I-HF-3-心力衰竭.doc

Medical Record Abstractor: Abstract data for your organizations selected measures with the measure code name (I-HF-3) designated in the left hand column under each data element question.病历摘录者：为医院所选择的策略摘录数据，包括每个数据元素问题下左栏中所指定策略编码(I-HF-3)。Hospital Name医院名称: +Plus symbol indicates required administrative data field加号表示所需的行政数据区+Patient Identifier Number 患者识别号+Admission Date入院日期_/_/_Day 日 month 月 year 年+Discharge Date 出院日期 / /Day日 month月 year 年Sex性别Admitting Physician Code/Number 入院医生编码/号码Attending Physician Code/Number主治医生编码/号码Principal Procedure Surgeons Code/Number主要手术医师编码/号码+Principal/Main Diagnosis or ICD Code主要诊断/国际疾病分类编码Present on Admission Diagnosis or ICD Codes入院诊断/国际疾病分类编码+Other Diagnosis or ICD Codes其他诊断/国际疾病分类编码Principal Procedure or ICD Code主要处置/国际疾病分类编码Principal Procedure Date主要处置日期+Other Procedure or ICD Codes其他处置/国际疾病分类编码After the case data abstraction and data flow is completed, circle the assigned Measure Category Assignment (MCA) Letter for each measure as guided by the allowable answer value “STOP” text:完成病案数据抽象化及数据流后，随着许可的回答数值“STOP”文本的指引，圈出每个策略指定的策略类型赋值字母：EXAMPLE: If answered No, STOP I-HF-3 data abstraction = case NOT in Measure Population = B 例：如果回答“是”，停止I-HF-2的数据抽象化=病案不在策略人群中=BIf there is no text prompt instructing you to STOP, continue data collection如果没有文本指示停止，继续收集数据。1. What is the date the patient was admitted to acute inpatient care?: Admission Date 患者收治入紧急住院治疗的日期是？：入院日期 (I-HF-3) / /Day 日 (01 31)Month月 (01 12) YYYY年 (2010 current year当前年份)2. Is there a principal diagnosis of heart failure or Principal ICD code of heart failure?: Principal Diagnosis Code是否有心力衰竭的国际疾病分类的主要诊断编码或主要诊断？：主要诊断编码 (I-HF-3) (Appendix A, Table 2.1 Heart Failure) 附件A 表2.1心力衰竭 Yes是 No否If answered No, STOP data abstraction for I-HF-3 = case NOT in Initial Population如果回答否/无法确定，停止I-HF-3的数据抽象化=病案不在初始人群中3. During this hospital stay did the patient have a heart transplant or left ventricular assistive device (LVAD) a) principal or b)other procedure?: Principal or Other Procedure在此住院期间，患者是否进行心脏移植或使用左室辅助装置a)主要处置或其他手术？：主要处置或其他处置 (I-HF-3) (Appendix A, Table 2.2, LVAD and Heart Transplant) 附件A 表2.2左室辅助装置及心脏移植 Yes是 No否If answered Yes for either 3a or 3b, STOP data abstraction for I-HF-3 = case NOT in Initial Population如果对问题3a或3b回答“是”，停止I-HF-3的数据抽象化=病案不在初始人群中4.Patients Birthdate: (dd/mm/yyyy): Birthdate患者出生日期：（日/月/年）：出生日期 ( I-HF-3)/ dd 日 mm 月 yyyy 年Age: year/s(admission date birthdate) 年龄: year/s (入院日期 出生日期)If age 18 years, STOP data abstraction for I-HF-3 = case NOT in Initial Population 如果年龄 18岁，停止I-HF-3的数据抽象化=病案不在初始人群中5. What was the patients discharge disposition on the day of discharge: Discharge Disposition在出院当天，患者的出院处置是什么？：出院处置 (I-HF-3) 1- Home 回家 2 Discharged or Transferred to Another Acute Care Hospital 出院或转入其他的急症护理医院 3 Left Against Medical Advice(AMA) 自动出院 4a - Expired on the day of or day after arrival 在到达当天/后死亡 4b Expired greater than 1 day after arrival 在到达超过1天后死亡 5 Discharged or Transferred to Other Type of Health Care Facility 出院或转去其他类似的医疗机构 6 Unknown/ Not Documented or unable to Determine (UTD) 未知/未记录或无法确定If answered 2, 3, 4a, 4b, STOP data abstraction for I-HF-3 = case NOT in Measure Population =B如果回答2,3, 4a 或4b，停止I-HF-3的数据抽象化=病案不在策略人群中=B6.Is the LVSF documented as an Ejection Fraction (EF) less than 40% or a narrative description consistent with “moderate” or “severe” systolic dysfunction: LVSD 左室收缩功能是否记录为左室射血分数少于40%或描述为“中度”或“重度”收缩功能不全？