Release Notes:
Data Element
Version 2018B1
| Name: | Reason for No Post-Discharge Appointment Within 7 Days |
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| Collected For: |
ACHF-02 |
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| Definition: | Documentation by a physician/APN/PA in the medical record of a reason for not scheduling a post-discharge appointment within 7 days.
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| Question: | Is there documentation by a physician/APN/PA in the medical record of a reason for not scheduling a post-discharge appointment within 7 days? |
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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) There is documentation of a reason for not scheduling a post-discharge appointment within 7 days.
N (No) There is no documentation of a reason for not scheduling a post-discharge appointment within 7 days, OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Reasons for not scheduling a post-discharge appointment within 7 days must be documented by the physician/APN/PA.
- If reasons are not mentioned in the context of 7 days after discharge, do not make inferences (e.g., do not assume that an appointment was scheduled for 14 days post-discharge because one was not available within 7 days unless documentation explicitly states so.)
- Reasons must be explicitly documented (e.g., “4 week wait at county clinic. Follow-up scheduled with Dr. X at 10:30 on X/XX/XXXX.”)
- When conflicting information is documented in the medical record, select “Yes”.
- If documentation indicates that the follow-up appointment was not scheduled because the patient is cognitively impaired, (e.g., comatose, obtunded, confused, short-term memory loss) and has no caregiver available to receive the details of the scheduled appointment, select “Yes”.
- The caregiver is defined as the patient's family or other person (e.g. home health, VNA provider, prison official or law enforcement personnel) who will be responsible for care of the patient after discharge.
- The following do not require physician/APN/PA documentation:
- Patient is a visitor from another country or a state or region outside of the provider's scope of referral
- Patient refusal of follow-up appointment
- Patient is discharged to a court/law enforcement setting
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| Suggested Data Sources: |
- Nursing notes
- Progress notes
- Physician orders
- Discharge summary
- Discharge instruction sheet,
- Home health referral form
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
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None
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None |
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