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1、Joint Commission International (I) Library of Measures, Version 2.0联合委员会国际策略库 2.0版本Heart Failure (I-HF-3)心力衰竭(I-HF-3)ACEI or ARB for Left Ventricular Systolic Dysfunction (LVSD) Measure血管紧张素转换酶抑制剂或血管紧张素受体拮抗剂治疗左心室收缩功能不齐Data Collection Tool for Hospital Patient Discharges出院患者数据收集工具Medical Record Abstr
2、actor: Abstract data for your organizations selected measures with the measure code name (I-HF-3) designated in the left hand column under each data element question.病历摘录者：为医院所选择的策略摘录数据，包括每个数据元素问题下左栏中所指定策略编码(I-HF-3)。Hospital Name医院名称: +Plus symbol indicates required administrative data field加号表示所需的行
3、政数据区+Patient Identifier Number 患者识别号+Admission Date入院日期_/_/_Day 日 month 月 year 年+Discharge Date 出院日期 / /Day日 month月 year 年Sex性别Admitting Physician Code/Number 入院医生编码/号码Attending Physician Code/Number主治医生编码/号码Principal Procedure Surgeons Code/Number主要手术医师编码/号码+Principal/Main Diagnosis or ICD Code主要诊断
4、/国际疾病分类编码Present on Admission Diagnosis or ICD Codes入院诊断/国际疾病分类编码+Other Diagnosis or ICD Codes其他诊断/国际疾病分类编码Principal Procedure or ICD Code主要处置/国际疾病分类编码Principal Procedure Date主要处置日期+Other Procedure or ICD Codes其他处置/国际疾病分类编码After the case data abstraction and data flow is completed, circle the assign
5、ed Measure Category Assignment (MCA) Letter for each measure as guided by the allowable answer value “STOP” text:完成病案数据抽象化及数据流后，随着许可的回答数值“STOP”文本的指引，圈出每个策略指定的策略类型赋值字母：EXAMPLE: If answered No, STOP I-HF-3 data abstraction = case NOT in Measure Population = B 例：如果回答“是”，停止I-HF-2的数据抽象化=病案不在策略人群中=BIf the
6、re is no text prompt instructing you to STOP, continue data collection如果没有文本指示停止，继续收集数据。1. What is the date the patient was admitted to acute inpatient care?: Admission Date 患者收治入紧急住院治疗的日期是？：入院日期 (I-HF-3) / /Day 日 (01 31)Month月 (01 12) YYYY年 (2010 current year当前年份)2. Is there a principal diagnosis o
7、f heart failure or Principal ICD code of heart failure?: Principal Diagnosis Code是否有心力衰竭的国际疾病分类的主要诊断编码或主要诊断？：主要诊断编码 (I-HF-3) (Appendix A, Table 2.1 Heart Failure) 附件A 表2.1心力衰竭 Yes是 No否If answered No, STOP data abstraction for I-HF-3 = case NOT in Initial Population如果回答否/无法确定，停止I-HF-3的数据抽象化=病案不在初始人群中
8、3. During this hospital stay did the patient have a heart transplant or left ventricular assistive device (LVAD) a) principal or b)other procedure?: Principal or Other Procedure在此住院期间，患者是否进行心脏移植或使用左室辅助装置a)主要处置或其他手术？：主要处置或其他处置 (I-HF-3) (Appendix A, Table 2.2, LVAD and Heart Transplant) 附件A 表2.2左室辅助装置
9、及心脏移植 Yes是 No否If answered Yes for either 3a or 3b, STOP data abstraction for I-HF-3 = case NOT in Initial Population如果对问题3a或3b回答“是”，停止I-HF-3的数据抽象化=病案不在初始人群中4.Patients Birthdate: (dd/mm/yyyy): Birthdate患者出生日期：（日/月/年）：出生日期 ( I-HF-3)/ dd 日 mm 月 yyyy 年Age: year/s(admission date birthdate) 年龄: year/s (入院
10、日期 出生日期)If age 18 years, STOP data abstraction for I-HF-3 = case NOT in Initial Population 如果年龄 18岁，停止I-HF-3的数据抽象化=病案不在初始人群中5. What was the patients discharge disposition on the day of discharge: Discharge Disposition在出院当天，患者的出院处置是什么？：出院处置 (I-HF-3) 1- Home 回家 2 Discharged or Transferred to Another A
11、cute Care Hospital 出院或转入其他的急症护理医院 3 Left Against Medical Advice(AMA) 自动出院 4a - Expired on the day of or day after arrival 在到达当天/后死亡 4b Expired greater than 1 day after arrival 在到达超过1天后死亡 5 Discharged or Transferred to Other Type of Health Care Facility 出院或转去其他类似的医疗机构 6 Unknown/ Not Documented or una
12、ble to Determine (UTD) 未知/未记录或无法确定If answered 2, 3, 4a, 4b, STOP data abstraction for I-HF-3 = case NOT in Measure Population =B如果回答2,3, 4a 或4b，停止I-HF-3的数据抽象化=病案不在策略人群中=B6.Is the LVSF documented as an Ejection Fraction (EF) less than 40% or a narrative description consistent with “moderate” or “seve
13、re” systolic dysfunction: LVSD 左室收缩功能是否记录为左室射血分数少于40%或描述为“中度”或“重度”收缩功能不全？：左室收缩功能障碍 (I-HF-3) Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered No, STOP I-HF-3 data abstraction = case NOT in Measure Population =B如果回答否，停止I-HF-3的数据抽象化=病案不在策略人群中=B 7. Is there documentation that an Angiotensin Conve
14、rting Enzyme Inhibitor (ACEI) was prescribed at discharge: ACEI Prescribed at Discharge (I-HF-3) 是否有在出院时开具血管紧张素转换酶抑制剂的文件？：出院时开具血管紧张素转换酶抑制剂 (Appendix C, ACEI Table 1.2) Yes 是 No or Unable to Determine (UTD) 否或无法确定If answered Yes, STOP I-HF-3 data abstraction = case met measure and is in the Numerator Population = E如果回答是，停止 I-HF-3的数据抽象化=病案符合策略并且在分子人群中 8. Is there documentation that an Angiotensin Receptor
