Release Notes:
Data Element
Version 2018B1
| Name: | Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation |
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| Collected For: |
CSTK-05 |
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| Definition: | The highest NIHSS score documented within 36 hours following initiation of IV alteplase. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. |
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| Question: | What is the highest NIHSS score documented within 36 hours following initiation of IV alteplase? |
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| Format: |
| Length: | 3 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Score = 0-42
UTD = Unable to Determine
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| Notes for Abstraction: |
- The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
- Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IV alteplase.
- For purposes of this data element, score documentation between 0 and 42 is acceptable.
- If only one NIHSS score is documented within the first 36 hours following initiation of IV alteplase and no other NIHSS score(s) are available for comparison, enter the value for that score.
- If multiple scores are documented within the first 36 hours following initiation of IV alteplase, select the highest score.
EXAMPLES:
- NIHSS Score is 10 at 1500 and 20 at 2300. Both scores are documented following the initiation of IV alteplase. Select NIHSS score of 20.
- IV alteplase initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
- IV alteplase initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
- If no NIHSS score is documented within 36 hours following IV alteplase, select “UTD”.
- If unable to determine the highest score documented within 36 hours following IV alteplase, select “UTD”.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing flow sheet
- Progress notes
- Admitting note
- Nursing assessment
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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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- Modified NIHSS scores
- Estimated NIHSS scores
- Scoring methodologies other than NIHSS
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