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  1. Measure Sets
  2. Perinatal Care Measures (PC) Q3 2025

Aaliyah Cruz - PC-01 April 2025 Result

Case Details

Result:In DenominatorConfidence:HIGH
Full Name:Aaliyah CruzDOB:12/14/1995
Sex:FemaleRace:White
Hospital:Huntsville Hospital Women and ChildrenPatient Type:Inpatient
Admitted At:4/1/2025 3:47 PMDischarged At:4/3/2025 8:30 AM
MRN:12345678FIN:12345678-1234
Override Result

PC-01

Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of gestation completed.

Rationale: For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 2021). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009).

Type Of Measure: Process

Improvement Noted As: Decrease in the rate.

Numerator: Patients with elective deliveries.

Denominator: Patients delivering newborns with >= 37 and <39 weeks of gestation completed.

More details

Initial Patient Population Algorithm

This is criteria is part of the Initial Patient Population for Mothers

1 Patient Age Criteria

The patient age which is calculated as Admission Date - Birthdate must be >= 8 years and < 65 years.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
Patient ProfileDate of Birth: 12/14/1995Profile ValueHIGH
Encounter ProfileAdmission Date: 4/1/2025Profile ValueHIGH
Result
Patient Age:30 years
Confidence:HIGH
Action:Continue Processing
2 Labor Procedure Criteria

At least one labor procedures must have occurred as defined in Table 11.01.1.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
ProcedureICD-10-PCS Code: 10D00Z0Code MatchHIGH10D00Z0 is Extraction of Products of Conception, High, Open Approach.
Result
Procedure Found:Yes
Confidence:HIGH
Action:Continue Processing

Measure Algorithm

3 No Conditions Possible Justifying Elective Delivery

No ICD-10-CM conditions possibly justifying elective delivery as defined in Table 11.01.7.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
ObservationNo ICD-10-CM codes found.Code MatchHIGH
ChartNo conditions found.LLMHIGH

Prompt: Are there any indications in the patient's chart that there was a condition that caused the delivery to be early?

Result
Condition Found:No
Confidence:HIGH
Action:Continue Processing
4 Gestational Age Criteria

The newborn must be >= 37 weeks and < 39 weeks at delivery.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
Chart38W 1DLLMHIGH

Prompt: What was the gestational age of the newborn at birth?

Reasoning: Let me carefully search through the medical record to find information about the gestational age of the newborn at birth.

Looking through the medical record, I find this entry: "EGA at Birth: 38W 1D" This appears under "Newborn Observations" and is labeled as "Admission History Newborn" with "Order entered secondary to inpatient admission."

EGA stands for "Estimated Gestational Age" and "38W 1D" means 40 weeks and 1 day. I also see another entry that might be relevant: "Apgar 1 Minute,by History: 8" and "Apgar 5 Minute,by History: 9" but these are Apgar scores, not gestational age. There's also "Maternal Last Menstrual Period: 4/26/2024" which could be used to calculate gestational age, but the record doesn't explicitly state the calculated gestational age based on this date. The most direct and clear answer is "38W 1D" which means 38 weeks and 1 day gestational age at birth.

So the answer to "What was the gestational age of the newborn at birth?" is "38 weeks 1 day" or "38W 1D" as recorded in the medical record. I should check if there's any other information that might contradict or provide more detail, but I don't see anything else that specifies the gestational age. The record clearly states "EGA at Birth: 38W 1D" which is the estimated gestational age at birth.

The confidence level would be HIGH because this is a direct and specific measurement recorded in the medical record.

Result
Gestational Age:38 weeks 1 day
Confidence:HIGH
Action:Continue Processing
5 No Planned Cesarean Birth in Labor

No ICD-10-CM procedures indicating the delivery was a planned cesarean birth as defined in Table 11.06.1.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
ObservationNo ICD-10-CM codes found.Code MatchHIGH
Result
Procedure Found:No
Confidence:HIGH
Action:Continue Processing
6 Medical Induction of Labor

At least one ICD-10-CM principal or other procedures codes indicating the labor was induced as defined in Table 11.06.1.

Evidences
SourceValueDiscovery TypeConfidenceEvidence
ProcedureNot FoundCode MatchHIGH
Result
Procedure Found:No
Confidence:HIGH
Action:Stop Processing - Assign To Measure Population