Performance Measurement Network

Question: Documentation of Stroke Education

Our organization has a stroke pamphlet that is utilized in discharge teaching for all stroke patients. The material covers all required elements of stroke education. The discharge education form has a place to document that the information was given. The nurse places an "H" in the box to indicate that the stroke "handout" was given to the patient/family. Is this documentation that the handout was given enough to answer "Yes" for each of the stroke eduation data elements?

Answer:

Documentation that the stroke pamphlet was given to the patient/caregiver is not sufficient. Documentation that written instructions/materials for each of the 5 edicational components(Education Addresses Activation of EMS; Follow-up After Discharge; Medications Prescribed at Discharge; Risk Factors for Stroke; and, Warning Signs and Symptoms of Stroke) must be present in the medical record.

The medical record is abstracted at face-value. Materials outside of the medical record are not to be reviewed or used in the abstraction process. Generally, copies of booklets/handouts are not included in the medical record. Inclusion of the handout with documentation that it was provided to the patient/caregiver to take home would meet at least 4 of the 5 components. Medication education must include at least the names of all discharge medications for which written instructions were provided to the patient and/or caregiver.

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

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