EHR Variable List

Attachment E: EHR Variable List

EHR Variables
Data Item
Personal Identifiable Information

Patient Information

Encounter Information

Emergency
Department Inpatient
Visits
Discharges

Outpatient
Visits

Meaningful
Use Data
Element
4

Patient Name

R

R

R

Patient Address including zip code

R

R

R

Patient SSN and Medicare number

R

R

R

Patient medical record number

R

R

R

Date of birth

R

R

R

4

Sex

R

R

R

4

Race

R

D

R

4

Ethnicity

R

D

R

4

Height

D

4

Weight

D

4

Marital Status

D

Tobacco use

D

If female, is patient pregnant and
gestation week

D

If patient has asthma: Asthma
Severity (intermittent, mild
persistent…severe persistent)

D

If patient has asthma: Asthma
Control (well controlled…very
poorly controlled)

D

Encounter number

R

R

R

R

Date of admission

4
R

Date of visit
Date and time of arrival

R

Date and time of provider contact

R

4

4
4

R = Required
D = Desired
1

For more information on the National Hospital Care Survey visit: http://www.cdc.gov/nchs/nhcs.htm

EHR Variables

Data Item
Encounter Information (cont’d)

Dx Information

Meaningful
Use Data
Element

R

R

4

Date and time of departure/
discharge

R

R

4

Date and time of admission order

R

Source(s) of payment

R

Admission diagnosis
R

D

R

R

R

4

R

R

4

R

4

Priority of admission

R

Source of admission (e.g.
emergency room)

R

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

Orders, Observations and
Medications

Outpatient
Visits

Date and time of departure/
discharge

All (other) diagnoses including
E codes and V codes
Admission, Discharge, and Notes

Emergency
Department Inpatient
Visits
Discharges

R

Present on Admission (POA) flags
for diagnoses

R

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

D

4

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

R

D

D

Discharge disposition (Return
appointment, Referred, Routine
discharge (if surgery), Admitted to
ED/hospital, etc.)

R

R

R

Provided or Ordered Diagnostic
testing (e.g., lab, imaging, EKG,
audiometry, biopsy)

R

R

R

4

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

R

R

R

4

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

R

R

R

4

Medications on admission, during
hospital stay and at discharge

R

R

R

2

For more information on the National Hospital Care Survey visit: http://www.cdc.gov/nchs/nhcs.htm

EHR Variables

Data Item
Care Providers

Clinic

Detailed Observations

NPIs of physicians

Emergency
Department Inpatient
Visits
Discharges
D

D

Outpatient
Visits
D

Health care providers seen
(including attending, resident,
intern, N.P., P. A., consulting,
specialist(s), Nurse, mental health
providers, social workers)

D

Is this provider the patient’s
primary care provider or was
patient referred for visit

D

Type of clinic/location where
visit occurred (family practice,
cardiology, etc.)

D

Has patient been seen in clinic/
location before

D

If yes, how many visits in previous
12 months (excluding this visit)

D

Vital signs (height, weight, blood
pressure, temperature)

D

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

Meaningful
Use Data
Element

4

D

Most recent results and dates
blood drawn for Total cholesterol

R

Most recent results and dates
blood drawn for HDL

R

Most recent results and dates
blood drawn for LDL

R

Most recent results and dates
blood drawn for Triglycerides

R

Most recent results and dates
blood drawn for HbA1c

R

Most recent results and dates
blood drawn for Blood glucose

R

Most recent results and dates
blood drawn for Serum creatinine

R

Immunizations - previous and
administered

R

R

Active problems

R

R

Pain level

D

4

3

For more information on the National Hospital Care Survey visit: http://www.cdc.gov/nchs/nhcs.htm

EHR Variables

Data Item
Detailed Observations (cont’d)

ED Visit Details

Out Patient Surgery

ED Disposition to Observation

ED admit to Hospital

Emergency
Department Inpatient
Visits
Discharges

Outpatient
Visits

Is this visit for a new problem,
chronic problem (routine or flareup), preventive care, pre-/postsurgery, surgery/procedure

D

If injury, cause and intentionality

D

Was patient triaged and if so,
triage level

R

Mode of arrival (e.g., ambulance,
police transport)

R

Was patient transferred from
another hospital or urgent care
facility

D

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

D

Initial or follow-up visit

D

Date and time Surgery/Procedure
began and ended

D

Provider(s) of anesthesia (e.g.
anesthesiologist, CRNA, resident,
surgeon)

D

Symptom(s) present during or
after surgery/procedure

D

Any follow-up with patient within
24 hours and outcome

D

If admitted to observation unit,
Dates and times (ED discharge,
observation unit discharge)

D

Date and time bed requested for
hospital admission

D

If admitted to hospital, Specialty
of admitting physician (e.g.,
hospitalist)

D

If admitted to hospital,Type of
unit admitted to

D

If admitted to hospital, Hospital
discharge date

D

If admitted to hospital, Hospital
discharge diagnosis

D

If admitted to hospital, Hospital
discharge disposition

D

Meaningful
Use Data
Element

4

For more information on the National Hospital Care Survey visit: http://www.cdc.gov/nchs/nhcs.htm