Question: Does the following documentation meet education regarding Risk factors for stroke?
The DC instruction sheet signed by the MD, the nurse, and the patient documents: "Has been advised to stop tobacco and Depovera". The patient is given a copy of the discharge instructions to take home. Will this written instruction suffice as addressing personal risk factors even though it wasn't titled 'personal risk factors'?
Answer:
No, the documentation is not sufficient. See the Alphabetical Data Dictionary pdf defintion for "Education Addresses Risk Factors for Stroke".
*"Individual risk factors that are not mentioned in the context of risk factors for stroke do not count,* (e.g., discharge instructions to limit alcohol without explicit documentation that excessive alcohol consumption is a risk factor for stroke)."
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK,