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Question: Documentation of Last Known well

In reading the criteria, most of the bullets refer to the documentation of Last Known Well by the physician/APN/PA. In one bullet it states "Time Last Known Well on a Code Stroke Form may be documented by a nurse." Is this the only place nurse documentation is taken?

Answer:

Debbie, Nursing documentation of Last Known Well / time Last Known Well in any source may be used for abstraction. If multiple times are documented in the record, use physician documentation when a Code Stroke Form is not used.

Code Stroke Form is the priority data source if used. The nurse may document the TLKW on the form. A MD co-signature is not required.

Hope this clarifies for you. Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, STK-4, Last Known Well
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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