压疮和跌倒指标库
护理敏感型医疗服务策略库数据字典
Contents
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2011 Joint Commission International This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data 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包括破折号)
长度: 10 –日-月-年(包括破折号)
Type 类型: Date日期
Occurs 发生: 1
Allowable Values允许的值:
DD 日 = Day日 (01-31)
MM 月 = Month月 (01-12)
YYYY 年 = Year年 (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服务的患者，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
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
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
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data 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: Patient's 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 patient’s 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: 1
Allowable 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。
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
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
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Event Date
数据元素名称：事件日期
Collected For: I-NSC-4, I-NSC-5
收集用于：I-NSC-4, I-NSC-5
Definition: The date the associated event type occurred.
定义：相关事件发生的日期。
Suggested Data Collection Question: What is the date recorded in the medical record that the associated event type occurred?
建议的数据收集问题：病历中记录的相关事件发生日期是？
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: 1
Allowable Values允许的值:
DD 日 = Day日 (01-31)
MM 月 = Month月 (01-12)
YYYY 年 = Year年 (2001-Current Year当前年份)
Notes for Abstraction: Medical record documentation only should be used to collect this data element. This information is abstracted once for each day on which an event (Event Type) occurs during the patient’s hospitalization.
抽象化注意事项: 只允许使用病历文件来收集此数据元素。每天摘录患者住院期间的一个事件（事件类型）一次。
Suggested Data Sources建议的数据来源:
∙ Licensed independent practitioner orders
有执照的独立从业者所下的医嘱
∙ Nursing notes护理记录
∙ Nursing flow sheet护理流程图
∙ Observation sheets观察图
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
∙ Physician orders医嘱
∙ Progress notes病程记录
∙ Psychiatrist notes精神科医生记录
∙ Restraint monitoring form约束具监测表
∙ Therapist notes治疗师记录
Additional Notes – Guidelines for Abstraction:
额外注释----抽象化指引
Inclusion 包括:
∙ None 无
Exclusion 不包括:
∙ None 无
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Fall Injury Level
数据元素名称： 跌倒/坠床伤害等级
Collected For: I-NSC-5
收集用于： I-NSC-5
Definition: The patient’s condition after 24 hours from the fall. 定义： 跌倒24小时后的患者病情。
Suggested Data
Collection Question: What was the injury level experienced by this patient
as a result of this fall?
建议的数据收集问题： 跌倒/坠床后患者的伤害等级是几级？
Format 格式: Length 长度: 1
Type 类型: Alphanumeric字母数字
Occurs 发生: 1
Allowable Values允许的值:
1 None - patient had no injuries
无—患者没有受伤
2 Minor - resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, bruise or abrasion
较小伤害—需要敷料、冰、清洁伤口、肢体隆起、典型药物治疗、擦伤或磨损。
3 Moderate - resulted in suturing, application of steri-strips/skin glue, splinting, or muscle or joint strain
中度伤害—导致缝合、使用无菌切口胶布/皮胶、夹板、或肌肉/关节损伤 4 Major - resulted in surgery, casting, traction, fracture, or required consultation for neurological or internal injury
重大伤害—导致手术、浇铸、牵引、骨折、或要求精神损伤/内部损伤会诊 5 Death - the patient died as a result of injuries sustained from the fall 死亡—患者由于跌倒/坠床伤害而死亡
6 UTD – Unable to Determine from the documentation
无法确定—无法从文件中确定
Notes for Abstraction抽象化注意事项:
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
∙ When the initial fall report is written by the nursing staff, the extent of the injury may not yet be known. A meth od to follow up on the patient’s condition after 24 hours from the fall must be established.
护理人员撰写跌倒/坠床初步报告时，伤害程度可能还未知。必须建立患者跌倒/坠床后24小时的患者病情追踪方法。
∙ When the patient is discharged within 24 hours from the fall determine injury level at the time of discharge.
患者跌倒/坠床24小时内出院时，决定出院时患者的伤害等级。
∙ X-ray, CT scan or other radiological evaluation resulting in a finding of no injury, with no treatment and no signs or symptoms of injury- select ―1 None‖.
X 光检查、CT 扫描或其他放射评估如未发现伤害，没有采取治疗，没有伤害迹象和症状—选择“1 无”
∙ Patients with coagulopathy who receive blood products as a result of a fall - select ―4 Major‖.
