Performance Measurement Network

Question: Rationale for Code Stroke Form as the Priority Data Source

We are still getting a lot of push back from the Stroke Coordinators and clinicians when we have to abstract a time from the Code Stroke Form (that is only completed by RN) that differs from physician documentation when it makes a difference to the measure results.

Please help us explain to them what is TJC's rationale for deeming the Code Stroke Form as the priority source?

Answer:

The rationale for using the Code Stroke Form as the priority data source is to drive accurate documentation of "Time Last Known Well" in the medical record. TLKW is imperative to accurate calculation of the measure.

STK-4 was operationalized in 2005 using the "Time Last Known Well" data element. Over the years, TLKW documentation has improved but remains challenging for some organizations/stroke teams/ individual clinicians. Earliest guidance simply stated to abstract the earliest documented time. Over the years, hierarchical approaches were tried to improve documentation; however, none of which completely resolved the issue or reduced the number of questions generated by the data element. With the increasing use of electronic medical records and the ability to create and designate a specific field for ONE documented "Time Last Known Well", the Code Stroke Form was selected as the priority data source. This approach correlates well with how a stroke team documents care and services provided during the acute stroke process in the ED.

Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-4,
File:

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