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

Data Element Name: Initial NIHSS Score Time
Collected For: CSTK-01
Definition:The time (military time) for which the NIHSS score was first performed at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIHSS serves several purposes, but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with t-PA.
Suggested Data Collection Question:What is the time for which the NIHSS 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 NIHSS 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 NIHSS 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 NIHSS 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 NIHSS score times (either different NIHSS assessments or corresponding with the sameassessment), enter the earliest time.
  • If the time of the first NIHSS 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 NIHSS Score Time refers to the time that the first NIHSS 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 NIHSS score was done at 0920. Time stamp on the note is 1159. The abstractor should select “0920 for Initial NIHSS Score Time.
    • Documentation indicates that the NIHSS score done on arrival was 12. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select “2100 for Initial NIHSS Score Time.
    • NIHSS score 12 [no time] documented. Time stamp on the note is 1513. The abstractor should select “1513 for Initial NIHSS Score Time.
  • Do not use physician orders as they do not demonstrate the NIHSS score was done (in the ED this may be used if signed/initialed by a nurse).
  • Times for scores done prior to arrival by a teleneurologist are acceptable if signed/initialed by a nurse.
  • If the time of the first NIHSS 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 NIHSS score time was 3300. No other documentation in the medical record provides a valid time. Since the initial NIHSS 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 NIHSS Score Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

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

Initial NIHSS 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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