Performance Measurement Network

Question: Documentation of Stroke Education

Our organization has a stroke pamphlet that is utilized in discharge teaching for all stroke patients. The material covers all required elements of stroke education. The discharge education form has a place to document that the information was given. The nurse places an "H" in the box to indicate that the stroke "handout" was given to the patient/family. Is this documentation that the handout was given enough to answer "Yes" for each of the stroke eduation data elements?

Answer:

Documentation that the stroke pamphlet was given to the patient/caregiver is not sufficient. Documentation that written instructions/materials for each of the 5 edicational components(Education Addresses Activation of EMS; Follow-up After Discharge; Medications Prescribed at Discharge; Risk Factors for Stroke; and, Warning Signs and Symptoms of Stroke) must be present in the medical record.

The medical record is abstracted at face-value. Materials outside of the medical record are not to be reviewed or used in the abstraction process. Generally, copies of booklets/handouts are not included in the medical record. Inclusion of the handout with documentation that it was provided to the patient/caregiver to take home would meet at least 4 of the 5 components. Medication education must include at least the names of all discharge medications for which written instructions were provided to the patient and/or caregiver.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-08, Stroke Education,

Copyright © by the contributing authors. All material on this collaboration platform is the property of the contributing authors.
Ideas, requests, problems regarding Performance Measurement Network? Send feedback
This website is using cookies. More info. That's Fine