：左室收缩功能障碍 (I-HF-3) Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered No, STOP I-HF-3 data abstraction = case NOT in Measure Population =B如果回答否，停止I-HF-3的数据抽象化=病案不在策略人群中=B 7. Is there documentation that an Angiotensin Converting Enzyme Inhibitor (ACEI) was prescribed at discharge: ACEI Prescribed at Discharge (I-HF-3) 是否有在出院时开具血管紧张素转换酶抑制剂的文件？：出院时开具血管紧张素转换酶抑制剂 (Appendix C, ACEI Table 1.2) Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered Yes, STOP I-HF-3 data abstraction = case met measure and is in the Numerator Population = E如果回答是，停止 I-HF-3的数据抽象化=病案符合策略并且在分子人群中 8. Is there documentation that an Angiotensin Receptor Blocker (ARB) was prescribed at discharge: ARB Prescribed at Discharge 是否有出院时开具血管紧张素受体拮抗剂的文件？：出院时开具血管紧张素受体拮抗剂(I-HF-3) (Appendix C, ARB Table 1.7) 附件C 血管紧张素受体拮抗剂 表1.7 Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered Yes, STOP I-HF-3 data abstraction = case met measure and is in the Numerator Population = E 如果回答是，停止I-HF-3的数据抽象化=病案符合策略并且在分子人群中=E 9. Is there documentation of BOTH a reason for not prescribing an ACEI at discharge AND not prescribing an ARB at discharge: Reason for No ACEI AND No ARB at Discharge 是否有出院时不开具血管紧张素转换酶抑制剂和血管紧张素受体拮抗剂原因的文件？：出院时不开具血管紧张素转换酶抑制剂和血管紧张素受体拮抗剂的原因 (I-HF-3) Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered Yes, STOP I-HF-3 data abstraction = case NOT in measure population =B如果回答是，停止I-HF-3的数据抽象化=病案不在策略人群中=B If answered No, STOP I-HF-3 data abstraction = case did not meet the measure and is IN the Measure Population =D如果回答否，停止止I-HF-3的数据抽象化=病案不符合策略但是在策略人群中=DAfter the case data abstraction and data flow is completed, circle the assigned Measure Category Assignment (MCA) Letter for each measure as guided by the allowable answer value text:完成病案数据抽象化及数据流后，随着允许的回答数值文本的指引，圈出每个策略指定的策略类型赋值字母：I-HF-3B-Excluded排除D-Not met measure*不符合策略E-Met/Passed measure* 符合/通过策略When calculating measure rate for all abstracted cases in the discharge month:在计算出院月中所有抽象病案的策略率时:Numerator cases = “E”分子病案= “E”Denominator cases = “D” plus “E”分母病案= D+EDivide the numerator counts/ by the denominator counts and multiply X 100 = percentage rate of measure compliance with recommended standard of care分子数目分母数目X100=遵守推荐的护理标准的策略的百分比Question 1Data Element Name: Admission Date数据元素名称：入院日期Collected For: All Records收集用于：所有病历Definition: The day, month, and year of admission to acute inpatient care. 定义：收治入急性住院服务的年月日。Suggested Data Collection Question: What is the date the patient was admitted to acute inpatient care?建议的数据收集问题：患者收治入急性住院服务的日期是哪一天？Format格式:Length: 10 DD-MM-YYYY (includes dashes)长度：10 日- 月-年(包括破折号)Type类型: Date日期Occurs发生: 1Allowable Values允许的值:DD日 = Day (01-31)MM月 = Month (01-12)YYYY年 = Year (2001-Current Year当前年份)Notes for Abstraction抽象化注意事项: The intent of this data element is to determine the date that the patient was actually admitted to acute inpatient care. 