Performance Measurement Network

Question: Hunt & Hess/ ICH score documentation required by tele neuro radiology prior to transfer

According to Release notes effective with July 1, 2015 discharges  Hunt &Hess/ ICH score obtained by teleneurology and documented in the medical record, select 'YES'.

Is there any specific documentation required to denote this was a teleradiology consult? We have a case where our neuroradiologist noted the CT findings and the ICH score in the chart on a patient that was transferred from another facility but the time was prior to the patient arriving at our hospital. This is standard practice for our neurointerventionalist on patients being transferred for further treatment. We just wanted to make sure that the note does not require identification as a teleneuroradiology consult but will be accepted as such when done prior to arrival. Thank you.

Answer:

There is no requirement for a telemedicine consult or a note labeled as such regarding abstraction of the ICH Score or Hunt and Hess; however, documentation should reflect that score was obtained via telemedicine in which case the arrival time would be used for the score time. Scores done by staff at another hospital prior to transfer to your hospital should not be counted as Initial ICH Score Performed / Initial Hunt and Hess Scale Performed.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Initial Hunt and Hess Scale Performed
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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