|Data Elements for Emergency Department Systems - Release 1.0 (Centers for Disease Control and Prevention, 1997, 274 p.)|
|SECTION 6 - ED PROCEDURE AND RESULT DATA|
PART OF THE ED PROCEDURE GROUP (6.01 - 6.08)*
*The ED Procedure Group includes data elements 6.01 - 6.08. A single iteration of this group is used to describe either a diagnostic or a therapeutic procedure performed during the ED visit. A diagnostic procedure is one intended to produce information about a patients problem or condition beyond the information obtained in a clinical history or physical examination. A therapeutic procedure is one intended to produce a beneficial effect on the course of a patients disease process or physiologic status. In some instances a single procedure will be both diagnostic and therapeutic. Each result of a diagnostic procedure is recorded in an ED Diagnostic Result Reporting Group (see data elements 6.09 and 6.10). The effect of a therapeutic procedure on the patients problem or condition can be recorded in an ED Outcome Observation
Explanation of why procedure was ordered.
For some ED procedures, such as diagnostic imaging studies and invasive therapeutic interventions, an explicit indication for the procedure is recorded to aid patient evaluation or management. A statement explaining why a procedure was ordered may also serve quality management and reimbursement purposes.
No universal system exists for encoding the reason for ordering a procedure. Until such a system is developed, local codes may be used or a text explanation of why the procedure was ordered may be entered.
Data Type (and Field Length)
CE - coded element (300).
Yes; the ED Procedure Group repeats when more than one procedure is performed.
Component 1 is the code for the procedure indication.
Component 2 is the procedure indication descriptor.
Component 3 is the coding system identifier.
Components 4 - 6 can be used for an alternate code, descriptor, and coding system identifier.
Text data also can be entered without an accompanying code, as
Component 1 = " "
Component 2 = Knee joint effusion, unknown etiology
Enter " " in Component 1 if no explanation of ED procedure
indication is warranted.
Enter Unknown in Component 1 if the explanation is not known.
Data Standards or Guidelines
Group (see data elements 8.30 - 8.34).