Data Element
Patient behaviors with risk to self or others (reported or observed) ICD 10, SNOMED
Submitted By: Holly Miller, MD / MedAllies
Data Element Information
Data Element Description Examples Include:
Wandering Z91.83
Falls Z91.81
Confusion F05
Aggressive behavior F02.81
Physical violence R45.6
Suicidal ideation R45.851
Use Case Description(s)
Use Case Description Use Case
These are data elements required to improve the safety of handoffs when clinical care responsibilities are passed to another care team member or care team either temporarily or permanently. Examples include hand offs at change of shift and permanent transitions of care to another care team or site of care. Handoffs occur in every health care setting and are a requirement whenever 24-hour care is provided, or care is provided intermittently in the patient’s home. This includes hospitals, LTPAC facilities, homes, and prisons. Although most handoffs occur between care providers using a common EHR/HIT system, many transitions of care from one site to another require exchange to occur between two different EHR/HIT systems. Even when handoffs occur within a single EHR system ease of access to these Special Alerts will significantly help to prevent medical errors and reduce the risk of injuries and harm.
Estimate the breadth of applicability of the use case(s) for this data element Estimate number of stakeholders
All providers of clinical care in 24-hour and home care settings will use these data elements at the beginning and at the end of their shifts. All providers of clinical care that receive patients in transfer from another site or team will use these data elements. This encompasses most providers.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) ICD 10, SNOMED, LOINC, RxNorm
Additional Specifications N/A
Current Use Extensively used in production environments
Supporting Artifacts These data elements are nearly universally captured in existing EHR systems but are not grouped and escalated to be readily utilized for patient care.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden The burden for collection is minimal given these observations are already collected in the EHR. The burden is to ensure that these data elements are captured and escalated to the alert level within an EHR system when they are applicable.
Other Implementation Challenges None
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This data element represents a subset of other data elements Problems, Encounter Diagnosis, thus represents a narrower breadth of applicability

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Fig 1 The "Data Class" and "Data Element" dropdown menus allow users to specify the exact content they wish to comment on.

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Fig 3 The "Comment on another data element" link enables users to create multiple comments addressing different elements within a single submission.

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Fig 4 The "File Upload" section permits users to attach supporting documentation that supplements their written comments.

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Fig 5 A red triangle with exclamation mark indicator appears next to the “Return to saved Comment” button when draft comments are saved in the system.

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Fig 6 The review screen allows users to verify comment content and make any necessary modifications before final submission.

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