SITE SPECIFIC DATA ITEMS (SSDI)/ GRADE

Description

International Normalized Ratio for Prothrombin Time (INR), an indicator of the liver’s ability to make clotting factors, is required to calculate the Model for End-Stage Liver Disease (MELD) score, is used to assign priority for liver transplant. The prothrombin time is a measure of how quickly the blood clots, which may also indicate liver disease. The international normalized ratio (INR) is a calculation of the patient’s prothrombin time divided by the normal mean prothrombin time for the particular thromboplastin reagent used and is expressed as a decimal number. An elevated level indicates the blood is too “thin” and does not clot properly, increasing the risk of bleeding. A value under 1.0 increases the risk of blood clots. The Model for End-Stage Liver Disease (MELD) is a numerical scale used to determine how urgently a patient with liver disease needs a liver transplant. Results from three routine lab tests are used to calculate the MELD score. International normalized ratio for prothrombin time (INR), one of the tests, measures the liver's ability to make blood clotting factors. There are several related data items that are defined to record the MELD score. * 3813: Bilirubin Pretreatment Total Lab Value * 3814: Bilirubin Pretreatment Unit of Measure * 3824: Creatinine Pretreatment Lab Value * 3825: Creatinine Pretreatment Unit of Measure * 3860: International Normalized Ratio

Notes

**Note 1:** **Physician Statement** * Physician statement of the International Normalized Ratio for Prothrombin Time (INR) can be used to code this data item when no other information is available. **Note 2:** **Pretreatment results only** * Record the value of the highest INR test results documented in the medical record prior to treatment. The value may be recorded in a lab report, history and physical, or clinical statement in the pathology report.