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Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Home » Education Addresses Risk Factors for Stroke

Release Notes:
Data Element
Version 2016B1

Data Element Name: Education Addresses Risk Factors for Stroke
Collected For: STK-8,
Definition:Documentation that the patient/caregiver received educational materials that address risk factors for stroke. Patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants.
Suggested Data Collection Question:Did the WRITTEN instructions or other documentation of educational material given to the patient/caregiver address risk factors for stroke?
Allowable Values:

Y (Yes)     WRITTEN instructions/educational material given to patient/caregiver address risk factors for stroke.

N (No)     WRITTEN instructions/educational material given to patient/caregiver do not address risk factors for stroke, OR unable to determine from medical record documentation.
Notes for Abstraction:
  • Educational material must specifically address risk factors for stroke:
    Stroke Risk Factors:
    • Overweight
    • Smoking
    • Sedentary lifestyle
  • See the inclusion list for acceptable risk factors for stroke. The list is not all-inclusive.
  • Individual risk factors that are not mentioned in the context of education provided on the risk factors for stroke, do not count (e.g., discharge instruction to limit alcohol without explicit documentation that excessive alcohol consumption is a risk factor for stroke).
    • If individual risk factors are mentioned in the context of education provided on the risk factors for stroke, then it may be inferred that the education was personalized and patient-specific.
  • Educational material which addresses risk factors for transient ischemic attack (TIA) is acceptable.
  • Documentation of education which does not include stroke and risk factors, select “No.”
    • “Stroke binder given to patient’s family.”
    • “Aneurysm education completed.”
  • If documentation reflects that educational material regarding risk factors for stroke was given to the patient/caregiver, select “Yes”, even if a copy of the material is not present in the medical record.
  • Documentation must clearly convey that the patient/caregiver was given a copy of the material to take home. When the material is present in the medical record and there is no documentation which clearly suggests that a copy was given, the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material. This applies to educational materials in the form of discharge instruction sheets, brochures, booklets, teaching sheets, videos, CDs, DVDs or other patient-oriented materials. Providing a link to electronic materials is not sufficient.
  • Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may be covered in material documented as given to the patient/caregiver.
  • Written instructions given anytime during the hospital stay are acceptable.
  • If the medical record contains documentation that instructions were given or sent to the patient/caregiver after discharge, select “No.”
  • If the patient refused written instructions/material which addressed risk factors for stroke, select “Yes.”
  • If documentation indicates that written instructions/material on risk factors for stroke were not given because the patient is cognitively impaired (e.g., comatose, obtunded, confused, short-term memory loss) and has no caregiver available, select “Yes.”
  • The caregiver is defined as the patient’s family or any other person (e.g.,home health, VNA provider, prison official or other law enforcement personnel) who will be responsible for care of the patient after discharge.
Suggested Data Sources:

  • Nursing notes
  • Progress notes
  • Discharge summary
  • Discharge instruction sheet
  • Education record
  • Home health referral form
  • Nursing discharge notes
  • Teaching sheet

Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary.
Additional Notes:

Guidelines for Abstraction:
Inclusion Exclusion
Risk Factors for Stroke:
  • Age
  • Atrial fibrillation
  • Carotid artery stenosis
  • Carotid/peripheral or other artery disease
  • Cigarette smoking
  • Diabetes mellitus
  • Excessive alcohol consumption
  • Heredity (family history)
  • High blood pressure
  • Other heart disease (e.g., coronary heart disease, heart failure, dilated cardiomyopathy)
  • Overweight (BMI greater than or equal to 25)
  • Physical inactivity
  • Poor diet (e.g., high in saturated fat, trans fat, cholesterol or sodium)
  • Prior stroke, TIA or heart attack
  • Race
  • Sex (gender)
  • Sickle cell disease (also called sickle cell anemia)

Unchecked checkbox next to instruction (e.g., blank checkbox on discharge instruction sheet next to “Stroke Risk Factors teaching sheet given to patient”).

Education Addresses Risk Factors for Stroke
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)