Specifications Manual for Joint Commission National Quality Measures (v2018B1)
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Release Notes:
Data Element
Version 2018B1

Name:Time Last Known Well
Collected For: ASR-IP-1, ASR-OP-1, STK-4
Definition:The time prior to hospital arrival at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health.
Question:At what time was the patient last known to be well or at his or her prior baseline state of health?
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 Date Last Known Well 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 Date Last Known Well.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx

Notes for Abstraction:
  • The Time Last Known Well must be a time prior to the patient’s Arrival Time. Do not use times after hospital arrival for Time Last Known Well.
  • For times that include “seconds,” remove the seconds and record the time as is.
    Example:
    15:00:35 would be recorded as 15:00
  • If the Time Last Known Well is unable to be determined from medical record documentation, select “UTD.”
    EXCEPTION:
    If the only Time Last Known Well is documented as a time immediately before hospital arrival without a specific time range in minutes, e.g., “symptoms started just prior to ED arrival,” and no other documentation mentioning time last known well is available in the medical record, use the Arrival Time for Time Last Known Well.
  • 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 Time Last Known Well was 3300. No other documentation in the medical record provides a valid time. Since the Time Last Known Well 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 CMS Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Time Last Known Well allows the case to be accepted into the warehouse.
  • If the Time Last Known Well is documented as one specific time and entered as Time Last Known Well on a “Code Stroke” form or stroke-specific electronic template, enter that time as the Time Last Known Well. Documentation of Time Last Known Well on a stroke-specific form or template should be selected regardless of other times last known well documented elsewhere in the medical record.
    EXCEPTIONS:
    • ANY physician/APN/PA documentation that Last Known Well /onset of signs/symptoms is unknown/uncertain/unclear takes precedence over specific time on “Code Stroke” form.
    • Crossing out of a specific time on a Code Stroke Form and a specific time documented on the same or different Code Stroke Form, use the specific time that is not crossed out.
    • A specific time on a Code Stroke Form and another time reference documented, e.g. <8 hours, on the same or different Code Stroke Forms, use the specific time.
    • Multiple specific times on the same or different Code Stroke Forms, use abstraction guidelines for multiple Times Last Known Well.
    • Unable to determine if a form is a Code Stroke Form, continue to review the medical record for Time Last Known Well documentation in other sources.
  • A Code Stroke Form is used by the stroke team or ED staff to document the acute stroke process.
  • See the inclusion list for acceptable terms used for a Code Stroke Form. The list is not all-inclusive.
  • Time Last Known Well on a Code Stroke Form may be documented by a nurse.
  • If the Time Last Known Well is documented as being a specific number of hours prior to arrival (e.g., felt left side go numb 2 hours ago) rather than a specific time, subtract that number from the time of ED arrival and enter that time as the Time Last Known Well.
  • If the Time Last Known Well is noted to be a range of time prior to ED arrival (e.g., felt left side go numb 2-3 hours ago), assume the maximum time from the range (e.g., 3 hours), and subtract that number of hours from the time of arrival to compute the time last known well.
  • If the time is noted to be “less than” a period of time prior to ED arrival, assume the maximum range.
    Example:
    Time Last Known Well less than one hour ago. Subtract one hour from the time of arrival to compute time last known well.
  • If both the Time Last Known Well and the time of symptom onset are documented, select the Time Last Known Well.
    Examples:
    • H&P states, “Patient watching TV with family and complained of blurred vision in both eyes at 8:30 PM.” ED MD notes, “Patient normal at 8:30 PM.” Time Last Known Well is 2030.
    • “Patient was doing well at 4:30 PM – noticed difficulty speaking around 6 PM.” Time Last Known Well is 1630.
    • Patient normal at 2200 before going to bed. Awoke at 0200 with headache and took two aspirin before returning to sleep. OK at 0700 and went to work. Felt confused, unable to speak without slurring at 0800. Time Last Known Well is 0700.
  • If the only time documented is time of symptom onset without mention of when the patient was last known well, use the time of symptom onset for time last known well.
    Example:
    “Sudden onset headache one hour before ED arrival,” documented by ED MD. Arrival time 19:24. No other documentation referencing time last known well available in medical record. Time Last Known Well is 18:24.
  • If there are multiple times of last known well documented in the absence of the Time Last Known Well explicitly documented on a “Code Stroke” form, use physician documentation first before other sources, e.g., nursing, EMS.
    Example:
    “Patient last seen normal this morning at 1000” per H&P. ED nurse documented 09:50 as time last well. Time Last Known Well is 1000.
  • If multiple times last known well are documented by different physicians or by the same provider, use the earliest time documented.
  • If there is documentation of one or more episodes of stroke symptoms AND documentation of symptom resolution between episodes, use the time of the most recent (last) episode prior to arrival, regardless if all symptoms resolved prior to arrival.
    Examples:
    • “Patient reported right hand paresthesia two days ago that resolved spontaneously after a few minutes. New onset of symptoms today around 0700 involving right arm and right leg.” Time Last Known Well is 0700.
    • “Wife states that he was having trouble with slurred speech and confusion yesterday. Symptom free this morning. Return of symptoms with facial droop noted around noon.” Time Last Known Well is 1200.
    • “Wife noticed slurred speech at 8:30 last night. Without symptoms early this morning. Wife noticed slurred speech again at 0900 during breakfast conversation.” Time Last Known Well is 0900.
    • “Wife noticed slurred speech at 8:30 last night. Symptom-free this morning. Came to ED to get checked out.” Time Last Known Well is 2030.
Suggested Data Sources:
  • Emergency department record
  • History and physical
  • Nursing flow sheet
  • Progress notes
  • Medication administration record (MAR)
  • Transfer sheet
  • Ambulance record
  • Code Stroke form/template
  • IV flow sheets

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Signs and Symptoms of Stroke
  • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache

Code Stroke Form
  • Stroke Activation Form
  • Stroke Alert Form
  • Stroke Assessment Form
  • Stroke Intervention Form
  • Stroke Rapid Response Form
  • Thrombolysis Checklist
  • tPA Eligibility Form

Code Stroke Form
  • Stroke Education Form
  • Core Measure Form

Time Last Known Well
Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)

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