Performance Measurement Network

Question: What is the Date and Time of Last Well Known?


This question has follow-up question(s): Follow-up to UserQuestionId03Stk100984

Patient arrival date/time in the ED was 7/4/2010 at 22:06. RN documents,"Seizure occured 15 mins ago while watching fireworks. Lasted approximately 45 secs.Witnessed by family. Patient with complaints of a headache at this time". The RN's note has was Created: 7/4/2010 22:10.

Would we answer YES to Last Known Well? Would the date be 7/4/2010 and time be 22:55? Or do we answer NO because the actual date and time aren't documented by the RN? Thank you for your help.

Answer:

Last Known Well is date and time that the patient was last known to be at their baseline or usual state of health. The patient presented quickly to the hospital and the seizure event was witnessed. Was the patient his usual self prior to the seizure?

This is the information needed to answer the decision "Last Known Well". The sole purpose of the data element "Last Known Well" is to allow a case to be excluded from the measure population when it cannot be clinically determined when the patient was last known to be at their baseline state of health, i.e., clinically "unknown" as opposed to not having a valid date and time documented in the chart.

If this patient was assigned an ICD-9-Cm Principal Diagnosis Code for ischemic stroke at discharge, select "Yes" for Last Known Well unless further documentation in the medical record castes doubt as to the Date and Time Last Known Well. The Time Last Known Well may be calculated with the documentation provided. Use the Arrival Time of 22:06 minus 15 minutes (21:51) as Time Last Known Well. Date Last Known Well and Arrival Date are the same 7/4.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-04, Time Last Known Well ,
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