该数据元素解释用于决定患者实际收治入急性住院服务的日期。 For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.对于留观并且随后收治入急性住院的患者，提取决定入院接受急性住院服务的日期 以及医嘱日期。不要提取患者收留观的日期。 For patients that are admitted for surgery and/or a procedure, if the admission order states the date the orders were written and they are effective for the surgery/procedure date, then the date of the surgery/procedure would be the admission date. 对于需要进行手术的患者，如果入院医嘱上写明医嘱日期，对于手术日期是有效的，那么手术日期就是入院日期。Suggested Data Sources 建议的数据来源: Physician orders 医师医嘱 Face Sheet 病案首页Inclusion Guidelines for Abstraction 包括抽象化指引: None 无Exclusion Guidelines for Abstraction 不包含的抽象化指引: Admit to observation 收留观 Arrival date 到达日期Question 2Data Element Name: ICD Principal Diagnosis Code (Main Diagnosis Code)数据元素名称：国际疾病分类主要诊断编码（主要诊断编码）Collected For: All Records 收集用于：所有病历Definition: The International Classification of Diseases, Sixth Revision, Ninth Revision, Clinical Modification or Tenth Revision code associated with the diagnosis established after study to be chiefly responsible for occasioning the admission of the patient for this hospitalization.定义：与经研究确定的导致患者本次住院就医主要原因的疾病有关的国际疾病分类、第六次修订、第九次修订、临床修订版或第十次修订编码。Please Note: For the initial version of the Library of Measures the ICD diagnosis (or procedure) codes can be found inAppendix A for each specific measure set. However, since not all accredited facilities utilized the ICD Code System, a response of Yes/No for this data element is allowed. 请注意： 对于策略库初始版本， 国际疾病分类诊断（或处置）编码可以在每个特定的策略库的附录A中找到。但是，由于不是所有的通过认证的医院都使用国际疾病分类编码系统，故允许使用Yes/No回应此数据元素。Suggested Data Collection Question: What was the ICD Principal Diagnosis code or documentation of a principal (main) diagnosis selected for this record?建议的数据收集问题：此病历所选的国际疾病分类主要诊断编码是什么或主要诊断的文件？Format格式: Length长度: 1Type类型: Alpha Occurs发生: 1Allowable Values允许的值: Y (Yes)是 There is documentation that the principal diagnosis code or principal diagnosis in the medical record is included in the selected measures Appendix A, ICD Diagnosis Code Table(s). 在所选的策略附录A ICD诊断编码表中包含病历中的主要诊断编码文件或主要诊断文件。N (No)/or unable to determine否或无法确定There is no documentation that the principal diagnosis code or principal diagnosis in the medical record is included in theselected measure Appendix A, ICD Diagnosis Code Table(s).在所选的策略附录A ICD诊断编码表中未包含病历中的主要诊断编码文件或主要诊断文件。Notes for Abstraction抽象化注意事项: The principal diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”主要诊断定义为“经研究确定的导致患者本次住院就医主要原因的疾病。” Refer to Appendix A for ICD Code Tables for each individual measure set参考每个策略库单独的附录A ICD编码表 Any valid ICD principal diagnosis code or documentation of a principal (main) diagnosis in the medical record is acceptable. 任何有效的ICD主要诊断编码或病历中的主要诊断记录均为可接受。Suggested Data Sources建议的数据来源: Discharge summary出院小结 Face sheet 病案首页Inclusion Guidelines for Abstraction包含的抽象化指引: Refer to each measure information section for the Appendix A, ICD Code(s) or documentation of a principal diagnosis (main diagnosis) which is utilized to calculate each measures population. 