Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record-Treatment(s)/Service(s) Provided |
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| Collected For: |
ACHF-03 |
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| Definition: | Documentation in the care transition record includes treatment(s) and service(s) provided during hospitalization. Treatments and services include anything offered to or done for the patient during the hospital stay to manage his/her heart failure. |
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| Question: | Is there documentation in the medical record of a care transition record which includes treatments and services provided during 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) There is documentation that the care transition record included treatment(s) and service(s) provided during hospitalization.
N (No) There is no documentation that the care transition record included treatment(s) and service(s) provided during hospitalization, OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Treatments and services provided during the hospital stay should be documented in the care transition record. The list of treatments and services includes, but is not limited to: laboratory tests and results; imaging services (e.g., MRI, PET/CT, ultrasound, x-rays and other radiology services); rehabilitation services (e.g., PT, OT, SLT); respiratory treatments (e.g., oxygen therapy, CPAP, BiPAP, nebulizer treatments); nutrition services; hospice services; mental health, or other counseling services.
- If one or more treatments or sevices are documented in the care transition record, select Yes'.
- Documentation of tests with results pending that require follow-up, select YES'.
- Unchecked checkbox or blank space for documentation of treatment or services, select NO'.
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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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