由于跌倒/坠床，接受血液制品的有凝血病的患者—选择“4. 重大伤害”
Suggested Data Sources建议的数据来源:
∙ Incident, variance or occurrence report
意外事件、变化或事件报告
∙ Nurses notes护理记录
∙ Progress notes病程记录
∙ Radiology report after time of fall 跌倒/坠床后的放射报告
Guidelines for Abstraction抽象化指引:
Inclusion 包含
∙ None 无
Exclusion 不包含
∙ None 无
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Month
数据元素名称： 月份
Collected For: I-NSC 4, I-NSC-5
收集用于： I-NSC 4, I-NSC-5
Definition: The 2 digit month during which the measure specific
episode occurred.
定义： 特定策略的事件发生的2位数月份。
Suggested Data
Collection Question: What was the month during which the measure
specific episode occurred?
建议的数据收集问题： 特定策略的事件发生的月份是？
Format 格式: Length 长度: 2
Type 类型: Alphanumeric 字母数字
Occurs 发生: 1
Allowable Values允许的值:
01 January1月 05 May5月 09 September9月 02 February 2月 06 June6月 10 October10月 03 March3月 07 July7月 11 November11月 04 April4月 08 August8月 12 December12月
Notes for Abstraction抽象化注意事项: None 无
Suggested Data Sources建议的数据来源:
∙ Measure specific data collection documentation (electronic or manual) 特定策略的数据收集文件（电子或手工）
Inclusion 包含
∙ None 无
Exclusion 不包含
∙ None 无
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Number of Injury Falls
数据元素名称： 跌倒/坠床受伤次数
Collected For: I-NSC-4
收集用于： I-NSC 4
Definition: The total number of patient falls that resulted in injury
(Level II or greater) and occurred on the eligible
reporting unit during the calendar month.
定义： 引起患者伤害（二等或更高等级）的跌倒/坠床总数及
历月期间合格的报告病区中跌倒/坠床发生总数。
Suggested Data
Collection Question: What was the total number of patient injury falls for
this unit during the calendar month?
建议的数据收集问题： 在此历月期间患者跌倒/坠床伤害的总数？
Format 格式: Length 长度: 4
Type 类型: Numeric 数字
Occurs 发生: 1
Allowable Values允许的值: 0-9999
Notes for Abstraction抽象化注意事项:
∙ Enter 0 if no falls occurred
如果没有跌倒/坠床发生，输入0
∙ Any event related to a patient injury fall that occurs on an eligible reporting unit and generates a report should be counted.
在合格的报告病区中发生的与患者跌倒/坠床伤害有关并且产生报告的事件都应计算在内。
Suggested Data Sources建议的数据来源:
∙ Secondary risk management sources
次要的风险管理资源
∙ Incident Reports
意外事件报告
∙ Variance Reports
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
变化报告
∙ Event Reports
事件报告
Inclusion 包含
∙ None 无
Exclusion 不包含
∙ None 无
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Number of Patient Falls
数据元素名称：患者跌倒/坠床次数
Collected For: NSC-4
收集用于：NSC-4
Definition: The total number of patient falls that occurred on the eligible reporting unit during the calendar month.
定义：在历月期间合格报告病区中发生的患者跌倒总数。
Suggested Data Collection Question: What was the total number of patient falls for this unit during the calendar month?
建议的数据收集问题：在历月期间此病区发生的患者跌倒总数是多少？
Format 格式:
Length 长度: 4
Type 类型: Numeric 数字
Occurs 发生: 1
Allowable Values允许的值: 0-9999
Notes for Abstraction抽象化注意事项:
∙ Enter 0 if no falls occurred; or Event Type 6 ―No falls this month‖.
如果没有跌倒/坠床发生，输入0。
∙ It is recommended that your facility outline internal data and staff sources that will be used to report on this measure and to be sure your data
conform to measure specifications.
建议医院概述将用于报告此策略的内部数据和员工来源并且确定数据符合策略标准。
∙ Any event related to a patient fall that occurs on an eligible reporting unit and generates a report should be counted.
