NIHSS Score Documented Closest to IV Alteplase Initiation (v2020A2)

Specifications Manual for Joint Commission National Quality Measures (v2020A2)

Posted: 10/30/2019

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Release Notes:
Data Element
Version 2020A2

Name:

NIHSS Score Documented Closest to IV Alteplase Initiation

Collected For:

CSTK-05

Definition:

The NIHSS score documented closest to IV alteplase initiation is the last NIHSS score documented prior to IV alteplase initiation at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

Question:

What is the last NIHSS score documented prior to initiation of IV alteplase at this hospital?

Format:

Length:	3
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Score = 0-42
UTD = Unable to Determine

Notes for Abstraction:

The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
Look for the last NIHSS score documented prior to IV alteplase initiation at this hospital.
Examples:
- “Initial NIHSS score 4 documented by the ED nurse at this hospital. “No other NIHSS scores were documented prior to IV alteplase initiation.” Select ‘4’.
- “Symptoms resolved by time of hospital arrival at 1200. Initial NIHSS score zero documented in ED. Symptoms returned at 1330, NIHSS score 2, and IV alteplase given at 1338.” Select ‘2’.
- “Patient transferred to this hospital. NIHSS score 10 done at transferring hospital. No NIHSS score documented at this hospital prior to IV alteplase.” Select ‘10’.
- “Nurse documented NIHSS score 8 via telemedicine prior to arrival at this hospital. IV alteplase initiated at 1712. NIHSS score 2 at 1800.” Select ‘8’.
For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to IV Alteplase Initiation Time at this hospital
If only one NIHSS score is documented prior to IV alteplase initiation and no other score(s) are available for comparison, enter the value for that score.
If no NIHSS score is documented prior to IV alteplase initiation, select “UTD”.
If unable to determine the last NIHSS score documented prior to IV alteplase initiation, select “UTD”.

Suggested Data Sources:

Consultation notes
History and physical
Nursing flow sheet
Progress notes
Transfer sheet
Admitting note
Ambulance record
Emerency room records
Nursing assessment

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS

Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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