a brief overview of the information contained within each section of the manual. It is intended for use as a quick reference to assist in the aggregation of the required data elements, which are to be derived from the results of each of the Joint Commission’s national quality measures used for accreditation purposes. The sections of this manual are interrelated and are most useful when considered together.

Section 1: Chart-Abstracted Measure Submission

The Chart-Abstracted Measure Submission provides an overview of the requirements for submitting aggregate data for accreditation purposes, including usage of the Direct Data Submission Platform (DDSP), measure selections, and submission deadlines.

Section 2: Aggregate Data Dictionary

The Aggregate Data Dictionary describes the aggregate data elements required to be entered for each chart-abstracted measure. It specifies those data elements that a hospital must aggregate after it processes its patient-level data through the measure algorithm. These aggregate data elements will be inputted by the hospital into the Direct Data Submission Platform (DDSP).

Section 3: Measure Exclusions

The Measure Exclusion section describes the denominator exclusion questions asked by the Direct Data Submission Platform (DDSP) for each chart-abstracted measure. These questions capture the counts of the number of cases excluded from the measure population by receiving a measure category assignment of ‘B’ (Not in Measure Population) when processed through the measure algorithm. The information in this section is intended to assist hospitals in their preparation for data entry of their aggregate data into the DDSP.

Section 4: Aggregate Data Element Tool

This section of the manual provides several tools to assist hospitals and their vendors in understanding the order in which the aggregate data elements will be entered into the Direct Data Submission Platform (DDSP).

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