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Question: Time of the teleneurology NIHSS

As a tertiary center our stroke physicians are often consulted via teleconferencing/telemed prior to transfer. The physician telemed note is part of the electronic medical record at our facility. As our records are electronic would the physician electronic signature on the note be acceptable or do scores need to initialed by the nurse? Is it a quality issue since the teleneurolgoy socre was performed prior to arrival?

Answer:

The NIHSS score may be documented by the MD/APN/PA or nurse. Total NIHSS scores obtained by teleneurology and documented in the medical record, select 'YES'. There isn't a requirement that the nurse initial the score obtained via teleneurology. The teleneurology score may be documented by the physician; however, it must be clearly documented that the score was obtained via teleneurology if that is the score you are using to select"YES" for the data element "Initial NIHSS Score Performed".

NIHSS scores done by teleneurology would be done prior to hospital arrival. This is not a quality issue. The abstraction guidelines for this data element are allowing teleneurology NIHSS scores to count as scores done by your hospital. Again, it needs to be clearly documented that the initial NIHSS was obtained via teleneurolgy and not done by another hospital who then transferred the patient without teleneurology involvement.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-01,
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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