Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record Transmitted |
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| Collected For: |
ACHF-03 |
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| Definition: | A care transition record is a document or set of documents containing standardized components specific to the patient's diagnosis, treatment, and care. A care transition record is transmitted to the next level of care provider no later than the seventh post-discharge day. |
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| Question: | Was a care transition record transmitted to the next level of care provider no later than the seventh post-discharge day? |
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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: |
1 The medical record contains a care transition record that was transmitted to the next level of care provider no later than the seventh post-discharge day.
2 The medical record contains a care transition record but was not transmitted to the next level of care provider by the seventh post-discharge day.
3 The medical record does not contain a care transition record, or unable to determine from medical record documentation.
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| Notes for Abstraction: | There must be documentation in the medical record to indicate that the care transition record was transmitted to the next level of care provider.
- A care transition record may consist of one document or several documents which could be considered a care transition “packet”. The hospital must be able to identify which document(s) make up the care transition record and the hospital must identify what specific documents are transmitted to the next level of care provider.
- The care transition record could be in the form of a continuing care plan, discharge instruction form, or another patient-specific document(s) contained in the medical record.
- The first post-discharge day is defined as the day after discharge.
- The next level of care provider is the clinician, hospital or clinic responsible for managing the patient's heart failure after hospital discharge.
- The next level of care provider may be a primary care physician, cardiologist, advanced practice nurse (APN), or physician assistant (PA).
- If the patient has referrals to more than one provider for follow-up after discharge, transmission of the care transition record must include the next level of care provider.
- Methods for transmitting the care transition record include, but are not limited to: U.S. mail, email, fax, EMR access, doctor's mailbox, medical transport personnel. Giving a copy of the care transition record to the patient DOES NOT comprise transmission.
- If the hospital has an electronic medical record (EMR), abstraction is a two-step process:
- Make a list of those next level of care providers who have complete access to the hospital EMR.
- Check the list of those providers who have EMR access against the providers named on the care transition record. If the next level of provider noted on the care transition record matches the list of providers who have EMR access, select allowable value '1'.
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| Suggested Data Sources: |
- Aftercare discharge plan
- Care transition record
- Continuing care plan
- Discharge plan
- Discharge summary
- Medication reconciliation form
- Physician orders
- Progress notes
- 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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