Performance Measurement Network

Question: Rehabilitation Assessment

We use an Adult Patient Profile that is done on admission by an RN. The profile has a section for Functional Level Prior and a section for Current Level of Functioning which includes ambulation, transferring, stairs, toileting, bathing, dressing, eating, and communication. Can we select "Yes" for the question, "Was the patient assessed for and/or did the patient receive rehab services during this hospitalization?", if the patient is independent for all activities.

Answer:

There is no mention of rehabilitation services on the form. As with "symptoms resolved", do not infer "independent" means that the patient was assessed for rehabilitation. Documentation must provide linkage with rehabilitation services to select 'Yes', e.g., "Symptoms resolved-no rehab needed"; "Patient returned to prior level of funcitoning, rehabilitation not indicated at this time"; "Patient unable to tolerate rehab". See Notes for Abstraction, *Assessed for Rehabilitation Services*.

http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm

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