Relevant to Measure

CAP-1, CAP-2, CAP-3, CAP-4, CAP-5

MDE ID

ARRIVAL_DATETIME_CAP

Assure Question Definition

The earliest documented day, month, and year the patient arrived at the hospital. (Date)
The earliest documented time (24 hour clock) the patient arrived at the hospital. (Time)

Answer Guidance

If the date/time of arrival is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples: 

• Documentation within the medical record indicates the Arrival Date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the Arrival Date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "UTD." 
• Documentation within the medical record indicates the Arrival Time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD." 
• Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the Arrival Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."

Review only the acceptable sources to determine the earliest date the patient arrived at the hospital.  This may differ from the admission date/time

Note:

Medical record documentation from all of the "only acceptable sources" should be carefully examined in determining the most correct date of arrival.  Arrival date should NOT be abstracted simply as the earliest date in the acceptable sources, without regard to other (i.e., ancillary services) substantiating documentation.  If documentation suggests that the earliest date in the acceptable sources does not reflect the date the patient arrived at the hospital, this date should not be used.

When reviewing A&E department records do NOT include any documentation from external sources (e.g. ambulance records, Consultant (or working as part of the Consultant team) office record, laboratory reports or ECGs) obtained prior to arrival.  The intent is to utilise any documentation, which reflects processes that occurred in A&E department or hospital.
If the patient is in an outpatient setting of the hospital (e.g. undergoing dialysis, chemotherapy, cardiac cath) and is subsequently admitted to the hospital, use the date the patient presents to the outpatient department as the arrival date/time.

If the patient is a "Direct Admit", as a transfer from another A&E department or acute care hospital, use the date the patient presents to the hospital as the arrival date/time.
For "Direct Admissions" to the hospital, use the earliest date/time the patient arrives at the hospital.
The source "Any A&E department documentation" includes A&E department record, A&E department/Outpatient Registration form, triage record and ECG reports, laboratory reports, x-ray reports etc. if these ancillary services were rendered while the patient was an A&E department patient.
The source "Procedure notes" refers to formal documents that describe a procedure that has been carried out (e.g., endoscopy, cardiac catheterisation). ECG and x-ray reports should NOT be considered procedures notes.

Acceptable Documentation Source

ONLY ACCEPTABLE SOURCES: 

• Accident and emergency notes
• Medical assessment unit notes
• Transfer notes
• Continuation notes or ward notes which make reference to date and time spent in Accident and Emergency
• Outpatient notes

DATE
Question Allowable Answers

DD

Day (01 - 31)

MM

Month (01 - 12)

YYYY

Year (2000 - 9999)

Unknown

Unknown

TIME
Question Allowable Answers

HH

Hour (00 - 23)

MM

Minutes (00 - 59)

Unknown

Unknown

24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon: If the time is in the a.m., conversion is not requiredIf the time is in the p.m., add 12 to the clock time hour
Examples:

f documented time is 11:59pm on 1/1/2014 enter 11.59  01/01/2016 
If documented time is midnight enter the following date: 00:00  02/01/2016

Relevant to Measure

CAP-2

MDE ID

PO_ABG_DATETIME_CAP

Assure Question Definition

The documented day, month, and year that the patient received pulse oximetry or arterial blood gas analysis on arrival (Date).
The documented time (24 hour clock) that the received pulse oximetry or arterial blood gas analysis on arrival. (Time)

Answer Guidance

If the date/time of pulse oximetry or arterial blood gas analysis on arrival is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples: 

• Documentation within the medical record indicates the Arrival Date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the Arrival Date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "UTD."
• Documentation within the medical record indicates the Arrival Time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD."
• Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the Arrival Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."

Acceptable Documentation Source

ONLY ACCEPTABLE SOURCES: 

• Accident and emergency notes
• Medical assessment unit notes
• Admission notes

DATE
Question Allowable Answers

DD

Day (01 - 31)

MM

Month (01 - 12)

YYYY

Year (2000 - 9999)

Unknown

Unknown

TIME
Question Allowable Answers

HH

Hour (00 - 23)

MM

Minutes (00 - 59)

Unknown

Unknown

24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon:

If the time is in the a.m., conversion is not

required

If the time is in the p.m., add 12 to the clock time hour
Examples:

If documented time is 11:59pm on 1/1/2014 enter 11.59  01/01/2016 
If documented time is midnight enter the following date: 00:00  02/01/2016

Relevant to Measure

CAP-4, CAP-5

MDE ID

ANTIBIOTIC_TABLE_CAP

Assure Question Definition

Method of administration of a dose of medication.  Medications may be administered in a variety of ways depending upon how they are supplied and prescribed.

