Code for the number of events during the last 90 days (or since last assessment if less than 90 days).
Inpatient acute hospital with overnight stay
Intent:
To record how many times the person was admitted to the hospital with an overnight stay in the last 90 days (or since last assessment).
Definition:
The person was formally admitted as an inpatient (by physician’s order), and stayed over one or more nights. It does not include admissions for day surgery, out-patient services, etc.
Process:
Review prior hospitalizations with the person and family. If available, review the clinical record. Sometimes transmittal or billing records from recent hospital admissions are available.
Coding:
Enter the number of hospital admissions in the box. Enter “0” if no hospital admissions occurred in the last 90 days.
Emergency room visit (not counting overnight stay)
Intent:
To record if during the last 90 days (or since last assessment) the person visited a hospital emergency room (e.g., for treatment or evaluation).
Definition:
Emergency room visit — A visit to an emergency room not accompanied by an overnight hospital stay.
Process:
Ask the person and family and review transmittal records if available.
Coding:
Enter the number of ER visits in the last 90 days (or since last assessment). Enter “0” if no ER visits occurred. Do not include instances in which the person was admitted to the hospital for an overnight stay after being seen in the ER.
Physician visit (or authorized assistant or practitioner)
A visit to a physician’s office or clinic by the person, or a physician’s visit to the person’s home.
This item includes a very broad spectrum of medical providers or specialists (e.g., MD or osteopaths, who is either the primary physician or consultant). Also include, for example, an authorized physician assistant or nurse practitioner.
Coding:
Enter the number of visits with a physician or authorized assistant or practitioner during the last 90 days.