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CMS Measure ID: CMS529v2    Performance/Reporting Period: 2022    NQF Number: Not Applicable
Description:

This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWR outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results obtained from encounters for adult Medicare Fee-For-Service patients admitted to acute care short stay hospitals.

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters in the emergency department (ED).
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter ocurring in the emergency department (ED).
Exclusion Criteria: Excludes concepts that represent services not performed in the emergency department, including critical care and observation services.

Constrained to codes in the Encounter, Performed: Emergency Department Visit value set (2.16.840.1.113883.3.117.1.7.1.292)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"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.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • 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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of inpatient hospitalization encounters.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for inpatient hospitalizations.
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 5.5 Guidance Update)

"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.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • 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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for observation in the inpatient setting.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for inpatient observation.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Observation Services value set (2.16.840.1.113762.1.4.1111.143)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"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.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • 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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring bicarbonate in blood, serum, or plasma.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring bicarbonate and carbon dioxide in the specimen source of blood, serum, or plasma.
Exclusion Criteria: Excludes concepts that represent partial pressure laboratory tests and laboratory tests using the specimen source of capillary blood.

Constrained to codes in the Laboratory Test, Performed: Bicarbonate lab test value set (2.16.840.1.113762.1.4.1045.139)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring creatinine in blood, serum, or plasma.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring creatinine in the specimen source of blood, serum, or plasma.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: Creatinine lab test value set (2.16.840.1.113883.3.666.5.2363)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring glucose.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring glucose in the specimen source of blood, serum, or plasma, including Point of Care (POC) testing.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: Glucose lab test value set (2.16.840.1.113762.1.4.1045.134)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring hematocrit.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring hematocrit in the specimen source of blood.
Exclusion Criteria: Excludes concepts that represent laboratory tests for hematocrit using the specimen source of capillary blood.

Constrained to codes in the Laboratory Test, Performed: Hematocrit lab test value set (2.16.840.1.113762.1.4.1045.114)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring potassium in blood, serum, or plasma.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring potassium in the specimen source of blood, serum, or plasma.
Exclusion Criteria: Excludes concepts that represent laboratory tests for potassium using the specimen source of capillary blood.

Constrained to codes in the Laboratory Test, Performed: Potassium lab test value set (2.16.840.1.113762.1.4.1045.117)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring sodium in blood, serum, or plasma.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring sodium in the specimen source of blood, serum, or plasma.
Exclusion Criteria: Excludes concepts that represent laboratory tests for sodium using the specimen source of capillary blood.

Constrained to codes in the Laboratory Test, Performed: Sodium lab test value set (2.16.840.1.113762.1.4.1045.119)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests measuring white blood cells.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring white blood cell count in the specimen source of blood.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: White blood cells count lab test value set (2.16.840.1.113762.1.4.1045.129)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Direct Reference Code

Constrained to 'Birth date' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Birthdate"

The "Patient Characteristic Birthdate" should document the patient’s date of birth.

Timing: The "Patient Characteristic, Birthdate" is a single point in time representing the date and time of birth. It does not have a start and stop time.

Note: "Patient Characteristic Birthdate" is fixed to LOINC code 21112-8 (Birth date) and therefore cannot be further qualified with a value set.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Ethnicity"

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to identify concepts for Medicare Fee-For-Service payer types.
Data Element Scope: This value set may use a model element related to Patient Characteristic.
Inclusion Criteria: Includes concepts that identify a patient with Medicare Fee-For-Service as a payer source.
Exclusion Criteria: Excludes concepts that represent non-Medicare Fee-For-Service as a payer source.

Constrained to codes in the Patient Characteristic, Payer: Medicare payer value set (2.16.840.1.113762.1.4.1104.10)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Payer"

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 relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Patient Characteristic, Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Payer"

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 relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Race"

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.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic, Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Sex"

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a physical exam with an observation or measurement of a patient's body temperature.
Data Element Scope: This value set may use a model element related to Physical Exam.
Inclusion Criteria: Includes concepts that represent a physical exam during which observation or measurement of a body temperature occurred.
Exclusion Criteria: No exclusions.

Constrained to codes in the Physical Exam, Performed: Body temperature value set (2.16.840.1.113762.1.4.1045.152)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a physical exam with an observation or measurement of body weight.
Data Element Scope: This value set may use a model element related to Physical Exam.
Inclusion Criteria: Includes concepts that represent a physical exam during which observation or measurement of a person's body weight occurred.
Exclusion Criteria: No exclusions.

Constrained to codes in the Physical Exam, Performed: Body weight value set (2.16.840.1.113762.1.4.1045.159)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Direct Reference Code

Constrained to 'Heart rate' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Direct Reference Code

Constrained to 'Oxygen saturation in Arterial blood by Pulse oximetry' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Direct Reference Code

Constrained to 'Respiratory rate' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Direct Reference Code

Constrained to 'Systolic blood pressure' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Physical Exam, Performed"

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

Timing:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.