["Encounter, Performed": "Encounter Inpatient"]

Performance/Reporting Period

2020

Value Set Description from VSAC

Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.4)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

startTime – the time the encounter began (admission time)
stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

startTime -the time the patient arrived at the location;
stopTime -the time the patient departed from the location

QDM Attributes

diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses syntax is preferred. Referencing the same diagnosis using Encounter, Performed (diagnoses attribute) and Diagnosis (datatype) should only occur if the measure must define a specified length of a prevalence period, e.g., the measure must assure that the diagnoses have been present for at least some defined time period before the encounter, and were addressed during the Encounter.

dischargeDisposition

The disposition or location to which the patient is transferred at the time of hospital discharge.

facilityLocations

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include, but are not limited to, intensive care units (ICUs), non- ICUs, burn critical-care unit, neonatal ICU, and respiratory-care unit. Each Encounter, Performed may have 1 or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as: Encounter, Performed: Inpatient Admission, ICU (location period), Non-ICU Admission (location period), Rehab (location period). Facility Locations (plural) is used for Encounter, Performed since there may be more than one facility location used in any given encounter.

principalDiagnosis

The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

relevantPeriod

Relevant Period addresses the time between the start of an action to the end of an action. Each datatype using relevant period defines specific definitions for the start and stop time for the action listed.