Performance Measurement Network

Question: Expired after discharge

Our EMR is updated to show when a patient expires after discharge. Are we expected to call patients to obtain a MRS (ie death when we know that they have already expired? I keep getting an OFI because the date that we were notified of the patient's death is not within the 75-105 day time frame. Can I use a date within the 75-105 time frame as the mRs date to prevent an OFI from occuring?


If the hospital is notified of the patient's death prior to 90 days, then the mRS call/interview is not needed; however, the case is in the denominator for CSTK-02 and not excluded. This is a process measure with emphasis on obtaining mRS within the 90 day timeframe. The Joint Commission does not expect the measure rate to be 100% for this measure. Hope this clarifies for you. Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-02, Modified Rankin Score (mRS),
Manual: Current Manual (current data collection period; prior to data transmission)

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