Performance Measurement Network

Question: STK-10 Assessed for Rehabilitation Services

The patient was admitted with a grade I SAH and was initially on bedrest. A stroke admission order set was used and both a PT and OT assessment were ordered. Both PT and OT document in a progress note the day of admission that they acknowledged the order but were not able to see the patient because of a schedule conflict. On the second hospital day, PT documents the following in a progress note: "PT/OT- Orders received, pt currently on strict bedrest, please re-order PT and OT when activity orders are upgraded." The pt. is later taken off bedrest and there are no subsequent progress notes from PT/OT or other members of the rehabilitation team. There is no other documented reason for not completing a rehabilitation assessment. the patient had no documented neuro deficit during the hospitalization.

Would the PT progress note quoted above be considered a documented reason for not completing a rehabilitation assessment?

Answer:

"Assessed for Rehabilitation Services" is a 'Yes' or 'No' data element. Either a rehab assessment was done before discharge or it was not. The algorithm does not allow exclusion for not completing the rehab assessment, i.e., reasons why the assessment was not done.

If rehabilitation services were not indicated for the patient and explicitly documented as such, e.g., "symptoms resolved-no rehab needed", this would be considered an assessment and you could select 'Yes'. Requests/orders for inpatient rehabilitation consults that were not performed, as is the case in the example provided, do not count as rehabilitation assessments (See Exclusion Guidelines for Abstraction). Select 'No' for Assessed for Rehabilitation Services for this patient.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-10,
File:

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