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Hospital Common Formats - Version 1.2: Event Descriptions, Sample Reports, and Forms

Event Descriptions, Sample Reports, and Forms

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UPDATES/NEW RELEASE  |  Users Guide/Quick Guide  |  HERF / PIF / SIR  |  Blood or Blood Product  |  
Device or Medical/Surgical Supply, including HIT  |  Fall  |  Healthcare-associated Infection  |  Medication or Other Substance  |  
Perinatal  |  Pressure Ulcer  |  Surgery or Anesthesia  |  Venous Thromboembolism  |  
ZIP File (All Event Descriptions, Sample Reports, and Forms)

 

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Event Descriptions, Sample Reports, and Forms are now available for each of the generic and event-specific categories of the Common Formats. The Common Formats Users Guide and Quick Guide are also available.

 

Disclaimer: The Common Formats Aggregate Reports contained on this page are mock-up reports and do not contain actual data. These reports are intended to provide example information on patient safety events.

Update: 04/24/2013

  

Summary of Updates

A few minor corrections were made to Common Formats Hospital Version 1.2 as part of the implementation of the Import Processor.

  1. The AHRQ Harm Scale language was updated (as it relates to 3.3.1 and 3.3.2 sections on the HERF/PIF/SIR Event Description).
    • Language for Question 7 on the Patient Information Form was modified to the following: "After any intervention to reduce harm, what was the degree of residual harm to the patient from the incident (and subsequent intervention)?" 
    • Clarifying language was added to refine the definition of mild harm from "Minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay" to "Bodily or psychological injury resulting in minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay."  
    • Clarifying language was added to the choices of anticipated duration of the harm to a patient. "Permanent (one year or greater)" has changed to "Permanent: not expected to revert to approximately normal (i.e., patient's baseline)" and "Temporary (less than one year)" has changed to "Temporary: expected to revert to approximately normal (i.e., patient's baseline)."
  1. The Pressure Ulcer Form Question 11, "What was the type of device or appliance?" was inadvertently switched from a "CHECK ONE:" (single choice) value set to a "CHECK ALL THAT APPLY:" (multiple choice) in the initial release of the technical specifications for Version 1.2 and has been corrected.
  2. On the Surgery Form Question 5, "Which combination of anesthesia and sedation was used?" "CHECK ONE:" response option d, "No anesthesia or sedation" was changed to "None" (for alignment with pre-defined value sets).
  3.  DE474, "What was the level of sedation?" was assigned a new OID, as the answer valueset included "No sedation", which was eliminated in v1.2.
  4. Validation rules in the Resources Workbook were updated to not validate against the ICD-10-CM implementation date, currently scheduled for October of 2013.
  5. CDA XML File Use Case documents have been updated for both Version 1.1 and Version 1.2 of the Hospital Common Formats to fix discrepancies found.

For detailed information describing the changes that were made to the Implementation Guide, Resources Workbook, and Paper Forms, please see highlighted items in the Technical Specification Summary for Common Formats Version 1.2 document.

  

   Clinical Release Notes

        Posted on 05/04/2013, 384 KB

Users Guide/Quick Guide


   Common Formats Users Guide

        Posted on 05/04/2013, 1,016 KB


   Common Formats Glossary

        Posted on 05/30/2012, 327 KB


   Common Formats Quick Guide

        Posted on 05/03/2012, 164 KB

HERF / PIF / SIR


   Healthcare Event Reporting Form (HERF), Patient Information Form (PIF) and Summary of Initial Report (SIR) Event Description

        Posted on 07/01/2013, 160 KB


   Sample Healthcare Event Reporting Form (HERF), Patient Information Form (PIF) and Summary of Initial Report (SIR) Aggregate Report

        Posted on 05/04/2013, 414 KB


   Sample Event Summary

        Posted on 04/03/2012, 82 KB


   Healthcare Event Reporting Form (HERF) Form

        Posted on 04/03/2012, 161 KB


   Patient Information Form (PIF) Form

        Posted on 05/04/2013, 213 KB


   Summary of Initial Report (SIR) Form

        Posted on 04/03/2012, 154 KB

Blood or Blood Product


   Blood or Blood Product Event Description

        Posted on 04/03/2012, 71 KB


   Blood or Blood Product Aggregate Report

        Posted on 04/03/2012, 87 KB


   Blood or Blood Product Form

        Posted on 04/03/2012, 123 KB

Fall


   Fall Event Description

        Posted on 04/03/2012, 67 KB


   Fall Aggregate Report

        Posted on 04/03/2012, 101 KB


   Fall Form

        Posted on 04/03/2012, 105 KB

Healthcare-associated Infection


   Healthcare-associated Infection Event Description

        Posted on 06/03/2012, 75 KB


   Healthcare-associated Infection Aggregate Report

        Posted on 04/03/2012, 105 KB


   Healthcare-associated Infection Form

        Posted on 04/03/2012, 567 KB

Medication or Other Substance


   Medication or Other Substance Event Description

        Posted on 04/03/2012, 84 KB


   Medication or Other Substance Aggregate Report

        Posted on 04/03/2012, 117 KB


   Medication or Other Substance Form

        Posted on 04/03/2012, 154 KB

Perinatal


   Perinatal Event Description

        Posted on 04/03/2012, 68 KB


   Perinatal Aggregate Report

        Posted on 04/03/2012, 94 KB


   Perinatal Form

        Posted on 04/03/2012, 125 KB

Pressure Ulcer


   Pressure Ulcer Event Description

        Posted on 04/03/2012, 83 KB


   Pressure Ulcer Aggregate Report

        Posted on 04/03/2012, 96 KB


   Pressure Ulcer Form

        Posted on 06/06/2013, 135 KB

Surgery or Anesthesia


   Surgery or Anesthesia Event Description

        Posted on 04/03/2012, 115 KB


   Surgery or Anesthesia Aggregate Report

        Posted on 04/03/2012, 166 KB


   Surgery or Anesthesia Form

        Posted on 10/22/2013, 277 KB

Venous Thromboembolism


   Venous Thromboembolism Event Description

        Posted on 04/03/2012, 73 KB


   Venous Thromboembolism Aggregate Report

        Posted on 04/03/2012, 91 KB


   Venous Thromboembolism Form

        Posted on 04/03/2012, 124 KB