在合格的报告病区中发生的与患者跌倒/坠床伤害有关并且产生报告的事件都应计算在内。
Suggested Data Sources建议的数据来源:
∙ Secondary risk management sources
次要的风险管理资源
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
∙ Incident Reports
意外事件报告
∙ Variance Reports
变化报告
∙ Event Reports
事件报告
Inclusion 包含
∙ None 无
Exclusion 不包含
∙ None 无
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Observed Pressure Ulcer(s)
数据元素名称： 压迫性溃疡观察
Collected For: I-NSC-2
收集用于： I-NSC-2
Definition: Documentation that a pressure ulcer was or was not
observed at the time of the prevalence study.
定义： 在患病率研究时观察到的或未观察到的压迫性溃疡的文
件。
Suggested Data
Collection Question: How many pressure ulcers were observed on the day
of the prevalence study?
建议的数据收集问题 患病率研究当天观察到的压迫性溃疡是多少起？
Format 格式: Length 长度: 1
Type 类型: Alphanumeric字母数字
Occurs 发生: 48
Allowable Values允许的值: 0-48
Notes for Abstraction抽象化注意事项:
∙ Skin breakdown due to arterial occlusion, venous insufficiency, diabetes related neuropathy, or incontinence dermatitis are not pressure. ulcers 由于动脉闭塞、静脉功能不全、与神经病有关的糖尿病、或失禁皮炎引起的皮肤破裂不是压迫性溃疡。
∙ No value should be recorded more than once.
只能记录一次数值。
∙ All observed pressure ulcers should be documented following prevalence study definitions.
在患病率研究定义后面应记录所有的压迫性溃疡观察。
Suggested Data Sources建议的数据来源:
∙ Pressure ulcer prevalence study worksheet or data collection tool
压迫性溃疡患病率研究工作表或数据收集工具
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Guidelines for Abstraction抽象化指引:
Inclusion 包含:
∙ All patients on eligible units present at the time the study is conducted. 在研究期间合格病区中出现的所有患者。
Exclusion 不包含:
∙ Patients who refuse to be assessed
拒绝接受评估的患者
∙ Patients who are off the unit at the time of the prevalence study, i.e. surgery, x-ray, physical therapy, etc.
在患病率研究期间离开病区的患者，也就是说，手术患者、X 光患者、理疗患者等
∙ Patients who are medically unstable at the time of the study for whom assessment would be contraindicated at the time of the study, i.e.
unstable blood pressure, uncontrolled pain, or fracture waiting repair.
在患病率研究期间病情不稳定的禁忌评估的患者，就是说，血压不稳定、疼痛难以控制、或骨折等待修护的患者
∙ Patients who are actively dying and pressure ulcer prevention is no longer a treatment goal.
临终患者，预防压迫性溃疡不再是治疗目标
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2011 Joint Commission International
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护理敏感型医疗服务策略库数据字典
Data Element Name: Observed Pressure Ulcer - Category/stage 数据元素名称： 压迫性溃疡观察—类型/阶段
Collected For: I-NSC-2
收集用于： I-NSC-2
Definition: Documentation of the category/stage for the observed
pressure ulcer using the NPUAP / EPUAP Pressure
Ulcer Classification System.
定义： 使用美国压疮顾问小组/欧洲压疮顾问小组压疮分类系
统观察的压疮类型/阶段的文件。
Suggested Data
Collection Question: What was the category/stage for this pressure ulcer? 建议的数据收集问题： 压疮的类型/阶段是什么？
Format 格式: Length 长度: 1
Type 类型: Alphanumeric字母数字
Occurs 发生: 48
Allowable Values允许的值:
1 Category/stage I - Non-blanchable erythema
第一阶段/类型--非苍白性发红
2 Category/stage II– Partial thickness skin loss
第二阶段/类型--部分皮肤层丢失
3 Category/stage III– Full thickness skin loss
第三阶段/类型—所有皮肤层丢失
4 Category/stage IV– Full thickness tissue loss
第三阶段/类型—所有组织层丢失
5 Unstageable/ Unclassified– Full thickness skin or tissue loss – depth unknown
不明确阶段/未分类--所有皮肤层/组织层丢失—深度不明
6 Suspected deep tissue injury– depth unknown
疑似深层组织受损--深度不明
7 There is no documentation of category/stage or Unable to Determine from the documentation
没有类型/阶段文件或无法从文件中确定。
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2011 Joint Commission International
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护理敏感型医疗服务策略库数据字典
Notes for Abstraction抽象化注意事项:
∙ Follow National Pressure Ulcer Advisory Panel (NPUAP) / European
Pressure Ulcer Advisory Pressure (EPUAP) Ulcer Classification System 遵循美国压疮顾问小组(NPUAP)/欧洲压疮顾问小组(EPUAP)压疮分类系统。
∙ This data element is completed for each documented pressure ulcer. 完成每个备有文件证明的压疮的数据元素。
Suggested Data Sources建议的数据来源:
∙ Nurses notes护理记录
∙ Pressure ulcer prevalence study worksheet or data collection tool
压迫性溃疡患病率研究工作表或数据收集工具
∙ Progress notes病程记录
Guidelines for Abstraction抽象化指引:
Inclusion 包含
∙ None 无
Exclusion 不包含
∙ None 无
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Observed Pressure Ulcer – Hospital-Acquired 数据元素名称： 压迫性溃疡观察—医院获得性
Collected For: I-NSC-2
收集用于： I-NSC-2
Definition: Documentation that the observed pressure ulcer
meets the criteria for hospital-acquired (nosocomial).
Hospital-acquired ulcers are those discovered or
documented after the first 24 hours from the time of
inpatient admission.
定义： 观察的压迫性溃疡满足医院获得性压疮的标准的记录。
医院获得性压疮为从住院患者入院首个24小时后发现
的或备有文件证明的医院获得性压疮。
Suggested Data
Collection Question: Was the pressure ulcer discovered or documented
after the first 24 hours from the time of inpatient
admission?
建议的数据收集问题： 压迫性溃疡是否在住院患者入院首个24小时后发现或
记录？
Format 格式: Length 长度: 1
Type 类型: Alphanumeric字母数字
Occurs 发生: 48
Allowable Values允许的值:
1 (Yes)是
Pressure Ulcer was discovered or documented after the first 24
hours from the time of inpatient admission
在住院患者入院首个24小时后发现或记录压迫性溃疡。
2 (No)否
Pressure Ulcer was discovered or documented within the first 24
hours from the time of inpatient admission
在住院患者入院首个24小时内发现或记录压迫性溃疡。
3 (UTD) 无法确定
Unable to Determine from the documentation.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
无法从文件中确定。
Notes for Abstraction抽象化注意事项:
∙ A community acquired pressure ulcer is defined by: Ulcer
discovered/documented within the first 24 hours from the time of inpatient admission
社区获得性压迫性溃疡定义为：在住院患者入院首个24小时内发现或记录的溃疡。
∙ Hospital-acquired pressure ulcers refer to new ulcer(s) developed after the first 24 hours from the time of inpatient admission.
医院获得压迫性溃疡指在住院患者入院首个24小时内产生的新溃疡。 ∙ An ulcer of category/stage II or greater observed after the first 24 hours from the time of inpatient admission AND for which there is no
documentation in the record indicating the date of first discovery; should be considered as hospital-acquired.
住院患者入院首个24小时后观察到的第二或更高的溃疡类型/阶段以及病历中没有显示首次发现的日期的记录；应考虑作为医院获得性压疮。 ∙ This data element is completed for each documented pressure ulcer. 完成每个备有文件证明的压迫性溃疡的数据元素。
Suggested Data Sources建议的数据来源:
∙ Nurses notes护理记录
∙ Pressure ulcer prevalence study worksheet or data collection tool 压疮患病率研究工作表或数据收集工具
∙ Progress notes病程记录
Guidelines for Abstraction抽象化指引:
Inclusion 包含:
∙ None 无
Exclusion 不包含:
∙ None 无
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Patient Days
Collected For:
I-NSC-4, I-NSC-5
Definition: The total number of patient days, per unit, for a month.
Suggested Data
Collection Question: What is the total number of patient days for this unit during the calendar month?
Format: Length: 5
Type: Numeric Occurs: 1
Allowable Values:
0 – 99999
Notes for Abstraction:
Hospital selects one method to determine patient
days, as appropriate to their patient population and as supported by their information resources. See below.
