["Assessment, Performed": "Malnutrition Risk Screening"]
Data Element Scope: Data elements included in this set indicate an individual has been screened for malnutrition.
Inclusion Criteria: Malnutrition Risk Screening criteria from multiple terminologies are included.
Exclusion Criteria: None.
Constrained to codes in the Malnutrition Risk Screening value set (2.16.840.1.113762.1.4.1095.92)
"Assessment, Performed"
Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.
Timing:
- relevant dateTime references timing for an assessment that occurs at a single point in time.
- relevant Period references a start and stop time for an assessment that occurs over a time interval
- author dateTime references the time the action was recorded.
- Refer to the eCQM expression to determine allowable timings to meet measure criterion.
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.
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.
relevantDateTime
relevantPeriod
relevantPeriod addresses the time between the start of an action to the end of an action. Each QDM datatype using relevantPeriod 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 datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod
result
The final consequences or data collected from the datatype. results can be used in four ways to express:
- That a result is present in the electronic record but any entry is acceptable
- 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:
- 100mg/dL for a lab test
- 140 mmHg for blood pressure
- as a percentage (actually as a quantity with % as units)
- as a titer or ratio (e.g., 1:4, 1:80)
- 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
- A result as a dateTime ("Assessment, Performed" and components)