Performance Measurement Network

Question: Follow-up to UserQuestionId03Stk100984

This is follow up to a prior question: "What is the Date and Time of Last Well Known?";.

Your 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. select "Yes" for Last Known Well unless further documentation in the medical record castes doubt as to the Date and Time Last Known Well Further documentation (below), Is this enough to cast doubt as to the date and Time of Last Known Well? HYSICIAN 7/4/2010 2238 HPI: Per family members patient was at fireworks, when she got out of car stated "I don't feel well" then leaned on the car and lost consciousness.Family members states "her eyes rolled back into her head and she shook a little". Did not fall to the ground, no confusion after event, no incontinence, tongue biting. Patient denies chest pain, shortness of breath, palpitations associated with event or at this time. Patient's family members state she has been "leaning to the side alot" over the past "few weeks". Also states she was started on new antipsychotic medications recently but they do not remember what they are. Patient denies any symptoms at this time, states she had a diffuse headache immediately after event that has resolved at this time. No fall, no trauma, episode lasted seconds.

Answer:

After reviewing this additional documentation, it seems that stroke was not even considered when the patient presented to the hospital and Date and Time Last Known Well were not addressed. Documentation that the patient was "leaning to the side alot" over the past "few weeks" may have been stroke-related. Retrospectively, the case was assigned ICD-9-CM Principal Diagnosis Code for ischemic stroke at discharge. Select 'Yes' for Last Known Well and 'UTD' for Date and Time Last Known Well, since it is missing from the documentation.

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

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