Performance Measurement Network

Question: ICH score documentation

Do the providers have to document each of the components used to obtain the ICH score in the medical record, or can they just document the calculated ICH score by itself?

Answer:

The "total ICH score",i.e. sum of the components, needs to documented in the medical record. A "total ICH score" will be a value between 0 and 6. The definition does NOT require documentation of each component, just the total ICH score.

If components of the score are documented, similar to how NIHSS is usually documented, that's OK as long as the components are added and a total ICH score documented. Documentation of components alone, e.g. Glasgow Coma Scale, is not sufficient.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-03b, Initial ICH Score Performed
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