Performance Measurement Network

Question: What should we do when conflicting or multiple times of last known well are documented?

The 3.ob specifications manual retired the medical heirarchy when abstracting the "Last Known Well". Reviewers were directed to transcribe the earliest time documented in the chart. This method is potentially inacccurate. For example,a nurse or MD in the ED may document an earlier time than the MD (neurologist)who is making the decision within the context of tPA administration. It may in fact be that the earlier time is inaccurate and a deeper line of questioning from the neurologist would reveal the accurate time and the patient becomes a candidate for tPA. What time would we record in this case? Should we always take the tme of Last Known Well as documented in the tPA decision?

An earlier question noted that the nurse recorded a specfic time and the MD documented > than 3 hours, "time unknown". In this case, we were directed to go with the MD note. Does "time unknown" always supercede a specific time despite who documents the information?


At the time of core measure alignment, the parent data element "Last Known Well" was added to the algorithm to account for situations when it cannot be clinically determined when the patient was last known to be at their baseline state of health. The data element "Last Known Well" is necessary to differentiate when it is clinically unknown from situations where a date and time are documented but are illegible, missing, or invalid, e.g. 3200 documented in the medical record rather than 2300. This distinction is required in an electronic algorithm per the Missing/Invalid data policy shared with CMS. The previous specs-light version allowed the abstractor to use 'NC' and lump clinically unable to determine, missing or invalid in one decision.

Since the physician must decide to order thrombolytic therapy before the nurse will administer, it was thought that the Last Known Well decision(allowable values 'Yes' or 'No') would be made by the physician. Last Known Well occurs before Date and Time LKW in the flow logic. This is the rationale for the previous example, "MD documented > than 3 hours, "time unknown"". Selection of 'Yes' will exclude the case from the meaure population and a date and time LKW are not needed.

Selection of 'No' for "Last Known Well" means that Last Known Well could be clinically determined, and a Date Last Known Well and Time Last Known Well are now required to complete the measure calculation. When multiple times are documented (as it frequently is), the guideline to "select the earliest time" was chosen to ease abstraction, since 'No' for Last Known Well is intended to mean that clinically it was known when the patient was last at his/her baseline state of health. If a date and time cannot be entered at this point (i.e., missing/invalid data), then 'UTD' must be selected and the case will be in the denominator and not in the numertor.

Since implementaion, we have received many questions about these particular data elements. It appears that they are less than clear to the field and still require work. Possibly, inclusion of the heirarchy again will help.

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

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