参考每个策略信息部分的 附录A ICD编码表或用于计算每个策略人群的主要诊断记录。 Refer to Appendix A for ICD Code Tables.参考附录A ICD编码表Exclusion Guidelines for Abstraction不包含的抽象化指引: Refer to Appendix A for ICD Code Tables Question 3aData Element Name: ICD Principal Procedure Code(Main Procedure Code)数据元素名称：国际疾病分类主要处置编码（主要处置编码）Collected For: All Records 收集用于：所有病历Definition: The International Classification of Diseases, Sixth Revision, Ninth Revision, Clinical Modification or Tenth Revision code that identifies the principal procedure performed during this hospitalization. The principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.定义：识别住院期间实施的主要处置的国际疾病分类、第六次修订、第九次修订、临床修订版或第十次修订编码。主要处置为实施的绝对治疗性处置，非诊断性处置或探索性处置，或治疗并发症的处置。Please Note: For the initial version of the Library of Measures the ICD diagnosis (or procedure) codes can be found inAppendix A for each specific measure set. However, since not all accredited facilities utilized the ICD Code System, a response of Yes/No for this data element is allowed. 请注意： 对于策略库初始版本， 国际疾病分类诊断（或程序）编码可以在每个特定的策略库的附录A中找到。但是，由于不是所有的通过认证的医院都使用国际疾病分类编码系统，故允许使用Yes/No回应此数据元素。Suggested Data Collection Question: What was the ICD code selected as the principal procedure or documentation of a principal procedure for this record?建议的数据收集问题：此病历所选的国际疾病分类主要处置编码是什么或主要处置的文件？Format格式: Length长度: 1Type类型: Alpha Occurs发生: 1Allowable Values允许的值: Y (Yes)是 There is documentation that there is a principal procedurecode or documentation of a principal procedure listed in the medical record that is included in theselected measure Appendix A, ICD Table(s).在所选的策略附录A ICD诊断编码表中包含病历中的主要处置编码文件或主要处置文件。N (No)/or unable to determine否或无法确定There is no documentation that there is a principal procedure code or documentation of a principal procedure in the medical record that is included in theselected measure Appendix A, ICD Table(s).在所选的策略附录A ICD诊断编码表中未包含病历中的主要处置编码文件或主要处置文件。Notes for Abstraction抽象化注意事项: The principal procedure is described as the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.主要处置为实施的绝对治疗性处置，非诊断性处置或探索性处置，或治疗并发症的处置。 Refer to Appendix A for ICD Code Tables for each individual measure set参考每个策略库单独的附录A ICD编码表 Any valid ICD principal procedure code or documentation of a principal (main) procedure in the medical record is acceptable.任何有效的ICD主要处置编码或病历中的主要处置记录均为可接受。Suggested Data Sources建议的数据来源: Discharge summary出院小结 Face sheet 病案首页Inclusion Guidelines for Abstraction包含的抽象化指引: Refer to each measure information section for the Appendix A ICD Code(s) or documentation of a principal procedure which is utilized to calculate each measures population. 参考每个策略信息部分的 附录A ICD编码表或用于计算每个策略人群的主要处置文件。 Question 3bData Element Name: ICD Other Procedure Codes数据元素名称：国际疾病分类其他处置编码Collected For: All Records收集用于：所有病历Definition: The International Classification of Diseases, Sixth Revision, Ninth Revision, Clinical Modification or Tenth Revision codes identifying all significant procedures other than the principal procedure.定义：识别除了主要处置外的所有重要处置的国际疾病分类、第六次修订、第九次修订、临床修订版或第十次修订编码。