Suggested Data Sources:
∙ Accounting or billing systems
∙ Admission/discharge/transfer systems ∙ Actual patient hours, short and long stay ∙ Actual short stay patient hours ∙ Multiple daily census reports
∙ Patient census records, including: Midnight census
Guidelines for Abstraction:
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Exclusion:
A negative number
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Prevalence Study Date 数据元素名称： 患病率研究的日期
Collected For: I-NSC-2 收集用于： I-NSC-2
Definition: The date of the prevalence study. 定义： 患病率研究的日期
Suggested Data
Collection Question: On what date was the prevalence study conducted? 建议的数据收集问题： 进行患病率研究的日期是什么时候？
Format 格式: Length 长度: 10 – DD日-MM 月-YYYY 年 Type 类型: Date 日期 Occurs 发生: 1
Allowable Values允许的值: DD 日 = Day日 (01-31)
MM 月 = Month月 (01-12)
YYYY 年 = Year年 (2001-Current Year当前年份)
Notes for Abstraction: None. 抽象化注意事项:无
Suggested Data Sources建议的数据来源:
∙ Pressure ulcer/restraint prevalence study worksheet or data collection tool. 压迫性溃疡/约束具患病率研究工作表或数据收集工具。
Guidelines for Abstraction抽象化指引: Inclusion 包含: ∙ None 无
Exclusion 不包含: ∙ None 无
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Type of Unit 数据元素名称： 病区类型
Collected For: I-NSC-2, I-NSC-4, I-NSC-5 收集用于： I-NSC-2, I-NSC-4, I-NSC-5
Definition: Unit type reflects the patient population and the
service line. It is used in risk stratification, so that reporting occurs for similar units.
定义： 病区类型反映患者人群及服务方式。病区类型用于风险
分层，以便报告类似病区的风险。
Suggested Data
Collection Question: What is the type of unit? 建议的数据收集问题： 病区类型是什么
Format 格式: Length 长度: 1 Type 类型: Alphanumeric 字母数字
Occurs 发生: 1
Allowable Values允许的值:
1 Critical Care – adult 急救护理—成人 2 Step-down – adult 二级护理—成人 3 Medical - adult 医疗护理—成人 4 Surgical - adult 外科护理—成人
5 Med-Surg Combined - adult 医疗外科相结合的护理—成人 6 Mixed acuity – adult Notes for Abstraction抽象化注意事项:
.
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2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
∙ To select the unit types first determine the acuity level of the patients typically served on the unit. If the unit has 90% or greater of the same acuity type, select that acuity level.
选择病区类型，首先决定病区通常服务的患者的疾病剧烈等级。如果病区有90%或以上的剧烈类型相同，选择该等级。
∙ To select a specialty unit or location type the patients served must be 80% or greater of the same specialty type to select the specialty or location type.
选择专科病区或地点类型， 80%或以上服务的患者的专科类型必须相同以便选择病区类型或地点类型。
Suggested Data Sources建议的数据来源: ∙ Hospital unit plan医院病区计划
∙ Unit nursing managers病区护理管理者
Guidelines for Abstraction抽象化指引: Inclusion 包含: ∙ None 无
Exclusion 不包含: ∙ None 无
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement
护理敏感型医疗服务策略库数据字典
Data Element Name: Year 数据元素名称： 年份
Collected For: I-NSC-4, I-NSC-5 收集用于： I-NSC-4, I-NSC-5
Definition: The 4-digit year during which the measure specific
episode occurred.
定义： 特定策略的事件发生的4位数年份。
Suggested Data
Collection Question: What was the year during which the measure specific
episode occurred?
建议的数据收集问题： 特定策略的事件发生的年份是哪一年？
Format 格式: Length 长度: 4 Type 类型: Alphanumeric 字母数字
Occurs 发生: 1
Allowable Values允许的值: YYYY = Year 年(2001 – Current Year当前
年份)
Notes for Abstraction: None 抽象化注意事项：无
Suggested Data Sources建议的数据来源:
∙ Organization-specific data collection documentation (electronic or manual) 医院特定的数据收集记录（电子或人工）
Guidelines for Abstraction抽象化指引: Inclusion 包含: ∙ None 无
Exclusion 不包含: ∙ None 无
.
Use keys to go to the title page
2011 Joint Commission International
This form is not part of the medical record and is intended for quality improvement