PCQN Core Dataset Data Dictionary
PCQN Core Dataset Data Dictionary
/ Variable / Format / Definition/Options / Notes /1 / Date of PC Consult Request / Date field / Date on which the PC service received the request for patient consult. /
2 / Hospital admission date / Date field / xx/xx/xxxx / If admit was avoided by PCS consult, hospital admission date is same as PC Consult date. /
3 / Age / Text box / XX (in years) /
4 / Patient gender / Check box / Select M or F / As the patient identifies /
5 / Patient location (unit type) at time of referral / Check box / · Med/Surg unit
· Step down/Telemetry
· Critical care
· Ambulatory/Outpatient clinic
· Emergency department
· Pediatrics
· Labor & Delivery
· Acute Rehab
· SNF
· Other / Select one only /
6 / Reasons given by referring provider for initial PC consult / Check box / · Goals of care discussion/Advance care planning
· Pain management
· Other symptom management
· Withdrawal of interventions: ventilator, renal replacement therapy, artificial nutrition hydration, pressors, antibiotics, radiation therapy, non-invasive ventilation
· Assess for transfer to comfort care bed or PC unit
· Comfort care: to implement comfort measures separate from or in addition to withdrawal of life-sustaining interventions
· Hospice referral/discussion
· Support for patient/family
· No reason given
· Other / Select all that apply; the main reasons for referral based on information gathered from referring provider /
7 / Primary diagnoses leading to PC consult / Check box / Primary classification
· Cancer: solid tumor, any organ
· Hematology: leukemia, lymphoma, myeloma
· Cardiac: MI, Heart failure, restrictive heart disease, pericarditis, restrictive pericarditis
· Pulmonary: COPD, ILD, restrictive lung disease, pulmonary embolus, pulmonary hypertension
· Vascular: peripheral vascular disease, AAA, aortic aneurysm
· Complex chronic conditions/failure to thrive: no single disease or condition is primary but several diseases contribute to overall decline
· Renal: ESRD, Acute renal failure
· Trauma: MVA, violence, accident
· Congenital/chromosomal conditions: congenital heart disease, sickle cell disease, cystic fibrosis, hemochromatosis
· Gastrointestinal: IBD, gastrointestinal bleeding from any source
· Hepatic: end-stage liver disease, cirrhosis, HCV, HBV, primary biliary cirrhosis
· Infectious/immunological/HIV: sepsis, pneumonia, pyelonephritis, meningitis, influenza, AIDS
· In-utero complication/condition
· Neurologic/stroke /neurodegenerative: stroke of any kind, SDH, intracranial hemorrhage, subarachnoid hemorrhage, Parkinson’s, ALS, Multiple sclerosis, muscular dystrophy
· Dementia
· Other / Select only one diagnosis that best reflects primary reason for palliative care consult
If unknown, select ‘other’ and type ‘unknown’ into text box. /
8 / Code status at time of consult / Check box / · Full Code: patient preference is to receive all available resuscitative efforts
· Partial Code: any limitation in resuscitation efforts short of comfort measures only
· DNR/DNI (Allow Natural Death): patient preference is not to receive any resuscitative efforts. If the patient wishes to receive any, but not all resuscitative efforts such as ICU-level monitoring, pressors, cardiversion, bipap then code status is partial. / Select only one /
9 / Advance Directive document on chart at time of consult / Yes/No / Yes/No / “On chart” means the document is available to providers, through the usual mechanism used at the institution
An advance directive is a legal, written document that includes either or both of the following:
1) Health care agent (a.k.a. ‘power of attorney for health care,’ ‘health care proxy’) - a person designated to make decisions about a one’s medical care if he/she cannot make those decisions for him/herself.
2) Living will (a.k.a. 'Health care directive') - wishes regarding medical care desired if one becomes unable to communicate in the setting of a serious health condition.
Examples of ADs: California Advance Health Care Directive and Five Wishes form /
10 / POLST on chart at time of consult / Yes/No / Yes/No / “Available” means the document is available to providers, through the usual mechanism used at the institution
A POLST is a portable document of physician/provider medical orders for certain treatments.
