Using The Joint Commission Guide for Data Entry of Chart-Abstracted Measures
Section 1: Chart-Abstracted Measure Submission
Direct Data Submission Platform (DDSP)
How to Use the DDSP
Chart-Abstraction Measure Selections
Aggregate Data Entry
Data Entry Open and Close
Quality Measure Specifications
Section 2: Aggregate Data Dictionary
Introduction
Data Edits and Statistical Equations
Stratified Measures
Attestation Of Zero Cases
Aggregate Data Elements Overview
Introduction
Measure Algorithm Logic
Measure Exclusions
ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients
HBIPS-2: Hours of physical restraint use
HBIPS-3: Hours of seclusion use
HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification
IMM-2: Influenza Immunization
OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients
OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival
PC-01: Elective Delivery
PC-02: Cesarean Birth (1/1/2023 through 6/30/2023 Discharges)
PC-02: Cesarean Birth (7/1/2023 through 12/31/2023 Discharges)
PC-05: Exclusive Breast Milk Feeding
PC-06: Unexpected Complications in Term Newborns
SUB-2: Alcohol Use Brief Intervention Provided or Offered and SUB-2a: Alcohol Use Brief Intervention
SUB-3: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge
TOB-2: Tobacco Use Treatment Provided or Offered and TOB-2a: Tobacco Use Treatment
TOB-3: Tobacco Use Treatment Provided or Offered at Discharge
VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism
Section 4: Aggregate Data Element Tool
Introduction
Measure Exclusion data elements
Tool #1
Tool #2
Tool #3
Tool #4
Tool #5
Tool #6