Question: Non Aneurysmal SAH Documentation
Are we allowed to consider imaging reports that may include that there were no aneurysms found as documentation of the stand alone reason for no nimodipine?
Thank you
Carol
Answer:
Carol,
Imaging reports that document no aneurysm/non-aneurysmal may be used for abstraction if signed by a physician/APN/PA only.
Notes for abstraction state:
Only accept terms identified in the list of inclusions. No other terminology will be accepted.
Terms must be documented by a physician/APN/PA only.
Head trauma
No aneurysm (head or neck)
Non-aneurysmal
Not aneurysmal
Trauma
Thank you for your inquiry.
Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-06,
Manual: Current Manual (current data collection period; prior to data transmission)