Answer Guidance

The measure is designed to capture the appropriate administration of appropriate antibiotics. The route of administration is appropriate if given orally or intravenously. A comprehensive list of terminology is given below.

Acceptable Documentation Source

• Drug prescription sheets – oral and IV
• Operative notes
•  Pharmacy information
• High dependency Unit notes
•  Intensive care unit notes
• Accident and Emergency Unit notes

Question Allowable Answers
 

MDE Value

Route

1

Oral

2

Intravenous

3

Intramuscular

4

Rectal

N

Not Applicable

0
10
Z

Unknown

Terminology used to answer this question

Applicable terminology:

Include any antibiotics given:
Intravenous:

• Bolus
• Infusion
• IV/I.V.
• IV piggyback/IVPB
• Parenteral

• Perfusion 

PO/NG/PEG tube:

• Any kind of feeding tube (e.g., percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, gastrostomy tube)
• By mouth
• Gastric tube
• G-tube
• Jejunostomy
• J-tube
• Nasogastric tube
• PO/P.O.
  Refer to Appendix C, Table 2.1 for a comprehensive list of Antimicrobial Medications.

Non-applicable terminology:

• Abdominal irrigation
• Chest irrigation
• Eardrops
• Enema/rectally
• Eye drops
• Inhalation
• Intracoronary
• Joint irrigation
• Mixed in cement
• Mouthwash
• Nasal sprays
• Peritoneal dialysate (antibiotic added to)
• Peritoneal irrigation
• Swish and spit
• Swish and swallow (S/S)
• Topical antibiotics
• Troches
• Vaginal administration
• Wound irrigation

Relevant to Measure

CAP-4, CAP-5

MDE ID

ANTIBIOTIC_TABLE_CAP

Assure Question Definition

The date (day, month and year) for which an antibiotic dose was administered.
An antibiotic may be defined as any drug, such as penicillin or streptomycin, containing any quantity of any chemical substance produced by a microorganism or made synthetically (i.e. quinolones) which has the capacity to inhibit the growth of or destroy bacteria and other microorganisms. Antibiotics are used in the prevention and treatment of infectious diseases.

Answer Guidance

If the date an antibiotic is administered is unable to be determined from medical record documentation, enter "UTD".
The medical record must be abstracted as documented (taken at "face value"). When the date documented is obviously in error (not a valid format/range or outside of the parameter of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples:

• Documentation indicates the Antibiotic Administration Date was on 42-02-2007. No other documentation in the medical record provides a valid date. Since the Antibiotic Administration Date is outside of the range listed in the Allowable Values for "Day," it is not a valid date and the abstractor should select "UTD."
• Patient expires on 12-02-2007 and documentation indicates the Antibiotic Administration Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."

Note:
Transmission of a case with an invalid date as described above, will be rejected from Clarity Data Warehouse. Use of "UTD" for Antibiotic Administration Date allows the case to be accepted into the warehouse.
Collect only antibiotics administered via an appropriate route (Hip/Knee, CABG: PO and IV; PN: PO, IV and IM) to answer this question.
The use of "infusion time" is acceptable as antibiotic administration time when other documentation cannot be found.
If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered.
Only use "Antibiotic NOS" in the following situations:

• For new antibiotics that are not yet listed in Table 2.1 
•  When there is documentation an antibiotic was administered but unable to identify the name.  It must be apparent that the medication is an antibiotic. 

Example:

• On 12-2-07, the ED record contains the documentation, "Antibiotic started name illegible, 2gm, IV, 0200-JM".  In the antibiotic grid, "Antibiotic NOS" would be entered for the name, IV for the route, 0200 for the time and 12-2-07 for the date. (If "Antibiotic started" had not been documented in this example, the medication could not be abstracted as an Antibiotic Received.

A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1).  If the route of administration of an antibiotic changes during the hospital stay (arrival through 36 hours for PN and arrival through 48 hours postop [72 hours postop for CABG and Other Cardiac Surgery] for Hip/Knee) record the antibiotic name once for each route by which it was administered.
Example:

• A patient arrives at the hospital at 07:15 on 05-05-2004.  Zithromax IV is administered in A&E at 09:30 on 05-05-2005.  On 06-05-2004 at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax 05-05-2004, 09:30, IV and Zithromax 06-05-2004, 09:00, PO.

