Attachment G - List of Var for EHR Ext of IP Disch 010616

Attachment G: List of Variables for EHR Extraction of Inpatient Discharges

National Hospital Care Survey:

Variables for Inpatient Discharges

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

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.

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. Date of admission and discharge

4. Encounter number

5. Admission diagnosis

6. All other diagnoses including E codes and V codes

7. Provided or Ordered during the inpatient stay:

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

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

8. Results of testing or procedures provided or ordered during the admission, as many as are available

9. Medications on admission, during hospital stay and at discharge

10. Priority of admission

11. Source of admission (e.g. emergency room)

12. Discharge disposition

13. Present on Admission (POA) flags for diagnoses

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

• Marital Status

• Source(s) of payment

• Any ICU, NICU or CCU use and number of days of care

• Height

• Weight

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

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.

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