Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Initial ICH Score Time
Collected For: CSTK-03
Definition:The time (military time) for which the ICH score was first performed at this hospital. The ICH Score is a clinical grading scale composed of factors related to a basic neurological examination (GCS), a baseline patient characteristic (age), and initial neuroimaging (ICH volume, IVH, infratentorial/supratentorial origin). The purpose of this grading scale is to provide a standard assessment tool that can be easily and rapidly determined at the time of ICH presentation by physicians without special training in stroke neurology and that will allow consistency in communication and treatment selection in clinical care and clinical research.
Suggested Data Collection Question:What is the time for which the ICH score was first performed at this hospital?
Format:
Length:5 - HH-MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Initial ICH Score Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Initial ICH Score Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • Use the time for which the ICH score was first performed. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different initial ICH score times (either different ICH assessments or corresponding with the same assessment), enter the earliest time.
  • If the time of the first ICH score is a time prior to hospital arrival because the score was obtained by teleneurology or MD/APN/PA directly receiving the patient via life flight, use the Arrival Time for the score time.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • Initial ICH Score Time refers to the time that the first ICH score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note”. If the only time documented with the score is the time stamp on the note, then select the time stamped.
    Examples:
    • Documentation indicates that the initial ICH score was done at 0920. Time stamp on the note is 1159. The abstractor should select “0920 for Initial ICH Score Time.
    • Documentation indicates that the ICH score done on arrival was 5. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select “2100 for Initial ICH Score Time.
    • ICH score 5 [no time] documented. Time stamp on the note is 1513. The abstractor should select “1513 for Initial ICH Score Time.
  • Do not use physician orders as they do not demonstrate the ICH score was done (in the ED this may be used if signed/initialed by a nurse).
  • If the time of the first ICH score is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the initial ICH score time was 3300. No other documentation in the medical record provides a valid time. Since the initial ICH score time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commission's Data Warehouse. Use of “UTD” for Initial ICH Score Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Admitting note
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Initial ICH Score Time
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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