Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.

Data Element

Incontinence
Description

Lack of voluntary control over urination or defecation

Comment

CMS-CCSQ Recommends the advancement of Incontinence to Level 2

Recommendation: CMS CCSQ recommends the Incontinence element be advanced to Level 2.

Rationale: Upgrading the Incontinence data element to Level 2 in the USCDI is essential for enhancing care in the long-term post-acute care (LTPAC) setting, where incontinence is a prevalent and significant concern that directly impacts patient quality of life and care planning.

Tracking incontinence, including both bladder and bowel continence, provides vital insights into a patient’s functional status, helping healthcare providers assess care needs, monitor changes in condition, and implement appropriate interventions. This data is already captured in standardized assessments such as Bladder Continence (H0350) and Bowel Continence (H0400) in assessments like the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), Minimum Data Set (MDS), and Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS). Upgrading Incontinence to Level 2 will signal the importance of capturing this data element in healthcare IT systems to vendors and may increase its adoption and improve its accessibility and interoperability, enabling better care coordination and facilitating more accurate outcomes tracking across healthcare settings. Additionally, the use of standardized coding systems, such as logical observation identifiers names and codes (LOINC) (Version 2.78), ensures consistency and facilitates seamless data exchange.

Level 2 Data Element: Incontinence

IMO supports the inclusion of Incontinence as a Level 2 data element in the Assessment and Plan of Treatment Data Class in USCDI V3. IMO agrees with the submitter that assessment of incontinence is important to the quality of patient care, structured documentation is well supported by established CMS assessment instruments with associated HIT standards and can be easily implemented in ONC Certified HIT. 

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