Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Posted: 9/13/2019
Home » Initial NIHSS Score Performed

Release Notes:
Data Element
Version 2020A1

Name:Initial NIHSS Score Performed
Collected For: CSTK-01
Definition:Documentation of the first National Instititutes of Health Stroke Scale (NIHSS) score that was done at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIHSS 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. Score documentation may range from 0 to 42.

Question:Is there documentation that an initial NIHSS score was done at this hospital?
Allowable Values:

Y (YES) Initial NIHSS score was done at this hospital.

N (No) Initial NIHSS score was not done at this hospital, OR Unable to determine (UTD) from the medical record documentation.
Notes for Abstraction:
  • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
  • If a total NIHSS score (i.e., sum of the category scores) is documented, select ‘YES’.
  • Total scores obtained by teleneurology and documented in the medical record, select ‘YES’.
  • Total scores obtained in response to a code stroke/stroke alert on an inpatient psychiatric or rehabilitation unit prior to admission to inpatient acute care, select 'YES'.
  • If components are scored but the total NIHSS score is not documented or left blank, select ‘NO’. Do not infer a total NIHSS score from documented category scores.

Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing flow sheet
  • Progress notes
  • Admitting note
  • Nursing assessment

Excluded Data Sources:
  • Any documentation dated/timed after discharge
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Modified NIHSS scores
  • Estimated NIHSS scores
  • Scoring methodologies other than NIHSS

Initial NIHSS Score Performed
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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