Do not abstract antibiotic administration information for a specific antibiotic from more than one data source.  For EACH antibiotic, enter an Antibiotic Administration Route, Date and Time.  If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilise "UTD" for the missing information.
Examples:

• Do not use Consultant orders as they do not demonstrate administration of the antibiotic (in A&E department this may be used if signed/initialed by a nurse). 
• In narrative documentation, only accept documentation that reflects the actual administration of the antibiotic.

The date of administration must be documented on each side of every page used as a data source.  If this is not the case, utilise "UTD" for the missing date.
If an A&E department form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for A&E department documentation only.  If this is not the case, utilise "UTD" for the missing date.
Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic. 

• First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Surgery End Time (72 hours postop for CABG or Other Cardiac Surgery).
• Second: Abstract the dose administered prior and closest to Surgical Incision Time.

Example: 

• Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00.  Antibiotic B was administered at 15:30 and 17:00. Abstract:
  
  • Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
  • Antibiotic B: 15:30 (first) and 17:00 (last)

Note:
This question has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery).  However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable.

Acceptable Documentation Source

• Drug prescription sheets – oral and IV
• Operative notes
•  Pharmacy information
• High dependency Unit notes
•  Intensive care unit notes
• Accident and Emergency Unit notes

Question Allowable Answers

DD

Day (01 - 31)

MM

Month (01 - 12)

YYYY

Year (2000 - 1999)

UTD

Unable to Determine

Terminology used to answer this question

Applicable terminology:

-

Non-applicable terminology:

-

Relevant to Measure

CAP-4, CAP-5

MDE ID

ANTIBIOTIC_TABLE_CAP

Assure Question Definition

The time (24 hour clock) for which an antibiotic dose was administered.

Answer Guidance

If the time an antibiotic is administered is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select "UTD".
Example:

• Documentation indicates the Antibiotic Administration Time was 3300. No other documentation in the medical record provides a valid time. Since the Antibiotic Administration Time is outside of the range listed in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD".

The use of "hang time" or "infusion time" is acceptable as antibiotic administration time when other documentation cannot be found.
If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered.
If collecting the time for an antibiotic administered via infusion (IV), the Antibiotic Administration Time refers to the time the antibiotic infusion was started 
A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1).  If the route of administration of an antibiotic changes during the hospital stay (arrival through 36 hours for PN and arrival through 48 hours post-op [72 hours post-op for CABG or Other Cardiac Surgery] for Hip/Knee) record the antibiotic name once for each route by which it was administered.
Example:

• A patient arrives at the hospital at 07:15 on 05-05-2004.  Zithromax IV is administered in A&E department at 09:30 on 05-05-2004.  On 06-05-2004 at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax 05-05-2004, 09:30, IV and Zithromax 06-05-2004, 09:00, PO.

Do not abstract antibiotic administration information for a specific antibiotic from more than one data source.  For EACH antibiotic name, enter an Antibiotic Administration Route, Date, time.  If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilise "UTD" for the missing information. 
Example:

• The signed and dated anaesthesia record contains the documentation: "Amoxicillin 1 gm at 10:50".  The route is missing from this documentation.  Enter "UTD" for the route in this grid entry.  Do not use the operative report that contains documentation of the route to collect the missing information from the anaesthesia record. 

Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic. 
Examples:

• Do not use Consultant orders as they do not demonstrate administration of the antibiotic (in A&E department this may be used if signed/initialed by a nurse).
• In narrative documentation, only accept documentation that reflects the actual administration of the antibiotic.

The date of administration must be documented on each side of every page used as a data source.  If this is not the case, utilise "UTD" for the missing date.
If an A&E department form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for A&E department documentation only.  If this is not the case, utilise "UTD" for the missing date.
Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic.

• First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Surgery End Time (72 hours postop for CABG or Other Cardiac Surgery). 
• Second: Abstract the dose administered prior and closest to Surgical Incision Time.  If two or more times are documented for the same dose, abstract the dose administered closest to Surgical Incision Time. 

Example: 

• Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00.  Antibiotic B was administered at 15:30 and 17:00. Abstract:
  
  • Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
  • Antibiotic B: 15:30 (first) and 17:00 (last)

Note:
This question has two approaches for abstraction.  The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery).  However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable.

Acceptable Documentation Source

• Drug prescription sheets – oral and IV
• Operative notes
•  Pharmacy information
• High dependency Unit notes
•  Intensive care unit notes
• Accident and Emergency Unit notes

Question Allowable Answers

HH

Hour (00 - 23)

MM

Minutes (00 - 59)

UTD

Unable to Determine

24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon:
If the time is in the am, conversion is not required
If the time is in the pm, add 12 to the clock time hour
Examples: