Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed

Collected For:

ACHF-03,

Definition:

Documentation in the care transition record includes follow-up treatment(s) and service(s) needed. Follow-up treatments and services include treatments and services to be initiated or continued to manage the patient's heart failure after discharge from the hospital.

Suggested Data Collection Question:

Is there documentation in the medical record of the care transition record which includes follow-up treatment and services needed?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation that the care transition record included follow-up treatment and services.

N (No) There is no documentation that the care transition record included follow-up treatment or services, OR unable to determine from medical record documentation.

Notes for Abstraction:

Follow-up treatments and services needed after hospital discharge should be documented in the care transition record. The list of treatments and services includes, but is not limited to: laboratory tests and results; imaging services (e.g., MRI, PET/CT, ultrasound, x-rays and other radiology services); rehabilitation services (e.g., PT, OT, SLT); respiratory treatments (e.g., oxygen therapy, CPAP BiPAP, nebulizer treatments); nutrition services; hospice or home care services; mental health, or other counseling services. Durable medical equipment needs and transportation needs (e.g., Medi-car) should be included.
Documentation of one or more follow-up treatments and/or sevices in the care transition record, select YES.
If medical record documentation indicates that no follow-up treatment or services were ordered, select YES.
Unchecked checkbox or blank space for documentation of follow-up treatment or services, select NO.

Suggested Data Sources:

Aftercare discharge plan
Care transition record
Continuing care plan
Discharge plan
Discharge summary
Medication reconciliation form
Physician orders
Progress notes
Referral form

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed

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