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. 2015 May 13;6(2):318–333. doi: 10.4338/ACI-2014-12-RA-0116

Table 2.

Sources and definitions of the auto-populated e-lndex and the physician-edited p-lndex.

Variable Auto-populated e-lndex Physician-edited p-lndex
Source Definition Source
Demographics (age and sex) Electronic health record (EHR) Age in years; sex: male or female Emergency physician note during emergency department (ED) visit
Comorbidities ICD-9 codes
Cancer (active or history of) Problem list in the EHR at the time of the index ED visit 140–172; 174–175; 179–209; V10.0–V10.82, V10.84–V10.91 Emergency physician and hospitalist notes during ED visit
Heart Failure (systolic or diastolic) Problem list in the EHR at the time of the index ED visit 402.01, 402.11, 402.91; 404.01, 404.03, 404.11, 404.13, 404.91, 404.93; 425.1, 425.11, 425.18; 425.4, 425.5, 425.7–425.9; 428 Emergency physician and hospitalist notes during ED visit
Chronic Lung Disease (includes asthma) Problem list in the EHR at the time of the index ED visit 491.0, 491.1, 491.20–491.22, 491.8, 491.9; 492.0, 492.8; 493.00–493.02, 493.10–493.12, 493.20–493.22, 493.81, 493.82, 493.90–493.92; 494.0, 494.1; 495–496; 500–505; 506.4; 515; 516.0– 516.2, 516.30–516.32, 516.34–516.37, 516.4, 516.5, 516.8, 516; 517.2; 518.1–518.3; 518.6; 518.83; 518.84 Emergency physician and hospitalist notes during ED visit
Vital Signs EHR The highest pulse and respiratory rate and the lowest systolic blood pressure, temperature, and oxygen saturation during the ED stay Expanded to include unstructured vital signs documented in emergency physician or hospitalist notes during ED visita
Mental status Nursing EHR flowsheet documentation (1) Level of consciousness; (2) Orientation; (3) Mentation element of the Schmid fall-risk assessment; (4) Altered mental status Emergency physician, nursing, and hospitalist notes during ED visit

a. Abstractors did not reference the original pre-hospital emergency medical care documentation or the pre-ED clinic notes.