Release Notes:
Data Element
Version 2018B1
| Name: | Initial NIHSS Score Date |
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| Collected For: |
CSTK-01 |
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| Definition: | The month, date, and year that the NIHSS score was first performed at this hospital. The NIH stroke scale measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIH stroke scale serves several purposes, but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with t-PA. |
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| Question: | What is the date that the NIHSS 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 NIHSS 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 NIHSS score dates (either different NIHSS assessments or corresponding with the sameassessment), enter the earliest date.
- If the initial NIHSS 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 NIHSS date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the initial NIHSS 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 NIHSS 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
- 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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None |
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