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CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Stroke
Sub-Domain: History of Disease/Injury Event
CRF: Hospital Arrival/Admission
Item count: 15 (15 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C14190
Stroke symptoms discover location type
StrokSymDiscLocTyp
Where was the patient when stroke was detected or when symptoms were discovered? Indicate the type of facility or setting from which the patient came from when stroke like symptoms were discovered.
Patient location when stroke symptoms discovered
Not in a healthcare setting;Another acute care facility;Chronic healthcare facility;Outpatient healthcare setting;Stroke occurred while patient was an inpatient in your hospital;Unknown;
Not in a healthcare setting;Another acute care facility;Chronic healthcare facility;Outpatient healthcare setting;Stroke occurred while patient was an inpatient in your hospital;Unknown;
Alphanumeric
If the patient was a resident of a nursing home, but was out with family for the day and suffered a stroke and the family/EMS brought the patient to your hospital, choose "Not in a healthcare setting". If the patient was at home, at work of even a visitor in your hospital and had stroke symptoms, then choose "Not in a healthcare setting". If the patient was transferred to your hospital from another hospital's ED or inpatient unit but was outside of a healthcare facility when the stroke occurred, choose "Not in a healthcare setting". If the patient was a resident of a nursing home and the stroke occurred at the NH, choose "Chronic healthcare facility". A chronic care facility would include nursing home, long-term care facility, inpatient rehab facility, and assisted-living facility. If the patient is at a clinic or physician office visit, or at your hospital but receiving outpatient procedure or service that did not require the patient to be admitted as an inpatient, select "Outpatient healthcare setting". If the patient was an inpatient in your hospital choose "Stroke occurred while patient was an inpatient at your hospital". If the patient was already within your ED or hospital and experienced new onset of stroke symptoms, then this is considered an inpatient stroke or TIA. Only those hospitals that are interested in collecting information regarding inpatient stroke care should enter these patients. Patients who have transient symptoms that are present on arrival to the ED but resolve, and then later return during the hospitalization and meet criteria for ischemic stroke should all be entered as inpatient strokes.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Stroke symptoms location when discovered type
 
Single Pre-Defined Value Selected
       
C14191
Last known to be well date and time
LastKnownWellDateTime
The date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her prior baseline. This element captures the date and time for last known well that is determined to be the most accurate after all the data have been evaluated and additional witnesses interviewed (if applicable).
Date and Time patient last known to be well
  
Date or Date & Time
When was the patient last known to be well (i.e., in their usual state of health or at their baseline), prior to the beginning of the current stroke/TIA? (To within 15 minutes of exact time is acceptable). If there are multiple times of "last known well" documented, either because subsequent more accurate information became available or because of different levels of expertise in sorting out the actual time of "last known well", use the time recorded according to the following hierarchy:
(1) stroke team/neurology; (2) admitting physician; (3) emergency department physician; (4) ED nursing notes; (5) EMS
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Supplemental - Highly Recommended based on study type, disease stage and disease type
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental–Highly Recommended
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Last known to be well date and time
 
Free-Form Entry
       
C05404
Symptom onset date and time
SymptmOnsetDateTime
Date (and time, if applicable and known) reported for onset of participant's/subject's symptoms
Date of onset
  
Date or Date & Time
The time of symptom discovery is either the time at which the patient was first noted by another person to have stroke symptoms or the self-reported time by an individual who may not be accurate or reliable in their assessment of stroke symptoms onset (e.g., in the setting of neglect or anosagnosia, or aphasia). When the event is witnessed by another person, then the time of discovery is identical to the time of last known well; however, when unwitnessed or self-reported by an unreliable patient, this time of discovery will be later chronologically than the time last known well.
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
7/25/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Symptom onset date and time
 
Free-Form Entry
       
C14192
Symptom awaken discover indicator
SympAwakenDiscInd
Indicate if symptoms were discovered shortly upon awakening from sleep.
Symptom discovery on awakening
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one. Unknown should be used if not documented or cannot be determined.
No references available
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Symptom discovery on awakening indicator
 
Single Pre-Defined Value Selected
       
C18686
Hospital transport other text
HospTrnsprtOTH
The free-text field related to 'Hospital transport type' specifying other text. Type of transportation from injury scene to hospital
Other, specify
  
Alphanumeric
This refers to the method of transport to your hospital, not to the method of initial transport to another facility if the patient was subsequently transferred to your hospital.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
1.0
5/27/2014
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
 
