Performance Measurement Network

Question: Elective carotid intervention documentation

Pt has prinicpal dx of 433.10 with principal px of 38.12. It is quite clear from reading the chart that this was a planned elective procedure, i.e., no documentation of acute stroke, pre-admission testing orders in chart written 2 days prior to admission with orders of surgical consent for left CEA, physician office visit documentation done 4 months prior to admisssion stating 'he is having left sided CEA with Dr X and this is planned in the near future'. However nowhere in the chart is the word elective documented other than nursing intra-op record which lists CEA surgery type as elective. Should 'Yes' or 'No' be selected for "Elective Carotid Intervention"?

Answer:

Select 'Yes' for Elective Carotid Intervention when it is clearly documented that the patient was admitted for purposes of performance of the carotid intervention as in the example provided.

Some other terms for inclusion have been added to future version 3.2 (effective 10-01-10)of the specifications manual, since 'elective' is not always documented even when it is clear to the abstractor that the patient was admitted for purposes of performing the procedure. This modification should help ease abstraction.

o Elective o Non-emergent o Planned o Pre-arranged o Pre-planned o Pre-scheduled o Previously arranged o Scheduled o Work-up

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