Note: For the purposes of the PCQN, please do not consider the POLST an AD. We would like to capture data on when we are completing POLSTs and when we are completing ADs other than POLSTs. /
11 / Number family meetings held / Numerals / Circle a number for each family meeting held. A family meeting can be scheduled or spontaneous and includes key member(s) of the PC team, key member(s) of the patient’s family, and addresses a wide range of issues (e.g. more than just symptoms or just disposition). /
12 / PC team disciplines involved in the consultation: / Check boxes / · Physician
· Certified nurse specialist
· Nurse practitioner
· Nurse
· Social worker
· Chaplain
· Pharmacist
· Psychologist/psychiatrist
· Physician Assistant
· Other / Select all that apply. If the patient is seen on multiple days, select disciplines that participated on any day. Discipline must be a regular and specifically recognized member of the PC team. The person of that discipline may have other responsibilities but is clearly identified and identifies as a member of the PC team. For example, a visit by a chaplain that sees all patients in the hospital but who does not participate as a member of the PC team would not be included. If that chaplain did attend PC team meetings (clinical and administrative) then that chaplain would be considered a member of the PC team and the visit would be recorded here. /
13 / Screening Results
· Pain
· Non-pain symptoms
· Psychosocial needs
· Spiritual needs
· Advance Care Planning/Goals of Care needs / Radio Buttons / · Positive
· Negative
· Patient/Family Declined
· Patient/Family Unable
SEE SEPARATE SCREENING ITEM DEFINITIONS DOCUMENT FOR MORE DETAIL. / SEE SEPARATE SCREENING ITEM DEFINITIONS DOCUMENT FOR MORE DETAIL. /
14 / Intervened / Check boxes / · Pain
· Non-pain symptoms
· Psychosocial issues: includes discharge planning, patient/family support, addressing grief and anxiety, assisting with funeral arrangements, attending to legal issues
· Spiritual needs: specific religious needs before and after death, meaning, relationships, legacy, arranging for specific clergy to visit or for rituals (can be done by any member of the team if specific issues as above are addressed) Example: “Are you at peace? Are you religious?”
· Advance Care Planning/Goals of care / PC team self-report of issues addressed as part of the consultation. Check for each issue whether it was addressed as part of the consultation. Note that an area should have been screened positive to be addressed with an intervention. /
15 / Other outcomes / Check boxes / · Code status clarified (discussed with patient; not necessarily changed)
· Advance Directive completed
· POLST completed
· Avoided Admission / Select all that apply /
16 / Hospital discharge date / Date field / · xx/xx/xxxx / Date of hospital discharge or date entire team signed off, if different. If team signs off, then discharge disposition is “hospital inpatient” (#18).
If hospital admission was avoided, discharge date is the same date as PCS consult. /
17 / Functional status at time of consult / Text box / · Palliative Performance Scale (0-100% score) / The Palliative Performance Scale indicates the PPS score at time of initial consult. As some patients are not seen immediately, this should be assessed and recorded during the first in-person visit with the patient. Circle lowest applicable percentage under PPS Level. PPS is recorded in 10% increments only. /
18 / Discharge disposition / Check box / Select Patient Status at Discharge:
· Alive
· Dead
Location:
· Home
· LTAC
· ECF
· Hospital Inpatient (when patient is transferred to another hospital or when team signs off prior to Discharge)
· Non-Hospital Inpatient
· Residential Care Facility/Assisted Living
· Respite/Shelter/SRO
Service:
· Home Health
· Palliative Care: Clinic-Based
· Palliative Care: Home-Based
· Hospice
· No Services / Patient Status at Discharge will determine outcomes. Select one from “Location” column and as many “Services” as apply. Reports can combine location and services. For example, report can indicate patients discharged to home with hospice, home health, palliative care or no services.
NOTE: Items previously noted as ‘other’ outcomes are now built into logic. Patient Status at Discharge now determines previous other outcomes marked as ‘death’, ‘died before seen’ (logic combines a death discharge and ‘patient not seen’), ‘Patient not seen’ is now built into the logic of the form. /
19 / Pain / Text box / · 0- none
· 1- mild
· 2- moderate
· 3- severe
· 7- Patient was seen by a team member who was unable to assess symptoms
· 9- patient was seen but was unable to rate (due to any cause: sedation, confusion, delirium , coma, altered mental status) / Daily assessments of “pain now” as reported by the patient. If patient cannot report or was not seen on that day mark the appropriate code. /
20 / Anxiety / Text box / · 0- none
· 1- mild
· 2- moderate
· 3- severe
· 7- Patient was seen by a team member who was unable to assess symptoms
· 9- patient was seen but was unable to rate (due to any cause: sedation, confusion, delirium , coma, altered mental status) / Daily assessments of “anxiety now” as reported by the patient. If patient cannot report or was not seen on that day mark the appropriate code. /
21 / Nausea/vomiting / Text box / · 0- none
· 1- mild
· 2- moderate
· 3- severe
· 7- Patient was seen by a team member who was unable to assess symptoms
· 9- patient was seen but was unable to rate (due to any cause: sedation, confusion, delirium , coma, altered mental status) / Daily assessments of “n/v now” as reported by the patient. If patient cannot report or was not seen on that day mark the appropriate code. /
22 / Dyspnea / Text box / · 0- none
· 1- mild
· 2- moderate
· 3- severe
· 7- Patient was seen by a team member who was unable to assess symptoms
· 9- patient was seen but was unable to rate (due to any cause: sedation, confusion, delirium , coma, altered mental status) / Daily assessments of “dyspnea now” as reported by the patient. If patient cannot report or was not seen on that day mark the appropriate code. /
23 / Bowel movement / Yes/No / Yes/No / Daily assessment of whether patient had a bowel movement in the past 24-48 hours (in cases where patient is not seen every day by the team can report bowel movement in past 48 hours) /
24 / Unique patient identifier / Text box / Equivalent of medical record number / Randomly assigned at the point of data upload into database (for confidentiality) /
June 18th, 2015