Performance Measurement Network

Question: Documentation for Stroke Education

This is follow up to a prior question: "";.

Can booklets be used for stroke education and heart failure education?

Answer:

Booklets, pamphlets, and other written materials are acceptable tools to use for stroke education, as well as HF patient education.

What is not acceptable is to document in the medical record, e.g. "stroke booklet given to patient". This type of notation does not adequately document that each educational component was addressed with the patient/caregiver.

Each of the 5 stroke education components is a separate Yes / No data element decision point. To select "Yes" for each, documentation of each component must be present in the medical record.

Written materials on each of the following components must be provided to the patient/caregiver and documented in the medical record: Activation of EMS Follow-up After Discharge Medications Prescribed At Discharge Risk Factors for Stroke Warning Signs and Symptoms of Stroke

See the "Alphabetical Data Element Dictionary" for a definition for each component and all Notes for Abstraction.

http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: HF-1, Discharge Instructions Appendix: Other
File:

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