4000
Free-Form Entry
       
C05418
Hospital transport type
HospTrnsprtTyp
Type of transportation from injury scene to hospital
Type of transport to hospital
Ground ambulance with physician;Ground ambulance no physician;Private transportation/taxi/other from home/scene;By foot;Helicopter;Other, specify;
Ground ambulance with physician;Ground ambulance no physician;Private transportation/taxi/other from home/scene;By foot;Helicopter;Other, specify;
Alphanumeric
This refers to the method of transport to your hospital, not to the method of initial transport to another facility if the patient was subsequently transferred to your hospital.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital transport type
 
Single Pre-Defined Value Selected
       
C14625
Hospital arrival date and time
HospArrivDateTime
Date (and time, if applicable and known) the participant/subject arrived at the hospital
Date of hospital arrival
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Supplemental - Highly Recommended based on study type, disease stage and disease type
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009)
Adult;Pediatric
Supplemental–Highly Recommended
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital arrival date and time
 
Free-Form Entry
       
C14193
Hospital observation stay no admission indicator
HospObservStayNoAdmInd
Indicates whether the patient was placed on a 24 hour observation status rather than formally admitted
Was the patient placed on a 24 hour observation status rather than formally admitted
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one. Unknown should be used if not documented or cannot be determined.
No references available
Adult;Pediatric
Exploratory
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital observation stay vs. in-patient admission indicator
 
Single Pre-Defined Value Selected
       
C14194
Hospital not admitted but transferred to another acute care hospital indicator
HospNotAdmTrnsfAnthAcCrHospInd
Whether a patient presented to the Emergency Department of the study hospital and was transferred to an outside hospital. Was patient evaluated in the ED for acute Stroke or TIA and subsequently transferred to another acute care hospital rather than being admitted to your hospital?
Was patient evaluated in the Emergency Department (ED) for acute Stroke or TIA and subsequently transferred to another acute care hospital rather than being admitted to your hospital
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one. Select Yes for patients who are evaluated in the Emergency Department, found to have a diagnosis of Ischemic Stroke, Subarachnoid Hemorrhage, Intracerebral Hemorrhage or Transient Ischemic Attack, and are subsequently transferred to another acute care hospital rather than being admitted to hospital. Select No for patients who are admitted or are not transferred to another acute hospital. Select Unknown if Not documented or Cannot be determined.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital not admitted but transferred to another acute care hospital indicator
 
Single Pre-Defined Value Selected
       
C05408
Hospital admission date and time
HospitlAdmissDateTime
Date (and time, if applicable and known) the participant/subject was admitted to the hospital
Date and Time of hospital admission
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Supplemental - Highly Recommended based on study type, disease stage and disease type.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental–Highly Recommended
3.0
7/25/2013
SCI CDEs: ADMITDT
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital admission date and time
 
Free-Form Entry
       
C14195
Hospital point of origin for admission or visit type
HospPointOrigAdmVisTyp
Documents whether the patient originated from the community or was transferred from one hospital to the study hospital.
Point of origin for admission/visit
Non-Health Care Facility Point of Origin;Clinic;Transfer From a Hospital (Different Facility);Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF);Transfer from another Health Care Facility;Emergency Room;Court/Law Enforcement;Transfer from One Distinct Unit of the Hospital to another Distinct Unit of the Same Hospital Resulting in a Separate Claim to the Payer;Transfer from Ambulatory Surgery Center;Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in a Hospice Program;Unknown;
The patient was admitted to this facility upon order of a physician. Usage Note: Includes patients coming from home, a physician’s office, or workplace.;The patient was admitted to this facility as a transfer from a freestanding or nonfreestanding clinic.;The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient or outpatient. Usage Note: Excludes Transfers from Hospital Inpatient in the Same Facility.;The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.;The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list.;The patient was admitted to this facility after receiving services in this facility’s emergency room. Usage Note: Excludes patients who came to the emergency room from another health care facility.;The patient was admitted to this facility upon the direction of court of law, or upon the request of a law enforcement agency. Usage Note: Includes transfers from incarceration facilities.;The patient was admitted to this facility as a transfer from hospital inpatient within this hospital resulting in a separate claim to the payer. Usage Note: For purposes of this code, Distinct Unit is defined as a unique unit or level of care at the hospital requiring the issuance of a separate claim to the payer. Examples could include observation services, psychiatric units, rehabilitation units, a unit in a critical access hospital, or a swing bed located in an acute hospital.;The patient was admitted to this facility as a transfer from an ambulatory surgery center.;The patient was admitted to this facility as a transfer from hospice.;Information not Available. The means by which the patient was admitted to this hospital is unknown.;
Alphanumeric
Choose one response. The answer to this question is independent of the answer for Patient Location When Stroke Symptoms Discovered. This question asks where the patient was located prior to arriving at your hospital, not where the patient was when they first developed stroke symptoms.
This element is intended to capture data about patients who are admitted to the hospital because of stroke events and is not for use with inpatient strokes (i.e., inpatient stroke = stroke that occurs while a patient is an inpatient in the hospital).
The Joint Commission (TJC)
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital point of origin for admission or visit type
 
