Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)
Home » Initial ICH Score Time

Release Notes:
Data Element
Version 2020A

Name:Initial ICH Score Time
Collected For: CSTK-03
Definition:The time (military time) for which 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.
Question:What is the time for which the ICH score was first performed at this hospital?
Length:5 - HH-MM (with or without colon) or UTD
Allowable Values:

HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour


Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Initial ICH Score Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Initial ICH Score Date.
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • Use the time for which the ICH score was first performed. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different initial ICH score times (either different ICH assessments or corresponding with the same assessment), enter the earliest time.
  • If the time of the first ICH score is a time prior to hospital arrival because the score was obtained by teleneurology or MD/APN/PA directly receiving the patient via life flight, use the Arrival Time for the score time.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • Initial ICH Score Time refers to the time that the first ICH score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note”. If the only time documented with the score is the time stamp on the note, then select the time stamped.
    • Documentation indicates that the initial ICH score was done at 0920. Time stamp on the note is 1159. The abstractor should select “0920 for Initial ICH Score Time.
    • Documentation indicates that the ICH score done on arrival was 5. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select “2100 for Initial ICH Score Time.
    • ICH score 5 [no time] documented. Time stamp on the note is 1513. The abstractor should select “1513 for Initial ICH Score Time.
  • If the time of the first ICH score 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 time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Documentation indicates the initial ICH score time was 3300. No other documentation in the medical record provides a valid time. Since the initial ICH score time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commission's Data Warehouse. Use of “UTD” for Initial ICH Score Time allows the case to be accepted into the warehouse.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Admitting note
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Only accept terms identified in the list of inclusions for the Time Stamp on the note. No other terminology will be accepted.

  • Author Time
  • Dictated Time
  • Documented Time
  • File Time
  • Note Time
  • Recorded Time
  • Signature Time (standard or electronic)
  • Date of Service Time
  • Decision to Admit Time
  • Note Creation Time
  • Open Note Time

Initial ICH Score Time
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.