Attachment H - List of Var for EHR Ext of ED Visits 010616

Attachment H: List of Variables for EHR Extraction of Emergency Department Visits

National Hospital Care Survey:

Variables for Emergency Department Visits

Your hospital can participate in the National Hospital Care Survey by submitting electronic health record (EHR) information in one of two ways:

1. A standardized minimum data set of Patient Encounter-Based data such as ONE of the following:

• Continuity of Care Document (CCD)

• Transition of Care Summary

• Discharge Summary

OR:

2. Data extracted from your hospital’s EHR or data repository consisting of:

   1. Needed data elements related to a patient visit

   2. A small set of Patient Encounter-Based personal identifiable information (PHI)

   3. If available, “Like to Have” data elements related to a patient visit

2. Data Elements extracted from your organization’s EHR or data repository

   1. Needed data elements related to a patient visit:

1. Date of birth

2. Sex

3. Dates and times of arrival, seen by provider and departure

4. Encounter number

5. All diagnoses including E codes and V codes

6. All reason(s) for visit and/or Chief Complaint

7. Clinician notes (e.g., physicians’, nurses’, P.A.s’ and N.P.s’ notes)

8. Disposition (e.g., released or transferred from ED, admitted to observation unit, admitted to hospital)

9. Provided or Ordered during the visit:

   1. Diagnostic testing (e.g., lab, imaging, EKG, audiometry, biopsy)

   2. Therapeutic procedures, including surgery, and non-medication treatments (e.g. physical therapy, speech therapy, home health care)

10. Results of testing or procedures provided or ordered during the visit, as many as are available

11. Medications and immunizations given in ED or at discharge

12. Was patient triaged and if so, triage level

13. Mode of arrival (e.g., ambulance, either air or ground; walk-in, including car, taxi, bus, or foot; public services such as police car or social service vehicle; unknown)

14. Active problems the patient has at the time of the visit

2. PHI:

• Name

• Address including zip code

• SSN and Medicare number

• Patient’s medical record number

3. “Like to Have” data elements related to a patient visit IF they are readily obtainable:

• NPIs of physicians

• Race

• Ethnicity

• Source(s) of payment

• Was patient transferred from another hospital or urgent care facility

• Vital signs on arrival and last taken (temperature, pulse, respiratory rate, blood pressure, pulse oximetry)

• Pain level

• Has patient been seen in this ED within last 72 hours and discharged

• Initial or follow-up visit

• Health care providers seen:

  • Emergency department providers (e.g., Attending, resident, intern, N.P., P.A.)

  • Consulting physician(s) and specialties

  • Other health care providers (e.g., nurse, mental health provider, social worker)

• If admitted to observation unit

• Dates and times (ED discharge, observation unit discharge)

• Date and time bed requested for hospital admission

• If admitted to hospital

• Specialty of admitting physician (e.g., hospitalist, general surgeon)

• Type of unit admitted to

• Hospital discharge date

• Hospital discharge diagnosis

• Hospital discharge disposition

For More Information contact:

Dr. Carol DeFrances, Branch Chief, Ambulatory and Hospital Care Statistics Branch

301–458–4440 or cdefrances@cdc.gov

Or visit the National Hospital Care Survey website: http://www.cdc.gov/nchs/nhcs.htm.

Page 3 of 3