Single Pre-Defined Value Selected
       
C14196
Hospital location patient first received care type
HospLocPatFirstReceiveCarTyp
Area of the hospital the patient first evaluated
Location patient first received care at hospital
Emergency Department/ Urgent Care;Direct Admit, not through ED;Imaging Suite;Unknown;
Emergency Department/ Urgent Care;Direct Admit, not through ED;Imaging Suite;Unknown;
Alphanumeric
Choose one. A patient presenting to the emergency department with stroke symptoms would have first received care in the Emergency Department (ED). However, for patients who are transferred from an outside hospital and directly admitted, then the place of first care would be the service where they were admitted (e.g., neurology inpatient service, intensive care unit). Select imaging for patients with suspected acute stroke who are taken directly to the imaging area prior to the ED registration. This data element is not applicable to strokes that occur after a patient has already been admitted or receiving care in the ED for another condition.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital location patient first received care type
 
Single Pre-Defined Value Selected
       
C14197
Hospital care upon admission type
HospCarAdmTyp
Where the patient was cared for and by whom (Where was the patient cared for and by what service?)
Patient care upon admission
Neuro Admit;Stroke Consult;In Stroke Unit;Other Service Admission;No Stroke Consult;Not in Stroke Unit;
Neuro Admit;Stroke Consult;In Stroke Unit;Other Service Admission;No Stroke Consult;Not in Stroke Unit;
Alphanumeric
Choose all that apply. To track the service on which care was rendered upon admission, select from the available options to indicate type of admission, whether a stroke consult was available, and whether this was in a stroke unit or not. First indicate if the patient was admitted by a neurologist or other service. Then indicate if the patient had a stroke consult. Finally indicate if the patient was cared for in a stroke unit.
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital care upon admission type
 
Multiple Pre-Defined Values Selected
       
C14198
Hospital presumptive admission diagnosis type
HospPresAdmDiagTyp
The presumptive diagnosis tries to identify presumptive diagnosis at the time of hospital admission.
Presumptive hospital admission diagnosis
Ischemic Stroke;Transient ischemic attack;Subarachnoid hemorrhage;Intracerebral hemorrhage;Stroke not otherwise specified;No stroke related diagnosis;Unknown;
Ischemic Stroke;Transient ischemic attack;Subarachnoid hemorrhage;Intracerebral hemorrhage;Stroke not otherwise specified;No stroke related diagnosis;Unknown;
Alphanumeric
Choose one response. This field is useful in understanding why certain therapies were performed or omitted, and to understand the nature of missed or delayed diagnosis
Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (Updated on 11/4/2009); Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Hospital presumptive admission diagnosis type
 
Single Pre-Defined Value Selected
       
C14199
Stroke complication of medical/ surgical procedure or therapy likelihood type
StrokCompMedSurProcTherLikeTyp
Was stroke a complication of medical or surgical procedure or therapy? This element attempts to capture if the stroke event was related to a medical or surgical procedure/ therapy the patient recently received (e.g., multifocal emboli after cardiac bypass surgery).
Was stroke a complication of medical or surgical procedure or therapy
Definitely;Probably;Possibly;Unlikely;
clear causal link such as multifocal emboli after cardiac bypass surgery;high likelihood of causality but other etiologies could also be plausible explanations;causality unclear but proximity to the procedure makes this a consideration;the causal link is not well established and the stroke has another more likely etiology;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Exploratory
3.0
6/21/2013
Aliases for variable name not defined
Hospital Arrival/Admission
History of Disease/Injury Event
Disease/Injury Related Events
Stroke complication of medical/ surgical procedure or therapy likelihood type
 
Single Pre-Defined Value Selected
       
06-25-2019
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