Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed |
|---|
| Collected For: |
ACHF-03 |
|---|
| Definition: | Documentation in the care transition record includes follow-up treatment(s) and service(s) needed. Follow-up treatments and services include treatments and services to be initiated or continued to manage the patient's heart failure after discharge from the hospital. |
|---|
| Question: | Is there documentation in the medical record of the care transition record which includes follow-up treatment and services needed? |
|---|
| Format: |
| Length: | 1 |
|---|
| Type: | Alphanumeric |
|---|
| Occurs: | 1 |
|---|
|
|---|
| Allowable Values: |
Y (Yes) There is documentation that the care transition record included follow-up treatment and services.
N (No) There is no documentation that the care transition record included follow-up treatment or services, OR unable to determine from medical record documentation.
|
|---|
| Notes for Abstraction: |
- Follow-up treatments and services needed after hospital discharge 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 or home care services; mental health, or other counseling services. Durable medical equipment needs and transportation needs (e.g., Medi-car) should be included.
- Documentation of one or more follow-up treatments and/or sevices in the care transition record, select YES'.
- If medical record documentation indicates that no follow-up treatment or services were ordered, select YES'.
- Unchecked checkbox or blank space for documentation of follow-up treatment or services, select NO'.
|
|---|
| 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
|
|---|
| Additional Notes: |
|
|---|
| Guidelines for Abstraction: |
|---|
| Inclusion |
Exclusion |
|
None
|
None |
|