The Joint Commission

(HAP/CAH) Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals

Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023)      
Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); As of March, 2024                                                  

Acknowledgement

Introduction

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


Section 3: Measure Exclusions

  • 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

Release Notes

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