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.

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

• startTime – when the diagnostic study is initiated
• stopTime – when the diagnostic study is completed

Examples:

• Initiation of a treadmill stress test to the time the treadmill stress test has completed
• Initiation of the ultrasound study until completion of the ultrasound study

 

Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

• startTime – when the diagnostic study is initiated
• stopTime – when the diagnostic study is completed

Examples:

• Initiation of a treadmill stress test to the time the treadmill stress test has completed
• Initiation of the ultrasound study until completion of the ultrasound study

 

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.

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

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

• startTime – the first day of insurance coverage with the referenced payer
• stopTime – the last day of insurance coverage with the referenced payer

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

The final consequences or data collected from the datatype. Results can be used in four ways, to express: (1) That a result is present in the electronic record but any entry is acceptable. (2) A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units. Examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). (3) A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code. (4) A result as a dateTime (Assessment, Performed and components). Note: Measures use Clinical Quality Language (CQL) logic to express the mathematical operators to constrain desired results to those above or below a certain threshold.