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Clinically Enhanced Data

Lab Data Requirements

6/13/2012

Lab Data Requirement Notes:

• Fields 1 (MHA Hospital ID), 2 (Medical Record Number), 3 (Patient Account Number), and 7 (Admit Date/Time) are required to link UB data.
• If only ADHF (Acute Decompensated Heart Failure) data is included, patients with any of the following ICD-9-CM codes as a principal diagnosis should be included:
  • 428.xx heart failure
  • 398.91 rheumatic heart failure
  • 402.01, 402.11, 402.91 hypertensive heart failure
  • 404.01, 404.03, 404.11, 404.13, 404.91, 404.93 hypertensive heart failure and kidney failure
• Optionality: R=Required, O=Optional, C=Conditional Data Field

Data Field Notes:

1. MHA Hospital ID
   3-digit number assigned to your hospital by MHA. Same as in UB data.
2. Medical Record Number
3. Patient Account Number
   Hospital internal number. Same as in UB data. Specific for a visit, but not necessarily for a patient if he/she has multiple visits.
4. Patient Date of Birth
5. Patient Sex
   
   Reference Table 1:

6. Patient Social Security Number
   Only include last 4 digits.
7. Admit Date/Time
8. Discharge Date/Time
9. Order Number
   Unique number for this particular lab order at this hospital.
10. Lab Test Name
    Name of this lab test that corresponds to #11.
11. Lab Test Code
    If LOINC codes not used, we will map your internal code numbers.
12. Ordering Provider
    Prefer NPI. If internal code is specified, we will map to NPI.
13. Order Date/Time
    Time this lab test was ordered.
14. Observation Date/Time
    Time of specimen collection. Required for the database. If not given, Analysis Date/Time will be stored.
15. Analysis Date/Time
    Time test run.
16. Observation Value (Result)
17. Observation Units
18. Observation Result Status This field is required if more than just Final or Corrected results are sent. We are interested in Final and Corrected results only. A Corrected result will override a Final result if both are given with the same Order number.

Reference Table 8:

19. Reference Range
    Normal range for observation value (#14). E.g., "3.5-4.5" or "<2.0"
20. Abnormal Flag
    "Y" for Abnormal result, "N" for Normal.
21. Order Type
    Reference Table 2:

Required if sending more than inpatient labs.

22. Specimen Type
    Required if LOINC code is not specified in #10.
    Reference Table 7:

23. Specimen Condition
    Required if test results on unacceptable specimens are included. Default “null” indicated specimen is acceptable.

Reference Table 9:

24. Observation Request Notes
    Free text up to 200 characters.
25. Observation Result Notes
    Free text up to 200 characters.