["Procedure, Performed": "Influenza Vaccination"]
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes concepts that represent an influenza vaccination.
Exclusion Criteria: No exclusions.
Constrained to codes in the Procedure, Performed: Influenza Vaccination value set (2.16.840.1.113883.3.526.3.402)
"Procedure, Performed"
Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.
Timing:
- relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
- relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
- startTime - The time the procedure begins.
- stopTime - The time the procedure ends.
- author dateTime references the time the action was recorded.
- Refer to the eCQM expression to determine allowable timings to meet measure criterion.
Notes:
- Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
- The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
- negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
- For clarification, see Appendix 6.6 with 2020 guidance about differentiating between successful and unsuccessful procedures.
authorDateTime
The time the data element was entered into the clinical software. Note, some datatypes include both relevant dateTime and author dateTime attributes. When both are present, author dateTime is included to accommodate negation rationale.
The author dateTime addresses when an activity is documented. Documentation can occur at the beginning, during, at the end, or subsequent to the end of the activity. The author dateTime should be used only if the relevantPeriod cannot be obtained or to represent the time negation rationale is documented.
Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
negationRationale
Indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the negation rationale attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes a world view that absence of evidence indicates information does not exist or an action did not happen. To express such lack of evidence, an eCQM author should use the CQL expression not exists with reference to the data element rather than the QDM data model. negation rationale in QDM signifies only a reason for such absence, i.e., the reason must be present to qualify for negation rationale. The syntax in the human readable HQMF is addressed in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, "Procedure, Performed not done." QDM versions starting with 5.3 use the syntax, "Procedure, not Performed." Section A-5 provides examples for expressing negation rationale in CQL.
Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
relevantDateTime
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.
Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatyperelated actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod