Leading the Way to Zero | The Joint Commission



Patient NameUnique Patient IdentifierBirthdateOutpatient Encounter DateOutpatient Departure DateICD-10 Principal DX CodeICD-10 Other DX CodeICD-10 Other DX CodeICD-10 Other DX CodeCPT? Procedure CodeCPT? Procedure Code DateCPT? Code with ModifierCPT? Code with ModifierCPT? Code with ModifierAmbulation YES or NOAmbulation Date/TimeDischarge Code1 Home2 Hospice-Home3 Hospice-Health Care Facility4 Acute Care Facility5 Other Health Care Facility6 Expired7 Left AMA8 Not Documented or UTDPACU Discharge Date/TimePostop ICU Admit or TransferYES or NOPreop Assessments CompletedYES or NOPreop Assessments Completion DateReason for No Regional AnesthesiaYES or NOReason for Not Ambulating the Day of SurgeryYES or NOReason for Not Discharging Patient to HomeYES or NORegional AnesthesiaThere is documentation that the procedure was performed using regional anesthesia.There is documentation that regional anesthesia was attempted but unsuccessful.There is no documentation that the procedure was performed using regional, nor attempted or UTD.Resident of Other Health Care FacilityYES or NOIMPORTANT: REFER TO IMPLEMENTATION GUIDE FOR MEASURE INFORMATION FORMS, ALGORITHMS, DATA ELEMENT DEFINITIONS AND NOTES FOR ABSTRACTION.PLEASE NOTE: THIS IS A SAMPLE TOOL AND IS PROVIDED AS AN EXAMPLE OF HOW YOU MAY CHOOSE TO FORMAT YOUR DATA COLLECTION TOOL; A DATA COLLECTION TOOL IS NOT REQUIRED. ................
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