Performance Measurement Network

Question: Stroke Education Documentation Examples

Which of the following documentation examples will meet the stroke education measure:

1.) Actual written educational material given to the patient included with the chart.

2.) A patient education form present on the chart with a check box listed for each of the 5 components AND documentation,(e.g., "X")that each component was reviewed with the patient/caregiver (actual written material given to the patient not on the chart).

3.) A patient education form with a check box next to a statement, such as, "patient given stroke educatonal material that includes: activation of the EMS, follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs/symptoms of stroke" (actual written material given to the patient not on the chart).

Answer:

Any of the above examples will meet the intent of the measure. Documentation that the patient/caregiver was provided with written materials for each of the 5 educational components must be present in the medical record, e.g., checked checkbox, list of the 5 components, etc.

Written materials given to the patient/caregiver may be present in the medical record, but are not required. When the material is present in the medical record and there is no clear doucmentation that a copy was given to the patient/caregiver, the inference may be made if the materials are stamped with the patient's name and medical record number AND hospital staff or the patient/caregiver have signed the material.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-08, stroke education
File:

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