Performance Measurement Network

Question: Time Last Known Well - Conflicting Physician Documentation


This question has follow-up question(s): How should Last Known Well be abastracted when there is conflicting documentation in the medical record?

The time of stroke symptom onset was documented as 11:05 in the physician H&P; however, an emergency department note documented 9:30. Which time should be used for "Time Last Known Well" when conflicting documentation is present in the medical record?

Answer:

The Stroke Implementation Guide, Version 2.a specifications provide a heirarchy for conflicting physician documentation. This version of the stroke specification remains effective through December 31, 2009. the heirarchy is below: 1. stroke team / neurology 2. admitting physician 3. emergency department physician 4. ED nursing notes 5. EMS

The heirarchy was eliminated in Version 3.0b specifications of the national specifications manual and notes for abstraction state, "If there are multiple times of last known well documented, use the earliest time recorded." Effective January 1, 2010, all certified PSCs should be using 3.0b specifications.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-04, Time Last Known Well ,
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