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Question: PRE-stroke Modified Rankin Indicator question for Cstroke reporting

I am new to Cstk. Question regarding the Pre-stroke mRS: does the term 'Rankin' or term 'mRS' need to be written in sentence, that's in the patient chart, in order to count/acceptable?

I ask b/c I have a Nurse Case Manager progress note, lacks any Rankin term, yet simply states that 'pt ambulated independently and worked full time prior to the admission' which would seem to match the 3rd bullet down, under 'Notes for Abstraction' in the CSTk spec manual, in which tells abstractor to select value 1, or 2, or 3. (it appears to me, that the Nurse note, has assessed the pt's level pta, and describes, the level, which in turn might meet, as to be the mRS Would this Nurse note be acceptable in order to select one of the 1,2,3 values, and answer yes to mRS pre-stroke Rankin was performed? thank you)

Answer:

Kathryn, The nurse's note may be used for abstraction of this data element. The term Modified Rankin Score (mRS) does not need to be documented. If you are unable to determined (UTD) a pre-stroke mRS from available medical record documentation, select '6'. Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-02,
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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