Table 2.
Care component | Data element | LOINC concepts (ID) | Property | Time | System | Scale | Method | Relation with populating indicator |
---|---|---|---|---|---|---|---|---|
Reason for encounter | Primary diagnosis | Primary diagnosis (18630-4) | Imp | Pt | Patient | Nom | — | Inclusion criteria |
Administrative | Length of stay | Hospital stay duration (78033-8) | Time | Pt | Patient | Qn | — | Patient days |
Pathophysiologic disease-related factors | Use of anticoagulants/coagulopathy diagnosis/the first day of surgical procedure | Bleeding risk [CCC] (81225-5) | Find | Pt | Cardiovascular system | Ord | Observed.CCC | Frequency of nursing assessment of risk factors |
Nursing diagnosis: visual impairment | Visual alteration [CCC] (28242-6) | Find | Pt | Eye | Ord | Observed.CCC | ||
Cognitive factors | Delirium | Delirium [MDSv3] (54626-7) | – | Pt | Patient | – | MDSv3 | |
Consciousness | Level of consciousness (80288-4) | Find | Pt | Patient | Ord | – | ||
Behavior factors | Fall history | Fall history on admission [MDSv3] (54849-5) | – | Pt | Patient | – | MDSv3 | |
Therapeutic factors | IV line | Intravenous apparatus (59457-2) | Find | Pt | Patient | Ord | Morse Fall Scale | |
Foley catheter | Indwelling catheter [MDS] (45628-5) | Find | Pt | Patient | Ord | MDS | ||
Incident characteristic | Injury level | Event outcome [MERSTH] (42545-4) | Find | Pt | Patient | Ord | Observed. MERSTH | Frequency of injurious falls |
CCC, clinical care classification; MDS, Minimum Data Set; MERSTH, Medical Event Reporting System Total Healthsystem.