Please Note: For the initial version of the Library of Measures the ICD diagnosis (or procedure) codes can be found inAppendix A for each specific measure set. However, since not all accredited facilities utilized the ICD Code System, a response of Yes/No for this data element is allowed. 请注意： 对于策略库初始版本， 国际疾病分类诊断（或处置）编码可以在每个特定的策略库的附录A中找到。但是，由于不是所有的通过认证的医院都使用国际疾病分类编码系统，故允许使用Yes/No回应此数据元素。Suggested Data Collection Question: What were the ICD other procedure code(s) or documentation of other procedure(s) selected for this record?建议的数据收集问题：此病历所选的国际疾病分类其他处置编码是什么或其他处置的文件？Format格式: Length长度: 1Type类型: Alpha Occurs发生: 1Allowable Values: Y (Yes) 是 There is documentation that there are other procedure code(s) or other procedures listed in the medical record that are included in theselected measure Appendix A, ICD Table(s).在所选的策略附录A ICD诊断编码表中包含病历中的其他处置编码文件或其他处置文件。N (No)/or unable to determine否或无法确定There is no documentation that there are other procedure code(s) or other procedures in the medical record that are included in theselected measure Appendix A, ICD Table(s).在所选的策略附录A ICD诊断编码表中未包含病历中的其他处置编码文件或其他处置文件。Notes for Abstraction抽象化注意事项: Refer to Appendix A for ICD Code Tables for each individual measure set参考每个策略库单独的附录A ICD编码表 Any valid ICD “other” procedure code(s) or documentation of “other” procedure(s) in the medical record is acceptable.任何有效的ICD“其他”处置编码或病历中的“其他”处置记录均为可接受。Suggested Data Sources建议的数据来源: Discharge summary出院小结 Face sheet 病案首页Inclusion Guidelines for Abstraction包含的抽象化指引: Refer to each measure information section for the Appendix A, ICD Code(s) or documentation of a procedure (s) which are utilized to calculate each measures population. 参考每个策略信息部分的 附录A ICD编码表或用于计算每个策略人群的处置文件。Exclusion Guidelines for Abstraction不包含的抽象化指引: None无 Question 4Data Element Name: Birthdate数据元素名称：出生日期Collected For: All Records收集用于：所有病历Definition: The day, month, and year the patient was born.定义：患者出生的年月日。Note: Patients age (in years) is calculated by Admission Date minus Birthdate. The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.注释：由入院日期-出生日期来计算患者年龄（岁）。该运算法则必须使用入院日期和出生日期的月日部分以产生最准确的年龄。Suggested Data Collection Question: What is the patients date of birth?建议的数据收集问题：患者的出生日期是？Format格式:Length: 10 DD -MM -YYYY (includes dashes)长度: 10 日-月-年(包括破折号)Type类型: Date 日期Occurs发生: 1Allowable Values允许的值:DD = Day日 (01-31)MM = Month月 (01-12)YYYY = Year 年(1880-Current Year当前年份)Notes for Abstraction抽象化注意事项:Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value由于此数据元素在决定所有策略人群中至关重要，摘录者不能假设声称的出生日期信息为正确的。如果摘录者通过评估病历决定出生日期是不正确的，她/他应纠正及重写下载的数值。Suggested Data Sources建议的数据来源: Emergency department record 急诊室病历 Face sheet 病案首页 Registration form 登记表Inclusion Guidelines for Abstraction包含的抽象化指引: None 无Exclusion Guidelines for Abstraction不包含的抽象化指引: None无 Question 5Data Element Name: Discharge Disposition数据元素名称：出院处置Collected For: All Records收集用于：所有病历Definition: The place or setting to which the patient was discharged.定义：患者出院所至的地方。Suggested Data Collection Question: What was the patients discharge disposition?建议的数据收集问题：患者的出院处置是什么？Format格式:Length长度: 2Type类型: Alphanumeric 字母数字Occurs发生: 1Allowable Values允许的值:1 Discharged to home care or self care (routine discharge).回家或自我护理（常规出院）2 Dis