Release Notes:
Data Element
Version 2018B1
| Name: | Initial ICH Score Date |
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| Collected For: |
CSTK-03 |
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| Definition: | The month, date, and year that the ICH score was first performed at this hospital. The ICH Score is a clinical grading scale composed of factors related to a basic neurological examination (GCS), a baseline patient characteristic (age), and initial neuroimaging (ICH volume, IVH, infratentorial/supratentorial origin). The purpose of this grading scale is to provide a standard assessment tool that can be easily and rapidly determined at the time of ICH presentation by physicians without special training in stroke neurology and that will allow consistency in communication and treatment selection in clinical care and clinical research. |
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| Question: | What is the date that the ICH score was first performed at this hospital? |
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| Format: |
| Length: | 10-MM-DD-YYYY (includes dashes) or UTD |
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| Type: | Date |
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| Occurs: | 1 |
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| Allowable Values: |
MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (2012-Current Year)
UTD = Unable to Determine
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| Notes for Abstraction: |
- Use the date that the ICH score was first performed. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more initial ICH score dates (either different ICH assessments or corresponding with the sameassessment), enter the earliest date.
- If the initial ICH score date is unable to be determined from medical record documentation, select “UTD”.
- The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select “UTD”.
Example:
Documentation indicates the initial ICH score date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the initial ICH score date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD”.
Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of “UTD” for Initial ICH Score Date allows the case to be accepted into the warehouse.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Admitting note
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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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