Performance Measurement Network

Question: Time Last Known Well


This question has follow-up question(s): Data Abstraction for "Last Known Well"

How should Time Last Known Well be abstracted for the following scenario?

ER MD documents: 1."found after waking from nap with slurred speech and confusion". 2. "Confusion 1 hour ago after waking from nap".

ER nsg. documents "confusion after waking from nap approx. 1 hr ago".

Answer:

Select ND path, "Not determined" per Version 2.a specifications for Date Last Known Well and Time Last Known Well.

Parent element definition Last Known Well added in Version 3.0a. Definition added to distinguish between cases when it clinically cannot be determined and missing/invalid data entered for date/time last known well. "If there is documentation referencing that the patient was discovered with symptoms already present (e.g., woke from nap with confusion / slurred speech)and the date or time of last known well cannot be determined, select “No”".

Two allowable values for Last Known Well. Y (Yes) There is documentation that the date and time of last known well was witnessed or reported.

N (No) There is no documentation that the date and time of last known well was witnessed or reported, OR date, time, or both date and time are unknown.

• In order to abstract allowable value “Yes”, both date and time of last known well must be documented. • If a date and time of last known well is listed in the medical record, without reference to the circumstances preceeding its detection, select “Yes.” • For patients with a documented date and time of witnessed onset of stroke signs and symptoms, select “Yes.” Examples: o “Patient driving to work on 12/05/20XX. Felt left side go numb at approximately 8:15 A.M. Pulled over and called 911 from cell phone.” o “ Wife reports that while eating dinner with patient, right corner of mouth started to droop and speech slurred about 6:00 P.M this evening.” o “Patient watching TV and complains to family of blurred vision in both eyes at 8:00 PM tonight.” • If there is documentation referencing that the patient was discovered with symptoms already present and the date or time of last known well cannot be determined, select “No”. Example: o “Patient OK last night. Went to bed and woke up in AM unable to move right arm and leg.” • If there is documentation that the date or time of last known well is unknown, select “No”. • The patient may self-report the date and time of last known well, OR the date and time may be reported by a family member, caregiver, or another third-party individual.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Date Last Known Well,
File:

Copyright © by the contributing authors. All material on this collaboration platform is the property of the contributing authors.
Ideas, requests, problems regarding Performance Measurement Network? Send feedback