Release Notes:
Data Element
Version 2018B1
| Name: | Assessed for Rehabilitation Services |
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| Collected For: |
STK-10 |
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| Definition: | Documentation that the patient was assessed for or received rehabilitation services during this hospitalization. Rehabilitation is a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. |
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| Question: | Was the patient assessed for and/or did the patient receive rehabilitation services during this hospitalization? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) Patient was assessed for and/or received rehabilitation services during this hospitalization.
N (No) Patient was not assessed for nor did patient receive rehabilitation services during this hospitalization, OR unable to determine from medical record documentation. |
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| Notes for Abstraction: |
- The assessment for rehabilitation services must be completed by a qualified provider. See the inclusion list.
- If a documented reason exists for not completing a rehabilitation assessment, select “Yes.”
Examples:
- “Patient returned to prior level of function, rehabilitation not indicated at this time.”
- “Patient unable to tolerate rehabilitation therapeutic regimen.”
- Patient/family refusal
- Do not infer that documentation of symptoms resolved means that a rehabilitation assessment was completed, unless mentioned in the context of rehabilitation services.
Example:
“Symptoms resolved – no rehab needed.”
- When an assessment is not found in the medical record but documentation indicates that rehabilitation services were initiated (i.e., Physical Therapy (PT), Occupational Therapy (OT), Speech Language Therapy (SLT), Neuropsychology) during the hospital stay, select “Yes.”
Examples:
- “PT x2 for range of motion (ROM) exercises at bedside.”
- “Patient aphasic – evaluated by speech pathology”
- When patient is transferred to a rehabilitation facility or referred to rehabilitation services following discharge, select “Yes.”
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| Suggested Data Sources: |
PHYSICIAN/APN/PA/KT/PT/OT/SLT OR NEUROPSYCHOLOGIST DOCUMENTATION ONLY FOR REHABILITATION ASSESSMENT:
- After Visit Summary (AVS)
- Consultation notes
- History and physical
- Progress notes
- Discharge summary
- Referral forms
- Rehabilitation records
- Therapy notes (e.g., KT/PT/OT/SLT)
Excluded Data Sources:
Any documentation other than Physician/APN/PA/KT/PT/OT/SLT/Neuropsychologist
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
- Assessment/Consult done by a member of the rehabilitation team
- Patient received rehabilitation services from a member of the rehabilitation team.
- Members of the rehabilitation team:
- Advanced Practice Nurse (APN)
- Kinesiotherapist (KT)
- Neuro-psychologist (PsychD)
- Occupational therapist (OT)
- Physical therapist (PT)
- Physician
- Physician Assistant (PA)
- Speech and language pathologist (SLT)
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- Request for consultation for rehabilitation services that was not performed
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