Performance Measurement Network

Question: Does all medical record documentation need to be dated and timed?

The physician documented his reason for not administering an antithrombotic by end of day 2 in a progress note; however, the note was not dated and a date was not found on the page. The orders in the chart on the pages preceeding and after this page were dated hospital day 2. Is this acceptable to select 'Yes' for "Reason for Not Adminsitering Antithrombotic By End of Hospital Day 2" or must the actual note be dated and timed?

Answer:

In the "Intro to the Data Dictionary", general abstraction guidelines for core measure data collection, it states that all documentation in the medical record must be legible and must be timed, dated and authenticated. *Documentation that is not timed, dated, or authenticated may still be used for abstraction if the definition for the data element does not require a specific date.*

Unlike the data elements "Date Last Known Well", "IV Throbolytic Initiation Date", "Arrival Date" for example, "Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2" utilizes 'Yes' or 'No' as allowable values and does not require a specific date in the month/day/year format. Even though the physician's note is not dated, it is possible to use surrounding documentation to determine the date. If after due diligence in reviewing all allowable data sources within the medical record, no date is not documented, i.e. “missing,” or the date cannot be determined, then “UTD - Unable to Determine,” OR 'No' should be selected for data elements using 'Yes' or 'No' as allowable values.

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

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK, STK-5 Antithrombotic therapy by end of hospital day 2
File:

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