Performance Measurement Network

Question: Data Abstraction for "Last Known Well"

This is follow up to a prior question: "Time Last Known Well";.
This question has follow-up question(s): ABstraction for Date Last Known Well

Which allowable value, 'YES' or 'No', should be selected for "Last Known Well" if medical record documentation states that the patient noticed numbness in the arm and leg 3-4 days ago? "No" because there is not a date and time documented? Or, "Yes" and use the date 4 days prior to arrival and 'UTD' for time?

Answer:

Select 'NO' for Last Known Well. Selection of 'No' will exclude the case from the measure population.

Last Known Well is a clinical decision point. The purpose of the parent data element Last Known Well is to allow for exclusion of the case when the clinician tries to determine the Date and Time Last Known Well and cannot clinically determine/unable to determine. This is different than 'UTD' (unable to determine) for missing/invalid data.

*In order to abstract value 'Yes' for Last Known Well, both date and time of last known well must be documented.* References, such as "numbness in leg and arm 3-4 days ago", may be used in abstraction; however, both the date and time are needed, (e.g., "experienced numbness in leg and arm yesterday around 10 AM").

When 'Yes' is selected for Last Known Well, the case is in the denominator. Both date and time last known well must be present in the medical record. If either date or time is 'UTD', the case falls out of the numerator. When a date range, such as 3-4 days, is documented, select the maximum (4 days). Date Last Known Well is Arrival Date Minus 4 days. When multiple times are documented, select the earliest.

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