Question: Arrival time Abstraction.

There is no EMS report for this encounter

In the EMR is a report called ED Patient Care Timeline

ED Nursing has documented of an NIH score 12/15 @ 1718

There is then an entry in ED patient care timeline 12/15 @ 1849 titled "Emergency encounter created".

Arrival time is documented in ED @ 1850

Pt goes to IR suite for thrombectomy with TICI 3 reperfusion time 12/15 @ 2029.

Can the ED Nursing NIH score @ 1718 be considered an obvious error because as there is no other documentation to support an arrival time of 12/15 @ 1718 and because of the "emergency encounter created" entry after this documentation?

Or should I look at all ED documentation and consider the 12/15 @ 1718 NIH entry as earliest ED documentation and therefore the arrival time?

Thank you

Answer:

Jennifer, When looking at the record, if the ED nursing NIHSS Score time documented appears to be an obvious error, this time should not be abstracted