Performance Measurement Network

Question: Documentation for tPA exclusion

Seeking clarification on STROKE-4, administration of tPA. My specific question is: A patient comes in to our ED within the two hour time frame (within 1.5 hours), and the physician documents that her "symptoms resolved." My assumption is that, this is the reason she would not be a candidate for tPA, however there is no specific wording of "thrombolytics" in this documentation. In talking with the physician (when reviewing the chart after the patient is discharged), this was the reason thrombolytics was not considered…however there is not explicit documentation. (The patient's discharge diagnosis was stroke). Is "symptoms resolved" adequate documentation of a reason for not administering thrombolytic therapy?

Answer:

"Symptoms resolved" without linkage with thrombolytic therapy, (e.g., "symptoms resolved - no t-PA"), is not sufficient documentation. Abstractors are instructed not to make inferences as to the reason why t-PA was not administered. This patient would not be in the numerator because there was no specific mention of "symptoms resolved" as the reason for no thrombolytics. Select "No" for IV Thrombolytic Therapy Administered.

As with all documented reasons, the reason must be linked with the therapy, medication, etc. in question in order to be excluded from the measure population. This logic applies to the stroke measures, as well as, similar data element definitions for core measue sets, e.g., Reason for Delay in PCI, Reason for No ASA on Arrival, etc.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Other
Related documents: STK, STK-04,
File:

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