Performance Measurement Network

Question: How should Last Known Well be abastracted when there is conflicting documentation in the medical record?

This is follow up to a prior question: "Time Last Known Well - Conflicting Physician Documentation";.

The ED physician documents onset/duration-3 hours and circles "cannot confirm onset". The ED nurse documents in her assessment date-08/24 and time of 0830 for onset. Who's documentation should be used for Date and Time Last Known Well?

Answer:

If there is documentation that the date or time of last known well in unknown, as in the above example,( i.e."cannot confirm"), select 'No' for "Last Known Well" to exclude the case.

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

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