Release Notes:
Data Element
Version 2016B1
| Data Element Name: | Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation |
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| Collected For: | CSTK-05, |
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| Definition: | The highest NIHSS score documented within 36 hours following initiation of IV thrombolytic (t-PA) therapy. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. |
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| Suggested Data Collection Question: | What is the highest NIHSS score documented within 36 hours following initiation of IV (t-PA) thrombolytic therapy? |
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| Format: | | Length: | 3 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Score = 0-42
UTD = Unable to Determine
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| Notes for Abstraction: |
- The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
- Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IV thrombolytic (t-PA) therapy.
- For purposes of this data element, score documentation between 0 and 42 is acceptable.
- If only one NIHSS score is documented within the first 36 hours following initiation of IV thrombolytic (t-PA) therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
- If multiple scores are documented within the first 36 hours following initiation of IV thrombolytic (t-PA) therapy, select the highest score.
EXAMPLES:
- NIHSS Score is 10 at 1500 and 20 at 2300. Both scores are documented following the initiation of IV thrombolytic therapy. Select NIHSS score of 20.
- IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
- IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
- If no NIHSS score is documented within 36 hours following IV thrombolytic (t-PA) therapy, select UTD.
- If unable to determine the highest score documented within 36 hours following IV thrombolytic (t-PA) therapy, select UTD.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing flow sheet
- Progress notes
- Admitting note
- Nursing assessment
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
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- Modified NIHSS scores
- Estimated NIHSS scores
- Scoring methodologies other than NIHSS
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Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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